Combination of conservative and surgical methods in the treatment of giant lymphedema of the scrotum: A case report

ObjectiveGenital lymphedema is a severe, disabling condition associated with a malfunction of the lymphatic system. Primary lymphedema of the scrotum is a variant of congenital dysplasia of lymphatic vessels. Secondary genital lymphedema is much more common and can be caused by parasitic invasion (filariasis) or damage to the lymphatic system during the treatment of cancer (radiation therapy, lymphadenectomy). Healthcare providers are frequently unable to detect and treat this illness successfully in ordinary clinical practice. This paper uses the case of a patient with stage 3 secondary lymphedema (unknown genesis) of both lower extremities and lymphedema of the scrotum, complicated by recurrent erysipelas, a history of lymphorrhoea, impaired skin trophic and multiple papillomatosis, to demonstrate the efficacy of a combination of conservative and surgical methods in the treatment of giant lymphedema of the scrotum.MethodsIn the treatment, the combination of decongestant physical therapy (CDPT, CDT) according to M. Földi was used at pre-surgery and post-surgery stages, combined with a reconstructive operation, including the removal of the affected tissues of the urogenital region, phalloplasty, and scrotoplasty with rotational skin flaps.ResultsA decrease in the circumference of the lowest extremities in the lower leg area by 68 cm on the right and by 69 cm on the left was achieved by conservative treatment. Due to the combination of conservative and surgical treatment, the patient's body weight decreased by 69.4 kg, and the scrotum decreased by 63 cm. Subsequently, the patient fully recovered his sexual function.ConclusionA combination of complex decongestive physical therapy and surgery is necessary for patients with advanced genital edema. The isolated use of surgical or conservative treatment does not provide a sufficient improvement in the patient's quality of life. Modern plastic surgery technologies enable patients to achieve complete functional and cosmetic recovery, while proper selection and usage of compression hosiery help preserve and improve the outcomes acquired following treatment

Does Transanal Total Mesorectal Excision of Rectal Cancer Improve Histopathology Metrics and/or Complication Rates? A Meta-Analysis

BACKGROUND: The aim of this meta-analysis was to determine whether transanal total mesorectal excision (taTME) improves histopathology metrics and/or complication rates when compared to robotic total mesorectal excision (R-TME) of resectable rectal cancer. METHODS: MEDLINE, Pubmed, Cochrane Library, and Scopus were systematically searched by two independent researchers. Six observational studies totaling 1,572 patients (811 taTME; 761R-TME) were included after screening 14 potentially eligible records. Mantel-Haenszel method using odds ratios with 95% confidence intervals (OR (95%CI)) and inverse variance with mean difference with 95% confidence intervals (MD (95%CI)) as an effect measure for dichotomous and continuous variables, respectively, was employed for meta-analysis. Statistical heterogeneity among effect estimates was evaluated using I(2) and Tau(2). RESULTS: Circumferential resection margin (CRM) involvement rates (3.8% taTME; 5.3% R-TME) did not differ [OR (95%CI)=0.86 (0.35, 2.15); p=0.75] with low among-study heterogeneity (I(2)=21%). Complication rates (35.4% taTME; 32.3% R-TME) did not differ [OR (95%CI)=0.92 (0.64, 1.32); p=0.65], although with moderate among-study heterogeneity (I(2)=40%). CRM involvement [OR (95%CI)=0.76 (0.40, 1.43); p=0.40] and complication rates [OR (95%CI)=0.84 (0.59, 1.21); p=0.35] did not significantly differ in subgroup meta-analysis including mid- and low rectal cancer. Distal resection margin (mm) did not significantly differ between the interventions [MD (95%CI)=-0.41 (-1.29, 0.47); p=0.37]. CONCLUSIONS: This meta-analysis found that taTME of rectal cancer does not improve histopathology metrics and complication rates when compared to R-TME

Transperineal Excision of Rectal Gastrointestinal Stromal Tumor

Gastrointestinal stromal tumors (GIST) of the rectum occur in approximately 4% of patients with rectal malignancies. Herein, we demonstrate a transperineal approach as a safe surgical technique for GISTs located anterior to the rectum. The proposed technique allows safe and effective excision of a tumor without disturbing the rectal anterior wall. Unlike previous techniques, this method stresses the importance of accurate preoperative assessment and use of the surgeon\u27s finger in the rectum to facilitate rectal wall preservation

