Learning curve and safety of the implementation of laparoscopic complete mesocolic excision with intracorporeal anastomosis for right-sided colon cancer: results from a propensity score-matched study.

BACKGROUND: Retrospective studies and randomized controlled trials support the safety of laparoscopic complete mesocolic excision (CME) for the treatment of right-sided colon cancer (RSCC). Few studies, however, examine the learning curve of this operation and its impact on safety during an implementation period. We aim to evaluate the learning curve and safety of the implementation of laparoscopic CME with intracorporeal anastomosis for RSCC. METHODS: Consecutive patients undergoing a laparoscopic right colectomy with intracorporeal anastomosis for RSCC between January 2016 and June 2023 were included. Clinical, perioperative, and histopathological variables were collected. Correlation and cumulative sum (CUSUM) analyses between the operating time and case number were performed. Breakpoints of the learning curve were estimated using the broken-line model. CME and conventional laparoscopic right colectomy outcomes were compared after propensity score matching (PSM). RESULTS: Two hundred and ninety patients underwent laparoscopic right colectomy during study period. One hundred and eight met inclusion criteria. After PSM, 56 non-CME and 28 CME patients were compared. CME group had a non-statistically significant tendency to a longer operating time (201 versus 195 min; p = 0.657) and a shorter hospital stay (3 versus 4 days; p = 0.279). No significant differences were found in total complication rates or their profile. Correlation analysis identified a significant trend toward operating time reduction with increasing case numbers (Pearson correlation coefficient = - 0.624; p = 0.001). According to the CUSUM analysis, an institutional learning curve was deemed completed after 13 cases and the broken-line model identified three phases: learning (1-6 cases), consolidation (7-13 cases), and mastery (after 13 cases). CONCLUSION: The learning curve of laparoscopic CME for RSCC can be achieved after 13 cases in centers with experience in advanced laparoscopic surgery and surgeons with familiarity with this technique. Its implementation within this setting seems to be as safe as performing a conventional right colectomy.

Resultados perioperatorios de la implementación de la resección completa del mesocolon por vía laparoscópica en cáncer de colon derecho y transverso

Introducción: La técnica de resección completa del mesocolon (RCM) en la hemicolectomía derecha consiste en la disección por planos embriológicos para lograr la resección completa del envoltorio mesocolónico, además de una ligadura vascular central (LVC) con linfadenectomía D3, que no se realiza normalmente con la técnica estándar. Esta técnica se asocia a mejores resultados de sobrevida global y libre de enfermedad que la cirugía convencional en trabajos retrospectivos. Sin embargo, no existen datos de su implementación a nivel nacional. El objetivo de este estudio es evaluar los resultados perioperatorios de la implementación del RCM en un centro universitario en nuestro medio. Materiales y Método: Estudio retrospectivo de cohorte de pacientes consecutivos sometidos a hemicolectomía derecha laparoscópica con técnica de RCM-LVC entre Enero 2022 y Junio 2023. Se recopilaron variables demográficas, perioperatorias, postoperatorias e histopatológicas. Los resultados se analizaron utilizando estadística descriptiva. Resultados: En el periodo, 29 pacientes se sometieron a RCM laparoscópica (mediana de edad 66(57-76) y 15(52%) sexo femenino). La mediana del tiempo quirúrgico fue 202,9 minutos. No hubo casos de conversión, filtración anastomótica, ni mortalidad. Hubo morbilidad en 9 casos (31%) y de estos solo 1(3,4%) fue Clavien-Dindo III (hematoma Pfannenstiel reintervenido). No hubo lesiones vasculares intraoperatorias. Mediana de hospitalización de 3 días. Doce casos (41%) eran etapa II y 8(28%) etapa III. La mediana de linfonodos resecados fue 23(18-28). Conclusión: Esta serie demuestra que la implementación de la RCM-LVC por vía laparoscópica para el tratamiento del cáncer de colon derecho y transverso es factible en centros con experiencia en cirugía colorrectal laparoscópica avanzada.

