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Pelvic exenteration and lateral LEER
Pelvic exenteration and lateral LEER
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Okay, no problem. Yep, so the title is Pelvic Exentration and Laterally Extended Endopelvic Resection. I've changed it slightly. I've also included this term, Laterally Extended Pelvic Resection. So that's a LEPRA, which is slightly different from LEA, which I will explain during my presentation. And I do have a lot of slides and I was talking to Asima yesterday and she suggested showing some videos. So I apologize if I go slightly a bit too long. And I wanted to show a little bit on ilial conduit at the end as well, but if there's not enough time today, that's fine. I can maybe do that another time. I'll check to see how much time I'm taking with my initial slides. So I'm gonna start with the LEA procedure because this is something that I think very few people are aware of. LEA, as I say, is a Laterally Extended Endopelvic Resection. It was innovated by this chap, Michael Hockel, who worked in Leipzig in East Germany. He's actually West German, but in the 80s, he decided to move to East Germany, where, as we were just hearing, the radiotherapy services were pretty poor. So he felt it would be an ideal opportunity for him to develop some of his surgical innovations in a center where there was very little good quality radiotherapy within the center. Michael spent many, many years developing his surgical innovations, in particular, LEA. And as you're all probably aware, he achieved the IGCS Lifetime Achievement Award last year. And congratulations to him. I know Michael quite well. I went to Leipzig and watched him do a few of these LEA procedures, attended his workshop, and got to know him extremely well, and began to understand exactly the principles behind the LEA procedure. So he's published quite well on this. This is one of his early publications from over 20 years ago now in Gynecologic Oncology on the LEA procedure. Since then, he's also published in the Lancet Oncology. And as I say, many other publications as well. This one's on pelvic extenuation in 2006. I'm not going to go through all of his publications, but I do want to highlight this one slide, which was in his first publication. And what it shows is that in his center and in his experience, he was achieving excellent survival rates, in particular, cure rates. You can see the survival curve here is flatlining at about 60% for central pelvic recurrences. But what's particularly surprising is he was also operating on patients with central disease that was extending to the pelvic sidewall or true pelvic sidewall recurrences, and achieving similar cure rates of almost 60%. Now, this really was absolutely unheard of because at the time, central disease extending to involve the pelvic sidewall was considered an absolute contraindication to an exenteration. But here we have Michael Hochul producing a series of 100 cases with 60% survival for pelvic sidewall disease. So this is what really enthused me to go and spend some time and learn from him. So what is LEAR? Well, LEAR, as I've mentioned already, is a laterally extended endopelvic resection. It involves really a total exenteration, but also excision of all of the parasyvical and paratuterine tissues, including excision of the obturator muscle and the entirety of the internal iliac vessels. So really it is an operation on the pelvic sidewall, excising some of the pelvic sidewall structures. LEPRA, which I'll talk more about later, is even more radical than that, where in addition to excising the obturator muscle and the internal iliac vessels, it also involves excising some of the pelvic sidewall nerves or the bone or the major blood vessels. So LEAR involves an exenteration plus excision of the obturator muscle, internal iliac vessels. LEPRA is more radical. But I'm going to initially talk about LEAR first. So the technique of LEAR really is quite straightforward. It's a step-by-step process. And the steps are, firstly, to excise the lower parietic lymph nodes, which we then send off for intraoperative frozen section analysis to exclude histological metastatic disease outside of the pelvis. And if the pelvic lymph nodes have not been excised before, we then excise the pelvic lymph nodes as well, which we also send for frozen section analysis. And again, determine whether there's metastatic spread to the pelvic lymph nodes. This would not be an absolute contraindication, but it's important information to have when carrying out a LEAR procedure. We then isolate the common iliac artery, not that that is going to be removed, but so that we can then clamp the common iliac artery should we encounter a horrendous bleeding when we then operate within the pelvis. We then isolate the external iliac artery and vein. And then similarly, the internal iliac artery and vein, which is then divided and cut. We then