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van Kessel CS, Waller J, Steffens D, Lee PJ, Austin KKS, Stalley PD, Solomon MJ. Improving Surgical Outcomes in Pelvic Exenteration Surgery: Comparison of Prone Sacrectomy With Anterior Cortical Sacrectomy Techniques. Ann Surg 2023; 278:945-953. [PMID: 37485983 DOI: 10.1097/sla.0000000000006040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
OBJECTIVE To assess the effect of changing our sacrectomy approach from prone to anterior on surgical and oncological outcomes. BACKGROUND In patients with advanced pelvic malignancy involving the sacrum, pelvic exenteration (PE) with en-bloc sacrectomy is the only potential curative option but morbidity is high. Over time sacrectomy techniques have evolved from prone sacrectomy (PS) to abdominolithotomy sacrectomy (ALS, ≤S3) and high anterior cortical sacrectomy (HACS, >S3) to optimize surgical outcomes. METHODS A retrospective, single institution analysis of prospectively collected data for patients undergoing PE with en-bloc sacrectomy between 1994 and 2021 was performed. RESULTS A total of 363 patients were identified and divided into PS (n=77, 21.2%), ALS (n=247, 68.0%), and HACS (n=39, 10.7%). Indications were: locally advanced (n=92) or recurrent (n=177) rectal cancer, primary other (n=31), recurrent other (n=60), and benign disease (n=3). PS resulted in longer operating time ( P <0.01) and more blood loss ( P <0.01). Patients with HACS had more major nerve (87.2%) and vascular (25.6%) resections ( P <0.01). Vertical rectus abdominis myocutaneous flap repair was less common following HACS (7.7%) than ALS (25.5%) and PS (27.3%) ( P =0.040). R0 rate was 80.8%, 65.8%, and 76.9% following ALS, PS, and HACS, respectively ( P =0.024). Wound-related complications and re-operations were significantly reduced following ALS and HACS compared with PS. CONCLUSIONS Changing our practice from PS to an anterior approach with ALS or HAS has been safe and improved overall surgical and perioperative outcomes, while maintaining good oncological outcomes. Given the improved perioperative and surgical outcomes, it would be important for surgeons to learn and adopt the anterior sacrectomy approaches.
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Affiliation(s)
- Charlotte S van Kessel
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jacob Waller
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter J Lee
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Paul D Stalley
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, NSW, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Rogers AC, Jenkins JT, Rasheed S, Malietzis G, Burns EM, Kontovounisios C, Tekkis PP. Towards Standardisation of Technique for En Bloc Sacrectomy for Locally Advanced and Recurrent Rectal Cancer. J Clin Med 2021; 10:jcm10214921. [PMID: 34768442 PMCID: PMC8584798 DOI: 10.3390/jcm10214921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/20/2022] Open
Abstract
Treatment strategies for advanced or recurrent rectal cancer have evolved such that the ultimate surgical goal to achieve a cure is complete pathological clearance. To achieve this where the sacrum is involved, en bloc sacrectomy is the current standard of care. Sacral resection is technically challenging and has been described; however, the technique has yet to be streamlined across units. This comprehensive review aims to outline the surgical approach to en bloc sacrectomy for locally advanced or recurrent rectal cancer, with standardisation of the operative steps of the procedure and to discuss options that enhance the technique.
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Affiliation(s)
- Ailín C. Rogers
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Department of Colorectal Surgery, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
| | - John T. Jenkins
- Department of Surgery, St. Mark’s Hospital, Watford Road, Harrow HA1 3UJ, UK; (J.T.J.); (E.M.B.)
| | - Shahnawaz Rasheed
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
| | - George Malietzis
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
| | - Elaine M. Burns
- Department of Surgery, St. Mark’s Hospital, Watford Road, Harrow HA1 3UJ, UK; (J.T.J.); (E.M.B.)
