Modified Gluteus Maximus V-Y Advancement Flap for Reconstruction of Perineal Defects After Resection of Intrapelvic Recurrent Rectal Cancer: Report of a Case

Technical advances in myocutaneous flap preparation have resulted in primary reconstruction now being generally indicated for malignant tumors extensively infiltrating the pelvic cavity and perineum. Pelvic tumor resection can dramatically improve the health-related quality of life (QOL) of patients with locally recurrent rectal cancer complicated by infection and pain. However, the removal of a wide area of perineum by these two procedures often leaves a large dead space. A gluteal thigh muscle, rectus abdominis muscle, or pedicle myocutaneous flap is usually made to reconstruct such extensive perineal defects. The subject of this case report was a 76-year-old woman with recurrent rectal cancer in the pelvis after abdominoperineal resection. The large pelvic tumor, which was causing severe pain, was resected and the extensive perineal defects were reconstructed using a modified maximus V-Y advancement flap. The operating time was approximately 30min, and the pain after surgery was much less severe. Moreover, she could walk the day after surgery and returned to normal daily life without requiring prolonged bed rest. No infection developed in the intrapelvic dead space postoperatively. This technique proved very useful for improving the patient's QOL.     

直肠癌术后局部复发的再治疗

目的　探讨直肠癌术后局部复发的原因及再手术的重要性。方法　回顾性分析 2 9例直肠癌术后局部复发病例 ,结合文献复习并进行讨论。结果　Dixon术后复发 17例 ,Miles术后复发 8例 ,经腹直肠切除结肠拉出术后复发 2例 ,经肛局部切除术后复发 2例 ;再手术中行Dixon术 3例 ,Miles术 14例 ,Hartmann术 5例 ,后盆腔脏器切除术 1例 ,全盆腔脏器切除术 2例 ,局部姑息治疗 4例。结论　保肛手术指征不能过度放宽 ;注重直肠癌围手术期综合治疗 ;对局部复发病例应采取积极的再治疗。     

直肠癌保肛术后复发的外科治疗

目的探讨直肠癌保肛术后局部复发的原因、早期诊断及合理的外科治疗方法。方法回顾性分析我院1998年1月~2005年2月直肠癌保肛术后复发15例的临床资料。结果局部复发6例,吻合口周围组织复发4例,盆腔及脏器浸润5例。术后1年内复发10例,2年内复发14例。临床根治性切除率为40%。结论初次手术时,必须按照根治性原则彻底切除原发灶及其周围组织。对于复发的病例,应对病人的情况进行综合分析,采取积极的以手术治疗为主的综合治疗方案,以延长病人的生存期。     

Immediate Reconstruction of the Perineal Wound With Gracilis Muscle Flaps Following Abdominoperineal Resection and Intraoperative Radiation Therapy for Recurrent Carcinoma of the Rectum

Background: Morbidity associated with a nonhealing perineal wound is the most common complication following proctectomy, particularly in the setting of recurrent carcinoma of the rectum and radiation therapy. Immediate reconstruction using the gracilis myocutaneous and muscle flaps significantly reduces the incidence of major infection associated with perineal wound closure. The purpose of this study was to assess the value of immediate reconstruction of the perineal wound using a gracilis flap in patients undergoing abdominoperineal resection and intraoperative radiation therapy.Methods: This study retrospectively reviewed our experience with immediate pelvic reconstruction using gracilis muscle flaps for patients undergoing rectal extirpation and irradiation for recurrent carcinoma of the rectum. From 1990 to 1995, 16 patients underwent abdominoperineal resection (APR) or pelvic exenteration accompanied by immediate wound closure with unilateral or bilateral gracilis muscle flaps. Morbidity and mortality outcomes were compared to those of 24 patients from our institution who, between 1988 and 1992, underwent proctectomy and irradiation for recurrent rectal carcinoma with primary closure of the perineal wound.Results: Major complications (i.e., major infection requiring hospitalization and/or operation) occurred in 2 (12%) of the patients with gracilis flaps versus 11 (46%) of the patients with primary closure (P = .028 by ² analysis for flap vs. primary closure). Minor complications (i.e., persistent sinus and subcutaneous abscess) occurred in 4 (25%) of the patients with gracilis flaps versus 5 (21%) of those with primary closure.Conclusion: Immediate perineal reconstruction using the gracilis myocutaneous flap following proctectomy and irradiation for recurrent rectal carcinoma significantly reduces the incidence of major infection associated with perineal wound closure.     

