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 enhances 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 indications, 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

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 relative contrain- nant process. An anterior exenteration includes resection of dications for exenterative surgery are reported [see Table 2], the rectum or neorectum and any involved viscera in front management algorithms continue to evolve, with a para- of the rectum, such as the reproductive organs, the bladder, digm shift from palliation to cure in patients with recurrent, or both [see Figure 1]. A posterior exenteration includes the locally advanced, and even metastatic disease. rectum or neorectum and any tissue posterior and lateral, Resection with negative microscopic margins (R0 resec- such as musculoskeletal tissue and neurovascular structures tion) and appropriate regional lymphadenectomy is the goal [see Figure 2]. Based on this defi nition, we therefore consider of reoperative surgery for pelvic recurrence. R1 and R2 sacrectomy a potential component of a posterior exentera- resection rates of up to 58%, however, have been reported tion. An anteroposterior exenteration involves a combination of anterior and posterolateral structures, including the bony sacropelvic components [see Figure 3].

Table 1 Prognostic Factors Negatively Operative Technique Impacting Outcomes Following Surgery for Anterior exenteration We use ureteral stents for all Recurrent Rectal Cancer reoperative cases and when extensive pelvic radiation has been given. The Lloyd-Davies position is used to allow Inability to achieve R0 resection35 Type of primary surgery (worse for APR vs LAR)20,85 access to the perineum. Care is taken to protect the extremi- Rising CEA86 ties from nerve injury with adequate padding of both the Advanced stage of primary tumor, i.e., T4, nodal disease42 tucked arms and lateral lower extremities in the stirrups. Recurrence-free interval < 12 months42 A midline exploratory laparotomy is used to conﬁ rm the 48 High sacral involvement (above S2) absence of extrapelvic disease and determine local resect- Multiple points of tumor fixation within pelvis20 Major blood transfusion, neural invasion35 ability. Any suspicious extrapelvic lesions are biopsied and Cortical and marrow sacral involvement35 sent for frozen-section analysis. Biopsy-proven extrapelvic Presence of pain preoperatively—sciatica42 disease may preclude pelvic resection for cure.

APR = abdominoperineal resection; CEA = carcinoembryonic antigen; LAR = low The left colon is mobilized and transected at the appropri- anterior resection. ate level for subsequent end colostomy. The entrance to the

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Vag. cuff

Factor © MAYO 2011 lleal conduit

Figure 1 Anterior exenteration: en bloc resection of rectum or neorectum and genitourinary and/or gynecologic structures and postresection defect requiring reconstruction. Reproduced with permission from the Mayo Clinic. pelvis must be completely cleared of extraneous tissue for The anterior and lateral lines of resection (decided on optimal pelvic exposure. Any adherent tissue (often small during preoperative review of imaging) are delineated, and bowel) to the pelvic tumor should be resected en bloc. Deep the involved structures and organs are mobilized widely for pelvic dissection to the presacral space then proceeds poste- subsequent en bloc resection. The presacral space is further riorly along the distal aorta and continues caudally over the developed, and the dissection is carried distally along the iliac vessels and ureters [see Figure 4]. Vesseloops are used to anterior sacrum while staying anterior to the Waldeyer retract the ureters and vascular structures. In the reoperative fascia. The dissection is then carried laterally along the pelvis, dense fi brosis and distorted anatomy require careful, pelvic sidewall on each side with careful protection of the meticulous dissection to avoid inadvertent injuries and lumbosacral plexus and internal iliac vessels. major bleeding complications. The most at-risk region for In women, anterior involvement may require resection signifi cant bleeding occurs during mobilization of the left of the posterior wall of vagina, which can be approached common iliac vein, and this dissection should proceed with transvaginally and transabdominally. In contrast, anterior caution. Posterior lumbar branches, if not identifi ed, can fi xation in men often requires cystoprostatectomy due to also lead to signifi cant blood loss if avulsed. invasion of the trigone and prostate. Partial cystectomy may

S1 S2

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Figure 2 Posterior exenteration: en bloc resection of rectum or neorectum and sacrum and a postresection defect requiring reconstruction. Reproduced with permission from the Mayo Clinic.

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S1 S2

Vag. cuff

Factor © MAYO 2011 lleal conduit

Figure 3 Anteroposterior exenteration: en bloc resection of both anterior and posterior structures and postresection defect requiring reconstruction. Reproduced with permission from the Mayo Clinic.

be suffi cient in rare cases. When the bladder is resected, the of the pelvis. The distal margins are sent and confi rmed to ureters are mobilized as close to the bladder as possible to be negative by pathology. With the ureters both isolated provide adequate length for urinary conduit reconstruction. and out of the pelvis, we then take down the pedicles to the To mobilize the bladder, the space of Retzius is entered to bladder and prostate and continue the anterior dissection by fully mobilize the anterior portion of the bladder. The blood opening the endopelvic fascia bilaterally. The dorsal venous supply to the bladder is taken by serially ligating the arteries complex is subsequently ligated. We then reach the urethra, and veins along the pelvic sidewall, coursing back and forth and after delivering the catheter into the wound, we transect from the internal iliac vessels. The wings of peritoneum to the urethra. the bladder are then taken down until the bilateral vasa are Construction of an end colostomy and urinary conduit identifi ed and clipped. We then isolate and trace both completes the procedure. In women who require posterior ureters to the bladder before clipping and bringing them out vaginal wall removal, reconstruction may be necessary [see Reconstruction, below]. For anterior resection, soft tissue reconstruction to fi ll a void in the pelvis is used selectively.

Median sacral Posterior exenteration (sacrectomy) First stage: anterior artery approach After placement of ureteral stents, a midline Lateral sacral artery exploratory laparotomy is used to confi rm the absence of extrapelvic disease and determine local resectability. The left colon is mobilized and transected at the appropriate level to Internal iliac be used later for colostomy, exposing the presacral space. artery Deep pelvic dissection then proceeds posteriorly along the lower aorta and continues distally over the iliac vessels and Superior gluteal ureters. The anterior and lateral lines of resection are delin- artery eated, and the involved structures and organs are mobilized widely for subsequent en bloc resection. Frozen-section biopsies are taken as needed to establish that margins are negative at the level of the proximal sacral transection. Vascular exposure often requires mobilization of the lower aorta and vena cava, in addition to the iliac arteries and veins. Circumferential mobilization of the common and D.F. external iliac arteries may be needed to facilitate exposure © MAYO of the veins. The internal iliac artery branches are ligated 2010 and divided distal to the takeoff of the posterior division of the superior gluteal artery branch to preserve blood fl ow to Figure 4 Anatomy of presacral space after rectal mobilization. The the gluteal fl aps [see Figure 5]. Multiple internal iliac vein Waldeyer fascia is not shown to illustrate the neurovascular structures. branches are ligated after control of the main trunk(s) of the Reproduced with permission from the Mayo Clinic. internal iliac vein. The branches are divided before ligation

