Care burden and outcome of the surgical management of ulcerative colitis: A retrospective analysis of the last 20 years in a tertiary hospital in Spain.

AIM: To analyze the surgical burden of UC care in the last two decades, analyzing the characteristics of the patients, surgical indications along with the short and long-term results. METHOD: Single-center retrospective cohort analysis of UC patients undergoing abdominal and anorectal surgery between January 2000 and December 2020. The care burden, clinical data and results were analyzed according to distribution by decades. RESULTS: 128 patients, 37% female, underwent 376 surgical interventions (296 intestinal procedures and 80 anorectal). Mean follow-up for the cohort was 106±64 months. Timing from diagnosis to first surgery was under 5 years in 53.3%. In the second decade of the study there were fewer operated patients (73 vs. 48) as well as the total number of interventions per patient (2.7 vs. 2.0). The proportion between elective and urgent surgery was reversed in the second decade, observing an increase in laparoscopic surgery (70% vs. 8%) together with a decrease in major postoperative morbidity (Clavien-Dindo≥IIIa) (20% vs 8.4%). 80 patients underwent a restorative proctocolectomy, with a failure of 5% at 1 year but 23.7% in the long term. 37 patients required anorectal surgery, of which 26 (71%) were serial interventions, most due to septic complications of the pouches. CONCLUSIONS: The number of colectomies and interventions per patient decreased in the last decade, while there were improvements in morbidity and surgical approach. The need for sequential surgeries and long-term active instrumental surveillance for possible functional deterioration constitutes a significant clinical burden.

Subcuticular suture and incisional surgical-site infection in elective hepatobiliary and pancreatic surgery: an open-label, pragmatic randomized clinical trial (CLOSKIN trial).

BACKGROUND: Subcuticular suture has proven to reduce superficial incisional SSI (si-SSI) in clean surgery. However, question remains regarding clean-contaminated procedures. The aim of this study is to assess if subcuticular suture is superior to staples in reducing si-SSI incidence in elective HBP surgery. METHODS: Single-centre, open-label, parallel, pragmatic randomized clinical trial conducted at a referral tertiary Hospital between January 2020 and April 2022. Patients eligible for elective HBP surgery were randomly assigned (1:1) to subcuticular suture or surgical staples wound closure using a minimisation method based on previously confirmed risk factors. The primary endpoint was the incidence of si-SSI. Considered secondary endpoints were major postoperative morbidity in both groups, additional wound complications, median hospital length of stay and need for re-hospitalisation. RESULTS: Of the 379 patients, 346 patients were randomly assigned to receive skin closure with staples (n = 173) or subcuticular suture (n = 173). After further exclusion of 11 participants, 167 and 168 patients, respectively in the control and the experimental group received their allocated intervention. For the primary endpoint, no significant differences in si-SSI rate were found: 17 (9.82%) staples group vs. 8 (4.62%) in subcuticular suture group (p = 0.062). Subset analysis confirmed absence of significant differences. As for secondary endpoints, overall wound complications did not differ significantly between two procedures: 19 (10.98%) vs. 10 (6.35%) (p = 0.127). There were no treatment related adverse events. However, occurrence of si-SSI contributed to major postoperative morbidity in both groups (p < 0.001 and p = 0.018) and to a substantially prolonged postoperative hospitalization (p = 0.015). CONCLUSIONS: Subcuticular suture might offer a relative benefit for skin closure reducing incidence of si-SSI after elective HBP surgery, although this was found not to be clinically relevant. Yet, this should not be interpreted as equivalence among both treatments. Therefore, wound closure strategy should not be based only on these grounds. TRIAL REGISTRATION NUMBER: ISRCTN Registry number ISRCTN37315612 (registration date: 14/01/2020).

