Efficacy of Surgical Reconstruction With Rectus Abdominis Flap Following en Bloc Resection of the Orbital Contents for Malignant Lacrimal Gland Cancer: A Case Series.

In cases of lacrimal gland carcinoma requiring surgical excision of the orbital contents, skull base, and surrounding bones, definitive blockage of the cranial cavity and reconstruction of the anterior skull base with irradiation-acceptable tissue (for possible subsequent radiotherapy) is necessary. However, considerations for quality of life, including cosmetic aspects, such as artificial eye placement and contour morphology, make reconstruction challenging. In three cases of advanced lacrimal gland carcinoma, we performed a reconstruction surgery following an en bloc resection of the orbital contents and lateral orbital bones. A rectus abdominis flap was used, considering both function and morphology. This flap, characterized by reliable anatomical structure and good blood flow, adequately filled the three-dimensional dead space. In our case, the flap fully survived, and no complications such as cerebrospinal fluid leakage or meningitis were observed. Six months after surgery, the flap volume was 31.7-73.3% of its initial size. Considering potential flap shrinkage in the future, it was deemed beneficial to use a slightly excessive volume.

Urachal adenocarcinoma with cervical invasion misdiagnosed as primary cervical adenocarcinoma: a case report and literature review.

Background: Urachal carcinoma (UrC) is a rare malignancy with no known specific early symptoms. It is often diagnosed at advanced stages and is associated with poor prognosis. Case presentation: This study presents a rare case of urachal adenocarcinoma (UrAC) invading the bladder and vagina in a female patient. Initially, the patient was misdiagnosed as having a primary cervical adenocarcinoma 2.5 years prior. Subsequently, anterior pelvic exenteration and bilateral ureterocutaneostomies were performed. Twenty months after the first surgery, the patient was diagnosed with rectal metastasis and received gemcitabine chemotherapy. After achieving a stable disease state, the patient underwent laparoscopic ultralow rectal anterior resection, ultralow anastomosis of the sigmoid colon and rectum, prophylactic transverse colostomy, and right common iliac and external iliac lymph node dissection. The patient then received a cycle of postoperative chemotherapy with oxaliplatin and capecitabine; however, treatment was stopped due to adverse reactions. The patient continues to receive regular follow-ups, and her general condition is good. Conclusions: UrC is rare, and preoperative differential diagnosis is difficult. This is the first report of UrC being misdiagnosed as cervical cancer. The presented case highlights the importance of accurate histopathological examination and comprehensive analysis. Anterior pelvic exenteration was also identified as a potentially effective treatment strategy for patients with local pelvic recurrence of UrC, although further investigation is required.

Post-traumatic reactions and quality of life after pelvic exenteration for gynecologic cancer: a retrospective cohort study.

OBJECTIVE: We examined post-traumatic reactions and quality of life in women with recurrent gynecologic cancer who underwent a pelvic exenteration (PE), a potentially life-saving radical surgery associated with life-altering sequelae. METHODS: Twenty-one women who had completed PE at least 6 months prior completed the Impact of Event Scale-Revised, a measure of post-traumatic stress, the Post-Traumatic Growth Inventory, a measure of post-traumatic growth, the Center for Epidemiologic Studies-Depression Scale, and the European Organization for Research and Treatment of Cancer 30-item core Quality of Life Questionnaire. We examined the associations between these outcome variables, and quality of life scores were compared to normative values for the general and gynecologic cancer populations. RESULTS: Thirty percent of women reported clinically significant post-traumatic stress symptoms and 71% endorsed clinically significant depressive symptoms. More post-traumatic stress was associated with less post-traumatic growth, more depressive symptoms, and worse quality of life. In general, women's quality of life was worse than the general population but comparable to women with stage III-IV ovarian cancer and women with cervical cancer. Social functioning was markedly lower in our sample and women reported more pain, diarrhea, and financial difficulties post-PE compared to published norms for the general population and women with ovarian or cervical cancer. There were no differences in quality of life based on age, type of PE, type of urinary diversion, or cancer type. CONCLUSIONS: Findings support long-term continued symptom management and the ongoing rehabilitation of patients to optimize physical, psychological, and social well-being in PE survivorship.

