The percentage of mesorectal infiltration as a prognostic factor after curative surgery for pT3 rectal cancer.

AIM: The aim of this study is to evaluate the prognostic value of a novel variable - the percentage of mesorectal infiltration (PMI) - in pT3 rectal cancer. METHOD: A cohort of 241 patients with pT3 rectal adenocarcinoma, operated on between February 2002 and May 2019, was selected for the analysis. Data concerning patient, treatment and tumour characteristics were collected. The depth of mesorectal infiltration (DMI) and the distance between the deepest invasion and the circumferential resection margin (CRM) were measured. The PMI was calculated using a formula combining these parameters. RESULTS: Neoadjuvant therapy was administered in 33.2% of cases. A complete mesorectal excision was achieved in 74% of patients. The CRM was affected in 24 patients (9.9%). The 5-year actuarial local recurrence (LR), overall recurrence (OR) and overall survival (OS) rates were 7.5%, 22.9% and 72.4%, respectively. The PMI was significantly associated with worse oncological outcomes regarding LR (p = 0.009), OR (p = 0.001) and OS (p = 0.016) rates. A cut-off value of PMI >60% had the highest specificity (80%) for LR (p = 0.026), OR (p = 0.04) and OS (p = 0.07). CONCLUSION: The PMI has an adverse prognostic impact on the oncological results following surgery for pT3 rectal cancer. It allows prediction of the risk of both LR and distant recurrence with higher accuracy than the DMI or the distance to the CRM. A PMI >60% may be used as a cut off value while subclassifying pT3 rectal tumours. It may influence decision-making while establishing adjuvant treatment and the follow-up schedule.

Gender dysphoria: laparoscopic sigmoid vaginoplasty. Another utility of indocyanine green.

AIM: Gender dysphoria is the disagreement between the gender of birth and the one with which the patient identifies. For its management it is mandatory to have a multidisciplinary team. Gender confirmation surgery with penoscrotal skin flap is the procedure of choice, and a sigmoid vaginoplasty is a feasible alternative. The new technologies and the help of indocyanine green (ICG) fluorescence can help to guarantee a correct neovagina vascularization. The objective of this paper is to present the surgical technique of laparoscopic sigmoid vaginoplasty assisted by ICG. METHODS: We present two patients with gender dysphoria and a history of stricture of the penoscrotal skin flap vaginoplasty. We performed sigmoid vaginoplasty by the laparoscopic approach. We began the procedure with the mobilization and section of 30 cm of sigmoid colon, selective ligation of the vessels assisted by ICG, 180° sigmoid rotation, externalized on antiperistaltic position, construction of colovestibular anastomosis and promontory fixation. We finished the procedure with virtual ileostomy construction and drain placement. RESULTS: Patients recovered satisfactorily and were discharged on the seventh day after surgery without complications. CONCLUSION: Sigmoid vaginoplasty is a safe and feasible procedure. ICG has great value, contributing to the selective ligation of the vessels, allowing 180° sigmoid rotation and guaranteeing the irrigation of the neovagina.

A video guide of five access methods to the splenic flexure: the concept of the splenic flexure box.

AIM: The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to show SFM approaches in an easy and practical way to make it easy to learn and teach. METHODS: Two different phases. First part: Cadaver-based study of the colonic splenic flexure anatomy. In order to demonstrate the different approaches, a balloon was placed through the colonic hepatic flexure in the lesser sac without sectioning any of the fixing ligaments of the splenic flexure. Second part: A real case series of laparoscopic SFM. RESULTS: First part: 11 cadavers were dissected. Five potential approaches to SFM were found: anterior, trans-omentum, lateral, medial infra-mesocolic, and medial trans-mesocolic. The illustrative system developed was named: Splenic Flexure "Box"(SFBox). Second part: One of the types of SFM described in first part was used in five patients with colorectal cancer. Each laparoscopic approach to the splenic flexure was illustrated in a video accompanied by illustration aids delineating the access. CONCLUSION: With the cadaver dissection and subsequent demonstration in real-life laparoscopic surgery, we have shown five types of laparoscopic splenic flexure mobilization. The Splenic Flexure "Box" is a useful way to learn and teach this surgical maneuver.

