Management of perineal complications following an abdominal perineal resection

INTRODUCTION — An abdominal perineal resection (APR) is a surgical procedure that removes the rectum and anus (perineal component) and creates an end colostomy (abdominal component). An APR is primarily used to resect a very low rectal cancer or anal cancer. It also is a salvage treatment for recurrent rectal or anal cancer and is a surgical treatment for severe inflammatory bowel disease.

The most frequent complications of a perineal resection include hemorrhage, perineal wound complications, persistent perineal sinus, and perineal hernia. Factors associated with an increased risk of perineal complications include intraoperative hemorrhage, intraoperative gross contamination, operative perineal wound management, preoperative radiation therapy, and indications for surgery (malignant versus benign) [1,2]. Management of the perineal wound ranges from packing to partial closure, primary closure, and closure with continuous irrigation [3]. Primary closure of the perineum following an APR is widely accepted when intraoperative hemostasis is intact and no gross contamination has occurred [4-6].

The perineal complications following an APR are reviewed here. Anastomotic and intra-abdominal, pelvic, and genitourinary complications are discussed elsewhere. (See "Management of anastomotic complications of colorectal surgery" and "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery".)

ANATOMY OF THE PERINEUM AND PELVIS — The perineum lies below the pelvic floor and anterior to the sacrum and coccyx. The perineum is bounded anteriorly by the pubic symphysis and the arcuate ligament, posteriorly by the coccyx, anterolaterally by the ischiopubic rami and the ischial tuberosities, and posterolaterally by the sacrotuberous ligaments (figure 1 and figure 2 and figure 3 and figure 4 and figure 5 and figure 6) [7,8].

HEMORRHAGE AND HEMATOMAS — Meticulous hemostasis during the perineal portion of the dissection is essential for reducing the risk of postoperative hemorrhage. The incidence of early and delayed postoperative perineal hemorrhage ranges from 0 to 4 percent [4]. Perineal bleeding can develop from several sources, including the presacral venous plexus, the prostate in men or vagina in women, the pelvic floor musculature, or distal branches of the internal iliac vessels. Life-threatening postoperative hemorrhage is related to lack of intraoperative control of hemostasis. Hematomas occur as fluid accumulates in an undrained or inadequately drained space.

Risk factors — Persistent and uncontrolled intraoperative bleeding is the typical cause of early, life-threatening postoperative perineal hemorrhage [3]. Packing of the perineal wound is a maneuver used to control severe intraoperative pelvic and presacral hemorrhage. Early postoperative hemorrhage occurs with the first dressing change if the packing only temporarily tamponaded the bleeding vessels or if a hemostatic thrombus is dislodged while the dressing is removed. Delayed bleeding is caused by erosion of the packing into previously sealed blood vessels and often becomes evident when the packing is removed. (See "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery", section on 'Presacral bleeding'.)

Management — Management of perineal bleeding depends upon the source and severity of blood loss. For severe bleeding, such as bleeding from presacral or pelvic vessels, repacking serves as a temporizing measure until the patient is stabilized and transferred to the operating room where the bleeding source can be identified and adequately controlled. The management of presacral bleeding and other pelvic sources of bleeding is discussed elsewhere. (See "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery", section on 'Presacral bleeding'.)

For bleeding sites directly involving the perineal tissues, bleeding can be controlled with direct suture ligature of bleeding points, spray electrocautery, or application of topical hemostatic agents. Most minor venous bleeding can be controlled with temporary perineal packing, which usually stops the bleeding within 48 to 72 hours. Operative intervention is rarely required to localize and control the site of minor bleeding.

Outcomes — There are no high-quality data from randomized trials to determine the optimal treatment for perineal bleeding or to assess the outcomes of postoperative hemorrhage or hematoma formation. There is anecdotal evidence to suggest that perineal hemorrhage and hematoma predisposes patients to the development of subsequent perineal wound complications [9,10].

