Sacral Resection Research Articles

How Does the Level of Sacral Resection for Primary Malignant Bone Tumors Affect Physical and Mental Health, Pain, Mobility, Incontinence, and Sexual Function?

En bloc resection for treatment of sacral tumors is the approach of choice for patients with resectable tumors who are well enough to undergo surgery, and studies describe patient survival, postoperative complications, and recurrence rates associated with this treatment. However, most of these studies do not provide patient-reported functional outcomes other than binary metrics for bowel and bladder function postresection. The purpose of this study was to use validated patient-reported outcomes tools to compare quality of life based on level of sacral resection in terms of (1) physical and mental health; (2) pain; (3) mobility; and (4) incontinence and sexual function. Our analysis included 33 patients (19 men, 14 women) who had a mean age of 53 years (range, 22-72 years) with a quality-of-life survey administered at a mean postoperative followup of 41 months (range, 6-123 months). The majority of patient-reported quality-of-life outcome surveys for this study were taken from the National Institute of Health's Patient Reported Outcome Measurement Information System (PROMIS) system. To assess physical and mental health, the PROMIS Global Items Survey with physical and mental subscores, Anxiety, and Depression scores were used. Pain outcomes were assessed using PROMIS Pain Intensity and Pain Interference surveys. Patient-reported lower extremity function was assessed using the PROMIS Mobility Survey. Patient-reported quality of life for sexual function was assessed using the PROMIS Sex Interest and Orgasm survey, whereas incontinence was measured using the International Continence Society Voiding and Incontinence scores and the Modified Obstruction and Defecation Score. Surveys were collected prospectively during clinic visits in the postoperative period. Patients were grouped by the level of osteotomy as determined by review of postoperative MRI or CT and half levels were grouped with the more cephalad level. This resulted in the inclusion of total sacrectomy (N = 6), S1 (N = 8), S2 (N = 10), S3 (N = 5), and S4 (N = 4). One-way analysis of variance tests on means or ranks were used to conduct statistical analysis between levels. Patients with more caudal resections had higher physical health (95% confidence interval [CI] total sacrectomy 36-42 versus S4 50-64, p < 0.001), less intense pain (95% CI total sacrectomy 47-60 versus S4 28-37, p < 0.001), less interference resulting from pain (95% CI total sacrectomy 58-69 versus S4 36-51, p = 0.004), higher mobility (95% CI total sacrectomy 24-46 versus S4 59-59, p = 0.002), and were more functionally able to achieve orgasm (95% CI S1 1-1 versus S4 2.2-5.3, p = 0.043). No difference was found for PROMIS Global Item Mental Health Subscore, Sex Interest, Sex Satisfaction, modified obstruction and defecation score, and International Continence Society Voiding and Incontinence although this could be the result of an inadequate sample size. Our analysis on patient-reported quality of life based on the level of bony resection in patients who underwent resection for primary sacral tumor indicates that patients with higher resections have more pain and loss of physical function in comparison to patients with lower resections. Additionally, use of the PROMIS outcomes allows for comparisons to normative data. Level III, therapeutic study.

Clinical Outcomes of Sacral Chordoma Surgeries

Introduction Chordoma is the most frequent primary spine tumor, with majority involved in the sacrococcygeal region. Because chordoma is rare, slowly growing, and locally aggressive, it is difficult to evaluate the effectiveness of treatment protocols and prediction of outcome. En bloc resection of primary sacral tumors is the primary modality. Rates of local recurrence and survival were dependent on negative surgical margins. Methods To assess our series of 36 sacral chordoma surgeries, emphasizing overall surgical and oncologic outcomes. Patients underwent sacral resections for chordoma at our institution between 1995 and 2011. Medical records of all patients were reviewed, including 36 patients who underwent primary en bloc sacral resections, either total and high sacrectomies by a combined anterior and posterior approach, or posterior-only en bloc midsacral resection. Results Sacral amputation was defined by the level: L5 (9 cases, 26%), S1 (8 cases, 23%), S2 (13 cases, 27%), and S3 (5 cases, 14%). Extent of resection was en bloc in 34 cases and intralesional in 2 cases. Flap reconstruction was performed in 29 cases (85%), with gluteal in 20 cases (69%) and VRAM in 9 cases (31%). All patients were followed-up 87 ± 54 months (range: 22–215 months) after surgery. Twenty-two patients have disease-free survival till date. Fourteen of the 34 patients who underwent en bloc resection had recurrence: 7 patients died 70 months after surgery and the other 7 survived 114 months after surgery. Among them, 5 cases had local sacral and iliac recurrence, while 10 cases had distal metastasis, such as liver, lung, and muscular skeleton. Conclusion En bloc sacral resections/reconstructions in patients with chordoma increase survival and decrease tumor recurrence.

