Perineal wound management after abdominoperineal rectal excision for carcinoma with unsatisfactory hemostasis or gross septic contamination: Primary closure vs. packing

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Abstract
This study was designed to compare the results of two methods on the rate of postoperative perineum healing. In this prospective, randomized, multicenter trial of 234 consecutive patients undergoing abdominoperineal rectal excision for carcinoma, 48 had unsatisfactory hemostasis or intraoperative gross septic contamination. Three patients were withdrawn because of protocol violation. Of the 45 remaining patients, 21 were randomized to undergo primary closure of the perineum with drainage while 24 underwent packing. Preoperative factors (sex, age, degree of obesity, weight loss, anemia, or presence of ascites), intraoperative findings (Dukes stage, degree of hemostasis, gross septic contamination), and postoperative oncologic courses (recurrence, mortality rate) were similar in both groups. All patients were followed for at least 12 months or until their demise. There was no significant difference in the number of early (one vs. zero) or late (five vs. four) deaths between primary closure and packing groups, respectively. Median duration of hospital stay was 25 and 27 days, respectively. Primary closure was associated with a significantly higher rate of healed perineums at one month (30 percent vs. 0 percent) (P = 0.01) and a shorter delay to complete cicatrization (median, 47 vs. 69 days) (P < 0.01). From three months onward, there was no difference in healing between the two groups, but two patients in the packing group had not healed at one year. Conversely, hematoma, perineal abscess, and reoperations were significantly more frequent (P < 0.01) in the primary closure group. Primary closure associated with drainage after abdominoperineal resection for carcinoma expedites perineal healing but morbidity is higher.