Total Pelvic Exenteration, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy for Rectal Cancer with Associate Peritoneal Metastases: Surgical Strategies to Optimize Safety

Abstract

Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment option for patients with peritoneal carcinomatosis. Total pelvic exenteration (TPE) is an established treatment option for locally advanced pelvic malignancy. These two procedures have high mortality and morbidity, and therefore, their combination is not currently recommended. Herein, we reported our experience on TPE associated with CRS/HIPEC with a critical analysis for rectal cancer with associate peritoneal metastases. Methods: From March 2006 to August 2020, 319 patients underwent a CRS/HIPEC in our hospital. Among them, 16 (12 men and four women) underwent an associated TPE. The primary endpoints were perioperative morbidity and mortality. Results: There was locally recurrent rectal cancer in nine cases, six locally advanced primary rectal cancer, and a recurrent appendiceal adenocarcinoma. The median Peritoneal Cancer Index (PCI) was 8. (4–16). Mean duration of the surgical procedure was 596 min (420–840). Complete cytoreduction (CC0) was achieved in all patients, while clear resection (R0) margins on the resected pelvic organs were achieved in 81.2% of cases. The median hospital stay was 46 days (26–129), and nine patients (56.2%) experienced severe complications (grade III to V) that led to death in two cases (12.5%). The total reoperation rate for patients was 6/16 (37.5%) and 3/16 (18.75%) with percutaneous radiological-guided drainage. Conclusions: In summary, TPE/extended TPE (ETPE) associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC in patients with resectable peritoneal surface diseases if a R0 resection could be achieved on all sites. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended.

Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis

“…Furthermore, the standardization of the surgery since the late 2000s and the extra-levator abdomino-perineal resection [ 2 ] (ELAPE) technique have led to a larger defect and increased perineal complications. In addition, advances in terms of pelvic oncology make it possible to manage increasingly advanced diseases or cancer recurrence [ 3 ], leading to the performance of pelvic exenterations [ 4 ].…”

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative

“…CRS-HIPEC is a well-established treatment modality for patients with synchronous or metachronous colorectal peritoneal metastases [ 73 ]. While it is associated with a long-term survival benefit, high rates of morbidity were observed to range from 12 to 65% [ 74 ]. Traditionally, CRS-HIPEC is not recommended in those needing a pelvic exenteration [ 75 ].…”

“…Traditionally, CRS-HIPEC is not recommended in those needing a pelvic exenteration [ 75 ]. Recent studies suggest the feasibility and safety of these two procedures being performed simultaneously, with an acceptable level of morbidity [ 74 , 75 ]. The PRODIGE-7 trial compared CRS and CRS-HIPEC in patients with peritoneal metastases.…”

“…Tuech et al recently demonstrated a complete cytoreduction in all patients undergoing CRS-HIPEC and TPE, with R0 margins achieved in 81.2%. Despite these promising results, severe complications occurred in 56.2% of patients and post-operative mortality was 12.5% [ 74 ].…”

Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta‐analysis

“…The extra‐levator abdominoperineal resection approach and the standardization of the procedure since the late 2000s have also resulted in larger defects and more perineal problems. Additionally, improvements in pelvic oncology allow for the management of increasingly complex conditions or cancer recurrences, 2 necessitating pelvic exenterations (PEs) 3 . The complication rate is reduced by utilizing a variety of tactics.…”