A. Zimmerman1, E. Rachlin1, C. Rog1, C. Hsu1, E. Silberfein1 1Baylor College Of Medicine,Surgical Oncology,Houston, TX, USA
Introduction: Rectal cancer with local invasion of adjacent pelvic organs is a difficult problem requiring multidisciplinary care. Pelvic exenteration, or the en-bloc resection of the neoplasm and associated viscera, is a procedure that offers the possibility of curative resection often at the expense of considerable morbidity. We are fortunate to be able to offer this procedure in our resource-limited, county hospital setting. Outcomes of these operations in underserved populations have not been explored.
Methods: A retrospective consecutive cohort study of 17 patients undergoing total or posterior pelvic exenteration for locally advanced rectal cancer at a single county hospital between 2010 and 2017 was performed. Demographic, pathologic, recurrence, and survival data were analyzed utilizing summary statistics. Collaboration among different surgical teams was assessed.
Results: The median age of the cohort was 54 years. The majority (71%) were women and of Hispanic ethnicity (41%). All but one of the patients underwent neoadjuvant treatment. Twelve patients (71%) underwent posterior pelvic exenteration and 5 underwent total pelvic exenteration. Four different teams of surgeons were involved in these operations including members from surgical oncology, gynecologic oncology, plastic surgery, and urology. Eight of the cases involved three or more teams of surgeons, and nine cases were performed by two teams. An R0 resection was accomplished in 13 patients (76%). The remaining patients underwent an R1 resection. The median length of stay was 11 days. The 30-day morbidity was 24% and overall there were 9 complications in 8 patients. All but 2 complications were Clavien-Dindo class I or II. At a median follow up of 986 days there were 3 local recurrences and 4 distant recurrences. There were 2 patient deaths at 875 and 1190 days post-op, respectively.
Conclusion: The outcomes for the treatment of locally advanced rectal adenocarcinoma at a safety net hospital with limited resources are favorable compared to contemporary reports in the medical literature. R0 resection remains the best indicator for mortality following pelvic exenteration. The 76% R0 rate at our institution is well above the published average, which ranges from 37-57%. This may reflect a high proportion of patients in our population with localized but neglected malignancies in contrast to aggressive biology that may be seen in insured patient populations. Despite the relative lack of resources at a county hospital, collaboration among surgical teams can be attained and pelvic exenteration can be performed safely with favorable outcomes.
