Introduction The empty pelvis syndrome is a significant source of morbidity following pelvic exenteration surgery. It remains poorly defined with research in this field being heterogeneous and of low quality. Furthermore, there has been minimal engagement with patient representatives following pelvic exenteration with respect to the empty pelvic syndrome. 'PelvEx-Beating the empty pelvis syndrome' aims to engage both patient representatives and healthcare professionals to achieve an international consensus on a core outcome set, pathophysiology and mitigation of the empty pelvis syndrome. Methods and analysis A modified-Delphi approach will be followed with a three-stage study design. First, statements will be longlisted using a recent systematic review, healthcare professional event, patient and public engagement, and Delphi piloting. Second, statements will be shortlisted using up to three rounds of online modified Delphi. Third, statements will be confirmed and instruments for measurable statements selected using a virtual patient-representative consensus meeting, and finally a face-to-face healthcare professional consensus meeting. Ethics and dissemination The University of Southampton Faculty of Medicine ethics committee has approved this protocol, which is registered as a study with the Core Outcome Measures in Effectiveness Trials Initiative. Publication of this study will increase the potential for comparative research to further understanding and prevent the empty pelvis syndrome.

Aim: Intraperitoneal drains are often placed during emergency colorectal surgery. However, there is a lack of evidence supporting their use. This study aimed to describe the efficacy and safety of intraperitoneal drain placement after emergency colorectal surgery. Method: COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) is a prospective, international, cohort study into which consecutive adult patients undergoing emergency colorectal surgery were enrolled (from 3 February 2020 to 8 March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included rate and time-to-diagnosis of postoperative intraperitoneal collections, rate of surgical site infections (SSIs), time to discharge and 30-day major postoperative complications (Clavien-Dindo III-V). Multivariable logistic and Cox proportional hazards regressions were used to estimate the independent association of the outcomes with drain placement. Results: Some 725 patients (median age 68.0years; 349 [48.1%] women) from 22 countries were included. The drain insertion rate was 53.7% (389 patients). Following multivariable adjustment, drains were not significantly associated with reduced rates (odds ratio [OR] =1.56, 95% CI: 0.48-5.02, p=0.457) or earlier detection (hazard ratio [HR] =1.07, 95% CI: 0.61-1.90, p=0.805) of collections. Drains were not significantly associated with worse major postoperative complications (OR=1.26, 95% CI: 0.67-2.36, p=0.478), delayed hospital discharge (HR=1.11, 95% CI: 0.91-1.36, p=0.303) or increased risk of SSIs (OR=1.61, 95% CI: 0.87-2.99, p=0.128). Conclusion: This is the first study investigating placement of intraperitoneal drains following emergency colorectal surgery. The safety and clinical benefit of drains remain uncertain. Equipoise exists for randomized trials to define the safety and efficacy of drains in emergency colorectal surgery.

Robotic surgery (RS) is increasingly employed in colorectal surgical practice, widening the range of surgical techniques offered to patients. We investigated the perceptions of patients with colorectal cancer in relation to RS, open surgery (OS) and conventional laparoscopic surgery (CLS), to identify ideas or assumptions which, in the context of shared surgeon–patient decision-making, may affect the resultant choice of surgical technique. We also investigated salient factors affecting patients’ perioperative experience, including those of RS patients, to guide improvements in care and preoperative patient preparation. This study was conducted on patients who underwent resection of left-sided colorectal cancer at a large UK teaching hospital from November 2020 to July 2021. Purposive sampling was used to ensure a roughly equal proportion of patients who underwent RS, CLS and OS. The patients included in the study participated in semi-structured interviews six weeks postoperatively. The interview schedule allowed discussion around patients’ experience of their surgery and postoperative recovery, and their perceptions of surgical techniques. Interview transcripts were coded manually using inductive thematic analysis, and analyst triangulation was employed to refine coding schemes and ensure reliability of emerging themes. Twenty-seven patients were recruited to the study; RS n = 9 (median age 69 [range 60–80] years); CLS n = 10 (median age 72 [range 32–82] years; OS n = 8 (median age 71 [range 60–75] years). Patients understood the technological benefits of RS but were concerned by a risk of technological failure causing patient harm. OS was understood to be associated with more pain and longer recovery than RS or CLS. Patients perceived CLS to be more technically challenging compared with OS. Less pain and smaller wounds than expected were significant positive factors in the experience of RS and CLS patients specifically. Complications and emotional impact were significant factors in the experience of all groups, for which many patients felt underprepared. Patients generally have a positive view of RS and technical innovation in surgery. Concerns mostly centred around failure of technology. Many patients felt unprepared for significant factors in their perioperative experience. Surgeons and healthcare providers should be prepared to address patients’ perceptions and expectations of colorectal surgery preoperatively.

Abstract Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien–Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk.

