Reconstruction with myocutaneous flaps following resection of locally recurrent rectal cancer

Local or regional recurrence is frequent in patients treated for rectal cancer. Many will die with regional disease in the absence of distant metastases. To achieve cure or palliation, radical surgery resulting in large pelvic defects may be warranted. Myocutaneous flap reconstruction may be used to achieve satisfactory closure. From 1988 to 1993, nine patients (5 female, 4 male) underwent 10 myocutaneous flap reconstructions for large perineal or pelvic defects following surgical extirpation of recurrent rectal cancer at Fox Chase Cancer Center. All nine patients had been previously treated with radiation therapy. Their clinical course was reviewed and quality of life assessed. The mean age at diagnosis of recurrence was 56 years. In six, this was a first, and in three patients a second recurrence. Clinical presentation was most often bleeding, abscess, or perineal pain. Resection was determined by extent of recurrence and included perineal resection, pelvic exenteration, cystectomy, sacrectomy, or coccygectomy. Extent of disease necessitated intraoperative radiation therapy in one case and placement of brachytherapy catheters in four. Bilateral gracilis flaps were used in four, unilateral in three, gluteus maximus in two, and combined gluteal and gracilis flaps in one patient. Six perineal and four combined perineal and vaginal defects were reconstructed. The mean length of surgery was 9.1 hours, and the length of hospitalization averaged 17.5 days. In nine of 10 cases, patients had prehospital level of function at discharge. Acute surgical flap-related complications included three cases of minor wound infection or separation, two of minimal but persistent drainage, and one of vaginal colonization. Chronic flap complications consisted of one fistula from a ureterocolostomy, five persistent sinuses that ultimately healed, and one incidence of delayed minimal wound separation. One late abscess necessitated reoperation for drainage. Perioperative mortality was zero. There was a single case of delayed flap loss at 2 years in the setting of malnutrition and neglect. The median actuarial survival following reconstruction is 32 months (mean = 22 months, range = 12-38 months). At last follow-up, five of nine patients are alive. A single patient has local failure, two have distant disease, and two are disease-free. Replies to quality of life surveys indicated physical, emotional, and functional well-being. Patients responded that they were content with their situation and indicated that to a large extent they were able to pursue normal activities. Pain was nonexistent or minimal in all patients surveyed. Patients with pain, bleeding, or infection from locally recurrent rectal cancer may survive many months. Surgical extirpation in these radiated fields may be indicated to control these symptoms or achieve cure. Anticipation of wounds too large for primary closure or secondary healing should not preclude surgical intervention. Myocutaneous flap reconstruction allows safe and effective closure with patients indicating minimal pain and an overall high level of function.