Extent and contraindications for sacral amputation in patients with recurrent rectal cancer: a systematic literature review

Abstract

Background

Abdominosacral amputation is a potentially curative surgical approach for patients with recurrent rectal cancer. Previous reports have described differing extents of sacral resection. Most of these reports stated that high sacral involvement of the tumor is a contraindication for surgery; however, the basis for this is unclear.

Methods

In this study, we reviewed the highest level of sacral amputation and the “contraindications” for this technique. Using a systematic literature survey, we analyzed the theoretical basis and the changes in surgical indications for recurrent rectal cancer.

Results

We retrieved 33 articles from Medline and one study from the Cochrane Center Register of Controlled Trials. The highest level of resection was at the level of L5/S and S1 in one article, S1/2 and S2 in nine articles and S2/3 and S3 in 11 articles. Fifteen articles stated contraindications regarding sacral level, including tumor involvement of S1, the S1/2 junction, or the level above the S2/3 junction. Reasons stated for these contraindications included the risks associated with surgery, namely bladder dysfunction, anorectal dysfunction, genital dysfunction, walking disorder, and spinal fluid leak. In terms of the rationale for the contraindications, three articles referred to four previously published reviews or case series. None of these supporting publications were randomized controlled trials and they did not include any statistical evaluation.

Conclusion

The consensus for contraindications for sacral amputation was formed empirically, without strong supporting evidence. The balance between curability and dysfunction should be further evaluated scientifically.