En Bloc Sacrectomy for Retrorectal Tumor: Factors Influencing Immediate Outcome
Keywords:
pelvic surgery, presacral tumor, retrorectal tumor, sacrectomyAbstract
Background: En bloc sacrectomy is the only chance for cure of retrorectal tumor. Total sacrectomy is acomplicated, time-consuming and collaborative operation with multiple potential postoperative morbidities and mortality.
Well-planned surgery, perioperative care and rehabilitation would be beneficial in surgical outcomes and decrease
postoperative complications.
Objective: To define the factors affecting the immediate outcomes of en bloc sacrectomy in patients with
retrorectal tumor.
Study design: A retrospective cohort at a single academic institute.
Methods: Data were collected retrospectively in all patients who underwent en bloc sacrectomy at the Lerdsin
Hospital between June 2008 and August 2013. We reviewed demographic data, clinical findings, past medical history,
tumor characteristics, tumor invasion, preoperative preparation: iliac artery embolization, ureteric stenting, surgical
procedures, intraoperative complication, estimated blood loss, units of blood transfusion, histopathologic findings,
postoperative morbidities and mortality, functional outcomes: constipation, urinary retention and gait disturbance.
Immediate surgical outcome was defined according to the postoperative complications, hospital length of stay, functional
outcomes and gait disturbance. All parameters were analyzed and determined for their significance.
Result: Fifteen patients (6 males and 9 females) who underwent sacrectomy (6 subtotal sacrectomy and 9 total
sacrectomy) were studied. The mean age was 53.8 years (range 26-83 years). Of these, 13 had preoperative iliac artery
embolization, 6 had ureteric stenting, 8 had anterior approach with bilateral internal iliac vessels ligation, 2 had protective
colostomy and 3 had lumbosacral reconstruction. The average operative time was 8.4 hours (4-14 hours). The mean
estimated blood loss was 5,020 mL (1,600-10,000 mL) and the average blood transfusion was 17.6 units (range 1-40 units).
Pathological diagnosis were chordoma (n=7), malignant peripheral nerve sheath tumor (n=3), chondrosarcoma (n=2), and
giant cell tumor, gastrointestinal stromal tumor (GIST) and leiomyosarcoma (1 each). Based on the Clavien-Dindo
Grading Systems for postoperative complications, 1 patient was categorized into Class I, 2 in Class II, 4 in Class IIIa, 7 in
Class IIIb and 1 in Class V. Eight patients (53%) had major complications and required re-operation and 1 patient died
from severe sepsis. Regarding functional outcomes, 14 of 15 patients had postoperative urinary retention and 10 of them
(67%) had constipation. The gait disturbance was as follows: 5 patients walked without assistance, 6 patients walked with
assistance and 3 patients needed wheelchairs. None had sacral hernia. The mean duration of hospital stay was 77 days
(range 24-186 days).
Conclusion: Subtotal sacrectomy was safe and had less complications whereas preoperative iliac artery embolization
did not influence intraoperative blood loss. The anterior approach with internal iliac vessel ligation decreased blood loss
especially in total sacrectomy and the posterior approach is a safe option for subtotal sacrectomy. The protective
colostomy did not affect the incidence of surgical site infection but helped in decreasing its severity. Despite preoperative
ureteric stenting, ureteric injury could not be prevented. The closure of sacral defect could be adequately undertaken
without prosthesis sheath by gluteal advancement flap or gluteus maximus approximation. There was no difference
between total and subtotal sacrectomy in terms of urinary retention and constipation. Gait disturbance is less in subtotal
sacrectomy compared to total sacrectomy. Without lumbopelvic reconstruction, total sacrectomy could give favorable
intermediate and long term outcome.
References
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retrorectal space. Dis Colon Rectum 2005;48(10):1964-74.
2. Uhlig BE, Johnson RL. Presacral tumors and cysts in adults. Dis
Colon Rectum 1975;18(7):581-9.
3. Johnson WR. Postrectal neoplasms and cysts. Aust N Z J Surg
1980;50(2):163-6.
