Standardisation of the definition of the types of oncological colectomy. Delphi method for consensus of experts of the Spanish association of surgeons.

There is no international consensus on the definition of the type of oncological resection that corresponds to each of the colectomies existing in the current literature. The objective is to define for each colectomy described in the literature: embryological dissection plane, vascular pedicles in which to perform central ligation, the extent of the colectomy, and the need for resection of the greater momentum. A consensus of experts is carried out through the Delphi methodology through two rounds from the Coloproctology Section of the Spanish Association of Surgeons. Study period: November 2021-January 2023. 120 experts were surveyed. Degrees of consensus: Very strong: >90%, Strong: 80-90%, Moderate: 50-80%, No consensus: <50%. The definition for each oncological colectomy was established by very strong, and strong recommendations. Each oncological colectomy was established as Right hemicolectomy (RHC), RHC with D3 lymphadenectomy, Extended-RHC, transverse colon segmental colectomy, splenic flexure segmental colectomy, subtotal colectomy, total colectomy, left hemicolectomy (LHC), extended-LHC, sigmoidectomy.

Chemoradiation, Consolidation Chemotherapy, and Watch and Wait for Early Rectal Cancer.

As watch and wait has become an attractive management alternative among patients with rectal cancer who achieve a clinical complete response to neoadjuvant chemoradiation, the focus of organ preservation has now shifted toward the use of this approach in patients with early rectal cancer. These patients would otherwise be treated without the use of neoadjuvant therapy for oncological reasons. The sole purpose of any neoadjuvant treatment here would be the achievement of a complete clinical response in an attempt to avoid total mesorectal excision. This has become particularly interesting after the incorporation of total neoadjuvant therapy regimens. These regimens have resulted in significantly higher rates of complete tumor regression and therefore become an interesting alternative among early rectal cancer patients where organ preservation is desired. The present review provides an overview of the currently available evidence and the preliminary experience with this rather controversial approach.

Prospective study about the security and efficacy of treatment without antibiotic therapy of patients diagnosed with acute uncomplicated diverticulitis after launching a protocol at a tertiary hospital.

INTRODUCTION: The main objective of our study is to analyze the results in our hospital after launching a treatment protocol without antibiotic therapy for patients diagnosed with acute uncomplicated diverticulitis. METHODS: Our observational, prospective, single-center study was developed after launching a treatment protocol without antibiotic therapy for patients diagnosed with acute uncomplicated diverticulitis (AUD) in January 2021. The follow-up period was from January 1, 2021 to September 30, 2023. Variables evaluated by the study have included demographic and analytical variables, as well as those related to diagnosis and whether the patients needed to start antibiotic treatment, inpatient treatment, or surgical procedures. RESULTS: In total, 199 patients were diagnosed with AUD, 75 of whom were treated without antibiotic therapy as outpatients. Seven of these patients needed to start antibiotic treatment because of adverse evolution; none of these patients required surgical procedures. The need for inpatient treatment, urgent care, or surgical procedures is similar to the group of patients treated with antibiotics. The main risk factor of failure of outpatient treatment without antibiotic therapy identified by the study was the presence of bacteriuria at diagnosis. CONCLUSIONS: Our results confirm previous reports, observing that treatment without antibiotic therapy in selected patients with AUD is safe.

Local Excision for organ preservation in early REctal cancer with No Adjuvant treatment (LORENA Trial): prospective observational study protocol.

INTRODUCTION: Local resection (LR) is an alternative to total mesorectal excision (TME) that avoids its associated morbidity to the detriment of oncological radicality in early stages of rectal cancer. There are several conditioning factors for the success of this strategy, such as poor prognosis histological factors (PPHF), involvement of resection margins, clinical under staging, or complications that may lead to the indication for radical surgery with TME. PATIENTS AND METHOD: An international multicenter prospective observational open-label study has been designed. Consecutive patients diagnosed with early rectal cancer (cT1N0 on MRI + / - endorectal ultrasound) whose lower limit is a maximum of 2 cm proximal to the ano-rectal junction will be included. The primary objective of the study is to determine the overall prevalence of PPHF after LR and requiring TME or postoperative radio-chemotherapy. DISCUSSION: The prevalence of PPHF conditioning the success of LR in early distal rectal cancer has been scarcely studied in the literature, and there are very few prospective data. Considering the increasing interest in the watch and wait strategy in rectal cancer and its possible application in early-stage tumors, it seems necessary to know this information. The results of this study will help guide clinical practice in patients with early distal rectal cancer. It will also provide quality information for the design of future comparative studies to improve organ preservation success in these patients. TRIAL REGISTRATION NUMBER: NCT05927584.

