Fistula-Associated Anal Adenocarcinoma: A 20-Year Single-Center Experience.

BACKGROUND: Fistula-associated anal adenocarcinoma (FAAC) is a rare consequence in patients with long-standing perianal fistulas. A paucity of data are available for this patient collective, making clinical characterization and management of this disease difficult. OBJECTIVE: This study aimed to describe a single-center experience with FAAC patients, their clinical course, and histopathological and molecular pathological characterization. METHODS: All patients receiving surgery for an anal fistula in 1999-2019 at a tertiary university referral hospital were included in this retrospective analysis. Patients with FAAC were eligible for histopathological analysis, including immunohistochemistry and molecular profiling. RESULTS: This study included 1004 patients receiving surgical treatment for an anal fistula, of whom 242 had an underlying inflammatory bowel disease (IBD). Ten patients were diagnosed with a fistula-associated anal carcinoma (1.0%), and six of these patients had an FAAC (0.6%). The mean overall survival of FAAC patients was 24 ± 3 months. FAAC immunohistochemistry revealed positive staining for CK20, CDX2 and MUC2, while stainings for CK5/6 and CK7 were negative. All FAAC specimens revealed microsatellite stability. Molecular profiling detected mutations in 35 genes, with the most frequent mutations being TP53, NOTCH1, NOTCH3, ATM, PIK3R1 and SMAD4. CONCLUSION: FAAC is rare but associated with poor clinical outcome. Tissue acquisition is crucial for early diagnosis and therapy and should be performed in long-standing, non-healing, IBD-associated fistulas in particular. The immunophenotype of FAAC seems more similar to the rectal-type mucosa than the anal glands.

Long-term outcome after SphinKeeper® surgery for treating fecal incontinence-who are good candidates?

PURPOSE: The efficacy of the novel SphinKeeper® procedure for the treatment of fecal incontinence (FI) is not yet well defined. This study aimed to assess long-term functional outcomes after SphinKeeper® surgery. METHODS: We included 32 patients with FI (28 female), who were operated at a tertiary referral center between August 2018 and September 2021. Functional outcome and quality of life were evaluated prospectively using validated questionnaires before and after surgery. Additionally, endoanal ultrasound and anal manometry were conducted prior and after SphinKeeper® implantation. Predictive parameters for treatment success were defined. RESULTS: The mean follow-up time was 22.62 ± 8.82 months. The St. Mark's incontinence score decreased significantly after surgery (median preoperative = 19 (IQR 17-22) versus median last follow-up = 12 (IQR 8-16), p = 0.001). Similarly, physical short-form health survey showed a significant improvement after SphinKeeper® implantation (p = 0.011). Patients with a higher degree of internal sphincter defect showed an improved objective therapy success (r = 0.633, p = 0.015) after SphinKeeper® operation, whereas the type and severity of FI had no impact on the functional outcome. Notably, a higher number of dislocated prostheses (r = 0.772, p = 0.015) showed a significant correlation with reduced improvement of incontinence. CONCLUSION: The SphinKeeper® procedure showed a significant long-term functional improvement in over half of the patients. Patients with a higher internal sphincter defect benefited most, whereas dislocation of the prostheses was associated with less favorable results.

Surgical Technique for Sphinkeeper® Implantation.

Fecal incontinence is a distressing condition characterized by the involuntary loss of solid and liquid stool and gas, It affects a significant proportion of the general population, with a reported prevalence ranging from 1% to 20%. Despite its considerable impact on quality of life, therapeutic options for fecal incontinence remain limited. Current treatment modalities for fecal incontinence include conservative approaches such as dietary modifications, pelvic floor exercises, and pharmacotherapy. Surgical interventions, including sphincteroplasty or sacral nerve stimulation, may be considered in more severe cases. Recently, THD Labs (THD S.p.A. Correggio (RE), Italy) introduced the Gatekeeper® as a novel device that supports the implantation of up to four solid prostheses into the intersphincteric groove. Early data were promising, with success rates above 50% and only a few perioperative complications. Subsequently, Gatekeeper® was modified by increasing the length and number (up to 10) of prostheses, and renamed Sphinkeeper® (THD). With this device, nine to 10 small incisions measuring 2 mm are made at a distance of 2-3 cm from the anus. The intersphincteric space is accessed using the delivery system, and positioning is verified through endoanal ultrasound. This procedure is repeated for all 10 prostheses placed around the entire circumference. The Sphinkeeper® offers the potential to improve the management of fecal incontinence, and offers patients a less-invasive alternative to traditional surgical approaches.

