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1.
Dis Colon Rectum ; 2022 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-35348529

RESUMO

BACKGROUND: In the past few years, positive circumferential resection margin has been found to be an indicator of advanced disease with high risk of distant recurrence rather than of local recurrence. OBJECTIVE: The objective was to analyze the prognostic impact of circumferential resection margin on local recurrence, distant recurrence, and survival rates in patients with rectal cancer. DESIGN: This was a multicenter, propensity score-matched analysis 2:1 comparing positive and negative circumferential resection margin. SETTINGS: The study was conducted at 5 high-volume centers in Spain. PATIENTS: Patients who underwent total mesorectal excision with a curative intent for middle-low rectal cancer between 2006 and 2014 were included. Clinical and histological characteristics were used for matching. MAIN OUTCOME MEASURES: The main outcomes were local recurrence, distant recurrence, overall survival, and disease-free survival. RESULTS: The unmatched initial cohort consisted of 1599 patients; 4.9% had a positive circumferential resection margin. After matching, 234 patients were included (156 with negative circumferential margin and 78 with positive circumferential margin). The median follow-up period was 52.5 months (22.0-69.5). Local recurrence was significantly higher in patients with positive circumferential margin (33.3% vs 11.5%; HR 3.2; 95% CI: 1.83-5.43; p < 0.001). Distant recurrence was similar in both groups (46.2% vs 42.3%; HR 1.09; 95% CI: 0.78-1.90; p = 0.651). There were no statistically significant differences in 5-year overall survival (48.6% vs 43.6%; HR 1.09; 95% CI: 0.92-1.78; p = 0.14). Disease-free survival was lower in patients with positive circumferential margin (36.1% vs 52.3%; HR 1.5; 95% CI: 1.05-2.06; p = 0.026). LIMITATIONS: This study was limited by its retrospective design. The different neoadjuvant treatment options were not been included in the propensity score. CONCLUSIONS: Positive circumferential resection margin is associated with higher local recurrence rate and worse disease-free survival in comparison with negative circumferential resection margin. However, positive circumferential resection margin was not a prognostic indicator of distant recurrence and overall survival. See Video Abstract at http://links.lww.com/DCR/B950.

2.
Dis Colon Rectum ; 2022 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-35239526

RESUMO

BACKGROUND: Both transanal hemorrhoidal dearterialization and vessel sealing device hemorrhoidectomy are safe and well tolerated for grade III-IV hemorrhoid treatment. The first is associated with a shorter need of postoperative analgesia than vessel sealing device hemorrhoidectomy. Whether one of them is superior regarding long-term results remains unclear. OBJECTIVE: The objective was to compare long-term results after transanal hemorrhoidal dearterialization and vessel sealing device hemorrhoidectomy. DESIGN: A multicenter randomized clinical trial was conducted. SETTING: This study was conducted at 6 centers. PATIENTS: Patients aged ≥18 years with grade III-IV hemorrhoids were included in the study. INTERVENTIONS: Patients were randomly assigned to transanal hemorrhoidal dearterialization (n=39) or vessel sealing device hemorrhoidectomy (n = 41). MAIN OUTCOME MEASURES: The primary outcome was hemorrhoid symptom recurrence assessed by a specific questionnaire 2 years postoperatively. Secondary outcomes included long-term complications, reoperations, fecal continence, patient's satisfaction, and quality of life. RESULTS: Five of the 80 patients included in the study were lost to follow-up. Thirty-six patients randomized to transanal hemorrhoidal dearterialization and 39 randomized to vessel sealing device hemorrhoidectomy were included in the long-term analysis. The differences between mean baseline and mean 2-year score in the two groups were similar (-11.0, SD 3.8 vs -12.5, SD 3.6; p = 0.080). Three patients in the transanal hemorrhoidal dearterialization group underwent supplementary procedures for hemorrhoid symptoms, compared with none in the vessel sealing device hemorrhoidectomy group (p = 0.106). Four patients in the vessel sealing hemorrhoidectomy group and none in the transanal hemorrhoidal dearterialization group experienced chronic opened wound (p = 0.116). No differences were found in terms fecal continence (p = 0.657), patient's satisfaction (p = 0.483) and quality of life. LIMITATIONS: No stratification for hemorrhoid grade and power calculation based on the main outcome trial but not on the end-point of this long-term study. CONCLUSIONS: Transanal hemorrhoidal dearterialization with mucopexy is associated with similar hemorrhoid symptom recurrence than vessel sealing device hemorrhoidectomy at two years. See Video Abstract at http://links.lww.com/DCR/B933. TRIAL REGISTRATION: clinicaltrials.gov (NCT02654249).

