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Journal de Gynecologie, Obstetrique Et... Apr 2016The purpose of this review is to assess the preoperative management in case of recurrent cervical cancer, to assess patients for a surgical curative treatment. (Review)
Review
OBJECTIVE
The purpose of this review is to assess the preoperative management in case of recurrent cervical cancer, to assess patients for a surgical curative treatment.
METHODS
English publications were searched using PubMed and Cochrane Library.
RESULTS
In the purpose of curative surgery, pelvic exenteration required clear margins. Today, only half of pelvic exenteration procedures showed postoperative clear margins. Modern imaging (RMI and Pet-CT) does not allow defining local extension of microcopic disease, and thus postoperative clear margins. Despite the same generic term of pelvic exenteration, there is a wide heterogeneity in surgical procedures in published cohorts.
CONCLUSION
Because clear margins are required for curative pelvic exenteration, but are not predictable by preoperative assessment. The larger surgery, i.e. the infra-elevator exenteration with vulvectomy, could be the logical surgical choice to increase the rate of clear margins and therefore, recurrent cervical carcinoma patient survival.
Topics: Carcinoma; Female; Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Uterine Cervical Neoplasms
PubMed: 26874666
DOI: 10.1016/j.jgyn.2016.01.004 -
Diseases of the Colon and Rectum Mar 2017The management of recurrent rectal cancer is challenging. At the present time, pelvic exenteration with en bloc sacrectomy offers the only hope of a lasting cure. (Review)
Review
BACKGROUND
The management of recurrent rectal cancer is challenging. At the present time, pelvic exenteration with en bloc sacrectomy offers the only hope of a lasting cure.
OBJECTIVE
The purpose of this study was to evaluate clinical outcome measures and complication rates following sacrectomy for recurrent rectal cancer.
DATA SOURCES
A search was conducted on Pub Med for English language articles relevant to sacrectomy for recurrent rectal cancer with no time limitations.
STUDY SELECTION
Studies reported sacrectomy with survival data for recurrent rectal adenocarcinoma.
MAIN OUTCOME MEASURE
Disease-free survival following sacrectomy for recurrent rectal cancer was the main outcome measured.
RESULTS
A total of 220 patients with recurrent rectal cancer were included from 7 studies, of which 160 were men and 60 were women. Overall median operative time was 717 (570-992) minutes and blood loss was 3.7 (1.7-6.2) L. An R0 (>1-mm resection margin) resection was achieved in 78% of patients. Disease-free survival associated with R0 resection was 55% at a median follow-up period of 33 (17-60) months; however, none of the patients with R1 (<1-mm resection margin) survived this period. Postoperative complication rates and median length of stay were found to decrease with more distal sacral transection levels. In contrast, R1 resection rates increased with more distal transection.
LIMITATION
The studies assessed by this review were retrospective case series and thus are subject to significant bias.
CONCLUSION
Sacrectomy performed for patients with recurrent rectal cancer is associated with significant postoperative morbidity. Morbidity and postoperative length of stay increase with the level of sacral transection. Nevertheless, approximately half of patients eligible for rectal excision with en bloc sacrectomy may benefit from disease-free survival for up to 33 months, with R0 resection predicting disease-free survival in the medium term.
Topics: Adenocarcinoma; Disease-Free Survival; Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Rectal Neoplasms; Retrospective Studies; Sacrum
PubMed: 28177998
DOI: 10.1097/DCR.0000000000000737 -
American Journal of Obstetrics and... Apr 2024This study aimed to provide procedure-specific estimates of the risk of symptomatic venous thromboembolism and major bleeding in the absence of thromboprophylaxis,... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This study aimed to provide procedure-specific estimates of the risk of symptomatic venous thromboembolism and major bleeding in the absence of thromboprophylaxis, following gynecologic cancer surgery.
DATA SOURCES
We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar for observational studies. We also reviewed reference lists of eligible studies and review articles. We performed separate searches for randomized trials addressing effects of thromboprophylaxis and conducted a web-based survey on thromboprophylaxis practice.
