Reconstruction of the pelvic floor after abdominoperineal excision

  • Alam N
  • Narang S
  • Daniels I
 et al. 
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Abstract

Introduction Extralevator abdominoperineal excision (ELAPE) involves the en bloc excision of the levator muscles and the rectum and the wider excision can increase morbidity and wound complications tthat will require some form of perineal reconstruction. The aim of this review is to provide an overview of the evidence for the use of biological mesh in the reconstruction of the pelvic floor after abdominoperineal excision. Method A systematic search of PubMed was conducted using the search terms 'ELAPE', 'extralevator abdominoperineal excision of rectum' or 'extralevator abdominoperineal resection'. The search yielded 17 studies for analysis after inclusion and exclusion criteria were applied. Results There were a total of 1055 patients across 17 studies. A biological mesh was used in perineal reconstruction in 463 patients with 206 patients using cross-linked porcine dermal collagen (Permacol™), 44 using porcine intestinal submucosa (Surgisis ©), 136 using human acellular dermal matrix (HADM) and 9 using a combination of Permacol™ and Surgisis©. Two studies did not specify the type of biological mesh used. There were 41 perineal hernias reported but rates were not consistently reported in all studies. The most common complications were perineal wound infection and perineal pain. However, there are no standardised measures for reporting perineal outcomes following ELAPE. There are very few studies comparing the use of biological mesh for perineal reconstruction for ELAPE. Two case series compared biological mesh with myocutaneous flaps and one series compared laparoscopic ELAPE with laparoscopic and open APER. Only one RCT was identified that compared patients undergoing ELAPE with perineal reconstruction using a biological mesh, with patients undergoing a conventional APER with no mesh. There was no significant difference in perineal hernia rates or perineal wound infections between the two groups although there were fewer positive circumferential resection margins in the ELAPE group. Conclusion The literature suggests that perineal closure using a biological mesh produces wound infection and complication rates that are comparable to other methods of reconstruction such as myocutaneous flaps. Biological mesh-assisted perineal reconstruction is a promising technique to improve wound healing but the results from high-quality prospective RCTs are required or national/international collaborative audits using statistical process control as a methodology of assessment of improvement.

Author-supplied keywords

  • Medline
  • acellular dermal matrix
  • case study
  • collagen
  • digestive system function disorder
  • excision
  • hernia
  • human
  • medical audit
  • methodology
  • morbidity
  • muscle
  • myocutaneous flap
  • patient
  • pelvis floor
  • perineal pain
  • process control
  • rectum
  • rectum abdominoperineal resection
  • submucosa
  • surgery
  • surgical mesh
  • wound complication
  • wound healing
  • wound infection

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Authors

  • N N Alam

  • S K Narang

  • I R Daniels

  • N J Smart

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