Morbidity and mortality following preoperative radiation therapy and total pelvic exenteration for primary rectal adenocarcinoma

Abstract

Pelvic exenteration, the standard treatment for patients with locally advanced rectal adenocarcinoma infiltrating neighbouring pelvic visceras, carried a significant morbidity and mortality rate. The aim of this study was to determine the morbidity and mortality rates in a group of patients who were treated with preoperative radiation therapy and total pelvic exenteration. Between January 1980 and January 1995, we treated 18 patients. Pretreatment staging was determined by clinical examination and computed tomography (CT) scan of the abdomen and pelvis. Each patient received preoperative radiation therapy of 45 Gy in 20 fractions delivered to the whole pelvis; approximately 6 weeks later total pelvic exenteration was performed. There were 17 males and 1 female, with a median age of 59 years. All patients underwent and completed the scheduled radiation therapy treatment. The main complaints related to radiotherapy were transient skin erythema in five patients and diarrhoea in four. Blood loss (estimated by the surgeon) ranged from 1000 ml to 4200 ml, with a mean loss of 2020 ml. Eight patients (44%) developed major complications: anastomatic leak from the uretero-intestinal suture line (n = 1); perineal wound infection (n = 2); abnormal wall infection (n = 1); haemorrhage from the right internal iliac vein (n = 1) and pneumonia (n = 1). Three patients required surgical reintervention for immediate postoperative haemorrhage from the sacral venous plexus (n = 1), small bowel obstruction (n = 1), and intra-abdominal and pelvic abscess (n = 1). There were two postoperative deaths (11%). The mean and median follow-up was 41 and 32 months, respectively. Two patients (12%) developed local recurrence at 5 and 8 months, and six developed distant recurrences (37%). The overall 5-year survival rate was 61%. Our treatment approach was associated with high morbidity and mortality rates, but was similar to previously published series based on total pelvic exenteration without prior radiation therapy. In addition, our therapeutic approach was associated with a low rate of overall local recurrences. Surgical Oncology 1995; 4: 295-301.