Prevention of risks related to pelviperineal defects

Résumé du document

The principal causes are disseminated coagulopathies related to prolonged sepsis and blood loss. With regard to blood loss, there are three delicate operative steps: careful dissection of the hypogastric venous trunk and its pelvic branches that may retract into the gluteal muscles, control of the periprostatic venous plexus of Santorini during anterior exenterations, and injury to the presacral venous plexus during abdominosacral resections. In case of uncontrollable bleeding, hemostatic pelvic packing may become indispensable. In major series, mean peroperative blood loss varying from 1000 to 7000 ml with extreme up to 25000 ml. No patients experienced dramatic perioperioperative outcome.

The main risk factors for onset of these complications include: a large perineal defect, prolonged duration of operative time, radiation therapy and postradiation fibrosis, and massive blood loss. Here TPE was associated with significant longer operative time and mean blood loss. Minor complication were pelvic abscess, intestinal obstruction, cardiovascular, renal, and pulmonary complications and major complication: enterocutaneous or enteroperineal fistulas and secondary perineal wound dehiscence, the most devastating, whose prevalence ranges from 4 to 24% in most of the large series with high rate of mortality. Immediate surgical treatment seems to be the best procedure. In our study, the patients with digestive leak underwent immediate re-operation and were discharged from hospital without septic disease.

Extraits

[...] Prevention of risks related to pelviperineal defects The principal causes are disseminated coagulopathies related to prolonged sepsis and blood loss. With regard to blood loss, there are three delicate operative steps: careful dissection of the hypogastric venous trunk and its pelvic branches that may retract into the gluteal muscles, control of the periprostatic venous plexus of Santorini during anterior exenterations, and injury to the presacral venous plexus during abdominosacral resections. In case of uncontrollable bleeding, hemostatic pelvic packing may become indispensable. [...]

[...] Monobloc multi-organ resection is justified if it permits avoidance of opening the tumor interface. It is possible to overcome anatomical limitations by invasive techniques such as extravascular dissection in case of pelvic sidewall or ureteral involvement and abdominosacral resection in case of posterior sacral involvement. The indications for sphincter preservation should be adapted according to age, continence, radiation therapy and the extent of resection (pelvi-perineal resection when pelvic floor is involved). Since combined treatment of metastatic site or peritoneal carcinomatosis has not yet been evaluated in literature, it can be considered if curative resection of that sites can be accomplished. [...]

[...] The prevention of risks related to pelviperineal defects calls for generous use of interposition musculocutaneous flaps. The vertical rectus abdominis musculocutaneous flap is the most widely used technique to fill the pelvis after exenterations. This flap prevents secondary perineal dehiscence, postoperative obstruction due to small intestinal incarceration in the pelvic cavity (40 to and decreases the rate of enteroperineal fistula in APR(5 to 16%). For these reasons, we recommend like several other authors, the use of VRAM flap after pelvic exenterations to decrease pelviperineal morbidity. [...]

[...] This retrospective study shows that extended pelvic resections for extra luminal recurrent rectal carcinomas, despite the complexity of the technique, can be performed with acceptable morbidity, no mortality and provides high probability for cure in selected patients. Very close collaboration between the different management specialists (radiologists, oncologists, radiation therapists, surgeons) is indispensable to plan optimal multimodal therapy and select the patients for whom optimal R0 resection can be expected. Radical surgery represents the most important independent predictive factor for overall and disease-free survival. The prevention of LR, i.e. total mesorectal excision, is of primordial importance in the initial management of rectal cancer. [...]