dissect and separate the vessels away from the sciatic nerve, cut through the obturator muscle, which we then peel off the bony pelvis and the sciatic nerve. We identify, ligate the individual perforating pelvic veins, and then complete the exenteration process, which means opening up the cave of Rhetzius, the presacral space. And if it's going to be an AP resection, as in an abdominal peroneal resection, as in a translevator resection, which most cases of LEAR usually are, we then dissect through the levator ani muscles and then complete the peroneal dissection, excising the urethra, vagina, and anus. So, what I'm going to do is show you some of the edited video clips. I think my screen's stopped. Apologies for this. I'll just escape. Do you want to share the presentation to me? Sorry? Do you want me to share? You can send it to me directly and I can share it. Okay. Two seconds. Sorry about this. I think my screen just stopped. So, this is what we're trying to achieve at the end of the operation. The external iliac artery and vein completely mobilized and dissected, and full visibility of the obturator nerve, the sciatic nerve, the internal iliac artery and veins have been ligated and cut and are part of the specimen. The obturator muscle, as you can see, has been removed, and we've got access into the lumbosacral plexus and the bony pelvis. All of the structures are removed and form part of the specimen. So, the case I'm going to present is a 37-year-old. She originally presented elsewhere with a 1B2 adenosguamous cancer, for which she had a radical hysterectomy and bilateral pelvic node dissection. She then, subsequent to that, had a central pelvic recurrence and was treated with chemoradiotherapy. The tumour, unfortunately, progressed through the chemoradiotherapy. I had an MRI scan which showed that she had a central pelvic tumour that was extending to involve the right obturator muscle. The PET-CT scan was clear, and she was then referred to our Centre for ALEA procedure. So, you can see here on this MRI scan, you can see this is the central pelvic recurrence that's extending over to the right pelvic side wall and involving the obturator muscle, but is clear of the bony pelvis. PET-CT is clear, and I'm going to show you the step-by-step procedure of ALEA procedure now. So, as I say, we start with the lower parietic lymph nodes, and unfortunately, I can't... Let me see if I can turn the... Oh, I won't. Okay. Sorry, I was scared. So, as I say, we start by excising the lower parietic lymph nodes, which we then send off for frozen section analysis. If they are histologically involved, then we have the option of cancelling the operation. In some instances, it can be considered a contraindication to proceeding with ALEA procedure. As you can see in this lady's case, the histology of the parietal lymph nodes was clear. We then, therefore, proceeded with the ALEA procedure, and step one then is to mobilise her, and you can see what I'm doing is really quite a lot of sharp dissection. This lady previously had a radical hysterectomy. She was then treated with X-beam radiotherapy, and when the tumour progressed, she was actually then given an extra boost of radiotherapy to the right pelvic side wall. So, what we're dealing with here, and I think many of you who have operated on post-radiotherapy pelvises will know that there can be significant scarring. So, step one is to mobilise the ureter, and then mobilise the common ALEA artery, and the purpose of that is really so that we can then clamp it should we run into problems with severe haemorrhage. So, of course, in that instance, so we keep a pair of DeBakey aortic vascular clamps handy so that we could clamp the common ALEA artery should we have problems with bleeding. We then mobilise the external ALEA vessels, and again, normally this should be a relatively straightforward procedure, but following the previous surgery and previous radiotherapy, there is significant scarring requiring quite a lot of sharp dissection. I tend to use scissors, and as you can see, they're angled scissors with a blunt tip, and I feel I'm able to get more accurate dissection using scissors, but obviously, other surgeons would use different instruments. After isolating the external iliac artery, we then aim for the internal iliac artery and the objective here really is to dissect it from the scar tissue and surrounding structures. You can see here in this case it's fused to the pelvic side wall and in particular the obturator nerves. So, when the internal iliac artery is mobilized, the objective then is to ligate the artery, which as I've mentioned earlier, is to form part of the specimen. So, this is the internal iliac artery ligated and cut. From here, we then get access to the internal iliac vein, which we then also isolate, ligate and cut. Right. So, the steps are to dissect the external iliac vessels, ligate and cut the internal iliac vessels, and then move on