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Background: High-risk patients undergoing abdominoperineal resection and pelvic exenteration may benefit from immediate flap reconstruction. However, there is currently no consensus on the ideal flap choice or patient for whom this is necessary. This study aimed to evaluate the long-term outcomes of using pedicled gracilis flaps for pelvic reconstruction and to analyze predictors of postoperative complications., Methods: This was a retrospective review of a single reconstructive surgeon's cases between January 2012 and June 2021 identifying patients who underwent perineal reconstruction secondary to oncologic resection. Preoperative and outcome variables were collected and analyzed to determine the risk of developing minor and major wound complications., Results: A total of 101 patients were included in the study with most patients (n = 88) undergoing unilateral gracilis flap reconstruction after oncologic resection. The mean follow-up period was 75 months. Of 101 patients, 8 (7.9%) developed early major complications, and an additional 13 (12.9%) developed late major complications. Minor complications developed in 33 patients (32.7%) with most cases being minor wound breakdown requiring local wound care. Most patients (n = 92, 91.1%) did not develop donor site complications. Anal cancer was significantly associated with early major complications, whereas younger age and elevated body mass index were significant predictors of developing minor wound complications., Conclusions: This study builds on our previous work that demonstrated the long-term success rate of gracilis flap reconstruction after large pelvic oncologic resections. A few patients developed donor site complications, and perineal complications were usually easily managed with local wound care, thus making the gracilis flap an attractive alternative to abdominal-based flaps., (Copyright © 2023 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Background: The incidence of anal squamous cell carcinoma (SCC) is rising, despite the introduction of a vaccine against human papillomavirus (HPV), the most common etiology of anal SCC. The rate of anal SCC is higher among women and sex-based survival differences may exist. We aimed to examine the association between sex and survival for stage I-IV anal SCC., Materials and Methods: The National Cancer Database was used to identify patients with stage I-IV anal SCC from 2004-2016. Outcomes were assessed utilizing log rank tests, Kaplan-Meier statistics, and Cox proportional-hazard modeling. Subgroup analyses by disease stage and by HPV status were performed. Outcomes of interest were median, 1-, and 5-year survival by sex., Results: There were 31,185 patients with stage I-IV anal SCC. 10,714 (34.3%) were male and 20,471 (65.6%) were female. 1- and 5- year survival was 90.2% (95% CI 89.8 - 90.7) and 67.7% (95% CI 66.9 - 68.5) for females compared to 85.8% (95% CI 85.1 - 86.5) and 55.9% (95% CI 54.7 - 57.0) for males. In subgroup analysis, females demonstrated improved unadjusted and adjusted survival for all stages of disease. Female sex was an independent predictor of improved survival (HR 0.68, 95% CI 0.65 - 0.71, P < 0.001)., Conclusions: We demonstrate better overall survival for females compared to males for stage I-IV anal SCC. It is not clear why women have a survival advantage over men, though exposure to prominent risk factors may play a role. High-risk men may warrant routine screening for anal cancer., (Copyright © 2021. Published by Elsevier Inc.)

Background/objectives: Racial disparities are known to impact cancer outcomes. The aim of this study was to assess current racial disparities in outcomes of anal squamous cell carcinoma (SCC)., Methods: The National Cancer Database was used to identify patients with anal SCC. The primary outcome was 5-year overall survival., Results: There were 32 255 (88.1%) White patients and 4342 (11.9%) Black patients identified with anal SCC. Compared to White patients, Black patients were more likely to be younger, have lower median income, and be insured with Medicaid (all P < .001). The 5-year overall survival of Black and White patients for stage I disease was 71.2% and 80.6% (P < .001), for stage II disease, was 64.6% and 69.3% (P = .001), for stage III disease was 50.9% and 58.1% (P < .001), and for stage IV disease was 22.1% and 21.9% (P = .20). In a cox regression analysis, Black race was associated with significantly worse survival in stage I (HR: 1.37, 95% CI: 1.07-1.76, P = .01), stage II (HR: 1.30, 95% CI: 1.14-1.48, P < .001), and stage III disease (HR: 1.31, 95% CI: 1.16-1.47, P < .001) but not for stage IV disease (HR: 1.09, 95% CI: 0.89-1.35, P = .41)., Conclusions: Black race is correlated with worse survival in patients diagnosed with anal SCC. This disparity in survival is likely multifactorial and requires further study., (© 2019 Wiley Periodicals, Inc.)

Background/objectives: The first-line treatment for anal squamous cell carcinoma is Nigro protocol chemoradiotherapy. Some patients will fail curative intent chemoradiotherapy and have persistent disease while others may have an initial response followed by disease recurrence. The goal of this study is to investigate survival in anal squamous cell carcinoma patients who fail first-line treatment., Methods: The National Cancer Database (2004-2013) was used to identify patients with anal squamous cell carcinoma. The primary outcome was overall survival., Results: There were 256 patients in the early salvage group who underwent abdominoperineal resection (APR) within 6 months of completing chemoradiotherapy and 181 patients in the late salvage group who had APR 6 months or more after completion of chemoradiotherapy. Both groups of patients had similar tumor size (45  vs 50 mm; P = 0.07) and rate of positive margins (21.5% vs 15.6%;P = 0.13). There was no significant difference in overall survival between early and late salvage APR (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.50-1.32; P = 0.40)., Conclusions: The overall survival of anal squamous cell carcinoma patients undergoing early vs late salvage APR after failure of chemoradiotherapy is similar. As a result, patients with persistent disease should be offered surgery just as readily as those with recurrent disease., (© 2019 Wiley Periodicals, Inc.)

