Three-dimensional endoanal ultrasound to assess the validity of Goodsall's Rule and the Midline Rule in predicting the path of perianal fistula-in-ano and the location of the internal opening.

BACKGROUND: Correct identification of the internal opening is essential in the management of perianal fistulae. The aim of this study was to assess the validity of Goodsall's Law and the Midline Rule in predicting the path of perianal fistula-in-ano and the location of the internal opening using 3-dimensional endoanal ultrasound. METHODS: An observational study including patients diagnosed with fistula-in-ano, at our institution from January 2006 to December 2020 was performed. Location and distance from the anal verge of the external opening, internal opening, and the path of the fistulous tract were recorded during physical examination and endoanal ultrasound. Goodsall's and Midline rules were applied to all fistulae according to the location of the external opening. The location of the internal opening as predicted by either rule was then compared to the real location of the internal opening identified during endoanal ultrasound examination. RESULTS: Nine hundred and nine patients [657 (72.3%) males, mean age 50.78 (49.84-51.72) years] were included. 665 (73.2%) of fistulae were transsphinteric. Concordance between predicted internal opening site and the true internal opening location was 0.601 (good match) for Goodsall's rule, and 0.416 (moderate match) for the Midline rule. Goodsall's rule proved to be more predictive in the anterior plane (p < 0.001). Both rules were more likely to make a correct diagnosis in posterior fistulae located 4.5-7.5 mm from the anal verge. CONCLUSIONS: Both Midline and Goodsall's rules are highly predictive of the course of fistula tracts located in the posterior plane, and are lower for anterior located fistulae, female patients and when the external opening is located further from the anal verge.

Does delaying curative surgery for colorectal cancer influence long-term disease-free survival? A cohort study.

BACKGROUND: Surgical wait list time is a major problem in many health-care systems and its influence on survival is unclear. The aim of this study is to assess the impact of wait list time on long-term disease-free survival in patients scheduled for colorectal cancer resection. MATERIALS AND METHODS: A prospective study was carried out in patients with colorectal cancer scheduled for surgery at a tertiary care center. Wait list time was defined as the time from completion of diagnostic workup to definitive surgery and divided into 2-week intervals from 0 to 6 weeks. The outcome variables were 2-year and 5-year disease-free survival. RESULTS: A total of 602 patients, 364 (60.5%) male, median age 73 years (range = 71) were defined. The median wait list time was 28 days (range = 99). Two and 5-year disease-free survival rates were 521 (86.5%) and 500 (83.1%) respectively. There were no differences in 2-year or 5-year disease-free survival for the whole cohort or by tumor stage between wait list time intervals except for AJCC stage II tumors which showed a higher 5-year disease-free survival for the 2-4 and 4-6-week wait list time interval (p = 0.021). CONCLUSIONS: Time from diagnosis to definitive surgery up to 6 weeks is not associated with a decrease in 2-year or 5-year disease-free survival (DFS) in AJCC stage I through III colorectal cancer patients. These are important findings in the light of the COVID-19 pandemic and offer a window of opportunity for preoperative optimization and prehabilitation.

Impact of the novel powered circular stapler on risk of anastomotic leakage in colorectal anastomosis: a propensity score-matched study.

