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European Journal of Surgical Oncology :... Nov 2022To review the evidence regarding surgical advances in the management of primary locally advanced rectal cancer. (Review)
Review
OBJECTIVES
To review the evidence regarding surgical advances in the management of primary locally advanced rectal cancer.
BACKGROUND
The management of rectal cancer has evolved significantly in recent decades, with improved (neo)adjuvant treatment strategies and enhanced perioperative protocols. Centralization of care for complex, advanced cases has enabled surgeons in these units to undertake more ambitious surgical procedures.
METHODS
A Pubmed, Ovid, Embase and Cochrane database search was conducted according to the predetermined search strategy. The review protocol was prospectively registered with PROSPERO (CRD42021245582).
RESULTS
14 studies were identified which reported on the outcomes of 3,188 patients who underwent pelvic exenteration (PE) for primary rectal cancer. 50% of patients had neoadjuvant radiotherapy. 24.2% underwent flap reconstruction, 9.4% required a bony resection and 34 patients underwent a major vascular excision. 73.9% achieved R0 resection, with 33.1% experiencing a major complication. Median length of hospital stay ranged from 13 to 19 days. 1.6% of patients died within 30 days of their operation. Five-year overall survival (OS) rates ranged 29%-78%.
LIMITATIONS
The studies included in our review were mostly single-centre observational studies published prior to the introduction of modern neoadjuvant treatment regimens. It was not possible to perform a meta-analysis on the basis that most were non-randomized, non-comparative studies.
CONCLUSIONS
Pelvic exenteration offers patients with locally advanced rectal cancer the chance of long-term survival with acceptable levels of morbidity. Increased experience facilitates more radical procedures, with the introduction of new platforms and/or reconstructive options.
Topics: Humans; Pelvic Exenteration; Retrospective Studies; Rectal Neoplasms; Rectum; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Treatment Outcome
PubMed: 35031157
DOI: 10.1016/j.ejso.2021.12.471 -
Zhonghua Wei Chang Wai Ke Za Zhi =... Oct 2023To investigate the safety and efficacy of total pelvic exenteration (TPE) for treating late complications of radiation-induced pelvic injury. This was a descriptive...
To investigate the safety and efficacy of total pelvic exenteration (TPE) for treating late complications of radiation-induced pelvic injury. This was a descriptive case series study. The inclusion criteria were as follows: (1) confirmed radiation-induced pelvic injury after radiotherapy for pelvic malignancies; (2) late complications of radiation-induced pelvic injury, such as bleeding, perforation, fistula, and obstruction, involving multiple pelvic organs; (3) TPE recommended by a multidisciplinary team; (4) patient in good preoperative condition and considered fit enough to tolerate TPE; and (5) patient extremely willing to undergo the procedure and accept the associated risks. The exclusion criteria were as follows: (1) preoperative or intraoperative diagnosis of tumor recurrence or metastasis; (2) had only undergone diversion or bypass surgery after laparoscopic exploration; and (3) incomplete medical records. Clinical and follow-up data of patients who had undergone TPE for late complications of radiation-induced pelvic injury between March 2020 and September 2022 at the Sixth Affiliated Hospital of Sun Yat-sen University were analyzed. Perioperative recovery, postoperative complications, perioperative deaths, and quality of life 1 year postoperatively were recorded. The study cohort comprised 14 women, nine of whom had recto-vagino-vesical fistulas, two vesicovaginal fistulas, one ileo-vesical fistula and rectal necrosis, one ileo-vesical and rectovaginal fistulas, and one rectal ulcer and bilateral ureteral stenosis. The mean duration of surgery was 592.1±167.6 minutes and the median blood loss 550 (100-6000) mL. Ten patients underwent intestinal reconstruction, and four the Hartmann procedure. Ten patients underwent urinary reconstruction using Bricker's procedure and 7 underwent pelvic floor reconstruction. The mean postoperative hospital stay was 23.6±14.9 days. Seven patients (7/14) had serious postoperative complications (Clavien-Dindo IIIa to IVb), including surgical site infections in eight, abdominopelvic abscesses in five, pulmonary infections in five, intestinal obstruction in four, and urinary leakage in two. Empty pelvis syndrome (EPS) was diagnosed in five patients, none of whom had undergone pelvic floor reconstruction. Five of the seven patients who had not undergone pelvic floor reconstruction developed EPS, compared with none of those who had undergone pelvic floor reconstruction. One patient with EPS underwent reoperation because of a pelvic abscess, pelvic hemorrhage, and intestinal obstruction. There were no perioperative deaths. During 18.9±10.1 months of follow-up, three patients died, two of renal failure, which was a preoperative comorbidity, and one of COVID-19. The remaining patients had gradual and significant relief of symptoms during follow-up. QLQ-C30 assessment of postoperative quality of life showed gradual improvement in all functional domains and general health at 1, 3, and 6 months postoperatively (all <0.05). TPE is a feasible procedure for treating late complications of radiation-induced pelvic injury combined with complex pelvic fistulas. TPE is effective in alleviating symptoms and improving quality of life. However, the indications for this procedure should be strictly controlled and the surgery carried out only by experienced surgeons.