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Lateral sacral artery

Internal Median iliac sacral artery artery

Internal iliac vein

Superior gluteal artery

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Figure 5 (a) Vascular exposure and dissection. Internal iliac artery branches are ligated, preserving gluteal blood ﬂ ow. (b) Ligation of the lateral sacral branches of the internal iliac vein, all the way down to the distal sacrum. (c) High ligation of the internal iliac vein. Reproduced with permission from the Mayo Clinic.

of the main trunk to avoid venous distention of the branche s, which can lead to troublesome bleeding. Lateral and middle sacral vein branches, which drain into the posterior aspect of the left common iliac vein and caval confl uence, are ligated and divided. Suture ligature is preferable for short, broad-based internal iliac vein branches. The vascular dissection is carried along both sides of the sacrum onto the pelvic fl oor. During this anterior stage of the operation, a colostomy and ileal or colonic urinary conduit are constructed as needed. A rectus abdominis myocutaneous fl ap is then prepared for subsequent perineal reconstruction. Using intraoperative fl uoroscopy, the sacral level of transection is determined and anterior osteotomies are performed. A screw is placed in the osteotomy site to facilitate alignment for fl uoroscopy [see Figure 6]. Prior to closing and turning the patient prone, a thick Silastic mesh is placed anterior to the sacrum and posterior to the vessels and soft tissue structures, to protect against injury when blind osteotomies are D.F. performed during the second stage (prone) of the procedure © MAYO [see Figure 7]. The abdomen is then closed, stomas are 2010 matured (fecal, urinary), and the patient is turned and placed in the prone position. Second stage: posterior approach The second stage of the procedure is carried out with the patient in the prone Figure 6 Unicortical transverse osteotomy, marked with a “screw” position. A posterior midline incision is made along the (arrow) to facilitate alignment with fl uoroscopy during posterior midportion of the sacrum, and the gluteus maximus muscles dissection. Reproduced with permission from the Mayo Clinic.

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steps outlined above apply. The sequence of this extensive procedure depends on multiple factors, but the anterior exenteration is typically completed ﬁ rst, followed by the posterior exenteration. When high sacral or extended sacropelvic resection is done, the operation is best executed in separate stages on distinct operating days. Our typical approach would be to start with the anterior dissection on day 1, complete the posterior approach with removal of tumor on day 3, and conclude with the spinopelvic reconstruction on day 5.

D.F. Reconstruction Reconstruction after exenteration typi- © MAYO 2010 cally involves the perineum and the gastrointestinal and/or genitourinary tracts. In women, vaginal reconstruction may be necessary when extended resections include the posterior vagina. Perineal wound complications after extended pelvic Figure 7 Placement of Silastic mesh to protect anterior vasculature resections represent a considerable source of morbidity for when posterior osteotomies are performed blindly. Reproduced with patients. Nonhealing perineal wounds after extended pelvic permission from the Mayo Clinic. resections are reported to occur in 7 to 66% of patients,22 and the addition of radiotherapy has been associated with major wound complications in 41% of patients after perineal are dissected away from the sacral attachments. The sacro- resection for rectal cancer.23 Exenterative surgery that spinous and sacrotuberous ligaments are divided to access includes sacropelvic resections represent some of the most the pelvic cavity posteriorly [see Figure 8]. The piriformis challenging wounds to fi ll and cover. muscle is divided while protecting the sciatic and pudendal Omental fl ap The main advantage of the omental pedi- nerves. Laminectomy, dural sac ligation, and sacral resec- cled fl ap after exenteration is its ability to fi ll the pelvic dead tion are then carried out [see Figure 9]. Final osteotomies are space.24 Filling this space with vascularized tissue may performed based on imaging studies that ensure tumor-free decrease the risk of pelvic sepsis and prevent small bowel margins. After resection, the specimen is examined by the from adhering to the raw surfaces, which may cause small pathologist and the surgical team to assess for gross mar- bowel obstructions. The omentum is mobilized and a right gins. The posterior wound is then reconstructed with a ped- or left omental pedicle is constructed based on the greatest icled myocutaneous rectus fl ap [see Figure 10]. Depending on length and bulk. Spreading and lengthening techniques can the extent of resection and estimated operative time for each be performed by detaching the gastroepiploic arcade from stage, the entire operation may be performed in 1 day or, the stomach on the origin side of the right or left gastroepi- increasingly in our experience, on separate operating days. ploic pedicle. The gastroepiploic artery and vein on the Combined anteroposterior exenteration When a combined opposite side are divided and ligated. The right gastroepi- anteroposterior component exenteration is performed, the ploic vessels are preferred because they are larger and have more epiploic branches than the left. A window can be fashioned through the transverse mesocolon to allow a more direct route to the pelvis. Vertical rectus abdominis myocutaneous (VRAM) fl ap The VRAM fl ap provides a well-vascularized, bulky tissue Internal paddle that can be transposed to the pelvis to fi ll dead space pudendal nerve & and reconstruct the perineum. This fl ap has become our vessels primary choice for soft tissue reconstruction following Sciatic nerve exenteration. Chessin and colleagues studied 59 patients who underwent a VRAM or primary closure following abdominoperineal resection for anorectal cancer treated 22 Piriformis with preoperative radiation. The patients who were recon- muscle structed with a VRAM fl ap had signifi cantly lower rates of perineal wound complications (15.8% versus 44.1%). More- over, patients had no abdominal wall hernias or infections associated with the fl ap harvest site. Radice and colleagues Sacrospinous ligament compared primary closure with pedicled omentum and D.F. VRAM fl ap and found that the VRAM fl ap signifi cantly © MAYO reduced wound infections and length of stay compared with 2010 25 Sacrotuberous ligament the other types of closure. The VRAM fl ap is mobilized by raising a supraumbilical Figure 8 Division of the sacrospinous and sacrotuberous ligaments skin paddle with underlying fat and rectus muscle. The and the piriformis muscle. Reproduced with permission from the anterior rectus sheath is taken with the fl ap, and the poste- Mayo Clinic. rior rectus sheath is left for abdominal wall closure. The

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Figure 9 Posterior sacral osteotomy (a), laminectomy (b), and dural sac ligation (c). Dashed lines outline margins of bony resection. Reproduced with permission from the Mayo Clinic. perforating vessels through the anterior rectus sheath are pelvis with the skin of the pedicle facing the perineum. It is carefully dissected to minimize the fascial resection. The important to avoid signifi cant twisting and tension when blood supply to the VRAM is the deep inferior epigastric securing the fl ap to the perineum [see Figure 11]. artery and vein, which are mobilized as a pedicle. Transab- Gluteus maximus myocutaneous fl ap The gluteus maximus dominal passage of the VRAM fl ap, sized to reconstruct myocutaneous fl ap is based on the inferior gluteal artery the perineal wound, is done by rotating the pedicle into the pedicle. The gluteus maximus fl ap can be constructed as a

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Figure 10 Transperineal delivery of pedicled myocutaneous rectus fl ap for perineal reconstruction. Inset shows fl ap reconstruction site Figure 11 Harvest of a vertical rectus abdominis myocutaneous fl ap after healing takes place. Reproduced with permission from the Mayo (VRAM) on a long pedicle to reach the pelvis for reconstruction. Clinic. Reproduced with permission from the Mayo Clinic.

