International standardization and optimization group for intersphincteric resection (ISOG-ISR): modified Delphi consensus on anatomy, definition, indication, surgical technique, specimen description and functional outcome.

AIM: Intersphincteric resection (ISR) is an oncologically complex operation for very low-lying rectal cancers. Yet, definition, anatomical description, operative indications and operative approaches to ISR are not standardized. The aim of this study was to standardize the definition of ISR by reaching international consensus from the experts in the field. This standardization will allow meaningful comparison in the literature in the future. METHOD: A modified Delphi approach with three rounds of questionnaire was adopted. A total of 29 international experts from 11 countries were recruited for this study. Six domains with a total of 37 statements were examined, including anatomical definition; definition of intersphincteric dissection, intersphincteric resection (ISR) and ultra-low anterior resection (uLAR); indication for ISR; surgical technique of ISR; specimen description of ISR; and functional outcome assessment protocol. RESULTS: Three rounds of questionnaire were performed (response rate 100%, 89.6%, 89.6%). Agreement (≥80%) reached standardization on 36 statements. CONCLUSION: This study provides an international expert consensus-based definition and standardization of ISR. This is the first study standardizing terminology and definition of deep pelvis/anal canal anatomy from a surgical point of view. Intersphincteric dissection, ISR and uLAR were specifically defined for precise surgical description. Indication for ISR was determined by the rectal tumour's maximal radial infiltration (T stage) below the levator ani. A new surgical definition of T3isp was reached by consensus to define T3 low rectal tumours infiltrating the intersphincteric plane. A practical flowchart for surgical indication for uLAR/ISR/abdominoperineal resection was developed. A standardized ISR surgical technique and functional outcome assessment protocol was defined.

Perioperative complications and short-term outcomes of sacrocolpopexy using self-adhesive mesh.

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the perioperative complications and short-term outcomes of patients who underwent sacrocolpopexy using a self-adhesive mesh. MATERIALS AND METHODS: This is a prospective, monocentric study conducted between October 2019 and December 2020. We included 20 consecutive patients on whom sacrocolpopexy using the Parietex ProGripTM Self-Fixating Mesh (Medtronic, Minneapolis, MN, USA) was performed. The patients' demographics, operative data, perioperative complications, and functional and anatomical outcomes were assessed. RESULTS: A total of 20 patients were included in this study. The objective cure rate was 95%, and the subjective cure rate was 94.12%. The failure of the surgery was defined as the recurrence of pelvic organ prolapse (POP) ≥ grade II. The preoperative POP quantification classifications were as follows: grade I: 0%; grade II: 70%; grade III: 30%; and grade IV: 0%. There were no mesh-related complications or other intraoperative complications. The postoperative complications included two urinary tract infections, two incisional hernias, and a prolapse recurrence. The mean operative time was 154 ± 37.04 minutes, and the mean hospital stay time was 7 ± 1.12 days. CONCLUSIONS: The present study found that the use of the Parietex ProGripTM Self-Fixating Mesh in abdominal sacrocolpopexy was not associated with greater rates of complications. KEY WORDS: Pelvic organ prolapse, Sacrocolpopexy, Self-fixating mesh.

Clinical-Pathological Correlations in the Acute Surgical Abdomen in the Pre and Post-Pandemic Period Covid-19.

Background: In the case of patients admitted with acute abdomen at the emergency department, interstitial pulmonary pathology (Covid-19 infections) represents a significant operative risk for the patients. The rate of postoperative complications is high with increased morbidity and mortality, a real challenge for the medical staff and surgical/intensive care unit teams. In emergency settings, patients were examined with targeted clinical and paraclinical parameters that assure a fast diagnosis to optimize a rapid medical and surgical treatment. Methods: We conducted a retrospective comparative study that included patients enrolled and diagnosed with an acute surgical abdomen in Surgical Clinic 1 Tg. Mures Emergency County Hospital. Patients were examined and analyzed at the emergency department UPU-SMURD. We included patients admitted over the two years (2019 and 2020) and divided them into two groups. Results: The total number of patients admitted in the UPU-Smurd emergency department Surgical Clinic I over the two years was 1033. There was a significant reduction in total cases diagnosed with the acute surgical abdomen in the pandemic period (p=0.033). The average time from the admission to the surgical procedure was significantly higher in the pandemic period 380Ã+-2 min in comparison with 222+-3 min (p=0.001) and also with an increased average operative time 223+-3 min versus 145+-2 min (p=0.002). Average hospitalization time was higher in the pandemic period 10+-1 (p=0.031) with no significant difference between the groups regarding Intensive Care Unit (ICU) admission (p=0.122). Overall mortality has more than doubled, with 31 cases (19%) in the pandemic and 28 (9%) in the non-pandemic. (p=0.001). Conclusions: The COVID-19 pandemic has played an essential role in treating acute surgical abdomen cases. The high solicitation rate of the emergency department delayed the diagnosis and treatment of severe surgical cases. As the scale of this pandemic is unprecedented, standard protocols with minor changes do not provide adequate results.

