Axillo-Femoral Bypass Followed by Pelvic Exenteration for Locally Advanced Sigmoid Colon Cancer Invading the Common...

Initially, unresectable locally advanced colorectal cancers are still not uncommon. Despite recently developed systemic treatment has extended the survival of patients with unresectable and recurrent disease, surgical resection offers the chance for a cure or long-term survival. Recently, with improvement in the safety of major vascular reconstruction, several reports have suggested that extended pelvic tumor resection with vascular reconstruction with curative intent can be performed safely; however, the indications for arterial vascular reconstruction remain controversial and are reported with a literature review.

A 73-year-old male patient whose fever was greater than 40° was admitted to the emergency department of our hospital. Computed tomography (CT) revealed a large mass on the left side of the aortic bifurcation, and a diagnosis of unresectable sigmoid colon cancer was made (cT4bN1M0). The tumor had substantially invaded the iliopsoas muscle and intramuscular abscess, left hydronephrosis due to left ureteral invasion, invasion of the left common and external iliac artery, and congestive edema of the left leg were observed. Transverse colostomy and left nephrostomy were created and percutaneous drainage of the iliopsoas abscess was performed. Four cycles of FOLFOX + bevacizumab were administered after the systemic infection had resolved. The tumor volume decreased, and no new lesions were observed. The patient underwent left axillo-femoral bypass followed by total pelvic exenteration, combined left common and external iliac artery resection, and right ureterocutaneostomy. His postoperative course was uneventful. Pathology revealed ypT4b (bladder) N0M0, ypStage II disease. The patient was followed without adjuvant chemotherapy and had no recurrence as of 10 months after surgery.

We experienced a case of total pelvic exenteration combined with the common and external iliac artery and reconstruction via axillo-femoral bypass. When treating complicated cases that cannot be cured by a single operation, it is necessary to carefully consider the optimal pathway for radical resection and to be very familiar with perioperative treatment and reconstructive methods.