The surgical neurovascular anatomy relating to partial and complete sacral and sacroiliac resections: a cadaveric, anatomic study.

Pelvic and sacral surgeries are considered technically difficult due to the complex multidimensional anatomy and the presence of significant neurovascular structures. Knowledge of the key neurovascular anatomy is essential for safe and effective execution of partial and complete sacral resections. The goal of this anatomic, cadaveric study is to describe the pertinent neurovascular anatomy during these procedures. Three embalmed human cadaveric specimens were used. Sacrectomies and sacroiliac joint resections were simulated and the structures at risk were identified. Both anterior and posterior approaches were evaluated. During sacroiliac joint resection, L5 nerve roots are at high risk for iatrogenic injury; the vasculatures at greatest risk are the common iliac vessels and internal iliac vessels with L5-S1 and S1-S2 high sacrectomies. Minor bleeding risk is associated with S2-S3 osteotomy because of the potential to damage superior gluteal vessels. S3-S4 osteotomy presents a low risk of bleeding. Adjacent nerve roots proximal to the resection level are at high risk during higher sacrectomies. Several sacrectomy techniques are available and selection often depends on the specific case and surgeon preference; nevertheless, anatomic knowledge is extremely important. Considering the highly variable anatomic relations of the vascular bundles, a preoperative evaluation with CT or MRI with vascular reconstruction may be helpful to decrease bleeding risk by preemptively binding the internal iliac vessels in cases where higher tumors are present. To decrease the risk of damaging nerve roots, it is recommended to perform the resection as close to the involved foramina as possible.

Effect of neoadjuvant pelvic perfusion on symptom control and resection of pelvic recurrent rectal cancer.

723 Background: Isolated pelvic perfusion (IPP) may improve disease control and facilitate pelvic resection in selected high-risk patients with advanced recurrent rectal cancer by reducing painful tumor burden and lessening chances of recurrence. Methods: IPP was done in 42 patients with locally advanced previously irradiated rectal cancer, 26 as preoperative therapy and 16 for palliation. A comparative larger non-perfused group included 63 patients with pelvic resection only via abdominal sacral resection (ABSR) for recurrent rectal cancer. Isolated pelvic perfusion (IPP) with a pump oxygenator, (temp &gt; 41ºc), delivered sequential (q 10 minutes) chemotherapy:– 5FU (5fluorouracil) 1,500 mg/m2, cisplatin/oxaliplatin 100/150 mg/m2, mitomycin 10mg/m2, for 60 minutes in 42 patients. Results: Palliative IPP in 16 advanced rectal cancer patients resulted in significant relief (1–4 months) of narcotic resistant pain (in 70%). Pre-operative IPP in 26 locally advanced rectal cancer patients achieved a clinical path (CR) in 2 patients, and significant regression in 11 patients rendering them resectable. Seven had RO pelvic resections. Of 6 other patients, 4 refused surgery, 2 were medically excluded. Median survival was 30 months in 7 resected patients (all had RO resections) and 2 were 5-year survivors. This is compared to outcome in 63 patients having pelvic resection alone for recurrence: 57 % had RO resection (median OS = 36 months), 28% had R1 resection (median OS = 15 months) and 15% had R2 resection (marrow invasion) (median OS = 21 months). Conclusions: Neoadjuvant IPP may facilitate resection of advanced or (borderline resectable) recurrent rectal cancer by reducing tumor bulk and identifying therapeutic responders likely to benefit from major pelvic resection while excluding non-responders mostly likely to benefit from non-surgical therapy. The potential to induce regression and facilitate RO resection merits further exploration

