Sacral Resection Operative Technique
and Outcome
Touraj Touran, MD; Daniel B. Frost, MD; Theodore X. O'Connell, MD \s=b\ Tumors involving the sacrum are difficult to treat. These include both primary tumors of the sacrum and locally invasive colorectal carcinomas. Sacral resection is often the only effective alternative for meaningful palliation or cure of sacral tumors. A review of 20 cases of sacral resections for primary sacral tumors (8) and locally invasive anorectal cancers (12) is presented. The mortality (0%) and morbidity (35% urinary complications, 25% wound disruptions, 1600-mL median blood loss) compare favorably with reports in the literature. Long-term survival was achieved with primary tumors of the sacrum. Local control of disease was achieved in the majority of patients with rectal cancer, with good palliation of preoperative pain. Long-term survival, however, is rare in this group. Surgical resection of sacral tumors can be undertaken with acceptable morbidity and mortality in selected patients.
(Arch Surg. 1990;125:911-913)
involving Tumors These include of primary and colorectal carcinomas. The the
and difficult the sa¬ crum locally invasive symp¬ toms often include severe pain in the sacral region. These tumors, whether primary or secondarily involving the sa¬ crum, generally do not respond to chemotherapy. Irradiation has a role in alleviating nerve root pain, but too often the tumor is either radioresistant or the area has already received maximum irradiation. Even when it is successful, the patient will only receive temporary relief from radiotherapy. There¬ fore, sacral resection is frequently the only effective alterna¬ tive for palliation or possible cure in these patients. Published reports of sacral resection are few.18 These se¬ ries report long operative times, massive blood losses, and, in one series, significant operative mortality.6 In addition, longterm sequelae such as fecal and urinary incontinence, lowerextremity instability, and wound disruptions are potential complications. To study the efficacy and outcome of this pro¬ cedure at our institution, we reviewed the experience at Kaiser Permanente Los Angeles (Calif) Medical Center from 1981 to 1988. to treat.
sacrum are uncommon
both
tumors
PATIENTS AND METHODS
Patients All patients undergoing sacral resections at Kaiser Permanente Los Angeles Medical Center from 1981 to 1988 were included in the study. Patients were divided into two groups: group A had primary sacral tumors and group had locally invasive anorectal cancers. The level of surgical resection of the sacrum is stated in Table 1. In group A, four patients had chordomas, two had presacrai teratomas, one had a cavernous hemangioma, and one had osteogenic sarcoma of the sacrum. Median age in this group was 55.5 years, with a range of 2.5 to 76 years. Patients were preoperatively evaluated with routine blood workup and computed tomographic scans. There was no evidence of metastatic disease in any of these patients preop¬ eratively. One patient with chordoma, one patient with a large presacral teratoma, and the patient with osteogenic sarcoma had received radiotherapy to the tumor in the past. Two patients had received preoperative chemotherapy. One patient had previously undergone urinary and fecal diversion. Patients in group all had invasive rectal cancers. Eleven patients had locally invasive adenocarcinoma of the rectum, while one patient had recurrent epidermoid cancer of the anus. Median age in this group was 67.5 years, with a range of 37 to 73 years. There was no evidence of metastatic disease in any of these patients on preoper¬ ative workup. Previous operations included five abdominoperineal resections, four low anterior resections, and two diverting colostomies. Nine patients had received a full course of radiation (s=4000 cGy) following their primary procedure as adjuvant therapy.
Technique An abdominosacral approach was used in 17 patients. The tech¬ nique is similar to the one described by Localio et al1 for resection of chordomas in 1967. The patient is placed in a semilateral position and the entire abdomen and pelvis are included in the operative field. Through an abdominal incision, the local and distant extent of the
Table 1.—Level of Sacral Resections* Level of Resection
Accepted for publication September 18,1989. From Kaiser Permanente Medical Center, Los Angeles, Calif. Read before the Southern California Chapter of the American College of Surgeons, Palm Springs, Calif, January 27,1989. Reprint requests to Department of Surgery, 1526 N Edgemont St, Los Angeles, CA 90027 (Dr O'Connell).
