Pathologic response assessed by Mandard grade is a better prognostic factor than down staging for disease-free survival after preoperative radiochemotherapy for advanced rectal cancer.

OBJECTIVE: The reduction in tumour stage induced by full course radiotherapy plus chemotherapy is apparent from histological changes. The purpose of this study was to determine the rate of complete pathological response and to evaluate the prognostic value for disease free survival (DFS) and disease specific survival (DSS) of the response. The relation between pretreatment variables (age, gender, stage, tumour height and [carcinoembryogenic antigen (CEA)] and postsurgical variables was compared to the pathological response. METHOD: A total of 119 patients with stage II or III rectal cancer underwent surgery 6 weeks after neoadjuvant treatment. Group A included patients with a complete or good pathological response (Mandard grade I-II) and group B patients with a poor response (Mandard grade III-IV-V). The pretreatment endo-rectal ultrasound scan stage was compared with histopathology stage of the resected specimen. DFS and DSS were compared using the log-rank test. RESULTS: All 119 patients (mean age 67.9 years, 83 males) underwent resection. The tumour was located in the upper, middle and lower third of the rectum in 11, 51 and 57 patients. 88 patients had a low anterior resection, 28 patients abdomino-perineal resection and three a Hartmann's operation. There was no postoperative death. The circumferential margin (CM) was involved in 10%. A complete pathological response was observed in 17 (14.2%) patients. Thirty-six (30.2%) patients had a group A and 83 a group B response. Group A showed DFS to be significantly higher than group B (log rank: P = 0.007). The DSS rate was not significantly different between the two groups (log rank P = 0.113). Down-staging was not related with DFS. No relation was found between pretreatment variables and response. A good pathological response was related to a lower rate of permanent colostomy but not with CM involvement or the number of lymph nodes. CONCLUSION: Tumour regression of grades I or II was a good indicator of DFS in locally advanced rectal cancer, treated by neoadjuvant chemotherapy and radiotherapy. Patients with a high regression grade were associated with a lower incidence of definitive stoma formation. The regression grade was shown to be a better prognostic factor than down-staging.

[Reflections on the past, present and future of minimally invasive surgery]. / Reflexiones sobre el pasado, presente y futuro de la cirugía mínimamente invasiva.

So-called "minimally invasive surgery" aims to contribute to reducing the effects of surgical trauma and its consequences. A milestone in the development of this concept has been the generalisation of techniques of the videoendoscopic approach in numerous surgical procedures. Outstanding amongst these is laparoscopy, which makes it possible to carry out different abdominal surgical techniques while guaranteeing maximum respect for the peritoneal surface and the abdominal wall itself. This is translated into lower morbidity and mortality and better recovery by the patients. For videoendoscopic access to become consolidated as the first option against the traditional or open approach, it is necessary that two requisites be met: the indication of surgery must be the same irrespective of the approach, and the results in terms of efficiency, safety and cost must be similar or superior. In the immediate future, with the increase in the experience of surgical teams and the improvement of technological capacity, there will be a growth in the number of procedures susceptible to approach using this technique.

[Laparoscopic surgery in colorectal diseases]. / Cirugía laparoscópica en las enfermedades colorrectales.

The present state of laparoscopic surgery in colorectal diseases is presented, showing results that are superior to open surgery during the hospital stay, infection of the wound and quality of life in the first postoperative month. It is technically possible to carry out all of the techniques of colorectal resection with assisted laparoscopic surgery. The counter-indications depend above all on the state of the patient and his disease: emergency laparoscopy of the colon and rectum barely have a place in the therapeutic arsenal. However, elective surgery contributes a great number of cases, as well as colon cancer, whose laparoscopic approach is only contraindicated if the neighbouring organs are affected or if surgery by laparoscopy is not radical and oncological, due to the case itself or if the surgical team lacks the technique, given that the results for curing cancer are identical to open surgery, with level I scientific evidence. The results of cure and survival from laparoscopic surgery of cancer of the rectum are being studied. A description is given of the details of the surgical technique of right and left colectomies, laparoscopic resections of the rectum and of total colectomy.