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11/14 gastro reoperative pelvic surgery — 8 local advancement or a V-Y advancement myocutaneous fl ap. The technique involves elevation and advancement of the superior half of the muscle and overlying skin. Two myocutaneous gluteus maximus fl aps are prepared, leaving the lower 50% of the underlying muscle intact. Both fl aps are dissected free and raised. After deepithelialization of its media part, one of the two fl aps is then advanced into the pelvic defect. After partial sacrectomy, even large cavities can be fi lled completely. The second fl ap is advanced toward the midline and sutured in layers to the fi rst fl ap, resulting in a solid midline reconstruction. Both donor defects are closed using a V-Y technique. For very large perineal defects following sacrectomy, the combination of an inferiorly based VRAM and bilateral fasciocutaneous V-Y advancement fl aps may be necessary for adequate closure. Gracilis fl ap When a VRAM fl ap is not available, the Figure 13 Total thigh fi llet fl ap after mobilization off the femur. gracilis muscle may be used to partially fi ll a pelvic defect. Reproduced with permission from the Mayo Clinic. The gracilis fl ap has an inconsistent blood supply and limited arc of rotation; additionally, the lack of bulk may be insuffi cient for obliteration of a large pelvic dead space. The gracilis fl ap is harvested by making a longitudinal incision are elevated based on the vascular muscle distribution sup- over the muscle of the medial thigh. Its blood supply is plied by the superfi cial femoral artery. This axial-pattern centered on the proximal pedicle of the profunda femoris myocutaneous fl ap is based on branches of the femoral ves- artery, and the distal pedicle originating from the saphenous sels, including lateral and medial circumfl ex arteries, which artery is ligated. The muscle and skin paddle, if constructed, arise from branches of the profunda femoris artery. The long are mobilized and rotated into the perineal wound [see myocutaneous fl ap includes the bulk of the quadriceps fem- Figure 12]. oris and can provide signifi cant coverage of pelvic defects. Total thigh fi llet fl ap Thigh fi llet fl aps can be constructed The total fi llet hemipelvectomy fl ap uses the majority of following hemipelvectomy using soft tissue from the ampu- the thigh musculature. The blood supply to this large fl ap tated limb [see Figure 13]. The posterior hemipelvectomy fl ap is based on preservation of the superfi cial and profunda is designed as a myocutaneous fl ap based on the superior femoris vessels, allowing for a substantial amount of muscle and inferior gluteal vessels. By preserving the gluteal ves- preservation. The circumfl ex vessels of the profunda femoris sels, large posterior fl aps incorporating the gluteal muscle artery perforate the adductor magnus muscle to the poste- can be rotated for coverage of the pelvic defect after the rior and lateral compartments of the thigh and play a role in bony pelvis has been removed. If oncologically appropriate, supporting a total thigh fi llet fl ap. The total thigh fi llet fl ap preservation of the internal iliac vessels will increase poste- provides the largest amount of vascularized tissue when rior fl ap blood supply and decrease fl ap necrosis. Limited massive defects require soft tissue reconstruction [see resection of the bony pelvis allows for preservation of the Figure 14]. sacral perforators. Urinary reconstruction When bladder resection is Long anterior hemipelvectomy fl aps are myocutaneous required, the construction of a functional urinary outlet fl aps of the anterior compartment musculature. These fl aps must be established. Options include continent procedures (Kock pouch, Indiana pouch) or incontinent urostomies. Because exenteration for malignancies often precludes continent procedures, options for urinary reconstruction include ureterocolostomy or, more commonly, an ileal or colon conduit. If the superior rectal artery is ligated but the inferior mesenteric artery and its sigmoidal branches are preserved to ensure blood supply, then the sigmoid colon becomes an excellent urinary conduit as it can be placed in either upper abdominal quadrant as necessary. This approach additionally avoids a small bowel anastomosis as required with construction of an ileal conduit. If the inferior mesenteric artery (IMA) has been taken, however, we do construct an ileal conduit. Vaginal reconstruction In women who undergo extended anterior exenteration, a portion of the posterior wall of the vagina may need to be removed to achieve negative margins. A variety of techniques have been described for neovaginal reconstruction after anterior pelvic exenteration. Figure 12 Gracilis fl ap rotating into the perineal wound. Repro- We prefer the rectus abdominis myocutaneous (RAM) fl ap duced with permission from the Mayo Clinic. for neovaginal reconstruction because of its consistent blood

