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Surgical Oncology Jun 2021This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone... (Review)
Review
This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone significant evolution over the past decades. Advances in pre-, intra-, and post-operative care have been directed towards achieving the 'holy grail' of an R0 resection, which remains the most important predictor of survival, quality of life, morbidity, and cost effectiveness following PE. Patient selection for surgery is largely determined by assessment of resectability. Pelvic magnetic resonance imaging determines the extent of local disease, while positron emission tomography remains the most accurate tool for exclusion of distant metastases. PE in the setting of metastatic disease or with palliative intent remains controversial. The intra-operative approach is based on the anatomical division of the pelvis into five compartments (anterior, central, posterior, and two lateral). Within each compartment are various possible dissection planes which are elected depending on the extent of tumour involvement. Innovations in surgical technique have allowed 'higher and wider' dissection planes with resultant en bloc excision of major vessels, major nerves, and bone. Evidence of improved R0 resection and survival rates with these techniques justifies the radicality of these novel approaches. Post-operative care for PE patients is technically demanding with a substantial hospital resource burden. Unique considerations for PE patients include the 'empty pelvis syndrome', urological complications, and management of post-operative malnutrition. While undeniably a morbid procedure, quality of life largely returns to baseline at six months, and for long-term survivors is sustained for up to five years.
Topics: Humans; Patient Selection; Pelvic Exenteration; Perioperative Care; Rectal Neoplasms
PubMed: 33799076
DOI: 10.1016/j.suronc.2021.101546 -
Chirurgia (Bucharest, Romania : 1990) Apr 2024Bearing in mind that the open procedure is already validated by multiple studies, the article aims to prove that pelvic exenteration performed in a minimally invasive...
Bearing in mind that the open procedure is already validated by multiple studies, the article aims to prove that pelvic exenteration performed in a minimally invasive fashion might offer better survival and to potentially identify prognostic factors for the outcome of these patients. Material and Data regarding past and present classifications and surgical indications are presented. Patient data were collected retrospectively. The most frequent diseases treated with pelvic exenteration, in terms of the hystological type, were gynecological malignancy and squamous cell carcinoma. Recurrent pelvic disease was found in 68.2% of patients. R0 resection was achieved in 72.7% of patients in the MI group, and in 73.7% of patients in the OP group. Peri-operative morbidity was reported to be 56.6% for open surgery, and 18.1% for minimally invasive. Average DFS was 20.15 months, ranging from 1.5 to 70.3 months, while the OS was calculated to be 38.1 months (0.33 1508) up until November 2023. Conclusion: Pelvic exenteration is a continuously improving surgical procedure, open approach being favored to minimally invasive one. On the other hand, hospitalization and morbidity are reduced when choosing the latter. R0 and lymph node status are important predictors for overall survival, as well as major early postoperative complications. All in all, pelvic exenteration is still a promising surgical procedure to extend cancer patients lives.
Topics: Humans; Pelvic Exenteration; Female; Retrospective Studies; Treatment Outcome; Male; Carcinoma, Squamous Cell; Middle Aged; Aged; Prognosis; Adult; Neoplasm Recurrence, Local; Romania; Genital Neoplasms, Female; Disease-Free Survival; Minimally Invasive Surgical Procedures
PubMed: 38743833
DOI: 10.21614/chirurgia.2024.v.119.i.2.p.201 -
European Journal of Surgical Oncology :... Nov 2022
Topics: Humans; Pelvic Exenteration; Postoperative Complications; Retrospective Studies
PubMed: 36243647
DOI: 10.1016/j.ejso.2022.08.002 -
Journal of Medicine and Life 2015Pelvic exenteration remains one of the most destructive surgical procedures in gynecologic oncology, performed in patients with locally advanced malignancies who were... (Review)
Review
Pelvic exenteration remains one of the most destructive surgical procedures in gynecologic oncology, performed in patients with locally advanced malignancies who were considered for a long time as unresectable. However, for these patients, an aggressive surgical approach seems to be the only potential curative solution. This is a literature review of the most important studies, which analyzes the benefits and the secondary risks of this demanding procedure.
Topics: Female; Genital Neoplasms, Female; Humans; Pelvic Exenteration; Pelvis
PubMed: 25866569
DOI: No ID Found -
European Journal of Surgical Oncology :... Jun 2022Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers...
BACKGROUND
Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers and major postoperative complications including survival.
METHODS
Retrospectively collected data for 195 consecutive patients who underwent total pelvic exenteration (January 2015-February 2020) at a single tertiary university hospital were analyzed.
