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Colorectal Disease : the Official... Jan 2024The aim of this study was to investigate the role of human factors in pelvic exenteration and how team performance is optimized in the preoperative, intraoperative and...
AIM
The aim of this study was to investigate the role of human factors in pelvic exenteration and how team performance is optimized in the preoperative, intraoperative and postoperative phases.
METHOD
Qualitative analysis of focus groups was used to capture authentic human interactions that reflect real-world multiprofessional performance. Theatre teams were treated as clusters, with a particular focus group containing participants who worked together regularly.
RESULTS
Three focus groups were conducted. Four themes emerged - driving force, technical skills, nontechnical skills and operational aspects - with a total of 16 subthemes. Saturation was reached by group 2, with no new subthemes emerging after this. There was some interaction between the themes and the subthemes. Broadly speaking, driving force led to the development of specialised technical skills and nontechnical skills, which were operationalized into successful service through operational aspects.
CONCLUSION
This study of teams performing pelvic exenteration is the first in the field using this methodology. It has generated rich qualitative data with authentic insights into the pragmatic aspects of developing and delivering a service. In addition, it shows how the themes are connected or 'coupled' in a network, for example technical and non-technical skills. In a complex system, 'tight coupling' leads to both high performance and adverse events. In this paper, we report the qualitative aspects of high performance by pelvic exenteration teams in a complex sociotechnical system, which depends on tight coupling of several themes.
Topics: Humans; Pelvic Exenteration; Focus Groups
PubMed: 38057630
DOI: 10.1111/codi.16825 -
Australian Health Review : a... Dec 2023Pelvic exenteration (PE) is a potentially curative, ultra-radical surgical procedure for the treatment of advanced pelvic tumours, which involves surgical resection of...
Pelvic exenteration (PE) is a potentially curative, ultra-radical surgical procedure for the treatment of advanced pelvic tumours, which involves surgical resection of multiple pelvic organs. Delivering such a complex low-volume, high-cost surgical program presents a number of unique health management challenges, and requires an organisation-wide approach involving both clinical and administrative teams. In contrast to the United Kingdom and France, where PE services have been historically decentralised, a centralised approach was developed early on in Australia and New Zealand (ANZ) with referral of these complex patients to a small number of quaternary centres. The PE program at the authors' institution was established in 1994 and has since evolved into the highest volume PE centre in the ANZ region and the largest single institution experience globally. These achievements have required navigation of specific funding and management issues, supported from inception by a proactive and collaborative relationship with hospital administration and management. The comprehensive state-wide quaternary referral model that has been developed has subsequently been successfully applied to other complex surgical services at the authors' institution, as well as by more recently established PE centres in Australia. This article aims to summarise the authors' experience with establishing and expanding this service and the lessons learned from a health management perspective.
Topics: Humans; Pelvic Exenteration; Pelvic Neoplasms; Australia; New Zealand; United Kingdom; Retrospective Studies
PubMed: 38029447
DOI: 10.1071/AH23186 -
ANZ Journal of Surgery Apr 2024Pelvic exenterations and cytoreduction are individually morbid procedures with oncological validity. The combination of these simultaneously in patients with rectal...
BACKGROUND
Pelvic exenterations and cytoreduction are individually morbid procedures with oncological validity. The combination of these simultaneously in patients with rectal cancers has not been evaluated. The present study aimed to assess the surgical and survival outcomes of the combined procedure.
METHODS
Retrospective, single-centre analysis of consecutive patients that underwent pelvic exenterations and cytoreductions for advanced or recurrent rectal cancers with peritoneal metastasis between 2013 and 2022. The primary outcome measure for safety was major complications (≥Grade IIIA). The threshold for considering the procedure unsafe was set at 50% for the upper confidence limit of major morbidity. Overall and recurrence-free survival were also assessed.
RESULTS
Thirty-nine patients underwent the combined procedure that included 24 total pelvic and 15 posterior pelvic exenterations. The median age of the cohort was 35 years, 18 (46.2%) had signet ring cell cancers, and eight patients (21%) had extraperitoneal disease as well. The median PCI was 4 and CC-0 was achieved in 38 patients (97.4%). Hyperthermic intraperitoneal chemotherapy was delivered in 15 patients, and four had placement of an intraperitoneal chemo port. Major complications were experienced by 7 patients (18%; 95% confidence interval: 7.5%-33.5%). Median recurrence-free and overall survivals were 9 and 17 months, respectively.
CONCLUSION
Combined pelvic exenterations and cytoreductions are safe operations in terms of morbidity. Survival, however, remains poor for this group of patients despite aggressive surgery.
