Perioperative immunonutrition in normo-nourished patients undergoing laparoscopic colorectal resection.

OBJECTIVE: To determine whether the joint implementation of immunonutrition and a laparoscopic approach improves morbidity, mortality, and length of stay (LOS) compared with dietary advice. BACKGROUND: Despite progress in recent years in the surgical management of patients with colorectal cancer, postoperative complications are frequent. Nutritional supplements enriched with immunonutrients have recently been introduced into clinical practice. However, the immunonutrition benefits in patients undergoing colorectal laparoscopic surgery are unknown. METHODS: This study was a prospective, randomized trial with two parallel treatment groups receiving an immune-enhancing dietary supplement for 7 days before colorectal resection and 5 days postoperatively or dietary advice. RESULTS: A total of 128 patients were randomized. At baseline, both groups were comparable with respect to age, sex, surgical risk, comorbidities, and analytical and nutritional parameters. The median postoperative LOS was 5 days and was not significantly different between the groups. Wound infection differed significantly between the groups (11.50 vs. 0.00 %, p = 0.006). No other differences between the groups were identified. CONCLUSIONS: The joint use of laparoscopy and supplementation with immunonutrients reduces surgical wound infection in patients undergoing colorectal surgery. TRIAL REGISTRATION: This study is registered with ClinicalTrial.gov : NCT0239396.

Tumor regression and survival after perioperative MAGIC-style chemotherapy in carcinoma of the stomach and gastroesophageal junction.

BACKGROUND: We assessed the effectiveness of perioperative MAGIC-style chemotherapy in our series focused on the tumor regression grade and survival rate. METHODS: We conducted a retrospective study of 53 patients following a perioperative regimen of epirubicin, cisplatin, and fluorouracil or capecitabine (ECF/X). Forty-four (83 %) neoplasias were located in the stomach and 9 (17 %) were located at the esophagogastric junction. Perioperative chemotherapy completion, resection, TNM staging, the tumor regression grade (Becker's classification) and survival were analyzed. RESULTS: Forty-five patients (85 %) completed the 3 preoperative cycles. R0 resection was achieved in 42 (79 %) patients. Thirty-five (66 %) patients completed the 3 postoperative cycles. Nine carcinomas (17 %) were considered major responders after preoperative chemotherapy. With multivariate analysis, only completion of perioperative chemotherapy (HR: 0.25; 95%CI: 0.08 - 0.79; p = 0.019) was identified as an independent prognostic factor for disease-specific survival. However, the protective effect of perioperative therapy was lost in patients with ypT3-4 and more than 4 positive lymph nodes (HR: 1.16; 95%CI: 1.02 - 1.32; p = 0.029). The tumor regression grade (major vs minor responders) was at the limit of significance only with univariate analysis. The 5-year overall and disease-specific survival rates were 18 % and 22 % respectively. CONCLUSIONS: The percentage of major responder tumors after preoperative chemotherapy was low. Completion of perioperative ECF/X chemotherapy may benefit patients with gastric carcinomas that do not invade the subserosa with few positive lymph nodes.

Percutaneous electric neurostimulation of dermatome T7 improves glycemic profile in obese and type 2 diabetic patients. A randomized clinical study.

INTRODUCTION: Endocrine pancreatic segregation is regulated by the autonomic nervous system. The parasympathetic system stimulates insulin production by the beta cells and inhibits the adrenergic discharge by the sympathetic nervous system. The aim of this study was to evaluate the effect of percutaneous neurostimulation (PENS) of dermatome T7, generating a somato-autonomic reflex, whose efferent pathway are the vagal branches that specifically stimulate the pancreas. The effect of this treatment on glycemia, insulin secretion and insulin resistance was investigated. METHODS: A prospective randomized clinical trial was performed. Patients with Body Mass Index>30kg/m(2) and diagnosis of diabetes mellitus treated with Metformin were included. Patients were divided into 2 groups: Patients undergoing PENS of dermatome T7 (12 sessions of 30minutes weekly) associated with a 1,200 Kcal/day diet (Group 1) and patients following only a 1,200Kcal/day diet (Group 2). All the patients underwent a blood sample extraction before the treatment and 7 days after finishing it. RESULTS: 60 patients were included: 30 in each group. After finishing the treatment, in Group 1 a significant decrease in glycemia (Mean decrease of 62,1mg/dl; P=.024) and HOMA (Mean decrease 1.37; P=.014) was observed. In Group 2, no significant differences between pre and post-treatment values were observed. CONCLUSION: PENS of dermatome T7 associated with a 1,200Kcal/day diet achieves a greater reduction in glycemia and insulin resistance than with diet exclusively after 3 months of treatment.

