Sacral Approach Research Articles

Early Outcomes of the Surgical Treatment of Sacrococcygeal Tumors in a Tertiary Level Government Hospital.

Sacrococcygeal teratomas (SCT) are the most common extragonadal tumors of early childhood. Their clinical characteristics and outcomes of patients with sacrococcygeal tumors who underwent excision in the Philippines has never been described, while numerous retrospective studies have been conducted in other countries. This was a retrospective, descriptive study over a four-year period (December 2014 to November 2018). The study described the patients' demographic data, manner of delivery, clinical presentation, prenatal diagnosis of tumor, Altman classification, and alpha fetoprotein levels. These information were obtained from the medical records of the patients. Additional data from the operative technique include the surgical approach, size of the mass, and gross involvement of adjacent structures and the final histopathologic results. Outcomes include the 30-day mortality and morbidity, and tumor recurrence. A total of 29 patients were included in the study with 22 females (75.86%) and seven males (24.14%). Twenty-five out of the 29 (86.21%) had a sacral or gluteal mass at birth while other presenting factors include a palpable abdominal mass (1), constipation (1), difficulty in urination (1), and an elevated AFP in one postoperative patient. Even if 27 out of the 29 patients underwent a maternal ultrasound, only three patients (10.34%) had a correct ultrasound interpretation of sacrococcygeal teratoma. Age at presentation was problematic, with 12 presenting at greater than one year of age while 10 were brought for consultation at greater than one month old. Only seven presented at the neonatal period. CT scan was the most common imaging tool utilized (37.93%), followed by ultrasound (27.59%). AFP was elevated in ten patients (34.48%). Six of the patients with elevated AFP had mature teratoma, two had yolk sac tumor, one had fibroepithelial polyp, and one was post chemotherapy but had mature teratoma based on the final histopathology report. Fifteen out of the 29 patients had Altman type I tumors (51.72%), seven (24.14%) had type II tumors, six (20.69%) had type III tumors, and only one patient had type IV tumor. Sacral approach in the excision of the sacrococcygeal tumor was performed in 25 patients (86.21%). There was no reported perioperative mortality for patients who underwent surgery for SCT during the study period. Twelve out of the 29 had postop morbidities, three with surgical site infection and three with rectal or vaginal perforation. Five patients had tumor recurrence occurring from two months to three years postoperatively. Early detection of sacrococcygeal teratomas even in the prenatal period is the norm in certain areas of the world, but in our country, prenatal detection is still a challenge. Even if the majority of the patients presented with a gluteal mass at birth, less than a third were brought to our tertiary government hospital in neonatal life. The sacral approach for SCT excision was employed for the great majority of our patients, but due to the advanced age at diagnosis and locally advanced disease, morbidities occurred in about a third of the patients. Therefore, early detection prenatally and early referral to a pediatric surgical center should be achievable goals for physicians dealing with these patients.

Opioid-free recovery after laparoscopic-assisted redo pull-through and loop ileostomy via sacral and thoracic erector spinae plane blocks

Multi-modal analgesia with a reduction in perioperative opioid use has been a goal for many institutions due to the ongoing opioid epidemic. A reduction in opioid use can also limit undesirable side effects such as nausea, respiratory depression, and ileus in the perioperative and postoperative periods. In this case report, we describe a child who had excellent pain control for colorectal surgery after receiving a novel sacral erector spinae plane block (ESPB) along with bilateral thoracic ESPB's with sustained-release liposomal bupivacaine (Exparel). While there is ample literature describing the efficacy of thoracic and lumbar ESPB's for post-operative analgesia, there is a paucity of information regarding the sacral approach to the ESPB when combined with liposomal bupivacaine and its application to perineal, perianal, and colorectal surgery.