BACKGROUND: Several risk factors for anastomotic leakage (AL) following colorectal surgery have been described. Improvement in devices for performing anastomosis is a modifiable factor that could reduce AL rates. The aim of this study was to assess the impact of technical improvements in the Echelon Circular™ powered stapler (ECPS) on the left-sided colorectal AL rate compared to current manual circular staplers (MCS). METHODS: A cohort study was carried out on consecutive patients between January 2017 and February 2020 in whom left-sided stapled colorectal anastomosis above 5 cm from anal verge was performed. The primary end point was the risk of AL depending on the type of circular stapler used. The ECPS cases were matched to MCS cases by propensity score matching to obtain comparable groups of patients. RESULTS: Two hundred seventy-nine patients met the inclusion criteria. A MCS anastomosis was performed in 218 patients and ECPS anastomosis in 61 (21.9%). Overall, AL was observed in 25 (9%) cases. Factors significantly associated with AL were American Society of Anesthesiologists score (p = 0.025) and type of circular stapler used (p = 0.021). After adjusting the cases with propensity score matching (119 cases MCS versus 60 ECPS), AL was observed in 14 (11.8%) patients in MCS group and in 1 (1.7%) patient in the ECPS group (p = 0.022). AL in the MCS group required reoperation in seven cases (5.8%), the remaining seven patients were treated conservatively. The patient in the ECSP group required an urgent Hartmann's procedure CONCLUSIONS: The ECPS device could have a positive impact by reducing AL rates in left-sided colorectal anastomosis. Multicenter controlled trials are needed for stronger evidence to change practice.

Outcomes of Hartmann's procedure and subsequent intestinal restoration. Which patients are most likely to undergo reversal?

BACKGROUND: Aim of the study was to describe characteristics and outcomes of Hartmann's procedure (HP) and subsequent intestinal restoration. METHODS: Retrospective study including all patients who underwent HP over a period of 16 consecutive years. We propose a classification and regression tree for a more accurate view of the relationship between the variables related to intestinal restoration and their weighting in the decision to reverse HP. RESULTS: 533 patients were included. Overall morbidity rate of HP was 53.5% and mortality 21.0%. Overall morbidity of the intestinal continuity reconstruction was 47.3% and mortality 0.9%. Patients with a benign disease, aged under 69 years and with low comorbidity, had an 84.4% probability of undergoing intestinal reconstruction. CONCLUSIONS: HP is associated with high morbidity and mortality. Restoration of intestinal continuity involves minor, but frequent, morbidity and a low mortality rate. Age and comorbidities can decrease, and even override, the decision to reverse HP.

Propensity score analysis of postoperative and oncological outcomes after surgical treatment for splenic flexure colon cancer.

PURPOSE: The surgical treatment of splenic flexure colon cancer (SFCC) is somehow not yet well standardized. Postoperative and oncological results of the three surgical techniques most commonly used to treat SFCC: extended right colectomy (ERC), egmental left colectomy (SLC), and left colectomy (LC) were evaluated. METHODS: The study included all patients with stage I-III SFCC treated by ERC, SLC, or LC between 2005 and 2016. Postoperative and long-term outcomes after the different surgical techniques were analyzed: Propensity score matching (PSM) was performed to compare the outcomes between these surgical techniques and survival analyses were performed using the Kaplan-Meier method and log-rank tests. RESULTS: A total of 170 SFCC patients were operated; ERC was performed in 71 (41.76%), SLC in 36 (21.18%), and LC in 63 (37.06%). There were no significant differences in the short and long-term postoperative outcomes. Three comparison groups were developed so that PSM could be performed between the surgical technique cases: ERC (n = 59) vs. LC (n = 50); ERC (n = 50) vs. SLC (n = 33); and SLC (n = 32) vs. LC (n = 44). No differences in the short or long-term outcomes of these techniques were observed. CONCLUSION: The short and long-term outcomes between ERC, SLC, and LC are similar. SLC should be considered oncologically as appropiate as the other more extensive resections.

Reversal of Hartmann's procedure: a single-centre experience of 533 consecutive cases.

AIM: Hartmann's procedure (HP) is common. However, restoration of intestinal continuity is not so frequent. The aim of this study was to determine predictive factors which might influence outcomes following the reversal of HP. METHOD: All consecutive patients who underwent elective and emergency HP in a single institution between January 1999 and December 2014 were included. Data concerning patient, disease and treatment features were collected. Univariate and multivariate binary logistic regression models were used to determine prognostic factors. RESULTS: A total of 533 consecutive patients underwent HP over the 16-year period. Factors that were associated with a higher probability of reversal were age (< 69 years), American Society of Anesthesiologists (ASA) grade (I or II), indication for HP (likelihood of anastomotic leakage) and length of rectal stump reaching or exceeding the sacral promontory. A reduced probability of intestinal reconstruction was associated with anal incontinence, Stage IV cancer, postoperative transfusion or elective surgery. CONCLUSION: Age, ASA grade, the indication for HP, the length of rectal stump, anal incontinence, tumour stage, postoperative transfusion and elective surgery determine the probability of reversal.

