新的国家专家网络(日本盆腔切除网络:J-PEN)成立,旨在改善日本盆腔切除的结果

IF 3.3 4区 医学 Q2 GASTROENTEROLOGY & HEPATOLOGY
Hideaki Yano, Alex Mirnezami, Masataka Ikeda, Kay Uehara, Shuichiro Matoba, Yuichiro Tsukada, Toshiki Mukai, Kei Kimura, Yudai Fukui, Naoyuki Toyota
{"title":"新的国家专家网络(日本盆腔切除网络:J-PEN)成立,旨在改善日本盆腔切除的结果","authors":"Hideaki Yano,&nbsp;Alex Mirnezami,&nbsp;Masataka Ikeda,&nbsp;Kay Uehara,&nbsp;Shuichiro Matoba,&nbsp;Yuichiro Tsukada,&nbsp;Toshiki Mukai,&nbsp;Kei Kimura,&nbsp;Yudai Fukui,&nbsp;Naoyuki Toyota","doi":"10.1002/ags3.70050","DOIUrl":null,"url":null,"abstract":"<p>Pelvic exenteration (PE) is a radical and extreme surgical procedure for <i>en bloc</i> removal of pelvic organs and tissues contiguously involved by cancer. PE has long been the mainstay, and often the only option to potentially provide cure, or long term control, in the management of patients with locally advanced and recurrent abdomino-pelvic malignancies. The concept focusses on attaining an R0 cancer resection margin (most commonly defined as ≥ 1 mm), by surgically removing margin-involved or margin-threatened organs and structures, as this is consistently demonstrated as the most important predictor of outcome [<span>1</span>]. Naturally, however, such radicality comes with significant risks of complications; of loss of function and quality of life; as well as substantial healthcare resource utilisation and health economic impact. Consequently, the deployment of PE as a surgical solution has in the past been correctly cautious, but at times also overly pessimistic, informed by historically poor outcomes.</p><p>In more recent times, the PE landscape has undergone a paradigm shift. Incremental developments in multiple disciplines have helped pave the way for substantially improved outcomes in carefully selected patients. These include but are not limited to advances in diagnostic radiology; oncology; anaesthesia and peri-operative medicine; intensive care; surgical devices and techniques; understanding of the pelvic anatomy; management and control of haemorrhage; reconstructive options; and interventional radiology [<span>2</span>]. As a result, the field of PE has evolved, with broadening indications and applications, and greater radicality, manifested by the fact that pelvic bones are increasingly resected as one of the most outermost tissues in a margin of concern, and reflecting the “higher and wider” approaches achievable [<span>3</span>].</p><p>The increasing application of PE has also emphasised some of the glaring unmet needs in the field. Examples of these are highlighted below but are not exhaustive. A lack of standardisation and differing protocols in MRI imaging techniques is one such unmet need. Poorly designed multidisciplinary team (MDT) models for the discussion of some of the most complex and heavily pre-treated patients an MDT may receive is another such unmet need. A further concern has been in the use of surgical terminology. Contemporary PE represents an umbrella term that in the modern era encompasses a diversity of resections, and to date a confusing array of terminology has been used to describe the different surgical interventions possible. Pathological handling of specimens, for example the method of specimen orientation and marking, the number of sections taken, and management of specimens with bone, is a further area of unmet need requiring a standardisation of reporting and minimum pathological datasets. Nevertheless to date no formal international system has been described. Importantly, as a result of the lack of such radiological, surgical and pathological standardisation and definitions and quality assurance, high quality research into the field of PE has stalled, hindering innovation and further advancement of the field. A further unmet need has been the lack of a suitable forum for medical specialties that are commonly involved in PE such as urological, vascular, orthopaedic, and plastic surgery; anaesthetists; nurse specialists; and oncologists. Such a forum would promote communication, exchange of ideas and dissemination of best practice, and again serve to advance the field. Finally, a further unmet need has been a lack of opportunity to teach and train the next generation in the field.</p><p>In order to overcome these universal challenges, collaboration at national and international level is essential. To assist with this, several networks have been set up, most notably the International PelvEx Collaborative Group, and the UK-wide PE network, UKPEN. The PelvEx Collaborative Group, which is the only global network for PE, has been holding face-to-face meetings annually since 2018 and contributing numerous publications to the literature [<span>4</span>]. UKPEN, since forming in 2019, has been implementing active initiatives to meet the aforementioned unmet needs through both online and face-to-face meetings. One such example of their contribution represents the now validated PE Lexicon, helping to create a common surgical language for complex pelvic cancer surgery [<span>2, 5</span>].