Resultados de una encuesta nacional sobre el manejo de los pacientes diagnosticados de diverticulitis aguda no complicada / Results of a national survey about the management of patients with acute uncomplicated diverticulitis

Introducción: El manejo de los pacientes diagnosticados de diverticulitis aguda no complicada ha evolucionado en los últimos años, y según diversas guías clínicas internacionales actuales, el tratamiento ambulatorio y sin antibioterapia puede ser utilizado en pacientes seleccionados. El objetivo de este estudio es evaluar la adhesión de los distintos centros nacionales a estas y otras recomendaciones en esta enfermedad. Métodos: Se realizó una encuesta online a nivel nacional que se dio a conocer a través de diversas aplicaciones informáticas y se analizaron estadísticamente los resultados obtenidos. Resultados: Participaron 104 cirujanos, representando 69 centros hospitalarios nacionales. En el 82,6% de los centros, se realiza manejo ambulatorio de los pacientes diagnosticados de diverticulitis aguda no complicada. El 23,2% de los centros tiene implantado un protocolo de tratamiento sin antibioterapia en pacientes seleccionados, mientras que en los centros que no siguen estas recomendaciones, las razones principales son las dificultades logísticas para su desarrollo (49,3%) y la ausencia de evidencia actual para ello (44,8%). Se han encontrado diferencias estadísticamente significativas al comparar la implantación de dichos protocolos entre centros con unidades acreditadas avanzadas y aquellas que no, con mayores tasas de manejo ambulatorio y sin antibioterapia en los centros acreditados avanzados (p≤0,05). Conclusiones: A pesar de ser una enfermedad muy frecuente, existe mucha heterogeneidad en su tratamiento a nivel nacional, por lo que sería recomendable la unificación de criterios diagnósticos y de tratamiento mediante la colaboración de las sociedades científicas y la simplificación de la puesta en marcha de protocolos hospitalarios.(AU)

Introduction: Management of patients diagnosed of acute uncomplicated diverticulitis has evolved lately and according to the latest guidelines, outpatient treatment and management without antibiotherapy may be used in selected patients. The aim of this study is to evaluate the adhesion among national centres to these and others recommendations related to this pathology. Methods: An online national survey, that has been broadcast by several applications, was performed. The results obtained were statistically analysed. Results: A total of 104 surgeons participated, representing 69 national hospitals. Of those, in 82.6% of the centers, outpatient management is performed for acute uncomplicated diverticulitis. 23.2% of the hospitals have a protocol stablished for treatment without antibiotherapy in selected patients. Centers that do not follow these protocols allege that the mean reasons are the logistic difficulties to set them up (49.3%) and the lack of current evidence for it (44.8%). Significative statistical differences have been found when comparing the establishment of such protocols between centers with advanced accredited units and those who are not, with higher rates of outpatient management and treatment without antibiotics in accredited units (P≤.05). Conclusions: In spite that this a very common disease, there is a huge national heterogeneity in its treatment. This is why it would adviseable to unify diagnostic and treatment criteria by the collaboration of scientific societies and the simplification of the development of hospitalary protocols.(AU)

Estudio observacional nacional sobre tratamiento quirúrgico de fístula anal: ¿tiene impacto en los resultados el tipo de hospital? / National observational study about the surgical treatment of anal fistula: does the kind of hospital modify the results?