3.
Surgery ; 172(1): 74-82, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35168815

RESUMO

BACKGROUND: Oncological outcomes of self-expanding metallic stent used as a bridge to surgery in potential curative patients with left-sided colonic cancer obstruction remain unclear. The aim of this study was to investigate perioperative and mid-term oncological outcomes of 2 of the currently most commonly performed treatments in left-sided colonic cancer obstruction. METHODS: This is a retrospective multicenter study including patients with left-sided colonic cancer obstruction treated with curative intent between 2013 and 2017. The presence of metastasis at diagnosis was an exclusion criterion. The primary outcome was to evaluate the noninferiority, in terms of overall survival, of bridge to surgery strategy compared with emergency colonic resection. The secondary outcomes were perioperative morbimortality, disease free survival, local recurrence, and distant recurrence. RESULTS: A total of 564 patients were included, 320 in the emergency colonic resection group and 244 in the bridge to surgery group. Twenty-seven patients of the bridge-to-surgery group needed urgent operation. Postoperative morbidity rates were statistically higher in the emergency colonic resection group (odds ratio [95% confidence interval] 0.37 [0.24-0.55], P < .001). There was no difference in 90-day mortality between groups (odds ratio [95% confidence interval] 0.85 [0.36-1.99], P = .702). The median follow-up was 3.80 years (2.29-4.92). The results show the noninferiority of bridge to surgery versus emergency colonic resection in terms of overall survival (hazard ratio [95% confidence interval) 0.78 [0.56-1.07], P = .127). There were no differences in disease free survival, distant recurrence, and local recurrence rates between bridge to surgery and emergency colonic resection groups. CONCLUSION: Self-expanding metallic stent as bridge to surgery might not lead to a negative impact on the long-term prognosis of the tumor compared with emergency colonic resection in expert hands and selected patients.


Assuntos
Neoplasias do Colo , Neoplasias Colorretais , Obstrução Intestinal , Neoplasias do Colo/complicações , Neoplasias do Colo/patologia , Neoplasias do Colo/cirurgia , Neoplasias Colorretais/cirurgia , Intervalo Livre de Doença , Humanos , Obstrução Intestinal/complicações , Obstrução Intestinal/cirurgia , Estudos Retrospectivos , Stents , Resultado do Tratamento
5.
Ann Surg ; 275(2): 271-280, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-34417367

RESUMO

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.


Assuntos
Colectomia/métodos , Mesocolo/cirurgia , Neoplasias do Colo Sigmoide/cirurgia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Método Simples-Cego , Resultado do Tratamento
6.
Surg Endosc ; 36(1): 196-205, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-33439344

RESUMO

BACKGROUND: Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings. METHODS: Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017). RESULTS: One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection. CONCLUSION: CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.


Assuntos
Pólipos do Colo , Laparoscopia , Idoso , Estudos de Coortes , Colectomia/métodos , Pólipos do Colo/diagnóstico , Colonoscopia/métodos , Feminino , Humanos , Laparoscopia/métodos , Estudos Retrospectivos
8.
ANZ J Surg ; 91(1-2): E25-E31, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32255271

RESUMO

BACKGROUND: Stage 2 colonic cancer comprises a heterogeneous group of patients with a spectrum of disease, from invasion of the sub-serosa to tumour perforation into visceral peritoneum/adjacent organs. This study evaluates the post-operative outcomes and prognostic factors of patients with both emergency and elective presentations of stage 2 colonic cancer treated with curative intent. METHODS: Retrospective analysis of a prospectively maintained database of adult patients (emergency and elective) who underwent curative surgery for stage 2 colonic cancer in a single tertiary referral centre between 2007 and 2016 was conducted. Multivariate analysis was performed to identify prognostic factors. Measured variables included demographics, complications, histology, disease-free survival and overall survival (OS). RESULTS: A total of 428 patients with stage 2 colonic cancer received curative surgical resection, and negative resection margins were achieved in all cases: T3 group (stage 2A): 316 (73.8%); T4a group (stage 2B): 78 patients (18.2%); and T4b group (stage 2C): 34 (8%). There were 187 (45.7%) post-operative complications, 32 (7.5%) anastomotic leaks and eight (1.9%) 30-day mortalities. Eighty patients (19.3%) died during the follow-up. During the follow-up period, 45 patients developed recurrence (all distant). Multivariate analysis identified age >70 years, American Society of Anesthesiologists grades III-IV and male gender as factors associated with poor OS, while recurrence was higher in those aged over 70 years and with stages 2B-2C disease. CONCLUSION: Surgical morbidity in patients with stage 2 colonic cancer who have undergone curative surgery is high. Older and more co-morbid patients have poorer OS. Stages 2B and 2C colon cancer patients have worse prognosis than those with stage 2A regarding recurrence. Future larger data sets are required to determine the role of transmural spread as a prognostic factor.


