Exercise effects on functional capacity and quality of life in older patients with colorectal cancer: study protocol for the ECOOL randomized controlled trial.

BACKGROUND: Surgery and treatment for colorectal cancer (CRC) in the elderly patient increase the risk of developing post-operative complications, losing functional independence, and worsening health-related quality of life (HRQoL). There is a lack of high-quality randomized controlled trials evaluating the potential benefit of exercise as a countermeasure. The primary aim of this study is to evaluate the effectiveness of a home-based multicomponent exercise program for improving HRQoL and functional capacity in older adults undergoing CRC surgery and treatment. METHODS: This randomized, controlled, observer-blinded, single-center trial aims to randomize 250 patients (>74 years) to either an intervention or a control group (i.e., usual care). The intervention group will perform an individualized home-based multicomponent exercise program with weekly telephone supervision from diagnosis until three months post-surgery. The primary outcomes will be HRQoL (EORTC QLQ-C30; CR29; and ELD14) and functional capacity (Barthel Index and Short Physical Performance Battery), which will be assessed at diagnosis, at discharge, and one, three, and six months after surgery. Secondary outcomes will be frailty, physical fitness, physical activity, inspiratory muscle function, sarcopenia and cachexia, anxiety and depression, ambulation ability, surgical complications, and hospital length of stay, readmission and mortality. DISCUSSION: This study will examine the effects of an exercise program in older patients with CRC across a range of health-related outcomes. Expected findings are improvement in HRQoL and physical functioning. If proven effective, this simple exercise program may be applied in clinical practice to improve CRC care in older patients. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT05448846.

Nomograms for morbidity and mortality after oncologic colon resection in the enhanced recovery era: results from a multicentric prospective national study.

PURPOSE: Predicting postoperative complications and mortality is important to plan the surgical strategy. Different scores have been proposed before to predict them but none of them have been yet implemented into the routine clinical practice because their difficulties and low accuracy with new surgical strategies and enhanced recovery. The main aim of this study is to identify risk factors for postoperative morbidity and mortality after colonic resection (CR) without protective stomas, in order to develop a comprehensive, up-to-date, simple, reliable, and applicable model for the preoperative assessment of patients with colon cancer. METHODS: Multivariable analysis was performed to identify risk factors for 60-day morbidity and mortality. Coefficients derived from the regression model were used in the nomograms to predict morbidity and mortality. RESULTS: Three thousand one hundred ninety-three patients from 52 hospitals were included into the analysis. Sixty-day postoperative complications rate was 28.3% and the mortality rate was 3%. In multivariable analysis the independent risk factors for postoperative complications were age, male gender, liver and pulmonary diseases, obesity, preoperative albumin, anticoagulant treatment, open surgery, intraoperative complications, and urgent surgery. Independent risk factors for mortality were age, preoperative albumin anticoagulant treatment, and intraoperative complications. CONCLUSIONS: Risk factors for morbidity and mortality after CR for cancer were identified and two easy predictive tools were developed. Both of them could provide important information for preoperative consultation and surgical planning in the time of enhance recovery.

Factors associated with low anterior resection syndrome after surgical treatment of rectal cancer.

AIM: To assess factors independently associated with low anterior resection syndrome (LARS) following resection or rectal cancer. METHOD: Cross-sectional study carried out in two acute-care teaching hospitals in Barcelona, Spain. Patients who had undergone sphincter preserving low anterior resection with curative intent, with total or partial mesorectal excision (with and without protective ileostomy) between January 2001 and December 2009 completed a self-administered questionnaire to assess bowel dysfunction after rectal cancer surgery. Predictors of LARS were assessed by univariate and multivariate analyses. RESULTS: The questionnaire was sent to 329 patients (response rate 57.7%). Six cases of incomplete questionnaires were excluded. The study population included 184 patients (66.8% men) with a mean age of 63 years. There were 44 (23.9%) patients with no LARS, 36 (19.6%) with minor LARS and 104 (56.2%) with major LARS. In the univariate analysis, total mesorectal excision (P = 0.0008), protective ileostomy (P = 0.002), preoperative and postoperative radiotherapy (P = 0.0000), postoperative chemotherapy (P = 0.0046) and age (P = 0.035) were significantly associated with major LARS, whereas in the multivariate analysis, total mesorectal excision (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.02-4.65), preoperative radiotherapy (OR 4.33, 95% CI 2.03-9.27) and postoperative radiotherapy (OR 9.52, 95% CI 1.74-52.24) were independent risk factors for major LARS. CONCLUSIONS: In this study, the risk of having major LARS increases with total mesorectal excision and both neoadjuvant and adjuvant radiotherapy. This article is protected by copyright. All rights reserved.

