Management of the Unhealed Perineal Wound After Proctectomy


PICO/clinical question

Patient population

Patients with unhealed perineal wounds/PPS following proctectomy

Intervention

Surgical advancement flap

Comparator

Non-operative strategy/local wound care

Outcome

Primary perineal wound healing





Literature Search Strategy


All studies evaluating the management of perineal wounds following proctectomy were considered for inclusion. Inclusion was not restricted to study design, and all types of studies (retrospective vs. prospective, randomized vs. non-randomized, observational, etc.) were eligible for consideration. Studies were identified via search of the Pubmed database (1991–2015) with the following MeSH terms: “postoperative complications”, “perineum”, and “wound healing”. The results were then evaluated for relevancy to the topic, and citation lists of relevant papers were reviewed for further references. All papers were evaluated for the quality of their evidence and recommendations via the GRADE approach (Grades of Recommendation, Assessment, Development, and Evaluation). Papers were classified in quality as high, moderate, low, or very low based on multiple factors including methodology, consistency, precision of results, and directness of the evidence given [12, 13].


Non-operative Strategies


Conservative approaches for the management of the unhealed perineal wound include local wound care, topical medications and antibiotics, chemical debridement agents, fibrin glue, and negative pressure wound therapy [5]. Perineal wounds allowed to heal by secondary intention, which was the historical standard prior to the adoption of primary closure, can often result in a prolonged healing course [14]. Important factors to consider for optimizing wound healing include nutritional status, blood supply, and immune function. Ongoing infection within the wound will impair the healing process, as will devitalized tissue such as necrotic material or fibrinous exudate. The removal of such devitalized tissues via surgical debridement and control of any localized sepsis has been shown to accelerate healing.


Debridement


Debridement refers to the surgical removal of devitalized tissue, with the goal to promote the growth of the underlying healthy tissue. Various forms of debridement include sharp debridement, biosurgical debridement, chemical debridement, mechanical debridement, enzymatic debridement, and autolytic debridement [14]. Sharp debridement, typically using either a scalpel or scissors, can be performed either in the operating room or at the bedside, depending on the extent of the wound debridement and patient pain control. The wet to dry dressing, frequently applied within the realm of postsurgical care, utilizes both mechanical and autolytic debridement. Comparisons of modern dressings (alginates, hydrocolloids, polyurethane foam, silicone foam) to traditional gauze dressings seem to suggest a modest improvement in wound healing with modern dressings, though these studies have been criticized for small sample sizes and methodological flaws [14].


Local Antibiotic Agents


As ongoing perineal sepsis is a risk factor for PPS and a major cause of delayed wound healing, many agents have been developed to target local pathogenic bacterial populations with the goal of preventing deep space infection and promoting healing. There are multiple delivery agents for local antibiotics, including sponges, fleeces, injections, and beads. Some agents appear to confer some benefit due to their space filling potential, with decreased seroma incidence and improved hemostasis [15]. A prospective trial found that gentamicin absorbable fleeces used following APR reduced postoperative wound infection to 6 % compared to 21 % of controls, but this did not translate into a statistically significant improvement in rates of wound healing [16]. A large multicenter randomized control trial comparing gentamicin-collagen fleeces following APR to standard care failed to demonstrate any reduction in perineal wound complications [17]. Due to the lack of consistent evidence demonstrating benefit, we do not recommend the routine use of local antibiotic agents. This advice is consistent with a large systemic review on the use of local gentamicin which did not support its use following APR [15].


