V-Y Gluteal Advancement Fasciocutaneous Flap for Reconstruction of Perineal Defects After Surgery for Anorectal Cancers— A Single-Center Experience (2024)

Abstract

An ideal method of perineal closure after resection for low rectal cancer surgery is a topic of debate. Morbidity associated with primary perineal closure due to wound break down delays recovery from surgery and adjuvant treatment with poor oncological outcome at the end. Herewith, we present our experience with V-Y gluteal advancement fasciocutaneous flap done for 131 patients for reconstruction of perineal and pelvic defect. With our experience, this is a safe and simple method with an acceptable complication rate that can be practiced by colorectal surgeons, even in the absence of a dedicated plastic surgery team.

Keywords: Rectal cancer, Perineal and pelvic defect, V-Y flap

Introduction

Advanced low rectal/anal cancers contribute to a significant proportion of colorectal cancer presentation in India and worldwide. As per the GLOBOCAN 2018 data in India, incidence and mortality of colorectal cancers were 24,251 (2.1%) and 20,056 (2.6%) respectively [1]. While worldwide colorectal cancer ranks the 3rd and 2nd commonest cancer in males and females respectively, it contributes 10.2% and 9.2% for incidence and mortality respectively. In the Indian scenario, younger age, signet-ring carcinoma, and higher stage are more common compared to Western countries [2].

These cancers demand wider resections to achieve clear margins leaving larger defects in the perineum as well as in the pelvic cavity.Furtherthe use of neoadjuvant chemoradiation compounds the wound morbidity as irradiated skin is prone to breakdown. The residual cavity in the pelvis after surgery can cause dead space, fluid accumulation, herniation of bowel loops, and bowel obstruction, collectively referred to as the “empty pelvis syndrome,” further adding to the perineal morbidity [3].

Complications as a result of inadequate wound healing increase hospital stay and cost, delay initiation of adjuvant therapy, and ultimately compromise oncologic outcomes. The goal of optimum perineal reconstruction is thus twofold: perineal skin closure with normal vascularized tissue to expedite the wound healing and obliteration in the dead space of the pelvis.

Autogenous perineal wound closure is advantageous, but for an optimum way of closure, there is no consensus yet [4]. There are multiple options for perineal reconstruction and the ones popularly used are the vertical rectus abdominis myocutaneous (VRAM) flap, gracilis myocutaneous flap, and the posterior thigh flap. Probably the least complex and easily learnt of reconstructions is the fasciocutaneous gluteal V-Y advancement flap. Herewith, we report our experience with the V-Y advancement flap in the closure of combined pelvic and perineal defects after surgery for low anorectal cancers.

Patients and Methods

Retrospective analysis of a prospectively maintained database was carried out from the colorectal surgery unit, department of surgical oncologyat, Tata Memorial Hospital, Mumbai. After an informed consent, patients have undergone surgery for low rectal or anal cancer with reconstruction of perineal defect by V-Y fasciocutaneous advancement flap between periods from Jan. 2013 until Jan. 2020. These surgeries included extralevator abdominoperineal resections (ELAPE), ischioanal APR, and pelvic exenterations. When the defects were deemed unsuitable for primary closure, V-Y advancement flap was planned.

All patients with adenocarcinoma of the rectum had received neoadjuvant radiation treatment. Exclusion criteria were patients with collagen disorders, patients with severe systemic diseases, patients who had complications more than Clavien-Dindo Gr IIIb, and patients who have had follow-up less than 6 months.

After discharge from the hospital, patients were serially followed every week for 3weeks and after that every 1month until 3months followed by regular surveillance according to oncology protocol for the stage. Any postoperative complication pertaining to V-Y flap was recorded and addressed accordingly. We judged flap survival clinically and have not done any separate imaging study for it.

Results (Table ​(Table11)

Of the 131 patients studied, 82 were male while 49 were female. The mean operating time for unilateral and bilateral flap was 91 and 135min, respectively.

The mean blood loss and hospital stay were 200cc and 12days, respectively.

In total, 67% (n = 88) of patients showed uneventful recovery after and 32.8% (n=43) of patients developed complications. Grade I and II complications were seen in 20.7% (n = 27) of patients while grade IIIa and IIIb complications are found in 4.6% (n=6) and 9.1% (n=12), respectively.

The total number of grade I and II complications was more with lithotomy (25%) compared to prone position (11%), while grade IIIb complications were more with prone (15.9%) compared to lithotomy position (5.7%).

Commonest complications were wound dehiscence (14%) followed by serous discharge (9.9%).

