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.

Incidence and treatment of positive pelvic sidewall lymph nodes in patients with rectal cancer

AIM

The involvement of pelvic sidewall (PSW) lymph nodes in rectal cancer is a marker of locally advanced disease and poor prognosis. Eastern countries generally advocate lateral lymph node dissection (LLND) over the Western approach of neoadjuvant chemoradiotherapy and more limited surgery. The aim of this study was to evaluate how these advanced cancers were treated in three UK Health Boards.

METHODOLOGY

This was a retrospective review of three colorectal multidisciplinary team meetings from 2008 to 2016. All patients with rectal cancer and suspicious PSW lymph nodes on pretreatment MRI were included.

RESULTS

There were 153 (6.2%) patients who met the inclusion criteria from a total of 2461 diagnosed rectal cancers. There was significant variability between the three centres with surgical intervention ranging from 59.2% to 84.4%, P = 0.015. There were 81 patients who had neoadjuvant chemoradiotherapy prior to surgery; of these 67 (82.7%) still had positive PSW nodes on the restaging MRI, but only 13 (19.4%) had LLND. There was no difference in local recurrence (15.3% vs 11.8%, P = 0.66), 5-year overall survival (69.2% vs 80.1%, P = 0.16) or 5-year disease-free survival (69.2% vs 79.4%, P = 0.72) between patients having LLND and those receiving standard neoadjuvant treatment followed by total mesorectal excision surgery.

CONCLUSIONS

This study has demonstrated that rectal cancer patients with PSW positive nodal disease have advanced disease, mostly of the lower rectum, and receive a highly heterogeneous spectrum of therapies, even within a relatively small geographical area. Greater accuracy in our preoperative staging is needed to select those patients who will benefit from LLND surgery.

Benefits of pre-emptive analgesia by local infiltration at day-case general anaesthetic open inguinal hernioplasty

Introduction The open prosthetic repair of inguinal hernias under local anaesthesia (LA) is well established, with the concept of intraoperative 'pre-emptive analgesia' evolving so that patients are as comfortable as possible. We used a peri-incisional LA solution in patients undergoing day-case inguinal hernioplasty under general anaesthesia (GA) and recorded use of analgesia in the immediate postoperative period. Methods In this observational cohort study, 100 consecutive unselected men underwent open inguinal hernia repair as a day case. Of these, 75 underwent repair under GA and 25 with peri-incisional LA solution (equal mixture of 0.5% bupivacaine and 1% lignocaine with 1:200,000 adrenaline). Analgesia prescribed at induction, for maintenance and after cessation of anaesthesia was scored in accordance with the World Health Organization (WHO) analgesic ladder. Results The median age in the GA group was 59 years (range: 25-89 years) and in the GA+LA group, it was 62 years (range: 27-88 years). Of the 100 patients, 82 underwent a mesh plug repair by seven surgeons whereas 18 underwent a flat (Lichtenstein) mesh repair by two surgeons. WHO analgesic induction and postoperative scores were significantly lower in the GA+LA group (p=0.034 and p<0.001 respectively). There was also a significant difference in use of postoperative antiemetics (23% vs 0% in the GA only and GA+LA cohorts respectively, p=0.020). Six patients (8%) in the GA group failed day-case discharge criteria. Conclusions Patients undergoing contemporary day-case GA inguinal hernioplasty with pre-emptive LA solution infiltration require lower levels of postoperative opioid analgesia and antiemetics. These cases are less likely to fail discharge criteria for planned day surgery.

Computed tomography as a first-line investigation for elderly patients admitted to a surgical assessment unit

Background Increases in life expectancy has meant that a higher proportion of patients presenting to surgical assessment units are now elderly. Abdominal computed tomography (CT) can provide early and accurate diagnosis in the elderly, even in the presence of incomplete clinical and biological findings. The aim of this study was to investigate the use of early CT imaging in elderly patients presenting directly to the surgical assessment unit. Materials and methods All consecutive patients aged 65 years and over admitted directly to the surgical assessment unit between January 2017 and April 2017 were identified. Data were collected on demographics, laboratory investigations, radiological investigations and hospital admission. The primary outcome measure was overall length of stay. Results A total of 200 consecutive patients were identified and included over a six-month period. This comprised 110 women and 90 men with a median age of 78 years (range 64-98 years). A total of 83 patients underwent CT on admission to the surgical assessment unit. White cell count (WCC) and C-reactive protein (CRP) results were significantly higher in patients undergoing CT (P = 0.001). Median length of stay for patients undergoing CT was 5 days (range 1-19 days). This was significantly lower than those patients not receiving CT imaging, at 6 days (range 1-105 days; P = 0.034). Discussion CT should be considered as a first-line investigation when elderly patients with an acute abdomen are admitted to surgical assessment units. Early CT can accelerate hospital discharge and decrease overall length of hospital stay.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Social deprivation in patients requiring pelvic exenterative surgery

AIM

Pelvic exenteration is an aggressive operation for locally advanced rectal cancer. Social deprivation has been shown to reduce life expectancy and has been linked to a poorer outcome in patients with colorectal cancer. The aim of this study was to analyse the effect of social deprivation scores on the outcome in these complex patients.

