Short‐ and long‐term outcomes of selective pelvic exenteration surgery in a low‐volume specialized tertiary setting

Abstract

Background: Most published data on pelvic exenteration comes from high-volume quaternary units, with limited data available from outside of this setting. This study reports outcomes of selective pelvic exenteration performed in a low-volume tertiary unit with multidisciplinary support. Methods: A retrospective review of consecutive patients who underwent pelvic exenteration surgery for rectal/anal carcinoma, or gynaecological malignancy at Royal Adelaide Hospital between June 2008 and September 2018. Descriptive statistics and Kaplan-Meier analysis of 5-year disease-free and overall survival for patients treated with curative intent were performed. Results: A total of 54 patients who underwent pelvic exenteration were included. Most patients presented with primary rectal adenocarcinoma, and posterior and total pelvic exenterations were the most common operations performed (>90%). Median total operating time was 323 min, median hospital stay was 15 days, and the readmission rate was 14.8%. The overall complication rate (per patient) was 70.4%, and the re-intervention rate was 20.4%. Thirteen percent of patients required intensive care unit-admission, and there was one postoperative death (1.9%). R0 resection margins were achieved in 81.5% of patients, with R1 and R2 margins in 13.0 and 5.6% of patients, respectively. Estimated 5-year disease-free survival was 38.8%, and 5-year overall survival was 65.7%. Conclusion: Short-and long-term outcomes of selective pelvic exenteration surgery are acceptable in a low-volume specialized tertiary setting with suitable multidisciplinary expertise. If the required expertise is not readily available, then outside referral is recommended.

Regional variance in treatment and outcomes of locally invasive (T4) rectal cancer in Australia and New Zealand: analysis of the Bi‐National Colorectal Cancer Audit

“…These results indicate that higher patient volumes improve both oncologic outcomes and postoperative mortality. Other centres, including ours, have reported results from a mid‐volume centre with comparable CRM positivity (18.6%) and postoperative mortality rates (1.9%) 30 . This suggests that, in selected patients, PE can be performed in a mid‐volume centre with acceptable outcomes, provided that adequate facilities and resources are available.…”

“…Other centres, including ours, have reported results from a mid-volume centre with comparable CRM positivity (18.6%) and postoperative mortality rates (1.9%). 30 This suggests that, in selected patients, PE can be performed in a mid-volume centre with acceptable outcomes, provided that adequate facilities and resources are available. Centralizing low-volume surgery can be disadvantageous for patients living in remote areas, increasing the travel burden of these often elderly and frail patients, reducing accessibility to neoadjuvant therapy, surgery and follow-up.…”

Short‐term outcomes following development of a dedicated pelvic exenteration service in a tertiary centre

“…The PelvEx database was established, and data collected prospectively from June 2017. From 2008 to June 2017, historical data were collected retrospectively from the Binational Colorectal Cancer Audit (BCCA), RAH Colorectal Cancer and Gynaecological Oncology databases, as previously reported 1 . Demographic, operative, pathological and postoperative data were collected from electronic and paper medical records.…”

“…Pelvic exenteration (PE) involves radical resection of two or more contiguous pelvic organs, followed by reconstruction or diversion of genitourinary and gastrointestinal function and repair of the pelvic defect 1 . This may include resection of bone or neurovascular pelvic structures.…”

Extended Radical Resection: The Standard of Care for Patients with Advanced Pelvic Malignancy

“…7,8 Although encouraging outcomes have been achieved in low-volume units, this generally has involved selected patients with centrally based and often primary tumors without pelvic sidewall or sacral involvement. 9 For patients with locally recurrent rectal cancer and where there is concern about tumor proximity to bone and neurovascular structures at the periphery of the pelvis, surgery should be centralized to high-volume units with a dedicated multidisciplinary surgical team.…”