Out of the 18 patients who developed wound dehiscence, 7 patients needed secondary suturing with debridement under general anesthesia, 2 had flap necrosis for which one patient was managed with mobilization of contralateral V-Y flap while the other was managed with gracilis flap, 6 patients underwent re-suturing under local anesthesia while 3 patients had minimal gaping which healed with secondary intention.

Other complications noted were purulent discharge, 3.8%; pain, 1.5%; and bleeding, 0.7%. Small bowel herniation and obstruction occurred in 2 patients (1.5%), in the beginning of our series but for both of these patients, pelvic filler was not given and only perineal closure was achieved. Subsequently, we changed our practice and used flap to fill the pelvic dead space also.

Looking at the oncological benefit with wider resection patients, we could achieve free margin in 92.4% of the patients.

Discussion

Primary perineal closure after surgery for low rectal cancer is often associated with wound morbidity, increase in hospital stay, and delay in adjuvant treatment. Additionally, there may be chances of pelvic herniation of small bowel causing obstruction. Neoadjuvant chemoradiation adds to the problem. Thus, prevailing high rates of perineal wound morbidity demand an alternative form of closure. Various alternative methods for closure have been described in literature such as vertical rectus abdominis myocutaneous flap, gluteal artery myocutaneous flap, gracilis muscle flap, deep inferior epigastric artery perforator flap, and biological mesh.

Biological mesh, though can decrease perineal hernia rate, has failed to improve perineal wound morbidity as it cannot fill the pelvic cavity and the cost is another issue [6]. Rectus abdominis flap takes away the credits of laparoscopic surgery for rectal cancer and gives donor site morbidity, and it may be unacceptable in the need of colostomy/urostomy [7]. Gracilis flap, though suitable for anterior perineal wound, has distant pedicle location and thus has limited mobility [7]. In the gluteus muscle myocutaneous flap, there is transfer of muscle unlike fasciocutaneous in which only skin and subcutaneous tissue are transferred, so it causes donor site morbidity [8]. Additionally, there is muscle atrophy, and loss of muscle impairs routine activities in the patient. Disadvantage of all these flaps is the need for a scrupulous and complex technique from a dedicated plastic surgery team.

After surgery of low rectal/anal cancers, perineal wound complications are reported in 60% of the patients [9], while in our study, we found that 68% of patients had an uncomplicated recovery of perineal wound with V-Y plasty flap closure and most of the other complications were acceptable and only 9.1% needed flap repair under general anesthesia.

As we continue to gain experience with this flap, it has become our standard protocol, especially after surgeries like ischioanal APR and pelvic exenteration, which leave bigger defects.

Ozay et al. have described their experience with 15 patients with this flap after ELAPE [10] here, we concur their experience but we have performed this flap on significantly larger number of patient population (n = 131).

Advantages of the V-Y fasciocutaneous gluteal advancement flap are that tissue is non-radiated and well-vascularized as it has reliable blood supply from two vessels—superior and inferior gluteal arteries. Dual blood supply makes this flap robust to withstand even adequate mobilization. Unlike many other flaps, reconstruction can be performed when the abdominal team is still operating, e.g., making urinary conduit after pelvic exenteration, and thus it minimizes operativetime. Because of the short learning curve, the flap does not need a reconstructive and microvascular surgery team and the scar lies in the more natural gluteal crease. It serves two main purposes: obliteration of pelvic dead space and covering of perinealdefect with healthy skin which allows patient receivetimely adjuvant treatment. Additional operative time needed for the flap is also acceptable.

Limitations of the Study

Due to retrospective evaluation, it is difficult to draw conclusions from few results due to the presence of multiple compounding factors; e.g., apparently Gr I and II complications were more in lithotomy position while serious IIIb complications were more in prone position in our series.

Further for documentation cost-effectiveness & superiority ofthisprocedure over other alternativemethods of closure, randomised controlled studies are needed.

We have not adopted any strict criteria for prone or supine position.

Conclusion

We suggest that the V-Y fasciocutaneous advancement flap is a simple and reliable promising method with shorter learning curve. It allows wider excision of primary low rectal cancer and helps in filling the perineal and pelvic dead space with well-vascularized tissue to prevent wound morbidity.

Declarations

Footnotes

Contributor Information

Rahulkumar N. Chavan, Email: moc.liamg@noegrus.luharrd.

Avanish P. Saklani, Email: moc.liamtoh@inalkasa.

Ashwin L. Desouza, Email: moc.liamg@azuosedniwhsa.

Jitender Rohila, Email: moc.liamg@alihorteej.rd.

Mufaddal Kazi, Email: moc.evil@izakladdafum.

Vivek Sukumar, Email: moc.evil@kskeviv.

Bhushan Jajoo, Email: moc.liamg@nahsuhboojaj.

References