Urethral Injury in Rectal Cancer Surgery: A Comprehensive Study Using Cadaveric Dissection, Imaging Analyses, and Clinical Series.

Male urethral injury during rectal cancer surgery is rare but significant. Scant information is available about the distances between the rectourethral space and neighboring structures. The aim of this study is to describe the anatomical relations of the male urethra. This three-pronged study included cadaveric dissection, retrospective MRI analysis, and clinical cases. Measurements included the R-Mu distance (shortest distance between the rectum and the membranous urethra), R-Am distance (distance from the anterior rectal wall to anal margin nearest to the membranous urethra), and the anal canal-rectum axis angle. The clinical study analyzed the incidence of urethral injury and associated factors among 244 consecutive men from January 2016 to January 2023. The overall incidence of urethral injury in our series was low (0.73%), but in men with tumors < 10 cm from the anal margin, it was 4% in abdominoperineal resection and 3.2% in TaTME. On preoperative MRI, the median R-Mu distance was 1 cm (IQR, range, 0.2-2.3), the median R-Am distance was 4.3 cm (range, 2-7.3), and the median anorectal angle was 128° (range, 87-160). In the cadaveric study (nine adult male pelvises), the mean R-Mu distance was 1.18 cm (range 0.8-2), and the mean R-Am distance was 2.64 cm (range 2.1-3). Avoiding urethral injury is crucial. The critical point for injury lies 2-7.3 cm from the anal margin, with a 0.2-2.3 cm distance between the rectum and the membranous urethra. Collaborating with anatomists and radiologists improves surgeons' anatomy knowledge.

Is Metformin Associated With Improved Response to Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer?

BACKGROUND: Efforts to determine whether metformin can increase the effectiveness of neoadjuvant chemoradiotherapy in rectal cancer have increased in recent years. However, retrospective studies have yielded inconclusive results. OBJECTIVES: The aim of this study was to compare oncological outcomes and survival after neoadjuvant chemoradiotherapy in patients with rectal cancer taking metformin versus in those not taking metformin. METHODS: This study analyzed 423 consecutive patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy and curative surgery between January 2010 and May 2020; of these, 59 were taking metformin and 364 were not taking metformin. RESULTS: Patients taking metformin had a lower proportion of tumor regression (6.8% versus 22.0%, P = 0.012) as well as a lower proportion of patients achieving a pathological complete response (6.8% versus 20.6%, P = 0.011). In the multivariate analysis, independent predictors of pathologic complete response were not taking metformin (OR: 5.26, 95% CI: 1.12-24.85, P= 0.035) and cT2 stage (OR: 3.49, 95% CI: 1.10-11.07, P= 0.034); the interval was also an independent predictor of tumor regression (OR: 1.78, 95% CI: 1.06-2.96, P= 0.028). No differences were observed in survival between groups. CONCLUSION: Metformin was not associated with better tumor responses or survival after neoadjuvant treatment.

Factors associated with prolonged hospital stay after laparoscopic adrenalectomy.

Laparoscopy is the standard technique for resecting adrenal tumors, but short-term outcomes such as length of stay (LOS) vary widely between centers. We aimed to identify factors associated with LOS after lateral transperitoneal laparoscopic adrenalectomy (LTLA). We analyzed consecutive patients undergoing unilateral LTLA between April 2003 and April 2020. Prolonged LOS was defined as a stay longer than the 75th percentile of the overall cohort. To identify potential factors associated with prolonged LOS, we compared collected data from patients with LOS ≤ 2 days versus LOS > 2 days and elaborated multivariate logistic regression models. We included 150 patients (73 men and 77 women, median age 54 years), with benign (n = 128) and malignant tumors (n = 22). The median LOS after LTLA was 2 days; 64 (42.7%) patients had prolonged hospitalization. Variables significantly associated with prolonged LOS in the univariate analysis included ASA III + IV (p = 0.016), pheochromocytoma (p < 0.001), learning curve (p = 0.032), surgery on Thursday or Friday (p < 0.001), 2D laparoscopy (p = 0.003), operative time (p < 0.001), estimated blood loss (p < 0.001), drainage (p < 0.001), specimen size (p = 0.011), conversions (p = 0.002), complications (p = 0.019), and hospital stay (p < 0.001). After adjustment for patient, surgical, and tumor characteristics, risk factors associated with prolonged LOS in the multivariate analysis were specimen size > 9 cm (OR:13.03, p = 0.005), surgery on Thursday or Friday (OR:6.92, p = 0.001), estimated blood loss ≥ 60 ml (OR:6.22, p = 0.021), and drainage (OR:5.29, p = 0.005). Prolonged length of stay after LTLA was associated with specimen size > 9 cm, operating on Thursday or Friday, estimated blood loss ≥ 60 mL, and drainage.

