RESUMO
BACKGROUND: Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings. METHODS: Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017). RESULTS: One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection. CONCLUSION: CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.
Assuntos
Pólipos do Colo , Laparoscopia , Idoso , Estudos de Coortes , Colectomia/métodos , Pólipos do Colo/diagnóstico , Colonoscopia/métodos , Feminino , Humanos , Laparoscopia/métodos , Estudos RetrospectivosRESUMO
BACKGROUND: The aim of this study was to analyze the incidence, patterns and prognostic factors of recurrence in patients with complicated colon cancer who had emergency surgery within 24 h of admission. METHODS: A retrospective observational study was performed on patients with obstructing or perforated colon cancer having resection with curative intent between 1996 and 2014 at a single center. Data were obtained from a prospectively maintained database. Patients who had rectal cancer, iatrogenic endoscopic perforation, stage IV disease, palliative surgery, a colonic stent or decompressive colostomy were excluded. RESULTS: The study included 393 patients. Obstruction was observed in 320 patients (81.4%) and perforation in 73 (18.6%). Hartmann's procedure was more frequently performed by general surgeons (7.5% vs 23.3%; p = 0.023). 30-day postoperative mortality was 13.5% (53/393), including 47 (14.7%) obstructed and 6 (8.2%) perforated patients. Postoperative complications (Clavien-Dindo III-IV) occurred in 87 patients (22.1%), including 68 (21.2%) of obstructed and 19 (26.0%) of perforated patients. Anastomotic dehiscence was diagnosed in 52 of 329 (15.8%) patients with primary anastomosis and was higher in the obstructing group than in the perforated group (17.4% vs 7.6%). There was a significantly higher anastomotic dehiscence rate after procedures performed by general surgeons when compared with those performed by colorectal surgeons (10.3% vs 21.3%; p = 0.005; OR 2.81, 95% CI 1.4-5.9). With a median follow-up of 6 years, the recurrence rate was 30.1% (67.4% distant, 22.8% local, 9.8% both). Overall and cancer-related survivals were 68.7% and 77.8%, respectively. The presence of positive nodes, male gender, anastomotic dehiscence and diffuse peritonitis were independent predictors for local recurrence while type of surgeon (general) was an independent factor for distant recurrence. CONCLUSIONS: Male gender, diffuse peritonitis, positive lymph nodes, type of surgeon and postoperative anastomotic dehiscence significantly influence recurrence of colorectal cancer in this series.
Assuntos
Colo/cirurgia , Neoplasias do Colo/patologia , Neoplasias do Colo/cirurgia , Obstrução Intestinal/cirurgia , Perfuração Intestinal/cirurgia , Recidiva Local de Neoplasia/patologia , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/etiologia , Fístula Anastomótica/cirurgia , Quimioterapia Adjuvante , Colectomia/efeitos adversos , Neoplasias do Colo/complicações , Neoplasias do Colo/tratamento farmacológico , Cirurgia Colorretal/estatística & dados numéricos , Emergências , Feminino , Seguimentos , Cirurgia Geral/estatística & dados numéricos , Humanos , Obstrução Intestinal/etiologia , Perfuração Intestinal/etiologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Peritonite/etiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Taxa de SobrevidaRESUMO
PURPOSE: The purpose of this study was to determine whether patients diagnosed with colorectal cancer and synchronous unresectable metastases (stage IV) can benefit from resection of the primary tumor in terms of an improvement in cancer-specific survival. METHODS: Stage IV colorectal cancer patients are eligible for inclusion in a randomized multicenter study carried out in 22 hospitals throughout Spain. Exclusion criteria are rectal tumors below 12 cm from the anal verge or locally advanced tumors, multiple bone or central nervous system metastases, and history of another primary cancer. The parallel design of the trial includes an arm of systemic chemotherapy alone versus an arm of resection of the primary tumor plus systemic chemotherapy after surgery. The primary endpoint of the study is cancer-specific survival that is assessed with a minimum follow-up of 24 months. Secondary endpoints are postoperative morbidity and mortality associated with resection of the primary tumor, complications and need of surgery in patients treated with systemic chemotherapy only, safety of systemic chemotherapy in both treatment strategies, and quality of life. CONCLUSIONS: Confirmation of a survival benefit of surgical resection of the primary tumor in stage IV colorectal cancer patients not amenable to curative therapy is very relevant from a clinical and societal perspective, particularly considering the increase in the incidence and prevalence of colorectal cancer in developed countries. ClinicalTrials.gov Identifier: NCT02015923.
