...decision was taken to proceed with a laparotomy, which showed a vital J pouch, although surrounded by scar tissue and purulent collections due to the long-term pelvic sepsis. The left gracilis ...muscle was still in place, viable, and well vascularized. ...the procedure was repeated for the right gracilis muscle, which was positioned above the left one and secured on the left ischial tuberosity. ...redo GMT procedure should be taken into account as a possible salvage strategy after recurrences of PVF.
Pelvic exenteration is the only radical treatment for locally advanced (ARC) or recurrent (RRC) rectal cancers. The long-term results of the procedure are variably reported in the literature, with ...recent series suggesting similar survival between ARC and RRC. The study aimed to analyze and compare the long-term survival and perioperative outcomes of patients undergoing pelvic exenteration for ARC and RRC in a tertiary center.
This was a retrospective analysis of prospectively collected data. Comparison of variables was performed using Chi-square, Fisher's exact or Wilcoxon rank sum test as appropriate. The Kaplan Meier method was used to analyze the disease-free survival (DFS) and the log-rank test to compare the two groups.
Since 2002, 46 patients underwent pelvic exenteration for ARC (28, 60.9%) and RRC (18, 39.1%). The groups had comparable characteristics, perioperative results, including postoperative complications, and rate of adjuvant chemotherapy. A R0 resection was obtained in 71.4% and 55.6% (p 0.41) and a T4 stage was diagnosed in 75% and 94.4% (p 0.22) of ARC and RRC patients, respectively. After a median follow-up time of 32.5 and 56.6 months (p 0.01), the 5-year DFS was significantly lower in the RRC group (23.6 vs 46.2%, p 0.006), even after exclusion of R1 cases (30 vs 54.5%, p 0.044).
The long-term disease free survival of patients undergoing pelvic exenteration is significantly worse when the procedure is performed for RRC, regardless of the tumor involvement of the resection margins.
•Pelvic exenteration is the treatment of choice for locally advanced or recurrent rectal cancer.•The radicality of surgery was highlighted as the most important predictive factor for outcomes.•Outcomes of patients undergoing exenteration in a tertiary center were analyzed and compared.•After exclusion of cases with positive resection margins, recurrent cancers had worse outcomes.
Surgery for ileocolonic Crohn’s disease can result in temporary or permanent stoma formation which can be associated with morbidity as parastomal and incisional hernias, readmissions due to ...obstruction or high stoma output, and have a negative impact on quality of life. We propose an international retrospective trainee-led study of the outcomes of temporary stomas in patients with Crohn’s disease. We aim to evaluate both the short-term (6 month) and mid-term (18 month) outcomes of temporary stomas in patients with Crohn’s Disease. Retrospective, multicentre, observational study including all patients who underwent elective or emergency surgery for ileal, colonic and ileocolonic Crohn’s disease during a 4-year study period. Primary outcome is the proportion of patients who still have an ileostomy or colostomy 18 months after the initial surgery. Secondary outcomes: complications related to stoma formation and stoma reversal surgery; time interval between stoma formation and stoma reversal; risk factors for stoma formation and non-reversal of the stoma. We present the study protocol for a trainee-led, multicentre, observational study. Previous research has demonstrated significant heterogeneity surrounding the formation and the timing of reversal surgery in patients having a temporary ileostomy following colorectal cancer surgery, highlighting the need to address these same questions in Crohn’s disease, which is the aim of our research.
Salvage surgery after failure of ileal pouch–anal anastomosis (IPAA) could be offered to selected patients. However, the results vary widely in different centers.
To assess the outcomes of salvage ...surgery by comparison with a control group matched for confounding variables.
From a prospective database of 1286 IPAA, patients undergoing transabdominal salvage surgery were compared for perioperative and functional outcomes and quality of life (QOL) to a 1:3 control group of primary IPAA cases.
