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.

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.

Introduction: The difference in outcome between right (RCD) and left colonic diverticulitis (LCD) is not well established. The aim of this study was to analyse the presentation and surgical outcome of RCD versus left-sided disease following emergency surgery. Method: We conducted a retrospective review of patients presenting with acute diverticulitis over a 10-year period from 2004 to 2014 to a tertiary unit. Patient demographics, Hinchey classification, need for emergency surgery, perioperative outcome and recurrence were evaluated. Results: In total 360 patients presented with acute diverticulitis, 218 (61%) were right-sided and 142 (39%) were left-sided. The mean age (57 yrs vs 68 yrs) and median length of stay (4 days vs 5 days) were significantly less in RCD (p < 0.001). The need for emergency surgery was similar between RCD and LCD (30.7% vs 23.2%, p = 0.12). Sixty-seven (31%) patients with RCD required emergency surgery, 42 (62.7%) of these were based on a presumptive diagnosis of appendicitis and underwent laparoscopic appendicectomy only. Operative morbidity (10.4% vs 51.5%, p < 0.001) and mortality were significantly higher in LCD (1.5% v 15.2%, p = 0.007). Subgroup analysis of non-appendicectomy, RCD patients, showed LCD were more likely to require surgery (11.5% vs 23.2%, p = 0.003). There was no difference in recurrence (p = 0.6). Conclusion: Right colonic diverticulitis patients are younger and disease course is more benign compared to LCD. Presentation can be confused with appendicitis without proper imaging. In the rare cases where emergency surgery is required, RCD is associated with a lower operative morbidity and mortality compared to left-sided disease. (C) 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Exenteration is an ultra-major surgery that involves radical en-bloc resection of all pelvic organs including the rectum, sigmoid colon, distal ureter, urinary bladder, internal reproductive organs, regional lymph nodes, and pelvic peritoneum. This chapter reviews the most up-to-date available evidence for adjuvant therapy following pelvic exenteration for colorectal cancer. The main limitation regarding the assessment of outcomes following pelvic exenteration is the relative paucity of prospective data, in particular the lack of evidence regarding adjuvant therapy. Pelvic radiotherapy with or without concurrent chemotherapy is an essential component for successful management of rectal cancer. In addition, the potential benefit of adjuvant chemotherapy in those patients who can be downstaged with neoadjuvant chemoradiotherapy is apparently irrelevant for those who are judged to require exenteration. Antibodies against vascular endothelial growth factor and epithelial growth factor receptor are the standard of care for metastatic colorectal cancer in addition to the conventional chemotherapy backbone.

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.

