Abdominal Resection Research Articles

Successes and challenges of implementing teleprehabilitation for onco-surgical candidates and patients\u2019 experience: a retrospective pilot-cohort study

This study documents the implementation of a multimodal teleprehabilitation program (e.g., completion rate, exercise metrics, and program successes and challenges) for cancer patients undergoing surgery. It also documents the patients’ experience of the program. This pilot-cohort study included adults scheduled for elective thoracic and abdominal cancer resection surgery, referred to the prehabilitation clinic to engage in physical activity, and received a teleprehabilitation program between August 1st, 2020, and February 28th, 2021. The technology platform provided to the patients included a tablet and a wearable device to facilitate communication and data collection. Data collected for this article were acquired through virtual physical activity monitoring in addition to patient charts. Qualitative data collected comprised of successes and challenges of implanting a teleprehabilitation program, in addition to patients’ perspectives of the program. Quantitative data collected comprised of the exercise metrics, perioperative functional outcomes, in addition to the surgical and postoperative outcomes. Ten patients (8 males and 2 females; mean age: 68.3 years, SD 11.96) diagnosed with various thoracoabdominal malignancies were included in the current descriptive study. The successes identified were related to recruitment and assessment, improvement in functional capacity, clinic scheduling and interventions, and optimal medical follow-up. The challenges identified were related to the adoption of the technologies by patients and the multidisciplinary team, the accurate acquisition of patient physical activity data, and the initial costs to acquire the new technologies. Patients were satisfied with the teleprehabilitation program (i.e., services delivered; average appreciation: 96%), and they perceived the technologies provided to be 90% user-friendly. The findings of the current study highlight important concepts in view of the current international health paradigm changes prioritizing remote interventions facilitated through digital communication technologies. It provides important insight into the clinical application of telehealth in elderly populations, notably in the context of acute preoperative cancer care. This article may provide guidance for other cancer care facilities aiming to implement teleprehabilitation programs.

Transanal total mesorectal excision and robotic ultra‐low anterior resection with en bloc left seminal vesicle excision: a video vignette

Transanal TME is typically utilised for resection of low rectal lesions to overcome the potential technical limitations of abdominal TME resections. Advanced applications for beyond TME surgery have rarely been described. Herein we adopt a hybrid robotic transanal TME approach with Indocyanine Green injection into the ureters for a safe en-bloc resection of seminal vesicle with an ultra-low anterior resection. The combined technique allows the abdominal operator to leave the standard anatomical plane and subsequently return to it for seamless seminal vesicle resection. This may provide a useful aid for colorectal surgeons when it comes to T4 resections.

Immediate Repair With a Self-Gripping Retromuscular Mesh for Abdominal Wall Defect Following Tumor Resection.

Background: Prosthetic repair is always employed after large abdominal wall tumor resection, while chronic pain is one of the mesh-related complications after traumatic fixation. The objective of this research was to evaluate the outcomes of retromuscular repair with self-gripping mesh after abdominal wall tumor resection.Methods: The study was a monocentric retrospective analysis following STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statements of all patients with abdominal wall tumor >5cm in diameter undergoing tumor excision and retromuscular repair with self-gripping mesh. Demographic, operative, early postoperative, and follow-up data were noted. Visual Analog Scale, ranging from 0 (no pain) to 10 (very severe pain), was used to estimate the wound pain.Results: 24 patients were included in this study, and the defect following tumor resection was 26.9±10.0cm2. There was no tumor recurrence or incisional hernia in median follow-up of 20months, and the mean VAS score was 0.4. Three had foreign body feeling and no one suffered chronic pain.Conclusions: Immediate repair with a self-gripping retromuscular mesh can be considered as an effective way to treat an abdominal wall defect after resecting an abdominal wall tumor.

Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study

BackgroundAbdominal visceral resections incur relatively higher rates of postoperative bleeding and venous thromboembolism (VTE). While guidelines recommend the use of perioperative chemical thromboprophylaxis, the most appropriate time for its initiation is unknown. Here, we investigated whether early (before skin closure) versus postoperative commencement of chemoprophylaxis affected VTE and bleeding rates following abdominal visceral resection. MethodsRetrospective review of all elective abdominal visceral resections undertaken between January 1, 2018, and June 30, 2019, across four tertiary-referral hospitals. Major bleeding was defined as the need for blood transfusion, reintervention, or > 20 g/L fall in hemoglobin from baseline. Clinical VTE was defined as imaging-proven symptomatic disease < 30 days post-surgery. ResultsA total of 945 cases were analyzed. Chemoprophylaxis was given early in 265 (28.0%) patients and postoperatively in 680 (72.0%) patients. Mean chemoprophylaxis exposure doses were similar between the two groups. Clinical VTE developed in 14 (1.5%) patients and was unrelated to chemoprophylaxis timing. Postoperative bleeding occurred in 71 (7.5%) patients, with 57 (80.3%) major bleeds, requiring blood transfusion in 48 (67.6%) cases and reintervention in 31 (43.7%) cases. Bleeding extended length-of-stay (median (IQR), 12 (7–27) versus 7 (5–11) days, p < 0.001). Importantly, compared to postoperative chemoprophylaxis, early administration significantly increased the risk of bleeding (10.6% versus 6.3%, RR 1.45, 95% CI 1.05–1.93, p = 0.038) and independently predicted its occurrence. ConclusionsThe risk of bleeding following elective abdominal visceral resections is substantial and is higher than the risk of clinical VTE. Compared with early chemoprophylaxis, postoperative initiation reduces bleeding risk without an increased risk of clinical VTE.

Transanal Local Excision of Rectal Cancer after Neoadjuvant Chemoradiation: Is There a Place for It or Should Be Avoided at All Costs?

Tumor response to neoadjuvant chemoradiation (nCRT) with tumor downsizing and downstaging has significantly impacted the number of patients considered to be appropriate candidates for transanal local excision (TLE). Some patients may harbor small residual lesions, restricted to the bowel wall. These patients, who exhibit major response ("near-complete") by digital rectal examination, endoscopic assessment, and radiological assessment may be considered for this approach. Although TLE is associated with minimal postoperative morbidity, a few clinical consequences and oncological outcomes must be evaluated in advance and with caution. In the setting of nCRT, a higher risk for clinically relevant wound dehiscences leading to a considerable risk for readmission for pain management has been observed. Worse anorectal function (still better than after total mesorectal excision [TME]), worsening in the quality of TME specimen, and higher rates of abdominal resections (in cases requiring completion TME) have been reported. The exuberant scar observed in the area of TLE also represents a challenging finding during follow-up of these patients. Local excision should be probably restricted for patients with primary tumors located at or below the level of the anorectal ring (magnetic resonance defined). These patients are otherwise candidates for abdominal perineal resections or ultra-low anterior resections with coloanal anastomosis frequently requiring definitive stomas or considerably poor anorectal function.

Robotic abdominal resection of tailgut cysts - A technical note with step-by-step description.

AimHere, we describe a step‐by‐step standardized technique for tailgut cyst resection using a single‐docking robotic approach.MethodEach step of the technique is illustrated using a composite collection of four operative patient videos to demonstrate the advantages and feasibility of this technique. The robot platform utilised is Da Vinci Xi.ResultsFive female patients have undergone this operation in our unit. The size of tumours ranged from 12 to 45 mm. Median operating time was 100 min (range 90–150). Mean blood loss in all the patients was less than 50 ml. There were no major intraoperative complications. One patient had a postoperative presacral collection which required radiological drainage. Length of stay in all patients was one day.ConclusionsThis technique using a single‐docking robotic approach appears safe and feasible. The robotic approach results in improved dexterity and more accurate dissection, better retraction and excellent vision which improves the ease of operating in the pelvis. Therefore, this approach can be replicated for use in a wide variety of patients with tailgut cysts.

