Opportunities and Limitations of Pelvic Exenteration Surgery

Purpose: The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient data. The aim of this review is to present the current standing of pelvic exenteration from a surgical, gynaecological and urological point of view. Methods: This review is based upon a literature review (MEDLINE (PubMed), CENTRAL (Cochrane) and EMBASE (Elsevier)) of retrospective studies on exenterative surgery from 1993–2020. Using MeSH (Medical Subject Headings) search terms, 1572 publications were found. These were evaluated and screened with respect to their eligibility using algorithms and well-defined inclusion and exclusion criteria. Therefore, the guidelines for systematic reviews (PRISMA) were used. Results: A complete tumour resection (R0) often represents the only curative option for advanced pelvic carcinomas and their recurrences. A recent systematic review showed significant symptom relief in 80% of palliative patients after pelvic exenteration. Surgical limitations (distant metastases, involvement of the pelvic wall, etc.) are diminished by adequate surgical expertise and close interdisciplinary cooperation. While the mortality rate is low (2–5%), the still relatively high morbidity rate (32–84%) can be minimized by optimizing the perioperative setting. Following exenterations, roughly 79–82% of patients report satisfying results according to PROs (patient-reported outcomes). Conclusion: Due to multimodality treatment strategies combined with extended surgical expertise and patients’ preferences, pelvic exenteration can be offered nowadays with low mortality and acceptable postoperative quality of life. The possibilities of surgical treatment are often underestimated. A multi-centre database (PelvEx Collaborative) was established to collect data and experiences to optimize the research in this field.

Natural Orifice Non-Descent Hysterectomy - Revisiting Fading Surgical Art

BACKGROUND We wanted to assess the feasibility of natural orifice non-descent hysterectomy (NONH) for various benign gynaecological indications. METHODS This retrospective study was conducted at a tertiary care centre including patients requiring hysterectomy for various gynaecological indications over 12 months. Outcomes including time of surgery, blood loss, intraoperative surgical technique, complications, and conversion to the abdominal route were noted. RESULTS A total of 68 cases of natural orifice non-descent hysterectomy were performed. The uterine fibroid was the most common (50 %) indication for surgery followed by adenomyosis. Uteri with previous multiple surgeries were also successfully operated vaginally. The average surgical time was 60 min, with minimal blood loss. Post-operative recovery was good and patients were discharged after 48 hours. CONCLUSIONS This article concludes that natural orifice is a safe route of non-descent hysterectomy even for larger and scarred uteri using various debulking and surgical techniques but requiring good anatomical knowledge, surgical expertise and teamwork. KEY WORDS Natural Orifice Non-Descent Hysterectomy (NONH); Surgical Variations; Debulking Technique; Post-Operative Recovery

Management of Post Cholecystectomy Bile Duct Injury: Pertinent Factors Contributing to Good Surgical Outcomes

Objective: Surgical management remains the mainstay treatment for bile duct injury (BDI) post-cholecystectomy. Achieving long-term patency and lessening anastomotic failure depends on important factors including the types of repairs, timing of repairs, and surgical expertise. The present study focused on the impact of these factors on the surgical outcomes of BDI repair. Materials and Methods: Fifty-nine patients who were treated with BDI post cholecystectomy at the surgical department between January 2003 and December 2018 were retrospectively reviewed. The patients were categorized as 11 in-house and 48 referral patients, of which 22 patients had bile duct repairs prior to referral. Surgical outcomes and factors, including types of repairs, timing of repairs, and surgical expertise, impacting on the treatment results were analyzed. Results: The mean age of the patients was 47.6 years. The BDI incidence in the authors’ hospital was 0.14%. Complications occurred in 21 patients (35.6%), of which intraabdominal collection was the most common at 10 patients (16.9%). The median length of hospital stay was 16 days for in-house patients and 17 days for the referral group (p=0.542). The mortality rate was 1.7%. The overall patency was 93% with mean follow up 106.4 months. Concerning the primary patency rate, the partial segments IV/V liver resection and hepaticojejunostomy techniques had better long-term patency compared to primary repairs at 92.3% versus 37.5% (p=0.017), and biliary bypass at 92.3% versus 80% (p=0.44). BDI repairs performed by primary surgeons increased the risk of anastomotic failure in comparison to those done by hepatobiliary surgeons with 10-year patency at 53.3% versus 95.4% (p=0.014). Delayed repairs longer than six weeks after injury offered positive long-term outcomes compared to early repairs done within six weeks after injury, with a 10-year patency at 85.4% versus 31.3% (p<0.001). Conclusion: Delayed repair performed by the hepatobiliary surgeon with appropriate surgical techniques decreased anastomosis stricture and achieved good overall surgical outcomes in the management of post cholecystectomy BDI. Keywords: Bile duct injury; Cholecystectomy; Surgical management

Cytoreductive Surgery for Peritoneal Carcinomatosis from Gastric Cancer: Technical Details

Due to limited systemic treatment options, peritoneal carcinomatosis of gastric origin is still associated with a dismal outcome and is claimed a terminal disease. In the past, surgery had not been considered as a potential treatment option. However, there is emerging evidence that in selected patients, locoregional treatment modalities including cytoreductive surgery of peritoneal carcinomatosis can improve survival in patients with gastric cancer. These operative procedures are complex and challenging, and a high surgical expertise of the treating physician is necessary to prevent major postoperative morbidity and mortality with a delay of further systemic therapy. This review summarizes our current knowledge and personal experience regarding the techniques of cytoreductive surgery for peritoneal metastasis of gastric origin.