</p><p>From a Japanese point of view, it is important to note that there are a number of challenges specific to Japan, beginning with terminology. Significantly, an exact equivalent in Japanese for the term “pelvic exenteration” does not exist. Kotsuban naizou zenteki (骨盤内臓全摘) is generally used but is not totally interchangeable in usage or definition with the English. There is also an absence of equivalents to key terms such as “beyond-TME” or “extra-anatomical resection”. Importantly, the 1 mm rule for resection margin status is also not widely accepted or endorsed by the Japanese surgical oncology community.</p><p>The treatment context for PE in Japan also differs from other countries. Historically, pelvic sidewall lymphadenectomy or dissection has been widely performed even in prophylactic settings and preoperative radiotherapy has been used more sparingly than western countries. Carbon ion radiotherapy is an increasingly applied modality to treat locally recurrent rectal cancer in Japan, and evidence for its utility is accumulating, however it is still unclear how this unique modality should be considered in the context of PE surgery. Furthermore, biological meshes, which are often used to reconstruct the defects from PE, are not currently available in Japan. Interestingly, adjunctive intraoperative treatments for advanced cancers such as intraoperative electron beam radiotherapy (IOERT) and hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) are rarely used in Japan in the context of PE, despite having been spearheaded by Japanese clinicians and researchers in the 1960s and 1970s. Taken together, these factors have made it challenging for Japanese exenterative surgeons to communicate and exchange knowledge and experience effectively with each other and international colleagues.</p><p>Against this backdrop of a globally evolving landscape and national and international unmet needs, Japanese exenterative experts gathered at PelvEx 2024 in London and, inspired by UKPEN, formed J-PEN (Japan Pelvic Exenteration Network). The aim is to develop and formalise a network and structure in Japan that works for patients, multidisciplinary team specialists, and for all allied specialties and that can help develop national standards and quality assurance across specialties and facilitate high quality research. J-PEN have now been holding monthly online meetings and have held case conferences in English inviting international experts at times. J-PEN can also be instrumental in providing a platform for the next generation of Japanese surgeons to engage in discussions in English. J-PEN's first face-to-face meeting is due in Tokyo in June 2025.</p><p>In conclusion, the surgical management of locally advanced and recurrent abdominopelvic cancers has undergone a paradigm shift, evolving from nihilism to cautious optimism. Radical exenterative surgery is increasingly suitable for carefully selected and very carefully counselled patients. PE is a resource intensive modality but can lead to excellent survival and good quality of life if R0 is achieved. At present several important unmet needs exist nationally and internationally, and J-PEN hopes to tackle these through a network of centres and individuals across Japan. It takes a team to perform an exenteration, and it will take a team of units to be able to meet these unmet needs. J-PEN is about collaboration and cooperation, not competition, to help achieve goals no individual unit or specialty can single-handedly achieve. PE in the modern era in Japan and indeed internationally represents high-stakes, ultra-high risk surgery with a dearth of high quality evidence, no clear Japanese standards, guidelines, or funding envelope, and in a period of increasing management scrutiny—this status quo cannot continue.</p><p>We believe that J-PEN can provide a unique platform for Japanese exenterative surgeons to share and enhance their understanding and experience of PE, and facilitate tackling the unmet needs in the field through national and international dialogue and collaboration.</p><p><b>Hideaki Yano:</b> conceptualisation (equal); writing – original draft (equal); project administration (equal); writing – review and editing (equal). <b>Alex Mirnezami:</b> conceptualisation (equal); writing – original draft (equal); writing – review and editing (equal). <b>Masataka Ikeda:</b> project administration (equal); writing – review and editing (supporting). <b>Kay Uehara:</b> project administration (equal); writing – review and editing (supporting). <b>Shuichiro Matoba:</b> project administration (equal); writing – review and editing (supporting). <b>Yuichiro Tsukada:</b> project administration (equal); writing – review and editing (supporting). <b>Toshiki Mukai:</b> project administration (equal); writing – review and editing (supporting). <b>Kei Kimura:</b> project administration (equal); writing – review and editing (supporting). <b>Yudai Fukui:</b> project administration (equal); writing – review and editing (supporting). <b>Naoyuki Toyota:</b> project administration (equal); writing – review and editing (supporting).</p><p>The authors have nothing to report.</p><p>The authors have nothing to report.</p><p>Kay Uehara is an editorial board member of Annals of Gastroenterological Surgery. The authors declare no conflicts of interest.