Bisgaard, Thue

Bulut, Orhan

Levic, Katarina

von Rosen, Kasper

English

Copenhagen University Research Information System

u n i ve r s i t y  o f  co pe n h ag e n  Københavns UniversitetLow incidence of perineal hernia repair after abdominoperineal resection for rectalcancerLevic, Katarina; von Rosen, Kasper; Bulut, Orhan; Bisgaard, ThuePublished in:Danish Medical JournalPublication date:2017Document versionPublisher's PDF, also known as Version of recordDocument license:CC BY-NCCitation for published version (APA):Levic, K., von Rosen, K., Bulut, O., & Bisgaard, T. (2017). Low incidence of perineal hernia repair afterabdominoperineal resection for rectal cancer. Danish Medical Journal, 64(7), [A5383].Download date: 03. Feb. 2020Dan Med J 64/7  July 2017 da n i s h m E d i c a l J O U R n a l   1abstRactIntroductIon: Perineal hernia may be a long-term compli-cation to conventional abdominoperineal resection or proc-tocolectomy. We analysed the incidence of post-operative perineal hernia repair and described patient-reported out-come measures (PROMS) after perineal hernia repair.Methods: This was a nationwide retrospective analysis of consecutive Danish patients undergoing conventional ab-dominoperineal resection or proctocolectomy for rectal cancer from 1 January 2004 to 31 December 2014 com-bined with patients undergoing a subsequent repair for a perineal hernia during the follow-up period from 1 January 2004 to 31 December 2016. Patients were sent a quality of life questionnaire (HerQles A) and related PROMS. results: The incidence of perineal hernia repair was 0.83%. A total of 2,170 patients underwent proctocolec-tomy and conventional abdominoperineal resection, and 18 patients had a subsequent perineal hernia repair. Four pa-tients developed a clinical hernia recurrence, another four patients reported moderate/severe perineal pain or heavi-ness during physical activity and complained of poor per-ception of health, and one patient reported that the perin-eal hernia repair had a negative impact on sexual function. conclusIons: The incidence of perineal hernia repair was below 1% after conventional abdominoperineal resection and proctocolectomy. PROMS and risk of recurrence may benefit from centralising perineal hernia repair. FundIng: none. trIal regIstratIon: not relevant. Perineal hernia can be defined as a protrusion of intra-abdominal contents through an acquired defect of the pelvic diaphragm [1]. Colorectal cancer is one of the most common cancers in the Western world [2]. The in-cidence of perineal hernia repair following conventional abdominoperineal resection and proctocolectomy is poorly investigated, but may be in the 0.34-11.8% range [3-8]. The correct incidence may be even higher because asymptomatic perineal hernias not requiring surgical re-pair will often not be registered. Symptoms associated with perineal hernia may be disabling; they include pri-marily bulging with discomfort or pain, secondarily urin-ary dysfunction, skin problems and more rarely intes-tinal obstruction [1]. The literature on surgical repair for post-operative perineal hernia is limited [8-13]. The opti-mal repair technique, the risk of recurrence and the pa-tient-reported outcome measures (PROMs) therefore remain unknown. The aims of this study were to estimate the surgery incidence for post-operative perineal hernia following conventional abdominoperineal resection and procto-colectomy for rectal cancer and to report the clinical outcomes and PROMs after perineal hernia repair.mEthOdsThis was a nationwide retrospective analysis of consecu-tive Danish patients undergoing conventional abdom-inoperineal resection or proctocolectomy for rectal can-cer from 1 January 2004 to 31 December 2014 combined with patients having a subsequent repair for a perineal hernia during the follow-up period from 1 January 2004 to 31 December 2016. The data sources were the Danish National Patient Registry and the Danish Colorectal Can-cer Group database. The patients’ medical records were reviewed for demographics, details on primary surgery, date of first report of a perineal hernia diagnosis, char-acteristics and surgical management of the perineal her-nia, intra- and post-operative complications, and date of clinically diagnosed recurrence. Information about op-eration for recurrence was provided by the Danish Na-tional Patient