Use of Darvadstrocel (Allogenic Stem Cell Therapy) for Crohn's Fistulas in Real Clinical Practice: The National Project to Implement Mesenchymal Stem Cell for the Treatment of Perianal Crohn's Fistula (the PRIME Study).

BACKGROUND: Perianal fistulas may affect 15-50% of patients with Crohn's disease. Treatment is complex, requiring a multidisciplinary approach. Darvadstrocel (allogenic mesenchymal cells obtained from lipoaspirates) was approved in 2018 by the European and Spanish Agencies of Medicines and Medical Products as a treatment for fistulas in Crohn's disease. Recent European Crohn's and Colitis Organisation and Spanish Working Group on Crohn's Disease and Ulcerative Colitis guidelines state that darvadstrocel is effective with a favorable safety profile and a strong level of evidence (2). OBJECTIVE: Presenting real-world effectiveness data for darvadstrocel in a Spanish population. DESIGN: Observational retrospective cohort study with prospective data gathering. SETTINGS: Fourteen institutions. PATIENTS: From November 2019-April 2022, all patients (73) treated with darvadstrocel in these institutions were included, fulfilling the following criteria: 1) complex fistula/s in a patient with Crohn's disease; 2) failure of conventional and antitumor necrosis factor treatment; 3) absence of collections >2 cm confirmed by pelvic MRI scan at the time of surgery. INTERVENTIONS: Darvadstrocel treatment. MAIN OUTCOME MEASURES: Clinical response (closure of ≥50% of external openings), complete clinical closure (100% of external openings) and radiological closure (no fluid collection >2 cm, no edema or inflammation) evaluated 6 months after treatment. RESULTS: Clinical response was observed in 63 patients (86.3%), complete clinical closure in 50 patients (68.5%) and radiological closure in 45 patients (69.2%). Combined clinical and radiological response was observed in 41 patients (63.1%). Not all clinically healed patients had radiological closure and vice versa. No serious adverse events were reported. LIMITATIONS: Retrospective. CONCLUSIONS: Study results were consistent with those reported in previous clinical trials, real-world efficacy findings from the INSPIRE study (assessing darvadstrocel effectiveness in Europe, Israel, Switzerland, UK, and Japan) and previously published literature. Darvadstrocel was effective and demonstrated a favorable safety profile when used in normal clinical practice for treatment of fistulas in Crohn's disease. See Video Abstract.

Exactitud diagnóstica en el cáncer de esófago localizado. Estudio observacional retrospectivo.

OBJECTIVE: To assess the accuracy of the diagnostic tests for a correct clinical tumor staging in localized esophageal cancer (EC). METHOD: Retrospective observational study of patients who underwent esophagectomy for cancer in a referral hospital between January 2003 and September 2019. Those patients who received neoadjuvant treatment were excluded in order to avoid bias from downstaging effects. The preoperative stage was compared with the pathological stage of the surgical specimen. Computed tomography (CT) , endoscopic ultrasound (EUS) and positron emission tomography (PET) were evaluated. The pT stage was correlated with the tumor length described in the esophagram (EG). RESULTS: Among the 63 patients included, the clinical staging was correct in 16 (global accuracy 25.4%), it was overstaged in 21 (33.2%) and understaged in 26 (41.3%). For cT staging, the accuracy of EUS was higher than that of CT (46.6% and 34.9%, respectively), specially for early stages. EG tumor length correlated with pT stage (p < 0.05). For cN staging, PET had the highest sensitivity (50.0%) and negative predictive value (75.0%). CONCLUSIONS: Despite the multiple diagnostic tools used, the global accuracy of clinical staging in localized EC is still a challenge. The lack of a test that stands out significantly from the others reinforces the need to use them in a complementary way.

