Sacral Resection Research Articles

Surgical Outcomes after Abdominoperineal Resection with Sacrectomy and Soft Tissue Reconstruction: Lessons Learned.

Abdominoperineal resection (APR), which involves resection of the rectum, anal canal, and perianal skin, results in a large dead space in the pelvis, devascularized tissues, and high bacterial loads. This predisposes to wound complications, especially in the setting of neoadjuvant chemoradiotherapy. Additional sacral resection further compounds these effects. We aimed to assess perineal wound outcomes and complications in patients who underwent flap reconstruction for APR with sacrectomy (APRS) at our institution. We reviewed the charts of all patients who underwent flap reconstruction for APRS over a 20-year period (1999-2018). Medical comorbidities, details of the surgical procedure, and major and minor wound complications were recorded and analyzed. Forty-six patients underwent flap reconstruction following APRS-28 (60%) for colorectal cancer, 8 (17%) for sacral chordoma, and 10 diagnosed with other malignant histologies. Rectus abdominis myocutaneous (RAM) flap reconstruction was used in 42 patients (91%). The median time to the first major perineal complication was 111 days (interquartile range: 22-660 days). Half of our cohort (n = 23) experienced a major perineal complication. No significant differences were found in major or minor perineal or abdominal wall complications between RAM flap and other flaps. APR with high sacrectomy was performed in 27 patients (59%) and was associated with significantly increased full-thickness dehiscence in the perineal region when compared with APR with low sacrectomy, 33 versus 0%, respectively (p = 0.0076). Complete flap loss occurred in one patient. The RAM flap was the workhorse flap for pelvic reconstruction following APRS in our cohort. Wound complications are common following APRS. High sacrectomy is associated with higher incidence of complications compared with low sacrectomy. Optimal surgical planning and patient counseling is fundamental to improve current surgical outcomes.

Meta-analysis of clinical effects of abdominal aortic balloon occlusion in resection of pelvic and sacral tumors

Objective To systematically evaluate the clinical effects of abdominal aortic balloon occlusion in resection of pelvic and sacral tumors. Methods All the randomized controlled trials (RCT) and cohort studies about abdominal aortic balloon occlusion in resection of pelvic and sacral tumors were electronically collected by searching databases, including China National Knowledge Infrastructure (CNKI), Wanfang Database, China Biology Medicine disc (CBMdisc), PubMed, Embase, Cochrane Library Database. Search time interval period was from construction of databases to December 31, 2018. Cochrane bias risk assessment table was used to evaluate the quality of RCT, and New Castle-Ottawa Scale (NOS) was used to evaluate the quality of cohort studies. Two researchers independently screened the literatures according to the inclusion and exclusion criteria, evaluated the quality of the included literatures and risk of bias, and extracted relevant research data. Meta-analysis of the clinical effects of abdominal aortic balloon occlusion for pelvic and sacral tumor resection was performed by RevMan5.3 software. Outcome observation indicators included intraoperative blood loss, intraoperative blood transfusion volume, operation duration time and incidences of postoperative complications. Results ① A total of 219 related literatures were screened out in this study. Six of them met the inclusion and exclusion criteria of literatures, which included 1 RCT and 5 retrospective cohort studies. A total of 609 patients with pelvic and sacral tumor resection were involved in these 6 literatures. Among them, 258 patients underwent abdominal aortic balloon occlusion, and 351 did not receive abdominal aortic balloon occlusion. ② Cochrane bias risk assessment results of 1 RCT were uncertain, and NOS scores of 5 retrospective cohort studies were 7 scores. According to the results of literature quality evaluation, 5 high-quality cohort studies were included in the Meta-analysis. ③ Meta-analysis of this study showed that the intraoperative blood loss, intraoperative blood transfusion volume, operation duration time (excluded clinical heterogeneity) of patients undergoing abdominal aortic balloon occlusion for pelvic and sacral tumors resection were significantly lower than those of patients without abdominal aortic balloon occlusion (SMD=-917.12, 95%CI: -1 239.61 to -594.62, P 0.05). Conclusions Abdominal aortic balloon occlusion can reduce the amount of bleeding and blood transfusion during pelvic and sacral tumor resection without increasing the incidence of complications, including nerve injury, wound infection, urethral injury and vaginal injury. Key words: Balloon occlusion; Aortic, abdominal; Sacrum; Pelvic tumor; Blood loss, surgical; Blood transfusion; Postoperative complications

