Perineal healing following salvage surgery for anal cancer

AIM

Approximately 25% of anal cancer patients undergo abdominoperineal excision or more extensive surgery. Following surgery, a high perineal complication rate has been reported. Enhanced recovery after surgery (ERAS) is an evidence-based multimodal interventional programme introduced to mitigate the risk of complications. This study aims to describe perineal healing in relation to ERAS compliance, type of resection and method of perineal reconstruction in patients with anal cancer after salvage surgery.

METHOD

This is a retrospective cohort study including all patients undergoing abdominal surgery for squamous cell anal cancer in Stockholm between January 2005 and December 2015. Data collection was from registers supplemented by chart review. All patients were followed until death or 1 year after surgery. The associations between ERAS compliance, patient and treatment characteristics and perineal wound healing were evaluated using logistic regression.

RESULTS

In total, 101 patients (67 women) were included, of whom 72 were ERAS compliant. Of patients alive, healing after surgery occurred in 61/98 and 84/89 at 3 months and 1 year, respectively. Perineal healing at 3 months was statistically significantly associated with younger age and type of perineal reconstruction (in favour of vertical rectus abdominis myocutaneous flap). No associations were observed at 1 year but almost all wounds were healed.

CONCLUSION

Age and type of perineal reconstruction appear to be significantly associated with improved healing at 3 months whereas compliance to an ERAS protocol and type of resection do not. Nearly all patients had a fully healed perineal wound 1 year after surgery for anal cancer.

Simultaneous stoma reinforcement and perineal reconstruction with biological mesh - A multicentre prospective observational study

Introduction

The optimal method for perineal reconstruction after extralevator abdominoperineal excision (elAPE) for low rectal cancer remains controversial. This study aimed to assess whether simultaneous perineal reconstruction and parastomal reinforcement with Strattice™ Reconstructive Tissue Matrix after elAPE could prevent hernia formation.

Methods

In this prospective, multicentre, observational, non-comparative study of consecutive patients undergoing elAPE for low rectal cancer underwent simultaneous perineal reconstruction and colostomy site reinforcement with Strattice™ mesh. All patients underwent long course chemoradiotherapy prior to surgery and had excision of the coccyx. Patients were assessed for perineal wound healing at 7 day, 1, 3, 6 and 12 months, perineal and parastomal hernia defects on clinical and radiological assessment at 1 year following surgery.

Results

19 patients (median age = 67 years, median BMI = 26, M:F = 11:8) were entered the study. 10 (52.6%) patients underwent laparoscopic elAPE. The median length of post-operative stay was 9 days. Complete wound healing was observed for 8(42%) patients at 1 month, 12(63%) at 3 months, and 19(100%) patients at 12 months. Median time for radiological and clinical assessment for hernias was 12 months. No perineal hernia was detected in 17 patients following CT assessment. Dynamic MRI was undertaken in 11 patients at 12 months and all showed no evidence of perineal hernia. 3 (16%) patients had a parastomal hernia detected radiologically. No mesh was removed during the 12 months follow up period.

Conclusion

Perineal and parastomal reconstruction with biological mesh is a feasible approach for parastomal and perineal hernia prevention after laparoscopic and open elAPE.

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In this case series, consecutive patients underwent simultaneous perineal reconstruction and colostomy site reinforcement with Strattice™ biological mesh.

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Simultaneous perineal and parastomal reconstruction with Strattice™ mesh is an effective method of hernia prevention after elAPE.

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High quality prospective RCTs and national/international collaborative audits are required to compare this technique with others for perineal reconstruction.

Perineal Wound Closure Using Biological Mesh Following Extralevator Abdominoperineal Excision

AIMS

This study aimed to describe the short-term perineal healing rates in patients with perineal reconstruction using a biological mesh following extralevator abdominoperineal excision (elAPE).

METHODS

In a retrospective, descriptive single-centre cohort study, 88 consecutive patients treated with elAPE and perineal closure using a biological mesh between January 2011 and December 2015 were reviewed. All available data from electronic hospital records was collected. Patients were followed for 1 year following surgery and perineal wound status assessed at 3 months and at 1 year.

RESULTS

In total, 63 patients were male and all but 8 patients were treated for primary rectal cancer. All patients but 3 had received radiotherapy prior to surgery. Multivisceral excisions were performed in 19 patients. Omentoplasty was performed in 55 patients and 3 different types of meshes were used during the study period. At 3 months, 58 patients (66%) had a healed perineum. No association was detected between patient, tumour or perioperative characteristics and perineal wound status at 3 months. At 1 year, 4 patients were deceased and among the remaining 84, the perineal wound was healed in 77 patients (92%).