Multiple Hepatic Hydatid Cysts - Review of the Literature and Case Report.

Introduction: Hydatid disease is a parasitic disease caused by and is commonly met in clinical practice. The most common location for hydatic cysts is the liver, while the lung is the second organ in terms of localization frequency. Case report: We present the case of a 40-year-old patient with pulmonary hydatid cysts (two hydatid cysts located in the upper and lower pulmonary left lobes), and multiple hepatic hydatid cysts (ten cysts located in both hepatic lobes). Initially, the patient underwent thoracic surgery and was subjected to atypical lung resection of the upper and lower left pulmonary lobes. The patient underwent surgical treatment of the hepatic hydatid cysts 6 months after the thoracic surgery. The patient underwent multiple partial cystectomies, cholecystectomy, Kehr drainage with two hepatic hydatid cysts showing biliary fistulas. The postoperative evolution was favorable with patient discharge 10 days following surgery. Conclusions: Although the hepatic hydatid cyst is a seemingly benign disease, there are complex cases of disseminated echinococcosis in clinical practice that may require complex treatment. Surgical treatment remains the best therapeutic option in these cases. Thus, for these patients, a careful postoperative follow-up is required to detect recurrence of hydatid disease.

LAR vs VLAR in Low Rectal Cancer - Postoperative Results - A Single-Center Experience.

Background: The management of rectal cancer recognizes surgical resection as the most important step towards a permanent cure. Respecting the oncological principles, functional preservation represents a priority in achieving an acceptable quality of life for the patient. This study aimed to compare the results after low anterior resection (LAR) versus very low anterior resection (VLAR), in terms of postoperative outcome. Methods: We conducted a retrospective, observational study on a group of 147 patients with LAR or VLAR done for low rectal cancer in the 1st Department of General Surgery of the Emergency County Hospital of Targu Mures, between January 2015 and December 2019. We considered as low rectal cancer tumors located between 5-10 cm from the anal verge and very low those situated less than 5 cm from it. Patients were divided in two groups according to the type of operation. The postoperative evolution was followed. Results: The two groups, LAR with 81 and VLAR with 66 cases, had homogenous distribution regarding patients demographic and biological parameters and tumor pathological features. A significantly (p=0.0223) longer surgical intervention time was reported in VLAR than in LAR procedures. We found no statistically significant differences between LAR and VLAR in terms of associated postoperative morbidity or mortality, neither in hospitalization time. Conclusions: There was no statistical difference in terms of early postoperative outcomes among LAR and VLAR. The most important factor in achieving good oncologic and functional results in low rectal cancer is choosing the adequate, tailored to the case surgical management.

Parietex ProGrip™ Self-Fixating Mesh in Surgical Treatment of Pelvic Organ Prolapse.

Introduction: Advanced pelvic organ prolapse is a public health problem, and its treatment can be difficult, requiring a multidisciplinary approach. Aim: The main objective of this article is to describe particular aspects of the use of Parietex ProGrip trade; Self-Fixating Mesh for abdominal sacrocolpopexy or sacrocervicopexy. The secondary objective is to present the initial results of the use of these self-fixating meshes. Results: Ten successive patients with a POP of grade 2 or higher have benefited from this procedure. No complications or recurrences of prolapse were detected at 1, 3 and 6 months postoperatively. The mean operative time was 102Â+-25.84 minutes. The mean length of hospital stay was 6.7Â+-0.67 days. Conclusions: The results of this surgical procedure demonstrate that Parietex ProGrip trade; Self- Fixating Mesh can be used without complications and with good postoperative results. The main advantage of using this mesh is that it does not require other fastening means. The lack of rejection reaction or foreign body pathology encourages the implementation of this surgical procedure. Further study is needed to consolidate these results.