A Novel Technique of Urine Drainage from Bilateral Kidneys with a Single Catheter

A 69-year-old woman who underwent posterior pelvic exenteration and sacral resection for rectal cancer presented with urine leakage from a vesicocutaneous fistula at the sacral resection site (Figs 1, 2). She had bladder dysfunction after surgery. To stop urine leakage, bilateral nephrostomy catheters and a urinary catheter were placed, and embolization of the fistula with coils, glue, Amplatzer vascular plugs (Abbott, St. Paul, Minnesota), and a modified covered stent was performed. Urine leakage decreased but persisted. Her activity was severely restricted by 3 catheters and a gauze pad that was always needed at the fistula site. Therefore, we attempted to use a single catheter to drain the bilateral renal pelvis and reduce the number of catheters, while maintaining bilateral renal function. A guide wire inserted via the right renal pelvis was grasped in the bladder by a snare inserted via the left renal pelvis (Fig 3), and through-and-through access was obtained. An 80-cm-long 7-F catheter (Percuflex Urinary Diversion Stent; Boston Scientific, Marlborough, Massachusetts) with handmade proximal side holes was coaxially inserted through the left nephrostomy route into the right renal pelvis to drain the bilateral renal pelvis (Fig 4). Consequently, urine from the bilateral renal pelvis was drained by the single catheter, and urine leakage from the vesicocutaneous fistula stopped. The patient has been doing well for 15 months with the single catheter, which is exchanged regularly. This technique may be useful to improve activity levels of patients by reducing the number of nephrostomy catheters without compromising bilateral renal function. Figure 2Lateral x-ray of pelvis during cystography demonstrating leakage of contrast medium from urinary bladder (arrowheads) through the skin defect (star) via the vesicocutaneous fistula (arrow). View Large Image Figure Viewer Download Hi-res image Figure 3Oblique x-ray of pelvis during establishment of through-and-through access. The snare (arrowheads) was inserted through the left renal pelvis and advanced into urinary bladder to grasp the guide wire (arrow), which was inserted through the contralateral side. View Large Image Figure Viewer Download Hi-res image Figure 4Abdominal x-ray demonstrating long catheter (arrow) draining bilateral renal pelvis. A modified covered stent and several coils (arrowhead) were placed within the vesicocutaneous fistula. The stent lumen was sealed off by tying a string around its center; additional coils were placed around it to further occlude the fistula. View Large Image Figure Viewer Download Hi-res image

En Bloc Resection with Partial Sacrectomy Helps to Achieve R0 Resection in Locally Advanced Rectal Cancer, Experience from a Tertiary Cancer Center.

Partial sacrectomy is a radical procedure that benefits a select group of patients with locally advanced primary or recurrent rectal cancer with posterior extension and carries potential for significant morbidity. This study was done to evaluate the morbidity and oncological outcome of patients who underwent partial sacral resection for rectal cancer in a tertiary cancer center. Seventeen patients underwent partial sacrectomy during the period from 2011 to 2015. Eleven patients had primary and six had recurrent rectal cancer. All patients were evaluated with MRI pelvis and metastatic evaluation with CT scan of the chest and abdomen and PET scan in patients with recurrent cancer. All patients had resection below the level of S2/S3 junction or lower. Three patients were females and the remaining were males. Median age was 56years. Overall morbidity was 76% and most common morbidity was wound related. The mean estimated relapse-free survival (RFS) for patients treated for primary rectal cancer was 20.3months (95% confidence interval (CI), 12.8-27.9) and the mean estimated overall survival (OS) 23.9months. Estimated mean RFS for patients who were operated for recurrent rectal cancer was 25.6months (95% CI, 17.7-33.5) and the median RFS was yet to reach. Estimated mean OS was 29.7months (95% CI, 15.5-43.8) and the median OS was 39.6months. Partial sacrectomy below the level of S2/S3 junction is a safe approach to facilitate en bloc resection of locally advanced primary and recurrent rectal cancer extending posteriorly with loss of plane with sacrum. In selected patients, this approach can improve survival at the cost of high morbidity.

