EP300 - Perineal Wound Complications Following Proctectomy for Crohn’s Disease: Impact of Omental Pedicle Flaps and Predictors of Return to the OR

Purpose/Background: Proctectomy for Crohn’s disease (CD) may be necessary due to refractory proctitis, perianal disease, dysplasia or cancer. Perineal wound complications and postoperative pelvic abscesses represent a significant potential source of morbidity after proctectomy for CD. The role of omental pedicle flaps (OPF) to reduce the risk of these complications in the setting of CD remains undefined. The aims of this study were to: a) determine if OPF had any impact on the incidence of perineal wound complications requiring a return to the operating room (OR) or the requirement for interventional radiological (IR) guided drainage of pelvic abscesses in patients with CD undergoing proctectomy; and b) define any clinicopathological characteristics or operative techniques associated with a higher risk of needing to return to the OR to address perineal wound complications.

Methods/Interventions: A retrospective analysis of an institutional review board-approved CD proctectomy database was undertaken to include the 10-year period between January 1st 2014 and December 31st 2023. Clinicopathological variables and operative techniques were extracted for each patient. Patients who had primary perineal closure (PPC) with an OPF were compared to those who underwent PPC alone. The OR return rate related to perineal wound complications and the rate of IR guided drainage of pelvic abscesses were compared between the two cohorts. Further analysis was undertaken to determine if any clinicopathological variables or operative techniques were associated with a greater risk of return to the OR. Statistical analysis was undertaken using GraphPad Prism version 10.3.1 and a p value < 0.05 was deemed to be statistically significant.

Results/Outcomes: 219 patients (71 with OPF and 148 without OPF) underwent proctectomy/proctocolectomy during the study period. No differences in the rate of unplanned returns to the OR (11.27% vs 9.46%, p=0.81) or the number of patients requiring IR guided drainage of pelvic abscesses (11.27% vs 6.76%, p=0.30) were identified between the two cohorts. Patients in the OPF cohort were more likely to have a history of tobacco use (p=0.02), fistulizing perianal disease (p=0.01), to have undergone extra-sphincteric dissection (p=0.03) and to have utilised an incisional wound VAC at the time of surgery (p=0.02) [See Figure 1]. The following factors were found more frequently in the cohort of patients who had an unplanned return to the OR for perineal wound complications regardless of OPF status: linear ulcerations (p < 0.001), non-necrotizing granulomata (p < 0.01), lymphoid aggregates (p=0.03) and fissuring ulceration (p < 0.01). Patients who required a return to the OR for management of their perineal wound were more likely to have positive proximal margin involvement (31.82% vs 12.18%, p=0.02). The same relationship was not found with distal margin involvement (p=0.35).

Conclusion/Discussion: No differences in return to the OR or IR drainage were found between the cohorts. The OPF cohort had higher risk wounds related to greater tobacco use, more complex perianal disease and wider perineal dissection. While the findings from this study should be interpreted with caution, it appears that careful patient selection for OPF might play a role in reducing the wound complication rate to a level similar to that seen in patients with lower risk perineal wounds.

Figure 1| Clinicopathological Variables, Operative Techniques & Outcomes Between OPF and Non OPF Cohorts. OPF = Omental Pedicle Flap
This figure demonstrates the higher rate of tobacco use, perianal fistulae, extrasphincteric dissection and use of incisional wound VACs in the omental pedicle flap cohort. Despite these differences, both cohorts shared a similar rate of unplanned return to the operating room to deal with perineal wound complications and a requirement for radiological guided drainage of pelvic abscesses.