SURGICAL SITE INFECTION IN RESECTIONS OF DIGESTIVE SYSTEM TUMOURS.

Postoperative infectious complications are extremely important to surgeons and the entire medical care team. Among these complications, surgical site infection (SSI) appears to be one of the earliest and most prevalent events and is considered an inherent complication of surgical procedures. In oncological patients submitted to resections of digestive system tumors, there is a confluence of several risk factors for SSI, making it necessary to establish measures to maximize the control of this condition to provide a better prognosis for these patients. Some risk factors for SSI are the manipulation of structures hosting the highest density of pathogenic microorganisms, such as the colon, the patient's performance status, the patient's nutritional status, the use of chemotherapy and/or radiotherapy, and the surgical procedure itself, which tends to last longer and be more complex than surgeries for benign conditions of the digestive system. Therefore, this review sought to provide a qualitative analysis and a summary of the literature regarding the SSI of postoperative tumor patients who underwent surgical resection and were well-structured postoperatively, to provide objective data on this problem, and alert about the well-structured needs of individualized pre-, peri-, and post-protocols to avoid the development of these events.

LIFT procedure: postoperative outcomes, risk factors for fistula recurrence and continence impairment.

Ligation of the intersphincteric fistula tract has been recently employed as definitive treatment of anal fistulas. However, it carries a potential risk of continence impairment, fistula recurrence, and repeated operations. This study aimed to assess postoperative outcomes related to this procedure and evaluate the potential influence of preoperative and intraoperative features. Patients who underwent LIFT procedure between June 2012 and September 2021 were retrospectively analyzed. Patients were divided according to whether they developed fistula recurrence and on the history of a surgery prior to the LIFT. Preoperative features, postoperative outcomes, and risk factors adverse outcomes were analyzed. Forty-eight patients were included, of which 25 received primary LIFT, being the high transsphincteric fistula pattern the most frequent (62.5%). The median follow-up was 13.3 months, with a recurrence rate of 20.8%, of which the majority presented an intersphincteric fistula pattern (50%); and continence impairment rate of 16.7%. A higher prevalence of diabetes (p = 0.026) and a trend towards a higher prevalence of patients with a history of high transsphincteric fistula (0.052) were observed in the group with fistula recurrence. The history of diabetes and the operation time with a cut-off value ≥ 69 min showed a trend as a risk factors for developing fistula recurrence (0.06) and postoperative continence impairment (0.07), respectively. The LIFT procedure seems to be safe in terms of morbidity, with a reasonable incidence of recurrences, showing better results when it is primarily performed. Preoperative characteristics should be considered as they may impact outcomes.

First day postoperative values of the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and C-reactive protein as complication predictors following gastric oncologic surgery.

INTRODUCTION: The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) level are simple laboratory test parameters that can provide us with information on the inflammatory status of the organism. CRP has been shown to be a predictor of postoperative complications, whereas NLR and PLR have shown greater usefulness in the prognosis of oncologic pathologies. AIM: To evaluate the associations of NLR and PLR with postoperative complications following gastric oncologic surgery and compare them with CRP. MATERIALS AND METHODS: A prospective study was conducted on 66 patients that underwent oncologic gastric surgery, within the time frame of January 2014 and March 2019. The variables analyzed were sociodemographic data, surgical technique, tumor extension, and NLR, PLR, and CRP levels from the first day after surgery, as well as postoperative complications. RESULTS: Seventeen patients (25.8%) presented with grade III-V complications, utilizing the Clavien-Dindo classification system. Mean NLR value was 11.30 and was associated with the appearance of major complications, with statistical significance (p = 0.009). Mean PLR was266.05 and was not significantly associated with complications (p = 0.149). Fifty-four patients had a mean CRP level of 143.24 and it was not related to the appearance of major complications (p = 0.164). CONCLUSIONS: The NLR is a simple and inexpensive parameter, which measured on postoperative day one, predicted the appearance of major postoperative complications in our study sample and appears to be a better predictive parameter than CRP for said complications. Further studies to confirm that trend need to be carried out.

Retinal vascular occlusions after nonocular surgeries / Oclusões vasculares retinianas após cirurgias não oculares

ABSTRACT Ophthalmologic complications of nonocular surgeries are rare events, but can lead to irreversible conditions of low visual acuity. They are often associated with spine, heart and neck surgery, however they can occur after procedures on other systems. The main local causes are ischemic optic neuropathies, vascular occlusions, cortical lesions, and acute angle-closure glaucoma. We report two cases of sudden low visual acuity secondary to vascular occlusions after gastrointestinal procedures. In the first case, a 57-year-old patient electively admitted for colon reconstruction after Hartmann's colostomy, progressed with intra- and postoperative complications and required subsequent complementary surgeries. Once month later he presented with sudden bilateral low visual acuity, painless and non-altitudinal, and was diagnosed as papillophlebitis, which resolved spontaneously with the progression of the condition. The second case, a 69-year-old patient with no comorbidities underwent rectal resection due to suspected malignant tumor, and progressed on the third postoperative day, with pain and bilateral low visual acuity secondary to acute angle-closure glaucoma, and branch retinal artery occlusion in right eye; treated with iridotomy and ocular hypotensive eye drops, with only slight recovery of vision. The article aims to discuss the etiological mechanisms of the reported conditions and present a literature review.

