RESUMEN
A limited ileocaecal resection is the most frequently performed procedure for ileocaecal CD and different anastomotic configurations and techniques have been described. This manuscript audited the different anastomotic techniques used in a national study and evaluated their influence on postoperative outcomes following ileocaecal resection for primary CD. This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing elective ileocaecal resection for primary CD from June 2018 May 2019. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes. 427 patients were included. The side to side anastomosis was the chosen configuration in 380 patients (89%). The stapled anastomotic (n = 286; 67%), techniques were preferred to hand-sewn (n = 141; 33%). Postoperative morbidity was 20.3% and anastomotic leak 3.7%. Anastomotic leak was independent of the type of anastomosis performed, while was associated with an ASA grade ≥ 3, presence of perianal disease and ileocolonic localization of disease. Four predictors of LOS were identified after multivariate analysis. The laparoscopic approach was the only associated with a reduced LOS (p = 0.017), while age, ASA grade ≥ 3 or administration of preoperative TPN were associated with increased LOS. The side to side was the most commonly used anastomotic configuration for ileocolic reconstruction following primary CD resection. There was no difference in postoperative morbidity according to anastomotic technique and configuration. Anastomotic leak was associated with ASA grade ≥ 3, a penetrating phenotype of disease and ileo-colonic distribution of CD.
Asunto(s)
Anastomosis Quirúrgica/métodos , Fuga Anastomótica/etiología , Ciego/cirugía , Enfermedad de Crohn/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Íleon/cirugía , Laparoscopía/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica/efectos adversos , Fuga Anastomótica/epidemiología , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Procedimientos Quirúrgicos Electivos/métodos , Femenino , Humanos , Laparoscopía/efectos adversos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Procedimientos de Cirugía Plástica/métodos , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: This trial aimed to provide randomized controlled data comparing Kono-S anastomosis and stapled ileocolic side-to-side anastomosis. BACKGROUND: Recently, a new antimesenteric, functional, end-to-end, hand-sewn ileocolic anastomosis (Kono-S) has shown a significant reduction in endoscopic recurrence score and surgical recurrence rate in Crohn disease (CD). METHODS: Randomized controlled trial (RCT) at a tertiary referral institution. Primary endpoint: endoscopic recurrence (ER) (Rutgeerts score ≥i2) after 6 months. Secondary endpoints: clinical recurrence (CR) after 12 and 24 months, ER after 18 months, and surgical recurrence (SR) after 24 months. RESULTS: In all, 79 ileocolic CD patients were randomized in Kono group (36) and Conventional group (43). After 6 months, 22.2% in the Kono group and 62.8% in the Conventional group presented an ER [P < 0.001, odds ratio (OR) 5.91]. A severe postoperative ER (Rutgeerts score ≥i3) was found in 13.8% of Kono versus 34.8% of Conventional group patients (P = 0.03, OR 3.32). CR rate was 8% in the Kono group versus 18% in the Conventional group after 12 months (P = 0.2), and 18% versus 30.2% after 24 months (P = 0.04, OR 3.47). SR rate after 24 months was 0% in the Kono group versus 4.6% in the Conventional group (P = 0.3). Patients with Kono-S anastomosis presented a longer time until CR than patients with side-to-side anastomosis (hazard ratio 0.36, P = 0.037). On binary logistic regression analysis, the Kono-S anastomosis was the only variable significantly associated with a reduced risk of ER (OR 0.19, P < 0.001). There were no differences in postoperative outcomes. CONCLUSIONS: This is the first RCT comparing Kono-S anastomosis and standard anastomosis in CD. The results demonstrate a significant reduction in postoperative endoscopic and clinical recurrence rate for patients who underwent Kono-S anastomosis, and no safety issues.ClinicalTrials.gov ID NCT02631967.
