The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

"Top down no-touch" technique in robotic complete mesocolic excision for extended right hemicolectomy with intracorporeal anastomosis

BACKGROUND

Proper identification of the mesocolic vessels is essential for achieving complete mesocolic excision (CME) in cases of colon cancer requiring an extended right hemicolectomy. In robotic procedures, we employed a "top down technique" to allow early identification of the gastrocolic trunk and middle colic vessels. The aim of our study was to illustrate the details of this technique in a series of 12 patients.

METHODS

The top down technique consists of two steps. First, the omental bursa was entered to identify the right gastroepiploic vein. Tracing down this vein as a landmark, the gastrocolic trunk was exposed, branches of this trunk and the middle colic vessels were divided. Second, dissection was directed to the ileocolic region and proceeded in an inferior-to-superior direction along the superior mesenteric vein to divide the ileocolic and right colic vessels consecutively. The ileotranverse anastomosis was created intracorporeally.

RESULTS

There were 8 males and 4 females with a mean age of 64.8 ± 16.9 years and a mean body mass index of 25.6 ± 3.7 kg/m². All the procedures were completed successfully. No conversions occurred. The mean operative time and blood loss were 312.1 ± 93.9 min and 110.0 ± 89.9 ml, respectively. The mean number of harvested lymph nodes was 45.2 ± 11.1. The mean length of hospital stay was 7.6 ± 4.7 days. Two patients had intraoperative complications and two had postoperative complications. There was no disease recurrence at a mean follow-up period of 10.4 ± 7.1 months.

CONCLUSIONS

The top down technique appears to be useful in robotic CME for an extended right hemicolectomy. Early identification of the gastrocolic trunk and middle colic vessels via this technique may prevent inadvertent vascular injury at the mesenteric root of the transverse colon.

The usefulness of the H-pouch configuration in salvage surgery for failed ileal pouches

AIM

Abdominal salvage surgery for a failed ileal pouch-anal anastomosis (5) is safe and feasible in experienced hands. When salvaging an ileal pouch or creating a new J, S or W pouch may not be feasible, construction of an H-pouch may be the final option. This study reports a single colorectal surgeon's experience on H-pouch anal anastomosis in patients referred with a failed ileal pouch.

METHOD

Patients undergoing transabdominal salvage surgery with H-pouch formation for a failed pouch from February 2012 to May 2016 were evaluated.

RESULTS

Five patients were identified with a mean age of 46 (22-63) years. The pathological diagnosis was mucosal ulcerative colitis in all patients. Three patients had an initial traditional two-stage J-pouch creation and two patients had an initial three-stage approach. The median time to redo pouch surgery after the index IPAA creation was 99 (11-158) months. One patient required excision of the pouch and two patients had a complication within 30 days of surgery.

CONCLUSION

The H-pouch is a good alternative for a failed IPAA when another type of reservoir is not an option.

Genotype-defined cancer risk in juvenile polyposis syndrome

Background

Germline mutations in SMAD4 and BMPR1A disrupt the transforming growth factor β signal transduction pathway, and are associated with juvenile polyposis syndrome. The effect of genotype on the pattern of disease in this syndrome is unknown. This study evaluated the differential impact of SMAD4 and BMPR1A gene mutations on cancer risk and oncological phenotype in patients with juvenile polyposis syndrome.

Methods

Patients with juvenile polyposis syndrome and germline SMAD4 or BMPR1A mutations were identified from a prospectively maintained institutional registry. Medical records were reviewed and the clinical patterns of disease were analysed.

Results

Thirty-five patients had germline mutations in either BMPR1A (8 patients) or SMAD4 (27). Median follow-up was 11 years. Colonic phenotype was similar between patients with SMAD4 and BMPR1A mutations, whereas SMAD4 mutations were associated with larger polyp numbers (number of patients with 50 or more gastric polyps: 14 versus 0 respectively). The numbers of patients with rectal polyps was comparable between BMPR1A and SMAD4 mutation carriers (5 versus 17). No patient was diagnosed with cancer in the BMPR1A group, whereas four men with a SMAD4 mutation developed gastrointestinal (3) or extraintestinal (1) cancer. The gastrointestinal cancer risk in patients with juvenile polyposis syndrome and a SMAD4 mutation was 11 per cent (3 of 27).

Conclusion

The SMAD4 genotype is associated with a more aggressive upper gastrointestinal malignancy risk in juvenile polyposis syndrome.