STUDY ELIGIBILITY CRITERIA
Observational studies enrolling ≥50 adult patients undergoing gynecologic cancer surgery procedures reporting absolute incidence for at least 1 of the following were included: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding requiring reintervention (including reexploration and angioembolization), bleeding leading to transfusion, or postoperative hemoglobin <70 g/L.
METHODS
Two reviewers independently assessed eligibility, performed data extraction, and evaluated risk of bias of eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors. The GRADE approach was applied to rate evidence certainty.
RESULTS
We included 188 studies (398,167 patients) reporting on 37 gynecologic cancer surgery procedures. The evidence certainty was generally low to very low. Median symptomatic venous thromboembolism risk (in the absence of prophylaxis) was <1% in 13 of 37 (35%) procedures, 1% to 2% in 11 of 37 (30%), and >2.0% in 13 of 37 (35%). The risks of venous thromboembolism varied from 0.1% in low venous thromboembolism risk patients undergoing cervical conization to 33.5% in high venous thromboembolism risk patients undergoing pelvic exenteration. Estimates of bleeding requiring reintervention varied from <0.1% to 1.3%. Median risks of bleeding requiring reintervention were <1% in 22 of 29 (76%) and 1% to 2% in 7 of 29 (24%) procedures.
CONCLUSION
Venous thromboembolism reduction with thromboprophylaxis likely outweighs the increase in bleeding requiring reintervention in many gynecologic cancer procedures (eg, open surgery for ovarian cancer and pelvic exenteration). In some procedures (eg, laparoscopic total hysterectomy without lymphadenectomy), thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding venous thromboembolism and bleeding.
Topics: Adult; Humans; Female; Anticoagulants; Venous Thromboembolism; Postoperative Complications; Hemorrhage; Thrombosis; Neoplasms
PubMed: 37827272
DOI: 10.1016/j.ajog.2023.10.006 -
Plastic and Reconstructive Surgery Jun 2021The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger...
BACKGROUND
The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques.
METHODS
A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach.
RESULTS
The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently.
CONCLUSIONS
Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.
Topics: Colorectal Neoplasms; Humans; Pelvic Exenteration; Perineum; Quality of Life; Surgical Flaps; Surgical Wound; Treatment Outcome
PubMed: 33973948
DOI: 10.1097/PRS.0000000000007976 -
Colorectal Disease : the Official... Jan 2022Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is... (Review)
Review
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.
Topics: Female; Humans; Meta-Analysis as Topic; Pelvic Exenteration; Pelvis; Perineum; Plastic Surgery Procedures; Rectal Neoplasms; Retrospective Studies
PubMed: 34653292
DOI: 10.1111/codi.15956 -
Techniques in Coloproctology Nov 2020Pelvic exenteration remains a viable and effective treatment option for the management of locally advanced or recurrent pelvic malignancy. The aim of this study was to...
BACKGROUND
Pelvic exenteration remains a viable and effective treatment option for the management of locally advanced or recurrent pelvic malignancy. The aim of this study was to present an early experience of robotic multivisceral resection of pelvic malignancy, and to compare this experience with similar series through a systematic review of the literature.
METHODS
A retrospective study was performed on patients who had robotic-assisted multi-visceral resection for pelvic malignancy at a single Colorectal Surgical unit based between two tertiary academic hospitals. Primary outcomes observed included operation type, operation time, perioperative complications, and hospital length of stay. Secondary outcomes included R0 resection status, lymph node harvest, and rate of recurrence at clinical follow-up.
RESULTS
Eight cases of robotic multivisceral resection were performed for primary locally advanced pelvic malignancy involving a rectal resection as part of their operative management. The median age of patients undergoing resection was 56 years (range 29-83 years). The male:female ratio was 6:2. The mean total operating time was 8.3 h (range 6-10 h). Perioperative blood transfusion requirements were minimal. Mean hospital length of stay was 15 days (range 7-26 days). No patients experienced any serious postoperative morbidity or mortality. All patients had clear margins on histological assessment and no patients have recurrence at 12-month follow-up.
