Defining Benchmarks for Pelvic Exenteration Surgery: A Multicentre Analysis of Patients with Locally Advanced and Recurrent Rectal Cancer.

OBJECTIVE: To establish globally applicable benchmark outcomes for pelvic exenteration (PE) in patients with locally advanced primary (LARC) and recurrent rectal cancer (LRRC), using outcomes achieved at highly specialised centres. BACKGROUND DATA: PE is established as the standard of care for selected patients with LARC and LRRC. There are currently no available benchmarks against which surgical performance in PE can be compared for audit and quality improvement. METHODS: This international multicentre retrospective cohort study included patients undergoing PE for LARC or LRRC at 16 highly experienced centres between 2018 and 2023. Ten outcome benchmarks were established in a lower-risk subgroup. Benchmarks were defined by the 75th percentile of the results achieved at the individual centres. RESULTS: 763 patients underwent PE, of which 464 patients (61%) had LARC and 299 (39%) had LRRC. 544 patients (71%) who met predefined lower risk criteria formed the benchmark cohort. For LARC patients, the calculated benchmark threshold for major complication rate was ≤44%; comprehensive complication index (CCI): ≤30.2; 30-day mortality rate: 0%; 90-day mortality rate: ≤4.3%; R0 resection rate: ≥79%. For LRRC patients, the calculated benchmark threshold for major complication rate was ≤53%; CCI: ≤34.1; 30-day mortality rate: 0%; 90-day mortality rate: ≤6%; R0 resection rate: ≥77%. CONCLUSIONS: The reported benchmarks for PE in patients with LARC and LRRC represent the best available care for this patient group globally and can be used for rigorous assessment of surgical quality and to facilitate quality improvement initiatives at international exenteration centres.

Trajectories of Quality of Life After Pelvic Exenteration: A Latent Class Growth Analysis.