Assuntos
Neoplasias do Colo , Recidiva Local de Neoplasia , Adulto , Idoso , Estudos de Coortes , Neoplasias do Colo/patologia , Neoplasias do Colo/cirurgia , Seguimentos , Humanos , Masculino , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Prognóstico , Estudos Retrospectivos
10.
Cancers (Basel) ; 12(11)2020 Nov 18.
Artigo em Inglês | MEDLINE | ID: mdl-33218006

RESUMO

BACKGROUND: Colorectal (CRC) and endometrial cancer (EC) are the most common types of cancer in Lynch syndrome (LS). Risk reducing surgeries (RRS) might impact cancer incidence and mortality. Our objectives were to evaluate cumulative incidences of CRC, gynecological cancer and all-cause mortality after RRS in LS individuals. METHODS: Retrospective analysis of 976 LS carriers from a single-institution registry. Primary endpoints were cumulative incidence at 75 years of cancer (metachronous CRC in 425 individuals; EC and ovarian cancer (OC) in 531 individuals) and all-cause mortality cumulative incidence, comparing extended (ES) vs. segmental surgery (SS) in the CRC cohort and risk reducing gynecological surgery (RRGS) vs. surveillance in the gynecological cohort. RESULTS: Cumulative incidence at 75 years of metachronous CRC was 12.5% vs. 44.7% (p = 0.04) and all-cause mortality cumulative incidence was 38.6% vs. 55.3% (p = 0.31), for ES and SS, respectively. Cumulative, incidence at 75 years was 11.2% vs. 46.3% for EC (p = 0.001) and 0% vs. 12.7% for OC (p N/A) and all-cause mortality cumulative incidence was 0% vs. 52.7% (p N/A), for RRGS vs. surveillance, respectively. CONCLUSIONS: RRS in LS reduces the incidence of metachronous CRC and gynecological neoplasms, also indicating a reduction in all-cause mortality cumulative incidence in females undergoing RRGS.

11.
JAMA Surg ; 155(8): e201625, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32492131

RESUMO

Importance: Two-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis seems to provide benefits in terms of postoperative morbidity compared with standard hand-sewn coloanal anastomosis associated with diverting ileostomy and further ileostomy reversal in patients operated on for low rectal cancer. Objective: To compare 30-day postoperative and 1-year follow-up results of Turnbull-Cutait pull-through hand-sewn coloanal anastomosis and standard hand-sewn coloanal anastomosis after ultralow rectal resection for rectal cancer. Design, Setting, and Participants: Multicenter randomized clinical trial. Neither patients nor surgeons were blinded for technique. Patients were recruited in 3 centers, Bellvitge University Hospital and Valle d'Hebron University Hospital in Spain and Instituto Nazionale Tumori Fondazione G. Pascale-Istituto di Ricovero e Cura a Carattere Scientifico in Italy. Patients undergoing ultralow anterior rectal resection needing hand-sewn coloanal anastomosis were randomly assigned to 2-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis or standard hand-sewn coloanal anastomosis associated with diverting ileostomy. Data were analyzed between June 2012 and October 2018. Interventions: All patients underwent ultralow anterior resection. Patients assigned to the 2-stage Turnbull-Cutait pull-through group underwent exteriorization of a segment of left colon through the anal canal and, after 6 to 10 days, the exteriorized colon was resected and a delayed hand-sewn coloanal anastomosis was performed. For patients assigned to standard coloanal anastomosis, the hand-sewn coloanal anastomosis was performed with diverting ileostomy at first operation. Closure of the ileostomy was planned after 6 to 8 months. Main Outcomes and Measures: Primary outcome was 30-day postoperative morbidity. For the standard hand-sewn coloanal anastomosis with diverting ileostomy group, overall postoperative morbidity includes 30-day postoperative complications of the ileostomy closure. Results: Ninety-two white patients, 72 men and 20 women, with a median age of 62 years, were randomized and included in the analysis. Forty-six patients received standard hand-sewn coloanal anastomosis with diverting ileostomy and 46 received the 2-stage pull-through hand-sewn coloanal anastomosis. Seven patients (15.2%) in the standard hand-sewn coloanal anastomosis group did not undergo reversal ileostomy, and 1 patient (2.2%) in the 2-stage pull-through hand-sewn coloanal anastomosis group did not undergo delayed coloanal anastomosis. The 30-day overall composite postoperative complications rate was similar between the 2 groups (34.8% in 2-stage pull-through hand-sewn coloanal anastomosis group vs 45.7% in standard hand-sewn coloanal anastomosis group; P = .40), with a difference of -10.9 (95% CI, -29.5 to 8.9). Conclusions and Relevance: The 2-stage pull-through hand-sewn coloanal anastomosis after ultralow anterior resection for low rectal cancer is safe and does not increase the postoperative morbidity rate compared with standard coloanal anastomosis with covering ileostomy followed by ileostomy closure. Trial Registration: ClinicalTrials.gov Identifier: NCT01766661.


