Apendicitis aguda por intususcepción secundaria a endometriosis. Reporte de caso / Acute appendicitis due to intussusception secondary to endometriosis. Case report

Introducción. La intususcepción del apéndice corresponde a su invaginación en el ciego. Existen varias causas, pero la endometriosis ha sido informada pocas veces. Aunque el diagnóstico se debe sospechar clínicamente, por lo general su causa solo se determina en el intraoperatorio, donde se deben tener en cuenta causas oncológicas que requieran una resección amplia. Caso clínico. Mujer de 21 años que consultó por dolor abdominal agudo generalizado. Se practicó una tomografía computarizada de abdomen, observando una intususcepción del apéndice en el ciego, estriación de la grasa pericecal y adenomegalias. Se realizó laparoscopia diagnóstica encontrando intususcepción casi completa del apéndice cecal, de aspecto neoplásico. Se convirtió a laparotomía para proceder a hemicolectomía derecha, con vaciamiento ganglionar y anastomosis del íleon al colon transverso. Discusión. La sospecha clínica de intususcepción debe corroborarse mediante ecografía, tomografía o estudios baritados. El tratamiento siempre es quirúrgico, como en el caso de nuestra paciente, quien evolucionó de forma adecuada y continuó asintomática después de un año de seguimiento. Conclusión. El diagnóstico temprano de la intususcepción permite realizar tratamientos quirúrgicos menos agresivos y disminuye el riesgo de filtración de la anastomosis. Se debe tener en cuenta el diagnóstico de endometriosis como posible causa. Se debe realizar el manejo complementario por parte de ginecología.

Introduction. The intussusception of the appendix corresponds to its invagination in the cecum. There are several causes, endometriosis being rarely reported. Although the diagnosis must be suspected clinically, its cause is generally only determined intraoperatively, where oncological causes that require extensive resection must be taken into account. Clinical case. A 21-year-old woman who consulted due to acute generalized abdominal pain, an abdominal tomography was performed, finding an intussusception of the appendix in the cecum, striation of pericecal fat, and lymph nodes. A diagnostic laparoscopy was performed, finding almost complete intussusception of the appendix, with a neoplastic appearance. She was converted to laparotomy to perform a right hemicolectomy, with lymph node dissection and ileal to transverse anastomosis. Discussion. Clinical suspicion of intussusception should be confirmed by ultrasound, abdominal tomography, or barium studies. Treatment is always surgical, as in the case of our patient, who evolved adequately and remained asymptomatic after one year of follow-up. Conclusion. Early diagnosis of intussusception allows for less aggressive surgical treatment and decreases the risk of anastomosis leakage. The diagnosis of endometriosis should be taken into account as a possible cause. Complementary management by gynecologists should be performed.

Recognition of the membrane anatomy-based laparoscopic assisted right hemicolectomy / 中华胃肠外科杂志

Although it has become a consensus in the field of colorectal surgery to perform radical tumor treatment and functional protection under the minimally invasive concept, there exist many controversies during clinical practice, including the concept of embryonic development of abdominal organs and membrane anatomy, the principle of membrane anatomy related to right hemicolectomy, D3 resection, and identification of the inner boundary. In this paper, we analyzed recently reported literature with high-level evidence and clinical data from the author's hospital to recognize and review the membrane anatomy-based laparoscopic assisted right hemicolectomy for right colon cancer, emphasizing the importance of priority of surgical dissection planes, vascular orientation, and full understanding of the fascial space, and proposing that the surgical planes should be dissected in the parietal-prerenal fascial space, and the incision should be 1 cm from the descending and horizontal part of the duodenum. The surgery should be performed according to a standard procedure with strict quality control. To identify the resection range of D3 dissection, it is necessary to establish a clinical, imaging, and pathological evaluation model for multiple factors or to apply indocyanine green and nano-carbon lymphatic tracer intraoperatively to guide precise lymph node dissection. We expect more high-level evidence of evidence-based medicine to prove the inner boundary of laparoscopic assisted radical right colectomy and a more rigorous consensus to be established.

Perioperative management and operative treatment of malignant tumor of anal canal merging severe abdominal protuberance / 中华胃肠外科杂志

Objective: To report the perioperative management and robot-assisted minimally invasive surgery results of one case with malignant tumor of anal canal combined with severe abdominal distention. Methods: A 66-year-old male suffer from adenocarcinoma of anal canal (T3N0M0) with megacolon, megabladder and scoliosis. The extreme distention of the colon and bladder result in severe abdominal distention. The left diaphragm moved up markedly and the heart was moved to the right side of the thoracic cavity. Moreover, there was also anal stenosis with incomplete intestinal obstruction. Preoperative preparation: fluid diet, intravenous nutrition and repeated enema to void feces and gas in the large intestine 1 week before operation. Foley catheter was placed three days before surgery and irrigated with saline. After relief of abdominal distention, robotic-assisted abdominoperineal resection+ subtotal colectomy+colostomy was performed. Results: Water intake within 6 hours post-operatively; ambulance on Day 1; anal passage of gas on Day 2; semi-fluid diet on Day 3; safely discharged on Day 6. Conclusion: Robotic-assisted minimally invasive surgery is safe and feasible for patients with malignant tumor of anal canal combined with severe abdominal distention after appropriate and effective preoperative preparation to relieve abdominal distention.