Laparoscopic Sacral Mesh Fixation for Ventral Rectopexy: Clinical Implications From a Cadaver Study.

BACKGROUND: Correct tack placement at the sacral promontory for mesh fixation in ventral mesh rectopexy is crucial to avoid bleeding, nerve dysfunction, and spondylodiscitis. OBJECTIVE: The present cadaver study was designed to assess the true location of tacks after mesh fixation during laparoscopic ventral mesh rectopexy in relation to vascular and nerve structures and bony landmarks. DESIGN: This was an interventional cadaver study. SETTING: This study was conducted after laparoscopic mesh fixation detailed pelvic dissection was performed following a standardized protocol. In addition, 64-row multidetector computed tomography was conducted to further define lumbosacral anatomy and tack positioning. PATIENTS: Eighteen fresh cadavers (10 female, 8 male) were included in this study. MAIN OUTCOME MEASURES: True tack position and vascular and neuronal involvement served as outcome measures. RESULTS: A total of 52 tacks were deployed (median 3, range 2-3 tacks). Median tack distance to the midsacral promontory was 16.1 mm (0.0-54.2). Only a total of 22 tacks (42.3%) were found on the right surface of the S1 vertebra, correlating with the planned deployment area. In 7 cadavers (38.8%), all tacks were deployed on the planned deployment area. The median distance to the major vessels was 10.5 mm (0.0-35.0), which was the internal iliac artery in half of the cases. Median distance of tacks to the right ureter was 32.1 mm (7.5-46.1). Neither major vessels nor the ureter was injured. Dissection of the hypogastric plexus was undertaken in 14 cadavers, and in each cadaver, tacks affected the hypogastric nerve plexus. LIMITATIONS: This study was limited by the moderate number of cadavers. CONCLUSIONS: Tack placement showed significant variation in our specimen, emphasising the need for reliable anatomic landmarks and sufficient exposure during ventral mesh rectopexy. Hypogastric nerve plexus involvement is common, thus detailed functional assessment after surgery is required. It also points out the importance of cadaver studies before implementing new surgical techniques into clinical practice. See Video Abstract at http://links.lww.com/DCR/B827. FIJACIN LAPAROSCPICA DE MALLA SACRA PARA RECTOPEXIA VENTRAL IMPLICACIONES CLNICAS DE UN ESTUDIO SOBRE CADAVERS: ANTECEDENTES:La colocación correcta de la tachuela en el promontorio sacro para la fijación de la malla en la rectopexia con malla ventral es crucial para evitar hemorragias, disfunción nerviosa y espondilodiscitis.OBJETIVO:El presente estudio en cadáveres fue diseñado para evaluar la verdadera ubicación de las tachuelas después de la fijación de la malla durante la rectopexia laparoscópica con malla ventral en relación con las estructuras vasculares y nerviosas y los puntos de referencia óseos.DISEÑO:Estudio intervencionista de cadáveres.AJUSTE:Después de la fijación laparoscópica de la malla, se realizó una disección pélvica detallada siguiendo un protocolo estandarizado. Además, se realizó una tomografía computarizada multidetector de 64 cortes para definir mejor la anatomía lumbosacra y la posición de la tachuela.PACIENTES:Se incluyeron en este estudio dieciocho cadáveres frescos (10 mujeres, 8 hombres).PRINCIPALES MEDIDAS DE RESULTADO:Posición real de tachuela y compromiso vascular y neuronal.RESULTADOS:Se utilizaron un total de 52 tachuelas (mediana 3, 2-3 tachuelas). La distancia media de tachuela al promontorio sacro medio fue de 16,1 mm (0,0-54,2). Solo se encontraron un total de 22 tachuelas (42,3%) en la superficie derecha de la vértebra S1, correlacionándose con el área planificada. En siete cadáveres (38,8%) todas las tachuelas se utilizaron en el área de planificada. La distancia media a los vasos principales fue de 10,5 mm (0,0-35,0), que era la arteria ilíaca interna en la mitad de los casos. La distancia media de las tachuelas al uréter derecho fue de 32,1 mm (7,5-46,1). No se lesionó ni los grandes vasos ni el uréter. La disección del plexo hipogástrico se realizó en 14 cadáveres y en cada cadáver, las tachuelas afectaron el plexo nervioso hipogástrico.LIMITACIONES:Número moderado de cadáveres incluidos en el estudio.CONCLUSIONES:La colocación de tachuelas mostró una variación significativa en nuestra muestra, enfatizando la necesidad de puntos de referencia anatómicos confiables y una exposición suficiente durante la rectopexia con malla ventral. La afectación del plexo nervioso hipogástrico es común, por lo que se requiere una evaluación funcional detallada después de la cirugía. También destaca la importancia de los estudios sobre cadáveres antes de implementar nuevas técnicas quirúrgicas en la práctica clínica. Consulte Video Resumen en http://links.lww.com/DCR/B827. (Traducción-Dr Yolanda Colorado).

