When is the best time for temporary stoma closure in laparoscopic sphincter-saving surgery for rectal cancer? A study of 259 consecutive patients.

BACKGROUND: There is no consensus regarding the best timing for temporary stoma closure after proctectomy for rectal cancer, especially if the patient requires adjuvant chemotherapy. This study aimed to assess whether the timing of stoma closure could influence postoperative morbidity. METHODS: Patients with rectal cancer undergoing laparoscopic proctectomy with temporary stoma were included and divided into three groups according to the delay of stoma closure after proctectomy: ≤60 days (Group A), 61-90 days (Group B), and >90 days (Group C). RESULTS: From 2008 to 2013, 259 patients (146 men, median age 61 years) were divided into Groups A (n = 65), B (n = 115), and C (n = 79). At the time of stoma closure, seven (11%) patients received adjuvant chemotherapy in Group A versus 42 (37%) in Group B (p = 0.0002) and 24 (30%) in Group C (p = 0.004), and peristomal hernia was noted in four patients (6%) in Group A versus 14 (12%) in Group B and 21 (27%) in Group C (p < 0.0001). Although overall postoperative morbidity was similar between groups, anastomotic leakage (at the stoma closure site) was noted in one patient in Group A versus zero in Group B versus four in Group C (p = 0.03). Median hospital stay was 5 days in Group A versus 6 in Group B versus 6 in Group C (p = 0.004). CONCLUSIONS: Our results suggested that timing of temporary stoma closure can influence postoperative morbidity. Best results were obtained if stoma closure was performed before 90 days, even during adjuvant chemotherapy. There is no benefit in delaying stoma closure after completion of adjuvant chemotherapy.

Is there a limit to transanal endoscopic surgery? A comparative study between standard and technically challenging indications among 168 consecutive patients.

AIM: To assess the surgical outcome of transanal endoscopic surgery (TES) for rectal neoplasms in technically challenging indications. METHOD: All patients who underwent TES for a rectal neoplasm from 2007 to 2014 were included. Technically challenging indications included a tumour with (i) diameter ≥ 5 cm, (ii) involving ≥ 50% of the rectal circumference and (iii) located ≥ 10 cm from the anal verge. Patients were divided into three groups according to how many of these features they had, as follows: Group 1, none; Group 2, one; Group 3, two or more. RESULTS: Of the 168 patients (80 benign and 88 malignant tumours) included in the study, 73 (44%) were in Group 1, 46 (27%) in Group 2 and 49 (29%) in Group 3. There was no difference between Group 1 and Group 2 with regard to peritoneal perforation (P = 0.210), severe postoperative morbidity (P = 0.804), length of hospital stay (P = 0.444), incomplete resection (P = 0.441), piecemeal resection (P = 0.740), locoregional recurrence (P = 0.307) and long-term symptomatic rectal stenosis (P = 0.076). Conversely Group 3 showed significantly impaired results compared with Group 1 with regard to peritoneal perforation (P = 0.003), piecemeal resection (P = 0.005), incomplete resection (P = 0.025), locoregional recurrence (P = 0.035) and long-term symptomatic rectal stenosis (P < 0.001), but no difference in severe postoperative morbidity (P = 0.328). CONCLUSION: Transanal endoscopic surgery for rectal neoplasms appears to be safe and effective, even in patients presenting with a technically challenging tumours. Although the short- and long-term outcomes after TES are worse in patients with highly challenging tumours, nevertheless the technique should still be considered in patients at high risk of requiring a proctectomy.

Increased ß2-adrenergic vasorelaxation at the early phase of endotoxemic shock in rats.

