Search

Aim: Pelviperineal wound complications frequently occur after salvage surgery for chronic pelvic sepsis despite using an omentoplasty. Sufficient perfusion of the omentoplasty following mobilization is essential for proper healing. This study investigated the impact on short‐term clinical outcomes of fluorescence angiography (FA) using indocyanine green for assessment of omental perfusion in patients undergoing salvage surgery. Method: This was a comparative cohort study including consecutive patients who underwent combined abdominal and transanal minimally invasive salvage surgery with omentoplasty at a national referral centre for chronic pelvic sepsis between December 2014 and August 2019. The historical and interventional cohorts were defined based on the date of introduction of FA in April 2018. The primary outcome was pelviperineal non‐healing, defined by the presence of any degree of pelviperineal infection at the final postoperative evaluation. Results: Eighty‐eight patients underwent salvage surgery with omentoplasty for chronic pelvic sepsis, of whom 52 did not have FA and 36 did have FA. The underlying primary disease was Crohn's disease (n = 50) or rectal cancer (n = 38), with even distribution among the cohorts (P = 0.811). FA led to a change in management in 28/36 (78%) patients. After a median of 89 days, pelviperineal non‐healing was observed in 22/52 (42%) patients in the cohort without FA and in 8/36 (22%) patients in the cohort with FA (P = 0.051). Omental necrosis was found during reoperation in 3/52 and 0/36 patients, respectively (P = 0.266). Conclusion: After introduction of FA to assess perfusion of the omentoplasty, halving of the pelviperineal non‐healing rate was observed in patients undergoing salvage surgery for chronic pelvic sepsis. [ABSTRACT FROM AUTHOR]

Aim: There is little evidence concerning the optimal surgical technique for the repair of perineal hernia. This study aimed to report on the evolution of a technique for repair of perineal hernia by analysing the experience in a tertiary referral centre. Method: This was a retrospective review of consecutive patients who underwent perineal hernia repair after abdominoperineal excision in a tertiary referral centre. The main study end‐points were rate of recurrent perineal hernia, perineal wound complications and related re‐intervention. Results: Thirty‐four patients were included: in 18 patients a biological mesh was used followed by 16 patients who underwent synthetic mesh repair. Postoperative perineal wound infection occurred in two patients (11%) after biological mesh repair compared with four (25%) after synthetic mesh repair (P = 0.387). None of the meshes were explanted. Recurrent perineal hernia following biological mesh was found in 7 of 18 patients (39%) after a median of 33 months. The recurrence rate with a synthetic mesh was 5 of 16 patients (31%) after a median of 17 months (P = 0.642). Re‐repair was performed in four (22%) and two patients (13%), respectively (P = 0.660). Eight patients required a transposition flap reconstruction to close the perineum over the mesh, and no recurrent hernias were observed in this subgroup (P = 0.030). No mesh‐related small bowel complications occurred. Conclusion: Recurrence rates after perineal hernia repair following abdominoperineal excision were high, and did not seem to be related to the type of mesh. If a transposition flap was added to the mesh repair no recurrences were observed, but this finding needs confirmation in larger studies. [ABSTRACT FROM AUTHOR]

Background: Abdominoperineal resection (APR) carries a high risk of perineal wound morbidity. Perineal wound closure using autologous tissue flaps has been shown to be advantageous, but there is no consensus as to the optimal method. The aim of this study was to evaluate the feasibility of a novel gluteal turnover flap (GT-flap) without donor site scar for perineal closure after APR. Methods: Consecutive patients who underwent APR for primary or recurrent rectal cancer were included in a prospective non-randomised pilot study in two academic centres. Perineal reconstruction consisted of a unilateral subcutaneous GT-flap, followed by midline closure. Feasibility was defined as uncomplicated perineal wound healing at 30 days in at least five patients, and a maximum of two flap failures. Results: Out of 17 potentially eligible patients, 10 patients underwent APR with GT-flap-assisted perineal wound closure. Seven patients had pre-operative radiotherapy. Median-added theatre time was 38 min (range 35–44 min). Two patients developed a superficial perineal wound dehiscence, most likely because of the excessive width of the skin island. Two other patients developed purulent discharge and excessive serosanguinous discharge, respectively, resulting in four complicated wounds at 30 days. No flap failure occurred, and no radiological or surgical reinterventions were performed. Median length of hospital stay was 10 days (IQR 8–12 days). Conclusions: The GT-flap for routine perineal wound closure after APR seems feasible with limited additional theatre time, but success seems to depend on correct planning of the width of the flap. The potential for reducing perineal morbidity should be evaluated in a randomised controlled trial. [ABSTRACT FROM AUTHOR]

