Long-term efficacy of endoscopic pilonidal sinus treatment: a single-centre Australian experience.

BACKGROUND: Endoscopic pilonidal sinus treatment (EPSiT) is a novel minimally invasive technique for treating pilonidal sinus disease (PSD) involving endoscopic assessment and treatment. This retrospective, non-randomized, observational study is the first Australian study of EPSiT and its largest long-term study to date. METHODS: From January 2014 to November 2019, 137 patients with PSD underwent EPSiT. Seventy-two had undergone previous surgery for PSD. Specialized Karl Storz video equipment (fistuloscope) was used. The rigid fistuloscope allowed direct visualization of cavities and secondary tracts. Cavities and tracts were then curetted endoscopically to remove all granulation tissues and hair/follicles. Ablation was then carried out under direct vision along with removal of debris. Patients were then followed up for a mean 56.2 months. RESULTS: 72.2% (n = 91) of patients undergoing EPSiT achieved primary healing (needing nil further intervention) at a median of 6 weeks; 13.5% (n = 17) experienced healing followed by recurrence while 14.3% (n = 18) experienced non-healing. Of the recurrence/non-healing groups, 20/35 underwent repeat EPSiT with healing occurring in 18/20 patients at a median of 7 weeks. The balance of patients (n = 15) underwent other definitive procedures. The mean operating time was 34 min. There were no major complications and 85% of patients were discharged the same day. Eleven patients were lost to follow-up. CONCLUSION: EPSiT combines high efficacy of treatment for PSD along with relatively low rates of recurrence. The minimally invasive nature of the procedure means repeat procedures can be performed (where necessary) with low morbidity and a reasonable rate of success.

Short-term outcomes in older patients with peritoneal malignancy treated with cytoreductive surgery and HIPEC: Experience with 245 patients from a national centre.

BACKGROUND: Cytoreductive Surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly accepted as the optimal management of selected patients with peritoneal malignancy. There is limited published evidence on outcomes in older patients treated by this complex therapeutic strategy. METHODS: A retrospective review of a prospective database of all patients who underwent CRS with HIPEC in a single institution over seven years. A comparative analysis of outcomes in patients under 65 undergoing CRS and HIPEC with patients ≥65 years was performed. The key endpoints were morbidity, mortality, reintervention rate and length of stay in the high dependency/intensive care (HDU/ICU) units. RESULTS: Overall, 245 patients underwent CRS and HIPEC during the study period, with 76/245 (31%) ≥65 years at the time of intervention. Tumour burden measured by the peritoneal carcinomatosis index (PCI) score was a median of 11 for both groups. Median length of hospital stay in the ≥65-year-old group was 14.5 days versus 13 days in the <65-year-old group (∗p = 0.01). Patients aged ≥65-years spent a median of one more day in the critical care unit ∗(p = 0.001). Significant morbidity (Clavien-Dindo ≥ Grade IIIa) was higher in the ≥65-year than the <65-year group (18.4% versus 11.2%). There were no perioperative deaths in the ≥65-year group. CONCLUSION: This study demonstrates higher perioperative major morbidity in ≥65-year group, but with low mortality in patients undergoing CRS/HIPEC for disseminated intraperitoneal malignancy. This increased morbidity does not translate into higher rates of re-interventions and highlights the importance of optimal patient selection.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases: outcomes from a national centre in the current era.

BACKGROUND: Multimodal therapy incorporating cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) improve survival for selected patients with colorectal peritoneal metastases (CPMs). Many countries have centralised management of these patients, aiming to improve outcomes. There is ongoing debate on the need for and complications associated with HIPEC administration. We report indications and outcomes after CRS/HIPEC treated in a national centre in the modern era. METHODS: A retrospective review of all CPM patients who underwent CRS and HIPEC since the initiation of an Irish national program in 2013. The primary endpoint was the overall survival associated with CRS/HIPEC. RESULTS: During the study period (April 2013-June 2020), 123 patients proceeded to planned CRS/HIPEC for CPM. Median age was 58 (IQR 47-67) and 55 patients (44.7%) were male. In 65 patients (52.8%), CPM was synchronous. In 7/123 (5.8%), disease was unresectable. The median peritoneal cancer index (PCI) was 10 (IQR 5-17). Overall, 104/123 (84.5%) underwent a complete cytoreduction (CC0/CC1). Thirteen out of 123 (10.5%) patients also had a synchronous liver resection. Forty out of 123 (32.5%) patients had adverse pathological features (poorly differentiated or signet ring cells). The median survival in patients after CC0, CC1 and CC2/3 resection was 50, 18 and 11 months respectively (*p = < 0.0001, Log-rank Mantel-Cox). In total, 14/123(11.4%) had a major post-operative complication and 4/123 (3.3%) required re-operation. There was one (0.8%) post-operative death. The median length of stay was 14 days (IQR 9-19). CONCLUSION: This study reports encouraging outcomes in patients with CPM undergoing CRS and HIPEC, especially when complete cytoreduction is achieved.