Prevention and Management of Nonhealing Perineal Wounds

The Perineal Wound

Prevention and Management of Nonhealing Perineal WoundsThe  perineal wound  resulting  from  an abdominoperineal resection  (APR) has always   been  considered  troublesome. Miles’  original description  of the treatment of the  perineal incision  involved leaving  it open  to heal by secondary intention, a  strategy resulting in  a  long-term chronic  wound.6

Modern use  of  chemotherapy and postoperative  radiation called  for more reliable closure of the perineum to expedite post  operative care.  However, even  when primary closure is instituted, high  rates of both wound infection (11–16%) and delayed wound healing can  be  apparent.2–6 A recent study from  the  University of Pennsylvania examined  the effect of surgical technique on perineal wound infection rates. In this study,  150 patients undergoing APR for  both inflammatory bowel  disease (IBD) and  cancer were evaluated. The overall rate  of major wound infection was  30%. Lithotomy position for perineal dissection was found to be major risk factors for major perineal  wound  complications. Those  patients who were turned to the prone position for perineal dissection and closure  had a wound infection rate of 11 versus 36% for those dissected in the lithotomy position (p < 0.005).7 In this study, a statistically significant increase  in perineal wound infection was  also seen in patients treated with neoadjuvant radiation therapy  (p ¼ 0.027),   those   undergoing   surgery  for   IBD (p ¼ 0.018),    and    in    cases    with   blood    loss      600   mL (p ¼ 0.032). These results are similar to those in a large study of over  600 patients at the Cleveland  Clinic where the total rate  of nonhealing was  16.2%.3 Obesity, neoadjuvant chemo-radiation,  and  intraoperative  bleeding  were   all  found  to significantly elevate risk of perineal wound infection in this review.

Proctectomy in  the setting of CD represents the  highest risk  of perineal wound infection across all  indications.  Pa- tients are often ill and malnourished, and  markedly immunosuppressed.  Complex fistulizing disease can make wide margins necessary. Primary closure is typically difficult, if not impossible.

Tissue flap reconstruction is often necessary both for wound healing and tissue coverage. The goal of flap reconstruction is to use  a nonirradiated, well-vascularized tissue to bridge a large defect.  Data  regarding  use   of  myocutaneous  flaps   in  the reconstruction of perineal wounds to aid healing and prevent wound complications are mostly retrospective. It is unclear that universal and  consistent  application of  these  techniques is necessary.8    However,  in  certain  instances, selective  use   of flap reconstruction can be beneficial; preoperative determination   of  those  wounds  best   managed  with flap   closure  is essential to minimizing postoperative wound complications.

Risk  factors that may  make  flap  reconstruction  a  better choice  include large  defect size,  reirradiated  anal  cancers,  presence of infected tissue, need for exenteration, procedures that include partial vaginectomy, and  patient conditions that increase  risk  for  wound infection and  primary  nonhealing, such  as  malnutrition and  prolonged  immunosuppression.9 The   use   of  neoadjuvant  chemotherapy  in   an   otherwise healthy patient is not a clear indication for use of flap closure  if blood loss is low, good apposition of tissue is possible (prone  positioning), and sepsis is nonexistent.

Flap choices most commonly include vertical  rectus ab- dominis myocutaneous (VRAM), gracilis, and gluteal flaps. The choice of flap is partially dependent upon surgeon experience, patient  positioning, and  tissue defect.  VRAM flaps  have  the most reliable  blood supply  and the advantage of the potential for a stable  skin pedicle  that can make large  defect or vaginal  reconstruction easier and tension free. The skin pedicle  works well  for  posterior  vaginal   wall  reconstruction and  forms a stable   “bridge”   in  those   with   large  central or  asymmetric perineal tissue losses. In a study of 18 patients who underwent VRAM following   APR for  recurrent anal  cancer,   four  were treated with immediate reconstruction and  healed uneventfully.  The remaining 14  patients were closed  primarily  with major wound complications in five.10  In another review, five of eight  patients operated upon  for  anal  cancer   with  primary closure developed serious wound complications while 14 with  VRAM closure  had uneventful recoveries.11

Gracilis flap closure  is a good strategy for smaller wounds or  wounds where  VRAM flap coverage is  unavailable (the patient has  or needs bilateral ostomies, or has  had  multiple abdominal operations in the past). Although the muscle alone  is  typically  used,   a  thigh skin  pedicle   can  be  harvested if needed. It suffers from a less-reliable blood supply and results in greater rates of tissue loss postoperatively. Even so, Shibata showed that  use  of  gracilis  flap  closure   resulted in  a  50% reduction in the rate  of wound failure  following proctectomy for the  treatment of recurrent rectal cancer.12