Half-Dose Sugammadex After Neostigmine Versus Neostigmine as a Routine Reversal Agent: A Pilot Randomized Trial

PurposeThe use of sugammadex at a lower dose after a routine reversal dose of neostigmine may prevent residual neuromuscular blockade (rNMB). Our goal was to investigate the effects of the use of half-dose sugammadex for reversing rNMB after administration of neostigmine, and compare these effects to a routine full-dose of neostigmine. DesignProspective, single-blinded, randomized trial. MethodsNinety-eight patients having lower abdominal tumor resection surgery under general anesthesia were randomized into two groups. Group N (Neostigmine) (n = 48) patients received standard reversal dose of intravenous neostigmine 0.05 mg/kg and atropine 0.02 mg/kg before extubationl Group N + S (Neostigmine + Sugammadex) (n = 50) patients received 1 mg/kg of intravenous sugammadex three minutes after a standard neostigmine reversal dose. The primary end-point was the incidence of a train-of-four (TOF) ratio less than 0.9 at tracheal extubation. Secondary end-points were periods between the start of administration of reversal agents and extubation or operating room discharge in minutes to achieve recovery of TOF ratio < 0.9 to 0.7 and TOF ratio ≥ 0.9. FindingsThe demographic data were not different between the two groups (P > .005). The incidence of rNMB presented as TOF ratio < 0.9 to 0.7 was present in 52% of Group N patients compared to 8% in Group N + S patients (P < .0001). The time to recovery between administering reversal and extubation as well as operating room discharge in Group N were; 18.52 ± 6.34 minutes and 23.27 ± 6.95 minutes, respectively, whereas; in Group N + S, they were; 12.86 ± 5.05 and 17.82 ± 4.99 minutes, respectively. (P < .0001, P < .0001, respectively). Adverse events were similar between groups (P > .05). ConclusionsA half-dose sugammadex (1 mg/kg) after full-dose reversal of neostigmine provides a lower incidence of rNMB and shorter recovery times as compared to full-dose neostigmine reversal agent. This practice is safe and effective in case of rNMB.

Abdominal anal resection with descent of the large intestine in the treatment of rectal cancer

One of the most frequent complications in the operation of abdominal-anal resection of the rectum is necrosis of the intestine reduced to the anal canal. According to most authors, necrosis occurs as a result of impaired blood supply in the graft due to sclerosed vessels, tension of the mesentery, compression of the intestinal wall and mesentery by the sphincter, and an insufficiently pronounced ryolan arch.

Regional Analgesia Does Not Reduce Cancer Recurrence. Case closed

Regional Analgesia Does Not Reduce Cancer Recurrence. Case closed

Clinical Significance of Nlr(Neutrophil Lymphocyte Ratio) and Plr(Platelet Lymphocyte Ratio) in Predicting Post Operative Complication in Major Abdominal Surgery

Background: The Expression Major abdominal surgery is defined as a lengthy surgical procedure that lasts more than 30 minutes. Gastrectomy, Pancreatectomy, Hepatectomy, Colectomy, Small Bowel Resection, Tumor Resection, And Laparoscopic Gastrointestinal Operations are among the procedures covered. The term "abdominal tumour resection" refers to a wide range of procedures used to remove benign and malignant intraabdominaltumours. There Is A Greater Tendency Of Systemic Inflammatory Reaction When The Abdomen Organs Are Exposed To The External Environment For A Long Period Of Time. As a result, the goal of this research was to concentrate on the clinical significance of the neutrophil lymphocyte ratio and platelet lymphocyte ratio in patients undergoing major abdominal surgery.&#x0D; This review included a total of 15 studies conducted between 2000 and 2021. The influence of Clinical Importance Of The Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio In Patients Undergoing Major Abdominal Surgery has been reviewed collectively.&#x0D; Results: 15 studies were included in this review were Iincluded. The present study evaluated the value of nlr and PLR as predictive markers of post operative complications in major abdominal surgeries. In the current study, we investigated the value of nlr and PLR for predicting post operative complications in patients undergoing major abdominal surgeries.&#x0D; Conclusions: In Cases of Major Abdominal Surgeries, The nlr and PLR Ratio Is An Important Inflammatory Predictive Value In Assessing Post-Operative Morbidity. The platelet/lymphocyte ratio (PLR) and the neutrophil/lymphocyte ratio (NLR) are two affordable, reproducible, and quantitative measures of systemic inflammation.