S1-2
Group A Group *Group A
with invasive anorectal
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/16/2015
(37)
S2-3
cancer.
3 5
(37) (41)
S3-4
(25) (17) (41) includes patients with primary sacral tumors; group B, patients 3 2
2 5
disease is assessed initially. Presence of metastatic disease would be a contraindication to performing sacral resection. Then the tumor is dissected free from the pelvic structures, which include the ureters, bladder, and, in the case of rectum-sparing procedures, the rectum. The small bowel is packed in the peritoneal cavity away from the pelvis. Fecal and urinary diversions are then performed as indicated. Through a separate intergluteal incision, the sacrum is exposed. The ligamentous attachments of the sacrum to the rest of the pelvis are incised. Using an osteotome or an oscillating orthopedic saw, the sacrum is then transected at the desired level. This allows the en bloc removal of the entire specimen through the sacral incision. The defect is then closed with advancement flaps. We have not found use of rotational flaps necessary in closing the defect.
Table
Combined Group A Group B Operative mortality 5.5 5.5 Operative time, h (median) 1600 Blood loss, mL (median) 1400 1500t 13 16 16 Hospital stay, d (median) *See Table 1 footnotes for description of patient groups. fExcluding the two pediatrie patients in group A, the median blood loss was
2400 mL.
RESULTS
Operative Results Group A, Primary Sacral Tumors. —There were no oper¬ ative deaths (Table 2). The median operative time was 5.5 hours (range, 3 to 8.5 hours), with a median blood loss of 1500 mL (range, 100 to 5000 mL). The median hospital stay was 13 days (range, 4 to 42 days). Three patients had postop¬ erative urinary retention/incontinence requiring self-catheterization at home for more than 2 months (Table 3). One of these patients had an artificial urinary sphincter placed 7 months postoperatively by the urology department. Fecal incontinence occurred in one patient who had presented with partial loss of bowel control preoperatively. He has done well with bowel training and daily enemas. Wound disruption occurred in two patients, both of whom had received over 5000 cGy of radiation to the primary tumor previously. Group B, Locally Invasive Anorectal Cancers.—There were no operative deaths (Table 2). The median blood loss was 1400 mL (range, 350 to 5500 mL), and the median operative time was 5 hours (range, 4 to 8 hours). Median hospital stay was 16 days (range, 8 to 110 days). Four patients had postop¬ erative urinary complications (Table 3). They required selfcatheterization. Two patients had wound breakdowns; both had received radiation to the pelvis as adjuvant therapy following their primary procedures. All patients had colostomies. One patient had a myocardial infarction while in the hospital; however, she survived and eventually left the hospi¬ tal after a prolonged hospitalization.
Outcome
Group A, Primary Sacral Tumors.—There were no deaths directly related to the sacral tumor in this group. One patient with chordoma had a local recurrence 2 years follow¬ ing the sacral resection and is currently undergoing radio¬ therapy. Another patient with chordoma died of a myocardial infarction 7 months following the operation. Two other pa¬ tients have no evidence of disease at this time, with short follow-ups (2 and 4 months). The patient with osteogenic sarcoma has had multiple pulmonary and hepatic métastases over the past few years, some of which have required exci¬ sion. He is still alive 7 years after his primary excision. There is no evidence of recurrence in the patients with presacrai teratomas.
Group B, Locally Invasive Rectal Cancers.—All patients in this group presented with pain in the sacral region. They obtained significant palliation of pain. Eleven patients had 6-month follow-ups. One had died of metastatic disease by this time, while one patient had local recurrence, making an abso¬ lute survival rate of 91% at 6 months (Table 4). At 12 months, only one of the patients followed up was disease free, with five patients still surviving. The absolute survival rate at 12 months was 63%. Only one patient is still alive more than 2 years after the operation and she has both local and meta¬ static disease. Five patients showed local recurrences at 4, 7, 9, and 24 months postoperatively. These results suggest that
2.—Operative Data*
Table
3.—Complications*
Complication Urinary incontinence/retention Fecal incontinence Wound
Infection/disruption
Miscellaneous
*Group
are as
(percentj.
