Management of acute and chronic pelvic sepsis after total mesorectal excision for rectal cancer-a 10-year experience of a national referral centre.

AIM: Uncontrolled pelvic sepsis following rectal cancer surgery may lead to dramatic consequences with significant impact on patients' quality of life. The aim of this retrospective observational study is to evaluate management of pelvic sepsis after total mesorectal excision for rectal cancer at a national referral centre. METHOD: Referred patients with acute or chronic pelvic sepsis after sphincter preserving rectal cancer resection, with the year of referral between 2010 and 2014 (A) or between 2015 and 2020 (B), were included. The main outcome was control of pelvic sepsis at the end of follow-up, with healed anastomosis with restored faecal stream (RFS) as co-primary outcome. RESULTS: In total 136 patients were included: 49 in group A and 87 in group B. After a median follow-up of 82 months (interquartile range 35-100) in group A and 42 months (interquartile range 22-60) in group B, control of pelvic sepsis was achieved in all patients who received endoscopic vacuum assisted surgical closure (7/7 and 2/2), in 91% (19/21) and 89% (31/35) of patients who received redo anastomosis (P = 1.000) and in 100% (18/18) and 95% (41/43) of patients who received intersphincteric resection (P = 1.000), respectively. Restorative procedures resulted in a healed anastomosis with RFS in 61% (17/28) of patients in group A and 68% (25/37) of patients in group B (P = 0.567). CONCLUSION: High rates of success can be achieved with surgical salvage of pelvic sepsis in a dedicated tertiary referral centre, without significant differences over time. In well selected and motivated patients a healed anastomosis with RFS can be achieved in the majority.

Rare case of perforated appendicitis presenting as persistent perineal discharge following laparoscopic abdominoperinal excision of rectum (APER).

Abdominoperineal excision of rectum (APER) is one of the widely used surgical procedures to treat low rectal cancer, benign conditions like Crohn's proctitis with anal involvement and as a salvage procedure for anal cancer. Perineal wound infection is a well-recognised complication following such major surgery. Occurrence of appendicitis in a few weeks' time following such a major surgery is uncommon. However, here we present a rare case report of perforated appendicitis presenting as persistent perineal discharge in an elderly man, following laparoscopic APER for a low rectal tumour. To our knowledge, this is the first time such a rare clinical presentation of appendicitis is reported in the history of medical literature. Through this case report, we aim to highlight the importance of considering such an uncommon presentation in patients with perineal discharge, following APER.

[Analysis of the effect of transgluteal percutaneous drainage in the treatment of deep pelvic abscess].

Objective: To investigate the safety and feasibility of transgluteal percutaneous drainage using double catheterization cannula in the treatment of deep pelvic abscess. Methods: A retrospective analysis of the clinical data of patients who underwent transgluteal percutaneous drainage using double catheterization cannula with deep pelvic abscesses admitted to the Jinling Hospital from May 2017 to September 2020 was conducted. Seven patients were enrolled, including 5 males and 2 females, who aged 26-74 (median 53.0) years old, and all of them had digestive fistula. One male patient was punctured again due to the tube falling off, and a total of 7 patients underwent 8 times of transgluteal percutaneous drainage, all under the guidance of CT. The puncture and drainage steps of the double catheterization cannula group are as follows: (1) Locate the puncture point under CT in the lateral position; (2) Place the trocar into the abscess cavity; (3) Confirm that the trocar is located in the abscess cavity under CT; (4) Pull out the inner core and insert into the double catheterization cannula through the operating hole; (5) Confirmthat the double catheterization cannula is located in the abscess cavity under CT; (6) The double catheterization cannula is properly fixed to prevent it from falling off. The white blood cells, C-reactive protein (CRP), procalcitonin, and interleukin-6 (IL-6) of all patients before the drainage and 1 days, 3 days, and 5 days after the drainage were collected, as well as the bacterial culture results of the drainage fluid. The changes of various infection biomarkers before and after the drainage were compared. Results: All 7 patients were cured. No complications such as hemorrhage and severe pain were observed. The average time with drainage tube was 60.8 (18-126) days. Five patients finally underwent gastrointestinal reconstruction surgery due to gastrointestinal fistula. The median serum interleukin-6 of patients before drainage, 1 day, 3 days and 5 days after drainage were 181.6 (113.0, 405.4) µg/L, 122.2 (55.8, 226.0) µg/L, 59.2 (29.0,203.5) µg/L and 64.1 (30.0,88.4) µg/L, respectively.The level of serum interleukin-6 at 3 days and 5 days after drainage was significantly lower than before drainage (F=3.586, P=0.026). Although the white blood cell count, C-reactive protein, and procalcitonin decreased gradually after drainage compared with before drainage, the difference was not statistically significant (all P>0.05). Conclusion: Transgluteal percutaneous drainage with double catheterization cannula is simple and effective, and can be used for the treatment of deep pelvic abscess.

