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European Journal of Surgical Oncology :... Nov 2022Pelvic exenteration is a complex, technically challenging procedure requiring detailed anatomical knowledge. Understanding the complexity of the pelvis beyond TME is an...
Pelvic exenteration is a complex, technically challenging procedure requiring detailed anatomical knowledge. Understanding the complexity of the pelvis beyond TME is an essential requirement for both operative planning and execution. This paper highlights the key anatomical approaches to extended pelvic resection as relevant to the Colorectal Surgeon.
Topics: Humans; Pelvic Neoplasms; Neoplasm Recurrence, Local; Pelvic Exenteration; Carcinoma; Pelvis; Rectal Neoplasms
PubMed: 35086682
DOI: 10.1016/j.ejso.2021.12.469 -
Diseases of the Colon and Rectum Jan 2021Achieving a negative resection through a pelvic exenteration for a recurrent or an advanced pelvic malignancy offers the potential for cure. Exenterative surgical units...
Preemptive Femoral-Femoral Crossover Grafting of Artery and Vein Before Pelvic Exenterative Surgery for Locally Advanced and Recurrent Pelvic Malignancy Involving the Aortoiliac Axis.
INTRODUCTION
Achieving a negative resection through a pelvic exenteration for a recurrent or an advanced pelvic malignancy offers the potential for cure. Exenterative surgical units have expanded the boundaries and redefined what constitutes resectable disease through improved surgical technique. In selected cases, contiguous tumor involvement of the aortoiliac axis requires en bloc resection and subsequent vessel reconstruction. However, vascular reconstruction can be challenging in a contaminated field during an extended radical resection.
TECHNIQUE
The aim of this Technical Note is to describe a novel method in the management of patients with recurrent or advanced pelvic malignancy involving the aortoiliac axis by performing preemptive femoral-femoral arterial and venous crossover grafts, with adjunctive arteriovenous loop fistula formation before undergoing an extended radical pelvic resection 4 weeks later.
RESULTS
Four patients have undergone preemptive femoral-femoral arterial and venous crossover grafts at our institution (median age = 60 y (range, 47-66 y); 2 women). There were no early complications, and all of the patients subsequently underwent extended radical pelvic resections for a pelvic malignancy.
CONCLUSIONS
Preemptive vascular reconstruction before major pelvic surgery reduces the risk of graft infection because this method avoids the wounds being contaminated by GI or genitourinary organisms. Other advantages to this technique include a reduction in the overall operating time for the pelvic exenteration, a significant reduction in the ischemia time to the lower limbs, and ensuring that the grafts are patent before embarking on major intra-abdominal surgery.
Topics: Aged; Aorta; Arteriovenous Shunt, Surgical; Blood Vessel Prosthesis; Female; Femoral Artery; Femoral Vein; Humans; Iliac Artery; Iliac Vein; Male; Middle Aged; Neoplasm Recurrence, Local; Pelvic Exenteration; Pelvic Neoplasms; Vascular Grafting
PubMed: 33306540
DOI: 10.1097/DCR.0000000000001819 -
Urology May 2024Neuroblastoma accounts for a significant portion of childhood tumors and can present in a variety of ways. Pelvic neuroblastoma has been reported but few cases exist of...
Neuroblastoma accounts for a significant portion of childhood tumors and can present in a variety of ways. Pelvic neuroblastoma has been reported but few cases exist of neuroblastoma invading or originating from the bladder or prostate. We present a 4-year-old patient with pelvic neuroblastoma arising from the prostate and describe the medical and surgical management of this challenging case. While pelvic neuroblastoma may have an improved prognosis, this case demonstrates the challenging surgical decisions that accompany these patients to maintain quality of life while balancing oncologic efficacy of treatment.
Topics: Humans; Neuroblastoma; Male; Prostatic Neoplasms; Child, Preschool; Pelvic Neoplasms
PubMed: 38401809
DOI: 10.1016/j.urology.2024.02.008 -
BMJ Case Reports Mar 2021Ectopic pregnancy is a common complication of early pregnancy. We present a very atypical case of an ectopic gestation in a woman who presented with a negative pregnancy...
