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Clinical Case Reports Sep 2023Radical gynecology oncology surgeries are feasible in patients refusing blood transfusion, when performed with careful preoperative (with hemoglobin optimization and...
KEY CLINICAL MESSAGE
Radical gynecology oncology surgeries are feasible in patients refusing blood transfusion, when performed with careful preoperative (with hemoglobin optimization and patients' counseling), intraoperative (with hemostasis and stepwise devascularization, hemodilution, and autologous cell salvage) and postoperative (considering iron infusion or erythropoietin) planning with a multidisciplinary team involvement.
ABSTRACT
We describe the case of a female Jehovah's Witness patient in her 60s undergoing pelvic exenteration, focusing on the preoperative, intraoperative, and postoperative measures that allowed an uncomplicated surgery without blood transfusion. Blood transfusions are common in the surgical management of gynecology oncology patients, up to 93% of patients undergoing pelvic exenteration may require blood products. However, increasingly more patients are cautious in receiving blood products, either for fear of potential risks or for religious believes. It is therefore vital to optimize the management of these patients in order to avoid blood transfusions. In this case, we summarize the management of a lady in her 60s who underwent laparotomy, pelvic exenteration, Bricker colicureterostomy, and end colostomy formation for recurrent endometrial carcinoma, despite previous total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by brachytherapy, chemotherapy, and external beam radiotherapy for high-grade serous carcinoma. Preoperatively, an advance decision to refuse blood products was discussed to ascertain all the options that were suitable. As her preoperative hemoglobin was acceptable (127 g/L), no further intervention was required. Intraoperatively, blood loss was effectively minimized with meticulous hemostasis, stepwise pelvic devascularization, intraoperative hemodilution, and cell salvage. Despite these interventions, total blood loss was 1030 mL and postoperative hemoglobin was 113 g/L. Postoperative measures therefore included intravenous iron infusion, minimization of phlebotomy, and optimization of cardiopulmonary status. Erythropoietin was also considered, but was not necessary as patient responded to the previous measures well and was successfully discharged after an uncomplicated recovery. Only few cases of total pelvic exenteration have been described in the literature for Jehovah's Witness patients. However, our case shows that laparotomy and pelvic exenteration is feasible in patients refusing blood products, if performed under a multidisciplinary team and with careful preoperative, intraoperative, and postoperative planning, also in the setting of previous radical hysterectomy and co-adjuvant therapy.
PubMed: 37720708
DOI: 10.1002/ccr3.7689 -
International Journal of Surgery... Nov 2023Advancing approaches to locally invasive pelvic malignancy creates a large tissue defect resulting in perineal wound complications, dehiscence, and perineal hernia. Use...
INTRODUCTION
Advancing approaches to locally invasive pelvic malignancy creates a large tissue defect resulting in perineal wound complications, dehiscence, and perineal hernia. Use of reconstructive flaps such as vertical rectus abdominus myocutaneous (VRAM) flap, gracilis, anterolateral thigh and gluteal flaps have been utilised in our institution to address perineal closure. The authors compared outcomes using different flap techniques along with primary perineal closure in advanced pelvic oncological resection.
METHODS
A prospectively maintained database of patients undergoing advanced pelvic oncological resection in a single tertiary hospital was retrospectively analysed. This study included consecutive patients between 2014 and 2021 according to the Strengthening The Reporting of Cohort Studies in Surgery (STROCSS) criteria. Primary outcome measures were the frequency of postoperative perineal complications between primary closure, VRAM, gluteal and thigh (anterolateral thigh and gracilis) reconstruction.
RESULTS
One hundred twenty-two patients underwent advanced pelvic resection with perineal closure. Of these, 40 patients underwent extra-levator abdominoperineal resection, and 70 patients underwent pelvic exenteration. Sixty-four patients received reconstructive flap closure, which included VRAM (22), gluteal (21) and thigh flaps (19). Perineal infection and dehiscence rates were low. Infection rates were lower in the flap group despite a higher rate of radiotherapy ( P <0.050). Reoperation rates were infrequent (<10%) but specific for each flap, such as donor-site hernia following VRAM and flap dehiscence after thigh flap reconstruction.
CONCLUSIONS
In patients who are at high risk of postoperative perineal infections, reconstructive flap closure offers acceptable outcomes. VRAM, gluteal and thigh flaps offer comparable outcomes and can be tailored to the individual patient.
