V49 - Pelvic Exenteration with CivaSheet Placement: A Video Abstract

Purpose/Background: Background: Rectal cancers represent a common cause of cancer within the United States that affects both men and women. Total neoadjuvant therapy (TNT) has become a mainstay of treatment for patients with rectal cancer, especially those deemed locally advanced. Following TNT, patients are assessed for treatment response and either undergo non operative management with intense surveillance ("watch and wait") versus surgery. Those who present with local recurrence after TNT and curative intent surgery present a clinical challenge in that further external radiation to the pelvis is limited due to prior high doses of radiation to the pelvis. Intraoperative radiation therapy, or IORT, is therefore a useful adjunct when considering curative or even palliative surgical options for patients with recurrent rectal cancer.

Methods/Interventions:

Methods: We present a patient with a history of previous T4 colon cancer who underwent subtotal colectomy, small bowel resection, and liver wedge resection as well as 12 cycles of FOLFOX and avastin. The patient subsequently underwent additional cycles of FOLFOX with avastin and multiple ablations of liver metastases. The patient developed an anastomotic recurrence with local invasion into the left seminal vesicle and medial right seminal vesicle. Following multi-disciplinary tumor board and lengthy discussion with the patient, the decision was made to undergo pelvic exenteration with intraoperative radiation therapy in the form of the CivaSheet for palliative intent given liver lesions.

Results/Outcomes:

Results: Given the size and anterior location of the recurrence, a robotic approach was recommended. Upon entering the abdomen, there was evidence of an anterior pelvic mass with invasion into the left pelvic sidewall. Posterior and lateral dissection of the mesorectum was performed down to the levators. The urology team then assisted with ureter identification, dissection, and ligation. Similarly, they were able to mobilize the bladder, anterior and lateral to allow for an en bloc resection of the specimen by identifying the distal rectum below the level of tumor involvement. The distal rectum was circumferentially mobilized and divided at the dentate line using the robotic stapler. The remainder of the proximal colon was mobilized for creation of an end colostomy. Our urologic colleagues created an ileal conduit for urinary diversion. The levator muscles were re-approximated using a barbed suture in a running manner. A CivaSheet was then cut into two pieces to allow for an ideal fit along the left pelvic sidewall and posterior pre-sacral space and affixed with sutures. The specimen was then externalized and end-colostomy brought up through a trephination in the patient's left lower quadrant. Irrigation was performed and a drain was left in the pelvis. The fascial defect from specimen extraction was closed in our standard ERAS manner and all skin approximated.

Conclusion/Discussion:

Conclusion: The patient tolerated the procedure well and was able to be discharged on postoperative day 21 due to ileus and postoperative oral intake intolerance. There were otherwise no concerning symptoms or postoperative concerns, making this an example of the successful use of IORT in the form of the CivaSheet in a patient with local cancer recurrence.