Anatomical Variations of Iliac Vein Tributaries and Their Clinical Implications During Complex Pelvic Surgeries.

BACKGROUND: During high sacrectomies and lateral pelvic compartment exenterations, isolating the external and internal iliac veins within the presacral area is crucial to avoid inadvertent injury and severe hemorrhage. Anatomical variations of external iliac vein tributaries have not been previously described, whereas multiple classifications of internal iliac vein tributaries exist. OBJECTIVE: We sought to clarify the iliac venous system anatomy using soft-embalmed cadavers. DESIGN: This is a descriptive study. SETTINGS: This study was conducted in Chulalongkorn University, Thailand. PATIENTS: We examined 40 iliac venous systems from 20 human cadavers (10 males, 10 females). INTERVENTIONS: Blue resin dye infused into the inferior vena cava highlighted the iliac venous system, which was meticulously dissected and traced to their draining organs. MAIN OUTCOME MEASURES: Iliac vein tributaries and their valvular system were documented and analyzed. RESULTS: The external iliac vein classically receives 2 tributaries (inferior epigastric and deep circumflex iliac) near the inguinal ligament. However, external iliac vein tributaries in the presacral area were found in 20 venous systems among 15 cadavers (75%). The mean diameter of each tributary was 4.0 ± 0.35 mm, with 72% arising laterally. We propose a simplified classification for internal iliac vein variations: pattern 1 in 12 cadavers (60%) where a single internal iliac vein joins a single external iliac vein to drain into the common iliac vein; pattern 2 in 7 cadavers (35%) where the internal iliac vein is duplicated; and pattern 3 in 1 cadaver (5%) where bilateral internal iliac veins drain into a common trunk before joining the common iliac vein bifurcation. LIMITATIONS: This study is limited by the number of cadavers included. CONCLUSIONS: A comprehensive understanding of previously unreported highly prevalent external iliac vein tributaries in the presacral region is vital during complex pelvic surgery. A simplified classification of internal iliac vein variations is proposed. See Video Abstract at http://links.lww.com/DCR/A900.

Urgent Pelvic Exenteration: Should the Indication Be Extended?

BACKGROUND: Pelvic exenteration carries significant risks of morbidity and mortality. Preoperative management is therefore crucial, and the exenteration procedure is usually performed in an elective setting. In cases of rectal cancer, however, tumor-related complications may cause a patient's condition to deteriorate rapidly, despite optimal management. Urgent pelvic exenteration then may be an option for these patients. OBJECTIVE: This study aims to compare the outcomes of pelvic exenteration between the urgent and elective settings. DESIGN: This is a retrospective study. SETTING: This study was conducted at King Chulalongkorn Memorial Hospital between February 2006 and June 2012. PATIENTS: Fifty-three patients with locally advanced rectal cancer were included. INTERVENTION: All patients underwent pelvic exenteration for locally advanced rectal cancer. They were assigned to urgent and elective setting groups according to their preoperative conditions. The urgent setting group included patients who required urgent pelvic exenteration because of intestinal obstruction, bowel perforation, bleeding, or uncontrolled sepsis, despite optimal management preoperatively. MAIN OUTCOME MEASURES: Twenty-six patients were classified in the urgent setting group, and 27 were classified in the elective setting group. Three-year overall and disease-free survivals were compared between the 2 groups. Thirty-day postoperative morbidity and mortality were also studied. RESULTS: Three-year overall survival was 62.2% and 54.4% in the elective and urgent groups (p = 0.7), whereas three-year disease-free survival was 43% and 63.8% (p = 0.33). The median follow-up time was 33 months. Thirty-day morbidity did not differ between the 2 groups (p = 0.49). A low serum albumin level was a significant risk factor for complications. There was no postoperative mortality in this study. LIMITATIONS: This was a retrospective study performed at 1 institution, and it lacked quality-of-life scores. CONCLUSION: Pelvic exenteration in an urgent setting is feasible and could offer acceptable outcomes. See Video Abstract at http://links.lww.com/DCR/A591.