Standardisation of the definition of the types of oncological colectomy. Delphi method for consensus of experts of the Spanish association of surgeons.

There is no international consensus on the definition of the type of oncological resection that corresponds to each of the colectomies existing in the current literature. The objective is to define for each colectomy described in the literature: embryological dissection plane, vascular pedicles in which to perform central ligation, the extent of the colectomy, and the need for resection of the greater momentum. A consensus of experts is carried out through the Delphi methodology through two rounds from the Coloproctology Section of the Spanish Association of Surgeons. Study period: November 2021-January 2023. 120 experts were surveyed. Degrees of consensus: Very strong: >90%, Strong: 80-90%, Moderate: 50-80%, No consensus: <50%. The definition for each oncological colectomy was established by very strong, and strong recommendations. Each oncological colectomy was established as Right hemicolectomy (RHC), RHC with D3 lymphadenectomy, Extended-RHC, transverse colon segmental colectomy, splenic flexure segmental colectomy, subtotal colectomy, total colectomy, left hemicolectomy (LHC), extended-LHC, sigmoidectomy.

Chemoradiation, Consolidation Chemotherapy, and Watch and Wait for Early Rectal Cancer.

As watch and wait has become an attractive management alternative among patients with rectal cancer who achieve a clinical complete response to neoadjuvant chemoradiation, the focus of organ preservation has now shifted toward the use of this approach in patients with early rectal cancer. These patients would otherwise be treated without the use of neoadjuvant therapy for oncological reasons. The sole purpose of any neoadjuvant treatment here would be the achievement of a complete clinical response in an attempt to avoid total mesorectal excision. This has become particularly interesting after the incorporation of total neoadjuvant therapy regimens. These regimens have resulted in significantly higher rates of complete tumor regression and therefore become an interesting alternative among early rectal cancer patients where organ preservation is desired. The present review provides an overview of the currently available evidence and the preliminary experience with this rather controversial approach.

Local Excision for organ preservation in early REctal cancer with No Adjuvant treatment (LORENA Trial): prospective observational study protocol.

INTRODUCTION: Local resection (LR) is an alternative to total mesorectal excision (TME) that avoids its associated morbidity to the detriment of oncological radicality in early stages of rectal cancer. There are several conditioning factors for the success of this strategy, such as poor prognosis histological factors (PPHF), involvement of resection margins, clinical under staging, or complications that may lead to the indication for radical surgery with TME. PATIENTS AND METHOD: An international multicenter prospective observational open-label study has been designed. Consecutive patients diagnosed with early rectal cancer (cT1N0 on MRI +/- endorectal ultrasound) whose lower limit is a maximum of 2 cm proximal to the ano-rectal junction will be included. The primary objective of the study is to determine the overall prevalence of PPHF after LR and requiring TME or postoperative radio-chemotherapy. DISCUSSION: The prevalence of PPHF conditioning the success of LR in early distal rectal cancer has been scarcely studied in the literature, and there are very few prospective data. Considering the increasing interest in the watch and wait strategy in rectal cancer and its possible application in early-stage tumors, it seems necessary to know this information. The results of this study will help guide clinical practice in patients with early distal rectal cancer. It will also provide quality information for the design of future comparative studies to improve organ preservation success in these patients. TRIAL REGISTRATION NUMBER: NCT05927584.

National observational study about the surgical treatment of anal fistula: Does the kind of hospital modify the results?

INTRODUCTION: Performing the surgical procedure in a high-volume center has been seen to be important for some surgical procedures. However, this issue has not been studied for patients with an anal fistula (AF). MATERIAL AND METHODS: A retrospective multicentric study was performed including the patients who underwent AF surgery in 2019 in 56 Spanish hospitals. A univariate and multivariate analysis was performed to analyse the relationship between hospital volume and AF cure and fecal incontinence (FI). RESULTS: 1809 patients were include. Surgery was performed in a low, middle, and high-volume hospitals in 127 (7.0%), 571 (31.6%) y 1111 (61.4%) patients respectively. After a mean follow-up of 18.9 months 72.3% (1303) patients were cured and 132 (7.6%) developed FI. The percentage of patients cured was 74.8%, 75.8% and 70.3% (p = 0.045) for low, middle, and high-volume hospitals. Regarding FI, no statistically significant differences were observed depending on the hospital volume (4.8%, 8.0% and 7.7% respectively, p = 0.473). Multivariate analysis didnt observe a relationship between AF cure and FI. CONCLUSION: Cure and FI in patients who underwent AF surgery were independent from hospital volume.

