Multicentre, prospective, randomized control non-inferiority trial of bladder catheter management in colon surgery.

AIM: Perioperative bladder catheterization is a controversial issue. Most current recommendations are based on data from open surgery extrapolated to enhanced recovery after surgery or fast-track programmes ranging between 24 and 48 h. The aim of this study is to provide a rationale for reducing catheterization time while at the same time avoiding acute urine retention (AUR), in patients undergoing scheduled laparoscopic colon surgery. METHOD: This is a multicentre, prospective, controlled, randomized non-inferiority study of bladder catheter management in patients undergoing scheduled laparoscopic colon surgery, randomized into two groups: experimental (with catheter removal immediately after surgery) and control (with catheter removal 24 h post-surgery). The main outcome will be the development of AUR, and secondary outcomes the development of urinary infection within the first 30 days and hospital stay. Demographic, surgical and pathological variables will also be evaluated, especially the development of adverse effects assessed according to the Clavien scale and the Comprehensive Complication Index. Following the literature, we assume an incidence of AUR of 11% and a margin of non-inferiority (delta) of 8% and estimate that a sample size of 208 patients per group will be required (with an estimated 10% of losses per group). CONCLUSIONS: In this study we try to demonstrate that the bladder catheter can be removed immediately after scheduled laparoscopic colon surgery, without increasing acute urine retention. This measure would offers the benefits of earlier mobilization and reduces catheter-related morbidity.

Randomised clinical trial to test the phenolization in sacrococcygeal pilonidal disease.

To test the efficacy and safety of phenolization in uncomplicated Sacrococcygeal pilonidal disease (SPD) the phenolization in uncomplicated SPD is feasible and secure in selected patients in observational studies. The greatest benefits are obtained to reduce the length of sick leave (LSL) and complications. Single-center randomised controlled clinical trial. Patients were recruited at University Hospital of Tarragona Joan XXIII of Spain. Patients were randomised into two treatment groups. All patients with uncomplicated sacrococcygeal disease, localised in the midline and with only 1 fistulous orifice. The patients were randomly assigned to the phenolization group (PhG) or conventional-surgery group (CsG). Both groups were managed without admission. The main endpoint was the recurrence of sacrococcygeal disease. Secondary endpoints included time of sick leave, complications, and readmission. 124 patients were included in the study. No disease recurrence was observed in either group. Clinical follow-up was carried out with a mean of 493.8 days (SD 6.59). The LSL was shorter in the PhG (mean 19.63 days, SD 28.15) than in the CSG (43.95 days, SD 38.60). The LSL reduction was -24.31 days (P .002). The phenolization in selected SPD is a safe and feasible procedure in selected patients. This approach could become the standard of care for patients with selected Sacrococcygeal pilonidal.

Protective properties of grape-seed proanthocyanidins in human ex vivo acute colonic dysfunction induced by dextran sodium sulfate.

PURPOSE: Anti-inflammatory and barrier-protective properties have been attributed to proanthocyanidins in the context of intestinal dysfunction, however little information is available about the impact of these phytochemicals on intestinal barrier integrity and immune response in the human. Here we assessed the putative protective properties of a grape-seed proanthocyanidin extract (GSPE) against dextran sodium sulfate (DSS)-induced acute dysfunction of the human colon in an Ussing chamber system. METHODS: Human proximal and distal colon tissues from colectomized patients were submitted ex vivo for a 30-min preventive GSPE treatment (50 or 200 µg mL-1) followed by 1-h incubation with DSS (12% w v-1). Transepithelial electrical resistance (TEER), permeation of a fluorescently-labeled dextran (FD4) and proinflammatory cytokine release [tumor necrosis factor (TNF)-α and interleukin (IL)-1ß] of colonic tissues were determined. RESULTS: DSS reduced TEER (45-52%) in both the proximal and distal colon; however, significant increments in FD4 permeation (fourfold) and TNF-α release (61%) were observed only in the proximal colon. The preventive GSPE treatment decreased DSS-induced TEER loss (20-32%), FD4 permeation (66-73%) and TNF-α release (22-33%) of the proximal colon dose-dependently. The distal colon was not responsive to the preventive treatment but showed a reduction in IL-1ß release below basal levels with the highest GSPE concentration. CONCLUSIONS: Our results demonstrate potential preventive effects of GSPE on human colon dysfunction. Further studies are required to test whether administering GSPE could be a complementary therapeutic approach in colonic dysfunction associated with metabolic disorders and inflammatory bowel disease.