Asunto(s)
Anastomosis Quirúrgica/efectos adversos , Colectomía/métodos , Enfermedad de Crohn/cirugía , Endoscopía/efectos adversos , Mesenterio/patología , Prevención Secundaria/métodos , Adulto , Anciano , Anastomosis Quirúrgica/métodos , Colon/cirugía , Enfermedad de Crohn/diagnóstico , Endoscopía/métodos , Femenino , Estudios de Seguimiento , Humanos , Íleon/cirugía , Modelos Logísticos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Modelos de Riesgos Proporcionales , Recurrencia , Medición de Riesgo , Índice de Severidad de la Enfermedad , Centros de Atención Terciaria , Resultado del TratamientoRESUMEN
BACKGROUND: Kono-S anastomosis was described for the first time in 2011 and it showed a lower surgical recurrence rate in patients with Crohn's disease when compared to the standard technique. The aim of this review is to assess the safety and effectiveness of this surgical procedure by analyzing the data existing in the literature. MATERIALS AND METHODS: Pubmed, EMBASE and Scopus databases were used as data sources for a systematic comprehensive search of all studies where Kono-S anastomosis was performed in patients with Crohn's disease. Perioperative data and clinical outcomes were measured. RESULTS: Five studies described the use of Kono technique to restore intestinal continuity. Postoperative complications rates seem to be acceptable, with the exception of one case regarding the surgical site infection and bowel obstruction rates of one of the studies compared to the others. Surgical recurrence rate ranges from 0 to 3.4% with significant differences between Kono-S anastomosis and other techniques in the only two existing comparative studies. CONCLUSION: Kono's anastomosis seems to be a safe procedure with encouraging results on the reduction of the need for reoperation due to relapse, but the few existing studies do not allow to draw final conclusions. Further comparative, randomized studies, with appropriate sample size, follow up and endoscopic evaluation are necessary to establish the real benefits in the use of this hand-sewn antimesenteric anastomosis compared to a stapled wide lumen side-to-side anastomosis.
Asunto(s)
Anastomosis Quirúrgica/métodos , Enfermedad de Crohn/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Humanos , Complicaciones Posoperatorias/epidemiología , Reoperación/estadística & datos numéricos , Seguridad , Prevención Secundaria , Resultado del TratamientoAsunto(s)
Neoplasias Colorrectales/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Incontinencia Fecal/diagnóstico , Complicaciones Posoperatorias/diagnóstico , Recto/cirugía , Proyectos de Investigación , Defecación , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Incontinencia Fecal/epidemiología , Incontinencia Fecal/etiología , Incontinencia Fecal/fisiopatología , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Calidad de Vida , Índice de Severidad de la Enfermedad , SíndromeRESUMEN
Local excision following chemoradiotherapy in rectal cancer is an organ-preserving procedure which aims at reducing morbidity and functional disorders associated with total mesorectal excision (TME) in selected patients. Although TME after chemoradiotherapy remains the gold standard for locally advanced mid and low rectal cancer, in the last years multicenter research trials have offered encouraging oncologic results which have allowed to preserve the rectum in patients with a pathologic complete response after chemoradiotherapy. A review of the available literature on this topic was conducted to define the state of the art of this conservative approach and to focus on the most controversial aspects concerning local excision performed after chemoradiotherapy, in particular tumor scatter and lymph node status, completion and salvage surgery, morbidity and quality of life. The analysis of these topics should be considered, in trial setting or in current practice, for their clinical implications. Oncologic outcomes of recent trials are encouraging for part of the patients presenting T2 rectal cancer; however, TME still remains the standard treatment in clinical practice. In such cases, local excision should include a surgical safety margin of at least 1 cm from the resection margin to achieve a true negative margin from residual tumor cells. The selection of the patients should be carefully performed and their consensus extremely detailed because TME is necessary in about 30% of cases. Failing that, morbidity and quality of life are negatively affected. However, about half of these patients refuse radical surgery (45%), thus undergoing only palliative care.