BACKGROUND: Advances in sphincter-saving procedures improved the quality of life of patients with rectal cancer. However, many of them experienced functional disturbances after surgery, including low anterior resection syndrome. OBJECTIVE: The aim of this study was to evaluate the severity of low anterior resection syndrome after transanal total mesorectal excision and compare it with the conventional transabdominal, top-to-bottom, total mesorectal excision. DESIGN: This was a single-center, retrospective analysis. SETTINGS: The study was conducted at a tertiary academic institution. PATIENTS: This study analyzed patients who underwent total mesorectal excision for mid to low rectal cancer from January 2016 to April 2018. Cases were matched one-to-one according to the tumor height and history of pelvic irradiation using the propensity score. MAIN OUTCOME MEASURES: The primary outcome measured was the severity of low anterior resection syndrome and fecal incontinence at 3, 6, and 12 months after surgery or stoma reversal, whichever was later. RESULTS: There were 35 patients in each group after matching; 67.1% were male, and 41.4% had neoadjuvant radiotherapy. At 3 months, the median low anterior resection syndrome score was 37 after transanal total mesorectal excision, which was significantly higher than the conventional approach, 32 (p = 0.045). Apart from this, the low anterior resection syndrome score, severity grading, and the Wexner score were comparable at 6 and 12 months. LIMITATIONS: A difference between the 2 groups might not be detected because of the study’s small sample size and because of its retrospective nature. CONCLUSIONS: A higher low anterior resection syndrome score was observed after transanal total mesorectal excision at the initial 3-month period, but such a difference was not observed thereafter. This study showed that both surgical techniques had similar anal and bowel functional outcomes in the long run. However, because of the limited case number and study design, further study is needed to prove this. See Video Abstract at http://links.lww.com/DCR/B146. SÍNDROME DE RESECCIÓN ANTERIOR BAJA DESPUÉS DE LA ESCISIÓN MESORRECTAL TOTAL TRANSANAL: UNA COMPARACIÓN CON EL ABORDAJE CONVENCIONAL DE SUPERIOR A INFERIOR ANTECEDENTES: Los avances en los procedimientos para salvar esfínteres mejoraron la calidad de vida de los pacientes con cáncer rectal. Sin embargo, muchos de ellos sufrieron trastornos funcionales después de la cirugía, incluyendo el síndrome de resección anterior baja. OBJETIVO: El objetivo de este estudio fue evaluar la gravedad del síndrome de resección anterior baja después de la escisión mesorrectal total transanal y comparar con la escisión mesorrectal total convencional transabdominal, de arriba a abajo. AJUSTES: El estudio se realizó en una institución académica terciaria. DISEÑO Y PACIENTES: Este fue un análisis retrospectivo de un solo centro de pacientes que se sometieron a una escisión mesorrectal total por cáncer rectal medio a bajo desde enero de 2016 hasta abril de 2018. Los casos fueron emparejados uno a uno de acuerdo con la altura del tumor y los antecedentes de irradiación pélvica con puntaje de propensión. PRINCIPALES MEDIDAS DE RESULTADO: La gravedad del síndrome de resección anterior baja y la incontinencia fecal a los 3, 6 y 12 meses después de la cirugía o la reversión del estoma, lo que ocurriera más tarde. RESULTADOS: Hubo 35 pacientes en cada grupo después del emparejamiento. El 67.1% eran hombres. El 41,4% tenía radioterapia neoadyuvante. A los tres meses, la puntuación media del síndrome de resección anterior baja fue de 37 después de la escisión mesorrectal transanal total, que fue significativamente mayor que el enfoque convencional, 32 (p = 0.045). Aparte de esto, la puntuación baja del síndrome de resección anterior, la clasificación de gravedad y la puntuación de Wexner fueron comparables a los 6 y 12 meses. LIMITACIONES: Es posible que no se detecte una diferencia entre los dos grupos debido al pequeño tamaño de la muestra del estudio. La naturaleza retrospectiva del estudio. CONCLUSIONES: Se observó una puntuación más alta en el síndrome de resección anterior baja después de la escisión mesorrectal total transanal en el período inicial de tres meses, pero dicha diferencia no se observó posteriormente. Este estudio mostró que ambas técnicas quirúrgicas tuvieron resultados similares de funcionamiento anal e intestinal a largo plazo. Sin embargo, debido al número limitado de casos y al diseño del estudio, es necesario realizar más estudios para demostrarlo. Consulte Video Resumen en http://links.lww.com/DCR/B146.

Background: There are no data comparing the use of self-gripping mesh with standard mesh in total extraperitoneal repair (TEP). In this prospective study we aim to study the incidence of chronic pain between Progrip (PG) and standard mesh fixed by fibrin sealant (FS). Materials and Methods: Under Institutional Review Board approval, from April 2016 to May 2017, patients with primary unilateral or bilateral inguinal hernia eligible for TEP were recruited. Before mesh insertion they were randomized into PG or FS (Tisseel). Demographics, intraoperative, and postoperative data were recorded. Patients were followed up for at least 1 year. Visual Analog Scale was used to record pain scores. Primary outcome was the incidence of chronic pain at 3 months after surgery. Results: One hundred fifty patients were randomized. Of the 150 patients (193 hernias), 76 were randomized to PG and 74 randomized to FS. Demographic data such as age, presence of comorbidities, smoking history, mean body mass index was comparable in both groups. Bilateral hernias occurred in 25 (32.9%) and 18 (24.3%) patients in PG and FS group, respectively. Mean mesh deployment time was 283.7 seconds (range, 140 to 720 s) in PG group and 301.9 seconds (range, 67 to 1006 s) in FS group (P=0.30). A total of 5 patients were lost at follow-up and they were excluded from subsequent data analysis. Seroma occurred in 15 (20.3%) and 16 (22.5%) patients in PG and FS group, respectively (P=0.45). Mean Visual Analog Scale at 2 weeks (cough) was highest at 1.05 and 1.02 in PG and FS group, respectively (P=0.62). Eight (12.3%) and 15 (23.4%) patients in PG and FG group, respectively, reported pain at 3-month follow-up (P=0.1). Of those who experienced pain, majority was mild pain which did not affect activities of daily living. At a mean follow-up of 13.1 +/- 5.4 months, no recurrence was detected. Conclusions: There was no significant difference in terms of chronic pain between PG and FS group. The use of PG is effective in TEP.

