Population-based screening improves histopathological prognostic factors in colorectal cancer.

INTRODUCTION: Diagnosis of colorectal cancer (CRC) based on clinical symptoms is usually established in its advanced stages. One strategy for reducing mortality is the early detection and removal of preneoplastic and initial neoplastic lesions, even before the first symptoms appear, by means of population-based screening campaigns. The aim of the present study is to determine whether CRC diagnosed via a screening campaign has more favourable histopathological prognostic factors than when diagnosed in the symptomatic phase. MATERIAL AND METHODS: The prospective study of all the patients undergoing programmed CRC surgery at the JM Morales Meseguer Hospital (Spain) is between 2004 and 2010. The patients were divided into two groups: one diagnosed from clinical symptoms and one through a screening campaign. The following factors were compared: tumour size; degree of tumour invasion of the wall; lymph node, perineural and lymphovascular involvement; tumour stage; and grade of differentiation. RESULTS: Compared to the symptomatic group, the screen-detected patients had smaller-sized tumours (lesions of less than 5 cm in 84 vs 69.55%, p < 0.001), a lower degree of colorectal wall invasion (T0-1 in 36 vs 9.02%, p < 0.001), less lymph node involvement (N0 in 72 vs 58.76%, p > 0.05), less vascular invasion (7.20 vs 15.22%, p = 0.79) and less perineural invasion (6.4 vs 20.70%, p < 0.001). The TNM staging in the screening group was lower than in the symptomatic group (stage 0-1 in 50.40 vs 18.58%, p < 0.001). CONCLUSIONS: CRC diagnosed through a population-based screening programme presents more favourable histopathological characteristics than that diagnosed from the appearance of symptoms.

Malignant degeneration of rectal endometriosis.

BACKGROUND: Endometriosis is a relatively common disease among women with child-bearing potential, and rare before puberty or following menopause. It consists of the presence of hormone-responsive endometrium outside the endometrial cavity. CASE REPORT: We report the case of a patient with a rectal lesion, initially approached as a primary rectal malignancy, where histopathology eventually revealed an adenocarcinoma arising from endometrial tissue in the colonic wall. DISCUSSION: Endometriosis has an estimated rated of 10-20%. Sites may be split up into two larger categories - gonadal and extragonadal. The frequency of extragonadal endometriosis in the bowel is estimated to involve 3%-37% of women with pelvic endometriosis, and most lesions are found in the sigmoid colon and rectum. The malignant transformation of endometriotic lesions is estimated between 0.3% and 1% of cases. The gold standard in the diagnosis of intestinal endometriosis is exploratory laparotomy and the pathological study of specimens. Adjuvant radiotherapy and chemotherapy, although used for some patients, have not proven effective.

[Complications and level of satisfaction after dermolipectomy and abdominoplasty post-bariatric surgery]. / Complicaciones y nivel de satisfacción tras la realización de una dermolipectomía y abdominoplastia después de efectuar una cirugía bariátrica.

BACKGROUND: Body contouring surgery is in high demand following the increase in bariatric surgery. But these types of procedures are associated with high complication rates that cause long hospital stays and have a negative effect on patient satisfaction. The purpose of this study is to identify predictors of complications in order to optimize outcomes in these patients and find a relationship between complication rate and satisfaction. MATERIAL AND METHODS: Out of a group of 175 post-bariatric patients, 72 patients underwent body contouring surgery following massive weight loss from 2003-2008. They were reviewed retrospectively for demographic data, pre- and postoperative weight status, co-morbidities and complications and reoperation rate. Patient satisfaction was evaluated. RESULTS: a) COMPLICATIONS: The overall complication rate was 45.8%. The most frequent were seromas (23.6%); infection (13.9%), bleeding (11.1%), hematoma (6.9%) (needing transfusions [6.9%]), skin necrosis (6.9%) and umbilical necrosis (4.2%). A total of 8 patients required reoperation (11.1%). b) Satisfaction rating: 1) very satisfied: 51.4%, 2) satisfied: 31.9%, 3) dissatisfied: 8.3%, 4) very dissatisfied: 8.3%. c) The presence of complications was significantly associated with patients' satisfaction, reoperation rate and longer hospital stays (P<.001). CONCLUSIONS: Post operative complications were frequent. No predictors could be found to prevent these complications and optimize patient selection and appropriate timing of surgery. Patients with complications had a significantly higher reoperation rate, longer hospital stay and more dissatisfaction. The patients' satisfaction was negatively influenced by complication occurrence and not by the aesthetic results.