Anatomical classification of and laparoscopic surgery for left-sided colorectal cancer with persistent descending mesocolon / 中华胃肠外科杂志

Objective: To investigate anatomical morphology and classification of persistent descending mesocolon (PDM) in patients with left-sided colorectal cancer, as well as the safety of laparoscopic radical surgery for these patients. Methods: This is a descriptive study of case series. Relevant clinical data of 995 patients with left colon and rectal cancer who had undergone radical surgery in Fujian Medical University Union Hospital from July 2021 to September 2022 were extracted from the colorectal surgery database of our institution and retrospectively analyzed. Twenty-four (2.4%) were identified as PDM and their imaging data and intra-operative videos were reviewed. We determined the distribution and morphology of the descending colon and mesocolon, and evaluated the feasibility and complications of laparoscopic surgery. We classified PDM according to its anatomical characteristics as follows: Type 0: PDM combined with malrotation of the midgut or persistent ascending mesocolon; Type 1: unfixed mesocolon at the junction between transverse and descending colon; Type 2: PDM with descending colon shifted medially (Type 2A) or to the right side (Type 2B) of the abdominal aorta at the level of the origin of the inferior mesentery artery (IMA); and Type 3: the mesocolon of the descending-sigmoid junction unfixed and the descending colon shifted medially and caudally to the origin of IMA. Results: The diagnosis of PDM was determined based on preoperative imaging findings in 9 of the 24 patients (37.5%) with left-sided colorectal cancer, while the remaining diagnoses were made during intraoperative assessment. Among 24 patients, 22 were male and 2 were female. The mean age was (63±9) years. We classified PDM as follows: Type 0 accounted for 4.2% (1/24); Type 1 for 8.3% (2/24); Types 2A and 2B for 37.5% (9/24) and 25.0% (6/24), respectively; and Type 3 accounted for 25.0% (6/24). All patients with PDM had adhesions of the mesocolon that required adhesiolysis. Additionally, 20 (83.3%) of them had adhesions between the mesentery of the ileum and colon. Twelve patients (50.0%) required mobilization of the splenic flexure. The inferior mesenteric artery branches had a common trunk in 14 patients (58.3%). Twenty-four patients underwent D3 surgery without conversion to laparotomy; the origin of the IMA being preserved in 22 (91.7%) of them. Proximal colon ischemia occurred intraoperatively in two patients (8.3%) who had undergone high ligation at the origin of the IMA. One of these patients had a juxta-anal low rectal cancer and underwent intersphincteric abdominoperineal resection because of poor preoperative anal function. Laparoscopic subtotal colectomy was considered necessary for the other patient. The duration of surgery was (260±100) minutes and the median estimated blood loss was 50 (20-200) mL. The median number of No. 253 lymph nodes harvested was 3 (0-20), and one patient (4.2%) had No.253 nodal metastases. The median postoperative hospital stay was 8 (4-23) days, and the incidence of complications 16.7% (4/24). There were no instances of postoperative colon ischemia or necrosis observed. One patient (4.2%) with stage IIA rectal cancer developed Grade B (Clavien-Dindo III) anastomotic leak and underwent elective ileostomy. The other complications were Grade I-II. Conclusions: PDM is frequently associated with mesenteric adhesions. Our proposed classification can assist surgeons in identifying the descending colon and mesocolon during adhesion lysis in laparoscopic surgery. It is crucial to protect the colorectal blood supply at the resection margin to minimize the need for unplanned extended colectomy, the Hartmann procedure, or permanent stomas.

Membrane anatomy in right colon cancer: definition and identification of mesocolic completeness / 中华胃肠外科杂志

Complete mesocolic excision (CME) and D3 resection of right colon cancer have been widely implemented, but the definition and identification of the completeness of the mesentery have not been fully agreed, especially the dorsal and medial borders. In this paper, we proposed the dorsal fascia of the colonic mesentery as the dorsal border of the mesocolon and the line connecting the roots of the ileocolic artery and the middle colic artery (ICA-MCA line) as the medial border of the CME by systematically studying the relationship between the mesentery and the mesenteric bed from the theory of membrane anatomy, combined with surgical experience and in-depth review of ontogenetic anatomy. We also proposed the visible "superior mesenteric vein notch" and "middle colic artery triangle" on surgical specimens as identifiers of mesocolic completeness.

Safety and feasibility of right colectomy via a transvaginal approach: early experience from a single center / 中华胃肠外科杂志

Objective: To investigate the safety and feasibility of performing right colectomy via a transvaginal approach. Methods: This was a retrospeltive cohort study. Data of 30 patients who had undergone transvaginal laparoscopic right colectomy (transvaginal group) and 23 women who had undergone laparoscopic right colectomy (laparoscopic group) from January 2019 to March 2022 in the Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital were collected retrospectively. The inclusion criteria for the transvaginal group were as follows: (1) post-menopausal woman; (2) transverse diameter of the tumor < 6 cm; and (3) diagnosis of benign polyps that were unresectable by endoscopy, mucinous tumors of the appendix, or confirmed right colon cancer not requiring D3 lymphadenectomy. The inclusion criteria for the laparoscopic group were as follows: (1) pathologically confirmed adenocarcinoma or high-grade intraepithelial neoplasia; (2) lesion located from the cecum to the right third of the transverse colon; and (3) clinically stage T1-4NanyM0. The exclusion criteria for the laparoscopic group were as follows: (1) distant metastasis discovered during surgical exploration; (2) multiple organ resection required or R0 resection not possible; or (3) conversion to open surgery required. Safety was evaluated on the basis of intra- and post-operative complications. Feasibility was assessed by postoperative recovery and quality of operative specimen. The body mass index was lower in the transvaginal than the laparoscopic group (22.0±3.1 kg/m2 vs. 24.1±2.6 kg/m2, t=2.617, P=0.012). Results: Among the 30 transvaginal laparoscopic right colectomies, 26 were pure transvaginal surgeries, three required laparoscopic assistance because of difficulties with anastomosis (n=2) or abdominal adhesions (n=1), and one required conversion to laparoscopic surgery because of vascular injury. Compared with the laparoscopic group, the transvaginal group had a longer surgery time (175.0 [147.5, 216.3] minutes vs. 120.0 [100.0, 120.0] minutes, U=63.000, P<0.001) and more blood loss (30.0 [10.0, 50.0] ml vs. 23.0 [10.0, 20.0] ml, U=208.000, P=0.011). The incidence of intraoperative complications (16.7% [5/30) vs. 0, P=0.061] was comparable between the two groups. In the transvaginal group, the sites of intraoperative injuries were bladder (n=3), ileocecal artery (n=1), and right uterine artery (n=1). The incidence of postoperative complications (20.0% [6/30] vs. 17.4% [4/23], χ2<0.001,P>0.999) was also comparable between the two groups. Clavien-Dindo grade III postoperative complications occurred in two patients in the transvaginal group (one patient had a pelvic hematoma that required embolization; the other had a vesico-vaginal fistula that required surgery). Postoperative visual analogue scale scores were significantly lower (P<0.001) in the transvaginal group. Times to first flatus, ambulation, and first intake and duration of postoperative hospital stay were comparable between the two groups (P>0.05). The proportion of specimens of moderate quality was 83.3% (25/30) in the transvaginal group and 100% (23/23) in the laparoscopic group; this difference is not significant (P=0.061). Among patients who underwent D2 lymph node dissection, the number of lymph nodes examined was comparable between the transvaginal (n=23) and laparoscopic groups (n=7) (18 [15, 27] vs. 20 [16, 29], U=69.500, P=0.589). Conclusion: Transvaginal right colon surgery is associated with less postoperative pain than laparoscopic surgery, but is not yet the preferred alternative because of the incidence of surgical complications.

