Contemporary outcomes of total pelvic exenteration in the treatment of colorectal cancer

A systematic review and meta-analysis on mortality rate following total pelvic exenteration in cancer patients

BACKGROUND

Total pelvic exenteration (TPE), an en bloc resection is an ultraradical operation for malignancies, and refers to the removal of organs inside the pelvis, including female reproductive organs, lower urological organs and involved parts of the digestive system. The aim of this meta-analysis is to estimate the intra-operative mortality, in-hospital mortality, 30- and 90-day mortality rate and overall mortality rate (MR) following TPE in colorectal, gynecological, urological, and miscellaneous cancers.

METHODS

This is a systematic review and meta-analysis in which three international databases including Medline through PubMed, Scopus and Web of Science on November 2023 were searched. To screen and select relevant studies, retrieved articles were entered into Endnote software. The required information was extracted from the full text of the retrieved articles by the authors. Effect measures in this study was the intra-operative, in-hospital, and 90-day and overall MR following TPE. All analyzes are performed using Stata software version 16 (Stata Corp, College Station, TX).

RESULTS

In this systematic review, 1751 primary studies retrieved, of which 98 articles (5343 cases) entered into this systematic review. The overall mortality rate was 30.57% in colorectal cancers, 25.5% in gynecological cancers and 12.42% in Miscellaneous. The highest rate of mortality is related to the overall mortality rate of colorectal cancers. The MR in open surgeries was higher than in minimally invasive surgeries, and also in primary advanced cancers, it was higher than in recurrent cancers.

CONCLUSION

In conclusion, it can be said that performing TPE in a specialized surgical center with careful patient eligibility evaluation is a viable option for advanced malignancies of the pelvic organs.

Empty pelvis syndrome: a retrospective audit from a tertiary cancer center

INTRODUCTION

Empty pelvis syndrome (EPS) has been defined as a complications arising as a sequel of empty space created after extensive pelvic surgery involving perineal resection. However this definition has been heterogenous throughout the limited literature available. Hence, EPS is a significant yet under recognized complication vexing both patients and surgeons. Even till date, prevention and management of EPS remain a challenge. Various preventive strategies have been employed each with its own complications. Few small studies mentioned incidence of this dreaded complication in between 20 and 40%. But most of these studies quote vague evidence and especially only after TPE surgeries. To the best of our knowledge, incidence after APR and PE has never been mentioned in literature.

PURPOSE

To assess the clinical burden of empty pelvis syndrome in patients undergoing abdominoperineal resection (APR), posterior exenteration (PE), or total pelvic exenteration (TPE) for low rectal cancers.

METHODS

This is a retrospective audit from a high-volume tertiary cancer center in India. Patients who underwent APR, PE, or TPE between the years 2013 to 2021 were screened and analyzed for incidence, presentation, and management of empty pelvic syndrome (EPS).

RESULTS

A total of 1224 patients' electronic medical records were screened for complications related to empty pelvis. The overall incidence of EPS was 95/1224 (7%) with 55/1024 (5%) in APR, 8/39 (20.5%) in PE, and 32/143 (21.9%) in TPE. The most common clinical presentation was small bowel obstruction 43/95 (45.2%) and most presented late, 56/95 (60%), i.e., after 30 days of surgery. Most of the patients who had EPS were managed conservatively 55/95 (57%).

CONCLUSION

EPS is a significant clinical problem that can lead to major morbidity, especially after exenterative surgeries warranting effective preventive strategies.

A systematic review of the pathological determinants of outcome following resection by pelvic exenteration of locally advanced and locally recurrent rectal cancer

BACKGROUND

Despite multimodal therapy 5-15% of patients who undergo resection for advanced rectal cancer (LARC) will develop local recurrence. Management of locally recurrent rectal cancer (LRRC) presents a significant therapeutic challenge and even with modern exenterative surgery, 5-year survival rates are poor at 25-50%. High rates of local and systemic recurrence in this cohort are reflective of the likely biological aggressiveness of these tumour types. This review aims to appraise the current literature identifying pathological factors associated with survival and tumour recurrence in patients undergoing exenterative surgery.

METHODS

A systematic review was carried out searching MEDLINE, EMBASE and COCHRANE Trials database for all studies assessing pathological factors influencing survival following pelvic exenteration for LARC or LRRC from 2010 to July 2021 following PRISMA guidelines. Risk of bias was assessed using QUIPS tool.

RESULTS

Nine cohort studies met inclusion criteria, reporting outcomes for 2864 patients. Meta-analysis was not possible due to significant heterogeneity of reported outcomes. Resection margin status and nodal disease were the most commonly reported factors. A positive resection margin was demonstrated to be a negative prognostic marker in six studies. Involved lymph nodes and lymphovascular invasion also appear to be negative prognostic markers with tumour stage to be of lesser importance. No studies assessed other adverse tumour features that would not otherwise be included in a standard histopathology report.

CONCLUSION

Pathological resection margin status is widely demonstrated to influence disease free and overall survival following pelvic exenteration for rectal cancer. With increasing R0 rates, other adverse tumour features must be explored to help elucidate differences in survival and potentially guide tailored oncological treatment.

Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications

AIM

Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis.

METHOD

The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted.

RESULTS

Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2 years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%).

CONCLUSION

The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.

Opportunities and Limitations of Pelvic Exenteration Surgery

PURPOSE

The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient data. The aim of this review is to present the current standing of pelvic exenteration from a surgical, gynaecological and urological point of view.

METHODS

This review is based upon a literature review (MEDLINE (PubMed), CENTRAL (Cochrane) and EMBASE (Elsevier)) of retrospective studies on exenterative surgery from 1993-2020. Using MeSH (Medical Subject Headings) search terms, 1572 publications were found. These were evaluated and screened with respect to their eligibility using algorithms and well-defined inclusion and exclusion criteria. Therefore, the guidelines for systematic reviews (PRISMA) were used.

RESULTS

A complete tumour resection (R0) often represents the only curative option for advanced pelvic carcinomas and their recurrences. A recent systematic review showed significant symptom relief in 80% of palliative patients after pelvic exenteration. Surgical limitations (distant metastases, involvement of the pelvic wall, etc.) are diminished by adequate surgical expertise and close interdisciplinary cooperation. While the mortality rate is low (2-5%), the still relatively high morbidity rate (32-84%) can be minimized by optimizing the perioperative setting. Following exenterations, roughly 79-82% of patients report satisfying results according to PROs (patient-reported outcomes).

CONCLUSION

Due to multimodality treatment strategies combined with extended surgical expertise and patients' preferences, pelvic exenteration can be offered nowadays with low mortality and acceptable postoperative quality of life. The possibilities of surgical treatment are often underestimated. A multi-centre database (PelvEx Collaborative) was established to collect data and experiences to optimize the research in this field.

