Risk-adjustment models for clean and colorectal surgery surgical site infection for the Spanish health system.

OBJECTIVE: To develop risk-adjusted models for two quality indicators addressing surgical site infection (SSI) in clean and colorectal surgery, to be used for benchmarking and quality improvement in the Spanish National Health System. STUDY DESIGN: A literature review was undertaken to identify candidate adjustment variables. The candidate variables were revised by clinical experts to confirm their clinical relevance to SSI; experts also offered additional candidate variables that were not identified in the literature review. Two risk-adjustment models were developed using multiple logistic regression thus allowing calculation of the adjusted indicator rates. DATA SOURCE: The two SSI indicators, with their corresponding risk-adjustment models, were calculated from administrative databases obtained from nine public hospitals. A dataset was obtained from a 10-year period (2006-2015), and it included data from 21 571 clean surgery patients and 6325 colorectal surgery patients. ANALYSIS METHODS: Risk-adjustment regression models were constructed using Spanish National Health System data. Models were analysed so as to prevent overfitting, then tested for calibration and discrimination and finally bootstrapped. RESULTS: Ten adjustment variables were identified for clean surgery SSI, and 23 for colorectal surgery SSI. The final adjustment models showed fair calibration (Hosmer-Lemeshow: clean surgery χ2 = 6.56, P = 0.58; colorectal surgery χ2 = 6.69, P = 0.57) and discrimination (area under receiver operating characteristic [ROC] curve: clean surgery 0.72, 95% confidence interval [CI] 0.67-0.77; colorectal surgery 0.62, 95% CI 0.60-0.65). CONCLUSIONS: The proposed risk-adjustment models can be used to explain patient-based differences among healthcare providers. They can be used to adjust the two proposed SSI indicators.

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.

Surgical management of appendiceal adenocarcinoid. Case report and literature review.

Adenocarcinoid tumour of the appendix is a rare entity characterised by the presence of a double component (neuroendocrine and glandular). It originates in the neuroendocrine cells of the appendicular mucosa. A preoperative diagnosis of a primary appendiceal tumour is uncommon and more so one suggesting an adenocarcinoid pathology. Optimal treatment is debated between a simple appendectomy and a more extensive resection, which occasionally includes hysterectomy and bilateral ovariectomy. Our aim is to report this rare entity and conduct a review of the literature on the different treatment options.

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.

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.

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.

[Marjolin's ulcer. A 10 year experience in a diabetic foot unit]. / Úlcera de Marjolin: experiencia de 10 años en una unidad de pie diabético.

BACKGROUND: Marjolin's ulcer is defined as the appearance of a neoplasm within a chronic wound. The most common histological type is squamous. A total of 2 cases treated in our hospital are presented. CLINICAL CASE: Case 1. A 71 year old man who presented with redness and suppuration from the wounds he had in his right foot after an electric shock 40 years earlier. The radiology showed involvement of the 4° and 5° metatarsal. Supracondylar amputation was performed, showing a well-differentiated invasive squamous cell carcinoma. CASE 2: A 56 year old male, paraplegic for 20 years. He was treated due to an infected right heel ulcer, with partial improvement, but the ulcers persisted. Biopsy was performed, reporting as epidermoid carcinoma. Infracondylar amputation was performed. The diagnosis was a well-differentiated squamous cell carcinoma infiltrating the dermis. CONCLUSION: The prevalence of Marjolin's ulcer is 1.3-2.2% of all ulcers. Diagnosis is difficult, so biopsy is recommended on any suspicious lesion or ulcer that has received conservative treatment for one month without improvement, although this time limit is not clear. The treatment is the surgery. Local excision with a margin of an inch is enough. If the ulcer is extensive, amputation is required. Survival is estimated between 66 and 80% at 2 years, with recurrence rates of 23%. Unfavourable factors are poor tumour differentiation and metástasis, appearing in 20% of cases.

Chylous Fistula following Axillary Lymphadenectomy: Benefit of Octreotide Treatment.

Chyle leak following axillary lymph node clearance is a rare yet important complication. The treatment of postoperative chyle fistula still remains unclear. Conservative management is the first line of treatment. It includes axillary drains on continuous suction, pressure dressings, bed rest, and nutritional modifications. The use of somatostatin analogue is well documented as a treatment for chylous fistulas after neck surgery. We present a case of chylous fistula after axillary surgery resolved with the use of octreotide.

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.

[Low-cost laparoscopic training: necessary time for acquiring expertise]. / Entrenamiento laparoscópico de bajo costo: tiempo de entrenamiento necesario para adquirir habilidades laparoscópicas básicas similares a las de un experto.

BACKGROUND: Today laparoscopic approach is essential, but learning is usually expensive and very limited. Homemade and low equipment costs are required. We undertook this study to quantify how many hours of training are necessary for a surgeon without laparoscopic experience in order to acquire the abilities to carry out procedures as a staff member with laparoscopic experience. METHODS: A low-cost laparoscopic trainer was constructed. Four exercises of increasing difficulty have been developed. Five residents without laparoscopic experience and four experts developed the study. A satisfaction questionnaire was completed. Data were analyzed comparing the average times for the accomplishment of each exercise between groups. RESULTS: Data showed that the more difficult an exercise is, the more training is required. The average time needed to acquire similar skills as experts was almost 7 h of training spread over 4 months. The level of confidence for approaching a laparoscopic procedure for residents after completing the training was increased by 70%. CONCLUSION: Laparoscopic training is essential in the formation of all surgeons and a reason why this low-cost and easily accessible method could become a basic tool for learning the first steps of the laparoscopic procedure.

[Colorectal stents: efficacy and complications in our center]. / Prótesis de colon y recto: eficacia y complicaciones en nuestro centro.

BACKGROUND: in emergency surgery, colorectal mortality is very high compared with elective surgery. An alternative is placement of endoscopic stents to correct the bowel obstruction and then allow elective surgery. Moreover, it is possible to use stents in the palliative treatment of patients at high surgical risk or with unresecable tumors. The aim of this study is to evaluate the rates of technical and clinical success and complications of colorectal stent placement over the past 5 years. METHODS: retrospective study of 33 patients in which stents were placed since 2006 to 2011. Variables were analyzed: 1) the indication (palliation or "bridge to surgery"), 2) rates of technical success and clinical success, and 3) complications (perforation, migration, bleeding, and reocclusion). RESULTS: in 24 patients the prosthesis was placed as a palliative treatment (72.7%) and in 9 cases as a "bridge to surgery". The technical success rate was 87.87% and 82.14% clinical success. There were five cases of bowel perforation with high pneumoperitoneum and a case of microperforation (18.1%). Five patients had reocclusion (17.2%); there were 3 and 4 with bleeding and migration. Three patients died within 24 hours after endoscopic treatment. In 9 cases of "bridge to surgery," technical success was 100% and 77% clinical success. One patient required emergency surgery due to migration of the prosthesis and reocclusion and another colonic perforation. CONCLUSIONS: endoscopic treatment is a good option as a transitional step to elective surgery or palliative treatment. But serious complications such as perforation or reocclusion should be considered.