title: High subcortical sacrectomy: a novel approach to facilitate complete resection of locally advanced and recurrent rectal cancer with high (S1-S2) sacral extension.
abstract: OBJECTIVE
  R0 resection of locally advanced or recurrent rectal cancer is the key determinant of outcome. Disease extension high on the sacrum has been considered a contraindication to surgery because of associated morbidity and difficulty in achieving complete pathological resection. Total sacrectomy has a high morbidity with poor function.
  
  
  METHODS
  We describe a novel technique of high subcortical sacrectomy (HiSS) to facilitate complete resection of disease extending to the upper sacrum at S1 and S2 to avoid high or total sacrectomy or a nonoperative approach to management. Details of patient demographics, radiology, operative details, postoperative histology, length of hospital stay and complications were entered into a prospectively maintained electronic patient database. All patients had had preoperative chemoradiotherapy.
  
  
  RESULTS
  During 2013-2014, five patients, including three with advanced primary cancer and two with recurrent rectal cancer, underwent excision using this approach. All patients had an R0 resection. Four patients had a minor postoperative complication (Clavien-Dindo Grades I and II) and one had a major complication (Clavien-Dindo Grade IIIb). There was no mortality at 90 days, and four patients were disease free at a median of 18 months.
  
  
  CONCLUSIONS
  Patients with locally advanced and recurrent rectal cancer involving the upper sacrum may be rendered suitable for potentially curative radical resection with a modified approach to sacral resection. This pilot series suggests that this novel technique results in a high rate of complete pathological resection with acceptable morbidity in patients for whom the alternatives would have been an incomplete resection, a total sacrectomy or nonoperative management.
authors.affiliation: Department of Colorectal Surgery, Norfolk and Norwich University hospital, Norwich and St Mark's hospital, London, UK.
authors.forename: I
authors.initials: I
authors.lastname: Shaikh
authors.affiliation: Department of Orthopaedics, Northwick Park Hospital, London, UK.
authors.forename: I
authors.initials: I
authors.lastname: Holloway
authors.affiliation: Department of Orthopaedics, Royal National Orthopaedic Hospital, London, Stanmore, UK.
authors.forename: W
authors.initials: W
authors.lastname: Aston
authors.affiliation: Department of Anaesthetics, St Mark's Hospital, London, UK.
authors.forename: S
authors.initials: S
authors.lastname: Littler
authors.affiliation: Department of Radiology, St Mark's Hospital, London, UK.
authors.forename: D
authors.initials: D
authors.lastname: Burling
authors.affiliation: Department of Surgery, St Mark's Hospital, London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Antoniou
authors.affiliation: Department of Surgery, St Mark's Hospital, London, UK.
authors.forename: J T
authors.initials: JT
authors.lastname: Jenkins
mesh_terms: D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery*; D010027:Osteotomy / Q000379:methods*; D010865:Pilot Projects; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012447:Sacrum / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome
keywords: Hight sacrectomy; advanced rectal cancer; rectal cancer beyond TME