Specimen extraction through natural orifices with Cai tubes in gastrointestinal surgery: a single-institute series of 234 cases / 中华胃肠外科杂志

Objective: To investigate the feasibility of Cai tube-assisted natural orifice specimen extraction surgery (NOSES) in gastrointestinal surgery. Methods: This was a descriptive case-series study. Inclusion criteria: (1) colorectal or gastric cancer diagnosed by preoperative pathological examination or redundant sigmoid or transverse colon detected by barium enema; (2) indications for laparoscopic surgery; (3) body mass index <30 kg/m2 (transanal surgery) and 35 kg/m2 (transvaginal surgery); (4) no vaginal stenosis or adhesions in female patients undergoing transvaginal specimen extraction; and (5) patients with redundant colon aged 18-70 years and a history of intractable constipation for more than 10 years. Exclusion criteria: (1) colorectal cancer with intestinal perforation or obstruction, or gastric cancer with gastric perforation, gastric hemorrhage, or pyloric obstruction; (2) simultaneous resection of lung, bone, or liver metastases ; (3) history of major abdominal surgery or intestinal adhesions; and (4) incomplete clinical data. From January 2014 to October 2022, 209 patients with gastrointestinal tumors and 25 with redundant colons who met the above criteria were treated by NOSES utilizing a Cai tube (China invention patent number:ZL201410168748.2) in the Department of Gastrointestinal Surgery, Zhongshan Hospital, Xiamen University. The procedures included eversion and pull-out NOSES radical resection in 14 patients with middle and low rectal cancer, NOSES radical left hemicolectomy in 171 patients with left-sided colorectal cancer, NOSES radical right hemicolectomy in 12 patients with right-sided colon cancer, NOSES systematic mesogastric resection in 12 patients with gastric cancer, and NOSES subtotal colectomy in 25 patients with redundant colons. All specimens were collected by using an in-house-made anal cannula (Cai tube) with no auxiliary incisions. The primary outcomes included 1-year recurrence-free survival (RFS) and postoperative complications. Results: Among 234 patients, 116 were male and 118 were female. The mean age was (56.6±10.9) years. NOSES was successfully completed in all patients without conversion to open surgery or procedure-related death. The negative rate of circumferential resection margin was 98.8% (169/171) with both two positive cases having left-sided colorectal cancer. Postoperative complications occurred in 37 patients (15.8%), including 11 cases (4.7%) of anastomotic leakage, 3 cases(1.3%) of anastomotic bleeding, 2 cases (0.9%) of intraperitoneal bleeding, 4 cases (1.7%) of abdominal infection, and 8 cases (3.4%) of pulmonary infection. Reoperations were required in 7 patients (3.0%), all of whom consented to creation of an ileostomy after anastomotic leakage. The total readmission rate within 30 days after surgery was 0.9% (2/234). After a follow-up of (18.3±3.6) months, the 1-year RFS was 94.7%. Five of 209 patients (2.4%) with gastrointestinal tumors had local recurrence, all of which was anastomotic recurrence. Sixteen patients (7.7%) developed distant metastases, including liver metastases(n=8), lung metastases(n=6), and bone metastases (n=2). Conclusion: NOSES assisted by Cai tube is feasible and safe in radical resection of gastrointestinal tumors and subtotal colectomy for redundant colon.

Internal hernia after laparoscopic left colectomy: case series and review of the literature

Objective: Laparoscopic colectomy has gained acceptance as a standard treatment for benign and malignant colorectal disease, such as diverticular disease and cancer, among others. Same as in open surgery, the laparoscopic approach carries a low risk of small bowel obstruction in the postoperative period, but in laparoscopic surgery, internal hernia after laparoscopic left colectomy may be a cause of small bowel obstruction with a significant risk of morbidity and mortality. This rare complication may be prevented with routine closure of the mesenteric defects created during the colectomy. Methods: We present four cases of internal herniation after laparoscopic colectomy. Two cases were after laparoscopic left colectomy and two after laparoscopic low anterior resection. All four cases had full splenic flexure mobilization. Routine closure of the mesenteric defect was not performed in the initial surgery. Results: The four patients were treated by laparoscopic reintervention with closure of the mesenteric defect. In two of them, conversion to open surgery was necessary. One of the patients developed recurrent internal herniation after surgical reintervention with mesenteric closure of the defect. All patients were managed without need for bowel resection, and mortality rate was 0%. Conclusion Internal herniation after laparoscopic colorectal surgery is a highly morbid complication that requires prompt diagnosis and management and should be suspected in the early postoperative period. Additional studies with extended follow-up are required to establish recommendations regarding its prevention and management. (AU)

