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POSTOPERATIVE COMPLICATIONS ASSOCIATED WITH PELVIC EXENTERATION IN WOMEN WITH GYNECOLOGICAL CANCER: AN INTEGRATIVE REVIEW* * Article extracted from the master’s/PhD thesis “EXENTERAÇÃO PÉLVICA: Análise de complicações pós-cirúrgicas e óbito hospitalar para construção de cartilha educativa”, Universidade Federal do Pará, Belém, PA, Brasil, 2018.

ABSTRACT

Objective:

to identify the main complications arising from the pelvic exenteration surgery in gynecological cancer and the in-hospital death outcome after the surgical procedure.

Method:

an integrative literature review considering 23 articles published from 2012 to 2020 in the LILACS and IBECS databases. The descriptors used were the following: genital cancer, gynecological cancer, pelvic exenteration, exenteration, postoperative complications, surgical complications and death, combined by means of the AND or OR Boolean connectors.

Results:

surgical applicability was verified for cervical, uterine, ovarian, vaginal and vulvar cancer; age was associated with comorbidities (diabetes and hypertension); total pelvic exenteration was predominant; and there were high mean surgical and hospitalization times due to infections.

Contributions

to the area: this research enables improvements in the health care provided in the PE pre-, peri- and post-operative periods, as it elucidates the main problems resulting from this surgery, their stratifications and management options.

DESCRIPTORS:
Neoplasms in the Female Genitals; Pelvic Exenteration; Postoperative Complications; Oncology; Comorbidity

RESUMO

Objetivo:

identificar as principais complicações advindas da cirurgia de exenteração pélvica em câncer ginecológico e o desfecho do óbito hospitalar após o procedimento cirúrgico.

Método:

revisão integrativa da literatura considerando 23 artigos publicados de 2012 a 2020 nas bases de dados LILACS e IBECS. Os descritores utilizados foram genital cancer, gynecological cancer, pelvic exenteration, exenteration, postoperative complications, surgical complications, death (idioma inglês), combinados através de conectores booleanos AND ou OR.

Resultados:

constatou-se aplicabilidade cirúrgica para câncer do colo uterino, útero, ovário, vaginal e vulvar; idade associada a comorbidades (diabetes e hipertensão); a exenteração pélvica total predominante; tempo médio de cirurgia e de institucionalização elevados em decorrência de infecções.

Considerações finais:

a pesquisa possibilita a melhoria da assistência de saúde prestada no pré, peri e pós-operatório de EP enquanto elucida os principais problemas resultantes desta cirurgia, suas estratificações e manejos.

DESCRITORES:
Neoplasias dos Genitais Femininos; Exenteração Pélvica; Complicações Pós-Operatórias; Oncologia; Comorbidade

RESUMEN

Objetivo:

identificar las principales complicaciones derivadas de la cirugía de exenteración pélvica en tumores ginecológicos y el desenlace de fallecimiento intrahospitalario después del procedimiento quirúrgico.

Método:

revisión integradora de la literatura en la que se consideraron 23 artículos publicados en las bases de datos LILACS e IBECS entre 2012 y 2020. Se utilizaron los siguientes descriptores: genital cancer, gynecological cancer, pelvic exenteration, exenteration, postoperative complications, surgical complications y death (idioma inglés), combinados por medio de conectores booleanos AND u OR.

Resultados:

se detectó lo siguiente: aplicabilidad quirúrgica para cáncer de cuello uterino, útero, ovario, vagina y vulva; edad asociada a comorbilidades (diabetes e hipertensión); predominio de exenteración pélvica total; elevado tiempo promedio de cirugía; e internación por infecciones.

Aportes al área:

este trabajo de investigación permite mejorar la atención de la salud provista en los períodos pre-, peri- y post-operatorios de la EP, puesto que deja en claro los principales problemas derivados de esta cirugía, sus estratificaciones y opciones de manejo.

DESCRIPTORES:
Neoplasias en los Genitales Femeninos; Exenteración Pélvica; Complicaciones Postoperatorias; Oncología; Comorbilidad

