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目的 评价盆腔脏器联合切除术（PE）对局部进展期直肠癌的疗效。方法 对12年中79例局部进展期直肠癌PE术后结果进行回顾性总结。结果 全盆腔脏器切除术（TPE）46例，其中保肛TPE5例，TPE联合骶骨切除1例，TPE联合半骨盆切除1例，后盆腔脏器切除术（PPE）33例。根治性切除65例（82．8％），合并症发生率48．6％，手术死亡2例（2．5％），根治术后再复发36例（58．1％），术后1、3、5年生存率75．8％、39．3％、35．8％。根治性切除与大体根治切除术后3年、5年生存率分别为44．2％、40．8％与11．1％、0。结论 PE是目前治疗局部进展期直肠癌有效的方法，积极的根治性切除病灶，可以有效提高其治愈率，改善生活质量。     

新辅助治疗联合盆腔脏器切除术治疗复发直肠癌

目的 探讨新辅助治疗联合盆腔脏器切除术对复发直肠癌的临床治疗价值。方法 对35例复发直肠癌患者,采用新辅助治疗方案。常规分次放疗,放疗总剂量（DT）46Gy,每周5次,每次2Gy。全身化疗2个疗程,每次予以奥沙利铂130mg／m^2,第1天静脉点滴;甲酰四氢叶酸钙（CF）200mg／m^2,第1～3天静脉点滴;氟脲嘧啶（5-Fu）500mg／m^2,第1～3天静脉点滴。治疗结束后4～6周进行盆腔脏器切除手术。结果 经新辅助治疗后,病理完全缓解6例,肿瘤平均缩小38．4％,65．7％的病例T期下降。全组无手术死亡,R0切除率为88．5％,手术并发症发生率为13．3％。本组总的3年生存率为82．8％;5年生存率为48．5％;其中获得R。切除的患者,3年生存率为90．3％,5年生存率为54．6%。结论 新辅助治疗联合盆腔脏器切除术是治疗复发直肠癌的有效方法。通过降低肿瘤病期,提高手术切除率,从而提高患者生存率。     

Posterior pelvic exenteration for primary rectal cancer

BACKGROUND: Indications for and the prognosis of posterior pelvic exenteration (PPE) in rectal cancer patients are not clearly defined. The aim of this study was to analyse the indications, complications and long-term results of PPE in patients with primary rectal cancer. METHODS: A retrospective review included patient demographics, tumour and treatment variables, and morbidity, recurrence, and survival statistics. These results were compared with a group of female patients who underwent standard resection for primary rectal cancer in the same period (non PPE group). RESULTS: The series included 30 women with an average age of 56.7 years (range 22-78). Tumour location was recorded in three cases in the upper rectum, 13 cases in the medium rectum and 14 cases in the lower rectum. A sphincter-preserving procedure was performed in 70% of the patients. Mean operative time was 4.2 h (range 2-7.5 h). Overall major morbidity rate in this series was 50% and mean hospital stay was 19.7 days (range 9-60 days). There was no hospital mortality. Pathological reports showed direct invasion of uterus, vagina or rectovaginal septum in 19 cases, involvement of perirectal tissue in 25 cases and positive lymph nodes in 18 cases. Comparison between PPE and non PPE groups showed no differences in mean tumour diameter, histological grade and tumour stage, but patients in the first group were younger. Although low tumours were seen more frequently in the PPE group (P = 0.003), the rate of sphincter-preserving procedure was comparable in both groups. Operative time was longer (P = 0.04) and morbidity was higher (P = 0.0058) in the PPE group. Local recurrence with or without distant metastases for the whole series was 30%. Five-year survival rate for patients who underwent curative resections (TNM I-III) was 48% in the PPE group vs 62% in the non PPE group (P = 0.09). CONCLUSIONS: In the present series, PPE prolonged operative time, increased postoperative complications and showed a trend toward poor prognosis in recurrence and survival. However, PPE offers the only hope for cure to patients with a primary rectal cancer that is adherent or invades reproductive organs.     