BACKGROUND AND PURPOSE: The early management of the cardiovascular dysfunction of septic shock is critical as it is associated with a poor outcome. Although the use of catecholamines is a common therapy in this syndrome, no data are available on the involvement of ß-adrenoceptor (ß-AR) subtypes and only few studies report an alteration of ß-adrenergic-induced vasodilation in septic shock. The purpose of the study was to evaluate vascular ß1, ß2 and ß3-AR expression and function in an endotoxemic rat model. EXPERIMENTAL APPROACH: Endotoxemia was induced in rats by intravenous injection of lipopolysaccharide (LPS). ß1, ß2 and ß3-AR mRNA expression was evaluated by RT-PCR in aorta and vascular ß1, ß2 and ß3-AR responses were determined on conducting (aorta) and/or resistance (mesenteric and renal) arteries by constructing relaxation curves in response to different ß-AR agonists. RESULTS: The maximal effect of isoproterenol decreased by 31 to 61% in the three vascular beds of LPS-treated rats compared to controls. In aortas from LPS-treated rats, ß1 and ß3-AR mRNA expression was decreased and associated to a reduced ß1 and ß3-induced vasodilation. Conversely, albeit ß2-AR mRNA was unchanged, the maximal ß2-AR-induced vasodilation increased by 49% in aortas from LPS-treated rats compared to controls. This increase was not affected by endothelium removal but was abolished in the presence of a ß2-AR antagonist or an adenylate cyclase inhibitor. CONCLUSIONS: In endotoxemia, ß2-AR vasodilation was increased by a potential recruitment of ß2-AR located on smooth muscle cells. This study suggests that vascular ß2-AR should be a putative new therapeutic target in septic shock.

What happens after R1 resection in patients undergoing laparoscopic total mesorectal excision for rectal cancer? A study in 333 consecutive patients.

AIM: There are no studies on the respective influence of microscopic involvement at the circumferential (R1c) and the distal margin (R1d) of the surgical specimen on oncological results after laparoscopic mesorectal excision. METHOD: We studied 333 consecutive patients undergoing laparoscopic mesorectal excision for cancer. An R1 resection was defined a by a circumferential and/or distal margin of 1 mm or less. RESULTS: Forty (12%) patients had an R1 resection including R1c [n = 28 (70%)], R1d [n = 7 (18%)] or both [n = 5 (12%)]. After a mean of 28 (0-97) months, comparisons of R1 with R0 resection were as follows: mortality 10% and 4% (NS), overall recurrence 48% and 19% (P < 0.001), 2-year disease-free survival rate 51% and 76% (P < 0.001) and overall survival (OS) rate 91% and 96% (NS). For R1c patients mortality was 14% (4% for R0; P = 0.026), overall recurrence 46% (19% for R0; P = 0.028) and 2-year OS 88% (96% for R0; P = 0.025). No significant differences were found between R1d and R0. The metastatic recurrence rate was greater in R1c then R0 (29% vs 12%; P = 0.036) but not for R1d (14% vs 12%; NS). Locoregional recurrence rates of R1c (7%) and R1d (0%) were similar to R0 (4%). CONCLUSION: This study shows that the poorer prognosis observed after R1 resection for rectal cancer is due to circumferential rather than distal involvement. This is mainly related to a higher rate of metastatic recurrence.

Efectividad de un programa de intervención sobre los estilos de vida en personas con obesidad atendidos en régimen de Hospital de día / Effectiveness of lifestyle intervention program in persons with obesity treated in a day hospital

Introducción. La obesidad es una enfermedad crónica que afecta aproximadamente al 25% de la población española, ocasionando una elevada morbimortalidad y costes sanitarios asociados. Objetivo. Evaluar la efectividad de un programa de intervención sobre los estilos de vida en pacientes obesos atendidos en régimen de hospital de día (HD). Métodos. Estudio de intervención prospectivo no controlado realizado en pacientes obesos atendidos en el HD de Endocrinología y Nutrición del Hospital Puerto Real, e incluidos en un programa de modificación de estilos de vida hasta alcanzar una pérdida de peso mínima >= 5%. Resultados. Se estudiaron 262 pacientes de 44,6 ± 16,0 años (71% mujeres) con un peso, índice de masa corporal y perímetro de cintura inicial de 110,4 ± 21,1 kg, 41,6 ± 6,6 kg/m2 y 120,5 ± 13,2 cm, respectivamente. Los pacientes que continuaron el seguimiento perdieron una media de 4,8 ± 4,8 kg (n = 165) y 7,0 ± 6,2 kg (n = 48) a los 3 y 6 meses respectivamente, alcanzando el objetivo de pérdida de peso >= 5% el 51,5% de los pacientes (n = 135). No se observaron diferencias significativas en la pérdida de peso en ninguna de las variables clínicas o de modalidad de seguimiento analizadas. El 43,5% de los pacientes abandonó voluntariamente el seguimiento sin cumplir el objetivo propuesto. Conclusión. La intervención sobre los estilos de vida en pacientes obesos atendidos en HD permite lograr pérdidas moderadas de peso a medio plazo, alcanzando una pérdida de peso >= 5% aproximadamente la mitad de los pacientes (AU)