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massive hemorrhage from presacral veins and the major iliac vessels. In the event of massive presacral vein bleeding, strategies used to stop the hemorrhage include packing, muscle patch, argon beam coagulation, thumbtacks, and bone wax.27–29 We have observed that packing, occasionally with the use of hemostatic agents such as Surgicel, controls presacral bleeding in the majority of cases. If bleeding continues, our next technique is to harvest a piece of rectus abdominis muscle and then to cauterize the muscle over the bleeding site; the resultant coagulum is remarkably hemostatic. Thumbtacks are reserved for situations when the origin of hemorrhage can be clearly visualized and stopped with point pressure; if inaccurately placed, tacks can make the bleeding much worse. Iliac artery and vein bleeding can be deadly and must be dealt with in an expeditious but controlled manner. Direct pressure can temporize bleeding while exposure is obtained. Proximal and distal control should be achieved. Vascular sutures and equipment must be readily available from the very beginning of the case to use for suture repair and/or ligation. For extended sacral resections, consideration should be given to controlling and ligating the internal iliac artery early in the procedure.30 In the previously irradiated pelvis, we think it is also important to collaborate with experienced vascular surgeons given the technical diffi culty working with fi brosed vessels. During dissection in the reoperative pelvis, it is essential to immediately identify normal anatomic structures. The genitourinary, vascular, and osseous structures such as the ureters, distal aorta, and sacral promontory, respectively, can provide landmarks to help guide the descent into the narrow confi nes of the pelvis. The typical anterior and posterior planes are often obliterated due to scar or fi brosis, Figure 14 Healed total thigh fi llet fl ap used to cover the defect. and orientation to critical structures is paramount as sharp Reproduced with permission from the Mayo Clinic. dissection with a knife, heavy scissors, or osteal elevators may be the only means to make any forward progress. Guidance from the perineum, such as application of vaginal retractors, distention of the bladder, or a rigid proctoscope supply and its ability to obliterate pelvic dead space [see through the neorectum, can also assist with understanding Figure 15]. Soper and colleagues reviewed 32 patients who the spatial relationships in the deep pelvis. had neovaginal reconstruction with a RAM fl ap after exenterative surgery (85% received radiation) and found a fl ap Complications complication rate of 32%, with only one patient developing The mortality in selected series after exenterative pelvic vaginal stenosis.26 Neovaginal reconstruction with a RAM surgery ranges from 0 to 9% overall.20,31–36 Causes of death fl ap has decreased perineal complications and maintains include uncontrolled hemorrhage at the time of surgery, renal preservation of the psychosexual self-image of the patient. failure, pelvic sepsis, and cardiovascular compromise.37,38 Sacropelvic reconstruction When tumors extend posteri- Between 24 and 68% of patients developed complications, orly into the sacrum or deep into the lateral sidewall and most of which were related to failure of perineal wound through the sciatic notch, sacropelvic resection, including healing.12,31,34,37–39 The incidence of complications increases hemipelvectomy, will be required to achieve negative with the extent of resection.37,39 Patients undergoing sacrec- margins. The type of hemipelvectomy performed depends tomy, hemipelvectomy, or IOERT have even higher rates of on the extent of the tumor. The four types of sacropelvic complications, most of which are related to the posterior resections include total sacrectomy (type 1), hemisacrectomy wound.20 The most signifi cant reported side effects of IOERT (type 2), hemisacrectomy + external hemipelvectomy (type 3), include dose-dependent peripheral neuropathy (16 to 34%) and total sacrectomy + hemipelvectomy (type 4), with types and ureteral stenosis (6%).40 1 and 3 being most commonly performed [see Figure 16]. Well-described postoperative complications include pelvic abscesses, small bowel obstructions, fi stula formation, Troubleshooting perineal wound problems, and ureteral obstruction. In a Pelvic exenterations are technically diffi cult, and surgeons series by Henry and colleagues, 53% developed complica- must be equipped to deal with inevitable problems. In tions after resection for pelvic recurrences.41 Nearly a third reoperative pelvic surgery, signifi cant danger exists with of the complications in this series were related to infection.

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a b

Figure 15 (a) In-setting of a vertical rectus abdominis myocutaneous ﬂ ap (VRAM) to close the large perineal defect after exenteration that includes resection of the posterior wall of the vagina. (b) Healed ﬂ ap with closure of the posterior vagina. Reproduced with permission from the Mayo Clinic.

Among these patients, there were 9.2% pelvic abscesses, urinary complications. Double-J stent placement, if possible, 5.7% abdominal wound infections, and 3.4% perineal wound is the best way to address hydronephrosis caused by ure- infections. The majority of superfi cial wound infections can teral obstruction versus nephroureteral stenting if an endo- be successfully managed with local drainage and wound scopic stent is unable to be placed. Finally, percutaneous care. Percutaneous drainage of pelvic abscesses is commonl y nephrostomy tubes can be used if a complete urinary diver- performed with catheters placed either anteriorly or posteri- sion is needed to heal a leak. orly. Abscesses low in the pelvis, which are not amenable to CT-guided percutaneous drainage, may be addressed Outcome Evaluation through the perineum or transanally in the operating room. Oncologic outcomes after exenteration are diffi cult to Chessin and colleagues noted a decrease in the perineal compare because of the lack of consistent classifi cation of wound complication rate, from 44 to 16%, with the use of these procedures. Moreover, published series often include a RAM fl ap to close the perineum.22 The increased use of a heterogeneous patient population. When recurrent disease vascularized tissue fl aps will continue to decrease infection- is confi ned to the axial and anterior locations (male and fe- related complications. male genitourinary organs, including the bladder), an R0 Urologic complications are also common with ureteral resection is frequently possible and therefore leads to better obstruction and leak occurring with construction of urinary survival. Moore and colleagues found that 72% of patients conduits.38 Permanent bladder dysfunction requiring inter- with a recurrent axial or anterior recurrence were able to mittent catheterization or cystectomy may also occur after achieve an R0 resection.42 This fi nding is in contrast to lat- posterior exenterations. Renal insuffi ciency resulting from eral and posterior recurrences, which have lower rates of R0 ureteral stenosis secondary to ureterolysis and pelvic irra- resection: 50 and 36%, respectively.42 Stocchi and colleagues diation has been described.3 A CT urogram with delayed noted a 3-year survival of 45% with en bloc resection involv- contrast imaging of the urinary system can diagnose most ing the urinary tract.43 Anterior recurrences are less likely to