HIGHLIGHTS

  1. Pelvic Exenteration (PE) is a complex oncological surgery.

  2. PE must be performed by means of well-established criteria.

  3. Advanced-stage gynecological tumors can be approached via PE.

  4. Infection stands out among the complications associated with PE.

HIGHLIGHTS

  1. Pelvic Exenteration (PE) is a complex oncological surgery.

  2. PE must be performed by means of well-established criteria.

  3. Advanced-stage gynecological tumors can be approached via PE.

  4. Infection stands out among the complications associated with PE.

INTRODUCTION

The therapeutic measures to approach gynecological cancer can vary and be combined in several ways according to staging of the disease and to the patient’s clinical condition11 Sociedade Brasileira de Oncologia Clínica. Manual de Condutas em Oncologia Clínica. Revista da Sociedade Brasileira de Oncologia Clínica. ISSN 1806-6054. 2011.. Pelvic Exenteration (PE) was described by Brunschwig in 1948 as a palliative procedure for the symptoms caused by locally advanced gynecological tumors. With the advancement in surgical techniques, PE evolved from a palliative to a curative procedure22 Diver EJ, Rauh-Hain A, Carmen MG del. Total Pelvic Exenteration for Gynecologic Malignancies. International Journal of Surgical Oncology. [Internet]. 2012 [access on 12 mar 2020]; 2: 1-9. Available in: http://dx.doi.org/10.1155/2012/693535.
http://dx.doi.org/10.1155/2012/693535...
.

Exenterations require extensive reconstruction and surgical recovery with significant morbidity and mortality associated with them, requiring careful selection of the patient to balance the cure or symptom palliation objectives22 Diver EJ, Rauh-Hain A, Carmen MG del. Total Pelvic Exenteration for Gynecologic Malignancies. International Journal of Surgical Oncology. [Internet]. 2012 [access on 12 mar 2020]; 2: 1-9. Available in: http://dx.doi.org/10.1155/2012/693535.
http://dx.doi.org/10.1155/2012/693535...
-33 Signorini Filho RC, Colturato LF, Giacon P de P, Gebrim LH. Indicações e Complicações da Exenteração Pélvica no Câncer Ginecológico. Femina. [Internet]. 2014 [access on 05 feb 2020]; 42(2): 77-82. Available in: https://pesquisa.bvsalud.org/portal/resource/pt/lil-749120.
https://pesquisa.bvsalud.org/portal/reso...
. They also require that the patient remains in the Intensive Care Unit immediately after the surgery, in addition to rigorous monitoring. Mortality is between 1% and 16% and its causes include sepsis, thromboembolism, kidney disease and cardiopulmonary failure. Infections (19%-86%), anastomotic leaks (8%-36%), fistulas (8%-36%) and intestinal and urethral obstructions (5%-10%) are some of the most frequent morbidities22 Diver EJ, Rauh-Hain A, Carmen MG del. Total Pelvic Exenteration for Gynecologic Malignancies. International Journal of Surgical Oncology. [Internet]. 2012 [access on 12 mar 2020]; 2: 1-9. Available in: http://dx.doi.org/10.1155/2012/693535.
http://dx.doi.org/10.1155/2012/693535...

3 Signorini Filho RC, Colturato LF, Giacon P de P, Gebrim LH. Indicações e Complicações da Exenteração Pélvica no Câncer Ginecológico. Femina. [Internet]. 2014 [access on 05 feb 2020]; 42(2): 77-82. Available in: https://pesquisa.bvsalud.org/portal/resource/pt/lil-749120.
https://pesquisa.bvsalud.org/portal/reso...
-44 Jager L, Nilsson PL, Rådestad AF. Pelvic exenteration for recurrent gynecologic malignancy: a study of 28 consecutive patients at a single institution. International Journal of Gynecological Cancer. [Internet]. 2013 [access on 05 feb 2020]; 23(4): 755-762. Available in: https://ijgc.bmj.com/content/23/4/755.
https://ijgc.bmj.com/content/23/4/755...
.

Evaluating the postoperative complications associated with PE in gynecological cancer is indispensable for professionals caring for patients with this disease, in addition to favoring practice grounded on validated instruments. The method used by Clavien-Dindo to classify post-surgical complications was formulated in 2004 and has been used in studies to assess complications in patients subjected to several types of surgery55 Moreira LF, Pessôa MCM, Mattana DS, Schmitz FF, Volkweis BS, Antoniazzi JL et al. Cultural adaptation and the Clavien-Dindo surgical complications classification translated to Brazilian. Rev. Col. Bras. Cir. [Internet]. 2016 [access on 12 mar 2020]; 43(3): 141-148. Available in: http://dx.doi.org/10.1590/0100-69912016003001.
http://dx.doi.org/10.1590/0100-699120160...
.

The objective of this study was to identify the main complications arising from the PE surgery in gynecological cancer and in-hospital death after the surgical procedure as outcome.

METHOD

This is an Integrative Literature Review (ILR) that gathers, assesses and synthesizes the results of research studies on a specific theme. Development of the study included the following stages: identification of the topic and selection of the research question; definition of the inclusion and exclusion criteria; and identification, categorization, analysis, interpretation and presentation of the results66 Ursi ES, Gavão CM. Perioperative prevention of skin injury: an integrative literature review. Rev Lat Am Enfermagem. [Internet]. 2006 [access on 07 jan 2020]; 14(1): 124-131. Available in: https://www.scielo.br/j/rlae/a/7hS3VgZvTs49LNX9dd85VVb/abstract/?lang=pt.
https://www.scielo.br/j/rlae/a/7hS3VgZvT...
.

