Pelvic Exenteration The Colorectal Surgeon: Principles and Indications Prof. Dean A Harris MD FRCS Consultant Colorectal Surgeon, ABMU LHB Swansea Hon. Clinical Professor, Swansea University Swansea Pelvic Oncology Group
Pelvic ExenterationThe Colorectal Surgeon:Principles and Indications
Prof. Dean A Harris MD FRCS
Consultant Colorectal Surgeon, ABMU LHB Swansea
Hon. Clinical Professor, Swansea University
Swansea Pelvic Oncology Group
Background
Anterior exenteration (APE) Posterior exenteration (PPE)
Total exenteration (TPE)
Swansea Pelvic Oncology Group
Results – Patients per year
21
3 3
10
3
9
20
1112
1514
17
21
8 8
22
3433
38
24
-5
0
5
10
15
20
25
30
35
40
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Results – Exenteration
0
20
40
60
80
100
120
Colorectal Gynae Urology Peritoneal
Total PE
Posterior PE
Anterior PE
Results
22 year study period (June 1992 – September 2014)
312 patients209 women, 103 menMedian age – 65 (range 27-90) years
191 colorectal, 87 gynaecological, 28 urological, and 6 peritoneal malignancies
255 (81.8%) primary malignancy
57 (18.2%) recurrent disease
Median length of stay following operation was 22 (range 3-332) days
Results – Overall Survival
Median survival:
56 months
5 year survival – 45%
Primary – 47%
Recurrent – 39%
p=0.044
Results- 5 year survival
Colorectal (n=191) - 51%
Gynae (n=55) - 37%
Urology (n=11) - 18%
Multivariate analysis
Significant factors associated with survival in primary disease:
Neoadjuvant therapy p=0.001
Resection margin p=0.006
Nodal status p=0.006
Disease recurrence p=0.001
Significant factors associated with survival in recurrent disease:
Resection margin p=0.001
Nodal status p=0.006
Selection for exenteration
• Adjacent organ involvement
• Fit for procedure (physical and mental)
• Predicted negative resection margins
• Absence of (unresectable) metastatic disease
MAXIMISE likelihood of R0 resection
MINIMISE functional compromise
APR with radical prostatectomy
Contraindications to exenteration-a moveable feast?
• (Metastatic disease)
• Extensive pelvic sidewall disease
– Extension through gr. sciatic notch
• EIA encasement
• High sacral involvement (S1/2)
Role of imaging
• Operability/ potential resection margins
– 3D roadmap
– who is required?
• Exclude M1 disease
• Distinguish T3 disease from T4 where possible
• Recurrence vs post-surgical change
Workup for rectal cancer
• CT chest/abdo/pelvis- M1 disease– CTA of inferior epigastric arteries
• MRI pelvis-identify potential CMI/ T stage
• EUA with ERUS-multidisciplinary
• PET-CT-if exenteration planned
• Dedicated pelvic oncology MDT
• Selective preoperative chemoradiotherapy• Restage: CT / MRI/ EUA +/- ERUS 6 weeks
• CPEX testing
• Operate 6-12 weeks- plan who will be needed
Compartments
Planes of attack
Techniques
P
CR
CR/V
CR/U/GYN
U
CR
CR/O
P
Open the abdomen
Early vascular ligation of tumour
Sidewall vascular control
Tumour mobilisation (post/lat/ant)
Division of DVC/urethra
Perineal approach (or turn pt. prone)
±sacral mobilisation and division
Pelvic/perineal reconstruction
Colorectal decision making
• Levator preservation?
– Extralevator abdominoperineal excision
– Intersphincteric excision of anus
• Colorectal anastomosis? support/innervation
– Sacrifice of sacrum or posterior wall vagina
– (avoidance of neoadjuvant RT)
Perineal Reconstructive Options
Gracilis muscle flap
Ant-Lat Thigh/Vastus Lateralis Myocutaneous flap
Thigh
Vertical Rectus Abdominis Myocutaneous (VRAM) flap
Abdomen
Perineum & Buttock
Local Fasciocutaneous flap
Inferior Gluteal Artery Myocutaneous (IGAM) flap
Vertical Rectus Abdominis Myocutaneous (VRAM)
Inferior Gluteal Artery Perforator flap
(IGAP)
Extended Lateral Sidewall Excision (ELSiE)
HiSS resection
p=0.032
Functional domains
Summary
Pelvic exenteration is an aggressive treatment option, with high morbidity but one that provides favourable long term outcomes for pelvic malignancies
Clear histological resection margins & the absence of nodal disease or vascular invasion are the main determinants of survival
Primary colorectal – highest survival rates (median – 92 months)
Recurrent urological – lowest survival rates (median – 9 months)
Overall 5 year survival – 45%
Acknowledgements
Organising Committee (Section of Oncology, BAUS)
Members of the Swansea Pelvic Oncology Group:
J Beynon MD Evans M Davies
O Freites ND Carr C Askill
AMM El-Sharkawi MG Lucas DQA Nguyen
P Bose P Drew C Rowley
AD McGregor D Pudney TV Chandrasekeran
N Fenn R Radwan B Patel
J Featherstone AR Morgan O Hatcher
K Lutchmann-Singh S Gwynne M Don Phan