Model for predicting early and late-onset postoperative pulmonary complications in perioperative patients receiving neuromuscular blockade: a secondary analysis.

Pulmonary complications continue to be the most common adverse event after surgery. The main objective was to carry out two independent predictive models, both for early pulmonary complications in the Post-Anesthesia Care Unit and late-onset pulmonary complications after 30 postoperative days. The secondary objective was to determine whether presenting early complications subsequently causes patients to have other late-onset events. This is a secondary analysis of a cohort study. 714 patients were divided into four groups depending on the neuromuscular blocking agent, and spontaneous or pharmacological reversal. Incidence of late-onset complications if we have not previously had any early complications was 4.96%. If the patient has previously had early complications the incidence of late-onset complications was 22.02%. If airway obstruction occurs, the risk of atelectasis increased from 6.88 to 22.58% (p = 0.002). If hypoxemia occurs, the incidence increased from 5.82 to 21.79% (p < 0.001). Based on our predictive models, we conclude that diabetes mellitus and preoperative anemia are two risk factors for early and late-onset postoperative pulmonary complications, respectively. Hypoxemia and airway obstruction in Post-Anesthesia Care Unit increased four times the risk of the development of pneumonia and atelectasis at 30 postoperative days.

Laparoscopic surgery in 3D improves results and surgeon convenience in sleeve gastrectomy for morbid obesity.

PURPOSE: Advanced laparoscopic procedures are still challenging. One critical issue is the lack of stereoscopic vision. The aim of this surgical study is to evaluate whether 3D vision offers any advantages for surgical performance over 2D vision during sleeve gastrectomy for morbid obesity using a laparoscopic system that allows changing between 2D and 3D optics. METHODS: A total of 78 patients were analyzed, with 37 in the 2D group and 41 in the 3D group. Performance time, hospital stay, complications, and early outcomes were collected. To assess the quality of the 2D and 3D techniques, visual analog scales from 0 to 10 were designed, and image quality, depth of field, precision in performing tasks, and general ergonomics were measured. RESULTS: According to the vision system used, the mean duration of surgery was 85 ± 16.8 min for patients operated on with the 2D system and 69 ± 16.9 min for those operated on with the 3D system. There were no significant differences between the overall percentages of complications according to the type of vision used. However, postoperative complications were more severe in the 2D laparoscopy group. The average length of stay was shorter for patients in the 3D group. Regarding the differences perceived by the surgeon, the depth of field and the precision of tasks were better in the 3D vision group. CONCLUSION: The 3D system provided greater depth perception and precision in more complex tasks, enabling safer surgery. This led to a reduction in the operative time and hospital stay. Moreover, the severity of complications was less.

Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. OBJECTIVE: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. METHODS: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. RESULTS: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. CONCLUSION: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project. / Consenso multidisciplinar sobre la terapia nutricional y metabólica en los programas de recuperación intensificada en cirugía abdominal: Proyecto NutRICA.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. OBJECTIVE: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. METHODS: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. RESULTS: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. CONCLUSION: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

Enhanced Recovery After Emergency Surgery: Utopia or Reality? / Rehabilitación multimodal en cirugía de urgencias: ¿utopía o realidad?

Enhanced Recovery After Surgery (ERAS) constitutes the application of a series of perioperative measures based on the evidence, in order to achieve a better recovery of the patient and a decrease of the complications and the mortality. These ERAS programs initially proved their advantages in the field of colorectal surgery being progressively adopted by other surgical areas within the general surgery and other surgical specialties. The main excluding factor for the application of such programs has been the urgent clinical presentation, which has caused that despite the large volume of existing literature on ERAS in elective surgery, there are few studies that have investigated the effectiveness of these programs in surgical patients in emergencies. The aim of this article is to show ERAS measures currently available according to the existing evidence for emergency surgery.

¿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.

A Narrative Review About Prehabilitation in Surgery: Current Situation and Future Perspectives. / Revisión narrativa de la prehabilitación en cirugía: situación actual y perspectivas futuras.

Prehabilitation has a multimodal conception based on three fundamental pillars: improvement of the patient's physical condition, nutritional optimization and cognitive intervention to reduce stress and anxiety, as well as other measures such as smoking cessation and correction of anemia. The aim of prehabilitation programs is to optimize the patient from the moment of diagnosis until the surgical intervention in order to reduce postoperative complications. As in the case of multimodal rehabilitation protocols, the actions of prehabilitation programs have synergistic effects, that is, small changes that, by themselves, do not have clinical significance but when added up, they produce a significant improvement in the postoperative evolution of patients. Although more studies are required to evaluate the impact of these programs on patients groups with different pathologies, interventions and risk factors, their progressive implementation is necessary in the daily clinical practice of our patients. The objective of this narrative review is to evaluate the available evidence about prehabilitation in surgery, focusing on current established strategies, knowledge gaps and future research.