Caracterización clínica y epidemiológica de los pacientes con cáncer de colon / Clinical and epidemiological characterization of patients with colon cancer

INTRODUCCIÓN. El cáncer de colon es una neoplasia del tubo digestivo considerada una de las más frecuentes en ambos sexos y que predomina en adultos mayores. OBJETIVO. Describir las características clínicas y epidemiológicas de los pacientes con cáncer de colon. MATERIALES Y MÉTODOS. Estudio observacional, descriptivo, retrospectivo. Población de 1 601 y muestra de 210 datos de Historias Clínicas Electrónicas de pacientes diagnosticados con cáncer de colon, atendidos por la Unidad de Oncología del Hospital de Especialidades Carlos Andrade Marín de la ciudad de Quito en el periodo enero de 2016 a diciembre de 2019. Criterios de inclusión: diagnóstico confirmado de Cáncer de Colon, edad igual o mayor a 18 años, y disponer de todos los datos clínicos requeridos en el estudio. Se utilizó el método de muestreo probabilístico con lo que se estimó una proporción para el estudio con un intervalo de confianza del 95%, un margen de error del 5% y una frecuencia esperada del 3%, de donde se obtuvo una muestra ajustada al 10% de pérdidas. El procesamiento de datos se realizó en los programas Microsoft Excel versión 16 y el Statistical Package for Social Sciences versión 24. RESULTADOS. La mayor presentación fue en adultos mayores de 50 años, con una relación 1:1 en cuanto a sexo, y en la procedencia, se ubicó mayoritariamente en la población de la región Sierra; las personas con una actividad económica de tipo profesional fueron las más afectadas; en lo que se refiere a los antecedentes se encontró mayor relación en los personales y dentro de estos los pólipos; no hubo relación con los antecedentes quirúrgicos ni familiares. El síntoma de debut más prevalente fue el dolor abdominal; la mayoría fueron sometidos a colonoscopia; predominó la lateralidad derecha y el tipo histológico principalmente identificado fue el adenocarcinoma. CONCLUSIÓN. No se observó relación estadísticamente significante entre estadíos, evolución y tratamientos instaurados, lo que pudo estar influenciado por el muestreo al azar; y que el 53,30% de los pacientes aún se encuentra en controles.

INTRODUCTION. Colon cancer is a neoplasm of the digestive tract considered one of the most frequent in both sexes and predominantly in older adults. OBJECTIVE. To describe the clinical and epidemiological characteristics of patients with colon cancer. MATERIALS AND METHODS. Observational, descriptive, retrospective study. Population of 1 601 and sample of 210 data from Electronic Medical Records of patients diagnosed with colon cancer, attended by the Oncology Unit of the Hospital de Especialidades Carlos Andrade Marín of the city of Quito in the period January 2016 to December 2019. Inclusion criteria: confirmed diagnosis of Colon Cancer, age equal to or older than 18 years, and having all the clinical data required in the study. The probability sampling method was used with which a proportion was estimated for the study with a confidence interval of 95%, a margin of error of 5% and an expected frequency of 3%, from which a 10% loss adjusted sample was obtained. Data processing was performed in Microsoft Excel version 16 and Statistical Package for Social Sciences version 24. The greatest presentation was in adults over 50 years of age, with a 1:1 ratio in terms of sex, and in terms of origin, it was mainly located in the population of the Sierra region; people with a professional economic activity were the most affected; in terms of history, a greater relationship was found in personal history and within these, polyps; there was no relationship with surgical or family history. The most prevalent debut symptom was abdominal pain; the majority underwent colonoscopy; right laterality predominated and the histological type mainly identified was adestatistically significant relationship was observed between stages, evolution and treatment, which could be influenced by random sampling; and that 53,30% of the patients are still in controls.

Invaginación sigmoidea en un adulto. ¿Está indicada la reducción endoscópica preoperatoria? / Sigmoid invagination in an adult. Is preoperative endoscopic reduction indicated?

Introducción. La invaginación intestinal o intususcepción es el deslizamiento de una parte del intestino dentro de otra adyacente. Es la causa más común de obstrucción intestinal en niños entre 3 meses y 6 años de edad, con una baja incidencia en adultos, correspondiente al 1 % del total de los cuadros obstructivos en el adulto. Su localización en colon es poco frecuente, pero conviene prestar especial atención por su asociación a lesiones malignas. Caso clínico. Varón de 39 años que acude a Urgencias con cuadro de obstrucción intestinal secundario a una invaginación en sigmoide. Se intenta reducción endoscópica, sin éxito, por lo que se indicó cirugía urgente, realizando sigmoidectomía y anastomosis colorrectal. El resultado anatomopatológico informó un adenoma de gran tamaño como causante de la invaginación. Conclusión. Existen controversias respecto al manejo endoscópico en invaginación intestinal en los adultos, especialmente en el colon, debido al elevado porcentaje de etiología tumoral maligna, recomendándose actualmente la resección en bloque sin reducción, para minimizar el riesgo de potencial siembra tumoral.

Introduction. Intestinal invagination or intussusception is the sliding of one part of the intestine into the adjacent one. It is the most common cause of intestinal obstruction in children between 3 months and 6 years of age, with a low incidence in adults, corresponding to 1% of all obstructive conditions in adults. Its location in the colon is rare, but special attention should be paid due to its association with malignant lesions. Case report. A 39-year-old male admitted to the emergency department with symptoms of intestinal obstruction secondary to a sigmoid intussusception. Endoscopic reduction was attempted, without success, so urgent surgery was indicated, performing sigmoidectomy and colorectal anastomosis. The pathology result reported a large adenoma as the cause of invagination. Conclusion. There are controversies regarding the endoscopic management of intussusception in adults, especially in the colon, due to the high percentage of malignant tumor etiology, currently recommending en bloc resection without reduction, to minimize the risk of potential tumor seeding.

