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Techniques in Coloproctology Nov 2023Posterior pelvic exenteration (PPE) for locally advanced rectal cancer is a technical and challenging procedure. The safety and feasibility of laparoscopic PPE remain to...
Laparoscopic posterior pelvic exenteration is safe and feasible for locally advanced primary rectal cancer in female patients: a comparative study from China PelvEx collaborative.
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.
Topics: Humans; Female; Pelvic Exenteration; Retrospective Studies; Rectal Neoplasms; Laparoscopy; Rectum; Treatment Outcome; Neoplasm Recurrence, Local
PubMed: 37243857
DOI: 10.1007/s10151-023-02824-z -
European Journal of Surgical Oncology :... Oct 2018Total pelvic exenteration (TPE) is a radical approach for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) in case of tumour invasion...
BACKGROUND
Total pelvic exenteration (TPE) is a radical approach for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) in case of tumour invasion into the urogenitary tract. The aim of this study is to assess surgical and oncological outcomes of TPE for LARC and LRRC in elderly patients compared to younger patients.
METHODS
All patients who underwent TPE for LARC and LRRC between January 1990 and March 2017 were retrospectively analyzed. Patients aged <70 years were classified as younger and ≥70 years as elderly patients.
RESULTS
In total 126 patients underwent TPE, of whom 88 younger and 38 elderly patients. Elderly patients had a significantly higher number of ASA > II patients (p = 0.01). Indication for surgery LARC (n = 73) and LRRC (n = 53) did not differ significantly. The 30-day mortality rate was significantly higher (p = 0.01) in elderly (13%) compared to younger patients (3%). Elderly patients experienced more anastomotic leakage (p = 0.02). Median overall survival (OS) was 75 months [95%CI 37.1; 112.9] for elderly and 45 months [95%CI 22.4; 67.8] for younger patients (p = 0.77). The 5-year OS rate was 44% in both groups. Median disease specific survival (DSS) was 78 months [95%CI 69.1; 86.9] for elderly and 60 months [95%CI 36.6; 83.4] for younger patients (p = 0.34). The 5-year DSS rate was 57% and 49%, respectively.
CONCLUSION
TPE is an invasive treatment for rectal cancer with high 30-day mortality in elderly patients. Oncological outcomes are similar in elderly and younger patients. Therefore, TPE should not be withheld because of high age only, but careful patient selection is needed.
Topics: Age Factors; Aged; Anastomotic Leak; Chemoradiotherapy, Adjuvant; Humans; Middle Aged; Neoadjuvant Therapy; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Neoplasm, Residual; Pelvic Exenteration; Rectal Neoplasms; Retrospective Studies; Survival Rate
PubMed: 30075979
DOI: 10.1016/j.ejso.2018.06.033 -
Surgery Today Dec 2016Pelvic infection is a significant clinical problem after pelvic exenteration. The clinical benefit of an omental flap in reducing the incidence of such infections is...
Pelvic infection is a significant clinical problem after pelvic exenteration. The clinical benefit of an omental flap in reducing the incidence of such infections is unknown. The aim of this study was to evaluate whether an omental flap after pelvic exenteration reduces the incidence of pelvic infection and the length of postoperative hospital stay. In this study, we demonstrate a safe, effective, simple method for reducing the incidence of pelvic infection using an omental flap. We performed pelvic exenteration for tumors that were suspected to have extensive invasion to the bladder, prostate, or uterus. The omentum was dissected from the transverse colon and greater curvature of the stomach. The flap was based on the right gastroepiploic vessels and tunneled in the retrocolic plane, through the mesentery of the transverse colon and ileocecum, to the defect. Twenty-seven patients were analyzed retrospectively. Ten patients received omental flaps, and 17 patients underwent pelvic exenteration without an omental flap. The incidence of pelvic infection was significantly reduced in the patients with omental flaps.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Omentum; Pelvic Exenteration; Pelvic Infection; Pelvic Neoplasms; Postoperative Complications; Retrospective Studies; Surgical Flaps; Treatment Outcome
PubMed: 27226018
DOI: 10.1007/s00595-016-1348-y -
Anticancer Research Jun 2021In selected patients, pelvic exenteration (PE) is curative, but morbidity and mortality are feared. Unfortunately, prerequisites for indicating PE are not generally...
