Prevention of complications following pelvic exenteration_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

TAO Yu ,  ZHANG Jian

Department of Colorectal Surgery, Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital), Shanghai 200003, P. R. China;

Corresponding author：

ZHANG Jian, Email: txzhangjian@126.com

Keywords：

pelvic exenteration; postoperative complication; prevention

DOI：

10.7507/1007-9424.202312003

Video：

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Abstract Full text Figures/Tables Video References Cited by

Pelvic exenteration has become an important procedure for radical treatment of locally advanced/recurrent rectal cancer, and in recent years, with the advancement of surgical techniques and the improvement of perioperative management ability, the long-term prognosis of patients has been significantly improved. However, the high incidence of perioperative complications seriously impacts the quality of life of patients and the course of postoperative recovery, which remains a major problem for surgeons. Precise surgical levels and appropriate intraoperative position help to fully expose the surgical field, accurately identify major vessels, and reduce the risk of intraoperative bleeding. Biological mesh, myocutaneous flap and omentoplasty are common pelvic floor reconstruction methods, and combined repair of pelvic defects by two of them may further reduce the incidence of empty pelvic syndrome. Iliac revascularization could effectively prevent postoperative thrombosis and ventricular septal syndrome. The application of minimally invasive techniques and the implementation of pre-rehabilitation measures might help to reduce postoperative complications. This article reviews the prevention strategies of complications after pelvic exenteration in order to provide some reference for clinical practice and surgical promotion.

Citation： TAO Yu, ZHANG Jian. Prevention of complications following pelvic exenteration. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2023, 30(12): 1421-1426. doi: 10.7507/1007-9424.202312003 Copy

