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Extended abdominoperineal resection in women: the barbadian experience

Zbar AP, Shenoy RK, Chiappa A - Int Semin Surg Oncol (2007)

Bottom Line: Exenterative procedures were performed in 2 cases of primary vaginal cancer, following Wertheim hysterectomy for carcinoma of the cervix with recurrence after radiation and in 2 further cases of anal cancer with extensive pelvic recurrence after primary chemoradiation.Our experience shows that careful primary closure of an extended abdominoperineal resection wound is effective and safe.Our one case of wound breakdown after primary repair underwent external beam and intracavitary irradiation primarily with wound breakdown of a primary repair followed by a delayed pedicled graciloplasty.

Affiliation: Professorial Department of Surgery The University of the West Indies, Queen Elizabeth Hospital, Barbados. azbar@uwichill.edu.bb

ABSTRACT

Background and objectives: We report our results of a selective approach to primary direct appositional vaginal repair versus transverse rectus abdominis flap repair (TRAM) in patients with extensive rectal/anal cancer or in cases with primary cancer of cervix, vagina or vulva involving the anal canal and anal sphincters.

Methods: Eighteen female patients (mean age: 62.9 years; range: 44-81 years) with a median follow-up of 14 months (range: 2-36 months) undergoing extended abdominoperineal reconstruction with total mesorectal excision between May 2002 and September 2005, were studied.

Results: Twelve patients underwent an extended abdominoperineal resection with hysterectomy and vaginectomy, with 6 patients undergoing primary TRAM flap reconstruction following pelvic exenteration. Exenterative procedures were performed in 2 cases of primary vaginal cancer, following Wertheim hysterectomy for carcinoma of the cervix with recurrence after radiation and in 2 further cases of anal cancer with extensive pelvic recurrence after primary chemoradiation. Fifteen cases are alive on follow-up with no evidence of disease; 2 patients who had recurrent carcinoma of the cervix and who underwent TRAM flap reconstruction, have recurrent disease after 5 and 6 months of follow-up, respectively.

Discussion: Our experience shows that careful primary closure of an extended abdominoperineal resection wound is effective and safe. Our one case of wound breakdown after primary repair underwent external beam and intracavitary irradiation primarily with wound breakdown of a primary repair followed by a delayed pedicled graciloplasty. TRAM flap reconstruction has been reserved in our unit for patients undergoing total pelvic extenteration. In general, we would recommend the use of TRAM flap reconstruction in younger sexually active patients where there has been external irradiation combined with brachytherapy.

Ligation of the inferior vaginal venous plexus.
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Figure 2: Ligation of the inferior vaginal venous plexus.

Mentions: Simple extension of the abdominoperineal resection with high posterior vaginectomy [12] has been well described and is shown in Figure 1, 2, 3. Formal vaginal and perineal reconstruction is performed by aligning the new fourchette after removing the entire posterior vaginal wall where necessary and by linking this to the apex of the perineal wound. High posterior vaginectomy requires ligation of the inferior vaginal venous plexi on both sides with care being taken at the posterior vaginal apex not to injure the lower end of the ureter on either side. Our group has described the use of the TRAM flap in the past for total pelvic exenteration [3] with double ostomy (ileal conduit and colostomy), however, the skin paddle may also be used for the construction of a neovagina as described by Bell and colleagues [6] as well as by others [13]. The TRAM flap for total pelvic exenteration is shown in Figure 4, 5, 6. Preoperative assessment of patients included endorectal ultrasonography, CT scanning and MR imaging where appropriate. The latter modality was used in recurrent cases to assess presacral infiltration in the sagittal plane although there were no cases where sacrectomy was required. One patient with a recurrent mass in the rectovaginal septum with carcinoma of the anus who received primary chemoradiation underwent transperineal sonography (Figure 7) which demonstrated the septal mass, the complete excision of which was guided by intraoperative ultrasound. The transcutaneous ultrasound technique has been described before by our group in organic and functional disease [14].

