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Peacock O, Brown K, Waters PS, Jenkins JT, Warrier SK, Heriot AG, Glyn T, Frizelle FA, Solomon MJ, Bednarski BK. Operative Strategies for Beyond Total Mesorectal Excision Surgery for Rectal Cancer. Ann Surg Oncol 2025:10.1245/s10434-025-17151-w. [PMID: 40102284 DOI: 10.1245/s10434-025-17151-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2025] [Accepted: 02/24/2025] [Indexed: 03/20/2025]
Affiliation(s)
- Oliver Peacock
- Department of Colorectal Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Kilian Brown
- Department of Colorectal Surgery, Surgical Outcomes Research Centre and Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | | | - John T Jenkins
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Satish K Warrier
- Department of Colorectal Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Alexander G Heriot
- Department of Colorectal Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Tamara Glyn
- Department of Colorectal Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Frank A Frizelle
- Department of Colorectal Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Michael J Solomon
- Department of Colorectal Surgery, Surgical Outcomes Research Centre and Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Brian K Bednarski
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Maudsley J, Clifford RE, Aziz O, Sutton PA. A systematic review of oncosurgical and quality of life outcomes following pelvic exenteration for locally advanced and recurrent rectal cancer. Ann R Coll Surg Engl 2025; 107:2-11. [PMID: 38362800 PMCID: PMC11658885 DOI: 10.1308/rcsann.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Pelvic exenteration (PE) is now the standard of care for locally advanced (LARC) and locally recurrent (LRRC) rectal cancer. Reports of the significant short-term morbidity and survival advantage conferred by R0 resection are well established. However, longer-term outcomes are rarely addressed. This systematic review focuses on long-term oncosurgical and quality of life (QoL) outcomes following PE for rectal cancer. METHODS A systematic review of the PubMed®, Cochrane Library, MEDLINE® and Embase® databases was conducted, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies were included if they reported long-term outcomes following PE for LARC or LRRC. Studies with fewer than 20 patients were excluded. FINDINGS A total of 25 papers reported outcomes for 5,489 patients. Of these, 4,744 underwent PE for LARC (57.5%) or LRRC (42.5%). R0 resection rates ranged from 23.2% to 98.4% and from 14.9% to 77.8% respectively. The overall morbidity rates were 17.8-87.0%. The median survival ranged from 12.5 to 140.0 months. None of these studies reported functional outcomes and only four studies reported QoL outcomes. Numerous different metrics and timepoints were utilised, with QoL scores frequently returning to baseline by 12 months. CONCLUSIONS This review demonstrates that PE is safe, with a good prospect of R0 resection and acceptable mortality rates in selected patients. Morbidity rates remain high, highlighting the importance of shared decision making with patients. Longer-term oncological outcomes as well as QoL and functional outcomes need to be addressed in future studies. Development of a core outcomes set would facilitate better reporting in this complex and challenging patient group.
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Affiliation(s)
| | - RE Clifford
- Institute of Translational Medicine, University of Liverpool, UK
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Rotaru V, Chitoran E, Zob DL, Ionescu SO, Aisa G, Andra-Delia P, Serban D, Stefan DC, Simion L. Pelvic Exenteration in Advanced, Recurrent or Synchronous Cancers-Last Resort or Therapeutic Option? Diagnostics (Basel) 2024; 14:1707. [PMID: 39202196 PMCID: PMC11353817 DOI: 10.3390/diagnostics14161707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/29/2024] [Accepted: 08/05/2024] [Indexed: 09/03/2024] Open
Abstract
First described some 80 years ago, pelvic exenteration remain controversial interventions with variable results and ever-changing indications. The previous studies are not homogenous and have different inclusion criteria (different populations and different disease characteristics) and methodologies (including evaluation of results), making it extremely difficult to properly assess the role of pelvic exenteration in cancer treatment. This study aims to describe the indications of pelvic exenterations, the main prognostic factors of oncologic results, and the possible complications of the intervention. Methods: For this purpose, we conducted a retrospective study of 132 patients who underwent various forms of pelvic exenterations in the Institute of Oncology "Prof. Dr. Al. Trestioreanu" in Bucharest, Romania, between 2013 and 2022, collecting sociodemographic data, characteristics of patients, information on the disease treated, data about the surgical procedure, complications, additional cancer treatments, and oncologic results. Results: The study cohort consists of gynecological, colorectal, and urinary bladder malignancies (one hundred twenty-seven patients) and five patients with complex fistulas between pelvic organs. An R0 resection was possible in 76.38% of cases, while on the rest, positive margins on resection specimens were observed. The early morbidity was 40.63% and the mortality was 2.72%. Long-term outcomes included an overall survival of 43.7 months and a median recurrence-free survival of 24.3 months. The most important determinants of OS are completeness of resection, the colorectal origin of tumor, and the presence/absence of lymphovascular invasion. Conclusions: Although still associated with high morbidity rates, pelvic exenterations can deliver important improvements in oncological outcomes in the long-term and should be considered on a case-by-case basis. A good selection of patients and an experienced surgical team can facilitate optimal risks/benefits.
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Affiliation(s)
- Vlad Rotaru
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Elena Chitoran
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Daniela-Luminita Zob
- Medical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Sinziana-Octavia Ionescu
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Gelal Aisa
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Prie Andra-Delia
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Dragos Serban
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Surgery Department 4, Bucharest University Emergency Hospital, 050098 Bucharest, Romania
| | - Daniela-Cristina Stefan
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Laurentiu Simion
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
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De Crignis L, Dupré A, Meeus P, Peyrat P, Rivoire M. Surgical outcomes in pelvic exenteration for advanced and recurrent malignancy: a high volume single institution experience. Langenbecks Arch Surg 2023; 408:221. [PMID: 37261533 DOI: 10.1007/s00423-023-02960-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/24/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Pelvic exenteration remains the only curative treatment for advanced pelvic malignancies. However, identification of predictive factors for successful surgical outcomes is still a controversial issue at present time. METHODS This retrospective study included data from all adult patients with colorectal or anal advanced pelvic malignancy registered for pelvic exenteration at the Leon Berard Cancer Center (Lyon, France). The primary endpoint was the surgical outcomes and aimed to define the predictive factors for postoperative complications. Secondary endpoints included overall survival and progression free survival in patients having experienced pelvic exenteration (PE). RESULTS Data from 141 patients with locally advanced tumor (N = 81) or recurrent malignancies (N = 60) diagnosed between May 1994 and November 2018 were collected. The median age was 63.3 years (95%CI 20.0-92.0). Malignancies included different locations (rectal: 69.5%, left colon: 17.0% and anal: 13.5%). Posterior pelvectomy was the most frequent surgery (81.6%). The median length of hospital stay was 23.3 days (95%CI 3.0-82.0). The major complication rate at 30 days was 24.8% and 38.1% at 90 days. The median overall survival was 54.5 months (95%CI 41.5-104.1) and the median PFS was 34.5 months (95%CI 19.6-NA). CONCLUSION In selected patients, pelvic exenteration is associated with good surgical and survival outcomes.
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Affiliation(s)
- Lucas De Crignis
- Department of Surgical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France.
| | - Aurélien Dupré
- Department of Surgical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
- Univ Lyon, Inserm, U1032 LabTau, 69003, Lyon, France
| | - Pierre Meeus
- Department of Surgical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
| | - Patrice Peyrat
- Department of Surgical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
| | - Michel Rivoire
- Department of Surgical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
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Das G, Sahewalla A, Purkayastha J, Talukdar A, Kalita D, Kamalasanan K, Kakoti L. Pelvic Exenteration for Locally Advanced Rectal Cancer: an Initial Experience from North-east India. Indian J Surg Oncol 2022; 13:559-563. [PMID: 35280239 PMCID: PMC8896847 DOI: 10.1007/s13193-022-01529-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 03/01/2022] [Indexed: 11/28/2022] Open
Abstract
UNLABELLED Pelvic exenteration is a surgery done to achieve margin negative resection in locally advanced rectal cancer infiltrating pelvic organs anterior to it. A retrospective observational study of patients undergoing pelvic exenteration for locally advanced rectal cancer was done at a single surgical unit of a tertiary care cancer centre. The period of study was from 1st January 2019 to 30th June 2021. A total of twelve patients underwent pelvic exenteration for locally advanced rectal cancer during the study period. The median duration of surgery was 310 min (range 250 to 380 min). The median duration of hospital stay was 14 days (range 12 to 30 days). Seven patients had documented postoperative complications, either major or minor, with a complication rate of 58.3%. Three patients required re-admission for complications. Two patients had COVID19 infection in the postoperative period but had uneventful recovery. Margin negative resection (R0) was achieved in eight patients (66.67%). Pelvic exenteration for locally advanced rectal cancer is a definitive surgery associated with a high morbidity rate. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s13193-022-01529-3.