Deep infection following reconstruction of pelvic fractures: prevalence, characteristics, and predisposing risk factors

PurposeTo identify the incidence, risk factors, and treatment course of patients who developed deep infection following fixation of pelvic fractures.MethodsOver a period of 8 years patients who underwent pelvic reconstruction in our institution and developed postoperative infection were included. Exclusion criteria were pathological fractures and infections that were not secondary to post-traumatic reconstruction. The mean time of follow-up was 43.6 months (33–144). For comparison purposes, we randomly selected patients that underwent pelvic fracture fixation from our database (control group). A logistic regression was fitted to patient characteristics including age, sex, ISS, and diabetic status.ResultsOut of 858 patients, 18 (2.1%) (12 males), with a mean age of 41 (18–73) met the inclusion criteria. The control group consisted of 82 patients with a mean age of 41 years (18–72). The mean ISS was 27.7 and 17.6 in the infection and control group, respectively. The mean time from pelvic reconstruction to the diagnosis of infection was 20 days (7–80). The median number of trips to theatre was 3 (1–16). Methicillin-resistant Staphylococcus aureus (MRSA) was the most frequently isolated organism in the years prior to 2012. Eradication was achieved in 93% of the patients. The most important risk factors for deep infection were ISS (OR 1.08, 1.03–1.13), posterior sacral approach (OR 17.03, 1.49–194.40), and diabetes (OR 36.85, 3.54–383.70).ConclusionIn this retrospective case–control study, deep infection following pelvic trauma was rare. A number of patient-, injury- and surgery-related factors have shown strong correlation with this serious complication.

THE HISTORY OF THE RECTAL CANCER SURGERY

In 1826, Lisfranc practiced a perineal circular incision, without opening the peritoneum. 50 years later, Verneuil and then Dolbeau and Denonvilliers practiced more extensive resections. In 1907, Lockart-Mummery described the operation that bears his name. In 1875, Kocher and Volkmann used the sacral approach that has been popularized by Kraske. Later, it became well known in the whole world and, with some little changes, it has been used in Europe by Bardenhaver, Hochenegg, Billroth, Rehn, Heinike and Rygidier and in the USA by Harrison Cripps, Edwards, Bevan and Grey Turner. Almost all of them resected the rectum and reestablished the continuity with a primary anastomosis. It seems that Volkmann practiced the combined abdominal and perineal approach for the first time in 1877, followed by Czerny and Köenning. Between 1896-1899, Quenu popularized this technique. In 1908, Ernest Miles began to use the technique and in 1914 he published the results. The resection of the posterior wall of the vagina in a rectum cancer has first been made by Hildebrant in 1879. The abdominal approach has been used by Hartmann in 1923. In 1930, Dixon together with Mayo, Waugh, Black and Judd described the “Mayo clinic operation”, meaning the resection of the rectal tumor with extraperitoneal anastomosis. They called that “anterior resection” and in 1948 they published their 20 years’ experience results and they definitely popularized the technique.

Sacrococcygeal teratoma in children: Single center experience

Introduction: Sacrococcygeal teratoma (SCT) represent the most common benign and malignant germ cell tumors (GCT) in newborns and infants developing from primordial germ cells of the human embryo. Most of them are benign, however those presenting later in life and having major intra-pelvic component have greater malignant potential. Early and complete excision of the SCT has been the mainstay of successful management. The aim of this study is to describe the patient's details, management done, histopathology of the tumor, recurrence and the over all outcome of patients with SCT. Materials and Methods: Patients with histological diagnosis of sacrococcygeal teratoma during the period of January 2014 and October 2016 were included in this retrospective observational study. Data was collected regarding age, gender, mode of presentation, associated anomalies, Altman’s classification, investigations, treatment modality, tumor histology according to type of tumour with margin of resection, and outcome of management. All the diagnosed cases of SCT presenting during the above duration were included for study. Results: Twenty eight patients were included in the study. Out of them 75% were females and 25% were males. 32.14% presented during neonatal period. 78.57% presented with external mass. The tumour was completely resected by sacral approach in 22 patients and by combined abdominosacral approach in 06 patients. Recurrence was detected in one patients (3.57%); with Altman types 1 mature teratoma. Patients were followed for a duration ranged between 1 months and 3 years. Conclusion: Early diagnosis and early complete enblock excision of the tumor with the coccyx was mainstay of treatment with good prognosis. Late presentation and the presence of malignant changes are associated with poor prognosis. Intraoperative spillage of the tumor should be avoided. Overall survival of SCT is high. Keywords: Sacrococcygeal tumors, Germ cell tumor, Immature tissue.

