JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 25, Number 1, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2014.0270
The Small Bowel in Its Hammock: How to Avoid Irradiation Thanks to the Sigmoid Sabine Irtan, MD, PhD,1,* Eric Mascard, MD,2 Ste´phanie Bolle, MD,3 Laurence Brugie`res, MD, PhD,4 and Sabine Sarnacki, MD, PhD1
Abstract
Background: High-dose irradiation is the cornerstone treatment of bone cancers of the pelvic rim. To protect the small bowel from irradiation and following consequences, we described the laparoscopic use of the sigmoid to perform a hammock. Materials and Methods: Three patients were diagnosed with metastatic Ewing’s sarcoma, localized malignant peripheral nerve sheath tumor, and localized BCOR-CCNB3 (Ewing-like) sarcoma of the pelvic rim at 13.1, 5.7, and 12.9 years, respectively. After neoadjuvant chemotherapy, the 2 female patients underwent a hemisacrectomy under S2 only by the posterior approach, whereas no orthopedic surgery was required for the male patient because of excellent local response to chemotherapy. A 54-Gy intensity-modulated radiotherapy of the posterior part of the pelvis was intended for all patients. Results: The laparoscopic procedure consisted in the fixation of the sigmoid loop to the anterior parietal wall on a transverse line just below the umbilicus, associated with a colostomy in the right iliac fossa. The anterior transposition of the two ovaries, uterus, and rectum and the dissection of left iliac vessels to move them anteriorly were added in female patients. Stomas were closed around 6 months after completion of the radiotherapy course, associated with the repositioning of the uterus, ovaries, and colon. With a mean follow-up of 22 months, all patients are alive without any recurrences or radiation-related symptoms. Conclusions: The laparoscopic ‘‘hammock technique’’ both protects the small bowel from irradiation and secures the orthopedic procedure by displacing the abdominal organs forward. dose exceeding 50 Gy, which induces early and late damages to the surrounding organs.6 The small bowel is particularly sensitive to high-dose radiotherapy, with functional and anatomical side effects such as malabsorption, diarrhea, stricture, or fistula formation.7 Indeed, histologic appearance in the small bowel at the time of delayed radiation injury has revealed severe villus blunting, lymphatic dilatation, and moderately dense inflammatory infiltrate in children receiving whole abdominal radiation therapy.8 Several surgical or nonsurgical methods have already been described to displace the bowel out of the radiotherapy field with various results in adults.9–15 In children, few articles have reported the use of a mesh or a tissue expander to compartmentalize the abdomen and separate it from the pelvis.16–19 Herein, we describe the use of the sigmoid colon to function as a hammock by the laparoscopic approach to avoid small bowel irradiation and subsequent consequences.
Introduction
M
alignant sarcoma of the pelvic bones is a rare disease with poor prognosis.1,2 In this particular location, Ewing’s sarcoma represents about 72% of the specific histopathological diagnoses and poses a challenge for local disease control and oncological outcome.3 Even if numerous advances and improvements in chemotherapy regimens, radiotherapy, and surgical techniques have been realized, there is still ongoing debate as to whether surgery and radiotherapy are comparable for local control.1,4 Some studies have advocated that the combination of both radiotherapy and surgery is more efficient in tumor control,1 whereas some others have tended to show that patients undergoing surgical resection, radiation therapy, or a combination of both fare similarly and significantly better than those not receiving either therapy.3,5 Whatever the treatment choice, radiation therapy needs a high
Departments of 1Paediatric Surgery and 2Orthopedic Surgery, Hoˆpital Necker Enfants Malades, Paris Descartes University, Paris, France. Departments of 3Radiotherapy and 4Pediatric Oncology, Gustave-Roussy Institute, Paris, France. *Current address: Service de Chirurgie Pe´diatrique Visce´rale, Sorbonnes Paris City University, Paris, France.
