Posterior Pelvic Exenteration Research Articles

A novel classification of posterior pelvic exenteration to assess prognosis in female patients with locally advanced primary rectal cancer: a retrospective cohort study from China PelvEx collaborative

PurposeSurgical techniques and the prognosis of posterior pelvic exenteration for locally advanced primary rectal cancer in female patients pose challenges that need to be addressed. Therefore, we investigated the short-term and survival outcomes of posterior pelvic exenteration in female patients using a novel Peking classification.MethodsWe retrospectively analysed a prospective database from China PelvEx Collaborative across three tertiary referral centres. A total of 172 patients who underwent combined resection for locally advanced primary rectal cancer were classified based on four subtypes (PPE-I [64/172], PPE-II [68/172], PPE-III [21/172], and PPE-IV [19/172]) according to the Peking classification; perioperative characteristics and short-term and oncological outcomes were analysed.ResultsDifferences were significant among the four groups regarding colorectal reconstruction (p < 0.001), perineal reconstruction (p < 0.001), in-hospital complications (p < 0.05), and urinary retention (p < 0.05). The R0 resection rates for PPE-I, PPE-II, PPE-III, and PPE-IV were 90.6%, 89.7%, 90.5%, and 89.5%, respectively. The 5-year overall survival rates of the PPE-I, PPE-II, PPE-III, and PPE-IV groups were 73.4%, 68.8%, 54.7%, and 37.3%, respectively. Correspondingly, their 5-year disease-free survival rates were 76.0%, 62.5%, 57.7%, and 43.1%, respectively. Notably, the PPE-IV group demonstrated the lowest 5-year overall survival rate (p < 0.001) and 5-year disease-free survival rate (p < 0.001).ConclusionThe Peking classification can aid in determining suitable surgical techniques and conducting prognostic assessments in female patients with locally advanced primary rectal cancer.

Urological outcomes following pelvic exenteration for non-urological malignancies

BackgroundPelvic exenteration (PE) is a major surgical procedure used as a salvage therapy for patients with locally advanced or recurrent pelvic malignancies. Urinary reconstruction is a major part of PE and is often associated with high rates of post-operative complications. In the current study we evaluate the short and long-term urological outcomes following PE for Colo-Rectal (CR) and gyneco-oncological (GO) malignancies. MethodsStudy included 22 patients who underwent PE for recurrent or locally advanced CR and GO malignancies in our institution between the years 2010–2018. The endpoint was post-operative freedom from urological complications. ResultsOf 22 patients included, 13 (59 %) and 9 (41 %) underwent PE for CR and GO malignancies respectively. The mean age of the patients was 54 years. The median follow-up was 19 months. Seven (78 %) patients with GO malignancy and 11 (85 %) with CR malignancy underwent PE for local recurrence. Hydronephrosis prior to surgery existed in 8 (36.3 %) patients, of which, 5 patients required kidney drainage via nephrostomy tube. Two patients underwent posterior pelvic exenteration (PPE) with bladder preservation whereas the remaining 20 underwent cystectomy with urinary diversion by ileal conduit. Hydronephrosis post PE developed in 13 patients (59 %). eight (36 %) patients needed kidney drainage by nephrostomy tubes post PE, of these, 6 (75 %) had disease recurrence. The 2 years freedom from kidney drainage was 68 %, however the median time for kidney drainage was 0.5 months. The median overall survival was 12.5 months. ConclusionThe rate of urological complications following PE is relatively high and associated with disease recurrence.

Pelvic Exenteration Surgery Outcomes Following Establishment of a Complex Pelvic Surgery Multidisciplinary Tertiary Unit