直肠癌根治术后引流的应用

目的 总结直肠癌根治术后应用引流的体会。方法 回顾性研究自１９９６年５月至２０００年５月行直肠癌根治术的８７例病例。结果 腹会阴联合切除术（ＡＰＲ）４０例,术后会阴切口一期愈合３７例（９２．５％）、感染３例（７．５％）、出血１例、肠梗阻１例;低位前切除术（ＬＡＲ）４７例,术后贫腔感染１例、吻合口漏１例。结论 直肠癌根治术后引流的应用是减少局部并发症的有效措施。     

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??iagnosis and treatment of local recurrent mid-lower rectal cancer WANG Zhen-jun. Department of General Surgery, Beijing Chaoyang Hospital,Capital Medical University, Beijing 100020,China Abstract Local recurrence of mid-lower rectal cancer persistently constitutes a challenging clinical problem. Recurrent lesion often located in anastomosis, perineum, osteal pelvis and adjacent organs in the pelvis. Clinical manifestation of local recurrent rectal cancer (LRRC) patients include blood stool, perineal pain, pelvic and presacral lump, et al. Regular postoperative physical examination, CT, MRI as well as tumor markers are important methods for diagnosis of LRRC. The treatment choice include excision as the main part of multimodality treatment or palliative radiochemotherapy on comprehensive analysis of type of recurrence, cancer biological features and involvement extent of recurrent cancer.     

Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer

BACKGROUND: Intraoperative tumour perforation, positive tumour margins, wound complications and local recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer. An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor. The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients. METHODS: The principles of operation are that the mesorectum is not dissected off the levator muscles, the perineal dissection is done in the prone position and the levator muscles are resected en bloc with the anus and lower rectum. The perineal defect is reconstructed with a gluteus maximus flap. Between 2001 and 2005, 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital. RESULTS: Two patients had ypT0 tumours, 20 ypT3 and six ypT4 tumours. Bowel perforation occurred in one, the circumferential resection margin (CRM) was positive in two, and four patients had local perineal wound complications. Two patients developed local recurrence after a median follow-up of 16 months. CONCLUSION: The extended posterior perineal approach with gluteus maximus flap reconstruction in APR has a low risk of bowel perforation, CRM involvement and local perineal wound complications. The rate of local recurrence may be lower than with conventional APR.     

Reconstruction of the pelvis and perineum with a free latissimus dorsi myocutaneous flap: a case report

Reconstruction of the perineum and pelvic cavity in continuity is an uncommon and difficult challenge. This case describes a 66-year-old man who presented following recurrence of a Dukes’ B rectosigmoid adenocarcinoma that had been treated nine years previously by anterior resection, 5-fluorouracil and radiotherapy. His recurrent disease was treated with radical pelvic exenteration with formation of an end colostomy and urinary ileal conduit.A post-operative pelvic collection necessitated incisional drainage via the perineum. This resulted in a perineal defect in continuity with the pelvic cavity, neither of which healed in spite of alternate day packing with antiseptic dressings. The perineum and cavity were reconstructed successfully with a microvascular transfer of the latissimus dorsi using the primary gracilis pedicle as recipient donor vessels.     