RESULTS
The 30-day mortality was 0.5%, and the rate of major postoperative complications (≥3 Clavien-Dindo) was 34.5%. Low albumin level (p = 0.02) and blood transfusion (p = 0.02) were significantly correlated with a major postoperative complication in univariate analyses. This had no impact on survival. Positive margins (p = 0.003), liver metastasis (p = 0.001) were related to poor survival in multivariate analyses for colorectal patients. A Charlson Comorbidity Index >6 (p < 0.05) was associated with poor survival in all patients.
CONCLUSION
The occurrence of major postoperative complication does not negatively impact the overall survival. Pelvic exenteration is a potential life-prolonging operation when negative margins can be obtained, despite known risks for complications. Comorbidity is a predictor for inferior outcomes.
Topics: Humans; Morbidity; Neoplasm Recurrence, Local; Pelvic Exenteration; Postoperative Complications; Retrospective Studies
PubMed: 34998633
DOI: 10.1016/j.ejso.2021.12.472 -
ANZ Journal of Surgery Nov 2022Management of advanced or recurrent pelvic cancer has evolved dramatically over the past few decades. Patients who were previously considered inoperable are now... (Review)
Review
Management of advanced or recurrent pelvic cancer has evolved dramatically over the past few decades. Patients who were previously considered inoperable are now candidates for potentially curative surgery and avoid suffering with intractable symptoms. Up to 10% of primary rectal cancers present with isolated advanced local disease and between 10% and 15% of patients develop localized recurrence following proctectomy. Advances in surgical technique, reconstruction and multidisciplinary involvement have led to a reduction in mortality and morbidity and culminated in higher R0 resection rates with superior longer-term survival outcomes. Recent studies boast over 50% 5-year survival for rectal with an R0 resection. Exenteration has cemented itself as an important treatment option for advanced primary/recurrent pelvic tumours, however, there are still a few controversies. This review will discuss some of these issues, including: limitations of resection and the approach to high/wide tumours; the role of acute exenteration; re-exenteration; exenteration in the setting of metastatic disease and palliation; the role of radiotherapy (including intra-operative and re-irradiation); management of the empty pelvis; and the impact on quality of life and function.
Topics: Humans; Pelvic Exenteration; Quality of Life; Rectal Neoplasms; Neoplasm Recurrence, Local; Pelvic Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 35490337
DOI: 10.1111/ans.17734 -
Current Treatment Options in Oncology Apr 2023Pelvic exenteration is a radical surgery, but oftentimes, it is the last curative option for patients with recurrent gynecologic malignancies who have exhausted more... (Review)
Review
Pelvic exenteration is a radical surgery, but oftentimes, it is the last curative option for patients with recurrent gynecologic malignancies who have exhausted more conservative therapies. Mortality and morbidity outcomes have improved over time, but there are still significant peri-operative risks. Considerations before pursing pelvic exenteration must include the likelihood of oncologic cure and patients' fitness to undergo such a procedure, particularly given the high rate of surgical morbidity. Pelvic sidewall tumors have been a traditional contraindication for pelvic exenteration due to the difficulty in obtaining negative margins, but the use of laterally extended endopelvic resection and intra-operative radiation therapy allows for more radical resection of recurrent disease. We believe that these procedures to achieve R0 resection can expand the use of curative-intent surgery in recurrent gynecologic cancer, but require the surgical expertise of colleagues in orthopedic and vascular surgery and collaboration with plastic surgery for complex reconstruction and optimization of post-operative healing. Surgery of recurrent gynecologic cancer including pelvic exenteration, requires careful patient selection, pre-operative medical optimization and prehabilitation, and thorough counseling to optimize outcomes, both oncologic and peri-operative. We believe the creation of a well-developed team, including surgical teams and supportive care services, can lead to the best patient outcomes and improved professional satisfaction amongst providers.
Topics: Pelvic Exenteration; Humans; Female; Genital Neoplasms, Female; Neoplasm Recurrence, Local
PubMed: 36847987
DOI: 10.1007/s11864-023-01055-6 -
Journal of Gynecologic Oncology May 2022Posterior pelvic exenteration (PPE) can be required to achieve complete resection in ovarian cancer (OC) patients with large pelvic disease. This study aimed to analyze...
OBJECTIVE
Posterior pelvic exenteration (PPE) can be required to achieve complete resection in ovarian cancer (OC) patients with large pelvic disease. This study aimed to analyze morbidity, complete resection rate, and survival of PPE.