Effect of preoperative eating patterns and preoperative weight loss on the short- and mid-term weight loss results of sleeve gastrectomy.

INTRODUCTION: Weight loss depends directly on the adhesion to the postoperative diet in patients undergoing a sleeve gastrectomy. The aim of this study is to evaluate the effect of different preoperative feeding patterns and the adhesion to a preoperative diet on short and mid- term postoperative weight loss. MATERIAL AND METHODS: A prospective study of all morbidly obese patients undergoing a laparoscopic sleeve gastrectomy as a bariatric procedure between 2008 and 2012 was performed. Preoperative feeding patterns and weight loss, preoperatively and postoperatively at 12 and 24 months, were evaluated. RESULTS: A total of 50 patients were included, with a mean preoperative BMI of 51,2+7,9 kg/m(2). All the patients presented a feeding pattern of big eaters, 44% of snackers, 40% of sweet eaters and 48% reported regular ingestion of «light¼ soft drinks. Mean preoperative excess weight loss (EWL) was 13,4% (range 10-31,4%). At 12 months mean EWL was 83,7% and at 24 months 82,4%. Pre and postoperative EWL showed a direct correlation at 12 and 24 months. Mean EWL was significantly lower in snackers, sweet eaters and those drinking «light¼ soft drinks regularly. CONCLUSION: Preoperative weight loss correlates directly with postoperative weight loss at 1 and 2 years. Snackers, sweet eaters and «light¼ soft drink consumers, associated with a big eater pattern, achieve a significantly lower postoperative weight loss.

Chronic idiopathic anal pain. Results of a diagnostic-therapeutic protocol in a colorectal referral unit.

INTRODUCTION: Chronic idiopathic anal pain (CIAP) remains a diagnosis of exclusion. Its study and management still lack a standardized protocol. The aim of this study is to evaluate the results obtained with the diagnostic-therapeutic protocol established in our service. MATERIAL AND METHODS: We performed a retrospective study of patients diagnosed with CIAP at the Colorectal Unit of the General University Hospital of Elche, between 2005 and 2011. RESULTS: We evaluated 57 patients with a diagnosis of chronic anal pain for functional anorectal disease (FAD). After the application of our diagnostic protocol, final diagnosis of chronic anal pain (CAP) was achieved in 43 cases (75%), including 22 cases of descending perineum syndrome, 12 of proctalgia fugax, 2 of pudendal neuritis and 7 of coccydynia. In 14 patients exclusion diagnosis of CIAP was established. Among the therapies used on patients with CIAP, biofeedback combined with conservative measures improved symptoms in 43% of the cases. Sacral nerve stimulation was assessed in patients who did not respond to other treatments. CONCLUSION: Through proper anamnesis, physical examination and complementary tests, a specific diagnosis of the cause of CAP by FAD can be achieved, reducing exclusion diagnosis of CIAP to 25% of cases. Conservative measures combined with biofeedback achieved an improvement in pain in more than 40% of the cases of CIAP in our study. Sacral nerve stimulation can be considered as a treatment option in refractory cases.

[Laparoscopic treatment of sigmoid colon intussusception secondary to giant submucosal lipoma]. / Tratamiento laparoscópico de invaginación en sigma por lipoma submucoso gigante.

