eP281 - Pelvic/Perineal Repair After APR with Rectus Abdominis Myocutaneous Flap (VRAM) for Extensive Perineal Involvement Due to and Multiple Fistulous Tracts

Purpose/Background: Describe and show an option for reconstruction of the perineal wound affected by multiple fistulous tractsMethods/Interventions: We will present a case of perineal wound closure using the Vertical Rectus Abdominis Myocutaneous Flap (VRAM) in a patient with extensive perineal involvement due to multiple fistulous tracts and squamous cell carcinoma (SCC) of the anal canal who had an incomplete response to standard chemoradiation therapy and control of pain.Results/Outcomes: HSH HIV-positive for 20 years receiving antiretroviral therapy with regular follow-up by the Infectious Disease Service. In May 2021, the patient was referred to the Colon and Rectal Surgery Department at Ipanema Hospital, Rio de Janeiro, due to a gluteal abscess. During the initial examination, two fistulous openings, significant edema, and purulent drainage were identified. At that time, surgical intervention with drainage, placement of Seton and intravenous antibiotic therapy were indicated.
Over a period of 2 years, multiple biopsies yielded inconclusive results and tuberculosis tests were negative. As an outpatient follow-up, the patient experienced recurrent complex perianal fistulas, raising suspicion of SCC of the anal canal. In 2023, after a new surgical procedure for perianal abscess drainage and biopsy, the diagnosis of SCC of the anal canal was confirmed. Subsequently, the patient was referred for standard chemoradiation therapy.
The patient returned complaining severe pain with a daily requirement for high doses of opioid medication. On examination, a significant tissue retraction was noted, attributed to multiple surgical interventions for abscess drainage, fistulotomies, and biopsies. Pelvic magnetic resonance imaging (MRI) revealed multiple complex fistulous tracts, irregularity in the distal third of the anal canal with a vegetative appearance and intermediate signal, suggestive of residual disease.
The patient underwent APR with VRAM perineal wound closure in April 2023 in a joint approach with the Plastic Surgery Department. The postoperative course was favorable and the patient was discharged on the twelfth post-operative day, good pain control with non opioid analgesic and a well-healing wound with a small dehiscence point.
The histopathological examination of the surgical specimen identified a 0.3 cm area of SCC with a 0.1 cm infiltration depth, with clear surgical margins and no lymph node involvement (pT1, pN0). The patient continues to receive multidisciplinary outpatient care, with a significant improvement in their quality of life, adaptation to the colostomy, complete healing of the operative wounds, and sporadic use of analgesics.Conclusion/

Discussion: It’s not uncommon for a surgeon to come across a situation where an extensive perineal/pelvic involvement will result in a large wound that can lead to severe disability for the patient.In this scenario, the VRAM myocutaneous flap proved to be an excellent option for wound closure, resulting in good aesthetic outcomes and pain control for the patient.