Расширенная эвисцерация малого таза с резекцией боковой стенки при злокачественных опухолях

Пациенты с опухолевым поражением боковой стенки таза – особая категория больных, которые до недавнего времени не рассматривались в качестве кандидатов для хирургического лечения.

Цель обзора литературы – проанализировать мировой опыт и представить актуальное состояние проблемы. мы проанализировали тематические статьи, опубликованные за период с 1967 по 2023 г., в которых рассматривалась радикальность резекции как ключевой фактор прогноза. В ходе ознакомления с результатами исследований установлено, что достижение резекций R0 возможно более чем в половине случаев. при этом 5-летняя выживаемость в некоторых исследованиях достигала 50 %, а послеоперационная летальность не превышала 7 %. авторы большинства исследований сообщают о высокой частоте развития послеоперационных осложнений, достигающей 82 %. Эвисцерация с расширенной латеральной диссекцией стенки таза может улучшить показатели выживаемости пациентов с местно-распространенными опухолями таза при условии правильного отбора пациентов и проведения таких операций в высокопотоковых специализированных центрах тазовой онкохирургии экспертного уровня.

1. Cochrane Database of Systematic Reviews (Reviews). Exenterative surgery for recurrent gynaecological malignancies. The Cochrane Library 2014;2. DOI: 10.1002/14651858.CD010449.pub2

2. Höckel M. Laterally extended endopelvic resection. Novel surgical treatment of locally recurrent cervical carcinoma involving the pelvic side wall. Gynecol Oncol 2003;91(2):369–77. DOI: 10.1016/s0090-8258(03)00502-x

3. Andikyan V., Khoury-Collado F., Sonoda Y. et al. Extended pelvic resections for recurrent or persistent uterine and cervical malignancies: An update on out of the box surgery. Gynecol Oncol 2012;125(2):404–8. DOI: 10.1016/j.ygyno.2012.01.031

4. Mibayashi R. Super-radical hysterectomy. Japan: Japan Society of Gyneсology & Obstetrics, 1941.

5. Brunschwig A., Walsh T.S. Resection of the great veins on the lateral pelvic wall. Surg Gynecol Obstet 1949;88:498–500.

6. Brunschwig A. Complete excision of pelvic viscera for advanced carcinoma. A one-stage abdominoperineal operation with end colostomy and bilateral ureteral implantation into the colon above the colostomy. Cancer 1948;1(2):177–83. DOI: 10.1002/1097-0142(194807)1:23.0.co;2-a

7. Barber H.R., Brunschwig A. Excision of major blood vessels at the periphery of the palves in patients receiving palevic exenteration: common and/or iliac arteries and veins 1947 to 1964. Surgery 1967;62(3):426–30. PMID: 6038178

8. Wanebo H.J., Whitehill R., Gaker D. et al. Composite pelvic resection an approach to advanced pelvic cancer. Arch Surg 1987; 122(12):1401–6. DOI: 10.1001/archsurg.1987.01400240047008

9. Caceres A., Mourton S.M., Bochner B.H. et al. Extended pelvic resections for recurrent uterine and cervical cancer: out-of-the-box surgery. Int J Gynecol Cancer 2008;18(5):1139–44. DOI: 10.1111/j.1525-1438.2007.01140.x

10. Jurado M., Alcázar J.L., Martinez-Monge R. et al. Resectability rates of previously irradiated recurrent cervical cancer (PIRCC) treated with pelvic exenteration: Is still the clinical involvement of the pelvis wall a real contraindication? A twenty-year experience. Gynecol Oncol 2010;116(1):38–43. DOI: 10.1016/j.ygyno.2009.09.035

11. Austin K.K.S., Solomon M.J. Pelvic exenteration with en bloc iliac vessel resection for lateral pelvic wall involvement. Dis Colon Rectum 2009;52(7):1223–33. DOI: 10.1007/DCR.0b013e3181a73f48