Factors related to lymph node harvest: does a recovery of more than 12 improve the outcome of colorectal cancer?

AIM: The nodal harvest was studied to identify factors that affected the number of lymph nodes (LNs) retrieved in patients undergoing curative surgery for colorectal cancer. The influence of predictive factors on overall and disease-free 5-year survival was analysed. METHOD: All patients diagnosed with colorectal cancer who underwent oncological resection consecutively from January 1996 to December 2011 in a single institution have been studied. Factors influencing LN retrieval were analysed. A logistic regression analysis was performed to determine the factors that predicted a recovery of more than 12 LNs. A Cox regression analysis was made to identify the predictive factors of overall and disease-free 5-year survival. RESULTS: A total of 1166 patients were included in the study. The factors associated with the number of LNs harvested in surgical resections were age, colorectal surgeon, right colectomy, total colectomy, year of surgery, number of LN metastases and lymphocyte response. The factors that predicted a recovery of ≥ 12 LNs were age < 60 years, right colectomy, year of surgery and expert pathologist. A recovery of ≥ 12 LNs did not show significant differences in overall and disease-free 5-year survival, but the factor of colorectal surgeon did. CONCLUSION: Number of LN metastases, lymphocyte response, type of surgical resection, age of patient and colorectal surgeon can predict the LN harvest. Survival in colorectal cancer, however, is probably more influenced by the performance of the operation by an expert surgeon than by recovery of more than 12 LNs.

[Early use of CT in the management of acute diverticulitis of the colon]. / El uso precoz de la tomografía computarizada en el manejo de la diverticulitis aguda.

OBJECTIVE: To assess the early use of CT for the diagnosis, staging, and management of acute diverticulitis. MATERIAL AND METHODS: A prospective study of 102 patients with a clinical diagnosis of acute diverticulitis of the left colon. Acute diverticulitis was initially divided into 3 clinical stages. Patients were restaged according to CT findings into stages I, IIa, IIb, and III. Diagnosis was subsequently confirmed intraoperatively or by colonoscopy or barium studies. RESULTS: 102 patients (52 females and 50 males, mean age of 59.4 (SD + 14.96 years)) were included; 84 (82.35%) patients with a clinical diagnosis of acute diverticulitis were confirmed to suffer this disease for a diagnostic error of 17.65% (n=18). Acute diverticulitis was diagnosed by CT in 84.3% (n=86). CT had a sensitivity of 100% and a specificity of 88.9%. CT changed clinical stage for 38% of patients because of understaging in 13% and of overstaging in 25%. When stages II and III were analyzed separately, 60 and 50% were overstaged, respectively. The reclassification of patients according to CT results had a significant impact on treatment. CONCLUSIONS: Early clinical staging with CT avoids diagnostic clinical errors in 17.65% of patients. CT changes the initial clinical staging of acute episodes in 38% of cases, thus avoiding unnecessary delays in surgery for severe cases, and unnecessary surgeries for mild cases.

