Accuracy of magnetic resonance enterography in the preoperative assessment of patients with Crohn's disease of the small bowel

Aim to assess the accuracy of magnetic resonance-enterography in predicting the extension, location and characteristics of the small bowel segments affected by Crohn's disease. Method This is a prospective study including a consecutive series of 38 patients with small bowel Crohn's disease who underwent surgery at a specialized colorectal unit of a tertiary hospital. Preoperative magnetic resonance enterography was performed in all patients, following a homogeneous protocol, within the three months prior to surgery. A thorough exploration of the small bowel was performed during the surgical procedure, using calibration spheres, according to the discretion of the surgeon. The accuracy of mag…

Resección extendida y exenteración pélvica en el cáncer de recto del tercio inferior

Approximately 10% of all low rectal cancer needs surgical resection extended to other pelvic structures. Indication for extended resection should be given according to a precise systemic and local preoperative staging. Magnetic Resonance Imaging is the most important instrument utilized by the Multidisciplinary Team to decide therapeutic strategy according to the surgical risk. The status of the pathological circumferential resection margin is the most important prognostic factor determining local recurrence risk and oncological outcome and for this reason it should be considered pivotal in the decision of the strategy of treatment. When extended resection is performed, the presence of an e…

Low rectal cancer: abdominoperineal resection or low Hartmann resection? A postoperative outcome analysis.

BACKGROUND In distal rectum cancers, when the sphincters are not affected and it is not possible to perform a coloanal anastomosis because of the presence of comorbidities or the advanced age of the patient, a low Hartmann resection with total mesorectal excision can be performed. Low Hartmann resection is usually considered to be a shorter procedure and to have an inferior morbidity compared with abdominoperineal resection of the rectum. OBJECTIVE This study aimed to compare the postoperative outcome of a series of patients with low rectal cancer who have undergone either low Hartmann resection or abdominoperineal resection. DESIGN This study is a retrospective analysis of data collected i…

Resultados quirúrgicos estándar tras resección oncológica de colon. Creación de un nomograma para la autoevaluación

Resumen Introduccion Existe un gran interes en los ultimos anos en identificar estandares de calidad en las distintas enfermedades, entre ellas, el cancer de colon debido a su alta prevalencia. El objetivo del presente estudio es definir unos valores estandar de calidad en los resultados de la cirugia del cancer de colon. Metodos Se han utilizado los datos del estudio prospectivo multicentrico nacional «ANACO», que incluye pacientes con cancer de colon intervenidos en 52 hospitales espanoles (2011-2012). Para el presente analisis se han excluido los centros con menos de 30 pacientes y han quedado finalmente 42 hospitales (2.975 pacientes). Se presentan los valores de 4 indicadores de calida…

Trends and outcome of neoadjuvant treatment for rectal cancer: A retrospective analysis and critical assessment of a 10-year prospective national registry on behalf of the Spanish Rectal Cancer Project

Introduction: Preoperative treatment and adequate surgery increase local control in rectal cancer. However, modalities and indications for neoadjuvant treatment may be controversial. Aim of this study was to assess the trends of preoperative treatment and outcomes in patients with rectal cancer included in the Rectal Cancer Registry of the Spanish Associations of Surgeons. Method: This is a STROBE-compliant retrospective analysis of a prospective database. All patients operated on with curative intention included in the Rectal Cancer Registry were included. Analyses were performed to compare the use of neoadjuvant/adjuvant treatment in three timeframes: I)2006–2009; II)2010–2013; III)2014–2…

Impact of perioperative transfusions and sepsis on long-term oncologic outcomes after curative colon cancer resection. A retrospective analysis of a prospective database

Objective: Intra-abdominal septic complications (IASC) affect short-term outcomes after surgery for colon cancer. Blood transfusions have been associated with worse short-term results.The role of IASC and blood transfusions on long-term oncologic results is still debated. This study aims to assess the impact of these two variables on survival after curative colon cancer resection. Patients and methods: Retrospective analysis of a prospectively maintained database of patients who underwent curative surgery for colon cancer at a university hospital, between 1993 and 2010. Cox regression was used to identify the role of IASC and transfusions (alone and combined) on local recurrence (LR), disea…

El factor cirujano y la calidad de la cirugía en el pronóstico del cáncer de recto. Implicaciones en la especialización y organización

Relationship of curative surgery on natural killer cell activity in colorectal cancer.

