Exenterative pelvic surgery

Marital status and survival in patients with rectal cancer: A population-based STROBE cohort study

To examine the impact of marital status on overall survival (OS) and rectal cancer-specific survival (RCSS) for aged patients.We used the Surveillance, Epidemiology and End Results database to identify aged patients (>65 years) with early stage rectal cancer (RC) (T1-T4, N0, M0) in the United States from 2004 to 2010. Propensity score matching was conducted to avoid potential confounding factors with ratio at 1:1. We used Kaplan-Meier to compare OS and RCSS between the married patients and the unmarried, respectively. We used cox proportion hazard regressions to obtain hazard rates for OS, and proportional subdistribution hazard model was performed to calculate hazard rates for RCSS.Totally, 5196 patients were included. The married (2598 [50%]) aged patients had better crude 5-year overall survival rate (64.2% vs 57.3%, P < .001) and higher crude 5-year cancer-specific survival rate (80% vs 75.9%, P < .001) than the unmarried (2598 (50%)), respectively. In multivariate analyses, married patients had significantly lower overall death than unmarried patients (HR = 0.77, 95% CI = 0.71-0.83, P < .001), while aged married patients had no cancer-specific survival benefit versus the unmarried aged patients (HR = 0.92, 95% CI = 0.81-1.04, P = .17).Among old population, married patients with early stage RC had better OS than the unmarried, while current evidence showed that marital status might have no protective effect on cancer-specific survival.

Double barreled wet colostomy: initial experience and literature review

Background. Pelvic exenteration and multivisceral resection in colorectal have been described as a curative and palliative intervention. Urinary tract reconstruction in a pelvic exenteration is achieved in most cases with an ileal conduit of Bricker, although different urinary reservoirs have been described. Methods. A retrospective and observational study of six patients who underwent a pelvic exenteration and urinary tract reconstruction with a double barreled wet colostomy (DBWC) was done, describing the preoperative diagnosis, the indication for the pelvic exenteration, the complications associated with the procedure, and the followup in a period of 5 years. A literature review of the case series reported of the technique was performed. Results. Six patients had a urinary tract reconstruction with the DBWC technique, 5 male patients and one female patient. Age range was from 20 to 77 years, with a medium age 53.6 years. The most frequent complication presented was a pelvic abscess in 3 patients (42.85%); all complications could be resolved with a conservative treatment. Conclusion. In the group of our patients with pelvic exenteration and urinary tract reconstruction with a DBWC, it is a safe procedure and well tolerated by the patients, and most of the complications can be resolved with conservative treatment.

Health-related quality of life after surgery for primary advanced rectal cancer and recurrent rectal cancer: a review

AIM

Health-related quality of life is an important outcome measure in treatment of cancer. A review of the literature was undertaken to provide an overview of health-related quality of life (HRQoL) after surgery for primary advanced or recurrent rectal cancer and to outline proposals for future HRQoL studies in this area.

METHOD

A systematic literature search was undertaken. Only studies concerning surgery for primary advanced or recurrent rectal cancer and describing methods used for measuring HRQoL were considered.

RESULTS

Seven studies were identified, including two prospective longitudinal studies, three cross-sectional studies and two based on qualitative data. Global quality of life, and physical, social, role and sexual function seemed to be impaired for a varying time after surgery. All the studies had methodical problems due to small sample size (12-44 patients) and different points of time for the assessment of HRQoL (12.3-47 months), which made it difficult to determine the period of time of impaired HRQoL and also if this is different after surgery for locally advanced or recurrent disease compared with after total mesorectal excision used for earlier tumours.

CONCLUSION

Several aspects of HRQoL are impaired for a variable time after treatment for locally advanced or recurrence of rectal cancer. Larger prospective longitudinal studies are needed to provide further information regarding the effects of this extensive surgery on quality of life.

