Navigating surgical anatomy of the Denonvilliers' fascia and dissection planes of the anterior mesorectum with a cadaveric simulation model.

Anterior dissection of the rectum in the male pelvis represents one of the most complex phases of total meso-rectal excision. However, the possible existence of different anatomical planes is controversial and the exact anatomical topography of Denonvilliers' fascia is still debated. The aim of the study is to accurately define in a cadaveric simulation model the existence and boundaries of Denonvilliers' fascia, identifying the anatomical planes suitable for surgical dissection. The pelvises of 31 formalin-preserved male cadavers were dissected. Careful and detailed dissection was carried out to visualize the anatomical structures and the potential dissection planes, simulating an anterior meso-rectum dissection. Denonvilliers' fascia was identified in 100% of the pelvises, as a single-layer fascia that originates from the peritoneal reflection and descends until its firm adhesion to the prostate capsule. The fascia divides the space providing an anterior and a posterior plane. Anteriorly to the fascia, during the caudal dissection, its firm adhesion to the prostate capsule forces to section it sharply. The cadaveric simulation model allowed an accurate description of Denonvilliers' fascia, defining several planes for anterior dissection of the meso-rectum.

Surgical Anatomy of the Rectovaginal Space: Does a Standalone Rectovaginal Septum or Denonvilliers Fascia Exist in Women?

BACKGROUND: Below the anterior peritoneal reflection, the anterior rectal wall and mesorectum are separated from the posterior vaginal wall by a virtual rectovaginal space. In this space, the description of a specific and independent rectovaginal septum as a female counterpart of Denonvilliers fascia has been the subject of debate over the years. OBJECTIVE: The aim of this study is to perform an accurate anatomical study of the rectovaginal area in a cadaveric simulation model of total mesorectal excision to evaluate the possible structures and the dissection planes contained within the rectovaginal space. DESIGN AND SETTING: This is a cadaveric study performed at the University of Valencia. PATIENTS: The pelvises of 25 formalin-preserved female cadavers were dissected. All the included specimens were sectioned in a midsagittal plane, at the level of the middle axis of the anal canal. MAIN OUTCOME MEASURES: Careful and detailed dissection was performed to visualize the anatomical structures and potential dissection planes during anterior mesorectal dissection in cadavers. Histological sections were made of the posterior vaginal wall. RESULTS: The rectovaginal space contains loose areolar tissue that allows an easy dissection plane distally. A distinct and independent rectovaginal fascia or septum is not present. The existence of 3 layers fused together in the posterior vaginal wall can be identified more or less precisely because of their different coloration. The histological study confirms this macroscopic arrangement of the posterior vaginal wall in 3 layers: the mucosa, the muscular, and the adventitia. An independent rectovaginal septum can be generated only with a splitting of the adventitia. LIMITATIONS: The cadaveric pelvic specimens of the oldest donors might have had age-related degeneration. CONCLUSIONS: The present anatomical study has shown only a plane of loose areolar tissue between the rectal and vaginal wall. We can conclude that there is no independent fascia or septum in the rectovaginal space. See Video Abstract at http://links.lww.com/DCR/B456. ANATOMÍA QUIRÚRGICA DEL ESPACIO RECTOVAGINAL: ¿EXISTE UN TABIQUE RECTOVAGINAL INDEPENDIENTE O UNA FASCIA DE DENONVILLIERS EN LAS MUJERES: Debajo del reflejo peritoneal anterior, la pared rectal anterior y el mesorrecto están separados de la pared vaginal posterior por un espacio rectovaginal virtual. En este espacio, la descripción de un tabique rectovaginal independiente específico como contraparte femenina de la fascia de Denonvilliers ha sido objeto de debate a lo largo de los años.Realizar un estudio anatómico preciso del área rectovaginal en un modelo de simulación cadavérica de escisión mesorrectal total, con el fin de evaluar las posibles estructuras y los planos de disección contenidos en el espacio rectovaginal.estudio cadavérico realizado en la Universidad de Valencia.Se disecaron las pelvis de 25 cadáveres femeninos conservados en formalina. Todas las muestras incluidas fueron seccionadas en un plano medio sagital, a la altura del eje medio del canal anal.Se llevó a cabo una disección cuidadosa y detallada para visualizar las estructuras anatómicas y los posibles planos de disección durante la disección mesorrectal anterior en cadáveres. Se realizaron cortes histológicos de la pared vaginal posterior.El espacio rectovaginal contiene tejido areolar laxo que permite un plano de disección fácil distalmente. No hay fascia o tabique rectovaginal distinto e independiente. La existencia de tres capas fusionadas en la pared vaginal posterior puede identificarse con mayor o menor precisión debido a su diferente coloración. El estudio histológico confirma esta disposición macroscópica de la pared vaginal posterior en tres capas: la mucosa, la muscular y la adventicia. Un tabique rectovaginal independiente solo se puede generar con una división de la adventicia.Las muestras pélvicas de cadáveres de los donantes más antiguos pueden haber tenido degeneración relacionada con la edad.El estudio anatómico actual solo ha mostrado un plano de tejido areolar laxo entre la pared rectal y vaginal. Podemos concluir que no hay fascia o tabique independiente en el espacio rectovaginal. Consulte Video Resumen en http://links.lww.com/DCR/B456. (Traducción-Dr. Adrian Ortega).