The Use of Fissios App© as a Complement to a Face-to-Face Respiratory Physiotherapy Program versus an Attendance-Only Face-to-Face Physiotherapy Program in Patients Scheduled for Thoracic Surgical Procedures Reduces the Risk of Developing Postoperative Pulmonary Complications-A Quasi-Experimental Study.

Postoperative pulmonary complications (PPCs) increase the hospital length of stay (LOS) and the cost of healthcare associated with surgical procedures. Strategies to reduce PPCs begin before surgery and continue in the postoperative period. Fissios App© is a smartphone application that contains perioperative medical advice and a structured respiratory physiotherapy program. The objective was to implement the use of this app in a group of patients scheduled for a thoracic surgical procedure and determine its efficacy in reducing PPCs. This was a quasi-experimental study in which all patients attended a face-to-face respiratory physiotherapy program, and the intervention group used Fissios App© as a complement. We prospectively recorded the postoperative evolution of both groups, analyzed the categorical differences and quantitative variables, and created a binary logistic regression model. We recruited 393 patients (131 intervention and 262 control). The intervention group had a lower incidence of PPCs (12.2% versus 24% in the control group, p = 0.006), a shorter LOS (a median of 3 days (IQR = 2-5) versus 4 days (IQR = 3-6, p = 0.001) in the control group), and a reduction in the risk of developing PPCs by 63.5% (OR: 0.365, 95% CI: 0.17-0.78). The use of Fissios App© improved the clinical outcomes after surgery and reduced the probability of developing PPCs.

Diagnostic Accuracy of Abdominal CT for Locally Advanced Colon Tumors: Can We Really Entrust Certain Decisions to the Reliability of CT?

Many different options of neoadjuvant treatments for advanced colon cancer are emerging. An accurate preoperative staging is crucial to select the most appropriate treatment option. A retrospective study was carried out on a national series of operated patients with T4 tumors. Considering the anatomo-pathological analysis of the surgical specimen as the gold standard, a diagnostic accuracy study was carried out on the variables T and N staging and the presence of peritoneal metastases (M1c). The parameters calculated were sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios, as well as the overall accuracy. A total of 50 centers participated in the study in which 1950 patients were analyzed. The sensitivity of CT for correct staging of T4 colon tumors was 57%. Regarding N staging, the overall accuracy was 63%, with a sensitivity of 64% and a specificity of 62%; however, the positive and negative likelihood ratios were 1.7 and 0.58, respectively. For the diagnosis of peritoneal metastases, the accuracy was 94.8%, with a sensitivity of 40% and specificity of 98%; in the case of peritoneal metastases, the positive and negative likelihood ratios were 24.4 and 0.61, respectively. The diagnostic accuracy of CT in the setting of advanced colon cancer still has some shortcomings for accurate diagnosis of stage T4, correct classification of lymph nodes, and preoperative detection of peritoneal metastases.

FiLaC® procedure for highly selected anal fistula patients: indications, safety and efficacy from an observational study at a tertiary referral center.

BACKGROUND: the ideal clinical profile of patients or fistula features for fistula laser closure (FiLaC®) technique remain to be established. The aim of this study was to analyze clinical outcomes and the safety profile of FiLaC® in search for an ideal setting for this technique. METHODS: a retrospective observational study was performed from a prospective database including all consecutive patients who underwent surgery for anal fistula (AF) with FiLaC® in the coloproctology unit of a tertiary referral center, between October 2015 and December 2021. The FiLaC® procedure was offered to AF patients who were considered to be at risk of fecal incontinence. Fistulas were described according to Parks' classification and categorized as complex or simple according to the American Gastroenterological Association (AGA) guidelines. Healing was defined by the closure of the internal and external openings for at least six months. Predictive factors of AF healing were investigated. RESULTS: a total of 36 patients were included, with a mean age of 48 ± 13.9 years. Twenty patients (55.6 %) were male and 13 patients (36 %) had Crohn's disease (CD). Fourteen patients (38.8 %) had a complex fistula. The primary and secondary healing rates were 55.6 % and 91.7 %, respectively, during a median follow-up time of 12 months (IQR 7-29). No fecal continence impairment was registered in any case. The proportion of patients with primary healing was significantly higher in CD patients (76.9 % vs 43.5 %, p = 0.048). CONCLUSIONS: FiLaC® is a sphincter-preserving procedure with an excellent safety profile and reasonable success rate despite of the strict patient selection. This technique may be attractive for patients with CD due to its higher primary healing rate.