Topics: Humans; Retrospective Studies; Perineum; Pelvic Neoplasms; Myocutaneous Flap; Postoperative Complications; Cohort Studies; Hernia, Abdominal; Rectal Neoplasms; Rectus Abdominis
PubMed: 37678294
DOI: 10.1097/JS9.0000000000000617 -
Journal of Surgical Case Reports Aug 2023Mixed epithelial-stromal tumours (MESTs) are a rare biphasic tumour that frequently arise in women from the renal and urogenital tract. They are also seen in men but are...
Mixed epithelial-stromal tumours (MESTs) are a rare biphasic tumour that frequently arise in women from the renal and urogenital tract. They are also seen in men but are exceptionally uncommon with only few cases reported to originate from the seminal vesicles. Malignant transformation of its epithelial or stromal components is possible; however, by in large, these tumours are benign in nature. We report the case of a 48-year-old man with no remarkable medical or surgical history who presented with a huge expanding pelvic and intra-abdominal mass that required extensive surgical management including a pelvic exenteration. Histopathological analysis concluded the diagnosis of benign MEST originating from the seminal vesicles with no malignant features. No further systemic therapy was recommended for our patient. Given the technical intricacy in the operative resection of this tumour, we aim to present our findings and surgical management of this complex MEST.
PubMed: 37662445
DOI: 10.1093/jscr/rjad490 -
International Journal of Surgery Case... Sep 2023Leiomyosarcoma is a malignant neoplasm that is derived from smooth muscle cells in walls of small blood vessels or branch of the inferior vena cava, the uterus and the...
INTRODUCTION
Leiomyosarcoma is a malignant neoplasm that is derived from smooth muscle cells in walls of small blood vessels or branch of the inferior vena cava, the uterus and the gastrointestinal tract. Different treatment options are present for the treatment of LMS. However, due to the rarity of LMS, the optimal treatment option is still to be discussed and determined.
PRESENTATION OF CASE
A 51-year-old male patient, previously healthy, presented for perianal pain. Biopsy of the mass found showed spindle cell tumors with mild atypia, dense cellularity, and pelvic MRI with contrast showed a well-circumscribed mass of the anus, developed between the layers of the external sphincter with possible invasion of the internal sphincter consistent with Leiomyosarcoma Grade I. Wide excision was performed. Close follow-up should be done every 3 to 6 months for the first 2 to 3 years, every 6 to 12 months for the following 3 years, and annually afterwards.
DISCUSSION
The symptoms of LMS include rectal bleeding with rectal and/or abdominal pain, weight loss, constipation, altered bowel motion and protruding mass. Treatment options include wide local excision, abdominoperineal resection, low anterior resection, bloc resection and pelvic exenteration. Patients who underwent wide local excision show a higher local recurrence rate as compared to patients who underwent radical resection. Distant metastasis is higher in patients who underwent radical resection.
CONCLUSION
The treatment options of anal LMS are controversial. At present, very few cases have been reported, thus no universally accepted standard of surgical treatment has been established.
PubMed: 37660489
DOI: 10.1016/j.ijscr.2023.108744 -
BMJ Open Aug 2023Pelvic exenteration (PE) surgery represents the only potentially curative treatment option for patients with locally advanced or recurrent rectal cancer (LARRC). Given...
INTRODUCTION
Pelvic exenteration (PE) surgery represents the only potentially curative treatment option for patients with locally advanced or recurrent rectal cancer (LARRC). Given the potential morbidity, whether or not PE should be recommended for an individual patient presents a major decisional conflict. This study aims to identify the outcomes of PE for which there is consensus among patients, carers and clinicians regarding their importance in guiding treatment decision-making, and to develop a risk prediction tool which predicts these outcomes.
METHODS AND ANALYSIS
This study will be conducted at a specialist PE centre, and employ a mixed-methods study design, divided into three distinct phases. In phase 1, outcomes of PE will be identified through a comprehensive systematic review of the literature (phase 1a), followed by exploration of the experiences of individuals who have undergone PE for LARRC and their carers (phase 1b, target sample size 10-20 patients and 5-10 carers). In phase 2, a survey of patients, their carers and clinicians will be conducted using Delphi methodology to explore consensus around the outcomes of highest priority and the level of influence each outcome should have on treatment decision-making. In phase 3 a, risk prediction tool will be developed using data from a single PE referral centre (estimated sample size 500 patients) to predict priority outcomes using multivariate modelling, and externally validated using data from an international PE collaboration.
ETHICS AND DISSEMINATION
Ethical approval has been granted for phases 1 and 2 (X22-0422 and 2022/ETH02659) and for maintenance of the database used in phase 3 (X13-0283 and HREC/13/RPAH/504). Informed consent will be obtained from participants in phases 1b and 2; a waiver of consent for secondary use of data in phase 3 will be sought. Study results will be submitted for publication in international and/or national peer reviewed journals.
