Bundles reduce anastomosis leak in patients undergoing elective colorectal surgery. A propensity score-matched study.

Background: anastomosis leak still being a handicap in colorectal surgery. Bowel mechanical preparation and oral antibiotics are not a practice recommended in many clinical practice guides. The aim is to analyse the decrease in frequency and severity of postoperative complications, mainly related to anastomotic leak, after the establishment of a bundle. Methods: Single-center, before-after study. A bundle was implemented to reduce anastomotic leaks and their consequences. The Bundle group were matched to Pre-bundle group by propensity score matching. Mechanical bowel preparation, oral and intravenous antibiotics, inflammatory markers measure and early diagnosis algorithm were included at the bundle. Results: The bundle group shown fewer complications, especially in Clavien Dindós Grade IV complications (2.3% vs. 6.2% p < 0.01), as well as a lower rate of anastomotic leakage (15.5% vs. 2.2% p < 0.01). A significant decrease in reinterventions, less intensive unit care admissions, a shorter hospital stay and fewer readmissions were also observed. In multivariate analysis, the application of a bundle was an anastomotic leakage protective factor (OR 0.121, p > 0.05). Conclusions: The implementation of our bundle in colorectal surgery which include oral antibiotics, mechanical bowel preparation and inflammatory markers, significantly reduces morbidity adjusted to severity of complications, the anastomotic leakage rate, hospital stay and readmissions. Register study: The study has been registered at clinicaltrials.gov Code: nct04632446.

[Computed tomographic colonography: applications, advantages and disadvantages]. / Colonografía tomográfica computarizada: aplicaciones, ventajas e inconvenientes.

INTRODUCTION: Complete preoperative study of the colon is required in the management of colorectal cancer, due to the frequent association of primary colonic neoplasms with colonic adenomas (28%) and/or synchronous carcinomas (5%) of the colon. We present a series of patients who underwent computed tomographic colonography, the indications for this procedure, and the results. PATIENTS AND METHODS: We performed a descriptive prospective study. Between May 2003 and August 2004, 50 computed tomographic colonographies were performed in 50 patients with suspected stenosing colorectal cancer and incomplete conventional colonoscopy. RESULTS: Fifty computed tomographic colonographies were performed. The findings were as follows: three were normal (6%), and in the remainder, one was a false positive for a suspected neoplastic pelvic mass (3.125%) and two were false positives (11.7%) for colonic polyps. Fifty percent of the findings (n = 32) were related to peritoneal metastases and colonic neoplasms. There were 12 technical complications [lack of cleaning of the colon (5), lack of distension (2), little air insufflation (5)]. Patient complications included vegetative manifestations in one (vomiting) and rectal bleeding in another. The overall complication rate was 27.4% (23.4% corresponded to technical complications and the remaining 4% were patient-related). There was no mortality related to the procedure. CONCLUSION: Because computed tomographic colonography is safe, effective and well tolerated by the patient, it should be considered as a technical alternative in the study of stenosing neoplasms of the proximal colon with incomplete colonoscopy. In addition, it allows other associated findings, both intra- and extracolonic, to be obtained and improves the diagnostic and therapeutic management of the patient.

Colonografía tomográfica computarizada: aplicaciones, ventajas e inconvenientes / Computed tomographic colonography: applications, advantages and disadvantages

Introducción: El estudio preoperatorio completo del colon es necesario para el tratamiento del cáncer colorrectal, debido a la frecuente asociación de la neoplasia primaria de colon con adenomas colónicos (28%) y/o carcinomas sincrónicos (5%) de colon. El objetivo de este trabajo es presentar nuestra serie de pacientes a los que se ha realizado colonografía tomográfica computarizada, sus indicaciones y sus resultados.Pacientes y métodos: Estudio descriptivo y prospectivo. Entre mayo de 2003 y agosto de 2004, se llevaron a cabo 50 colonografías tomográficas computarizadas en 50 pacientes con sospecha de cáncer colorrectal estenosante y colonoscopia preoperatoria incompleta. Resultados: Se realizaron 50 colonografías tomográficas computarizadas. Los hallazgos fueron los siguientes: 3 de ellas fueron normales (6%) y en las restantes se encontró un falso positivo para masa pelviana sospechosa de neoplasia (3,125%) y 2 falsos positivos (11,7%) para pólipos colónicos. El 50% de los hallazgos (n = 32) estuvo en relación con metástasis peritoneales y neoplasias de colon. Hubo 12 casos de complicación técnica (5 falta de limpieza del colon, 2 falta de distensión, 5 escasa insuflación de aire) y 2 del paciente (1 manifestación vegetativa [vómitos], 1 sangrado rectal). La tasa global de complicaciones fue del 27,4% (el 23,4% debidas a complicaciones técnicas y el 4% restante a los pacientes). No hubo mortalidad relacionada con el procedimiento. Conclusión: La colonografía tomográfica computarizada, por su seguridad, eficacia y buena tolerancia por parte del paciente, debe considerarse una técnica alternativa de estudio del colon proximal ante una neoplasia estenosante con colonoscopia incompleta. Además, permite obtener otros hallazgos asociados, intra y extracolónicos, así como mejorar el manejo diagnóstico y terapéutico del paciente

