Citizens' willingness to support farmers' adoption of low crude protein diet in pig production.

Livestock farming has a detrimental effect on the environment since it generates a lot of gas emissions. In pig farming, the use of feed is among the substantial sources of animal farm emissions among the European Union. Nevertheless, the use of Low Dietary Crude Protein (LCP) may reduce the environmental impacts of pig farming and provide diverse ecosystem services (ESs). Concurrently, these pig diets alternatives may result more expensive than the conventional ones, which may negatively affect farmers' intention to adopt these alternatives. Citizens' payment for ESs may be a viable strategy to motivate farmers to implement more sustainable pig diets. The primary objective of this study is to assess the extent to which citizens of Catalonia (Spain) are willing to pay for the ESs generated by the implementation of a LCP diet in pig production. In pursuit of this goal, we conducted an online survey among 501 citizens, including a Discrete Choice Experiment. Participants evaluated three feed scenarios, and their choices were scrutinized using conditional logit model. Results revealed that citizens prefer the new pig diets, including both LCP and Very LCP (VLCP) diets, over the conventional pig diet. However, there is a clear preference toward the VLCP diet justified by their willingness to pay (WTP) of €67/year/adult.

Navigating surgical anatomy of the Denonvilliers' fascia and dissection planes of the anterior mesorectum with a cadaveric simulation model.

Anterior dissection of the rectum in the male pelvis represents one of the most complex phases of total meso-rectal excision. However, the possible existence of different anatomical planes is controversial and the exact anatomical topography of Denonvilliers' fascia is still debated. The aim of the study is to accurately define in a cadaveric simulation model the existence and boundaries of Denonvilliers' fascia, identifying the anatomical planes suitable for surgical dissection. The pelvises of 31 formalin-preserved male cadavers were dissected. Careful and detailed dissection was carried out to visualize the anatomical structures and the potential dissection planes, simulating an anterior meso-rectum dissection. Denonvilliers' fascia was identified in 100% of the pelvises, as a single-layer fascia that originates from the peritoneal reflection and descends until its firm adhesion to the prostate capsule. The fascia divides the space providing an anterior and a posterior plane. Anteriorly to the fascia, during the caudal dissection, its firm adhesion to the prostate capsule forces to section it sharply. The cadaveric simulation model allowed an accurate description of Denonvilliers' fascia, defining several planes for anterior dissection of the meso-rectum.

Lasting Symptoms After Esophageal Resection (LASER): European Multicenter Cross-sectional Study.

OBJECTIVE: To identify the most prevalent symptoms and those with greatest impact upon health-related quality of life (HRQOL) among esophageal cancer survivors. BACKGROUND: Long-term symptom burden after esophagectomy, and associations with HRQOL, are poorly understood. PATIENTS AND METHODS: Between 2010 and 2016, patients from 20 European Centers who underwent esophageal cancer surgery, and were disease-free at least 1 year postoperatively were asked to complete LASER, EORTC-QLQ-C30, and QLQ-OG25 questionnaires. Specific symptom questionnaire items that were associated with poor HRQOL as identified by EORTC QLQ-C30 and QLQ-OG25 were identified by multivariable regression analysis and combined to form a tool. RESULTS: A total of 876 of 1081 invited patients responded to the questionnaire, giving a response rate of 81%. Of these, 66.9% stated in the last 6 months they had symptoms associated with their esophagectomy. Ongoing weight loss was reported by 10.4% of patients, and only 13.8% returned to work with the same activities.Three LASER symptoms were correlated with poor HRQOL on multivariable analysis; pain on scars on chest (odds ratio (OR) 1.27; 95% CI 0.97-1.65), low mood (OR 1.42; 95% CI 1.15-1.77) and reduced energy or activity tolerance (OR 1.37; 95% CI 1.18-1.59). The areas under the curves for the development and validation datasets were 0.81 ±â€Š0.02 and 0.82 ±â€Š0.09 respectively. CONCLUSION: Two-thirds of patients experience significant symptoms more than 1 year after surgery. The 3 key symptoms associated with poor HRQOL identified in this study should be further validated, and could be used in clinical practice to identify patients who require increased support.

Surgical Anatomy of the Rectovaginal Space: Does a Standalone Rectovaginal Septum or Denonvilliers Fascia Exist in Women?