Topics: Humans; Adult; Peritoneal Neoplasms; Combined Modality Therapy; Retrospective Studies; Pelvic Exenteration; Cytoreduction Surgical Procedures; Percutaneous Coronary Intervention; Neoplasm Recurrence, Local; Rectal Neoplasms; Antineoplastic Combined Chemotherapy Protocols; Hyperthermia, Induced; Survival Rate
PubMed: 38012077
DOI: 10.1111/ans.18808 -
The British Journal of Surgery Jan 2024
Topics: Female; Humans; Pelvic Exenteration; Surgical Flaps; Plastic Surgery Procedures; Vagina; Perineum
PubMed: 37988590
DOI: 10.1093/bjs/znad395 -
Annals of Surgical Oncology Feb 2024
Topics: Humans; Pelvic Exenteration; Pelvis; Surgical Flaps; Lymph Node Excision; Laparoscopy; Rectal Neoplasms
PubMed: 37973645
DOI: 10.1245/s10434-023-14556-3 -
The American Journal of Case Reports Nov 2023BACKGROUND Surgery for locally advanced rectal cancer with frozen pelvis is challenging. Therefore, we designed the "modular pelvic exenteration" surgical strategy to...
BACKGROUND Surgery for locally advanced rectal cancer with frozen pelvis is challenging. Therefore, we designed the "modular pelvic exenteration" surgical strategy to achieve better radical resection. CASE REPORT A 51-year-old man with rectal cancer refused surgery and received chemotherapy and radiotherapy. He was intolerant to chemotherapy and did not respond well to radiotherapy. With cancer progression, he presented at our hospital with emaciation, fatigue, dysuria, bloody urine, bloody stool, and anal pain. Computed tomography and magnetic resonance imaging revealed the rectal tumor involved multiple adjacent organs and caused rectovesical fistula, bilateral hydronephrosis, hydroureterosis, and local pelvic infection. The rectal tumor was fixed in the pelvic cavity, presenting a frozen pelvis pattern. There was no distant metastasis. As the patient could not tolerate chemotherapy, was unsuitable for immune-check point inhibitor because the tumor had microsatellite stability, and did not respond well to radiotherapy, surgical resection seemed the most suitable treatment option. After the patient's anemia and malnutrition improved, our designed modular pelvic exenteration surgery was performed. In this strategy, we divided pelvic organs and tissues into 4 independent modules. After combining the modules planned to be resected, we delineated the pre-resection margin. By this strategy, the tumor was removed en bloc, with a clear resection margin. The patient was discharged 13 days after the operation, without complications. Follow-up for 24 months revealed no signs of tumor recurrence. CONCLUSIONS For locally advanced rectal cancer with frozen pelvis, the modular pelvic exenteration strategy may help to achieve satisfactory surgical effects in selected patients.
Topics: Male; Humans; Middle Aged; Pelvic Exenteration; Margins of Excision; Neoplasm Recurrence, Local; Rectal Neoplasms; Pelvis
PubMed: 37968899
DOI: 10.12659/AJCR.941684 -
BMJ Case Reports Nov 2023Late relapses of Wilms tumour are extremely uncommon but still represent possible events. Even more rarely Wilms tumours present as extrarenal neoplasms, for which it...
Late relapses of Wilms tumour are extremely uncommon but still represent possible events. Even more rarely Wilms tumours present as extrarenal neoplasms, for which it could be difficult to diagnose and treat them promptly.We present a unique case of late recurrence of Wilms tumour 16 years after the primary diagnosis, with location in the gynaecological system. The relapse presented as a vaginal mass, and it gradually raised up to involve the majority of pelvic organs. We accurately studied the tumour extension, even realising a 3D preoperative reconstruction, and we managed to evaluate the patient with a multidisciplinary team involving general surgeons, urologists, gynaecologists and plastic surgeons. We finally decided for an extended surgical approach and realised a complete pelvic exenteration. Three months after surgery, the patient is in a good general condition, without major surgical complications and with no radiological signs of pelvic tumour relapse.
Topics: Female; Humans; Pelvic Exenteration; Neoplasm Recurrence, Local; Wilms Tumor; Kidney Neoplasms; Recurrence; Retrospective Studies
PubMed: 37967928
DOI: 10.1136/bcr-2023-256270 -
Surgical Case Reports Nov 2023Anorectal fistula cancer is often diagnosed in an advanced state, and radical resection is difficult when invasion of the pelvic wall is observed. In addition, there is...
BACKGROUND
Anorectal fistula cancer is often diagnosed in an advanced state, and radical resection is difficult when invasion of the pelvic wall is observed. In addition, there is currently no clear evidence for perioperative treatment of locally advanced cases. We report a case of anorectal fistula cancer with widespread infiltration diagnosed during the course of Crohn's disease, which was curatively resected after preoperative chemoradiotherapy.