Protective ileostomy: complications and mortality associated with its closure.

INTRODUCTION: diverting loop ileostomies are widely used in colorectal surgery to protect low rectal anastomoses. However, they may have various complications, among which are those associated with the subsequent stoma closure. The present study analyses our experience in a series of patients undergoing closure of loop ileostomies. METHOD: retrospective study of all the patients undergoing ileostomy closure at our hospital between 2006-2010. There were 89 patients: 56 males (63%) and 33 females (37%) with a mean age of 55 (38-71) years. The most common indication for ileostomy was protection of a low rectal anastomosis, 81 patients (91%). The waiting time until stoma closure, type and frequency of the complications, length of hospital stay and mortality rate are analysed. RESULTS: waiting time before surgery was 8 (1-25) months. Forty-one patients (45,9%) developed some type of complication, three were reoperated (3.37%) and one patient died (1.12%). The most important complications were intestinal obstruction (32.6%), diarrhoea(6%), surgical wound infection (6%), enterocutaneous fistula (4.5%), rectorrhagia (3.4%) and anastomotic leak (1.12%). The mean length of patient stay was 7.54 (2-23) days. CONCLUSIONS: protective ostomies in low rectal anastomoses have proved to be the only preventive measure for reducing the morbidity and mortality rates for anastomotic leakage. However, creation means subsequent closure, which must not be considered a minor procedure but an operation with possibly significant complications, including death, as has been shown in publications on the subject and in our own series.

[Improvement in the quality of life of faecal incontinent patients after sacral root stimulation treatment]. / Mejora de la calidad de vida en los pacientes con incontinencia fecal tratados con estimulación de raíces sacras.

INTRODUCTION: Faecal incontinence (FI) is a highly prevalent disorder that severely affects the health related quality of life (HRQOL) of the patients who suffer from it. Neuromodulation is a minimally invasive treatment that has demonstrated its efficacy in the treatment of FI symptoms over the past 10 years. The aim of this study is to check whether there is an improvement in the quality of life, using EuroQuol (EQ-5D), in patients with faecal incontinence treated with sacral root neuromodulation. METHODOLOGY: An observational study with prospective recording of quality of life data, before and after, using the EQ-5D on a series of patients diagnosed with moderate to severe FI with a complete or repaired sphincter who had a definitive MEDTRONIC Interstim(®) 3023 implant after a subchronic stimulation phase with a good response. RESULTS: The initial mean number of leaks was 3.1±1, and the final was 0.5±0.6. The mean number of escapes per week decreased to 2.6 escapes (CI 95%: 2.1-3.1) after the definitive implant of the sacral root stimulator (P<.001). The mean baseline health status score was 55.9±13, and after neuromodulation it was 63.1±13. Thus, the visual analogue scale score increased by 7.1 points (CI 95%: 0.37-14) after the definitive implant of the sacral root stimulator (P<.05). In the HRQOL variables studied with the EQ-5D questionnaire, we found an improvement with neuromodulation in the mobility and the presence of anxiety and/or depression variables. On the other hand we found an improvement with the neurostimulator implant, which was not significant, in personal care, performing daily activities and the presence of pain and/or discomfort. The current health was better in 11 patients (57.9%), the same in 7 (36.8%) and worse in 1 (5.3%). CONCLUSIONS: Neuromodulation is a therapy that has demonstrated a significant improvement in HRQOL measured with the EQ-5D.

Early diagnosis of anastomotic leakage in colorectal surgery: prospective observational study of the utility of inflammatory markers and determination of pathological levels.

