The Role of Autologous Flap Reconstruction in Patients with Crohn's Disease Undergoing Abdominoperineal Resection.

BACKGROUND Patients with symptomatic Crohn's disease who undergo abdominoperineal resection can experience impaired postoperative wound healing. This results in significant morbidity, burdensome dressing changes, and increased postoperative pain. When abdominoperineal resection is performed for oncological reasons, autologous flap reconstruction is occasionally performed to optimize wound healing and reconstruction outcomes. However, the role of flap reconstruction after abdominoperineal resection for Crohn's disease has not been established. OBJECTIVE This study examines the utility of flap reconstruction in patients with symptomatic Crohn's disease undergoing abdominoperineal resection. We hypothesize that patients with immediate flap reconstruction after abdominoperineal resection will demonstrate improved wound healing. DESIGN This study is a retrospective chart review. SETTINGS Eligible patients at our institution were identified from 2010 to 2018 by using a combination of Current Procedural Terminology, International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision codes. PATIENTS Of 40 adult patients diagnosed with Crohn's disease, 20 underwent abdominoperineal resection only and 20 underwent abdominoperineal resection with flap reconstruction. INTERVENTIONS Immediate autologous flap reconstruction was performed after abdominoperineal resection. MAIN OUTCOME MEASURES The primary outcomes measured were the presence of postoperative perineal wounds and postoperative wound care burden. RESULTS Patients in the abdominoperineal resection with flap reconstruction group demonstrated significantly worse preoperative disease traits, including fistula burden, than patients in the abdominoperineal resection only group. A lower number of patients tended to be associated with a persistent perineal wound in the flap group at 30 days (abdominoperineal resection with flap reconstruction = 55% vs abdominoperineal resection only = 70%; p = 0.327) and at 6 months (abdominoperineal resection with flap reconstruction = 25% vs abdominoperineal resection only = 40%; p = 0.311) postoperatively. There was also a trend toward a lower incidence of complications in the flap group. Patients in the abdominoperineal resection with flap reconstruction group tended to experience lower postoperative pain than patients in the abdominoperineal resection only group. LIMITATIONS This retrospective cohort study was limited by its reliance on data in electronic medical records, and by its small sample size and the fact that it was a single-institution study. CONCLUSIONS In select patients who have severe perianal fistulizing Crohn's disease, there may be a benefit to immediate flap reconstruction after abdominoperineal resection to lower postoperative wound care burden without significant intraoperative or postoperative risk. In addition, flap reconstruction may lead to lower postoperative pain. See Video Abstract at http://links.lww.com/DCR/B416. EL ROL DE LA RECONSTRUCCIN CON COLGAJO AUTLOGO EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIN ABDOMINOPERINEAL ANTECEDENTES:Los pacientes con enfermedad de Crohn sintomatica que se someten a una reseccion abdominoperineal pueden experimentar una curacion posoperatoria deficiente de la herida. Esto da como resultado una morbilidad significativa, cambios de aposito molestos y un aumento del dolor posoperatorio. Cuando se realiza una reseccion abdominoperineal por razones oncologicas, ocasionalmente se realiza una reconstruccion con colgajo autologo para optimizar los resultados de la curacion y reconstruccion de la herida. Sin embargo, no se ha establecido la funcion de la reconstruccion con colgajo despues de la reseccion abdominoperineal para la enfermedad de Crohn.OBJETIVO:Este estudio examina la utilidad de la reconstruccion con colgajo en pacientes con enfermedad de Crohn sintomatica sometidos a reseccion abdominoperineal. Presumimos que los pacientes con reconstruccion inmediata con colgajo despues de la reseccion abdominoperineal demostraran una mejor curacion de la herida.DISENO:Revision retrospectiva de expedientes.MARCO:Los pacientes elegibles en nuestra institucion se identificaron entre 2010 y 2018 mediante una combinacion de los codigos de Terminologia actual de procedimientos, Clasificacion internacional de enfermedades 9 y Clasificacion internacional de enfermedades 10.PACIENTES:Cuarenta pacientes adultos diagnosticados con enfermedad de Crohn que se someten a reseccion abdominoperineal solamente (APR-solo = 20) y reseccion abdominoperineal con reconstruccion con colgajo (APR-colgajo = 20).INTERVENCION (ES):Reconstruccion inmediata con colgajo autologo despues de la reseccion abdominoperineal.MEDIDAS DE RESULTADOS PRINCIPALES:Presencia de herida perineal posoperatoria y carga de cuidado de la herida posoperatoria.RESULTADOS:Los pacientes del grupo APR-colgajo demostraron rasgos de enfermedad preoperatoria significativamente peores, incluida la carga de la fistula, en comparacion con los pacientes del grupo APR-solo. Un numero menor de pacientes tendio a asociarse con una herida perineal persistente en el grupo de colgajo a los 30 dias (APR-colgajo = 55% vs APR-solo = 70%; p = 0.327) y 6 meses (APR-colgajo = 25% vs APR-solo = 40%; p = 0.311) postoperatoriamente. Tambien hubo una tendencia hacia una menor incidencia de complicaciones en el grupo APR-colgajo. Los pacientes del grupo APR-colgajo tendieron a experimentar menos dolor posoperatorio en comparacion con el grupo APR-solo.LIMITACIONES:Estudio de cohorte retrospectivo basado en datos de historias clinicas electronicas. Tamano de muestra pequeno y estudio de una sola institucion.CONCLUSIONES:En pacientes seleccionados que tienen enfermedad de Crohn fistulizante perianal grave, la reconstruccion inmediata del colgajo despues de la reseccion abdominoperineal puede beneficiar a reducir la carga posoperatoria del cuidado de la herida sin riesgo intraoperatorio o posoperatorio significativo. Ademas, la reconstruccion con colgajo puede resultar un dolor posoperatorio menor. Consulte Video Resumen en http://links.lww.com/DCR/B416.