Surgical treatment for colorectal cancer: analysis of the influence of an enhanced recovery programme on long-term oncological outcomes-a study protocol for a prospective, multicentre, observational cohort study.

INTRODUCTION: The evidence currently available from enhanced recovery after surgery (ERAS) programmes concerns their benefits in the immediate postoperative period, but there is still very little evidence as to whether their correct implementation benefits patients in the long term. The working hypothesis here is that, due to the lower response to surgical aggression and lower rates of postoperative complications, ERAS protocols can reduce colorectal cancer-related mortality. The main objective of this study is to analyse the impact of an ERAS programme for colorectal cancer on 5-year survival. As secondary objectives, we propose to analyse the weight of each of the predefined items in the oncological results as well as the quality of life. METHODS AND ANALYSIS: A multicentre prospective cohort study was conducted in patients older than 18 years of age who are scheduled to undergo surgery for colorectal cancer. The study involved 12 hospitals with an implemented enhanced recovery protocol according to the guidelines published by the Spanish National Health Service. The intervention group includes patients with a minimum implementation level of 70%, and the control group includes those who fail to reach this level. Compliance will be studied using 18 key performance indicators, and the results will be analysed using cancer survival indicators, including overall survival, cancer-specific survival and relapse-free survival. The time to recurrence, perioperative morbidity and mortality, hospital stay and quality of life will also be studied, the latter using the validated EuroQol Five questionnaire. The propensity index method will be used to create comparable treatment and control groups, and a multivariate regression will be used to study each variable. The Kaplan-Meier estimator will be used to estimate survival and the log-rank test to make comparisons. A p value of less than 0.05 (two-tailed) will be considered to be significant. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the Aragon Ethical Committee (C.P.-C.I. PI20/086) on 4 March 2020. The findings of this study will be submitted to peer-reviewed journals (BMJ Open, JAMA Surgery, Annals of Surgery, British Journal of Surgery). Abstracts will be submitted to relevant national and international meetings. TRIAL REGISTRATION NUMBER: NCT04305314.

¿Podemos prevenir la dehiscencia anastomótica en cirugía oncológica colorrectal mediante el empleo de la angiografía de fluorescencia con verde de indocianina? / Could we pevent anastomotic leak in colorectal oncological surgery by using indocyanine green fluorescence angiography?

Resumen Objetivo La dehiscencia anastomótica (DA) en cirugía colorrectal es una de las complicaciones más devastadoras. El empleo de la angiografía de fluorescencia con verde de indocianina, se ha introducido en este campo como una herramienta prometedora para reducir la incidencia de DA. El objetivo de este estudio es valorar en nuestro medio, los resultados de la introducción de esta técnica en cuanto a prevención de DA. Materiales y Método: Se llevó a cabo un estudio prospectivo, incluyendo 59 pacientes sometidos a cirugía colorrectal resectiva a los que se les realizó una evaluación mediante angiografía con verde de indocianina intraoperatoria de la vascularización anastomótica. Resultados: Tras la aplicación de la técnica, se modificó el punto de sección en 9 pacientes (15,25%); en los cuales no se registró ninguna DA. La tasa de complicaciones global fue de 35,59% (n = 21) objetivando 3 dehiscencias anastomóticas en la serie. Conclusión: Esta técnica se perfila como una estrategia adicional en la prevención de la aparición de DA. Serán necesarios estudios randomizados con inclusión de mayor número de pacientes para obtener resultados concluyentes.

Aim: Anastomotic leakage (AL) following colorectal surgery is one of the most devastating complication. The use of indocyanine green fluorescence angiography has been developed as a promising tool to reduce the incidence of AL. The aim of this study is to evaluate the impact of this technique on the prevention of AL. Materials and Method: A prospective study was carried out, including 59 patients undergoing resective colorectal surgery. It was performed intraoperatively indocyanine green angiography evaluation of the anastomotic perfusión in all of then. Results: The section point was modified in 9 patients (15.25%); in which no AL was registered. The overall complication rate was 35.59% (n = 21), founding 3 anastomotic dehiscences in the serie. Conclusion: In conclusion, in our experience this technique is an additional strategy in the prevention of the AL. Randomized control trial including more patients will be necessary to obtain conclusive results.

Colorectal surgery and surgical site infection: is a change of attitude necessary?