Introduction: Obesity is a chronic disease that affects approximately 25% of the Spanish population, causing high morbidity and associated healthcare costs. Objective: To evaluate the effectiveness of an intervention program on lifestyles in obese patients treated in a day hospital scheme. Methods: A prospective non- controlled intervention study was conducted on obese patients treated in the Endocrinology and Nutrition day hospital, Puerto Real University Hospital, and included in program of lifestyle modification to achieve a weight loss of >= 5% minimum. Results: We studied 262 patients with a mean age of 44.6 ± 16.0 years (71% women) with an initial weight, body mass index and waist circumference of 110.4 ± 21.1 kg, 41.6 ± 6.6 Kg/m2 and 120.5 ± 13.2 cm, respectively. Patients who continued in the study lost an average of 4.8 ± 4.8 kg (n = 165) and 7.0 ± 6.2 kg (n = 48) at three and six months, respectively, with 51.5% (n = 135) patients reaching the weight loss goal of >= 5%. There were no statistically differences in weight loss between any clinical or follow-up variables analysed. 43.5% of patients voluntarily left the study without reaching the weight loss goal. Conclusion: The intervention on lifestyles in obese patients treated in a day hospital achieves moderate weight loss in the medium term, with half of patients achieving a weight loss >= 5% (AU)

GSK-3ß function in bone regulates skeletal development, whole-body metabolism, and male life span.

Glycogen synthase kinase 3 ß (GSK-3ß) is an essential negative regulator or "brake" on many anabolic-signaling pathways including Wnt and insulin. Global deletion of GSK-3ß results in perinatal lethality and various skeletal defects. The goal of our research was to determine GSK-3ß cell-autonomous effects and postnatal roles in the skeleton. We used the 3.6-kb Col1a1 promoter to inactivate the Gsk3b gene (Col1a1-Gsk3b knockout) in skeletal cells. Mutant mice exhibit decreased body fat and postnatal bone growth, as well as delayed development of several skeletal elements. Surprisingly, the mutant mice display decreased circulating glucose and insulin levels despite normal expression of GSK-3ß in metabolic tissues. We showed that these effects are due to an increase in global insulin sensitivity. Most of the male mutant mice died after weaning. Prior to death, blood glucose changed from low to high, suggesting a possible switch from insulin sensitivity to resistance. These male mice die with extremely large bladders that are preceded by damage to the urogenital tract, defects that are also seen type 2 diabetes. Our data suggest that skeletal-specific deletion of GSK-3ß affects global metabolism and sensitizes male mice to developing type 2 diabetes.

[Effectiveness of lifestyle intervention program in persons with obesity treated in a day hospital]. / Efectividad de un programa de intervención sobre los estilos de vida en personas con obesidad atendidos en régimen de Hospital de día.

INTRODUCTION: Obesity is a chronic disease that affects approximately 25% of the Spanish population, causing high morbidity and associated healthcare costs. OBJECTIVE: To evaluate the effectiveness of an intervention program on lifestyles in obese patients treated in a day hospital scheme. METHODS: A prospective non- controlled intervention study was conducted on obese patients treated in the Endocrinology and Nutrition day hospital, Puerto Real University Hospital, and included in program of lifestyle modification to achieve a weight loss of ≥ 5% minimum. RESULTS: We studied 262 patients with a mean age of 44.6±16.0 years (71% women) with an initial weight, body mass index and waist circumference of 110.4±21.1kg, 41.6±6.6Kg/m(2) and 120.5±13.2cm, respectively. Patients who continued in the study lost an average of 4.8±4.8kg (n=165) and 7.0±6.2kg (n=48) at three and six months, respectively, with 51.5% (n=135) patients reaching the weight loss goal of ≥ 5%. There were no statistically differences in weight loss between any clinical or follow-up variables analysed. 43.5% of patients voluntarily left the study without reaching the weight loss goal. CONCLUSION: The intervention on lifestyles in obese patients treated in a day hospital achieves moderate weight loss in the medium term, with half of patients achieving a weight loss ≥5%.

Laparoscopic ventral rectopexy: a prospective long-term evaluation of functional results and quality of life.

