Fournier's gangrene and fecal diversion. When, in which patients, and what type should I perform?

INTRODUCTION: Fournier's gangrene (FG) is a necrotizing fasciitis affecting the perineum and urogenital tissue. The mortality rate is high although early detection and aggressive debridement can reduce mortality by up to 16%. The prevalence of sequelae is very high and a colostomy is often necessary to control the perineal wound. MATERIAL AND METHODS: A retrospective study was carried out to recruit all patients operated on by the General Surgery and Urology Departments with a diagnosis of GF at the University Hospital over 22 years. Mortality, the Fournier gangrene severity index (FGSI), and fecal diversion (either surgical (colostomy) or straight (Flexi-seal)) are collected. RESULTS: A total of 149 patients met the inclusion criteria. FG's most frequent cause was a perianal abscess (107 patients-72%). Eighteen patients (12%) died of a specific cause of FG. Age (p = 0.014) and patients with an oncological history (p = 0.038) both were the only mortality risk factors for mortality according to logistic regression. Fifty patients required some form of fecal diversion in the postoperative period (32 colostomies and 18 Flexi-seal). Neither the use of postoperative fecal diversion (surgical or Flexi-seal) nor the timing of its use had any effect on postoperative mortality. CONCLUSIONS: One in eight patients died in the immediate postoperative period secondary to FG. Despite improved outcomes, 22% required a colostomy during admission. However, neither the performance of a colostomy nor the timing was associated with decreased FG-associated mortality. Non-invasive methods should be used first and surgical bowel diversion should be postponed as long as possible.

Quality of life and outcomes after rubber band ligation for haemorrhoidal disease.

PURPOSE: The main objective of this study was to assess the impact on quality of life after rubber band ligation (RBL) in patients with symptomatic grade II-III haemorrhoids who did not improve after 6 months of conservative treatment, using quality of life scores. METHODS: This was a prospective cohort observational study where patients with haemorrhoidal disease and indication for RBL were included between December 2019 and December 2020. RBL was offered as first-line treatment in this group. Patient´s quality of life was assessed by scores: HDSS (Hemorrhoidal Disease Symptom Score) and SHS (Short Health Scale).Secondary objectives were: to evaluate the rate of patients requiring one or more RBL procedures, to establish the overall success rate of RBL and to analyse complications. RESULTS: A total of 100 patients were finally included. Regarding the impact on quality of life after RBL, a significant reduction was found in the HDSS and SHS scores (p < 0.001). The main improvement was found in the first month and it was maintained until the sixth month. A high degree of satisfaction with the procedure was reported by 76% of patients. The overall success rate of banding was 89%. A 12% complication rate was detected, the most frequent complication was severe anal pain (58.3%) and self-limiting bleeding (41.7%). CONCLUSION: Rubber band ligation, as a treatment for symptomatic grade II-III haemorrhoids that do not respond to medical treatment, leads to a significant improvement in patients' symptoms and quality of life. It also has a high degree of satisfaction between patients.

Upfront surgery versus self-expanding metallic stent as bridge to surgery in left-sided colonic cancer obstruction: A multicenter observational study.

BACKGROUND: Oncological outcomes of self-expanding metallic stent used as a bridge to surgery in potential curative patients with left-sided colonic cancer obstruction remain unclear. The aim of this study was to investigate perioperative and mid-term oncological outcomes of 2 of the currently most commonly performed treatments in left-sided colonic cancer obstruction. METHODS: This is a retrospective multicenter study including patients with left-sided colonic cancer obstruction treated with curative intent between 2013 and 2017. The presence of metastasis at diagnosis was an exclusion criterion. The primary outcome was to evaluate the noninferiority, in terms of overall survival, of bridge to surgery strategy compared with emergency colonic resection. The secondary outcomes were perioperative morbimortality, disease free survival, local recurrence, and distant recurrence. RESULTS: A total of 564 patients were included, 320 in the emergency colonic resection group and 244 in the bridge to surgery group. Twenty-seven patients of the bridge-to-surgery group needed urgent operation. Postoperative morbidity rates were statistically higher in the emergency colonic resection group (odds ratio [95% confidence interval] 0.37 [0.24-0.55], P < .001). There was no difference in 90-day mortality between groups (odds ratio [95% confidence interval] 0.85 [0.36-1.99], P = .702). The median follow-up was 3.80 years (2.29-4.92). The results show the noninferiority of bridge to surgery versus emergency colonic resection in terms of overall survival (hazard ratio [95% confidence interval) 0.78 [0.56-1.07], P = .127). There were no differences in disease free survival, distant recurrence, and local recurrence rates between bridge to surgery and emergency colonic resection groups. CONCLUSION: Self-expanding metallic stent as bridge to surgery might not lead to a negative impact on the long-term prognosis of the tumor compared with emergency colonic resection in expert hands and selected patients.

