Prone en bloc sacrectomy with proctectomy: a surgical approach to the inaccessible and hostile pelvis.

AIM: Reoperative pelvic surgery is rarely hostile and unsafe. Kraske's procedure has historically been used to approach the mid-rectum and to resect retrorectal tumors. However, it provides limited access to the pelvis and is best in the 'virgin' pelvis. We have encountered a select group of patients who required completion proctectomy or resection of a disconnected ileoanal J-pouch where trans-abdominal access to the pelvis was not possible and access to the pelvis could only be safely gained by a prone en bloc sacrectomy. METHOD: We describe a prone approach that provides an alternative route of access to the hostile pelvis. After exposure of the sacrum and coccyx and transection of the sacrum, access to the mesorectal plane is achieved and a proctectomy (or resection of an ileoanal J-pouch) can be completed. The procedure is similar to the Kraske approach but requires a higher and wider exposure similar to the extent of an abdominal resection; however, the operation is performed in 'reverse'. RESULTS: We found that this approach was feasible and safe in the previously operated, hostile pelvis. We employed it in one patient to excise a disconnected J-pouch with chronic sepsis and in another patient for a completion proctectomy. Both patients had an uneventful recovery and clear margins were obtained with no complications. CONCLUSION: The en bloc prone sacrectomy approach is a useful alternative in a very select group of patients with difficult trans-abdominal access to the pelvis. Experience in pelvic surgery and identification of clear anatomical landmarks is paramount to avoid catastrophic uncontrollable bleeding.

Is neoadjuvant chemoradiotherapy sufficient in patients with advanced rectal malignancy and positive extra-mesorectal lateral lymph nodes?

AIM: There is current debate about the optimal management of lateral pelvic lymph nodes (LPLNs) in rectal cancer between Western and Eastern centres. This paper aims to report the rate of histologically proven positive LPLNs in a group of patients undergoing the conventional Western approach to primary and recurrent rectal cancer. METHOD: A retrospective cohort review of all patients who underwent LPLN dissection at Royal Prince Alfred Hospital in Sydney, Australia. This included patients who underwent pelvic exenteration who had LPLNs excised either en bloc for laterally invasive or recurrent tumours or as part of selective node dissection for suspicious lymph nodes on preoperative imaging. Histopathological results for these patients were compared with node status at preoperative imaging. RESULTS: Seventy-one patients satisfied the inclusion criteria. Of those patients with positive nodes on histology, 27% (9/33) with radiologically positive LPLNs were treated with preoperative radiotherapy and 75% (9/12) with radiologically positive LPLNs were not treated with preoperative radiotherapy (P = 0.004). None of the 12 patients with radiologically negative nodes treated with radiotherapy had positive nodes; 25% (3/12) of the patients with radiologically negative nodes who were not treated with radiotherapy had positive nodes. Fifty-three per cent of patients developed postoperative complications. CONCLUSION: Our study suggests that in patients with radiologically positive LPLNs chemoradiotherapy may not be enough to sterilize these extra-mesorectal lymph nodes as a large proportion (27%) will have residual viable adenocarcinoma cells. In patients with radiologically negative LPLNs, however, the addition of chemoradiotherapy may serve to adequately sterilize these lymph nodes without the need for prophylactic LPLN dissection.

Pre-emptive triple tributary internal iliac vein ligation reduces catastrophic haemorrhage from sacrectomy during pelvic exenterative surgery.

