Clinical characterization of patients with anal fistula during follow-up of anorectal abscess: a large population-based study.

PURPOSE: Approximately 15-50% of patients with an anorectal abscess will develop an anal fistula, but the true incidence of this entity is currently unknown. The aim of the study was to determine the incidence of anorectal abscess and development of a fistula in a specific population area and to identify potential risk factors associated with demographic, socioeconomic and pre-existing disease (e.g. diabetes and inflammatory bowel disease). METHODS: A longitudinal observational study was designed including a large cohort study in an area with 7,553,650 inhabitants in Spain 1st january 2014 to 31st december 2019. Adults who attended for the first time with an anorectal abscess and had a minimum of 1-year follow-up were included. The diagnosis was made using ICD-10 codes for anorectal abscess and anal fistula. RESULTS: During the study period, we included 27,821 patients with anorectal abscess. There was a predominance of men (70%) and an overall incidence of 596 per million population. The overall incidence of anal fistula developing from abscesses was 20%, with predominance in men, and a lower incidence in the lowest income level. The cumulative incidence of fistula was higher in men and in younger patients (p < 0.0001). On multivariate analysis, patients aged 60-69 years (hazard ratio 2.0) and those with inflammatory bowel disease (hazard ratio 1.8-2.0) had a strong association with fistula development (hazard ratio 2.0). CONCLUSIONS: One in five patients with an anorectal abscess will develop a fistula, with a higher likelihood in men. Fistula formation was strongly associated with inflammatory bowel disease.

Strategies to improve the flow of admissions and hospital stays: a Delphi study of an adaptation of the Appropriateness Evaluation Protocol (AEP).

INTRODUCTION AND AIM: The Appropriateness Evaluation Protocol (AEP) tool analyzes inappropriate hospital stays and admissions. This study aimed to adapt the AEP questionnaire in order to analyse the appropriateness of hospital admissions and stays in our healthcare reality. METHODS: A study was conducted using the Delphi method in which 15 experts in clinical management and hospital care participated. The initial questionnaire items were taken from the first version of the AEP. In the first round, the participants contributed new items that they considered relevant in our current reality. In rounds 2 and 3, they evaluated 80 items according to their relevance using a Likert scale from 1 to 4 (maximum usefulness). Pursuant to the study's design, AEP items were considered adequate if the mean score according to the experts' evaluation was greater than or equal to 3. RESULTS: The participants defined a total of 19 new items. In the end, 47 items earned a mean score greater than or equal to 3. The resulting modified questionnaire include 17 items in "Reasons for Appropriate Admissions," 5 in "Reasons for Inappropriate Admissions," 15 in "Reasons for Appropriate Hospital Stays," and 10 in "Reasons for Inappropriate Hospital Stays." CONCLUSIONS: The identification according to expert opinion of priority items to determine the appropriateness of admissions and extended stays could be used in the future to help create an instrument to be used in our setting.

Airborne ultrasonic application on hot air-drying of pork liver. Intensification of moisture transport and impact on protein solubility.

Nowadays, there is increasing interest in developing strategies for the efficient and sustainable use of animal by-products, such as pork liver. In order to stabilize the product, a prior dehydration stage may be required due to its high perishability. The water removal process of pork liver is energy costly and time consuming, which justifies its intensification using novel technologies. In this sense, the aim of this study was to assess the effect of the airborne application of power ultrasound on the hot air-drying of pork liver. For that purpose, drying experiments were carried out at 30, 40, 50, 60 and 70 °C on pork liver cylinders at 2 m·s-1 with (US) and without ultrasonic application (AIR). The drying process was modeled from the diffusion theory and, in the dried pork liver, the protein solubility was analyzed in order to determine the effect of drying on the protein quality. The ultrasound application increased the drying rate, shortening the drying time by up to 40% at 30 °C. The effect of power ultrasound at high temperatures (60 and 70 °C) was of lesser magnitude. Drying at 70 °C involved a noticeable reduction in the protein solubility for dried liver, while the impact of ultrasound application on the solubility was not significant (p > 0.05).

[Identification and review of low-value clinical practices in General and Digestive Surgery]. / Identificación y revisión de prácticas clínicas de poco valor clínico en Cirugía General y Digestiva.

