eP217 - Perineal Wound Closure Following Radical Pelvic Surgery: Assessment of Morbidity Following Primary Closure and Various Types of Tissue Flap Reconstruction

Sunday, June 2, 2024

9:24 AM – 9:29 AM ET, USA

Location: Baltimore Convention Center, Room 318-320

ePoster Presenter(s)

Aron P. Bercz, MD (he/him/his)

Research Resident
Memorial Sloan Kettering Cancer Center
Memorial Sloan Kettering Cancer Center
New York, NY, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Author(s)

Janet Alvarez, MD (she/her/hers)

Research Scholar
Memorial Sloan-Kettering Cancer Center
New York, NY, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.
Roni Rosen, MD

Research Fellow
Memorial Sloan Kettering Cancer Center
Memorial Sloan Kettering Cancer Center
New York, NY, United States

All relevant financial disclosures have been managed and will be listed below.
This individual has no financial relationships with ineligible companies.
MD

Matthew Drescher, BA

Medical Student
Virginia Tech Carillon School of Medicine
Roanoke, Virginia, United States

Disclosure information not submitted.
HS

Hiroyuki Sonoda, n/a

Research Intern
Memorial Sloan Kettering Cancer Center
New York, New York, United States

Disclosure information not submitted.
IW

Iris Wei, MD

Surgeon
Memorial Sloan Kettering Cancer Center
New York City, New York, United States

Disclosure information not submitted.
Georgios Karagkounis, MD

Assistant Attending
Memorial Sloan Kettering Cancer Center
New York, New York, United States

Disclosure information not submitted.
Maria Widmar, MD, MPH, FACS (she/her/hers)

Assistant Attending
Memorial Sloan Kettering Cancer Center
Weill Cornell Medical Center
New York, New York, United States

All relevant financial disclosures have been managed and will be listed below.
This individual has no financial relationships with ineligible companies.
Garrett M. Nash, MD, MPH

Vice Chair, Department of Surgery
Memorial Sloan Kettering
New York, New York, United States

Disclosure information not submitted.
Martin Weiser, MD

Attending Surgeon and Professor
Memorial Sloan Kettering Cancer Center
Cornell Medical College
New York, New York, United States

All relevant financial disclosures have been managed and will be listed below.
This individual has no financial relationships with ineligible companies.
Philip B. Paty, FASCRS, FACS

Attending Surgeon, Colorectal Surgery Service
Memorial Sloan Kettering Cancer Center
New York, New York, United States

Disclosure information not submitted.
EM

Evan Matros, MD

attending
sloan kettering
new york, New York, United States

Disclosure information not submitted.
Julio Garcia-Aguilar, MD, PhD (he/him/his)

Chief Attending
Memorial Sloan Kettering Cancer Center
Memorial Sloan Kettering Cancer Center
New York, New York, United States

Disclosure information not submitted.
J. Joshua Smith, MD, PhD

Associate Attending
Memorial Sloan Kettering Cancer Center
MSKCC, Weill Cornell Medical College
New York, New York, United States

Disclosure information not submitted.

Senior Author(s)

Emmanouil Pappou, MD, PhD

Assistant Attending
Memorial Sloan Kettering Cancer Center
new York, New York, United States

All relevant financial disclosures have been managed and will be listed below.
This individual has no financial relationships with ineligible companies.

Purpose/Background: Wound healing complications following radical resection of pelvic malignancies remain an ongoing challenge. Fasciocutaneous and myocutaneous tissue flaps are increasingly utilized to close sizeable perineal defects but may be associated with additional risks compared to primary perineal closure. This study evaluates the surgical outcomes of perineal reconstruction options following radical pelvic operations.Methods/Interventions: A retrospective review was conducted at a comprehensive cancer center examining 414 patients who underwent either salvage abdominoperineal resection (APR, n=337, 81%) or pelvic exenteration (PE, n=77, 19%) for rectal cancer (n=363, 88%) or anal cancer (n=51, 12%) from January 2012 to December 2020. We identified 150 patients who underwent tissue flap (TF) based perineal reconstruction: 101 vertical rectus abdominis (VRAM), 37 gluteal, and 12 gracilis flaps. We noted 264 who underwent primary closure (PC) of the perineal wound (81 with omental flaps, 183 without). 387 (93%) patients received prior pelvic radiotherapy. Clinicopathologic data and frequency of complications within 90 days of surgery were collected. Statistical analysis was performed using two-sided Fisher’s exact and Wilcoxon’s tests for comparison of percentages and means, respectively.Results/Outcomes: In the setting of primary rectal cancer, there was an association with utilization of PC (n=285, 76% vs 24%, p < 0.001). Conversely, TF was correlated with use in the setting of anal cancer requiring salvage surgery (n=45, 71% vs 29%, p < 0.001) and recurrent rectal cancer (n=67, 57% vs 43%, p < 0.001). Additionally, TF was correlated with MRI staged T4 tumors (34% vs 14%, p < 0.001) and was associated with greater need for extralevator resection (68% vs 47%, p < 0.001), sacrectomy (18% vs 6%, p < 0.001), and intraoperative radiation (23% vs 7%, p < 0.001). Vaginal reconstruction was performed in 31 (31%) of the total VRAM cases. Postoperatively, TF patients had associated longer lengths of stay (LOS, mean 11.8 vs 7.6 days, p < 0.001) and were subject to more readmissions (39% vs 18%, p < 0.001), invasive re-interventions (29% vs 17%, p=0.0086), bleeding requiring transfusion (34% vs 10%, p < 0.001), wound infections (25% vs 14%, p=0.0092), and wound dehiscences (26% vs 11%, p < 0.001) compared to PC. Two TF patients (1%) experienced 90-day mortality events, compared to none with PC. Subgroup analysis demonstrated that TF was associated with increased rates of bleeding and dehiscence events in the setting of non-extralevator and extralevator APR, but no differences in overall complications were observed in the setting of PE (Table 1). Comparing different TF subtypes, increased rates of bleeding events were associated with VRAM flaps (41%, p=0.028), but no difference in wound infection, wound dehiscence, flap necrosis, readmission, or re-intervention rates were noted (Table 2, Figure 1). For patients who underwent PC with or without omental flap, there was no associated difference in LOS, overall complications, readmissions, or re-interventions.Conclusion/

Discussion: Perineal reconstruction following complex pelvic surgery is patient-specific, with consideration for the pathology, defect size, and donor site availability. Patients who require TF are inherently more complex, underscoring the reason for TF selection. For extensive resections, TF achieves the necessary reconstruction aims without associated difference in morbidity. However, PC has favorable outcomes in lower complexity cases and should be considered when feasible."Table 1

Subgroup analysis of TF vs PC in setting of non-extralevator APR, extralevator APR, and pelvic exenteration.
Table 2

90-day complications by tissue flap type.
Figure 1

90-day complications by method of perineal closure."