| | - Christos Kontovounisios
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
- Department of Surgery and Cancer, The Royal Marsden Campus, Chelsea and Westminster Hospital and Imperial College, Paddington, London SW10 9NH, UK
- Correspondence:
| | - Paris P. Tekkis
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
- Department of Surgery and Cancer, The Royal Marsden Campus, Chelsea and Westminster Hospital and Imperial College, Paddington, London SW10 9NH, UK
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Pareekutty NM, Balasubramanian S, Kadam S, Jayaprakash D, Ankalkoti B, Nayanar S, Muttath G, Anilkumar B. En Bloc Resection with Partial Sacrectomy Helps to Achieve R0 Resection in Locally Advanced Rectal Cancer, Experience from a Tertiary Cancer Center. Indian J Surg Oncol 2019; 10:141-148. [PMID: 30948890 DOI: 10.1007/s13193-018-0837-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 11/23/2018] [Indexed: 02/07/2023] Open
Abstract
Partial sacrectomy is a radical procedure that benefits a select group of patients with locally advanced primary or recurrent rectal cancer with posterior extension and carries potential for significant morbidity. This study was done to evaluate the morbidity and oncological outcome of patients who underwent partial sacral resection for rectal cancer in a tertiary cancer center. Seventeen patients underwent partial sacrectomy during the period from 2011 to 2015. Eleven patients had primary and six had recurrent rectal cancer. All patients were evaluated with MRI pelvis and metastatic evaluation with CT scan of the chest and abdomen and PET scan in patients with recurrent cancer. All patients had resection below the level of S2/S3 junction or lower. Three patients were females and the remaining were males. Median age was 56 years. Overall morbidity was 76% and most common morbidity was wound related. The mean estimated relapse-free survival (RFS) for patients treated for primary rectal cancer was 20.3 months (95% confidence interval (CI), 12.8-27.9) and the mean estimated overall survival (OS) 23.9 months. Estimated mean RFS for patients who were operated for recurrent rectal cancer was 25.6 months (95% CI, 17.7-33.5) and the median RFS was yet to reach. Estimated mean OS was 29.7 months (95% CI, 15.5-43.8) and the median OS was 39.6 months. Partial sacrectomy below the level of S2/S3 junction is a safe approach to facilitate en bloc resection of locally advanced primary and recurrent rectal cancer extending posteriorly with loss of plane with sacrum. In selected patients, this approach can improve survival at the cost of high morbidity.
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Affiliation(s)
- Nizamudheen M Pareekutty
- 1Department of Surgical Oncology, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur district, Kerala 670103 India
| | - Satheesan Balasubramanian
- 1Department of Surgical Oncology, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur district, Kerala 670103 India
| | - Sachin Kadam
- 1Department of Surgical Oncology, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur district, Kerala 670103 India
| | - Dipin Jayaprakash
- 1Department of Surgical Oncology, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur district, Kerala 670103 India
| | - Basavaraj Ankalkoti
- 1Department of Surgical Oncology, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur district, Kerala 670103 India
| | - Sangeetha Nayanar
- 2Department of Radiation Oncology, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur district, Kerala 670103 India
| | - Geetha Muttath
- 3Department of Pathology, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur district, Kerala 670103 India
| | - Bindu Anilkumar
- 4Department of Cancer Registry and Biostatistics, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur district, Kerala 670103 India
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Systematic Review of Pelvic Exenteration With En Bloc Sacrectomy for Recurrent Rectal Adenocarcinoma: R0 Resection Predicts Disease-free Survival. Dis Colon Rectum 2017; 60:346-352. [PMID: 28177998 DOI: 10.1097/dcr.0000000000000737] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The management of recurrent rectal cancer is challenging. At the present time, pelvic exenteration with en bloc sacrectomy offers the only hope of a lasting cure. OBJECTIVE The purpose of this study was to evaluate clinical outcome measures and complication rates following sacrectomy for recurrent rectal cancer. DATA SOURCES A search was conducted on Pub Med for English language articles relevant to sacrectomy for recurrent rectal cancer with no time limitations. STUDY SELECTION Studies reported sacrectomy with survival data for recurrent rectal adenocarcinoma. MAIN OUTCOME MEASURE Disease-free survival following sacrectomy for recurrent rectal cancer was the main outcome measured. RESULTS A total of 220 patients with recurrent rectal cancer were included from 7 studies, of which 160 were men and 60 were women. Overall median operative time was 717 (570-992) minutes and blood loss was 3.7 (1.7-6.2) L. An R0 (>1-mm resection margin) resection was achieved in 78% of patients. Disease-free survival associated with R0 resection was 55% at a median follow-up period of 33 (17-60) months; however, none of the patients with R1 (<1-mm resection margin) survived this period. Postoperative complication rates and median length of stay were found to decrease with more distal sacral transection levels. In contrast, R1 resection rates increased with more distal transection. LIMITATION The studies assessed by this review were retrospective case series and thus are subject to significant bias. CONCLUSION Sacrectomy performed for patients with recurrent rectal cancer is associated with significant postoperative morbidity. Morbidity and postoperative length of stay increase with the level of sacral transection. Nevertheless, approximately half of patients eligible for rectal excision with en bloc sacrectomy may benefit from disease-free survival for up to 33 months, with R0 resection predicting disease-free survival in the medium term.
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