Pelvic Diameter is not Associated with Positive Circumferential Resection Margin in Rectal Cancer: Retrospective Analysis of 78 Cases

Abstract Objective To identify if there is an association between pelvic entry and pelvic outlet diameters with increased positive circumferential resection margin (CRM) in rectal cancer. Introduction Positive CRMin rectalcancerisa majorpredictor forlocal anddistant recurrence. Pelvic diameters may be related to the difficulty of dissection, as well as intrinsic tumor characteristics such as tumor size, location, distance from the anal margin, and T stage, which may compromise the integrity of the mesorectum and circumferential margin involvement. Methods A retrospective review of the patient's medical records who underwent surgical resection of rectal adenocarcinoma from January 2012 to June 2022 was performed. The patient's preoperative staging, operative characteristics, and histopathologic outcomes were gathered from the medical records. Preoperative MRI scanning was done in all patients. MRI pelvimetry was done by two observers. CRM involvement was recorded as stated in the pathology report. Pelvimetry variables were dichotomized according to their mean values for correlation analysis. The odds ratio (OR) was calculated from a binary logistics regression model to assess the relation between the positive CRM and the independent variables. Results A total of 78 patients were included in this study. A positive CRM was reported in 10 patients (12.8%). BMI >27.4 + 6.6 (p = 0.02), positive extramural vascular invasion (p = 0.027), positive CRM by MRI scanning (p = 0.004), and anal sphincter involvement (p = 0.03) were associated with positive CRM. Pelvimetry values were not associated with a positive CRM. Conclusion No association was found between the pelvic diameters measured by MRI pelvimetry with a positive CRM.

Assessing demographic and socioeconomic factors in patients with advanced colorectal cancer.

BACKGROUND: The aim of the study was to determine the socioeconomic and demographic factors associated with advanced colorectal cancer (CRC) presentation at our institution. METHODS: From January 2009 to January 2018, patients that underwent CRC surgery at our institution were included and retrospectively analyzed. Univariate and multivariate logistic regression were used to determine independent risk factors for presenting with advanced CRC. RESULTS: A total of 277 patients were included, 53.5% presented with advanced CRC. The multivariate analysis identified that living in a rural area (odds ratio [OR] = 5.25; 95% confidence interval [95% CI]: 2.27-12-10; p < 0.001), weight loss (OR = 2.33; 95% CI: 1.35-4.09; p = 0.002), needing emergency surgery (OR = 4.68; 95% CI: 1.25-17.49; p = 0.022), location in the rectum in comparison with colon (OR = 2.66; 95% CI: 1.44-4.91; p = 0.002), and location in the mid rectum (OR = 6.10; 95% CI: 2.31-16.12; p < 0.001) were associated with higher odds of advanced CRC stage at presentation. CONCLUSIONS: Patients with lower socioeconomic status, with symptoms, and needing emergency surgery were associated with advanced CRC stage at presentation. Special interventions to improve access to care in this population should be planned to enhance CRC outcomes.

INTRODUCCIÓN: El objetivo del presente estudio es determinar los factores socioeconómicos y demográficos asociados con la presentación de cáncer colorrectal (CCR) en etapas avanzadas en nuestra institución. MÉTODOS: De Enero 2009 a Enero 2018, aquellos pacientes operados por CCR fueron incluidos y analizados de forma retrospectiva. Se realizó análisis de regresión logística para determinar los factores de riesgo independientes para presentar CCR avanzado. RESULTADOS: Se incluyeron un total de 277 pacientes, de los cuales 53.5% se diagnosticaron con CCR avanzado. En el análisis multivariable: vivienda en zona rural (OR = 5.25; 95% CI: 2.27-12-10; p < 0.001), pérdida de peso (OR = 2.33; 95% CI: 1.35-4.09; p = 0.002), necesidad de cirugía de urgencia (OR = 4.68; 95% CI: 1.25-17.49; p = 0.022), tumores en recto (OR = 2.66; 95% CI: 1.44-4.91; p = 0.002), fueron factores asociados a mayor probabilidad de presentación avanzada del CCR. CONCLUSIONES: Pacientes con nivel socioeconómico bajo, aquellos que acuden sintomáticos, y los que requieren de inicio cirugía de urgencia, fueron factores asociados a presentaciones avanzadas de CCR. Se requieren intervenciones especiales para mejorar el acceso a un diagnóstico temprano y oportuno en estos grupos poblacionales.

Plastic biliary stent migration as a cause of ascending colon perforation.

