{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T02:57:22Z","timestamp":1789181842815,"version":"build-2803163510"},"reference-count":14,"publisher":"American Medical Association (AMA)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Surg"],"published-print":{"date-parts":[[2025,4,1]]},"abstract":"<jats:sec><jats:title>Importance<\/jats:title><jats:p>Perineal wound complications are common following abdominoperineal resection for rectal cancer and might have substantial and long-lasting implications for patients\u2019 recovery.<\/jats:p><\/jats:sec><jats:sec><jats:title>Objective<\/jats:title><jats:p>To evaluate the superiority of gluteal turnover flap closure compared to primary closure in patients with rectal cancer undergoing abdominoperineal resection.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design, Setting, and Participants<\/jats:title><jats:p>The BIOPEX-2 study was an investigator-initiated, parallel-group, multicenter randomized clinical trial conducted at 19 centers in the Netherlands and the UK between June 2019 and November 2023, including 12 months of follow-up. Data analysis was performed from October 2023 to December 2023. Independent perineal wound assessors were masked to the type of closure. Eligibility criteria were resection of rectal cancer by abdominoperineal resection, aged 18 years or older, and ability to complete follow-up. In modified intention-to-treat analyses, patients were assigned to either primary closure or gluteal turnover flap closure.<\/jats:p><\/jats:sec><jats:sec><jats:title>Intervention<\/jats:title><jats:p>Gluteal turnover flap closure started with a half-moon\u2013shaped perineal skin island that was incised and deepithelialized. Subsequently, the subcutaneous fat was dissected toward the gluteal fascia, after which the dermis was sutured to the contralateral levator remnant, followed by midline closure.<\/jats:p><\/jats:sec><jats:sec><jats:title>Main Outcomes and Measures<\/jats:title><jats:p>The primary outcome was uncomplicated wound healing at 30 days postoperatively, defined as a Southampton wound score less than 2. Secondary outcomes included presacral abscess formation and wound-related readmissions.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 175 patients were randomized, but 7 did not undergo abdominoperineal resection and 3 withdrew consent. In the modified intention-to-treat analyzes, 86 patients were assigned to primary closure and 79 patients to gluteal turnover flap closure. Of these 165 patients, mean (SD) patient age was 67 (10) years, and 57 patients (34.5%) were female. Uncomplicated perineal wound healing was present in 49 of 82 patients (60%) after primary closure, which did not significantly differ from flap closure (42 of 76 patients [55%]). Presacral abscess developed significantly more often after primary closure than flap closure (19 of 86 patients [22%] vs 7 of 78 patients [9%]; <jats:italic>P<\/jats:italic>\u2009=\u2009.02), and more percutaneous presacral abscess drainage was performed in the control group (primary closure) (7 patients [8%] vs 1 patient [1%]; <jats:italic>P<\/jats:italic>\u2009=\u2009.04). Perineal wound\u2013related readmission occurred in 18 patients (21%) after primary closure and in 10 patients (13%) after gluteal flap closure (<jats:italic>P<\/jats:italic>\u2009=\u2009.17).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion and Relevance<\/jats:title><jats:p>In this parallel-group, multicenter randomized clinical trial, gluteal turnover flap closure did not show superiority over primary closure in 30-day perineal wound healing after abdominoperineal resection for rectal cancer. However, flap closure significantly reduced presacral abscess formation.<\/jats:p><\/jats:sec><jats:sec><jats:title>Trial Registration<\/jats:title><jats:p>ClinicalTrials.gov Identifier: <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/clinicaltrials.gov\/study\/NCT04004650\">NCT04004650<\/jats:ext-link><\/jats:p><\/jats:sec>","DOI":"10.1001\/jamasurg.2024.6818","type":"journal-article","created":{"date-parts":[[2025,2,5]],"date-time":"2025-02-05T16:00:55Z","timestamp":1738771255000},"page":"378","source":"Crossref","is-referenced-by-count":15,"title":["Perineal Wound Closure Using Gluteal Turnover Flap After Abdominoperineal Resection for Rectal Cancer"],"prefix":"10.1001","volume":"160","author":[{"given":"Saskia I.","family":"Kreisel","sequence":"first","affiliation":[{"name":"Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands"},{"name":"Treatment and Quality of Life, Cancer Centre Amsterdam, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Sharabiany","sequence":"additional","affiliation":[{"name":"Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands"},{"name":"Treatment and Quality of Life, Cancer Centre Amsterdam, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jurriaan","family":"Tuynman","sequence":"additional","affiliation":[{"name":"Department of Surgery, Amsterdam UMC location VUmc, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric H. J.","family":"Belgers","sequence":"additional","affiliation":[{"name":"Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Baljit","family":"Singh","sequence":"additional","affiliation":[{"name":"Department of Surgery, University Hospitals Leicester, Leicester, United Kingdom"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sanjay","family":"Chaudhri","sequence":"additional","affiliation":[{"name":"Department of Surgery, University Hospitals Leicester, Leicester, United Kingdom"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna A. W.","family":"van Geloven","sequence":"additional","affiliation":[{"name":"Department of Surgery, Tergooi Medical Centre, Hilversum, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronald J. C. L. M.","family":"Vuylsteke","sequence":"additional","affiliation":[{"name":"Department of Surgery, Spaarne Gasthuis, Haarlem, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johannes