BACKGROUND: Below the anterior peritoneal reflection, the anterior rectal wall and mesorectum are separated from the posterior vaginal wall by a virtual rectovaginal space. In this space, the description of a specific and independent rectovaginal septum as a female counterpart of Denonvilliers fascia has been the subject of debate over the years. OBJECTIVE: The aim of this study is to perform an accurate anatomical study of the rectovaginal area in a cadaveric simulation model of total mesorectal excision to evaluate the possible structures and the dissection planes contained within the rectovaginal space. DESIGN AND SETTING: This is a cadaveric study performed at the University of Valencia. PATIENTS: The pelvises of 25 formalin-preserved female cadavers were dissected. All the included specimens were sectioned in a midsagittal plane, at the level of the middle axis of the anal canal. MAIN OUTCOME MEASURES: Careful and detailed dissection was performed to visualize the anatomical structures and potential dissection planes during anterior mesorectal dissection in cadavers. Histological sections were made of the posterior vaginal wall. RESULTS: The rectovaginal space contains loose areolar tissue that allows an easy dissection plane distally. A distinct and independent rectovaginal fascia or septum is not present. The existence of 3 layers fused together in the posterior vaginal wall can be identified more or less precisely because of their different coloration. The histological study confirms this macroscopic arrangement of the posterior vaginal wall in 3 layers: the mucosa, the muscular, and the adventitia. An independent rectovaginal septum can be generated only with a splitting of the adventitia. LIMITATIONS: The cadaveric pelvic specimens of the oldest donors might have had age-related degeneration. CONCLUSIONS: The present anatomical study has shown only a plane of loose areolar tissue between the rectal and vaginal wall. We can conclude that there is no independent fascia or septum in the rectovaginal space. See Video Abstract at http://links.lww.com/DCR/B456. ANATOMÍA QUIRÚRGICA DEL ESPACIO RECTOVAGINAL: ¿EXISTE UN TABIQUE RECTOVAGINAL INDEPENDIENTE O UNA FASCIA DE DENONVILLIERS EN LAS MUJERES: Debajo del reflejo peritoneal anterior, la pared rectal anterior y el mesorrecto están separados de la pared vaginal posterior por un espacio rectovaginal virtual. En este espacio, la descripción de un tabique rectovaginal independiente específico como contraparte femenina de la fascia de Denonvilliers ha sido objeto de debate a lo largo de los años.Realizar un estudio anatómico preciso del área rectovaginal en un modelo de simulación cadavérica de escisión mesorrectal total, con el fin de evaluar las posibles estructuras y los planos de disección contenidos en el espacio rectovaginal.estudio cadavérico realizado en la Universidad de Valencia.Se disecaron las pelvis de 25 cadáveres femeninos conservados en formalina. Todas las muestras incluidas fueron seccionadas en un plano medio sagital, a la altura del eje medio del canal anal.Se llevó a cabo una disección cuidadosa y detallada para visualizar las estructuras anatómicas y los posibles planos de disección durante la disección mesorrectal anterior en cadáveres. Se realizaron cortes histológicos de la pared vaginal posterior.El espacio rectovaginal contiene tejido areolar laxo que permite un plano de disección fácil distalmente. No hay fascia o tabique rectovaginal distinto e independiente. La existencia de tres capas fusionadas en la pared vaginal posterior puede identificarse con mayor o menor precisión debido a su diferente coloración. El estudio histológico confirma esta disposición macroscópica de la pared vaginal posterior en tres capas: la mucosa, la muscular y la adventicia. Un tabique rectovaginal independiente solo se puede generar con una división de la adventicia.Las muestras pélvicas de cadáveres de los donantes más antiguos pueden haber tenido degeneración relacionada con la edad.El estudio anatómico actual solo ha mostrado un plano de tejido areolar laxo entre la pared rectal y vaginal. Podemos concluir que no hay fascia o tabique independiente en el espacio rectovaginal. Consulte Video Resumen en http://links.lww.com/DCR/B456. (Traducción-Dr. Adrian Ortega).

Validation of a Novel Fecal Incontinence Scale: The Rapid Assessment Fecal Incontinence Score (RAFIS).

OBJECTIVE: The development and validation of a new version of the fecal incontinence (FI) scale "Rapid Assessment Fecal Incontinence Score" (RAFIS) incorporating domains for severity, type of stool loss, and global perception of the effect of incontinence on quality of life (QoL). BACKGROUND: FI negatively impacts on QoL. Currently used incontinence questionnaires have outstanding limitations on the global assessment of the impact of the disease on QoL that patients perceive. We developed a new version of RAFIS with a more complete questionnaire. MATERIALS AND METHODS: A 3-phase study was performed to evaluate the applicability and reliability of our questionnaire as a tool for assessing FI. Our score was completed by 98 patients (78 women; mean age: 57±13 y) who presented with FI and who were referred from 4 colorectal surgery centers. The RAFIS was assessed for internal consistency, test-retest reliability, and sensitivity to change. A multivariate analysis was performed. Comparisons were made with the Wexner Cleveland Clinic Incontinence Score and the Fecal Incontinence Quality of Life Scale. RESULTS: The RAFIS showed good internal consistency and test-retest reliability, differentiating the severity of incontinence but not the etiology. There was a moderate-high correlation between the new scale and the reference scales. Sensitivity to change, compared with the Wexner Score, was moderate. Comparison with established QoL instruments showed a moderate negative correlation. Logistic regression of the RAFIS discriminated between mild and moderate-severe impact on QoL. No correlation was detected with the new score to the presence of an anal sphincter defect or sphincter hypotonia. CONCLUSION: The RAFIS scale is easy to administer and compares well with other validated incontinence instruments.

Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico / Stoma reversal after surgery for complicated acute diverticulitis: A multicentre retrospective study

INTRODUCCIÓN: El objetivo del estudio es analizar la tasa de reconstrucción del estoma tras cirugía por diverticulitis aguda complicada (DAC), su demora, factibilidad, complicaciones y factores de riesgo de mantenerlo. MÉTODOS: Estudio retrospectivo multicéntrico de pacientes intervenidos mediante cirugía urgente por DAC con realización de un estoma en 10 hospitales durante 6 años. Se analiza la frecuencia de reconstrucción del estoma, fundamentalmente de los terminales, y el tiempo en que se produce, así como los factores relacionados con ella. RESULTADOS: De 385 pacientes intervenidos por DAC, a 312 (81%) se les realizó un estoma: 292 fueron colostomías terminales y 20 estomas derivativos. Durante el seguimiento, en 161 (51,6%), se intentó el cierre a una mediana de 9 meses. Las causas más frecuentes de no efectuarlo fueron la comorbilidad y el fallecimiento del paciente. La edad más avanzada se mostró factor adverso en el análisis multivariante y la tasa actuarial de reconstrucción fue mayor en hombres y en quienes no se realizó un Hartmann. La cirugía pudo completarse en todos menos en un paciente y en 4 se asoció un estoma derivativo. La morbimortalidad fue del 35,7 y 1,9%, respectivamente. Hubo un 8,4% de reintervenciones y un 6% de fallos de sutura, quedando 12 pacientes (7,9%) con un estoma tras el intento de reconstrucción. CONCLUSIONES: La cirugía de la DAC se asocia muy frecuentemente a la construcción de un estoma terminal, que en casi un 50% no se reconstruirá. Además, la intervención de reconstrucción tiene una demora notable y está asociada a una morbimortalidad nada despreciable

INTRODUCTION: The aim was to analyse the stoma reversal rate after surgery for complicated acute diverticulitis (CAD), and more specifically the end-stoma-reversal, as well as the delay, feasibility, complications and risk factors for stoma maintenance. METHODS: A multicentre retrospective study of patients who had undergone urgent surgery for CAD with stoma formation in ten hospitals during a period of 6 years. The frequency of reversal over time and the factors affecting the decision for reversal were analysed. RESULTS: Out of 385 patients operated for CAD, 312 underwent stoma creation: 292 end colostomies and 20 diverting stomas. During follow-up, stoma reversal surgery was performed in 161 patients (51.6%) after a median of 9 months. The main causes for not performing stoma reversal were comorbidities and the death of the patient. Advanced age was an adverse factor in the multivariate analysis, and the actuarial rate of reversal was higher in men and in patients with no previous Hartmann's operation. Stoma reversal surgery was completed in all but one patient, and a loop ileostomy was associated in four. Morbidity and mortality rates were 35.7% and 1.9%, respectively. A total of 8.4% of patients underwent re-operation, and 6% experienced an anastomotic leak. Twelve patients remained with a stoma after the attempted reconstruction surgery. CONCLUSIONS: Surgery for CAD is frequently associated with an end stoma, which will ultimately not be reversed in almost 50% of patients. Moreover, reversal surgery is frequently delayed and is associated with significant morbidity and mortality

Stoma reversal after surgery for complicated acute diverticulitis: A multicentre retrospective study. / Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico.

INTRODUCTION THE AIM: was to analyse the stoma reversal rate after surgery for complicated acute diverticulitis (CAD), and more specifically the end-stoma-reversal, as well as the delay, feasibility, complications and risk factors for stoma maintenance. METHODS: A multicentre retrospective study of patients who had undergone urgent surgery for CAD with stoma formation in ten hospitals during a period of 6 years. The frequency of reversal over time and the factors affecting the decision for reversal were analysed. RESULTS: Out of 385 patients operated for CAD, 312 underwent stoma creation: 292 end colostomies and 20 diverting stomas. During follow-up, stoma reversal surgery was performed in 161 patients (51.6%) after a median of 9 months. The main causes for not performing stoma reversal were comorbidities and the death of the patient. Advanced age was an adverse factor in the multivariate analysis, and the actuarial rate of reversal was higher in men and in patients with no previous Hartmann's operation. Stoma reversal surgery was completed in all but one patient, and a loop ileostomy was associated in four. Morbidity and mortality rates were 35.7% and 1.9%, respectively. A total of 8.4% of patients underwent re-operation, and 6% experienced an anastomotic leak. Twelve patients remained with a stoma after the attempted reconstruction surgery. CONCLUSIONS: Surgery for CAD is frequently associated with an end stoma, which will ultimately not be reversed in almost 50% of patients. Moreover, reversal surgery is frequently delayed and is associated with significant morbidity and mortality.

Acute diverticulitis and surgical treatment.