Aggressive angiomyxoma of the pelvis and perineum: a case report and review of the literature

Aggressive angiomyxoma is a rare mesenchymal tumour arising from soft tissue of the pelvis and perineum. Other features of this tumour are non-specific clinical signs, local invasion, a high local recurrence rate, and recurrence long after initial excision. We provide a case report with a review of the literature. A 57-year-old woman with a large bulky mass in the perineum was admitted to our institution. She had previously undergone iterative surgery for excision of pelvic and perineal masses. The preoperative diagnostic procedure is described as well as the therapeutic surgical approach (a double simultaneous laparotomic and perineal approach was opted for). The surgical procedure was difficult, time-consuming and dangerous owing to an extensive area of hard retroperitoneal sclerosis involving the low urinary viscera, the vaginal stump and the mesorectum. Radical excision of the mass favoured the re-establishment of the normal pelvic anatomy, resolution of the preoperative symptoms and complete recovery of working capability. Surgical excision is the gold standard in the treatment of aggressive angiomyxoma. This benign neoplasm may sometimes present a malignant course owing to involvement of pelvic viscera. It is also associated with a high late recurrence rate due to local aggressiveness, and longterm follow-up is therefore necessary.     

直肠癌根治会阴部造口术后二期股薄肌移植肛门成形

目的　回顾性总结32例直肠癌根治会阴部造口术后二期股薄肌移植肛门成形术的治疗效果。方法　采用Williams 5级评分法对重建前后肛门功能进行评价。结果　二期股薄肌移植肛门成形术前,32例患者肛门功能均在4级以上[4级28.4%(9/32),5级71.6%(23/32)],二期股薄肌移植肛门成形术后肛门功能明显好转。结论　二期股薄肌移植肛门成形术是直肠癌根治会阴部造口术后有效的肛门重建手段。     

Curative surgery for local pelvic recurrence of rectal cancer

BACKGROUND/AIMS: Local pelvic recurrence of rectal cancer after radical resection has been associated with morbidity and cancer-related death. This study retrospectively evaluated outcome following curative resection for rectal cancer recurring after surgery on the basis of prognosis, type of procedure and perioperative morbidity. METHODS: A total of 85 consecutive patients with local pelvic recurrence of rectal cancer were evaluated. Of these, 43 underwent microscopic curative surgery for local recurrence. Among the 43 patients, 23 underwent surgery alone and 17 received preoperative radiotherapy (40 Gy) (XRT group) in addition to the surgery. Of the 43 patients, 26 were asymptomatic. RESULTS: Curative resection was higher in the recurrences that were associated with implantation, incomplete surgical margin clearance, and intrapelvic lymph node metastasis than in other types of recurrence. With regard to surgical procedure, abdominoperineal resection (APR), with or without sacral resection, was standard following previous sphincter-preserving surgery, while total pelvic exenteration (TPE), with or without sacral resection, was common following previous APR. Local excision was not considered appropriate surgery. There was a high incidence of perioperative morbidity (64%) in patients receiving TPE. Re-recurrence was observed in 18 patients (50%) after curative surgery. After a follow-up of 2 years or more, the local re-recurrence rate was 28%. The overall 5-year survival rate for patients receiving curative resection was 39%, for patients in the XRT group, 51%, and for patients in the surgery-alone group, 24% (p = 0.07). The survival rate in 26 asymptomatic patients was higher than in 17 patients with symptoms, with 5-year survival rates of 62 and 23% (p < 0.05), respectively. The cumulative local control in the preoperative radiotherapy plus en bloc surgery group (XRT group) was significantly better than in the surgery-alone group (p < 0.01), and survival in the XRT group tended to be better than in surgery alone. CONCLUSIONS: These results suggest that careful patient selection according to the pattern of recurrence, area of invasion and presence of symptoms is important for successful curative surgery. Aggressive surgery with adjuvant therapy may lead to an improved salvage rate.     

中低位直肠癌局部复发诊断和治疗

中低位直肠癌根治手术后局部复发是诊断和治疗上的难题,常见复发的部位包括吻合口、会阴部、骨性骨盆、盆内邻近脏器,表现为便血、会阴部疼痛不适,盆腔和骶前肿物等。手术后定期体格检查、CT、核磁、肿瘤标记物是目前诊断直肠癌局部复发的重要方法。对局部复发直肠癌的治疗决策,应根据局部复发的类型、复发癌的生物学特性和浸润范围等因素进行综合分析,从而决定是采取手术为主的综合治疗还是行放化疗等策略。     

Gracilis myocutaneous flap for reconstructing perineal defects resulting from radiation and radical surgery

