Pelvic Exenteration: Innovative Technology Brings Hope to Patients with Locally Advanced Colorectal Cancer | Zhang Jian, Shanghai Changzheng Hospital | Panda Patient Education Live Replay
Treating locally advanced and recurrent rectal cancer has always been a challenge in medicine, especially when tumors invade the pelvis and surrounding organs, where traditional treatments often struggle to control the disease effectively.
Pelvic exenteration (PE), as an innovative surgical technique, offers new hope for such patients.
Panda & Friends invites Prof. Zhang Jian from the Department of Colorectal Surgery, Changzheng Hospital, Naval Medical University, to provide a detailed introduction to the background, surgical procedure, indications, contraindications, and clinical applications of this technique.
Due to surgical footage in the replay video, it may not pass review. Please scan the QR code at the end of the article to watch the replay.
Article Summary | Li Heng
Article Proofreading | Da Congming
Responsible Editor | Xian Ning
[ Conference Date: November 24, 2024 ]
Pelvic Exenteration
Overview
Pelvic exenteration is typically indicated for locally advanced or recurrent rectal cancer, particularly when the tumor has extended into the pelvis and surrounding vital organs.
The extensive surgical scope involves the removal of multiple organs, including the rectum, bladder, prostate (in males), uterus, and vagina (in females), and sometimes involves pelvic floor tissues, parts of the pelvic bone, and the vascular system.
The core goal of the surgery is to achieve an R0 resection (complete removal of cancer cells with no residual disease), thereby improving patient survival rates, reducing the risk of recurrence, and restoring quality of life as much as possible.
The application of this procedure has gradually gained recognition in Shanghai and has been included in certain medical programs, indicating high clinical validation of its effectiveness and feasibility.
With advancements in imaging technology, precise preoperative assessment has become more feasible and efficient. Doctors can accurately locate the tumor and its extent of invasion through preoperative imaging, allowing for personalized resection plans that ensure safe margins and reduce postoperative recurrence. Precise preoperative evaluation provides clear surgical goals for doctors and brings greater treatment confidence to patients.
Pelvic Exenteration
From Traditional Surgery to Innovative Pelvic Exenteration
01
Traditional Surgery VS Pelvic Exenteration
Compared to traditional surgery, which only targets the rectum and its immediate surrounding area, the innovative pelvic exenteration expands the surgical scope and demonstrates significant advantages in rectal cancer treatment. Notably, there are two different approaches to pelvic exenteration:
1. Total pelvic exenteration
2. Extended total pelvic exenteration combined with pelvic wall resection
02
Traditional Radical Rectal Cancer Surgery
Traditional radical rectal cancer surgery is suitable for cases where the tumor is confined to the rectum and its surrounding area (within the yellow area in the image above). For patients whose tumors have spread to other pelvic organs, its effectiveness is limited. The surgical scope typically includes:
Rectum: Removal of the rectal segment containing the tumor.
Mesorectum and lymph nodes: Including the mesorectum, mesentery, and lymph nodes adjacent to the rectum.
03
Pelvic Exenteration
The scope of pelvic exenteration is significantly expanded, involving the removal of multiple vital organs. During surgery, precise judgment of the extent of cancer invasion and preservation of organ function are required.
1. When the tumor is confined within the bony pelvis, the surgical scope typically includes:
1. Digestive: Rectum, anal canal;
2. Urinary: Bladder, ureters, urethra/prostate;
3. Reproductive: Uterus, vagina/seminal vesicles;
4. Unilateral or bilateral pelvis: Internal iliac vessels and their branches, lateral lymph nodes, obturator nerve, external iliac arteries and veins;
5. Pelvic floor: S4/S5 coccyx + pelvic floor muscle group (pubococcygeus, iliococcygeus, coccygeus).
At least 3 of the above 5 systems are removed "en bloc".