Preventing Parastomal Hernia Using a Modified Sugarbaker Technique With Composite Mesh During Laparoscopic Abdominoperineal Resection: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to assess the reduction in the incidence of parastomal hernia (PH) after placement of prophylactic synthetic mesh using a modified Sugarbaker technique when a permanent end-colostomy is needed. SUMMARY OF BACKGROUND DATA: Prevention of PH formation is crucial given the high prevalence of PH and difficulties in the surgical repair of PH. METHODS: A randomized, prospective, double-blind, and controlled trial. Rectal cancer patients undergoing laparoscopic abdominoperineal resection with permanent colostomy were randomized (1 : 1) to the mesh and nonmesh arms. In the mesh group, a large-pore lightweight composite mesh was placed in the intraperitoneal/onlay fashion using a modified Sugarbaker technique. PH was detected by computed tomography (CT) after a minimum follow-up of 12 months. Analysis was per-protocol. RESULTS: The mesh group included 24 patients and the control group 28. Preoperative data, surgical time, and postoperative morbidity were similar. The median follow-up was 26 months. After CT examination, 6 of 24 PHs (25%) were observed in the mesh group compared with 18 of 28 (64.3%) in the nonmesh group (odds ratio 0.39, 95% confidence interval 0.18-0.82; P = 0.005). The Kaplan-Meier curves showed significant differences in favor of the mesh group (long-rank = 4.21, P = 0.04). The number needed to treat was 2.5, which confirmed the effectiveness of the intervention. CONCLUSIONS: Placement of a prosthetic mesh by the laparoscopic approach following the modified Sugarbaker technique is safe and effective in the prevention of PH, reducing significantly the incidence of PH.

Low anterior resection syndrome: a survey of the members of the American Society of Colon and Rectal Surgeons (ASCRS), the Spanish Association of Surgeons (AEC), and the Spanish Society of Coloproctology (AECP).

BACKGROUND: Low anterior resection syndrome (LARS) is frequent following sphincter-sparing procedures for rectal cancer. OBJECTIVE: This study aims to assess surgeons' awareness of LARS. DESIGN: This was a survey study. SETTINGS: Members of the American Society of Colon and Rectal Surgeons (ASCRS), the Spanish Association of Surgeons (AEC), and the Spanish Society of Coloproctology (AECP). PARTICIPANTS: Three hundred thirty-four surgeons from the ASCRS and 150 from the Spanish Societies completed a 23-item electronic questionnaire. MAIN OUTCOME MEASURES: Surgeons' opinions regarding different aspects of LARS. RESULTS: The proportion of rectal cancer patients undergoing sphincter-sparing operations ranged between 71 and 90 %. Low anterior resection with end-to-end anastomosis was the most frequently cited procedure after mesorectal excision. More than 80 % of participants were recognized to be moderately or extremely aware of the condition, but regarding the method used to assess LARS, the majority relied on clinical manifestations. Around 35 % of surgeons considered that severe LARS developed in less than 40 % of patients. The most important factor related to defecatory function impairment in the surgeons' opinion was the distance from the anal margin to anastomosis. Other factors thought to be involved were anastomotic leakage, preoperative radiation therapy, age, and postoperative radiotherapy, with similar percentages in the two groups of surgeons. Lifestyle changes and dietary measures associated with or without drug treatment was the modality of choice. The experience with transanal irrigation or sacral nerve stimulation was limited. It was considered that <30 % of patients chronically suffer from severe LARS with significant quality of life impairment. LIMITATIONS: The limitations of this study are the international mix and expert status of the specialists. CONCLUSIONS: The probability of patients suffering from LARS was underestimated despite reporting good knowledge of the syndrome. Validated methods for the assessment of LARS were rarely used. Deficient awareness regarding risk factors for LARS was documented. Knowledge of therapeutic options was also limited.

