Factors affecting operative morbidity and long-term outcomes in patients undergoing surgery for presacral tumours: a multicentric cohort study from the Turkish Collaborative Group for Quality Improvement in Colorectal and Pelvic Surgery.

AIM: Data regarding the operative management of presacral tumours present various dilemmas due to their rarity and heterogeneous nature. The aim of this study was to evaluate the management strategy, factors associated with operative morbidity and long-term postoperative outcomes in a large group of patients undergoing surgery for presacral tumours. METHOD: This study was designed as a multicentre retrospective cohort study. Records of patients who underwent surgery for presacral tumours at 10 tertiary colorectal centres between 1996 and 2017 were evaluated. RESULTS: One hundred and twenty seven patients (44 men) with a mean age of 46 years and body mass index of 27 kg/m2 were included. Fifty eight per cent of the patients had low sacral lesions (below S3). The operative approaches were transabdominal (17%), transsacral (65%) and abdominosacral (17%). The postoperative morbidity was 19%. Thirty per cent of the patients had a malignant tumour. Longer duration of symptoms (p = 0.001), higher American Society of Anesthesiologists score (p = 0.01), abdominosacral operations (p = 0.0001) and presacral tumours located above S3 (p = 0.004) were associated with an increased risk of postoperative morbidity. Overall long-term postoperative recurrence and mortality were 6% and 5%, respectively, within a 3-year mean follow-up period in patients with presacral malignant tumours. CONCLUSION: Reduced physical condition, omission of symptoms prior to surgery, combined resections and high sacral tumours are the risk factors associated with postoperative complications in patients undergoing surgery for presacral tumours. Meticulous planning of the operation and intensified perioperative care may improve the outcomes in high-risk patients.

Current Status and Surgical Technique for Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis

Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is the procedure of choice for patients with ulcerative colitis (UC), some patients with colonic Crohn's disease (CD), and those with familial adenomatous polyposis (FAP); albeit, owing to its complexity, it should be performed by experienced professionals. RP/IPAA is the recommended surgical treatment for UC when the standard medical therapy is ineffective. This procedure has been demonstrated to provide patients with a good quality of life, such as in FAP patients with extensive disease in the rectum. The CD has been associated with higher rates of perianal involvement and disease recurrence, but some patients with CD limited to the large intestine and minimal perianal or ileal disease may also be considered for this operation. First, all patients undergo a detailed preoperative evaluation that includes a review of previous imaging, pathology, and colonoscopy findings, a perianal examination, an evaluation of the anorectal functions, mechanical bowel preparation, and prophylaxis against deep venous thrombosis and infectious complications. A staged approach is the most commonly preferred technique for RP/IPAA, which can be performed in 2 or 3 stages. The IPAA can be performed by laparoscopic, robotic, or open approach. The type of approach is determined based on the patient's condition, medication used, elective or emergency setting, and the surgeon's expertise level. A successful IPAA requires tension-free pouch anastomosis. The most common IPAA pouch types are the J or S pouches; alternatively, an H pouch may be created, which is mainly used in redo pouches. In experienced centers, > 95% of the patients become stoma-free in 10 years. IPAA is a complex procedure, and the complications after pouch surgery are pouchitis, pelvic sepsis, pouch failure, or anastomotic stricture. The majority of long-term complications can be prevented in such cases with a comprehensive preoperative evaluation and through the use of appropriate surgical techniques and postoperative care conducted at experienced centers. The techniques for performing RP/IPAA with their long-term outcomes have been reviewed in this article.