A 65-year-old male with pancreatic cancer stage IV and history of endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placement 43 days earlier, arrived to the emergency department with 8-hour right upper quadrant pain, fever, and shivering. Contrast enhanced computed tomography showed migration of the biliary stent to the ascending colon, with signs of perforation on its antimesenteric edge. A surgical approach by laparotomy was decided. The biliary stent was found perforating the ascending colon and in contact with the abdominal wall. The stent contained the colonic perforation, avoiding leakage. Removal of migrated endoprosthesis and primary closure was made. The patient remained in observation and with IV antibiotics, a new was performed ERCP with placement of an 8 cm by 10 Fr Amsterdam-type plastic stent on the 7th day due to cholangitis, with subsequent complete recovery. Endoscopic placement of stents has become a well-established procedure for biliary disease. Stent migration may be present in up to 6-8% of the cases. In most cases, distal migration has an uncomplicated passage, but it may cause bowel injury in up to 1%. This life-threatening complication requires prompt evaluation and management either by endoscopic or surgical approach.

Prognosis of Mesorectal Tumor Deposits in Patients with Rectal Cancer Treated with Neoadjuvant Chemoradiotherapy and Total Mesorectal Excision.

BACKGROUND: Tumor deposits (TDs) are associated with adverse prognostic factors and decreased survival in colon cancer. However, there is no information of their survival impact in rectal cancer with neoadjuvant chemoradiotherapy (n-CRT). METHODS: Retrospective study in 223 patients with rectal cancer with n-CRT. A survival analysis of factors associated with decreased overall survival (OS) including TDs was performed. RESULTS: From 223 patients, 131 (58.7%) were men, mean age 59.8 (± 13.06) years, and 42 (18.8%) of them revealed TDs. Survival analysis of TDs showed no association with mortality. Factors associated with decreased 5-year OS were the histologic grade (p = 0.42), perineural invasion (p = 0.001), and mesorectal quality (p = 0.067). Perineural invasion (HR = 2.335, 95% CI = 1.198-4.552) remained as independent factor in the multivariate analysis. CONCLUSIONS: TDs were not associated with mortality in rectal cancer patients treated with n-CRT. Factors associated with decreased survival were inadequate mesorectal quality and perineural invasion.

Colonic lipomas an uncommon cause of intussusception in adult patients: report of three cases and literature review.

Colonic lipomas are infrequent, benign, non-epithelial, fatty neoplasms. Most of the colonic lipomas are asymptomatic, but around 25% of patients may develop symptoms. Nowadays, surgical resection of the involved segment is the treatment of choice. We report three cases of colonic intussusceptions caused by colonic lipomas in adult patients. The patients underwent surgical resection, and the diagnosis was confirmed by histopathological examination of the specimens.

Los lipomas colónicos son neoplasias benignas, adiposas, no epiteliales poco frecuentes. La mayoría de los lipomas de colon son asintomáticos, pero alrededor del 25% de los pacientes pueden desarrollar síntomas. En la actualidad, la resección quirúrgica del segmento afectado es el tratamiento de elección. Presentamos tres casos de intususcepción intestinal secundaria a lipomas colónicos en pacientes adultos. Los pacientes fueron sometidos a resección quirúrgica y el diagnóstico se confirmó mediante examen histopatológico.

Exenteración pélvica para cáncer de recto localmente avanzado y recurrente: resultados a largo plazo y factores pronósticos.

OBJETIVO: El objetivo de este trabajo fue analizar los resultados perioperatorios y a largo plazo de los pacientes sometidos a exenteración pélvica para cáncer de recto en un centro de referencia en la Ciudad de México. MÉTODO: Se incluyeron todos los pacientes que se sometieron a exenteración pélvica por cáncer de recto entre 1995 y 2019. Se analizaron variables demográficas, clínicas, quirúrgicas y patológicas. RESULTADOS: Se incluyeron 18 pacientes operados por cáncer de recto (16 localmente avanzados y 2 recurrentes). La relación hombre: mujer fue de 1:3.5. La morbilidad mayor fue del 27.7%. El sangrado intraoperatorio ≥ 1000 ml se asoció con morbilidad (80 vs. 20%; p = 0,029) y mortalidad posoperatoria (100 vs. 0; p = 0.043). La mediana de sobrevida global fue 102 meses. Las sobrevidas global y libre de enfermedad a los 5 años fueron del 44.4% y el 38.8%, respectivamente. La invasión linfovascular fue un factor de mal pronóstico para sobrevida libre de enfermedad (p = 0.017). CONCLUSIONES: La exenteración pélvica para el cáncer de recto es un procedimiento quirúrgico con altas morbilidad y mortalidad. La invasión linfovascular es un factor de mal pronóstico para la sobrevida libre de enfermedad. INTRODUCTION: Pelvic exenteration is a radical treatment for locally advanced and recurrent pelvic tumors. The aim of this study was to analyze the perioperative and long-term outcomes of patients undergoing pelvic exenteration for rectal cancer at a referral center in Mexico City. METHOD: We included all patients who underwent pelvic exenteration due to rectal cancer between 1995 and 2019. Demographic, clinical, surgical and pathological variables were analyzed. RESULTS: 18 patients were included (16 locally advanced and 2 recurrent). The male-female ratio was 1:3.5. The highest morbidity was 27.7%. Intraoperative bleeding ≥ 1000 ml was associated with postoperative morbidity (80 vs. 20%; p = 0.029) and mortality (100 vs. 0; p = 0.043). The median overall survival was 102 months. Overall survival and disease free survival at 5 years after exenteration were 44.4% and 38.8%, respectively. Lymphovascular invasion of the tumor was a poor prognostic factor for disease free survival (p = 0.017). CONCLUSIONS: Pelvic exenteration for rectal cancer is a surgical procedure with high morbidity and mortality. Lymphovascular invasion is a poor prognostic factor for disease-free survival.