Long Term Results of Modified Intersphincteric Resections for Low Rectal Cancer: A Single Center Experience.

BACKGROUND AND OBJECTIVES: The objective of this article is to evaluate the long-term oncological and functional outcomes following modified intersphincteric resections (ISR) for low rectal cancer. The modified technique consisted of the abandonment of colonic J-pouches, transverse coloplasty, or defunctioning temporary stoma in favor of a direct handsewn coloanal anastomosis (CAA). MATERIAL AND METHODS: Sixty consecutive patients with type II and III (juxta-anal or intra-anal) low rectal tumors underwent modified ISR by the same surgical team and were followed for a period of five years. Functional outcomes using the Wexner Score, postoperative complications, recurrence rates, morbidity, and mortality rates were assessed. RESULTS: The five-year survival rate was 93.3% with a disease-free interval at three years of 98%. Morbidity was 15% (n = 9) consisting of intestinal wall necrosis (n = 6), stenosis (n = 2), and sacral metastasis (n = 1). The Wexner score values were, at 1 year, 8.5 (range, 4-13); at three years 7.2 (range, 2-11); and at 5 years 6.7 (range, 2-12). A second surgery was needed in only one case that showed postoperative transmural necrosis of the colonic wall. CONCLUSIONS: In highly selected patients with type II or III low rectal tumors and proper preoperative imaging staging, ISR might be a viable alternative to other techniques such as abdominoperineal resection and low anterior resection, both from a functional and an oncological perspective.

Gastrointestinal mixed adenoneuroendocrine carcinoma (MANEC): An immunohistochemistry study of 13 microsatellite stable cases.

BACKGROUND: Mixed adenoneuroendocrine carcinoma (MANEC) is currently included in the category of neuroendocrine carcinomas but the therapeutically management is not yet defined. AIMS: To present the immunohistochemical (IHC) features of the epithelial mesenchymal transition (EMT) of MANEC. MATERIALS AND METHODS: The clinicopathological features of 13 consecutive cases of MANEC (6 gastric and 7 colorectal) were correlated with the IHC expression of the biomarkers E-cadherin, ß-catenin, N-cadherin, vimentin, maspin, CD44 and S100. In all of the cases open surgery was performed. RESULTS: All of the cases showed microsatellite stable status, expressed E-cadherin and membrane ß-catenin in both components (neuroendocrine and adenocarcinoma) and were negative for N-cadherin, vimentin and S-100. The colorectal MANECs were negative for maspin. In gastric MANECs, maspin showed cytoplasm positivity in the neuroendocrine component and nuclear translocation in the adenocarcinoma cells. CD44 was positive in all of the cases, in both components. No tumor buddings were identified. Three of the 13 patients survived for at least 32 months, all of them showing lymphatic emboli but not lymph node metastases. Pure neuroendocrine lymph node metastases were seen in only four of the cases: one from stomach, two of the ascending colon and two cases of the upper rectum. CONCLUSIONS: Gastrointestinal MANEC is a microsatellite stable tumor with nodular growth, which components might originate from a CD44-positive stem-like precursor cell. Lymph node status remains the most reliable prognostic parameter and agressivity seems to not be influenced by tumor budding degree or EMT-related features. The histologic aspect of metastatic component (neuroendocrine versus adenocarcinoma) should be included in the histopathological reports and might be used for establishing the proper-targeted therapy of MANEC.

Monobloc Total Thyroidectomy Using Sealing Devices: Preliminary Results and Comparative Analysis.

