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due March 25th. Hello

1:34

and welcome back by I'm the Knife

1:36

listeners to part four of this special

1:38

series on pelvic exenteration surgery for locally

1:40

advanced and recurrent rectal cancer. This

1:43

series is brought to you by Behind the

1:45

Knife and the team at the colorectal surgical

1:47

department at Royal Prince Alfred Hospital or RPA

1:49

here in Sydney, Australia. The

1:52

team from RPA is Professor Michael Solomon who

1:54

is the head of the pelvic exenteration program,

1:57

Dr. Jacob Waller, an advanced trainer in

1:59

general surgery. surgery and my name is

2:01

Kilian Brown and I'm a colorectal surgery fellow. For

2:04

each of the four episodes in this series

2:07

we've invited a different international expert in exenteration

2:09

surgery to join us for the discussion and

2:12

today it's our pleasure to welcome Professor Gabrielle

2:14

van Ramhor. Professor

2:16

van Ramhor is a consultant colorectal

2:18

surgeon at Ghent University Hospital and

2:21

associate professor at Ghent University in

2:23

Belgium. After

2:25

completing her PhD in surgical training

2:27

she undertook fellowships in complex pelvic

2:29

oncology at the Netherlands Cancer Institute

2:31

in Amsterdam and then here at an

2:34

RPA in Sydney. Professor

2:37

van Ramhor has published extensively in

2:39

colorectal and surgical oncology and has

2:41

both a clinical and academic interest

2:43

in pelvic exenteration. So Gabrielle

2:45

it's great to see you online. Thanks for joining us

2:47

for the episode and for being part of the series.

2:50

Thank you so much for this honorable invitation

2:52

Kilian and I'm very happy to join the

2:54

Sydney team online today. So

2:57

today is the fourth and final episode in

2:59

this series. For the first

3:01

three episodes we covered general principles of

3:03

pelvic exenteration surgery as well as some

3:05

of the specific surgical techniques for anterior

3:07

lateral and posterior compartment sections. So be

3:10

sure to check those out if you

3:12

miss them. But today we're

3:14

going to talk mainly about reconstruction

3:16

after pelvic exenteration as well

3:19

as some of the post-operative complications that

3:21

can occur. So

3:23

we'll start off with a case. Jake

3:25

a 71 year old man who

3:27

underwent total pelvic exenteration 11 days

3:29

ago for a primary rectal cancer

3:31

and had previously been treated with

3:34

chemoradious therapy initially was

3:36

well after the operation and recovering

3:38

according to an expected trajectory. But over

3:40

the last 24 hours or so it

3:43

started to develop fevers and you're asked to see

3:45

him on the ward because he becomes tachycardic and

3:47

you note that over the last 24 hours his

3:51

drain output has been high and

3:53

he has new perineal discharge. So

3:55

how would you approach this situation? So

3:58

I think it's important in these types of cases. Can

4:00

you possibly complications in aging? Now.

4:03

And say, the patient and simultaneously

4:05

assess and resuscitate them. Nor.

4:07

So of allies threshold the starting

4:09

empirical broad spectrum antibody cover. And

4:12

when they got signed that sepsis. In.

4:14

This particular case, where this parody of

4:16

discharge in the history of hydride out

4:19

with my concern is. Primarily.

4:21

For an interim nominal source of of the

4:23

sepsis. Gimme looking closely at

4:25

the content of these drives and the discharge

4:27

coming from the pair name. A

4:30

manly want to determine if these perlin is

4:32

this in Tehreek or possibly this year it

4:34

I'd like to send the drain fluid. Offer.

4:37

A crap name I'd arrived just in abdominal say

4:39

taste and with oral and I have a contrast.

4:41

To. Look for a pelley collection or late. I

4:44

also want to make so that we as coaches of

4:47

the patient's blood and conduit year and as well as

4:49

a an x ray the chest is to exclude any

4:51

other sources for the sailor. Okay

4:54

so this is a seat a scan or

4:56

can you say. So. It's difficult

4:58

on these two slices that is definitely

5:00

a fluid collection in the pelvis, which

5:02

is gas containing. The. Little

5:05

bit difficult in the patients, had discarded

5:07

time played most of the exaggeration patients

5:09

at the to a map will have

5:11

some form of collection. Am

5:13

on these images it's difficult to

5:15

tell where these fluid nice potentially

5:17

coming from. And so

5:19

the drain fluid craton in subs can

5:22

be comes back and is grossly elevated

5:24

and you proceed with a C T

5:26

intravenous polygram which shows a small amount

5:28

of contrast. Extra citing from. The.