Influence of Muscle Mass Area and Visceral Obesity on 30-day Mortality After Colorectal Surgery with Primary Anastomosis.

BACKGROUND: Muscle mass and visceral fat may be assessed at the level of the third lumbar vertebra (L3) in computed tomography (CT). Both variables have been related with adverse surgical outcomes. OBJECTIVE: The objective of the study was to study the association of skeletal muscle index (SMI) and visceral fat area (VFA) with 30-day mortality in colorectal surgery. METHODS: This is a retrospective cohort study conducted at a tertiary referral hospital in Mexico City. Patients who underwent colorectal surgery with primary anastomosis from January 2007 to December 2018 were included in the study. Their preoperative CT scans were analyzed with the NIH ImageJ software at the level of the third lumbar vertebra to determine their SMI (L3-SMI) and the VFA. Logistic regression analysis (adjusted by surgery anatomical location) was used to determine the association between these variables and surgical 30-day mortality. RESULTS: A total of 548 patients were included; 30-day mortality was 4.18% (23 patients). On univariable analysis, L3-SMI, low SMI, anastomosis leak, pre-operative albumin, estimated blood loss, age, steroid use, Charlson comorbidity index score >2, and type of surgery were associated with 30-day mortality. On multivariable analysis, low SMI remained an independent risk factor with an odds ratio of 4.74, 95% confidence interval 1.22-18.36 (p = 0.02). CONCLUSION: Low SMI was found to be an independent risk factor for 30-day mortality in patients submitted to colorectal surgery with a primary anastomosis, whether for benign or malignant diagnosis. VFA was not associated with 30-day mortality.

Open versus laparoscopic surgery for the treatment of diverticular colovesical fistulas: A systematic review and meta-analysis.

BACKGROUND: The aim of this study was to analyze the evidence regarding open versus laparoscopic surgery for the treatment of diverticular colovesical fistula (CVF) in terms of perioperative outcomes. METHODS: A systematic review was performed using PubMed, Cochrane, Google Scholar, and Web of Science databases for studies comparing laparoscopic versus open surgery for CVF. We pooled odds ratios (OR) and mean differences (MD) using random or fixed effects models. RESULTS: Five non-randomized studies with 227 patients met the inclusion criteria. All were retrospective studies, published between 2014 and 2020. For laparoscopic surgery, the pooled rate for conversion to laparotomy was 36%. Laparoscopic and open procedures required similar operative time (MD: -11.62; 95% confidence interval [CI]: -51.41 to 28.16). No difference was found in terms of stoma rates between laparoscopic and open surgery (OR: 1.12; 95% CI 0.44-2.86). Overall, the rate of total postoperative complications was lower in the laparoscopic group (OR: 0.55; 95% CI: 0.30-0.99). The pooled analysis showed equivalent rates of anastomotic leaks (OR: 0.61; 95% CI 0.15-2.45), surgical site infections (OR: 0.44; 95% CI 0.19-1.01), and mortality (OR: 0.18; 95% CI 0.03-1.15). The length of stay was significantly reduced with laparoscopic surgery (MD: -2.89; 95% CI -4.20 to -1.58). CONCLUSION: Among patients with CVF, the laparoscopic approach appears to have shorter hospital length of stay, with no differences in anastomotic leaks, surgical site infections, stoma rates, and mortality, when compared with open surgery.

Sociodemographic factors related with emergency colorectal cancer surgery at a referral center in Mexico.