Metastatic conjunctival squamous cell carcinoma presenting as infectious sclerokeratouveitis.

Purpose: We describe a case of metastatic conjunctival squamous cell carcinoma (SCC) presenting as an infectious sclerokeratouveitis in a patient with autoimmune disease. Observations: A 63-year-old Caucasian female presented to the cornea service with a raised perilimbal scleral infiltrate, hypopyon, and corneal perforation concerning for infectious necrotizing sclerokeratoveitis. She had an ocular history of a recurrent "pyogenic granuloma" and her medical history was notable for well-controlled systemic lupus erythematosus and rheumatoid arthritis. Scleral debridement and repair with a corneal patch graft was performed. Bacterial cultures grew 4+ Proteus mirabilis sensitive to tobramycin. One month later, she developed bulky painless scleral lesions with leukoplakic features. A scleral biopsy revealed squamous cell carcinoma. Imaging suggested ciliary body and medial rectus infiltration without perineural invasion. Right anterior exenteration was performed as immunotherapy was felt to be unlikely to achieve success in light of her autoimmune conditions. Six months later, she developed a palpable right parotid mass with biopsy confirming metastatic squamous cell carcinoma. She underwent a right parotidectomy and is now undergoing consolidative radiotherapy. Conclusions and Importance: Ocular surface neoplasia can present as a necrotizing sclerokeratouveitis, contributed by both the tumor and an atypical infectious process. Malignancy with superinfection should be in the differential diagnosis of recurrent ocular surface inflammation.

Immunotherapy in the treatment of rectal invasion by prostate cancer with focal neuroendocrine differentiation: a case report and literature review.

Background: Incidences of rectal infiltration by prostate cancer (PCa) are reported to affect up to 12% of patients studied. PCa invading the rectum is prone to cause difficulty in defecation, bloody stool and pain, leading to a decline in patients' quality of life. Unfortunately, the prognosis for these patients is poor and the survival period is short. Total pelvic exenteration (TPE) has been demonstrated to mitigate pain and improve symptoms such as defecation difficulty, dysuria, and hematuria. However, most patients still harbor residual tumor and fail to exhibit any improvement in long-term survival. Case Description: Here, we present a case of PCa invading the rectum with focal neuroendocrine differentiation, characterized by clinical presentations of defecation difficulties and rectal bleeding. A TPE procedure was performed, with a whole exome sequencing (WES) assay indicating that the patient exhibited a high tumor mutation burden (TMB) and high microsatellite instability (MSI-H). Subsequently, the patient received androgen deprivation therapy (ADT) combined with adjuvant immunotherapy following the procedure. At the subsequent six-year follow-up, no local or systemic recurrence was observed, and the prostate-specific antigen (PSA) level remained undetectable. Conclusions: This disease entity remains relatively rare in the literature. Accurate differential diagnosis is important. TPE combined with immunotherapy may improve the prognosis. It is of utmost importance to achieve an accurate differential diagnosis, which necessitates the collaboration of multiple disciplines and the performance of requisite tests, including immunohistochemistry and genetic testing.

An uncommon case of anorectal malignant melanoma (ARMM): Clinical presentation and surgical outcome.

INTRODUCTION AND IMPORTANCE: Anorectal mucosal melanoma (ARMM) is a rare disease with a poor prognosis. However, surgery is often difficult, due to the lentiginous growth pattern of such melanoma. CASE PRESENTATION: A 61 years old lady presented with anal pain for 1 year, associated with painless fresh per rectal bleeding post defecation and altered bowel habit. Physical examination showed hyperpigmentation at the anal verge, extending to the dentate line. CT, MRI and PET imaging showed localised disease. She underwent pelvic exanteration and radical lymph node dissection with gracilis flap coverage. Post operatively, she recovers well, and was discharged well on day 8. HPE came back as malignant melanoma, with 1 out 12 lymph nodes involved. She was subsequently referred to oncology, started on pembrolizumab immunotherapy. CLINICAL DISCUSSION: Anorectal melanoma is an aggressive disease, often present with delayed diagnosis. Multiple imaging has been proposed, however none is standardized to diagnose ARMM. Immunohistochemical stains such as S-100 protein, MelanA and tyrosinase and with HMB-45 help in diagnosis and are sensitive for melanocytic differentiation. Surgery excision remains the most common and superior initial treatment for ARMM. One retrospective study done to compare different treatment modalities has shown that patients with surgical excision and radiation therapy had the highest median survival at 32.3 months but surgical excision remains the single best modality for ARMM. CONCLUSION: Suspicious hyperpigmentation at the anal region should raise clinical awareness. Surgical excision with optimal margin is indicated to achieve favourable symptom control, reduce local recurrence and improve survival rate.