Robotic endoscopic cooperative surgery for colorectal tumors: a feasibility study (with video).

Laparoscopic endoscopic cooperative colorectal surgery (LECS-CR) is a promising technique to achieve full-thickness resection of colorectal tumors. This approach has shown good rates of complete resection and low local recurrence, especially for large laterally spreading tumors, which are difficult to remove via endoscopy alone. However, it is often difficult to prevent peritoneal leakage of intestinal content, causing infections and risks of cancer spreading. It was hypothesized that a robotic assistance could make the procedure easier and decrease intestinal fluid leakage. This preclinical trial aims to assess the feasibility of robotic and endoscopic cooperative colorectal surgery (RECS-CR). LECS-CR was performed in five female pigs and RECS-CR was also performed in five female pigs. With the animal under general anesthesia, pseudotumors were created on the colonic mucosa at a distance comprised between 20 and 25cm from the anal verge. Desired resection margins were marked endoscopically and two stay sutures were placed either robotically or laparoscopically. A mucosa-to-submucosa dissection was performed endoscopically along the markings. Complete full-thickness dissection was performed cooperatively. The specimen was withdrawn endoscopically. The colon was closed using a self-fixating running suture. Abdominal contaminations, operating times, complications, and complete resections were evaluated and compared between LECS-CR and RECS-CR. The mean number of colonies of Escherichia coli in the RECS group was significantly lower than in the LECS group (36.7 ± 30.2 vs. 142.2 ± 78.4, respectively, p < 0.05). Operating time was comparable (118 ± 11.2 vs. 98.6 ± 25.7, respectively, p = 0.22). Two stenoses occurred in the LECS group. R0 resection was achieved in all cases. This study suggests that RECS-CR is feasible and has the potential to reduce intestinal content leakage, potentially preventing postoperative infections.

798 A Rare Complication and Unexpected Pathology Following an Anterior Exenteration – A Case Report

Abstract We present a case report of an unexpected pathology in addition to a rare complication in a 62-year-old female following an anterior exenteration and an abdominal wall reconstruction. Initial biopsies characterised the malignancy as a potential urachal adenocarcinoma, but the final pathology revealed a solitary endometrial adenocarcinoma metastasis from endometrial cancer 6 years previously. Due to the nature of the tumour, an abdominal wall resection was required, and reconstruction involved a pedicled thigh flap. Post-operatively the small bowel herniated under the flap and this resulted in true mechanical small bowel obstruction. The loop of herniated bowel is visible on CT imaging in the area of the proximal thigh. The patient returned to theatre for an emergency laparotomy and the abdominal wall defect was closed instead with a surgical implant derived from animal tissue. The patient made an excellent recovery, was discharged home, and continues to do well. This patient is an example of excelling in adversity.

ABDOMINAL ANAL RESECTIONS OF THE RECTUM. OWN RESULTS. INTERSFINCTER RESECTIONS. CONTROVERSIAL ISSUES

The article presents current literature data on the eff ectiveness of intersphincteric resections, as well as a comparative analysis of their results of abdominal and anal resections of the rectum.A meta-analysis of foreign and domestic literature indicates that the incidence of postoperative mortality in intersphincteric resections of the rectum is 2%, complications – 10-15%, and fi ve-year survival is over 80%, but the functional consequences of operations want to be better because unsatisfactory results have a place in almost half of the patients.Our research shows that the mortality rate after abdominal and anal resections is 2.4%, postoperative complications – 15%, and fi ve-year survival – more than 77%. The functional results of abdominal and anal resections in low-ampullary rectal cancers were quite satisfactory in more than 90% of patients.Thus, intersphincteric resections of the rectum make it possible to preserve the closing function of the rectum after radical removal of malignant neoplasms of the lower ampullary and anal canal, but the use of this operation is controversial.In our opinion, it is necessary to more actively test the method of intersphincteric resection in the proctology departments of medical institutions of Ukraine.