Assuntos
Neoplasias Colorretais/cirurgia , Neoplasias Primárias Múltiplas/cirurgia , Determinação de Ponto Final , Humanos , Consentimento Livre e Esclarecido , Metástase Neoplásica , Tamanho da Amostra , Análise de SobrevidaRESUMO
BACKGROUND: Postoperative ileus is a common problem with significant clinical and economic consequences. We hypothesized that Gastrografin may have therapeutic utility by accelerating the recovery of postoperative ileus after colorectal surgery. The aim of this trial was to study the impact of oral Gastrografin administration on postoperative prolonged ileus (PPI) after elective colorectal surgery. METHODS: The main endpoint of this randomized, double-blinded, controlled trial was time of resolution of PPI. The secondary endpoints were overall hospital length of stay, time to start oral intake, time to first passage of flatus or stools, time of need of nasogastric tube, and need of parenteral nutrition. Included criteria were patients older than 18 years, operated for colonic neoplasia, inflammatory bowel disease, or diverticular disease. There were two treatments: Gastrografin administration and placebo. The sample size was calculated taking into account the average length of postoperative ileus after colorectal resection until tolerance to oral intake. Statistical analysis showed that 29 subjects in each group were needed. RESULTS: Twenty-nine patients per group were randomized. Groups were comparable for age, gender, ASA Physical Status Classification System, stoma construction, and surgical technique. No statistical differences were observed in mean time to resolution between the two groups, 9.1 days (CI 95%, 6.51-11.68) in Gastrografin group versus 10.3 days (CI 6.96-10.29) in Placebo group (P = 0.878). Even if not statistically significant, time of resolution of PPI, overall length of stay, time of need of nasogastric tube, and time to tolerance of oral intake were shorter in the G group. CONCLUSIONS: Gastrografin does not accelerate significantly the recovery of prolonged postoperative ileus after elective colorectal resection when compared with placebo. However, it seems to clinically improve all the analyzed variables.
Assuntos
Cirurgia Colorretal/efeitos adversos , Diatrizoato de Meglumina/uso terapêutico , Fármacos Gastrointestinais/uso terapêutico , Íleus/tratamento farmacológico , Idoso , Método Duplo-Cego , Feminino , Humanos , Íleus/etiologia , Intubação Gastrointestinal , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias , Fatores de TempoRESUMO
BACKGROUND: The evidence is sparse concerning the natural history of acute diverticulitis after successful conservative management. This observational study aimed to evaluate the rate, severity, and need of surgery for recurrence after a first episode of acute diverticulitis successfully managed conservatively. METHODS: All patients admitted for acute diverticulitis between 1994 and 2011 were considered for inclusion in the study. Severity of the first episode, demographic data, comorbidities, management, recurrence, and elective or emergency surgery during the follow-up period were prospectively recorded. RESULTS: The study included 560 patients. The mean follow-up period was of 67.2 ± 44.4 months. Severe diverticulitis was diagnosed in 22.3 % of the cases. Recurrence was observed in 14.8 % of the patients, and the rate of severe recurrence was 3.4 %. Most of the recurrences occurred during the first year of follow-up evaluation. Chronic corticoid therapy (P = 0.043) and the presence of more than one abscess (P < 0.001) were significantly related to recurrence. In the event of a mild recurrence, the first episode was either mild or severe (P = 0.172). In the case of severe recurrence, most patients presented with a previous severe diverticulitis (P < 0.001). During the follow-up period, 6.8 % of the patients needed an elective operation, and 1.4 % of them underwent emergency surgery. CONCLUSION: The rate of severe recurrence after successful nonoperative management of acute diverticulitis was low, and emergency surgery was rare. Prophylactic surgery, even in cases of recovered severe diverticulitis, should be considered on a case-by-case basis. Strict follow-up assessment during the first year is advised.
