Flap reconstruction versus primary perineal closure after abdominoperineal resection: a systematic review and...

Abdominoperineal resection (APR), extralevator APR (ELAPE), and pelvic exenteration are indispensable for ultra-low pelvic malignancies but frequently create large perineal defects with substantial wound morbidity. Myocutaneous flap reconstruction (FR) has been proposed to reduce these complications compared to primary closure (PC), but evidence remains inconsistent.

A systematic review and meta-analysis was conducted following PRISMA guidelines (PROSPERO CRD420251250827). Databases were searched, and studies comparing postoperative complications of FR to PC after APR/ELAPE/PE were included. The primary outcome was perineal wound complications. Secondary outcomes included major/minor perineal wound complications, perineal hernia, small-bowel obstruction, unplanned readmission, and length of hospital stay. Pooled odds ratios (ORs) and mean differences (MD) were calculated.

A total of 18 studies (2614 patients) were included. The preoperative radiation rate was higher in the FR group (66.4 vs. 50.2%, p < 0.05). The overall perineal wound complication rates were comparable between PC and FR groups (OR 0.90, 95% CI 0.56-1.47, p = 0.687, I² = 77.8%). However, FR was associated with a significantly lower risk of pelvic abscess (OR 3.1, 95% CI 1.64-5.85, p = 0.0005, I2 = 16.9%). In subgroup analyses, studies limited to APR/ELAPE reported higher major complication rates with PC (OR 1.80, 95% CI 1.15-2.81, p = 0.0101, I² = 0) group. No significant differences were found for perineal hernia, readmission, or hospital stay.

Myocutaneous flap reconstruction may reduce the risk of pelvic abscess and major pelvic complications after APR/ELAPE. Further high-quality trials are needed to confirm this finding.