Introduction: Complete mesocolic excision (CME) consists in the dissection on embryologic planes in order to achieve a complete resection of the mesocolic envelope and performing a central vascular ligation (CVL) with a D3 lymphadenectomy which is not routinely done for standard right colectomies. CME has been associated with better overall survival and disease-free survival in comparison with conventional surgery in retrospective studies. However, there is no data on its implementation in Chile. The aim of this study is to assess the perioperative results of the implementation of CME in our center. Methods: A retrospective cohort study was conducted. Consecutive patients undergoing a laparoscopic right hemicolectomy with CME-CVL between January 2022 and June 2023 were included. Demographic, perioperative, postoperative and histopathological data were collected. Results were analyzed using descriptive statistics. Results: During the study period, 34 patients underwent CME; 29 of them underwent laparoscopic CMECVL (median age 66 (57-76) and 15 (52%) female). The median operating time was 202,9 minutes. There were no cases of conversion, anastomotic leakage or mortality. There was morbidity in 9 cases (31%) and one of these (3,4%) was a Clavien-Dindo III morbidity (reoperation due to a Pfannenstiel haematoma). There were no intraoperative vascular injuries. The median length of stay was 3 days. Twelve cases (41%) were stage II and 8(28%) stage III. The median number of lymph nodes harvested was 23(18-28). Conclusion: This series demonstrate that the implementation of laparoscopic CME-CVL for right and transverse colon cancer is feasible in centers with experience in advanced laparoscopic colorectal cancer.

Clinical features and prognosis of malignant small bowel tumors: Experience from a university hospital in Chile.

BACKGROUND: Small bowel tumors (SBT) are infrequent and represent a small proportion of digestive neoplasms. There is scarce information about SBT in Latin America. AIM: To describe the epidemiology, clinical characteristics, diagnostic methods, and survival of malignant SBTs. METHODS: Retrospective observational study of adult patients with histopathological diagnosis of SBT between 2007 and 2021 in a university hospital in Chile. RESULTS: A total of 104 patients [51.9% men; mean age 57 years] with SBT. Histological type: neuroendocrine tumor (NET) (43.7%, n=38), gastrointestinal stromal tumors (GIST) (21.8%, n=19), lymphoma (17.2%, n=15) and adenocarcinoma (AC) (11.5%, n=10). GIST was more frequent in duodenum (50%; n=12) and NET in the ileum (65.8%; n=25). Metastasis was observed in 17 cases, most commonly from colon and melanoma. Nausea and vomiting were significantly more often observed in AC (p=0.035), as well as gastrointestinal bleeding in GIST (p=0.007). The most common diagnostic tools were CT and CT enteroclysis with an elevated diagnostic yield (86% and 94% respectively). The 5-year survival of GIST, NET, lymphoma and AC were 94.7% (95%CI: 68.1-99.2), 82.2% (95%CI: 57.6-93.3), 40.0% (95%CI: 16.5-82.8) and 25.9% (95%CI: 4.5-55.7%), respectively. NET (HR 6.1; 95%CI: 2.1-17.2) and GIST (HR 24.4; 95%CI: 3.0-19.8) were independently associated with higher survival compared to AC, adjusted for age and sex. CONCLUSIONS: Malignant SBT are rare conditions and NETs are the most common histological subtype. Clinical presentation at diagnosis, location or complications may suggest a more probable diagnosis. GIST and NET are associated with better survival compared to other malignant subtypes.

¿Ha disminuido la colectomía por crisis de colitis ulcerosa?

Background: Treatment for moderate-severe active ulcerative colitis (UC) includes steroids, biologic therapy and total colectomy. Aim: To describe the features of patients with moderate to severe active UC, their hospital evolution and need for colectomy. Material and Methods: Non-concurrent cohort study of all patients admitted to our institution with a diagnosis of moderate or severe UC crisis between January 2008 and May 2019. Truelove Witts (TW) criteria were used to categorize disease severity. Twelve-month colectomy-free survival was estimated with Kaplan-Meier survival analysis. Results: One hundred-twenty patients aged 16 to 89 (median 35) years had 160 admissions for acute moderate to severe UC. Median admission per patient was 1 (1-3), and median hospital stay was six days (1-49). Cytomegalovirus and Clostridioides difficile were found in 17.5 and 14.2% of crises, respectively. Corticosteroids were used in all crises and biologic therapy in 6.9% of them. Emergency or elective colectomies were performed in 18.3 and 6.7% of patients, respectively. The need for emergency total colectomy decreased from 24.6 to 7.8% (Risk ratio 3.16, p < 0.01) between de first and second half of the study period. Kaplan-Meier analysis for long term colectomy-free survival in both periods confirmed this decrease (p < 0.01). Conclusions: Medical treatment for moderate to severe UC crises had a 86.3% success and a small percentage required emergency total colectomy. Emergency surgery decreased in the last decade.