Negative Pressure Wound Therapy


Vacuum assisted closure (VAC) is typically performed with foam wound dressings (either packed or at the skin surface) under negative pressure, and has become an increasingly common tool used for difficult surgical wounds to expedite the secondary intention healing process [18]. Its proposed mechanism decreases bacterial colonization within the wound, as well as tissue edema and wound tension, while increasing blood flow to the wound area [19]. Further, the device may confer benefit by creating a mechanical stimulus at the wound site, stimulating neo-angiogenesis, and enhancing granulation tissue production [20]. The tight seal associated with the VAC equipment additionally prevents exogenous contamination between dressings. Some frequent issues with these devices include their high costs, bulky size (which prevents patient mobility), and increased expertise required for dressing changes and device management [20]. It also should be avoided in patients susceptible to fistula formation [21]. Maintaining the necessary tight seal of the appliance may also be difficult due to the contours of the perineal space [22]. Recent improvements in technology including smaller, battery-operated vacuum canisters that have allowed increased patient mobility and more frequent use in the outpatient setting [22].

While there is considerable literature on negative pressure therapy, there is little data on the use in persistent perineal wounds other than a few small case series [19, 22]. Fujino et al. reported four cases, two to prevent and two to treat perineal wounds following proctectomy. All of these cases were successful without noted complication [19]. Yousaf et al. reported a single case of a large PPS (extending up to S2 via sinogram) following proctocolecotmy for IBD, which healed successfully with VAC therapy after 15 days [22]. This therapy has proven to be a safe and effective modality for wound healing and has shown promise in both the prevention and closure of complex perineal wounds [18].


Endoscopic Approaches: Sinusoscopy


The use of an endoscope to visualize and washout the perineal sinus cavity is a novel technique described by Al-Sheikh et al. [21]. They describe successful closure of three perineal sinus cavities, between 55 and 655 days old, with a technique that involves introduction of a pediatric gastroscope into the perineal sinus cavity. The gastroscope is used to irrigate the cavity with a hydrogen peroxide and saline mixture under direction visualization followed by endoscopic breakdown of loculations and curettage. This has the added benefit of allowing for monitoring for cancer recurrence with biopsies. This procedure is not recommended unless the perineal sinus is well developed, and may have the risk of causing sepsis or intraperitoneal air. There is little evidence on the safety of this technique and no additional studies to validate its efficacy.


Hyperbaric Oxygen Therapy


The use of hyperbaric oxygen therapy has demonstrated efficacy in improving healing in difficult, chronic wounds such as diabetic foot ulcers [6]. A small case series featuring IBD patients with persistent “extreme” PPS following proctectomy showed complete healing in all four patients with preoperative hyperbaric oxygen (25–30 sessions, 2.2–2.4 atm) combined with rectus abdominus muscle (RAM) flap, despite having previously failed multiple surgical interventions [6]. While this paper showed promising results with rapid wound healing of severe and chronic sinuses, further large and prospective studies are required to investigate any potential role of hyperbaric oxygen in the setting of perineal wounds.


Operative Strategies


The goals of reconstruction of the perineum following APR, as suggested by Sinna et al., include: avoid tumor recurrence, fill the dead space, and obtain skin healing [1]. The decision to reconstructa perineal wound, either immediately following APR or after development of PPS, is complex and multifactorial. The available evidence for the most common approaches will be outlined below. Prior to any additional operative intervention it is critical to evaluate patient anatomy, patient surgical risk factors, and patient care goals.


Omental Pedicle Grafts


The significant anatomical vacancy left following proctectomy leaves a space that can fill with fluid and become infected. One strategy is the use of omental pedicle grafts to fill the defect. Technically this can be accomplished via creation of a vascular pedicle (typically based off the right or left gastro-epiploicvessels), with pelvic delivery via either a retrocolic or paracolic approach [20]. This graft can typically be performed with a laparoscopic approach, and is not as time-intensive or invasive as other autologous tissue grafts. A systemic review of omental pedicle flaps evaluated 14 studies including 891 patients. Primary perineal wound healing was 67 % with an average time of 24 days for patients receivingo mental pedicle flaps compared to 50 % with an average time of 79 days for patients without omental pedicle flap. Importantly, operating time was only minimally increased and there were few reported complications to the procedure [20]. One disadvantage to this technique in the setting of an unhealed perineal wound is the necessity of an additional major abdominal operation [23]. It is for this reason that the majority of such omental pedicle grafts are performed as immediate reconstructions during the abdominal portion of APR or proctocolectomy.