H. W.","family":"de Wilt","sequence":"additional","affiliation":[{"name":"Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jarno","family":"Melenhorst","sequence":"additional","affiliation":[{"name":"Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeroen W. A.","family":"Leijtens","sequence":"additional","affiliation":[{"name":"Department of Surgery, St Laurentius Hospital, Roermond, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maarten","family":"Vermaas","sequence":"additional","affiliation":[{"name":"Department of Surgery, IJsselland Hospital, Capelle aan de IJssel, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joost","family":"Rothbarth","sequence":"additional","affiliation":[{"name":"Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cornelis","family":"Verhoef","sequence":"additional","affiliation":[{"name":"Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacobus W. A.","family":"Burger","sequence":"additional","affiliation":[{"name":"Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fatih","family":"Polat","sequence":"additional","affiliation":[{"name":"Department of Surgery, Canisius Wilhemina Hospital, Nijmegen, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hans F. J.","family":"Fabry","sequence":"additional","affiliation":[{"name":"Department of Surgery, Bravis Hospital, Bergen op Zoom, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arend G. J.","family":"Aalbers","sequence":"additional","affiliation":[{"name":"Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan H.","family":"Wijsman","sequence":"additional","affiliation":[{"name":"Department of Surgery, Amphia Hospital, Breda, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bas","family":"Lamme","sequence":"additional","affiliation":[{"name":"Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jarmila D. W.","family":"van der Bilt","sequence":"additional","affiliation":[{"name":"Department of Surgery, Flevo Hospital, Almere, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oren","family":"Lapid","sequence":"additional","affiliation":[{"name":"Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan","family":"van Dieren","sequence":"additional","affiliation":[{"name":"Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roel","family":"Hompes","sequence":"additional","affiliation":[{"name":"Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands"},{"name":"Department of Surgery, Amsterdam UMC location VUmc, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pieter J.","family":"Tanis","sequence":"additional","affiliation":[{"name":"Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands"},{"name":"Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gijsbert D.","family":"Musters","sequence":"additional","affiliation":[{"name":"Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands"},{"name":"Department of Surgery, Zaans Medical Centre, Zaandam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"6","key":"soi240106r1","doi-asserted-by":"publisher","first-page":"1074","DOI":"10.1097\/SLA.0000000000002020","article-title":"Biological mesh closure of the pelvic floor after extralevator abdominoperineal resection for rectal cancer: a multicenter randomized controlled trial (the BIOPEX-study).","volume":"265","author":"Musters","year":"2017","journal-title":"Ann Surg"},{"issue":"8","key":"soi240106r2","doi-asserted-by":"publisher","first-page":"952","DOI":"10.1097\/DCR.0000000000001349","article-title":"Propensity score adjusted comparison of pelviperineal morbidity with and without omentoplasty following abdominoperineal resection for primary rectal cancer.","volume":"62","author":"Blok","year":"2019","journal-title":"Dis Colon Rectum"},{"issue":"12","key":"soi240106r3","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejso.2023.107114","article-title":"Quality of life in patients with a perineal hernia.","volume":"49","author":"Kreisel","year":"2023","journal-title":"Eur J Surg Oncol"},{"issue":"11","key":"soi240106r4","doi-asserted-by":"publisher","first-page":"1563","DOI":"10.1007\/s00384-015-2328-1","article-title":"Persistent perineal morbidity is common following abdominoperineal excision for rectal cancer.","volume":"30","author":"Asplund","year":"2015","journal-title":"Int J Colorectal Dis"},{"issue":"5","key":"soi240106r5","doi-asserted-by":"publisher","first-page":"1602","DOI":"10.1097\/PRS.0000000000002107","article-title":"Primary versus flap closure of perineal defects following oncologic resection: a systematic review and meta-analysis.","volume":"137","author":"Devulapalli","year":"2016","journal-title":"Plast Reconstr Surg"},{"issue":"2","key":"soi240106r6","doi-asserted-by":"publisher","first-page":"138","DOI":"10.1111\/codi.14471","article-title":"Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis.","volume":"21","author":"Yang","year":"2019","journal-title":"Colorectal Dis"},{"issue":"4","key":"soi240106r7","doi-asserted-by":"publisher","first-page":"1721","DOI":"10.1007\/s11845-024-03651-3","article-title":"Primary closure versus vertical rectus abdominis myocutaneous (VRAM) flap closure of perineal wound following abdominoperineal resection-a systematic review and meta-analysis.","volume":"193","author":"Temperley","year":"2024","journal-title":"Ir J Med Sci"},{"issue":"1","key":"soi240106r8","doi-asserted-by":"publisher","first-page":"132","DOI":"10.1007\/s00268-020-05788-5","article-title":"Donor site morbidity of patients receiving vertical rectus abdominis myocutaneous flap for perineal, vaginal or inguinal reconstruction.","volume":"45","author":"Schellerer","year":"2021","journal-title":"World J Surg"},{"issue":"9","key":"soi240106r9","doi-asserted-by":"publisher","first-page":"1094","DOI":"10.1111\/codi.14715","article-title":"Gluteal turnover flap for perineal reconstruction following abdominoperineal resection for rectal cancer - 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