[Recommendations for the patient during the treatment of colorectal cancer through the enhanced recovery.] / Recomendaciones para el paciente durante el tratamiento del cáncer colorrectal mediante la vía de recuperación intensificada.

It is estimated that colorectal cancer is the cancer disease with the highest incidence in Spain  due to the increase in life expectancy and changes in the lifestyle of the population . Early detection through disease screening programs allows for more effective treatment and a higher survival rate . Advances in treatment have been made, such as targeted therapies, which focus on specifically attacking cancer cells and preventing their growth . However, much remains to be done in terms of prevention and treatment of colorectal cancer. More research and medical advances are required to combat this disease.

Se estima que el cáncer colorrectal es la enfermedad oncológica que presenta mayor incidencia en España  debido al incremento en la esperanza de vida y a los cambios en el estilo de vida de la población . La detección precoz mediante los programas de cribado de la enfermedad permite un tratamiento más efectivo y una mayor tasa de supervivencia . Se han realizado avances en el tratamiento, como las terapias dirigidas, que se centran en atacar específicamente a las células cancerosas y prevenir su crecimiento . Sin embargo, todavía queda mucho por hacer en términos de prevención y tratamiento del cáncer colorrectal. Se requiere más investigación y más avances médicos para combatir esta enfermedad.

Delaying surgery by more than 10 weeks after long-course neoadjuvant radiotherapy in locally advanced rectal cancer patients improves pathologic complete response.

BACKGROUND: We currently do not know the optimal time interval between the end of chemoradiotherapy and surgery. Longer intervals have been associated with a higher pathological response rate, worse pathological outcomes and more morbidity. The aim of this study was to evaluate the effect and safety of the current trend of increasing time interval between the end of chemoradiotherapy and surgery (< 10 weeks vs. ≥ 10 weeks) on postoperative morbidity and pathological outcomes. This study analyzed 232 consecutive patients with locally advanced rectal cancer treated with long-course neoadjuvant chemoradiotherapy from January 2012 to August 2018. 125 patients underwent surgery before 10 weeks from the end of chemoradiotherapy (Group 1) and 107 patients underwent surgery after 10 or more weeks after the end of chemoradiotherapy (Group 2). Results have shown that wait for ≥ 10 weeks did not compromise surgical safety. Pathological complete response and tumor stage was statistically significant among groups. The effect of wait for ≥ 10 weeks before surgery shown higher tumor regression than the first group (Group 1, 12.8% vs Group 2, 31.8%; p < 0.001). On multivariate analysis, wait for ≥ 10 weeks was associated with pathological compete response. Patients from the second group were four time more likely to achieve pathologic complete response than patients from the first group (OR, 4.27 95%CI 1.60-11.40; p = 0.004). Patients who undergo surgery after ≥ 10 weeks of the end of chemoradiotherapy are four time more likely to achieve complete tumor remission without compromise surgical safety or postoperative morbidity.

La cirugía transanal como herramienta en la dehiscencia de la anastomosis colorrectal / Transanal surgery: A tool in the colorectal anastomotic leakage

El tratamiento de la dehiscencia de sutura después de cirugía oncológica del cáncer de recto supone un reto quirúrgico. El objetivo de este trabajo es mostrar como la cirugía transanal combinada con el abordaje abdominal es una herramienta muy útil para decidir el tratamiento individualizado en función del grado de dehiscencia y ayudarnos al manejo local de la misma. Presentamos tres casos de pacientes con dehiscencia de sutura colorrectal. En dos de ellos se muestra el tratamiento de una dehiscencia colorrectal aguda y como la cirugía transanal nos permite comprobar la viabilidad y descartar isquemia subyacente. Por otro lado, nos facilita un buen drenaje de la colección adyacente, así como si es necesaria la colocación de un sistema vacuum y de sus recambios siguientes. El último caso se trata de una dehiscencia tardía con sinus presacro crónico y su tratamiento mediante acceso transanal para destechamiento del mismo