OBJETIVO: Evaluar la exactitud diagnóstica para el estadiaje clínico del cáncer de esófago (CE) localizado. MÉTODO: Estudio observacional retrospectivo de los pacientes esofagectomizados por CE en un hospital de referencia entre enero de 2003 y septiembre de 2019. Se excluyeron aquellos que recibieron neoadyuvancia para evitar sesgos de infraestadiaje. Se comparó el estadio preoperatorio con el estadio patológico de la pieza quirúrgica. Se evaluaron la tomografía computarizada (TC), la ecoendoscopia (EUS) y la tomografía por emisión de positrones (PET). El estadio pT se correlacionó con la longitud tumoral descrita en el esofagograma (EG). RESULTADOS: De los 63 pacientes incluidos, el estadiaje clínico fue correcto en 16 (exactitud 25.4%), con sobreestadiaje en 21 (33.2%) e infraestadiaje en 26 (41.3%). Para el estadiaje cT, la EUS fue superior a la TC (exactitud 46.6% y 34.9%, respectivamente), en especial para estadios precoces. La longitud tumoral del EG se correlacionó con el estadio pT (p < 0.05). Para el estadiaje cN, la PET tuvo la mayor sensibilidad (50.0%) y el mayor valor predictivo negativo (75.0%). CONCLUSIONES: A pesar de las múltiples herramientas diagnósticas empleadas, la exactitud diagnóstica en el CE localizado es limitada. La ausencia de una prueba que destaque de manera significativa refuerza la necesidad de emplearlas de forma complementaria.

Care burden and outcome of the surgical management of ulcerative colitis: A retrospective analysis of the last 20 years in a tertiary hospital in Spain.

AIM: To analyze the surgical burden of UC care in the last two decades, analyzing the characteristics of the patients, surgical indications along with the short and long-term results. METHOD: Single-center retrospective cohort analysis of UC patients undergoing abdominal and anorectal surgery between January 2000 and December 2020. The care burden, clinical data and results were analyzed according to distribution by decades. RESULTS: 128 patients, 37% female, underwent 376 surgical interventions (296 intestinal procedures and 80 anorectal). Mean follow-up for the cohort was 106±64 months. Timing from diagnosis to first surgery was under 5 years in 53.3%. In the second decade of the study there were fewer operated patients (73 vs. 48) as well as the total number of interventions per patient (2.7 vs. 2.0). The proportion between elective and urgent surgery was reversed in the second decade, observing an increase in laparoscopic surgery (70% vs. 8%) together with a decrease in major postoperative morbidity (Clavien-Dindo≥IIIa) (20% vs 8.4%). 80 patients underwent a restorative proctocolectomy, with a failure of 5% at 1 year but 23.7% in the long term. 37 patients required anorectal surgery, of which 26 (71%) were serial interventions, most due to septic complications of the pouches. CONCLUSIONS: The number of colectomies and interventions per patient decreased in the last decade, while there were improvements in morbidity and surgical approach. The need for sequential surgeries and long-term active instrumental surveillance for possible functional deterioration constitutes a significant clinical burden.

Prognostic Value of the Circumferential Resection Margin After Curative Surgery for Rectal Cancer: A Multicenter Propensity Score-Matched Analysis.