77
78 Materials and Methods
We report a procedure performed from 2011 to 2013 in 3 patients, one male and two females, 13.1, 5.7, and 12.9 years old, respectively, and diagnosed with metastatic Ewing’s sarcoma of the right iliac branch, localized malignant peripheral nerve sheath tumor of the left sciatic notch, and localized BCOR-CCNB3 (Ewing-like) sarcoma of the left hemisacrum, respectively. All 3 patients underwent neoadjuvant chemotherapy according to ongoing protocols. A left en bloc hemisacrectomy under S2 preserving contralateral sacral nerves was performed by the posterior approach for the 2 female patients, whereas no orthopedic surgery was required for the male patient because of excellent local response to chemotherapy. No reconstruction was performed for the oldest female, whereas the youngest female patient underwent a sacroiliac ostheosynthesis. A 54-Gy intensitymodulated radiotherapy (IMRT) of the posterior part of the pelvis was intended for all patients after either surgery or neoadjuvant chemotherapy. Technique
The laparoscopy procedure was performed as a first step of the orthopedic surgery for the 2 female patients and as the whole procedure for the male patient. Three ports were used for each procedure: one 10-mm optic umbilical port and two 5-mm working ports in the right and left flanks. The creation of the hammock consisted in the fixation of the sigmoid loop to the anterior peritoneal wall. The sigmoid loop was moved anteriorly to the right part of the abdomen, and the distal part of the loop was fixed in the right iliac fossa with resorbable sutures, whereas the proximal part of the loop was sutured from the right to the left flank on a transverse line just below the umbilicus (Fig. 1). For the 2 female patients, a stoma was created in the right iliac fossa with the distal part of the sigmoid loop in order to facilitate the healing of the sacral scar. Prior to the realization of the hammock, other procedures were performed: anterior transposition of the two ovaries and of the rectum for the 2 female patients, anterior
FIG. 1. Operative view of the sigmoid loop fixation to the anterior parietal wall with resorbable sutures. Thanks to adherence of the remaining sigmoid to the peritoneum, the small bowel cannot slip into the pelvis.
IRTAN ET AL.
fixation of the uterus in one of them, and dissection of left iliac vessels to move them anteriorly in the other. For the male patient, as no stoma was realized, the hammock procedure was completed by the suture of the sigmoid mesocolon to the junction of the mesentery to the right mesocolon to prevent slippage of the small intestine into the pelvis. The stoma was opened at the end of the orthopedic procedure to prevent septic risks. Results
The peri- and postoperative courses were uneventful for all 3 patients regarding the laparoscopic procedure. However, the continuous hemorrhage during the hemisacrectomy led to cardiac arrest requiring resuscitation in the younger female patient, whereas the older female patient needed a skin graft because of difficulties in the healing process of the sacral scar. Radiotherapy was delayed to the second postoperative month in this latter case. The analysis of radiotherapy fields after the radiation delivery showed that less than 5% of the small bowel received 30 Gy in all 3 patients. Stomas were closed 5 and 7 months after radiotherapy completion, associated with the laparoscopic repositioning of the uterus and ovaries and the reversal of the sigmoid colon sling. With a follow-up of 7, 29, and 30 months, all patients are alive without recurrence or radiation-related symptoms. The older female patient presented neurological bladder due to the orthopedic surgery-related sacral nerve injury that is treated by daily urinary catheterization. No fecal incontinence has been noticed. Discussion
We report an original laparoscopic technique using the sigmoid as a hammock to protect the small bowel from the consequences of high-dose radiotherapy in sacral malignancies. Even if most malignancies originating from the sacrum are sensitive to chemotherapy or radiotherapy in children, surgery has an important role and requires en bloc resection of the tumor to achieve safe margins. In some locations, bilateral sacral nerves may be sacrificed during surgical resection with inevitable postoperative morbidity, including urinary and fecal incontinence, sciatic nerves, and sexual dysfunction. However, if the tumor originates from an ala sacralis, hemisacrectomy can be performed, with preservation of the contralateral sacral nerves becoming a major priority to avoid functional complications. In this latter, a combined anterior–posterior approach is usually done to achieve complete en bloc resection while controlling and protecting the ipsilateral sacral nerves and the lumbosacral trunk. The anterior approach is usually performed by a midline skin incision from the umbilicus to the pubis symphisis but has been recently reported by laparoscopy in adults for en bloc sacral chordoma resection.20 In the cases reported here, the laparoscopic anterior approach has allowed the dissection of the rectum and its mesentery without needing to pack gauze into the presacral space to protect the rectum as in the open approach.21 The laparoscopic procedure has eased the dissection of the rectum, its mesentery, and iliac vessels in front of the tumor, has secured the posterior approach, and, regarding postoperative irradiation, has allowed the small bowel to be kept out of the radiation field.
