Resecciones colorrectales laparoscópicas en una comunidad rural / Laparoscopic colorectal resections in a rural community

Antecedentes: La cirugía laparoscópica colorrectal continúa en camino de convertirse en el abordaje de elección para el tratamiento de la patología colorrectal benigna y maligna. Sin embargo, su aplicabilidad aún es baja y está mayormente limitada a grandes centros urbanos. Objetivo: analizar la factibilidad de un programa de cirugía laparoscópica colorrectal en un centro de comunidad rural. Como objetivo secundario, comparar los resultados con la cirugía abierta convencional Material y métodos: se analizó una base de datos prospectiva de todos los pacientes operados de forma electiva y consecutiva entre junio de 2012 y diciembre de 2016. Se empleó un criterio de alta estandarizado. Los pacientes fueron divididos en dos grupos según la cirugía fuese laparoscópica (grupo A) o convencional (grupo B). El análisis de variables se realizó con los métodos de Chi cuadrado y T-test según corresponda. Resultados: se realizaron 129 resecciones colorrectales con una proporción de varones del 60% y una mediana de edad de 64 años. El 83% pertenecía a comunidades vecinas. Hubo un 35% de pacientes ASA I, 56% ASA II y 9% ASA III. La distancia promedio del lugar de residencia fue 75 km con una superficie de distribución de 24 000 km2. La mediana de internación fue de 4 días. La aplicabilidad de la laparoscopia fue del 74% con una tasa de conversión del 6%. Ambos grupos fueron similares en términos de sexo, IMC, diagnóstico, ASA, proporción de ASA III-IV, antecedentes clínicos y quirúrgicos, así como también distancia de su lugar de residencia. El grupo A presentó una media de edad menor que el grupo B (61 años vs. 69 años; p < 0,01). No se observaron diferencias en términos de tipo de cirugía y tiempo operatorio. La morbilidad posoperatoria fue 18% y la tasa de readmisión fue del 4%, sin diferencias entre grupos. Conclusiones: la cirugía laparoscópica colorrectal puede ser realizada en un centro rural con bajo índice de readmisión y complicaciones y resultados comparables a los de la cirugía abierta convencional.

Of benign tumors and colorectal cancer. However, its use is low and limited to large urban centers. Objective: The aim of this study was to analyze the feasibility of a laparoscopic colorectal surgery program in a rural community center. The secondary outcome was to compare these results with those of conventional open surgery. Material and methods: We analyzed a prospective data base of all the patients undergoing scheduled and consecutive surgery between June 2012 and December 2016. A standardized discharge criterion was used. The patients were divided into two groups: laparoscopic surgery (group A) and conventional surgery (group B). The variables were analyzed with the chi-square test or Student's t test, as applicable. Results: A total of 129 colorectal resections were performed; median age was 64 years, 60% were men and 83% belonged to neighbor communities. The ASA physical status classification system was grade 1 in 35% of the patients, grade 2 in 56% and grade 3 in 9%. The average distance between patients' place of residence was of 75 km comprising an area of 24,000 km2. Patients were hospitalized for a median of 4 days. The applicability of laparoscopy was 74% with a conversion rate of 6%. There were no significant differences in sex, BMI, diagnosis, ASA grade, proportion of ASA grade 3-4 patients, clinical history, previous surgeries and distance from the place of residency. Compared to group B, patients in group A were younger (61.6 years vs. 69 years; p < 0.01). There were no differences in terms of type of surgery and surgery duration. Postoperative morbidity was 18% and the readmission rate was 4%, with no differences between the groups. Conclusions: Laparoscopic colorectal surgery can be performed in a rural center with low readmission rate and complications; these results are similar to those of conventional open surgery.

Reconstrucción perineal con colgajo miocutáneo vertical de recto anterior del abdomen luego de amputación abdomino perineal extraelevador. Una alternativa factible para el cirujano colorrectal / Perineal reconstruction with vertical myocutaneous flap of the anterior rectus abdominis after extra-elevating perineal abdominal amputation. A feasible alternative for the colorectal surgeon

Las complicaciones perienales luego de la amputación abdominoperineal son frecuentes y clínicamente relevantes en términos de estadía hospitalaria, costos, calidad de vida y los resultados oncológicos. La utilización creciente de radioterapia pre operatoria y la incorporación gradual a la técnica extra-elevador, ha llevado a un aumento en la morbilidad perineal. Es por elloque la búsqueda de una técnica confiable y con buenos resultados para el cierre perineal se hace necesaria. Se han publicado muchas series que describen diferentes técnicas de cierre del defecto perineal, pero faltan estudios clínicos de alta calidad que indiquen cuál es la mejor opción. Cuando la proctectomía resulta en un amplio defecto perineal, el colgajo vertical del recto del abdomen parece ser la mejor opción. Presentamos dos casos de tumores anorectales localmente avanzados en los que se realizó una amputación abdominoperineal extraelevador con posterior reconstrucción perineal con colgajo de recto anterior y, a su vez, describimos la técnica quirúrgica. (AU)