Computed tomography-measured body composition parameters do not influence survival in non-metastatic colorectal cancer.

BACKGROUND: There is an increasing interest in studying the impact of altered body composition parameters and colorectal cancer (CRC) treatment outcomes. The aim of this study is to explore the impact of computed tomography (CT)-measured visceral obesity, sarcopenia and myosteatosis on survival of non-metastatic CRC. METHODS: Consecutive patients with stage I-III CRC who underwent curative-intent treatment between January 2010 and December 2015 were included. By measuring the visceral fat area, and the skeletal muscle index and radiodensity in the pre-operative staging CT, patients were classified as visceral obese, sarcopenic or myosteatotic. The associations between CT-based body composition parameters and survival were assessed using log-rank tests and a Cox regression analysis. RESULTS: Of 359 patients, 263 (73.3%) were visceral obese, 85 (23.7%) sarcopenic and 80 (22.3%) myosteatotic. Overall (OS), cancer-specific (CSS) and disease-free survivals (DFS) at 5 years were 78.8%, 84.7% and 75%, respectively. Myosteatosis and the combination of myosteatosis and visceral obesity were associated with a reduced DFS (hazard ratio 1.67; 95% confidence interval 1.06-2.61 and hazard ratio 1.85; 95% confidence interval 1.15-2.96, respectively). However, after performing a multivariate analysis including other relevant clinicopathological factors, none of the body composition parameters were associated with any long-term outcome measures, even after stratifying by cancer stage. CONCLUSIONS: CT-measured body composition parameters do not independently influence survival in non-metastatic CRC. There is a need for larger cohort studies with standardized patient selection and methodology to confirm these findings.

Telemedicine for postoperative follow-up, virtual surgical clinics during COVID-19 pandemic.

Recent coronavirus outbreak and "stay at home" policies have accelerated the implementation of virtual healthcare. Many surgery departments are implementing telemedicine to enhance remote perioperative care. However, concern still arises regarding the safety of this modality in postoperative follow-up after gastrointestinal surgery. The aim of the present prospective study is to compare the use of telemedicine clinics to in-person follow-up for postoperative care after gastrointestinal surgery during COVID-19 outbreak. METHODS: Prospective study that included all abdominal surgery patients operated since the COVID-19 outbreak. On discharge, patients were given the option to perform their postoperative follow-up appointment by telemedicine or by in-person clinics. Demographic, perioperative, and follow-up variables were analyzed. RESULTS: Among 219 patients who underwent abdominal surgery, 106 (48%) had their postoperative follow-up using telemedicine. There were no differences in age, gender, ASA score, and COVID-19 positive rate between groups. Patients who preferred telemedicine over in-person follow-up were more likely to have undergone laparoscopic surgery (71% vs. 51%, P = 0.037) and emergency surgery (55% vs. 41%; P = 0.038). Morbidity rate for telemedicine and in-person group was 5.7% and 8%, (P = 0.50). Only 2.8% of patients needed an in-person visit following the telemedicine consult, and 1.9% visited the emergency department. CONCLUSIONS: In the current pandemic, telemedicine follow-up can be safely and effectively performed in selected surgical patients. Patients who underwent laparoscopic and emergency procedures opted more for telemedicine than in-person follow-up.

Implementation of intracorporeal anastomosis in laparoscopic right colectomy is safe and associated with a shorter hospital stay.

