Today is about pelvic interaction, and the goal is for you to understand that there is a resuscitation surgery for when patients with ulcerative colitis have a recidivism. Ulcerative colitis is the main cancer in Mozambique, so it is important that you have a notion of this type of surgery. Our goal today is to talk a little bit about the initial treatment of ulcerative colitis. What is this treatment that we have when the ulcerative colitis presents a recidivism? You will see this when you have your video, you are already seeing it, right? Let's talk about what are the main indications and contraindications and how the reconstruction and rehabilitation of this surgery is done in oncological gynecology. The initial treatment for ulcerative colitis, let's say the classic way, in initial stages, reads from 1 to 2, 1b1, 1b2, 1b3, we already indicate radiotherapy, or 2 to 1, which are those tumors smaller than 4 cm that invade the vagina in selected cases, preferably done with surgery, as long as the patient does not have positive lymph nodes or parameters involved in the resonance, some factor that indicates radiotherapy that she will need adjuvant, and these patients that are operated on can go into follow-up or do radiotherapy with or without chemotherapy, depending on what you study. The patients that are 1b3, 2a2, up to 4a, you will do a radiotherapy treatment with chemotherapy as a follow-up. These patients are not candidates for surgery initially, the treatment with radiotherapy, remembering that it is with a healing purpose, but you will not do a surgery like this if you have radiotherapy available. Fortunately, this radiotherapy arrived in Mozambique, so these cases ended up not being operated. These patients also go into follow-up. However, there is a considerable residue rate. In the best centers, this residue rate reaches around 15% to 30%, and you can have metastases at a distance, especially in cases that are already 4b, that is, cases with metastases at a distance. In these cases, you can use chemotherapy with platen and taxol, or pax-taxel with isoflamyces platen, which is another typical scheme that is well used, and also with belvacizumab in these cases that have residue. So when the patient has a residue at a distance, you use chemotherapy with or without radiotherapy. So it reverses the order a little. And when the patient has only a local-regional residue, that is, it is residualized in the pelvis, but it has no disease at a distance. This distance disease factor is very important. So if the patient did a surgery, did not do radiotherapy and it residualized, you can use the rescue radiotherapy, as long as it has not done the dose of radiotherapy. Remember that radiotherapy has a limit dose, you cannot irradiate the same person several times. So this is all calculated because there is a risk of literally destroying the quality of life of the person. You can't re-irradiate all cases. However, after surgery, you can use the surgery in selected cases, as long as that surgery will not bring so much morbidity or mortality to that patient. And whenever you operate, you end up doing the radiotherapy with chemo, if the patient was a virgin of previous radiotherapy. This is very important, it is not to re-irradiate. These are the patients who were not subjected to previous radiotherapy, only surgery. If you have a local-regional residue, without metastases at a distance, after a radiotherapy treatment, the surgery becomes the only curative option for these patients. So today's class aims to identify which patients you can offer this curative option. We will also see that not all are candidates for this rescue surgery, and those who are not candidates end up going to chemotherapy or exclusive palliative care. This residual surgery was first described in the 1940s, by this professor Alexander Branschweig, very famous in the field of oncological surgery. He did the first surgeries, his first paper was published, and it was of 22 patients with 5 deaths. That is, you see that it is a very high mortality rate at the time. That is, you operate 20 and 5 die during surgery, it is almost prohibitive to do this. However, it was seen that among these 22 patients, those who had survived the surgery, some of them achieved a long-term survival, that is, they lived a long time. So when you have a residue, the type of surgery you do depends on where the residue is. If you have a residue exclusively in the uterus, after the radiotherapy, you can try to do a radical resuscitation stereotomy. You can't always do that, because sometimes everything is glued, adhered to the radiotherapy, and you end up having to remove a neighboring organ. But if you can remove it with free margins, if it is in small tumors, a confirmed residue only in the uterus, it is a possible thing to be done. So it's not always reintegration, sometimes a stereotomy you can get free margins for this patient. The important thing is that you can get free margins, as you will see, there are some works that show that this is what really gives free survival and the chance of healing this patient. Or it is the pelvic interaction, which are absolutely immobile surgeries, with the resection of the pelvic organs, bladder, rectum, uterus, and sometimes even, as you can see in this photo, of the pelvic surface, of the musculature, of the skin, of the vulva, so they are these organs. The indications for her are in the local-regional residue of the uterus cancer, without the presence of metastases at a distance, and as I said, it is the only option that you will have a curative for these patients who have a local-regional residue. If the patient has a local-regional residue or metastases at a distance, you will see that it is a formal contraindication. So, for those who have a localized residual disease, the chance of healing varies from 30% to 70%. This rate varies a lot because it depends on the institution that published it. Because