Ectopic pregnancy is a common complication of early pregnancy. We present a very atypical case of an ectopic gestation in a woman who presented with a negative pregnancy test, a large pelvic mass, weight loss and bowel obstruction.
Topics: Female; Humans; Pelvic Neoplasms; Pregnancy; Pregnancy, Ectopic
PubMed: 33653828
DOI: 10.1136/bcr-2019-233534 -
Annals of Surgery Nov 2019To determine factors associated with outcomes following pelvic exenteration for advanced nonrectal pelvic malignancy.
OBJECTIVE
To determine factors associated with outcomes following pelvic exenteration for advanced nonrectal pelvic malignancy.
BACKGROUND
The PelvEx Collaborative provides large volume data from specialist centers to ascertain factors associated with improved outcomes.
METHODS
Consecutive patients who underwent pelvic exenteration for nonrectal pelvic malignancy between 2006 and 2017 were identified from 22 tertiary centers. Patient demographics, neoadjuvant therapy, histopathological assessment, length of stay, 30-day major complication/mortality rate were recorded.The primary endpoints were factors associated with survival. The secondary endpoints included the difference in margin rates across the cohorts, impact of neoadjuvant treatment on survival, associated morbidity, and mortality.
RESULTS
One thousand two hundred ninety-three patients were identified. 40.4% (n = 523) had gynecological malignancies (endometrial, ovarian, cervical, and vaginal), 35.7% (n = 462) urological (bladder), 18.1% (n = 234) anal, and 5.7% had sarcoma (n = 74).The median age across the cohort was 63 years (range, 23-85). The median 30-day mortality rate was 1.7%, with the highest rates occurring following exenteration for recurrent sarcoma or locally advanced cervical cancer (3.3% each). The median length of hospital stay was 17.5 days. 34.5% of patients experienced a major complication, with highest rate occurring in those having salvage surgery for anal cancer.Multivariable analysis showed R0 resection was the main factor associated with long-term survival. The 3-year overall-survival rate for R0 resection was 48% for endometrial malignancy, 40.6% for ovarian, 49.4% for cervical, 43.8% for vaginal, 59% for bladder, 48.3% for anal, and 48.1% for sarcoma.
CONCLUSION
Pelvic exenteration remains an important treatment in selected patients with advanced or recurrent nonrectal pelvic malignancy. The range in 3-year overall survival following R0 resection (40%-59%) reflects the diversity of tumor types.
Topics: Aged; Aged, 80 and over; Cause of Death; Cohort Studies; Databases, Factual; Disease-Free Survival; Female; Humans; Kaplan-Meier Estimate; Middle Aged; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Neoplasm Staging; Pelvic Exenteration; Pelvic Neoplasms; Prognosis; Proportional Hazards Models; Retrospective Studies; Risk Assessment; Survival Analysis; Tertiary Care Centers
PubMed: 31634184
DOI: 10.1097/SLA.0000000000003533 -
Cancer Treatment Reviews Jul 2018One of the late complications associated with radiation therapy (RT) is a possible increased risk of second cancer. In this systematic review, we analysed the incidence... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
One of the late complications associated with radiation therapy (RT) is a possible increased risk of second cancer. In this systematic review, we analysed the incidence of rectal cancer following primary pelvic cancer irradiation.
METHODS
A literature search was conducted using the PubMed and EMBASE libraries. Original articles that reported on secondary rectal cancer after previous RT for a primary pelvic cancer were included. Sensitivity analyses were performed by correcting for low number of events, high risk of bias, and outlying results.
RESULTS
A total of 5171 citations were identified during the literature search, 23 studies were included in the meta-analyses after screening. A pooled analysis, irrespective of primary tumour location, showed an increased risk for rectal cancer following RT (N = 403.243) compared with non-irradiated patients (N = 615.530) with a relative risk (RR) of 1.43 (95% confidence interval [CI] 1.18-1.72). Organ specific meta-analysis showed an increased risk for rectal cancer after RT for prostate (RR 1.36, 95%CI 1.10-1.67) and cervical cancer (RR 1.61, 95% CI 1.10-2.35). No relation was seen in ovarian cancer patients. The modality of RT did not influence the incidence of rectal cancer.
