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Tilliashaykhov Mirzogolib Nigmatovich, director, of Republican Specialized Scientific and Practical Medical Center of Oncology and Radiology Zakhirova Nargiza Nematovna, leading researcher, of Republican Specialized Scientific and Practical Medical Center of Oncology and Radiology
E-mail: evovision@bk.ru
SURGICAL RECONSTRUCTION OF THE PELVIC BOTTOM AFTER EKZENTERATION AT LOCAL WIDESPREAD CERVICAL CANCER
Abstract: Pathogenesis mechanisms, clinical picture, diagnostics and treatment of manifestations of a syndrome of an empty small pelvis are described. Being based on the data of the world literature, authors have brought and analysed the modern directions in treatment of such patients and also methods of reconstruction of a pelvic bottom after a pelvic ekzenteration.
Carrying out further researches in this direction as reconstruction of a pelvic bottom is important aspect of prevention of a syndrome of an empty small pelvis after a pelvic ekzenteration is necessary.
Keywords: ekzenteration of a small pelvis, syndrome of an empty small pelvis, reconstruction.
Malignant new growths of bodies of a small pelvis in ously, it becomes necessary to perform extended multispectral
structure of oncological incidence make 16% of all localizations [1].
At women the share of new growths of genitals makes 18.3% from from all malignant new growths [2, 3].
Treatment of patients with locally-spread primary and recurrent forms of cervical cancer remains in many respects an unresolved problem [4]. In literature, still there is no uniform unified definition of the concept "locally-spread tumor of a small pelvis". According to V. I. Shirokorad, the definition of locally-spread cancer of rectum offered by onkoproktologa of Federal State Budgetary Institution Russian oncological scientific center of N. N. Blochin" the Russian Ministry of Health as motionless or restrictedly mobile tumor which doesn't have the remote metastasises, sprouting all layers of a rectum wall with involvement in tumoral process or inflammatory infiltration of the next bodies and fabrics, possible formation of fistulas or purulent cavities it can be extrapolated to locally-spread tumors of bodies of a small pelvis of any localization [5].
Despite the different organ affiliation of these tumors, there are general principles of their diagnosis, selection of patients for surgical treatment, general approaches to surgical treatment [4, 5]. This is due to the general biological features of locally advanced pelvic tumors, which include: predominantly local tumor growth, relatively rare metastasis to distant organs, frequent occurrence of local recurrences after special treatment, low malignant potential for large tumor sizes, the possibility of resection of the organ affected secondary to invasion from the primary source [5]. If several pelvic organs, especially the urinary tract, the female internal genital organs and the rectum, are involved in the tumor process simultane-
resections of the pelvic organs up to the total pelvic exenteration (TPE) [8, 9, 10, 11, 12].
TRE is usually divided into front, rear and total. Anterior TRE includes removal of the bladder, urethra, vagina, uterus with appendages. The posterior TRE includes removal of the uterus with appendages and rectum.
With complete TRE, a complete monoblock removal of all pelvic organs is performed [5, 12]. The terms "anterior TRE" and "back TRE" are applicable only to female patients [12]. Depending on the attitude towards the pelvic floor, TRE is divided into supralevator (with preservation of the pelvic diaphragm, the operation is performed by abdominal access) and infratulatory (with removal of the pelvic floor muscles, the operation is performed by the abdominal-perineal access) [4]. In the case of a resection of the pelvic bones, TRE is called a composite one [6].
The most frequent oncological pathology, about which 70% of TRE is performed, is squamous cell carcinoma of the cervix [6, 7].
A single approach to the choice of indications and contraindications to TRE is not available [11].