Colonic lipomas have very low frequency, are usually asymptomatic and diagnosis is made incidentally. Seventy-five per cent of lipomas larger than 4 cm are symptomatic, causing abdominal pain, rectal bleeding, obstruction and exceptionally invagination. The resection of invaginated segment is mandatory in cases with invagination and can be performed by laparoscopy when colonic dilation is moderate. We present a 73-year-old man who entered the emergency department complaining of intermitent abdominal pain, rectal bleeding, absence of bowel movements and flatulence, during four days. A CT scan showed a generalized colonic dilation until left lower quadrant. A colo-colonic invagination secondary to an endoluminal lipoma was observed in sigmoid colon. A laparoscopic sigmoidectomy was performed with extracorporeal termino-terminal anastomosis. The postoperative period was uneventful and the patient was discharged from the hospital five days later. A sumbmucous colonic lipoma was diagnosed in the pathological study.

Dual regulation of P-glycoprotein expression by trichostatin A in cancer cell lines.

BACKGROUND: It has been reported that the histone deacetylase inhibitor (iHDAc) trichostatin A (TSA) induces an increase in MDR1 gene transcription (ABCB1). This result would compromise the use of iHDACs in combination with other cytotoxic agents that are substrates of P-glycoprotein (Pgp). It has also been reported the use of alternative promoters by the ABCB1 gene and the existence of a translational control of Pgp protein. Finally, the ABCB1 gene is located in a genetic locus with the nested gene RUNDC3B in the complementary DNA strand, raising the possibility that RUNDC3B expression could interfere with ABCB1 alternative promoter regulation. METHODS: A combination of RT-PCR, real time RT-PCR, Western blot and drug accumulation assays by flow cytometry has been used in this study. RESULTS: The iHDACs-induced increase in MDR1 mRNA levels is not followed by a subsequent increase in Pgp protein levels or activity in several pancreatic and colon carcinoma cell lines, suggesting a translational control of Pgp in these cell lines. In addition, the MDR1 mRNA produced in these cell lines is shorter in its 5' end that the Pgp mRNA produced in cell lines expressing Pgp protein. The different size of the Pgp mRNA is due to the use of alternative promoters. We also demonstrate that these promoters are differentially regulated by TSA. The translational blockade of Pgp mRNA in the pancreatic carcinoma cell lines could be related to alterations in the 5' end of the MDR1 mRNA in the Pgp protein expressing cell lines. In addition, we demonstrate that the ABCB1 nested gene RUNDC3B expression although upregulated by TSA is independent of the ABCB1 alternative promoter used. CONCLUSIONS: The results show that the increase in MDR1 mRNA expression after iHDACs treatment is clinically irrelevant since this mRNA does not render an active Pgp protein, at least in colon and pancreatic cancer cell lines. Furthermore, we demonstrate that TSA in fact, regulates differentially both ABCB1 promoters, downregulating the upstream promoter that is responsible for active P-glycoprotein expression. These results suggest that iHDACs such as TSA may in fact potentiate the effects of antitumour drugs that are substrates of Pgp. Finally, we also demonstrate that TSA upregulates RUNDC3B mRNA independently of the ABCB1 promoter in use.

Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results.