Validation of a Novel Fecal Incontinence Scale: The Rapid Assessment Fecal Incontinence Score (RAFIS).

OBJECTIVE: The development and validation of a new version of the fecal incontinence (FI) scale "Rapid Assessment Fecal Incontinence Score" (RAFIS) incorporating domains for severity, type of stool loss, and global perception of the effect of incontinence on quality of life (QoL). BACKGROUND: FI negatively impacts on QoL. Currently used incontinence questionnaires have outstanding limitations on the global assessment of the impact of the disease on QoL that patients perceive. We developed a new version of RAFIS with a more complete questionnaire. MATERIALS AND METHODS: A 3-phase study was performed to evaluate the applicability and reliability of our questionnaire as a tool for assessing FI. Our score was completed by 98 patients (78 women; mean age: 57±13 y) who presented with FI and who were referred from 4 colorectal surgery centers. The RAFIS was assessed for internal consistency, test-retest reliability, and sensitivity to change. A multivariate analysis was performed. Comparisons were made with the Wexner Cleveland Clinic Incontinence Score and the Fecal Incontinence Quality of Life Scale. RESULTS: The RAFIS showed good internal consistency and test-retest reliability, differentiating the severity of incontinence but not the etiology. There was a moderate-high correlation between the new scale and the reference scales. Sensitivity to change, compared with the Wexner Score, was moderate. Comparison with established QoL instruments showed a moderate negative correlation. Logistic regression of the RAFIS discriminated between mild and moderate-severe impact on QoL. No correlation was detected with the new score to the presence of an anal sphincter defect or sphincter hypotonia. CONCLUSION: The RAFIS scale is easy to administer and compares well with other validated incontinence instruments.

Acute diverticulitis and surgical treatment.

Diverticulitis is a common condition in industrialized countries and an important cause of hospital admissions. Its growing trend is a challenge for the surgeons who perform emergency surgery, because approximately 15-25% of the patients will require surgery, being the surgical management of complicated acute diverticulitis controversial. The past decade has seen a paradigm shift in the treatment of sigmoid diverticulitis based on new epidemiological studies and refinement of surgical techniques that has produced a reassessment of our guidelines. CT imaging and sepsis scores allows to stratify the patients and better define the therapeutic strategies in each case. Special considerations must also be made for patients with a high surgical risk, such as immunosuppressed ones. The recommendations to perform surgery after two episodes of uncomplicated diverticulitis have been re-evaluated and the belief that new episodes may be complicated and associated with high morbidity and mortality has been rejected, since the clinical manifestations of this disease are usually defined by the first attack. In complicated cases, more patients can be treated with resection and primary anastomosis with or without an associated stoma, whose reversal rate is much higher than that of a Hartmann's procedure. Likewise, laparoscopic surgery performing a peritoneal lavage and drainage without associated resection may have an increasing role in the management of these patients, although with controversial results, having become laparoscopic colon resection the approach of choice for the treatment of this pathology in elective settings.

Influencia del volumen quirúrgico en los resultados oncológicos después de estandarizar la cirugía en el Proyecto Español del Cáncer de Recto / Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery in the Spanish Rectal Cancer Project

INTRODUCCIÓN: Determinar la influencia del volumen quirúrgico en los resultados oncológicos del Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos. MÉTODOS: Se incluyeron 2.910 pacientes consecutivos tratados con una operación curativa entre marzo de 2006 y marzo de 2010 en 36 hospitales. Los hospitales se clasificaron según el número de pacientes operados por año en: pequeños (12-23), intermedios (24-35) y grandes (≥ 36). RESULTADOS: Con un seguimiento de al menos cinco años la incidencia acumulada de recidiva local fue 6,6 (IC 95% 5,6-7,6), la de metástasis 20,3 (IC 95% 18,8-21,9) y la de supervivencia global 73,0 (IC 95% 74,7-71,3). En el análisis de regresión multinivel, la supervivencia global fue mayor en los hospitales que operaban 36 o más pacientes [HR 0,727 (IC 95% 0,556-0,951); p = 0,02]. El riesgo de recidiva local y metástasis no se relacionó con el volumen quirúrgico. Además, hubo una variación significativa en las tasas de supervivencia global (mediana hazard ratio [MHR] 1,184 [IC 95% 1,071-1,333]), recidiva local (MHR 1,308 [IC 95% 1,010-1,668]) y metástasis (MHR 1,300 [IC 95% 1,181-1,476]) entre todos los hospitales. CONCLUSIONES: En los grupos multidisciplinares seleccionados e incluidos en el proyecto de la Asociación Española de Cirujanos, que incluye la enseñanza de la escisión total del mesorrecto y la realimentación de los resultados, la supervivencia global es mayor en los hospitales con mayor volumen quirúrgico, y la variabilidad interhospitalaria de la tasa de recidiva local no se explica por el volumen quirúrgico

