The management of recurrent pelvic malignancy. Pete Sagar The General Infirmary at Leeds England. Things could be worse. TWO-timing Shane Warne has been caught cheating with ANOTHER woman. EXCLUSIVE: SHANE'S AT IT AGAIN Cheat Aussie star's two-month affair - PowerPoint PPT Presentation
TRANSCRIPT
The management of recurrent pelvic malignancy
Pete Sagar
The General Infirmary at Leeds
England
Things could be worse
EXCLUSIVE: SHANE'S AT IT AGAINCheat Aussie star's two-month affairBy Megan Lloyd Davies And Richard Smith
MESSAGES: Warne sent a string of texts
TWO-timing Shane Warne has been caught cheating with ANOTHER woman.
Presentation
• PAIN
The problem
• 8-10 000 cases annually of rectal cancer in the UK
• Local pelvic recurrence in 5-15%
Treatment – radiotherapy/chemotherapy
• Good initial palliation
• Long term survivors are rare
• Reserved for end stage disease
Treatment- surgery
• Multimodality therapy
• Team approach essential
• Technical demands
Preoperative assessment
• Biopsy to confirm diagnosis
• CT chest and abdomen
• MRI pelvis
• EUA
• Fitness for operation
The Leeds MDT meeting
Accommodation for relatives
Accommodation for relatives (NHS)
Patterns of pelvic invasion
• Localised type
• Sacral invasion
• Pelvic side wall invasion
Localized type
• Recurrent tumour is localized to the adjacent tissues or connective tissue
Peri-anastomotic recurrence
Perineal recurrence
Mucinous adenocarcinoma
Sacral invasion
• Recurrent tumour invades the lower sacrum (S3, S4, S5) or coccyx
Chordoma with sacral invasion
Sacral invasion- gadolinium enhanced
Lateral invasion
• Recurrent tumour invades pelvic side wall
Pelvic side wall invasion
Vesico-ureteric junction
Planes of attack
APR+S vs TPE+S
Rectus abdominus flap
Anatomical points
When not to operate
Choose your patient!
Contraindications
• Extrapelvic disease
• Invasion of S1 or S2
• Invasion through greater sciatic notch
• Extensive pelvic side wall involvement
• ASA IV-V
Para-aortic nodal involvement
Greater sciatic notch involvement
Surgical intervention contraindicated
Extension through both greater sciatic foramina
Technical tips
Perianastomotic recurrence
Peri-anastomotic recurrence
• Residual mesentery
• Anticipate tearing around the anastomosis
• Beware the medial course of the ureters
Anterior invasion into bladder
Anterior spread
• Trial dissection
• Plane anterior to the bladder
• APER
• Involve the urologist
Sidewall vessel involvement
vessels
Pelvic side wall
• BLEEDING
• Suture
• Fibrillar surgicell
• Argon beamer
• Be prepared to pack
Presacral space, no direct invasion
Pre-sacral mass
• Control iliac vessels before dissection of mass
• Incise peritoneum and develop plane between mass and sacrum