Biosynthetic Mesh Reconstruction after Abdominoperineal Resection for Low Rectal Cancer: Cross Relation of Surgical Healing and Oncological Outcomes: A Multicentric Observational Study
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Summary
The large perineal defect, with impaired wound healing and delayed start of the adjuvant chemotherapy, can make the reconstructive phase of abdominoperineal resection for low rectal cancer extremely challenging. Using biosynthetic mesh for the neo-perineum reconstruction after a Miles’ procedure is a poorly investigated technique, which, in our series, resulted in safe, reproducible results affected by limited complications. Moreover, for improved perineal wound healing, it guaranteed a faster start of the adjuvant therapy with clear reduction in oncological outcomes (i.e., recurrences and death).
Abstract
Background: Local wound complications are among the most relevant sequelae after an abdominoperineal resection (APR) for low rectal cancer.
One of the proposed techniques to improve the postoperative recovery and to accelerate the initiation of adjuvant chemotherapy is the mesh reinforcement of the perineal wound. The aim of the current study is to compare the surgical and oncological outcomes after APR performed with a biosynthetic mesh reconstruction versus the conventional procedure.
Methods: From 2015 to 2020, in two tertiary centres, the surgical outcomes, the wound events (i.e., surgical site infections, wound dehiscence and the complete healing time) and the oncological outcomes (i.e., time length to start adjuvant chemo-radiotherapy, an over 8-week delay in chemotherapy and the recurrence rate) were etrospectively analysed in patients undergoing APR reinforced with biosynthetic mesh (Group A) and conventional APR (Group B).
Results Sixty-one patients were treated with APR (25 in Group A and 36 in Group B). Patients in Group A presented lower time for : healing (16 versus 24 days, p = 0.015), inferior perineal wound dehiscence rates (one versus nine cases, p = 0.033), an earlier adjuvant therapy start (26 versus 70days, p = 0.003) and a lower recurrence rate (16.6% vs. 33.3%, p = 0.152).
Conclusions: In our series, the use of a biosynthetic mesh for the neo-perineum reconstruction after a Miles’ procedure has resulted in safe, reproducible results affected by limited complications, guarantying a rapid start of the adjuvant therapy with clear benefits in oncological outcomes. Further randomized clinical trials with long-term follow-up are needed to validate these results.
Introduction
Malignant disease of the colon and rectum is one of the most frequent cancers in Western countries, and despite the advances of oncological therapies, the surgical approach remains a milestone for its treatment. In recent decades, the scientific community has continuously provided relevant evolutions in surgical techniques with a widespread adoption of minimally invasive approaches, such as laparoscopic and robotic resections, transanal endoscopic microsurgery (TEM) and transanal total mesorectal excision (TATME) for low rectal cancers. Nevertheless, in 15–20% of the cases, due to the localization of the disease (within 5 cm of the anal verge), the infiltration of he anal sphincter muscles or the impossibility to achieve a negative resection margin (5 cm proximally and 2 cm distally), a conservative technique preserving the perineal plane and the sphincteric structures is precluded.
These cases require a more demolitive surgery, such as abdominoperineal resection (APR or Miles’ procedure), consisting in a permanent colostomy after the removal of the sigmoid colon, rectum and anus. Despite using the laparoscopic or robotic approach, the large perineal defect can make the reconstructive phase of this procedure extremely challenging, especially when an extralevator abdominoperineal excision (ELAPE) is needed; the process involves dissecting outside the extralevator muscles plane and removing the entire pelvic floor to achieve oncological radicality.
Therefore, perineal wound closure and healing is often impaired, potentially with the onset of serious complications, leading to a delay of the adjuvant oncological therapy; therapy that is proven to be crucial in reducing the distal recurrence rate and increasing the patient’s disease-free survival.
Moreover, the risk of perineal wound complications after APR could be even higher after neo-adjuvant chemoradiotherapy (CHT-RT), which is often performed in distal rectal cancer patients. The surgical complications may include intra-abdominal or pelvic abscesses, hematoma, wound dehiscence, perineal hernia and delayed wound healing. Evidence-based medicine and international guidelines suggest starting the adjuvant chemotherapy within 6–8 weeks after the successful completion of surgery, once complete or near-complete healing of the perineal wound has been achieved.
The main surgical techniques for perineal reconstruction after APR, in addition to the direct closure of the perineal wound where it is technically possible, include fascialmyocutaneous flaps, omentoplasty, tissue expanders, silicone breast implants and synthetic or biological prostheses. Materials used in synthetic prostheses, such as polypropylene, create visceral adhesions in contact with the peritoneum and the pelvic floor organs that can cause erosions, fistulas, or perforations; for this reason, these meshes are not recommended in perineal wound reconstruction. On the other hand, biological prostheses, despite being more advantageous, have limitations related to low resistance and reduced integration into the tissue (ingrowth), the tendency of shrinking, high costs, the risk of rejection reactions or transmission of viral infections and the need of tissue tracking and preoperative soaking.
The use of biosynthetic prosthetic materials in recent years has revolutionized the pelvic–perineal reconstructive surgery, achieving satisfactory results. These prostheses have a chemical structure very similar to the natural polymers contained in biological tissues, such as collagen, which gives these materials excellent biocompatibility. The interaction between the three-dimensional matrix of the synthetic copolymers and human tissue promotes cell adhesion and cell growth. In some circumstances, the body “metabolizes” the polymer by degrading it over time until it is completely reabsorbed after tissue regeneration. This is the case of the GORE® BIO-A® Tissue Reinforcement [W. L. Gore & Associates, Inc., Newark, DE, USA] prosthetic material, which was applied in our study.
The aim of the current observational retrospective study is to analyse and compare the surgical and oncological outcomes in patients undergoing Miles’ APR and perineal wound reconstruction with or without the use of an absorbable biosynthetic prosthesis in two high-volume tertiary centres.
Web site article (complete)
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Authors
Claudio Gambardella, Federico Maria Mongardini, Menelaos Karpathiotakis, Francesco Saverio Lucido, Francesco Pizza, Salvatore Tolone, Simona Parisi, Giusiana Nesta, Luigi Brusciano, Antonio Gambardella, Ludovico Docimo and Massimo Mongardini