RESUMO Complicações oftalmológicas de cirurgias não oculares são raras, mas podem levar a condições irreversíveis de baixa acuidade visual. Em geral são associadas à cirurgia de coluna, coração ou pescoço, mas podem ocorrer após procedimentos em outros sistemas. As principais causas são neuropatias ópticas isquêmicas, oclusões vasculares, lesões corticais, e glaucoma agudo de ângulo fechado. Relatamos dois casos de baixa acuidade visual súbita, secundária a oclusões vasculares, após procedimentos cirúrgicos gastrointestinais. No primeiro caso, um paciente de 57 anos foi internado de forma eletiva para reconstrução do cólon após colostomia de Hartmann. Evoluiu com complicações nos períodos intra- e pós-operatório, e necessitou de outras cirurgias complementares. Um mês depois apresentou baixa acuidade visual bilateral súbita, indolor e não altitudinal, e foi diagnosticado como papiloflebite, com resolução espontânea na evolução. O segundo caso, uma paciente de 69 anos, sem comorbidades, foi submetida à ressecção do reto por suspeita de tumor maligno e, no terceiro dia de pós-operatório, evoluiu com dor e baixa acuidade visual bilateral, secundária a glaucoma agudo de ângulo fechado, e oclusão de ramo da artéria retiniana no olho direito; tratada com iridotomia e colírios hipotensores, com recuperação parcial da visão. O objetivo do artigo é discutir os mecanismos etiológicos das doenças relatadas, e apresentar uma revisão da literatura.

Incidence of surgical infection and risk factors in colorectal surgery - A prospective cohort study.

OBJECTIVE: The objective was to measure the incidence of surgical site infection (SSI) and identify risk factors, in patients undergoing elective surgery of the colon and rectum. MATERIALS AND METHODS: A prospective cohort study was performed from January 2017 to December 2018. RESULTS: A total of 130 patients were studied. The cumulative incidence of SSI was 12.3%. The 56.25% were superficial wound infections and the 31.25%, organ-space infection. The risk factors significantly associated with SSI were the non-administration of pre-operative oral nutrition, diabetes mellitus, heart disease, symptomatic state at the diagnosis of colorectal cancer (CRC), and ≥ 2 altered nutritional biochemical parameters at diagnosis. After multivariate , risk factors associated with SSI were: non-administration of preoperative enteral nutrition (odds ratio [OR] = 0.27; 95% confidence interval [CI]: 0.07-1.0), DM (OR = 3.0; 95% CI: 0.9-9.9), the heart disease (OR = 4.6; 95% CI: 1.1-18.6), and laparoscopic surgery (OR = 0.28; 95% CI: 0.08-0.97). The average stay was higher in patients with a diagnosis of SSI (11.9 vs. 9.2 days). CONCLUSIONS: Independent risk factors for SSI in CRC were the non-administration of pre-operative enteral nutrition, the existence of heart disease, and open surgery.

OBJETIVO: Estudiar la incidencia de infección del sitio quirúrgico y evaluar sus factores de riesgo en pacientes intervenidos de cirugía colorrectal electiva. MÉTODO: Se realizó un estudio de cohortes prospectivo desde enero de 2017 hasta diciembre de 2018. RESULTADOS: Se incluyeron 130 pacientes. La incidencia acumulada de infección del sitio quirúrgico fue del 12,3% (n = 16), siendo el 56,25% infecciones de herida y el 31,25% infecciones órgano-espacio. Los factores de riesgo asociados a infección del sitio quirúrgico con significación estadística fueron la no administración de nutrición oral preoperatoria, la diabetes mellitus, la enfermedad cardiaca, la presencia de síntomas en el momento del diagnóstico de cáncer colorrectal y tener al menos dos parámetros bioquímicos nutricionales alterados. Tras el análisis multivariante se asociaron la no administración de nutrición enteral preoperatoria (odds ratio [OR] = 0,27; intervalo de confianza del 95% [IC95%]: 0,07-1,0), la diabetes mellitus (OR = 3,0; IC95%: 0,9-9,9), la enfermedad cardiaca (OR = 4,6; IC95%: 1,1-18,6) y la cirugía laparoscópica (OR = 0,28; IC95%: 0,08-0,97). La estancia media fue mayor en los pacientes con diagnóstico de infección del sitio quirúrgico (11,9 frente a 9,2 días). CONCLUSIONES: Los factores de riesgo independientes para el desarrollo de infección del sitio quirúrgico en los pacientes con cáncer colorrectal fueron la no administración de nutrición oral preoperatoria, la enfermedad cardiaca y la cirugía abierta.

HARTMANN PROCEDURE OR RESECTION WITH PRIMARY ANASTOMOSIS FOR TREATMENT OF PERFORATED DIVERTICULITIS? SYSTEMATIC REVIEW AND META-ANALYSIS.