Management of a Pelvic Abscess and Abdominal Fistula after Palliative Total Pelvic Exenteration with Intraoperative Radiotherapy in Recurrent Rectal Cancer Without NPWT: A Case Report

ABSTRACT

A 59-year-old man with recurrent rectal cancer and type 2 diabetes mellitus underwent palliative total pelvic exenteration and intraoperative radiotherapy. After surgery, he experienced a pelvic abscess and abdominal-perineal fistula. Profuse exudate contaminated the midline abdominal incision through the abdominal-perineal fistula and delayed healing. Because of a residual tumor and the high cost, negative-pressure wound therapy was not performed. After 76 days of local treatment that involved removing necrotic tissue, controlling inflammation with an antimicrobial silver dressing, absorbing and draining exudate with a hypertonic saline dressing, promoting granulation and preventing infection with a silver alginate dressing, and promoting re-epithelialization with recombinant human epidermal growth factor gel, the abdominal wound and abdominal-perineal fistula healed successfully.

Surgical treatment of locally recurrent rectal cancer: a narrative review

Objective

To summarize the recent literature on surgical treatment of locally recurrent rectal cancer (LRRC).

Background

LRRC is a heterogeneous disease that requires a multidisciplinary treatment approach. The treatment and prognosis depend on the site and type of recurrence. Radical resection remains the primary method for achieving long-term survival and improving symptom control. Preoperative chemoradiotherapy can reduce tumor volume and improve the R0 resection rate. Surgeons must clearly understand pelvic anatomy, develop a detailed preoperative plan, adopt a multidisciplinary approach for the surgical resection of the tumor as well as any invaded soft tissues, vessels, and bones, and ensure proper reconstruction. However, extended radical surgery often leads to a higher risk of postoperative complications and a low quality of life.

Methods

We searched English-language articles with keywords “locally recurrent rectal cancer”, “surgery” and “multidisciplinary team” in PubMed published between January 2000 to October 2020.

Conclusions

LRRC is a complex problem. Long-term survival is not impossible following multidisciplinary treatment in appropriately selected LRRC patients. The management of LRRC relies on a specialist team that determines the biological behavior of the tumor and evaluates treatment options through multidisciplinary discussions, thereby balancing the surgical costs and benefits, alleviating postoperative complications, and improving patients’ quality of life.

The Role of Exenterative Surgery in Advanced Urological Neoplasms

Pelvic exenterative surgery is both complex and challenging, especially in the setting of locally recurrent disease. In recent decades, improved surgical techniques have facilitated more extensive resection of both locally advanced and recurrent pelvic malignancies, but its role in urological cancer surgery is highly selective. However, it remains an important part of the armamentarium for the management of bladder and prostate cancer cases where there is local invasion into adjacent organs or localized recurrence. Better diagnostics, reconstructive options and centralized care have reduced associated morbidity considerably, and it is still used rarely in palliative settings. Despite this, there is sparse prospective evidence reporting on long-term oncological or quality of life outcomes.

Total Pelvic Exenteration for Locally Advanced and Recurrent Rectal Cancer: Urological Outcomes and Adverse Events

BACKGROUND

Little has been reported on urological complications of total pelvic exenteration (TPE) for locally advanced or recurrent rectal cancer.

OBJECTIVE

To assess urological reconstructive outcomes and adverse events in this setting.

DESIGN, SETTING, AND PARTICIPANTS

A total of 104 patients underwent TPE from 2004 to 2016 in this single-centre, retrospective study. Electronic and paper records were evaluated for data extraction. Mean follow-up was 36.5 mo.

INTERVENTION

TPE.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Urological complications were analysed using two-tailed t and chi-square tests, binary logistic regression analysis.

RESULTS AND LIMITATIONS

Sixty-three (61%) patients received radiotherapy prior to TPE. Incontinent diversions included ileal conduit (n = 95), colonic conduits (n = 4), wet colostomy (n = 1), and cutaneous ureterostomy (n = 1). Three patients had a continent diversion. The overall urological complication rate was 54%. According to Clavien-Dindo classification, 30 patients, five patients, and one patient had grade III, IV, and V complications, respectively. The commonest complication was urinary tract infection (in 32 [31%] patients). Anastomotic leaks were seen in 14 (13%) cases, of which eight (8%) were urinary leaks. Fistulas were seen in three (3%) patients, involving the urinary system. A return to theatre was required in 12 (12%) patients. Ureteroenteric strictures were seen in seven (7%). No differences were seen in urological outcomes in patients with primary or recurrent rectal cancer (p = 0.69), or by radiation status (p = 0.24). The main limitation is the retrospective nature of the study.

CONCLUSIONS

TPE is complex with recognised high risk of morbidity. In this cohort, there was no significant difference in outcomes between primary and recurrent disease, and surgery after radiation.

PATIENT SUMMARY

In this study, we assessed urological complications following total pelvic exenteration. Urinary complications affected more than half of patients. Urinary tract infection is the commonest risk. Approximately one-third of patients required surgical, radiological, or endoscopic intervention ± intensive care admission. Radiation prior to the operation did not affect urinary complications.

The obesity paradox in beyond total mesorectal excision surgery for locally advanced and recurrent rectal cancer

The objective is to investigate preoperative body mass index (BMI) in patients receiving beyond total mesorectal excision (bTME) surgery. The primary end point is length of postoperative stay. Secondary end points are length of intensive care stay, postoperative morbidity and overall survival. BMI is the most commonly used anthropometric measurement of nutrition and studies have shown that overweight and obese patients can have improved surgical outcomes. Patients who underwent a bTME operation for locally advanced or recurrent rectal cancer were put into three BMI (kg/m2) groups of normal weight (18.5-24.9), overweight (25-29.9) and obese (≥ 30) for analysis. Included are 220 consecutive patients from a single centre. The overall length of stay, in days ± standard deviation (range), for normal weight, overweight and obese patients was 21.14 ± 16.4 (6-99), 15.24 ± 4.3 (7-32) and 19.10 ± 9.8 (8-62) respectively (p = 0.002). The mean ICU length of stay was 5.40 ± 9.1 (1-69), 3.37 ± 2.4 (0-19) and 3.60 ± 2.4 (1-14), respectively (p = 0.030). There was no significant difference between the three groups in terms of postoperative morbidity or overall survival. Patients with a normal weight BMI in this cohort have a significantly longer length of stay in ICU and in hospital than overweight or obese patients. This is seen with no significant difference in morbidity or overall survival.

Systematic review of outcomes following pelvic exenteration for the treatment of primary and recurrent locally advanced rectal cancer

BACKGROUND

Pelvic exenteration represents the best treatment option for cure of locally advanced or recurrent rectal cancer. This systematic review sought to evaluate current literature regarding short and long term treatment outcomes and long term survival following pelvic exenteration.