Impacto en la morbilidad de la técnica quirúrgica abierta vs cerrada en cáncer de colon. Un reporte de 6 años de un centro único / Impact on morbidity of the open vs closed surgical technique in colon cancer.A 6-Year single-center study

Introducción: La cirugía laparoscópica es una alternativa segura para el tratamiento en el cáncer de colon y además permite todas las ventajas de un procedimiento de mínima invasión. El objetivo de la presente investigación fue medir el impacto en la morbilidad de la técnica quirúrgica abierta vs cerrada en cáncer de colon. Metodología: El estudio se realizó en el Hospital Solón Espinosa Ayala, en Quito-Ecuador, período marzo del 2012 hasta marzo del 2017, con una muestra no probabilística, se incluyeron pacientes mayores de edad, con cáncer de colon. Se incluyen variables socio-demográficas, histología, días de hospitalización, sangrado quirúrgico, tiempo quirúrgico, estancia hospitalaria, márgenes quirúrgicos, ganglios reseca-dos, inicio de dieta, % de conversión quirúrgica, complicación quirúrgica, recidiva, morbilidad quirúrgica, mortalidad quirúrgica. Se utiliza estadística descriptiva univariada y bivariada.Resultados: Se analizan 85casos, 52 casos se realizaron cirugía abierta y 33 casos se realizaron cirugía laparoscópica.La conversión quirúrgica fue 75% por adherencias y 25% por infiltración a duodeno. El tiempo quirúrgico similar 121 a 180 minutos 61%. Complicaciones laparoscópicas 2,3% y 9,4% abierta (colecciones pélvicas y fistulas intestinales 2.4% vs 1.7%). La desnutrición no presentó relación. Inicio de dieta 2 a4 días 83% laparoscópica y 67% abierta. Hospitalización de 4 a 8 días fue laparoscópica 87% y abierta 78%. Pérdida sanguínea menor a 100cc fue laparoscópicas 82%, y abiertas 60%. La resección de ganglios (+13) en laparoscopía 69.6% y abierta 68.1%. El margen proximal de pieza quirúrgica por laparoscopía 5.1 a 10cm (43.5%), por abierta (55.3%), la recaída tumoral del 56.2%y 52.3%. El estado vital por laparoscopía fue fallecido 12.5%, y abierta 28.8%, en relación a su enfermedad tumoral Conclusión: Las comorbilidades quirúrgicas y recuperación fueron menores por laparoscopía, pero la cirugía abierta mostro mejores resultados anatomopatológicos post quirúrgicos

Introduction:Laparoscopic surgery is a safe alternative for colon cancer treatment and allows all the advantages of a minimally invasive procedure. The objective of the present investigation was to measure the impact on morbidity of the open vs. closed surgical technique in colon cancer.Methodology: The study was carried out at the Solón Espinosa Ayala Hospital, in Quito-Ecuador, from March 2012 to March 2017, with a non-probabilistic sample, including elderly patients with colon cancer. Socio-demographic variables, histology, days of hospitalization, surgical bleeding, surgical time, hospital stay, surgical margins, resected lymph nodes, the start of the diet, % surgical conversion, surgical com-plication, recurrence, surgical morbidity, and surgical mortality are included. Univariate and bivariate de-scriptive statistics are used.Results: 85 cases are analyzed; 52 underwent open surgery, and 33 underwent laparoscopic surgery. The surgical conversion was 75% due to adhesions and 25% due to duodenal infiltration. The similar surgical time is 121 to 180 minutes 61%. Laparoscopic complications 2.3% and 9.4% open (pelvic col-lections and intestinal fistulas 2.4% vs 1.7%). Malnutrition was not related. Start of diet 2 to 4 days 83% laparoscopic and 67% open. Hospitalization from 4 to 8 days was laparoscopic 87% and open 78%. Blood loss less than 100cc was laparoscopic in 82% and opened in 60%. Lymph node resection (+13) in lapa-roscopy 69.6% and open 68.1%. The proximal margin of the surgical piece by laparoscopy is 5.1 to 10cm (43.5%), by open (55.3%), the tumor recurrenceof 56.2% and 52.3%. The mortality in laparoscopy surgery was 12.5%, and in open surgery was 28.8%.Conclusion: Laparoscopy's surgical comorbidities and recovery were lower, but open surgery showed better post-surgical pathological results

Fístula gastrocólica secundaria a cáncer de colon / Gastrocolic fistula secondary to colon cáncer / Fístula gastrocólica secundária a câncer de cólon

La fístula gastrocólica descrita en 1755 por Albrecht von Haller, se define como la comunicación anormal entre el colon generalmente transverso y estómago en su curvatura mayor. Se conocen distintas etiologías, siendo un hallazgo poco frecuente con escasos reportes en la literatura. Se presenta el caso de una paciente de 85 años con historia de anemia y adelgazamiento que consulta por cuadro de vómitos fecaloideos, sin alteraciones de tránsito digestivo bajo, sin dolor ni distensión abdominal con ruidos hidroaéreos normales y sonda nasogástrica con contenido fecaloideo. La Tomografía (fig. 1) confirma una lesión de probable etiología maligna del ángulo esplénico del colon fistulizado a estómago por lo que se decide la realización de una colectomía sectorial con anastomosis primaria y gastrectomía subtotal, evolucionando favorablemente con un alta a los 6 días. La anatomía patológica informa adenocarcinoma de colon moderadamente diferenciado con compromiso gástrico.