Assuntos
Doença Diverticular do Colo/terapia , Abscesso/etiologia , Abscesso/terapia , Doença Aguda , Antibacterianos/uso terapêutico , Drenagem , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Hidratação , Seguimentos , Glucocorticoides/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Índice de Gravidade de DoençaRESUMO
PURPOSE: Chemotherapy is established as primary treatment in patients with stage IV colorectal cancer and unresectable metastases. Data from nonrandomized clinical trials have fueled persistent uncertainty if primary tumor resection (PTR) before chemotherapy prolongs survival. We investigated the prognostic value of PTR in patients with newly diagnosed stage IV colon cancer who were not amenable to curative treatment. PATIENTS AND METHODS: Patients enrolled in the multicenter, randomized SYNCHRONOUS and CCRe-IV trials were included in the analysis. Patients with colon cancer with synchronous unresectable metastases were randomly assigned at 100 sites in Austria, Germany, and Spain to undergo PTR or up-front chemotherapy (No PTR group). The chemotherapy regimen was left at discretion of the local team. Patients with tumor-related symptoms, inability to tolerate surgery and/or systemic chemotherapy, and history of another cancer were excluded. The primary end point was overall survival (OS), and the analyses were performed with intention-to-treat. RESULTS: A total of 393 patients were randomly assigned to undergo PTR (n = 187) or no PTR (n = 206) between November 2011 and March 2017. Chemotherapy was not administered to 6.4% in the No PTR group and 24.1% in the PTR group. The median follow-up time was 36.7 months (95% CI, 36.6 to 37.3). The median OS was 16.7 months (95% CI, 13.2 to 19.2) in the PTR group and 18.6 months (95% CI, 16.2 to 22.3) in the No PTR group (P = .191). Comparable OS between the study groups was further confirmed on multivariate analysis (hazard ratio, 0.944 [95% CI, 0.738 to 1.209], P = .65) and across all subgroups. Patients with serious adverse events were more common in the No PTR group (10.2% v 18.0%; P = .027). CONCLUSION: Among patients with colon cancer and synchronous unresectable metastases, PTR before systemic chemotherapy was not associated with prolonged OS.
Assuntos
Neoplasias do Colo , Humanos , Feminino , Masculino , Idoso , Neoplasias do Colo/patologia , Neoplasias do Colo/tratamento farmacológico , Neoplasias do Colo/mortalidade , Pessoa de Meia-Idade , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Estadiamento de Neoplasias , Metástase Neoplásica , Idoso de 80 Anos ou mais , AdultoRESUMO
BACKGROUND: The aim of this study was to analyze factors contributing to prolonged postoperative ileus (POI) after elective bowel resection in patients with colorectal cancer. METHODS: This was a retrospective review of a prospectively maintained database of patients operated on for colorectal cancer during 2006-2009. Patients with abdominal procedures and bowel resection without anastomotic leakage were included. Prolonged POI was defined as no flatus by postoperative day (POD) 6, with or without intolerance to oral intake by POD 6. Variables studied included demographics, prior medical conditions, details of the surgical procedure, and hospital stay. RESULTS: A total of 773 patients met the inclusion criteria. POI occurred in 15.9%. The mean hospital stay was 11 days without POI and 20 days for POI patients (P < 0.001). Factors associated with POI in the univariate analysis were ASA III-IV (P < 0.005), male sex (P < 0.004), smoking (P < 0.015), chronic pulmonary disease (COPD) (P < 0.002), rectal cancer (P < 0.02), and ileostomy (P < 0.001). Multivariate logistic regression analysis showed male sex [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.04-3.5]; COPD (OR 1.9, 95% CI 1.25-31.0), and ileostomy (OR 1.9; 95% CI 1.23-3.07) as risk factors for POI. CONCLUSIONS: The risk of POI seems increased in patients with preoperative COPD and patients with an ileostomy, especially in men. Consideration of these factors could be important for the prevention and treatment of POI.
