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Exenteration

Exenteration

Definition

Exenteration is a major operation during which all the contents of a body cavity are removed. Pelvic exenteration refers to the removal of the pelvic organs and adjacent structures; orbital exenteration refers to the removal of the entire eyeball, orbital soft tissues, and some or all of the eyelids.


Purpose

The pelvis is the basin-shaped cavity that contains the bladder, rectum, and reproductive organs. The internal reproductive organs include the ovaries, fallopian tubes, uterus, and cervix for women, and the prostate and various ducts and glands for men. Pelvic exenteration is performed to surgically remove cancer that involves these organs and that has not responded well to other types of treatment. Pelvic exenteration is also indicated when cancer returns after an earlier treatment. In women, the operation is performed mostly for advanced and invasive cases of endometrial, ovarian, vaginal, and cervical cancer; for aggressive prostate cancer in men; and rectal cancer in either sex.

Orbital exenteration is performed to remove the eye and surrounding tissues when cancer of the orbital contents cannot be controlled by simple removal or irradiation. It is often the only course of treatment for advanced cancers of the eyelid, eyeball, optic nerve, or retina.

Exenteration is a major operation for both patient and surgeon; it is technically very challenging because it involves elaborate reconstructive surgery. Although it is a radical surgical procedure, exenteration often provides the only opportunity available for patients to eliminate the cancer and to prevent it from recurring.


Demographics

No data are available regarding the demographic nature of patients undergoing exenteration, given the numerous conditions that may warrant it. Cancer affects individuals of any age, sex, race, or ethnicity, although incidence may differ among these groups by cancer type.


Description

Both pelvic and orbital exenterations are considered to be major surgery and are performed under general anesthesia. The exact surgical procedure performed depends on the type of exenteration.


Pelvic exenteration

Pelvic exenterations start with an incision in the lower abdomen. Blood vessels are clamped and the organs specified by the procedure are removed. The site of incision is then stitched up. There are three types of pelvic exenteration: anterior, posterior, and total.

anterior exenteration. This operation is called anterior exenteration because it removes organs toward the front of the pelvic cavity. It usually involves the removal of the female reproductive organs, bladder, and urethra. (In males, an operation that removes the bladder and prostate is called a cystoprostatectomy). Patients selected for this operation have cancers in areas that allow the rectum to be spared.

A new method for excreting urine must be created. One common approach, called an ileal conduit, diverts the ureters to a pouch made of small intestine, which is then connected to the abdominal wall. Urine exits the body through a small opening called a stoma, and collects in a small bag attached to the body. Vaginal reconstruction may also be performed during the exenteration, or in a later procedure.

posterior exenteration. Posterior exenteration removes organs that are located in the back part of the pelvic cavity. These include the reproductive organs, plus the lower part of the bowel; the bladder and urethra are kept intact. A patient who has undergone posterior exenteration will require a colostomy , a procedure that connects the colon to the abdominal wall; waste exits the body through a stoma and is collected in a small bag.

total pelvic exenteration. This operation removes the bladder, urethra, rectum, anus, and supporting muscles and ligaments, together with the reproductive organs. Total pelvic exenteration is performed when there is no opportunity to perform a less extensive operation, because of the location and size of the cancer. A urinary stoma and a colostomy stoma will be created to collect waste.


Orbital exenteration

This operation removes the eyeball and surrounding tissues of the orbit. (Since the eye is surrounded by bone, orbital exenteration is often easier to tolerate than pelvic exenteration.) Orbital exenteration with partial preservation of eyelids and conjunctiva can sometimes be achieved. After the surgical site has healed, patients can be fitted with a temporary ocular prosthesis (plastic eye), although many patients prefer to wear an eye patch. Later, facial prostheses can be attached to the facial skeleton.


Diagnosis/Preparation

The evaluation of patients before pelvic exenteration includes a thorough physical examination with rectal and pelvic examination. Endorectal ultrasound and imaging studies such as computed tomography scans (CT scans ) and magnetic resonance imaging (MRI) are routinely used to obtain pictures of the abdominal and pelvic areas and evaluate the spread of the cancer.

