Pelvic Cancer Surgery Research Articles

Postoperative venous thromboembolism risk stratification in patients with uterine cancer

Gynecologic cancers are associated with a high risk of venous thromboembolism (VTE). Recent ASCO clinical practice guidelines have recommended all patients undergoing pelvic surgery for cancer, including minimally invasive surgery (MIS), receive 7–10 days of pharmacologic thromboprophylaxis, extended up to 4 weeks for high-risk patients. High risk is not well defined in the guidelines. The Caprini and Khorana score are VTE risk assessment tools that have been clinically validated in other populations but not in patients with uterine cancer.

Multiquadrant Robotic Assisted Primary Cytoreduction for Stage III C Ovarian Cancer Part II Modified Posterior Exenteration

<h3>Study Objective</h3> To demonstrate Part II of multi-quadrant robotic assisted pelvic primary cytoreductive surgery for Stage IIIC epithelial ovarian cancer. <h3>Design</h3> A prospective single patient underwent robotic assisted cytoreductive surgery. Docking time for pelvic and abdominal dissection was recorded. The multiple procedures that patient underwent was recorded for operative time along with intraoperative complications and postoperative complication, estimated blood loss, and length of hospitalization. <h3>Setting</h3> Tertiary hospital. <h3>Patients or Participants</h3> Patient is a 56-year-old female presents with abdominal pain. CT scan showed no ascites soft tissue mass in the right hepatic gutter omental mass with minimal pelvic fluid and pelvic mass. CA 125 was 533. <h3>Interventions</h3> Robotic Xi. <h3>Measurements and Main Results</h3> The abdominal docking time was 2 minutes and 30 seconds. The pelvic docking time which was the time from de-docking after completion of abdominal dissection to rotating the boom to re-docking for pelvic dissection was 5 minutes and 30 seconds. Total operative time for both pelvic and abdominal dissection was 246 minutes. The operative time for right diaphragm peritonectomy 30 minutes and resection of omental caking with complete omentectomy was 68 minutes. The pelvic dissection which consisted of en bloc modified posterior exenteration procedure with total intracorporal sigmoid rectal anastomosis was 126 minutes. A complete cytoreductive surgery with no gross residual was achieved. EBL 200 cc and length of hospitalization was 4 days. There was no intraoperative or postoperative complication. <h3>Conclusion</h3> Robotic assisted multi-quadrant surgery is feasible to achieve upper abdominal, abdominal and pelvic procedures to achieve an optimal cytoreductive surgery for stage IIIc ovarian cancer.

Validación de los modelos de impresión 3D paciente-específicos para cirugía ortopédica oncológica pélvica

IntroductionPelvic ring tumors pose a challenge due to the difficulty in obtaining adequate surgical margins. Tools such as surgical navigation or 3D printing for the fabrication of patient-specific surgical positioning templates help in preoperative planning and intraoperative execution. Their correct positioning is essential in complex locations such as the pelvis, so it is necessary to identify positioning errors. The aim of this study is to demonstrate the reliability of 3D template placement for pelvic ring osteotomies. Material and methodsExperimental study in cadaver with 10 hemipelvis. CT was performed to obtain the three-dimensional model, planning of osteotomies, design of positioning templates in ischiopubic (I), iliopubic (P), supracetabular (S) and iliac crest (C) branches; and a positioning marker (rigid-body) on the C and S templates for navigation. The templates and rigid-body are 3D printed and positioned according to pre-planning. Navigation allows the final position of the inserts and osteotomies to be checked. ResultsThe positioning of the templates with respect to the preoperative planning varied depending on the location, being greater the error in those of the iliac crest. Using navigation the mean error of distance to the cutting plane is 3.5mm, except in pubis (5-8mm), being conditioned by the position of the rigid body. ConclusionThe use of patient-specific templates printed in 3D is a reliable tool for performing osteotomies in pelvic cancer surgery.

Surgical management of recto-vaginal fistula (about 6 cases).