Topics: Humans; Female; Pelvic Exenteration; Quality of Life; Retrospective Studies; COVID-19; Pelvis; Rectum; Radiation Injuries; Postoperative Complications; Intestinal Obstruction; Fistula
PubMed: 37849264
DOI: 10.3760/cma.j.cn441530-20230816-00053 -
Cancer Investigation 1994Pelvic recurrence following curative resection for colorectal carcinoma continues to pose a challenge to the oncologist despite current multimodality therapy. Pelvic... (Review)
Review
Pelvic recurrence following curative resection for colorectal carcinoma continues to pose a challenge to the oncologist despite current multimodality therapy. Pelvic exenteration with or without sacral resection may provide long-term disease-free survival and a chance of cure for a small subset of patients in whom the recurrent disease is confined to the pelvis and can be resected with "clear" margins. For others with residual disease, exenteration may offer good palliation for the intractable symptoms, but no survival advantage. The clinical decision to perform exenteration with palliative intent must be individualized. This is generally not advised because of the short life expectancy in the face of prolonged convalescence. This technically demanding procedure is associated with significant morbidity, especially in patients with prior pelvic radiation. Current advances in urinary diversion and methods of pelvic reconstruction may significantly reduce these problems. The surgeon's experience and careful patient selection remain the most important determinants of success with this operation.
Topics: Adult; Aged; Colorectal Neoplasms; Female; Humans; Male; Middle Aged; Morbidity; Neoplasm Recurrence, Local; Pelvic Exenteration; Quality of Life
PubMed: 8131093
DOI: 10.3109/07357909409024873 -
Seminars in Surgical Oncology 1999Pelvic exenteration is a demanding, yet potentially curative operation, for patients with advanced pelvic cancer. The majority will present with recurrence after prior... (Review)
Review
Pelvic exenteration is a demanding, yet potentially curative operation, for patients with advanced pelvic cancer. The majority will present with recurrence after prior surgery and radiotherapy. After exenteration, 5-year survival is 40% to 60% in patients with gynecologic cancer as compared to 25% to 40% for patients with colorectal cancer. Physiologic age and absence of co-morbidities appear to be more important when selecting patients for exenteration than chronological age. Careful pre-operative staging, including either computed tomography (CT) scan or magnetic resonance imaging (MRI), usually will identify patients with distant metastases, extrapelvic nodal disease, or disease involving the pelvic sidewall (which generally precludes surgery). The recent application of intra-operative radiotherapy or postoperative high-dose brachytherapy for patients with more advanced pelvic disease, which may include sidewall involvement, may expand the standard indications for exenteration. However, the intent of this procedure, with or without radiotherapy, should be resection of all tumor with the aim of cure since the place of palliative exenteration is controversial at best. The operative details of exenteration are presented, as are two surgical approaches to composite resection of pelvic structures in continuity with sacrectomy. Filling the pelvis with large tissue flaps, usually a rectus abdominus flap, has decreased morbidity rates, particularly with small bowel complications. Peri-operative mortality is usually 5% to 10%, and significant morbidity occurs in over 50% of patients. Restorative techniques for both urinary and gastrointestinal tracts can diminish the need for stomas and, along with vaginal reconstruction, can significantly improve quality of life for many patients after exenteration. These advances in surgery and radiotherapy help make the procedure a viable option for patients with otherwise incurable pelvic malignancy.
Topics: Female; Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Pelvic Neoplasms; Quality of Life; Radiotherapy, Adjuvant; Survival Rate
PubMed: 10504662
DOI: 10.1002/(sici)1098-2388(199910/11)17:3<152::aid-ssu3>3.0.co;2-j -
The American Journal of Case Reports Nov 2023BACKGROUND Surgery for locally advanced rectal cancer with frozen pelvis is challenging. Therefore, we designed the "modular pelvic exenteration" surgical strategy to...