BACKGROUND: Recently, positive circumferential resection margin has been found to be an indicator of advanced disease with a high risk of distant recurrence rather than local recurrence. OBJECTIVE: The study aimed to analyze the prognostic impact of the circumferential resection margin on long-term oncological outcomes in patients with rectal cancer. DESIGN: This was a multicenter, propensity score-matched (2:1) analysis comparing the positive and negative circumferential resection margins. SETTINGS: The study was conducted at 5 high-volume centers in Spain. PATIENTS: Patients who underwent total mesorectal excision with curative intent for middle-low rectal cancer between 2006 and 2014 were included. MAIN OUTCOME MEASURES: The main outcomes were local recurrence, distant recurrence, overall survival, and disease-free survival. RESULTS: The unmatched initial cohort consisted of 1599 patients, of whom 4.9% had a positive circumferential resection margin. After matching, 234 patients were included (156 with a negative circumferential margin and 78 with a positive circumferential margin). The median follow-up period was 52.5 (22.0-69.5) months. Local recurrence was significantly higher in patients with a positive circumferential margin (33.3% vs 11.5%; p < 0.001). Distant recurrence was similar in both groups (46.2% vs 42.3%; p = 0.651). There were no statistically significant differences in 5-year overall survival (48.6% vs 43.6%; p = 0.14). Disease-free survival was lower in patients with a positive circumferential margin (36.1% vs 52.3%; p = 0.026). LIMITATIONS: This study was limited by its retrospective design. The different neoadjuvant treatment options were not included in the propensity score. CONCLUSIONS: The positive circumferential resection margin was associated with a higher local recurrence rate and worse disease-free survival in comparison with the negative circumferential resection margin. However, the positive circumferential resection margin was not a prognostic indicator of distant recurrence and overall survival. See Video Abstract at http://links.lww.com/DCR/B950 . VALOR PRONSTICO DEL MARGEN DE RESECCIN CIRCUNFERENCIAL DESPUS DE LA CIRUGA CURATIVA PARA EL CNCER DE RECTO UN ANLISIS MULTICNTRICO EMPAREJADO POR PUNTAJE DE PROPENSIN: ANTECEDENTES:En los últimos años, se ha encontrado que el margen de resección circunferencial positivo es un indicador de enfermedad avanzada con alto riesgo de recurrencia a distancia más que de recurrencia local.OBJETIVO:El objetivo fue analizar el impacto pronóstico del margen de resección circunferencial sobre la recidiva local, a distancia y las tasas de supervivencia en pacientes con cáncer de recto.DISEÑO:Este fue un análisis multicéntrico emparejado por puntaje de propensión 2: 1 que comparó el margen de resección circunferencial positivo y negativo.AJUSTES:El estudio se realizó en 5 centros Españoles de alto volumen.PACIENTES:Se incluyeron pacientes sometidos a escisión total de mesorrecto con intención curativa por cáncer de recto medio-bajo entre 2006-2014. Las características clínicas e histológicas se utilizaron para el emparejamiento.PRINCIPALES MEDIDAS DE RESULTADO:Los resultadoes principales fueron la recurrencia local, la recurrencia a distancia, la supervivencia global y libre de enfermedad.RESULTADOS:La cohorte inicial no emparejada consistió en 1599 pacientes; El 4,9% tuvo un margen de resección circunferencial positivo. Tras el emparejamiento se incluyeron 234 pacientes (156 con margen circunferencial negativo y 78 con margen circunferencial positivo). La mediana del período de seguimiento fue de 52,5 meses (22,0-69,5). La recurrencia local fue significativamente mayor en pacientes con margen circunferencial positivo, 33,3% vs 11,5% [HR 3,2; IC 95%: 1,83-5,43; p < 0,001]. La recidiva a distancia fue similar en ambos grupos (46,2 % frente a 42,3 %) [HR 1,09, IC 95 %: 0,78-1,90; p = 0,651]. No hubo diferencias significativas en la supervivencia global a 5 años (48,6 % frente a 43,6 %) [HR 1,09, IC 95 %: 0,92-1,78; p = 0,14]; La supervivencia libre de enfermedad fue menor en pacientes con margen circunferencial positivo, 36,1% vs 52,3% [HR 1,5; IC 95%: 1,05-2,06; p = 0,026].LIMITACIONES:Este estudio estuvo limitado por el diseño retrospectivo. Las diferentes opciones de tratamientos neoadyuvantes no se han incluido en la puntuación de propensión.CONCLUSIONES:El margen de resección circunferencial positivo se asocia con una mayor tasa de recurrencia local y peor supervivencia libre de enfermedad en comparación con el margen de resección circunferencial negativo. Sin embargo, el margen de resección circunferencial positivo no fue un indicador pronóstico de recidiva a distancia ni de supervivencia global. Consulte el Video del Resumen en http://links.lww.com/DCR/B950 . (Traducción- Dr. Yesenia Rojas-Khalil ).

Care burden and outcome of the surgical management of ulcerative colitis: A retrospective analysis of the last 20 years in a tertiary hospital in Spain.

AIM: To analyze the surgical burden of UC care in the last two decades, analyzing the characteristics of the patients, surgical indications along with the short and long-term results. METHOD: Single-center retrospective cohort analysis of UC patients undergoing abdominal and anorectal surgery between January 2000 and December 2020. The care burden, clinical data and results were analyzed according to distribution by decades. RESULTS: 128 patients, 37% female, underwent 376 surgical interventions (296 intestinal procedures and 80 anorectal). Mean follow-up for the cohort was 106±64 months. Timing from diagnosis to first surgery was under 5 years in 53.3%. In the second decade of the study there were fewer operated patients (73 vs. 48) as well as the total number of interventions per patient (2.7 vs. 2.0). The proportion between elective and urgent surgery was reversed in the second decade, observing an increase in laparoscopic surgery (70% vs. 8%) together with a decrease in major postoperative morbidity (Clavien-Dindo≥IIIa) (20% vs 8.4%). 80 patients underwent a restorative proctocolectomy, with a failure of 5% at 1 year but 23.7% in the long term. 37 patients required anorectal surgery, of which 26 (71%) were serial interventions, most due to septic complications of the pouches. CONCLUSIONS: The number of colectomies and interventions per patient decreased in the last decade, while there were improvements in morbidity and surgical approach. The need for sequential surgeries and long-term active instrumental surveillance for possible functional deterioration constitutes a significant clinical burden.

