Correction to: Quantifying the extent of fistulotomy. How much sphincter can we safely divide? A three-dimensional endosonographic study.

In the Fig. 1 of the original published version of this article the numbers were switched as well as in the text of Results section, lines 5 and 6. The revised figure and the corrected text are now presented correctly in this article.

Quantifying the extent of fistulotomy. How much sphincter can we safely divide? A three-dimensional endosonographic study.

PURPOSE: To quantify the longitudinal division of the internal anal sphincter (IAS) and external anal sphincter (EAS) after fistulotomy using three-dimensional endoanal ultrasound (3D-EAUS) and correlate the results with postoperative faecal incontinence. METHODS: A prospective, consecutive study was performed from December 2008 to October 2010. All patients underwent 3D-EAUS before and 8 weeks after surgery. Thirty-six patients with simple perianal fistula were included. Patients with an intersphincteric or low transphincteric fistula (<66% sphincter involved) without risk factors for incontinence underwent fistulotomy. The outcome measures were the longitudinal extent of division of the IAS and EAS in relation to total sphincter length and continence (Jorge and Wexner scores). RESULTS: One-year follow-up revealed a 0% recurrence rate. There was a strong correlation between preoperative 3D-EAUS measurement of fistula height with intraoperative and postoperative 3D-EAUS measurement of IAS and EAS division (p < 0.001). The relationship between the level of EAS division and faecal incontinence showed a significant difference in incontinence rates between fistulotomies limited to the lower two thirds of the EAS and those above this level. Five patients (13.9%) had worse anal continence after surgery, although this was mild in all patients (<3/20 Jorge and Wexner scale). There was no significant difference in continence scores before and after surgery (p > 0.05). CONCLUSIONS: In patients without risk factors, division of the EAS during fistulotomy limited to the lower two thirds of the EAS is associated with excellent continence and cure rates.

[Implementation of a perioperative multimodal rehabilitation protocol in elective colorectal surgery. A prospective randomised controlled study]. / Implantación de un protocolo de rehabilitación multimodal perioperatoria en cirugía colorrectal electiva. Estudio prospectivo, aleatorizado y controlado.

INTRODUCTION: Multimodal rehabilitation (MMR) consists of a combination of several methods for management of the surgical patient, designed to reduce the response to surgical stress and a more comfortable and earlier recovery. OBJECTIVE: To assess the implementation of an MMR protocol in a Colorectal Surgery Unit, and to compare the results with the traditional model, as well as assessing its efficacy as regards recovery and hospital stay. MATERIAL AND METHODS: A total of 119 patients who received elective surgery for colorectal diseases in a period during 2009-2010 were prospectively and randomly analysed. The patients were divided into 2 groups: 58 patients were assigned to the traditional group and 61 to the MMR group. The MMR group protocol consisted of, preoperative education, early feeding and mobilisation. RESULTS: Both groups were homogeneous as regards the preoperative variables evaluated, the type of disease and the procedures carried out. The nasogastric tube was kept in place for 4 (1-9) days compared to 1 day (0-2) in the MMR group, with no differences in the number of re-insertions. Significant differences were found in the introduction of a liquid diet (3 [1-5] days traditional versus 0 [0-2] MMR) (P<.001), and passing of first flatulence (3 [1-6] days traditional versus 1 [1-3] MMR) (P<.001). The MMR group had a postoperative stay of 4.15±2.18 versus 9.23±6.97 days in the traditional group (P<.001). No significant differences were found in complications or readmissions. CONCLUSIONS: MMR in colorectal surgery in the Spanish public health system is feasible and enables surgical patients to have a faster recovery without increasing complications, leading to an earlier hospital discharge.

[Evaluation of three-dimensional endoanal endosonography of perianal fistulas and correlation with surgical findings]. / Evaluación de las fístulas perianales mediante ecografía endoanal tridimensional y correlación con los hallazgos intraoperatorios.