El uso precoz de la tomografía computarizada en el manejo de la diverticulitis aguda / Early use of CT in the management of acute diverticulitis of the colon

Objetivo: valorar el uso precoz de la tomografía computarizada (TC) para el diagnóstico, estadificación y manejo de la diverticulitis aguda. Material y métodos: realizamos un estudio prospectivo de 102 pacientes con el diagnóstico clínico de diverticulitis aguda de colon izquierdo. La diverticulitis aguda fue inicialmente dividida en tres estadios. Los pacientes fueron reestadiados en los estadios I, IIa, IIb y III de acuerdo a los hallazgos encontrados en la TC. El diagnóstico se confirmó después intraoperatoriamente, por colonoscopia o estudio con bario. Resultados: fueron incluidos 102 pacientes (52 mujeres y 50 hombres) con una edad media de 59,4 (DS ± 14,96). En 84 (82,35%) pacientes con el diagnóstico clínico de diverticulitis aguda se confirmó este diagnóstico con un error diagnóstico del 17,65% (n = 18). La diverticulitis aguda se diagnosticó con la TC en el 84,3% (n = 86). La TC tuvo una sensibilidad del 100% y especificidad del 88,9%. La TC cambió la estadificación clínica en un 38% debido a una infraestadificación del 13% y una sobreestadificación del 25%, que llega al 60 y al 50% en los estadios clínicos II y III, respectivamente. La reclasificación o reestadificación de los pacientes de acuerdo con los hallazgos en la TC tiene una consecuencia importante en la indicación quirúrgica. Conclusiones: la estadificación clínica precoz de la diverticulitis con la TC evita errores de diagnóstico clínico en el 17,65%. La TC modifica la estadificación clínica de severidad en el 38% evitando la cirugía innecesaria y el retraso en el tratamiento quirúrgico

Objective: to assess the early use of CT for the diagnosis, staging, and management of acute diverticulitis. Material and methods: a prospective study of 102 patients with a clinical diagnosis of acute diverticulitis of the left colon. Acute diverticulitis was initially divided into 3 clinical stages. Patients were restaged according to CT findings into stages I, IIa, IIb, and III. Diagnosis was subsequently confirmed intraoperatively or by colonoscopy or barium studies. Results: 102 patients (52 females and 50 males, mean age of 59.4 (SD + 14.96 years)) were included; 84 (82.35%) patients with a clinical diagnosis of acute diverticulitis were confirmed to suffer this disease for a diagnostic error of 17.65% (n =18). Acute diverticulitis was diagnosed by CT in 84.3% (n = 86). CT had a sensitivity of 100% and a specificity of 88.9%. CT changed clinical stage for 38% of patients –because of understaging in 13% and of overstaging in 25%. When stages II and III were analyzed separately, 60 and 50% were overstaged, respectively. The reclassification of patients according to CT results had a significant impact on treatment. Conclusions: early clinical staging with CT avoids diagnostic clinical errors in 17.65% of patients. CT changes the initial clinical staging of acute episodes in 38% of cases, thus avoiding unnecessary delays in surgery for severe cases, and unnecessary surgeries for mild cases

Esplenosis gástrica: causa infrecuente de hemorragia digestiva alta / Gastric splenosis: an uncommon cause of upper gastrointestinal hemorrhage

La esplenosis representa el resultado del autotrasplante de tejido esplénico que generalmente sigue a un traumatismo o cirugía esplénica, cuando células esplénicas viables y pulpa se diseminan e implantan en la cavidad peritoneal. Presentamos un caso de esplenosis gástrica que simulaba una tumoración submucosa gástrica y causó una anemia ferropénica debida a hemorragia digestiva alta crónica (AU)

Neumoperitoneos no quirúrgicos: una difícil decisión terapéutica / Nonsurgical pneumoperitoneum: a difficult therapeutic decision

La presencia de neumoperitoneo por perforación visceral conlleva en la mayoría de casos la realización de una laparotomía diagnóstico-terapéutica. A continuación se presentan cuatro casos de neumoperitoneos "no quirúrgicos", tres de los cuales fueron manejados de forma expectante al no detectar por exploraciones radiológicas la presencia de perforación. Se discute la etiopatogenia del neumoperitoneo y los criterios de tratamiento no quirúrgico de aquellos pacientes ventilados artificialmente y con neumoperitoneos secundarios a traumatismos abdominales cerrados y iatrogénicos postendoscopia (AU)