Assuntos
Colectomia , Neoplasias Colorretais/cirurgia , Íleus/etiologia , Complicações Pós-Operatórias , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Colorretais/mortalidade , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Íleus/epidemiologia , Incidência , Laparoscopia , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
INTRODUCTION: As colo-anal anastomoses continue to have a high risk of post-surgical dehiscence it is recommended to combine this with a protective stoma. The main purpose of this study was to determine the post-operative morbidity and mortality rate in patients operated on using the Turnbull-Cutait (T-C) technique with delayed colo-anal anastomosis without a protective ileostomy. MATERIAL AND METHODS: An observational study was conducted on 17 patients. The surgical indication was classified as "primary" (group I), and "secondary" (group II) when rescue was performed due to complications in the short to long-term after rectal resection. The surgical technique consisted of two stages: 1) low anterior resection, circumferential mucosectomy from the pectinate line, pulling the colon through the anal canal; 2) resection of the pull-through segment and colo-anal anastomosis between the fifth and tenth day. Demographic data, associated comorbidities, and ASA score were recorded, as well as post-surgical complications, post-surgical mortality, and technical failure (defined as performing a definitive stoma). RESULTS: The review consisted of 13 patients in group I and 4 in group II. Twelve patients were operated on due to rectal cancer, one patient due to a recto-vesico-vaginal fistula, two due to rescue of early complications (from the Emergency Department), and two were operated due to chronic complications after rectal resection. Six patients (35.3%) had one or more complications, three of them required new surgery. There were no postoperative deaths. CONCLUSIONS: The T-C could be a first option in cancer of the rectum, with no need for a protective ileostomy. It could be an alternative in urgent re-interventions of patients who have rectal surgery complications.
Assuntos
Canal Anal/cirurgia , Colo/cirurgia , Complicações Pós-Operatórias/mortalidade , Adolescente , Adulto , Idoso , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Adulto JovemRESUMO
PURPOSE: Hartmann's procedure (HP) still remains the most frequently performed procedure for diffuse peritonitis due to perforated diverticulitis. The aims of this study were to assess the feasibility and safety of resection with primary anastomosis (RPA) in patients with purulent or fecal diverticular peritonitis and review morbidity and mortality after single stage procedure and Hartmann in our experience. METHODS: From January 1995 through December 2008, patients operated for generalized diverticular peritonitis were studied. Patients were classified into two main groups: RPA and HP. RESULTS: A total of 87 patients underwent emergency surgery for diverticulitis complicated with purulent or diffuse fecal peritonitis. Sixty (69%) had undergone HP while RPA was performed in 27 patients (31%). At the multivariate analysis, RPA was associated with less post-operative complications (P < 0.05). Three out of the 27 patients with RPA (11.1%) developed a clinical anastomotic leakage and needed re-operation. CONCLUSIONS: RPA can be safely performed without adding morbidity and mortality in cases of diffuse diverticular peritonitis. HP should be reserved only for hemodynamically unstable or high-risk patients. Specialization in colorectal surgery improves mortality and raises the percentage of one-stage procedures.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Diverticulite/complicações , Perfuração Intestinal/complicações , Peritonite/etiologia , Peritonite/cirurgia , Idoso , Anastomose Cirúrgica , Demografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Peritonite/mortalidade , Cuidados Pós-Operatórios , Procedimentos de Cirurgia Plástica , Índice de Gravidade de DoençaRESUMO
INTRODUCTION: The high morbidity and mortality of emergency surgery, has led to the use of endoluminal self-expanding metal implants (stents) in the management of intestinal occlusion. The purpose of this study was to review the results of the management of intestinal occlusion treatment in a Colorectal Surgery Unit in those patients who had a stent implant, and the relationship between chemotherapy and complications. MATERIAL AND METHODS: A retrospective study was carried out on patients treated with a stent in a university hospital between 2004 and 2010. RESULTS: A total of 93 patients were treated, of which 77 were considered palliative for a stage IV neoplasm of the colon with non-resectable metastases or due to a performance status > 2. Other indications were 7 ASA IV patients with acute renal failure, 6 with benign disease, and 3 due to other causes. The technical and clinical success of the procedure was 93.5% and 78.5%, respectively. Delayed occlusion was 19.3% and perforation 6.4%. There was migration (2.1%) and intestinal bleeding (2.1%) and 1.1% with tenesmus. No significant differences were seen between complications and chemotherapy. The overall mortality was 17.2%. CONCLUSIONS: Stents, as a definitive treatment option in palliative patients with and without chemotherapy, is an alternative treatment that is not exempt from complications. We believe that in patients with mortality risk factors and patients with tumours with non-resectable metastases it could be the initial treatment of choice.
