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7 Patient Optimisation for Colorectal Surgery 203
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Empty Pelvis Syndrome Complication
https://t.me/med1917
Management Following Pelvic
Exenteration
Martha Quinn and Colin W. Steele
Abstract
Pelvic surgery is becoming more aggressive in order to achieve clear margin
resection of locally invasive rectal cancer and recurrent pelvic malignancies
including anal, rectal, cervical and endometrial cancer. 5-year survival rates
following these procedures are in the region of 40% for all tumours, which compares with < 5% in locally advanced rectal cancer if managed non-operatively.
Operative strategies often incorporate multiple pelvic compartments in order
to achieve margin clearance. Sacral or other pelvic bony resection is necessitated in many cases. Such resectional strategies lead to large pelvic defects
requiring closure following surgery. Strategies employed in closure, range from
primary closure, use of adjuncts such as vacuum devices and mesh, to myocutaneous flap reconstruction. Despite these strategies there remains a rate of wound
infection, breakdown of perineal closure, long term sinus formation, and indeed
entero-atmospheric fistulation. In this chapter we will describe common complications associated with the empty pelvis following pelvic exenterative surgery.
We will discuss perineal wound closure; prevention strategies in these patients;
recognition and management of complications should they occur.
8
Keywords
Exenterative surgery•Myocutaneous flap•Fistula•Perineal hernia•Perineal
•
Pelvic sinus•Exenteration•Empty pelvis•Perineal wound problems
sinus
M. Quinn (B) · C. W. Steele
University Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
e-mail: Martha.Quinn@ggc.scot.nhs.uk
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
M. Evans e t al. (eds.), Coloproctology, https://doi.org/10.1007/978-3-031-59630-8_8
205
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Key Points
•
Pelvic exenterative surgery can be associated with large pelvic defects and a
unique set of complications termed ‘empty pelvis syndrome’
•
Several strategies are described to aid pelvic wound closure and healing, but
there is no consensus about which is optimal
•
Despite the use of adjuncts to aid closure the risk of wound infection/
breakdown, long term sinus formation, and entero-perineal fistula remains
•
Avoidance of and aggressive management of pelvic sepsis is important to
minimize short and long term complications of pelvic exenteration
•
If complications occur multi-disciplinary management including radiological
colorectal, urological and plastic surgical expertise is needed.
8.1 Introduction
The radicality and extent of pelvic oncological surgery has expanded in recent
times with ‘higher and wide’ resections increasingly performed [1]. The rational
for these extended resections is the improved 5-year survival seen in those with
negative margin resections [2]. Lateral compartment and bony resection of the
pelvis and sacrum are now routinely performed in specialist centres. Whilst pelvic
exenteration, including extended resections, can be curative they frequently result
in a large pelvic defect or dead space. The dead space can result in an increasingly recognized unique set of complications that have been termed ‘empty pelvis
syndrome’ [3].
8.2 Empty Pelvis Syndrome
Empty pelvis syndrome is a term that is frequently used in the surgical literature,
but to date there is no consensus definition of this condition [4]. It is a recognized
series of complications that arise due to the pelvic dead space after significant
pelvic surgery with a perineal defect [3]. Pelvic exenteration is associated with a
high risk of post-operative complications. A substantial proportion of these complications result from a pelvic collection, or problems with the perineal wound
following closure.
The problems and complications associated with the empty pelvis are frequently
compounded by the delivery of pelvic radiotherapy, and in the setting of recurrence disease potential re-irradiation. The result is devascularised, radiotherapy
damaged tissue and skin that is reported to be at a 50% increased risk of breakdown [5]. Resection of the rectum and anus with contiguous structures inevitably
leads to dead space permitting accumulation of fluid, and displacement of organs,
in particular small bowel, into the pelvis (Fig. 8.1). The sequalae of complications
that result include: pelvic abscess, entero-perineal/entero-atmospheric fistulae, and
wound healing problems including chronic sinus and perineal hernia [3]. Indeed,
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Fig. 8.1 Empty Pelvis. A—Total pelvic exenteration with low anterior resection, and subtotal
vaginectomy. B—Prone position following high sacrectomy, pelvic drain visible entering perineal
defect from abdomen. Both images exemplify the significant potential ‘dead space’
pelvic exenterative surgery is complicated by fistulae in 10% of patients and is a
major burden for patients and healthcare providers.
