EP120 - En Bloc External Iliac Vessel Resection And Reconstruction In Cytoreductive Surgical Procedures At The Philippine General Hospital

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Purpose/Background: Advanced tumors affecting the lateral pelvic compartment are challenging to treat. Traditionally, involvement of major iliac vessels ruled out attempts at curative surgery. However, recent advances in cytoreductive surgery have shown that en bloc resection and reconstruction of these vessels is feasible in carefully-selected patients. This study aimed to explore the pathological and surgical outcomes of these procedures at a tertiary referral center in the Philippines.

Methods/Interventions: A review of our operative database over the last six years was conducted. The study included all patients who underwent an en bloc resection and reconstruction of the external iliac vessels from January 2019 to September 2024. Data collected included: patient demographics, diagnosis, and pathological and surgical outcomes.

Results/Outcomes: From January 2019 to September 2024, six abdominopelvic surgeries with en bloc resection and reconstruction of the external iliac vessels were performed at PGH. The mean age of the patients was 58 years (43-79 years). Majority were females (M:F ratio 1:5), had known malignancies and were being treated for tumor recurrence or progression.

In most cases, both artery and vein were involved. The interposition grafts used were polytetrafluoroethylene (PTFE) and polyester (Dacron), depending on size matching of native vessel and available graft. The average postoperative length of stay (LOS) was 12.3 days (6-26 days). There were no perioperative deaths or limb losses, but half required reintervention. Two patients underwent re-exploration and graft revision for acute graft thrombosis on the first postoperative day, while one patient needed graft explantation and peripheral bypass due to infection a year later. Although half had an R1 resection, all vascular margins were negative for tumor.

Conclusion/Discussion: Among our cases, vascular involvement typically affected both arteries and veins. When the iliacs are involved, surgery often required removing both due to their close proximity. The most ideal conduit for reconstruction is still unclear, but prosthetic grafts are often preferred over autogenous grafts due to their ease of use and for having fewer complications, especially for patients needing postoperative radiotherapy.

Graft thrombosis and infections have been previously documented. Prosthetic graft infections can occur at implantation due to contamination by the surgical team or colonization by microorganisms. Preventive measures include proper skin preparation, limiting preoperative stays and operating times, and using antimicrobial prophylaxis close to incision time and reloading during lengthy procedures. Furthermore, vascular reconstruction alongside digestive surgeries has higher infection risk. One way to mitigate this is by separating the surgical fields of vascular resection and reconstruction (i.e. intraperitoneal and inguinal) by performing a femoral-femoral bypass before or during the initial surgery. Cancer, a prothrombotic state, puts patients at risk for graft thrombosis. For cancer surgeries with vascular reconstruction, routine postoperative anticoagulation with low molecular weight heparin (LMWH) is recommended unless contraindicated.

At present, vascular invasion should not be a limitation to performing curative surgery. Advanced surgical techniques and dedicated vascular teams make oncologic resection for advanced tumors with vascular involvement feasible, offering outcomes similar to disease that is free of vascular involvement.