# Flap reconstruction in rectal resection and exenteration surgery: a single centre retrospective cohort study

## TL;DR

This study shows that complex rectal cancer surgery with flap reconstruction can be successfully performed in a public hospital with outcomes similar to specialized centers.

## Contribution

The study demonstrates the feasibility of ELAPE with flap reconstruction in a non-tertiary hospital setting.

## Key findings

- ELAPE with flap reconstruction had complication rates comparable to tertiary centers.
- No complete flap failures occurred, with major complications at 33.3%.
- Multidisciplinary collaboration is key to achieving successful outcomes in public hospitals.

## Abstract

To evaluate the outcomes of flap reconstruction following extralevator abdominoperineal excision (ELAPE) compared to abdominoperineal resection (APR) in the treatment of locally advanced and recurrent rectal cancer, in the context of demonstrating the feasibility of performing ELAPE with flap reconstruction for rectal cancer in a large public (non-tertiary) hospital. The primary outcome was the assessment of postoperative complication rates to determine whether outcomes fell within acceptable standards for complex pelvic reconstruction. Secondary outcomes included flap-specific complications, operative parameters, postoperative length of stay, and correlations between flap complexity, operative duration, complication grade, and recovery metrics.

This retrospective cohort study analysed 39 patients who underwent reconstructive ELAPE or APR at a secondary referral centre between April 2018 and August 2024. Data were collected from a prospectively maintained database and validated using clinical records and MDT meeting summaries. Patient demographics, surgical details, flap types, postoperative outcomes, and complication rates were evaluated. Statistical analyses included descriptive statistics and correlation assessments.

Twenty-seven patients underwent ELAPE with flap reconstruction, utilizing vertical rectus abdominis myocutaneous (VRAM), inferior gluteal artery (IGAM), gracilis, and V-Y advancement flaps. Outcomes, including complication rates and length of hospital stay, were comparable to those reported by tertiary centres. Major complications (Clavien-Dindo grade III and above) occurred in 33.3% of ELAPE cases, with flap-specific complications such as superficial infections (14.8%) and dehiscence requiring intervention (7.4%). Median length of stay for ELAPE was 18 days. No cases of complete flap failure were observed.

This study demonstrates that ELAPE with flap reconstruction can be safely and effectively performed in a large public hospital setting, with outcomes comparable to high-volume tertiary centres. The findings underscore the importance of multidisciplinary collaboration in achieving high-quality surgical and reconstructive outcomes, and how these can be achieved in a large public hospital.