Chronic Pelvic Abscedation After Completion Proctectomy in a Rectal Stump Insufficiency; Treatment With Gracilis Muscle Flap Following Vacuum Assisted Closure Therapy
A 58-year-old man underwent Hartmann procedure for obstructed lower rectal cancer at another hospital in September 2011. Pathological findings at that time indicated a stage IIIB tumor that had infiltrated beyond the muscularis propria into pericolorectal tissues with three lymph nodes showing metastases (pT3N1M0). The patient underwent chemoradiotherapy; weekly, 5-fluorouracyl (500 mg/m2) and folinic acid (500 mg/m2) were administered over 6 weeks as one cycle. After two cycles of chemotherapy, chemoradiotherapy was administered using the intensity-modulated radiation therapy technique to a dose of 50.4 Gy radiation after the surgery. The patient was referred to our division for reversal of the Hartmann procedure on January 2012. However, he had complained of intermittent periods of fever and perineal pain since his surgery and lately had suffered from purulent secretion through the anus. The top of the rectal stump was palpated about 4 to 5 cm from the anal verge, but it had irregular borders and was hardened. Also, a hole was palpated at the tip of the rectal stump. During the digital examination, about 80 mL of pus and mucus evacuated through the anus, and a decreased anal sphincter tonus was found. Endoscopy revealed a short rectal stump just 2 cm above the dentate line, as well as a disruption and a draining hole centered on the top of the stump. The opening was wide enough to allow the introduction of the scope into the abscess cavity, which measured 6 cm × 3 cm and was filled with necrotic material (). Magnetic resonance imaging showed a large presacral collection of 7 cm and some osteonecrotic changes of the sacrum.\nThe adjuvant radiotherapy, the short rectal stump and the poor anal sphincter tonus increased the risk of bad functional outcome; therefore, we decided to perform a complete proctectomy with VAC. The rectal resection was performed, and the perineal cavity was left open, but was packed with four rolls of gauze in order to ensure perineal hemostasis prior to putting the VAC system in place. The pack was removed one day later, and the VAC system was set in place (the wound measured 10 cm × 15 cm, ) under general anesthesia and set at a 125-mmHg depression (Type of foam: VAC GranuFoam Medium Dressing Kit, Kinetic Concept Inc.). Owing to the considerable pain and the position of the wounds, the VAC system had to be reapplied in theater 3-times a week initially, which was later reduced to twice weekly. Sequential wound assessment demonstrated marked improvements with visible granulation tissue following the application of the VAC system set at a 125-mmHg continuous topical negative pressure (). The amount of fluid was 200 mL every day during the first five days and decreased to 10 mL during the last two days. Three weeks later, a significant reduction in the wound size (5 cm × 6 cm, ) was evident, and on day 28, VAC therapy was stopped because the size of the cavity was no longer decreasing. However, the remnant of the cavity was still large, and fibrosis prevented apposition of the remaining soft tissue structures. Thus, we decided to filled the cavity with a gracilis muscle flap. The muscle flap were obtained from the left thighs' gracilis muscle and was then positioned within the bulk of the pelvic dead space, and the perineum was reconstructed. First, the muscle flap was taken from the detached gracilis muscle containing the medial circumflex femoral artery, vein, and nerve to promote better blood supply to the flap. The flap was then rotated in the direction of the sacrum and sutured (). A suction drain was placed on the left thigh, and the perineum was closed with primary sutures. Although a postoperative sinus developed in the perineal wound, a good blood supply prevented graft failure, and the sinus closed spontaneously in a short period. Two months after the gracilis muscle flap transposition, the perianal wound was completely healed.