Assuntos
Doenças do Colo/cirurgia , Obstrução Intestinal/cirurgia , Stents/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Árvores de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Stage 2 colonic cancer comprises a heterogeneous group of patients with a spectrum of disease, from invasion of the sub-serosa to tumour perforation into visceral peritoneum/adjacent organs. This study evaluates the post-operative outcomes and prognostic factors of patients with both emergency and elective presentations of stage 2 colonic cancer treated with curative intent. METHODS: Retrospective analysis of a prospectively maintained database of adult patients (emergency and elective) who underwent curative surgery for stage 2 colonic cancer in a single tertiary referral centre between 2007 and 2016 was conducted. Multivariate analysis was performed to identify prognostic factors. Measured variables included demographics, complications, histology, disease-free survival and overall survival (OS). RESULTS: A total of 428 patients with stage 2 colonic cancer received curative surgical resection, and negative resection margins were achieved in all cases: T3 group (stage 2A): 316 (73.8%); T4a group (stage 2B): 78 patients (18.2%); and T4b group (stage 2C): 34 (8%). There were 187 (45.7%) post-operative complications, 32 (7.5%) anastomotic leaks and eight (1.9%) 30-day mortalities. Eighty patients (19.3%) died during the follow-up. During the follow-up period, 45 patients developed recurrence (all distant). Multivariate analysis identified age >70 years, American Society of Anesthesiologists grades III-IV and male gender as factors associated with poor OS, while recurrence was higher in those aged over 70 years and with stages 2B-2C disease. CONCLUSION: Surgical morbidity in patients with stage 2 colonic cancer who have undergone curative surgery is high. Older and more co-morbid patients have poorer OS. Stages 2B and 2C colon cancer patients have worse prognosis than those with stage 2A regarding recurrence. Future larger data sets are required to determine the role of transmural spread as a prognostic factor.
Assuntos
Neoplasias do Colo , Recidiva Local de Neoplasia , Adulto , Idoso , Estudos de Coortes , Neoplasias do Colo/patologia , Neoplasias do Colo/cirurgia , Seguimentos , Humanos , Masculino , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Prognóstico , Estudos RetrospectivosRESUMO
PURPOSE: Double-barreled wet colostomy consists of simultaneous urinary and fecal diversions into a lateral colostomy and is indicated after pelvic exenteration or in palliative operations, when complete intestinal and urinary reconstruction is not possible. We report experience at our institution with Double-barreled wet colostomy regarding postoperative and long-term morbidity and mortality. METHODS: All patients who underwent double-barreled wet colostomy construction at our institution from 1980 through 2008 were included in the study. Medical records were reviewed for type and history of the malignant tumor, previous treatments, comorbidity according to the American Society of Anesthesiologists' score, type and length of surgery, length of hospital stay, and postoperative (within 30 days after the operation) and long-term morbidity and mortality. RESULTS: The study comprised 41 patients. The underlying disease was a malignant pelvic tumor in 30 patients (primary in 6 and recurrent in 24 patients) and a nonmalignant disease in 11 patients. Surgical mortality was 2.4%, and the postoperative morbidity rate was 65.9%. Double-barreled wet colostomy-related morbidity observed during follow-up included pyelonephritis (9.8%, with renal deterioration due to chronic pyelonephritis in 2.4%), stenosis of the uretero-colonic anastomosis (2.4%), and lithiasis in the urine reservoir (7.3%). Follow-up was discontinued after a mean of 18.6 (SD, 19.9) months in 14 patients who had been referred from other centers. A total of 27 patients were followed in our center for a mean of 32.2 (range, 1-156) months. Of these, 7 patients are currently alive, 1 with recurrent disease; 14 patients died from local or distant recurrence; and 6 patients died of causes other than malignancy. CONCLUSION: Double-barreled wet colostomy is a safe alternative for patients who need simultaneous urinary and fecal diversion, although the risk of ascending urinary infection must be taken into consideration.