The research guiding question (In women with gynecological cancer, how do PE surgeries influence the occurrence of post-surgical complications resulting in death during hospitalization?) was defined using the PICOT (Population, Intervention, Control, Outcome and Time) mnemonics, which ensured better traceability of the publications.

The study search was conducted from January to March 2020 in the following databases: National Library of Medicine National Institutes of Health (PubMed), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) and Índice Bibliográfico Español en Ciencias de la Salud (IBECS). The Descriptors in Health Sciences (Descritores em Ciências da Saúde, DeCS) and from the MeSH database were the following: genital cancer, gynecological cancer, pelvic exenteration, exenteration, postoperative complications, surgical complications and death, combined by means of the AND or OR Boolean connectors.

The inclusion criteria adopted corresponded to primary studies published in full in English, Spanish and Portuguese; published between 2012 and 2020; addressing PE performance with curative or palliative purposes, exclusively for diagnoses of onco-gynecological malignancies; and which assessed post-surgical complications and post-surgical in-hospital deaths.

The exclusion criteria corresponded to secondary productions and case studies, in addition to papers addressing PE performance only targeting at exposure to surgical techniques. Consequently, 23 novel research studies were selected for the review, meeting the inclusion criteria.

Figure 1
Flowchart corresponding to selection of the articles for the Integrative Literature Review.

The assumptions established in national research studies were considered during data extraction and when evaluating the level of evidence of the productions66 Ursi ES, Gavão CM. Perioperative prevention of skin injury: an integrative literature review. Rev Lat Am Enfermagem. [Internet]. 2006 [access on 07 jan 2020]; 14(1): 124-131. Available in: https://www.scielo.br/j/rlae/a/7hS3VgZvTs49LNX9dd85VVb/abstract/?lang=pt.
https://www.scielo.br/j/rlae/a/7hS3VgZvT...
,88 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: Método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto- enferm. [Internet]. 2008 [access on 07 feb 2020]; 17(4): 758-764. Available in: http://dx.doi.org/10.1590/S0104-07072008000400018.
http://dx.doi.org/10.1590/S0104-07072008...
. The articles were identified by title, year, country, database, level of evidence, objectives and main results.

The Results and Discussion sections are presented in a descriptive way, grouped into semantic categories originated from saturation of the following information: clinical characterization; characterization of the surgical procedure; characterization of the post-surgical complications; and in-hospital death after PE as outcome.

RESULTS

The studies selected are presented in Chart 1.

The search showed nonexistence of publications in Brazilian journals, although two research studies (9%) were produced at the national level; six (26%) were published in the International Journal of Gynecological Cancer and five (22%) in Gynecologic Oncology (Chart 1).

Regarding locus, five (22%) are from the United States; two (9%) come from Berlin and Jena (Germany) and from Bologna and Campobasso (Italy); two (9%) from Brazil; and another two (9%) are from Japan. As for year of publication, seven (30%) were published in 2012; six (26%) in 2014; three (13%) in 2019, two (9%) in 2013 and another two (9%) in 2017. 2015, 2016 and 2018 presented only one (4%) publication each.

Regarding the research designs, 23 (100%) were retrospective studies, with only two (9%) cohort studies among them. In relation to the time to conduct the studies, four (17%) required nine years to be concluded; another four (17%) lasted three years; three (13%) required 11 years; two (9%) studies considered a 17-year time frame; and another two (9%) covered 13 years.

In relation to the sample, the highest number was 282 women88 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: Método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto- enferm. [Internet]. 2008 [access on 07 feb 2020]; 17(4): 758-764. Available in: http://dx.doi.org/10.1590/S0104-07072008000400018.
http://dx.doi.org/10.1590/S0104-07072008...
and the smallest sample had 10 participants99 Schmidt AM, Imesch P, Fink D, Egger H. Indications and long-term clinical outcomes in 282 patients with pelvic exenteration for advanced or recurrent cervical cancer. Gynecologic Oncology. [Internet]. 2012 [access on 12 mar 2020]; 125 (3): 604-609. Available in: https://linkinghub.elsevier.com/retrieve/pii/S0090825812001722.
https://linkinghub.elsevier.com/retrieve...
. The total sum of participants was 1,552, with a mean of 67.47 in each research study.

Chart 1
Evidence corresponding to the scientific productions. Belém, Pará, Brazil. 2021.

DISCUSSION

The studies were categorized into four areas, emphasizing the main findings to synthesize them, directing the results to knowledge about the profile of the major complications resulting from pelvic exenteration surgeries in gynecological cancer to promote practice grounded on scientific knowledge.