Introducción: En algunos procedimientos quirúrgicos se ha demostrado que la centralización en hospitales de alto volumen mejora los resultados obtenidos. Sin embargo, este punto aún no ha sido estudiado en los pacientes que son intervenidos por una fístula anal (FA). Material y métodos: Se realizó un estudio multicéntrico retrospectivo en el que se incluyeron los pacientes operados de FA durante el año 2019 en 56 centros españoles. Se hizo un análisis uni y multivariante para analizar la relación entre el tamaño del lugar, el porcentaje de curación de la fístula y el desarrollo de incontinencia fecal (IF). Resultados: Se incluyeron en el estudio a 1.809 pacientes. La cirugía se llevó a cabo en un hospital pequeño en 127 usuarios (7,0%), uno mediano en 571 (31,6%) y uno grande en 1.111 (61,4%). Tras un seguimiento medio de 18,9 meses, 72,3% de los participantes (1.303) se consideraron curados y 132 (7,6%) presentaron IF. El porcentaje de los rehabilitados de la FA fue de 74,8, 75,8 y 70,3% (p = 0,045) en los centros pequeño, mediano y grande, respectivamente. En cuanto a la IF no se evidenciaron diferencias significativas según el tipo de lugar (4,8, 8,0 y 7,7%, respectivamente, p = 0,473). En el análisis multivariante no se observó relación entre el tamaño del hospital y la curación de la fístula o el desarrollo de IF. Conclusión: Los resultados de curación e IF posoperatoria en los pacientes sometidos a una cirugía por FA fueron independientes del volumen hospitalario.(AU)

Introduction: Performing the surgical procedure in a high-volume center has been seen to be important for some surgical procedures. However, this issue has not been studied for patients with an Anal Fistula (AF). Material and methods: A retrospective multicentric study was performed including the patients who underwent AF surgery in 2019 in 56 Spanish hospitals. A univariate and multivariate analysis was performed to analyse the relationship between hospital volume and AF cure and Fecal Incontinence (FI). Results: 1809 patients were include. Surgery was performed in a low, middle, and high-volume hospitals in 127 (7.0%), 571 (31.6%) y 1111 (61.4%) patients respectively. After a mean follow-up of 18.9 months 72.3% (1303) patients were cured and 132 (7.6%) developed FI. The percentage of patients cured was 74.8%, 75.8% and 70.3% (p=0.045) for low, middle, and high-volume hospitals. Regarding FI, no statistically significant differences were observed depending on the hospital volume (4.8%, 8.0% and 7.7% respectively, p=0.473). Multivariate analysis didńt observe a relationship between AF cure and FI. Conclusion: Cure and FI in patients who underwent AF surgery were independent from hospital volume.(AU)

Results of a national survey about the management of patients with acute uncomplicated diverticulitis.

INTRODUCTION: Management of patients diagnosed of acute uncomplicated diverticulitis has evolved lately and according to the latest guidelines, outpatient treatment and management without antibiotherapy may be used in selected patients. The aim of this study is to evaluate the adhesión among national centres to these and others recommendations related to this pathology. METHODS: An online national survey, that has been broadcast by several applications, was performed. The results obtained were statistically analysed. RESULTS: A total of 104 surgeons participated, representing 69 national hospitals. Of those, in 82.6% of the centres, outpatient management is performed for acute uncomplicated diverticulitis. 23.2% of the hospitals have a protocol stablished for treatment without antibiotherapy in selected patients. Centres that do not follow these protocols allege that the mean reasons are the logistic difficulties to set them up (49.3%) and the lack of current evidence for it (44.8%). Significative statistical differences have been found when comparing the establishment of such protocols between centres with advanced accredited units and those who are not, with higher rates of outpatient management and treatment without antibiotics in accredited units (p ≤ .05). CONCLUSIONS: In spite that this a very common disease, there is a huge national heterogeneity in its treatment. This is why it would adviseable to unify diagnostic and treatment criteria by the collaboration of scientific societies and the simplification of the development of hospitalary protocols.

National observational study about the surgical treatment of anal fistula: Does the kind of hospital modify the results?

INTRODUCTION: Performing the surgical procedure in a high-volume center has been seen to be important for some surgical procedures. However, this issue has not been studied for patients with an anal fistula (AF). MATERIAL AND METHODS: A retrospective multicentric study was performed including the patients who underwent AF surgery in 2019 in 56 Spanish hospitals. A univariate and multivariate analysis was performed to analyse the relationship between hospital volume and AF cure and fecal incontinence (FI). RESULTS: 1809 patients were include. Surgery was performed in a low, middle, and high-volume hospitals in 127 (7.0%), 571 (31.6%) y 1111 (61.4%) patients respectively. After a mean follow-up of 18.9 months 72.3% (1303) patients were cured and 132 (7.6%) developed FI. The percentage of patients cured was 74.8%, 75.8% and 70.3% (p = 0.045) for low, middle, and high-volume hospitals. Regarding FI, no statistically significant differences were observed depending on the hospital volume (4.8%, 8.0% and 7.7% respectively, p = 0.473). Multivariate analysis didnt observe a relationship between AF cure and FI. CONCLUSION: Cure and FI in patients who underwent AF surgery were independent from hospital volume.

