Management of enteroperineal fistulas following pelvic exenteration: Insights from a high-volume referral centre

Aim

Total pelvic exenteration (TPE) has emerged as the standard treatment for advanced anorectal, genitourinary and soft-tissue pelvic tumours. Long-term complications, particularly empty pelvis syndrome (EPS) leading to enteroperineal fistula (EPF), remain inadequately addressed. The surgical management of EPF poses significant challenges, with limited published data and no official guidelines. This study aimed to investigate the incidence and outcomes of EPFs after TPE and to describe the management of reoperative surgery in this patient cohort.

Method

Patients who underwent TPE at Royal Prince Alfred Hospital, Sydney, Australia, between 2009 and 2024 were identified. Clinical data from a prospectively maintained database on reoperative surgery for EPFs were obtained. Patients were excluded if reoperative surgery was clearly unrelated to previous exenteration. Comparisons were then made between the two strategies used for surgical management of EPFs, namely small bowel resection with anastomosis and intestinal bypass with distal limbs exclusion.

Results

Among 491 patients who underwent TPE, 22 (4.5%) developed an EPF requiring reoperative procedures. The 30-day major complication rate was 18.2%. Postoperative complications were prevalent (95.2%) across both groups. The median time to EPF surgery post-TPE was 21.7 months. Notably, intensive care unit (ICU) admission was 2 days shorter and length of stay was 14 days shorter in the bypass group than in the small bowel resection with anastomosis group, although both differences were not statistically significant.

Conclusion

Strategies for preventing EPFs remain elusive; however, surgical management is feasible with acceptable short-term outcomes. The optimal strategy should be tailored to individual patient characteristics.