Devulapalli Chris, Jia Wei Anne Tong, DiBiagio Jennifer R, Baez Marcelo L, Baltodano Pablo A, Seal Stella M, Sacks Justin M, Cooney Carisa M, Rosson Gedge D
Baltimore, Md.
From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; and the Welch Services Center, William H. Welch Medical Library.
Plast Reconstr Surg. 2016 May;137(5):1602-1613. doi: 10.1097/PRS.0000000000002107.
Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to compare primary closure with myocutaneous flap reconstruction of perineal defects following abdominoperineal resection or pelvic exenteration with regard to surgical-site complications.
A comprehensive literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the MEDLINE, EMBASE, Google Scholar, and Cochrane Library databases. After data extraction from included studies, meta-analysis was performed to compare outcome parameters defining surgical-site complications of flap and primary closure.
Our systematic review yielded 10 eligible studies (one randomized controlled trial and nine retrospective studies) involving 566 patients (226 flaps and 340 primary closures). Eight studies described rectus abdominis myocutaneous flaps and two studies used gracilis flaps. In meta-analysis, primary closure was more than twice as likely to be associated with total perineal wound complications compared with flap closure (OR, 2.17; 95 percent CI, 1.34 to 3.14; p = 0.001). Rates of major perineal wound complications were also significantly higher in the primary closure group (OR, 3.64; 95 percent CI, 1.43 to 7.79; p = 0.005). There was no statistically significant difference between primary and flap closure for minor perineal wound complications, abdominal hernias, length of stay, or reoperation rate.
This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure for pelvic reconstruction. The authors' results have validated the use of myocutaneous flaps for reducing perineal morbidity following abdominoperineal resection or pelvic exenteration.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.
腹会阴联合切除术及盆腔脏器清除术用于切除恶性肿瘤时，可导致巨大的会阴缺损，并伴有严重的手术部位并发症。有人提出采用肌皮瓣代替一期缝合以促进伤口愈合。我们进行了一项系统评价，比较腹会阴联合切除术或盆腔脏器清除术后会阴缺损采用一期缝合与肌皮瓣重建在手术部位并发症方面的差异。
按照系统评价和Meta分析的首选报告项目指南，在MEDLINE、EMBASE、谷歌学术和考克兰图书馆数据库中进行全面的文献检索。从纳入研究中提取数据后，进行Meta分析，比较定义皮瓣和一期缝合手术部位并发症的结局参数。
我们的系统评价纳入了10项符合条件的研究（1项随机对照试验和9项回顾性研究），涉及566例患者（226例采用皮瓣，340例采用一期缝合）。8项研究描述了腹直肌肌皮瓣，2项研究使用了股薄肌皮瓣。在Meta分析中，与皮瓣缝合相比，一期缝合发生会阴伤口总并发症的可能性是皮瓣缝合的两倍多（比值比，2.17；95%置信区间，1.34至3.14；P = 0.001）。一期缝合组严重会阴伤口并发症的发生率也显著更高（比值比，3.64；95%置信区间，1.43至7.79；P = 0.005）。会阴伤口轻微并发症、腹部疝、住院时间或再次手术率在一期缝合和皮瓣缝合之间无统计学显著差异。
这是第一项对盆腔重建中一期缝合与肌皮瓣缝合进行比较的系统评价及Meta分析。作者的结果证实了肌皮瓣在降低腹会阴联合切除术或盆腔脏器清除术后会阴并发症发生率方面的应用价值。
临床问题/证据级别：治疗性，II级。