Care burden and outcome of the surgical management of ulcerative colitis: A retrospective analysis of the last 20 years in a tertiary hospital in Spain / Carga asistencial y resultados del tratamiento quirúrgico de la colitis ulcerativa: un análisis retrospectivo de los últimos 20 años en un hospital terciario de España

Aim: To analyze the surgical burden of UC care in the last two decades, analyzing the characteristics of the patients, surgical indications along with the short and long-term results. Method: Single-center retrospective cohort analysis of UC patients undergoing abdominal and anorectal surgery between January 2000 and December 2020. The care burden, clinical data and results were analyzed according to distribution by decades. Results: 128 patients, 37% female, underwent 376 surgical interventions (296 intestinal procedures and 80 anorectal). Mean follow-up for the cohort was 106±64 months. Timing from diagnosis to first surgery was under 5 years in 53.3%. In the second decade of the study there were fewer operated patients (73 vs. 48) as well as the total number of interventions per patient (2.7 vs. 2.0). The proportion between elective and urgent surgery was reversed in the second decade, observing an increase in laparoscopic surgery (70% vs. 8%) together with a decrease in major postoperative morbidity (Clavien-Dindo≥IIIa) (20% vs 8.4%). 80 patients underwent a restorative proctocolectomy, with a failure of 5% at 1 year but 23.7% in the long term. 37 patients required anorectal surgery, of which 26 (71%) were serial interventions, most due to septic complications of the pouches. Conclusions: The number of colectomies and interventions per patient decreased in the last decade, while there were improvements in morbidity and surgical approach. The need for sequential surgeries and long-term active instrumental surveillance for possible functional deterioration constitutes a significant clinical burden. (AU)

Objetivo: Analizar la carga quirúrgica asistencial por CU en 20 años, analizando las características de los pacientes, indicaciones quirúrgicas y resultados a corto y largo plazo. Método: Análisis retrospectivo unicéntrico de pacientes intervenidos de enero del 2000 a diciembre del 2020. La carga asistencial, los datos clínicos y los resultados se analizaron según distribución por décadas. Resultados: Ciento veintiocho pacientes, 37% mujeres, con 376 intervenciones quirúrgicas (296 procedimientos intestinales y 80 anorrectales). El seguimiento medio de la cohorte fue de 106±64 meses. El lapso entre el diagnóstico y la primera cirugía fue <5 años en el 53,3%. En la segunda década del estudio hubo menos pacientes operados (73 frente a 48) y un menor número de intervenciones por paciente (2,7 frente a 2,0). La proporción entre cirugía electiva y urgente se revirtió en la segunda década, observándose un aumento de la cirugía laparoscópica (70% vs. 8%) junto con una disminución de la morbilidad postoperatoria mayor (Clavien-Dindo≥IIIa) (20% vs 8.4%). Se realizó una proctocolectomía restauradora a 80 pacientes, con un fracaso al año del 5% pero del 23,7% a largo plazo. Treinta y siete pacientes requirieron cirugía anorrectal, de los cuales 26 (71%) fueron intervenciones seriadas, la mayoría por complicaciones sépticas de los reservorios. Conclusiones: El número de colectomías y de intervenciones por paciente disminuyó en la última década, a la vez que hubo mejorías en la morbilidad y el abordaje quirúrgico. La necesidad de cirugías secuenciales y de una vigilancia instrumental activa a largo plazo por el posible deterioro funcional constituye una importante carga clínica. (AU)

Care burden and outcome of the surgical management of ulcerative colitis: A retrospective analysis of the last 20 years in a tertiary hospital in Spain / Carga asistencial y resultados del tratamiento quirúrgico de la colitis ulcerativa: un análisis retrospectivo de los últimos 20 años en un hospital terciario de España

Aim: To analyze the surgical burden of UC care in the last two decades, analyzing the characteristics of the patients, surgical indications along with the short and long-term results. Method: Single-center retrospective cohort analysis of UC patients undergoing abdominal and anorectal surgery between January 2000 and December 2020. The care burden, clinical data and results were analyzed according to distribution by decades. Results: 128 patients, 37% female, underwent 376 surgical interventions (296 intestinal procedures and 80 anorectal). Mean follow-up for the cohort was 106±64 months. Timing from diagnosis to first surgery was under 5 years in 53.3%. In the second decade of the study there were fewer operated patients (73 vs. 48) as well as the total number of interventions per patient (2.7 vs. 2.0). The proportion between elective and urgent surgery was reversed in the second decade, observing an increase in laparoscopic surgery (70% vs. 8%) together with a decrease in major postoperative morbidity (Clavien-Dindo≥IIIa) (20% vs 8.4%). 80 patients underwent a restorative proctocolectomy, with a failure of 5% at 1 year but 23.7% in the long term. 37 patients required anorectal surgery, of which 26 (71%) were serial interventions, most due to septic complications of the pouches. Conclusions: The number of colectomies and interventions per patient decreased in the last decade, while there were improvements in morbidity and surgical approach. The need for sequential surgeries and long-term active instrumental surveillance for possible functional deterioration constitutes a significant clinical burden. (AU)

