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Reoperative Pelvic Surgery gastrointestinal tract and abdomen REOPERATIVE PELVIC SURGERY Eric J. Dozois, MD, FACS, FASCRS, and Daniel I. Chu, MD Reoperative pelvic surgery is technically challenging and nerve roots, sciatic nerve, piriformis, obturator internus carries with it signifi cant potential risk. The inherent risks of muscles, and ligaments, including the sacrotuberous and any pelvic operation, such as bleeding and injury to critical sacrospinous. For extended sacropelvic resections, an expe- structures such as the ureters, are magnifi ed by the oblitera- rienced orthopedic oncologic spine surgeon greatly enhance s tion of previous embryonic fusion planes and anatomic the ability to preserve important nerve roots and ensure relationships within the confi nes of a narrow, deep opera- adequate oncologic musculoskeletal margins. tive fi eld. This topic review addresses the surgical indica- tions, techniques, and pitfalls when dealing with recurrent Operative Management pelvic pathology and provides an overview of safe and effective approaches to reoperative pelvic surgery. recurrent malignancy: rectal cancer Pelvic pathology that requires reoperative surgery in the gastrointestinal tract usually involves four surgical themes: Despite modern management, locally recurrent rectal (1) recurrent malignancies, for which we use recurrent rectal cancer remains a signifi cant problem, with the incidence of 1–3 cancer as an example; (2) complications from ileal pouch- recurrence as high as 33% in some series. Only approxi- anal anastomoses (IPAAs) for infl ammatory bowel disease; mately 20% of patients with recurrent disease, however, 4 (3) complications from low pelvic anastomoses; and (4) pal- may be amenable to repeat curative resection. Although the liative situations. For any of these indications, the goals of incidence of metastatic disease in recurrent rectal cancer reoperative pelvic surgery are twofold: (1) resection/repair approaches 70%, up to 50% of patients die with local disease 2,5–9 of the primary indication, which could include pelvic exen- only. In addition, although most local recurrences teration for recurrent rectal cancers to resection/repair of a occur within the fi rst 2 to 3 years following initial curative problematic coloanal anastomosis, and (2) reconstruction resection, a small number do recur after longer periods of 10,11 when possible, which could include complex soft tissue and time. The 5-year survival following surgery for recurrent genitourinary constructs to restoration of gastrointestinal rectal carcinoma is reported to be as high as 58%. Morbidity, continuity. however, is reported to be between 20 and 80%, with most postoperative complications consisting of wound complications.3,12,13 Pelvic Anatomy Several controversies exist regarding surgery for locally An advanced understanding of pelvic anatomy that recurrent rectal cancer. These controversies include the includes soft tissue, gastrointestinal, genitourinary, neuro- effectiveness and response to adjuvant chemoradiotherapy, vascular, and osseous structures is essential in the evaluatio n intraoperative electron beam radiotherapy (IOERT), and and management of complex pelvic pathology. Previous operative parameters such as the timing of resection. These surgery, pelvic radiation, and large tumors can distort the factors affect not only the prognosis of the patients but well-defi ned embryologic fusion planes such as the presa- also patient selection and fi nal outcomes. The selection of cral space, making pelvic dissections particularly diffi cult patients for recurrent pelvic operation includes a wide range and dangerous. Several important neural and vascular struc- of variables, including the patient’s fi tness for surgery, the tures, such as the pelvic autonomic plexus and iliac vessels, extent of recurrent disease, the presence of metastatic dis- respectively, are located in the pelvis, and injury or removal ease, and the intent of the resection (cure versus palliation). of them as part of en bloc resection may have important The extent and magnitude of the operation must be physiologic sequelae as well as long-term neurologic and discussed with the patient. The possibility of a permanent musculoskeletal consequences. colostomy and urostomy and the complications of reopera- Bleeding is one of the most signifi cant risks of reoperative tive pelvic surgery, such as hemorrhage, poor wound heal- pelvic surgery. The arterial and venous anatomy associated ing, and urinary and sexual dysfunction, should be reviewed with the rectum, as well as the urologic and gynecologic in detail. organs, must be clearly delineated so that mobilization and/ Operative Planning or ligation of vessels necessary to remove these organs can be safely performed. When