Reconstruction Following Abdominoperineal Resection (APR): Indications and Complications from a Single Institution Experience

Abstract/Summary Background Abdominoperineal resection (APR) is the surgical treatment of low-lying rectal cancers and other pelvic malignancies. Plastic surgery offers a means to close these complicated defects through obliterating dead space, providing tension free closure, and introducing vascularized tissue into a radiated field. The indications for reconstructive surgery and choice of reconstruction are debatable. This study aims to identify when and which reconstruction is preferred. Methods A retrospective comparative analysis was performed on all patients undergoing APR at Stanford Hospital between 2007-2013. Data points included demographics, disease, operative positioning, and postoperative complications. Univariate analysis and multivariate logistic regression analysis were performed to identify markers of flap reconstruction and complications. Results 178 APRs were performed; 51 underwent flap reconstruction. The odds ratio (OR) of all complications between flap and primary closure was not significant, 1.36 (0.69 – 2.66). Independent predictors for flap reconstruction included prone positioning, anal squamous cell carcinoma, prior smoking, and neoadjuvant chemoradiation therapy. Univariate predictors of flap reconstruction included female gender and combined vaginectomy. Independent predictors of complications included current and prior smoking. Muscle flap closure was associated with lower recipient site complications compared to V-to-Y advancement closure (20% vs 50%, p=0.039). Conclusion Flap reconstruction following APR is associated with prone positioning, neoadjuvant chemoradiation, women, prior smoking and anal SCC resections. Pedicled muscle flaps had a significantly lower rate of recipient site complications compared to V-to-Y advancement flaps and should be the flap reconstruction of choice. The VRAM was superior to the gracilis in overall reduction of complications.