2. Extended total pelvic exenteration combined with pelvic wall resection further expands the scope to:
1. Bone: S1/S2/S3, pubis, ischium, ilium, lumbar vertebrae;
2. Nerves: S1-S3 nerves, lumbosacral trunk, sciatic nerve main trunk, femoral nerve;
3. Pelvic wall muscle group (piriformis, psoas major/minor, iliacus, obturator internus);
4. Female external genitalia / male external genital organs.
At least one of the above is removed "en bloc" with the tumor lesion. Currently, only Changzheng Hospital is capable of performing this type of surgery.
Pelvic Exenteration
Indications and Contraindications
01
Indications
1. Tumor lesions are confined within the pelvis, with no extra-pelvic metastasis.
2. Extra-pelvic lesions exist simultaneously, but systemic tumor progression is stable, and intra-pelvic lesions can achieve R0 resection. If drug therapy ensures stable systemic progression, surgery may be considered after multidisciplinary discussion to assess potential benefits.
3. Good systemic condition: Patients must have adequate physical strength and immune function to withstand high-risk surgery.
4. Emergency situations: Intra-pelvic lesions with infection, abscess, bleeding, or fistula that affect systemic treatment or are life-threatening.
02
Contraindications
1. Unresectable radioactive seeds at the surgical site in the pelvis: If seeds are near the acetabulum or femoral head, incomplete resection can hinder wound healing and increase the risk of massive intraoperative bleeding and postoperative complications.
2. Tumor invasion of the common or external iliac vessels with a history of radiotherapy: Vascular healing capacity is compromised, and artificial vessels cannot be used as substitutes.
3. Expected survival of less than 3 months, where surgery may not provide sufficient survival benefit.
4. Tumor penetration through the greater sciatic foramen: Tumor extension into deeper tissues significantly increases surgical difficulty and risk.
Pelvic Exenteration
Clinical Outcomes and Survival Rates: Significantly Improving Patient Prognosis
01
Standardized Treatment
The Shanghai Medical Association has established strict management guidelines for pelvic exenteration: precise preoperative evaluation and personalized resection plans have enabled this surgery to demonstrate significant survival advantages in the treatment of advanced rectal cancer.
02
Discussion on Current Medical Landscape: The Potential of Pelvic Exenteration
Colorectal cancer is the second most common cancer globally. Approximately 5% to 10% of patients are diagnosed with tumors that have already extended to surrounding organs (beyond the yellow line). Additionally, about 4% to 8% of patients experience postoperative recurrence, resulting in 45,000 to 60,000 patients requiring treatment annually, particularly those with locally advanced and recurrent cases.
As the tumor progresses, internal scarring and disrupted blood supply prevent drugs from penetrating effectively. When tumors extend to the prostate, bladder, uterine appendages, or vagina, drug efficacy is limited, making pelvic exenteration an effective treatment option.
Prof. Zhang points out that the survival period for untreated patients is typically 10 to 17 months, with death often caused by complications. For patients with locally advanced and recurrent colorectal cancer, relying solely on drug therapy yields limited results; complete surgical resection is essential. Thousands of patients could potentially benefit from pelvic exenteration each year, but very few actually undergo the procedure, primarily due to a lack of information and access to qualified surgeons. Disseminating information through platforms like Panda groups can help more patients benefit, ultimately promoting overall public health.
03
Discussion on Long-term Survival Rates and Quality of Life
The efficacy of pelvic exenteration in treating advanced rectal cancer has made significant progress, with survival rates substantially outperforming traditional treatments, especially for locally advanced and recurrent cases.
Prof. Michael Solomon from Australia is the world's leading expert in this procedure, having successfully performed over 1,200 surgeries to date. Research data shows that among 1,065 patients with advanced primary rectal cancer, the R0 radical resection success rate reached 89%, with an overall survival rate of 66% and a 10-year survival rate of up to 75%, far exceeding those relying solely on drug therapy.