When high-dose radiotherapy for carcinoma of the rectum, cervix, vagina or vulva fails and subsequent surgical excision by extended abdominoperineal resection or exenteration is performed, healing is often greatly delayed, for many months, and a scarred, deformed perineum results. The introduction of myocutaneous flaps opened up a new field for reconstruction of defects in a number of areas. The authors used a gracilis myocutaneous flap in 15 patients for primary reconstruction following surgical resection for failed radiotherapy of a primary carcinoma (of the rectum in 6, the cervix in 7 and the vulva in 2) and as a secondary procedure in 2 patients, 1 with an unhealed perineum 4 months after irradiation and extended abdominal resection for carcinoma of the rectum, and the other with extensive perineal necrosis following radiotherapy and chemotherapy. The operative technique, which is relatively simple, is described and illustrated. Since all patients had received radiotherapy, the myocutaneous flap was used primarily and successfully to reduce morbidity and healing time. However, even without radiotherapy, the deformity following exenteration is unacceptable and reconstruction by the method described should probably be planned as part of this operation. Not only can primary healing be expected, but the neovagina has a relatively normal appearance with satisfactory sensation and function.     

低位直肠癌行后盆腔脏器切除联合远端阴道及会阴体切除术后会阴重建的方式及体会

目的总结低位直肠癌累及远端阴道及会阴体时行后盆腔脏器切除及远端阴道及会阴体切除后会阴重建的各种方法的应用体会。方法总结我院2008年10月至2013年9月期间收治的10例直肠癌联合远端阴道及会阴体切除后的重建方式及围手术期的临床资料。结果10例患者中2例行子宫及阴道全切除,3例行子宫及阴道后壁切除,5例行单纯远端阴道和（或）会阴体切除。分别采用大网膜填塞（4例）、阴道前壁翻转缝合（3例）、子宫后倾（2例）、带蒂乙状结肠（2例）重建盆腔及阴道会阴缺损。1例患者盆腔严重感染,2例患者会阴部切口感染或裂开。结论女性低位直肠癌患者行后盆腔联合脏器切除后切口相关并发症率极高,可根据盆腔、会阴及阴道的缺损情况选用子宫或网膜填塞盆腔、带蒂肠段或肌皮瓣、生物补片等方法进行一期修复缺损,采用腹直肌或臀大肌肌皮瓣修复会阴巨大缺损成为目前主流的修复方式,但国内该技术报道极少,值得积极开展应刚。     

Is total pelvic exenteration reasonable primary treatment for rectal carcinoma?

Total pelvic exeneration (TPE) is reasonable primary surgical therapy in select patients with large bulky locally invasive rectal cancers that can be removed en bloc. Many do not have either nodal or distant metastasis. Furthermore, TPE can be curative and often is palliative for similar lesions that are recurrent or nonresponsive to radiation therapy. Operative mortality rates should be under 10% and can be under 5% for primary cases. Although improvement in preoperative management and operative technique, especially with urinary conduits and postoperative care is clear, both early and late complications are significant. Unfortunately, preoperative identification of those patients requiring TPE rather than abdominoperineal or low anterior resection remains poor. Furthermore, recent improvements in techniques for pelvic slings to prevent small bowel entrapment and protection from irradiation or myocutaneous flaps to obliterate the massive dead space are not yet clearly established as preventors of either early or later complications.     