Absceso del psoas ilíaco secundario a un tumor de colon izquierdo fistulizado al retroperitoneo: caso clínico y análisis de la literatura / Iliopsoas abscess resulting from penetrating left colon cancer to the retroperitoneum: case report and literature review / Abscesso do iliopsoas secundário a tumor de cólon esquerdo fistulizado para o retroperitônio: caso clínico e análise da literatura

Los abscesos del psoas ilíaco secundarios a un tumor de colon fistulizado son excepcionales y potencialmente graves. La mayoría son adenocarcinomas de tipo mucinoso. Su tratamiento es complejo ya que, para lograr una resección oncológica pretendidamente curativa, es necesario realizar una resección ampliada con mayor morbimortalidad. Presentamos el caso de una paciente con un adenocarcinoma mucinoso de colon izquierdo fistulizado al músculo ilíaco y la pared anterolateral del abdomen en la que se realizó una resección multivisceral que incluyó el colon izquierdo, el músculo y la cresta ilíaca y parte de la pared anterolateral del abdomen.

Iliopsoas abscess secondary to perforation of colon cancer is an extremely rare and potentially life-threatening condition. Most tumors are mucinous adenocarcinomas. Its treatment its complex, as most patients need radical extended resections to achieve good oncological results, which are in turn, graved with higher morbidity and mortality. We present the case of a patient with a left colon mucinous adenocarcinoma penetrating to the iliopsoas muscle and the anterolateral abdominal wall that required a multivisceral resection including left colon, iliac muscle and crest and part of the anterolateral abdominal wall.

Abscessos do iliopsoas secundários a um tumor de cólon fistulizado são raros e potencialmente graves. A maioria são adenocarcinomas do tipo mucinoso. Seu tratamento é complexo, pois, para se obter uma ressecção oncológica supostamente curativa, é necessário realizar uma ressecção ampliada com maior morbimortalidade. Apresentamos o caso de um paciente com adenocarcinoma mucinoso de cólon esquerdo fistulizado para o músculo ilíaco e parede ântero-lateral do abdome no qual foi realizada ressecção multivisceral que incluiu cólon esquerdo, músculo e crista ilíaca e parte do a parede anterolateral do abdome.

Proteína C reactiva y su relación con las complicaciones posoperatorias en cirugía colorrectal electiva / Association between C-reactive protein and postoperative complications in elective colorectal surgery

RESUMEN Antecedentes: el uso de la proteína C reactiva (PCR) ha adquirido relevancia como identificador de complicaciones posoperatorias La morbilidad en cirugía colorrectal se estima en un 30% de los pacientes operados, lo que demanda medidas para su temprana identificación y terapéutica. Objetivo: describir las curvas de mediciones sucesivas de PCR y su relación con el desarrollo de complicaciones posoperatorias y niveles de glóbulos blancos en una serie de pacientes operados de cirugía colorrectal. Materiales y métodos: se realizó una revisión retrospectiva sobre un registro prospectivo de 2205 pacientes operados por la División de Cirugía Gastroenterológica del Hospital de Clínicas, entre enero de 2019 y julio de 2020. Se incluyeron 69 pacientes que cumplieron con los criterios de selección. Se consignaron datos del seguimiento clínico y dosaje de PCR, recuento de glóbulos blancos, vía de abordaje y desarrollo de complicaciones. Resultados: el promedio de edad fue de 59 años (DS 13,6; rango 33-85), 31 fueron hombres (43%). La tasa de complicaciones fue del 13,04%; más frecuente fue la fístula anastomótica (fístula, colección), seguida por complicaciones de la herida (hematoma, evisceración). Todos los pacientes mostraron un ascenso inicial del valor de PCR entre el 2° y 3er día, en relación con la lesión quirúrgica, los no complicados presentaron una cinética de descenso y los complicados. curvas de segundo ascenso o no descenso en las mediciones seriadas de PCR, y exhibían valores superiores de PCR cada día Se advirtieron diferencias estadísticamente significativas entre los valores de proteína C reactiva al 5° día posoperatorio en el subgrupo de pacientes complicados con respecto a aquellos con un curso indolente (28 mg/dL vs. 6,1 mg/dL, p < 0,001; IC: 11,24-39,61). hubo diferencia significativa al 5o día entre complicados y no complicados, independientemente de la vía de abordaje. con un valor de corte de PCR de 10,92 mg/dL obtuvimos una sensibilidad del 87,50% y una especificidad del 100% para excluir complicaciones. Conclusiones: la medición de la proteína C reactiva de forma seriada en los posoperatorios de cirugía colorrectal mostró un correlato con la identificación temprana de las complicaciones en nuestra serie, tanto en sus valores absolutos diarios como en la cinética de su comportamiento. se formula el uso de valores de corte para el alta segura.

ABSTRACT Background: The use of C-reactive protein (CRP) has gained relevance as a marker of marker of postoperative complications. As the incidence of complications of colorectal surgery is estimated to be of 30%, measures should for their early identification and treatment. Objective: To describe the performance of consecutive CRP determinations and their relationship with the development of postoperative complications and with white blood cell count in a series of patients undergoing colorectal surgery. Materials and methods: A retrospective review was performed using a prospective registry of 2205 patients operated on at the Department of Digestive Surgery of Hospital de Clínicas, between January 2019 and July 2020. A total of 69 patients fulfilling the selection criteria were included. Clinical follow-up data, CRP levels, white blood cell count, type of approach and development of complications were recorded. Results: Mean age was 59 years (SD 13.6; range 33-85) and 31 were men (43%). The complication rate was 13.04%. Anastomotic leak (fistula, fluid collection) was the most common complication, followed by surgical site complications (hematoma, evisceration). All patients showed an initial increase in CRP values between days 2 and 3, in relation with the surgical lesion, and then decreased in those without complications. Patients with complications had second rise or lack of decrease in serial CRP measurements, and higher CRP values each day. There were statistically significant differences between the CRP levels on postoperative day 5 in the subgroup of patients with complications compared with those with an indolent course (28 mg/dL vs. 6.1 mg/dL, p < 0.001; CI: 11.24-39.61). There was a significant difference on day 5 between patients with and without complications, irrespective of the approach. With a cut-off value of CRP of 10.92 mg/dL on postoperative day 5 we obtained a sensitivity of 87.50% and specificity of 100% to rule out complications. Conclusions: Serial determination of CRP in the postoperative period after colorectal surgery was associated with early identification of complications in our series, both in daily absolute values and in the kinetics of its performance. The use of cut-off values for safe discharge is proposed.