Group A 3 (37.5) 1 (12.5) 2 (25) 0 (0)
Group B 4 (33)
Combined 7
(35) (5) 5 (25) 1 (5) 1
-t 3 1
(25) (8)
described In the footnotes to Table 1. Values
are
number
-( All patients In group had colostomies. tOne patient in group had a myocardial infarction.
Table 4.—Outcome in
Follow-up, mo (n) 6
12 24
Group
Disease-Free Survival, No. (%)
*
Survival,
(11)_9 (82)_10 (8)_1 (12.5)_5 (7)
*Patients with invasive anorectal
0
(0)
(%) (91) (62.5) (14)
No.
1
cancer.
the patients in this group do well for the first 6 months after the sacral resection, with significant palliation of their pain. However, after this time, the disease-free survival drops sharply, and by 2 years the survival rate is less than 20%. COMMENT
Sacral resection is often the only effective treatment of tumors involving the sacrum. These tumors, either primary sacral tumors or locally invasive rectal cancers, are different entities and are best reviewed separately.
Primary Tumors of the Sacrum It is difficult to make generalizations about this group of tumors since, as demonstrated in our series, these tumors are different pathological entities. Chordomas, presacrai teratomas, and other slow-growing malignant neoplasms constitute the majority of sacral tumors requiring excision. The surgeon is often confronted with a tumor of small metastatic potential occupying the narrow pelvic space potentially causing neuro¬ logical, urinary, and fecal symptoms. Ideally, the tumor could be completely excised without urinary or fecal complications. The abdominosacral approach was first described by Localio et al1 for excision of chordomas. We have found this ap¬ proach to provide the best exposure for the typical chordoma. The occasional small chordoma can, however, be resected through a sacral approach. Unlike other reports, we have not found angiography or myelography to be useful in planning the operation.5 Spinal instability is a potential risk of sacral resection. However, our results concur with those previously re¬ ported46,8 that spinal stability can be maintained if the first sacral vertebra is preserved. Urinary complications and
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/16/2015
wound disruption were the two major complications. Urinary incontinence occurred in three patients. Both cases of wound disruption occurred in patients who had received radiothera¬ py to the tumor preoperatively. Radiotherapy should not be used for chordomas, as these tumors are not radiosensitive.
unavailable for follow-up after 8 months, while another patient has no evidence of disease 7 months postoperatively. Despite the discouraging survival rates, palliation was signif¬ icant: all patients had excellent relief of their preoperative pain following the operation. Return of pain usually signaled
Locally Invasive Rectal Cancers Patients with symptomatic recurrence of invasive anorec¬ tal cancer involving the sacrum with no evidence of metastatic disease are candidates for this operation. The decision is made after a thorough discussion of therapeutic options with the patient. Obviously, the final decision to perform the resection depends on the intraoperative findings of local and distant
1. Localio SA, Francis KC, Rossano PG. Abdominosacral resection of sacrococcygeal chordoma. Ann Surg. 1967;166:394-402. 2. Localio SA, Eng K, Ranson JH. Abdominosacral approach for retrorectal tumors. Ann Surg. 1980;191:555-560. 3. Takagi H, Morimoto T, Kato T, Yasue M, Endo T, Suzuki R. Pelvic exenteration combined with sacral resection for recurrent rectal cancer. J Surg
extent of the disease. We have not found disease-free interval from the time of initial surgery to be a useful predictor of postoperative recurrence of disease. Reports of sacral resection for locally invasive rectal can¬ cers are few.46 The most extensive report is by Wanebo and coworkers.6 In their series, 28 patients underwent resection of recurrent rectal cancer. Even though their end results are comparable with ours in terms of 1- and 2-year disease-free survivals, their operation itself was truly heroic. Median blood loss was reported at 6000 mL, median operative time was 18 hours, and their operative mortality was 12%. Another series by Takagi et al4 reports surgical excision in 7 patients. In this series, an ileal conduit for urinary diversion was done for all patients. Their mean operative time was 8.8 hours and median blood loss was 6200 mL, with no operative mortality. These reports make sacral resection appear to be a heroic operation, intimidating to both the surgeon and the patient. Our results do not completely support this, as we experienced no operative mortality, much shorter operative times, and less blood loss. The incidence of complications is, however, significant, the most notable being urinary complications, major wound disruptions, and eventual local recurrence. Each series has its own technical nuances; however, we have found certain modifications to be useful in performing this operation. We do not routinely expose the hypogastric blood vessels in the pelvis since we have not found this maneu¬ ver to be necessary in maintaining hemostasis, as supported by our low median blood loss. Furthermore, nerve roots and sciatic nerves are not routinely exposed.8 All our patients' permeai wounds were closed with simple advancement flaps. Rotational flaps were not used. Our results clearly indicate that this is not a curative proce¬ dure. Our 1- and 2-year survival rates of 62% and 14%, respectively, may be misleadingly low, since two patients
were
local recurrence.