Management of Sacral Tumors Requiring Spino-Pelvic Reconstruction with Different Histopathologic Diagnosis: Evaluation with Four Cases

In this retrospective study, surgical results of four patients with sacral tumors having disparate pathologic diagnoses, who were treated with partial or total sacrectomy and lumbopelvic stabilization were abstracted. Two patients were treated with partial sacral resection and two patients were treated with total sacrectomy and spinopelvic fixation. Fixation methods included spinopelvic fixation with rods and screws in two cases, reconstruction plate in one case, and fresh frozen allografts in two cases. Fibular allografts used for reconstruction accelerated bony union and enhanced the stability in two cases. Addition of polymethyl methacrylate in the cavity in the case of a giant cell tumor had a positive stabilizing effect on fixation. As a result, we can conclude that mechanical instability after sacral resection can be stabilized securely with lumbopelvic fixation and polymethyl methacrylate application or addition of fresh frozen allografts between the rods can augment the stability of the reconstruction.

Abdominosacral resection in the surgical treatment of rectal cancer

Surgery is the only potentially radical treatment option for locally advanced and recurrent rectal tumors invading the sacral vertebrae. However, the choice of tactics for this patient category remains a difficult task. In spite of the fact that chemoradiation therapy yields good results, it is very difficult to differentiate postradiation changes and residual tumor; the immediate results of combined surgical interventions accompanied by sacral resection remain unsatisfactory, which restricts their use in routine practice and the frequency of unradical operations and local recurrences remains high. Optimization of the results of abdominosacral resection in patients with rectal cancer requires that the definite principles should be adhered to. The chief task of treatment (radical surgery) is fulfilled via resection of the sacrum and, if indicated, other organs even to the extent of performing total pelvic evisceration. In the present view, radiotherapy is a compulsory component of combined treatment that enhances surgical radicalism. However, its impact on the results of this intervention type has been inadequately studied so far. Careful selection of patients to undergo abdominosacral resection determines high requirements for preoperative tumor imaging techniques. Due to their technical complicacy, it is recommended that this operation should be made only by specialized cancer centers having capacities for performing combined treatment for colorectal cancer.

Management and retrospective analysis of primary and metastatic sacral tumors and infections: evaluation with 73 cases.

This study aims to evaluate the clinicopathologic characteristics and treatment modalities of 73 patients with benign and malign sacral tumors and infections from a single institution. Seventy-three patients (42 males, 31 females; mean age 48.9 years), who were treated between July 1991 and December 2013, with benign, malign tumors, and infections of the sacrum were retrospectively analyzed for a mean follow-up period of 25.4 months, and a review of the literature was conducted. While 36 patients were treated surgically, 37 were treated medically. Fifty-four patients were diagnosed with malign, and 19 with benign or infectious tumors. In 54 patients with malign tumors, metastasis was the most common diagnosis in 20 patients followed by chordoma in 11, and multiple myeloma in 10 patients. Common benign lesions were osteomyelitis in four patients, and giant cell tumor and schwannoma in three patients each. Local recurrence was most commonly observed in the chordoma and chondrosarcoma groups with a rate of 50%. Seven patients including five with metastatic disease, one with chondrosarcoma, and one with chordoma died during follow-ups. While urinary and anal incontinence developed in seven patients after sacral resection, deep infection was reported in four, and superficial infection was reported in two patients. Because of the high complication rates in malign sacral tumors, we should perform wide resections with partial or total sacrectomy. Chordoma and chondrosarcoma patients should be screened closely due to a possible recurrence risk after sacrectomy while preserving the nerve roots as possible. Aggressive curettage should be combined with adjuvant methods in benign lesions due to high recurrence rates in sacral localization.

244. Pelvic exenteration and composite sacral resection in the surgical treatment of locally recurrent rectal cancer

244. Pelvic exenteration and composite sacral resection in the surgical treatment of locally recurrent rectal cancer

Sacral resection with pelvic exenteration for advanced primary and recurrent pelvic cancer: a single-institution experience of 100 sacrectomies.