5:30

right? You're a terrorist. To Ali

5:32

conduit and asked my sis

5:34

so. Will. Step away from the

5:37

case for a moment and talk about

5:39

the reconstruction face. Who is interaction? So

5:41

this is after. The. Specimens been

5:44

delivered. Jake What are the

5:46

systems or organs that might

5:48

require repay or reconstruction? Yeah.

5:50

So I think we've spoken a little bit

5:52

about it in the previous episodes in the

5:55

series. But firstly, does. Your. logical

5:57

reconstructions i usually this is the

5:59

creation of an odd conduit. However

6:01

as we spoke about in episode 2 there

6:03

are other options. Then in episode 3

6:05

we spoke about vascular reconstruction and that

6:08

it's only required if we need to

6:10

excise the common or the external iliacs

6:12

with the specimen. We

6:14

then need to think about restoring our

6:17

intestinal continuity especially in these patients where

6:19

a conduit has been harvested. Ideally we

6:21

want to try and limit the number of bowel and that's the most

6:23

easy if we can. Occasionally we'll

6:25

need bony reconstruction in the form of

6:28

either sacral implants or a pubic bone

6:30

mesh to restore continuity of the pelvic

6:32

ring. And then finally we

6:34

need to close the perineal defect and then

6:36

the abdomen before we mature our stomas. So

6:40

let's talk a little bit about perineal

6:42

reconstruction. Broadly speaking as Jake

6:44

mentioned the options are to close

6:46

primarily or the alternative is a

6:48

myocutaneous or other sort of flap.

6:51

Gabrielle could you tell us a

6:53

little bit about the options and your general approach

6:55

to selecting a flap and when you might use

6:58

one? Yes, Katie and

7:00

of course generally the risk assessment

7:02

is based on the likelihood of

7:04

encountering wound problems in the future

7:06

in case you choose for primary

7:08

closure. So we

7:11

know that wound problems such

7:13

as the hissing zone infection or

7:15

hernias are more common in patients

7:18

who have undergone preoperative radiotherapy, those

7:21

who undergone an extra-neurved type abdominal

7:23

perineal resection, a saccrectomy

7:25

or total extensoration but also

7:27

patients for instance those with

7:29

anal SCC can have

7:31

large residual skin defects that

7:33

need closure. So those

7:36

could all be used as arguments

7:38

to refer flap over primary closure

7:41

and this has also been highlighted in

7:43

a publication from your team by

7:45

Jacobs in the British Journal of

7:47

Surgery 2013. Of course

7:49

there are no randomised data with this

7:52

type of choice for the

7:54

reconstruction and sometimes if you choose

7:56

to omit a flap And

7:58

the patient does develop problems. Snoring can

8:00

end up with a feeling of and

8:03

we should as good as know what

8:05

is that. I used to slam so

8:07

it's very specific and know sometimes. for

8:10

instance if a patient has a large

8:12

incision hernia you would not choose an

8:14

abdominal slapped such a severe amp flom

8:16

but the majority of the articles onset

8:19

reconstruction after buff concentration have used to

8:21

be around flat as well as for

8:23

a know as he sees. Interruptus

8:26

including to to region new up,

8:28

a sigh or be two folded Pro:

8:30

New flaps. And. Despair usually depend

8:33

on the experience of your local plastic

8:35

surgeon. If those were the ones who,

8:37

it's harvest. And. So

8:39

for. Those listening to the

8:41

audio but not necessarily looking at the

8:43

video ad is a comprehensive overview of

8:46

up flap options by a rails team

8:48

and will provide a link. To.

8:50

That to article in the show nights. To.

8:53

Prof: what's your view on and flaps

8:55

i think your preference generally it at

8:57

up he eyes for of the rams

9:00

slap what's the rationale to that and

9:02

and and generally speaking Wendy's effect. For.

9:05

Those watching and I think those slides

9:07

you doesn't give a pretty good summary.

9:09

that is. Probably. On Iran,

9:11

twenty percent of all our exonerations will

9:14

use flaps and their money for. Large.

