Deloyers procedure compared to ileorectal anastomosis as restoration techniques of bowel continuity after extended left colon resection.

BACKGROUND: Restoration of bowel continuity after left extended colectomy may be challenging because the remaining colon may not reach the rectal stump without tension to perform a safe anastomosis. Performing a total colectomy with ileorectal anastomosis (IRA) is an option, but the quality of life can be significantly impaired due to loose stools and an increase in bowel frequency. In contrast, the preservation of the right colon and ileocaecal valve in the Deloyers procedure (DP) might ensure a better stool consistency and bowel transit, and therefore a superior quality of life. MATERIALS AND METHODS: A transverse study comparing patients that underwent DP versus patients with an IRA was performed. Postoperative morbidity, mortality, functional outcomes, and quality of life were analysed between groups. Quality of life after the surgical procedure was assessed with the SF-36 V2® health survey. RESULTS: A total of 16 patients with DP and 32 with IRA were included. The groups had similar demographic characteristics concerning age, sex, body mass index, ASA classification, diagnosis and Charlson comorbidity index. The median follow-up was 55 months for DP and 99 months for IRA. Postoperative complications were similar in both groups. Patients in the DP group had fewer bowel movements (P = 0.01), tenesmus (P = 0.04) and use of loperamide (P = 0.03). DP patients achieved better scores in physical pain (P = 0.02) and general health (P < 0.01) than IRA patients. CONCLUSIONS: DP for intestinal continuity restoration after extended left colon resection is a safe and feasible alternative, possibly achieving better functional outcomes and quality-of-life compared to IRA.

Oncological Implications of Lymph Nodes Retrieval and Perineural Invasion in Colorectal Cancer: Outcomes from a Referral Center.

BACKGROUND: In colorectal cancer (CRC), regional lymphadenectomy provides prognostic information and guides management. The current consensus states that at least 12 lymph nodes (LN) should be evaluated. The aims of this study were to identify whether the number of LN is a predictor for survival and recurrence, and to reveal the role of LN ratio (LNR) and perineural invasion (PNI) in predicting prognosis after curative resection of CRC. METHODS: We included all patients who underwent surgery for CRC between 2000 and 2016 in an academic medical center in Mexico. The LNR cutoff value was 0.25. We analyzed two groups according to the number of LN retrieved: Group 1 (≥ 12 LN) and Group 2 (< 12 LN). RESULTS: We included 305 patients, 13.8% in Stage I, 45.6% in Stage II, and 40.6% in Stage III. The male: female ratio was 1.1. The mean age was 62.6 ± 14 years (range, 19-92). In 233 patients (76.4%), ≥ 12 LN were obtained. Recurrence rates in Groups 1 and 2 were 20.2% versus 26.4%, respectively (p = 0.16). PNI was present in 34 patients (13.2%). An LN harvest < 10 increased local and distant recurrences (p = 0.03). Stage III patients with an LNR ≥ 0.25 had higher overall recurrence rates (p = 0.012) and mortality (p = 0.029). In a multivariate Cox regression analysis, PNI-negative tumors were an independent prognostic factor for disease-free survival (p = 0.011, hazard ratio = 2.78, 95% confidence interval = 1.26-6.16). CONCLUSIONS: An LN retrieval < 10 increased local and distant recurrence rates. LNR was an independent prognostic factor for survival in Stage III tumors. PNI was the only significant independent prognostic factor affecting disease-free survival in our patients.

Postoperative outcomes and functional results after Deloyer's procedure - a retrospective cohort study / Desfechos pós-operatórios e resultados funcionais após o procedimento de Deloyer ­ um estudo de coorte retrospectivo

ABSTRACT Introduction: The objective of our study was to describe surgical outcomes of Deloyers procedure in our referral center, and to compare the results of patients with and without protective ileostomy. Methods: Patients undergoing a Deloyers procedure from 2013 to 2016 were prospectively included. General characteristics, intraoperative variables, postoperative course, and functional outcomes were analyzed. Patients were compared into two groups: group (1) patients undergoing Deloyers procedure without ileostomy, and group (2) Deloyers procedure with protective ileostomy. Results: Sixteen patients undergoing isoperistaltic transposition of the right colon remnant were included, of which 9 (63%) were males with a median age of 47 (range 22-76) years. The main surgical indication was the restoration of bowel transit (62.5%). There was higher major morbidity rate in the Deloyers procedure with protective ileostomy group, but without statistical significance (20% vs. 9%, p = 0.92). No leaks or deaths were reported. The length of hospital stay was 7 days. The mean number of bowel movements per day was 4 at 18 months of follow up. Only four (25%) patients used irregularly loperamide. Conclusions: The Deloyers procedure has satisfactory results and is reproducible with low morbidity. The major and minor morbidity rates were similar between groups, suggesting that the costs and risks of a second procedure can be avoided by providing a safe primary anastomosis.