FiLaC procedure for highly selected anal fistula patients: indications,safety and efficacy from an observational study at a tertiary referral center / Procedimiento FiLaC para pacientes con fístula anal altamente seleccionados: indicaciones, seguridad y eficacia de un estudio observacional en un centro de referencia terciario

Background: the ideal clinical profile of patients or fistula features for fistula laser closure (FiLaC®) technique remain to be established. The aim of this study was to analyze clinical outcomes and the safety profile of FiLaC® in search for an ideal setting for this technique. Methods: a retrospective observational study was performed from a prospective database including all consecutive patients who underwent surgery for anal fistula (AF) with FiLaC® in the coloproctology unit of a tertiary referral center, between October 2015 and December 2021. The FiLaC® procedure was offered to AF patients who were considered to be at risk of fecal incontinence. Fistulas were described according to Parks’ classification and categorized as complex or simple according to the American Gastroenterological Association (AGA) guidelines. Healing was defined by the closure of the internal and external openings for at least six months. Predictive factors of AF healing were investigated. Results: a total of 36 patients were included, with a mean age of 48 ± 13.9 years. Twenty patients (55.6 %) were male and 13 patients (36 %) had Crohn’s disease (CD). Fourteen patients (38.8 %) had a complex fistula. The primary and secondary healing rates were 55.6 % and 91.7 %, respectively, during a median follow-up time of 12 months (IQR 7-29). No fecal continence impairment was registered in any case. The proportion of patients with primary healing was significantly higher in CD patients (76.9 % vs 43.5 %, p = 0.048). Conclusions: FiLaC® is a sphincter-preserving procedure with an excellent safety profile and reasonable success rate despite of the strict patient selection. This technique may be attractive for patients with CD due to its higher primary healing rate.(AU)

The Use of Fissios App© as a Complement to a Face-to-Face Respiratory Physiotherapy Program versus an Attendance-Only Face-to-Face Physiotherapy Program in Patients Scheduled for Thoracic Surgical Procedures Reduces the Risk of Developing Postoperative Pulmonary Complications-A Quasi-Experimental Study.

Postoperative pulmonary complications (PPCs) increase the hospital length of stay (LOS) and the cost of healthcare associated with surgical procedures. Strategies to reduce PPCs begin before surgery and continue in the postoperative period. Fissios App© is a smartphone application that contains perioperative medical advice and a structured respiratory physiotherapy program. The objective was to implement the use of this app in a group of patients scheduled for a thoracic surgical procedure and determine its efficacy in reducing PPCs. This was a quasi-experimental study in which all patients attended a face-to-face respiratory physiotherapy program, and the intervention group used Fissios App© as a complement. We prospectively recorded the postoperative evolution of both groups, analyzed the categorical differences and quantitative variables, and created a binary logistic regression model. We recruited 393 patients (131 intervention and 262 control). The intervention group had a lower incidence of PPCs (12.2% versus 24% in the control group, p = 0.006), a shorter LOS (a median of 3 days (IQR = 2-5) versus 4 days (IQR = 3-6, p = 0.001) in the control group), and a reduction in the risk of developing PPCs by 63.5% (OR: 0.365, 95% CI: 0.17-0.78). The use of Fissios App© improved the clinical outcomes after surgery and reduced the probability of developing PPCs.

Diagnostic Accuracy of Abdominal CT for Locally Advanced Colon Tumors: Can We Really Entrust Certain Decisions to the Reliability of CT?