to the next part of the operation, which is to dissect the internal iliac vessels off the pelvic sidewall. At this point, we transect the right ureter, and as you can see, the right ureter has previously been stented as a result of ureteric obstruction from the pelvic sidewall recurrence, and that then gives us access to the sciatic nerve of the pelvic sidewall. The purpose is to preserve the sciatic nerve, otherwise there can be significant morbidity problems postoperatively. So, this is the sciatic nerve being dissected and preserved. That takes us towards the obturator muscle, which is just in the centre of your screen here, and then inferior to the external iliac vessels and the obturator nerve. We then incise through the obturator muscle, which, as I mentioned earlier, is going to form part of the specimen. It's at this point you can encounter quite significant problems with pelvic sidewall veins, which is why it's important to then use haemostatic instruments. I use what we call the small jaw. So, the steps are to cut through the obturator muscle and dissect off the bony pelvis, the sciatic nerve and the lumbosacral nerves. He must statically seal the perforating veins. We're now detecting the muscle of the sciatic nerve, and as I say preserving the sciatic nerve, and best as possible, the lumbosacral axis lies inferior to the sciatic nerve. And thereafter, it's pretty much a standard exenteration. We prepare the presacral space behind the rectum and anus. The cave of rexius anterior has already been prepared in advance. We then hemostatically cut through towards the levator ani muscles and cut through the levator ani muscles. This, as I say, is going to be a translevator exenteration. And then aim for a perineal approach, excising the urethra, vagina, and anus. And here, we're excising the rectum off the anterior surface of the sacrum. And then completing the procedure. So, this is what you'd see at the end of that procedure. As I've shown earlier, the external iliac artery and vein isolated, the internal iliac artery and vein ligated and cut and forming part of the specimen. The obturator nerve should be visible in its entirety, as should be the sciatic nerve and the remainder of the lumbosacral plexus. The obturator muscle has been removed and the rest of it is the bony pelvis. So, these are the steps again, and I'm glad you're recording it because, as I say, there are quite a lot of steps, but each of the steps are relatively straightforward. This is the specimen, and as you can see, this is the obturator muscle completely excised with the specimen. This is demonstrating the internal iliac vessels and here the internal iliac vessels and the ureter. This is the growth specimen, and histologically, you can see, this is what we're aiming for, which is an R-O excision, which is a complete histological tumour-free surgical margin. And in this particular case, you can see the muscle is forming the boundary of that surgical margin. And in fact, in this lady's case, we had a good six millimetre margin on that right pelvic side wall. Now, this is a different case that I did. It's a left-sided lia, and I'm going to show you because we've used the... I'm going to try and turn the volume off. Dr. Raj, you muted yourself. Okay, I think unfortunately... So you can see the obturator nerve and the sciatic nerve. And below that, you can see the lumbosacral plexus. So, can you all still hear me? Hello? Yes, we hear you. Okay, sorry about that music in the background. I wasn't sure how to get rid of it. But I think you probably saw there the anatomy of the pelvic sidewall demonstrating the sciatic nerve and the lumbosacral plexus with the obturator nerve. So, that really is what you should have at the end of a LEAR procedure. Pretty much all of the pelvic sidewall structures removed, except for the external iliac vessels and the nerves and the bony pelvis. LEPRA, as I say, is a little bit more radical. It's a LEAR plus excision of either the nerves or the bone or the major blood vessel, which would obviously indicate the external iliac artery or vein. So, it's what many people describe as truly out-of-the-box surgery. This is... I don't have a huge number of cases. I used to get national referrals from across the UK. But again, I didn't have a huge number. But I combined my cases with David Sigler in Prague and Giovanni Scambia in Italy, in Rome. And together, we did a combined series and published in Gynaecological Oncology as out-of-the-box surgery. And we did this really as an opportunity to compare practices, increase the overall number of cases within the study, and to learn from each other's experiences. You can see here the breakdown. The great majority had excision of the major vessels, but others also had excision of the nerves or the pelvic bone. And what we showed in our publication is that the complication rate really is fairly high. There was a 30% early post-operative complication