Reconstruction after laparoscopic right colectomy (LRC) can be achieved by performing an intracorporeal (IA) or an extracorporeal anastomosis (EA). This study aims to assess the safety of implementing IA in LRC, and to compare its perioperative outcomes with EA during an institution's learning curve. Patients undergoing elective LRC with IA or EA in a teaching university hospital between January 2015 and December 2018 were included. Demographic, clinical, perioperative and histopathological data were collated and outcomes investigated. One hundred and twenty-two patients were included; forty-three (35.2%) had an IA. The main indication for surgery was cancer in both groups (83.7% for IA and 79.8% for EA; p = 0.50). Operative time was longer for IA (180 [150-205] versus 150 [120-180] minutes; p < 0.001). A Pfannenstiel incision was used as extraction site in 97.7% of patients receiving an IA; while a midline incision was used in 97.5% of patients having an EA (p < 0.001). Hospital stay was significantly shorter for IA (3 [3, 4] versus 4 [3-6] days; p = 0.003). There were no differences in postoperative complications rates between groups. There was a 4.7% and 3.8% anastomotic leak rate in the IA and EA group, respectively (p = 1). Re-intervention and readmission rates were similar between groups, and there was no mortality during the study period. The implementation of IA in LRC is safe. Despite longer operative times, IA is associated with a shorter hospital stay when compared to EA in the setting of an institution's learning curve.

[Treatment of a severe Clostridium difficile infection with colonic lavages. Report of one case]. / Ileostomía en asa derivativa y lavado colónico intraoperatorio como alternativa de tratamiento en un caso de colitis grave por Clostridium difficile.

A loop ileostomy with intraoperative anterograde colonic lavage has been described as an alternative to colectomy in the management of cases of Clostridium difficile infection refractory to medical treatment. We report a 69 years old diabetic women admitted with a septic shock. An abdominal CAT scan showed a pan-colitis that seemed to be infectious. A polymerase chain reaction was positive for Clostridium Difficile. Due to the failure to improve after full medical treatment, a derivative loop ileostomy and intra-operatory colonic lavage were performed, leaving a Foley catheter in the proximal colon. In the postoperative period, anterograde colonic instillations of Vancomycin flushes through the catheter were performed every 6 hours. Forty eight hours after surgery, the patient improved. A colonoscopy prior to discharge showed resolution of the pseudomembranous colitis.

Ileostomía en asa derivativa y lavado colónico intraoperatorio como alternativa de tratamiento en un caso de colitis grave por Clostridium difficile / Treatment of a severe Clostridium difficile infection with colonic lavages. Report of one case

A loop ileostomy with intraoperative anterograde colonic lavage has been described as an alternative to colectomy in the management of cases of Clostridium difficile infection refractory to medical treatment. We report a 69 years old diabetic women admitted with a septic shock. An abdominal CAT scan showed a pan-colitis that seemed to be infectious. A polymerase chain reaction was positive for Clostridium Difficile. Due to the failure to improve after full medical treatment, a derivative loop ileostomy and intra-operatory colonic lavage were performed, leaving a Foley catheter in the proximal colon. In the postoperative period, anterograde colonic instillations of Vancomycin flushes through the catheter were performed every 6 hours. Forty eight hours after surgery, the patient improved. A colonoscopy prior to discharge showed resolution of the pseudomembranous colitis.

[An elevated neutrophil/lymphocyte ratio is associated with poor prognosis in stage II resected colon cancer]. / Un índice neutrófilo/linfocito elevado se asocia a peor pronóstico en cáncer de colon etapa II resecado.

BACKGROUND: The neutrophil/lymphocyte ratio is an effective marker of inflammation ana can have prognostic value in surgical patients. AIM: To evaluate the effect of an increased neutrophil/lymphocyte ratio (NLR) on perioperative complications ana overall ana disease-free survival in patients undergoing elective resection for stage II colon cancer. MATERIAL AND METHODS: Data was obtained from clinical charts, preoperative blood results and hospital records of all patients undergoing an elective curative resection for colon cancer, between 2000 and 2007. Preoperative NLR was calculated. Follow-up was obtained from a prospectively maintained colorectal cancer database, clinical records and questionnaires. Uni and multivariable analysis were performed to identify associations, and survival analysis was performed using Kaplan-Meier curves. RESULTS: One hundred twenty two patients with a mean age of 69 years (52% males), were evaluated. Median follow-up was 73 months, and overall survival for 1 and 5 years was 95% and 68%, respectively. On a multivariable analysis after adjusting for age, sex, tumor depth invasion, use of adjuvant therapies and American Society of Anesthesiology preoperative risk score, an NLR > 5 was associated with an increased perioperative complication rate (odds ratio: 3.06, p = 0.033). Kaplan-Meier survival analysis showed a worse overall and disease-free survival for patients with NLR greater than five. CONCLUSIONS: A preoperative NLR of five or more is associated with greater perioperative morbidity and worse oncological outcomes in patients undergoing resection for elective stage II colon cancer.