Ocular ultrasound examination, CT scan, and angiography evaluation (used to image blood vessels) are usually performed to prepare for orbital exenteration.

Some patients begin treatment with chemotherapy and/or radiation before the procedure. Surgery is typically performed approximately six weeks later.

In the case of pelvic exenteration, the patient will be given a bowel prep to cleanse the colon and prepare it for surgery. This procedure is required to lower the level of intestinal bacteria, thus helping to prevent post-surgical infections. Antibiotics are also typically given to help decrease bacteria levels in the bowel.


Aftercare

Pelvic exenteration

After a pelvic exenteration, a drainage tube is inserted at the site of the incision. There usually is some bleeding, discharge, and considerable tenderness and pain for a few days. At least a three- to five-day hospital stay is usually required. Side effects depend on the type of pelvic exenteration performed, but often include urination difficulty, especially if adjustment to a catheter is required; and a very painful lower abdomen.

Stitches are usually removed from the skin on the third day, or before the patient is sent home. A prescription for pain medication is usually given as well as instructions for follow-up care.


Ocular exenteration

After ocular exenteration, most patients have a headache for several days, which goes away with over-the-counter pain medications. An eye ointment is also prescribed that contains antibiotics and steroids to help the healing process.


Risks

As with any operation, there is a risk of complications due to anesthesia, wound infection, or injury to adjacent organs or structures.

In the case of pelvic exenteration, the following complications are also possible:

  • hemorrhage that may require a blood transfusion
  • injury to the bowel
  • urinary tract infection
  • urinary retention requiring permanent use of a catheter
  • bowel obstruction

After removal of the reproductive organs, women will no longer have monthly periods nor will they be able to become pregnant. For men, surgery involving the prostate and the nerves around the rectum may also result in the inability to produce sperm or to have an erection.

In the case of orbital exenteration, the following complications have been known to occur:

  • growth of an orbital cyst (rare)
  • chronic throbbing orbital pain
  • sinusitis (nasal stuffiness)
  • ear problems
  • reoccurrence of malignancy

Normal results

During and after recovery from exenteration, it is normal for a patient to undergo a period of psychological adjustment to the major change in lifestyle (e.g., learning to care for a urostomy or colostomy) or appearance (e.g., following orbital exenteration). It is important that all aspects of the procedure be discussed with the patient before undergoing surgery, and that any psychosocial distress that the patient experiences after exenteration be addressed.


Morbidity and mortality rates

There is a 3044% chance of complications during pelvic exenteration, and the operative mortality rate ranges from 35%. About one-third of patients will experience such postoperative complications as bowel obstruction, fistula formation, inflammation or failure of the kidneys, narrowing of the ureters, or pulmonary embolism (a blood clot that travels to the lungs). The five-year survival rate after pelvic exenteration ranges from 2361%. For patients who undergo pelvic or orbital exenteration, short- and long-term morbidity and mortality rates depend on the particular condition that required the procedure.


Alternatives

Exenteration is generally pursued only if no other less invasive options are available to the patient. Alternatives, however, include chemotherapy, radiation therapy, and more conservative surgery.

Resources

books

Yanoff, Myron, and Jay Duker. Ophthalmology, 1st ed. London: Mosby International Ltd., 1999.

periodicals

Clarke, A., N. Rumsey, J. R. O. Collin, and M. Wyn-Williams. "Psychosocial Distress Associated with Disfiguring Eye Conditions." Eye 17, no. 1 (January 2003): 3540.

Ramamoorthy, Sonia L., and James W. Fleshman. "Surgical Treatment of Rectal Cancer." Hematology/Oncology Clinics of North America 16, no. 4 (August 2002): 927.

Sevin, B. U., and O. R. Koechlie. "Pelvic Exenteration." Surgical Clinics of North America 81, no. 4 (August 1, 2001): 7719.

