Economic burden of long-term treatment of severe fecal incontinence.

INTRODUCTION: Find out the long-term economic cost associated with the treatment of severe fecal incontinence by SNS versus symptomatic conservative treatment and definitive colostomy. METHODS: Detailed descriptive study of the costs of the healthcare process (interventions, consultations, devices, complementary tests, hospitalization, etc.) of 3 treatment alternatives for fecal incontinence using analytical accounting tools of the Health Service based on clinical activity data. The frequency of use of health resources or the quantity of products dispensed in pharmacies (medication, diapers, ostomy material, etc.) was estimated in each case. Costs derived from adverse situations were included. Patients with severe fecal incontinence, defined by a score greater than 9 on the Wexner severity scale, in whom first-line treatments had failed, were included. Data from a consecutive cohort of 93 patients who underwent an SNS between 2002 and 2016 were used; patients who underwent definitive colostomy (n=2); parastomal hernia (n=3); and colostomy stenosis (n=1). RESULTS: The mean cumulative cost in 10 years per patient in each alternative was: € 10,972.9 symptomatic treatment (62% diapers); € 17,351.57 SNS (95.83% interventions; 81.6% devices); € 25,858.54 definitive colostomy (70.4% ostomy material and accessories). CONCLUSIONS: Management of severe fecal incontinence implies a great burden in economic terms. The colostomy is the alternative that generates the most direct cost, followed by SNS and symptomatic treatment.

Recidiva e incidencia de fístula tras el drenaje urgente de un absceso anal. Resultados a largo plazo / Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results

Introducción: El absceso anal es el problema proctológico urgente más frecuente. La tasa de recidiva y la incidencia de fístula publicada tras el drenaje y desbridamiento de un absceso anal es ampliamente variable. El presente estudio tiene como objetivo analizar la tasa de recurrencia y la incidencia de fístula a largo plazo tras el drenaje y desbridamiento urgente de un absceso anal. Métodos: Estudio observacional retrospectivo de una cohorte prospectiva con absceso anal de origen criptoglandular. Todos los pacientes (n = 303) fueron evaluados a los dos meses y al año de la intervención. Al quinto año se revisaron todas las historias clínicas y se llamó telefónicamente o se citó en consulta para valoración. Se registraron los antecedentes específicos de patología anal, características del absceso, momento y tipo de la recidiva, presencia de sintomatología en la primera revisión y presencia de fístula clínica y/o ecográfica. Resultados: Seguimiento medio de 119,7 meses. Tasa de recidiva 48,2% (82,2% en 1er año). Doscientas veintidós ecografías realizadas. Incidencia de fístula ecográfica: 70% sintomáticos vs. 2,4% asintomáticos (p < 0,001). Incidencia global de fístula 40,3%. Los antecedentes de patología anal y la presencia de clínica en la revisión postoperatoria aumentan significativamente la posibilidad de recidiva (p < 0,001). La fístula es estadísticamente más frecuente si el absceso presenta recurrencia (p < 0,001). Conclusiones: Tras el drenaje y desbridamiento de un absceso anal la mitad de los pacientes recidivan y un 40% desarrollan fístula. Seguimientos mayores de un año no son necesarios. La ecografía endoanal para la evaluación de la presencia de fístula es muy cuestionable en ausencia de signos o síntomas(AU)

Introduction: Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess. Methods: Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded. Results: Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001). Conclusion: After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms(AU)

Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results.

INTRODUCTION: Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess. METHODS: Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded. RESULTS: Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001). CONCLUSION: After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.

Economic burden of long-term treatment of severe fecal incontinence. / Impacto económico del tratamiento a largo plazo de la incontinencia fecal grave.

INTRODUCTION: Find out the long-term economic cost associated with the treatment of severe fecal incontinence by SNS versus symptomatic conservative treatment and definitive colostomy. METHODS: Detailed descriptive study of the costs of the healthcare process (interventions, consultations, devices, complementary tests, hospitalization, etc.) of 3 treatment alternatives for fecal incontinence using analytical accounting tools of the Health Service based on clinical activity data. The frequency of use of health resources or the quantity of products dispensed in pharmacies (medication, diapers, ostomy material, etc.) was estimated in each case. Costs derived from adverse situations were included. Patients with severe fecal incontinence, defined by a score greater than 9 on the Wexner severity scale, in whom first-line treatments had failed, were included. Data from a consecutive cohort of 93 patients who underwent an SNS between 2002 and 2016 were used; patients who underwent definitive colostomy (n=2); parastomal hernia (n=3), and colostomy stenosis (n=1). RESULTS: The mean cumulative cost in 10 years per patient in each alternative was: € 10,972.9 symptomatic treatment (62% diapers); € 17,351.57 SNS (95.83% interventions; 81.6% devices); € 25,858.54 definitive colostomy (70.4% ostomy material and accessories). CONCLUSIONS: Management of severe fecal incontinence implies a great burden in economic terms. The colostomy is the alternative that generates the most direct cost, followed by SNS and symptomatic treatment.

Fistulectomy and endorectal advancement flap repair for cryptoglandular anal fistula: recurrence and functional outcome over 10 years of follow-up.