each institution has a certain criterion to use. There are institutions that end up doing more surgeries in worse cases, others that select many cases, so that's why there is this variance. But it will be around 40% to 50% in the best cases. What do you have to consider in a surgery of this size? The first thing you have to think about is the free interval of the disease. Ideally, it should be more than two years. Those patients who have persistent diseases after radiotherapy, that is, after 4, 5, 6 months, you have reexamined the patient after radiotherapy These are bad candidates. Ideally, it should be more than two years, but you will evaluate case by case. The size of the tumor, ideally, is the one that has less than 3 or less than 5, but this varies from each center. But this is what I call the ideal candidate. It is not because a patient has a tumor of 3.5 that you will not do a surgery like this. The last one I operated on had a tumor of 11 cm, but we managed to give free margins. It is a worse candidate, but it is not an absolute contraindication. But the ideal is that it is less than 3 cm. The possibility of free margins is a great indication of this surgery. Why? Because if you do a morbid surgery and you left it with a positive margin, even if it is with a tumor of 2 mm back, this patient in a few months will recede and you did nothing but bring suffering to this patient. So if you think you will not get free margins, this patient is not suitable for surgery. Pelvic interaction, in my opinion, I think it has to be done in a reference center, it is not for anywhere you can do it. You need support and surgery, hospital support, etc. These patients also need a certain psychological and social support, because you will substantially modify the quality of life of these patients. Absolute contraindications. Distance disease, no one will do the surgery on a patient with metastasis. Patients with peritoneal dissemination, also a contraindication. Invasion of the lumbosacral nervous system. You can suspect this in the resonance or in patients who have that pain in the sciatic nerve, which is the pain in the spine, which goes to the posterior of the thigh. Extrapelvic lymphoma, also a contraindication. It is controversial, although people think that paraortic is not a contraindication. And age is also controversial. Even with the report that the prognosis is worse in younger patients, oddly enough. They are classified in anterior interaction, which includes the removal of the bladder, the uterus, if still there is, or the vagina. Classified in posterior, which includes the rectum, the vagina and the uterus, if still there is. Or total, which is when you remove the bladder, the rectum, the vagina and the uterus. And it is also another classification that was proposed by Magrini in the 90s and is well used to this day. Which is type 1, 2 and 3. And this classification, type 1, 2 and 3, takes into account the elevators of the anus and the orogenital diaphragm. Above the elevator is type 1, below the elevator is type 2, and when you include the vulva in the resection, it is type 3. This has a lot to do with the reconstruction, which obviously, the more elevators of the anus you remove, the worse it is for you to rebuild. In the pre-op evaluation, the ideal is that you have a CT PET, but I know it is not available everywhere. Even here in Brazil, it is not available everywhere. But if you don't have it, you will release the hand of the abdominal and pelvic torso tomography to discard metastases at a distance. And a pelvic magnetic resonance to evaluate the local extension of the resonance. And it is a mandatory item, a pathological anatomy confirming the residue. It is prohibited to do a non-interaction surgery without pathological anatomy confirmation. Sometimes it can be only radionecrosis, radiotherapy defect, then biopsy confirming cancer is mandatory. The pelvic magnetic resonance is mainly used to evaluate the lateral extension of it. See that these yellow stripes correspond to the endopelvic face. This is what you need to know if it is a central or lateral residue. This stripe on the left side of the patient has an irregularity. This infiltrated the musculature of the pelvic side and becomes a greater difficulty for you to do this surgery. Unlike this patient here, which has a much smaller residue, you see that it did not infiltrate this endopelvic face, it was a 2 cm residue. So the possibility of getting free margins in this patient is greater. So this would be the best candidate. And as I said, free margins is the main thing. If you leave a millimeter of tumor behind, this patient will receive in a short time and you will have suffered and even risk of death. Because there are people who die from this surgery. So getting free margins is the main prognostic factor of this. So what would be the ideal candidate for exenteration? It would be that patient who has a free interval of disease greater than 2 years, with a small tumor, with less than 3 or less than 5 tumors for some authors, possibility of free margins, that is, you will have to look at this endopelvic face, which is where these yellow stripes are, and see that on the regularity you have a tumor drawn there. The important reference center is that this patient has a psychological condition. So it's not possible to do this for everyone. It has to be a patient who accepts these symptoms, colostomy, urinary derivation, which are often definitive. The candidate that would not be ideal, but still possible for exenteration, is the one with a free interval of disease less than 1 year, those that develop right after the radiation, it is not the best, but it is still possible to do this. With tumors greater than 3 or greater than 5, it is not an absolute contraindication, but the result becomes worse. And that has a lateral extension of the infiltration of the tumor receptor, it is very difficult to have free margins