[The role of laparoscopy in emergency abdominal surgery]. / El papel de la laparoscopia en la cirugía abdominal urgente.

Abdominal emergencies can also be operated on through the laparoscopic approach: the approach can be diagnostic laparoscopy, surgery assisted by laparoscopy or laparotomy directed according to the findings of the laparoscopy. The general contraindications refer above all to the state of haemodynamic instability of the patient and to seriously ill patients (ASA IV). In the absence of any specific counter-indications for the specific laparoscopic procedure to be carried out, many abdominal diseases requiring emergency surgery can be performed with the laparoscopic approach. The most frequent indications are appendicitis, acute colecistitis, gastroduodenal perforation, occlusion of the small intestine, and some abdominal traumas. With a correct selection of patients and the appropriate experience of the surgeon, the results are excellent and better than open surgery (less infection of the wound, complications, hospital stay and postoperative pain). A detailed explanation is given of the basic aspects of the surgical technique in the most frequent procedures of emergency laparoscopy.

Reflexiones sobre el pasado, presente y futuro de la cirugía mínimamente invasiva / Reflections on the past, present and future of minimally invasive surgery

La denominada “cirugía mínimamente invasiva” pretende contribuir a reducir los efectos del trauma quirúrgico y sus consecuencias. Un hito fundamental en el desarrollo de este concepto ha sido la generalización de técnicas de abordaje videoendoscópico en numerosos procedimientos quirúrgicos. Entre ellos destaca la laparoscopia, que permite la realización de diversas técnicas quirúrgicas abdominales garantizando el máximo respeto a la superficie peritoneal y a la propia pared abdominal. Ello se traduce en menor morbimortalidad y mejor recuperación de los pacientes.Para que el acceso videoendoscópico se consolide como primera opción frente al abordaje tradicional o abierto, es necesario que se cumplan dos requisitos: la indicación de la cirugía debe ser la misma con independencia del abordaje, y los resultados en términos de eficiencia, seguridad y coste deben de ser similares o superiores. En el futuro inmediato, conforme aumente la experiencia de los equipos quirúrgicos y mejore la capacidad tecnológica, se producirá un incremento en el número de procedimientos susceptibles de ser abordados por esta técnica

So-called “minimally invasive surgery” aims to contribute to reducing the effects of surgical trauma and its consequences. A milestone in the development of this concept has been the generalisation of techniques of the videoendoscopic approach in numerous surgical procedures. Outstanding amongst these is laparoscopy, which makes it possible to carry out different abdominal surgical techniques while guaranteeing maximum respect for the peritoneal surface and the abdominal wall itself. This is translated into lower morbidity and mortality and better recovery by the patients. ;;For videoendoscopic access to become consolidated as the first option against the traditional or open approach, it is necessary that two requisites be met: the indication of surgery must be the same irrespective of the approach, and the results in terms of efficiency, safety and cost must be similar or superior. In the immediate future, with the increase in the experience of surgical teams and the improvement of technological capacity, there will be a growth in the number of procedures susceptible to approach using this technique

Cirugía laparoscópica en las enfermedades colorrectales / Laparoscopic surgery in colorectal diseases

