Pelvic and Lower Gastrointestinal Tract Anatomical Characterization of the Average Male.

OBJECTIVE: Colorectal surgeons report difficulty in positioning surgical devices in males, particularly those with a narrower pelvis. The objectives of this study were to (1) characterize the anatomy of the pelvis and surrounding soft tissue from magnetic resonance and computed tomography scans from 10 average males (175 cm, 78 kg) and (2) develop a model representing the mean configuration to assess variability. METHODS: The anatomy was characterized from existing scans using segmentation and registration techniques. Size and shape variation in the pelvis and soft tissue morphology was characterized using the Generalized Procrustes Analysis to compute the mean configuration. RESULTS: There was considerable variability in volume of the psoas, connective tissue, and pelvis and in surface area of the mesorectum, pelvis, and connective tissue. Subject height was positively correlated with mesorectum surface area (P = .028, R2 = 0.47) and pelvis volume ( P = .041, R2 = 0.43). The anterior-posterior distance between the inferior pelvic floor muscle and pubic symphysis was positively correlated with subject height ( P = .043, r = 0.65). The angle between the superior mesorectum and sacral promontory was negatively correlated with subject height ( P = .042, r = -0.65). The pelvic inlet was positively correlated with subject weight ( P = .001, r = 0.89). CONCLUSIONS: There was considerable variability in organ volume and surface area among average males with some correlations to subject height and weight. A physical trainer model created from these data helped surgeons trial and assess device prototypes in a controllable environment.

Xanthogranulomatous Oophoritis Presenting as an Adnexal Mass and Bowel Obstruction. A Case Report.

BACKGROUND: Xanthogranulomatous inflammation of the female genital tract is a rare entity. When the gynecological organs are affected, it is particularly unusual for xanthogranulomataus inflammation to involve only the ovary. CASE: A 45-year-old woman with an intrauterine device, long-term exposure to nicotine, and hyperlipidemia presented with an adnexal mass and bowel obstruction. She underwent 2 exploratory laparotomies, ureteral stent placement, left salpingooophorectomy, and rectosigmoid resection with end colostomy. Pathology revealed xanthogranulomatous oophoritis without involvement of the associated fallopian tube. CONCLUSION: The synergistic effects of intrauterine device use, abnormal lipid levels, and long-term nicotine exposure may have contributed to the development of this patient's condition. Knowledge of xanthogranulomatous inflammation is essential to avoid misdiagnosis of malignancy and excessive surgical intervention.

Incidence and Operative Excision of Presacral Masses: An Institutional Analysis.

Presacral masses are rare lesions that encompass a broad range of pathologic findings. Most presacral masses are benign. The aim of this study was to analyze the clinical presentation, pathology, and surgical treatment of presacral masses at a single academic institution over a decade. In this retrospective study, we reviewed all surgically excised presacral tumors between 2003 and 2013. Clinical and pathologic data were recorded. Thirteen patients had surgical excision of a presacral mass. The median age was 42 years (standard deviation ± 19.7) and average follow-up was 11.9 months (standard deviation ± 17.5). The majority of patients were symptomatic. Forty-six per cent (6/13) had sacral or rectal pain. Thirty-eight per cent (5/13) of patients had a palpable mass on digital rectal examination. Sixty-nine per cent of patients had an MRI, 84.6 per cent a CT, and 61.5 per cent multimodality imaging. Most presacral masses were benign (10/13, 77%). Twenty-three per cent (3/13) were malignant. A majority were excised via posterior approach (9/13, 69%), but 31 per cent (4/13) required an anterior or combined approach. Presacral masses are rare, even at a high-volume tertiary care center. They are commonly evaluated with a multiple imaging modalities, are most likely benign, and can be excised via posterior approach.

MR enterography in the management of patients with Crohn disease.

