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Primary vs. Delayed Perineal Proctectomy There is no Free Lunch
Michael Alosilla1, Thomas Curran1, Thomas Cataldo1, Deborah Nagle1, Vitaliy Poylin1
1Beth Israel Deaconess Medical Center, Boston, MA, USA

Background: Perineal wound complications associated with anorectal excision are associated with prolonged wound healing and readmission. In order to avoid these problems the surgeon may choose to leave the anorectum in situ. The study's purpose is to compare complications and outcomes after primary vs. delayed anorectum removal.

Methods: Retrospective review of all patients undergoing proctectomy or proctocolectomy with permanent stoma between 2004 and 2014 in a single tertiary institution. Palliative procedures and patients with less than 6 months follow up were excluded. Comparisons between primary and delayed proctectomy groups were made.

Results: We identified 117 proctectomy patients. 69 (59%) patients had anorectum removed (AR) at index operation and 41% had the anorectum left in place (ARLIP). AR patients had higher ASA class (p=0.001), higher utilization of minimally invasive surgery (52% vs. 7%, p<0.001) and were more likely to have colostomy vs. ileostomy (58% vs. 14%, p<0.001).ARLIP patients developed pelvic abscess significantly more frequently (26% vs. 4%, p=0.003). 22 AR patients (32%)had perineal complications and 10 (15%) required re-operations. 12 ARLIP patients (25%) returned for delayed perineal proctectomy at a mean time of 277 days; 7 of those (58%) developed post-operative wound complications.There was no difference in time to perineal wound healing between AR and ARLIP groups (154 vs. 211 days, p=0.319).

Conclusion: Although leaving the anorectum in place avoids a primary perineal wound, both approaches are associated with a significant number of complications including re-operation. The decision to remove the anorectum at the index operation should be individualized and accompanied by appropriate counseling.

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