Diverticulitis is a common condition in industrialized countries and an important cause of hospital admissions. Its growing trend is a challenge for the surgeons who perform emergency surgery, because approximately 15-25% of the patients will require surgery, being the surgical management of complicated acute diverticulitis controversial. The past decade has seen a paradigm shift in the treatment of sigmoid diverticulitis based on new epidemiological studies and refinement of surgical techniques that has produced a reassessment of our guidelines. CT imaging and sepsis scores allows to stratify the patients and better define the therapeutic strategies in each case. Special considerations must also be made for patients with a high surgical risk, such as immunosuppressed ones. The recommendations to perform surgery after two episodes of uncomplicated diverticulitis have been re-evaluated and the belief that new episodes may be complicated and associated with high morbidity and mortality has been rejected, since the clinical manifestations of this disease are usually defined by the first attack. In complicated cases, more patients can be treated with resection and primary anastomosis with or without an associated stoma, whose reversal rate is much higher than that of a Hartmann's procedure. Likewise, laparoscopic surgery performing a peritoneal lavage and drainage without associated resection may have an increasing role in the management of these patients, although with controversial results, having become laparoscopic colon resection the approach of choice for the treatment of this pathology in elective settings.

Tratamiento quirúrgico de la diverticulitis aguda. Estudio retrospectivo multicéntrico / Surgical treatment of acute diverticulitis. A retrospective multicentre study

INTRODUCCIÓN: Se pretende analizar los resultados a corto y medio plazo de diferentes técnicas quirúrgicas en el tratamiento de la diverticulitis aguda complicada (DAC). MÉTODOS: Estudio retrospectivo y multicéntrico de pacientes operados de urgencia o de urgencia diferida por DAC. RESULTADOS: Estudiamos a 385 pacientes: 218 hombres y 167 mujeres, de edad media 64,4 ± 15,6 años, intervenidos en 10 hospitales. La mediana (25-758 percentiles) de evolución desde el inicio de los síntomas hasta la cirugía fue de 48 h(24-72), y su indicación más frecuente, un cuadro peritonítico (66%). El abordaje fue generalmente abierto (95,1%) y los hallazgos más comunes, peritonitis purulenta (34,8%) o absceso pericólico (28,6%). La técnica más habitual fue el procedimiento de Hartmann (PHT) en 278 (72,2%), seguida de resección y anastomosis primaria (RAP) en 69 (17,9%). Se complicaron 205 pacientes (53,2%) y fallecieron 50 (13%). Edad avanzada, inmunodepresión, factores de riesgo quirúrgico y peritonitis fecal se asociaron a mayor mortalidad. El lavado peritoneal laparoscópico (LPL) tuvo elevada tasa de reintervenciones, implicando frecuentemente un estoma, y la RAP se complicó con dehiscencia de sutura en el 13,7% de pacientes, sin diferencias en la morbimortalidad al compararla con el PHT. La mediana de estancia postoperatoria fue de 12 días; su mayor duración se relacionó con la mayor edad, riesgo quirúrgico ASA, hospital y complicaciones postoperatorias. CONCLUSIONES: La cirugía por DAC tiene importante morbimortalidad y se asocia frecuentemente a un estoma terminal. Además, el LPL presenta alta tasa de reintervenciones. LA RAP, aun asociando un estoma de protección, parece de elección en muchos casos

INTRODUCTION: To analyze short and medium-term results of different surgical techniques in the treatment of complicated acute diverticulitis (CAD). METHODS: Multicentre retrospective study including patients operated on as surgical emergency or deferred-urgency with the diagnosis of CAD. RESULTS: A series of 385 patients: 218 men and 167 women, mean age 64.4 ± 15.6 years, operated on in 10 hospitals were included. The median (25th-75th percentile) time from symptoms to surgery was 48 (24-72) h, being peritonitis the main surgical indication in a 66% of cases. Surgical approach was usually open (95.1%), and the commonest findings, a purulent peritonitis (34.8%) or pericolonic abscess (28.6%). Hartmann procedure (HP) was the most used technique in 278 (72.2%) patients, followed by resection and primary anastomosis (RPA) in 69 (17.9%). The overall postoperative morbidity and mortality was 53.2% and 13% respectively. Age, immunosupression, presence of general risk factors and faecal peritonitis were associated with increased mortality. Laparoscopic peritoneal lavage (LPL) was associated with an increased reoperation rate frequently involving a stoma, and anastomotic leaks presented in 13.7 patients after RPA, without differences in morbimortality when compared with HP. Median postoperative length of stay was 12 days, and was correlated with age, surgical risk, ASA score, hospital and postoperative complications. CONCLUSIONS: Surgery for CAD has important morbidity and mortality and is frequently associated with an end-stoma. Moreover LPL presented high reoperation rates. It seems better to resect and anastomose in most cases, even with an associated protective stoma

Surgical treatment of acute diverticulitis. A retrospective multicentre study. / Tratamiento quirúrgico de la diverticulitis aguda. Estudio retrospectivo multicéntrico.