IntroductionRecto-vaginal fistula (RVF) is defined as a pathological epithelialized communication between the posterior wall of the vagina and the anterior wall of the rectum through the recto-vaginal septum. RVFs are rare and represent less than 5% of rectal fistulas. Occurring after childbirth or during a proctological pathology, they create a deep distress for the patients. The aim of our work is to analyze the epidemiological particularities and the risk factors of occurrence of RVF as well as the modalities and results of our therapeutic management.Materials and methodsOur work is retrospective analytic and comparative concerning 6 cases operated in the department of general surgery 3 of the UHC Ibn Rochd of Casablanca for recto vaginal fistula or recidive over a period of 7 years from 2012 to 2018.ResultsThe analysis of the results of our study allowed us to note: A frequency of occurrence of RVF of about 0.48%. The average age at diagnosis was 55 in our patients. The etiologies were dominated by post-radiation (33.33%) and post-operative (16.66%) RVFs. The predominant mode of delivery in our study was vaginal delivery (83.33%). The antecedents were dominated by pelvic irradiation in 50% of patients, and pelvic surgery for cervical cancer and/or rectal cancer (50%). The diagnosis was revealed by a vaginal stool output in all patients. Surgical treatment was performed in all our patients. The surgical technique of choice in our series was drainage by Stenon, in 83.33% of patients. A protective stoma was performed in all our patients studied, a colostomy in 66.66%, and an ileostomy in 33.33% of patients. The immediate postoperative evolution was excellent in all our patients, while the short- and medium-term evolution revealed the occurrence of recurrence in one third of the patients (33.33%). The treatment of choice for recurrence was the interposition of a pedicled fat flap of the labia majora, known as the modified Martius technique. The morbidity, represented mainly by recurrence, was 25%, with a mortality rate of 0%.DiscussionThe occurrence of RVF in all its etiologies seems to be infrequent. However, its real incidence remains poorly documented in the literature, it varies between 0.3% and 15.3%. RVFs are considered simple or complex depending on their size, location and etiology. The high or low location and the etiology of the RVF determine the choice of the approach during surgical management. The diagnosis is most often clinical. The examination will try to find the cause of the RVF and the associated lesions. RVF can be asymptomatic. The importance of the symptoms depends on the topography of the fistula, the diameter of the orifice, and the quality of the intestinal transit. No additional investigations are required to confirm the diagnosis of RVF, since the positive diagnosis is essentially clinical. However, in the case of a high or complex fistula, the clinician can support his or her pre-therapeutic assessment with the exploration of imaging data, especially those of the digestive opacification, MRI and pelvic CT. The causes of RVFs are multiple. However, their proportions are difficult to establish. Post-obstetrical RVFs, those due to Crohn's disease, and post-op are probably the most frequent. The literature describes a variety of surgical approaches and treatment options for RVF. However, there are no treatment recommendations. The available data are vague and do not define an optimal treatment. Medical treatment with antibiotics and sitz baths is often necessary to control the local infection. The surgical management of RVFs is complex and follows several principles. The therapeutic arsenal is very varied and constitutes a real “escalation”, ranging from simple drainage by suture to the radical treatment represented by abdominal-pelvic amputation. The results of the treatment of simple VF are excellent in all studies. The healing rate varies from 75 to 100% depending on the authors.ConclusionThe results of this study confirm the low incidence of RVF, and show that vaginal delivery and a history of pelvic surgery (for rectal or cervical cancer) are the most frequent predictors of RVF. Thus, from a therapeutic point of view, medical treatment is always required, it allows the flow of the fistula to be reduced, which facilitates preparation for the surgical procedure.

