Vedolizumab in Crohn’s disease with rectal fistulas and presacral abscess:A case report

BACKGROUND Fistula and intraabdominal abscess are common complications of Crohn’s disease(CD),but complex rectal fistula with abscess formation is rare.Tumor necrosis factor antagonists combined with percutaneous drainage or surgical intervention is optimal treatment for fistulizing CD with intraabdominal abscess.There is no study showing the efficacy of vedolizumab in such complicated condition.CASE SUMMARY A 47-year-old man has decompensated liver cirrhosis,Child B.He suffered from abdominal pain,bloody diarrhea,fever,and body weight loss.CD with rectoprostatic fistula,rectopresacral fistula,presacral abscess and cytomegalovirus(CMV)infection were noted.He received antibiotics,anti-viral therapy,transverse colostomy and vedolizumab treatment.Six months later,he had deep remission and complete fistula tracts closure.CONCLUSION Early vedolizumab and stool diversion are effective and safe in treating CD with complex rectal fistula with abscess formation.

Massive presacral bleeding during rectal surgery: From anatomy to clinical practice

AIM: To investigate control of two different types of massive presacral bleeding according to the anatomy of the presacral venous system. METHODS: A retrospective review was performed in 1628 patients with middle or low rectal carcinoma who were treated surgically in the Department of Colorectal Surgery, Changhai Hospital, Shanghai, China from January 2008 to December 2012. In four of these patients, the presacral venous plexus (n = 2) or basivertebral veins (n = 2) were injured with massive presacral bleeding during mobilization of the rectum. The first two patients with low rectal carcinoma were operated upon by a junior associate professor and the source of bleeding was the presacral venous plexus. The other two patients with recurrent rectal carcinoma were both women and the source of bleeding was the basivertebral veins.RESULTS: Two different techniques were used to con-trol the bleeding. In the first two patients with massive bleeding from the presacral venous plexus, we used suture ligation around the venous plexus in the area with intact presacral fascia that communicated with the site of bleeding (surrounding suture ligation). In the second two patients with massive bleeding from the basivertebral veins, the pelvis was packed with gauze, which resulted in recurrent bleeding as soon as it was removed. Following this, we used electrocautery applied through one epiploic appendix pressed with a long Kelly clamp over the bleeding sacral neural foramen where was felt like a pit Electrocautery adjusted to the highest setting was then applied to the clamp to "weld" closed the bleeding point. Postoperatively, the blood loss was minimal and the drain tube was removed on days 4-7. CONCLUSION: Surrounding suture ligation and epiploic appendices welding are effective techniques for controlling massive presacral bleeding from presacral venous plexus and sacral neural foramen, respectively.

Posterior approach (Kraske procedure) for surgical treatment of presacral tumors

Presacral tumors are rare,but can comprise a great variety of histological types.Congenital tumors are the most common.Once the diagnosis is established,surgical resection is essential because of the potential for malignancy or infection.Previous biopsy is not necessary or may be even harmful.To decide the best surgical approach(abdominal,sacral or combined) an individual and multidisciplinary analysis must be carried out.We report three cases of cystic presacral masses in which a posterior approach(Kraske procedure) enabled complete resection,the only way to decrease local recurrence.All patients had a satisfactory recovery.A brief overview of retrorectal tumors is presented,focusing on classification,clinical presentation,diagnosis and surgical management.

Presacral venous bleeding during mobilization in rectal cancer

AIM To analyze the anatomy of sacral venous plexus flow, the causes of injuries and the methods for controlling presacral hemorrhage during surgery for rectal cancer.METHODS A review of the databases MEDLINE? and Embase? was conducted, and relevant scientific articles published between January 1960 and June 2016 were examined. The anatomy of the sacrum and its venous plexus, as well as the factors that influence bleeding, the causes of this complication, and its surgical management were defined.RESULTS This is a review of 58 published articles on presacral venous plexus injury during the mobilization of the rectum and on techniques used to treat presacral venous bleeding. Due to the lack of cases published in the literature, there is no consensus on which is the best technique to use if there is presacral bleeding during mobilization in surgery for rectal cancer. This review may provide a tool to help surgeons make decisions regarding how to resolve this serious complication.CONCLUSION A series of alternative treatments are described; however, a conventional systematic review in which optimal treatment is identified could not be performed because few cases were analyzed in most publications.