Registry. Patients undergoing extralevator abdominoperineal excision, intersphincteric abdomino-perineal excision and coccygectomy were not included in the analysis.Patients undergoing a perineal hernia repair were sent a validated hernia-related quality of life question-naire (HerQles) which included a verbal rating scale with questions on pain and heaviness from the perineum dur-ing physical activity, daily work and leisure (none, mild, moderate or severe pain or heaviness). In addition, pa-tients were asked about possible negative effects of the perineal hernia repair on performing household chores and about their perception of their health and sexual function (disagree, slightly disagree, slightly agree or agree). The study was approved by the Danish Data Pro-tection Agency and the Danish Health Authority prior to study start.low incidence of perineal hernia repair after abdominoperineal resection for rectal cancerKatarina Levic1, Kasper von Rosen2, Orhan Bulut1,3 & Thue Bisgaard1ORiginal aRticlE1) Department of Surgical Gastro -enterology,  Hvidovre Hospital 2) Department of Plastic Surgery,  Breast Surgery and Burns Treatment, Rigshospitalet3) Institute of Clinical Medicine,  University  of Copenhagen, Denmark  Dan Med J 2017;64(7):A5383 2  da n i s h m E d i c a l J O U R n a l Dan Med J 64/7  July 2017statisticsThe study was descriptive, explorative and hypothesis-generating. Data are presented as median (range). The nature of the study design precluded sample size calcu-lation. Trial registration: not relevant.REsUltsThe incidence of perineal hernia repair was 0.83% – 2,170 patients underwent proctocolectomy and conven-tional abdominoperineal resection, and 18 patients  underwent a subsequent perineal hernia repair. Details about patients, rectal cancer operation and perineal her-nia repair technique are presented in table 1. Of the 18 patients who developed perineal hernia following conventional abdominoperineal resection or proctocolectomy, 13 patients had the pelvic defect closed by suture without reinforcement at the primary operation. A fasciocutaneous gluteal flap (n = 2) or bio-logical mesh (Permacol; Covidien, Mansfield, Massa-chusetts, USA) (n = 3) was also used as closure method. Complications were seen in two patients who developed post-operative perineal wound infection after rectal re-section (treated conservatively). The median time to perineal hernia repair was 19 months (range: 4-123). The 18 perineal hernia repair procedures were performed at six surgical centres in Denmark. The surgical hernia repair technique was done by perineal approach (n = 14), abdominal approach  (n = 2) or combined abdominoperineal approach (n = 2).  A total of 16 patients had a mesh repair and only two patients had another type of repair performed (Table 1). Perineal wound infection (treated conservatively) was observed in one patient (perineal approach with Per-macol). The median follow-up after hernia repair was 27 months (range: 6-85). During this period, four of the 18 patients (all four operated by perineal approach with Permacol reinforcement) developed a recurrence. Thus, three patients were operated for recurrence and one was treated conservatively. Three patients died during follow-up and three patients were lost to follow up, re-sulting in 12 responders to the HerQles A questionnaire and PROMs (Table 1). Four patients reported moderate/severe perineal pain or heaviness during physical activity and com-plained of poor perception of health, and one patient re-ported a negative impact on sexual function due to the perineal hernia repair (Table 1).discUssiOnIn the present nationwide study, we found a low inci-dence of perineal hernia repair (below 1%). However, the ten-year-risk of hernia recurrence was relatively high. Moreover, PROMs were negatively associated with perineal hernia repair. Conventional abdominoperineal resection was previously a frequent surgical procedure in patients undergoing rectal cancer surgery [14], but in recent years extralevator abdominoperineal excision (ELAPE) has become increasingly popular owing to re-ports of reduction in circumferential resection margin positivity [15], and ELAPE now accounts for 10-15% of operations for rectal cancer in Denmark [16]. However, the perineal defect following ELAPE is larger, and re-ported hernia rates (26%) are higher than with conven-tional