Evaluación de factores de riesgo asociados a dehiscencia anastomótica en cirugía colorrectal: análisis multivariado de 748 pacientes / Evaluation of the risk factors associated with anastomotic dehiscence in colorectal surgery: multivariate analysis of 748 pacients

INTRODUCCIÓN: La dehiscencia anastomótica (DA) es una complicación severa en cirugía colorrectal con una incidencia que oscila entre 2 y 19%. La literatura internacional muestra numerosos estudios sobre la identificación de factores de riesgo (FR), mientras que en la nacional existen solo dos series que analizan esta complicación. OBJETIVO: Realizar una caracterización descriptiva de resultados institucionales y establecer la tasa de DA, sus factores de riesgo asociados y la mortalidad. MATERIALES Y MÉTODO: Serie de casos no concurrente, cuya muestra son pacientes consecutivos intervenidos de patología colorrectal con anastomosis primaria con o sin ostoma derivativo entre los años 2004 y 2016. Se realiza modelo de regresión logística univariable y multivariable. RESULTADOS: Se obtuvieron 748 pacientes, 50,5% mujeres, media de edad fue 56,2. Las indicaciones quirúrgicas más frecuentes fueron cáncer colorrectal en 381 (50,9%) pacientes y enfermedad diverticular en 163 (21,8%). La DA fue de 5,6% (42/748) y la mortalidad fue de 2% (15/748), siendo de 1% para los electivos (7/681). En el análisis univariado encontramos que los FR que tuvieron significancia estadística fueron la albúmina (p < 0,001), altura anastomosis (p < 0,001), transfusión (p < 0,001), localización (colon derecho > izquierdo) (p = 0,011), mientras que en el análisis multivariado fueron la albúmina (p = 0,002) con un OR 3,64 (IC 95% 1,58-8,35) y transfusión (p = 0,015) con un OR 7,15 (IC 95% 1,46-34,91). CONCLUSIÓN: Nuestra serie es la más grande reportada en Chile, con resultados similares a estudios internacionales y nacionales. Establecemos que la hipoalbuminemia y la presencia de transfusiones intraoperatorias se asocian a alta tasa de DA.

INTRODUCTION: Anastomotic leakage (AL) is a severe complication in colorectal surgery, its incidence ranges from 2 to 19%. In international literature, we found numerous studies on the identification of risk factors (RF), while in the national there are only two series that analyze this complication. AIM: Perform a descriptive characterization of institutional results and establish the AL rate, its associated risk factors and mortality. MATERIALS AND METHOD: Non-concurrent series of cases, whose sample is consecutive patients operated for colorectal pathology with primary anastomosis with or without a derivative ostoma between 2004 and 2016. Univariate and multivariable logistic regression model was performed. RESULTS: There were 748 patients, 50.5% women, mean age was 56.2. The most frequent surgical indications were colorectal cancer in 381 (50.9%) patients and diverticular disease in 163 (21.8%). The AL was 5.6% (42/748) and the mortality was 2% (15/748), being 1% for the electives (7/681). In the univariate analysis, we found that the RF that had statistical significance were albumin (p < 0.001), anastomosis height (p < 0.001), transfusion (p < 0.001), location (right colon > left) (p = 0.011), while that in the multivariate analysis were albumin (p = 0.002) with an OR 3.64 (IC 95% 1.58-8.35) and transfusion (p = 0.015) with an OR 7.15 (IC 95% 1.46-34.91). CONLUSION: Our series is the largest reported in Chile, with similar results to international and national studies. We establish that hypoalbuminemia and the presence of intraoperative transfusions are associated with a high rate of AL.