"Long-term oncologic outcomes and risk factors for distant recurrence after pathologic complete response following neoadjuvant treatment for locally advanced rectal cancer. A nationwide, multicentre study".

BACKGROUND: Pathologic complete response (pCR) after multimodal treatment for locally advanced rectal cancer (LARC) is used as surrogate marker of success as it is assumed to correlate with improved oncologic outcome. However, long-term oncologic data are scarce. METHODS: This retrospective, multicentre study updated the oncologic follow-up of prospectively collected data from the Spanish Rectal Cancer Project database. pCR was described as no evidence of tumour cells in the specimen. Endpoints were distant metastases-free survival (DMFS) and overall survival (OS). Multivariate regression analyses were run to identify factors associated with survival. RESULTS: Overall, 32 different hospitals were involved, providing data on 815 patients with pCR. At a median follow-up of 73.4 (IQR 57.7-99.5) months, distant metastases occurred in 6.4% of patients. Abdominoperineal excision (APE) (HR 2.2, 95%CI 1.2-4.1, p = 0.008) and elevated CEA levels (HR = 1.9, 95% CI 1.0-3.7, p = 0.049) were independent risk factors for distant recurrence. Age (years) (HR 1.1; 95%-CI 1.05-41.09; p < 0.001) and ASA III-IV (HR = 2.0; 95%-CI 1.4-2.9; p < 0.001), were the only factors associated with OS. The estimated 12, 36 and 60-months DMFS rates were 96.9%, 91.3%, and 86.8%. The estimated 12, 36 and 60-months OS rates were 99.1%, 94.9% and 89.3%. CONCLUSIONS: The incidence of metachronous distant metastases is low after pCR, with high rates of both DMFS and OS. The oncologic prognosis in LARC patients that achieve pCR after neoadjuvant chemo-radiotherapy is excellent in the long term.

Watch and Wait Approach for Rectal Cancer.

The administration of neoadjuvant chemoradiotherapy (nCRT) followed by total mesorrectal excision (TME) and selective use of adjuvant chemotherapy can still be considered the standard of care in locally advanced rectal cancer (LARC). However, avoiding sequelae of TME and entering a narrow follow-up program of watch and wait (W&W), in select cases that achieve a comparable clinical complete response (cCR) to nCRT, is now very attractive to both patients and clinicians. Many advances based on well-designed studies and long-term data coming from big multicenter cohorts have drawn some important conclusions and warnings regarding this strategy. In order to safely implement W&W, it is important consider proper selection of cases, best treatment options, surveillance strategy and the attitudes towards near complete responses or even tumor regrowth. The present review offers a comprehensive overview of W&W strategy from its origins to the most current literature, from a practical point of view focused on daily clinical practice, without losing sight of the most important future prospects in this area.

Treatment for acute uncomplicated diverticulitis without antibiotherapy: systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: Use of antibiotics in selected cases of acute uncomplicated diverticulitis (AUD) has recently been questioned. OBJECTIVE: The aim of this study is to examine the safety and efficacy of treatment regimens without antibiotics compared with that of traditional treatments with antibiotics in selected patients with AUD. DATA SOURCES: PubMed, Medline, Embase, Web of Science, and the Cochrane Library. METHODS: A systematic review was performed according to PRISMA and AMSTAR guidelines by searching through Medline, Embase, Web of Science, and the Cochrane Library for randomized clinical trials (RCTs) published before December 2022. The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis. STUDY SELECTION: RCTs on treating AUD without antibiotics published in English before December 2022 were included. INTERVENTION: Treatments without antibiotics were compared with treatments with antibiotics. MAIN OUTCOME MEASURES: The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis. RESULTS: The search yielded 1163 studies. Four RCTs with 1809 patients were included in the review. Among these patients, 50.1% were treated conservatively without antibiotics. The meta-analysis showed no significant differences between nonantibiotic and antibiotic treatment groups with respect to rates of readmission [odds ratio (OR)=1.39; 95% CI: 0.93-2.06; P =0.11; I2 =0%], change in strategy (OR=1.03; 95% CI: 0.52-2,02; P =0.94; I2 =44%), emergency surgery (OR=0.43; 95% CI: 0.12-1.53; P =0.19; I2 =0%), worsening (OR=0.91; 95% CI: 0.48-1.73; P =0.78; I2 =0%), and persistent diverticulitis (OR=1.54; 95% CI: 0.63-3.26; P =0.26; I2 =0%). LIMITATIONS: Heterogeneity and a limited number of RCTs. CONCLUSIONS: Treatment for AUD without antibiotic therapy is safe and effective in selected patients. Further RTCs should confirm the present findings.

