Impact of Intraoperative Decision-Making on Pathological Margin Status in Patients Undergoing Pelvic Exenteration for Locally Recurrent Rectal Cancer.

BACKGROUND: A key component of preoperative preparation for pelvic exenteration surgery is the development of an operative plan in a multidisciplinary setting based on the extent of local tumor invasion on preoperative imaging. Changes to the extent of resection or operative plan may occur intraoperatively based on intraoperative findings. OBJECTIVE: To report the frequency and extent of intraoperative deviation from the planned extent of resection during pelvic exenteration for locally recurrent rectal cancer and determine whether this resulted in a more or less radical resection. DESIGN: Retrospective observational study. SETTINGS: A high-volume pelvic exenteration center. PATIENTS: Patients who underwent pelvic exenteration for locally recurrent rectal cancer between January 2015 and December 2020. MAIN OUTCOME MEASURES: Frequency and extent of intraoperative deviation from the planned extent of resection, R0 resection rate. RESULTS: One hundred thirty-six patients underwent pelvic exenteration for locally recurrent rectal cancer, of whom 110 (81%) had R0 resection margins. Twelve patients were excluded because of missing information, and 49 patients (40%) had a change to the operative plan. Operative changes were major in 30 patients (61%), more radical in 40 patients (82%), and margin relevant in 24 patients (49%). In patients in whom there was a change to the operative plan and R0 resection was achieved, the median distance to a relevant margin was 2.5 mm (range, 0.1-10 mm). Of 8 patients with a change in operative plan and R1 resection, 3 were margin relevant, of whom all were considered major, and 2 were more radical and 1 was less radical. LIMITATIONS: Generalizability outside of specialist units may be limited. CONCLUSIONS: Intraoperative changes to the planned extent of resection occur commonly and most often result in an unanticipated major or more radical resection. Such changes may contribute to high rates of R0 resection margins in specialist pelvic exenteration units that use an ultraradical approach in these patients. See Video Abstract . IMPACTO DE LA TOMA DE DECISIONES INTRAOPERATORIA SOBRE EL ESTADO DEL MARGEN PATOLGICO EN PACIENTES SOMETIDOS A EXENTERACIN PLVICA POR RECURRENCIA LOCAL EN CNCER DE RECTO: ANTECEDENTES:Un componente clave de la preparación preoperatoria para exenteración pélvica es el desarrollo de un plan quirúrgico en un entorno multidisciplinario, basado en el grado de invasión tumoral local en las imágenes preoperatorias. Es posible que se produzcan cambios intraoperatorios en la extensión de la resección o en el plan quirúrgico según los hallazgos intraoperatorios.OBJETIVO:Informar la frecuencia y la extensión de la desviación intraoperatoria de la extensión planificada de la resección durante la exenteración pélvica para el cáncer de recto localmente recurrente, y si esto resultó en una resección más o menos radical.DISEÑO:Estudio observacional retrospectivo.ESCENARIO:Un centro de exenteración pélvica de alto volumen.PACIENTES:Pacientes sometidos a exenteración pélvica por cáncer de recto localmente recurrente entre enero de 2015 y diciembre de 2020.PRINCIPALES MEDIDAS DE RESULTADO:Frecuencia y extensión de desviación intraoperatoria de la extensión planeada de resección, tasa de resección R0.RESULTADOS:136 pacientes fueron sometidos a exenteración pélvica por cáncer de recto localmente recurrente, de los cuales 110 (81%) tuvieron márgenes de resección R0. 12 pacientes fueron excluidos por falta de información y 49 pacientes (40%) tuvieron un cambio en el plan quirúrgico. Los cambios operatorios fueron mayores en 30 pacientes (61%), más radicales en 40 pacientes (82%) y con relevancia sobre márgenes en 24 pacientes (49%). En los pacientes en los que hubo un cambio en el plan quirúrgico y se logró la resección R0, la distancia mediana hasta un margen relevante fue de 2.5 mm (rango 0.1-10 mm). De ocho pacientes con un cambio en el plan quirúrgico y resección R1, tres tuvieron relevancia sobre márgenes de los cuales todos se consideraron mayores, dos fueron más radicales y uno fue menos radical.LIMITACIONES:La generalización fuera de las unidades especializadas puede ser limitada.CONCLUSIONES:Los cambios intraoperatorios en la extensión planificada de la resección ocurren comúnmente y con mayor frecuencia resultan en una resección mayor imprevista y más radical. Dichos cambios pueden contribuir a altas tasas de márgenes de resección R0 en unidades especializadas en EP que emplean un enfoque ultrarradical en estos pacientes. (Traducción-Dr. Jorge Silva Velazco ).

Combined Liver-Kidney Transplant for Juvenile Polycystic Kidney Disease and Concomitant Hereditary Factor V Deficiency.

Factor V deficiency is a congenital bleeding diathesis that, in selected cases, may be managed with liver transplant. In this case, we describe the treatment of an adult patient with kidney failure secondary to juvenile onset polycystic kidney disease who received a combined liver-kidney transplant as a method to manage the risks associated with the need for a kidney transplantin the setting of factorV deficiency and high sensitization.

Long-term results of mesh pelvic floor reconstruction to address the empty pelvis syndrome.