References
Oncol. 1983;24:161-166. 4. Takagi H, Morimoto T, Hara S, Suzuki R, Horio S. Seven cases of pelvic exenteration combined with sacral resection for locally recurrent rectal cancer. J Surg Oncol. 1986;32:184-188. 5. Huth JF, Dawson EG, Eilber FR. Abdominosacral resection for malignant tumors of the sacrum. Am J Surg. 1984;148:157-161. 6. Wanebo HJ, Gaker DL, Whitehill R, Morgan R, Constable W. Pelvic recurrence of rectal cancer, options for curative resection. Ann Surg.
1987;205:482-495. 7. Wanebo HJ, Marcove RC. Abdominal sacral resection of locally recurrent rectal cancer. Ann Surg. 1981;194:458-471. 8. Karakousis CP. Sacral resection with preservation of continence. Surg Gynecol Obstet. 1986;163:271-273.
Invited Commentary Blood loss in this series is remarkably low considering the fact that 74% of patients in group A and 58% in group had the sacrum transected at S2-3 or higher. The blood loss is consider¬ ably lower than that seen in other series. Morbidity and mor¬ tality were likewise in a very acceptable range, which all support the authors' conclusions that this particular operation can be undertaken with an acceptable morbidity. The long-term results in group involving locally invasive anorectal cancers are quite dismal. The presence of pain in all patients preoperatively signified nerve root invasion, which predictably would have a poor prognosis. Although 63% were alive at 12 months, only one patient was disease free at that time, and only five patients of the entire group were surviving, all with disease. One patient was living at 2 years with disease. The authors' conclusion that this group does well for 6 months with freedom from pain does not seem to justify the expense and morbidity accompanying the surgery when compared with more standard practices of palliation that would yield similar results. ROBERT J. SCHWEITZER, MD Oakland, Calif
In Other AMA Journals ARCHIVES OF DERMATOLOGY
Cytomegalovirus Is Predictably Present in Perineal Ulcers From Immunosuppressed Patients
Thomas D. Horn, MD, Antoinette F. Hood, MD We examined five consecutive skin biopsy specimens taken from perineal ulcers on immunosuppressed patients. Examination of hematoxylin-eosin-stained sections in conjunction with immunohistochemistry using monoclonal antibodies to early and late viral antigens resulted in identification of cytomegalovirus in all specimens. Cells containing cytomegalovirus were present in the ulcer base and papillary dermis. Herpes simplex virus was identified in three of five specimens. This series demonstrates that cytomegalovirus is predictably present in perineal ulcers from immunocompromised patients, but does not establish this virus as the cause of the ulcers (Arch Dermatol. 1990;126:642-644). Reprint requests to the Department of Dermatology, The Johns Hopkins Medical Institutions, 600 Wolfe St, Blalock 913F, Baltimore, MD 21205 (Dr Horn).