[A high-resolution gastroenterology clinic in Andalusia: what is it, and how should it work]. / Consulta de alta resolución de digestivo en Andalucía: qué es y cómo debe funcionar?

INTRODUCTION: The present concept in our healthcare system is that medical care should be given on an outpatient basis with hospitalization occurring only when essential. We therefore put forth the development of the "all in one" outpatient office or "high resolution" outpatient clinic. For such purpose we administered a questionnaire to various Andalusian hospitals to define and determine those aspects necessary in the development of the aforementioned outpatient office. MATERIALS AND METHODS: The questionnaire was filled out by 10 Andalusian hospitals. This is a prospective-descriptive study of responses from all 10 participating hospitals. The 27 questions inquired on the existence of such an outpatient office and the infrastructure needed to develop this service: How many patients are seen, where is it physically located, where do patients come from, criteria for assigning patients to this medical office, condition of incoming patients, whether ultrasound scans are performed, whether an integrated hospital computer system exists, nursing staff, how many visits are required before coming to a diagnosis, and finally whether this type of outpatient office is needed, and if so, why. RESULTS: Of all 10 hospitals, 5 of them had this type of clinic. All of them considered this type of outpatient service essential. The number of patients treated should be "10", in the hospital itself. There are differences as to whether patients should come from the emergency room or a primary care physician. It seems logical to assume that only patients who can be diagnosed via ultrasounds or endoscopy should be chosen. To allow an ultrasonogram the patient should visit the outpatient office in a state of "fasting" and with standard blood counts from the primary care physician. The outpatient clinic should have a computer system and its own nurse. According to participating hospitals this type of outpatient visits is very useful in our present healthcare system, as it allows higher levels of collaboration between Primary Care and the specialist; it also provides a rapid orientation regarding patient pathology, and acts as a "filter" for the rest of the healthcare system. CONCLUSIONS: The outpatient office should be tended to by an attending specialist in the field (FEA) with knowledge and experience in ultrasounds and gastrointestinal endoscopy, as well as user competency with the required computer programs. In our present-day system this can be considered a modality of high-resolution outpatient services and a model of efficiency.

Consulta de alta resolución de digestivo en Andalucía: ¿qué es y cómo debe funcionar? / No disponible