Clinical characterization

The publications have variables in common such as age, characteristics of the tumors, classification of the type of surgical procedure used, and complications arising from the PE surgeries. The mean age was 56±10 years old, although it should not be considered individually as a determinant for selection. However, aging is associated with comorbidities, which can contraindicate the surgery when they are not controlled1111 Huang M, Iglesias DA, Westin SN, Fellman B, Urbauer D, Schmeler KM, et al. Pelvic Exenteration: Impact of age on surgical and oncologic Outcomes. Gynecol Oncol. [Internet]. 2014 [access on 05 feb 2020]; 132(1): 114-118. Available in: https://www.gynecologiconcology-online.net/article/S0090-8258(13)01336-X/fulltext.
https://www.gynecologiconcology-online.n...
.

In a study conducted with 161 women, although age was a determinant in the incidence of comorbidities such as diabetes mellitus and systemic arterial hypertension, this factor does not imply higher frequencies of postoperative complications in aged women1111 Huang M, Iglesias DA, Westin SN, Fellman B, Urbauer D, Schmeler KM, et al. Pelvic Exenteration: Impact of age on surgical and oncologic Outcomes. Gynecol Oncol. [Internet]. 2014 [access on 05 feb 2020]; 132(1): 114-118. Available in: https://www.gynecologiconcology-online.net/article/S0090-8258(13)01336-X/fulltext.
https://www.gynecologiconcology-online.n...
.

In relation to the characteristics of the tumors in 1,545 participants, the most frequently diagnosed cancer was cervical with 963 (62%), followed by uterine with 179 (12%), ovarian with 141 (9%) vaginal with 139 (9%) and vulvar with 105 (7%). The histopathological types were evaluated in 744 women, with prevalence of the squamous cell carcinoma type in 358 (48%).

Various types of onco-gynecological conditions can be treated by means of exenteration surgeries, depending on the disease staging evidenced, the patient’s clinical condition, and previous consent to undergo the surgery88 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: Método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto- enferm. [Internet]. 2008 [access on 07 feb 2020]; 17(4): 758-764. Available in: http://dx.doi.org/10.1590/S0104-07072008000400018.
http://dx.doi.org/10.1590/S0104-07072008...
,1212 Andikyan V, Khoury-Collado F, Gerst SR, Talukdar S, Bochner BH, Sandhu SJ, et al. Anterior pelvic exenteration with total vaginectomy for recurrent or persistent genitourinary malignancies: review of surgical technique, complications, and outcome. Gynecologic Oncology. [Internet]. 2012 [access on 12 mar 2020]; 126: 346-350. Available in: https://www.gynecologiconcology-online.net/article/S0090-8258(12)00322-8/fulltext.
https://www.gynecologiconcology-online.n...
,2121 Oranratanaphan S, Termrungruanglert W, Sirisabya N. Characteristics of gynecologic oncology patients in King Chulalongkorn Memorial Hospital - complications and outcome of pelvic exenteration. Asian Pacific Journal of Cancer Prevention. [Internet]. 2013 [access on 05 jan 2020]; 14(4): 2529-2532. Available in: http://koreascience.or.kr/article/JAKO201321251181184.page.
http://koreascience.or.kr/article/JAKO20...
.

PE can be appropriate for patients with advanced or recurrent primary tumors that cannot be treated with radiotherapy. Complete resection with no evidence of residual disease has been associated with better results with a five-year survival rate of 74% against 21% when complete resectability is not possible22 Diver EJ, Rauh-Hain A, Carmen MG del. Total Pelvic Exenteration for Gynecologic Malignancies. International Journal of Surgical Oncology. [Internet]. 2012 [access on 12 mar 2020]; 2: 1-9. Available in: http://dx.doi.org/10.1155/2012/693535.
http://dx.doi.org/10.1155/2012/693535...
,1818 Soeda S, Furukawa S, Sato T, Ueda M, Kamo N, Endo Y, et al. Pelvic Exenteration as Potential Cure and Symptom Relief in Advanced and Recurrent Gynaecological Cancer. Anticancer Res. [Internet]. 2019 [access on 12 mar 2020]; 39(10): 5631-5637. Available in: https://doi.org/10.21873/anticanres.13759.
https://doi.org/10.21873/anticanres.1375...
.

The occurrence of vulvar cancer (105 [7%]) was quite limited when compared to the cervical and uterine cancer diagnoses, being more frequent in aged patients. The outcome for an exenterative course of action arises from the absence of routine outpatient gynecological monitoring. Regarding the women from the young age group, they predominantly present cervical cancer diagnoses1111 Huang M, Iglesias DA, Westin SN, Fellman B, Urbauer D, Schmeler KM, et al. Pelvic Exenteration: Impact of age on surgical and oncologic Outcomes. Gynecol Oncol. [Internet]. 2014 [access on 05 feb 2020]; 132(1): 114-118. Available in: https://www.gynecologiconcology-online.net/article/S0090-8258(13)01336-X/fulltext.
https://www.gynecologiconcology-online.n...
.