HOW TO AVOID GUT IRRADIATION THANKS TO THE SIGMOID
Many methods have been described in the literature to achieve small bowel protection with different results. Some techniques are nonoperative, using the impact of different physical measures such as prone positioning,22 bladder distension and lower abdominal wall compression,23 or use of a ‘‘belly board’’ while the patient lies in the prone position on an open table, allowing the bowel to fall below the table.24 Significant improvements have been noticed with a decrease in irradiation of at least 50%. Other techniques are operative, using either a prosthetic material or a human tissue to occupy the pelvic cavity. Tissue expanders have shown a reduction of 50% in the risk of chronic intestinal complications in adults25 and were laparoscopically inserted.13 Use of pelvic mesh slings has also been reported in children with pelvic malignancies, avoiding radiation-association enteritis in the long-term followup.16,18 The combination of a tissue expander and a polyglactic acid mesh in a 9-year-old boy relapsing from alveolar rhabdomyosarcoma has allowed 95% of the intestine to be spared from total irradiation.17 In the early adult experience, compression of the ureters, the bladder, or the iliac vessels and infections with abscess formation and fistulization have been related to the long-term placement of large tissue expanders in the pelvis. Dislodgement, spontaneous deflation, and extrusion of expander have also been reported.26,27 To avoid difficulties with prosthetic devices, some authors have proposed partitioning the abdomen with human tissue. The omentum is sutured circumferentially to the peritoneum at the level of the sacral promontory and umbilicus, creating a sling or hammock,28 whereas the posterior rectus sheath and peritoneum are used to exclude the small bowel from the radiotherapy field in rectal cancer.29 However, the peritoneum and omentum are thin tissues, triggering the risk of internal hernia and small bowel slippage. We therefore decided to use the sigmoid, a more solid tissue, as a barrier. By performing the intervention laparoscopically, we get a better view of the presacral and pelvic region and extend the procedure of radiation preservation to other pelvic organs (ovaries, uterus, rectum, and iliac vessels). The nonanatomical location of the sigmoid does not interfere with the normal transit. The male patient who had no stoma has suffered from constipation very transiently in the initial postoperative course but easily moved his bowels afterward. The female patients did not present any colonic dysmotility before the closure of the stoma. Finally, besides putting the organs out of the field of radiotherapy, the use of IMRT greatly contributes to minimizing the risk of radiation-induced toxicity for the normal tissues. IMRT by a linear accelerator or helical tomotherapy allows clear definition of both target lesions and surrounding normal tissues and hence the improvement of dose distribution.15 IMRT combined with the anterior displacement of organs avoids consequent late effects without impairing overall and event-free survival.30 However, chronic symptoms can present up to three decades after radiation, underlying the need for a very long follow-up. Conclusions
The laparoscopic ‘‘hammock technique’’ is an efficient and safe approach to protect the small bowel from irradiation by using the sigmoid. It also eases the orthopedic procedure,
79
which can be performed only by a posterior approach, and avoids the injury of pelvic organs during the section of the sacrum by displacing them forward. Long-term follow-up is mandatory to better evaluate the efficiency of this protective procedure. Disclosure Statement
No competing financial interests exist. References
1. Carrie C, Mascard E, Gomez F, Habrand JL, et al. Nonmetastatic pelvic Ewing sarcoma: Report of the French Society of Pediatric Oncology. Med Pediatr Oncol 1999;33: 444–449. 2. Bacci G, Boriani S, Balladelli A, et al. Treatment of nonmetastatic Ewing’s sarcoma family tumors of the spine and sacrum: The experience from a single institution. Eur Spine J 2009;18:1091–1095. 3. Jawad MU, Haleem AA, Scully SP. Malignant sarcoma of the pelvic bones: Treatment outcomes and prognostic factors vary by histopathology. Cancer 2011;117:1529–1541. 4. Donati D, Yin J, Di Bella C, et al. Local and distant control in non-metastatic pelvic Ewing’s sarcoma patients. J Surg Oncol 2007;96:19–25. 5. Yock TI, Krailo M, Fryer CJ, et al. Local control in pelvic Ewing sarcoma: Analysis from INT-0091—A report from the Children’s Oncology Group. J Clin Oncol 2006;24: 3838–3843. 6. Bo¨lling T, Willich N, Ernst I. Late effects of abdominal irradiation in children: A review of the literature. Anticancer Res 2010;30:227–231. 7. Ransom J L, Novak RW, Kumar APM, Hustu HO, Pratt CB. Delayed gastrointestinal complications after combined modality therapy of childhood rhabdomyosarcoma. Int J Radiat Oncol Biol Phys 1979;5:1275–1279. 8. Donaldson SS, Jundt S, Ricour C, Sarrazin D, Lemerle J, Schweisguth O. Radiation enteritis in children. A retrospective review, clinicopathologic correlation, and dietary management. Cancer 1975;35:1167–1178. 9. Sugarbaker PH. Intrapelvic prosthesis to prevent injury of the small intestine with high dosage pelvic irradiation. Surg Gynecol Obstet 1983;157:269–271. 10. Hindley A, Cole H. Use of peritoneal insufflation to displace the small bowel during pelvic and abdominal radiotherapy in carcinoma of the cervix. Br J Radiol 1993;66:67–73. 11. Burnett AF, Coe FL, Klement V, et al. The use of a pelvic displacement prosthesis to exclude the small intestine from the radiation field following radical hysterectomy. Gynecol Oncol 2000;79:438–443. 12. Valle M, Federici O, Ialongo P, Graziano F, Garofalo A. Prevention of complications following pelvic exenteration with the use of mammary implants in the pelvic cavity: Technique and results of 28 cases. J Surg Oncol 2011;103: 34–38. 13. McKay GD, Wong K, Kozman DR. Laparoscopic insertion of pelvic tissue expander to prevent radiation enteritis prior to radiotherapy for prostate cancer. Radiat Oncol 2011;6:47. 14. Stacey R, Green JT. Radiation-induced small bowel disease: Latest developments and clinical guidance. Ther Adv Chronic Dis 2014;5:15–29. 15. Shadad AK, Sullivan FJ, Martin JD, Egan LJ. Gastrointestinal radiation injury: Prevention and treatment. World J Gastroenterol 2013;19:199–208.