What is the best method of rectovaginal fistula repair? A 25-year single-center experience.

The surgical treatment of rectovaginal fistula (RVF) remains challenging and there is a lack of data to demonstrate the best, single procedure. The aim of this study was to assess the results of different surgical operations for rectovaginal fistula. Patients with RVF who underwent surgical repair between 1992 and 2017 at a single, tertiary care center were included. Twenty different procedures were performed including: primary closure, closure with sphincter repair, flap repairs, plug/fibrin/mesh repair, examination under anesthesia (EUA) ± seton placement, abdominal resections with and without diversion and ileostomy takedown, gracilis muscle transposition, fistulotomy/ligation of intersphincteric fistula tract. All patients with RVF due to diverticulitis and patients without complete data from paper charting were excluded. Success was defined based on the absence of symptoms related to RVF and absence of diverting stoma at 6months. One hundred twenty-four women were analyzed. The median age was 45 (range 18-84) years. Median follow-up time from the last procedure was 6months (range 0-203months). The total number of patients considered successfully treated at the end of their treatment was 91 (91/124, 73.4%). When considering all procedures (n = 255), the success rate for flap procedures was 57.9% (22/38), followed by abdominal resections with and without proximal diversion and ileostomy takedown (16/29, 55.2%) and primary closure with sphincter repair (17/32, 53.1%) while fistula plug, and fibrin glue had among the lowest success rates (4/22, 18.2%). The highest success rate was observed among patients whose RVF etiology was due to malignancy (11/16, 68.8%) followed by unknown (8/14, 57%) and iatrogenic (21/48, 43.8%) causes. Local procedures such as mucosal flap or primary closure and sphincteroplasty are associated with a high success rate should be considered in patients with low-lying, simple RVF. Abdominal resections with and without proximal diversions and ileostomy takedown have a relatively high success rate in selected patients. The low success rate of fibrin glue and fistula plugs demonstrates their low efficacy in RVF; thus, these procedures should be avoided in the treatment algorithm.

P0665 - Discordant histology of abdominal and thoracic post chemotherapy residual tumor resection in patients with metastatic germ cell tumor

P0665 - Discordant histology of abdominal and thoracic post chemotherapy residual tumor resection in patients with metastatic germ cell tumor