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Affiliation(s)
- Gaurav Das
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, a unit of Tata Memorial Centre, House no. 15, 4th floor, Nalini Bala Devi path, Sublane 2, Sreenagar, Guwahati, 781005 Assam India
| | - Ashutosh Sahewalla
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, a unit of Tata Memorial Centre, House no. 15, 4th floor, Nalini Bala Devi path, Sublane 2, Sreenagar, Guwahati, 781005 Assam India
| | - Joydeep Purkayastha
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, a unit of Tata Memorial Centre, House no. 15, 4th floor, Nalini Bala Devi path, Sublane 2, Sreenagar, Guwahati, 781005 Assam India
| | - Abhijit Talukdar
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, a unit of Tata Memorial Centre, House no. 15, 4th floor, Nalini Bala Devi path, Sublane 2, Sreenagar, Guwahati, 781005 Assam India
| | - Deepjyoti Kalita
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, a unit of Tata Memorial Centre, House no. 15, 4th floor, Nalini Bala Devi path, Sublane 2, Sreenagar, Guwahati, 781005 Assam India
| | - Kiran Kamalasanan
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, a unit of Tata Memorial Centre, House no. 15, 4th floor, Nalini Bala Devi path, Sublane 2, Sreenagar, Guwahati, 781005 Assam India
| | - Lopamudra Kakoti
- Department of Oncopathology, Dr. B. Borooah Cancer Institute, a unit of Tata Memorial Centre, Guwahati, India
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Casey L, Larach JT, Waters PS, Kong JCH, McCormick JJ, Heriot AG, Warrier SK. Application of minimally invasive approaches to pelvic exenteration for locally advanced and locally recurrent pelvic malignancy - A narrative review of outcomes in an evolving field. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2330-2337. [PMID: 36068124 DOI: 10.1016/j.ejso.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 07/26/2022] [Accepted: 08/05/2022] [Indexed: 11/28/2022]
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Konstantinidis IT, Lee B, Trisal V, Paz I, Melstrom K, Sentovich S, Lai L, Raoof M. National postoperative and oncologic outcomes after pelvic exenteration for T4b rectal cancer. J Surg Oncol 2020; 122:739-744. [PMID: 32516469 DOI: 10.1002/jso.26058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/08/2020] [Accepted: 05/22/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Studies reporting outcomes after pelvic exenteration for rectal cancer are limited. The objective of this study was to evaluate early postoperative and oncologic outcomes in a national multi-institutional cohort. METHODS Using the National Cancer Database (NCDB), which collects data from over 1500 commission on cancer (CoC)-accredited hospitals, we analyzed patients undergoing pelvic exenteration for T4b rectal adenocarcinoma. RESULTS There were 1367 pelvic exenterations performed in 552 hospitals. Median age was 60 years, the majority of patients (n = 831; 60.8%) were female. Neoadjuvant radiation was used only in 57%; 24.3% of resections had positive margins. Following exenteration, 30-day mortality rate, 90-day mortality rate, and readmission rates were: 1.8%, 4.4%, and 7.4%. Age ≥ 60 years and higher Charlson-Deyo comorbidity index were independently associated with increased 90-day mortality (P < .001). Overall survival (OS) was 50 months. After adjustment of significant covariates, negative margin status (adjusted HR, 0.6, 95% CI, 0.5-0.8; P < .001) and receipt of perioperative radiation or chemoradiation (adjusted HR, 0.5; 95% CI, 0.4-0.6; P < .001) were significantly associated with decreased risk of death. Only 71% of the patients received perioperative radiation. CONCLUSIONS Pelvic exenterations are being performed safely in Coc-accredited hospitals. However, up to one fourth of patients undergo resections with positive margins or are subject to underutilization of perioperative radiation therapy. Increased use of radiation may increase negative margin resections and improve patient outcomes.
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Affiliation(s)
| | - Byrne Lee
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Vijay Trisal
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Issac Paz
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Kurt Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Stephen Sentovich
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Lily Lai
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Brown KG, Solomon MJ. Decision making, treatment planning and technical considerations in patients undergoing surgery for locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Baird DLH, Kontovounisios C, Simillis C, Pellino G, Rasheed S, Tekkis PP. Factors associated with metachronous metastases and survival in locally advanced and recurrent rectal cancer. BJS Open 2020; 4:1172-1179. [PMID: 32856767 PMCID: PMC7709378 DOI: 10.1002/bjs5.50341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 07/15/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Better understanding of the impact of metachronous metastases in locally advanced and recurrent rectal cancer may improve decision-making. The aim of this study was to investigate factors influencing metachronous metastasis and its impact on survival in patients who have a beyond total mesorectal excision (bTME) operation. METHODS This was a retrospective study of consecutive patients who had bTME surgery for locally advanced and recurrent rectal cancer at a tertiary referral centre between January 2006 and December 2016. The primary outcome was overall survival. Cox proportional hazards regression analyses were performed. The influence of metachronous metastases on survival was investigated. RESULTS Of 220 included patients, 171 were treated for locally advanced primary tumours and 49 for recurrent rectal cancer. Some 90·0 per cent had a complete resection with negative margins. Median follow-up was 26·0 (range 1·5-119·6) months. The 5-year overall survival rate was 71·1 per cent. Local recurrence and metachronous metastasis rates were 11·8 and 22·2 per cent respectively. Patients with metachronous metastases had a worse overall survival than patients without metastases (median 52·9 months versus estimated mean 109·4 months respectively; hazard ratio (HR) 6·73, 95 per cent c.i. 3·23 to 14·00). Advancing pT category (HR 2·01, 1·35 to 2·98), pN category (HR 2·43, 1·65 to 3·59), vascular invasion (HR 2·20, 1·22 to 3·97) and increasing numbers of positive lymph nodes (HR 1·19, 1·07 to 1·16) increased the risk of metachronous metastasis. Nine of 17 patients (53 per cent) with curatively treated synchronous metastases at presentation developed metachronous metastases, compared with 40 of 203 (19·7 per cent) without synchronous metastases (P = 0·002). Corresponding median length of disease-free survival was 17·5 versus 90·8 months (P < 0·001). CONCLUSION As metachronous metastases impact negatively on survival after bTME surgery, factors associated with metachronous metastases may serve as selection tools when determining suitability for treatment with curative intent.
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Affiliation(s)
- D. L. H. Baird
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
| | - C. Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of Colorectal SurgeryChelsea and Westminster HospitalLondonUK
| | - C. Simillis
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
| | - G. Pellino
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
| | - S. Rasheed
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of Colorectal SurgeryChelsea and Westminster HospitalLondonUK
| | - P. P. Tekkis
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of Colorectal SurgeryChelsea and Westminster HospitalLondonUK
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Predictors of overall survival following extended radical resections for locally advanced and recurrent pelvic malignancies. Langenbecks Arch Surg 2020; 405:491-502. [PMID: 32533361 DOI: 10.1007/s00423-020-01895-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 05/15/2020] [Indexed: 01/11/2023]
Abstract
PURPOSE In an era of personalised medicine, there is an overwhelming effort for predicting patients who will benefit from extended radical resections for locally advanced pelvic malignancy. However, there is paucity of data on the effect of comorbidities and postoperative complications on long-term overall survival (OS). The aim of this study was to define predictors of 1-year and 5-year OS. METHODS Data were collected from prospective databases at two high-volume institutions specialising in beyond TME surgery for locally advanced and recurrent pelvic malignancies between 1990 and 2015. The primary outcome measures were 1-year and 5-year OS. RESULTS A total of 646 consecutive extended radical resections were performed between 1990 and 2015. The majority were female patients (371, 57.4%) and the median age was 63 years (range 19-89 years). One-year OS, primary rectal adenocarcinoma had the best survival while recurrent colon cancer had the worse survival (p = 0.047). The 5-year OS between primary and recurrent cancers were 64.7% and 53%, respectively (p = 0.004). Poor independent prognostic markers for 5-year OS were increasing ASA score, cardiovascular disease, recurrent cancers, ovarian cancers, pulmonary embolus and acute respiratory distress syndrome. A positive survival benefit was demonstrated with preoperative radiotherapy (HR 0.55; 95% CI 0.4-0.75, p < 0.001). CONCLUSION Patient comorbidities and specific complications can influence long-term survival following extended radical resections. This study highlights important predictors, enabling clinicians to better inform patients of the potential short- and long-term outcomes in the management of locally advanced and recurrent pelvic malignancy.
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Peacock O, Waters PS, Bressel M, Lynch AC, Wakeman C, Eglinton T, Koh CE, Lee PJ, Austin KK, Warrier SK, Solomon MJ, Frizelle FA, Heriot AG. Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era. Br J Surg 2019; 106:1685-1696. [PMID: 31339561 DOI: 10.1002/bjs.11242] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/31/2019] [Accepted: 04/26/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Despite advances in the rates of total mesorectal excision (TME) for rectal cancer surgery, decreased local recurrence rates and increased 5-year survival, there still exists large variation in the quality of treatment received. Up to 30 per cent of rectal cancers are locally advanced at presentation and approximately 5-10 per cent still breach the mesorectal plane and invade adjacent structures despite neoadjuvant therapy. With the evolution of extended resections for rectal cancers beyond the TME plane, proponents advocate that these resections should be performed only in specialist centres. The aim was to assess the prognostic factors and patterns of failure after beyond TME surgery for T4 rectal cancers. METHODS Data were collected from prospective databases at three high-volume institutions specializing in beyond TME surgery for T4 rectal cancers between 1990 and 2013. The primary outcome measures were overall survival, local recurrence and patterns of first failure. RESULTS Three hundred and sixty patients were identified. The negative resection margin (R0) rate was 82·8 per cent (298 patients) and the local recurrence rate was 12·5 per cent (45 patients). The type of surgical procedure (Hartmann's: hazard ratio (HR) 4·49, 95 per cent c.i. 1·99 to 10·14; P = 0·002) and lymphovascular invasion (HR 2·02, 1·08 to 3·77; P = 0·032) were independent predictors of local recurrence. The 5-year overall survival rate for all patients was 61 (95 per cent c.i. 55 to 67) per cent. The 5-year cumulative incidence of first failure was 8 per cent for local recurrence, 6 per cent for local and distant disease, and 18 per cent for distant disease. CONCLUSION This study has demonstrated that a coordinated approach in specialist centres for beyond TME surgery can offer good oncological and long-term survival in patients with T4 rectal cancers.
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Affiliation(s)
- O Peacock
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - P S Waters
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - M Bressel
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A C Lynch
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - C Wakeman
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - T Eglinton
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - C E Koh
- Department of Colorectal Surgery and Royal Prince Alfred Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - P J Lee
- Department of Colorectal Surgery and Royal Prince Alfred Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K K Austin
- Department of Colorectal Surgery and Royal Prince Alfred Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S K Warrier
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - M J Solomon
- Department of Colorectal Surgery and Royal Prince Alfred Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Unit, University of Sydney, Sydney, New South Wales, Australia
| | - F A Frizelle
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - A G Heriot
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Nadiradze G, Yurttas C, Königsrainer A, Horvath P. Significance of multivisceral resections in oncologic surgery: A systematic review of the literature. World J Meta-Anal 2019; 7:269-289. [DOI: 10.13105/wjma.v7.i6.269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/07/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Multivisceral resections (MVR) are often necessary to reach clear resections margins but are associated with relevant morbidity and mortality. Factors associated with favorable oncologic outcomes and elevated morbidity rates are not clearly defined.
AIM To systematically review the literature on oncologic long-term outcomes and morbidity and mortality in cancer surgery a systematic review of the literature was performed.
METHODS PubMed was searched for relevant articles (published from 2000 to 2018). Retrieved abstracts were independently screened for relevance and data were extracted from selected studies by two researchers.