"Optimal recovery" after colon cancer surgery in the elderly, a comparative cohort study: Conventional care vs. enhanced recovery vs. prehabilitation.

BACKGROUND: Colon cancer in elderly patients is an increasing problem due to its prevalence and progressive aging population. Prehabilitation has experienced a great grown in this field. Whether it is the best standard of care for these patients has not been elucidated yet. METHODS: A retrospective comparative cohort study of three different standards of care for elderly colon cancer patients (>65 years) was conducted. A four-weeks trimodal prehabilitation program (PP), enhanced recovery program (ERP) and conventional care (CC) were compared. Global complications, major complications (Clavien-Dindo ≥ 3), reinterventions, mortality, readmission and length of stay were measured. Optimal recovery, defined as postoperative course without major complications, no mortality, hospital discharge before the fifth postoperative day and without readmission, was the primary outcome measure. The influence of standard of care in optimal recovery and postoperative outcomes was assessed with univariate and multivariate logistic regression models. RESULTS: A total of 153 patients were included, 51 in each group. Mean age was 77.9 years. ASA Score distribution was different between groups (ASA III-IV: CC 56.9%, ERP 25.5%, PP 58.9%; p = 0.014). Optimal recovery rate was 55.6% (PP 54.9%, ERP 66.7%, CC 45.1%; p = 0.09). No differences were found in major complications (p = 0.2) nor reinterventions (p = 0.7). Uneventful recovery favors ERP and PP groups (p = 0.046 and p = 0.049 respectively). CONCLUSIONS: PP and ERP are safe and effective for older colon cancer patients. Fewer overall complications and readmissions happened in ERP and PP patients. Major complications were independent of the standard of care used.

Watch and wait: Why, to whom and how.

The current standard of care for the treatment of locally advanced rectal cancer includes neoadjuvant chemoradiation (nCRT) followed by total mesorrectal excision (TME). The observation of significant primary tumor response to radiation and chemotherapy led to the idea of organ-preserving strategies in selected patients who achieved clinical, endoscopic and radiological evidence of complete tumor regression. One of these strategies includes no immediate surgery with close surveillance, known as the Watch and Wait strategy (W&W). The potential benefits of this approach with the avoidance of radical TME have to be weighed against the potential risk of local tumor regrowth. Exploration of these advantages and disadvantages will attempt to answer why W&W may be an attractive alternative to rectal cancer patients and their treating physicians. In order to safely implement this strategy, some key issues related to baseline staging, neoadjuvant treatment regimens, timing for tumor response assessment, must be carefully considered. The combination of these features will attempt to clarify "how" and "to whom" the W&W strategy may be considered. Ultimately, in the setting of contemporary neoadjuvant treatment regimens including total neoadjuvant therapy strategies (TNT), the achievement of a clinical complete response is likely to affect a significant proportion of patients. As endoscopic and radiological imaging modalities have evolved and improved, W&W is expected to become an integral part during multidisciplinary management decision. Finally, understanding the clinical consequences of local tumor regrowth both in terms of local and distant relapse may allow for optimal and safe selection of patients fully aware of advantages or disadvantages of this strategy.

Patients' Perceived Satisfaction Through Telephone-Assisted Tele-Consultation During the SARS-CoV-2 Pandemic Period: Observational Single-Centre Study at a Tertiary-Referral Colorectal Surgery Department.

Introduction: The pandemic produced by SARS-CoV-2 has obliged us to set up the tele-assistance to offer a continuity of care. This implies an innovation, being the degree of satisfaction of patients unknown. Methods: A telephonic survey was conducted with the validated in the Spanish tool Telehealth Usability Questionnaire (Telehealth Usability Questionnaire; rating from 1-7) of all candidate patients assisted consecutively in the Coloproctology Unit. We included demographic variables, education level, job status, diagnosis and consultation type. A descriptive study was done. The relationship between the willingness of consultation model in the future (telemedicine vs traditional) and the categorical variables was analysed through the chi-squared test. Results: A total of 115 patients were included. The average age was 59.9 years, being 60% women. The average score in each of the survey items was higher than 6 in all the questions but 1. 26.1% of the surveyed patients confessed being advocated to tele-assistance in the future. The only factors related to greater willingness to tele-assistance were male gender (37% vs 18.8%; P = .03) and a higher academic preparation level in favour of higher technical studies (35.9%) and university studies (32.4%) opposite to the rest (P = .043). The rest of variables studied, job status, labour regimen, diagnostic group and consultation type did not show any relationship. Conclusions: A vast majority of patients answered favourably to almost all the items of the survey. However, only 26.1% of them would choose a model of tele-assistance without restrictions.