Background: Pelvic exenteration surgery (PES) is a complex operation associated with significant morbidity. PES requires sub-specialised multidisciplinary input along with expertise in complex pelvic surgery and anatomy. The majority of published data on PES comes from high volume units, however there is emerging evidence of comparable short and long-term outcomes in lower volume units where dedicated multidisciplinary teams are established. This study reports outcomes of PES in a lower volume centre with a collaborative multidisciplinary surgical approach. Methods: A retrospective review of patients who underwent PES for benign or malignant pathology at Liverpool and Macquarie University Hospitals between September 2015 and June 2022. Descriptive statistics were performed and KaplanMeier survival analysis for patients treated for malignancy with curative intent. Results: A total of 67 patients undergoing pelvic exenteration were included (53.8% female; with mean age 59 years). Indications for PES were colorectal cancer (56.7%), gynaecological cancer (22.4%), other malignancy (9.0%) and complex benign pathology (11.9%). Posterior or total pelvic exenteration was performed in 88.1%. Median hospital stay was 16 days. Clavien-Dindo grade III or IV complications occurred in 34.3%. There were two post-operative deaths (3.0%; one palliative intent). For patients treated with curative intent (n=51), R0 resection margin was achieved in 92.2%, and R1 margin in 7.8%. Estimated five-year disease-free survival was 57.1%, and five-year overall survival was 65.5%. Conclusion: Short and long-term outcomes of PES in a low volume unit with appropriate multidisciplinary expertise are comparable to published data on pelvic exenteration from higher volume units.

Predictive factors of surgical complications after pelvic exenteration for gynecological malignancies: a large single-institution experience.

To evaluate pre-operative predictors of early (<30 days) severe complications (grade Dindo 3+) in patients with gynecological malignancy submitted to pelvic exenteration (PE). We retrospectively analyzed 129 patients submitted to surgery at Fondazione Policlinico Gemelli between 2010 and 2019. We included patients affected by primary or recurrent/persistent cervical, endometrial, or vulvar/vaginal cancers. Post-operative complications were graded according to the Dindo classification. Logistic regression was used to analyze potential predictors of complications. We performed 63 anterior PE, 10 posterior PE, and 56 total PE. The incidence of early severe post-operative complications was 27.9% (n=36), and the early mortality rate was 2.3% (n=3). More frequent complications were related to the urinary diversion and intestinal surgery. In univariable analysis, hemoglobin ≤10 g/dL (odds ratio [OR]=4.2; 95% confidence interval [CI]=1.65-10.7; p=0.003), low albumin levels (OR=3.9; 95% CI=1.27-12.11; p=0.025), diabetes (OR=4.15; 95% CI=1.22-14.1; p=0.022), 2+ comorbidities at presentation (OR=5.18; 95% CI=1.49-17.93; p=0.012) were predictors of early severe complications. In multivariable analysis, only low hemoglobin and comorbidities at presentation were independent predictors of complications. Pelvic exenteration is an aggressive surgery characterized by a high rate of post-operative complications. Pre-operative assessment of comorbidities and patient health status are crucial to better select the right candidate for this type of surgery.

Laparoscopic posterior pelvic exenteration is safe and feasible for locally advanced primary rectal cancer in female patients: a comparative study from China PelvEx collaborative.

Posterior pelvic exenteration (PPE) for locally advanced rectal cancer is a technical and challenging procedure. The safety and feasibility of laparoscopic PPE remain to be determined. This study aims to compare short-term and survival outcomes of laparoscopic PPE (LPPE) with open PPE (OPPE) in female patients. From January 2015 to December 2020, data from 105 female patients who underwent PPE at three institutions were retrospectively analyzed. The short-term and oncological outcomes between LPPE and OPPE were compared. A total of 54 cases with LPPE and 51 cases with OPPE were enrolled. The operative time (240 vs. 295min, p = 0.009), blood loss (100 vs. 300ml, p < 0.001), surgical site infection (SSI) rate (20.4% vs. 58.8%, p = 0.003), urinary retention rate (3.7% vs. 17.6%, p = 0.020), and postoperative hospital stay (10 vs. 13days, p = 0.009) were significantly lower in the LPPE group. The two groups showed no significant differences in the local recurrence rate (p = 0.296), 3-year overall survival (p = 0.129), or 3-year disease-free survival (p = 0.082). A higher CEA level (HR1.02, p = 0.002), poor tumor differentiation (HR3.05, p = 0.004), and (y)pT4b stage (HR2.35, p = 0.035) were independent risk factors for disease-free survival. LPPE is safe and feasible for locally advanced rectal cancers and shows lower operative time and blood loss, fewer SSI complications, and better preservation of bladder function without compromising oncological outcomes.