rate with a 20% late post-operative complication rate. So, 50% really in total. And what we saw was that as the radicality of the operation increased, so did the complication rate. However, we did achieve R0 excision in almost 86% of our cases. And there was significant survival benefit in the RO cases, but also some survival benefit in those cases that had R1 disease or surgical margin involved, which is microscopic surgical involvement of the surgical margin. If you want to read more on this topic, the best publication is this one by my colleagues, David Siblett and Gwenelle Ferron. They've reviewed the entire literature on out-of-the-box surgery or LEPRA. And this was published two years ago in Gynaecological Oncology. In terms of the technique of nerve excision, it's quite straightforward. You actually just cut it. And if you notice in the video that I showed you, that part of the lumbosacral nerve had been cut and that patient did require some post-operative rehabilitation. I think it took about three to four. She was using a walking stick for at least three to four months before achieving her normal gait. But the technique really is straightforward. You just cut the nerves as and when required. In terms of bone excision, clearly you'd get an orthopedic surgeon involved and they would categorize the bone excisions into whether it's the ileum, the acetabulum or the ischium. And the difficult part of this surgery would be the reconstruction of the pelvis interoperatively once the bony pelvis has been removed. And as you can see, the radicanum is the procedure cancer. In terms of blood vessel excision, again, you almost certainly want to get a vascular surgeon involved. But if you were excising the external iliac artery, you'd either do a crossover vessel from the contralateral side or you'd use some quite complex vessel grafts to try and restore blood flow. Now, I think we were hearing from the previous presentation that and Asima was mentioning that it's a procedure that's not well carried out in India, but in fact, these are the ESCO guidelines and LEIA and LEPRA are in fact allowed within the guidelines. This is the most recent cervix cancer guidelines from ESCO and it talks about pelvic side wall recurrence after primary surgery and it does mention the use of LEIA or out of the box procedures. And similarly, I was on the guidelines group for this edition, in fact, with David Siebel and a number of other European gynae oncologists. And here as well, we've recommended that for central pelvic or pelvic side wall recurrence after radiotherapy, one can consider the option of LEIA or out of the box surgery. Of course, one has to consider quality of life. In extreme cases, there is the option of a hemipelvectomy or a hindquarter amputation. There are prostheses available. Again, this would obviously require a huge amount of preoperative selection and patient counselling. And you can imagine the postoperative rehabilitation for cases such as this is fairly extreme. So the question that comes as to whether exenterations and LEIAs or LEPRAs are curative or palliative procedures, predominantly that they should be considered only as a curative procedure. And one still has to balance the problems of complications and survival, quality of life outcomes and what the alternative treatment options might be. Exenterations were first introduced by Brunswick in New York in the US actually as a palliative procedure. But as we've seen improvements in our palliative care now, I think the indications for doing an exenteration or a LEIA as a palliative procedure really is very, very minimised. I've mentioned here already that Brunswick carried out the first exenteration in the States. One has to consider alternative treatment options in addition to surgical options. All of this really is as a result of improvement in our surgical technique, whether it be techniques and training or skills, instrumentations, hemostatic agents or postoperative care and management of complications, but also improvement in anaesthetics and in particular ITU in postoperative care. There are international guidelines on pelvic exenterative procedures. These cover not just gynae, but also colorectal and urology. And I've mentioned already the great importance of preoperative patient counselling and in particular discussing complication rates and quality of life outcomes. I think if you're going to carry out these procedures, expect a median inpatient stay of at least 14 days. I've mentioned in the last series we had complication rates, whether it be early and late, approaching 50%. And for that reason, I think you have to have a good team working with your GI surgeons, vascular surgeons, urologists and radiologists in that you may be able to carry out these procedures without their support necessarily in most instances, but you certainly will need their support should patients develop complications afterwards. Briefly, I'm going to