Predicting Difficult Laparoscopic Total Mesorectal Excision for Locally-advanced Mid-low Rectal Cancer: The EuMaRCS Score Validation.

BACKGROUND/AIM: The European MRI and Rectal Cancer Surgery (EuMaRCS) score was proposed to identify preoperatively difficult laparoscopic total mesorectal excision (L-TME) for locally advanced rectal cancer (LARC). This study aimed to test EuMaRCS's validity. PATIENTS AND METHODS: Data were retrieved from a European multicenter database, including patients with mid/low LARC, treated with neoadjuvant chemoradiation therapy and L-TME with primary anastomosis. The EuMaRCS score was calculated on: BMI>30 (3 points), interspinous distance<96.4 mm (2 points), ymrT stage≥T3b (4 points), and male sex (1 point). RESULTS: The sample was composed of 141 patients, of whom 23 (16.3%) had a difficult L-TME. The EuMaRCS score demonstrated high accuracy in predicting difficult surgery (AROC: 0.806, 95%CI=0.72-0.88), with a cut-off >3 being associated with the best balance in sensitivity (82.6%) and specificity (66.1%). CONCLUSION: The EuMaRCS score represents a validated tool to predict preoperatively difficult L-TME in LARC patients.

Risk factors for anastomotic leak and postoperative morbidity and mortality after elective right colectomy for cancer: results from a prospective, multicentric study of 1102 patients.

BACKGROUND: Studies focused on postoperative outcome after oncologic right colectomy are lacking. The main objective was to determine pre-/intraoperative risk factors for anastomotic leak after elective right colon resection for cancer. Secondary objectives were to determine risk factors for postoperative morbidity and mortality. METHODS: Fifty-two hospitals participated in this prospective, observational study (September 2011-September 2012), including 1102 patients that underwent elective right colectomy. Forty-two pre-/intraoperative variables, related to patient, tumor, surgical procedure, and hospital, were analyzed as potential independent risk factors for anastomotic leak and postoperative morbidity and mortality. RESULTS: Anastomotic leak was diagnosed in 93 patients (8.4 %), and 72 (6.5 %) of them needed radiological or surgical intervention. Morbidity, mortality, and wound infection rates were 29.0, 2.6, and 13.4 %, respectively. Preoperative serum protein concentration was the only independent risk factor for anastomotic leak (p < 0.0001, OR 0.6 per g/dL). When considering only clinically relevant anastomotic leaks, stapled technique (p = 0.03, OR 2.1) and preoperative serum protein concentration (p = 0.004, OR 0.6 g/dL) were identified as the only two independent risk factors. Age and preoperative serum albumin concentration resulted to be risk factors for postoperative mortality. Male gender, pulmonary or hepatic disease, and open surgical approach were identified as risk factors for postoperative morbidity, while male gender, obesity, intraoperative complication, and end-to-end anastomosis were risk factors for wound infection. CONCLUSIONS: Preoperative nutritional status and the stapled anastomotic technique were the only independent risk factors for clinically relevant anastomotic leak after elective right colectomy for cancer. Age and preoperative nutritional status determined the mortality risk, while laparoscopic approach reduced postoperative morbidity.

Traumatic abdominal hernia complicated by necrotizing fasciitis.

Necrotizing fasciitis is a critical illness involving skin and soft tissues, which may develop after blunt abdominal trauma causing abdominal wall hernia and representing a great challenge for physicians. A 52-year-old man was brought to the emergency department after a road accident, presenting blunt abdominal trauma with a large non-reducible mass in the lower-right abdomen. A first, CT showed abdominal hernia without signs of complication. Three hours after ICU admission, he developed hemodynamic instability. Therefore, a new CT scan was requested, showing signs of hernia complication. He was moved to the operating room where a complete transversal section of an ileal loop was identified. Five hours after surgery, he presented a new episode of hemodynamic instability with signs of skin and soft tissue infection. Due to the high clinical suspicion of necrotizing fasciitis development, wide debridement was performed. Following traumatic abdominal wall hernia (TAWH), patients can present unsuspected injuries in abdominal organs. Helical CT can be falsely negative in the early moments, leading to misdiagnosis. Necrotizing fasciitis is a potentially fatal infection and, consequently, resuscitation measures, wide-spectrum antibiotics, and early surgical debridement are required. This type of fasciitis can develop after blunt abdominal trauma following wall hernia without skin disruption.

Transanal evisceration caused by rectal laceration.

Transrectal evisceration caused by colorectal injury is an unusual entity. This pathology is more frequent in elderly patients and it is usually produced spontaneously. Rectal prolapse is the principal predisposing factor. An 81-year-old woman was taken to the hospital presenting exit of intestinal loops through the anus. After first reanimation measures, an urgent surgery was indicated. We observed the absence of almost every small intestine loop in the abdominal cavity; these had been moved to the pelvis. After doing the reduction, a 3 to 4 cm linear craniocaudal perforation in upper rectum was objectified, and Hartmann's procedure was performed. We investigated and knew that she frequently manipulate herself to extract her faeces. The fast preoperative management avoided a fatal conclusion or an extensive intestinal resection. Reasons that make us consider rectal self-injury as the etiologic factor are explained.

Formación del residente en cirugíalaparoscópica: resultados de nuestraexperiencia / Resident training in laparoscopic surgery: results of our experience

Objetivo. La aparición de la laparoscopia ha revolucionado la cirugía de la última década. Es fundamental, por tanto, la formación adecuada de nuestros residentes que permita su progresiva incorporación a la realización de intervenciones por vía laparoscópica. Material y método. Analizamos las intervenciones laparoscópicas realizadas por los cinco últimos residentes formados en nuestro servicio. Describimos el tipo y número de intervenciones laparoscópicas en las que ha participado cada residente, como cirujano o como ayudante. Distinguimos entre cirugía urgente y programada. Analizamos detalladamente las dos intervenciones más frecuentes: apendicectomía y colecistectomía laparoscópicas. Resultados. El total de intervenciones laparoscópicas en las que participaron los residentes fue de 985.En 373 lo hicieron como cirujano principal, siendo urgentes 235 (63 por ciento) y programadas 138 (37 por ciento). Las intervenciones laparoscópicas realizadas fueron: laparoscopia diagnóstica, apendicectomía, colecistectomía, sutura de ulcus perforado, confección de colostomía en asa, funduplicatura 360o, coledocotomía y sigmoidectomía. Hemos constatado una progresión en la incorporación de los residentes a la realización de intervenciones laparoscópicas como cirujano. Este hecho se ve reflejado claramente al analizar las apendicectomías y colecistectomías laparoscópicas. Dicha progresión se cumple tanto en intervenciones urgentes como programadas. Con respecto a la participación como ayudantes, existe una completa incorporación desde el inicio de su formación, no existiendo diferencias entre residentes. Conclusión. Presentamos la demostración práctica de cómo podemos formar a nuestros residentes en laparoscopia. Su incorporación a la cirugía laparoscópica es prioritaria. El residente debe concluir su formación dominando, como poco, la práctica de la apendicectomía y de la colecistectomía laparoscópicas (AU)