Introduction: Complete preoperative study of the colon is required in the management of colorectal cancer, due to the frequent association of primary colonic neoplasms with colonic adenomas (28%) and/or synchronous carcinomas (5%) of the colon. We present a series of patients who underwent computed tomographic colonography, the indications for this procedure, and the results. Patients and methods: We performed a descriptive prospective study. Between May 2003 and August 2004, 50 computed tomographic colonographies were performed in 50 patients with suspected stenosing colorectal cancer and incomplete conventional colonoscopy. Results: Fifty computed tomographic colonographies were performed. The findings were as follows: three were normal (6%), and in the remainder, one was a false positive for a suspected neoplastic pelvic mass (3.125%) and two were false positives (11.7%) for colonic polyps. Fifty percent of the findings (n = 32) were related to peritoneal metastases and colonic neoplasms. There were 12 technical complications [lack of cleaning of the colon (5), lack of distension (2), little air insufflation (5)]. Patient complications included vegetative manifestations in one (vomiting) and rectal bleeding in another. The overall complication rate was 27.4% (23.4% corresponded to technical complications and the remaining 4% were patient-related). There was no mortality related to the procedure. Conclusion: Because computed tomographic colonography is safe, effective and well tolerated by the patient, it should be considered as a technical alternative in the study of stenosing neoplasms of the proximal colon with incomplete colonoscopy. In addition, it allows other associated findings, both intra- and extracolonic, to be obtained and improves the diagnostic and therapeutic management of the patient

Treatment of long-standing extensive perianal hidradenitis suppurativa using double rotation plasty, V-Y plasty and free grafts.

BACKGROUND: Perianal hidradenitis suppurativa is a chronic recurrent inflammatory, suppurating, and fistulizing disease of apocrine glands, adjacent anal canal skin, and soft tissues. The standard treatment used for extensive cases is a staged surgical procedure allowing the wound to heal by secondary intention or the delayed use of skin grafts. CASE PRESENTATION: A long-standing case, disabling for the patient, with extensive involvement of the buttock region, treated in one stage, which for reconstruction required the use of sliding plasties and free skin grafts, is reported. RESULTS: The outcome was satisfactory. Primary closure after wide excision using plastic-surgery techniques may help us resolve complex situations and obtain good results and a rapid recovery. CONCLUSION: The method of closure with a combination of skin flaps and skin graft in one stage can be considered a valid surgical option for a group of patients with extensive perianal hidradenitis.

Metástasis hepáticas secundarias a leiomiosarcoma de recto. Presentación de un caso / Liver metastases secondary to rectal leiomyosarcoma. A case report

Se presenta un caso de metástasis hepáticas en una paciente afectada por un leiomiosarcoma de localización rectal. Se incide en la rareza de este tipo de tumores, así como en su agresividad y posibilidades terapéuticas (AU)

Gastric surgery and bezoars.

We present a series of 56 patients with gastrointestinal bezoar following previous gastric surgery for gastroduodenal peptic ulcer. The following parameters were studied: factors predisposing to bezoar formation (type of previous surgery, alimentation, and mastication), form of clinical presentation, diagnostic tests, and treatment. A bilateral truncal vagotomy plus pyloroplasty had been performed previously on 84% of patients, 44% revealed excessive intake of vegetable fiber, and 30% presented with bad dentition. The most frequent clinical presentation was intestinal obstruction (80%). This was diagnosed mainly by clinical data and simple abdominal radiology. The main exploratory technique for diagnosing cases of gastric bezoar was endoscopy. Surgery is necessary for treating the intestinal forms, and one should always attempt to fragment the bezoar and milk it to the cecum, reserving enterotomy and extraction for cases where this is not possible. The small intestine and stomach should always be explored for retained bezoars. Gastric bezoars should always receive conservative treatment, endoscopic extraction, and/or enzymatic dissolution; gastrotomy and extraction should be performed when this fails.