9:16

Skyn defect. So as you said Ricardas

9:19

a say all right he added skin

9:21

is where will use it and slept

9:23

stunt prevent O'neill's it's the first thing.

9:25

says. Let's add to prevent perennial

9:28

when bike down or close Largely

9:30

Thanks for us really. And

9:32

the ones we mostly is other v

9:35

ram which sun on those looking at

9:37

it. We. Is he is the

9:39

vertigo the ram as opposed to the horizontal

9:41

they ram. And develop

9:43

gotta bring into account. Your.

9:45

Style most and where this time as

9:47

a guy to basically when you got

9:50

double standards and. I think we

9:52

read up an article about how to measure whether

9:54

news damn a site will be from Where the

9:56

stumbled Airbus measure that after a. The.

9:58

rams and sometimes bilateral VRAMs,

10:00

but that's pretty unusual. So

10:03

that's the principle there. I think during

10:05

the time of the Exenderation for the last 25

10:08

years, we've gone through cycles where people

10:10

were doing flaps for even simple

10:12

APRs and I think we've

10:15

seen that cycle go through and they're very

10:17

big defects and the flaps don't fill the

10:19

empty pelvis really. I mean, people go

10:22

around saying, do a flap that will fill your empty

10:24

pelvis. But I think after an Exenderation, the

10:26

whole pelvis is empty and a flap all it is is

10:29

sitting down on the skins. It's not

10:31

the answer for the empty pelvis. So

10:33

I'll use in that bottom right hand is

10:35

a Gluteal VY for a

10:37

morbidly obese patient with extensive

10:39

perineal skin that's been placed in

10:42

the prone position. It's very hard to get a fat

10:44

abdominal VRAM down through a

10:46

narrow pelvis. So that's

10:49

really for obese people with a lot of perineal

10:51

skin. And the Gracilis, which

10:53

is not a robust, another very big one, is

10:55

really for wound breakdown further down

10:57

the track where you just don't want to

11:00

go into the abdomen again and it's a

11:02

fairly narrow and not deep. And in that

11:04

case down the bottom left, we're trying to

11:06

cover some small bowel where

11:08

there's no vagina and no pelvic floor

11:10

at all. That's

11:12

probably broadly the principle. But again,

11:14

as Gabriel said, it really depends on your

11:16

local plastic surgeons, what they're happy

11:19

to do and how big is the

11:21

defect. And Gabriel, the

11:23

general preference at your unit and I won't

11:25

ask you to speak on the whole of

11:27

Europe but is there a lot of variation

11:29

in people's preferences? Well,

11:32

in our institution, we prefer to VRAM

11:34

flat also because it's a relatively

11:37

easy flap that usually can be

11:39

harvested by one of the registrars.

11:42

It's quite a reliable flap as well

11:44

with very low rates of flat loss

11:46

of flat necrosis. So

11:49

that's an advantage and also can be

11:51

used for vaginal reconstructions. But some of

11:53

the centers would prefer to use by

11:55

natural grassless flat. So that would

11:57

be another option and I know that from the

11:59

end. Scandinavian and some UK centers

12:01

to be proff

12:06

I've talked a lot about VRAM could you just

12:08

broadly take us through the steps of the

12:11

operation and any specific sort of pitfalls that

12:13

people should be aware of? Oh

12:16

pitfalls, I know lots of them. I agree

12:20

with Gabrielle just what I did forget the

12:22

poster of a journal reconstruction is really important

12:25

for a VRAM or a flap where

12:27

we've preserved the bladder and the anterior of a

12:29

journal wall. On the top left

12:31

is just measuring the flap out and taking into

12:34

account their bill what the Langer's

12:36

lines are feeling as well

12:39

as you know the fat in

12:41

the abdomen because you've got to raise the

12:43

skin to close over. I use proline mesh

12:46

to replace the rectus. We usually

12:48

preserve the posterior rectus sheath to

12:51

cover the bowel inside and

12:53

we close our primary clothes the

12:55

posterior rectus sheath to the contralateral

12:57

linear and raise flaps of the

12:59

skin and fat on each side.

