Laparoscopic colon surgery: time to leave the urinary catheter in the operating room?

INTRODUCTION: 'Fast track' guidelines have incorporated multimodal measures to optimize perioperative outcomes in surgery, with laparoscopy being a pivotal component for its advantages in early recovery. In this setting, current recommendations regarding the use of a urinary catheter suggest its removal within the first 24-hours postoperatively.  However, few studies have assessed the feasibility of leaving the operating room without it. The purpose of this study is to compare the perioperative outcomes of patients undergoing elective laparoscopic colonic resections leaving the operating room with and without a urinary catheter. METHODS: A retrospective study was conducted utilizing prospectively collected data from patients undergoing elective colon resections over a 17-month period. The patients were classified into two groups based on the presence or absence of a urinary catheter upon leaving the operating room, and subsequently, their perioperative outcomes were compared. RESULTS: A total of 107 patients met the inclusion criteria (n = 28 with a urinary catheter and n = 79 without). Cancer was the most prevalent diagnosis (83.2%), and right hemicolectomy the most frequently performed surgery (32.7%). Two events of urinary catheter reinsertions were reported, both in the no-catheter group (0% vs 2.53%, p = 0.969), and there were no cases of urinary tract infections. The overall and severe complications rates exhibited no significant differences (25% vs. 26.6%, p = 1, and 7.14% vs. 5.06%, p = 1) and the length of stay was similar (p = 0.220). CONCLUSION: Removing the urinary catheter before leaving the operating room appears to be safe and associated with very low rates of urinary retention in selected patients undergoing laparoscopic colonic or upper rectal resections.

Learning curve and safety of the implementation of laparoscopic complete mesocolic excision with intracorporeal anastomosis for right-sided colon cancer: results from a propensity score-matched study.

BACKGROUND: Retrospective studies and randomized controlled trials support the safety of laparoscopic complete mesocolic excision (CME) for the treatment of right-sided colon cancer (RSCC). Few studies, however, examine the learning curve of this operation and its impact on safety during an implementation period. We aim to evaluate the learning curve and safety of the implementation of laparoscopic CME with intracorporeal anastomosis for RSCC. METHODS: Consecutive patients undergoing a laparoscopic right colectomy with intracorporeal anastomosis for RSCC between January 2016 and June 2023 were included. Clinical, perioperative, and histopathological variables were collected. Correlation and cumulative sum (CUSUM) analyses between the operating time and case number were performed. Breakpoints of the learning curve were estimated using the broken-line model. CME and conventional laparoscopic right colectomy outcomes were compared after propensity score matching (PSM). RESULTS: Two hundred and ninety patients underwent laparoscopic right colectomy during study period. One hundred and eight met inclusion criteria. After PSM, 56 non-CME and 28 CME patients were compared. CME group had a non-statistically significant tendency to a longer operating time (201 versus 195 min; p = 0.657) and a shorter hospital stay (3 versus 4 days; p = 0.279). No significant differences were found in total complication rates or their profile. Correlation analysis identified a significant trend toward operating time reduction with increasing case numbers (Pearson correlation coefficient = - 0.624; p = 0.001). According to the CUSUM analysis, an institutional learning curve was deemed completed after 13 cases and the broken-line model identified three phases: learning (1-6 cases), consolidation (7-13 cases), and mastery (after 13 cases). CONCLUSION: The learning curve of laparoscopic CME for RSCC can be achieved after 13 cases in centers with experience in advanced laparoscopic surgery and surgeons with familiarity with this technique. Its implementation within this setting seems to be as safe as performing a conventional right colectomy.