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Oncologic outcomes for lower sacral resection have resulted in 5-year survival rates as high as 37% in some Sacral patients.20 These results from lower sacral involvement have Resection 12prompted questions on whether similar outcomes could be expected in patients with high sacral involvement. Our initial experience with high sacrectomy, defi ned as above the third sacral body, showed promising results with an R0 resection in all nine patients: 30-day mortality of zero and median survival of 31 months.39 Wanebo and colleagues reported two series of patients with recurrent rectal cancer who underwent high sacral resection, achieving 5-year survival rates of 31 and 33%, respectively.1,48 Our group recently reported survival outcomes in 30 patients with locally recur- External rent rectal cancer undergoing extended sacral resection and Hemipelvectomy demonstrated a 46% 5-year survival and 43% 5-year disease- 46 34free survival with R0 resection, achieved in 93% of patients. Moreover, there were no operative deaths and an acceptable morbidity. Surgery provided excellent local tumor control, with only one patient having re-recurrence in the pelvis. Improved survival in patients with recurrent rectal cancer © MAYO is possible when IOERT is added to resection compared 2011 with patients who do not receive IOERT.49 When IOERT is used as part of a multimodality approach, a 15% increase in survival has been demonstrated.3 Although there are no randomized trials comparing surgery alone and surgery with IOERT, there seems to be a benefi t not only for patients Figure 16 Sacropelvic resection classifi cation (types 1 to 4). Repro- with negative margins but also in those with microscopic duced with permission from the Mayo Clinic. and grossly positive margins. Haddock and colleagues recently published the Mayo Clinic’s experience with multimodal therapy for locally advanced recurrent colorectal become fi xed to the bony pelvis and are more amenable to cancer that included the use of IOERT.50 In our practice, the complete excision and, therefore, improved survival. dose of IOERT given at the time of surgery is dependent on The ability to achieve an R0 resection with lateral and pos- the resection margin [see Table 4]. Survival estimates at terior recurrences is more diffi cult because of the potential 5 years were 46%, 27%, and 16% for R0, R1, and R2 resection, for increased points of fi xation.20,42 Recent series have been respectively. For carefully selected patients, exenterative able to obtain R0 resections in 51 to 100% of patients, which resection of pelvic recurrence can provide a 5-year survival included lateral and posterior recurrences.35,37,39,44–46 The 5- of up to 39%, which is similar to that seen after resection of year survival rate for this heterogeneous patient population solitary metastasis to the lung, liver, and brain.37 has ranged from 20 to 39%. An R0 resection was the For re-recurrent rectal cancer, our experience suggests most important variable in predicting 5-year survival [see that an R0 re-resection provides outcomes similar to those Table 3].20,37 Similar results have been reported by our group of surgery for fi rst-time recurrent rectal cancer.51 From 47 for recurrent rectal cancers involving the aortoiliac axis.47 patients with re-recurrent rectal cancer, we achieved R0, R1, Major vascular reconstructions involving the aorta and and R2 resection margins in 60%, 32%, and 8% of patients, iliac arteries and veins were performed to achieve an R0 respectively. Approximately 81% of patients required non- resection in over 50% of these patients, with reported 4-year bowel organ resection, including seven sacral resections. survival and disease-free survival rates of 55% and 45%, Thirty-day mortality was nil, and 5-year overall survival respectively. and disease-free survival were 33% and 27%, respectively.

Table 3 Survival Following Exenteration for Recurrent Rectal Cancer Study, Year Number of Patients Type of Exenteration R0 (%) Survival Saito et al, 200344 85 Posterior, combined 51 5 yr (39%) Moriyan et al, 200487 57 Posterior, combined 84 3 yr (54%) 5 yr (36%) Melton et al, 200688 29 Anterior, posterior, combined 62 2 yr (63%) 5 yr (20%) Schurr et al, 200889 72; 45 resected Anterior, posterior, combined 82 Overall median: 54.9 mo Colibaseanu et al, 201446 30 High posterior 93 5 yr (46%)

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Table 4 Intraoperative Radiotherapy Doses and guides drainage if indicated. Pelvic MRI can be particularly useful to elucidate fi stula tracts and the extent of sepsis. Related to Resection Margin A pouchogram can assess the architecture of the pouch and Margin IOERT Dose (Gy) demonstrate an anastomotic leak. Pouchoscopy provides R0 (< 5 mm) 750–1,250 information about the health of the lining of the pouch and can determine whether Crohn disease is present. An exami- R1 1,000–1,500 nation under anesthesia may be necessary to complete the Localized R2 1,500–2,000 assessment of the pouch, ensure control of sepsis, and deter- IOERT = intraoperative electron beam radiotherapy. mine the strategy for pouch salvage. Confi rming a diagnosis of Crohn disease is important because biologic therapy, such as infl iximab, may convert a patient with Crohn disease to a surgical candidate or suppress the disease enough to allow Reoperative pelvic surgery for patients with recurrent a pouch revision to be more successful.55,56 or even re-recurrent rectal cancers can therefore provide Although some minor reconstructive options may be signifi cant benefi t to patients, and situations thought to be performed transanally, most major pouch reconstruction nonoperable should be carefully reviewed for the possibility options require an abdominal approach with pelvic explora- of an R0 resection. tion. Reports of reoperative pouch reconstruction success complications following ipaa vary from 48 to 93%, with success in large part depending Reoperative pelvic surgery in patients with infl ammatory on the patient’s underlying disease (Crohn disease versus bowel disease typically occurs in patients who have compli- UC) and whether the complication is a mechanical versus an 52 cations following IPAA for ulcerative colitis (UC). Indica- infection-related cause. Patients with a history of pelvic tions for surgery [see Table 5] can be divided into mechanical sepsis or those with a delayed diagnosis of Crohn disease or infection-related problems.52 Mechanical complications often experience minimal success from reoperative pouch include anastomotic strictures refractory to anal dilation, long surgery. efferent limbs, pouch septa, or a twisted pouch. Infection- Although perineal approaches such as ileal pouch related complications from anastomotic dehiscence and advancements are well described, an abdominal approach is pelvic sepsis may occur in approximately 25% of patients typically required to safely free the pouch from the sacrum following IPAA, leading to fi brosis, chronic fi stula, and and pelvic fl oor, especially in the setting of previous pelvic 57,58 abscesses.53,54 The goals of reoperative surgery in the setting sepsis. When reoperating in the setting of previous pelvic of a failing pouch will vary depending on several factors sepsis, excision of all infected tissue and control of all exist- including underlying pathology (i.e., Crohn disease or ing sinuses and fi stulas is imperative to prevent recurrence. malignancy) and the presence of sepsis. The type of reop- Operative Technique erative pouch surgery therefore varies from partial reconstruction, defi ned as pouch repair without disconnecting the The patient is typically placed in the Lloyd-Davies anastomosis, to complete reconstruction, defi ned as pouch position with all extremities safely padded to avoid nerve disconnection with redo/repair of the pouch and reanasto- injuries. Bilateral ureteral stents may be placed to ease the mosis, to permanent pouch excision with end ileostomy. identifi cation of the ureters during surgery. A lower midline incision is made, and the abdomen is explored. The incision Operative Planning should be limited if possible to the level of the umbilicus as When patient symptoms suggest complications in the it allows the small bowel to be packed cephalad under the pouch following surgery for UC, a thorough evaluation intact upper abdominal wall. The small bowel is often found should be undertaken to clarify the source of the problem. to be adhesed to pelvic structures and to the retroperitoneu m, Imaging such as CT and MRI evaluates for pelvic infection which requires tedious and careful lysis. The ureters and gonadal vessels should be identifi ed and looped with Silas- tic vessel loops. The course of the ureters is typically normal until the level of the pelvic brim and then becomes more Table 5 Indication for Reoperative Pouch medial as it enters a previously operated pelvis; therefore, Surgery identifi cation of the ureters in the lower abdomen above the pelvic brim is a good strategy to begin identifying normal Mechanical Stricture: neoterminal ileum, pouch, anastomotic anatomy. Long efferent limb with S pouch The ileal pouch is found deep within the pelvis, often Pouch septum densely adherent to the anterior, lateral, and posterior walls Twisted pouch of the pelvis. Additional proximal small bowel often fi lls Redundant blind limb the pelvis, and a signifi cant amount of time is inevitably Infection related spent lysing adhesions and obtaining orientation to achieve Fistula/chronic sinus tract: pouch-vaginal, pouch-sacral, proper exposure. Embryonic fusion planes are nonexistent; pouch-perirectal, pouch–abdominal wall, pouch–small bowel therefore, dissection of the pouch is bloody and fraught with Pelvic abscess risk to injuring nearby structures such as the iliac and Anastomotic dehiscence gonadal vessels, ureters, pelvic nerves, and presacral veins. Retained rectal mucosa It is often helpful to identify anatomic landmarks, including