INTRODUCTION: To analyze short and medium-term results of different surgical techniques in the treatment of complicated acute diverticulitis (CAD). METHODS: Multicentre retrospective study including patients operated on as surgical emergency or deferred-urgency with the diagnosis of CAD. RESULTS: A series of 385 patients: 218 men and 167 women, mean age 64.4±15.6 years, operated on in 10 hospitals were included. The median (25th-75th percentile) time from symptoms to surgery was 48 (24-72) h, being peritonitis the main surgical indication in a 66% of cases. Surgical approach was usually open (95.1%), and the commonest findings, a purulent peritonitis (34.8%) or pericolonic abscess (28.6%). Hartmann procedure (HP) was the most used technique in 278 (72.2%) patients, followed by resection and primary anastomosis (RPA) in 69 (17.9%). The overall postoperative morbidity and mortality was 53.2% and 13% respectively. Age, immunosupression, presence of general risk factors and faecal peritonitis were associated with increased mortality. Laparoscopic peritoneal lavage (LPL) was associated with an increased reoperation rate frequently involving a stoma, and anastomotic leaks presented in 13.7 patients after RPA, without differences in morbimortality when compared with HP. Median postoperative length of stay was 12 days, and was correlated with age, surgical risk, ASA score, hospital and postoperative complications. CONCLUSIONS: Surgery for CAD has important morbidity and mortality and is frequently associated with an end-stoma. Moreover LPL presented high reoperation rates. It seems better to resect and anastomose in most cases, even with an associated protective stoma.

An open access database for the evaluation of heart sound algorithms.

In the past few decades, analysis of heart sound signals (i.e. the phonocardiogram or PCG), especially for automated heart sound segmentation and classification, has been widely studied and has been reported to have the potential value to detect pathology accurately in clinical applications. However, comparative analyses of algorithms in the literature have been hindered by the lack of high-quality, rigorously validated, and standardized open databases of heart sound recordings. This paper describes a public heart sound database, assembled for an international competition, the PhysioNet/Computing in Cardiology (CinC) Challenge 2016. The archive comprises nine different heart sound databases sourced from multiple research groups around the world. It includes 2435 heart sound recordings in total collected from 1297 healthy subjects and patients with a variety of conditions, including heart valve disease and coronary artery disease. The recordings were collected from a variety of clinical or nonclinical (such as in-home visits) environments and equipment. The length of recording varied from several seconds to several minutes. This article reports detailed information about the subjects/patients including demographics (number, age, gender), recordings (number, location, state and time length), associated synchronously recorded signals, sampling frequency and sensor type used. We also provide a brief summary of the commonly used heart sound segmentation and classification methods, including open source code provided concurrently for the Challenge. A description of the PhysioNet/CinC Challenge 2016, including the main aims, the training and test sets, the hand corrected annotations for different heart sound states, the scoring mechanism, and associated open source code are provided. In addition, several potential benefits from the public heart sound database are discussed.

Influencia del volumen quirúrgico en los resultados oncológicos después de estandarizar la cirugía en el Proyecto Español del Cáncer de Recto / Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery in the Spanish Rectal Cancer Project

INTRODUCCIÓN: Determinar la influencia del volumen quirúrgico en los resultados oncológicos del Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos. MÉTODOS: Se incluyeron 2.910 pacientes consecutivos tratados con una operación curativa entre marzo de 2006 y marzo de 2010 en 36 hospitales. Los hospitales se clasificaron según el número de pacientes operados por año en: pequeños (12-23), intermedios (24-35) y grandes (≥ 36). RESULTADOS: Con un seguimiento de al menos cinco años la incidencia acumulada de recidiva local fue 6,6 (IC 95% 5,6-7,6), la de metástasis 20,3 (IC 95% 18,8-21,9) y la de supervivencia global 73,0 (IC 95% 74,7-71,3). En el análisis de regresión multinivel, la supervivencia global fue mayor en los hospitales que operaban 36 o más pacientes [HR 0,727 (IC 95% 0,556-0,951); p = 0,02]. El riesgo de recidiva local y metástasis no se relacionó con el volumen quirúrgico. Además, hubo una variación significativa en las tasas de supervivencia global (mediana hazard ratio [MHR] 1,184 [IC 95% 1,071-1,333]), recidiva local (MHR 1,308 [IC 95% 1,010-1,668]) y metástasis (MHR 1,300 [IC 95% 1,181-1,476]) entre todos los hospitales. CONCLUSIONES: En los grupos multidisciplinares seleccionados e incluidos en el proyecto de la Asociación Española de Cirujanos, que incluye la enseñanza de la escisión total del mesorrecto y la realimentación de los resultados, la supervivencia global es mayor en los hospitales con mayor volumen quirúrgico, y la variabilidad interhospitalaria de la tasa de recidiva local no se explica por el volumen quirúrgico