BACKGROUND: Laparoscopic ventral rectopexy for rectal prolapse combines the advantages of a minimally invasive approach with the low recurrence rate observed after abdominal procedures. To date, only a few long-term functional studies and no quality of life assessment are available. The aim of this study was to assess long-term functional outcomes and quality of life after laparoscopic ventral rectopexy. METHODS: Between January 2007 and December 2008, patients who underwent laparoscopic ventral rectopexy for full-thickness external rectal prolapse and/or rectocele were prospectively included. Fecal incontinence and constipation were scored (Wexner score and Rome II criteria). Quality of life was assessed using the gastrointestinal quality of life form (GIQLI). RESULTS: Thirty-three patients were included and 30 (91 %) completed all the questionnaires. There was no morbidity or mortality. The mean length of hospital stay was 5 ± 1 days (range 3-7 days). After a mean follow-up of 42 ± 7 months (range 32-52 months), recurrence of rectocele was observed in two patients (6 %). At the end of follow-up, constipation was improved in 13/18 patients (72 %) and two patients (7 %) presented de novo constipation. The patients' Wexner score improved between preoperative status and end of follow-up (12 ± 7 vs. 4 ± 3, p = 0.002). Compared to the preoperative score, quality of life significantly improved over time: 77 ± 21 preoperatively versus 107 ± 17 at 1 year versus 109 ± 18 at the end of follow-up (p < 0.001). CONCLUSIONS: This prospective study showed that laparoscopic ventral rectopexy was associated with excellent postoperative outcomes and a low long-term recurrence rate. Long-term functional results were excellent in terms of continence, with significant improvement of quality of life and without worsening constipation.

Prior abdominal open surgery does not impair outcomes of laparoscopic colorectal surgery: a case-control study in 367 patients.

AIM: This prospective case-matched study was conducted to compare the outcome of laparoscopic colorectal surgery in patients with and without prior abdominal open surgery (PAOS). METHOD: From June 1997 to December 2010, 167 patients with PAOS (including midline, Pfannenstiel, subcostal, right upper quadrant or transverse incision) were manually matched to all identical patients without PAOS from our prospective laparoscopic colorectal surgery database. Matching criteria included age, gender, American Society of Anesthesiology (ASA) score, body mass index, diagnosis and surgical procedure performed. Primary end-points were postoperative 30-day mortality and morbidity. Secondary end-points included operating time, conversion rate and length of stay. RESULTS: A total of 367 patients (167 with PAOS and 200 without PAOS) were included in this study. PAOS was associated with a significantly increased mean operating time (229±66 min vs 216±71 min, P=0.044). The conversion rate was significantly higher in patients with PAOS, compared with patients without PAOS (22%vs 13%, P=0.017). There was one (0.3%) postoperative death. The overall postoperative morbidity rate was similar in both groups (22%vs 19%, P=0.658), including Grade 3 or Grade 4 morbidity, according to Dindo's classification (5%vs 5%, P=0.694). Mean hospital stay showed no difference between both groups (10±7 days vs 9±5 days, P=0.849). CONCLUSION: This large case-control study suggests that PAOS does not affect postoperative outcomes. For this reason, a systematic laparoscopic approach in patients with PAOS, even with midline incision, should be considered in colorectal surgery.

Functional disorders after rectal cancer resection: does a rehabilitation programme improve anal continence and quality of life?

AIM: A poor functional outcome is often reported after total mesorectal excision (TME) for rectal cancer, especially when sphincter-saving resection with intersphincteric dissection is performed for low tumours. Anal sphincter rehabilitation is widely proposed for faecal incontinence. Very few studies have reported results to improve anal dysfunction following rectal surgery. This prospective study aimed to assess the benefits of sphincter training after TME in terms of functional outcome and quality of life. METHODS: Anal sphincter training was performed in patients undergoing laparoscopic sphincter-saving TME for rectal cancer. Rehabilitation was performed after ileostomy closure. This group was compared with 24 matched patients. Assessment included one functional and two quality of life questionnaires (SF-36 Health Status and Faecal Incontinence Quality of Life score). RESULTS: From 2007 to 2009, 22 patients underwent laparoscopic TME. The median follow-up after stoma closure was 21.2 (range 8-46) months. The mean stool frequency per day was significantly lower after sphincter training (2.6 in the training group vs 4.0 in the control group, P=0.025). Following rehabilitation, patients complained significantly less about dyschezia (22 vs 63%, P=0.008). Both groups had similar continence (Wexner score 8.3 after training vs 9.9 in controls, NS). Quality of life was significantly improved by sphincter training as measured by the vitality (P=0.004) and mental functioning (P=0.02) subscales on the SF-36 Health Status questionnaire and by the depression and self-perception (P = 0.005) categories of the Faecal Incontinence Quality of Life score. CONCLUSION: This study suggests that anal sphincter training following TME could decrease stool frequency and improve both general and specific quality of life.

