Management of a Pelvic Abscess and Abdominal Fistula after Palliative Total Pelvic Exenteration with Intraoperative Radiotherapy in Recurrent Rectal Cancer Without NPWT: A Case Report.

ABSTRACT: A 59-year-old man with recurrent rectal cancer and type 2 diabetes mellitus underwent palliative total pelvic exenteration and intraoperative radiotherapy. After surgery, he experienced a pelvic abscess and abdominal-perineal fistula. Profuse exudate contaminated the midline abdominal incision through the abdominal-perineal fistula and delayed healing. Because of a residual tumor and the high cost, negative-pressure wound therapy was not performed. After 76 days of local treatment that involved removing necrotic tissue, controlling inflammation with an antimicrobial silver dressing, absorbing and draining exudate with a hypertonic saline dressing, promoting granulation and preventing infection with a silver alginate dressing, and promoting re-epithelialization with recombinant human epidermal growth factor gel, the abdominal wound and abdominal-perineal fistula healed successfully.

Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer.

BACKGROUND AND OBJECTIVES: The primary treatment for locally advanced cases of cervical cancer is chemoradiation followed by high-dose brachytherapy. When this treatment fails, pelvic exenteration (PE) is an option in some cases. This study aimed to develop recommendations for the best management of patients with cervical cancer undergoing salvage PE. METHODS: A questionnaire was administered to all members of the Brazilian Society of Surgical Oncology. Of them, 68 surgeons participated in the study and were divided into 10 working groups. A literature review of studies retrieved from the National Library of Medicine database was carried out on topics chosen by the participants. These topics were indications for curative and palliative PE, preoperative and intraoperative evaluation of tumor resectability, access routes and surgical techniques, PE classification, urinary, vaginal, intestinal, and pelvic floor reconstructions, and postoperative follow-up. To define the level of evidence and strength of each recommendation, an adapted version of the Infectious Diseases Society of America Health Service rating system was used. RESULTS: Most conducts and management strategies reviewed were strongly recommended by the participants. CONCLUSIONS: Guidelines outlining strategies for PE in the treatment of persistent or relapsed cervical cancer were developed and are based on the best evidence available in the literature.

The influence of surgeon volume on outcomes after pelvic exenteration for a gynecologic cancer.

OBJECTIVE: To determine the effect of surgeon experience on intraoperative, postoperative and long-term outcomes among patients undergoing pelvic exenteration for gynecologic cancer. METHODS: This was a retrospective analysis of all women who underwent exenteration for a gynecologic malignancy at MD Anderson Cancer Center, between January 1993 and June 2013. A logistic regression was used to model the relationship between surgeon experience (measured as the number of exenteration cases performed by the surgeon prior to a given exenteration) and operative outcomes and postoperative complications. Cox proportional hazards regression was used to model survival outcomes. RESULTS: A total of 167 exenterations were performed by 19 surgeons for cervix (78, 46.7%), vaginal (43, 25.8%), uterine (24, 14.4%), vulvar (14, 8.4%) and other cancer (8, 4.7%). The most common procedure was total pelvic exenteration (69.4%), incontinent urinary diversion (63.5%) and vertical rectus abdominis musculocutaneous reconstruction (42.5%). Surgical experience was associated with decreased estimated blood loss (p<0.001), intraoperative transfusion (p=0.009) and a shorter length of stay (p=0.03). No difference was noted in the postoperative complication rate (p=0.12-0.95). More surgeon experience was not associated with overall or disease specific survival: OS (hazard ratio [HR]=1.02; 95% confidence interval [CI]=0.97-1.06; p=0.46) and DSS (HR=1.01; 95% CI=0.97-1.04; p=0.66), respectively. CONCLUSION: Patients undergoing exenteration by more experienced surgeons had improvement in intraoperative factors such as estimated blood loss, transfusion rates and length of stay. No difference was seen in postoperative complication rates, overall or disease specific survival.

A qualitative study of the development of a multidisciplinary case conference review methodology to reduce involved margins in pelvic exenteration surgery for recurrent rectal cancer.

AIM: Pelvic exenteration surgery remains the only curative option for recurrent rectal cancer. Microscopically involved surgical margins (R1) are associated with a higher risk of local recurrence and decreased survival. Our study aimed to develop a post hoc multidisciplinary case conference review and investigate its potential for identifying areas for improvement. METHOD: Patients who underwent pelvic exenteration surgery for recurrent rectal cancer with R1 resections at a tertiary referral centre between April 2014 and January 2016 were retrospectively reviewed from a prospectively maintained database. Patients with non-rectal cancers or who underwent palliative surgery were excluded. Cases, imaging and histopathology were evaluated by a dedicated panel including colorectal surgeons, an abdominal radiologist and a gastrointestinal pathologist. RESULTS: R1 resections were reported in 32 of 110 pelvic exenterations. Patients with other tumours were excluded and one patient had a palliative resection. Nine male patients with 11 exenterations were included with a median age of 56 years. All patients had positive soft tissue margins, and one patient also had an involved bony margin. Failures were due to (interdisciplinary) communication problems, specific management of tumour biology (multifocality, spiculated tumours), which can lead to radiological undercalling, and inadequate surgical technical planning. In hindsight, surgery would have been withheld from one patient. CONCLUSION: A retrospective multidisciplinary case evaluation of pelvic exenteration patients with involved surgical margins led to a list of recommendations which included the need to plan for wider surgical soft tissue resections and improvement in interdisciplinary communication. Lessons learned may increase clear margin rates in future resections.