Simulation of Supralevator Abscesses and Complex Fistulas in Cadavers: Pelvic Dissemination and Drainage Routes.

BACKGROUND: Most perianal abscesses have a cryptoglandular origin, following the pathogenesis described by Parks in 1961. Supralevator abscesses have the most uncommon location. Nevertheless, such pathology results in a high morbidity because of their difficult diagnosis and treatment. OBJECTIVE: This study aimed to deepen the knowledge of the pathogenesis and management of supralevator abscesses, as well as the complications derived from incorrect treatment, by using simulation in cadavers. DESIGN: This study is an anatomosurgical description of pelvic and perianal zone and simulation of the different types of supralevator abscesses, their correct drainage routes, and secondary complex fistulas due to incorrect drainage. SETTINGS: This dynamic article is based on cadaveric simulation. PATIENTS: Three cadaveric pelvises (2 male and 1 female) were prepared in formalin and sagittally sectioned, and one perineal dissection was performed of a fresh male pelvis. This is an iconographic description of 3 patients treated for supralevator abscesses in our colorectal surgical unit. MAIN OUTCOME MEASURES: The virtual anatomical spaces map out a correct treatment. RESULTS: We reproduced the origin of the different types of supralevator abscesses, as well as their locations and possible drainage pathways, and we determined the definitive treatment of secondary fistulas and their morbidity due to their incorrect drainage. LIMITATIONS: The limitations of this study are inherent to anatomical studies without real case intervention. CONCLUSIONS: A proper anatomical knowledge of the supralevator abscesses and surgical training by using cadaveric simulations could improve the diagnostic criteria, facilitate the correct decision on surgical drainage pathways, and, thus, decrease postoperative morbidity in patients with this disease.

How to reduce the superior mesenteric vein bleeding risk during laparoscopic right hemicolectomy.

PURPOSE: The superior right colic vein (SRCV) has been proposed as the main cause of superior mesenteric vein bleeding by avulsion during laparoscopic right hemicolectomy. Our objective is to identify the main vessel causing transverse mesocolic tension during the extraction of the surgical specimen or extracorporeal anastomosis and to perform an anatomical description of the SRCV. METHODS: In this cadaveric study, we performed a simulation of right hemicolectomy and anatomical description of the surgical area of the gastrocolic trunk of Henle (SAGCTH), the gastrocolic trunk of Henle (GCTH), and SRCV. The length of the exteriorization of the anastomotic transverse colon (ATC) was measured before and after sectioning the vascular vessel causing the exteriorization tension. RESULTS: Five fresh cadavers and 12 formalin were dissected. In 100% of the specimens, the SRCV was present and drained in 95% into the GCTH and in 5% directly into the superior mesenteric vein (SMV). In 100% of the specimens, the SRCV caused the tension when extracting the ATC. The mean length of exteriorization of the ATC before and after SRCV section was 7.2 and 10.4 cm in formalin cadavers, meaning a 44% of increment in the length of exteriorization. In fresh cadavers, the mean length of exteriorization increased to 2.7 cm, meaning a 28% of the initial length of exteriorization. CONCLUSIONS: The SRCV is the main cause of tension in the extraction of the surgical specimen after right hemicolectomy. Its high tie increases the length of the ATC exteriorization, in about 3 cm, and could reduce the risk of SMV bleeding during laparoscopic right hemicolectomy and facilitate an extracorporeal anastomosis free of tension.

Standard outcome indicators after colon cancer resection. Creation of a nomogram for autoevaluation. / Resultados quirúrgicos estándar tras resección oncológica de colon. Creación de un nomograma para la autoevaluación.