Sacro-coccygeal Teratoma in a Child of 6 Months: A Case Report

Sacro-coccygeal teratoma (SCT) is a type of tumor which mostly occurs in newborn babies. The vast majority of this type of tumor is benign. That pathology can be diagnosed antenatally or at birth. Teratomas, especially those diagnosed in the neonatal period, occur most frequently in the sacrococcygeal region. Clinically in many cases, we can observe a large swelling (mass) in the sacrococcygeal region. In some cases, there are signs of compression following by the displacement of the rectum and pelvic organs. Alphafetoprotein is the main biological test used. In association morphologically by echography, CT-scan, MRI and others, the tumor is classified. The classification used is the topographical one of TSCs, which was proposed by Altman to the American Academy of Pediatric Surgery. The mainstay of therapy is the complete surgical removal. We present a case of a newborn (6 months), female, with teratoma sacro-coccygeal. At birth the baby was noticed to have large swelling (mass), without any sign of compression of others organs. Clinical and paraclinical signs permitted us to conclude of a SCT type II of Altman’s classification. A surgery was performed with a sacral approach. Histologically, tumors were classified into good (mature) category.

Sacrococcygeal teratoma type IV presenting with urine retention in infants

Abstract Background Sacrococcygeal teratoma (SCT) is the commonest tumor in neonatal period. The type IV variant is a concealed presacral tumor which presents a diagnostic challenge as symptoms are only apparent due to the mass effects of the tumor. A common presentation is urine retention. We herein present two cases of patients with type IV tumors who presented with acute urinary retention with the aim of highlighting the challenges in diagnosis of the concealed tumor which apart from its malignant potential has serious obstructive effects on the urinary tract that can lead to irreversible kidney damage. Case presentation We report two infants a 2 month old female and an 11 month old female who presented with acute urine retention. Both infants had been previously managed in peripheral facilities by urethral catheterization in an attempt to relieve the obstruction which remained persistent. On assessment at our facility both infants were noted to have a pre-sacral mass that was palpable on DRE and confirmed by CT scan. One infant had associated bilateral hydronephrosis from the obstructive effects of the mass on the urinary system. We used a combined abdominal and posterior sacral approach to resect the tumor in both patients with compete resolution of symptoms. Conclusion SCT type IV presents a diagnostic challenge to the clinician due to its less apparent nature. Patients may present with urologic anomalies due to bladder outlet obstruction and in cases in which diagnosis is delayed, hydronephrosis and renal parenchymal disease may be an associated finding. Clinical assessment in infants presenting with urine retention and constipation of unknown origin should always include a digital rectal examination with particular attention to the posterior rectal wall which can reveal a presacral mass.

Sacral chordoma: clinical experience of a series of 11 patients over 18years.

Sacral chordoma are rare low-to-intermediate grade malignant tumours that occur most commonly within the sacrum. Sacrectomy with wide resection margins seems to offer the best long-term prognosis. This study aims to review the management of sacral chordomas including the duration of symptoms, features, treatment, complications and local recurrence rate following surgery at a tertiary centre.We retrospectively reviewed 11 patients treated at our institution between years 1999 and 2015. Patient data included age, sex, history, radiographs, surgical details, onset of recurrence, subsequent treatment, disease-free survival and overall survival were analyzed. Nine patients underwent surgical management with 1 through a sacral approach and eight patients through a combined abdominosacral approach. Despite wide resection in our series, sacral chordoma poses a major problem with approximately 60% of patients having local recurrence in their follow-up.