Serving Queensland: reflecting on geographical access to the pelvic exenteration service in Queensland.

BACKGROUND: Pelvic exenteration for rectal cancer involves a radical multi-visceral resection to improve complete surgical clearance, and access is limited within Queensland. METHODS: A retrospective review of a prospective database of the referrals to the pelvic exenteration service in the Royal Brisbane and Women's Hospital from 2009 to2023. Geographic, as well as clinical and demographic information was collected. RESULTS: One hundred and seventy six patients were referred to the pelvic exenterations service. In total 93 patients were referred from a major city, 52 from inner regional areas, and 31 from outer regional or remote areas. One hundred and three referred patients (58.5%) proceeded to surgery, significantly more of whom were referred from a major city (P < 0.001). Of the patients referred from outer regional, inner regional, and major cities, a similar proportion of patients proceeded to surgery (55%, 52%, and 63.4%). Patients not proceeding to surgery in major cities and inner regional areas were most commonly unfit to proceed, whereas in outer regional areas most patients decided against surgery (61.5%). In the 14-year period, overall referrals increased, with inner regional referrals increasing the most over time. Overall survival was not significantly impacted by remoteness. CONCLUSION: Awareness of the pelvic exenteration service in regional Queensland may have resulted in less referrals to the service. It is important to confirm a broad-reaching service to optimize patient care.

Clinical Outcomes and Prognostic Factors in Eyelid Malignancy: A 17-Year Retrospective Analysis of Surgical Management and Reconstruction Techniques.

Purpose: To assess clinical outcomes in patients undergoing surgical excision and eyelid reconstruction for malignancies. Methods: This 17-year retrospective study (2004-2021) analyzed patients with malignant eyelid tumors who underwent excision and reconstruction. Data on tumor type, size, location, surgical techniques, complications, and prognostic factors for recurrence were evaluated. Result: A total of 152 patients underwent surgical excision and reconstruction for eyelid malignancies. Basal cell carcinoma (52.6%) was the most common, followed by sebaceous cell carcinoma (32.2%). Direct lid closure was the most frequent reconstructive method. Postoperative complications, including ectropion, entropion, and canalicular obstruction, were minimal but required additional surgery in some cases. Recurrence occurred in 13 patients. Lymph node involvement (OR 21.291, p = 0.004) and positive intraoperative frozen margins (OR 7.083, p = 0.018) were significant risk factors for local recurrence. Conclusion: Surgical excision and reconstruction are effective treatments for eyelid malignancies, with techniques tailored to tumor size, location, and extension to ensure proper lid function. Lymph node involvement and positive intraoperative frozen margins are key predictors of local recurrence.

IMPACT organizational survey highlighting provision of services for patients with locally advanced and recurrent colorectal cancer across Great Britain and Ireland.