RESULTS Included were 37 studies with 3112 patients receiving MVR for colorectal cancer (1095 for colon cancer, 1357 for rectal cancer, and in 660 patients origin was not specified). The most common resected organs were the small intestine, bladder and reproductive organs. Median postoperative morbidity rate was 37.9% (range: 7% to 76.6%) and median postoperative mortality rate was 1.3% (range: 0% to 10%). The median conversion rate for laparoscopic MVR was 7.9% (range: 4.5% to 33%). The median blood loss was lower after laparoscopic MVR compared to the open approach (60 mL vs 638 mL). Lymph-node harvest after laparoscopic MVR was comparable. Report on survival rates was heterogeneous, but the 5-year overall-survival rate ranged from 36.7% to 90%, being worst in recurrent rectal cancer patients with a median 5-year overall survival of 23%. R0 -resection, primary disease setting and no lymph-node or lymphovascular involvement were the strongest predictors for long-term survival. The presence of true malignant adhesions was not exclusively associated with poorer prognosis.
Included were 16 studies with 1.600 patients receiving MVR for gastric cancer. The rate of morbidity ranged from 11.8% to 59.8%, and the main postoperative complications were pancreatic fistulas and pancreatitis, anastomotic leakage, cardiopulmonary events and post-operative bleedings. Total mortality was between 0% and 13.6% with an R0 -resection achieved in 38.4% to 100% of patients. Patients after R0 resection had 5-year overall survival rates of 24.1% to 37.8%.
CONCLUSION MVR provides, in a selected subset of patients, the possibility for good long-term results with acceptable morbidity rates. Unlikelihood of achieving R0 -status, lymphovascular- and lymph -node involvement, recurrent disease setting and the presence of metastatic disease should be regarded as relative contraindications for MVR.
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Affiliation(s)
- Giorgi Nadiradze
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Can Yurttas
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Philipp Horvath
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
- National Center for Pleura and Peritoneum, Tübingen 72076, Germany
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The effect of preoperative nutritional status on postoperative complications and overall survival in patients undergoing pelvic exenteration: A multi-disciplinary, multi-institutional cohort study. Am J Surg 2019; 218:275-280. [PMID: 30982571 DOI: 10.1016/j.amjsurg.2019.03.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/23/2019] [Accepted: 03/28/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Optimization of preoperative nutritional status has been recommended and associated with improved outcomes for other oncologic procedures, but has not been studied in patients undergoing pelvic exenteration. METHODS A retrospective chart review of 199 patients was conducted. Overall survival (OS) was calculated using the Kaplan-Meier method and multivariate analysis was performed with Cox proportional hazards. RESULTS 199 patients underwent PE with 61 (31%), 78 (40%) and 58 (29%) patients having colorectal, gynecologic and urologic histological diagnoses, respectively. Median OS following PE was 25 months. Preoperative serum albumin <3.5 g/dL was associated with worsened OS (HR 1.661; 95% CI 1.052-2.624) as well as increased incidence of any postoperative complication (85.9% vs 72.3%, p = 0.034), but was not associated with 90-day mortality (11.3% vs 7.9%, p = 0.457). CONCLUSION Poor preoperative nutritional status is associated with increased complications and decreased OS. Surgeons should maximize preoperative nutritional status to improve perioperative outcomes and long-term survival.
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Mesquita-Neto JWB, Mouzaihem H, Macedo FIB, Heilbrun LK, Weaver DW, Kim S. Perioperative and oncological outcomes of abdominoperineal resection in the prone position vs the classic lithotomy position: A systematic review with meta-analysis. J Surg Oncol 2019; 119:979-986. [PMID: 30729542 DOI: 10.1002/jso.25402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/26/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES This study is a systematic review with meta-analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out in the prone jack-knife position (P-APR) vs the classic lithotomy position (C-APR). METHODS We conducted an electronic search through PubMed utilizing the PRISMA guidelines. We included all randomized and nonrandomized studies which allowed for comparative analysis between the two groups. Research that focused on and analyzed the extralevator abdominal excision were excluded. Pooled variables and number of events were analyzed using the random-effect model. RESULTS The final analysis included seven nonrandomized retrospective cohorts encompassing 1663 patients. P-APR was associated with decreased operative time (OT) (DM, -43.8 minutes; P < 0.01) and estimated blood loss (EBL) (DM, 86.9 mL; P < 0.01). There were no observed differences regarding perineal wound infections (PWI) (odds ratio [OR], 0.36; P = 0.18), intraoperative perforation of rectum (IOP) (OR, 0.98; P = 0.97), circumferential resection margin (CRM) positivity (OR, 1.02; P = 0.98) or 5-year LR (OR, 1.00; P = 0.99). CONCLUSION The prone approach for APR is associated with decreased EBL and OT, although not with any change in the incidence of PWI or IOP. Moreover, surgical positioning per se does not appear to affect the CRM positivity rates or LR rate.
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Affiliation(s)
- Jose Wilson B Mesquita-Neto
- Department of Surgery, Barbara-Ann Karmanos Comprehensive Cancer Center, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Hassan Mouzaihem
- Department of Surgery, Barbara-Ann Karmanos Comprehensive Cancer Center, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Francisco Igor B Macedo
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Lance K Heilbrun
- Department of Biostatistics, Barbara-Ann Karmanos Comprehensive Cancer Center, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Donald W Weaver
- Department of Surgery, Barbara-Ann Karmanos Comprehensive Cancer Center, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Steve Kim
- Department of Surgery, Barbara-Ann Karmanos Comprehensive Cancer Center, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
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Kulu Y, Mehrabi A, Khajeh E, Klose J, Greenwood J, Hackert T, Büchler MW, Ulrich A. Promising Long-Term Outcomes After Pelvic Exenteration. Ann Surg Oncol 2018; 26:1340-1349. [PMID: 30519763 DOI: 10.1245/s10434-018-07090-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pelvic exenteration (PE) is a complex and challenging surgical procedure. The reported results of this procedure for primary and recurrent disease are limited and conflicting. METHODS This study analyzed patient outcomes after all PEs performed in the authors' department between October 2001 and December 2016. Relevant patient data were obtained from a prospective database. Morbidity and mortality were reported for all patients. For patients with malignant disease, differences in perioperative outcomes, prognostic indicators for overall survival, and local and systemic disease recurrence were analyzed using uni- and multivariate analyses. RESULTS The study enrolled 187 patients. Of the 183 patients with malignant disease, 63 (38.2%) had primary locally advanced tumors and 115 (62.5%) had recurrent tumors. The 10-year overall survival rate was 63.5% for the patients with primary tumors that were curatively resected and 20.9% for the patients with recurrent disease (p = 0.02). The 10-year survival rate for the patients with extrapelvic disease who underwent curative resection was 37%. Multivariable analysis identified margin positivity (p < 0.01), surgery lasting longer than 7 h (p = 0.02), and recurrent disease (p < 0.01) as predictors of poor survival. Multivariate analysis of local and systemic disease recurrence showed recurrent disease (p < 0.01) as the only significant prognostic factor. CONCLUSIONS Pelvic exenteration has good long-term results, even for patients with extrapelvic disease. The oncologic outcome for patients with recurrent disease is worse than for patients with primary disease. However, even for these patients, long-time survival is possible.
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Affiliation(s)
- Yakup Kulu
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Johannes Klose
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Johanna Greenwood
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alexis Ulrich
- Chirurgische Klinik I, Lukaskrankenhaus Neuss, Neuss, Germany
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Pokharkar A, Kammar P, D'souza A, Bhamre R, Sugoor P, Saklani A. Laparoscopic Pelvic Exenteration for Locally Advanced Rectal Cancer, Technique and Short-Term Outcomes. J Laparoendosc Adv Surg Tech A 2018; 28:1489-1494. [PMID: 29741977 DOI: 10.1089/lap.2018.0147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
| | - Praveen Kammar
- Colorectal Services, Tata Memorial Hospital, Mumbai, India
| | - Ashwin D'souza
- Colorectal Services, Tata Memorial Hospital, Mumbai, India
| | - Rahul Bhamre
- Colorectal Services, Tata Memorial Hospital, Mumbai, India
| | - Pavan Sugoor
- Colorectal Services, Tata Memorial Hospital, Mumbai, India
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18
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Platt E, Dovell G, Smolarek S. Systematic review of outcomes following pelvic exenteration for the treatment of primary and recurrent locally advanced rectal cancer. Tech Coloproctol 2018; 22:835-845. [PMID: 30506497 DOI: 10.1007/s10151-018-1883-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 11/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pelvic exenteration represents the best treatment option for cure of locally advanced or recurrent rectal cancer. This systematic review sought to evaluate current literature regarding short and long term treatment outcomes and long term survival following pelvic exenteration. METHODS A systematic search of the MEDLINE, PubMed and Ovid databases was conducted to identify suitable articles published between 2001 and 2016. The article search was performed in line with Cochrane methodology and reported according to the Preferred Reporting Items for Systematic reviews and Meta-analyses statement. RESULTS Sixteen studies were included in the final analysis, incorporating 1016 patients. Sixty-three percent of patients were male and median patient age was 59 years. Median operating time was 7.2 h with median blood loss of 1.9 l. Median postoperative stay was 17 days with a median 30-day mortality of 0. Complication rates were 31.6-86% with a return to theatre rate of 14.6%. Median R0 resection rate was 74% and was higher for primary cancer (82.6% versus 58% for recurrent cancer). Mean overall survival was 31 months and median 5-year survival was 32%. Recurrently identified indicators of adverse outcome included R1/2 resection, preoperative pelvic pain and previous abdominoperineal resection of the rectum. CONCLUSIONS Pelvic exenteration remains a major operation associated with significant morbidity and mortality. Despite advances in preoperative assessment and staging, R1 resection rates remain high. There is also a high degree of variability of reporting outcomes and standardisation of this process would aid comparison of results between centres and drive forward research in this area.
