Combined Robotic Ventral Mesh Rectopexy and Sacrocolpopexy for Multicompartmental Pelvic Organ Prolapse.

BACKGROUND: Multispecialty management should be the preferred approach for the treatment of pelvic floor dysfunction because there is often multicompartmental prolapse. OBJECTIVE: To assess the safety of combined robotic ventral mesh rectopexy and either uterine or vaginal fixation for the treatment of multicompartmental pelvic organ prolapse at our institution. DESIGN: Retrospective analysis. SETTINGS: Tertiary referral academic center. PATIENTS: All patients who underwent a robotic approach and combined procedure and whose cases were discussed at a biweekly pelvic floor multidisciplinary team meeting. MAIN OUTCOME MEASURES: Operative time, intraoperative blood loss and complications, postoperative pelvic organ prolapse quantification score, length of stay, 30-day morbidity, and readmission. RESULTS: From 2018 to 2021, there were 321 operations for patients with multicompartmental prolapse. The mean age was 63.4 years. The predominant pelvic floor dysfunction was rectal prolapse in 170 cases (60%). Pelvic organ prolapse quantification scores were II in 146 patients (53%), III in 121 patients (44%), and IV in 9 patients (3%); 315 of 323 cases included robotic ventral mesh rectopexy (98%). Sacrocolpopexy or sacrohysteropexy was performed in 281 patients (89%). Other procedures included 175 hysterectomies (54%), 104 oophorectomies (32%), 151 sling procedures (47%), 149 posterior repairs (46%), and 138 cystocele repairs (43%). The operative time for ventral mesh rectopexy was 211 minutes and for combined pelvic floor reconstruction was 266 minutes. Average length of stay was 1.6 days. Eight patients were readmitted within 30 days: 1 with a severe headache and 7 with postoperative complications (2.5%), such as pelvic collection and perirectal collection, both requiring radiologic drainage. Four complications required reoperation: epidural abscess, small-bowel obstruction, missed enterotomy requiring resection, and urinary retention requiring sling revision. There were no mortalities. LIMITATIONS: Retrospective single-center study. CONCLUSIONS: A combined robotic approach for multicompartmental pelvic organ prolapse is a safe and viable procedure with a relatively low rate of morbidity and no mortality. This is the highest volume series of combined robotic pelvic floor reconstruction in the literature and demonstrates a low complication rate and short length of stay. See Video Abstract . RECTOPEXIA Y SACROCOLPOPEXIA ROBTICA VENTRAL COMBINADAS CON MALLA PARA EL PROLAPSO DE RGANOS PLVICOS MULTICOMPARTIMENTALES: ANTECEDENTES:El tratamiento multiespecializado debe ser el enfoque preferido para el tratamiento de la disfunción del suelo pélvico, ya que a menudo hay prolapso multicompartimental.OBJETIVO:Evaluar la seguridad de la rectopexia robótica combinada con malla ventral y fijación uterina o vaginal para el tratamiento del prolapso multicompartimental de órganos pélvicos en nuestra institución.DISEÑO:Análisis retrospectivo.AJUSTES:Centro académico de referencia terciarioPACIENTES:Todos los pacientes que se sometieron a un enfoque robótico y un procedimiento combinado y se discutieron en una reunión quincenal del equipo multidisciplinario sobre el piso pélvico.MEDIDAS DE RESULTADO:Tiempo operatorio, pérdida de sangre intraoperatoria y complicaciones. Puntuación de cuantificación del prolapso de órganos pélvicos posoperatorio, duración de la estancia hospitalaria, morbilidad a 30 días y reingreso.RESULTADOS:De 2018 a 2021, se realizaron 321 operaciones de pacientes con prolapso multicompartimental. La edad media fue 63.4 años. La disfunción del suelo pélvico predominante fue el prolapso rectal en 170 casos (60%). Las puntuaciones de cuantificación del prolapso de órganos pélvicos fueron II en 146 pacientes (53%), III en 121 (44%) y IV en 9 (3%); 315 de los 323 casos incluyeron rectopexia robótica de malla ventral (98%). Se realizó sacrocolpopexia o sacrohisteropexia en 281 pacientes (89%). Otros procedimientos incluyeron 175 histerectomías (54%), 104 ooforectomías (32%), 151 procedimientos de cabestrillo (47%), 149 reparaciones posteriores (46%) y 138 reparaciones de cistocele (43%). El tiempo operatorio para la rectopexia con malla ventral fue de 211 minutos y la reconstrucción combinada del piso pélvico de 266 minutos. La estancia media fue de 1.6 días. Ocho pacientes reingresaron dentro de los 30 días, 1 con dolor de cabeza intenso y 7 pacientes con complicaciones posoperatorias (2.5%): colección pélvica y colección perirrectal, ambas requirieron drenaje radiológico. Cuatro complicaciones requirieron reoperación: absceso epidural, obstrucción del intestino delgado, enterotomía omitida que requirió resección y retención urinaria que requirió revisión del cabestrillo. No hubo mortalidades.LIMITACIONES:Estudio retrospectivo unicéntrico.CONCLUSIONES:Un enfoque robótico combinado para el prolapso multicompartimental de órganos pélvicos es un procedimiento seguro y viable con una tasa relativamente baja de morbilidad y ninguna mortalidad. Esta es la serie de mayor volumen de reconstrucción robótica combinada del suelo pélvico en la literatura y demuestra una baja tasa de complicaciones y una estancia hospitalaria corta. (Traducción-Dr. Aurian Garcia Gonzalez )See Editorial on page 195.