BACKGROUND: Diagnosis of colorectal cancer (CRC) after emergency presentation is associated with a worse prognosis. AIM: The aim of the study was to determine the sociodemographic factors related with emergency CRC surgery at our institution. METHODS: From January 2009 to December 2017, patients that underwent CRC surgery at our institution were included in the study. Univariate and multivariate logistic regression were used to determine the effect of the potential risk factors on the rate of emergency surgery. RESULTS: A total of 247 patients underwent CRC surgery at our institution. The rate of emergency surgery was 7.7%. On univariate analysis, patients without a family history of cancer (odds ratio [OR]: 4.95), living in a rural area (OR: 3.7), and late clinical cancer stage (OR: 5.06) were associated with emergent surgery. Mid-income status was a protective factor for emergency surgery (OR: 0.14, p = 0.003). On multivariate analysis, late clinical cancer stage (OR: 4.41, 95% CI 1.21-16.05, p = 0.024) and mid-income economic status (OR: 0.41, 95% CI 0.04-0.55, p = 0.004) were identified as independent risk factors for emergency surgery. CONCLUSION: Social, economic, and demographic factors were identified as predictors for emergent CRC surgery.

ANTECEDENTES: El diagnóstico de cáncer colorrectal (CCR) en el contexto de urgencia está asociado a un mal pronóstico. OBJETIVO: Determinar los factores sociodemográficos asociados a cirugía de urgencia en el CCR en nuestra institución. MÉTODO: De enero de 2009 a diciembre de 2017 se incluyeron los pacientes operados de CCR y se realizaron análisis univariado y multivariado para determinar los potenciales factores de riesgo. RESULTADOS: Se incluyeron en el estudio 247 pacientes operados de CCR. El 7.7% de las cirugías fueron de urgencia. En el análisis univariado, los pacientes sin antecedentes familiares de cáncer (odds ratio [OR]: 4.95), los habitantes de zonas rurales (OR: 3.7) y aquellos en etapas avanzadas del cáncer (OR: 5.06) se asociaron a cirugía de urgencia. Los pacientes con nivel socioeconómico medio tuvieron menos probabilidad de que su cirugía fuera de urgencia (OR: 0.14; p = 0.003). En el análisis multivariado, debutar con una etapa clínica avanzada (OR: 4.41; intervalo de confianza del 95% [IC95%]: 1.21-16.05; p = 0.024) y tener un nivel socioeconómico medio (OR: 0.41; IC95%: 0.04-0.55; p = 0.004) fueron factores independientes para cirugía de urgencia por CCR. CONCLUSIONES: Los factores sociales, económicos y demográficos se encontraron relacionados con la necesidad de cirugía de urgencia por CCR.

Assessment of quality-of-care indicators for colorectal cancer surgery at a single centre in a developing country.

BACKGROUND: The implementation of quality-of-care indicators aiming to improve colorectal cancer (CRC) outcomes has been previously described by Cancer Care Ontario. The aim of this study was to assess the quality-of-care indicators in CRC at a referral centre in a developing country and to determine whether improvement occurred over time. METHODS: We performed a retrospective study of our prospectively collected database of patients after CRC surgery from 2001 to 2016. We excluded patients who underwent local transanal excision, pelvic exenteration or palliative procedures. We evaluated trends over time using the Cochran-Armitage test for trend. RESULTS: A total of 343 patients underwent surgical resection of CRC over the study period. There was improvement of the following indicators over time: the proportion of patients detected by screening (p = 0.03), the proportion of patients with preoperative liver imaging (p = 0.001), the proportion of patients with stage II or III rectal cancer who received neoadjuvant chemotherapy (p = 0.03), the proportion of patients with pathology reports that indicated the number of lymph nodes examined and the number of positive nodes (p = 0.001), and the proportion of patients with pathology reports describing the details on margin status (p = 0.001). CONCLUSION: This study showed the feasibility of applying the Cancer Care Ontario indicators for evaluating outcomes in CRC treatment at a single centre in a developing country. Although there was an improvement of some of the quality-of-care indicators over time, policies and interventions must be implemented to improve the fulfillment of all indicators.

