Robotic resection of presacral tumors

BACKGROUND

Presacral tumors are a rare entity typically treated with an open surgical approach. A limited number of minimally invasive resections have been described. The aim of the study is to evaluate the safety and efficacy of roboticresection of presacral tumors.

METHODS

This is a retrospective single system analysis, conducted at a quaternary referral academic healthcare system, and included all patients who underwent a robotic excision of a presacral tumor between 2015 and 2023. Outcomes of interest were operative time, estimated blood loss, complications, length of stay, margin status, and recurrence rates.

RESULTS

Sixteen patients (11 females and 5 males) were included. The median age of the cohort was 51 years (range 25-69 years). The median operative time was 197 min (range 98-802 min). The median estimated blood loss was 40 ml, ranging from 0 to 1800 ml, with one patient experiencing conversion to open surgery after uncontrolled hemorrhage. Urinary retention was the only postoperative complication that occurred in three patients (19%) and was solved within 30 days in all cases. The median length of stay was one day (range 1-6 days). The median follow-up was 6.7 months (range 1-110 months). All tumors were excised with appropriate margins, but one benign and one malignant tumor recurred (12.5%). Ten tumors were classified as congenital (one was malignant), two were mesenchymal (both malignant), and five were miscellaneous (one malignant).

CONCLUSIONS

Robotic resection of select presacral pathology is feasible and safe. Further studies must be conducted to determine complication rates, outcomes, and long-term safety profiles.

Ischiorectal Fossa Tumors: Thirty-Year Single Institution Experience

BACKGROUND

Primary tumors of the ischiorectal fossa are rare and comprise a wide array of pathologies with varying malignant potential. Due to the low prevalence, there is a paucity of data in the literature. This paper presents a case-series on the management of ischiorectal fossa tumors.

OBJECTIVE

To present a 30-year experience managing ischiorectal fossa tumors.

DESIGN

Retrospective single center analysis.

SETTINGS

A quaternary referral academic healthcare center.

PATIENTS

All patients treated for ischiorectal fossa tumors.

INTERVENTIONS

All patients underwent surgical management of their disease.

MAIN OUTCOME MEASURES

Disease recurrence and overall survival.

RESULTS

A total of 34 patients (53% female) were identified with a median follow-up of 23 months. Twenty-one patients (62%) were diagnosed with benign and 13 (38%) with malignant tumors. All underwent surgical resection. Median tumor size was 8.4 cm. R0 resection was obtained in 28 patients. Twelve (35%) developed recurrence (nine following R0 resection) with a median time of 6.5 months. There were no surgical related mortalities.

LIMITATIONS

Limitations to the study include its retrospective nature, single center experience, and small patient sample size.

CONCLUSIONS

Ischiorectal fossa tumors are primarily benign, however they are associated with high recurrence rates even in the setting of an R0 resection. Treatment should be approached in a multidisciplinary fashion and preferably in centers with experience treating these tumors. Close post treatment surveillance is imperative. See Video Abstract.

Aggressive Angiomyxoma of the Pelvis: 35-Year Experience

BACKGROUND

Aggressive angiomyxoma is a very rare mesenchymal tumor most commonly found in the pelvic and perineal regions. Although many are estrogen and progesterone hormone receptor positive, the pathogenesis is unknown. Due to its rarity, there is a paucity of literature relating to this pathology. This article presents a case series on the management of aggressive angiomyxoma of the pelvis.

OBJECTIVE

To present a 35-year experience managing aggressive angiomyxoma of the pelvis.

DESIGN

This was a retrospective single-system analysis.

SETTINGS

This study was conducted at a quaternary referral academic health care system.

PATIENTS

All patients treated for aggressive angiomyxoma of the pelvis.

INTERVENTIONS

All patients underwent surgical or medical management of their disease.

MAIN OUTCOME MEASURES

The primary outcomes were disease recurrence and mortality. Secondary outcomes included risk factors for recurrence.

RESULTS

A total of 32 patients (94% women) were identified with a median follow-up of 65 months. Thirty patients (94%) underwent operative resection and 2 patients were treated solely with medical management. Fifteen achieved an R0 resection (negative microscopic margins) at the index operation, of which 4 (27%) experienced tumor recurrence. There were no mortalities. No risk factors for disease recurrence were identified.

LIMITATIONS

Limitations to our study include its nonrandomized retrospective nature, single health care system experience, and small patient sample size.