Procalcitonin (PCT) and C-Reactive Protein (CRP) are acute-phase reactants that indicate the presence and severity of an infection. The aim of this study was to verify the utility of CRP and PCT as tools for early diagnosis of anastomotic leakage (AL) in patients undergoing elective colorectal surgery. A prospective observational study including 95 patients undergoing elective colorectal surgery with anastomosis, where patients were divided into two groups according to whether or not AL happened. Different variables were compared using a uni- and multivariate analyses to identify the risk factors for AL. Receiver Operating Characteristic (ROC) curves were added to establish a cut-off point for CRP and PCT. The inflammatory marker levels were analysed in other complications different from AL. AL was detected in 11 patients (14%), 7 required an emergency reoperation. The overall morbidity rate was 42.1% and the mortality was 3.2%. In the univariate study, increased CRP on days 3 and 5, male sex and intraoperative complications were significantly associated with AL. In the multivariate study, CRP on day 5 was the only factor related to AL. AUC at ROC curves showed that CRP results ≥ 15.3 mg/dL on day 3 and 9.1 mg/dL on day 5 were predictors of AL. Normal CRP and PCT values had a high negative predictive value. CRP on postoperative day 5 is a reliable marker for early detection of anastomotic leakage in colorectal surgery. Both CRP and PCT on days 3 and 5 have a high negative predictive value.Trial registration: The study has been registered at ClinicalTrials.gov. Code: NCT04632446.

[Frozen section doesn't reduce the number of reoperations for cancer after hemithyroidectomy]. / La biopsia intraoperatoria no reduce la tasa de reintervenciones por cáncer tras hemitiroidectomía.

UNLABELLED: FUNDAMENTALS AND OBJECTIVES: Frozen section (FS) constitutes a diagnostic procedure in patients following hemithyroidectomy. It is used to diagnose malignant lesions and to avoid reoperations. Our objective is to confirm this test as useless to rule out cancer. PATIENTS AND METHODS: Retrospective and comparative trial between two series of patients following hemithyroidectomy. G I: 179 patients operated in 1995-2002. In this period we performed systematic FS. Sensitivity (S), specificity (E) and predictive values (PPV, NPV) are analyzed. G II: 126 patients were operated between 2003-2008. Selective FS was performed (23 patients). Both groups are compared: hospital stay, number of FS, percentage of cancer, definitive biopsy and reoperations. RESULTS: Data analyzed in the first period: S: 48%, E: 100%, PPV: 100%, NPV: 90%, positive likelihood ratio>10, negative likelihood ratio 0.52. When both periods are compared no significant differences between reoperations are found. CONCLUSION: FS during hemithyroidectomy does not reduce reoperations for cancer.

Increased survival and decreased recurrence in colorectal cancer patients diagnosed in a screening programme.

INTRODUCTION: Population-based screening programmes for colorectal cancer (CRC) allow an early diagnosis, even before the onset of symptoms, but there are few studies and none in Spain on the influence they have on patient survival. The aim of the present study is to show that patients receiving surgery for CRC following diagnosis via a screening programme have a higher survival and disease-free survival rate than those diagnosed in the symptomatic stage. MATERIAL AND METHODS: Prospective study of all the patients undergoing programmed surgery for CRC at the JM Morales Meseguer Hospital in Murcia (Spain) between 2004 and 2010. The patients were divided into two groups: (a) those diagnosed through screening (125 cases); and (b) those diagnosed in the symptomatic stage (565 cases). Survival and disease-free survival were analysed and compared for both groups using the Mantel method. RESULTS: The screen-detected CRC patients show a higher rate of survival (86.3% versus 72.1% at 5 years, p<0.05) and a lower rate of tumour recurrence (73.4% versus 88.3% at 5 years, p<0.05). CONCLUSIONS: Population-based screening for CRC is an effective strategic measure for reducing mortality specific to this neoplasia.

Single-port transanal endoscopic microsurgery: a developing technique.

