title: Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database.
abstract: OBJECTIVE
  The perineal wound following abdominoperineal excision (APR) is associated with a high complication rate. We aimed to evaluate the risk factors for wound complications and examine the effect of flap reconstruction on wound healing.
  
  
  METHODS
  The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was searched for patients who underwent APR for rectal adenocarcinoma. They were divided into two groups: primary closure of the perineal wound and flap reconstruction. A logistic regression analysis was performed to identify the risk factors for deep surgical site infection (SSI) and wound dehiscence.
  
  
  RESULTS
  A total of 8449 (94%) patients from the database underwent primary closure and 550 (6%) underwent flap reconstruction. Patients who underwent flap reconstruction had a longer operation time, a higher incidence of deep SSI, wound dehiscence, more blood transfusion requirement and a higher rate of return to the operating room (all P < 0.001). Risk factors for deep SSI were African American race (OR 1.5, P = 0.02), American Society of Anesthesiologists (ASA) classification ≥ 4 (OR 3.2, P < 0.001), body mass index (BMI) ≥ 35 kg/m(2) (OR 1.7, P = 0.006), weight loss (OR 2, P < 0.001) and closure with a flap (OR 1.9, P < 0.001). Risk factors for wound dehiscence included ASA classification ≥ 4 (OR 2.2, P = 0.003), history of smoking (OR 2.2, P < 0.001), history of chronic obstructive pulmonary disease (OR 1.7, P = 0.03), BMI ≥ 35 kg/m(2) (OR 1.9, P = 0.001) and closure with a flap (OR 2.9, P < 0.001).
  
  
  CONCLUSIONS
  Perineal wound complications are related to a patient's race, ASA classification, smoking, obesity and weight loss. Compared with primary closure, closure with a flap was associated with higher odds of wound infection and dehiscence and was not protective of wound complications in the presence of other risk factors. Therefore optimizing the patient's medical condition will lead to a better outcome irrespective of the technique used for perineal wound closure.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: A A
authors.initials: AA
authors.lastname: Althumairi
authors.affiliation: Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: J K
authors.initials: JK
authors.lastname: Canner
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: S L
authors.initials: SL
authors.lastname: Gearhart
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: B
authors.initials: B
authors.lastname: Safar
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: S H
authors.initials: SH
authors.lastname: Fang
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: E C
authors.initials: EC
authors.lastname: Wick
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: J E
authors.initials: JE
authors.lastname: Efron
mesh_terms: D000005:Abdomen / Q000601:surgery; D000230:Adenocarcinoma / Q000601:surgery*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010502:Perineum / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000009:adverse effects* / Q000379:methods; D012004:Rectal Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D013524:Surgical Flaps / Q000009:adverse effects*; D013529:Surgical Wound Dehiscence / Q000209:etiology*; D013530:Surgical Wound Infection / Q000209:etiology*; D016896:Treatment Outcome
keywords: Abdominoperineal excision; flap reconstruction; rectal cancer; wound healing