Understanding the Philosophy, Anatomy, and Surgery of the Extra-TME Plane of Locally Advanced and Locally Recurrent Rectal Cancer; Single Institution Experience with International Benchmarking

Abstract

Pelvic exenteration surgery has become a widely accepted procedure for treatment of locally advanced (LARC) and locally recurrent rectal cancer (LRRC). However, there is still unwarranted variation in peri-operative management and subsequently oncological outcome after this procedure. In this article we will elaborate on the various reasons for the observed differences based on benchmarking results of our own data to the data from the PelvEx collaborative as well as findings from 2 other benchmarking studies. Our main observation was a significant difference in extent of resection between exenteration units, with our unit performing more complete soft tissue exenterations, sacrectomies and extended lateral compartment resections than most other units, resulting in a higher R0 rate and longer overall survival. Secondly, current literature shows there is a tendency to use more neoadjuvant treatment such as re-irradiation and total neoadjuvant treatment and perform less radical surgery. However, peri-operative chemotherapy or radiotherapy should not be a substitute for adequate radical surgery and an R0 resection remains the gold standard. Finally, we describe our experiences with standardizing our surgical approaches to the various compartments and the achieved oncological and functional outcomes.

Surgical, survival and quality of life outcomes in over 1000 pelvic exenterations: lessons learned from a large Australian case series

“…This may indicate that a more radical approach (i.e., 'higher and wider resection') may be required to achieve the 'holy grail' of a clear resection margin. 1 Our centre has previously described the evolution of pelvic exenteration outcomes over time, demonstrating an association between improved surgical margins, mortality rates and overall survival with the increase in annual surgical volume and a more aggressive surgical approach to achieve an R0 margin. 10,25 This may explain the differences in outcomes between the current study and the PelvEx collaborative data, as most of the included centres have contributed very small sample sizes (e.g.…”

“…Improved outcomes are evidenced despite the apparent differences in extent of surgical resection within the compared reports; with our patients undergoing more extensive resections including significantly higher rate of bone involvement and resection as well as complete pelvic exenteration (i.e., two stomas). This may indicate that a more radical approach (i.e., ‘higher and wider resection’) may be required to achieve the ‘holy grail’ of a clear resection margin 1 …”

“…The diagnoses of the pelvic malignancies grouped above were based on histological assessment and radiological imaging. The preoperative management, evolution of our surgical approach, and postoperative care for our patients has been exhaustively reported in the literature 1,5,15‐20 …”

“…The preoperative management, evolution of our surgical approach, and postoperative care for our patients has been exhaustively reported in the literature. 1,5,[15][16][17][18][19][20]…”

“…Over the last three decades, the management of patients presenting with advanced primary or locally recurrent malignancies within the pelvis has drastically evolved, with pelvic exenteration now recognized as the mainstream curative treatment option for selected patients. 1 This extensive radical procedure is performed to completely resect all malignant disease to achieve a clear resection margin (R0). 2 Consequently, partial or complete resection of the pelvic viscera, vessels, muscles, nerves, ligaments, and bone including sacrum, may be required.…”