Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

AIM: The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. METHOD: Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. RESULTS: Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%). CONCLUSION: The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Face, Content, and Construct Validity Evaluation of Simulation Models in General Surgery Laparoscopic Training and Education: A Systematic Review.

BACKGROUND: Laparoscopic technical surgical skills (LTS) are considered a fundamental competence for General Surgery residents. Several simulation tools (ST) have been explored to develop LTS. Although a plethora of systematic reviews evaluate the translation of LTS developed in simulation to real surgery, there is a lack of evidence that clarifies effectiveness of different validated ST in acquisition of LTS in surgical residents. The aim of this systematic review (SR) is to summarize published evidence on ST validation used for surgery education and training. METHODS: A protocol was published in PROSPERO. A SR was carried out following PRISMA guidelines. Complete published articles in English or Spanish that validate either content or construct, plus another form of validation of ST to acquire LTS in general surgery were included. Articles that used only one validation or did not validate an ST were excluded. RESULTS: 1052 publications were initially identified across all searched databases. Title review identified 204 studies eligible for full text screening. 10 studies were included for final review. Two studies assessed both face and content, 4 face and construct, and 4 face, content and construct validity. None of the studies presented comparable outcomes due to metrics variation and scores used for the validation strategies. CONCLUSIONS: This study assessed validated laparoscopic simulation models, particularly in content and construct validity. Articles reported an increased use of simulation models in laparoscopic training with positive feedback from trainees, but few studies reported validation of training model. Validation strategies are not standardized, limiting comparability between them.

Clinical, Anatomical, and Pathological Grading Score to Predict Technical Difficulty in Laparoscopic Splenectomy for Non-traumatic Diseases.

BACKGROUND: We aimed to develop a grading system based on preoperative parameters that would predict surgical difficulty and morbidity in elective laparoscopic splenectomy. STUDY DESIGN: We retrospectively assessed morbidity in 439 patients who underwent laparoscopic splenectomy for benign and malignant disorders between 1993 and 2013. Medical and surgical records were reviewed and analyzed. We compared preoperative data concerning demographic, clinical, pathological, anatomical, laboratory, and radiological factors with three surgical outcomes: operative time, intraoperative bleeding, and surgical conversion. Univariate and multivariate analyses were performed to identify statistically significant variables. A logistic regression model was used to identify determinant variables and to compose a predictive score. External validation of the score was performed using an independent cohort of 353 patients. RESULTS: Four preoperative parameters (age, male sex, type of pathology, and spleen size based on final spleen weight) were significantly related with operative time, operative bleeding, and conversion to open surgery. Using these results, we developed a classification system with three levels of difficulty: low (≤4 points), medium (4.5-5.5 points), and high (≥6 points), based on the four preoperative parameters. The correlation was highly significant (p = <0.001) according to Spearman's correlation. The area under the ROC curve was 0.671 (95 % CI 0.596-0.745). The external validation showed significant correlations with the present model. CONCLUSIONS: The grading score described here is simple to calculate from the physical examination, laboratory tests, and US or CT images, and we believe it could be useful to preoperatively assess the technical complexity of laparoscopic splenectomy.

The role of sentinel lymph node in colon cancer evolution.

INTRODUCTION: The aim of this study is to evaluate the sentinel lymph node mapping (SLNM) with methylene blue staining "ex vivo" in colon cancer, as well as calculate the upstaging obtained by the determination of micrometastases and its correlation with the evolution of the disease. METHODS: Between 2008 and 2011, 101 patients with colon cancer undergoing resection were studied prospectively with SLNM and detection of micrometastases. The correlation of SLN micrometastases with the disease evolution was evaluated in patients with a follow-up of more than one year. RESULTS: The SLNM rate was 92 cases (91%). Only SLN was positive for micrometastases in 9 cases, with a 14% upstaging. The incidence of false negatives was 9 patients (10%). Mean follow of N0 patients (n=74) was 38 months. The SLN- (negative) group (65 patients) had a recurrence rate of 4 patients (7%), whereas this rate was 2 patients (22%) in the group of SLN+(positive) (9 patients), but without significant differences. No differences in survival were observed. CONCLUSIONS: SLNM is a reproducible technique without significant increase in time and costs. Upstaging was obtained in 14% of patients staged as N0 by conventional technique. At follow-up of N0 patients with SLN+there seems to be a higher rate of recurrence, which could change the guidelines of adjuvant treatment, but we must interpret the results it with caution because the sample is small.

Our experience in the short-term diagnostic-therapeutic management of the patient with anal dysplasia.

INTRODUCTION: Anal intraepithelial neoplasia (AIN) is a premalignant lesion of anal squamous cell carcinoma. HIV-positive males who have sex with males, are the most affected at-risk population. Cytology and anuscopy are the best accepted methods for its diagnosis, although it is controversial which patients should complete it with a biopsy. Neither which patients should undergo treatment nor which is the best treatment is not well established. With this study, we would like to present our experience in the diagnostic-therapeutic management of AIN in the short term. METHODS: Retrospective observational study of patients at risk of AIN with altered anal cytology who underwent high-resolution anuscopy with biopsy. After histological confirmation of dysplasia, they started treatment with trichloroacetic acid. Its effectiveness was verified by subsequent cytology. The demographic variables of the sample and the results of both diagnostic and treatment tests were analyzed. RESULTS: The majority were HIV-positive males (104/115) and 50% had sexual relations with other men. We included 115 patients with altered anal cytology, of whom 92% had dysplasia on biopsy. 97% with atypia of uncertain significance on cytology had histological dysplasia. Cytology normalized after treatment in 60% of patients. CONCLUSION: Early detection of AIN should be routinely considered in known at-risk populations. Any cytological abnormality should be biopsied. Tricholoroacetic acid can be an effective treatment achieving a high percentage of regression, although currently, the information we have is of low level of evidence.

[Single incision laparoscopic surgery: analysis of the national register]. / Cirugía laparoscópica a través de incisión única. análisis del registro nacional.

INTRODUCTION: Laparoscopic surgery through a single incision is an innovative concept which is a challenge for surgeons to implement and develop. The interest aroused by these techniques in Spain led to the Endoscopy Section of the Spanish Association of Surgeons (AEC) to start a National Register for Single-Incision Surgery (RNCIU). The aim of this study was to collect the primary clinical data, techniques, and the possible complications of these techniques in Spain. MATERIAL AND METHODS: Data were gathered using a form available on the AEC website. The forms included in this study correspond to those received between June 2010 and June 2011. RESULTS: A total of 35 centers had taken part during the study period, with 1,198 forms being collected. The surgeries performed included 62.2% cholecystectomies, 22% appendectomies, and 7.8% colectomies. Procedures on solid organs (3.4%), bariatric surgery (2.7%), and various hernia repairs (1.9%), were also registered. The overall incidence of complications was 0.8%. The mortality rate in the series was 0.1%. CONCLUSIONS: Single incision laparoscopic surgery is a novel concept that is not beyond our scientific community. The results of the Register demonstrate the feasibility of numerous effective and safe procedures. Finally, the RNCIU is an important data source to be able to study sub-groups of diseases in detail, with the aim of advancing the knowledge of these techniques and generating scientific evidence.