BACKGROUND: Mortality after emergency surgery in randomized controlled trials. The Hartmann procedure remains the treatment of choice for most surgeons for the urgent surgical treatment of perforated diverticulitis; however, it is associated with high rates of ostomy non-reversion and postoperative morbidity. AIM: To study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment. METHOD: Systematic search in the literature of observational and randomized articles comparing resection with primary anastomosis vs. Hartmann's procedure in the emergency treatment of perforated diverticulitis. Analyze as primary outcomes the mortality after the emergency operation and the general morbidity after it. As secondary outcomes, severe morbidity after emergency surgery, rates of non-reversion of the ostomy, general and severe morbidity after reversion. RESULTS: There were no significant differences between surgical procedures for mortality, general morbidity and severe morbidity. However, the differences were statistically significant, favoring primary anastomosis in comparison with the Hartmann procedure in the outcome rates of stoma non-reversion, general morbidity and severe morbidity after reversion. CONCLUSION: Primary anastomosis is a good alternative to the Hartmann procedure, with no increase in mortality and morbidity, and with better results in the operation for intestinal transit reconstruction.

Intraoperative haemodynamic optimisation therapy with venoarterial carbon dioxide difference and pulse pressure variation - does it work?

BACKGORUND: Current evidence suggests that intraoperative goal-directed haemodynamic therapy (GDT) should be considered for high-risk patients undergoing major gastrointestinal surgery. We aimed to evaluate if an algorithm using venoarterial carbon dioxide difference (CO2 gap) and pulse pressure variation (PPV) as therapeutic targets during GDT would decrease the major complications after gastrointestinal surgery. METHODS: This was a before-and-after study (n = 204) performed in a tertiary hospital on patients who underwent elective open major gastrointestinal surgeries. The inclusion criteria were surgeries expected to last more than two hours, family and physician's agreement on total postoperative support, and survival expectancy of at least three months. The exclusion criteria were previous haemodynamic instability, presence of infection, cardiac arrhythmias, and emergency surgery. In the intervention group (IG), an algorithm was applied using fluids, dobutamine, and noradrenaline during the intraoperative period aiming at MAP > 65 mm Hg, SpO2 > 95%, CO2 gap < 6 mm Hg, and PPV < 13%. The control group (CG) comprised consecutive eligible patients who were operated by the same team before the institution of the algorithm. RESULTS: The rates of moderate and severe postoperative complications were lower in the IG (11% vs. 23%; IC: RR = 0.47, 95% CI: 0.246-0.929; P = 0.025). The respective 90- and 180-day mortality rates in the IG and CG were 9.8% vs. 22.5% (P = 0.014) and 12.6% vs. 25.5% (P = 0.020). CONCLUSIONS: An algorithm aiming to minimise the CO2 gap and normalise PPV was feasible and effective in decreasing rates of moderate and severe complications after surgery in high-risk patients.

The impact of properly diagnosed sarcopenia on postoperative outcomes after gastrointestinal surgery: A systematic review and meta-analysis.

BACKGROUND: Sarcopenia is defined as the loss of muscle mass combined with loss of muscle strength, with or without loss of muscle performance. The use of this parameter as a risk factor for complications after surgery is not currently used. This meta-analysis aims to assess the impact of sarcopenia defined by radiologically and clinically criteria and its relationship with complications after gastrointestinal surgeries. MATERIALS AND METHODS: A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO registration number: CRD42019132221). Articles were selected from the PUBMED and EMBASE databases that adequately assessed sarcopenia and its impact on postoperative complications in gastrointestinal surgery patients. Pooled estimates of pre-operative outcome data were calculated using the odds ratio (OR) and 95% confidence interval (CI). Subgroup analysis were performed to assess each type of surgery. RESULTS: The search strategy returned 1323, with 11 studies meeting the inclusion criteria. A total of 4265 patients were analysed. The prevalence of sarcopenia between studies ranged from 6.8% to 35.9%. The meta-analysis showed an OR for complications after surgery of 3.01 (95% CI 2.55-3.55) and an OR of 2.2 (95% CI 1.44-3.36) for hospital readmission (30 days). CONCLUSION: Sarcopenia, when properly diagnosed, is associated with an increase in late postoperative complications, as well as an increase in the number of postoperative hospital readmissions for various types of gastrointestinal surgery. We believe that any preoperative evaluation should include, in a patient at risk, tests for the diagnosis of sarcopenia and appropriate procedures to reduce its impact on the patient's health.

Acute superior mesenteric venous thrombosis results in high rates of readmission and morbidity.

