[Pelvic exenteration for late complications of radiation-induced pelvic injury: a preliminary study].

Objective: To investigate the safety and efficacy of total pelvic exenteration (TPE) for treating late complications of radiation-induced pelvic injury. Methods: This was a descriptive case series study. The inclusion criteria were as follows: (1) confirmed radiation-induced pelvic injury after radiotherapy for pelvic malignancies; (2) late complications of radiation-induced pelvic injury, such as bleeding, perforation, fistula, and obstruction, involving multiple pelvic organs; (3) TPE recommended by a multidisciplinary team; (4) patient in good preoperative condition and considered fit enough to tolerate TPE; and (5) patient extremely willing to undergo the procedure and accept the associated risks. The exclusion criteria were as follows: (1) preoperative or intraoperative diagnosis of tumor recurrence or metastasis; (2) had only undergone diversion or bypass surgery after laparoscopic exploration; and (3) incomplete medical records. Clinical and follow-up data of patients who had undergone TPE for late complications of radiation-induced pelvic injury between March 2020 and September 2022 at the Sixth Affiliated Hospital of Sun Yat-sen University were analyzed. Perioperative recovery, postoperative complications, perioperative deaths, and quality of life 1 year postoperatively were recorded. Results: The study cohort comprised 14 women, nine of whom had recto-vagino-vesical fistulas, two vesicovaginal fistulas, one ileo-vesical fistula and rectal necrosis, one ileo-vesical and rectovaginal fistulas, and one rectal ulcer and bilateral ureteral stenosis. The mean duration of surgery was 592.1±167.6 minutes and the median blood loss 550 (100-6000) mL. Ten patients underwent intestinal reconstruction, and four the Hartmann procedure. Ten patients underwent urinary reconstruction using Bricker's procedure and 7 underwent pelvic floor reconstruction. The mean postoperative hospital stay was 23.6±14.9 days. Seven patients (7/14) had serious postoperative complications (Clavien-Dindo IIIa to IVb), including surgical site infections in eight, abdominopelvic abscesses in five, pulmonary infections in five, intestinal obstruction in four, and urinary leakage in two. Empty pelvis syndrome (EPS) was diagnosed in five patients, none of whom had undergone pelvic floor reconstruction. Five of the seven patients who had not undergone pelvic floor reconstruction developed EPS, compared with none of those who had undergone pelvic floor reconstruction. One patient with EPS underwent reoperation because of a pelvic abscess, pelvic hemorrhage, and intestinal obstruction. There were no perioperative deaths. During 18.9±10.1 months of follow-up, three patients died, two of renal failure, which was a preoperative comorbidity, and one of COVID-19. The remaining patients had gradual and significant relief of symptoms during follow-up. QLQ-C30 assessment of postoperative quality of life showed gradual improvement in all functional domains and general health at 1, 3, and 6 months postoperatively (all P<0.05). Conclusions: TPE is a feasible procedure for treating late complications of radiation-induced pelvic injury combined with complex pelvic fistulas. TPE is effective in alleviating symptoms and improving quality of life. However, the indications for this procedure should be strictly controlled and the surgery carried out only by experienced surgeons.目的： 初步探讨全盆腔脏器切除（TPE）治疗盆腔放射性损伤晚期并发症的安全性及有效性。 方法： 采用观察性研究的方法，纳入标准：（1）盆腔恶性肿瘤放疗后确诊为盆腔放射性损伤；（2）盆腔放射性损伤晚期并发症（包括出血、穿孔、瘘及梗阻等），合并复杂盆腔瘘并累及盆腔多器官；（3）多学科团队会诊评估认为TPE手术可达到R0切除，建议进行TPE手术；（4）患者术前状态良好，可以耐受TPE手术；（5）患者手术意愿强烈，充分接受手术风险。排除标准：（1）术前或术中诊断肿瘤复发或转移；（2）腹腔镜探查后仅行转流或短路等姑息性手术；（3）临床资料不完整。根据上述标准，回顾性纳入中山大学附属第六医院放射性肠损伤数据库中2020年3月至2022年9月期间，因盆腔放射性损伤晚期并发症接受TPE或扩大TPE（合并其他脏器）手术患者的临床及随访资料。观察手术和术后恢复情况，记录术后并发症发生情况、围手术期死亡情况和术后1年生活质量情况。 结果： 本研究共纳入14例患者，均为女性患者，包括9例直肠-阴道-膀胱瘘、2例膀胱阴道瘘、1例回肠-膀胱瘘+直肠坏死、1 例回肠-膀胱瘘+直肠阴道瘘和1例直肠溃疡+双侧输尿管狭窄。手术时间为（592.1±167.6）min，中位出血量为550（100~6 000）ml，10 例进行了肠道重建，4例接受了Hartmann手术；10例采用Bricker手术进行泌尿系重建；7例接受盆底重建。术后住院天数为（23.6±14.9）d。7例（7/14）患者在围手术期出现Clavien-DindoⅢa~Ⅳb级并发症，包括手术部位感染8例次、腹盆腔脓肿5例次、肺部感染5例次、肠梗阻4例次及回肠膀胱瘘2例次。5例患者诊断空盆腔综合征（EPS），均为未进行盆底重建的患者，未进行盆底重建患者EPS发生比例为5/7；进行盆底重建的患者均未发生EPS。1例EPS患者因盆腔脓肿、盆腔出血和肠梗阻，需要二次手术。无围手术期死亡。随访（18.9±10.1）个月，3例患者死亡，其中2例死亡原因为肾衰竭，均为术前合并症，1例因新型冠状病毒肺炎死亡；其余患者在随访过程中临床症状逐步缓解，术后生活质量QLQ-C30评估显示，术后1、3、6个月所有功能领域及总体健康状况均逐步改善（均P<0.05）。 结论： TPE手术是治疗盆腔放射性损伤晚期并发症合并复杂盆腔瘘的一种可行的手术方法，可有效缓解临床症状、改善生活质量。但应严格把握手术适应证，并在有经验的中心开展。.