Se presenta el estado actual de la cirugía laparoscópica en las enfermedades colorrectales, que muestra resultados superiores a la cirugía abierta en estancia hospitalaria, infección de herida y calidad de vida en el primer mes postoperatorio. Las indicaciones son cualquier enfermedad colorrectal. Todas las técnicas de resección colorrectal son técnicamente realizables con cirugía laparoscópica asistida. Las contraindicaciones son dependientes sobre todo del estado del paciente y de su enfermedad: la laparoscopia urgente de colon y recto apenas tiene sitio en el armamentario terapéutico. Sin embargo, la cirugía programada aporta una gran cantidad de casos, incluyendo también el cáncer de colon, cuyo abordaje laparoscópico se contraindica sólo si hay afectación de órganos vecinos o si la cirugía por laparoscopia no es radical y oncológica, por razones del caso o de falta de técnica del equipo quirúrgico, dado que los resultados de curación de cáncer son idénticos a la cirugía abierta, con nivel I de evidencia científica. Están en estudio los resultados de curación y supervivencia de la cirugía laparoscópica del cáncer de recto. Se describen los detalles de técnica quirúrgica de las colectomías derecha e izquierda, de las resecciones laparoscópicas del recto y de la colectomía total

The present state of laparoscopic surgery in colorectal diseases is presented, showing results that are superior to open surgery during the hospital stay, infection of the wound and quality of life in the first postoperative month. It is technically possible to carry out all of the techniques of colorectal resection with assisted laparoscopic surgery. The counter-indications depend above all on the state of the patient and his disease: emergency laparoscopy of the colon and rectum barely have a place in the therapeutic arsenal. However, elective surgery contributes a great number of cases, as well as colon cancer, whose laparoscopic approach is only contraindicated if the neighbouring organs are affected or if surgery by laparoscopy is not radical and oncological, due to the case itself or if the surgical team lacks the technique, given that the results for curing cancer are identical to open surgery, with level I scientific evidence. The results of cure and survival from laparoscopic surgery of cancer of the rectum are being studied. A description is given of the details of the surgical technique of right and left colectomies, laparoscopic resections of the rectum and of total colectomy

El papel de la laparoscopia en la cirugía abdominal urgente / The role of laparoscopy in emergency abdominal surgery

La urgencia abdominal también puede ser intervenida mediante abordaje laparoscópico: el planteamiento puede ser de laparoscopia diagnóstica, cirugía asistida por laparoscopia o laparotomía dirigida según los hallazgos de la laparoscopia. Las contraindicaciones generales se refieren sobre todo al estado de inestabilidad hemodinámica del paciente y a pacientes graves (ASA IV). En ausencia de contraindicación específica para el procedimiento laparoscópico concreto a realizar, muchas enfermedades abdominales que requieren cirugía urgente pueden realizarse con abordaje laparoscópico. Las indicaciones más frecuentes son la apendicitis, la colecistitis aguda, la perforación gastroduodenal, la oclusión de intestino delgado, y algunos traumas abdominales. Con una correcta selección de pacientes y la oportuna experiencia del cirujano, los resultados son excelentes, y mejoran la cirugía abierta (menos infección de herida, complicaciones, estancia hospitalaria y dolor postoperatorio). Se explican con detalle los aspectos básicos de la técnica quirúrgica en los procedimientos más frecuentes de laparoscopia de urgencia

Abdominal emergencies can also be operated on through the laparoscopic approach: the approach can be diagnostic laparoscopy, surgery assisted by laparoscopy or laparotomy directed according to the findings of the laparoscopy. The general contraindications refer above all to the state of haemodynamic instability of the patient and to seriously ill patients (ASA IV). In the absence of any specific counter-indications for the specific laparoscopic procedure to be carried out, many abdominal diseases requiring emergency surgery can be performed with the laparoscopic approach. The most frequent indications are appendicitis, acute colecistitis, gastroduodenal perforation, occlusion of the small intestine, and some abdominal traumas. With a correct selection of patients and the appropriate experience of the surgeon, the results are excellent and better than open surgery (less infection of the wound, complications, hospital stay and postoperative pain). A detailed explanation is given of the basic aspects of the surgical technique in the most frequent procedures of emergency laparoscopy

Estado actual del tratamiento quirúrgico de las metástasis hepáticas deorigen colorrectal: una visión práctica / Present state of the surgical treatment of hepatic metastasis of colorectal origin: a practical view