OBJECTIVE: Superior mesenteric venous thrombosis (MVT) is a poorly understood clinical entity, and as such, outcomes are poorly described. This study aimed to identify predictors of bowel ischemia after MVT and to compare outcomes for patients treated medically (group 1) with those for patients treated with bowel resection (group 2). METHODS: This was a retrospective, single-institution study capturing all patients diagnosed with symptomatic acute MVT on computed tomography imaging from 2008 to 2018. Demographics, comorbidities, imaging, laboratory values, and treatment were included. Predictors of bowel resection were analyzed by univariate and multivariate statistics. Outcomes including mortality, readmissions for abdominal pain, and chronic mesenteric venous congestion were compared using χ2 test. RESULTS: There were 121 patients included in the study; 98 patients were treated medically (group 1), 19 patients were treated with bowel resection (group 2), and 4 patients were treated with endovascular recanalization (group 3). Group 1 and group 2 were compared directly. Patients requiring bowel resection tended to have higher body mass index (P = .051) and a hypercoagulable disorder (P = .003). Patients who required bowel resection were more likely to present with lactic acidosis (P < .001) and leukocytosis (P < .001) with bowel wall thickening on scan (P < .001). On multivariable analysis, a genetic thrombophilia was a strong predictor of bowel ischemia (odds ratio, 3.81; 95% confidence interval, 1.12-12.37). One-year mortality and readmission rates did not differ between groups. However, readmission rates for abdominal pain were high for both groups (group 1, 44.90%; group 2, 57.89%; P = .317), and a significant proportion of patients exhibited chronic mesenteric venous congestion on repeated scan (group 1, 42.86%; group 2, 47.37%; P = .104). CONCLUSIONS: A genetic hypercoagulable disorder is a predictor of bowel ischemia due to MVT. Regardless of treatment, outcomes after MVT are morbid, with high rates of readmission for abdominal pain. An alternative approach to treat these patients is needed, given the poor outcomes with current strategies.

Risk Factors for Prolonged Postoperative Ileus in Colorectal Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Prolonged postoperative ileus (PPOI) represents a frequent complication following colorectal surgery, affecting approximately 10-15% of these patients. The objective of this study was to evaluate the perioperative risk factors for PPOI development in colorectal surgery. METHODS: The present systematic review and meta-analysis was conducted in accordance with the PRISMA Statement. PubMed, EMBASE, SciELO, and LILACS databases were searched, without language or time restrictions, from inception until December 2018. The keywords used were: Ileus, colon, colorectal, sigmoid, rectal, postoperative, postoperatory, surgery, risk, factors. The Newcastle-Ottawa scale and the Jadad scale were used for bias assessment, while the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used for quality assessment of evidence on outcome levels. RESULTS: Of the 64 studies included, 42 were evaluated in the meta-analysis, comprising 29,736 patients (51.84% males; mean age 62 years), of whom 2844 (9.56%) developed PPOI. Significant risk factors for PPOI development were: male sex (OR 1.43; 95% CI 1.25-1.63), age (MD 3.17; 95% CI 1.63-4.71), cardiac comorbidities (OR 1.54; 95% CI 1.19-2.00), previous abdominal surgery (OR 1.44; 95% CI 1.19, 1.75), laparotomy (OR 2.47; 95% CI 1.77-3.44), and ostomy creation (OR 1.44; 95% CI 1.04-1.98). Included studies evidenced a moderate heterogeneity. The quality of evidence was regarded as very low-moderate according to the GRADE approach. CONCLUSIONS: Multiple factors, including demographic characteristics, past medical history, and surgical approach, may increase the risk of developing PPOI in colorectal surgery patients. The awareness of these will allow a more accurate assessment of PPOI risk in order to take measures to decrease its impact on this population.

Surgical glove use for specimen removal in laparoscopy, the cheapest available: a prospective study.

Despite the proven benefits of laparoscopic surgery, it is indeed very costly. The aim of our study was to show an effective way to reduce one of the costs. Between January 2012 and December 2018, we used sterile unpowdered latex-free surgical gloves for specimen retrieval in 243 selected cases of laparoscopic cholecystectomy and appendectomy. The mean retrieval time was 6.7 ± 3.6 min. All procedures were performed safely. Minor wound infection was noted in three patients but there was no case of port site hernia in our series. We conclude that specimen retrieval using sterile, unpowdered, latex-free surgical gloves is safe, effective and cheap. No special additional preparation is required.

Effect of Preoperative Administration of Oral Arginine and Glutamine in Patients with Enterocutaneous Fistula Submitted to Definitive Surgery: a Prospective Randomized Trial.

BACKGROUND: The use of glutamine and arginine has shown several advantages in postoperative outcomes in patients after gastrointestinal surgery. We determined the effects of its use in patients with enterocutaneous fistula after operative treatment. PATIENTS AND METHODS: Forty patients with enterocutaneous fistula were randomly assigned to one of two groups. The control group received the standard medical care while the patients of the experimental group were supplemented with enteral administration of 4.5 g of arginine and 10 g of glutamine per day for 7 days prior to the surgery. The primary outcome variable was the recurrence of the fistula and the secondary outcomes were preoperative and postoperative serum concentrations of interleukin 6 and C-reactive protein and postoperative infectious complications. RESULTS: Twenty patients were assigned to each group. The fistula recurred in two patients (10%) of the experimental group and in nine patients (45%) of the control group (P < 0.001). We found a total of 13 infectious complications in six patients of the control group (all with fistula recurrence) and none in the experimental group. Mean preoperative serum concentrations of interleukin 6 and C-reactive protein were lower in patients from the experimental group. In addition, these levels were lower in patients who had recurrence if compared to patients that did not recur. CONCLUSION: Preoperative administration of oral arginine and glutamine could be valuable in the postoperative recovery of patients with enterocutaneous fistulas submitted to definitive surgery.