BACKGROUND: Information on the course of quality of life after surgery for advanced cancers within the pelvis is important to guide patient decision-making; however, the current evidence is limited. OBJECTIVE: To identify quality-of-life trajectory classes and their predictors after pelvic exenteration. DESIGN: Prospective cohort study. SETTINGS: Highly specialized quaternary pelvic exenteration referral center. PATIENTS: Patients undergoing pelvic exenteration due to advanced/recurrent cancers within the pelvis between July 2008 and July 2022. MAIN OUTCOME MEASURES: Quality-of-life data included the 36-item Short-Form Survey (physical and mental component scores) and the Functional Assessment of Cancer Therapy-Colorectal instruments, which were collected at 11 distinct points from baseline to 5 years postoperatively. Predictors included patient characteristics and surgical outcomes. Latent class analysis was used to identify the likelihood of a better quality-of-life class, and logistic regression models were used to identify predictors of the identified classes. RESULTS: The study included 565 participants. Two distinct quality-of-life trajectory classes were identified for the Physical Component Score (class 1: high stable and class 2: high decreasing). Three distinct classes were identified for the Mental Component Score (class 1: high increasing, class 2: moderate stable, and class 3: moderate decreasing) and for Functional Assessment of Cancer Therapy-Colorectal total score (class 1: high increasing, class 2: high decreasing, and class 3: low decreasing). Across the 3 quality-of-life domains, overall survival probabilities were also higher in class 1 ( p < 0.0001). Age, repeat exenteration, neoadjuvant therapy, surgical margin, length of operation, and hospital stay were significant predictors of quality-of-life classes. LIMITATIONS: This study was conducted at a single highly specialized quaternary pelvic exenteration referral center, and findings may not apply to other centers. CONCLUSIONS: This study demonstrates that quality of life after pelvic exenteration diverges into distinct trajectories, with most patients reporting an optimal course. See Video Abstract . TRAYECTORIAS EN LA CALIDAD DE VIDA DESPUS DE EXENTERACIN PLVICA ANLISIS DE CRECIMIENTO DE CLASES LATENTES: ANTECEDENTES:La información sobre la evolución en la calidad de vida después de cirugía en cánceres avanzados situados en la pelvis es importante para guiar la toma de decisiones sobre el paciente; sin embargo, la evidencia actual es muy limitada.OBJETIVO:Identificar las clases de trayectorias en la calidad de vida y sus factores pronóstico después de la exenteración pélvica.DISEÑO:Estudio de cohortes prospectivo.AJUSTES:Centro de referencia altamente especializado en la exenteración pélvica cuaternaria.PACIENTES:Todos aquellos sometidos a exenteración pélvica por cáncer avanzados/recurrentes situados en la pelvis entre Julio de 2008 y Julio de 2022.PRINCIPALES MEDIDAS DE RESULTADO:Los datos sobre la calidad de vida incluyeron el Cuestionario de Salud SF-36 (puntuaciones de componentes físicos y mentales) y la evaluación funcional entre la terapia del cáncer/-herramientas colorrectales, recopilados en 11 puntos distintos desde el diagnóstico hasta los 5 años después de la operación.Los predictores incluyeron las características de los pacientes y los resultados quirúrgicos. Se utilizó el análisis de clases latentes para identificar la probabilidad de una mejor calidad de vida y se utilizaron modelos de regresión logística para identificar predictores de las clases identificadas.RESULTADOS:El estudio incluyó a 565 participantes. Se identificaron dos clases distintas de trayectorias de calidad de vida para la puntuación del componente físico (clase 1: alta estable y clase 2: alta decreciente), se identificaron tres clases distintas para la puntuación del componente mental (clase 1: alta creciente; clase 2: moderadamente estable; y clase 3: moderada disminución) y para la evaluación funcional de la terapia contra el cáncer-puntuación total colorrectal (clase 1: aumento alto; clase 2: disminución alta; y clase 3: disminución baja). En los tres dominios de calidad de vida, las probabilidades de supervivencia general también fueron mayores en las clases 1 (p <0,0001). La edad, las exenteraciones pélvicas repetidas, la terapia neoadyuvante, el margen quirúrgico, la duración de la operación y la estadía hospitalaria fueron predictores significativos en las clases de calidad de vida.LIMITACIONES:El presente estudio fué realizado en un único centro de referencia altamente especializado en exenteración pélvica cuaternaria y es posible que los hallazgos no se apliquen a otros centros.CONCLUSIONES:Demostramos con nuestro estudio que la calidad de vida después de la exenteración pélvica diverge en trayectorias distintas, y que la mayoría de los pacientes nos reportaron de una évolución óptima. (Traducción-Dr. Xavier Delgadillo ).

The health-related quality of life of early-onset colorectal cancer patients: an Australian cross-sectional study.

AIM: Early-onset colorectal cancer (EOCRC) patients are more likely to have advanced disease and undergo more aggressive treatment modalities. However, current literature investigating the health-related quality of life (HRQoL) of EOCRC patients is scarce. This study aimed to determine the HRQoL of an Australian cohort of EOCRC patients including a subset who underwent pelvic exenteration (PE) or cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHOD: A cross-sectional study of EOCRC patients treated at the Royal Prince Alfred Hospital, Sydney Australia was performed. Patients were divided into groups based on the time interval from their index operation: ≤2 years and >2 years. HRQoL was evaluated using the SF-36v2 questionnaire. RESULTS: A total of 50 patients were included. For patients ≤2 years from surgery, the median physical component summary (PCS) and mental health component summary (MCS) scores were 53.3 (36.4-58.9) and 47.3 (37.5-55.7). In the >2 years group, the median PCS and MCS scores were 50.6 (43.3-57.7) and 50.2 (39.04-56.2), respectively. Stage I (vs. stage II) disease and emergency (vs. elective) surgery conferred poorer PCS scores in patients ≤2 years from surgery. No other variables impacted PCS or MCS scores in EOCRC patients in either group. CONCLUSIONS: HRQoL of EOCRC patients was equivocal to the Australian population. Having an earlier stage of diagnosis and emergency index operation was associated with poorer levels of physical functioning in patients ≤2 years from surgery. However, because of the limitations of this study, these findings require validation in future large-scale prospective research.