4. Cody HS 3rd, Marcove RC, Quan SH. Malignant retrorectal
tumors: 28 years’ experience at Memorial Sloan-Kettering
Cancer Center. Dis Colon Rectum 1981;24(7):501-6.
5. Freier DT, Stanley JC, Thompson NW. Retrorectal tumors in
adults. Surg Gynecol Obstet 1971;132(4):681-6.
6. Jao SW, Beart RW Jr, Spencer RJ, et al. Retrorectal tumors.
Mayo Clinic experience, 1960-1979. Dis Colon Rectum 1985;
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7. Daniel D, Nicolas D, Pierre-Alain C: Classification of Surgical
Complications: A New Proposal With Evaluation in a Cohort of
6336 Patients and Results of a Survey. Ann Surg 2004; 240(2):
205-213.
8. Fourney DR, Rhines LD, Hentschel SJ, et al. En bloc resection
of primary sacral tumors: classification of surgical approaches
and outcome. J Neurosurg Spine 2005;3(2):111-22.
9. Randall RL, Bruckner J, Lloyd C, Pohlman TH, Conrad EU 3rd.
Sacral resection and reconstruction for tumors and tumor-like
conditions. Orthopedics 2005;28(3):307-13.
10. Wuisman P, Lieshout O, Sugihara S, van Dijk M. Total sacrectomy
and reconstruction: oncologic and functional outcome. Clin
Orthop Relat Res 2000;(381):192-203.
11. Fakhry SM, Sheldon GF. Massive transfusion in the surgical
patient. In: Jeffries LC, Brecher ME, editors. Massive Transfusion
American Association of Blood Banks, Bethesda; 1994.
12. McLoughlin GS, Sciubba DM, Suk I, et al. En bloc total
sacrectomy performed in a single stage through a posterior
approach. Neurosurgery 2008;63(1 suppl 1).
13. Clarke MJ, Dasenbrock H, Bydon A, Sciubba DM, McGirt MJ,
Hsieh PC, Yassari R, Gokaslan ZL, Wolinsky JP. Posterior-only
approach for en bloc sacrectomy: clinical outcomes in 36
consecutive patients. Neurosurgery 2012;71(2):357-64
14. Localio SA, Eng K, Ranson JH: Abdominosacral approach for
retrorectal tumors. Ann Surg 1980;191:555-60.
15. Wanebo HJ, Marcove RC: Abdominal sacral resection of
locally recurrent rectal cancer. Ann Surg 1981;194:458-71.
16. McCormick PC, Post KD: Surgical approaches to the sacrum,
in Doty JR, Rengachary SS (eds): Surgical Disorders of Sacrum.
New York: Thieme Medical Publishers; 1994. p. 257-65.
17. Wuisman P, Lieshout O, Sugihara S, van Dijk M. Total sacrectomy
and reconstruction: oncologic and functional outcome. Clin
Orthop Relat Res 2000:192Y203.
18. Ohata N, Ozaki T, Kunisada T, Morimoto Y, Tanaka M, Inoue H.
Extended total sacrectomy and reconstruction for sacral
tumor. Spine 2004;29:123Y6.
19. Santi MD, Mitsunaga MM, Lockett JL. Total sacrectomy for a
giant sacral schwannoma. A case report. Clin Orthop Relat
Res 1993:285Y9.
20. Miles WK, Chang DW, Kroll SS, Miller MJ, Langstein H, Reece
GP, et al. Reconstruction of large sacral defects following
total sacrectomy. Plast Reconstr Surg 105:2387-2394, 2000
21. Ian suk. Dissecting a complex neurosurgical illustration: stepby-
step development. World Neurosurg 2011;76:497-507.
retrorectal space. Dis Colon Rectum 2005;48(10):1964-74.
2. Uhlig BE, Johnson RL. Presacral tumors and cysts in adults. Dis
Colon Rectum 1975;18(7):581-9.
3. Johnson WR. Postrectal neoplasms and cysts. Aust N Z J Surg
1980;50(2):163-6.