Proctologic emergency consultation during COVID-19: Comparative cross-sectional cohort study.

INTRODUCTION: Proctologic issues entail a frequent reason for consultation in the emergency department (ED). We aim to analyze how the SARS-COV-2 pandemic has impacted in the demand for proctological consultations. MATERIAL AND METHOD: Descriptive comparative retrospective study of cross-sectional cohorts of patients attending the ED for proctological complaints from March to April in 2020 and 2019. Demographic variables, comorbidities, reasons for consultation and diagnosis, treatment and readmission were included. Four periods were analyzed according to the different stages of the pandemic derived limitations. RESULTS: A total of 191 patients were reviewed, 58 in 2020 and 133 in 2019 with an average age of 48 years (SD 20.1) and 112 (58.6%) males. The average number of daily consultations was 2.18 patients in 2019 versus 0.95 in 2020 (p=0.025) meaning a 56% reduction in consultations for proctological reasons. This difference in average consultations was significant in both periods of lockout (p=0.001) and previous de-escalation (p=0.014). The diagnosis distribution was similar between both periods; however, perianal abscesses doubled their rate in 2020, 22.4% versus 11.3% (p=0.045). There was an increasing need for surgery, 31% vs 15% (p=0.011) with no difference in outpatients regimen after emergency surgery (12.5% vs 7.5%, p=0.201). Three patients in 2020 required readmission to the ED (5.2% vs 12.9%, p=0.086). CONCLUSION: There was a decrease of a 56% in proctologic emergency consultation, however, the need for surgery was twice more frequent during the study period. Reflection on the use of emergencies for proctological reasons is warranted.

Adult Intestinal Intussusception: Practical Issues and Concerns.

CASE SUMMARY: A 37-year-old woman with no relevant past medical history presented to the emergency department after a 2-day-long period of crampy abdominal pain with an inability for oral intake because of persistent vomiting. The physical examination was unremarkable. Abdominal CT scan with water-soluble oral contrast revealed an ileocecal intussusception (Fig. 1). Because the patient was hemodynamically stable and no abdominal tenderness was found, a delayed surgical intervention was planned with laparoscopic approach. During intervention, the intestinal invagination was reduced, a cecal neoplasm suspected, and a right hemicolectomy with complete mesocolic excision was performed (Fig. 2). Postoperative recovery was uneventful, with discharge on postoperative day 5. The definite pathological report showed well-differentiated colon adenocarcinoma pT2N1aMx, with 1 of 49 positive lymph nodes.

Interval colonoscopy following acute diverticulitis should not be discouraged yet: results from a retrospective cohort.

BACKGROUND: Although included in some guidelines, the recommendation of interval colonoscopy after an acute diverticulitis (AD) episode has recently been questioned. In this study, we evaluated the incidence of colon cancer during the follow-up of an episode of AD. METHODS: A retrospective review was carried out of patients with conservatively treated AD at our Institution (January 2011 to December 2018) with or without endoscopic study. Patients who had no colonoscopy performed were followed for two years. The demographic, clinical, radiological, follow-up and anatomopathological records were analysed. We determined CT scan validity for the differential diagnosis of CC and AD; sensibility, specificity, predictive values and likelihood ratios were calculated. Patients lost to follow-up and patients who had had colonoscopy in the previous three years were excluded. RESULTS: This study included 285 patients with a mean age of 59 years. A total of 225 interval colonoscopies were performed and 60 patients without colonoscopy were followed up. There were 19 CC (6.7%) diagnosed, 14 with interval colonoscopy and 5 during follow-up; 8 (42.1%) happened in patients who had had an episode of uncomplicated AD. Although CT scan accuracy is high, 87.7%, positive and negative likelihood ratios were low, 4.67 and 0.64, respectively. CONCLUSIONS: Interval colonoscopy should still be advisable after an episode of AD. The rationale for this statement is based on a non-negligible rate of hidden CC and an important uncertainty in the differential diagnosis.