METHODS

A systematic search of the MEDLINE, PubMed and Ovid databases was conducted to identify suitable articles published between 2001 and 2016. The article search was performed in line with Cochrane methodology and reported according to the Preferred Reporting Items for Systematic reviews and Meta-analyses statement.

RESULTS

Sixteen studies were included in the final analysis, incorporating 1016 patients. Sixty-three percent of patients were male and median patient age was 59 years. Median operating time was 7.2 h with median blood loss of 1.9 l. Median postoperative stay was 17 days with a median 30-day mortality of 0. Complication rates were 31.6-86% with a return to theatre rate of 14.6%. Median R0 resection rate was 74% and was higher for primary cancer (82.6% versus 58% for recurrent cancer). Mean overall survival was 31 months and median 5-year survival was 32%. Recurrently identified indicators of adverse outcome included R1/2 resection, preoperative pelvic pain and previous abdominoperineal resection of the rectum.

CONCLUSIONS

Pelvic exenteration remains a major operation associated with significant morbidity and mortality. Despite advances in preoperative assessment and staging, R1 resection rates remain high. There is also a high degree of variability of reporting outcomes and standardisation of this process would aid comparison of results between centres and drive forward research in this area.

Cohort study of long-term survival and quality of life following pelvic exenteration

BACKGROUND

Pelvic exenteration (PE) is the preferred treatment available for selected patients diagnosed with locally advanced or recurrent cancer confined to the pelvis. Currently, the majority of the literature reports only on short-term survival and quality-of-life (QoL) outcomes. The aim of this prospective cohort study was to describe long-term survival and QoL outcomes following PE.

METHODS

This was a cohort study of consecutive patients undergoing PE from 1994 to 2016 at a major teaching hospital in Sydney, Australia. From 2008, consenting patients were also included in a prospective QoL study. Main outcomes were long-term survival and QoL assessed with SF-36® and FACT-C questionnaires. Survival was estimated using the Kaplan-Meier method.

RESULTS

Some 515 patients underwent PE for locally advanced or recurrent cancer. The cumulative 5- and 10-year overall survival rates were 48·6 and 37·8 per cent respectively. The survival estimates were significantly higher for patients with advanced primary rectal cancer (P = 0·045) and those in whom a clear resection margin was achieved (P < 0·001). Some 287 patients were enrolled into the QoL study. Response rates at baseline, 6 months and 5 years were 92·0, 70·0 and 33 per cent respectively. Patients had recovered to their preoperative QoL status by 6 months and, among survivors, QoL remained essentially unchanged during the 5-year follow-up.

CONCLUSION

Patients who underwent PE owing to advanced primary rectal cancer or achieved a clear resection margin had a greater chance of survival. Overall, QoL returned to baseline within 6 months after surgery.

Locally Advanced Disease and Pelvic Exenterations

Advanced primary and recurrent colorectal cancer can be successfully treated by experienced, dedicated centers delivering good outcomes with low mortality and morbidity. Development and implementation of a comprehensive referral pathway is to be encouraged. Multidisciplinary team management is essential in the management of this complex group of patients and is associated with significantly more complete preoperative evaluation and more accurate provision of patient information, as well as improved access to the most appropriate individualized management plan. A structured selection process can improve outcomes through standardized approaches to service delivery to provide the highest quality of care.

Extended pelvic resections for the treatment of locally advanced and recurrent anal canal and colorectal cancer: technical aspects and morbimortality predictors aftet 24 consecutive cases

OBJECTIVE

to evaluate the profile of morbidity and mortality and its predictors related to extensive pelvic resections, including pelvic exenteration, to optimize the selection of patients and achieve better surgical results.

METHODS

we performed 24 major resections for anorectal pelvic malignancy from 2008 to 2015 in the Instituto do Câncer do Ceará. The factors analyzed included age, weight loss, resected organs, total versus posterior exenteration, angiolymphatic and perineural invasion, lymph node metastasis and overall and disease-free survival.

RESULTS

the median age was 57 years and the mean follow-up was ten months. Overall morbidity was 45.8%, with five (20.8%) serious complications. There were no deaths in the first 30 postoperative days. The median overall survival was 39.5 months, and disease-free survival, 30.7 months. Concomitant resection of the bladder was an isolated prognostic factor for higher risk of complications (87.5% vs. 26.7%, p = 0.009). Angiolymphatic invasion and lymph node metastasis did not reach significance with respect to disease-free survival.

CONCLUSION

treatment of advanced anorectal tumors is challenging, often requiring combined resections, such as cystectomy and sacrectomy, and complex reconstructions. The magnitude of the operation still carries a high morbidity rate, but is a procedure considered safe and feasible, with a low mortality and adequate locoregional tumor control when performed in referral centers.

OBJETIVOS

avaliar o perfil de morbimortalidade e seus fatores preditivos relacionados às ressecções pélvicas extensas, incluindo a exenteração pélvica, com o intuito de otimizar a seleção dos pacientes e obtenção de melhores resultados cirúrgicos.

MÉTODOS

foram realizadas 24 grandes ressecções pélvicas por neoplasia maligna anorretal de 2008 a 2015 no Instituto do Câncer do Ceará. Os fatores analisados incluíram idade, perda de peso, órgão ressecados, exenteração total versus posterior, invasão angiolinfática e perineural, metástase linfonodal e sobrevida global e livre de doença.

RESULTADOS

a mediana de idade foi 57 anos e o tempo médio de seguimento foi dez meses. A morbidade global foi 45,8%, com cinco (20,8%) complicações graves. Não houve óbito nos primeiros 30 dias de pós-operatório. A sobrevida global média foi 39,5 meses e a sobrevida livre de doença foi 30,7 meses. A ressecção concomitante da bexiga foi fator prognóstico isolado com maior risco para complicações (87,5% vs. 26,7%, p=0.009). Invasão angiolinfática e metástase linfonodal não alcançaram significância com relação à sobrevida livre de doença.

CONCLUSÃO

o tratamento dos tumores anorretais avançados é desafiador, necessitando frequentemente de ressecções combinadas, como a cistectomia e sacrectomia, além de reconstruções complexas. A magnitude da cirurgia ainda carrega uma elevada taxa de morbidade, porém é um procedimento considerado seguro e factível, com uma baixa mortalidade e adequado controle locorregional tumoral quando realizado em centros de referência.

Outcomes of pelvic exenteration for recurrent and primary locally advanced rectal cancer

BACKGROUND

Pelvic exenteration is the only radical treatment for locally advanced (ARC) or recurrent (RRC) rectal cancers. The long-term results of the procedure are variably reported in the literature, with recent series suggesting similar survival between ARC and RRC. The study aimed to analyze and compare the long-term survival and perioperative outcomes of patients undergoing pelvic exenteration for ARC and RRC in a tertiary center.

