Systematic Review of Pelvic Exenteration With En Bloc Sacrectomy for Recurrent Rectal Adenocarcinoma: R0 Resection Predicts Disease-free Survival

Abstract

BACKGROUND: The management of recurrent rectal cancer is challenging. At the present time, pelvic exenteration with en bloc sacrectomy offers the only hope of a lasting cure. OBJECTIVE: The purpose of this study was to evaluate clinical outcome measures and complication rates following sacrectomy for recurrent rectal cancer. DATA SOURCES: A search was conducted on Pub Med for English language articles relevant to sacrectomy for recurrent rectal cancer with no time limitations. STUDY SELECTION: Studies reported sacrectomy with survival data for recurrent rectal adenocarcinoma. MAIN OUTCOME MEASURE: Disease-free survival following sacrectomy for recurrent rectal cancer was the main outcome measured. RESULTS: A total of 220 patients with recurrent rectal cancer were included from 7 studies, of which 160 were men and 60 were women. Overall median operative time was 717 (570–992) minutes and blood loss was 3.7 (1.7–6.2) L. An R0 (>1-mm resection margin) resection was achieved in 78% of patients. Disease-free survival associated with R0 resection was 55% at a median follow-up period of 33 (17–60) months; however, none of the patients with R1 (<1-mm resection margin) survived this period. Postoperative complication rates and median length of stay were found to decrease with more distal sacral transection levels. In contrast, R1 resection rates increased with more distal transection. LIMITATION: The studies assessed by this review were retrospective case series and thus are subject to significant bias. CONCLUSION: Sacrectomy performed for patients with recurrent rectal cancer is associated with significant postoperative morbidity. Morbidity and postoperative length of stay increase with the level of sacral transection. Nevertheless, approximately half of patients eligible for rectal excision with en bloc sacrectomy may benefit from disease-free survival for up to 33 months, with R0 resection predicting disease-free survival in the medium term.

Population-based study of surgical treatment with and without tumour resection in patients with locally recurrent rectal cancer

“…Today, pelvic exenteration is considered the best potentially curative procedure for many patients with locally advanced tumour in the pelvis. Cancer‐specific survival following this procedure is good, and the complication and morbidity profiles are acceptable. A very small proportion of the patients in this study had more extensive surgery, including partial resection of the sacrum or pelvic side wall; these procedures are also becoming increasingly used in highly specialized centres.…”

Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery

“…Clear surgical margins (R0) are associated with improved survival in patients with primary and recurrent pelvic malignancy . In order to achieve an R0 resection, surrounding structures may have to be removed en bloc , most commonly in locally advanced primary or recurrent anorectal and associated pelvic malignancy.…”

“…In order to achieve an R0 resection, surrounding structures may have to be removed en bloc , most commonly in locally advanced primary or recurrent anorectal and associated pelvic malignancy. In selected patients, there has therefore been a paradigm shift to increasingly radical surgical resection in the form of extralevator abdominoperineal excision (APE) or extended pelvic exenteration .…”

Preliminary results of a cohort study of induction chemotherapy-based treatment for locally recurrent rectal cancer

“…Despite better preoperative and surgical treatment of rectal cancer, the incidence of locally recurrent rectal cancer remains approximately 5–10 per cent. Unlike primary rectal cancer, local recurrence is not confined to a well defined surgical compartment, and multicompartment exenterative procedures are often required to achieve clear resection margins.…”