</p>","PeriodicalId":8030,"journal":{"name":"Annals of Gastroenterological Surgery","volume":"9 5","pages":"880-882"},"PeriodicalIF":3.3000,"publicationDate":"2025-06-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/ags3.70050","citationCount":"0","resultStr":"{\"title\":\"New National Network of Experts (Japan Pelvic Exenteration Network: J-PEN) Formed in a Bid to Improve Outcomes of Pelvic Exenteration in Japan\",\"authors\":\"Hideaki Yano,&nbsp;Alex Mirnezami,&nbsp;Masataka Ikeda,&nbsp;Kay Uehara,&nbsp;Shuichiro Matoba,&nbsp;Yuichiro Tsukada,&nbsp;Toshiki Mukai,&nbsp;Kei Kimura,&nbsp;Yudai Fukui,&nbsp;Naoyuki Toyota\",\"doi\":\"10.1002/ags3.70050\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p>Pelvic exenteration (PE) is a radical and extreme surgical procedure for <i>en bloc</i> removal of pelvic organs and tissues contiguously involved by cancer. PE has long been the mainstay, and often the only option to potentially provide cure, or long term control, in the management of patients with locally advanced and recurrent abdomino-pelvic malignancies. The concept focusses on attaining an R0 cancer resection margin (most commonly defined as ≥ 1 mm), by surgically removing margin-involved or margin-threatened organs and structures, as this is consistently demonstrated as the most important predictor of outcome [<span>1</span>]. Naturally, however, such radicality comes with significant risks of complications; of loss of function and quality of life; as well as substantial healthcare resource utilisation and health economic impact. Consequently, the deployment of PE as a surgical solution has in the past been correctly cautious, but at times also overly pessimistic, informed by historically poor outcomes.</p><p>In more recent times, the PE landscape has undergone a paradigm shift. Incremental developments in multiple disciplines have helped pave the way for substantially improved outcomes in carefully selected patients. These include but are not limited to advances in diagnostic radiology; oncology; anaesthesia and peri-operative medicine; intensive care; surgical devices and techniques; understanding of the pelvic anatomy; management and control of haemorrhage; reconstructive options; and interventional radiology [<span>2</span>]. As a result, the field of PE has evolved, with broadening indications and applications, and greater radicality, manifested by the fact that pelvic bones are increasingly resected as one of the most outermost tissues in a margin of concern, and reflecting the “higher and wider” approaches achievable [<span>3</span>].</p><p>The increasing application of PE has also emphasised some of the glaring unmet needs in the field. Examples of these are highlighted below but are not exhaustive. A lack of standardisation and differing protocols in MRI imaging techniques is one such unmet need. Poorly designed multidisciplinary team (MDT) models for the discussion of some of the most complex and heavily pre-treated patients an MDT may receive is another such unmet need. A further concern has been in the use of surgical terminology. Contemporary PE represents an umbrella term that in the modern era encompasses a diversity of resections, and to date a confusing array of terminology has been used to describe the different surgical interventions possible. Pathological handling of specimens, for example the method of specimen orientation and marking, the number of sections taken, and management of specimens with bone, is a further area of unmet need requiring a standardisation of reporting and minimum pathological datasets. Nevertheless to date no formal international system has been described. Importantly, as a result of the lack of such radiological, surgical and pathological standardisation and definitions and quality assurance, high quality research into the field of PE has stalled, hindering innovation and further advancement of the field. A further unmet need has been the lack of a suitable forum for medical specialties that are commonly involved in PE such as urological, vascular, orthopaedic, and plastic surgery; anaesthetists; nurse specialists; and oncologists. Such a forum would promote communication, exchange of ideas and dissemination of best practice, and again serve to advance the field. Finally, a further unmet need has been a lack of opportunity to teach and train the next generation in the field.</p><p>In order to overcome these universal challenges, collaboration at national and international level is essential. To assist with this, several networks have been set up, most notably the International PelvEx Collaborative Group, and the UK-wide PE network, UKPEN. The PelvEx Collaborative Group, which is the only global network for PE, has been holding face-to-face meetings annually since 2018 and contributing numerous publications to the literature [<span>4</span>]. UKPEN, since forming in 2019, has been implementing active initiatives to meet the aforementioned unmet needs through both online and face-to-face meetings. One such example of their contribution represents the now validated PE Lexicon, helping to create a common surgical language for complex pelvic cancer surgery [<span>2, 5</span>].