Background: The multidisciplinary perioperative and anaesthetic management of patients undergoing pelvic exenteration is essential for good surgical outcomes. No clear guidelines have been established, and there is wide variation in clinical practice internationally. This consensus statement consolidates clinical experience and best practice collectively, and systematically addresses key domains in the perioperative and anaesthetic management.Methods: The modified Delphi methodology was used to achieve consensus from the PelvEx Collaborative. The process included one round of online questionnaire involving controlled feedback and structured participant response, two rounds of editing, and one round of web-based voting. It was held from December 2019 to February 2020. Consensus was defined as more than 80 per cent agreement, whereas less than 80 per cent agreement indicated low consensus.Results: The final consensus document contained 47 voted statements, across six key domains of perioperative and anaesthetic management in pelvic exenteration, comprising preoperative assessment and preparation, anaesthetic considerations, perioperative management, anticipating possible massive haemorrhage, stress response and postoperative critical care, and pain management. Consensus recommendations were developed, based on consensus agreement achieved on 34 statements.Conclusion: The perioperative and anaesthetic management of patients undergoing pelvic exenteration is best accomplished by a dedicated multidisciplinary team with relevant domain expertise in the setting of a specialized tertiary unit. This consensus statement has addressed key domains within the framework of current perioperative and anaesthetic management among patients undergoing pelvic exenteration, with an international perspective, to guide clinical practice, and has outlined areas for future clinical research.

Aim The Enhanced Recovery After Surgery (ERAS (R)) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units. Method An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted. Results Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017. Conclusions Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.

Aim Complete mesocolic excision (CME) lacks consistent data advocating operative superiority compared to conventional surgery for colon cancer. We performed a systematic review and meta-analysis, analysing population characteristics and perioperative, pathological and oncological outcomes. Methods D3 extended lymphadenectomy dissection was considered comparable to CME, and D2 and D1 dissection to be comparable to conventional surgery. Outcomes reviewed included lymph node yield, R1 resection, overall complications, overall survival and disease-free survival. Results In all, 3039 citations were identified; 148 studies underwent full-text reviews and 31 matched inclusion criteria: total cohort 26 640 patients (13 830 CME/D3 vs. 12 810 conventional). Overall 3- and 5-year survival was higher in the CME/D3 group compared with conventional surgery: relative risk (RR) 0.69 (95% CI 0.51-0.93, P = 0.016) and RR 0.78 (95% CI 0.64-0.95, P = 0.011) respectively. Five-year disease-free survival also demonstrated CME/D3 superiority (RR 0.67, 95% CI 0.52-0.86, P < 0.001), with similar findings at 1 and 3 years. There were no statistically significant differences between the CME/D3 and conventional group in overall complications (RR 1.06, 95% CI 0.97-1.14, P = 0.483) or anastomotic leak (RR 1.02, 95% CI 0.81-1.29, P = 0.647). Conclusions Meta-analysis suggests CME/D3 may have a better overall and disease-free survival compared to conventional surgery, with no difference in perioperative complications. Quality of evidence regarding survival is low, and randomized control trials are required to strengthen the evidence base.

Background: A resection with clear margins (R0 resection) is the most important prognostic factor in patients with locally recurrent rectal cancer (LRRC). However, this is achieved in only 60 per cent of patients. The aim of this study is to investigate whether the addition of induction chemotherapy to neoadjuvant chemo(re)irradiation improves the R0 resection rate in LRRC. Methods: This multicentre, international, open-label, phase III, parallel-arms study will enrol 364 patients with resectable LRRC after previous partial or total mesorectal resection without synchronous distant metastases or recent chemo- and/or radiotherapy treatment. Patients will be randomized to receive either induction chemotherapy (three 3-week cycles of CAPOX (capecitabine, oxaliplatin), four 2-week cycles of FOLFOX (5-fluorouracil, leucovorin, oxaliplatin) or FOLFORI (5-fluorouracil, leucovorin, irinotecan)) followed by neoadjuvant chemoradiotherapy and surgery (experimental arm) or neoadjuvant chemoradiotherapy and surgery alone (control arm). Tumours will be restaged using MRI and, in the experimental arm, a further cycle of CAPOX or two cycles of FOLFOX/FOLFIRI will be administered before chemoradiotherapy in case of stable or responsive disease. The radiotherapy dose will be 25 x 2.0 Gy or 28 x 1.8 Gy in radiotherapy-naive patients, and 15 x 2.0 Gy in previously irradiated patients. The concomitant chemotherapy agent will be capecitabine administered twice daily at a dose of 825 mg/m(2) on radiotherapy days. The primary endpoint of the study is the R0 resection rate. Secondary endpoints are long-term oncological outcomes, radiological and pathological response, toxicity, postoperative complications, costs, and quality of life. Discussion: This trial protocol describes the PelvEx II study. PelvEx II, designed as a multicentre, open-label, phase III, parallel-arms study, is the first randomized study to compare induction chemotherapy followed by neoadjuvant chemo(re)irradiation and surgery with neoadjuvant chemo(re)irradiation and surgery alone in patients with locally recurrent rectal cancer, with the aim of improving the number of R0 resections.