Resection of recurrent rectal cancer

Acurative treatment of locally recurrent rectal cancer (LRRC) can only be achieved with acomplete resection and microscopically tumor-free surgical margins (R0). Imaging techniques are the most important investigations for the preoperative staging of local and systemic diseases. Due to substantial improvements in surgical strategies and techniques, previously unresectable tumors can now be excised. Several publications have demonstrated the oncological benefits of high sacral resection for LRRC. High subcortical sacrectomy (HiSS), extended lateral resection and extended lateral pelvic sidewall excision (ELSiE) belong to the newer surgical options. Biological meshes, various myocutaneous flaps, titanium and bone allografts can be used for reconstruction. Specialized centers provide an efficient management of complications and postoperative treatment.

Anterior robotic approach in en-bloc sacrectomy: a preliminary experience

En-bloc sacrectomy is a highly demanding surgical procedure necessary to obtain wide margin in sacral tumor. The double approach, anterior and posterior approach, is usually preferred for tumors extending proximally to S3 level where iliac internal vessels are at a higher risk for damage during posterior surgery. It can be justified also in selected cases to decrease the risk of posterior approach as in local recurrence or in patients who already underwent laparotomy. Our intent was to apply robotic-assisted techniques for performing anterior preparatory approach for sacrectomy surgery. Between December 2010 and December 2014, three cases of sacrectomies were performed in a previous robotic-assisted preparatory approach to separate the rectum from the tumor. Dissections were successfully performed in all cases close to the pelvic floor. The surgeon was able to position a Gore-Tex spacer between the anterior tumor surface and the rectum in all cases. The anterior dissections were performed with a perfect control of bleeding. No complications related to the anterior approach were reported. Robot-assisted surgery can be considered a valid and minimally invasive technique which allows a safe anterior dissection of the pelvic structures dividing tumors from surrounding tissues. It allows to place a spacer to protect organs during posterior sacral resection performed on the same day or at a later time. Further experiences are advocated to evaluate its efficiency in sacral tumors of greater size.

What Is the Effect of High-dose Radiation on Bone in Patients With Sacral Chordoma? A CT Study.

Effects of high-dose radiation using protons and photons on bone are relatively unexplored, but high rates of insufficiency fractures are reported, and the causes of this are incompletely understood. Imaging studies with pre- and postradiation scans can help one understand the effect of radiation on bone. The purpose of this study was to assess the effects of high-dose radiation on the trabecular density of bone in the sacrum using CT-derived Hounsfield units (HU). Between 2009 and 2015, we treated 57 patients (older then 18 years) with sacral chordoma. Fourteen (25%) of them were treated with radiation only. The general indication for this approach is inoperability resulting from tumor size. Forty-two (74%) patients were treated with transverse sacral resections and high-dose radiotherapy (using either protons or photons or a combination) before surgery and after surgery. During this time period, our indication for this approach generally was symptomatic sacral chordoma in which resection would prevent further growth and reasonable sacrifice of nerve roots was possible. Of those patients, 21 (50%) had CT scans both before and after radiation treatment. We used HU as a surrogate for bone density. CT uses HU to derive information on tissue and bone quantity. A recent study presented reference HU values for normal (mean 133 ± 38 HU), osteoporotic (101 ± 25 HU), and osteopenic bone (79 ± 32 HU). To adjust for scanning protocol-induced changes in HU, we calculated the ratio between bone inside and outside the radiation field rather than using absolute values. To assess the effect of radiation, we tested whether there was a difference in ratio (sacrum/L1) before and after radiation. A control measurement was performed (L2/L1) and also tested for a difference before and after radiation. Statistical analyses were performed using the paired t-test. The effects of radiation appeared confined to the intended field, because the bone density outside the treated field was not observed to decrease. The ratio of HU (a surrogate for bone density) in L2 relative to L1 did not change after radiotherapy (preradiation mean: 0.979 ± 0.009, postradiation mean: 0.980 ± 0.009, mean difference outside the radiation field: -0.001, 95% confidence interval [CI], -0.009 to 0.007, p = 0.799). The ratio of HU within the radiation field relative to L1 decreased after radiotherapy (preradiation mean: 0.895 ± 0.050, postradiation mean: 0.658 ± 0.050, mean difference inside the radiation field: 0.237, 95% CI, 0.187-0.287, p < 0.001), suggesting the bone density stayed the same outside the radiation field but decreased inside the radiation field. Trabecular bone density decreased after high-dose radiation therapy in a small group of patients with sacral chordoma. High-dose radiation is increasingly gaining acceptance for treating sacral malignancies; further long-term prospective studies using calibrated CT scanners and preferably bone biopsies are needed. Level IV, therapeutic study.