Aplicabilidad del Colon Leakage Score como predictor de filtración anastomótica en cirugía de cáncer colorrectal / Applicability of the Colon Leakage Score as an anastomotic leakage predictor in colorectal cancer surgery

Introducción: La filtración anastomótica (FA) en cirugía colorrectal aumenta la morbimortalidad. La identificación de factores de riesgo y la creación de un modelo predictivo ayudaría en la decisión de crear un ostoma desfuncionalizante, hecho que, actualmente, recae en el criterio del cirujano. Dekker creó el Colon Leakage Score (CLS) estableciendo criterios objetivos. Objetivo: Establecer el CLS en pacientes intervenidos por cáncer de colon izquierdo y recto en Clínica INDISA, estableciendo valores de corte locales, su sensibilidad y especificidad. Pacientes y Método: Corresponde a un estudio de pruebas diagnósticas, cuya intervención es la aplicación del CLS comparándolo con la presencia de filtración anastomótica (gold standard), definida por criterios clínicos y radiológicos. Se utilizó análisis de curvas ROC, índice de Youden y regresión logística. Resultados: De 180 pacientes, hubo FA en 12 (6,6%). La media de CLS en quienes hubo FA fue de 11,5 y en quienes no hubo FA de 6,9 (p = 0,0001). El área bajo la curva para predicción de FA con el CLS fue de 0,829 (IC 95% 0,69-0,96), con un valor de corte de 11, sensibilidad de 67% y especificidad de 89%. En el análisis de regresión logística, el OR para la predicción de FA utilizando el CLS fue de 1,48 (IC 95% 1,22-1,79 p < 0,001). Conclusión: El CLS es una herramienta que permite predecir el riesgo de FA en pacientes intervenidos por cáncer de colon izquierdo y recto. Ante un valor mayor o igual a 11 se debería crear un ostoma protector, generando un cambio en la práctica clínica.

Introduction: Anastomotic filtration increases morbidity and mortality in colorrectal surgery. Identification of risk factors and creation of a predictive model would help the decision of creating a defunctionalizing ostoma, that currently is taken by the surgeon. Dekker created de Colon Leakege Score (CLS) with objective criteria. Objective: Establish CLS in patients that underwent left colon and rectum surgery with cancer diagnosis in Clinica INDISA, define the local cutting value, it's specificity and sensibility. Patients and Methods: Corresponds to a diagnostic test's study, that intervention is CLS application, comparing with the presence of anastomotic filtration (gold standard), defined by clinical and radiologic criteria. For the analysis, ROC curves, Youden's index and logistic regression. Results: From 180 patients, anastomotic filtration was present in 12 (6.6%). Average CLS score in patients with anastomotic filtration was 11.5 and in those without anastomotic filtration was 6.9 (p = 0.0001). Area under the curve for anastomotic filtration prediction using CLS was 0.829 (CI 95% 0.69-0.96) with a cutting value of 11, 67% of sensibility and 89% of specificity. Logistic regression analysis, OR for anastomotic filtration prediction using CLS was 1.48 (CI 95% 1.22-1.79 p < 0.001). Conclusion: CLS is a tool that permits predicting anastomotic filtration risk in patients that underwent left colon and rectum surgery. With a CLS value equal or more than 11, we should create a protective ostoma, generating a clinical practice local change.

Anal fistula: results of surgical treatment in a consecutive series of patients

OBJECTIVES: To evaluate the results of surgical treatment of patients with anal fistulas in a consecutive series of patients. METHODS: A retrospective analytical study of a consecutive series of cases prospectively collected. The sample comprised 210 patients who underwent surgery; demographic data, signs and symptoms, intraoperative classification of the fistulas and healing time were analyzed. RESULTS: The median age was 38 years and 69.0% of the patients were male. The most frequent symptom was perianal orifice with purulent drainage. The fistulas were classified as transsphincteric in 60.9% and the most used operative treatment was the marsupialization of fistulotomy, in 84.2% of cases. Complete healing occurred in all patients between 2 and 16 weeks. One hundred and seventy-eight patients, 84.8% of the patients who underwent surgery, were evaluated at least one year after surgery and recurrence occurred in 6.4% of cases. CONCLUSIONS: There was male prevalence (2.2/1), and most fistulas were transsphincteric. The marsupialization of fistulotomy was the most used operative treatment, and it presented acceptable low rates of morbidity and recurrence of 6.4%. (AU)