Aim High stoma output and dehydration is common following ileostomy formation. However, the impact of this on renal function, both in the short term and after ileostomy reversal, remains poorly defined. We aimed to assess the independent impact on kidney function of an ileostomy after rectal cancer surgery and subsequent reversibility after ileostomy closure. Methods This retrospective single-site cohort study identified patients undergoing rectal cancer resection from 2003 to 2017, with or without a diverting ileostomy. Renal function was calculated preoperatively, before ileostomy closure, and 6 months after ileostomy reversal (or matched times for patients without ileostomy). Demographics, oncological treatments and nephrotoxic drug prescriptions were assessed. Outcome measures were deterioration from baseline renal function and development of moderate/severe chronic kidney disease (CKD >= 3). Multivariate analysis was performed to assess independent risk factors for postoperative renal impairment. Results Five hundred and eighty-three of 1213 patients had an ileostomy. Postoperative renal impairment occurred more frequently in ileostomates (9.5% absolute increase in rate of CKD >= 3; P < 0.0001) vs no change in patients without an ileostomy (P = 0.757). Multivariate analysis identified ileostomy formation, age, anastomotic leak and renin-angiotensin system inhibitors as independently associated with postoperative renal decline. Despite stoma closure, ileostomates remained at increased risk of progression to new or worse CKD [74/438 (16.9%)] compared to patients without an ileostomy [36/437 (8.2%), P = 0.0001, OR 2.264 (1.49-3.46)]. Conclusions Ileostomy formation is independently associated with kidney injury, with an increased risk persisting after stoma closure. Strategies to protect against kidney injury may be important in higher risk patients (elderly, receiving renin-angiotensin system antihypertensives, or following anastomotic leakage).

Aim At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection. Method Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival. Results Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006). Conclusion Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Aim Postoperative anastomotic leakage (AL) or bleeding (AB) significantly impacts on patient outcome following colorectal resection. To minimize such complications, surgeons can utilize different techniques perioperatively to assess anastomotic integrity. We aim to assess published anastomotic complication rates following left-sided colonic resection, comparing the use of intra-operative flexible endoscopy (FE) against conventional tests used to assess anastomotic integrity. Methods PubMed/MEDLINE and Embase online databases were searched for non-randomized and randomized case-control studies that investigated postoperative AL and/or AB rates in left-sided colonic resections, comparing intra-operative FE against conventional tests. Data from eligible studies were pooled, and a meta-analysis using Review Manager 5.3 software was performed to assess for differences in AL and AB rates. Results Data from six studies were analysed to assess the impact of FE on postoperative AL and AB rates (1084 and 751 patients respectively). Use of FE was associated with reduced postoperative AL and AB rates, from 6.9% to 3.5% and 5.8% to 2.4% respectively. Odds ratios favoured intra-operative FE: 0.37 (95% CI 0.21-0.68, P = 0.001) for AL and 0.35 (95% CI 0.15-0.82, P = 0.02) for AB. Conclusion This meta-analysis showed that the use of intra-operative FE is associated with a reduced rate of postoperative AL and AB, compared to conventional anastomotic testing methods.

Objective: To determine factors associated with outcomes following pelvic exenteration for advanced nonrectal pelvic malignancy. Background: The PelvEx Collaborative provides large volume data from specialist centers to ascertain factors associated with improved outcomes. Methods: Consecutive patients who underwent pelvic exenteration for nonrectal pelvic malignancy between 2006 and 2017 were identified from 22 tertiary centers. Patient demographics, neoadjuvant therapy, histopathological assessment, length of stay, 30-day major complication/mortality rate were recorded. The primary endpoints were factors associated with survival. The secondary endpoints included the difference in margin rates across the cohorts, impact of neoadjuvant treatment on survival, associated morbidity, and mortality. Results: One thousand two hundred ninety-three patients were identified. 40.4% (n = 523) had gynecological malignancies (endometrial, ovarian, cervical, and vaginal), 35.7% (n = 462) urological (bladder), 18.1% (n = 234) anal, and 5.7% had sarcoma (n = 74). The median age across the cohort was 63 years (range, 23-85). The median 30-day mortality rate was 1.7%, with the highest rates occurring following exenteration for recurrent sarcoma or locally advanced cervical cancer (3.3% each). The median length of hospital stay was 17.5 days. 34.5% of patients experienced a major complication, with highest rate occurring in those having salvage surgery for anal cancer. Multivariable analysis showed R0 resection was the main factor associated with long-term survival. The 3-year overall-survival rate for R0 resection was 48% for endometrial malignancy, 40.6% for ovarian, 49.4% for cervical, 43.8% for vaginal, 59% for bladder, 48.3% for anal, and 48.1% for sarcoma. Conclusion: Pelvic exenteration remains an important treatment in selected patients with advanced or recurrent nonrectal pelvic malignancy. The range in 3-year overall survival following R0 resection (40%-59%) reflects the diversity of tumor types.