Resultados perioperatorios de la implementación de la resección completa del mesocolon por vía laparoscópica en cáncer de colon derecho y transverso

Introducción: La técnica de resección completa del mesocolon (RCM) en la hemicolectomía derecha consiste en la disección por planos embriológicos para lograr la resección completa del envoltorio mesocolónico, además de una ligadura vascular central (LVC) con linfadenectomía D3, que no se realiza normalmente con la técnica estándar. Esta técnica se asocia a mejores resultados de sobrevida global y libre de enfermedad que la cirugía convencional en trabajos retrospectivos. Sin embargo, no existen datos de su implementación a nivel nacional. El objetivo de este estudio es evaluar los resultados perioperatorios de la implementación del RCM en un centro universitario en nuestro medio. Materiales y Método: Estudio retrospectivo de cohorte de pacientes consecutivos sometidos a hemicolectomía derecha laparoscópica con técnica de RCM-LVC entre Enero 2022 y Junio 2023. Se recopilaron variables demográficas, perioperatorias, postoperatorias e histopatológicas. Los resultados se analizaron utilizando estadística descriptiva. Resultados: En el periodo, 29 pacientes se sometieron a RCM laparoscópica (mediana de edad 66(57-76) y 15(52%) sexo femenino). La mediana del tiempo quirúrgico fue 202,9 minutos. No hubo casos de conversión, filtración anastomótica, ni mortalidad. Hubo morbilidad en 9 casos (31%) y de estos solo 1(3,4%) fue Clavien-Dindo III (hematoma Pfannenstiel reintervenido). No hubo lesiones vasculares intraoperatorias. Mediana de hospitalización de 3 días. Doce casos (41%) eran etapa II y 8(28%) etapa III. La mediana de linfonodos resecados fue 23(18-28). Conclusión: Esta serie demuestra que la implementación de la RCM-LVC por vía laparoscópica para el tratamiento del cáncer de colon derecho y transverso es factible en centros con experiencia en cirugía colorrectal laparoscópica avanzada.

Introduction: Complete mesocolic excision (CME) consists in the dissection on embryologic planes in order to achieve a complete resection of the mesocolic envelope and performing a central vascular ligation (CVL) with a D3 lymphadenectomy which is not routinely done for standard right colectomies. CME has been associated with better overall survival and disease-free survival in comparison with conventional surgery in retrospective studies. However, there is no data on its implementation in Chile. The aim of this study is to assess the perioperative results of the implementation of CME in our center. Methods: A retrospective cohort study was conducted. Consecutive patients undergoing a laparoscopic right hemicolectomy with CME-CVL between January 2022 and June 2023 were included. Demographic, perioperative, postoperative and histopathological data were collected. Results were analyzed using descriptive statistics. Results: During the study period, 34 patients underwent CME; 29 of them underwent laparoscopic CMECVL (median age 66 (57-76) and 15 (52%) female). The median operating time was 202,9 minutes. There were no cases of conversion, anastomotic leakage or mortality. There was morbidity in 9 cases (31%) and one of these (3,4%) was a Clavien-Dindo III morbidity (reoperation due to a Pfannenstiel haematoma). There were no intraoperative vascular injuries. The median length of stay was 3 days. Twelve cases (41%) were stage II and 8(28%) stage III. The median number of lymph nodes harvested was 23(18-28). Conclusion: This series demonstrate that the implementation of laparoscopic CME-CVL for right and transverse colon cancer is feasible in centers with experience in advanced laparoscopic colorectal cancer.

Clinical features and prognosis of malignant small bowel tumors: Experience from a university hospital in Chile.

BACKGROUND: Small bowel tumors (SBT) are infrequent and represent a small proportion of digestive neoplasms. There is scarce information about SBT in Latin America. AIM: To describe the epidemiology, clinical characteristics, diagnostic methods, and survival of malignant SBTs. METHODS: Retrospective observational study of adult patients with histopathological diagnosis of SBT between 2007 and 2021 in a university hospital in Chile. RESULTS: A total of 104 patients [51.9% men; mean age 57 years] with SBT. Histological type: neuroendocrine tumor (NET) (43.7%, n=38), gastrointestinal stromal tumors (GIST) (21.8%, n=19), lymphoma (17.2%, n=15) and adenocarcinoma (AC) (11.5%, n=10). GIST was more frequent in duodenum (50%; n=12) and NET in the ileum (65.8%; n=25). Metastasis was observed in 17 cases, most commonly from colon and melanoma. Nausea and vomiting were significantly more often observed in AC (p=0.035), as well as gastrointestinal bleeding in GIST (p=0.007). The most common diagnostic tools were CT and CT enteroclysis with an elevated diagnostic yield (86% and 94% respectively). The 5-year survival of GIST, NET, lymphoma and AC were 94.7% (95%CI: 68.1-99.2), 82.2% (95%CI: 57.6-93.3), 40.0% (95%CI: 16.5-82.8) and 25.9% (95%CI: 4.5-55.7%), respectively. NET (HR 6.1; 95%CI: 2.1-17.2) and GIST (HR 24.4; 95%CI: 3.0-19.8) were independently associated with higher survival compared to AC, adjusted for age and sex. CONCLUSIONS: Malignant SBT are rare conditions and NETs are the most common histological subtype. Clinical presentation at diagnosis, location or complications may suggest a more probable diagnosis. GIST and NET are associated with better survival compared to other malignant subtypes.

