Extralevator versus standard abdominoperineal excision: Does radiotherapy play a part in wound breakdown?

A Musbahi, D Kamali, A Sharpe, Y Viswanath, A Reddy. James Cook University Hospital, Middlesbrough U.K.

Introduction

Little data are available on post-operative outcomes of extralevator abdominoperineal excision (ELAPE) such as wound complications, herniation and infections compared to standard abdominoperineal excision (SAPE). ELAPE is purported to have a better oncological outcome than SAPE. However, due to the larger perineal defect, it is postulated that there is a greater perineal wound breakdown and herniation after ELAPE than SAPE.  This study evaluated the association between wound breakdown and the use of pre-op radiotherapy in either of ELAPE and SAPE.

Methods:

Data were collected on all ELAPE and SAPE resections at a single major surgical unit for patients with rectal cancer between January 2009 and December 2014. Information was collected on length of stay, pre-op staging, histological grading, pre-op CEA measurement, pre-op CT and MRI results as well as post-op complications including perineal wound breakdown, diabetes and immunosuppression status.   Patient notes and computer records were reviewed to obtain data on perineal wound complications, specifically wound breakdown and symptomatic perineal herniation. Categorical data was analysed using Fisher exact test where appropriate. A P value of <0.05 was considered as significant,

Results

Data on 45 patients (35 male; mean age 67.4 years; 24 ELAPE and 21 SAPE) were recorded. 39/45 (87%) patients had radiotherapy prior to surgery [20/24 ELAPE and 19/21 SAPE]. 10/24 ELAPE and 5/21 SAPE developed wound breakdown. 3/4 of patients with diabetes developed wound breakdown. Of the ELAPE patients who had undergone prior radiotherapy, 7/20 had wound breakdown, one of whom was diabetic. There was no significant difference in the number of patients with wound breakdown in the ELAPE group with and without pre-op radiotherapy. 5/19 SAPE patients who had pre-op radiotherapy developed wound breakdown. 2/5 were diabetics. The two remaining patients without adjuvant radiotherapy in the SAPE group did not develop wound breakdown. Radiotherapy was not a significant factor in wound breakdown in patients undergoing SAPE. There was no significant difference in wound breakdown in the SAPE group between radiotherapy and wound healing. There was no perineal herniation in either group of patients.

Conclusion:

Radiotherapy is common in patients undergoing abdominoperineal resection of either type. Wound breakdown rates were high in both surgical group of patients, in particular those who underwent ELAPE. However, radiotherapy was not a significant factor in wound breakdown between either group. Furthermore, there was no significant difference in wound breakdown in diabetic patients in either group.

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