TP5.2.4 Patency of radiocephalic versus brachiocephalic arteriovenous fistula in a major tertiary hospital

Introduction The patency of brachiocephalic fistulae is generally considered to be superior to radiocephalic fistulae. We have explored this in a major tertiary hospital. Method This was a retrospective review of fistulae created between 1st January 2015 and 31st July 2020. Index cases were identified from a prospectively maintained vascular access database. Patient demographics, procedure details and subsequent interventions are described. Results There were 915 fistulae created on 813 patients (528 males and 285 females). There were 388 radiocephalic fistulae created on 374 patients and 363 brachiocephalic fistulae were formed on 301 patients. Both groups had 315 fistulae with patency data available. Age and a diagnosis of diabetes were comparable. There were significantly fewer female patients in the radiocephalic cohort (p = 0.004). Primary patency at 3 months, 1 year and 3 years were 84.6%, 58.1% and 37.9% for radiocephalic and 87.9%, 63.1% and 37.0% for brachiocephalic fistula (p = 0.273). Primary assisted patency at 3 months, 1 year and 3 years were 92.3%, 87.0%, 77.4% for radiocephalic and 96.1%, 88.6%, 79.9% for brachiocephalic fistulas (p = 0.295). Secondary patency at 3 months, 1 year and 3 years were 93.3%, 88.3% and 81.5% for radiocephalic fistulas and 97.4%, 90.6% and 85.7% for brachiocephalic fistulas (p = 0.134). Conclusion We have demonstrated similar primary, primary-assisted and secondary patency for radiocephalic and brachiocephalic fistulae. Pre-operative ultrasound vein mapping, selective ultrasound surveillance, surgical expertise and careful patient selection may contribute to the high secondary patency and absence of difference between the groups.

Management of a misidentified and misnumbered intraocular glass foreign body with an endoscope in a case of endophthalmitis

An endoscope is a useful adjunct for the retinal surgeon to overcome haze of a compromised anterior segment. It allows early surgery in trauma and infections which translates to better results. Intraocular glass foreign body is a challenging condition, demanding highly skilled surgical expertise. We present endoscopic removal of an intraocular foreign glass body in a badly traumatised and infected eye. The surgical challenge was accentuated by an imaging misdiagnosis of ‘twin metallic foreign bodies’.

An Analysis of the Effect of selected Factors on microsurgical Performance

Background Microsurgery is a specific surgical expertise that involves operating on very small structures, and requires the assistance of a magnifying device: a microscope or loupes. Several factors have been identified that could affect the quality of microsurgical performance in training or surgical procedures. Objective The objective of this study was to assess the impact of the selected factors – caffeine, alcohol and physical exercise – on a microsurgical task prior its performance. Methods Ten students from the 5th and 6th years of medical studies who had completed the advanced microsurgical course performed a “6-stitches test” on a latex glove spanned over a cup prior to and after consumption of caffeine, alcohol and performing physical exercises. The times taken to complete the task at baseline and post-exposure were recorded. Results The results of the study show a statistically significant positive effect of caffeine and a statistically significant negative effect of physical exercise on microsurgical performance when performed shortly before the task. Small dose of alcohol taken before the task showed had little effect on performance.

Gossypiboma neck: a case report with review of literature

<p class="abstract">Gossypiboma is a dreaded event in surgical expertise. We report a case of post hemithyroidectomy gossypiboma removed 4 years post primary surgery. Initially suspecting it to be a tubercular abscess and fistula, we surprisingly found a surgical gauze on neck exploration. To understand the magnitude of this problem we assembled data on reported gossypibomas post neck surgeries. A detailed search of literature revealed 16 publications (20 cases) with varied clinical picture and differentials. Our case is only the fourth published case wherein there is such a long-standing history and the first to assemble data and review literature on exclusive neck gossypibomas. Although, neck is regarded as a confined cavity with very few obvious crevices where foreign body can be left behind iatrogenically; still, gossypiboma needs to be kept as a differential, especially with a previous surgical history.</p>

Breast conserving surgery using oxidized regenerated cellulose as filling biomaterial: recommendations to improve clinical outcomes

Oxidized regenerated cellulose is considered an optimal local hemostatic agent thanks to its favorable biocompatibility, absorption characteristics and ease-of-use. Recently, oxidized regenerated cellulose has also been used as a filler in breast conserving surgery with a reconstructive purpose in order to repair partial breast defects and improve aesthetic outcomes. However, some postoperative problems due to its use, such as allergic reactions, seroma, foreign-body reaction and misdiagnosis during the follow-up of breast cancer patients, have been shown. These possible surgical complications can undermine clinical outcomes and lead to delay the beginning of oncological treatments with a negative impact on patient quality of life and survival. An adequate surgical expertise and the compliance with some specific recommendations are crucial in order to minimize postoperative issues and optimise aesthetic outcomes.