Staged sacrectomy—an adaptive approach
Authors: Ramamurthy Rajaraman , Bose Jagadish Chandra , Muthusamy Vimalakannan , Natarajan Mayilvahanan , Kunjithapatham Deiveegan 
Published: February 2011

Object
Sacral tumors are commonly diagnosed late and therefore present at an advanced stage. The late presentation makes curative surgery technically demanding. Sacrectomy is fraught with a high local recurrence rate and potential complications: deep infection; substantial blood loss; large-bone and soft-tissue defects; bladder, bowel, and sexual dysfunction; spinopelvic nonunion; and gait disturbance. The aim of this study was to analyze the complications and morbidity of sacrectomy and the modifications meant to reduce the morbidity.

Methods
This is a retrospective study of the patients who underwent sacrectomy between February 1997 and September 2008 in the Department of Surgical Oncology, Government Royapettah Hospital, Kilpauk Medical College, in Chennai, Tamilnadu, India. Sacrectomy was performed using 1 of the following approaches: posterior approach, abdominolateral approach, or abdominosacral approach, either as sequential or staged operations. The morbidity rate after the sequential and staged abdominosacral approaches was analyzed. Functional assessment was made based on the Enneking functional scoring system. The results were analyzed and survival analysis was done using the Kaplan-Meier method (with SPSS software).

Results
Nineteen patients underwent sacrectomy, of which 12 operations were partial, 3 were subtotal, and 4 were total sacrectomy. Histological diagnosis included giant cell tumor, chordoma, chondroblastoma, adenocarcinoma of rectum, and retroperitoneal sarcoma. The giant cell tumor was the most common tumor in this series, followed by chordoma. The patients' mean age at diagnosis was 32 years. There were 10 male and 9 female patients. Fortyseven percent of patients had bowel and bladder disturbances postoperatively, and 57.89% of patients had wound complications. The median follow-up duration was 24 months (range 2–140 months). The 5-year overall survival rate was 70.4%, and the 5-year disease-free survival rate was 65% (based on the Kaplan-Meier method). The local recurrence rate (5 cases) was 26.32%. The median duration for first recurrence was 12 months (range 3–17 months). Distant metastasis occurred in 1 patient (5.26%), and 4 patients died, 1 of them due to pulmonary thromboembolism, in the postoperative period. Based on the Enneking system of functional evaluation, 5 patients (26.32%) had excellent outcome, 6 (31.57%) had good outcome, 5 (26.32%) had fair outcome, and 3 (15.78%) had poor outcome. Spinopelvic reconstruction was not performed in any of the patients, and all were ambulatory postoperatively. The staged abdominosacral approach has markedly reduced patient morbidity in terms of reduction of operating time, blood loss, anesthesia complications, and wound complications.

Conclusions
Sacrectomy, a dreaded operation that often results in morbidity, is now feasible with modifications and improvement in surgical technique. The staged abdominosacral approach reduces the immediate postoperative morbidity. Use of a gluteal advancement flap reduces the incidence of wound complications. With modern surgical facilities and postoperative care, sacrectomy is feasible via the staged abdominosacral approach.