“Optimal recovery” after colon cancer surgery in the elderly, a comparative cohort study: Conventional care vs. enhanced recovery vs. prehabilitation / “Recuperación óptima” tras cirugía por cáncer de colon en el paciente añoso. Resultados de un estudio de cohorte: Cuidados convencionales, Recuperación intensificada y programa de prehabilitación

Background: Colon cancer in elderly patients is an increasing problem due to its prevalence and progressive aging population. Prehabilitation has experienced a great grown in this field. Whether it is the best standard of care for these patients has not been elucidated yet. Methods: A retrospective comparative cohort study of three different standards of care for elderly colon cancer patients (>65 years) was conducted. A four-weeks trimodal prehabilitation program (PP), enhanced recovery program (ERP) and conventional care (CC) were compared. Global complications, major complications (Clavien-Dindo ≥ 3), reinterventions, mortality, readmission and length of stay were measured. Optimal recovery, defined as postoperative course without major complications, no mortality, hospital discharge before the fifth postoperative day and without readmission, was the primary outcome measure. The influence of standard of care in optimal recovery and postoperative outcomes was assessed with univariate and multivariate logistic regression models. Results: A total of 153 patients were included, 51 in each group. Mean age was 77.9 years. ASA Score distribution was different between groups (ASA III-IV: CC 56.9%, ERP 25.5%, PP 58.9%; p = 0.014). Optimal recovery rate was 55.6% (PP 54.9%, ERP 66.7%, CC 45.1%; p = 0.09). No differences were found in major complications (p = 0.2) nor reinterventions (p = 0.7). Uneventful recovery favors ERP and PP groups (p = 0.046 and p = 0.049 respectively). Conclusions: PP and ERP are safe and effective for older colon cancer patients. Fewer overall complications and readmissions happened in ERP and PP patients. Major complications were independent of the standard of care used. (AU)

Introducción: El cáncer de colon (CC) en pacientes de edad avanzada es un problema creciente por su prevalencia y envejecimiento progresivo de la población. La prehabilitación ha experimentado un gran crecimiento en este campo sin haberse dilucidado si es el mejor estándar de cuidados para estos pacientes. Métodos: Estudio retrospectivo comparativo de cohortes de tres estándares diferentes de cuidados para pacientes mayores de 65 años con CC. Se compararon un programa de prehabilitación (PP) trimodal de cuatro semanas, uno de recuperación intensificada (RI) y cuidados convencionales (CC). Se midieron complicaciones globales, complicaciones mayores (Clavien-Dindo ≥ 3), reintervenciones, mortalidad, reingresos y estancia hospitalaria. La recuperación óptima fue la medida de resultado primaria. La influencia del estándar de atención en la recuperación óptima y los resultados postoperatorios se evaluó con modelos de regresión logística univariante y multivariante. Resultados: Se incluyeron 153 pacientes, 51 por grupo. La edad media fue 77,9 años. La distribución del ASA fue diferente entre los grupos (ASA III–IV: CC 56,9%, RI 25,5%, PP 58,9%; p = 0,014). La tasa de recuperación óptima fue del 55,6% (PP 54,9%, RI 66,7%, CC 45,1%; p = 0,09). No se encontraron diferencias en complicaciones mayores (p = 0,2) ni reintervenciones (p = 0,7). La recuperación sin incidencias favorece a los grupos RI y PP (p = 0,046 y p = 0,049 respectivamente). Conclusiones: PP y RI son seguros y efectivos para pacientes mayores con CC. Las complicaciones generales y reingresos en pacientes con RI y PP fueron menores. Las complicaciones mayores resultaron independientes del estándar de cuidados utilizado. (AU)

"Optimal recovery" after colon cancer surgery in the elderly, a comparative cohort study: Conventional care vs. enhanced recovery vs. prehabilitation.