Objective: Palliative pelvic exenteration (PPE) is a technically complex operation with high morbidity and mortality rates, considered in patients with limited life expectancy. There is little evidence to guide practice. We performed a systematic review to evaluate the impact of PPE on symptom relief and quality of life (QoL). Methods: A systematic review was conducted according to the PRISMA guidelines using Ovid MEDLINE, EMBASe, and PubMed databases for studies reporting on outcomes of PPE for symptom relief or QoL Descriptive statistics were used on pooled patient cohorts. Results: Twenty-three historical cohorts and case series were included, comprising 509 patients. No comparative studies were found. Most malignancies were of colorectal, gynaecological and urological origin. Common indications for PPE were pain, symptomatic fistula, bleeding, malodour, obstruction and pelvic sepsis. The pooled median postoperative morbidity rate was 53.6% (13-100%), the median in-hospital mortality was 63% (0-66.7%), and median OS was 14 months (4-40 months). Some symptom relief was reported in a median of 79% (50-100%) of the patients, although the magnitude of effect was poorly measured. Data for QoL measures were inconclusive. Five studies discouraged performing PPE in any patient, while 18 studies concluded that the procedure can be considered in highly selected patients. Conclusion: Available evidence on PPE is of low-quality. Morbidity and mortality rates are high with a short median OS interval. While some symptom relief may be afforded by this procedure, evidence for improvement in QoL is limited. A highly selective individualised approach is required to optimise the risk:benefit equation. (C) 2019 Elsevier Ltd, BASO - The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Laparoscopic surgery is well established for colon cancer, with defined benefits. Use of laparoscopy for the performance of restorative proctocolectomy (RPC) with ileoanal anastomosis is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these difficulties we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique, which is combined with an abdominal approach using a single‐incision platform (SIP).

Splenic artery aneurysms (SAA) are the third most common intra-abdominal aneurysm. Complications include invasion into surrounding structures often in association with preexisting pancreatic disease. We describe an 88-year-old female, with no history of pancreatic disease, referred with lower gastrointestinal bleeding. CT angiography showed a splenic artery pseudoaneurysm with associated collection and fistula to the transverse colon at the level of the splenic flexure. The pseudoaneurysm was embolised endovascularly with metallic microcoils. Rectal bleeding ceased. The patient recovered well and follow-up angiography revealed no persistence of the splenic artery pseudoaneurysm. SAA rupture results in 29%–50% mortality. Experienced centres report success with the endovascular approach in haemodynamically unstable patients, as a bridge to surgery, and even on a background of pancreatic disease. This case highlights the importance of prompt CT angiography, if endoscopy fails to identify a cause of gastrointestinal bleeding. Endovascular embolisation provides a safe and effective alternative to surgery, where anatomical considerations and local expertise permit.

AimR0 resection of locally advanced or recurrent rectal cancer is the key determinant of outcome. Disease extension high on the sacrum has been considered a contraindication to surgery because of associated morbidity and difficulty in achieving complete pathological resection. Total sacrectomy has a high morbidity with poor function.MethodWe describe a novel technique of high subcortical sacrectomy (HiSS) to facilitate complete resection of disease extending to the upper sacrum at S1 and S2 to avoid high or total sacrectomy or a nonoperative approach to management. Details of patient demographics, radiology, operative details, postoperative histology, length of hospital stay and complications were entered into a prospectively maintained electronic patient database. All patients had had preoperative chemoradiotherapy.ResultsDuring 2013-2014, five patients, including three with advanced primary cancer and two with recurrent rectal cancer, underwent excision using this approach. All patients had an R0 resection. Four patients had a minor postoperative complication (Clavien-Dindo Grades I and II) and one had a major complication (Clavien-Dindo Grade IIIb). There was no mortality at 90days, and four patients were disease free at a median of 18months.ConclusionPatients with locally advanced and recurrent rectal cancer involving the upper sacrum may be rendered suitable for potentially curative radical resection with a modified approach to sacral resection. This pilot series suggests that this novel technique results in a high rate of complete pathological resection with acceptable morbidity in patients for whom the alternatives would have been an incomplete resection, a total sacrectomy or nonoperative management.

Complete pathological resection of locally advanced or recurrent rectal and anal cancer is regarded as one of the most important determinants of oncological outcome. Disease in the lateral pelvic sidewall has been considered a contraindication for pelvic exenteration surgery owing to the significant likelihood of incomplete resection.