Isoperistaltic versus antiperistaltic ileocolic anastomosis. Does it really matter? Results from a randomised clinical trial (ISOVANTI).

BACKGROUND: Right hemicolectomy is a very common surgery. Many studies compare different options for laparoscopic ileocolic anastomoses: intra- or extracorporeal; handsewn or stapled; side-to-side or end-to-side. However, there are no studies about the influence that peristalsis could have on this anastomosis. The aim of this study is to compare safety and feasibility of isoperistaltic and antiperistaltic anastomosis in terms of postoperative morbidity and mortality between both groups. The secondary endpoint is to compare long-term functional outcomes (chronic diarrhoea) and quality of life (GIQLI questionnaire) after a 1-year follow-up period. METHODS: A double-blind, randomised, prospective trial in patients undergoing scheduled surgery for right colon cancer with laparoscopic right hemicolectomy and isoperistaltic (ISO) or antiperistaltic (ANTI) ileocolic anastomoses. RESULTS: Hundred and eight patients were included in the study. Patients were randomised either to isoperistaltic or antiperistaltic configuration (54 ISO/ANTI). No significant differences in baseline variables were found. No differences in surgical time (130 [120-150] min ISO vs. 140 [127-160] ANTI, p = 0.481), nor in anastomotic time (19 [17-22] vs. 20 [16-25], p = 0.207) and nor in postoperative complications: 37.0% ISO versus 40.7% ANTI, (p = 0.693) were found. There were no differences in postoperative ileus (p = 0.112) nor in anastomotic leakage (3.7% vs. 5.56%, p = 1.00). Differences in "time to first flatus" and "time to first deposition" were found in favour of the antiperistaltic group (p = 0.004 and p = 0.017). Anastomotic configuration did not influence hospital stay (3 days [2-6] isoperistaltic vs. 3 [2-4] antiperistaltic, p = 0.236). During follow-up, there were no differences between the two groups at 1, 6 and 12 months (p = 0.154, p = 0.498 and p = 0.683), nor in chronic diarrhoea rates in GIQLI scores (24% ISO vs. 31.4% ANTI, p = 0.541). CONCLUSIONS: The isoperistaltic and antiperistaltic ileocolic anastomosis present similar results in terms of performance, safety and functionality. However, further studies must be carried out in order to assess relationship between postoperative ileus and anastomosis configuration. TRIAL REGISTRATION: Randomised Clinical trial (Identifier: NCT02309931).

Reintervención tras complicaciones en cirugía laparoscópica colorrectal. ¿Aporta ventajas el abordaje laparoscópico? / Reoperation after laparoscopic colorectal surgery. Does the laparoscopic approach have any advantages?

Introducción: El abordaje laparoscópico en la cirugía por complicaciones colorrectales es controvertido. Sin embargo, puede proporcionar ventajas sobre la cirugía abierta. El objetivo del estudio es comparar el abordaje laparoscópico vs. el abordaje abierto en la reintervención por complicaciones tras cirugía colorrectal. Métodos: Se han analizado de forma retrospectiva, sobre una base de datos prospectiva, los pacientes intervenidos mediante cirugía laparoscópica colorrectal desde enero de 2006 a diciembre de 2015. Los pacientes que requirieron reintervenciones urgentes por complicaciones en el postoperatorio se dividieron según el abordaje (cirugía laparoscópica [CL] y cirugía abierta [CA]) y según su gravedad clínica (en función del índice de peritonitis de Mannheim [IPM]). Resultados: De 763 pacientes, 40 requirieron cirugía urgente (24 CA/16 CL). Se realizaron más ileostomías en el grupo CL (68,7% vs. 29,2%) y más colostomías en el grupo CA (37,5% vs. 6,2%), p<0,05. El IPM fue mayor en el grupo CA (27,31±6,47 [19-35] vs. 18,4±7,2 [11-24], p<0,001). La estancia hospitalaria tras la reintervención, tolerancia oral e infección de herida quirúrgica fueron favorables en CL (p<0,05). En pacientes con un IPM≤26, el abordaje laparoscópico mostró menor estancia hospitalaria, menor permanencia en unidad de críticos, tolerancia oral más temprana y menor infección de herida quirúrgica (p<0,05). Conclusiones: El abordaje laparoscópico en la reintervención por complicaciones tras cirugía colorrectal laparoscópica asocia una recuperación más rápida objetivada en un inicio precoz de tolerancia oral, menor estancia hospitalaria y menor tasa de hernia incisional en pacientes con bajo índice de gravedad (AU)