8.3 Prevention Strategies
The prevention of empty pelvis associated complications has focused on closure
methods and attempts to prevent perineal wound healing problems.
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8.3.1 Negative Pressure
Due to the nature of the wounds and extensive incisions required in pelvic
exenteration the complexity of perineal wound defect reconstruction has become
increasingly challenging. This can also compounded by the loss of the high internal iliac system vasculature resulting in the loss of the superior gluteal artery
that is necessary for gluteal flap reconstruction [6]. Radiotherapy in combination with large defects often with slightly impaired blood supply results in high
rates of wound infection, seen in up to 37.5% of patients [7, 8]. Despite this,
there is limited published evidence on the management of wound complications
following pelvic exenteration. Management options tend to be patient-specific,
including: antibiotics; bedside, or surgical washout; radiological or surgical placement of drains postoperatively; as well as the use of devices such as negative
pressure or vacuum assisted closure. The World Health Organisation now lists
negative pressure dressings as one of their recommendations to reduce surgical
site infections [9], and these are accepted components of general surgical wound
care bundles, which have been shown to reduce infective complications following
colorectal surgery [10]. In recent meta-analyses negative pressure was found to
reduce surgical site infection following perineal wound closure (odds ratio 0.29)
[11].
8.3.2 Myocutaneous Flap Reconstruction
A recent systematic review synthesized the results of 18 studies that have reported
on the results of perineal reconstruction following pelvic exenteration [3]. Of these
only three studies had follow-up that was greater than two years. The review found
that of the 10 studies included 234 patients had myocutaneous flap reconstruction,
51.9% of whom were treated for recurrent malignancy, and 60.7% of patients had
been pre-treated with radiotherapy [3].
Myocutaneous flap reconstruction is considered due to the bulk of muscle which
can fill the dead space in the pelvis [12] (Fig. 8.2) Historically, vertical rectus
abdominus flap (VRAM) was most frequently used [13]. Though the options are
myriad, with gluteal fold flaps popular [14], and in our centre the extensive use of
anterolateral thigh flaps without increase in rates of infection or herniation [15].
Increasingly, iliac vasculature and branches to the gluteal muscles are sacrificed
in the pursuit of R0 resections and influence flap making decision making. Whilst
VRAM flaps can provide muscle bulk and vascularized skin they remove the rectus
muscle, and in so doing leave there are concerns about the ability to form bilateral
stomata and the risk of subsequent herniation may be high. Thigh flaps do not
carry this morbidity, though depending on the dead space required to be filled,
gracilis flaps may not represent the most appropriate strategy to fill the dead space
given their lack of volume [16].
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Fig. 8.2 Myocutaneous flap reconstruction of large perineal defects. A: Anterolateral thigh (ALT)
flap raised on circumflex femoral perforator vessels. B: Large pelvic defect following pubic bone
resection filled. C: Skin paddle also raised and defect closed
In a recent systematic review, major perineal wound complications were
observed in 16.3% of cases across 10 studies, whilst minor perineal wound problems were seen in 31.3% [3]. Reoperation rates are high, with one in five patients
requiring plastic surgical input, though complete flap loss was rare at 4.6%. Omental flap reconstruction as a single strategy is rarely performed on account of high
complication rates most likely due to devascularisation of the omental pedicle.
However, in some small series reduced infection rates in patients having omentoplasty used as an adjunct for filling of the dead space have been reported
[17].
8.3.3 M esh
Many exenterative centres advocate the use of native tissue to fill pelvic dead space
wherever possible. However, there may be times where native tissue alone simply
cannot fill the perineal defect or that the availability of plastic surgery services is
not possible. The Sydney group have documented the use of a biological mesh cup
in the pelvis with promising results, although it should be noted that it is associated
with a complication rate of more than one in three patients with a predominance of
pelvic collections and a 5% enteroperineal fistula rate, albeit in a small cohort of 36
patients [18, 19]. After abdominoperineal resection, the BIOPEX study found that
biological mesh was superior to primary closure [20]. Perineal hernia rates were
7% compared with 30% in primary closure with no differences in re-operative
rates for small bowel obstruction. It should be noted that the BIOPEX study did
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not include a group with myocutaneous flap closure, therefore future research that
compares mesh with myocutaneous flap reconstruction would be of great interest.