Ureteric reconstruction during posterior or lateral pelvic exenteration for locally advanced and recurrent malignancy

Ureteric reconstruction during posterior or lateral pelvic exenteration for locally advanced and recurrent malignancy

Posterior pelvic exenteration in advanced stage ovarian cancer – a case series

Due to the anatomical location of the ovaries, in the close proximity of the rectosigmoidian loop, local invasion of this segment is frequently encountered especially in cases presenting peritoneal carcinomatosis of the Douglas pouch. The aim of the current paper is to report a case series of 16 patients diagnosed with ovarian cancer and rectosigmoidian invasion submitted to surgery with curative intent. In all cases resection to no residual disease was achieved. Due to the advanced level of rectal invasion, anastomosis was not performed, in all cases the continuity of the digestive tract being reestablished through left colostomy. In conclusion in certain cases presenting locally invasion of the nodules of peritoneal carcinomatosis, modified posterior exenteration might be needed.

Open abdomen technique used in complications of major gynecological oncology surgery

To evaluate the open abdomen technique (laparostomy) used in complications of major gynecological oncology surgery. We analyzed retrospectively the surgical database of all patients who had undergone major open surgery by the same gynecologic oncologist over a 5-year period. All patients who had had open abdomen procedure were identified; demographic data and indications of primary surgery, temporary abdominal closure procedure details, fascia closure and morbidity, mortality rates were evaluated. Intraabdominal infection and intraoperative massive hemorrhage were the major indications for all open abdomen cases. Mannheim Peritonitis Index was used perioperatively to determine open abdomen decision in intraabdominal infections. Vacuum Assisted Abdominal Closure system and Bogota Bag were used for temporary abdominal closure techniques. Out of the total 560 patients who had undergone major oncological surgery, 19 patients (3.3%) had open abdomen procedure due to surgical complications. Eleven patients had intraabdominal infection, six patients had hemodynamic instability due to peri and postoperative hemorrhage, two patients had gross fecal contamination during posterior pelvic exenteration surgery. The fascia was closed totally in 15 (78%), partially in 3 (15%) and could not be closed in 1 patient who had died secondary to multiorgan failure. Total morbidity and mortality rates were 26% (5/19) (two intrabdominal abscess, one pulmonary embolism, one skin necrosis, one enteroatmospheric fistula) and 5.2% (1/19) respectively. Open abdomen is a life-saving procedure when applied with correct indications and timing. Gynecological oncologic surgeries are candidates to serious complications and gynecologic oncologists dealing with such surgery should be as experienced as general surgeons in this regard.

Laparoscopic posterior pelvic exenteration for clear cell adenocarcinoma arising in an episiotomy scar

Malignant degeneration of endometriosis is a very rare event, especially when it develops in an episiotomy scar. A 53-year-old woman with an enlarged perineal mass presented to the hospital. She had undergone vaginal delivery with episiotomy twice. Imaging analyses showed a mass involving the levator ani muscle apart from the rectum, with lymph node metastases to the right inguinal and internal iliac regions. A biopsy specimen of the right inguinal lymph node revealed poorly differentiated adenocarcinoma. She underwent neoadjuvant chemotherapy according to the treatment strategy of anal fistula cancer. Laparoscopic posterior pelvic exenteration and pelvic lymph node dissection with anterior inguinal node dissection was performed, along with perineal reconstruction. Pathological examination revealed clear cell adenocarcinoma with lymph node metastases, derived from extrapelvic endometriosis in the episiotomy scar. She was treated with adjuvant chemotherapy according to the treatment strategy of vulvar cancer, and showed no evidence of recurrence after 15 months of surgery.

Posterior pelvic exenteration for ovarian cancer: surgical and oncological outcomes.

