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Curative treatment of most primary tumors of the sacrum requires an oncologic sacral resection. This surgery is typically resource-intensive, involving multiple specialties to manage resections of nerves, bones, and visceral structures. The operating time may extend to 20 hours for the most involved cases, which may include occasionally disconnecting the spine from the pelvis on one or both sides, then reconstructing the defects.
Few centers perform these demanding surgeries. But because Mayo Clinic's multidisciplinary model is designed to manage surgical complexity, Mayo averages approximately 20 sacral resections per year and continually seeks opportunities to improve techniques, safety, and outcomes.
"Considerable resources have to come together to make sacral resection happen safely and successfully. We are fortunate to have both the multidisciplinary depth and the ease of interaction at Mayo to make us one of the few centers in the United States to regularly undertake some of the largest resections,'' says orthopedic surgeon Peter S. Rose, M.D.
"The majority of Mayo's sacral resection patients regain a semblance of normal daily living after surgery," Dr. Rose says. One resumed water skiing despite the loss of a leg; another participated in a high school wrestling match.
Adds his orthopedics colleague Franklin H. Sim, M.D.: "Because all our specialists are on site and practice is integrated, Mayo can field large teams and do it quickly — from mobilizing spine and sacral specialists, to multiple related surgical specialties, to anesthesiologists who help patients tolerate long and multiple procedures, to the medical and radiation oncologists, pathologists, and radiologists who help establish the diagnosis, prepare patients for surgery, and plan the operations. Our rehabilitation specialists help patients regain their functional independence as they recover from the procedures."
The Mayo team focuses on the following areas of advancing the science of improving sacral resections:
Mayo's large volume of procedures enabled development of a classification scheme for sacral resections. This scheme is based on staging and reconstruction protocols used in 43 resections performed at Mayo in recent years:
Type I resection total sacrectomy without lumbar excision and bilateral medial iliac excision
Type II resection hemisacrectomy with medial iliac resection
Type III hemisacrectomy with external hemipelvectomy
Type IV total sacrectomy with external hemi-pelvectomy
The team looks at potential for improved outcomes and efficiency through the timing of mobilizing various surgical teams such as colorectal, neurologic, and plastic surgeons. Previously, these surgical procedures were performed in a single session.
Recently, the Mayo team began staging the resections into shorter surgical sessions as opposed to a single marathon surgery. "This approach tends to be safer for patients and reduces complications and costs because patients spend less time in intensive care," Dr. Rose says.
In the biomechanics laboratory and through cadaveric studies, Michael J. Yaszemski, M.D., Ph.D., has helped direct biomechanical studies to research better ways to restore or reconstruct stable anatomy after large, challenging resections that result in severe loss of structure.
Although sacral cancers are among the most challenging and pose a high risk of morbidity and mortality from many potential causes, Dr. Rose sees encouraging progress from Mayo's teamwork. "By systematically targeting and addressing each area, we believe we can positively impact overall outcomes," he says.
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