Sacrococcygeal Teratoma in Children- Experience in a Tertiary Military Hospital

Introduction: Sacrococcygeal teratoma (SCT) is the most common solid tumour found in neonates. Most SCTs are reported in neonates and children, but SCTs are found in adults also. SCTs occur more commonly in females than males. If not detected antenatally, clinical features at birth are prominent in most cases as a palpable or visible mass. Surgery is the principal mode of treatment. The standard treatment for SCT with malignant elements is surgery and chemotherapy.
 Objective: To share the experience with sacrococcygeal teratoma, the most common tumour found in newborn in a tertiary military hospital.
 Materials and Methods: This observational study was carried out in the Department of Paediatric Surgery, CMH Dhaka during the period of January 2010 to December 2015. During the study period a total of 6 neonates with SCT were admitted in this hospital that were included in the study.
 Results: The age of the patients ranged from 3 days to 1 month. Out of them 5(83.33%) were female, 1(16.67%) was male with a female to male ratio of 5:1. Four neonates (66.67%) had type-I and 2(33.33%) had type II SCT. They were not diagnosed antenatally. All presented in neonatal period and were operated as elective cases. Five neonates (83.33%) were born by normal vaginal delivery and one (16.67%) was born by Caesarean section due to cervical dystocia. All patients had elevated alpha fetoprotein (AFP). Posterior sacral approach was sufficient in all the cases and histopathology revealed benign lesion. There was no perioperative death but 1 patient (16.67%) developed malignant recurrence within 1st year and 1 patient (16.67%) developed neurogenic bladder with bilateral hydronephrosis.
 Conclusion: SCTs are rare tumours that occur most frequently in neonates. Antenatal diagnosis is possible in many cases in this modern era. Follow up of cases after surgery should not only the look out for tumour recurrence, it includes the management of possible secondary urinary and/or bowel incontinence.
 Journal of Armed Forces Medical College Bangladesh Vol.13(1) 2017: 17-21

Sacrococcygeal Teratoma: Experience with 36 Patients in a Teritiary Care Hospital

Introduction: Sacrococcygeal teratomas (SCT) are the most common solid tumours in the neonatal period, originate from embryonic totipotent cells. Most of them are benign however some that present later in life and have major intra-pelvic component have greater malignant potential. Complete surgical excision provides an excellent prognosis. The aim of this study was to describe the clinical profile, age of presentation, sex distribution, diagnostic evaluation and management of children with a histological confirmed diagnosis of sacrococcygeal teratoma.Material and Methods: Patients with histological diagnosis of sacrococcygeal teratoma during a period from January 2011 to December 2012 were included in this retrospective study. Data collected included age of presentation, sex distribution, symptoms, associated anomalies, diagnostic evaluation, operative approach technique employed, tumour histology, operative complications and outcome.Results: Thirty six patients with diagnosis of sacrococcygeal teratoma were included in the study. Of these children, 58.33% were females and 41.66% were males. The median age at presentation was four days. 69.44% of patients presented during the neonatal period. 77.77% of patients presented with sacrococcygeal mass followed by lower abdominal mass in 11.11%. The tumour was resected by sacral approach in 27 patients and abdomino sacral approach in nine patients. Tumour was resectable in 34 patients and two had incomplete resection. Follow up duration varied from six months to 24 months.Conclusion: Sacrococcygeal teratomas represent a group of benign and malignant lesions of children. Neonates present with benign disease and aggressive lesions are seen as age progresses. Overall survival of SCT is high.J Nepal Paediatr Soc 2015;35(1):89-93

Sacrococcygeal Teratoma in Children

Introduction Germ cell tumors originate in the primary stem cell located either inside or outside the gonadal system. Teratomas are the major group, with the sacrococcygeal location being the most common extragonadal site, independent of their being benign or malignant. We describe five cases of sacrococcygeal teratoma and emphasize aspects of diagnosis, surgical techniques, and complementary approaches. Patients and Methods A total of five cases of sacrococcygeal teratoma were reported and a literature review was performed using an online database, Pubmed.gov. The authors emphasize aspects of diagnosis, classification, prognosis, and the therapeutic options. Results The five cases were females and the age range from 38 weeks intrauterine (ultrasonography diagnosis) to 1.5 years. The clinical presentation usually was a sacral mass or fecal constipation. The Altman classification was type 1 in three cases and type 4 in two cases. The serum levels of α-fetoprotein was normal in three cases. Preoperative high serum α-fetoprotein levels returned to normal levels 10 days after surgery. The radical surgical resection of the tumor and the coccyx was done in all cases through a posterior sacral approach and midline incision. The surgery did not compromise the neurological function. No tumor recurrence was seen in by radiologic and α-fetoprotein examinations after a medium follow-up of 15.3 years. Conclusion The sacrococcygeal region is the most frequent site of teratomas in children. Complete tumor resection and removal of the coccyx are the main objective in curative treatment of the teratoma. Diagnosis and treatment as early as possible is essential to prevent it from becoming malignant.