13:02

Anchor the proline mesh down to

13:04

the pubic bone and you

13:06

really got to do that otherwise you'll get hernias on

13:09

the pubic bone and

13:11

then so that in and I usually bring

13:14

the stomas out lateral to the linear semilineuris

13:16

which is where we put

13:18

the lateral edge of the proline

13:20

mesh and importantly

13:22

watching that epigastric when you're closing

13:25

the abdomen you don't kink off

13:27

the inferior epigastric. The

13:30

VRAM is a lot easier as you get

13:32

down when you do a complete pelvic exoneration

13:34

and also when you take pubic bone because

13:36

it's almost like only one or two

13:39

centimeters on the vessels when you've still got a

13:41

prostate you've still got a bladder and

13:43

you've got to bring the VRAM underneath the

13:45

anterior compartment then it's a little bit trickier.

13:47

You can mobilize the bladder and bring it

13:50

down through the muscle if

13:52

you really can't get it down underneath the

13:54

large prostate and learn up. on

14:00

flaps and quality of life and

14:03

other things

14:05

that can go wrong after flap reconstruction?

14:11

Well clearly of course we have a wound that

14:13

needs to be constructed and wounds

14:15

especially in this area can get infected or have access

14:18

formation. Also the essence is quite common and some of those distances

14:24

would be very minor and would only

14:26

need some wet dressings in the ward. If you have a

14:28

major complication and you need to for instance revise or

14:32

even complete necrosis, the

14:35

patient goes back and forth into

14:37

theatre and that

14:39

can have a major impact on

14:42

the patient's physical activities especially in

14:44

the first month after surgery. It's

14:47

also fairly uncommon but still very

14:49

annoying if that occurs is this

14:51

entrepreneurial fish list may

14:53

occur or ulcers or chronic

14:56

sinuses which can have a

14:58

great impact, a negative impact

15:00

on patients and setting abilities

15:02

and overall physical activity. So

15:05

Prath have you got anything to add

15:07

on flap related complications? I

15:10

think invariably after irradiated particularly if

15:13

there's a sacrectomy the top end of the

15:15

back will separate a little bit

15:17

and as Gabriel said it's just really requires

15:19

you know local wound care. I'm

15:21

a bit nervous with back dressings when

15:23

you've got a small bowel

15:26

and astromosis with a conduit because we've had a

15:28

few fistulas related I think

15:31

to vac pressure so I'm a bit nervous about using

15:33

that that's the only thing in

15:35

the early post-op period. Flaps

15:37

don't really prevent either small bowel leaks

15:39

or conduit leaks so they'll separate as

15:41

well and that's why I think

15:43

the VRAM is the most robust one compared

15:45

to gracilis but all of the normal flap

15:48

complications occur but as always in

15:50

an increased incidence and

15:53

non-exenderation patients. I

15:56

can maybe add to this then soon know

15:59

if you have urinary leak that needs to

16:01

be treated and

16:05

with regards to donor side problems like

16:10

major diet science complications actually quite rare. But even

16:12

if you reconstruct the abdominal wall

16:14

after harvesting a B-rem flap with

16:16

a mesh up to

16:18

13% of the patients will

16:20

develop an incisional union which can

16:23

be challenging to treat to these patients. from

16:41

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getting things done efficiently. Go to

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free. That's grammarly.com/business teams.

16:57

Prof, I was just going to ask about

16:59

the use of mesh in the pelvis to try

17:01

and keep small bowel contents away from those wounds.

17:04

Is this something that you do and could

17:06

you just broadly take us through the principles

17:08

around pelvic meshes? Well

17:11

there's a lot of different types

17:13

of mesh whether they're biodegradable meshes,

17:15

whether they're permanent mesh. I

17:18

think when there's bone particularly the

17:20

pubic bone and particularly if you take the whole pubic

17:22

bone you need to reconstruct

17:24

the pubic bone otherwise there's nothing

17:26

to attach your residual abdominal wall

17:28

and rectus and you get the

17:31

whole abdomen collapses down to the

17:33

sacrum and that's impossible to get

17:35

stoma. So we'll tend to

17:38

use proline for the

17:40

pubic bone and then reinsert the

17:42

penis, reinsert the rectus to the

17:45

proline and that actually gives excellent

17:47

support. So for bone

17:49

I'll definitely use proline. For perineal

17:52

hernia repairs I'll use proline. I

17:54

won't use proline just as a

17:56

routine pelvic floor and because it's a permanent mesh

18:00

the empty pelvis is such a common different

18:06

ones from stratus biowas over the years, the

18:08

one on the right's a biowas, I think.