Low anterior resection syndrome (LARS) in patients with epithelial ovarian cancer after primary debulking surgery.

OBJECTIVE: To evaluate the prevalence of low anterior resection syndrome (LARS) in patients with debulking surgery for primary advanced epithelial ovarian cancer and to identify potential risk factors for development of LARS. METHODS: We reviewed data on 552 consecutive patients with primary epithelial ovarian cancer (EOC), who underwent upfront or interval cytoreductive surgery including low anterior resection at two different academic institutions (Kliniken-Essen-Mitte, Germany, and Medical University of Vienna, Austria). Intestinal dysfunction was assessed by the validated LARS-questionnaire via telephone call. We performed descriptive statistics and a binary logistic regression model to evaluate risk factors for LARS. RESULTS: In total, 341 patients were eligible and 206 (60.4%) were successfully contacted and provided complete information. Major LARS was observed in 78 (37.9%) patients, minor LARS in 44 (21.4%) patients, and no LARS in 84 (40.8%) patients. The prevalence rate of major LARS was not influenced by time interval between surgery and LARS assessment, type of cytoreductive surgery, and recurrent disease at the time of assessment. In multivariate analyses, number of anastomosis was independently associated with an increased risk for presence of major LARS (OR 3.76 [1.95-7.24]). In the present cohort, 25.2% patients had more than one bowel anastomosis. CONCLUSIONS: LARS in general and major LARS in particular seem to be a frequent long-term complication after debulking surgery including low anterior resection in primary advanced EOC patients. Particularly EOC patients with more than one bowel anastomosis during surgery seem to be at an increased risk for major LARS.

Laparoscopic ventral mesh rectopexy for obstructive defecation syndrome: still the way to go?

Laparoscopic ventral mesh rectopexy (VMR) has become a popular surgical technique for treating women with full-thickness rectal prolapse with a low recurrence rate, as demonstrated by several studies. In addition, it is increasingly applied to female patients with obstructive defecation syndrome (ODS) caused by intussusception ± rectocele. Functional improvement can be achieved in a high number of patients with ODS, but expectations need to be discussed carefully, as a few patients may not benefit at all. In particular, long-term data on functional outcome and complications following laparoscopic VMR for ODS are still lacking in the literature. Notably, laparoscopic VMR appears to be better than alternative operations for prolapse, intussusception, and rectocele in terms of efficacy, recurrence rates, and adverse effects, but there is a lack of evidence directly comparing techniques through randomized controlled trials; thus, its exact role stills needs to be defined in the future.

Minimal-invasive approach for penetrating Crohn's disease is not associated with increased complications.

BACKGROUND: Laparoscopic surgery for penetrating Crohn's disease (CD) still remains highly conflicting due to a lack of sufficient data. Therefore, the following large study was designed to compare postoperative outcomes after minimal-invasive resections for penetrating and non-penetrating CD. METHODS: Consecutive patients, who underwent laparoscopic intestinal resection for symptomatic CD at a tertiary academic referral center, were included. Patients were divided according to perioperative findings in penetrating and non-penetrating type of disease. All clinical data were obtained from an institutional database and analyzed retrospectively. RESULTS: Of 234 patients enrolled, 101 patients [females: n = 54 (53.5 %)] were operated on for non-penetrating CD and 133 patients [females: n = 50 (37.6 %)] for penetrating CD. Fistulas (p < 0.001), inflammatory mass (p < 0.001) and abscess formation (p < 0.001) were observed more frequently in the perforating group. Ileocolic resections were performed predominantly in both groups [perforating CD: n = 110 (82.7 %), non-perforating CD: n = 82 (81.2 %)], with more complex resections (>1 intestinal resection) found in perforating CD (p < 0.001). Conversion rates did not differ significantly. Notably, 30-day postoperative morbidity was comparable for both groups [perforating CD: n = 20 (15 %), non-perforating CD: n = 19 (18.8 %), p = 0.44]. Postoperative complication rates graded according to the Clavien-Dindo classification showed no difference too (p = 0.49). CONCLUSION: Laparoscopic surgery can be conducted safely in selected patients with penetrating CD without increasing the risk of postoperative complications. This finding needs to be implemented in future guidelines.

