Exenteración pélvica total laparoscópica mediante técnica de cirugía mínimamente invasiva transanal
Wed - July 27, 2016
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Cirugía trans anal
A 59-year-old man presenting with fecal occult blood visited our hospital. He was diagnosed with advanced lower rectal cancer, which was contiguous with the prostate and the left seminal vesicle. There were no metastatic lesions with lymph nodes or other organs. We performed laparoscopic total pelvic exenteration (LTPE) using transanal minimal invasive surgery technique with bilateral en bloc lateral lymph node dissection for advanced primary rectal cancer after neoadjuvant chemoradiotherapy. The total operative time was 760 min, and the estimated blood loss was 200 ml. LTPE is not well established technically, but it has many advantages including good visibility of the surgical field, less blood loss, and smaller wounds. A laparoscopic approach may be an appropriate choice for treating locally advanced lower rectal cancer, which requires TPE. Total pelvic exenteration (TPE) was first described by Brunschwig as a palliative treatment for the terminal stages of advanced pelvic malignancies. Although TPE is highly invasive, it is a potentially curative procedure for locally advanced rectal cancer invading adjacent organs. One drawback of TPE is its high rate of postoperative complications and high morbidity. Recently, the usefulness of laparoscopic extended surgery for rectal cancer was reported, and it can decrease a complication rate [4, 5]. Here, we report our experience of laparoscopic total pelvic exenteration (LTPE) with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer. A 59-year-old man was admitted to our hospital for the treatment of a rectal tumor. The tumor was found via colonoscopy during an examination at a medical checkup. The colonoscopy revealed an ulcerated tumor at the anterior rectum, 4 cm from the anal verge. Histopathologic examination revealed moderately differentiated adenocarcinoma. CT and MRI scans showed that the rectal tumor was contiguous with the prostate and the left seminal vesicle. PET-CT showed no evidence of metastasis. The carcinoembryonic antigen (CEA) level was elevated at 105.1 ng/mL. After neoadjuvant chemoradiotherapy (CRT) (S-1 100 mg/m2/6 weeks, 2 Gy*25/5 weeks = 50 Gy), CEA level decreased to 24.3 ng/mL but the size of the tumor and the degree of invasion were unchanging. From the CT and MRI, the invasion to adjacent organs was still undeniable; therefore, we thought that TPE was appropriate surgery for this patient from the point of view of curability. We performed LTPE 8 weeks after chemoradiotherapy. In conclusion, LTPE is a potentially safe and feasible procedure. However, reports on LTPE for advanced rectal cancer are scarce; therefore, more studies are necessary to evaluate the long-term safety of LTPE.
