Clincal practice of pelvic exenteration for late complications of pelvic radiation injury / 中华胃肠外科杂志

Pelvic radiation injury can potentially involve multiple pelvic organs, and due to its progressive and irreversible nature, its late stage can be complicated by fistulas, perforations, obstructions and other complications involved multiple pelvic organs, which seriously affect the long-term survival and the quality of life of patients. As a multidisciplinary surgical approach, pelvic exenteration has potential application in the treatment of late complications of pelvic radiation injury by completely removing the irradiated lesion, relieving symptoms and avoiding recurrence of symptoms. In clinical practice, we should advocate the concept of "pelvic radiation injury", emphasize multidisciplinary collaboration, fully evaluate the overall status of patients, primary tumor and pelvic radiation injury. We should follow the principles of "damage-control" and "extended resection", and follow the principle of enhanced recovery after surgery to achieve the goal of ensuring the surgical safety, relieving patients' symptoms and improving patients' quality of life and long-term survival.

Surgical skills and precautions of pelvic exenteration combined with pelvic wall resection / 中华胃肠外科杂志

The treatment of locally advanced rectal cancer (LARC) or locally recurrent rectal cancer (LRRC) has been a difficulty and challenge in the field of advanced rectal cancer, while pelvic exenteration (PE), as an important way to potentially achieve radical treatment of LARC and LRRC, has been shown to significantly improve the long-term prognosis of patients. The implementation of PE surgery requires precise assessment of the extent of invasion of LARC or LRRC and adequate preoperative preparation through multidisciplinary consultation before surgery. The lateral pelvis involves numerous tissues, blood vessels, and nerves, and resection is most difficult, and the ureteral and Marcille triangle approaches are recommended; while the supine transabdominal approach combined with intraoperative change to the prone jacket position facilitates adequate exposure of the surgical field and enables precise overall resection of the bony pelvis and pelvic floor muscle groups invaded by the tumor. Empty pelvic syndrome has always been an major problem to be solved during PE. The application of extracellular matrix biological mesh to reconstruct pelvic floor defects and isolate the abdominopelvic cavity is expected to reduce postoperative pelvic floor related complications. Reconstruction of the urinary system and important vessels after PE is essential, and the selection of appropriate reconstruction methods helps to improve the patient's postoperative quality of life, while more new methods are also being continuously explored.

Exenteração pélvica para câncer do colo uterino recidivado pós-radioterapia: experiência de um centro terciário do Nordeste brasileiro / Post-radiotherapy pelvic exenteration in relapsed cervical cancer: experience of a tertiary health service in the northeast of Brazil

OBJETIVO: analisar complicações, morbidade, mortalidade e sobrevida num grupo de pacientes com câncer de colo uterino com recidiva pélvica central submetidas à exenteração pélvica pós-tratamento primário com radioterapia. MÉTODOS: estudo retrospectivo de uma série de 16 casos de exenteração pélvica pós-tratamento primário com radioterapia. Foi realizada estatística descritiva, curva de sobrevida pelo método de Kaplan-Meier e análise de regressão linear múltipla para avaliar fatores prognósticos. RESULTADOS: dezesseis pacientes foram submetidas à exenteração pélvica. O carcinoma epidermoide, o estádio IIb e o grau indiferenciado foram as condições mais frequentes. A recidiva tumoral pós-operatória ocorreu na metade dos casos. Onze pacientes apresentaram complicações perioperatórias ou pós-operatórias e as mais frequentes foram infecções pélvica e da ferida operatória e fístulas urinárias. A sobrevida global foi de 64,3 por cento, com um seguimento mediano de 11 meses. A análise de regressão linear múltipla não revelou fatores prognósticos significativos na sobrevida das pacientes. CONCLUSÕES: a taxa de sobrevida foi de 64,3 por cento. Nenhum fator associado a pior prognóstico foi encontrado nesta série.

PURPOSE: to analyze complications, morbidity, mortality and survival rate in a group of patients with cervical cancer with central pelvic relapse after primary radiotherapy treatment. METHODS: retrospective study of a series of 16 cases of pelvic exenteration after primary radiotherapy treatment. Descriptive statistics, survival curve through Kaplan-Meier's method, and regression analysis to evaluate prognosis were performed. RESULTS: sixteen patients have undergone pelvic exenteration. Epidermoid carcinoma, IIb stage and undifferentiated grade were the most frequent conditions. Post-operatory tumor relapse occurred in half the cases. Eleven patients presented peri or post-surgical complications, the most frequent being pelvic infection, that of the surgical wound, and urinary fistulae. Global survival rate was 64.3 percent, with average follow-up of 11 months. Regression analysis did not detect any significant prognosis factor for the patient survival. CONCLUSIONS: the survival rate was 64.3 percent. No particular factor associated to poor prognosis has been found in the present series of cases.