Recurrent and advanced primary pelvic cancers present a complex clinical issue requiring multidisciplinary care and radical extended surgery. Sacral resection is necessary for tumors that invade posteriorly but is associated with increased morbidity and mortality. This study aimed to analyze the morbidity and survival associated with pelvic exenteration involving sacrectomy for advanced pelvic cancers at a single institution. This study used patient demographics, operative and pathologic reports, and prospective survival data to determine factors affecting patient outcomes. Data were collected for patients who had operations between July 1998 and April 2012 at Royal Prince Alfred Hospital. One hundred patients underwent pelvic exenteration with a sacrectomy for advanced pelvic cancers. Sacrectomy was performed for 18 primary and 61 recurrent rectal cancers, 17 anal cancers, and 4 other cancers. This study looked at postoperative major and minor morbidity rates, as well as disease-free and overall survival rates after sacral resection. It compared the outcomes of high sacrectomy (at or above S2) versus low sacrectomy. Clear margins were achieved in 72 of 100 patients. The overall complication rate was 74% (43% major and 67% minor) with no 30-day or in-hospital mortality. Estimated overall and disease-free survival rates after curative resection were 38% and 30% at 5 years. Involved margins (p = 0.006), lymph node involvement (p = 0.008), and anterior organ invasion (p = 0.008) had a negative impact on patient survival. High sacrectomy increased the incidence of neurologic deficit postoperatively (p = 0.04) but did not alter the rate of R0 resection or patient survival. Retrospective data were required to analyze patient morbidity, as well as operative and pathologic factors. This series supports sacral resection for curative surgery in advanced pelvic cancers, achieving excellent R0 and long-term survival rates. Cortical bone invasion and high sacrectomy were not contraindications to surgery and had acceptable outcomes.

Pelvic exenteration and composite sacral resection in the surgical treatment of locally recurrent rectal cancer

BackgroundThe incidence of rectal cancer recurrence after surgery is 5–45%. Extended pelvic resection which entails En-bloc resection of the tumor and adjacent involved organs provides the only true possible curative option for patients with locally recurrent rectal cancer. AimTo evaluate the surgical and oncological outcome of such treatment. Patients and methodsBetween 2006 and 2012 a consecutive series of 40 patients with locally recurrent rectal cancer underwent abdominosacral resection (ASR) in 18 patients, total pelvic exenteration with sacral resection in 10 patients and extended pelvic exenteration in 12 patients. Patients with sacral resection were 28, with the level of sacral division at S2–3 interface in 10 patients, at S3–4 in 15 patients and S4–5 in 3 patients. ResultsForty patients, male to female ratio 1.7:1, median age 45years (range 25–65years) underwent extended pelvic resection in the form of pelvic exenteration and abdominosacral resection. Morbidity, re-admission and mortality rates were 55%, 37.5%, and 5%, respectively. Mortality occurred in 2 patients due to perineal flap sepsis and massive myocardial infarction. A R0 and R1 sacral resection were achieved in 62.5% and 37.5%, respectively. The 5-year overall survival rate was 22.6% and the 4-year recurrence free survival was 31.8%. ConclusionExtended pelvic resection as pelvic exenteration and sacral resection for locally recurrent rectal cancer are effective procedures with tolerable mortality rate and acceptable outcome. The associated morbidity remains high and deserves vigilant follow up.

A new type of reconstruction of the hemipelvis after Type 3 amputative sacrectomy using pedicled fibula

This is a technical note of pelvic reconstruction performed by an advanced multidisciplinary team. The authors report a new 3-stage reconstruction of the hemipelvis after Type 3 sacrectomy involving instrumented spinoiliac arthrodesis and pedicled fibula grafting in 2 patients. The anterior stage of the procedure begins with a transabdominal approach to mobilize the viscera and to free up the tumor from the vessels. The posterior divisions of internal iliac vessels, the middle sacral vessels, and the lateral sacral vessels are then ligated. An anterior vertebrectomy is done at the appropriate level, followed by an anterior osteotomy through the lateral planed surgical margin of the sacrum close to the salvaged sacroiliac joint. The second stage includes a major sacral resection with lower-extremity amputation from the pubic symphysis through the intact side of the sacrum, ipsilateral pedicled fibula harvesting, and closure with an ipsilateral pedicled quadriceps flap. The final stage involves reconstruction with lumboiliac instrumentation. The pedicled fibular graft left from the second stage is then placed distally within the previously created iliopectineal docking site and proximally within the L-5 docking site. The authors believe that this is a feasible and reproducible technique with theoretical advantages that have to be proved in the long-term follow-up.