Accelerated Recovery Protocol in Extended Combined and Single-Stage Surgery for Pelvic Cancer

Introduction. The study aimed to evaluate a routine accelerated recovery management in patients with extended combined pelvic surgery.Materials and methods. We surveyed the records and outcomes in various oncological patients following the accelerated recovery protocol after a routine extended combined pelvic surgery at the Moscow City Oncology Hospital No. 1 during 2018–2020.Results and discussion. Locally advanced tumours comprised 37 (75.5 %) cases, and the remaining 12 (24.5 %) were nonpelvic resections due to metastasis. Radical surgery was achieved in 41 (83.7 %) cases, while the other 8 (16.3 %) were symptomatic due to the emerged complications of intestinal permeability disruption, bleeding, urinary obstruction, paracancrotic abscess, internal fistulae or pain syndrome. Postoperative complications were evaluated in the Clavien-Dindo classification.Conclusion. The results obtained suggest the feasibility of an accelerated recovery protocol-based practice in extended combined pelvic surgery.

Anatomy research on Denonvilliers fascia and its significance in nerve-preservation rectal cancer surgery

Urinary and sexual dysfunctions due to intraoperative pelvic autonomic nerve injury have become the most common complications of rectal cancer surgery, seriously affecting postoperative quality of life. How to protect the nerve and urogenital function while ensuring radical resection for rectal cancer has become the focus of research. We previously carried out a series of systematic studies on Denonvilliers fascia, an important anatomical structure closely related to protection of pelvic autonomic nerve, and demonstrated the importance of Denonvilliers fascia in preservation of intraoperative pelvic autonomic nerve and protection of postoperative urogenital function from aspects of anatomy, physiology, tissue, operation practice and so on. Meanwhile, based on the interim results of our multicenter randomized controlled study, we confirmed that total mesorectal excision with preservation of Denonvilliers fascia (innovative TME, iTME) could effectively reduce the incidence of postoperative urinary and sexual dysfunctions in male patients with mid-low rectal cancer, without sacrificing oncologic outcome. In this article, combined with our research results, we review the literature on anatomy research progress of Denonvilliers fascia to demonstrate the significance and research prospect of Denonvilliers fascia in the pelvic autonomic nerve preservation surgery for rectal cancer.

Laparoscopic assessment improves case selection for exenterative surgery in recurrent cervical and endometrial cancer

The objective of this study is to evaluate the role of laparoscopy in the case selection of patients for pelvic exenteration to treat recurrent cervical or endometrial cancer. Pelvic exenteration is a rare surgical procedure performed by specialised multidisciplinary surgical teams. We performed a review of 55 consecutive laparoscopies for patients being evaluated for possible exenterative surgery for recurrent cervical or endometrial cancer at a single centre in the UK with a significant exenterative surgical practice. All patients had no evidence of metastatic disease on imaging prior to the laparoscopy. Despite thorough radiological assessment laparoscopy detected peritoneal, nodal or extrapelvic metastases in 20.8% of cases. 5.6% of the patients who underwent exenterative surgery were found to have unresectable pelvic disease intraoperatively. In these cases, the extent of disease was not determined radiologically or during the initial exploratory laparotomy. In our view, laparoscopic assessment is an essential component of the pre-operative work up of patients with recurrent cervical or endometrial cancer being considered for exenterative surgery. Impact statement What is already known on this subject? Pelvic exenteration is potentially curative in cases of recurrent pelvic malignancy. Case selection is essential to determine those patients without metastases and with resectable pelvic disease – this will improve patient outcomes, avoid the unnecessary morbidity of major surgery, as well as the psychological consequences of abandoned procedures. The only two previous studies, published in 1998 (Plante and Roy 1998) and 2002 (Köhler et al. 2002) have shown laparoscopic assessment to be safe and improve case selection. What do the results of this study add? This study provides evidence that in the context of modern imaging modalities, including PET-CT scans, laparoscopic assessment continues to improve case selection for exenterative surgery. What are the implications of these findings for clinical practice and/or further research? This study provides further evidence of the benefit of laparoscopy in the assessment of patients being considered for exenterative surgery for recurrent pelvic cancer. Routine laparoscopy improves case selection and will enhance patient experiences and outcomes.

