Total sacrectomy for recurrent rectal cancer - A case report featuring technical details and potential pitfalls

George Melich; Michael Weber; Barry Stein; Vincenzo Minutolo; Manuel Arena; Goffredo O Arena

doi:10.1016/j.ijscr.2014.04.026

Total sacrectomy for recurrent rectal cancer - A case report featuring technical details and potential pitfalls

Int J Surg Case Rep. 2014;5(7):403-7. doi: 10.1016/j.ijscr.2014.04.026. Epub 2014 Apr 30.

Authors

George Melich¹, Michael Weber¹, Barry Stein¹, Vincenzo Minutolo², Manuel Arena², Goffredo O Arena³

Affiliations

¹ McGill University Health Center, 1650 Cedar Ave, Montreal, QC H3G 1A4, Canada.
² Deparment of Surgical Sciences, Organ Transplantation and Advances Technologies, University of Catania, via Santa Sofia 84, 95137 Catania, Italy.
³ McGill University Health Center, 1650 Cedar Ave, Montreal, QC H3G 1A4, Canada. Electronic address: goffredoarena@gmail.com.

Abstract

Introduction: Total sacrectomy for recurrent rectal cancer is controversial. However, recent publications suggest encouraging outcomes with high sacral resections. We present the first case report describing technical aspects, potential pitfalls and treatment of complications associated with total sacrectomy performed as a treatment of recurrent rectal cancer.

Presentation of case: A fifty-three year old man was previously treated at another institution with a low anterior resection (LAR) followed by chemo-radiation and left liver tri-segmentectomy for metastatic rectal cancer. Three years following the LAR, the patient developed a recurrence at the site of colorectal anastomosis, manifesting clinically as a contained perforation, forming a recto-cutaneous fistula through the sacrum. Abdomino-perineal resection (APR) and complete sacrectomy were performed using an anterior-posterior approach with posterior spinal instrumented fusion and pelvic fixation using iliac crest bone graft. Left sided vertical rectus abdominis muscle flap and right sided gracilis muscle flap were used for hardware coverage and to fill the pelvic defect. One year after the resection, the patient remains disease free and has regained the ability to move his lower limbs against gravity.

Discussion: The case described in this report features some formidable challenges due to the previous surgeries for metastatic disease, and the presence of a recto-sacral cutaneous fistula. An approach with careful surgical planning including considerationof peri-operative embolization is vital for a successful outcome of the operation. A high degree of suspicion for pseudo-aneurysms formation due infection or dislodgement of metallic coils is necessary in the postoperative phase.

Conclusion: Total sacrectomy for the treatment of recurrent rectal cancer with acceptable short-term outcomes is possible.A detailed explanation to the patient of the possible complications and expectations including the concept of a very high chancefor recurrence is paramount prior to proceeding with such a surgery.

Keywords: Colorectal; Rectal cancer; Recurrence; Sacrectomy.