INTRODUCCIÓN: The purpose of this prospective multicentre multilevel study was to investigate the influence of hospital caseload on long-term outcomes following standardization of rectal cancer surgery in the Rectal Cancer Project of the Spanish Society of Surgeons. METHODS: Data relating to 2910 consecutive patients with rectal cancer treated for cure between March 2006 and March 2010 were recorded in a prospective database. Hospitals were classified according to number of patients treated per year as low-volume, intermediate-volume, or high volume hospitals (12-23, 24-35, or ≥ 36 procedures per year). RESULTS: After a median follow-up of 5 years, cumulative rates of local recurrence, metastatic recurrence and overall survival were 6.6 (CI 95% 5.6-7.6), 20.3 (CI 95% 18.8-21.9) and 73.0 (CI95% 74.7 - 71.3) respectively. In the multilevel regression analysis overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more patients (HR 0,727 [CI 95% 0,556-0,951]; P=.02). The risk of local recurrence and metastases were not related to the caseload. Moreover, there was a statistically significant variation in overall survival (median hazard ratio [MHR] 1.184 [CI 95% 1.071-1,333]), local recurrence (MHR 1.308 [CI 95% 1.010-1.668]) and metastases (MHR 1.300 [CI 95% 1.181; 1.476]) between all hospitals. CONCLUSIONS: Overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more PATIENTS: However, local recurrence was not influenced by caseload

Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery in the Spanish Rectal Cancer Project. / Influencia del volumen quirúrgico en los resultados oncológicos después de estandarizar la cirugía en el Proyecto Español del Cáncer de Recto.

UNLABELLED: INTRODUCCIóN: The purpose of this prospective multicentre multilevel study was to investigate the influence of hospital caseload on long-term outcomes following standardization of rectal cancer surgery in the Rectal Cancer Project of the Spanish Society of Surgeons. METHODS: Data relating to 2910 consecutive patients with rectal cancer treated for cure between March 2006 and March 2010 were recorded in a prospective database. Hospitals were classified according to number of patients treated per year as low-volume, intermediate-volume, or high volume hospitals (12-23, 24-35, or ≥36 procedures per year). RESULTS: After a median follow-up of 5 years, cumulative rates of local recurrence, metastatic recurrence and overall survival were 6.6 (CI95% 5.6-7.6), 20.3 (CI95% 18.8-21.9) and 73.0 (CI95% 74.7 - 71.3) respectively. In the multilevel regression analysis overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more patients (HR 0,727 [CI95% 0,556-0,951]; P=.02). The risk of local recurrence and metastases were not related to the caseload. Moreover, there was a statistically significant variation in overall survival (median hazard ratio [MHR] 1.184 [CI95% 1.071-1,333]), local recurrence (MHR 1.308 [CI95% 1.010-1.668]) and metastases (MHR 1.300 [CI95% 1.181; 1.476]) between all hospitals. CONCLUSIONS: Overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more patients. However, local recurrence was not influenced by caseload.

Preoperative chemotherapy in patients with intermediate-risk rectal adenocarcinoma selected by high-resolution magnetic resonance imaging: the GEMCAD 0801 Phase II Multicenter Trial.

BACKGROUND: The need for preoperative chemoradiation or short-course radiation in all T3 rectal tumors is a controversial issue. A multicenter phase II trial was undertaken to evaluate the efficacy and safety of neoadjuvant capecitabine and oxaliplatin combined with bevacizumab in patients with intermediate-risk rectal adenocarcinoma. METHODS: We recruited 46 patients with T3 rectal adenocarcinoma selected by magnetic resonance imaging (MRI) who were candidates for (R0) resection located in the middle third with clear mesorectal fascia and who were selected by pelvic MRI. Patients received four cycles of neoadjuvant capecitabine and oxaliplatin combined with bevacizumab (final cycle without bevacizumab) before total mesorectal excision (TME). In case of progression, preoperative chemoradiation was planned. The primary endpoint was overall response rate (ORR). RESULTS: On an intent-to-treat analysis, the ORR was 78% (n = 36; 95% confidence interval [CI]: 63%-89%) and no progression was detected. Pathologic complete response was observed in nine patients (20%; 95% CI: 9-33), and T downstaging was observed in 48%. Forty-four patients proceeded to TME, and all had R0 resection. During preoperative therapy, two deaths occurred as a result of pulmonary embolism and diarrhea, respectively, and one patient died after surgery as a result of peritonitis secondary to an anastomotic leak (AL). A 13% rate of AL was higher than expected. The 24-month disease-free survival rate was 75% (95% CI: 60%-85%), and the 2-year local relapse rate was 2% (95% CI: 0%-11%). CONCLUSION: In this selected population, initial chemotherapy results in promising activity, but the observed toxicity does not support further investigation of this specific regimen. Nevertheless, these early results warrant further testing of this strategy in an enriched population and in randomized trials.

Tratamiento de las fístulas de ano complejas de causa criptoglandular. ¿Aún se requiere un cirujano con experiencia? / Treatment of complex cryptoglandular anal fistulas. Does it still require an experienced surgeon?