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Extended abdominoperineal resection in women: the barbadian experience

Zbar AP, Shenoy RK, Chiappa A - Int Semin Surg Oncol (2007)

Ligation of the inferior vaginal venous plexus.
© Copyright Policy - open-access
Figure 2: Ligation of the inferior vaginal venous plexus.
Mentions: Simple extension of the abdominoperineal resection with high posterior vaginectomy [12] has been well described and is shown in Figure 1, 2, 3. Formal vaginal and perineal reconstruction is performed by aligning the new fourchette after removing the entire posterior vaginal wall where necessary and by linking this to the apex of the perineal wound. High posterior vaginectomy requires ligation of the inferior vaginal venous plexi on both sides with care being taken at the posterior vaginal apex not to injure the lower end of the ureter on either side. Our group has described the use of the TRAM flap in the past for total pelvic exenteration [3] with double ostomy (ileal conduit and colostomy), however, the skin paddle may also be used for the construction of a neovagina as described by Bell and colleagues [6] as well as by others [13]. The TRAM flap for total pelvic exenteration is shown in Figure 4, 5, 6. Preoperative assessment of patients included endorectal ultrasonography, CT scanning and MR imaging where appropriate. The latter modality was used in recurrent cases to assess presacral infiltration in the sagittal plane although there were no cases where sacrectomy was required. One patient with a recurrent mass in the rectovaginal septum with carcinoma of the anus who received primary chemoradiation underwent transperineal sonography (Figure 7) which demonstrated the septal mass, the complete excision of which was guided by intraoperative ultrasound. The transcutaneous ultrasound technique has been described before by our group in organic and functional disease [14].

Bottom Line: Exenterative procedures were performed in 2 cases of primary vaginal cancer, following Wertheim hysterectomy for carcinoma of the cervix with recurrence after radiation and in 2 further cases of anal cancer with extensive pelvic recurrence after primary chemoradiation.Our experience shows that careful primary closure of an extended abdominoperineal resection wound is effective and safe.Our one case of wound breakdown after primary repair underwent external beam and intracavitary irradiation primarily with wound breakdown of a primary repair followed by a delayed pedicled graciloplasty.

Affiliation: Professorial Department of Surgery The University of the West Indies, Queen Elizabeth Hospital, Barbados. azbar@uwichill.edu.bb

ABSTRACT

Background and objectives: We report our results of a selective approach to primary direct appositional vaginal repair versus transverse rectus abdominis flap repair (TRAM) in patients with extensive rectal/anal cancer or in cases with primary cancer of cervix, vagina or vulva involving the anal canal and anal sphincters.

Methods: Eighteen female patients (mean age: 62.9 years; range: 44-81 years) with a median follow-up of 14 months (range: 2-36 months) undergoing extended abdominoperineal reconstruction with total mesorectal excision between May 2002 and September 2005, were studied.

Results: Twelve patients underwent an extended abdominoperineal resection with hysterectomy and vaginectomy, with 6 patients undergoing primary TRAM flap reconstruction following pelvic exenteration. Exenterative procedures were performed in 2 cases of primary vaginal cancer, following Wertheim hysterectomy for carcinoma of the cervix with recurrence after radiation and in 2 further cases of anal cancer with extensive pelvic recurrence after primary chemoradiation. Fifteen cases are alive on follow-up with no evidence of disease; 2 patients who had recurrent carcinoma of the cervix and who underwent TRAM flap reconstruction, have recurrent disease after 5 and 6 months of follow-up, respectively.

Discussion: Our experience shows that careful primary closure of an extended abdominoperineal resection wound is effective and safe. Our one case of wound breakdown after primary repair underwent external beam and intracavitary irradiation primarily with wound breakdown of a primary repair followed by a delayed pedicled graciloplasty. TRAM flap reconstruction has been reserved in our unit for patients undergoing total pelvic extenteration. In general, we would recommend the use of TRAM flap reconstruction in younger sexually active patients where there has been external irradiation combined with brachytherapy.

View Similar Images In: Results  - Collection
View Article: PubMed Central - HTML -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=1779795&rFormat=json&query=null&req=5