ObjectivePosterior pelvic exenteration (PPE) can be required to achieve complete resection in ovarian cancer (OC) patients with large pelvic disease. This study aimed to analyze morbidity, complete resection rate, and survival of PPE.MethodsNinety patients who underwent PPE in our Comprehensive Cancer Center between January 2010 and February 2021 were retrospectively identified. To analyze practice evolution, 2 periods were determined: P1 from 2010 to 2017 and P2 from 2018 to 2021.ResultsA 82.2% complete resection rate after PPE was obtained, with rectal anastomosis in 96.7% of patients. Complication rate was at 30% (grade 3 in 9 patients), without significant difference according to periods or quality of resection. In a binary logistic regression adjusted on age and stoma, only age of 51–74 years old was associated with a lower rate of complication (odds ratio=0.223; p=0.026). Median overall and disease-free survivals (OS and DFS) from initial diagnosis were 75.21 and 29.84 months, respectively. A negative impact on OS and DFS was observed in case of incomplete resection, and on DFS in case of final cytoreductive surgery (FCS: after ≥6 chemotherapy cycles). Age ≥75-years had a negative impact on DFS for new OC surgery. For patients with complete resection, OS and DFS were decreased in case of interval cytoreductive surgery and FCS in comparison with primary cytoreductive surgery.ConclusionPPE is an effective surgical measure to achieve complete resection for a majority of patients. High rate of colorectal anastomosis was achieved without any mortality, with acceptable morbidity and high protective stoma rate.

Impact of nutritional status and body composition on postoperative outcomes after pelvic exenteration for locally advanced and locally recurrent rectal cancer.

BackgroundPelvic exenteration for locally advanced rectal cancer (LARC) and locally recurrent (LRRC) rectal cancer provides radical resection and local control, but is associated with considerable morbidity. The aim of this study was to determine risk factors, including nutritional status and body composition, for postoperative morbidity and survival after pelvic exenteration in patients with LARC or LRRC.MethodsPatients with LARC or LRRC who underwent total or posterior pelvic exenteration in a tertiary referral centre from 2003 to 2018 were analysed retrospectively. Nutritional status was assessed using the Malnutrition Universal Screening Tool (MUST). Body composition was estimated using standard-of-care preoperative CT of the abdomen. Logistic regression analyses were performed to identify risk factors for complications with a Clavien–Dindo grade of III or higher. Risk factors for impaired overall survival were calculated using Cox proportional hazards analysis.ResultsIn total, 227 patients who underwent total (111) or posterior (116) pelvic exenteration were analysed. Major complications (Clavien–Dindo grade at least III) occurred in 82 patients (36.1 per cent). High risk of malnutrition (MUST score 2 or higher) was the only risk factor for major complications (odds ratio 3.99, 95 per cent c.i. 1.76 to 9.02) in multivariable analysis. Mean follow-up was 44.6 months. LRRC (hazard ratio (HR) 1.61, 95 per cent c.i. 1.04 to 2.48) and lymphovascular invasion (HR 2.20, 1.38 to 3.51) were independent risk factors for impaired overall survival.ConclusionA high risk of malnutrition according to the MUST is a strong risk factor for major complications in patients with LARC or LRRC undergoing exenteration surgery.

Impact of surgical treatment for locally recurrent rectal cancer on the quality of life of patients