MATERIALS AND METHODS

This was a retrospective analysis of prospectively collected data. Comparison of variables was performed using Chi-square, Fisher's exact or Wilcoxon rank sum test as appropriate. The Kaplan Meier method was used to analyze the disease-free survival (DFS) and the log-rank test to compare the two groups.

RESULTS

Since 2002, 46 patients underwent pelvic exenteration for ARC (28, 60.9%) and RRC (18, 39.1%). The groups had comparable characteristics, perioperative results, including postoperative complications, and rate of adjuvant chemotherapy. A R0 resection was obtained in 71.4% and 55.6% (p 0.41) and a T4 stage was diagnosed in 75% and 94.4% (p 0.22) of ARC and RRC patients, respectively. After a median follow-up time of 32.5 and 56.6 months (p 0.01), the 5-year DFS was significantly lower in the RRC group (23.6 vs 46.2%, p 0.006), even after exclusion of R1 cases (30 vs 54.5%, p 0.044).

CONCLUSION

The long-term disease free survival of patients undergoing pelvic exenteration is significantly worse when the procedure is performed for RRC, regardless of the tumor involvement of the resection margins.

Influence of tumor size on outcomes following pelvic exenteration

OBJECTIVE

Pelvic exenteration (PE) is often the only curative option for locally advanced or recurrent pelvic malignancies. Despite radical surgery, recurrence risk and morbidity remain high. In this study, we sought to determine tumor size effect on perioperative outcomes and subsequent survival in patients undergoing PE.

METHODS

Retrospective chart review was performed for female patients who underwent PE at two comprehensive cancer centers from 2000 to 2015. Demographics, complications and outcomes were recorded. Statistical analyses were performed using chi-square, student's t-test, logistic regression, non-parametric tests, log-rank test, and Cox proportional hazards.

RESULTS

Of 151 women who underwent PE, 144 had available pathologic tumor size. Gynecologic oncology, surgical oncology, and urology performed 84, 29, and 31 exenterations, respectively. Tumor dimensions ranged from 0 to 25.5cm. Perioperative complications, 30-day mortality, reoperation, and readmission rates were not associated with tumor size. Obesity and prior radiation increased risk for major perioperative complication while anterior exenterations decreased risk. Larger tumors were more likely to undergo total pelvic exenteration (OR 1.14; 95%CI 1.03-1.27), have positive margins (OR 1.11; 95%CI 1.02-1.22), and recur (65%, 42% and 20% for tumors >4cm, ≤4cm and no residual tumor respectively, p=0.016). Tumor size >4cm and positive margins were associated with worse overall survival amongst gynecologic oncology patients.

CONCLUSION

Tumor size was not associated with perioperative morbidity. Larger tumors were associated with positive margins, more extensive resection, and worse survival in gynecologic oncology patients. Larger studies are needed to further understand tumor size impact on PE outcomes within specific tumor types.

Short- and long-term outcomes following pelvic exenteration for gynae-oncological and colorectal cancers: A 9 year consecutive single-centre cohort study

OBJECTIVES

Radical pelvic exenteration can be undertaken for locally invasive or recurrent disease in both colorectal and gynaecological malignancies. In the UK this procedure is usually undertaken by the respective surgical specialties who have undergone divergent surgical training. This study describes and compares outcomes between colorectal and gynae-oncological teams following pelvic exenteration for primary and recurrent gynaecological and colorectal cancers in a single-centre multi-disciplinary team.

METHOD

A retrospective review of consecutive pelvic exenteration patients undertaken over a nine-year period in a tertiary referral centre. Analyses comparing short- and long-term morbidity and mortality outcomes were undertaken by chi-square test for categorical variables and Mann-Whitney U for continuous variables. Cumulative survival rates were calculated according to the Kaplan-Meier method and factors associated with recurrence and survival determined using a Cox regression model.

RESULTS

Thirty-four exenterations were undertaken; fourteen colorectal and twenty gynae-oncological. Morbidity was seen in 50% of colorectal and 75% of gynae-oncological patients. Recurrence was seen earlier and with greater frequency in the gynaeoncology group (44.4% and median time 11 months) than the colorectal group (21.4%, median time 41 months; p > 0.05). Survival in the gynae-oncology group was also lower than the colorectal group at 1-year (69.6% vs. 92.9%) and 5-years (58.0% vs. 92.9%; p = 0.115). The majority of gynae-oncological mortality occurred within 3-years of surgery, whilst the majority of mortality in the colorectal group was after 5-years.

CONCLUSION

Long-term patient outcome measures, including disease recurrence and 5-year survival, for colorectal exenteration appear better than for gynaeoncology patients, however, no statistical significant difference exists between short-term outcome measures between specialties. This is likely to be caused by different baseline pathologies and disease pattern influencing longer term prognosis but may also be a function of differing surgical thresholds and patient selection bias between specialties. Peri-operative and short-term morbidity appear equivalent despite divergent surgical backgrounds and training.

Efficacy of an additional flap operation in bladder-preserving surgery with radical prostatectomy and cystourethral anastomosis for rectal cancer involving the prostate

Purpose

Sphincter-preserving operations performed with bladder-preserving surgery and a cystourethral anastomosis (CUA) do not require a urinary stoma, but leakage from the CUA may develop. The aim of this study was to evaluate the efficacy of performing an additional flap operation.

Methods

The subjects were 39 patients who underwent bladder-preserving surgery for advanced rectal cancer involving the prostate, between 2001 and 2015.32 of whom had a CUA and one of whom had a neobladder. Five of these 32 patients underwent an ileal flap operation, 2 underwent an omental flap operation, and 3 underwent an operation using both flaps.

Results

Leakage developed in 3 (30%) of the 10 patients who underwent additional flap operations, but in 14 (60.9%) of the 23 patients who did not undergo a flap operation. The mean periods of catheterization for the patients who suffered leakage were 31 weeks (8–108 weeks) in those without a flap and 16 weeks (8–20 weeks) in those with a flap. Four (33.3%) of the 12 patients with leakage after surgery without a flap had a period of urinary catheterization >30 weeks, and 2 (16.7%) had leakage of CTCAE grade 3. There were no cases of leakage after flap surgery.

Conclusion

An additional flap operation may decrease the risk of leakage from a CUA.

Cystoprostatectomy versus prostatectomy alone for locally advanced or recurrent pelvic cancer

BACKGROUND

There is minimal published data evaluating the oncological outcome of rectal resection with prostatectomy alone versus rectal resection with cystoprostatectomy in patients undergoing pelvic exenteration for locally advanced or recurrent pelvic cancer. This study aims to evaluate the oncological and functional outcomes of performing rectal resection with prostatectomy alone compared with rectal resection with cystoprostatectomy in patients undergoing pelvic exenteration.