Although patients may experience a challenging recovery initially, most return to near-normal levels within 12 months post-surgery, particularly in cases without severe symptoms. For example, an 18-year-old patient suffered from extremely poor quality of life due to a rectovaginal fistula and infection, making it impossible to sit comfortably. Post-surgery, despite some physical discomfort, her quality of life improved significantly, and she no longer experiences pain at rest.
In 2022, Prof. Zhang's team completed 200 pelvic exenterations and expects to reach 600 by the end of 2024, marking the maturation and widespread application of this technique. Pelvic exenteration demonstrates immense therapeutic potential for cases where traditional treatments are ineffective or unsuitable.
04
Surgical Risks and Benefits
Pelvic exenteration has seen remarkable progress in recent years, currently achieving the following clinical standards:
1. Blood loss and mortality: 80% of patients experience intraoperative blood loss under 500 ml, with a postoperative mortality rate of only 2%. For patients who have undergone radiotherapy, blood loss typically exceeds 1000 ml, but in complex cases, it is generally controlled within 2000 ml.
2. Hospitalization and recovery period: Average hospital stay is 14-21 days, with a full recovery period of 30-120 days. Postoperative recovery quality is high, especially for patients without prior radiotherapy.
3. Resection rate and survival probability:
a) R0 (complete resection with no residual) rate for locally advanced colorectal cancer can reach 95%;
b) R0 resection rate for recurrent colorectal cancer is 78%;
c) Three-year recurrence-free probability reaches 85%-90%;
d) Ten-year survival rate aligns with the Australian team's data, at approximately 75%.
Preoperative Evaluation and Postoperative Management:
Surgical planning is based on precision medicine, with precise preoperative localization to determine which cases can be completely resected and which cannot. Postoperative close monitoring, including dynamic ctDNA monitoring, scientifically assesses surgical outcomes and recurrence risk. Patients initially feel physically weak post-surgery, but quality of life typically improves gradually over time.
Pelvic Exenteration
Case Discussion: Experience and Reflections
1. Carefully differentiate between "advanced stage" and "locally advanced/recurrent" to formulate treatment plans cautiously.
A study of 150 patients (97 recurrent, 63 locally advanced) who underwent pelvic exenteration showed that adjuvant therapy may affect tissues, increasing surgical difficulty, such as impairing tissue healing and raising the risk of intraoperative and postoperative bleeding.
Therefore, it is recommended to develop personalized treatment plans based on patient conditions, conduct comprehensive evaluations, prioritize surgery, and arrange subsequent treatments as needed postoperatively. This approach optimizes treatment efficacy while minimizing potential risks, ensuring patient safety and prognosis.
For advanced stages that do not require combined resection of surrounding organs needing reconstruction, neoadjuvant chemoradiotherapy can be chosen.
For locally advanced/recurrent cases requiring combined resection of organs/vessels/nerves needing reconstruction, postoperative radiotherapy is recommended.
2. Postoperative recovery is more complex for recurrent patients or cases with perianal invasion.
Impaired anal function requires leaving the wound open post-surgery, which helps alleviate patient suffering and promotes natural wound healing. In such cases, patients can continue daily activities like walking, eating, defecating, and urinating. For patients without radiotherapy, the wound typically heals in about a month; for those who had radiotherapy, recovery takes longer, usually around 4 months.
3. Approach watch-and-wait treatment with caution.
Some patients' tumors may shrink significantly or even disappear after treatment, appearing effective, but recurrence rates are high. Tumors may extend outward to other organs like the urethra or prostate, potentially causing severe complications, abscess formation, and loss of organ function. Therefore, we must remain cautious regarding watch-and-wait and conservative treatment strategies, strengthen follow-up, and recognize that surgery may ultimately be the solution.
Shanghai Changzheng Hospital
Introduction to the Department of Colorectal Surgery
01
Department Resources and Technical Platform
The Department of Colorectal Surgery at Changzheng Hospital currently possesses comprehensive treatment resources and a technical platform, including:
1. Low sphincter-preserving surgery: A complete surgical system.
2. Integrated pelvic surgery center: Capable of performing 4 to 8 pelvic exenterations weekly, accumulating rich clinical experience.
