Complications from the primary tumour are not related with survival in patients with synchronous stage IV colorectal cancer receiving chemotherapy without primary tumour resection.

BACKGROUND: The aim of this study was to evaluate the rate of complications from the primary tumour (CPT) requiring surgical or endoscopic intervention during chemotherapy treatment in patients with incurable synchronous stage IV colorectal cancer, the possibility of predicting such complications and their influence on survival. METHODS: One hundred and twenty-five patients were initially treated with chemotherapy. Patients were grouped on the basis of appearance or not of CPT. We assessed the relation between age, gender, carcinoembryonic antigen (CEA) level, primary tumour location, alkaline phosphatase level, unilobar or bilobar liver involvement, presence of peritoneal carcinomatosis, the number of sites of metastatic disease, the addition of target therapies to chemotherapy, the ability to traverse the tumour with an endoscope and the appearance of complications due to the primary tumour and overall survival. RESULTS: Mean age was 64.9 years, and 89 patients were men. Over a mean of 234 days, 25 patients (20 %) developed a CPT. Eighteen patients required surgery, and seven were treated exclusively by an endoscopic procedure. Mean survival was 15.8 months. We found a statistically relevant correlation between the inability to traverse the tumour with an endoscope and the occurrence of a CPT. There was no statistical differences in survival between both groups, but patients receiving target therapies had better survival. CONCLUSION: Twenty percent of patients will suffer a CPT during chemotherapy treatment. The inability to pass the tumour with an endoscope can predict the CPT. Survival was only related to the addition of target therapies to chemotherapy.

Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial).

OBJECTIVE: We compare the results of 2 different strategies for the management of patients with uncomplicated left colonic diverticulitis and to analyze differences in quality of life and economic costs. BACKGROUND: The most frequent standard management of acute uncomplicated diverticulitis still is hospital admission both in Europe and United States. METHODS: This multicenter, randomized controlled trial included patients older than 18 years with acute uncomplicated diverticulitis. All the patients underwent abdominal computed tomography. There were 2 strategies of management: hospitalization (group 1) and outpatient (group 2). The first dose of antibiotic was given intravenously to all patients in the emergency department and then group 1 patients were hospitalized whereas patients in group 2 were discharged. The primary end point was the treatment failure rate of the outpatient protocol and need for hospital admission. The secondary end points included quality-of-life assessment and evaluation of costs. RESULTS: A total of 132 patients were randomized: 4 patients in group 1 and 3 patients in group 2 presented treatment failure without differences between the groups (P=0.619). The overall health care cost per episode was 3 times lower in group 2, with savings of €1124.70 per patient. No differences were observed between the groups in terms of quality of life. CONCLUSIONS: Outpatient treatment is safe and effective in selected patients with uncomplicated acute diverticulitis. Outpatient treatment allows important costs saving to the health systems without negative influence on the quality of life of patients with uncomplicated diverticulitis. Trial registration ID: EudraCT number 2008-008452-17.

Functional outcome of sacral nerve stimulation in patients with severe constipation.

BACKGROUND: Sacral nerve stimulation has been reported as an effective treatment for constipation. OBJECTIVE: This study aimed to evaluate the therapeutic efficacy of permanent sacral nerve stimulation on the treatment of idiopathic constipation resistant to medical and behavioral management over a median follow-up period of 25.6 (range, 6-96) months. DESIGN: A retrospective review of a prospectively maintained institutional review board-approved database was performed. SETTING: The study was performed at 2 tertiary-care European institutions with expertise in sacral nerve stimulation. PATIENTS: Patients were considered eligible if they had had symptoms for at least 1 year and if conservative treatment had failed. INTERVENTION: Patients were tested by percutaneous nerve evaluation before the procedure. If this evaluation was successful, patients underwent sacral nerve therapy with an implanted device. MAIN OUTCOME MEASURE: Patients were evaluated by means of a bowel function diary and the Wexner constipation score. RESULTS: A total of 48 consecutive patients (39 females, median age 50.0 years (range, 17-79 years) entered the study. Twenty-three patients were implanted with a permanent stimulator. On an intention-to-treat basis, only 14 of 48 patients (29.2%) met the definition of a successful outcome at the latest follow-up period (median, 25.6 (range, 6-96) months). The mean Wexner score decreased from 20.2 (SD 3.6) at baseline to 5.8 (SD 4.1) at the latest follow-up examination (p < 0.001). However, 6 of 14 patients (42.8%) were still using laxatives and/or enemas at the last follow-up. LIMITATIONS: The study was limited by the pragmatic approach necessary to evaluate the results in routine clinical practice. CONCLUSIONS: This study shows that sacral nerve stimulation has limited efficacy on an intention-to-treat basis as a routinely recommended therapy for intractable idiopathic constipation.