1.	Steffens D, Solomon MJ, Lee P, et al. Surgical, survival and quality of life outcomes in over 1 000 pelvic exenterations: lessons learned from a large Australian case series. ANZ J Surg, 2023, 93(5): 1232-1241.
2.	Platt E, Dovell G, Smolarek S. Systematic review of outcomes following pelvic exenteration for the treatment of primary and recurrent locally advanced rectal cancer. Tech Coloproctol, 2018, 22(11): 835-845.
3.	Devulapalli C, Jia Wei AT, DiBiagio JR, et al. Primary versus flap closure of perineal defects following oncologic resection: A systematic review and meta-analysis. Plast Reconstr Surg, 2016, 137(5): 1602-1613.
4.	Bogner A, Fritzmann J, Müssle B, et al. Pelvic exenteration for colorectal and non-colorectal cancer: a comparison of perioperative and oncological outcome. Int J Colorectal Dis, 2021, 36(8): 1701-1710.
5.	Lee P, Francis KE, Solomon MJ, et al. Triangle of Marcille: the anatomical gateway to lateral pelvic exenteration. ANZ J Surg, 2017, 87(7-8): 582-586.
6.	Solomon MJ, Brown KG, Koh CE, et al. Lateral pelvic compartment excision during pelvic exenteration. Br J Surg, 2015, 102(13): 1710-1717.
7.	Austin KK, Solomon MJ. Pelvic exenteration with en bloc iliac vessel resection for lateral pelvic wall involvement. Dis Colon Rectum, 2009, 52(7): 1223-1233.
8.	Ishii M, Shimizu A, Lefor AK, et al. Surgical anatomy of the pelvis for total pelvic exenteration with distal sacrectomy: a cadaveric study. Surg Today, 2021, 51(4): 627-633.
9.	Solomon MJ, Tan KK, Bromilow RG, et al. Sacrectomy via the abdominal approach during pelvic exenteration. Dis Colon Rectum, 2014, 57(2): 272-277.
10.	Sutton PA, Brown KGM, Ebrahimi N, et al. Long-term surgical complications following pelvic exenteration: Operative management of the empty pelvis syndrome. Colorectal Dis, 2022, 24(12): 1491-1497.
11.	Solomon MJ, Austin KK, Masya L, et al. Pubic bone excision and perineal urethrectomy for radical anterior compartment excision during pelvic exenteration. Dis Colon Rectum, 2015, 58(11): 1114-1119.
12.	Han JG, Wang ZJ, Gao ZG, et al. Perineal wound complications after extralevator abdominoperineal excision for low rectal cancer. Dis Colon Rectum, 2019, 62(12): 1477-1484.
13.	Dijkstra EA, Kahmann NLE, Hemmer PHJ, et al. A low incidence of perineal hernia when using a biological mesh after extralevator abdominoperineal excision with or without pelvic exenteration or distal sacral resection in locally advanced rectal cancer patients. Tech Coloproctol, 2020, 24(8): 855-861.
14.	Khaw CW, Ebrahimi N, Lee P, et al. Long-term results of mesh pelvic floor reconstruction to address the empty pelvis syndrome. Colorectal Dis, 2022, 24(10): 1211-1215.
15.	Zeiderman MR, Nuño M, Sahar DE, et al. Trends in flap reconstruction of pelvic oncologic defects: Analysis of the national inpatient sample. J Plast Reconstr Aesthet Surg, 2021, 74: 2085-2094.
16.	Kim E, Fernando C, McCombie A, et al. Abdominal and perineal hernia rates following vertical rectus abdominis myocutaneous (VRAM) flap reconstruction—a supraregional experience. J Plast Reconstr Aesthet Surg, 2022, 75(3): 1158-1163.
17.	Zhang C, Yang X, Bi H. Application of depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. BMC Surg, 2022, 22(1): 304.
18.	Eseme EA, Scampa M, Viscardi JA, et al. Surgical outcomes of VRAM vs. gracilis flaps in vulvo-perineal reconstruction following oncologic resection: A proportional meta-analysis. Cancers (Basel), 2022, 14(17): 4300.