Introducción: la idea actual de nuestro sistema sanitario esque la asistencia sea ambulatoria y que se utilice la hospitalizacióncuando sea precisa. En este sentido es de destacar el desarrollo dela consulta única o de alta resolución. Por ello, se ha realizado unaencuesta entre varios hospitales andaluces con la idea de definir ydeterminar qué aspectos son necesarios para poder desarrollaresta consulta.Material y métodos: la encuesta ha sido contestada por 10hospitales andaluces. Se trata de un estudio prospectivo descriptivode las respuestas contestadas por los distintos hospitales. Laspreguntas son 27 en las que se reflexiona sobre la existencia de laconsulta y la infraestructura para desarrollarla: cuántos pacientesse ven, dónde se pasa esta consulta, de dónde provienen los pacientes,los criterios para derivar los pacientes a esta consulta, lascondiciones en las que acude el enfermo, si se realiza ecografía deabdomen, si se dispone de sistema informático integrado hospitalario,enfermera, en cuántas visitas se emite un diagnóstico del pacientey, por último, se pregunta si se cree que es necesaria estaconsulta y por qué.Resultados: de los 10 hospitales 5 tienen consulta de alta resolución,aunque todos consideran que la deberían tener. El númerode pacientes atendidos debe ser 10 y en el propio hospital.Existen diferencias en considerar si los pacientes deben provenirdesde Urgencias o desde el médico de cabecera. Parece lógicopensar que sólo se deben derivar pacientes cuya patología puedaser diagnosticada mediante ecografía y/o endoscopia. El pacientedebería acudir a la consulta en ayunas y con analítica del médicode cabecera, para así poder realizarles la ecografía. La consultadebe constar de sistema informático y de una enfermera propia.Según los encuestados este tipo de consultas es muy útil en nuestroactual sistema, porque permite mayor colaboración entreAtención Primaria y el especialista, y consigue una orientación rápidade la patología del paciente actuando de filtro adecuado parael resto de las consultas

Introduction: the present concept in our healthcare system isthat medical care should be given on an outpatient basis with hospitalizationoccurring only when essential. We therefore put forththe development of the “all in one” outpatient office or “high resolution”outpatient clinic. For such purpose we administered aquestionnaire to various Andalusian hospitals to define and determinethose aspects necessary in the development of the aforementionedoutpatient office.Materials and methods: the questionnaire was filled out by10 Andalusian hospitals. This is a prospective-descriptive study ofresponses from all 10 participating hospitals. The 27 questionsinquired on the existence of such an outpatient office and the infrastructureneeded to develop this service: How many patientsare seen, where is it physically located, where do patients comefrom, criteria for assigning patients to this medical office, conditionof incoming patients, whether ultrasound scans are performed,whether an integrated hospital computer system exists,nursing staff, how many visits are required before coming to a diagnosis,and finally whether this type of outpatient office is needed,and if so, why.Results: of all 10 hospitals, 5 of them had this type of clinic.All of them considered this type of outpatient service essential.The number of patients treated should be “10”, in the hospital itself.There are differences as to whether patients should comefrom the emergency room or a primary care physician. It seemslogical to assume that only patients who can be diagnosed via ultrasoundsor endoscopy should be chosen. To allow an ultrasonogramthe patient should visit the outpatient office in a state of“fasting” and with standard blood counts from the primary carephysician.The outpatient clinic should have a computer system and itsown nurse. According to participating hospitals this type of outpatientvisits is very useful in our present healthcare system, as it allowshigher levels of collaboration between Primary Care and thespecialist; it also provides a rapid orientation regarding patientpathology, and acts as a “filter” for the rest of the healthcare system (AU)

[Autotransfusion after orthopedic surgery. Analysis of quality, safety and efficacy of salvaged shed blood]. / Autotransfusión postoperatoria en cirugía ortopédica. Un análisis de la calidad, seguridad y eficacia de la sangre recuperada de los drenajes postoperatorios.