Sexual and functional long-term outcomes following advanced pelvic cancer and reconstruction using vertical rectus abdominis myocutaneous and gluteal myocutaneous flap

IntroductionAfter extensive pelvic surgery for cancer two flap types are used at Skåne University Hospital (SUS), Sweden for perineal reconstruction: vertical rectus abdominis myocutaneous flap and gluteal flap with or without vaginal reconstruction. The objective was to study the long-term outcomes in patients treated for advanced pelvic cancer receiving a flap. MethodPatients with pelvic cancer subjected to surgery including perineal reconstruction between January 2010 and August 2016 at SUS were included retrospectively. Participating patients were scheduled for an out-patient visit. Questionnaires addressing quality of life, (QLQ-C30 and EQ-5D) and sexual function (FSFI and IIEF) were filled in. Sensitivity test, using monofilaments on the gluteal/posterior thigh area, neovaginal measurements using silicon gauges and muscular functionality tests (timed stands test and stairs test) were performed. ResultsThirty-six (24 women, 12 males) out of 71 invited patients conceded participation. Patients scored a median of 85/100 regarding global health using EQ-5D. All women reported sexual dysfunction and 75% (9/12) of men reported severe erectile dysfunction. Neovaginal measurements showed adequate reconstructions. Sensitivity test implied decreased sensitivity on the operated side compared to the unoperated side in patients with gluteal flap. Both physical tests demonstrated adequate muscular functionality in everyday life activities after reconstructions using gluteal flap. ConclusionThis long-term follow up after extensive surgery treating pelvic cancer with perineal flap reconstruction implies high quality of life, good muscular functionality and adequate neovaginal measurements. However sexual function is impaired among both sexes and sensitivity in the surgical area of the gluteal flap is decreased.

Combined laparoscopic and transperineal endoscopic total pelvic exenteration for local recurrence of rectal cancer.

Transanal minimally invasive surgery is a combination of single-port surgery and transanal surgery and was initially developed as a treatment for rectal tumors. Recently, this approach has also been used for more advanced or extended pelvic surgery. We present a surgical video of combined laparoscopic and transperineal endoscopic total pelvic exenteration performed in a male patient with recurrent rectal cancer and discuss the pros and cons of this approach. The operating time was 775min and the operative blood loss was 485ml. The pathology was recurrent adenocarcinoma invading the prostate and urethra with negative surgical margins. The postoperative course was uneventful except for a urinary tract infection that was treated with antibiotics. The transanal/perineal endoscopic approach may have some benefits for extended pelvic surgery for recurrent rectal cancer.

EDITORIAL COMMENT

The authors have conducted informative and important health services research on the “trends in extended-duration pharmacological prophylaxis (EDPP) to prevent venous thromboembolism (VTE) following radical cystectomy (RC)” using the national administrative claims database for the period 2012-2017. 1 URL-D-19-01447R1. 2019. Google Scholar Allowing for limitations of methodology using such databases, it was notable that a low proportion (19%) of cases received EDPP overall in the study period. Encouragingly, there was an improving time-trend from 9% utilization in 2012 to 26% in 2017. However, given that VTE following radical abdominal and/or pelvic surgery for cancer is a major cause of morbidity, mortality and cost, the findings of the current study portray an unfavorable picture for the current state of clinical practice with respect to EDPP utilization. Indeed, provided there are no contraindications, most international and/or national guidelines recommend the use of EDPP in this setting for high-risk cases. 2 Tikkinen KAO Craigie S Agarwal A et al. Procedure-specific risks of thrombosis and bleeding in urological cancer surgery: systematic review and meta-analysis. Eur Urol. 2018; 73: 242-251 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar ,3 Key NS Bohlke K Falanga A Venous thromboembolism Prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update summary. J Oncol Practice. 2019; (Jop1900368) Crossref PubMed Scopus (19) Google Scholar The AUA Best Practice Statement from 2008 highlights the importance of thromboprophylaxis following RC, amongst other urological procedures, but falls short of touching upon the subject of EDPP in that context. 4 Forrest JB Clemens JQ Finamore P et al. AUA best practice statement for the prevention of deep vein thrombosis in patients undergoing urologic surgery. J Urol. 2009; 181: 1170-1177 Crossref PubMed Scopus (90) Google Scholar However, the evidence is accumulating to issue clear guidelines in support of EDPP, particularly as over 50% of symptomatic VTEs occur after discharge from hospital. 5 Sagalovich D Say R Kaouk J Mehrazin R The role of extended venous thromboembolism prophylaxis following urologic pelvic surgery. Urol Oncol. 2018; 36: 83-87 Crossref PubMed Scopus (5) Google Scholar , 6 VanDlac AA Cowan NG Chen Y et al. Timing, incidence and risk factors for venous thromboembolism in patients undergoing radical cystectomy for malignancy: a case for extended duration pharmacological prophylaxis. J Urol. 2014; 191: 943-947 Crossref PubMed Scopus (76) Google Scholar , 7 Kukreja JE Levey HR Scosyrev E et al. Effectiveness and safety of extended-duration prophylaxis for venous thromboembolism in major urologic oncology surgery. Urol Oncol. 2015; 33 (387.e387-316) Crossref PubMed Scopus (35) Google Scholar Lower compliance to EDPP use may in part be due to underappreciation of the risks in the absence of clear guidelines. 8 Sterious S Simhan J Uzzo RG et al. Familiarity and self-reported compliance with american urological association best practice recommendations for use of thromboembolic prophylaxis among american urological association Members. J Urol. 2013; 190: 992-998 Crossref PubMed Scopus (40) Google Scholar By highlighting the current trends in EDPP utilization after RC, the current study provides opportunities to look more closely into this issue and update the guidelines in relation to EDPP use following major urological oncological surgery, including RC.