Data regarding the use of gluteal advancement flaps is not as robust.  These flaps  can  be used  successfully  in  the closure  of large  tissue defects created by  cylindrical APR.13  In a  series reported by  Baird,  15 of 16 patients achieved  wound  healing using this technique, though 7 patients did require local revision or ongoing  local wound care to achieve complete healing.14

Numerous studies have evaluated the outcomes of primary closure   of  the  perineal wound versus  secondary delayed closure.  Most reviews conclude that primary closure  is significantly superior to  secondary closure.15–19   More  rapid wound healing for  resumption of oncologic care,  improved quality of life, and less need for prolonged nursing assistance/ wound care make primary closure a better choice. A prospec- tive randomized trial that compared primary versus second- ary   closure techniques            demonstrated a significant improvement in wound healing  in the initial 3 postoperative months with primary closure of any type.20  Although perineal wound infections were also higher in the primary closure group, they were  generally under 20%.

Clearly, wound infection and nonhealing in proctectomy is multifactorial.  Knowledge  of risks  and   mitigation  of  risk factors play a very important role in the anticipation, preven- tion, and treatment of this complication. Myocutaneous flaps may be used selectively in those patients with risk factors for perineal wound dehiscence.

Operative Planning

It is estimated that    14% of patients with CD will ultimately require proctectomy12  for  failure of both  medical  manage- ment and  local  surgical  therapy.  A  complete proctectomy needs to be carefully timed and  planned in these individuals who  may  be  malnourished and  immunosuppressed. Early studies  demonstrated wound failure  rates between 36.8 and 78.9%.21–23 A more recent study by Yamamoto et al reported a 23% rate of failure  for primary closure  after proctectomy in the  setting of CD.24  These  wounds pose an impressive chal- lenge  that often  requires several  treatment strategies based on patient factors to allow  for successful healing. There  are typically two scenarios that lead to proctectomy: fulminant or toxic colitis  with  extensive rectal involvement and  refrac- tory perianal sepsis with fistulization and anal stenosis. These conditions require different approaches.

A subtotal colectomy with an end  ileostomy and a mucous fistula  or   a   Hartmann closure    of   the    rectal   stump  is recommended in most patients with fulminant or toxic colitis and  rectal involvement as  most  patients  are  extremely ill, malnourished, and steroid dependent; removing the  abdominal  portion  of the colon  alone  results in  rapid  reversal  of symptoms. Avoidance of proctectomy is feasible in the majority of these patients; attempts at proctectomy in these sick patients often result in  excessive  hemorrhage,  damage to pelvic nerves and surrounding structures, and other technical misadventures. Uncertainty regarding the diagnosis (CD vs. ulcerative colitis)  can  also  make  proctectomy undesirable. The risk of perineal sepsis and  wound dehiscence increases significantly in these  critically  ill patients. Need  for expeditious colectomy is paramount;  subsequent consideration  of proctectomy or  reconstruction can  be  done  later  when  the patient is well  nourished, pathology has been  reviewed, and immunosuppression has been discontinued. In patients with CD with  rectal involvement, further medical management of residual rectal disease  may  be  favorable to  proctectomy as long as  symptoms are  tolerable.  Occasionally,  treatment of the  remaining rectum allows  ileorectal anastomosis to take place.  If not,  a  staged completion proctectomy in  a healthy patient may  serve  to decrease risks  of complications.

Patients with  longstanding, complex   perianal  CD  who require proctocolectomy are  a  far  more  common problem. These patients may need proctectomy secondary to advanced complex perianal  fistulas or stenosis that has rendered the anus  nonfunctional. Perianal  sepsis created by abscesses or undrained fistulas or  sinus  tracts may  increase the risk  of perineal wound complications. In the setting of active perianal  sepsis,  it is  advisable to  proceed with  abscess drainage first,  seton placement if required,  and  delayed resection  to allow  the acute phase  of  infection to pass.  Fecal  diversion (diverting ileostomy/colostomy or  Hartmann procedure) in severe  cases  may  allow  the disease to  transition to a more quiescent state  prior to  proctectomy and   may  be  a  good stepwise  strategy, along  with  abscess drainage, to allow resolution of the septic focus  and  general  improvement of the  patient’s health and  nutrition.

Special technical considerations that may be specific to CD exist  because of  its unique  pathology.  Fistulas,  both transphincteric and supralevator, can complicate proctectomy by creating a  fibrotic,  inflamed field  that makes  native  tissue apposition difficult. Rectal strictures, as well as patient factors including malnutrition  and  immunosuppression,  are   also potential complicating features  of CD.