Background: The desire for perfect haemostasis has led the medical equipment industry to produce ideal instruments for safe thyroidectomy. Thus, haemostasis and sealing instruments such as the LigaSureTM Small Jaw, ThunderbeatTM Open Fine Jaw and HarmonicTM Focus have been indicated for thyroid surgery. Aim: The purpose of this study is to present the initial results of using these three surgical instruments for performing monobloc thyroidectomy. Material and Methods: We performed a prospective study between January 2014 and July 2019 in which we included all the patients operated by same surgeon using those 3 sealing devices. Thyroidectomies were performed using LigaSureTM Small Jaw (group 1), the ThunderbeatTM Open Fine Jaw (group 2) and HarmonicTM Focus (group 3). The groups were statistically compared in term of duration of surgery and hospitalisation, early postoperative complications as well as voice alteration or acute respiratory failure. Results: No significant differences were observed among groups in terms of patient demographics, pathological diagnoses, postoperative complications, length of hospitalization, and clinical outcomes. Operating time was shorter in group 1. Conclusions: New surgical instruments have beneficial properties, including shortening the operative time, maintaining a clean operating field, and minimising smoke released during the operation.

Upper Gastrointestinal Tract Hemorrhage: Unexpected Discovery.

Pica is a serious condition that is characterized by ingesting inedible things which can prove to be fatal (glass, pebbles, etc.) We present the case of a 64-year-old male patient who is admitted to the emergency room with the following complaints: upper GI tract bleeding manifested through hematemesis and melena, epigastric pain, lack of bowel movements. A contrast computed tomograohy is performed showing the presence of a hyper-dense stomach content, gastric wall thickening, abdominal fluid but with no signs of intestinal occlusion. A laparotomy is performed and ollowing an anterior gastrotomy a large quantity of pebbles is found along with a hemorrhagic and stenotic tumor of the lesser curvature. Taking into account the intraoperative aspect the decision was made to perform an end-to-side stapled esophago-jejunal anastomosis on an omega loop with a Braun entero-entero anastomosis following total gastric resection and D1 lymphadenectomy. Postoperative course is uneventful. A barium swallow carried out on the 10th day following surgery shows a functional anastomosis without leakage. On day 11, the patient is discharged. Pica is usually discovered by accident, most frequently on the operating table which is why thorough preoperative examination and investigations are required.

Comparative oncological outcomes and survival following surgery for low rectal cancer - a single center experience.

In patients with low rectal cancer, intersphincteric resection (ISR) technique is a better alternative of abdominoperineal resection (APR), but is recommended to be done in non-locally advanced stages (=T2) only. The aim of this study was to evaluate the long-term oncological outcome and survival rate in patients with early and locally advanced stages that underwent ISR, as compared to APR. In order to assess the quality of life and prognosis of patients with low rectal cancer, the 5-year follow-up was done in 72 consecutive cases diagnosed in pT1-T4 stage that underwent ISR or APR. Histopathological and clinical parameters were compared between the two included groups. Although the quality of life was better in patients which underwent ISR, the 5-year overall survival rate was not found to be influenced by the used surgical technique (71% for ISR and 58% for APR) either by the histological grade of differentiation (p=0.62), independently from the T stage (p=0.61). Regardless of the type of surgery, the independent prognostic factors proved to be lymph node status (p=0.001), lymph node ratio (p=0.001), and clinical stage (p=0.0001). Lymph node status remains the most important prognostic factor of patients with low rectal cancer. Independently from the histological subtype and depth of tumor infiltration, good oncological results can be obtained when performing ISR in selected cases.

Anterior Transabdominal Laparoscopic Adrenalectomy, without Ligatures, for a Symptomatic Right Adrenal Myelolipoma with Intratumoral Hemorrhage.

Myelolipomas represent 3-7% fromthe primary tumors of the adrenal gland. Most often they are incidental findings. In most cases are asymptomatic, rarely they present symptoms (pain, abdominal discomfort, hematuria or signs of internal hemorrhage). Histologically benign, this variety of tumor requires only local excision, in symptomatic forms. Their dimensions are generally up to 4-5 cm, so the laparoscopic approach seems the most appropriate. We present the case of a 65 years old patient, electively operated for a right adrenal tumor formation.Alaparoscopic right adrenalectomy was performed using an anterior transabdominal approach. No ligatures, clips or sutures were used. The intervention was accomplished with the Ligasure Maryland forceps and the Force Triad platform (Covidien Medtronic-USA). The postoperative evolution was favorable and the pathological examination highlighted an adrenal myelolipoma with intratumoral hemorrhage.