A series of immunosuppressant mechanisms can manifest during surgical procedures, mediated by immune system cells or by humoral factors, to which the immunosuppressant effects of anesthesia or blood transfusion may be added, possibly further prejudicing the patient's immunological status, having important clinical repercussions such as increased incidence of postoperative infection or tumor reappearance. Autotransfusion of various types is an effective alternative to homologous transfusion as the former avoids immunodepressant effects. Preoperative autotransfusion [preoperative donation of autologous blood (PTAB)] has been shown to be one of the safest and most effective techniques and is the gold standard for autotransfusion. Problems of over collection, anemia and over transfusion that sometimes occur with PTAB can be solved with better screening procedures. Intraoperative autotransfusion (IAT) and postoperative autotransfusion (PAT) avoid such problems completely. However, IAT is only cost-effective in certain procedures (bleeding > 1,000-1,500 mL) and is not applicable in others, such as knee arthroplasty. PAT, on the other hand, in addition to being a good complement to other autotransfusion methods, may be the technique of choice in some procedures, such as knee arthroplasty, particularly if PTAB is contraindicated or if it is logistically difficult for a hospital to provide.However, in spite of its demonstrated efficacy, PAT of filtered blood has many critics, who warn of possible side effects and recommend the use of washed blood, which would make the procedure enormously more expensive unless it is performed with the same equipment used for IAT. Therefore, this review will analyze the hematologic characteristics of filtered blood, including metabolic status and survival of red blood cells, the components of the hemostatic system and inflammatory mediators, the content of fat particles and the possibility of their clearance, the incidence of infections and the dissemination of tumor cells. This analysis can reach the conclusion that salvaged filtered blood is a source of red blood cells of sufficient quality to be safely reinfused and that their reinfusion contributes significantly to reduce the need for homologous blood.

Autotransfusión postoperatoria en cirugía ortopédica. Un análisis de la calidad, seguridad y eficacia de la sangre recuperada de los drenajes postoperatorios / Autotransfusion after orthopedic surgery. Analysis of quality, safety and efficacy of salvaged shed blood

En los procesos quirúrgicos pueden evidenciarse una serie de mecanismos de inmunosupresión, mediados tanto por las células del sistema inmunitario como por factores humorales, a los que se les pueden sumar los efectos inmunosupresores de la anestesia y las transfusiones sanguíneas, que pueden deteriorar aún más el estado inmunológico del paciente, lo que puede tener importantes repercusiones clínicas como aumento de infecciones postoperatorias o de recidivas tumorales.La autotransfusión, en sus distintas modalidades, se presenta como una alternativa eficaz a las transfusiones de sangre homóloga al evitar los efectos inmunosupresores de las mismas. La autotransfusión preoperatoria (donación preoperatoria de sangre autóloga) ha demostrado ser una de las técnicas transfusionales más seguras y eficaces y constituye el "patrón oro" en autotransfusión. Los problemas de sobrecolección, anemización y sobretransfusión que a veces presenta la donación preoperatoria de sangre autóloga pueden solucionarse con una mejor selección de los pacientes.Mediante la autotransfusión intra y postoperatoria se obvian por completo estos problemas. No obstante, la autotransfusión intraoperatoria sólo es coste-efectiva en determinadas intervenciones (hemorragia > 1.000-1.500 ml) y no es aplicable en otras, como la cirugía protésica de rodilla. Por su parte, la autotransfusión postoperatoria, además de ser un buen complemento del resto de técnicas de autotransfusión, en determinadas intervenciones quirúrgicas, como la de prótesis de rodilla, puede ser la técnica de elección, máxime si la donación preoperatoria de sangre autóloga está contraindicada en el paciente o es logísticamente difícil de implantar en el centro.Sin embargo, a pesar de haber demostrado su eficacia, la autotransfusión postoperatoria en forma de sangre filtrada cuenta aún con un gran número de detractores, los cuales advierten sobre una serie de posibles efectos adversos y preconizan el uso de sangre lavada, lo que encarecería enormemente el procedimiento, salvo que se realice con el mismo equipo utilizado para la autotransfusión intraoperatoria durante la intervención. Por ello, en la presente revisión se lleva a cabo un análisis detallado de las características hematológicas de la sangre filtrada, el estado metabólico y la supervivencia de sus hematíes, el contenido en componentes del sistema hemostásico y de mediadores inflamatorios, el contenido de partículas grasas y las posibilidades de eliminación y la incidencia de complicaciones infecciosas y de diseminación de células tumorales. De este análisis se puede llegar a la conclusión de que la sangre total filtrada y no lavada es una fuente de eritrocitos de calidad suficiente para ser reinfundidos sin problemas, y que su reinfusión contribuye significativamente a una reducción de las necesidades de sangre homóloga (AU)

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