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Abdominal versus Thigh Based Reconstruction of Perineal Defects in Cancer Patients
Jens Berli, Dr.
Johns Hopkins Hospital, Baltimore, MD, USA.
Introduction: An abdominoperineal resection (APR) is a highly invasive procedure that leaves the patient with pelvic dead space and a large perineal defect. Traditionally the pedicled vertical rectus abdominus myocutaneous flap (VRAM) is used to reconstruct the perineal defect to improve functional outcomes and reduce complications. Oftentimes, the VRAM cannot be utilized due to previous abdominal surgery or need for multiple ostomy placement. Using the VRAM in this setting would create significant morbidity to the abdominal wall. The pedicled anterolateral thigh flap (ALT) is a described alternative to the VRAM and allows the perineum to be reconstructed sparing the abdominal wall. In the current study, we report complex perineal reconstruction in cancer patients using either the VRAM or the ALT flap when clinically appropriate.
Methods: A retrospective chart review (2010-2012) of prospectively entered data was conducted to identify all VRAM and ALT flaps that were utilized for perineal reconstruction following APR. Complications were defined as: partial and complete flap failure, seroma, dehiscence, infection, abdominal or perineal herniation, necrosis, and bleeding. Patient demographics such as gender, race, prior surgery, tumor stage, body mass index (BMI), smoking status, alcohol consumption, medical comorbidities, chemoradiation status, oncologic margin status, need for re-operation, readmissions, time to initiation of chemotherapy, and time to complete healing were also recorded. A two-sided Fisher’s exact test was used for categorical variables and a student’s T-test for continuous variables.
Results: We identified 19 patients of which 10 underwent an ALT and 9 underwent a VRAM. There were no significant differences in gender, age, BMI, race, or co-morbidities between patients receiving ALT or VRAM reconstruction (p>0.05). Surgical outcomes and complications of ALT versus VRAM demonstrated no significant differences in the rate of infection, hematoma, bleeding, or necrosis. No flap failures, either full or partial, occurred in any of the groups. The mean length of stay after reconstruction was 9.7 ± 3.4 days in the ALT group and 13.4 ± 7.7 days in the VRAM group (p>0.05).
Conclusion: Perineal reconstruction with the pedicled ALT or VRAM flaps can be performed safely, with acceptable complication rates in the presence of contamination, compromised soft-tissue vascularity, and radiotherapy. Our results from a single surgeon suggest that the ALT is an acceptable alternative to the VRAM for the reconstruction of perineal defects when there are concerns of using the abdominal wall as a soft-tissue flap harvest site. The ALT flap for perineal reconstruction allows the armamentarium of the reconstructive surgeon to expand and offer patients robust vascularized tissue for restoration of form and function.
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