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/16/2015
and Outcome
Touraj Touran, MD; Daniel B. Frost, MD; Theodore X. O'Connell, MD \s=b\ Tumors involving the sacrum are difficult to treat. These include both primary tumors of the sacrum and locally invasive colorectal carcinomas. Sacral resection is often the only effective alternative for meaningful palliation or cure of sacral tumors. A review of 20 cases of sacral resections for primary sacral tumors (8) and locally invasive anorectal cancers (12) is presented. The mortality (0%) and morbidity (35% urinary complications, 25% wound disruptions, 1600-mL median blood loss) compare favorably with reports in the literature. Long-term survival was achieved with primary tumors of the sacrum. Local control of disease was achieved in the majority of patients with rectal cancer, with good palliation of preoperative pain. Long-term survival, however, is rare in this group. Surgical resection of sacral tumors can be undertaken with acceptable morbidity and mortality in selected patients.
(Arch Surg. 1990;125:911-913)
involving Tumors These include of primary and colorectal carcinomas. The the
and difficult the sa¬ crum locally invasive symp¬ toms often include severe pain in the sacral region. These tumors, whether primary or secondarily involving the sa¬ crum, generally do not respond to chemotherapy. Irradiation has a role in alleviating nerve root pain, but too often the tumor is either radioresistant or the area has already received maximum irradiation. Even when it is successful, the patient will only receive temporary relief from radiotherapy. There¬ fore, sacral resection is frequently the only effective alterna¬ tive for palliation or possible cure in these patients. Published reports of sacral resection are few.18 These se¬ ries report long operative times, massive blood losses, and, in one series, significant operative mortality.6 In addition, longterm sequelae such as fecal and urinary incontinence, lowerextremity instability, and wound disruptions are potential complications. To study the efficacy and outcome of this pro¬ cedure at our institution, we reviewed the experience at Kaiser Permanente Los Angeles (Calif) Medical Center from 1981 to 1988. to treat.
sacrum are uncommon
both
tumors
PATIENTS AND METHODS
Patients All patients undergoing sacral resections at Kaiser Permanente Los Angeles Medical Center from 1981 to 1988 were included in the study. Patients were divided into two groups: group A had primary sacral tumors and group had locally invasive anorectal cancers. The level of surgical resection of the sacrum is stated in Table 1. In group A, four patients had chordomas, two had presacrai teratomas, one had a cavernous hemangioma, and one had osteogenic sarcoma of the sacrum. Median age in this group was 55.5 years, with a range of 2.5 to 76 years. Patients were preoperatively evaluated with routine blood workup and computed tomographic scans. There was no evidence of metastatic disease in any of these patients preop¬ eratively. One patient with chordoma, one patient with a large presacral teratoma, and the patient with osteogenic sarcoma had received radiotherapy to the tumor in the past. Two patients had received preoperative chemotherapy. One patient had previously undergone urinary and fecal diversion. Patients in group all had invasive rectal cancers. Eleven patients had locally invasive adenocarcinoma of the rectum, while one patient had recurrent epidermoid cancer of the anus. Median age in this group was 67.5 years, with a range of 37 to 73 years. There was no evidence of metastatic disease in any of these patients on preoper¬ ative workup. Previous operations included five abdominoperineal resections, four low anterior resections, and two diverting colostomies. Nine patients had received a full course of radiation (s=4000 cGy) following their primary procedure as adjuvant therapy.
Technique An abdominosacral approach was used in 17 patients. The tech¬ nique is similar to the one described by Localio et al1 for resection of chordomas in 1967. The patient is placed in a semilateral position and the entire abdomen and pelvis are included in the operative field. Through an abdominal incision, the local and distant extent of the
Table 1.—Level of Sacral Resections* Level of Resection
Accepted for publication September 18,1989. From Kaiser Permanente Medical Center, Los Angeles, Calif. Read before the Southern California Chapter of the American College of Surgeons, Palm Springs, Calif, January 27,1989. Reprint requests to Department of Surgery, 1526 N Edgemont St, Los Angeles, CA 90027 (Dr O'Connell).