Primary neuroendocrine tumor in the presacral region: A case report

BACKGROUND Primary neuroendocrine tumors (NETs) in the presacral region are extremely rare, some of which are caused by other primary tumors or metastatic rectal carcinoids. Nevertheless, cases of NETs have been increasing in recent years. This report describes the first primary neuroendocrine tumor in the presacral region that was found at our hospital within the last five years. CASE SUMMARY The patient was identified as a 36-year-old woman with a presacral mass and pelvic floor pain. A digital rectal examination revealed a presacral mass with unclear margins and obvious tenderness. Magnetic resonance imaging (MRI) demonstrated a 57 mm × 29 mm presacral lump. An ultrasound-guided needle biopsy confirmed a well-differentiated neuroendocrine tumor. No other primary or metastatic tumors were found. CONCLUSION Comprehensive consideration of our case report and literature reported by others suggests that a conclusive diagnosis of NETs should be based on computed tomography/MRI and pathological examinations. The treatment of primary NETs in the presacral region mainly relies on surgical procedures with follow-up.

Pain Management in a Parturient with Presacral Mass

Presacral masses are rare lesions and due to obscure anatomic location and etiological heterogeneity, they pose a diagnostic and therapeutic challenge. Literature is limited on the pain management of a parturient with presacral mass. We describe here a parturient in her second trimester with severe pain from a presacral mass. A high clinical acumen with early multidisciplinary involvement are needed to establish a diagnosis and provide treatment options for the well-being of the patient, minimize fetal teratogenicity, avoid chronic symptoms and long-term disability.

Double tailgut cysts (presacral and precoccygeal hamartomas) with CA 19-9 elevation

Tailgut cyst, also called retrorectal hamartoma, is a rare congenital lesion and is usually located anterior to the sacrum and posterior to the rectum. We report a case of double tailgut cyst (presacral and precoccygeal hamartoma). A 62-year- old female visited the hospital complaining of anal pain and pressure in the perianal area for one month. Digital rectal examination revealed a round mass with hard consistency in the lateral and posterior part of rectum 5 cm from the anal verge. Pelvic magnetic resonance imaging showed two cystic and solid presacral masses (lateral and posterior part of rectum) compressing the rectum. The patient underwent surgical resection for pathologic diagnosis. At operation, two masses were located in the left presacral space without invasion to adjacent organs and soft tissue. Pathologic examination revealed double tailgut cysts without malignant transformation. A differential diagnosis of perirectal cystic hamartoma includes epidermal cysts, cystic teratomas, dermoid cysts, anal gland cysts, sarcoma and rectal duplications. Regional inflammatory process frequently complicates this lesion and perirectal fistula can develop. Tailgut cyst also has a malignancy potential, with development of adenocarcinomas. To establish a definite diagnosis and prevent complication, complete surgical resection is recommended.

Surgical treatment of retrorectal(presacral) tumors

Retrorectal(also known as presacral) tumor(RT) is a rare disease of retrorectal space. They can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history and physical examination. The primary and only satisfactory treatment is surgery for RTs. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primary local control, which is often difficult to achieve for malignantlesions.

Chinese expert consensus on standardized treatment for presacral cysts

Presacral cysts are cystic or cyst–solid lesions between the sacrum and rectum,almost involving adjacent pelvic floorstructures including sacrococcygeal fascia,rectum,and anal sphincter.Presacral cysts are usually benign,currently believed to arise from aberrant embryogenesis.Presacral cysts are clinically rare and the true incidence is unknown.Surgical resection remains the major treatment for presacral cysts.Unless the cysts are completely resected,recurrence is unavoidable.Recurrent cysts or hard-to-heal sinuses in the sacrococcyx cause patients extreme pain.However,the current knowledge of presacral cysts is insufficient.They are occasionally confused with other diseases such as ovarian cysts and perianal abscesses.Moreover,lack of the correct surgical concept and skills leads to palliative treatment for complex presacral cysts and serious complications such as impairing the function of the anal sphincter or important blood vessels and nerves.The consensus summarizes the opinions and experiences of multidisciplinary experts in presacral cysts and aims to provide clinicians with a more defined concept of the treatment,standardize the surgical approach,and improve the efficacy of presacral cysts.

