Surgeons have grappled with the treatment of recurrent and T4b locally advanced rectal cancer(LARC)for many years.Their main objectives are to increase the overall survival and quality of life of the patients and to m...Surgeons have grappled with the treatment of recurrent and T4b locally advanced rectal cancer(LARC)for many years.Their main objectives are to increase the overall survival and quality of life of the patients and to mitigate postoperative complications.Currently,pelvic exenteration(PE)with or without neoadjuvant treatment is a curative treatment when negative resection margins are achieved.The traditional open approach has been favored by many surgeons.However,the technological advancements in minimally invasive surgery have radically changed the surgical options.Recent studies have demonstrated promising results in postoperative complications and oncological outcomes after robotic or laparoscopic PE.A recent retrospective study entitled“Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer:A 9-year review”was published in the World Journal of Gastrointestinal Surgery.As we read this article with great interest,we decided to delve into the latest data regarding the benefits and risks of minimally invasive PE for LARC.Currently,the small number of suitable patients,limited surgeon experience,and steep learning curve are hindering the establishment of minimally invasive PE.展开更多
AIM： To analyze the major complications after exenteration of gynecological and rectal malignancies.METHODS： Twenty-two patients with gynecological malignancy and 6 with rectal malignancy underwent pelvic exenterati...AIM： To analyze the major complications after exenteration of gynecological and rectal malignancies.METHODS： Twenty-two patients with gynecological malignancy and 6 with rectal malignancy underwent pelvic exenteration （PE） between 1996 and 2005. PE was performed for primary malignancy in 71.4% of cases （vulvar cancer in 13, cancer rectal in 5, cervical cancer in 1 and Bartholin＇s gland cancer in 1 cases respectively and recurrent malignancy in 28.6% of cases （cervical cancer in 5, ovarian cancer in 1, uterine sarcoma in 1 and rectal cancer in 1 cases respectively）. Posterior PE, total PE and anterior PE were most often performed.RESULTS： Major complications in the operative field involving the urinary tract infection or the wound dehiscence occurred in 12 patients （42.9%）. Early complications included massive bleeding from the sacral plexus, adult respiratory distress syndrome （ARDS）, thrombophlebitis, acute renal failure, urinary bladder dysfunction, ureter damage, re-operation and pulmonary embolus. Urinary incontinence was observed in 2 women as a late complication. In 1 patient a nephrostomy was performed in 1 patient due to extensive hydronephrosis and 1 patient had complications connected with the gastrointestinal tract. The mortality rate was 7%, of which inter-operative mortality accounted for 3.5%. Major complications often occurred in advanced primary vulvar cancer affecting those with recurrent malignancies.CONCLUSION： PE is more beneficial to patients with primary vulvar and rectal cancer than to those with recurrent cancer. Knowledge of the inherent complications and morbidity of PE is essential.展开更多
AIM To identify short-term and oncologic outcomes of pelvic exenterations(PE) for locally advanced primary rectal cancer(LAPRC) in patients included in a national prospective database.METHODS Few studies report on PE ...AIM To identify short-term and oncologic outcomes of pelvic exenterations(PE) for locally advanced primary rectal cancer(LAPRC) in patients included in a national prospective database.METHODS Few studies report on PE in patients with LAPRC. For this study, we included PE for LAPRC performed between 2006 and 2017, as available, from the Rectal Cancer Registry of the Spanish Association of Surgeons [Asociación Espa?ola de Cirujanos(AEC)]. Primary endpoints included procedure-associated complications, 5-year local recurrence(LR), disease-free survival(DFS) and overall survival(OS). A propensitymatched comparison with patients who underwent non-exenterative surgery for low rectal cancers was performed as a secondary endpoint.RESULTS Eight-two patients were included. The mean age was 61.8 ± 11.5 years. More than half of the patients experienced at least one complication. Surgical site infections were the most common complication(abdominal wound 18.3%, perineal closure 19.4%). Thirty-three multivisceral resections were performed, including two hepatectomies and four metastasectomies. The long-term outcomes of the 64 patients operated on before 2013 were assessed. The five-year LR was 15.6%, the distant recurrence rate was 21.9%, and OS was 67.2%, with a mean survival of 43.8 mo. R+ve resection increased LR [hazard ratio(HR) = 5.58, 95%CI: 1.04-30.07, P = 0.04]. The quality of the mesorectum was associated with DFS. Perioperative complications were independent predictors of shorter survival(HR = 3.53, 95%CI: 1.12-10.94, P = 0.03). In the propensity-matched analysis, PE was associated with better quality of the specimen and tended to achieve lower LR with similar OS.CONCLUSION PE is an extensive procedure, justified if disease-free margins can be obtained. Further studies should define indications, accreditation policy, and quality of life in LAPRC.展开更多