S1-2
Group A Group *Group A
with invasive anorectal
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/16/2015
(37)
S2-3
cancer.
3 5
(37) (41)
S3-4
(25) (17) (41) includes patients with primary sacral tumors; group B, patients 3 2
2 5
disease is assessed initially. Presence of metastatic disease would be a contraindication to performing sacral resection. Then the tumor is dissected free from the pelvic structures, which include the ureters, bladder, and, in the case of rectum-sparing procedures, the rectum. The small bowel is packed in the peritoneal cavity away from the pelvis. Fecal and urinary diversions are then performed as indicated. Through a separate intergluteal incision, the sacrum is exposed. The ligamentous attachments of the sacrum to the rest of the pelvis are incised. Using an osteotome or an oscillating orthopedic saw, the sacrum is then transected at the desired level. This allows the en bloc removal of the entire specimen through the sacral incision. The defect is then closed with advancement flaps. We have not found use of rotational flaps necessary in closing the defect.
Table
Combined Group A Group B Operative mortality 5.5 5.5 Operative time, h (median) 1600 Blood loss, mL (median) 1400 1500t 13 16 16 Hospital stay, d (median) *See Table 1 footnotes for description of patient groups. fExcluding the two pediatrie patients in group A, the median blood loss was
2400 mL.
RESULTS
Operative Results Group A, Primary Sacral Tumors. —There were no oper¬ ative deaths (Table 2). The median operative time was 5.5 hours (range, 3 to 8.5 hours), with a median blood loss of 1500 mL (range, 100 to 5000 mL). The median hospital stay was 13 days (range, 4 to 42 days). Three patients had postop¬ erative urinary retention/incontinence requiring self-catheterization at home for more than 2 months (Table 3). One of these patients had an artificial urinary sphincter placed 7 months postoperatively by the urology department. Fecal incontinence occurred in one patient who had presented with partial loss of bowel control preoperatively. He has done well with bowel training and daily enemas. Wound disruption occurred in two patients, both of whom had received over 5000 cGy of radiation to the primary tumor previously. Group B, Locally Invasive Anorectal Cancers.—There were no operative deaths (Table 2). The median blood loss was 1400 mL (range, 350 to 5500 mL), and the median operative time was 5 hours (range, 4 to 8 hours). Median hospital stay was 16 days (range, 8 to 110 days). Four patients had postop¬ erative urinary complications (Table 3). They required selfcatheterization. Two patients had wound breakdowns; both had received radiation to the pelvis as adjuvant therapy following their primary procedures. All patients had colostomies. One patient had a myocardial infarction while in the hospital; however, she survived and eventually left the hospi¬ tal after a prolonged hospitalization.
Outcome
Group A, Primary Sacral Tumors.—There were no deaths directly related to the sacral tumor in this group. One patient with chordoma had a local recurrence 2 years follow¬ ing the sacral resection and is currently undergoing radio¬ therapy. Another patient with chordoma died of a myocardial infarction 7 months following the operation. Two other pa¬ tients have no evidence of disease at this time, with short follow-ups (2 and 4 months). The patient with osteogenic sarcoma has had multiple pulmonary and hepatic métastases over the past few years, some of which have required exci¬ sion. He is still alive 7 years after his primary excision. There is no evidence of recurrence in the patients with presacrai teratomas.
Group B, Locally Invasive Rectal Cancers.—All patients in this group presented with pain in the sacral region. They obtained significant palliation of pain. Eleven patients had 6-month follow-ups. One had died of metastatic disease by this time, while one patient had local recurrence, making an abso¬ lute survival rate of 91% at 6 months (Table 4). At 12 months, only one of the patients followed up was disease free, with five patients still surviving. The absolute survival rate at 12 months was 63%. Only one patient is still alive more than 2 years after the operation and she has both local and meta¬ static disease. Five patients showed local recurrences at 4, 7, 9, and 24 months postoperatively. These results suggest that
2.—Operative Data*
Table
3.—Complications*
Complication Urinary incontinence/retention Fecal incontinence Wound
Infection/disruption
Miscellaneous
*Group
are as
(percentj.
