Tailoring surgery for obstructed defecation syndrome to the 'iceberg diagram': Long-term results.

BACKGROUND: Patients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has been proposed for an accurate diagnosis. The iceberg diagram deals with lesions, which, if neglected, may worsen the prognosis. The aim of this study was to evaluate the effect of using the iceberg diagram on the clinical results. METHODS: Patients operated for obstructed defecation syndrome based on the iceberg diagram between 2008 and 2018 were evaluated pre- and postsurgery. All patients underwent psychosomatic assessment, abdominal and perineal examination, proctoscopy, vaginoscopy, transanal ultrasound, and defecography. Postoperative complications were also evaluated. RESULTS: Of the 80 operated patients, 73 were females; median age was 47 (range 26-78) years. All had a rectal internal mucosal prolapse and 85% had a rectocele. The most frequent occult diseases were functional (mental distress [46%]) or organic (colpo-cysto-enterocele [44%]). Surgery was tailored according to the iceberg diagram with prolapsectomy and rectocele repair the most commonly used among 8 different procedures. A total of 14% of patients had a postoperative complication. Median follow-up was 72 months. Obstructed defecation syndrome score significantly decreased from 10.5 ± 4.8 (mean + standard deviation) to 3.4 ± 3.6 (P < .01) and 68% of patients reported to be either improved or cured. CONCLUSION: The use of the iceberg diagram in obstructed defecation syndrome patients assists in identifying latent "submerged lesions' that may negatively impact the functional outcome of surgery. A clinical approach to patients with obstructed defecation syndrome tailored according to the iceberg diagram allows the identification of occult lesions and to achieve good long-term results.

Aggressive Surgical Approach for Treatment of Primary and Recurrent Retroperitoneal Soft Tissue Sarcoma.

To analyze treatment and survival in a series of resected patients with primary or recurrent retroperitoneal sarcoma (RPS) treated and prospectively followed at a single institution. Between July 1994 and December 2015, 89 patients (36 M, 53 F; mean age 60 years, range 25-79) were evaluated. For the purpose of analysis, complete resection was defined as removal of gross tumor with histologically confirmed clear resection margins. Eighty-three out of the 89 patients (93%), 46 of whom affected by primary RPS, and 37 by recurrent RPS, underwent surgical exploration. Sixty-two had a grossly and microscopically complete resection. Fifty-three out of 83 patients (64%) underwent removal of contiguous intra-abdominal organs. Preoperative mortality was nil and significant preoperative complications occurred in six cases only (7%). High-grade tumor pointed out to be a significant variable for a worse survival in all 83 patients amenable to undergo surgical resection (57% 5 years survival for low grade vs 14% for high grade; P = 0.0004). Among completely resected patients, only histologic grade clearly affected disease-free survival (72% 5 years survival for low grade vs 50% for high grade; P = 0.04), while the role of preoperative blood transfusions (67% 5 years survival for non-transfused patients vs 29% for transfused patients; P = 0.05) has to be evaluated in connection to patient complexity. Histological grade and recurrence are the most valuable prognostic predictors; in this clinical subset, an aggressive surgical approach in both primary and recurrent RPS is associated with a best long-term survival and disease-free survival.

[Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal and appendiceal origin].

BACKGROUND: We report our initial experience combining cytoreductive surgery (CRS) plus intraperitoneal chemotherapy with hyperthermia (HIPEC) in a selected group of patients presenting with disseminated peritoneal carcinomatosis (PC) of colorectaL or appendiceaL origin at a single tertiary referral institution. METHODS: The study included patients who underwent CRS with HIPEC at the Sheba Medical Center between April 2009 and December 2011. The HIPEC technique was administered with the open Coliseum technique reaching a steady state of mitomycin-C delivery at 410 C for perfusion duration of 90 minutes. RESULTS: AnaLysis included 45 patients (18 males) incorporating 42 cases of primary colorectal cancer (CRC) or appendiceal cancer and 3 cases of pseudomyxoma peritonei. Thirty-seven patients (82%) underwent CC-0 resections with a median overall hospital stay of 8 days (range 5-43). There was one perioperative death at 90 days. The perioperative complication rate was 31.1%. The median follow-up was 12 months (range 2-36) during which 13 patients died. Among the CRC and appendiceal cancer group the median overall survival was 20.2 months and the median progression free survival was 16.4 months (Kaplan-Meier analysis). During follow-up, 23 patients experienced disease progression. CONCLUSION: The selective use of cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for patients with peritoneal carcinomatosis from colorectal or appendiceal origin is safe with acceptable morbidity and low mortality.

Fine-needle aspiration cytology of thyroid nodules: experience at the Queen Elizabeth Hospital, Barbados (1998-2002).

Fine-needle aspiration cytology (FNAC) of the thyroid nodule has become part of accepted practice defining the role of surgery. This study assessed a 5-year period comparing cytologic with histopathologic diagnosis in 256 samples from 234 patients (203 women and 31 men). Inadequate cytologic samples were obtained in 21.1% of cases. The sensitivity and positive predictive values for the detection by FNAC of thyroid neoplasms was 21.1% and 30.8%, respectively, with a specificity and negative predictive value of 79.5% and 70.0%, respectively. The overall FNAC accuracy was 61.9%. It is anticipated that improvement in diagnosis will develop from specific cytopathological training in thyroid FNAC, consideration of the cytopathologist performing the aspiration biopsy, and the development of immunohistochemical and molecular techniques applied to the cytologic smears. The principal inherent difficulty with thyroid FNAC is the inability to confidently distinguish hyperplastic follicular adenomas from microinvasive follicular carcinomas.