In cervical cancer cases, PE has been used for centrally recurrent carcinoma and for adenocarcinoma, with well-documented cure potential and survival rates varying from 16% to 60%. It is directly correlated to complete tumor resection, evidencing that resectability is established as a key aspect of preoperative planning22 Diver EJ, Rauh-Hain A, Carmen MG del. Total Pelvic Exenteration for Gynecologic Malignancies. International Journal of Surgical Oncology. [Internet]. 2012 [access on 12 mar 2020]; 2: 1-9. Available in: http://dx.doi.org/10.1155/2012/693535.
http://dx.doi.org/10.1155/2012/693535...
.

Most of the recurrent uterine tumors spread beyond the pelvis, making PE an appropriate intervention for only a selected group of patients with recurrent uterine malignancies22 Diver EJ, Rauh-Hain A, Carmen MG del. Total Pelvic Exenteration for Gynecologic Malignancies. International Journal of Surgical Oncology. [Internet]. 2012 [access on 12 mar 2020]; 2: 1-9. Available in: http://dx.doi.org/10.1155/2012/693535.
http://dx.doi.org/10.1155/2012/693535...
,99 Schmidt AM, Imesch P, Fink D, Egger H. Indications and long-term clinical outcomes in 282 patients with pelvic exenteration for advanced or recurrent cervical cancer. Gynecologic Oncology. [Internet]. 2012 [access on 12 mar 2020]; 125 (3): 604-609. Available in: https://linkinghub.elsevier.com/retrieve/pii/S0090825812001722.
https://linkinghub.elsevier.com/retrieve...
-1010 Moreno-Palacios E, Diestro MD, Santiago JD, Henández A, Zapardiel I. Pelvic Exenteration in Gynecologic Cancer: La Paz University Hospital Experience. International Journal of Gynecological Cancer. [Internet]. 2015 [access on 12 mar 2020]; 25(6): 1109-1114. Available in: https://ijgc.bmj.com/content/25/6/1109.
https://ijgc.bmj.com/content/25/6/1109...
,1919 Baiocchi G, Guimaraes GC, Oliveira RAR, Kumagai LY, Faloppa CC, Aguiar S, et al. Prognostic factors in pelvic exenteration for gynecological malignancies. EJSO the Journal of Cancer Surgery. [Internet]. 2012 [access on 12 mar 2017]; 38: 948-954. Available in: https://pubmed.ncbi.nlm.nih.gov/22818842/.
https://pubmed.ncbi.nlm.nih.gov/22818842...
. Women with ovarian cancer are susceptible to the dissemination of malignant cells inside the abdomen, and are seldom candidates for PE11 Sociedade Brasileira de Oncologia Clínica. Manual de Condutas em Oncologia Clínica. Revista da Sociedade Brasileira de Oncologia Clínica. ISSN 1806-6054. 2011.-22 Diver EJ, Rauh-Hain A, Carmen MG del. Total Pelvic Exenteration for Gynecologic Malignancies. International Journal of Surgical Oncology. [Internet]. 2012 [access on 12 mar 2020]; 2: 1-9. Available in: http://dx.doi.org/10.1155/2012/693535.
http://dx.doi.org/10.1155/2012/693535...
,2020 Berreta R, Marchesi F, Volpi L, Ricotta G, Monica M, Sozzi G, et al. Posterior pelvic exenteration and retrograde total hysterectomy in patients with locally advanced ovarian cancer: Clinical and functional outcome. Asia Oceania J Obstet Gynaecol. [Internet]. 2016 [access on 10 jan 2020]; 55 (3): 346-50. Available in: https://www.sciencedirect.com/science/article/pii/S1028455916300328?via%3Dihub.
https://www.sciencedirect.com/science/ar...
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A retrospective study analyzed 35 cases of patients with ovarian cancer that were subjected to modified posterior PE with a curative purpose. The survival analysis in relation to residual disease confirmed an optimistic prognosis in patients with optimal resection, with a mean disease-free survival period of 33.6 months in R0 patients, 19.6 months in R1 patients, and 14.3 months in R2 patients. There were post-surgical complications in 83% of the patients, with early complications as the most frequent (65.7%). More severe complications (Grades III and IV) were evidenced in 37.7% of the patients. There were no cases of surgery-associated mortality2323 Pathiraja P, Sandhu H, Instone M, Haldar K, Kehoe S. Should pelvic exenteration for symptomatic relief in gynaecology malignancies be offered? Arch Gynecol Obstet. [Internet]. 2014 [access on 12 mar 2020]; 289(3): 657-62. Available in: https://link.springer.com/article/10.1007%2Fs00404-013-3023-5.
https://link.springer.com/article/10.100...
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The PE indications are recurrent in cases of necrosis secondary to the radiotherapy treatment, including hemorrhages due to tumor invasion and fistulas1212 Andikyan V, Khoury-Collado F, Gerst SR, Talukdar S, Bochner BH, Sandhu SJ, et al. Anterior pelvic exenteration with total vaginectomy for recurrent or persistent genitourinary malignancies: review of surgical technique, complications, and outcome. Gynecologic Oncology. [Internet]. 2012 [access on 12 mar 2020]; 126: 346-350. Available in: https://www.gynecologiconcology-online.net/article/S0090-8258(12)00322-8/fulltext.
https://www.gynecologiconcology-online.n...
,2222 Chiantera V, Rossi M, De Iaco P, Koehler C, Marnitz S, Gallotta V, et al. Pelvic exenteration for recurrent endometrial adenocarcinoma: a retrospective multi-institutional study about 21 patients. International Journal of Gynecological Cancer. [Internet]. 2014 [access on 05 feb 2020]; 24(5): 880-884 (b). Available in: https://ijgc.bmj.com/content/24/5/880.
https://ijgc.bmj.com/content/24/5/880...
,2929 Tortorella L, Casarin J, Mara KC, Weaver AL, Multinu WF, Glaser GE, et al. Prediction of short-term surgical complications in women undergoing pelvic exenteration for gynecological malignancies. Gynecologic Oncology. [Internet]. 2018 [access on 05 jan 2020]; 152(1): 151-156. Available in: https://www.gynecologiconcology-online.net/article/S0090-8258(18)31350-7/fulltext.
https://www.gynecologiconcology-online.n...

