Pelvectomie totale et cancer du rectum. À propos de 20 observations

Abstract

Study aim The report of a series of 20 patients with the aim of trying to specify the implications of pelvic exenteration for rectal cancer. Patients and methods From 1986 to 1996, 20 total pelvic exenterations were performed for rectal adenocarcinoma. This retrospective study included locally extended carcinomas ( n=10), and recurrences ( n=10) after anterior resection ( n=7), and after abdominoperineal resection ( n=3). The subjects included 13 men and seven women with a mean age of 54 years (34–74years). Complaints were major and serious: pain ( n=20), rectal syndrome ( n=17), recto-vesical fistula ( n=5) recto-vaginal fistula ( n=5), urinary infection ( n=13), and hematuria ( n=6). Preoperative radiotherapy was performed in 11 patients and preoperative radio chemotherapy in six. The surgical procedure included a total pelvic exenteration with perineectomy in 12 patients, and a total pelvic exenteration with preservation of levator ani and perineum in eight, associated in two cases with a partial resection of the sacrum, and in two other cases with partial hepatectomy for a single liver metastasis. Urinary diversion was a trans ileal ureterostomy in 17 patients and a direct double ureterostomy in three. Results The mean duration of surgery was 6 h. The mean preoperative blood loss was 1,200 L. Nine patients received blood transfusion. There was no postoperative mortality but in contrast, the morbidity rate was high with mainly urinary and digestive complications, pelvic sepsis and thromboembolic complications. After pathological examination, tumoral resections were classified R0 in 19 cases, and R1 in one. All tumors were T4 with tumoral invasion of the bladder ( n=15), prostate ( n=6), seminal vesicles ( n=4), ureter ( n=3), vagina ( n=7), urethra ( n=1), and sacrum ( n=1). Lymph node involvement was present in four patients. The 3 and 5 year actuarial survival rate was respectively 47 and 18%. Thirteen patients died of their cancer, nine from metastases, and four from local recurrence with a mean survival of 29 and 32 months respectively. Seven patients were alive at the time of this study, six without actual recurrence. Conclusions In spite of its aggressive aspect, total pelvic exenteration seems justified in rectal carcinoma when extended to the urinary tract, when it causes major functional disorders, when there are no detectable metastases, and when the tumor has no posterior or lateral fixation. Local tumoral evolution can usually be controlled by pelvic exenteration but prolongation of survival is not demonstrated.