CONTEXTE: Action Cancer Ontario a déjà décrit l'application d'indicateurs de la qualité des soins dans le but d'améliorer l'issue du cancer colorectal (CCR). Le but de cette étude était d'évaluer les indicateurs de la qualité de soins pour le CCR dans un centre de référence d'un pays en voie de développement et de déterminer si des améliorations ont pu être observées avec le temps. MÉTHODES: Nous avons procédé à une étude rétrospective de notre base de données recueillies prospectivement auprès de patients ayant subi une chirurgie pour CCR entre 2001 et 2016. Nous avons exclu les patients qui ont subi une exérèse transanale locale, une exentération pelvienne ou des traitements palliatifs. Nous avons évalué les tendances au fil du temps à l'aide du test Cochran­Armitage pour dégager les tendances. RÉSULTATS: En tout, 343 patients ont subi une résection chirurgicale de CCR au cours de la période de l'étude. On a noté une amélioration des indicateurs suivants au fil du temps : proportion de patients ayant subi un dépistage (p = 0,03), proportion de patients ayant subi des épreuves d'imagerie hépatique préopératoires (p = 0,001), proportion de patients atteints d'un cancer rectal de stade II ou III ayant reçu une chimiothérapie néoadjuvante (p = 0,03), proportion de patients dont les rapports d'anatomopathologie indiquaient le nombre de ganglions lymphatiques examinés et le nombre de ganglions positifs (p = 0,001) et proportion de patients dont les rapports d'anatomopathologie décrivaient le statut des marges (p = 0,001). CONCLUSION: Cette étude a démontré l'applicabilité des indicateurs d'Action Cancer Ontario pour évaluer les résultats du traitement pour CCR dans un seul centre d'un pays en voie de développement. Même si certains des indicateurs de la qualité des soins se sont améliorés au fil du temps, il faut appliquer des politiques et des interventions pour améliorer tous les indicateurs.

A systematic review and meta-analysis of diverting loop ileostomy versus total abdominal colectomy for the treatment of Clostridium difficile colitis.

BACKGROUND: Clostridium difficile is an increasingly common source of in-patient morbidity and mortality. We aim to assess the effects of diverting loop ileostomy (DLI) versus total abdominal colectomy (TAC) for Clostridium difficile colitis (CDC), in terms of mortality and morbidity. METHODS: Systematic literature search was performed using PubMed, Embase, Cochrane, and Web of Science databases for randomized and non-randomized studies comparing DLI and TAC for fulminant CDC. Meta-analysis was carried out for mortality and postoperative complications. RESULTS: Five non-randomized studies qualified for inclusion in the quantitative synthesis. In total, 3683 patients were allocated to DLI (n = 733) or TAC (n = 2950). The overall mortality was equivalent (OR 0.73; 95% CI 0.45-1.20; P = 0.22). Regarding secondary outcomes, the pooled analysis revealed the following equivalent rates of postoperative events: thromboembolism (OR 0.45; 95% CI 0.14-1.43; P = 0.18), acute renal failure (OR 1.71; 95% CI 0.91-3.23; P = 0.10), surgical site infection (OR 0.95; 95% CI 0.11-8.59; P = 0.97), pneumonia (OR 0.98; 95% CI 0.36-2.66; P = 0.97), urinary tract infection (OR 0.81; 95% CI 0.26-2.52; P = 0.72), and reoperation (OR 0.95; 95% CI 0.50-1.82; P = 0.78). The ostomy reversal rate was significantly higher in DLI (OR 12.55; 95% CI 3.31-47.55; P = 0.0002). CONCLUSIONS: The overall morbidity and mortality rates between DLI and TAC for the treatment of CDC seemed to be equivalent. Evidence from a randomized controlled trial is needed to clarify the timing and understand the impact of DLI for CDC.

Sarcopenia in patients with colorectal cancer: A comprehensive review.

Colorectal cancer (CRC) is the third most commonly diagnosed cancer globally and the second cancer in terms of mortality. The prevalence of sarcopenia in patients with CRC ranges between 12%-60%. Sarcopenia comes from the Greek "sarx" for flesh, and "penia" for loss. Sarcopenia is considered a phenomenon of the aging process and precedes the onset of frailty (primary sarcopenia), but sarcopenia may also result from pathogenic mechanisms and that disorder is termed secondary sarcopenia. Sarcopenia diagnosis is confirmed by the presence of low muscle quantity or quality. Three parameters need to be measured: muscle strength, muscle quantity and physical performance. The standard method to evaluate muscle mass is by analyzing the tomographic total cross-sectional area of all muscle groups at the level of lumbar 3rd vertebra. Sarcopenia may negatively impact on the postoperative outcomes of patients with colorectal cancer undergoing surgical resection. It has been described an association between sarcopenia and numerous poor short-term CRC outcomes like increased perioperative mortality, postoperative sepsis, prolonged length of stay, increased cost of care and physical disability. Sarcopenia may also negatively impact on overall survival, disease-free survival, recurrence-free survival, and cancer-specific survival in patients with non-metastatic and metastatic colorectal cancer. Furthermore, patients with sarcopenia seem prone to toxic effects during chemotherapy, requiring dose deescalations or treatment delays, which seems to reduce treatment efficacy. A multimodal approach including nutritional support (dietary intake, high energy, high protein, and omega-3 fatty acids), exercise programs and anabolic-orexigenic agents (ghrelin, anamorelin), could contribute to muscle mass preservation. Addition of sarcopenia screening to the established clinical-pathological scores for patients undergoing oncological treatment (chemotherapy, radiotherapy or surgery) seems to be the next step for the best of care of CRC patients.