The predictive role of thrombocytosis in benign, borderline and malignant ovarian tumors

Ovarian cancer is a lethal gynecological malignancy. Although CA-125 is commonly measured in women with adnexal mass, it is estimated that it only has a positive predictive value (PPV) of 69% and a negative predictive value (NPV) of 88% for the detection of ovarian cancer. The aim of this study was to investigate the diagnostic significance and predictive impact of thrombocytosis in women with suspected or confirmed ovarian cancer. This was a retrospective study of women who had surgery for adnexal mass over a 48-month period between September 2014 and September 2018 at Swansea Gynecological Oncology Center in Wales, UK. A total of 294 women who underwent surgery for high-risk pelvic mass or biopsy-confirmed ovarian cancer were identified. 206 women (70%) had final histology confirming ovarian cancer, 54 women (18%) had benign tumors while 34 women (12%) had borderline tumors. 90/206 women (43.7%) with ovarian cancer had thrombocytosis prior to primary surgery or neoadjuvant chemotherapy compared to 8/54 (14.8%) for benign tumors and 4/34 (11.8%) for borderline tumors. Thrombocytosis was observed in 23.2%, 40%, 45.1%, and 65.1% of Stages I, II, III, and IV ovarian cancer, respectively. Thrombocytosis was a stronger predictor of ovarian malignancy in younger women of less than 60 years (p = .041). Overall, the positive likelihood ratio of platelet count in the detection of ovarian cancer was 2.61 while the negative likelihood ratio was 0.72, with a diagnostic odds ratio of 3.625. Thrombocytosis was strongly associated with advanced stage ovarian cancer (Stage III/IV) (p = .002). Interestingly, 4/8 (50%) women with thrombocytosis in the benign ovarian tumor group were diagnosed with ovarian fibroma/fibrothecoma, which often mimics advanced ovarian cancer at presentation. Predictive markers for borderline tumors continue to remain a challenge. We believe that there is a role for platelet count in primary care algorithm for women with suspected ovarian cancer. We suspect that platelets play a role in the metastasis of ovarian cancer.

Incidence of delayed venous thromboembolic events in patients undergoing abdominal and pelvic surgery for cancer: a systematic review and meta-analysis.

