Optimal approaches to flap reconstruction following abdominoperineal resection: A systematic review

Abdominoperineal resection (APR) frequently results in a large volume perineal defect. Flap reconstruction is commonly undertaken to reduce the rate of perineal complications associated with primary closure. Several techniques can be employed including vertical rectus abdominis (VRAM), gluteal myocutaneous and gluteal fasciocutaneous flaps. We aimed to compare perineal complication rates between flap reconstruction techniques.

A systematic review was conducted following PRISMA guidelines. Databases were searched for studies reporting perineal complications following flap reconstruction post-APR. Demographic data for each study was extracted along with overall perineal complication rate, infectious complication, flap necrosis, dehiscence, and failure.

In total, 31 studies with 764 patients were included. Rectal cancer was the underlying pathology in 71.3 % (545/764), anal cancer in 23.6 % (180/764), and other in 5.1 % (39/764). VRAM flap reconstruction was performed in 57.2 % of cases (437/764), gluteal myocutaneous in 25.1 % (192/764), and gluteal fasciocutaneous in 17.7 % (135/764). Infection, dehiscence, haematoma, seroma, and flap failure rates were comparable among the different groups. Flap necrosis occurred in 4.6 % of the VRAM group and was significantly higher than in the other groups (P = 0.028). The rate of reoperation (9.1 %) was also significantly higher in the VRAM group (P = 0.038). Perineal hernia formation occurred in 14.9 % of the gluteal fasciocutaneous group and was significantly higher than in the other groups (P < 0.001).

Flap necrosis and reoperation rates are higher after VRAM flap reconstruction. Perineal hernia rates are higher in gluteal fasciocutaneous flap reconstruction. A randomised controlled trial is needed to further investigate the outcomes of flap reconstruction.