Reconstrucción del defecto de exenteración pélvico/perineal extendida con colgajo libre compuesto dorsal ancho-escapular-paraescapular y malla. La lógica en la elección / Reconstruction of extended pelvic/perineal exenteration defect with a composite latissimus dorsi-scapular-parascapular free flap and a mesh. The rationale behind the technique

Presentamos los fundamentos funcionales y reconstructivos en un caso de exenteración pélvica extendida. El propósito es analizar el defecto quirúrgico y los requerimientos reconstructivos, aspectos no suficientemente descritos en la literatura. Se trata de un varón de 62 años, con carcinoma epidermoide perineal de origen uretral (82x117x108 mm) que invadía vejiga, pelvis y fosa pararrectal. El defecto escisional fue reconstruido con un colgajo compuesto dorsal ancho-escapular-paraescapular y una malla bicapa (polipropileno y politetrafluoroetileno extendido). Describimos una reconstrucción multiplanar orientada a 3 requerimientos funcionales definidos: 1.- soporte visceral para evitar la herniación perineal; 2.- colapso del espacio muerto para minimizar el riesgo de infección; y 3.- cobertura cutánea estable en una región exigente. Sin complicaciones postoperatorias en el corto o largo plazo, el paciente puede deambular adecuadamente y se encuentra libre de enfermedad 1 año después de la intervención. Hasta donde hemos podido conocer, este caso presenta por primera vez el uso del colgajo compuesto descrito en la reconstrucción del defecto de exenteración pélvica

The article reports the functional, reconstructive rationale behind a case of extended pelvic exenteration. Our aim is to analyze the surgical defect and consequent reconstructive requirements, aspects which have not been adequately addressed in the literature. A case is presented of a 62-year-old man presenting with an 82x117x108 mm perineal squamous cell carcinoma of urethral origin invading bladder, pelvic bone and pararectal fossa. The resection defect was reconstructed with a composite latissimus dorsi-scapular-parascapular flap and a bilayer mesh (polypropylene and extended polytetrafluoroethylene). A multiplanar reconstruction is shown that addresses 3 distinct functional requirements: 1.- visceral support to prevent perineal herniation; 2.- collapse of dead space to minimize the risk of infection; and 3.- a stable skin cover for a demanding area. With no postoperative short or long-term complications, the patient is ambulating and free of disease at one-year follow-up. To the best of the authors' knowledge, this is the first report of the described composite flap in the reconstruction of the pelvic exenteration defect

Watch and wait approach in rectal cancer: Current controversies and future directions.

According to the main international clinical guidelines, the recommended treatment for locally-advanced rectal cancer is neoadjuvant chemoradiotherapy followed by surgery. However, doubts have been raised about the appropriate definition of clinical complete response (cCR) after neoadjuvant therapy and the role of surgery in patients who achieve a cCR. Surgical resection is associated with significant morbidity and decreased quality of life (QoL), which is especially relevant given the favourable prognosis in this patient subset. Accordingly, there has been a growing interest in alternative approaches with less morbidity, including the organ-preserving watch and wait strategy, in which surgery is omitted in patients who have achieved a cCR. These patients are managed with a specific follow-up protocol to ensure adequate cancer control, including the early identification of recurrent disease. However, there are several open questions about this strategy, including patient selection, the clinical and radiological criteria to accurately determine cCR, the duration of neoadjuvant treatment, the role of dose intensification (chemotherapy and/or radiotherapy), optimal follow-up protocols, and the future perspectives of this approach. In the present review, we summarize the available evidence on the watch and wait strategy in this clinical scenario, including ongoing clinical trials, QoL in these patients, and the controversies surrounding this treatment approach.