30 Gregorio N de, Gregoria A de, Ebner F, Frriedl TWP, Huober J, Hefty R, et al. Pelvic exenteration as ultimate ratio for gynecologic cancers: single-center analyses of 37 cases. Arch Gynecol Obstet. [Internet]. 2019 [access on 12 mar 2020]; 300(1):161-168. Available in: https://doi.org/10.1007/s00404-019-05154-4.
https://doi.org/10.1007/s00404-019-05154...
-3131 Bizzarri N, Chiantera V, Ercoli A, Fagotti A, Tortorella L, Conte C, et al. Minimally Invasive Pelvic Exenteration for Gynecologic Malignancies: A Multi-Institutional Case Series and Review of the Literature. Minim Invasive Gynecol. [Internet]. 2019 [access on 10 jan 2020]; 26(7):1316-1326. Available in: https://doi.org/10.1016/j.jmig.2018.12.019.
https://doi.org/10.1016/j.jmig.2018.12.0...

Characterization of the surgical procedure

The profile of the surgical procedures was well characterized, with six surgical techniques standing out: Total PE (TPE), Posterior PE (PPE), Anterior PE (APE), Anterior PE with Total Vaginectomy (APETV), Modified Posterior PE (MPPE), and Laterally Extended Endopelvic Resection (LEER).

It is worth noting the prevalence of TPE, which was performed in 877 (57%) patients, with a mean of 38 procedures per study99 Schmidt AM, Imesch P, Fink D, Egger H. Indications and long-term clinical outcomes in 282 patients with pelvic exenteration for advanced or recurrent cervical cancer. Gynecologic Oncology. [Internet]. 2012 [access on 12 mar 2020]; 125 (3): 604-609. Available in: https://linkinghub.elsevier.com/retrieve/pii/S0090825812001722.
https://linkinghub.elsevier.com/retrieve...
; followed by APE, performed in 346 (22%) women, with a mean of 15 procedures per study; and by PPE, performed in 198 (13%) patients, with a mean of nine procedures per study.

Performing urinary and/or intestinal diversions is crucial to preserve survival of patients with gynecological cancer. In all 23 studies, 411 (51%) corresponded to the incontinent type, ileal conduit subtype, with high incidence of containment pouches for urinary diversion, by means of the Indiana, Miami and Mainz techniques, with 71 (9%). Intestinal diversions were observed in 419 citations, by means of the Hartman Colostomy techniques and with a frequency of 235 (56%), followed by colorectal anastomosis with 129 (31%).