The treatment of anastomotic leakage after oncological surgery for rectal cancer is a surgical challenge. The goal of this study is to show how transanal surgery combined with the abdominal approach is a very useful tool to decide on individualized treatment depending on the degree of dehiscence and to assist us in its local management. We present three cases of patients with colorectal anastomotic dehiscence. In two, we demonstrate the treatment of acute colorectal leakage and how transanal surgery allows us to confirm its viability and rule out any underlying ischemia. Furthermore, it facilitates good drainage of the adjacent collection as well as the placement of a vacuum system, if necessary, and its subsequent replacements. The last case is a delayed dehiscence with chronic presacral sinus, and its treatment by transanal access for fenestration

Transanal surgery: A tool in the colorectal anastomotic leakage. / La cirugía transanal como herramienta en la dehiscencia de la anastomosis colorrectal.

The treatment of anastomotic leakage after oncological surgery for rectal cancer is a surgical challenge. The goal of this study is to show how transanal surgery combined with the abdominal approach is a very useful tool to decide on individualized treatment depending on the degree of dehiscence and to assist us in its local management. We present three cases of patients with colorectal anastomotic dehiscence. In two, we demonstrate the treatment of acute colorectal leakage and how transanal surgery allows us to confirm its viability and rule out any underlying ischemia. Furthermore, it facilitates good drainage of the adjacent collection as well as the placement of a vacuum system, if necessary, and its subsequent replacements. The last case is a delayed dehiscence with chronic presacral sinus, and its treatment by transanal access for fenestration.

Perforación rectal espontánea con evisceración transanal del intestino delgado. A propósito de un caso y revisión de la literatura / Spontaneous perforation of the rectum with transanal evisceration of the small bowel: A case report and review of the literature

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Resultados clínico-oncológicos de la respuesta patológica completa en el cáncer de recto después de tratamiento neoadyuvante / Clinical and oncological results of the pathological complete response in rectal cancer after neoadjuvant treatment

Introduction Neoadjuvant chemo-radiotherapy is the treatment of choice for rectal cancer in order to reduce local recurrence. Patients with a pathological complete response (PCR) have a better prognosis. The aim of this study was to determine the influence of PCR on the oncological outcomes in our patients. Methods All patients with stage ii/iii rectal cancer treated with neoadjuvant chemo-radiotherapy and radical resection between 2007 and 2011were identified from a prospective database, and grouped based on whether they achieved PCR or not (non-PCR). Clinical, histological and oncological outcome data were compared. Results A total of 162 patients were included (62% men), with a mean age of 65 years. In terms of pre-operative TNM staging, 82 patients (50%) were T2, 75 (46%) were T3, and 5 (3%) were T4. Forty-two patients (25%) were N1, and 87 (53%) were N2. Low anterior resection and abdominoperineal resection were performed in 125 (77%) and 25 (15%) patients. Forty-three patients (26.5%) had postoperative morbidity. PCR was achieved in 19 patients (11.7%). After a median follow-up of 26 months, there are no recurrences in the PCR group, and in the non-PCR group, local recurrence was 1.4% (P = .78), and distant metastasis was 8.4% (P = .21). Overall survival (P = .39) and survival free of diseases (P = .23) were better in the PCR group, but the differences were not significant. Conclusion Patients with pathological complete response have better oncological outcome (AU)