Asunto(s)
Quimioradioterapia Adyuvante , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Neoplasias del Recto/patología , Neoplasias del Recto/terapia , Humanos , Márgenes de Escisión , Estadificación de Neoplasias , Tratamientos Conservadores del Órgano/métodos , Selección de Paciente , Calidad de Vida , Resultado del TratamientoRESUMEN
Surgery for rectal cancer has been completely revolutionized thanks to the adoption of new technologies and up-to-date surgical procedures that have been applied to the traditional milestone represented by Total Mesorectal Excision (TME). The multimodal and multidisciplinary approach, with new technologies increased the patients' life expectancies; nevertheless, they have placed the surgeon in front of newer issues, represented by both oncological outcomes and the patients' need of a less destructive surgery and improved quality of life. In this review we will go through laparoscopic, robotic and transanal TME surgery, to show how the correct choice of the most appropriate technique, together with a deep knowledge of oncological principles and pelvic anatomy, is crucial to pursue an optimal cancer treatment. Novel technologies might also help to decrease the patients' fear of surgery and address important issues such as cosmesis and improved preservation of postoperative functionality.
RESUMEN
PURPOSE: We report a case of primitive colonic dedifferentiated liposarcoma along with lymph node metastases. METHODS: The patient's clinical, radiologic, surgical, and histologic data were reviewed, as well as the literature on colonic dedifferentiated liposarcoma with a focus on the incidence of lymph node metastasis in gastrointestinal sarcomas and on the differential diagnosis with other spindle cell tumors in the gastrointestinal tract. RESULTS: A 53-year-old man was referred to our hospital with a 3 year-history of pain on the right back that was refractory to drugs. He performed an abdominal computed tomography scan which revealed a colonic wall thickening in the hepatic flexure and a few serosal nodularities. With these findings, the patient underwent an extended right hemicolectomy. On histopathologic examination, it turned out to be a colonic dedifferentiated liposarcoma with lymph node metastases. CONCLUSIONS: The present case was a challenging diagnosis both at presurgical and histopathological level because it strongly mimicked a colonic adenocarcinoma. This was due to non-specific clinical and radiological presentation, to the non-characteristic histologic morphology and to the misleading presence of lymph node metastases. Malignant stromal tumors of the gastrointestinal tract beyond gist are fairly rare entities. Colonic dedifferentiated liposarcoma must be kept in mind and must be considered in the differential diagnosis of gastrointestinal tumors.
Asunto(s)
Neoplasias del Colon/diagnóstico , Liposarcoma/diagnóstico , Metástasis Linfática/patología , Mesodermo/patología , Neoplasias del Colon/diagnóstico por imagen , Neoplasias del Colon/patología , Quinasa 4 Dependiente de la Ciclina/metabolismo , Diagnóstico Diferencial , Humanos , Liposarcoma/diagnóstico por imagen , Liposarcoma/patología , Masculino , Mesodermo/diagnóstico por imagen , Persona de Mediana Edad , Proteínas Proto-Oncogénicas c-mdm2/metabolismo , Tomografía Computarizada por Rayos XAsunto(s)
Tumores del Estroma Gastrointestinal/diagnóstico por imagen , Neurilemoma/diagnóstico por imagen , Neoplasias Gástricas/diagnóstico por imagen , Errores Diagnósticos , Femenino , Tumores del Estroma Gastrointestinal/diagnóstico , Humanos , Persona de Mediana Edad , Neurilemoma/diagnóstico , Neoplasias Gástricas/diagnósticoRESUMEN
