Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. May 15, 2017; 9(5): 218-227
Published online May 15, 2017. doi: 10.4251/wjgo.v9.i5.218
Critical evaluation of contemporary management in a new Pelvic Exenteration Unit: The first 25 consecutive cases
Min Hoe Chew, Yu-Ting Yeh, Ee-Lin Toh, Stephen Aditya Sumarli, Ghee Kheng Chew, Lui Shiong Lee, Mann Hong Tan, Tiffany Priyanthi Hennedige, Shin Yi Ng, Say Kiat Lee, Tze Tec Chong, Hairil Rizal Abdullah, Terence Lin Hon Goh, Mohamed Zulfikar Rasheed, Kok Chai Tan, Choong Leong Tang
Min Hoe Chew, Yu-Ting Yeh, Ee-Lin Toh, Stephen Aditya Sumarli, Choong Leong Tang, Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
Ghee Kheng Chew, Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore 169608, Singapore
Lui Shiong Lee, Department of Urology, Singapore General Hospital, Singapore 169608, Singapore
Mann Hong Tan, Department of Orthopaedic Surgery, Singapore General Hospital, Singapore 169608, Singapore
Tiffany Priyanthi Hennedige, Division of Oncological Imaging, National Cancer Centre Singapore, Singapore 169610, Singapore
Shin Yi Ng, Say Kiat Lee, Hairil Rizal Abdullah, Department of Anaesthesiology, Singapore General Hospital, Singapore 169608, Singapore
Tze Tec Chong, Vascular Surgery, Singapore General Hospital, Singapore 169608, Singapore
Terence Lin Hon Goh, Mohamed Zulfikar Rasheed, Kok Chai Tan, Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore 169608, Singapore
Author contributions: Chew MH designed the study and is its guarantor; Yeh YT, Toh EL and Sumarli SA performed the data collection and statistical analysis; Chew MH and Yeh YT drafted the initial manuscript; Chew GK, Lee LS, Tan MH, Hennedige TP, Ng SY, Lee SK, Chong TT, Abdullah HR, Goh TLH, Rasheed MZ, Tan KC and Tang CL revised the article for important intellectual content in their respective fields of medical expertise.
Institutional review board statement: This study was reviewed and approved by the Singapore General Hospital’s Institutional Review Board (CIRB Ref: 2014/244/B).
Informed consent statement: The inform consent requirement was waived by the Singapore General Hospital’s Institutional Review Board.
Conflict-of-interest statement: All authors declare no conflicts of interest related to this research or its publication.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Min Hoe Chew, MBBS, MRCS(Ed), MMED(Surg), FRCS(Ed), FAMS, Adjunct Associate Professor, Consultant, Department of Colorectal Surgery, Singapore General Hospital, 20 College Road, Academia, Singapore 169608, Singapore. chew.min.hoe@singhealth.com.sg
Telephone: +65-64722000 Fax: +65-63706534
Received: December 9, 2016
Peer-review started: December 9, 2016
First decision: January 10, 2017
Revised: February 2, 2017
Accepted: March 12, 2017
Article in press: March 13, 2017
Published online: May 15, 2017
Processing time: 154 Days and 6.4 Hours
Abstract
AIM

To critically appraise short-term outcomes in patients treated in a new Pelvic Exenteration (PE) Unit.

METHODS

This 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 χ2 test or Fisher’s exact test, as applicable.

RESULTS

All 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.

CONCLUSION

By utilizing modern assessment and surgical techniques, our PE Unit can manage complex pelvic cancers with acceptable morbidities, zero-rate mortality and equivalent oncologic outcomes.

Keywords: Colorectal cancer; Advanced pelvic tumour; Sacrectomy; Oncological outcome; Pelvic exenteration; Chordoma

Core tip: Pelvic exenteration surgery was introduced by Brunswick in 1948 as a palliative treatment for advanced pelvic tumour, which carries high morbidity and mortality rates. However, decades of medical evolution in preoperative imaging, adjuvant therapy, better anatomical knowledge of the pelvis and modernized surgical techniques has made this procedure safe and effective for treating complex pelvic tumours. This study describes and demonstrates how our new Pelvic Exenteration Unit utilises the advantage of modern assessment and contemporary surgical techniques to achieve excellent outcomes.