Perineal complications after abdominoperineal amputation are frequent and clinically relevant in terms of hospital stay, costs, quality of life and oncological results. The growing utilization of pre-operative radiotherapy and the gradual incorporation to the extra-elevator technique, has leaded to an increase in perineal morbidity. That is why the search for a reliable technique with good postoerative outcomes for the perineal closure is necessary. Many series describing different closure techniques of the perineal defect have been published, but high quality clinical studies have to indicate which the best option is. When the proctectomy results in a wide perineal defect, the vertical rectus abdominis flap seems to be the best option. We presented two cases of locally advanced anorectal tumors in which an extraelevatory abdominoperineal amputation was carried out with posterior perineal reconstruction with vertical rectus abdomins flap and we described the surgical technique. (AU)

Postoperative complications at a university hospital: is there a difference between patients operated by supervised residents vs. trained surgeons?

BACKGROUND: The surgical residency system ensures supervised practices to progressively move from simple to complex surgical procedures. However, ethical dilemmas could arise if patient outcome is negatively affected by this learning methodology. The objective of this study was to evaluate whether the supervised participation of residents acting as operating surgeons influences the postoperative complication rate. METHODS: Surgeries performed between June 2010 and May 2011 were analyzed. The Dindo-Clavien classification was used to stratify the severity of complications. The complication rates of patients operated by supervised residents (SR) and trained surgeons (TS) were compared considering potential confounders related to the patient and surgical procedure. RESULTS: A total of 3697 consecutive surgical procedures were included. Age, gender, and American Society of Anesthesiologists (ASA) risk were not different between patients of both groups. The overall complication rate was 10.8 %, without significant differences between the SR and TS groups (9.8 vs. 11.4 %; P = 0.14). The severity of complications was similar in both groups. Multivariate analysis adjusted for confounders confirmed that resident participation was not an independent risk factor for complications (odds ratio 1.52; 95 % CI 0.79-2.92; P = 0.20). CONCLUSIONS: Supervised resident participation, as operating surgeon, does not negatively impact postoperative patient outcome. Residency training may therefore be considered as an ethical and safe learning methodology whenever implemented in the framework of an academic teaching hospital.

Laparoscopic colorectal resections: a simple predictor model and a stratification risk for conversion to open surgery.

BACKGROUND: The advantages associated with the laparoscopic approach are lost when conversion is required. Available predictive models have failed to show external validation. Body surface area is a recently described risk factor not included in these models. OBJECTIVE: The aim of this study was to develop a clinical rule including body surface area for predicting conversion in patients undergoing elective laparoscopic colorectal surgery. DESIGN: This was a prospective cohort study. SETTING: This study was conducted at a single large tertiary care institution. PATIENTS: Nine hundred sixteen patients (mean age, 63.9; range, 14-91 years; 53.2% female) who underwent surgery between January 2004 and August 2011 were identified from a prospective database. MAIN OUTCOME MEASURES: Conversion rate was analyzed related to age, sex, obesity, disease location (colon vs rectum), type of disease (neoplastic vs nonneoplastic), history of previous surgery, and body surface area. A predictive model for conversion was developed with the use of logistic regression to identify independently associated variables, and a simple clinical prediction rule was derived. Internal validation of the model was performed by using bootstrapping. RESULTS: The conversion rate was 9.9% (91/916). Rectal disease, large patient size, and male sex were independently associated with higher odds of conversion (OR, 2.28 95%CI, 1.47-3.46]), 1.88 [1.1-3.44], and 1.87 [1.04-3.24]). The prediction rule identified 3 risk groups: low risk (women and nonlarge males), average risk (large males with colon disease), and high risk (large males with rectal disease). Conversion rates among these groups were 5.7%, 11.3%, and 27.8% (p < 0.001). Compared with the low-risk group, ORs for average- and high-risk groups were 2.17 (1.30-3.62, p = 0.004) and 6.38 (3.57-11.4, p < 0.0001). LIMITATIONS: The study was limited by the lack of external validation. CONCLUSION: This predictive model, including body surface area, stratifies patients with different conversion risks and may help to inform patients, to select cases in the early learning curve, and to evaluate the standard of care. However, this prediction rule needs to be externally validated in other samples (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A137).