Floor plan - 2013 Annual Meeting - American Association for Hand ...

Outcomes of Immediate VRAM Flap Reconstruction versus Primary Closure in Patients
Undergoing Chemoradiation and Abdominoperineal Resection for Anorectal Cancer
Institution where the work was prepared: The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
Charles E. Butler, MD; Õzlem Gûndeslioglu, MD; Miguel A. Rodriguez-Bigas, MD; The University of Texas M.D.
Anderson Cancer Center
BACKGROUND & PURPOSE:
Perineal wound complications occur in up to 60% of patients who undergo chemoradiotherapy and abdominoperineal resection (APR)
for anorectal cancer. The most common and problematic wound complications are perineal abscess and wound dehiscence owing to
the poor vascularity of surrounding tissues, a large, non-collapsible pelvic dead space, and bacterial contamination. Vertical rectus
abdominis myocutaneous (VRAM) flaps, transferred from the abdomen to the perineum, have been used in an attempt to minimize
these complications by obliterating the dead space and closing the perineal skin defect with non-irradiated, vascularized tissue. The
purpose of this study was to compare the surgical outcomes of anorectal cancer patients who underwent chemoradiotherapy and APR
with immediate VRAM flap reconstruction or primary closure.
METHODS:
We retrospectively reviewed the records of all patients who underwent chemoradiotherapy and APR for anorectal cancer from 1993 to 2005
at a major cancer center. Patient, tumor, and treatment characteristics and surgical outcomes in patients who underwent VRAM flap reconstruction
(flap group, n = 35) were compared with those in patients who had primary closure (control group, n = 76) of the perineal wound.
RESULTS:
There were no differences in radiation dose, patient age, medical comorbidities, body mass index, or tumor stage between the groups.
Overall, there was no significant difference in the incidence of perineal wound complications between the groups; however, severe complications
were less frequent in the flap group. The flap group had a significantly lower incidence of perineal abscess (9% vs. 37%, p =
0.002), major wound dehiscence (3% vs. 30%, p = 0.014), and need for drainage procedures for perineal/pelvic fluid collections (3% vs.
25%, p = 0.003) than the control group. Despite flap harvest and donor site closure in the flap group, there was no difference in the incidence
of abdominal wall complications between the groups during the study's mean patient follow-up of 3.8 years.
CONCLUSIONS:
VRAM flap reconstruction of irradiated APR tissue defects reduces the incidence of severe perineal wound complications without
increasing the incidence of postoperative abdominal wall complications. Strong consideration should be given to immediate VRAM
flap reconstruction following chemoradiotherapy and APR for anorectal cancer. Prospective studies may help identify preoperative
and/or intraoperative factors that affect the risk of perineal complications and thus identify patients who would benefit the most from
VRAM flap reconstruction.
Comparison of Surgical Outcomes Using VRAM Flaps vs. Thigh-based Flaps for
Reconstruction of Abdominoperineal Resection and Pelvic Exenteration Defects
Institution where the work was prepared: The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
Rebecca A. Nelson, MD; Charles E. Butler, MD; The University of Texas M.D. Anderson Cancer Center
BACKGROUND & PURPOSE:
Pelvic/perineal defects following abdominoperineal resection (APR) and pelvic exenteration (PE) are commonly repaired with regional
flaps from the thigh or abdomen. Previous studies have described the use of these flaps but have not compared outcomes between
flaps from the two donor sites. This study compared the surgical outcomes with vertical rectus abdominis musculocutaneous (VRAM)
flaps and thigh-based flaps used for immediate reconstruction of APR and PE defects.
METHODS:
The study included all consecutive patients with a primary colorectal or urogynecologic malignancy who underwent APR or PE and
immediate reconstruction with a VRAM or thigh-based (gracilis, anterolateral thigh, or posterior thigh) flap at a major cancer center from
1993 to 2007. Data were obtained from a prospectively maintained database, and surgical outcomes were retrospectively compared
between patients in the VRAM and thigh flap groups. Patient, tumor, and treatment characteristics were entered into a stepwise logistic
regression model to identify predictors of donor and recipient site complications.
RESULTS:
A total of 133 patients (114 VRAM, 19 thigh) were included. The mean follow-up was 23 months. There were no significant differences
in patient demographics, tumor pathology or stage, adjuvant therapy, or co-morbid conditions between the groups. Patients in the
thigh group had a significantly greater incidence of superficial donor site infection (26% vs. 6% in the VRAM group) and recipient site
complications (cellulitis, 21% vs. 4%; pelvic abscess formation, 32% vs. 6%; and major wound dehiscence, 21% vs. 5%). There were no
differences in abdominal wall complications (including dehiscence, incisional or parastomal hernia, seroma, and infection), despite flap
harvest from the abdominal wall in the VRAM group. Patients in the thigh group had a significantly greater incidence of prolonged (>2
weeks) donor site wound healing (37% vs. 16% in the VRAM group), had a longer mean hospital stay (20 days vs. 12.4 days), and required
more time for healing of donor and recipient site wounds (79% and 61% longer, respectively). Obesity (body mass index ? 30) was an
independent predictor of major donor site complications (odds ratio (OR), 3.3), and previous abdominal surgery (OR, 3.5) and tobacco
use (OR, 1.7) were predictors of major recipient site complications.
CONCLUSIONS:
Reconstruction of APR and PE defects with VRAM flaps results in fewer donor and recipient site complications than reconstruction
using thigh-based flaps, without increased abdominal wall morbidity. If available, abdominal flaps should be considered the primary
flap choice to repair these defects.
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