Introducción La radioquimioterapia es el tratamiento de elección en el cáncer de recto para conseguir el control de la enfermedad. Los pacientes con respuesta patológica completa (RPC) presentan mejor pronóstico. El objetivo del trabajo es conocer nuestra incidencia de RPC y analizar los resultados oncológicos. Métodos Pacientes con neoplasia de recto estadios ii/iii , recogidos prospectivamente en el periodo comprendido entre 2007 y 2011. Los pacientes son sometidos a neoadyuvancia y a cirugía radical. Se dividen en 22 grupos según tengan o no RPC y se comparan las variables demográficas, clínicas e histológicas y su relación con la evolución oncológica. Resultados Se analizan 162 pacientes (62% varones) con una edad media de 65 a. La incidencia de RPC es del 11,7% (19 pacientes). El 50% de los pacientes son T2, el 46% son T3 y el 3% son T4, mientras que el 25% son N1 y el 53% son N2 antes de la neoadyuvancia. En 25 pacientes (15%)se ha practicado una amputación de recto y en 125 (77%) una resección anterior baja. La morbilidad global es del 26,5%(43 pacientes). Con una mediana de seguimiento de 26 meses, ningún paciente con RPC ha presentado recurrencia tumoral. En el grupo de NO-RPC la recidiva local es del 1,4% (p = 0,78) y las metástasis del 8,4% (p = 0,21), siendo la supervivencia global y la libre de enfermedad mayor en el grupo con RPC pero sin diferencias significativas (p = 0,39, p = 0,23). Conclusión La presencia de RPC después de tratamiento neoadyuvante se relaciona con mejores resultados oncológicos (AU)

[Clinical and oncological results of the pathological complete response in rectal cancer after neoadjuvant treatment]. / Resultados clínico-oncológicos de la respuesta patológica completa en el cáncer de recto después de tratamiento neoadyuvante.

INTRODUCTION: Neoadjuvant chemo-radiotherapy is the treatment of choice for rectal cancer in order to reduce local recurrence. Patients with a pathological complete response (PCR) have a better prognosis. The aim of this study was to determine the influence of PCR on the oncological outcomes in our patients. METHODS: All patients with stage ii/iii rectal cancer treated with neoadjuvant chemo-radiotherapy and radical resection between 2007 and 2011 were identified from a prospective database, and grouped based on whether they achieved PCR or not (non-PCR). Clinical, histological and oncological outcome data were compared. RESULTS: A total of 162 patients were included (62% men), with a mean age of 65 years. In terms of pre-operative TNM staging, 82 patients (50%) were T2, 75 (46%) were T3, and 5 (3%) were T4. Forty-two patients (25%) were N1, and 87 (53%) were N2. Low anterior resection and abdominoperineal resection were performed in 125 (77%) and 25 (15%) patients. Forty-three patients (26.5%) had postoperative morbidity. PCR was achieved in 19 patients (11.7%). After a median follow-up of 26 months, there are no recurrences in the PCR group, and in the non-PCR group, local recurrence was 1.4% (P=.78), and distant metastasis was 8.4% (P=.21). Overall survival (P=.39) and survival free of diseases (P=.23) were better in the PCR group, but the differences were not significant. CONCLUSION: Patients with pathological complete response have better oncological outcome.

Vólvulo de colon y recidiva del vólvulo: ¿qué debemos hacer? / Colonic volvulus and recurrence of volvulus: what should we do?

Introducción: El vólvulo de colon (VC) es una patología infrecuente en nuestro medio que cursa con clínica de oclusión intestinal; el manejo diagnóstico y terapéutico es una constante controversia. El objetivo de este trabajo es presentar nuestra serie, analizar los resultados y plantear una actitud terapéutica para disminuir la recidiva del vólvulo. Material y métodos Estudio retrospectivo y descriptivo de los pacientes diagnosticados de VC entre enero de 1997 y diciembre de 2009.Resultados Se incluye a 54 pacientes que presentaron un total de 89 episodios de VC, con una edad media de 74 años y con un 70% de patología asociada, destacando un 44% de casos con estreñimiento y un 53% con enfermedades neurológicas. El vólvulo se localiza en sigma en el 87% de los casos y en el colon derecho en el 13%. El 92% de los casos presentó clínica de oclusión. El tratamiento endoscópico tuvo una eficacia del 61% y se practicó cirugía urgente en el 31% de los casos y en el 40% de los primeros episodios de VC. El 62% de los casos tratados sin cirugía presentó recidiva del vólvulo y en éstos se realizó cirugía en el 72%. En el total de la serie se realiza cirugía en 35 casos (64%); la sigmoidectomía con anastomosis primaria es la técnica más empleada. La mortalidad global de la serie fue de 7 casos (12%) y del 16% en los casos de cirugía por recidiva. Conclusiones La técnica diagnóstica y terapéutica inicial del VC es la endoscopia descompresiva. La cirugía electiva precoz evita la alta tasa de recidiva asociada a mayor mortalidad (AU)