PURPOSE: To prospectively evaluate image quality and diagnostic efficacy of a low radiation-high contrast (LR-HC) CT Enterography (CTE) in active Inflammatory Bowel Disease (IBD). MATERIALS AND METHODS: Eighty-five (36M; 49F; 17-75â¯yrs) patients with active IBD underwent contrast-enhanced CTE and were stratified in two groups according to age (< or ≥45â¯yrs): Group A (Nâ¯=â¯45; 32⯱â¯9â¯yrs; 58⯱â¯10â¯kg) and Group B (Nâ¯=â¯40; 58⯱â¯10â¯yrs; 61⯱â¯13â¯kg). Each group received a different amount of radiation (Noise Index, NI) and non-ionic iodinated contrast media (LOCM) as follows: Group A (NIâ¯=â¯15; 2.5â¯ml/kg) and Group B (NIâ¯=â¯12.5; 2â¯ml/kg). Thyroid functional tests were performed in all patients of group A at 4-6 wks. Signal- and contrast-to-noise ratios were calculated for liver (L) and abdominal aorta (A). Statistical analysis was performed by Student's t- or Chi-square test for continuous and categorical data, respectively. RESULTS: No patient of Group A developed signs of thyrotoxicosis. SNRL, CNRL and diagnostic accuracy of CTE were 8.4⯱â¯1.7 vs 8.9⯱â¯2.1 (pâ¯=â¯0.256), 5.4⯱â¯1.5 vs 5.6⯱â¯1.7 (pâ¯=â¯0.486) and 91.1 vs 92.5% (pâ¯=â¯0.764) whereas the effective dose and the LOCM administered were 6.7⯱â¯2.2 vs 13.9⯱â¯6.0â¯mSv (pâ¯<â¯0.001) and 144⯱â¯25 vs 122⯱â¯25â¯ml (pâ¯<â¯0.001) for Group A and B, respectively. CONCLUSION: LR-HC CTE is a dose-effective protocol in the evaluation of active IBD in young patients.
Asunto(s)
Medios de Contraste , Enfermedades Inflamatorias del Intestino/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Algoritmos , Femenino , Humanos , Enfermedades Inflamatorias del Intestino/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Dosis de Radiación , Sensibilidad y Especificidad , Adulto JovenRESUMEN
PURPOSE: Venous vascular anatomy of the right colon presents a high degree of variability. Henle's Gastrocolic Trunk is considered an important anatomical landmark by colorectal surgeons. The classical description concerns a bipod vascular structure or tripod, but several variants are associated to it. The aim of this study is to merge the most updated literature on the anatomy knowledge of the Gastrocolic Trunk by evaluating all possible variants, as well as to underline its surgical importance due to its topographical relationships. METHODS: Twelve studies describing the anatomy of the gastrocolic trunk were selected, each of them dealing with a more or less extensive series of cases. A distinction was drawn between the gastropancreatic trunk, devoid of the colonic component, and the gastrocolic trunk; and then the frequency of the different resulting variants was reported. The data obtained from cadavers and radiological studies were analyzed separately. RESULTS: The Gastrocolic Trunk is found in 74% of cadaver studies, and in 86% of radiological studies. Its most frequent configuration is represented by the union of right gastroepiploic vein + anterior superior pancreaticoduodenal vein + superior right colic vein, respectively, 32.5% and 42.5%, followed by the right colic vein which replaces (26.9%, 12.3%) or is added (10%, 20.1%) to the superior right colic vein. CONCLUSIONS: The superior right colic vein joins the right gastroepiploic vein and the anterior superior pancreaticoduodenal vein thus forming, in most cases, the gastrocolic trunk. The anatomical knowledge of vascular structures forms the basis for both the interpretation of preoperative radiological images and the surgical procedure itself, despite the considerable anatomical variability of tributaries.