3. Radiotherapy: The department is equipped with dedicated intraoperative radiotherapy equipment and postoperative radiotherapy protocols, providing precise treatment. We strictly select candidates for radiotherapy to ensure maximum patient benefit.
4. Digital operating rooms: The department features advanced digital operating rooms and DSA interventional equipment, supporting more efficient and precise surgical and interventional procedures.
5. Hyperthermic intraperitoneal chemotherapy (HIPEC): Provides intraoperative and postoperative HIPEC, effectively enhancing postoperative recovery.
02
Team Collaboration and Medical Alliance
The Department of Colorectal Surgery at Changzheng Hospital boasts an experienced surgical team, maintaining high professional standards backed by its military medical background. The department has established a close medical alliance with Prof. Shao Guoyi's team, providing mutual support in managing complex cases and effectively improving treatment outcomes.
Currently, four doctors on the team can independently perform total pelvic surgery: Zhang Jian, Zhou Haiyang, Su Ning, and Shao Guoyi.
03
Outpatient and Examination Arrangements
Changzheng Hospital operates across two campuses: Changzheng Hospital (10 beds for pelvic surgery) and 905 Hospital (20 beds for pelvic surgery), both offering comprehensive outpatient examination and treatment services.
Director Zhang Jian holds outpatient clinics at the main Changzheng Hospital campus every Monday morning, with a bed scheduling wait time of approximately 2-3 weeks. Patients can choose to visit according to their needs.
Shanghai Changzheng Hospital
Treatment Costs for Pelvic Exenteration
The cost of pelvic surgery at Changzheng Hospital offers high cost-effectiveness, largely due to Shanghai's special DRG separate billing project, which allows for full reimbursement, significantly reducing the financial burden on patients:
1. Surgical costs and reimbursement
Total surgical costs typically do not exceed 200,000 RMB.
For most patients, medical insurance covers a high percentage: rural resident insurance covers about 60%-70%, and urban employee insurance covers about 90%. Some patients' actual out-of-pocket expenses are around 20,000 RMB.
2. Albumin costs: To prevent organ edema or postoperative pulmonary edema, 10 vials of albumin are usually administered intraoperatively. Albumin must be paid out-of-pocket by patients, with insurance covering it only under specific circumstances. Based on experience, patients need to prepare approximately 20 vials of albumin postoperatively.
3. Postoperative monitoring costs (MRD testing): Monitors residual lesions post-surgery to accurately assess recurrence risk. The standard MRD cost is about 30,000 RMB. The hospital applies for a 10,000 RMB subsidy for patients through the Health Commission project, reducing the actual patient cost to approximately 19,800 RMB. Compared to PET-CT scans costing around 7,000 RMB each, MRD testing offers higher sensitivity and long-term cost-effectiveness, avoiding unnecessary repeated imaging.
4. Blood transfusion costs: Arrange for relatives and friends to donate blood in advance to avoid high costs or safety risks associated with "market blood".
5. Reserve funds and other expenses: Postoperative rehabilitation and dressing changes are mainly conducted at 905 Hospital and Jiangyin Hospital. It is recommended to prepare approximately 100,000 RMB to cover albumin, blood transfusions, postoperative rehabilitation, and other unforeseen additional costs. (If patients receive radiotherapy and experience poor wound healing, rehabilitation costs may increase.)
Are peritoneal metastasis and retroperitoneal lymph nodes within the scope of pelvic resection?
This depends on the specific location and extent of peritoneal and retroperitoneal lymph node metastasis:
1. If peritoneal metastasis is confined to the middle and lower abdomen without upper abdominal or small bowel mesentery involvement, it can be resected concurrently.
2. If metastasis is located higher in the retroperitoneum, surgical efficacy is limited due to proximity to major blood vessels and nerve plexuses, making surgery generally unsuitable.
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