Papel de la terapia presión negativa en la prevención de infección del sitio quirúrgico en cirugía colorrectal / Role of negative pressure wound therapy in the prevention of surgical site infection in colorectal surgery

Introducción: La infección del sitio quirúrgico (SSI) es una de las principales complicaciones quirúrgicas, con una incidencia del 10-20% en cirugía colorrectal. Las terapias basadas en presión negativa (NPWT) han mostrado su eficacia en el tratamiento de heridas crónicas, traumáticas, en las dehiscencias de piel, en el uso de colgajos o injertos. El objetivo principal del estudio es valorar la eficacia de NPWT en la prevención de SSI en cirugía colorrectal. Los objetivos secundarios son valorar la reducción del ingreso hospitalario y analizar los factores de riesgo de SSI. Métodos: Estudio casos y controles prospectivo. Ochenta pacientes intervenidos tras diagnóstico de enfermedad colorrectal, de forma programada o urgente durante el año 2017. Cuarenta pacientes fueron tratados con NPWT preventivo durante una semana. Cuarenta pacientes fueron tratados según protocolo habitual postoperatorio de cuidado de herida quirúrgica. Resultados: No se encontraron diferencias entre NPWT y grupo control en variables demográficas, comorbilidades, abordaje quirúrgico, indicación urgente o programada, preparación colónica o procedimiento quirúrgico. Se objetivó SSI con el empleo de NPWT en 3 (8%) pacientes (IC del 95%, 0-17,5). SSI en 10 (25%) pacientes (IC del 95%, 12,5-37,5) (p = 0,034); OR 0,7 (IC del 95% 0,006-0,964). La estancia hospitalaria en el grupo NPWT fue de 8 días vs. 12 días en el grupo control (0 p= 0,22). En el análisis multivariante se encontró como único factor relacionado con SSI la preparación colónica (p = 0,047; OR: 0,8, IC 0,45-0,93). Conclusiones: El uso de dispositivos NPWT para la cobertura de incisiones cerradas tras cirugía colorrectal puede disminuir la incidencia de SSI

Background: Surgical site infection (SSI) is one of the most frequent complications in colorectal surgery. It is diagnosed in 10 - 20% of colorectal procedures. Negative Pressure Wound Therapy (NPWT) has shown efficacy in the treatment of chronic and traumatic wounds, wound dehiscence, flaps and grafts. The main objective of this study is to assess NPWT in the prevention of SSI in colorectal surgery. Hospital stay reduction and SSI risk factors are secondary objectives. Methods: We present a prospective case-control study including 80 patients after a colorectal diagnosis and surgical procedure (elective and non-elective) in 2017. Forty patients were treated with prevention NPWT for one week. Forty patients were treated according to the standard postoperative surgical wound care protocol. Results: No significant differences were found in demographic variables, comorbidities, surgical approach, elective or non-elective surgery, mechanical bowel preparation and surgical procedure. Three patients has SSI in the NPWT group (8%) (95%CI 0 - 17.5). Ten patients presented SSI in the control group (25%) (95%CI 12.5 - 37.5) (p = 0.034); OR 0.7 (95%CI 0.006-0.964). Hospital stay in the NPWT group was 8 days versus 12 days in the non-NPWT group (p = 0.22). In the multivariate analysis, mechanical bowel preparation was found to be the only risk factor for SSI (p = 0.047; OR: 0.8, CI 0.45-0.93). Conclusions: NPWT is a useful SSI prevention treatment in colorectal surgery

Role of negative pressure wound therapy in the prevention of surgical site infection in colorectal surgery. / Papel de la terapia presión negativa en la prevención de infección del sitio quirúrgico en cirugía colorrectal.

BACKGROUND: Surgical site infection (SSI) is one of the most frequent complications in colorectal surgery. It is diagnosed in 10 - 20% of colorectal procedures. Negative Pressure Wound Therapy (NPWT) has shown efficacy in the treatment of chronic and traumatic wounds, wound dehiscence, flaps and grafts. The main objective of this study is to assess NPWT in the prevention of SSI in colorectal surgery. Hospital stay reduction and SSI risk factors are secondary objectives. METHODS: We present a prospective case-control study including 80 patients after a colorectal diagnosis and surgical procedure (elective and non-elective) in 2017. Forty patients were treated with prevention NPWT for one week. Forty patients were treated according to the standard postoperative surgical wound care protocol. RESULTS: No significant differences were found in demographic variables, comorbidities, surgical approach, elective or non-elective surgery, mechanical bowel preparation and surgical procedure. Three patients has SSI in the NPWT group (8%) (95%CI 0 - 17.5). Ten patients presented SSI in the control group (25%) (95%CI 12.5 - 37.5) (p=0.034); OR 0.7 (95%CI 0.006-0.964). Hospital stay in the NPWT group was 8 days versus 12 days in the non-NPWT group (p=0.22). In the multivariate analysis, mechanical bowel preparation was found to be the only risk factor for SSI (p=0.047; OR: 0.8, CI 0.45-0.93). CONCLUSIONS: NPWT is a useful SSI prevention treatment in colorectal surgery.

