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PPS11. Empty Pelvis Syndrome After Beyond Total Mesorectal Excision (bTME) for Rectal Cancer: Impact of Surgical Complexity and Flap Reconstruction

Thursday, March 5, 2026
10:00 AM - 10:30 AM MST
Location: HUB Poster Park - West Hall 1-3
Introduction: Extended pelvic resections beyond total mesorectal excision (bTME) are increasingly performed for locally advanced or recurrent rectal cancer to achieve margin-negative resection. These operations carry a high risk of pelvic morbidity, including the constellation of complications known as Empty Pelvis Syndrome (EPS). The incidence and risk factors for EPS following bTME remain poorly defined, particularly across the spectrum of surgical complexity and reconstructive approaches.


Methods: A retrospective review of a prospectively maintained database identified all patients who underwent bTME for rectal adenocarcinoma at a tertiary cancer center (2006–2023). bTME was defined as resection extending beyond standard TME planes with enbloc organ or vascular resection. Patients with sphincter preservation surgery were excluded. Surgical complexity was categorized using the UK Pelvic Exenteration Lexicon, with high complexity defined by resection of bony structures or the pelvic sidewall. The primary outcome was UK Pelvic Exenteration Network’s EPS-related complications (pelvic abscess, small bowel obstruction, enteroperineal fistula, chronic perineal sinus). Univariable and multivariable analyses identified predictors of EPS.


Results: Among 478 patients (mean age 58 years; 45.0% female; 40.8% recurrent disease), 176 (36.8%) underwent high-complexity resections. Flap reconstruction was performed in 96.7% (25.1% omental, 59.2% abdominal-based, 11.9% extremity-based, 0.4% both extremity and abdominal-based). Overall, 117 (24.5%) patients had an EPS event of whom 32 (27.3%) required reoperation including late reoperations. EPS events occurred more frequently after high- vs. low-complexity surgery (36.4% vs. 17.6%, p<0.001) and varied by flap type (12.2% none, 28.3% omental, 20.1% abdominal-based, 42.1% extremity-based; p=0.004). On multivariable analysis, high complexity (adjusted OR 2.70, 95% CI 1.69–4.31, p<0.001) and extremity-based flaps (aOR 5.67, 95% CI 1.12–28.7, p=0.040) were independently associated with increased EPS risk.


Conclusions: EPS events occur in over one-fifth of patients undergoing bTME and is strongly associated with extent of resection and type of reconstruction. These findings highlight the morbidity of aggressive pelvic surgery and emphasize the need for tailored reconstruction and multidisciplinary planning to optimize outcomes and patient counseling.

Learning Objectives:

  • Define Empty Pelvis Syndrome (EPS) and its clinical significance following beyond total mesorectal excision (bTME) for locally advanced or recurrent rectal cancer.
  • Identify surgical and reconstructive factors, particularly complexity level and flap type, associated with increased risk of EPS after bTME.
  • Apply knowledge of EPS risk factors to optimize multidisciplinary planning, reconstruction strategies, and patient counseling in complex pelvic surgery.