8.3.4 Spacers
Breast prothesis have been trialled as a way of filling the pelvic dead space, with
the advantage of being able to “size” them to fit the pelvis. Two studies have
reported the use of spacers either in a tailored fashion or as a standard sized spacer
[21, 22]. Strikingly, removal of only 3 spacers was required and no enteroperineal
fistulae were observed. Of 86 breast prostheses placed there was a 10.3% risk of
wound infection, and 13.3% pelvic abscess rate.
Obstetric balloons and tissue expanders have also been used as a way of filling
the pelvic dead space [23, 24]. The technique describes mobilisation of the caecum so that it can be placed on top of the tissue expander. Then the expander is
gradually reduced until removal on post-operative day five. However, both studies
document episodes of small bowel obstruction following removal of the device,
albeit the rates are low. This is counteracted by a low rate of pelvic abscess in the
spacer patients which is higher in the mesh and flap groups, though it should be
noted that the follow up published to date is short at 3 months.
8.4 Summary
There are many options for perineal reconstruction described. In patients with
multiple comorbidities who are at high risk for complications it is arguable that
outcomes may be better with primary closure [25]. Studies comparing biological
mesh to primary closure in extralevator APER have found no increased wound
complications risk using mesh, and that it may be associated with a lower hernia
rate [26]. However, the exenteration community should be cautious when extrapolating these results to exenterative surgery, considering the defects faced are often
larger, with loss of the internal iliac systems and gluteal arterial branches resulting in reduced perfusion of primary tissue for closure. Filling pelvic dead space
can be achieved with myocutaneous flap, mesh or permanent/temporary spacers.
Each may have a role. The data available to guide decision making is mostly from
single centre retrospective experience. These results reported are consequently at
risk of bias, and influenced by surgical trends towards larger defects and more
radical resection. Some centres do not have ready access to plastic surgical support and therefore need alternative solutions. Use of mesh and spacers is possible
and appears safe in filling pelvic dead space but do not provide a solution when
skin reconstruction is required. Larger defects, and those in which skin coverage
is required are likely to require myocutaneous flap reconstruction with a variety
of approaches described that can be tailored to the reconstructive need. Pelvic
abscess rates appear lower in flap reconstruction patients than mesh, however,
larger series are required to confirm the data described to date. The rate of wound
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complication is reported as higher with flaps but there are many influences on this
phenomenon, including the potentially larger size of the defect that is associated
with skin reconstruction. The literature reported to date is limited by short follow
up and centre volume is likely to influence outcome. However, each strategy has
its merits in reducing the more serious complications of small bowel obstruction
and enteroperineal fistula that surgeons worry most about.
8.5 Complications and Management of Empty Pelvis
Syndrome
Exenterative surgery that results in large pelvic dead spaces and perineal wound
defects is associated with a high rate of complications. The reported incidence
of gastrointestinal complications has increased over time, probably reflecting
the increasingly radical exenterative surgery now being commonly performed.
Approximately 15% of patients suffer from prolonged ileus, 1–3% from anastomotic leak, and 1–2% from enterocutaneous fistula [7]. Some studies have found
that longer time to first defecation is observed when a VRAM flap is used, which
may in part be related to increased operative time [27].
8.5.1 Pelvic Collection
The large pelvic dead space and large raw surface area in the pelvis following
pelvic exenteration frequently results in post operative pelvic collections, reported
in 25–45% of patients [8, 28], see Fig. 8.3. The authors advocate usage of a wide
bore surgical drain left in the pelvis at the time of resection. Given the elevated risk
of urine leak and pelvic collection some consideration should be given to leaving
this in place for some time, especially if the route for percutaneous drainage is
likely to be difficult or through myocutaneous flaps.
Fig. 8.3 Pelvic Collections.
Pelvic collection in patient
following total pelvic
exenteration
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Upon recognition of undrained simple pelvic collection, most patients can be
managed with radiological insertion of drains, often using interventional radiology.