METHOD

A retrospective review of all patients undergoing pelvic exenteration for primary rectal cancer between 2006 and 2014 was performed. Deprivation scores were calculated for all patients using the Welsh Index of Multiple Deprivation. Patients were then grouped into quartiles, from Q1 (most deprived) to Q4 (least deprived). The primary outcome measure was 5-year survival.

RESULTS

In all, 120 patients were included (65 female) with a median age of 64 (31-90) years. No differences between quartiles were identified for neoadjuvant therapy (P = 0.687) or type of exenteration (P = 0.690). The median length of stay was significantly higher in the most deprived groups (Q1-Q2; P = 0.023). There was a significant difference in survival between the groups, with lowest 5-year survival rates (53%) in the most deprived quartile (Q1) (P = 0.015).

CONCLUSION

Social deprivation is significantly associated with postoperative length of stay and survival in patients undergoing pelvic exenteration for primary rectal cancer.

Pelvic exenteration for advanced malignancy in elderly patients

Background

Pelvic exenteration is an aggressive surgical procedure reserved for highly selected patients. Surgery in the elderly is often associated with increased morbidity and mortality. The aim of this study was to review outcomes following exenteration for advanced pelvic malignancy in this subgroup of patients.

Methods

All patients aged 70 years and over who underwent pelvic exenteration between 1999 and 2014 were included in the study. This comprised all primary rectal, gynaecological and bladder tumours. The primary outcome measure was 5-year overall survival. Secondary endpoints were postoperative morbidity and 30-day mortality.

Results

A total of 94 patients were included, with a median age of 76 (range 70–90) years. There were 65 rectal, 20 gynaecological and nine bladder tumours. The administration of neoadjuvant therapy was significantly different among tumour types (P = 0·002). A total of 32 patients (34 per cent) developed postoperative complications, and there were six deaths (6 per cent) within 30 days of surgery. Median survival was 64 months for patients with rectal cancer, 30 months for those with gynaecological tumours and 15 months for those with bladder cancer. Five-year survival rates in these groups were 47, 31 and 22 per cent respectively (P = 0·023).

Conclusion

Given the possibility of long-term survival, pelvic exenteration should not be withheld on the grounds of advanced age alone.

Quality-of-life outcomes following pelvic exenteration for primary rectal cancer

Background

For patients with locally advanced tumours and contiguous organ involvement, pelvic exenteration (PE) can offer cure with relatively low mortality. The literature surrounding quality of life (QoL) in patients undergoing PE is limited. Furthermore, there are no matched comparisons of QoL between abdominoperineal resection (APR) and PE. The aim of this study was to compare differences in long-term QoL for patients with primary rectal cancer undergoing APR versus PE.

Methods

All patients who underwent either APR or PE between January 2011 and December 2012 were identified. Patients were asked to complete the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire before surgery and 2 weeks afterwards. Subsequent questionnaires were requested at 3, 6, 12 and 24 months after operation.

Results

A total of 110 patients were included in the study (54 APR, 56 PE). Median length of stay following operation was 11 (range 3–70) days for APR and 15 (7–84) days for PE. Patients undergoing PE experienced lower physical (mean score 42 versus 56; P = 0·010), role (20 versus 33; P = 0·047), emotional (57 versus 73; P = 0·010) and social (34 versus 52; P = 0·005) functional levels 2 weeks after surgery. Long-term dyspnoea and financial worries were experienced only after PE. Patients undergoing PE had a lower overall global health status at 2 weeks after operation (40 versus 53; P = 0·012). Levels were comparable between groups from 3 months after surgery.

Conclusion

QoL recovery following PE was equivalent to that after APR alone. Patients should not be denied exenterative surgery based on perceived poor QoL.

Determinants of survival following pelvic exenteration for primary rectal cancer

BACKGROUND

Pelvic exenteration is a potentially curative treatment for locally advanced primary rectal cancer. Previous studies have been limited by small sample sizes and heterogeneous data. A consecutive series of patients was studied to identify the clinicopathological determinants of survival.

METHODS

All patients undergoing pelvic exenterative surgery for primary rectal cancer (1992-2014) at this hospital were analysed. The primary outcome measure was 5-year overall survival. Secondary endpoints included length of hospital stay, complication rate, 30-day mortality and disease recurrence rate. Statistical analysis was performed using Kaplan-Meier and Cox regression analysis.

RESULTS

A total of 174 patients with a median age of 65 (range 31-90) years were included. Ninety-six patients underwent posterior pelvic exenteration and 78 had total pelvic exenteration. Median follow-up was 48 (range 1-229) months. Two patients (1.1 per cent) died within 30 days of surgery and 16.1 per cent returned to the operating theatre. The 5-year survival rate following complete resection (R0) was 59.3 per cent. In univariable analysis, adverse survival was associated with advanced age (P = 0.003), metastatic disease (P = 0.001), pathological node status (P = 0.001), circumferential resection margin (P = 0.001), local recurrence (P = 0.015) and the need for neoadjuvant therapy (P = 0.039).