Hartmann procedure or resection with primary anastomosis for treatment of perforated diverticulitis? systematic review and meta-analysis / Procedimento de hartmann ou ressecção com anastomose primária para tratamento da diverticulite perfurada? revisão sistematizada e metanálise

ABSTRACT Background: The Hartmann procedure remains the treatment of choice for most surgeons for the urgent surgical treatment of perforated diverticulitis; however, it is associated with high rates of ostomy non-reversion and postoperative morbidity. Aim: To study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment. Method: Systematic search in the literature of observational and randomized articles comparing resection with primary anastomosis vs. Hartmann's procedure in the emergency treatment of perforated diverticulitis. Analyze as primary outcomes the mortality after the emergency operation and the general morbidity after it. As secondary outcomes, severe morbidity after emergency surgery, rates of non-reversion of the ostomy, general and severe morbidity after reversion. Results: There were no significant differences between surgical procedures for mortality, general morbidity and severe morbidity. However, the differences were statistically significant, favoring primary anastomosis in comparison with the Hartmann procedure in the outcome rates of stoma non-reversion, general morbidity and severe morbidity after reversion. Conclusion: Primary anastomosis is a good alternative to the Hartmann procedure, with no increase in mortality and morbidity, and with better results in the operation for intestinal transit reconstruction.

RESUMO Racional: O procedimento a Hartmann permanece sendo o tratamento de escolha da maioria dos cirurgiões para o tratamento cirúrgico de urgência da diverticulite perfurada, entretanto está associado com altas taxas de não reversão da ostomia e de morbidade pós-operatória. Objetivo: Estudar os resultados após o procedimento de Hartmann vs. ressecção com anastomose primária, com ou sem ileostomia, para o tratamento da diverticulite perfurada com peritonite purulenta ou fecal (grau de Hinchey III ou IV), e comparar as vantagens entre as duas formas de tratamento. Método: Busca sistemática na literatura de artigos observacionais e randomizados comparando ressecção com anastomose primária vs. procedimento de Hartmann no tratamento de urgência da diverticulite perfurada. Analisar como desfechos primários a mortalidade após a operação de urgência e a morbidade geral após ela; como desfechos secundários, a morbidade severa após a operação de urgência, as taxas de não reversão da ostomia, a morbidade geral e severa após a reversão. Resultados: Não houve diferenças significativas entre os procedimentos cirúrgicos para mortalidade, morbidade geral e morbidade severa. Contudo, as diferenças foram significativas estatisticamente favorecendo anastomose primária na comparação com procedimento de Hartmann nos desfechos taxas de não reversão do estoma, morbidade geral e morbidade severa após reversão. Conclusão: A anastomose primária apresenta-se como boa alternativa ao procedimento de Hartmann, sem aumento de mortalidade e morbidade, e com melhores resultados na operação de reconstrução do trânsito intestinal.

Percutaneous Image-Guided Abdominal Interventions for Leaks and Fistulas Following Sleeve Gastrectomy and Roux-en-Y Gastric Bypass.

BACKGROUND: Bariatric surgery offers the only effective long-term weight loss therapy for morbidly obese patients. Numerous studies have demonstrated a mortality and morbidity reduction associated with weight loss surgery, but these interventions also have significant rates of complications. It is important for the bariatric surgeons to recognize these complications and acknowledge which of them can be solved in a minimally invasive manner in order to offer to patients the best treatment. The aim of this article was to review factors and success rates associated with percutaneous image guide abdominal interventions to treat the complications of bariatric surgery. MATERIALS AND METHODS: Retrospective descriptive study. Eighty-two patients with complications after bariatric surgery were included. Of these, 56 presented fistula with or without abdominal collection. RESULTS: Of the total patients, 54% are male and 46% female. The average age was 49.4 (range 16-62). Of the 56 cases, 37 (66.1%) occurred after laparoscopic sleeve gastrectomy, and 19 (33.9%) post-Roux-en-Y gastric bypass. The fistula was resolved by percutaneous image guide abdominal interventions in 49 opportunities, of which 67% required only conservative treatment afterwards, the remaining 33% required endoscopic treatment with prostheses, fibrin sealants, and/or clips. No mortality was reported in the series. CONCLUSION: Percutaneous image-guided abdominal interventions play a significant role in the treatment of complications following bariatric surgery. The minimally invasive treatment of fistula after bariatric surgery is safe and effective.