AIM: As the "empty pelvis syndrome" continues to pose challenges in patients undergoing radical pelvic exenteration, there remains an ongoing need to consider solutions to mitigate or avoid its associated morbidity. As such, this study aims to review the long-term outcomes of a proposed strategy of pelvic reconstruction with BioA mesh. METHOD: We conducted a retrospective observational cohort study, reviewing cases of pelvic exenteration and/or pelvic bone resection involving BioA mesh pelvic reconstruction between 2017 and 2021 at our quaternary institution, identified from a prospectively collected database. The primary outcome was pelvic complications including perineal fistula, wound breakdown and pelvic collections. RESULTS: Over a 4-year period, there were a total of 36 patients who had pelvic exenteration and/or pelvic bone resection with BioA mesh pelvic reconstruction. The overall pelvic complication rate was 36% (n = 13), including 11 symptomatic pelvic collections, two enteroperineal fistulas, and no cases of perineal hernia. Reoperation was required in two patients. There was no perioperative mortality. CONCLUSION: Given that pelvic complications post BioA mesh reconstruction are of an acceptable rate and can be considered minor, using this technique is a safe and practical strategy in patients undergoing major pelvic surgery with or without pelvic bone resection.

Long-term surgical complications following pelvic exenteration: Operative management of the empty pelvis syndrome.

AIM: Pelvic exenteration (PE) has become the standard of care for locally advanced and recurrent rectal cancer. The high short-term morbidity reported from this procedure is well established; however, longer term complications of such radical surgery and their management have not been fully addressed. This study aimed to investigate the incidence, indications and outcomes of long-term (more than 90-day) reoperative surgery in this group of patients, with a focus on the empty pelvis syndrome (EPS). METHODS: Clinical data were extracted from a prospectively maintained database, with additional data pertaining to indications, operative details and outcomes of reoperative surgery obtained from electronic medical records. Patients were excluded if reoperative surgery was endoscopic or radiologically guided, was for the investigation or treatment of recurrent disease, or was clearly unrelated to previous surgery. RESULTS: Of 716 patients who underwent PE, 75 (11%) required 101 reoperative abdominal or perineal procedures, 52 (51%) of which were in 40 (6%) patients for complications of EPS. This group were more likely to have undergone a total PE (65% vs. 43%; P < 0.01) with either major bony (70% vs. 50%; P < 0.01) and/or nerve (40% vs. 25%; P = 0.03) resections at index exenteration. The patho-anatomy, surgical management and outcomes of these patients are described herein, considering separately complications of entero-cutaneous fistula, entero-perineal fistula, small bowel obstruction and local management of perineal wound complications. CONCLUSION: Six per cent of PE patients will require re-intervention for the management of EPS. Reliable strategies for preventing EPS remain elusive; however, surgical management is feasible with acceptable short-term outcomes with the optimum strategy to be selected on an individual patient basis.

A Tale of Two Meckel's: small bowel obstruction secondary to Meckel's Diverticulum.

We present two rare cases of small bowel obstruction (SBO) secondary to Meckel's diverticulum (MD) where the mechanism of obstruction was not readily apparent. Both were cases of virgin abdomen with pre-operative CT scans demonstrating SBO without a clear underlying cause or mass. Diagnostic laparoscopy was performed, which established the underlying cause to be MD, and laparoscopic-assisted resection was undertaken to resect small bowel and perform a side-to-side stapled anastomosis. We subsequently describe the different mechanisms by which MD can cause obstruction as described in the literature.

Insidious presentation of intussusception with appendicitis.

Intussusception in relation to appendicitis is an uncommon occurrence and is rarely described in the literature. We describe a case of diagnostic uncertainty and finding of ileocolic intussusception associated with appendicitis in a 22-year-old male. The patient presented with a history of acute right-sided abdominal pain. He underwent a computed tomography scan showing ileocolic intussusception following an operation with the finding of an inflamed appendix, which was likely to have served as a mechanical lead point of the intussusception. Due to the presence of ischaemia of the right colon, he underwent a right hemicolectomy.

A prospective evaluation of cervical spine immobilisation in low-risk trauma patients at a tertiary Emergency Department.

BACKGROUND: In the Emergency Department cervical spine immobilisation precautions are frequently used. There is controversy in regard to the balance of risks and benefits of routine immobilisation in conscious patients. METHODS: A prospective multi-methods evaluation in a tertiary trauma referral centre. The objectives were to investigate current practices and rate of concordance with established international guidelines. A provider survey focused on current knowledge, skills and attitudes and was disseminated to nurses, doctors and paramedics treating trauma patients. Additionally, clinical data were collected on a cohort of immobilised trauma patients. Demographic data were analysed using SPSS and content analysis was completed by manifest coding. RESULTS: The response rate to the survey was 85.2%. Interdisciplinary providers included nurses (n=46), doctors (n=68) and paramedics (n=41). Content analysis revealed a range of themes for improving care. Themes identified included improved application of guidelines, tailored use of equipment in low-risk patients, improved access to radiology results, and staff education. The series of five case vignettes provided to participants revealed a high level of variance in intended approaches to immobilisation. In the cohort of trauma patients (n=54), the median age was 54 years and the most common mechanism of injury was falls (40.7%). Median time spent with immobilisation was 325min. Adherence to a recognised decision tool was 35/54 (64.8%). Precautions were initiated by paramedics in 42/54 (77.8%). CONCLUSIONS: Despite widespread dissemination of guidelines, observed approaches to patient immobilisation appear to be highly variable in this trauma centre. Reducing variation for low-risk patients is likely to improve the patient journey and minimise the risk of prolonged immobilisation. Further assessment of the causes of variation could define goals for targeted translational change.