CONCLUSION

Pelvic exenteration is an aggressive treatment option with a high morbidity rate that provides favourable long-term outcomes in patients with locally advanced primary rectal cancer.

How safe is it to manage diverticular colovesical fistulation non-operatively?

AIM

Colovesical fistula (CVF) is an uncommon condition. Diagnosis and management varies according to presentation and aetiology. The identification of patients suitable for conservative management and their outcome following this approach has not been well documented.

METHODS

The clinical outcomes of all patients diagnosed with a CVF over a 7-year period from an uro-radiological database were reviewed. Cases secondary to diverticular disease were analysed with respect to the approach by which they were managed: those treated surgically and those managed conservatively.

RESULTS

Sixty-two patients (32 men) were diagnosed with CVF of whom 53 (85%) had diverticular disease. Twenty-seven (mean age 69 years, range 42-90) underwent surgery (with a stoma in 59%) with a 30-day mortality of 15%. Those managed conservatively (n = 26) were older (mean age 76 years, range 39-87) and frailer (62% American Society of Anesthesiologists Grades III and IV). At 1 and 3 years following diagnosis there was no difference in mortality between these two groups and only one death was as a consequence of urosepsis.

CONCLUSION

Many patients with CVF secondary to diverticular disease can be safely managed non-operatively.

Abstract 4653: Role of serum HE4 in studying ovarian cancer progression and response to therapy with ARCHITECT HE4 assay

Human epididymis protein 4 (HE4) is a whey acidic four-disulfide core protein. Serum HE4 has been shown to be a promising biomarker for epithelial ovarian cancer (EOC) with manual HE4 EIA assays. The ARCHITECT system is one of the major automated formats for cancer immunodiagnostics. This abstract describes the clinical performance of an investigational ARCHITECT HE4 assay in the measurement of serum HE4 from longitudinal samples of subjects with EOC and single-point samples from healthy subjects, and subjects with malignancy, benign diseases, EOC or other malignant diseases.

PROCEDURES: The ARCHITECT HE4 Assay is a paramagnetic microparticle chemiluminescent assay adopting the sensitive CHEMIFLEX® technology. Single-point and longitudinal serum samples were tested with an investigational ARCHITECT HE4 Assay reagent lot on the ARCHITECT i2000SR. Single-point sera were collected from healthy subjects (N = 400), subjects with pregnancy (N = 50) and benign disease (N = 612), and subjects which were diagnosed with EOC (N = 314) and other cancers (N = 250) including endometrial, breast, gastrointestinal, lung, and bladder cancer. Longitudinal sera (N = 506), including initial time point and follow-up visits (average = 5.7 per subject), were collected from subjects (N = 76) which were diagnosed with EOC. All of the single-point and longitudinal samples were handled in accordance with IRB-approved and GCP-compliant protocols.

RESULTS: Using an ARCHITECT HE4 cut-off value of &gt;140 pmol/L, the percent distributions of ARCHITECT HE4 by cohort are: 3% of healthy subjects, 0% with pregnancy, 7.2% of subjects with benign diseases, 53.5% with EOC and 28.4% with other cancers. Using the upper 95% point of the distribution of the HE4 ratio at 14% to categorize the successive HE4 readings into those that were and were not significantly elevated for the longitudinal samples, the sensitivity, specificity and positive predictive value of HE4 elevation versus disease progression were 53.4% (95% CI: 44.1%-62.5%), 78.8% (95% CI: 74.7% - 82.4%) and 43.2% (95% CI: 32.9% - 54.1%) respectively. The total concordance between HE4 elevation and disease progression was 73%. Receiver Operator Characteristic analysis showed an area under the curve of 0.685 (SE = 0.033) for the diagnosis of progression from the ratio of successive HE4 readings. When comparing the change of the HE4 ratio with the diagnostic response to therapy, a decrease in HE4 reflected response to therapy with a sensitivity of 82% and a specificity of 53%.

CONCLUSIONS: The study with single-point samples has shown the utility of ARCHITECT HE4 values as a serum biomarker for EOC. The longitudinal increase of ARCHITECT HE4 values in sera seemed to be effective in recognizing the progression of EOC. The longitudinal decrease of ARCHITECT HE4 values in sera seemed to correlate with the response of EOC subjects to therapy.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4653.

Short-term treatment in a general hospital following a suicide attempt

The authors discuss the value of short-term psychiatric treatment in the nonpsychiatric wards of a general hospital for patients who attempt suicide. During 1974 a total of 124 such patients were seen in the emergency room of Meir General Hospital in Kfar Saba, Israel. Following an initial psychiatric examination, 110 of the patients were admitted to the internal medicine or surgical wards. After further observation 30% were transferred to psychiatric hospitals, and the rest were treated in the general hospital's nonpsychiatric wards for an average of three days. There were no suicide attempts during hospitalization. The authors emphasize the usefulness of a short hospitalization to separate the patient from his traumatic home environment until his return to it becomes feasible.