OBJECTIVE: This study aims to assess the accuracy of three-dimensional endoanal ultrasound (3D-US), two-dimensional ultrasound (2D-US) and physical examination (PE) for the diagnosis of perianal fistulas and correlate the results with intraoperative findings. MATERIALS AND METHODS: A prospective, observational study with consecutive inclusion of patients was performed between December 2008 and August 2009. Twenty-nine patients diagnosed with a perianal fistula due to undergo surgery were included. All patients underwent PE, 2D-US and 3D-US, and the results were compared to intraoperative findings. The examinations were repeated with hydrogen peroxide instilled through the external opening. RESULTS: Internal opening (IO): no significant differences with regards to the number of IO diagnosed by PE and 2D-US or 3D-US (P>0.05). Primary tract: good concordance between 3D US and surgery (k=0.61), and this was higher than any of the other techniques used (PE: k=0.41; 2D-US: k=0.56). Secondary tracts: both 2D and 3D-US show good concordance with surgery (86%, k=0.66; 90%, k=0.73, respectively). Abscesses/cavities: The ultrasound examinations showed a moderate concordance with surgery (k=0.438, k=0.540, respectively). CONCLUSIONS: 3D-US shows a higher diagnostic accuracy than 2D-US when compared with surgery to estimate primary fistula height in transphincteric fistulas. 3D-US shows good concordance with surgery for diagnosing primary and secondary tracts and a high sensitivity and specificity for diagnosis of the IO. There was a tendency to overestimate fistula height with 2D-US as shown by the lower specificity of 2D-US for the diagnosis of high transphincteric fistulas and lower sensitivity of 2D-US for low transphincteric fistulas.

Implantación de un protocolo de rehabilitación multimodal perioperatoria en cirugía colorrectal electiva. Estudio prospectivo, aleatorizado y controlado / Implementation of a perioperative multimodal rehabilitation protocol in elective colorectal surgery. A prospective randomised controlled study

Introducción La rehabilitación multimodal (RMM) consiste en la combinación de varios métodos para el manejo del paciente quirúrgico encaminados a disminuir la respuesta al estrés quirúrgico y una recuperación más cómoda y precoz. Objetivo Valorar la implantación de un protocolo de RMM en una unidad de cirugía colorrectal y comparar los resultados con el modelo tradicional, valorando su eficacia en cuanto a recuperación y estancia. Material y métodos Se analizó prospectiva y aleatorizadamente a 119 pacientes intervenidos de forma electiva por enfermedad colorrectal entre 2009 y 2010. Se asignó a 58 pacientes al grupo tradicional y 61 al grupo RMM. La RMM consistió en educación preoperatoria, alimentación y movilización precoz. Resultados Ambos grupos eran homogéneos en cuanto a variables preoperatorias valoradas, el tipo de enfermedad y los procedimientos realizados. La sonda nasogástrica se mantuvo en el grupo tradicional 4 (1-9) días frente a 1 (0-2) días en el grupo RMM, sin diferencias en la reinserción de la sonda. Se encontraron diferencias significativas en el inicio de la dieta líquida —3 (1-5) días tradicional, frente a 0 (0-2) con RMM (p<0,001)— y expulsión de la primera ventosidad —3 (1-6) días tradicional, frente a 1 (1-3) con RMM (p<0,001)—. Los pacientes en el grupo RMM tuvieron una estancia postoperatoria de 4,15±2,18, frente a 9,23±6,97 días del grupo tradicional (p<0,001). No se encontraron diferencias significativas en las complicaciones o reingresos. Conclusiones La RMM en cirugía colorrectal en el sistema sanitario público español es factible y permite una más rápida recuperación de los pacientes operados sin aumentar las complicaciones, permitiendo un alta hospitalaria precoz (AU)

Introduction Multimodal rehabilitation (MMR) consists of a combination of several methods for management of the surgical patient, designed to reduce the response to surgical stress and a more comfortable and earlier recovery. Objective To assess the implementation of an MMR protocol in a Colorectal Surgery Unit, and to compare the results with the traditional model, as well as assessing its efficacy as regards recovery and hospital stay. Material and methods A total of 119 patients who received elective surgery for colorectal diseases in a period during 2009-2010 were prospectively and randomly analysed. The patients were divided into 2 groups: 58 patients were assigned to the traditional group and 61 to the MMR group. The MMR group protocol consisted of, preoperative education, early feeding and mobilisation. Results Both groups were homogeneous as regards the preoperative variables evaluated, the type of disease and the procedures carried out. The nasogastric tube was kept in place for 4 (1-9) days compared to 1 day (0-2) in the MMR group, with no differences in the number of re-insertions. Significant differences were found in the introduction of a liquid diet (3 [1-5] days traditional versus 0 [0-2] MMR) (P<.001), and passing of first flatulence (3 [1-6] days traditional versus 1 [1-3] MMR) (P<.001). The MMR group had a postoperative stay of 4.15±2.18 versus 9.23±6.97 days in the traditional group (P<.001). No significant differences were found in complications or readmissions. Conclusions MMR in colorectal surgery in the Spanish public health system is feasible and enables surgical patients to have a faster recovery without increasing complications, leading to an earlier hospital discharge (AU)