Sacrococcygeal teratoma

Background / aim Sacrococcygeal teratomas are the most common tumor during the neonatal period. They are either benign (mature) or malignant (immature, composed of embryonic elements). This retrospective study aims at reviewing our experience in management and outcome of this pathology during the period from January 2008 to November 2013. Patients and methods Charts were designed to collect the following data: the age at presentation, sex, clinical presentation, associated anomalies, Altman’s classification, investigations, management modality, tumor histology with respect to type and resection margins, outcome of treatment, and bowel or urinary complications. Results A total of 20 patients were included in this study. There were six male patients and 14 female patients. Ten patients were Altman type I, seven were type II, one was type III, and two were type IV. Surgical intervention was carried out using a posterior sacral approach in 17 patients (all type I and II patients) or combined abdominal and posterior sacral approaches in the remaining three patients (types III and IV). Recurrence occurred in two patients; these were types III and IV. We had one mortality. Two patients reported involuntary bowel movements, two reported frequent soiling, and five reported constipation. Conclusion Awareness about this pathology among practitioners is essential and would have avoided complications in this series. Early diagnosis and complete excision with removal of the coccyx is associated with good prognosis. Recurrence is related to tumor spillage during excision. Long-term lower gastrointestinal problems (constipation, fecal soiling) correlate with Altman’s classification of the tumor. Keywords : Altman’s classification, sacrococcygeal teratoma, Teratomas

Excision of high sacral giant cell tumor and reconstruction with bone cement

We report the case of a woman who had a right sacroiliac giant cell tumor with S1 nerve root involvement. No specific functional defects were noted after she underwent combined anterior abdominal and posterior sacral approaches for tumor excision and reconstruction with bone cement. Our goal is to determine whether or not, with carefully planned procedures and delicate nerve protection, the biomechanical stability of the sacrum was affected after the tumor resection. We believe that bone cement impaction can be considered as an alternative reconstructive method instead of high-priced, complicated fixation devices or allografts that are not readily available.

P-0293 Benefits From The Abdominosacral Approach In Prone Jackknife Position In Patients With Low Rectal Cancers – Virtual Surgery

ABSTRACT Introduction From the oncological surgeon's perspective, rectal cancers constitute a more serious challenge than tumors located in the remaining parts of the large intestine. This is related to the fact that the rectum lies extraperitoneally in the pelvic cavity. Anatomical relationships in the minor pelvis markedly hinder the possibilities of retaining oncological aseptics and completeness of resection – particularly in the case of low-rectal tumors. At the onset of the 21st century, surgical treatment of most low-rectal tumors is based on the technique of abdominoperineal resection (APR), which was proposed by Miles as early as 1908. Optimal resection of the primary tumor, along with the area of its lymphatic drainage, is virtually impossible using this technique due to the previously mentioned anatomical relationships. These limitations are reflected by the high frequencies of isolated local recurrence and poor survival rates in patients subjected to APR. Due to obvious reasons, recent years have been a period of an ongoing search for novel surgical techniques that would replace “historical” APR. “Conservative” and “radical” approaches may be distinguished among attempts at surgical treatment optimization. Methods The “radical” approach involved the implementation of a technique of abdominosacral amputation of the rectum (ASAR) which was developed at our clinic. The idea behind this method is a sacral approach in a prone jackknife position by means of coccygectomy, along with the removal of terminal segments of the sacrum when needed. The free surgical approach enables sharp dissection under direct vision and guarantees optimal resection of CRM-negative surgical specimens. Since the ASAR technique has been improved upon for over a decade, its long-term therapeutic results are already available. These results are as favorable as those obtained by means of TME in upper- and mid-rectal cancer cases. Along with low morbidity rates, these results suggest that ASAR should be implemented as a routine technique for low-rectal cancer resection. The aim of this report is to share our nearly 15-year experiences with ASAR and present technical details of this procedure suing the form of “virtual surgery.” Results Between February 15th, 1998 and February 15th, 2012, 318 consecutive patients with stage II and III low-rectal adenocarcinomas (located within 6 cm from the anorectal junction) underwent ASAR at the 1st Department of Surgical Oncology, Regional Comprehensive Cancer Center (RCCC) in Wroclaw, Poland. Most patients had preoperative radiotherapy in accordance with compulsory standards. Our analysis included 277 low-rectal cancer patients operated on before February 15th, 2010 (i.e. with at least 2-year follow-up data). Five-year relative survival years and local recurrence rates determined in this group corresponded to 74% and 3.8%, respectively. Conclusion In conclusion, this analysis showed satisfactory outcomes of patients who were operated on by means of ASAR, and confirmed that extensive sacral approach during the second stage of this procedure raises possibilities of retaining oncological aseptics and completeness of the resection.