The need to perform ultra-radical operations, right up to TRE, occurs when several pelvic organs are involved simultaneously in the tumor process: the bladder, urethra, internal female genitalia, the rectum or sigmoid colon [1, 5, 12]. With local common pelvic tumors of any localization with the invasion of the Ljeto triangle, combined surgical interventions become impossible, and TRE is considered to be the operation of choice [5, 7]. In most centers, the contraindication to performing TRE is the presence of distant metastases and
intra-abdominal dissemination of the tumor [11]. Also possible contraindications is the presence of metastases in the pelvic and para-aortic lymph nodes. According to H. R. Barber and W. Jones, out of 148 women with recurrent cervical cancer after radiotherapy, there were metastases in the lymph nodes at the time of TRE and only 4 of 148 patients survived 5 years [13]. The triad of symptoms - ureterohydronephrosis, edema of the lower limb, ishialgia - indicates a neglected locally advanced oncological process [6,]. Ischialgia is the most formidable symptom, indicative of the invasion of the tumor into the area of the sciatic foramen and the impossibility of performing radical surgical intervention [7].
When planning TRE for recurrence of the oncological process, it is necessary to estimate the time of its appearance, size and localization [4]. Most authors note a direct relationship between survival and time of recurrence of squamous cell carcinoma of the cervix [6].
From the topographic point of view, depending on the relationship to the lateral wall of the pelvis, recurrent tumors are divided into central and lateral tumors. If central recurrence in the absence of distant metastases is an "ideal" indication for TRE, then the advisability of performing TRE in lateral relapses is controversial [14]. In relation to oncogynecologic pathology, M. Hockel et al. proved that a tumor fixed to the lateral wall of the pelvis, but not exceeding 5 cm, very rarely sprouts the intracellular fascia and can be radically removed by lateral extended endopelvic resection (LREP), which involves the removal of internal iliac vessels, intracavitary fascia and muscles pelvis (internal blocking, pubic-coccygeal, ilio-coccygeal and coccygeal muscles) in the zone of lateral pelvic recurrence [14]. In this case, M. Hockel et al. R0 resection was performed in 97% of cases, and the survival of patients did not differ from that after standard TRE performed for central recurrence [14]. The TRE technique is repeatedly described and consists of explorative, ablative and reconstructive stages [6, 7].
The explorative stage of the operation includes revision of the abdominal and pelvic organs, assessment of the "lymphatic status" (pelvic, para-aortic lymphadenectomy with urgent histological examination), opening of the avascular cellular spaces of the pelvis and evaluation of the relationship between the tumor and the pelvic wall [7]. The ablative stage of the operation involves a radical monoblock pelvic organo-complex with a tumor [5, 6]. Depending on the nature of the spread of the tumor process, anterior, posterior or total TRE is performed. The reconstructive stage of TRE is the formation of the intestinal and urinary stoma with the purpose of derivation of urine and feces or, if possible, performing reconstructive operations to restore the natural passage [4], as well as reconstruction of the pelvic floor. The solution of the problem of urine diversion is associated with the introduction into clin-
ical practice of various cystoplasty operations using isolated intestinal segments [11]. Depending on the specific clinical situation, it is possible to form a heterotopic reservoir with a "wet" (for example, ileumconduit Briker) or a continental stoma, as well as orthotopic cystoplasty with restoration of the natural passage of urine. Weakened patients with high operational risk may have ureterocutaneostomy [5]. Fecal excretion is carried out either by forming an end single-stem colostomy, or by restoring the natural passage of intestinal contents by the formation of a low colorectal or coloanal anastomosis [4, 5].
Removal of pelvic organs with a single block in supraleva-tor TRE leads to the formation of a peritoneal cover devoid of a "dead" space, and for infrared TRE - also an extensive pelvic floor defect [4]. After TRE, translocation of the small intestine loops to the pelvic cavity occurs, fixing them with adhesive adhesions to the walls of the pelvis and pelvic floor devoid of peritoneal cover [13]. Radiation therapy, which is performed by the majority of patients with regard to the primary oncological process or its relapse to TRE, leads to pelvic fibrosis fibrosis, progressive vascular hyalinosis, impaired vascularization of pelvic tissue. Fixation of small intestine loops irradiated to irradiated pelvic walls can lead to the formation of intestinal obstruction, small intestinal fistulas, including small intestinal, lymphocele and pelvic abscesses, and pelvic hernias [4, 15]. A number of authors call this group of complications "empty pelvis syndrome" (empty pelvis syndrome)
[15]. The emergence of these complications after TRE is associated with high postoperative mortality [16].
