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Yatabe Y, Hanaoka M, Hanazawa R, Hirakawa A, Mukai T, Kimura K, Yamanoi K, Kono J, Yokota M, Takahashi H, Kobayashi A, Kobayashi K, Ichikawa N, Yasui M, Nakane K, Yamamoto M, Takenaka A, Nakamura Y, Takemasa I, Yabusaki N, Akamoto S, Tatarano S, Murata K, Manabe T, Fujimura T, Kawamura M, Egi H, Yamaguchi S, Terai Y, Inoue S, Ito A, Kinugasa Y. Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan. Surg Endosc 2024:10.1007/s00464-024-10966-w. [PMID: 38886231 DOI: 10.1007/s00464-024-10966-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/26/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. METHODS Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. RESULTS In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). CONCLUSION This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.
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Affiliation(s)
- Yusuke Yatabe
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Marie Hanaoka
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Ryoichi Hanazawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Toshiki Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kei Kimura
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Hyogo, Japan
| | - Koji Yamanoi
- Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Jin Kono
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mitsuru Yokota
- Department of General Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroki Takahashi
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Kenji Kobayashi
- Department of Gastroenterological Surgery, Kariya Toyota General Hospital, Aichi, Japan
| | - Nobuki Ichikawa
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Keita Nakane
- Department of Urology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Manabu Yamamoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Atsushi Takenaka
- Division of Urology, Department of Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yuya Nakamura
- Department of Surgery, National Hospital Organization, Himeji Medical Center, Hyogo, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Hokkaido, Japan
| | | | | | - Shuichi Tatarano
- Department of Urology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kohei Murata
- Department of Surgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Tatsuya Manabe
- Department of Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | | | - Mikio Kawamura
- Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroyuki Egi
- Department of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Ehime, Japan
| | - Shigeki Yamaguchi
- Division of Colorectal Surgery, Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshito Terai
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shigetaka Inoue
- Department of Surgery, Fukuoka Red Cross Hospital, Fukuoka, Japan
| | - Akihiro Ito
- Department of Urology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yusuke Kinugasa
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
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Khan JS, Piozzi GN, Rouanet P, Saklani A, Ozben V, Neary P, Coyne P, Kim SH, Garcia-Aguilar J. Robotic beyond total mesorectal excision for locally advanced rectal cancers: Perioperative and oncological outcomes from a multicentre case series. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108308. [PMID: 38583214 DOI: 10.1016/j.ejso.2024.108308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/14/2024] [Accepted: 03/23/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Around 20% of rectal tumors are locally advanced with invasion into adjacent structures at presentation. These may require surgical resections beyond boundaries of total mesorectal excision (bTME) for radicality. Robotic bTME is under investigation. This study reports perioperative and oncological outcomes of robotic bTME for locally advanced rectal cancers. MATERIALS AND METHODS A multicentre, retrospective analysis of prospectively collected robotic bTME resections (July 2015-November 2020). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. RESULTS One-hundred-sixty-eight patients (eight centres) were included. Median age and BMI were 60.0 (50.0-68.7) years and 24.0 (24.4-27.7) kg/m2. Female sex was prevalent (n = 95, 56.8%). Fifty patients (29.6%) were ASA III-IV. Neoadjuvant chemoradiotherapy was given to 125 (74.4%) patients. Median operative time was 314.0 (260.0-450.0) minutes. Median estimated blood loss was 150.0 (27.5-500.0) ml. Conversion to laparotomy was seen in 4.8%. Postoperative complications occurred in 77 (45.8%) patients; 27.3% and 3.9% were Clavien-Dindo III and IV, respectively. Thirty-day mortality was 1.2% (n = 2). R0 rate was 92.9%. Adjuvant chemotherapy was offered to 72 (42.9%) patients. Median follow-up was 34.0 (10.0-65.7) months. Distant and local recurrences were seen in 35 (20.8%) and 15 patients (8.9%), respectively. Overall survival (OS) at 1, 3, and 5-years was 91.7, 82.1, and 76.8%. Disease-free survival (DFS) at 1, 3, and 5-years was 84.0, 74.5, and 69.2%. CONCLUSION Robotic bTME is technically safe with relatively low conversion rate, good OS, and acceptable DFS in the hands of experienced surgeons in high volume centres. In selected cases robotic approach allows for high R0 rates during bTME.
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Affiliation(s)
- Jim S Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; University of Portsmouth, Portsmouth, UK.
| | | | - Philippe Rouanet
- Department of Surgery, Institut Régional du Cancer de Montpellier, Montpellier Cancer Research Institute, University of Montpellier, Montpellier, France.
| | - Avanish Saklani
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - Volkan Ozben
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Acibadem Atakent Hospital, Istanbul, Turkey.
| | - Paul Neary
- Division of Colorectal Surgery, The Adelaide and Meath Hospital Ireland, Dublin, Ireland.
| | - Peter Coyne
- Department of Colorectal Surgery, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK.
| | - Seon Hahn Kim
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA.
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S V, Pareekutty NM, Balasubramanian S. Outcomes Following Treatment of Pelvic Exenteration for Rectal Cancer in a Tertiary Care Center. Indian J Surg Oncol 2024; 15:420-427. [PMID: 38741635 PMCID: PMC11088593 DOI: 10.1007/s13193-024-01918-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 03/01/2024] [Indexed: 05/16/2024] Open
Abstract
Pelvic exenteration is potentially curative for operable locally advanced primary and locally recurrent rectal cancers. R0 resection is associated with higher survival. This procedure is associated with low mortality rates but high postoperative morbidity proportional to the extent of resection. This study was done to find out the survival outcome and morbidity associated with this procedure and to determine prognostic factors associated with postoperative outcomes. Seventy-three patients with rectal cancer underwent pelvic exenteration between January 2009 and December 2020. Sixty-six patients had locally advanced rectal cancer and 7 patients had recurrent cancer. All patients with primary tumors were evaluated with MRI pelvis and CT scan of the chest and abdomen while patients with recurrence were evaluated with a PET scan. The median follow-up duration was 39 months. The majority of patients were in the age group 40-69 years. Thirty patients were males and 43 were females. The 30-day postoperative major morbidity was reported in 28 patients (38.4%). The most common morbidity was wound dehiscence. The mean overall survival (OS) was 110.6 months (95% CI, 97.5-123.7) and mean disease free survival (DFS) was 85 months (95% CI, 71.0-100.4). R0 resection was associated with favorable overall survival. Tailored exenterations were associated with low morbidity. En bloc partial sacrectomy helped achieve R0 resection in patients who underwent the procedure. Extended resections yielded high R0 resection rates with favorable survival (65 months) but were associated with high morbidity. These procedures shall be best practiced in high-volume institutes of expertise. Supplementary Information The online version contains supplementary material available at 10.1007/s13193-024-01918-w.
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Affiliation(s)
- Vijayasarathy S
- Department of Surgical Oncology, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur District, Kerala, 670103 India
| | - Nizamudheen M. Pareekutty
- Department of Surgical Oncology, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur District, Kerala, 670103 India
| | - Satheesan Balasubramanian
- Department of Surgical Oncology, Malabar Cancer Center, Moozhikkara (PO), Thalassery, Kannur District, Kerala, 670103 India
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Milanko NA, Kelly ME, Turner G, Kong J, Behrenbruch C, Mohan H, Guerra G, Warrier S, McCormick J, Heriot A. Evaluating postoperative hernia incidence and risk factors following pelvic exenteration. Int J Colorectal Dis 2024; 39:70. [PMID: 38717479 PMCID: PMC11078832 DOI: 10.1007/s00384-024-04638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/12/2024]
Abstract
Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251-1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre. METHOD A retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination. RESULTS A total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative. CONCLUSION This study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.
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Affiliation(s)
- Nicole Anais Milanko
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia.
| | - Michael Eamon Kelly
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Trinity St James Cancer Institute, Dublin, Ireland
| | - Greg Turner
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Auckland District Health Board, Auckland, New Zealand
| | - Joeseph Kong
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Cori Behrenbruch
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Helen Mohan
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Glen Guerra
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Satish Warrier
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Jacob McCormick
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Department of General Surgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Alexander Heriot
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia.
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5
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Contemporary results from the PelvEx collaborative: improvements in surgical outcomes for locally advanced and recurrent rectal cancer. Colorectal Dis 2024; 26:926-931. [PMID: 38566456 DOI: 10.1111/codi.16948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 04/04/2024]
Abstract
AIM The PelvEx Collaborative collates global data on outcomes following exenterative surgery for locally advanced and locally recurrent rectal cancer (LARC and LRRC, respectively). The aim of this study is to report contemporary data from within the collaborative and benchmark it against previous PelvEx publications. METHOD Anonymized data from 45 units that performed pelvic exenteration for LARC or LRRC between 2017 and 2021 were reviewed. The primary endpoints were surgical outcomes, including resection margin status, radicality of surgery, rates of reconstruction and associated morbidity and/or mortality. RESULTS Of 2186 patients who underwent an exenteration for either LARC or LRRC, 1386 (63.4%) had LARC and 800 (36.6%) had LRRC. The proportion of males to females was 1232:954. Median age was 62 years (interquartile range 52-71 years) compared with a median age of 63 in both historical LARC and LRRC cohorts. Compared with the original reported PelvEx data (2004-2014), there has been an increase in negative margin (R0) rates from 79.8% to 84.8% and from 55.4% to 71.7% in the LARC and LRRC cohorts, respectively. Bone resection and flap reconstruction rates have increased accordingly in both cohorts (8.2%-19.6% and 22.6%-32% for LARC and 20.3%-41.9% and 17.4%-32.1% in LRRC, respectively). Despite this, major morbidity has not increased. CONCLUSION In the modern era, patients undergoing pelvic exenteration for advanced rectal cancer are undergoing more radical surgery and are more likely to achieve a negative resection margin (R0) with no increase in major morbidity.
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Lazarovich A, Drori T, Guttman Y, Rosenzweig B, Ben-Yaaqov A, Korach J, Nissan A, Dotan Z. Urological outcomes following pelvic exenteration for non-urological malignancies. Heliyon 2024; 10:e29640. [PMID: 38644885 PMCID: PMC11031810 DOI: 10.1016/j.heliyon.2024.e29640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/17/2023] [Accepted: 04/11/2024] [Indexed: 04/23/2024] Open
Abstract
Background Pelvic exenteration (PE) is a major surgical procedure used as a salvage therapy for patients with locally advanced or recurrent pelvic malignancies. Urinary reconstruction is a major part of PE and is often associated with high rates of post-operative complications. In the current study we evaluate the short and long-term urological outcomes following PE for Colo-Rectal (CR) and gyneco-oncological (GO) malignancies. Methods Study included 22 patients who underwent PE for recurrent or locally advanced CR and GO malignancies in our institution between the years 2010-2018. The endpoint was post-operative freedom from urological complications. Results Of 22 patients included, 13 (59 %) and 9 (41 %) underwent PE for CR and GO malignancies respectively. The mean age of the patients was 54 years. The median follow-up was 19 months. Seven (78 %) patients with GO malignancy and 11 (85 %) with CR malignancy underwent PE for local recurrence. Hydronephrosis prior to surgery existed in 8 (36.3 %) patients, of which, 5 patients required kidney drainage via nephrostomy tube. Two patients underwent posterior pelvic exenteration (PPE) with bladder preservation whereas the remaining 20 underwent cystectomy with urinary diversion by ileal conduit. Hydronephrosis post PE developed in 13 patients (59 %). eight (36 %) patients needed kidney drainage by nephrostomy tubes post PE, of these, 6 (75 %) had disease recurrence. The 2 years freedom from kidney drainage was 68 %, however the median time for kidney drainage was 0.5 months. The median overall survival was 12.5 months. Conclusion The rate of urological complications following PE is relatively high and associated with disease recurrence.