just cover pelvic exenteration. There are different types of exenteration, supralevator or translevator, depending on whether you're going to do an abdominal peroneal approach. Posterior would be removal of the pelvic organs and the rectum, anterior the gynae organs and the bladder. Total, of course, removal of all pelvic organs. This again is what you'd expect to see following a supralevator exenteration. You can see it's fairly dry. And I'm going to talk more about this in just a moment. You'll see that it's dry because the presacral space is actually avascular, as is the parorectal space. Most of the cave of Retzis and the paravacical space is also avascular. So once you've prepared the spaces, in fact, the only area that needs ligating is the central part. And in actual fact, it's a relatively straightforward operation. You don't need to worry about damaging the bladder or the ureters or the bowel because clearly they're going to be removed. The only thing you really need to be concerned about is whether you experience extreme bleeding on the pelvic sidewall. But I would argue that managing bleeding on the pelvic sidewall is actually relatively easier to manage when all the pelvic organs are removed rather than when you're doing, let's say, a radical hysterectomy and the pelvic organs are still in situ. That's a specimen you shouldn't be expecting to achieve. And that's the pathology specimen. The steps, again, are straightforward. I'm not going to go through them now because of time, but you're recording this presentation, so you're welcome to obviously go through these steps in your spare time. I wanted to finish off with a few slides. I was trained by John Monaghan, and this is his series of pelvic exaggerations between 74 and 92. There were 83 cases. That's about four or five cases a year. He himself was trained by Stanley Way. Many of you will still be aware of Stanley Way, who wrote some of the landmark papers, predominantly on vulval cancer surgery. But he also had a vast experience of exentrative surgery and developed the procedure within the Garnier Oncology Centre in Gateshead many years ago. And he's also published on this technique himself. I'd also like to mention Kanishka Karunaratne. He is clinical director of the Garnier Department of National Cancer Institute in Colombo, Sri Lanka. Before I started my subspec training, I did two, three months training with him. And in fact, I got most of my experience of exentrative surgery from him. We can talk more about that if we have time for discussions later. So I owe my thanks to Kanishka, as well as my trainers and mentors. I've published myself on this. This is my publication that week, where we compared our exentrative series with our colorectal colleagues and in fact, showed similar survival outcomes. And if you want to read more on this topic, this is the book that I wrote with John Monaghan, Bonnie's Garnier Surgery, Chapter 24, Exentrative Surgery. We've also done a Cochrane review. This, unfortunately, is probably outdated now. We're about to update it with Christophe Pommel and Des Barton. But again, it defines the place of exentrative surgery for recurrent Garnier malignancies. I think I should mention as well, Saklani at the Tataian Memorial, he's published heavily on exenterations. And I think in terms of the procedure, you know, it's got to be applicable to your home country and your health organization. I'm obviously spend most of my time operating in UK. And obviously, the practices in the UK may well be quite different to in India. So a lot of my experience may not be useful for you guys. But clearly, Saklani has a huge experience of exenterations in Mumbai. But of course, also Penton Baker in Pune, which is not far from Mumbai. And of course, they both got excellent publications on this topic as well, in relation to their experience of exenteration in India. But I think lesson number one, when it comes to pelvic exenteration is, as I did, learn from the experts. And also, I like to think, as Aseema did, also learn from the experts. I don't know if you've got time for our little conduit. It's only another five minutes. But do you think it's best I stop now? Please carry on because we will have all that together in our. Okay. All right. So it's just a few minutes. I'm not going to say I'm not going to review the entire literature. I think it was really just to give you all a flavor. That again, an allele conduit is quite a straightforward operation. I do them myself. And I do a Wallace type two. It's an incontinent conduit. There are continent ones, which I'm not experienced in. But of course, if I had a patient similar to the one that was presented earlier, then of course, I would involve my urology colleagues. And there are one or two centers around the UK that do perform these procedures, especially in young patients. My experiences with an incontinent allele conduit, and I would do what's called a Wallace