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Affiliation(s)
- E Platt
- Colorectal Unit, Derriford Hospital, Plymouth Hospital NHS Trust, Plymouth, UK.
| | - G Dovell
- Colorectal Unit, Derriford Hospital, Plymouth Hospital NHS Trust, Plymouth, UK
| | - S Smolarek
- Colorectal Unit, Derriford Hospital, Plymouth Hospital NHS Trust, Plymouth, UK
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19
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Abstract
BACKGROUND Multivisceral resections seem to be naturally associated with an elevated morbidity rate. Data regarding the impact of multivisceral resections on progression-free and overall survival are only available in insufficient quantities. OBJECTIVE Data on multivisceral resections in cancer surgery are presented exemplified by gastric cancer, colorectal cancer and peritoneal metastases, focusing on overall and progression-free survival as well as morbidity and mortality. MATERIAL AND METHODS A PubMed search was carried out including the following terms: multivisceral resection, peritoneal metastases, cytoreduction, morbidity, HIPEC (hyperthermic intraperitoneal chemotherapy) RESULTS: Multivisceral resections should only be performed if an R0 status can be achieved for all tumor entities. Preoperative performance of an FDG-PET-CT scan (fluorodeoxyglucose positron emission tomography computed tomography scan) can help in the selection of appropriate patients. In gastric cancer, extensive lymphatic metastases are associated with a poor overall survival despite multivisceral resection. Recurrent rectal cancer shows elevated morbidity rates and also decreased overall survival rates. Maximum cytoreductive surgery can be conducted for peritoneal metastasized appendiceal neoplasms and colorectal cancer with acceptable morbidity and without an increased risk for reduced overall survival. CONCLUSION After adequate patient selection and exclusion of stage IV distant metastatic disease, multivisceral resections can be offered to patients with the goal of an R0 resection.
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Affiliation(s)
- P Horvath
- Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - A Königsrainer
- Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland.
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20
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Beyond total mesorectal excision in locally advanced rectal cancer with organ or pelvic side-wall involvement. Eur J Surg Oncol 2018; 44:1226-1232. [DOI: 10.1016/j.ejso.2018.03.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 02/28/2018] [Accepted: 03/31/2018] [Indexed: 01/07/2023] Open
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21
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Iversen H, Martling A, Johansson H, Nilsson PJ, Holm T. Pelvic local recurrence from colorectal cancer: surgical challenge with changing preconditions. Colorectal Dis 2018; 20:399-406. [PMID: 29161761 DOI: 10.1111/codi.13966] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/03/2017] [Indexed: 02/08/2023]
Abstract
AIM Although the rate of local recurrence (LR) after colorectal cancer surgery has decreased, it still poses major surgical and oncological challenges. The aims of this study, based on an audit from a tertiary referral centre, was to evaluate determinants associated with outcomes after surgery for pelvic LR and how these have changed over time. METHOD Retrospective analysis of all resections for pelvic LR of colorectal cancer performed at the Karolinska University Hospital from January 2003 until August 2009 (period 1) and from September 2009 until November 2013 (period 2) . RESULTS Ninety-five patients with pelvic LR were operated on with a curative intent. An R0 resection was achieved in 77% and an R1 resection in 23%. Lateral compartments were invaded in 48% and this proportion increased in resections performed in period 2 (37% vs 60%, P = 0.05). R1 resections were associated with a higher risk of local re-recurrence than R0 resections (64% vs 16%; OR = 8.90, 95% CI: 2.71-29.78). Lateral recurrences were associated with a lower R0-resection rate than nonlateral recurrences (63% vs 90%; OR = 0.20, 95% CI: 0.05-0.64) and a higher risk of treatment failure in terms of local re-recurrence or distant metastases, or death, as first event (hazard ratio [HR] = 1.75, 95% CI: 1.06-2.75). However, in a multivariate analysis only R1 resections remained a significant prognostic factor for treatment failure (HR = 2.37, 95% CI: 1.32-4.27). CONCLUSION The proportion of lateral pelvic recurrences has increased over time. In comparison with non-lateral LRs, lateral LRs are more difficult to resect radically and are associated with worse overall and disease-free survival. However, with radical surgery many patients with pelvic locally recurrent colorectal cancer may be offered curative treatment.
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Affiliation(s)
- H Iversen
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - A Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - H Johansson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - P J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - T Holm
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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Abstract
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.
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Abstract
BACKGROUND Pelvic exenterations are extensive surgical procedures for locally advanced or recurrent malignancies of the pelvis. However, this is often at the cost of significant morbidity due to perioperative pain, which has been poorly studied. OBJECTIVE This study aims to review perioperative pain management in patients undergoing pelvic exenteration. DESIGN This is a retrospective review of patients undergoing pelvic exenteration between January 2013 and December 2014. Data were gathered from medical records and a prospectively maintained database. SETTING This study was conducted at a single quaternary referral center for pelvic exenteration. PATIENTS Consecutive patients underwent pelvic exenteration at a single center. INTERVENTIONS Pelvic exenteration was performed in consecutive patients. MAIN OUTCOMES MEASURES Primary outcomes were the prevalence of preoperative pain, preoperative opiate use (type, dosage), and postoperative pain (verbal numerical rating scale). Secondary outcomes included the number of pain consultations and correlations between preoperative opiate use, length of stay, and extent of resection (en bloc sacrectomy and nerve excision). RESULTS Ninety-nine patients underwent pelvic exenteration. Sixty-one patients (61.6%) underwent major nerve resection and/or sacrectomy. Thirty patients (30%) required opiates preoperatively, with a mean daily morphine equivalent of 72.9 mg (SD 65.0 mg). Patients on preoperative opiates were more likely to have worse pain postoperatively and to require higher opiate doses and more pain consultations (9.3 vs 4.8; p < 0.001). Major nerve excision and sacrectomy were not associated with worse postoperative pain. By discharge, 60% still required opiate analgesia. LIMITATIONS Retrospective study design, the subjective nature of pain assessment because of a lack of valid methods to objectively quantify pain, and the lack of long-term follow-up were limitations of this study. CONCLUSIONS Perioperative pain is a significant issue among patients undergoing pelvic exenteration. One in three patients require high-dose opiates preoperatively that is associated with worse pain outcomes. Potential areas to improve pain outcomes in these complex patients could include increased use of regional anesthesia, antineuropathic agents, and opiate-sparing techniques. See Video Abstract at http://links.lww.com/DCR/A572.
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Mesquita JWBD, Machado DB, Macedo DJ, Cordeiro DF, Brito EVD, Costa MLV. Extended pelvic resections for the treatment of locally advanced and recurrent anal canal and colorectal cancer: technical aspects and morbimortality predictors aftet 24 consecutive cases. Rev Col Bras Cir 2017; 43:93-101. [PMID: 27275590 DOI: 10.1590/0100-69912016002005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 03/07/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to evaluate the profile of morbidity and mortality and its predictors related to extensive pelvic resections, including pelvic exenteration, to optimize the selection of patients and achieve better surgical results. METHODS we performed 24 major resections for anorectal pelvic malignancy from 2008 to 2015 in the Instituto do Câncer do Ceará. The factors analyzed included age, weight loss, resected organs, total versus posterior exenteration, angiolymphatic and perineural invasion, lymph node metastasis and overall and disease-free survival. RESULTS the median age was 57 years and the mean follow-up was ten months. Overall morbidity was 45.8%, with five (20.8%) serious complications. There were no deaths in the first 30 postoperative days. The median overall survival was 39.5 months, and disease-free survival, 30.7 months. Concomitant resection of the bladder was an isolated prognostic factor for higher risk of complications (87.5% vs. 26.7%, p = 0.009). Angiolymphatic invasion and lymph node metastasis did not reach significance with respect to disease-free survival. CONCLUSION treatment of advanced anorectal tumors is challenging, often requiring combined resections, such as cystectomy and sacrectomy, and complex reconstructions. The magnitude of the operation still carries a high morbidity rate, but is a procedure considered safe and feasible, with a low mortality and adequate locoregional tumor control when performed in referral centers. OBJETIVOS avaliar o perfil de morbimortalidade e seus fatores preditivos relacionados às ressecções pélvicas extensas, incluindo a exenteração pélvica, com o intuito de otimizar a seleção dos pacientes e obtenção de melhores resultados cirúrgicos. MÉTODOS foram realizadas 24 grandes ressecções pélvicas por neoplasia maligna anorretal de 2008 a 2015 no Instituto do Câncer do Ceará. Os fatores analisados incluíram idade, perda de peso, órgão ressecados, exenteração total versus posterior, invasão angiolinfática e perineural, metástase linfonodal e sobrevida global e livre de doença. RESULTADOS a mediana de idade foi 57 anos e o tempo médio de seguimento foi dez meses. A morbidade global foi 45,8%, com cinco (20,8%) complicações graves. Não houve óbito nos primeiros 30 dias de pós-operatório. A sobrevida global média foi 39,5 meses e a sobrevida livre de doença foi 30,7 meses. A ressecção concomitante da bexiga foi fator prognóstico isolado com maior risco para complicações (87,5% vs. 26,7%, p=0.009). Invasão angiolinfática e metástase linfonodal não alcançaram significância com relação à sobrevida livre de doença. CONCLUSÃO o tratamento dos tumores anorretais avançados é desafiador, necessitando frequentemente de ressecções combinadas, como a cistectomia e sacrectomia, além de reconstruções complexas. A magnitude da cirurgia ainda carrega uma elevada taxa de morbidade, porém é um procedimento considerado seguro e factível, com uma baixa mortalidade e adequado controle locorregional tumoral quando realizado em centros de referência.
