Hematoma oclusivo a nivel del pie de asa posgastrectomía: diagnóstico precoz y tratamiento / Occlusive hematoma inside the jejuno-jejunal anastomosis after gastrectomy: Early diagnosis and treatment

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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)

[Current situation of colorectal trauma]. / Estado actual de los traumatismos colorrectoanales.

Mortality from colorectal trauma decreased from the end of the 19th Century, when death was the rule, to the 21st Century, when mortality is 5%. The greatest advances were produced during wars, mainly due to improved transport conditions, antisepsis, advances in operating and anesthetic techniques, the management of fluids, blood and blood products, the use of antibiotics, exteriorization of wounds, and the use of colostomy. Injuries to the anus, rectum and colon are infrequent. Their prevalence is difficult to establish because they can be caused by several factors. In Spain, the most frequent causes are traffic accidents and iatrogenic lesions, while in America the most common causes are stab or gunshot wounds. Although the etiology of these injuries is diverse, two major groups of colorectal trauma can be established: accidental injuries and iatrogenic trauma. Clinical symptoms vary, ranging from abdominal, pelvic, perianal or anal pain, sometimes associated with rectorrhagia, to peritonismus or shock. Diagnosis is based on physical and rectal examination and laboratory, radiological, and endoscopic investigations. Laparoscopy can also be used on occasions. Treatment should be individualized, depending on the patient's history, current status, the time elapsed since injury, the status of the injured intestine, the degree of fecal contamination, associated lesions, and the surgeon's experience.

Estado actual de los traumatismos colorrectoanales / Current situation of colorectal trauma

La mortalidad por heridas de colon y recto ha disminuido en el mundo, desde finales del siglo XIX, cuando la mortalidad era la regla, hasta el siglo XXI, al 5%. Durante los conflictos bélicos se produjeron los mayores avances. Esto se debe principalmente a la mejora en las condiciones de traslado, la antisepsia, los avances en las técnicas operatorias y anestésicas, el manejo de fluidos, sangre y hemoderivados, el uso de antibióticos, la exteriorización de las heridas y el empleo de la colostomía. Los traumatismos anales, rectales y colónicos son poco frecuentes. Su prevalencia es difícil de establecer debido a los diversos factores que intervienen en su origen. En España predominan los accidentes de tráfico y las lesiones iatrogénicas, frente a las lesiones por arma blanca o de fuego más frecuentes en América. La etiología es diversa, pero se pueden establecer 2 grandes grupos de traumatismos colorrectales: traumatismos accidentales y traumatismos iatrogénicos. Los síntomas clínicos son variados, con dolor abdominal, pelviano, perianal o anal, asociado o no a rectorragia, hasta peritonismo franco o cuadro de shock. El diagnóstico se basa en la exploración física, el tacto rectal y las pruebas complementarias analíticas, radiológicas, endoscópicas y en ocasiones laparoscópicas. El tratamiento se ha de individualizar en cada caso según los antecedentes patológicos del paciente, su estado actual, el tiempo de evolución, la situación del intestino lesionado, el grado de contaminación fecal, las lesiones asociadas y la experiencia del cirujano (AU)

Mortality from colorectal trauma decreased from the end of the 19th Century, when death was the rule, to the 21st Century, when mortality is 5%. The greatest advances were produced during wars, mainly due to improved transport conditions, antisepsis, advances in operating and anesthetic techniques, the management of fluids, blood and blood products, the use of antibiotics, exteriorization of wounds, and the use of colostomy. Injuries to the anus, rectum and colon are infrequent. Their prevalence is difficult to establish because they can be caused by several factors. In Spain, the most frequent causes are traffic accidents and iatrogenic lesions, while in America the most common causes are stab or gunshot wounds. Although the etiology of these injuries is diverse, two major groups of colorectal trauma can be established: accidental injuries and iatrogenic trauma. Clinical symptoms vary, ranging from abdominal, pelvic, perianal or anal pain, sometimes associated with rectorrhagia, to peritonismus or shock. Diagnosis is based on physical and rectal examination and laboratory, radiological, and endoscopic investigations. Laparoscopy can also be used on occasions. Treatment should be individualized, depending on the patient's history, current status, the time elapsed since injury, the status of the injured intestine, the degree of fecal contamination, associated lesions, and the surgeon's experience (AU)