Central perforated VRAM flap and neurostimulated levator augmentation for functional and aesthetical reconstruction after abdominoperineal excision in cancer
Restricted accessResearch articleFirst published online July, 2022
Central perforated VRAM flap and neurostimulated levator augmentation for functional and aesthetical reconstruction after abdominoperineal excision in cancer
Preservation of quality of life regarding fecal continence after abdominoperineal excision (APE) in cancer is challenging. Simultaneous soft tissue coverage and restoration of continence mechanism can be provided through an interdisciplinary collaboration of colorectal and plastic reconstructive surgery.
OBJECTIVE:
Evaluation of surgical procedure and outcome combining soft tissue reconstruction using a central perforated vertical rectus abdominis myocutaneous flap (VRAM), implementing a perineostoma and restoring anorectal angle augmenting the levator ani by neurostimulated graciloplasty.
METHODS:
14 Patients underwent APE due to cancer. In all patients coverage was achieved by pedicled VRAM and simultaneous pull-through descendostomy (perineostoma). 10 of those patients received a levator augmentation additionally. Postoperative complications, functional measures of continence as well as quality of life were obtained.
RESULTS:
Perineal minor complication rate was 43% without need of surgical intervention. All but one VRAM survived. Continence measures and disease specific life quality showed a good preservation of continence in most patients.
CONCLUSION:
The results present a complex therapy option accomplished by a collaboration of two highly specialized partners (visceral and plastic surgery) after total loss of the sphincter function and consecutive fecal insufficiency after APE.
HolmTLjungAHäggmarkTJurellGLagergrenJ. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg.2007; 94: 232-8. doi: 10.1002/bjs.5489.
2.
ShuklaHSTewariM. An evolution of clinical application of inferior pedicle based rectus abdominis myocutaneous flap for repair of perineal defects after radical surgery for cancer. J Surg Oncol.2010; 102: 287-94. doi: 10.1002/jso.21605.
3.
ButlerCEGündesliogluAÖRodriguez-BigasMA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg.2008; 206: 694-703. doi: 10.1016/j.jamcollsurg.2007.12.007.
4.
MustersGDBuskensCJBemelmanWATanisPJ. Perineal wound healing after abdominoperineal resection for rectal cancer. Dis Colon Rectum.2014; 57: 1129-39. doi: 10.1097/DCR.0000000000000182.
NelsonRAButlerCE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg.2009; 123: 175-83. doi: 10.1097/PRS.0b013e3181904df7.
7.
MenonAClarkMAShatariTKehCKeighleyMRB. Pedicled flaps in the treatment of nonhealing perineal wounds. Color Dis.2005; 7: 441-4. doi: 10.1111/j.1463-1318.2005.00838.x.
8.
WangEDConklingNXuXChernHFinlaysonEVarmaMG, et al. Perineal Flap Reconstruction following Oncologic Anorectal Extirpation. Plast Reconstr Surg.2015; 135: 176e-184e. doi: 10.1097/PRS.0000000000000837.
9.
MathesSJBostwickJ. A rectus abdominis myocutaneous flap to reconstruct abdominal wall defects. Br J Plast Surg.1977; 30: 282-3. doi: 10.1016/0007-1226(77)90118-7.
10.
ShuklaHSHughesLE. The rectus abdominis flap for perineal wounds. Ann R Coll Surg Engl.1984; 66: 337-9.
11.
SoperJTSecordAAHavrileskyLJBerchuckAClarke-PearsonDL. Comparison of gracilis and rectus abdominis myocutaneous flap neovaginal reconstruction performed during radical pelvic surgery: Flap-specific morbidity. Int J Gynecol Cancer.2007; 17: 298-303. doi: 10.1111/j.1525-1438.2007.00784.x.
12.
LefevreJHParcYKernéisSShieldsCTouboulEChaouatM, et al. Abdomino-perineal resection for anal cancer. Ann Surg.2009; 250: 707-11. doi: 10.1097/SLA.0b013e3181bce334.
13.
SpasojevicMMariathasanABGoscinskiMThorgersenEBSolbakkenAMGullestadH-P, et al. Vertical rectus abdominis musculocutaneous flap repair improves perineal wound healing after abdominoperineal resection for irradiated locally advanced rectal cancer. Ann Surg Oncol.2018; 25: 1357-65. doi: 10.1245/s10434-018-6363-3.
14.
LevySSerrorKBoccaraD. Vertical rectus abdominis musculocutaneous flap repair improves perineal wound healing after abdominoperineal resection for irradiated locally advanced rectal cancer. Ann Surg Oncol.2018; 25: 3773-3773. doi: 10.1245/s10434-018-6562-y.
15.
DevulapalliCJia WeiATDiBiagioJRBaezMLBaltodanoPASealSM, et al. Primary versus flap closure of perineal defects following oncologic resection. Plast Reconstr Surg.2016; 137: 1602-13. doi: 10.1097/PRS.0000000000002107.
16.
ChessinDBHartleyJCohenAMMazumdarMCordeiroPDisaJ, et al. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: A cohort study. Ann Surg Oncol.2005; 12: 104-10. doi: 10.1245/ASO.2005.03.100.
17.
Saldana RuizNKaiserAM. Fecal incontinence – Challenges and solutions. World J Gastroenterol.2017; 23: 11. doi: 10.3748/wjg.v23.i1.11.
18.
HowPEvansJMoranBSwiftIBrownG. Preoperative MRI sphincter morphology and anal manometry: can they be markers of functional outcome following anterior resection for rectal cancer? Color Dis.2012; 14: e339-45. doi: 10.1111/j.1463-1318.2012.02942.x.
19.
RongenMJGMUludagÖEl NaggarKGeerdesBPKonstenJBaetenCGMI. Long-term follow-up of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum.2003; 46: 716-21. doi: 10.1007/s10350-004-6645-7.
20.
MatzelKEMadoffRDLaFontaineLJBaetenCGMIBuieDWChristiansenJ, et al. Complications of dynamic graciloplasty. Dis Colon Rectum.2001; 44: 1427-35. doi: 10.1007/bf02234593.
21.
IsbertCSchlegelNReibetanzJKrajinovicKSchmidtKGermerC-T, et al. Neurostimulated levator augmentation – a new approach in restoring continence. Int J Colorectal Dis.2015; 30: 505-12. doi: 10.1007/s00384-015-2134-9.
22.
GlattBSDisaJJMehraraBJPusicALBolandPCordeiroPG. Reconstruction of extensive partial or total sacrectomy defects with a transabdominal vertical rectus abdominis myocutaneous flap. Ann Plast Surg.2006; 56: 526-30. doi: 10.1097/01.sap.0000205772.15061.39.
23.
SchadenDSchauerGHaasFBergerA. Myocutaneous flaps and proctocolectomy in severe perianal Crohn’s disease – A single stage procedure. Int J Colorectal Dis.2007; 22: 1453-7. doi: 10.1007/s00384-007-0337-4.
24.
HorchREHohenbergerWEweidaAKneserUWeberKArkudasA, et al. A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration. Int J Colorectal Dis.2014; 29: 813-23. doi: 10.1007/s00384-014-1868-0.
25.
VonlanthenRSlankamenacKBreitensteinSPuhanMAMullerMKHahnloserD, et al. The impact of complications on costs of major surgical procedures. Ann Surg.2011; 254: 907-13. doi: 10.1097/SLA.0b013e31821d4a43.
26.
BullardKMTrudelJLBaxterNNRothenbergerDA. Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum.2005; 48: 438-43. doi: 10.1007/s10350-004-0827-1.
