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Supra-elevator total pelvic exenteration for the treatment of locally advanced rectal adenocarcinoma
Apresentação do caso
A.P.S., male, 60 years old, referred on 09/2019 to the Oncology Surgery Service having had diarrhea for 1 year, evolving with rectovesical fistula, and colonoscopy revealing a lesion in the middle rectum started 8cm from the anal zone and extended to the sigmoid colon. Biopsy tubular adenocarcinoma. ECOG 1. Rectal examination up to 7 cm without lesions. Submitted decompression colostomy. Thoracic and total abdomen CT scans showing a rectus-sigmoid transition tumor measuring 12 cm in length, with satellite lymphadenomegaly. Bladder thickening, associated with invasion of seminal vesicles and prostate and CEA of 58. EC IIIB. Referred to oncology for evaluation of neoadjuvant treatment. Performed 3 cycles of FOLFOX. Submitted to total supra-elevator pelvic exenteration on 11/2020, colorectal anastomosis 4 cm from the anal zone and urinary reconstruction using Bricker. Evolved on the 7th PO with urinary fistula with reoperation for suturing a 0.5 cm hole in the bricker wall. He presented good evolution, being discharged from the hospital without complications on the 13th PO. He did not perform an oncology adjuvant. Mucinous adenocarcinoma pathology infiltrating seminal vesicle, prostate and bladder (pT4bN1b), free margins. Follow-up with no evidence of disease recurrence.
Total pelvic exenteration (TPE) removes all of the pelvic organs, including the rectum, bladder, and internal reproductive organs (prostate and seminal vesicles in males or uterus, ovaries, and vagina in females). It is required for curative resection of T4 tumors. TPE is a potentially morbid procedure that is used in the treatment of locally advanced rectal cancer involving adjacent organs or locally recurrent rectal cancer (as a salvage procedure).
In specialized centers, pelvic exenterative surgery can provide long-term survival in patients with locally advanced rectal cancer, provided that negative resection margins are attained. Nodal status was also a determinant of overall survival.
Compared with patients undergoing multivisceral resection for recurrences, patients undergoing multivisceral resection for locally advanced primary rectal cancer have better disease control (89 versus 38 percent) and survival (43 to 66 percent versus 1 to 8 percent).
Patients with locally advanced colorectal adenocarcinoma have survival and prognosis dependent on complete surgery (R0 resection). In cases with PE indication, it is recommended to be evaluated on oncology service with a multidisciplinary team.
Keywords: total pelvic exenteration (TPE); rectal cancer, multivisceral resection
Tumores coloretais e canal anal*
MAURICIO PEREIRA SILVA FILHO, FLAVIA FERREIRA MAGALINI, JUNEA CARIS OLIVEIRA, RENATO MORATO ZANATTO