Reconstruction of the Irradiated Extended Abdominoperineal Excision (APE) Defect for Locally Advanced Colorectal Cancer
Tóm tắt
There is substantial evidence for neoadjuvant chemoradiotherapy and extended abdominoperineal excision (APE) for improving local recurrence rates and overall survival for rectal carcinoma. While oncologic outcomes are improved, the large irradiated defect in the pelvic floor can potentiate poor operative outcomes. We describe a reconstructive option, the inferior gluteal artery myocutaneous (IGAM) transposition flap, which can enable wide tumour resections by providing substantial non-irradiated tissue bulk. Ten consecutive patients underwent either standard APE with direct primary closure or extended APE with IGAM transposition flap reconstruction between 2007 and 2009 for mStage I–IIIC disease. Patients underwent staging computed tomography and pelvic magnetic resonance imaging, and neoadjuvant chemoradiotherapy after multi-disciplinary team discussion. Eight patients underwent extended APE and IGAM transposition flap reconstruction due to locally advanced stage of their carcinoma. Oncologic, reconstructive and post-operative outcomes were assessed. All cases demonstrated good closure of the APE defect, with no intra-operative perforations and no immediate operative complications. Histological margins were clear (R0) in all specimens, with mean closest distance to margin 10.8 mm (range 4–20 mm). Mean follow-up was 11.3 months, with no locoregional recurrences. There was no donor site morbidity and no perineal hernia; patients reported high degrees of satisfaction with aesthetic outcome. As the extended APE becomes increasingly utilized for rectal carcinoma, a reliable reconstructive option is increasingly important. The IGAM island transposition flap imports well-vascularized, non-irradiated tissue to reconstruct the defect, provides tissue bulk and potentiates good oncologic and reconstructive outcomes.
Tài liệu tham khảo
Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23(36):9257–64.
Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Soreide O. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum. 2004;47(1):48–58.
Miles W. A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet. 1908;2:1812–3.
Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg. 2007;94(2):232–8.
West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol. 2008;26(21):3517–22.
Boccola MA, Rozen WM, Ek EW, Teh BM, Croxford M, Grinsell D. Inferior gluteal artery myocutaneous island transposition flap reconstruction of irradiated perineal defects. J Plast Reconstr Aesthet Surg. 2009;63:1169–75.
Frykholm GJ, Glimelius B, Pahlman L. Preoperative or postoperative irradiation in adenocarcinoma of the rectum: final treatment results of a randomized trial and an evaluation of late secondary effects. Dis Colon Rectum. 1993;36(6):564–72.
Anonymous. Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Engl J Med. 1997;336(14):980–7.
Camma C, Giunta M, Fiorica F, Pagliaro L, Craxi A, Cottone M. Preoperative radiotherapy for resectable rectal cancer: a meta-analysis. JAMA. 2000;284(8):1008–15.
Bosset JF, Calais G, Mineur L, Maingon P, Radosevic-Jelic L, Daban A, et al. Enhanced tumorocidal effect of chemotherapy with preoperative radiotherapy for rectal cancer: preliminary results—EORTC 22921. J Clin Oncol. 2005;23(24):5620–7.
Gerard JP, Conroy T, Bonnetain F, Bouche O, Chapet O, Closon-Dejardin MT, et al. Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: results of FFCD 9203. J Clin Oncol. 2006;24(28):4620–5.
Bujko K, Nowacki MP, Nasierowska-Guttmejer A, Michalski W, Bebenek M, Pudelko M, et al. Sphincter preservation following preoperative radiotherapy for rectal cancer: report of a randomised trial comparing short-term radiotherapy vs. conventionally fractionated radiochemotherapy. Radiother Oncol. 2004;72(1):15–24.
den Dulk M, Marijnen CA, Putter H, Rutten HJ, Beets GL, Wiggers T, et al. Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial. Ann Surg. 2007;246(1):83–90.
Glynne-Jones R, Mawdsley S, Pearce T, Buyse M. Alternative clinical end points in rectal cancer—are we getting closer? Ann Oncol. 2006;17(8):1239–48.
Salerno G, Chandler I, Wotherspoon A, Thomas K, Moran B, Brown G. Sites of surgical wasting in the abdominoperineal specimen. Br J Surg. 2008;95(9):1147–54.
Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg. 2005;242(1):74–82.
Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg. 2008;206(4):694–703.
Tei T, Stolzenburg T, Buntzen S, Laurberg S, Kjeldsen H. Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery. Br J Surg. 2003;90:575–80.
Shibata D, Hyland W, Busse P, Kim HK, Sentovich SM, Steele Jr G, et al. Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol. 1999;6(1):33–7.
Fajardo LF, Berthrong M. Radiation injury in surgical pathology. Part I. Am J Surg Pathol. 1978;2(2):159–99.
Baird WL, Hester TR, Nahai F, Bostwick 3rd J. Management of perineal wounds following abdominoperineal resection with inferior gluteal flaps. Arch Surg. 1990;125(11):1486–9.