Transanal endoscopic surgery with total wall excision is required with rectal adenomas due to the high frequency of adenocarcinoma.

BACKGROUND: Colorectal adenomatous polyps are considered premalignant lesions, although a high percentage are already malignant at the time of their removal. Full-thickness excision in patients with adenoma detected in preoperative biopsy enables much more accurate pathology examination and has shown that local surgery is appropriate for T1 adenocarcinoma. OBJECTIVE: To determine whether full-thickness excision during transanal endoscopic surgery is the treatment of choice for rectal adenoma, and to identify possible predictors of invasive adenocarcinoma associated with this type of lesion. DESIGN: Prospective, observational study. SETTING: The study was conducted at a university teaching hospital. PATIENTS: All patients scheduled for transanal endoscopic surgery after detection of adenoma in a preoperative biopsy between June 2004 and February 2013 entered the study. MAIN OUTCOME MEASURES: The principal variable was the presence of invasive adenocarcinoma in the pathology study. Other study variables were the epidemiological variables sex and age; the clinical variables tumor size, number of quadrants affected, distance from the anal verge, and tumor location; and the morphological variables tumor aspect, degree of dysplasia, preoperative biopsy (tubulo-villous), endorectal ultrasound, and pelvic MRI stage. Variables found to be related to the risk of malignancy in rectal adenomas were evaluated using univariate and multivariate analysis. RESULTS: Of 471 patients who underwent surgery, 277 had a preoperative diagnosis of adenoma. Final pathology studies showed 52 (18.8%) invasive adenocarcinomas, among which 27 were pT1 (52%), 16 pT2 (30.7%), and 9 pT3 (17.3%). Factors predictive of invasive adenocarcinoma were sessile morphology (OR 3.2, 95%CI 1.4-7.1), high-grade dysplasia (OR 2.3, 95%CI 1.2-4.8), and endorectal ultrasound stage uT2-T3 (OR 3.8, 95%CI 1.6-9). LIMITATIONS: The limitations are derived from the observational design. CONCLUSIONS: In this sample, half of the adenocarcinomas from adenomas were T1 adenocarcinomas. Because a high proportion of rectal adenomas are, in fact, invasive adenocarcinomas, full-thickness excision is appropriate.

Transanal endoscopic microsurgery with 3-D (TEM) or high-definition 2-D transanal endoscopic operation (TEO) for rectal tumors. A prospective, randomized clinical trial.

PURPOSE: Transanal endoscopic microsurgery (TEM) is a three-dimensional viewing endoscopic system procedure which provides access to rectal tumors through a rectoscope. Two-dimensional transanal endoscopic operation (TEO), with the introduction of high-definition vision, achieves results that are comparable to those of the classical TEM. The main aim of the study was to compare the effectiveness of TEO and TEM systems in a prospective, randomized clinical trial. STUDY POPULATION: patients meeting inclusion criteria for diagnosis of rectal tumors with curative intent. Sample size, 36 patients. Patients were randomized to receive one of the two procedures. Study variables recorded were the following: preoperative data (time taken to assemble equipment, surgical time, quality of pneumorectum), postoperative morbidity and mortality, pathology study of the tumors, and economic analysis. RESULTS: Thirty-six patients were analyzed according to intention to treat. Two patients were excluded. The final per-protocol analysis was 34 patients. There were no significant differences in the preoperative or operative variables, quality of pneumorectum, postoperative variables, or pathology results. A trend toward benefit was observed in favor of TEO in time required for assembly, surgical suture time, and total surgical time though the differences were not statistically significant. Statistically significant differences were found in terms of the total cost of the procedure, with mean costs of 2,031 ± 440 for TEO and 2,603 ± 507 for TEM (95% CI 218.15-926.486 , p = 0.003). CONCLUSION: No technical or clinical differences were observed between the results obtained with the two systems except lower cost with TEO.