Diagnóstico inesperado en paciente con sospecha de GIST: infiltración gástrica por mieloma múltiple.

El mieloma múltiple se caracteriza por la proliferación neoplásica medular de células plasmáticas productoras de inmunoglobulina monoclonal. Un porcentaje pequeño de pacientes presenta compromiso extramedular en forma de plasmocitoma, siendo la localización más habitual las vías respiratorias altas. La afectación gastrointestinal es rara y la clínica asociada dependerá de la localización, la extensión y el mecanismo de infiltración. La afectación gástrica en forma de tumoración tiene un aspecto y una sintomatología similares a los de otras lesiones, por lo que es necesario realizar un diagnóstico histológico para un adecuado tratamiento. A continuación se presenta el caso de un mieloma múltiple con afectación gástrica.Multiple myeloma is characterized by medullary neoplastic proliferation of plasma cells producing monoclonal immunoglobulin. A small percentage of patients have extramedullary involvement in form of plasmacytoma, the most common location being the upper respiratory tract. Gastrointestinal involvement is rare and the associated symptoms will depend on the location, extent and mechanism of infiltration. Gastric involvement presents an appearance and symptoms similar to other lesions, so a histological diagnosis is necessary for proper treatment. This article presents the case of multiple myeloma with gastric involvement.

Late anastomotic leakages in rectal surgery: a wake-up call about their impact on long-term results.

OBJECTIVE: To assess the impact of the incidence of late anastomotic dehiscences, defined as those occurring after the 60th post-operative day, in the final results of rectal cancer treatment. METHODS: A retrospective analysis was performed reviewing all anastomotic leakages (AL) recorded in a prospective rectal cancer database, from November 2006 to December 2015. RESULTS: The analysis included 395 (71.5%) colo-rectal anastomosis performed in 552 patients undergoing rectal cancer surgery. Overall 32 (8.1%). AL were identified: 25 (78%) early and 7 (22%) late. Late AL compared to early AL were significantly associated with: higher ASA score (p = 0.021), higher CLS score (p = 0.005), lower rectal tumours (p = 0.014), neo-adjuvant radio-chemotherapy (p = 0.028), presence of ileostomy (p = 0.013), early hospital discharge (p = 0.048) and with the need for definitive stoma creation (p = 0.003). CONCLUSIONS: Late AL can represent up to 22% of all AL; with significant long-term implications such as an increase of the requirement of definitive stoma or chronic pelvic sepsis. This findings could modify the long-term outcomes in rectal cancer published. In our experience, the late AL do not represent a distinct clinical process compared to early forms, with exception of the chronological criteria.

OBJETIVO: Valorar el impacto de la incidencia de dehiscencias anastomóticas tardías, definidas como las aparecidas después del día 60 del posoperatorio, en los resultados finales del tratamiento del cáncer de recto. MÉTODO: Estudio retrospectivo de todas las dehiscencias anastomóticas recogidas a largo plazo en un registro prospectivo de cáncer de recto entre noviembre de 2006 y diciembre de 2015. RESULTADOS: Se realizaron 395 anastomosis colorrectales en 552 pacientes con cáncer de recto (71.5%) y se diagnosticaron 32 dehiscencias anastomóticas (8.1%): 25 precoces (78%) y 7 tardías (22%). Las tardías se diferenciaron de las precoces por presentarse en pacientes con mayor puntuación ASA (p = 0.021), mayor puntuación predictiva CLS (p = 0.005), tumores más bajos (p = 0.014), neoadyuvancia (p = 0.028), ileostomía (p = 0.013), menos tiempo de estancia posoperatoria (p = 0.048) y mayor necesidad de estomas definitivos (p = 0.003). CONCLUSIONES: Las dehiscencias anastomóticas tardías pueden suponer el 22% de las dehiscencias totales y se acompañan de un aumento de estomas definitivos y de sepsis pélvica crónica que podrían empeorar los estándares publicados en cáncer de recto. En nuestra experiencia no son diferentes de las formas precoces salvo en su cronología.