Assuntos
Canal Anal/cirurgia , Colo/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Idoso , Anastomose Cirúrgica/métodos , Feminino , Humanos , Ileostomia , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento
12.
Lancet Gastroenterol Hepatol ; 5(8): 729-738, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32325012

RESUMO

BACKGROUND: Previous studies have found that mechanical bowel preparation with oral antibiotics can reduce the incidence of surgical-site infections, but no randomised controlled trial has assessed oral antibiotics alone without mechanical bowel preparation. The aim of this study was to determine whether prophylaxis with oral antibiotics the day before elective colon surgery affects the incidence of postoperative surgical-site infections. METHODS: In this multicentre, pragmatic, randomised controlled trial (ORALEV), patients undergoing colon surgery were recruited from five major hospitals in Spain and 47 colorectal surgeons at these hospitals participated. Patients were eligible for inclusion if they were diagnosed with neoplasia or diverticular disease and if a partial colon resection or total colectomy was indicated. Participants were randomly assigned (1:1) using online randomisation tables to either administration of oral antibiotics the day before surgery (experimental group) or no administration of oral antibiotics before surgery (control group). For the experimental group, ciprofloxacin 750 mg was given every 12 h (two doses at 1200 h and 0000 h) and metronidazole 250 mg every 8 h (three doses at 1200 h, 1800 h, and 0000 h) the day before surgery. All patients were given intravenous cefuroxime 1·5 g and metronidazole 1 g at the time of anaesthetic induction. The primary outcome was incidence of surgical-site infections. Patients were followed up for 1 month after surgery and all postsurgical complications were registered. This study was registered with EudraCT, 2014-002345-21, and ClinicalTrials.gov, NCT02505581, and is closed to accrual. FINDINGS: Between May 2, 2015, and April 15, 2017, we assessed 582 patients for eligibility, of whom 565 were eligible and randomly assigned to receive either no oral antibiotics (n=282) or oral antibiotics (n=282) before surgery. 13 participants in the control group and 16 in the experimental group were subsequently excluded; 269 participants in the control group and 267 in the experimental group received their assigned intervention. The incidence of surgical-site infections in the control group (30 [11%] of 269) was significantly higher than in the experimental group (13 [5%] of 267; χ2 test p=0·013). Oral antibiotics were associated with a significant reduction in the risk of surgical-site infections compared with no oral antibiotics (odds ratio 0·41, 95% CI 0·20-0·80; p=0·008). More complications (including surgical-site infections) were observed in the control group than in the experimental group (76 [28%] vs 51 [19%]; p=0·017), although there was no difference in severity as assessed by Clavien-Dindo score. No differences were noted between groups in terms of local complications, surgical complications, or medical complications that were not related to septic complications. INTERPRETATION: The administration of oral antibiotics as prophylaxis the day before colon surgery significantly reduces the incidence of surgical-site infections without mechanical bowel preparation and should be routinely adopted before elective colon surgery. FUNDING: Fundación Asociación Española de Coloproctología.


Assuntos
Antibacterianos/uso terapêutico , Ciprofloxacina/uso terapêutico , Colo/cirurgia , Metronidazol/uso terapêutico , Cuidados Pré-Operatórios/normas , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Intravenosa , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/administração & dosagem , Ciprofloxacina/administração & dosagem , Colectomia/efeitos adversos , Colectomia/métodos , Colo/patologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Humanos , Incidência , Masculino , Metronidazol/administração & dosagem , Pessoa de Meia-Idade , Método Simples-Cego , Espanha/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia
13.
Am J Surg ; 220(1): 170-177, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31759455

RESUMO

BACKGROUND: Anastomotic leak (AL) after ileocolic anastomosis influences morbidity, mortality, length of hospitalization and costs. This study analyzes risk and protective factors for AL on ileocolic anastomoses. METHODS: We retrospectively analyzed our single institution patients' series undergoing elective ileocolic anastomosis for AL between 1/2008-12/2017. AL grade A/B (antibiotic treatment and/or radiological drainage) were summarized as mild, grade C (surgical re-intervention) corresponds to severe AL. RESULTS: We included 470 patients (mean age 70.8 years, 43.2% females). Overall AL rate was 9.4% (44 patients) with 6.0% severe and 3.4% mild AL. There was no difference in AL between hand sewn and stapled anastomoses. Multivariate analysis revealed preoperative serum albumin (p = 0.004), smoking habits (p = 0.005) and perioperative blood transfusion (p = 0.038) as risk factors for AL. Suture oversewing as anastomotic reinforcement resulted as independent protective factor (p < 0.001). CONCLUSION: Poor nutritional status, smoking habits and perioperative blood transfusion are negative factors influencing on AL. Suture oversewing as anastomotic reinforcement associates with significantly less AL.


