Recently, the "Chinese Expert Consensus on Standardized Diagnosis and Treatment of Presacral Cysts" (hereinafter referred to as the "Consensus"), which is served as the corresponding author by Wang Gangcheng, deputy director of the Department of General Surgery of Henan Cancer Hospital, was officially published in the Chinese Journal of Oncology (October 2021, Vol. 43, No. 10).
An anterior sacral cyst is a cystic or cystic solid mass located between the sacral coccyx and the rectum, which is closely related to pelvic floor tissues such as the sacral coccygeal fascia, rectum, and sphincter, and is mostly benign. Treatment is predominantly surgical resection, but if the sac wall is not completely removed, it may lead to recurrence or the formation of a sinus tract in the sacrumcoma that is difficult to heal, causing great pain to the patient.
At present, the clinical understanding of presacral cysts is insufficient, and even confuses them with diseases such as ovarian cysts and perianal abscesses, and it is urgent to have relevant guidelines to guide them.
The Consensus was introduced as the first expert consensus in the field of presacral cysts in China. Its formulation provides a reference standard for the majority of doctors, which is conducive to improving the complete resection rate of presacral cysts, reducing the corresponding injuries and postoperative complications of surgery, and ultimately solving the problem of presacral cyst treatment.
There are misunderstandings
Philosophy needs to change
"There are many doctors who have misunderstandings about presacral cysts, and even confuse them with diseases such as ovarian cysts and perianal abscesses." Wang Gangcheng said.
The primary task of the treatment of presacral cysts is not to recur, to reduce the appearance of complications. But in reality, many patients have had relapses. "There was once a 26-year-old patient who treated an anterior sacral cyst for 18 years and underwent three surgeries." Wang Gangcheng recalled, "Surgery did not fundamentally solve the problem, the extraction of sac fluid is also a symptom but not a cure, during treatment, there are even doctors who recommend patients to go to plastic surgery and beauty department." ”
The cyst has been removed, why are they still recurring? In fact, this is related to the traditional concept and surgical method. Many doctors lack the concept and surgical skills to completely remove the sac wall in the treatment of presacral cysts, which often leads to palliative treatment of presacral cysts that are difficult to remove, and improper surgical methods may even damage the sphincter or important blood vessels, nerves, etc., resulting in complications such as incontinence and heavy bleeding. ”
How to change the doctor's understanding of the presacral cyst and surgical skills is a problem that Wang Gangcheng has been thinking about. A Chinese expert consensus on anterior sacral cyst may be able to resolve. As a result, Wang Gangcheng accumulated experience in surgery, collected data, innovated surgical methods, collected and sorted out the previous problems and summarized the literature, and finally formed a consensus through many expert discussions.
Focus on clinical difficulties
The Consensus makes recommendations
The Consensus explains the origin and pathology of presacral cysts, the relevant anatomy of surgery, clinical diagnosis, surgical concept of presacral cyst surgery, surgical methods of resection, perioperative complications and treatment, follow-up and follow-up treatment.
Wang Gangcheng said that a considerable number of surgeons believe that the presacral cyst is a benign lesion, and some of the remaining cyst walls are fine, but the sac wall secretes mucus drainage that is not smooth, resulting in co-infection, only to treat the symptoms but not the root cause, it is difficult to achieve results.
Wang Gangcheng put forward seven suggestions in the Consensus:
1. It is highly recommended to completely remove the cyst wall of the anterior sacral cyst and the saculs caudal fascia that is closely related to it;
2. It is recommended to remove the coccyx;
3. It is not recommended to use electric knife cauterization and anhydrous alcohol to destroy the secretion function of the capsule wall;
4. It is not recommended to use hardeners to destroy the secretory function of the capsule wall;
5. Drainage of anterior sacral cyst is not recommended;
6. It is not recommended to drain sac contents through the rectum or through the anus;
7. Routine puncture biopsy is not recommended.
Standardize surgical methods
Choose according to the situation
Wang Gangcheng said: 'The smaller the wound, the better', there is nothing wrong with this sentence itself, but if a prerequisite is ignored, it is a misunderstanding. The prerequisite is that the anterior sacral cyst must be removed cleanly, and the exposure of the surgical field of vision needs to be at the expense of an extended incision. ”
In the surgical method of treating anterior sacral cyst, Wang Gangcheng mentioned three surgical methods:
1. Transperineal approach, including a longitudinal incision (recommended for patients with small cyst size, cysts very low S4 level, able to tolerate S4 and S5 vertebral body resection), an anterior sacral arc incision (recommended for patients with anterior sacral cyst with an upper pole below S2), transperineal floor sphincter space incision (the incision is only suitable for cyst resection in a very low position and small volume).
2. Transabdominal approach: including laparoscopic anterior sacrosacral cyst resection (recommended for initial treatment, loose space with sacrachycoccyst and rectal wall, anterior sacral cyst that does not cross the back of the sacral bone, and requires the surgical team to have skilled laparoscopic techniques. Anterior abdominal sacral resection (for patients with a history of open surgery, difficulty separating severe abdominal adhesions, difficulty in transperineal approach resection, and higher position cysts).
3. Abdominal perineal joint approach: recommended for presacral cysts with large size, the upper cyst is very high above the S4 level, and the lower pole is closely related to the sacrovascular part.
At the same time, in the Consensus, the perioperative complications and treatment of presacral cysts are also introduced.
The consensus summarizes the opinions of experts related to presacral cysts, and plays a role in promoting doctors' understanding of presacral cysts, establishing the correct concept of treatment, standardizing the surgical methods of presacral cysts and improving surgical resection skills.
(Source: Henan Provincial Cancer Hospital)