Abdomino-Perineal Resection for Anal Cancer Impact of a Vertical Rectus Abdominis Myocutaneus Flap on Survival, Recurrence, Morbidity, and Wound Healing

Objectives: To evaluate the results of a vertical rectus abdominis myocutaneus (VRAM) flap after abdomino-perineal resection (APR) for anal cancer (AC). Background Data: APR is the only curative treatment for AC that recurs or persists after radiochemotherapy. To obtain a clear surgical margin, APR frequently includes a significant perineal exenteration, leaving a large defect surrounded by irradiated tissue. VRAM may facilitate the healing of such a wound and, by providing tissue that can cover a large defect, can facilitate a wide resection and thus may influence survival. Methods: All patients who underwent APR for AC between 1996 and 2007 were included. Results: Ninety-five patients (70 women) underwent APR, including 43 patients who subsequently received a VRAM flap. The remaining patients had an omentoplasty. Indications for APR were recurrence of AC (n = 46), persistence of disease (n = 41), and contraindication to radiotherapy (n = 8). The groups (VRAM vs. No VRAM) differed in age at surgery (56.3 vs. 62.1; P = 0.0263); administration of chemotherapy in addition to radiotherapy (81% vs. 59%; P = 0.0218); and stage (ypT3-T4 67.6% vs. 38.4%; P = 0.0394). Five-year overall and disease-free survival did not differ between the 2 groups (58.1% vs. 54.5%; P = 0.6756; 41.1% vs. 48.9%; P = 0.2756). Perineal complications were significantly less frequent following VRAM (26.8% vs. 48.9%; P = 0.0336), with reduced time to healing (18.7 vs. 117 days; P = 0.0019) and the ratio of wound healing to survival time (5.6% vs. 19.4%; P = 0.0176). No difference was observed in the incidence of abdominal incisional hernias (9.3% vs. 9.6%), but patients who underwent a VRAM flap pelvic reconstruction had fewer perineal hernias (0% vs. 15.4%; P = 0.0072). Conclusions: Survival in the 2 groups was equivalent despite the presence of more advanced cancers in the VRAM flap cohort. This may be explained by the more extensive resections that were performed in this group. VRAM is an effective technique for reducing both the perineal complication rate and wound-healing delay in patients undergoing APR for AC that does not increase abdominal wall morbidity. (Ann Surg 2009;250: 707-711)