Impacto del estoma derivativo en un protocolo de rehabilitación multimodal en cirugía de recto / Impact of a diverting stoma in an enhanced recovery programme for rectal cancer

OBJETIVO: La asociación de ileostomía disminuye la gravedad de las complicaciones tras anastomosis rectal baja pero puede alargar la estancia postoperatoria. El objetivo del presente estudio es averiguar si un estoma derivativo modifica la estancia postoperatoria o las complicaciones, en pacientes intervenidos bajo un régimen de rehabilitación multimodal perioperatoria (RHMM). MÉTODOS: Analizamos a 104 pacientes intervenidos de resección con anastomosis por adenocarcinoma rectal con cuidados de RHMM: 66 varones y 38 mujeres, mediana de edad de 64 años (RIQ: 55-75). En el grupo A, se incluyó a los que se asoció ileostomía derivativa y en el B a aquellos sin ileostomía. RESULTADOS: Grupo A = 58, grupo B = 46 pacientes sin diferencias en edad, ASA, IMC, factores de riesgo, ni en el tipo de abordaje, laparoscópico en un 34%, si bien hubo más neoadyuvancia en el grupo A: 77,5 frente a 36,9%. En este grupo, la intervención habitual fue la exéresis total del mesorrecto (96%) y en el B la subtotal (90%). No hubo diferencias en las complicaciones postoperatorias (34,4 frente a 28,2%; p = 0,322) ni en la de dehiscencias anastomóticas (8,3 frente a 10,8%; p = 0,475), o íleo prolongado (20,7 frente a 10,9%; p = 0,140). Tampoco las hubo en la estancia postoperatoria (7,9 frente a 6,9 días; p = 0,058), reingresos (7 frente a 13,6%; p = 0,22), o en la estancia total incluyendo reingresos (8,4 frente a 9,1 días; p = 0,49). CONCLUSIONES: La asociación de una ileostomía no alarga la EP ni incrementa las complicaciones en pacientes intervenidos de resección rectal en régimen de RHMMP

PURPOSE: The association of a loop ileostomy decreases the severity of complications after rectal surgery but can increase the postoperative stay. The aim of this study is to investigate if a diverting ileostomy influences the postoperative outcomes in a series of patients included in a multimodal rehabilitation program (MMRP). METHODS: We analyzed a series of 104 patients that underwent elective surgery with primary anastomosis for rectal adenocarcinoma using a MMRP: 66 men and 38 women, with a median age of 64 (IQR: 55-75) years. Group A included patients with an associated loop ileostomy, and Group B, those without a protective stoma. RESULTS: Group A = 58, group B = 46 patients without differences in age, ASA, BMI and other risk factors, nor in the surgical approach (laparoscopic in 34%), although there were more neoadjuvant treatments in group A: 77.5 vs. 36.9%; P=.001. In group A, the most common operation was total mesorectal excision (96%) and in the B, a subtotal mesorectal excision (90%). There were no differences in postoperative complications (Group A 34.4 vs. group B28.2%; P=.322), anastomotic leaks (8.3 vs. 10.8%; P=.475), or postoperative ileus (20.7 vs. 10.9%; P=.140), neither in postoperative stay (7.9 vs. 6.9 days; P= .058, readmissions (7 vs. 13.6%; P= .22), or postoperative stay, including readmissions (8.4 vs. 9.1 days; P= .49). CONCLUSIONS: The association of a loop ileostomy does not extend the length of stay nor increases the rate of complications in patients that underwent a rectal resection with anastomosis included in a MMRP

Impact of a diverting stoma in an enhanced recovery programme for rectal cancer.

PURPOSE: The association of a loop ileostomy decreases the severity of complications after rectal surgery but can increase the postoperative stay. The aim of this study is to investigate if a diverting ileostomy influences the postoperative outcomes in a series of patients included in a multimodal rehabilitation program (MMRP). METHODS: We analyzed a series of 104 patients that underwent elective surgery with primary anastomosis for rectal adenocarcinoma using a MMRP: 66 men and 38 women, with a median age of 64 (IQR: 55-75) years. Group A included patients with an associated loop ileostomy, and Group B, those without a protective stoma. RESULTS: Group A = 58, group B = 46 patients without differences in age, ASA, BMI and other risk factors, nor in the surgical approach (laparoscopic in 34%), although there were more neoadjuvant treatments in group A: 77.5 vs. 36.9%; P=.001. In group A, the most common operation was total mesorectal excision (96%) and in the B, a subtotal mesorectal excision (90%). There were no differences in postoperative complications (Group A 34.4 vs. group B28.2%; P=.322), anastomotic leaks (8.3 vs. 10.8%; P=.475), or postoperative ileus (20.7 vs. 10.9%; P=.140), neither in postoperative stay (7.9 vs. 6.9 days; P= .058, readmissions (7 vs. 13.6%; P= .22), or postoperative stay, including readmissions (8.4 vs. 9.1 days; P= .49). CONCLUSIONS: The association of a loop ileostomy does not extend the length of stay nor increases the rate of complications in patients that underwent a rectal resection with anastomosis included in a MMRP.

[Effect of neoadjuvant chemotherapy on the results of resection of colorectal liver metastases]. / Efecto de la quimioterapia neoadyuvante en los resultados de la cirugía de resección de las metástasis hepáticas de origen colorrectal.

