Using Computed-Tomgraphy-Based Pelvimetry and Visceral Obesity Measurements to Predict Total Mesorectal Excision Quality for Patients Undergoing Rectal Cancer Surgery

Vladimir Bolshinsky; David Sweet; Dominic Vitello; Xue Jia; Stefan Holubar; James Church; Brian R Herts; Scott R Steele

doi:10.1097/DCR.0000000000003147

Using Computed-Tomgraphy-Based Pelvimetry and Visceral Obesity Measurements to Predict Total Mesorectal Excision Quality for Patients Undergoing Rectal Cancer Surgery

Dis Colon Rectum. 2024 Mar 22. doi: 10.1097/DCR.0000000000003147. Online ahead of print.

Authors

Vladimir Bolshinsky¹, David Sweet², Dominic Vitello³, Xue Jia⁴, Stefan Holubar⁵, James Church⁶, Brian R Herts², Scott R Steele⁵

Affiliations

¹ Peninsula Health, Melbourne, Australia.
² Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
³ Northwestern University Feinberg School of Medicine, Chicago, Illinois.
⁴ Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.
⁵ Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio.
⁶ Columbia University Medical Center, Herbert Irving Pavilion, New York, New York.

PMID: 38517090
DOI: 10.1097/DCR.0000000000003147

Abstract

Background: A complete total mesorectal excision is the gold standard in curative rectal cancer surgery. Ensuring quality is challenging in a narrow pelvis, and obesity amplifies technical difficulties. Pelvimetry is the measurement of pelvic dimensions, but its role in gauging preoperatively difficulty of proctectomy is largely unexplored.

Objective: To determine pelvic structural factors associated with incomplete total mesorectal excision following curative proctectomy and build a predictive model for total mesorectal excision quality.

Design: Retrospective cohort study.

Setting: A quaternary referral center database of patients diagnosed with rectal adenocarcinoma (2009-2017).

Patients: Curative-intent proctectomy for rectal adenocarcinoma.

Interventions: All radiological measurements were obtained from preoperative CT-images using validated imaging processing software tools. Completeness of total mesorectal excision was obtained from histology reports.

Main outcome measures: Ability of radiological pelvimetry and obesity measurements to predict total mesorectal excision quality.

Results: Of the 410 cases meeting inclusion criteria, 362 had a complete total mesorectal excision (88%). A multivariable regression identified a deeper sacral curve (per 100 mm2 [OR: 1.14, 95% CI: 1.06-1.23, p < 0.001]), and greater transverse distance of pelvic outlet (per 10 mm [OR:1.41, 95% CI: 1.08-1.84, p = 0.012]) as independently associated with incomplete total mesorectal excision. An increased area of pelvic inlet (per 10 cm2); OR: 0.85, [95% CI: 0.75-0.97, p = 0.02] was associated with a higher rate of complete mesorectal excision. No difference in visceral obesity ratio and visceral obesity (ratio >0.4 vs.<0.4) between body mass index (<30 vs. ≥30) or sex was identified. A model was built to predict mesorectal quality using variables: depth of sacral curve, area of pelvic inlet and transverse distance of pelvic outlet.

Limitations: Retrospective analysis not controlled for choice of surgical approach.

Conclusions: Pelvimetry is predictive of total mesorectal excision quality in rectal cancer surgery and can alert surgeons preoperatively to cases of unusual difficulty. This predictive model may contribute to treatment strategy and aid in comparison of outcomes between traditional and novel techniques of total mesorectal excision. See Video Abstract.