BACKGROUND Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery.Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bl...BACKGROUND Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery.Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bladder preserving prostatectomy with vesicourethral anastomosis,while achieving clear margins.AIM To determine the feasibility of robotic assisted bladder sparing pelvic exenteration.METHODS We describe robotic assisted pelvic exenteration in three cases of locally advanced rectal cancer involving prostate and seminal vesicles(SV).The da Vinci S robotic system was used.Robotic console was docked at left oblique position for abdominal phase and redocked to between the patient’s legs for pelvic phase.All three cases were performed fully robotically at Tan Tock Seng Hospital by colorectal and urological teams.RESULTS Case 1:67-year-old with low rectal tumour 3 cm from anal verge involving the prostate.He underwent neo-adjuvant chemoradiotherapy and robotic abdominoperineal resection with en-bloc prostatectomy.Case 2:66-year-old with low rectal tumour 3 cm from anal verge involving prostate and bilateral SV.He underwent neo-adjuvant chemoradiotherapy and robot assisted ultra-low anterior resection with coloanal anastomosis and en-bloc prostatectomy.Case 3:57-year-old with metachronous rectal tumour in the rectovesical pouch inseparable from the anterior mid rectum,prostate and bilateral SV.He underwent robot assisted ultra-low anterior resection with en-bloc prostatectomy.Bladder neck margin revealed cauterized tumour cells,and he underwent total cystectomy and ileal conduit creation.Histology revealed no residual tumour.All patients are currently disease free CONCLUSION Robot assisted bladder sparing pelvic exenteration can be safely performed in locally advanced rectal cancer with acceptable surgical outcome while preserving benefits of minimally invasive surgery.展开更多
AIM: To determine the immediate surgical outcome and recovery of bowel function following posterior pelvic exenteration (PPE) for primary rectal cancer with suspected local invasion to the female internal reproductive...AIM: To determine the immediate surgical outcome and recovery of bowel function following posterior pelvic exenteration (PPE) for primary rectal cancer with suspected local invasion to the female internal reproductive organs, in comparison with a case-control series of standard resection for primary rectal cancer. METHODS: We analyzed 10 consecutive female patients undergoing PPE for the aforementioned indication between December 2003 and May 2006 in a single institution. Data were prospectively collected during hospitalization, including patient demographics, tumor- and operation-related variables and early surgical outcomes. These patients were compared with a group of female patients, matched for age, co-morbidity and location of tumor, who underwent standard resection for primary rectal cancer in the same period (non PPE group). RESULTS: In the PPE group, pathological reports showed direct invasion of the reproductive organs in 4 cases and an involvement of lymph nodes in 7 cases. A sphincter-saving operation was performed in each case. Operative time was longer (274 min vs 157 min, P < 0.001) and blood loss was greater (769 mL vs 203 mL, P = 0.008) in the PPE group. Time to first bowel movement, time to first defecation, time to resumption of normal diet, and hospital stay were not significantly different between the two groups. Postoperative complication rates were also similar.CONCLUSION: PPE for rectal cancer was associatedwith longer operative time and increased blood loss, but did not compromise immediate surgical outcomes and postoperative bowel function compared to standard rectal resection.展开更多
To critically appraise short-term outcomes in patients treated in a new Pelvic Exenteration (PE) Unit. METHODSThis retrospective observational study was conducted by analysing prospectively collected data for the firs...To critically appraise short-term outcomes in patients treated in a new Pelvic Exenteration (PE) Unit. METHODSThis retrospective observational study was conducted by analysing prospectively collected data for the first 25 patients (16 males, 9 females) who underwent PE for advanced pelvic tumours in our PE Unit between January 2012 and October 2016. Data evaluated included age, co-morbidities, American Society of Anesthesiologists (ASA) score, Eastern Cooperative Oncology Group (ECOG) status, preoperative adjuvant treatment, intra-operative blood loss, procedural duration, perioperative adverse event, lengths of intensive care unit (ICU) stay and hospital stay, and oncological outcome. Quantitative data were summarized as percentage or median and range, and statistically assessed by the χ<sup>2</sup> test or Fisher’s exact test, as applicable. RESULTSAll 25 patients received comprehensive preoperative assessment via our dedicated multidisciplinary team approach. Long-course neoadjuvant chemoradiotherapy was provided, if indicated. The median age of the patients was 61.9-year-old. The median ASA and ECOG scores were 2 and 0, respectively. The indications for PE were locally invasive rectal adenocarcinoma (n = 13), advanced colonic adenocarcinoma (n = 5), recurrent