Sigue habiendo controversias en el manejo de las fístulas de ano complejas de origen criptoglandular (FC) incluso tras el empleo de técnicas novedosas teóricamente más simples. Para clarificar el papel del cirujano colorrectal en su tratamiento, se efectúa una revisión crítica de la literatura basándonos en que el precario balance entre erradicar la sepsis y mantener la función anorrectal afecta la elección. Se discuten técnicas como la fistulotomía, colgajos de avance, reparación esfinteriana inmediata o ligadura del trayecto interesfintérico. También se analizan las nuevas tecnologías preservadoras del esfínter como el sellado, empleo de tapones y terapia celular. Sin embargo, con escasas excepciones, la evidencia científica es baja o nula debido a la escasez de ensayos clínicos y a que hay gran variabilidad de presentaciones y de detalles técnicos que pueden influir en el resultado. Por tanto, la experiencia en el tratamiento de las FC sigue siendo esencial (AU)

There is still controversy on the management of complex cryptoglandular fistulas, even after employing the newest, theoretically simple, techniques. A critical review of the literature was performed, in order to clarify the role of the surgeon, where the precarious balance between eradicating sepsis and maintaining anorectal influences the choice. Techniques, such as fistulotomy, immediate sphincter repair or ligature of the intersphincter trajectory, are discussed. The new sphincter preserving techniques, such as sealing, use of plugs and cell therapy are also analysed. However, with a few exceptions, the scientific evidence is low or zero, due to the lack of clinical trials and to the large variation in the presentations and technical details that could influence the results. For this reason, experience in treating complex cryptoglandular fistulas is still essential (AU)

[Treatment of complex cryptoglandular anal fistulas. Does it still require an experienced surgeon?]. / Tratamiento de las fístulas de ano complejas de causa criptoglandular. ¿Aún se requiere un cirujano con experiencia?

There is still controversy on the management of complex cryptoglandular fistulas, even after employing the newest, theoretically simple, techniques. A critical review of the literature was performed, in order to clarify the role of the surgeon, where the precarious balance between eradicating sepsis and maintaining anorectal influences the choice. Techniques, such as fistulotomy, immediate sphincter repair or ligature of the inter-sphincter trajectory, are discussed. The new sphincter preserving techniques, such as sealing, use of plugs and cell therapy are also analysed. However, with a few exceptions, the scientific evidence is low or zero, due to the lack of clinical trials and to the large variation in the presentations and technical details that could influence the results. For this reason, experience in treating complex cryptoglandular fistulas is still essential.

Influence of rescrubbing before laparotomy closure on abdominal wound infection after colorectal cancer surgery: results of a multicenter randomized clinical trial.

OBJECTIVE: To test the hypothesis that strict asepsis in closing wounds following laparotomy reduces the risk for surgical wound infection in elective colorectal cancer surgery. DESIGN: Multicenter randomized clinical trial conducted from June 1, 2009, through June 1, 2010. SETTINGS: Colorectal surgery units of 9 Spanish hospitals. PATIENTS: A total of 969 patients who underwent elective colorectal cancer surgery were eligible for randomization. In closing the laparotomy wound, the patients were randomized to 2 groups: conventional (n=516) and new operation (n=453). In the conventional group, a new set of instruments was used, surgical staff changed their gloves, and the surgical drapes surrounding the laparotomy were covered by a new set of drapes. The new operation group involved removing all drapes, the surgical staff scrubbed again, and a new set of drapes and instruments was used. MAIN OUTCOME MEASURES: Incisional (superficial and deep) surgical site infection 30 days after the operation and risk factors for postoperative wound infections. RESULTS: A total of 146 incisional surgical site infections (15.1%) were diagnosed. Of these, 96 (9.9%) were superficial and 50 (5.1%) were deep infections. On an intent-to-treat basis, significant differences were found between both groups (66 [12.8%] in the conventional group vs 80 [17.7%] in the new operation group [P=.04]). CONCLUSION: This study does not support the use of rescrubbing to reduce the incidence of incisional surgical site infection. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN19463413

Enhanced recovery in colorectal surgery: a multicentre study.

BACKGROUND: Major colorectal surgery usually requires a hospital stay of more than 12 days. Inadequate pain management, intestinal dysfunction and immobilisation are the main factors associated with delay in recovery. The present work assesses the short and medium term results achieved by an enhanced recovery program based on previously published protocols. METHODS: This prospective study, performed at 12 Spanish hospitals in 2008 and 2009, involved 300 patients. All patients underwent elective colorectal resection for cancer following an enhanced recovery program. The main elements of this program were: preoperative advice, no colon preparation, provision of carbohydrate-rich drinks one day prior and on the morning of surgery, goal directed fluid administration, body temperature control during surgery, avoiding drainages and nasogastric tubes, early mobilisation, and the taking of oral fluids in the early postoperative period. Perioperative morbidity and mortality data were collected and the length of hospital stay and protocol compliance recorded. RESULTS: The median age of the patients was 68 years. Fifty-two % of the patients were women. The distribution of patients by ASA class was: I 10%, II 50% and III 40%. Sixty-four % of interventions were laparoscopic; 15% required conversion to laparotomy. The majority of patients underwent sigmoidectomy or right hemicolectomy. The overall compliance to protocol was approximately 65%, but varied widely in its different components. The median length of postoperative hospital stay was 6 days. Some 3% of patients were readmitted to hospital after discharge; some 7% required repeat surgery during their initial hospitalisation or after readmission. The most common complications were surgical (24%), followed by septic (11%) or other medical complications (10%). Three patients (1%) died during follow-up. Some 31% of patients suffered symptoms that delayed their discharge, the most common being vomiting or nausea (12%), dyspnoea (7%) and fever (5%). CONCLUSION: The following of this enhanced recovery program posed no risk to patients in terms of morbidity, mortality and shortened the length of their hospital stay. Overall compliance to protocol was 65%. The following of this program was of benefit to patients and reduces costs by shortening the length of hospital stay. The implantation of such programmes is therefore highly recommended.