Objective: To investigate the impact of surgical treatment on quality of life in patients with locally recurrent rectal cancer (LRRC). Methods: A descriptive case series study was performed. The complete clinical data of 62 patients who met the diagnostic criteria of LRRC and treated by surgical procedures in Huashan Hospital of Fudan University from January 2012 to November 2019 were analyzed retrospectively. All the patients were followed up at least 12 months. Assessments of urinary function, sexual function, mobility function of lower limb and quality of life were documented. Patients with distant metastasis and surgical history of the urinary system were excluded. According to the criteria of Memorial Sloan Kettering Cancer Center (MSKCC), recurrence were divided into central (n=27), anterior (n=20), posterior (n=7), and lateral (n=8) subtypes. Baseline characteristics, surgical procedures and short-term complications were analyzed. International prostate symptom score (IPSS) and grade of voiding dysfunction were used to evaluate the urinary function. Higher score of IPSS and higher grade of voiding dysfunction indicated worse voiding function. Sexual function for both genders was assessed preoperatively and postoperatively. International index of erectile function-5 (IIEF-5) was used for assessment of male patients and higher score indicated better function. Female sexual function index (FSFI) was used in females and higher score indicated better function. Short-form health survey with 36 items (SF-36), yielding an 8-scale profile of functional health (physical functioning, role-physical, bodily pain, general health, vitality, social functioning, emotional health and mental health) was used to evaluate the quality of life. The higher score indicated the better quality of life. Results: All the operations of 62 patients completed successfully and R0 resection rate was 88.7% (55/62). Postoperative surgical complications occurred in 16 cases (25.8%), including 3 patients of Clavien-Dindo classification III. At postoperative 3-month, 42 patients without ileum cystectomy or ureterostomy suffered from different grade of voiding dysfunction. IPSS increased significantly after the surgery (before surgery: 12.36±4.75, after surgery: 18.40±4.77, t=-9.128, P<0.001). There was no significant difference among the subtypes (P>0.05). At postoperative 12-month, IIEF-5 decreased from 14 (0~25) to 9 (0~19) in males (Z=-5.174, P<0.001) and FSFI deceased from 8.4 (2.0-27.0) to 2.0 (2.0-18.4) in females (Z=-3.522, P<0.001). Scores of physical functioning and role-physical decreased significantly [physical functioning: before surgery 70 (35-85), after surgery 65 (30-80), Z=-3.685, P<0.001; role-physical: before surgery 50 (0-50), after surgery 25(0-75), Z=-4.065, P<0.001], while those of social functioning role-emotional and mental health increased significantly after the surgery [social functioning: before surgery 44 (22-78), after surgery 56 (0-89), Z=-3.509, P<0.001; role-emotional: before surgery 17 (0-100), after surgery 33 (0-100), Z=-2.439, P=0.015; mental health: before surgery 40 (36-76), after surgery 52 (24-80), Z=-3.395, P<0.001]. All surgical procedures decreased the voiding function of LRRC patients and the sexual function of male patients (all P<0.01). However, only total pelvic exenteration and posterior pelvic exenteration decreased FSFI in female patients [before surgery: 8.4 (2.0-27.0) after surgery: 2.0 (2.0-18.4), Z=-2.810, P=0.005]. Conclusions: Multi-visceral resection in LRRC patients may damage voiding and sexual function. However, successful and effective surgical treatment can improve the psychosocial health of LRRC patients.

Perineal reconstruction with pedicled rectus abdominis myocutaneous flap after posterior pelvic exenteration –A 3D model study

IntroductionLimited literature exists regarding the positional relationship between the pedicled-rectus abdominis myocutaneous (p-RAMC) flap and residual pelvic organs post posterior pelvic exenteration (PPE). Presentation of caseFour patients underwent PPE and reconstruction with a p-RAMC flap. After harvesting the p-RAMC flap with the deep inferior epigastric artery and veins as the vascular pedicle, the intra-pelvic shortest pathway of the flap was created. We dissected the subcutaneous tissues of the flap donor site toward the perineal defect along the inner wall of the pelvis. The pubic origin of the rectus abdominis muscle was preserved. A three-dimensional model was constructed using an image processing software. The vascular pedicle ran almost linearly along the inner wall of the pelvis. The muscle belly was placed on the pelvic floor through the posterior wall of the urinary bladder which filled the dead space of the resected area. All flaps survived without significant complications. DiscussionAssigning the cranial side of the flap to the perineum and caudal side to the pelvic floor could reduce postoperative intrapelvic complications. By preserving the pubic origin of the rectus abdominis muscle, a shock absorber of the pedicle of the flap was created, preventing over-traction of the flap while passing through the intrapelvic pathway. ConclusionA p-RAMC flap via intra-pelvic shortest pathway is an ideal reconstructive method for large skin defect in perineal area after PPE.

