Search

In this month's issue of Colorectal Disease, Boyle et al [1] report on the impact of COVID-19 on colorectal cancer care during the first wave of the pandemic and highlight the key lessons learnt by institutions in the United Kingdom (UK). The impact of the first peak of the COVID-19 pandemic on colorectal cancer services in England and Wales: A national survey, by Boyle et al In the short term this was necessary to divert staff to manage COVID-19 patients in the pandemic but in the medium and longer term, this unwanted side effect has led to untold harm amongst these patients. [Extracted from the article]

This trial randomised and analysed the parastomal hernia (PSH) and complication rates of 201 patients undergoing an end colostomy. In this month's issue of Colorectal Disease, Correa-Marinez et al. report on the secondary end points of the Stoma-Const randomized controlled trial [1]. Stoma-related complications: A report from the Stoma-Const randomized controlled trial, Correa-Marinez et al. [Extracted from the article]

Aim: Anal cancer incidence and mortality rates are rising in the United Kingdom (UK). Surgery is an important treatment modality for persistent or recurrent disease. There is a paucity of data on outcomes for patients undergoing pelvic exenteration for anal squamous cell carcinoma (SCC) for persistent or recurrent disease. The aim of this study was to investigate the outcomes for patients who were treated with pelvic exenteration for anal SCC from two high‐volume, high‐complexity pelvic exenteration units in the UK. Method: A retrospective review of prospectively maintained databases from 2011 to 2020 was undertaken. Primary endpoints included R0 resection rates, overall and disease‐free survival at 2 and 5 years. Results: From 2011 to 2020, 35 patients with anal SCC were selected for exenteration. An R0 resection was achieved in 26 patients (77%). Of the remaining patients, seven patients had an R1 resection and one had a R2 resection. One further patient was excluded from additional analysis as the disease was inoperable at the time of laparotomy. With a median follow‐up of 19.5 months (interquartile range 7.9–53.5 months), overall survival was 50% (17/34). Patients with an R1/2 resection had a significantly poorer overall survival [0.27 (0.09–0.76), p = 0.021] than those patients in whom R0 resection was achieved. Disease‐free survival was 38.2% (13/34) and an R1/R2 resection was associated with a significantly reduced disease‐free survival [0.12 (0.04–0.36), p < 0.001]. Conclusion: Complete R0 resection for recurrent or persistent anal SCC is possible in the majority of patients and improves overall and disease‐free survival compared with R1/R2 resection. [ABSTRACT FROM AUTHOR]

Video S1 also describes our preferred flap reconstruction technique using a (left) superior gluteal artery perforator flap, with the bulk of the flap being used to fill the pelvis and skin to reconstruct the vagina. High-resolution MRI has the highest accuracy for staging of rectal cancer and assessing the lateral pelvic side wall lymph nodes and disease extent [4]. Video S1 demonstrates the technique of open pelvic sidewall excision and gluteal flap perineal reconstruction in a female patient with recurrent rectal cancer following long-course chemoradiotherapy. [Extracted from the article]

Aim: Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis. Method: The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted. Results: Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2 years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%). Conclusion: The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging. [ABSTRACT FROM AUTHOR]

Aim: Ileal pouch–anal anastomosis (IPAA), or a 'pouch', allows restoration of intestinal continuity after proctocolectomy for ulcerative colitis or familial adenomatous polyposis. Most patients have a good long‐term outcome after IPAA, but in a significant proportion the functional outcome and quality of life are unsatisfactory. We term this outcome 'the pouch behaving badly'. Managing this, especially one is when unfamiliar with the possible underlying pathologies, is a challenge for both patient and clinician. We aim to outline the clinical approach to the pouch behaving badly, highlighting key aspects of investigation and management. Method: This is a narrative review of the literature covering the investigation and management of postoperative complications and morbidity after IPAA. Results: Management of the pouch behaving badly requires a careful clinical assessment. The patient may present with multiple symptoms and a clear picture of the symptomatology and past history should be constructed before thorough examination and specialist investigation. We divide the pathology that underlies this clinical scenario into surgical, inflammatory, mechanical, functional and dysplastic causes and outline the investigation and management of each one. Conclusion: The pouch behaving badly is a challenging problem for both patient and clinician. A detailed clinical assessment with careful specialist investigation is key to diagnosing the underlying pathology. We stress the importance of patient‐centred care – the aim is to improve quality of life. [ABSTRACT FROM AUTHOR]

Magnetic resonance imaging/positron emission tomography provides a roadmap for surgical planning and serves as a predictive biomarker in patients with recurrent gynecological cancers undergoing pelvic exenteration. This is a case of a young woman with a recurrent rectal cancer, post neoadjuvant chemoradiotherapy, who had a total pelvic exenteration and high sacrectomy with wide sidewall excisions (Video S1). Pelvic exenteration involving sacrectomy is a superspecialist procedure requiring multidisciplinary surgical involvement [[1]]. [Extracted from the article]

Ischial pressure sore reconstruction using an inferior gluteal artery perforator (IGAP) flap. Video S1 demonstrates the use of a gluteal flap for perineal reconstruction following exenterative surgery. [Extracted from the article]