新辅助治疗联合盆腔脏器切除术治疗复发直肠癌

目的探讨新辅助治疗联合盆腔脏器切除术对复发直肠癌的临床治疗价值。方法对35例复发直肠癌患者,采用新辅助治疗方案。常规分次放疗,放疗总剂量(DT)46Gy,每周5次,每次2Gy。全身化疗2个疗程,每次予以奥沙利铂130mg/m2,第1天静脉点滴;甲酰四氢叶酸钙(CF)200mg/m2,第1~3天静脉点滴;氟脲嘧啶(5-Fu)500mg/m2,第1~3天静脉点滴。治疗结束后4~6周进行盆腔脏器切除手术。结果经新辅助治疗后,病理完全缓解6例,肿瘤平均缩小38.4%,65.7%的病例T期下降。全组无手术死亡,R0切除率为88.5%,手术并发症发生率为13.3%。本组总的3年生存率为82.8%;5年生存率为48.5%;其中获得R0切除的患者,3年生存率为90.3%,5年生存率为54.6%。结论新辅助治疗联合盆腔脏器切除术是治疗复发直肠癌的有效方法。通过降低肿瘤病期,提高手术切除率,从而提高患者生存率。     

A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database

Aim The study was conducted in a dedicated centre treating the majority of Danish patients with intended curative total pelvic exenteration for primary advanced (PARC) or locally recurrent (LRRC) rectal cancer. We compared PARC and LRRC and analysed postoperative morbidity and mortality, and long‐term outcome. Method There were 90 consecutive patients (PARC/LRRC 50/40) treated between January 2001 and October 2010, recorded on a prospectively maintained database. Results The median age was 63 (32–75) years with a gender ratio of 7 women to 83 men. All patients were American Society of Anesthesiologists level I or II. Sacral resection was performed in five patients with PARC and 15 with LRRC (P = 0.002). R0 resection was achieved in 33 (66%) patients with PARC and in 15 (38%) with LRRC, R1 resection in 17 (34%) with PARC and 20 (50%) with LRRC and R2 resection in five (13%) with LRRC. R0 resection was more frequent in PARC (P = 0.007). Forty‐four (49%) patients had no postoperative complications. Fifty‐five major complications were registered. Two (2.2%) patients died within 30 days, and the total in‐hospital mortality was 5.6%. The median follow‐up was 12 (0.4–91) months. The 5‐year survival was 46% for PARC and 17% for LRRC (P = 0.16). Conclusion Pelvic exenteration is associated with considerable morbidity but low mortality in an experienced centre. Pelvic exenteration can improve long‐term survival, especially for patients with PARC. However, pelvic exenteration is also justified for patients with LRRC.     

全盆腔脏器切除术治疗直肠癌术后盆腔局部复发

目的评价全盆腔脏器切除术(total pelvic exenteration，TPE)治疗盆腔局部复发直肠癌(locally recurrent rectal cancer，LRRC)的疗效。方法对1989-2003年行TPE治疗的35例直肠癌患者的临床资料进行分析。结果行TPE30例、保肛TPE2例、TPE联合骶、尾骨切除2例、TPE联合半骨盆切除1例。根治性切除率80％，手术死亡率3％，术后盆腔再复发率48％。全组术后5年生存率16％，根治性切除组为19％，无淋巴结转移者5年生存率24％，有淋巴结转移者为0。结论TPE手术成功的关键在于严格的适应证选择和作到真正的根治性切除。     