PROSPERO REGISTRATION NUMBER
CRD42022351909.
Topics: Humans; Pelvic Exenteration; Rectal Neoplasms; Research Design; Consensus; Databases, Factual; Neoplasms, Second Primary; Review Literature as Topic
PubMed: 37648387
DOI: 10.1136/bmjopen-2023-075304 -
International Journal of Clinical... 2023The aim of this study was to explore prognostic factors, develop and internally validate a prognostic nomogram model, and predict the cancer-specific survival (CCS) of... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
The aim of this study was to explore prognostic factors, develop and internally validate a prognostic nomogram model, and predict the cancer-specific survival (CCS) of epithelial ovarian cancer (EOC) patients with pelvic exenteration (PE) treatment.
METHODS
A total of 454 EOC patients from the Surveillance, Epidemiology, and End Results (SEER) database were collected according to the inclusion criteria and randomly divided into the training ( = 317) and validation ( = 137) cohorts. Prognostic factors of EOC patients with PE treatment were explored by univariate and multivariate stepwise Cox regression analyses. A predictive nomogram was constructed based on selected risk factors. The predictive power of the constructed nomogram was assessed by the time-dependent receiver operating characteristic (ROC) curve. Kaplan-Meier (KM) curve stratified by patients' nomoscore was also plotted to assess the risk stratification of the established nomogram. In internal validation, the C index, calibration curve, and decision curve analysis (DCA) were employed to assess the discrimination, calibration, and clinical utility of the models, respectively.
RESULTS
In the training cohort, age, histological type, Federation of Gynecology and Obstetrics (FIGO) stage, number of examined lymph nodes, and number of positive lymph nodes were found to be independent prognostic factors of postoperative CSS. A practical nomogram model of EOC patients with PE treatment was constructed based on these selected risk factors. Time-dependent ROC curves and KM curves showed the superior predictive capability and excellent clinical stratification of the nomogram in both training and validation cohorts. In the internal validation, the C index, calibration plots, and DCA in the training and validation cohorts confirmed that the nomogram presents a high level of prediction accuracy and clinical applicability.
CONCLUSION
Our nomogram exhibited satisfactory survival prediction and prognostic discrimination. It is a user-friendly tool with high clinical pragmatism for estimating prognosis and guiding the long-term management of EOC patients with PE treatment.
Topics: Female; Humans; Pregnancy; Carcinoma, Ovarian Epithelial; Nomograms; Ovarian Neoplasms; Pelvic Exenteration; Prognosis
PubMed: 37637510
DOI: 10.1155/2023/9219067 -
International Wound Journal Dec 2023A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure... (Meta-Analysis)
Meta-Analysis
Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis.
A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.
Topics: Humans; Myocutaneous Flap; Pelvic Exenteration; Rectus Abdominis; Surgical Mesh; Wound Healing; Rectal Neoplasms; Perineum; Postoperative Complications
PubMed: 37539486
DOI: 10.1111/iwj.14284 -
Cureus Jun 2023Introduction Non-transitional cell carcinomas of the bladder (NTCCB) represent a significant clinical challenge due to their rarity, heterogeneity, and poor prognosis....
Introduction Non-transitional cell carcinomas of the bladder (NTCCB) represent a significant clinical challenge due to their rarity, heterogeneity, and poor prognosis. Despite their poor prognosis, the treatment of NTCCB has historically been based on the same principles used for transitional cell carcinomas (TCCs). Our study focuses on the management of non-transitional cell carcinomas and aims to identify areas where treatment outcomes can be improved based on our institutional experience. Materials and methods A retrospective analysis of patients with NTCCB who presented at Kasturba Hospital Manipal was conducted between 2012 to 2021. Patient data were collected, and demographic characteristics, presenting symptoms, history of other primary malignancies, comorbidities, location of the tumour, stage at presentation, histopathological subtype, site of systemic metastasis, and primary treatment given were analyzed descriptively. Median overall survival was determined by calculating the time from the initial diagnosis to the date of death. Results Among 31 patients with NTCCB, 15 (48%) presented with metastatic disease, five (16%) with locally advanced disease, and 11 (36%) with localized disease. The most common histopathological subtypes were squamous cell carcinoma and adenocarcinoma, as noted in 14 (45.2%) and 13 (41.9%) patients, respectively, followed by neuroendocrine tumours in two (6.5%), extra-adrenal phaeochromocytoma in one (3.3%), and sarcomatoid carcinoma in one (3.3%) patient, respectively. The lung was the most frequent site of systemic metastasis as noted in six (40%) patients, followed by the liver and skeletal system in three (20%) patients each, peritoneum in two (13.3%), cerebral cortex in one (6.7%), and non-regional lymph nodes in one (6.7%) patient. The primary treatment given included palliative chemotherapy in 14 (45.2%) patients, radical cystectomy with ileal conduit in 10 (32.3%), neoadjuvant chemotherapy only in four (12.9%), partial cystectomy in one (3.2%), pelvic exenteration with ileal conduit in one (3.2%), and peritoneal debulking with palliative chemotherapy in one (3.2%) patient. The overall median survival was 15 months, with a one-year survival rate of 67.4%. Conclusion NTCCB exhibits aggressive clinical behaviour and presents with nonspecific clinical features in the early stages, often leading to late diagnosis and an advanced tumour stage at presentation. Multi-institutional studies with larger patient cohorts are needed to recommend best clinical practices for early detection and optimal treatment strategies to improve patient survival.