Predictors of dehydration and acute renal failure in patients with diverting loop ileostomy creation after colorectal surgery.

BACKGROUND: Despite the potential benefits of fecal diversion after low pelvic anastomosis in colorectal surgery, diverting loop ileostomy construction is related to significant rates of complications. AIM: To determine potential predictors of high output related complications in patients with diverting loop ileostomy creation after colorectal surgery. METHODS: Patients who underwent open and laparoscopic colorectal surgery requiring a diverting loop ileostomy from January 2010 to March 2018 were retrospectively analyzed. We included patients older than 18 years, who underwent colorectal surgery with primary low pelvic anastomosis, and with the creation of a diverting loop ileostomy, at elective or emergency settings for the treatment of benign or malignant conditions. Univariate and multivariate logistic regression analysis was used to determine the effect of the potential predictors on the rate of high output related complications. The high output related complications were dehydration and acute renal failure that required visits to the emergency department and hospitalizations. RESULTS: Of the 102 patients included in the study, 23.5% (n = 24) suffered high output related complications. In this group of patients at least one visit to the emergency department (mean 1.6), and at least one readmission to the hospital was needed. The factors associated with high-output ileostomy, in the univariate analysis, were: urgent surgical intervention (OR = 2.6; P = 0.047), the development of postoperative complications (OR = 3; P = 0.024), have ulcerative colitis (OR = 4.8; P = 0.017), use of steroids (OR = 4.3; P = 0.010), mean output at discharge greater than 1000 mL/24 h (OR = 3.2; P = 0.016), and use of loperamide at discharge (OR = 2.8; P = 0.032). Multivariate logistic regression analysis identified two independent risk factors for high output related complications: ulcerative colitis [OR = 7.6 (95%CI: 1.81-31.95); P = 0.006], and ileostomy output at discharge ≥ 1000 mL/24 h [OR = 3.3 (1.18-9.37); P = 0.023]. CONCLUSION: In our study, patients with ulcerative colitis and those with an ileostomy output above 1000 mL/24 h at discharge, were at increased risk of high output related complications.

Multivariate analysis of risk factors for complications after loop ileostomy closure.

BACKGROUND: Despite the advantages of diverting loop ileostomy construction, it is related to complications. OBJECTIVE: The aim of the study was to determine the risk factors for complications after loop ileostomy closure. METHODS: Patients who underwent loop ileostomy closure from January 2010 to March 2018 were retrospectively analyzed. Multivariate logistic regression was used to determine the effect of the potential risk factors on the rate of each complication. RESULTS: A total of 136 patients underwent reversal. Indications for the initial operation were colorectal cancer (39.7%), diverticulitis (25.7%), idiopathic chronic ulcerative colitis (ICUC) (8.1%), familial adenomatous polyposis (FAP) (7.4%), and others (19.1%). Multivariate analysis identified the following risk factors: type of incision (midline laparotomy) (odds ratio [OR] = 6.5) for wound infection; treatment with immunomodulator (OR = 12.5) for anastomotic leak; history of FAP (OR = 9.8) for intestinal obstruction; previous use of immunomodulator (OR = 10.0) and performing reversal through midline incision (OR = 18.9) for reoperation; and ≥ 65 years old (OR = 3.5) for medical complications. The rate of incisional hernia was 11%, and the risk factors were time to closure < 3 months (OR = 6.4) and parastomal hernia (OR = 13.2). CONCLUSIONS: Several patient-related and surgical technique factors should be considered at the time of loop ileostomy closure to reduce post-operative morbidity.

