Total pelvic exenteration as a therapeutic option in advanced malignant disease of the pelvis.

Between 1966 and 1986, 99 patients underwent total pelvic exenteration at the Ellis Fischel State Cancer Center. Fifty-eight per cent of these were done for recurrence of carcinoma of the cervix uteri after radiation. The second most common type of malignant condition treated with total pelvic exenteration was localized advanced adenocarcinoma of the rectum. Fourteen of 99 patients died prior to discharge and after five years, 36 of 80 patients had survived. Seven deaths after discharge were attributed to the operation. There were 97 complications in 64 of the 99 patients after total pelvic exenteration prior to discharge. Between 1976 and 1981, one out of 14 patients undergoing total pelvic exenteration for locally advanced recurrent carcinoma of the cervix uteri died prior to discharge. Eight of 13 of the patients who survived that operation lived for five years. Total pelvic exenteration should be strongly considered in selected patients with locally advanced malignant lesions of the pelvis.

Transvaginal parametrial needle biopsy for detection of postirradiation recurrent cancer of the cervix.

During the 27-year period from 1956 to 1982, transvaginal parametrial needle biopsies were performed on 76 patients clinically suspected of harboring postirradiation recurrent cervical cancer without mucosal lesions suitable for biopsy under direct vision. Needle biopsies indicated cancer in 41 patients, resulting in 20 abdominal explorations. Eleven of these patients underwent total pelvic exenteration. Three patients survived longer than 5 years. Among 35 patients whose biopsies did not suggest cancer, eight proved to be false-negative as demonstrated by later progression of local and systemic disease. The remaining 27 patients in whom biopsies showed negative results were cured by radiation therapy. Bleeding, easily controlled by vaginal packing, occurred in one patient; in another, a pelvic abscess was drained 7 days after the biopsy. The authors conclude that when judiciously performed, transvaginal parametrial needle biopsy has a high diagnostic yield (89%) with minimal morbidity (2.6%). Its application during the careful observation of patients suspected to harbor recurrence may increase the operability rate and may offer selected patients a chance for cure by radical pelvic surgery.

Exenterative surgery for locally advanced rectosigmoid cancers. Is it worthwhile?

Among 1480 patients treated for cancers of the rectosigmoid over a 30-year period, 24 patients underwent total pelvic exenteration. These patients, 13 men and 11 women, had a median age of 64 years. Pathologic staging revealed 15 Dukes' B and nine Dukes' C lesions. For 17 patients, this operation was the only form of therapy. The operative mortality rate was 20.8%; however, the mortality rate has decreased to 13.3% during the past 20 years and to 9% in the past decade. Five complications occurred in the group surviving the procedure, resulting in a 26.3% morbidity rate. Three of the five complications occurred in patients who had previous radiation therapy or surgery. The overall 5-year survival rate was 41.6%. Those patients surviving the operation had 5- and 10-year survival rates of 52.6% and 31.5%, respectively. There were seven patients in whom the disease recurred at an average of 20.3 months after exenteration, and all died an average of 8 months later. The recurrence rate for patients with Dukes' B lesions was 27% compared with 57% for patients with Dukes' C lesions. The remaining 12 disease-free patients had a mean survival of 11 years. At present, four patients are alive and well 6 to 30 years after exenteration. The best predictor of morbidity was treatment before exenteration (p less than .005). Age older than 65 years and the presence of nodal metastases may contribute to increased mortality rates and recurrence, respectively, but these relationships were not statistically significant for the group. Total pelvic exenteration is advocated for selected primary, locally advanced, rectosigmoid lesions in good-risk patients; it can be achieved now with acceptable morbidity and mortality rates and a survival rate in excess of 40% at 5 years.

The current role of ultraradical surgery in the treatment of pelvic cancer.

Based on the results of experience accumulated in the past 30 years, exenterative pelvic surgery should be a part of the armamentarium of specially prepared oncologic surgeons. It is most frequently indicated for radiation failures in the treatment of carcinoma of the cervix, although it may be justified as primary treatment of selected cases of stage IV lesions without evidence of dissemination outside the pelvis. It is also justified for postirradiation radionecrosis causing sloughing and fistula, provided adequate relief cannot be offered by simple urinary and fecal diversion. For carcinoma of the rectum and pelvic colon, exenteration has a role in the advanced lesions that appear not to have become disseminated outside the pelvis but that involve contiguous viscera. Reoperation for recurrent carcinoma of the rectum is rarely successful, and this dreaded complication is best avoided by a well-planned and adequate standard first operation, or by the early recognition that a more extended operation is necessary. It is to be hoped that adjuvant radiation therapy, either preoperative or postoperative, or both, may be proved effective in preventing recurrence, especially for lesions below the peritoneal reflection, which is the most frequent site of recurrent disease. Finally, ultraradical pelvic surgery has reached its anatomical and pathologic limit. It only remains for the mortality and survival results to be further improved by continued refinements in the technicalities of the operation and in the judgment and selection of patients for it. Multimodal adjunctive therapy has an emerging role, as does selection of patients for functional preservation and reconstruction. The procedures should continue to be done in institutions where special studies are being conducted and where trained and experienced personnel are available with the necessary ancillary services.