Functional Outcomes Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Prospective Cohort Study.

BACKGROUND: Pre-operative physical status and its association with post-operative surgical outcomes is poorly understood in patients with peritoneal malignancy who undergo cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). The aims of this study were to determine the pre-operative physical function in patients having CRS-HIPEC and investigate the association between physical function and post-operative outcomes. PATIENTS AND METHODS: Patients undergoing CRS-HIPEC between 2017 and 2021 were recruited at a single quaternary referral hospital in Sydney, Australia. The primary physical function measures were the 6-min walk test (6MWT) and the five-times sit to stand test (5STS). Data were collected pre-operatively and at post-operative day 10, and were analysed according to pre-operative patient characteristics and post-operative outcomes such as length of hospital stay (LOS) and complications. RESULTS: The cohort of patients that participated in functional assessments consisted of 234 patients, with a median age of 56 years. Patients having CRS-HIPEC performed worse on the 6MWT pre-operatively compared with the general Australian population (p < 0.001). Post-operatively, these patients experienced a further deterioration in 6MWT and 5STS performance and the degree of the post-operative decline in function was associated with post-operative morbidity. A higher level of pre-operative physical function was associated with shorter LOS and minor post-operative complications. CONCLUSIONS: Patients who have undergone CRS-HIPEC were functionally impaired pre-operatively compared with the general population and experience a further deterioration of physical function post-operatively. A higher level of pre-operative physical function is associated with minor post-operative morbidity, which is highly relevant for pre-operative optimisation of patients with cancer.

Implementation of a peri-operative pain-management algorithm reduces the use of opioid analgesia following pelvic exenteration surgery.

AIM: This study aimed to investigate the implementation and pain-related outcomes of a peri-operative pain-management regimen for patients undergoing pelvic exenteration surgery at a university teaching hospital. METHOD: This is a single-site prospective observational cohort study involving 100 patients who underwent pelvic exenteration surgery between January 2017 and December 2018. A pain-management algorithm regarding the use of opioid-sparing multimodal analgesia was developed between the departments of anaesthesia, pain management and intensive care. The primary outcomes were: compliance with a pain-treatment algorithm compared with a similar retrospective surgical patient cohort in 2013-2014; and requirements for regular doses of opioid analgesia at discharge, measured in oral morphine equivalent daily dose (oMEDD). RESULTS: Following the introduction of a pain-management algorithm, regional anaesthesia techniques (spinal anaesthesia, transversus abdominus plane block, preperitoneal catheters or epidural analgesia) were used in 83/98 (84.7%) of the 2017-2018 cohort compared with 13/73 (17.8%) of the 2013-2014 cohort (p < 0.001). There was a reduction in the median dose of opioid analgesics (oMEDD) at time of discharge, from 150 mg (interquartile range [IQR]: 75.0-235.0 mg) in the 2013-2014 cohort to 10 mg (IQR: 0.00-45.0 mg) in the 2017-2018 cohort (p < 0.001). There was no change in pain intensity (assessed using the Verbal Numerical Rating Score) or oMEDD in the first 7 days following surgery. CONCLUSION: Since implementation of a novel peri-operative pain-treatment algorithm, the use of opioid-sparing regional techniques and preperitoneal catheters has increased. Additionally, the dose of opioids required at the time of discharge has reduced significantly.

Pain, pain management and related outcomes following pelvic exenteration surgery: a systematic review.

AIM: Pelvic exenteration surgery can improve survival in people with advanced colorectal cancer. This systematic review aimed to review pain intensity and other outcomes, for example the management of pain, the relationship between pain and the extent of surgery and the impact of pain on short-term outcomes. METHOD: Electronic databases were searched from inception to 1 May 2021. We included interventional studies of adults with any indication for pelvic exenteration surgery that also reported pain outcomes. Risk of bias was assessed using ROBINS-1. RESULTS: The search found 21 studies that reported pain following pelvic exenteration [n = 1317 patients, mean age 58.4 years (SD 4.8)]. Ten studies were judged to be at moderate risk of bias. Before pelvic exenteration, pain was reported by 19%-100% of patients. Five studies used validated measures of pain intensity. No study measured pain at all three time points in the surgical journey. The presence of pain before surgery predicted postoperative adverse pain outcomes, and pain is more likely to be experienced in those who require wider resections, including bone resection. CONCLUSION: Considering that pain following pelvic exenteration is commonly described by patients, the literature suggests that this symptom is not being measured and therefore addressed.