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Affiliation(s)
- A. Lazarovich
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - T. Drori
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Y. Guttman
- Department of Surgical Oncology C, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B. Rosenzweig
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A. Ben-Yaaqov
- Department of Surgical Oncology C, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - J. Korach
- Department of Gynecological Oncology (GO), Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A. Nissan
- Department of Surgical Oncology C, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Z.A. Dotan
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Li Y, Zhuang M, Hu G, Zhang J, Qiu W, Mei S, Tang J. A novel classification of posterior pelvic exenteration to assess prognosis in female patients with locally advanced primary rectal cancer: a retrospective cohort study from China PelvEx collaborative. Int J Colorectal Dis 2024; 39:59. [PMID: 38664256 PMCID: PMC11045567 DOI: 10.1007/s00384-024-04632-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
PURPOSE Surgical techniques and the prognosis of posterior pelvic exenteration for locally advanced primary rectal cancer in female patients pose challenges that need to be addressed. Therefore, we investigated the short-term and survival outcomes of posterior pelvic exenteration in female patients using a novel Peking classification. METHODS We retrospectively analysed a prospective database from China PelvEx Collaborative across three tertiary referral centres. A total of 172 patients who underwent combined resection for locally advanced primary rectal cancer were classified based on four subtypes (PPE-I [64/172], PPE-II [68/172], PPE-III [21/172], and PPE-IV [19/172]) according to the Peking classification; perioperative characteristics and short-term and oncological outcomes were analysed. RESULTS Differences were significant among the four groups regarding colorectal reconstruction (p < 0.001), perineal reconstruction (p < 0.001), in-hospital complications (p < 0.05), and urinary retention (p < 0.05). The R0 resection rates for PPE-I, PPE-II, PPE-III, and PPE-IV were 90.6%, 89.7%, 90.5%, and 89.5%, respectively. The 5-year overall survival rates of the PPE-I, PPE-II, PPE-III, and PPE-IV groups were 73.4%, 68.8%, 54.7%, and 37.3%, respectively. Correspondingly, their 5-year disease-free survival rates were 76.0%, 62.5%, 57.7%, and 43.1%, respectively. Notably, the PPE-IV group demonstrated the lowest 5-year overall survival rate (p < 0.001) and 5-year disease-free survival rate (p < 0.001). CONCLUSION The Peking classification can aid in determining suitable surgical techniques and conducting prognostic assessments in female patients with locally advanced primary rectal cancer.
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Affiliation(s)
- Yuegang Li
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Meng Zhuang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Gang Hu
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jinzhu Zhang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Wenlong Qiu
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Shiwen Mei
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jianqiang Tang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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8
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Kazi M, Raghavan S, Desouza A, Saklani A. Pelvic exenterations combined with cytoreductions for T4 rectal cancers with peritoneal metastasis: a safety analysis. ANZ J Surg 2024; 94:702-707. [PMID: 38012077 DOI: 10.1111/ans.18808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Pelvic exenterations and cytoreduction are individually morbid procedures with oncological validity. The combination of these simultaneously in patients with rectal cancers has not been evaluated. The present study aimed to assess the surgical and survival outcomes of the combined procedure. METHODS Retrospective, single-centre analysis of consecutive patients that underwent pelvic exenterations and cytoreductions for advanced or recurrent rectal cancers with peritoneal metastasis between 2013 and 2022. The primary outcome measure for safety was major complications (≥Grade IIIA). The threshold for considering the procedure unsafe was set at 50% for the upper confidence limit of major morbidity. Overall and recurrence-free survival were also assessed. RESULTS Thirty-nine patients underwent the combined procedure that included 24 total pelvic and 15 posterior pelvic exenterations. The median age of the cohort was 35 years, 18 (46.2%) had signet ring cell cancers, and eight patients (21%) had extraperitoneal disease as well. The median PCI was 4 and CC-0 was achieved in 38 patients (97.4%). Hyperthermic intraperitoneal chemotherapy was delivered in 15 patients, and four had placement of an intraperitoneal chemo port. Major complications were experienced by 7 patients (18%; 95% confidence interval: 7.5%-33.5%). Median recurrence-free and overall survivals were 9 and 17 months, respectively. CONCLUSION Combined pelvic exenterations and cytoreductions are safe operations in terms of morbidity. Survival, however, remains poor for this group of patients despite aggressive surgery.
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Affiliation(s)
- Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Sriniket Raghavan
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
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Steffens D, Blake J, Solomon MJ, Lee P, Austin KKS, Byrne CM, Karunaratne S, Koh CE. Trajectories of Quality of Life After Pelvic Exenteration: A Latent Class Growth Analysis. Dis Colon Rectum 2024; 67:531-540. [PMID: 38156798 DOI: 10.1097/dcr.0000000000003080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Information on the course of quality of life after surgery for advanced cancers within the pelvis is important to guide patient decision-making; however, the current evidence is limited. OBJECTIVE To identify quality-of-life trajectory classes and their predictors after pelvic exenteration. DESIGN Prospective cohort study. SETTINGS Highly specialized quaternary pelvic exenteration referral center. PATIENTS Patients undergoing pelvic exenteration due to advanced/recurrent cancers within the pelvis between July 2008 and July 2022. MAIN OUTCOME MEASURES Quality-of-life data included the 36-item Short-Form Survey (physical and mental component scores) and the Functional Assessment of Cancer Therapy-Colorectal instruments, which were collected at 11 distinct points from baseline to 5 years postoperatively. Predictors included patient characteristics and surgical outcomes. Latent class analysis was used to identify the likelihood of a better quality-of-life class, and logistic regression models were used to identify predictors of the identified classes. RESULTS The study included 565 participants. Two distinct quality-of-life trajectory classes were identified for the Physical Component Score (class 1: high stable and class 2: high decreasing). Three distinct classes were identified for the Mental Component Score (class 1: high increasing, class 2: moderate stable, and class 3: moderate decreasing) and for Functional Assessment of Cancer Therapy-Colorectal total score (class 1: high increasing, class 2: high decreasing, and class 3: low decreasing). Across the 3 quality-of-life domains, overall survival probabilities were also higher in class 1 ( p < 0.0001). Age, repeat exenteration, neoadjuvant therapy, surgical margin, length of operation, and hospital stay were significant predictors of quality-of-life classes. LIMITATIONS This study was conducted at a single highly specialized quaternary pelvic exenteration referral center, and findings may not apply to other centers. CONCLUSIONS This study demonstrates that quality of life after pelvic exenteration diverges into distinct trajectories, with most patients reporting an optimal course. See Video Abstract . TRAYECTORIAS EN LA CALIDAD DE VIDA DESPUS DE EXENTERACIN PLVICA ANLISIS DE CRECIMIENTO DE CLASES LATENTES ANTECEDENTES:La información sobre la evolución en la calidad de vida después de cirugía en cánceres avanzados situados en la pelvis es importante para guiar la toma de decisiones sobre el paciente; sin embargo, la evidencia actual es muy limitada.OBJETIVO:Identificar las clases de trayectorias en la calidad de vida y sus factores pronóstico después de la exenteración pélvica.DISEÑO:Estudio de cohortes prospectivo.AJUSTES:Centro de referencia altamente especializado en la exenteración pélvica cuaternaria.PACIENTES:Todos aquellos sometidos a exenteración pélvica por cáncer avanzados/recurrentes situados en la pelvis entre Julio de 2008 y Julio de 2022.PRINCIPALES MEDIDAS DE RESULTADO:Los datos sobre la calidad de vida incluyeron el Cuestionario de Salud SF-36 (puntuaciones de componentes físicos y mentales) y la evaluación funcional entre la terapia del cáncer/-herramientas colorrectales, recopilados en 11 puntos distintos desde el diagnóstico hasta los 5 años después de la operación.Los predictores incluyeron las características de los pacientes y los resultados quirúrgicos. Se utilizó el análisis de clases latentes para identificar la probabilidad de una mejor calidad de vida y se utilizaron modelos de regresión logística para identificar predictores de las clases identificadas.RESULTADOS:El estudio incluyó a 565 participantes. Se identificaron dos clases distintas de trayectorias de calidad de vida para la puntuación del componente físico (clase 1: alta estable y clase 2: alta decreciente), se identificaron tres clases distintas para la puntuación del componente mental (clase 1: alta creciente; clase 2: moderadamente estable; y clase 3: moderada disminución) y para la evaluación funcional de la terapia contra el cáncer-puntuación total colorrectal (clase 1: aumento alto; clase 2: disminución alta; y clase 3: disminución baja). En los tres dominios de calidad de vida, las probabilidades de supervivencia general también fueron mayores en las clases 1 (p <0,0001). La edad, las exenteraciones pélvicas repetidas, la terapia neoadyuvante, el margen quirúrgico, la duración de la operación y la estadía hospitalaria fueron predictores significativos en las clases de calidad de vida.LIMITACIONES:El presente estudio fué realizado en un único centro de referencia altamente especializado en exenteración pélvica cuaternaria y es posible que los hallazgos no se apliquen a otros centros.CONCLUSIONES:Demostramos con nuestro estudio que la calidad de vida después de la exenteración pélvica diverge en trayectorias distintas, y que la mayoría de los pacientes nos reportaron de una évolución óptima. (Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Joshua Blake
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Peter Lee
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher M Byrne
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sascha Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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10
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Thorgersen EB, Solbakken AM, Strøm TK, Goscinski M, Spasojevic M, Larsen SG, Flatmark K. Short-term results after robot-assisted surgery for primary rectal cancers requiring beyond total mesorectal excision in multiple compartments. Scand J Surg 2024; 113:3-12. [PMID: 37787437 DOI: 10.1177/14574969231200654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
AIM Rectal cancers requiring beyond total mesorectal excision (bTME) are traditionally operated using an open approach, but the use of minimally invasive robot-assisted procedures is increasing. Introduction of minimal invasive surgery for complex cancer cases could be associated with compromised surgical margins or increased complication rates. Therefore, reporting results both clinical and oncological in large series is important. Since bTME procedure reports are heterogeneous, comparing results is often difficult. In this study, a magnetic resonance imaging (MRI) classification system was used to describe the bTME surgery according to pelvic compartments. METHODS Consecutive patients with primary rectal cancer operated with laparoscopic robot-assisted bTME were prospectively included for 2 years. All patients had tumors that threatened the mesorectal fascia, invaded adjacent organs, and/or involved metastatic pelvic lateral lymph nodes. Short-term clinical outcomes and oncological specimen quality were registered. Surgery was classified according to pelvic compartments resected. RESULTS Clear resection margins (R0 resection) were achieved in 95 out of 105 patients (90.5%). About 26% had Accordion Severity Grading System of Surgical Complications grade 3-4 complications and 15% required re-operations. About 7% were converted to open surgery. The number of compartments resected ranged from one to the maximum seven, with 83% having two or three compartments resected. All 10 R1 resections occurred in the lateral and posterior compartments. CONCLUSIONS The short-term clinical outcomes and oncological specimen quality after robot-assisted bTME surgery were comparable to previously published open bTME surgery. The description of surgical procedures using the Royal Marsden MRI compartment classification was feasible.
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Affiliation(s)
- Ebbe B Thorgersen
- Department of Gastroenterological Surgery Oslo University Hospital The Radium Hospital Pb 4950 Nydalen 0424 Oslo Norway
| | - Arne M Solbakken
- Department of Gastroenterological Surgery, Oslo University Hospital, The Radium Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Tumor Biology, Oslo University Hospital, The Radium Hospital, Oslo, Norway
| | - Tuva K Strøm
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Mariusz Goscinski
- Department of Gastroenterological Surgery, Oslo University Hospital, The Radium Hospital, Oslo, Norway
| | - Milan Spasojevic
- Department of Gastroenterological Surgery, Oslo University Hospital, The Radium Hospital, Oslo, Norway
| | - Stein G Larsen
- Department of Gastroenterological Surgery, Oslo University Hospital, The Radium Hospital, Oslo, Norway
| | - Kjersti Flatmark
- Department of Gastroenterological Surgery, Oslo University Hospital, The Radium Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Tumor Biology, Oslo University Hospital, The Radium Hospital, Oslo, Norway
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11
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Shur JD, Qiu S, Johnston E, Tait D, Fotiadis N, Kontovounisios C, Rasheed S, Tekkis P, Riddell A, Koh DM. Multimodality Imaging to Direct Management of Primary and Recurrent Rectal Adenocarcinoma Beyond the Total Mesorectal Excision Plane. Radiol Imaging Cancer 2024; 6:e230077. [PMID: 38363197 PMCID: PMC10988347 DOI: 10.1148/rycan.230077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/11/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024]
Abstract
Rectal tumors extending beyond the total mesorectal excision (TME) plane (beyond-TME) require particular multidisciplinary expertise and oncologic considerations when planning treatment. Imaging is used at all stages of the pathway, such as local tumor staging/restaging, creating an imaging-based "roadmap" to plan surgery for optimal tumor clearance, identifying treatment-related complications, which may be suitable for radiology-guided intervention, and to detect recurrent or metastatic disease, which may be suitable for radiology-guided ablative therapies. Beyond-TME and exenterative surgery have gained acceptance as potentially curative procedures for advanced tumors. Understanding the role, techniques, and pitfalls of current imaging techniques is important for both radiologists involved in the treatment of these patients and general radiologists who may encounter patients undergoing surveillance or patients presenting with surgical complications or intercurrent abdominal pathology. This review aims to outline the current and emerging roles of imaging in patients with beyond-TME and recurrent rectal malignancy, focusing on practical tips for image interpretation and surgical planning in the beyond-TME setting. Keywords: Abdomen/GI, Rectum, Oncology © RSNA, 2024.