INTRODUCTION: There are currently widespread clinical practices that, because they do not have been supported by available scientific evidence, are inappropriate for most patients. The objective of the present study was to identify and review these low-value clinical practices in General Surgery. MATERIAL AND METHODS: A systematic review of the specialized databases and the published guidelines with identification of low-value practices in General Surgery was carried out. Of the low-value practices selected for a tertiary and university hospitals through the consensus of expert surgeons, those that do not provide clinical value were identified. RESULTS: In a first search, 4,019 recommendations were found, of which 60 were selected because they were focused on General Surgery. After evaluation by the experts, a total of 29 clinical recommendations were selected to be implemented in a specialty service, which were divided into those corresponding to diagnostic processes (n=9), procedures and surgical technique (n=10) and of perioperative care and medication (n=10). CONCLUSIONS: There is evidence in the literature of some clinical practices that provide little value in General Surgery. The changes referring to do-not-do these practices should be implemented in current clinical practice of this specialty.

Clinical results of infrared coagulation as a treatment of high-grade anal dysplasia: a systematic review.

BACKGROUND: Anal intraepithelial neoplasia (AIN) (or low/high grade squamous intraepithelial neoplasia (L/HSIL)) is the precursor of anal of early invasive anal cancer. Different treatment options for local ablation of localized lesions have been reported. The aim of this study was to analyze the clinical efficacy and safety of infrared coagulation for the treatment of anal dysplasia. METHODS: A search of the literature was performed in 2019 using PubMed and Cochrane to identify all eligible trials published reporting data on the treatment of anal dysplasia with infrared coagulation. The percentage of squamous cell carcinoma of the the anus that developed in the follow-up and results on major complications after treatment were the primary outcomes. RESULTS: Twenty-four articles were identified from which 6 were selected with a total of 360 patients included, with a median age of 41.8 years. Three studies were prospective and 3 retrospective, only one was a randomized trial. All articles included males, 4 articles included HIV-positive women and only one article included non HIV infected males. No patient developed major complications after infrared coagulation therapy. Pain was the most common symptom found after the procedure in the different series and mild bleeding that did not require transfusion was the most common complication occurring in 4 to 78% of patients. Median follow-up was between 4.7 and 69 months. No patient developed squamous cell carcinoma after infrared treatment. Recurrent HSIL varied from 10 to 38%. Two studies reported results from follow-up of untreated patients showing that between 72 and 93% of them had persistent HSIL at last follow-up and 4.8% developed squamous cell carcinoma. CONCLUSIONS: Infrared coagulation is a safe and effective method for ablation of high-grade anal dysplasia that could help prevent anal cancer. Continued surveillance is recommended due to the risk of recurrence.

Assessment of brain activity during voluntary anal sphincter contraction: Comparative study in women with and without fecal incontinence.

BACKGROUND: Voluntary anal sphincter function is driven by an extended network of brain structures, most of which are still unknown. Disturbances in this function may cause fecal incontinence. The aim of this study was to characterize the cerebral areas involved in voluntary contraction of the anorectal sphincter in healthy women and in a group of patients with fecal incontinence by using a standardized functional magnetic resonance imaging (fMRI) protocol. METHODS: This comparative study included 12 healthy women (mean age 53.17 ± 4.93 years) and 12 women with fecal incontinence (56.25 ± 6.94 years). An MRI-compatible anal manometer was used to register voluntary external anal sphincter contraction. During brain fMRI imaging, participants were cued to perform 10-s series of self-paced anal sphincter contractions at an approximate rate of 1 Hz. Brain structures linked to anal sphincter contractions were mapped and the findings were compared between the 2 study groups. KEY RESULTS: There were no differences in the evoked brain activity between the 2 groups. In healthy women, group fMRI analysis revealed significant activations in medial primary motor cortices, supplementary motor area, bilateral putamen, and cerebellum, as well as in the supramarginal gyrus and visual areas. In patients with fecal incontinence, the activation pattern involved similar regions without significant differences with healthy women. CONCLUSIONS & INFERENCES: This brain fMRI-anorectal protocol was able to map the brain regions linked to voluntary anal sphincter function in healthy and women with fecal incontinence.