Introduction: Colonic volvulus (CV) is an uncommon disease in our country, which may present clinically as an intestinal obstruction or occlusion. Its diagnosis and therapeutic management remains controversial. The objective of this article is to present our series, analyse the results and establish a therapeutic approach to decrease the recurrence of the volvulus. Material and methods: A retrospective, descriptive study of patients diagnosed with CV between January 1997 and December 2009. Results: The study included 54 patients, with a mean age of 74 years, who had a total of 89 CV episodes. There was associated disease in 70% of the cases, which included 44% with constipation and 53% with neurological diseases. The volvulus was located in the sigmoid in 87% of cases and in the right colon in 13%. The large majority (92%) of cases had intestinal obstruction. Endoscopic treatment was effective in 61% and urgent surgery was performed in 31% of the cases, and in 40% of the first episodes of CV. There was recurrence of volvulus in 62% of cases treated with surgery, and surgery was performed in 72% of these. In the whole series, surgery was performed in 35 cases (64%), with sigmoidectomy with primary anastomosis being the technique most employed. The overall mortality of the series was 7 cases (12%), with 16% being in cases of surgery due to recurrence. Conclusions: The diagnostic technique and initial treatment of CV is endoscopic decompression. Early elective surgery prevents the high recurrence rate associated with highermortality (AU)

[Colonic volvulus and recurrence of volvulus: what should we do?]. / Vólvulo de colon y recidiva del vólvulo: ¿qué debemos hacer?

INTRODUCTION: Colonic volvulus (CV) is an uncommon disease in our country, which may present clinically as an intestinal obstruction or occlusion. Its diagnosis and therapeutic management remains controversial. The objective of this article is to present our series, analyse the results and establish a therapeutic approach to decrease the recurrence of the volvulus. MATERIAL AND METHODS: A retrospective, descriptive study of patients diagnosed with CV between January 1997 and December 2009. RESULTS: The study included 54 patients, with a mean age of 74 years, who had a total of 89 CV episodes. There was associated disease in 70% of the cases, which included 44% with constipation and 53% with neurological diseases. The volvulus was located in the sigmoid in 87% of cases and in the right colon in 13%. The large majority (92%) of cases had intestinal obstruction. Endoscopic treatment was effective in 61% and urgent surgery was performed in 31% of the cases, and in 40% of the first episodes of CV. There was recurrence of volvulus in 62% of cases treated with surgery, and surgery was performed in 72% of these. In the whole series, surgery was performed in 35 cases (64%), with sigmoidectomy with primary anastomosis being the technique most employed. The overall mortality of the series was 7 cases (12%), with 16% being in cases of surgery due to recurrence. CONCLUSIONS: The diagnostic technique and initial treatment of CV is endoscopic decompression. Early elective surgery prevents the high recurrence rate associated with higher mortality.

[Morbidity and mortality associated with diverting ileostomy closures in rectal cancer surgery]. / Morbilidad y mortalidad en relación con el cierre de ileostomías derivativas en la cirugía del cáncer de recto.