What Constitutes a Clear Margin in Patients With Locally Recurrent Rectal Cancer Undergoing Pelvic Exenteration?

OBJECTIVES: To determine what constitutes a clear resection margin (R0) in patients with LRRC. SUMMARY OF BACKGROUND DATA: R0 is the most important predictor of survival in patients with LRRC. However, it is not clear what constitutes an R0. A 1-2 mm margin is often used to define R0 but this is based on primary rectal cancer studies. The same definition of R0 is likely inappropriate considering the anatomy and etiology of local recurrences. METHODS: A prospective maintained database was reviewed. A R2 margin was defined as macroscopic residual disease. R1 was defined as a microscopically involved margin (0 mm margin) and R0 as at least a 0.1 mm margin. Associations between R status and local recurrence was explored using X2 test. Associations between margins and overall survival and local recurrence free survival were explored using Kaplan-Meier analysis. RESULTS: There were 210 patients eligible for inclusion for analysis. Of these, 165 (78.6%), 35 (16.7%), and 10 (4.8%) patients had R0, R1, and R2 margins, respectively. Overall survival was significantly different between patients with R0 versus R1 margins but wider resection margins do not confer a survival benefit [57 months (95% confidence interval 38.5-75.5) vs 33 months (95% confidence interval 20.3-45.7), P = 0.03]. Local recurrence free survival was significantly different between patients with R0 versus R1 margins (2- and 5-year local recurrence free survivals of 53.5% and 20.4% vs 25.9% and 14.8%, respectively, P = 0.001 for both). Margins >0.5 mm were not predictive of local recurrence free survival. CONCLUSIONS: A microscopically clear resection margin is most important in predicting overall survival. Margins up to 0.5 mm offers a local recurrence benefit but does not confer survival benefit.

Differences in Surgical Outcomes and Quality-of-Life Outcomes in Pelvic Exenteration Between Locally Advanced Versus Locally Recurrent Rectal Cancers.