Revisiting the double-barreled wet colostomy for simultaneous urinary and fecal diversion--an Indian experience

Pelvic exenteration in advanced malignancies is usually a curative procedure aimed at improving quality of life. We analyzed the perioperative data and outcomes in 12 patients who underwent simultaneous urinary and fecal diversion with a double-barreled wet colostomy after total pelvic exenteration. Eight males and four females aged between 25 and 73 years underwent the procedure with mean operative duration of 350 min and mean postoperative stay of 15 days. Three patients developed early complications while four developed late complications. During follow up ranging from 6 to 64 months, four patients died of disease progression while four died of unrelated causes. One lady was lost to follow up, the remaining had a mean survival of 32.9 months. None had deterioration in renal function or peristomal dermatitis and all were well accustomed to managing one stoma. Our results show that double-barreled wet colostomy is technically simple and reduces surgical morbidity while providing satisfactory outcomes and patient comfort.

Follow-up of double-barreled wet colostomy after pelvic exenteration at a single institution

PURPOSE

Double-barreled wet colostomy consists of simultaneous urinary and fecal diversions into a lateral colostomy and is indicated after pelvic exenteration or in palliative operations, when complete intestinal and urinary reconstruction is not possible. We report experience at our institution with Double-barreled wet colostomy regarding postoperative and long-term morbidity and mortality.

METHODS

All patients who underwent double-barreled wet colostomy construction at our institution from 1980 through 2008 were included in the study. Medical records were reviewed for type and history of the malignant tumor, previous treatments, comorbidity according to the American Society of Anesthesiologists' score, type and length of surgery, length of hospital stay, and postoperative (within 30 days after the operation) and long-term morbidity and mortality.

RESULTS

The study comprised 41 patients. The underlying disease was a malignant pelvic tumor in 30 patients (primary in 6 and recurrent in 24 patients) and a nonmalignant disease in 11 patients. Surgical mortality was 2.4%, and the postoperative morbidity rate was 65.9%. Double-barreled wet colostomy-related morbidity observed during follow-up included pyelonephritis (9.8%, with renal deterioration due to chronic pyelonephritis in 2.4%), stenosis of the uretero-colonic anastomosis (2.4%), and lithiasis in the urine reservoir (7.3%). Follow-up was discontinued after a mean of 18.6 (SD, 19.9) months in 14 patients who had been referred from other centers. A total of 27 patients were followed in our center for a mean of 32.2 (range, 1-156) months. Of these, 7 patients are currently alive, 1 with recurrent disease; 14 patients died from local or distant recurrence; and 6 patients died of causes other than malignancy.

CONCLUSION

Double-barreled wet colostomy is a safe alternative for patients who need simultaneous urinary and fecal diversion, although the risk of ascending urinary infection must be taken into consideration.

Video-assisted double-barreled wet colostomy: a new minimally invasive simultaneous diversion to patients after pelvic radiation therapy

INTRODUCTION

A wet colostomy can be done when the simultaneous diversion of fecal and urine streams are necessary. Laparoscopic access is gaining space in urinary diversion procedures. The aim of the present study was to present the technique and results of the first case reported of a video-assisted double-barreled wet colostomy.

PATIENT AND METHODS

In this article, we report a case of a 50-year-old woman with actinic complex urinary and fecal fistula, treated through a retroperitoneoscopic double-barreled wet colostomy. Only the left kidney had function, so she was treated by video endoscopic retroperitoneal dissection of the left ureter, preplanned transverse 5-cm incision for exteriorization of left colon and ureter, extracorporeal section of the left colon with a linear stapler, extracorporeal antireflux ureterocolonic anastomosis, and maturation of the stoma 10 cm proximal to the end of the proximal colonic loop.

RESULTS

Operative time was 135 minutes. No transfusion was required nor had intraoperative complications occurred. Oral intake was initiated in postoperative day 2, and the patient was discharged postoperative day 6 without complications. Normal activities were recovered after 21 days. In a 3-month follow-up, there were no infectious complications, and good urinary drainage was observed. She was satisfied and adapted to the stoma.

CONCLUSIONS

Video-assisted double-barreled wet colostomy is a feasible procedure. The same goals of the open procedure were achieved, offering the advantages of the laparoscopic approach.