59 The use of sacral nerve stimulation in patients with rectal prolapse

Rectal prolapse is a common disorder that can afflict up to 1% of all adults over the age of 65. Once a prolapse has occurred, 50-75% also complain of fecal incontinence from various causes. Some patient’s fecal incontinence resolved after 6 months from surgical repair but for those with long term prolapse, fecal incontinence persist and does not improved. Sacral nerve stimulator (SNS) has long been placed initially for urinary incontinence in 1988 and subsequently for fecal incontinence since 1995, with good success. With the high incidence of fecal incontinence associated with rectal prolapse, we evaluate the placement of SNS for patient with complaint of rectal prolapse prior to their surgical repair, to assess if improving sphincter tone and continence will improve their prolapse and spare them from a surgical pexy and or resection. a prospective study of patients who presented with rectal prolapse was assessed with physical exam, documentation of prolapse, Wexner incontinence score as well as anal manometry. Patient was then offered SNS prior to their surgical repair. If SNS fails, surgical repair includes laparoscopic/robotic rectopexy, laparoscopic/robotic rectopexy with low anterior resection, and Altmeiyer repair. SNS were placed in a single stage and assessed at 1 month, 3 months, 6 month and a year then yearly with history and physical exam as well as anal manometry. If there was no improvement, the patient would then undergo a surgical repair. 28 patients (female median age 79) underwent placement of SNS after presenting with rectal prolapse. Of these, 9 of 28 (30%) patients achieved treatment improvement at 6 months & success without daily prolapse after an average of 21 months. One of the 28 had a perineal resection a month prior by another colorectal surgeon and proceeded to prolapse 36 days later. The other 18 patients went on for abdominal or perineal repair based on medical problems and patient preference. 15 patients had Altmeiyer, 2 laparoscopic resections with rectopexy and 1 laparoscopic rectopexy alone. The median follow-up of 29 months (range 2-52). Of the 9 patients who did not undergo repair, one had 2 episodes of prolapse with a bout of severe constipation but improved and yet to have surgical intervention. None of the devices needed to be explanted. SNS can be effective for those with rectal prolapse whose prolapse is less than 3cm in length. It provides a less invasive options for patients improving their fecal incontinence and prolapse without a more invasive surgery. Unfortunately, this was only successful in 9 patients with short segment prolapse. The numbers are too low at this time without a larger trial. Currently, it cannot replace neither abdominal or perineal resection but does offer an option to both treat fecal incontinence as well as rectal prolapse. Despite the low numbers, SNS can be considered before undertaking resection for short segment rectal prolapse.

Advanced gastric cancer with abdominal wall invasion treated with curative resection after chemotherapy: a case report

IntroductionIn patients with gastric cancer, 6–27% of patients are diagnosed with T4b disease that invades adjacent organs, and curative resection can improve the prognosis of these patients.Case presentationA 70-year-old Japanese man presented with an abdominal tumor and was diagnosed with advanced gastric cancer (L-Circ type 3 T4b N2 M0 H0 stage IVA, based on the 15th edition of the Japanese Classification of Gastric Carcinoma) with extensive abdominal wall invasion. We performed open gastrojejunal bypass for gastric obstruction and initiated a chemotherapeutic regimen comprising S-1 (120 mg/day) and oxaliplatin (100 mg/m2). Upper gastrointestinal endoscopy performed after the administration of six courses of the S-1 and oxaliplatin regimen revealed a persistent primary lower gastric wall lesion; however, the diameter of the abdominal wall invasion and metastatic lymph nodes was significantly reduced, in addition to decreased serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels. Subsequently, the patient underwent distal gastrectomy with D2 lymphadenectomy combined with transverse colon and abdominal wall resection. We performed radical en bloc resection and achieved a tumor-free resection margin. Simple abdominal wall closure was performed without mesh or musculocutaneous flap placement. Histopathological examination of the resected tumor specimen showed direct invasion of the mesocolon and rectus abdominis muscle. The patient was postoperatively diagnosed with L Gre-Ant type5 T4b (SI: rectus abdominis muscle) N2 PM0 DM0 Stage IIIA R0 Grade 2a gastric cancer based on histopathological findings and received S-1 as adjuvant chemotherapy, 2 months postoperatively. No recurrence was detected 6 months postoperatively.ConclusionsWe report a case of advanced gastric cancer with extensive abdominal wall invasion that was successfully treated with gastrectomy combined with resection of adjacent organs showing tumor invasion after effective systemic chemotherapy. A therapeutic approach comprising curative surgery combined with perioperative chemotherapy is useful in patients with T4b gastric cancer.

Discrepancy between surgeon and radiological assessment of ligation level of the inferior mesenteric artery in patients operated for rectal cancer\u2014impacting registry-based research and surgical practice