Small intestinal obstruction after TRE occurs in 5-11% of patients [16], and mortality after repeated operations for intestinal obstruction may reach 50% [16]. As mentioned above, the contact of the small intestine loops
Interdisciplinary issues with peritoneal pancreatic walls of the pelvis are the cause of postoperative small intestinal obstruction [16]. But the most significant factor associated with small intestinal obstruction after TRE, according to J. W. Jr. Orr et al. is the presence of a thin-intestinal anastomosis of the previously irradiated intestine, which is formed during the creation of an ileum conduit for the supra-zirical derivation of urine [16]. J. W. Jr. Orr et al. this fact is explained by the contact of the "fresh" small intestinal anastomosis of the irradiated intestine with irradiated pelvic wall irradiated walls and the formation of dense splices [16]. Using an isolated segment of the transverse colon to create a conduit for urine diversion and the formation of transvers otransverso anastomosis reduces the risk of post-operative intestinal obstruction
[16]. Although a number of authors report a high mortality of patients after surgery for intestinal obstruction [15, 16], J. W. Jr. Orr et al. believe that the mortality in this group of patients can be reduced by forming bypass intestinal anasto-
moses without intestinal resection, since attempts to release the irradiated small intestine of tightly fixed in the cavity of the small pelvis may be associated with impaired blood supply to the intestine, accidental trauma to the intestine or ureter [16].
The performance of anterior TRE is associated with a high frequency of formation of rectal-vaginal fistulas, which reaches 23.7% [16]. According to J. W. Jr. Orr et al., Since radiation therapy causes tissue fibrosis and endarteritis, extensive dissection of the rectum vaginal septum in the process of anterior TRE can disrupt blood circulation in the rectal wall, increase the risk of rectal injury, which predispose to the formation of a rectal-vaginal fistula. Performing a modified anterior TRE without a wide dissection of the rectum-vaginal septum reduces the incidence of rectal-vaginal fistula [16].
The small intestinal fistula is one of the most serious complications of TRE. The frequency of their formation is 5-16% [13]. The formation of the small intestinal fistula is associated with poor prognosis [10, 15].
The most significant factor that increases the risk of forming small intestinal fistulas, as well as small intestinal obstruction, is the presence of a thin-intestinal anastomosis and the formation of an ileum conduit [6, 5].
This is due to the fact that the ileum conduit is formed using a loop of the ileum, which, while in the small pelvis during radiation therapy, could receive a high dose of radiation or exceed the tolerant one. The use of staplers does not
reduce the frequency of small intestinal fistulas, but their use shortens the operation time, unifies the technique of forming an anastomosis and reduces tissue trauma and abdominal contamination with intestinal contents [16].
Conclusion. In recent years, TRE has been further developed and firmly established in the arsenal of many oncological institutions. This was facilitated by the improvement of the procedure of surgery, the emergence of modern electro-surgical equipment, the development of anesthesiology and resuscitation. However, so far TRE remains an opinion of a crippling operation with a potentially low survival rate. One of the reasons for such an attitude toward this operation may be an underestimation by oncologists of the significance of the reconstructive stage of the operation, a low awareness of the techniques for reconstructing the pelvic floor and the prevention of potentially fatal complications such as small intestinal obstruction, small intestinal fistulas and pelvic abscesses. In this situation, according to VI. Widespread, a promising solution can be the creation of localized localized tumors, as well as the consolidation of the efforts of urologists, gynecologists, coloproctologists, radiologists, chemotherapists and plastic surgeons.
Creation of the direction of pelvic surgery will avoid the subjectivism of certain specialties and develop common tactical approaches in the treatment of patients with locally advanced and recurrent pelvic tumors.
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