Navigating surgical anatomy of the Denonvilliers' fascia and dissection planes of the anterior mesorectum with a cadaveric simulation model

Anterior dissection of the rectum in the male pelvis represents one of the most complex phases of total meso-rectal excision. However, the possible existence of different anatomical planes is controversial and the exact anatomical topography of Denonvilliers' fascia is still debated. The aim of the study is to accurately define in a cadaveric simulation model the existence and boundaries of Denonvilliers' fascia, identifying the anatomical planes suitable for surgical dissection. The pelvises of 31 formalin-preserved male cadavers were dissected. Careful and detailed dissection was carried out to visualize the anatomical structures and the potential dissection planes, simulating an anterior meso-rectum dissection. Denonvilliers' fascia was identified in 100% of the pelvises, as a single-layer fascia that originates from the peritoneal reflection and descends until its firm adhesion to the prostate capsule. The fascia divides the space providing an anterior and a posterior plane. Anteriorly to the fascia, during the caudal dissection, its firm adhesion to the prostate capsule forces to section it sharply. The cadaveric simulation model allowed an accurate description of Denonvilliers' fascia, defining several planes for anterior dissection of the meso-rectum

Prognostic Impact of pT Stage and Peritoneal Invasion in Locally Advanced Colon Cancer

BACKGROUND: TNM stage has been identified as an independent variable for local recurrence and survival after colon cancer resection. It is still unclear whether peritoneal invasion (pT4a) is a risk factor for adverse oncologic outcome or whether these patients have better results compared with contiguous organs infiltration (pT4b), independent from nodal status (pN). OBJECTIVE: The purpose of this study was to analyze whether peritoneal invasion is an independent risk factor for worse oncologic outcome after curative colon cancer resection. DESIGN: This was a retrospective analysis with multivariate regression of a prospective database, according to Strengthening the Reporting of Observational Studies in Epidemiology Statement. SETTINGS: The study was conducted in a specialized colorectal unit of a tertiary hospital. PATIENTS: A consecutive series of pT3-pT4a-pT4b patients with colon cancer who underwent curative surgery (1993-2010) were included, and patients with metastasis were excluded. MAIN OUTCOME MEASURES: A multivariate Cox regression analysis was performed to assess independent risk factors for 5-year local recurrence, peritoneal carcinomatosis-like recurrence, disease-free survival, and cancer-specific survival. RESULTS: A total of 1010 patients were analyzed (79.3% pT3, 9.9% pT4a, and 10.8% pT4b). At diagnosis, 22.0% had obstructive symptoms, and 10.5% had bowel perforation. A total of 72.2% of the surgeries were elective, and in 15.6% en bloc resection of contiguous organs was performed. Median follow-up was 62 months (38-100 mo) . For the whole group, 5-year actuarial rates were 8.8% for local recurrence, 2.5% for peritoneal carcinomatosis, 75.5% for disease-free survival, and 81.8% for cancer-specific survival. At multivariate analysis, pT4a stage was an independent risk factor for local recurrence (p = 0.002; HR = 3.1), peritoneal carcinomatosis (p = 0.02; HR = 4.9), worse disease-free survival (p = 0.002; HR = 1.9), and cancer-specific survival (p = 0.001; HR = 2.2). When considering only the 566 patients with ≥12 nodes identified, T stage was still associated with higher local recurrence (p = 0.04) and carcinomatosis rate (p = 0.04), as well as worse disease-free (p = 0.009) and cancer-specific survival (p = 0.014). LIMITATIONS: This was a retrospective, single-center study. CONCLUSIONS: pT4a stage is an independent risk factor for worse oncologic outcome after curative colon cancer resection compared with pT3 and pT4b stages. The current pT4a-pT4b classification should be reconsidered. Of note, even in pT4a patients, 5-year carcinomatosis rate does not exceed 6%. See Video Abstract at http://links.lww.com/DCR/A926

La Granja Sinyent: posible Casa Compuertas, Polinyà del Xúquer = The Farm of Sinyent: A possible Sluice HousePolinyà del Xúquer, Valencia, Spain

ResumenLa Granja Sinyent es una edificación de gran valor histórico, datada como mínimo en el siglo XIII, en avanzado estado de degradación por el paso del tiempo y falta de mantenimiento. Está ubicada en el municipio de Polinyà del Xúquer y desde el año 2011 pertenece a AVA (Asociación Valenciana de Agricultores), organización concienciada de su mantenimiento y puesta en valor, como muestran las intervenciones ya realizadas en los últimos años para frenar el avance de deterioro.En el presente artículo se realiza una descripción de la construcción y se resume la información histórica recogida de investigaciones previas ajenas.Se muestra la posible evolución del inmueble tras la realización del levantamiento planimétrico, que ha permitido establecer el orden cronológico de las distintas actuaciones llevadas a cabo, según los diferentes detalles constructivos. Se realiza una estimación del posible aspecto de la Granja en los diferentes periodos históricos.Por último, se presenta de forma sustentada por una serie de evidencias, la hipótesis de “Casa Compuertas” como respuesta a la incógnita, todavía hoy sin resolver, del uso y función original de la Granja Sinyent.AbstractThe Farm of Sinyent is a building of great historical value, dated from at least the thirteenth century, in an advanced state of degradation over time and lack of maintenance. It is located in the municipality of Polinyà del Xúquer and since 2011 belongs to AVA (Valencian Farmers Association), an organization concerned of its maintenance and value, as shown the actions they already have done to stop the advance of deterioration in recent years.In this article a description of the construction is done and collecting historical information beyond previous research summarized. The possible evolution of the property is shown after completion of the planimetric survey, which has established the chronological order of the various actionscarried out by the different construction details. An estimation of the possible appearance of the Farm in different historical periods is performed.Finally, it presents so supported by a series of evidence, the hypothesis of “Sluice House” in response to the unknown, still unresolved, use and original function of the Farm Sinyent

Surgical Anatomy of the Rectovaginal Space: Does a Standalone Rectovaginal Septum or Denonvilliers Fascia Exist in Women?

Below the anterior peritoneal reflection, the anterior rectal wall and mesorectum are separated from the posterior vaginal wall by a virtual rectovaginal space. In this space, the description of a specific and independent rectovaginal septum as a female counterpart of Denonvilliers fascia has been the subject of debate over the years

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research