Unusual presentation of a neuroendocrine tumor in the ileostomy specimen after rectal cancer treatment: a case report.

Background: Neuroendocrine tumors of the small intestine are uncommon, but at the same time they are the most frequent subtype of neuroendocrine tumor in the gastrointestinal system. They originate from enterochromaffin cells, which are involved in the creation of serotonin. This asymptomatic characteristic in the initial presentation is usually why these tumors are discovered at a late stage, sometimes in association with symptomatic metastatic disease. Case Description: We present a case-report of a 52-year-old gentleman with a suggestive family history of hereditary cancer syndrome (mother with lung cancer and maternal uncle with colon cancer at the age of 40 years old). The patient was diagnosed with rectal cancer and he received neoadjuvant chemotherapy with short-course radiotherapy followed by a robotic low anterior resection with diverting loop ileostomy. Following closure of his ileostomy, the pathology report of the ileostomy resection specimen showed a 1.1 cm neuroendocrine tumor with negative margins. Conclusions: This extraordinary unusual presentation could be very fortuity for the patient, who in every other opportunity just found this neuroendocrine tumor after advanced or maybe metastatic diseases.

A meta-analysis of laparoscopic versus ultrasound-guided transversus abdominis plane block in laparoscopic colorectal surgery.

BACKGROUND: Enhanced recovery programmes in laparoscopic colorectal surgery (LCS) employ combined approaches to achieve postoperative analgesia. Transversus abdominis plane (TAP) block is a locoregional anaesthetic technique that may reduce postoperative pain. AIMS: To perform a systematic review and meta-analysis to compare the effectiveness of laparoscopic- versus ultrasound-guided TAP block in LCS. METHODS: Databases were searched for relevant articles from inception until March 2022. All randomised controlled trials (RCTs) that compared laparoscopic (LTB) versus ultrasound-guided (UTB) TAP blocks in LCS were included. The primary outcome was narcotic consumption at 24 h postoperatively, whilst secondary outcomes included pain scores at 24 h postoperatively, operative time, postoperative nausea and vomiting (PONV) and complication rates. Random effects models were used to calculate pooled effect size estimates. RESULTS: Three RCTs were included capturing 219 patients. Studies were clinically heterogenous. On random effects analysis, LTB was associated with significantly lower narcotic consumption (SMD - 0.30 mg, 95% CI = - 0.57 to - 0.03, p = 0.03) and pain scores (SMD - 0.29, 95% CI = - 0.56 to - 0.03, p = 0.03) at 24 h. However, there were no differences in operative time (SMD - 0.09 min, 95% CI = - 0.40 to 0.22, p = 0.56), PONV (OR = 0.97, 95% CI = 0.36 to 2.65, p = 0.96) or complication (OR = 1.30, 95% CI = 0.64 to 2.64, p = 0.47) rates. CONCLUSIONS: LTB is associated with significantly less narcotic usage and pain at 24 h postoperatively but similar PONV, operative time and complication rates, compared to UTB. However, the data were inconsistent, and our findings require further investigation. LTB obviates the need for ultrasound devices whilst also decreasing procedure logistical complexity.

Transanal Endoscopic Platforms: TAMIS versus Rigid Platforms: Pros and Cons.

Transanal endoscopic surgery encompasses the minimally invasive surgical techniques used to operate in the rectum under magnification while maintaining pneumorectum via a resectoscope or port. The view, magnification, and surgical precision afforded by these advanced transanal techniques have resulted in excellent specimen quality and low recurrence rates, especially compared with traditional transanal surgery. For rigid platforms, the surgeon operates through a rigid 4-cm diameter steel proctoscope of varying lengths that is clamped to the operating table with an articulating arm. Transanal minimally invasive surgery (TAMIS) is a newer flexible platform using a disposable port which "hooks" into the anorectal ring to remain in place. The cost-effectiveness and versatility of the TAMIS platform have resulted in its popularity and use in more advanced applications such as transanal total mesorectal excision. Ultimately, the choice of operating platform should be based on surgeon preference, patient characteristics, availability, and cost. The pros and cons of each platform will be discussed in this article.

