Experiencia, complicaciones y factores pronósticos con el reservorio anal en la colitis ulcerosa. Estudio observacional / Experience, complications and prognostic factors of the ileoanal pouch in ulcerative colitis: An observational study

Introducción: La proctocolectomía restauradora con reservorio ileoanal es el tratamiento de elección en gran parte de los pacientes con colitis ulcerosa tras el fracaso del tratamiento médico. Nuestro objetivo principal fue analizar la morbilidad asociada a este procedimiento y la viabilidad del reservorio a corto y largo plazo. Como objetivo secundario identificamos los factores de riesgo asociados al fallo del reservorio. Métodos: Estudio retrospectivo observacional unicéntrico donde se analizan pacientes intervenidos de proctocolectomía total restauradora con reservorio ileoanal tras el diagnóstico de colitis ulcerosa entre los años 1983 y 2015. Se identificaron y analizaron las complicaciones tempranas (< 30 días) y tardías (> 30 días). Se consideró fallo del reservorio la necesidad de extirpación del reservorio o la imposibilidad para reconstruir el tránsito. Se llevó a cabo un análisis univariante y multivariante para identificar los factores asociados al fallo del reservorio ileoanal. Resultados: Hubo 139 pacientes analizados. Un paciente falleció en el postoperatorio. La mediana de seguimiento fue de 12 años. En 54 pacientes (39%) se realizó anastomosis manual. Presentaron complicaciones inmediatas 44 pacientes (32%), 15 pacientes (11%) con fístula anastomótica. Complicaciones tardías fueron diagnosticadas en 90 pacientes (65%), las más frecuentes fueron las fístulas asociadas al reservorio (29%). Hubo 42 pacientes (32%) con fallo del reservorio. La edad > 50 años (p < 0,01; HR: 5,55), la anastomosis manual (p < 0,01; HR: 3,78), la fístula del reservorio vaginal (p=0,02; HR: 2,86), la pélvica (p < 0,01; HR: 5,17) y la cutánea (p = 0,01; HR: 3,01) fueron los principales factores de riesgo asociados al fallo del reservorio encontrados en el análisis multivariante. Conclusión: La proctocolectomía restauradora es una técnica con elevada morbilidad a corto y largo plazo. Controlando los factores de riesgo del fallo del reservorio se podrían mejorar los resultados a largo plazo

Introduction: Ileoanal pouch following restorative proctocolectomy is the treatment for ulcerative colitis after failed medical treatment. Our main aim was to evaluate early and late morbidity associated with restorative proctocolectomy. The secondary aim was to assess risk factors for pouch failure. Methods: A retrospective, observational, single-center study was performed. Patients who had undergone restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis from 1983-2015 were included. Early (< 30 days) and late (> 30 days) adverse events were analyzed. Pouch failure was defined as the need for pouch excision or when ileostomy closure could not be performed. Univariate and multivariate analyses were performed to assess pouch failure risk factors. Results: The study included 139 patients. One patient subsequently died in the early postoperative period. Mean follow-up was 23 years. Manual anastomoses were performed in 54 patients (39%). Early adverse events were found in 44 patients (32%), 15 of which (11%) had anastomotic fistula. Late adverse events were found in 90 patients (65%), and pouch-related fistulae (29%) were the most commonly found in this group. Pouch failure was identified in 42 patients (32%). In the multivariate analysis, age > 50 years (p < 0.01; HR: 5.55), handsewn anastomosis (p < 0.01; HR: 3.78), pouch-vaginal (p = 0.02; HR: 2.86), pelvic (p < 0.01; HR: 5.17) and cutaneous p = 0.01; HR: 3.01) fistulae were the main pouch failure risk factors. Conclusion: Restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis has high morbidity rates. Long-term outcomes could be improved if risk factors for failure are avoided

Experience, complications and prognostic factors of the ileoanal pouch in ulcerative colitis: An observational study. / Experiencia, complicaciones y factores pronósticos con el reservorio anal en la colitis ulcerosa. Estudio observacional.