Rectal cancer surgery in older people does not increase postoperative complications--a retrospective analysis.

BACKGROUND: Rectal cancer surgery in the older population remains a highly controversial topic. The present study was designed to assess whether older patients had an increased risk for postoperative complications after rectal resection for malignancies. METHODS: Consecutive patients (n=627), who underwent rectal cancer resection at a single institution, were included in the study and analyzed retrospectively. Short-term complications were compared between patients≥80 years (n=55) and <80 years (n=572). Additionally, predictive factors for postoperative complications were analyzed. RESULTS: The older aged group showed a significantly higher rate of co-morbidities compared to controls, in terms of cardiovascular and pulmonary diseases (P=0.002, P=0.006). In older patients, a Hartmann's procedure and transanal endoscopic microsurgery (TEM) were performed most frequently (P<0.0001).The overall complication rate was 39% (n=244) (medical: n=59 (9%), surgical: n=185 (30%)), including 24 (44%) complications in the older aged group (medical: n=6 (11%), surgical: n=18 (33%)). Notably, the incidence of surgical and medical complications showed no significant difference between patients and controls (P=0.58, P=0.69).Neurological and cardiovascular disorders were associated with an increased risk for a eventful postoperative course in the older aged group (P=0.03, P=0.04). CONCLUSIONS: Rectal cancer resection can be performed safely in selected older patients. Age itself should not be considered as a risk factor for postoperative complications.

Treatment of fecal incontinence-is there a light in the end of the tunnel?

Fecal incontinence (FI) is a common disease with higher incidence rates in the elderly population. Treatment of affected patients remains challenging and ranges from conservative management to surgical techniques. Despite all efforts patients often undergo several therapeutic measurements to achieve reasonable functional improvements.Although sacral neuromodulation still remains a key therapy with success rates up to 80%, a significant number of patients do not respond sufficiently and require further treatment.Several artificial bowel sphincter devices exist, which can lead to better functional control in selected patients. Notably, complications after these surgeries do occur frequently and the need for implant replacement is still considerable high.A novel anal band, developed by Agency for Medical Innovations (A.M.I., Austria) is currently under evaluation. This device, composed of silicone and polyester, is placed around the anus outside the external sphincter muscle complex aiming to improve stool continence via mechanical pressure. Early results of this new operation are eagerly awaited.

Endosonographic monitoring of Sphinkeeper® prostheses movements: does physical activity have an impact?

The Sphinkeeper® procedure for treating faecal incontinence (FI) may be associated with potential implant migration (IM) and dislocation (ID), with considerable variations regarding their occurrence and effects on consecutive functional outcome. This study assessed IM and ID following the Sphinkeeper® procedure and its correlation with physical activity. This was a prospective observational clinical study of ten patients undergoing Sphinkeeper® operation due to FI between August 2020 and November 2020 at the Medical University of Vienna. Patients were followed-up after 1, 2, 3 and 6 months and 1 year postoperatively. Each follow-up visit included endosonographic monitoring of protheses location and manometric examinations. Additionally, functional outcome and physical activity were assessed using validated standardized questionnaires. The median number of prostheses implanted was 10 (IQR 9-10). The St. Mark's incontinence (SMS) score improved significantly until the last follow-up (p = 0.049), without observing a significant effect on the physical SF-12 score. The median rate of implants leading to IM and ID was 3 (range 1-4) and 2 (range 1-2) after 3 months of follow-up. A strong association of deltaSMS with number of dislocated prostheses at one month after Sphinkeeper® implantation was observed (r = 0.654, p = 0.078). Physical activity, assessed by the international physical activity questionnaire, did not have an impact on the correct prosthesis placement (1 month: p = 0.527; 2 months: p = 0.886; 3 months: p = 0.180; 6 months: p = 0.111). IM and ID of Sphinkeeper® prostheses occurred frequently early after surgery and affected functional outcome negatively. Physical activity did not have an influence on the implants displacement.

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago.

BACKGROUND: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. METHODS: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. RESULTS: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. CONCLUSIONS: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Repeat intestinal resections increase the risk of recurrence of Crohn's disease.