</p><p>From a Japanese point of view, it is important to note that there are a number of challenges specific to Japan, beginning with terminology. Significantly, an exact equivalent in Japanese for the term “pelvic exenteration” does not exist. Kotsuban naizou zenteki (骨盤内臓全摘) is generally used but is not totally interchangeable in usage or definition with the English. There is also an absence of equivalents to key terms such as “beyond-TME” or “extra-anatomical resection”. Importantly, the 1 mm rule for resection margin status is also not widely accepted or endorsed by the Japanese surgical oncology community.</p><p>The treatment context for PE in Japan also differs from other countries. Historically, pelvic sidewall lymphadenectomy or dissection has been widely performed even in prophylactic settings and preoperative radiotherapy has been used more sparingly than western countries. Carbon ion radiotherapy is an increasingly applied modality to treat locally recurrent rectal cancer in Japan, and evidence for its utility is accumulating, however it is still unclear how this unique modality should be considered in the context of PE surgery. Furthermore, biological meshes, which are often used to reconstruct the defects from PE, are not currently available in Japan. Interestingly, adjunctive intraoperative treatments for advanced cancers such as intraoperative electron beam radiotherapy (IOERT) and hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) are rarely used in Japan in the context of PE, despite having been spearheaded by Japanese clinicians and researchers in the 1960s and 1970s. Taken together, these factors have made it challenging for Japanese exenterative surgeons to communicate and exchange knowledge and experience effectively with each other and international colleagues.</p><p>Against this backdrop of a globally evolving landscape and national and international unmet needs, Japanese exenterative experts gathered at PelvEx 2024 in London and, inspired by UKPEN, formed J-PEN (Japan Pelvic Exenteration Network). The aim is to develop and formalise a network and structure in Japan that works for patients, multidisciplinary team specialists, and for all allied specialties and that can help develop national standards and quality assurance across specialties and facilitate high quality research. J-PEN have now been holding monthly online meetings and have held case conferences in English inviting international experts at times. J-PEN can also be instrumental in providing a platform for the next generation of Japanese surgeons to engage in discussions in English. J-PEN's first face-to-face meeting is due in Tokyo in June 2025.</p><p>In conclusion, the surgical management of locally advanced and recurrent abdominopelvic cancers has undergone a paradigm shift, evolving from nihilism to cautious optimism. Radical exenterative surgery is increasingly suitable for carefully selected and very carefully counselled patients. PE is a resource intensive modality but can lead to excellent survival and good quality of life if R0 is achieved. At present several important unmet needs exist nationally and internationally, and J-PEN hopes to tackle these through a network of centres and individuals across Japan. It takes a team to perform an exenteration, and it will take a team of units to be able to meet these unmet needs. J-PEN is about collaboration and cooperation, not competition, to help achieve goals no individual unit or specialty can single-handedly achieve. PE in the modern era in Japan and indeed internationally represents high-stakes, ultra-high risk surgery with a dearth of high quality evidence, no clear Japanese standards, guidelines, or funding envelope, and in a period of increasing management scrutiny—this status quo cannot continue.</p><p>We believe that J-PEN can provide a unique platform for Japanese exenterative surgeons to share and enhance their understanding and experience of PE, and facilitate tackling the unmet needs in the field through national and international dialogue and collaboration.</p><p><b>Hideaki Yano:</b> conceptualisation (equal); writing – original draft (equal); project administration (equal); writing – review and editing (equal). <b>Alex Mirnezami:</b> conceptualisation (equal); writing – original draft (equal); writing – review and editing (equal). <b>Masataka Ikeda:</b> project administration (equal); writing – review and editing (supporting). <b>Kay Uehara:</b> project administration (equal); writing – review and editing (supporting). <b>Shuichiro Matoba:</b> project administration (equal); writing – review and editing (supporting). <b>Yuichiro Tsukada:</b> project administration (equal); writing – review and editing (supporting). <b>Toshiki Mukai:</b> project administration (equal); writing – review and editing (supporting). <b>Kei Kimura:</b> project administration (equal); writing – review and editing (supporting). <b>Yudai Fukui:</b> project administration (equal); writing – review and editing (supporting). <b>Naoyuki Toyota:</b> project administration (equal); writing – review and editing (supporting).</p><p>The authors have nothing to report.</p><p>The authors have nothing to report.</p><p>Kay Uehara is an editorial board member of Annals of Gastroenterological Surgery. 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摘要