METHODS
Ninety patients who underwent PPE in our Comprehensive Cancer Center between January 2010 and February 2021 were retrospectively identified. To analyze practice evolution, 2 periods were determined: P1 from 2010 to 2017 and P2 from 2018 to 2021.
RESULTS
A 82.2% complete resection rate after PPE was obtained, with rectal anastomosis in 96.7% of patients. Complication rate was at 30% (grade 3 in 9 patients), without significant difference according to periods or quality of resection. In a binary logistic regression adjusted on age and stoma, only age of 51-74 years old was associated with a lower rate of complication (odds ratio=0.223; p=0.026). Median overall and disease-free survivals (OS and DFS) from initial diagnosis were 75.21 and 29.84 months, respectively. A negative impact on OS and DFS was observed in case of incomplete resection, and on DFS in case of final cytoreductive surgery (FCS: after ≥6 chemotherapy cycles). Age ≥75-years had a negative impact on DFS for new OC surgery. For patients with complete resection, OS and DFS were decreased in case of interval cytoreductive surgery and FCS in comparison with primary cytoreductive surgery.
CONCLUSION
PPE is an effective surgical measure to achieve complete resection for a majority of patients. High rate of colorectal anastomosis was achieved without any mortality, with acceptable morbidity and high protective stoma rate.
Topics: Aged; Carcinoma, Ovarian Epithelial; Cytoreduction Surgical Procedures; Female; Humans; Middle Aged; Ovarian Neoplasms; Pelvic Exenteration; Retrospective Studies
PubMed: 35320883
DOI: 10.3802/jgo.2022.33.e31 -
European Journal of Surgical Oncology :... Nov 2022Pelvic exenteration is widely recognised as the gold standard of care for locally advanced tumours of the pelvis. Surgery in pursuit of curative resection comes at the...
Pelvic exenteration is widely recognised as the gold standard of care for locally advanced tumours of the pelvis. Surgery in pursuit of curative resection comes at the cost of significant morbidity. Perioperative complications are commonplace with the majority managed without further surgical intervention. Boundaries of resection are expanding, resulting in increasing incidence of excision of major vascular structures and bone. Optimisation of patients is paramount prior to such significant surgical insult. Specialist centres with designated multidisciplinary teams should be used whenever possible. Addressing anaemia and nutrition play a significant role in prehabilitation. Intra-operatively consideration should be given to prevention of empty pelvis syndrome, perineal reconstruction, safe control of vascular structures and minimising risk of fistulae. Post-operative complications are common however employment of enhanced recovery protocols, minimally invasive surgery and opiate sparing analgesia protocols may in time lead to improvements for patients. Enteric fistulae and urine leak remain the most devastating and risk reduction strategies should be employed. Early recognition and aggressive management of complications is essential.
Topics: Humans; Pelvic Exenteration; Pelvis; Perineum; Postoperative Complications; Minimally Invasive Surgical Procedures
PubMed: 35101315
DOI: 10.1016/j.ejso.2021.12.470 -
Current Opinion in Oncology Sep 2014To review recently published literature presenting an overview of the current insights and (clinical and technical) developments on pelvic exenterative surgery for... (Review)
Review
PURPOSE OF REVIEW
To review recently published literature presenting an overview of the current insights and (clinical and technical) developments on pelvic exenterative surgery for gynecological malignancies.
RECENT FINDINGS
Lateral recurrences, positive pelvic node status, age and high body mass index should be abandoned as contraindications for pelvic exenteration. F-fluorodeoxyglucose positron emission tomography-computed tomography is a valuable imaging tool, especially for the detection of enlarged lymph nodes and for distinguishing fibrosis from recurrence. Combined omental plus vertical rectus abdominis myocutaenous flaps give significant reduction in complications, whereas fascia sparing (myo)cutaneous flaps seem promising in decreasing donor-site complications.
SUMMARY
Pelvic exenteration is indicated when curative alternatives are inferior or exhausted for advanced primary or locally gynecological recurrent cancer confined to the pelvis. Palliative pelvic exenteration should only be considered when disease-related morbidity is uncontrollable with other therapeutic modalities. Modifications in different surgical steps are still evolving to decrease the pelvic exenteration associated high morbidity. A complete resection and lymph node invasion free status are directly related to a better prognosis.
Topics: Female; Fluorodeoxyglucose F18; Genital Neoplasms, Female; Humans; Pelvic Exenteration; Positron-Emission Tomography; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 25050632
DOI: 10.1097/CCO.0000000000000109