Combined reconstruction of the rectum and vagina following irradiation and surgical treatment for clear cell carcinoma.

A technique for concomitant reconstruction of the rectum and vagina using using a loop of sigmoid colon is described. In addition to repair of postirradiation defects, the technique might play a role in reconstruction after radical operation for carcinoma in selected patients.

Reconstructive surgery for the complications of pelvic irradiation.

Severe damage to the pelvic viscera is a complication of irradiation therapy that, unfortunately, cannot always be avoided. Resulting rectal and rectocolonic strictures, rectovaginal fistulas, and shortening and stenosis of the vagina present very difficult problems that frequently require a colostomy for relief and may permanently impair sexual function. The authors present a new approach to correction of these unfortunate lesions based on the use of proximal nonirradiated colon which serves as a vascular pedicle graft to correct the defect without a complicated and massive resection. Twenty-two such operations have been done with 19 satisfactory to excellent results and two total failures (one death from small bowel complications). All patterns and combinations of irradiation injury have been found amenable to this technique of repair. These have included both web and linear strictures with and without fistulas. In half of the patients, it was possible to make use of normal colon bypassed by a prior colostomy. Normal nonirradiated colon with good blood supply will heal satisfactorily to irradiated colon or rectum, thus making excision of all the irradiated tissue unnecessary. The results of this surgical approach have thus far been gratifying and warrant further trials for these distressing injuries.

Pelvic abscess following preoperative radiation and abdominoperineal resection: management with a free flap.

The case of a woman treated for a large rectal cancer with high-dose radiation therapy and abdominoperineal resection followed by a large pelvic abscess is presented. Wound healing, reconstruction, and rehabilitation were achieved with a free latissimus dorsi myocutaneous flap. The importance of providing well-vascularized tissue for wound healing in the infected irradiated wound is emphasized.

Experience with a modified Witzel gastrostomy without gastropexy.

The records of 161 adult patients who underwent a modification of the Witzel gastrostomy without gastropexy at Ellis Fischel State Cancer Hospital, Columbia, Missouri, between 1977 and 1980, are reviewed in detail and form the basis of this report. Six of these patients had gastrostomies on two different occasions. There was no mortality or major complication directly attributed to the procedure in this group of patients. Technical details are examined and considered most important in preventing intraperitoneal or extraperitoneal leak of gastric contents and migration of the catheter, the most commonly found complications of other techniques. Anterior gastropexy is considered unnecessary, thus simplifying the operation and eliminating gastric deformity and other related problems. The liberal indications of this procedure are discussed, and potential areas of technical pitfalls are reviewed. The personal experience of one of the authors (EMB) with 774 gastrostomies during a 15-year period using this technique confirms these conclusions. A random sample of 200 records of these patients were examined for complications of the operation. This study suggests that tube gastrostomy by the technique described is a reliable and safe procedure with wide applicability for patients undergoing major abdominal surgery. The relatively few complications are more than compensated for by the degree to which postoperative comfort and care are facilitated.

Repair of postirradiation damage to colorectum: a progress report.

The results of 21 operations for repair of rectovaginal fistula and/or stricture secondary to irradiation for pelvic cancer are presented. The operations rely on the use of proximal nonirradiated colon with normal blood supply for effecting the repair. In patients having had a previous colostomy, it is possible to use the proximal end of the bypassed colon for this purpose. There is minimal dissection of the rectal ampulla and the presacral space is never entered. Continuity is established by anastomosis to the anterior rectal wall via an abdominal approach alone, or by a combined abdominovaginal or abdominoperineal approach. It has been found that nonirradiated colon of normal vascularity can be expected to heal to irradiated colon or rectum, thus making the extensive resections associated with correction of these abnormalities unnecessary. The functional result in 18 of 19 patients who underwent this procedure was satisfactory to excellent. One patient had a poor result because of partial rectal incontinence. Two operations out of the 21 were total failures and one of these patients died of complications secondary to irradiation damage to the small intestine. One patient has not yet had final colostomy closure. The results are considered promising enough to warrant continued trial.

Current status of urinary diversion.

The need for urinary diversion is widespread for both benign and malignant disease and for patient of all ages. In the past 25 years, the urinary conduit concept of diversion has been the most widely practiced modality and has produced results that have been gratifying and acceptance, though not perfect. It is doubtful that a "perfect" solution to bladder substitution will ever be found, i.e., a solution without complications and without risk to long-term renal function. Of the various conduit operations, ileal conduit has been the one most widely employed. This procedure has produced a lower incidence of pyelonephritis and hyperchloremic acidosis than any method of diversion prior to 1950. However, it has been associated with significant complications and a threat to long-term renal function is now being recognized. Various efforts at improving these results are under way, aimed chiefly at avoiding the effects of ureteral anastomosis to irradiated bowel and at the development of non-refluxing ureteral anastomoses. Only time and careful study will determine the results of these efforts. We should adopt standardized parameters in the next 25 years in order to make meaningful comparisons possible. The parameters of greatest importance are a definition of complications clearly resulting from the diversion, a definition of pyelonephritis, and an agreement on a standard definition of "renal deterioration".