1
|
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: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
2
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
3
|
Johnson YL, West MA, Gould LE, Drami I, Behrenbruch C, Burns EM, Mirnezami AH, Jenkins JT. Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications. Colorectal Dis 2022; 24:16-26. [PMID: 34653292 DOI: 10.1111/codi.15956] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/12/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
AIM Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis. METHOD The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted. RESULTS Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2 years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%). CONCLUSION The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.
Collapse
Affiliation(s)
- Yanika L Johnson
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
| | - Malcolm A West
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
- Complex Cancer Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | - Laura E Gould
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | - Ioanna Drami
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | | | | | - Alexander H Mirnezami
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
- Complex Cancer Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | | |
Collapse
|
4
|
Bankar S, Desouza A, Paliwal V, Pandey D, Gori J, Sukumar V, Rohila J, Saklani A. Novel use of the Bakri balloon to minimize empty pelvis syndrome following laparoscopic total pelvic exenteration. Colorectal Dis 2020; 22:2322-2325. [PMID: 32810348 DOI: 10.1111/codi.15319] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/11/2020] [Indexed: 12/21/2022]
Abstract
AIM Pelvic exenteration is the only surgical option for locally advanced pelvic malignancies infiltrating the surrounding organs. The resultant pelvic void after the procedure is responsible for a number of complications, collectively termed empty pelvis syndrome (EPS). We aim to show how EPS can be minimized by presenting a case series demonstrating the surgical technique of laparoscopic total pelvic exenteration with bilateral pelvic node dissection along with a novel use of the Bakri balloon. METHOD This is a case series of three successive patients undergoing laparoscopic total pelvic exenteration for locally advanced primary, nonmetastatic rectal adenocarcinoma over a period of 1 month in a specialized colorectal unit at a tertiary cancer centre. The Bakri balloon was deployed in all three patients and retained for variable time intervals postoperatively. Features of EPS were prospectively documented. RESULTS In the first patient, the Bakri balloon was completely deflated and removed on postoperative day (POD) 5. The patient developed subacute intestinal obstruction which resolved with conservative management by POD 12. In the second and third patients, the Bakri balloon was deflated in a sequential manner, beginning on POD 8, until it was finally removed on POD 11. Neither of these patients had any abdominal complaints. A postoperative CT scan of both these patients showed the small bowel loops clearly above the pelvic inlet. CONCLUSIONS The Bakri balloon is a simple, safe and cost-effective method to reduce the complications of EPS following laparoscopic total pelvic exenteration. A prospective study is ongoing to objectively quantify the benefits of this technique.
Collapse
Affiliation(s)
- S Bankar
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - A Desouza
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - V Paliwal
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - D Pandey
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - J Gori
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - V Sukumar
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - J Rohila
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - A Saklani
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| |
Collapse
|
5
|
Tuech JJ, Pinson J, Nouhaud FX, Wood G, Clavier T, Sabourin JC, Di Fiore F, Monge M, Papet E, Coget J. Total Pelvic Exenteration, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy for Rectal Cancer with Associate Peritoneal Metastases: Surgical Strategies to Optimize Safety. Cancers (Basel) 2020; 12:cancers12113478. [PMID: 33238384 PMCID: PMC7700214 DOI: 10.3390/cancers12113478] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment for patients with peritoneal carcinomatosis. Pelvic exenteration is an established treatment option for locally advanced pelvic malignancy. Based on the argument that high-risk complications arise from each procedure, the majority of researchers do not recommend performing a CRS/HIPEC with pelvis exenteration. Herein, we critically analyzed the data from 16 patients treated by these two procedures for 15 rectal and one appendiceal adenocarcinomas. Clear resection (R0) margins were achieved in 81.2% of cases. The median hospital stay was 46 days (26–129), and nine patients (56.2%) experienced severe complications that led to death in two cases (12.5%). Survival rates were not clarified, since the follow-up is ongoing. Pelvis exenteration associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC if a R0 resection could be achieved. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended. Abstract Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment option for patients with peritoneal carcinomatosis. Total pelvic exenteration (TPE) is an established treatment option for locally advanced pelvic malignancy. These two procedures have high mortality and morbidity, and therefore, their combination is not currently recommended. Herein, we reported our experience on TPE associated with CRS/HIPEC with a critical analysis for rectal cancer with associate peritoneal metastases. Methods: From March 2006 to August 2020, 319 patients underwent a CRS/HIPEC in our hospital. Among them, 16 (12 men and four women) underwent an associated TPE. The primary endpoints were perioperative morbidity and mortality. Results: There was locally recurrent rectal cancer in nine cases, six locally advanced primary rectal cancer, and a recurrent appendiceal adenocarcinoma. The median Peritoneal Cancer Index (PCI) was 8. (4–16). Mean duration of the surgical procedure was 596 min (420–840). Complete cytoreduction (CC0) was achieved in all patients, while clear resection (R0) margins on the resected pelvic organs were achieved in 81.2% of cases. The median hospital stay was 46 days (26–129), and nine patients (56.2%) experienced severe complications (grade III to V) that led to death in two cases (12.5%). The total reoperation rate for patients was 6/16 (37.5%) and 3/16 (18.75%) with percutaneous radiological-guided drainage. Conclusions: In summary, TPE/extended TPE (ETPE) associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC in patients with resectable peritoneal surface diseases if a R0 resection could be achieved on all sites. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended.