BACKGROUND: Although pelvic exenteration remains the only curative option for locally advanced rectal cancer and locally recurrent rectal cancer, only limited evidence is available on the differences in surgical and quality-of-life outcomes between the two. OBJECTIVE: This study aimed to compare surgical outcomes and identify any differences or predictors of quality of life of patients with locally advanced rectal cancer and locally recurrent rectal cancer undergoing pelvic exenteration. DESIGN: This was a cohort study. SETTING: This study was conducted at Royal Prince Alfred Hospital, Sydney, Australia. PATIENTS: This study included patients with locally advanced rectal cancer and locally recurrent rectal cancer who underwent pelvic exenteration between July 2008 and March 2019. MAIN OUTCOME MEASURES: The main outcome measures included Short Form 36 version 2 and Functional Assessment of Cancer Therapy-Colorectal score. RESULTS: A total of 271 patients were included in this study. Locally advanced rectal cancer patients had higher rates of R0 resection ( p = 0.003), neoadjuvant chemoradiotherapy ( p < 0.001), and had greater median overall survival (75.1 vs. 45.8 months), although the latter was clinically but not statistically significant. There was a higher blood loss ( p < 0.001), longer length of stay ( p = 0.039), and longer operative time ( p = 0.002) in the locally recurrent rectal cancer group. This group also had a higher mean baseline physical component summary score and Functional Assessment of Cancer Therapy-Colorectal score; however, there were no significant differences in complications or quality-of-life outcomes between with the two groups at any time points postoperatively up to 12 months. LIMITATION: The study was from a specialized experienced center, which could limit its generalizability. CONCLUSIONS: Patients with locally recurrent rectal cancer tend to require a more extensive surgery with a longer operative time and more blood loss and longer recovery from surgery, but despite this, their quality of life is comparable to those with locally advanced rectal cancer. See Video Abstract at http://links.lww.com/DCR/B1000 . DIFERENCIAS EN LOS RESULTADOS QUIRRGICOS Y LOS RESULTADOS DE LA CALIDAD DE VIDA EN LA EXENTERACIN PLVICA ENTRE EL CNCER DE RECTO LOCALMENTE AVANZADO Y EL CNCER DE RECTO LOCALMENTE RECIDIVANTE: ANTECEDENTES:Aunque la exenteración pélvica sigue siendo la única opción curativa para el cáncer de recto localmente avanzado y el cáncer de recto localmente recurrente, solo hay evidencia limitada disponible sobre las diferencias en los resultados quirúrgicos y de calidad de vida entre los dos.OBJETIVO:Este estudio tuvo como objetivo comparar los resultados quirúrgicos e identificar cualquier diferencia o predictor de la calidad de vida de los pacientes con cáncer de recto localmente avanzado y cáncer de recto localmente recurrente sometidos a exenteración pélvica.DISEÑO:Este fue un estudio de cohorte.AJUSTE:Este estudio se realizó en el Royal Prince Alfred Hospital, Sydney, Australia.PACIENTES:Este estudio incluyó pacientes con cáncer de recto localmente avanzado y cáncer de recto localmente recurrente que se sometieron a exenteración pélvica entre julio de 2008 y marzo de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado incluyeron el formulario corto 36 versión 2 y la puntuación de la evaluación funcional de la terapia del cáncer colorrectal.RESULTADOS:Un total de 271 pacientes fueron incluidos en este estudio. Los pacientes con cáncer de recto localmente avanzado tuvieron tasas más altas de resección R0 ( p = 0,003), quimiorradioterapia neoadyuvante ( p < 0,001) y una mediana de supervivencia general más alta (75,1 frente a 45,8 meses),a pesar de que esta última fue clínica pero no estadísticamente significativa. Hubo una mayor pérdida de sangre ( p < 0,001), una estancia más prolongada ( p = 0,039) y un tiempo operatorio más prolongado ( p = 0,002) en el grupo de cáncer de recto localmente recurrente. También tenían una puntuación de componente físico inicial media más alta y una puntuación de Evaluación funcional de la terapia del cáncer colorrectal; sin embargo, no hubo diferencias significativas en las complicaciones o los resultados de la calidad de vida entre los dos grupos en ningún momento después de la operación hasta los 12 meses.LIMITACIÓN:El estudio fue de un centro especializado con experiencia, lo que podría limitar su generalización.CONCLUSIONES:Los pacientes con cáncer de recto localmente recurrente tienden a requerir una cirugía más extensa con un tiempo operatorio más largo y más pérdida de sangre y una recuperación más prolongada de la cirugía, pero a pesar de esto, su calidad de vida es comparable a aquellos con cáncer de recto localmente avanzado. Consulte Video Resumen en http://links.lww.com/DCR/B1000 . (Traducción-Dr. Yolanda Colorado ).

Elderly Patients Have Better Quality of Life but Worse Survival Following Pelvic Exenteration: A 25-Year Single-Center Experience.

OBJECTIVE: To describe quality of life (QOL) and survival outcomes following pelvic exenteration (PE) in old and young patients. BACKGROUND: PE is a management option for complete resection in locally advanced pelvic cancers. Few studies have examined the impact of age on the outcome in elderly patients following PE. PATIENTS AND METHODS: Prospective cohort of consecutive patients undergoing partial and complete PE between 1994 and 2019. Patients were divided into a younger (< 65 years) or older cohort (≥ 65 years) based on their age. QoL was assessed using the SF-36 and FACT-C questionnaires and survival estimated using the Kaplan-Meier method. RESULTS: For 710 patients who underwent PE during the study period, FACT-C total score was significantly better in the elderly during the whole follow-up period of 5 years. Mental component score (SF-36) was significantly better at baseline (p = 0.008) and at 24 months postoperatively (p = 0.042), in the elderly group. Median overall survival was 75 months in the younger cohort and 53 months in the older cohort (p = 0.004). In subgroup analysis, older patients with recurrent or primary rectal cancer had a median survival of 37 and 70 months, respectively. Postoperative cardiovascular complications were greater in the elderly cohort (p < 0.001). CONCLUSIONS: Elderly patients had better overall QoL but lower survival that is probably related to cardiovascular complications rather than to cancer as both groups had similar R0 resection rate. Hence, the elderly population should be considered equally for PE.

