A teaching project on rectal cancer and concentration of procedures: a comparison of oncological results between Catalonia and the rest of autonomous communities.

INTRODUCTION: the goal of this study was to compare the oncological results (local recurrence, metastasis and overall survival) obtained by the Proyecto Docente del Cáncer de Recto of the Spanish Association of Surgeons (AEC) (Proyecto Vikingo, PV) in Catalonia versus the rest of Spanish autonomous communities. METHODS: the PV database includes 4,508 patients who underwent a curative resection between March 2006 and December 2010, from the first 59 hospitals included in PV; 1,163 were from Catalonia and 3,345 were from the rest of Spain. There was a minimum follow-up of five years. RESULTS: in Catalonia, the five-year cumulative incidence was 8% (95% CI: 6.4-9.9) for local recurrence, 17.7% (95% CI: 15.4-20.2) for metastasis and 75% (95% CI: 72.4-77.7) for overall survival. In the rest of autonomous communities, these figures were 7% (95% CI: 6.2-8.2) for local recurrence, 22.3% (95% CI: 20.7-23.9) for metastasis, and 71% (95% CI: 69.4-72.9) for overall survival. Variables associated with tumor recurrence in PV included Hartmann's procedure, intraoperative perforation and circumferential margin involvement. CONCLUSION: the results obtained by the Proyecto Docente del Cáncer de Recto were homogeneous between Catalonia and the rest of the autonomous communities.

Complicated diverticular disease: Position statement on outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage and laparoscopic approach. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Section of the Spanish Association of Surgeons. / Enfermedad diverticular complicada: toma de posición sobre tratamiento ambulatorio, intervención de Hartmann, lavado-drenaje peritoneal y cirugía laparoscópica. Documento de consenso de la Asociación Española de Coloproctología y Sección de Coloproctología de la Asociación Española de Cirujanos.

The Spanish Association of Coloproctology (AECP) and the Coloproctology Section of the Spanish Association of Surgeons (AEC), propose this consensus document about complicated diverticular disease that could be used for decision-making. Outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage, and the role of a laparoscopic approach in colonic resection are exposed.

Oncological results of the educational Rectal Cancer Project in Spain 10 years after its implementation. / Resultados oncológicos del Proyecto docente del Cáncer de Recto en España 10 años después de su inicio.

INTRODUCTION: The objective of this observational, prospective, multicenter and multilevel study was to evaluate the oncological outcomes (local recurrence, metastasis and overall survival) of the Rectal Cancer Project of the Spanish Association of Surgeons (AEC) 10 years after its initiation, comparing the results with Scandinavian registries. METHODS: The AEC teaching project database includes 17,620 patients to date, of which 4,508 were operated on with a potentially curative resection between March 2006 and December 2010. All of them come from the first 59 hospitals included in the project, and therefore followed for at least 5 years, and are the subject of the present study. RESULTS: The cumulative incidence of local recurrence was 7.3 (95% CI: 8.2-6.5), metastasis 21.0 (CI 95%: 22.4-19.7) and overall survival 72.3 (CI 95%: 80.3-77.6). The multilevel regression analysis with the hospital variable as a random effect, showed a significant variation among the hospitals for the cancer outcome variables: general survival, local recurrence and metastasis (δ2=0.053). CONCLUSIONS: This study indicates that the results observed in the AEC' Rectal Cancer Project are inferior than those observed in the Scandinavian registries that we tried to emulate and that this is attributable to the variability of practice in some centers.

Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology.

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.

Basaloid large cell lung carcinoma presenting as cutaneous metastasis at the colostomy site after abdominoperineal resection for rectal carcinoma.