Pelvic Exenteration in Patients with Persistent and Recurrent Cervical Cancer: A Case Series from Belarus

<strong>INTRODUCTION:</strong> The prognosis of patients with persistent or recurrent cervical cancer (CC) is poor, and patient selection for exenterative surgery is challenging. The aim of this study was to determine the outcomes of patients undergoing pelvic exenteration (PE) for persistent or recurrent CC after treatment with radiotherapy in Belarus. <strong>METHODS:</strong> A retrospective study was performed of 22 patients with persistent and recurrent CC who underwent supralevator PE from 2006 to 2012 at NN Alexandrov National Cancer Centre. Anterior PE was performed in 16 (72.7%) patients, posterior PE in 2 (9.1%) and total PE in 4 (18.2%) patients. <strong>RESULTS:</strong> The mean surgical procedure time was 289.1 minutes. Urinary diversion was performed in 20 patients: 5 (25.0%) underwent ureterostomy and 15 (75.0%) underwent neobladder formation. Fecal diversion with end colostomy (Hartman’s procedure) was performed in 5 patients and in one patient a rectosigmoid resection with anastomosis was performed. The median follow-up time was 87 months (range, 4.4–146.0 months). To date, 16 (72.7%) patients have died of cervical cancer and there were no deaths due to other causes. The median survival was 17 months with a 5-year survival rate of 31.8% (SE 9.9%). Cox regression analysis showed that surgical margin status and pelvic lymph node involvement were independent risk factors for survival. <strong>CONCLUSIONS:</strong> PE was found to be a safe and feasible option for patients with persistent or recurrent cervical cancer who do not have other potentially curative treatment options. Careful patient selection is needed to determine which patients will benefit from this treatment. <strong>HIGHLIGHTS:</strong> <ul><li>Treatment options are limited for patients with persistent or recurrent cervical cancer</li><li>Pelvic exenteration is a safe and feasible option for women in Belarus</li><li>Positive surgical margins and positive lymph node status are risk factors affecting survival</li></ul>

Robotic pelvic exenteration and extended pelvic resections for locally advanced or synchronous rectal and urological malignancy.

PurposeTo describe the surgical technique and examine the feasibility and outcomes following robotic pelvic exenteration and extended pelvic resection for rectal and/or urological malignancy.Materials and MethodsWe present a case series of seven patients with locally advanced or synchronous urological and/or rectal malignancy who underwent robotic total or posterior pelvic exenteration between 2012–2016.ResultsIn total, we included seven patients undergoing pelvic exenteration or extended pelvic resection. The mean operative time was 485±157 minutes and median length of stay was 9 days (6–34 days). There was only one Clavien–Dindo complication grade 3 which was a vesicourethral anastomotic leak requiring rigid cystoscopy and bilateral ureteric catheter insertion. Eighty-five percent of patients had clear colorectal margins with a median margin of 3.5 mm (0.7–8.0 mm) while all urological margins were clear. Six out of seven patients had complete (grade 3) total mesorectal excision. Three patients experienced recurrence at a median of 22 months (21–24 months) post-operatively. Of the three recurrences, one was systemic only whilst two were both local and systemic. One patient died from complications of dual rectal and prostate cancer 31 months after the surgery.ConclusionsWe report a large series examining robotic pelvic exenteration or extended pelvic resection and describe the surgical technique involved. The robotic approach to pelvic exenteration is highly feasible and demonstrates acceptable peri-operative and oncological outcomes. It has the potential to benefit patients undergoing this highly complex and morbid procedure.

Retrograde Retroperitoneal Type B1 Radical Hysterectomy in Distorted Pelvic Anatomy: Our Experience

Retrograde hysterectomy is indicated when adhesion around the uterus is strong and the usual surgical method is not possible. We describe a technique of retrograde retroperitoneal type B1 radical hysterectomy in patients with distorted pelvic anatomy. We performed the retrograde retroperitoneal type B1 radical hysterectomy in 17 patients during the period 2017–2019 in the department of surgical oncology at our centre. Eleven patients underwent this procedure for ovarian tumour as part of primary or interval cytoreduction, three patients for Grade IV endometriosis, one patient for locally advanced carcinoma rectum as part of posterior pelvic exenteration, and one patient for advanced carcinoma endometrium and as part of cytoreductive surgery (peritonectomy with HIPEC) in one patient with pseudomyxoma peritonei. Out of the 17 patients, only one patient had prolonged bladder morbidity which settled with conservative management. The patient who underwent the procedure as part of cytoreductive surgery had persistent increased frequency of stools for 1 month following the ileorectal anastomosis. She settled with conservative management and frequency of stools decreased. Two patients had wound morbidity. Retrograde retroperitoneal type B1 radical hysterectomy with preservation of pelvic nerves is technically feasible thereby decreasing the postoperative morbidity in patients with distorted pelvic anatomy. The technique described by us is a boon to the surgeon on encountering a difficult pelvic anatomy during the surgery.