Laparoscopy-assisted versus open colectomy for treatment of colon cancer in the elderly: morbidity and mortality outcomes in 545 patients.

BACKGROUND: Advanced age is a risk factor of major abdominal surgery due to diminished functional reserve and increased comorbidity. Laparoscopy-assisted colectomy is a well-established procedure in colon cancer surgery. The aim of this study was to compare early outcome of elective laparoscopy surgery and open colectomy in colon cancer patients according to age. METHODS: A total of 545 patients with colonic adenocarcinoma underwent elective surgery between 2005 and 2009. There were 277 patients in the laparoscopic group and 268 in the open. Patient characteristics in both groups were homogeneous and further stratified into three subgroups by age: <75, between 75-84, and ≥ 85 years. Main outcome measures were early morbidity, mortality, and hospital stay. RESULTS: Open surgery group showed a higher overall morbidity rate (37.3 vs. 21.6%, P = 0.001), medical complications (16.4 vs. 10.5%, P = 0.033), surgical complications (23.5 vs. 15.5%, P = 0.034), and mortality (6.7 vs. 3.2%, P = 0.034). The overall morbidity rate difference between open and laparoscopy approach disappeared in the oldest group (≥ 85 years old). Surgical site infections rate was inferior for patients <75 years old in laparoscopy group compared with open. Mortality was also significantly inferior in laparoscopy group in younger patients (<75 years, 0 vs. 3%, P = 0.038). Mean hospital stay was shorter for patients in <75 and 75-84 groups with laparoscopic approach (7.8 vs. 11.4 days and 10 vs. 14.3, respectively, P = 0.001) as compared with those who underwent open surgery, but these differences disappeared in patients aged ≥ 85 years. CONCLUSION: Laparoscopy-assisted colectomy in patients underwent elective surgical resections for colon cancer showed advantages in rate of early complications in patients younger than 85 years of age and was found to be as safe and well tolerated as open surgery in patients over 85 years of age.

Double barreled wet colostomy: initial experience and literature review.

BACKGROUND: Pelvic exenteration and multivisceral resection in colorectal have been described as a curative and palliative intervention. Urinary tract reconstruction in a pelvic exenteration is achieved in most cases with an ileal conduit of Bricker, although different urinary reservoirs have been described. METHODS: A retrospective and observational study of six patients who underwent a pelvic exenteration and urinary tract reconstruction with a double barreled wet colostomy (DBWC) was done, describing the preoperative diagnosis, the indication for the pelvic exenteration, the complications associated with the procedure, and the followup in a period of 5 years. A literature review of the case series reported of the technique was performed. RESULTS: Six patients had a urinary tract reconstruction with the DBWC technique, 5 male patients and one female patient. Age range was from 20 to 77 years, with a medium age 53.6 years. The most frequent complication presented was a pelvic abscess in 3 patients (42.85%); all complications could be resolved with a conservative treatment. CONCLUSION: In the group of our patients with pelvic exenteration and urinary tract reconstruction with a DBWC, it is a safe procedure and well tolerated by the patients, and most of the complications can be resolved with conservative treatment.

[Ileostomy closure in a colorectal surgery unit. Comparative analysis of different techniques]. / Evolución del cierre de ileostomía en una unidad de cirugía colorrectal. Análisis comparativo según la técnica.