AIM: Locally advanced and recurrent colorectal cancer represents a complex clinical entity, which requires multidisciplinary decision-making and management. The aim of this work is to understand the provision of clinical services in this cohort of patients across Great Britain and Ireland (GB&I) as a key essential step to help facilitate future service development and improvement. METHOD: A cross-sectional, organizational survey was sent to all colorectal cancer multidisciplinary teams (MDTs) across GB&I. It consisted of 12 key questions addressing the provision of specialist services and advanced surgical techniques. Results are reported in line with the CHERRIES guideline. RESULTS: One hundred and seventy-five MDTs across GB&I participated, with 142 English, 13 Welsh, 14 Scottish, 3 Northern Irish and 3 Irish MDTs. The overall response rate was 93.5% (175/187). Ninety (51.4%) hospital sites reported having a specialist dedicated or subsection MDT. Specialist advanced nursing support was available in 46 (26.2%) hospitals, with a dedicated advanced colorectal cancer outpatient clinic available in 31 (17.7%) hospitals. One hundred and thirteen MDTs (64.5%) offered surgery for advanced colonic cancer, 82 (46.8%) for recurrent colonic cancer, 58 (33.1%) for advanced rectal cancer and 39 (22.2%) for recurrent rectal cancer. A variable number of MDTs offered specialist surgical techniques, including distal sacrectomy [33 (18.9%)], high sacrectomy [16 (9.1%)], complex vascular resection ± reconstruction [33 (18.9%)] and extended lymphadenectomy (pelvic sidewall or para-aortic) [44 (25.1%)]. CONCLUSION: The IMPACT organizational survey highlights the current variation in the delivery and provision of clinical services for patients with advanced and recurrent colorectal cancer across Great Britain and Ireland.

Five-year quality-of-life assessment by urinary diversion type after pelvic Exenterations.

OBJECTIVE: To determine whether urinary diversion procedures performed at time of pelvic exenteration affect quality of life in patients with recurrent gynecologic malignancies. METHODS: We performed a retrospective secondary longitudinal analysis of quality of life according to type of urinary diversion patients received. Participants completed a series of validated questionnaires at various time points. We allocated patients based on urinary diversion type to either the continent group (CD; 29 [55 %]) or noncontinent group (NCD; 24 [45 %]). RESULTS: We noted a significant improvement in global health scores from baseline over time (time p = 0.027). Physical functioning scores showed a statistically significant difference over time (at 24 months: NCD, -4.3 [95 % CI, -14.1 to 5.4]; CD, 0.4 [95 % CI, -7.1 to 7.9]. p < 0.001). Social functioning scores were persistently higher for the CD vs NCD group at all time points but did not differ significantly between the groups at baseline (p = 0.75) or over time within the same group (time p = 0.122). Body image scores significantly decreased (reduced burden) over time for both groups (p = 0.044) and were consistently higher in the NCD vs CD group. CONCLUSIONS: Patients experienced a return to their baseline quality of life within a year of surgery. Clinicians should prioritize and improve identifying and discussing postoperative challenges such as changes in physical and social functioning and body image.

A clinical study of rhino-orbital-cerebral mucormycosis during the COVID-19 pandemic in western Maharashtra.

Background: The aim of the study was to describe the epidemiology and study the risk factors, clinical presentation, management, and outcome of rhino-orbital-cerebral mucormycosis (ROCM) in terms of mortality, exenteration, eye salvage, and vision salvage. Methods: This retrospective, observational study was carried out over a period of two months. A detailed history was noted, and an ophthalmological examination was done. The diagnosis was done by Potassium hydroxide (KOH) mount and fungal culture. Magnetic resonance imaging (MRI) of the orbit, brain, and paranasal sinuses were performed. Medical (intravenous amphotericin B, posaconazole), surgical (retrobulbar amphotericin B injection, exenteration, Functional Endoscopic Sinus Surgery (FESS)), or combined management was evaluated, and clinical outcomes was noted. Results: The mean age of patients was 54.2 years and the male-to-female ratio was 1.77/1. The most common underlying risk factor for ROCM was uncontrolled diabetes mellitus (70%), followed by the use of corticosteroids for the management of coronavirus disease 2019 (COVID-19) infection in 68% of patients. The most common clinical presentation was diminution of vision followed by eschar, ptosis, and proptosis. Medical and FESS were done in all patients; exenteration was done in 12% of patients. Sixty-six percent of patients were alive with regression of ROCM, 20% of patients were alive with residual, 8% of patients were alive with the progression of ROCM, and 6% of patients had expired. Among the ones who are alive, the ocular outcome was orbital exenteration in 12.76%, the eye was salvaged in 25.53 and vision salvage was achieved in 61.70%. Conclusion: ROCM affects older males. Immunosuppression due to COVID-19 infection, diabetes mellitus, and corticosteroid use in the management of COVID-19 are the main risk factors for the development of ROCM. Antifungal therapy along with surgical debridement decreases mortality.