Turns, D. "Psychosocial Issues: Pelvic Exenterative Surgery." Journal of Surgical Oncology 76 (March 2001): 22436.

organizations

American Academy of Ophthalmology. P.O. Box 7424, San Francisco, CA 94120-7424. (415) 561-8500. <http://www.aao.org>.

American Cancer Society. 1599 Clifton Road NE, Atlanta, GA 30329. (800) ACS-2345. <http://www.cancer.org>.

American College of Obstetricians and Gynecologists. 409 12th St., SW, P.O. Box 96920, Washington, DC 20090-6920. <http://www.acog.org>.

other

Husain, Amreen, and Nelson Teng. "Pelvic Exenteration." eMedicine, January 31, 2003 [cited April 5, 2003]. <http://www.emedicine.com/med/topic3332.htm>.

Monique Laberge, PhD Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


As exenteration is considered to be major surgery, the procedure is performed under the strict conditions that a hospital operating room affords. A team of physicians, nurses, and other health care workers are involved in the procedure. Pelvic exenteration may be performed by a gynecologist, gynecologic oncologist, urologist, and/or plastic surgeon. Orbital exenteration may be performed by an ophthalmologist and/or oculoplastic surgeon.

QUESTIONS TO ASK THE DOCTOR


  • Why is exenteration recommended in my case?
  • What organs or other structures will be removed?
  • In the case of pelvic exenteration, what methods of urinary/fecal diversion will be performed?
  • In the case of orbital exenteration, what are my options in terms of cosmetic prostheses?
  • What nonsurgical options are available to me?
  • How long after surgery may I resume normal activity?

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"Exenteration." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. . Retrieved September 22, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/exenteration-0

Exenteration

Exenteration

Definition

An exenteration is a major operation during which all the contents of a body cavity are removed. Pelvic exenteration refers to the removal of all the organs and adjacent structures of the pelvis, and orbital exenteration refers to the removal of the entire contents of the ocular orbit, sometimes including the eyelids as well.

Purpose

The pelvis is the basin-shaped cavity that contains the bladder, rectum and reproductive organs. (The reproductive organs include the ovaries, uterus and cervix for women and the prostate for men.) Pelvic exenteration is performed to surgically remove cancer that involves these organs and that has not responded well to other types of treatment. For example, pelvic exenteration might be performed for primary rectal cancer because 5%-10% of primary rectal cancers spread to nearby pelvic organs. Pelvic exenteration is also indicated when cancer returns after an earlier treatment, as rectal cancer does in some 20% of cases. In women, the operation is additionally performed mostly for advanced and invasive cases of endometrial, ovarian, vulvar, vaginal and cervical cancer , and in men for aggressive prostate cancer .

Similarly, orbital exenteration is performed to remove the eye and surrounding tissues when cancer of the orbital contents cannot be controlled by simple removal or irradiation. It is often the only course of treatment for advanced basal cell carcinoma of the eyelids, for cancers that have spread to the optic nerve, or retinoblastomas larger than 1/4 inch (0.6 cm), as well as for large tumors of the eyeball.

Exenteration is not only a major operation for a patient to undergo, it is also technically very challenging, because it involves elaborate reconstructive surgery . It is a radical surgical procedure, but it often provides the only opportunity available for patients to eliminate the cancer and to prevent cancer from recurring.

Precautions

Pelvic exenterations should not be performed on patients diagnosed with inflammation of the roots of spinal nerves, sciatica, lymphedema, liver cancer, extrapelvic disease, and obstructions of the urinary tract.

All precautions applying to major surgery apply to exenterations, whether pelvic or ocular.

After pelvic exenteration, sexual intercourse should be avoided as directed by the surgeon. This is to allow the wound to heal properly.

Description

Pelvic exenteration

There are three types of pelvic exenterations.

ANTERIOR EXENTERATION.

This operation usually removes in women the uterus, bladder, vagina, and entire urethra. Patients selected for this operation have cancers that are located so as to allow the rectum to be spared. Vaginal reconstruction is performed afterwards if required. It is called anterior because it removes organs toward the front or in front of the pelvis.