Risk factors for major complications after surgical treatment of primary ileocecal Crohn's disease. A multicentric Latin American experience.

INTRODUCTION: Complications after ileocecal resection for Crohn's disease (CD) are frequent. The aim of this study was to analyze risk factors for postoperative complications after these procedures. MATERIALS AND METHODS: We conducted a retrospective analysis of patients treated surgically for Crohn's disease limited to the ileocecal region during an 8-year period at 10 medical centers specialized in inflammatory bowel disease (IBD) in Latin America. Patients were allocated into 2 groups: those who presented major postoperative complications (Clavien-Dindo > II), the "postoperative complication" (POC) group; and those who did not, the "no postoperative complication" (NPOC) group. Preoperative characteristics and intraoperative variables were analyzed to identify possible factors for POC. RESULTS: In total, 337 patients were included, with 51 (15.13%) in the POC cohort. Smoking was more prevalent among the POC patients (31.37 vs. 17.83; P = .026), who presented more preoperative anemia (33.33 vs. 17.48%; P = .009), required more urgent care (37.25 vs. 22.38; P = .023), and had lower albumin levels. Complicated disease was associated with higher postoperative morbidity. POC patients had a longer operative time (188.77 vs. 143.86 min; P = .005), more intraoperative complications (17.65 vs. 4.55%; P < .001), and lower rates of primary anastomosis. In the multivariate analysis, both smoking and intraoperative complications were independently associated with the occurrence of major postoperative complications. CONCLUSION: This study shows that risk factors for complications after primary ileocecal resections for Crohn's disease in Latin America are similar to those reported elsewhere. Future efforts in the region should be aimed at improving these outcomes by controlling some of the identified factors.

¿Ha disminuido la colectomía por crisis de colitis ulcerosa? / Has colectomy for moderate-severe active ulcerative colitis decreased?

BACKGROUND: Treatment for moderate-severe active ulcerative colitis (UC) includes steroids, biologic therapy and total colectomy. Aim: To describe the features of patients with moderate to severe active UC, their hospital evolution and need for colectomy. MATERIAL AND METHODS: Non-concurrent cohort study of all patients admitted to our institution with a diagnosis of moderate or severe UC crisis between January 2008 and May 2019. Truelove Witts (TW) criteria were used to categorize disease severity. Twelve-month colectomy-free survival was estimated with Kaplan-Meier survival analysis. Results: One hundred-twenty patients aged 16 to 89 (median 35) years had 160 admissions for acute moderate to severe UC. Median admission per patient was 1 (1-3), and median hospital stay was six days (1-49). Cytomegalovirus and Clostridioides difficile were found in 17.5 and 14.2% of crises, respectively. Corticosteroids were used in all crises and biologic therapy in 6.9% of them. Emergency or elective colectomies were performed in 18.3 and 6.7% of patients, respectively. The need for emergency total colectomy decreased from 24.6 to 7.8% (Risk ratio 3.16, p < 0.01) between de first and second half of the study period. Kaplan-Meier analysis for long term colectomy-free survival in both periods confirmed this decrease (p < 0.01). CONCLUSIONS: Medical treatment for moderate to severe UC crises had a 86.3% success and a small percentage required emergency total colectomy. Emergency surgery decreased in the last decade.

