Kirk K. S. Austin

Pelvic exenteration with en bloc iliac vessel resection for lateral pelvic wall involvement.

PURPOSE: Lateral pelvic recurrence is considered a poor prognostic variable and a relative contraindication to surgery because of the difficulty in achieving clear margins. The aim of this study was to outline our surgical approach to lateral pelvic sidewall involvement and assess the oncologic and long-term outcomes. METHODS: A retrospective review of a prospective database was performed. Patient demographics, cancer and operative details, intent, margins, lymph node status, rerecurrence at resection site, follow-up, living and death details were assessed. RESULTS: En bloc lateral pelvic wall dissection and vascular resection with pelvic exenteration was performed in 36 patients of 107 exenterations. All patients underwent surgery with curative intent. Negative margins were achieved in 19 patients (53%). Ten patients (28%) developed recurrence at the site of resection compared with 26 patients (72%) who remained disease free at the site of surgery. Sixteen patients (46%) are disease-free with the average disease-free interval of 30 months. Twenty-five patients (69%) are alive with a mean follow-up of 19 months. No mortalities occurred in this cohort of patients. CONCLUSION: Despite the complexity of this technique, it is safe and feasible. Careful preoperative radiologic assessment and a multidisciplinary approach are paramount to achieving clear margins.

The Outcomes and Patterns of Treatment Failure After Surgery for Locally Recurrent Rectal Cancer

Objective: To assess the outcomes and patterns of treatment failure of patients who underwent pelvic exenteration surgery for recurrent rectal cancer. Background: Despite advances in the management of rectal cancer, local recurrence still occurs. For appropriately selected patients, pelvic exenteration surgery can achieve long-term disease control. Methods: Prospectively maintained databases of 5 high volume institutions for pelvic exenteration surgery were reviewed and data combined. We assessed the combined endpoints of overall 5-year survival, cancer-specific 5-year mortality, local recurrence, and the development of metastatic disease. Results: Five hundred thirty-three patients who had undergone surgery for locally recurrent rectal cancer were identified. Five-year cancer-specific survival for patients with a complete (R0) resection is 44%, which was achieved in 59% of patients. For those with R1 and R2 resections, the 5-year survival was 26% and 10%, respectively. Radical resection required sacrectomy in 170 patients (32%), and total cystectomy in 105 patients (20%). Treatment failure included local recurrence alone in 75 patients (14%) and systemic metastases with or without local recurrence in 226 patients (42%). Chemoradiotherapy before exenteration was associated with a significant (P < 0.05) improvement in overall 5-year cancer-specific survival for those patients with an R0 resection. Postoperative chemotherapy did not alter outcomes. Conclusions: R0 resection of the pelvic recurrence is the most significant factor affecting overall and disease-free survival. The surgery is complex and often highly morbid, and where possible patients should be given perioperative chemoradiotherapy. Further investigations are required to determine the role of adjuvant chemotherapy.

Sacral Resection With Pelvic Exenteration for Advanced Primary and Recurrent Pelvic Cancer: A Single-Institution Experience of 100 Sacrectomies

BACKGROUND: Recurrent and advanced primary pelvic cancers present a complex clinical issue requiring multidisciplinary care and radical extended surgery. Sacral resection is necessary for tumors that invade posteriorly but is associated with increased morbidity and mortality. OBJECTIVE: This study aimed to analyze the morbidity and survival associated with pelvic exenteration involving sacrectomy for advanced pelvic cancers at a single institution. DESIGN: This study used patient demographics, operative and pathologic reports, and prospective survival data to determine factors affecting patient outcomes. SETTINGS: Data were collected for patients who had operations between July 1998 and April 2012 at Royal Prince Alfred Hospital. PATIENTS: One hundred patients underwent pelvic exenteration with a sacrectomy for advanced pelvic cancers. Sacrectomy was performed for 18 primary and 61 recurrent rectal cancers, 17 anal cancers, and 4 other cancers. MAIN OUTCOME MEASURES: This study looked at postoperative major and minor morbidity rates, as well as disease-free and overall survival rates after sacral resection. It compared the outcomes of high sacrectomy (at or above S2) versus low sacrectomy. RESULTS: Clear margins were achieved in 72 of 100 patients. The overall complication rate was 74% (43% major and 67% minor) with no 30-day or in-hospital mortality. Estimated overall and disease-free survival rates after curative resection were 38% and 30% at 5 years. Involved margins (p = 0.006), lymph node involvement (p = 0.008), and anterior organ invasion (p = 0.008) had a negative impact on patient survival. High sacrectomy increased the incidence of neurologic deficit postoperatively (p = 0.04) but did not alter the rate of R0 resection or patient survival. LIMITATIONS: Retrospective data were required to analyze patient morbidity, as well as operative and pathologic factors. CONCLUSIONS: This series supports sacral resection for curative surgery in advanced pelvic cancers, achieving excellent R0 and long-term survival rates. Cortical bone invasion and high sacrectomy were not contraindications to surgery and had acceptable outcomes.

Pubic Bone Excision and Perineal Urethrectomy for Radical Anterior Compartment Excision During Pelvic Exenteration.