Assuntos
Fístula Anastomótica/etiologia , Colo/cirurgia , Doença de Crohn/cirurgia , Íleo/cirurgia , Medição de Risco/métodos , Deiscência da Ferida Operatória/complicações , Idoso , Fístula Anastomótica/epidemiologia , Feminino , Humanos , Masculino , Morbidade/tendências , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologia , Deiscência da Ferida Operatória/epidemiologia , Taxa de Sobrevida/tendências
14.
Tech Coloproctol ; 23(12): 1141-1161, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31728784

RESUMO

BACKGROUND: The aim of this study was to analyze the incidence, patterns and prognostic factors of recurrence in patients with complicated colon cancer who had emergency surgery within 24 h of admission. METHODS: A retrospective observational study was performed on patients with obstructing or perforated colon cancer having resection with curative intent between 1996 and 2014 at a single center. Data were obtained from a prospectively maintained database. Patients who had rectal cancer, iatrogenic endoscopic perforation, stage IV disease, palliative surgery, a colonic stent or decompressive colostomy were excluded. RESULTS: The study included 393 patients. Obstruction was observed in 320 patients (81.4%) and perforation in 73 (18.6%). Hartmann's procedure was more frequently performed by general surgeons (7.5% vs 23.3%; p = 0.023). 30-day postoperative mortality was 13.5% (53/393), including 47 (14.7%) obstructed and 6 (8.2%) perforated patients. Postoperative complications (Clavien-Dindo III-IV) occurred in 87 patients (22.1%), including 68 (21.2%) of obstructed and 19 (26.0%) of perforated patients. Anastomotic dehiscence was diagnosed in 52 of 329 (15.8%) patients with primary anastomosis and was higher in the obstructing group than in the perforated group (17.4% vs 7.6%). There was a significantly higher anastomotic dehiscence rate after procedures performed by general surgeons when compared with those performed by colorectal surgeons (10.3% vs 21.3%; p = 0.005; OR 2.81, 95% CI 1.4-5.9). With a median follow-up of 6 years, the recurrence rate was 30.1% (67.4% distant, 22.8% local, 9.8% both). Overall and cancer-related survivals were 68.7% and 77.8%, respectively. The presence of positive nodes, male gender, anastomotic dehiscence and diffuse peritonitis were independent predictors for local recurrence while type of surgeon (general) was an independent factor for distant recurrence. CONCLUSIONS: Male gender, diffuse peritonitis, positive lymph nodes, type of surgeon and postoperative anastomotic dehiscence significantly influence recurrence of colorectal cancer in this series.


Assuntos
Colo/cirurgia , Neoplasias do Colo/patologia , Neoplasias do Colo/cirurgia , Obstrução Intestinal/cirurgia , Perfuração Intestinal/cirurgia , Recidiva Local de Neoplasia/patologia , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/etiologia , Fístula Anastomótica/cirurgia , Quimioterapia Adjuvante , Colectomia/efeitos adversos , Neoplasias do Colo/complicações , Neoplasias do Colo/tratamento farmacológico , Cirurgia Colorretal/estatística & dados numéricos , Emergências , Feminino , Seguimentos , Cirurgia Geral/estatística & dados numéricos , Humanos , Obstrução Intestinal/etiologia , Perfuração Intestinal/etiologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Peritonite/etiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Taxa de Sobrevida
15.
Int J Surg ; 55: 175-181, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29857055

RESUMO

BACKGROUND: Management of left colonic perforation in emergency depends largely upon the attending surgeon. The primary endpoint of this observational, retrospective study analyses surgical technique chosen by the colorectal specialized (CS) or general surgeon (GS) and changes over time. MATERIALS AND METHODS: Interventions for left colonic perforation from 2004 to 2015 are grouped for CS or GS. Type of operation (Hartmann (HP), primary anastomosis (RPA) ±covering ileostomy (IL)), year, Peritonitis Severity Score (PSS), morbidity, mortality, anastomotic dehiscence and stoma closure were recorded. RESULTS: 190 patients were included. CS performed RPA ±â€¯IL in 83 pts (74.1%) and HP in 29 pts (25.9%) while GS performed RPA ±â€¯IL in 26 pts (33.3%) and HP in 52 pts (66.7%), (p < 0.001). CS performed over time more RPA with covering ileostomy to the detriment of HP. No differences were observed between the two surgeon-groups in terms of overall morbidity and mortality. Anastomotic dehiscence was higher among GS (20% vs 4.8%, p = 0.046). Mortality after HP overtrumped RPA (26.8% versus 11.0%, p = 0.009). Regression analysis showed that HP's probability increased 3.7 times by GS, 2.3 times by each PSS point and decreased 32.5% every forthcoming year (p < 0.001). A multinomial logistic model illustrates evolution of surgical management over time, CS leading towards extension of reconstructive techniques, subsequently adopted by GS. CONCLUSIONS: CS attempt bowel reconstruction in more patients than GS in left colonic perforation without differences in overall postoperative morbidity or mortality. CS introduced covering IL to further indicate primary anastomosis avoiding HP. GS stepwise adopted this management although results are improved by CS. These findings favor primary anastomosis with/without covering ileostomy in left colonic perforation in selected patients where PSS can be used as a tool to discriminate best candidates.


