Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
SOuRCe (Surgical Outcomes Research Centre), Sydney, New South Wales, Australia.
Colorectal Dis. 2018 Nov;20(11):1004-1013. doi: 10.1111/codi.14311. Epub 2018 Jul 16.
Pelvic exenteration surgery remains the only curative option for recurrent rectal cancer. Microscopically involved surgical margins (R1) are associated with a higher risk of local recurrence and decreased survival. Our study aimed to develop a post hoc multidisciplinary case conference review and investigate its potential for identifying areas for improvement.
Patients who underwent pelvic exenteration surgery for recurrent rectal cancer with R1 resections at a tertiary referral centre between April 2014 and January 2016 were retrospectively reviewed from a prospectively maintained database. Patients with non-rectal cancers or who underwent palliative surgery were excluded. Cases, imaging and histopathology were evaluated by a dedicated panel including colorectal surgeons, an abdominal radiologist and a gastrointestinal pathologist.
R1 resections were reported in 32 of 110 pelvic exenterations. Patients with other tumours were excluded and one patient had a palliative resection. Nine male patients with 11 exenterations were included with a median age of 56 years. All patients had positive soft tissue margins, and one patient also had an involved bony margin. Failures were due to (interdisciplinary) communication problems, specific management of tumour biology (multifocality, spiculated tumours), which can lead to radiological undercalling, and inadequate surgical technical planning. In hindsight, surgery would have been withheld from one patient.
A retrospective multidisciplinary case evaluation of pelvic exenteration patients with involved surgical margins led to a list of recommendations which included the need to plan for wider surgical soft tissue resections and improvement in interdisciplinary communication. Lessons learned may increase clear margin rates in future resections.
盆腔廓清术仍然是复发性直肠癌唯一的根治性选择。显微镜下累及的手术切缘（R1）与更高的局部复发风险和降低的生存率相关。我们的研究旨在制定一个回顾性多学科病例会议回顾，并研究其识别改进领域的潜力。
我们对 2014 年 4 月至 2016 年 1 月在三级转诊中心接受盆腔廓清术治疗 R1 切除的复发性直肠腺癌患者进行了回顾性分析。从一个前瞻性维护的数据库中排除了非直肠癌或接受姑息性手术的患者。病例、影像学和组织病理学由包括结直肠外科医生、腹部放射科医生和胃肠病理学家在内的专门小组进行评估。
110 例盆腔廓清术中报告了 32 例 R1 切除。排除了其他肿瘤的患者，且一名患者接受了姑息性切除术。9 名男性患者共 11 例接受了廓清术，中位年龄为 56 岁。所有患者均有软组织切缘阳性，1 例患者还存在累及骨缘。失败的原因包括（学科间）沟通问题、肿瘤生物学的特定管理（多灶性、刺状肿瘤），这可能导致影像学低估，以及手术技术规划不足。事后看来，有 1 例患者本应避免手术。
对累及手术切缘的盆腔廓清术患者进行回顾性多学科病例评估后，提出了一系列建议，包括需要规划更广泛的软组织切除术和改善学科间的沟通。从中学到的经验教训可能会提高未来切除手术的切缘清晰率。