The occurrence of a tumor at the colostomy site after abdominoperineal resection for rectal carcinoma is rare and it may be related to a previously resected carcinoma or another primary tumor. We report a 61-year-old man who developed an ulcerated skin nodule at her colostomy site 6 years after resection of a rectal adenocarcinoma. Histopathologically, the skin nodule was composed of atypical large and pleomorphic cells with high mitotic rate and they were arranged in nests and within lymphatic channels in the dermis. The neoplastic cells were immunoreactive for cytokeratin (CK) AE1/3, CK7, CK34ßE12, epithelial membrane antigen and vimentin while detection of human papillomavirus and Epstein-Barr virus DNA was negative. A diagnosis of basaloid large cell carcinoma of pulmonary origin was suggested and it was confirmed by computed tomography-guided fine needle aspiration of a right subpleural mass. A metastatic tumor at the colostomy site is an exceptional finding and may be the first manifestation of lung cancer, especially if it consist of pleomorphic large cells with high mitotic rate and basaloid immunophenotype.

[Standardising sigmoidectomy by single umbilical incision]. / Estandarizando la sigmoidectomía por incisión umbilical única.

The increase in single-incision endoscopic surgery has led to more and more procedures and surgical groups who perform them. Segmental resection is the procedure most likely to benefit from this approach since it achieves a significant minimisation in the parietal access; with umbilical mini-laparotomy the entrance ports are grouped together and extraction of the piece and preparation of the anastomosis can be performed. Among the colorectal procedures, sigmoidectomy seems to be the most appropriate area to start using these techniques by groups with laparoscopic colorectal experience. Our aim is the standardisation of single-incision sigmoidectomy, analysing the process with the support of video sequences, and placing emphasis on the factors where it differs from conventional laparoscopy and on the key points in order to avoid problems during the execution of the process.

[Analysis of experience in the use of dynamic pelvic magnetic resonance imaging in the assessment of obstructive defaecation syndrome]. / Análisis de nuestra experiencia mediante el uso de resonancia magnética dinámica pelviana en la evaluación del síndrome de defecación obstructiva.

INTRODUCTION: The aetiological diagnosis of obstructive defaecation syndrome (ODS) requires, among others, imaging tests. The purpose of this study is to descriptively analyse and compare the findings of dynamic pelvic magnetic resonance imaging (DPMRI) with the clinical examinations in patients with ODS. MATERIAL AND METHODS: A prospective comparative study was made between the physical examination and the DPMRI, with a descriptive analysis of the results. A total of 30 patients were included (2 males and 28 females), with a median age of 60 (range 23-76) years, with symptoms of ODS. An anamnesis and detailed physical examination and a DPMRI were performed on all of them. Functional (anismus) and morphological changes (rectocele, enterocele, intussusception, etc.), were analysed. RESULTS: The physical examination did not detect anomalies in 6 (20%) patients. A rectocele was diagnosed in 21 (70%) of the cases, and 2 (6.7%) a rectal mucosal prolapse. The DPMRI showed evidence of pelvic floor laxity in 22 (73.3%) cases, an enterocele in 4 (13.3%), a sigmoidocele in 2 (6.7%), intussusception in 8 (26.7%), rectal mucosal prolapse in 4 (13.3%), anismus in 3 (10%), and a cystocele in 4 (13.3%). The rectocele was the most frequent diagnosis, being given in 26 (86.6%) patients. CONCLUSIONS: Magnetic resonance imaging provides an overall pelvic assessment with good definition of the tissues, and does not use ionising radiation, is well tolerated, and provides us with complementary information to arrive at the diagnosis, and establish the best treatment for ODS. Larger studies comparing videodefaecography (VD), currently considered the Gold Standard technique, are needed to be able to demonstrate whether it is superior or not to DPMRI.

Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer.