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Affiliation(s)
- José Wilson Benevides de Mesquita
- Departamento de Oncologia Digestiva. Instituto do Câncer do Ceará - Hospital Haroldo Juaçaba (HHJ-ICC). Fortaleza/CE, Brasil, Departamento de Oncologia Digestiva, Instituto do Câncer do Ceará, Hospital Haroldo Juaçaba, Fortaleza CE , Brasil
| | - Davy Bruno Machado
- Departamento de Oncologia Digestiva. Instituto do Câncer do Ceará - Hospital Haroldo Juaçaba (HHJ-ICC). Fortaleza/CE, Brasil, Departamento de Oncologia Digestiva, Instituto do Câncer do Ceará, Hospital Haroldo Juaçaba, Fortaleza CE , Brasil
| | - Dárcio Jânio Macedo
- Programa de Cancerologia Cirúrgica. Instituto do Câncer do Ceará - Hospital Haroldo Juaçaba (HHJ-ICC). Fortaleza/CE, Brasil, Instituto do Câncer do Ceará, Hospital Haroldo Juaçaba, Fortaleza CE , Brasil
| | - Diego Fonseca Cordeiro
- Escola Cearense de Oncologia. Instituto do Câncer do Ceará - Hospital Haroldo Juaçaba (HHJ-ICC). Fortaleza/CE, Brasil, Escola Cearense de Oncologia, Instituto do Câncer do Ceará, Hospital Haroldo Juaçaba, Fortaleza CE , Brasil
| | - Eurivaldo Valente de Brito
- Escola Cearense de Oncologia. Instituto do Câncer do Ceará - Hospital Haroldo Juaçaba (HHJ-ICC). Fortaleza/CE, Brasil, Escola Cearense de Oncologia, Instituto do Câncer do Ceará, Hospital Haroldo Juaçaba, Fortaleza CE , Brasil
| | - Marcelo Leite Vieira Costa
- Departamento de Cirurgia da Faculdade de Medicina da Universidade Federal do Ceará. Fortaleza/CE, Brasil, Universidade Federal do Ceará, Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza CE , Brazil
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Guo Y, Chang E, Bozkurt M, Park M, Liu D, Fu JB. Factors affecting hospital length of stay following pelvic exenteration surgery. J Surg Oncol 2017; 117:529-534. [PMID: 29044540 DOI: 10.1002/jso.24878] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 09/19/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Total pelvic exenteration are performed in patients with locally advanced or recurrent pelvic malignances. Many patients have prolong hospital length of stay (LOS), but risk factors are not clearly identified. METHODS From 2002 through 2012, 100 consecutive patients undergoing pelvic exenteration were retrospectively reviewed. A general linear model was used to examine risk factors for prolonged hospital LOS. RESULTS Among the 100 patients, 51 had gastrointestinal cancer, 14 had genitourinary cancer, 31 had gynecologic cancer, and 4 had sarcoma. Perioperative complications included infection (n = 44), anastomotic leak/fistula (n = 6), wound or flap dehiscence (n = 11), and ileus or bowel obstruction (n = 30). The median (Interquartile range (IQR)) hospital LOS was 15 days (10-21.5 days). On multivariate regression analysis, hospital LOS was significantly prolonged by underweight status, genitourinary cancer or sarcoma diagnosis, ≥2 infections, anastomotic leak/fistula, requiring rehabilitation consult and admission, and ≥2 consultations (P = 0.05). CONCLUSION In patients undergoing pelvic exenteration, prolonged hospital LOS is associated with underweight status, genitourinary cancer or sarcoma diagnosis, more than one infection, anastomotic leak/fistula, requiring rehabilitation consult and admission, and more than one consultation. Further study is needed to assess whether minimizing these risk factors can improve hospital LOS in these patients.
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Affiliation(s)
- Ying Guo
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eugene Chang
- Department of Medicine, Division of Physical Medicine and Rehabilitation, Toronto Rehabilitation Institute, Toronto, Canada
| | - Mehtap Bozkurt
- Department of Physical Medicine and Rehabilitation, Dicle University Faculty of Medicine, Diyarbakir, Turkey
| | - Minjeong Park
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack B Fu
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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26
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Botoncea M, Varlam CM, Chiujdea A, Molnar C. Supralevator Total Pelvic Exenteration Without Colostomy — Case Report. JOURNAL OF INTERDISCIPLINARY MEDICINE 2017. [DOI: 10.1515/jim-2017-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background: Pelvic exenteration is an ultra-radical surgical procedure described by Brunschwig in 1948, which attempts to surgically cure patients with recurrent pelvic cancer after radiotherapy. Several variants of pelvic exenteration are described that allow a more limited or extensive resection, depending on the stage of the disease.
Case report: We report the case of a 54-year-old woman, who was diagnosed with a tumoral rectovaginal fistula after a recurrent cervical cancer that had been treated with a total hysterectomy with bilateral adnexectomy and a left percutaneous nephrostomy, as well as interaortocaval lymph node resection. The patient had undergone a supralevator total pelvic exenteration with pelvic and interaortocaval lymphadenectomy. The reconstruction process included right ureterostomy, left nephrostomy, and colocutaneous anal anastomosis (Parks procedure).
Conclusions: Supralevator total pelvic exenteration provides hope for cure in patients with pelvic malignancies that reappear after radiotherapy. The restoration of the digestive tract and avoiding colostomy with a colocutaneous anastomosis increases the quality of life in these cases.
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Affiliation(s)
- Marian Botoncea
- Clinic of Surgery I, County Emergency Clinical Hospital , Tîrgu Mureș , Romania
| | | | - Adrian Chiujdea
- Clinic of Obstetrics and Gynecology I, County Emergency Clinical Hospital , Tîrgu Mureș , Romania
| | - Călin Molnar
- Clinic of Surgery I, County Emergency Clinical Hospital , Tîrgu Mureș , Romania
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27
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Dosokey EMG, Brady JT, Neupane R, Jabir MA, Stein SL, Reynolds HL, Delaney CP, Steele SR. Do patients requiring a multivisceral resection for rectal cancer have worse oncologic outcomes than patients undergoing only abdominoperineal resection? Am J Surg 2017. [PMID: 28622838 DOI: 10.1016/j.amjsurg.2017.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Abdominoperineal Resection (APR) remains an important option for patients with advanced rectal cancer though some may require multivisceral resection (MVR) in addition to APR. We hypothesized that oncological outcomes would be worse with MVR. METHODS A retrospective review from 2006 to 2015 of 161 patients undergoing APR or MVR for rectal cancer, of whom 118 underwent curative APR or APR with MVR. Perioperative, oncologic and survival metrics were evaluated. RESULTS There were 82 patients who underwent APR and 36 who underwent MVR. Surgical approach and incidence of complications were similar (All P > 0.05). There was 1 local recurrence in each of the APR and MVR groups at a mean follow-up of 34 and 32 months, respectively. Distant recurrences occurred in 3 APR patients and 4 MVR patients. CONCLUSIONS APR and APR with MVR can be performed with comparable morbidity and oncologic outcomes.
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Affiliation(s)
- Eslam M G Dosokey
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Surgical Oncology, SECI, Assiut University, Assiut, Egypt
| | - Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Ruel Neupane
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Murad A Jabir
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sharon L Stein
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Harry L Reynolds
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Conor P Delaney
- Digestive Disease and Surgical Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Scott R Steele
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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28
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Short- and long-term outcomes following pelvic exenteration for gynae-oncological and colorectal cancers: A 9 year consecutive single-centre cohort study. Int J Surg 2017; 43:38-45. [PMID: 28529192 DOI: 10.1016/j.ijsu.2017.05.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/04/2017] [Accepted: 05/16/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Radical pelvic exenteration can be undertaken for locally invasive or recurrent disease in both colorectal and gynaecological malignancies. In the UK this procedure is usually undertaken by the respective surgical specialties who have undergone divergent surgical training. This study describes and compares outcomes between colorectal and gynae-oncological teams following pelvic exenteration for primary and recurrent gynaecological and colorectal cancers in a single-centre multi-disciplinary team. METHOD A retrospective review of consecutive pelvic exenteration patients undertaken over a nine-year period in a tertiary referral centre. Analyses comparing short- and long-term morbidity and mortality outcomes were undertaken by chi-square test for categorical variables and Mann-Whitney U for continuous variables. Cumulative survival rates were calculated according to the Kaplan-Meier method and factors associated with recurrence and survival determined using a Cox regression model. RESULTS Thirty-four exenterations were undertaken; fourteen colorectal and twenty gynae-oncological. Morbidity was seen in 50% of colorectal and 75% of gynae-oncological patients. Recurrence was seen earlier and with greater frequency in the gynaeoncology group (44.4% and median time 11 months) than the colorectal group (21.4%, median time 41 months; p > 0.05). Survival in the gynae-oncology group was also lower than the colorectal group at 1-year (69.6% vs. 92.9%) and 5-years (58.0% vs. 92.9%; p = 0.115). The majority of gynae-oncological mortality occurred within 3-years of surgery, whilst the majority of mortality in the colorectal group was after 5-years. CONCLUSION Long-term patient outcome measures, including disease recurrence and 5-year survival, for colorectal exenteration appear better than for gynaeoncology patients, however, no statistical significant difference exists between short-term outcome measures between specialties. This is likely to be caused by different baseline pathologies and disease pattern influencing longer term prognosis but may also be a function of differing surgical thresholds and patient selection bias between specialties. Peri-operative and short-term morbidity appear equivalent despite divergent surgical backgrounds and training.
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29
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Rausa E, Kelly ME, Bonavina L, O'Connell PR, Winter DC. A systematic review examining quality of life following pelvic exenteration for locally advanced and recurrent rectal cancer. Colorectal Dis 2017; 19:430-436. [PMID: 28267255 DOI: 10.1111/codi.13647] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/23/2017] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- E Rausa
- Department of Colorectal Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland.,Department of Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, San Donato Milanese (Milano), Italy
| | - M E Kelly
- Department of Colorectal Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - L Bonavina
- Department of Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, San Donato Milanese (Milano), Italy
| | - P R O'Connell
- Department of Colorectal Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland.,Section of Surgery, UCD School of Medicine, Dublin, Ireland
| | - D C Winter
- Department of Colorectal Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland.,Section of Surgery, UCD School of Medicine, Dublin, Ireland
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30
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Kontovounisios C, Tan E, Pawa N, Brown G, Tait D, Cunningham D, Rasheed S, Tekkis P. The selection process can improve the outcome in locally advanced and recurrent colorectal cancer: activity and results of a dedicated multidisciplinary colorectal cancer centre. Colorectal Dis 2017; 19:331-338. [PMID: 27629565 DOI: 10.1111/codi.13517] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/23/2016] [Indexed: 12/31/2022]
Abstract
AIM There is wide disparity in the care of patients with multivisceral involvement of rectal cancer. The results are presented of treatment of advanced and recurrent colorectal cancer from a centre where a dedicated multidisciplinary team (MDT) is central to the management. METHOD All consecutive MDT referrals between 2010 and 2014 were examined. Analysis was undertaken of the referral pathway, site, selection process, management decision, R0 resection rate, mortality/morbidity/Clavien-Dindo (CD) classification of morbidity, length of stay (LOS) and improvement of quality of life. RESULTS There were 954 referrals. These included locally advanced primary rectal cancer (LAPRC b-TME) (39.0%), rectal recurrence (RR) (22.0%), locally advanced primary colon cancer (LAPCC T3c/d-T4) (21.1%), colon cancer recurrence (CR) (12.4%), locally advanced primary anal cancer (LAPAC-failure of CRT/T3c/d-T4) (3.0%) and anal cancer recurrence (AR) (2.2%). Among these patients 271 operations were performed, 212 primary and 59 for recurrence. These included 16 sacrectomies, 134 total pelvic exenterations and 121 other multi-visceral exenterative procedures. An R0 resection (no microscopic margin involvement) was achieved in 94.4% and R1 (microscopic margin involvement) in 5.1%. In LAPRC b-TME the R0 rate was 96.1% and for RR it was 79%. The LOS varied from 13.3 to 19.9 days. RR operations had the highest morbidity (CD 1-2, 33.3%) and LAPRC operations had the highest rate of CD 3-4 complications (18.4%). Most (39.6%) of the referred patients were from other UK hospitals. CONCLUSION Advanced colorectal cancer can be successfully treated in a dedicated referral centre, achieving R0 resection in over 90% with low morbidity and mortality. Implementation of a standardized referral pathway is encouraged.