Evaluación de factores de riesgo asociados a dehiscencia anastomótica en cirugía colorrectal: análisis multivariado de 748 pacientes / Evaluation of the risk factors associated with anastomotic dehiscence in colorectal surgery: multivariate analysis of 748 pacients

INTRODUCCIÓN: La dehiscencia anastomótica (DA) es una complicación severa en cirugía colorrectal con una incidencia que oscila entre 2 y 19%. La literatura internacional muestra numerosos estudios sobre la identificación de factores de riesgo (FR), mientras que en la nacional existen solo dos series que analizan esta complicación. OBJETIVO: Realizar una caracterización descriptiva de resultados institucionales y establecer la tasa de DA, sus factores de riesgo asociados y la mortalidad. MATERIALES Y MÉTODO: Serie de casos no concurrente, cuya muestra son pacientes consecutivos intervenidos de patología colorrectal con anastomosis primaria con o sin ostoma derivativo entre los años 2004 y 2016. Se realiza modelo de regresión logística univariable y multivariable. RESULTADOS: Se obtuvieron 748 pacientes, 50,5% mujeres, media de edad fue 56,2. Las indicaciones quirúrgicas más frecuentes fueron cáncer colorrectal en 381 (50,9%) pacientes y enfermedad diverticular en 163 (21,8%). La DA fue de 5,6% (42/748) y la mortalidad fue de 2% (15/748), siendo de 1% para los electivos (7/681). En el análisis univariado encontramos que los FR que tuvieron significancia estadística fueron la albúmina (p < 0,001), altura anastomosis (p < 0,001), transfusión (p < 0,001), localización (colon derecho > izquierdo) (p = 0,011), mientras que en el análisis multivariado fueron la albúmina (p = 0,002) con un OR 3,64 (IC 95% 1,58-8,35) y transfusión (p = 0,015) con un OR 7,15 (IC 95% 1,46-34,91). CONCLUSIÓN: Nuestra serie es la más grande reportada en Chile, con resultados similares a estudios internacionales y nacionales. Establecemos que la hipoalbuminemia y la presencia de transfusiones intraoperatorias se asocian a alta tasa de DA.

INTRODUCTION: Anastomotic leakage (AL) is a severe complication in colorectal surgery, its incidence ranges from 2 to 19%. In international literature, we found numerous studies on the identification of risk factors (RF), while in the national there are only two series that analyze this complication. AIM: Perform a descriptive characterization of institutional results and establish the AL rate, its associated risk factors and mortality. MATERIALS AND METHOD: Non-concurrent series of cases, whose sample is consecutive patients operated for colorectal pathology with primary anastomosis with or without a derivative ostoma between 2004 and 2016. Univariate and multivariable logistic regression model was performed. RESULTS: There were 748 patients, 50.5% women, mean age was 56.2. The most frequent surgical indications were colorectal cancer in 381 (50.9%) patients and diverticular disease in 163 (21.8%). The AL was 5.6% (42/748) and the mortality was 2% (15/748), being 1% for the electives (7/681). In the univariate analysis, we found that the RF that had statistical significance were albumin (p < 0.001), anastomosis height (p < 0.001), transfusion (p < 0.001), location (right colon > left) (p = 0.011), while that in the multivariate analysis were albumin (p = 0.002) with an OR 3.64 (IC 95% 1.58-8.35) and transfusion (p = 0.015) with an OR 7.15 (IC 95% 1.46-34.91). CONLUSION: Our series is the largest reported in Chile, with similar results to international and national studies. We establish that hypoalbuminemia and the presence of intraoperative transfusions are associated with a high rate of AL.

Síndrome de la resección anterior baja: un alto precio del tratamiento del cáncer de recto / Low anterior resection syndrome: a high cost of rectal cancer treatment

En los últimos 30 años el tratamiento del cáncer del recto ha mejorado significativamente gracias al manejo multidisciplinario y a la introducción del concepto de resección total del mesorrecto (RTM), logrando disminuir las tasas de recidiva local y aumentar la sobrevida. Si bien los avances oncológicos y técnicos en términos de tasas de conservación del esfínter anal son innegables, las secuelas funcionales son significativas, especialmente las relacionadas a la función intestinal, sexual y urinaria. Hasta un 90% de los pacientes sometidos a una RTM refiere secuelas intestinales cuyos síntomas se conocen como el síndrome de la resección anterior baja (SRAB). Recientemente se han diseñado sistemas de valoración específicos que han evidenciado su alta incidencia y prevalencia. En esta revisión se entrega una mirada actualizada de la fisiopatología, factores de riesgo, formas de presentación, evaluación clínica y las distintas alternativas de prevención y tratamiento del SRAB.

In the last 30 years, oncologic outcomes of rectal cancer treatment have been significantly improved due to multimodal management and the introduction of the concept of total mesorectum excision. Although the improvements in oncological treatment and surgical techniques are undeniable, multimodal treatment results in the onset of disorders of the intestinal, sexual and urinary function in a high proportion of these patients. Up to 90% of patients undergoing a low anterior resection refer bowel disorders such as fecal incontinence, urgency, increased frequency and fragmentation of defecation. These elements are included in an entity known as the low anterior resection syndrome and specific assessment tools have been designed recently, evidencing the high incidence and prevalence of this syndrome. In the present review, we update the pathophysiology, risk factors, clinical presentation, evaluation and the alternatives of prevention and treatment of low anterior resection syndrome.

