A very aggressive surgery that may prolong survival for specific rectal cancer patients: extended sacropelvic resection

This study assessed the safety, feasibility, and cancer specific outcomes of extended sacropelvic resection (ESR) for locally recurrent (cancer that has returned at or near its original site) rectal cancer.

Despite improvements in treatment, local recurrence following surgery for rectal cancer remains a persistent problem. Between 5% and 30% of patients will experience local recurrence. Patients with extensive local cancer may benefit from ESR to improve their outcomes.

ESR is a very complicated operation involving removal of a portion of the sacrum (a triangular bone in the lower back) and/or removal of organs from the pelvic cavity (these include the bladder, rectum, anus), and in some cases removal of part of the pelvis and leg. Recent data suggests that there may be survival advantage to this aggressive surgical approach. However, there is limited data regarding the safety of these operations and the benefit to rectal cancer patients.

This study analyzed the records of 406 patients who had surgery for locally recurrent rectal cancer. In total, 30 patients who had undergone ESR were identified. For 24 of these patients it was the first time the cancer had returned, for 5 patients it was the second recurrence and for 1 patient it was the third recurrence. 87% patients underwent radiation therapy before the ESR and 67% patients received radiation therapy during the surgery. Patients were followed for an average of 2.7 years and post-surgery complications and patient survival were recorded.

Complete removal of the cancer was achieved in 93% of cases. No patients died as a result of the surgical procedure, however, 76% of patients experienced complications after the operation, including wound infections or breakdown (40%), abscesses in the pelvis (17%) and hemorrhage (blood loss; 13%). 57% of patients required walking aids after the operation: 13% used a wheelchair, 10% used a walker and 23% used a cane.

After 2 years, 86% of patients were still alive and after 5 years 46% of patients were still alive. After 2 years 79% of patients remained disease free and after 5 years 43% of patients still remained disease free. 

The authors concluded that ESR for locally recurrent rectal cancer can be feasible and safe. However, as this is a very aggressive surgical approach the benefits need to be carefully weighed against the risks when selecting patients.