Can Navigation-assisted Surgery Help Achieve Negative Margins in Resection of Pelvic and Sacral Tumors?

Navigation-assisted resection has been proposed as a useful adjunct to resection of malignant tumors in difficult anatomic sites such as the pelvis and sacrum where it is difficult to achieve tumor-free margins. Most of these studies are case reports or small case series, but these reports have been extremely promising. Very few reports, however, have documented benefits of navigation-assisted resection in series of pelvic and sacral primary tumors. Because this technology may add time and expense to the surgical procedure, it is important to determine whether navigation provides any such benefits or simply adds cost and time to an already complex procedure. (1) What proportion of pelvic and sacral bone sarcoma resections utilizing a computer-assisted resection technique achieves negative margins? (2) What are the oncologic outcomes associated with computer-assisted resection of pelvic and sacral bone sarcomas? (3) What complications are associated with navigation-assisted resection? Between 2009 and 2015 we performed 24 navigation-assisted resections of primary tumors of the pelvis or sacrum. Of those, four were lost to followup after the 2-year postoperative visit. In one patient, however, there was a failure of navigation as a result of inadequate imaging, so nonnavigated resection was performed; the remaining 23 were accounted for and were studied here at a mean of 27 months after surgery (range, 12-52 months). During this period, we performed navigation-assisted resections in all patients presenting with a pelvis or sacral tumor; there was no selection process. No patients were treated for primary tumors in these locations without navigation during this time with the exception of the single patient in whom the navigation system failed. We retrospectively evaluated the records of these 23 patients and evaluated the margin status of these resections. We calculated the proportion of patients with local recurrence, development of metastases, and overall survival at an average 27-month followup (range, 12-52 months). We queried a longitudinally maintained surgical database for any complications and noted which, if any, could have been directly related to the use of the navigation-assisted technique. In our series, 21 of 23 patients had a negative margin resection. In all patients the bone margin was negative, but two with sacral resections had positive soft tissue margins. Six of 23 patients experienced local recurrence within the study period. Three patients died during the study period. Seventeen patients demonstrated no evidence of disease at last recorded followup. We noted three intraoperative complications: one dural tear, one iliac vein laceration, and one bladder injury. Eight patients out of 23 had wound complications resulting in operative débridement. Two patients in the series developed transient postoperative femoral nerve palsy, which we believe were caused by stretch of the femoral nerve secondary to the placement of the reference array in the pubic ramus. Navigation-assisted resection of pelvic and sacral tumors resulted in a high likelihood of negative margin resection in this series, and we observed relatively few complications related specifically to the navigation. We have no comparison group without navigation, and future studies should indeed compare navigated with nonnavigated resection approaches in these anatomic locations. We did identify a potential navigation-related complication of femoral nerve palsy in this series and suggest careful placement and observation of the reference array during the operative procedure to lessen the likelihood of this previously unreported complication. We suggest it is worthwhile to consider the use of navigation-assisted surgery in resection of tumors of the pelvis and sacrum, but further study will be needed to determine its precise impact, if any, on local recurrence and other oncologic outcomes. Level IV, therapeutic study.

A biomechanical approach to advances in sacropelvic reconstruction

The sacrum is the only mechanical connection between the spine and pelvis/lower extremities. In the setting of a primary, or in select patients a locally advanced recurrent malignancy, curative treatment requires en-bloc sacrectomy. In addition to the surgery in this area being challenging due to the complexity of the pelvic anatomy, adjacent visceral and vascular structures; spinal-pelvic continuity is often lost. Historically following sacral resection patients were left “un-reconstructed” and the spinal column floated between the remaining pelvis, forming a soft-tissue sling which can become painful and lead to a poor patient outcome. Our institution has pioneered a means to reconstruct these defects following high sacral resection in order to restore continuity between the spine, pelvis and femur which has been shown to improve patient outcomes. The purpose of this article is to describe a biomechanical approach to sacral reconstruction.