INTRODUCCIÓN: The purpose of this prospective multicentre multilevel study was to investigate the influence of hospital caseload on long-term outcomes following standardization of rectal cancer surgery in the Rectal Cancer Project of the Spanish Society of Surgeons. METHODS: Data relating to 2910 consecutive patients with rectal cancer treated for cure between March 2006 and March 2010 were recorded in a prospective database. Hospitals were classified according to number of patients treated per year as low-volume, intermediate-volume, or high volume hospitals (12-23, 24-35, or ≥ 36 procedures per year). RESULTS: After a median follow-up of 5 years, cumulative rates of local recurrence, metastatic recurrence and overall survival were 6.6 (CI 95% 5.6-7.6), 20.3 (CI 95% 18.8-21.9) and 73.0 (CI95% 74.7 - 71.3) respectively. In the multilevel regression analysis overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more patients (HR 0,727 [CI 95% 0,556-0,951]; P=.02). The risk of local recurrence and metastases were not related to the caseload. Moreover, there was a statistically significant variation in overall survival (median hazard ratio [MHR] 1.184 [CI 95% 1.071-1,333]), local recurrence (MHR 1.308 [CI 95% 1.010-1.668]) and metastases (MHR 1.300 [CI 95% 1.181; 1.476]) between all hospitals. CONCLUSIONS: Overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more PATIENTS: However, local recurrence was not influenced by caseload

Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery in the Spanish Rectal Cancer Project. / Influencia del volumen quirúrgico en los resultados oncológicos después de estandarizar la cirugía en el Proyecto Español del Cáncer de Recto.

UNLABELLED: INTRODUCCIóN: The purpose of this prospective multicentre multilevel study was to investigate the influence of hospital caseload on long-term outcomes following standardization of rectal cancer surgery in the Rectal Cancer Project of the Spanish Society of Surgeons. METHODS: Data relating to 2910 consecutive patients with rectal cancer treated for cure between March 2006 and March 2010 were recorded in a prospective database. Hospitals were classified according to number of patients treated per year as low-volume, intermediate-volume, or high volume hospitals (12-23, 24-35, or ≥36 procedures per year). RESULTS: After a median follow-up of 5 years, cumulative rates of local recurrence, metastatic recurrence and overall survival were 6.6 (CI95% 5.6-7.6), 20.3 (CI95% 18.8-21.9) and 73.0 (CI95% 74.7 - 71.3) respectively. In the multilevel regression analysis overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more patients (HR 0,727 [CI95% 0,556-0,951]; P=.02). The risk of local recurrence and metastases were not related to the caseload. Moreover, there was a statistically significant variation in overall survival (median hazard ratio [MHR] 1.184 [CI95% 1.071-1,333]), local recurrence (MHR 1.308 [CI95% 1.010-1.668]) and metastases (MHR 1.300 [CI95% 1.181; 1.476]) between all hospitals. CONCLUSIONS: Overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more patients. However, local recurrence was not influenced by caseload.

Variabilidad interhospitalaria de la dehiscencia anastomótica en el Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos: La influencia del volumen quirúrgico / Hospital variation in anastomotic leakage after rectal cancer surgery in the Spanish Association of Surgeons project: The contribution of hospital volume

INTRODUCCIÓN: El objetivo de este estudio observacional multicéntrico fue determinar la tasa de dehiscencia anastomótica en los hospitales que participan en el Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos y evaluar si había diferencias atribuibles al volumen quirúrgico entre los hospitales que participan en él. MÉTODOS: La variación interhospitalaria se cuantificó mediante un estudio multinivel realizado con una base de datos prospectiva de los pacientes operados por un adenocarcinoma de recto con una resección anterior en 84 hospitales, entre marzo de 2006 y diciembre de 2013. En los análisis se incluyeron: las variables demográficas, la clasificación de la American Society of Anaesthesiologists, la utilización de un estoma de derivación, la localización y el estadio del tumor, la administración de tratamiento neoadyuvante y el volumen quirúrgico anual del hospital. RESULTADOS: Se analizó a 7.231 pacientes operados consecutivamente. La tasa de dehiscencia anastomótica fue del 10,0%. Los porcentajes de dehiscencia de los hospitales, estratificados por el volumen quirúrgico annual, variaron entre el 9,9 y el 11,3%. En el análisis de regresión multinivel el sexo masculino, los tumores localizados por debajo de 12 cm medidos desde el margen anal y los estadios T avanzados favorecieron la aparición de la dehiscencia, mientras que la presencia de un estoma de derivación la previno. El volumen quirúrgico anual del hospital no se asoció con la dehiscencia (OR: 0,852; [0,487-1,518]; p = 0,577). Además, se observó una variación significativa de la tasa de dehiscencia entre los hospitales (MOR: 1,475; [1,321-1,681]; p < 0,001). CONCLUSIÓN: La dehiscencia anastomótica varía de forma estadísticamente significativa entre los hospitales incluidos en el proyecto, y esta diferencia no se puede atribuir al volumen quirúrgico anual