Incidence of venous thromboembolism (VTE) following discharge for abdominal cancer surgery is uncertain. We searched MEDLINE and Embase for studies evaluating the incidence of VTE at 3 months from surgery. Studies indicating use of post-hospital VTE prophylaxis were excluded. Two independent reviewers performed study selection, data abstraction and risk of bias. Random-effects model was used to estimate pooled incidence, and weights were estimated using inverse variance method. Statistical heterogeneity was explored via subgroup analysis. Of 4215 abstracts retrieved, 11 reported the incidence of VTE at 3 months. There were three randomized trials (n = 520), one prospective cohort study (n = 284) and seven retrospective cohort studies (n = 65 308). VTE incidence among prospective studies was 9.6% (95% confidence interval (CI) 2.9-16.4), while for retrospective studies was 2.2% (95% CI 1.4-3.0). Heterogeneity was high (I2 = 92% and 81%, respectively). The incidence of symptomatic VTE was 1.3% (95% CI 0.4-2.3) for prospective studies. VTE was diagnosed by screening venography in most of the prospective studies, whereas retrospective studies did not use a screening method. Subgroup analysis based on the type of organ surgery performed explained the heterogeneity. VTE incidence following abdominal cancer surgery varies greatly depending on the study type, with differences largely explained by the method of assessment of VTE. The fact that VTE incidence among retrospective studies was closer to the incidence of symptomatic events (non-screen detected) in the prospective studies, suggests that the screened events were mostly asymptomatic and their clinical significance is unclear.

Extended venous thromboembolism prophylaxis after abdominopelvic cancer surgery: a retrospective review.

Extended prophylaxis against venous thromboembolism (vte) after abdominal or pelvic cancer surgery with low molecular weight heparin (lmwh) is recommended by multiple guidelines. The primary objective of the present study was to assess adherence to that guideline recommendation at tertiary care centres within Hamilton Health Sciences (hhs). Given that an estimated 70% of the study population would be expected to receive extended prophylaxis, a sample size of 105 patients was calculated. Patients who had undergone abdominal or pelvic surgery for cancer from March 2012 to December 2015 were identified, and data were collected from electronic health records. The primary outcome was prescription of extended vte prophylaxis. Of 105 patients, only 3 received extended vte prophylaxis. Those 3 patients had serous carcinoma of the uterus, transitional cell carcinoma of the bladder, and cecal cancer. Of the 3 patients, 2 were followed by the thrombosis service while in hospital; none of the other 102 patients received any form of extended vte prophylaxis. Based on multiple randomized controlled trials, guidelines suggest lmwh prophylaxis for up to 4 weeks after major abdominal or pelvic cancer surgery. Despite those recommendations, postoperative extended vte prophylaxis is not commonly prescribed at hhs facilities. Next steps will include identification of barriers and an examination of how those barriers could be addressed. Failure to use prophylaxis is not consistent with evidence-based guidelines and is placing patients at risk of vte.

Pelvic Exenterations for Cervical Cancer Recurrences—a Safe Option in Indian Scenario

Cervical cancer is still a major health problem in India with majority of patients presenting with locally advanced stages. Management of local recurrences of cervical cancer after chemoradiation is a challenging task. Pelvic exenteration is a radical surgery with en bloc resection of pelvic organs is an accepted treatment modality for local recurrence of cervical cancer. In a low-resource country like India where alternate treatment modalities like chemotherapy and targeted therapy are unaffordable to these patients, this radical surgery may be the only treatment modality which gives long-term survival benefit. The aim of the study is to evaluate the morbidity and survival outcome following pelvic exenteration in patients with recurrent cervical cancer in our institution. After obtaining institutional review board approval, a retrospective audit was conducted of all patients who underwent pelvic exenterative surgery for recurrent cervical cancer in our institution from January 2007 to December 2017. The parameters assessed were age of the patient, histologic type and grade, stage of disease, surgical procedures performed, type of reconstruction, intra-operative complications, length of hospital stay, and post-operative morbidity. Patients were followed until March 2017. Survival time was calculated from the date of surgery to the date of last contact or death. Survival estimation was done by Kaplan-Meier method. Between 2007 and 2017, 30 patients underwent the surgery. Mean age of the cohort was 50.9 years (range 33–67 years). Histological type was squamous cell carcinoma in 23 and adenocarcinoma in 7 patients. Twelve patients had anterior exenteration, one had posterior and 17 had total exenteration. The mean operating time was 367.3 min (210–600 min). No post-operative mortality was observed. Post-operative complications were seen in 66.6% of which the most common was of the urinary tract including 4 patients with recurrent urosepsis, one patient with obstructive uropathy and acute renal failure necessitating laparotomy and ureteric reimplantation. Two patients developed fistulae, one urinary and one bowel. Median follow-up time was 27.5 months (1.8–99.1 months). A five-year overall survival for the cohort was 60.5%. It is suggested that pelvic exenteration is an effective technique with reasonable long-term survival benefit and acceptable morbidity in selected patients with cervical cancer recurrence.