18:11

And probably that's the one we would

18:13

use the most for a very empty

18:15

pelvis. But it still gets

18:18

infected. We've had to remove more biowas than

18:20

anything else and it's quite hard to get

18:22

out when it's partially degraded as well.

18:24

So I don't

18:26

think we've got the answer for mesh. But mesh is

18:30

really to stop perineal hernia.

18:32

Perineal hernia perhaps isn't

18:34

such a big thing in exaggeration patients as

18:36

it is in smaller resections. If

18:38

you have a small hole in your squirting small

18:40

bowel through it, you're more likely to get strangled

18:43

when you've got a monstrous defect,

18:45

no sacrum, then it's really just the

18:47

whole descending abdomen which is quite manageable,

18:51

just with double underpants wearing or

18:53

even a support. And

18:56

Gabrielle, what's the practice in your centre do

18:58

you use pelvic mesh or? Well

19:01

we don't have any biological mesh stocked

19:03

as it is and as Prof said,

19:05

a mercedent tells an

19:08

uncertain and non-absorbable mesh

19:10

in the pelvic floor for

19:12

primary surgery. So

19:14

we do rely more on flat

19:16

repairs than mesh repairs. But

19:19

the biological mesh is an interesting

19:21

study published by Bloch on handles

19:23

of surgery 2022 which

19:26

was the long-term follow-up of the Biopax study.

19:28

As you may

19:30

know that study was actually

19:32

negative in the first short-term

19:34

findings as the 30-day wound

19:36

healing was not different between

19:39

primary closure and the use of biological

19:42

mesh. But after five

19:44

years like seven percent of the

19:46

biomass patients had developed a perineal

19:48

hernia versus 30 percent

19:50

after primary closure. So

19:53

even though no improvements were found in qualitative

19:55

life and functional outcomes between the groups this

19:58

fact described after the study. extra

20:00

levator of double-premial resections

20:05

does make one think about

20:07

two to

20:10

use biological machine. It's an interesting point.

20:12

Prof, we briefly kind of talked

20:14

about the reconstruction of the pubic bone. What about after

20:16

the parectomy? When do we require reconstruction of the

20:20

bony elements? Well you only need support of

20:22

the pelvis if you lose the S1

20:25

both front and back and

20:28

then you've lost the actual support of

20:31

both of the spine and also if

20:33

there's no sacroelectric joint then they

20:35

can't walk really because it collapses in.