OBJETIVOS: Avaliar os resultados do tratamento cirúrgico de pacientes portadores de fístulas anais em uma série consecutiva de pacientes. MÉTODOS: Estudo analítico, retrospectivo, de uma série consecutiva de casos que foram coletados de forma prospectiva. A casuística englobou 210 pacientes operados, tendo sido analisados os dados demográficos, os sinais e sintomas, a classificação transoperatória das fístulas e o tempo até a cicatrização completa. RESULTADOS: A mediana de idade foi de 38 anos e 69,0% dos pacientes eram homens. O sintoma mais frequente foi a drenagem de secreção purulenta por orifício perianal. As fístulas foram classificadas como transesfincterianas em 60,9%, e o tratamento operatório mais empregado foi a fistulotomia com marsupialização do trajeto fistuloso, em 84,2% dos casos. A cicatrização completa ocorreu em todos os pacientes entre 2 e 16 semanas. Cento e setenta e oito pacientes, 84,8% dos pacientes operados, foram avaliados com, pelo menos, um ano de pós-operatório e a recidiva ocorreu em 6,4% dos casos. CONCLUSÕES: Houve prevalência do gênero masculino (2,2/1) com a maioria das fístulas transesfincterianas. A fistulotomia com marsupialização foi o tratamento operatório mais empregado e apresentou baixos índices de morbidade, com recidiva de 6,4%. (AU)

Surgical-site infection risk in oncologic digestive surgery

Surgical-site infection (SSI) is the most prevalent type of hospital infection in surgical patients and is associated with an increase in hospital stay, costs and morbidity/lethality. The knowledge of the main risk factors for this type of infection is important for the establishment of prevention measures regarding modifiable risks factors. The objective of the preset study was to assess the occurrence of SSI and study the risk factors in oncologic surgeries of the digestive system at Hospital de Câncer in Barretos, São Paulo, Brazil. Individuals undergoing oncologic surgeries of the digestive system in the period of 08/01/2007 to 08/10/2008 were prospectively followed for 30 days after surgery. Possible risk factors related to the patient and to the surgical procedure were also studied. A total of 210 surgeries were analyzed, with a global SSI incidence of 23.8 percent. The following variables were independently associated with SSI: time and type of surgery, radiotherapy before surgery and surgeon's years of experience. The risk factors found in this study have been described by other authors and are not amenable to intervention for SSI prevention. Further studies are recommended with the objective of investigating interventions that could reduce the risk for SSI in this type of surgery.

Abdominoperineal resection does not decrease quality of life in patients with low rectal cancer

PURPOSE: Issues related to body image and a permanent stoma after abdominoperineal resection may decrease quality of life in rectal cancer patients. However, specific problems associated with a low anastomosis may similarly affect quality of life for patients undergoing low anterior resection. The aim of this study was to compare quality of life of low rectal cancer patients after undergoing abdominoperineal resection versus low anterior resection. METHODS: Demographics, tumor and treatment characteristics, and prospectively collected preoperative quality-of-life data for patients undergoing low anterior resection or abdominoperineal resection for low rectal cancer between 1995 and 2009 were compared. Quality of life collected at specific time intervals was compared for the two groups, adjusting for age, body mass index, use of chemoradiation, and 30 days postoperative complications. The short-form-36 questionnaire was used to determine quality of life. RESULTS: The query returned 153 patients (abdominoperineal resection = 68, low anterior resection = 85) with a median follow-up of 24 (3-64) mo. The after abdominoperineal resection group had a higher mean age (63 + 12 vs. 54 + 12, p < 0.001) and more American Society of Anesthesiologists classification 3/4 patients (65 percent vs. 43 percent, p = 0.03) than low anterior resection. Other demographics, tumor stage, use of chemoradiation, overall postoperative complication rates, and quality-of-life follow-up time were not statistically different in both groups. Patients undergoing abdominoperineal resection had a lower baseline short-form-36 mental component score than those undergoing low anterior resection. However, 6 mo after surgery this difference was no longer statistically significant and essentially disappeared at 36 mo after surgery. CONCLUSION: Patients undergoing abdominoperineal resection for low rectal cancer have a similar long-term quality of life as those undergoing low anterior resection. These findings can help clinicians to better counsel patients with low rectal cancer who are being considered for abdominoperineal resection.