Surgery for constipation: systematic review and practice recommendations: Graded practice and future research recommendations.

AIM: This manuscript forms the final of seven that address the surgical management of chronic constipation (CC) in adults. The content coalesces results from the five systematic reviews that precede it and of the European Consensus process to derive graded practice recommendations (GPR). METHODS: Summary of review data, development of GPR and future research recommendations as outlined in detail in the 'introduction and methods' paper. RESULTS: The overall quality of data in the five reviews was poor with 113/156(72.4%) of included studies providing only level IV evidence and only four included level I RCTs. Coalescence of data from the five procedural classes revealed that few firm conclusions could be drawn regarding procedural choice or patient selection: no single procedure dominated in addressing dynamic structural abnormalities of the anorectum and pelvic floor with each having similar overall efficacy. Of one hundred 'prototype' GPRs developed by the clinical guideline group, 85/100 were deemed 'appropriate' based on the independent scoring of a panel of 18 European experts and use of RAND-UCLA consensus methodology. The remaining 15 were all deemed uncertain. Future research recommendations included some potential RCTs but also a strong emphasis on delivery of large multinational high-quality prospective cohort studies. CONCLUSION: While the evidence base for surgery in CC is poor, the widespread European consensus for GPRs is encouraging. Professional bodies have the opportunity to build on this work by supporting the efforts of their membership to help convert the documented recommendations into clinical guidelines.

Surgery for constipation: systematic review and clinical guidance: Paper 1: Introduction & Methods.

AIM: This manuscript provides the introduction and detailed methodology used in subsequent reviews to assess the outcomes of surgical interventions with the primary intent of treating chronic constipation in adults and to develop recommendations for practice. METHOD: PRISMA guidance was adhered to throughout. A literature search was performed in public databases between January 1960 and February 2016. Studies that fulfilled strictly-defined PICOS (patients, interventions, controls, outcome, and study design) criteria were included. The process involved two groups of participants: (i): 'a clinical guidance group' of 18 UK experts (including junior support) who performed the systematic reviews and produced summary evidence statements (SES) based strictly on data synthesis in each review. The same group then produced prototype graded practice recommendations (GPRs) based on coalescence of SES and expert opinion; (ii): a European Consensus group of 18 ESCP (European Society of Coloproctology) nominated experts from nine European countries evaluated the appropriateness of each prototype GPR based on published RAND/UCLA methodology. RESULTS: An overview of the search results is provided in this manuscript. A total of 156 studies from 307 full text articles (from 2551 initially screened records) were included, providing data on procedures characterized by: (i) colonic resection (n = 40); (ii) rectal suspension (n = 18); (iii) rectal wall excision (n = 44); (iv) rectovaginal septum reinforcement (n = 47); (v) sacral nerve stimulation (n = 7). The overall quality of evidence was poor with 113/156 (72.4%) studies providing only Oxford level IV evidence. The best evidence was extracted for rectal excisional procedures, where the majority of studies were Oxford level I or II. The five subsequent reviews provide a total of 99 SES (reflecting perioperative variables, efficacy, harms and prognostic variables) that contributed to 100 prototype GPRs covering patient selection, procedural considerations and patient counselling. The final manuscript details the 85/100 GPRs that were deemed appropriate by European Consensus (remaining 15 were all uncertain) and future research recommendations. CONCLUSION: This manuscript and the following 6 papers suggest that the evidence base for surgical management of chronic constipation is currently poor although some expert consensus exists on best practice. Further studies are required to inform future commissioning of treatments and of research funding.

Surgery for constipation: systematic review and practice recommendations: Results III: Rectal wall excisional procedures (Rectal Excision).