Group A 3 (37.5) 1 (12.5) 2 (25) 0 (0)
Group B 4 (33)
Combined 7
(35) (5) 5 (25) 1 (5) 1
-t 3 1
(25) (8)
described In the footnotes to Table 1. Values
are
number
-( All patients In group had colostomies. tOne patient in group had a myocardial infarction.
Table 4.—Outcome in
Follow-up, mo (n) 6
12 24
Group
Disease-Free Survival, No. (%)
*
Survival,
(11)_9 (82)_10 (8)_1 (12.5)_5 (7)
*Patients with invasive anorectal
0
(0)
(%) (91) (62.5) (14)
No.
1
cancer.
the patients in this group do well for the first 6 months after the sacral resection, with significant palliation of their pain. However, after this time, the disease-free survival drops sharply, and by 2 years the survival rate is less than 20%. COMMENT
Sacral resection is often the only effective treatment of tumors involving the sacrum. These tumors, either primary sacral tumors or locally invasive rectal cancers, are different entities and are best reviewed separately.
Primary Tumors of the Sacrum It is difficult to make generalizations about this group of tumors since, as demonstrated in our series, these tumors are different pathological entities. Chordomas, presacrai teratomas, and other slow-growing malignant neoplasms constitute the majority of sacral tumors requiring excision. The surgeon is often confronted with a tumor of small metastatic potential occupying the narrow pelvic space potentially causing neuro¬ logical, urinary, and fecal symptoms. Ideally, the tumor could be completely excised without urinary or fecal complications. The abdominosacral approach was first described by Localio et al1 for excision of chordomas. We have found this ap¬ proach to provide the best exposure for the typical chordoma. The occasional small chordoma can, however, be resected through a sacral approach. Unlike other reports, we have not found angiography or myelography to be useful in planning the operation.5 Spinal instability is a potential risk of sacral resection. However, our results concur with those previously re¬ ported46,8 that spinal stability can be maintained if the first sacral vertebra is preserved. Urinary complications and
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/16/2015
wound disruption were the two major complications. Urinary incontinence occurred in three patients. Both cases of wound disruption occurred in patients who had received radiothera¬ py to the tumor preoperatively. Radiotherapy should not be used for chordomas, as these tumors are not radiosensitive.
unavailable for follow-up after 8 months, while another patient has no evidence of disease 7 months postoperatively. Despite the discouraging survival rates, palliation was signif¬ icant: all patients had excellent relief of their preoperative pain following the operation. Return of pain usually signaled
Locally Invasive Rectal Cancers Patients with symptomatic recurrence of invasive anorec¬ tal cancer involving the sacrum with no evidence of metastatic disease are candidates for this operation. The decision is made after a thorough discussion of therapeutic options with the patient. Obviously, the final decision to perform the resection depends on the intraoperative findings of local and distant
1. Localio SA, Francis KC, Rossano PG. Abdominosacral resection of sacrococcygeal chordoma. Ann Surg. 1967;166:394-402. 2. Localio SA, Eng K, Ranson JH. Abdominosacral approach for retrorectal tumors. Ann Surg. 1980;191:555-560. 3. Takagi H, Morimoto T, Kato T, Yasue M, Endo T, Suzuki R. Pelvic exenteration combined with sacral resection for recurrent rectal cancer. J Surg
extent of the disease. We have not found disease-free interval from the time of initial surgery to be a useful predictor of postoperative recurrence of disease. Reports of sacral resection for locally invasive rectal can¬ cers are few.46 The most extensive report is by Wanebo and coworkers.6 In their series, 28 patients underwent resection of recurrent rectal cancer. Even though their end results are comparable with ours in terms of 1- and 2-year disease-free survivals, their operation itself was truly heroic. Median blood loss was reported at 6000 mL, median operative time was 18 hours, and their operative mortality was 12%. Another series by Takagi et al4 reports surgical excision in 7 patients. In this series, an ileal conduit for urinary diversion was done for all patients. Their mean operative time was 8.8 hours and median blood loss was 6200 mL, with no operative mortality. These reports make sacral resection appear to be a heroic operation, intimidating to both the surgeon and the patient. Our results do not completely support this, as we experienced no operative mortality, much shorter operative times, and less blood loss. The incidence of complications is, however, significant, the most notable being urinary complications, major wound disruptions, and eventual local recurrence. Each series has its own technical nuances; however, we have found certain modifications to be useful in performing this operation. We do not routinely expose the hypogastric blood vessels in the pelvis since we have not found this maneu¬ ver to be necessary in maintaining hemostasis, as supported by our low median blood loss. Furthermore, nerve roots and sciatic nerves are not routinely exposed.8 All our patients' permeai wounds were closed with simple advancement flaps. Rotational flaps were not used. Our results clearly indicate that this is not a curative proce¬ dure. Our 1- and 2-year survival rates of 62% and 14%, respectively, may be misleadingly low, since two patients
were
local recurrence.