Risk factors for post-discharge venous thromboembolism in patients undergoing colorectal resection: a NSQIP analysis.

Extended thromboprophylaxis after abdominal and pelvic cancer surgery to prevent venous thromboembolic events (VTE) is recommended but adherence is sub-optimal. Identifying patients at highest risk for post-discharge events may allow for selective extended thromboprophylaxis. The aim of our study was to identify the different risk factors of venous thromboembolism for in-hospital and post-discharge events. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2012-2016 database was queried for all patients having colorectal resection. Primary outcome was postoperative VTE occurrence within 30 days. A multinomial logistic regression was performed to identify in-hospital and post-discharge predictors of VTE, adjusting for potential confounders. Out of 260,258 patients, 5381 (2.1%) developed VTE. A total of 3442 (1.3%) were diagnosed during the initial hospital stay and 1929 (0.8%) post-discharge. Risk factors for in-hospital and post-discharge VTE were different as patients with an in-hospital event were more likely to be older, male, known for preoperative steroid use, have poor functional status, significant weight loss, preoperative sepsis, prolonged operative time, undergoing an emergency operation. In the post-discharge setting, steroid use, poor functional status, preoperative sepsis, and postoperative complications remained significant. Postoperative complications were the strongest predictor of in-hospital and post-discharge VTE. Patients with inflammatory bowel disease had a higher risk of VTE than patients with malignancy for both in-patient and post-discharge events. Patients at high-risk for post-discharge events have different characteristics than those who develop VTE in-hospital. Identifying this specific subset of patients at highest risk for post-discharge VTE may allow for the selective use of prolonged thromboprophylaxis.

Concurrent pelvic reconstruction and minimally invasive pelvic cancer surgery.

We present our experience in performing concurrent prolpase repair at the time of gynecologic cancer surgery. The uterosacral ligaments are tagged before performing hysterectomy and pelvic dissection. The uterosacral ligament suspensory sutures are then placed laparoscopically after completion of pelvic cancer surgery. The remainder of the prolapse surgery is performed through a transvaginal approach. Many of our patients who undergo concurrent prolapse repair and gynecolgical cancer surgery receive chemotherapy and pelivc radiation. Concuurent prolapse repair improves their prolaspe symptoms. Concurrent prolapse repair should be performed at the same time as gynecologic cancer surgery.

A qualitative study of the development of a multidisciplinary case conference review methodology to reduce involved margins in pelvic exenteration surgery for recurrent rectal cancer

Pelvic exenteration surgery remains the only curative option for recurrent rectal cancer. Microscopically involved surgical margins (R1) are associated with a higher risk of local recurrence and decreased survival. Our study aimed to develop a post hoc multidisciplinary case conference review and investigate its potential for identifying areas for improvement. Patients who underwent pelvic exenteration surgery for recurrent rectal cancer with R1 resections at a tertiary referral centre between April 2014 and January 2016 were retrospectively reviewed from a prospectively maintained database. Patients with non-rectal cancers or who underwent palliative surgery were excluded. Cases, imaging and histopathology were evaluated by a dedicated panel including colorectal surgeons, an abdominal radiologist and a gastrointestinal pathologist. R1 resections were reported in 32 of 110 pelvic exenterations. Patients with other tumours were excluded and one patient had a palliative resection. Nine male patients with 11 exenterations were included with a median age of 56 years. All patients had positive soft tissue margins, and one patient also had an involved bony margin. Failures were due to (interdisciplinary) communication problems, specific management of tumour biology (multifocality, spiculated tumours), which can lead to radiological undercalling, and inadequate surgical technical planning. In hindsight, surgery would have been withheld from one patient. A retrospective multidisciplinary case evaluation of pelvic exenteration patients with involved surgical margins led to a list of recommendations which included the need to plan for wider surgical soft tissue resections and improvement in interdisciplinary communication. Lessons learned may increase clear margin rates in future resections.