Pelvic exenteration for primary and recurrent gynaecological malignancies

OBJECTIVE

Analyse the outcome of pelvic exenteration for gynaecological malignancies in a tertiary referral center. Post-operative in-hospital morbidity, long-term morbidity, disease free and overall survival rates were studied.

STUDY DESIGN

Between 1991 and 2004, 42 patients underwent an anterior, total or posterior exenteration for gynaecological malignancies. Follow-up was obtained from patient files; disease free and overall survival were calculated and prognostic factors were studied.

RESULTS

A pelvic exenteration was performed in 14 patients for primary and 28 patients for recurrent gynaecological cancers. In-hospital complications occurred in 19 patients (45%) of whom seven patients needed a reoperation (17%). Late complications occurred in 31 patients (75%); 21 reinterventions were performed (50%). Five-year disease free and overall survival was, respectively, 48 and 52%. Age, type of surgery, histology, localisation of the tumour, lateral wall involvement, completeness of resection and primary versus recurrent cancer were not identified as prognostic factors for recurrence or survival.

CONCLUSION

Long-term survival is possible in about 50% of patients after pelvic exenteration for gynaecological cancers, but is associated with significant post-operative morbidity.

Double-barrelled wet colostomy with simultaneous urinary and faecal diversion: results in 9 patients and review of the literature

OBJECTIVE

Double-barrelled wet colostomy is a urinary diversion technique indicated when a concurrent faecal diversion is needed. It is a simple procedure, technically easy to accomplish and well received by patients. The purpose of this study is to report the results of double-barrelled wet colostomy, with emphasis on operating technique, morbidity, functional results and a review of the literature on the subject.

METHODS

The medical records of 9 consecutive patients, between January 2001 and May 2005, who underwent surgical extended resections with double-barrelled wet colostomy for a malignant central pelvic mass, were reviewed retrospectively. The patients were asked to respond to a questionnaire assessing quality of life. The questionnaire used was the QLQ-C30 version 3, proposed by the European Organization for Research and Treatment of Cancer (EORTC).

RESULTS

This study presents results obtained from 9 patients, emphasizing morbidity and quality of life. One patient presented with pyelonephritis. We did not identify complications such as hydroelectrolytic disturbances, peristomal dermatitis or hydronephrosis. The patients who submitted to the procedure exhibited high levels of quality of life and found caring for the stomas straight forward.

CONCLUSIONS

We conclude that double-barrelled wet colostomy is an excellent choice for patients who require concurrent urinary and faecal diversion, one that does not present technical difficulties and does not require a prolonged operating time. It avoids the complications frequently present in standard wet colostomy and does not rule out making a continent urinary reservoir later, in patients that meet healing criteria.

Qualitative assessment of patient experiences related to extended pelvic resection for rectal cancer

BACKGROUND

Patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) represent a complex management challenge. While there is potential for cure in a subset of patients, the cost in terms of morbidity can be high. Few descriptions of the physical, psychological, social, and emotional experiences of these patients exist.

METHODS

Face-to-face interviews were completed with ten LARC and LRRC patients treated with multimodal therapy that included surgery. Patient opinions and experiences were explored in depth until information redundancy and common themes were delineated using qualitative research methods. Clinical information was obtained from the database.

RESULTS

Nine of the ten patients were male, seven had LARC, and the median age was 71. Six themes were identified from the patient interviews. Themes reflected patients' highly focused desire to seek wellness and cure, but also revealed misunderstanding of their disease biology, probability of cure, therapeutic options, and treatment morbidity.

CONCLUSIONS

Patient experiences confirm that this is challenging treatment to complete, and that patient understanding of pre-operative information is incomplete. Our findings underscore the need for a multidisciplinary approach when managing this patient population, with emphasis on both supportive care needs and the technically skilled delivery of surgery, chemotherapy, and radiotherapy.

Exenterative pelvic surgery—eleven year experience of the Swansea Pelvic Oncology Group

AIMS

To review indications for surgery and outcomes of patients with complex locally advanced pelvic malignancies treated by a multidisciplinary Pelvic Oncology Group.