INTRODUCTION: Ileoanal pouch following restorative proctocolectomy is the treatment for ulcerative colitis after failed medical treatment. Our main aim was to evaluate early and late morbidity associated with restorative proctocolectomy. The secondary aim was to assess risk factors for pouch failure. METHODS: A retrospective, observational, single-center study was performed. Patients who had undergone restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis from 1983-2015 were included. Early (<30 days) and late (>30 days) adverse events were analyzed. Pouch failure was defined as the need for pouch excision or when ileostomy closure could not be performed. Univariate and multivariate analyses were performed to assess pouch failure risk factors. RESULTS: The study included 139 patients. One patient subsequently died in the early postoperative period. Mean follow-up was 23 years. Manual anastomoses were performed in 54 patients (39%). Early adverse events were found in 44 patients (32%), 15 of which (11%) had anastomotic fistula. Late adverse events were found in 90 patients (65%), and pouch-related fistulae (29%) were the most commonly found in this group. Pouch failure was identified in 42 patients (32%). In the multivariate analysis, age >50 years (p<0.01; HR: 5.55), handsewn anastomosis (p<0.01; HR: 3.78), pouch-vaginal (p=0.02; HR: 2.86), pelvic (p<0.01; HR: 5.17) and cutaneous p=0.01; HR: 3.01) fistulae were the main pouch failure risk factors. CONCLUSION: Restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis has high morbidity rates. Long-term outcomes could be improved if risk factors for failure are avoided.

The use of a simple anal sling in the management of anal incontinence.

BACKGROUND. Many patients presenting with anal incontinence (AI) are frail, with attendant comorbidities precluding the use of complicated, expensive reconstructive techniques. In these cases, revisiting a simple approach-designed to provide some sort of effective barrier to stool-is worthwhile where the options include a customized peri-anal sling or the use of an anal plug. METHODS. Analysis of an unselected cohort of 33 patients (mean age 54 years; range 27-86 years) with AI is presented, these patients having undergone insertion of an elastic band peri-anal sling between December 2004 and December 2009. Pre- and post-operative assessment included the Jorge-Wexner score of incontinence, anorectal manometry and the Rockwood Fecal Incontinence Quality of Life (FIQoL) score. RESULTS. The follow-up period ranged from 50 to 108 months with a mean of 65 months. Early post-operative complications included spontaneous disruption of the sling at the fourth and seventh post-operative day in two patients and local infection in a further two cases. Late complications included skin erosion in two patients, (one occurring 3 years post-operatively) and breakage of the sling in a further seven patients. Explantation was performed in 13 cases, and re-implantation in 10 patients. No differences were noted in resting or squeeze manometry, with significant improvement in the Jorge-Wexner scores in 32 cases and in all of the four Rockwood quality of life scales. CONCLUSIONS. An anal sling is an effective and simple surgical option for the management of selected cases presenting with anal incontinence. Longer-term data are awaited comparing this technique with other standard surgical alternatives.

Prognostic value of stem cell quantification in stage II colon cancer.

BACKGROUND: Cancer stem cells (CSCs) are a subset of tumor cells with capacity to self-renew and generate the diverse cells that make up the tumor. The aim of this study is to evaluate the prognostic value of CSCs in a highly homogeneous population of stage II colon cancer. METHODS: One hundred stage II colon cancer patients treated by the same surgical team between 1977 and 2005 were retrospectively analyzed. None of the patients received adjuvant chemotherapy. Inmunohistochemistry expression of CD133, NANOG and CK20 was scored, using four levels: <10%, 11-25%, 26-50% and >50% positivity. Kaplan-Meier analysis and log rank test were used to compare survival. RESULTS: The average patient age was 68 years (patients were between 45-92 years of age) and median follow up was 5.8 years. There was recurrent disease in 17 (17%); CD133 expression (defined by >10% positivity) was shown in 60% of the tumors, in 95% for NANOG and 78% for CK20. No correlation was found among expression levels of CD133, NANOG or CK20 and relapse-free survival (RFS) or overall survival (OS). However, a statistical significant correlation was found between established pathological prognostic factors and RFS and OS. CONCLUSIONS: Stem Cell quantification defined by CD133 and NANOG expression has no correlation with RFS or OS in this cohort of Stage II colon cancer.