PERINEAL WOUND COMPLICATIONS — The risk of perineal wound complications following an abdominal perineal resection (APR) ranges from 14 to 80 percent and includes surgical site infection, abscess, dehiscence, and delayed healing [1]. The following findings were noted in a retrospective review of 153 patients undergoing an APR [2]:

●A major perineal wound complication (>2 cm dehiscence, perineal abscess, or any wound requiring reoperation or readmission) occurred in 14 percent.

●A minor perineal wound complication (<2 cm dehiscence, stitch abscess, or sinus tracts) occurred in 24 percent. Patients with a major wound complication were excluded from the analysis for minor wounds.

The incidence of perineal wound infection with subsequent delayed healing ranged from 11 to 50 percent in different series [11-17]. A variety of factors can contribute to the development of infection. Following resection of the pelvic contents (eg, rectum, mesentery) and perineum (eg, pelvic floor musculature, anus), a large cavity is created that is partially surrounded by the pelvic bone. Serous fluid and blood accumulate in this space, which can serve as a reservoir for bacterial colonization and can contribute to wound infection and/or formation of a chronic perineal sinus.

Risk factors — Risk factors for perineal wound complications can be classified according to the following subgroups: patient characteristics, indications for surgery, preoperative radiation treatment, and intraoperative findings and technical approach. The following are associated with an increased risk of perineal wound complications [1,4,11]:

●Patient characteristics – Patient-related risk factors include diabetes, obesity, tobacco smoking, and excessive alcohol consumption [2,3,18]. As an example, in a retrospective review of 120 rectal cancer patients undergoing an APR, significantly higher rates of perineal complications occurred in patients with obesity (odds ratio 1.14, 95% CI 1.04-1.25) and patients with diabetes (odds ratio 8.75, 95% CI 1.69-45.3) [2].

●Indications for surgery – Indications for an APR include anal (includes anal canal, anal margin, or perianal skin) and rectal cancers and inflammatory bowel disease. A perineal resection performed for anal cancer or inflammatory bowel disease is associated with a higher risk of wound complications than one performed for rectal cancer. The following findings were noted in the above retrospective review [2].

•Patients with a diagnosis of anal cancer had a significantly higher rate of major complications compared with patients with rectal cancer or inflammatory bowel disease (8 of 16 versus 12 of 120 and 1 of 12 patients, respectively).

•Patients with anal cancer and patients with inflammatory bowel disease had higher rates of minor wound complications compared with patients with rectal cancer (4 of 8 versus 5 of 11 versus 23 of 108 patients).

●Preoperative radiation treatment – Preoperative radiation treatments (RTs) to the rectum and pararectal tissues may be associated with a significant increase in perineal wound complications [19-24]. This was best illustrated by a systematic review and meta-analysis of 32 studies [25]. Compared with APR alone, APR following pelvic RT was associated with greater than two times the risk of perineal wound complications (odds ratio 2.22, 95% CI 1.45-3.40). The increase in risk was similar whether the conventional or extralevator technique of APR was used.

●Intraoperative findings and technical approach – Intraoperative fecal contamination, hypothermia, rectal injury during dissection, and prolonged operating times have been associated with an increased risk of perineal wound complications [11]. Closure of the pelvic peritoneum is associated with a fixed fibrotic cavity [26] and a prolonged time (>6 months) for perineal wound healing after primary closure [1]. Failure to close the perineum, however, can be associated with an increased risk of formation of a chronic perineal sinus [1,3].

The technique of "extralevator" or "cylindrical" APR, typically utilized for patients with rectal cancer, has been associated with an increased risk of perineal wound complications [27]. (See "Abdominal perineal resection (APR): Open technique".)

Prevention — Meticulous surgical technique, including the avoidance of fecal contamination and control of hemostasis, is critical to reducing the risk of perineal wound infection. A variety of other techniques can also be beneficial:

●Intersphincteric dissection for benign disease – When performing an APR for benign disease, the dissection should be performed in the intersphincteric space rather than the wide resection performed for malignancy [28].