19.	Gielen AHC, Colier E, Qiu SS, et al. Research highlight: surgical outcomes of gluteal VY plasty after extensive abdominoperineal resection or total pelvic exenteration. Langenbecks Arch Surg, 2023, 408(1): 157.
20.	Miyamoto Y, Akiyama T, Sakamoto Y, et al. Omental flap after pelvic exenteration for pelvic cancer. Surg Today, 2016, 46(12): 1471-1475.
21.	Lee P, Tan WJ, Brown KGM, et al. Addressing the empty pelvic syndrome following total pelvic exenteration: does mesh reconstruction help? Colorectal Dis, 2019, 21(3): 365-369.
22.	Ng KS, Lee PJM. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol, 2021, 37: 101546.
23.	Hagemans JAW, Voogt ELK, Rothbarth J, et al. Outcomes of urinary diversion after surgery for locally advanced or locally recurrent rectal cancer with complete cystectomy; ileal and colon conduit. Eur J Surg Oncol, 2020, 46(6): 1160-1166.
24.	Bloemendaal AL, Kraus R, Buchs NC, et al. Double-barrelled wet colostomy formation after pelvic exenteration for locally advanced or recurrent rectal cancer. Colorectal Dis, 2016, 18(11): O427-O431.
25.	Peacock O, Smith N, Waters PS, et al. Preemptive femoral-femoral crossover grafting of artery and vein before pelvic exenterative surgery for locally advanced and recurrent pelvic malignancy involving the aortoiliac axis. Dis Colon Rectum, 2021, 64(1): e2-e5. .
26.	Fernández-Alonso L, Fernández-Alonso S, Aguilar EM. Iliac artery reconstruction with the superficial femoral vein after major oncologic resection. Vasc Endovascular Surg, 2017, 51(5): 350-351.
27.	Brown KG, Koh CE, Solomon MJ, et al. Spiral saphenous vein graft for major pelvic vessel reconstruction during exenteration surgery. Ann Vasc Surg, 2015, 29(6): 1323-1326.
28.	Zhang XX, Zhu JQ, Zhang H, et al. Resection of a retrohepatic leiomyosarcoma of the inferior vena cava combined with caudate lobectomy and reconstruction with an allogenic vein. Hepatobiliary Pancreat Dis Int, 2021, 20(1): 80-82.
29.	Zhuang M, Chen H, Li Y, et al. Laparoscopic posterior pelvic exenteration is safe and feasible for locally advanced primary rectal cancer in female patients: a comparative study from China PelvEx collaborative. Tech Coloproctol, 2023, 27(11): 1109-1117.
30.	Tang J, Liu J, Du B, et al. Short- and long-term outcomes of laparoscopic versus open pelvic exenteration for locally advanced rectal cancer: a single-center propensity score matching analysis. Tech Coloproctol, 2023, 27(1): 43-52.
31.	PelvEx Collaborative. Minimally invasive surgery techniques in pelvic exenteration: a systematic and meta-analysis review. Surg Endosc, 2018, 32(12): 4707-4715.
32.	Kumar NA, Sasi SP, Shinde RS, et al. Minimally invasive surgery for pelvic exenteration in primary colorectal cancer. JSLS, 2020, 24(3): e2020.00026.
33.	Levett DZH, Jack S, Swart M, et al. Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation. Br J Anaesth, 2018, 120(3): 484-500.
34.	Maňásek V, Bezděk K, Foltys A, et al. The impact of high protein nutritional support on clinical outcomes and treatment costs of patients with colorectal cancer. Klin Onkol, 2016, 29(5): 351-357.
35.	Heger P, Probst P, Wiskemann J, et al. A systematic review and meta-analysis of physical exercise prehabilitation in major abdominal surgery (PROSPERO 2017 CRD42017080366). J Gastrointest Surg, 2020, 24(6): 1375-1385.