Though there is little data  regarding the association of CD-related anorectal strictures with  the  outcomes of  proctec- tomy, Linares et al reported their experience with  19 proctectomies in  such  patients.  Nine  patients had  delayed healing and  in three, healing  was  not  complete by 12 months.25  In a review of patients with CD with rectal  stricture  compared with   those that did  not,  Fields  et al  reported that 50%  of patients with rectal stricture also had concomitant perirectal abscesses, whereas only  17.1% of those without rectal stricture26 were  affected by  undrained perianal  sepsis.  Given these  findings, rectal stricture is  more likely  a  marker for active perineal sepsis,  which  in turn is more likely to account for   wound  failure.   In  patients with  a  rectal  stricture, a thorough exam of the perirectal region to ensure adequate control of  sepsis prior to  radical  resection may  indirectly result  in better overall wound healing.

Patient Factors

Patients with  severe systemic disease may  suffer from  protein-calorie malnutrition characterized  by weight loss  and low  albumin and  prealbumin  levels.  These  deficiencies are typically obvious and  those patients with  albumin levels  below  3 g/dL may  benefit from  preoperative total parenteral nutrition.  However,  even  despite advances  in  overall nutrition and health of chronically ill patients, microdeficiencies of certain vitamins can still hamper postoperative wound healing. In the setting of active and  recurrent CD, food intake is typically overall decreased. A recent study demonstrated that even  for  patients in  clinical  remission,  avoidance of  major food groups continued, with 18 to 33% of patients with IBD avoiding grains,  dairy, and/or vegetables.27

Zinc, vitamin A, and vitamin C are all essential nutrients for wound healing. Glucocorticoids  impair  zinc absorption and increase vitamin C losses. Furthermore, zinc and vitamin A are lost in  the stool  during bouts  of diarrhea and  steatorrhea, respectively. Zinc losses  are  significantly higher in  patients with   fistulizing CD, despite a  normal  weight and   even   a normal albumin level.28 For patients on corticosteroids, vitamin   A 10,000  to  15,000  IU/day  has  been  recommended to enhance wound healing.29,30  Vitamin C supplementation is also recommended at a dose of 100 to 200 mg/day  to enhance wound healing.29  The suggested dosing  for zinc supplementation is 40 mg  of elemental zinc  (176-mg zinc  sulfate) for 10  days;  however,  these doses should  not  be  continued for more than 2 to 3 weeks as excess zinc may interfere with other metabolites and  result in other  mineral deficiencies.28

There is abundant evidence in the literature that obesity  is also a risk factor  for wound infection after rectal resection.31 Nystrom and  colleagues compared wound thickness to rates of postoperative infection in 189 colorectal operations; they  found  that for wounds > 3.5 cm, the rate of infection was 20% versus 6.8% for wounds that were  < 3.5 cm in depth.32  The difficulty of managing a perineal wound is compounded in an obese  patient, as access  for wound care  is more difficult and  the  larger wound  takes longer to  heal.  In  a  retrospective review of 584 consecutive patients, Benoist et al reported a higher rate of complications in left-sided and pelvic resection in obese  patients. They reported a mortality rate of 5% after  proctectomy among obese patients versus  0.5% among  non- obese  patients. Forty-three percent of obese  patients undergoing   proctocolectomy required  a   blood   transfusion,   as

opposed to 19% of nonobese patients (p < 0.02).33

The  detrimental  effects  of  smoking  on  the  healing of perineal wounds in the  setting of CD are likely multifactorial. Smoking  is  a well-known risk  factor for  clinical  relapse of CD,34–36 as well  as an  independent risk  factor  for  impaired wound  healing.37,38 For  patients who   are  active  smokers, abstention from  smoking is advised  for at least  4 to 6 weeks preoperatively to achieve  a significant decrease in the  rate of wound complications.37,38

Antitumor Necrosis Factor Therapies

A recent prospective database demonstrates that patients oper- ated on within  3 months of infliximab administration did not experience an increased rate of intraoperative complications.39

A retrospective review by  Colombel and  colleagues  supports these   conclusions.40  A prospective study  of  413  consecutive patients at Massachusetts General Hospital, 24% of whom  had received  infliximab treatment within 12 weeks  of an operative procedure, found no significant difference in rates of postoperative complications in these patients versus patients that did not receive  infliximab preoperatively.41 Although the literature fails to separately consider perineal wound complications, it seems reasonable to adhere to general guidelines for operative intervention and antitumor necrosis factor therapy when considering perineal reconstruction.

Evaluation and  Treatment of Perineal Wounds

A  subset of  patients will  inevitably present  with  perineal wound  failures. The  first consideration  should always   be whether treatment needs  to be  performed urgently.  Sepsis clearly mandates immediate operative intervention to drain  pus  and obtain  source control of the  septic process. Patients who present nonurgently need  a thorough evaluation of the wound to assess for the best treatment strategy.