●Primary closure – Primary closure of the perineum in multiple layers is the optimal approach for the uncontaminated perineal wound [5,9,10,17,29]. The rigidity of the surrounding pelvic structures and the limited tissue for primary reapproximation of the perineal wound can create tension on the closure and lead to dehiscence and other perineal wound complications [1].

In the setting of inadequate hemostasis or gross contamination, primary closure with drainage is associated with expedited healing but increased morbidity. The potential benefit of a primary closure was illustrated in a randomized trial of 45 patients undergoing an APR for rectal cancer who had incomplete intraoperative hemostasis and/or septic contamination who were treated with primary closure or perineal packing [10]. Primary closure was associated with a significantly higher rate of wound closure at one month (30 versus 0 percent) and a significantly higher risk of postoperative perineal complications such as hematoma, perineal abscess, and reoperation (19 versus 1 event).

Closed suction drainage — Closed suction drainage is associated with improved perineal wound healing [1,30,31]. A randomized trial of 165 patients undergoing APR for rectal cancer found that patients treated with closed suction drainage had a significantly higher rate of perineal wound healing at one month compared with patients treated with passive drainage (75 versus 61 percent) [31]. There are no high-quality data from large randomized trials on optimal placement of the drains (transabdominal or transperineal) or the duration of usage. Drains typically remain in place for two to five days [13,32].

●Pelvic floor reconstruction by tissue transposition – Several retrospective studies but no randomized trials have evaluated the utility of reconstruction of the pelvic floor with tissue transfer of muscle flaps, pedicled myocutaneous flaps, and pedicled omental flaps [33-39]. The reconstructive procedures are complex and provide minimal benefit [33-35]. Therefore, the author does not advocate pelvic floor reconstruction for uncomplicated perineal resections.

●The utility of perineal flaps (eg, rectus abdominis, gracilis flaps) in patients post-radiotherapy is controversial. A systematic review of prospective studies and retrospective reviews indicates that overall wound healing and complication rates may be improved with the use of flap closure in patients who have received radiotherapy; however, the evidence is limited, and a prospective randomized controlled study would be necessary to make firm recommendations [39].

●Antibiotics – Prophylactic antibiotics should be administered to all patients no later than 60 minutes prior to skin incision [40]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Antimicrobial prophylaxis'.)

Supplementary local application of reabsorbable gentamicin-impregnated collagen fleece sponges inserted into the sacral cavity (carriers releasing antibiotics) has been associated with a reduction of perineal wound infections and higher healing rates following an APR in some studies [41-43]. A systematic review including four trials and four studies (three comparative) did not find sufficient evidence to support the routine use of local gentamicin application for perineal wound healing [44]. However, the included trials and studies were so heterogenous that a meta-analysis by data pooling was not possible.

●Biologic mesh reconstruction has been proposed as a method to decrease perineal wound complications following extralevator APR. A systematic review, which included only one randomized trial and several comparative studies, indicated that biologic mesh reconstruction was potentially a more cost-effective alternative to a myocutaneous flap reconstruction with a similar complication rate [45]. Another randomized trial comparing APR with primary closure versus biologic mesh closure after preoperative RT did not find any difference in the rate of perineal wound infection [46]. The authors of neither the systematic review nor the randomized trial found enough evidence to advocate routine use of biologic mesh reconstruction after APR.

●Incisional negative pressure wound therapy (iNPWT) – Negative pressure wound therapy has been applied to the closed perineal incision to decrease perineal wound complications [47,48]. A systematic review of five studies (three retrospective studies, one case series, and a video case report) demonstrated a significantly decreased incidence of surgical site infection with the use of iNPWT compared with controls (9 versus 41 percent) [49]. The evidence is limited without large prospective studies, and, as such, a firm recommendation for iNPWT cannot be made.