POSTERIOR EXENTERATION.

This operation removes in women the uterus, ovaries, Fallopian tubes, anus, supporting muscles and ligaments, and all the vagina except a portion of the wall that supports the urethra. In men, the bladder is also removed. It is called posterior because it removes organs located in the back part of the pelvis.

TOTAL PELVIC EXENTERATION.

This operation removes the bladder, rectum and anus, supporting muscles and ligaments, together with either the prostate in men or the gynecologic (reproductive) organs in women. Total pelvic exenteration is performed when there is no opportunity to perform a less extensive operation, because of the location and size of the cancer. For women, vaginal reconstruction is performed, which also helps reconstruction of the pelvic area. In both anterior and total pelvic exenteration, a urinary tract can be constructed.

The exact surgical procedure followed depends on the type of exenteration, but generally, all pelvic exenterations start with an incision in the lower abdomen. Blood vessels are clamped and the organs specified by the procedure are removed. The site of incision is then stitched up.

Orbital exenteration

This operation removes the eyeball and surrounding tissues of the orbit. The eye is surrounded by bone, so orbital exenteration is easier to tolerate than pelvic exenteration and patients may even undergo the operation as outpatients. Orbital exenteration with partial preservation of eyelids and conjunctiva can sometimes be achieved. Within two weeks of surgery, patients are usually fitted with a temporary ocular prothesis (plastic eye). Later, facial prostheses are also attached to the facial skeleton.

Both pelvic and orbital exenterations are performed using general anesthesia.

Preparation

The evaluation of patients before pelvic exenteration includes a thorough physical exam with rectal and pelvic examination. Endorectal ultrasound and imaging studies , such as computed tomography scans (CT scans) and magnetic resonance imaging (MRI), are routinely used to obtain pictures of the abdominal and pelvic areas and evaluate the spread of the cancer.

Ocular ultrasound examination, CT scan and angiography evaluation is usually performed to prepare for ocular exenteration.

Preparing for the operation usually depends on the type of exenteration procedure selected. Most patients receive a combination of radiation therapy and chemtherapy before the operation. Surgery is typically performed approximately six weeks later.

In the case of pelvic exenteration, patients are required to clean as much waste as possible out of the large intestine, using various laxatives or enemas. This cleaning of the colon and rectum is required so as to eliminate stool and lower the level of bacteria, thus preventing infections after surgery. Antibiotics are also typically given to help sterilize the colon.

Aftercare

Pelvic exenteration

After a pelvic exenteration, a drainage tube is inserted at the site of the incision. There usually is some bleeding, discharge and considerable tenderness and pain for a few days. This is a major operation that requires at least a three-to five-day hospital stay. Side effects depend on the type of pelvic exenteration performed, but always include urination difficulty, especially if adjustment to a catheter is required, and a very painful lower abdomen.

Some exenterations require a temporary or permanent colostomy , meaning the creation of an opening (stoma) in the abdomen to allow solid waste to leave the body. Permanent colostomy may be needed, for example, if the rectum is removed. In such cases, the patient needs time to adjust and be taught how to irrigate, empty, clean and wear the colostomy bags.

Stitches are usually removed from the skin on the third day or before the patient is sent home. A prescription for pain medication is usually given as well as instructions for follow up care.

Ocular exenteration

After ocular exenteration, most patients have a headache for several days which goes away using medication such as tylenol. An eye ointment is also prescribed that contains antibiotics and steroids to help the healing process.

Risks

No surgical procedure is risk-free. Complications are always possible, especially if the operation is major. As with any operation, possible exenteration risks include possible complications due to the anesthetic and wound infection.

In the case of pelvic exenteration, the following complications are also possible:

  • hemorrhage that may require a blood transfusion
  • injury to the bowel
  • urinary tract infection
  • urinary retention requiring permanent use of a catheter
  • bowel obstruction
  • urinary tract infection

The following considerations also apply: after removal of the reproductive organs, women will no longer have monthly periods nor will they be able to become pregnant. For men, surgery involving the prostate and the nerves around the rectum may also result in the inability to produce sperm or to have an erection.