Introduction: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly used to treat peritoneal metastases from appendiceal or colorectal origin. We evaluate our institution's experience and survival outcomes with this procedure, and its efficacy in symptom relief. Methods: This is a single-centre retrospective observational study on patients with peritoneal metastases (PM) from appendiceal neoplasm or colorectal cancer who underwent CRS/HIPEC in Queen Mary Hospital. Our primary endpoints were overall survival (OS) and morbidity and mortality of this procedure; secondary endpoints included disease-free survival (DFS) and symptom-free survival. Results: Between 2006 and 2018, thirty CRS/HIPEC procedures were performed for 28 patients - 17 (60.7%) had appendiceal PM while 11 (39.9%) had colorectal PM. The median peritoneal cancer index was 20; complete cytoreduction was achieved in 83.3% patients. High-grade morbidity occurred in 13.3% cases. There was no 30-day mortality. Two-year OS were 71.6% and 50% for low-grade appendiceal PM and colorectal PM patients (p = 0.20). Complete cytoreduction improved OS (2-year OS 75.4% vs 20%, p = 0.04). Median DFS was 11.8 months. Median symptom-free duration was 36.8 months; patients with complete cytoreduction were more likely to remain asymptomatic (82.9% at 1 year, vs 60% in incomplete cytoreduction group, p < 0.01). 91.7% low-grade appendiceal PM patients and 58.4% colorectal PM patients remained asymptomatic at post-operative one year (p = 0.31). Conclusion: CRS/HIPEC is beneficial to appendiceal PM and selected colorectal PM patients - improving survival and offering prolonged symptom relief, with reasonable morbidity and mortality. Complete cytoreduction is key to realising this benefit. (C) 2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V.

Background According to the American Joint Committee on Cancer staging for cancer of the colon, a minimum of 12 lymph nodes (LN) has to be sampled for accurate staging. This has bearing on the long-term prognosis and the need for adjuvant chemotherapy. The aim of this study was to revisit the association of lymph node yield and the long-term survival in patients with stages I and II, i.e. node-negative, colon cancer. Method Consecutive patients who underwent elective or emergency curative resections for cancer of colon between the years 2003 and 2012 were retrospectively reviewed. Only patients with stage I or II diseases (AJCC 8th edition) were included. They were analysed in three groups, LN<12, LN12-19 and LN≥20. Their clinic-pathological characteristics were compared. The disease-free (DFS) and overall survival (OS) were estimated with the Kaplan-Meier method and compared with the log-rank test. Results There was a total of 659 patients included in the analysis. Twelve or more LN were found in 65.6% of the specimens. The mean follow-up was 83.9 months. LN≥20 had significantly better DFS ( p = 0.015) and OS ( p = 0.036), whereas LN<12 had similar DFS and OS when compared to LN12-19. The advantage in DFS and OS were mainly seen in those with stage II diseases. A lymph node yield of greater than 20 was one of the predictors of favourable DFS, hazard ratio 0.358; 95% CI 0.170–.756, p = 0.007. Conclusion The lymph node yield had a significant association with survival outcomes. A lymph node yield of 20 or more was associated with better survival outcomes. On the other hand, lymph node yield less than 12 was not shown to have inferior survival outcomes when compared to those between 12 and 19.

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.