The development of sphincter saving surgery for rectal cancer: the long way from a perineal colostomy to restoration of continence

The treatment of rectal cancer started with the first perineal resection by Lisfranc in 1826. In the beginning of rectal surgery sphincter salvage had no priority. Hochenegg published the first successful rectal resection with preservation of the sphincter in Vienna in 1888. The further development of sphincter salvage was inhibited by the discovery of a high recurrence rate after perineal resection by Miles. He proposed the abdominoperineal resection for all cancers of the rectum independent of their localization. Most surgeons in Europe and USA followed Miles’ proposal, but in Vienna sphincter salvage was further practiced by Hochenegg and his team. Later, his assistant Finsterer developed the abdominosacral resection. Dixon from the Mayo Clinic reported good results with a solely abdominal operation for tumors of the upper part of the rectum, which he called “anterior resection” in contrast to the posterior (perineal and sacral) resections. From this point sphincter salvage became slowly popular, supported by the use of stapling instruments. The final step was the development of techniques to save the sphincter even in tumors of the lower third of the rectum by ultralow resections.

Single-Stage Anterior High Sacrectomy for Locally Recurrent Rectal Cancer

A review of prospectively collected data on a consecutive series of patients undergoing single-stage anterior high sacrectomy for locally recurrent rectal carcinoma (LRRC). To determine the clinical outcome of patients who underwent anterior high sacrectomy for LRRC. High sacrectomy for oncological resection remains technically challenging. Surgery has the potential to achieve cure in carefully selected patients. Complete (R0) tumor excision in LRRC may require sacrectomy. High sacral resections (S3 and above) typically require a combined anterior/supine and posterior/prone procedure. We investigated our experience performing single-stage anterior high sacrectomy for LRRC. A consecutive series of patients with LRRC without systemic metastases who underwent resection with curative intent requiring high sacrectomy were identified. A review of a prospectively maintained colorectal and spine cancer database data was performed. An oblique dome high sacral osteotomy was performed during a single-stage anterior procedure. Outcome measures included surgical resection margin status, hospital length of stay, postoperative complications, physical functioning status, and overall survival. Nineteen consecutive patients were treated between 2002 and 2011. High sacrectomy was performed at sacral level S1-S2 in 4 patients, S2-S3 in 9 patients, and through S3 in 6 patients. An R0 resection margin was achieved histologically in all 19 cases. There was 1 early (<30 d) postoperative death (1/19, 5%). At median follow-up of 38 months, 13 patients had no evidence of residual disease, 1 was alive with disease, and 4 had died of disease. Morbidities occurred in 15 of the 19 patients (79%). Although high sacrectomy may require a combined anterior and posterior surgical approach, our series demonstrates the feasibility of performing single-stage anterior high sacrectomy in LRRC, with acceptable risks and outcomes compared with the literature. The procedure described by us for LRRC lessens the need for a simultaneous or staged prone posterior resection, with favorable R0 tumor resections, patient survival, and clinical outcomes. N/A.