应用盆腔脏器联合切除术治疗局部复发型直肠癌

目的 评价盆腔脏器联合切除术对局部复发型直肠癌的治疗意义。方法 对我院33例局部复发型直肠癌应用盆腔脏器联合切除术治疗的病例进行回顾性总结。结果 33例患中17例接受全盆腔脏器切除术治疗，14例接受后盆腔脏器切除术；2例为直肠癌合并输尿管下段切除。29例（87．9％）手术为根治术，手术死亡率3．0％。盆腔受累最多的器官是骶前组织和阴道。术后约88．9％的患疼痛症状消失。8例（24．2％）再次复发，并再用手术。全组2、3、4年生存率分别为36．4％、21．2％、18．2％。结论 积极的盆腔脏器联合切除术可以明显改善局部复发型直肠癌的预后，提高术后生活质量。     

The role of pelvic exenteration in the management of recurrent rectal cancer

BACKGROUND: Use of extirpative surgery in the setting of recurrent rectal cancer is controversial given the poor overall outcome of such patients and the morbidity associated with exenteration. METHODS: A retrospective review of patients treated for recurrent rectal cancer from 1990 to 2002 was performed. RESULTS: Twenty-two patients underwent pelvic exenteration. Seventeen underwent potentially curative resection, 5 were for palliation only. There was 1 operative death. Fifteen suffered at least 1 complication; 9 suffered multiple complications. Ten patients required readmission to the hospital. The overall disease-free interval was 11 months. Potentially curative and palliative resections resulted in median survivals of 20.4 and 8.4 months, respectively (P = 0.049). CONCLUSIONS: While patients may derive oncologic and palliative benefits from exenteration, the price in terms of operative morbidity remains high. Newer measures of operative morbidity are necessary to better appraise the value of this radical approach to recurrent rectal cancer.     

Extended surgery for local recurrence and advanced rectal cancer

Although much effort has been directed at reducing the incidence of local recurrence after surgical resection of rectal cancer, there remain a significant number of patients who will develop local recurrence without evidence of metastatic disease. Such patients, as well as patients with locally advanced rectal cancer at presentation, may represent a surgical challenge. Application of sound surgical principals and team work can lead to a good long term outcome. This paper sets out to discuss the philosophy and techniques involved in the surgical management of such patients.     

Combined treatment of pelvic exenterative surgery and intra-operative pelvic hyperthermochemotherapy for locally advanced rectosigmoid cancer: Report of a case

A huge rectosigmoidal cancer which extended into the urinary bladder in a 64-year-old man is herein described. The tumor occupied the pelvic and lower abdominal cavities, while the rectosigmoid was totally obstructed. No hepatic or pulmonary metastasis was evident. The ventral and flank sides of the peritoneum in the right lower abdomen, right common iliac vessels, bilateral ureters, terminal ileum, cecum, ascending colon, and urinary bladder were all directly invaded by the tumor, but the aorta, sacrum, and lower rectum were free of cancer. Consequently, an anterior pelvic exenteration was carried out along with an ileal conduit and a right hemicolectomy. Immediately after the exenteration, intra-pelvic hyperthermochemotherapy was performed using a 46–47°C perfusate containing 40 g/ml of mitomycin C (MMC) and 200 g/ml of cisplatin (CDDP), for 90 min, in an attempt to prevent any further local recurrence. A right hemicolectomy and a permanent colostomy were done simultaneously with the hyperthermia treatment. After an uneventful postoperative course, the patient was prescribed adjuvant chemotherapy, i.e., two administrations of 17 mg/m² and 21 mg/m² of MMC, and ten doses of 710 mg/m² of 5-fluorouracil (5-FU) followed by five doses of 535 mg/m² of 5-FU. At the time of this writing, the patient is still alive without recurrence at 21 months after surgery.     