Gallbladder cholesterolosis: an aetiological factor in acute pancreatitis of uncertain origin.

To investigate the possible relationship between gallbladder cholesterolosis and acute pancreatitis, we studied 3797 cholecystectomy specimens and found 55 cases of gallbladder cholesterolosis unassociated with biliary lithiasis. From the reviewed case notes, 27 of these patients presented with recurrent attacks of acute pancreatitis which disappeared after cholecystectomy (follow-up 65.1 months). A microscopic study revealed frank cholesterolosis in all cases with a pseudopolyp transformation of the mucosa, some polyps reaching a diameter of 2 mm. We postulate that the mechanism could be temporary impaction of cholesterolosis polyps at the sphincter of Oddi and suggest that patients with recurrent attacks of acute pancreatitis and negative aetiological investigation must be considered as at high risk of having gallbladder cholesterolosis and that they could benefit from cholecystectomy.

[Cancer of the anus: incidence and behavior of melanoma in our series]. / Cáncer de ano: incidencia y comportamiento del melanoma en nuestra serie.

From January 78, to December 88, we have treated 717 cases of colorectal carcinoma; 136 were located less than 5 cm from the anal margin. There were 117 adenocarcinomas; it was difficult to decide if the origin was the anal canal or the rectal ampulla. The remaining 19 tumors were: 9 malignant melanomas, 6 squamous cell carcinomas, 3 cloacogenic carcinomas, 1 rectal carcinoid, 1 leiomyosarcoma. We point out the high incidence of anal melanoma, 47.36% of total number of anal cancers, excluding adenocarcinomas. The clinical diagnosis was cancer of the anus; melanoma was not suspected in any of the cases. In 5 cases the preoperative biopsy did not diagnose melanoma. Since lesions were considered resectable, surgical treatment was always abdominoperineal resection. Pathological study of the surgical specimen showed lymph node metastases in all cases, in contrast to only 45.87% of adenocarcinomas. When lymph nodes were infiltrated by the tumor there were no differences in survival of patients with malignant melanoma and adenocarcinoma; nevertheless, when comparing the total group of patients with adenocarcinoma there were important differences. Summarizing, the diagnosis of malignant melanoma of the anus, compared to adenocarcinoma, implies a poor prognosis, probably related to the highest tendency to spread to the lymph nodes.

[Blood transfusion worsens the prognosis in colorectal cancer. Preliminary study in a series of 717 cases]. / La transfusión sanguínea ensombrece el pronóstico del cáncer colorrectal. Estudio preliminar en una serie de 717 casos.

We have conducted an investigation on the relationship between blood transfusion and recurrence of resected colorectal cancer and survival of the patients. During the past ten years 717 patients have been surgically treated of colorectal cancer in our hospital; 442 of the cases were Duke's stages B or C, and the resection had been considered radical. In both groups, recurrences were most frequent in patients who received blood transfusions; survival was also lower in this group of patients.

[Motility of the colon: electric and manometric description of the mass movement]. / Motilidad del colon: descripción eléctrica y manométrica del movimiento de masa.

"Mass movement" was described at the beginning of the century by radiologists, who occasionally observed during exploration a sudden transport of barium from one section of the colon to another. In this paper we focused our attention on the electromechanical factors that accompany evacuation through a colostomy, since we thought that these would be the myoelectrical and pressure translation of the "mass phenomenon" described by radiologists. We used an electromyographic recording probe to which a conventional microtransducer probe was affixed by suction. Using this method we made 24-hour recordings in 8 patients with sigmoid colostomy. We observed five large evacuations. When the electrical and pressure phenomena that occurred a few minutes before evacuation were analyzed, two clearly differentiated phases were apparent. The first, which we called the "previous phenomenon", consisted of a succession of contractions and spike potentials over a mean period of 5.6 min. (sigma = 2.22), after which a "large contraction" appeared, with a mean pressure value of 127 mmHg (sigma = 38.77) and a mean electrical value of 10.6 mv. The mean duration of this phenomenon was 24.93 sec (sigma = 6.19) and it was recorded almost synchronically in the three recording points studied. Undoubtedly, these electrical-pressure phenomena resulted from mass transport since in all 5 cases a large discharge through the colostomy was seen.