Collapse
Affiliation(s)
- Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
- Correspondence: ; Tel.: +33-232-888-142; Fax: +33-232-8884
| | - Jean Pinson
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
| | | | - Gregory Wood
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (G.W.); (T.C.)
| | - Thomas Clavier
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (G.W.); (T.C.)
| | - Jean-Christophe Sabourin
- Department of Pathology, Iron Group, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France;
| | - Frederic Di Fiore
- Department of Digestive Oncology, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France;
| | - Matthieu Monge
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
| | - Eloïse Papet
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
| | - Julien Coget
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
| |
Collapse
|
6
|
Carboni F, Federici O, Giofre' M, Zazza S, Valle M. Empty pelvis syndrome: the use of breast prosthesis in the prevention of complications. Colorectal Dis 2019; 21:1321-1325. [PMID: 31230404 DOI: 10.1111/codi.14737] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 06/03/2019] [Indexed: 12/16/2022]
Abstract
AIM Empty pelvis syndrome and radiation-induced bowel injury are two major clinical issues resulting from the pelvic dead space after pelvic exenteration (PE). In order to avoid these complications, different methods of pelvic floor reconstruction have been proposed. We report our experience on the use of breast prosthesis. METHOD Fifty-three patients who underwent PE and three who underwent palliative surgery with silicone breast prosthesis placement were included. RESULTS Forty-seven posterior PE, six total PE and three palliative procedures were identified. Sphincter preservation was feasible in 34 patients (62.3%). There were no deaths. Overall morbidity was 37.5%. There were no complications such as sepsis or obstruction related to the prosthesis. Adjuvant radiotherapy was delivered in 16 cases (30.1%) without any side-effects. Reconstruction of intestinal continuity was possible in 12 patients (36.3%) with sphincter preservation and the prosthesis allowed a prompt identification of the rectal stump. CONCLUSION Breast prosthesis placement is a simple and safe method to minimize complications resulting from empty pelvis syndrome and can be adopted to exclude bowel loops from the radiation field. Reconstruction of intestinal continuity after resection is also simplified.
Collapse
Affiliation(s)
- F Carboni
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - O Federici
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - M Giofre'
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - S Zazza
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - M Valle
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| |
Collapse
|
7
|
Bacalbasa N, Tomescu D, Balescu I. Use of Inflated Foley Catheters to Prevent Early Empty Pelvis Complications Following Pelvic Exenteration. Anticancer Res 2015; 35:5543-5546. [PMID: 26408723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
For most patients with bulky pelvic tumors, pelvic exenteration remains the only curative option. Although initially reported as a palliative procedure, nowadays it is rather performed with curative intent. Once the resectional phase is ended, a large defect will remain at the level of the pelvic diaphragm, predisposing to severe complications which are generically included under the name of empty pelvis syndrome. It has been widely demonstrated that this type of complication is associated with severe mortality, even if the patient is free of any pelvic recurrence. We present the case of a 56-year-old patient submitted to total pelvic exenteration for locally invasive previously chemo-irradiated cervical cancer who presented six months after surgery with a severe enteroperineal fistula. We decided to reoperate on the patient; intraoperatively we found recurrence on both pelvic walls and an enteroperineal fistula caused by tumoral invasion. We performed an intestinal resection with enteroenteral anastomosis. In order to isolate the intestinal loops from the unresectable pelvic recurrence, in the pelvis we placed three Foley catheters inflated with 60 ml of saline each, in order to hold the intestinal loops away from the pelvic wall. The postoperative course was uneventful. The urinary cathethers were removed after six weeks.
Collapse
Affiliation(s)
- Nicolae Bacalbasa
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Dana Tomescu
- Fundeni Clinical Institute, Department of Anaethesia and Critical Care III, Bucharest, Romania
| | | |
Collapse
|