Unhealed Perineal Wound

Introduction

Excision of the rectum via a combined abdominal and perineal approach (i.e., an abdominoperineal resection [APR]) has been a time-honored technique for the management of rectal cancer and inflammatory bowel disease (IBD). However, achieving prompt and satisfactory healing of the perineum after such an approach is still a challenge. A wound that has not healed by 6 months after the surgery is considered an unhealed perineal wound (UPW), even though many such wounds will eventually heal by 1 year. The rate of failed perineal wound healing varies greatly in the literature; however, a reasonable estimate suggests that it occurs 20% to 30% of the time. Despite changes in practice that have minimized the number of patients undergoing an APR, some circumstances may lead to this operation secondarily.

Special Situations Leading to an Unhealed Perineal Wound

• 1.

  Failed restorative proctectomy: The focus on sphincter-preserving approaches for both anorectal cancer and IBD has decreased the attention given to the UPW or persistent perineal sinus. However, sometimes complications of these sphincter-saving procedures may require a subsequent proctectomy. At this time, avoiding the morbidity of an unhealed perineal wound may be more difficult.

• 2.

  Failed ileal-anal pouch: Although ileal pouch–anal anastomosis has largely replaced total proctocolectomy with ileostomy as the surgical treatment for ulcerative colitis, pouch failure occurs in approximately 5% to 10% of cases and sometimes requires abdominoperineal excision of the pelvic pouch. Pouch excision has been associated with a risk for UPW of 40% and 10% at 6 and 12 months, respectively.

• 3.

  Recurrent anal and rectal cancer: Combined modality chemoradiation has supplanted surgery as the primary treatment for squamous cell carcinoma of the anal canal, yet when recurrent disease is diagnosed, salvage APR is generally performed in an irradiated field. Similarly, recurrent rectal cancer after low anterior resection may be approached with aggressive multivisceral resections including proctectomy, often combined with preoperative and/or intraoperative radiation. Challenges of reconstruction in these circumstances may be formidable and lead to considerable morbidity.

APR is likely to be a continuing problem facing colorectal surgeons. Prevention and management of this complication continue to be important topics and are the subjects of this chapter.

Causes

Technical, patient-related, or disease-related factors may lead to a failure of perineal wounds to heal.