OBJECTIVE: To evaluate the long-term clinical and manometric results of fistulotomy and sphincter reconstruction for the treatment of complex fistula-in-ano. BACKGROUND: Complex fistula-in-ano is difficult to treat due to the occurrence of postoperative anal incontinence and the high rate of recurrence. METHODS: Seventy patients who were diagnosed with complex fistula-in-ano and underwent fistulotomy and sphincter reconstruction between October 2000 and October 2006 were analyzed in the present study. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Appointments were scheduled every 6 months during the first and second year of treatment and every 2 years thereafter. Recurrence and incontinence were evaluated during each visit. Continence was assessed according to the Wexner continence grading scale. Anal manometry was performed 3 and 12 months after treatment and every 2 years thereafter. Anal endosonography was conducted 6 months after treatment. RESULTS: Fistulas were classified as medium-high trans-sphincteric in 64 patients (91.42%) and were recurrent in 22 patients (32%). Before surgery, 22 patients (32%) reported fecal incontinence, which improved after surgery in 15 cases (70%), from 6.75 to 1.88 (P < 0.005) on the Wexner Scale. Eight preoperative continent patients (16.6%) reported postoperative incontinence (Wexner Score < 3), and 6 patients (8.5%) had recurrent incontinence. Among these patients, 2 developed recurrent incontinence 6 months after treatment, 2 developed recurrent incontinence 1 year after treatment, 1 developed recurrent incontinence 2 years after treatment, and 1 developed incontinence 5 years after treatment. CONCLUSIONS: Fistulotomy with sphincter reconstruction is an effective technique for the treatment of complex fistula-in-ano. Continence and anal manometry results were improved in incontinent patients and were not jeopardized in continent ones. Fistulotomy with sphincter reconstruction is an especially suitable technique for incontinent patients with recurrent fistulas.

Perianal versus endoanal application of glyceryl trinitrate 0.4% ointment in the treatment of chronic anal fissure: results of a randomized controlled trial. Is this the solution to the headaches?

BACKGROUND: Application of nitroglycerin (glyceryl trinitrate) ointment with perianal administration is a widely used treatment for chronic anal fissure. However, headache occurs after application in 20% to 70% patients and leads to withdrawal in 10% of patients. OBJECTIVE: The aim of the study was to investigate whether endoanal application of the ointment may lower the frequency of headaches without sacrificing effectiveness. compare the effects of perianal versus endoanal administration of nitroglycerin ointment on frequency of headache and rate of healing in the treatment of chronic anal fissure. DESIGN: This was a prospective randomized clinical trial (ClinicalTrial.gov, NCT01132391). SETTINGS AND PATIENTS: Study participants were consecutive patients with a diagnosis of chronic anal fissure treated at a university teaching hospital in Elche, Alicante, Spain. INTERVENTION: Patients were randomly assigned to receive perianal (n = 26) or endoanal (n = 26) administration of 0.4% nitroglycerin ointment (375 mg of ointment containing 1.5 mg of glyceryl trinitrate), applied every 12 hours over an 8-week period. MAIN OUTCOME MEASURES: The primary endpoint of the study was the number of patients with headache within 3 hours after application of the ointment, analyzed with the intention-to-treat principle. Intensity of headache pain was rated on a 10-point visual analog scale. Secondary endpoints included frequencies of fissure healing, anorectal pain, rectal bleeding, pruritus, and incontinence. RESULTS: Headaches were reported in 14 (54%) patients with perianal treatment and in 6 patients (23%) with anorectal treatment (p = 0.003). The median headache pain score was 6 (range, 0-10) in the perianal group and 4.5 (range, 0-10) in the endoanal group (p = 0.03). Disabling headaches led to crossover from perianal to endoanal treatment in 4 patients (15%), and from endoanal to perianal treatment in 1 patient (4%) (p = 0.004). Of the 4 patients who switched from perianal to endoanal treatment, 2 reported improvement in headaches and 2 stopped treatment. The patient who switched from endoanal to perianal treatment also showed no improvement and stopped treatment. The healing rate at 24-week follow-up was 62% (16 patients) with perianal treatment and 77% (20 patients) with endoanal treatment (p < 0.05). LIMITATIONS: Effects on sphincter pressure were not evaluated because manometric measurements were not available. CONCLUSIONS: Endoanal application significantly reduces the frequency of headaches due to treatment with 0.4% nitroglycerin ointment and results in a higher healing rate compared with perianal administration. However, roughly 1 in 4 patients still experiences headaches. Our data suggest that endoanal application may be a better option for treatment of anal fissure with nitroglycerin ointment.

Microbiological spectrum of the intraperitoneal surface after elective right-sided colon cancer: are there differences in the peritoneal contamination after performing a stapled or a handsewn anastomosis?

