Merchea, Amit

Abstract Background Presacral tumours are rare, heterogeneous lesions. Historical classification systems for presacral tumours have provided a valuable framework, but were based on limited available data. This study aimed to develop a contemporary classification aligned with current tumour entities and clinical practice. Methods A prospectively registered systematic review of surgically managed presacral tumours published from 1975 to 2025 was combined with a retrospective multisite institutional surgical pathology review from 1986 to 2025. Pathological descriptors were extracted, cross-referenced, harmonized to current terminology, and organized through multidisciplinary expert review to obtain a new classification. Results The systematic review identified 5997 records, of which 203 studies met the inclusion criteria and contributed 181 pathological terms after generic and unclassifiable diagnoses were removed. Review of 3606 pathology reports identified 19 additional terms, bringing the total to 200 pathological terms. After harmonization to current terminology and exclusion of non-neoplastic processes, a contemporary classification was developed using biological descriptors: developmental versus acquired origin; tissue lineage (neurogenic, osseous/haematopoietic, soft tissue, or miscellaneous); and tumour behaviour (benign, locally recurrent without metastatic potential, locally recurrent with low metastatic potential, malignant non-sarcoma, or malignant sarcoma). Conclusion The Mayo Clinic classification of presacral tumours updates historical systems by reflecting the broader, more modern spectrum of neoplasms and distinguishing lesions by lineage and biological behaviour. It may improve diagnostic clarity, communication, and selection of appropriate observation, multidisciplinary assessment, and treatment pathways.

Abstract Background Presacral tumours are rare and heterogeneous lesions arising within a complex anatomical space, resulting in variability in diagnosis and management. Increasing incidental detection and evolving surgical and oncological strategies have highlighted the need for contemporary guidance. The aim of this study was to establish an international expert consensus on the optimal diagnosis and management of presacral tumours. Methods An international panel of colorectal surgeons from high-volume units was convened. Evidence- and practice-based statements were developed after domain-based literature reviews and refined through five online and two in-person meetings. Consensus was achieved using a modified Delphi process with anonymous voting. Results In total, 16 colorectal surgeons participated in the study. Ten domains were identified resulting in the development of 22 statements based on expert opinion and retrospective studies. After two rounds, unanimous (100%) agreement was achieved for all statements. High-resolution MRI with structured synoptic reporting is endorsed as central to risk stratification. Selective image-guided transperineal or parasacral biopsy is recommended for high-risk lesions where histology would alter management. Complete surgical resection is defined as the operative goal, with approach tailored to tumour biology and anatomy; minimally invasive surgery is considered appropriate in selected cases. Non-operative surveillance is supported for carefully selected asymptomatic, low-risk cystic lesions. Postoperative surveillance is recommended in a risk-adapted manner according to histopathology and margin status. Conclusion This international consensus provides a pragmatic, risk-stratified framework for the multidisciplinary diagnosis and management of presacral tumours. These recommendations aim to reduce practice variation, support decision-making in specialized centres, and inform future prospective collaborative research.

Despite European colorectal liver metastases (CRLM) transplant trials having been performed entirely using deceased donor liver transplant (DDLT), there has been speculation about whether similar results can be achieved in the United States, given the lack of MELD score prioritization. A formal transplant protocol for unresectable CRLM was implemented in our center at the start of 2022 with the plan to utilize DDLT. Between 2022 and 2025, 86 patients with CRLM were referred to our program, and 19 patients underwent a formal transplant evaluation. Median time from listing until transplant was 31 days (range 3–115 d). Median allocation MELD was 8 (range 6–15). The donor livers were from DCDs, older donors, or National Share livers, which had been declined by all other centers. All but 2 of the cases underwent advanced perfusion. There were no cases of primary nonfunction, postreperfusion syndrome, acute kidney injury, hepatic artery thrombosis, or ischemic cholangiopathy. The length of stay for the median posttransplant was 5 days. Graft and patient survival were 100% at the time of maximal follow-up. Recurrence developed in 3 recipients (25.0%), 1 of whom was treated and has no evidence of disease. These findings support the viability of DDLT for CRLM using advanced perfusion, contingent on strict protocol adherence. Center-specific waitlist dynamics must inform the choice between DDLT and living donor liver transplant (LDLT).

Abstract Aim Recent evidence challenges the current standard of offering surgery to patients with ileocaecal Crohn's disease (CD) only when they present complications of the disease. The aim of this study was to compare short‐term results of patients who underwent primary ileocaecal resection for either inflammatory (luminal disease, earlier in the disease course) or complicated phenotypes, hypothesizing that the latter would be associated with worse postoperative outcomes. Method A retrospective, multicentre comparative analysis was performed including patients operated on for primary ileocaecal CD at 12 referral centres. Patients were divided into two groups according to indication of surgery for inflammatory (ICD) or complicated (CCD) phenotype. Short‐term results were compared. Results A total of 2013 patients were included, with 291 (14.5%) in the ICD group. No differences were found between the groups in time from diagnosis to surgery. CCD patients had higher rates of low body mass index, anaemia (40.9% vs. 27%, p < 0.001) and low albumin (11.3% vs. 2.6%, p < 0.001). CCD patients had longer operations, lower rates of laparoscopic approach (84.3% vs. 93.1%, p = 0.001) and higher conversion rates (9.3% vs. 1.9%, p < 0.001). CCD patients had a longer hospital stay and higher postoperative complication rates (26.1% vs. 21.3%, p = 0.083). Anastomotic leakage and reoperations were also more frequent in this group. More patients in the CCD group required an extended bowel resection (14.1% vs. 8.3%, p : 0.017). In multivariate analysis, CCD was associated with prolonged surgery (OR 3.44, p = 0.001) and the requirement for multiple intraoperative procedures (OR 8.39, p = 0.030). Conclusion Indication for surgery in patients who present with an inflammatory phenotype of CD was associated with better outcomes compared with patients operated on for complications of the disease. There was no difference between groups in time from diagnosis to surgery.

Abstract Aim The aim of this study was to describe the surgical management, outcomes and risk of malignancy of presacral tailgut cysts. Method A retrospective analysis of all patients who underwent resection of tailgut cyst at Mayo Clinic in Arizona, Florida and Minnesota between 2008 and 2020 was performed. Demographics, presentation, evaluation, surgical approach, postoperative complications, pathology and recurrence rates were reviewed. Results Seventy‐three patients were identified (81% female) with a mean age of 45 years. Thirty‐nine patients (53%) were symptomatic, most commonly with pelvic pain (26 patients). Digital rectal examination identified a palpable mass in 68%. Mean tumour size was 6 cm. Resection was primarily performed through a posterior approach (77%, n = 56), followed by a transabdominal approach (18%, n = 13) and a combined approach (5%, n = 4). Six patients underwent a minimally invasive resection (laparoscopic/robotic). Coccygectomy or distal sacrectomy was performed in 41 patients (56%). Complete resection was achieved in 94% of patients. Thirty‐day morbidity occurred in 18% and was most commonly wound related; there was no mortality. Malignancy was identified in six patients (8%). For the 30 patients with follow‐up greater than 1 year, the median follow‐up was 39 months (range 1.0–11.1 years). Local recurrence was identified in three patients and distant metastatic disease in one patient. Conclusion The rate of malignancy in presacral tailgut cysts based on this current review was 8%. Overall recurrence was 5% at a median of 24 months.