Reconstruction of Ischemic Necrosis of the Anal Canal and Perianal Soft Tissue Following Transarterial Embolization for Rectal Bleeding-A Rare Case Report

Introduction: Acute ischemia of the rectum or anal canal is uncommon because of its excellent blood supply. Following the use of transarterial embolization (TAE) for rectal bleeding has rarely been reported. We describe the case of a 62-year-old woman with a diagnosis of ischemic necrosis of the anal canal and perianal soft tissue following TAE for rectal bleeding. The patient was treated with surgical debridement and reconstructed with bilateral V-Y advancement gluteal fasciocutaneous flaps. Materials and Methods: A 62-year-old Taiwanese woman was diagnosed with acute aortic dissection (Stanford type A) and received reconstruction of the ascending aorta. Rectal bleeding was noted approximately 2 weeks postoperatively. Angiography revealed extravasation of the inferior mesenteric artery and bilateral internal iliac arteries and TAE was then performed. Unfortunately, perianal skin necrosis occurred a few days later, and post-embolization bowel ischemia of the anal canal and perianal soft tissue was found. After fecal diversion, the patient underwent surgical debridement and wound care with wet dressing several times. On post-embolization day 30, we performed bilateral V-Y advancement gluteal fasciocutaneous flaps for reconstruction. Results: Although there was a wound dehiscence a few days after the reconstruction, the wound healed gradually after weeks of delicate wound care. There were no other complications, such as anal stricture or anal ectropion was noted. The muscular tissue and anal sphincter remained intact. Discussion: Defects in the skin and subcutaneous tissue in the perianal region can be treated in many ways, such as primary closure, secondary healing, skin grafts, local flaps, reginal flaps, distant pedicle flaps, perforator flaps, and free flaps. Because the patient had multiple systemic diseases and had undergone major surgery, we chose bilateral V-Y advancement gluteal fasciocutaneous flaps as a safe, easy, fast, and effective surgical technique. 60 days after the reconstruction, the wound healed completely with normal appearance. Throughout the treatment, the muscular tissue and anal sphincter remained intact. Digital rectal examination revealed a normal anal tone. The closure of the colostomy with normal defecation function should be feasible in the future. Conclusion: Though there are many options for perianal reconstruction, the V-Y advancement gluteal fasciocutaneous flap is a relatively easy and quick method which is also able to cover the large defect over the perianal region. For patients who underwent perianal reconstruction, the closure of the colostomy should be considered to improve the quality of life.

關鍵字

perianal reconstruction ； V-Y advancement gluteal fasciocutaneous flap ； transarterial embolization

並列摘要

背景：由於其良好的血液供應，直腸或肛管的急性缺血並不常見。而使用經動脈栓塞術治療直腸出血後造成的案例更罕見。我們描述了一名62歲女性的病例，她因直腸出血而進行經動脈栓塞術後被診斷為肛管和肛門周圍軟組織缺血性壞死。患者接受手術清創治療，並用雙側V-Y推進臀部筋膜皮瓣重建。材料及方法：一位62歲的台灣女性被診斷出患有急性主動脈剝離並接受升主動脈重建。術後約2週觀察到直腸出血。血管造影顯示腸系膜下動脈和雙側髂內動脈有顯影劑外滲，並進行了動脈栓塞術。不幸的是，幾天後發生肛門周圍皮膚壞死，並發現栓塞後肛管和肛門周圍軟組織缺血。接受腸造口術後，患者多次接受清創手術和濕敷傷口換藥。栓塞後第30天，我們行雙側V-Y推進臀部筋膜皮瓣重建。結果：雖然在重建後幾天有部分傷口裂開，但經過數週的仔細傷口照護，傷口逐漸癒合。沒有其他併發症像是肛門狹窄、肛門外翻等狀況出現。肌肉組織和肛門括約肌保持完整。討論：肛門周圍皮膚和皮下組織的缺陷可以通過多種方式進行治療，例如直接縫合、次級癒合、皮膚移植、局部皮瓣、區域皮瓣、遠端根蒂皮瓣、穿通支皮瓣和游離皮瓣。由於患者有多種全身性疾病，並接受過大手術，我們選擇雙側V-Y推進臀部筋膜皮瓣作為一種安全、簡便、快速、有效的手術技術。重建60天後，傷口完全癒合，外觀正常。在整個治療過程中，肌肉組織和肛門括約肌保持完整。直腸指診檢查顯示肛門張力正常。將來可以關閉腸造口回復正常的排便功能。結論：雖然肛門周圍重建有多種選擇，但V-Y推進臀部筋膜皮瓣是一種相對簡單快捷的方法，也能夠覆蓋肛門周圍區域的大面積缺損。對於接受肛門周圍重建後的患者，應考慮關閉腸造口以增進生活品質。

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