CORR Insights®: Can Augmented Reality Be Helpful in Pelvic Bone Cancer Surgery? An In Vitro Study.

CORR Insights®: Can Augmented Reality Be Helpful in Pelvic Bone Cancer Surgery? An In Vitro Study.

Tu1576 - Incidence of Delayed Venous Thromboembolic Events in Patients Undergoing Abdominal and Pelvic Surgery for Cancer, a Systematic Review

Tu1576 - Incidence of Delayed Venous Thromboembolic Events in Patients Undergoing Abdominal and Pelvic Surgery for Cancer, a Systematic Review

Can Augmented Reality Be Helpful in Pelvic Bone Cancer Surgery? An In Vitro Study.

Application of surgical navigation for pelvic bone cancer surgery may prove useful, but in addition to the fact that research supporting its adoption remains relatively preliminary, the actual navigation devices are physically large, occupying considerable space in already crowded operating rooms. To address this issue, we developed and tested a navigation system for pelvic bone cancer surgery assimilating augmented reality (AR) technology to simplify the system by embedding the navigation software into a tablet personal computer (PC). Using simulated tumors and resections in a pig pelvic model, we asked: Can AR-assisted resection reduce errors in terms of planned bone cuts and improve ability to achieve the planned margin around a tumor in pelvic bone cancer surgery? We developed an AR-based navigation system for pelvic bone tumor surgery, which could be operated on a tablet PC. We created 36 bone tumor models for simulation of tumor resection in pig pelves and assigned 18 each to the AR-assisted resection group and conventional resection group. To simulate a bone tumor, bone cement was inserted into the acetabular dome of the pig pelvis. Tumor resection was simulated in two scenarios. The first was AR-assisted resection by an orthopaedic resident and the second was resection using conventional methods by an orthopaedic oncologist. For both groups, resection was planned with a 1-cm safety margin around the bone cement. Resection margins were evaluated by an independent orthopaedic surgeon who was blinded as to the type of resection. All specimens were sectioned twice: first through a plane parallel to the medial wall of the acetabulum and second through a plane perpendicular to the first. The distance from the resection margin to the bone cement was measured at four different locations for each plane. The largest of the four errors on a plane was adopted for evaluation. Therefore, each specimen had two values of error, which were collected from two perpendicular planes. The resection errors were classified into four grades: ≤ 3 mm; 3 to 6 mm; 6 to 9 mm; and > 9 mm or any tumor violation. Student's t-test was used for statistical comparison of the mean resection errors of the two groups. The mean of 36 resection errors of 18 pelves in the AR-assisted resection group was 1.59 mm (SD, 4.13 mm; 95% confidence interval [CI], 0.24-2.94 mm) and the mean error of the conventional resection group was 4.55 mm (SD, 9.7 mm; 95% CI, 1.38-7.72 mm; p < 0.001). All specimens in the AR-assisted resection group had errors < 6 mm, whereas 78% (28 of 36) of errors in the conventional group were < 6 mm. In this in vitro simulated tumor model, we demonstrated that AR assistance could help to achieve the planned margin. Our model was designed as a proof of concept; although our findings do not justify a clinical trial in humans, they do support continued investigation of this system in a live animal model, which will be our next experiment. The AR-based navigation system provides additional information of the tumor extent and may help surgeons during pelvic bone cancer surgery without the need for more complex and cumbersome conventional navigation systems.