Transanal minimally invasive surgery for rectal cancer.

Due to the increased uptake of rectal cancer screening and the increasing rates of complete clinical response to chemoradiotherapy, more early-stage and down-staged rectal cancers are being treated. This has triggered surgeons to question the necessity for proctectomy and its associated morbidity and consider local excision and organ preservation in selected cases. Transanal minimally invasive surgery (TAMIS) has evolved as an oncologically safe yet cost-effective platform for local excision of rectal tumors using traditional laparoscopic instruments. This review highlights the recent advances and current role of TAMIS in the treatment of rectal cancer.

The Impact of Neoadjuvant Chemotherapy on Margin Re-excision in Breast-Conserving Surgery.

BACKGROUND: Neoadjuvant chemotherapy (NAC) can improve cosmesis by reducing resection volume. Breast-conserving surgery (BCS) aims to achieve clear excision margins while optimizing cosmesis. However, the influence of NAC on margin re-excision after BCS is unclear. This study examines the rate and determinants of margin re-excision in patients undergoing BCS following NAC in our institution. METHODS: From 2011-2015, all patients treated with NAC prior to BCS were identified from a prospectively maintained database. Mann-Whitney and Fisher's exact test tests were used to compare variables in patients who did and did not require re-excision. Patients undergoing primary surgical treatment in 2015 comprised an unmatched comparison group. RESULTS: Of 211 patients treated with NAC, 69 initially underwent BCS. The re-excision rate was 32% (n = 22) compared to 17% in the primary operable group (38 of 221, p = 0.02). Re-excision rates were lowest in triple-negative and HER2+ tumors (0% and 10%, respectively). Lobular carcinoma and ER+ tumors had a significantly higher rate of re-excision (100% and 42%, respectively). Of 22 patients undergoing re-excision, 9 had further BCS and 13 had a mastectomy. CONCLUSION: The re-excision rate following NAC is almost twice that of patients who underwent primary operative management. Her2+ and triple-negative tumors have lower re-excision rates and may represent a selected cohort most suitable for BCS. Patients with invasive lobular carcinoma or ER+ disease have significantly higher rates of margin positivity, and these patients should be considered for a cavity shave during primary surgery to reduce the rates of re-excision.

Breast screening in symptomatic women over 35 years of age: improvements in service efficiency.

INTRODUCTION: The rationalization of cancer services in Ireland saw all women with symptomatic breast problems referred to one of the eight regional cancer centers. A pilot triaging system was introduced in St Vincent's University Hospital to streamline these services. Women over 35 years who do not meet urgent referral criteria are referred for a mammogram prior to a clinic appointment ("image first"). The aim of this study was to retrospectively determine the recall rates, biopsy rates, and rate of breast cancer identification within this cohort of patients. This was compared to a screening population of patients. METHODS: Patients triaged into the "image first" group within a one-year period were identified. Results of the initial mammogram, further imaging and subsequent biopsies were recorded. Data relating to number of recalls, number of patients biopsied and number of cancers identified within the Merrion Unit of the National Breastcheck Screening Program was obtained for comparison. RESULTS: One thousand six hundred eighty-eight referrals were triaged as "image first" over this period. 185 (11%) of patients required a biopsy of an identified lesion. Breast cancer was diagnosed in 65 patients (3.9%). During the same study period, of the 42,099 women who were screened for breast cancer, 496 (1.8%) underwent biopsy and 267 (0.63%) were diagnosed with breast cancer. CONCLUSION: Image first patients, who represent a cohort of "symptomatic" non-urgent women, have a greater rate of breast cancer detection than an asymptomatic screening population. This may have an impact on the appropriate triaging of symptomatic women in a national cancer center.

Change of paradigm in treating elderly with breast cancer: are we undertreating elderly patients?

Developed countries face significant population ageing in the near future. Within 20 years, the average age will approach 50 years and the largest population cohort will be those over 65 years. The incidence of breast cancer increases with age, with a risk in women of 0.44% by the age of 30, 3.82% by the age of 70 and 10% by the age of 80. Breast cancer is responsible for one out of every three cancer-related deaths. Elderly patients have higher mortality rates and most breast cancer-related deaths are observed in women over 65. There appears to be a trend that elderly patients with breast cancer receive less than the standard treatment compared to younger counterparts and this leads to poorer outcomes. The rationale for treating elderly breast cancer patients more conservatively is that breast cancers in this cohort are more commonly oestrogen receptor (ER) positive which gives the clinician the option to treat with hormonal manipulation alone. In addition, elderly patients present at a later stage compared to younger patients who frequently present with early (stages I and II) breast cancer. This review aims to give an overview of the diagnosis, treatment options and surveillance of breast cancer in elderly women (over 75 years) and to discuss the change in perception of the term 'elderly' and the reasons for undertreatment in the elderly patients.