盆腔切除术(PE)是一种根治性和极端的外科手术,用于整体切除盆腔器官和连续受累的癌症组织。长期以来,PE一直是治疗局部晚期和复发性腹部-盆腔恶性肿瘤的主要方法,而且往往是唯一可能提供治愈或长期控制的选择。该概念的重点是通过手术切除边缘受损伤或边缘受威胁的器官和结构来获得R0肿瘤切除边缘(最常见的定义为≥1mm),因为这一直被证明是预后[1]最重要的预测因素。然而,这种激进性自然伴随着并发症的重大风险;丧失功能和生活质量;以及大量的医疗资源利用和卫生经济影响。因此,在过去,PE作为手术解决方案的部署是正确的谨慎,但有时也过于悲观,因为历史上预后不佳。近年来,私募股权领域经历了范式转变。多学科的渐进式发展为精心挑选的患者的显著改善结果铺平了道路。这些包括但不限于诊断放射学的进步;肿瘤;麻醉与围手术期医学;重症监护;手术器械和技术;了解骨盆解剖;出血的管理和控制;重建选项;介入放射学b[2]。因此,PE领域已经发展,适应症和应用范围越来越广,更激进,骨盆骨作为最外层的组织之一被越来越多地切除,反映了“更高更广”的方法可以实现[10]。越来越多的PE应用也强调了该领域一些明显的未满足需求。下面列出了这些例子,但并不详尽。MRI成像技术缺乏标准化和不同的协议是这样一个未满足的需求。设计不良的多学科团队(MDT)模型,用于讨论MDT可能接受的一些最复杂和大量预处理的患者,这是另一个未满足的需求。另一个值得关注的问题是外科术语的使用。当代PE代表了一个总括性的术语,在现代包含了各种各样的切除,迄今为止,人们已经使用了一系列令人困惑的术语来描述可能的不同手术干预。标本的病理处理,例如标本定位和标记的方法、所取切片的数量以及带骨标本的管理,是需要标准化报告和最小病理数据集的另一个未满足需求的领域。然而,迄今为止还没有正式的国际制度。重要的是,由于缺乏这样的放射学、外科和病理学的标准化和定义以及质量保证,高质量的研究在PE领域停滞不前,阻碍了该领域的创新和进一步发展。另一个未满足的需求是缺乏一个合适的论坛来讨论通常涉及PE的医学专业,如泌尿外科、血管外科、骨科和整形外科;麻醉师;护士专家;和肿瘤学家。这样一个论坛将促进交流、思想交流和传播最佳做法,并再次有助于推动这一领域的发展。最后,另一个未得到满足的需求是缺乏在实地教育和培训下一代的机会。为了克服这些普遍挑战,国家和国际一级的合作至关重要。为了协助实现这一目标,已经建立了几个网络,其中最著名的是国际PelvEx协作组和英国范围内的PE网络UKPEN。PelvEx协作组是唯一的全球PE网络,自2018年以来每年举行面对面会议,并为文献论坛贡献了大量出版物。自2019年成立以来,英国笔会一直在通过在线和面对面会议实施积极举措,以满足上述未满足的需求。他们贡献的一个例子就是现在被验证的PE词典,它有助于为复杂的盆腔癌手术创造一种通用的外科语言[2,5]。从日本的角度来看,重要的是要注意日本特有的许多挑战,首先是术语。值得注意的是,日语中不存在与“盆腔切除”一词完全对应的词。通常使用“Kotsuban naizou zenteki”,但在用法或定义上与英语并不完全可互换。此外,也没有类似于“tme以外”或“解剖外切除”等关键术语的对应词。 重要的是,1毫米的切除切缘规则也没有被日本外科肿瘤学界广泛接受或认可。日本PE的治疗背景也与其他国家不同。从历史上看,盆腔侧壁淋巴结切除术或夹层已广泛实施,甚至在预防设置和术前放疗的使用比西方国家更少。在日本,碳离子放疗越来越多地应用于治疗局部复发性直肠癌,其实用性的证据也在不断积累,但目前尚不清楚在PE手术的背景下如何考虑这种独特的方式。此外,通常用于PE缺损重建的生物网格目前在日本还不可用。有趣的是,尽管日本的临床医生和研究人员在20世纪60年代和70年代率先提出了术中电子束放疗(IOERT)和术中腹腔热化疗(HIPEC)等晚期癌症的辅助术中治疗方法,但在日本的PE治疗中很少使用。综上所述,这些因素使得日本的口腔外科医生与彼此以及国际同行有效地沟通和交流知识和经验具有挑战性。在全球不断变化的环境和国内和国际未满足的需求的背景下,日本的盆腔切除专家聚集在伦敦的PelvEx 2024上,受UKPEN的启发,成立了J-PEN(日本盆腔切除网络)。其目的是在日本建立一个网络和结构,为患者、多学科团队专家和所有相关专业服务,并有助于制定跨专业的国家标准和质量保证,促进高质量的研究。日本笔会现在每月举行一次在线会议,并举行英语案例会议,有时邀请国际专家。J-PEN还可以为下一代日本外科医生提供一个用英语进行讨论的平台。日本笔会的首次面对面会议将于2025年6月在东京举行。总之,局部晚期和复发的腹部盆腔癌的手术治疗经历了范式转变,从虚无主义到谨慎乐观主义。根治性拔肠手术越来越适合于精心挑选和非常仔细咨询的患者。PE是一种资源密集型的方式,但如果达到R0,则可以导致良好的生存和良好的生活质量。目前国内和国际上存在几个重要的未满足需求,J-PEN希望通过日本各地的中心和个人网络来解决这些问题。它需要一个团队来执行清除,并且它将需要一个团队的单位来满足这些未满足的需求。J-PEN是关于协作与合作,而不是竞争,以帮助实现单个单位或专业无法单独实现的目标。现代PE在日本乃至国际上都是高风险、超高风险的手术,缺乏高质量的证据,没有明确的日本标准、指南或资金来源,而且在管理审查日益严格的时期,这种现状不能继续下去。我们相信,J-PEN可以为日本的口腔外科医生提供一个独特的平台,分享和加强他们对口腔外科的理解和经验,并通过国内和国际的对话和合作,促进解决该领域未满足的需求。矢野英明:概念化(平等);写作-原稿(同等);项目管理(同等);写作-审查和编辑(同等)。Alex Mirnezami:概念化(平等);写作-原稿(同等);写作-审查和编辑(同等)。池田正孝:项目管理(平等);写作-审查和编辑(辅助)。Kay Uehara:项目管理(同等);写作-审查和编辑(辅助)。Matoba修一郎:项目管理(同等);写作-审查和编辑(辅助)。津田雄一郎:项目管理(同等);写作-审查和编辑(辅助)。向井俊树:项目管理(同等);写作-审查和编辑(辅助)。木村庆:项目管理(同等);写作-审查和编辑(辅助)。Yudai Fukui:项目管理(同等);写作-审查和编辑(辅助)。丰田直行:项目管理(同等);写作-审查和编辑(辅助)。作者没有什么可报告的。作者没有什么可报告的。Kay Uehara是《胃肠外科年鉴》的编委会成员。作者声明无利益冲突。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
New National Network of Experts (Japan Pelvic Exenteration Network: J-PEN) Formed in a Bid to Improve Outcomes of Pelvic Exenteration in Japan