METHODS

Consecutive patients undergoing pelvic exenteration for locally advanced or recurrent pelvic cancer between 1998 and 2012 were identified from a prospectively maintained database. Patients undergoing rectal resection with prostatectomy alone were compared with a control group who underwent rectal resection with cystoprostatectomy and urostomy formation. The primary outcome was overall survival. Secondary outcomes analysed in the prostatectomy group included completeness of resection, continence and erectile function.

RESULTS

Eleven rectal resections with prostatectomy were compared with 20 rectal resections with cystoprostatectomy. R0 resection was achieved in 73 and 65% respectively. There was no difference in overall survival (P = 0.40). Urinary continence was achieved in 36% of prostatectomy alone patients, while 27% experienced mild incontinence. Erectile function was poor, with only one patient able to maintain normal erections.

CONCLUSION

In appropriately selected patients with invasive pelvic tumours, rectal resection with prostatectomy alone provides adequate oncological outcomes. The ability to achieve an R0 resection was not compromised and overall survival is comparable with cystoprostatectomy. Urinary function is reasonable in most patients, although sexual function is compromised in almost all.

Pelvic exenteration for the treatment of locally advanced colorectal and bladder malignancies in the modern era

BACKGROUND

Although pelvic exenteration (PE) remains an important treatment for advanced pelvic malignancies, it has historically been associated with high morbidity and mortality with unclear long-term benefits. The objectives of this study were (1) estimate complication and mortality rates, (2) determine predictors of complications, and (3) estimate overall survival after PE for patients with locally advanced colorectal and bladder tumors.

METHODS

A total of 377 patients were retrospectively identified from the 2005-2010 NSQIP PUF and an additional 1,111 from the 2004-2010 Surveillance Epidemiology and End Results database with T4M0 colorectal or bladder cancers. A logistic regression model was fitted to estimate early morbidity and mortality. The Kaplan-Meier method was used to estimate survival after PE compared to nonoperative management.

RESULTS

Fifty-seven percent of patients had a complication, but 30-day mortality was only 2%. Patients with preoperative dyspnea and higher ASA class had the highest risk of morbidity. PE for the treatment of T4M0 rectal and bladder cancer was associated with significantly improved long-term survival compared to nonoperative therapy.

CONCLUSIONS

PE is associated with a high complication rate but low 30-day mortality. The results of this study provide strong evidence to support PE as a viable treatment option for locally advanced rectal and bladder malignancies in appropriately selected patients.

Indications and outcome of pelvic exenteration for locally advanced primary and recurrent rectal cancer

OBJECTIVE

The outcome of pelvic exenteration was compared in patients with locally advanced primary (LAP) cancer and recurrent rectal cancer (RRC).

BACKGROUND

There are few reports comparing the results of pelvic exenteration for primary advanced rectal cancer and RRC.

METHODS

Consecutive patients undergoing pelvic exenteration between 2006 and 2011 were identified from a prospectively maintained database. The main endpoints were 3-year disease-free survival (DFS) and local recurrence-free survival (LRFS).

RESULTS

Of 100 exenterative operations, 55 were for LAP cancer and 45 for RRC. Exenteration of 1 pelvic compartment was required in 30 cases, 2 compartments in 49 cases, and 3 of 4 compartments in 21 cases. R0, R1, and R2 resections were achieved in 78, 15, and 7 cases, respectively. R0 rates were significantly higher in LAP cancer than in RRC (91% vs 62%, P = 0.001). Three-year DFS for R0, R1, and R2 resections was 67%, 49%, and 0%, respectively (P < 0.001). For R0 resections only, DFS in LAP cancer was 76% and 57% in RRC (P = 0.212). On multivariate analysis, a positive resection margin (hazard ratio, 4.04; P < 0.001) and positive lymph node staging (hazard ratio, 2.43; P = 0.022) were significant predictors of reduced DFS. Three-year LRFS for R0 resection was 86% for LAP cancer and 84% for RRC (P = 0.817). On multivariate analysis, only a positive resection margin was a significant predictor of reduced LRFS (hazard ratio, 5.48; P = 0.002).

CONCLUSIONS

Resection margin status is more important than primary or recurrent cancer in predicting long-term outcome.

Clinical, MRI, and PET-CT criteria used by surgeons to determine suitability for pelvic exenteration surgery for recurrent rectal cancers: a Delphi study

BACKGROUND

Surgical resection with clear margins is the major predictor of long-term survival in recurrent rectal cancer. The extent of pelvic exenteration surgery depends on many factors including clinical and radiological criteria.

OBJECTIVE

The aim of this study was to establish which clinical, MRI, and PET criteria were considered important by surgeons who perform pelvic exenteration surgery, when assessing a patient with recurrent rectal cancer for pelvic exenteration surgery.

DESIGN

A 2-stage Delphi study was conducted among an international panel of 36 colorectal surgeons recruited via a snowball-sampling method. Surgeons rated the importance of 99 clinical and radiological criteria by using a 9-point scale.

MAIN OUTCOME MEASURES

Consensus was attained when at least 85% of the panel rated criteria within 3 points.

RESULTS

Clinical factors suggestive of systemic disease, symptoms of advanced local recurrence such as pain, surgical fitness, and cognitive impairment were considered important by the panel when considering suitability for surgery. Agreement regarding the indication for surgery was reached for 20 radiological factors. Strong agreement was achieved for factors associated with tumor involvement in the axial and anterior compartments. For only 16 of these 20 radiological factors was there an agreement that a clear resection margin was likely to be achieved.

LIMITATIONS

Further rounds of Delphi may have yielded greater consensus.

CONCLUSION

This study has identified a set of criteria considered by experts to be important in evaluating patients' suitability for pelvic exenteration surgery. Evaluation of these criteria is required to determine their clinical utility in predicting a negative resection margin at pelvic exenteration surgery.

Multivisceral resection in colorectal cancer: a systematic review

BACKGROUND

The objective of this study was to critically evaluate current literature on outcomes following multivisceral resection (MVR) in colorectal cancer (CRC). Adequate surgical resection with clear margins is imperative in achieving long-term survival in colorectal cancer. Where there is adherence to or invasion of adjacent organs, (MVR) may be needed to achieve complete disease clearance.

METHODS

A systematic review of MVR in CRC was performed. Pubmed/Medline and Cochrane databases were searched for English language articles from 1995 to 2012 using a predefined strategy. Retrieved abstracts were independently screened for relevance and data extracted from selected studies by 2 researchers. Results are reported as weighted means.

RESULTS

Included were 22 studies comprising 1575 patients (87.0% primary colorectal cancer; 13.0% recurrent, 63.8% rectal; 36.2% colon). The most common organs resected were the bladder and reproductive organs. The perioperative mortality was 4.2% with morbidity of 41.5% (95% CI, 40.8-42.2%). The overall 5-year survival rate was 50.3% (95% CI, 49.9-50.8%). Surgery for recurrence was associated with worse outcomes than primary tumors with 5-year survival 19.5% (95% CI, 17.8-21.1%) for recurrent rectal cancer and primary rectal tumors 5-year overall survival 52.8% (95% CI, 52.0-53.8%). R0 resection was the strongest factor associated with long-term survival.