abdominoperineal resection [17]. Due to this shift in the operative technique used for rectal cancer, more patients with perineal hernia are expected in the future. The literature on surgical repair of post-operative perineal hernia is limited and predominantly linked to case reports or it comprises heterogeneous retrospec-tive studies of dubious quality [3, 4, 10, 12, 18]. The inci-dence of perineal hernia is therefore uncertain. The two largest studies consisted of 245 and 1,776 patients with abdominoperineal resection (both single-centre studies), reporting an incidence of 11.8% and 0.62%, respectively (29 and 19 perineal hernia repairs) [3, 8]. The present study reports nationwide hernia repair rates and reports more than 2,000 cases of abdominoperineal resection. Furthermore, the post-operative clinical outcome after hernia repair in available previous studies focuses on re-currence rates, and no other symptoms are reported. tablE 1The patients’ periopera-tive and long-term char-acteristics in relation to the primary procedure and the hernia repair pro-cedure (N = 18). Gender, male/female, n 11/7 Age, yrs, median (range) 74 (57-91)Preoperative CRT, n 10 Primary surgical procedure, nConventional APR 17 Open   8 Laparoscopic   9Proctocolectomy   1 Complications   2Surgical hernia repair, nMesh repair: Permacol/Bard Composix 16 (14/2)Suture repair: Prolene   1VRAM-flap   1PROMs, nModerate or severe perineal pain or heaviness 4Pain or heaviness affecting household chores 4Pain or heaviness preventing leaving the house 3Poor perception on general health 4Negative impact on sexual function 1APR = abdominoperineal resection; CRT = chemo and/or radiation ther-apy; PROMs = patient-related outcome measures; VRAM = vertical rec-tus abdominis myocutaneous. Dan Med J 64/7  July 2017 da n i s h m E d i c a l J O U R n a l   3The perineal defect can be repaired using a primary suturing technique, muscle flaps or mesh reinforcement by abdominal, perineal, combined abdominoperineal or laparoscopic transabdominal approach [3, 4, 6, 8-11, 13]. Mesh reinforcement rather than simple suture re-pair is performed in the majority of patients owing to the potential of the mesh to reduce hernia recurrence compared with primary suturing [3-5, 8-12], especially  if a non-absorbable mesh is used [8]. Thus, the authors found a significantly lower risk of recurrence after mesh re-enforcement than after suture repair. Despite the low number of patients, the authors suggested that mesh re-enforcement should be used routinely in perineal hernia repair (corresponding to the repair technique for ventral and groin hernias). In the literature, the risk of recur-rence varies considerably, from 0% to 100% [3, 4, 6, 8, 10-12, 18]. However, the majority of these studies are small with a cohort comprising fewer than ten patients and with insufficient and short follow-up. In the two largest studies, counting 29 and 19 perineal hernia repairs, re-spectively, the recurrence rates were 5% and 16% [3, 8]. These studies, along with the present study reporting a recurrence rate of 22%, represent the largest published material on the subject. However, the literature remains limited which precludes any final conclusions on optimal repair technique. The present study is the first to address PROMs  after surgical repair of perineal hernia. However, conclu-sions are also hampered by the fact that patient num-bers were small and preoperative complaints were not registered. Since chronic perineal pain and reduction ac-companied by loss of quality of life are reported in one fifth of patients after conventional abdominoperineal  resection [19, 20] it is problematic to distinguish symp-toms from perineal hernia repair. There are several limitations to the present study. These mainly include the retrospective nature of the study design and the fact that we registered the number of patients with a surgical repair for a perineal hernia and not patients treated conservatively, which prevents final conclusions on the “true” incidence of perineal hernia following conventional rectal cancer resection. Finally, PROMs and clinical outcomes were based on very low numbers of patients, and the results from this analysis can therefore be no more than hypothesis-generating.For the future, well-designed quality trials with long-term follow-up and well-defined pre- and post-op-erative outcome variables are warranted. The main out-comes should be risk of clinical/surgical recurrence and PROMs in relation to the various repair techniques used. Finally, watchful waiting studies (repair versus conserva-tive treatment) may be important to establish an evi-dence-based indication for treatment.In conclusion, the incidence of perineal hernia after conventional rectal cancer surgery was below 1%.  