INTRODUCTION: Surgical site infection (SSI) can be as high as 30% in patients undergoing colorectal surgery and is associated with an increase in morbidity and mortality. The aim of this study is to evaluate the impact of a set of simple preventive measures that have resulted in a reduction in surgical site infection in colorectal surgery. APPLIED METHOD: Prospective study with two groups of patients treated in the colorectal unit of the "Clinico Universitario Lozano Blesa" hospital in Zaragoza. One group was subject to our measures from February to May 2015. The control group was given conventional treatment within a time period of 3 months before the set of measures were implemented. RESULTS: One hundred forty-nine patients underwent a major colorectal surgical procedure. Seventy (47%) belonged to the control group and were compared to the remaining 79 patients (53% of the total), who were subject to our treatment bundle in the period tested. Comparing the two groups revealed that our set of measures led to a general reduction in SSI (31.4 vs. 13.6%, p = 0.010) and in superficial site infection (17.1 vs. 2.5%, p = 0.002). As a consequence, the postoperative hospital stay was shortened (10.0 vs. 8.0 days, p = 0.048). However, it did not, the number of readmissions nor the re-operation rate. SSI was clearly related to open surgery. CONCLUSIONS: The preventive set of measures applied in colorectal surgery led to a significant reduction of the SSI and of the length of hospital stay.

Tratamiento de la base apendicular por laparoscopia mediante el uso de endograpadoras: análisis de nuestros resultados / Appendicular stump laparoscopic management: our results analysis

Objetivo: El objetivo de este estudio es analizar los resultados de nuestro centro en cuanto al cierre del muñón apendicular en la apendicectomía laparoscópica, mediante el empleo de endograpadora. Material y método: Análisis retrospectivo de las apendicectomías laparoscópicas con sección de la base apendicular con endograpadora, llevadas a cabo entre enero de 2013 y marzo de 2015, recogiendo variables demográficas, clínicas y de técnica quirúrgica. Resultados: Se incluyeron en el análisis 238 pacientes. Se registraron complicaciones en 41 pacientes, con una tasa de reingreso del 5% y un 2,5% de pacientes reintervenidos. La estancia media posquirúrgica fue de 3,64 días. Discusión y conclusiones: En el cierre del muñón apendicular, la endograpadora se presenta como una técnica adecuada en cuanto a estancia postoperatoria y complicaciones posquirúrgicas. A pesar de las ventajas de su uso, debe valorarse en apendicectomías no complicadas el empleo de otras técnicas como endoloops.

Objective: The objective of this study is to analyse the results in our centre as regards the closure of the appendix stump in laparoscopic appendectomy using an endo-stapler. Material and methods: A retrospective analysis, collecting the demographic, clinical, and surgical technique variables, was conducted on laparoscopic appendectomies with section of the appendix base with an endo-stapler performed between January 2013 and March 2015. Results: A total of 239 patients were included in the analysis. Complications were recorded in 41 patients, with a re-admission rate of 5%, and 2.5% of patients received further surgery. The mean post-surgical stay was 3.64 days. Discussion and conclusions: The endo-stapler is a suitable technique in the closure of the appendix stump, as regards post-surgical hospital stay and complications. Despite the advantages of its use, the employment of other techniques, such as endo-loops, should be evaluated in non-complicated appendectomies.

Fascitis necrosante clostridial asociada a neoplasia colónica perforada: importancia de un diagnóstico precoz / Necrotizing fasciitis following colon neoplasm perforation: the clue of an early detection

Introducción: La gangrena espontánea por Clostridium septicum es una entidad poco frecuente con una alta mortalidad que se asocia a pacientes neoplásicos y/o inmunodeprimidos. Caso clínico: Presentamos un caso de gangrena clostridial en un paciente con neoplasia de colon ascendente perforada a retroperitoneo. Discusión-conclusiones: Aunque es poco común deberemos pensar en una infección clostridial en pacientes sépticos y sospecha de neoplasia colónica. En ausencia de diagnóstico y tratamiento precoz, el pronóstico es fatal.

Introduction: Spontaneous gangrene due to Clostridium septicum is a low frequency pathology with a high mortality rate. It is related to neoplasic and/or immunodeficient patients. Case report: We present the case of a patient who presented clostridial gangrene associated with a perforated colon neoplasm. Discussion-conclusions: Although it is not very common it must supposed a clostridial infection in septic patients with colon neoplasm suspect. If diagnosis and treatment are delayed the prognostic of the patient is fatal.

[Devastating surgical complications after aflibercept chemotherapy]. / Devastadora complicación tras tratamiento con aflibercept.

BACKGROUND: The use of a new chemotherapy as adjuvant treatment of colorectal cancer is not free of complications. Monoclonal antibodies are associated with bleeding and intestinal perforations. OBJECTIVE: To report the case of a patient who developed a serious complication after treatment with an antiangiogenic drug for colorectal neoplasm. CLINICAL CASE: The case is presented of a 42-year-old male operated on due to subocclusive rectal cancer with metástasis at the time of diagnosis. Sixteen months after surgery during second-line adjuvant therapy, an intestinal perforation was observed with haemorrhage and intestinal leak to retroperitoneum and left lower extremity. Despite intensive medical and surgical treatment this complication had fatal consequences. CONCLUSIONS: Future research should be directed at obtaining biomarkers for the specific use of antiangiogenic agents in order to decrease the rate of adverse factors.