CONCLUSIONS

Multivisceral resection provides the best possibility of long-term survival in locally advanced primary colorectal cancer in which a clear margin has been achieved.

Pelvic exenteration for rectal cancer: a systematic review

BACKGROUND

Pelvic exenteration is a potentially curative treatment for locally advanced primary or recurrent rectal cancer.

OBJECTIVE

This systematic review examines the current evidence regarding clinical and oncological outcomes in patients with locally advanced primary and recurrent rectal cancer who undergo pelvic exenteration.

DATA SOURCES

A literature search of PubMed, Medline, and the Cochrane library was undertaken, and studies published in the English language from January 2000 to August 2012 were identified.

STUDY SELECTION

Prospective and retrospective studies that report outcomes of pelvic exenteration for primary advanced and locally recurrent rectal cancer with or without subgroup evaluation were included for examination.

MAIN OUTCOME MEASURES

Oncological outcomes included 5-year survival, median survival, and local recurrence rates. Clinical outcomes included complication rates and perioperative mortality rates.

RESULTS

A total of 23 studies with 1049 patients were reviewed. The complication rates ranged from 37% to 100% (median, 57%) and the perioperative mortality rate ranged from 0% to 25% (median, 2.2%). The rate of local recurrence ranged from 4.8% to 61% (median, 22%). The median survival for primary advanced rectal cancers was 14 to 93 months (median, 35.5 months) and 8 to 38 months (median, 24 months) for locally recurrent rectal cancer.

LIMITATIONS

Our review was limited by the small sample sizes from single-institutional studies reporting outcomes over long periods of time with heterogeneity in both the disease and treatments reported.

CONCLUSIONS

Although the human costs and risks are significant, the potentially favorable survival outcomes make this acceptable in the absence of other effective treatment modalities that would otherwise result in debilitating symptoms that afflict patients who have advanced pelvic malignancy.

Assessment of the selection process for myocutaneous flap repair and surgical complications in pelvic exenteration surgery

BACKGROUND

This study aimed to explore and quantify the selection process to guide the decision on closure type (myocutaneous flap repair (MFR) or primary closure) for people undergoing pelvic exenteration.

METHODS

This was a retrospective analysis of a prospectively maintained database with review of hospital records for verification and capture of missing data. Associations between four risk factors (previous radiotherapy, previous abdominoperineal resection, need for total exenteration, need for sacrectomy) were assessed individually and collectively as predictors of closure type and wound complications.

RESULTS

A total of 203 pelvic exenteration procedures were reviewed (75 primary and 122 recurrent cancers). Thirty-nine patients (19·2 per cent) had MFR and 164 (80·8 per cent) primary closure. Patients who had MFR were significantly more likely to exhibit each risk factor, confirming the selective decision process. MFR had higher rates of complications across all four risk factors, individually and combined. In the primary closure group, there was a significant correlation between the number of risk factors and the proportion of patients with a complication (r = 0·25, P = 0·008). In contrast, no such relationship was found for the MFR group (r = 0·01, P = 0·973). Among patients who had any complication, the primary closure group had significantly lower rates of any wound dehiscence (15 of 64 versus 17 of 28; P < 0·001) and total infection (16 of 64 versus 14 of 28; P = 0·019) compared with the MFR group.

CONCLUSION

Rates of wound and septic complications after pelvic exenteration were low in patients with fewer than two risk factors who had a primary closure. MFR had significantly higher complication rates, and should be reserved for patients with two or more risk factors or extensive skin involvement.

Biological and clinical availability of adipose-derived stem cells for pelvic dead space repair

Adipose-derived stem cells (ADSCs) are a very attractive cell source for regenerative and reconstructive medicine. Although ADSCs have already been used in cardiovascular disease and cosmetic surgery, they have not yet been used in gastroenterological surgery. In this study, we clarified the utility of the combined application of ADSCs and resected intraperitoneal fatty tissues as a sealant for the pelvic dead space that sometimes causes severe and fatal complications in colorectal and gynecological surgeries. In pelvic dead space model mice, mouse ADSCs efficiently maintained transplanted intraperitoneal fatty tissues without any incidence of adhesion to surrounding organs. In vivo and in vitro analyses revealed that transplanted ADSCs differentiated into endothelial cells by expressing the angiogenic factors vascular endothelial growth factor and hepatocyte growth factor. Mouse and human ADSCs contained a CD45(-)CD34(+) subset possessing high colony formation and sphere formation abilities. In addition, the CD45(-)CD34(+) subset consisted of two characteristic subsets: the CD34(+)CD90(+) angiogenic subset and the CD34(+)CD90(-) adipogenic subset. Grafts of human ADSCs with fat transplanted into mice were efficiently maintained for more than 12 months without volume reductions. A comparative study of graft maintenance efficacy between cultured human ADSCs and freshly isolated ADSCs indicated that the cultivation of ADSCs decreased their graft maintenance ability. These findings suggested that the angiogenic and adipogenic subsets act in coordination with each other and are essential for efficient graft maintenance.

Pelvic exenteration for colorectal cancer: oncologic outcome in 59 patients at a single institution

Background

Pelvic exenteration (PE) continues to be the only curative option in selected patients with advanced or recurrent pelvic neoplasms. A current debate exists concerning the appropriate selection of patients for PE, with the most important factor being the absence of extrapelvic disease.

Aim

To evaluate the outcome of patients submitted to exenterative surgery.

Patients and methods

A review of the clinical charts of patients with colorectal cancer who underwent PE between January 1994 and June 2010 at the Institute National of Cancerología in Mexico City was performed.

Results

We selected 59 patients, 53 of whom were females (90%), and six of whom were males (10%). Mean age at the time of diagnosis was 50 years (range, 21–77 years). A total of 51 patients underwent posterior PE (86%), and eight patients underwent total PE (14%). Operative mortality occurred in two cases (3%), and 29 patients developed complications (49%). Overall, 11 patients (19%) experienced local failure with mean disease-free survival time of 10.2 months. After a mean follow-up of 28.3 months, nine patients are still alive without evidence of the disease (15%).

Conclusions

PE should be considered in advanced colorectal cancer without extrapelvic metastatic disease. PE is accompanied by considerable morbidity (49%) and mortality (3%), but local control is desirable. Overall survival justifies the use of this procedure in patients with primary or recurrent locally advanced rectal cancer.

A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database

AIM

The study was conducted in a dedicated centre treating the majority of Danish patients with intended curative total pelvic exenteration for primary advanced (PARC) or locally recurrent (LRRC) rectal cancer. We compared PARC and LRRC and analysed postoperative morbidity and mortality, and long-term outcome.