Salvage surgery patients (30) had a higher rate of hand-sewn anastomoses (80 vs 20%, p <0.0001) and reoperations (10 vs 2.2%, p 0.02) than control group (90). A higher number of daytime and nighttime bowel movements (7.4 vs 4.1, p <0.0001, and 2.6 vs 1.8, p=0.002), a lower median CGQL score (0.7 vs 0.8, p=0.0001) and a higher rate of pouch fistulae (13.3 vs 1.1%, p=0.003) were reported after salvage surgery. Pouch failure rate after salvage surgery was 10.1%, 18.7% and 26.8% at 1, 5 and 10 years (vs 0%, 3.5% and 8.4% in control group, p=0.0085).
Although worse functional outcomes and decreased QOL have to be expected, salvage surgery after pouch failure is associated with acceptable outcomes when performed in a referral center.
Anastomotic complications after ileal pouch-anal anastomosis (IPAA) are often associated with excessive tension and poor blood supply. Carrying out a tension-free IPAA might prove difficult in a ...proportion of cases, especially if mucosectomy and hand-sewn anastomosis are necessary. The aim of the study was to analyse the outcomes of mesenteric lengthening in patients undergoing IPAA in a tertiary centre. Consecutive patients who required mesenteric lengthening during IPAA surgery between 2000 and 2019 were retrospectively included. Short and long-term outcomes were analyzed. Chi square, Fisher’s exact test and Wilcoxon rank sum test were used as appropriate. Kaplan–Meier analysis was carried out to report the long-term rate of pouch failure. Some 131 patients (78 UC, three indeterminate colitis, 50 FAP) were included. The need for mesenteric lengthening, due to short mesentery or intraoperative complications, was unpredictable in 15 patients. The rate of surgical complications was 20.6%; eight patients required a reoperation, two of them experienced postoperative pouch ischemia. After a median follow-up time of 9.4 years, the risk of pouch failure in FAP and UC patients was 7.2% and 13% at 10 years. Despite the indication to mucosectomy has been reducing over the years, mesenteric lengthening is still required in a significant proportion of UC and FAP patients, also because of unforeseeable intraoperative conditions necessities.
The association between volume, complications and pathological outcomes is still under debate regarding colorectal cancer surgery. The aim of the study was to assess the association between centre ...volume and severe complications, mortality, less-than-radical oncologic surgery, and indications for neoadjuvant therapy.
Retrospective analysis of 16,883 colorectal cancer cases from 80 centres (2018-2021). Outcomes: 30-day mortality; Clavien-Dindo grade >2 complications; removal of ≥ 12 lymph nodes; non-radical resection; neoadjuvant therapy. Quartiles of hospital volumes were classified as LOW, MEDIUM, HIGH, and VERY HIGH. Independent predictors, both overall and for rectal cancer, were evaluated using logistic regression including age, gender, AJCC stage and cancer site.
LOW-volume centres reported a higher rate of severe postoperative complications (OR 1.50, 95% c.i. 1.15-1.096, P = 0.003). The rate of ≥ 12 lymph nodes removed in LOW-volume (OR 0.68, 95% c.i. 0.56-0.85, P < 0.001) and MEDIUM-volume (OR 0.72, 95% c.i. 0.62-0.83, P < 0.001) centres was lower than in VERY HIGH-volume centres. Of the 4676 rectal cancer patients, the rate of ≥ 12 lymph nodes removed was lower in LOW-volume than in VERY HIGH-volume centres (OR 0.57, 95% c.i. 0.41-0.80, P = 0.001). A lower rate of neoadjuvant chemoradiation was associated with HIGH (OR 0.66, 95% c.i. 0.56-0.77, P < 0.001), MEDIUM (OR 0.75, 95% c.i. 0.60-0.92, P = 0.006), and LOW (OR 0.70, 95% c.i. 0.52-0.94, P = 0.019) volume centres (vs. VERY HIGH).
Colorectal cancer surgery in low-volume centres is at higher risk of suboptimal management, poor postoperative outcomes, and less-than-adequate oncologic resections. Centralisation of rectal cancer cases should be taken into consideration to optimise the outcomes.