Factors affecting morbidity after conversion of laparoscopic colorectal resections

BACKGROUND

The impact of conversion on postoperative outcomes of laparoscopic colorectal surgery remains controversial. The purpose of this study was to assess whether a conversion results in increased postoperative morbidity and mortality, and to evaluate whether any specific factors affect the outcomes of converted procedures.

METHODS

Outcomes of procedures requiring conversion among patients undergoing elective laparoscopic colorectal resection between 1992 and 2011 were compared with those for operations completed laparoscopically. Subset analyses were also performed to evaluate the selective impact of patient-, disease- and treatment-related factors and the timing of conversion during surgery on outcomes. Primary endpoints were postoperative mortality and morbidity.

RESULTS

Of 2483 patients undergoing laparoscopic colorectal resection, 270 (10.9 per cent) required conversion to open surgery. The 30-day postoperative mortality rate was comparable after laparoscopically completed and converted procedures (0.4 versus 0 per cent respectively; P = 0.610). Factors significantly associated with morbidity after conversion were smoking, cardiovascular co-morbidity, previous abdominal operations (particularly colectomy or hysterectomy) and adhesions. Overall morbidity was not affected by conversion (27.0 per cent at 30 days in both groups; P > 0.999). However, patients experiencing morbidity tended to have had earlier conversions: median (range) 40 (15-90) min into surgery versus 50 (15-240) min for those who did not develop morbidity (P = 0.006). The risk of reoperation for postoperative morbidity was higher following conversion because of complications (13 versus 2.9 per cent; P = 0.024).

CONCLUSION

Conversions of laparoscopic colorectal resection are not associated with increased overall morbidity, regardless of the timing of conversion.

Long term outcomes of neuroendocrine carcinomas (high-grade neuroendocrine tumors) of the colon, rectum, and anal canal

INTRODUCTION AND AIM

Neuroendocrine carcinomas (NEC) of the large intestine are rare and aggressive neoplasms. This study was designed to review the experience at a single institution and analyze the outcomes to improve our understanding of these tumors.

METHODS

The patients with NEC (high-grade neuroendocrine tumor) of the colon, rectum, and anal canal were identified from June 1993 to April 2011. Clinical features studied were patient demographics, presenting symptoms, tumor location, tumor stage, treatment status and length of follow-up.

RESULTS

Twenty-five patients were identified. Stages of the diseases were I (n=5), II (n=1), III (n=10) and IV (n=9). Locations of the tumors were: colon (36%); rectum (28%) and anal canal (36%). Rectal bleeding (36%) and pain (32%) were the most common symptoms but 16% of patients were asymptomatic. Among the patients with local or locally advanced disease, only five patients had surgery alone. The remainder of the patients underwent chemotherapy with/without radiation. Mean follow-up was 33.7 ± 8.4 months after diagnosis. NEC of the large bowel and anal canal has very distinctive pathologic features and a very poor prognosis. More than one third of the patients with NEC had metastatic disease at the time of diagnosis. When these tumors are in an advanced stage none of the treatment modalities impact on survival.

CONCLUSION

The present study showed the poor prognosis of these rare tumors.

Scolicidal activity of taurolidine for the treatment of hydatid disease

OBJECTIVES

In this experimental study, we have evaluated in vivo and in vitro activities of taurolidine (TRD) against protoscolices of Echinococcus granulosus.

BACKGROUND

Scolicidal agent application is mandatory for the interventional treatment of hydatid cysts. Serious adverse effects of current scolicidal agents forced the scientist to search for less toxic chemicals.

METHODS

One milliliter of protoscolices suspension was administered into twelve Petri's dishes, six of them containing 5 ml of isotonic saline, and six of them containing 5 ml (5 mg/ml) TRD. Forty, male Balb/c mice were divided into five equal groups. Group 1: protoscolices inoculated group; Group 2: protoscolices inoculated and thereafter immediately administered with a single dose intravenous (IV) 0.5 ml TRD (400 mg/kg); Group 3: protoscolices inoculated and thereafter immediately administered with a single dose intraperitoneal (IP) 0.5 ml TRD (400 mg/kg); Group 4: three months after inoculating the protoscolices, one day before the sacrifice single dose IV 0.5 ml TRD (400 mg/kg) administered; Group 5: three months after inoculating the protoscolices, one day before the sacrifice single dose IP 0.5 ml TRD (400 mg/kg) administered.

