Criterios de ambulatorización en proctología. Fístula anal en CMA / No disponible

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Validation in colorectal procedures of a useful novel approach for the use of C-reactive protein in postoperative infectious complications.

AIM: Our aim was to validate a novel use of C-reactive protein (CRP) measurement to identify postoperative infectious complications in patients undergoing colorectal surgery, and to compare the predictive value in this setting against white blood cell (WBC) count and neutrophil-to-lymphocyte ratio (NLR). METHOD: This was a retrospective study of CRP, NLR and WBC measurements in patients undergoing colorectal surgery. CRP, NLR and WBC were recorded on the second postoperative day and on the day of infectious complication (patients who developed infectious complications) or within 3 days prior to discharge (subjects with no complications). The test for detecting infectious complications consisted of comparing the value of the inflammatory marker on the day on which a complication was suspected against the value recorded on the second postoperative day. The test was considered positive if a given value was higher than the registered peak at postoperative day 2. Factors influencing the postoperative peak CRP were also studied. RESULTS: A total of 254 patients were retrospectively studied. Patients whose CRP value was higher than on the second postoperative day had a diagnostic accuracy for infectious complications of up to 94.4% and sensitivity, specificity, positive predictive value and negative predictive value of up to 97.4%, 93.4%, 85.7% and 99.1%, respectively. Poorer results were observed when WBC count and NLR were used rather than CRP measurement. Multiple linear regression analysis showed that surgical procedure and approach, as well as additional resections, were independent factors for 48 h peak CRP. CONCLUSION: C-reactive protein is a better parameter than WBC count and NLR for detecting infectious complications. Our proposed methodology presents good diagnostic accuracy and performance and could potentially be used for any surgical procedure.

Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer.

BACKGROUND: Abdominal perineal excision (APE) was originally described with levator ani removal for rectal cancer. An even wider, more aggressive extralevator resection for APE has been proposed. Although some surgeons are performing a very wide 'extralevator APE (ELAPE)', there are few data to recommend it routinely. This multicentre study aimed to compare outcomes of APE and ELAPE. METHODS: A multicentre propensity case-matched analysis comparing two surgical approaches (APE and ELAPE) was performed. All patients who underwent abdominoperineal resection of a rectal tumour were considered for the analysis. Tumour height was defined by magnetic resonance imaging measurement and patients with stage II-III tumours had neoadjuvant radiochemotherapy. Involvement of the circumferential resection margin (CRM) and intraoperative tumour perforation were the main outcome measures. A logistic regression model was used to study the relationship between the surgical approaches and outcomes. RESULTS: From January 2008 to March 2013 a total of 1909 consecutive patients underwent APE or ELAPE, of whom 914 matched patients (457 in each group) formed the cohort for analysis. Intraoperative tumour perforation occurred in 7.9 and 7.7 per cent of patients during APE and ELAPE respectively (P = 0.902), and there was CRM involvement in 13.1 and 13.6 per cent (P = 0.846). There were no differences between APE and ELAPE in terms of postoperative complication rates (52.3 versus 48.1 per cent; P = 0.209), need for reoperation (7.7 versus 7.0 per cent; P = 0.703), perineal wound problems (26.0 versus 21.9 per cent; P = 0.141), mortality rate (2.0 versus 2.0 per cent; P = 1.000) and local recurrence rate at 2 years (2.7 versus 5.6 per cent; P = 0.664). CONCLUSION: ELAPE does not improve rates of CRM involvement, intraoperative tumour perforation, local recurrence or mortality.

Urachal-sigmoid fistula in an adult male without urachal cyst.

Urachal anomalies are uncommon defects arising either by incomplete obliteration of the urachus during the foetal period or by its reopening after postnatal regression. Five anomalies have been described: congenital patent urachus, urachal cyst, umbilical-urachal sinus, vesico-urachal diverticulum, and alternating sinus. Only congenital patent urachus is present at childbirth. The other forms are usually acquired disorders. Nevertheless, they commonly appear in children, being less common in the adult. Colic-urachal fistulas are quite uncommon findings. Only three cases have been reported thus far. The aim of this study is to report the fourth case of sigmoid-urachal fistula, and the first one appearing without an urachal cyst.