12. Brown K.G.M., Solomon M.J., Koh Cherry E. Pelvic Exenteration surgery: the evolution of radical surgical techniques for advanced and recurrent pelvic malignancy. Dis Colon Rectum 2017;60(7):745–54. DOI: 10.1097/DCR.0000000000000839

13. Daix M., Gomez C.M., Angeles M.A. et al. Extended pelvic resection for gynecological malignancies: a review of out-of-thebox surgery. Gynecol Oncol 2022;165(2):393–400. DOI: 10.1016/j.ygyno.2022.03.002

14. Cibula D., Raspollini M.R., Planchamp F. et al. ESGO/ESTRO/ ESP Guidelines for the management of patients with cervical cancer – update 2023. Int J Gynecol Cancer 2023;33(5):649–66. DOI: 10.1136/ijgc-2023-004429

15. Lee P., Francis K.E., Solomon M.J. et al. Triangle of Marcille: the anatomical gateway to lateral pelvic exenteration. ANZ J Surg 2017;87(7–8):582–6. DOI: 10.1111/ans.13872

16. Vizzielli G., Naik R., Dostalek L. et al. Laterally extended pelvic resection for gynaecological malignancies: a multicentric experience with out-of-the-box surgery. Ann Surg Oncol 2019;26(2):523–30. DOI: 10.1245/s10434-018-07088-8

17. Höckel M. Long-term experience with (laterally) extended endopelvic resection (LEER) in relapsed pelvic malignancies. Curr Oncol Rep 2015;17(3):435. DOI: 10.1007/s11912-014-0435-8

18. Solomon M.J., Brown K.G.M., Koh S.E. et al. Lateral pelvic compartment excision during pelvic exenteration. Br J Surg 2015;102(13):1710–7. DOI: 10.1002/bjs.9915

19. Höckel M., Wolf B., Hentschel B. et al. Surgical treatment and histopathological assessment of advanced cervicovaginal carcinoma: A prospective study and retrospective analysis. Eur J Cancer 2017;70:99–110. DOI: 10.1016/j.ejca.2016.10.016

20. Laporte G.A., Zanini L.A.G., Zanventtor P.H. et al. Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer. J Surg Oncol 2019;121(5):718–29. DOI: 10.1002/jso.25759

21. Höckel M. Laterally extended endopelvic resection (LEER) – principles and practice. Gynecol Oncol 2008;111(2 Suppl):S13–7. DOI: 10.1016/j.ygyno.2008.07.022

22. Shaikh I., Aston W., Hellawell G. et al. Extended lateral pelvic sidewall excision (ELSiE): an approach to optimize complete resection rates in locally advanced or recurrent anorectal cancer involving the pelvic sidewall. Tech Coloproctol 2014;18(12):1161–8. DOI: 10.1007/s10151-014-1234-9

23. Daix M., Angeles M.A., Leray H. et al. Anterior pelvic exenteration and laterally extended pelvic resection: a step by step procedure. Int J Gynecol Cancer 2022;32(1):107–8. DOI: 10.1136/ijgc-2021-003047

24. Cibula D., Mitáš P. Laterally extended endopelvic resection with external iliac vessels resection and crossover ileofemoral bypass. Int J Gynecol Cancer 2019;29(8):1338. DOI: 10.1136/ijgc-2019-000461

25. Sozzi G., Petrillo M., Gallotta V. et al. Laparoscopic laterally extended endopelvic resection procedure for gynecological malignancies. Int J Gynecol Cancer 2020;30(6):853–9. DOI: 10.1136/ijgc-2019-001129

26. Kanao H., Chang E.J., Omi M. et al. Laparoscopic pelvic exenteration and laterally extended endopelvic resection for postradiation recurrent cervical carcinoma: technical feasibility and short-term oncologic outcome. Gynecol Oncol 2021;161(1):34–8. DOI: 10.1016/j.ygyno.2020.12.034