Un índice neutrófilo/linfocito elevado se asocia a peor pronóstico en cancer de colon etapa II resecado / An elevated neutrophil/lymphocyte ratio is associated with poor prognosis in stage II resected colon cancer

Background: The neutrophil/lymphocyte ratio is an effective marker of inflammation ana can have prognostic value in surgical patients. Aim: To evaluate the effect of an increased neutrophil/lymphocyte ratio (NLR) on perioperative complications ana overall ana disease-free survival in patients undergoing elective resection for stage II colon cancer. Material and Methods: Data was obtained from clinical charts, preoperative blood results and hospital records of all patients undergoing an elective curative resection for colon cancer, between 2000 and 2007. Preoperative NLR was calculated. Follow-up was obtained from a prospectively maintained colorectal cancer database, clinical records and questionnaires. Uni and multivariable analysis were performed to identify associations, and survival analysis was performed using Kaplan-Meier curves. Results: One hundred twenty two patients with a mean age of69years (52% males), were evaluated. Median follow-up was 73 months, and overall survival for 1 and 5years was 95% and 68%, respectively. On a multivariable analysis after adjusting for age, sex, tumor depth invasion, use of adjuvant therapies and American Society of Anesthesiology preoperative risk score, an NLR > 5 was associated with an increased perioperative complication rate (odds ratio: 3,06, p = 0,033). Kaplan-Meier survival analysis showed a worse overall and disease-free survival for patients with NLR greater than five. Conclusions: A preoperative NLR of five or more is associated with greater perioperative morbidity and worse oncological outcomes in patients undergoing resection for elective stage II colon cancer.

[Perianal tuberculosis: report of two cases]. / Ulceración perianal: Dos casos de una rara manifestación de tuberculosis extrapulmonar.

Perianal tuberculosis is an uncommon variant of extra pulmonary tuberculosis and mimics other common perianal conditions. We report two patients with perianal tuberculosis. An 82-year-old male presenting with purulent perianal discharge and weight loss. A pelvic magnetic resonance imaging showed a low trans sphincteric anorectal fistula with abscess formation. A fistulectomy was performed and the pathological study showed a granulomatous-tuberculous chronic inflammation. Mycobacteria were recovered from gastric contents. A 48-year-old male with the same symptoms. An ulcerated lesion in the anal region was biopsied, disclosing a granulomatous inflammatory process with Ziehl-Nielsen stainable organisms.

[High risk febrile neutropenia in acute leukemia. The experience of a public hospital. National Program of Antineoplastic Drugs in Adult, Hospital del Salvador, 1991-2001]. / Neutropenia febril de alto riesgo en leucemia aguda. Experiencia en un hospital público. Programa Nacional de Drogas Antineoplásicas del Adulto (PANDA), Hospital del Salvador, 1991-2001.

BACKGROUND: Febrile neutropenia is one of the most important problems to face during the treatment of acute leukemia. AIM: To assess the results of a standardized protocol for the treatment of febrile neutropenia and compare it with a period in which treatment was not standardized. PATIENTS AND METHODS: One hundred and eight episodes of febrile neutropenia in 69 patients, treated with a standardized antimicrobial protocol between 1996 and 2001, were analyzed. The protocol consisted in the use of a combination of antimicrobial whose spectrum was broadened progressively according to the isolated microorganisms and the involved foci. These were compared with 83 episodes in 54 patients, treated without standardized protocols between 1990 and 1995. RESULTS: Both groups of patients were comparable. Their ages ranged from 15 to 65 years old. The male/female ratio was 1.3 and the lymphoblastic/myeloid leukemia ratio was 1.4. Sixty one percent of episodes occurred during induction chemotherapy and mean duration of neutropenia was 17 days. A clinically significant focus was identified in 72% of episodes and a microorganism was isolated blood culture in 35% of them. There was a predominance of gram negative organisms. The mortality decreased from 18 to 9% in the period 1996-2000 (p = 0.094). CONCLUSIONS: The use of a standardized antimicrobial protocol reduced the mortality in febrile neutropenia, even when colony stimulating factors and filtered air rooms are unavailable.