Patterns of recurrence/persistence of criptoglandular anal fistula after the LIFT procedure. Long-term observacional study. / Patrones de recurrencia/persistencia en la operación de LIFT para la fístula anal de origen criptoglandular. Estudio observacional a largo plazo.

OBJECTIVE: To study the recurrence/persistence rate of complex cripotoglandular anal fistula after the LIFT procedure and analyse the patterns of recurrence/persistence. PATIENTS AND METHODS: Observational study of patients with transe-sphincteric or supra-sphincteric anal fistula treated using the LIFT procedure from December 2008 to April 2016. Variables studied included clinical characteristics, surgical technique and results. Clinical cure was defined and imaging studies were used in doubtful cases. Wexner's score was used for continence evaluation. The minimum follow-up time was one year. RESULTS: A total of 55 patients were operated on: 53 with a trans-sphincteric fistula and 2 supra-sphincteric. There were 16 failures (29%): 7 complete fistulas (original), 6 intersphincteric (downstage), and 3 external residual tracts. A posterior location and complexity of the tract were risk factors for recurrence/persistence. The presence of a seton did not improve results. No case presented decrease of continence (Wexner 0). Nine patients presented minor complications (9%): 4 intersphincteric wounds with delayed closure and one external hemorrhoidal thrombosis. The median time to closure of the external opening was 5 weeks (IR 2-6). Intersphincteric wounds closed in 4-8 weeks. CONCLUSION: In our experience, the LIFT technique is a safe and reproducible procedure with low morbidity, no repercussion on continence and a success rate over 70%. There are 3types of recurrence: the intersphincteric fistula, the original fistulatula (trans- or supra-sphincteric) and the residual external tract. Considering the types of recurrence, only 12,7% of patients need more complex surgery to solve their pathology. The rest of the recurrences/persistence were solved by simple procedures (fistulotomy in intersphincteric forms and legrado in residual tracts).

Results of short term radiotherapy followed by radical surgery for rectal cancer: A long-term unicenter observational study. / Resultados de la radioterapia de ciclo corto seguida de cirugía radical en el cáncer de recto: estudio unicéntrico y observacional a largo plazo.

INTRODUCTION: Short-term radiotherapy (STR) for rectal cancer (RC) has rarely been used in Spain. The aim of the present study is to describe oncological results after RTC and surgery for RC. METHODS: This is a retrospective analysis of a consecutive series of patients treated with STR and surgery for RC (1999-2012). Epidemiological data, staging, complications of STR, STR-surgery interval, surgical approach, rate of anastomotic/perineal wound dehiscence, and pathological data (regression degree and staging) were collected. Global survival, disease free survival, local recurrence rate and incidence of toxicity, response and complications of combined treatment are reported. RESULTS: Of 1229 patients treated, 209 patients received STR and surgery. The median follow-up was 6.2 years. Mean age was 68 years and 66% of the patients were men. A total of 88% were cT3-4 and 44% cN+17 (8.1%) patients had resectable synchronous metastases. Acute and chronic toxicity due to STR was <5%. In 75% of the cases the STR-surgery interval was <15 days, and in 9%> 4 weeks. Seven patients (3.3%) presented complete response. Nine (4.3%) patients presented an local recurrence rate. Global survival at 5, 10 and 15 years was 67.8, 49.2 and 37.5%, respectively. Disease free survival at 5, 10 and 15 years was 66.1, 47.1 and 33%, respectively. CONCLUSIONS: The results compare favorably with multicentric historical series. STR offers certain advantages that could be increased by increasing the STR-surgery interval and/or interspersed with sequential chemotherapy.

Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery in the Spanish Rectal Cancer Project. / Influencia del volumen quirúrgico en los resultados oncológicos después de estandarizar la cirugía en el Proyecto Español del Cáncer de Recto.