Massive Sacral Chordoma Resection and Reconstruction with a Combination of Pedicled and Free Flaps

Massive Sacral Chordoma Resection and Reconstruction with a Combination of Pedicled and Free Flaps

Sacral chordoma in an adult showing an aggressive clinical course: A case report

The current report presents a case of a 78-year-old male with sacral chordoma, showing an aggressive clinical course. The patient underwent sacral resection, however, nine months later, multiple metastases were detected by magnetic resonance imaging. The metastases progressed rapidly and 15 months following surgery the patient succumbed to respiratory dysfunction. An autopsy revealed multiple metastases of the lung, liver, heart, kidneys and vertebrae. Pathologically, the tumors did not show proliferation of anaplastic cells or dedifferentiation; however, the metastatic tumor cells were smaller than the primary tumor cells. The Ki-67 labeling indices were <5% in all of the patient’s tumors, therefore, the capacity for cellular proliferation of the tumors was considered to be low. Chordoma in adults are generally slow-growing tumors and are associated with a relatively prolonged course and frequent local recurrences. Therefore, it must be recognized that chordoma may grow rapidly and show an aggressive clinical course, even when the Ki-67 labeling index is low.

Conversion of high sacral to midsacral amputation via S-2 nerve preservation during partial S-2 sacrectomy for chordoma

Chordomas of the sacrum require en bloc resection to reduce the risk of recurrence, but this may sacrifice nerves vital to bladder, bowel, and sexual function. High, mid-, and low sacral amputations have been previously classified based on nerve root sacrifice, not bony amputation. Sacrifice of the S-2 nerves or those above results in a high sacral amputation, but preserving the S-2 nerves converts it into a midsacral amputation. Preservation of the S-2 nerves has been shown to improve functional outcome, despite the bony osteotomy being unchanged. Thus, keeping the same bony amputation while preserving the S-2 nerve roots may allow for improved functional outcome while still achieving the same goal of oncological resection. Preservation of the S-2 nerves may be particularly difficult during amputation at the S-2 pedicle or above, and the authors describe their technique for preserving the S-2 nerves during partial sacrectomy at or just above the S-2 pedicle. Four cases of sacral chordoma resections are presented to illustrate the technique.

Impact of Flap Reconstruction on Perineal Wound Complications Following Ablative Surgery for Advanced and Recurrent Rectal Cancers

To determine the effect of flap reconstruction on perineal complications in locally advanced rectal cancers (LARC) and locally recurrent rectal cancers (LRRC). Prior studies have suggested that flap reconstruction may decrease wound complications after ablative surgery for rectal cancer but are limited by small sample sizes, heterogeneity of pathologies, and lack of comparison groups. A retrospective cohort study (1999-2010) was performed on consecutive patients undergoing abdominoperineal resection (APR) or pelvic exenteration for locally advanced/locally recurrent rectal cancers. Differences in perineal complications between patients treated with and without perineal flap reconstruction were analyzed by using univariable, multivariable, and propensity score regression analyses. Flap reconstruction was performed in 52 of 177 patients (29%). Patients receiving flap reconstruction had multiple risk factors for perineal morbidity, including longer operative times and more complex procedures. In our final multivariable analyses that were stratified by type of ablative procedure, we found a trend toward lower odds of perineal complications in patients receiving flaps (p=0.065) compared with primary closure after pelvic exenteration. Although operative time and sacrectomy were significant determinants of perineal morbidity for pelvic exenteration patients, no significant predictors of perineal outcomes were identified for patients undergoing APR. This study suggests that flap reconstruction may provide some protective effect against perineal complications in patients undergoing pelvic exenteration, although this was not observed for APR. The most important determinants of perineal complications after pelvic exenteration were operative time and sacral resection, but no predictive factors for post-APR perineal outcomes were identified.

Intraoperative Neurophysiological Monitoring During Sacrectomy Procedures

ABSTRACT.Previously intraoperative neurophysiological monitoring (IONM) has not been used along with a computer based navigation system for en bloc resection of a sacral Ewing sarcoma. In order to improve the post-operative neurological outcome of the patient we decided to include IONM in our procedure. A partial or complete resection of a sacral tumor may result in the loss of neurological functions due to close proximity of vascular, neural, and visceral structures. A prolonged two-stage surgical procedure may be a high risk procedure for position related brachial plexus injury.An 18-year-old male presented with left lower extremity weakness, which worsened with gait. His MRI was consistent with a sacral mass causing compression on the left S1 and S2 roots. A surgical resection was planned with anterior and posterior approaches. IONM helped guide the surgical team to prevent damaging the sacral roots on the normal side (right) and position related upper extremity brachial plexus injuries.Our technique involving IONM can be used safely for accurate en bloc removal of a sacral tumor with a safe margin while protecting the neural function and minimizing recurrence. This case report demonstrates that intraoperative neurophysiological monitoring was useful in identifying and reversing impending nerve injury during sacrectomy surgery. Significant changes were seen in ulnar and posterior tibial somatosensory evoked potentials (SSEPs). We recommend that IONM should be considered for safe margin en bloc sacral tumor resection and prevention of injury to the sacral root and brachial plexus.