Comparative study of one-stage colectomy of the descending colon in emergency and elective surgery without mechanical preparation.

PURPOSE: The aim of this study was to compare one-stage colectomy of the descending colon without mechanical preparation in emergency and elective surgery. METHODS: From January 2004 to September 2009, 327 consecutive patients underwent surgery in a coloproctology unit for several conditions of the descending colon, 122 on an emergency basis and 205 as elective surgery. In the emergency surgery group, patients with septic shock, multiorgan failure, immunodeficiency or corticoid treatment, ASA IV stage, generalized fecal peritonitis (Hinchey IV stage), nonviable cecum or unresectable tumors were excluded (n = 54). In the elective surgery group, patients who underwent intraoperative colonoscopy, total abdominal colectomy, or an ostomy were excluded (n = 59). In the remaining 214 patients, a colectomy of the descending colon with primary colorectal anastomosis was performed without mechanical bowel preparation, 68 in emergency surgery and 146 in elective surgery. The end points of the study were mortality, anastomotic dehiscence, and surgical site infection. RESULTS: No differences were found in mortality (0 in the emergency group vs 3 (2%) in the elective group; P = .571), symptomatic anastomotic dehiscence (1 in the emergency group (1.4%) vs 4 in the elective group (2.7%); P = 1.000), or surgical site infection (7 (10.2%) in the emergency group vs 8 (5.4%) in the elective group; P = .250). CONCLUSIONS: In emergencies involving the descending colon one-stage surgery may be performed without colonic preparation as safely as elective surgery in selected patients considered suitable for segmental resection of the descending colon and primary anastomosis.

[Incidence of psychiatric disorders in patients with fecal incontinence]. / Incidencia de problemas psiquiátricos en pacientes con incontinencia fecal.

OBJECTIVE: To evaluate the presence of psychiatric alterations in patients with fecal incontinence. PATIENTS AND METHOD: Eighty consecutive patients (67 women) with fecal incontinence were evaluated. All the patients completed the the specific GHQ-28 questionnaire to evaluate psychiatric symptoms. The questionnaire had previously been validated in the Spanish language. A score equal to or higher than 6 points was considered to indicate pathology. Incontinence was evaluated by the Cleveland Clinic Florida-Fecal Incontinence severity score (range 0 - 20). Psychiatric antecedents prior to fecal incontinence were recorded. RESULTS: Thirty-two patients (40%) had pathological scores on the GHQ-28 questionnaire (mean 13.59, range: 7-26). The mean Cleveland score was 11.52 (range: 2-20). Patients with pathological GHQ-28 scores had higher fecal incontinence scores (14.28 vs 9.68; p < 0.0001). A significant lineal correlation was found between GHQ-28 scores and the severity of fecal incontinence (p < 0.0001). Psychiatric antecedents were found in 17 patients (21.3%). In these patients no correlation was found between GHQ-28 score and the severity of incontinence. In the subgroup of patients without psychiatric antecedents this correlation was maintained (p < 0.003). Of these, 20 (31.7%) had pathologic scores on the GHQ-28, and the mean incontinence severity score was significantly higher than that of those with a normal GHQ-28 score (13.15 vs. 9.25; p < 0.004). CONCLUSIONS: The prevalence of psychiatric alterations is high in patients with fecal incontinence and is correlated with its severity. Patients with psychiatric antecedents can bias evaluation of the association between psychiatric alterations and the severity of fecal incontinence.