BACKGROUND Surgery for locally advanced rectal cancer with frozen pelvis is challenging. Therefore, we designed the "modular pelvic exenteration" surgical strategy to achieve better radical resection. CASE REPORT A 51-year-old man with rectal cancer refused surgery and received chemotherapy and radiotherapy. He was intolerant to chemotherapy and did not respond well to radiotherapy. With cancer progression, he presented at our hospital with emaciation, fatigue, dysuria, bloody urine, bloody stool, and anal pain. Computed tomography and magnetic resonance imaging revealed the rectal tumor involved multiple adjacent organs and caused rectovesical fistula, bilateral hydronephrosis, hydroureterosis, and local pelvic infection. The rectal tumor was fixed in the pelvic cavity, presenting a frozen pelvis pattern. There was no distant metastasis. As the patient could not tolerate chemotherapy, was unsuitable for immune-check point inhibitor because the tumor had microsatellite stability, and did not respond well to radiotherapy, surgical resection seemed the most suitable treatment option. After the patient's anemia and malnutrition improved, our designed modular pelvic exenteration surgery was performed. In this strategy, we divided pelvic organs and tissues into 4 independent modules. After combining the modules planned to be resected, we delineated the pre-resection margin. By this strategy, the tumor was removed en bloc, with a clear resection margin. The patient was discharged 13 days after the operation, without complications. Follow-up for 24 months revealed no signs of tumor recurrence. CONCLUSIONS For locally advanced rectal cancer with frozen pelvis, the modular pelvic exenteration strategy may help to achieve satisfactory surgical effects in selected patients.
Topics: Male; Humans; Middle Aged; Pelvic Exenteration; Margins of Excision; Neoplasm Recurrence, Local; Rectal Neoplasms; Pelvis
PubMed: 37968899
DOI: 10.12659/AJCR.941684 -
International Journal of Colorectal... Aug 2021Pelvic exenteration (PE) is the only option for long-term cure of advanced cancer originating from different types of tumor or recurrent disease in the lower pelvis. The...
BACKGROUND
Pelvic exenteration (PE) is the only option for long-term cure of advanced cancer originating from different types of tumor or recurrent disease in the lower pelvis. The aim was to show differences between colorectal and non-colorectal cancer in survival and postoperative morbidity.
METHODS
Retrospective data of 63 patients treated with total pelvic exenteration between 2013 and 2018 are reported. Pre-, intra-, and postoperative parameters, survival data, and risk factors for complications were analyzed.
RESULTS
A total of 57.2% (n = 37) of the patients had colorectal cancer, 22.3% had gynecological malignancies (vulvar (n = 6) or cervical (n = 8) cancer), 11.1% (n = 7) had anal cancer, and 9.5% had other primary tumors. A total of 30.2% (n = 19) underwent PE for a primary tumor and 69.8% (n = 44) for recurrent cancer. The 30-day in-hospital mortality was 0%. Neoadjuvant treatment was administered to 65.1% (n = 41) of the patients and correlated significantly with postoperative complications (odds ratio 4.441; 95% CI: 1.375-14.342, P > 0.05). R0, R1, R2, and Rx resections were achieved in 65.1%, 19%, 1.6%, and 14.3% of the patients, respectively. In patients undergoing R0 resection, 2-year OS and RFS were 73.2% and 52.4%, respectively. Resection status was a significant risk factor for recurrence-free and overall survival (OS) in univariate analysis. Multivariate analysis revealed age (P = 0.021), ASA ≥ 3 (P = 0.005), high blood loss (P = 0.028), low preoperative hemoglobin level (P < 0.001), nodal positivity (P < 0.001), and surgical complications (P = 0.003) as independent risk factors for OS.
CONCLUSION
Pelvic exenteration is a procedure with high morbidity rates but remains the only curative option for advanced or recurrent colorectal and non-colorectal cancer in the pelvis.
Topics: Anus Neoplasms; Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 33677655
DOI: 10.1007/s00384-021-03893-y -
ANZ Journal of Surgery May 2023Pelvic exenteration surgery is complex, necessitating co-ordinated multidisciplinary input and improved referral pathways. A state-wide pelvic exenteration...
BACKGROUND
Pelvic exenteration surgery is complex, necessitating co-ordinated multidisciplinary input and improved referral pathways. A state-wide pelvic exenteration multidisciplinary team (MDT) meeting was established in SA and the outcomes of this were audited and compared with historical data.
METHODS
All patients referred for discussion between August 2021 and July 2022 to the SA State-wide Pelvic Exenteration MDT were included in this study. MDT discussion centred around disease resectability, risk versus benefit of surgery, and need for local or interstate referral. Prospective data collection included patient demographics and MDT recommendations of surgery, palliation, or referral. Patients referred for surgery locally or interstate were compared with a retrospective patient cohort treated previously between January and December 2020.