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Affiliation(s)
- Joshua D. Shur
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Sheng Qiu
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Edward Johnston
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Diana Tait
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Nicos Fotiadis
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Christos Kontovounisios
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Shahnawaz Rasheed
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Paris Tekkis
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Angela Riddell
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Dow-Mu Koh
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
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12
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Giannas E, Kavallieros K, Nanidis T, Giannas J, Tekkis P, Kontovounisios C. Re-Do Plastic Reconstruction for Locally Advanced and Recurrent Colorectal Cancer Following a beyond Total Mesorectal Excision (TME) Operation-Key Considerations. J Clin Med 2024; 13:1228. [PMID: 38592018 PMCID: PMC10932044 DOI: 10.3390/jcm13051228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
Innovation in surgery and pelvic oncology have redefined the boundaries of pelvic exenteration for CRC. However, surgical approaches and outcomes following repeat exenteration and reconstruction are not well described. The resulting defect from a second beyond Total Mesorectal Excision (TME) presents a challenge to the reconstructive surgeon. The aim of this study was to explore reconstructive options for patients undergoing repeat beyond TME for recurrent CRC following previous beyond TME and regional reconstruction. MEDLINE and Embase were searched for relevant articles, yielding 2353 studies. However, following full text review and the application of the inclusion criteria, all the studies were excluded. This study demonstrated the lack of reporting on re-do reconstruction techniques following repeat exenteration for recurrent CRC. Based on this finding, we conducted a point-by-point discussion of certain key aspects that should be taken into consideration when approaching this patient cohort.
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Affiliation(s)
- Emmanuel Giannas
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Konstantinos Kavallieros
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Theodoros Nanidis
- Department of Plastic Surgery, The Royal Marsden Hospital, London SW3 6JJ, UK;
| | - John Giannas
- Department of Plastic and Reconstructive Surgery, Euroclinic, 115 21 Athens, Greece;
- Department of Plastic and Reconstructive Surgery, The London Welbeck Hospital, London W1G 83N, UK
| | - Paris Tekkis
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
- Department of Surgery, The Royal Marsden Hospital, London SE3 6JJ, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
- Department of Surgery, The Royal Marsden Hospital, London SE3 6JJ, UK
- 2nd Surgical Department Evaggelismos, Athens General Hospital, 115 21 Athens, Greece
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13
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Fahy MR. A review of functional and surgical outcomes of gynaecological reconstruction in the context of pelvic exenteration. Surg Oncol 2024; 52:101996. [PMID: 38096764 DOI: 10.1016/j.suronc.2023.101996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/02/2023] [Accepted: 09/17/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND Radical surgical excision may be the only curative option for patients with advanced pelvic malignancy, but concerns surrounding the functional outcomes and survivorship of patients undergoing exenterative surgery remain. This is especially important in the context of vulvovaginal resection, where patients are often younger and surgery can have a profoundly negative impact on quality of life, body image and overall wellbeing. Reconstructive procedures are an important means of mitigating these adverse effects but outcomes are poorly described. AIM To define the outcomes associated with gynaecological reconstructive procedures following pelvic exenterative surgery and to compare them with the outcomes of those patients who did not undergo reconstruction. METHODS An international, multicentre retrospective investigation comparing the outcomes of reconstruction with no reconstruction. The protocol was prospectively registered (NCT05074069). RESULTS 334 patients were included. 77 patients had a neovagina reconstructed, 139 patients underwent flap reconstruction and 118 were not reconstructed. Patients who underwent reconstruction had a longer operative time and hospital stay with an increased risk of minor perineal complications. Reconstruction did not confer an increased risk of surgical reintervention, and overall complication rates were equivalent. Procedure-specific major morbidity was 5.2 % and 11.5 % for neovaginal and flap reconstruction, respectively. 66 % of patients undergoing neovaginal reconstruction experienced no long term morbidity. 7 % developed neovaginal stenosis and 12 % suffered disease recurrence. CONCLUSION Neovaginal reconstruction is safe in carefully selected patients and offers specific advantages over alternative techniques, with few patients requiring reoperation. Primary closure does not increase perineal morbidity.
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14
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Watts R, Jackson D, Harris C, van Zundert A. Anaesthesia for pelvic exenteration surgery. BJA Educ 2024; 24:57-67. [PMID: 38304069 PMCID: PMC10829085 DOI: 10.1016/j.bjae.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 02/03/2024] Open
Affiliation(s)
- R. Watts
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - D. Jackson
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - C. Harris
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - A. van Zundert
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
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15
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Saklani A, Kazi M, Desouza A, Sharma A, Engineer R, Krishnatry R, Gudi S, Ostwal V, Ramaswamy A, Dhanwat A, Bhargava P, Mehta S, Sundaram S, Kale A, Goel M, Patkar S, Vartey G, Kulkarni S, Baheti A, Ankathi S, Haria P, Katdare A, Choudhari A, Ramadwar M, Menon M, Patil P. Tata Memorial Centre Evidence Based Management of Colorectal cancer. Indian J Cancer 2024; 61:S29-S51. [PMID: 38424681 DOI: 10.4103/ijc.ijc_66_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 03/02/2024]
Abstract
ABSTRACT This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis.
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Affiliation(s)
- Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
- Department of Surgical Oncology, Advanced Centre of the Treatment, Research, and Education in Cancer, Kharghar, Navi Mumbai, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Ankit Sharma
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
- Department of Surgical Oncology, Advanced Centre of the Treatment, Research, and Education in Cancer, Kharghar, Navi Mumbai, India
| | - Reena Engineer
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Rahul Krishnatry
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shivkumar Gudi
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Vikas Ostwal
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Anant Ramaswamy
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Aditya Dhanwat
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Prabhat Bhargava
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shaesta Mehta
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Sridhar Sundaram
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Aditya Kale
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Mahesh Goel
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Shraddha Patkar
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Gurudutt Vartey
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Suyash Kulkarni
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Akshay Baheti
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Suman Ankathi
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Purvi Haria
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Aparna Katdare
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Amit Choudhari
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Mukta Ramadwar
- Homi Bhabha National Institute, Mumbai, India
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Munita Menon
- Homi Bhabha National Institute, Mumbai, India
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Prachi Patil
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
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Wang J, Liu H, Li A, Jiang H, Pan Y, Chen X, Yin L, Lin M. A new membrane anatomy-oriented classification of radical surgery for rectal cancer. Gastroenterol Rep (Oxf) 2023; 11:goad069. [PMID: 38145104 PMCID: PMC10739184 DOI: 10.1093/gastro/goad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/08/2023] [Accepted: 11/10/2023] [Indexed: 12/26/2023] Open
Abstract
For patients with different clinical stages of rectal cancer, tailored surgery is urgently needed. Over the past 10 years, our team has conducted numerous anatomical studies and proposed the "four fasciae and three spaces" theory to guide rectal cancer surgery. Enlightened by the anatomical basis of the radical hysterectomy classification system of Querleu and Morrow, we proposed a new classification system of radical surgery for rectal cancer based on membrane anatomy. This system categorizes the surgery into four types (A-D) and incorporates corresponding subtypes based on the preservation of the autonomic nerve. Our surgical classification unifies the pelvic membrane anatomical terminology, validates the feasibility of classifying rectal cancer surgery using the theory of "four fasciae and three spaces," and lays the theoretical groundwork for the future development of unified and standardized classification of radical pelvic tumor surgery.
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Affiliation(s)
- Jiaqi Wang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Hailong Liu
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Ajian Li
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Huihong Jiang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Yun Pan
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Xin Chen
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Lu Yin
- Department of General Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Moubin Lin
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
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Faur IF, Clim A, Dobrescu A, Prodan C, Hajjar R, Pasca P, Capitanio M, Tarta C, Isaic A, Noditi G, Nati I, Totolici B, Duta C, Lazar G. VRAM Flap for Pelvic Floor Reconstruction after Pelvic Exenteration and Abdominoperineal Excision. J Pers Med 2023; 13:1711. [PMID: 38138938 PMCID: PMC10744748 DOI: 10.3390/jpm13121711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Due to the still large number of patients diagnosed with pelvic neoplasms (colorectal, gynecological, and urological) in advanced stages right from the initial diagnosis, surgery represents the mainstay of treatment, often implying wide, eventually multi-organ resections in order to achieve negative surgical margins. Perineal wound morbidity, particularly in extralevator abominoperineal excision, leads to complications and local infection rates of up to 40%. Strategies to reduce postoperative wound complications are being pursued to address this issue. The VRAM flap remains the gold standard for autologous reconstruction after pelvic oncological resection; it was initially designed for abdominal wall defects and later expanded for large pelvic tissue defects. The flap's application is based on its physical characteristics, including abundant tissue and a generous skin paddle, which effectively obliterates dead space after exenterations. The generous skin paddle offers good cosmetic and functional outcomes at the recipient site. This article describes the case of a patient histopathologically diagnosed with stage IIIA squamous cell carcinoma of the uterine cervix who received multimodal onco-surgical treatment. The surgical mainstay of this treatment is pelvic exenteration. Pelvic reconstruction after this major surgery was performed using a vertical flap with the rectus abdominis.
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Affiliation(s)
- Ionut Flaviu Faur
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania; (I.F.F.); (C.P.); (R.H.); (P.P.); (M.C.); (C.T.); (A.I.); (G.N.); (C.D.)
- X Department of General Surgery, ”Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Adelina Clim
- IInd Obstetric and Gynecology Clinic “Dominic Stanca”, 400124 Cluj-Napoca, Romania;
| | - Amadeus Dobrescu
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania; (I.F.F.); (C.P.); (R.H.); (P.P.); (M.C.); (C.T.); (A.I.); (G.N.); (C.D.)
- X Department of General Surgery, ”Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Catalin Prodan
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania; (I.F.F.); (C.P.); (R.H.); (P.P.); (M.C.); (C.T.); (A.I.); (G.N.); (C.D.)
| | - Rami Hajjar
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania; (I.F.F.); (C.P.); (R.H.); (P.P.); (M.C.); (C.T.); (A.I.); (G.N.); (C.D.)
| | - Paul Pasca
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania; (I.F.F.); (C.P.); (R.H.); (P.P.); (M.C.); (C.T.); (A.I.); (G.N.); (C.D.)
| | - Marco Capitanio
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania; (I.F.F.); (C.P.); (R.H.); (P.P.); (M.C.); (C.T.); (A.I.); (G.N.); (C.D.)
| | - Cristi Tarta
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania; (I.F.F.); (C.P.); (R.H.); (P.P.); (M.C.); (C.T.); (A.I.); (G.N.); (C.D.)
- X Department of General Surgery, ”Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Alexandru Isaic
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania; (I.F.F.); (C.P.); (R.H.); (P.P.); (M.C.); (C.T.); (A.I.); (G.N.); (C.D.)
- X Department of General Surgery, ”Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - George Noditi
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania; (I.F.F.); (C.P.); (R.H.); (P.P.); (M.C.); (C.T.); (A.I.); (G.N.); (C.D.)
- X Department of General Surgery, ”Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Ionel Nati
- 2nd Department of Obstetric & Ginecology, ”Iuliu Hatieganu” University of Medicine and Pharmacy, Victor Babeș Street Number 8, 400347 Cluj-Napoca, Romania; (I.N.); (G.L.)
- Ist Clinic of Oncological Surgery, Oncological Institute “Prof. Dr. I. Chiricuta”, 400015 Cluj-Napoca, Romania
| | - Bogdan Totolici
- Ist Clinic of General Surgery, Arad County Emergency Clinical Hospital, 310158 Arad, Romania;
- Department of General Surgery, Faculty of Medicine, “Vasile Goldiș” Western University of Arad, 310025 Arad, Romania
| | - Ciprian Duta
- IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania; (I.F.F.); (C.P.); (R.H.); (P.P.); (M.C.); (C.T.); (A.I.); (G.N.); (C.D.)
- X Department of General Surgery, ”Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Gabriel Lazar
- 2nd Department of Obstetric & Ginecology, ”Iuliu Hatieganu” University of Medicine and Pharmacy, Victor Babeș Street Number 8, 400347 Cluj-Napoca, Romania; (I.N.); (G.L.)