INTRODUCTION: Derivative ileostomies are frequently performed to protect low anastomosis. The closure of the ileostomy has shown, under some circumstances, high associated mortality/morbidity rates. This study attempts to quantify the morbidity and mortality associated with ileostomy closure in rectal neoplasm patients and to determine if the length of time between the procedure of construction and closure increases the morbidity/mortality. MATERIAL AND METHOD: A retrospective study was performed, using the database of the colo-rectal surgical group in the department of general surgery. The subjects were the 62 patients treated between January 1, 2000 and December 31, 2006 who received both a low anterior resection to treat rectal neoplasm and a subsequent ileostomy closure. RESULTS: The mean patient age was 65 years (38-83) and consisted of 19 women (30.7%) and 43 men (69.3%). The mean time between the construction and closure was 10.48 months (2-56) and the mean hospital stay was 7.8 days (3-32). The overall morbidity/mortality rate was 33.8% and 6.4%. The most frequent surgical complications were postoperative intestinal occlusion (16.9%) and wound infection (11.2%). CONCLUSIONS: The study showed high morbidity/mortality rate for the closure of temporary ileostomy. Patients who received the closure more than 11.65 months after the low anterior resection had significantly higher morbidity/mortality rates.

Morbilidad y mortalidad en relación con el cierre de ileostomías derivativas en la cirugía del cáncer de recto / Morbidity and mortality associated with diverting ileostomy closures in rectal cancer surgery

Introducción. El uso de la ileostomía en asa temporal para la protección de anastomosis bajas es frecuente. El cierre de estas ileostomías conlleva morbilidad. Este estudio se diseñó con el propósito de cuantificar la morbimortalidad asociada al cierre de las ileostomías en pacientes intervenidos por neoplasia del recto y determinar si el tiempo transcurrido entre la construcción y el cierre de la ileostomía aumenta la morbimortalidad. Material y método. Se realizó un estudio de tipo retrospectivo, utilizando la base de datos de la Unidad de Coloproctología del Servicio de Cirugía General, para determinar el grupo de pacientes a quienes se les realizó una resección anterior baja por neoplasia del recto y posteriormente el cierre de la ileostomía en el período entre el 1 de enero de 2000 y el 31 de diciembre de 2006. Resultados. Analizamos a 62 pacientes con cierre de ileostomía realizado en el período descrito. La media de edad de los pacientes fue de 65 (intervalo, 38-83) años; 19 (30,7%) eran mujeres y 43 (69,3%), varones. El tiempo medio transcurrido entre la construcción y el cierre fue de 10,48 (2-56) meses y la estancia hospitalaria, de 7,8 (3-32) días. La morbilidad total asociada al cierre de ileostomía fue del 33,8% y la mortalidad, del 6,4%. La infección de herida (11,2%) y la oclusión intestinal postoperatoria (16,9%) fueron las complicaciones quirúrgicas más frecuentes. Conclusiones. El cierre de la ileostomía temporal se relaciona con gran morbimortalidad. El tiempo entre construcción y cierre mayor a 11,65 meses es un factor de riesgo para morbilidad asociada al cierre de las ileostomías (AU)

Introduction. Derivative ileostomies are frequently performed to protect low anastomosis. The closure of the ileostomy has shown, under some circumstances, high associated mortality/morbidity rates. This study attempts to quantify the morbidity and mortality associated with ileostomy closure in rectal neoplasm patients and to determine if the length of time between the procedure of construction and closure increases the morbidity/mortality. Material and method. A retrospective study was performed, using the database of the colo-rectal surgical group in the department of general surgery. The subjects were the 62 patients treated between January 1, 2000 and December 31, 2006 who received both a low anterior resection to treat rectal neoplasm and a subsequent ileostomy closure. Results. The mean patient age was 65 years (38-83) and consisted of 19 women (30.7%) and 43 men (69.3%). The mean time between the construction and closure was 10.48 months (2-56) and the mean hospital stay was 7.8 days (3-32). The overall morbidity/mortality rate was 33.8% and 6.4%. The most frequent surgical complications were postoperative intestinal occlusion (16.9%) and wound infection (11.2%). Conclusions. The study showed high morbidity/mortality rate for the closure of temporary ileostomy. Patients who received the closure more than 11.65 months after the low anterior resection had significantly higher morbidity/mortality rates (AU)

[Ischemic colitis: two forms of clinical presentation and outcome]. / Colitis isquémica: dos formas de evolución clínica.