La acreditación y dedicación en Coloproctología se asocian a buenos cuidados perioperatorios / Accreditation and dedication in Coloproctology is associated with good perioperative care

El objetivo de este estudio es analizar las relaciones de determinados cuidados perioperatorios en cirugía colorrectal (CCR) con datos epidemiológicos de cirujanos efectuando un agrupamiento particional para buscar asociaciones relevantes. Métodos Se emplearon datos de una encuesta sobre cuidados perioperatorios en CCR a miembros de las asociaciones coloproctológicas españolas, analizando respuestas relacionadas con preparación cólica (PMC), sonda nasogástrica (SNG), drenajes (D) y alimentación precoz (AP), sobre las que existe evidencia científica (EC) que muestra innecesarias las primeras e importante la última. Aplicamos una variante de Particle Swarm Optimization (PSO), para agrupar conglomerados de datos optimizando variables con criterios de agrupación estadística. Resultados Se analizaron 130 encuestas hallando 2 grupos claros que incluían respectivamente al 21,5 y 78,5% de la muestra. El 68% de cirujanos del grupo A eran European Board in Coloproctology, frente a ninguno del B y los del primero desarrollaban 80% de actividad coloproctológica frente al 60% del resto. A preguntas sobre PMC, SNG, D y AP respondieron homogéneamente siguiendo la EC los del grupo A, mientras los otros lo hicieron de modo disperso y sin seguirla. Edad, puesto de trabajo o rango académico no fueron relevantes en el agrupamiento. Conclusiones El algoritmo evolutivo se ha mostrado capaz de identificar grupos según el empleo de cuidados perioperatorios en CCR. La acreditación y dedicación se han asociado a comportamientos basados en la EC (AU)

Complex data analysis methods require optimisation techniques such as evolutionary algorithms in order to generate reliable results. The objective of this study is to analyse the relationships of particular perioperative care in colorectal surgery (CRS) with surgeon epidemiological data, performing partition grouping to look for significant relationships. Methods Data were used from a survey of members of Spanish coloproctology associations on perioperative care in colorectal surgery, and analysing the responses associated with mechanical bowel preparation (MBP), nasogastric intubation (NGI), drainages (D), and early feeding (EF), over the existing scientific evidence (SE) which shows that the first ones are unnecessary and the importance of the last one. We applied a variant of particle swarm optimization (PSO), to group data conglomerates, optimising variables with statistical grouping criteria. Results A total of 130 surveys were analysed, finding 2 clear groups which included 21.5% and 78.5% of the sample, respectively. Sixty eight per cent of the surgeons in Group A belonged to the European Board in Coloproctology, compared to none in Group B, and the former performed 80% of the coloproctology activity, compared to 60% of the rest. A responded homogeneously to questions on MBP, NGI, D and EF, those of group A following the SE, while the others did it randomly and without following it. Age, work position or academic range were not significant in the grouping. Conclusions The evolutionary algorithm was shown to be able to identify groups according to the use of perioperative care in CRS. Accreditation and dedication was associated with behaviour based on the SE (AU)

[Accreditation and dedication in coloproctology is associated with good perioperative care]. / La acreditación y dedicación en coloproctología se asocian a buenos cuidados perioperatorios.

UNLABELLED: Complex data analysis methods require optimisation techniques such as evolutionary algorithms in order to generate reliable results. The objective of this study is to analyse the relationships of particular perioperative care in colorectal surgery (CRS) with surgeon epidemiological data, performing partition grouping to look for significant relationships. METHODS: Data were used from a survey of members of Spanish coloproctology associations on perioperative care in colorectal surgery, and analysing the responses associated with mechanical bowel preparation (MBP), nasogastric intubation (NGI), drainages (D), and early feeding (EF), over the existing scientific evidence (SE) which shows that the first ones are unnecessary and the importance of the last one. We applied a variant of particle swarm optimization (PSO), to group data conglomerates, optimising variables with statistical grouping criteria. RESULTS: A total of 130 surveys were analysed, finding 2 clear groups which included 21.5% and 78.5% of the sample, respectively. Sixty eight per cent of the surgeons in Group A belonged to the European Board in Coloproctology, compared to none in Group B, and the former performed 80% of the coloproctology activity, compared to 60% of the rest. A responded homogeneously to questions on MBP, NGI, D and EF, those of group A following the SE, while the others did it randomly and without following it. Age, work position or academic range were not significant in the grouping. CONCLUSIONS: The evolutionary algorithm was shown to be able to identify groups according to the use of perioperative care in CRS. Accreditation and dedication was associated with behaviour based on the SE.