- Ist Clinic of Oncological Surgery, Oncological Institute “Prof. Dr. I. Chiricuta”, 400015 Cluj-Napoca, Romania
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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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Brown KGM, McBride KE, Anderson T, Solomon MJ. Delivering complex surgical services: lessons learned from the evolution of a specialised pelvic exenteration centre. AUST HEALTH REV 2023; 47:735-740. [PMID: 38029447 DOI: 10.1071/ah23186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023]
Abstract
Pelvic exenteration (PE) is a potentially curative, ultra-radical surgical procedure for the treatment of advanced pelvic tumours, which involves surgical resection of multiple pelvic organs. Delivering such a complex low-volume, high-cost surgical program presents a number of unique health management challenges, and requires an organisation-wide approach involving both clinical and administrative teams. In contrast to the United Kingdom and France, where PE services have been historically decentralised, a centralised approach was developed early on in Australia and New Zealand (ANZ) with referral of these complex patients to a small number of quaternary centres. The PE program at the authors' institution was established in 1994 and has since evolved into the highest volume PE centre in the ANZ region and the largest single institution experience globally. These achievements have required navigation of specific funding and management issues, supported from inception by a proactive and collaborative relationship with hospital administration and management. The comprehensive state-wide quaternary referral model that has been developed has subsequently been successfully applied to other complex surgical services at the authors' institution, as well as by more recently established PE centres in Australia. This article aims to summarise the authors' experience with establishing and expanding this service and the lessons learned from a health management perspective.
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Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Kate E McBride
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Teresa Anderson
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
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Stelzner S, Kittner T, Schneider M, Schuster F, Grebe M, Puffer E, Sims A, Mees ST. Beyond Total Mesorectal Excision (TME)-Results of MRI-Guided Multivisceral Resections in T4 Rectal Carcinoma and Local Recurrence. Cancers (Basel) 2023; 15:5328. [PMID: 38001587 PMCID: PMC10670363 DOI: 10.3390/cancers15225328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
Rectal cancer invading adjacent organs (T4) and locally recurrent rectal cancer (LRRC) pose a special challenge for surgical resection. We investigate the diagnostic performance of MRI and the results that can be achieved with MRI-guided surgery. All consecutive patients who underwent MRI-based multivisceral resection for T4 rectal adenocarcinoma or LRRC between 2005 and 2019 were included. Pelvic MRI findings were reviewed according to a seven-compartment staging system and correlated with histopathology. Outcomes were investigated by comparing T4 tumors and LRRC with respect to cause-specific survival in uni- and multivariate analysis. We identified 48 patients with T4 tumors and 28 patients with LRRC. Overall, 529 compartments were assessed with an accuracy of 81.7%, a sensitivity of 88.6%, and a specificity of 79.2%. Understaging was as low as 3.0%, whereas overstaging was 15.3%. The median number of resected compartments was 3 (interquartile range 3-4) for T4 tumors and 4 (interquartile range 3-5) for LRRC (p = 0.017). In 93.8% of patients with T4 tumors, a histopathologically complete (R0(local)-) resection could be achieved compared to 57.1% in LRRC (p < 0.001). Five-year overall survival for patients with T4 tumors was 53.3% vs. 32.1% for LRRC (p = 0.085). R0-resection and M0-category emerged as independent prognostic factors, whereas the number of resected compartments was not associated with prognosis in multivariate analysis. MRI predicts compartment involvement with high accuracy and especially avoids understaging. Surgery based on MRI yields excellent loco-regional results for T4 tumors and good results for LRRC. The number of resected compartments is not independently associated with prognosis, but R0-resection remains the crucial surgical factor.
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Affiliation(s)
- Sigmar Stelzner
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany; (A.S.); (S.T.M.)
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, D-04103 Leipzig, Germany
| | - Thomas Kittner
- Department of Radiology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany;
| | - Michael Schneider
- Department of Urology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany; (M.S.); (F.S.)
| | - Fred Schuster
- Department of Urology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany; (M.S.); (F.S.)
| | - Markus Grebe
- Department of Gynaecology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany;
| | - Erik Puffer
- Institut of Pathology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany;
| | - Anja Sims
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany; (A.S.); (S.T.M.)
| | - Soeren Torge Mees
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany; (A.S.); (S.T.M.)
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Risbey CWG, Brown KGM, Solomon MJ, Koh C, Karunaratne S, Steffens D. Impact of geographical health disparities on outcomes following pelvic exenteration at a centralised quaternary referral centre. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107082. [PMID: 37738872 DOI: 10.1016/j.ejso.2023.107082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/22/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Pelvic exenteration (PE) is an ultra-radical procedure performed for primary or recurrent malignancies confined to the pelvis. Health outcomes for rural Australian populations are generally inferior compared to those from metropolitan centres, however, the effect of geographical location on outcomes following PE is poorly defined. The aim of this study was to investigate how geographical location affects oncological, quality of life (QoL) and survival outcomes following PE. METHODS Consecutive patients undergoing PE between 1994 and 2022 at a single centre were included. Patient post codes were linked with the Australian Statistical Geography Standard Remoteness Structure to stratify patients into five groups based on the geographical location of their residence. Primary outcome measures included patient survival, QoL and oncological outcomes. RESULTS A total of 953 patients were included, of which 626 (65.7%) were from major cities, 227 (23.8%) inner regional, 84 (8.8%) outer regional, 9 (0.9%) remote, and 7 (0.7%) very remote areas. Rural patients were more likely to undergo PE for primary rectal cancer (p = 002) and less likely for recurrent, non-rectal carcinoma (p = 0.027). Rural patients less frequently had health insurance (p < 0.001) but were more likely to have undergone neoadjuvant radiotherapy (p = 0.022). No difference in length-of-admission, in-hospital complication rates, QoL at 36 months or survival was observed between groups. CONCLUSIONS Despite geographical disparities, rural populations undergoing PE achieved equally favourable outcomes as populations from metropolitan areas. Enhancing access to specialised care may facilitate better outcomes of patients residing in regional and remote areas.
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Affiliation(s)
- Charles W G Risbey
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Cherry Koh
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Sascha Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia.
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Gould LE, Pring ET, Moorghen M, Burns EM, Antoniou A, Steele CW, Roxburgh CS, Jenkins JT. Pathological determinants of outcome following resection of locally advanced or locally recurrent rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106971. [PMID: 37442715 DOI: 10.1016/j.ejso.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/17/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION Pathological factors that influence and predict survival following pelvic exenteration (PE) for locally advanced (LARC) or locally recurrent rectal cancer (LRRC), especially LRRC, remain poorly understood. A clear resection margin has previously been demonstrated to be of most significance. MATERIALS AND METHODS A retrospective cohort study was performed for all patients undergoing a curative PE for LARC or LRRC between 2008 and 2021 at a tertiary referral UK specialist colorectal hospital. Cox regression analysis was planned to identify pathological factors associated with overall (OS), disease free (DFS) and local recurrence free survival (LRFS). RESULTS 388 patients were included in the analysis with 256 resections for LARC and 132 for LRRC. 62.4% of patients were male with a median age of 59 years (IQR 49-67). 247 (64%) partial pelvic exenterations and 141 (36%) total pelvic exenterations performed. Overall R0 rate 86.6%. Poorly differentiated tumours and a positive resection margin independently influenced OS, DFS and LRFS on multivariate analysis in LARC. On multivariate analysis venous invasion negatively influenced DFS and poorly differentiated lesions negatively influenced LRFS in LRRC. CONCLUSIONS A positive resection margin and poorly differentiated tumours are significant negative prognostic markers for survival and recurrence in LARC. The results of this study support the need to look for alternative prognostic markers beyond that in the existing standard reporting dataset for rectal cancers. With increasing R0 rates, novel prognostic pathological markers are required to help guide treatment and surveillance for patients with LRRC.
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Affiliation(s)
- Laura E Gould
- School of Cancer Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK; St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK.
| | - Edward T Pring
- St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK
| | - Morgan Moorghen
- St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK
| | - Elaine M Burns
- St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK; Complex Cancer Clinic, St Mark's- The National Bowel Hospital, Harrow, UK
| | - Anthony Antoniou
- St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK; Complex Cancer Clinic, St Mark's- The National Bowel Hospital, Harrow, UK
| | - Colin W Steele
- School of Cancer Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK; Department of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Campbell Sd Roxburgh
- School of Cancer Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK; Department of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - John T Jenkins
- St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK; Complex Cancer Clinic, St Mark's- The National Bowel Hospital, Harrow, UK
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Solbakken AM, Sellevold S, Spasojevic M, Julsrud L, Emblemsvåg HL, Reims HM, Sørensen O, Thorgersen EB, Fauske L, Ågren JSM, Brennhovd B, Ryder T, Larsen SG, Flatmark K. Navigation-Assisted Surgery for Locally Advanced Primary and Recurrent Rectal Cancer. Ann Surg Oncol 2023; 30:7602-7611. [PMID: 37481493 PMCID: PMC10562504 DOI: 10.1245/s10434-023-13964-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/03/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND In some surgical disciplines, navigation-assisted surgery has become standard of care, but in rectal cancer, indications for navigation and the utility of different technologies remain undetermined. METHODS The NAVI-LARRC prospective study (NCT04512937; IDEAL Stage 2a) evaluated feasibility of navigation in patients with locally advanced primary (LARC) and recurrent rectal cancer (LRRC). Included patients had advanced tumours with high risk of incomplete (R1/R2) resection, and navigation was considered likely to improve the probability of complete resection (R0). Tumours were classified according to pelvic compartmental involvement, as suggested by the Royal Marsden group. The BrainlabTM navigation platform was used for preoperative segmentation of tumour and pelvic anatomy, and for intraoperative navigation with optical tracking. R0 resection rates, surgeons' experiences, and adherence to the preoperative resection plan were assessed. RESULTS Seventeen patients with tumours involving the posterior/lateral compartments underwent navigation-assisted procedures. Fifteen patients required abdominosacral resection, and 3 had resection of the sciatic nerve. R0 resection was obtained in 6/8 (75%) LARC and 6/9 (69%) LRRC cases. Preoperative segmentation was time-consuming (median 3.5 h), but intraoperative navigation was accurate. Surgeons reported navigation to be feasible, and adherence to the resection plan was satisfactory. CONCLUSIONS Navigation-assisted surgery using optical tracking was feasible. The preoperative planning was time-consuming, but intraoperative navigation was accurate and resulted in acceptable R0 resection rates. Selected patients are likely to benefit from navigation-assisted surgery.
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Affiliation(s)
- Arne M Solbakken
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Simen Sellevold
- Department of Orthopaedic Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Milan Spasojevic
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Lars Julsrud
- Department of Radiology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Hanne-Line Emblemsvåg
- Department of Radiology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Henrik M Reims
- Department of Pathology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Olaf Sørensen
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Ebbe B Thorgersen
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Lena Fauske
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | - Bjørn Brennhovd
- Department of Urology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Truls Ryder
- Department of Oncologic Plastic Surgery, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Stein G Larsen
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Kjersti Flatmark
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Tumour Biology, Institute for Cancer Research, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
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Zhuang M, Chen H, Li Y, Mei S, Liu J, Du B, Wang X, Wang X, Tang J. Laparoscopic posterior pelvic exenteration is safe and feasible for locally advanced primary rectal cancer in female patients: a comparative study from China PelvEx collaborative. Tech Coloproctol 2023; 27:1109-1117. [PMID: 37243857 DOI: 10.1007/s10151-023-02824-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/08/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE Posterior pelvic exenteration (PPE) for locally advanced rectal cancer is a technical and challenging procedure. The safety and feasibility of laparoscopic PPE remain to be determined. This study aims to compare short-term and survival outcomes of laparoscopic PPE (LPPE) with open PPE (OPPE) in female patients. METHOD From January 2015 to December 2020, data from 105 female patients who underwent PPE at three institutions were retrospectively analyzed. The short-term and oncological outcomes between LPPE and OPPE were compared. RESULTS A total of 54 cases with LPPE and 51 cases with OPPE were enrolled. The operative time (240 vs. 295 min, p = 0.009), blood loss (100 vs. 300 ml, p < 0.001), surgical site infection (SSI) rate (20.4% vs. 58.8%, p = 0.003), urinary retention rate (3.7% vs. 17.6%, p = 0.020), and postoperative hospital stay (10 vs. 13 days, p = 0.009) were significantly lower in the LPPE group. The two groups showed no significant differences in the local recurrence rate (p = 0.296), 3-year overall survival (p = 0.129), or 3-year disease-free survival (p = 0.082). A higher CEA level (HR 1.02, p = 0.002), poor tumor differentiation (HR 3.05, p = 0.004), and (y)pT4b stage (HR 2.35, p = 0.035) were independent risk factors for disease-free survival. CONCLUSION LPPE is safe and feasible for locally advanced rectal cancers and shows lower operative time and blood loss, fewer SSI complications, and better preservation of bladder function without compromising oncological outcomes.