Feasibility of laparoscopic-assisted transanal pelvic exenteration in locally advanced rectal cancer with anterior invasion.

Transanal (Ta) pelvic exenteration is a promising, minimally invasive method for treating locally advanced colorectal cancer. However, since it is technically difficult to perform, Ta pelvic exenteration is rarely reported in locally advanced T4 rectal cancer cases. The aim of this study was to evaluate the feasibility of transabdominal laparoscopy-assisted Ta pelvic exenteration. Six patients (4 males and 2 females) had laparoscopy-assisted Ta total or posterior pelvic exenteration for locally advanced or recurrent colorectal cancer cases at the Nagasaki University Hospital between September 2018 and August 2019. Clinical and pathological outcomes were measured and analyzed. The median operation time and intraoperative blood loss were 481 (range 456-709) minutes and 352.5 (range 257-1660) ml, respectively. R0 resection was achieved in all cases, and no patient required open surgery. Two patients had grade 3 complications (Clavien-Dindo) or higher. There was no mortality, and no reoperation was required. The results suggest that laparoscopic-assisted Ta pelvic exenteration is an acceptable procedure, may help overcome the current technical difficulties, and may improve outcomes in patients with locally advanced rectal cancer.

Analysis on risk factors of the degree of radical resection and prognosis of patients with locally recurrent rectal cancer

Objective: To evaluate the factors affecting the degree of radical resection and the prognosis of patients with locally recurrent rectal cancer (LRRC). Methods: A retrospective case-control study was performed. Clinical data of 111 patients with LRRC undergoing operation at the General Surgery Department of Peking University First Hospital from January 2009 to August 2019 were analyzed retrospectively. The "Peking University First Hospital F typing" was performed according to the preoperative images of the pelvic involvement. The pelvis was assigned into four directions: the front wall, lateral sides of the pelvic wall and the sacrum. According to the degree of pelvic wall involvement, F typing included F0 type (no involvement of the pelvic wall, the cancer only involved the adjacent organs or invaded conteriorly the urinary tract, genital organs or small intestine), F1 type (cancer involved the pelvic wall in one direction, such as the sacrum, or one side of the pelvic wall), F2 type (cancer involved the pelvic wall in two directions) and F3 type (cancer involved the pelvic wall in three directions). Case inclusion criteria: (1) LRRC was confirmed by imaging and pathological examination of samples (puncture or endoscopic biopsy); (2) complete clinical and follow-up data; (3) informed consent of patient. Those with dysfunction of heart, lung, etc., intolerance of operation, F3 type indicated by image, and distant metastasis were excluded. The degree of radical resection was evaluated according to the postoperative pathological results. Patients were followed up every 12 months and related examinations were arranged. The univariate analysis of radical resection was performed by χ(2) test, and the multivariate analysis was performed by logistic methods. The survival rate was calculated by Kaplan-Meier method and the survival curve was drawn. The survival rate was compared by log-rank test. Cox proportional hazards model was used to analyze the factors affecting the prognosis of patients with LRRC. Results: A total of 111 patients were included in this study. Of 111 patients, 59 were male and 52 were female; recurrent age of 36 cases was ≥ 65 years old; CEA level of 48 cases was ≥15 μg/L. According to the "Peking University First Hospital F typing", 70 cases were F0 type, 38 F1 type and 3 F2 type. Surgical procedures were abdominoperineal resection (n=28), posterior pelvic exenteration (n=32), and total pelvic exenteration (n=51, including 1 case of TPE combined with sacrectomy). According to the postoperative pathological results, R0, R1 and R2 resections were 83, 20 and 8 cases, respectively. Univariate analysis showed that the degree of radical resection was associated with the secondary surgical procedure, F typing and lymph node metastasis (all P<0.05). Multivariate analysis showed that F typing (F1-F2) was an independent risk factor for non- R0 resection (OR=37.256, 95%CI:8.572 to 161.912, P<0.001). The morbidity of operative complications was 22.5% (25/111); the perioperative mortality was 1.8% (2/111); the local recurrence rate after the second operation was 37.8% (42/111). The 3- and 5-year overall survival rates were 41.2% and 21.9% respectively. The 3-year survival rates of patients with and without postoperative chemotherapy were 52.7% and 32.4% respectively (P=0.005). The 3-year survival rates of patients with lower (<15 μg/L) and higher CEA level (≥15 μg/L) were 52.9% and 24.3% respectively (P<0.001). The 3-year survival rates of patients with R0, R1 and R2 resection were 49.8%, 21.3% and 8.5% respectively (P=0.002). The 3-year survival rates of patients with F0, F1 and F2 type were 52.7%, 22.0% and 0 respectively (P<0.001). Cox analysis confirmed that the degree of radical resection (HR=2.088, 95%CI:1.095 to 3.979, P=0.025), the CEA level before the secondary operation (HR=1.857, 95%CI:1.157 to 2.980, P=0.010) and postoperative chemotherapy (HR=1.826, 95%CI:1.137 to 2.934, P=0.013) were independent factors affecting the prognosis. Conclusions: The indication of LRRC surgical treatments must be strictly limited. Evaluation of the fixation site to the pelvic wall is helpful for improving the rate of R0 resection. Lower preoperative CEA level, radical resection and postoperative chemotherapy are protective factors of prolonged overall survival time of patients with LRRC.