Characteristics of Early-Onset vs Late-Onset Colorectal Cancer: A Review.

Importance: The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer. Observations: Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts. Conclusions and Relevance: The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.

Computed tomography-measured body composition parameters do not influence survival in non-metastatic colorectal cancer.

BACKGROUND: There is an increasing interest in studying the impact of altered body composition parameters and colorectal cancer (CRC) treatment outcomes. The aim of this study is to explore the impact of computed tomography (CT)-measured visceral obesity, sarcopenia and myosteatosis on survival of non-metastatic CRC. METHODS: Consecutive patients with stage I-III CRC who underwent curative-intent treatment between January 2010 and December 2015 were included. By measuring the visceral fat area, and the skeletal muscle index and radiodensity in the pre-operative staging CT, patients were classified as visceral obese, sarcopenic or myosteatotic. The associations between CT-based body composition parameters and survival were assessed using log-rank tests and a Cox regression analysis. RESULTS: Of 359 patients, 263 (73.3%) were visceral obese, 85 (23.7%) sarcopenic and 80 (22.3%) myosteatotic. Overall (OS), cancer-specific (CSS) and disease-free survivals (DFS) at 5 years were 78.8%, 84.7% and 75%, respectively. Myosteatosis and the combination of myosteatosis and visceral obesity were associated with a reduced DFS (hazard ratio 1.67; 95% confidence interval 1.06-2.61 and hazard ratio 1.85; 95% confidence interval 1.15-2.96, respectively). However, after performing a multivariate analysis including other relevant clinicopathological factors, none of the body composition parameters were associated with any long-term outcome measures, even after stratifying by cancer stage. CONCLUSIONS: CT-measured body composition parameters do not independently influence survival in non-metastatic CRC. There is a need for larger cohort studies with standardized patient selection and methodology to confirm these findings.

Implementation of intracorporeal anastomosis in laparoscopic right colectomy is safe and associated with a shorter hospital stay.

Reconstruction after laparoscopic right colectomy (LRC) can be achieved by performing an intracorporeal (IA) or an extracorporeal anastomosis (EA). This study aims to assess the safety of implementing IA in LRC, and to compare its perioperative outcomes with EA during an institution's learning curve. Patients undergoing elective LRC with IA or EA in a teaching university hospital between January 2015 and December 2018 were included. Demographic, clinical, perioperative and histopathological data were collated and outcomes investigated. One hundred and twenty-two patients were included; forty-three (35.2%) had an IA. The main indication for surgery was cancer in both groups (83.7% for IA and 79.8% for EA; p = 0.50). Operative time was longer for IA (180 [150-205] versus 150 [120-180] minutes; p < 0.001). A Pfannenstiel incision was used as extraction site in 97.7% of patients receiving an IA; while a midline incision was used in 97.5% of patients having an EA (p < 0.001). Hospital stay was significantly shorter for IA (3 [3, 4] versus 4 [3-6] days; p = 0.003). There were no differences in postoperative complications rates between groups. There was a 4.7% and 3.8% anastomotic leak rate in the IA and EA group, respectively (p = 1). Re-intervention and readmission rates were similar between groups, and there was no mortality during the study period. The implementation of IA in LRC is safe. Despite longer operative times, IA is associated with a shorter hospital stay when compared to EA in the setting of an institution's learning curve.

Ileal pouch-anal anastomosis in ulcerative colitis: outcomes, functional results, and quality of life in patients with more than 10-year follow-up.