80
16. Meric F, Hirschl RB, Mahboubi S, et al. Prevention of radiation enteritis in children, using a pelvic mesh sling. J Pediatr Surg 1994;29:917–921. 17. Abhyankar A, Jenney M, Huddart SN, Tilsley DW, Cox R, Saad M. Use of a tissue expander and a polyglactic acid (Vicryl) mesh to reduce radiation enteritis: Case report and literature review. Pediatr Surg Int 2005;21:755–757. 18. Haider N, O’Sullivan C, Corbally MT, Fitzgerald RJ. Abdominopelvic mesh compartmentalization reduces the complications of radiotherapy in children: A preliminary report. Eur J Pediatr Surg 2006;16:348–351. 19. Pe´rez-Mun˜oz I, Grimer RJ, Spooner D, et al. Use of tissue expander in pelvic Ewing’s sarcoma treated with radiotherapy. Eur J Surg Oncol 2014;40:197–201. 20. Dubory A, Missenard G, Lambert B, Court C. ‘‘En bloc’’ resection of sacral chordomas by combined anterior and posterior surgical approach: A monocentric retrospective review about 29 cases. Eur Spine J 2014;23:1940–1948. 21. Li D, Guo W, Tang X, Ji T, Zhang Y. Surgical classification of different types of en bloc resection for primary malignant sacral tumors. Eur Spine J 2011;20: 2275–2281. 22. Bayley AJ, Catton CN, Haycocks T, et al. A randomized trial of supine vs. prone positioning in patients undergoing escalated dose conformal radiotherapy for prostate cancer. Radiother Oncol 2004;70:37–44. 23. Gallagher MJ, Brereton HD, Rostock RA, et al. A prospective study of treatment techniques to minimize the volume of pelvic small bowel with reduction of acute and late effects associated with pelvic irradiation. Int J Radiat Oncol Biol Phys 1986;12:1565–1573. 24. Shanahan TG, Mehta MP, Bertelrud KL, et al. Minimization of small bowel volume within treatment fields utilizing customized ‘‘belly boards.’’ Int J Radiat Oncol Biol Phys 1990;19:469–476.
IRTAN ET AL.
25. Herbert SH, Solin LJ, Hoffman JP, et al. Volumetric analysis of small bowel displacement from radiation portals with the use of a pelvic tissue expander. Int J Radiat Oncol Biol Phys 1993;25:885–893. 26. Hoffman JP, Lanciano R, Carp NZ, et al. Morbidity after intraperitoneal insertion of saline filled tissue expanders for small bowel exclusion from radiotherapy fields: A prospective four-year experience with 34 patients. Am Surg 1994;60:473–482. 27. Geller MA, Argenta PA, Thomas SG, Dusenbery KE, Judson PL, Boente MP. Feasibility and morbidity of using saline filled tissue expanders to reduce radiation-induced bowel injury in patients with gynecologic malignancies. Eur J Obstet Gynecol Reprod Biol 2009;143:93–97. 28. Choi HJ, Lee HS. Effect of omental pedicle hammock in protection against radiation-induced enteropathy in patients with rectal cancer. Dis Colon Rectum 1995;38:276–280. 29. Evans DB, Shumate CR, Ames FC, Rich TA. Use of Dexon mesh for abdominal partitioning above the peritoneal reflection. Dis Colon Rectum 1991;34:833–835. 30. Leseur J, Carrie C, Le Prise´ E, et al. Intensity-modulated radiotherapy for cancers in childhood. Cancer Radiother 2009;13:536–542.