27. Lago V., Guijarro-Campillo A.R., Vidal B.S. et al. An easy learning approach to a complex surgical technique: a step-by-step siterelapse Lateral Extended Endopelvic Resection (LEER). Ann Surg Oncol 2023;30(8):4991–3. DOI: 10.1245/s10434-023-13368-9

28. Di Donna M.C., Cucinella G., Zaccaria G. et al. Salvage cytoreductive surgery for pelvic side wall recurrent endometrial cancer: robotic combined laterally extended endopelvic resection (LEER) and laterally extended pelvic resection (LEPR) debulking. Int J Gynecol Cancer 2023;33(1):126–7. DOI: 10.1136/ijgc-2022-003746

29. Rajendran S., Brown R.G., Solomon M.J. et al. Complete resection of the iliac vascular system during pelvic exenteration: an evolving surgical approach to lateral compartment excision. Br Med J 2021;108(8):885–7. DOI: 10.1093/bjs/znab070

30. Martin A.L., Sinha S., Peres L.C. et al. The impact of distance to closest negative margin on survival after pelvic exenteration. Gynecol Oncol 2022;165(3):514–21. DOI: 10.1016/j.ygyno.2022.04.004

31. PelvExCollaborative. Pelvic exenteration for advanced nonrectal pelvic malignancy. Ann Surg 2019;270(5):899–905. DOI: 10.1097/SLA.0000000000003533

32. Sbarra M., Miccò M., Corvino M. et al. CT findings after pelvic exenteration: review of normal appearances and most common complications. Radiol Med 2019;124(7):693–703. DOI: 10.1007/s11547-019-01009-9

33. Yamada K., Ishizawa T.K., Niwa K. et al. Patterns of pelvic invasion are prognostic in the treatment of locally recurrent rectal cancer. Br J Surg 2001;88(7):988–93. DOI: 10.1046/j.0007-1323.2001.01811.x

34. Moore H.G., Shoup M., Riedel E. et al. Colorectal cancer pelvic recurrences: determinants of resectability. Dis Colon Rectum 2004;47(10):1599–606. DOI: 10.1007/s10350-004-0677-x

35. Park S.J., Mun J., Lee S. et al. Laterally extended endopelvic resection versus chemo or targeted therapy alone for pelvic sidewall recurrence of cervical cancer. Front Oncol 2021;11:683441. DOI: 10.3389/fonc.2021.683441

36. Park S.J., Kim J., Kim J.-W. et al. Safety and feasibility of laterally extended endopelvic resection for sarcoma in the female genital tract: a prospective cohort study. Obstet Gynecol Sci 2022;65(4):355–67. DOI: 10.5468/ogs.22071

37. Brown K.G.M., Solomon M.J., Lau Y.C. et al. Sciatic and femoral nerve resection during extended radical surgery for advanced pelvic tumours: long-term survival, functional, and quality-of-life outcomes. Ann Surg 2021;273(5):982–8. DOI: 10.1097/SLA.0000000000003390

38. Harji D., Mauriac P., Bouyer B. et al. The feasibility of implementing an enhanced recovery programme in patients undergoing pelvic exenteration. Eur J Surg Oncol 2021;47(12):3194–201. DOI: 10.1016/j.ejso.2021.07.013

39. Pring E.T., Gould L.E., Malietzis G. et al. BiCyCLE Research Group. BiCyCLE NMES-neuromuscular electrical stimulation in the perioperative treatment of sarcopenia and myosteatosis in advanced rectal cancer patients: design and methodology of a phase II randomised controlled trial. BMC Medicine 2021;22(1):621. DOI: 10.1186/s13063-021-05573-2

40. Tinelli G., Cappuccio S., Parente E. et al. Resectability and vascular management of retroperitoneal gynecological malignancies: a large single-institution case-series. Anticancer Res 2017;37(12): 6899–906. DOI: 10.21873/anticanres.12153