Total Pelvic Exenteration with Precise Abdominolithotomy Sacrectomy for Locally Advanced Rectal Cancer

Abstract

Introduction:

En bloc sacrectomy offers the only hope of a lasting cure for locally advanced/recurrent rectal cancer involving the presacral fascia or sacrum. ^{1 –3} However, it is a technically challenging procedure.

Methods:

Here, we reported a technique of total pelvic exenteration (TPE) with precise abdominolithotomy sacrectomy. A 32-year-old man was diagnosed with locally advanced rectal cancer. Neoadjuvant therapy was used to downstage the tumor. A radiation dose of 45 Gy was administered in 25 fractions. The concurrent chemotherapy regimen was a biweekly schedule of FOLFOX. Each cycle of FOLFOX consisted of oxaliplatin (85 mg/m²) and folinic acid (400 mg/m²) infusion on day 1 followed by a 46-h infusion of 5-fluorouracil (5-FU, 2800 mg/m²) repeated every 2 weeks. After the neoadjuvant treatment, the tumor perforated, involving the presacral fascia at distal sacrum, levator ani, sphincter muscles and the prostate. After precluding distant metastasis, TPE with distal sacrectomy was performed. The abdominal dissection was performed according to our published method. ⁴ After anterior and lateral dissection, mobilization proceeded posteriorly until the level of planned sacrectomy. The perineal phase began with a circumanal incision. The lateral and anterior dissection were guided by the abdominal surgeon. Following that, the coccyx was identified posteriorly and the surgeon proceeded to free the posterior and lateral side of the sacrum from the gluteus maximus and sacrococcygeal ligaments until the planned resection line. After division of the presacral tissue with diathermy, osteotomy was performed anteriorly using an ultrasonic bone scalpel. Hemostasis was ensured and reconstruction was performed. The perineal defect was closed primarily without using a tissue flap.

Results:

The operative time was 660 minutes, and blood loss was 600 mL. Postoperative course was uneventful, and the patient was discharged 14 days after surgery. Pathology report showed a moderately differentiated rectal adenocarcinoma invading the presacral fascia and prostate. All margins were negative on the final pathology. The patient was followed up 6 months after surgery. The CEA and radiological results were normal. No evidence of recurrence or metastasis was found.

Conclusion:

We described a precise technique of TPE with abdominolithotomy sacrectomy for locally advanced/recurrent rectal cancer.

H.Z. had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: H.Z. and J.Z. Acquisition, analysis, or interpretation of data: All authors. Drafting of the article: All authors. Critical revision of the article for important intellectual content: All authors. Supervision: H.Z.

Conflict of interest disclosures:

None reported.

Authors have received patient consent for video recording/publication in advance

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Source of video:

Shanghai Changzheng Hospital, Shanghai, China.

Ethical Approval:

This study was approved by the Ethics Committee of Changzheng Hospital.

Runtime of video: 7 mins 33 secs.

File size: 241 MB.