Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
BMC Surg. 2021 Apr 15;21(1):194. doi: 10.1186/s12893-021-01189-0.
Pelvic sepsis after surgery for rectal cancer is a severe complication, mostly originating from anastomotic leakage. Complex salvage surgery, during which an omentoplasty is often used for filling of the pelvic cavity, is seldomly required. If this fails, a symptomatic recurrent presacral abscess with a risk of progressive inflammation can develop. Such patients have often undergone multiple surgeries and have disturbed abdominal wall integrity, adhesion formation, and presence of one or two stoma(s). Subsequent salvage surgery via the conventional anterior abdominal approach is therefore less suitable. We describe three cases with a chronic presacral sinus and failure of first salvage surgery. All three patients underwent a prone only approach with tailored sacrectomy. This novel approach provided direct access to the pelvic abscess with optimal exposure for complete and safe debridement. A unilateral or bilateral gluteal V-Y fasciocutaneous advancement flap was created to completely fill the cavity with well vascularized tissue.
Three male patients of 80, 66 and 51 years of age initially underwent low anterior resection with neo-adjuvant radiotherapy for rectal cancer. The first patients underwent intersphincteric resection of the anastomosis with omentoplasty 128 months after index surgery, and second salvage surgery 2 months later. The second patient underwent abdominoperineal resection with omentoplasty for locally recurrent rectal cancer, cystoprostatectomy with revision of the omentoplasty for pelvic sepsis 100 months after index surgery, and second salvage surgery 16 months later. In the third patient, the anastomosis was dismantled with subsequent intersphincteric proctectomy and omentoplasty 20 months after index surgery, and second salvage surgery was performed 93 months later. Second salvage surgery in all three patients was indicated because of symptomatic recurrent pelvic sepsis. Second salvage surgery consisted of sacrectomy, complete debridement of the presacral area, and filling with a gluteal advancement flap. This resulted in favorable postoperative recovery with ultimate healing of the pelvic cavity.
The dorsal approach with tailored sacrectomy and gluteal V-Y advancement flap is a valuable option in highly selected patients to treat recurrent pelvic sepsis after multiple prior transabdominal interventions for chronic presacral sinus.
直肠癌手术后盆腔感染是一种严重的并发症，主要源于吻合口漏。通常需要进行复杂的挽救性手术，在此过程中，经常使用网膜成形术来填充盆腔。如果手术失败，可能会发展为症状性复发性直肠前脓肿，伴有进行性炎症的风险。此类患者通常已接受多次手术，且存在腹部完整性受损、粘连形成以及存在一个或两个造口的情况。因此，通过传统的经腹前路进行后续挽救性手术不太合适。我们描述了 3 例慢性直肠前窦和首次挽救性手术失败的病例。所有 3 例患者均采用仅俯卧位入路联合定制式骶骨切除术。这种新方法可直接进入盆腔脓肿，提供最佳的暴露，以安全彻底地清创。采用单侧或双侧臀肌 V-Y 筋膜皮瓣推进术，用血运丰富的组织完全填充腔隙。
3 例患者均为男性，年龄分别为 80 岁、66 岁和 51 岁，最初均接受新辅助放化疗的低位前切除术治疗直肠癌。第一位患者在指数手术后 128 个月时接受了吻合口的经括约肌间切除术和网膜成形术，2 个月后接受了第二次挽救性手术。第二位患者在指数手术后 100 个月时因局部复发性直肠癌行腹会阴联合切除术和网膜成形术，行膀胱前列腺切除术并修改网膜成形术治疗盆腔感染，16 个月后接受了第二次挽救性手术。第三位患者在指数手术后 20 个月时拆除吻合口，随后行经括约肌间直肠切除术和网膜成形术，93 个月后接受了第二次挽救性手术。这 3 例患者均因症状性复发性盆腔感染而进行第二次挽救性手术。第二次挽救性手术包括骶骨切除术、直肠前区彻底清创以及臀肌推进皮瓣填充，术后恢复良好，最终盆腔愈合。
对于经过多次经腹干预治疗慢性直肠前窦后出现复发性盆腔感染的高度选择患者，采用定制式骶骨切除术和臀肌 V-Y 推进皮瓣的背侧入路是一种有价值的选择。