INTRODUCTION: Transanal endoscopic microsurgery is a widely used and valid technique with established indications. However, the cost of surgical anoscopes is not available in all centers. Many authors have described transanal resection of rectal tumors through a single laparoscopy port such as the SILS system. MATERIALS AND METHODS: We analyzed 5 cases of patients undergoing transanal resection with an SILS device. The clinical, surgical, and oncological data were assessed. RESULTS: The median distance to the anal margin was 7.2 cm (range, 5 to 10 cm) and median tumor size was 3 cm (range, 1 to 6 cm). Median operating time was 75 minutes (range, 60 to 120 min). A postsurgical rectorrhagia occurred in 1 of the case. Two cases were adenocarcinoma, 2 were adenomas, and the other was a mucosa without any tumor remnants. The margins were negative in all cases. CONCLUSIONS: Transanal resection of rectal tumors using the SILS technique is a feasible procedure. Longer series and prospective studies are necessary.

[Presacral tumor as a differential diagnosis of recurrent pilonidal sinus]. / Tumor presacro como diagnóstico diferencial del sinus pilonidal recidivado.

BACKGROUND: Retrorectal or presacral space is occupied during embryological stem cell development and therefore may contain a heterogeneous group of tumors. CLINICAL CASE: We report the case of a 22-year-old male with a pilonidal cyst operated due to recurrent pilonidal sinus cyst. Final diagnosis after pelvic computed tomography is large retrorectal cystic tumor and magnetic resonance diagnosis of a presacral cystic compatible wtih germ cell tumor. The tumor was removed surgically through the abdomen and diagnosis of cystic teratoma was established. CONCLUSION: Retrorectal tumors are rare lesions whose presence must be ruled out in case of recurrent sinus.

Antecedentes: durante el desarrollo embriológico, el espacio retrorrectal o presacro está ocupado por células pluripotenciales y, por tanto, puede contener un grupo heterogéneo de tumores. Caso clínico: se comunica el caso de un paciente masculino de 22 años de edad, intervenido de sinus pilonidal recidivado. Con estudios de tomografía computada de pelvis y resonancia magnética nuclear se sospechó la existencia de un tumor quístico presacro compatible con tumor germinal; la lesión se extirpó quirúrgicamente por vía abdominal y se estableció el diagnóstico definitivo de teratoma quístico. Conclusiones: los tumores retrorrectales son lesiones poco habituales que es necesario descartar en caso de sinus recidivantes.

Gastrointestinal bleeding and bowel obstruction as a presentation of Bouveret syndrome.

BACKGROUND: Bouveret syndrome is a rare entity consisting of duodenal obstruction due to a gallstone from the gallbladder. CLINICAL CASES: We present two patients with very different ages and comorbidities whose conditions were resolved in two different ways: a 41-year-old female with right upper quadrant pain and vomiting who underwent surgical correction of obstruction and fistula, and an 81-year-old female with a high bowel obstruction, only treating the obstruction without intervention of the fistula. CONCLUSIONS: It is important to include high gastrointestinal obstruction in the differential diagnosis. Diagnosis can be made either by radiological or endoscopic techniques and therapeutic options are diverse, ranging from endoscopic removal to surgery (with the resolution of obstruction and fistula in the same surgical procedure). This condition usually affects elderly patients with high comorbidities and high surgical risk; therefore, most authors recommend using the most conservative possible treatment.

Evaluation of a clinical pathway to improve colorectal cancer outcomes.

The aims of this preintervention and postintervention study were to monitor and evaluate the clinical pathway (CP) for colorectal cancer (CRC) over a 5-year period and to compare 2 groups of patients (before and after the intervention) with regard to different variables of effectiveness. Group I comprised 68 patients who underwent planned surgery between January 2002 and January 2003. Group II comprised a sample of 202 patients who underwent surgery between January 2004 and December 2008. No significant differences were found in the majority of the parameters measured: postoperative stay, compliance with antibiotic prophylaxis, compliance with the staging study, mortality, rate of infection, and reoperations. The mean length of stay (±standard deviation) for patients without complications was reduced significantly (9.2 ± 3.6 in group I versus 7.7 ± 1.7 in group II, P = .031). The CP for CRC did not achieve most of the objectives for which it was designed.