Sacrococcygeal teratoma in infants and children

The purpose of this study is to share our experience with extensive sacrococcygeal teratoma, paying particular attention to neurological function, intraoperative hemorrhage, rate of tumor recurrence, and the surgical procedure. Infants and children with sacrococcygeal teratoma were selected and generally examined in order to detect other associated anomalies. Patients with giant sacrococcygeal tumor and high output heart failure were managed by the abdominosacral route while patients with small sacrococcygeal tumor and normal cardiac function were managed by the sacral approach. All operated patients were observed and followed-up regularly for a period of 1-3 years after tumor excision. This study presents 22 patients with sacrococcygeal teratoma managed over a period of 40 months; 18 patients presented in the first 2 months of life and four children aged 2-4 years. Fifteen patients were treated by sacral excision and seven patients were corrected by abdomenosacral excision and temporary colostomy. Benign teratoma presented in 17 patients, one of whom died (6%), and five patients had malignant tumor, one of whom died (20%). The fecal and urinary state was good in all patients treated by the sacral route. Patients corrected by abdominosacral excision showed varied degrees of urinary incontinence and constipation. Survival in excised malignant tumor was good following chemotherapy; three patients received chemotherapy with a 70% survival rate. Benign sacrococcygeal teratoma has an excellent outcome after early surgery, but the incidences of malignancy increase if resection is delayed.

Ultrasound Evaluation of the Sacral Area and Comparison of Sacral Interspinous and Hiatal Approach for Caudal Block in Children

Ultrasound Evaluation of the Sacral Area and Comparison of Sacral Interspinous and Hiatal Approach for Caudal Block in Children

Morphometry of sacral hiatus and its clinical relevance in caudal epidural block

Sacral approach to epidural space produces reliable and effective block of sacral nerves. It is necessary to have a detailed knowledge of sacral hiatus (SH) for optimal access into sacral epidural space. This study was undertaken to evaluate various landmarks of SH. One hundred and fourteen adult dry human sacral bones were examined for morphometric analysis using vernier caliper. SH was categorized on the basis of shape. Most commonly encountered shape of hiatus was inverted U (40.35%). Its apex and base were most commonly observed against fourth and fifth sacral vertebrae, respectively. Various defects in dorsal wall of sacral canal were recorded. Height and anteroposterior depth at the apex of hiatus were ranged 4.30-38.60 and 1.90-10.40 mm, respectively. Mean intercornual distance at base was 11.95 +/- 2.78 mm. The triangle formed by right and left posterior superior iliac spines and apex of SH was found equilateral in 45% cases only. Sacral cornua were marked by their bilateral presence in 55.26% and impalpable in 21.05% cases. Minimum distance between S2 and apex was 7.25 mm which suggested that it would not be safe to push the needle beyond 7 mm into sacral canal so as to avoid dural puncture. In 8.77% cases, depth of hiatus was less than 3 mm. Single bony landmark may not help in locating SH because of anatomical variations. Depth of hiatus less than 3 mm may be one of the causes for failure of needle insertion. Surrounding bony irregularities, different shapes of hiatus and defects in dorsal wall of sacral canal should be taken into consideration before undertaking caudal epidural block so as to avoid its failure.

222. An Alternative Approach to Caudal Block in Children: Comparison of the Sacral Intervertebral Approach and Sacral Hiatal Approach

222. An Alternative Approach to Caudal Block in Children: Comparison of the Sacral Intervertebral Approach and Sacral Hiatal Approach

An Alternative Approach to Caudal Block in Children: Comparison of the Sacral Intervertebral Approach and Sacral Hiatal Approach

An Alternative Approach to Caudal Block in Children: Comparison of the Sacral Intervertebral Approach and Sacral Hiatal Approach

222: An Alternative Approach to Caudal Block in Children: Comparison of the Sacral Intervertebral Approach and Sacral Hiatal Approach

222: An Alternative Approach to Caudal Block in Children: Comparison of the Sacral Intervertebral Approach and Sacral Hiatal Approach