INTRODUCTION: Lately there has been an increasing interest in identifying quality standards in different pathologies, among them colon cancer due to its great prevalence. The main goal of this study is to define the quality standards of colon cancer surgery based on a large prospective national study dataset. METHODS: Data from the prospective national study ANACO were used. This study included a consecutive series of patients operated on for colon cancer in 52 Spanish hospitals (2011-2012). Centers with less than 30 patients were excluded. The present analysis finally included 42 centers (2975 patients). Based on the results obtained in 4main indicators from each hospital (anastomotic leak, lymph-nodes found in the specimen, mortality and length of stay), a nomogram that allows the evaluation of the performance of each center was designed. Standard results for further 5 intraoperative and 5 postoperative quality indicators were also reported. RESULTS: Median of anastomotic leak and mortality rate was 8.5% (25th-75th percentiles 6.1%-12.4%) and 2.5% (25th-75th percentiles 0.6%-4.7%), respectively. Median number of nodes found in the surgical specimen was 15,1 (25th-75th percentiles 18-14 nodes). Median length of postoperative stay was 7.7 days (25th-75th percentiles 6.9-9.2 days). Based on these data, a nomogram for hospital audit was created. CONCLUSIONS: Standard surgical results after colon cancer surgery were defined, creating a tool for auto-evaluation and allowing each center to identify areas for improvement in the surgical treatment of colon cancer.

Total pelvic exenteration extended to pelvic bones with subsequent VRAM flap reconstruction in patient with recurrent anal squamous cell carcinoma following chemoradiotherapy.

Anal squamous cell carcinoma, typically associated with human papillomavirus infection, remains a rare malignancy. This article outlines a case of local recurrence in a male patient with a history of HIV and hepatitis C virus infection, previously treated with chemoradiotherapy. Extensive tumour involvement called for total pelvic exenteration extended to anterior osteomuscular compartment and genitalia. The surgical approach involved multidisciplinary collaboration and detailed preoperative planning using three-dimensional reconstruction. Key surgical considerations comprised the following: achieving tumour-free margins (R0 resection), extensive osteotomies and intricate pelvic floor reconstruction with prosthetic mesh and flap reconstruction. The procedure successfully yielded an R0 resection, maintaining adequate lower limb functionality. Our case report underscores the benefits of pelvic exenteration in locally advanced or recurrent pelvic tumours, invariably following careful patient selection and exhaustive preoperative studies.

Primary Papillary Colonic Adenocarcinoma With PDGFRA Mutation. A New Morphological Subtype? A Case Report and Review of Literature.

Classic colon carcinomas are defined as adenocarcinomas, characterized by groups of medium/large cells with basophilic and polymorphous nuclei and an eosinophilic elongated cytoplasm, that rearrange on glandular structures. Signs of poor prognosis include high tumor budding, lymphovascular and perineural invasion, poor differentiation, positive margins, and CDX2 loss. Less frequent colon carcinoma subtypes are: mucinous, medullary, signet-ring cell, squamous cell, small cell and undifferentiated carcinoma, among others. In the following case report, we present a 65-year-old woman with a T2N0Mx colon carcinoma with a remarkable papillary and follicular histological appearance. The immunohistochemical stains confirmed an intestinal origin (CDX2+) and excluded a thyroid, gynecological, and urological metastasis, with tumor cells negative for GATA3, PAX8, TTF-1, and thyroglobulin. There was no loss of mismatch repair proteins and p53 showed a wild-type staining. next generation sequencing showed a platelet-derivated growth factor receptor alpha (PDGFRA) mutation. To the best of our knowledge, there have been only two examples of primary papillary colon carcinoma reported in the literature, and neither of them with a PDGFRA mutation. We describe one tumor and discuss its pathological features.

A comparison of whole-mount and conventional sections for pathological mesorectal extension and circumferential resection margin assessment after total mesorectal excision.