ANTECEDENTES: A pesar de las ventajas de la ileostomía en asa de derivación, múltiples complicaciones se han asociado a su uso. OBJETIVO: Determinar los factores de riesgo para presentar complicaciones tras el cierre de una ileostomía en asa. MÉTODO: Se realizó un análisis retrospectivo de los pacientes sometidos a cierre de ileostomía en asa de enero de 2010 a marzo de 2018. Se determinaron los factores de riesgo utilizando regresión multivariable. RESULTADOS: Se incluyeron 136 pacientes. Las indicaciones para cirugía fueron cáncer colorrectal (39.7%), diverticulitis (25.7%), colitis ulcerosa crónica idiopática (CUCI) (8.1%), poliposis adenomatosa familiar (PAF) (7.4%) y otras (19.1%). Se identificaron los siguientes factores de riesgo: incisión en línea media (OR: 6.5) para infección de herida; tratamiento inmunomodulador (OR: 12.5) para fuga de anastomosis; antecedente de PAF (OR: 9.8) para oclusión intestinal; tratamiento inmunomodulador (OR: 10) e incisión en línea media (OR: 18.9) para reintervención; y edad ≥ 65 años (OR: 3.5) para complicaciones médicas. La frecuencia de hernia incisional fue del 11%: < 3 meses para el cierre (OR: 6.4) y hernia parastomal (OR: 13.2). CONCLUSIONES: Numerosos factores relacionados con el paciente y con la técnica quirúrgica deben de ser considerados al momento del cierre de la ileostomía en asa para reducir la morbilidad posoperatoria.

Factors associated with emergent colectomy in patients with neutropenic enterocolitis.

PURPOSE: Neutropenic enterocolitis (NEC) is a severe complication of neutropenia. NEC is characterized by segmental ulceration, intramural inflammation, and necrosis. Factors present in patients who underwent colectomy have never been studied. The present study aimed to describe the clinical factors present in patients who underwent emergent colectomy for the treatment of neutropenic enterocolitis. METHODS: Patients admitted with neutropenic enterocolitis from November 2009 to May 2018 were retrospectively analyzed. Logistic regression analysis was used to determine clinical factors associated with emergent colectomy. RESULTS: Thirty-nine patients with NEC were identified. All patients had a hematological disorder. Medical treatment was the only management in 30 (76.9%) patients, and 9 (23.1%) patients underwent colectomy. No differences were found between the treatment groups regarding sex, age, or comorbidities. Patients were more likely to undergo colectomy if they developed abdominal distention (OR = 12, p = 0.027), hemodynamic failure (OR = 6, p = 0.042), respiratory failure (OR = 17.5, p = 0.002), multi-organic failure (OR = 9.6, p = 0.012), and if they required ICU admission (OR = 11.5, p = 0.007). Respiratory failure was the only independent risk factor for colectomy in multivariable analysis. In-hospital mortality for the medical and surgical treatment groups was 13.3% (n = 4) and 44.4% (n = 4), respectively (p = 0.043). CONCLUSIONS: In our study, most NEC patients were treated conservatively. Patients were more likely to undergo colectomy if they developed organ failures or required ICU admission. Early surgical consultation is suggested in all patients with NEC.

Oncological Implications of Lymph Nodes Retrieval and Perineural Invasion in Colorectal Cancer: Outcomes from a Referral Center.

BACKGROUND: In colorectal cancer (CRC), regional lymphadenectomy provides prognostic information and guides management. The current consensus states that at least 12 lymph nodes (LN) should be evaluated. The aims of this study were to identify whether the number of LN is a predictor for survival and recurrence, and to reveal the role of LN ratio (LNR) and perineural invasion (PNI) in predicting prognosis after curative resection of CRC. METHODS: We included all patients who underwent surgery for CRC between 2000 and 2016 in an academic medical center in Mexico. The LNR cutoff value was 0.25. We analyzed two groups according to the number of LN retrieved: Group 1 (≥ 12 LN) and Group 2 (< 12 LN). RESULTS: We included 305 patients, 13.8% in Stage I, 45.6% in Stage II, and 40.6% in Stage III. The male: female ratio was 1.1. The mean age was 62.6 ± 14 years (range, 19-92). In 233 patients (76.4%), ≥ 12 LN were obtained. Recurrence rates in Groups 1 and 2 were 20.2% versus 26.4%, respectively (p = 0.16). PNI was present in 34 patients (13.2%). An LN harvest < 10 increased local and distant recurrences (p = 0.03). Stage III patients with an LNR ≥ 0.25 had higher overall recurrence rates (p = 0.012) and mortality (p = 0.029). In a multivariate Cox regression analysis, PNI-negative tumors were an independent prognostic factor for disease-free survival (p = 0.011, hazard ratio = 2.78, 95% confidence interval = 1.26-6.16). CONCLUSIONS: An LN retrieval < 10 increased local and distant recurrence rates. LNR was an independent prognostic factor for survival in Stage III tumors. PNI was the only significant independent prognostic factor affecting disease-free survival in our patients.