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Affiliation(s)
- C Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - E Tan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - N Pawa
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - G Brown
- Department of Radiology, The Royal Marsden Hospital, London, UK
| | - D Tait
- Department of Clinical Oncology, The Royal Marsden Hospital, London, UK
| | - D Cunningham
- Gastrointestinal and Lymphoma Unit, The Royal Marsden Hospital, London, UK
| | - S Rasheed
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - P Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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31
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Efficacy of an additional flap operation in bladder-preserving surgery with radical prostatectomy and cystourethral anastomosis for rectal cancer involving the prostate. Surg Today 2017; 47:1119-1128. [PMID: 28260135 PMCID: PMC5532415 DOI: 10.1007/s00595-017-1484-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/12/2017] [Indexed: 02/07/2023]
Abstract
Purpose Sphincter-preserving operations performed with bladder-preserving surgery and a cystourethral anastomosis (CUA) do not require a urinary stoma, but leakage from the CUA may develop. The aim of this study was to evaluate the efficacy of performing an additional flap operation. Methods The subjects were 39 patients who underwent bladder-preserving surgery for advanced rectal cancer involving the prostate, between 2001 and 2015.32 of whom had a CUA and one of whom had a neobladder. Five of these 32 patients underwent an ileal flap operation, 2 underwent an omental flap operation, and 3 underwent an operation using both flaps. Results Leakage developed in 3 (30%) of the 10 patients who underwent additional flap operations, but in 14 (60.9%) of the 23 patients who did not undergo a flap operation. The mean periods of catheterization for the patients who suffered leakage were 31 weeks (8–108 weeks) in those without a flap and 16 weeks (8–20 weeks) in those with a flap. Four (33.3%) of the 12 patients with leakage after surgery without a flap had a period of urinary catheterization >30 weeks, and 2 (16.7%) had leakage of CTCAE grade 3. There were no cases of leakage after flap surgery. Conclusion An additional flap operation may decrease the risk of leakage from a CUA.
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Kokelaar RF, Evans MD, Davies M, Harris DA, Beynon J. Locally advanced rectal cancer: management challenges. Onco Targets Ther 2016; 9:6265-6272. [PMID: 27785074 PMCID: PMC5066998 DOI: 10.2147/ott.s100806] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Between 5% and 10% of patients with rectal cancer present with locally advanced rectal cancer (LARC), and 10% of rectal cancers recur after surgery, of which half are limited to locoregional disease only (locally recurrent rectal cancer). Exenterative surgery offers the best long-term outcomes for patients with LARC and locally recurrent rectal cancer so long as a complete (R0) resection is achieved. Accurate preoperative multimodal staging is crucial in assessing the potential operability of advanced rectal tumors, and resectability may be enhanced with neoadjuvant therapies. Unfortunately, surgical options are limited when the tumor involves the lateral pelvic sidewall or high sacrum due to the technical challenges of achieving histological clearance, and must be balanced against the high morbidity associated with resection of the bony pelvis and significant lymphovascular structures. This group of patients is usually treated palliatively and subsequently survival is poor, which has led surgeons to seek innovative new solutions, as well as revisit previously discarded radical approaches. A small number of centers are pioneering new techniques for resection of beyond-total mesorectal excision tumors, including en bloc resections of the sciatic notch and composite resections of the first two sacral vertebrae. Despite limited experience, these new techniques offer the potential for radical treatment of previously inoperable tumors. This narrative review sets out the challenges facing the management of LARCs and discusses evolving management options.
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Affiliation(s)
- R F Kokelaar
- Department of Colorectal Surgery, Singleton Hospital, Swansea, UK
| | - M D Evans
- Department of Colorectal Surgery, Singleton Hospital, Swansea, UK
| | - M Davies
- Department of Colorectal Surgery, Singleton Hospital, Swansea, UK
| | - D A Harris
- Department of Colorectal Surgery, Singleton Hospital, Swansea, UK
| | - J Beynon
- Department of Colorectal Surgery, Singleton Hospital, Swansea, UK
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33
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Techniques and Outcome of Surgery for Locally Advanced and Local Recurrent Rectal Cancer. Clin Oncol (R Coll Radiol) 2015; 28:103-115. [PMID: 26683258 DOI: 10.1016/j.clon.2015.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 11/10/2015] [Accepted: 11/11/2015] [Indexed: 02/07/2023]
Abstract
Locally advanced primary rectal cancer is variably defined, but generally refers to T3 and T4 tumours. Radical surgery is the mainstay of treatment for these tumours but there is a high-risk for local recurrence. National Institute for Health and Care Excellence (2011) guidelines recommend that patients with these tumours be considered for preoperative chemoradiotherapy and this is the starting point for any discussion, as it is standard care. However, there are many refinements of this pathway and these are the subject of this overview. In surgical terms, there are two broad settings: (i) patients with tumours contained within the mesorectal envelope, or in the lower rectum, limited to invading the sphincter muscles (namely some T2 and most T3 tumours); and (ii) patients with tumours directly invading or adherent to pelvic organs or structures, mainly T4 tumours - here referred to as primary rectal cancer beyond total mesorectal excision (PRC-bTME). Major surgical resection using the principles of TME is the mainstay of treatment for the former. Where anal sphincter sacrifice is indicated for low rectal cancers, variations of abdominoperineal resection - referred to as tailored excision - including the extralevator abdominoperineal excision (ELAPE), are required. There is debate whether or not plastic reconstruction or mesh repair is required after these surgical procedures. To achieve cure in PRC-bTME tumours, most patients require extended multivisceral exenterative surgery, carried out within specialist multidisciplinary centres. The surgical principles governing the treatment of recurrent rectal cancer (RRC) parallel those for PRC-bTME, but typically only half of these patients are suitable for this type of major surgery. Peri-operative morbidity and mortality are considerable after surgery for PRC-bTME and RRC, but unacceptable levels of variation in clinical practice and outcome exist globally. To address this, there are now major efforts to standardise terminology and classifications, to allow appropriate comparisons in future studies.
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Solomon MJ, Brown KGM, Koh CE, Lee P, Austin KKS, Masya L. Lateral pelvic compartment excision during pelvic exenteration. Br J Surg 2015; 102:1710-7. [PMID: 26694992 DOI: 10.1002/bjs.9915] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/05/2015] [Accepted: 07/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Involvement of the lateral compartment remains a relative or absolute contraindication to pelvic exenteration in most units. Initial experience with exenteration in the authors' unit produced a 21 per cent clear margin rate (R0), which improved to 53 per cent by adopting a novel technique for en bloc resection of the iliac vessels and other side-wall structures. The objective of this study was to report morbidity and oncological outcomes in consecutive exenterations involving the lateral compartment. METHODS Patients undergoing pelvic exenteration between 1994 and 2014 were eligible for review. RESULTS Two hundred consecutive patients who had en bloc resection of the lateral compartment were included. R0 resection was achieved in 66·5 per cent of 197 patients undergoing surgery for cancer and 68·9 per cent of planned curative resections. For patients with colorectal cancer, a clear resection margin was associated with a significant overall survival benefit (P = 0·030). Median overall and disease-free survival in this group was 41 and 27 months respectively. Overall 1-, 3- and 5-year survival rates were 86, 46 and 35 per cent respectively. No predictors of survival were identified on univariable analysis other than margin status and operative intent. Excision of the common or external iliac vessels or sciatic nerve did not confer a survival disadvantage. CONCLUSION The continuing evolution of radical pelvic exenteration techniques has seen an improvement in R0 margin status from 21 to 66·5 per cent over a 20-year interval by routine adoption of a more lateral anatomical plane. Five-year overall survival rates are comparable with those for more centrally based tumours.
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Affiliation(s)
- M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney Local Health District, New South Wales, Australia.,Discipline of Surgery, University of Sydney, Sydney, New South Wales, Australia
| | - K G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - C E Koh
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney Local Health District, New South Wales, Australia
| | - P Lee
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
| | - K K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
| | - L Masya
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia
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Abstract
OBJECTIVE MRI is the modality of choice for rectal cancer staging. The high soft-tissue contrast of MRI accurately assesses the extramural tumor spread and relation to mesorectal fascia and the sphincter complex. This article reviews the role of MRI in the staging and treatment of rectal cancer. The relevant anatomy, MRI techniques, preoperative staging, post-chemoradiation therapy (CRT) imaging, and tumor recurrence are discussed with special attention to recent advances in knowledge. CONCLUSION MRI is the modality of choice for staging rectal cancer to assist surgeons in obtaining negative surgical margins. MRI facilitates the accurate assessment of mesorectal fascia and the sphincter complex for surgical planning. Multiparametric MRI may also help in the prediction and estimation of response to treatment and in the detection of recurrent disease.
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36
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Yang HY, Park SC, Hyun JH, Seo HK, Oh JH. Outcomes of pelvic exenteration for recurrent or primary locally advanced colorectal cancer. Ann Surg Treat Res 2015; 89:131-7. [PMID: 26366382 PMCID: PMC4559615 DOI: 10.4174/astr.2015.89.3.131] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 04/13/2015] [Accepted: 04/24/2015] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The objective of this study was to assess the clinical outcomes of pelvic exenteration for patients with primary locally advanced colorectal cancer (LACRC) or locally recurrent colorectal cancer (LRCRC), and to identify clinically relevant prognostic factors. METHODS Between January 2001 and December 2010, 40 consecutive patients with primary LACRC or LRCRC underwent pelvic exenteration at the National Cancer Center, Republic of Korea. We retrospectively reviewed their medical records. RESULTS The median age was 59 years and the median follow-up time was 26 months (range, 1-117 months). The overall complication and in-hospital mortality rates were 70% (28/40) and 7.5% (3/40), respectively. The complication rates were similar between patients with primary LACRC (69.6%) and those with LRCRC (70.6%). The overall recurrence rate was 50% (17/34), and was lower in patients with primary LACRC than in patients with LRCRC (33.3% vs. 76.9%, P = 0.032). The 5-year overall survival was significantly different between primary LACRC and patients with LRCRC (58.7% vs. 11.8%, P = 0.022). Multivariate analysis revealed that radicality (R0 vs. R1/R2) was an independent prognostic factor for overall survival (P = 0.020). CONCLUSION The complication and operative mortality rates of pelvic exenteration remained high, but pelvic exenteration might provide an opportunity for long-term survival and good local control. Complete (R0) resection was the only independent prognostic factor for overall survival.