Wide Excision and Split Thickness Skin Grafts


The use of wide excision of the sinus followed by split thickness skin grafting of the perineum is an operative intervention that has the advantage of less donor site morbidity and ease of procurement of the graft compared to a muscle flap or omental flap. McLeod et al. reported healing in five of nine patients with this technique in a small case series [24]. Due to a difficult wound environment in the perineum, with high levels of sheering forces, the split thickness skin graft is now rarely utilized in perineal wounds when other grafts are available [8].


Gracilis Muscle Flap


The gracilis muscle flap is performed with a longitudinal incision in the medial thigh to harvest a gracilis muscle vascular pedicle (from the medial circumflex femoral artery), and subsequently transposing the pedicle to the perineal defect [3]. The loss of gracilis muscle, either unilaterally or bilaterally, does not cause significant functional limitations. This advancement flap is most successful when the sinus to be filled is relatively narrow, and is less ideal when there is an extensive pelvic space for which it may be less than sufficient [3]. The gracilis flap has a high partial skin necrosis rate which may compromise the flap and cause further morbidity [25].


Rectus Abdominus Myocutaneous Flap


The rectus abdominus muscle (RAM) flap can be harvested in various configurations with a pedicle derived from the superior or inferior epigastric arteries [26]. This can be performed with multiple variations at the donor site including a vertical harvest (VRAM), transverse approach (TRAM), and oblique orientation (Taylor’s Flap) [27]. Noted advantages to this flap include its availability within the operative field, ability to be harvested extraperitoneally, and its reliability. It can provide substantial bulk when a large pelvic defect needs to be closed. However as laparoscopic approaches become more common for the abdominal portion of the operation, the RAM may create unwanted abdominal sequelae such as increased postoperative pain and pulmonary complications [27]. Additionally a major potential drawback with the use of the rectus abdominus muscle in the setting of colorectal surgery is the loss of potential sites for ostomy creation [3]. Other potential donor site morbidity include the possibility of ventral hernias at the donor site due to weakening of the abdominal wall, which may be ameliorated with propylene mesh placement at the procurement site [26]. Other variations intended to decrease the donor site morbidity include the muscle sparing VRAM (ms-VRAM), the deep inferior epigastric perforator flap, as well as fascial-sparing techniques [27].














































Intervention

References

Study design

GRADE of evidence

Summary of recommendations

Debridement and curettage

Lewis et al. (2001) [14]

Review and metanalysis

Moderate

Some modern dressings (i.e., hydrocolloid, alginate, and foam dressings) may improve secondary intention wound healing compared to traditional gauze, however many trails suffered from methodological flaws and may be prone to bias.

Local antibiotic agents

Collin et al. (2013) [17]

Multicenter RCT (7 hospitals, n = 102)

High

No significant differences in perineal wound healing were noted between those who received local gentamicin-collagen and those who did not.

Negative pressure (VAC) wound therapy

Fujino et al. (2015) [19]

Case series (n = 4)

Very low

VAC therapy appears to be a useful adjunct to speed perineal wound healing by secondary intention.

Endoscopic approaches

Al-sheikh et al. (2015) [21]

Case series (n = 3)

Very low

Patients tolerate the procedure safely without serious complication, and exhibited perineal wound healing. Further evidence is needed with larger trials prior to further recommendation.

Hyperbaric oxygen

Chan et al. (2014) [6]

Case series (n = 4)

Very low

Hyperbaric oxygen therapy, followed by PPS excision and RAM flap, led to complete wound healing in all patients in study. Appears to be a safe treatment modality for extreme and persistent perineal wounds

Only gold members can continue reading. Log In or Register to continue

Jul 13, 2018 | Posted by in ABDOMINAL MEDICINE | Comments Off on Management of the Unhealed Perineal Wound After Proctectomy
Premium Wordpress Themes by UFO Themes