Twenty (87%) publications addressed surgical time as a useful parameter to analyze the patients, and 18 (78%) addressed hospitalization time after performing PE due to gynecological tumors. The mean time required to perform the surgical procedure was 485 minutes, ranging from a minimum of 2692323 Pathiraja P, Sandhu H, Instone M, Haldar K, Kehoe S. Should pelvic exenteration for symptomatic relief in gynaecology malignancies be offered? Arch Gynecol Obstet. [Internet]. 2014 [access on 12 mar 2020]; 289(3): 657-62. Available in: https://link.springer.com/article/10.1007%2Fs00404-013-3023-5.
https://link.springer.com/article/10.100...
to a maximum of 6481212 Andikyan V, Khoury-Collado F, Gerst SR, Talukdar S, Bochner BH, Sandhu SJ, et al. Anterior pelvic exenteration with total vaginectomy for recurrent or persistent genitourinary malignancies: review of surgical technique, complications, and outcome. Gynecologic Oncology. [Internet]. 2012 [access on 12 mar 2020]; 126: 346-350. Available in: https://www.gynecologiconcology-online.net/article/S0090-8258(12)00322-8/fulltext.
https://www.gynecologiconcology-online.n...
. Extended surgical times are associated with the surgical technical abilities of the professionals involved and with local neoplastic involvement1212 Andikyan V, Khoury-Collado F, Gerst SR, Talukdar S, Bochner BH, Sandhu SJ, et al. Anterior pelvic exenteration with total vaginectomy for recurrent or persistent genitourinary malignancies: review of surgical technique, complications, and outcome. Gynecologic Oncology. [Internet]. 2012 [access on 12 mar 2020]; 126: 346-350. Available in: https://www.gynecologiconcology-online.net/article/S0090-8258(12)00322-8/fulltext.
https://www.gynecologiconcology-online.n...
.

The mean hospitalization time was 24 days2424 Petruzziello A, Kondo W, Hatschback SB, Guerreiro JA, Penegalli Filho F, Vendrame C, et al. Surgical results of pelvic exenteration in the treatment of gynecologic cancer. World Journal of Surgical Oncology. [Internet]. 2014 [access on 12 mar 2020]; 12: 1-7. Available in: https://wjso.biomedcentral.com/articles/10.1186/1477-7819-12-279.
https://wjso.biomedcentral.com/articles/...
, with a maximum of 65 days2525 Tanaka S, Nagase S, Kaiho-Sakuma M, Nagai T, Kurosawa H, Toyoshima M, et al. Clinical outcome of pelvic exenteration in patients with advanced or recurrent uterine cervical cancer. International Journal of Clinical Oncology. [Internet]. 2014 [access on 12 mar 2020]; 9(1): 133-138. Available in: https://link.springer.com/article/10.1007%2Fs10147-013-0534-9.
https://link.springer.com/article/10.100...
, justified by the postoperative complications related to paralytic ileus and intestinal anastomosis leaks, observed in three patients.

Characterization of the post-surgical complications

The classification instruments used were the Clavien-Dindo Classification Scale (10 [43%]), the MSKCC System (two [9%[), CTCAE (one [4%]) and the Accordion Severity Grading System (one [4%])88 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: Método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto- enferm. [Internet]. 2008 [access on 07 feb 2020]; 17(4): 758-764. Available in: http://dx.doi.org/10.1590/S0104-07072008000400018.
http://dx.doi.org/10.1590/S0104-07072008...
.

Nearly 1,233 complication episodes were classified by means of the time criteria. Of these, 818 (66%) occurred early in time, 390 (32%) were late, and 25 (2%) complications were notified in the transoperative period. 693 (63%) notifications of problems comprised between grades G1 and G2 were observed, as well as 240 (35%) between G3 and G4; and the most severe complications (G5) were present in 13 (2%) notifications.

The most incident complications observed after performing PE surgeries secondary to gynecological cancer were infections, with abdominal and pelvic abscesses standing out. The urinary complications can be related to events such as problems performing the urinary diversion and occurrence of renal failure. The intestinal complications were mainly related to the creation of diversions, although some problems related to anastomosis patency were also notified.

Suture dehiscence was reported 176 times (10%), which may explain the high number of surgical reapproaches. The fistulas (7%) were the result of the illness process itself and of the involvement of multiple pelvic organs, as well as to the complication secondary to the surgery. It was possible to observe respiratory, cardiac and blood-related complications in participants who stayed many days in the hospital environment. Rehospitalization (post-surgical complication) was found in 34 (2%) cases.

The mean surgery time was 446 (95-970) minutes, 39 minutes below the expected mean value, and the hospitalization median was 24 (7-210) days. The rate of complications was 49 (21.3%) cases. Seven (3%) perioperative deaths were recorded at 30 days. The surgery was performed with tumor-free resection margins (R0) in 166 (72.2%) patients. The overall mortality rates were 75%, 57.6%, 55.6% and 53.6% for vulvar, cervical, vaginal and endometrial cancer, respectively88 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: Método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto- enferm. [Internet]. 2008 [access on 07 feb 2020]; 17(4): 758-764. Available in: http://dx.doi.org/10.1590/S0104-07072008000400018.
http://dx.doi.org/10.1590/S0104-07072008...
.