20:37

So if you have to take a

20:39

complete S1 out with no S2 obviously

20:42

and all the way down then you need to

20:44

put some form of bridge in to support the

20:46

pelvis and we've been

20:48

using titanium 3D reconstructed

20:51

prosthesis which are the two on the photo and

20:55

that's fine when they're primary

20:57

bone tumors or chordomas or

20:59

that. Once you're

21:01

doing recurrectal cancer or advanced primary wing

21:03

you're doing bowel and

21:06

conduits the infection rate and explant

21:08

rate is really high. So I

21:11

think 3D reconstructed

21:13

S1s are for primary bone

21:15

tumor exonerations where you're just getting

21:17

the bowel out of the way

21:19

and there's not opening a bowel

21:21

because the complications and the empty

21:23

pelvis and sepsis with a titanium

21:25

implant or any implant is a really

21:27

bad thing. So we've also gone

21:30

more over the years. We've done

21:32

over 440 sacroectomies now of doing

21:36

the anterior cortex of S1 from the front

21:38

and not leaving the posterior support so that

21:40

that acts as the support and not putting

21:43

any implants in if we have to do

21:45

high sacroectomies and I think that's taken a

21:47

lot of the morbidity out of the high

21:50

reconstructions of the segment. So

21:55

just back to the case, the patient as we

21:57

said had a small but clinically

21:59

significant leak from the right uretiro,

22:02

ileolanastomosis. That improved with

22:04

antibiotics, nephrostomy tubes

22:06

and the drain that was in the

22:09

pelvis and the repeat pylogram two

22:11

weeks later showed that there was no

22:13

contrast to excretization and clinically

22:15

the leak had dried up. Unfortunately

22:18

the patient did develop the essence of

22:20

the perineal wound and

22:22

chronic perineal sinus requiring dressings in

22:24

the community. Which

22:28

brings us to the empty pelvis syndrome so

22:30

this is something that we've talked about through

22:32

this episode and others but perhaps we can

22:35

address it specifically. So Gabriel

22:37

how do you conceptualize this issue you know

22:39

what is it I know there's no

22:41

agreed definition but how

22:43

big a problem is this in

22:46

accentuation surgery? Okay I'm afraid that

22:48

empty pelvis syndrome is actually very common

22:50

depending on which definition you'd like to

22:52

adhere to. The University

22:54

of Southampton and Charles West

22:56

is investigating within the Calvax

22:58

Collaborative and how

23:01

this should be defined and

23:03

what they've suggested is that

23:05

empty pelvis is a spectrum

23:07

of complications including pelvic sepsis,

23:09

bowel obstruction, radial sinus and faecal.

23:12

But most of this has to do with the

23:15

large void that's being generated by

23:17

the reticulat of the surgery and

23:20

the migration of the bowel into this

23:22

void. So the

23:24

complications that you know occur

23:27

other ones I just mentioned such

23:30

as bowel obstruction and which can

23:32

occur quite late after surgery but also

23:34

immediately after surgery and

23:36

many patients will need drainage

23:38

and antibiotics for infected pelvic

23:40

collections and

23:42

interperineal fish saloon

23:45

quite frequently in patients

23:47

who've had problems in

23:49

this area. Okay

23:53

and so what about prevention Gabriel

23:55

are there any techniques that proposed

23:57

and that work to reduce the

24:00

Well I think one

24:02

of the most common concepts is

24:04

to keep the pelvis as full

24:06

as you can by for instance

24:08

saving uterus. So if you don't

24:10

need to perform hysterectomy, just keep

24:12

it in so it fills up

24:14

the pelvis. Also you

24:16

can fill up the pelvis with nomenclasty.

24:18

The patient has enough omentum that can

24:20

be brought down into the pelvis. A

24:24

flap is not, it's most

24:26

likely the closest skin defect but not

24:28

always likely to fill up the pelvis

24:30

as prof or the enlightenters. There

24:33

have been descriptions of the use

24:35

of for instance breast prostheses within the

24:37

pelvis but if not,

24:40

many people are being enthusiastic about

24:42

this and implying this in their

24:44

clinical practice. And

24:47

so Prof in your experience have you used some

24:50

of these techniques that Gabrielle has mentioned

24:52

in terms of omentoplasty and breast implants

24:54

and what do you find works

24:56

or doesn't work? The

24:59

omentum we'll always use if we got any

25:01

omentum and getting it all the way down.

25:03

It's really good for covering bone,

25:05

raw bone. That's what I think it's really good

25:07

for. So it doesn't fill the pelvis at all.

25:10

All it does is coat the empty outside

25:12

of the pelvis. Rarely do you have in

25:14

the size of the defects we're talking about enough

25:17

omentum, there's never enough omentum and blood supply to

25:19

get it down if it's that fat anyway. But

25:22

I will definitely use it always

25:24

for the pelvis but mainly to cover

25:26

your raw bone. It's also good if

25:28

you put proline mesh in

25:30

to reconstruct the anterior bone

25:33

then I often use the

25:35

omentum or you have to reconstruct the inguinal

25:37

ligament with proline mesh which I often do,

25:40

which I use for that and then using the

25:42

omentum to coat the inside of it. So you've

25:44

got almost a dual mesh but you're using the

25:46

omentum on the inside so the bone doesn't stick

25:49

to it. So that's where I'll usually use the

25:51

omentum. For those watching at that

25:54

slide on the right, that's someone who's had a

25:56

high sacrectomy and really you can see

25:58

there's absolutely nothing muscles have been

26:00

atrophied, they've lost their nerve and blood supply.