A novel supraorbital surgical approach for enucleation in dromedary camels (Camelus dromedaries): cadaveric study.

BACKGROUND: Enucleation and exenteration are widely utilized ophthalmic procedures in veterinary practice, involving the complete removal of the eye and comprehensive extraction of orbital contents, respectively. These procedures are indicated for pain relief, excision, and management of neoplasia metastases, and addressing severe medically untreatable conditions. AIM: This study aimed to develop an orbital enucleation surgical approach. The study evaluated the applicability of the new approach and investigated the impact of the surgical procedure. METHODS: Anatomical dissection of three cadaveric heads and surgical orbital enucleation in four cadaveric heads were performed. Anatomical data was collected, and feasibility, safety and applicability of the procedure were assessed. RESULTS: Anatomical dissection showed a distinctive large orbital fossa, providing a suitable surgical window to access orbital structures. The procedure was found to be feasible, facilitating the complete removal of the orbital content. Notably, the preservation of intact eyelids was prioritized to enhance cosmetic appearance. CONCLUSION: The presented orbital enucleation technique proved to be feasible, safe, reproducible, and required basic surgical skills to perform.

Endoscopic lavage for an infected pelvic hematoma in a patient with pelvic sepsis after anterior pelvic exenteration.

Anastomotic leakage and subsequent pelvic sepsis are serious complications after surgery for pelvic malignancies, particularly challenging due to the large pelvic cavity dead space post-exenteration. We report a 47-year-old man treated for a severely infected pelvic hematoma and sepsis following anastomotic leakage after anterior pelvic exenteration. Post robot-assisted exenteration for locally advanced sigmoid colon cancer treated with neoadjuvant chemotherapy, a pelvic abscess from anastomotic dehiscence was identified. Initial CT-guided drainage and subsequent laparoscopic drainage were performed. On postoperative day 22, a bleeding left internal iliac pseudoaneurysm required embolization. Despite these efforts, the sepsis worsened due to an enlarged, infected hematoma. Endoscopic lavage, in collaboration with skilled endoscopists, successfully removed the hematoma, leading to an improved inflammatory response, and the patient was discharged. Endoscopic lavage proved to be the safest and most effective treatment for pelvic sepsis with an infected hematoma after various attempted interventions.

Beyond total mesorectal excision: The emerging role of minimally invasive surgery for locally advanced rectal cancer.

Multivisceral resection and/or pelvic exenteration represents the only potential curative treatment for locally advanced rectal cancer (LARC); however, it poses significant technical challenges, which account for the high risk of morbidity and mortality associated with the procedure. As complete histopathologic resection is the most important determinant of patient outcomes, LARC often requires an extended resection beyond the total mesorectal excision plane to obtain clear resection margins. In an era when laparoscopic surgery and robot-assisted surgery are becoming commonplace, the optimal approach to extensive pelvic interventions remains controversial. However, acceptance of the suitability of minimally invasive surgery is slowly gaining traction. Nonetheless, there is still a lack of evidence in the literature about minimally invasive approaches in multiple and extensive surgical resections, highlighting the need for research studies to explore, validate, and develop this issue. This editorial aims to provide a critical overview of the currently available applications and challenges of minimally invasive abdominopelvic surgery for LARC. Furthermore, we discuss recent developments in the field of robotic surgery for LARC, with a specific focus on new innovations and emerging frontiers.

A Case Series of Eye Removal Surgeries: Five Years of Experience at a Tertiary Eye Care Centre in Malaysia.