Sacrectomía parcial por abordaje posterior único. [Partial sacrectomy by single posterior approach.

&lt;p class="TRABAJOS"&gt;&lt;strong&gt;Introducción: &lt;/strong&gt;Los tumores del sacro corresponden a menos del 7% de los tumores espinales. Prevalecen los secundarios por mieloma múltiple o carcinomas de próstata, mama, pulmón o colón. De los primarios, el cordoma es el maligno más frecuente y el tumor de células gigantes el benigno.&lt;/p&gt;&lt;p class="TRABAJOS"&gt;Por su evolución, compromiso de estructuras extra óseas y la escasa respuesta a la coadyuvancia, la cirugía es el tratamiento más utilizado, la vía de abordaje y la necesidad de instrumentación dependerá del tumor a tratar.&lt;/p&gt;&lt;p class="TRABAJOS"&gt;&lt;strong&gt;Objetivos:&lt;/strong&gt; Los objetivos de este trabajo son: evaluar la utilización de resección parcial de sacro, analizar la técnica quirúrgica y reconocer complicaciones.&lt;/p&gt;&lt;p class="TRABAJOS"&gt;&lt;strong&gt;Material y métodos:&lt;/strong&gt; Cuatro pacientes con diagnóstico de tumor sacro ubicado por debajo de S1, que consulta por dolor y que las imágenes confirman la lesión. A todos se les realiza una resección en bloque por vía posterior preservando S1. Se describe la técnica.&lt;/p&gt;&lt;p class="TRABAJOS"&gt;&lt;strong&gt;Resultados:&lt;/strong&gt; La anatomopatológica fue: un cordoma, un tumor maligno de vaina nerviosa, un condrosarcoma y una metástasis de carcinoma prostático. Se preservo la función de S1 en todos los pacientes; uno presenta disfunción vesical permanente. Se observaron una dehiscencia de herida, una infección y fistula de líquido cefalorraquídeo. Con un seguimiento entre 6 y 24 meses todos los pacientes se encuentran libre de patología.&lt;/p&gt;&lt;p class="TRABAJOS"&gt;&lt;strong&gt;Conclusiones: &lt;/strong&gt;La resección parcial del sacro por abordaje único vía posterior puede ser indicada cuando la lesión comprometa desde S2 hacia distal y sin compromiso sacroilíaco. La preservación de raíces es de vital importancia para garantizar mejores resultados post operatorios y menor tasa de infección.&lt;/p&gt;

Sacral resection in surgical treatment of locally advanced primary and recurrent rectal and anal cancer: short-term outcomes

To assess safety of rectum removal with distal sacral resection. The short-term results of surgical treatment of primary and recurrent locally advanced rectal and anal cancer with sacral fixation have been analyzed. 32 patients underwent combined operations with sacral resection at the level of S2-S5. In 12 patients only one point of tumor fixation (F1) was revealed, 10 patients had two points of fixation (F2), three patients had three fixation points (F3) and in 7 cases the tumor was fixed to four points (F4) of fixation to different pelvic structures. Mean intraoperative blood loss and surgery time was 551±81 ml and 320±20 min in cases of sacral fixation only that was significantly lower compared with F2 cases - 1278±551 ml and 433±45 min, F3 cases - 2200±600 ml and 620±88 min, F4 cases - 2157±512.5 ml and 519±52,3 min, respectively (р<0.05). Complications requiring surgical intervention occurred in 9% patients (n=3). Among 23 patients with intact bladder and ureters urinary disorders occurred in 42% (n=10). Resection margin was negative along posterior surface of the specimen in all cases. Advanced surgery with distal sacral resection is advisable for radical removal of locally advanced and recurrent rectal and anal canal cancer fixed to the sacrum with negative resection margin. These operations are feasible in specialized centers and should be performed by specially trained oncological or colorectal surgeon.