Analysis of the postoperative hemostatic profile of colorectal cancer patients subjected to liver metastasis resection surgery.

BACKGROUND: Liver resection surgery has advanced greatly in recent years, and the adoption of fasttrack programs has yielded good results. Combination anesthesia (general anesthesia associated to epidural analgesia) is an anesthetic-analgesic strategy commonly used for the perioperative management of patients undergoing surgery of this kind, though there is controversy regarding the coagulation alterations it may cause and which can favor the development of spinal hematomas. AIM: To study the postoperative course of liver resection surgery, an analysis was made of the outcomes of liver resection surgery due to colorectal cancer metastases in our centre in terms of morbiditymortality and hospital stay according to the anesthetic technique used (general vs combination anesthesia). METHODS: A prospective study was made of 61 colorectal cancer patients undergoing surgery due to liver metastases under general and combination anesthesia between January 2014 and October 2015. The patient characteristics, intraoperative variables, postoperative complications, evolution of hemostatic parameters, and stay in intensive care and in hospital were analyzed. RESULTS: A total of 61 patients were included in two homogeneous groups: general anesthesia (n = 30) and combination anesthesia (general anesthesia associated to epidural analgesia) (n = 31). All patients had normal coagulation values before surgery. The international normalized ratio (INR) in both the general and combination anesthesia groups reached maximum values at 2448 h (mean 1.37 and 1.45 vs 1.39 and 1.41, respectively), followed by a gradual decrease. There was less intraoperative bleeding in the combination anesthesia group (769 mL) than in the general anesthesia group (1200 mL) (P < 0.05). Of the 61 patients, 38.8% in the general anesthesia group experienced some respiratory complication vs 6.6% in the combination anesthesia group (P < 0.001). The time to gastrointestinal tolerance was significantly correlated to the type of anesthesia, though not so the stay in critical care or the time to hospital discharge. CONCLUSION: Epidural analgesia in liver resection surgery was seen to be safe, with good results in terms of pain control and respiratory complications, and with no associated increase in complications secondary to altered hemostasis.

Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery: a single center cohort study / Aceleração da recuperação após protocolo cirúrgico versus cuidados perioperatórios convencionais em cirurgia colorretal: um estudo de coorte em centro único

Abstract Background Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. Methods Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. Results There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p = 0.009); and severe complications (15.5% vs. 5.3%; p < 0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p = 0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p = 0.154), or readmission (6.39% vs. 4.39%; p = 0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. Conclusions The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay.

Resumo Justificativa O protocolo ERAS - do Inglês Enhanced Recovery After Surgery - consiste em um conjunto de medidas perioperatórias destinadas a melhorar a recuperação do paciente e diminuir o tempo de internação e as complicações pós-operatórias. Avaliamos a implantação e os resultados de um protocolo ERAS para cirurgia colorretal. Métodos Estudo observacional em centro único. Os dados foram coletados de pacientes consecutivos submetidos à cirurgia colorretal aberta ou laparoscópica durante dois períodos: três anos antes (pré-ERAS) e dois anos após (pós-ERAS) a implantação de um protocolo ERAS. As características basais de ambos os grupos foram comparadas. O desfecho primário foi o número de pacientes com 180 dias de acompanhamento com complicações moderadas ou graves. Os desfechos secundários foram tempo de internação pós-cirurgia e complicações específicas. Os dados foram extraídos de prontuários dos pacientes. Resultados O grupo pré-ERAS foi composto por 360 pacientes e o grupo pós-ERAS por 319. No grupo pré ERAS, 214 pacientes (59,8%) desenvolveram pelo menos uma complicação versus 163 (51,10%) no grupo pós-ERAS. Um número maior de pacientes do grupo pré-ERAS desenvolveu complicações moderadas ou graves (31,9% vs. 22,26%, p = 0,009); e complicações graves (15,5% vs. 5,3%; p < 0,0001). A mediana do tempo de internação foi de 13 (17) dias no grupo pré-ERAS e de 11 (10) dias no grupo pós-ERAS (p = 0,034). Não houve diferença nas taxas de mortalidade (4,7% vs. 2,5%; p = 0,1554) ou de reinternação (6,39% vs. 4,39%; p = 0,31). A conformidade geral do protocolo ERAS na coorte pós-ERAS foi de 88%. Conclusões A implantação do protocolo ERAS para cirurgia colorretal foi associada a uma redução significativa das complicações pós-operatórias e do tempo de internação.

[Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study]. / Aceleração da recuperação após protocolo cirúrgico versus cuidados perioperatórios convencionais em cirurgia colorretal. Um estudo de coorte em centro único.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. METHODS: Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. RESULTS: There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p=0.009); and severe complications (15.5% vs. 5.3%; p<0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p=0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p=0.154), or readmission (6.39% vs. 4.39%; p=0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. CONCLUSIONS: The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay.

