Optimal technique of perineal reconstruction following extralevator abdominoperineal excision: A systematic review

The optimal method of perineal reconstruction following extralevator abdominoperineal excision (ELAPE) is a debated topic among plastic surgeons, with current options including direct closure, biological mesh, flaps or a combination. This systematic review was conducted in accordance with the PRISMA guidelines to evaluate the available medical literature on the optimal modality of perineal reconstruction. We hypothesised that the use of flaps is the superior method, with complex cases requiring the use of an additional flap or incorporation of a supporting biological mesh. The specific outcomes of each reconstruction modality assessed included the a) length of hospital stay, b) perineal complications, c) hernias, d) recurrence, e) mortality and f) functional outcomes. A comprehensive search of the MEDLINE and EMBASE databases yielded 1081 articles. Following independent screening using a PICOT framework-guided inclusion and exclusion criteria, and a subsequent quality assessment, 21 papers were incorporated into the review for qualitative analysis; Among the 21 papers, 15 were retrospective cohort studies, 4 were prospective cohort studies, 1 was an observational cohort study and 1 was a randomised control trial. The literature suggests that when used exclusively, flaps and biological meshes achieved a higher percentage of fully healed perineum without complications compared to flap–mesh or flap–flap hybrids. However, these findings are inconclusive and undermined by several critical limitations. Further long-term randomised control trials are required to determine the superior method for perineal reconstruction.