Introduction: The laparoscopic approach in colorectal complications is controversial because of its difficulty. However, it has been proven that it can provide advantages over open surgery. The aim of this study is to compare laparoscopic approach in reoperations for complications after colorectal surgery with the open approach taking into account the severity of the patient prior to reoperation. Methods: Patients who underwent laparoscopic colorectal surgery from January 2006 to December 2015 were retrospectively reviewed. Patients requiring urgent surgical procedures for complications in the postoperative period were divided in two groups: laparoscopic surgery (LS) and open surgery (OS). To control clinical severity prior to reoperation, The Mannheim Peritonitis Index (MPI) was calculated. Results: A total of 763 patients were studied, 40 required urgent surgery (24 OS/16 LS). More ileostomies were performed in the LS group (68.7% vs. 29.2%) and more colostomies in the OS group (37.5% vs. 6.2%), p<0.05. MPI was higher in OS group (27.31±6.47 [19-35] vs. 18.36±7.16 [11-24], p<0.001). Hospital stay after re-intervention, oral tolerance and surgical wound infection, were favorable in LS (p<0.05 in all cases). In patients with MPI score ≤26, laparoscopic approach showed shorter hospital stay after re-intervention, less stay in the critical care unit after re-intervention, earlier start of oral tolerance and less surgical wound infection (p<0.05). Conclusions: A laparoscopic approach in re-intervention for complications after laparoscopic colorectal surgery associates a faster recovery reflected in a shorter hospital stay, earlier start of oral tolerance and a lower abdominal wall complication rate in patients with low severity index (AU)

Reoperation after laparoscopic colorectal surgery. Does the laparoscopic approach have any advantages? / Reintervención tras complicaciones en cirugía laparoscópica colorrectal. ¿Aporta ventajas el abordaje laparoscópico?

INTRODUCTION: The laparoscopic approach in colorectal complications is controversial because of its difficulty. However, it has been proven that it can provide advantages over open surgery. The aim of this study is to compare laparoscopic approach in reoperations for complications after colorectal surgery with the open approach taking into account the severity of the patient prior to reoperation. METHODS: Patients who underwent laparoscopic colorectal surgery from January 2006 to December 2015 were retrospectively reviewed. Patients requiring urgent surgical procedures for complications in the postoperative period were divided in two groups: laparoscopic surgery (LS) and open surgery (OS). To control clinical severity prior to reoperation, The Mannheim Peritonitis Index (MPI) was calculated. RESULTS: A total of 763 patients were studied, 40 required urgent surgery (24 OS/16 LS). More ileostomies were performed in the LS group (68.7% vs. 29.2%) and more colostomies in the OS group (37.5% vs. 6.2%), p<0.05. MPI was higher in OS group (27.31±6.47 [19-35] vs. 18.36±7.16 [11-24], p<0.001). Hospital stay after re-intervention, oral tolerance and surgical wound infection, were favorable in LS (p<0.05 in all cases). In patients with MPI score ≤26, laparoscopic approach showed shorter hospital stay after re-intervention, less stay in the critical care unit after re-intervention, earlier start of oral tolerance and less surgical wound infection (p<0.05). CONCLUSIONS: A laparoscopic approach in re-intervention for complications after laparoscopic colorectal surgery associates a faster recovery reflected in a shorter hospital stay, earlier start of oral tolerance and a lower abdominal wall complication rate in patients with low severity index.

Torsión e infarto omental: una infrecuente complicación tardía del bypass gástrico / Omenal torsion and infarction: An unusual complication after Roux-en-Y Gastric Bypass

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El colgajo V-Y como método de reparación de defectos perianales extensos / V-Y advancement flaps for extensive perianal defect repair