Background: During creation of a pedicled omentoplasty, blood flow to segments of the omentum might become compromised. If unrecognized, this can lead to omental necrosis. The purpose of this study was to investigate the potential added intra-operative value of the use of fluorescence angiography (FA) with indocyanine green (ICG) to assess omental perfusion. Methods: All consecutive patients undergoing a pedicled omentoplasty in a 6-month period (April 1 2018–October 1 2018) in a University hospital were included. The primary outcome was change in management due to FA. Secondary outcomes included the amount of additionally resected omentum, added surgical time, and quantitative fluorescent values (time to fluorescent enhancement, contrast quantification). Results: Fifteen patients had pelvic surgery with omentoplasty and FA. Change in management occurred in 12 patients (80%) and consisted of resecting a median of 44 g (range 12–198 g) of poorly perfused omental areas that were not visible by conventional white light. The median added surgical time for the use of FA and subsequent management was 8 min (range 3–39 min). The first fluorescent signal in the omental tissue appeared after a median of 20 s (range 9–37 s) after injection of ICG. The median signal-to-baseline ratio was 23.7 (interquartile range 12.2–29.7) in well perfused and 2.5 (interquartile range 1.7–4.0) in poorly perfused tissue. Conclusions: FA of a pedicled omentoplasty allows a real-time assessment of omental perfusion and leads to change in management in 80% of the cases in this pilot study. These findings support the conduct of larger studies to determine the impact on patient outcome in this setting. [ABSTRACT FROM AUTHOR]

Let Vk be the Weyl module of dimension (k 2n) - ( k-22n) for the group G = Sp(2n,F) arising from the k-th fundamental weight of the Lie algebra of G. Thus, Vk affords the grassmann embedding of the k-th symplectic polar grassmannian of the building associated to G. When char(F) = p > 0 and n is sufficiently large compared with the difference n - k, the G-module Vk is reducible. In this paper we are mainly interested in the first appearance of reducibility for a given h := n - k. It is known that, for given h and p, there exists an integer n(h, p) such that Vk is reducible if and only if n ⩾n(h, p). Moreover, let n ⩾ n(h, p) and Rk the largest proper non-trivial submodule of Vk. Then dim(Rk) = 1 if n = n(h, p) while dim(Rk) > 1 if n > n(h, p). In this paper we will show how this result can be obtained by an investigation of a certain chain of G-submodules of the exterior power Wk := Λ kV, where V = V(2n,F). [ABSTRACT FROM AUTHOR]

The article presents a case study of a patient who underwent an emergency surgery due to small bowel herniation through an unhealed perineal wound. It mentions that the perineal soft tissue defect was closed using a unilateral semicircular gluteal perforator flap following pelvic floor reconstruction with a biological mesh. It notes that abdominoperineal resection (APR) is associated with substantial morbidity related to the perineal wound.

Intra-operative fluorescence angiography might aid the surgeon in assessing omental perfusion as a complement to conventional assessment. The accompanying video (Video S1 in the online Supporting Information) demonstrates the use of fluorescence angiography of a pedicled omentoplasty to identify occult omental ischaemia. By the use of fluorescence angiography a large area of poorly perfused omentum not seen by conventional white light assessment was identified and resected. [Extracted from the article]

A letter to the editor in response to the article "Predictors of wound dehiscence and its impact on mortality after abdominoperineal resection: data from the National Surgical Quality Improvement Program" by A. Rencuzogullari and others published in a 2016 issue of the periodical is presented.