La resección hepática constituye la única posibilidad real de curación para un grupo seleccionado de pacientes con metástasis hepáticas de cáncer colorrectal. La supervivencia obtenida en estos pacientes es de un 30-40 por ciento a los 5 años y un 20-25 por ciento a los 10 años de la cirugía; ningún otro tratamiento se acerca a estos resultados. La clave para conseguir estos resultados es el tratamiento de estos pacientes por un equipo multidisciplinar, equipo que debe contar con la participación de cirujanos especialmente entrenados en las técnicas de resección hepática. En la presente revisión se describen: la estadificación preoperatoria de las metástasis hepáticas de origen colorrectal por técnicas de imagen, los criterios de selección para la cirugía, los estándares de la técnica quirúrgica y el tratamiento adyuvante que forman parte del Protocolo de la Sección de Cirugía Hepatobiliar del Hospital de Navarra, basados en nuestra experiencia en 150 hepatectomías y en la mejor evidencia científica disponible. (AU)

[Present state of the surgical treatment of hepatic metastasis of colorectal origin: a practical view]. / Estado actual del tratamiento quirúrgico de las metástasis hepáticas de origen colorrectal: una visión práctica.

Hepatic resection is the only real possibility of cure for a selected group of patients with hepatic metastasis of colorectal cancer. Survival obtained in these patients is of some 30-40% after 5 years and some 20-25% after ten years following surgery; no other treatment approaches these results. The key for obtaining these results is the treatment of these patients by a multidisciplinary team, a team that must include the participation of surgeons specially trained in the techniques of hepatic resection. The present review describes: the pre-operational staging of hepatic metastasis of colorectal origin by diagnostic imaging techniques, the selection criteria for surgery, the standards of the surgical technique and the adjuvant treatment that forms part of the Protocol of the Hepatobiliary Surgery Section of the Hospital of Navarra, based on our experience in 150 hepatectomies and on the best scientifically available evidence.

Ganglio centinela en carcinoma de mama: situación actual. Criterios de actuación en el Hospital de Navarra / The sentinel lymph node in breast carcinoma: present situation. Criteria for action in the Hospital of Navarra

No disponible

Tratamiento quirúrgico de la obstrucción intestinal aguda por cáncer colorrectal. experiencia reciente en 1994-1998 / Surgical treatment of acute intestinal obstruction due to colorectal cancer: recent experience occurring between 1994 and 1998

Introducción. Estudiamos prospectivamente la morbimortalidad de la cirugía urgente por obstrucción intestinal secundaria a cáncer colorrectal en 5 años (1994-1998).Pacientes y método. Incluimos a todos los pacientes tratados en este período, seleccionando la técnica de acuerdo con el riesgo del paciente y el estado del colon. Resultados. Fueron intervenidos de urgencia por obstrucción completa 60 pacientes (un 17 por ciento de todos los cánceres colorrectales intervenidos en el servicio) de los que 12 fueron de colon derecho, 45 de colon transverso e izquierdo y tres de recto. Se realizaron 50 resecciones de colon: 44 con anastomosis primaria (colectomía derecha, izquierda, segmentaria, resección anterior de recto, y colectomía subtotal) y 6 intervenciones de Hartmann, así como 9 colostomías de descarga o derivación ileocólica y una tumorectomía. Se realizó lavado anterógrado del colon en 11 de 25 pacientes candidatos a ello por resección de tumores de colon izquierdo sin colostomía. La mortalidad operatoria fue de 3 pacientes (5 por ciento) y la morbilidad del 45 por ciento, con una estancia media de 17 días. Se produjeron 2 fístulas anastomóticas que no precisaron reintervención. Conclusiones. Seleccionando la técnica quirúrgica según el estado del paciente se pueden obtener buenos resultados de morbimortalidad en estos enfermos, a pesar de realizar resección y anastomosis, sin colostomía, en la mayoría de los casos (AU)