[Introduction of laparoscopy in the treatment of rectal cancer in a coloproctology unit]. / Introducción de la laparoscopia en el tratamiento del cáncer de recto en una unidad de coloproctología.

INTRODUCTION: The application of the laparoscopic approach to the treatment of rectal cancer is controversial. The aim of the present study was to evaluate whether the introduction of this technique in a coloproctology unit modified the quality of rectal cancer surgery. MATERIAL AND METHOD: We performed a prospective, nonrandomized study of all patients with rectal cancer who underwent surgery with curative intent in 2003 and 2004. Patients with stage T4 tumors were excluded. Of the 59 patients included, 33 underwent laparoscopic surgery and 26 underwent open surgery. A series of intraoperative and postoperative variables and characteristics of the surgical specimen were compared between the two groups. RESULTS: No differences were found between the two groups in the type of intervention performed or in the rate of sphincter preservation. Overall morbidity was 39% in the laparoscopic group and 34% in the open surgery group (NS). Anastomotic dehiscence was 9.5% and 5.8% respectively (NS). The length of hospital stay was similar in both groups. The distal margin was adequate in all patients. The circumferential resection margin was positive (< 1 mm) in 10.7% of patients in the laparoscopic group who underwent total mesorectal excision and in 13.6% of those in the open surgery group (NS). The mean number of isolated nodes was 12.5 in the laparoscopic group and 15.5 in the open surgery group (NS). CONCLUSION: The introduction of the laparoscopic approach in the treatment of rectal cancer in our unit has not lowered surgical quality, as measured by clinical and histopathological variables.

[The surgical treatment of hemorrhoids]. / Tratamiento quirúrgico de las hemorroides.

Surgery is the most effective treatment in patients with symptomatic grade III-IV hemorrhoids who have not responded to outpatient treatment, when there is associated abnormalities (anal fissure, anal fistula, skin tags) and in thrombosed hemorrhoids. Hemorrhoidectomy is currently the "gold standard" treatment. Randomized controlled trials comparing open with closed hemorrhoidectomy show no significant differences in pain scores. Stapled hemorrhoidectomy produces less postoperative pain than hemorrhoidectomy but is less effective in terms of symptom control. No treatment is superior to others in reducing postoperative pain except the use of drugs and anesthetic techniques. In patients with prolapsed internal hemorrhoids and thrombosed hemorrhoids, treatment may initially consist of an urgent hemorrhoidectomy with the same results as those obtained with elective surgery.

Nonobstructive dysphagia and recovery of motor disorder after antireflux surgery.

BACKGROUND: Changes in motor disorder after Nissen 360 degrees surgery were studied based on clinical signs of preoperative nonobstructive dysphagia. MATERIALS AND METHODS: Forty-seven patients undergoing Nissen 360 degrees fundoplication for gastroesophageal reflux were studied with pH recording and esophageal manometry before and 1 year after fundoplication. Amplitude of contraction of the distal third of the esophagus (ACDTE) and the presence of primary propulsive waves were studied. RESULTS: Fourteen patients had clinical signs of preoperative dysphagia. Of these, 50% had an ACDTE lower than 30 mm Hg, and 71.4% nonpropulsive waves (P <0.05). Forty-three percent and 30%, respectively, of patients with dysphagia recovered ACDTE and the presence of primary propulsive waves 1 year after the procedure, as compared with 66.6% (P <0.05) and 81.8% (P <0.01%) of patients without dysphagia. CONCLUSIONS: A correlation was found between preoperative dysphagia and esophageal motility disorders (P <0.05). One year after fundoplication, recovery was significantly higher in patients without preoperative dysphagia.