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Curative treatment of most primary tumors of the sacrum requires an oncologic sacral resection. This is typically a resource-intensive operation because the surgery involves multiple specialties to manage resections of nerves, bones and visceral structures. The operating time may extend to 20 hours for the most involved cases, including occasionally disconnecting the spine from the pelvis on one or both sides and reconstructing the defects.
Few centers perform these demanding surgeries. But because Mayo Clinic's multidisciplinary model is designed to manage surgical complexity, Mayo Clinic in Rochester, Minn., averages approximately 20 sacral resections a 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 U.S. to regularly undertake some of the largest resections," says Peter S. Rose, M.D.
"The majority of Mayo's sacral resection patients regain a semblance of normal daily living after surgery," Dr. Rose adds. One patient resumed water skiing, despite the loss of a leg, and another participated in a high school wrestling match.
Adds his colleague orthopedic surgeon Franklin H. Sim, M.D.: "Because all of our specialists are on-site and practice is integrated, Mayo can field large teams and do it quickly. This involves a tremendous mobilization of expertise, from spine and sacral specialists, to multiple related surgical specialists, to anesthesiologists with expertise in helping patients tolerate long and multiple procedures."
"Then there are the medical and radiation oncologists, pathologists, and radiologists who help to establish the diagnosis, prepare patients for surgery and plan the operations," notes Dr. Sim. "Following the procedure, our rehabilitation specialists help patients regain their functional independence as they recover."
The Mayo team focuses on the following areas of advancing the science of improving sacral resections:
The large volume of procedures Mayo's surgeons handle has enabled them to develop a classification scheme of sacral resections. This scheme is based on staging and reconstruction protocols used in 43 of the largest resections performed at Mayo in recent years.
Type I resection total sacrectomy
Type II resection hemisacrectomy with medial iliac resection
Type III resection hemisacrectomy with external hemipelvectomy
Type IV resection total sacrectomy with external hemipelvectomy
The Mayo team looks at the 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.
The Mayo team began staging the resections by breaking each 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 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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