Simultaneous Treatment of Complex Incisional Hernia and Stoma Reversal.

Purpose: The simultaneous repair of incisional hernias (IH) and the reconstruction of the intestinal transit may pose a challenge for many surgeons. Collaboration between units specialized in abdominal wall and colorectal surgery can favor simultaneous treatment. Methods: Descriptive study of patients undergoing simultaneous surgery of complex IH repair and intestinal transit reconstruction from the start of treatment in a joint team. All interventions were performed electively and with the collaboration of surgeons experts in abdominal wall and colorectal surgery. Results: 23 patients are included. 11 end colostomies, 1 loop colostomy, 6 end ileostomies and 5 loop ileostomies. Seven (30%) patients presented with a medial laparotomy incisional hernia, 3 (13%) with a parastomal incisional hernia, and 13 (56%) with a medial and parastomal incisional hernia. Closure of the hernial defect was achieved in 100% of cases, and reconstruction of the intestinal tract was achieved in 22 (95%). Component separation was required in 17 patients (74%), which were 11 (48%) posterior and 6 (26%) anterior. In-hospital morbidity was 9%, and only two patients presented Clavien-Dindo morbidity > III when requiring reoperation, one due to hemorrhage of the surgical bed and another due to dehiscence of the coloproctostomy. The mean follow-up was 11 months, with 20 (87%) patients having no complications. Mesh had to be removed in one patient with anastomotic dehiscence, no mesh had to be removed due to surgical site infection.

[Intra-abdominal desmoid tumor mimicking a pancreatic tumor in a patient with familial colonic polyposis]. / Tumor desmoide intraabdominal simulando una tumoración pancreática en una paciente con poliposis colónica familiar.

INTRODUCTION: Fibromatosis consists of a benign fibroblastic proliferation with local infiltrative growth. Two types are recognized: a superficial and a deep form, also known as desmoid tumor. The latter may occur sporadically or in association with familial adenomatous polyposis and Gardner's syndrome. Pancreatic presentation is exceptional and only eight cases have been described in the literature. CASE REPORT: We report the case of a 29-year-old woman with a history of familial colonic polyposis and two pancreatic lesions. In the surgical specimen, two poorly defined pancreatic lesions were observed with infiltration of neighboring organs. Histologically, the lesions corresponded to mesenchymal proliferation with a fusocellular pattern without cytological atypica, which were diagnosed as desmoid tumors. DISCUSSION: The etiology of fibromatosis is unknown. In patients with familial colonic polyposis, the most common localization of desmoid tumor is intra-abdominal. Pancreatic presentation is unusual, requiring differential diagnosis with other pancreatic neoplasms.

Evaluation of the impact of preoperative education in ambulatory laparoscopic cholecystectomy. A prospective, double-blind randomized trial. / Valoración del impacto de la educación preoperatoria en la colecistectomía laparoscópica ambulatoria. Ensayo prospectivo aleatorizado doble ciego.