Objetivo: Analizar la carga quirúrgica asistencial por CU en 20 años, analizando las características de los pacientes, indicaciones quirúrgicas y resultados a corto y largo plazo. Método: Análisis retrospectivo unicéntrico de pacientes intervenidos de enero del 2000 a diciembre del 2020. La carga asistencial, los datos clínicos y los resultados se analizaron según distribución por décadas. Resultados: Ciento veintiocho pacientes, 37% mujeres, con 376 intervenciones quirúrgicas (296 procedimientos intestinales y 80 anorrectales). El seguimiento medio de la cohorte fue de 106±64 meses. El lapso entre el diagnóstico y la primera cirugía fue <5 años en el 53,3%. En la segunda década del estudio hubo menos pacientes operados (73 frente a 48) y un menor número de intervenciones por paciente (2,7 frente a 2,0). La proporción entre cirugía electiva y urgente se revirtió en la segunda década, observándose un aumento de la cirugía laparoscópica (70% vs. 8%) junto con una disminución de la morbilidad postoperatoria mayor (Clavien-Dindo≥IIIa) (20% vs 8.4%). Se realizó una proctocolectomía restauradora a 80 pacientes, con un fracaso al año del 5% pero del 23,7% a largo plazo. Treinta y siete pacientes requirieron cirugía anorrectal, de los cuales 26 (71%) fueron intervenciones seriadas, la mayoría por complicaciones sépticas de los reservorios. Conclusiones: El número de colectomías y de intervenciones por paciente disminuyó en la última década, a la vez que hubo mejorías en la morbilidad y el abordaje quirúrgico. La necesidad de cirugías secuenciales y de una vigilancia instrumental activa a largo plazo por el posible deterioro funcional constituye una importante carga clínica. (AU)

Características y resultados oncológicos del carcinoma epidermoide de ano: análisis comparativo entre los pacientes inmunocompetentes y los inmunodeprimidos / Characteristics and oncological results of epidermoid anal carcinoma: Comparison analysis between immunocompetent and immunosuppressed patients

Objetivos: La mayoría de los ensayos clínicos realizados sobre pacientes con cáncer escamoso anal (CEA) excluyen pacientes inmunodeprimidos. El objetivo del presente estudio es comparar las características y los resultados oncológicos entre pacientes con CEA inmunocomprometidos e inmunocompetentes. Métodos: Estudio multicéntrico comparativo retrospectivo que incluye 2 cohortes consecutivas de pacientes, inmunocomprometidos e inmunocompetentes, diagnosticados de carcinoma escamoso anal. Se han investigado las características de los pacientes, los tratamientos realizados, la respuesta clínica al tratamiento con quimiorradioterapia (QRT), la recidiva local o a distancia, la supervivencia global (SG) y la supervivencia libre de enfermedad (SLE). Resultados: De enero 2012 a diciembre 2017 hemos estudiado a 84 pacientes, 47 (55,6%) mujeres, afectos de CEA, de los cuales 22 (26%) han sido pacientes inmunocomprometidos y 62 (74%) inmunocompetentes. Los pacientes inmunocomprometidos fueron más jóvenes (53 vs. 61 años; p=0,001), con un menor tamaño tumoral (p=0,044), y presentaban un mayor consumo de tabaco (p=0,034) y de drogas de uso parenteral (p=0,001). No se objetivaron diferencias significativas en los tratamientos administrados (p=0,301), tampoco difirió la respuesta clínica a la QRT (83 vs. 100%). Tampoco se observaron diferencias significativas en la supervivencia global (60 vs. 64%; p=0,756) o en la supervivencia libre de enfermedad a 5 años (SLE) (65 vs. 68%; p=0,338). Conclusiones: En el presente estudio no se observaron diferencias significativas en relación con los resultados oncológicos a largo plazo entre pacientes inmunocompetentes e inmunocomprometidos diagnosticados de CEA, con un grado de cumplimiento del tratamiento similar. Esta evidencia podría deberse al estrecho seguimiento y buen control terapéutico de pacientes infectados por HIV. (AU)