In-hospital death after PE as outcome

A total of 27 deaths were detected in this research series88 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: Método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto- enferm. [Internet]. 2008 [access on 07 feb 2020]; 17(4): 758-764. Available in: http://dx.doi.org/10.1590/S0104-07072008000400018.
http://dx.doi.org/10.1590/S0104-07072008...
, a factor that can be analyzed considering the large sample of patients (n=282) and their collective pathological profile: advanced or recurrent cervical cancer and already subjected to 212 previous surgeries.

Post-surgical morbidities are determinants in the outcome of in-hospital death. The authors verify this fact when detecting high occurrence of post-surgical infections (n=20), fistulas (n=42), anastomosis leak (n=21) and thrombosis (n=10) in their sample88 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: Método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto- enferm. [Internet]. 2008 [access on 07 feb 2020]; 17(4): 758-764. Available in: http://dx.doi.org/10.1590/S0104-07072008000400018.
http://dx.doi.org/10.1590/S0104-07072008...
. The outcomes other than in-hospital death (n=13) were recorded in four different productions reporting 379 post-surgical complications, with infections standing out (n=109)44 Jager L, Nilsson PL, Rådestad AF. Pelvic exenteration for recurrent gynecologic malignancy: a study of 28 consecutive patients at a single institution. International Journal of Gynecological Cancer. [Internet]. 2013 [access on 05 feb 2020]; 23(4): 755-762. Available in: https://ijgc.bmj.com/content/23/4/755.
https://ijgc.bmj.com/content/23/4/755...
,1010 Moreno-Palacios E, Diestro MD, Santiago JD, Henández A, Zapardiel I. Pelvic Exenteration in Gynecologic Cancer: La Paz University Hospital Experience. International Journal of Gynecological Cancer. [Internet]. 2015 [access on 12 mar 2020]; 25(6): 1109-1114. Available in: https://ijgc.bmj.com/content/25/6/1109.
https://ijgc.bmj.com/content/25/6/1109...
,2222 Chiantera V, Rossi M, De Iaco P, Koehler C, Marnitz S, Gallotta V, et al. Pelvic exenteration for recurrent endometrial adenocarcinoma: a retrospective multi-institutional study about 21 patients. International Journal of Gynecological Cancer. [Internet]. 2014 [access on 05 feb 2020]; 24(5): 880-884 (b). Available in: https://ijgc.bmj.com/content/24/5/880.
https://ijgc.bmj.com/content/24/5/880...
,2929 Tortorella L, Casarin J, Mara KC, Weaver AL, Multinu WF, Glaser GE, et al. Prediction of short-term surgical complications in women undergoing pelvic exenteration for gynecological malignancies. Gynecologic Oncology. [Internet]. 2018 [access on 05 jan 2020]; 152(1): 151-156. Available in: https://www.gynecologiconcology-online.net/article/S0090-8258(18)31350-7/fulltext.
https://www.gynecologiconcology-online.n...
.

Consequently, an integrated multiprofessional team is of fundamental importance for success of the procedure, contributing to reducing adverse events and deaths.

CONCLUSION

The PE technique represents a challenge for care management by the multiprofessional team due to the complexity of the pathologies eligible for the surgical act. Therefore, this review achieved the objectives outlined when highlighting the main complications arising from the procedure and the outcome of premature death in the hospital environment. It was evident that infectious complications are still the most incident ones despite the pharmacotherapeutic advances, a fact that can be explained by radicality of the procedure. The need to conduct new studies to discuss mortality after PE is noted, considering its association with the total number of post-surgical complications evidenced.

Observation and management of post-PE complications should be priorities for the care team, with the objective of rapidly reversing the harmful effects. For this, the use of classification tools should be a common practice in the hospital environment, always applied and rethought considering the institutional particularities and those of the assisted clientele, aiming at their better dissemination and feasibility in the professional scope.

The study brings about a number of contributions for Nursing, in the sense of improving the health care provided in the PE pre-, peri- and post-operative periods.

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  • *
    Article extracted from the master’s/PhD thesis “EXENTERAÇÃO PÉLVICA: Análise de complicações pós-cirúrgicas e óbito hospitalar para construção de cartilha educativa”, Universidade Federal do Pará, Belém, PA, Brasil, 2018.

Edited by

Associate editor:

Dra. Virginia Souza

Publication Dates

  • Publication in this collection
    07 Aug 2023
  • Date of issue
    2023

History

  • Received
    04 Aug 2021
  • Accepted
    08 Feb 2023
Universidade Federal do Paraná Av. Prefeito Lothário Meissner, 632, Cep: 80210-170, Brasil - Paraná / Curitiba, Tel: +55 (41) 3361-3755 - Curitiba - PR - Brazil
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