COMPLICATIONS AFTER TRANSABDOMINAL SOAVE'S PROCEDURE IN CHILDREN WITH HIRSCHSPRUNG'S DISEASE.

BACKGROUND: Hirschsprung's disease is a congenital disorder that causes functional obstruction of large bowel. AIM: To evaluate complication and bowel function score of children with Hirschsprung's disease who underwent transabdominal Soave's procedure. METHODS: In this study all the children with Hirschsprung's disease who underwent transabdominal Soave procedure were evaluated regarding bowel function and complication of trans-abdominal Soave's procedure. RESULTS: Were enrolled 160 children. Enterocolitis and constipation were seen in 15% of the cases. Fecal incontinency was the least frequent study which was seen in 1% of the children. CONCLUSION: Constipation and enterocolitis was the most frequent complication following transabdominal Soave technique.

Complications after transabdominal soave's procedure in children with hirschsprung's disease / Complicações após o procedimento de soave transabdominal em crianças com doença de hirschsprung

ABSTRACT Background: Hirschsprung's disease is a congenital disorder that causes functional obstruction of large bowel. Aim: To evaluate complication and bowel function score of children with Hirschsprung's disease who underwent transabdominal Soave's procedure. Methods: In this study all the children with Hirschsprung's disease who underwent transabdominal Soave procedure were evaluated regarding bowel function and complication of trans-abdominal Soave's procedure. Results: Were enrolled 160 children. Enterocolitis and constipation were seen in 15% of the cases. Fecal incontinency was the least frequent study which was seen in 1% of the children. Conclusion: Constipation and enterocolitis was the most frequent complication following transabdominal Soave technique.

RESUMO Racional: A doença de Hirschsprung é um distúrbio congênito que causa obstrução funcional do intestino grosso. Objetivo: Avaliar as complicações e o escore de função intestinal de crianças com a doença submetidas ao procedimento transabdominal de Soave. Métodos: Neste estudo, todas as crianças com doença de Hirschsprung submetidas ao procedimento transabdominal de Soave foram avaliadas quanto à função intestinal e complicação do procedimento. Resultados: Foram incluídas 160 crianças. Enterocolite e constipação foram observadas em 15% dos casos. A incontinência fecal foi menos frequente e observada em 1% das crianças. Conclusão: Obstipação e enterocolite foram as complicações mais frequentes após a técnica de Soave transabdominal em crianças.

Long-term outcomes of (Gore) fistula plug versus ligation of intersphincteric fistula tract for anal fistula / Desfechos de longo prazo do tampão de fístula (Gore) versus ligadura do trato da fístula interesfincteriana (LIFT) para fístula anal

ABSTRACT Background: The surgical treatment of anal fistula is complex due to the possibility of fecal incontinence. Fistulotomy and cutting Setons have the same incidence of fecal incontinence depending on the complexity of the fistula. Sphincter-preserving procedures such as anal fistula plug and ligation of intersphincteric fistula tract procedure may result in more recurrence requiring repeated operations. The aim of this study was to evaluate and compare the outcomes of treating fistula in Ano utilizing two methods: Fistula plug (Gore Bio-A) and ligation of intersphincteric tract (LIFT). Methods: Fifty four patients (33 males; 21 female, median ages 42 [range 32-47] years) with high anal inter-transphenteric fistula were treated with LIFT and fistula plug procedures from September 2011 until August 2016 by a single surgeon and were retrospectively evaluated. All were followed for a median of 23.9 (range 4-54) months with clinical examination. Twenty one patients underwent fistula plug and 33 patients underwent LIFT procedure (4 patients of the LIFT group underwent LIFT and rectal mucosa advancement flap). The healing rate and complications were evaluated clinically and through telephone calls. Results: The mean operative time for the Plug was 25 ± 17 min and for the LIFT was 40 ± 20 min (p = 0.017) and the mean hospital stay was 2.4 ± 1.1 and 1.9 ± 0.3 (p = 0.01) respectively. The early complications of the plug and LIFT procedures included; anal pain (33.3%, 66.6%, p = 0.13), perianal discharge (77.8%, 91%, p = 0.62), anal pruritus (38.9%, 50.0%, p = 0.71) and bleeding per rectum (16.7%, 33.3%, p = 0.39) respectively. The overall mean follow-up was 20.9 ± 16.8 months, p = 0.68. There was no statistically significant difference between the two groups (21.9 ± 7.5 months, 19.9 ± 16.1 months, p = 0.682). The healing rate was 76.2% (16/21 patients) in the fistula plug group and 81.1% (27/33 patients) in the LIFT group (p = 0.73). Patients who had LIFT procedure and a mucosal advancement flap had 100% healing rate (4 out of 4 patients). No incontinence of stool or feces and no fistula plug expulsion were seen in our patients. The healing time ranged from 1 to 6 months after surgery. There was no post-operative perianal abscess, cellulitis or pain. Conclusions: LIFT and anal plug are safe procedures for patients with primary and recurrent anal fistula. Both techniques showed excellent results in terms of healing and complication rate. None of our patients had incontinence after 5 years follow-up. The best success rate in our patients was seen after LIFT procedure with mucosal advancement flap. Larger and controlled randomized trials are needed for better assessment of treatment options.