UNLABELLED: INTRODUCCIóN: The purpose of this prospective multicentre multilevel study was to investigate the influence of hospital caseload on long-term outcomes following standardization of rectal cancer surgery in the Rectal Cancer Project of the Spanish Society of Surgeons. METHODS: Data relating to 2910 consecutive patients with rectal cancer treated for cure between March 2006 and March 2010 were recorded in a prospective database. Hospitals were classified according to number of patients treated per year as low-volume, intermediate-volume, or high volume hospitals (12-23, 24-35, or ≥36 procedures per year). RESULTS: After a median follow-up of 5 years, cumulative rates of local recurrence, metastatic recurrence and overall survival were 6.6 (CI95% 5.6-7.6), 20.3 (CI95% 18.8-21.9) and 73.0 (CI95% 74.7 - 71.3) respectively. In the multilevel regression analysis overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more patients (HR 0,727 [CI95% 0,556-0,951]; P=.02). The risk of local recurrence and metastases were not related to the caseload. Moreover, there was a statistically significant variation in overall survival (median hazard ratio [MHR] 1.184 [CI95% 1.071-1,333]), local recurrence (MHR 1.308 [CI95% 1.010-1.668]) and metastases (MHR 1.300 [CI95% 1.181; 1.476]) between all hospitals. CONCLUSIONS: Overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more patients. However, local recurrence was not influenced by caseload.

Hospital variability in postoperative mortality after rectal cancer surgery in the Spanish Association of Surgeons project: The impact of hospital volume.

OBJECTIVE: This multicentre observational study examines variation between hospitals in postoperative mortality after elective surgery in the Rectal Cancer Project of the Spanish Society of Surgeons and explores whether hospital volume and patient characteristics contribute to any variation between hospitals. METHODS: Hospital variation was quantified using a multilevel approach on prospective data derived from the multicentre database of all rectal adenocarcinomas operated by an anterior resection or an abdominoperineal excision at 84 surgical departments from 2006 to 2013. The following variables were included in the analysis; demographics, American Society of Anaesthesiologists classification, tumour location and stage, administration of neoadjuvant treatment, and annual volume of surgical procedures. RESULTS: A total of 9809 consecutive patients were included. The rate of 30-day postoperative mortality was 1.8% Stratified by annual surgical volume hospitals varied from 1.4 to 2.0 in 30-day mortality. In the multilevel regression analysis, male gender (OR 1.623 [1.143; 2.348]; P<.008), increased age (OR: 5.811 [3.479; 10.087]; P<.001), and ASA score (OR 10.046 [3.390; 43.185]; P<.001) were associated with 30-day mortality. However, annual surgical volume was not associated with mortality (OR 1.309 [0.483; 4.238]; P=.619). Besides, there was a statistically significant variation in mortality between all departments (MOR 1.588 [1.293; 2.015]; P<.001). CONCLUSION: Postoperative mortality varies significantly among hospitals included in the project and this difference cannot be attributed to the annual surgical volume.

Total pelvic exenteration for the treatment of advanced primary or recurrent pelvic neoplasia.

INTRODUCTION: Complete resection with clear margins in locally advanced pelvic visceral tumors, primary or recurrent, occasionally requires total pelvic exenteration (TPE). METHODS: We reviewed the results of EFA in 34 consecutive patients operated on between June 2006 and December 2013. RESULTS: Median age was 62 (40-82) years; 24 (70%) were male. The tumor origin most frequent was advanced primary rectal tumor (APRT), with 19 cases (55.9%) and most common type of exenteration was supraelevator (61.8%). R0 resection was achieved in 24 (70.6%) patients and in 16 (85%) of the APRT. Fifteen (79%) patients had pT4 APRT, and 4 (20%) pN +. Reconstruction of the bowel and bladder was performed with two stomas in 17 cases (50%), colorectal anastomosis and Bricker in 11 (32.3%) and wet double barreled colostomy in 6 (17.6%). There was no postoperative mortality; 23 (67,5%) patients had complications, and 5 (14.6%) required a postoperative reoperation to solve them. Median follow-up was 23 (13-45) months. Overall survival (OS) and disease free survival (DFS) at 2 years were 67% and 58% respectively, and the median OS and DFS was 59 months (95% CI 26-110) and 39 months (95% CI 14-64), respectively. The DFS of R0 was significantly better (p=0.003) than R1. CONCLUSIONS: TPE is a potentially curative procedure for advanced pelvic visceral malignancies with similar morbi-mortality than other extended excisional surgery.