Enhanced recovery after esophageal resection. / Rehabilitación multimodal en la cirugía resectiva del esófago.

ERAS is a multimodal perioperative care program which replaces traditional practices concerning analgesia, intravenous fluids, nutrition, mobilization as well as a number of other perioperative items, whose implementation is supported by evidence-based best practices. According to the RICA guidelines published in 2015, a review of the literature and the consensus established at a multidisciplinary meeting in 2015, we present a protocol that contains the basic procedures of an ERAS pathway for resective esophageal surgery. The measures involved in this ERAS pathway are structured into 3areas: preoperative, perioperative and postoperative. The consensus document integrates all the analyzed items in a unique time chart. ERAS programs in esophageal resection surgery can reduce postoperative morbidity, mortality, hospitalization and hospital costs.

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.

Enhanced recovery after surgery in gastric resections. / Rehabilitación multimodal en la cirugía de resección gástrica.

INTRODUCTION: Enhanced recovery after surgery is a modality of perioperative management with the purpose of improving results and providing a faster recovery of patients. This kind of protocol has been applied frequently in colorectal surgery, presenting less available experience and evidence in gastric surgery. METHODS: According to the RICA guidelines published in 2015, a review of the bibliography and the consensus established in a multidisciplinary meeting in Zaragoza on the 9th of October 2015, we present a protocol that contains the basic procedures of fast-track for resective gastric surgery. RESULTS: The measures to be applied are divided in a preoperative, perioperative and postoperative stage. This document provides recommendations concerning the appropriate information, limited fasting and administration of carbohydrate drinks 2hours before surgery, specialized anesthetic strategies, minimal invasive surgery, no routine use of drainages and tubes, mobilization and early oral tolerance during the immediate postoperative period, as well as criteria for discharge. CONCLUSIONS: The application of a protocol of enhanced recovery after surgery in resective gastric surgery can improve and accelerate the functional recovery of our patients, requiring an appropriate multidisciplinary coordination, the evaluation of obtained results with the application of these measures and the investigation of controversial topics about which we currently have limited evidence.

[Prevalence of anal diseases after Scopinaro's biliopancreatic bypass for super-obese patients]. / Prevalencia de afección anal en el paciente superobeso mórbido tras bypass biliopancreático de Scopinaro.

INTRODUCTION: Biliopancreatic diversion by Scopinaro (BD) is a mixed (malabsortive and restrictive) bariatric technique that is successful in achieving long lasting weight lost in super obese patients. In fact, the diarrhoea (steatorrhea) that is expected after any malabsortive technique can sometimes cause significant nutritional changes and anal disease: these patients are frequently referred to our coloproctology outpatient clinic due to haemorrhoids, fissures, anal sepsis and fistula basically due to changes in quality and quantity of their faeces. The aim of this paper is to find out not only the prevalence of anal disease in our series of super obese surgical patients but also to compare the incidence between the two surgical techniques we perform in our department. MATERIAL AND METHOD: We analyzed 263 consecutive patients operated on BD of Scopinaro (50-200 cm) and modified-BD (75-225 cm) in our Department. Patients who had previously suffered from anal surgery were excluded. RESULTS: There were 45 patients (18%) who suffered from anal problems of which 38 cases (84.4%) were BD-S and only 7 cases with BD-M complained of anal disorders (p < 0.05). Overall, at the 18th month review, the mean number of motions per day was 3.5 (range, 1-15). Patients with BD-S had 5 motions per day as a mean. The mean number of motions for BD-M was 2. The frequency order of anal pathology observed was: anal fissure, haemorrhoids, abscess and fistula. CONCLUSIONS: Higher incidence of anal pathology after BD of Scopinaro is another factor to take into account to avoid performing classic Scopinaro BD as opposed to modified BD for the treatment of morbid super obesity. It is mandatory to be conservative when facing anal problems in these patients, and firstly we must modify eating habits and the nutritional status. Surgery must be highly respectful to anal sphincters to avoid incontinence.

[Local recurrence in colon and rectal cancer]. / Recidiva local en el cáncer de colon y recto.

Data on the incidence of colorectal cancer are alarming and reveal that it is currently the second cause of death from cancer. Most of these deaths are due to recurrence after surgery with curative intent. The factors associated with locoregional recurrence are mainly related to the tumor's histopathological characteristics and grade of invasion. With adequate training the surgeon should not appear among these factors. In rectal cancer this training involves the technique of mesorectal excision, adequate circumferential margin and selective neoadjuvant chemoradiotherapy. After curative resection, patients should be followed-up to detect asymptomatic recurrence. Isolated local recurrence occurs in 20-30% of patients, but even with liver or lung metastases curative surgery can be attempted and success depends on correct multidisciplinary preoperative evaluation. If the diagnosis is made when the tumor is in an incurable phase, the aim is to improve the patient's quality of life.