Background: Anal melanoma is a rare disease with a poor prognosis. Limited data are available regarding oncologic outcomes during the last decade and surgical practice patterns. This study aimed to investigate survival and operative oncologic outcomes for patients with anal melanoma., Methods: The National Cancer Database (2004-2013) was used to identify patients with nonmetastatic anal melanoma who underwent surgical treatment. The primary outcome was overall survival., Results: The study enrolled 439 patients in the local excision group and 214 patients in the abdominoperineal resection (APR) group. The patients in the APR group were older (70 vs 65 years; p < 0.001) and had larger tumors (40 vs 25 mm; p < 0.001). After resection, the APR patients were more likely to have positive lymph nodes (65.7% vs 12.5%; p < 0.001) and less likely to have positive margins (10% vs 29.8%; p < 0.001). Overall survival did not differ significantly between the APR and local excision patients (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.67-1.01; p = 0.06). The patients undergoing local excision showed was a significant survival advantage for those with negative margins (HR, 0.70, 95% CI, 0.53-0.93; p = 0.009). Among the patients undergoing APR, a significant survival advantage was observed for those with negative nodes (HR, 0.50; 95% CI, 0.35-0.69; p = 0.002) and negative margins (HR, 0.34; 95% CI, 0.15-0.77; p < 0.001)., Conclusions: The overall survival of anal melanoma patients is similar after local excision and APR. Patients with positive margins, positive lymph nodes, or both have a significantly decreased overall survival.

Anal squamous cell carcinoma (SCC) is a rare cancer and accounts for approximately 4% of all cancers of the lower alimentary tract. The dominant etiology is infection with human papilloma virus (HPV), which is the most common sexually transmitted disease in the United States. Integration of HPV DNA into the host genome seems to be the driving mechanism behind carcinogenesis. Vaccines directed against oncogenic HPV serotypes exist, and their utility for preventing anal neoplasia is under investigation. Additional risk factors for developing SCC include HIV infection, anal receptive intercourse, smoking, and immunosuppression. Patients with known anal intraepithelial neoplasia (AIN) must be carefully screened with periodic digital rectal exam and anoscopy. The most common presenting symptom is bleeding, with up to one third of patients presenting asymptomatic. Once tissue diagnosis is made, staging of primary tumor is accomplished with either MRI or transanal ultrasound. Distant disease is evaluated with CT of chest abdomen and pelvis vs whole body PET/CT. The gold standard treatment for stage I-III disease remains the Nigro protocol, first described in 1974. Stage I disease not involving sphincter may be treated with local excision. Distant disease is treated with systemic chemotherapy with radiation reserved for locoregional symptoms. Careful surveillance is mandatory after completion of chemoradiation. Salvage abdominoperineal resection can achieve locoregional control in up to 77% of patients with persistent or recurrent disease. Morbidity is high, mostly owing to wound complications, and as such a flap reconstruction of the perineum is warranted., (Copyright © 2018. Published by Elsevier Inc.)

Purpose: Perineal wound complications are common following abdominoperineal resection. This study investigates the factors contributing to these complications., Methods: Patients undergoing abdominoperineal resection at our institution from June 1997 to May 2003 were reviewed. Significant predictors associated with minor (separation <2 cm, stitch abscesses, or sinus tracts) or major (>2 cm of separation, reoperation required, or readmission) wound complications were ascertained., Results: Of 153 patients, there were 22 major (14 percent) and 32 minor (24 percent) wound complications. Patients with anal cancer had a higher rate of major complications than those with rectal cancer or inflammatory bowel disease. Minor wound complications were more common in patients with anal cancer and inflammatory bowel disease than those with rectal cancer. Factors associated with a higher rate of major wound complications included flap closure, tumor size, body mass index, diabetes, and indication for the procedure. When the subset of patients with rectal cancer was considered, higher rates of major wounds were associated with increased body mass index, diabetes, and stage. Minor complications were associated with a two-team approach and increasing body mass index., Conclusions: This is currently the largest review of perineal wound complications following abdominoperineal resection. Patients with anal cancer and inflammatory bowel disease were at higher risk for perineal wound complications than those with rectal cancer. Preoperative radiation and primary closure were not associated with increased complications following abdominoperineal resection for rectal cancer.

The current standard of care for the treatment of anal cancer as demonstrated by all of the completed phase 3 clinical trials remains 5-FU and mitomycin C in combination with radiation therapy. The basic elements of the approach outlined by Nigro have not changed in the last 30 years. Future phase 3 trials will serve to further perfect this approach and outline the role of HPV and dysplasia in the development and progression of this disease.