INTRODUCTION: The objective of this study is to assess whether the results of loop ileostomy closure in terms of morbidity and hospital stay are influenced by the type of anastomosis and suture used. METHOD: All patients who underwent loop ileostomy closure were reviewed. A retrospective cohort study comparing morbidity and hospital stay according to the type of anastomosis (TT/LL) and the type of suture (hand sewn/mechanical) was performed. RESULTS: From January 2003 to November 2011 a total of 167 loop ileostomy closures were analized. The groups were: type of anastomosis (TT 95/LL 72) and type of suture (manual 105/stapled 62). In 76% of the observed population the underlying disease was cancer. Mortality occurred in one case. The stratified morbidity analysis by type of complications showed no significant differences between the groups in terms of local (7.4% TT, LL 8.3%, 6.7% hand sewn, stapled 9.7%), general (TT 9.5%, 16.7% LL, hand sewn 6.7%, 6.5% stapled) and surgical (TT 15.8%, 19.4% LL, hand sewn 17.1%, 17.7% stapled) complications, nor in the rate of reoperations (TT 6.3%, 6.9% LL, hand sewn 6.7%, 6.5% stapled) and hospital stay in days (TT 7.8, 8 LL, hand sewn 8.6, stapled 6.7) CONCLUSIONS: Closure of loop ileostomy can be performed regardless of the type of suture or anastomosis used, with the same rate of morbidity and hospital stay.

Robotic transanal endoscopic microsurgery in benign rectal tumour.

AIM: To present a case of resection of a rectal tumour by a transanal robotic approach. PATIENT: A 58-year-old woman with a 3-cm tumour located 6 cm proximal to anal verge (uT1N0). RESULTS: We describe the details of the surgical technique. A complete resection with adequate margins was accomplished. The defect was closed with a running suture. Operation time was 180 min. There were no complications and the patient was discharged 24 h after surgery. CONCLUSION: A complete resection of a rectal tumour by a robotic approach is feasible and safe. More studies are needed to clearly define the indications where this new approach can show clear advantages over other transanal resection approaches.

[Use of the round ligament in the repair of large bile duct defects in type II Mirizzi's syndrome]. / Utilización del ligamento redondo en la reparación de defectos amplios de la vía biliar en el síndrome de Mirizzi de tipo II.

Mirizzi's syndrome is a rare complication of cholelithiasis, and type II (cholecystocholedochal fistula) can be a technical challenge due to inflammation and the biliary duct defect. We report two cases that were treated with a simple and little known technique that uses the round ligament as a plasty to seal the large bile duct defect.

[Missed injuries in patients with multiple trauma: analysis of a trauma registry]. / Lesiones inadvertidas en el politraumatizado: análisis de un registro de trauma.

INTRODUCTION: The frequency of missed injuries (MI) in patients with trauma oscillates between 0.5 and 38%, depending on the distinct studies and their inclusion criteria. In the present study, we evaluated the incidence, contributory factors and clinical relevance of these lesions, based on the Severe Trauma Registry of our center. PATIENTS AND METHODS: We retrospectively analyzed a registry of 912 cases of severe trauma, which were prospectively gathered. Of these, 19 patients had a MI (2%). Demographic (age and sex) and clinical variables (severity scales and mechanism of injury) were compared and avoidable contributory factors and clinically relevant MI were evaluated. RESULTS: Of the 19 patients with a MI, 58% had closed injuries. No statistically significant differences were found in any of the variables studied, although penetrating injuries were clearly more frequent in patients with MI than in those without. Forty-seven percent of MI were musculoskeletal, 26% were visceral and 21% were vascular. Sixty-three percent of contributory factors were potentially avoidable and the most frequent reason for MI was incorrect clinical evaluation. Mortality due to lesions with a delayed diagnosis was 21%. CONCLUSIONS: Incorrect clinical evaluation was the avoidable factor that would have the greatest impact on reducing the number of MI. Another factor that clearly contributes to reduction of MI is appropriate interpretation of radiological images in the context of a tertiary survey. All teams treating these patients should periodically evaluate their results and intervene in the factors contributing to missed diagnoses.