Assessing the Impact of a Sacral Resection on Morbidity and Survival After Extended Radical Surgery for Locally Recurrent Rectal Cancer

To describe the experience of sacrectomy with extended radical resection in the treatment of locally recurrent rectal cancer. Resections of the bony pelvis, especially the sacrum, are becoming more common as part of extended radical exenterations for patients with recurrent rectal cancer. However, sacrectomy has been shown to carry a significant decrease in survival. Morbidity rates have been associated with the level of the sacrectomy (ie, >S3 junction). An analysis was conducted using prospective data from patients with recurrent rectal cancer who underwent pelvic exenteration involving sacrectomy from July 1998 until June 2011. The impact of the proximal level of sacrectomy [low (≤S3) vs high (≥S2-S3 disc)] was compared. Of 240 exenteration patients, 79 underwent sacrectomy, with 49 for recurrent rectal cancer. An R0 margin was achieved in 36 (74%) patients. Achievement of clear operative margins (R0) conferred a large and significant benefit for disease-free survival compared with R1 and R2 resections (median 45 months vs 19 and 8 months, respectively; P = 0.045). Complications were reported in 40 (82%) patients, with major and minor complications in 19 (39%) and 38 (78%) patients, respectively. The proximal level of the sacrectomy (high vs low) did not significantly impair the ability to achieve a clear margin and was not associated with an increase in major or minor complications. This large, single-center series has demonstrated that extended pelvic exenteration involving sacrectomy has excellent R0 margins and survival rates for recurrent rectal cancer. A high sacrectomy has comparable results with a more distal abdominosacral resection.

Surgical techniques for spinopelvic reconstruction following total sacrectomy: a systematic review

To identify all available reconstruction methods for a total sacrectomy. Secondarily, we aimed to evaluate outcomes based on different interventions. We searched PubMed to identify sacral resections for tumors requiring internal fixation for stabilization. Demographic information, fixation techniques and postoperative outcomes were abstracted. Twenty-three publications (43 patients) met inclusion criteria from an initial search of 856 (κ 0.93). Mean age was 37years and follow-up was 33months. Fixation methods included a combination of spinopelvic fixation (SPF), posterior pelvic ring fixation (PPRF), and/or anterior spinal column fixation (ASCF). For the purposes of analysis, patients were segregated based on whether they received ASCF. Postoperative complications including wound/instrument infections, GI or vascular complications were reported at a higher rate in the non-ASCF group (1.63 complications/patient vs. 0.7 complications/patient). Instrument failure was seen in 5 (16.1%) out of the 31 patients with reported outcomes. Specifically, 1 out of 8 patients (12.5%) with ASCF compared with 4 out of 23 patients (17.4%) without ASCF had hardware failure. At final follow-up, 35 of 39 patients were ambulating. While surgical treatment of primary sacral tumors remains a challenge, there have been advances in reconstruction techniques following total sacrectomy. SPF has shifted from intrapelvic rod and hook constructs to pedicle and iliac screw-rod systems for improved rigidity. PPRF and ASCF have adapted for deficiencies in the posterior ring and anterior column. A trend toward a lower rate of hardware failure emerged in the group utilizing anterior spinal column support. Despite a more involved reconstruction with ASCF, surgical complications such as infection rates and blood loss were lower compared to the group without ASCF. While we cannot definitively say one system is superior to the other, based on the data gleaned from this systematic review, it is our opinion that incorporation of ASCF in reconstructing the spinopelvic junction may lead to improved outcomes. However, most importantly, we recommend that the treating surgeon operate on patients requiring a total sacrectomy based on his or her level of comfort, as these cases can be extremely challenging even among experts.