A New Approach for Pelvic Tumors Invading the Rectum
© 2021 António Gentil Martins, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Objective: Sometimes pelvic tumors invade the rectal wall, needing removal
Design: An alternative technique of radical/conservative surgery (trying to preserve as much as possible the muscular complex) is presented, inspired by De La Torre treatment of Hirschprung’s disease. The lower rectum is only partially resected on the non-involved side, where only mucosa is removed, followed by a lower end to end rectal anastomosis
Results: Normal defecation
Conclusion: A good surgical alternative
Introduction and Objectives
To show a new technique for excision of tumors invading the lower rectum, through the presentation of a recurring presacral tumor which had invaded the posterior rectal wall [1].
Material and Methods
Patient operated aged 6 years (in 2003) for a presacral Teratoma, surgery being followed by chemotherapy (Carboplatino 600 mg/sqm, VP16 120mg/sqm and Bleomycin 15 mg/sqm x 4). Tumor markers (CEA, CA125, alpha-fetoprotein and BHCG were negative. Excision was considered “complete”.
3 years later (2006) a recurrence appeared slightly over the left side, sized 3x3cms, adherent to the anus but moderately mobile. The Patient was given preoperative chemotherapy with Pei (VP16 120mg/sqm, Cisplatino 10mg/sqm and Ifosfamide 1.135 mg/sqm x 5) with a size reduction of about 70%. A small inguinal left node proved to be free of disease [2-3].
The recurrence was excised through a posterior midline approach, requiring excision of part of the muscular complex and of the rectal muscular wall. Bone scintigraphy was normal and tumor markers remained negative.
February 2008 a further recurrence appeared, as well as bilateral lung metastases that were removed by open thoracotomy.
Figure 1: MRI of the recurrent tumor ( second recurrence (2008)
He had chemotherapy (with Gemcitabine and Oxaliplatin x 2) that led to veno-occlusive disease, from which he completely recovered with Di-fibrotide). He was then given Gemcitabine (150mg/sqm), and Paclitaxel (1.500mg/sqm) x3, with no significant improvement in the recurrent tumor but with some improvement in the lung metastases. It was then decided to remove the recurrence as well as the lung metastases. Considering the bad prognosis, a permanent colostomy was to be avoided in order to improve the quality of his expected short life.
Surgical Technique
Again a posterior midline incision was used. The recurrence was found to invade the whole posterior rectal wall. Inspired in De La Torre’s technique for Hirschsprung’s Disease, the rectal wall was individualized above the tumor and sectioned at that level, followed by the removal of the invaded lower part of the rectum, although anteriorly removing only the mucosa and maintaining the muscular rectal wall, in order to try to preserve , at least, part of the muscular complex.
Figure 2: Schematic view of the excisions to be
Figure 3: Anus split with the upper midline incision and appearance of the pelvic cavity where the tumor was contained
Figure 4: The muscular complex of the rectum , opposing the tumor, to be stripped of mucosa, but preserving, at least partially, the muscular wall.
Then the right colon was pulled down, as in De La Torre’s technique for Hirschsprungs Disease, the lowered rectosigmoid being anastomosed inferiorly to the rectum, at the level of the pectineal line.
Figure 5: Colon to be pulled down as in De La Torre for Hirschsprungs disease.
Figure 6: Final appearance of the surgical approach
Figure 7: Operative specimen
Discussion and Results
Histology showed the tumor to be a bi-germinal immature Teratoma, with predominance of neuro-epithelial elements, grade III, again with an apparently complete excision. 36 Grays were then administered locally,
The Patient recovered satisfactory social continence (controlled feces and flatus) He was treated again with Chemotherapy (PEI, with the already quoted dosages x 4). 3 lung metastases were removed on the right side, and 5 (smaller) on the left. His general health, post-operatively, was quite satisfactory, although unfortunately the bad prognoses remained.
Conclusion
Considering the Patient’s quality of life, the described technique may be a good alternative for the removal of presacral tumors in general, and even the best choice to use in one of the extremely difficult situations that surgeons sometimes have to face [4-5].
Disclaimer: This Paper is a single author piece and presents no conflict of interests
References
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- De la Torre-Mondragon L, Ortega Salgado JA (1998) Transanal endorectal pull-through for Hirschsprung’s Disease - J Pediatric Surgery 33: 1283-1286.
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