RESULTS

All the protoscolices were dead in TRD-added Petri's Dishes in 90 minutes. In group 2 and group 3, no mouse had an intraabdominal hydatid cyst.

CONCLUSION

The results of this study are encouraging us to suggest TRD as an alternative scolicidal agent. Further clinical studies are needed to define the effectiveness and the mode of application of TRD for the treatment of hydatid disease (Tab. 1, Fig. 4, Ref. 30).

Risk of infection and hernia recurrence for patients undergoing ventral hernia repair with non-absorbable or biological mesh during open bowel procedures

BACKGROUND

Ventral hernia repair (VHR) with mesh performed concurrently with colorectal surgery is presumably associated with significant risks of infection and recurrence. The purpose of this study is to evaluate the outcomes of patients undergoing VHR with non-absorbable mesh (NAM) or biological mesh (BM) at the same time as open colorectal surgery.

METHODS

A retrospective review of short- and long-term outcomes for 25 patients undergoing repair of VHR with NAM or BM at the same time as an open colorectal procedure from 1991 to 2007 was performed.

RESULTS

The mean age of the patients was 50.8 ± 12.7 years. Fifteen patients (60 %) underwent VHR with NAM versus 10 (40 %) with BM at the time of colorectal surgery. Mean follow-up after surgery was 32.9 ± 38.2 months. Overall wound infection, mesh infection and hernia recurrence rates were 44, 36 and 36 %, respectively. There was no difference between the NAM and BM mesh repair groups in terms of operative indications (p = 0.23) and operations performed (p = 0.47). Both groups had similar gender, ASA score, age, BMI, operating time, hernia recurrence rate, wound infection and follow-up.

CONCLUSIONS

Although a proportion of patients who undergo concomitant use of mesh for VHR during colorectal resection has reasonable outcomes, there is a high associated risk of wound and mesh infection. Thus, a judicious decision regarding the use of mesh for hernia repair needs to be made on a case-by-case basis for patients undergoing open bowel surgery at the same time.

An alternative sutureless repair technique with amelogenin for duodenal perforation

BACKGROUND

Among the various sutureless techniques, fibrin glue has proved to be effective in the treatment of peptic ulcer perforation as an alternative to classical suture repair. Albeit rare, a potential disadvantage of fibrin glue use is viral transmission or anaphylaxis. The aim of this study is to introduce a new technique for the closure of duodenal perforation using a novel recombinant enamel protein called amelogenin.

METHODS

In this case-control experimental study, 32 adult male Wistar Albino rats weighing 250-300 g were randomly divided into four groups, each containing 8 rats. Duodenal perforation of 0.2 cm were performed in the postpyloric region in all rats. Each group received primary repair, primary repair with omentoplasty, fibrin glue, and amelogenin, respectively. All animals were killed on the postoperative day five and the bursting pressure measurements, hydroxyproline levels and histopathologic values of the wound site were evaluated.

RESULTS

Bursting pressure levels of the fibrin glue and amelogenin groups were significantly lower than the primary repair and primary repair with omentoplasty groups (P < 0.05) However, no significant difference existed between the fibrin glue and amelogenin groups in this respect (P > 0.05). There was also no statistically significant difference among all groups regarding tissue hydroxyproline levels and histopathologic values (P > 0.05).

CONCLUSION

Application of amelogenin as an alternative sutureless repair technique did not improve wound healing in this animal model of duodenal perforation.

Investigation of zinc and copper levels in methimazole-induced hypothyroidism: relation with the oxidant-antioxidant status

Thyroid hormones are associated with the oxidative and antioxidative status of the organism. Depression of metabolism by hypothyroidism has been reported to decrease oxidant production and thus protect tissues against oxidant damage. The purpose of the present study was to investigate Zn and Cu levels in MMI-induced hypothyroidism and to show whether there is a connection between these trace elements and the oxidant-antioxidant status in experimental hypothyroidism. 3-Nitrotyrosine was measured as a marker of nitro-oxidative stress. In order to examine the antioxidant status of MMI-induced hypothyroidism in rats, GSH and SOD levels were determined as well. Significantly decreased 3-nitrotyrosine, Cu and Zn levels were observed in our experimental model when compared with the controls. On the other hand, GSH and SOD levels remained constant. It may be suggested that Cu and Zn serve as antioxidant molecules and exert their effects in an indirect manner to reduce oxidative stress in experimental hypothyroidism.