Functional outcomes following pelvic exenteration: results from a prospective cohort study.

AIM: Postoperative functional outcomes following pelvic exenteration surgery for treatment of advanced or recurrent pelvic malignancies are poorly understood. The aim of this study was to determine the short-term functional outcomes following pelvic exenteration surgery using objective measures of physical function. METHOD: Patients undergoing pelvic exenteration surgery between January 2017 and May 2020 were recruited at a single quaternary referral hospital in Sydney, Australia. The primary measures were the 6-min walk test (6MWT) and the five times sit to stand (5STS) test. Data were collected at baseline (preoperatively), 10 days postoperatively and at discharge from hospital, and were analysed according to tumour type, extent of exenteration, sacrectomy, length of hospital stay, major nerve resection and postoperative complications. RESULTS: The cohort of patients that participated in functional assessments consisted of 135 patients, with a median age of 61 years. Pelvic exenteration patients had a reduced 6MWT distance preoperatively compared to the general population (P < 0.001). Following surgery, we observed a further decrease in 6MWT distance (P < 0.001) and an increase in time to complete 5STS (P < 0.001) at postoperative day 10 compared to baseline, with a slight improvement at discharge. There were no differences in 6MWT and 5STS outcomes between patients based on comparisons of surgical and oncological factors. CONCLUSION: Pelvic exenteration patients are functionally impaired in the preoperative period compared to the general population. Surgery causes a further reduction in physical function in the short term; however, functional outcomes are not impacted by tumour type, extent of exenteration, sacrectomy or nerve resection.

Outcomes following repeat exenteration for locally advanced pelvic malignancy.

AIM: This study aims to assess surgical outcomes and survival following first, second and third pelvic exenterations for pelvic malignancy. METHOD: Consecutive patients undergoing pelvic exenteration for pelvic malignancy at a quaternary referral centre from January 1994 and December 2017 were included. Demographics and surgical outcomes were compared between patients who underwent first, second and third pelvic exenterations by generalized mixed modelling with repeated measures. Survival was assessed using Cox proportional hazards models and Kaplan-Meier plots. RESULTS: Of the 642 exenterations reviewed, 29 (4.5%) were second and 6 (0.9%) were third exenterations. Patients selected for repeat exenteration were more likely to have asymptomatic local recurrences detected on routine surveillance (P < 0.001). Postoperative wound complications increased with repeat exenteration (6%, 17%, 33%; P = 0.003, respectively). Additionally, postoperative length of stay increased from 27 to 38 and 48 days, respectively (P = 0.004). Median survival from first exenteration was 4.75, 5.30 and 8.14 years respectively amongst first, second and third exenteration cohorts (P = 0.849). Median survival from the most recent exenteration was 4.75 years after a first exenteration, 2.02 years after a second exenteration and 1.45 years after a third exenteration (P = 0.0546). CONCLUSION: This study demonstrates that repeat exenteration for recurrent pelvic malignancy is feasible but is associated with increased complication rates and length of admission and reduced likelihood of attaining R0 margin. Moreover, these data indicate that repeat exenteration does not afford a survival advantage compared with patients having a single exenteration. These data suggest that repeat exenteration for recurrent pelvic malignancy may be of questionable therapeutic value.

The Price We Pay for Radical Curative Pelvic Exenterations: Prevalence and Management of Pain.

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.

Pelvic Exenteration Surgery: The Evolution of Radical Surgical Techniques for Advanced and Recurrent Pelvic Malignancy.