腹腔镜直肠癌腹会阴联合切除术的三大难题及其解决方案

目的探讨腹腔镜直肠癌腹会阴联合切除术（APR）中的三大难题（腹部无切口的前提下完成腹膜外乙状结肠造口、缝合封闭盆底腹膜和预防术后会阴切口感染）及其解决方案。方法回顾性分析2010年9月至2013年5月间在北京协和医院基本外科接受择期腹腔镜APR手术60例低位直肠癌患者的临床资料。术中在完成淋巴结清扫及肿瘤切除后,以左下腹穿刺点为中心行腹腔镜下腹膜外乙状结肠造口术：并借鉴经肛门内镜微创手术（TEM）独特的腔内缝合技术,使用TEM持针钳,用可吸收线连续缝合关闭盆底腹膜;对成功关闭盆底腹膜的患者于术后第3天开始行骶前间隙持续灌洗预防会阴切口感染。结果计划实施腹腔镜APR的60例患者中,除1例（1．7％）中转开腹外,59例（98-3％）顺利完成腹部无切口的腹膜外乙状结肠造VI术,造口并发症发生率3．4％（2／59）。56例（94．9％）成功缝合关闭盆底腹膜,中位缝合耗时为15min,术后无一例出现会阴疝、腹内疝或粘连性肠梗阻。57例（包括中转开腹1例）成功关闭盆底腹膜后行骶前间隙持续灌洗者,骶前引流管留置的中位时间为7．8d;术后未并发粘连性肠梗阻：会阴切口甲、乙和丙级愈合率分别为87．7％（50／57）、8．8％（5／57）和3．5％（2／57）。盆底腹膜缝合失败、骶前间隙自然引流的3例患者术后1例发生粘连性肠梗阻,1例会阴切口丙级愈合。结论腹腔镜APR手术中腹膜外乙状结肠造口可行且安全;采用TEM腔内缝合技术关闭盆底腹膜便捷而有效;术后持续骶前灌洗对预防会阴切口感染的作用值得深入探讨。     

The management of recurrent rectal carcinoma

Rectal carcinoma remains an enigma to surgical and medical oncologists. The chemo- and radiotherapeutic approaches have been fraught with failure, and when this happens the patient is left to the challenge of the surgical oncologist who sometimes must perform extensive re-resection to include adjacent structures. Experienced surgical judgement is assisted by preoperative and intraoperative criteria, which are contraindications to resection: preoperatively, they include metastases, fixation of tumour to pelvic wall, sciatica, obstruction of both ureters and leg edema. Intraoperatively, metastases within aortic nodes or beyond the pelvis and extension of disease laterally or deep to pelvic wall or to multiple loops of bowel are all contraindications. These tumours are often slow to metastasize so that aggressive local surgical resection is warranted to minimize the morbidity prone complications associated with low-lying perineal or pelvic recurrence of rectal cancer.     

Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection

BACKGROUND: Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection. METHODS: Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy. RESULTS: Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months). CONCLUSION: The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.     

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目的 探讨直肠癌局部复发形式、原因，以提高其治疗效果。方法 回顾性分析1975-2001年间收治的术后局部复发形式、发生的原因及其治疗情况。结果 术后局部复发207例，占同期全部直肠癌（2538例）的8.1%，局部复发形式中，首次Miles手术者（102例）多为会阴部及骶前腔的复发，为52例（51%）。另外22例为阴道壁复发。首次Dixon手术后主要为吻合口及其周围组织的复发，分别为71例及65例，占87.7%（71/81）及80.2%(65/81)。淋巴结转移癌的复发为55例，占26.6%（55/207），复发是由于肠管切除不足，原发灶周围组织清除不足，会阴部组织切除不足及淋巴结切除范围不足所致。复发病例再次手术切除率为66.1%(137/207)，其中的63例（46%）达到了临床根治程度，病变切除及根治切除者5年生存率分别为23.3%及34.9%。结论 欲降低直肠癌术后局部复发率和提高生存率，必须按根治原则彻底切除原发灶及其周围组织，并彻底清除淋巴结。对于复发病例，应积极进行手术治疗，可延长生存期。     

应用盆腔脏器联合切除术治疗局部复发型直肠癌

目的 评价盆腔脏器联合切除术对局部复发型直肠癌的治疗意义。方法 对我院33例局部复发型直肠癌应用盆腔脏器联合切除术治疗的病例进行回顾性总结。结果 33例患中17例接受全盆腔脏器切除术治疗，14例接受后盆腔脏器切除术；2例为直肠癌合并输尿管下段切除。29例（87．9％）手术为根治术，手术死亡率3．0％。盆腔受累最多的器官是骶前组织和阴道。术后约88．9％的患疼痛症状消失。8例（24．2％）再次复发，并再用手术。全组2、3、4年生存率分别为36．4％、21．2％、18．2％。结论 积极的盆腔脏器联合切除术可以明显改善局部复发型直肠癌的预后，提高术后生活质量。