CONCLUSIONS
This review demonstrates an increased risk for second primary rectal cancer in patients who received RT to the pelvic region. This increased risk was modest and could not be confirmed for all primary pelvic cancer sites. The present study does not provide data to change guidelines for surveillance for rectal cancer in previously irradiated patients.
Topics: Humans; Incidence; Neoplasms, Radiation-Induced; Pelvic Neoplasms; Rectal Neoplasms
PubMed: 29957373
DOI: 10.1016/j.ctrv.2018.05.008 -
Zentralblatt Fur Chirurgie Apr 2015Extended resections of pelvic malignancies, especially in cases of recurrent malignancies, result in the formation of large tissue defects in the region of the pelvic... (Review)
Review
Extended resections of pelvic malignancies, especially in cases of recurrent malignancies, result in the formation of large tissue defects in the region of the pelvic floor and perineum, which are difficult to deal with. Both after extra levator rectal excision and pelvic exenteration, wound healing deficiencies and local infections of the perineal wound are frequent. Primary closure is often impossible due to a lack of tissue substance after resection and an additional previous radiotherapy in most cases. This can result in poor or non-healing wounds, a consecutive need of complex care and an increased risk of secondary problems including tumour recurrences. A permanent wound closure of good quality can therefore only be achieved by plastic surgery. This can be done by local or distant muscle flaps with or without skin, for example, the gluteus maximus flap, the vertical rectus abdominis muscle flap (VRAM) or free flaps such as the latissimus dorsi flap.
Topics: Female; Humans; Male; Neoplasm Recurrence, Local; Pelvic Exenteration; Pelvic Neoplasms; Plastic Surgery Procedures; Sacrum; Surgical Flaps; Wound Healing
PubMed: 25874472
DOI: 10.1055/s-0035-1545809 -
Diseases of the Colon and Rectum May 2018Pelvic exenteration carries significant risks of morbidity and mortality. Preoperative management is therefore crucial, and the exenteration procedure is usually... (Comparative Study)
Comparative Study
BACKGROUND
Pelvic exenteration carries significant risks of morbidity and mortality. Preoperative management is therefore crucial, and the exenteration procedure is usually performed in an elective setting. In cases of rectal cancer, however, tumor-related complications may cause a patient's condition to deteriorate rapidly, despite optimal management. Urgent pelvic exenteration then may be an option for these patients.
OBJECTIVE
This study aims to compare the outcomes of pelvic exenteration between the urgent and elective settings.
DESIGN
This is a retrospective study.
SETTING
This study was conducted at King Chulalongkorn Memorial Hospital between February 2006 and June 2012.
PATIENTS
Fifty-three patients with locally advanced rectal cancer were included.
INTERVENTION
All patients underwent pelvic exenteration for locally advanced rectal cancer. They were assigned to urgent and elective setting groups according to their preoperative conditions. The urgent setting group included patients who required urgent pelvic exenteration because of intestinal obstruction, bowel perforation, bleeding, or uncontrolled sepsis, despite optimal management preoperatively.
MAIN OUTCOME MEASURES
Twenty-six patients were classified in the urgent setting group, and 27 were classified in the elective setting group. Three-year overall and disease-free survivals were compared between the 2 groups. Thirty-day postoperative morbidity and mortality were also studied.
RESULTS
Three-year overall survival was 62.2% and 54.4% in the elective and urgent groups (p = 0.7), whereas three-year disease-free survival was 43% and 63.8% (p = 0.33). The median follow-up time was 33 months. Thirty-day morbidity did not differ between the 2 groups (p = 0.49). A low serum albumin level was a significant risk factor for complications. There was no postoperative mortality in this study.
LIMITATIONS
This was a retrospective study performed at 1 institution, and it lacked quality-of-life scores.
CONCLUSION
Pelvic exenteration in an urgent setting is feasible and could offer acceptable outcomes. See Video Abstract at http://links.lww.com/DCR/A591.