Pelvic exenteration was first described by Alexander Brunschwig in 1948 in New York as a palliative procedure for recurrent carcinoma of the cervix. Because of initially high rates of morbidity and mortality, the practice of this ultraradical operation was largely confined to a small number of American centers for most of the 20 century. The post-World War II era saw advances in anaesthesia, blood transfusion, and intensive care medicine that would facilitate the evolution of more radical and heroic abdominal and pelvic surgery. In the last 3 decades, pelvic exenteration has continued to evolve into one of the most important treatments for locally advanced and recurrent rectal cancer. This review aimed to explore the evolution of pelvic exenteration surgery and to identify the pioneering surgeons, seminal articles, and novel techniques that have led to its current status as the procedure of choice for locally advanced and recurrent rectal cancer.

Validation of MRI and Surgical Decision Making to Predict a Complete Resection in Pelvic Exenteration for Recurrent Rectal Cancer.

BACKGROUND: The main predictor of long-term survival in patients with recurrent rectal cancer is surgical resection with a clear resection margin. MRI plays a role in patient selection and surgical planning. OBJECTIVE: This study aimed to validate MRI in determining pelvic involvement by comparing MRI to histological outcomes, to assess the effect of MRI on surgical planning by comparing MRI findings with the surgical procedure, and to compare MRI anatomical involvement with resection outcome to assess if MRI can predict a clear resection margin. DESIGN: Retrospective study reviewing prepelvic exenteration MRI and correlating organ, involving an MRI with pathological involvement and surgical outcomes. SETTINGS: Single quaternary referral center with a special interest in pelvic exenteration. PATIENTS: The patients included 40 men and 22 women with median age of 60 years who had locally recurrent rectal cancer. MAIN OUTCOME MEASURES: The accuracy of MRI as measured using sensitivity and specificity by correlating MRI involvement with pathological involvement was the primary outcome measured. RESULTS: Recurrence in the anterior and central compartments was identified with accuracy on MRI and was likely to be associated with clear resection margins. MRI was less accurate at determining pelvic sidewall involvement. Lateral recurrence, high sacral, and nerve involvement were more likely to be associated with a positive resection margin. Sensitivity and specificity for pelvic sidewall structures was 46% and 91%. Involvement of nerve roots (60%-69%) and the upper sacrum (80%) on MRI was more likely to predict a positive resection margin than involvement of major pelvic viscera (22%). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: MRI findings can be used to help predict resection margin. Prospective work with MRI interpretation and close correlation and involvement by pathologists is needed to address imaging and surgical limitations at the pelvic sidewall and high posterior margin.

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.

Urological complications after cystectomy as part of pelvic exenteration are higher than that after cystectomy for primary bladder malignancy.

BACKGROUND: Total cystectomy and subsequent reconstruction of the urinary tract may be required for primary malignancy of the bladder, or in the context of multi-visceral resection for more advanced pelvic tumors. Complications following urinary diversion are a major source of morbidity, particularly in pelvic exenteration (PE) patients. METHODS: All patients who underwent radical cystectomy alone or during PE at a single tertiary referral centre between 2008 and 2014 were reviewed. Postoperative urological complications were collected and compared between groups. RESULTS: Two hundred and thirty-one patients underwent en bloc cystectomy (98 cystectomy alone, 133 as part of a PE). Postoperative urological complications occurred in 33% of the cystectomy alone group and 59% of the PE group (P < 0.001). PE for recurrence had higher complications than PE for primary malignancy (67% vs. 48%, P = 0.035). Urological leaks occurred in 3%, 6%, and 14% of patient who had cystectomy alone, PE for primary malignancy and PE for recurrence. Major blood loss and previous pelvic radiotherapy independently predicted conduit-associated complications in PE patients (P = 0.002 and 0.035). CONCLUSIONS: Urological complications of cystectomy, particularly urine leaks and sepsis, are more common in patients undergoing PE compared to those with cystectomy alone. Prior pelvic radiotherapy, the extent of surgical resection and major blood loss may contribute to urological morbidity. J. Surg. Oncol. 2017;115:307-311. © 2016 Wiley Periodicals, Inc.

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.