Surgical strategy for presacral tumors： analysis of 33 cases

Background Presacral tumors are highly infrequent tumors located in the space known as presacral or retrorectal space. Although there have been substantial improvements in the prognosis of patients with malignant presacral tumors, the development of newer surgical strategy is likely to further improve the oncologic outcomes of malignant presacral tumors. The aim of this article was to report our experience in 33 cases, and to review the surgical strategy, pathological features and the prevention of complications from our experience. Methods A retrospective analysis was conducted on 33 cases （20 male and 13 female） with presacral tumors surgically treated in our hospital between January 1998 and April 2009. The surgical approaches included trans-abdominal in 10 cases （30%）, trans-sacral in 18 cases （55%） and combined abdominal-sacral in 5 cases （15%）. All patients got followed up （14-123 months, mean of 45.1 months）. At last, the general information, clinical symptoms, histodiagnosis, surgical types and postoperative complications of all cases in our series were assessed. Results Ages of 33 patients ranged from 18 to 71 years, with an average of 48.5 years. Pathological findings： 6 epidermoid cysts, 5 teratomas, 3 leiomyomas, 9 neurofibromas, 5 neurilemmomas, 1 enterogenous cyst, 1 liposarcoma, 1 leiomyosarcoma, 1 angiosarcoma, and 1 neurofibrosarcoma. All tumors were excised with no perioperative death. A colostomy was taken in one case with angiosarcoma involving the rectum because of the intraoperative injury of the rectum. Blood loss during surgery was 400-11 000 ml （mean of 2400 ml）. Four （12%） cases had local recurrence during follow-up： 2 because of inadequate drainage after dermoidectomy, both of them were cured by surgical resection and drainage; recurrence occurred in a case of teratoma in 18 months after surgery, cured by a trans-sacral excision; local recurrence and lung metastasis occurred simultaneously in a case of angiosarcoma in 6 months postoperatively and the patient died one month later of respiratory failure. Conclusions The main treatment of most presacral tumors is surgical resection. Selection of surgical approach is very important for complete resection of the presacral tumors. The location, size and peculiarities of tumors, conditions of the skin and soft tissues and the patients＇ somatotype are all determinative factors. Multidisciplinary cooperation is also very necessarv.

A new strategy for managing presacral venous hemorrhage：bipolar coagulation hemostasis

Massive presacral venous hemorrhage is dangerous and difficult to manage. Traditional methods for controlling this condition include packing with laparotomy pads, the use of sterile thumbtacks,1 ligation of the internal iliac vessel,2 and selective arterial embolization.3 These methods are generally ineffective. Recently, several other methods for controlling presacral bleeding have been reported, such as occlusion of the wound with rectus muscle fragment welding,4 oppression with sterile normal saline bags,5 balloon tamponade,6 and the use of endoscopic staples.7 However, these measures fail to arrest the bleeding in some patients, resulting in massive hemorrhage and even death.

Thin steel plate with thumbtack fixation in the treatment of massive presacral venous plexus hemorrhage

Background Massive presacral venous plexus hemorrhage during radical resection of rectal carcinoma is rare, but when it occurs, bleeding can be uncontrollable, leading to death in some cases. Medical adhesive gauze sticking and packing and thumbtack compressive fixation are often used for hemostasis, but these methods are not effective in cases of uncontrollable massive hemorrhage. Therefore, identifying a practical, accurate, and reliable method of hemostasis in these cases is essential.Methods Between January 2004 and December 2009, we treated 3 patients with massive presacral venous plexus hemorrhage during resection of rectal carcinoma by placing small, trimmed thin steel plates at the bleeding sites. The plates were fixed with a saddle-type application of thumbtacks.Results Bleeding was successfully controlled in all 3 patients, and intestinal anastomosis was carried out after hemostasis. No complications were observed.Conclusions Application of a small, thin steel plate to the bleeding site with thumbtack fixation is a simple and effective method of hemostasis in patients with massive presacral venous plexus hemorrhage during resection of rectal carcinoma.

A novel transperineal approach for surgical resection of presacral tumors with an arc-shaped incision in front of the apex of the coccyx(with video)

Introduction Presacral cystic tumors are rare and are composed of many types of tumors located in the presacral space[1].The mainstay of treatment is total excision without preoperative biopsy[2].In recent years,the number of patients with presacral cystic tumors who have been treated in the Affiliated Cancer Hospital of Zhengzhou University has increased.In particular,>25%of patients have presented with residual presacral cystic walls with perineal refractory sinuses due to the failure of presacral tumor operations in other hospitals.We studied the surgical records of patients with failed primary procedures and suggested that inadequate surgical exposure due to a lack of proper surgical approach was the main reason.Therefore.