Asunto(s)
Variación Anatómica , Colectomía/métodos , Neoplasias del Colon/cirugía , Laparoscopía/métodos , Venas Mesentéricas/anatomía & histología , Cadáver , Colectomía/efectos adversos , Colon/irrigación sanguínea , Colon/patología , Colon/cirugía , Neoplasias del Colon/patología , Humanos , Complicaciones Intraoperatorias/etiología , Complicaciones Intraoperatorias/prevención & control , Laparoscopía/efectos adversos , Venas Mesentéricas/diagnóstico por imagen , Periodo Preoperatorio , Estómago/irrigación sanguíneaAsunto(s)
Enfermedad de Crohn/cirugía , Humanos , Masculino , Estudios Prospectivos , Recurrencia , Factores de Riesgo , FumarRESUMEN
BACKGROUND: Perianal fistulizing Crohn's disease is a challenging clinical situation that requires proper management. Some features seen on the endoanal ultrasound can be helpful in discriminating between cryptoglandular and Crohn's disease fistulas. OBJECTIVE: The aim of this study was to define the diagnostic accuracy of 3-dimensional endoanal ultrasound in differentiating between Crohn's disease and cryptogenic fistulas. DESIGN: This was a prospective observational study. SETTINGS: The study was conducted in the colorectal unit of an IBD referral center. PATIENTS: Consecutive patients referred for suspected perianal sepsis from September 2015 to December 2016 were included. INTERVENTIONS: Three-dimensional endoanal ultrasonography was the studied intervention. MAIN OUTCOMES MEASURES: Sensitivity, specificity, and positive and negative likelihood ratios of 4 ultrasonographic features (Crohn's ultrasound fistula sign, the presence of a double track, debris or an abscess within the fistula track, and the maximum width of the track) in discriminating between cryptoglandular and Crohn's disease fistulas were calculated. The interobserver agreement for each feature was quantified. RESULTS: In this study, 158 patients, of whom 33 had a diagnosis of Crohn's disease, were included. The interobserver agreement was good for all of the ultrasonographic features. All of these features were more frequent in cases of Crohn's disease fistulas (p = 0.0001). The maximum width of the fistula track was highly accurate for discriminating between cryptogenic and Crohn's disease fistulas (area under the receiver operating characteristic curve = 0.922). The simultaneous presence of 2 features was suggestive of Crohn's disease fistula. In particular, the presence of a track width >4 mm in conjunction with either a double track or the Crohn's ultrasound fistula sign showed very high specificity (1.00). Conversely, a fistula track width ≤3 mm had high sensitivity (0.97). LIMITATIONS: Patients included in the cryptogenic group might be diagnosed as having Crohn's disease at follow-up. CONCLUSIONS: The combination of specific endoanal ultrasonographic features allows for highly accurate discrimination between Crohn's disease and cryptogenic fistulas. See Video Abstract at http://links.lww.com/DCR/A619.
Asunto(s)
Canal Anal/diagnóstico por imagen , Enfermedad de Crohn/complicaciones , Endosonografía/métodos , Fístula Rectal , Adulto , Canal Anal/patología , Diagnóstico Diferencial , Femenino , Humanos , Imagenología Tridimensional/métodos , Masculino , Estudios Prospectivos , Fístula Rectal/diagnóstico , Fístula Rectal/etiología , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: In the management of Crohn's disease [CD] patients, having a simple score combining clinical, endoscopic, and imaging features to predict the risk of surgery could help to tailor treatment more effectively. AIMS: We aimed to prospectively evaluate the 1-year risk factors for surgery in refractory/severe CD and to generate a risk matrix for predicting the probability of surgery at 1 year. METHODS: CD patients needing a disease re-assessment at our tertiary inflammatory bowel disease [IBD] centre underwent clinical, laboratory, endoscopic, and bowel sonography [BS] examinations within 1 week. The optimal cut-off values in predicting surgery were identified using receiver operating characteristic [ROC] curves for the Simple Endoscopic Score for CD [SES-CD], bowel wall thickness [BWT] at BS, and small bowel CD extension at BS. Binary logistic regression and Cox regression were then carried out. Finally, the probabilities of surgery were calculated for selected baseline levels of covariates and results were arranged in a prediction matrix. RESULTS: Of 100 CD patients, 30 underwent surgery within 1 year. SES-CD ≥9 (odds ratio [OR] 15.3; p <0.001], BWT ≥7 mm [OR 15.8; p <0.001], small bowel CD extension at BS ≥33 cm [OR 8.23; p <0.001], and stricturing/penetrating behaviour [OR 4.3; p <0.001] were the only independent factors predictive of surgery at 1 year, based on binary logistic and Cox regressions. Our matrix model combined these risk factors, and the probability of surgery ranged from 0.48% to 87.5% [16 combinations]. CONCLUSIONS: Our risk matrix combining clinical, endoscopic, and ultrasonographic findings can accurately predict the 1-year risk of surgery in patients with severe/refractory CD requiring a disease re-evaluation. This tool could be of value in clinical practice, serving as the basis for a tailored management of CD patients.
