Total Pelvic Exenteration, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy for Rectal Cancer with Associate Peritoneal Metastases: Surgical Strategies to Optimize Safety

Jean-Jacques Tuech; Jean Pinson; François-Xavier Nouhaud; Gregory Wood; Thomas Clavier; Jean-Christophe Sabourin; Frederic Di Fiore; Matthieu Monge; Eloïse Papet; Julien Coget

doi:10.3390/cancers12113478

Total Pelvic Exenteration, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy for Rectal Cancer with Associate Peritoneal Metastases: Surgical Strategies to Optimize Safety

Cancers (Basel). 2020 Nov 23;12(11):3478. doi: 10.3390/cancers12113478.

Affiliations

¹ Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France.
² Department of Urology, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France.
³ Department of Anesthesiology and Critical Care, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France.
⁴ Department of Pathology, Iron Group, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France.
⁵ Department of Digestive Oncology, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France.

Abstract

Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment option for patients with peritoneal carcinomatosis. Total pelvic exenteration (TPE) is an established treatment option for locally advanced pelvic malignancy. These two procedures have high mortality and morbidity, and therefore, their combination is not currently recommended. Herein, we reported our experience on TPE associated with CRS/HIPEC with a critical analysis for rectal cancer with associate peritoneal metastases.

Methods: From March 2006 to August 2020, 319 patients underwent a CRS/HIPEC in our hospital. Among them, 16 (12 men and four women) underwent an associated TPE. The primary endpoints were perioperative morbidity and mortality.

Results: There was locally recurrent rectal cancer in nine cases, six locally advanced primary rectal cancer, and a recurrent appendiceal adenocarcinoma. The median Peritoneal Cancer Index (PCI) was 8. (4-16). Mean duration of the surgical procedure was 596 min (420-840). Complete cytoreduction (CC0) was achieved in all patients, while clear resection (R0) margins on the resected pelvic organs were achieved in 81.2% of cases. The median hospital stay was 46 days (26-129), and nine patients (56.2%) experienced severe complications (grade III to V) that led to death in two cases (12.5%). The total reoperation rate for patients was 6/16 (37.5%) and 3/16 (18.75%) with percutaneous radiological-guided drainage.

Conclusions: In summary, TPE/extended TPE (ETPE) associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC in patients with resectable peritoneal surface diseases if a R0 resection could be achieved on all sites. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended.

Keywords: cytoreductive surgery; empty pelvis syndrome; hyperthermic intraperitoneal chemotherapy; ileal conduit; pelvic exenteration; peritoneal carcinomatosis; peritoneal metastases; urinary leakage.