CASE PRESENTATION
A 49-year-old man who had been diagnosed with Crohn's disease (ileocolonic type) at the age of 25 and was found to have an anorectal fistula and perianal abscess at the age of 44 was referred to our department with complaints of abdominal pain and diarrhea. Computed tomography (CT) showed anal stenosis due to a pelvic mass. Pathological analysis of a biopsy taken under general anesthesia indicated mucinous carcinoma. Magnetic resonance imaging (MRI) revealed infiltration into the prostate, seminal vesicles, levator ani muscle, and left internal obturator muscle, and the patient was diagnosed with cT4N0M0 cStage IIIB anorectal fistula cancer (UICC TNM classification 8th edition). After performing a laparoscopic sigmoid colostomy, chemoradiation therapy (capecitabine + oxaliplatin, 50.4 Gy/28fr) was initiated. The patient then underwent laparoscopic total pelvic exenteration, colonic conduit diversion, extensive perineal resection, and reconstruction using bilateral gluteus maximus flaps and a right rectus abdominis musculocutaneous flap. The pathological diagnosis was mucinous adenocarcinoma, pT4, and all margins were negative. No recurrence was evident 6 months after the operation without adjuvant chemotherapy.
CONCLUSION
We described a case of curative resection after preoperative chemoradiotherapy for anorectal fistula cancer with extensive invasion that was diagnosed during the course of Crohn's disease.An accumulation of cases is needed to determine the usefulness of preoperative chemoradiation therapy for local control of anorectal fistula cancer associated with Crohn's disease.
PubMed: 37962718
DOI: 10.1186/s40792-023-01778-6 -
IJU Case Reports Nov 2023Venous hemorrhage from ectopic varices is potentially fatal. This report describes a rare case in which bleeding from mesenteric varices in an ileal conduit was treated...
INTRODUCTION
Venous hemorrhage from ectopic varices is potentially fatal. This report describes a rare case in which bleeding from mesenteric varices in an ileal conduit was treated successfully by embolization therapy.
CASE PRESENTATION
The patient was an 82-year-old man who had previously undergone total pelvic exenteration for colon cancer with creation of an ileal conduit for urinary diversion. He subsequently developed liver cirrhosis and underwent partial hepatectomy for hepatocellular carcinoma. 9 years after his colon surgery, he was admitted with gross hematuria. Computed tomography revealed subcutaneous mesenteric varices in the ileal conduit and hemorrhage as a result of rupture of the varices. The bleeding continued despite repeated manual compression but was eventually stopped by embolization therapy.
CONCLUSION
Embolization therapy may be helpful for hemostasis in the event of intractable bleeding from mesenteric varices in an ileal conduit.
PubMed: 37928295
DOI: 10.1002/iju5.12644 -
Journal of Gynecologic Oncology Mar 2024To acknowledge that minimally invasive pelvic exenteration is a feasible alternative to open surgery and potentially identify prediction factors for patient outcome.
OBJECTIVE
To acknowledge that minimally invasive pelvic exenteration is a feasible alternative to open surgery and potentially identify prediction factors for patient outcome.
METHODS
The study was designed as a retrospective single team analysis of 12 consecutive cases, set between January 2008 and January 2022.
RESULTS
Six anterior and 6 total pelvic exenterations were performed. A 75% of cases were treated using a robotic approach. In 4 cases, an ileal conduit was used for urinary reconstruction. Mean operative time was 360±30.7 minutes. for anterior pelvic exenterations and 440±40.7 minutes. for total pelvic exenterations and mean blood loss was 350±35 mL. An R0 resection was performed in 9 cases (75%) and peri-operative morbidity was 16.6%, with no deaths recorded. Median disease-free survival was 12 months (10-14) and overall survival (OS) was 20 months (1-127). In terms of OS, 50% of patients were still alive 24 months after surgery. Taking into consideration the follow up period,16.6% of females under 50 or above 70 years old did not reach the cut off and 4 out of 6 patients that failed to reach it were diagnosed with distant metastases or local recurrence (p=0.169).
CONCLUSION
Our experience is very much consistent with literature in regard to primary site of cancer, post-operative complications, R0 resection and survival rates. On the other hand, minimally invasive approach and urinary reconstruction type were in contrast with cited publications. Minimally invasive pelvic exenteration is indeed a safe and feasible procedure, providing patients selection is appropriately performed.
Topics: Female; Humans; Aged; Genital Neoplasms, Female; Pelvic Exenteration; Robotic Surgical Procedures; Retrospective Studies; Laparoscopy; Neoplasm Recurrence, Local
PubMed: 37921597
DOI: 10.3802/jgo.2024.35.e12