Spontaneous liver rupture secondary to distal right hepatic artery microaneurysms in a patient admitted due to Staphylococcus aureus pneumonia

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Spontaneous liver rupture secondary to distal right hepatic artery microaneurysms in a patient admitted due to Staphylococcus aureus pneumonia.

Spontaneous liver rupture is an uncommon and life-threatening condition often associated with high mortality rate. The most common causes are preeclampsia and HELLP syndrome during pregnancy, liver tumours and overdosing of anticoagulant therapy, however, hepatic rupture in the absence of underlying pathology is an extremely rare occurrence. Treatment can include observation, embolization, hepatic artery ligation, hepatic lobectomy, hematoma evacuation and packing, and even liver transplantation has been described.

Evaluación de la recidiva y supervivencia a largo plazo en enfermos de cáncer de colon izquierdo obstructivo: endoprótesis puente a cirugía / The long-term recurrence rate and survival of obstructive left-sided colon cancer patients: a stent as a bridge to surgery

Introducción: la endoprótesis como puente a cirugía curativa en pacientes con cáncer de colon izquierdo obstructivo es una alternativa al tratamiento clásico. El objetivo de nuestro estudio es evaluar la recidiva de la enfermedad así como la morbimortalidad del tratamiento. Pacientes y métodos: estudio retrospectivo observacional donde se analizan los pacientes que acudieron al Servicio de Urgencias con cuadro de obstrucción intestinal por tumoración en colon izquierdo entre junio de 2006 y enero de 2014. Se incluyó a los pacientes a los cuales se les colocó una endoprótesis por vía endoscópica y posteriormente fueron intervenidos con intención curativa. El periodo de observación fue hasta mayo de 2017. Resultados: cincuenta y tres pacientes fueron tratados con endoprótesis; de ellos, nueve fallecieron en el postoperatorio. Los pacientes fallecidos eran más frecuentemente varones (100% en fallecidos vs. 62% en no fallecidos, p = 0,02), con más edad (81,4 ± 5,1 vs. 71,6 ± 10,8, p < 0,001) y tenían hemoglobinas más bajas al ingreso (12,9 vs. 13,6, p < 0,001), mayor número de leucocitos (12.918 vs. 9.437, p < 0,001) y mayor coagulopatía (INR 1,6 vs. 1, p < 0,001). Tuvieron una recidiva a distancia ocho pacientes con una mediana de supervivencia libre de enfermedad de 19,1 meses. Se compararon las variables en función de la aparición de enfermedad a distancia y la media de edad fue menor en los pacientes que presentaron recidiva (65,9 ± 11,3 vs. 74,9 ± 9,9 p < 0,001). Conclusiones: el uso de endoprótesis como puente a cirugía curativa en los pacientes con cáncer de colon izquierdo obstructivo en nuestro hospital ha presentado unos resultados comparables a estudios previos

Background: a colonic stent as a bridge to elective surgery for left-sided malignant colonic obstruction is an alternative to the classical treatment. The aim of our study was to evaluate the recurrence rate as well as the morbidity and mortality of this treatment. Patients and methods: patients admitted to the Emergency Department with left-sided malignant colonic obstruction between June 2006 and January 2014 were analyzed in a retrospective observational study. Patients who underwent self-expanding metallic stent placement via endoscopy as a bridge to surgery were included. The observation period was performed until May 2017. Results: fifty-three patients were treated with a colonic stent as a bridge to surgery; nine patients died during the postoperative period. The deceased patients were more frequently male (100% in the deceased vs 62% in the non-deceased, p = 0.02), with a more advanced age (81.4 ± 5.1 vs 71.6 ± 10.8, p < 0.001), lower hemoglobin levels on admission (12.9 vs 13.6 p < 0.001), a greater number of leukocytes (12,918 vs 9,437, p < 0.001) and greater coagulopathy (INR 1.6 vs 1, p < 0.001). Eight patients had a distant relapse with a median disease-free survival of 19.1 months. The variables were compared according to the appearance of distant disease and the mean age was lower in patients with a recurrence (65.9 ± 11.3 vs 74.9 ± 9.9, p < 0.001). Conclusions: the results of the use of a stent as a bridge to curative surgery in patients with obstructive left colon cancer in our hospital is comparable to previous studies

The long-term recurrence rate and survival of obstructive left-sided colon cancer patients: a stent as a bridge to surgery.