Operative management should be avoided if possible. Multiple percutaneous drains
into the pelvic space can be used as an irrigation system if required to lavage the
cavity over time. In one study of patients undergoing surgery for locally advanced
or recurrent rectal cancer, 14 out of 101 patients underwent drainage of fluid collections. This study included patients undergoing low anterior resection as well as
PE, therefore, true numbers for exenteration are likely to be much higher [29].
Patients have to be monitored closely as presentation can be insidious with rising inflammatory markers and an absence of any new symptoms. Additionally,
urinary reconstruction carries the risk of urinary leakage which can culminate in
a cascade of septic and haemorrhagic complications if not detected early. Sepsis,
increased drain output, or leakage from perineal wounds are the most common
presentation. For this reason the authors routinely place a large bore drain to the
pelvis and check drain electrolytes at day two after surgery and regularly thereafter
in line with previous recommendations by the Sydney group [30]. Early urinary
leakage should be considered surgical failure and reintervention strongly considered (<6 days). Late urine leaks should be suspected in the setting of persistent
inflammation/infection with no other obvious source. The diagnosis is made via
drain electrolytes and CT with a delayed excretory phase (CT IVU). Nephrotomies
are often required for urinary diversion and it should be remembered that the
ureteric stents can be used to aid placement by using them to dilate up the renal
pelvis.
In the setting of a bladder preserving complex urinary tract reconstruction
(Boari flap/transureterureterostomy (TUU)) the system will be decompressed and
nephrostomy placement can be extremely difficult. There is a small risk of renal
cortical damage/Haemorrhage and resultant development of renal artery pseudoaneurysms (see Fig. 8.4). If required, Nephrostomies should be placed by an
experienced interventional radiologist.
8.5.2 Haemorrhagic Complications
Bleeding during, or after pelvic exteration can be catastrophic. Delayed bleeding occurs most often due to erosion of internal iliac vessel stumps, frequently
associated with pelvic sepsis [31]. There are also reports of long-term ureteric
stent erosion into iliac arteries as they cross the pelvic brim [32]. In this setting
a covered iliac stent can successfully manage the bleeding, however there is the
acceptance that the stent will be chronically infected and the patient may require
lifelong antibiotics.
Pelvic collection or pelvic urinoma can lead to the fatal triad of infected urine
leak followed by enteric fistula and then delayed haemorrhage. Haemorrhage is
often recognizable by a herald bleed into the pelvic drains or through the perineal
wound. This should be aggressively managed and empirical embolization of the
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Fig. 8.4 Nephrostomy placement in leaking urinary system post TUU reconstruction. A: Perinephric haematoma from nephrostomy placement. B: Angiographic embolization of bleeding
renal arteries
internal iliac stumps performed if any suspicion of delayed haemorrhage exists
(Fig. 8.5).
If there is an open pelvic defect, delayed haemorrhage can result in exsanguination with the only tamponade option being to pack the pelvis via the
perineum.
8.5.3 Wound Complications
By their nature it is difficult to get perineal wounds to heal, particularly after
previous radiotherapy exposure. Persistent perineal sinus (PPS) can occur following pelvic exenteration due to the perineal wound and empty pelvis syndrome
which can often result in a pelvic collection. The management of PPS has been
described in a review article, with options from vacuum assisted closure up to
flap reconstruction depending on patient and wound characteristics [33]. In the
authors experience drainage of pelvic collections and prevention of persistent sepsis is critical to try and avoid this. Packing should not be used if wounds open
up and they should be allowed to drain freely. Packing of a perineal wound can
lead to persistent issues with failure to resolve sepsis and retained packing should
be avoided (Fig. 8.6). Attentive wound care with regular lavage will permit most
wounds to heal. In the setting of a non-healing perineal wound with a residual
sinus consideration should be given to deroofing the perineal defect. MRI should
be performed prior to this to ensure that no small bowel is in close proximity,
and there is no recurrent disease driving the sinus. Any foreign body within the
tract that is chronically infected will stop the wound healing [34]. Retained packing, hair, bony fragments are all causative agents in this setting. Once the wound
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