Pelvic exenteration (PE) is a radical and extreme surgical procedure for en bloc removal of pelvic organs and tissues contiguously involved by cancer. PE has long been the mainstay, and often the only option to potentially provide cure, or long term control, in the management of patients with locally advanced and recurrent abdomino-pelvic malignancies. The concept focusses on attaining an R0 cancer resection margin (most commonly defined as ≥ 1 mm), by surgically removing margin-involved or margin-threatened organs and structures, as this is consistently demonstrated as the most important predictor of outcome [1]. Naturally, however, such radicality comes with significant risks of complications; of loss of function and quality of life; as well as substantial healthcare resource utilisation and health economic impact. Consequently, the deployment of PE as a surgical solution has in the past been correctly cautious, but at times also overly pessimistic, informed by historically poor outcomes.

In more recent times, the PE landscape has undergone a paradigm shift. Incremental developments in multiple disciplines have helped pave the way for substantially improved outcomes in carefully selected patients. These include but are not limited to advances in diagnostic radiology; oncology; anaesthesia and peri-operative medicine; intensive care; surgical devices and techniques; understanding of the pelvic anatomy; management and control of haemorrhage; reconstructive options; and interventional radiology [2]. As a result, the field of PE has evolved, with broadening indications and applications, and greater radicality, manifested by the fact that pelvic bones are increasingly resected as one of the most outermost tissues in a margin of concern, and reflecting the “higher and wider” approaches achievable [3].