RESULTS
Over 12 months, 91 patients were discussed (including nine multiple times), by a mean of 18 meeting participants each month. Forty-eight patients (58.5%) had primary malignancy, 25 (30.5%) recurrent malignancy, and 9 (11.0%) had non-malignant disease. Colorectal cancer was the most common presentation (56.1%), followed by gynaecological (30.5%) and urological (6.1%) malignancy. Pelvic exenteration surgery was recommended to be performed locally in 53.7% of patients and the remainder for non-surgical treatment, palliation, or re-discussion. During this time, 44 patients underwent surgery locally (versus 34 in 2020) and only 4 referred interstate (versus 8 in 2020).
CONCLUSION
The establishment of a dedicated state-wide pelvic exenteration MDT has resulted in better coordination of care for patients with locally advanced pelvic malignancy in SA, and significantly reduced the need for interstate referral.
Topics: Humans; South Australia; Pelvic Exenteration; Retrospective Studies; Carcinoma; Patient Care Team
PubMed: 36567641
DOI: 10.1111/ans.18220 -
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 -
Colorectal Disease : the Official... May 2017Pelvic exenteration is a complex surgical procedure associated with considerable morbidity. Quality of life (QoL) is a crucial metric of surgical outcome. The aim of... (Review)
Review
AIM
Pelvic exenteration is a complex surgical procedure associated with considerable morbidity. Quality of life (QoL) is a crucial metric of surgical outcome. The aim of this review was to assess the QoL following pelvic exenteration for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC).
METHOD
A comprehensive search of studies published between 2000 and 2016 that examined QoL outcome following pelvic exenteration was performed. Functional Assessment of Cancer Therapy - Colorectal (FACT-C), SF-36 version 2, European Organization for Research and Treatment of Cancer QLQ-C30, and Brief Pain Inventory assessments from these studies were reviewed.
RESULTS
Seven studies reporting on 382 patients were included. Baseline QoL was the strongest predictor of postoperative QoL. Female gender, total pelvic exenteration with or without bone resection, and positive surgical margins were associated with a reduced QoL. In the majority of patients, QoL gradually improved between 2 and 9 months post-operation.
CONCLUSION
QoL is an important patient-reported outcome. This review highlights factors associated with reduced postoperative QoL that should be borne in mind when surgical resection is being considered.
Topics: Female; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Pelvic Exenteration; Postoperative Complications; Postoperative Period; Quality of Life; Rectal Neoplasms; Treatment Outcome
PubMed: 28267255
DOI: 10.1111/codi.13647 -
Journal of Robotic Surgery Dec 2021The aim of our study was to explain the technique and evaluate the feasibility and safety of robotic anterior pelvic exenteration in cases of residual/recurrent cervical...
The aim of our study was to explain the technique and evaluate the feasibility and safety of robotic anterior pelvic exenteration in cases of residual/recurrent cervical cancer as a salvage therapy. The study was conducted as a retrospective review of all the cases of central residual/recurrent cervical cancer who underwent anterior pelvic exenteration by robotic approach with curative intent at our centre between January 2013 and December 2019. Information regarding various treatment related parameters like duration of surgery, estimated blood loss, length of hospital stay, early and late complications and recurrence and survival was collected and evaluated. 14 patients underwent anterior pelvic exenteration by robotic approach in this period. The median age of patients at time of exenteration was 52.5 years. 13 out of 14 patients had received combined chemoradiation as a part of intial treatment. The median duration of surgery was 305 min with a median estimated blood loss of 135 ml and median length of hospital stay of 6.5 days. Early complications like urosepsis, uretero-ileal anastomotic leak and paralytic ileus occurred in 36% patients and late complications like ureteric stricture and bowel perforation occurred in 28.6% patients. Negative surgical margins could be achieved in all the patients. Over a median follow-up period of 17.5 months, five patients developed recurrence and five patients experienced mortality, with four out of five patients dying due to recurrent disease. The 12-month DFS was 68.2% and the 12-month OS was 77.1%. Robotic anterior pelvic exenteration is a safe and feasible option in selected patients with recurrent/residual cervical cancer as a salvage procedure, with acceptable morbidity and mortality.
Topics: Feasibility Studies; Female; Humans; Middle Aged; Neoplasm Recurrence, Local; Pelvic Exenteration; Retrospective Studies; Robotic Surgical Procedures; Salvage Therapy; Uterine Cervical Neoplasms
PubMed: 33515209
DOI: 10.1007/s11701-021-01195-7