ABSTRACT
PURPOSE: We evaluate outcomes of our single center using vertical rectus abdominis myocutaneous (VRAM) flaps for reconstruction after abdominoperineal resection (APR). Our goal was to analyze factors that may affect perineal wound healing, a problematic complication with APR reconstructions due to location and high frequency of neoadjuvant chemoradiation. METHODS: This single-center, retrospective study analyzed all VRAM flap perineal reconstruction patients after APR defect over a 10-year period (from July 2008 to June 2018). Outcome measures focused on factors that may affect perineal wound healing complication rates: cancer stage (I/II vs III/IV), neoadjuvant chemoradiation, surgeon's years in practice (<5 years vs >5 years), and pelvic closed suction drain use. RESULTS: Twenty-eight patients met inclusion criteria. The overall major perineal wound complication rate was 14.3% (4 patients). Lack of perioperative closed suction pelvic drain use was associated with a significantly higher rate of major perineal wound complications (28.6% vs 0% and p = 0.031). All four major wound complications occurred in patients who did not have a pelvic drain. The major perineal wound complication rate for patients who underwent neoadjuvant chemoradiation was 22% vs 0% with no neoadjuvant chemoradiation (p = 0.107). CONCLUSION: While our cohort represents a relatively small single-center study, our 14.3% rate of major perineal wound complications is consistent with previous studies in the literature. Our findings show that perioperative pelvic closed suction drain use is associated with a lower rate of perineal wound complications. While neoadjuvant chemoradiation trended toward a higher incidence of perineal wound complications, it did not reach statistical significance.
ABSTRACT
INTRODUCTION: The risk of redo fundoplication has been demonstrated to be significantly higher in patients of younger age, those with ongoing retching, and those who underwent more extensive dissection of the esophageal hiatus at the initial operation. The purpose of this study was to review the management and outcomes of patients who required one or more re-operations for recurrence after laparoscopic fundoplication. MATERIALS AND METHODS: After obtaining Institutional Review Board approval, we performed a retrospective review of all patients who underwent laparoscopic Nissen fundoplication from 2000 to 2013 and subsequently required a redo operation for recurrence. Patient demographics, neurologic impairment, interval time between re-operations, operative approach, use of mesh, and length of follow-up were analyzed. Two-tailed independent Student's t test was used to compare continuous variables, and two-tailed chi-squared test with Yates's correction (Fisher's exact test where appropriate) was used for discrete variables. RESULTS: Eighty-two patients (10.3% of the sample) required re-operation during the study period. The mean age at initial surgery was 1.8 ± 3.6 years. Fifteen patients (18.3%) required more than one re-operation. Of the 102 re-operations performed, 68 were successfully managed laparoscopically, 3 required conversion to an open procedure, and 31 were performed open from the outset. Of those patients requiring more than one re-operation, there was no difference in age, weight, use of mesh, or time to subsequent re-operations compared with patients that only required one redo fundoplication. CONCLUSIONS: The incidence of patients requiring another operation after a redo operation after an initial laparoscopic fundoplication is 18%. Patient demographics and time to re-operation have not been found to be predictive of which patient will require multiple re-operations for recurrence. However, younger patients and those with a shorter time to re-operation may increase the likelihood of failure.