Drenaje de abscesos pélvicos posquirúrgicos guiado por ecoendoscopia mediante prótesis de aposición luminal / EUS-guided drainage of postsurgical pelvic abscesses using lumen-apposing metal stents

El drenaje guiado por ecoendoscopia (USE) de colecciones pélvicas es una alternativa al drenaje percutáneo o quirúrgico. Se presenta nuestra experiencia con el uso de prótesis de aposición luminal (LAMS) en el drenaje de abscesos pélvicos posquirúrgicos

Endoscopic ultrasound (EUS) guided drainage of pelvic collections is an alternative to percutaneous or surgical drainage. We present our experience using lumen-apposing metal stents (LAMS) for the drainage of postoperative pelvic abscesses

Endoscopic ultrasound guided versus surgical transrectal drainage of pelvic abscesses.

BACKGROUND: Pelvic abscesses are common but only small case series reporting outcome of either endoscopic ultrasound (EUS) guided or surgical transrectal drainage have been reported. METHODS: We performed a retrospective consecutive cohort study, assessing effectivity and safety of EUS guided or surgical transrectal drainage of previously untreated pelvic abscesses from all causes, diagnosed using CT scan between 09/2010 and 06/2014 in a Dutch teaching hospital. RESULTS: Forty-six patients with comparable demographics, apart from stoma presence (p = .016), were included. The success rate after a single intervention was 83% in the EUS guided compared to 48% in the surgical transrectal drainage group (p = .013). However, the mean duration of drainage was threefold in the EUS group [42 versus 13 days (p = .001)]. The length of stay in hospital was similar for both EUS and surgical group [24 versus 20 days (p = .56)] as was abscess resolution during follow-up [78% versus 74%]. We recorded a total of 12 anastomotic leaks [3 versus 9]. In the occurrence of leakage, only one stoma was finally closed in each group. CONCLUSION: EUS guided and surgical transrectal drainage of pelvic abscesses from any cause are safe, nonetheless EUS guided drainage(if feasible) seems more effective after a single treatment, with high overall cure rates.

Low Hartmann's procedure or intersphincteric proctectomy for distal rectal cancer: a retrospective comparative cohort study.

PURPOSE: Two non-restorative options for low rectal cancer not invading the sphincter are the low Hartmann's procedure (LH) or intersphincteric proctectomy (IP). The aim of this study was to compare postoperative morbidity with emphasis on pelvic abscesses after LH and IP. METHODS: All patients that had LH or IP for low rectal cancer were included in three centres between 2008 and 2014 in this retrospective cohort study. Follow-up was performed for at least 12 months. RESULTS: A total of 52 patients were included: 40 LH and 12 IP. Median follow-up was 29 months (IQR 23). There were no differences between groups in gender, age and ASA classification. Seven patients in the LH group (18%) and four patients in the IP group (33%) developed a complication within 30-day postoperative with a Clavien-Dindo classification grade III or higher (P = 0.253). Four out of 40 patients (10%) in the LH group and two out of 12 patients (17%) in the IP group developed a pelvic abscess (P = 0.612). Reinterventions were performed in 11 (28%) patients in the LH group and five (42%) patients in the IP group (P = 0.478), with a total number of reinterventions of 13 and 20, respectively. Six and 15 interventions were related to pelvic abscesses, respectively. CONCLUSION: Pelvic abscesses seem to occur in a similar rate after both LH and IP. Previous reports from the literature suggesting that IP might be associated with less infectious pelvic complications compared to LH are not supported by this study, although numbers are small.