BACKGROUND/AIM
In selected patients, pelvic exenteration (PE) is curative, but morbidity and mortality are feared. Unfortunately, prerequisites for indicating PE are not generally defined. The aim of the study was to identify prognostic factors for survival after PE in advanced pelvic gynecological malignancies for finding possible prerequisites for the indication of PE.
PATIENTS AND METHODS
Between 2002 and 2016, 49 patients underwent pelvic exenteration for advanced pelvic malignancies apart from ovarian cancer. Progression-free survival (PFS) and overall survival (OS) were calculated based on the Kaplan-Meier method. Factors significantly affecting 5-year overall survival were identified using multivariate regression analysis. Survival distributions between the best and the worst group were compared by the log rank test.
RESULTS
Forty-nine patients with recurrent or primary pelvic gynecological malignancy (20 recurrent disease, 29 primary disease) were included. Seventeen patients had oligometastatic disease at surgical intervention. Resection margin, age, primary versus secondary exenteration and metastatic disease were independent prognostic factors in multivariate regression analysis. A significant difference was observed in 5-year overall survival regarding the best group (57.14%) and the worst group (10%) (p=0.009). Cervical cancer was the only identified risk factor for increased morbidity.
CONCLUSION
Pelvic exenteration is a valuable therapeutic option with most long-term survivors in the group of patients below 63 years, as primary treatment, with clear microscopic margins and no distant metastases. These four factors may serve as valuable prerequisites for the indication of pelvic exenteration as survival and morbidity in this group of patients compares favorably to alternative therapeutic options.
Topics: Adult; Aged; Aged, 80 and over; Female; Genital Neoplasms, Female; Humans; Middle Aged; Neoplasm Recurrence, Local; Pelvic Exenteration; Survival Analysis; Treatment Outcome
PubMed: 34083295
DOI: 10.21873/anticanres.15086 -
Journal of Laparoendoscopic & Advanced... Dec 2018Since last two decades minimally invasive techniques have revolutionized surgical field. In 2003 Pomel first described laparoscopic pelvic exenteration, since then very...
Since last two decades minimally invasive techniques have revolutionized surgical field. In 2003 Pomel first described laparoscopic pelvic exenteration, since then very few reports have described minimally invasive approaches for total pelvic exenteration. We report the 10 cases of locally advanced rectal adenocarcinoma which were operated between the periods from March 1, 2017 to November 11, 2017 at the Tata Memorial Hospital, Mumbai. All male patients had lower rectal cancer with prostate involvement on magnetic resonance imaging (MRI). One female patient had uterine and fornix involvement. All perioperative and intraoperative parameters were collected retrospectively from prospectively maintained electronic data. Nine male patients with diagnosis of nonmetastatic locally advanced lower rectal adenocarcinoma were selected. All patients were operated with minimally invasive approach. All patients underwent abdominoperineal resection with permanent sigmoid stoma. Ileal conduit was constructed with Bricker's procedure through small infraumbilical incision (4-5 cm). Lateral pelvic lymph node dissection was done only when postchemoradiotherapy MRI showed enlarged pelvic nodes. All 10 patients received neoadjuvant chemo radiotherapy, whereas 8 patients received additional neoadjuvant chemotherapy. Mean body mass index was 21.73 (range 19.5-26.3). Mean blood loss was 1000 mL (range 300-2000 mL). Mean duration of surgery was 9.13 hours (range 7-13 hours). One patient developed paralytic ileus, which was managed conservatively. One patient developed intestinal obstruction due to herniation of small intestine behind the left ureter and ileal conduit. The same patient developed acute pylonephritis, which was managed with antibiotics. Mean postoperative stay was 14.6 days (range 9-25 days). On postoperative histopathology, all margins were free of tumor in all cases. Minimally invasive approaches can be used safely for total pelvic exenteration in locally advanced lower rectal adenocarcinoma. All patients had fast recovery with less blood loss. In all patients R0 resection was achieved with adequate margins. Long-term oncological outcomes are still uncertain and will require further follow-up.