Evaluación de las fístulas perianales mediante ecografía endoanal tridimensional y correlación con los hallazgos intraoperatorios / Evaluation of three-dimensional endoanal endosonography of perianal fistulas and correlation with surgical findings

Objetivo Evaluar la fiabilidad diagnóstica de la ecografía tridimensional (ECO 3D) vs. la bidimensional (ECO 2D) y la exploración física en el diagnóstico de las fístulas perianales correlacionándolo con los hallazgos intraoperatorios. Material y método Estudio prospectivo, observacional con pacientes incluidos de forma consecutiva entre diciembre 2008 y agosto 2009. Se incluyen 29 pacientes diagnosticados de fístula perianal subsidiarios de tratamiento quirúrgico. Se realizó una exploración física, ECO 2D, ECO 3D comparándolos con los hallazgos intraoperatorios. Cuando el orificio fistuloso externo se encuentra abierto, se repiten ambas exploraciones instilando agua oxigenada. Resultados Orificio fistuloso interno: sin diferencias significativas entre la exploración física y las ecografías (p>0,05). Trayecto fistuloso primario: el grado de concordancia entre la ECO 3D y los hallazgos intraoperatorios es bueno (k=0,61), y superior al resto de exploraciones físicas (k=0,41; ECO 2D: k=0,56). Trayecto fistuloso secundario: ECO 2D y ECO 3D muestran buena concordancia con la cirugía (86%, k=0,66; 90%, k=0,73, respectivamente). Abscesos/cavidades adyacentes: las ecografías muestran una concordancia moderada con los hallazgos intraoperatorios (k=0,438, k=0,540, respectivamente).Conclusiones La ECO 3D tiene una fiabilidad diagnóstica mayor a la ECO 2D comparando con los hallazgos intraoperatorios para estimar la altura de las fístulas transesfintéricas. ECO 3D muestra buena concordancia con la cirugía en el diagnóstico de trayectos primarios y secundarios y una alta fiabilidad para el orificio fistuloso interno. Existe una tendencia a sobreestimar la altura de la fístula con ECO 2D, esto se deduce de la menor especificidad de la ECO 2D para el diagnóstico de fístulas transesfintéricas altas y la menor sensibilidad en las fístulas transesfintéricas bajas (AU)

Objective This study aims to assess the accuracy of three-dimensional endoanal ultrasound (3D-US), two-dimensional ultrasound (2D-US) and physical examination (PE) for the diagnosis of perianal fistulas and correlate the results with intraoperative findings. Materials and methods A prospective, observational study with consecutive inclusion of patients was performed between December 2008 and August 2009. Twenty-nine patients diagnosed with a perianal fistula due to undergo surgery were included. All patients underwent PE, 2D-US and 3D-US, and the results were compared to intraoperative findings. The examinations were repeated with hydrogen peroxide instilled through the external opening. Results Internal opening (IO): no significant differences with regards to the number of IO diagnosed by PE and 2D-US or 3D-US (P>0.05). Primary tract: good concordance between 3D US and surgery (k=0.61), and this was higher than any of the other techniques used (PE: k=0.41; 2D-US: k=0.56). Secondary tracts: both 2D and 3D-US show good concordance with surgery (86%, k=0.66; 90%, k=0.73, respectively). Abscesses/cavities: The ultrasound examinations showed a moderate concordance with surgery (k=0.438, k=0.540, respectively).Conclusions3D-US shows a higher diagnostic accuracy than 2D-US when compared with surgery to estimate primary fistula height in transphincteric fistulas. 3D-US shows good concordance with surgery for diagnosing primary and secondary tracts and a high sensitivity and specificity for diagnosis of the IO. There was a tendency to overestimate fistula height with 2D-US as shown by the lower specificity of 2D-US for the diagnosis of high transphincteric fistulas and lower sensitivity of 2D-US for low transphincteric fistulas (AU)