Asunto(s)
Enfermedad de Crohn/diagnóstico por imagen , Enfermedad de Crohn/cirugía , Endoscopía Gastrointestinal , Ultrasonografía , Adulto , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Curva ROC , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Centros de Atención Terciaria , Adulto JovenRESUMEN
OBJECTIVE: To evaluate the diagnostic efficacy of single-pass contrast-enhanced multidetector CT (CE-MDCT) performed with a low-radiation high-contrast (LR-HC) dose protocol in selected patients with non-traumatic acute bowel disease. METHODS: 65 (32 males, 33 females; aged 20-67 years) consecutive patients with non-traumatic acute bowel disease underwent single-pass CE-MDCT performed 70-100 s after i.v. bolus injection of a non-ionic iodinated contrast medium (CM) (370 mgI ml-1). In 46 (70%) patients with a clinical and/or ultrasonographic suspicion of inflammatory bowel disease, up to 1.2-1.4 l of a 7% polyethylene-glycol solution was orally administered 45-60 mins prior to the CT examination. Patients were then divided into two groups according to age: Group A (20-44 years; n = 34) and Group B (45-70 years; n = 31). Noise index (NI) and CM dose were selected as follows: Group A (NI = 15; 2.5 ml kg-1) and Group B (NI = 12.5; 2 ml kg-1). All patients of Group A underwent thyroid functional tests at 4-6 weeks. Final diagnoses were obtained by open (n = 12) or laparoscopic surgery (n = 4), endoscopy w/without biopsy (n = 24) and clinical (n = 19) and/or instrumental (ultrasonography) (n = 6) follow-up at 11 ± 4 months (range 6-18 mo.). Statistical analysis was performed by χ2 and Student's t-test for categorical and continuous variables, respectively. RESULTS: Sensitivity and specificity were 91.3 vs 95.4% (p = 0.905) and 90.9 vs 88.8% (p = 0.998) with an overall diagnostic accuracy of 91.1 vs 93.5% (p = 0.756), whereas the radiation (in millisievert) and CM dose (in millilitre) were 7.5 ± 2.8 mSv and 155 ± 30 ml for Group A and 14.1 ± 5.3 mSv and 130 ± 24 ml for Group B (p < 0.001), respectively. No patients of Group A showed laboratory signs of thyrotoxicosis at follow-up. CONCLUSION: The LR-HC has proved to be a safe and a dose-effective protocol in the evaluation of selected young patients with non-traumatic acute bowel disease. Advances in knowledge: (1) As reaching the highest diagnostic benefit to risk ratio (AHARA) appears to be the current principle of MDCT imaging, an increased amount of iodinated CM (0.7-0.9 gI ml-1) can be safely administered to young patients (<40 years) with normal thyroid and renal function to compensate for the lower image quality resulting from low-dose CT protocols performed with the standard filter back-projection algorithm. Such an approach will result in a significant reduction of the radiation dose, which could be otherwise achieved only using iterative reconstruction algorithms combined with either low tube voltage and/or low tube current protocols. (2) An optimal scan delay (Tdelay) for a venous phase caudocranial acquisition can be calculated by the following formula: Tdelay = CI + 25 - TSD, where CI is the duration of the contrast injection, 25 is the average of the sum of abdominal aortic and peak hepatic arrival times and TSD is the scan duration. With such an approach, the radiation exposure resulting from bolus tracking, albeit performed with low-dose scans, can be spared in patients with normal transit times.