PURPOSE: Ileal pouch-anal anastomosis (IPAA) has become the surgical procedure of choice for patients with ulcerative colitis (UC). IPAA was incorporated into our institution in 1984, and thereafter, more than 200 procedures have been performed. The functional results and morbidity of this surgery have been reported previously. However, long-term functional outcomes and quality of life have not been evaluated. METHODS: As a cohort study, we identified all consecutive patients who underwent IPAA for UC between 1984 and 2017 and selected those with more than 10-year follow-up. Demographic data, morbidity, and pouch survival information were obtained. Long-term functional results and quality of life were evaluated through an e-mail survey using the Öresland score and the Cleveland Global Quality of Life scales, respectively. RESULTS: Of 201 patients, 116 met the inclusion criteria. Median follow-up was 20 (10-34) years. Early post-operative complications (30 days) were observed in 19 (16.4%) patients and 66 (56.9%) presented adverse events. The IPAA preservation rate at 10 and 20 years was 96.5% and 93.1%, respectively. Long-term functional scores presented a median of 6 (1-15) points. IPAA function was satisfactory in 11 (20.0%) patients, acceptable in 18 (32.7%), and deficient in 26 (47.3%). The median score for global quality of life was 0.8 (0.23-1.0) points. CONCLUSION: IPAA as treatment for UC meets the expectations of cure of the disease, maintaining adequate long-term intestinal functionality associated with a good quality of life in most patients.

IMPACT OF A SIMULATED LAPAROSCOPIC TRAINING PROGRAM IN A THREE-YEAR GENERAL SURGERY RESIDENCY.

BACKGROUND: A General Surgery Residency may last between 2-6 years, depending on the country. A shorter General Surgery Residency must optimize residents' surgical exposure. Simulated surgical training is known to shorten the learning curves, but information related to how it affects a General Surgery Residency regarding clinical exposure is scarce. AIM: To analyze the effect of introducing a validated laparoscopic simulated training program in abdominal procedures performed by residents in a three-year General Surgery Residency program. METHODS: A non-concurrent cohort study was designed. Four-generations (2012-2015) of graduated surgeons were included. Only abdominal procedures in which the graduated surgeons were the primary surgeon were described and analyzed. The control group was of graduated surgeons from 2012 without the laparoscopic simulated training program. Surgical procedures per program year, surgical technique, emergency/elective intervention and hospital-site (main/community hospitals) were described. RESULTS: Interventions of 28 graduated surgeons were analyzed (control group=5; laparoscopic simulated training program=23). Graduated surgeons performed a mean of 372 abdominal procedures, with a higher mean number of medium-to-complex procedures in laparoscopic simulated training program group (48 vs. 30, p=0.02). Graduated surgeons trained with laparoscopic simulated training program performed a higher number of total abdominal procedures (384 vs. 319, p=0.04) and laparoscopic procedures (183 vs. 148, p<0.05). CONCLUSIONS: The introduction of laparoscopic simulated training program may increase the number and complexity of total and laparoscopic procedures in a three-year General Surgery Residency.

Impact of a simulated laparoscopic training program in a three-year general surgery residency / Impacto de um programa de treinamento laparoscópico simulado em residência de cirurgia geral de três anos

ABSTRACT Background: A General Surgery Residency may last between 2-6 years, depending on the country. A shorter General Surgery Residency must optimize residents' surgical exposure. Simulated surgical training is known to shorten the learning curves, but information related to how it affects a General Surgery Residency regarding clinical exposure is scarce. Aim: To analyze the effect of introducing a validated laparoscopic simulated training program in abdominal procedures performed by residents in a three-year General Surgery Residency program. Methods: A non-concurrent cohort study was designed. Four-generations (2012-2015) of graduated surgeons were included. Only abdominal procedures in which the graduated surgeons were the primary surgeon were described and analyzed. The control group was of graduated surgeons from 2012 without the laparoscopic simulated training program. Surgical procedures per program year, surgical technique, emergency/elective intervention and hospital-site (main/community hospitals) were described. Results: Interventions of 28 graduated surgeons were analyzed (control group=5; laparoscopic simulated training program=23). Graduated surgeons performed a mean of 372 abdominal procedures, with a higher mean number of medium-to-complex procedures in laparoscopic simulated training program group (48 vs. 30, p=0.02). Graduated surgeons trained with laparoscopic simulated training program performed a higher number of total abdominal procedures (384 vs. 319, p=0.04) and laparoscopic procedures (183 vs. 148, p<0.05). Conclusions: The introduction of laparoscopic simulated training program may increase the number and complexity of total and laparoscopic procedures in a three-year General Surgery Residency.