BACKGROUND: Colon cancer in elderly patients is an increasing problem due to its prevalence and progressive aging population. Prehabilitation has experienced a great grown in this field. Whether it is the best standard of care for these patients has not been elucidated yet. METHODS: A retrospective comparative cohort study of three different standards of care for elderly colon cancer patients (>65 years) was conducted. A four-weeks trimodal prehabilitation program (PP), enhanced recovery program (ERP) and conventional care (CC) were compared. Global complications, major complications (Clavien-Dindo ≥ 3), reinterventions, mortality, readmission and length of stay were measured. Optimal recovery, defined as postoperative course without major complications, no mortality, hospital discharge before the fifth postoperative day and without readmission, was the primary outcome measure. The influence of standard of care in optimal recovery and postoperative outcomes was assessed with univariate and multivariate logistic regression models. RESULTS: A total of 153 patients were included, 51 in each group. Mean age was 77.9 years. ASA Score distribution was different between groups (ASA III-IV: CC 56.9%, ERP 25.5%, PP 58.9%; p = 0.014). Optimal recovery rate was 55.6% (PP 54.9%, ERP 66.7%, CC 45.1%; p = 0.09). No differences were found in major complications (p = 0.2) nor reinterventions (p = 0.7). Uneventful recovery favors ERP and PP groups (p = 0.046 and p = 0.049 respectively). CONCLUSIONS: PP and ERP are safe and effective for older colon cancer patients. Fewer overall complications and readmissions happened in ERP and PP patients. Major complications were independent of the standard of care used.

Resultados quirúrgicos estándar tras resección oncológica de colon. Creación de un nomograma para la autoevaluación / Standard outcome indicators after colon cancer resection. Creation of a nomogram for autoevaluation

INTRODUCCIÓN: Existe un gran interés en los últimos años en identificar estándares de calidad en las distintas enfermedades, entre ellas, el cáncer de colon debido a su alta prevalencia. El objetivo del presente estudio es definir unos valores estándar de calidad en los resultados de la cirugía del cáncer de colon. MÉTODOS: Se han utilizado los datos del estudio prospectivo multicéntrico nacional «ANACO», que incluye pacientes con cáncer de colon intervenidos en 52 hospitales españoles (2011-2012). Para el presente análisis se han excluido los centros con menos de 30 pacientes y han quedado finalmente 42 hospitales (2.975 pacientes). Se presentan los valores de 4indicadores de calidad principales a partir de los cuales se ha creado un nomograma que permite definir unos resultados estándar de la cirugía del cáncer de colon. Además se proporcionan los resultados estándares de otros 10 indicadores de calidad secundarios (5 intraoperatorios y 5 postoperatorios). RESULTADOS: La mediana de fuga anastomótica y de mortalidad de los 42 hospitales fue de 8,5% (percentiles 25-75: 6,1-12,4%) y de 2,5% (percentiles 25-75: 0,6-4,7%), respectivamente. La mediana de ganglios aislados fue de 15,1 (percentiles 25-75: 18-14 ganglios). La mediana de estancia hospitalaria postoperatoria fue de 7,7 días (percentiles 25-75: 6,9-9,2 días). Basándonos en estos resultados se ha construido un nomograma para la autoevaluación de los distintos hospitales. CONCLUSIONES: El presente análisis ha permitido definir unos resultados quirúrgicos estándar tras la resección del cáncer de colon y se ha creado un instrumento de autoevaluación para las distintas unidades, de tal forma que cada centro puede identificar posibles áreas de mejora en el tratamiento de esta enfermedad

INTRODUCTION: Lately there has been an increasing interest in identifying quality standards in different pathologies, among them colon cancer due to its great prevalence. The main goal of this study is to define the quality standards of colon cancer surgery based on a large prospective national study dataset. METHODS: Data from the prospective national study ANACO were used. This study included a consecutive series of patients operated on for colon cancer in 52 Spanish hospitals (2011-2012). Centers with less than 30 patients were excluded. The present analysis finally included 42 centers (2975 patients). Based on the results obtained in 4main indicators from each hospital (anastomotic leak, lymph-nodes found in the specimen, mortality and length of stay), a nomogram that allows the evaluation of the performance of each center was designed. Standard results for further 5 intraoperative and 5 postoperative quality indicators were also reported. RESULTS: Median of anastomotic leak and mortality rate was 8.5% (25th-75th percentiles 6.1%-12.4%) and 2.5% (25th-75th percentiles 0.6%-4.7%), respectively. Median number of nodes found in the surgical specimen was 15,1 (25th-75th percentiles 18-14 nodes). Median length of postoperative stay was 7.7 days (25th-75th percentiles 6.9-9.2 days). Based on these data, a nomogram for hospital audit was created. CONCLUSIONS: Standard surgical results after colon cancer surgery were defined, creating a tool for auto-evaluation and allowing each center to identify areas for improvement in the surgical treatment of colon cancer

Standard outcome indicators after colon cancer resection. Creation of a nomogram for autoevaluation. / Resultados quirúrgicos estándar tras resección oncológica de colon. Creación de un nomograma para la autoevaluación.