Delorme's Procedure for Complete Rectal Prolapse: A Study of Recurrence Patterns in the Long Term.

Introduction. The objective of this study was to determine the recurrence rate and associated risk factors of full-thickness rectal prolapse in the long term after Delorme's procedure. Patients and Methods. The study involved adult patients with rectal prolapse treated with Delorme's surgery between 2000 and 2012 and followed up prospectively in an outpatient unit. We assessed epidemiological data, Wexner constipation and incontinence score, recurrence patterns, and risk factors. Data were analyzed by univariate and multivariate studies and follow-up was performed according to Kaplan-Meier technique. The primary outcome was recurrence. Results. A total of 42 patients, where 71.4% (n = 30) were women, with a median age of 76 years (IQR 66 to 86), underwent Delorme's surgery. The median follow-up was 85 months (IQR 28 to 132). There was no mortality, and morbidity was 9.5%. Recurrence occurred in five patients (12%) within 14 months after surgery. Actuarial recurrence at five years was 9.9%. According to the univariate analysis, constipation and concomitant pelvic floor repair were the only factors found to be associated with recurrence. Multivariate analysis showed no statistically significant differences among variables studied. Kaplan-Meier estimate revealed that constipation was associated with a higher risk of recurrence (log-rank test, p = 0.006). Conclusions. Delorme's procedure is a safe technique with an actuarial recurrence at five years of 9.9%. The outcomes obtained in this study support the performance of concomitant postanal repair and levatorplasty to reduce recurrences. Also, severe constipation is associated with a higher recurrence rate.

Preventing complications in colorectal anastomosis: results of a randomized controlled trial using bioabsorbable staple line reinforcement for circular stapler.

BACKGROUND: Anastomotic complications, including leaks, stenoses, and bleeding, cause considerable mortality and morbidity after colorectal surgery. OBJETIVE: The purpose of this work was to evaluate the effectiveness of bioabsorbable staple line reinforcement in reducing colorectal anastomotic complications. DESIGN: This was a prospective randomized clinical study. SETTINGS: This study was conducted at a university hospital within a specialized colorectal unit. PATIENTS: Patients undergoing left colon resection for a benign or malignant condition were eligible. A total of 302 patients participated, including 154 control subjects and 148 with reinforcement. INTERVENTION: Patients were prospectively randomly assigned to reinforcement of circular stapled anastomosis with a bioabsorbable device versus stapled circular anastomosis without reinforcement. MAIN OUTCOME MEASURES: The primary end point was the rate of pooled incidences of anastomotic complications (leakage, bleeding, or stenosis). Secondary outcomes were the rate of reoperations and the length of hospital stay. RESULTS: Baseline characteristics were similar between both groups. Intention-to-treat analysis revealed that there were no significant differences in the pooled incidences of anastomotic complications (p = 0.821). Regarding individual complications, we did not observe statistical differences between groups, including leakage (6.6% vs 4.8%; p = 0.518), hemorrhage (1.4% vs 1.3%; p = 0.431), or stenosis (2.9% vs 6.8%; p = 0.128). Again, no significant differences were observed in length of stay (7 days; p = 0.242) or rate of reoperation (7.3% vs 9.6%; p = 0.490). A patient (0.3%) in the control group died. LIMITATIONS: Sample size calculation was performed including all 3 of the complications, which may render it underpowered to detect differences regarding a specific complication. Anastomoses located within 5 cm from the anal verge were excluded from the study. CONCLUSIONS: The results obtained show that bioabsorbable staple line reinforcement in a colorectal anastomosis >5 cm from the anal verge does not reduce the rate of pooled anastomotic complications (ie, leaks, bleeding, or stenosis).

Phenotype characteristics of patients with colonic serrated polyposis syndrome: a study of 23 cases.