RESUMO Racional: Residência em Cirurgia Geral pode durar entre 2-6 anos, dependendo do país. Residência mais curta deve otimizar a exposição dos residentes às cirurgias. Sabe-se que o treinamento cirúrgico simulado encurta as curvas de aprendizado, mas a informação relacionada à como isso afeta a residência em relação à exposição clínica é escassa. Objetivo: Analisar o efeito da introdução de um programa de treinamento laparoscópico simulado validado em procedimentos abdominais realizados por residentes em um programa de Residência em Cirurgia Geral de três anos. Métodos: Um estudo de coorte não simultâneo foi desenhado. Quatro gerações (2012-2015) de cirurgiões graduados foram incluídos. Apenas os procedimentos abdominais em que os cirurgiões graduados foram o cirurgião principal foram descritos e analisados. O grupo controle foi de cirurgiões graduados de 2012 sem programa de treinamento laparoscópico simulado. Procedimentos cirúrgicos por ano de programa, técnica cirúrgica, intervenção de emergência ou eletiva e local do hospital (hospitais principais/comunitários) foram descritos. Resultados: Intervenções de 28 cirurgiões graduados foram analisadas (controle=5; programa de treinamento simulado=23). Os cirurgiões graduados realizaram média de 372 procedimentos abdominais, com maior número médio de procedimentos de médio a complexo no grupo de programa de treinamento simulado (48 vs. 30, p=0,02). Cirurgiões graduados treinados com programa de treinamento simulado realizaram número maior de procedimentos abdominais totais (384 vs. 319, p=0,04) e procedimentos laparoscópicos (183 vs. 148, p<0,05). Conclusões: A introdução do programa de treinamento laparoscópico simulado pode aumentar o número e a complexidade dos procedimentos totais e laparoscópicos na Residência em Cirurgia Geral de três anos.

[Management of severe ulcerative colitis: An up-to-date]. / Diagnóstico y manejo de colitis ulcerosa grave: Una mirada actualizada.

Ulcerative Colitis (UC) is a chronic inflammatory disease involving the colon, with alternating periods of remission and activity. Exacerbations can be severe and associated with complications and mortality. Diagnosis of severe UC is based on clinical, biochemical and endoscopic variables. Patients with severe UC must be hospitalized. First line therapy is the use of intravenous corticoids which achieve clinical remission in most patients. However, 25% of patients will be refractory to corticoids, situation that should be evaluated at the third day of therapy. In patients without response, cytomegalovirus infection must be quickly ruled out to escalate to second line therapy with biological drugs or cyclosporine. Total colectomy must not be delayed if there is no response to second line therapy, if there is a contraindication for second line therapies or there are complications such as: megacolon, perforation or massive bleeding. An active management with quick escalation on therapy allows to decrease the prolonged exposure to corticoids, reduce colectomy rates and its perioperative complications.

Diagnóstico y manejo de colitis ulcerosa grave: una mirada actualizada / Management of severe ulcerative colitis: an up-to-date

Ulcerative Colitis (UC) is a chronic inflammatory disease involving the colon, with alternating periods of remission and activity. Exacerbations can be severe and associated with complications and mortality. Diagnosis of severe UC is based on clinical, biochemical and endoscopic variables. Patients with severe UC must be hospitalized. First line therapy is the use of intravenous corticoids which achieve clinical remission in most patients. However, 25% of patients will be refractory to corticoids, situation that should be evaluated at the third day of therapy. In patients without response, cytomegalovirus infection must be quickly ruled out to escalate to second line therapy with biological drugs or cyclosporine. Total colectomy must not be delayed if there is no response to second line therapy, if there is a contraindication for second line therapies or there are complications such as: megacolon, perforation or massive bleeding. An active management with quick escalation on therapy allows to decrease the prolonged exposure to corticoids, reduce colectomy rates and its perioperative complications.

Rates and Predictors of Endoscopic and Clinical Recurrence After Primary Ileocolic Resection for Crohn's Disease.

