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.

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.

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 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.