Vólvulo cecal y del colon sigmoide como manifestación gastrointestinal de la esclerosis sistémica: reporte de un caso / Cecal and sigmoid colon volvulus as a gastrointestinal manifestation of systemic sclerosis: A case report

Introducción. La esclerosis sistémica es una enfermedad del colágeno de etiología autoinmune, con manifestaciones gastrointestinales hasta en un 90 % de los pacientes. Aunque es infrecuente, se han descrito algunos casos de vólvulos colónicos, pero es extremadamente rara la presentación de vólvulo cecal y del colon sigmoide en un mismo paciente. Caso clínico.Paciente femenina de 65 años, con antecedente de esclerosis sistémica, quien consultó a urgencias por dolor y distensión abdominal, asociados a emesis, con ausencia de flatos y deposiciones. Por imágenes sugestivas de obstrucción intestinal con zona de transición en el colon sigmoide se indicó laparotomía exploratoria, con hallazgo de vólvulo del sigmoide. Posteriormente reingresó por sintomatología similar, con imágenes sugestivas de vólvulo cecal. Se realizó hemicolectomía derecha con ileostomía y posterior cierre de ileostomía en misma hospitalización. Discusión. El vólvulo del colon sigmoide y ciego en un mismo paciente es una condición muy infrecuente. Existen pocos casos reportados en la literatura. Conclusión. La resección del segmento colónico afectado es el estándar de manejo quirúrgico.

Introduction. Systemic sclerosis is a collagen disease of autoimmune etiology, with gastrointestinal manifestations in up to 90% of patients. Although infrequent, some cases of colonic volvulus have been described, but the presentation of cecal and sigmoid colon volvulus in the same patient is extremely rarely. Clinical case. A 65-year-old female patient, with a history of systemic sclerosis, who consulted the emergency room due to abdominal pain and distension, associated with emesis and absence of flatus and stools. Due to images suggestive of intestinal obstruction with a transition zone in the sigmoid colon, an exploratory laparotomy was indicated, with the finding of a sigmoid volvulus. She was later readmitted for similar symptoms, with images suggestive of cecal volvulus. Right hemicolectomy was performed with ileostomy and subsequent closure of the ileostomy in the same hospitalization. Discussion. Volvulus of the sigmoid and cecum in the same patient is a very rare condition. There are few cases reported in the literature. Conclusion. Resection of the affected colonic segment is the standard of care management.

Resultados de la cirugía de urgencia en pacientes con cáncer de colon perforado / Results of emergency surgery in patients with perforated colon cancer

RESUMEN: Gran parte de los pacientes con cáncer de colon (CC), son diagnosticados y tratados de forma electiva. Sin embargo, aproximadamente un 20 % de ellos debutará como una emergencia (obstrucción o perforación). El objetivo de este estudio fue determinar morbilidad postoperatoria (MPO) y supervivencia global (SVG) en pacientes resecados por CC perforado (CCP). Serie de casos retrospectiva de pacientes con CCP, sometidos a colectomía y linfadenectomía, de forma consecutiva, en Clínica RedSalud Mayor y Hospital de Temuco, Chile, entre 2010 y 2019. Las variables resultados fueron SVG y MPO. Otras variables de interés fueron: tiempo quirúrgico, resecabilidad, número de linfonodos resecados, estancia hospitalaria, mortalidad operatoria, recurrencia y supervivencia libre de enfermedad (SLE). Los pacientes fueron seguidos de forma clínica. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión; y análisis de SV con curvas de Kaplan Meier. Se intervinieron 15 pacientes (60 % mujeres), con una mediana de edad de 62 años. La localización más frecuente fue sigmoides (6 casos; 40,0 %). La resecabilidad de la serie fue 100 %. La medianas del tiempo quirúrgico, número de linfonodos resecados y estancia hospitalaria; fueron 80 min, 20 y 5 días respectivamente. La MPO fue 26,7 % (4 casos). Con una mediana de seguimiento de 36 meses, se verificó una recurrencia de 40,0 %. Por otra parte, la SVG y SLE a 5 años fue 46,7 % y 33,3 % respectivamente. Los resultados obtenidos, en términos de MPO y SVG, fueron similares a series internacionales.

SUMMARY: Most patients with colon cancer (CC) are diagnosed and treated electively. However, a fifth of them will debut as an emergency (obstruction or perforation). The aim of this study was to determine postoperative morbidity (POM) and overall survival (OS) in patients resected by perforated CC (PCC). Retrospective case series of patients with PCC undergoing colectomy and lymphadenectomy, consecutively, at RedSalud Mayor Clinic and Temuco hospital, Chile, between 2010 and 2019. The outcome variable were POM and OS. Other variables of interest were surgical time, resectability, number of resected lymph nodes, hospital stay, mortality, recurrence, and disease-free survival (DFS). Patients were followed clinically. Descriptive statistics was used (measures of central tendency and dispersion), and OS analysis was applying Kaplan Meier curves.15 patients (60 % women) were intervened, with a median age of 62 years. The most frequent location was the sigmoid colon (6 cases, 40.0 %). Resectability of the series was 100 %. Median surgical time, number of lymph nodes resected, and hospital stay; they were 80 min, 20 and 5 days respectively. POM was 26.7 % (4 cases). With a median follow-up of 36 months, recurrence was 40.0 %. On the other hand, OS and DFS at 5 years were 46.7 % and 33.3 %, respectively. The observed results, in terms of POM and OS, were like international series.

