title: Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience.
abstract: BACKGROUND
  Abdominoperineal resection (APR) is the surgical treatment of low-lying rectal cancers and other pelvic malignancies. Plastic surgery offers a means to close these complicated defects through obliterating dead space, providing tension-free closure, and introducing vascularized tissue into a radiated field. The indications for reconstructive surgery and choice of reconstruction are debatable. This study aims to identify when and which reconstruction is preferred.
  
  
  METHODS
  A retrospective comparative analysis was performed on all patients undergoing APR at Stanford Hospital between 2007 and 2013. Data points included demographics, disease, operative positioning, and postoperative complications. Univariate analysis and multivariate logistic regression analysis were performed to identify markers of flap reconstruction and complications.
  
  
  RESULTS
  A total of 178 APRs were performed, of which 51 underwent flap reconstruction. The odds ratio of all complications between flap and primary closure was not significant at 1.36 (0.69-2.66). Independent predictors for flap reconstruction included prone positioning, anal squamous cell carcinoma (SCC), prior smoking, and neoadjuvant chemoradiation therapy. Univariate predictors of flap reconstruction included female gender and combined vaginectomy. Independent predictors of complications included current and prior smoking. Muscle flap closure had lower recipient site complications than V-to-Y advancement closure (20% vs. 50%, p = 0.039).
  
  
  CONCLUSIONS
  Flap reconstruction following APR is associated with prone positioning, neoadjuvant chemoradiation, female gender, prior smoking, and anal SCC resections. Pedicled muscle flaps had a significantly lower rate of recipient site complications than V-to-Y advancement flaps and therefore should be the flap reconstruction of choice. The vertical rectus abdominis myocutaneous flap was superior to the gracilis flap in terms of the overall reduction of complications.
authors.affiliation: Division of Plastic Surgery, Stanford University, 770 Welch Road Suite #400, Palo Alto, CA 94304, USA.
authors.forename: Clifford C
authors.initials: CC
authors.lastname: Sheckter
authors.affiliation: Division of Plastic Surgery, Stanford University, 770 Welch Road Suite #400, Palo Alto, CA 94304, USA.
authors.forename: Afaaf
authors.initials: A
authors.lastname: Shakir
authors.affiliation: Division of Plastic Surgery, Stanford University, 770 Welch Road Suite #400, Palo Alto, CA 94304, USA.
authors.forename: Hong
authors.initials: H
authors.lastname: Vo
authors.affiliation: Division of Plastic Surgery, Stanford University, 770 Welch Road Suite #400, Palo Alto, CA 94304, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Tsai
authors.affiliation: Division of Plastic Surgery, Stanford University, 770 Welch Road Suite #400, Palo Alto, CA 94304, USA.
authors.forename: Rahim
authors.initials: R
authors.lastname: Nazerali
authors.affiliation: Division of Plastic Surgery, Stanford University, 770 Welch Road Suite #400, Palo Alto, CA 94304, USA. Electronic address: glee@stanford.edu.
authors.forename: Gordon K
authors.initials: GK
authors.lastname: Lee
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery*; D001005:Anus Neoplasms / Q000601:surgery; D015992:Body Mass Index; D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010502:Perineum / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D013524:Surgical Flaps; D016896:Treatment Outcome
keywords: Abdominoperineal resection; Colo-rectal cancer; Gluteal flap; Rectus flap; V–Y advancement