CONCLUSIONS
Robotic multivisceral resection for malignant disease of the pelvis is a safe and feasible minimally invasive approach in highly selected cases.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Pelvic Exenteration; Rectal Neoplasms; Retrospective Studies; Robotic Surgical Procedures; Robotics; Treatment Outcome
PubMed: 32662050
DOI: 10.1007/s10151-020-02290-x -
Plastic and Reconstructive Surgery May 2016Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to compare primary closure with myocutaneous flap reconstruction of perineal defects following abdominoperineal resection or pelvic exenteration with regard to surgical-site complications.
METHODS
A comprehensive literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the MEDLINE, EMBASE, Google Scholar, and Cochrane Library databases. After data extraction from included studies, meta-analysis was performed to compare outcome parameters defining surgical-site complications of flap and primary closure.
RESULTS
Our systematic review yielded 10 eligible studies (one randomized controlled trial and nine retrospective studies) involving 566 patients (226 flaps and 340 primary closures). Eight studies described rectus abdominis myocutaneous flaps and two studies used gracilis flaps. In meta-analysis, primary closure was more than twice as likely to be associated with total perineal wound complications compared with flap closure (OR, 2.17; 95 percent CI, 1.34 to 3.14; p = 0.001). Rates of major perineal wound complications were also significantly higher in the primary closure group (OR, 3.64; 95 percent CI, 1.43 to 7.79; p = 0.005). There was no statistically significant difference between primary and flap closure for minor perineal wound complications, abdominal hernias, length of stay, or reoperation rate.
CONCLUSIONS
This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure for pelvic reconstruction. The authors' results have validated the use of myocutaneous flaps for reducing perineal morbidity following abdominoperineal resection or pelvic exenteration.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, II.
Topics: Anus Neoplasms; Female; Genital Neoplasms, Female; Genital Neoplasms, Male; Gracilis Muscle; Hernia, Abdominal; Humans; Length of Stay; Male; Myocutaneous Flap; Pelvic Exenteration; Perineum; Postoperative Complications; Randomized Controlled Trials as Topic; Plastic Surgery Procedures; Rectus Abdominis; Reoperation; Retrospective Studies; Treatment Outcome; Wound Healing
PubMed: 26796372
DOI: 10.1097/PRS.0000000000002107 -
Health Technology Assessment... Mar 2013Cancer of the uterine cervix is a common cause of mortality in women. After initial treatment women may be symptom free, but the cancer may recur within a few years. It... (Review)
Review
Positron emission tomography/computerised tomography imaging in detecting and managing recurrent cervical cancer: systematic review of evidence, elicitation of subjective probabilities and economic modelling.
BACKGROUND
Cancer of the uterine cervix is a common cause of mortality in women. After initial treatment women may be symptom free, but the cancer may recur within a few years. It is uncertain whether it is more clinically effective to survey asymptomatic women for signs of recurrence or to await symptoms or signs before using imaging.
OBJECTIVES
This project compared the diagnostic accuracy of imaging using positron emission tomography/computerised tomography (PET-CT) with that of imaging using CT or magnetic resonance imaging (MRI) alone and evaluated the cost-effectiveness of adding PET-CT as an adjunct to standard practice.
DATA SOURCES
Standard systematic review methods were used to obtain and evaluate relevant test accuracy and effectiveness studies. Databases searched included MEDLINE, EMBASE, Science Citation Index and The Cochrane Library. All databases were searched from inception to May 2010.
REVIEW METHODS
Study quality was assessed using appropriately modified Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. Included were any studies of PET-CT, MRI or CT compared with the reference standard of histopathological findings or clinical follow-up in symptomatic women suspected of having recurrent or persistent cervical cancer and in asymptomatic women a minimum of 3 months after completion of primary treatment. Subjective elicitation of expert opinion was used to supplement diagnostic information needed for the economic evaluation. The effectiveness of treatment with chemotherapy, radiotherapy, chemoradiotherapy, radical hysterectomy and pelvic exenteration was systematically reviewed. Meta-analysis was carried out in RevMan 5.1 (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark) and Stata version 11 (StataCorp LP, College Station, Texas, USA). A Markov model was developed to compare the relative cost-effectiveness using TreeAge Pro software version 2011 (TreeAge Software Inc., Evanston, IL, USA).
