Advanced Or Recurrent Rectal Cancer/Pelvic Cancers
Surgeries for advanced rectal and pelvic tumours are highly complex and challenging. These cancers often involve surrounding organs such as the bladder, prostate, uterus or ovaries. Vital structures of nerves, blood vessels and the tail bone such as the sacrum may also be involved.
Dr Chew Min Hoe performed his fellowship at the Royal Prince Alfred Hospital, Sydney under the tutelage of Professor Michael Solomon.
He has had extensive experience from his tenure at Singhealth performing and supervising more than 70 to 80 such operations. He is also part of an international consortium, PelvEx, which has published many advances in techniques and best care practices.
WHEN IS SURGERY RECOMMENDED?
These surgeries are known as Pelvic Exenterations and are only suitable in patients who are medically fit; and whereby the surgery team has evaluated and determined that a safe and curative operation is possible for this tumour.
Pelvic Exenteration surgery in metastatic disease may be considered if the patient has difficult symptoms that are causing considerable pain and discomfort; and/or if they cannot receive any further chemotherapy or radiotherapy.
WHY IS SURGERY RECOMMENDED?
Pelvic tumours can involve many vital structures which often lead to persistent and unrelenting pain, intestine blockage, bleeding, foul-smelling discharges due to cancer fistulation or malignant ulcers, or recurrent pelvic infections that require frequent hospitalization and limit further treatment.
Studies have shown that while chemotherapy or radiotherapy have been traditionally offered, these offer only short-term relief of symptoms, and often relapse. Patients also have poor cancer survival.
WHAT TO EXPECT
Tumours originating from the rectum, gynecological or urological organs behave differently and surgery for each will need to be discussed among different specialists and experts.
Our team will coordinate and organise the following:
Multi-disciplinary team evaluation and discussions
Biopsies of the tumour if possible, in order to confirm the diagnosis. These may not always be possible as the tumour may be located in difficult areas to access, such as the bone or pelvis.
Radiological imaging to determine if the tumour can be removed
Discussions with the patient and caregivers about the risks and benefits of the surgical plan
Determine if pre-treatment is needed, such as radiotherapy or chemotherapy
GOALS OF TREATMENT:
To ensure complete tumour clearance (R0) for good survival
To restore and improve quality of life for cancer patients
As the surgery may be long, patients and caregivers will be advised on an estimate of the duration of hospitalization in the ICU and ward. This can range from an average of 2 weeks and beyond, depending on the complexity of the tumour surgery.
Complications of this procedure may be higher due to the advanced nature of the cancer and the difficulties of the surgery. The surgical team will monitor the patient closely and provide necessary nutrition and rehabilitation support to optimize recovery.
Stomas may be needed for both bowel contents (feces) and/or urine (ileal conduit) as well. Many of these stomas are usually permanent as wide radical surgery has been performed to remove all possible tumour and to reduce recurrence.
In addition, the tumour itself or many of the treatments prior may have made control (continence) of passing motion or urine difficult with problems of incontinence or immense difficulty in voiding.
Stomas in these circumstances may allow for better quality of life as it avoids accidental soilage of oneself, reduce skin blisters and pains due to frequent soilage, and which further makes walking or sitting difficult. Finally, it also avoids the need to wear diapers, which can affect some patients’ perception of dignity.
Plastic surgeon expertise is often needed for flap reconstruction to help close the large pelvic wounds that are needed to remove the extensive cancers. The flaps are muscle and skin transferred from one part of the body (usually the abdominal wall muscle or thigh muscle) into the pelvis in order to close the "defect" created.
The need for a flap will be individualized and will be discussed before surgery. Recovery will be personalized and guidance on activity and wound care will be supervised closely by the team.
Chew MH; Brown Wendy E; Masya Lindy; Harrison James D; Myers Eddie; Solomon Michael J
Clinical, MRI, and PET-CT criteria used by surgeons to determine suitability for pelvic exenteration surgery for recurrent rectal cancers: a Delphi study.
Diseases of the colon and rectum 2013; 56(6):717-725
Chew MH, Yeh YT, Toh EL, S A Sumari, Chew GK, Lee LS, Tan MH, T P Hennedige, Ng SY, Lee SK, Chong TT, H R Abdullah, T HG Lin, M Z Rasheed, Tan KC, Tang CL
Critical evaluation of contemporary management in a new pelvic exenteration unit: The first 25 consecutive cases.
World J Gastrointest Oncol 2017 May 15; 9(5): 218-227
Aslim EJ, Chew MH, Chew GK, Lee LS
Urological outcomes following pelvic exenteration for advanced pelvic cancer are not inferior to those following radical cystectomy