INTRODUCTION: Lately there has been an increasing interest in identifying quality standards in different pathologies, among them colon cancer due to its great prevalence. The main goal of this study is to define the quality standards of colon cancer surgery based on a large prospective national study dataset. METHODS: Data from the prospective national study ANACO were used. This study included a consecutive series of patients operated on for colon cancer in 52 Spanish hospitals (2011-2012). Centers with less than 30 patients were excluded. The present analysis finally included 42 centers (2975 patients). Based on the results obtained in 4main indicators from each hospital (anastomotic leak, lymph-nodes found in the specimen, mortality and length of stay), a nomogram that allows the evaluation of the performance of each center was designed. Standard results for further 5 intraoperative and 5 postoperative quality indicators were also reported. RESULTS: Median of anastomotic leak and mortality rate was 8.5% (25th-75th percentiles 6.1%-12.4%) and 2.5% (25th-75th percentiles 0.6%-4.7%), respectively. Median number of nodes found in the surgical specimen was 15,1 (25th-75th percentiles 18-14 nodes). Median length of postoperative stay was 7.7 days (25th-75th percentiles 6.9-9.2 days). Based on these data, a nomogram for hospital audit was created. CONCLUSIONS: Standard surgical results after colon cancer surgery were defined, creating a tool for auto-evaluation and allowing each center to identify areas for improvement in the surgical treatment of colon cancer.

Estudio comparativo prospectivo aleatorizado entre apendicectomía laparoscópica por puerto único y apendicectomía laparoscópica convencional / Prospective, randomized comparative study between single-port laparoscopic appendectomy and conventional laparoscopic appendectomy

INTRODUCCIÓN: La apendicectomía laparoscópica es probablemente en la actualidad la técnica de elección en las apendicitis agudas. La cirugía laparoscópica por puerto único (PU) ha intentado instalarse como técnica alternativa. El objetivo de este estudio es comparar la seguridad y eficacia del PU frente a la apendicectomía laparoscópica convencional (LC). MATERIAL Y MÉTODOS: De enero del 2011 a septiembre del 2012 se aleatorizó prospectivamente a 120 pacientes con apendicitis aguda (PU 60, LC 60). Se seleccionó a pacientes entre 15 y 65 años con inicio de síntomas < 48 h comparándose el IMC, tiempo operatorio, inicio de ingesta, estancia hospitalaria, dolor postoperatorio, anatomía patológica y costes. RESULTADOS: La edad media, IMC, sexo y tiempo de inicio de síntomas hasta el diagnóstico fueron similares. No se encontraron diferencias del tiempo operatorio, inicio de ingesta ni estancia hospitalaria. Se evidenciaron diferencias en el dolor postoperatorio siendo mayor en el PU (4 ± 1,3) que en la LC (3,3 ± 0,5) con una p = 0,004. La apendicitis flemonosa predominó para ambos grupos. Hubo 3 reingresos por absceso intraabdominal (PU 2, LC 1) que requirieron tratamiento antibiótico intravenoso. Un caso del PU requirió asistencia intraoperatoria de un trocar de 5 mm en FID por necesidad de drenaje. El coste fue mayor en el PU debido al dispositivo empleado. CONCLUSIÓN: La apendicectomía por PU es segura, eficaz con resultados similares a la LC en pacientes seleccionados y, aunque el coste es mayor, serán los resultados obtenidos a largo plazo los que determinen el futuro de esta técnica

