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Outcomes After En Bloc Iliac Vessel Excision and Reconstruction During Pelvic Exenteration

Brown, Kilian G. M. B.Biomed.1; Koh, Cherry E. M.B.B.S. (Hons.), M.S., F.R.A.C.S.1,2,3; Solomon, Michael J. M.B.B.Ch. (Hons.), M.Sc., F.R.C.S.I., F.R.A.C.S.1,2,3,4; Qasabian, Raffi M.B.B.S., B.Sc., F.R.A.C.S.5; Robinson, David M.A., M.B.B.S., F.R.A.C.S.5; Dubenec, Steven M.B.B.S., B.Sc. (Med.), F.R.A.C.S.5

doi: 10.1097/DCR.0000000000000421
Original Contributions: Colorectal/Anal Neoplasia
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BACKGROUND: Advanced pelvic cancers involving the lateral pelvic compartment, and particularly the iliac vasculature, are difficult to manage. Common or external iliac vessel involvement has traditionally been considered a contraindication for curative surgery.

OBJECTIVE: The purpose of this study was to investigate pathological and surgical outcomes, particularly postoperative morbidity of pelvic exenteration with en bloc major iliac vascular excision and reconstruction.

DESIGN: This study was a case series.

SETTINGS: The study was conducted at a quaternary referral center for pelvic exenteration in Sydney.

PATIENTS: Patients included those undergoing en bloc iliac vessel excision as part of their pelvic exenteration for a locally advanced pelvic malignancy.

MAIN OUTCOME MEASURES: Over the study period, 336 patients underwent pelvic exenteration. Twenty-one patients (6.3%) underwent en bloc vascular excision of 29 vessels for tumor involvement. Twenty-four vessels required reconstruction. The primary outcomes were postoperative complications and pathologic outcomes. Survival rates were estimated using the Kaplan-Meier technique.

RESULTS: Operating time for patients who underwent vascular excision and reconstruction was longer, but this did not reach significance (631 vs 531 minutes; p = 0.052). Mean blood loss was significantly higher in the vascular excision and reconstruction group (6.8 vs 3.4 L; p < 0.001). Patients who required en bloc vascular excision were less likely to have R0 margins compared with patients who did not (38% vs 78%; p < 0.001). There was no intraoperative or 30-day mortality. Overall graft patency and limb loss at 1 year were 96% and 0%. A total of 52% of patients had at least 1 vascular related complication. Median overall and disease-free survival times were 34 and 26 months.

LIMITATIONS: This study is limited by a relatively small number of heterogeneous patients.

CONCLUSIONS: En bloc vascular resection and reconstruction for contiguous tumor involvement is feasible and safe in selected patients. Advanced pelvic tumors involving iliac vessels should not be precluded from curative surgery in specialized institutions.

1 Surgical Outcomes Research Centre, Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia

2 Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia

3 Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia

4 Discipline of Surgery, University of Sydney, Sydney, New South Wales, Australia

5 Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia

Financial Disclosure: None reported.

Correspondence: Michael J. Solomon, M.B.B.Ch. (Hons.), M.Sc., F.R.C.S.I., F.R.A.C.S., Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, PO Box M157, Missenden Road, New South Wales 2050, Australia. E-mail: professor.solomon@sydney.edu.au

© 2015 The American Society of Colon and Rectal Surgeons