Objective: Most evidence, including recent randomized controlled trials, analysing anal squamous cell carcinoma (SCC) do not consider immunocompromise patient population. The aim of this study was to compare clinical and oncological outcomes among immunocompetent and immunocompromised patients with anal squamous cell carcinoma. Method: Multicentric retrospective comparative study including 2 cohorts of consecutive patients, immunocompetent and immunocompromised, diagnosed with anal SCC. This study evaluated clinical characteristics, clinical response to radical chemoradiotherapy (CRT) and long-term oncological results including both local and distant recurrence, overall survival (OS) and disease-free survival (DFS). Results: A total of 84 patients, 47 (55.6%) female, diagnosed with anal SCC from January 2012 to December 2017 were included, 22 (26%) and 62 (74%) patients in immunocompromised and immunocompetent groups respectively. Patients in immunocompromised group were significantly younger (53 vs. 61 years; P=0.001), with smaller tumoral size (P=0.044) and reported higher rates of substance abuse.including tobacco use (P=0.034) and parenteral drug consumption (P=0.001). No differences were found in administered therapies (P=301) neither in clinical response to chemoradiotherapy (83 vs. 100%). Moreover, similar 5-year OS (60 vs. 64%; P=0.756) and DFS (65 vs. 68%; P=0.338) were observed. Conclusion: The present study shows no significant differences in long-term oncological results among immunocompetent and immunocompromised patients diagnosed with anal SCC, with a similar oncologic treatment. This evidence might be explained due to the close monitoring and adequate therapeutic control of HIV positive patients. (AU)

Characteristics and oncological results of epidermoid anal carcinoma: Comparison analysis between immunocompetent and immunosuppressed patients.

OBJECTIVE: Most evidence, including recent randomized controlled trials, analysing anal squamous cell carcinoma (SCC) do not consider immunocompromise patient population. The aim of this study was to compare clinical and oncological outcomes among immunocompetent and immunocompromised patients with anal squamous cell carcinoma. METHOD: Multicentric retrospective comparative study including 2 cohorts of consecutive patients, immunocompetent and immunocompromised, diagnosed with anal SCC. This study evaluated clinical characteristics, clinical response to radical chemoradiotherapy (CRT) and long-term oncological results including both local and distant recurrence, overall survival (OS) and disease-free survival (DFS). RESULTS: A total of 84 patients, 47 (55.6%) female, diagnosed with anal SCC from January 2012 to December 2017 were included, 22 (26%) and 62 (74%) patients in immunocompromised and immunocompetent groups respectively. Patients in immunocompromised group were significantly younger (53 vs. 61 years; P = 0.001), with smaller tumoral size (P = 0.044) and reported higher rates of substance abuse including tobacco use (P = 0.034) and parenteral drug consumption (P = 0.001). No differences were found in administered therapies (P = 301) neither in clinical response to chemoradiotherapy (83 vs. 100%). Moreover, similar 5-year OS (60 vs. 64%; P = 0.756) and DFS (65 vs. 68%; P = 0.338) were observed. CONCLUSION: The present study shows no significant differences in long-term oncological results among immunocompetent and immunocompromised patients diagnosed with anal SCC, with a similar oncologic treatment. This evidence might be explained due to the close monitoring and adequate therapeutic control of HIV positive patients.

Characteristics and oncological results of epidermoid anal carcinoma: Comparison analysis between immunocompetent and immunosuppressed patients. / Características y resultados oncológicos del carcinoma epidermoide de ano: análisis comparativo entre los pacientes inmunocompetentes y los inmunodeprimidos.