Radiofrequency ablation for recurrent pelvic cancer

Objective Local recurrence of pelvic cancer is a therapeutic challenge. The purpose of the study was to evaluate radiofrequency ablation (RFA, intra‐operative or CT‐guided) for the treatment of pelvic recurrence in patients not eligible for curative surgical resection. Method Charts of all patients treated for pelvic recurrence by RFA between March 2004 and March 2005 were reviewed. Results Eight patients (two females) had RFA for inoperable local recurrence [rectal adenocarcinoma (six) and sarcoma (two)]. Surgical resection of the primary tumour had been performed at a median age of 50.2 (36.7–61.6) years. Recurrence occurred after a median of 49.5 (11.7–63.5) months. The mean size of the recurrence was 33.4 (20–45) mm. RFA was given on a median number of two occasions (1–3). Complications occurred in six patients including minor pain [pelvic (six); sciatic nerve irritation (four)]; ureteric obstruction requiring stenting (two) and colo‐vesical fistula (one), requiring ileal urinary diversion. After a median follow‐up of 18.2 months (11–32), six patients were still alive. Patients, who had experienced pain prior to RFA were pain‐free. Five patients showed evidence of further tumour growth but were asymptomatic. Conclusion Radiofrequency ablation is a feasible therapeutic option for recurrent pelvic cancer. It allows good symptom control in patients with pain but morbidity is high.     

Patterns of recurrence following pelvic exenteration and external radiotherapy for locally advanced primary rectal adenocarcinoma

Background: Local recurrence remains the main site of failure after pelvic exenteration for locally advanced primary rectal adenocarcinoma. This is a report on the patterns of recurrence in a group of such patients treated with pelvic exenteration and radiotherapy. Methods: Between 1980 and 1992, we treated 49 patients. Thirty-one received preoperative radiotherapy (pre-RT), 4,500 cGy. Six weeks later, we performed posterior pelvic exenteration (PPE) in 21 patients, and total pelvic exenteration (TPE) in 10. Nine patients received postoperative radiotherapy (post-RT), 5,000 cGy after a PPE. Nine patients had surgery only, PPE (n=7) and TPE (n=2). Results: Surgical mortality occurred in 16% of those patients who received pre-RT. The median follow-up was 52 months. Recurrences occurred in 23% of those patients who received pre-RT (local, one; local/distant, one; distant, four); in 88% of those patients treated with surgery only (local/distant, four; distant, four); and in 11% of those treated with post-RT (distant, one). The 5-year survival for patients who received radiotherapy was 66 versus 44% for those treated with surgery only. Conclusion: Local control of locally advanced primary rectal adenocarcinoma requiring a pelvic exenteration is improved by the addition of radiotherapy. When recurrences do occur they are predominantly at extrapelvic sites.Results of this study were presented at The 48th Annual Cancer Symposium of the Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

Meta‐analysis of survival based on resection margin status following surgery for recurrent rectal cancer

Aim To determine the presence and duration of survival advantages was investigated for resection margin status (R0, R1 or R2) following surgery for locally recurrent rectal cancer (LRRC). Method A systematic review of the literature was performed for studies comparing resection margin status for LRRC. Weighted mean differences and meta‐analysis of hazard ratios were used as a measure of median and overall cumulative survival. Results Twenty‐two studies were included, providing outcome for 1460 patients undergoing surgery for LRRC. 57% underwent an R0 resection, 25% an R1 resection and 11% an R2 resection. The most commonly performed operations were abdominoperineal excision (35%), exenteration (23%) and anterior resection (21%). The range of median survival per resection margin was R0 28–92 months, R1 12–50 months, R2 6–17 months. Patients undergoing an R0 resection survived on average for 37.6 (95% confidence interval: 23.5–51.7) months longer than those undergoing R1 resection and 53.0 (31.2–74.8) months longer than those undergoing R2 resection. This correlated to a hazard ratio of 2.03 (1.73–2.38) for R0 vs R1 and 3.41 (2.21–5.25) for R0 vs R2. Patients undergoing R1 resection survived on average 13.3 (7.23–19.4) months longer than those undergoing R2 resection [hazard ratio of 1.68 (1.33–2.12)]. Conclusion Patients undergoing R0 resection have the greatest survival advantage following surgery for recurrent rectal cancer. There is a survival advantage for R1 over R2 resection, but there may be no benefit of R2 resection over palliative treatment.