OBJECTIVES: To characterize the clinical presentation and outcomes of ischemic colitis in our environment with a view to identifying risk factors. METHOD: Fifty-one patients diagnosed in our hospital with ischemic colitis over a 5-year period (1998-2002) were retrospectively analyzed. Demographic data, clinical symptoms, diagnosis and treatment were studied. Two groups (surgical patients [n = 28] and nonsurgical patients [n = 23]) were compared. RESULTS: No significant differences between the two groups were found in demographic data and associated disease. Diagnosis was performed by colonoscopy in nonsurgical patients and by analysis of the surgical specimen in almost all surgical patients. The presenting symptom was lower gastrointestinal bleeding in nonsurgical patients (p < 0.05) and peritonism in surgical patients (p < 0.05). Mortality was significantly higher in patients older than 80 years than in younger patients. CONCLUSIONS: Lower gastrointestinal bleeding was more common as the presenting symptom in transitory forms of ischemic colitis. An acute abdomen indicates serious forms requiring surgery. Therefore the initial clinical symptoms determine the treatment provided. Advanced age is a poor prognostic factor for ischemic colitis. Risk factors in our series were presentation as acute abdomen and advanced age.

Colitis isquémica: dos formas de evolución clínica / Ischemic colitis: two forms of clinical presentation and outcome

Objetivos. Caracterizar la presentación y los resultados de la enfermedad en nuestro medio con el fin de identificar los factores de riesgo. Método. Se ha estudiado retrospectivamente, en un período de 5 años (1998-2002), a 51 pacientes diagnosticados de colitis isquémica en nuestro centro, mediante la revisión de los datos demográficos, los síntomas clínicos, los métodos diagnósticos y el tratamiento. Se comparan 2 grupos: el de pacientes operados (grupo O; n = 28) y el de no operados (grupo NO; n = 23). Resultados. No encontramos diferencias significativas entre los 2 grupos en cuanto a los datos demográficos ni a la enfermedad asociada. En los pacientes tratados médicamente, la enfermedad se diagnostica a través de una colonoscopia, mientras que en los operados prácticamente siempre se consigue el diagnóstico gracias al análisis de la pieza de resección. Los pacientes del grupo NO comienzan con rectorragia (p < 0,05) mientras que los del grupo O acuden por clínica de peritonismo (p < 0,05). La mortalidad entre los pacientes mayores de 80 años es significativamente mayor que en los de menor edad. Conclusiones. La presentación clínica en forma de rectorragia es más frecuente en las formas de colitis isquémica transitorias, mientras que el abdomen agudo define las formas graves que precisan intervención quirúrgica; la clínica inicial es la que determina el tratamiento recibido. Asimismo, la edad avanzada es un factor de mal pronóstico de la enfermedad. En nuestra serie, la presentación en forma de abdomen agudo y la edad avanzada se definen como factores de riesgo (AU)

Objectives. To characterize the clinical presentation and outcomes of ischemic colitis in our environment with a view to identifying risk factors. Method. Fifty-one patients diagnosed in our hospital with ischemic colitis over a 5-year period (1998-2002) were retrospectively analyzed. Demographic data, clinical symptoms, diagnosis and treatment were studied. Two groups (surgical patients [n = 28] and nonsurgical patients [n = 23]) were compared. Results. No significant differences between the two groups were found in demographic data and associated disease. Diagnosis was performed by colonoscopy in nonsurgical patients and by analysis of the surgical specimen in almost all surgical patients. The presenting symptom was lower gastrointestinal bleeding in nonsurgical patients (p < 0.05) and peritonism in surgical patients (p < 0.05). Mortality was significantly higher in patients older than 80 years than in younger patients. Conclusions. Lower gastrointestinal bleeding was more common as the presenting symptom in transitory forms of ischemic colitis. An acute abdomen indicates serious forms requiring surgery. Therefore the initial clinical symptoms determine the treatment provided. Advanced age is a poor prognostic factor for ischemic colitis. Risk factors in our series were presentation as acute abdomen and advanced age (AU)