ZORLAYICI PERİNE DEFEKTLERİNDE ONARIM SEÇENEKLERİ

Öz

Amaç: İleri evre kolorektal veya jinekolojik kanserlerin cerrahi tedavisinde abdominoperineal rezeksiyon ve pelvik ekzenterasyon ameliyatları büyük perineal defektlere ve ciddi cerrahi alan morbiditesine neden olabilir. Radyasyon ve onkolojik cerrahiye bağlı yara iyileşme problemlerini engellemek için çeşitli bölgesel flepler yara kapatılmasında kullanılabilir. Gereç ve Yöntem: Mayıs 2021 ile Ağustos 2023 arasında gerçekleştirilen pelvik rekonstrüksiyon vakaları geriye dönük olarak altı aylık takip süresi ile incelendi. Toplamda 10 hasta çalışmaya dahil edildi. Bu hastalara karın temelli flepler (n=4) ve uyluk temelli flepler (n=6) kullanılarak perineal defekt rekonstrüksiyonu gerçekleştirildi. Bu iki hasta grubu hastaların demografik özellikleri, etiyoloji, tercih edilen tedavi yöntemi ve ameliyat sonrası gelişen komplikasyonlar açısından karşılaştırıldı. Bulgular: Beş kadın ve beş erkeğe kapsamlı pelvik rekonstrüksiyon uygulandı; yaş ortalaması 49,6 (26-76 aralığı) ve ortalama vücut kitle indeksi (VKI) 28,6 kg/m2 (21,3-50 aralığı) idi. Beş hastaya daha önce radyoterapi uygulanmıştı. Perine defektinin tipine göre toplam 11 flep uygulandı. Bir hastada yara yerinde küçük bir ayrılma (<5 cm) oldu. İki hastada yara yerinde büyük açılma oldu (>5 cm) ve yeniden ameliyat edilmeleri gerekti. Crohn hastalığı olan hastada spontan fistül oluşumu sonucu karın içi abse gelişti. Fleplerde kısmi veya tam kayıp izlenmedi. Sonuç: Onarım seçenekleri defektin boyutuna ve rezeksiyonun derecesine bağlı olarak değişmektedir. Rekonstrüksiyonda öncelikli amaç pelvik ölü boşluğu ortadan kaldırmak ile karın içi içeriğin perineden ayrılmasını sağlamak, ince bağırsakların fıtıklaşmasını önlemek ve komplikasyonsuz yara iyileşmesini sağlamaktır.

Anahtar Kelimeler

• Abdominoperineal rezeksiyon
• flep
• pelvik ekzenterasyon
• perineal rekonstrüksiyon
• radyoterapi

RECONSTRUCTION OPTIONS FOR CHALLENGING PERINEAL DEFECTS

Öz

Objective: Abdominoperineal resection and pelvic exenteration for the surgical treatment of advanced colorectal or gynaecological cancers can result in large perineal defects and severe surgical site morbidity. Several regional flaps can be used to treat radiation- and extirpative surgery-related wound breakdowns. This study aims to retrospectively evaluate the efficiency of different flaps used in the reconstruction of perineal defects. Material and Method: A retrospective review of pelvic reconstructions performed between May 2021 and August 2023 was conducted, with a 6-month follow-up. Ten patients who underwent abdominoperineal resection with immediate abdominal-based flap (n=4) or thigh-based flap (n=6) reconstruction of the perineal/pelvic defect were evaluated. The two groups were compared in terms of patient characteristics, aetiology, preferred treatment, and postoperative complications. Result: Five women and five men underwent comprehensive pelvic reconstruction. The mean age was 49.6 years (range 26–76) and mean BMI of 28.6 kg/m2 (range 21.3–50). Five patients had previously undergone radiotherapy. In total, 11 flaps were created based on the type of perineal defect. One patient experienced a minor dehiscence (<5 cm). Two patients experienced major dehiscence (>5 cm), and required reoperation. A patient with Crohn’s disease developed one intra-abdominal abscess because of spontaneous fistula formation. There was no vascular compromise in the flaps. Conclusion: Repair options vary depending on the nature of the defect and extent of resection. The primary goals of reconstruction are to eliminate pelvic dead space and separate the intra-abdominal content from the perineum to prevent herniation and strangulation of the small intestines and to ensure that the perineal wound heals without complications.

