LONG TERM MORBIDITYAFTER MULTIVISCERAL RESECTION

FOR PRIMARY RETROPERITONEAL SARCOMA.A monoinstitutional study

Marco Fioremarco.fiore@istitutotumori.mi.it

• Liberal en-bloc visceral resections

“Extended surgical approach”

Storm, Mahvi – Ann Surg 1990

• Loco-regional peritonectomy and miomectomy of the psoas

• Vascular surgery and bone resection

Extended surgery

Limited surgery

Grade 3 18%Grade 4 12%Grade 5 3%

Postoperative Morbidity

Giorgione, Three Ages of man (1500-1501)

Long term…?

• Consecutive primary RPS surgically treated “extended multivisceral resection policy”

• Retrospective study – Renal function (baseline; 6 months; censored time)– Late abdominal complications– Chronic pain & medications (Brief Pain Inventory)– Lower Limb Neurological impairment (Lower

Extremity Functional Scale, LEFS)

INT Milan – 2002-2011

femoralisilio-hypogastric

lateralis femoral-cutaneous

ilio-inguinal

genito-femoralis

Lower limb neurological impairment…

Results

• 243 patients operated• 160 patients alive at time of the study• 91 (57%) evaluable for the study• 69 not included for

• Refusal• …

• Median follow up at time of study (for those who

answered) 49 months

Number of organ resected (91 pts)

0-1 organs: 17.60%≥ 2 organs: 82.40%0-3 organs: 52.75%≥ 4 organs: 47.25%

Nephrectomy: 65.93%

Possible causes of lower limb neurological impairment

Psoas Muscle Resection Femoral Nerve Resection

67.4%

3.4%

Oncologic Outcome

5-yr CCI for local recurrence 21% (16-28%, 95%CI)5-yr CCI for distant metastasis 25% (20-32%, 95%CI)

Poster 117POST-RELAPSE OUTCOME OF RETROPERITONEAL SARCOMA TREATED BY PRIMARY EXTENDED RESECTION: MORE ABOUT THE TUMOR LESS ABOUT THE SURGEONAlex Gronchi1; Rosalba Miceli2; Marc Antoine Allard3; Dario Callegaro1; Cecile Le Pechoux4; Marco Fiore, MD1; Charles Honoré3; Roberta Sanfilippo5; Sara Coppola3; Silvia Stacchiotti, MD5; Philippe Terrier6; Paolo G. Casali5; Axel LeCesne7; Chiara Colombo1; Sylvie Bonvalot3

Altered creatinine level ≥ 1.5 fold UNL

7.7%

Renal function

Only 1 patient needed hemodialysis for controlateral nephrolitiasis

“Creatinine index” = [Alt./Not alt. at time of study] – [Alt./Not alt. at baseline]

Always normal

Altered postop

Altered preop

0.0

1.0

2.0

3.0

4.0

Serum Creatinine at time of study (mg/dL)

14.7% in the subgroup with nephrectomy

Late abdominal complication

• Incisional hernia repair 3.3%• Bowel Obstruction 5.7%

– Emergency surgery 4.4%• Change in defecation 44.8%

– Incontinence 3.8%

• Urinary incontinence 10.2%

Chronic Pain intensity and QoL

Median Pain

Interference w

ith aciti

vity

Interference w

ith m

ood

Interference w

ith jo

b

Interference w

ith so

cial lif

e

Interfenrence w

ith sle

ep

Interference w

ith jo

y of li

fe

10 9

8 7

6 5

4 3

2 1

0

50%

Visual Analogue Scale

“Median pain over the last 24 hours”

“Brief Pain Inventory” :Assessment of any kind of pain(not necessarily due to previous surgery)

6.7%

Chronic Pain intensity and QoL

50%

6.7% 18.6% 16.9% 18.6% 11.9% 11.9% 11.9%

• Postoperative Sensibility Disorder: 78.41%– Still present at time of study 71.79%– Medications needed 34.09%

Series10

102030405060708090

100

pain

paresthesia

anesthesia

Neuropathic Pain > 2 wks

NoYes

Lower limb neurological impairment(…related to surgical procedure)

Lack of knee strenght

Use of crutches Accidental falls Physiotherapy0%

10%20%30%40%50%60%70%80%90%

100%

YesNo

Lower limb neurological impairment(…related to surgical procedure)

Median LEFS score 60 / 80 (38-79, IQ range)

Lower limb neurological impairment(…related to surgical procedure)

Who had LTM…?

1. Bowel obstruction2. Emergency surgery3. Incisional hernia4. Change in defecation5. Change in urination6. Reduced libido7. Impotence 8. Retrograde ejaculation9. Dyspareunia10.Accidental falls11.Lack of knee strenght

Any ≥ 3 from the list

Correlation with early postoperative morbidity

No periopera

tive M

Periopera

tive M

>G30%

20%40%60%80%

100%

>3 LTM 1-2 LTM No LTM

No periopera

tive M

Periopera

tive M

>G30%

20%

40%

60%

80%

100%

Preop Alt Postop Alt Always N

NA

No periopera

tive M

Periopera

tive M >G3

0%20%40%60%80%

100%

QoL >6 QoL <6

P = 0.3814

Number of Long Term Morbidities

Late Renal Morbidity Pain & QoL

P = 0.01974

Correlation with early postoperative morbidityLEFS Score at time of survey

Postoperative MNo Postoperative MP = 0.05218

Conclusion

• Primary extended multivisceral resection for RPS was followed by minor long term morbidities in 1/3 of patients (more frequent in case of early perioperative complications)

• Chronic pain and lower limb function were acceptable• Late renal function was impaired in a minority of patients

(7.7% overall; 14.7% after nephrectomy)• The impact on QoL deserves a prospective evaluation, since

the baseline evaluation was not assessed• Outlined data favor the safety and feasibility of the extended

approach and will be confirmed prospectively

marco.fiore@istitutotumori.mi.it