Tratamiento local de la fisura anal crónica con diltiazem vs. nitroglicerina. Estudio comparativo / Local treatment of a chronic anal fissure with diltiazem vs. nitroglycerin. A comparative study

Objetivo Investigar el valor de la utilización de fármacos relajantes de la musculatura lisa y analizar los resultados de la utilización tópica de diltiazem 2% como alternativa a la nitroglicerina 0,2% en el tratamiento de la fisura anal crónica (FAC).Métodos Revisión de las FAC contenidas en una base de datos de fisuras anales con recogida prospectiva, incluyendo 145 pacientes tratados con medidas estándar en 2 periodos de tiempo consecutivos. Durante el primer periodo, se asignaron alternativamente a no recibir más tratamiento (Grupo EST) o a tratarse con nitroglicerina local (Grupo NTG). En un segundo periodo, todos fueron tratados con diltiazem local (Grupo DTZ). Se analizan los resultados después de un mes de tratamiento y las recidivas. Resultados Inicialmente hubo diferencias significativas en las tasas de mejoría (45% EST, 62,5% NTG y 80% DTZ; p<0,01), pero no en la curación (27% EST, 40% NTG y 39% DTZ) y el tratamiento fue completado por 124 pacientes (85,5%). Ocurrieron más efectos adversos y más abandonos en el grupo NTG. En el seguimiento posterior, durante una mediana de 2 años, hubo un 25% de recidivas y casi todas respondieron al tratamiento médico reiterado. Conclusiones Aunque los fármacos relajantes de la musculatura lisa no consiguen más curaciones que las medidas tradicionales en las FAC, brindan más alivio sintomático, ofreciendo una oportunidad para evitar la cirugía. El diltiazem local carece de efectos secundarios y es mejor aceptado que la nitroglicerina. Las recidivas son frecuentes, pero responden bien al tratamiento médico repetido (AU)

Aim To assess the value of using smooth muscle relaxants drugs and assess the results of the topical use of 2% diltiazem as an alternative to 0.2% nitroglycerin in the treatment of chronic anal fissure (CAF).Methods Review of the CAF contained in a prospectively collected database of anal fissures including one hundred forty-five patients diagnosed with CAF and treated with standard measures (ST) in two consecutive periods. During the first period they were allocated alternatively to not receive further treatment (ST group) or to be treated with nitroglycerin ointment (NTG group). In the second period all were treated with local diltiazem (DTZ group). One hundred forty-five patients entered the study and 124 completed it. Results Initially there were significant differences in improvement rates (45% ST, 62.5% NTG and 80% DTZ, p<0.01), but not in the cure rates (27% ST, 40% NTG and 39% DTZ) and the treatment was completed by 124 patients (85.5%). There were more side effects and more dropouts in the NTG group. In the subsequent follow-up for a median period of 25 months there were 25% recurrences and almost all responded to repeated medical treatment. Conclusions Smooth muscle relaxant drugs do not achieve a higher cure rate than the traditional measures used in CAF, but offer more symptomatic relief, providing an opportunity to avoid surgery. Topical diltiazem does not have the side effects of the nitroglycerin and is better accepted by patients (AU)

Autoevaluación de una vía clínica para mejora del proceso quirúrgico carcinoma de recto / Self-evaluation of a clinical pathway to improve the results of rectal cancer

Objetivo Analizar si la autoevaluación de una vía clínica mejora los resultados del tratamiento del cáncer de recto (CR).Pacientes y método Pacientes intervenidos de CR divididos en 3 grupos según modificaciones bianuales de una vía clínica analizando diversos indicadores. Resultados Ciento sesenta y seis pacientes: grupo A: 2002–2003, n=50; B: 2004–2005, n=53 y C: 2006–2007, n=63; sin diferencias en edad, sexo o comorbilidad. El estudio preoperatorio mejoró con la introducción de TC toracoabdominopélvico: un 76% en el grupo C frente a un 6% del A (p<0,001). Todos los tumores del grupo C fueron estadificados mediante RM, ECO rectal o ambas, frente a un 84% del A (p<0,001). La tasa de amputaciones de recto pasó del 42% en el grupo A, al 17% en el C (p=0,007). Un 48% de cirujanos del grupo A frente al 94% en el C (p<0,001) tenían dedicación específica a la coloproctología. La media de adenopatías analizadas fue: grupo A: 6,2±4,5 frente a 13±6,5 en el C (p<0,001) y se informó del margen circunferencial en un 24% del grupo A frente al 76% en el C (p<0,001). Parámetros como la transfusión perioperatoria de hemoderivados, ingreso en UCI, uso de sonda nasogástrica, tolerancia precoz o analgesia epidural también mejoraron progresivamente. La mortalidad operatoria descendió de forma no significativa hasta el 4,7% y las dehiscencias anastomóticas del 24% al 9,5%, reduciéndose la estancia postoperatoria de 15–11 días (p=0,029).Conclusiones Se han mejorado múltiples indicadores de forma significativa en un período relativamente corto al efectuar autoevaluaciones del proceso (AU)