IMPORTANCE: Considering the lack of equipoise regarding the timing of cholecystectomy in patients with moderately severe and severe acute biliary pancreatitis (ABP), it is critical to assess this ...issue. OBJECTIVE: To assess the outcomes of early cholecystectomy (EC) in patients with moderately severe and severe ABP. DESIGN, SETTINGS, AND PARTICIPANTS: This cohort study retrospectively analyzed real-life data from the MANCTRA-1 (Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis) data set, assessing 5304 consecutive patients hospitalized between January 1, 2019, and December 31, 2020, for ABP from 42 countries. A total of 3696 patients who were hospitalized for ABP and underwent cholecystectomy were included in the analysis; of these, 1202 underwent EC, defined as a cholecystectomy performed within 14 days of admission. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality and morbidity. Data analysis was performed from January to February 2023. MAIN OUTCOMES: Mortality and morbidity after EC. RESULTS: Of the 3696 patients (mean SD age, 58.5 17.8 years; 1907 51.5% female) included in the analysis, 1202 (32.5%) underwent EC and 2494 (67.5%) underwent delayed cholecystectomy (DC). Overall, EC presented an increased risk of postoperative mortality (1.4% vs 0.1%, P < .001) and morbidity (7.7% vs 3.7%, P < .001) compared with DC. On the multivariable analysis, moderately severe and severe ABP were associated with increased mortality (odds ratio OR, 361.46; 95% CI, 2.28-57 212.31; P = .02) and morbidity (OR, 2.64; 95% CI, 1.35-5.19; P = .005). In patients with moderately severe and severe ABP (n = 108), EC was associated with an increased risk of mortality (16 15.5% vs 0 0%, P < .001), morbidity (30 30.3% vs 57 5.5%, P < .001), bile leakage (2 2.4% vs 4 0.4%, P = .02), and infections (12 14.6% vs 4 0.4%, P < .001) compared with patients with mild ABP who underwent EC. In patients with moderately severe and severe ABP (n = 108), EC was associated with higher mortality (16 15.5% vs 2 1.2%, P < .001), morbidity (30 30.3% vs 17 10.3%, P < .001), and infections (12 14.6% vs 2 1.3%, P < .001) compared with patients with moderately severe and severe ABP who underwent DC. On the multivariable analysis, the patient’s age (OR, 1.12; 95% CI, 1.02-1.36; P = .03) and American Society of Anesthesiologists score (OR, 5.91; 95% CI, 1.06-32.78; P = .04) were associated with mortality; severe complications of ABP were associated with increased mortality (OR, 50.04; 95% CI, 2.37-1058.01; P = .01) and morbidity (OR, 33.64; 95% CI, 3.19-354.73; P = .003). CONCLUSIONS AND RELEVANCE: This cohort study’s findings suggest that EC should be considered carefully in patients with moderately severe and severe ABP, as it was associated with increased postoperative mortality and morbidity. However, older and more fragile patients manifesting severe complications related to ABP should most likely not be considered for EC.
The formation of an advancement rectal flap could be technically demanding in the presence of high perianal of rectovaginal fistula, and the outcomes could be frustrated by the inadequate view, ...bleeding and a poor exposure through the standard transanal approach. The application of the transanal minimally invasive surgery (TAMIS) to the advancement rectal flap procedure could overcome these difficulties. In the lithotomy position, a partial fistulectomy was performed and the internal opening was closed. A full-thickness flap was mobilized initially through the classic transanal approach. Subsequently, the TAMIS port was inserted and the mobilization of the flap was carried on proximally for as long as required. The laparoscopic visualization allowed a perfect view, a proper orientation of the flap and accurate hemostasis. The TAMIS-flap procedure seems a promising technique to perform a long advancement rectal flap to treat high perianal or rectovaginal fistulae (Video, Supplemental Digital Content 1, http://links.lww.com/SLE/A208).
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