cervical carcinoma (n = 3) and malignant sacral chordoma (n = 3). The procedures comprised 10 total PEs, 4 anterior PEs, 7 posterior PEs and 4 isolated lateral PEs. The median follow-up period was 17.6 mo. The median operative time was 11.5 h. The median volume of blood loss was 3306 mL, and the median volume of red cell transfusion was 1475 mL. The median lengths of ICU stay and of hospital stay were 1 d and 21 d, respectively. There was no case of mortality related to surgery. There were a total of 20 surgical morbidities, which occurred in 12 patients. The majority of the complications were grade 2 Clavien-Dindo. Only 2 patients experienced grade 3 Clavien-Dindo complications, and both required procedural interventions. One patient experienced grade 4a Clavien-Dindo complication, requiring temporary renal dialysis without long-term disability. The R0 resection rate was 64%. There were 7 post-exenteration recurrences during the follow-up period. No statistically significant relationship was found among histological origin of tumour, microscopic resection margin status and postoperative recurrence (P = 0.67). Four patients died from sequelae of recurrent disease during follow-up. CONCLUSIONBy utilizing modern assessment and surgical techniques, our PE Unit can manage complex pelvic cancers with acceptable morbidities, zero-rate mortality and equivalent oncologic outcomes.展开更多
The present study reports a rare primitive neuroectodermal tumor (PNET) of prostate.A 27-year-old male was admitted to Harbin Medical University Cancer Hospital (Harbin,China) for dysuria and dyschezia. Magnetic reson...The present study reports a rare primitive neuroectodermal tumor (PNET) of prostate.A 27-year-old male was admitted to Harbin Medical University Cancer Hospital (Harbin,China) for dysuria and dyschezia. Magnetic resonance imaging (MRI) revealed a large mass thatmay involve the bladder and rectum next to the prostate. Histopathological analysis of biopsyof prostate indicated mesenchymal origin tumor, and immunohistochemistric stainingconfirmed diagnosis of PNET of prostate. En bloc total pelvic exenteration and double barrelsigmoidostomy were performed. Double stomas in the skin incision were used for fecal andurinary diversion, respectively. Short-term outcome is satisfactory, while long-term efficacyremains to be poor. Clinical features of PNET of prostate should be paid much more attentionand radical surgery and adjuvant chemotherapy should be recommended.展开更多
文摘Surgeons have grappled with the treatment of recurrent and T4b locally advanced rectal cancer(LARC)for many years.Their main objectives are to increase the overall survival and quality of life of the patients and to mitigate postoperative complications.Currently,pelvic exenteration(PE)with or without neoadjuvant treatment is a curative treatment when negative resection margins are achieved.The traditional open approach has been favored by many surgeons.However,the technological advancements in minimally invasive surgery have radically changed the surgical options.Recent studies have demonstrated promising results in postoperative complications and oncological outcomes after robotic or laparoscopic PE.A recent retrospective study entitled“Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer:A 9-year review”was published in the World Journal of Gastrointestinal Surgery.As we read this article with great interest,we decided to delve into the latest data regarding the benefits and risks of minimally invasive PE for LARC.Currently,the small number of suitable patients,limited surgeon experience,and steep learning curve are hindering the establishment of minimally invasive PE.
文摘AIM： To analyze the major complications after exenteration of gynecological and rectal malignancies.METHODS： Twenty-two patients with gynecological malignancy and 6 with rectal malignancy underwent pelvic exenteration （PE） between 1996 and 2005. PE was performed for primary malignancy in 71.4% of cases （vulvar cancer in 13, cancer rectal in 5, cervical cancer in 1 and Bartholin＇s gland cancer in 1 cases respectively and recurrent malignancy in 28.6% of cases （cervical cancer in 5, ovarian cancer in 1, uterine sarcoma in 1 and rectal cancer in 1 cases respectively）. Posterior PE, total PE and anterior PE were most often performed.RESULTS： Major complications in the operative field involving the urinary tract infection or the wound dehiscence occurred in 12 patients （42.9%）. Early complications included massive bleeding from the sacral plexus, adult respiratory distress syndrome （ARDS）, thrombophlebitis, acute renal failure, urinary bladder dysfunction, ureter damage, re-operation and pulmonary embolus. Urinary incontinence was observed in 2 women as a late complication. In 1 patient a nephrostomy was performed in 1 patient due to extensive hydronephrosis and 1 patient had complications connected with the gastrointestinal tract. The mortality rate was 7%, of which inter-operative mortality accounted for 3.5%. Major complications often occurred in advanced primary vulvar cancer affecting those with recurrent malignancies.CONCLUSION： PE is more beneficial to patients with primary vulvar and rectal cancer than to those with recurrent cancer. Knowledge of the inherent complications and morbidity of PE is essential.
