Exenterative surgery for locally advanced rectosigmoid cancers. Is it worthwhile?

Among 1480 patients treated for cancers of the rectosigmoid over a 30-year period, 24 patients underwent total pelvic exenteration. These patients, 13 men and 11 women, had a median age of 64 years. Pathologic staging revealed 15 Dukes' B and nine Dukes' C lesions. For 17 patients, this operation was the only form of therapy. The operative mortality rate was 20.8%; however, the mortality rate has decreased to 13.3% during the past 20 years and to 9% in the past decade. Five complications occurred in the group surviving the procedure, resulting in a 26.3% morbidity rate. Three of the five complications occurred in patients who had previous radiation therapy or surgery. The overall 5-year survival rate was 41.6%. Those patients surviving the operation had 5- and 10-year survival rates of 52.6% and 31.5%, respectively. There were seven patients in whom the disease recurred at an average of 20.3 months after exenteration, and all died an average of 8 months later. The recurrence rate for patients with Dukes' B lesions was 27% compared with 57% for patients with Dukes' C lesions. The remaining 12 disease-free patients had a mean survival of 11 years. At present, four patients are alive and well 6 to 30 years after exenteration. The best predictor of morbidity was treatment before exenteration (p less than .005). Age older than 65 years and the presence of nodal metastases may contribute to increased mortality rates and recurrence, respectively, but these relationships were not statistically significant for the group. Total pelvic exenteration is advocated for selected primary, locally advanced, rectosigmoid lesions in good-risk patients; it can be achieved now with acceptable morbidity and mortality rates and a survival rate in excess of 40% at 5 years.