Longitudinal Outcomes of Abdominoperineal Resection Reconstruction: A Single-center Retrospective Review

Reconstruction after abdominoperineal resection (APR) typically utilizes primary closure, locoregional myocutaneous flaps (gracilis or vertical rectus myocutaneous [VRAM]), or omental flaps. Although flap coverage is considered superior to primary closure, no specific flap is preferred, and reconstructive complications can occur in 20%-50% patients. The purpose of this study was to compare outcomes of perineal reconstruction with VRAM, gracilis, and omental flaps.

A single-institution retrospective cohort review was performed on all adult patients who underwent APR defect reconstruction with VRAM, gracilis, or omental flaps by the plastic surgery service between 2014 and 2023. Demographic, operative, and outcomes-associated variables were noted (surgical site infection, nonhealing wounds, flap necrosis/failure, need for additional procedures/operations, etc.).

A total of 80 patients were identified, 11 diagnosed with inflammatory bowel disease (1 Crohn disease and 10 ulcerative colitis), and 58 diagnosed with colorectal cancer. Flap reconstruction was as follows: 24 VRAM, 49 gracilis, 7 omental. Mean follow-up was 34.9 months (1.56 wk, 9.12 y). Enterocutaneous fistula formation was significantly more likely in VRAM versus gracilis flaps (gracilis odds ratio: 0.11, P = 0.02), when adjusted for neoadjuvant chemoradiation. Overall complication rate was 72.5% of patients, of whom 45% required procedural intervention.

Perineal reconstruction after APR can be achieved by various methods. Although the literature has shown flap closure to be more efficacious, differences in overall postoperative complication rate across flap type are minimal. Alternatives to VRAM reconstruction should be considered in patients predisposed to fistula formation.