INTRODUCTION: Distance from anal verge of rectal tumours and their anatomical relationships contribute to determine the multidisciplinary therapeutic strategy based on the combination of radio-chemotherapy and radical surgery. Our aims are to investigate which is the most accurate method for the preoperative measuring of the distance from the anal verge in rectal tumours and if the pelvic MRI can substitute the classical instrumental methods. METHODS: Prospective study of diagnostic precision between flexible colonoscopy (FC), preoperative rigid rectosigmoidoscopy (pRR) and pelvic MRI in patients scheduled to radical surgery. Rigid intraoperative rectoscopy (iRR) was considered the reference test. The correlations between the different techniques and their determination coefficient as well as the intraclass correlation coefficient and the degree of agreement between the different tests were analyzed. RESULTS: 96 patients (65% males), mean age (SD): 68 (14.1) years were included. 72% received neoadjuvant treatment. The mean distance to the anal margin measured by FC = 103.5 mm, was significantly greater than others, which had similar values: pRR = 81.1; MRI = 77.4; iRR = 82.9 mm (P < .001). A significant intraclass correlation was observed and there was high agreement between all pre- and intraoperative measurements except for the performed by FC, which overestimated the results. MRI provided more individualized and accurate information. CONCLUSIONS: There is variability between the measurement methods, being colonoscopy the least reliable. MRI offers objective, comparable, accurate and individualized values that can replace those obtained by pRR for tumours of any location in the rectum.

LONG-TERM EVOLUTION OF CONTINENCE AND QUALITY OF LIFE AFTER SPHINCTEROPLASTY FOR OBSTETRIC FECAL INCONTINENCE.

PURPOSE: Evaluate the long-term evolution of continence and patient's quality of life after surgical treatment for obstetric fecal incontinence. METHODS: A prospective longitudinal study was conducted including consecutive patients who underwent sphincteroplasty for severe obstetric fecal incontinence. The first phase analyzed changes in continence and impact on quality of life. The second phase studied the long-term evolution reevaluating the same group of patients six years later. Degree of fecal incontinence was calculated using the Cleveland Clinic Score. Quality of life assessment was carried out with the Fecal Incontinence Quality of Life Scale. RESULTS: 35 patients with median age of 55 (range, 28-73) completed the study. Phase One Results: After a postoperative follow-up of 30 months (4-132), Cleveland Clinic Score had improved significantly from a preoperative of 15.7 ± 3.1 to 6.1 ± 5 (p <0.001). Phase Two Results: median follow-up in phase two was 110 months (76- 204). The Cleveland Clinic Score lowered to 8.4 ± 4.9 (p = 0.04). There were no significant differences between phases one and two in terms of quality of life: lifestyle (3.47 ± 0.75 vs. 3.16 ± 1.04), coping/behavior (3.13 ± 0.83 vs 2.80 ± 1.09), depression/self-perception (3.65 ± 0.80 vs 3.32 ± 0.98) and embarrassment (3.32 ± 0.9 vs 3.12 ± 1). CONCLUSION: Sphincteroplasty offers good short-medium term outcomes in continence and quality of life for obstetric fecal incontinence treatment. Functional clinical results deteriorate over time but did not impact on patients' quality of life.

Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer. / Validación de la resonancia magnética pélvica como método de elección para determinar la distancia al margen anal en el cáncer de recto.

INTRODUCTION: Distance from anal verge of rectal tumors and their anatomical relationships contribute to determine the multidisciplinary therapeutic strategy based on the combination of radio-chemotherapy and radical surgery. Our aims are to investigate which is the most accurate method for the preoperative measuring of the distance from the anal verge in rectal tumors and if the pelvic MRI can substitute the classical instrumental methods. METHODS: Prospective study of diagnostic precision between flexible colonoscopy (FC), preoperative rigid rectosigmoidoscopy (pRR) and pelvic MRI in patients scheduled to radical surgery. Rigid intraoperative rectoscopy (iRR) was considered the reference test. The correlations between the different techniques and their determination coefficient as well as the intraclass correlation coefficient and the degree of agreement between the different tests were analyzed. RESULTS: 96 patients (65% males), mean age (SD): 68 (14.1) years were included. 72% received neoadjuvant treatment. The mean distance to the anal margin measured by FC=103.5mm, was significantly greater than others, which had similar values: pRR=81.1; MRI=77.4; iRR=82.9mm (P<.001). A significant intraclass correlation was observed and there was high agreement between all pre- and intraoperative measurements except for the performed by FC, which overestimated the results. MRI provided more individualized and accurate information. CONCLUSIONS: There is variability between the measurement methods, being colonoscopy the least reliable. MRI offers objective, comparable, accurate and individualized values that can replace those obtained by pRR for tumors of any location in the rectum.