What is Extended Lateral Pelvic Sidewall Excision (ELSiE)?
Extended lateral pelvic sidewall excision (ELSiE) is a surgical approach to treat recurrent or locally advanced anorectal cancer affecting the pelvic sidewall.
Total pathological resection of a locally recurrent or advanced anal and rectal cancer is deemed as one of the most crucial factors of oncological outcome. Lateral pelvic sidewall disease has been regarded as a contraindication to pelvic exenteration surgery due to the significant probability of incomplete resection. To overcome this, a new technique called ELSiE is employed for complete resection of disease involving the lateral pelvic sidewall. This specific technique helps to increase the rate of R0 resection for rectal cancers involving the piriformis muscle, sciatic nerve, or the tumours extending via the sciatic notch. R0 resection specifies a microscopically margin-negative resection, where there is neither microscopic nor gross tumour residue leftover in the primary tumour bed.
Indications for Extended Lateral Pelvic Sidewall Excision (ELSiE)
The main indication for extended lateral pelvic sidewall excision (ELSiE) is advanced or recurrent anorectal cancer particularly involving the pelvic sidewalls, sciatic nerves, or extending through the sciatic notch.
Preparation for Extended Lateral Pelvic Sidewall Excision (ELSiE)
Pre-procedure preparation for extended lateral pelvic sidewall excision (ELSiE) will involve the following steps:
- A thorough examination by your doctor is performed to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
- You will be asked if you have allergies to medications, anaesthesia, or latex.
- You should inform your doctor of any medications, vitamins, or supplements that you are taking.
- You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
- You should refrain from alcohol or tobacco at least a few days prior to surgery.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You will be placed on a special diet prior to surgery and laxatives may be used to clean out your bowel.
- You may be instructed to shower with an antibacterial soap the night prior to surgery to help lower your risk of infection after surgery.
- Arrange for someone to drive you home as you will not be able to drive yourself after surgery.
- A written consent will be obtained from you after the surgical procedure has been explained in detail.
Procedure for Extended Lateral Pelvic Sidewall Excision (ELSiE)
The novel ELSiE surgery is usually performed under general anaesthesia and involves 2 phases; making an incision in a prone position and completing the excision in a supine position. The procedure begins with the patient in a prone position and making a surgical cut along the lateral pelvic region to dissect the piriformis muscle and excise the ischial spine and then excise or isolate the sciatic nerve as needed. This approach provides excellent visibility of the sacrospinous ligaments, outer pelvic sidewall, and sciatic notch along with superior control of vessels throughout the piriformis muscle and sciatic notch. A subsequent incision is made along the abdominal approach to dissect the pelvic sidewall and carry out thorough excision of anorectal tumours that have spread to the pelvic sidewall. Utmost care is taken to prevent any damage to surrounding soft tissue structures during the operation. At the end of the procedure, incisions are closed with absorbable sutures and sterile dressings are applied.
Postoperative Care and Recovery
In general, postoperative care instructions and recovery after extended lateral pelvic sidewall excision (ELSiE) will involve the following steps:
- You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anaesthetic reactions to the medications and anaesthesia used. Your nurse will also monitor your blood oxygen level and other vital signs as you recover.
- You will likely require at least 3 to 4 days of hospital stay after surgery.
- You may experience pain, inflammation, and discomfort in the operated area. Pain and anti-inflammatory medications are provided as needed.
- Medications may also be prescribed as needed for symptoms associated with anaesthesia, such as vomiting and nausea.
- Walking and moving around in bed is strongly encouraged as it lowers the risk of blood clots and pneumonia. It also helps to stimulate your bowels and assist with passing gas.
- Antibiotics are prescribed to address the risk of surgery-related infection.
- Your diet is slowly advanced post surgery. You will start with clear liquids, then progress to having normal solid foods, as tolerated.
- It is important to keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
- Refrain from smoking for a specific period of time as it can negatively affect the healing process.
- Refrain from strenuous activities and lifting anything heavier than 10 pounds for the first couple of months. Gradual increase in activities over a period of time is recommended.
- Eating a healthy low fat and high-fibre diet is strongly recommended to promote healing and a faster recovery as well as drinking 8 to 10 glasses of water daily to prevent constipation. Laxatives or stool softeners may also be recommended as needed.
- Most patients will need to take off work at least a month to rest and promote healing. Walking is a good exercise and is strongly recommended to improve your endurance.
- Refrain from driving until you are fully fit and receive your doctor’s consent, usually about 2 to 4 weeks.
- You will be able to resume your normal activities within a couple of weeks but may have certain activity restrictions.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
Extended lateral pelvic sidewall excision (ELSiE) is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:
- Hematoma (accumulation of blood in the wound)
- Seroma (accumulation of clear fluid in the wound)
- Damage to surrounding soft tissue structures, such as nerves, vessels, and organs
- Post-procedure pain, requiring narcotics for relief
- Blood clots
- Anaesthetic/allergic reactions