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Affiliation(s)
- M Zhuang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - H Chen
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
| | - Y Li
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - S Mei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - J Liu
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - B Du
- Department of Colorectal Surgery, Gansu Provincial Hospital, Lanzhou, 730000, China
| | - X Wang
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - J Tang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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Assi H, Guné H, Buchwald P, Lagergren J, Lydrup ML, Öberg M. A New Technique for Pelvic and Vaginal Reconstruction in Abdominoperineal Rectal Excision: Combination of Gluteus Maximus Flap and Fasciocutaneous Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5317. [PMID: 37817923 PMCID: PMC10561799 DOI: 10.1097/gox.0000000000005317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/24/2023] [Indexed: 10/12/2023]
Abstract
Resection of advanced rectal cancer might result in significant tissue loss, including pelvic floor and parts of the vaginal wall. Pelvic floor reconstruction using a musculocutaneous flap offers optimized healing abilities and the possibility of vaginal reconstruction. In Skåne University Hospital, two different flap techniques are used to reconstruct the perineum: the vertical rectus abdominis musculocutaneous flap and the gluteus maximus (GM) flap. A combination of a GM flap and a fasciocutanous flap, referred to locally as a GM special (GMS) flap, is used for posterior vaginal wall reconstruction in women undergoing abdominoperineal resections including parts of or the total posterior vaginal wall. The GMS flap was introduced through a national collaboration in Sweden in 2013. The aim of this article is to offer a detailed description and illustrations of the surgical technique used to construct the GMS flap, focusing on the posterior vaginal wall reconstruction. In our experience, the GMS flap is a resilient and cosmetically appealing choice that is technically easily harvested. The flap has acceptable morbidity and long-term results with adequate neovaginal measurements. Collaborative work is further encouraged.
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Affiliation(s)
- Hanin Assi
- From the Department of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Henrik Guné
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Pamela Buchwald
- From the Department of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Jakob Lagergren
- Department of Surgery, Capio S:t Göran Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Marie-Louise Lydrup
- From the Department of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Martin Öberg
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
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Pividori M, Gangloff D, Ferron G, Meresse T, Delay E, Rivoire M, Perez S, Vaucher R, Frobert P. Outcomes of DIEP flap reconstruction after pelvic cancer surgery: A retrospective multicenter case series. J Plast Reconstr Aesthet Surg 2023; 85:242-251. [PMID: 37531805 DOI: 10.1016/j.bjps.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Flap reconstruction is often required after pelvic tumor resection to reduce wound complications. The use of perforator flaps has been shown to reduce donor site morbidity. The purpose of this study was to evaluate the outcomes of pedicled deep inferior epigastric perforator (pDIEP) flap reconstruction. METHODS This was a retrospective multicenter study of patients who underwent immediate pDIEP flap reconstruction for a pelvic or perineal defect after tumor resection between November 2012 and June 2022. The primary outcome was abdominal donor site morbidity, and the secondary outcome was perineal morbidity. RESULTS Thirty-four patients (median age, 57.5 years) who underwent pelvic exenteration (n = 31), extralevator abdominoperineal excision (n = 2), or extended vaginal hysterectomy (n = 1) were included. The most common indications were recurrent cervical (n = 19) and anal (n = 4) squamous cell carcinoma. Twenty-nine patients (85%) had a history of radiotherapy. Only one patient (3%) had major (Clavien-Dindo ≥ III) donor site complications (surgical site infection due to tumor recurrence). Eleven patients (32%) had at least one major recipient site complication (surgical site infection [n = 1], total [n = 2] or partial [n = 1] flap loss, perineal dehiscence [n = 2], hematoma [n = 1], fistula [n = 5]). No incisional or perineal hernias were observed during follow-up. Ninety-day survival was 100%. CONCLUSION Pedicled DIEP flap reconstructions performed by experienced surgical teams had good outcomes for perineal or vaginal reconstruction, with low abdominal morbidity, in patients with advanced pelvic malignancies who had undergone median laparotomy. The risks and benefits of this procedure should be carefully evaluated preoperatively using clinical and imaging data.
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Affiliation(s)
- Marc Pividori
- Department of Reconstructive and Plastic Surgery, Hospices Civils de Lyon, 103, Grande-Rue de la Croix-Rousse, 69317 Lyon, France; Department of Reconstructive and Plastic Surgery, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France.
| | - Dimitri Gangloff
- Department of Plastic Surgery, Institut Claudius Regaud Institut Universitaire du Cancer de Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse Cedex 9, France
| | - Gwenaël Ferron
- Department of Surgical Oncology, Institut Claudius Regaud Institut Universitaire du Cancer de Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse Cedex 9, France
| | - Thomas Meresse
- Department of Plastic Surgery, Institut Claudius Regaud Institut Universitaire du Cancer de Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse Cedex 9, France
| | - Emmanuel Delay
- Department of Reconstructive and Plastic Surgery, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
| | - Michel Rivoire
- Department of Surgical Oncology, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
| | - Simon Perez
- Department of Reconstructive and Plastic Surgery, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
| | - Richard Vaucher
- Department of Reconstructive and Plastic Surgery, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
| | - Paul Frobert
- Department of Reconstructive and Plastic Surgery, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
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Brown K, Solomon M, Ng KS, Sutton P, Koh C, White K, Steffens D. Development of a risk prediction tool for patients with locally advanced and recurrent rectal cancer undergoing pelvic exenteration: protocol for a mixed-methods study. BMJ Open 2023; 13:e075304. [PMID: 37648387 PMCID: PMC10471871 DOI: 10.1136/bmjopen-2023-075304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Pelvic exenteration (PE) surgery represents the only potentially curative treatment option for patients with locally advanced or recurrent rectal cancer (LARRC). Given the potential morbidity, whether or not PE should be recommended for an individual patient presents a major decisional conflict. This study aims to identify the outcomes of PE for which there is consensus among patients, carers and clinicians regarding their importance in guiding treatment decision-making, and to develop a risk prediction tool which predicts these outcomes. METHODS AND ANALYSIS This study will be conducted at a specialist PE centre, and employ a mixed-methods study design, divided into three distinct phases. In phase 1, outcomes of PE will be identified through a comprehensive systematic review of the literature (phase 1a), followed by exploration of the experiences of individuals who have undergone PE for LARRC and their carers (phase 1b, target sample size 10-20 patients and 5-10 carers). In phase 2, a survey of patients, their carers and clinicians will be conducted using Delphi methodology to explore consensus around the outcomes of highest priority and the level of influence each outcome should have on treatment decision-making. In phase 3 a, risk prediction tool will be developed using data from a single PE referral centre (estimated sample size 500 patients) to predict priority outcomes using multivariate modelling, and externally validated using data from an international PE collaboration. ETHICS AND DISSEMINATION Ethical approval has been granted for phases 1 and 2 (X22-0422 and 2022/ETH02659) and for maintenance of the database used in phase 3 (X13-0283 and HREC/13/RPAH/504). Informed consent will be obtained from participants in phases 1b and 2; a waiver of consent for secondary use of data in phase 3 will be sought. Study results will be submitted for publication in international and/or national peer reviewed journals. PROSPERO REGISTRATION NUMBER CRD42022351909.
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Affiliation(s)
- Kilian Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Paul Sutton
- Colorectal & Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Cherry Koh
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kate White
- Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
- The Daffodil Centre, University of Sydney and Cancer Council NSW, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Nekkanti SS, Jajoo B, Mohan A, Vasudevan L, Peelay Z, Kazi M, Desouza A, Saklani A. Empty pelvis syndrome: a retrospective audit from a tertiary cancer center. Langenbecks Arch Surg 2023; 408:331. [PMID: 37615748 DOI: 10.1007/s00423-023-03069-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
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.
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Affiliation(s)
- Sri Siddhartha Nekkanti
- Department of Gastrointestinal Oncology, Colorectal Division, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Bhushan Jajoo
- Siddharth Gupta Memorial Cancer Hospital, Sawangi, Wardha, Maharastra, 442001, India
| | - Anand Mohan
- Department of Gastrointestinal Oncology, Colorectal Division, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Lakshanya Vasudevan
- Department of Clinical Research, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Zoya Peelay
- Department of Clinical Research, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Mufaddal Kazi
- Department of Gastrointestinal Oncology, Colorectal Division, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Ashwin Desouza
- Department of Gastrointestinal Oncology, Colorectal Division, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Avanish Saklani
- Department of Gastrointestinal Oncology, Colorectal Division, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India.
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Ryan OK, Doogan KL, Ryan ÉJ, Donnelly M, Reynolds IS, Creavin B, Davey MG, Kelly ME, Kennelly R, Hanly A, Martin ST, Winter DC. Comparing minimally invasive surgical and open approaches to pelvic exenteration for locally advanced or recurrent pelvic malignancies - Systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1362-1373. [PMID: 37087374 DOI: 10.1016/j.ejso.2023.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/30/2023] [Accepted: 04/05/2023] [Indexed: 04/24/2023]
Abstract
INTRODUCTION Pelvic exenteration (PE) is a complex multivisceral surgical procedure indicated for locally advanced or recurrent pelvic malignancies. It poses significant technical challenges which account for the high risk of morbidity and mortality associated with the procedure. Developments in minimally invasive surgical (MIS) approaches and enhanced peri-operative care have facilitated improved long term outcomes. However, the optimum approach to PE remains controversial. METHODS A systematic literature search was conducted in accordance with PRISMA guidelines to identify studies comparing MIS (robotic or laparoscopic) approaches for PE versus the open approach for patients with locally advanced or recurrent pelvic malignancies. The methodological quality of the included studies was assessed systematically and a meta-analysis was conducted. RESULTS 11 studies were identified, including 2009 patients, of whom 264 (13.1%) underwent MIS PE approaches. The MIS group displayed comparable R0 resections (Risk Ratio [RR] 1.02, 95% Confidence Interval [95% CI] 0.98, 1.07, p = 0.35)) and Lymph node yield (Weighted Mean Difference [WMD] 1.42, 95% CI -0.58, 3.43, p = 0.16), and although MIS had a trend towards improved towards improved survival and recurrence outcomes, this did not reach statistical significance. MIS was associated with prolonged operating times (WMD 67.93, 95% CI 4.43, 131.42, p < 0.00001) however, this correlated with less intra-operative blood loss, and a shorter length of post-operative stay (WMD -3.89, 955 CI -6.53, -1.25, p < 0.00001). Readmission rates were higher with MIS (RR 2.11, 95% CI 1.11, 4.02, p = 0.02), however, rates of pelvic abscess/sepsis were decreased (RR 0.45, 95% CI 0.21, 0.95, p = 0.04), and there was no difference in overall, major, or specific morbidity and mortality. CONCLUSION MIS approaches are a safe and feasible option for PE, with no differences in survival or recurrence outcomes compared to the open approach. MIS also reduced the length of post-operative stay and decreased blood loss, offset by increased operating time.
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Affiliation(s)
- Odhrán K Ryan
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Katie L Doogan
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Éanna J Ryan
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland.
| | - Mark Donnelly
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Ian S Reynolds
- Department of Surgery, Royal College of Surgeons in Ireland, 123. St. Stephen's Green, Dublin 2, Ireland
| | - Ben Creavin
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Matthew G Davey
- Department of Surgery, Royal College of Surgeons in Ireland, 123. St. Stephen's Green, Dublin 2, Ireland
| | - Michael E Kelly
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Rory Kennelly
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland; Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ann Hanly
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland; Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland; Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland; Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland; School of Medicine, University College, Dublin, Dublin 4, Ireland
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Fleming CA, Harji D, Salut C, Cauvin T, Robert G, Denost Q. Robotic-assisted soft-tissue pelvic exenteration for primary and recurrent pelvic tumours: IDEAL stage 2a evaluation. Br J Surg 2023; 110:923-926. [PMID: 36441181 DOI: 10.1093/bjs/znac422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 07/20/2023]
Affiliation(s)
| | - Deena Harji
- Department of Colorectal Surgery, CHU, Bordeaux, France
| | | | - Thomas Cauvin
- Department of Colorectal Surgery, CHU, Bordeaux, France
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
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Rajendran S, Nguyen CL, Brown KGM, Solomon MJ. The evolution of oncovascular pelvic surgery: A historical perspective. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1314-1316. [PMID: 36690534 DOI: 10.1016/j.ejso.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/08/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
Pelvic exenteration surgery has evolved dramatically in recent decades and now represents the standard of care for many patients with advanced pelvic malignancy. Most recently the use of complex vascular resection and reconstructive techniques have been applied in advanced pelvic oncology surgery at specialist units and these oncovascular techniques are considered one of the frontiers in this field. This article summaries the historical evolution of oncovascular surgery in the pelvis and sets the scene for where this treatment is going. The role of vascular resection and reconstruction in curative treatment of advanced pelvic malignancy is an evolving area that is redefining the boundaries of what was historically thought possible.
