| Invited Lecture(JSGS) |
| Fri. November 1st 14:00 - 14:30 Room 5: Portopia Hotel South Wing Ohwada A |
| Pushing the boundaries of exenterative surgery in pursuit of better outcomes in patients with advanced pelvic malignancies | |||
| Hideaki Yano | |||
| University Hospital Southampton NHS Foundation Trust, Consultant Colorectal Surgeon / National Center for Global Health and Medicine, Department of Surgery | |||
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| Until recently outcomes of pelvic exenteration for locally advanced pelvic malignancies remained poor with high morbidity and mortality, unfavourable survival and reduced quality of life (QoL). The last couple of decades, however, have witnessed a paradigm shift with incremental advances in imaging (radiology), neoadjuvant treatment (oncology), perioperative management (perioperative medicine) and surgical techniques. Modern imaging with thin-sliced CT, high-resolution MRI and PET facilitates better patient selection and serves for detailed margin assessment and surgical planning. Total neoadjuvant treatment (TNT) not only downstages or downsizes tumours but may help select more suitable patients. Prehabilitation is paramount to optimise patients in terms of nutrition, fitness and psychological status and it is known that the earlier the intervention, the better the outcomes. Pelvic exenteration is technically demanding particularly due to a) its proximity to, or involvement of, adjacent musculoskeletal structures and b) extensive fibrosis resulting from previous (chemo-)radiotherapy +/- surgery. Structures requiring resection include pubic bone or ischiopubic rami anteriorly; distal or higher sacrum posteriorly; or obturator internus / piriformis muscle on lateral aspects. Ischial spine is a particularly important anatomical landmark to conduct pelvic sidewall resection and sacrectomy. Careful preoperative surgical planning based on MRI is highly crucial to achieve R0 resection safely. Improved understanding of pelvic anatomy and new surgical instruments have helped conduct complex procedures in a safer manner. Pelvic and/or perineal reconstruction using biological meshes or flaps is also important to address "empty pelvis syndrome". More recently, it has been increasingly realised that involvement of non-expendable vessels or major nerves such as sciatic or femoral nerves is no longer an absolute contraindication. Vascular resection and reconstruction and/or nerve resection and reconstruction have been utilised to facilitate R0 resection with improved function and quality of life. Intraoperative electron radiotherapy (IOERT) is also used in a number of specialised centres with a view to improving local control for resectable tumours and to potentially mitigating against the possibility of R1 for borderline resectable tumours. These advances, individually or in combination, have enabled safer delivery of exenterative surgery with improved survival and QoL and broadened the indication criteria for such a massive undertaking in selected cases. In conclusion, radical exenterative surgery for locally advanced pelvic malignancies is increasingly suitable with further widening criteria for carefully selected and very carefully counselled patients. It requires intensive resource but can lead to excellent survival figures and good QoL if R0 is achieved. |
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