The 100 classic papers in ulcerative colitis: a bibliometric analysis.

BACKGROUND: The identification of the top 100 papers in ulcerative colitis (UC) using citation analysis provides a unique insight into the advancement of disease understanding and subsequent treatment innovations that have progressed over time. METHODS: The Thomson Reuters Web of Knowledge was used to identify the 100 most cited UC manuscripts. Title, first and senior authors, institution and department of first author, journal, country of origin, year and topic of each manuscript were analyzed. RESULTS: The top 100 manuscripts were published between 1955-2012. Thirty eight percent of the manuscripts originated from the US followed by the UK (26%). Genetics was the topic with the most publications (n = 27), followed by treatment (n = 22) and immunological pathways (n = 17). Truelove had the highest amount of authorships. The institutions with the highest number of publications were St. Mark's, London and the Radcliffe Infirmary. CONCLUSION: This list of highly cited papers identifies the topics and authors that have made the most impact in the study of UC over the last century. This paper provides a reference of what could be considered as the most influential UC papers and serves as a reference of what comprises a 'highly citable' manuscript for both researchers and clinicians.

The 100 most influential manuscripts in colorectal cancer: A bibliometric analysis.

PURPOSE: Bibliometric analysis highlights the key topics and studies which have led to the current understanding and treatment of a disease of interest. In this original article we analyze the 100 most cited manuscripts in the field of colorectal cancer (CRC). MATERIALS AND METHODS: The Thomson Reuters Web of Science database with the search terms 'colorectal cancer,' 'colorectal cancer surgery,' 'colon cancer,' 'rectal cancer,' 'colorectal carcinoma,' 'colon carcinoma,' 'rectal carcinoma' and/or 'colonoscopy' was used to identify the manuscripts for the study. Only full length manuscripts were included. The 100 most cited papers were identified and further analyzed by topic, journal, author, year and institution. The journals' 5 year impact factor and Eigenfactor scores were recorded. RESULTS: 146,833 eligible papers were returned. Within the top 100 cited manuscripts, the most studied topic was genetics in CRC (n = 41), followed by chemotherapy (n = 20) and surgical management (n = 7). The most cited paper authored by Fearon et al. (7850 citations) focused on genetic models of tumorgenesis. The NEJM published the highest number of papers (n = 23 with 42,576 citations). The country and year with the greatest number of publications were the USA (n = 62) and 2004 (n = 13) respectively. CONCLUSION: The most cited manuscripts highlighted in the current work describe the genetic, immunologic, basic science and surgical techniques that have resulted in the current understanding and treatment of CRC. The majority of these works were published in high impact journals and have been cited at least 900 times each reflecting their quality and influence. This work provides a reference of what could be considered as the most influential papers in CRC and serves as a reference for researchers and clinicians as to what makes a 'citable' paper.

A review of sacral nerve stimulation parameters used in the treatment of faecal incontinence.

Sacral nerve stimulation (SNS) was originally developed in the field of urinary incontinence. Without adaptation, it was subsequently applied to treat faecal incontinence. SNS has now become a first line therapy for this socially disabling condition, however the mechanism of action is unknown. This review examines the evidence for stimulation parameters currently used for SNS in humans and considers the potential electrophysiological effects of changing these parameters. However, without a proper understanding of the physiology of SNS, changing stimulation parameters remains empirical.

Influences of the colonic microbiome on the mucous gel layer in ulcerative colitis.

The colonic mucus gel layer (MGL) is a critical component of the innate immune system acting as a physical barrier to microbes, luminal insults, and toxins. Mucins are the major component of the MGL. Selected microbes have the potential to interact with, bind to, and metabolize mucins. The tolerance of the host to the presence of these microbes is critical to maintaining MGL homeostasis. In disease states such as ulcerative colitis (UC), both the mucosa associated microbes and the constituent MGL mucins have been shown to be altered. Evidence is accumulating that implicates the potential for mucin degrading bacteria to negatively impact the MGL and its stasis. These effects appear more pronounced in UC.   This review is focused on the host-microbiome interactions within the setting of the MGL. Special focus is given to the mucolytic potential of microbes and their interactions in the setting of the colitic colon.