Objectives To analyse whether the self-evaluation of a clinical pathway improves the results of rectal cancer (RC) treatment. Patients and method Patients operated on for RC were divided into 3 groups according to biannual modifications of a clinical pathway analysing several indicators.Results166 patients: Group A: 2002–3 n=50, B: 2004–5 n=53 and C: 2006–7 n=63, without any differences in age, gender or comorbidity. Preoperative study improved with the introduction of CT scan: 76% in Group C vs. 6% in Group A (P<0.001). All Group C tumours were staged using MR, rectal ultrasound or both, compared to 84% in Group A (P<0.001). The rate of abdominal-perineal resections was reduced from 42% (Group A) to 17% (Group C); (P=0.007) and about 48% of surgeons in Group A vs. 94% in the C had a specific activity in coloproctology (P<0.001). The average lymph node count was: Group A=6.2±4.5 vs. 13±6.5 in the C and circumferential margin analysis was reported in 24% of Group A vs. 76% in Group C (P<0.001). Parameters such as perioperative blood transfusion, ICU admission, use of nasogastric tube, early feeding or epidural analgesia also improved progressively. Operative mortality decreased non-significantly to 4.7% and anastomotic leaks from 24% to 9.5% with a reduction in postoperative stay from 15 to 11 days during the period analysed (P=0.029).Conclusions Several indicators have significantly improved in a relatively short period of time due to self-evaluations of the process (AU)

[Local treatment of a chronic anal fissure with diltiazem vs. nitroglycerin. A comparative study]. / Tratamiento local de la fisura anal crónica con diltiazem vs. nitroglicerina. Estudio comparativo.

AIM: To assess the value of using smooth muscle relaxants drugs and assess the results of the topical use of 2% diltiazem as an alternative to 0.2% nitroglycerin in the treatment of chronic anal fissure (CAF). METHODS: Review of the CAF contained in a prospectively collected database of anal fissures including one hundred forty-five patients diagnosed with CAF and treated with standard measures (ST) in two consecutive periods. During the first period they were allocated alternatively to not receive further treatment (ST group) or to be treated with nitroglycerin ointment (NTG group). In the second period all were treated with local diltiazem (DTZ group). One hundred forty-five patients entered the study and 124 completed it. RESULTS: Initially there were significant differences in improvement rates (45% ST, 62.5% NTG and 80% DTZ, p<0.01), but not in the cure rates (27% ST, 40% NTG and 39% DTZ) and the treatment was completed by 124 patients (85.5%). There were more side effects and more dropouts in the NTG group. In the subsequent follow-up for a median period of 25 months there were 25% recurrences and almost all responded to repeated medical treatment. CONCLUSIONS: Smooth muscle relaxant drugs do not achieve a higher cure rate than the traditional measures used in CAF, but offer more symptomatic relief, providing an opportunity to avoid surgery. Topical diltiazem does not have the side effects of the nitroglycerin and is better accepted by patients.

[Self-evaluation of a clinical pathway to improve the results of rectal cancer]. / Autoevaluación de una vía clínica para mejora del proceso quirúrgico carcinoma de recto.

OBJECTIVES: To analyse whether the self-evaluation of a clinical pathway improves the results of rectal cancer (RC) treatment. PATIENTS AND METHOD: Patients operated on for RC were divided into 3 groups according to biannual modifications of a clinical pathway analysing several indicators. RESULTS: 166 patients: Group A: 2002-3 n=50, B: 2004-5 n=53 and C: 2006-7 n=63, without any differences in age, gender or comorbidity. Preoperative study improved with the introduction of CT scan: 76% in Group C vs. 6% in Group A (P<0.001). All Group C tumours were staged using MR, rectal ultrasound or both, compared to 84% in Group A (P<0.001). The rate of abdominal-perineal resections was reduced from 42% (Group A) to 17% (Group C); (P=0.007) and about 48% of surgeons in Group A vs. 94% in the C had a specific activity in coloproctology (P<0.001). The average lymph node count was: Group A=6.2+/-4.5 vs. 13+/-6.5 in the C and circumferential margin analysis was reported in 24% of Group A vs. 76% in Group C (P<0.001). Parameters such as perioperative blood transfusion, ICU admission, use of nasogastric tube, early feeding or epidural analgesia also improved progressively. Operative mortality decreased non-significantly to 4.7% and anastomotic leaks from 24% to 9.5% with a reduction in postoperative stay from 15 to 11 days during the period analysed (P=0.029). CONCLUSIONS: Several indicators have significantly improved in a relatively short period of time due to self-evaluations of the process.

Changes in anorectal morphologic and functional parameters after fistula-in-ano surgery.