Anahtar Kelimeler

• Abdominoperineal resection
• flap
• pelvic exenteration
• perineal reconstruction
• radiotherapy

Kaynakça

1. Mericli AF, Martin JP, Campbell CA. An algorithmic anatomical subunit approach to pelvic wound reconstruction. Plast Reconstr Surg 2016;137(3):1004-17. [CrossRef] google scholar
2. Bialowas C, Nguyen B, Patel A. Best solutions for perineal and pressure sore reconstruction. Plast Reconstr Surg 2021;148(6):1026e-39e. [CrossRef] google scholar
3. Westbom CM, Talbot SG. An algorithmic approach to perineal reconstruction. Plast Reconstr Surg Glob Open 2019;7(12):e2572. [CrossRef] google scholar
4. Witte DYS, von Ramshorst GH, Lapid O, Bouman MB, Tuynman JB. Flap reconstruction of perineal defects after pelvic exenteration: A systematic description of four choices of surgical reconstruction methods. Plast Reconstr Surg 2021;147(6):1420-35. [CrossRef] google scholar
5. Kosutic, D. Classification of Perineal Defects. Kosutic D., editors. Perineal reconstruction. Switzerland: Springer; 2023. p.59-63. [CrossRef] google scholar
6. Baumann DP, Butler CE. Component separation improves outcomes in VRAM flap donor sites with excessive fascial tension. Plast Reconstr Surg 2010;126(5):1573-80. [CrossRef] google scholar
7. Hawkins AT, Albutt K, Wise PE, Alavi K, Sudan R, Kaiser AM, et al. Abdominoperineal resec-tion for rectal cancer in the twenty-first century: Indications, techniques, and outcomes. J Gastroin-test Surg 2018;22(8):1477-87. [CrossRef] google scholar
8. Kennelly RP, Heeney A, White A, Fennely D, Sheahan K, Hyland JMP, et al. A prospective analysis of patient outcome following treatment of T3 rectal cancer with neoadjuvant chemoradiotherapy and transanal excision. Int J Colorectal Dis 2012;27(6):759-64. [CrossRef] google scholar

9. Folkesson J, Birgisson H, Pahlman L, Cedermark B, Glimelius B, Gunnarsson U. Swedish rectal cancer trial: Long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol 2005;23(24):5644-50. [CrossRef] google scholar
10. Tilney HS, Rasheed S, Northover JM, Tekkis PP. The influence of circumferential resection margins on longterm outcomes following rectal cancer surgery. Dis Colon Rectum 2009;52(10):1723-9. [CrossRef] google scholar
11. Lin Y, Lin H, Xu Z, Zhou S, Chi P. Comparative outcomes of preoperative chemoradiotherapy and selective postoperative chemoradiotherapy in clinical Stage T3N0 low and mid rectal cancer. J Invest Surg 2019;32(7):679-87. [CrossRef] google scholar
12. Brady MS, Kavolius JP, Quan SH. Anorectal melanoma. A 64-year experience at Memorial Sloan-Kettering Cancer Center. Dis Colon Rectum 1995;38(2):146-51. [CrossRef] google scholar
13. Salgado CJ, Chim H, Skowronski PP, Oeltjen J, Rodriguez M, Mardini S. Reconstruction of acquired defects of the vagina and perineum. Semin Plast Surg 2011;25(2):155-62. [CrossRef] google scholar
14. Hui K, Zhang F, Pickus E, Rodriguez LF, Teng N, Lineaweaver WC. Modification of the vertical rectus abdominis musculocutaneous (VRAM) flap for functional reconstruction of complex vulvoperineal defects. Ann Plast Surg 2003;51(6):556-60. [CrossRef] google scholar
15. Zeng A, Qiao Q, Zhao R, Song K, Long X. Anterolateral thigh flap-based reconstruction for oncologic vulvar defects. Plast Reconstr Surg 2011;127(5):1939-45. [CrossRef] google scholar
16. Gravvanis AI, Tsoutsos DA, Karakitsos D, Panayotou P, Iconomou T, Zografos G, et al. Application of the pedicled anterolateral thigh flap to defects from the pelvis to the knee. Microsurgery 2006;26(6):432-8. [CrossRef] google scholar
17. Koulaxouzidis G, Penna V, Bannasch H, Neeff HP, Manegold P, Aigner F, et al. The ad-ipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal de-fects. Int J Colorectal Dis 2019;34(3):501-11. [CrossRef] google scholar
18. Soper JT, Rodriguez G, Berchuck A, Clarke-Pearson DL. Long and short gracilis myocutaneous flaps for vulvovaginal reconstruction after radical pelvic surgery: Comparison of flap-specific complications. Gynecol Oncol 1995;56(2):271-5. [CrossRef] google scholar
19. Houdek MT, Bakri K, Tibbo ME, Wagner ER, Rose PS, Sim FH, et al. Outcome and complications following vertical rectus abdominis myocutaneous flap surgery to reconstruct sacrectomy defects. Plast Reconstr Surg 2018;142(5):1327-35. [CrossRef] google scholar
20. Chang DW, Wang B, Robb GL, Reece GP, Miller MJ, Evans GR, et al. Effect of obesity on flap and donorsite complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg 2000;105(5):1640-8. [CrossRef] google scholar
21. Campbell CA, Butler CE. Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects. Plast Reconstr Surg 2011;128(2):447-58. [CrossRef] google scholar
22. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg 2009;123(1):175-83. [CrossRef] google scholar
23. Largo RD, Chu CK, Chang E, Liu J, Abu-Ghname A, Wang H, et al. Perforator mapping of the profunda artery perforator flap: Anatomy and clinical experience. Plast Reconstr Surg 2020;146(5):1135-45. [CrossRef] google scholar