[Physiopathology of paralytic ileus secondary to chemical peritonitis. Experimental study in dogs]. / Fisiopatología del íleo paralítico secundario a peritonitis química. Estudio experimental en perros.

The intestinal paralysis that follows peritonitis has been classically explained as the result of local inflammation of the overlying serosa (Stokes's law). The main object of this study is to determine if these motor alterations, the most relevant of them being intestinal paralysis, are really due to local factors or to general factors in view of the intense affectation that peritonitis induces in the organism. For this purpose we used animals with an isolated and exteriorized intestinal loop to study loop motility during peritonitis in the absence of direct local contact with the process. To test the operation of the smooth intestinal muscle and intrinsic plexus we used two types of motor stimuli: hormonal (insulin) and pure (prostigmine). We found that the isolated loop presented the normal motor characteristics of the small intestine. When peritonitis was achieved, all motor activity ceased in the intracavitary loops and in the isolated loops exposed to acid, so all the intestinal segments were completely paralyzed. The administration of insulin under these circumstances only had effect on the exteriorized loop, where we recorded motor activity similar to that of normal conditions. The administration of prostigmine caused the appearance of a sharp, synchronic contraction of the three intestinal segments studied. Based on these findings, we conclude that the smooth fiber of the small intestine is not paralyzed during peritonitis and can exhibit intense contraction when the motor plate is stimulated with prostigmine.(ABSTRACT TRUNCATED AT 250 WORDS)

[Colorectal cancer: are diagnostic delay, degree of spread and survival related? Clinical analysis of 307 cases followed up for more than 4 years]. / Cáncer colorrectal: existe relación entre el retraso diagnóstico, su grado de extensión y la supervivencia? Análisis clínico en 307 casos seguidos más de cuatro años.

It seems logical to think that the longer the interval between the patient's first symptom of colorrectal cancer and operation, the greater the tumoral extension found by the surgeon will be, and the lower the postoperative survival. Nevertheless, there is much evidence to indicate that this may not always be true. We've analyzed the problem in 307 patients operated of colorectal cancer in our service from January 1979 to December 1984 and followed-up until now. We investigated the time interval from the first clinical symptom until operation, and survival. These variables were related to the Duke grade. As regards the preoperative interval, the average (in months) for Duke's grade A was 7.41 (sigma = 16.88), for D it was 7.41 (sigma = 9.47) and for C, 5.13 (sigma = 8.41). There were no statistically significant differences. As for survival, after four years all the grade A patients, 64% of the grade B patients and 35% of the grade C patients followed-up survived. We've found no relation between diagnostic delay and postoperative survival. These results suggest that it is not true that the longer the symptomatic period, the greater the tumoral spread. As such, diagnostic delay is not a good prognostic indicator for predecting tumoral spread or survival.

[Colorectal carcinoma in young adults. Our experience]. / Carcinoma colorrectal en adultos jóvenes. Nuestra experiencia.

Colorectal cancer usually appears in patients over 60 years-old. However, all the series communicate a small percentage of cases in young patients, ranging from 2 to 10% of the total. We have found important discrepancies between authors who have worked on the possible distinctive characteristics of colorectal cancer of the young over the last decade. This motivated us to examine more closely the clinical, follow-up and prognostic features of colorectal cancerous disease in the young as compared to that occurring in the general population. We analyzed retrospectively the clinical histories of our patients with special reference to the following parameters: sex, diagnostic delay (time from the appearance of the first symptom to diagnosis), index symptom, site, Dukes' grade, type of surgical treatment, complications, recurrence and survival. We found that 4.9% of our patients with colorectal cancer were as old as 40 years. The clinical presentation, tumoral site and Dukes grade were similar in the young adult and in the general population. In spite of the fact that there were no differences in these parameters, in younger patients the surgeon was more aggressive, more often performing a radical operation. Perhaps for this reason, this age group had a higher percentage of complications and recurrences. We found no differences in the 4-year survival or in the time survived after surgery.