Address correspondence to: Sabine Irtan, MD, PhD Service de Chirurgie Pe´diatrique Visce´rale Sorbonnes Paris City University Hoˆpital Trousseau 26 rue Arnold Netter 75012 Paris France E-mail: [email protected]
Copyright of Journal of Laparoendoscopic & Advanced Surgical Techniques is the property of Mary Ann Liebert, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
The Small Bowel in Its Hammock: How to Avoid Irradiation Thanks to the Sigmoid Sabine Irtan, MD, PhD,1,* Eric Mascard, MD,2 Ste´phanie Bolle, MD,3 Laurence Brugie`res, MD, PhD,4 and Sabine Sarnacki, MD, PhD1
Abstract
Background: High-dose irradiation is the cornerstone treatment of bone cancers of the pelvic rim. To protect the small bowel from irradiation and following consequences, we described the laparoscopic use of the sigmoid to perform a hammock. Materials and Methods: Three patients were diagnosed with metastatic Ewing’s sarcoma, localized malignant peripheral nerve sheath tumor, and localized BCOR-CCNB3 (Ewing-like) sarcoma of the pelvic rim at 13.1, 5.7, and 12.9 years, respectively. After neoadjuvant chemotherapy, the 2 female patients underwent a hemisacrectomy under S2 only by the posterior approach, whereas no orthopedic surgery was required for the male patient because of excellent local response to chemotherapy. A 54-Gy intensity-modulated radiotherapy of the posterior part of the pelvis was intended for all patients. Results: The laparoscopic procedure consisted in the fixation of the sigmoid loop to the anterior parietal wall on a transverse line just below the umbilicus, associated with a colostomy in the right iliac fossa. The anterior transposition of the two ovaries, uterus, and rectum and the dissection of left iliac vessels to move them anteriorly were added in female patients. Stomas were closed around 6 months after completion of the radiotherapy course, associated with the repositioning of the uterus, ovaries, and colon. With a mean follow-up of 22 months, all patients are alive without any recurrences or radiation-related symptoms. Conclusions: The laparoscopic ‘‘hammock technique’’ both protects the small bowel from irradiation and secures the orthopedic procedure by displacing the abdominal organs forward. dose exceeding 50 Gy, which induces early and late damages to the surrounding organs.6 The small bowel is particularly sensitive to high-dose radiotherapy, with functional and anatomical side effects such as malabsorption, diarrhea, stricture, or fistula formation.7 Indeed, histologic appearance in the small bowel at the time of delayed radiation injury has revealed severe villus blunting, lymphatic dilatation, and moderately dense inflammatory infiltrate in children receiving whole abdominal radiation therapy.8 Several surgical or nonsurgical methods have already been described to displace the bowel out of the radiotherapy field with various results in adults.9–15 In children, few articles have reported the use of a mesh or a tissue expander to compartmentalize the abdomen and separate it from the pelvis.16–19 Herein, we describe the use of the sigmoid colon to function as a hammock by the laparoscopic approach to avoid small bowel irradiation and subsequent consequences.
Introduction
M
alignant sarcoma of the pelvic bones is a rare disease with poor prognosis.1,2 In this particular location, Ewing’s sarcoma represents about 72% of the specific histopathological diagnoses and poses a challenge for local disease control and oncological outcome.3 Even if numerous advances and improvements in chemotherapy regimens, radiotherapy, and surgical techniques have been realized, there is still ongoing debate as to whether surgery and radiotherapy are comparable for local control.1,4 Some studies have advocated that the combination of both radiotherapy and surgery is more efficient in tumor control,1 whereas some others have tended to show that patients undergoing surgical resection, radiation therapy, or a combination of both fare similarly and significantly better than those not receiving either therapy.3,5 Whatever the treatment choice, radiation therapy needs a high
Departments of 1Paediatric Surgery and 2Orthopedic Surgery, Hoˆpital Necker Enfants Malades, Paris Descartes University, Paris, France. Departments of 3Radiotherapy and 4Pediatric Oncology, Gustave-Roussy Institute, Paris, France. *Current address: Service de Chirurgie Pe´diatrique Visce´rale, Sorbonnes Paris City University, Paris, France.