Assuntos
Colo/cirurgia , Doenças do Colo/cirurgia , Cirurgia Colorretal/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Perfuração Intestinal/cirurgia , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Cirurgia Colorretal/métodos , Feminino , Cirurgia Geral/métodos , Humanos , Ileostomia/efeitos adversos , Ileostomia/métodos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Peritonite/epidemiologia , Peritonite/etiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento
16.
Eur J Surg Oncol ; 44(7): 1031-1039, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29665980

RESUMO

BACKGROUND: The aim of this study was to analyze the quality of life (QoL), low anterior resection syndrome (LARS) and fecal incontinence after surgery for mid to low rectal cancer and its relationship with the type of surgical procedure performed. METHODS: A cross-sectional cohort survey study of 358 patients operated on for mid to low rectal cancer. Patients were included in three groups: abdominoperineal resection (APR), low mechanical colorectal anastomosis (CRA) and hand-sewn coloanal anastomosis (CAA). The QLQ-C30/CR29 questionnaires, LARS and Vaizey scores were used to study QoL and defecatory dysfunction. Multivariable analysis was used to estimate the prognostic effect of the variables on QoL and LARS scores. RESULTS: 62.6% of the patients answered the survey. The global QoL score was similar among APR, CRA and CAA. Patients' body image perception was significantly worse after APR than after CRA or CAA. LARS score was better in CRA group (p = 0.002). A major LARS was observed in 83.3% of the patients who underwent CAA and in 56.6% of the patients who underwent CRA. No relationship between surgical procedures and the global QoL score was observed. Neoadjuvant radiotherapy (p = 0.048) and CAA (p = 0.005) were associated with a major LARS. The Vaizey score was higher for CAA than for CRA (p = 0.036). CONCLUSIONS: Though CAA group presents worse LARS and higher faecal incontinence scores respect CRA patients, and APR is related with a worse body image, global QoL was similar in the three groups.


Assuntos
Anastomose Cirúrgica/métodos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Incontinência Fecal/epidemiologia , Mesentério/cirurgia , Complicações Pós-Operatórias/epidemiologia , Qualidade de Vida , Neoplasias Retais/cirurgia , Reto/cirurgia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Canal Anal , Imagem Corporal/psicologia , Estudos de Coortes , Estudos Transversais , Incontinência Fecal/fisiopatologia , Incontinência Fecal/psicologia , Feminino , Humanos , Ileostomia , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Terapia Neoadjuvante/estatística & dados numéricos , Estadiamento de Neoplasias , Tratamentos com Preservação do Órgão , Períneo/cirurgia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/psicologia , Radioterapia/estatística & dados numéricos , Neoplasias Retais/patologia , Fatores de Risco , Fatores Sexuais , Espanha , Inquéritos e Questionários , Síndrome , Adulto Jovem
17.
Cir Esp (Engl Ed) ; 96(4): 226-233, 2018 Apr.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29606350

RESUMO

INTRODUCTION: Currently, there is growing interest in analyzing the results from surgical units and the implementation of quality standards in order to identify good healthcare practices. Due to this fact, the Spanish Association of Coloproctology (AECP) has developed a unit accreditation program that contemplates basic standards. The aim of this article is to evaluate and analyze the specific quality indicators for the surgical treatment of colorectal cancer, established by the program. Data were collected from colorectal units during the accreditation process. METHODS: We analyzed prospectively collected data from elective colorectal surgeries at 18 Spanish coloproctology units during the period 2013-2017. Three main and four secondary quality indicators were considered. Colon and rectal surgeries were analyzed independently; furthermore, results were compared according to surgical approach. RESULTS: A total of 3090 patients were included in the analysis. The global anastomotic leak rate was 7.8% (6.6% colon vs 10.6% rectum), while the surgical site infection rate was 12.6% (11.4% colon vs 14.8% rectum). Overall 30-day mortality was 2.3%, and anastomotic leak-related mortality was 10.2%. There were higher surgical site infection and mortality rates in the patients operated by open approach, however there was no difference in the anastomotic leak rate when compared with minimally invasive approaches. CONCLUSIONS: The evaluation of these results has determined optimal quality indices for the units accredited in the treatment of colorectal cancer. Furthermore, it allows us to establish realistic references in our country, thereby providing a better understanding and comparison of outcomes.


