Plastic Surgery Research Council
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PSRC 60th Annual Meeting
Program and Abstracts

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Surgical Site Complications Following Primary Versus Flap Closure of Pelvic Defects Following Abdominoperineal Resection (APR) or Pelvic Exenteration (PE): A Systematic Review and Meta Analysis
Chris Devulapalli, M.D, Anne Tong, MBBS, Jen DiBiagio, B.S, Marcelo L. Baez, M.D, Pablo Baltodano Fallas, M.D, Stella Seal, MLS, Carisa M. Cooney, MPH, Justin M. Sacks, M.D, Gedge Rosson, M.D.
Johns Hopkins University, Baltimore, MD, USA.

Purpose: Abdominoperineal resection (APR) and pelvic exenteration (PE) for resection of malignancies can lead to large pelvic defects. Resulting perineal wound complications pose significant morbidity for patients following these operations, particularly ones with previously irradiated fields. Myocutaneous flaps have been proposed in place of primary closure of large perineal defects to improve local wound healing. We have conducted a systematic review and meta-analysis to compare primary closure to myocutaneous flap reconstruction of perineal defects following APR or PE in regards to surgical site complications.
Methods: A literature search for human cohort studies comparing surgical outcomes of myocutaneous flaps with primary closure for pelvic reconstruction after APR or PE was performed using Medline, EMBASE, Google Scholar and Cochrane databases from January 2011 to June 2014. Patient demographics, comorbidites, oncologic information, length of stay, and surgical outcome data were extracted from included studies. Meta-analysis was performed to investigate differences between primary closure and mycutaneous flap closure within the following surgical outcomes: total perineal complications, major perineal complications, minor perineal complications, abdominal wall complications.
Results: Following a 3-reviewer independent screening process, 10 eligible studies (1 randomized-controlled trial, 9 retrospective studies) involving 479 patients (186 flaps, 293 primary closures) met inclusion criteria. Eight studies described rectus abdominus myocutanous (RAM) flaps, 2 studies used gracillis flaps, and one study reported on a mixed cohort of both. Pooled odds ratio forest plots of assessed surgical site occurrences were created from meta-analysis. Total perineal complications were twice as likely to occur with primary closure compared to myocutaneous flap closure (OR= 2.05; p=0.001). Major perineal complications approached statistical significance, being more than twice as likely to occur with primary closure compared to flap closure (OR=2.22; p=0.05). There were no statistical differences between primary and flap closure in regards to minor perineal complications, abdominal wall complications, length of stay, or reoperation rate.
Conclusion: Myocutaneous flap closure of pelvic defects following APR or PE for oncologic resection can be useful in decreasing the number of perineal complications, particularly major infectious complications, compared to primary closure. In spite of the increased muscular and fascial disruption posed by harvesting RAM flaps, there were no statistical differences in abdominal wall complications between the 2 groups. Large prospective studies with matched cohorts would be beneficial to further investigate these operations with high morbidity rates.


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