CONCLUSION

The use of biological meshes in perineal reconstruction following elAPE is feasible and safe, and the perineal wound is healed in the majority of the patients within 3 months.

Pattern of bone marrow involvement in non Hodgkin's lymphoma classified according to WHO classification: Report of a developing country Pakistan

BACKGROUND:

Limited information is available from developing countries in patients of non-Hodgkin's lymphoma (NHL). Hence, we reviewed the demographical profile along with bone marrow infiltration pattern in patients with NHL presented at Liaquat National Hospital and Medical College.

MATERIALS AND METHODS:

In this descriptive study, adult patients with NHL were enrolled from January 2011 to December 2015.

RESULTS:

One hundred and Eighty-four histopathologically confirmed cases of NHL were identified. There were 139 males and 45 females, with a male-to-female ratio of 3:1. The mean age was 48.5 ± 16.0 years with the median age of 50 years. B-symptoms were present in 80.4% of patients. Lymph node enlargement was present in 71.1% of the cases. One hundred and sixty-eight patients had B-cell lymphoma (91.3%) and 16 patients had T-cell lymphoma (8.6%). Overall 158 (85.8%) patients had aggressive lymphoma. The frequency of bone marrow infiltration in our NHL patients was found to be 31.5%. Pattern of infiltrate was diffuse (14.6%) predominantly followed by interstitial (6.5%) and paratrabecular (5.4%) types of infiltration. The least common was nodular infiltrate accounted in 9 (4.8%) patients.

CONCLUSIONS:

B-cell lymphoma is more frequent than T-cell lymphoma. Younger age, aggressive lymphoma, and predominance of B-symptoms are more frequently seen. Diffuse bone marrow infiltration is more common in our set up probably because of a relatively late presentation in our patients.

Outcomes of open reduction and internal fixation in displaced intra-articular scapular fractures : a case series

Scapular fractures are rare injuries and usually occur due to high energy trauma. Displaced Intra articular fractures usually require operative treatment and yields better outcomes as compared to conservative management. To assess the functional and radiological outcomes of displaced intra-articular scapular fractures managed with open reduction and internal fixation. 12 patients were retrospectively reviewed and included in the study. Post-operative functional outcomes were assessed using mean quick DASH (Disability of arm, hand and shoulder) score while radiological outcomes were analyzed as percentage of implant cut-through, mal-union, non-union or infection.  The mean follow up was 14 months. Mean age was 40 years. The mean quick DASH score was 7.19 +/- 4.86. All of the patients had successful clinical and radiological healing and pain-free movements. Open reduction and internal fixation in displaced intra-articular scapular-fractures yields excellent and promising outcomes.

Toe-tourniquet syndrome: A rare potentially devastating entity

Toe-tourniquet syndrome is a rare and commonly misdiagnosed condition caused by a hair or a fiber wrapped around digits (fingers and toes). A four months baby girl who was crying and presented with redness and swelling at her 2nd and 3rd toes of right foot. Child had red and swollen 2nd and 3rd toes of right foot with hair end protruding through wounds. Constricting hairs were cut and removed. Toetourniquet syndrome is a rare entity which is caused by hair wrapped around a toe or a digit. Diagnosis is mostly clinical. In order to prevent this condition to happen, education of parents and clinicians is a cornerstone.

Bladder carcinoma following cyclophosphamide therapy. A case report

Cyclophosphamide was introduced in 1958 in an effort to minimize the side effects of nitrogen mustard. Cyclophosphamide (Cytoxan, Endoxan) is not an alkylating agent which has been used for the treatment of a variety of non-malignant as well as malignant diseases. It has also recently been the focus of considerable interest as an immunosuppressive agent, perhaps the most potent immunosuppressive drug that has been synthesized. Reports of urologic complications from this drug are haemorrhagic cystitis, vesical fibrosis and urothelial carcinoma.

'Steroid psychosis': a case report

The occurrence of psychiatric complications following the administration of ACTH and corticosteroids is well recognized. Psychiatric disturbances usually take the form of euphoria or elation in mood. Depression is less likely, and irritability or aggressiveness may occur. In about 5 per cent of cases the alteration in mood may be accompanied by clouding of consciousness, delusions, hallucinations and disorientation. This picture of an organic confusional state is said to result from high doses and prolonged therapy with corticosteroids and ACTH. The latter is recognized to cause psychiatric sequelae more often than the corticosteroids (Truelove and Witts, 1959). Disturbances may appear within six to seven hours of initial therapy (Goolker and Schein, 1953), after prolonged administration, or even after complete withdrawal of the hormone therapy.