OBJECTIVE: This multicentre observational study aimed to determine the anastomotic leak rate in the hospitals included in the Rectal Cancer Project of the Spanish Society of Surgeons and examine whether hospital volume may contribute to any variation between hospitals. METHODS: Hospital variation was quantified using a multilevel approach on prospective data derived from the multicentre database of all adenocarcinomas of the rectum operated by an anterior resection at 84 surgical departments from 2006 to 2013. The following variables were included in the analysis; demographics, American Society of Anaesthesiologists classification, use of defunctioning stoma, tumour location and stage, administration of neoadjuvant treatment, and annual volume of elective surgical procedures. RESULTS: A total of 7231 consecutive patients were included. The rate of anastomotic leak was 10.0%. Stratified by annual surgical volume hospitals varied from 9.9 to 11.3%. In multilevel regression analysis, the risk of anastomotic leak increased in male patients, in patients with tumours located below 12 cm from the anal verge, and advanced tumour stages. However, a defunctioning stoma seemed to prevent this complication. Hospital surgical volume was not associated with anastomotic leak (OR: 0.852, [0.487-1.518]; P=.577). Furthermore, there was a statistically significant variation in anastomotic leak between all departments (MOR: 1.475; [1.321-1.681]; P<0.001). CONCLUSION: Anastomotic leak varies significantly among hospitals included in the project and this difference cannot be attributed to the annual surgical volumen

[Hospital variation in anastomotic leakage after rectal cancer surgery in the Spanish Association of Surgeons project: The contribution of hospital volume]. / Variabilidad interhospitalaria de la dehiscencia anastomótica en el Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos: La influencia del volumen quirúrgico.

OBJECTIVE: This multicentre observational study aimed to determine the anastomotic leak rate in the hospitals included in the Rectal Cancer Project of the Spanish Society of Surgeons and examine whether hospital volume may contribute to any variation between hospitals. METHODS: Hospital variation was quantified using a multilevel approach on prospective data derived from the multicentre database of all adenocarcinomas of the rectum operated by an anterior resection at 84 surgical departments from 2006 to 2013. The following variables were included in the analysis; demographics, American Society of Anaesthesiologists classification, use of defunctioning stoma, tumour location and stage, administration of neoadjuvant treatment, and annual volume of elective surgical procedures. RESULTS: A total of 7231 consecutive patients were included. The rate of anastomotic leak was 10.0%. Stratified by annual surgical volume hospitals varied from 9.9 to 11.3%. In multilevel regression analysis, the risk of anastomotic leak increased in male patients, in patients with tumours located below 12 cm from the anal verge, and advanced tumour stages. However, a defunctioning stoma seemed to prevent this complication. Hospital surgical volume was not associated with anastomotic leak (OR: 0.852, [0.487-1.518]; P=.577). Furthermore, there was a statistically significant variation in anastomotic leak between all departments (MOR: 1.475; [1.321-1.681]; P<0.001). CONCLUSION: Anastomotic leak varies significantly among hospitals included in the project and this difference cannot be attributed to the annual surgical volume.

Variabilidad interhospitalaria de la mortalidad postoperatoria en el proyecto del cáncer de recto de la Asociación Española de Cirujanos. La influencia del volumen quirúrgico / Hospital variability in postoperative mortality after rectal cancer surgery in the Spanish association of surgeons project: The impact of hospital volume

INTRODUCCIÓN: El objetivo de este estudio observacional multicéntrico ha sido examinar la variación de la mortalidad postoperatoria de la cirugía electiva entre los hospitales que participan en el Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos, y evaluar si el volumen quirúrgico anual del hospital y las características de los pacientes contribuyen a la variación entre los hospitales. MÉTODOS: La variación interhospitalaria se cuantificó mediante un estudio multinivel realizado con una base de datos prospectiva de los pacientes operados por un adenocarcinoma de recto con una resección anterior y una amputación abdominoperineal en 84 hospitales, entre marzo de 2006 y diciembre de 2013. En los análisis se incluyeron: las variables demográficas, la clasificación ASA, la localización y el estadio del tumor, la administración de tratamiento neoadyuvante y el volumen quirúrgico anual del hospital. RESULTADOS: Se analizó a 9.809 pacientes operados consecutivamente. La tasa de mortalidad operatoria fue 1,8%. Los porcentajes de mortalidad de los hospitales estratificados por el volumen quirúrgico anual variaron entre 1,4 y 2,0%. En el análisis de regresión multinivel, el sexo masculino (OR 1,623 [1,143; 2,348]; p < 0,008), la edad avanzada (OR 5,811 [3,479; 10,087)]; p < 0,001) y la puntuación del ASA (OR 10,046 [3,390; 43,185]; p < 0,001) se asociaron con la mortalidad a los 30 días de la operación. Sin embargo, el volumen quirúrgico anual del hospital no se asoció con la mortalidad (OR 1,309 [0,483; 4,238]; p = 0,619). Además, se observó una variación significativa de la mortalidad entre los hospitales (MOR 1,588 [1,293; 2,015]; p < 0,001). CONCLUSIÓN:La mortalidad operatoria varía de forma estadísticamente significativa entre los hospitales incluidos en el proyecto, y esta diferencia no se puede atribuir al volumen quirúrgico anual