BACKGROUND: a colonic stent as a bridge to elective surgery for left-sided malignant colonic obstruction is an alternative to the classical treatment. The aim of our study was to evaluate the recurrence rate as well as the morbidity and mortality of this treatment. PATIENTS AND METHODS: patients admitted to the Emergency Department with left-sided malignant colonic obstruction between June 2006 and January 2014 were analyzed in a retrospective observational study. Patients who underwent self-expanding metallic stent placement via endoscopy as a bridge to surgery were included. The observation period was performed until May 2017. RESULTS: fifty-three patients were treated with a colonic stent as a bridge to surgery; nine patients died during the postoperative period. The deceased patients were more frequently male (100% in the deceased vs 62% in the non-deceased, p = 0.02), with a more advanced age (81.4 ± 5.1 vs 71.6 ± 10.8, p < 0.001), lower hemoglobin levels on admission (12.9 vs 13.6 p < 0.001), a greater number of leukocytes (12,918 vs 9,437, p < 0.001) and greater coagulopathy (INR 1.6 vs 1, p < 0.001). Eight patients had a distant relapse with a median disease-free survival of 19.1 months. The variables were compared according to the appearance of distant disease and the mean age was lower in patients with a recurrence (65.9 ± 11.3 vs 74.9 ± 9.9, p < 0.001). CONCLUSIONS: the results of the use of a stent as a bridge to curative surgery in patients with obstructive left colon cancer in our hospital is comparable to previous studies.

Carcinoma epidermoide primario de recto medio: una histología atípica / Primary squamous cell carcinoma of the rectum: an atypical histology

El carcinoma primario escamoso de recto forma parte del diagnóstico diferencial de los tumores rectales, presentando una baja incidencia en la población. Se desconoce su etiopatogenia así como la biología del tumor, por lo que es difícil establecer un tratamiento al respecto, no existiendo un consenso sobre el mismo. Presentamos el caso de una mujer de 47 años con un carcinoma epidermoide de recto medio tratada con radioterapia y quimioterapia neoadyuvante y posterior resección quirúrgica (AU)

Squamous cell carcinoma of the rectum is one of the differential diagnoses of rectal tumors. It represents a low incidence in the population. The etiopathogenesis and the biology of these tumors are unclear, for this reason the gold standard treatment is difficult to establish. We present a 47-years-old woman who had a squamous cell carcinoma in medium rectum. She was treated with radiation therapy and chemotherapy and the treatment was followed by surgical excision (AU)

Primary squamous cell carcinoma of the rectum: an atypical histology.

Squamous cell carcinoma of the rectum is one of the differential diagnoses of rectal tumors. It represents a low incidence in the population. The etiopathogenesis and the biology of these tumors are unclear, for this reason the gold standard treatment is difficult to establish. We present a 47-years-old woman who had a squamous cell carcinoma in medium rectum. She was treated with radiation therapy and chemotherapy and the treatment was followed by surgical excision.

[José Goyanes. Surgeon and humanist]. / José Goyanes. Cirujano y humanista.

José Goyanes was a renowned Spanish surgeon. A short biographical summary of his life is presented, with the posts he occupied and the awards he received. He was a world pioneer in vascular surgery where he made outstanding contributions to this speciality, many of them pioneering and some of his publications were before those of Alexis Carrel, Nobel prize-winner in Medicine. He was also an authority on oncology and an expert in the majority of surgical techniques in use in his era. He was a writer, historian, essayist and notable traveller which earned him the name of "Universal Man". He has not been fully recognised as a man of science.

José Goyanes. Cirujano y humanista / José Goyanes. Surgeon and humanist

José Goyanes fue un cirujano español muy renombrado. Se hace un breve resumen biográfico de su figura con los puestos que ocupó y los galardones que recibió. Fue pionero mundial de la cirugía vascular con grandes aportaciones, muchas de ellas pioneras en esta especialidad y publicadas, algunas, previamente a las de Alexis Carrel, premio Nobel de Medicina. También fue una autoridad en materia oncológica y dominó la mayor parte de las técnicas quirúrgicas en uso en su época. Fue escritor, historiador, ensayista y viajero notable, lo que le valió la calificación de “Hombre Universal”. No ha sido plenamente reconocido como hombre de ciencia (AU)

José Goyanes was a renowned Spanish surgeon. A short biographical summary of his life is presented, with the posts he occupied and the awards he received. He was a world pioneer in vascular surgery where he made outstanding contributions to this speciality, many of them pioneering and some of his publications were before those of Alexis Carrel, Nobel prize-winner in Medicine. He was also an authority on oncology and an expert in the majority of surgical techniques in use in his era. He was a writer, historian, essayist and notable traveller which earned him the name of “Universal Man”. He has not been fully recognised as a man of science (AU)

Hernia interna tras sigmoidectomía laparoscópica / Internal hernia after laparoscopic sigmoidectomy

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