INTRODUCTION: Outpatient laparoscopic cholecystectomy is a safe procedure and provides a better use of health resources and perceived satisfaction without affecting quality of care. Preoperative education has shown less postoperative stress, pain and nausea in some interventions. The principal objective of this study is to assess the impact of preoperative education on postoperative pain in patients undergoing ambulatory laparoscopic cholecystectomy. Secondary objectives were: to evaluate presence of nausea, morbidity, hospital admissions, readmissions rate, quality of life and satisfaction. METHODS: Prospective, randomized, and double blind study. Between April 2014 and May 2016, 62 patients underwent outpatient laparoscopic cholecystectomy. INCLUSION CRITERIA: ASA I-II, age 18-75, outpatient surgery criteria, abdominal ultrasonography with cholelithiasis. Patient randomization in two groups, group A: intensified preoperative education and group B: control. RESULTS: Sixty-two patients included, 44 women (71%), 18 men (29%), mean age 46,8 years (20-69). Mean BMI 27,5. Outpatient rate 92%. Five cases required admission, two due to nausea. Pain scores obtained using a VAS was at 24-hour, 2,9 in group A and 2,7 in group B. There were no severe complications or readmissions. Results of satisfaction and quality of life scores were similar for both groups. CONCLUSIONS: We did not find differences due to intensive preoperative education. However, we think that a correct information protocol should be integrated into the patient's preoperative preparation. Registered in ISRCTN number ISRCTN83787412.

Retracted: Impact on quality of life of using an onlay mesh to prevent incisional hernia in midline laparotomy: a randomized clinical trial.

BACKGROUND: Recent studies have demonstrated the effectiveness of using prophylactic meshes to achieve abdominal wall closure, decreasing the risk of incisional hernia. However, the effect of prophylactic mesh placement on a patient's quality of life has not yet been evaluated. STUDY DESIGN: A controlled, prospective, randomized, and blind study was carried out. The patients in group A (mesh) were fitted with a polypropylene mesh to reinforce the standard abdominal wall closure. The patients in group B (nonmesh) were given a standard abdominal wall closure and were not fitted with the mesh. All patients were administered the 36-Item Short-Form generic health questionnaire during their preoperation visit and during their 1-month, 6-month, and 1-year follow-up appointments. The scores of the questionnaires have been compared with those recorded when the questionnaire was administered before surgery. RESULTS: The Kaplan-Meier survival curves show that the likelihood of incisional hernia at 12 months is 1.5% in mesh group compared with 35.9% in nonmesh group (p > 0.0001), which means that the differences are statistically significant. Patients with mesh placement had greater improvement in general health and bodily pain than patients in nonmesh group at 1-month and 6-month post operation. One year after operation, patients in the mesh group had statistically significant better quality of life than patients in the nonmesh group in the physical functioning, general health perceptions, vitality, social role functioning, mental health, physical component summary and mental component summary dimensions. CONCLUSIONS: Fitting a prophylactic supra-aponeurotic mesh prevents incisional hernia.

Transanal endoscopic surgery in rectal cancer.

Total mesorectal excision (TME) is the standard treatment for rectal cancer, but complications are frequent and rates of morbidity, mortality and genitourinary alterations are high. Transanal endoscopic microsurgery (TEM) allows preservation of the anal sphincters and, via its vision system through a rectoscope, allows access to rectal tumors located as far as 20 cm from the anal verge. The capacity of local surgery to cure rectal cancer depends on the risk of lymph node invasion. This means that correct preoperative staging of the rectal tumor is necessary. Currently, local surgery is indicated for rectal adenomas and adenocarcinomas invading the submucosa, but not beyond (T1). Here we describe the standard technique for TEM, the different types of equipment used, and the technical limitations of this approach. TEM to remove rectal adenoma should be performed in the same way as if the lesion were an adenocarcinoma, due to the high percentage of infiltrating adenocarcinomas in these lesions. In spite of the generally good results with T1, some authors have published surprisingly high recurrence rates; this is due to the existence of two types of lesions, tumors with good and poor prognosis, divided according to histological and surgical factors. The standard treatment for rectal adenocarcinoma T2N0M0 is TME without adjuvant therapy. In this type of adenocarcinoma, local surgery obtains the best results when complete pathological response has been achieved with previous chemoradiotherapy. The results with chemoradiotherapy and TEM are encouraging, but the scientific evidence remains limited at present.