77
78 Materials and Methods
We report a procedure performed from 2011 to 2013 in 3 patients, one male and two females, 13.1, 5.7, and 12.9 years old, respectively, and diagnosed with metastatic Ewing’s sarcoma of the right iliac branch, localized malignant peripheral nerve sheath tumor of the left sciatic notch, and localized BCOR-CCNB3 (Ewing-like) sarcoma of the left hemisacrum, respectively. All 3 patients underwent neoadjuvant chemotherapy according to ongoing protocols. A left en bloc hemisacrectomy under S2 preserving contralateral sacral nerves was performed by the posterior approach for the 2 female patients, whereas no orthopedic surgery was required for the male patient because of excellent local response to chemotherapy. No reconstruction was performed for the oldest female, whereas the youngest female patient underwent a sacroiliac ostheosynthesis. A 54-Gy intensitymodulated radiotherapy (IMRT) of the posterior part of the pelvis was intended for all patients after either surgery or neoadjuvant chemotherapy. Technique
The laparoscopy procedure was performed as a first step of the orthopedic surgery for the 2 female patients and as the whole procedure for the male patient. Three ports were used for each procedure: one 10-mm optic umbilical port and two 5-mm working ports in the right and left flanks. The creation of the hammock consisted in the fixation of the sigmoid loop to the anterior peritoneal wall. The sigmoid loop was moved anteriorly to the right part of the abdomen, and the distal part of the loop was fixed in the right iliac fossa with resorbable sutures, whereas the proximal part of the loop was sutured from the right to the left flank on a transverse line just below the umbilicus (Fig. 1). For the 2 female patients, a stoma was created in the right iliac fossa with the distal part of the sigmoid loop in order to facilitate the healing of the sacral scar. Prior to the realization of the hammock, other procedures were performed: anterior transposition of the two ovaries and of the rectum for the 2 female patients, anterior
FIG. 1. Operative view of the sigmoid loop fixation to the anterior parietal wall with resorbable sutures. Thanks to adherence of the remaining sigmoid to the peritoneum, the small bowel cannot slip into the pelvis.
IRTAN ET AL.
fixation of the uterus in one of them, and dissection of left iliac vessels to move them anteriorly in the other. For the male patient, as no stoma was realized, the hammock procedure was completed by the suture of the sigmoid mesocolon to the junction of the mesentery to the right mesocolon to prevent slippage of the small intestine into the pelvis. The stoma was opened at the end of the orthopedic procedure to prevent septic risks. Results
The peri- and postoperative courses were uneventful for all 3 patients regarding the laparoscopic procedure. However, the continuous hemorrhage during the hemisacrectomy led to cardiac arrest requiring resuscitation in the younger female patient, whereas the older female patient needed a skin graft because of difficulties in the healing process of the sacral scar. Radiotherapy was delayed to the second postoperative month in this latter case. The analysis of radiotherapy fields after the radiation delivery showed that less than 5% of the small bowel received 30 Gy in all 3 patients. Stomas were closed 5 and 7 months after radiotherapy completion, associated with the laparoscopic repositioning of the uterus and ovaries and the reversal of the sigmoid colon sling. With a follow-up of 7, 29, and 30 months, all patients are alive without recurrence or radiation-related symptoms. The older female patient presented neurological bladder due to the orthopedic surgery-related sacral nerve injury that is treated by daily urinary catheterization. No fecal incontinence has been noticed. Discussion
We report an original laparoscopic technique using the sigmoid as a hammock to protect the small bowel from the consequences of high-dose radiotherapy in sacral malignancies. Even if most malignancies originating from the sacrum are sensitive to chemotherapy or radiotherapy in children, surgery has an important role and requires en bloc resection of the tumor to achieve safe margins. In some locations, bilateral sacral nerves may be sacrificed during surgical resection with inevitable postoperative morbidity, including urinary and fecal incontinence, sciatic nerves, and sexual dysfunction. However, if the tumor originates from an ala sacralis, hemisacrectomy can be performed, with preservation of the contralateral sacral nerves becoming a major priority to avoid functional complications. In this latter, a combined anterior–posterior approach is usually done to achieve complete en bloc resection while controlling and protecting the ipsilateral sacral nerves and the lumbosacral trunk. The anterior approach is usually performed by a midline skin incision from the umbilicus to the pubis symphisis but has been recently reported by laparoscopy in adults for en bloc sacral chordoma resection.20 In the cases reported here, the laparoscopic anterior approach has allowed the dissection of the rectum and its mesentery without needing to pack gauze into the presacral space to protect the rectum as in the open approach.21 The laparoscopic procedure has eased the dissection of the rectum, its mesentery, and iliac vessels in front of the tumor, has secured the posterior approach, and, regarding postoperative irradiation, has allowed the small bowel to be kept out of the radiation field.
HOW TO AVOID GUT IRRADIATION THANKS TO THE SIGMOID
Many methods have been described in the literature to achieve small bowel protection with different results. Some techniques are nonoperative, using the impact of different physical measures such as prone positioning,22 bladder distension and lower abdominal wall compression,23 or use of a ‘‘belly board’’ while the patient lies in the prone position on an open table, allowing the bowel to fall below the table.24 Significant improvements have been noticed with a decrease in irradiation of at least 50%. Other techniques are operative, using either a prosthetic material or a human tissue to occupy the pelvic cavity. Tissue expanders have shown a reduction of 50% in the risk of chronic intestinal complications in adults25 and were laparoscopically inserted.13 Use of pelvic mesh slings has also been reported in children with pelvic malignancies, avoiding radiation-association enteritis in the long-term followup.16,18 The combination of a tissue expander and a polyglactic acid mesh in a 9-year-old boy relapsing from alveolar rhabdomyosarcoma has allowed 95% of the intestine to be spared from total irradiation.17 In the early adult experience, compression of the ureters, the bladder, or the iliac vessels and infections with abscess formation and fistulization have been related to the long-term placement of large tissue expanders in the pelvis. Dislodgement, spontaneous deflation, and extrusion of expander have also been reported.26,27 To avoid difficulties with prosthetic devices, some authors have proposed partitioning the abdomen with human tissue. The omentum is sutured circumferentially to the peritoneum at the level of the sacral promontory and umbilicus, creating a sling or hammock,28 whereas the posterior rectus sheath and peritoneum are used to exclude the small bowel from the radiotherapy field in rectal cancer.29 However, the peritoneum and omentum are thin tissues, triggering the risk of internal hernia and small bowel slippage. We therefore decided to use the sigmoid, a more solid tissue, as a barrier. By performing the intervention laparoscopically, we get a better view of the presacral and pelvic region and extend the procedure of radiation preservation to other pelvic organs (ovaries, uterus, rectum, and iliac vessels). The nonanatomical location of the sigmoid does not interfere with the normal transit. The male patient who had no stoma has suffered from constipation very transiently in the initial postoperative course but easily moved his bowels afterward. The female patients did not present any colonic dysmotility before the closure of the stoma. Finally, besides putting the organs out of the field of radiotherapy, the use of IMRT greatly contributes to minimizing the risk of radiation-induced toxicity for the normal tissues. IMRT by a linear accelerator or helical tomotherapy allows clear definition of both target lesions and surrounding normal tissues and hence the improvement of dose distribution.15 IMRT combined with the anterior displacement of organs avoids consequent late effects without impairing overall and event-free survival.30 However, chronic symptoms can present up to three decades after radiation, underlying the need for a very long follow-up. Conclusions
The laparoscopic ‘‘hammock technique’’ is an efficient and safe approach to protect the small bowel from irradiation by using the sigmoid. It also eases the orthopedic procedure,
79
which can be performed only by a posterior approach, and avoids the injury of pelvic organs during the section of the sacrum by displacing them forward. Long-term follow-up is mandatory to better evaluate the efficiency of this protective procedure. Disclosure Statement
No competing financial interests exist. References
1. Carrie C, Mascard E, Gomez F, Habrand JL, et al. Nonmetastatic pelvic Ewing sarcoma: Report of the French Society of Pediatric Oncology. Med Pediatr Oncol 1999;33: 444–449. 2. Bacci G, Boriani S, Balladelli A, et al. Treatment of nonmetastatic Ewing’s sarcoma family tumors of the spine and sacrum: The experience from a single institution. Eur Spine J 2009;18:1091–1095. 3. Jawad MU, Haleem AA, Scully SP. Malignant sarcoma of the pelvic bones: Treatment outcomes and prognostic factors vary by histopathology. Cancer 2011;117:1529–1541. 4. Donati D, Yin J, Di Bella C, et al. Local and distant control in non-metastatic pelvic Ewing’s sarcoma patients. J Surg Oncol 2007;96:19–25. 5. Yock TI, Krailo M, Fryer CJ, et al. Local control in pelvic Ewing sarcoma: Analysis from INT-0091—A report from the Children’s Oncology Group. J Clin Oncol 2006;24: 3838–3843. 6. Bo¨lling T, Willich N, Ernst I. Late effects of abdominal irradiation in children: A review of the literature. Anticancer Res 2010;30:227–231. 7. Ransom J L, Novak RW, Kumar APM, Hustu HO, Pratt CB. Delayed gastrointestinal complications after combined modality therapy of childhood rhabdomyosarcoma. Int J Radiat Oncol Biol Phys 1979;5:1275–1279. 8. Donaldson SS, Jundt S, Ricour C, Sarrazin D, Lemerle J, Schweisguth O. Radiation enteritis in children. A retrospective review, clinicopathologic correlation, and dietary management. Cancer 1975;35:1167–1178. 9. Sugarbaker PH. Intrapelvic prosthesis to prevent injury of the small intestine with high dosage pelvic irradiation. Surg Gynecol Obstet 1983;157:269–271. 10. Hindley A, Cole H. Use of peritoneal insufflation to displace the small bowel during pelvic and abdominal radiotherapy in carcinoma of the cervix. Br J Radiol 1993;66:67–73. 11. Burnett AF, Coe FL, Klement V, et al. The use of a pelvic displacement prosthesis to exclude the small intestine from the radiation field following radical hysterectomy. Gynecol Oncol 2000;79:438–443. 12. Valle M, Federici O, Ialongo P, Graziano F, Garofalo A. Prevention of complications following pelvic exenteration with the use of mammary implants in the pelvic cavity: Technique and results of 28 cases. J Surg Oncol 2011;103: 34–38. 13. McKay GD, Wong K, Kozman DR. Laparoscopic insertion of pelvic tissue expander to prevent radiation enteritis prior to radiotherapy for prostate cancer. Radiat Oncol 2011;6:47. 14. Stacey R, Green JT. Radiation-induced small bowel disease: Latest developments and clinical guidance. Ther Adv Chronic Dis 2014;5:15–29. 15. Shadad AK, Sullivan FJ, Martin JD, Egan LJ. Gastrointestinal radiation injury: Prevention and treatment. World J Gastroenterol 2013;19:199–208.