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11/14 gastro reoperative pelvic surgery — 13 the normal proximal ureters, distal aorta, and common iliac symphysis to estimate adequate length. The options avail- vessels, before proceeding deeper into the pelvis. Iliac veins able to provide suffi cient reach for a new pouch are some- such as the left common iliac are at particular risk for injury what limited due to the restricted vascular supply, and if due to their fragile thin wall, relative immobility, and trajec- there is suffi cient doubt regarding a tension-free reach, then tory across the midline. The dissection plane should remain an end ileostomy should be constructed. anterior to the Waldeyer fascia to avoid the presacral veins. The pouch mesentery is tethered by its main vascular sup- Complications ply, usually from the superior mesenteric artery (SMA), and Postoperative complications after reoperative pouch sur- follows the curvature of the sacrum from the promontory. gery include loss of the ileal pouch if not initially intended, The surgeon should be able to raise this mesentery off the pouch dysfunction, infection, hemorrhage, and/or injury to posterior wall to completely encircle the pouch mesentery. surrounding structures, such as the ureters and pelvic A clear path to the pouch can then be appreciated. Lateral nerves. The preponderance of complications tends to fall in and anterior dissection of the pouch continues to the pelvic the same category as the indication for the reoperation. In an fl oor, with care to preserve the ureters as they approach the early Mayo Clinic study, postoperative infectious complica- bladder neck and genitourinary structures such as the pros- tions such as recurrent fi stulas or abscesses were observed tate or vagina. Once the pouch is suffi ciently exposed, either in up to 59% of patients after reoperative surgery for infection- partial reconstruction is performed, or, in cases of complete related pouch problems such as chronic fi stulas.59 For reconstruction or pouch excision, the pouch is transected mechanical problems such as anastomotic strictures, steno- sharply with a knife or scissors at the pelvic fl oor and sis recurred in 52% of patients after the initial reoperation. delivered out of the abdominal fi eld. The need for more than one operation was observed in up For complete pouch reconstruction, the old pouch is to 73% of patients. Approximately 69% of patients who excised and a new J pouch, approximately 12 to 15 cm in underwent more than one reoperative procedure ultimately length, is constructed using sequential fi rings of a stapling lost their pouch compared with a 14% chance of pouch loss device. Presuming that tension-free reach is feasible, a hand- in those patients who only underwent one reoperative sur- sewn IPAA is then constructed using Lone Star retractors gery. Careful initial pouch construction and a single, defi ni- for perineal exposure. Circumferential, interrupted, full- tive reoperative surgery for pouch-related complications if thickness bites of absorbable sutures secure the apex of the they occur are therefore critical to long-term pouch success. new ileal pouch to the distal anal canal with a posterior orientation of the pouch mesentery. Outcome Evaluation For pouch excisions, we perform a mucosectomy of the Many technical approaches to pouch reoperation, with remaining anal canal from the dentate line to remove any varying success, have been described.60 Shawki and col- residual mucosa and close the proximal end of the anal canal leagues reported on 76 patients who underwent reoperation using several layers of interrupted absorbable sutures placed for pouch complications.61 The most common indication for transanally. The pouch is transected at a healthy-appearing reoperation was sepsis and sepsis-related complications. Of point on the prepouch ileum, and a tension-free end 23 patients who required reoperative pouch surgery, seven ileostomy is constructed at a premarked stoma site. patients underwent complete pouch reconstruction and 16 patients underwent pouch revision. The pouch salvage Troubleshooting rate in these patients was 69%. The most common reason for The loss of normal anatomic planes in cases of pelvic pouch failure was a diagnosis of Crohn disease and pelvic sepsis, with chronic fi stulas and abscesses, makes reopera- sepsis. MacLean and colleagues described 63 combined tive pouch surgery technically challenging, and dissection abdominoperineal pouch reconstructions in 57 patients, may appear to be blind at certain points. The best strategy of whom 30% underwent pouch reconstruction and 70% that the surgeon can employ in these circumstances is to underwent revision.62 The primary indication for reopera- constantly assess where the critical structures such as the tion was pouch-vaginal fi stula and pelvic sepsis. Pouch ureters, bladder, and gynecologic and neurovascular struc- revision success was achieved in 67% of patients. tures are or may be. It can be helpful to perform an endos- Mathis and colleagues reported 51 patients with an initial copy through the pouch to better delineate the size and diagnosis of UC, of whom 22 patients were subsequently orientation of the pouch and its efferent/afferent limbs, proved to have Crohn disease.52 Sixty-fi ve percent under- which may aid with pelvic dissection. went pouch reoperation for infectious complications and When performing complete pouch reconstruction, the 35% underwent reoperation for mechanical complications. neoterminal ileum must have suffi cient reach to the pelvis Complete reconstruction was performed in 43% and partial for a tension-free anastomosis. The same technical principles reconstruction in 57%. Pouch survival following reconstruc- used during index pouch construction to obtain reach should tion was 93% at 1 year and 89% at 5 years. Most failed be employed: complete mobilization of the small bowel pouches (75%) occurred in patients with a later diagnosis of mesentery off the retroperitoneum to the root of the SMA Crohn disease. Pouch survival in patients with a mechanical at the duodenum, sequential scoring of the peritoneum indication was 91% compared with pouch survival of 79% along the axis of the new pouch mesentery, and ligation of in those with an infectious indication. Although this is often mesenteric vessels only if collateral circulation is readily a technically demanding surgery, these results indicate that identifi able to the new pouch. The apex of the pouch should a signifi cant proportion of pouches may be salvaged with an once again easily reach the inferior aspect of the pubis experienced team.

