Introduction

Since the introduction of the abdominoperineal resection of the rectum (APR) for cancer or IBD [1], an increasing number of perineal complications have been reported. Delayed wound healing and local infection are in fact common complications. Healing depends on the patient's general and nutritional status, the nature of the underlying disease, the technique used for perineal reconstruction (primary closure or healing by secondary intention) and the development of perineal infection. Simple primary skin closure has been used in the past with poor results, mainly from insufficient control of local infection [2]. For some decades, frequent dressing of the perineal wound with swabs has been considered the treatment of choice, although healing by secondary intention involves prolonged hospital stay and persistent wound drainage, usually requiring frequent dressings and occasionally the development of a persistent perineal sinus (PPS). In the seventies, the introduction of closed suction drainage brought new interest to primary perineal closure techniques. McLeod et al. [3] evaluated the results of primary closure and suction drainage on 57 APRs (40 ulcerative colitis, 4 Crohn's disease, 10 carcinoma of the rectum, 2 had carcinoma of the anus and 1 had anal incontinence), reporting an overall 72% closure rate and concluding that primary healing can be achieved in a large proportion of patients operated on for cancer or IBD. More recently, the introduction of neoad-juvant radiotherapy seems to have greatly increased the risk of perineal wound complication after APR with direct primary closure.

Common experience shows that when the perineum is left open, healing by secondary intention is accompanied by a significant morbidity, prolonged hospitalisation, discomfort, protracted postoperative drainage and higher risk of PPS. The patient usually requires daily care of the perineum for 2-12 months. The wound heals more slowly in patients with inflammatory disease of the colon.

The presence of a persistent perineal sinus is cer tainly a disabling complication for the patient as it is usually accompanied by foul secretions, perineal pain, chronic pelvic pain, local dermatitis, infections and dyspareunia. It represents the most frequent late complication of APR and it is a challenging condition for the surgeon. According to Eftaiha and Abcarian [4], after a 4-month period from APR, the perineal wound completely healed in 78% of patients. For this reason it is important to monitor the perineal wound at 4 months. If the repair process has failed, it is important to differentiate unhealed perineal wound (UPW), those wounds still open at 6 months from initial surgery, from persistent perineal sinus (PPS), those steady fibrous wounds still present 1 year after surgery and probably unable to heal by themselves. According to some authors, a small shallow UPW can be successfully treated with curettage and local treatments, while long and complex UPW as well as PPS usually require a more extended surgical approach [5-7]. As reported by Opelka, after 6 months from radical proctectomy, the perineum heals in 58% of the patients with IBD and 70% of the patients with carcinoma. After 1 year, the wound is completely closed in 98% of the patients [8]. In all cases, especially when cancer is involved, an evaluation under anaesthesia with multiple-site biopsies is mandatory.

The anatomical limits of a perineal sinus largely depend upon the operation performed. When the rectum and the anal canal are removed, the anterior aspect of the sinus is usually formed in the female by the posterior aspect of the uterus and the posterior vaginal wall, and by the bladder, the seminal vesicles and the prostate gland in the male. These organs are rather fix, but they can nevertheless slide down to some extent with the loops of the small bowel, contributing to the closure of the pelvic defect. The lateral and the posterior aspect of the small pelvis are formed by the pelvic sidewalls and by the anterior aspect of the sacrum and coccyx covered by the pre-sacral fascia. These structures do not take part in the process that finally leads to the closure of the pelvic wound. When APR is performed, the levator ani muscle is partially removed with the specimen so that its margins are very seldom useful for primary closure. Lubbers et al. [9] have reported a reduced number of perineal wound dehiscence and PPS after intersphincteric or perimuscular dissection of the rectum compared to wide APR.

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