CONCLUSIONS

Aggressive angiomyxoma is a rare, slow-growing tumor with locally invasive features and a high potential for recurrence even after resection with negative margins. Imaging modalities such as CT or MRI should be obtained to aid in diagnosis and surgical planning. Workup should be paired with preoperative biopsy and testing for hormone receptor status, which can increase diagnostic accuracy and guide medical treatment. Close posttreatment surveillance is imperative to detect recurrence. See Video Abstract .

ANGIOMIXOMA AGRESIVO DE PELVIS EXPERIENCIA DE AOS

ANTECEDENTES:El angiomixoma agresivo es un tumor mesenquimal muy raro que se encuentra más comúnmente en las regiones pélvica y perineal. Aunque muchos son positivos para los receptores hormonales como el estrógeno y la progesterona, la patogénesis es aún desconocida. Debido a su rareza, existe escasa literatura relacionada con esta patología. Este artículo presenta una serie de casos sobre el tratamiento del angiomixoma agresivo de pelvis.OBJETIVO:Presentar una experiencia de 35 años en el manejo del angiomixoma agresivo de pelvis.DISEÑO:Este fue un análisis retrospectivo de sistema único.AJUSTES:Este estudio se llevó a cabo en un sistema de salud académico de referencia de nivel cuaternario.PACIENTES:Todos los pacientes tratados por angiomixoma agresivo de pelvis.INTERVENCIONES:Todos los pacientes se sometieron a tratamiento quirúrgico y/o médico de su enfermedad.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron la recurrencia de la enfermedad y la mortalidad. Los resultados secundarios incluyeron factores de riesgo de recurrencia.RESULTADOS:Se identificaron un total de 32 pacientes (94% mujeres) con una mediana de seguimiento de 65 meses. Treinta (94%) fueron sometidos a resección quirúrgica y dos fueron tratados únicamente con tratamiento médico. Quince lograron una resección R0 (márgenes microscópicos negativos) en la operación inicial, de los cuales cuatro (27%) experimentaron recurrencia tumoral. No hubo mortalidades. No se identificaron factores de riesgo para la recurrencia de la enfermedad.LIMITACIONES:Las limitaciones de nuestro estudio incluyen su naturaleza retrospectiva no aleatoria, la experiencia de un solo sistema de atención médica y el tamaño pequeño de la muestra de pacientes.CONCLUSIONES:El angiomixoma agresivo es un tumor raro, de crecimiento lento, con características localmente invasivas y un alto potencial de recurrencia incluso después de una resección con márgenes negativos. Se deben obtener modalidades de imágenes como CT y/o MRI para la ayuda diagnóstica y la planificación quirúrgica. El estudio debe combinarse con una biopsia preoperatoria y pruebas del estado de los receptores hormonales, que pueden aumentar la precisión del diagnóstico y guiar el tratamiento médico. Es imperativa una estrecha vigilancia posterior al tratamiento para detectar recurrencia. (Traducción-Dr Osvaldo Gauto ).

Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes

BACKGROUND

Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage.

METHODS

Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes.

RESULTS

The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays.

CONCLUSION

Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.

Sexual dysfunction following surgery for rectal cancer: a single-institution experience

Although much focus is placed on oncological outcomes for rectal cancer, it is important to assess quality of life after surgery of which sexual function is an important component. This study set about to describe the prevalence of sexual dysfunction by resection type and gender among patients undergoing surgery for rectal cancer, usingretrospective analysis. All English-speaking living patients who underwent surgery for stage I-III rectal cancer with curative intent between 2012 and 2016 were identified from a prospectively maintained database at our institution. Eligible patients were invited to complete either the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF). Primary outcomes were overall rates of sexual dysfunction, defined as more than one standard deviation below the mean of the normal population for each tool. A total of 147 patients responded, yielding a response rate of 38%. The overall sexual dysfunction rate was 70% at a median time from surgery of 38 months. Sixty-two men (62%) and 41 women (87%) reported overall scores that fell below one standard deviation of the population mean. There was no significant difference in sexual dysfunction for both male and female patients between low anterior resection, coloanal anastomosis, or abdominoperineal resection.. The present study revealed a high rate of sexual dysfunction after rectal cancer surgery, particularly in female patients. This study serves as a reminder to surgeons and their teams to openly discuss the impact of surgery on sexual function and ensure adequate consent and appropriate peri-operative management strategies. The retrospective nature of the analysis is the limitation of this study.

