title: Sacral resection for recurrent rectal cancer: analysis of morbidity and treatment results.
abstract: OBJECTIVE
  Composite sacropelvic resection for locally advanced recurrent rectal cancer is a high-risk procedure that benefits select patients. We reviewed our recent institutional experience to evaluate case selection, morbidity, and outcomes.
  
  
  METHODS
  Between 1987 and 2004, 29 patients underwent composite resection for recurrent locoregional rectal cancer (17 females; median age, 60 years). Clinicopathologic indicators were evaluated as indicators of survival by log-rank test and Cox proportional hazards model.
  
  
  RESULTS
  Of 29 total patients, 27 (93 percent) received radiotherapy with their previous surgery (n = 10; 34 percent) or before sacrectomy (n = 17; 59 percent), and 12 (41 percent) received intraoperative therapy. Sacral resections were performed at S2/S3 (55 percent) or S4/S5 (45 percent) using anterior (41 percent) or combined anterior-posterior approach (59 percent), with adherence to (62 percent) or cortical invasion in (38 percent) the sacrum. A majority of those who had undergone previous abdominoperineal resection had total exenteration (9/13), whereas most patients who had undergone a previous sphincter-preserving procedure had abdominoperineal resection (12/16) and none had exenteration. Pedicle flaps (omental, 11; abdominal rectus, 7) often were used. A median of five (range, 1-33) units of blood was given intraoperatively. Transfusions were associated with previous abdominoperineal resection (P < 0.03), correlating strongly with postoperative morbidity (P < 0.02). There were 33 complications in 17 (59 percent) patients, most commonly perineal wound breakdown (9 (31 percent)) and pelvic abscess (5 (17 percent)). Median hospital stay was 18 (range, 7-56) days, significantly longer in patients with previous abdominoperineal resection (P < 0.02) or postoperative morbidity (P < 0.03). The only postoperative death was from pelvic sepsis. Resection was complete (R0) in 18 patients (62 percent), with microscopically positive margins (R1) in 10 (34 percent) and grossly positive margins (R2) in 1 (3 percent). Two-year and five-year recurrence rates were 47 and 85 percent, respectively; disease-specific survival was 63 and 20 percent, respectively. Less transfusion (P = 0.03), R0 resection (P = 0.005), lack of anterior organ involvement (P = 0.02), and absence of cortical bone invasion (P < 0.001) were associated with better survival on univariate analysis; original colorectal cancer stage was not.
  
  
  CONCLUSIONS
  Sacrectomy for rectal cancer is a high-risk procedure that can achieve clear resection margins with low mortality in select patients. This procedure has a low cure rate but may provide local disease control with acceptable morbidity.
authors.affiliation: Division of Colorectal Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
authors.forename: Genevieve B
authors.initials: GB
authors.lastname: Melton
authors.forename: Philip B
authors.initials: PB
authors.lastname: Paty
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Boland
authors.forename: John H
authors.initials: JH
authors.lastname: Healey
authors.forename: Salvatore G
authors.initials: SG
authors.lastname: Savatta
authors.forename: Jorge E
authors.initials: JE
authors.lastname: Casas-Ganem
authors.forename: José G
authors.initials: JG
authors.lastname: Guillem
authors.forename: Martin R
authors.initials: MR
authors.lastname: Weiser
authors.forename: Alfred M
authors.initials: AM
authors.lastname: Cohen
authors.forename: Bruce D
authors.initials: BD
authors.lastname: Minsky
authors.forename: W Douglas
authors.initials: WD
authors.lastname: Wong
authors.forename: Larissa K
authors.initials: LK
authors.lastname: Temple
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D011183:Postoperative Complications; D016016:Proportional Hazards Models; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D012447:Sacrum / Q000473:pathology / Q000601:surgery*; D016019:Survival Analysis; D016896:Treatment Outcome