BACKGROUND AND AIMS: The utility of postoperative medical prophylaxis (POMP) and the treatment of mild endoscopic recurrence remain controversial. METHODS: This study is a retrospective review of patients undergoing a primary ileocolic resection for CD at a single academic center. Endoscopic recurrence (ER) was defined using the Rutgeerts score (RS), and clinical recurrence (CR) was defined as symptoms of CD with endoscopic or radiologic evidence of neo-terminal ileal disease. RESULTS: There were 171 patients who met inclusion criteria. The cumulative probability of ER (RS ≥ i-1) at 1, 2, and 5 years was 29, 51, and 77 %, respectively. The only independent predictors of ER were the absence of POMP (HR 1.50; P = 0.03) and penetrating disease behavior (HR 1.50; P = 0.05). The cumulative probability of CR at 1, 2, and 5 years was 8, 13, and 27 %, respectively. There was a higher rate of clinical recurrence in patients with RS-2 compared to RS-1 on the initial postoperative endoscopy (HR 2.50; P = 0.02). In 11 patients not exposed to POMP with i-1 on initial endoscopy, only 2 patients (18 %) progressed endoscopically during the study period while 5 patients (45 %) regressed to i-0 on subsequent endoscopy without treatment. CONCLUSIONS: Postoperative medical prophylaxis decreased the likelihood of ER while certain phenotypes of CD appear to increase the risk of developing ER and CR. There may be a role for watchful waiting in patients with mild endoscopic recurrence on the initial postoperative endoscopy.

Insuficiencia intestinal secundaria a síndrome de intestino corto: resultados de un programa multidisciplinario de rehabilitación intestinal / Intestinal failure due to short bowel syndrome: impact of a multidisciplinary intestinal rehabilitation program

Background: In patients suffering intestinal failure due to short bowel, the goal of an Intestinal Rehabilitation Program is to optimize and tailor all aspects of clinical management, and eventually, wean patients off lifelong parenteral nutrition. Aim: To report the results of our program in patients suffering intestinal failure. Patients and Methods: A registry of all patients referred to the Intestinal Failure unit between January 2009 and December 2015 was constructed. Initial work up included prior intestinal surgery, blood tests, endoscopic and imaging studies. Also demographic data, medical and surgical management as well as clinical follow-up, were registered. Results: Data from 14 consecutive patients aged 26 to 84 years (13 women) was reviewed. Mean length of remnant small bowel was 100 cm and they were on parenteral nutrition for a median of eight months. Seven of 14 patients had short bowel secondary to mesenteric vascular events (embolism/thrombosis). Medical management and autologous reconstruction of the bowel included jejuno-colic anastomosis in six, enterorraphies in three, entero-rectal anastomosis in two, lengthening procedures in two, ileo-colic anastomosis in one and reversal Roux-Y gastric bypass in one. Thirteen of 14 patients were weaned off parenteral nutrition. Conclusions: Our Multidisciplinary Intestinal Rehabilitation Program, allowed weaning most of the studied patients off parenteral nutrition.

Resultados inmediatos y alejados del reservorio ileal con anastomosis reservorio-anal practicado en forma simultánea o diferida con la proctocolectomía en pacientes portadores de colitis ulcerosa / Ileal pouch-anal anastomosis performed simultaneously or delayed with the proctocolectomy: short and long-term results in patients with ulcerative colitis