The increasing application of PE has also emphasised some of the glaring unmet needs in the field. Examples of these are highlighted below but are not exhaustive. A lack of standardisation and differing protocols in MRI imaging techniques is one such unmet need. Poorly designed multidisciplinary team (MDT) models for the discussion of some of the most complex and heavily pre-treated patients an MDT may receive is another such unmet need. A further concern has been in the use of surgical terminology. Contemporary PE represents an umbrella term that in the modern era encompasses a diversity of resections, and to date a confusing array of terminology has been used to describe the different surgical interventions possible. Pathological handling of specimens, for example the method of specimen orientation and marking, the number of sections taken, and management of specimens with bone, is a further area of unmet need requiring a standardisation of reporting and minimum pathological datasets. Nevertheless to date no formal international system has been described. Importantly, as a result of the lack of such radiological, surgical and pathological standardisation and definitions and quality assurance, high quality research into the field of PE has stalled, hindering innovation and further advancement of the field. A further unmet need has been the lack of a suitable forum for medical specialties that are commonly involved in PE such as urological, vascular, orthopaedic, and plastic surgery; anaesthetists; nurse specialists; and oncologists. Such a forum would promote communication, exchange of ideas and dissemination of best practice, and again serve to advance the field. Finally, a further unmet need has been a lack of opportunity to teach and train the next generation in the field.

In order to overcome these universal challenges, collaboration at national and international level is essential. To assist with this, several networks have been set up, most notably the International PelvEx Collaborative Group, and the UK-wide PE network, UKPEN. The PelvEx Collaborative Group, which is the only global network for PE, has been holding face-to-face meetings annually since 2018 and contributing numerous publications to the literature [4]. UKPEN, since forming in 2019, has been implementing active initiatives to meet the aforementioned unmet needs through both online and face-to-face meetings. One such example of their contribution represents the now validated PE Lexicon, helping to create a common surgical language for complex pelvic cancer surgery [2, 5].

From a Japanese point of view, it is important to note that there are a number of challenges specific to Japan, beginning with terminology. Significantly, an exact equivalent in Japanese for the term “pelvic exenteration” does not exist. Kotsuban naizou zenteki (骨盤内臓全摘) is generally used but is not totally interchangeable in usage or definition with the English. There is also an absence of equivalents to key terms such as “beyond-TME” or “extra-anatomical resection”. Importantly, the 1 mm rule for resection margin status is also not widely accepted or endorsed by the Japanese surgical oncology community.