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16. Meric F, Hirschl RB, Mahboubi S, et al. Prevention of radiation enteritis in children, using a pelvic mesh sling. J Pediatr Surg 1994;29:917–921. 17. Abhyankar A, Jenney M, Huddart SN, Tilsley DW, Cox R, Saad M. Use of a tissue expander and a polyglactic acid (Vicryl) mesh to reduce radiation enteritis: Case report and literature review. Pediatr Surg Int 2005;21:755–757. 18. Haider N, O’Sullivan C, Corbally MT, Fitzgerald RJ. Abdominopelvic mesh compartmentalization reduces the complications of radiotherapy in children: A preliminary report. Eur J Pediatr Surg 2006;16:348–351. 19. Pe´rez-Mun˜oz I, Grimer RJ, Spooner D, et al. Use of tissue expander in pelvic Ewing’s sarcoma treated with radiotherapy. Eur J Surg Oncol 2014;40:197–201. 20. Dubory A, Missenard G, Lambert B, Court C. ‘‘En bloc’’ resection of sacral chordomas by combined anterior and posterior surgical approach: A monocentric retrospective review about 29 cases. Eur Spine J 2014;23:1940–1948. 21. Li D, Guo W, Tang X, Ji T, Zhang Y. Surgical classification of different types of en bloc resection for primary malignant sacral tumors. Eur Spine J 2011;20: 2275–2281. 22. Bayley AJ, Catton CN, Haycocks T, et al. A randomized trial of supine vs. prone positioning in patients undergoing escalated dose conformal radiotherapy for prostate cancer. Radiother Oncol 2004;70:37–44. 23. Gallagher MJ, Brereton HD, Rostock RA, et al. A prospective study of treatment techniques to minimize the volume of pelvic small bowel with reduction of acute and late effects associated with pelvic irradiation. Int J Radiat Oncol Biol Phys 1986;12:1565–1573. 24. Shanahan TG, Mehta MP, Bertelrud KL, et al. Minimization of small bowel volume within treatment fields utilizing customized ‘‘belly boards.’’ Int J Radiat Oncol Biol Phys 1990;19:469–476.
IRTAN ET AL.
25. Herbert SH, Solin LJ, Hoffman JP, et al. Volumetric analysis of small bowel displacement from radiation portals with the use of a pelvic tissue expander. Int J Radiat Oncol Biol Phys 1993;25:885–893. 26. Hoffman JP, Lanciano R, Carp NZ, et al. Morbidity after intraperitoneal insertion of saline filled tissue expanders for small bowel exclusion from radiotherapy fields: A prospective four-year experience with 34 patients. Am Surg 1994;60:473–482. 27. Geller MA, Argenta PA, Thomas SG, Dusenbery KE, Judson PL, Boente MP. Feasibility and morbidity of using saline filled tissue expanders to reduce radiation-induced bowel injury in patients with gynecologic malignancies. Eur J Obstet Gynecol Reprod Biol 2009;143:93–97. 28. Choi HJ, Lee HS. Effect of omental pedicle hammock in protection against radiation-induced enteropathy in patients with rectal cancer. Dis Colon Rectum 1995;38:276–280. 29. Evans DB, Shumate CR, Ames FC, Rich TA. Use of Dexon mesh for abdominal partitioning above the peritoneal reflection. Dis Colon Rectum 1991;34:833–835. 30. Leseur J, Carrie C, Le Prise´ E, et al. Intensity-modulated radiotherapy for cancers in childhood. Cancer Radiother 2009;13:536–542.
Address correspondence to: Sabine Irtan, MD, PhD Service de Chirurgie Pe´diatrique Visce´rale Sorbonnes Paris City University Hoˆpital Trousseau 26 rue Arnold Netter 75012 Paris France E-mail: [email protected]
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