Single-incision laparoscopic colonic surgery.

AIM: SILS is an area of growing interest in colorectal surgery. We report our preliminary experience of 13 consecutively selected patients undergoing colonic surgery using SILS. METHOD: From July 2009 to January 2010, 13 patients (five men) of median age 56 (23-82) years and a body mass index (BMI) of 23.5 (18-30) kg/m(2) underwent colonic surgery. Procedures included subtotal colectomy (1), ileocolic resection (2), right colectomy (4) and sigmoidectomy for benign disease (6). Three instruments (including camera) were introduced through a single 2.5-cm port (SILS™ Port Multiple Instrument Access Port; Covidien Inc., Norwalk, Connecticut, USA) inserted at the umbilicus. RESULTS: The median operating time was 150 (100-240) min, and the median size of the umbilical port incision was 32 (25-50) mm. There was no postoperative mortality and morbidity, and the median hospital stay was 6 (4-10) days. The cosmetic result was judged to be excellent in 12 of 13 patients who felt it to be better than expected. CONCLUSION: This preliminary experience shows that SILS is technically feasible and safe for colonic resection.

Single port access proctectomy with total mesorectal excision and intersphincteric resection with a primary transanal approach.

AIM: Minimally invasive surgery is advancing with single port access (SPA). We describe a technique for a SPA transabdominal combined with transanal approach to perform laparoscopic proctectomy with total mesorectal excision (TME) and intersphincteric resection of low rectal adenocarcinoma. METHOD: Transanal intersphincteric resection was followed by laparoscopic abdominal proctectomy with TME. An SPA device was placed at the site of the future stoma through a 2.5-cm incision. A hand-sewn side-to-end coloanal anastomosis was performed and a terminal loop ileostomy was created at the site of the SPA device. RESULTS: The procedure was performed on two healthy nonobese women who had not had previous abdominal surgery. The operating times were 195 and 210 min, and blood loss < 250 ml. The postoperative course was uneventful, with discharge on postoperative days 5 and 6. Pathological examination revealed adequate surgical margins and lymph node retrieval with an intact mesorectum. Four weeks after stoma closure, the scar in the right lower quadrant was 35 mm in one patient and 45 mm in the other, and the scar from the 5-mm port was barely visible. CONCLUSION: This preliminary experience shows that proctectomy with TME and intersphincteric resection can be safely performed using only two ports.

Conservative management is associated with a decreased risk of definitive stoma after anastomotic leakage complicating sphincter-saving resection for rectal cancer.

AIM: Anastomotic leakage (AL) after sphincter-saving resection (SSR) for rectal cancer can result in a definitive stoma (DS). The aim of the study was to assess risk factors for DS after AL-complicating SSR. METHOD: Between 1997 and 2007, 200 patients underwent SSR for rectal cancer. AL occurred in 20.5% (41/200) [symptomatic 13.5% (n = 27), asymptomatic 7% (n = 14)]. Possible risk factors for DS after AL were analysed. RESULTS: Management of AL consisted in no treatment (n = 14), medical treatment (n = 6), local drainage (n = 10) and abdominal reoperation (n = 11). After a median follow-up of 38 months, the overall rate of DS was 3% (n = 6): 0% for asymptomatic vs 22% after symptomatic AL (P = 0.061). After reoperation, the risk of DS was 13% when the anastomosis was preserved vs 100% after Hartmann's procedure (P = 0.007). Risk factors of DS after AL included obesity, age over 65, American Society of Anesthesiologists (ASA) score > 2 and abdominal reoperation for AL. CONCLUSION: The risk of DS after SSR for cancer is low (3%) but rises to 22% after symptomatic AL. This risk depends on the surgical treatment for AL and is up to 100% if a Hartmann's procedure is performed.

Laparoscopic colorectal anastomosis using the novel Chex(®) circular stapler: a case-control study.