[Genital actinomycosis and pelvic abscesses in a woman with a 13-year-old intrauterine device].

A 55-year-old woman who had had the same intrauterine device (IUD) for 13 years was referred to the gynaecology outpatient clinic due to constitutional symptoms, abdominal pain and vaginal discharge. Diagnostic imaging showed multiple pelvic abscesses, and severe chronic endometritis with Actinomyces was found in an endometrial biopsy. The patient underwent surgical drainage of the accessible abscesses and started long-term antibiotic treatment. This case report illustrates that actinomycosis is an important differential diagnosis in symptomatic women with IUD and suspected gynaecologic malignancy.

CT-guided Drainage of Deep Pelvic Abscesses via a Percutaneous Presacral Space Approach: A Clinical Report and Review of the Literature.

RATIONALE AND OBJECTIVES: Some deep pelvic abscesses are not accessible through anterior or lateral approaches because of the presence of organs and structures. The objective of this study was to assess the feasibility, safety, tolerability, and efficacy of a percutaneous presacral space approach by reviewing our clinical experience and the literature. MATERIALS AND METHODS: The outcomes of 12 patients, who have undergone computed tomography (CT)-guided percutaneous presacral space drainage, were retrospectively reviewed, including demographic, clinical, and morphological data in the medical records. RESULTS: From August 2010 to June 2015, 98 patients underwent CT-guided percutaneous drainage of pelvis abscesses in our institution. A percutaneous presacral space approach was adopted in 12 cases. The fluid collections were related to postoperative complications in nine patients (75%) and inflammatory or infectious intraabdominal disease in the remaining three patients (acute diverticulitis: n = 1; appendicitis: n = 1; Crohn disease: n = 1) (25%). The mean duration of drainage was 9.5 days (range 3-33). Escherichia coli was the most frequently present microorganism (in 50.0% of the all samples). No procedure-related complications were observed, either during or after the procedure. Drainage was successful in 10 patients (83.3%). Drainage failed in one patient because of massive anastomotic dehiscence. The other one died from pulmonary embolus 10 days after drainage. CONCLUSIONS: When an anterior or lateral transabdominal approach is inaccessible, CT-guided transperineal presacral space approach drainage is a safe, well-tolerated, and effective procedure, except for patients with massive anastomotic dehiscence.

[Primary Pelvic Cystic Echinococcosis]. / Primer Pelvik Kistik Ekinokokkoz .

Cystic echinococcosis caused by Echinococcus granulosus is still an important health problem in endemic areas. Cystic echinococcosis may involve different organs or areas with the most common sites being the liver and the lungs. Pelvic involvement has previously been reported and was mainly accepted as secondary to cystic echinococcosis in other organs, isolated pelvic involvement is very rare. In this case report, we aimed to present the case with pelvic cystic mass that was finally diagnosed with isolated pelvic cystic echinococcosis in and after the operation, and we would like to draw attention to include "cystic echinococcosis" in the differential diagnosis of pelvic masses.

Redo-surgery by transanal colonic pull-through for failed anastomosis associated with chronic pelvic sepsis or rectovaginal fistula.

PURPOSE: Redo-surgery with new colorectal (CRA) or coloanal (CAA) anastomosis for failed previous CRA or CAA is exposed to failure and recurrent leakage, especially in case of rectovaginal fistula (RVF) or chronic pelvic sepsis (CPS). In these two situations, transanal colonic pull-through and delayed coloanal anastomosis (DCAA) could be an alternative to avoid definitive stoma. This study aimed to assess results of such redo-surgery with DCAA for failed CRA or CAA with CPS and/or RVF. METHODS: All patients who underwent DCAA for failed CRA or CAA with CPS and/or RVF were reviewed. Success was defined as a patient without any stoma at the end of follow-up. Long-term functional results were assessed using the low anterior resection syndrome (LARS) score. RESULTS: 24 DCAA were performed after failed CRA or CAA with CPS (n = 15) or RVF (n = 9). Sixteen (67%) patients had a diverting stoma at the time (n = 5) or performed during DCAA (n = 11). After a mean follow-up of 29 ± 19 months, success rate was 79% (19/24): 5 patients had a permanent stoma because of recurrent sepsis (n = 2), anastomotic stricture (n = 1), or poor functional outcomes (n = 2). Functional outcomes were satisfactory (no or minor LARS) in 82% of the successful patients. CONCLUSION: In case of failed CRA or CAA with CPS or RVF, DCAA was associated with a 79% success rate. It could therefore be proposed as an alternative to standard redo-CRA or CAA when the risk of recurrent sepsis and failure with subsequent definitive stoma is thought to be high.