BackgroundThe reliability of the registered ligation level of the inferior mesenteric artery (IMA) in the Swedish Colorectal Cancer Registry has been questioned. The primary aim of this study was to evaluate this parameter in the registry by comparing the registered ligation levels with a postoperative computed tomography angiography (CT-angiography) in patients operated for rectal cancer.MethodsPatients operated for rectal cancer at two Swedish university hospitals were prospectively included between December 2016 and December 2019. At the 1-year postoperative follow-up, an additional CT-angiography was performed and independently examined by two radiologists. The radiological assessment of the ligation level was compared to registry data, using different measures of agreement.ResultsA total of 94 patients were included, 55 (59%) were men and 39 (41%) women. All patients underwent abdominal resection: conventional or robot-assisted laparoscopic surgery, n=56 (60%), or open resection, n=38 (40%). The ligation level as assessed on CT-angiography was high in 29 (31%) patients and low in 65 (69%). The registered level of ligation of the IMA and the radiological assessment of the CT-angiographies were consistent in 77/94 cases, demonstrating an 82% agreement and a sensitivity and specificity of 86% and 72%, respectively. The estimated Kappa value was 0.58, reaching 0.64 after prevalence bias adjustment.ConclusionThis study showed that CT-angiography can be used to evaluate the reliability of the registered ligation level in the Swedish Colorectal Cancer Registry. The demonstrated agreement between the registry and postoperative CT-angiography was moderate to good. This discrepancy impacts registry-based research using IMA ligation data and may ultimately influence surgical practice.Trial registrationClinical Trials identifier NCT03875612

Novel Genetic Variant Predicts Surgical Recurrence Risk in Crohn's Disease Patients.

We aimed to identify a model of clinical and genetic risk factors through hypothesis-free search across genome that can predict the surgical recurrence risk after the first abdominal surgery in CD patients. Two independent inflammatory bowel disease (IBD) cohort studies were used to derive and validate the genetic risk profile. The study subjects were genotyped using Illumina Immunochip custom genotyping array. Surgical recurrence was defined as having the second or more abdominal bowel resections after the first abdominal surgery at the time of study enrollment; nonsurgical recurrence was defined as having no further abdominal resection after the first abdominal surgery. Among 372 CD patients who had at least 1 abdominal surgery at the study enrollment, 132 (35.5%) had subsequent surgical recurrence after their first abdominal surgery, and 240 (64.5%) required no subsequent abdominal surgery at the end of follow up. Among clinical factors, multivariable analysis showed that history of immunomodulatory use (odds ratio [OR], 3.96; P = 0.002) and early era of CD first surgery (OR, 1.12; P = 1.01E-04) remained significant. Genotypic association tests identified a genome-wide significant locus rs2060886 in TCF4 at chr18q21.2 associated with surgical recurrence risk (OR, dom, 4.10 [2.37-7.11]; P = 4.58E-08). Novel genetic locus rs2060886 in TCF4 was associated with surgical recurrence risk at genome-wide significance level among CD patients after their first abdominal surgery. Early era of CD first intestinal surgery predicts higher surgical recurrence risk. These results suggest that genetic variants may help guide the CD management strategy in patients at the highest risk of repeated abdominal surgeries.

Myomectomy scar pregnancy ‒ a serious, but scarcely reported entity: literature review and an instructive case

Abstract Objectives Uterine myomas are a frequent finding in reproductive age women with an estimated incidence 12–25%. 1. Treatment of uterine myomas to facilitate good pregnancy rates and outcome, such as hysteroscopic, laparoscopic, abdominal resection uterine artery embolization among others were evaluated in terms of pregnancy outcome. While the literature is replete of the pregnancy complication of uterine rupture after myomectomies, 2–4 there are very few publications evaluate a relatively rare pregnancy complication associated with placental implantation within the uterine cavity at the site of the previous myomectomy, namely the myomectomy scar pregnancy (MSP). Despite their relative rarity, this type of pathologically adherent placenta rightfully belongs to the well-known entity of placenta accreta spectrum (PAS). Case presentation We present a complicated case of MSP and review the available literature to raise attention to its clinical appearance, its prenatal diagnosis so appropriate intrapartum management can be planned. Conclusions Despite the rarity of MSP, continuous attention should be given at every single routinely scheduled or indication driven obstetrical US scan following myomectomies to evaluate the placental site implantation regardless of the route and technique of their initial surgical procedure.