26:03

So there's really nothing that will fit or long-term

26:05

prevent that and I think he's actually got a,

26:08

I'm not sure I think we may have used his rectus muscle

26:10

even in that, but he actually thought there

26:12

was no problem, he thought he had a normal bottom. So

26:15

he wasn't in any, he wore a couple of

26:17

underpants tighter that's all and that's

26:19

really just shows the difference between a wide

26:21

defect and a narrow defect. And

26:24

so what about managing some of

26:27

these complications specifically? I mean

26:29

probably from a re-operative surgical

26:32

point of view, refractory bowel

26:34

obstruction and perineal fistulas, probably

26:36

the most difficult to deal with. So when

26:38

do you operate on these and how do you operate

26:41

on these? I guess

26:43

they're all from bitter experience, a

26:45

little comment, but the one thing going back

26:47

just before I got out of that is that if

26:49

you scan everyone who's at a real exaggeration at

26:52

any time there is a fluid filled cavity

26:54

and radiologists are always

26:57

causing it, saying this could be infectious, anyone

26:59

has a fever and they do the scan, the

27:02

infectious disease people want to get it drained or

27:04

the wound open, just don't do that because you

27:06

open the wound it never heals, you

27:08

drain it and it's still there. So really

27:11

leave it alone and prepare a patient

27:13

if someone does do a CT when

27:15

they've gone home that they're going to

27:17

say there's a big collection and don't

27:19

let them touch it. That's the first

27:22

thing I'd say. The second thing

27:24

is invariably you

27:26

have to fill up with the small bowel if

27:28

they have any sigmoid or the cecum is quite

27:30

a good thing. If I've done

27:32

a conduit I'll have mobilized the right colon to

27:35

bring the enterone to the ostomy to keep that

27:37

up in the abdomen. You can drop the cecum

27:39

down in, that's quite good filler of

27:41

the pelvis but it's invariably the small bowel that

27:43

finishes up and then if you finish up with

27:45

a small bowel obstruction I think

27:47

we sit on them for a long time. They

27:50

often take two weeks to get going so don't

27:52

race in to do anything. Eventually it will unblock

27:54

but if you have an empty pelvis and you have

27:56

a small bowel obstruction the aim is

27:58

not to go in there and take all the loops

28:01

out of the pelvis, straighten them up, because they'll

28:03

all drop back in again and you'll finish up

28:05

with the obstruction. So the

28:07

aim is to find the afferent and

28:09

efferent limbs that are going into the

28:11

pelvis and do a side-to-side bypass, leaving

28:14

it in as the filler of the pelvis. So

28:17

if you try and get them out into raw

28:19

bone attachments, you'll finish up with the fistulas, you'll

28:21

finish up with a lost bowel. So

28:23

if you have a chronic small bowel or

28:26

even a more acute small bowel,

28:29

then do a side-to-side bypass and

28:31

leave the obstructed area if it's

28:33

viable in the pelvis. Similarly,

28:35

if you have an entroparenel fistula,

28:38

then do a bypass, but in that case

28:40

do an exclusion bypass because you want to

28:42

make sure that the small bowel

28:44

content doesn't continue to go

28:47

down to the perineal wound, which may be

28:49

the easiest track. And the other thing

28:52

for those watching is if you do the exclusion bypass, make

28:54

sure you leave the blood supply to the

28:56

bowel that you're leaving in to the pelvis,

28:58

but also sew the staple lines away from

29:00

the original ones because I've had a couple

29:02

of where they've actually reopened into

29:04

the staple line and started the perineal

29:07

fistula six months later. They're

29:10

all bitter experienced ones there. Okay.

29:14

So, I mean, we've talked

29:16

about some of the specific complications of exenteration

29:18

surgery. Obviously, this is radical surgery and all

29:20

sorts of things can go wrong. I think

29:22

in one of the earlier episodes,

29:24

Prof, you said they all get complications. It's just

29:27

a matter of which one, and these

29:29

are just some of the sort of

29:31

more surgically specific complications

29:33

that can occur. Any

29:37

final comments, Gabrielle or Prof, on

29:40

complications in general after exenteration? I

29:42

mean, how do you counsel patients

29:44

about such radical surgery where you're

29:46

expecting that almost all of them

29:48

will develop some small complication, if

29:50

not major? Yeah,

29:53

I think in the decision making, I

29:56

think it's very important to be honest

29:58

with patients. And

30:01

if you're really honest and you tell

30:03

them you will probably get a complication.