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Affiliation(s)
- Hwa Yeon Yang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jong Hee Hyun
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Ho Kyung Seo
- Center for Prostate Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Kye BH, Kim HJ, Kim G, Kim JG, Cho HM. Multimodal Assessments Are Needed for Restaging after Neoadjunvant Chemoradiation Therapy in Rectal Cancer Patients. Cancer Res Treat 2015; 48:561-6. [PMID: 26323642 PMCID: PMC4843748 DOI: 10.4143/crt.2015.114] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 07/07/2015] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Restaging after neoadjuvant treatment is done for planning the surgical approach and, increasingly, to determine whether additional therapy or resection can be avoided for selected patients. MATERIALS AND METHODS Local restaging after neoadjuvant chemoradiation therapy (nCRT) was performed in 270 patients with locally advanced (cT3or4 or N+) rectal cancer. Abdomen and pelvic computed tomography (APCT) was used in all 270 patients, transrectal ultrasound (TRUS) in 121 patients, and rectal magnetic resonance imaging (MRI) in 65 patients. Findings according to imaging modalities were correlated with pathologic stage using Cohen's kappa (κ) to test agreement and intra-class correlation coefficient α to test reliability. RESULTS Accuracy for prediction of ypT stage according to three imaging modalities was 45.2% (κ=0.136, α=0.380) in APCT, 49.2% (κ=0.259, α=0.514) in rectal MRI, and 57.9% (κ=0.266, α=0.520) in TRUS. Accuracy for prediction of ypN stage was 66.0% (κ=0.274, α=0.441) in APCT, 71.8% (κ=0.401, α=0.549) in rectal MRI, and 66.1% (κ=0.147, α=0.272) in TRUS. Of 270 patients, 37 (13.7%) were diagnosed as pathologic complete responder after nCRT. Rectal MRI for restaging did not predict complete response. On the other hand, TRUS did predict three complete responders (κ=0.238, α=0.401). CONCLUSION APCT, rectal MRI, and TRUS are unreliable in restaging rectal cancer after nCRT. We think that multimodal assessment with rectal MRI and TRUS may be the best option for local restaging of locally advanced rectal cancer after nCRT.
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Affiliation(s)
- Bong-Hyeon Kye
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hyung-Jin Kim
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Gun Kim
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jun-Gi Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeon-Min Cho
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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Radwan RW, Jones HG, Rawat N, Davies M, Evans MD, Harris DA, Beynon J. Determinants of survival following pelvic exenteration for primary rectal cancer. Br J Surg 2015; 102:1278-84. [PMID: 26095525 DOI: 10.1002/bjs.9841] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/26/2015] [Accepted: 04/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pelvic exenteration is a potentially curative treatment for locally advanced primary rectal cancer. Previous studies have been limited by small sample sizes and heterogeneous data. A consecutive series of patients was studied to identify the clinicopathological determinants of survival. METHODS All patients undergoing pelvic exenterative surgery for primary rectal cancer (1992-2014) at this hospital were analysed. The primary outcome measure was 5-year overall survival. Secondary endpoints included length of hospital stay, complication rate, 30-day mortality and disease recurrence rate. Statistical analysis was performed using Kaplan-Meier and Cox regression analysis. RESULTS A total of 174 patients with a median age of 65 (range 31-90) years were included. Ninety-six patients underwent posterior pelvic exenteration and 78 had total pelvic exenteration. Median follow-up was 48 (range 1-229) months. Two patients (1.1 per cent) died within 30 days of surgery and 16.1 per cent returned to the operating theatre. The 5-year survival rate following complete resection (R0) was 59.3 per cent. In univariable analysis, adverse survival was associated with advanced age (P = 0.003), metastatic disease (P = 0.001), pathological node status (P = 0.001), circumferential resection margin (P = 0.001), local recurrence (P = 0.015) and the need for neoadjuvant therapy (P = 0.039). CONCLUSION Pelvic exenteration is an aggressive treatment option with a high morbidity rate that provides favourable long-term outcomes in patients with locally advanced primary rectal cancer.
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Affiliation(s)
- R W Radwan
- Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - H G Jones
- Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - N Rawat
- Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - M Davies
- Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - M D Evans
- Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
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Does radiotherapy of the primary rectal cancer affect prognosis after pelvic exenteration for recurrent rectal cancer? Dis Colon Rectum 2015; 58:65-73. [PMID: 25489696 DOI: 10.1097/dcr.0000000000000213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Radiotherapy reduces local recurrence rates but is also capable of short- and long-term toxicity. It may also render treatment of local recurrence more challenging if it develops despite previous radiotherapy. OBJECTIVE This study examined the impact of radiotherapy for the primary rectal cancer on outcomes after pelvic exenteration for local recurrence. DESIGN We conducted a retrospective review of exenteration databases. SETTING The study took place at a quaternary referral center that specializes in pelvic exenteration. PATIENTS Patients referred for pelvic exenteration from October 1994 to November 2012 were reviewed. Patients who did and did not receive radiotherapy as part of their primary rectal cancer treatment were compared. MAIN OUTCOME MEASURES The main outcomes of interest were resection margins, overall survival, disease-free survival, and surgical morbidities. RESULTS There were 108 patients, of which 87 were eligible for analysis. Patients who received radiotherapy for their primary rectal cancer (n = 41) required more radical exenterations (68% vs 44%; p = 0.020), had lower rates of clear resection margins (63% vs 87%; p = 0.010), had increased rates of surgical complications per patient (p = 0.014), and had a lower disease-free survival (p = 0.022). Overall survival and disease-free survival in patients with clear margins were also lower in the primary irradiated patients (p = 0.049 and p < 0.0001). This difference in survival persisted in multivariate analysis that corrected for T and N stages of the primary tumor. LIMITATIONS This study is limited by its retrospective nature and heterogeneous radiotherapy regimes among radiotherapy patients. CONCLUSIONS Patients who previously received radiotherapy for primary rectal cancer treatment have worse oncologic outcomes than those who had not received radiotherapy after pelvic exenteration for locally recurrent rectal cancer.
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Georgiou PA, Bhangu A, Brown G, Rasheed S, Nicholls RJ, Tekkis PP. Learning curve for the management of recurrent and locally advanced primary rectal cancer: a single team's experience. Colorectal Dis 2015; 17:57-65. [PMID: 25204543 DOI: 10.1111/codi.12772] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 07/15/2014] [Indexed: 12/12/2022]
Abstract
AIM The study aimed to define the learning curve required to gain satisfactory training to perform pelvic exenterative surgery for recurrent or locally advanced primary rectal cancer. METHOD Consecutive patients undergoing exenterative pelvic surgery for recurrent and locally advanced primary rectal cancer, by one surgical team, between 2006 and 2011 were studied. They were divided into quartiles (Q1-Q4) according to the date of surgery. A risk-adjusted cumulative sum (RA-CUSUM) model was used to evaluate the learning curve. The chi-squared test with gamma ordinal was used to assess the change with time in the four quartiles. RESULTS One hundred patients (70 males; median age 61 (25-85) years; 55 primary cancers) were included in the study. Thirty patients underwent abdominosacral resection. The number of patients who underwent plastic reconstruction (n = 53) increased from 12 in Q1 to 15 in Q4 (P = 0.781). The median operation time, intra-operative blood loss and hospital stay were 8 (3-17) h, 1.5 (0.1-17) l and 15 (9-82) days respectively. There was no significant change with time. Complete resection (R0) was achieved in 78 patients. Microscopic (R1) or macroscopic (R2) residual disease was present in 15 and seven patients respectively. The number of major complications was 20, and minor 30. RA-CUSUM analysis demonstrated an improvement in any complications after 14, in major after 12 and in minor after 25 operations. CONCLUSION Pelvic exenterative surgery for recurrent or locally advanced primary rectal cancer is complex and requires a minimum of 14 cases for an expert colorectal surgeon to gain the desirable training and experience to improve morbidity.
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Affiliation(s)
- P A Georgiou
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, Chelsea and Westminster Campus, London, UK
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41
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Double barreled wet colostomy: initial experience and literature review. ScientificWorldJournal 2014; 2014:961409. [PMID: 25574498 PMCID: PMC4269158 DOI: 10.1155/2014/961409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 11/03/2014] [Accepted: 11/14/2014] [Indexed: 11/18/2022] Open
Abstract
Background. Pelvic exenteration and multivisceral resection in colorectal have been described as a curative and palliative intervention. Urinary tract reconstruction in a pelvic exenteration is achieved in most cases with an ileal conduit of Bricker, although different urinary reservoirs have been described. Methods. A retrospective and observational study of six patients who underwent a pelvic exenteration and urinary tract reconstruction with a double barreled wet colostomy (DBWC) was done, describing the preoperative diagnosis, the indication for the pelvic exenteration, the complications associated with the procedure, and the followup in a period of 5 years. A literature review of the case series reported of the technique was performed. Results. Six patients had a urinary tract reconstruction with the DBWC technique, 5 male patients and one female patient. Age range was from 20 to 77 years, with a medium age 53.6 years. The most frequent complication presented was a pelvic abscess in 3 patients (42.85%); all complications could be resolved with a conservative treatment. Conclusion. In the group of our patients with pelvic exenteration and urinary tract reconstruction with a DBWC, it is a safe procedure and well tolerated by the patients, and most of the complications can be resolved with conservative treatment.