The possibilities of treatment of recurrent colorectal cancer with sacral invasion

To describe current methods of surgical treatment of rare form of recurrent rectal cancer with sacral invasion. The article presents the methodology for the treatment of patients with recurrent colorectal cancer and sacral invasion using preoperative chemoradiotherapy followed by high-tech surgery of recurrent tumor removal with sacral resection at various levels (including high intersection at S1 level). It was concluded that chemoradiotherapy is indicated in patients with recurrent colorectal cancer if it was not made at the first stage of treatment. Additional radiotherapy up to optimum overall focal dose prior to surgery is advisable in those patients who previously underwent radiotherapy with partial dose. This type of operations has high risk of complications and requires a personalized approach to the selection of patients. However, R0-resection is associated with favorable long-term prognosis, significantly increased survival and overall quality of life. Combined surgery for recurrent tumors with sacral invasion should be performed by multidisciplinary surgical team in specialized centers using current possibilities of anesthesiology and intensive care.

218 - Patient-Reported Outcomes after Sacral Resection Based on the Level of Nerve Root Resection

218 - Patient-Reported Outcomes after Sacral Resection Based on the Level of Nerve Root Resection

Hypotensive Epidural Anesthesia Reduces Blood Loss in Pelvic and Sacral Bone Tumor Resections

Resection of pelvic and sacral tumors can cause severe blood loss, complications, and even postoperative death. Hypotensive epidural anesthesia has been used to mitigate blood loss after elective arthroplasty, but to our knowledge, it has not been studied as an approach that might make resection of pelvic and sacral tumors safer. The purposes of this study were (1) to compare the blood loss and blood product use for patients undergoing pelvic and sacral tumor surgery under standard anesthesia or hypotensive epidural anesthesia; (2) to assess the frequency of end-organ damage with the two techniques; and (3) to compare 90-day mortality between the two techniques. Between 2000 and 2014, 285 major pelvic and sacral resections were performed at one center. A total of 174 (61%) had complete data sets for analysis of blood loss, transfusion use, complications, and mortality at 90 days. Of those, 102 (59%) underwent hypotensive epidural anesthesia, whereas the remainder received standard anesthetic care. The anesthetic approach was determined by the anesthetists in charge of the case with hypotensive epidural anesthesia exclusively performed by one of two subspecialty trained anesthetists as their routine for major pelvic or sacral surgery. The groups were comparable in terms of potential confounding variables such as age, gender, tumor volume, and operation performed. Hypotensive epidural anesthesia was defined as a technique using an extensive epidural block up to T2-3 dermatome, peripherally administered low-concentration intravenous adrenaline infusion, and using unimpeded spontaneous respiration to achieve controlled hypotension, precise rate control of the heart, and enhanced velocity of venous return, all aggregated thus to minimize blood loss during pelvic surgery while preserving vital perfusion. The groups were assessed for perioperative blood loss calculated from pre- and postsurgery hemoglobin and transfusion use as well as postoperative complications, morbidity, and mortality at 90 days. There was less mean blood loss in the hypotensive epidural anesthesia group (1457 mL, SD 1721, 95% confidence interval [CI], 1114-1801 versus 2421 mL, SD 2297, 95% CI, 1877-2965; p = 0.003). Patients in the hypotensive epidural anesthesia group on average received fewer packed red cell transfusions (2.7 units, SD 2.9, 95% CI, 2.1-3.2 versus 3.9 units, SD 4.4, 95% CI, 2.9-5.0; p = 0.03). There were no differences in the proportions of patients experiencing end-organ injury (7%, n = seven of 102 versus 6%, n = four of 72; p = 0.72). With the numbers available, there was no difference in 90-day mortality rate between groups (1.9%, n = two of 102 versus 1.3%, n = one of 72; p = 0.77). We found that hypotensive epidural anesthesia resulted in less blood loss, fewer transfusions, and no apparent increase in serious complications in pelvic and sacral tumor surgery performed in the setting of a high-volume tertiary sarcoma referral hospital. We recommend that further collaborative studies be undertaken to confirm our results with hypotensive epidural anesthesia in surgery for pelvic tumors. Level III, therapeutic study.

Proposed Scoring System for Evaluating Neurologic Deficit after Sacral Resection: Functional Outcomes of 170 Consecutive Patients.