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11/14 gastro reoperative pelvic surgery — 14 low anastomotic complications cavity before confi dence in the integrity of the anastomosis. Similar to reoperative pouch surgery, the primary indica- If a persistent fi stula to bowel remains after months, an tions for reoperative surgery for low anastomotic complica- eventual operation may be required for anastomotic revision or diversion. A diverting proximal stoma is often required tions are for mechanical or infection-related complications. in conjunction with local measures to control sepsis. Mechanical problems are usually related to anastomotic When reoperative surgery is performed for a failed anas- strictures secondary to ischemia or surgical technique. tomosis, it is important to consider the tissue quality of the Infection-related complications are inevitably related to pelvic fl oor, sphincter function, and remaining rectum or anastomotic dehiscence. The overall incidence of anasto- anus. In motivated patients with intact sphincter function, motic leaks following low anterior resection is reported from reoperation with attempted coloanal anastomoses may lead 1 to 19%, with signifi cant challenges in management when to a successful outcome. In the setting of chronic pelvic sep- 63–66 they occur. Apart from substantial patient morbidity and sis, the remaining rectal stump is often fi brotic and a high the risk of mortality, resultant function is signifi cantly worse risk for a new anastomosis, but the anal canal is typically and the cost of treatment of the anastomotic leak has been soft and pliable, providing a point for a coloanal anastomo- 67–69 shown to be substantial. Of even more concern has been sis. Preoperative manometry is useful to assess sphincter the fi nding that local recurrence is increased and survival function. Patients must also be aware that bowel length may is decreased following anastomotic leak in the setting of limit the surgeon’s ability to create a low anastomosis and surgery for colorectal cancer.70–73 Anastomotic leaks may also that a permanent ostomy may be required. In addition, a lead to chronic fi brosis and scarring and thus ultimately diverting loop ileostomy is required for at least 3 months if lead to chronic complications, including decreased neorectal a low pelvic anastomosis can be created. capacitance, incontinence, or stricture.64,74 Operative Technique Operative Planning The technical strategy of reoperative surgery for low The location, size, and containment of an anastomotic leak anastomotic complications is similar to the approach used typically dictate how a patient clinically presents. Patients for recurrent pelvic malignancies and reoperative pouch with free anastomotic leaks within the peritoneal cavity surgery. In brief, the patient is placed in the Lloyd-Davies present with classic signs of hemodynamic compromise and position to provide access to the perineum, and all extremi- peritonitis; however, patients with very low, well-contained ties are safely padded. Bilateral ureteral stents may be placed leaks within the pelvis may present subclinically and pose a to ease the identifi cation of the ureters during surgery. diagnostic challenge. In general, patients with clinical dete- A lower midline incision is made, and the abdomen is rioration, sepsis, or diffuse peritonitis require immediate explored. The small bowel is packed into the upper abdo- surgical intervention. Patients who are not systemically ill men, and the pelvis is exposed. Critical structures, including with subclinical leaks may not require immediate reoperation the ureters, gonadal vessels, and iliac vessels, should be and can often be managed with CT- or ultrasonography- immediately identifi ed and tagged if necessary. The distal guided percutaneous drain placement for cavities greater bowel should then be mobilized to the level of the anasto- than 3 cm versus aspiration for small cavities less than 3 cm. mosis. It is helpful to know what type of anastomosis was Management algorithms have been developed to address made (hand sewn, stapled, end to end, or end to side) to anastomotic leaks.75 For leaks with extensive peritoneal guide the dissection. The use of a fi nger or instruments such contamination, signifi cant breakdown of the anastomosis, or as a rigid proctoscope or vaginal retractor may also assist evidence of ischemia, the operative plan requires takedown with identifying important pelvic structures. Defi nitive surgical options depend on the indication for of the anastomosis with complete diversion in the form of an the reoperative surgery. For mechanical problems such as a ileostomy or colostomy. If the anastomotic ring is mostly benign stricture, resection with (1) no reanastomosis versus intact and there are no signs of bowel ischemia, then the (2) reanastomosis and possible proximal diversion requires strategy includes preserving the anastomosis, draining the exposure beyond the original anastomosis to allow room for region, and placing a proximal diverting loop ileostomy, distal transection. This distal margin may be at the level of which may salvage the anastomosis. Local repairs are typi- the pelvic fl oor. In cases of very low anastomoses, it may be cally not successful; however, an omental fl ap in addition necessary to perform the distal transection from a transanal to proximal diversion may assist in healing of the pelvic approach with an intersphincteric dissection to meet the anastomosis. Other novel techniques with limited support- abdominal dissection plane. ing data include covered stents, vacuum-assisted closure For infection-related problems such as an anastomotic 76,77 devices, or over-the-scope clips. leak, the surgical option depends on the extent of contami- The critical goal in reoperative pelvic surgery for infection- nation, time to reoperation, degree of dehiscence, patient related complications is to control sepsis. Salvage or recon- stability, and overall clinical assessment. These options struction of the anastomosis will be most successful 6 to include (1) attempted primary repair/buttressing with wide 12 months later. In very low anastomotic leaks with a con- drainage and possible proximal diversion, (2) resection with necting abscess, transanal drainage may be performed in the reanastomosis and possible proximal diversion, or (3) resec- operating room under direct vision. In this instance, the tion with no reanastomosis. Although fecal diversion may anastomosis is opened and the abscess is drained, followed not prevent another postoperative complication, it is impor- by placement of a catheter in the defect for irrigation. In the tant to consider as it may decrease the magnitude of morbid- management of pelvic abscesses using drains, serial sino- ity should another anastomotic dehiscence or deep surgical grams must reveal no fi stula and resolution of the abscess space infection recur.

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Table 6 Mobilization Techniques for Difﬁ cult Reconstructions Maneuver Goals Example Primary Separation of embryonic fusion planes Cattell and Mattox maneuvers Division of peri-organ “ligaments” Splenic flexure mobilization Secondary Ligation of vascular pedicles Ligation of the inferior mesenteric vein and artery Preservation of collateral blood supply Preserving the middle colic artery to supply ileal pouch Tertiary Extended resection to mobile proximal bowel Deloyers procedure and retroileal reconstruction Stoma construction End ileostomy or colostomy