In the case of orbital exenteration, the following complications have been known to occur:

  • growth of an orbital cyst (rare)
  • chronic throbbing orbital pain
  • sinusitis (nasal stuffiness)
  • ear problems

See Also Adenocarcinoma; Cervical cancer; Endometrial cancer; Melanoma; Ovarian cancer; Vaginal cancer; Vulvar cancer

Resources

BOOKS

Deardorff, W. W. and J. Reeves. Preparing for Surgery: A Mind-Body Approach to Enhance Healing and Recovery. Oakland: New Harbinger, 1997.

Shields, J. A. Diagnosis and Management of Orbital Tumors. St. Louis: W. B. Saunders Publishing Company, 1989.

PERIODICALS

Kennedy, R. E., R. Frezzotti, R. Bonanni, A. Nuti, E. Polito, G.Bonavolonta, S. Evers, P. Soros, R. Brilla, H. Gerding, I. W. Husstedt, and K. W. Dolphin. "Indications and surgical techniques for orbital exenteration." Advances in Ophthalmic Plastic Reconstructive Surgery 9 (1992): 163-173.

Kersten, R. C., D. T. Tse, R. L. Anderson. "The role of orbital exenteration in choroidal melanomas." Ophthalmology 92 (1985): 436-443.

Moffat, F. L. J. and R. E. Falk. "Radical surgery for extensive rectal cancer: is it worthwhile?" Recent Results in Cancer Research 146 (1998): 71-83.

Petros, J. G., P. Augustinos, M. Lopez, J. S. Spratt, W. J. Temple, E. B. Saettler, R. E. Hautmann, D. Turns. "Pelvic exenteration for carcinoma of the colon and rectum." Seminars in Surgical Oncology 17 (October-November 1999): 206-212.

Turns, D. "Psychosocial issues: pelvic exenterative surgery."Journal of Surgical Oncology 76 (March 2001): 224-236.

OTHER

Women's Health Matters. <http://www.womenshealthmatters.ca/centres/cancer/cervical/treatment/index.html>.

Information on eye cancer: Web sites: <http://www.EyeCancerBook.com/> and <http://eyecancerinfo.com/>.

Monique Laberge, Ph.D.

KEY TERMS

Anus

The terminal orifice of the gastrointestinal (GI) or digestive tract which includes all organs responsible for getting food in and out of the body.

Catheter

Long thin tubes that carry urine from the kidneys to the bladder.

Conjunctiva

A clear membrane that covers the inside of the eyelids and the outer surface of the eye.

Cyst

Any closed cavity surrounded by a wall made up of cells joined by cementing substances and that contains liquid or semi-solid material.

General anesthesia

Method used to stop pain from being felt during an operation. General anesthesia is the most powerful type and is generally used only for major operations, such as brain, neck, chest, abdomen, and pelvis surgery.

Ocular orbit

Bony cavity containing the eyeball.

Resection

The complete or partial removal of an organ or tissue.

Rectum

The last part of the large intestine (colon) that connects it to the anus.

QUESTIONS TO ASK THE DOCTOR

  • Why do I need the operation?
  • What are the benefits of having the operation?
  • What are the risks of having the operation?
  • What if I don't have this operation?
  • Where can I get a second opinion?
  • What has been your experience in doing the operation?
  • How long will it take me to recover?
  • What are the surgeon's qualifications?

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"Exenteration." Gale Encyclopedia of Cancer. . Encyclopedia.com. 22 Sep. 2017 <http://www.encyclopedia.com>.

"Exenteration." Gale Encyclopedia of Cancer. . Encyclopedia.com. (September 22, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/exenteration

"Exenteration." Gale Encyclopedia of Cancer. . Retrieved September 22, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/exenteration

exenteration

exenteration (eks-en-ter-ay-shŏn) n. (in ophthalmology) an operation in which all the contents of the eye socket (orbit) are removed, leaving only the bony walls intact.

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