RESULTS
For the diagnostic review, a total of 7524 citations were identified, of which 12 test accuracy studies were included in the review: six studies evaluated PET-CT, two evaluated MRI, three evaluated CT and one evaluated both MRI and CT. All studies were small and the majority evaluated imaging in women in whom recurrence was suspected on the basis of symptoms. The PET-CT studies evaluated local and distant recurrence and most used methods similar to current practice, whereas five of the six CT and MRI studies evaluated local recurrence only and not all employed currently used methods. Meta-analysis of PET-CT studies gave a sensitivity of 92.2% [95% confidence interval (CI) 85.1% to 96.0%] and a specificity of 88.1% (95% CI 77.9% to 93.9%). MRI sensitivities and specificities varied between 82% and 100% and between 78% and 100%, respectively, and CT sensitivities and specificities varied between 78% and 93% and between 0% and 95%, respectively. One small study directly compared PET-CT with older imaging methods and showed more true-positives and fewer false-negatives with PET-CT. The subjective elicitation from 21 clinical experts gave test accuracy results for asymptomatic and symptomatic women and the results for symptomatic women were similar to those from the published literature. Their combined opinions also suggested that the mean elicited increase in accuracy from the addition of PET-CT to MRI and/or CT was less than the elicited minimum important difference in accuracy required to justify the routine addition of PET-CT for the investigation of women after completion of primary treatment. For the effectiveness review, a total of 24,943 citations were identified, of which 62 studies were included (chemotherapy, 19 randomised controlled trials; radiotherapy or chemoradiotherapy, 16 case series; radical hysterectomy and pelvic exenteration, 27 case series). None provided the effectiveness of cisplatin monotherapy, the most commonly used chemotherapeutic agent in the NHS, compared with supportive care in a background of other treatment such as radiotherapy in recurrent and persistent cervical cancer. The model results showed that adding PET-CT to the current treatment strategy of clinical examination, MRI and/or CT scan was significantly more costly with only a minimal increase in effectiveness, with incremental cost-effectiveness ratios for all models being > £1M per quality-adjusted life-year (QALY) and the additional cost per additional case of recurrence being in the region of £600,000.
LIMITATIONS
There was considerable uncertainty in many of the parameters used because of a lack of good-quality evidence in recurrent or persistent cervical cancer. The evidence on diagnostic and therapeutic impact incorporated in the economic model was poor and there was little information on surveillance of asymptomatic women.
CONCLUSIONS
Given the current evidence available, the addition of PET-CT to standard practice was not found to be cost-effective in the diagnosis of recurrent or persistent cervical cancer. However, although probabilistic sensitivity analysis showed that the main conclusion about cost-ineffectiveness of PET-CT was firm given the range of assumptions made, should more reliable information become available on accuracy, therapeutic impact and effectiveness, and the cost of PET-CT reduce, this conclusion may need revision. Current guidelines recommending imaging for diagnosis using expensive methods such as PET-CT need to be reconsidered in the light of the above.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Asymptomatic Diseases; Chemoradiotherapy; Cost-Benefit Analysis; Female; Humans; Hysterectomy; Magnetic Resonance Imaging; Models, Economic; Multimodal Imaging; Pelvic Exenteration; Positron-Emission Tomography; Quality-Adjusted Life Years; Recurrence; Sensitivity and Specificity; State Medicine; Survival Analysis; Tomography, X-Ray Computed; United Kingdom; Uterine Cervical Neoplasms
PubMed: 23537558
DOI: 10.3310/hta17120 -
Medicina (Kaunas, Lithuania) Jan 2023The standard treatment approach in locally advanced cervical cancer (LACC) is exclusive concurrent chemoradiation therapy (RTCT). The risk of local residual disease... (Review)
Review