INTRODUCTION: Serrated polyposis syndrome (SPS) is a rare entity characterized by the presence of multiple hyperplastic polyps in the colon and an increased risk of presentation and development of colorectal cancer (CRC). OBJECTIVE: To evaluate the clinical and phenotypical characteristics of patients that present one of the 3 WHO criteria for the diagnosis of SPS diagnosed and treated a tour hospital. PATIENTS AND METHODS: Patients with the diagnosis of SPS during 2005-2012 were revised; 24.208 colonoscopies were performed during this period. Age, sex, family history of CRC (APC/MYH), proximal/mixed/distal phenotype, indication for colonoscopy, number, size, location of the hyperplastic polyps, presence of mixed/adenomatous polyps, CRCI, follow-up and endoscopio/surgical treatment. RESULTS: A total of 23 cases were included (19 male). The median age was 51. A total of 34% had a prior family history of CRC or polpyps. Distal phenotype was more frequent (48%). Another 73% presented synchronous adenomatous polyps, and 26% a CRC. A total of 57% were asymptomatic. Surgery was performed in 9 cases (6 for cancer and 3 for polyposis), and 14 were treated by polypectomy and observation. Eleven patients (47%) presented recurrent/persistent lesions after initial surgical/endoscopic treatment. CONCLUSION: SPS is an heterogeneous syndrome that is variable in the type, size, distribution and number of polyps, and is more common in male smokers with a distal phenotype. The majority of patients also present synchronous adenomatous polyps. These patients require an organized multidisciplinary evaluation.

Rate of detection of advanced neoplasms in proximal colon by simulated sigmoidoscopy vs fecal immunochemical tests.

BACKGROUND & AIMS: We compared the ability of biennial fecal immunochemical testing (FIT) and one-time sigmoidoscopy to detect colon side-specific advanced neoplasms in a population-based, multicenter, nationwide, randomized controlled trial. METHODS: We identified asymptomatic men and women, 50-69 years old, through community health registries and randomly assigned them to groups that received a single colonoscopy examination or biennial FIT. Sigmoidoscopy yield was simulated from results obtained from the colonoscopy group, according to the criteria proposed in the UK Flexible Sigmoidoscopy Trial for colonoscopy referral. Patients who underwent FIT and were found to have ≥75 ng hemoglobin/mL were referred for colonoscopy. Data were analyzed from 5059 subjects in the colonoscopy group and 10,507 in the FIT group. The main outcome was rate of detection of any advanced neoplasm proximal to the splenic flexure. RESULTS: Advanced neoplasms were detected in 317 subjects (6.3%) in the sigmoidoscopy simulation group compared with 288 (2.7%) in the FIT group (odds ratio for sigmoidoscopy, 2.29; 95% confidence interval, 1.93-2.70; P = .0001). Sigmoidoscopy also detected advanced distal neoplasia in a higher percentage of patients than FIT (odds ratio, 2.61; 95% confidence interval, 2.20-3.10; P = .0001). The methods did not differ significantly in identifying patients with advanced proximal neoplasms (odds ratio, 1.17; 95% confidence interval, 0.78-1.76; P = .44). This was probably due to the lower performance of both strategies in detecting patients with proximal lesions (sigmoidoscopy detected these in 19.1% of patients and FIT in 14.9% of patients) vs distal ones (sigmoidoscopy detected these in 86.8% of patients and FIT in 33.5% of patients). Sigmoidoscopy, but not FIT, detected proximal lesions in lower percentages of women (especially those 50-59 years old) than men. CONCLUSIONS: Sigmoidoscopy and FIT have similar limitations in detecting advanced proximal neoplasms, which depend on patients' characteristics; sigmoidoscopy underperforms for women 50-59 years old. Screening strategies should be designed on the basis of target population to increase effectiveness and cost-effectiveness. ClinicalTrials.gov number: NCT00906997.

[Interposition of the small intestine between the colon and the rectum as a way of achieving a pelvic anastomosis without pressure]. / Interposición de intestino delgado entre el colon y el recto como forma de lograr una anastomosis pélvica sin tensión.

PURPOSE: There are some circumstances in which the descending colon does not reach the pelvis to complete a colorectal anastomosis without tension. Re-establishing intestinal continuity by interposing small bowel as a bridge between the colon and the rectum could be an acceptable surgical alternative. METHODS: We describe the interposition of one or two segments of small bowel as a way of restoring continuity of the colon and rectum in three patients in whom it was not possible to perform a colorectal anastomosis without tension due to ischaemic colon, synchronous cancer or difficulty in accessing the supramesocolic space, respectively. RESULTS: Intestinal continuity was re-established in all patients with no significant morbidity and good intestinal function. CONCLUSION: The interposition of small bowel segments between the colon and the rectum should be considered a valid surgical option when it is not possible to achieve a well-perfused, tension-free pelvic colorectal anastomosis.