Surgical treatment for colorectal cancer: analysis of the influence of an enhanced recovery programme on long-term oncological outcomes-a study protocol for a prospective, multicentre, observational cohort study.

INTRODUCTION: The evidence currently available from enhanced recovery after surgery (ERAS) programmes concerns their benefits in the immediate postoperative period, but there is still very little evidence as to whether their correct implementation benefits patients in the long term. The working hypothesis here is that, due to the lower response to surgical aggression and lower rates of postoperative complications, ERAS protocols can reduce colorectal cancer-related mortality. The main objective of this study is to analyse the impact of an ERAS programme for colorectal cancer on 5-year survival. As secondary objectives, we propose to analyse the weight of each of the predefined items in the oncological results as well as the quality of life. METHODS AND ANALYSIS: A multicentre prospective cohort study was conducted in patients older than 18 years of age who are scheduled to undergo surgery for colorectal cancer. The study involved 12 hospitals with an implemented enhanced recovery protocol according to the guidelines published by the Spanish National Health Service. The intervention group includes patients with a minimum implementation level of 70%, and the control group includes those who fail to reach this level. Compliance will be studied using 18 key performance indicators, and the results will be analysed using cancer survival indicators, including overall survival, cancer-specific survival and relapse-free survival. The time to recurrence, perioperative morbidity and mortality, hospital stay and quality of life will also be studied, the latter using the validated EuroQol Five questionnaire. The propensity index method will be used to create comparable treatment and control groups, and a multivariate regression will be used to study each variable. The Kaplan-Meier estimator will be used to estimate survival and the log-rank test to make comparisons. A p value of less than 0.05 (two-tailed) will be considered to be significant. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the Aragon Ethical Committee (C.P.-C.I. PI20/086) on 4 March 2020. The findings of this study will be submitted to peer-reviewed journals (BMJ Open, JAMA Surgery, Annals of Surgery, British Journal of Surgery). Abstracts will be submitted to relevant national and international meetings. TRIAL REGISTRATION NUMBER: NCT04305314.

Surgical (close lateral internal sphincterotomy) versus chemical (botulinum toxin) sphincterotomy as treatment of chronic anal fissure.

BACKGROUND AND OBJECTIVE: The aim of this prospective randomized trial was to compare the effectiveness and morbidity of surgical vs chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up period. PATIENTS AND METHOD: Eighty patients with chronic anal fissure were treated either with close lateral internal sphincterotomy (group 1) or with chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter (group 2). RESULTS: Overall healing was 90% in the close sphincterotomy group and 45% in the toxin botulinum group (p < 0.001). There was a group of patients with clinical factors (duration of disease over 12 months and presence of a sentinel pile before treatment) associated with a higher recurrence of anal fissure. Final percentage of incontinence was 5% in the close sphincterotomy group and 0% in the botulinum toxin group (p > 0.05). All incontinent patients were aged more than 50 years. CONCLUSIONS: We recommend surgical sphincterotomy as the first therapeutic approach in patients with clinical factors of recurrence. However, we recommend the use of botulinum toxin in patients older than 50 years or with associated risk factors of incontinence, despite the higher rate of recurrence, since it avoids the greater risk of incontinence seen with surgery.

Surgical (close lateral internal sphincterotomy) versus chemical (botulinum toxin) sphincterotomy as treatment of chronic anal fissure

FUNDAMENTO Y OBJETIVO: Comparar en un estudioprospectivo y aleatorizado la efectividad y morbilidaddel tratamiento con esfinterotomía quirúrgicay toxina botulínica en la fisura anal crónica.PACIENTES Y MÉTODO: Se trató a 80 pacientes confisura anal crónica mediante esfinterotomía lateralinterna cerrada (grupo 1) o esfinterotomíaquímica con la inyección en el esfínter internode 25 U de toxina botulínica (grupo 2).RESULTADOS: La tasa de curación global a los 3años fue del 90% en la esfinterotomía cerrada ydel 45% con la toxina botulínica (p 0.05). Todos los pacientes incontinentestuvieron una edad superior a 50 años.CONCLUSIONES: Recomendamos la esfinterotomíaquirúrgica como la técnica de elección enpacientes con factores de recurrencia. Preferimosla utilización de toxina botulínica en pacientesmayores de 50 años o con factores deriesgo de incontinencia, ya que, a pesar delmayor riesgo de recurrencia, evita el mayorriesgo de incontinencia descrito en la esfinterotomíaquirúrgica

BACKGROUND AND OBJECTIVE: The aim of this prospectiverandomized trial was to compare theeffectiveness and morbidity of surgical vs chemicalsphincterotomy in the treatment of chronicanal fissure after a 3-year follow-up period.PATIENTS AND METHOD: Eighty patients with chronicanal fissure were treated either with close lateralinternal sphincterotomy (group 1) or with chemicalsphincterotomy with 25 U botulinum toxininjected into the internal sphincter (group 2).RESULTS: Overall healing was 90% in the closesphincterotomy group and 45% in the toxinbotulinum group (p 0.05). All incontinentpatients were aged more than 50 years.CONCLUSIONS: We recommend surgical sphincterotomyas the first therapeutic approach in patientswith clinical factors of recurrence. However,we recommend the use of botulinum toxinin patients older than 50 years or with associatedrisk factors of incontinence, despite thehigher rate of recurrence, since it avoids thegreater risk of incontinence seen with surgery