Abstract
BACKGROUND: Perineal wound management after radical pelvic surgery is complex and diverse. This retrospective study evaluated surgical morbidity and predictors of wound complications associated with different perineal closure techniques. METHODS: Medical records of patients who underwent abdominoperineal resection or pelvic exenteration followed by tissue flap reconstruction (TFR) or primary closure (PC) between 2012 and 2020 were reviewed. Postoperative morbidity, including wound dehiscence, infection, flap loss, and Clavien-Dindo complications, were assessed. RESULTS: In all, 414 patients underwent surgery for rectal (364) or anal (50) malignancies, with 150 receiving TFR and 264 receiving PC; an omental flap was used in 81 patients who underwent PC. TFR was more commonly used in complex situations (for example exenteration, sacrectomy, vaginectomy, intraoperative radiation). Compared with PC, TFR was associated with higher 90-day rates of wound dehiscence (27 versus 11%; P < 0.001), wound infection (25 versus 14%; P < 0.001) and grade ≥III Clavien-Dindo complications (32 versus 17%; P = 0.001). Flap loss occurred in 2 patients (1%) who underwent TFR. No differences were observed among TFR subtypes, or between patients who underwent PC with and without an omental flap. Multivariate analysis demonstrated that anal cancer (odds ratio (OR) 5.24, 95% confidence interval (c.i.) 1.07 to 25.58; P = 0.041) and extralevator resection (OR 3.09, 95% c.i. 1.07 to 8.92; P = 0.037) were independent predictors of wound dehiscence, whereas vaginectomy was a predictor of wound dehiscence in the TFR subgroup (OR 17.9, 95% c.i. 1.05 to 304.73; P = 0.046). CONCLUSION: TFR was associated with higher morbidity due to greater case complexity, but there were no difference in outcomes across flap subtypes. Anal cancer, extralevator resection, and vaginectomy were independent predictors of dehiscence. Omental flaps did not increase the risk of wound complications.