INTRODUCTION: Laparoscopic appendectomy is probably the technique of choice in acute appendicitis. Single port laparoscopic surgery (SILS) has been proposed as an alternative technique. The objective of this study is to compare the safety and efficacy of SILS against conventional laparoscopic appendectomy (LA). MATERIAL AND METHODS: From January 2011 to September 2012, 120 patients with acute appendicitis were prospectively randomized; 60 for SILS and 60 for LA. Patients between 15 and 65 years were selected, with onset of symptoms less than 48 h. We compared BMI, surgery time, start of oral intake, hospital stay, postoperative pain, pathology, and costs. Results The median age, BMI, sex, and time of onset of symptoms to diagnosis were similar. There were no statistically significant differences in the operative time, start of oral intake, or hospital stay. There was a significant difference in postoperative pain being higher in SILS (4 ± 1.3) than in LA (3.3 ± 0.5) with a P = .004. Flemonous appendicitis predominated in both groups in a similar percentage. A total of 3 cases with intra-abdominal abscess (SILS 2, LA 1) required readmission and resolved spontaneously with intravenous antibiotic treatment. One case of SILS required assistance by a 5 mm trocar in the RLC for drainage placement. The cost was higher in SILS due the single port device. CONCLUSION: SILS appendectomy is safe, effective, and has similar results to LA in selected patients, and although the cost is greater, the long term results will determine the future of this technique

Prospective, randomized comparative study between single-port laparoscopic appendectomy and conventional laparoscopic appendectomy.

INTRODUCTION: Laparoscopic appendectomy is probably the technique of choice in acute appendicitis. Single port laparoscopic surgery (SILS) has been proposed as an alternative technique. The objective of this study is to compare the safety and efficacy of SILS against conventional laparoscopic appendectomy (LA). MATERIAL AND METHODS: From January 2011 to September 2012, 120 patients with acute appendicitis were prospectively randomized; 60 for SILS and 60 for LA. Patients between 15 to 65 years were selected, with onset of symptoms less than 48h. We compared BMI, surgery time, start of oral intake, hospital stay, postoperative pain, pathology and costs. RESULTS: The median age, BMI, sex and time of onset of symptoms to diagnosis were similar. There were no statistically significant differences in the operative time, start of oral intake or hospital stay. There was a significant difference in postoperative pain being higher in SILS (4±1.3) than in LA (3.3±0.5) with a P=.004. Flemonous appendicitis predominated in both groups in a similar percentage. A total of 3 cases with intra-abdominal abscess (SILS 2, LA 1) required readmission and resolved spontaneously with intravenous antibiotic treatment. One case of SILS required assistance by a 5mm trocar in the RLC for drainage placement. The cost was higher in SILS due the single port device. CONCLUSION: SILS appendectomy is safe, effective and has similar results to LA in selected patients, and although the cost is greater, the long term results will determine the future of this technique.

Anal fistula plug is a valid alternative option for the treatment of complex anal fistula in the long term.

OBJECTIVE: This prospective, two-centre study was designed to evaluate long-term outcomes when using a collagen plug to treat cryptoglandular anal fistulae. MATERIALS AND METHOD: Over 3 years, 60 consecutive patients with cryptoglandular fistulae were treated using an anal fistula plug by experienced surgeons. Preoperative, postoperative and follow-up data were collected in a dedicated database. Success was defined as the closure of all fistula openings and the absence of discharge. Faecal incontinence scores were administered at baseline and at 6 months follow-up. RESULTS: Eleven patients had multiple fistula tracts. All fistulae treated in this series were classified as complex. Seventeen fistulae were anterior tracts in females, and the remaining tracts were trans-sphincteric in nature. Thirty-eight tracts were recurrent. Mean operative time was 26 ± 10 min. No major complications, active sepsis or mortality were observed. Success rate with a mean follow-up of 13 months was 60% of patients and 70% of tracts. Mean time for recurrence was 5.7 months. Two recurrent patients were successfully treated with a redo plug procedure, and five were successfully closed with a post-plug fistulotomy, leading to a global 72% success rate without continence impairment. Of the patients with a minimum follow-up of 6 months (mean, 18.5 months; range, 6-34 months), 29 in 32 (90.6%) were healed at final evaluation. In these patients, the mean preoperative CCF incontinence score was 0.73. This was reduced to 0.14 at 6-month follow-up. The mean reduction of CCF incontinence score was -0.6 (95% CI, 1.3 to -0.1; p = 0.01). CONCLUSION: Fistula tract treatment with the anal fistula plug is a safe and viable surgical option that should be offered to complex fistula patients. The reasons and risk factors for recurrence remain to be explored.