Topics: Disease-Free Survival; Emergencies; Female; Humans; Male; Middle Aged; Morbidity; Pelvic Exenteration; Pelvic Neoplasms; Postoperative Complications; Retrospective Studies; Survival Rate; Thailand
PubMed: 29624550
DOI: 10.1097/DCR.0000000000001083 -
Journal of the College of Physicians... Jun 2018To evaluate the outcomes of patients undergoing radiotherapy for primary local control of pelvic ewing sarcoma (ES).
OBJECTIVE
To evaluate the outcomes of patients undergoing radiotherapy for primary local control of pelvic ewing sarcoma (ES).
STUDY DESIGN
Case series.
PLACE AND DURATION OF STUDY
Shaukat Khanum Memorial Cancer Hospital, Lahore, from January 2010 to October 2015.
METHODOLOGY
Patients with primary pelvic ES were included in the analysis and all other primary disease sites were excluded. All of them were treated with radiotherapy and followed the EuroEwing-99 chemotherapy protocol. Tumor volume, relapse and metastases were noted.
RESULTS
There were 13 patients with pelvic ES. The median age at the time of diagnosis was 15 years with IQR of 7 years (range 2-19 years). Tumor volume was more than 400ml in more than 50% of the patients. Eight patients (61.5%) had local relapses and 5 patients (38.5%) had combined local and distant disease metastases.
CONCLUSION
These results showed poor local control and overall survival in local pelvic ES cases in children and adolescents. Intensity modulated radiotherapy (IMRT) can be used to deliver higher doses of radiation. Compressed cycles of chemotherapy should be evaluated in local setting.
Topics: Adolescent; Antineoplastic Combined Chemotherapy Protocols; Child; Combined Modality Therapy; Female; Humans; Infant; Male; Neoplasm Metastasis; Neoplasm Recurrence, Local; Pelvic Neoplasms; Retrospective Studies; Sarcoma, Ewing; Survival Rate; Treatment Outcome; Tumor Burden; Young Adult
PubMed: 29848420
DOI: 10.29271/jcpsp.2018.06.445 -
Abdominal Radiology (New York) Jan 2020The aim of the study was to identify the frequency of isolated pelvic metastasis with the goal of determining the utility of pelvic CT as a surveillance strategy in...
BACKGROUND
The aim of the study was to identify the frequency of isolated pelvic metastasis with the goal of determining the utility of pelvic CT as a surveillance strategy in patients with resected biliary tract cancer (BTC).
METHODS
Study eligibility criteria included patients 18 years or older with BTC who underwent R0 or R1 surgical resection at University of Michigan between 2004 and 2018, with a minimum 6-month disease-free surveillance period. CT and MRI reports were independently graded by two radiologists as positive (organ metastasis, peritoneal carcinomatosis, or enlarged lymph nodes), equivocal (borderline lymph nodes or non-nodular ascites), or negative (absence of or benign findings) in the abdomen and pelvis separately. A 3rd blinded radiologist reviewed all positive and equivocal scans. Clinic notes were reviewed to identify new or worsening signs and symptoms that would warrant an earlier pelvic surveillance scan. A 95% binomial proportion confidence interval was used to find the probability of isolated pelvic metastasis.
RESULTS
BTC were anatomically classified as extra-hepatic (distal and hilar) cholangiocarcinoma (38; 25%), intra-hepatic cholangiocarcinoma (57; 38%), and gallbladder cancer (56; 37%). 151 patients met eligibility criteria, of which 123 (81%) had no pelvic metastasis, 51 (34%) had localized upper abdominal metastasis, and 23 (15%) had concomitant abdominal and pelvic metastasis. Median follow-up time was 19.2 months. One (0%) subject with resected BTC (intra-hepatic) developed isolated osseous pelvic metastasis during surveillance (95% CI 0.004-0.1; p = 0.0003). 3 (2%) subjects developed isolated simple ascites (equivocal grade) without concurrent upper abdominal metastasis.
CONCLUSION
Isolated pelvic metastasis is a rare occurrence during surveillance in patients with resected BTCs, and therefore, follow-up pelvic CT in absence of specific symptoms may be unnecessary.
Topics: Biliary Tract Neoplasms; Female; Humans; Male; Middle Aged; Pelvic Neoplasms; Pelvis; Tomography, X-Ray Computed
PubMed: 31385009
DOI: 10.1007/s00261-019-02159-0