RESUMO Introdução: O tratamento cirúrgico da fístula anal é complexo devido à possibilidade de incontinência fecal. A fistulotomia e o seton de corte têm a mesma incidência da incontinência fecal, dependendo da complexidade da fístula. Procedimentos de preservação do esfíncter, como o tampão da fístula anal e o procedimento LIFT (ligadura do trato da fístula interesfincteriana), podem resultar em mais recorrência, exigindo cirurgias repetidas. O objetivo deste estudo foi avaliar e comparar os desfechos do tratamento da fístula anal utilizando dois métodos: Tampão de fístula (Gore Bio-A) e Ligadura do Trato Interesfincteriano (LIFT). Métodos: Cinquenta e quatro pacientes (33 homens; 21 mulheres, com mediana de idade de 42 [variação 32-47] anos) foram tratados com LIFT e procedimentos com tampão de fístula de setembro de 2011 até agosto de 2016 por um único cirurgião e foram avaliados retrospectivamente. Todos foram acompanhados por uma mediana de 23,9 (variação de 4 a 54) meses com exame clínico. Vinte e um pacientes foram submetidos a tampão de fístula e 33 pacientes foram submetidos ao procedimento LIFT (4 pacientes do grupo LIFT foram submetidos a LIFT e retalho de avanço da mucosa retal). A taxa de cicatrização e as complicações foram avaliadas clinicamente e por meio de ligações telefônicas. Resultados: O tempo cirúrgico médio para o Tampão foi de 25 ± 17 minutos e para o LIFT foi de 40 ± 20 minutos (p = 0,017) e o tempo médio de internação foi de 2,4 ± 1,1 e 1,9 ± 0,3 (p = 0,01), respectivamente. As primeiras complicações dos procedimentos de tampão e LIFT incluíram: dor anal (33,3%, 66,6%, p = 0,13), secreção perianal (77,8%, 91%, p = 0,62), prurido anal (38,9%, 50,0%, p = 0,71) e sangramento pelo reto (16,7%, 33,3 %, p = 0,39) respectivamente. A média geral de acompanhamento foi de 20,9 ± 16,8 meses, p = 0,68. Não houve diferença estatisticamente significativa entre os dois grupos (21,9 ± 7,5 meses, 19,9 ± 16,1 meses, p = 0,682). A taxa de cicatrização foi de 76,2% (16/21 pacientes) no grupo com tampão de fístula e 81,1% (27/33 pacientes) no grupo LIFT (p = 0,73). Pacientes submetidos ao procedimento LIFT e um retalho de avanço da mucosa tiveram 100% de taxa de cura (4 de 4 pacientes). Nenhuma incontinência fecal e nenhuma expulsão do tampão da fístula foram observadas em nossos pacientes. O tempo de cicatrização variou de 1 a 6 meses após a cirurgia. Não houve abscesso perianal, celulite ou dor no pós-operatório. Conclusões: LIFT e tampão anal são procedimentos seguros para pacientes com fístula anal primária e recorrente. Ambas as técnicas apresentaram excelentes resultados em termos de cicatrização e taxa de complicações. Nenhum de nossos pacientes teve incontinência após 5 anos de acompanhamento. A melhor taxa de sucesso em nossos pacientes foi observada após o procedimento LIFT com retalho de avanço da mucosa. Ensaios clínicos randomizados de maior porte e controlados são necessários para melhor avaliação das opções de tratamento.

Does Mechanical Bowel Preparation Reduce the Risk of Developing Infectious Complications in Pediatric Colorectal Surgery? A Systematic Review and Meta-Analysis.

OBJECTIVES: To evaluate whether the application of mechanical bowel preparation (MBP) before colorectal surgery reduces the risk of developing infectious complications in children. STUDY DESIGN: In this systematic review and meta-analysis, PubMed, Embase, and the Cochrane Library were systematically searched to identify all articles comparing pediatric patients receiving MBP with pediatric patients not receiving MBP before colorectal surgery. Results are presented with weighted risk differences based on the number of events and sample size per study. RESULTS: Six original studies were included comparing MBP (n = 810) and no MBP (n = 1167). The overall risk of developing infectious complications was 10.1% in patients with MBP, compared with 9.1% in patients without MBP, resulting in a nonsignificant risk difference of -0.03% (95% CI, -0.09% to 0.03%). Concerning the number of wound infections and anastomotic leaks, we found nonsignificant risk differences of -0.03% (95% CI, -0.08% to 0.02%) and 0.01% (95% CI, -0.01% to 0.02%), respectively. CONCLUSION: Based on the current literature, there is insufficient evidence to indicate that the use of MBP leads to a significant difference in the risk of developing infectious complications in pediatric colorectal surgery.