BACKGROUND: Eye removal surgeries, also called anophthalmic surgeries, are usually performed for a painful blinded eye due to various underlying causes. In this case review, we intended to study the indications, the types of anophthalmic surgeries, and post-operative complications related to eye removal surgeries. METHOD:  Five years of retrospective case review of surgical eye removals was conducted from 1st June 2018 to 31st May 2023 at Hospital Canselor Tuanku Muhriz (HCTM), University of Kebangsaan Malaysia (UKM). Medical record files were used to analyse the age, gender, affected eye, types of surgeries, and indications of the eye removal surgery. RESULTS:  Fourteen eyes underwent anophthalmic surgeries inclusive of evisceration (78.57%, n = 11), enucleation (14.29%, n = 2), and exenteration (7.14%, n = 1). Among the evisceration group, 63.64% (n = 7) were due to endophthalmitis, 27.27% (n = 3) were due to ocular trauma, and 9.09% (n = 1) were done for a painful blind due to neovascular glaucoma. Two enucleation surgeries were performed for retinoblastoma and one exenteration for orbital metastatic malignancy. CONCLUSION:  The preferred choice of anophthalmic surgery was in favour of evisceration, especially when the underlying causes were due to benign conditions. The most common indications of anophthalmic surgeries were endophthalmitis, trauma, and malignancies. Enucleation and exenteration were performed mainly for the blinded eye due to the intraocular malignancies and malignancy with an extraocular spread. A fairly lesser number of anophthalmic surgeries over the five years could imply an improvement in the conservative management approach of a painful blinded eye.

[Pelvic Exenteration - Is it worth taking on greater risk?] / Kismedencei exenteráció ­ érdemes vállalni a nagyobb kockázatot?

Bevezetés: A lokálisan elorehaladott vagy recidív kismedencei daganatok kezelésére a totális (TPE) vagy parciális kismedencei exenteráció (PPE) lehet az egyetlen kuratív mutét, mely a beteg túlélését növelheti. A mortalitáscsökkenés ellenére a morbiditás még mindig magas, az R0 reszekció elérése sokszor nehéz. Anyag és módszer: Retrospektív módon elemeztük az osztályunkon 2016. 09. 01. és 2022. 10. 31. között végzett kismedencei exenteráció (PE) mutéti adatait a morbiditás, mortalitás, specimenhisztológia tekintetében. Az életminoségét az EORTC-QLQ-C30 általános és CR29 vastagbél mutétekhez adaptált kérdéssor segítségével mértük. Eredmények: 32 betegen történt PE. 20 (62,5%) volt no és 12 (37,5%) férfi. A medián életkor 60 év volt (41-82 év, IQR: 13). 7 mutét laparoszkópos (21,8%) és 25 nyitott módon történt (78,2%). 27 esetben (84,3%) primer lokálisan elorehaladott és 5 (15,7%) esetben pedig recidív, lokálisan elorehaladott végbél tumor miatt végeztük a mutétet. A 13 TPE-bol (40,6%), 8 supralevatoricus, záróizom megtartással (SLTPE) és 5 infralevatoricus, záróizom eltávolítással (ILTPE) történt. Supralevatoricus poszterior exenterációt (SLPPE) 16 esetben (50%), infralevatoricus poszterior exenterációt (ILPPE) 3 esetben (9,4%) és S4/5 szintu sacrum reszekciót 5 esetben (15,6%) végeztünk. A kiterjedt medencei és gáti defektus zárása egy vagy kétoldali gluteus maximus musculocutan lebeny alkalmazásával 6 esetben történt (18,75%), anasztomózist 15 betegnél (46,87%) készítettünk. A vizelet-deviáció minden esetben izolált ileum szegmentum alkalmazásával történt Bricker szerint. R0 reszekciót 27 (84,3%), R1 reszekciót 2 (6,25%) esetben igazolt a szövettani vizsgálat, míg 3 esetben (9,375%) R2 reszekció történt. A medián mutéti ido 170 perc volt (60-360 perc, IQR: 97,5). Clavien Dindo ≥ 3 szövodményt összesen 8 esetben (25%) észleltünk. Hasuri tályog 2 esetben, bélelzáródás 1 esetben, rektum csonk nekrózis 1 esetben, vékonybél-perforáció 1 esetben, uretersérülés 1 esetben, beforgatott gluteus maximus musculocutan lebeny részleges elhalása 1 esetben és biológiai háló fölé nyelezett gracilis izomlebenylebeny elhalása 1 esetben fordult elo. Egy beteget veszítettünk el 30 napon belül (3,1%) posztoperatív hasuri vérzés okozta hypovolemias shock miatt. Átlagos kórházi tartózkodás 14,4 nap volt (7-39 nap, SD: 9). A medián túlélés 16,5 hónap (0,67-74 hónap, IQR: 28,5), a medián betegségmentes túlélés 15,5 hónap (0,67-74 hónap, IQR: 29) volt. A QLQ-CR29 vastagbél mutétekhez adaptált életminoség felmérés alapján a funkcionalitást 73%-nak, a panaszokat pedig 15%-nak mértük. Következtetések: A kezdetben palliatív mutétként végzett beavatkozás kuratívvá vált. A radioterápia növeli a negatív reszekciós szél valószínuségét, ami szignifikáns prediktora a betegségmentes túlélésnek (DFS), ugyanakkor pedig a morbiditás, szövodményi kockázat növelésének is a leggyakoribb szignifikáns oka. A PE potenciálisan kuratív mutét lehet lokálisan elorehaladott végbéldaganatok esetén túlélési elonnyel és lokális recidíva csökkenéssel, elfogadható életminoséggel.