Repair of complex incisional hernias using double prosthetic repair: single-surgeon experience with 50 cases.

BACKGROUND: The treatment of complex incisional hernias is still difficult and controversial. With technologic developments we can modify and update the operative techniques described for treating complex abdominal wall hernias. METHODS: This is a prospective study of 50 patients with complex incisional hernias undergoing complex abdominal wall herniorrhaphy at a university hospital. All patients were evaluated in a multidisciplinary clinic dedicated to abdominal wall reconstruction. All patients underwent pre-operative computed tomography. Complex incisional hernias were regarded as those with multiple recurrences (>3 times), a previous mesh complicated by fistula and chronic infection, giant diffuse lumbar hernias, an associated parastomal hernia, or hernias developing after bariatric surgery. The operative technique was a double reconstruction prosthetic mesh. The type of repair as well as clinical, operative, and follow-up data were analyzed. RESULTS: Eight patients had considerable loss of tissue, 5 had trophic skin lesions, and 2 had chronic suppurative infection. The mean size of the defects was 18.2 cm. Morbidity included 5 cases of seroma, 2 neuralgias, and 2 cutaneous necroses. The mean duration of hospital stay was 5 days (range, 2-9). Complete follow-up (mean, 48 months; range, 12-108) showed no recurrent hernias. CONCLUSION: While awaiting a longer follow-up to confirm the results, we conclude that complex incisional hernias can be repaired safely and with a low morbidity and recurrence rate by means of a double prosthetic repair technique.

Degeneración maligna de endometriosis de recto / Malignant degeneration of rectal endometriosis

INTRODUCCIÓN: la endometriosis es una patología relativamente frecuente en mujeres en edad fértil y poco prevalerte en mujeres prepúberes o postmenopáusicas. CASO CLÍNICO: presentamos el caso clínico de una mujer de 57 años, con antecedentes de histerectomía y doble anexectomía por endometriosis ovárica, diagnosticada de neoplasia de recto T3N1. Se realizó neoadyuvancia preoperatoria y resección anterior baja, sin complicaciones. La anatomía patológica describía infiltración de la pared rectal por adenocarcinoma pobremente diferenciado de origen ginecológico. DISCUSIÓN: la endometriosis tiene una prevalencia estimada del 10-20% y su lugar de aparición puede ser variado, tanto gonadal como extragonadal. La frecuencia de endometriosis extragonadal de localización intestinal se estima en un 3-37% de mujeres con endometriosis pélvica, y de estas la mayoría se localizan en colon sigmoide y recto. La transformación maligna de un foco de endometriosis se estima entre el 0,3 y el 1%. El gold estándar para el diagnóstico es la resección y estudio histológico. La radioterapia y quimioterapia adyuvante todavía no ha demostrado su clara utilidad

BACKGROUND: Endometriosis is a relatively common disease among women with child-bearing potential, and rare before puberty or following menopause. It consists of the presence of hormone-responsive endometrium outside the endometrial cavity. CASE REPORT: We report the case of a patient with a rectal lesion, initially approached as a primary rectal malignancy, where histopathology eventually revealed an adenocarcinoma arising from endometrial tissue in the colonic wall. DISCUSSION: Endometriosis has an estimated rated of 10-20%. Sites may be split up into two larger categories - gonadal and extragonadal. The frequency of extragonadal endometriosis in the bowel is estimated to involve 3%-37% of women with pelvic endometriosis, and most lesions are found in the sigmoid colon and rectum. The malignant transformation of endometriotic lesions is estimated between 0.3% and 1% of cases. The gold standard in the diagnosis of intestinal endometriosis is exploratory laparotomy and the pathological study of specimens. Adjuvant radiotherapy and chemotherapy, although used for some patients, have not proven effective