Perineal repair after extralevator abdominoperineal excision for low rectal cancer.

Christensen, Henrik Kidmose; Nerstrøm, Peter; Tei, Troels; Laurberg, Søren

BACKGROUND Extralevator abdominoperineal excision for low rectal cancer includes resection of the pelvic floor as a part of the operative technique to reduce the risk of tumor-involved section margins. OBJECTIVE This study aimed to compare perineal defect reconstruction with a fasciocutaneous gluteal flap vs biological mesh regarding healing and occurrence of perineal hernia. DESIGN Retrospective review of medical records comparing surgical methods during 2 consecutive periods. SETTINGS Tertiary care university medical center (Colorectal Section, Surgical Department P, Aarhus University Hospital, Denmark). PATIENTS Patients with low rectal cancer who underwent extralevator abdominoperineal excision from December 2005 through October 2008 were included. INTERVENTION The perineum was reconstructed with a fasciocutaneous gluteal flap in the first period and with a biological mesh in the second period. MAIN OUTCOME MEASURES We assessed rates of perineal wound infection requiring surgical intervention and perineal hernia diagnosed by clinical examination. RESULTS The study comprised 57 patients: 33 patients with gluteal flap and 24 with biological mesh reconstruction. Perineal hernia developed in 7 (21%) patients in the gluteal flap group and in none (0%) of the patients in the mesh group (P < .01). Median follow-up was 3.2 (1.7-4.3) years for gluteal flap and 1.7 (0.4-2.2) years for biologic mesh. All hernias occurred within the first postoperative year (median, 6 months; range, 1-12 months). Infectious complications were seen in 2 patients (6%) with a gluteal flap and in 4 patients (17%) with mesh repair (P = .26). After 3 months, all patients were completely healed except for 1 patient in each group with a persistent perineal sinus. The median (range) hospital stay was 14 (8-23) days in the flap group and 9 days (6-35) in the mesh group (P < .05). LIMITATIONS This was a nonrandomized retrospective observational study comparing 2 methods used in different time periods. CONCLUSION We recommend biological mesh reconstruction of the pelvic floor after extralevator abdominoperineal resection because this method can achieve a high healing rate with an acceptable risk of infection, a low hernia rate, and a shorter hospital stay without donor-site morbidity.