A Preliminary Phenomenological Exploration of Experiences of the Empty Pelvis Syndrome Derived From a Modified-Delphi: The Price of Survival Following Pelvic Exenteration for Advanced Pelvic Cancer.

OBJECTIVE: The empty pelvis syndrome (EPS) is common after pelvic exenteration (PE), causing fluid collections, bowel obstruction, perineal sinuses, and fistulas. The best approach to fill the pelvis to mitigate this remains controversial, and the impact of EPS on health-related quality of life (HrQoL) is unknown. This study is the first to begin to explore lived-experiences of EPS complications. METHODS: Unstructured EPS virtual focus group meetings were conducted with a convenience sample of patients who underwent PE, as an extension of a modified-Delphi study. Interpretative phenomenological analysis was conducted on verbatim transcripts to generate group experiential themes. RESULTS: Twelve patients (eight UK, one Dutch, and three Belgian) participated in four focus groups. Eight EPS complications were reported, (two pelvic collections, five chronic perineal sinuses, and one bowel obstruction). Group experiential themes were 'Out of Options', depicting patients forced to accept complications or limited survival; 'The New Normal', with EPS potentially delaying adaptation to post-PE HrQoL; 'Information Influencing Adaptation,' emphasising the significance of patients understanding EPS to cope with its effects; and 'Symptoms,' reporting manifestations of EPS, the resultant physical limitations, and an intangible feeling that patients lost part of themselves. CONCLUSIONS: EPS may influence patient decision-making, regret, adaptation, and information-seeking. It can cause a variety of unpleasant symptoms and physical limitations, which may include phantom phenomenon. This work supports ongoing purposeful HrQoL research to better define these themes.

Locally advanced rectal cancer in a young adult affected with dyskeratosis congenita (Zinsser-Cole-Engman syndrome): a case report.

BACKGROUND: Dyskeratosis congenita (DKC), also known as Zinsser-Cole-Engman syndrome, is a progressive genetic disease with a triad of reticulate skin pigmentation, nail dystrophy, and leukoplakia. Approximately 8-10% of patients with DKC develop malignancies, and cases of colorectal cancer with DKC in young people have been reported previously. CASE PRESENTATION: A 25-year-old man with DKC since approximately 10 years of age developed fever and lower abdominal discomfort. Diagnostic imaging revealed locally advanced rectal cancer with lymph node metastasis, direct invasion of the prostate, and pelvic abscess due to tumor microperforation (cT4bN2M0 cStage IIIC). Biopsy showed well to moderately differentiated ductal adenocarcinoma. Genetic testing was negative for RAS and BRAF gene mutations, and microsatellite instability (MSI) testing was also negative. After sigmoid colostomy, the patient was treated with total neoadjuvant therapy (TNT) with systemic chemotherapy (six courses of FOLFOX + panitumumab) followed by chemoradiation therapy (50.4 Gy with capecitabine). After TNT, the primary tumor and metastatic lymph nodes shrank. According to the findings of colonoscopy and magnetic resonance image (MRI), we diagnosed near complete response (near-CR) and decided to follow the patient without surgery by every 3 months re-evaluation. However, 5 months after TNT, tumor regrowth was detected on colonoscopy and imaging, and the patient underwent total pelvic exenteration. He developed paralytic ileus as a postoperative complication, and was discharged on the 38th postoperative day. Pathological examination revealed a residual tumor with invasion of the periprostatic tissue. There was no metastasis in the pararectal and lateral pelvic lymph nodes, but one extramural non-contiguous cancerous extension (tumor deposit) was observed (ypT4bN1cM0 ypStage IIIC). The patient has been free of recurrence for one year after surgery. CONCLUSIONS: DKC often develops into various tumors in the digestive system at an early age; therefore, appropriate surveillance may be required. In addition, considering that cancers in patients with DKC occur at a young age, fertility preservation and survivorship are also important, and adequate explanations and care should be provided to patients before and after treatment.

Modified posterior pelvic exenteration combined with ileocecal resection for locally advanced endometrial cancer.

There are several retrospective studies which have suggested that optimal cytoreductive surgery for stage IV endometrial cancer improves survival [1-3]. In addition, some investigators have reported that achieving maximal cytoreduction to a visibly disease-free outcome in the abdominal cavity for endometrial cancer with distant metastases can extend patients' survival [4]. Due to the anatomic proximity of the rectosigmoid colon to the female pelvic organs and its involvement in locally advanced endometrial cancer, an en bloc resection of the uterus, adnexa, and rectosigmoid, also known as a modified posterior pelvic exenteration (MPPE), is performed to achieve optimal cytoreduction [5,6]. Additionally, if the tumor has infiltrated the ileal end and/or cecum, ileocecal resection can be added. I report the details of the technique for this surgery requiring intestinal reconstruction. We routinely placed a transanal drainage tube after a MPPE to decrease the rate of anastomotic leakage and the need for a diverting stoma [7]. No visible tumors were observed after surgery. No intraoperative or early postoperative complications occurred. The patient did not have an impediment in her postoperative bladder and bowel function. Concerning the extent of hysterectomy during surgery, the procedure was performed as described in that of a class II hysterectomy [8]. This might partly explain the preservation of these function. Subsequently, she was treated with 6 cycles of doxorubicin and cisplatin chemotherapy. Two years after surgery, she is alive with no evidence of recurrence. The patient provided informed consent for use of this video.

Cost Analysis of Pelvic Exenteration Surgery for Advanced Pelvic Malignancy.

BACKGROUND: Pelvic exenteration (PE) is a radical procedure involving multi-visceral resection for locally advanced pelvic malignancies. Such radical surgery is associated with prolonged operating theater time and hospital stay, as well as a substantial risk of postoperative complications, and therefore significant financial cost. This study aimed to comprehensively detail the inpatient cost of PE at a specialist center in the Australian public sector. METHODS: A retrospective costing review of consecutive PE operations at Royal Prince Alfred Hospital in Sydney between March 2014 and June 2022 was performed. Clinical data were extracted from a prospectively maintained database, and in-hospital costing data were provided by the hospital Performance Unit. All statistical analyses were performed using SPSS. RESULTS: Pelvic exenteration was performed for 461 patients, of whom 283 (61 %) had primary or recurrent rectal cancer, 160 (35 %) had primary or recurrent non-rectal cancer, and 18 (4 %) had a benign indication. The median admission cost was $108,259.4 ($86,620.8-$144,429.3) (Australian dollars [AUD]), with the highest costs for staffing followed by the operating room. Overall, admission costs were higher for complete PE (p < 0.001), PE combined with cytoreductive surgery (CRS) (p < 0.001), and older patients (p = 0.006). DISCUSSION: The total admission cost for patients undergoing PE reflects the complexity of the procedure and the multidisciplinary requirement. Patients of advanced age undergoing complete PE and PE combined with CRS incurred greater costs, but the requirement of a sacrectomy, vertical rectus abdominal flap reconstruction, major nerve or vascular excision, or repair were not associated with higher overall cost in the multivariate analysis.