Topics: Adenocarcinoma; Adult; Female; Follow-Up Studies; Humans; Laparoscopy; Male; Middle Aged; Neoplasm Staging; Pelvic Exenteration; Rectal Neoplasms; Rectum; Retrospective Studies; Time Factors; Young Adult
PubMed: 29741977
DOI: 10.1089/lap.2018.0147 -
European Journal of Surgical Oncology :... Aug 2023Pelvic exenteration (PE) is a complex multivisceral surgical procedure indicated for locally advanced or recurrent pelvic malignancies. It poses significant technical... (Meta-Analysis)
Meta-Analysis Review
Comparing minimally invasive surgical and open approaches to pelvic exenteration for locally advanced or recurrent pelvic malignancies - Systematic review and meta-analysis.
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.
Topics: Humans; Pelvic Neoplasms; Pelvic Exenteration; Pelvis; Minimally Invasive Surgical Procedures; Blood Loss, Surgical
PubMed: 37087374
DOI: 10.1016/j.ejso.2023.04.003 -
Techniques in Coloproctology Jun 2020Transanal minimally invasive surgery is a combination of single-port surgery and transanal surgery and was initially developed as a treatment for rectal tumors....
BACKGROUND
Transanal minimally invasive surgery is a combination of single-port surgery and transanal surgery and was initially developed as a treatment for rectal tumors. Recently, this approach has also been used for more advanced or extended pelvic surgery.
METHODS
We present a surgical video of combined laparoscopic and transperineal endoscopic total pelvic exenteration performed in a male patient with recurrent rectal cancer and discuss the pros and cons of this approach.
RESULTS
The operating time was 775 min and the operative blood loss was 485 ml. The pathology was recurrent adenocarcinoma invading the prostate and urethra with negative surgical margins. The postoperative course was uneventful except for a urinary tract infection that was treated with antibiotics.
CONCLUSIONS
The transanal/perineal endoscopic approach may have some benefits for extended pelvic surgery for recurrent rectal cancer.
Topics: Humans; Laparoscopy; Male; Neoplasm Recurrence, Local; Pelvic Exenteration; Rectal Neoplasms; Transanal Endoscopic Surgery
PubMed: 32236744
DOI: 10.1007/s10151-020-02187-9 -
Annals of Surgery Feb 2017The aim of this study was to assess resection margin status and its impact on survival after abdominoperineal excision and pelvic exenteration for primary or recurrent... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The aim of this study was to assess resection margin status and its impact on survival after abdominoperineal excision and pelvic exenteration for primary or recurrent rectal cancer.
SUMMARY OF BACKGROUND DATA
Resection margin is important to guide therapy and to evaluate patient prognosis.
METHODS
A meta-analysis was performed to assess the impact of resection margin status on survival, and a regression analysis to analyze positive resection margin rates reported in the literature.
RESULTS
The analysis included 111 studies reporting on 19,607 participants after abdominoperineal excision, and 30 studies reporting on 1326 participants after pelvic exenteration. The positive resection margin rates for abdominoperineal excision were 14.7% and 24.0% for pelvic exenteration. The overall survival and disease-free survival rates were significantly worse for patients with positive compared with negative resection margins after abdominoperineal excision [hazard ratio (HR) 2.64, P < 0.01; HR 3.70, P < 0.01, respectively] and after pelvic exenteration (HR 2.23, P < 0.01; HR 2.93, P < 0.01, respectively). For patients undergoing abdominoperineal excision with positive resection margins, the reported tumor sites were 57% anterior, 15% posterior, 10% left or right lateral, 8% circumferential, 10% unspecified. A significant decrease in positive resection margin rates was identified over time for abdominoperineal excision. Although positive resection margin rates did not significantly change with the size of the study, some small size studies reported higher than expected positive resection margin rates.