BACKGROUND: Which factors predict recurrence in patients with Crohn's disease in the era of immunosuppressive medications is still under debate. OBJECTIVE: The current study was conducted to assess long-term outcome after ileocolic resection for Crohn's disease and to define predictive factors for surgical relapse. DESIGN: This is a retrospective study. SETTINGS: The study was conducted in a tertiary referral center. PATIENTS: A consecutive cohort of patients (n = 203) with Crohn's disease who underwent ileocolic resection between 1997 and 2006 were analyzed. The mean follow-up time was 8.4 (±2.4) years. MAIN OUTCOME MEASURES: The cumulative probability for repeated intestinal resection for recurrent Crohn's disease was described by Kaplan-Meier curves. Predictors of surgical recurrence were analyzed by univariate tests. RESULTS: One hundred five patients (51.7%) were exposed to azathioprine/6-mercaptopurine, and 28 patients (13.8%) were exposed to tumor necrosis factor-α blockers after operation. During the follow-up period, 32 patients (15.8%) were reoperated on for disease recurrence. At 5 and 10 years after index surgery, 95.5% and 81.3% of the patients had reoperation-free survival. Previous resections for Crohn's disease (HR, 2.981; 95% CI, 1.411-6.29; p = 0.003) and urgent indication for surgery (HR, 2.729; 95% CI, 1.047-7.116; p = 0.03) were significant risk factors for reoperation. In addition, patients with postoperative complications following ileocolonic resection were more likely to require reoperation (HR, 1.712; 95% CI, 041-2.817; p = 0.03). In a multiple Cox regression model, previous intestinal resection for Crohn's disease remained significant (p = 0.0114) with a HR of 2.654 (95% CI, 1.246-5.654). LIMITATIONS: The limitation is the retrospective design of the study, with its potential selection bias. CONCLUSION: In the present analysis, previous intestinal resection for Crohn's disease was found to be an independent risk factor for surgical recurrence. Consequently, shorter surveillance intervals in this group of patients should be considered.

Complete cytoreduction for pseudomyxoma peritonei is optimal but maximal tumor debulking may be beneficial in patients in whom complete tumor removal cannot be achieved.

BACKGROUND: Pseudomyxoma peritonei is a diffuse peritoneal malignancy that generally originates form a perforated appendiceal tumor. Optimal treatment requires extensive surgical resection to achieve complete cytoreduction combined with hyperthermic intraperitoneal chemotherapy. In a proportion of patients this is impossible, in particular, owing to extensive irresectable small-bowel involvement. There is ongoing debate as to the role of maximal tumor debulking in such cases. OBJECTIVE: : The aim of this study was to assess the outcomes of patients who underwent major tumor debulking for pseudomyxoma peritonei of appendiceal origin and to compare outcomes with patients who had complete cytoreduction during the same period. DESIGN: This is a retrospective study. SETTINGS: This investigation was conducted at a tertiary referral center for peritoneal surface malignancy. PATIENTS: A prospective database of 953 consecutive patients with peritoneal malignancy undergoing surgery at a UK national referral center between 1994 and 2012 was analyzed. Of these patients, 748 (78%) had surgery for pseudomyxoma peritonei of appendiceal origin. MAIN OUTCOME MEASURES: Survival, morbidity, and mortality in both groups were compared. Univariate and multivariate analyses were performed to identify negative prognostic factors in the group that underwent major tumor debulking. RESULTS: Complete cytoreductive surgery was achieved in 543/748 (73%) patients, and 205 (27%) had maximal tumor debulking. Median age was 56 years (172 (31.7%) men) in the complete cytoreductive surgery group and 59 years (108 (52.7%) men) in the maximal tumor debulking group. Overall survival at 3, 5, and 10 years was 90%, 82%, and 64% in the complete cytoreductive group and 47%, 30%, and 22% in the maximal tumor debulking group. The median survival in the maximal tumor debulking group was 32.8 months (95% CI, 24.1-41.5). LIMITATIONS: The retrospective analysis of prospective data was a limitation of this study. CONCLUSIONS: Maximal tumor debulking may help patients with pseudomyxoma peritonei in whom complete cytoreduction cannot be achieved with almost half alive at 3 years with long-term survival in some.

Anastomotic leakage after low anterior resection for rectal cancer: comparison of stapled versus compression anastomosis.