Management — Management of a perineal wound complication depends on the clinical findings (eg, fever, pain, drainage) and radiographic findings if performed (eg, pelvic abscess). In the acute phase, patients typically present with drainage from the perineal wound. A physical examination must be performed to directly assess the wound for purulent drainage, abscess formation, dehiscence, and small bowel or other organ evisceration. A computed tomography (CT) scan of the pelvis and a white blood count (WBC) is indicated when the patient has pain and fever. The following steps are performed when managing a perineal wound complication:

●For patients with draining wounds in the absence of overt pelvic sepsis (eg, fever, pain), the management includes local wound opening and drainage, debridement of ischemic tissues, removal of foreign bodies, and packing with wet-to-dry dressings or the application of a vacuum-assisted closure (VAC) device. (See "Basic principles of wound management" and "Negative pressure wound therapy".)

●For patients with a pelvic abscess, management includes hospital admission, image-guided percutaneous drainage, and administration of broad-spectrum intravenous antibiotics.

●For patients with evisceration of bowel or other abdominal contents, the management is emergency operative intervention.

Outcomes — The majority of perineal wound complications are effectively managed when the above principles are followed. However, some perineal wounds fail to heal despite these measures, and risk, management, and outcomes are discussed in the following section. (See 'Persistent perineal sinus' below.)

Based upon evidence from retrospective reviews, it is inconclusive if there is an association between perineal wound infections following an APR for rectal cancer and a high incidence of local recurrence [50-52]. A retrospective review of 228 patients with rectal cancer who had undergone an APR with curative intent reported perineal wound infection in 30 patients (13 percent) [50]. The incidence of local recurrence was significantly higher in patients with perineal infections compared with those without a perineal infection (33 versus 9 percent). An intra-abdominal infection occurred in 24 patients and was not associated with an increased risk of local recurrence. In addition, a retrospective review of 258 patients undergoing an APR identified a local recurrence in 24 patients (9.3 percent); however, there was no difference in local recurrence rate based upon perineal infection [51].

For patients who develop a perineal wound dehiscence, there is an increased risk of mortality. In a retrospective review of 249 patients undergoing an APR for rectal cancer, patients who developed a wound dehiscence had a shorter survival time compared with patients without a dehiscence (66.6 versus 76.6 months, hazard ratio [HR] 1.7, 95% CI 1.1-2.8) [52].

PERSISTENT PERINEAL SINUS — A persistent perineal sinus is a perineal wound that remains unhealed for longer than six months after surgery [53]. The sinus is typically a long fibrous tract covered by infected granulation tissue with a narrow external opening [54]. It is a common occurrence, especially in patients with inflammatory bowel disease, with an incidence ranging from 14 to 40 percent [55].

Patients can present with pain, discharge, and bleeding from the sinus. Careful examination of the perineal area is essential to confirming the diagnosis, with bacterial swabs to identify a possible secondary infection and biopsy of the tract to diagnose malignant transformation or a local recurrence. The sinus tract should be evaluated with imaging to define the anatomy and rule out causes of nonhealing such as an enteroperineal fistula, undrained sepsis, retained rectal mucosa, or retained foreign body. Magnetic resonance imaging (MRI) of the pelvis is routinely performed as our initial study, with sinography, small bowel series, and computed tomographic (CT) enterography used as adjuncts, depending on the index of suspicion of an enteroperineal fistula.

Risk factors — Many of the risk factors for development of a persistent perineal sinus following an abdominal perineal resection (APR) mirror risk factors for other perineal wound complications (see 'Perineal wound complications' above). A number of risk factors for the development of a persistent perineal sinus have been identified. The supportive data are generally limited to small case series.

●Crohn disease versus ulcerative colitis – Patients with Crohn disease have poorer healing rates than patients with ulcerative colitis [16]. In a retrospective review of 39 patients with Crohn disease and 388 patients with ulcerative colitis who had undergone a proctocolectomy, nonhealing of the perineal wound occurred significantly more often in patients with Crohn disease compared with patients with ulcerative colitis (12.8 versus 0.8 percent) [56].