with a lateral extension procedure, but the margin ends up being much smaller. It's not the best, but it's still possible. The one that extends a lot on the side wall, that has bone filtration, etc. These are not candidates, so it ends up going to palliative treatment. These major surgeries, called LIA, were first described by Professor Michael Hockel, at the beginning of the 2000s, it is called LIA, which is Lateral Extended Endopelvic Resection, that is, you remove the lateral musculature of piriform, obturator, this kind of thing. These are very morbid surgeries. If you read the work of Professor Hockel, he will have excellent results, but these results are not reproducible in any other center. Even in large centers, I even had a conversation with some European centers, no one can do what he does. So our LIA rate is more or less around 30% to 40%, which is the survival rate, the cure rate of degeneration. But it has become a possibility. In the past, you didn't even do this surgery, it was already exactly contraindicated, but it still has this possibility of offering a cure to the patient. These surgeries are complex, basically, as you can see in the photo, in red is the iliac artery, in blue is the external iliac vein, and below that you can dry out all the musculature that is there. In white is the nevus obturator, in this case it has been preserved, but you can even dry it out to get margins. You see that there is a time when you see the musculature below and you only see the bone wall. So you can extend to the side to get margins. But they are absolutely complex surgeries, with bleeding, etc. It has to be someone with a certain experience to be able to do this. For these patients who are non-favorable candidates, but still have a possibility, you can start chemotherapy neoadjuvant, if you think you won't be able to do it. There is another work, this was the first work I did as a co-author, when I lived in Italy, when I was a fellow there. I raised all these cases, and there were some cases, about 30 cases, that they had done neoadjuvant chemotherapy, they were unfavorable cases. And when you got an answer, you were able to take this patient to surgery, and the reception rate was relatively good. So it's not for everyone. If you get free margins, you will do the surgery first, but that patient you think won't get margins, you can use neoadjuvant chemotherapy. The scheme they did there is a TIP scheme, which is very toxic, with phosphamide. I don't know if you can do it in Mozambique, but platinum is an option to use it. But that's the exception. The main thing is that if you can do the surgery with free margins, you start the surgery. Some points of controversy are to perform lymphadenectomy in exenteration. I am particularly against it. I think that if you have already done radiotherapy, these lymph nodes, in theory, are treated. Except if you have a single or two lymph nodes that are increased in size. This one you end up choosing to dry out. You will not contraindicate because of a lymph node that is increased. You remove the lymph node together, as long as it is from the usual drainage of the colon. Not that it is an axillary lymph node, but if it is a pelvic or even inguinal lymph node, I don't see it as a contraindication for pelvic exenteration. But systematic lymphadenectomy, after radiotherapy, I don't see the role either. I think radiotherapy has already treated it. How are we going to rebuild and rehabilitate this patient? These are mobile surgeries. We will need to do an intestinal reconstruction, a vaginal reconstruction for young patients, a urinary derivation, which can be a continental reservoir, and rebuild this pelvic axillary. Intestinal reconstruction is always possible. You can do this anastomosis. With the grampiators available today, at least here in Brazil, we can do a good passage of these patients. These patients have to be aware that they will need an anastomosis, or at least temporary anastomosis, or protection for this anastomosis. And many times it is a definitive anastomosis. Sometimes we can't even rebuild. You have to dry the internal musculature, etc. These can't be done. It is a definitive anastomosis. So the patient has to agree with this kind of thing. And the urinary reconstruction is the classic, which is the BRCA, which is the ileal conduct. You do an anastomosis of the ureter in the intestinal half, which is excluded from the intestinal trance, and has a urinary bag in it. In wet colostomy, you do a double derivation in the ureter and the intestinal, in the same bag. There are some results in which the umbilical cord is catheterized, so that the urine comes out. And in the bladder, it is not used, because the results were very bad. Because the results were very bad. You put a bladder ring in a radiated area and the incontinence rate was very high. For vaginal reconstruction, you can use muscle splints, the Facial Cutaneous Splint and Retisigmoid. I will say that none of them is very good, but they are options to rebuild in these very young patients. Pelvic hollow is a big problem. If you do this, you remove all the organs, so there is that hollow and there is a dead space to fill. One of the solutions is to put an increase there, which sometimes ends up occupying this space. It is one of the possibilities. The reconstruction of the foot can be done with splints, whether it is muscular, gluteus, gluteus, or even VY. It is something you can use to rebuild. As a conclusion, disinteration surgery is for absolutely selected cases. You have to consider the patient's performance, free interval of disease, absence of metastases at a distance, and especially the possibility of free margins. I think that's what I brought to you about disinteration surgery. If you have any questions, we are here to answer.

pelvic interaction surgery

ulcerative colitis

resuscitation surgery

oncological gynecology

exenteration surgery

reconstruction