Many different options of neoadjuvant treatments for advanced colon cancer are emerging. An accurate preoperative staging is crucial to select the most appropriate treatment option. A retrospective study was carried out on a national series of operated patients with T4 tumors. Considering the anatomo-pathological analysis of the surgical specimen as the gold standard, a diagnostic accuracy study was carried out on the variables T and N staging and the presence of peritoneal metastases (M1c). The parameters calculated were sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios, as well as the overall accuracy. A total of 50 centers participated in the study in which 1950 patients were analyzed. The sensitivity of CT for correct staging of T4 colon tumors was 57%. Regarding N staging, the overall accuracy was 63%, with a sensitivity of 64% and a specificity of 62%; however, the positive and negative likelihood ratios were 1.7 and 0.58, respectively. For the diagnosis of peritoneal metastases, the accuracy was 94.8%, with a sensitivity of 40% and specificity of 98%; in the case of peritoneal metastases, the positive and negative likelihood ratios were 24.4 and 0.61, respectively. The diagnostic accuracy of CT in the setting of advanced colon cancer still has some shortcomings for accurate diagnosis of stage T4, correct classification of lymph nodes, and preoperative detection of peritoneal metastases.

FiLaC® procedure for highly selected anal fistula patients: indications, safety and efficacy from an observational study at a tertiary referral center.

BACKGROUND: the ideal clinical profile of patients or fistula features for fistula laser closure (FiLaC®) technique remain to be established. The aim of this study was to analyze clinical outcomes and the safety profile of FiLaC® in search for an ideal setting for this technique. METHODS: a retrospective observational study was performed from a prospective database including all consecutive patients who underwent surgery for anal fistula (AF) with FiLaC® in the coloproctology unit of a tertiary referral center, between October 2015 and December 2021. The FiLaC® procedure was offered to AF patients who were considered to be at risk of fecal incontinence. Fistulas were described according to Parks' classification and categorized as complex or simple according to the American Gastroenterological Association (AGA) guidelines. Healing was defined by the closure of the internal and external openings for at least six months. Predictive factors of AF healing were investigated. RESULTS: a total of 36 patients were included, with a mean age of 48 ± 13.9 years. Twenty patients (55.6 %) were male and 13 patients (36 %) had Crohn's disease (CD). Fourteen patients (38.8 %) had a complex fistula. The primary and secondary healing rates were 55.6 % and 91.7 %, respectively, during a median follow-up time of 12 months (IQR 7-29). No fecal continence impairment was registered in any case. The proportion of patients with primary healing was significantly higher in CD patients (76.9 % vs 43.5 %, p = 0.048). CONCLUSIONS: FiLaC® is a sphincter-preserving procedure with an excellent safety profile and reasonable success rate despite of the strict patient selection. This technique may be attractive for patients with CD due to its higher primary healing rate.

"Long-term oncologic outcomes and risk factors for distant recurrence after pathologic complete response following neoadjuvant treatment for locally advanced rectal cancer. A nationwide, multicentre study".

BACKGROUND: Pathologic complete response (pCR) after multimodal treatment for locally advanced rectal cancer (LARC) is used as surrogate marker of success as it is assumed to correlate with improved oncologic outcome. However, long-term oncologic data are scarce. METHODS: This retrospective, multicentre study updated the oncologic follow-up of prospectively collected data from the Spanish Rectal Cancer Project database. pCR was described as no evidence of tumour cells in the specimen. Endpoints were distant metastases-free survival (DMFS) and overall survival (OS). Multivariate regression analyses were run to identify factors associated with survival. RESULTS: Overall, 32 different hospitals were involved, providing data on 815 patients with pCR. At a median follow-up of 73.4 (IQR 57.7-99.5) months, distant metastases occurred in 6.4% of patients. Abdominoperineal excision (APE) (HR 2.2, 95%CI 1.2-4.1, p = 0.008) and elevated CEA levels (HR = 1.9, 95% CI 1.0-3.7, p = 0.049) were independent risk factors for distant recurrence. Age (years) (HR 1.1; 95%-CI 1.05-41.09; p < 0.001) and ASA III-IV (HR = 2.0; 95%-CI 1.4-2.9; p < 0.001), were the only factors associated with OS. The estimated 12, 36 and 60-months DMFS rates were 96.9%, 91.3%, and 86.8%. The estimated 12, 36 and 60-months OS rates were 99.1%, 94.9% and 89.3%. CONCLUSIONS: The incidence of metachronous distant metastases is low after pCR, with high rates of both DMFS and OS. The oncologic prognosis in LARC patients that achieve pCR after neoadjuvant chemo-radiotherapy is excellent in the long term.