Purpose: The definition of rectal cancer based on the sigmoid take-off (STO) was incorporated into the Dutch guideline in 2019, and became mandatory in the national audit from December 2020. This study aimed to evaluate the use of the STO in clinical practice and the added value of online training, stratified for the period before (group A, historical cohort) and after (group B, current cohort) incorporation into the national audit. Methods: Participants, including radiologists, surgeons, surgical and radiological residents, interns, PhD students, and physician assistants, were asked to complete an online training program, consisting of questionnaires, 20 MRI cases, and a training document. Outcomes were agreement with the expert reference, inter-rater variability, and accuracy before and after the training. Results: Group A consisted of 86 participants and group B consisted of 114 participants. Familiarity with the STO was higher in group B (76% vs 88%, p = 0.027). Its use in multidisciplinary meetings was not significantly higher (50% vs 67%, p = 0.237). Agreement with the expert reference was similar for both groups before (79% vs 80%, p = 0.423) and after the training (87% vs 87%, p = 0.848). Training resulted in significant improvement for both groups in classifying tumors located around the STO (group A, 69–79%; group B, 67–79%, p < 0.001). Conclusions: The results of this study show that after the inclusion of the STO in the mandatory Dutch national audit, the STO was consequently used in only 67% of the represented hospitals. Online training has the potential to improve implementation and unambiguous assessment. [ABSTRACT FROM AUTHOR]

Purpose: Comparative studies on efficacy of treatment strategies for anastomotic leakage (AL) after low anterior resection (LAR) are almost non-existent. This study aimed to compare different proactive and conservative treatment approaches for AL after LAR. Methods: This retrospective cohort study included all patients with AL after LAR in three university hospitals. Different treatment approaches were compared, including a pairwise comparison of conventional treatment and endoscopic vacuum-assisted surgical closure (EVASC). Primary outcomes were healed and functional anastomosis rates at end of follow-up. Results: Overall, 103 patients were included, of which 59 underwent conventional treatment and 23 EVASC. Median number of reinterventions was 1 after conventional treatment, compared to 7 after EVASC (p < 0.01). Median follow-up was 39 and 25 months, respectively. Healed anastomosis rate was 61% after conventional treatment, compared to 78% after EVASC (p = 0.139). Functional anastomosis rate was higher after EVASC, compared to conventional treatment (78% vs. 54%, p = 0.045). Early initiation of EVASC in the first week after primary surgery resulted in better functional anastomosis rate compared to later initiation (100% vs. 55%, p = 0.008). Conclusion: Proactive treatment of AL consisting of EVASC resulted in improved healed and functional anastomosis rates for AL after LAR for rectal cancer, compared to conventional treatment. If EVASC was initiated within the first week after index surgery, a 100% functional anastomosis rate was achievable. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to compare perineal wound healing between gluteal turnover flap and primary closure in patients undergoing abdominoperineal resection (APR) for rectal cancer. Methods: Patients who underwent APR for primary or recurrent rectal cancer with gluteal turnover flap in two university hospitals (2016–2021) were compared to a multicentre cohort of primary closure (2000–2017). The primary endpoint was uncomplicated perineal wound healing within 30 days. Secondary endpoints were long-term wound healing, related re-interventions, and perineal herniation. The perineal hernia rate was assessed using Kaplan Meier analysis. Results: Twenty–five patients had a gluteal turnover flap and 194 had primary closure. The uncomplicated perineal wound-healing rate within 30 days was 68% (17/25) after gluteal turnover flap versus 64% (124/194) after primary closure, OR 2.246; 95% CI 0.734–6.876; p = 0.156 in multivariable analysis. No major wound complications requiring surgical re-intervention occurred after flap closure. Eighteen patients with gluteal turnover flap completed 12-month follow-up, and none of them had chronic perineal sinus, compared to 6% (11/173) after primary closure (p = 0.604). The symptomatic 18-month perineal hernia rate after flap closure was 0%, compared to 9% after primary closure (p = 0.184). Conclusions: The uncomplicated perineal wound-healing rate after the gluteal turnover flap and primary closure after APR is similar, and no chronic perineal sinus or perineal hernia occurred after flap closure. Future studies have to confirm potential benefits of the gluteal turnover flap. [ABSTRACT FROM AUTHOR]