title: Layer-oriented total pelvic exenteration for locally advanced primary colorectal cancer.
abstract: OBJECTIVE
  The clinical outcomes of patients who have undergone total pelvic exenteration (TPE) for locally advanced primary colorectal cancer have not been satisfactory. For the last 13 years, we have performed layer-oriented, en bloc resection of tumor for which TPE is indicated, in the hope of improving postoperative outcomes. The clinical outcomes of these cases were retrospectively analyzed.
  
  
  METHODS
  A total of 54 patients who underwent TPE from 1986 to 2013 were retrospectively analyzed. Since 2002, a layer-oriented removal for clinical T4 colorectal cancer, as in T3 or less invasive tumors removed by total mesorectal excision, was applied to 23 cases for which TPE was indicated. Postoperative mortality, morbidity, overall survival (OS), and disease-free survival (DFS) were evaluated.
  
  
  RESULTS
  On univariate analysis, good postoperative OS and DFS were associated with the layer-oriented operative maneuver, blood loss less than 2000 mL, negative nodal metastasis, and no preoperative radiation therapy. Male sex was the marginal determinant correlated with good OS and DFS. Depth of invasion to T3 was the marginal determinant correlated with good DFS. On multivariate analysis using the 4 factors identified on univariate analyses, the layer-oriented operative procedure was a significant determinant for both good OS and DFS, together with negative nodal metastases. Postoperative mortality and morbidity in the layer-oriented excision were acceptable.
  
  
  CONCLUSIONS
  For primary colorectal cancers for which TPE is indicated, layer-oriented excision was a safe and effective procedure, and it may be recommended as one of the standard surgical approaches in TPE.
authors.affiliation: Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara City, Chiba, 2990111, Japan. k-koda@med.teikyo-u.ac.jp.
authors.forename: Keiji
authors.initials: K
authors.lastname: Koda
authors.affiliation: Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara City, Chiba, 2990111, Japan.
authors.forename: Kiyohiko
authors.initials: K
authors.lastname: Shuto
authors.affiliation: Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara City, Chiba, 2990111, Japan.
authors.forename: Kenichi
authors.initials: K
authors.lastname: Matsuo
authors.affiliation: Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara City, Chiba, 2990111, Japan.
authors.forename: Chihiro
authors.initials: C
authors.lastname: Kosugi
authors.affiliation: Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara City, Chiba, 2990111, Japan.
authors.forename: Mikito
authors.initials: M
authors.lastname: Mori
authors.affiliation: Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara City, Chiba, 2990111, Japan.
authors.forename: Atsushi
authors.initials: A
authors.lastname: Hirano
authors.affiliation: Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara City, Chiba, 2990111, Japan.
authors.forename: Yukihiko
authors.initials: Y
authors.lastname: Hiroshima
authors.affiliation: Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara City, Chiba, 2990111, Japan.
authors.forename: Kuniya
authors.initials: K
authors.lastname: Tanaka
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000453:epidemiology / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007430:Intraoperative Care; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery; D009367:Neoplasm Staging; D010385:Pelvic Exenteration / Q000379:methods*; D010388:Pelvis / Q000473:pathology / Q000601:surgery; D019990:Perioperative Care; D011379:Prognosis; D016896:Treatment Outcome
keywords: Layer-oriented operation; Prognosis; Prognostic factor; Surgical technique; Survival; Total pelvic exenteration