●Perianal Crohn disease – In a small, retrospective series, the incidence of a persistent perineal sinus was significantly higher in patients with preoperative perianal disease compared with patients who had no perianal Crohn disease (19 of 27 versus 0 of 9 patients in one series) [57]. (See "Perianal Crohn disease".)

●Pelvic or perineal sepsis – In a series of 35 consecutive patients with inflammatory bowel disease who underwent pouch excision at a single institution, pelvic or perineal sepsis was an independent predictor for the development of a persistent perineal sinus following an APR (odds ratio 8.0, 95% CI 1.4-46) [58].

●Preoperative radiation therapy – Preoperative radiation therapy is a risk factor for the development of a chronic perineal sinus. A retrospective review of 94 patients undergoing an APR for rectal cancer found significantly delayed perineal wound healing in patients treated with preoperative radiation therapy compared with no radiation therapy at one month (64 versus 23 percent), three months (48 versus 9 percent), and one year (25 versus 4 percent) [59]. Experimental studies suggest that this effect is mediated at least in part by the development of endarteritis obliterans [60]. (See "Basic principles of wound healing".)

Management — Among patients with a persistent perineal sinus, initial conservative management with the application of topical analgesics, antiseptics, and local wound care can decrease perineal pain and alleviate odor but rarely results in complete healing [53]. As a result, early intervention is recommended.

There are no randomized trials to determine the optimal management of a perineal sinus, but the following options are available:

●Curettage and primary closure.

●Sinus excision with partial coccygectomy and either primary closure or reconstruction with a flap or skin graft.

●Cleft closure, which is a modification of the Bascom cleft lift for pilonidal disease [61].

●Reconstruction with split-thickness skin grafting, omentoplasty, gracilis muscle transposition, rectus abdominis myocutaneous flap, or gluteus maximus VY-advancement flap [62-64].

●Vacuum-assisted closure has the potential to assist with healing complicated perineal wounds [65,66]. (See "Basic principles of wound management".)

At our institution, we routinely perform a wide local excision of the sinus and sinus tract, with or without partial coccygectomy, and use vacuum-assisted closure devices to facilitate healing by secondary intention. We reserve reconstruction with flaps for extremely large defects in otherwise suitable surgical candidates.

Outcomes — The rate of complete healing with the above techniques for patients with a persistent perineal sinus varies widely in the literature, ranging from 15 to 90 percent [67].

PERINEAL HERNIA — A perineal hernia, defined as a protrusion of intra-abdominal contents through a defect in the pelvic floor, may contain small bowel, large bowel, bladder, uterus, and/or omentum [3]. The most common symptoms include pain, discomfort when standing or sitting, urinary symptoms (eg, dysuria, stress incontinence), intestinal obstruction, and/or breakdown of the perineal skin [68-71]. A perineal bulge, wound dehiscence, or evisceration can be identified on physical examination.

Risk factors — The most important risk factor is the type of closure of the perineal wound. Symptomatic perineal hernia is estimated to occur in fewer than 1 percent of patients following an abdominal perineal resection (APR) with the use of primary closure of the perineal wound [68,72]. In contrast, the historic incidence of asymptomatic perineal hernia was as high as 7 percent, when packing of the perineal wound was the standard of care [73].

Other risk factors for perineal herniation are unclear given the small number of reported cases using current techniques [68-70,72]. In addition to packing of the perineal wound, other risk factors for perineal herniation include coccygectomy, previous hysterectomy, pelvic irradiation, neoadjuvant chemoradiation, female sex, failure to close the peritoneal defect, poor nutrition, history of tobacco use greater than 15 years, and perineal wound infection.

Management — The management of the perineal hernia depends upon the clinical presentation.

●In the acute setting with evisceration of the abdominal contents, immediate operative reduction and packing is performed [3].