Low rectal gastrointestinal stromal tumor-multimodality therapy: Reports and Review

Gastrointestinal stromal tumor (GIST) is one among the most common mesenchymal tumors of the gastrointestinal tract. Common in the stomach, these are also found in other segments, and there has recently been a spate of reports about rectal and colonic GIST. This article highlights two rectal GISTs that were encountered and underwent laparoscopic abdominoperineal resection (APR) and laparoscopic APR plus Total laparoscopic hystrectomy (TLH) (laparoscopic posterior pelvic exenteration) for the involvement of the posterior vaginal wall. The patients both had smooth postoperative periods and are on tyrosine kinase inhibitors, refusing local external radiotherapy. This article highlights the issues surrounding the management of low rectal GIST, a rare but potentially deadly disease.

Laparoscopic Posterior Pelvic Exenteration (Complete and Supralevator) for Locally Advanced Adenocarcinoma of the Rectum in Females: Surgical Technique and Short-Term Outcomes.

Background: Laparoscopic posterior exenteration (total and supralevator) is a complex and rarely done procedure. In this study we describe the surgical technique and short-term perioperative outcomes in 7 female patients of locally advanced carcinoma rectum operated with laparoscopic pelvic exenteration. Materials and Methods: We report 7 cases of carcinoma rectum involving either posterior wall of the uterus or vagina, which were operated with a laparoscopic procedure. All perioperative and intraoperative data were collected retrospectively from prospectively maintained electronic data. Results: Nine female patients with the diagnosis of nonmetastatic locally advanced lower rectal adenocarcinoma were selected. In MRI 4 patients had uterus-cervix involvement and 3 patients had a posterior vaginal wall and anal sphincter involvement. Four patients were operated with laparoscopic supralevator posterior exenteration and 3 patients were operated with laparoscopic complete posterior exenteration. Three patients underwent vaginal reconstruction, which was done with bilateral V-Y plasty. All 7 patients received neoadjuvant chemoradiotherapy (NACTRT), 3 patients also received additional chemotherapy (CAPOX regimen) due to poor response to NACTRT. Mean body mass index (BMI) was 23.85 (range 19-27.20). Mean duration for complete posterior exenteration was 9.63 hours (range 7-12 hours). Mean duration for supralevator posterior exenteration was 6.81 hours (range 6.25-7.5 hours). The mean postoperative stay was 10.71 days (range 7-16 days). Mean blood loss was 700 mL (range 200-1800 mL). On postoperative histopathology, all margins were free of tumor in all cases. Conclusion: Laparoscopic approach for locally advanced carcinoma rectum in female patients is feasible with less morbidity and safe short-term oncological outcomes. Careful selection of patients based on MRI is a must before undertaking the minimally invasive surgery approach. Long-term outcomes are still unknown and will require long-term follow-up.