Does an Ileostomy Rod Prevent Stoma Retraction? A Meta-analysis of Randomized Controlled Trials

A rod passed through the mesenteric window is commonly used during maturation of ileostomies, but evidence for the effectiveness of this procedure is limited. PURPOSE: The aim of this meta-analysis was to determine whether ileostomy rods decrease stoma retraction rates in patients undergoing loop ileostomy (LI). METHODS: The PubMed, EMBASE, Cochrane Library, MEDLINE via Ovid, Cumulative Index of Nursing and Allied Health Literature, and Web of Science databases were systematically searched for randomized controlled trials (RCT) published in English from 1990 to the present date using the MeSH terms ostomy, rod, and bridge to compare ileostomies with a rod to those without a rod. Study information, patient demographics, characteristics, and stoma retraction rates were abstracted. The primary endpoint, stoma retraction, was defined as the disappearance of normal stomal protrusion to at, or below, skin level. The Mantel-Haenszel method of meta-analysis with odds ratio and 95% confidence interval (OR [95% CI]) was used. Among-study statistical heterogeneity was assessed using Cochrane chi-squared and I² tests. Tau² analysis to assess between-study variance was employed when I² was greater than 50%. The number needed to treat/harm (NNT) was calculated to assess clinical relevance of any statistical difference. Visual assessment of funnel plots and Egger\u27s test were used to assess for publication bias. RESULTS: Of the 228 publications identified, 3 RCTs totaling 392 patients (194 LI with rod and 198 LI without rod) met the inclusion criteria for analysis. Overall bias risk was low. The stoma retraction rate was 3.1% (6/194) in patients with a rod versus 4.5% (9/198) in patients with LI without a rod at a mean follow-up of 3 months. This difference was not statistically or clinically significant (OR [95% CI] = 0.60 (0.21-1.72); P = .34; NNT = 69), with low statistical heterogeneity noted among the studies (I² = 0%). CONCLUSION: This meta-analysis found that ileostomy rods do not decrease stoma retraction rates at 3-month follow-up. Studies examining the rate of all potential complications in patients who do and do not receive rod placement following IL are needed to help surgeons make evidence-based decisions

Double-Barreled Wet Colostomy Versus Separate Urinary and Fecal Diversion in Patients Undergoing Total Pelvic Exenteration: A Cohort Meta-Analysis

BACKGROUND: The aim of this meta-analysis was to determine whether double-barreled wet colostomy (DBWC) provides similar urinary tract infection rates as separate urinary and fecal diversion (SUFD) in patients undergoing pelvic exenteration. METHODS: The MEDLINE, PubMed, Cochrane Library, and Scopus databases were systematically searched by two independent researchers. The primary endpoint was the urinary tract infection rate. The Mantel-Haenszel method with odds ratios with 95% confidence intervals (OR (95%CI)) was used as an effect measure for dichotomous variables. A random-effects model was used for the meta-analysis. Statistical heterogeneity among effect estimates was evaluated using I2 and Tau2. RESULTS: Three observational studies that included a total of 257 patients (159 DBWC; 98 SUFD) were included after 14 potentially eligible records were screened. Pooled urinary tract infection rates were 1.9% (3/159) in DBWC and 6.1% (6/98) in SUFD. This difference was not statistically significant [OR (95%CI) = 0.27 (0.06, 1.19); p=0.08] with low among-study heterogeneity (I2=0%). CONCLUSIONS: This meta-analysis did not find a significant difference in urinary tract infection rates between DBWC and SUFD in patients undergoing total pelvic exenteration. Further clinical studies will be required to further understand the pros and cons of these procedures

Three-Plane Model to Standardize Laparoscopic Right Hemicolectomy with Extended D3 Lymph Node Dissection