Retrorectal tumors in adults:Magnetic resonance imaging findings

AIM:To retrospectively evaluate the magnetic resonance imaging (MRI) features of adult retrorectal tumors and compare with histopathologic findings.METHODS:MRI features of 21 patients with preoperative suspicion of retrorectal tumors were analyzed based on the histopathological and clinical data.RESULTS:Fourteen benign cystic lesions appeared hypointense on T1-weighted images,and hyperintense on T2-weighted images with regular peripheral rim.Epidermoid or dermoid cysts were unilocular,and tailgut cysts were multilocular.Presence of intracystic intermediate signal intensity was observed in one case of tailgut cyst with a component of adenocarcinoma.Six solid tumors were malignant lesions and showed heterogeneous intensity on MRI.Mucinous adenocarcinomas showed high signal intensity on T2-weighted and mesh-like enhancing areas on fat-suppressed T2-weighted images.There was a fistula between the mass and anus with an internal opening in mucinous adenocarcinomas arising from anal fistula.Gastrointestinal stromal tumors displayed low signal intensity on T1-weighted images,and intermediate to high signal intensity on T2-weighted images.Central necrosis could be seen as a high signal on T2-weighted images.CONCLUSION:MRI is a helpful technique to define the extent of the retrorectal tumor and its relationship to the surrounding structures,and also to demonstrate possible complications so as to choose the best surgical approach.

A Single Center Retrospective Analysis of Kraske’s Transsacral Approach: A Review

Aim: Presacral lesions are uncommon and represent a diagnostic and surgical challenge. The aim of this study is to present our experience with Kraske’s transsacral resection and to review current literature. Methods: Seven patients who had a transsacral resection between 2001 and 2013?were reviewed retrospectively. Results: Two men and five women with a mean age of 39 (range 17?- 60) years were diagnosed with a presacral lesion. The clinical presentation was nonspecific;pain was the most common symptom. All lesions were palpable on digital rectal examination. Magnetic resonance imaging (MRI) was necessary to assess the tumor’s extent, biological behavior and relationship to adjacent structures. MRI predicted malignancy with 100% accuracy. All lesions were located below S3 and underwent a transsacral resection. Pathological examination revealed four tailgut cysts, two epidermoid cysts and one chordoma. Postoperative complications included wound infections (two cases) and spasms of the gluteus muscle (one case). We reported no recurrence or mortality. Conclusion: Clinical awareness, the use of MRI in the routine work-up and avoidance of an incisional biopsy result in a good outcome after surgical resection of presacral lesions. Kraske’s approach can be used for presacral lesions below S3, resulting in low morbidity, no recurrence and no mortality.

Retrorectal Cystic Hamartoma with Malignant Transformation

Retrorectal cystic hamartomas are rare congenital lesions that can undergo malignant transformation, and adenocarcinoma is the most frequently described histological type. The authors describe a case of a 53-year-old female patient with a localized well-differentiated adenocarcinoma that developed in a retrorectal cystic hamartoma. The patient was submitted to surgery (a Kraske procedure), with an R1 resection, followed by adjuvant radio-chemotherapy. After 23 months of follow up, the patient remains free from disease recurrence. Given the rarity of this entity, this case allows us to reflect on the differential diagnosis, therapeutic approach and patients’ follow-up.

CT导向的内镜下针刀治疗回肠储袋窦道

Ileal pouch-anal anastomosis surgery can be complicated by anastomotic leaks,leading to the formation of abscess and chronic sinus that have been routinely managed by a surgical approach.We developed the endoscopic needle knife sinusotomy(NKSi)technique,which has become a valid alternative.The basic principle of endoscopic NKSi is dissection and drainage of the sinus through its orifice internally into the lumen of pouch body.The success of NKSi requires an access to the sinus from the pouch side.One of the most challenging situations for NKSi is a closed orifice of the sinus,which leaves an isolated chronic abscess cavity.Here we report a case of complicated presacral sinus with a closed orifice that was not amenable to NKSi,necessitating a CT-guided guide wire placement and subsequent NKSi.