Study Of Risk Factors Of Postoperative Perineal Wound Complications After Abdominoperineal Resection For Rectal Cancer

Part I Establishment of a nomogram predicting risk factors of postoperative perineal wound complications after abdominoperineal resection for rectal cancerObjective:To investigate the risk factors and establish a nomogram predicting the risk factors of postoperative perineal wound complications after abdominoperineal resection for rectal cancer.Methods:A retrospective analysis was conducted in 213 patients with rectal cancer who underwent abdominoperineal resection in the Department of General Surgery,the First Affiliated Hospital of Nanjing Medical University from January 2010 to December 2016.The postoperative perineal wound complications after abdominoperineal resection were classified by Clavien-Dindo Classification System.Univariate and multivariate Logistic analyses were conducted to determine the risk factors of perineal wound complications.A nomogram was established according to the multivariate analysis results.Results;A total of 43 perineal wound complications occurred:12 cases of fat liquefaction,4 cases of errhysis,15 cases of infection,2 cases of bleeding,2 cases of incision split,3 cases of hematoma,3 cases of sinus,and 2 cases of incisional hernia,of which were 27 cases of level II or above complications according to Clavien-Dindo Classification System.In univariate analysis,preoperative albumin level(OR=4.171,95%CI:1.882-9.244,P<0.001),blood loss during surgery(OR=2.385,95%CI:1.174-4.844,P=0.016),and neoadjuvant chemoradiotherapy(OR=7.637,95%CI:3.655-15.959,P<0.001)were risk factors associated with postoperative perineal wound complications.Preoperative albumin level(OR=0.010,95%CI:0.001-0.129,P<0.001),location of skin drainage(OR=0.087,95%CI:0.010-0.725,P=0.024),blood loss during surgery(OR=6.476,95%CI:1.505-27.863,P=0.012),and neoadjuvant chemoradiotherapy(OR=7.479,95%CI:1.887-29.640,P=0.004)were independent risk factorsoflevel Ⅱ or above complications in multivariate logistic regression analysis.The established nomogram showed good C-index of 0.863 and good calibration.Conclusion:A lot of factors have influence on the perineal wound problems after abdominoperineal resection for rectal cancer.A nomogram could help predict occurrence rate of the postoperative perineal wound complications.Part Ⅱ A Meta-analysis of postoperative perineal wound complications after abdominoperineal resection for rectal cancerObjective:To investigate the risk factors of postoperative perineal wound complications after abdominoperineal resection for rectal cancer.Methods:The databases of Medline、Embase、Web of Science、Ovid、Cochrane Library、CBM、CNKI、VIPand WANFANG were searched for the studies of abdominoperineal resection up to October,2016.The quality of the included studies was assessed by using "Cochrane collaboration’s tool for assessing risk of bias" and"the Newcastle-Ottawa Scale".The meta-analyses were performed with Review Manager 4.3 software.Results:A total of 41 studies with 15287 patients were included.Meta-analyses showed that,neoadjuvant radiotherapy(OR=2.55,95%CI:1.66～3.93,P<0.01)、obesity(OR=2.12,95%CI:1.05～4.26,P=0.04)significantly increased the perineal wound problems afterabdominoperineal resection for rectal cancer;omentoplasty(OR=0.30,95%CI:0.14～0.67,P=0.003)、presacral space clysis(OR=0.11,95%CI:0.01～0.94,P=0.04)、abdominal drainage(OR=0.36,95%CI:0.21～0.63,P<0.01)、perineal skin drainage(OR=41.72,95%CI:2.39～727.90,P=0.01)and local application of gentamicin(OR=0.17,95%CI:0.07～0.40,P<0.01)significantly decreased the perineal wound problems;however,extralevator abdominoperineal excision(OR=0.88,95%CI:0.57～1.35,P=0.56)、laparoscopy(OR=1.02,95%CI:0.47～2.21,P=0.96)、biologic mesh reconstruction(OR=1.81,95%CI:0.95～3.46,P=0.07)、myocutaneous flap reconstruction(OR=1.32,95%CI:0.18～9.91,P=0.79)and negative pressure drainage(OR=0.69,95%CI:0.35～1.34,P=0.27)had no influence on the healing of perineal wound after abdominoperineal resection for rectal cancer.Conclusion:A lot of factors have influence on the perineal wound problems after abdominoperineal resection for rectal cancer.Due to the limitations of the included studies,multicentric large-number and high-quality randomized controlled trials are required to validate the current results.