Department of Gastroenterological Surgery, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway.
Department of Plastic Surgery, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway.
Ann Surg Oncol. 2018 May;25(5):1357-1365. doi: 10.1245/s10434-018-6363-3. Epub 2018 Mar 1.
Radiotherapy (RT) and subsequent abdominoperineal resection (APR) for locally advanced rectal cancer (LARC) is associated with significant perineal wound morbidity. The aim of the present study was to investigate if vertical rectus abdominis musculocutaneous (VRAM) flap repair after APR in LARC patients improves perineal wound healing compared with direct perineal wound closure (non-VRAM).
LARC patients (n = 329) operated with APR between January 2006 and December 2015 after neoadjuvant RT of ≥ 25 Gy were identified, including 260 and 69 patients in the non-VRAM and VRAM groups, respectively. Perineal wound healing was assessed 3 months postoperatively, and risk factors for perineal wound complications and associations with short- and long-term outcome were analyzed.
Delayed perineal wound healing after 3 months was more frequent in the non-VRAM group (31.5%) compared with the VRAM group (10.4%) (p < 0.01). In the non-VRAM group, 26.9% of patients developed pelvic abscess, compared with 10.1% in the VRAM group (p < 0.01). Significant risk factors for perineal wound morbidity were non-VRAM (odds ratio [OR] 3.94, 95% confidence interval [CI] 1.72-9.00; p = 0.02), positive circumferential resection margin (R1; OR 3.64, 95% CI 1.91-6.93; p < 0.01), pelvic abscess (OR 3.27, 95% CI 1.90-5.63; p < 0.01), and short-course RT (OR 3.81, 95% CI 1.75-8.30; p < 0.01). Perineal wound morbidity was not associated with impaired long-term oncologic outcome.
VRAM flap reconstruction of the perineum is associated with an increased wound healing rate and may protect against pelvic abscess development. However, procedure-related long-term morbidity is incompletely studied and the procedure should be reserved for selected patients.
局部晚期直肠癌（LARC）患者接受放射治疗（RT）和随后的腹会阴联合切除术（APR），会导致显著的会阴伤口并发症。本研究旨在探讨 LARC 患者接受 APR 后行垂直腹直肌肌皮瓣（VRAM）修复是否比直接会阴伤口缝合（非 VRAM）更能改善会阴伤口愈合。
本研究纳入了 2006 年 1 月至 2015 年 12 月间接受新辅助放疗剂量≥25Gy 的 LARC 患者（n=329），包括非 VRAM 组和 VRAM 组，分别有 260 例和 69 例患者。术后 3 个月评估会阴伤口愈合情况，并分析会阴伤口并发症的风险因素及与短期和长期结局的关系。
非 VRAM 组（31.5%）延迟的会阴伤口愈合在 3 个月后更为常见，而 VRAM 组（10.4%）则相对少见（p<0.01）。非 VRAM 组中，26.9%的患者发生了骨盆脓肿，而 VRAM 组为 10.1%（p<0.01）。会阴伤口并发症的显著危险因素是非 VRAM（比值比[OR]3.94，95%置信区间[CI]1.72-9.00；p=0.02）、环周切缘阳性（R1；OR 3.64，95% CI 1.91-6.93；p<0.01）、骨盆脓肿（OR 3.27，95% CI 1.90-5.63；p<0.01）和短程放疗（OR 3.81，95% CI 1.75-8.30；p<0.01）。会阴伤口并发症与长期肿瘤学结局受损无关。
VRAM 皮瓣重建会阴可提高伤口愈合率，并可能预防骨盆脓肿的发生。然而，与手术相关的长期并发症尚未完全研究，该手术应保留给特定患者。