OBJECTIVE: This multicentre observational study examines variation between hospitals in postoperative mortality after elective surgery in the Rectal Cancer Project of the Spanish Society of Surgeons and explores whether hospital volume and patient characteristics contribute to any variation between hospitals. METHODS: Hospital variation was quantified using a multilevel approach on prospective data derived from the multicentre database of all rectal adenocarcinomas operated by an anterior resection or an abdominoperineal excision at 84 surgical departments from 2006 to 2013. The following variables were included in the analysis; demographics, American Society of Anaesthesiologists classification, tumour location and stage, administration of neoadjuvant treatment, and annual volume of surgical procedures. RESULTS: A total of 9809 consecutive patients were included. The rate of 30-day postoperative mortality was 1.8% Stratified by annual surgical volume hospitals varied from 1.4 to 2.0 in 30-day mortality. In the multilevel regression analysis, male gender (OR 1.623 [1.143; 2.348]; P < .008), increased age (OR: 5.811 [3.479; 10.087]; P < .001), and ASA score (OR 10.046 [3.390; 43.185]; P < .001) were associated with 30-day mortality. However, annual surgical volume was not associated with mortality (OR 1.309 [0.483; 4.238]; P = .619). Besides, there was a statistically significant variation in mortality between all departments (MOR 1.588 [1.293; 2.015]; P < .001). CONCLUSION: Postoperative mortality varies significantly among hospitals included in the project and this difference cannot be attributed to the annual surgical volume

Hospital variability in postoperative mortality after rectal cancer surgery in the Spanish Association of Surgeons project: The impact of hospital volume.

OBJECTIVE: This multicentre observational study examines variation between hospitals in postoperative mortality after elective surgery in the Rectal Cancer Project of the Spanish Society of Surgeons and explores whether hospital volume and patient characteristics contribute to any variation between hospitals. METHODS: Hospital variation was quantified using a multilevel approach on prospective data derived from the multicentre database of all rectal adenocarcinomas operated by an anterior resection or an abdominoperineal excision at 84 surgical departments from 2006 to 2013. The following variables were included in the analysis; demographics, American Society of Anaesthesiologists classification, tumour location and stage, administration of neoadjuvant treatment, and annual volume of surgical procedures. RESULTS: A total of 9809 consecutive patients were included. The rate of 30-day postoperative mortality was 1.8% Stratified by annual surgical volume hospitals varied from 1.4 to 2.0 in 30-day mortality. In the multilevel regression analysis, male gender (OR 1.623 [1.143; 2.348]; P<.008), increased age (OR: 5.811 [3.479; 10.087]; P<.001), and ASA score (OR 10.046 [3.390; 43.185]; P<.001) were associated with 30-day mortality. However, annual surgical volume was not associated with mortality (OR 1.309 [0.483; 4.238]; P=.619). Besides, there was a statistically significant variation in mortality between all departments (MOR 1.588 [1.293; 2.015]; P<.001). CONCLUSION: Postoperative mortality varies significantly among hospitals included in the project and this difference cannot be attributed to the annual surgical volume.

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.

Preoperative chemotherapy in patients with intermediate-risk rectal adenocarcinoma selected by high-resolution magnetic resonance imaging: the GEMCAD 0801 Phase II Multicenter Trial.

BACKGROUND: The need for preoperative chemoradiation or short-course radiation in all T3 rectal tumors is a controversial issue. A multicenter phase II trial was undertaken to evaluate the efficacy and safety of neoadjuvant capecitabine and oxaliplatin combined with bevacizumab in patients with intermediate-risk rectal adenocarcinoma. METHODS: We recruited 46 patients with T3 rectal adenocarcinoma selected by magnetic resonance imaging (MRI) who were candidates for (R0) resection located in the middle third with clear mesorectal fascia and who were selected by pelvic MRI. Patients received four cycles of neoadjuvant capecitabine and oxaliplatin combined with bevacizumab (final cycle without bevacizumab) before total mesorectal excision (TME). In case of progression, preoperative chemoradiation was planned. The primary endpoint was overall response rate (ORR). RESULTS: On an intent-to-treat analysis, the ORR was 78% (n = 36; 95% confidence interval [CI]: 63%-89%) and no progression was detected. Pathologic complete response was observed in nine patients (20%; 95% CI: 9-33), and T downstaging was observed in 48%. Forty-four patients proceeded to TME, and all had R0 resection. During preoperative therapy, two deaths occurred as a result of pulmonary embolism and diarrhea, respectively, and one patient died after surgery as a result of peritonitis secondary to an anastomotic leak (AL). A 13% rate of AL was higher than expected. The 24-month disease-free survival rate was 75% (95% CI: 60%-85%), and the 2-year local relapse rate was 2% (95% CI: 0%-11%). CONCLUSION: In this selected population, initial chemotherapy results in promising activity, but the observed toxicity does not support further investigation of this specific regimen. Nevertheless, these early results warrant further testing of this strategy in an enriched population and in randomized trials.