Published online Dec 7, 2018. doi: 10.3748/wjg.v24.i45.5144
Peer-review started: October 15, 2018
First decision: October 23, 2018
Revised: November 5, 2018
Accepted: November 16, 2018
Article in press: November 16, 2018
Published online: December 7, 2018
Processing time: 62 Days and 9.4 Hours
Colorectal cancer is the fourth cause of death caused by cancer according to reports from the United States. Up to 33% of rectal cancers might present as locally advanced, requiring multidisciplinary approaches. Pelvic exenteration (PE) combined with multimodal treatment has resulted in increased survival in this population of patients, but there remains a need for further reports in the literature concerning the management of patients with primary locally advanced rectal cancer.
Previous studies suggested that an aggressive approach, with surgery combined with other treatment modalities, might confer good outcome in terms of tumour clearance and survival in locally advanced primary rectal cancer (LAPRC). Few reports have been published detailing the outcome of nationwide databases.
This study aimed to investigate the outcome of PE for primary rectal cancer in patients included in the National Spanish Association of Surgeons Rectal Cancer Registry.
This is a retrospective, observational study drafted according to the STROBE statement. Patients who underwent PE for LAPRC between 2006 and 2017 and who were registered in the Spanish Registry of Rectal Cancer of the Spanish Association of Surgeons were included if surgery was performed with curative intent and if 5-year follow up had been completed.
Short-term morbidity and mortality of the procedure and 5-year oncologic outcome represented the primary aims of this study. Secondary aims included a comparison of outcomes with a matched group of patients from the registry who underwent non-exenterative surgery for low rectal cancer during the same time frame.
PE were associated with perioperative mortality in approximately 2.5% of patients, and perioperative morbidity was common. More than 50% of patients had at least one complication, which required reoperation in 10%. Up to 10% of patients suffered from intra-abdominal septic complication. Wound-associated complications at the perineum were common, almost reaching 20%. The rate of resections with margins that involved tumours was 23%, and good quality of the mesorectum was achieved in 74% of specimens.
Oncologic outcome was acceptable, with good life expectancy provided a free-free resection margin had been achieved. An involved margin was independently associated with increased risk of local recurrence [hazard ratio (HR) = 5.58, 95%CI: 1.04-30.07, P = 0.04]. Survival was impaired by perioperative complications [HR = 3.53, 95%CI: 1.12-10.94, P = 0.03].
In terms of comparison with non-exenterative procedures, the latter were associated with fewer blood transfusions (P = 0.035) and more anastomoses (P < 0.001). However, resections with involved margins were less common after PE.
PE is an extensive procedure with a significant rate of perioperative adverse events. However, our analysis of patients with LAPRC treated with this procedure over 10 years confirmed that the survival benefits justify an aggressive attitude, provided that oncologic clearance is achievable. These procedures must be performed in a dedicated unit, and patients be managed under the care of multidisciplinary teams.
An aggressive attitude could confer a significant survival gain in carefully selected patients with LAPRC. The use of national and International registries is of great value to monitor the performance of centres dealing with PE and internal auditing; therefore, their use should be encouraged.