AIM: To assess the outcomes of rectal excisional procedures in adults with chronic constipation. METHOD: Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level. RESULTS: Forty-seven studies were identified, providing data on outcomes in 8340 patients. Average length of procedures was 44 min and length of stay (LOS) was 3 days. There was inadequate evidence to determine variations in procedural duration or LOS by type of procedure. Overall morbidity rate was 16.9% (0-61%), with lower rates observed after Contour Transtar procedure (8.9%). No mortality was reported after any procedures in a total of 5896 patients. Although inconsistently reported, good or satisfactory outcome occurred in 73-80% of patients; a reduction of 53-91% in Longo scoring system for obstructive defecation syndrome (ODS) occurred in about 68-76% of patients. The most common long-term adverse outcome is faecal urgency, typically occurring in up to 10% of patients. Recurrent prolapse occurred in 4.3% of patients. Patients with at least 3 ODS symptoms together with a rectocoele with or without an intussusception, who have failed conservative management, may benefit from a rectal excisional procedure. CONCLUSION: Rectal excisional procedures are safe with little major morbidity. It is not possible to advise which excisional technique is superior from the point of view of efficacy, peri-operative variables, or harms. Future study is required.

Use of the Harmonic scalpel for Delorme's procedure.

AIM: There are many surgical techniques that deal with external rectal prolapse but perineal procedures have the advantage of reduced invasiveness. Therefore, despite concerns regarding high recurrence rates, the technique is still used by many surgeons. METHOD: This manuscript and video describe our early clinical experience using the Harmonic scalpel in 11 consecutive patients who underwent a Delorme's procedure for external rectal prolapse. RESULTS: The median age of patients was 76 (range: 30-94) years. There were no intra-operative complications, and the median operative time was 78 min. Intra-operative blood loss was minimal (mean 45 ml; range 20-70 ml). Median length of stay was 2 (range: 0-8) days. Overall morbidity and recurrence were both 18%, with a median follow-up of 15 (range: 1-23) months. Nine patients were operated on by a senior trainee with consultant supervision. CONCLUSION: The advantages of this device are mainly those of ease of mucosal dissection, minimal blood loss and shorter operative time in comparison with published series.

Return to work after general surgery: A comparative study.

PURPOSES: There is scarce information on the time to return to work after general surgery. The aim of this study was to analyze time off work after elective cholecystectomy and to compare the results with those in patients undergoing other surgical interventions. METHODS: Observational and comparative study. Inclusion criteria were: being of working age and undergoing elective laparoscopic cholecystectomy (group 1) or unilateral inguinal hernia or haemorrhoidectomy (group 2). RESULTS: 36 patients were included: 18 patients in each group. Overall, return to work occurred at a mean of 35.7 days, with no significant differences (p=0.656) between groups (group 1: 36.6 days vs. group 2: 35.44 days). The reasons for not returning to work earlier were fear of complications (37.5%), pain control (37.5%), surgeon recommendation (12.5%), and general practitioner recommendation (12.5%). CONCLUSIONS: Time to recovery after laparoscopic cholecystectomy is prolonged. No statistically significant differences with less complex surgical procedures were detected.

Heat-induced gelation mechanism of blood plasma modulated by cysteine.

This work aims to determine changes at molecular level of plasma proteins provoked by adding cysteine (Cys, 0.025% to 0.35% w/v) as a reducing agent and their relationship with the heat-induced gel properties obtained when subsequently the solutions were submitted to a thermal treatment. Results show that adding Cys to plasma solutions at concentrations ≥0.15% actually entails modifications in the secondary structure of their main proteins, that is, serum albumin-α-helix rich-and globulin fraction-ß-sheet rich. Basically, a reduction of the intensity of the infrared (IR) bands assigned to both structures takes place concomitant to an increase of extended structures that seem to act as intermediates for the subsequent protein aggregation process through nonnative intermolecular ß-sheets. Cleavage of disulfide bonds is also evidenced at Cys concentrations ≥0.15% by nonreducing sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), with the effects being directly proportional to Cys concentration. However, beneficial effects on gel hardness are gradually obtained at Cys concentrations ≤0.15%, that is, when the effects at molecular level are at most just budding, while not more improvements on this textural parameter are obtained at higher Cys concentrations. By contrast, water retention capacity is gradually diminishing as Cys concentration increases, but with a significant reduction only obtained at the highest tested concentration. These results suggest a negative effect of Cys on gel microstructure at high concentrations, which probably can be attributed to protein aggregation taking place at room temperature.