The overall benefits of perineal hernia repair remain un-certain. The incidence of perineal hernia repair is low, and therefore every surgeon only performs only a very limited number of operations. Furthermore, the recur-rence rate is probably high, and the surgical technique used varies. All of these factors indicate that centralisa-tion of the surgical treatment may be warranted.  cORREspOndEncE: Katarina Levic. E-mail: katarina.levic@regionh.dkaccEptEd: 11 April 2017cOnflicts Of intEREst: Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dklitERatURE1. Khalil PN, Kleespies A, Angele MK, et al. Small bowel incarceration in recurrent perineal hernia after abdominoperineal resection. Int J Colorectal Dis 2011;26:957-8. 2. Siegel R, Desantis C, Jemal A. Colorectal cancer statistics. Cancer J Clin 2014;64:104-17. 3. So JB, Palmer MT, Shellito PC. Postoperative perineal hernia. Dis Colon Rectum 1997;40:954-7. 4. de Campos FGCM, Habr-Gama A, Araújo SE et al. Incidence and manage-ment of perineal hernia after laparoscopic proctectomy. Surg Laparosc Endosc Percutan Tech 2005;15:366-70. 5. Mjoli M, Sloothaak DAM, Buskens CJ et al. Perineal hernia repair after abdominoperineal resection: a pooled analysis. Colorectal Dis 2012;14: e400-e406. 6. Aboian E, Winter DC, Metcalf DR et al. Perineal hernia after proctectomy: prevalence, risks, and management., Dis Colon Rectum 2006;49:1564-8. 7. Musters GD, Buskens CJ, Bemelman WA et al. Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis. Dis Colon Rectum 2014;57:1129-39. 8. Martijnse IS, Holman F, Nieuwenhuijzen GAP et al. Perineal hernia repair after abdominoperineal rectal excision. Dis Colon Rectum 2012;55:90-5. 9. Svane M, Bulut O, Svane M et al. Perineal hernia after laparoscopic abdominoperineal resection – reconstruction of the pelvic floor with a biological mesh (PermacolTM).  Int J Colorectal Dis 2012;27:543-4.10. Dulucq J-L, Wintringer P, Mahajna A. Laparoscopic repair of postoperative perineal hernia. Surg Endosc 2006;20:414-8. 11. Musters GD, Lapid O, Stoker J et al. Is there a place for a biological mesh in perineal hernia repair? Hernia 2016;20:747-54.12. Abbas Y, Garner J. Laparoscopic and perineal approaches to perineal her-nia repair. Tech Coloproctol 2014;18:361-4. 13. Goedhart-de Haan AMS, Langenhoff BS, Petersen D et al. Laparoscopic repair of perineal hernia after abdominoperineal excision. Hernia 2016;20: 741-6.14. Danish Colorectal Cancer Group (DCCG). Annual report 2015. www.dccg.dk/pdf/Aarsrapport_2015.pdf (28 Feb 2016). 15. West NP, Anderin C, Smith KJE et al. European Extralevator Abdomino-perineal Excision Study Group. Multicentre experience with extra levator abdominoperineal excision for low rectal cancer. Br J Surg 2010;97: 588-99. Post-operative perineal hernia, posterior view. 4  da n i s h m E d i c a l J O U R n a l Dan Med J 64/7  July 201716. Ingeholm P, Gögenür I, Iversen L. Danish Colorectal Cancer Group Database. Clin Epidemiol 2016;8:465-8. 17. Sayers AE, Patel RK, Hunter IA. Perineal hernia formation following extralevator abdominoperineal excision. Color Dis 2015;17:351-5. 18. Allen SK, Schwab K, Day A et al. Laparoscopic repair of postoperative perineal hernia using a two-mesh technique. Color Dis 2015;17:O70-O73. 19. Colov EP, Klein M, Gögenur I. Wound complications and perineal pain after extralevator versus standard abdominoperineal excision. Dis Colon Rectum 2016;59:813-21. 20. Feddern ML, Jensen TS, Laurberg S. Chronic pain in the pelvic area or lower extremities after rectal cancer treatment and its impact on quality of life. Pain 2015;156:1765-71. 

Low incidence of perineal hernia repair after abdominoperineal resection for rectal cancer

https://curis.ku.dk/portal/files/188527149/055c21bd9f50fa61f92b2401d97fc517845b.pdf

Low incidence of perineal hernia repair after abdominoperineal resection for rectal cancer

Abstract

Similar works

Full text

Available Versions

Copenhagen University Research Information System