The treatment context for PE in Japan also differs from other countries. Historically, pelvic sidewall lymphadenectomy or dissection has been widely performed even in prophylactic settings and preoperative radiotherapy has been used more sparingly than western countries. Carbon ion radiotherapy is an increasingly applied modality to treat locally recurrent rectal cancer in Japan, and evidence for its utility is accumulating, however it is still unclear how this unique modality should be considered in the context of PE surgery. Furthermore, biological meshes, which are often used to reconstruct the defects from PE, are not currently available in Japan. Interestingly, adjunctive intraoperative treatments for advanced cancers such as intraoperative electron beam radiotherapy (IOERT) and hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) are rarely used in Japan in the context of PE, despite having been spearheaded by Japanese clinicians and researchers in the 1960s and 1970s. Taken together, these factors have made it challenging for Japanese exenterative surgeons to communicate and exchange knowledge and experience effectively with each other and international colleagues.

Against this backdrop of a globally evolving landscape and national and international unmet needs, Japanese exenterative experts gathered at PelvEx 2024 in London and, inspired by UKPEN, formed J-PEN (Japan Pelvic Exenteration Network). The aim is to develop and formalise a network and structure in Japan that works for patients, multidisciplinary team specialists, and for all allied specialties and that can help develop national standards and quality assurance across specialties and facilitate high quality research. J-PEN have now been holding monthly online meetings and have held case conferences in English inviting international experts at times. J-PEN can also be instrumental in providing a platform for the next generation of Japanese surgeons to engage in discussions in English. J-PEN's first face-to-face meeting is due in Tokyo in June 2025.

In conclusion, the surgical management of locally advanced and recurrent abdominopelvic cancers has undergone a paradigm shift, evolving from nihilism to cautious optimism. Radical exenterative surgery is increasingly suitable for carefully selected and very carefully counselled patients. PE is a resource intensive modality but can lead to excellent survival and good quality of life if R0 is achieved. At present several important unmet needs exist nationally and internationally, and J-PEN hopes to tackle these through a network of centres and individuals across Japan. It takes a team to perform an exenteration, and it will take a team of units to be able to meet these unmet needs. J-PEN is about collaboration and cooperation, not competition, to help achieve goals no individual unit or specialty can single-handedly achieve. PE in the modern era in Japan and indeed internationally represents high-stakes, ultra-high risk surgery with a dearth of high quality evidence, no clear Japanese standards, guidelines, or funding envelope, and in a period of increasing management scrutiny—this status quo cannot continue.

We believe that J-PEN can provide a unique platform for Japanese exenterative surgeons to share and enhance their understanding and experience of PE, and facilitate tackling the unmet needs in the field through national and international dialogue and collaboration.

Hideaki Yano: conceptualisation (equal); writing – original draft (equal); project administration (equal); writing – review and editing (equal). Alex Mirnezami: conceptualisation (equal); writing – original draft (equal); writing – review and editing (equal). Masataka Ikeda: project administration (equal); writing – review and editing (supporting). Kay Uehara: project administration (equal); writing – review and editing (supporting). Shuichiro Matoba: project administration (equal); writing – review and editing (supporting). Yuichiro Tsukada: project administration (equal); writing – review and editing (supporting). Toshiki Mukai: project administration (equal); writing – review and editing (supporting). Kei Kimura: project administration (equal); writing – review and editing (supporting). Yudai Fukui: project administration (equal); writing – review and editing (supporting). Naoyuki Toyota: project administration (equal); writing – review and editing (supporting).

The authors have nothing to report.

The authors have nothing to report.

Kay Uehara is an editorial board member of Annals of Gastroenterological Surgery. The authors declare no conflicts of interest.

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来源期刊
Annals of Gastroenterological Surgery
Annals of Gastroenterological Surgery GASTROENTEROLOGY & HEPATOLOGY-
CiteScore
5.30
自引率
11.10%
发文量
98
审稿时长
11 weeks
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