PATIENTS AND METHODS

Between March 1992 and March 2003, 130 patients were jointly assessed in a monthly clinic involving urological, gynaecological, colorectal and plastic surgeons, an oncologist and nurse specialists. Seventy-six patients proceeded to exenterative surgery.

RESULTS

Rectal carcinoma and gynaecological cancers were the two most common indications for surgery. Median follow-up was 14 months (range 1-120 months). There were no deaths within 30 days of surgery. The morbidity rate was 28%. Predicted 5 years survival was 53% in cases with clear histological margins and no lymph node metastasis.

CONCLUSION

With careful patient selection and multi specialty care pelvic exenteration is a safe and effective option in the treatment of complex locally advanced pelvic malignancy.

Epigenetics of cervical cancer. An overview and therapeutic perspectives

Cervical cancer remains one of the greatest killers of women worldwide. It is difficult to foresee a dramatic increase in cure rate even with the most optimal combination of cytotoxic drugs, surgery, and radiation; therefore, testing of molecular targeted therapies against this malignancy is highly desirable. A number of epigenetic alterations occur during all stages of cervical carcinogenesis in both human papillomavirus and host cellular genomes, which include global DNA hypomethylation, hypermetylation of key tumor suppressor genes, and histone modifications. The reversible nature of epigenetic changes constitutes a target for transcriptional therapies, namely DNA methylation and histone deacetylase inhibitors. To date, studies in patients with cervical cancer have demonstrated the feasibility of reactivating the expression of hypermethylated and silenced tumor suppressor genes as well as the hyperacetylating and inhibitory effect upon histone deacetylase activity in tumor tissues after treatment with demethylating and histone deacetylase inhibitors. In addition, detection of epigenetic changes in cytological smears, serum DNA, and peripheral blood are of potential interest for development of novel biomolecular markers for early detection, prediction of response, and prognosis.

Pre-exenterative chemotherapy, a novel therapeutic approach for patients with persistent or recurrent cervical cancer

Background

Most cervical cancer patients with pelvic recurrent or persistent disease are not candidates for exenteration, therefore, they only receive palliative chemotherapy. Here we report the results of a novel treatment modality for these patients pre-exenterative chemotherapy- under the rational that the shrinking of the pelvic tumor would allow its resection.

Methods

Patients with recurrent or persistent disease and no evidence of systemic disease, considered not be candidates for pelvic exenteration because of the extent of pelvic tumor, received 3-courses of platinum-based chemotherapy. Response was evaluated by CT scan and bimanual pelvic examination; however the decision to perform exenteration relied on the physical findings. Toxicity to chemotherapy was evaluated with standard criteria. Survival was analyzed with the Kaplan-Meier method.

Results

Seventeen patients were studied. The median number of chemotherapy courses was 4. There were 9 patients who responded to chemotherapy, evaluated by bimanual examination and underwent pelvic exenteration. Four of them had pathological complete response. Eight patients did not respond and were not subjected to surgery. One patient died due to exenteration complications. At a median follow-up of 11 months, the median survival for the whole group was 11 months, 3 months in the non-operated and 32 months in those subjected to exenteration.

Conclusion

Pre-exenterative chemotherapy is an alternative for cervical cancer patients that are no candidates for exenteration because of the extent of the pelvic disease. Its place in the management of recurrent disease needs to be investigated in randomized studies, however, its value for offering long-term survival in some of these patients with no other option than palliative care must be stressed.

Pelvic exenteration and sphincter preservation in the treatment of soft tissue sarcomas

BACKGROUND

Pelvic sarcomas are rare and there are very few effective therapeutic alternatives. A complete resection is considered the main factor associated to a good prognosis, which justifies the employment of a pelvic exenteration (PE) in selected cases.

METHODS

Between 1980 and 2000, 96 PE were performed, nine of which were for sarcomas. The clinical characteristics, surgical and anatomopathological aspects and the patients' evolution were described.

RESULTS

The median follow-up time was 24 months (ranging from 1 to 57 months). In relation to the sphincters preservation, at least one sphincter was preserved in five patients. There were two post-operative deaths. In the last follow-up, six patients were alive without any evidence of the disease.