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Jones EL, Jones TS, Paniccia A, Merkow JS, Wells DM, Pearlman NW, McCarter MD. Smaller pelvic volume is associated with postoperative infection after pelvic salvage surgery for recurrent malignancy. Am J Surg 2014; 208:1016-22; discussion 1021-2. [DOI: 10.1016/j.amjsurg.2014.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 08/25/2014] [Accepted: 08/29/2014] [Indexed: 11/16/2022]
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Kelly ME, Courtney D, Nason GJ, Winter DC. Exenterative Surgery for Advanced Prostate Cancer. CURRENT SURGERY REPORTS 2014. [DOI: 10.1007/s40137-014-0070-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Kye BH, Cho HM. Overview of radiation therapy for treating rectal cancer. Ann Coloproctol 2014; 30:165-74. [PMID: 25210685 PMCID: PMC4155135 DOI: 10.3393/ac.2014.30.4.165] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 07/23/2014] [Indexed: 12/13/2022] Open
Abstract
A major outcome of importance for rectal cancer is local control. Parallel to improvements in surgical technique, adjuvant therapy regimens have been tested in clinical trials in an effort to reduce the local recurrence rate. Nowadays, the local recurrence rate has been reduced because of both good surgical techniques and the addition of radiotherapy. Based on recent reports in the literature, preoperative chemoradiotherapy is now considered the standard of care for patients with stages II and III rectal cancer. Also, short-course radiotherapy appears to provide effective local control and the same overall survival as more long-course chemoradiotherapy schedules and, therefore, may be an appropriate choice in some situations. Capecitabine is an acceptable alternative to infusion fluorouracil in those patients who are able to manage the responsibilities inherent in self-administered, oral chemotherapy. However, concurrent administration of oxaliplatin and radiotherapy is not recommended at this time. Radiation therapy has long been considered an important adjunct in the treatment of rectal cancer. Although no prospective data exist for several issues, we hope that in the near future, patients with rectal cancer can be treated by using the best combination of surgery, radiation therapy, and chemotherapy in near future.
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Affiliation(s)
- Bong-Hyeon Kye
- Department of Surgery, St. Vincent Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Hyeon-Min Cho
- Department of Surgery, St. Vincent Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
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Thaysen HV, Jess P, Rasmussen PC, Nielsen MB, Laurberg S. Health-related quality of life after surgery for advanced and recurrent rectal cancer: a nationwide prospective study. Colorectal Dis 2014; 16:O223-33. [PMID: 24373460 DOI: 10.1111/codi.12551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 12/07/2013] [Indexed: 12/12/2022]
Abstract
AIM Advances in the treatment of rectal cancer have made it possible to perform complex rectal cancer surgery (COMP-RCS) in patients with primary advanced rectal cancer penetrating beyond the total mesorectal excision planes and in patients with locally recurrent rectal cancer. The aim of this study was to examine health-related quality of life (HRQoL) before and during the first 2 years after COMP-RCS. METHOD Between 2001 and 2008, 180 patients were treated with COMP-RCS at Aarhus University Hospital. HRQoL was assessed preoperatively and 3, 6, 12, 18 and 24 months after surgery using three questionnaires. The results were compared with those for patients treated with standard rectal cancer surgery (STAN-RCS) and with data from the general Danish population (NORM-data). RESULTS One hundred and twenty-two (68%) patients responded to the questionnaires. Of these 80 (66%) with disease-free survival for 2 years after surgery were included in the main analysis. The lowest level of functioning and the highest degree of symptoms were reported preoperatively. The majority of the HRQoL scales improved or remained stable during the first postoperative year; a decrease was observed for body image only. One year after surgery, HRQoL in patients treated with COMP-RSC was comparable to that for patients treated with STAN-RCS. Lower levels were found for physical and emotional role functioning, compared with NORM-data. CONCLUSION Patients treated with COMP-RCS experienced improvement in HRQoL in the first year after surgery. One year after surgery, HRQoL was similar to that of patients treated with STAN-RCS. Compared with NORM-data, lower levels were found for physical and emotional role functioning.
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Affiliation(s)
- H V Thaysen
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
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Pelvic exenterations for specific extraluminal recurrences in the era of total mesorectal excision: is there still a chance for cure?: a single-center review of patients with extraluminal pelvic recurrence for rectal cancer from March 2004 to November 2010. Am J Surg 2014; 209:352-62. [PMID: 25524284 DOI: 10.1016/j.amjsurg.2014.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 12/05/2013] [Accepted: 01/05/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The benefits in terms of curative resection and survival of pelvic exenterations for specific extraluminal pelvic recurrences from rectal cancer in the era of total mesorectal excision were assessed. METHODS We conducted a single-center review of patients with extraluminal pelvic recurrence from colorectal cancer between March 2004 and November 2010. Twenty-seven pelvic exenterations (13 posterior and 14 total) were performed. Independent predicative factors such as age, sex, local control on first surgery, pelvic sidewall excision, initial International Union Against Cancer (UICC) staging, sphincter-preserving resection at first surgery, tumor presentation on computed tomography and magnetic resonance imaging (pelvis sidewall involvement, number of fixation sites, ureteral involvement), local disease-free interval, previous symptoms, and postoperative treatment were analyzed. RESULTS No operative mortality was noted in this series. Overall morbidity rate was 74%; 22% of the patients developed severe complications. Complete surgical clearance (R0) was obtained in 63% of the patients. The rate of R0 resections was lower in total pelvic exenteration (57%) than in posterior pelvic exenteration (69%). Three years overall survival and disease-free survival were 76% and 59%, respectively. Curative resection (R0) was the only independent prognostic factor for overall survival (P = .0016) and disease-free survival (P < .0001). CONCLUSION Pelvic exenterations for extraluminal pelvic recurrences from rectal cancer afford a high R0 resection rate with acceptable morbidity.
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Abstract
OBJECTIVE The aim of this study was to evaluate the utility of reimaging rectal cancer post-CRT (chemoradiotherapy) with magnetic resonance (MR) imaging of the pelvis for local staging and computed tomography of thorax, abdomen, and pelvis (CT TAP) to identify distant metastases. BACKGROUND The success of neoadjuvant CRT for locally advanced rectal cancer has changed an already complex management algorithm. There is no consensus whether patients should be restaged before surgery. METHODS Data from 5 institutions with prospectively maintained databases including patients who received neoadjuvant CRT for locally advanced rectal cancer were acquired. Only patients who had been staged pre- and post-CRT with MR imaging and CT TAP were included. MR findings were correlated with histopathological stage using weighted κ (kappa) statistics to test agreement, where a κ value of less than 0.5 was deemed unacceptable. RESULTS A total of 285 patients fulfilled the criteria for the study; 84% had American Joint Committee for Cancer stage 3 disease pre-CRT, and the remainder had stage 2 disease. Fourteen patients did not proceed to surgery post-CRT-2 were observed as "complete responders," and the remainder either had unresectable disease or were unfit for surgery. MR imaging could not predict T stage (κ = 0.212) or nodal involvement (κ = 0.336). Most pertinently, MR imaging was unable to detect a complete pathological response (κ = 0.021), nor could it discriminate T4 disease (κ = 0.445). CT TAP restaging altered management in 6.7% of patients, who had metastatic disease. CONCLUSIONS MR reimaging using standard protocols is of limited value in determining surgical approaches; a better modality of local restaging is required.
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Xin KY, Ng DWJ, Tan GHC, Teo MCC. Role of pelvic exenteration in the management of locally advanced primary and recurrent rectal cancer. J Gastrointest Cancer 2014; 45:291-7. [PMID: 24563189 DOI: 10.1007/s12029-014-9586-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIM A review of a single-centre experience of pelvic exenteration as a treatment modality for patients with locally advanced primary and recurrent rectal cancer. The perioperative outcomes, morbidity and long term oncological outcomes are reviewed. MATERIALS & METHODS Patients undergoing pelvic exenterations for recurrent and locally advanced rectal cancer between 1 January 2006 and 1 August 2012 were identified from a prospective database. All patients underwent pre-operative staging investigations with computed tomography (CT) scan of chest, abdomen and pelvis and pelvic magnetic resonance imaging (MRI). Patients with locally advanced primary rectal cancer were counselled for pre-operative chemoradiation. Structures such as the urinary bladder and female reproductive organs were resected en bloc where indicated with the lesion. Urological or plastic reconstructions were employed where indicated. The primary outcome measured was overall survival and secondary outcomes measured were time to local recurrence (LR) and systemic recurrence. Disease-free survival was examined by the Kaplan-Meier Method (Fig. 1). RESULTS Pelvic exenterations were performed in 13 patients with a median age of 59 (range 26-81). The rate of major post-operative complications was 8% (n = 1), where the patient had anastomotic leakage. There were no mortalities in the perioperative period. All patients were operated with curative intent and negative circumferential margins were shown in 9 out of 13 patients (70%). The DFS was 19.4 and the OS was 22.5 months. CONCLUSION An aggressive approach with en bloc resection of organs involved provides survival benefit to patients with locally advanced primary and recurrent rectal cancer with an acceptable morbidity profile.
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Affiliation(s)
- Koh Ye Xin
- Department of Surgical Oncology, National Cancer Centre Singapore, 9 Hospital Drive, Singapore, 169612, Singapore
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Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg 2013; 100:E1-33. [PMID: 23901427 DOI: 10.1002/bjs.9192_1] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. METHODS Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus. RESULTS The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management. CONCLUSION The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.
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Mohan HM, Evans MD, Larkin JO, Beynon J, Winter DC. Multivisceral resection in colorectal cancer: a systematic review. Ann Surg Oncol 2013; 20:2929-36. [PMID: 23666095 DOI: 10.1245/s10434-013-2967-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND The objective of this study was to critically evaluate current literature on outcomes following multivisceral resection (MVR) in colorectal cancer (CRC). Adequate surgical resection with clear margins is imperative in achieving long-term survival in colorectal cancer. Where there is adherence to or invasion of adjacent organs, (MVR) may be needed to achieve complete disease clearance. METHODS A systematic review of MVR in CRC was performed. Pubmed/Medline and Cochrane databases were searched for English language articles from 1995 to 2012 using a predefined strategy. Retrieved abstracts were independently screened for relevance and data extracted from selected studies by 2 researchers. Results are reported as weighted means. RESULTS Included were 22 studies comprising 1575 patients (87.0% primary colorectal cancer; 13.0% recurrent, 63.8% rectal; 36.2% colon). The most common organs resected were the bladder and reproductive organs. The perioperative mortality was 4.2% with morbidity of 41.5% (95% CI, 40.8-42.2%). The overall 5-year survival rate was 50.3% (95% CI, 49.9-50.8%). Surgery for recurrence was associated with worse outcomes than primary tumors with 5-year survival 19.5% (95% CI, 17.8-21.1%) for recurrent rectal cancer and primary rectal tumors 5-year overall survival 52.8% (95% CI, 52.0-53.8%). R0 resection was the strongest factor associated with long-term survival. CONCLUSIONS Multivisceral resection provides the best possibility of long-term survival in locally advanced primary colorectal cancer in which a clear margin has been achieved.
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Affiliation(s)
- H M Mohan
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland.
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