AIM: The purposes of this study were to create a three-plane model for laparoscopic right hemicolectomy and to compare short-term outcomes of anterior medial-to-lateral (aM-to-L) and caudal-to-cranial access by retroperitoneal tunneling (Ca-to-Cr), as described based on the three-plane model. METHODS: A three-plane model was developed to clarify the steps of an operation. Consecutive cases of right colon cancer were operated upon with an aM-to-L approach in the earlier period and then with a Ca-to-Cr approach, and postoperative outcomes were evaluated. Short-term results were compared. RESULTS: Sixty-two patients were divided into aM-to-L (n=29) and Ca-to-Cr (n=33) groups. The two groups did not differ in terms of the patients\u27 baseline characteristics. Median operative time was 220 min (IQR 190-260) for the aM-to-L group and 222.5 min (IQR 180-255) for the Ca-to-Cr group (p=0.73). Estimated blood loss was similar in both groups (p=0.13). Median length of hospital stay was 6 days (IQR 5-8) in the aM-to-L group and 7 days (IQR 6-9) in the Ca-to-Cr group (p=0.17). Median number of harvested lymph nodes was 45.5 (IQR 25-44.9) in the aM-to-L group and 30 (IQR 18-48.5) in the Ca-to-Cr group (p=0.34). CONCLUSION: The approach used to reach the superior mesenteric vessels for laparoscopic right hemicolectomy with D3 lymph node dissection does not affect the short-term outcome of the operation. The present three-plane model gives surgeons additional insight to perform this operation

Impact of Robotic Learning Curve on Histopathology in Rectal Cancer: A Pooled Analysis

BACKGROUND: A beneficial impact of robotic proctectomy on circumferential resection margin (CRM) is expected due to the robot\u27s articulating instruments in the pelvis. There are however concerns about a negative impact on the quality of total mesorectal excision (TME) due to the lack of tactile feedback. The aim of this study was to assess whether surgeons\u27 learning curve impacted CRM and TME quality. METHODS: In a multicenter study, individual patient data of robotic proctectomy for resectable rectal cancer were pooled. Patients were stratified into two phases of surgeons\u27 learning curve. Cumulative sum (CUSUM) analysis was used to determine the transition from learning phase (LP) to plateau phase (PP), which were compared. CRM was microscopically measured in mm by pathologists. TME quality was classified by pathologists as complete, nearly complete or incomplete. T-test and Chi-squared tests were used to compare continuous and categorical variables, respectively. RESULTS: 235 patients underwent robotic proctectomy by five surgeons. 83 LP patients were comparable to 152 PP patients for age (p = 0.20), gender (67.5% vs. 65.1% males; p = 0.72), BMI (p = 0.82), cancer stage (p = 0.36), neoadjuvant chemoradiation (p = 0.13), distance of tumor from anal verge (5.8 ± 4.4 vs. 5.5 ± 3.3; p = 0.56). CRM did not differ (7.7 ± 11.4 mm vs. 8.4 ± 10.3 mm; p = 0.62). The rate of complete TME quality was significantly improved in PP patients as compared to LP patients (73.5% vs. 92.1%; p \u3c 0.001). CONCLUSION: While learning had no impact on circumferential resection margins, the quality of TME significantly improved during surgeons\u27 plateau phase as compared to their learning phase

Delayed colorectal cancer care during covid-19 pandemic (decor-19). Global perspective from an international survey

Background The widespread nature of coronavirus disease 2019 (COVID-19) has been unprecedented. We sought to analyze its global impact with a survey on colorectal cancer (CRC) care during the pandemic. Methods The impact of COVID-19 on preoperative assessment, elective surgery, and postoperative management of CRC patients was explored by a 35-item survey, which was distributed worldwide to members of surgical societies with an interest in CRC care. Respondents were divided into two comparator groups: 1) ‘delay’ group: CRC care affected by the pandemic; 2) ‘no delay’ group: unaltered CRC practice. Results A total of 1,051 respondents from 84 countries completed the survey. No substantial differences in demographics were found between the ‘delay’ (745, 70.9%) and ‘no delay’ (306, 29.1%) groups. Suspension of multidisciplinary team meetings, staff members quarantined or relocated to COVID-19 units, units fully dedicated to COVID-19 care, personal protective equipment not readily available were factors significantly associated to delays in endoscopy, radiology, surgery, histopathology and prolonged chemoradiation therapy-to-surgery intervals. In the ‘delay’ group, 48.9% of respondents reported a change in the initial surgical plan and 26.3% reported a shift from elective to urgent operations. Recovery of CRC care was associated with the status of the outbreak. Practicing in COVID-free units, no change in operative slots and staff members not relocated to COVID-19 units were statistically associated with unaltered CRC care in the ‘no delay’ group, while the geographical distribution was not. Conclusions Global changes in diagnostic and therapeutic CRC practices were evident. Changes were associated with differences in health-care delivery systems, hospital’s preparedness, resources availability, and local COVID-19 prevalence rather than geographical factors. Strategic planning is required to optimize CRC care

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)