Assuntos
Neoplasias Colorretais/cirurgia , Indicadores de Qualidade em Assistência à Saúde , Acreditação , Idoso , Procedimentos Cirúrgicos do Sistema Digestório/normas , Feminino , Unidades Hospitalares , Humanos , Masculino , Estudos Prospectivos , Espanha
18.
Cir. Esp. (Ed. impr.) ; 96(4): 226-233, abr. 2018. tab
Artigo em Espanhol | IBECS | ID: ibc-173188

RESUMO

INTRODUCCIÓN: Actualmente existe un creciente interés por analizar los resultados de salud en las unidades quirúrgicas, implementando estándares de calidad que permitan dilucidar buenas prácticas asistenciales. Con este motivo la Asociación Española de Coloproctología desarrolló un programa de acreditación de unidades, teniendo en cuenta unos estándares básicos. El objetivo de este artículo es evaluar y analizar los indicadores de calidad específicos del tratamiento quirúrgico del cáncer colorrectal establecidos en el programa, en varias unidades en proceso de acreditación. MÉTODOS: Se analizaron los datos recogidos de forma prospectiva de la cirugía programada colorrectal en 18 unidades de coloproctología durante los años 2013 a 2017. Se consideraron 3 indicadores de calidad principales y 4 secundarios, analizando de forma independiente la cirugía de colon y de recto. Además se compararon los resultados según el abordaje quirúrgico. RESULTADOS: Se incluyeron para el análisis un total de 3.090 pacientes. La tasa global de fuga anastomótica fue de 7,8% (6,6% colon vs 10,6% en el recto), mientras que la de infección de herida quirúrgica fue de 12,6% (11,4% colon vs 14,8% en el recto). La mortalidad global a los 30 días fue de un 2,3%, siendo la relacionada con fuga anastomótica de un 10,2%. Se evidenció una mayor incidencia de infecciones y muertes en los pacientes con abordaje abierto, pero no hubo diferencias en la tasa de dehiscencia con respecto a abordajes mínimamente invasivos. CONCLUSIONES: Los resultados de este estudio determinan índices de calidad óptimos de las unidades acreditadas en el tratamiento del cáncer colorrectal, y además nos permite establecer referencias realistas en nuestro país, que ayudarán a una mejor comparación de resultados


INTRODUCTION: Currently, there is growing interest in analyzing the results from surgical units and the implementation of quality standards in order to identify good healthcare practices. Due to this fact, the Spanish Association of Coloproctology (AECP) has developed a unit accreditation program that contemplates basic standards. The aim of this article is to evaluate and analyze the specific quality indicators for the surgical treatment of colorectal cancer, established by the program. Data were collected from colorectal units during the accreditation process. METHODS: We analyzed prospectively collected data from elective colorectal surgeries at 18 Spanish coloproctology units during the period 2013-2017. Three main and four secondary quality indicators were considered. Colon and rectal surgeries were analyzed independently; furthermore, results were compared according to surgical approach. RESULTS: A total of 3090 patients were included in the analysis. The global anastomotic leak rate was 7.8% (6.6% colon vs 10.6% rectum), while the surgical site infection rate was 12.6% (11.4% colon vs 14.8% rectum). Overall 30-day mortality was 2.3%, and anastomotic leak-related mortality was 10.2%. There were higher surgical site infection and mortality rates in the patients operated by open approach, however there was no difference in the anastomotic leak rate when compared with minimally invasive approaches. CONCLUSIONS: The evaluation of these results has determined optimal quality indices for the units accredited in the treatment of colorectal cancer. Furthermore, it allows us to establish realistic references in our country, thereby providing a better understanding and comparison of outcomes


Assuntos
Humanos , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Neoplasias Colorretais/cirurgia , Indicadores de Qualidade em Assistência à Saúde , Infecções/epidemiologia , Sociedades/organização & administração , Estudos Prospectivos , Cirurgia Colorretal/métodos , Cirurgia Colorretal/estatística & dados numéricos , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Neoplasias do Colo/cirurgia
19.
Cir. Esp. (Ed. impr.) ; 96(3): 138-148, mar. 2018. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-171861

