Gluteal Flap Reconstruction Following Complex Rectal Cancer Surgery: A Large Consecutive Series of Perineal Wounds Exploring Risk Factors for Complications.

AIM: To determine whether high complexity pelvic exenterations alter perineal wound morbidity and to assess risk factors for perineal flap complications following complex rectal cancer surgery.

METHODS

A retrospective analysis of consecutive adults undergoing complex rectal cancer resections with immediate gluteal flap perineal reconstruction between January 2013-July 2021 at a tertiary referral centre. Conventional complex cancer resections were compared with "high complexity" exenterations, including en bloc sacrectomy and extended lateral pelvic side wall excision. Primary outcomes were short-term (wound infection, necrosis, dehiscence) and long-term (sinus, fistula, hernia) perineal flap complications.

RESULTS

We identified 194 patients (median 56 years, 60% male) with gluteal flap reconstructions; 163 (84%) for advanced or recurrent rectal cancer. Gluteal artery perforator flaps were predominantly used (176, 92%). Wound infections were more common in the conventional group (23.2% vs. 6.3%, p = 0.001), but no other differences in complications were observed between groups. Obesity (HR 2.70, 95% CI 1.22-5.97, p = 0.014) and total pelvic exenteration (HR 2.13, 95% CI 1.07-4.23, p = 0.031) were associated with short-term complications. Age over 65 years predicted readmission/reoperation (HR 2.66, 95%CI 1.07-6.6, p = 0.040). Ureteric/ileal conduit leaks were associated with long-term complications (HR 3.37, 95% CI 1.21-9.34, p = 0.024). No flap losses occurred.

CONCLUSION

Gluteal fasciocutaneous perforator flaps provide reliable perineal reconstruction after complex rectal cancer surgery. The extent of surgery and resulting defect size did not significantly influence perineal wound complication rates.