Prognostic factors in Fournier gangrene.

BACKGROUND: Fournier gangrene is a necrotizing fasciitis, arising in the genital and perineal area. This entity is still associated with a high mortality rate despite improvements in antibiotic and surgical treatment. METHODS: This is a retrospective study of all the patients diagnosed and surgically treated for Fournier gangrene at General University Hospital Ramon y Cajal between 1988 and 2008. Possible prognostic factors that could have any influence on the evolution of Fournier gangrene were analyzed. RESULTS: Seventy patients were analyzed, 62 males (88.6%) and 8 females (11.4%) with a mean age of 57.9 ± 13.5 years. Most frequent clinical manifestations were perineal pain (82.9%) and fever (60%). Physical examination revealed edema (91.4%), erythema (88.6%) and perineal skin necrosis (60%). All the patients underwent surgical debridement of necrotic tissue. In 54.3% reoperations were necessary for new surgical debridements. Medical complications rate was 27.1% and mortality one 22.9%. Ethylism, coexistence of neoplasms, presence of skin necrosis, myonecrosis, abdominal wall affection, number of debrided areas, reoperations, concentration of creatinine in serum>1.4 mg/dL, and hemoglobin <10 g/dL, and platelet count <150 × 10(9)/L in whole blood are associated with higher mortality rates. CONCLUSION: Identification of prognostic factors may help to determine high-risk patients in order to establish an optimal treatment, according to severity of the infection and general status.

Ultrashort bowel syndrome: surgical management and long-term results of an exceptional case.

Management of the short bowel syndrome is a multidisciplinary and very complex problem. The authors report the successful long-term results of an original combination of autologous gastrointestinal reconstruction in a boy who at the age of 16 years lost all but 5 cm of the small bowel. This case demonstrates that lengthening and antipropulsive interposition of a long segment of the colon can be another alternative to early transplantation in exceptional cases.

The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study.

PURPOSE: The aim of this trial was to evaluate the safety, efficacy, and impact on quality of life of the Acticon trade mark artificial bowel sphincter for fecal incontinence. METHODS: A multicenter, prospective, nonrandomized clinical trial was conducted under a common protocol. Patients were evaluated with anal physiology, endoanal ultrasonography, a fecal incontinence scoring system, fecal incontinence quality of life assessment, and overall health evaluation. Patients with a fecal incontinence score of 88 or greater (scale, 1-120) were considered candidates for the study. Implanted patients underwent identical reevaluation at 6 and 12 months postimplant. RESULTS: One hundred twelve of 115 patients (86 females) enrolled were implanted. Mean age was 49 (range, 18-81) years. A total of 384 device-related or potentially device-related adverse events were reported in 99 enrolled patients. Of these events, 246 required no intervention or only noninvasive intervention. Seventy-three revisional operations were required in 51 (46 percent) of the 112 implanted patients. Infection rate necessitating surgical revision was 25 percent. Forty-one patients (37 percent) have had their devices completely explanted, of which 7 have had successful reimplantations. In patients with a functioning neosphincter, improvement in quality of life and anal continence was documented. Mean matched fecal incontinence scores in 63 patients at 6 months follow-up was improved from 105 preimplant to 51 postimplant. In 55 patients at 12 months follow-up, mean matched fecal incontinence scores were 105 preimplant 48 postimplant. A successful outcome was achieved in 85 percent of patients with a functioning device. Intention to treat success rate was 53 percent. CONCLUSIONS: Although morbidity and the need for revisional surgery are high, the artificial bowel sphincter can improve anal incontinence and quality of life in patients with severe fecal incontinence.