Cross-section analysis. A quality-of-life oriented scoring system for evaluation of lower limbs, bladder, and bowel functions of patients after sacral tumor resection has been proposed and was adopted in a clinical research. Surgical resections of sacral tumors usually cause postoperative neurologic deficits. A widely agreed scoring system for detailed evaluation of functional outcomes is not yet established. The scoring system has three domains with three items in each domain, being allocated 0 to 3 points of each item according to the degree of functional impairment. Overall function scale is presented in percentage form. In the current single-center cross-section study, it was adopted to evaluate and quantify the postoperative functional outcomes of 170 consecutive patients who underwent sacrectomy. Significant observer agreement (P < 0.01) was found in all nine items of the proposed system. Detailed functional outcome and difference between each group can be well described by the scoring results. Preservation of bilateral S1 nerve roots preserved majority of motor and sensory function in lower limbs. The probability and degree of urine incontinence (P = 0.003) and abnormal bladder sensation (P = 0.039) was significantly lower in patients with bilateral S3 nerve preserved than those whose unilateral S3 was severed. Patients with unilateral S3 preserved had a lower incidence and degree of dysuria (P = 0.056), constipation (P = 0.059), bowel incontinence (P = 0.007), and abnormal rectal sensation (P = 0.002) than those whose bilateral S3 were sacrificed. Functional outcomes for patients with retained coccyx were better than those with coccyx transected. Functional outcome of different level sacral nerve preservation was semi-quantified and profiled. Detailed and intuitive description of neurologic deficits after sacral tumor resection is the major purpose of current scoring system. The ease of use and reproducibility makes it a practical tool to evaluate function status after sacrectomy under oncologic condition. 4.

High subcortical sacrectomy: a novel approach to facilitate complete resection of locally advanced and recurrent rectal cancer with high (S1-S2) sacral extension.

R0 resection of locally advanced or recurrent rectal cancer is the key determinant of outcome. Disease extension high on the sacrum has been considered a contraindication to surgery because of associated morbidity and difficulty in achieving complete pathological resection. Total sacrectomy has a high morbidity with poor function. We describe a novel technique of high subcortical sacrectomy (HiSS) to facilitate complete resection of disease extending to the upper sacrum at S1 and S2 to avoid high or total sacrectomy or a nonoperative approach to management. Details of patient demographics, radiology, operative details, postoperative histology, length of hospital stay and complications were entered into a prospectively maintained electronic patient database. All patients had had preoperative chemoradiotherapy. During 2013-2014, five patients, including three with advanced primary cancer and two with recurrent rectal cancer, underwent excision using this approach. All patients had an R0 resection. Four patients had a minor postoperative complication (Clavien-Dindo Grades I and II) and one had a major complication (Clavien-Dindo Grade IIIb). There was no mortality at 90days, and four patients were disease free at a median of 18months. Patients with locally advanced and recurrent rectal cancer involving the upper sacrum may be rendered suitable for potentially curative radical resection with a modified approach to sacral resection. This pilot series suggests that this novel technique results in a high rate of complete pathological resection with acceptable morbidity in patients for whom the alternatives would have been an incomplete resection, a total sacrectomy or nonoperative management.

Residual neurological function after sacral root resection during en-bloc sacrectomy: a systematic review.