[Indications and methods of hysterectomy]. / A méheltávolítás javallatai és módszerei.

Hysterectomy is one of the most frequently performed gynecological operations. The most common indications for hysterectomy are symptomatic uterine fibroids, endometriosis, and uterine and pelvic organ prolapse. The procedure can be performed by vaginally or abdominally and with laparoscopic assistance. Choosing the perfect method the gynecologist should take into consideration how the procedure can be performed most safely to fulfill the needs of the patient. In the last few years the number of the laparoscopic procedures has been increasing.

[Anaerobic nonclostridial infection of pelvis: classification and its practical application].

Anaerobic nonclostridial infection of pelvis are analysed in 89 patients that were on treatment in the department of festering surgery in 1999-2012 years. Clinical classification of disease is offered and it is applied in practice for dividing of research array into clinically-morphological groups with the aim of the differentiated going near a surgical treatment.

The success of rectus and gracilis muscle flaps in the treatment of chronic pelvic sepsis and persistent perineal sinus: a systematic review.

AIM: Chronic pelvic sepsis is a challenging problem, which may require muscle flaps to fill the pelvic cavity. The aim of this systematic review was to determine the relative success of rectus and gracilis flaps used for this purpose. METHOD: A systematic review was conducted to identify papers that reported the outcome of rectus or gracilis myocutaneous flaps in the treatment of persistent perineal sinuses or chronic pelvic sepsis. Reports of muscle flaps used for reconstruction or treatment of fistula in the absence of chronic sepsis were excluded. A successful outcome was defined as complete perineal healing within 12 months of surgery. RESULTS: The review identified 19 studies reporting the outcome of 73 rectus and 87 gracilis flaps. Their respective success was 84% and 64%. Heterogeneity of the underlying cases did not allow for direct comparison of the flaps. Full healing of the flaps was generally achieved within 3 months. Donor site morbidity was minimal. CONCLUSION: The surgical treatment of chronic pelvic sepsis should be tailored to the individual, but the rectus flap has a reasonable success rate with little morbidity.

Anterior ilioinguinal incision for drainage of high-located perianal abscess.

Most perianal abscesses originate from infected anal glands at the base of the anal crypts. Most abscesses below are usually drained through perianal incision and can be treated successfully. However, when perianal abscesses extend to the high intrapelvic cavity, it may be inadequate treatment through a single route incision through a perianal approach. The aim of this technical note is to show that combined anterior ilioinguinal and perianal incisions may provide optimal surgical field and multiple drainages. Here, we report a 56-year-old male patient with perianal-originating parapsoas abscesses. Residual abscess still remained after initial perianal incision and drainage after 1-month treatment. We presented combined anterior ilioinguinal and perianal incision technique methods for proper drainage in this complicated case. No recurrent or residual abscess remained after 2 weeks of operation. So, combined anterior ilioinguinal incision is feasible for high-located perianal abscess.

Appendicitis and uterine abscess: presentation of an unusual fistula between the gynaecological and gastrointestinal tracts.

The authors present the case of a 65-year-old woman with clinical and radiological evidence of pelvic sepsis and a medical history of endometrial ablation 20 years previously. She underwent laparotomy after failing to settle with a course of intravenous antibiotics and her appendix was found to have perforated into the uterus with abscess formation which had not discharged vaginally presumably due to widespread intrauterine synechia following her endometrial ablation. She underwent appendectomy and hysterectomy and made a full recovery with no complications. Macroscopic and microscopic examination suggested the appearances are those of an abscess of the uterine fundus with part of the appendix incorporating into the abscess mass.