A exenteração pélvica no tratamento do câncer de reto estádio T4: experiência de 15 casos operados / Pelvic exenteration for T4 rectal cancer: a series of 15 ressectable cases

RACIONAL: A exenteração pélvica tem sido a melhor opção terapêutica radical para o tratamento dos tumores de reto T4. No entanto, essa operação ainda permanece com mortalidade significante e alta morbidade. OBJETIVO: Relatar série de 15 casos de exenteração pélvica para tumores de reto T4, analisando a morbidade, mortalidade e sobrevida dos pacientes. MÉTODOS: Foram estudados 15 pacientes com câncer de reto T4 no Serviço de Cirurgia Geral - Oncocirurgia do Hospital do Servidor Publico Estadual de São Paulo, SP, submetidos a exenteração pélvica no período de 1998 e 2006. Sete eram do sexo masculino enquanto oito eram do sexo feminino, com média de idade de 65 anos. Todos apresentavam sintomas incapacitantes. As operações foram: exenteração infra-elevadora (n = 6), exenteração supra-elevadora (n = 4), exenteração posterior (n = 3) e exenteração posterior com cistectomia e ureterectomia parciais (n = 2). RESULTADOS: A média de tempo cirúrgico foi de 403 minutos (280-485). A média de sangramento foi de 1620 mL (300-4800). A mortalidade pós-operatória foi de 6,66 por cento (n = 1). A morbidade pós-operatória foi de 53,3 por cento (n = 8). Os exames histológicos evidenciaram que todas as ressecções foram R0. Envolvimento linfonodal foi observado em quatro pacientes (26,66 por cento) sendo que todos faleceram em decorrência da neoplasia. A sobrevida global em cinco anos foi de 35,7 por cento. CONCLUSÃO: A exenteração pélvica ainda apresenta alta morbidade, no entanto permanece justificada, pois pode conferir maior controle do câncer de reto T4 em longo prazo.

BACKGROUND: Pelvic exenteration is the best therapeutic choice for treatment of T4 rectal cancer. Although, this operation still presents considerable mortality and high morbidity. AIM: To report on a series of 15 patients with a T4 rectal cancer at a general hospital and describe the outcomes (morbidity, mortality and long-term survival) following pelvic exenteration. METHODS: Complete follow-up data were available on 15 patients who underwent pelvic exenteration for T4 rectal cancer between 1998 and 2006. These subjects comprised seven men and eight women with a mean age of 65 years. All of them presented serious incapacitating complaints. The surgical procedures included: infraelevator exenteration (n = 6), supraelevator exenteration (n = 4), posterior exenteration (n = 3) and, posterior exenteration plus partial cystectomy and ureterectomy (n = 2). RESULTS: The mean duration of surgery was 403 minutes (280-485). The mean blood loss was 1620 mL (300-4.800). The postoperative mortality was 6,66 percent (n = 1). The overall rate morbidity was 53,3 percent (n = 8). The pathological examination showed that all resections were R0. Lymph node involvement was present in four patients (26,66 percent), and all of them died due to tumor recurrence. The overall 5-year survival rate was 35,7 percent. CONCLUSION: In spite of its aggressive nature and high morbidity, pelvic exenteration seems justified in rectal carcinoma when the disease extends to the urinary or genital tract. This procedure may offer long-term disease control.

Surgical Management of Recurrent Cervical Cancer

The majority of patients with recurrent cervical cancer are incurable and treatment is based on the type of primary therapy delivered. Only a very small percentage of the patients with recurrent cervical cancer following primary radiotherapy will have central pelvic recurrences that are amenable to surgical resection and curable by pelvic exenteration. These procedures should be undertaken only after the completion of exhaustive attempts to exclude extrapelvic disease.

Exenteración pélvica en el Instituto Nacional de Cancerología / Pelvic exenteration in the Instituto Nacional de Cancerologia

Introducción. Desde 1948, la exenteración pélvica ha sido la alternativa de tratamiento en el rescate para pacientes con recurrencia por cáncer en la pelvis, sobre todo de tipo ginecológico. El procedimiento original ha sido modificado infinidad de ocasiones en un intento por mejorar el estado general y la calidad de vida de las pacientes sometidas a esta intervención. Objetivo. Efectuamos una revisión de la literatura y transmitimos la evaluación sobre el abordaje integral de las pacientes con recurrencia por cáncer ginecológico, con especial énfasis en el manejo perioperatorio estándar de las pacientes candidatas a esta intervención. Material y métodos. Revisión de la literatura, y análisis crítico de los departamentos involucrados, en el manejo perioperatorio de estas pacientes. Se describen con detalle desde el proceso de selección de las mujeres candidatas, rutas de manejo, monitoreo, evaluaciones preoperatorias, técnica quirúrgica más comúnmente empleada en el Instituto Nacional de Cancerología, hasta los cuidados posoperatorios y seguimiento de las pacientes. Resultados. Resultados. La selección meticulosa de las pacientes candidatas al procedimiento se inicia desde la primera entrevista con evaluación del entorno de la pacientes, soporte familiar, factibilidad económica y decision final por parte de la paciente. Participación de un equipo quirúrgico y de enfermería, multidisplinario, familiarizado con el procedimiento y colaborando sincrónicamente en las fases exenterativa y de reconstrucción. Apego y compromiso en la vigilancia estrecha del posoperatorio y evolución a corto, mediano y largo plazo de las pacientes. Conclusiones. El éxito de este tipo de procedimiento requiere pacientes bien seleccionadas, en centro oncológicos de experiencia, participación multidisciplinaria durante la resección quirúrgica, pero sobre todo del compromiso real por parte del equipo quirúrgico y de enfermería durante el manejo posoperatorio