METHOD

There were 90 consecutive patients (PARC/LRRC 50/40) treated between January 2001 and October 2010, recorded on a prospectively maintained database.

RESULTS

The median age was 63 (32-75) years with a gender ratio of 7 women to 83 men. All patients were American Society of Anesthesiologists level I or II. Sacral resection was performed in five patients with PARC and 15 with LRRC (P=0.002). R0 resection was achieved in 33 (66%) patients with PARC and in 15 (38%) with LRRC, R1 resection in 17 (34%) with PARC and 20 (50%) with LRRC and R2 resection in five (13%) with LRRC. R0 resection was more frequent in PARC (P=0.007). Forty-four (49%) patients had no postoperative complications. Fifty-five major complications were registered. Two (2.2%) patients died within 30 days, and the total in-hospital mortality was 5.6%. The median follow-up was 12 (0.4-91) months. The 5-year survival was 46% for PARC and 17% for LRRC (P=0.16).

CONCLUSION

Pelvic exenteration is associated with considerable morbidity but low mortality in an experienced centre. Pelvic exenteration can improve long-term survival, especially for patients with PARC. However, pelvic exenteration is also justified for patients with LRRC.

Retrospective review of pelvic malignancies undergoing total pelvic exenteration

Background

In patients with locally advanced or recurrent pelvic malignancies, total pelvic exenteration (TPE) may be necessary for curative treatment. Despite improvements in mortality rates since TPE was first described, morbidity rates remain high due to the extensive resection and the aggressiveness of these tumors. We have studied the outcomes of TPE surgery performed at our institution.

Methods

Fifty-three patients with various pelvic pathologies underwent TPE between 2004 and 2010. Patients were divided into two groups based on pathology: colorectal (n = 36) versus non-colorectal (n = 17) malignancies. Demographics, operative reports, pathology reports, periprocedural events, and outcomes were analyzed. Comparison of the two groups was performed using student’s t-test and Fisher’s exact test. Survival curves were constructed using the Kaplan–Meier method and compared using the log rank test.

Results

The colorectal and non-colorectal groups were similar in demographics, operative times, length of stay, estimated blood loss, and rates of preoperative and intraoperative radiation use. Chemotherapy use was increased in the colorectal group compared with the non-colorectal group (55.6% vs. 23.5%, P = 0.04). Complication rates were similar: 86% in the colorectal group and 76% in the non-colorectal group. In the colorectal group, 27.8% of patients developed perineal abscesses, whereas no patients developed these complications in the non-colorectal group (P = 0.02). No survival difference was seen in primary versus recurrent colorectal tumors; however, within the colorectal group there was a survival advantage when comparing R0 resection to R1 and R2 resection combined. Median survival rates were 27.3 months for R0 resection and 10.7 months for R1 and R2 resection combined. The median survival was 21.4 months for the colorectal group and 6.9 months for the non-colorectal group (P = 0.002).

Conclusions

Patients undergoing TPE for colorectal tumors have improved survival when compared with patients undergoing exenteration for pelvic malignancies of other origins. Within the colorectal group, the extent of resection demonstrated a significant survival benefit of an R0 resection compared with R1 and R2 resections. Despite TPE carrying a high morbidity rate, mortality rates have improved and careful patient selection can optimize outcomes.

Total pelvic exenteration for rectal cancer: outcomes and prognostic factors

BACKGROUND

To perform complete resection of locally advanced and recurrent rectal carcinoma, total pelvic exenteration (TPE) may be attempted. We identified disease-related outcomes and prognostic factors.

METHODS

We conducted a single-centre review of patients who underwent TPE for rectal carcinoma over a 10-year period.

RESULTS

We included 28 patients in our study. After a median follow-up of 35 months, 53.6% of patients were alive with no evidence of disease. The 3-year actuarial disease-free and overall survival rates were 52.2% and 75.1%, respectively. On univariate analysis, recurrent disease, preoperative body mass index greater than 30 and lymphatic invasion were poor prognostic factors for disease-free survival, and only lymphatic invasion predicted overall survival. Additionally, multivariate analysis identified lymphatic invasion as an independent poor prognostic factor for disease-free survival in this patient population with locally advanced and recurrent rectal carcinoma.

CONCLUSION

Despite the significant morbidity, TPE can provide long-term survival in patients with rectal carcinoma. Additionally, lymphatic invasion on final pathology was an independent prognostic factor for disease-free survival.

Single institution experience comparing double-barreled wet colostomy to ileal conduit for urinary and fecal diversion

OBJECTIVE

To compare outcomes and feasibility of double-barreled wet colostomy and ileal conduit (IC) in patients undergoing total pelvic exenteration (TPE).

METHODS

Between 2004 and 2010, 54 patients underwent TPE for pelvic malignancies. Of those patients, 53 had complete records available for analysis. Two groups were identified based on the technique used for urinary diversion, either by way of an IC or a double-barreled wet colostomy (DBWC). Demographics, comorbidities, complications, length of stay, operative times, morbidity, and mortality were compared between the 2 groups.

RESULTS

Forty-three patients (81%) underwent a DBWC and ten patients (19%) underwent an IC. The 2 groups were similar in terms of age, gender, and comorbidities. Eighteen patients underwent an R0 resection (39%) and twenty-eight (61%) patients had a non-R0 resection. Seven patients (13%) had a complete response to therapy with no evidence of malignancy. A majority of the patients (68%) undergoing TPE had colorectal histology. Thirty-day morbidity directly related to complications of urinary or fecal diversion was 78% in the DBWC group and 58% in the IC group. There was no perioperative mortality in either group.

CONCLUSION

DBWC is a safe and feasible alternative to the traditional IC for urinary diversion. This technique is easy to learn and is associated with similar operative times, length of stay, morbidity, and mortality compared with IC.

Multidisciplinary approach to recurrent/unresectable rectal cancer: how to prepare for the extent of resection

Local recurrence from rectal cancer is a complex problem that should be managed by a multidisciplinary team. Pelvic re-irradiation and intraoperative radiation should be considered in the management of these patients. Long-term survival can be achieved in patients who undergo radical surgery with negative margins of resections. The morbidity of these procedures is high and at times may compromise quality of life. Palliative surgical procedures can be considered; however, in some cases, palliative resections may not be better than nonsurgical palliation.