OBJECTIVE: Most evidence, including recent randomized controlled trials, analysing anal squamous cell carcinoma (SCC) do not consider immunocompromise patient population. The aim of this study was to compare clinical and oncological outcomes among immunocompetent and immunocompromised patients with anal squamous cell carcinoma. METHOD: Multicentric retrospective comparative study including 2 cohorts of consecutive patients, immunocompetent and immunocompromised, diagnosed with anal SCC. This study evaluated clinical characteristics, clinical response to radical chemoradiotherapy (CRT) and long-term oncological results including both local and distant recurrence, overall survival (OS) and disease-free survival (DFS). RESULTS: A total of 84 patients, 47 (55.6%) female, diagnosed with anal SCC from January 2012 to December 2017 were included, 22 (26%) and 62 (74%) patients in immunocompromised and immunocompetent groups respectively. Patients in immunocompromised group were significantly younger (53 vs. 61 years; P=0.001), with smaller tumoral size (P=0.044) and reported higher rates of substance abuse. including tobacco use (P=0.034) and parenteral drug consumption (P=0.001). No differences were found in administered therapies (P=301) neither in clinical response to chemoradiotherapy (83 vs. 100%). Moreover, similar 5-year OS (60 vs. 64%; P=0.756) and DFS (65 vs. 68%; P=0.338) were observed. CONCLUSION: The present study shows no significant differences in long-term oncological results among immunocompetent and immunocompromised patients diagnosed with anal SCC, with a similar oncologic treatment. This evidence might be explained due to the close monitoring and adequate therapeutic control of HIV positive patients.

Care burden and outcome of the surgical management of ulcerative colitis: A retrospective analysis of the last 20 years in a tertiary hospital in Spain.

AIM: To analyze the surgical burden of UC care in the last two decades, analyzing the characteristics of the patients, surgical indications along with the short and long-term results. METHOD: Single-center retrospective cohort analysis of UC patients undergoing abdominal and anorectal surgery between January 2000 and December 2020. The care burden, clinical data and results were analyzed according to distribution by decades. RESULTS: 128 patients, 37% female, underwent 376 surgical interventions (296 intestinal procedures and 80 anorectal). Mean follow-up for the cohort was 106±64 months. Timing from diagnosis to first surgery was under 5 years in 53.3%. In the second decade of the study there were fewer operated patients (73 vs. 48) as well as the total number of interventions per patient (2.7 vs. 2.0). The proportion between elective and urgent surgery was reversed in the second decade, observing an increase in laparoscopic surgery (70% vs. 8%) together with a decrease in major postoperative morbidity (Clavien-Dindo≥IIIa) (20% vs 8.4%). 80 patients underwent a restorative proctocolectomy, with a failure of 5% at 1 year but 23.7% in the long term. 37 patients required anorectal surgery, of which 26 (71%) were serial interventions, most due to septic complications of the pouches. CONCLUSIONS: The number of colectomies and interventions per patient decreased in the last decade, while there were improvements in morbidity and surgical approach. The need for sequential surgeries and long-term active instrumental surveillance for possible functional deterioration constitutes a significant clinical burden.

The use of seton as a bridge to definitive ligation of the intersphincteric fistula tract procedure for fistula-in-ano: a systematic review and meta-analysis