Crohn disease is a complex pathologic process with an unpredictable lifelong course that includes frequent relapses. It often affects young patients, who are most vulnerable to the potential adverse effects of repeated exposure to ionizing radiation from computed tomography performed for diagnosis and surgical planning. The small intestine is the bowel segment that is most frequently affected, but it is the least accessible with endoscopic techniques. Magnetic resonance (MR) enterography has the potential to safely and noninvasively meet the imaging needs of patients with Crohn disease without exposing them to ionizing radiation. Appropriate use of MR enterography requires a carefully crafted protocol to depict signs of active inflammation as well as complications such as bowel obstruction, fistulas, and abscesses. Interpretation of MR enterographic images requires familiarity with the imaging signs and mimics of active bowel inflammation and stenosis. Although MR enterography currently is helpful for management in individual patients, the standardization of acquisition protocols and interpretive methods would increase its usefulness for more rigorous, systematic assessments of Crohn disease treatment regimens.

Use of sentinel node mapping for cancer of the colon: 'to map or not to map".

Sentinel lymph node (SLN) mapping has become a cornerstone of oncologic surgery because it is a proven method for identifying nodal disease in melanoma and breast cancer. In addition, it can ameliorate the surgical morbidity secondary to lymphadenectomy. However, experience with SLN mapping for carcinoma of the colon and other visceral malignancies is limited. This study represents an update to our initial pilot experience with SLN mapping for carcinoma of the colon. Consenting patients over the age of 18 diagnosed with adenocarcinoma of the colon were included in this study. At the time of operation, 1 to 2 mL of isosulfan blue was injected with a 25-gauge needle into the subserosa at 4 sites around the edge of the palpable tumor. The SLN was identified visually and excised followed by a standard lymphadenectomy and surgical resection. SLNs were evaluated by standard hematoxylin and eosin (H&E) evaluation as well as immunohistochemical (IHC) techniques for carcinoembryonic antigen and cytokeratin if the H&E was negative. Sixty-nine patients underwent SLN mapping. A SLN was identified in 93 per cent (64 of 69) of patients. Nodal metastases were identified in 38 per cent (26 of 69) of patients overall. In 5 patients, the only positive node identified was the SLN, 2 of which were positive by IHC criteria alone. Therefore, 3 per cent (2 of 69) of patients were upstaged by SLN mapping. This technique was 100 per cent specific while being 46 per cent sensitive. Fourteen patients had false-negative SLNs. Metastasis to regional lymph nodes remains the key prognostic factor for colon cancer. SLN mapping is feasible for colon cancer and can identify a subset of patients who could benefit from adjuvant chemotherapy. Although SLN mapping did not alter the surgical management of colon cancer, it does make possible a more focused and cost-effective pathologic evaluation of nodal disease. We do not suggest routine utilization of SLN mapping for colon cancer, but we believe that the data supports proceeding with a national trial.

Long-term results of local excision with and without chemoradiation for adenocarcinoma of the rectum.

The role of local excision for rectal carcinoma remains controversial. We reviewed 285 patients undergoing curative resection for rectal cancer between 1984 and 2001. Surgical procedures were local excision (LE; n = 49), abdominoperineal resection (APR; n = 124), and low anterior resection (LAR; n = 112). Median follow-up for all patients was 6.2 years. For patients undergoing local excision, postoperative tumor stages were Tis (22%), T1 (41%), T2 (18%), and T3 (18%). Twelve patients received postoperative radiation >/= 45 Gy, and 4 patients received adjuvant chemotherapy. Of the 49 patients who underwent LE, the 5- and 10-year overall survival rates were 76% and 42%, respectively. The 5- and 10-year disease-free survival rates were 69% and 58%, respectively. The incidence of local recurrence was 16% and the incidence of distant recurrence was 6%. For the 11 patients who experienced disease recurrence, the median time to recurrence was 13 months (range, 1-59 months). Of the 8 patients who developed local recurrence, 4 refused salvage treatment, 2 underwent salvage APR, and 2 underwent repeat excision. Of the 4 who underwent salvage surgery, one is alive with no evidence of disease, one developed distant disease, and 2 died with unknown disease status. Adjuvant therapy did not affect survival or recurrence rates in patients undergoing LE compared with other surgeries. The rate of local failure (16%) is comparable to that observed in the Cancer and Leukemia Group B (CALGB) 8984 prospective study and suggests that highly selected patients undergoing local excision can expect good local control of rectal cancer.