BACKGROUND: Although colonic surgery is performed with strict aseptic measures, some contamination is nearly impossible to avoid. In stapled anastomosis, the hole opened in the colon is minimum, just necessary for introducing the parts of the mechanical devices. In handsewn anastomosis, the colonic lumen is more exposed to the peritoneum, despite colonic occlusion with clamps while the suture is performed. PATIENTS AND METHODS: A prospective, randomized study was performed between October 2009 and June 2011. Inclusion criteria were a diagnosis of right-sided colon cancer and having undergone an elective surgery with curative aims. The patients were divided into two groups: those patients undergoing a stapled ileocolonic anastomosis (group 1) and those undergoing a handsewn anastomosis (group 2). A microbiological sample was obtained from the peritoneal surface before opening the colon and after finishing the anastomosis in each group. Data were correlated with the wound infection and intra-abdominal infection rates. RESULTS: Eighty-four patients were included in the study: 42 patients in each group. There were two intra-abdominal abscesses (5 %) in each group (NS). Wound infection rate was 10 % in group 1 and 7 % in group 2 (NS). Mean operative time was 98.8 min in the stapled group and 105.2 min in the handsewn one (P = 0.013). Positive cultures were obtained in 79 % of the cases after stapled anastomosis and 73 % after handsewn ones (NS). CONCLUSION: Peritoneal contamination appears in over 70 % of cases after ileocolonic anastomosis. Significant differences in peritoneal contamination, wound infection, and intra-abdominal abscess between stapled and handsewn anastomoses could not be demonstrated.

[Is there any indication for inserting a drain in elective laparoscopic cholecystectomy?]. / ¿Existe alguna indicación de colocación de drenaje en la colecistectomía laparoscópica electiva?

INTRODUCTION: Classically, a sub-hepatic drain was inserted routinely in a cholecystectomy to prevent intra-abdominal abscesses, possible post-surgical bleeding, and biliary fistulas. Over the years, it has been demonstrated that the systematic use of a drain does not have any benefits, and many studies conclude that, in special circumstances (bleeding, signs of gallbladder inflammation, incidental opening, or suspected bile leak), and depending on the experience of the individual surgeon, the insertion of a drain may be of use. MATERIAL AND METHODS: [corrected] A prospective study was conducted on 100 elective laparoscopic cholecystectomies performed due to symptomatic cholelithiasis or gallbladder polyps. A sub-hepatic drain was inserted in 15 of them. The indications for inserting it were: in 11 patients as a "control" due to a gallbladder bed bleed controlled during surgery, and in 4 due to a gallbladder opening with the excretion of turbid-purulent bile. The main outcomes investigated were the clinical benefit achieved by the insertion of the drain, the hospital stay, and the quantifying of the pain by the patients 24h after surgery, using a visual analogue scale. RESULTS: The insertion of a drain was of no benefit to any patient. The median hospital stay increased by 1 day in patients with a drain (P=.002). The median pain score at 24h was higher in patients with a drain inserted (P=.018). CONCLUSION: The insertion of a sub-hepatic drain after elective laparoscopic cholecystectomy increases post-surgical pain and prolongs hospital stay, and does not prevent the occurrence of intra-abdominal abscesses.

Long-term clinical results of double-pursestring stapled hemorrhoidopexy in a selected group of patients for the treatment of chronic hemorrhoids.