CONCLUSION

Pelvic exenterations should be performed for the treatment of selected cases of locally advanced pelvic sarcomas. Sphincter preservation may be performed, provided that oncological resection principles are obeyed.

The double-barreled wet ileostomy: an alternative method for simultaneous urinary and intestinal diversion without intestinal anastomosis after total colectomy and pelvic exenteration

BACKGROUND

Although the number of cases of locally advanced colorectal cancer related to familial adenomatous polyposis (FAP) has decreased as a result of a better understanding of the disease, the condition still can offer therapeutic challenges.

CASE PRESENTATION

We report a case of a rectal tumor with prostate invasion associated with FAP, treated with neoadjuvant radiotherapy and total extended proctocolectomy with cystoprostatectomy. The reconstruction was undertaken with a double-barreled ileostomy with ureteral reimplantation on the distal segment of the ileostomy. Data including surgical aspects, post-operative complications, and outcome were evaluated.

CONCLUSION

The double-barreled wet ileostomy is a technically straightforward and safe procedure that is easily executed and may be an alternative to simultaneous diversion in extreme situations. To the best of our knowledge, this is the first description of this procedure in the literature.

Pelvic exenteration and sphincter preservation: An analysis of 96 cases

BACKGROUND

Pelvic exenteration (PE) is characterized by its technical complexity and morbidity rate. Appropriate patient selection prior to the operation allows for more conservative surgeries, preserving sphincters, and continent reconstruction of the intestinal and urinary tract, contributing to better results.

METHODS

Between 1980 and 2000, 96 PE were performed. Factors related to sphincter preservation as well as factors associated to prognosis were respectively analyzed.

RESULTS

Of the 96 PE, at least one sphincter in 36 patients was preserved (37.5%). In the 1990s, the sphincter preservation rate was significantly higher than in the 1980s (47.6 vs. 18.2%) (P = 0.005). More serious complications happened in 19.8% of the patients and the post-operative mortality rate was 15.6%. The post-operative complication rate was not influenced by sphincter preservation (P = 0.276). In nine patients, the resection margins were compromised microscopically (R1) and in five patients, there were macroscopically compromised (R2). The resection margins were not influenced by the type of surgery (P = 0.104), nor by the preservation of sphincters (P = 0.881). Twenty-three patients experienced relapses, 13 being local, eight distant, and two local and distant. Disease free survival at 5 years was 40.5%, and the primary site of the tumor was a factor associated to differences in disease free survival (P = 0.027). Overall 5-year survival was 41.9% and was significantly associated to the number of organs compromised (P = 0.040) and sphincter preservation (P = 0.026). Patients who were submitted to R0 type resection had a median survival of 40.9 months, while R1 and R2 type resections had a median 21.2 month survival.

CONCLUSIONS

The appropriate pre-operative selection of the patient and rigorous oncological criteria permit PE to be performed while preserving the sphincters in selected cases, without harming survival rates.

Pelvic exenteration and reconstruction

For the past six decades, pelvic extenteration has been utilized in the treatment of localized central pelvic recurrences after chemo/radiotherapy. The radicality of the procedure that includes resection of the bladder, vulva/vagina, and rectum, although with curative intent, results in comprehensive changes for the patient. For this reason, all patients should undergo extensive psychosocial counseling to prepare them for the changes in body image and lifestyle. Extirpation of the pelvic viscera has undergone a number of modifications since Brunschwig first described it in 1948 to maximize survivability and minimized anatomical distortion. Most of the advancements have been focused on the reconstructive phase after pelvic exenteration. A few select patients can be free of any external appliances such as a colostomy bag with utilization of a low colorectal anastomosis, and can maintain sexual intimacy with creation of a neovagina. In addition, reconstruction of the pelvic floor with omental flaps, dura mater grafts and myocutaneous flaps have decreased postoperative morbidity. In this article, we provide a review of pelvic exenteration in gynecologic oncology, emphasizing preoperative evaluation, surgical techniques and their postoperative management.