[Curative pelvic exenteration for recurrent cervical carcinoma in the era of concurrent chemotherapy and radiation therapy. A systematic review]. / L'exentération pelvienne curative en cas de récurrence d'un cancer du col de l'utérus à l'ère de la radio-chimiothérapie concomitante : revue de la littérature.

OBJECTIVE: The purpose of this review is to assess the preoperative management in case of recurrent cervical cancer, to assess patients for a surgical curative treatment. METHODS: English publications were searched using PubMed and Cochrane Library. RESULTS: In the purpose of curative surgery, pelvic exenteration required clear margins. Today, only half of pelvic exenteration procedures showed postoperative clear margins. Modern imaging (RMI and Pet-CT) does not allow defining local extension of microcopic disease, and thus postoperative clear margins. Despite the same generic term of pelvic exenteration, there is a wide heterogeneity in surgical procedures in published cohorts. CONCLUSION: Because clear margins are required for curative pelvic exenteration, but are not predictable by preoperative assessment. The larger surgery, i.e. the infra-elevator exenteration with vulvectomy, could be the logical surgical choice to increase the rate of clear margins and therefore, recurrent cervical carcinoma patient survival.

Pelvic exenteration for primary and recurrent vulvar cancer.

Twenty-one patients who underwent pelvic exenteration for primary (n = 8) or recurrent (n = 13) vulvar malignancy at the M. D. Anderson Cancer Center between 1956 and 1989 were evaluated. A posterior exenteration was performed in 12 patients, anterior exenteration was performed in 6, and total exenteration was performed in 3. In patients with primary tumors, radical vulvectomy and inguinal lymphadenectomy were also performed. The median patient age was 57 years. The mean tumor diameters were 5 cm (primary) and 4 cm (recurrent). Infections were the most frequent postoperative complications (n = 15), followed by pulmonary (n = 4) and cardiac problems (n = 3). There were no treatment-related deaths. Five patients required further surgery to correct late postoperative sequelae. Four of eight patients experienced recurrence after treatment of their primary tumor; the recurrences were local only (n = 1), in the inguinal area (n = 2), or local and in the pelvis (n = 1). Nine of the 13 patients treated for recurrent tumors developed a second recurrence; the second recurrences were all within the pelvis, although two also had a distant component. The 5-year survival rates were 70% for patients treated for primary disease and 38% for patients treated for recurrent disease. Pelvic exenteration is indicated for selected patients with advanced vulvar malignancy.

[Treatment of the pelvis after total pelvic exenteration. Experience of the Regional Paul Strauss Cancer Center of Strasbourg]. / Traitement du pelvis après exentération pelvienne totale. Expérience du Centre Régional de Lutte contre le Cancer Paul Strauss de Strasbourg.

Intestinal morbidity after total pelvic exenteration presents usually as fistulae. These appear particularly if irradiation has been carried out in the pelvis or the abdomen before surgery, and particularly as a result of the types of surgery carried out in the emptied pelvis. An analysis of 92 exenterations of the pelvis of which 52 were total exenterations led us to look at how treatments in the pelvis have evolved technically and to analyse the contribution they have made to reducing the number of fistulae and obstructions found as a result of this major surgery. Making a "sac" by packing the pelvis as suggested by the pioneer of this exceptionally extensive pelvic surgery gradually has been replaced by the use of endogenous material such as the omentum and more recently by the use of absorbable synthetic materials (vicryl) which give rise to progressive reperitonealisation. The authors approve of this last way of dealing with the emptied pelvic cavity because the synthetic material is very well tolerated clinically and the polyglactine 910 mesh is not predisposed to infection when it is used to make a hammock to prevent chronic radiation enteritis by holding the small intestines out of the pelvis.

Cervical cancer: women aged 35 and younger compared to women aged 36 and older.

One hundred fifty-three patients with invasive cervical cancer were evaluated and treated at one of the two teaching hospitals of the Intergrated Ob-Gyn Residency Program of Wright State University, Dayton, Ohio, from 1 July 1983 to 30 June 1989. Sixteen patients with recurrent cervical cancer who initially had received their treatment elsewhere were excluded. Forty-one of the 137 newly diagnosed patients with cervical cancer were aged 35 years or less. This review was undertaken because of frequent reports of the increasing incidence of cervical cancer in women aged 35 and under. Some reports also reveal a worse prognosis for the younger age group. This investigation provided the opportunity to evaluate cervical cancer patients aged 35 and under and compare the results to the evaluations of women aged 36 and over. Evaluation of age, stage, presenting symptoms, number of positive lymph nodes, pap smear history, pregnancy within 1 year of diagnosis, treatment, and survival was carried out in patients aged 35 years and less and compared to their older counterparts aged 36 and over with cervical cancer.

Types of pelvic exenterations: a reappraisal.

Subgrouping of pelvic exenterations as supralevator (type I), infralevator (type II), with vulvectomy (type III), and, an added category, extended can be helpful to facilitate communication when referring to these patients. It also can facilitate a more detailed analysis of operative risk factors, complications, and results and can increase our knowledge of the indications and limitations of the different exenterative procedures.

Pelvic exenteration for carcinoma of the cervix.

Pelvic exenteration for carcinoma of the cervix uteri carries a 15 per cent operative mortality and a 23.3 per cent five-year survival. Total exenteration, not anterior exenteration or modified exenteration, is the operation of choice in the heavily irradiated patient. The criteria for operability are proof of persistence of disease, proof of no extension of disease beyond the pelvis, proof of freedom of disease at the lateral margins of resection and proof that pelvic-lymph-node metastases are minimal. Only 2 of 33 patients with positive pelvic lymph nodes survived for five years. Ileal-loop urinary diversion has been a major factor in diminishing the complications and deaths from this procedure.