PURPOSE: Surgical technique and perioperative management in rectal cancer surgery have been substantially improved and standardized during the last decades. However, anastomotic leakage following low anterior resection still is a significant problem. Based on animal experimental data of improved healing of compression anastomosis, we hypothesized that a compression anastomotic device might improve healing rates of the highest-risk anastomoses. METHODS: All low anterior resections for rectal cancer performed or directly supervised by the senior author between January 2004 and June 2012 were analyzed. Only patients with a stapled or compression anastomosis located within 6 cm from the anal verge were included. Until December 2008, circular staplers were employed, while since January 2009, a novel compression anastomotic device was used for rectal reconstruction exclusively. RESULTS: Out of 197 patients operated for rectal cancer, a total of 96 (34 females, 35.4 %) fulfilled inclusion criteria. Fifty-eight (60.4 %) were reconstructed with circular staplers and 38 (39.6 %) using a compression anastomotic device. Significantly, more laparoscopic procedures were recorded in the compression anastomosis group, but distribution of gender, age, body mass index, American Society of Anaesthesiologists score, rate of preoperative radiotherapy, tumor staging, or stoma diversion rate were similar. Anastomotic leakage was observed in seven cases (7/58, 12.1 %) in the stapled and twice (2/38, 5.3 %) in the compression anastomosis group (p = 0.26). CONCLUSIONS: In this series, rectal reconstruction following low anterior resection using a novel compression anastomotic device was safe and (at least) equally effective compared to traditional circular staplers concerning leak rate.

Technical and functional outcome after sacral neuromodulation using the "H" technique.

BACKGROUND: Sacral neuromodulation (SNM) is a widely accepted treatment for pelvic floor disorders, including constipation and fecal incontinence (FI). In 2017, a standardized electrode placement method, the H technique, was introduced to minimize failure rates and improve clinical outcomes. We aimed to investigate the technical feasibility and functional outcome of the procedure. METHODS: In this prospective study, we evaluated the first 50 patients who underwent SNM according to the H technique between 2017 and 2020 at a tertiary care hospital. Patient demographic and clinical data were collected, and the impact of various factors on patients' postoperative quality of life (QoL) was assessed after a follow-up of 40 months. Functional outcome was monitored prospectively using a standardized questionnaire. RESULTS: Of 50 patients, 36 (72%) reported greater than 50% symptom relief and received a permanent implant (95% CI: 58.3-82.5). We observed 75% success in relieving FI (95% CI: 58.9-86.3) and 64% in constipation (95% CI: 38.8-83.7). Complication occurred in five (10%) patients. Preoperative vs. postoperative physical and psychological QoL, Vaizey score, and obstructed defecation syndrome (ODS) scores revealed significant improvements (all p < 0.01). Male gender was significantly associated with postoperative complications (p = 0.035). CONCLUSION: We provide evidence for the technical feasibility and efficacy of the SNM implantation using the H technique. The medium-term results are promising for patients with FI and constipation. Male patients and those with a BMI > 25 are more prone to perioperative complications.

Meeting actual benchmarks for short- and long-term outcomes after cytoreductive surgery for peritoneal surface malignancy at a newly established academic treatment center.

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is a curative treatment for selected patients with peritoneal surface malignancy. Reaching actual outcomes benchmarks is challenging given the complex nature of peritoneal surface malignancy surgery. The aim of this study was to assess how the benchmarks for morbidity and oncologic outcome can be reached at a newly established program for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. METHODS: Building on existing institutional experience in complex abdominal surgery and interdisciplinary ovarian cancer treatment, a peritoneal surface malignancy center for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy was established at the Medical University of Vienna using a structured mentoring process. This is a retrospective analysis of the first 100 consecutive patients. Morbidity and mortality were assessed using the Clavien-Dindo classification, and oncologic outcomes using overall survival. RESULTS: Major morbidity and mortality were 26% and 3%, and median overall survival was 49.0 months. In patients with colorectal peritoneal metastases, the median overall survival was 35.1 months (all colorectal peritoneal metastases patients) and 48.8 months in the subgroup with Peritoneal Surface Disease Severity Score ≤3. No median overall survival could be calculated in patients with low-grade appendiceal mucinous neoplasms, appendiceal adenocarcinoma, or peritoneal mesothelioma due to >50% of patients being alive at the end of follow-up. CONCLUSION: We show that the current morbidity and oncological outcomes benchmarks can be reached within the first 100 cases of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at a newly established peritoneal surface malignancy center. Previous institutional experience in complex abdominal surgery and a structured mentoring process are key factors in achieving this goal.