INTRODUCCIÓN: Algunas enfermedades perianales precisan cirugías agresivas que crean la necesidad de recurrir a técnicas reparadoras para reconstruir la integridad de esta región. El objetivo de este estudio es analizar los resultados a corto y largo plazo tras reconstrucción perianal con colgajos V-Y. MÉTODO: Se ha revisado retrospectivamente nuestra base de datos institucional prospectiva (2000-2013), y se ha incluido en el presente análisis a todos los pacientes a los que se ha realizado una reconstrucción perianal con colgajo V-Y, tras escisión amplia perianal por enfermedad benigna o maligna. Se recogieron datos demográficos, quirúrgicos y la morbilidad a corto y largo plazo. RESULTADOS: Se analizó a un total de 10 pacientes, 6 varones y 4 mujeres, con edad media de 58,1 ± 17,4 años. El tiempo quirúrgico fue 143,5 ± 41,3 min y la estancia hospitalaria media tras la cirugía 7,8 ± 7,7 días. En 8 pacientes aparecieron complicaciones postoperatorias: dehiscencia parcial del colgajo (n = 6) y estenosis anal tardía (n = 4). En ningún caso se produjo la pérdida del colgajo. Siete pacientes presentaron buenos resultados en cuanto a la continencia anal, 2 pacientes incontinencia variable y en un caso se realizó una colostomía terminal por incontinencia grave. CONCLUSIÓN: Los colgajos V-Y son una técnica factible y efectiva para cubrir grandes defectos tras cirugías perianales agresivas; sin embargo, no están exentos de morbilidad postoperatoria

OBJECTIVES: Some perianal pathologies require aggressive surgery that will need techniques to allow to re-establish the integrity of the perianal region. The purpose is to analyze short and long term results after perineal reconstruction with V-Y flaps. OBJECTIVES: Some perianal pathologies require aggressive surgery that will need techniques to allow to re-establish the integrity of the perianal region. The purpose is to analyze short and long term results after perineal reconstruction with V-Y flaps. METHODS: A retrospective review of prospectively collected database was conducted at Virgen de la Arrixaca's Hospital in Murcia (España) between January 2000 and December 2013. The study includes all patients who underwent a perineal reconstruction with V-Y flaps. Demographic and surgical data and short-/long- term morbidity was recorded. RESULTS: 10 patients were included, 6 males and 4 females. The average age was 58,1 ± 17,4 years. Surgical indication included both malignant and benign pathologies. Operating time was 143,5 ± 41,3 min. R0 resection was performed in all cases although histopathological analysis showed involvement of the deeper margin in 3 cases. Length of hospital stay was 7,8 ± 7,6 days. Regarding complications: 6 patients had partial dehiscence of the flap. None of the patients lost the flap completely. The most frequent late complication was anal stenosis (n = 4). Follow up showed total continence in 7 patients. Two patients had variable fecal and/or flatus incontinence. A colostomy was made in one case due to severe incontinence. CONCLUSIONS: V-Y flaps are an effective and feasible technique to cover large perianal defects after aggressive surgeries. However, this technique is not free of postoperative morbidity

V-Y advancement flaps for extensive perianal defect repair. / El colgajo V-Y como método de reparación de defectos perianales extensos.

OBJECTIVES: Some perianal pathologies require aggressive surgery that will need techniques to allow to re-establish the integrity of the perianal region. The purpose is to analyze short and long term results after perineal reconstruction with V-Y flaps. METHODS: A retrospective review of prospectively collected database was conducted at Virgen de la Arrixaca's Hospital in Murcia (España) between January 2000 and December 2013. The study includes all patients who underwent a perineal reconstruction with V-Y flaps. Demographic and surgical data and short-/long- term morbidity was recorded. RESULTS: 10 patients were included, 6 males and 4 females. The average age was 58,1±17,4 years. Surgical indication included both malignant and benign pathologies. Operating time was 143,5±41,3min. R0 resection was performed in all cases although histopathological analysis showed involvement of the deeper margin in 3 cases. Length of hospital stay was 7,8±7,6 days. Regarding complications: 6 patients had partial dehiscence of the flap. None of the patients lost the flap completely. The most frequent late complication was anal stenosis (n=4). Follow up showed total continence in 7 patients. Two patients had variable fecal and/or flatus incontinence. A colostomy was made in one case due to severe incontinence. CONCLUSIONS: V-Y flaps are an effective and feasible technique to cover large perianal defects after aggressive surgeries. However, this technique is not free of postoperative morbidity.

Tratamiento de la hemorragia presacra tras cirugía colorrectal mediante el uso del balón de Bakri / Treatment of presacral bleeding after colorectal surgery with Bakri balloon

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