INTRODUCTION: The objective of the study is to compare 2 techniques for histological handling of rectal cancer specimens, namely whole-mount in a large block vs conventional sampling using small blocks, for mesorectal pathological assessment of circumferential resection margin status and depth of tumor invasion into the mesorectal fat. METHODS: This is a prospective study including 27 total mesorectal excision specimens of rectal cancer from patients treated for primary rectal carcinoma between 2020 and 2022 in a specialized multidisciplinary Colorectal Unit. For each total mesorectal excision specimen, 2 contiguous representative tumoral slices were selected and comparatively analyzed with whole-mount and small blocks macroscopic dissection techniques, enabling comparison between them in the same surgical specimen. The agreement between the 2 techniques to assess the distance of the tumor from the circumferential resection margin as well as the depth of tumor invasion was evaluated with the Student's t-test for paired samples, Pearson's correlation coefficient, and the Bland-Altman method comparison analysis. RESULTS: Complete mesorectal excision was observed in 8% of cases. Circumferential resection margin involvement was observed in only one case (4 %). The whole-mount and small block techniques obtained similar results when we assessed the distance to the circumferential resection margin (t-test P = 0.8, r = 0.92) and the depth of mesorectal infiltration (t-test P = 0.6, r = 0.95). CONCLUSIONS: Both gross dissection techniques (whole-mount vs multiple small cassettes) are equivalent and reliable to assess the distance to circumferential resection margin and the depth of mesorectal infiltration in the mesorectal fat in rectal cancer staging.

Early colorectal cancer diagnosed after endoscopic resection: Conservative treatment is safe in most of the cases. Proposal for a risk-based management.

INTRODUCTION: Endoscopic resection offers advantages over surgical resection for early colorectal cancer (ECC). However, there might be a presumed risk of recurrence. We aimed to determine the risk of recurrence after endoscopic removal of ECC. METHODS: A single-centre series of endoscopic resections for ECC. Patients were stratified according to four risk factors: positive resection margins, Haggitt 4, lymphatic/vascular invasion and tumour budding. RESULTS: We included 127 patients. Haggitt classification was grade 4 in 54.0%. Positive margins were found in 43 (33.9%), 16 (12.6%) had lymphatic or vascular invasion, and 5 (4.0%) had high grade budding. In 82 (64.5%) endoscopic excision was the definitive treatment, 45 (35.4%) underwent surgery. Six patients (13.3%) had residual tumour on specimen and/or node metastases. Postoperative complications occurred in ten (22.2%). At a median follow-up of 63 months, none of the 82 patients treated with endoscopic resection alone had recurrence. After stratifying patients according to risk factors, those who had residual tumour also had ≥2 risk factors. CONCLUSIONS: Endoscopic follow up might be a valid option for patients with ECC. A risk-adjusted management seems prudent.

Early colorectal cancer diagnosed after endoscopic resection: Conservative treatment is safe in most of the cases. Proposal for a risk-based management.

INTRODUCTION: Endoscopic resection offers advantages over surgical resection for early colorectal cancer (ECC). However, there might be a presumed risk of recurrence. We aimed to determine the risk of recurrence after endoscopic removal of ECC. METHODS: A single-centre series of endoscopic resections for ECC. Patients were stratified according to four risk factors: positive resection margins, Haggitt 4, lymphatic/vascular invasion and tumour budding. RESULTS: We included 127 patients. Haggitt classification was grade 4 in 54.0%. Positive margins were found in 43 (33.9%), 16 (12.6%) had lymphatic or vascular invasion, and 5 (4.0%) had high grade budding. In 82 (64.5%) endoscopic excision was the definitive treatment, 45 (35.4%) underwent surgery. Six patients (13.3%) had residual tumour on specimen and/or node metastases. Postoperative complications occurred in ten (22.2%). At a median follow-up of 63 months, none of the 82 patients treated with endoscopic resection alone had recurrence. After stratifying patients according to risk factors, those who had residual tumour also had ≥2 risk factors. CONCLUSIONS: Endoscopic follow up might be a valid option for patients with ECC. A risk-adjusted management seems prudent.

Postoperative Complications in Hemorrhoidal Disease and Special Conditions.