Delivery of surgical care in Samoa: perspectives on capacity, barriers and opportunities by local providers

BACKGROUND

The Pacific Island nation of Samoa faces a number of challenges in delivering surgical care. Our group aimed to identify the barriers and opportunities to improving the delivery of safe, affordable, timely surgical care in Samoa.

METHODS

A mixed-methods approach was undertaken. The quantitative analysis used a modified version of the World Health Organization Emergency and Essential Surgical Checklist while the qualitative methodology used semi-structured interviews. Respondents were asked to share their views on the capacity, quality, accessibility and future directions of surgery in Samoa. Interviews were transcribed and analysed using open and axial coding techniques.

RESULTS

Stakeholders had a positive outlook on the delivery of surgical care, but it was suggested that existing services were not meeting needs. Respondents cited limited access to equipment and resources, compounded by insufficient organizational and logistical infrastructure. Shortage of medical staff and retention was identified as a key issue. Shortcomings in primary care and poor health literacy were seen as significant barriers to accessing care.

CONCLUSION

Documenting locally identified barriers and solutions to surgical care in Samoa is an important first step towards the development of formal strategies for improving surgical services nationally.

Collecting data for global surgical indicators: a collaborative approach in the Pacific Region

In 2015, the Lancet Commission on Global Surgery (LCoGS) recommended six surgical metrics to enable countries to measure their surgical and anaesthesia care delivery. These indicators have subsequently been accepted by the World Bank for inclusion in the World Development Indicators. With support from the Royal Australasian College of Surgeons and the Pacific Islands Surgical Association, 14 South Pacific countries collaborated to collect the first four of six LCoGS indicators. Thirteen countries collected all four indicators over a 6-month period from October 2015 to April 2016. Australia and New Zealand exceeded the recommended LCoGS target for all four indicators. Only 5 of 13 countries (38%) achieved 2-hour access for at least 80% of their population, with a range of 20% (Papua New Guinea and Solomon Islands) to over 65% (Fiji and Samoa). Five of 13 (38%) countries met the target surgical volume of 5000 procedures per 100 000 population, with six performing less than 1600. Four of 14 (29%) countries had at least 20 surgical, anaesthesia and obstetric providers in their workforce per 100 000 population, with a range of 0.9 (Timor Leste) to 18.5 (Tuvalu). Perioperative mortality rate was reported by 13 of 14 countries, and ranged from 0.11% to 1.0%. We believe it is feasible to collect global surgery indicators across the South Pacific, a diverse geographical region encompassing high-income and low-income countries. Such metrics will allow direct comparison between similar nations, but more importantly provide baseline data that providers and politicians can use in advocacy national health planning.

Students' perceptions of the Undergraduate Medicine and Health Sciences Admissions Test (UMAT)

AIM

Medical schools are still evaluating the place of general cognitive tests in medical student selection. This study explored medical student perceptions of UMAT, and how they prepared for taking the test.

METHOD

Medical students at The University of Auckland and University of Otago in New Zealand were invited to complete a mixed-modality survey.

RESULTS

Students had reservations, with 56% reporting UMAT is not an important test for medical students' selection and 67% that it is not a fair test. Eighty-one percent believe it is a stressful or very stressful test. The degree of importance or stress related to the weighting of UMAT in selection decisions. More than half of students spent more than $100 on books and $400 on courses to prepare for UMAT, in addition to the costs of sitting the test.

CONCLUSION

At present, the majority of medical students in New Zealand who responded to the survey do not see UMAT as an acceptable test of non-cognitive attributes. It is costly to students and also stressful.

Taking the pulse: medical student workforce intentions and the impact of debt

AIM

To define what factors are important to medical students as they make decisions about where they will live, work and train after graduation, and to explore the effects of student debt

METHOD

A mixed quantitative-qualitative questionnaire to all 5th and 6th year medical students residing in New Zealand in 2008. Questions related to students' perspectives of the workforce, debt, and workforce intentions.

RESULTS

372 medical students completed the survey (55% response rate from those in NZ at the time of the survey). Fifty-two percent of students planned to leave New Zealand at the start of PGY2 or 3. The average debt was $75,752. Thirty-six percent said their debt would influence their choice of vocation, 39% their choice of location of work in New Zealand and 64% their choice of locality of work in the world. Twenty-six percent and 25% believed that they would be valued by the hospital management and government respectively. Students most commonly cited financial incentives to work overseas and to locum.

CONCLUSION

Strategies to counter emigration trends in the New Zealand health workforce need an holistic approach. Debt levels need to be countered, and the perceived lack of value of graduates needs to be rectified.