PURPOSE: To examine long-term recurrence and anal continence of patients with anal fistula treated by fistulectomy and endorectal advancement flap repair. METHOD: Retrospective analysis of a prospective cohort of 115 patients (77.4% males, mean age 48.9 years) requiring 130 procedures, with a minimum follow-up of 10 years. Recurrence included reappearance of fistula after wound healing or presence of an abscess or chronic suppuration in the operated area at follow-up. Fecal incontinence was evaluated by the Cleveland Clinic Florida (CCF-FI) fecal incontinence scoring system. RESULTS: The mean and SD duration of the follow-up period was 155.5 (21.7) months. Recurrence developed in 31 (23.8%) cases, 28 (90.3%) of which within the first year, with a mean time to recurrence of 4.9 (2.9) months. The success rate was 76.2%. Anal continence was normal in 80% of patients before surgery, 63.8% at 1-year follow-up, and 71.5% at the end of follow-up (p < 0.001). Overall, continence worsened in 16.9% of cases. The mean (95% CI) CCF-FI score was 0.78 (0.35-1.21) preoperatively, 1.04 (0.64-1.43) at 1 year after surgery, 0.90 (0.52-1.29) at 5 years, and 1.16 (0.66-1.67) at the end of the study (p < 0.05). Neither recurrence nor continence was significantly associated with previous anal or fistula surgical procedures or complexity of the fistula. CONCLUSION: In this study, fistulectomy and endorectal advancement flap repair was associated with a long-term high rate of success. Most recurrences occurred within the first year and continence showed a mild deterioration over time. CLINICAL TRIAL REGISTRATION: Not applicable.

Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results. / Recidiva e incidencia de fístula tras el drenaje urgente de un absceso anal. Resultados a largo plazo.

INTRODUCTION: Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess. METHODS: Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded. RESULTS: Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001) CONCLUSION: After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.

Resultados oncológicos según el tipo de resección en el tratamiento del cáncer de recto / Oncological results according to type of resection for rectal cancer

INTRODUCCIÓN: El objetivo de este trabajo observacional multicéntrico ha sido comparar los resultados de la resección anterior (RA) y la amputación abdominoperineal (AAP) en el tratamiento del cáncer de recto. MÉTODO: Entre marzo de 2006 y marzo de 2009, 1.598 pacientes diagnosticados de un tumor del tercio medio o inferior de recto fueron operados en los primeros 38 hospitales incluidos en el Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos. La cirugía se consideró curativa en 1.343 pacientes. Los resultados clínicos y oncológicos se analizaron con relación al tipo de resección. Todos los pacientes fueron incluidos en el análisis de los resultados clínicos; para el análisis de los resultados oncológicos solo se consideraron los pacientes con operaciones curativas. RESULTADOS: En 1.139 (71,3%) de los 1.598 pacientes se practicó una RA y en 459 (28,7%) una AAP. De los 1.343 pacientes operados con intención curativa, en 973 (72,4%) se practicó una RA y en 370 (27,6%) una AAP. No hubo diferencias entre RA y AAP en la mortalidad operatoria (29 vs. 18 pacientes; p = 0,141). Con un seguimiento de 60,0 (49,0-60,0) meses no se encontraron diferencias entre ambas operaciones en la recidiva local (HR 1,68 [0,87-3,23]; p = 0,12) ni en las metástasis (HR 1,31 [0,98-1,76]; p = 0,064). Sin embargo, la supervivencia global fue menor con la AAP (HR 1,37 [1,00-1,86]; p = 0,048). CONCLUSIÓN: Este estudio no ha identificado la AAP como factor determinante de recidiva local ni de metástasis, pero sí de la disminución de la supervivencia global

OBJECTIVE: This multicentre observational study aimed to compare outcomes of anterior resection (AR) and abdominal perineal resection (APR) in patients treated for rectal cancer. Methods Between March 2006 and March 2009 a cohort of 1,598 patients diagnosed with low and mid rectal cancer were operated on in the first 38 hospitals included in the Spanish Rectal Cancer Project. In 1,343 patients the procedure was considered curative. Clinical and outcome results were analysed in relation to the type of surgery performed. All patients were included in the analysis of clinical results. The analysis of outcomes was performed only on patients treated by a curative procedure. RESULTS: Of the 1,598 patients, 1,139 (71.3%) underwent an AR and 459 (28.7%) an APR. In 1,343 patients the procedure was performed with curative intent; from these 973 (72.4%) had an AR and 370 (27.6%) an APR. There were no differences between AR and APR in mortality (29 vs. 18 patients; P = .141). After a median follow up of 60.0 [49.0-60.0] months there were no differences in local recurrence (HR 1.68 [0.87-3.23]; P = .12), metastases (HR 1.31 [0.98-1.76]; P = .064). However, overall survival was worse after APR (HR 1.37 [1.00-1.86]; P = .048). CONCLUSION: This study did not identify abdominoperineal excision as a determinant of local recurrence or metastases. However, patients treated by this operation have a decreased overall survival

Oncological results according to type of resection for rectal cancer.

OBJECTIVE: This multicentre observational study aimed to compare outcomes of anterior resection (AR) and abdominal perineal resection (APR) in patients treated for rectal cancer. METHODS: Between March 2006 and March 2009 a cohort of 1,598 patients diagnosed with low and mid rectal cancer were operated on in the first 38 hospitals included in the Spanish Rectal Cancer Project. In 1,343 patients the procedure was considered curative. Clinical and outcome results were analysed in relation to the type of surgery performed. All patients were included in the analysis of clinical results. The analysis of outcomes was performed only on patients treated by a curative procedure. RESULTS: Of the 1,598 patients, 1,139 (71.3%) underwent an AR and 459 (28.7%) an APR. In 1,343 patients the procedure was performed with curative intent; from these 973 (72.4%) had an AR and 370 (27.6%) an APR. There were no differences between AR and APR in mortality (29 vs. 18 patients; P=.141). After a median follow up of 60.0 [49.0-60.0] months there were no differences in local recurrence (HR 1.68 [0.87-3.23]; P=.12), metastases (HR 1.31 [0.98-1.76]; P=.064). However, overall survival was worse after APR (HR 1.37 [1.00-1.86]; P=.048). CONCLUSION: This study did not identify abdominoperineal excision as a determinant of local recurrence or metastases. However, patients treated by this operation have a decreased overall survival.