Fístula sigmoidouracal en un paciente adulto en ausencia de quiste de uraco / Urachal-sigmoid fistula in an adult male without urachal cyst

Presentamos el caso de un paciente varón de 57 años que consultó por descarga umbilical de material fecaloideo junto con dolor e irritación periumbilical años después de haber comenzado con episodios intermitentes de neumaturia y fecaluria. Ninguna de las exploraciones complementarias realizadas aportaron información relevante para el diagnóstico. La intervención quirúrgica demostró la existencia de una fístula sigmoidouracal. Creemos de interés este caso debido a la rareza de este diagnóstico ya que sólo han sido descritos tres casos en la literatura siendo éste el único caso en que no se apreció la presencia previa de un quiste uracal (AU)

Impact of surgeon organization and specialization in rectal cancer outcome.

PURPOSE: The present study was designed to assess the differences in the outcome of patients with rectal cancer treated by a group of surgeons before and after being organized as a Coloproctology Unit at the same University Department of Surgery. METHODS: Comparison of two periods of rectal cancer surgery: I (1986-91) and II (1992-95). Period I: 94 patients were operated on by 14 general surgeons. Period II: 108 patients were operated on by only 4 surgeons of the same group organized as a Colorectal Surgery Unit after visiting referral centres abroad, adopting techniques such as total mesorectal excision (TME) for middle and low rectal cancer and washout of rectal stump. Mean follow-up during periods I and II was 69.1 and 42.0 months, respectively. A prospective data base analysis was used. Survival and local recurrence rates were calculated by the actuarial method. For comparison between groups the log rank method was used. RESULTS: The two groups were comparable with respect to mean age, gender, TNM and rectal tumour location. A significant increase in radical resectability and a decrease of the Abdominoperineal resection (APR)/Low anterior resection (LAR) ratio were observed in the second period. The overall pelvic recurrence rate was 25% in the first period and 11 in the second (P < 0.01). Significant differences were also found when the patients with LAR were compared between both periods, 30% vs 9% (P < 0.01) and specially when the 10 cm anal verge distance was considered to divide the LAR groups. No differences were found regarding the APR procedures in both periods. There was improved cancer-specific survival for the LAR group in the second period (P=0.03). CONCLUSION: Specialization and centralization influence the quality of rectal cancer surgery, mainly local recurrence rates and survival after low anterior resection.

[Evaluation of anorexia in patients with bile duct obstruction]. / Evaluación de la anorexia en enfermos con obstrucción de la vía biliar.

INTRODUCTION: Obstructive jaundice is often accompanied by protein-caloric malnutrition. The objective of the present study is to analyze the incidence and the degree of alterations in the food ingestion of patients with obstructive jaundice. MATERIAL AND METHODS: In a prospective, cross-sectional study 50 patients with obstructive jaundice (19 benign and 31 malignant) were evaluated. The anorexia was evaluated using Welch's test (subjective evaluation) and by means of quantifying the caloric ingestion. An anthropometric parameter (ideal weigh < 95%) and two biochemical ones (albumin < 3.5 g/dl and pre-albumin < 17 mg/dl) were used to define the degree of malnutrition. RESULTS: 96% of the patients presented alterations in the Welch test and in 72% of the patients the caloric ingestion was below the estimated needs. Overall, the ingestion of food was reduced by 76.3 +/- 30% of the estimated needs (84.7 +/- 28% in the benign cases and 70.9 +/- 32% in the malignant cases). Both the Welch test (r = 0.59; p = 0.01) and the caloric ingestion (r = 0.53; p < 0.001) were inversely correlated with the serum bilirubin. In patients with malnutrition criteria, the caloric ingestion was reduced by 30% against the 12% reduction in the non-malnourished patients (p < 0.05). There was a direct correlation between the two methods used in the assessment of the anorexia (r = 0.71; p < 0.001). CONCLUSIONS: Obstructive jaundice is associated with an important reduction in the caloric ingestion, and this is manifested in both biliary obstructions of a benign origin, and in those of neoplasic origins.