PURPOSE: This study aimed to analyze changes in anal continence and morphologic and functional anorectal variables after fistula-in-ano surgery in a patient series with a high rate of complex fistulas. METHODS: One hundred twenty patients with a mean age of 46.9 (standard deviation, 12.8) years were prospectively analyzed by evaluating anal continence, results of endoanal ultrasound examination and anorectal manometry, and pudendal nerve terminal motor latency before and after fistula-in-ano surgery. RESULTS: Forty-three patients (35.8%) were referred for recurrent fistulas; fistulas in and 70 (58.3%) were considered complex. Preoperatively, 17 patients (14.2%) presented with impaired continence. At follow-up, 59 patients (49.2%) had some degree of incontinence (P < 0.001). The techniques that most affected continence were rectal advancement flap and fistulotomy. Endoanal ultrasound examination showed that the number of patients with internal anal sphincter defects increased from 37 (30.8%) to 78 (74.3%) after surgery (P < 0.001); those with external anal sphincter defects increased from 17 (15.9%) to 34 (32.4%) (P < 0.001). Techniques most associated with increases in internal anal sphincter defects were fistulotomy (P < 0.003) and rectal advancement flap (P < 0.004). Anal manometry showed significant decreases in maximal resting pressure and maximum squeeze pressure in patients with previous incontinence (P < 0.001), and in those with internal anal sphincter defects (P < 0.001). Fistulotomy decreased both resting pressure (P < 0.004) and squeeze pressure (P < 0.007), whereas rectal advancement flap significantly reduced only resting pressure. Pudendal nerve latency did not differentiate continent and incontinent patients, and showed no postoperative change. CONCLUSIONS: Anal continence is significantly affected after fistula-in-ano surgery, mainly because of sphincteric lesions that affect anal canal pressures and that can be imaged with endoanal ultrasound. It is important to preoperatively recognize sphincter defects to allow adequate surgical treatment.

Tumores presacros. Análisis de nuestra experiencia en 20 casos tratados quirúrgicamente / Presacral tumors. Analysis of 20 surgically treated patients

Introducción Los tumores presacros son una enfermedad infrecuente y poco conocida. Presentamos nuestra experiencia en su tratamiento quirúrgico. Métodos Análisis de una serie (1995–2008).Resultados Estudiamos a 20 pacientes (14 mujeres y 6 varones), media de edad de 46 (29–71) años. Los pacientes con tumores benignos tenían una media ± desviación estándar de edad (43,5±10,2 años) menor que los que presentaban tumores malignos (62±10,7; p=0,002). La mediana de duración de los síntomas fue de 1 año (2 meses–50 años). El primer síntoma fue supuración, masa palpable o estreñimiento en 10 casos; dolor abdominal en 4, lumbalgia en 4 y hallazgo casual en 3. El abordaje quirúrgico fue perineal en 9 (45%) casos, abdominal en 8 (40%) y combinado en 3 (15%). Hubo 15 (75%) tumores benignos; los más frecuentes, los teratomas, con 5 casos. Otros 5 fueron malignos: 2 cordomas, 1 teratoma quístico maligno, 1 cistoadenocarcinoma mucinoso y 1 linfoma. La media de estancia hospitalaria fue 6,6±5 días. Hubo complicaciones posquirúrgicas en 5 (20%) casos. Tras una media de seguimiento de 3,5±4 años, fallecieron 2 pacientes (teratoma maligno y cistoadenocarcinoma) por comorbilidad y recidiva inextirpable, respectivamente, y ha recidivado uno benigno (schwannoma); los demás están libres de enfermedad. Conclusiones El tratamiento quirúrgico realizado por un grupo de cirujanos experimentado en cirugía pelviana-perineal, puede obtener buenos resultados con pocas complicaciones, a excepción de algunos tumores malignos, según la infiltración de estructuras vecinas y su tipo histológico (AU)

Introduction Presacral tumors are a rare and little known pathology. We present our experience in its surgical treatment. Methods Analysis of a series (1995–2008).Results20 patients (14 women and 6 men), average age 46 (29–71) years. Patients with benign tumors were younger (43.5±10.2) years that those who had malignant tumors (62±10.7; p=0.002). The median duration of symptoms was 1 year (2 month–50 years). The first symptom was suppuration, palpable mass or constipation in 10 cases or constipation, abdominal pain in 4, back pain in 4 and a casual finding in 3. The surgical approach was perineal in 9 (45%), abdominal in 8 (40%) and combined in 3 (15%) cases. Fifteen (75%) tumors were benign, with teratomas being the most frequent (5 cases). Another 5 were malignant: 2 chordomas, 1 malignant cystic teratoma, 1 malignant mucinous cystadenocarcinoma and 1 lymphoma. Mean postoperative stay was 6.6±5 days. There were post-surgical complications in 5 (20%) patients. After an average follow-up of 3.5±4 years, 2 patients died (malignant teratoma and cystadenocarcinoma, respectively) due to morbidity and to a non-resectable recurrence, and a benign schwannoma has recurred, the rest being free of disease. Conclusions Surgical treatment by a group of surgeons experienced in perineal and pelvic surgery can obtain good results with few complications, with the exception of some malignant tumors, depending on the infiltration of adjacent structures and their histological type (AU)