Case Series/Study

(CS-045) Mesenchymal Stem Cell and Regenerative Therapy with Bilateral Gracilis Flaps for Perineal Reconstruction of a Wound Infection in the Setting of Anal Squamous Cell Carcinoma: A Case Report

Co-Author(s):

Julian Gendreau, MD; Kirti Tiwari, BS; Pamela Burgess, MD; Philippe Taupin, PhD; Eric Martin, DO

Introduction: Perineal wounds in immunocompromised patients can often be difficult to treat. To date, there is no evidence of using mesenchymal stem cell therapy in the perineal reconstruction of immunocompromised patients after multiple failed flaps. In this report, the authors describe the first application of mesenchymal stem cell therapy for the management of a complex perineal wound site of an HIV-positive male who underwent resection of a squamous cell carcinoma of the anus and developed a postoperative infection. This complex wound was refractory to treatment attempts with both a single vertical rectus abdominis myocutaneous (VRAM) flap and also bilateral myocutaneous gracilis flaps (MGFs). Methods: The patient was a 60-year-old HIV-positive male with squamous cell carcinoma (T1N0M0) of the anal margin. His HIV was poorly controlled with a last known CD-4 count of 44. He was status post an initial wide local excision of the disease while subsequently undergoing 5040 cGy radiotherapy in the anal canal and perianal area. He developed an infection postoperatively and was treated with both a VRAM flap and bilateral MGFs, which subsequently failed. Therefore, the decision was made to apply mesenchymal stem cell therapy, with the application of dermal matrices and other regenerative medicine products for further reconstruction.
 Results: After the initial application of the mesenchymal stem cell therapy, the patient underwent serial operative debridement for source control. During these debridements, there was application of additional mesenchymal stem cells, bovine dermis, porcine bladder xenograft and other regenerative medicine products. This achieved a highly successful clinical outcome, as the wound was reduced to measuring only 5 cm long x 3 cm wide and 3 cm deep. Upon further continued postoperative follow up, the patient was doing well clinically and denied significant pain, drainage or symptoms of any systemic illness. Discussion: This is the first case providing evidence that mesenchymal stem cell therapy, in combination with regenerative medicine, can be used to achieve good clinical outcomes in patients with squamous cell carcinoma of the anus that have undergone reconstructions in a disadvantageous field. We believe this method will be beneficial for surgeons in attempting to heal complex wounds in the setting of previously failed reconstruction of the perineum for squamous cell carcinoma of the anus or any other disease pathology. Trademarked Items: -Osiris umbilical cord mesenchymal stem cell grafts (Osiris Therapeutics, Columbia, MD, USA) were sutured in place covering the exposed bed of gracilis muscle and perineal soft tissues.
- A 10 cm by 15 cm SurgiMend acellular dermal matrix mesh (Integra, Plainsboro Township, NJ, USA) was placed onto the anterior rectus sheath, in an in-lay fashion.
-A mixture of ACell extracellular matrix (ECM) powder (ACell, Columbia, MD, USA), Ascent powder, Red One amniotic membrane liquid, and EpiFix amnion/chorion allograft powder (MiMedx, Marietta, GA, USA) was injected into the surrounding tissue in a circumferential manner.
- A mixture of ACell ECM powder, Amniofill placental-based ECM powder, and NEOX®FLO umbilical cord-based particulate (Amniox Medical, Miami, FL, USA) was applied to the wound. Final wound closure was completed by suturing an ACell ECM xenograft over the exposed tissue. References: