Mode of Presentation in 1070 Patients With Perforated Epithelial Appendiceal Tumors, Predominantly with Pseudomyxoma Peritonei.

BACKGROUND: Perforated epithelial appendiceal tumors are uncommon and can give rise to pseudomyxoma peritonei. Pseudomyxoma peritonei is rare, almost always of appendiceal origin, and presents in various ways relevant to abdominal surgeons. OBJECTIVE: The aim of this study was to report the mode of presentation of pseudomyxoma peritonei of appendiceal origin in patients treated in a high-volume UK peritoneal malignancy center. DESIGN: A retrospective observational study was conducted. SETTINGS: This was a single-center study. PATIENTS: Retrospective analysis of a prospective database of consecutive patients undergoing surgery between March 1994 and December 2016 was performed. MAIN OUTCOME MEASURES: Mode of presentation was classified into 7 categories: "histological diagnosis at abdominal surgery for presumed appendicitis," "probable pseudomyxoma peritonei" based on abnormality on cross-sectional imaging (± image-guided biopsy)," "abnormal imaging (other cause suspected) and operative finding of pseudomyxoma peritonei," "diagnostic laparoscopy," "ovarian mass," "new-onset hernia," and "miscellaneous." RESULTS: Overall, 1070 patients underwent surgery (female 61%, male 39%); median age was 57. The mode of presentation was abnormality on cross-sectional imaging in 324 of 1070 patients (30.3%), histological diagnosis at emergency surgery for presumed appendicitis in 203 of 1070 patients (19%), and abnormal imaging with eventual pseudomyxoma peritonei diagnosis in 180 of 1070 patients (16.8%); 124 of 651 women (19.2%) presented with an ovarian mass. New-onset hernia was the presenting feature in 9.9%; 83 of 1070 patients (7.7%) were diagnosed at diagnostic laparoscopy, and 32 of 1070 patients (3%) were described as "miscellaneous." Overall, 775 of 1070 patients (72.4%) had complete cytoreductive surgery with 10-year survival of 63.5%. LIMITATIONS: Results are limited by the retrospective nature of the study, radiological improvements over the study period, and the number of patients who had overlapping features at presentation. CONCLUSION: Perforated appendiceal tumors present in various ways but predominantly at cross-sectional imaging or coincidentally at laparoscopy or laparotomy. All abdominal surgeons will occasionally encounter cases, often unexpectedly, and recognition and referral to a specialized unit results in excellent outcomes in most cases. See Video Abstract at http://links.lww.com/DCR/B256. MODO DE PRESENTACIÓN EN 1070 PACIENTES CON TUMORES EPITELIALES APENDICULARES PERFORADOS, PREDOMINANTEMENTE CON PSEUDOMIXOMA PERITONEAL: Los tumores epiteliales apendiculares perforados son poco frecuentes y pueden dar lugar a Pseudomyxoma peritonei. El pseudomixoma peritoneal es raro, casi siempre de origen apendicular, y se presenta de diversas formas relevantes para los cirujanos abdominales.El objetivo fue informar el modo de presentación del Pseudomixoma peritoneal de origen apendicular en pacientes tratados en un centro de malignidad peritoneal de alto volumen en el Reino Unido.Se realizó un estudio observacional retrospectivo.Este fue un estudio de centro único.Análisis retrospectivo de una base de datos prospectiva de pacientes consecutivos sometidos a cirugía entre marzo de 1994 y diciembre de 2016.El modo de presentación se clasificó en 7 categorías: "diagnóstico histológico en la cirugía abdominal por presunta apendicitis", "probable Pseudomixoma peritoneal" basado en la anormalidad en la imagen de corte transversal (biopsia guiada por imagen +/-), "imagen anormal (se sospecha otra causa) y hallazgo quirúrgico de Pseudomixoma peritoneal", "laparoscopia diagnostica", "masa ovarica", "hernia de reciente aparicion" y "varios".En total, 1070 pacientes fueron operados (mujeres 61%, hombres 39%); edad media 57. El modo de presentación fue anormalidad en la imágen transversal en 324/1070 (30.3%), el diagnóstico histológico en cirugía de emergencia por presunta apendicitis en 203/1070 (19%), la imágen anormal con eventual diagnóstico de Pseudomixoma peritoneal en 180 / 1070 (16.8%), 124/651 (19.2%) las mujeres presentaron una masa ovárica. La hernia de reciente aparición fue la característica de presentación en 9.9%, 83/1070 (7.7%) fueron diagnosticados por laparoscopia diagnóstica y 32/1070 (3%) "misceláneos". En general, 775/1070 (72,4%) se sometió a cirugía citorreductora completa con una supervivencia a 10 años del 63,5%.Una deficiencia es que los resultados están limitados por la naturaleza retrospectiva del estudio, las mejoras radiológicas a lo largo del período de estudio, y varios pacientes tenían características superpuestas en la presentación.Los tumores apendiculares perforados se presentan de varias maneras, pero predominantemente en imágenes transversales o casualmente en laparoscopia o laparotomía. Todos los cirujanos abdominales encontrarán ocasionalmente con casos, a menudo inesperados, y el reconocimiento y la derivación a una unidad especializada da lugar a excelentes resultados en la mayoría de los casos. Consulte Video Resumen en http://links.lww.com/DCR/B256.).

Right colonic transposition technique: when the left colon is unavailable for achieving a pelvic anastomosis.

PURPOSE: On occasion, the left colon is not available for rectal or low pelvic anastomosis either because of synchronous pathology, previous resections, or inadequate blood supply. The short middle colic pedicle prevents use of the transverse colon for this purpose. In this situation, the right colon is a good anastomotic conduit. The aim of this video is to demonstrate the right colonic transposition technique. METHODS: Intraoperative footage was filmed and edited in a multimedia format. Operative details were as follows: the diseased left colon and transverse colon are excised; the right colon is fully mobilized and transposed 180 degrees anticlockwise around the axis of the ileocolic pedicle, so the hepatic flexure reaches into the pelvis without tension. The hepatic flexure is then used for anastomosis within the pelvis either to the residual rectum or anus (see Supplemental Digital Content, Videos 1-3, http://links.lww.com/DCR/A46, http://links.lww.com/DCR/A47, and http://links.lww.com/DCR/A48). Case notes were reviewed to analyze clinical outcome and bowel function. RESULTS: Three patients underwent the technique, 2 females and 1 male (median age, 45 (range, 30-55) years). Median operating time was 98 (range, 95-114) minutes. There were no anastomotic failures or other major complications. One patient had a superficial wound infection. The median in-hospital stay was 7 (range, 7-8) days. The median time to first bowel movement was 3 (range, 3-4) days; the median daily stool frequency was 4 (range, 3-4) on discharge, decreasing to 2 daily stools 12 months after surgery. Stoma formation and total colectomy were successfully avoided in each patient. CONCLUSIONS: Right colonic transposition is a useful technique to enable the construction of a tension-free rectal anastomosis with a good blood supply. The use of the right colon in these clinicopathological situations can be achieved with low morbidity and results in good short- and long-term bowel function in these patients. Careful preservation of the ileocolic pedicle and division of the right colic vessels are essential to facilitate successful anastomosis.

Geographic variation in follow-up after rectal cancer surgery.

Most patients with rectal cancer are treated with curative-intent surgery; adjuvant chemotherapy and radiation are often used as well. A recent survey of members of the American Society of Colon and Rectal Surgeons (ASCRS) revealed considerable variation in surveillance intensity after primary treatment. We evaluated whether geographic factors may be responsible for the observed variation. Vignettes of hypothetical patients and a questionnaire based on the vignettes were mailed to the 1782 members of ASCRS. Repeated-measures analysis of variance was used to compare practice patterns, as revealed by the responses, according to US Census Regions and Divisions, Metropolitan Statistical Areas (MSA), and state-specific managed care organization (MCO) penetration rates. There was significant variation in surveillance intensity according to the US Census Region and Division in which the surgeon practiced. Non-US respondents employed CT of the abdomen and pelvis, chest radiography, and colonoscopy significantly more often than US respondents. MSA was not a significant source of variation. Surveillance patterns varied significantly by MCO penetration rate for office visits and CT of the abdomen and pelvis but not for other modalities. The US Census Region and Division in which the surgeon practices have a significant effect on surveillance intensity following completion of primary curative-intent therapy for rectal cancer patients. The MSA in which the surgeon practices does not affect surveillance intensity significantly and MCO penetration rate affects follow-up intensity minimally. All significant differences are clinically rather modest, however. These data should be useful in the design of controlled trials on this topic.

Patient surveillance after curative-intent surgery for rectal cancer.

The follow-up of patients with rectal cancer after potentially curative resection has significant financial and clinical implications for patients and society. The ideal regimen for monitoring patients is unknown. We evaluated the self-reported practice patterns of a large, diverse group of experts. There is little information available describing the actual practice of clinicians who perform potentially curative surgery on rectal cancer patients and follow them after recovery. The 1795 members of the American Society of Colon and Rectal Surgeons were asked, via a detailed questionnaire, how often they request 14 discrete follow-up modalities in their patients treated for cure with TNM stage I, II, or III rectal cancer over the first five post-treatment years. 566/1782 (32%) responded and 347 of the respondents (61%) provided evaluable data. Members of the American Society of Colon and Rectal Surgeons typically follow their own patients postoperatively rather than sending them back to their referral source. Office visit and serum CEA level are the most frequently requested items for each of the first five postoperative years. Endoscopy and imaging tests are also used regularly. Considerable variation exists among these highly experienced, highly credentialed experts. The surveillance strategies reported here rely most heavily on relatively simple and inexpensive tests. Endoscopy is employed frequently; imaging tests are employed less often. The observed variation in the intensity of postoperative monitoring is of concern.