AIM: The purpose of this study was to assess the safety and effectiveness of a new cost-effective circular stapler for colorectal anastomosis, the Chex(®) CS. METHOD: From 2007 to 2009, a case-control study was conducted of 54 patients who underwent left colectomy with stapled anastomosis using the Chex stapler. The patients were matched to 64 patients in whom the anastomoses were performed using the CDH(®) stapler or the EEA(®) stapler. The following criteria were matched: sex, age, body mass index, American Society of Anesthesiology grade, diagnosis, formation of a temporary stoma and surgical approach. Primary end-points were postoperative mortality and morbidity. The surgeon was asked to fill out a questionnaire to assess the ergonomics of the device using an analogue visual scale. A cost analysis was performed to compare the cost of the different devices. RESULTS: There were no postoperative deaths. Morbidity, including anastomotic leakage (9%vs 8%, P = 1.000), was similar in the two groups. The surgeon's overall appreciation was scored at 8.1/10 (3-9.5), including the best score for stapler removal (9.5). No major device failure was observed during the study. Mean surgical costs were significantly lower in the Chex group: € 903 ± 73 (885-1192) vs the control group € 971 ± 61 (956-1263) (P < 0.0001). CONCLUSION: This study suggests that colorectal anastomosis using the Chex circular stapler is safe and does not increase overall morbidity. In particular, this device did not have a higher rate of anastomotic leakage in our patients than more expensive models currently used in our hospital.

T4 colorectal cancer: is laparoscopic resection contraindicated?

AIM: T4 colorectal cancer remains a contraindication for laparoscopy. It is argued that the risk of incomplete resection could be higher than in open surgery. Furthermore, difficulty in dissection could lead to a very high rate of conversion. There is little information on this. The study aimed at assessing feasibility and operative and oncologic results of laparoscopic resection for T4 colorectal cancer. METHOD: Between 2006 and 2009, 39 patients with colorectal cancer with suspected involvement of another organ (T4) on computed tomography scanning and/or magnetic resonance imaging were included. The cancers were in the right colon (n = 18), left colon (n =9) and rectum (n = 12). The distribution of possible organ involvement was abdominal or pelvic side-wall (n = 21), urinary bladder (n = 4), small bowel or colon (n = 6), vagina and ovary (n = 3), prostate or seminal vesicles (n = 3) and duodenum (n = 2). RESULTS: The overall conversion rate was 18%. Postoperative mortality and morbidity were 2.5 and 33%, respectively. Clinical anastomotic leakage rate was 15% (n = 6). Abdominal reoperation was required in three (7%) patients. Pathological invasion to other organs (pT4) was confirmed in 30 (77%) patients. The R1 resection rate was 13% (4 of 30). After a median follow up of 19 months (range 1.5-45 months), the overall survival and disease-free survival rates were 97 and 89%, respectively. CONCLUSION: This study suggests that laparoscopic surgery is feasible for colorectal T4 cancer resection. Laparoscopy cannot therefore be considered an absolute contraindication for T4 colorectal cancer.

Transanal endoscopic microsurgery (TEM) for rectal tumor: the first French single-center experience.

OBJECTIVE: Transanal endoscopic microsurgery (TEM) allows complete local excision of rectal tumor, especially in the middle and upper part of the rectum, and provides an alternative to conventional surgery. This is a report of the first French single-center experience to assess the feasibility and postoperative results for rectal tumor excised by TEM. METHODS: From October 2007 to December 2008, 27 patients underwent TEM for excision of either rectal adenoma (n=19) or carcinoma (n=8). The median distance from the anal verge was 60mm (range: 10-140). RESULTS: TEM excision was performed in 26/27 patients. Intraoperative technical difficulties were recorded in two patients (peritoneal perforation and gas leakage, respectively). The morbidity rate was 22% (n=6), including two patients (7%) with major complications (delayed rectal bleeding) requiring readmission to hospital for both, and surgical hemostasis for one. R0 resection rates for adenoma and carcinoma were 84% and 75%, respectively. Immediate salvage surgery was performed in one patient because of a T2R1 carcinoma. At the time of the median follow-up at nine months (range: 2.5-17.5), no patient had experienced a recurrence. CONCLUSION: TEM is a safe and effective procedure with low morbidity for local rectal tumor resection. It allows local excision of benign tumors, especially those that are inaccessible to conventional local surgery resection, thereby avoiding radical surgery. In cases of carcinoma, its role in local surgery remains controversial and is yet to be defined.