30:06

If it's during the surgery, it will be A,

30:08

B, or C. In the

30:10

week after surgery, it will be D, E, or

30:12

F. In the two weeks

30:14

later, it will probably be an abscess or

30:17

pneumonia or an infectious flu is collection. Then

30:21

people actually understand that you know what you

30:23

are dealing with and that you're used to

30:25

managing these patients. And

30:27

also think it's worthwhile to explore

30:29

what people expect from surgery. It's

30:32

so much easier to make these decisions

30:34

in patients who have a lot of

30:37

pain with tumors growing

30:39

into the prostate, can't sit anymore,

30:41

for whom a pelvic accentuation will

30:43

actually be a relief. Instead

30:47

of like 75-year-olds, they actually

30:50

have a very good

30:52

quality of life, not dependent on

30:54

anything or anyone to

30:57

cancer them to have two stomas and

30:59

undergo this radical type of surgery with

31:02

the associated morbidity and possibly

31:04

even mortality if a patient is in a

31:07

bad condition. So you

31:10

really have to reflect on what you can

31:12

bring to these patients and what you're trying

31:14

to achieve. If

31:16

there's any space to pre-habilitate the

31:19

patients or to reconsider or use

31:21

other options, an

31:23

honest conversation with the patients will also

31:26

help them to

31:28

accept the consequences of

31:30

the operation in

31:32

the long term. Any

31:35

comment? Absolutely. And I

31:38

think Gabrielle has explained it really

31:40

well. I think pre-habilitation and particularly

31:42

psychological counseling, pain control, diet, physio,

31:47

they need to be in the right ballpark of what they're about

31:49

to start. I think a lot of them

31:51

come to us sometimes now and they

31:53

just said, �Oh, look, it'll just be like your

31:55

previous operation.� And really, you've got to get

31:58

them out of that ballpark and into the monstrous thing. getting

32:00

into. I think in palliative

32:02

exaggerations, you don't palliate them. It takes

32:04

six months to get

32:08

over an exaggeration. So if you're looking for

32:10

short-term palliation, it's really not the operation you

32:13

should be doing. So I think getting the

32:15

patient into the ballpark of what's

32:17

going to happen, broadly speaking,

32:19

I tell them everyone gets a complication

32:22

and how you handle the complications is

32:24

really what the specialization of

32:26

the exaggeration surgery is. And so it's

32:28

not just prehab, it's also rehab. You

32:30

can't just dump them out into the

32:32

community without a support service for someone

32:34

after an exaggeration. So that's

32:36

extremely important for centers to make

32:39

sure you have prehabilitation and rehabilitation

32:41

set up for those patients. Otherwise,

32:43

they just get

32:45

isolated and with no one

32:48

to contact. And not surprisingly, most people

32:50

don't want to touch them because they're

32:52

really nervous about what's going on. So

32:55

I think prehab, rehab, and the

32:57

consultation and get them to see. We

33:00

have a psychologist who

33:03

works with us and we have a psychiatrist as

33:05

well as a pain specialist. And remembering

33:07

a third are malnourished who come into

33:09

an exaggeration now, and

33:11

a third are already hooked on chronic opiates by the

33:13

time they get to us. So you've got

33:15

to be prepared for all of those things to get them

33:18

through the precision. But

33:20

then also, I always say it's apples

33:22

and oranges. What some people call an

33:24

exaggeration really is just another abdominal, perineal

33:26

excision. So I guess what we're talking

33:29

about is what you've really seen. As

33:32

major bone is more than 50% of ours.

33:34

So I think there's apples and

33:36

oranges in what we're talking about as well. In

33:41

some ways, you've got to be a bit cruel at the

33:43

first consultation to get them in the right ballpark and

33:45

then get them working with you. And they've really

33:47

got to work with you and you've

33:49

got to work with them physically and mentally

33:51

to get them through. It's a big onslaught. I

33:55

think there's a bigger one in the body in terms of the

33:57

recovery. So

33:59

that's That's all we have time for today

34:02

in this episode and it also brings

34:04

us to the end of this special

34:06

series on pelvic exenteration for locally advanced

34:08

and recurrent rectal cancer. Jake

34:10

and I would like to thank Professor Gabriel

34:12

Van Ramhorst for joining us today and providing

34:14

her comments and insights and also

34:16

we'd like to thank Behind the Knife for making

34:18

this possible. Most importantly,

34:20

we want to thank Professor Michael Solman

34:23

for supporting this project and on behalf

34:25

of the Behind the Knife listeners, thank

34:27

you Prof for sharing your extensive experience

34:30

in exenteration surgery. For

34:32

those of you who want to know more, we've

34:34

provided lots of references to videos and other technical

34:36

articles in the show notes and so you can

34:38

have a look at those and

34:40

if you do have any questions, feel free to

34:42

get in touch with us here at RPA. Thanks

34:45

again and don't forget to Dominate the Day.