RESUMO

INTRODUCCIÓN: La exenteración pélvica (EP) ofrece la mejor oportunidad de curación para neoplasias malignas primarias o recurrentes de órganos pélvicos localmente avanzadas con invasión de estructuras adyacentes. Los objetivos de este estudio fueron analizar los resultados de las exenteraciones pélvicas por diferentes orígenes que incluyeron resección rectal y valorar los resultados de la reconstrucción fecal y urinaria. MÉTODOS: Estudio retrospectivo de una serie de 111 exenteraciones pélvicas con resección rectal para distintos tipos de cáncer pélvico realizadas entre enero de 2000 y abril de 2014 en dos centros de referencia terciarios nacionales. RESULTADOS: Se realizaron 36 anastomosis colorrectales. Las reconstrucciones urológicas realizadas fueron 30 colostomías húmedas en asa lateral (DBWC), 14 conductos ileales de Bricker (CIB) y 2 ureterocutaneostomías. Setenta y un pacientes (64%) presentaron complicaciones postoperatorias. Seis muertes (5,4%) ocurrieron dentro de los 30 días postoperatorios. La supervivencia global a 5 años después de resección R0 fue del 62,6%; R1: 42,7%; R2: 24,2% (p = 0,018). La invasión del margen de resección se asoció con los peores índices de supervivencia global, recidiva local y recurrencia a distancia. CONCLUSIONES: Las exenteraciones pélvicas por diferentes neoplasias deben realizarse en centros de referencia y por cirujanos especializados. La anastomosis después de la exenteración pélvica supraelevadora modificada para el cáncer de ovario es segura. La DBWC puede considerarse una opción válida para la reconstrucción urológica. El factor pronóstico más importante después de la exenteración pélvica para los tumores pélvicos malignos es el estado de los márgenes quirúrgicos


INTRODUCTION: Pelvic exenteration (PE) offers the best chance of cure for locally advanced primary or recurrent pelvic organ malignancies invading adjacent organs. The aims of this study were to analyse results for any pelvic exenteration that includes rectal resection and the analysis of results of fecal and urinary reconstruction. METHOD: From January 2000 to April 2014, 111 PE with rectal resection for any pelvic cancer were analysed retrospectively at two national tertiary referral centers. RESULTS: Thirty-six colorectal anastomosis were performed. Urologic reconstructions performed were 30 double barrelled wet colostomy (DBWC), 14 Bricker ileal conduit (BIC), and 2 ureterocutaneostomies. Postoperative complications occurred in 71 patients (64%). Six deaths (5.4%) occurred within 30 postoperative days. Five-year overall survival following R0 resection was 62.6%; R1: 42.7%; R2: 24.2% (P = .018). The resection margin status was associated with overall survival, local recurrence and distant recurrence. CONCLUSION: Pelvic exenterations for any cause need to be performed in referral centers and by specialized surgeons. Anastomosis after modified supralevator pelvic exenteration for ovarian cancer, is safe. DBWC can be considered a valid option for urologic reconstruction. The most important prognostic factor after pelvic exenteration for malignant pelvic tumors is the status of surgical margins


Assuntos
Humanos , Exenteração Pélvica/métodos , Reto/cirurgia , Neoplasias Pélvicas/cirurgia , Colo/cirurgia , Estudos Retrospectivos , Anastomose Cirúrgica/métodos , Colostomia/métodos , Recidiva Local de Neoplasia/cirurgia
20.
Cir Esp (Engl Ed) ; 96(3): 138-148, 2018 Mar.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29229359

RESUMO

INTRODUCTION: Pelvic exenteration (PE) offers the best chance of cure for locally advanced primary or recurrent pelvic organ malignancies invading adjacent organs. The aims of this study were to analyse results for any pelvic exenteration that includes rectal resection and the analysis of results of fecal and urinary reconstruction. METHOD: From January 2000 to April 2014, 111 PE with rectal resection for any pelvic cancer were analysed retrospectively at two national tertiary referral centers. RESULTS: Thirty-six colorectal anastomosis were performed. Urologic reconstructions performed were 30 double barrelled wet colostomy (DBWC), 14 Bricker ileal conduit (BIC), and 2 ureterocutaneostomies. Postoperative complications occurred in 71 patients (64%). Six deaths (5.4%) occurred within 30 postoperative days. Five-year overall survival following R0 resection was 62.6%; R1: 42.7%; R2: 24.2% (P=.018). The resection margin status was associated with overall survival, local recurrence and distant recurrence. CONCLUSION: Pelvic exenterations for any cause need to be performed in referral centers and by specialized surgeons. Anastomosis after modified supralevator pelvic exenteration for ovarian cancer, is safe. DBWC can be considered a valid option for urologic reconstruction. The most important prognostic factor after pelvic exenteration for malignant pelvic tumors is the status of surgical margins.


Assuntos
Exenteração Pélvica/métodos , Neoplasias Pélvicas/cirurgia , Reto/cirurgia , Idoso , Procedimentos Cirúrgicos do Sistema Digestório , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária , Procedimentos Cirúrgicos Urológicos
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