Postoperative outcomes and functional results after Deloyer's procedure - a retrospective cohort study / Desfechos pós-operatórios e resultados funcionais após o procedimento de Deloyer ­ um estudo de coorte retrospectivo

ABSTRACT Introduction: The objective of our study was to describe surgical outcomes of Deloyers procedure in our referral center, and to compare the results of patients with and without protective ileostomy. Methods: Patients undergoing a Deloyers procedure from 2013 to 2016 were prospectively included. General characteristics, intraoperative variables, postoperative course, and functional outcomes were analyzed. Patients were compared into two groups: group (1) patients undergoing Deloyers procedure without ileostomy, and group (2) Deloyers procedure with protective ileostomy. Results: Sixteen patients undergoing isoperistaltic transposition of the right colon remnant were included, of which 9 (63%) were males with a median age of 47 (range 22-76) years. The main surgical indication was the restoration of bowel transit (62.5%). There was higher major morbidity rate in the Deloyers procedure with protective ileostomy group, but without statistical significance (20% vs. 9%, p = 0.92). No leaks or deaths were reported. The length of hospital stay was 7 days. The mean number of bowel movements per day was 4 at 18 months of follow up. Only four (25%) patients used irregularly loperamide. Conclusions: The Deloyers procedure has satisfactory results and is reproducible with low morbidity. The major and minor morbidity rates were similar between groups, suggesting that the costs and risks of a second procedure can be avoided by providing a safe primary anastomosis.

RESUMO Introdução: O objetivo de nosso estudo foi descrever os resultados cirúrgicos do procedimento de Deloyer em nosso centro de referência e comparar os resultados de pacientes com e sem ileostomia de proteção. Métodos: Pacientes submetidos ao procedimento de Deloyer de 2013 a 2016 foram incluídos prospectivamente. Foram analisadas as características gerais, as variáveis intraoperatórias, o curso pós-operatório e os desfechos funcionais. Os pacientes foram comparados em dois grupos: Grupo 1) pacientes submetidos ao procedimento de Deloyer (PD) sem ileostomia, e grupo 2) procedimento de Deloyer com ileostomia de proteção (IP). Resultados: Foram incluídos 16 pacientes submetidos à transposição isoperistáltica da porção remanescente do cólon direito, dos quais 9 (63%) eram do sexo masculino com idade média de 47 anos (variação de 22-76) anos. A principal indicação cirúrgica foi a restauração do trânsito intestinal (62,5%). Houve maior morbidade maior no grupo IP, mas sem significância estatística (20% vs. 9%, p = 0,92). Nenhum vazamento ou óbito foi relatado. A duração da hospitalização foi de 7 dias. O número médio de evacuações por dia foi 4, aos 18 meses de seguimento. Apenas quatro (25%) pacientes utilizaram irregularmente a loperamida. Conclusões: O procedimento de Deloyer tem resultados satisfatórios e é reprodutível com baixa morbidade. As taxas de morbidades maiores e menores foram semelhantes entre os grupos, sugerindo que os custos e riscos de um segundo procedimento podem ser evitados proporcionando-se uma anastomose primária segura.

Usefulness of Gum Chewing to Decrease Postoperative Ileus in Colorectal Surgery with Primary Anastomosis: A Randomized Controlled Trial.

BACKGROUND: Postoperative ileus generates a high impact on morbidity, hospital stay, and costs. OBJECTIVE: To study the efficiency and safety of chewing gum to decrease postoperative ileus in colorectal surgery. METHOD: A randomized controlled trial was performed including 64 patients who underwent elective colorectal surgery with primary anastomosis in a tertiary referral center. Patients were divided in two groups: (i) A: gum chewing group (n = 32), and (ii) B: patients who had standard postoperative recovery (n = 32). RESULTS: Postoperative ileus was observed in 6% (2/32) of the gum-chewing group and in 21.8% (7/32) in the standard postoperative recovery group, with an odds ratio of 0.167 (95% CI: 0.37-0.75; p = 0.006). Vomiting was present in two patients from group A and in eight from group B (6.25 vs. 25.0%; p = 0.03). Passage of flatus within the first 48 hours was present in 30 patients from group A and in 20 from group B (94 vs. 63%; p = 0.002). There was earlier oral feeding (96 ± 53 vs. 117 ± 65 hours; p= 0.164) and a shorter length of hospital stay (7 ± 5 vs. 9 ± 5 days; p= 0.26) in the gum-chewing group (p N.S.). CONCLUSIONS: The use of chewing gum after colorectal surgery was associated with less postoperative ileus and vomiting, and with an increased passage of flatus within the first 48 hours after surgery. Since gum chewing is an inexpensive procedure and is not associated with higher morbidity, it can be safely used for a faster postoperative recovery in elective colorectal surgery.