Sacrectomy is a highly demanding surgery representing the main treatment for primary tumors arising in the sacrum and pelvis. Unfortunately, it is correlated with loss of important function depending on the resection level and nerve roots sacrificed. The current literature regarding residual function after sacral resection comes from several small case series. The goal of this review is to appraise residual motor function and gait, sensitivity, bladder, bowel, and sexual function after sacrectomies, with consideration to the specific roots sacrificed. An exhaustive literature search was conducted. All manuscripts published before May 2015 regarding residual function after sacrectomy were considered; if a clear correlation between root level and functioning was not present, the paper was excluded. The review identified 15 retrospective case series, totaling 244 patients; 42 patients underwent sacrectomies sparing L4/L4, L4/L5 and L5/L5; 45 sparing both L5 and one or both S1 roots; 8 sparing both S1 and one S2; 48 sparing both S2; 11 sparing both S2 and one S3, 54 sparing both S3, 9 sparing both S3 and one or both S4, and 27 underwent unilateral variable resection. Patients who underwent a sacrectomy maintained functionally normal ambulation in 56.2% of cases when both S2 roots were spared, 94.1% when both S3 were spared, and in 100% of more distal resections. Normal bladder and bowel function were not present when both S2 were cut. When one S2 root was spared, normal bladder function was present in 25% of cases; when both S2 were spared, 39.9%; when one S3 was spared, 72.7%; and when both S3 were spared, 83.3%. Abnormal bowel function was present in 12.5% of cases when both S1 and one S2 were spared; in 50.0% of cases when both S2 were spared; and in 70% of cases when one S3 was spared; if both S3 were spared, bowel function was normal in 94% of cases. When even one S4 root was spared, normal bladder and bowel function were present in 100% of cases. Unilateral sacral nerve root resection preserved normal bladder function in 75% of cases and normal bowel function in 82.6% of cases. Motor function depended on S1 root involvement. Total sacrectomy is associated with compromising important motor, bladder, bowel, sensitivity, and sexual function. Residual motor function is dependent on sparing L5 and S1 nerve roots. Bladder and bowel function is consistently compromised in higher sacrectomies; nevertheless, the probability of maintaining sufficient function increases progressively with the roots spared, especially when S3 nerve roots are spared. Unilateral resection is usually associated with more normal function. To the best of our knowledge, this is the first comprehensive literature review to analyze published reports of residual sacral nerve root function after sacrectomy.

Advanced and Recurrent Rectal Cancer

Rectal cancer accounts for one-third of all colorectal cancers and has an increasing incidence in patients under 40 years of 1.8 to 2.6% annually. Significant advances in multidisciplinary therapy for rectal cancer have resulted in an improved relative 5-year survival; prognosis is strongly dependent on the extent of disease. Although the majority of patients present with disease localized to the mesorectum, locally advanced rectal cancer (LARC) occurs in up to 10% of patients. Surgical extirpation remains the mainstay of curative therapy for LARC and locally recurrent rectal cancer (LRRC). This review covers risk factors for pelvic recurrence, clinical presentation, diagnosis and staging, preparation for surgery, multimodality therapy for advanced and locally recurrent rectal cancer, pelvic reconstruction, and palliative procedures. Figures show Harrison-Anderson-Mick applicator for intraoperative brachytherapy, an algorithm for treating LARC (extension beyond mesorectal fascia or advanced modal disease), an algorithm for treating LRRC, and intraoperative photographs showing oblique sacral resection, extended right lateral pelvic resection, and vertical rectus myocutaneous flap procurement. Tables list risk factors associated with rectal cancer recurrence, and a classification schema of LRRC. This review contains 6 highly rendered figures, 2 tables, and 119 references

Abdominosacral resection for locally recurring rectal cancer.

AIMTo investigate feasibility and outcome of abdominal-sacral resection for treatment of locally recurrent rectal adenocarcinoma.METHODSA population of patients who underwent an abdominal-sacral resection for posterior recurrent adenocarcinoma of the rectum at the National Cancer Institute of Milano, between 2005 and 2013, is considered. Retrospectively collected data includes patient characteristics, treatment and pathology details regarding the primary and the recurrent rectal tumor surgical resection. A clinical and instrumental follow-up was performed. Surgical and oncological outcome were investigated. Furthermore an analytical review of literature was conducted in order to compare our case series with other reported experiences.RESULTSAt the time of abdomino-sacral resection, the mean age of patients was 55 (range, 38-64). The median operating time was 380 min (range, 270-480). Sacral resection was performed at S2/S3 level in 3 patients, S3/S4 in 3 patients and S4/S5 in 4 patients. The median operating time was 380 ± 58 min. Mean intraoperative blood loss was 1750 mL (range, 200-680). The median hospital stay was 22 d. Overall morbidity was 80%, mainly type II complication according to the Clavien-Dindo classification. Microscopically negative margins (R0) is obtained in all patients. Overall 5-year survival after first surgical procedure is 60%, with a median survival from the first surgery of 88 ± 56 mo. The most common site of re-recurrence was intrapelvic.CONCLUSIONSacral resection represents a feasible approach to posterior rectal cancer recurrence without evidence of distant spreading. An accurate staging is essential for planning the best therapy.

Outcomes of composite sacral resection for advanced primary and recurrent rectal cancer

Outcomes of composite sacral resection for advanced primary and recurrent rectal cancer