Etiology and pathogenesis of bloodstream infections associated with the use of long-term central vascular catheter (CVC) in patients who undergone gastrointestinal surgery

CVC is the main factor of risk of bloodstream infections. This study purpose was determining both etiology and pathogenesis of these infections in 80 patients who undergone gastrointestinal surgery and who worn long lasting CVC, in the institution HC-UFU. Cultures were made in nostril, skin of the insertion site, tip and catheter hub, in addition to hemoculture in those suspects of sepsis. The colonization incidence rate of the catheter tip was 12.5/ 1,000 catheter days and the CVC associate infection rate was 3.1/1,000 catheter days. Frequencies of skin, hub and catheter tip colonization were 13.8 percent, 8.9 percent and 13.3 percent, respectively. Coagulase-negative Staphylococci were the most found microorganisms in nostril (74 percent), skin (45.4 percent) and hub (75 percent) and Gram-negative bacilli (50 percent), followed by S. aureus (25 percent) the most common ones in catheter tip. Approximately 51 percent of patients received antibiotics and most of them (53.7 percent) had therapeutic purpose. The frequency of patients with clinical sepsis was 27.5 percent. Three cases of bacteremia associated with the use of CVC were detected (3.8 percent), with S. aureus in two of them and K. pneumoniae in the third one. There was not seen any association of skin and hub colonization with their presence in the catheter tip and in the blood of these patients, but S. aureus was recovered from nostril of those with sepsis by this pathogenic agent. A greater concern is suggested over preventive measures and control of these primary and secondary bloodstream, as well as catheter tip colonization.

Hemorroidectomía cerrada: análisis de los resultados / Closed Hemorroidectomía: analysis of the results

Antecedentes: Se ha postulado que la hemorroidectomía cerrada puede provocar menos dolor y causar menos complicaciones. Objetivo: Evaluar una serie prospectiva de hemorroidectomías con cierre mucoso-cutáneo primario. Lugar de aplicación: Instituto Dupuytren de Buenos Aires. Diseño: Registro prospectivo de datos. Población: Entre enero de 1998 y diciembre de 2002, se operaron en tiempo electivo 271 pacientes por hemorroides de 3º y 4º grado. Método: Se evaluaron las complicaciones inmediatas y alejadas en la hemorroidectomía con técnica cerrada. Resultados: Se registraron complicaciones postoperatorias inmediatas en el 5,36%. Entre ellas se hallaron retención urinaria en el 2,95%, dolor intenso en 1,85%, hemorragia profusa en 0,37% y absceso en 0,37%. La primera evacuación ocurrió dentro de las 48 horas en el 76% de los operados. En la evolución postoperatoria la cicatrización completa se comprobó en el 84% de los pacientes a los 16 días; con 45% de dehiscencia parcial de la sutura en el control a los 7 días. En el seguimiento alejado se pudieron evaluar 211 enfermeros (78%), encontrándose solamente disminución del calibre del conducto anal y sin manifestación clínica en 54 de ellos (24%). Conclusiones: La hemorroidectomía cerrada es una técnica adecuada dado que las complicaciones fueron escasas y de relative importancia ya que no pusieron en riesgo ni prolongaron la evolución. El seguimiento alejado no mostró complicaciones. La exterminación institucional puede efectuarse durante el mismo día de la operación si se establecen formas de comunicación con el equipo quirúrgico.