Assuntos
Colostomia/métodos , Exenteração Pélvica , Derivação Urinária/métodos , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-OperatóriasRESUMO
BACKGROUND: The management of colonic obstruction has changed in recent years. In distal obstruction, optimal treatment remains controversial, particularly after the appearance and use of colonic endoluminal stents. The purpose of this study was to review the current treatment of acute malignant large bowel obstruction according to the level of evidence of the available literature. METHODS: A systematic search was conducted in PubMed, MEDLINE, Embase, and Google Scholar for articles published through January 2013 to identify studies of large bowel obstruction and colorectal cancer. Included studies were randomized and nonrandomized controlled trials, reviews, systematic reviews, and meta-analysis. RESULTS: After a literature search of 1,768 titles and abstracts, 218 were selected for full-text assessment; 59 studies were ultimately included. Twenty-five studies of the diagnosis and treatment of obstruction and 34 studies of the use of stents were assessed. CONCLUSIONS: In view of the various alternatives and the lack of high-grade evidence, the treatment of distal colonic obstruction should be individually tailored to each patient.
Assuntos
Colectomia , Neoplasias Colorretais/complicações , Neoplasias Colorretais/cirurgia , Colostomia , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Doença Aguda , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/etiologia , Ensaios Clínicos como Assunto , Colo Sigmoide/cirurgia , Colonoscopia , Neoplasias Colorretais/diagnóstico , Meios de Contraste , Enema , Medicina Baseada em Evidências , Humanos , Íleo/cirurgia , Obstrução Intestinal/diagnóstico , Laparoscopia , Cuidados Paliativos/métodos , Medicina de Precisão , Reto/cirurgia , Stents , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: The colonic pouch is considered as an alternative to the standard straight low anastomosis after resection for rectal cancer. The aim of this prospective randomized trial was to compare short- and long-term functional results of colonic J-pouch (CJP) and transverse coloplasty (TCP) after low anterior resection for rectal cancer. METHODS: Between 2000 and 2005, patients with mid or low rectal cancer scheduled for an elective sphincter-preserving resection were eligible. The primary end point was to compare bowel functional results 6 months and 3 years after ileostomy closure. Fecal incontinence score and a questionnaire that included items for clinical evaluation of bowel function were used. RESULTS: One-hundred six patients were randomized; 54 patients were allocated to the CJP group and 52 in the TCP group. There were no differences between the 2 groups in terms of demographic and clinical data. Overall, postoperative complication rate was 19.8% without differences between the groups. Two patients (1.9%; one in each group) presented with anastomotic dehiscence. Long-term incomplete evacuation rates were 29.2% in the CPT group and 33.3% in the CJP group, without substantial differences. Overall, short- and long-term functional outcomes of both procedures were comparable. No differences were observed in terms of fecal incontinence or in all the items included in the questionnaire. CONCLUSION: TCP reconstruction after rectal cancer resection and coloanal anastomosis is functionally similar to CJP both in short- and long-term outcomes. The TCP technique does not seem to improve significantly the incomplete defecation symptom respect to CJP. REGISTRATION NUMBER: NCT01396928; http://register.clinicaltrial.gov.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Neoplasias Retais/cirurgia , Idoso , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Incontinência Fecal/etiologia , Feminino , Humanos , Ileostomia/efeitos adversos , Ileostomia/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Neoplasias Retais/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The aim of this study was to evaluate and compare the morbidity associated with 2 strategies of treatment of colorectal anastomotic leakage: surgical drainage of anastomosis with loop ileostomy versus anastomotic takedown. METHODS: An observational study of patients operated on for ileocolic or colorectal anastomotic leakage between 2001 and 2009. Patients were classified into 2 groups: group 1, salvage of the anastomosis, and group 2, anastomotic takedown. Mortality and morbidity were assessed. Morbidity and mortality of bowel restoration were also evaluated. RESULTS: Thirty-nine patients were included into group 1 and 54 into group 2. Mortality was 15% for group 1 and 37% for group 2 (P = .022). The rate of patients suitable for stoma reversal was 91% for loop ileostomy and 38% for end stoma (P < .001). Morbidity was 18% after loop ileostomy closure and 71% after end stoma reversal (P = .021). Hospitalization was 10 days and 21 days, respectively (P = .009). There was no mortality. CONCLUSIONS: Salvage of anastomosis with loop ileostomy is an effective strategy to control peritoneal sepsis for colorectal anastomotic leakage.