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Affiliation(s)
- Saissan Rajendran
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; University of Sydney, New South Wales, Australia
| | - Chu Luan Nguyen
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, New South Wales, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; The Institute of Academic Surgery at RPA, Sydney, Australia; University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; The Institute of Academic Surgery at RPA, Sydney, Australia; University of Sydney, New South Wales, Australia.
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32
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Stelzner S, Heinze T, Heimke M, Gockel I, Kittner T, Brown G, Mees ST, Wedel T. Beyond Total Mesorectal Excision: Compartment-based Anatomy of the Pelvis Revisited for Exenterative Pelvic Surgery. Ann Surg 2023; 278:e58-e67. [PMID: 36538640 DOI: 10.1097/sla.0000000000005715] [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: 11/26/2022]
Abstract
OBJECTIVE Magnetic resonance imaging-based subdivision of the pelvis into 7 compartments has been proposed for pelvic exenteration. The aim of the present anatomical study was to describe the topographic anatomy of these compartments and define relevant landmarks and surgical dissection planes. BACKGROUND Pelvic anatomy as it relates to exenterative surgery is complex. Demonstration of the topographic peculiarities of the pelvis based on the operative situs is hindered by the inaccessibility of the small pelvis and the tumor bulk itself. MATERIALS AND METHODS Thirteen formalin-fixed pelvic specimens were meticulously dissected according to predefined pelvic compartments. Pelvic exenteration was simulated and illustrated in a stepwise manner. Different access routes were used for optimal demonstration of the regions of interest. RESULTS All the 7 compartments (peritoneal reflection, anterior above peritoneal reflection, anterior below peritoneal reflection, central, posterior, lateral, inferior) were investigated systematically. The topography of the pelvic fasciae and ligaments; vessels and nerves of the bladder, prostate, uterus, and vagina; the internal iliac artery and vein; the course of the ureter, somatic (obturator nerve, sacral plexus), and autonomic pelvic nerves (inferior hypogastric plexus); pelvic sidewall and floor, ischioanal fossa; and relevant structures for sacrectomy were demonstrated. CONCLUSIONS A systematic approach to pelvic anatomy according to the 7 magnetic resonance imaging-defined compartments clearly revealed crucial anatomical landmarks and key structures facilitating pelvic exenterative surgery. Compartment-based pelvic anatomy proved to be a sound concept for beyond TME surgery and provides a basis for tailored resection procedures.
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Affiliation(s)
- Sigmar Stelzner
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Tillmann Heinze
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
| | - Marvin Heimke
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Thomas Kittner
- Department of Radiology, Dresden-Friedrichstadt General Hospital, Dresden, Germany
| | - Gina Brown
- Department of Surgery and Cancer, Gastrointestinal Imaging, Imperial College, London, UK
| | - Sören T Mees
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Dresden, Germany
| | - Thilo Wedel
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
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Palma CA, van Kessel CS, Solomon MJ, Leslie S, Jeffery N, Lee PJ, Austin KKS. Bladder preservation or complete cystectomy during pelvic exenteration of patients with locally advanced or recurrent rectal cancer, what should we do? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1250-1257. [PMID: 36658054 DOI: 10.1016/j.ejso.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/15/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023]
Abstract
INTRODUCTION In patients with locally advanced (LARC) or locally recurrent (LRRC) rectal cancer and bladder involvement, pelvic exenteration (PE) with partial (PC) or radical (RC) cystectomy can potentially offer a cure. The study aim was to compare PC and RC in PE patients in terms of oncological outcome, post-operative complications and quality-of-life (QoL). MATERIALS & METHODS This was a retrospective cohort analysis of a prospectively maintained surgical database. Patients who underwent PE for LARC or LRRC cancer with bladder involvement between 1998 and 2021 were included. Post-operative complications and overall survival were compared between patients with PC and RC. RESULTS 60 PC patients and 269 RC patients were included. Overall R0 resection was 84.3%. Patients with LRRC and PC had poorest oncological outcome with 69% R0 resection; patients with LARC and PC demonstrated highest R0 rate of 96.3% (P = 0.008). Overall, 1-, 3- and 5-year OS was 90.8%, 68.1% and 58.6% after PC, and 88.7%, 62.2% and 49.5% after RC. Rates of urinary sepsis or urological leaks did not differ between groups, however, RC patients experienced significantly higher rates of perineal wound- and flap-related complications (39.8% vs 25.0%, P = 0.032). CONCLUSION PC as part of PE can be performed safely with good oncological outcome in patients with LARC. In patients with LRRC, PC results in poor oncological outcome and a more aggressive surgical approach with RC seems justified. The main benefit of PC is a reduction in wound related complications compared to RC, although more urological re-interventions are observed in this group.
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Affiliation(s)
- Catalina A Palma
- Department of Urology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Charlotte S van Kessel
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery at RPA, Sydney, Australia; University of Sydney, New South Wales, Australia.
| | - Scott Leslie
- Institute of Academic Surgery at RPA, Sydney, Australia; University of Sydney, New South Wales, Australia; Department of Urology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Nicola Jeffery
- Department of Urology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter J Lee
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; University of Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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Saravanabavan S, Kazi M, Murugan J, Vispute T, Vijayakumaran P, Desouza A, Saklani A. Outcomes of extended total mesorectal excision in patients with locally advanced rectal cancer. Colorectal Dis 2023. [PMID: 37246309 DOI: 10.1111/codi.16606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 04/09/2023] [Accepted: 04/25/2023] [Indexed: 05/30/2023]
Abstract
AIM Extended total mesorectal excision (eTME) is a complex procedure involving en bloc resection of the structures surrounding the various quadrants of the rectum. This study, presenting the largest series so far of patients undergoing eTME, aimed to assess the surgical and survival outcomes of patients following treatment with eTME and to compare these outcomes with historical data on pelvic exenteration. METHOD The study is a retrospective review of all patients with locally advanced rectal cancer requiring an eTME (2014-2020). The database includes the demographic profile, operative details, histopathological features and follow-up. RESULTS One hundred and sixty three patients who underwent eTME were analysed. The overall Clavien-Dindo complication rate of > IIIa was 21.1%. The anterior quadrant was the most common anatomical site resected (68.5%). The R1 resection rate was 10.4%. After a median follow-up of 28 months, there were 51 recurrences in the study and twenty two deaths were recorded. The local recurrence rate was 7.3% among the study population. The disease-free survival (DFS) and overall survival were 66.7% and 80.4%, respectively, at 3 years. The majority of the recurrences were distant metastasis (84.3%). In univariate analysis, the quadrant involved did not affect survival. In multivariate analysis, signet ring histology, metastatic presentation, inadequate tumour response and R1 resection affected DFS. CONCLUSION The recurrence pattern, R1 resection rate and survival outcomes of patients in the present study were comparable with those for patients undergoing an exenteration. Therefore, eTME is probably a safe alternative to pelvic exenterations when R0 resection is achievable and when the procedure is performed in high-volume specialist tertiary care centres.
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Affiliation(s)
- Srivishnu Saravanabavan
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Janesh Murugan
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Tejas Vispute
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Preeti Vijayakumaran
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
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Ouyang Y, Zhu Y, Chen H, Li G, Hu X, Luo H, Li Z, Han S. Case Report: Long-term survival of a patient with advanced rectal cancer and multiple pelvic recurrences after seven surgeries. Front Oncol 2023; 13:1169616. [PMID: 37256170 PMCID: PMC10225707 DOI: 10.3389/fonc.2023.1169616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/04/2023] [Indexed: 06/01/2023] Open
Abstract
Background Rectal cancer has a high risk of recurrence and metastasis, with median survival ranging from 24 months to 36 months. K-RAS mutation is a predictor of poor prognosis in rectal cancer. Advanced rectal cancer can be stopped in its tracks by pelvic exenteration. Case summary A 51-year-old woman was diagnosed with advanced rectal cancer (pT4bN2aM1b, stage IV) with the KRAS G12D mutation due to a change in bowel habits. The patient had experienced repeated recurrences of rectal cancer after initial radical resection, and the tumor had invaded the ovaries, sacrum, bladder, vagina and anus. Since the onset of the disease, the patient had undergone a total of seven surgeries and long-term FOLFIRI- or XELOX-based chemotherapy regimens, with the targeted agents bevacizumab and regorafenib. Fortunately, the patient was able to achieve intraoperative R0 resection in almost all surgical procedures and achieve tumor-free survival after pelvic exenteration. The patient has been alive for 86 months since her diagnosis. Conclusions Patients with advanced rectal cancer can achieve long-term survival through active multidisciplinary management and R0 surgery.
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Affiliation(s)
- Ye Ouyang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yilin Zhu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Haoyi Chen
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Guoquan Li
- Department of General Surgery, Guangdong Province Huizhou Sixth Hospital, Huizhou, China
| | - Xiongwei Hu
- Department of General Surgery, Guangdong Province Huizhou Sixth Hospital, Huizhou, China
| | - Hongyu Luo
- Department of General Surgery, Guangdong Province Huizhou Sixth Hospital, Huizhou, China
| | - Zhou Li
- Department of Gastrointestinal Surgery, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shuai Han
- Department of Gastrointestinal Surgery, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Bedrikovetski S, Traeger L, Jay AA, Oehler MK, Cho J, Wagstaff M, Vather R, Sammour T. Is preoperative sarcopenia associated with postoperative complications after pelvic exenteration surgery? Langenbecks Arch Surg 2023; 408:173. [PMID: 37133529 PMCID: PMC10156810 DOI: 10.1007/s00423-023-02913-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/26/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE Pelvic exenteration (PE) involves radical surgical resection of pelvic organs and is associated with considerable morbidity. Sarcopenia is recognised as a predictor of poor surgical outcomes. This study aimed to determine if preoperative sarcopenia is associated with postoperative complications after PE surgery. METHODS This retrospective study included patients who underwent PE with an available preoperative CT scan between May 2008 and November 2022 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia. Total Psoas Area Index (TPAI) was estimated by measuring the cross-sectional area of the psoas muscles at the level of the third lumbar vertebra on abdominal CT, normalised for patient height. Sarcopenia was diagnosed based on gender-specific TPAI cut-off values. Logistic regression analyses were performed to identify risk factors for major postoperative complications with a Clavien-Dindo (CD) grade ≥ 3. RESULTS In total, 128 patients who underwent PE were included, 90 of whom formed the non-sarcopenic group (NSG) and 38 the sarcopenic group (SG). Major postoperative complications (CD grade ≥ 3) occurred in 26 (20.3%) patients. There was no detectable association with sarcopenia and an increased risk of major postoperative complications. Preoperative hypoalbuminemia (P = 0.01) and a prolonged operative time (P = 0.002) were significantly associated with a major postoperative complication on multivariate analysis. CONCLUSION Sarcopenia is not a predictor of major postoperative complications in patients undergoing PE surgery. Further efforts aimed specifically at optimising preoperative nutrition may be warranted.