Objetivo: Analizar las diferencias en los resultados quirúrgicos entre 2 grupos en colitis ulcerosa: proctocolectomía, reservorio ileal y anastomosis reservorio-anal (RIARA), simultáneo con la proctocolectomía (grupo 1) o diferido (grupo 2). Material y método: Estudio retrospectivo en 126 pacientes sometidos a RIARA. En todos los pacientes se confeccionó un RIARA en «J¼, excepto en 4 que se hizo en «S¼. Todos fueron protegidos con ileostomía. Complicaciones Clavien-Dindo II-V fueron registradas. Resultados: Pacientes con una mediana de edad de 37 años (12-61), 72 eran de género femenino (57%). Se practicó proctocolectomía y RIARA en 24 pacientes (19%) y proctectomía y RIARA en 102 (81%). Se observaron complicaciones postoperatorias en 19 pacientes (13%). Infección de la herida y sepsis pelviana, en 4% respectivamente, fueron las más frecuentes. Tres pacientes fueron reintervenidos: 2 por hemoperitoneo y uno por necrosis isquémica del reservorio. No hubo mortalidad postoperatoria. No se observó diferencia significativa en la morbilidad postoperatoria entre los grupos. Se observaron complicaciones a largo plazo en 48 pacientes (38%): obstrucción intestinal en 18 pacientes (14%), fístula reservorio-vaginal (FRV) en 9 (12,5%), y reservoritis crónica en 8 (6,9%) fueron las más frecuentes. Al comparar los 2 grupos, se observó mayor frecuencia de FRV en el grupo 1 (p = 0,02). Conclusión: En este estudio no se demostró diferencia en la morbilidad postoperatoria entre el grupo 1 y 2. En los resultados alejados hubo mayor frecuencia significativa de FRV en el grupo 1.

Aim: To compare the surgical results of both groups: Simultaneous with the proctocolectomy (SRP) (group 1) or delayed after colectomy (DRP) (group 2). Material and methods: Retrospective study on 126 patients submitted to RP. All patients had a J-pouch, except 4 S. All of them protected with a loop ileostomy. The median time between colectomy and IPAA was 5 months (4-6 range). Clavien-Dindo II-V complications were registered. Results: 126 patients had IPAA. Age median 37 years (12-61 range); 72 (57%) women. SRP in 24 (19%) and DRP was performed in 102 (81%). Postoperative complications were recorded in 19 patients (13%). Wound infection and pelvic sepsis were observed in 4% each. Three patients needed early reoperation: two for hemoperitoneum and one for ischemic necrosis of the pouch. There was no post-operative mortality. No significant difference in 30 days postoperative complication rate was found between SRP and DRP. On long-term follow-up: Intestinal obstruction in 18 patients (14%), pouch-vaginal fistula (PVF) in 9 (12.5%) and chronic pouchitis in 8 (6.9%) were the most common complications. PVF was significantly more frequent on group 1. Conclusion: In this series, no significant difference was found in the early surgical results between group 1 and 2. In the long term, PVF was significantly more common in group 1.

[Benefit of adjuvant 5-fluorouracil based chemotherapy for colon cancer: a retrospective cohort study]. / Beneficio de la quimioterapia adyuvante en pacientes con cáncer de colon: cohorte retrospectiva de un hospital clínico universitario.

BACKGROUND: Multiple clinical trials have demonstrated the benefits of adjuvant 5-fluorouracil-based chemotherapy for patients with resectable colon cancer (CC), especially in stage III. AIM: To describe the clinical characteristics of a cohort of CC patients treated at a single university hospital in Chile since 2002, and to investigate if chemotherapy had an effect on survival rates. MATERIAL AND METHODS: Review of a tumor registry of the hospital. Medical records of patients with CC treated between 2002 and 2012 were reviewed. Death certificates from the National Identification Service were used to determine mortality. Overall survival was described using the Kaplan-Meier method. A multivariate Cox proportional hazard regression model was also used. RESULTS: A total of 370 patients were treated during the study period (202 in stage II and 168 in stage III). Adjuvant chemotherapy was administered to 22 and 70% of patients in stage II and III respectively. The median follow-up period was 4.6 years. The 5-year survival rate for stage II patients was 79% and there was no benefit observed with adjuvant chemotherapy. For stage III patients, the 5-year survival rate was 81% for patients who received adjuvant chemotherapy, compared to 56% for those who did not receive chemotherapy (hazard ratio (HR): 0.29; 95% confidence interval (CI): 0.15-0.56). The benefit of chemotherapy was found to persist after adjustment for other prognostic variables (HR: 0.47; 95% CI: 0.23-0.94). CONCLUSIONS: Patients with colon cancer in stage III who received adjuvant chemotherapy had a better overall survival.