Surgical approach of megacecum secondary to descending colon tumor / Abordagem cirúrgica de megaceco secundário a tumor de cólon descendente

Intestinal obstruction is the most frequent clinical manifestation of colon tumors, most of which are located in the descending and recto-sigmoid colon. Emergency bowel obstruction surgery is associated with high mortality and morbidity risks and the ideal approach remains controversial. Multi-stage procedures and the use of stents as bridges for surgery are promising options. A case of a 61-year-old patient with an acute obstructive abdomen secondary to colorectal neoplasm is presented, with emphasis on its diagnosis and treatmen (AU)

Obstrução intestinal é a manifestação clínica mais frequente de tumores de cólon sendo esses, em sua maioria, localizados no cólon descendente e reto-sigmoide. A cirurgia de emergência para obstrução intestinal é associada a altos riscos de mortalidade e de morbidade e a abordagem ideal permanece controversa. Procedimentos em vários estágios e o uso de stents como ponte para cirurgia são opções promissoras. É apresentado um caso de paciente de 61 anos, com abdome agudo obstrutivo secundário à neoplasia colorretal, com ênfase em seu diagnóstico e tratamento (AU)

Abordaje laparoscópico de la neoplasia mucinosa apendicular de bajo grado / Laparoscopic approach of low-grade appendiceal mucinous neoplasm

RESUMEN Las neoplasias mucinosas apendiculares son infrecuentes y se clasifican en neoplasias mucinosas de bajo grado, de alto grado y adenocarcinoma mucinoso. Se consideran precursoras del pseudomixoma peritoneal, caracterizado por la acumulación de mucina dentro de la cavidad abdominal. Informamos tres casos de neoplasia mucinosa apendicular de bajo grado, dos varones y una mujer, que presentaron dolor abdominal agudo, diagnosticados preoperatoriamente mediante tomografía y que fueron manejados con un abordaje laparoscópico (apendicectomía, resección parcial de ciego y colectomía derecha, respectivamente). Los tres casos tuvieron una buena evolución posoperatoria y no hubo complicaciones. Se concluye que las neoplasias mucinosas apendiculares son raras y no tienen una presentación clínica específica. El abordaje laparoscópico es una opción segura y factible. La frecuencia y la duración del seguimiento de estos pacientes es motivo de controversia.

ABSTRACT Appendiceal mucinous neoplasms are rare and are classified in low-grade mucinous neoplasm, high-grade mucinous neoplasm and mucinous adenocarcinoma. They are considered precursors of pseudomyxoma peritonei, characterized by the accumulation of mucin within the abdominal cavity. We report three cases of low-grade appendiceal mucinous neoplasm, two men and one woman, who presented with acute abdominal pain. The diagnoses were made preoperatively by computed tomography scan and the tumors were managed through laparoscopic approach (appendectomy, partial resection of the cecum and right colectomy, respectively). The three patients evolved with favorable postoperative outcome without complications. Appendiceal mucinous neoplasms are rare without specific clinical presentation. The laparoscopic approach is a safe and feasible option. The frequency and duration of surveillance in these patients are still controversial.

Risk factors for anastomotic leakage following total or subtotal colectomy

Introduction: A higher rate of anastomotic leakage (AL) is reported after ileosigmoid anastomosis (ISA) or ileorectal anastomosis (IRA) in total or subtotal colectomy (TSC) compared with colonic or colorectal anastomosis. Themain aimof the present studywas to assess potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity. Methods: We identified 180 consecutive patients in a prospective referral, single center database, in which 83 of the patients underwent TSC with ISA or IRA. Data regarding the clinical characteristics, surgical treatment, and outcome were assessed to determine their association with the cumulative incidence of AL and surgical morbidity. Results: Ileosigmoid anastomosis was performed in 51 of the patients (61.5%) and IRA in 32 patients (38.6%). The cumulative incidence of ALwas 15.6% (13 of 83 patients). A higher AL rate was found in patients under 50 years-old (p=0.038), in the electivelaparoscopic approach subgroup (p=0.049), and patients in the inflammatory bowel disease (IBD) subgroup (p=0.009). Furthermore, 14 patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA. Discussion: A relatively high incidence of AL after TSC was observed in a relatively safe surgical procedure. Our findings suggest that the risk of AL may be higher in IBD patients. According to our results, identifying risk factors prior to surgerymay improve short-term outcomes. (AU)

Unusual Case Report of Synchronous Caecal and Sigmoid Volvulus / Reporte de un caso inusual de presentación sincrónica de vólvulo cecal y de sigmoide

Abstract In the spectrum of patients with intestinal obstruction, volvulus is one of the least frequent etiologies (5-15 %). Synchronous volvulus of two colonic segments in a patient is regarded as rare, with few cases reported in the literature. The present report of synchronous cecal and sigmoid volvulus documents one of them: a patient who underwent subtotal colectomy and formation of ileostomy. Although the preoperative diagnosis of this entity is rare, it should be considered in these intraoperative findings for both intraoperative management, with resection and anastomosis or resection and stoma, and postoperative management. It has a significant impact on mortality if patients are treated with broad-spectrum antibiotic coverage, given the bacterial translocation and sepsis that they experience.

Resumen En el espectro de los pacientes con obstrucción intestinal, el vólvulo es una de las etiologías menos frecuentes, siendo esta del 5 % al 15 %. La presentación sincrónica de dos segmentos colónicos volvulados en el mismo paciente se considera una entidad rara, con pocos casos reportados en la literatura. El presente caso de vólvulo sincrónico del ciego y del sigmoide documenta uno de ellos, en un paciente que se llevó a colectomía subtotal con ileostomía. Aunque el diagnóstico preoperatorio de esta entidad es poco frecuente, se debe tener en cuenta a la hora de encontrarse estos hallazgos intraquirúrgicos para el manejo tanto intraoperatorio, con resección y anastomosis o resección y estoma, como posoperatorios, lo que tiene un impacto importante en la mortalidad, si se manejan los pacientes con cubrimiento antibiótico de amplio espectro, dada la translocación bacteriana y septicemias con los que cursan estos pacientes.