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Affiliation(s)
- Sergei Bedrikovetski
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, 5E 332, Port Road, Adelaide, South Australia, 5000, Australia.
| | - Luke Traeger
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, 5E 332, Port Road, Adelaide, South Australia, 5000, Australia
| | - Alice A Jay
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, 5E 332, Port Road, Adelaide, South Australia, 5000, Australia
| | - Martin K Oehler
- Department of Gynaecological Oncology, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
- Centre for Cancer Biology, University of South Australia, Adelaide, South Australia, Australia
| | - Jonathan Cho
- Discipline of Obstetrics and Gynaecology, Adelaide Medical School, Robinson Research Institute, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Marcus Wagstaff
- Urology Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ryash Vather
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, 5E 332, Port Road, Adelaide, South Australia, 5000, Australia
- Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, 5E 332, Port Road, Adelaide, South Australia, 5000, Australia
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Gielen AHC, Colier E, Qiu SS, Keymeulen KBMI, Stassen LPS, Melenhorst J. Research highlight: surgical outcomes of gluteal VY plasty after extensive abdominoperineal resection or total pelvic exenteration. Langenbecks Arch Surg 2023; 408:157. [PMID: 37088846 PMCID: PMC10123027 DOI: 10.1007/s00423-023-02896-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/13/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To describe a suitable alternative technique for reconstruction of the pelvic floor after extensive resection. To review our outcomes of gluteal VY plasty in the reconstruction of the pelvic floor after extensive abdominoperineal resection (conventional or extralevator abdominoperineal resection, total pelvic exenteration, or salvage surgery). DESIGN Retrospective cohort study. SETTING An academic hospital and tertiary referral centre for the treatment of locally advanced or locally recurrent rectal cancer, and salvage surgery in The Netherlands. PATIENTS Forty-one consecutive patients who underwent a pelvic floor reconstruction with gluteal VY plasty at Maastricht University Medical Centre between January 2017 and February 2021 were included. The minimum duration of follow-up was 2 years. MAIN OUTCOME MEASURES Perineal herniation is the primary outcome measure. Furthermore, the occurrence of minor and major postoperative complications and long-term outcomes were retrospectively assessed. RESULTS Thirty-five patients (85.4%) developed one or more complications of whom twenty-one patients experienced minor complications and fourteen patients developed major complications. Fifty-seven percent of complications was not related to the VY reconstruction. Six patients (14.6%) recovered without any postoperative complications during follow-up. Three patients developed a perineal hernia. CONCLUSIONS A gluteal VY plasty is a suitable technique for reconstruction of the pelvic floor after extensive perineal resections resulting in a low perineal hernia rate, albeit the complication rate remains high in this challenging group of patients.
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Affiliation(s)
- Anke H C Gielen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
| | - Evie Colier
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Shan S Qiu
- Department of Plastic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Kristien B M I Keymeulen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands.
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands.
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Kazi M, Desouza A, Saklani A. What are the preoperative predictors of a futile pelvic exenteration in rectal cancers? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:633-640. [PMID: 36357296 DOI: 10.1016/j.ejso.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/06/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Early recurrences and deaths after a morbid procedure like pelvic exenteration are devastating events. The present study aimed at determining the incidence and predictors of futile pelvic exenterations. METHODS Consecutive pelvic exenterations for advanced and recurrent rectal adenocarcinomas operated between January 2013 and January 2021 were included with a minimum of six months follow-up. Futility of exenteration was defined as recurrence or death within six months of operation. Multivariate logistic regression was used to define predictors of futility. RESULTS Two-hundred eighty-five patients were included and 61 patients (21.4%) had a futile resection. Poorly differentiated (or signet) histology, presence of lateral pelvic nodes, M1 disease, and the need for pelvic bone resections predicted a futile resection. The probability of futility was 10%, 20%, 35-40%, 55-60%, and >75% when none, one, two, three, and all four of the predictors were present. The model was able to correctly predict futility in 70% of the cases suggesting moderate discrimination, and showed good calibration. CONCLUSIONS Futile pelvic exenterations were observed in one-fifth of patients. Four strong predictors of futility were identified. The risk of early failures was additive when combination of these adverse features was present, and can be used for patient selection and prognostication.
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Affiliation(s)
- Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, India; Homi Bhabha National Institute, Mumbai, 400012, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, India; Homi Bhabha National Institute, Mumbai, 400012, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, India; Homi Bhabha National Institute, Mumbai, 400012, India.
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Reynolds IS, Brown LB. Academic surgery at home and abroad: A guide for students and residents. Am J Surg 2023; 225:442-445. [PMID: 36195504 DOI: 10.1016/j.amjsurg.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/06/2022] [Accepted: 09/13/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Ian S Reynolds
- Department of Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Lawrence B Brown
- Department of General Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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40
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Rajendran S, Brown KGM, Solomon MJ. Oncovascular surgery for advanced pelvic malignancy. Br J Surg 2023; 110:144-149. [PMID: 36427187 DOI: 10.1093/bjs/znac414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/22/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of units with experience in extended radical resections for advanced pelvic tumours has grown substantially in recent years. The use of complex vascular resections and reconstructive techniques in these units is expected to increase with experience. This review aimed to provide a cutting-edge overview of this evolving surgical approach to complex pelvic tumours with vascular involvement. METHODS This was a narrative review of published data on major vascular resection and reconstruction for advanced pelvic tumours, including preoperative evaluation, techniques used, and outcomes. Advice for treatment decisions is provided, and based on current literature and the personal experience of the authors. Current controversies and future directions are discussed. RESULTS Major vascular resection and reconstruction during surgery for advanced pelvic tumours is associated with prolonged operating time (510-678 min) and significant blood loss (median 2-5 l). R0 resection can be achieved in 58-82 per cent at contemporary specialist units. The risk of major complications is similar to that of extended pelvic resection without vascular involvement (30-40 per cent) and perioperative mortality is acceptable (0-4 per cent). Long-term survival is achievable in approximately 50 per cent of patients. CONCLUSION En bloc resection of the common or external iliac vessels during exenterative pelvic surgery is a feasible strategy for patients with advanced tumours which infiltrate major pelvic vascular structures. Oncological, morbidity, and survival outcomes appear comparable to more central pelvic tumours. These encouraging outcomes, combined with an increasing interest in extended pelvic resections globally, will likely lead to more exenteration units developing oncovascular experience.
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Affiliation(s)
- Saissan Rajendran
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Carvalho F, Qiu S, Panagi V, Hardy K, Tutcher H, Machado M, Silva F, Dinen C, Lane C, Jonroy A, Knox J, Worley L, Whibley J, Perren T, Thain J, McPhail J. Total Pelvic Exenteration surgery - Considerations for healthcare professionals. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:225-236. [PMID: 36030135 DOI: 10.1016/j.ejso.2022.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/22/2022] [Accepted: 08/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Associated with considerable risk of morbidity, Total Pelvic Exenteration (TPE) is a life-altering procedure involving a significant prolonged recovery. As a result, and with the view of achieving the best outcomes and lessen short and long-term morbidities, a well-thought-out and coordinated multidisciplinary team approach, is crucial to the provision of safe and high-quality care. METHOD Using a nominal group technique and qualitative methodology, this article explores the current practices in the care of oncology patients who undergo TPE surgery, in a tertiary cancer centre, by highlighting considerations of a collaboratively multi-disciplinary team. RESULTS This article provides guidance on the multi-disciplinary team approach, relating to TPE surgery, with discussion of clinical concerns, and with the goal of high patient satisfaction, provision of effective care and the lessening of short and long-term morbidities. CONCLUSION Oncology patients that undergo TPE surgery benefit from the contribution of a diversified multidisciplinary team as skilled and competent care that meets patient's health and social care needs is provided in a holistic, comprehensive, and timely care manner. Improving patient's care, pathway and postoperative outcomes, with the use of clinical expertise and support from professionals in the multidisciplinary team, can maximise care.
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Affiliation(s)
- Filipe Carvalho
- The Royal Marsden Hospital NHS Foundation Trust, London, UK.
| | - Shengyang Qiu
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Vasia Panagi
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Katy Hardy
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Hannah Tutcher
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Marta Machado
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | | | - Caroline Dinen
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Carol Lane
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Alleh Jonroy
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Jon Knox
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Lynn Worley
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | | | - Tobias Perren
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Jane Thain
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
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Johnstone CSH, Roberts D, Mathieson S, Steffens D, Koh CE, Solomon MJ, McLachlan AJ. Pain, pain management and related outcomes following pelvic exenteration surgery: a systematic review. Colorectal Dis 2022; 25:562-572. [PMID: 36572393 DOI: 10.1111/codi.16462] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/30/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
AIM Pelvic exenteration surgery can improve survival in people with advanced colorectal cancer. This systematic review aimed to review pain intensity and other outcomes, for example the management of pain, the relationship between pain and the extent of surgery and the impact of pain on short-term outcomes. METHOD Electronic databases were searched from inception to 1 May 2021. We included interventional studies of adults with any indication for pelvic exenteration surgery that also reported pain outcomes. Risk of bias was assessed using ROBINS-1. RESULTS The search found 21 studies that reported pain following pelvic exenteration [n = 1317 patients, mean age 58.4 years (SD 4.8)]. Ten studies were judged to be at moderate risk of bias. Before pelvic exenteration, pain was reported by 19%-100% of patients. Five studies used validated measures of pain intensity. No study measured pain at all three time points in the surgical journey. The presence of pain before surgery predicted postoperative adverse pain outcomes, and pain is more likely to be experienced in those who require wider resections, including bone resection. CONCLUSION Considering that pain following pelvic exenteration is commonly described by patients, the literature suggests that this symptom is not being measured and therefore addressed.
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Affiliation(s)
- Charlotte S H Johnstone
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Roberts
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
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Fitzsimmons T, Thomas M, Tonkin D, Murphy E, Hollington P, Solomon M, Sammour T, Luck A. Establishing a state-wide pelvic exenteration multidisciplinary team meeting in South Australia. ANZ J Surg 2022; 93:1227-1231. [PMID: 36567641 DOI: 10.1111/ans.18220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/04/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pelvic exenteration surgery is complex, necessitating co-ordinated multidisciplinary input and improved referral pathways. A state-wide pelvic exenteration multidisciplinary team (MDT) meeting was established in SA and the outcomes of this were audited and compared with historical data. METHODS All patients referred for discussion between August 2021 and July 2022 to the SA State-wide Pelvic Exenteration MDT were included in this study. MDT discussion centred around disease resectability, risk versus benefit of surgery, and need for local or interstate referral. Prospective data collection included patient demographics and MDT recommendations of surgery, palliation, or referral. Patients referred for surgery locally or interstate were compared with a retrospective patient cohort treated previously between January and December 2020. RESULTS Over 12 months, 91 patients were discussed (including nine multiple times), by a mean of 18 meeting participants each month. Forty-eight patients (58.5%) had primary malignancy, 25 (30.5%) recurrent malignancy, and 9 (11.0%) had non-malignant disease. Colorectal cancer was the most common presentation (56.1%), followed by gynaecological (30.5%) and urological (6.1%) malignancy. Pelvic exenteration surgery was recommended to be performed locally in 53.7% of patients and the remainder for non-surgical treatment, palliation, or re-discussion. During this time, 44 patients underwent surgery locally (versus 34 in 2020) and only 4 referred interstate (versus 8 in 2020). CONCLUSION The establishment of a dedicated state-wide pelvic exenteration MDT has resulted in better coordination of care for patients with locally advanced pelvic malignancy in SA, and significantly reduced the need for interstate referral.
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Affiliation(s)
- Tracy Fitzsimmons
- Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michelle Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Darren Tonkin
- Colorectal Unit, Department of Surgery, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Elizabeth Murphy
- Colorectal Unit, Division of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Paul Hollington
- Flinders Medical Centre, Division of Surgery and Perioperative Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Tarik Sammour
- Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Andrew Luck
- Colorectal Unit, Division of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
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Khan M, Wilkerson H, Vassos N, Hannay JA, Thway K, Messiou C, Hayes AJ, Strauss DC, Smith MJ. Oncologic outcomes of surgically managed primary pelvic soft tissue sarcoma; tumour biology or surgical constraints of the true pelvis? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 49:941-949. [PMID: 36566120 DOI: 10.1016/j.ejso.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/06/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pelvic soft tissue sarcomas are rare. Potentially curative resection remains challenging due to anatomical constraints of true pelvis and tumour spread through various anatomical hiatus. We sought to review the oncological outcomes of surgically managed cases at our centre and determine whether outcomes differ for patients with localised (limited to pelvis) versus extensive disease (with extra-pelvic extension). METHODS Sixty-seven patients who underwent surgical resection with curative intent at the centre for primary, non-metastatic, WHO intermediate to high-grade soft tissue sarcoma of the true pelvis from January 2012 through January 2020 were analysed. Establishment of the extent of disease was made by review of pre-treatment imaging and surgical notes. Oncologic endpoints examined were resection margin, recurrence rate, disease-free and overall survival. RESULTS Rates of complete oncological resection and disease control were similar for tumours with localised or extensive disease. On logistic regression analysis, tumour grade, and a negative resection margin (R0) correlated with the risk of recurrence (p=<0.05). On further multinomial analysis, R0 resection was associated with improved local control, but not metastatic relapse (p = 0.003). 5-year local recurrence-free and distant metastasis-free survival were 61.3% and 67.1%, respectively. Five and 10-year overall survival were 64% and 36%, respectively. Age >50 years and high tumour grade were associated with a worse outcome (p < 0.05). CONCLUSIONS When potentially curative surgery is performed for pelvic sarcoma, disease-extent does not influence oncologic outcomes. While a complete oncologic resection determines the risk of local recurrence, tumour grade and metastatic relapse remain primary prognostic determinants for overall survival.
