Abstract
Objective: To examine the changes in exenterative surgery over three decades analysing oncological outcomes and whether changes in surgical approach have led to improved patient outcomes
Background: Advances in surgical technology, perioperative care and pattern of disease recurrence have coincided with an evolutionary change in exenterative surgery.
Methods: A review of prospectively maintained databases of pelvic exenteration surgery from 1988 – 2018 at two high volume specialised institutions. The total cohort was divided into three major time points (1988- 2004, 2005-2010 and 2011 to 2018) to allow comparative analysis. Primary endpoints were overall survival in primary and recurrent disease at each time point. Secondary endpoints included anastomotic leak, blood transfusion, ileus, wound infection rates and evolution of case complexity. Data were analysed using R with a p<0.05 considered significant.
Results: Six hundred and seventy patients underwent exenterative surgery. In 2011–2018 there was an increase in resection of recurrent malignancy with a continuous increase in gastro-intestinal malignancies resected over each time period(p<0.001,<0.01) and a reduction in gynaecological malignancy(p<0.001). A significant increase in sacrectomy, pelvic sidewall resection and ileal conduit reconstruction was observed (p<0.01,<0.001). In 2005–2010 patients had increased rates of ileus and anastomotic leak(p<0.05). Patients undergoing resection for primary disease had improved overall survival at time points 1998-2004 and 2011–2018 compared to those with recurrent disease(p=0.007,<0.001). Overall survival was significantly improved in patients with primary versus recurrent disease(p=0.022).
Conclusion: There has been a significant improvement in survival in patients undergoing pelvic exenteration surgery from primary disease. Case complexity has increased without significant morbidity.
BACKGROUND: The oncological role of pelvic exenteration for locally advanced and recurrent pelvic malignancies arising from the anorectum, gynaecological or urological systems is now well established. Despite this, the surgical community has been slow to accept pelvic exenteration, undoubtedly owing to concerns about high morbidity and mortality rates based on historical data. Therefore, the aims of this study were to assess the general major complications and predictors of morbidity following exenterative surgery for locally advanced and recurrent pelvic malignancies.
METHODS: Data were collected from prospective databases at two high-volume institutions specialising in beyond TME surgery for locally advanced and recurrent pelvic malignancies between 1990 and 2015. The primary outcome measures were major complications (Clavien-Dindo 3 or above) and predictors for morbidity.
RESULTS: A total of 646 consecutive patients requiring exenterative surgery for local advanced pelvic malignancies were identified. The median age was 63 years (range 19-89 years), and the majority were female patients (371; 57.4%). Five hundred and forty patients did not suffer a major complication (83.6%) following pelvic exenterative surgery. One or more major complications were observed in the remaining 106 patients (16.4%). The most common major complications were intra-abdominal collection (43.7%; n=59/135) and wound infection (14.1%; n=19/135). The overall inpatient mortality rate was 0.46% (n=3/646). Independent predictors for major morbidity following exenterative surgery for locally advanced or recurrent pelvic malignancies were squamous cell carcinoma of anus, sacrectomy, past history of peripheral vascular disease and requirement for blood transfusion.
CONCLUSION: Our series adds to the increasing evidence that good outcomes can be achieved for pelvic exenterative surgery in locally advanced and recurrent pelvic malignancies. A coordinated approach in specialist centres for beyond TME surgery demonstrates this is a safe and feasible procedure, offering low major complication rates.