BACKGROUND AND OBJECTIVE: The aim of this prospective controlled trial was to evaluate the long-term clinical and manometric results of stapled hemorrhoidopexy performed by expert surgeons in a selected group of patients for the treatment of chronic hemorrhoids. SETTINGS: This study took place in the outpatient clinic and at the Day Surgery Unit attached to the University Hospital of Elche. PATIENTS: From March 2003 to May 2005, 200 consecutive patients with third-degree hemorrhoids and treated with double-pursestring stapled hemorrhoidopexy with a PPH33-03 stapler were included in the study. MAIN OUTCOME MEASURES: Demographic, manometric, and clinical features were analyzed, as well as the variables related to surgery, postoperative course, and follow-up. Manometry was repeated at the 6-month, 1-year, and 5-year follow-up. RESULTS: Median follow-up was 110 months. Four patients (2%) reported daily rectal bleeding. One patient with active rectal bleeding was taken for reoperation within the first 12 postoperative hours. Seventy percent of patients reported pain ≤ 2 on the first postoperative day, 85% on the fourth postoperative day, and 95% on the seventh postoperative day. Pain was measured with a linear analog scale from 0 to 10 (0 = no pain; 10 = unbearable pain). Seventeen patients (8.5%) reported tenesmus during the first week. Eight patients (4%) reported persistent pain: in 5 patients, the pain resolved within the next 6 months; 2 patients presented with anal fissure; and 1 patient required the removal of the staples. Two patients (1%) reported residual soiling at the 5-year revision. Fourteen patients (7%) experienced recurrence with symptomatic prolapse. Six (3%) underwent further surgery: stapled hemorrhoidopexy was indicated again in 2 patients, and 4 patients underwent a Milligan-Morgan open hemorrhoidectomy, because they did not have a uniform prolapse. Six patients required treatment with rubber band ligation. There were no statistically significant differences between preoperative and postoperative manometric values. CONCLUSIONS: The new PPH33-03 stapler, the learning process of the modified surgical procedure, and the correct selection of patients will overcome the main objections to stapled hemorrhoidopexy.

Plasma ghrelin levels after percutaneous electrical nerve stimulation of dermatome T6 for the treatment of obesity. / Evaluación de la grelina plasmática tras aplicación de neuroestimulación percutánea del dermatoma T6 en el tratamiento de la obesidad.

INTRODUCTION: Obese patients often find it difficult to adhere to long-term low-calorie diets. One of the reasons for dietary failure is the permanent feeling of hunger. Ghrelin is an orexigenic hormone, secreted by enterochromaffin cells in the gastric fundus. The aim of this study was to analyze changes in plasma ghrelin levels after PENS of dermatome T6 associated to a low-calorie diet, as well as changes in appetite and weight loss, as compared to a control group on a low-calorie alone. MATERIAL AND METHODS: A prospective, non-randomized study was conducted including 20 patients who underwent PENS of dermatome T6 associated to a low-calorie diet before undergoing bariatric surgery to lose weight (Group 1), and 20 patients who were only prescribed a low-calorie diet before surgery (Group 2). In Group 1, plasma ghrelin levels were measured at 5 timepoints: before the first PENS session (Sample 1a); after the first PENS session (Sample 1b); before the last PENS session (Sample 2a); after the last PENS session (Sample 2b); and one month after treatment completion (Sample 3). In Group 2, only two samples were collected: before the start of the diet (Sample 1) and after 12 weeks of diet (Sample 2). RESULTS: After 12 weeks of treatment, BMI decreases of 8.42%±2.6% and 1.32%±0.98% were seen in Group 1 and Group 2 respectively (p=0.007). A significant decrease was seen in ghrelin levels between samples 1a and 2a, and between samples 1a and 3. In Group 2, a non-significant increase was seen in ghrelin levels. CONCLUSION: PENS of dermatome T6 was associated to decreased plasma ghrelin levels. This therapy, associated to a low-calorie diet, achieves a BMI reduction greater than 8% after 12 weeks of treatment.

Results of the national survey on the treatment of chronic anal fissure in Spanish hospitals. / Resultados de la encuesta nacional sobre el tratamiento de la fisura anal crónica en los hospitales españoles.