dissection is carried out in the Patients being considered for resection should undergo lateral pelvic sidewall, for example, multiple branches of the evaluation and staging by a multidisciplinary team. Physical internal iliac arteries and veins will be encountered, result- examination of the rectum, inguinal nodal basins, and ing in major blood loss when not approached carefully. In vagina in women helps determine the extent of recurrence the previously irradiated pelvis, the vascular dissection and resectability. Evaluation of the remaining colon via necessary for en bloc tumor removal or sacral resection can endoscopy is imperative to rule out synchronous tumors be facilitated by an experienced vascular surgeon as vessels and adequacy of bowel for reconstruction. Staging of the are often densely fi brosed and yet highly fragile. extent of locoregional disease is best accomplished with If sacrectomy is to be performed, the surgeon must be computed tomography (CT) or magnetic resonance imaging familiar with the relationship between the thecal sac, sacral (MRI). Positron emission tomography (PET) is useful to Scientifi c American Surgery © 2014 Decker Intellectual Properties Inc DOI 10.2310/7800.2047 11/14 gastro reoperative pelvic surgery — 2 assist in distinguishing tumor recurrence from postradiation Table 2 Absolute and Relative Contraindications scar and to rule out distant metastatic disease. In the setting of recurrent pelvic tumor and previous treatment, MRI may for Exenterative Surgery better delineate the tumor in relation to the musculoskeletal Absolute contraindications anatomy. Unresectable distant metastasis Bilateral pelvis sidewall disease Evaluation of all outside records, including operative Poor performance status notes, chemotherapy regimens, and total radiation doses, provides invaluable information for both perioperative and Relative contraindications Extensive unilateral sidewall disease intraoperative management. In reoperative pelvic surgery, Inability to achieve R0 resection it is imperative that the technical details of any previous Sacral involvement above S3 operations be thoroughly reviewed as this information helps Encasement of iliac vessels formulate a strategy for resection and reconstruction while decreasing ambiguity at the time of reoperation. Radiation history is important in the evaluation of patients with recurrent rectal cancer because treatment with after reoperative surgery for recurrent rectal carcinomas. In chemoradiation is a signifi cant part of the multidisciplinary a Mayo Clinic series, the reported curative negative resec- management of recurrent disease. The type and extent of tion margin was 45% in 394 patients who underwent surgi- radiation are crucial in decision making as maximum allow- cal exploration for recurrent rectal carcinoma. These patients able dosages need to be calculated. In a multicenter study, had a statistically signifi cant improved 5-year survival of Valentini and colleagues reported an 8.5% complete patho- 37% compared with 16% in patients in whom negative logic response and a 29% downstaging following reirradia- margins were not achieved.20 MD Anderson Cancer Center tion.14 Das and colleagues similarly reported an improved similarly achieved negative margins in 76% of 85 patients 3-year survival of up to 66% in patients with recurrent rectal undergoing resection for recurrent rectal cancer.21 The 5-year cancer treated with preoperative chemoradiation.15 If addi- disease-free survival was 46%, and multivariate analysis tional external-beam radiation is administered, plans for showed that an R1 resection was associated with a negative surgical intervention are expedited, thus allowing for the prediction of survival. Surgical margins therefore remain synergistic benefi ts of both external and intraoperative the most signifi cant factor for long-term survival when radiation. operating for recurrent rectal carcinoma.2,20,21 Without any treatment, mean survival is approximately In the published literature, multiple classifi cation schemas 8 months in patients with locally recurrent rectal cancer. exist that categorize the extent and boundaries of pelvic Chemoradiation may alleviate symptoms, but 5-year sur- exenterations. For the purposes of this topic review, we vival remains poor at less than 5%.16–19 The prognostic classify exenteration into (1) anterior, (2) posterior, or (3) factors associated with poor outcomes after resection for combined anteroposterior resections using the rectum or recurrent rectal cancer are listed here [see Table 1], but sur- neorectum (if a previous low anterior resection or coloanal gery remains the best chance for cure in patients with recur- anastomosis was performed) as a focal point of the malig- rent rectal cancer. Although absolute and
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