Pelvic resection of recurrent rectal cancer - Technical considerations andoutcomes

PURPOSE: Pelvic recurrence of rectal cancer is an ominous event for the pat ient and a formidable challenge to the managing surgeon. We reviewed the re sults of abdomino-sacral resection to manage these patients and correlated outcome (survival and recurrence) with known prognostic factors. METHODS: A n abdominosacral resection was performed on 61 patients with pelvic recurre nce (53 with curative intent and 6 for palliation; 2 had extended pelvic re section). Of the 53 patients (32 males; average age, 53 years) previous res ection included abdominoperineal resection in 27 patients, abdominoperineal resection plus hepatic lobectomy in 2 patients, low anterior resection in 19 patients, plus trisegmentectomy in I patient, and advanced primary cance rs in 4 patients, initial primary stage was Dukes B (64 percent) and Dukes C (36 percent). AU had been irradiated (3,000-6,500 in 50 patients, 8,300 a nd 11,000 in 2 patients, and unknown dose in 3 patients). Preoperative carc inoembryonic antigen was elevated (>5 ng/ml) in 54 percent. Extent of resec tion: high sacral resection S-1-S2 was done in 32 patients, midsacrum in 14 patients, and low S4-S-5 in 6 patients. Twenty-eight patients (60 percent) required partial or complete bladder resection with or without adjacent vi scera, and all had internal iliac and obturator node dissection. RESULTS: T here were four postoperative (within 60 days) deaths, 8 percent in curative groups (5.4 percent overall). Major complications included prolonged intub ation (20 percent), sepsis (34 percent), posterior wound infection or flap separation (38 percent). The survival rate in the curative group C 19 posto perative survivors) was 31 percent at live years, with 13 patients survivin g beyond five years. Seven of these patients survived from 5 to 21 years, w hereas six patients recurred again and died within 5.5 to 7.5 years after a bdominosacral resection. Disease-free survival rate at five years was 23 pe rcent. Recent reconstruction with large composite myocutaneous gluteal flap s in 5 patients permitted complete sacral wound coverage, resulting in earl ier ambulation and reduced hospital stay. CONCLUSIONS: Abdominosacral resec tion permits removal of pelvic recurrence of rectal cancer that is fixed to the sacrum and is associated with long-term survival in 32 percent of pati ents. Recent technical advances have improved the short-term outcome and ha ve made the procedure more feasible for surgical teams familiar with these techniques.