Assuntos
Fístula Anastomótica/cirurgia , Colo/cirurgia , Drenagem , Ileostomia , Reto/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Fístula Anastomótica/mortalidade , Drenagem/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: To evaluate the probability of recurrence and the virulence of colonic diverticulitis correlated with immunocompromised status. METHODS: Nine hundred thirty-one patients admitted in a single tertiary referral university hospital over a 14-year period were included. Patients were divided into 2 groups: group 1, 166 immunosuppressed patients, and group 2, 765 nonimmunosuppressed patients. The variables studied were sex, age, American Society of Anesthesiologist status, reasons of immunosuppression (eg, chronic use of corticosteroids, transplant recipients, and diseases affecting the immune system), severity of the diverticulitis episode, recurrence, emergency and elective surgery, and morbidity and mortality rates. RESULTS: Two hundred thirteen patients underwent an emergency operation during the first hospitalization and 26 patients in further episodes. One hundred thirty-six patients developed 1 or more recurrent episodes of diverticulitis. The overall recurrence rate was similar in both groups. Patients in group 1 with a severe first episode presented significantly higher rates of recurrence and severity without needing more emergency surgery. Mortality after emergency surgery was 33.3% in group 1 and 15.9% in group 2 (P = .004). CONCLUSIONS: After successful medical treatment of acute diverticulitis, patients with immunosuppression need not be advised to have an elective sigmoidectomy.
Assuntos
Doença Diverticular do Colo/terapia , Hospedeiro Imunocomprometido , Idoso , Antibacterianos/uso terapêutico , Dieta , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Doença Diverticular do Colo/epidemiologia , Emergências , Feminino , Seguimentos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Recidiva , Descanso , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: To evaluate the impact of surgeon specialization on emergency colorectal resection in terms of mortality, morbidity, and type of operation performed. DESIGN: Observational study from January 1, 1993, through December 31, 2006. SETTING: Bellvitge University Hospital, Barcelona, Spain. PATIENTS: A total of 1046 patients underwent emergency colorectal resection. Patients were classified into 2 groups: those operated on by a colorectal surgeon (CS) and those operated on by a general surgeon (GS). MAIN OUTCOME MEASURES: Preoperative variables studied were sex, age, American Society of Anesthesiologists grade, associated medical disease, presentation, reason for surgery, and type of operation. Univariate relations between predictors and outcomes were estimated, and multivariate logistic regression analysis was used to assess the prognostic effect of the combination of the variables. RESULTS: Patients in the CS group underwent a significantly higher percentage of resection and primary anastomosis. The postoperative morbidity rate was 52.2% in the CS group and 60.5% in the GS group (P = .01). The anastomotic dehiscence rate was lower in the CS group (6.2%) than in the GS group (12.1%) (P = .01). Postoperative mortality decreased among patients in the CS group (17.9%) with respect to the patients in the GS group (28.3%) (P < .001). Being operated on by a CS was predictive in both the univariate and multivariate analyses for postoperative complications and mortality, and it was the only variable with predictive value for anastomotic dehiscence. CONCLUSIONS: Specialization in colorectal surgery has a significant influence on morbidity, mortality, and anastomotic dehiscence after emergency operations.