Asunto(s)
Enfermedades del Colon/diagnóstico por imagen , Colonoscopía/métodos , Tomografía Computarizada Multidetector/métodos , Enfermedad Aguda , Adulto , Anciano , Colonoscopía/normas , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tomografía Computarizada Multidetector/normas , Estudios Prospectivos , Dosis de Radiación , Sensibilidad y Especificidad , Adulto JovenRESUMEN
INTRODUCTION: Evidence regarding long-term oncological outcomes following conversion to open surgery (COS) during laparoscopic colorectal resection (LCR) is controversial. The aim of this study is to assess the impact on cancer recurrence of a failed laparoscopic attempt. METHODS: MEDLINE, Scopus and ISI Web of Knowledge databases were searched for articles reporting data on cancer recurrence in patients undergoing completed LCR and COS. Data were pooled by fixed or random effect modeling, according to the presence of heterogeneity. Primary outcomes were local recurrence (LR) and distance recurrence (DR). RESULTS: Seven studies involving 2493 patients (completed LCR, n 2201 and COS, n 292) were included. The pooled analysis showed that COS resections have an higher risk of LR (OR 1.97, 95% CI 1.14-3.42, p = 0.1); no difference was found in DR (OR 1.09, 95% CI 0.67-1.77, p = 0.71). However, an higher rate of T4 tumor was present in the converted group (OR 2.62, 95% CI 1.71-4, p = 0.0). Subgroup analysis including studies with T stage matched populations showed no significant statistical difference in LR rate; however, a trend toward higher recurrence was still clear. CONCLUSION: There is no consistent evidence that a failed laparoscopic attempt does not result in a poorer oncological outcome; therefore, a careful selection of patients for LCR for cancer is required.
Asunto(s)
Colectomía , Neoplasias Colorrectales , Laparoscopía , Recurrencia Local de Neoplasia , Anciano , Colectomía/efectos adversos , Colectomía/métodos , Neoplasias Colorrectales/patología , Neoplasias Colorrectales/cirugía , Humanos , Periodo Intraoperatorio , Laparoscopía/efectos adversos , Laparoscopía/métodos , Metástasis de la Neoplasia , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/prevención & control , Evaluación de Procesos y Resultados en Atención de SaludRESUMEN
INTRODUCTION: Fecal diversion is considered an effective procedure to protect bowel anastomosis at high risk for leak. Some concerns exist regarding the risk for a significant morbidity associated to ileostomy creation itself and moreover to its closure. Surgical expertise and closure techniques are considered potential factors influencing morbidity. Aim of the study is to present a single-institution experience with ileostomy closures, in a teaching hospital, whereas ileostomy reversal is mainly performed by young residents. METHODS: A prospective database was investigated to extract data of patients who underwent loop ileostomy closure between January 2005 and December 2014. Ileostomy reversion was always realized in a handsewn fashion, performing either a direct closure (DC) or a resection plus end-to-end anastomosis (EEA). Postoperative morbidity was graded according to Clavien-Dindo classification. Outcomes after DC and EEA were compared by Fisher's exact test and Wilcoxon rank-sum test. RESULTS: Two hundred ninety-eight patients were included. Ileostomy reversal was performed by EEA in 236 patients (79.19 %) and by DC in 62 patients (20.81 %). Surgery was performed with a peristomal access in 296 cases (99.33 %). Incidence of anastomotic leak was 0.67 % (2/298). Overall reoperation rate was 0.34 % (1/298). Short-term overall morbidity rate was 20.47 %; but major complications (≥ grade III) occurred in only one patient (0.34 %). Mortality was nil. No significant differences in postoperative morbidity were found between the DC and EEA group. CONCLUSION: Loop ileostomy reversal is a safe procedure, associated to a low major morbidity and excellent results, even if performed with a handsewn technique by supervised trainee surgeons.