The standard treatment approach in locally advanced cervical cancer (LACC) is exclusive concurrent chemoradiation therapy (RTCT). The risk of local residual disease after six months from RTCT is about 20-30%. It is directly related to relapse risk and poor survival, such as in patients with recurrent cervical cancer. This systematic review aims to describe studies investigating salvage surgery's role in persistent/recurrent disease in LACC patients who underwent definitive RTCT. Studies were eligible for inclusion when patients had LACC with radiologically suspected or histologically confirmed residual disease after definitive RTCT, diagnosed with post-treatment radiological workup or biopsy. Information on complications after salvage surgery and survival outcomes had to be reported. The methodological quality of the articles was independently assessed by two researchers with the Newcastle-Ottawa scale. Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the PubMed, Scopus, Cochrane, Medline, and Medscape databases in May 2022. We applied no language or geographical restrictions but considered only English studies. We included studies containing data about postoperative complications and survival outcomes. Eleven studies fulfilled the inclusion criteria and all were retrospective observational studies. A total of 601 patients were analyzed concerning the salvage surgery in LACC patients for persistent/recurrent disease after RTCT treatment. Overall, 369 (61.4%) and 232 (38.6%) patients underwent a salvage hysterectomy (extrafascial or radical) and pelvic exenteration (anterior, posterior, or total), respectively. Four hundred and thirty-nine (73%) patients had histologically confirmed the residual disease in the salvage surgical specimen, and 109 patients had positive margins (overall range 0-43% of the patients). The risk of severe (grade ≥ 3) postoperative complications after salvage surgery is 29.8% (range 5-57.5%). After a median follow-up of 38 months, the overall RR was about 32% with an overall death rate of 40% after hysterectomy or pelvic exenteration with or without lymphadenectomy. There is heterogeneity between the studies both in their design and results, therefore the effect of salvage surgery on survival and recurrence cannot be adequately estimated. Future homogeneous studies with an appropriately selected population are needed to analyze the safety and efficacy of salvage hysterectomy or pelvic exenteration in patients with residual tumors after definitive RTCT.
Topics: Female; Humans; Uterine Cervical Neoplasms; Retrospective Studies; Neoplasm Recurrence, Local; Hysterectomy; Chemoradiotherapy; Postoperative Complications
PubMed: 36837394
DOI: 10.3390/medicina59020192 -
European Journal of Surgical Oncology :... Nov 2022Shared decision-making in pelvic exenteration is a complex and detailed process, which must balance clinical, oncological and patient-reported outcomes (PROs), whilst...
BACKGROUND
Shared decision-making in pelvic exenteration is a complex and detailed process, which must balance clinical, oncological and patient-reported outcomes (PROs), whilst addressing and valuing the patient priorities. Communicating patient-centred information on quality of life (QoL) and functional outcomes is an essential component of this. The aim of this systematic review was to understand the impact of pelvic exenteration on QoL PROs over a longitudinal period and to develop QoL trajectories to support decision-making in this context.
METHODS
MEDLINE, Embase and Web of Science databases were searched between 1 January 2000 and 20 December 2021 Studies reporting on PROs, including QoL, in adults undergoing pelvic exenteration were included. Risk of bias was assessed using the ROBINS-I assessment tool. Data from studies reporting QoL using the same outcome measure at the same candidate timepoint were extracted and synthesised to develop a longitudinal QoL trajectory.
RESULTS
Fourteen studies consisting of 1370 patients were included in this review. QoL trajectories were constructed in the domains of physical function, psychological function, role function, sexual function, body image and general and specific symptoms. Decision-making was only assessed by one study, with satisfaction with decision-making reported to be high. There is an initial decline in QoL scores in the domains of physical function, role function, sexual function, body image and general health and symptoms deteriorating during the first 3-6 months post-operatively. Psychological function is the only QoL domain that remains stable throughout the post-operative period.
CONCLUSION
Mapping QoL trajectories provides a visual representation of post-operative progress, highlighting the enduring impact of pelvic exenteration on patients and can be used to inform pre-operative shared decision-making.
Topics: Adult; Humans; Pelvic Exenteration; Quality of Life; Patient Reported Outcome Measures; Body Image; Decision Making
PubMed: 36030134
DOI: 10.1016/j.ejso.2022.08.001