●In the elective setting for symptomatic patients, several options for repair are available, including primary repair via the perineal approach, abdominal approach, or a combined approach, insertion of prosthetic or biologic mesh material, omentoplasty, closure with myocutaneous flaps (eg, gracilis flap, rectus abdominis flap), and/or retroflexion of the uterus [68-71,73,74]. The procedures are challenging, and there is no consensus on the optimal repair.

●In patients with an asymptomatic perineal hernia, surgical repair is not indicated. There are no high-quality data to suggest that repair of asymptomatic perineal hernias results in a reduction in complications such as incarceration or strangulation. We recommend counseling patients regarding the common symptoms associated with perineal hernias and prompt them to seek medical attention should these symptoms arise.

The surgical principles for repair of a perineal hernia are the same as for other hernias and include mobilization of the hernia sac, reduction of the contents, excision of the sac, and repair of the defect. The abdominal approach is preferred because of superior visualization of the hernia sac and contents and therefore a lower risk of injury to major blood vessels and the bowel [75]. The abdominal approach also facilitates placement of mesh or a myocutaneous flap, but there are no high-quality data supporting efficacy following the use of the modalities during perineal hernia repair. At our institution, we prefer an abdominal approach with mesh placement, using a running, continuous suture to secure the mesh to avoid creating smaller potential defects (as can happen with the use of interrupted sutures) through which incarceration and/or strangulation can occur.

Attempting to primarily repair the hernia from the perineum alone is the least likely approach to effectively repair the hernia. Exposure is limited, and the pelvic floor must be reconstructed.

Outcomes — There is little information available on the outcomes following repair of a postoperative perineal hernia. The recurrence rates range from 0 to 38 percent, with perineal wound infection being cited as the major risk factor for recurrence [68,69]. Prevention of a perineal hernia with meticulous operative technique and primary closure of the perineum is the optimal approach.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Colorectal cancer" and "Society guideline links: Colorectal surgery for cancer".)

SUMMARY AND RECOMMENDATIONS — Perineal wound complications are common following an abdominal perineal resection (APR). The most frequent complications include hemorrhage, perineal wound complications, pelvic sepsis, persistent perineal sinus, and perineal hernia.

●Meticulous hemostasis must be achieved when performing an APR, particularly with respect to the presacral vessels, to reduce the risk of early postoperative hemorrhage. For severe bleeding, such as bleeding from presacral or pelvic vessels, repacking serves as a temporizing measure. For bleeding sites directly involving the perineal tissues, bleeding can be controlled with direct suture ligature of bleeding points, spray electrocautery, or application of topical hemostatic agents. (See 'Hemorrhage and hematomas' above.)

●The technical principles that reduce perineal wound complications include avoidance of fecal contamination, meticulous hemostasis, primary closure of the perineal wound in several layers, and closed-suction drainage of the pelvis. (See 'Prevention' above.)

●For patients with draining wounds in the absence of overt pelvic sepsis (eg, fever, pain), management includes local wound opening and drainage, debridement of ischemic tissues, removal of foreign bodies, and packing with wet-to-dry dressings or the application of a vacuum-assisted closure (VAC) device. (See 'Perineal wound complications' above.)

●For patients with a pelvic abscess, management includes hospital admission and image-guided percutaneous drainage, and administration of broad-spectrum intravenous antibiotics is warranted. (See 'Perineal wound complications' above.)

●Persistent perineal sinuses will rarely heal with conservative management alone. Optimal management includes an initial trial of a VAC device, with operative repair reserved for those who fail to heal. (See 'Persistent perineal sinus' above.)

●A perineal hernia is a rare complication following an APR. In the acute setting with evisceration of the abdominal contents, management includes immediate operative reduction and packing. (See 'Perineal hernia' above.)

●In the elective setting for patients with a symptomatic perineal hernia (eg, pain or discomfort), the perineal hernia can be repaired using the combined abdominal and perineal approach and placement of a prosthetic or biologic mesh or myocutaneous flap to reconstruct the pelvic floor. (See 'Perineal hernia' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Lara J Williams, MD, MSc, FRCSC, who contributed to an earlier version of this topic review.