BACKGROUND: Hemorrhoidal disease is still one of the most prevalent proctological diseases. Pain is the most common complication after surgery but bleeding, urinary retention and perianal infection are also frequent. There is also an important group of patients, such as those with inflammatory bowel disease, pregnancy or immunosuppression, who can present an increased rate or more severe complications. OBJECTIVE: To describe the complications following different surgical and instrumental techniques for hemorrhoids in a literature review. Special situations were reviewed to determine how they affect the management of the disease. METHODS: During August 2019, a narrative review of hemorrhoid surgery complications and special situations was performed using the Pubmed MESH DATABASE. CONCLUSION: Pain, urinary retention and bleeding remain the most frequent complications after surgery for hemorrhoids; however, special situations must be taken into account in order to choose the best technique to prevent more severe complications.

Inflammatory Bowel Disease patients requiring surgery can be treated in referral centres regardless of the COVID-19 status of the hospital: results of a multicentric European study during the first COVID-19 outbreak (COVIBD-Surg).

Outcomes of inflammatory bowel disease (IBD) patients requiring surgery during the outbreak of Coronavirus disease 19 (COVID-19) are unknown. Aim of this study was to analyse the outcomes depending on the COVID-19 status of the centre. Patients undergoing surgery in six COVID-19 treatment and one COVID-free hospitals (five countries) during the first COVID-19 peak were included. Variables associated with risk of moderate-to-severe complications were identified using logistic regression analysis. A total of 91 patients with Crohn's disease (54, 59.3%) or ulcerative colitis (37, 40.7%), 66 (72.5%) had surgery in one of the COVID-19-treatment hospitals, while 25 (27.5%) in the COVID-19-free centre. More COVID-19-treatment patients required urgent surgery (48.4% vs. 24%, p = 0.035), did not discontinue biologic therapy (15.1% vs. 0%, p = 0.039), underwent surgery without a SARS-CoV-2 test (19.7% vs. 0%, p = 0.0033), and required intensive care admission (10.6% vs. 0%, p = 0.032). Three patients (4.6%) had a SARS-CoV-2 infection postoperatively. Postoperative complications were associated with the use of steroids at surgery (Odds ratio [OR] = 4.10, 95% CI 1.14-15.3, p = 0.03), presence of comorbidities (OR = 3.33, 95% CI 1.08-11, p = 0.035), and Crohn's disease (vs. ulcerative colitis, OR = 3.82, 95% CI 1.14-15.4, p = 0.028). IBD patients can undergo surgery regardless of the COVID-19 status of the referral centre. The risk of SARS-CoV-2 infection should be taken into account.

Small bowel obstruction secondary to a pericecal hernia in an adult patient, an extremely rare condition.

Internal hernias are defined by the protrusion of an abdominal organ through a peritoneal or mesenteric aperture. They are responsable for up to 5.8% of all small bowel obstructions (SBOs). Pericecal hernia is a highly unusual variation. We present a case of a 17-year-old Asian male turned to the emergency department due to abrupt abdominal pain and peritonitis. An emergent laparotomy revealed a small bowel herniation through the avascular space of Treves with small bowel necrosis. A pericecal hernia is an extremely unusual clinical entity; however, it should be considered in the differential diagnosis of SBO.

ANTECEDENTES: La hernia interna se define como la protrusión de un órgano abdominal a través de un orificio peritoneal o mesentérico. Las hernias son causa de hasta el 5% de las obstrucciones de intestino delgado. La hernia pericecal es un subtipo extremadamente infrecuente. Presentamos el caso de un varón asiático de 17 años que acudió a nuestro centro por un cuadro de abdomen agudo con dolor y peritonitis. Durante la laparotomía se evidenció la herniación del intestino delgado a través del espacio avascular de Treves, con necrosis del mismo. La hernia pericecal es un subtipo extremadamente raro, pero que debemos plantearnos en el diagnóstico diferencial del síndrome de obstrucción intestinal.