BACKGROUND: The risk of significant haemorrhage in pelvic exenterative surgery requiring sacrectomy has been well described. Patients requiring a sacrectomy above S3 are placed in the prone position, posing an increased challenge to gaining control of haemorrhage when it occurs. We describe a technique of pre-emptive control of the internal iliac vein and its three named tributaries to tame the pelvis prior to sacrectomy. METHODS: A retrospective, descriptive analysis was performed on a cohort of 25 consecutive patients operated on by one of the authors (AA E) between January 2005 and December 2010; all of whom underwent pre-emptive internal iliac vein triple tributary venous ligation, either unilaterally or bilaterally prior to sacrectomy above the level of S3. RESULTS: The cohort of patients was a heterogenous group ranging in age from 20 to 80 (mean 46.2) years, with primary tumours in 19 (76%), and secondary tumours in 6 (24%). Median operating time was 8.5 h (range 2.32-19.67 h). Median blood loss was 5500 mL (range 1600-18000 mL), with associated median transfusion of packed red blood cells of 9 units (range 0-34 units). Average stay in the intensive care unit was 1 day (range 0-10 days), with a median length of hospital stay of 18 days (range 5-148 days). There was no intraoperative mortality, with one death at 30 days secondary to gram-negative septicaemia. Postoperative morbidity occurred in 17 (68%) patients. CONCLUSION: Our results show that pre-emptive triple tributary internal iliac vein ligation is feasible for taming the pelvis prior to sacrectomy in the prone position where control of significant haemorrhage can prove challenging. The technique has broader relevance for visceral resections in the pelvis involving the pelvic side walls.

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.

Lateral pelvic compartment excision during pelvic exenteration.

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.

Survival after pelvic exenteration for T4 rectal cancer.

BACKGROUND: The purpose of this study was to analyse retrospectively the pooled results after pelvic exenteration for locally advanced T4 rectal cancer. Historically, patients with T4 rectal cancers requiring pelvic exenteration have been offered only palliative surgery or no operation. METHODS: The basic treatment principle was preoperative (chemo)radiotherapy, radical surgery and, in some patients, adjuvant chemotherapy. Risk factors for local recurrence, distant metastases and overall survival were studied in univariable and multivariable analyses. RESULTS: Ninety-five patients with T4 rectal cancer who underwent pelvic exenteration in two tertiary referral centres up to 2013 were studied. Clear margins (R0) were achieved in 87 per cent of patients. Adjuvant chemotherapy was administered in 33 per cent, independent of the resection margin, lymph node status and postoperative T category. The 5-year local recurrence rate was 17 per cent, with a distant metastasis rate of 16 per cent and overall survival rate of 62 per cent. In multivariable analysis the only factor associated with death was omission of adjuvant chemotherapy (P = 0.016). The effect of adjuvant chemotherapy was more pronounced in the elderly: patients aged over 70 years who had chemotherapy had a 5-year overall survival rate of 80 per cent, compared with 39 per cent of elderly patients who did not receive chemotherapy (P = 0.019). CONCLUSION: Pelvic exenteration led to an R0 resection rate of 87 per cent for T4 rectal cancer, giving good local control and overall survival comparable to population-based colorectal cancer survival rates. Adjuvant chemotherapy may improve overall survival further, even in the elderly.

Outcomes of pelvic exenteration for locally advanced primary rectal cancer: Overall survival and quality of life.

INTRODUCTION: Radical surgery with pelvic exenteration offers the only potential for cure in patients with locally advanced primary rectal cancer. This study describes the clinical and patient-reported quality of life outcomes over 12 months for patients having pelvic exenteration for locally advanced primary rectal cancer at a specialised centre for pelvic exenteration. METHODS: Clinical data of consecutive patients undergoing pelvic exenteration for locally advanced primary rectal cancer and patient-reported outcomes were collected at baseline, hospital discharge and at 1, 3, 6, 9 and 12 months. Patient-reported outcomes included cancer-specific quality of life (QoL) and physical and mental health status. Quality of life trajectories were modelled over the 12 months from the date of surgery using linear mixed models. RESULTS: 104 patients with locally advanced rectal cancer underwent pelvic exenteration at Royal Prince Alfred Hospital, Sydney, between December 1994 and October 2014. Complete soft tissue exenteration was performed in 38%. A clear margin was obtained in 86% with a 62% overall five-year survival. QoL outcome questionnaires were completed by 62% of patient cohort. The average FACT-C score returned to pre-surgery QoL by 2 months after surgery, and the average QoL continued to increase slowly over the 12 months. CONCLUSION: Our results support an aggressive approach to advanced primary rectal cancer and lend weight to the oncological role of pelvic exenteration for this group of patients. Quality of life improves rapidly after pelvic exenteration for locally advanced primary rectal cancer and continues to improve over the first year.