Right-sided diverticulitis accounts for the majority of diverticulitis in Asian countries but represents only a small portion of diverticulitis in Western countries. There is a paucity of evidence concerning management of right-sided diverticulitis because of the rarity of right-sided diverticulitis in Western countries. Compared with left-sided diverticulitis, right-sided diverticulitis has a significantly earlier age of onset. In asymptomatic patients, the most accurate method of diagnosis in right-sided diverticulosis is by contrast enema. Right-sided diverticulitis is often difficult to diagnose clinically due to its similarity with appendicitis. Imaging studies are invaluable in assessing right-sided diverticulitis. A large number of patients with right-sided diverticulitis are diagnosed intra-operatively during laparoscopy. Laparoscopic surgery has also been applied to the management of acute right sided diverticulitis. To operate on diverticulitis using a laparoscopic approach, one needs to be familiar with both the medial-to-lateral and lateral-to-medial dissection approach.

Over the past few decades, studies have focused on the safety of stapled anastomosis, especially when compared to that of the handsewn technique. However, studies on the improvement of stapling technology are limited. This study aimed to investigate whether linear triple-row staples (tri-staples) had any advantage over double-row staples.

BackgroundPelvic exenteration for locally recurrent rectal cancer (LRRC) is associated with variable outcomes, with the majority of data from single-centre series. This study analysed data from an international collaboration to determine robust parameters that could inform clinical decision-making. MethodsAnonymized data on patients who had pelvic exenteration for LRRC between 2004 and 2014 were accrued from 27 specialist centres. The primary endpoint was survival. The impact of resection margin, bone resection, node status and use of neoadjuvant therapy (before exenteration) was assessed. ResultsOf 1184 patients, 614 (519 per cent) had neoadjuvant therapy. A clear resection margin (R0 resection) was achieved in 554 per cent of operations. Twenty-one patients (18 per cent) died within 30days and 380 (321 per cent) experienced a major complication. Median overall survival was 36months following R0 resection, 27months after R1 resection and 16months following R2 resection (P<0001). Patients who received neoadjuvant therapy had more postoperative complications (unadjusted odds ratio (OR) 153), readmissions (unadjusted OR 233) and radiological reinterventions (unadjusted OR 212). Three-year survival rates were 481 per cent, 339 per cent and 15 per cent respectively. Bone resection (when required) was associated with a longer median survival (36 versus 29months; P<0001). Node-positive patients had a shorter median overall survival than those with node-negative disease (22 versus 29months respectively). Multivariable analysis identified margin status and bone resection as significant determinants of long-term survival. ConclusionNegative margins and bone resection (where needed) were identified as the most important factors influencing overall survival. Neoadjuvant therapy before pelvic exenteration did not affect survival, but was associated with higher rates of readmission, complications and radiological reintervention. Complete resection is key

Background: Perfusion plays an important role in anastomotic healing. Indocyanine-green fluorescence angiogram allows objective bowel perfusion assessment. This study aimed to investigate the impact of perfusion assessment on intraoperative decision during left-sided colorectal resections. Method: This was a prospective, single-centre, observational study recruiting patients with left-sided colorectal resections. Perfusion of bowel segment was assessed with ICG fluorescence angiogram prior to resection and anastomosis intra-operatively. The planned transection site and the actual transection site after perfusion assessment were compared. The decision for diversion stoma was also evaluated. Results: 110 patients with cancer of the sigmoid colon (29.1%) and rectum (70.9%) were recruited. Total mesorectal excision was performed in 51.8% of patients. The transection site was revised in 34.5% of cases: 30.9% more proximally and 3.6% more distally. The median distance between the intended and actual transection sites was 2 cm (range 1-17 cm). A proximal revision in the transection site was more likely seen in rectal cancers (p = 0.036, OR 3.58, 95% CI 1.09-11.78) and relatively under-perfused left colon (p = 0.036, OR 1.01, 95% CI 1.01-1.02). Three (2.7%) patients were spared from a diversion stoma. The overall anastomotic leakage rate was 5.5%. Conclusion: ICG fluorescence angiogram altered operative decisions in a significant proportion of cases. The impact on transection site was more pronounced in patients with rectal cancers and those with relatively under-perfused colon. (C) 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.