CONCLUSIONS
Resection margin status influences survival and a multidisciplinary approach in experienced centers may result in reduced positive resection margins. For advanced anterior rectal cancer, posterior pelvic exenteration instead of abdominoperineal excision may improve resection margins.
Topics: Abdomen; Humans; Margins of Excision; Pelvic Exenteration; Perineum; Rectal Neoplasms; Rectum; Survival Analysis; Treatment Outcome
PubMed: 27537531
DOI: 10.1097/SLA.0000000000001963 -
Colorectal Disease : the Official... Mar 2021This study aims to assess surgical outcomes and survival following first, second and third pelvic exenterations for pelvic malignancy.
AIM
This study aims to assess surgical outcomes and survival following first, second and third pelvic exenterations for pelvic malignancy.
METHOD
Consecutive patients undergoing pelvic exenteration for pelvic malignancy at a quaternary referral centre from January 1994 and December 2017 were included. Demographics and surgical outcomes were compared between patients who underwent first, second and third pelvic exenterations by generalized mixed modelling with repeated measures. Survival was assessed using Cox proportional hazards models and Kaplan-Meier plots.
RESULTS
Of the 642 exenterations reviewed, 29 (4.5%) were second and 6 (0.9%) were third exenterations. Patients selected for repeat exenteration were more likely to have asymptomatic local recurrences detected on routine surveillance (P < 0.001). Postoperative wound complications increased with repeat exenteration (6%, 17%, 33%; P = 0.003, respectively). Additionally, postoperative length of stay increased from 27 to 38 and 48 days, respectively (P = 0.004). Median survival from first exenteration was 4.75, 5.30 and 8.14 years respectively amongst first, second and third exenteration cohorts (P = 0.849). Median survival from the most recent exenteration was 4.75 years after a first exenteration, 2.02 years after a second exenteration and 1.45 years after a third exenteration (P = 0.0546).
CONCLUSION
This study demonstrates that repeat exenteration for recurrent pelvic malignancy is feasible but is associated with increased complication rates and length of admission and reduced likelihood of attaining R0 margin. Moreover, these data indicate that repeat exenteration does not afford a survival advantage compared with patients having a single exenteration. These data suggest that repeat exenteration for recurrent pelvic malignancy may be of questionable therapeutic value.
Topics: Humans; Margins of Excision; Neoplasm Recurrence, Local; Pelvic Exenteration; Pelvic Neoplasms; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Treatment Outcome
PubMed: 33058495
DOI: 10.1111/codi.15402 -
The American Surgeon Nov 2023This retrospective study aimed to demonstrate surgical operative approach of total pelvic exenteration combined with sacral resection with rectal cancer and elucidate...
BACKGROUND
This retrospective study aimed to demonstrate surgical operative approach of total pelvic exenteration combined with sacral resection with rectal cancer and elucidate the relationships between the level of sacral resection and short-term outcomes.
METHODS
Twenty cases were selected. Data regarding sex, age, body mass index, neoadjuvant therapy, location of sacral resection ("Upper" or "Lower" relative to the level between the 3rd and 4th sacral segment), operative time, bleeding, and curability (R0/R1) were collected and compared to determine their association with complications exhibiting a Clavien-Dindo grade III.
RESULTS
The complication rate was significantly higher for recurrent cancers (n = 10, 76.9%) than for primary cancers (n = 1, 14.3%) ( = .007), and for "Upper" resection (n = 8, 72.7%) than for "Lower" resection (n = 3, 33.3%) ( = .078). Significant differences were observed when complication rates for "Lower" and primary cancer resection (n = 3, .0%) were compared between "Upper" and recurrent cancers (n = 8, 100.0%) ( = .007).
CONCLUSION
In patients with recurrent rectal cancer, "Upper" sacral resection during total pelvic exenteration is associated with a high complication rate, highlighting the need for careful monitoring.
Topics: Humans; Pelvic Exenteration; Retrospective Studies; Neoplasm Recurrence, Local; Rectal Neoplasms; Sacrococcygeal Region; Treatment Outcome
PubMed: 36041858
DOI: 10.1177/00031348221124328