Background: There is still controversy over the usefulness of seton placement prior to the ligation of the intersphincteric fistula tract (LIFT) surgery in the management of anal fistula. Objective: To evaluate the impact of preoperative seton placement on the outcomes of LIFT surgery for the management of fistula-in-ano. Design: systematic review and meta-analysis. Data Sources: A search was performed on the MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar databases. Study Selection: Original studies without language restriction reporting the primary healing rates with and without seton placement as a bridge to definitive LIFT surgery were included. Intervention: The intervention assessed was the LIFT with and without prior seton placement. Main Outcome Measures: The main outcome was defined as the primary healing rate with and without the use of seton as a bridge to definitive LIFT surgery. Results: Ten studiesmet the criteria for systematic review, all retrospective,with a pooled study population of 772 patients. There were no significant differences in the percentages of recurrence between patients with and without seton placement (odds ratio [OR] 1.02; 95% confidence interval [CI] 0.73-1.43: p=0.35). The I2 value was 9%, which shows the homogeneity of the results among the analyzed studies. The 10 included studies demonstrated a weighted average overall recurrence of 38% (interquartile range [IQR] 27-42.7%), recurrence with the use of setonwas 40%(IQR26.6-51.2%), and without its use, the recurrence rate was 51.3% (IQR 31.3-51.3%) Limitations: The levels of evidence found in the available literature were relatively fair, as indicated after qualitative evaluation using the Newcastle-Ottawa scale and the Attitude Heading Reference System (AHRS) evidence levels. Conclusions: Our meta-analysis suggests that the placement of seton as a bridge treatment prior to LIFT surgery does not significantly improve long-term anal fistula healing outcomes. Ligation of the intersphincteric fistula tract surgery can be performed safely and effectively with no previous seton placement. International prospective register of systematic reviews-PROSPERO registration number: CDR42020149173. (AU)

Early-rectal Cancer Treatment: A Decision-tree Making Based on Systematic Review and Meta-analysis / Cáncer de recto inicial: árbol de decisión clínica basado en una revisión sistemática y metaanálisis

Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes. This systematic-review and meta-analysis design is based on the "PICO" process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery. The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%-91.7% and 80%-94% for LE, in contrast to 92.3%-94.3% and 94.4%-97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09-1.45) and DSS (HR: 1.19; 95%CI, 1.01-1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50-4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15-0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present. In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process

La escisión local (EL) se ha planteado como una alternativa a la escisión mesorrectal total en el tratamiento del cáncer de recto inicial. A pesar de la reducción de la morbilidad, los resultados de la EL todavía son motivo de preocupación. Esta revisión sistemática y metaanálisis se basa en el proceso «PICO» con el objetivo de responder a tres preguntas relacionadas con la EL, a saber, como tratamiento principal del cáncer de recto inicial, el método óptimo de EL y su posible papel en el tratamiento completo de tumores histológicos de alto riesgo y complicaciones de la cirugía de rescate. Los resultados han puesto de manifiesto que la supervivencia general (SG) y la supervivencia específica por enfermedad (SEE) notificadas fueron del 71-91% y del 80-94% en el caso de la EL, en comparación con el 92,3-94,3% y el 94,4-97% en el caso de la cirugía radical, respectivamente. Un análisis complementario de los estudios de la Base de Datos Nacional reveló una SG (HR: 1,26; IC95%: 1,09-1,45) y una SEE inferiores (HR: 1,19; IC95%: 1,01-1,41) después de EL. Además, los pacientes que aceptaron la EL fueron mucho más propensos a presentar una recidiva local (RR: 3,44; IC95%: 2,50-4,74). Se llevó a cabo un análisis de los planteamientos quirúrgicos transanales disponibles. No se encontraron importantes diferencias entre ellos, pero las recidivas locales eran inferiores en comparación con las de la EL transanal tradicional (OR: 0,24; IC95%: 0,15-0,4). Por último, hubo malos resultados de supervivencia entre los pacientes a quienes se les realizó cirugía de rescate, lo que favorece el tratamiento completo (quimiorradioterapia o cirugía) cuando hay histología de alto riesgo. En conclusión, la EL podría considerarse adecuada siempre que se pueda lograr una muestra de espesor completo y el paciente esté informado del riesgo de una posible necesidad de tratamiento completo. Los casos de cáncer de recto inicial deben tratarse en un equipo multidisciplinario y las preferencias del paciente deben tenerse en cuenta en el proceso de toma de decisiones

Early-rectal Cancer Treatment: A Decision-tree Making Based on Systematic Review and Meta-analysis.

Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes. This systematic-review and meta-analysis design is based on the "PICO" process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery. The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%-91.7% and 80%-94% for LE, in contrast to 92.3%-94.3% and 94.4%-97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09-1.45) and DSS (HR: 1.19; 95%CI, 1.01-1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50-4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15-0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present. In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process.

Laparoscopy-induced severe renal failure after appendectomy.

Laparoscopy has gained importance in the abdominal emergency surgery field. Acute appendicitis is one of the major indications for emergency surgery, being laparoscopy the gold standard approach. We report a case of a 39-years-old female presenting with acute kidney injury (AKI) after laparoscopy. Differential diagnosis was considered with prerenal AKI etiology due to sepsis and low fluid input, however this was ruled out due to absence of electrolyte imbalance and no correlation with septic parameters. Laparoscopy CO2 pneumoperitoneum can potentially lead to multiple organ failure, including renal. Laparoscopy induced AKI is related with both hormonal stimuli for renal vasoconstriction and increased intra-abdominal pressure, causing hypoxemia and tubular renal injury. In conclusion, very few cases of laparoscopy induced AKI in young patients with no previous renal disease have been reported. Surgeons must consider this complication in the differential diagnosis of postoperative AKI.

Local irrigation with silver nitrate, a non-surgical approach for persistent anal fistula / Irrigação local com nitrato de prata, uma abordagem não cirúrgica para fístula anal persistente

ABSTRACT Purpose: Treatment of persistent anal fistula implies a major challenge for surgeons, with risk of additional recurrence and potential continence impairment. We present a non-surgical treatment based on irrigation with silver nitrate 1% solution. Methods: This is a prospective study including patients with persistent anal fistula after surgery, who were treated with silver nitrate 1% solution irrigation from May 2015 to March 2017. Patients with evidence of abscess, presence of >1 external opening and those with bowel inflammatory disease were excluded. 3-5 cc of silver nitrate 1% solution were instilled through a catheter. The procedure was repeated on a weekly basis, conducting a maximum of 7 sessions per patient. Results: 18 patients (13 male, 72.2%) with a median age of 48 years old (IQR 41-55) were treated using silver nitrate 1% solution. A median of 5 sessions per patient was performed (IQR 3-6). The median follow-up period was 18 months (IQR 9-25). After the described period 8 patients' (44.4%) presented complete resolution of the fistula, 2 patients' (11.2%) were classified as partial healing and in 8 patients' (44.4%) the treatment was considered to fail. 6 patients' experienced self-limited pain during instillation, with persistence up to 24 h in 2 of them. Conclusions: Treatment with silver nitrate 1% solution is a minimally invasive procedure, with a favourable safety profile, that can be performed in an outpatients' basis achieving a complete healing rate of 44.4%. Therefore, this method should be considered for the treatment of recurrent or persistent anal fistula.

RESUMO Objetivo: O tratamento da fístula anal persistente é um grande desafio para os cirurgiões, com risco de recorrência adicional e potencial comprometimento da continência. Os autores apresentam um tratamento não cirúrgico baseado na irrigação com solução de nitrato de prata a 1%. Métodos: Este foi um estudo prospectivo incluindo pacientes com fístula anal persistente após a cirurgia que foram tratados com irrigação com solução de nitrato de prata a 1% entre maio de 2015 e março de 2017. Pacientes com evidência de abscesso, presença de mais de uma abertura externa e aqueles com doença inflamatória intestinal foram excluídos. Usando um cateter, instilou-se 3 a 5 cc. de solução de nitrato de prata a 1%. O procedimento foi repetido semanalmente, em um máximo de sete sessões por paciente. Resultados: Um total de 18 pacientes (13 homens, 72,2%) com idade mediana de 48 anos (IQR 41-55) foram tratados com solução de nitrato de prata a 1%. Uma mediana de cinco sessões por paciente foi realizada (IQR 3-6). A mediana do período de acompanhamento foi de 18 meses (IQR 9-25). Após o período descrito, oito pacientes (44,4%) apresentaram resolução completa da fístula, dois pacientes (11,2%) foram classificados como cicatrização parcial e em oito pacientes (44,4%) o tratamento falhou. Seis pacientes apresentaram dor autolimitada durante a instilação, que persistiu por até 24 horas em dois deles. Conclusões: O tratamento com solução de nitrato de prata a 1% é um procedimento minimamente invasivo, com perfil de segurança favorável, que pode ser realizado em regime ambulatorial, atingindo taxa de cura completa de 44,4%. Portanto, este método deve ser considerado para o tratamento da fístula anal recorrente ou persistente.