文摘AIM To identify short-term and oncologic outcomes of pelvic exenterations(PE) for locally advanced primary rectal cancer(LAPRC) in patients included in a national prospective database.METHODS Few studies report on PE in patients with LAPRC. For this study, we included PE for LAPRC performed between 2006 and 2017, as available, from the Rectal Cancer Registry of the Spanish Association of Surgeons [Asociación Espa?ola de Cirujanos(AEC)]. Primary endpoints included procedure-associated complications, 5-year local recurrence(LR), disease-free survival(DFS) and overall survival(OS). A propensitymatched comparison with patients who underwent non-exenterative surgery for low rectal cancers was performed as a secondary endpoint.RESULTS Eight-two patients were included. The mean age was 61.8 ± 11.5 years. More than half of the patients experienced at least one complication. Surgical site infections were the most common complication(abdominal wound 18.3%, perineal closure 19.4%). Thirty-three multivisceral resections were performed, including two hepatectomies and four metastasectomies. The long-term outcomes of the 64 patients operated on before 2013 were assessed. The five-year LR was 15.6%, the distant recurrence rate was 21.9%, and OS was 67.2%, with a mean survival of 43.8 mo. R+ve resection increased LR [hazard ratio(HR) = 5.58, 95%CI: 1.04-30.07, P = 0.04]. The quality of the mesorectum was associated with DFS. Perioperative complications were independent predictors of shorter survival(HR = 3.53, 95%CI: 1.12-10.94, P = 0.03). In the propensity-matched analysis, PE was associated with better quality of the specimen and tended to achieve lower LR with similar OS.CONCLUSION PE is an extensive procedure, justified if disease-free margins can be obtained. Further studies should define indications, accreditation policy, and quality of life in LAPRC.
文摘BACKGROUND Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery.Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bladder preserving prostatectomy with vesicourethral anastomosis,while achieving clear margins.AIM To determine the feasibility of robotic assisted bladder sparing pelvic exenteration.METHODS We describe robotic assisted pelvic exenteration in three cases of locally advanced rectal cancer involving prostate and seminal vesicles(SV).The da Vinci S robotic system was used.Robotic console was docked at left oblique position for abdominal phase and redocked to between the patient’s legs for pelvic phase.All three cases were performed fully robotically at Tan Tock Seng Hospital by colorectal and urological teams.RESULTS Case 1:67-year-old with low rectal tumour 3 cm from anal verge involving the prostate.He underwent neo-adjuvant chemoradiotherapy and robotic abdominoperineal resection with en-bloc prostatectomy.Case 2:66-year-old with low rectal tumour 3 cm from anal verge involving prostate and bilateral SV.He underwent neo-adjuvant chemoradiotherapy and robot assisted ultra-low anterior resection with coloanal anastomosis and en-bloc prostatectomy.Case 3:57-year-old with metachronous rectal tumour in the rectovesical pouch inseparable from the anterior mid rectum,prostate and bilateral SV.He underwent robot assisted ultra-low anterior resection with en-bloc prostatectomy.Bladder neck margin revealed cauterized tumour cells,and he underwent total cystectomy and ileal conduit creation.Histology revealed no residual tumour.All patients are currently disease free CONCLUSION Robot assisted bladder sparing pelvic exenteration can be safely performed in locally advanced rectal cancer with acceptable surgical outcome while preserving benefits of minimally invasive surgery.