Management of locally advanced primary and recurrent rectal cancer

Treatment for patients with locally advanced and recurrent rectal cancer differs significantly from patients with rectal cancer restricted to the mesorectum. Adequate preoperative imaging of the pelvis is therefore important to identify those patients who are candidates for multimodality treatment, including preoperative chemoradiation protocols, intraoperative radiotherapy, and extended surgical resections. Much effort should be made to select patients with these advanced tumors for treatment in specialized referral centers. This has been shown to reduce morbidity and mortality and improve long-term survival rates. In this article, we review the best treatment options for patients with locally advanced and recurrent rectal cancer. We also emphasize the necessity of a multidisciplinary team, including a radiologist, radiation oncologist, urologist, surgical oncologist, plastic surgeon, and gynecologist in the diagnosis and treatment of patients with these pelvic tumors.

Reoperation for recurrent colorectal cancer

Recurrence of colorectal carcinoma represents a significant challenge. As the majority of recurrences involve more than just the anastomosis, surgical resection is ordinarily a major undertaking. Curative resection may require resection of other organs and structures, resulting in complex reconstructive procedures and substantial morbidity. In addition, carefully selected patients with distant metastases to sites such as the liver and lungs may also undergo potentially curative resection. Long-term survival following curative surgery for recurrence, however, ranges from only 15 to 40%. In addition to resection for curative intent, some patients may benefit from palliative procedures designed to relieve symptoms. Surgery alone is not usually sufficient therapy in these patients. Chemotherapy and radiation therapy play a vital adjunctive role in the management of recurrent disease. This article strives to review the risk factors and patterns of recurrence, selection of individuals for resection of recurrent disease, and outcomes of surgical procedures.

Total pelvic exenteration for primary and recurrent malignancies

Introduction

Complete resection is the most important prognostic factor in surgery for pelvic tumors. In locally advanced and recurrent pelvic malignancies, radical margins are sometimes difficult to obtain because of close relation to or growth in adjacent organs/structures. Total pelvic exenteration (TPE) is an exenterative operation for these advanced tumors and involves en bloc resection of the rectum, bladder, and internal genital organs (prostate/seminal vesicles or uterus, ovaries and/or vagina).

Methods

Between 1994 and 2008, a TPE was performed in 69 patients with pelvic cancer; 48 with rectal cancer (32 primary and 16 recurrent), 14 with cervical cancer (1 primary and 13 recurrent), 5 with sarcoma (3 primary and 2 recurrent), 1 with primary vaginal, and 1 with recurrent endometrial carcinoma. Ten patients were treated with neoadjuvant chemotherapy and 66 patients with preoperative radiotherapy to induce down-staging. Eighteen patients received IORT because of an incomplete or marginal complete resection.

Results

The median follow-up was 43 (range, 1–196) months. Median duration of surgery was 448 (range, 300–670) minutes, median blood loss was 6,300 (range, 750–21,000) ml, and hospitalization was 17 (range, 4–65) days. Overall major and minor complication rates were 34% and 57%, respectively. The in-hospital mortality rate was 1%. A complete resection was possible in 75% of all patients, a microscopically incomplete resection (R1) in 16%, and a macroscopically incomplete resection (R2) in 9%. Five-year local control for primary locally advanced rectal cancer, recurrent rectal cancer, and cervical cancer was 89%, 38%, and 64%, respectively. Overall survival after 5 years for primary locally advanced rectal cancer, recurrent rectal cancer, and cervical cancer was 66%, 8%, and 45%.

Conclusions

Total pelvic exenteration is accompanied with considerable morbidity, but good local control and acceptable overall survival justifies the use of this extensive surgical technique in most patients, especially patients with primary locally advanced rectal cancer and recurrent cervical cancer.

Prevention of severe pelvic abscess formation following extended radical surgery for locally recurrent rectal cancer

BACKGROUND

For treatment of locally recurrent rectal cancer (LRRC), extended radical surgery is sometimes required to obtain a negative margin. Such surgery is often associated with severe postoperative pelvic abscess (PA) formation. The aim of this study was to determine the effects of reconstructive surgery using a large rectus abdominis myocutaneous (RAM) flap and anal preservation surgery on the incidence of severe PA.

METHOD

Between February 1998 and June 2008, 44 patients underwent extended surgery for LRRC. Patients were divided into the pre-2004 group (n = 15) and the post-2004 group (n = 29). To reduce the risk of infections, we modified the surgical approach after 2004 to include a larger volume of RAM flap (modified RAM flap) and implemented anal preservation surgery.

RESULTS

The overall incidence of severe PA was significantly lower in the post-2004 group [6 of 29 (21%)] than the pre-2004 group [9 of 15 (60%), P = 0.017]. The incidence of severe PA was lower in the anal preservation group [1 of 12 (8.3%)] compared with those who did not undergo such surgery [14 of 32 (44%), P = 0.035]. Modified RAM flap reduced the incidence of severe PA, albeit insignificantly (pre-2004 group: 57%, post-2004 group: 23%). All three patients who underwent anal preservation and modified RAM flap reconstruction did not develop severe PA. Multiple logistic analysis identified no anal preservation (Odds ratio [OR] = 10.6) and performing of sacrectomy (OR = 20.0) as risk factors for severe PA.

CONCLUSION

Anal preservation surgery is an effective measure against the development of severe PA after radical resection of LRRC.

The role of intraoperative radiotherapy in solid tumors

BACKGROUND

Combined multimodality therapy is becoming standard treatment for many solid tumors, but the role of intraoperative radiotherapy in the management of solid tumors remains uncertain. The aim is to review the indication, application, and outcomes of intraoperative radiotherapy in the management of nongynecological solid tumors.

METHODS

A literature search was performed using Medline, Embase, Ovid, and Cochrane database for studies between 1965 and 2008 assessing intraoperative radiotherapy, using the keywords "intraoperative radiotherapy," "colorectal cancer," "breast cancer," "gastric cancer," "pancreatic cancer," "soft tissue tumor," and "surgery." Only publications in English with available abstracts and regarding adult humans were included, and the evidence was critically evaluated.

RESULTS

Our search retrieved 864 publications. After exclusion of nonclinical papers, duplicated papers and exclusion of brachytherapy papers, 77 papers were suitable to assess the current role of intraoperative radiotherapy. The clinical application and evidence base of intraoperative radiotherapy for each cancer is presented.

CONCLUSIONS

Current studies in all common cancers show an additional benefit in local recurrence rates when intraoperative radiotherapy is included in the multimodal treatment. However, intraoperative radiotherapy may not improve overall survival and has significant morbidity depending on the site of the tumor. Intraoperative radiotherapy does have a role in the multidisciplinary management of solid tumors, but further studies are required to more precisely determine the extent of benefit.

Carcinoma of the colon: margins of resection

Resection of colonic carcinoma with curative intent must encompass: (1) margins of bowel wall that are wider than the extent of microscopic intramural tumor spread beyond the macroscopic edge of the tumor; (2) lymphatic tissue draining the tumor and possibly containing cancer cells; (3) structures adhering to the tumor and possibly infiltrated by tumor cells. The minimal extent of resection that satisfies these requirements and possible benefits of extending the resection are reviewed.