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