Troubleshooting Figure 18]. These techniques may have already been per- Reconstruction of gastrointestinal continuity can pose a formed during the index anastomotic construction, but if major challenge after resection of a previous low anastomo- not, these principles should be applied to help reestablish sis. When bowel length may not seem adequate for a tension- gastrointestinal continuity. free anastomosis, several maneuvers can be employed Complications before resorting to an end ileostomy or colostomy [see Table 6]. These include (1) primary maneuvers: mobilization The spectrum of postoperative complications after of the embryonic fusion planes and detachment of periorgan reoperative pelvic surgery for anastomotic complications is ligaments such as the splenic and hepatic ﬂ exures; (2) determined by the indication for reoperation and the reop- secondary maneuvers: directed ligation of vascular pedicles erative procedure. For infection-related indications such as such as the inferior mesenteric artery (IMA) and vein (IMV) anastomotic leaks, early studies observed high morbidity that restrict mobility [see Figure 17]; and (3) tertiary maneu- and mortality (72%) with diverting loop colostomy and vers, such as retroileal colorectal anastomoses or bowel drainage versus complete anastomotic resection and end rotations from the proximal transverse or right colon [see colostomy, which had no reported morbidity and mortality

b c

IMA

LCV

IMA

Figure 17 Increasing colon length with primary and secondary maneuvers. (a) Primary maneuvers such as splenic ﬂ exure mobilization provide additional reach for the proximal colon, but maximal reach is restricted by the inferior mesentery artery (IMA). (b) After high ligation of the IMA, the colon is further restricted by the inferior mesenteric vein (IMV). Transection of the IMV must be performed proximal to the conﬂ uence of the left colic vein (LCV). (c) Ligation of the IMV proximal to the LCV provides maximum colon reach to the pelvis for tension-free colorectal or coloanal anastomoses. Reproduced with permission from the Mayo Clinic.

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b c

MC SMA

RC IC

Figure 18 Tertiary maneuvers. (a) Resection of colon to the proximal transverse colon and ligation of the middle colic artery (MC) prepares for two maneuvers that allow for a tension-free, low anastomosis. (b) Deloyers procedure. Counterclockwise rotation of the remaining right colon around the axis of the superior mesenteric artery (SMA) may allow for a tension-free low pelvic anastomosis. (c) Retroileal reconstruction. Tun- neling the remaining right colon through the ileal mesentery may allow for a tension-free low pelvic anastomosis. Reproduced with permission from the Mayo Clinic. IC = ileocolic artery; RC = right colic artery.

(0%).78 These early fi ndings applied the management prin- reanastomosis. Pitel and colleagues reported on 66 patients ciples used in perforated diverticulitis, which is most often comprising 44 colorectal and 22 coloanal anastomoses.79 treated with an end colostomy (the Hartmann procedure). Mortality was again nil, and morbidity was 32%, consisting More recent studies after reoperative surgery for anasto- of a 7.7% anastomotic leak rate, 9.3% readmission rate, motic complications have reported higher morbidity, from and 15.4% reintervention rate. Although these studies 26 to 55%.79–81 Genser and colleagues looked at 50 consecu- demonstrate a signifi cant risk of morbidity after reoperative tive patients who underwent reoperative surgery for anasto- surgery for anastomotic complications, the morbidity motic strictures (40%) and infection-related indications such appears to be relatively minor and manageable, with no as chronic pelvic sepsis (28%) and fi stula (6%).80 All patients reported mortality. underwent resection and anastomosis, with 54% and 46% of these patients receiving a new colorectal or coloanal Outcome Evaluation anastomosis, respectively. Mortality was nil, but morbidity Reoperative surgery for anastomotic complications can approached 26%. Morbidity was generally minor (Dingo be safe and effective. For mechanical complications such as grade < 3) and included intraoperative injury to the bladder, benign strictures, functional outcomes are excellent. Schlegel prolonged ileus, urinary tract infections, and one readmis- and colleagues observed 27 patients who underwent resec- sion for dehydration from a diverting ileostomy. Only one tion and reanastomosis for low anastomotic strictures and case of presacral hemorrhage (Dingo grade 4) required found no recurrent strictures and satisfactory functional reoperation. results up to 28.7 months postoperatively.82 Other series Other groups have also reported no mortality after reop- have reported restenosis rates in up to 4% of patients but erative surgery but have shown associated morbidity.79,81 similarly acceptable, long-term functional results.80,81 Lefevre and colleagues studied 34 patients who underwent In the series by Genser and colleagues that included both reoperative surgery for mechanical and infection-related mechanical and infection-related anastomotic complications, indications.81 The mean operating time was 279 minutes and all patients successfully underwent reoperation and up to morbidity was 55%, with a 12% anastomotic leak rate after 94% of patients ultimately had their intestinal continuity

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11/14 gastro reoperative pelvic surgery — 17 reestablished.80 The median number of bowel movements 4. Sagar PM, Pemberton JH. Surgical management of locally was two during the day and zero at night, and 70% of recurrent rectal cancer. Br J Surg 1996;83:293–304. patients had less than three stools a day up to 21 months on 5. McDermott FT, Hughes ES, Pihl E, et al. Local recurrence follow-up. Pitel and colleagues reported a median follow-up after potentially curative resection for rectal cancer in a of 35.7 months and long-term success rates in 78.8% of their series of 1008 patients. Br J Surg 1985;72:34–7. 66 redo colorectal and coloanal patients with a median 6. Pilipshen SJ, Heilweil M, Quan SH, et al. Patterns of pelvic Wexner score of 8.79 These studies suggest that although recurrence following defi nitive resections of rectal cancer. technically demanding, reoperative pelvic surgery for anas- Cancer 1984;53:1354–62. tomotic complications is associated with resolution of the 7. Rich T, Gunderson LL, Lew R, et al. Patterns of recurrence original complication, acceptable morbidity, and satisfactory of rectal cancer after potentially curative surgery. Cancer long-term functional outcomes. 1983;52:1317–29. 8. Gunderson LL, Sosin H. Areas of failure found at reopera- palliative reoperative pelvic surgery tion (second or symptomatic look) following “curative sur- Palliative reoperative pelvic surgery may be necessary in gery” for adenocarcinoma of the rectum. Clinicopathologic select patients to relieve pain from recurrent cancers, malig- correlation and implications for adjuvant therapy. Cancer nant bowel obstructions, chronic abscesses, and/or fi stulas 1974;34:1278–92. that negatively affect quality of life. Brophy and colleagues 9. Mannaerts GH, Rutten HJ, Martijn H, et al. Abdominosacral reported on 35 patients who underwent palliative exentera- resection for primary irresectable and locally recurrent tion procedures for recurrent pelvic carcinoma with refrac- rectal cancer. Dis Colon Rectum 2001;44:806–14. tory symptoms including pain, bleeding, obstruction, and 10. Palmer G, Martling A, Cedermark B, et al. A population- fi stulas.83 Operative morbidity and mortality were 47% and based study on the management and outcome in patients 3%, respectively. The median overall survival was 20 months, with locally recurrent rectal cancer. Ann Surg Oncol 2007; and improvement in quality of life was reported in 88% of 14:447–54. patients. Esnaola and colleagues prospectively assessed pain 11. Bakx R, Visser O, Josso J, et al. Management of recurrent in 45 patients with unresectable recurrent rectal cancer from rectal cancer: a population based study in greater Amster- which 30 patients (67%) underwent a palliative resection.84 dam. 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