References
Oncol. 1983;24:161-166. 4. Takagi H, Morimoto T, Hara S, Suzuki R, Horio S. Seven cases of pelvic exenteration combined with sacral resection for locally recurrent rectal cancer. J Surg Oncol. 1986;32:184-188. 5. Huth JF, Dawson EG, Eilber FR. Abdominosacral resection for malignant tumors of the sacrum. Am J Surg. 1984;148:157-161. 6. Wanebo HJ, Gaker DL, Whitehill R, Morgan R, Constable W. Pelvic recurrence of rectal cancer, options for curative resection. Ann Surg.
1987;205:482-495. 7. Wanebo HJ, Marcove RC. Abdominal sacral resection of locally recurrent rectal cancer. Ann Surg. 1981;194:458-471. 8. Karakousis CP. Sacral resection with preservation of continence. Surg Gynecol Obstet. 1986;163:271-273.
Invited Commentary Blood loss in this series is remarkably low considering the fact that 74% of patients in group A and 58% in group had the sacrum transected at S2-3 or higher. The blood loss is consider¬ ably lower than that seen in other series. Morbidity and mor¬ tality were likewise in a very acceptable range, which all support the authors' conclusions that this particular operation can be undertaken with an acceptable morbidity. The long-term results in group involving locally invasive anorectal cancers are quite dismal. The presence of pain in all patients preoperatively signified nerve root invasion, which predictably would have a poor prognosis. Although 63% were alive at 12 months, only one patient was disease free at that time, and only five patients of the entire group were surviving, all with disease. One patient was living at 2 years with disease. The authors' conclusion that this group does well for 6 months with freedom from pain does not seem to justify the expense and morbidity accompanying the surgery when compared with more standard practices of palliation that would yield similar results. ROBERT J. SCHWEITZER, MD Oakland, Calif
In Other AMA Journals ARCHIVES OF DERMATOLOGY
Cytomegalovirus Is Predictably Present in Perineal Ulcers From Immunosuppressed Patients
Thomas D. Horn, MD, Antoinette F. Hood, MD We examined five consecutive skin biopsy specimens taken from perineal ulcers on immunosuppressed patients. Examination of hematoxylin-eosin-stained sections in conjunction with immunohistochemistry using monoclonal antibodies to early and late viral antigens resulted in identification of cytomegalovirus in all specimens. Cells containing cytomegalovirus were present in the ulcer base and papillary dermis. Herpes simplex virus was identified in three of five specimens. This series demonstrates that cytomegalovirus is predictably present in perineal ulcers from immunocompromised patients, but does not establish this virus as the cause of the ulcers (Arch Dermatol. 1990;126:642-644). Reprint requests to the Department of Dermatology, The Johns Hopkins Medical Institutions, 600 Wolfe St, Blalock 913F, Baltimore, MD 21205 (Dr Horn).
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