Evolution of pelvic exenteration surgery- resectional trends and survival outcomes over three decades

Abstract

Objective: To examine the changes in exenterative surgery over three decades analysing oncological outcomes and whether changes in surgical approach have led to improved patient outcomes.

Background: Advances in surgical technology, perioperative care and pattern of disease recurrence have coincided with an evolutionary change in exenterative surgery.

Methods: A review of a prospectively maintained databases of pelvic exenteration surgery from 1988 to 2018 at two high volume specialised institutions. The total cohort was divided into three major time points (1988-2004, 2005-2010 and 2011 to 2018) to allow comparative analysis. Primary endpoints were overall survival in primary and recurrent disease at each time point. Secondary endpoints included anastomotic leak, blood transfusion, ileus, wound infection rates and evolution of case complexity. Data were analysed using R with a p < 0.05 considered significant.

Results: Six hundred and seventy patients underwent exenterative surgery. In 2011-2018 there was an increase in resection of recurrent malignancy with a continuous increase in GI malignancies resected over each time period(p < 0.001,<0.01) and a reduction in gynaecological malignancy(p < 0.001). A significant increase in sacrectomy, pelvic sidewall resection and ileal conduit reconstruction was observed (p < 0.01,<0.001).In 2005-2010 patients had increased rates of ileus and anastomotic leak(p < 0.05). Patients undergoing resection for primary disease had improved overall survival at time points 1988-2004 and 2011-2018 compared to those with recurrent disease(p = 0.007,<0.001). Overall survival was significantly improved in patients with primary versus recurrent disease(p = 0.022).

Conclusion: There has been a significant improvement in survival in patients undergoing pelvic exenteration surgery from primary disease. Case complexity has increased without significant morbidity.

Keywords: Evolution of exenteration; Gynaecological malignancy; Pelvic exenteration; Pelvic malignancy; Rectal cancer; Recurrent rectal cancer.