BACKGROUND: Malignant infiltration of the pubic bone traditionally is considered inoperable. Consequently, there is little published on surgical approaches to resection of the anterior pelvic bone. En bloc partial or complete pubic bone excision can be performed depending on the degree of involvement. OBJECTIVE: This article describes our surgical approach of pelvic exenteration with en bloc composite pubic bone excision. DESIGN: The surgical technique describes 2 distinct aspects of the surgery, first, a perineal as opposed to abdominal transection of the urethra, and, second, varying extents of en bloc pubic bone excision. SETTINGS: This study was conducted at a tertiary care hospital. MAIN OUTCOME MEASURES: Pelvic tumors infiltrating the pubic bone require radical en bloc composite bone resection to achieve an R0 margin that should translate to longer-term survival versus nonoperative treatments. RESULTS: Results of our study are currently under review. CONCLUSIONS: As the magnitude of pelvic exenteration surgery continues to evolve for all compartments of the pelvis, malignant infiltration of the anterior pelvic bone should not be considered a contraindication to surgery.

Posterior high sacral segmental disconnection prior to anterior en bloc exenteration for recurrent rectal cancer

This article describes a novel technique for en bloc resection of locally recurrent rectal cancer that invades the high sacral bone (above S3). The involved segment of the sacrum is mobilised with osteotomes during an initial posterior approach before an anterior abdominal phase where the segment of sacral bone is delivered with the specimen. This allows en bloc resection of the involved sacrum while preserving uninvolved distal and contralateral sacral bone and nerve roots. The goal is to obtain a clear bony margin and offer a chance of cure while improving functional outcomes by maintaining pelvic stability and minimising neurological deficit.

Outcomes of Pelvic Exenteration with en Bloc Partial or Complete Pubic Bone Excision for Locally Advanced Primary or Recurrent Pelvic Cancer.

INTRODUCTION: Neoplasms infiltrating the pubic bone have until recently been considered a contraindication to surgery. Paucity of existing published data in regard to surgical techniques and outcomes exist. OBJECTIVE: This study aims to address outcomes of our recently published technique for en bloc composite pubic bone excision during pelvic exenteration. DESIGN: A prospective database was reviewed to identify patients who underwent a partial or complete pubic bone composite excision over a 12-year period. SETTINGS: This study was conducted at a tertiary level exenteration unit. MAIN OUTCOME MEASURES: Primary outcomes measured were resection margin and survival. Secondary outcomes included patient and operative demographics, type of cancer, extent of pubic bone excision, morbidity, and 30-day mortality. RESULTS: Twenty-nine of over 500 patients undergoing exenterations (mean age, 57.9; 20 males) underwent en bloc complete (11 patients) or partial (18 patients) composite pubic bone excision. Twenty-two patients (76%) underwent resection for recurrent as opposed to advanced primary malignant disease of which rectal adenocarcinoma was the most common followed by squamous-cell carcinoma. The median operating time was 10.5 (range, 6–15) hours, and median blood loss was 2971 (range, 300–8600) mL. Seventeen (59%) patients had a concurrent sacrectomy performed mainly S3 and below. A total cystectomy was performed in 26 patients (90%). Fifteen of 20 male patients (75%) had a perineal urethrectomy. A clear (R0) resection margin was achieved in 22 patients (76%) with a 5-year overall survival of 53% after a median follow-up of 3.2 years (r = 1.4–12.3 years). There was no 30-day mortality. Seventy percent of patients experienced morbidity with a pelvic collection the most common. LIMITATIONS: This study was limited because it was a retrospective review, it occurred at a single site, and it used a small heterogeneous sample. CONCLUSION: Within the realm of evolving exenteration surgery, en bloc composite pubic bone excision offers results comparable to central, lateral, and posterior compartment excisions, and, as such, is a reasonable strategy in the management of neoplasms infiltrating the pubic bone.

Triangle of Marcille: the anatomical gateway to lateral pelvic exenteration

To perform more radical surgery for complex pelvic malignancies and recurrent colorectal cancer, the surgeon must increasingly operate outside the conventional anatomical planes. Published in 1963 the ‘Triangle of Marcille’ (lumbosacral triangle) remained primarily of intellectual interest being found lateral to the traditional operating field. However, with the advancement of complex colorectal and gynaecological surgery it now provides a schema to assist surgeons in becoming acquainted with a complex and poorly understood anatomical region. Additionally, it prepares the surgeon for the extent of lateral dissection required to achieve the ‘holy grail’ for oncological surgery in pelvic malignancy, the complete resection (R0).

The Evolution of Pelvic Exenteration Practice at a Single Center: Lessons Learned from over 500 Cases

Considerable progress has been made in the management of patients with locally advanced or recurrent cancers of the pelvis over the past 60 years since the inception of pelvic exenteration. Early progress in pelvic exenteration was marred by the high surgical mortality and morbidity, which drew scepticism from the broader surgical community. Subsequent evolution in the procedure hinged on establishing surgical safety and a better understanding of outcome predictors. Surgical mortality from pelvic exenteration is now comparable to that of elective resection for primary colorectal cancers. The importance of a clear resection margin is also now well established in providing durable local control and predicting long-term survival that, in turn, has driven the development of novel surgical techniques for pelvic side wall resection, en bloc sacrectomy, and pubic bone resection. A tailored surgical approach depending on the location of the tumor with resection of contiguously involved organs, yet preserving uninvolved organs to minimize unnecessary surgical morbidity, is paramount. Despite improved surgical and oncological outcomes, surgical morbidity following pelvic exenteration remains high with reported complication rates ranging between 20% and 80%. Extended antibiotic prophylaxis and preemptive parenteral nutrition in the immediate postoperative period may reduce septic and nutritional complications. A high index of suspicion is needed in the early diagnosis and management of complications that may avoid prolonged duration of hospitalization. An acceptable quality of life has been reported among patients after pelvic exenteration. Further research into novel chemotherapy, immunotherapy, and reconstructive options are currently underway and are needed to further improve outcomes.