INTRODUCTION: The treatment of chronic anal fissure (FAC) differs depending on the professional. To come to a consensus, the current situation in Spain should be studied. The aim of this study is to evaluate the current situation of the management of FAC in Spanish hospitals. METHODS: Descriptive study, with data from a survey of surgeons of the Spanish Association of Coloproctology. Data was collected according to the doctor's autonomous community, type of hospital and professional category; FAC management data and 3 clinical cases. RESULTS: Response was obtained from 152 surgeons. Pharmacological measures stand out as the first therapeutic step (93.38%). In patients with hypertonia and with no risk factors for fecal incontinence (FI), 55.9% use hygienic-dietary measures associated with nitroglycerin ointment (MHG+NTG). The second step is internal lateral sphincterotomy (ELI) (43.4%). MHG+NTG (75.7%) is used in patients with FI risk factors and in case of failure, ELI is used with a prior ultrasound and/or manometry. In young patients with unexplained hypertonia and incapacitating proctalgia with no risk factors for FI, MHG+NTG (55.9%) is used and, if it is not successful, they are treated with ELI (46.1%). CONCLUSIONS: The management of FAC in Spain shows similarities with the international guideline suggestions. Nevertheless, some differences can be seen from the first stages of treatment.

Evaluation of the stapled transanal rectal resection technique with two staplers in the treatment of obstructive defecation syndrome.

BACKGROUND: This study was designed to assess the safety and effectiveness of stapled transanal rectal resection (STARR) and to compare the results of two staplers. STUDY DESIGN: From February 2001 to June 2005, 37 patients diagnosed with obstructive defecation syndrome were treated with the STARR technique. We analyzed variables related to the patient, diagnosis based on anorectal exploration, surgical technique used, and clinical and radiologic results. We compared these results in patients with procedure prolapsed hemorrhoids (PPH)33-01 (group 1, n = 17) or PPH33-03 (group 2, n = 20). The patients were followed postoperatively at 1, 3, and 6 months, and annually. RESULTS: Intraoperative hemorrhage at the stapled suture occurred in 13 patients from group 1 and in 6 patients from group 2 (p = 0.03). The degree of postoperative pain was not different between the two groups. During the followup period, radiologic and clinical correction of the rectocele and intussusception was found in 94.6% of the patients, with a recurrence in 1 patient from each group. One patient from group 1 developed stenosis of the anastomosis, which improved with digital dilatations. Six patients from group 1 and none from group 2 (p < 0.05) had granulomas on the staple line at the sites of the reabsorbable reinforcing stitches, which were related to postoperative bleeding and anal discomfort. CONCLUSIONS: STARR is an effective alternative for treatment of obstructive defecation syndrome, with a low morbidity and a shorter hospital stay. The use of PPH33-03 instead of PPH33-01 decreases the risk of hemorrhagic complications and enables more secure implantation as an outpatient procedure.

Effectiveness of a physician-oriented feedback intervention on inappropriate hospital stays.

OBJECTIVE: To evaluate the effectiveness of a combined intervention to reduce inappropriate hospital stays. DESIGN: Quasi-experimental pre-test/post-test with a non-equivalent control group. SETTING: Three teaching hospitals in the National Health System in Alicante, Spain. STUDY PARTICIPANTS: Intervention group (2 Surgical Units with 1451 hospital stays) and control group (1 Surgical Unit with 1268 hospital stays). INTERVENTION: Structured oral presentation followed by direct feedback to surgeons about their own percentages of inappropriate stays and daily evaluation of appropriateness by the surgeons during their rounds. MAIN OUTCOME MEASURES: Reduction in the percentage of inappropriate stays identified by the Appropriateness Evaluation Protocol during the intervention period compared to the basal period. RESULTS: The intervention group reduced its percentage of inappropriate stays from 14.3% to 7.9% (absolute reduction: -6.40; 95% CI -10.7 to -2.14; relative reduction: 44.8%), while no changes occurred in the control group. The reduction was in the number of inappropriate stays attributable to the patients' medical management that went from 12.7% to 5.8% (absolute reduction: -6.92; 95% CI -10.90 to -2.92), while no significant changes occurred in inappropriate stays due to other causes. CONCLUSIONS: A combined intervention of feedback and physician participation in appropriateness evaluations is effective in reducing the percentage of inappropriate hospital stays, particularly those attributable to conservative medical patterns at discharge.