type two. There's also the Bricker procedure. And the Wallace type two really is quite simple and straightforward. Once the ureters are cut, one would then make a small incision in each ureter, about one to two centimeters in length. We would then spatula the ends of both those ureters and suture, do a side by side suture of those two ureters to create a ureteric platform. And then suture the proximal end of the allele conduit to that ureteric platform, of course, using stents as well. And that really is it. It's a really simple, straightforward operation. So, I'm going to show you a quick video of an allele conduit now. And that should take us to the end of the presentation. So, here we're just preparing the ureter and retaining as best as possible the mesoureter that provides the blood flow and blood supply to the ureter. This is the video I showed you earlier of the right ureter. It's the same patient, in fact. So, both ureters isolated and cut. The lady had a total exenteration, so I'm also preparing an end colostomy. And again, with all colostomies, it's about preserving the vascularity to the colon. Here, I'm identifying an area of the small bowel that I'm going to use as the conduit. And of course, we'd want to pick an area outside of the radiotherapy field, and usually about 20, 30 centimetres away from the ileocecal junction. Once the conduit is prepared, we then re-anastomose the remaining parts of the small bowel, and then create the ureteric platform, as I showed you in the illustration earlier, and then simply suture the proximal end of the conduit. That's been isolated to that ureteric platform, which is what I'm doing here. So, you can see I'm using interrupted sutures. Both ureters are stented. And it's no different than doing a hand-to-hand bowel anastomosis, single layer, and use ICG. We can talk more about this if there's time. And this is to assess the vascularity, not just of the conduit, but also of the small bowel that's been re-anastomosed, but also of both ureters, and also the end colostomy. So, you can see all the bowel is going green, confirming that there is good vascularity. The bit I'm demonstrating here is the small bowel re-anastomosis. This is the vascularity to the ileal conduit. And this is the blood flow and vascularity to where the ureters have been sutured to prepare the ureteric platform, which has then been sutured to the proximal end of the ileal conduit. And I'm satisfied that all those structures are adequately vascularized. And most of the post-operative complication are as a result of poor vascularity. So, this is a good interoperative method of objectively assessing that the vascularity has not been adversely affected during the dissection. So, I think I'll conclude here. I think, you know, the topic of pelvic extension and leprosy is clearly ethically a very demanding topic. Just because you can't operate doesn't mean you should. Clearly, you need to get multidisciplinary input, and of course, MDT support from your Garnier colleagues, as well as your clinicians. So, I think that's all I have to say. From your Garnier colleagues, as well as your clin-oncs and med-oncs, case selection is absolutely critical, as is preoperative patient counselling. And of course, one has to stay focused on quality of life, year outcomes, and focus on reconstruction, rehabilitation. And of course, not all centres should be doing this. And what we should be aiming for is developing centres of national excellence. Thank you very much. Thank you, Raj. I mean, you know…
Video Summary
The presentation focused on pelvic exenteration and laterally extended endopelvic resections (LEAR and LEPRA). LEAR, developed by Michael Hockel, is used for treating specific central pelvic recurrences and involves radical removal of pelvic tissues, excising the obturator muscle and internal iliac vessels. LEPRA is more radical, involving additional excision of pelvic sidewall nerves, bones, or major vessels. The speaker detailed the surgical steps of a LEAR procedure, emphasizing the importance of intraoperative assessment and ensuring clear tumor margins. They highlighted the historical context and evolution of exenterative surgeries, their indications, and the role of alternative treatments. The speaker stressed the importance of multidisciplinary team involvement, preoperative patient counseling, and consideration of quality of life outcomes. Additionally, the presentation briefly covered the construction of an ileal conduit, a simpler surgical option for urinary diversion. The speaker concluded with the need for careful case selection and suggested that such complex procedures should be concentrated in centers of national excellence to optimize outcomes.
Asset Subtitle
Dr Raj Naik
Keywords
pelvic exenteration
LEAR
LEPRA
surgical oncology
tumor margins
multidisciplinary team
quality of life
ileal conduit
Contact
education@igcs.org
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