RAS Mutation Decreases Overall Survival After Optimal Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy of Colorectal Peritoneal Metastasis: A Modification Proposal of the Peritoneal Surface Disease Severity Score.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are currently the most accepted treatment for peritoneal metastases from colorectal cancer. Restrictive selection criteria are essential to obtain the best survival benefits for this complex procedure. The most widespread score for patient selection, the peritoneal surface disease severity score (PSDSS), does not include current biological factors that are known to influence on prognosis. We investigated the impact of including RAS mutational status in the selection criteria for these patients. METHODS: We studied the risk factors for survival by multivariate analysis using a prospective database of consecutive patients with carcinomatosis from colorectal origin treated by CRS and HIPEC in our unit from 2009 to 2017. The risk factors obtained were validated in a multicentre, international cohort, including a total of 520 patients from 15 different reference units. RESULTS: A total of 77 patients were selected for local análisis. Only RAS mutational status (HR: 2.024; p = 0.045) and PSDSS stage (HR: 2.90; p = 0.009) were shown to be independent factors for overall survival. Early PSDSS stages I and II associated to RAS mutations impaired their overall survival with no significant differences with PSDSS stage III overall survival (p > 0.05). These results were supported by the international multicentre validation. CONCLUSIONS: By including RAS mutational status, we propose an updated RAS-PSDSS score that outperforms PSDSS alone providing a quick and feasible preoperative assessment of the expected overall survival for patients with carcinomatosis from colorectal origin undergone to CRS + HIPEC.

HIPECT4: multicentre, randomized clinical trial to evaluate safety and efficacy of Hyperthermic intra-peritoneal chemotherapy (HIPEC) with Mitomycin C used during surgery for treatment of locally advanced colorectal carcinoma.

BACKGROUND: Local relapse and peritoneal carcinomatosis (PC) for pT4 colon cancer is estimated in 15,6% and 36,7% for 12 months and 36 months from surgical resection respectively, achieving a 5 years overall survival of 6%. There are promising results using prophylactic HIPEC in this group of patients, and it is estimated that up to 26% of all T4 colon cancer could benefit from this treatment with a minimal morbidity. Adjuvant HIPEC is effective to avoid the possibility of peritoneal seeding after surgical resection. Taking into account these results and the cumulative experience in HIPEC use, we will lead a randomized controlled trial to determine the effectiveness and safety of adjuvant treatment with HIPEC vs. standard treatment in patients with colon cancer at high risk of peritoneal recurrence (pT4). METHODS/DESIGN: The aim of this study is to determine the effectiveness and safety of adjuvant HIPEC in preventing the development of PC in patients with colon cancer with a high risk of peritoneal recurrence (cT4). This study will be carried out in 15 Spanish HIPEC centres. Eligible for inclusion are patients who underwent curative resection for cT4NxM0 stage colon cancer. After resection of the primary tumour, 200 patients will be randomized to adjuvant HIPEC followed by routine adjuvant systemic chemotherapy in the experimental arm, or to systemic chemotherapy only in the control arm. Adjuvant HIPEC will be performed simultaneously after the primary resection. Mitomycin C will be used as chemotherapeutic agent, for 60 min at 42-43 °C. Primary endpoint is loco-regional control (LC) in months and the rate of loco-regional control (%LC) at 12 months and 36 months after resection. DISCUSSION: We assumed that adjuvant HIPEC will reduce the expected absolute risk of peritoneal recurrence from 36% to 18% at 36 months for T4 colon-rectal carcinoma. TRIAL REGISTRATION: NCT02614534 ( clinicaltrial.gov ) Nov-2015.

Perioperative care in colorectal surgery: current practice patterns and opinions.

Objective Evidence regarding perioperative care in colorectal surgery has recently increased, leading to changes in classical clinical procedures that make the perioperative period safer and shorter. This survey aimed to evaluate the opinions of Spanish colorectal surgeons on the perioperative management of their patients. Method Emailed surveys submitted to the members of Spanish Coloproctological Associations. Results One hundred and thirty-one (31.7%) of the 413 members participated in the study and responded thus: 21% use clinical pathways and 8% use fast track (FT); 36% use epidural analgesia in colonic surgery and 57% in rectal; 40% use warm air and 23% warm fluids to maintain intraoperative normothermia; 53% prescribe >/= 3000 ml. of iv fluids on the first postoperative day and 6.2%

Mechanical bowel preparation and antibiotic prophylaxis in colorectal surgery: use by and opinions of Spanish surgeons.

OBJECTIVE: Antibiotic prophylaxis (AP) and mechanical bowel preparation (MBP) previous to surgery have classically been regarded as important in colorectal surgery. The latter has recently been questioned. We evaluated opinion of Spanish surgeons about the use of these measures. METHOD: E-mail survey among all members of Spanish Coloproctologic Associations. RESULTS: Of 413 participants in the survey, 131 (31.7%) responded; 87% of surgeons used cathartics (70%), enemas (2%) or both (28%) for MBP. MBP was used 60% in right colon surgery, 90% in left colon and 99% in rectal surgery. Surgeons with more case load or those who specialized in colorectal surgery used significantly less MBP; 60% of the surgeons thought that MBP made surgery easier and reduced contamination; 35% thought that it decreased wound infection (WI) and 17% thought that it prevented anastomotic leaks. For 77%, it was regarded as useful or very useful. AP was used by 99.3% of surgeons including systemic alone in 86.2% and combined with oral in 16.8%. The first dose was given 2 h before surgery by 20.2% of the surgeons, at the anaesthetic induction by 78.3% and postoperatively by 1.5%; 43% used single dose only, 44.5% extended to 24 h and 12.5% for two or more days; 95% thought that AP reduced WI and 96% considered that it was useful. CONCLUSION: There is general agreement on AP. MBP remained a common practice among Spanish colorectal surgeons except for right colonic resection. Surgeons with more case load and specialization used it significantly less.

Evolución de los parámetros sanguíneos tras cirugía de la obesidad mórbida mediante la técnica del cruce duodenal / Evolution of the blood parameters alter morbid obesity surgery with the duodenal crossing technique

Objetivo: Valorar la evolución de los parámetros sanguíneos en pacientes obesos mórbidos que han sido sometidos a cirugía mediante la técnica del cruce duodenal. Métodos: Se estudian 110 pacientes, a los que tras la cirugía se les ha realizado controles ponderales y de los parámetros analíticos más influenciados por este tipo de cirugía (hematocrito, hemoglobina, glucosa, proteínas totales, albúmina, calcio, PTH, ALT, índice de Quick, bilirrubina total, colesterol y triglicéridos, hierro, ferritina, ácido fólico y vitamina B12). El control postoperatorio se ha realizado a los 3, 6, 12, 18, 24, 36, 48 y 60 meses. El seguimiento mínimo es de un año. Resultados: La pérdida de peso es superior al 50% del sobrepeso y mantenida a lo largo del estudio, alcanzando a más del 75% de los pacientes. En el seguimiento postoperatorio existe un claro déficit de hierro que condiciona la existencia de anemia, así como una elevación evidente de la PTH. La normalización de las cifras de glucemia, colesterol y triglicéridos alcanza cifras cercanas al 100%. Conclusiones: Las alteraciones de los parámetros sanguíneos que presentan los pacientes obesos mórbidos sometidos a la técnica del cruce duodenal, indicadores de complicaciones nutricionales, afectan aproximadamente a un 10% de los pacientes (excepto el déficit de Fe y la alteración de la PTH) y son fácilmente corregidos en su mayoría con suplementos farmacológicos y nutricionales, adaptándose el organismo a estos déficits, sin que existan alteraciones clínico-biológicas severas y con tendencia a la normalización (AU)

Objective: To assess the course of blood parameters from patients with morbid obesity submitted to the duodenal crossing surgical technique. Methods: 110 patients were studied in whom post-surgical monitoring of ponderal and laboratory parameters (the ones most influenced by this type of surgery such as hematocrit, hemoglobin, glucose, total proteins, albumin, calcium, PTH, ALT, Quick's index, total bilirubin, cholesterol and triglycerides, iron, ferritin, folic acid, and vitamin B12) has been carried out. Postsurgical monitoring has been carried out at months 3, 6, 12, 18, 24, 36, 48, and 60. The shortest follow-up time has been one year. Results: Weight loss is higher than 50% of the weight in excess and is maintained throughout the study, comprising more than 75% of the patients. During the postsurgical follow-up, there is a clear iron deficiency concurrent with the presence of anemia, as well as an evident increase in PTH. Normalization of glycemia, cholesterol, and triglyceride levels reaches almost 100%. Conclusions: changes in blood parameters presented by patients with morbid obesity submitted to the duodenal crossing technique, indicators of nutritional complications, affect about 10% of the patients (with the exception of iron deficiency and PTH impairment), and most of them are easily corrected with pharmacological and nutritional supplements, the body getting adapted to these deficits, without any severe clinical-biological impairment and with a trend towards normalization (AU)

[Evolution of the blood parameters after morbid obesity surgery with the duodenal crossing technique]. / Evolución de los parámetros sanguíneos tras cirugía de la obesidad mórbida mediante la técnica del cruce duodenal.

OBJECTIVE: To assess the course of blood parameters from patients with morbid obesity submitted to the duodenal crossing surgical technique. METHODS: 110 patients were studied in whom post-surgical monitoring of ponderal and laboratory parameters (the ones most influenced by this type of surgery such as hematocrit, hemoglobin, glucose, total proteins, albumin, calcium, PTH, ALT, Quick's index, total bilirubin, cholesterol and triglycerides, iron, ferritin, folic acid, and vitamin B12) has been carried out. Postsurgical monitoring has been carried out at months 3, 6, 12,18, 24, 36, 48, and 60. The shortest followup time has been one year. RESULTS: Weight loss is higher than 50% of the weight in excess and is maintained throughout the study, comprising more than 75% of the patients. During the postsurgical follow-up, there is a clear iron deficiency concurrent with the presence of anemia, as well as an evident increase in PTH. Normalization of glycemia, cholesterol, and triglyceride levels reaches almost 100%. CONCLUSIONS: changes in blood parameters presented by patients with morbid obesity submitted to the duodenal crossing technique, indicators of nutritional complications, affect about 10% of the patients (with the exception of iron deficiency and PTH impairment), and most of them are easily corrected with pharmacological and nutritional supplements, the body getting adapted to these deficits, without any severe clinical-biological impairment and with a trend towards normalization.

Controversias en el tratamiento quirúrgico del tumor carcinoide rectal / Controversy in the surgical treatment of the rectal carcinoid tumor

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Adenocarcinoma primitivo de intestino delgado con presentación de novo / Primary smal bowel adenocarcinoma de novo

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Cáncer de mama en varones / Breast cancer in men

El cáncer mamario en varones es una enfermedad infrecuente,que representa menos del 1% de la patología tumoral malignaen los pacientes de este sexo. Es difícil establecer criterios y guíasde diagnóstico y terapéutica sobre esta enfermedad, por lo quese utilizan los procedimientos empleados en el manejo del cáncerde mama en mujeres también para los hombres. Hemos realizadoun estudio retrospectivo de los 33 casos diagnosticados en losúltimos 40 años y seguidos durante un largo periodo en nuestraunidad, analizando en global los resultados y extrayendo ciertascaracterísticas particulares diferentes a las mujeres

The breast cancer in men is an infrequent disease, that representsless of 1% of the malignant tumorlike pathology inthe patients of this sex. It is difficult to establish criteria andguides of therapeutic and diagnosis on this disease, reasonwhy the procedures used in the handling of the breast cancerin women are also used for the men. We have made a retrospectivestudy of the 33 cases diagnosed in the last 40 yearsand followed for a long period in our unit, analyzing in globalthe results and extracting certain particular characteristics differentfrom the women