Physical Examination

  1. Wound size:  Wound size  may  range from  a  superficial sinus to a complete dehiscence of the perineal wound.
  2. Wound  effluent:  Purulent, serous,  or  feculent  discharge should  be noted.
  3. Foreign body  reaction: Foreign  material and stitch granulomas  need  to be removed.
  4. Tissue quality: Evaluate the viability of the perineal tissue.

Ensure all fibrinous exudate is debrided and  all nonviable tissue is resected to healthy tissue.

Although  rare, conversion of a nonhealing wound or fistula to either squamous cell  carcinoma or  adenocarcinoma has  been reported.42–46   Chronic,  nonhealing wounds, or  wounds that appear hard,  ulcerated, or  fungating should be biopsied. The use of examination under anesthesia  is often needed to better explore the wound, debride necrotic tissue, and facilitate biopsy.

In deeper wounds that are difficult to fully evaluate due to extent  or  patient  discomfort, the  utilization of  additional imaging (either  computed tomography [CT] scan or magnetic resonance imaging [MRI]) may  be helpful. Undrained collections, foreign bodies,   and  enterocutaneous fistulas  can  be detected  and  defined.

Treatment Strategies for Perineal Wound Complications

The  initial management of nonseptic wound  dehiscence is typically conservative. In general,  this is comprised of wound care  with dressing changes.  If all  sources of  infection are controlled and  all necrotic tissue is debrided, 89% of wounds will heal within 6 months.47

The decision to proceed with simple dressing changes as opposed to more aggressive options depends upon the quality and size of the wound, patient comorbidities, and  overall  health. A large, clean wound in a radiated field can still take a significant amount of time to heal. Costs and inconvenience to the  patient associated with this strategy need to be considered. Nonrandomized studies and case reports exist describing  the use  of  negative-pressure  vacuum-assisted  wound closure   systems for  the  primary  treatment  of  infected or nonhealing perineal wounds.48,49 For some  contaminated wounds or wounds in patients who  cannot undergo simultaneous   flap   reconstruction,  this may   be  an  alternative to consider.  In a larger wound,  it  may  be  used as  a bridge  to myocutaneous flap reconstruction.

Persistent  perineal sinus   is  defined by  Watts  et  al  as persistence greater than  6 months postoperatively.49  Treatment options include serial debridement and  curettage, lay open techniques with marsupialization, or wide excision with primary closure or tissue flap  closure.  The goal is to remove chronic  fibrosis and  establish conditions more likely to heal. Wide  excision  was  described  by  Ferrari  and  DenBesten. In their series, they reported favorable results for wide excision, coccygectomy, and  skin  graft.50  Despite reports  of favorable results, one must keep  in mind  that skin grafts in the perineal region  are  exposed to a difficult  wound environment in the setting of  high   sheer   forces  and   are  typically not  used routinely if other tissue coverage options are  available.

Numerous studies demonstrate the benefit of  myocutaneous    flaps    for    management  of    non-healing    perineal wounds.8,51–54 Kapoor  et al demonstrated that selective use of flaps offers significant improvements in wound complication  rates.8   As with the use  of  flaps   for  primary  closure, gracilis  flaps  for  the  management of a  nonhealing perineal wound may  be slightly less successful  than VRAM flaps (50–100% vs. 90%, respectively); however,  gracilis flaps have  the advantage of avoiding an abdominal incision. The same is true for gluteal rotational flaps.  Rotational tissue flaps  require a healthy, well-nourished patient and a clean wound bed free of sepsis  with  good  granulation tissue to be successful. Tissue flaps  should  be  considered in  select patients with delayed closure or persistent sinuses.51 Use of flaps for delayed wound healing  is dependent upon  the  size and  quality of the wound and the  ability of the patient to medically tolerate additional procedures.

Conclusions

Perineal wounds after  proctectomy can be a challenging issue  for the clinician.  Individuals with CD, recurrent anal or rectal cancer, and  previous pelvic radiation are at increased risk for wound  failure.   Considerations regarding  staged  operative interventions as well  as myocutaneous flaps  may help  prevent wound failure  in  these  instances.  Attention to patient nutrition and comorbidities can minimize the risk of infection and subsequent nonhealing as well. Patients with nonhealing wounds despite preventative measures should be examined for foreign  bodies,  granulation tissue, and deep sinus tracts. If optimization of patient nutrition, drainage of septic  foci, and local  debridement and   wound  treatment fail  to  result in wound  healing,    then   a   myocutaneous  flap   should   be considered.

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