06.12 Gracilis flap reconstruction following abdominoperineal resection and proctocolectomy

O. M. DeLozier¹, Z. E. Stiles¹, J. M. Monroe¹, P. V. Dickson¹, J. L. Deneve¹, A. Mathew¹, D. Shibata¹, R. M. Chandler¹, S. W. Behrman^{1  1}Univeristy Of Tennessee Health Science Center,Surgery,Memphis, TN, USA

Introduction:
Vascularized pedicle flap reconstruction of the perineal defect following abdominoperineal resection (APR) or proctocolectomy (PC) can reduce pelvic wound complications.  We assessed outcomes utilizing pedicle-based gracilis flap reconstruction (GFR) in the setting of immunosuppressant therapy, fistulous disease, and neoadjuvant chemoradiation.

Methods:
Patients undergoing APR or PC with GFR were retrospectively reviewed.  Analysis included diagnoses, comorbidities, preoperative chemoradiation and immunosuppression, along with donor and recipient site complications.

Results:
Forty-one patients underwent GFR for rectal cancer (n=31) inflammatory bowel disease (n=7), or severe fistulizing disease (n=3) .  Mean age was 60, BMI was 26.8, and serum albumin was 3.3.  Nineteen (46%) patients used tobacco.  Ten patients (24%) were immunosuppressed, and 27 (66%) underwent preoperative chemoradiation.  Nineteen (46%) flaps were unilateral, and 22 (54%) were bilateral.  Twenty (49%) patients had minor wound complications, treated with dressing changes or antibiotics (2 donor, 18 perineal).  Eight (20%) patients had major complications (2 donor, 6 perineal), with 3 (7%) patients requiring reoperation for flap necrosis or abscess.  The three threatened flaps were unilateral, and salvaged with debridement and drainage, one requiring reinforcement with a gracilis flap from the contralateral thigh. Thigh donor site morbidity was minimal, occurring in 4 (10%) patients, all managed non-operatively.  Patients with major complications were older (57 vs 68 years old, p=0.07), but, otherwise, similar regarding BMI, serum albumin, tobacco use, operative time, and blood loss in this series of 41 patients.

Conclusion:
In high-risk perineal wounds, gracilis flap offers durable reconstruction with acceptably low morbidity.  Donor site complications were rare, and all managed non-operatively.  A minimal number of flaps were threatened, and all were salvaged with operative intervention.  The three threatened flaps were unilateral, perhaps suggesting superiority of bilateral flaps.