INTRODUCTION: Surgery is the treatment of choice in patients with colorectal liver metastases. However, only 10% to 20% of these cases are resectable. The use of neoadjuvant chemotherapy may allow surgery in patients with tumors initially considered unresectable. The aim of this study was to compare the results of liver resection due to colorectal liver metastases in patients with and without neoadjuvant chemotherapy. PATIENTS AND METHOD: We studied 105 patients who underwent surgery for liver metastases from colorectal cancer. The patients were divided into two groups according to treatment: surgery in patients with initially resectable tumors (group 1) and neoadjuvant chemotherapy plus surgery (group 2) in patients with initially irresectable tumors, who were considered for surgery after response to chemotherapy. Age, sex, origin of primary tumor, time of presentation, number, maximum size and location of metastases, CEA, resection margin, postoperative morbidity and mortality, length of hospital stay, recurrence rate, survival and disease-free survival were compared between the 2 groups of patients. RESULTS: When group 1 was compared with group 2, statistically significant differences were observed in synchronicity (30.8% vs 77.4%), bilobarity (13.5% vs 58.5%), number and size of metastases (1 vs 3 nodules and 4 cm vs 2 cm), resectability rate (96.1% vs 81.1%), disease-free interval (25 vs 11 months) and long-term survival at 1, 3 and 5 years (93%, 67% and 36% vs 78%, 26% and 12%). However, no statistically significant differences were found in postoperative morbidity and mortality (28.8% and 0% in group 1 and 22.6% and 1.8% in group 2, respectively). CONCLUSIONS: Neoadjuvant chemotherapy was not associated with greater postoperative morbidity and mortality after resection of colorectal liver metastases, but long-term survival was lower in the group of patients receiving this treatment modality than in those with tumors initially considered resectable.

Efecto de la quimioterapia neoadyuvante en los resultados de la cirugía de resección de las metástasis hepáticas de origen colorrectal / Effect of neoadjuvant chemotherapy on the results of resection of colorectal liver metastases

Introducción. La cirugía es el tratamiento de elección de los pacientes con metástasis hepáticas de cáncer colorrectal, pero sólo un 10-20% de los casos son resecables. El uso de quimioterapia neoadyuvante puede rescatar para la cirugía a pacientes inicialmente considerados irresecables. El objetivo de este trabajo es comparar los resultados de la resección de metástasis hepáticas de origen colorrectal en pacientes con y sin quimioterapia neoadyuvante. Pacientes y método. Se ha estudiado a 105 pacientes intervenidos por metástasis hepáticas de cáncer colorrectal, divididos en dos grupos según la estrategia de tratamiento: cirugía en los pacientes inicialmente considerados resecables (grupo C) y quimioterapia neoadyuvante más cirugía (grupo QT+C) en los que inicialmente se consideró irresecables y que tras quimioterapia se convirtieron en resecables. Se ha comparado la edad y el sexo, el origen del tumor primario, el tiempo de aparición, el número, el tamaño máximo y la localización de las metástasis, CEA, el margen de resección, la morbilidad y la mortalidad postoperatorias, el tiempo de ingreso, la tasa de recidivas y la supervivencia en general y la libre de enfermedad. Resultados. Al comparar a los dos grupos, C y QT+C, han resultado significativas la presencia de metástasis sincrónicas (el 30,8 y el 77,4%), la distribución bilobar (el 13,5 y el 58,5%), el número y el tamaño de las metástasis (1 contra 3 nódulos y 4 contra 2 cm), la tasa de resecabilidad (el 96,1 y el 81,1%), el intervalo libre de enfermedad (25 y 11 meses) y la supervivencia actuarial a 1, 3 y 5 años (el 93, el 67 y el 36% contra el 78, el 26 y el 12%). Sin embargo, no hemos encontrado diferencias en cuanto a la morbilidad y la mortalidad postoperatorias, que fueron del 28,8 y el 0%, respectivamente, en el grupo C y del 22,6 y el 1,8% en el grupo QT+C. Conclusiones. La quimioterapia neoadyuvante no tuvo relación con mayor morbimortalidad postoperatoria tras la resección de metástasis hepáticas de origen colorrectal, pero la supervivencia general a largo plazo en el grupo de pacientes que recibieron este tratamiento fue inferior a la del grupo de pacientes considerados inicialmente resecables (AU)

Introduction. Surgery is the treatment of choice in patients with colorectal liver metastases. However, only 10% to 20% of these cases are resectable. The use of neoadjuvant chemotherapy may allow surgery in patients with tumors initially considered unresectable. The aim of this study was to compare the results of liver resection due to colorectal liver metastases in patients with and without neoadjuvant chemotherapy. Patients and method. We studied 105 patients who underwent surgery for liver metastases from colorectal cancer. The patients were divided into two groups according to treatment: surgery in patients with initially resectable tumors (group 1) and neoadjuvant chemotherapy plus surgery (group 2) in patients with initially irresectable tumors, who were considered for surgery after response to chemotherapy. Age, sex, origin of primary tumor, time of presentation, number, maximum size and location of metastases, CEA, resection margin, postoperative morbidity and mortality, length of hospital stay, recurrence rate, survival and disease-free survival were compared between the 2 groups of patients. Results. When group 1 was compared with group 2, statistically significant differences were observed in synchronicity (30.8% vs 77.4%), bilobarity (13.5% vs 58.5%), number and size of metastases (1 vs 3 nodules and 4 cm vs 2 cm), resectability rate (96.1% vs 81.1%), disease-free interval (25 vs 11 months) and long-term survival at 1, 3 and 5 years (93%, 67% and 36% vs 78%, 26% and 12%). However, no statistically significant differences were found in postoperative morbidity and mortality (28.8% and 0% in group 1 and 22.6% and 1.8% in group 2, respectively). Conclusions: Neoadjuvant chemotherapy was not associated with greater postoperative morbidity and mortality after resection of colorectal liver metastases, but long-term survival was lower in the group of patients receiving this treatment modality than in those with tumors initially considered resectable (AU)