文摘AIM: To determine the immediate surgical outcome and recovery of bowel function following posterior pelvic exenteration (PPE) for primary rectal cancer with suspected local invasion to the female internal reproductive organs, in comparison with a case-control series of standard resection for primary rectal cancer. METHODS: We analyzed 10 consecutive female patients undergoing PPE for the aforementioned indication between December 2003 and May 2006 in a single institution. Data were prospectively collected during hospitalization, including patient demographics, tumor- and operation-related variables and early surgical outcomes. These patients were compared with a group of female patients, matched for age, co-morbidity and location of tumor, who underwent standard resection for primary rectal cancer in the same period (non PPE group). RESULTS: In the PPE group, pathological reports showed direct invasion of the reproductive organs in 4 cases and an involvement of lymph nodes in 7 cases. A sphincter-saving operation was performed in each case. Operative time was longer (274 min vs 157 min, P < 0.001) and blood loss was greater (769 mL vs 203 mL, P = 0.008) in the PPE group. Time to first bowel movement, time to first defecation, time to resumption of normal diet, and hospital stay were not significantly different between the two groups. Postoperative complication rates were also similar.CONCLUSION: PPE for rectal cancer was associatedwith longer operative time and increased blood loss, but did not compromise immediate surgical outcomes and postoperative bowel function compared to standard rectal resection.
文摘To critically appraise short-term outcomes in patients treated in a new Pelvic Exenteration (PE) Unit. METHODSThis retrospective observational study was conducted by analysing prospectively collected data for the first 25 patients (16 males, 9 females) who underwent PE for advanced pelvic tumours in our PE Unit between January 2012 and October 2016. Data evaluated included age, co-morbidities, American Society of Anesthesiologists (ASA) score, Eastern Cooperative Oncology Group (ECOG) status, preoperative adjuvant treatment, intra-operative blood loss, procedural duration, perioperative adverse event, lengths of intensive care unit (ICU) stay and hospital stay, and oncological outcome. Quantitative data were summarized as percentage or median and range, and statistically assessed by the χ<sup>2</sup> test or Fisher’s exact test, as applicable. RESULTSAll 25 patients received comprehensive preoperative assessment via our dedicated multidisciplinary team approach. Long-course neoadjuvant chemoradiotherapy was provided, if indicated. The median age of the patients was 61.9-year-old. The median ASA and ECOG scores were 2 and 0, respectively. The indications for PE were locally invasive rectal adenocarcinoma (n = 13), advanced colonic adenocarcinoma (n = 5), recurrent cervical carcinoma (n = 3) and malignant sacral chordoma (n = 3). The procedures comprised 10 total PEs, 4 anterior PEs, 7 posterior PEs and 4 isolated lateral PEs. The median follow-up period was 17.6 mo. The median operative time was 11.5 h. The median volume of blood loss was 3306 mL, and the median volume of red cell transfusion was 1475 mL. The median lengths of ICU stay and of hospital stay were 1 d and 21 d, respectively. There was no case of mortality related to surgery. There were a total of 20 surgical morbidities, which occurred in 12 patients. The majority of the complications were grade 2 Clavien-Dindo. Only 2 patients experienced grade 3 Clavien-Dindo complications, and both required procedural interventions. One patient experienced grade 4a Clavien-Dindo complication, requiring temporary renal dialysis without long-term disability. The R0 resection rate was 64%. There were 7 post-exenteration recurrences during the follow-up period. No statistically significant relationship was found among histological origin of tumour, microscopic resection margin status and postoperative recurrence (P = 0.67). Four patients died from sequelae of recurrent disease during follow-up. CONCLUSIONBy utilizing modern assessment and surgical techniques, our PE Unit can manage complex pelvic cancers with acceptable morbidities, zero-rate mortality and equivalent oncologic outcomes.
基金This study was partly supported by Natural Scientific Research Project(H2018048)of Heilongjiang province Science and Technology Department,and it was partly supported by the China Scholarship Council.
文摘The present study reports a rare primitive neuroectodermal tumor (PNET) of prostate.A 27-year-old male was admitted to Harbin Medical University Cancer Hospital (Harbin,China) for dysuria and dyschezia. Magnetic resonance imaging (MRI) revealed a large mass thatmay involve the bladder and rectum next to the prostate. Histopathological analysis of biopsyof prostate indicated mesenchymal origin tumor, and immunohistochemistric stainingconfirmed diagnosis of PNET of prostate. En bloc total pelvic exenteration and double barrelsigmoidostomy were performed. Double stomas in the skin incision were used for fecal andurinary diversion, respectively. Short-term outcome is satisfactory, while long-term efficacyremains to be poor. Clinical features of PNET of prostate should be paid much more attentionand radical surgery and adjuvant chemotherapy should be recommended.