RESUMO Introdução: O objetivo de nosso estudo foi descrever os resultados cirúrgicos do procedimento de Deloyer em nosso centro de referência e comparar os resultados de pacientes com e sem ileostomia de proteção. Métodos: Pacientes submetidos ao procedimento de Deloyer de 2013 a 2016 foram incluídos prospectivamente. Foram analisadas as características gerais, as variáveis intraoperatórias, o curso pós-operatório e os desfechos funcionais. Os pacientes foram comparados em dois grupos: Grupo 1) pacientes submetidos ao procedimento de Deloyer (PD) sem ileostomia, e grupo 2) procedimento de Deloyer com ileostomia de proteção (IP). Resultados: Foram incluídos 16 pacientes submetidos à transposição isoperistáltica da porção remanescente do cólon direito, dos quais 9 (63%) eram do sexo masculino com idade média de 47 anos (variação de 22-76) anos. A principal indicação cirúrgica foi a restauração do trânsito intestinal (62,5%). Houve maior morbidade maior no grupo IP, mas sem significância estatística (20% vs. 9%, p = 0,92). Nenhum vazamento ou óbito foi relatado. A duração da hospitalização foi de 7 dias. O número médio de evacuações por dia foi 4, aos 18 meses de seguimento. Apenas quatro (25%) pacientes utilizaram irregularmente a loperamida. Conclusões: O procedimento de Deloyer tem resultados satisfatórios e é reprodutível com baixa morbidade. As taxas de morbidades maiores e menores foram semelhantes entre os grupos, sugerindo que os custos e riscos de um segundo procedimento podem ser evitados proporcionando-se uma anastomose primária segura.

Advantages of Minimally Invasive Surgery for the Treatment of Colovesical Fistula.

BACKGROUND: Colovesical fistulas in two-thirds of the cases are due to diverticular disease. In recent years, a minimally invasive approach has shown advantages over the traditional open approach. The goal of this study was to evaluate the surgical results and safety of the laparoscopic procedure in patients with colovesical fistula. MATERIAL AND METHODS: We retrospectively evaluated 24 patients who underwent surgery for colovesical fistula in a referral center from 2005 to 2011. Patients were divided into two groups: (i) laparoscopic approach, and (ii) open approach. RESULTS: The laparoscopic and open groups had similar characteristics with respect to age and gender distribution. There were a higher number of bladder repairs in the open approach group (83.3 vs. 16.6%; p = 0.01). The operative time (212 ± 74 min vs. 243 ± 69 min; p = 0.313) and intraoperative bleeding (268 ± 222 ml vs. 327 ± 169 ml; p = 0.465) were similar in both groups. The conversion rate of the laparoscopic approach to open surgery was 25%. There was no difference in morbidity (41.1 vs. 25%; p = 0.414), although the laparoscopic group had a shorter hospital stay (9 ± 4 days vs. 15 ± 11 days; p = 0.083) without statistical significance. CONCLUSIONS: The treatment of colovesical fistula by a laparoscopic approach is safe and is associated with less bladder repairs and a shorter hospital stay.

Effect of L-arginine or L-citrulline oral supplementation on blood pressure and right ventricular function in heart failure patients with preserved ejection fraction.

BACKGROUND: The effect of L-arginine and L-citrulline on blood pressure and right ventricular function in heart failure patients with preserved ejection fraction (HFpEF) is unknown. We have therefore evaluated, in a randomized clinical trial, the effect of these aminoacids in chronic outstanding and stable patients with HFpEF. METHODS AND RESULTS: All patients underwent an echocardiogram and radioisotopic ventriculography rest/exercise, and were randomized in a consecutive manner to the L-arginine group (n = 15; 8 g/day); and the citrulline malate group (n = 15; 3 g/day). The duration of follow-up was two months. The principal echocardiographic finding was a statistically significant decrease in pulmonary artery pressure in the L-arginine (56.3 ± 10 vs 44 ± 16.5 mm Hg, p < 0.05) and the citrulline (56.67 ± 7.96 vs 47.67 ± 8.59 mm Hg, p < 0.05) groups. Duration on treadmill and right ventricular ejection fraction post exercise increased, while diastolic and systolic artery pressure decreased significantly in both groups. There were no other statistically significant differences between the groups. CONCLUSIONS: Administration of L-arginine and citrulline to patients with HFpEF improved right ventricular function by increasing right ventricular ejection fraction, and probably decreasing systolic pulmonary artery pressure.