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Affiliation(s)
- Misbah Khan
- The Royal Marsden Hospital NHS Foundation Trust, United Kingdom
| | | | - Nikolaos Vassos
- The Royal Marsden Hospital NHS Foundation Trust, United Kingdom
| | | | - Khin Thway
- The Royal Marsden Hospital NHS Foundation Trust, United Kingdom; The Institute of Cancer Research, United Kingdom
| | - Christina Messiou
- The Royal Marsden Hospital NHS Foundation Trust, United Kingdom; The Institute of Cancer Research, United Kingdom
| | - Andrew J Hayes
- The Royal Marsden Hospital NHS Foundation Trust, United Kingdom; The Institute of Cancer Research, United Kingdom
| | - Dirk Cornelius Strauss
- The Royal Marsden Hospital NHS Foundation Trust, United Kingdom; The Institute of Cancer Research, United Kingdom
| | - Myles Jf Smith
- The Royal Marsden Hospital NHS Foundation Trust, United Kingdom; The Institute of Cancer Research, United Kingdom.
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45
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Minimally invasive surgery for maximally invasive tumors: pelvic exenterations for rectal cancers. JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:131-138. [PMID: 36601490 PMCID: PMC9763485 DOI: 10.7602/jmis.2022.25.4.131] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 12/23/2022]
Abstract
Purpose Trials comparing minimally invasive rectal surgery have uniformly excluded T4 tumors. The present study aimed to determine the safety of minimally invasive surgery (MIS) for locally-advanced rectal cancers requiring pelvic exenterations based on benchmarked outcomes from the international PelvEx database. Methods Consecutive patients of T4 rectal cancers with urogenital organ invasion that underwent MIS exenterations between November 2015 and June 2022 were analyzed from a single center. A safety threshold was set at 20% for R1 resections and 40% for major complications (≥grade IIIA) for the upper limit of the 95% confidence interval (CI). Results The study included 124 MIS exenterations. A majority had a total pelvic exenteration (74 patients, 59.7%). Laparoscopic surgery was performed in 95 (76.6%) and 29 (23.4%) had the robotic operation. Major complications were observed in 35 patients (28.2%; 95% CI, 20.5%-37.0%). R1 resections were found pathologically in nine patients (7.3%; 95% CI, 3.4%-13.4%). The set safety thresholds were not crossed. At a median follow-up of 15 months, 44 patients (35.5%) recurred with 8.1% local recurrence rate. The 2-year overall and disease-free survivals were 85.2% and 53.7%, respectively. Conclusion MIS exenterations for locally-advanced rectal cancers demonstrated acceptable morbidity and safety in term of R0 resections at experienced centers. Longer follow-up is required to demonstrate cancer survival outcomes.
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46
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Minimum radial margin in pelvic exenteration for locally advanced or recurrent rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2502-2508. [PMID: 35768314 DOI: 10.1016/j.ejso.2022.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/27/2022] [Accepted: 06/13/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to clarify the suitable radial margin (RM) for favourable outcomes after pelvic exenteration (PE), focusing on the discrepancy between the concepts of circumferential resection margin (CRM) and traditional R status. METHODS Seventy-three patients with locally advanced (LARC, n = 24) or locally recurrent rectal cancer (LRRC, n = 49) who underwent PE between 2006 and 2018 were retrospectively analysed. Patients were histologically classified into the following 3 groups; wide RM (≥1 mm, n = 45), narrow RM (0-1 mm, n = 10), and exposed RM (n = 18). The analysis was performed not only in the entire cohort but also in each disease group separately. RESULTS The rates of traditional R0 (RM > 0 mm) and wide RM were 75.3% and 61.6%, respectively, resulting in the discrepancy rate of 13.7% between the two concepts. Preoperative radiotherapy was given in 12.3%. In the entire cohort, the local recurrence and overall survival (OS) rates for narrow RMs were significantly worse than those for wide RMs (p < 0.001 and p = 0.002), but were similar to those for exposed RMs. In both LARC and LRRC, RM < 1 mm resulted in significantly worse local recurrence and OS rates compared to the wide RMs. Multivariate analysis showed that RM < 1 mm was an independent risk factor for local recurrence in both LARC (HR 15.850, p = 0.015) and LRRC (HR 4.874, p = 0.005). CONCLUSIONS Narrow and exposed RMs had an almost equal impact on local recurrence and poor OS after PE. Preoperative radiotherapy might have a key role to ensure a wide RM.
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47
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Sutton PA, Brown KGM, Ebrahimi N, Solomon MJ, Austin KKS, Lee PJ. Long-term surgical complications following pelvic exenteration: Operative management of the empty pelvis syndrome. Colorectal Dis 2022; 24:1491-1497. [PMID: 35766998 DOI: 10.1111/codi.16238] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 01/07/2023]
Abstract
AIM Pelvic exenteration (PE) has become the standard of care for locally advanced and recurrent rectal cancer. The high short-term morbidity reported from this procedure is well established; however, longer term complications of such radical surgery and their management have not been fully addressed. This study aimed to investigate the incidence, indications and outcomes of long-term (more than 90-day) reoperative surgery in this group of patients, with a focus on the empty pelvis syndrome (EPS). METHODS Clinical data were extracted from a prospectively maintained database, with additional data pertaining to indications, operative details and outcomes of reoperative surgery obtained from electronic medical records. Patients were excluded if reoperative surgery was endoscopic or radiologically guided, was for the investigation or treatment of recurrent disease, or was clearly unrelated to previous surgery. RESULTS Of 716 patients who underwent PE, 75 (11%) required 101 reoperative abdominal or perineal procedures, 52 (51%) of which were in 40 (6%) patients for complications of EPS. This group were more likely to have undergone a total PE (65% vs. 43%; P < 0.01) with either major bony (70% vs. 50%; P < 0.01) and/or nerve (40% vs. 25%; P = 0.03) resections at index exenteration. The patho-anatomy, surgical management and outcomes of these patients are described herein, considering separately complications of entero-cutaneous fistula, entero-perineal fistula, small bowel obstruction and local management of perineal wound complications. CONCLUSION Six per cent of PE patients will require re-intervention for the management of EPS. Reliable strategies for preventing EPS remain elusive; however, surgical management is feasible with acceptable short-term outcomes with the optimum strategy to be selected on an individual patient basis.
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Affiliation(s)
- Paul A Sutton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Colorectal and Peritoneal Oncology Centre, The Christie Hospital, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Nargus Ebrahimi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
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48
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Apte SS, Cohen LCL, Larach JT, Mohan HM, Snow HA, Wagner T, McCormick JJ, Warrier SK, Gyorki DE, Waters PS, Heriot AG. Major vascular reconstruction in colorectal adenocarcinoma and retroperitoneal sarcoma: A retrospective study of safety and margins in a tertiary referral centre. Surg Oncol 2022; 45:101871. [DOI: 10.1016/j.suronc.2022.101871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/18/2022] [Accepted: 10/03/2022] [Indexed: 12/03/2022]
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49
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Fahy MR, Kelly ME, Aalbers AGJ, Abdul Aziz N, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alberda W, Albert M, Andric M, Angeles MA, Angenete E, Antoniou A, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Beynon J, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelan W, Chan KKL, Chang GJ, Chang M, Chew MH, Chok AY, Chong P, Clouston H, Codd M, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovich L, Daniels IR, Davies M, Delaney CP, de Wilt JHW, Denost Q, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Eglinton T, Enriquez-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fearnhead NS, Ferron G, Flatmark K, Fleming FJ, Flor B, Folkesson J, Frizelle FA, Funder J, Gallego MA, Gargiulo M, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther DN, Glyn T, Glynn R, Golda T, Griffiths B, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kazi M, Kelley SR, Keller DS, Ketelaers SHJ, Khan MS, Kiran RP, Kim H, Kim HJ, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kristensen HØ, Kroon HM, Kumar S, Kusters M, Lago V, Lampe B, Lakkis Z, Larach JT, Larkin JO, Larsen SG, Larson DW, Law WL, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Maciel J, Manfredelli S, Mann C, Mantyh C, Mathis KL, Marques CFS, Martinez A, Martling A, Mehigan BJ, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, Mikalauskas S, McArthur DR, McCormick JJ, McCormick P, McDermott FD, McGrath JS, Malde S, Mirnezami A, Monson JRT, Navarro AS, Negoi I, Neto JWM, Ng JL, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, Nugent T, Oliver A, O’Dwyer ST, O’Sullivan NJ, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock O, Pellino G, Peterson AC, Pinson J, Poggioli G, Proud D, Quinn M, Quyn A, Rajendran N, Radwan RW, Rajendran N, Rao C, Rasheed S, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Selvasekar C, Shaikh I, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Sorrentino L, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Spasojevic M, Sumrien H, Sutton PA, Swartking T, Takala H, Tan EJ, Taylor C, Tekin A, Tekkis PP, Teras J, Thaysen HV, Thurairaja R, Thorgersen EB, Toh EL, Tsarkov P, Tsukada Y, Tsukamoto S, Tuech JJ, Turner WH, Tuynman JB, Valente M, van Ramshorst GH, van Zoggel D, Vasquez-Jimenez W, Vather R, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Urrejola G, Wakeman C, Warrier SK, Wasmuth HH, Waters PS, Weber K, Weiser MR, Wheeler JMD, Wild J, Williams A, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline. Br J Surg 2022; 109:1251-1263. [PMID: 36170347 DOI: 10.1093/bjs/znac317] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/18/2022] [Accepted: 08/18/2022] [Indexed: 12/31/2022]
Abstract
This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.
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Kazi M, Desouza A, Bankar S, Jajoo B, Dohale S, Vadodaria D, Ghadi A, Ghandade N, Vasudevan L, Nashikkar C, Saklani A. The use of an obstetric balloon as a pelvic spacer in preventing empty pelvis syndrome after total pelvic exenteration in rectal cancers - A prospective safety and efficacy study for the Bakri balloon. Colorectal Dis 2022; 25:616-623. [PMID: 36408669 DOI: 10.1111/codi.16424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/22/2022]
Abstract
AIM Empty pelvis syndrome (EPS) is a source of considerable morbidity following total pelvic exenteration. None of the available methods have been universally successful in mitigating this problem. The aim of this work was to evaluate the safety and efficacy of the obstetric Bakri balloon in preventing empty pelvis syndrome. METHOD This study was a combined prospective and retrospective study of all total pelvic exenterations for rectal cancers from a single institution performed between October 2013 and May 2022. Since December 2019 the Bakri balloon was used in all patients who provided consent. EPS within 90 days was the primary end point, and included bowel obstruction, pelvic collection and entero-perineal fistula. Comparison with those patients who did not have a Bakri balloon was performed. RESULTS Seventy-five patients with a Bakri balloon were compared with 96 patients without a balloon placed after pelvic exenteration. No patient experienced an untoward complication from balloon deployment. The incidence of EPS was 13.3% and 22.9% in the Bakri and no Bakri cohorts, respectively (p = 0.110). Every component of EPS was proportionally lower, without statistical significance. Based on point estimates, the number needed to treat to prevent EPS using the Bakri balloon was 10. CONCLUSIONS Use of the Bakri balloon was safe without serious adverse events. The incidence of EPS after total pelvic exenteration was not statistically different with the use of the Bakri balloon despite a 9.6% reduction. A larger comparative study is needed to evaluate the efficacy of the balloon.
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Affiliation(s)
- Mufaddal Kazi
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Ashwin Desouza
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Sanket Bankar
- Department of Surgical Oncology, Dr D. Y. Patil Medical College Hospital and Research Centre, Pimpri, Pune, India.,Dr D. Y. Patil Vidyapeeth, Pune, India
| | - Bhushan Jajoo
- Division of Surgical Oncology, SGM Cancer Hospital, Swangi, Wardha, India
| | - Sayali Dohale
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | - Divya Vadodaria
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | - Aayushi Ghadi
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | - Netra Ghandade
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | | | | | - Avanish Saklani
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
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