Melton Genevieve B, Paty Philip B, Boland Patrick J, Healey John H, Savatta Salvatore G, Casas-Ganem Jorge E, Guillem José G, Weiser Martin R, Cohen Alfred M, Minsky Bruce D, Wong W Douglas, Temple Larissa K
Division of Colorectal Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Dis Colon Rectum. 2006 Aug;49(8):1099-107. doi: 10.1007/s10350-006-0563-9.
Composite sacropelvic resection for locally advanced recurrent rectal cancer is a high-risk procedure that benefits select patients. We reviewed our recent institutional experience to evaluate case selection, morbidity, and outcomes.
Between 1987 and 2004, 29 patients underwent composite resection for recurrent locoregional rectal cancer (17 females; median age, 60 years). Clinicopathologic indicators were evaluated as indicators of survival by log-rank test and Cox proportional hazards model.
Of 29 total patients, 27 (93 percent) received radiotherapy with their previous surgery (n = 10; 34 percent) or before sacrectomy (n = 17; 59 percent), and 12 (41 percent) received intraoperative therapy. Sacral resections were performed at S2/S3 (55 percent) or S4/S5 (45 percent) using anterior (41 percent) or combined anterior-posterior approach (59 percent), with adherence to (62 percent) or cortical invasion in (38 percent) the sacrum. A majority of those who had undergone previous abdominoperineal resection had total exenteration (9/13), whereas most patients who had undergone a previous sphincter-preserving procedure had abdominoperineal resection (12/16) and none had exenteration. Pedicle flaps (omental, 11; abdominal rectus, 7) often were used. A median of five (range, 1-33) units of blood was given intraoperatively. Transfusions were associated with previous abdominoperineal resection (P < 0.03), correlating strongly with postoperative morbidity (P < 0.02). There were 33 complications in 17 (59 percent) patients, most commonly perineal wound breakdown (9 (31 percent)) and pelvic abscess (5 (17 percent)). Median hospital stay was 18 (range, 7-56) days, significantly longer in patients with previous abdominoperineal resection (P < 0.02) or postoperative morbidity (P < 0.03). The only postoperative death was from pelvic sepsis. Resection was complete (R0) in 18 patients (62 percent), with microscopically positive margins (R1) in 10 (34 percent) and grossly positive margins (R2) in 1 (3 percent). Two-year and five-year recurrence rates were 47 and 85 percent, respectively; disease-specific survival was 63 and 20 percent, respectively. Less transfusion (P = 0.03), R0 resection (P = 0.005), lack of anterior organ involvement (P = 0.02), and absence of cortical bone invasion (P < 0.001) were associated with better survival on univariate analysis; original colorectal cancer stage was not.
Sacrectomy for rectal cancer is a high-risk procedure that can achieve clear resection margins with low mortality in select patients. This procedure has a low cure rate but may provide local disease control with acceptable morbidity.
对于局部晚期复发性直肠癌，复合骶骨盆腔切除术是一种高风险手术，仅使部分患者受益。我们回顾了我院近期的经验，以评估病例选择、发病率和治疗结果。
1987年至2004年间，29例患者接受了复发性局部区域直肠癌的复合切除术（17例女性；中位年龄60岁）。通过对数秩检验和Cox比例风险模型评估临床病理指标作为生存指标。
29例患者中，27例（93%）在先前手术时（n = 10；34%）或骶骨切除术前（n = 17；59%）接受了放疗，12例（41%）接受了术中治疗。骶骨切除在S2/S3水平（55%）或S4/S5水平（45%）进行，采用前路（41%）或前后联合入路（59%），骶骨存在粘连（62%）或皮质侵犯（38%）。大多数先前接受过腹会阴联合切除术的患者进行了全盆腔脏器切除术（9/13），而大多数先前接受过保肛手术的患者进行了腹会阴联合切除术（12/16），且无一例进行全盆腔脏器切除术。经常使用带蒂皮瓣（网膜瓣11例；腹直肌瓣7例）。术中平均输血5（范围1 - 33）单位。输血与先前的腹会阴联合切除术相关（P < 0.03），与术后发病率密切相关（P < 0.02）。17例（59%）患者出现33例并发症，最常见的是会阴伤口裂开（9例（31%））和盆腔脓肿（5例（17%））。中位住院时间为18（范围7 - 56）天，先前接受过腹会阴联合切除术的患者（P < 0.02）或术后出现并发症的患者（P < 0.03）住院时间明显更长。唯一的术后死亡原因是盆腔感染。18例患者（62%）切除彻底（R0），10例（34%）显微镜下切缘阳性（R1），1例（3%）肉眼切缘阳性（R2）。两年和五年复发率分别为47%和85%；疾病特异性生存率分别为63%和20%。单因素分析显示，较少的输血量（P = 0.03）、R0切除（P = 0.005）、无前方器官受累（P = 0.02）和无皮质骨侵犯（P < 0.001）与较好的生存率相关；原发结直肠癌分期则无此关联。
直肠癌骶骨切除术是一种高风险手术，在部分患者中可实现切缘阴性且死亡率低。该手术治愈率低，但可能提供局部疾病控制且发病率可接受。