4. Cody HS 3rd, Marcove RC, Quan SH. Malignant retrorectal
tumors: 28 years’ experience at Memorial Sloan-Kettering
Cancer Center. Dis Colon Rectum 1981;24(7):501-6.
5. Freier DT, Stanley JC, Thompson NW. Retrorectal tumors in
adults. Surg Gynecol Obstet 1971;132(4):681-6.
6. Jao SW, Beart RW Jr, Spencer RJ, et al. Retrorectal tumors.
Mayo Clinic experience, 1960-1979. Dis Colon Rectum 1985;
28(9):644-52.
7. Daniel D, Nicolas D, Pierre-Alain C: Classification of Surgical
Complications: A New Proposal With Evaluation in a Cohort of
6336 Patients and Results of a Survey. Ann Surg 2004; 240(2):
205-213.
8. Fourney DR, Rhines LD, Hentschel SJ, et al. En bloc resection
of primary sacral tumors: classification of surgical approaches
and outcome. J Neurosurg Spine 2005;3(2):111-22.
9. Randall RL, Bruckner J, Lloyd C, Pohlman TH, Conrad EU 3rd.
Sacral resection and reconstruction for tumors and tumor-like
conditions. Orthopedics 2005;28(3):307-13.
10. Wuisman P, Lieshout O, Sugihara S, van Dijk M. Total sacrectomy
and reconstruction: oncologic and functional outcome. Clin
Orthop Relat Res 2000;(381):192-203.
11. Fakhry SM, Sheldon GF. Massive transfusion in the surgical
patient. In: Jeffries LC, Brecher ME, editors. Massive Transfusion
American Association of Blood Banks, Bethesda; 1994.
12. McLoughlin GS, Sciubba DM, Suk I, et al. En bloc total
sacrectomy performed in a single stage through a posterior
approach. Neurosurgery 2008;63(1 suppl 1).
13. Clarke MJ, Dasenbrock H, Bydon A, Sciubba DM, McGirt MJ,
Hsieh PC, Yassari R, Gokaslan ZL, Wolinsky JP. Posterior-only
approach for en bloc sacrectomy: clinical outcomes in 36
consecutive patients. Neurosurgery 2012;71(2):357-64
14. Localio SA, Eng K, Ranson JH: Abdominosacral approach for
retrorectal tumors. Ann Surg 1980;191:555-60.
15. Wanebo HJ, Marcove RC: Abdominal sacral resection of
locally recurrent rectal cancer. Ann Surg 1981;194:458-71.
16. McCormick PC, Post KD: Surgical approaches to the sacrum,
in Doty JR, Rengachary SS (eds): Surgical Disorders of Sacrum.
New York: Thieme Medical Publishers; 1994. p. 257-65.
17. Wuisman P, Lieshout O, Sugihara S, van Dijk M. Total sacrectomy
and reconstruction: oncologic and functional outcome. Clin
Orthop Relat Res 2000:192Y203.
18. Ohata N, Ozaki T, Kunisada T, Morimoto Y, Tanaka M, Inoue H.
Extended total sacrectomy and reconstruction for sacral
tumor. Spine 2004;29:123Y6.
19. Santi MD, Mitsunaga MM, Lockett JL. Total sacrectomy for a
giant sacral schwannoma. A case report. Clin Orthop Relat
Res 1993:285Y9.
20. Miles WK, Chang DW, Kroll SS, Miller MJ, Langstein H, Reece
GP, et al. Reconstruction of large sacral defects following
total sacrectomy. Plast Reconstr Surg 105:2387-2394, 2000
21. Ian suk. Dissecting a complex neurosurgical illustration: stepby-
step development. World Neurosurg 2011;76:497-507.
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Published
2015-06-30
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Yongchaitrakul T, Kiatisevi P. En Bloc Sacrectomy for Retrorectal Tumor: Factors Influencing Immediate Outcome. Thai J Surg [Internet]. 2015 Jun. 30 [cited 2024 Nov. 6];36(2). Available from: https://he02.tci-thaijo.org/index.php/ThaiJSurg/article/view/226177
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