1. Steffens D, Solomon MJ, Lee P, et al. Surgical, survival and quality of life outcomes in over 1 000 pelvic exenterations: lessons learned from a large Australian case series. ANZ J Surg, 2023, 93(5): 1232-1241.
2. Platt E, Dovell G, Smolarek S. Systematic review of outcomes following pelvic exenteration for the treatment of primary and recurrent locally advanced rectal cancer. Tech Coloproctol, 2018, 22(11): 835-845.
3. Devulapalli C, Jia Wei AT, DiBiagio JR, et al. Primary versus flap closure of perineal defects following oncologic resection: A systematic review and meta-analysis. Plast Reconstr Surg, 2016, 137(5): 1602-1613.
4. Bogner A, Fritzmann J, Müssle B, et al. Pelvic exenteration for colorectal and non-colorectal cancer: a comparison of perioperative and oncological outcome. Int J Colorectal Dis, 2021, 36(8): 1701-1710.
5. Lee P, Francis KE, Solomon MJ, et al. Triangle of Marcille: the anatomical gateway to lateral pelvic exenteration. ANZ J Surg, 2017, 87(7-8): 582-586.
6. Solomon MJ, Brown KG, Koh CE, et al. Lateral pelvic compartment excision during pelvic exenteration. Br J Surg, 2015, 102(13): 1710-1717.
7. Austin KK, Solomon MJ. Pelvic exenteration with en bloc iliac vessel resection for lateral pelvic wall involvement. Dis Colon Rectum, 2009, 52(7): 1223-1233.
8. Ishii M, Shimizu A, Lefor AK, et al. Surgical anatomy of the pelvis for total pelvic exenteration with distal sacrectomy: a cadaveric study. Surg Today, 2021, 51(4): 627-633.
9. Solomon MJ, Tan KK, Bromilow RG, et al. Sacrectomy via the abdominal approach during pelvic exenteration. Dis Colon Rectum, 2014, 57(2): 272-277.
10. Sutton PA, Brown KGM, Ebrahimi N, et al. Long-term surgical complications following pelvic exenteration: Operative management of the empty pelvis syndrome. Colorectal Dis, 2022, 24(12): 1491-1497.
11. Solomon MJ, Austin KK, Masya L, et al. Pubic bone excision and perineal urethrectomy for radical anterior compartment excision during pelvic exenteration. Dis Colon Rectum, 2015, 58(11): 1114-1119.
12. Han JG, Wang ZJ, Gao ZG, et al. Perineal wound complications after extralevator abdominoperineal excision for low rectal cancer. Dis Colon Rectum, 2019, 62(12): 1477-1484.
13. Dijkstra EA, Kahmann NLE, Hemmer PHJ, et al. A low incidence of perineal hernia when using a biological mesh after extralevator abdominoperineal excision with or without pelvic exenteration or distal sacral resection in locally advanced rectal cancer patients. Tech Coloproctol, 2020, 24(8): 855-861.
14. Khaw CW, Ebrahimi N, Lee P, et al. Long-term results of mesh pelvic floor reconstruction to address the empty pelvis syndrome. Colorectal Dis, 2022, 24(10): 1211-1215.
15. Zeiderman MR, Nuño M, Sahar DE, et al. Trends in flap reconstruction of pelvic oncologic defects: Analysis of the national inpatient sample. J Plast Reconstr Aesthet Surg, 2021, 74: 2085-2094.
16. Kim E, Fernando C, McCombie A, et al. Abdominal and perineal hernia rates following vertical rectus abdominis myocutaneous (VRAM) flap reconstruction—a supraregional experience. J Plast Reconstr Aesthet Surg, 2022, 75(3): 1158-1163.
17. Zhang C, Yang X, Bi H. Application of depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. BMC Surg, 2022, 22(1): 304.
18. Eseme EA, Scampa M, Viscardi JA, et al. Surgical outcomes of VRAM vs. gracilis flaps in vulvo-perineal reconstruction following oncologic resection: A proportional meta-analysis. Cancers (Basel), 2022, 14(17): 4300.
19. Gielen AHC, Colier E, Qiu SS, et al. Research highlight: surgical outcomes of gluteal VY plasty after extensive abdominoperineal resection or total pelvic exenteration. Langenbecks Arch Surg, 2023, 408(1): 157.
20. Miyamoto Y, Akiyama T, Sakamoto Y, et al. Omental flap after pelvic exenteration for pelvic cancer. Surg Today, 2016, 46(12): 1471-1475.
21. Lee P, Tan WJ, Brown KGM, et al. Addressing the empty pelvic syndrome following total pelvic exenteration: does mesh reconstruction help? Colorectal Dis, 2019, 21(3): 365-369.
22. Ng KS, Lee PJM. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol, 2021, 37: 101546.
23. Hagemans JAW, Voogt ELK, Rothbarth J, et al. Outcomes of urinary diversion after surgery for locally advanced or locally recurrent rectal cancer with complete cystectomy; ileal and colon conduit. Eur J Surg Oncol, 2020, 46(6): 1160-1166.
24. Bloemendaal AL, Kraus R, Buchs NC, et al. Double-barrelled wet colostomy formation after pelvic exenteration for locally advanced or recurrent rectal cancer. Colorectal Dis, 2016, 18(11): O427-O431.
25. Peacock O, Smith N, Waters PS, et al. Preemptive femoral-femoral crossover grafting of artery and vein before pelvic exenterative surgery for locally advanced and recurrent pelvic malignancy involving the aortoiliac axis. Dis Colon Rectum, 2021, 64(1): e2-e5. .
26. Fernández-Alonso L, Fernández-Alonso S, Aguilar EM. Iliac artery reconstruction with the superficial femoral vein after major oncologic resection. Vasc Endovascular Surg, 2017, 51(5): 350-351.
27. Brown KG, Koh CE, Solomon MJ, et al. Spiral saphenous vein graft for major pelvic vessel reconstruction during exenteration surgery. Ann Vasc Surg, 2015, 29(6): 1323-1326.
28. Zhang XX, Zhu JQ, Zhang H, et al. Resection of a retrohepatic leiomyosarcoma of the inferior vena cava combined with caudate lobectomy and reconstruction with an allogenic vein. Hepatobiliary Pancreat Dis Int, 2021, 20(1): 80-82.
29. Zhuang M, Chen H, Li Y, et al. Laparoscopic posterior pelvic exenteration is safe and feasible for locally advanced primary rectal cancer in female patients: a comparative study from China PelvEx collaborative. Tech Coloproctol, 2023, 27(11): 1109-1117.
30. Tang J, Liu J, Du B, et al. Short- and long-term outcomes of laparoscopic versus open pelvic exenteration for locally advanced rectal cancer: a single-center propensity score matching analysis. Tech Coloproctol, 2023, 27(1): 43-52.
31. PelvEx Collaborative. Minimally invasive surgery techniques in pelvic exenteration: a systematic and meta-analysis review. Surg Endosc, 2018, 32(12): 4707-4715.
32. Kumar NA, Sasi SP, Shinde RS, et al. Minimally invasive surgery for pelvic exenteration in primary colorectal cancer. JSLS, 2020, 24(3): e2020.00026.
33. Levett DZH, Jack S, Swart M, et al. Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation. Br J Anaesth, 2018, 120(3): 484-500.
34. Maňásek V, Bezděk K, Foltys A, et al. The impact of high protein nutritional support on clinical outcomes and treatment costs of patients with colorectal cancer. Klin Onkol, 2016, 29(5): 351-357.
35. Heger P, Probst P, Wiskemann J, et al. A systematic review and meta-analysis of physical exercise prehabilitation in major abdominal surgery (PROSPERO 2017 CRD42017080366). J Gastrointest Surg, 2020, 24(6): 1375-1385.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Prevention of complications following pelvic exenteration

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