Operative results and quality of life after gracilis muscle transposition for recurrent rectovaginal fistula.

PURPOSE: The aim of this study was to assess the efficacy of gracilis muscle transposition for recurrent rectovaginal fistula. METHODS: Gracilis muscle transposition for recurrent rectovaginal fistula was performed in eight patients. Causes of fistulas included Crohn's disease (n = 5), perineal surgery (n = 2), and obstetrical injury (n = 1). All patients underwent a mean of three (range, 1-6) previous repairs. Fecal diversion was performed in all cases. RESULTS: Six of eight patients (75%) healed after gracilis muscle transposition alone. The other two patients required a second gracilis. These two patients failed with another recurrence and one of them underwent laparotomy with successful omental interposition. Thus, after a median follow-up of 28 (range, 4-55) months, the per-gracilis muscle transposition healing rate was 60% (6/10) and the overall healing success rate after gracilis muscle transposition and other procedures was 88% (7/8). For patients with Crohn's disease, four of five (80%) presented no recurrent rectovaginal fistula. Seven of eight patients underwent ileostomy closure after gracilis, but two required subsequent stomas, one for a late recurrence. Overall, five of eight patients are stoma-free. Despite healing, postoperative quality of life and sexual activity remained significantly altered. CONCLUSION: Gracilis muscle transposition can be proposed in cases of recurrent rectovaginal fistula. The procedure has a good success rate, especially in Crohn's disease patients.

Cloning and molecular characterization of the acyl-CoA: diacylglycerol acyltransferase 1 (DGAT1) gene from Echium.

Boraginaceae species, such as those from the genus Echium, contain high levels of the Delta(6)-desaturated gamma-linolenic (18:3n-6) and octadecatetraenoic (18:4n-3) acids. These are unusual fatty acids among the plant kingdom that are gaining interest due to their benefits to human health. The potential utility of acyltransferases aimed at an increase in oil yield and fatty acid profiling has been reported. In this work, a gene encoding an acyl-CoA:diacylglycerol acyltransferase (DGAT, EC 2.3.1.20) was cloned from Echium pitardii. Genomic and cDNA sequences obtained revealed a gene structure composed of 16 exons, yielding a protein (EpDGAT) of 473 amino acids with high similarity to DGAT1 enzymes of plants. Protein features such as a predicted structure with a highly hydrophilic N-terminus followed by 10 transmembrane domains, as well as the presence of diverse specific signatures, also indicate that EpDGAT belongs to the DGAT1 family. indeed. DGAT activity of the protein encoded by EpDGAT was confirmed by heterologous expression of the full-length cDNA in a yeast mutant (H1246) defective in the synthesis of triacylglycerols. Fatty acid composition of the triacylglycerols synthesized by EpDGAT in H1246 yeast cultures supplemented with polyunsaturated fatty acids suggest a substrate preference for the trienoic fatty acids alpha-linolenic acid (18:3n-3) and gamma-linolenic acid over the dienoic linoleic acid (18:2n-6). Site-directed mutagenesis has revealed the presence of a critical residue (P(178) in EpDGAT) within a reported thiolase signature for binding of acyl-enzyme intermediates that might be involved in the active site of the enzyme. Transcript analysis for EpDGAT shows an ubiquitous expression of the gene which is increased in leaves during senescence.

Actuación en un desprendimiento prematuro de placenta normalmente inserta. Estudio de un caso / Management of abruptio placentae of the normally implanted placenta: a case report

El desprendimiento placentario es una causa importante de morbimortalidad materna y fetal. Se presenta un caso de desprendimiento de placenta moderada en una gestante a término, cuyos primeros signos de alarma fueron presencia de líquido amniótico sanguinolento e irritabilidad uterina. Una identificación precoz y una actuación adecuada por parte de la matrona contribuirán a un pronóstico materno y fetal lo mejor posible (AU)

Placental abruption is an important cause of maternal and fetal mortality and morbidity. This article presents a case of moderate placental abruption in a full-term pregnancy. Blood-stained amniotic fluid and uterine Contractions were also detected. Early detection and proper management by the midwife would help Achieve the best possible outcome for both the mother and the fetus (AU)