PubMed: 37492844
DOI: 10.7759/cureus.40879 -
The Pan African Medical Journal 2023in patients with advanced primary or recurrent gynecologic, urologic, or rectal cancers without metastatic disease, extensive aggressive surgery such as pelvic...
INTRODUCTION
in patients with advanced primary or recurrent gynecologic, urologic, or rectal cancers without metastatic disease, extensive aggressive surgery such as pelvic exenteration may be necessary for curative intent treatment. This study aims to present the initial experience and clinical outcome of curative pelvic exenteration procedures for advanced or recurrent pelvic cancer in our center.
METHODS
a retrospective cross-sectional study was conducted at the colorectal unit at King Hussein Medical Center in Amman, Jordan, between March 2014 and December 2021. All patients who underwent pelvic exenteration procedures were included in this study. Demographic characteristics, type of procedure, completeness of excision, postoperative complications, morbidity, and mortality were analyzed.
RESULTS
a total of 30 patients underwent thirty-one operations. There were 22 females and eight males with a median age of 55 (range 25-86) years. Twenty-six surgeries were for advanced primary and 5 for recurrent malignancies. Twenty-nine operations were performed for colorectal and 2 for gynecological tumors. There were 19 posterior pelvic exenterations, 2 posterior pelvic exenterations with sacrectomy, and ten total pelvic exenterations. Completeness of tumor excision R0 was observed in 21 specimens, incomplete (R1/R2) in 6 specimens. The overall complication rate was 67.7% and 30-day mortality was 16.7%. Ten (33.3%) patients are disease free at a median follow-up of 22 months.
CONCLUSION
in our study, pelvic exenteration provides above 40% overall survival at a median follow-up of two years. Gaining experience in this type of procedure, a multidisciplinary approach, careful patients' selection, and preoperative counseling will reduce postoperative morbidity and mortality.
Topics: Male; Humans; Female; Adult; Middle Aged; Aged; Aged, 80 and over; Pelvic Exenteration; Retrospective Studies; Cross-Sectional Studies; Neoplasm Recurrence, Local; Rectal Neoplasms; Postoperative Complications; Treatment Outcome
PubMed: 37455871
DOI: 10.11604/pamj.2023.44.170.37182 -
Techniques in Coloproctology Nov 2023When working with patients who have locally advanced rectal cancer (LARC) the ability to undertake minimally invasive procedures becomes more challenging but no less...
When working with patients who have locally advanced rectal cancer (LARC) the ability to undertake minimally invasive procedures becomes more challenging but no less important for patient outcomes. We performed a minimally invasive approach to surgery for LARC invading the posterior vagina and sacrum. The patient was a 75-year-old lady who presented with a locally advanced rectal tumour staged T4N2 with invasion into the posterior wall of the vagina and coccyx/distal sacrum. We introduce a robotic abdominoperineal resection, posterior vaginectomy and abdomino-lithotomy sacrectomy using a purely perineal approach with no robotic adjuncts or intracorporal techniques. Final histology showed moderately differentiated adenocarcinoma invading the vagina and sacrum, ypT4b N0 TRG2 R0 and the patient entered surgical follow-up with no immediate intra- or postoperative complications. A literature review shows the need for more minimally invasive techniques when relating to major pelvic surgery and the benefits of a purely perineal approach include less expensive resource use, fewer training requirements and the ability to utilise this technique in centres that are not robotically equipped.
PubMed: 37452925
DOI: 10.1007/s10151-023-02827-w