Apendicitis y parásitos: a propósito de 2 casos / Appendicitis and parasites: Reporting of 2 cases

Objetivo: Enfatizar la importancia de sospechar esta etiología en la patogenia de la apendicitis aguda, especialmente en pacientes procedentes de países endémicos. Casos clínicos: Presentamos dos casos, con cursos clínicos divergentes.

Aim: We would like to emphasize the importance of having a high grade of suspect about the parasitic etiology of appendicitis acute, especially in patients from endemic countries. Case report: We present two cases with divergent clinical evolution.

[Retropneumoperitoneum due to endoscopic dilation. Is conservative management possible?]. / Retroneumoperitoneo secundario a dilatación endoscópica de anastomosis colorrectal: ¿permite un manejo conservador?

BACKGROUND: The incidence of anastomotic stricture varies due to the different definitions given to the condition. In most cases they are asymptomatic, and if there are symptoms, they are usually those of a partial intestinal obstruction. CASE REPORT: The case is presented of an 80 year old patient who underwent a lower anterior resection for rectal neoplasm. After ileostomy closure, he presented with subocclusive symptoms caused by stenosis of colorectal anastomosis. This stenosis was managed with endoscopic dilations, and one of these dilations produced an anastomotic perforation with pneumoperitoneum, retropneumoperitoneum, and pneumothorax. Once the patient was clinically and haemodynamically stable, the perforation was treated with conservative measures, resolving the complication satisfactorily. CONCLUSIONS: The literature describes several management options for colorectal anastomoses strictures, such as surgical resection, rubber dilators, endoscopic dilation, all of which might produce colonic perforation. Its management ranges from conservative measures to surgical intervention.

[Breast metastases]. / Metástasis en mama.

Metastases in the breast resulting from extra-mammary tumours are infrequent, and the prognosis is poor. The main challenge in diagnosis is to differentiate between this condition and that of primary breast cancer so as to avoid unnecessary surgery. We present two cases that we encountered recently.

Functional brain study of chronic traumatic head injury

Explosive aggressive behaviour is a significant clinical and medico-legal problem in patients suffering from head injury. However, experts in neuropsychiatry have proposed a specific category for this disorder: the "organic aggressive syndrome:". The basic reason for proposing this diagnosis is that it describes the specificity of the violent conduct secondary to "brain damage" with greater precision. Early diagnosis and treatment of the injury is critical. The impact of hnetium-99m-hexamethylpropuleneamine oxime (HMPAO) was examined for measuring brain damage in correlation to neuropsychological performance in patients with traumatic brain injury (TBI). We thus report the case of a twelve-year-old child with a history of CET, who presents with serious episodes of heteroaggressiveness and suggest the usefulness of single photon emission computerized tomography (SPECT) to establish the validity of this psychiatric diagnosis. The appearance of modern functional neuro-image techniques (SPECT) may help to increase the validity of clinical diagnoses in the field of psychiatry in general and of forensic psychiatry in particularly, as the related findings may be used as demarcation criteria to establish syndromic diagnoses

Asociación de atrofia medial del lóbulo temporal en TC e hipocaptación temporoparietal mediante SPECT / Association between medial temporal lobe atrophy on ct and parietotemporal uptake decrease on SPECT to the study of cognitive impairment and depressive symptoms

La tomografía computarizada (TC) y la resonancia magnética (RM) cerebrales aportan a la evaluación diagnóstica del paciente con depresión y deterioro cognoscitiva significativo una excelente información anatómica, mientras la tomografía computarizada de emisión de fotón único (SPECT cerebral), permite obtener una información funcional a través de la medición del flujo sanguíneo cerebral regional (FSCr). Objetivo: Evaluar la validez de la combinación de atrofia del lóbulo medial temporal e hipocaptación temporoparietal al diagnóstico de demencia degenerativa primaria, así como su capacidad para discriminar entre demencia degenerativa primaria y depresión. Material: 23 pacientes, 9 hombres (39,1 por ciento) y 14 mujeres (60,9 por ciento), edad media de 61 años, con el diagnóstico de depresión y deterioro cognoscitivo significativo sin cumplir criterios de demencia, según códigos diagnósticos GMS-HAS y DSM-IV. 10 individuos sanos, de similares características sociodemograficas y sin historia anterior de trastorno psiquiátrico, neurológico ni abuso de drogas. Métodos: se ha realizado sistemáticamente tomografía axial computarizada (TC) y por emisión de fotón único (SPECT) cerebrales en sujetos mayores de 65 años con un MEC <24 y menores de 65 años con un MEC > 27. Resultados: se han establecido 6 patrones de perfusión cerebral para el grupo de pacientes El más frecuentemente observado fue el patrón C (39,13 por ciento), hipoperfusión temporal y/o parietal bilateral. Conclusiones: