Consenso Baiona sobre Incontinencia Fecal: Asociación Española de Coloproctología / Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology

La incontinencia fecal (IF) constituye un importante problema sanitario, tanto a nivel individual como para los diferentes sistemas de salud, lo que origina una preocupación generalizada para su resolución o, al menos, disminuir en lo posible los numerosos efectos indeseables que provoca, al margen del elevado gasto que ocasiona. Existen diferentes criterios relacionados con las pruebas diagnósticas a realizar, y lo mismo acontece con relación al tratamiento más adecuado, dentro de las numerosas opciones que han proliferado durante los últimos años, no siempre basadas en una rigurosa evidencia científica. Por dicho motivo, desde la Asociación Española de Coloproctología (AECP) nos propusimos elaborar un Consenso que sirviese de orientación a todos los profesionales sanitarios interesados en el problema, conscientes, no obstante, de que la decisión terapéutica debe tomarse de manera individualizada: características del paciente/experiencia del terapeuta. Para su elaboración optamos por la técnica de grupo nominal. Los niveles de evidencia y los grados de recomendación se establecieron de acuerdo a los criterios del Oxford Centre for Evidence-Based Medicine. Por otra parte, en cada uno de los ítems analizados se añadieron, de forma breve, recomendaciones de los expertos.(AU)

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a Consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.(AU)

Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology.

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.

Sacral Neuromodulation in Patients With Low Anterior Resection Syndrome: The SANLARS Randomized Clinical Trial.

BACKGROUND: Sacral neuromodulation might be effective to palliate low anterior resection syndrome after rectal cancer surgery, but robust evidence is not available. OBJECTIVE: To assess the impact of sacral neuromodulation on low anterior resection syndrome symptoms as measured by validated scores and bowel diaries. DESIGN: Randomized, double-blind, 2-phased, controlled, multicenter crossover trial (NCT02517853). SETTINGS: Three tertiary hospitals. PATIENTS: Patients with major low anterior resection syndrome 12 months after transit reconstruction after rectal resection who had failed conservative treatment. INTERVENTIONS: Patients underwent an advanced test phase by stimulation for 3 weeks and received the pulse generator implant if a 50% reduction in low anterior resection syndrome score was achieved. These patients entered the randomized phase in which the generator was left active or inactive for 4 weeks. After a 2-week washout, the sequence was changed. After the crossover, all generators were left activated. MAIN OUTCOME MEASURES: The primary outcome was low anterior resection syndrome score reduction. Secondary outcomes included continence and bowel symptoms. RESULTS: After testing, 35 of 46 patients (78%) had a 50% or greater reduction in low anterior resection syndrome score. During the crossover phase, all patients showed a reduction in scores and improved symptoms, with better performance if the generator was active. At 6- and 12-month follow-up, the mean reduction in low anterior resection syndrome score was -6.2 (95% CI -8.97 to -3.43; p < 0.001) and -6.97 (95% CI -9.74 to -4.2; p < 0.001), with St. Mark's continence score -7.57 (95% CI -9.19 to -5.95, p < 0.001) and -8.29 (95% CI -9.91 to -6.66; p < 0.001). Urgency, bowel emptiness sensation, and clustering episodes decreased in association with quality-of-life improvement at 6- and 12-month follow-up. LIMITATIONS: The decrease in low anterior resection syndrome score with neuromodulation was underestimated because of an unspecific measuring instrument. There was a possible carryover effect in sham stimulation sequence. CONCLUSIONS: Neuromodulation provides symptoms and quality-of-life amelioration, supporting its use in low anterior resection syndrome. See Video Abstract . NEUROMODULACIN SACRA EN PACIENTES CON SNDROME DE RESECCIN ANTERIOR BAJA ENSAYO CLNICO ALEATORIZADO SANLARS: ANTECEDENTES:La neuromodulación sacra podría ser eficaz para paliar el síndrome de resección anterior baja después de la cirugía de cáncer de recto, pero no hay pruebas sólidas disponibles.OBJETIVO:Evaluar el impacto de la neuromodulación sacra en los síntomas del síndrome de resección anterior baja, medido mediante puntuaciones validadas y diarios intestinales.DISEÑO:Ensayo cruzado multicéntrico, controlado, aleatorizado, doble ciego, de dos fases (NCT02517853).LUGARES:Tres hospitales terciarios.PACIENTES:Pacientes con puntuación de resección anterior baja importante, 12 meses después de la reconstrucción del tránsito después de la resección rectal en quienes había fracasado el tratamiento conservador.INTERVENCIONES:Los pacientes se sometieron a una fase de prueba avanzada mediante estimulación durante tres semanas y se les implantó el generador de impulsos si se lograba una reducción del 50% en la puntuación del síndrome de resección anterior baja, ingresando a la fase aleatorizada en la que el generador se dejaba activo o inactivo durante cuatro semanas. Después de observar por 2 semanas, se cambió la secuencia. Después del cruce, todos los generadores quedaron activados.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la reducción de la puntuación del síndrome de resección anterior baja. Los resultados secundarios incluyeron continencia y síntomas intestinales.RESULTADOS:Después de las pruebas, 35 de 46 pacientes (78%) tuvieron una reducción ≥50% en la puntuación del síndrome de resección anterior baja. Durante el cruce, todos los pacientes mostraron una reducción en las puntuaciones y una mejora de los síntomas, con un mejor rendimiento si el generador estaba activo. A los 6 y 12 meses de seguimiento, la reducción media en la puntuación del síndrome de resección anterior baja fue -6,2 (-8,97; -3,43; p < 0,001) y -6,97 (-9,74; -4,2; p < 0,001), con Puntuación de continencia de St. Mark's -7,57 (-9,19; -5,95, p < 0,001) y -8,29 (-9,91; -6,66; p < 0,001). La urgencia, la sensación de vacío intestinal y los episodios de agrupamiento disminuyeron en asociación con una mejora en la calidad de vida a los 6 y 12 meses de seguimiento.LIMITACIONES:La disminución en la puntuación del síndrome de resección anterior baja con neuromodulación se subestimó debido a un instrumento de medición no específico. Posible efecto de arrastre en la secuencia de estimulación simulada.CONCLUSIONES:La neuromodulación mejora los síntomas y la calidad de vida, lo que respalda su uso en el síndrome de resección anterior baja. (Traducción-Dr. Mauricio Santamaria ).

Impact on defecatory, urinary and sexual function after high-tie sigmoidectomy: a post-hoc analysis of a multicenter randomized controlled trial comparing extended versus standard complete mesocolon excision.

OBJECTIVE: To assess the effect of high inferior mesenteric artery tie on defecatory, urinary, and sexual function after surgery for sigmoid colon cancer. Performing a sigmoidectomy poses a notable risk of causing injury to the preaortic sympathetic nerves during the high ligation of the inferior mesenteric artery, as well as to the superior hypogastric plexus during dissection at the level of the sacral promontory. Postoperative defecatory and genitourinary dysfunction after sigmoid colon resection are often underestimated and underreported. METHODS: This study is a secondary research of a multicenter, single-blind, randomized clinical trial. The trial involved patients with sigmoid cancer who underwent either extended complete mesocolic excision (e-CME) or standard CME (s-CME). Patients completed questionnaires to assess defecatory, urinary, and sexual function before, 1 month after surgery, and 1 year after surgery. Multivariate analysis was conducted to identify factors associated with functional dysfunction. RESULTS: Seventy-nine patients completed functional assessments before and 1 year after surgery. One year after sigmoidectomy with a high tie of the inferior mesenteric artery, 15.2% of patients had minor low anterior resection syndrome (LARS) and 12.7% had major LARS; 22.2% of males and 29.4% of females had urinary dysfunction; and 43.8% of males and 27.3% of females had sexual dysfunction. After multivariate analysis, no significant associations were found between clinical and surgical factors and gastrointestinal or urinary dysfunction after 1 year of surgery. Age was identified as the only factor linked to sexual dysfunction in both sexes (women, ß = - 0.54, p = 0.002; men ß = - 0.38, p = 0.010). Regarding recovery outcomes, diabetes mellitus was identified as a contributing factor to suboptimal gastrointestinal recovery (p = 0.033) and urinary recovery in women (p = 0.039). Furthermore, the treatment arm was found to be significantly associated with the recovery of erectile function after 1 year of surgery (p = 0.046). CONCLUSIONS: A high tie of the inferior mesenteric artery during sigmoidectomy is associated with a high incidence of defecatory and genitourinary dysfunction. Age was identified as a significant factor associated with sexual dysfunction 1 year after sigmoid colon resection in both sexes. TRIAL REGISTRATION: Clinical trials NCT03083951 HIGHLIGHTS: • One year after high-tie sigmoidectomy, 27.9% of patients had LARS; 22.2% of the men and 29.4% of the women had urinary dysfunction; and 43.8% of the men and 27.3% of the women had sexual dysfunction. • e-CME is associated with a high rate of urinary dysfunction in men 1 year after surgery. However, after multivariate analysis, no association was found between e-CME and urinary dysfunction in men. • Age was correlated with the recovery of sexual function in both sexes 1 year after surgery. Furthermore, diabetes mellitus was identified as the factor associated with poorer recovery of urinary function in females.

Sacral nerve modulation for patients with fecal incontinence: long-term outcome and effects on sexual function.

Sacral nerve modulation has become an established treatment for fecal and urinary incontinence, and sexual disorders. The objective of this study was to evaluate the long-term outcome of sacral neuromodulation in patients with fecal or combined fecal and urinary incontinence (double incontinence), assessing its safety, efficacy, and impact on quality of life and sexual function. This was a multicentric, retrospective, cohort study including patients with fecal or double incontinence who received sacral neuromodulation at seven European centers between 2007 and 2017 and completed a 5-year follow-up. The main outcome measures included improvements of incontinence symptoms and quality of life compared with baseline, evaluated using validated tools and questionnaires at 1-, 6-, 12-, 36- and 60-month follow-up. 108 (102 women, mean age 62.4 ± 13.4 years) patients were recruited, of whom 88 (81.4%) underwent definitive implantation of the pacemaker. Patients' baseline median Cleveland Clinic Incontinence Score was 15 (10-18); it decreased to 2 (1-4) and 1 (1-2) at the 12- and 36-month follow-up (p < 0.0001), remaining stable at the 5-year follow-up. Fecal incontinence quality of life score improved significantly. All patients with sexual dysfunction (n = 48) at baseline reported symptom resolution at the 5-year follow-up. The study was limited by the retrospective design and the relatively small patient sample. Sacral nerve modulation is an effective treatment for fecal and double incontinence, achieving satisfactory long-term success rates, with resolution of concomitant sexual dysfunction.

Diversity bias in colorectal surgery: a global perspective.

There is a specific lack of data on equity and injustices among colorectal surgeons regarding diversity. This study aimed to explore colorectal surgeon's lived experience of diversity bias with a specific focus on gender, sexual orientation or gender identity and race or religion. A bespoke questionnaire was designed and disseminated to colorectal surgeons and trainees through specialty association mailing lists and social media channels. Quantitative and qualitative data points were analysed. 306 colorectal surgeons responded globally. 58.8% (n = 180) identified as male and 40.5% (n = 124) as female. 19% were residents/registrars. 39.2% stated that they had personally experienced or witnessed gender inequality in their current workplace, 4.9% because of sexual orientation, and 7.5% due to their race or religion. Sexist jokes, pregnancy-related comments, homophobic comments, liberal use of offensive terms and disparaging comments and stereotypical jokes were commonly experienced. 44.4% (n = 135) did not believe their institution of employer guaranteed an environment of respect for diversity and only 20% were aware of society guidelines on equality and diversity. Diversity bias is prevalent in colorectal surgery. It is necessary to work towards real equality and inclusivity and embrace diversity, both to promote equity among colleagues and provide better surgical care to patients.

Extended Versus Standard Complete Mesocolon Excision in Sigmoid Colon Cancer: A Multicenter Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to evaluate whether extended complete mesocolic excision (e-CME) for sigmoid colon cancer improves oncological outcomes without compromising morbidity or functional results. BACKGROUND: In surgery for cancer of the sigmoid colon and upper rectum, s-CME removes the lymphofatty tissue surrounding the inferior mesenteric artery (IMA), but not the lymphofatty tissue surrounding the portion of the inferior mesenteric vein that does not run parallel to the IMA. Evidence about the safety and efficacy of extending CME to include this tissue is lacking. METHODS: This single-blind study randomized sigmoid cancer patients at 4 centers to undergo e-CME or s-CME. The primary outcome was the total number of lymph nodes harvested. Secondary outcomes included disease-free and overall survival at 2 years, morbidity, and bowel and genitourinary function. Clinicaltrials.gov: NCT03107650. RESULTS: We analyzed 93 patients (46 e-CME and 47 s-CME). Perioperative outcomes were similar between groups. No differences between groups were found in the total number of lymph nodes harvested [21 (interquartile range, IQR, 14-29) in e-CME vs 20 (IQR, 15-27) in s-CME, P = 0.873], morbidity (P = 0.829), disease-free survival (P = 0.926), or overall survival (P = 0.564). The extended specimen yielded a median of 1 lymph node (range, 0-6), none of which were positive.Bowel function recovery was similar between arms at all timepoints. Males undergoing e-CME had worse recovery of urinary function (P = 0.026). CONCLUSION: Extending lymphadenectomy to include the IMV territory did not increase the number of lymph nodes or improve local recurrence or survival rates.

Impact of perioperative transfusions and sepsis on long-term oncologic outcomes after curative colon cancer resection. A retrospective analysis of a prospective database / Impacto de las trasfusiones y de las sepsis perioperatorias en los resultados oncológicos de largo plazo tras cirugía curativa de cáncer de colon. Análisis retrospectivo de una base prospectiva

Objective: Intra-abdominal septic complications (IASC) affect short-term outcomes after surgery for colon cancer. Blood transfusions have been associated with worse short-term results. The role of IASC and blood transfusions on long-term oncologic results is still debated. This study aims to assess the impact of these two variables on survival after curative colon cancer resection. Patients and methods: Retrospective analysis of a prospectively maintained database of patients who underwent curative surgery for colon cancer at a university hospital, between 1993 and 2010. Cox regression was used to identify the role of IASC and transfusions (alone and combined) on local recurrence (LR), disease-free survival (DFS), and cancer-specific survival (CSS). Results: Out of the 1686 patients analyzed, 1277 fit in the inclusion criteria. Colorectal surgeons performed the procedure in 82.2% of the patients. Blood transfusions were administered to 25.8% of the patients. Thirty-day complication and mortality rates were 34.5% and 6.1%. IASC occurred in 9.9%. The mean follow-up was 66 months. The 5-year rates of LR, DFS, and CSS were 7%, 79.8%, and 85.1%. The year of surgery and pT (Hazard ratio 9.35, 95% CI 1.23-70.9, for T4) and pN (Hazard ratio 2.57, 95% CI 1.39-4.72, for N2) stages were independent risk factors for LR. The same variables, bowel obstruction and surgeries performed by surgeons not specialized in colorectal surgery, were also associated with worse DFS and CSS. IASC and blood transfusions were not associated with LR, DFS, and CSS, whether alone or combined. Conclusions: IASC and transfusions were not associated with worse oncological outcomes after curative colon cancer surgery per se. Other factors were more important predictors of survival

Objetivos: Las complicaciones sépticas intra-abdominales(CSIA) empeoran los resultados a corto plazo después de cirugía por cáncer de colon. Las trasfusiones de sangre también han sido relacionadas con peores resultados a corto plazo. El impacto de la CSIA y de las transfusiones en los resultados oncológicos es todavía debatido. Objetivo del presente estudio fue valorar el impacto de estas dos variables en la supervivencia de pacientes intervenidos por cáncer de colon. Pacientes y métodos: Análisis retrospectivo de una base prospectiva de pacientes sometidos a cirugía curativa por cáncer de colon en un hospital universitario(1993-2010). Se utilizó regresión de Cox para valorar el efecto de CSIA y trasfusiones(aislados o en combinación) sobre recidiva local(RL), supervivencia libre de enfermedad(SLE) y supervivencia cáncer-especifica(SCE). Resultados: De los 1686 pacientes analizados, se incluyeron 1277. La cirugía fue realizada por cirujanos colorrectales en el 82,2% de los pacientes. El 25,8% recibió transfusiones. Las tasas de complicaciones y mortalidad a los 30 días fueron del 34,5% y 6,1%. La frecuencia de CSIA fue del 9,9%. El seguimiento mediano fue de 66 meses. Las tasas a los 5 años de RL,SLE y SCE fueron 7%, 79,8% y 85,1%. El año de tratamiento, los estadios pT(Cociente de riesgo 9,35,IC95% 1,23-70,9,en T4)y pN(Cociente de riesgo 2,57,IC95% 1,39-4,72,en N2)resultaron como factores de riesgo para RL. Las mismas variables, la obstrucción intestinal y la cirugía realizada por cirujanos no colorrectales se asociaron también a peor SLE y SCE. CSIA y trasfusiones no resultaron asociadas con RL, SLE y SCE, ni de forma aislada ni combinadas. Conclusiones: Las CSIA y trasfusiones no afectaron per se los resultados oncológicos de la cirugía de cáncer de colon. Otros factores resultaron más importantes predictores de supervivencia

Impact of perioperative transfusions and sepsis on long-term oncologic outcomes after curative colon cancer resection. A retrospective analysis of a prospective database.

OBJECTIVE: Intra-abdominal septic complications (IASC) affect short-term outcomes after surgery for colon cancer. Blood transfusions have been associated with worse short-term results. The role of IASC and blood transfusions on long-term oncologic results is still debated. This study aims to assess the impact of these two variables on survival after curative colon cancer resection. PATIENTS AND METHODS: Retrospective analysis of a prospectively maintained database of patients who underwent curative surgery for colon cancer at a university hospital, between 1993 and 2010. Cox regression was used to identify the role of IASC and transfusions (alone and combined) on local recurrence (LR), disease-free survival (DFS), and cancer-specific survival (CSS). RESULTS: Out of the 1686 patients analyzed, 1277 fit in the inclusion criteria. Colorectal surgeons performed the procedure in 82.2% of the patients. Blood transfusions were administered to 25.8% of the patients. Thirty-day complication and mortality rates were 34.5% and 6.1%. IASC occurred in 9.9%. The mean follow-up was 66 months. The 5-year rates of LR, DFS, and CSS were 7%, 79.8%, and 85.1%. The year of surgery and pT (Hazard ratio 9.35, 95% CI 1.23-70.9, for T4) and pN (Hazard ratio 2.57, 95% CI 1.39-4.72, for N2) stages were independent risk factors for LR. The same variables, bowel obstruction and surgeries performed by surgeons not specialized in colorectal surgery, were also associated with worse DFS and CSS. IASC and blood transfusions were not associated with LR, DFS, and CSS, whether alone or combined. CONCLUSIONS: IASC and transfusions were not associated with worse oncological outcomes after curative colon cancer surgery per se. Other factors were more important predictors of survival.

Systematic review of functional outcomes and quality of life after transanal endoscopic microsurgery and transanal minimally invasive surgery: a word of caution.

PURPOSE: The introduction of transanal endoscopic or minimally invasive surgery has allowed organ preservation for rectal tumors with good oncological results. Data on functional and quality-of-life (QoL) outcomes are scarce and controversial. This systematic review sought to synthesize fecal continence, QoL, and manometric outcomes after transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS). METHODS: A systematic review of the literature including Medline, Embase, and the Cochrane Library databases was conducted searching for articles reporting on functional outcomes after TEM or TAMIS between January 1995 and June 2018. The evaluated outcome parameters were pre- and postoperative fecal continence (primary endpoint), QoL, and manometric results. Data were extracted using the same scales and measurement units as from the original study. RESULTS: A total of 29 studies comprising 1297 patients were included. Fecal continence outcomes were evaluated in 23 (79%) studies with a wide variety of assessment tools and divergent results. Ten studies (34%) analyzed QoL changes, and manometric variables were assessed in 15 studies (51%). Most studies reported some deterioration in manometric scores without major QoL impairment. Due to the heterogeneity of the data, it was not possible to perform any pooled analysis or meta-analysis. CONCLUSIONS: These techniques do not seem to affect continence by themselves except in minor cases. The possibility of worsened function after TEM and TAMIS should not be underestimated. There is a need to homogenize or standardize functional and manometric outcomes assessment after TEM or TAMIS.

Comparative Oncologic Outcomes of Upper Third Rectal Cancers: A Meta-analysis.

INTRODUCTION: Preoperative radiation combined with mesorectal excision has reduced local recurrence rates in rectal cancer. The role for neoadjuvant therapy in upper third rectal cancer remains unclear. The current study aimed to use meta-analytical techniques to compare outcomes of upper third rectal tumors relative to those of the middle and lower rectum. MATERIALS AND METHODS: Meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases were searched for studies comparing outcomes between patients with upper third and more distal rectal cancer undergoing primary resection. Patients receiving neoadjuvant treatment were excluded. Results were reported as odds ratios (ORs) with 95% confidence intervals (95% CIs). RESULTS: A total of 174 citations were reviewed; 5 studies comprising 3381 patients were included in the analysis. There was no difference in the rate of T3/4 tumors (OR, 1.303; 95% CI, 0.920-1.847; P = .137), lymph node positivity (OR, 1.004; 95% CI, 0.865-1.165; P = .961), and circumferential resection margin positivity (OR, 0.898; 95% CI, 0.556-1.450; P = .660) between upper third and more distal rectal cancers. However local recurrence (OR, 0.495; 95% CI, 0.302-0.811; P = .005) and distant recurrence (OR, 0.613; 95% CI, 0.511-0.734; P < .001) were reduced in patients with upper third rectal cancer. CONCLUSIONS: These data suggest that upper third rectal cancer has reduced local and distant recurrence rates despite similarity in disease stage and margin positivity. Further studies examining effects of neoadjuvant radiation in rectal cancer should consider upper rectal tumors as a distinct entity to middle and lower rectal tumors.

A randomized clinical trial comparing the initial vascular approach to the inferior mesenteric vein versus the inferior mesenteric artery in laparoscopic surgery of rectal cancer and sigmoid colon cancer.

BACKGROUND: The inferior mesenteric artery approach with a selective lateral splenic flexure mobilization is the most widely used initial step in laparoscopic rectal and left colon surgery. Surgery started through the inferior mesenteric vein (IMV) with systematic medial mobilization (MM) has some theoretical advantages that have never been analyzed in a clinical trial. The aim of this study was to compare the two techniques with regards to surgical technique variables (conversion, surgical time, bleeding, morbidity, and mortality) and pathological outcomes. METHODS: A single-blinded, randomized, controlled trial of patients operated electively by laparoscopic with curative intention for rectal or sigmoid cancer was performed at a single, specialized colorectal surgery department from April 2016 to October 2017. RESULTS: 49 patients were included in each group. There were no statistical differences in patient demographics between the two approaches. Pathological outcomes did not differ between the two groups. Intra-operative characteristics showed a higher conversion rate in patients in which the inferior mesenteric artery was dissected first (p = 0.031). The artery approach also increased intra-operative bleeding (p = 0.049), but there were no differences regarding operative time. On multivariate analysis, the artery approach was associated with a higher risk of conversion (OR 8.68; p = 0.050). Post-operatory complications did not differ between artery and vein dissection. CONCLUSIONS: In our study, the initial approach by the IMV with a systematic MM of the splenic flexure has allowed us to reduce the conversion rate without increasing complications or the surgical time. No differences were observed in the pathological results. Both approaches seem to be safe and effective and well-trained laparoscopic surgeons should have the two techniques available to them for use as needed.

Tratamiento de la fístula anal mediante clip con el dispositivo OTSC(R): resultados a corto plazo / Treatment of Fistula-in-ano With OTSC(R) Proctology Clip Device: Short-term Results

INTRODUCCIÓN: El tratamiento de la fístula anal con el dispositivo OTSC(R)(over-the-scope-clip) consiste en la inserción de un clip de una aleación elástica denominado Nitinol que ejerce una presión constante sobre el orificio fistuloso interno y facilita el cierre de la fístula. El objetivo de este estudio es analizar los resultados a corto plazo de esta técnica en una serie de casos. MÉTODOS: Análisis retrospectivo de una serie de casos intervenidos de cierre de fístula anal entre junio de 2015 y marzo de 2017 tratados en una unidad especializada con el dispositivo OTSC®. Se incluyeron pacientes con fístulas anales simples y complejas, tratadas previamente o sin tratamientos previos, de origen criptoglandular o por enfermedad de Crohn estable. Se consideró fracaso de la técnica a la supuración anal o complicaciones relacionadas con la inserción del clip. RESULTADOS: Se intervino a 10 pacientes con fístula anal con una mediana de edad de 54 años (rango: 41-70 años). Nueve fístulas fueron de origen criptoglandular y una por enfermedad de Crohn controlada. Tres pacientes presentaron fístulas simples y siete, complejas. El 80% de los pacientes habían presentado cirugías anales previas. La tasa de curación de la fístula fue del 60% con un seguimiento mediano de 15 meses (rango: 6-26 meses). Tres pacientes presentaron recidiva clínica y un paciente requirió extracción del clip por dolor invalidante. No hubo aparición de incontinencia fecal. CONCLUSIONES: El tratamiento de la fístula anal con el dispositivo OTSC(R) es una técnica conservadora de esfínteres segura con resultados satisfactorios a corto plazo

INTRODUCTION: The treatment of anal fistula with the OTSC(R) (over-the-scope-clip) proctology device involves the placement of an elastic alloy clip called Nitinol on the internal fistula opening to achieve fistula healing. The aim of this study was to analyze preliminary results of this technique in a case series. METHODS: This was a retrospective analysis of patients who underwent OTSC(R) clip placement for fistula-in-ano treatment between June 2015 and March 2017 at a specialized colorectal unit. Patients with simple and complex fistulae, either previously treated or not, were included in the study. Both cryptoglandular and stable Crohn's disease fistulae were considered for this approach. Technique failure was determined by the re-appearance of anorectal suppuration or in clip-related complications. RESULTS: Ten patients were treated surgically for anal fistula with a median age of 54 years (range: 41-70 years). The etiology of the fistulae was mainly cryptoglandular. Three patients had simple fistulae, whereas seven had complex disease. 80% of the patients had already undergone previous fistula surgery. No events occurred during the procedure. The success rate for healing was 60%, with a median follow-up of 15months (range: 6-26 months). Three patients developed suppuration relapse and one patient required clip extraction due to invalidating anal pain. No fecal incontinence was recorded after the procedure. CONCLUSIONS: The treatment of anal fistulae with the OTSC(R) device is a safe sphincter-saving technique in the short term

Treatment of Fistula-in-ano With OTSC® Proctology Clip Device: Short-term Results. / Tratamiento de la fístula anal mediante clip con el dispositivo OTSC®: resultados a corto plazo.

INTRODUCTION: The treatment of anal fistula with the OTSC® (over-the-scope-clip) proctology device involves the placement of an elastic alloy clip called Nitinol on the internal fistula opening to achieve fistula healing. The aim of this study was to analyze preliminary results of this technique in a case series. METHODS: This was a retrospective analysis of patients who underwent OTSC® clip placement for fistula-in-ano treatment between June 2015 and March 2017 at a specialized colorectal unit. Patients with simple and complex fistulae, either previously treated or not, were included in the study. Both cryptoglandular and stable Crohn's disease fistulae were considered for this approach. Technique failure was determined by the re-appearance of anorectal suppuration or in clip-related complications. RESULTS: Ten patients were treated surgically for anal fistula with a median age of 54 years (range: 41-70years). The etiology of the fistulae was mainly cryptoglandular. Three patients had simple fistulae, whereas seven had complex disease. 80% of the patients had already undergone previous fistula surgery. No events occurred during the procedure. The success rate for healing was 60%, with a median follow-up of 15months (range: 6-26months). Three patients developed suppuration relapse and one patient required clip extraction due to invalidating anal pain. No fecal incontinence was recorded after the procedure. CONCLUSIONS: The treatment of anal fistulae with the OTSC® device is a safe sphincter-saving technique in the short term.

Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: An institutional analysis of 800 patients.

BACKGROUND: Our aim was to assess whether the individual surgeon is an independent risk factor for anastomotic leak in double-stapled colorectal anastomosis after left colon and rectal cancer resection. METHODS: This retrospective analysis of a prospectively collected database consists of a consecutive series of 800 patients who underwent an elective left colon and rectal resection with a colorectal, double-stapled anastomosis between 1993 and 2009 in a specialized colorectal unit of a tertiary hospital with 7 participating surgeons. The main outcome variable was anastomotic leak, defined as leak of luminal contents from a colorectal anastomosis between 2 hollow viscera diagnosed radiologically, clinically, endoscopically, or intraoperatively. Pelvic abscesses were also considered to be an anastomotic leak. Radiologic examination was performed when there was clinical suspicion of leak. RESULTS: Anastomotic leak occurred in 6.1% of patients, of which 33 (67%) were treated operatively, 6 (12%) with radiologic drains, and 10 (21%) by medical treatment. Postoperative mortality rate was 2.9% for the whole group of 800 patients. In patients with anastomotic leak, mortality rate increased up to 16% vs 2.0% in patients without anastomotic leak (P < .0001). At multivariate analysis, rectal location of tumor, male sex, bowel obstruction preoperatively, tobacco use, diabetes, perioperative transfusion, and the individual surgeon were independent risk factors for anastomotic leak. The surgeon was the most important factor (mean odds ratio 4.9; range 1.0 to 13.5). The variance of anastomotic leak between the different surgeons was 0.56 in the logit scale. CONCLUSION: The individual surgeon is an independent risk factor for leakage in double-stapled, colorectal, end-to-end anastomosis after oncologic left-sided colorectal resection.

Perforación rectal espontánea con evisceración transanal del intestino delgado. A propósito de un caso y revisión de la literatura / Spontaneous perforation of the rectum with transanal evisceration of the small bowel: A case report and review of the literature

No disponible