Assuntos
Colectomia/efeitos adversos , Doenças do Colo/cirurgia , Cirurgia Colorretal/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Doenças Retais/cirurgia , Idoso , Anastomose Cirúrgica/efeitos adversos , Colo , Emergências , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/epidemiologia , Reto , Especialidades Cirúrgicas/estatística & dados numéricos , Deiscência da Ferida Operatória/epidemiologia , Deiscência da Ferida Operatória/etiologia , Resultado do TratamentoRESUMO
INTRODUCTION: The introduction of one-stage procedures in emergency colonic surgery many years ago has relegated the use of the Hartmann procedure to the most seriously-ill patients, which has led to the high morbidity and mortality rates associated with this surgical technique. The aim of our study was to investigate our results using Hartmanns procedure and to evaluate several prognostic factors of postoperative mortality in this group of patients. PATIENTS AND METHODS: From January 1995 to December 2000, 79 patients (34 men and 45 women) with a mean age of 71.5 years underwent Hartmanns operation. Almost all the series (91.1%) had comorbidities. In this group of patients, morbidity and mortality were analyzed retrospectively, and a multivariate logistic regression analysis was performed to study prognostic factors of postoperative mortality. RESULTS: The indications for surgery were acute peritonitis (77.2%), intestinal obstruction (18.9%), and lower gastrointestinal hemorrhage (3.7%). The most frequent etiology was acute diverticulitis (36 patients), followed by complicated colorectal carcinoma (18 patients). In 70.9% of the patients (56 patients) one or more postoperative complications was observed. Reoperation was performed in 15 patients (18.9%) and overall postoperative mortality was 45.5%. Renal failure (creatinine > or = 120 micromol/l) and high surgical ASA score (III or IV) reached statistical significance as predictive factors of mortality in these patients (p=.001 and p=.005, respectively). CONCLUSION: The patients who underwent Hartmanns procedure with high surgical ASA score and/or renal failure were at significantly higher risk of mortality.
Assuntos
Doenças do Colo/mortalidade , Doenças do Colo/cirurgia , Serviços Médicos de Emergência , Procedimentos Cirúrgicos Operatórios/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
PURPOSE: The aims of this study were to assess the prognostic value for mortality of several factors in patients with colonic obstruction and to study the differences between proximal and distal obstruction. METHODS: Two-hundred and thirty-four consecutive patients who underwent emergency surgery for colonic obstruction were studied. Patients with an obstructive lesion distal to the splenic flexure were assessed as having a distal colonic obstruction. Resection and primary anastomosis was the operation of choice in selected patients. Alternative procedures were Hartmann's procedure in high-risk patients, subtotal colectomy in cases of associated proximal colonic damage, and colostomy or intestinal bypass in the presence of irresectable lesions. Obstruction was considered proximal when the tumor was situated at the splenic flexure or proximally and a right or extended right colectomy was performed. A range of factors were investigated to estimate the probability of death: gender, age, American Society of Anesthesiologists score, nature of obstruction (benign vs. malign), location of the lesion (proximal vs. distal), associated proximal colonic damage and/or peritonitis, preoperative transfusion, preoperative renal failure, and laboratory data (hematocrit < or = 30 percent, hemoglobin < or = 10 g/dl, and leukocyte count >15,000/mm3). Univariate and multivariate forward steptwise logistic regression analysis was used to study the prognostic value of each significant variable in terms of mortality. RESULTS: One or more complications were detected in 109 patients (46.5 percent). Death occurred in 44 patients (18.8 percent). No differences were observed between proximal and distal obstruction. Age (>70 years), American Society of Anesthesiologists III-IV score, preoperative renal failure, and the presence of proximal colon damage with or without peritonitis were significantly associated with postoperative mortality in the univariate analysis. Only American Society of Anesthesiologists score, presence of proximal colon damage, and preoperative renal failure were significant predictors of outcome in multivariate logistic regression. CONCLUSION: Large bowel obstruction still has a high of mortality rate. An accurate preoperative evaluation of severity factors might allow stratification of patients in terms of their mortality risk and help in the decision-making process for treatment. Such an evaluation would also enable better comparison between studies performed by different authors. Principles and stratification similar to those of distal lesions should be considered in patients with proximal colonic obstruction.