Laparoscopic right colectomy: a systematic review and meta-analysis of observational studies comparing two types of anastomosis.

Because of its technical difficulty, totally laparoscopic right colectomy with intracorporeal anastomosis is performed only by a small number of surgeons and most of them use a laparoscopic-assisted technique with extracorporeal anastomosis. This systematic review aims to evaluate differences in outcomes of patients undergoing right laparoscopic colectomy, either with intracorporeal or extracorporeal anastomosis. Electronic databases were searched for studies published between 1991 and 2012. Randomized controlled trials and case-control studies comparing intracorporeal to extracorporeal anastomosis in laparoscopic right colectomy were included in the systematic review. Meta-analytical models were used to evaluate anastomotic leak rate and short-term overall morbidity. Defined primary outcomes of interest were operating time, conversion rate, return of bowel function, anastomotic leak rate, and length of hospital stay. Randomized controlled trials were not found, confirming the paucity of the literature on this topic. Six case-control studies were identified involving 484 patients undergoing right laparoscopic colectomy, 272 with intracorporeal and 212 with extracorporeal anastomosis. Best outcomes seem to be associated with totally laparoscopic right colectomy with intracorporeal anastomosis, especially in terms of return of bowel function, length of hospital stay, and cosmetic results. However, our meta-analysis did not show a significant difference between the two techniques in terms of anastomotic leak rate (OR 0.98; 95 % CI 0.30-3.15) or for short-term overall morbidity (OR 0.68; 95 % CI 0.41-1.12). Comparative analysis of outcomes is in favor of intracorporeal anastomosis. However, the meta-analysis results do not allow us to draw definitive conclusions. Further prospective randomized trials are necessary to confirm our findings.

[Waiting list in general and digestive surgery: patient expectations, quality of life during waiting time and overall satisfaction]. / Lista de espera en Cirugía General y Digestiva: expectativas del paciente, calidad de vida durante la espera y grado de satisfacción.

INTRODUCTION: The structural resources of the National Health system are limited, and therefore early surgery cannot be performed on all patients. The objective was to analyse the satisfaction perceived by the patient as regards the delay of treatment by waiting list of three types of surgery. The influence of expectations on waiting times, and impaired quality of life due to the clinical symptoms during the delay, were studied. MATERIAL AND METHODS: A prospective study was conducted using a postal questionnaire. We compared the expectations (scale of 1 to 5), the impact on quality of life for symptoms (scale of 1 to 5) and the level of patient satisfaction (scale of 1 to 5) with respect to time on the waitng list for cholelithiasis, inguinal hernia and haemorrhoids. The predictors of patient dissatisfaction were analysed. RESULTS: A total of 57 patients were included. When comparing the characteristics of patients with and without satisfaction over time on the waiting list, days on the waiting list (P=.044), the change in the quality of life due to the symptoms (P=.028), and expectations (P<.001) were significantly different between the two groups. In the multivariate analysis, the expectation was associated with patient dissatisfaction as regards the time on waiting list (OR: 3.14 95% CI: 5.91 to 220.73, P<.001). CONCLUSIONS: The level of patient dissatisfaction is associated with expectations about time in waiting list.

Does correlation exist between anorectal manometry and endoanal ultrasound findings in healthy subjects according to age?

BACKGROUND: different studies have demonstrated the correlation between anorectal manometry and endoanal ultrasonography data in patients with fecal incontinence, but there is no almost interest describing the same in healthy subjects according to age. AIMS: to study the possible correlation between anorectal manometry and endoanal ultrasonography data in a homogeneous group of healthy women, also according to age. MATERIAL AND METHODS: prospective observational study of a healthy subjects cohort (n=14). Homogeneous group of healthy volunteer women divided in 2 subgroups according to age. RESULTS: there was no proved correlation between the internal anal sphincter's measurement and the resting pressure in the whole sample as well as the analysis according to age. Neither there was any proved statistically significant correlation between the external anal sphincter´s thickness and the squeeze pressure, in the whole sample and by groups. CONCLUSIONS: it does not exist statistically significant correlation between the thickness of the sphincters and its function in a healthy subjects homogeneous group, neither in 2 groups according to age.