Aim of this study has been to evaluate natural killer (NK) activity in patients with colorectal tumors before and after curative surgery.Forty colorectal cancer patients without distant metastases were stratified according to American Joint Committee on Cancer/International Union Against Cancer staging system into three categories: Stage I (n = 12), Stage II (n = 15), and Stage III (n = 13). All of them underwent curative resection, and there were no major postoperative complications. Venous blood samples were obtained preoperatively, at surgical wound closure, and on the 1st, 7th, and 21st postoperative days. Mononuclear cells were isolated over Ficoll-Hypaque (Lymphoprep, Nycomed Pharma A…

Therapeutic effects of different doses of botulinum toxin in chronic anal fissure

PURPOSE: The aim of this study was to evaluate the clinical and manometric results of three different doses of botulinum toxin and two methods of injection for the treatment of chronic idiopathic anal fissure. METHODS: Sixty-nine patients with chronic anal fissure were included in a nonrandomized, prospective trial of intrasphincteric injection of botulinum toxin. All patients reported postdefecatory anal pain lasting more than two months. Scoring systems were developed for anal pain, bleeding, and defecatory difficulty. Maximum resting and squeeze anal pressures were determined before and one month after treatment. Twenty-three patients undergoing a 5-U injection of diluted botulinum toxin…

Preoperative chemoradiation may not always be needed for patients with T3 and T2N+ rectal cancer

BACKGROUND: Preoperative chemoradiation is becoming the standard treatment for patients with locally advanced rectal cancer. However, since the introduction of total mesorectal excision (TME), local recurrence rates have been reduced significantly, and some patients can be spared from potentially toxic over treatment. The current study was designed to assess the factors that predict recurrence in an institutional series of patients with rectal cancer who had clinical T2 lymph node-positive (cT2N+) tumors or cT3N0/N+ tumors and underwent radical surgery without receiving preoperative chemoradiation. METHODS: Between November 1997 and November 2008, the authors' multidisciplinary group preope…

Reply to Kellyet al.

Reply to Saqibet al.

The ideal lateral internal sphincterotomy: clinical and endosonographic evaluation following open and closed internal anal sphincterotomy

To evaluate the relationship between extent of internal sphincter division following open and closed sphincterotomy, as assessed by anal endosonography, with fissure persistence/recurrence and faecal incontinence.A total of 140 consecutive patients undergoing lateral internal sphincterotomy (LIS) for idiopathic chronic anal fissure were prospectively studied. Preoperative clinical assessment was performed together with a postoperative clinical and endosonographic examination. Three zones of the internal sphincter, identifiable by endosonography, were used to describe the uppermost extent of LIS. Primary end-points were fissure persistence/recurrence and faecal incontinence.A total of 140 pa…

Progress in the multidisciplinary treatment of gastrointestinal cancer and the impact on clinical practice: perioperative management of rectal cancer

Ultralow Anterior Resection for Prolapsed Giant Solitary Rectal Polyp of Peutz-Jeghers Type

Effect of Intraperitoneal Sterile Urine Injection on Abdominal Myoelectrical Activity in the Spinal Rat Model

The abdominal muscle reflex contractions in response to intraperitoneal injection of homologous sterile urine and acid, alkaline, hypo- and hyperosmolar solutions are studied in an acute spinal rat model by conventional and integrated electromyographic techniques. Intraperitoneal injection of homologous sterile urine causes a powerful and almost immediate abdominal muscle contracture of relative short duration. This response seems not to be related to urine pH or osmolarity, since only when solutions with extreme variations in these parameters are injected intraperitoneally are significant abdominal muscle contractions observed.

Tratamientos terapéutica de la fisura anal crónica

Current treatment of chronic anal fissure continues to be based on conventional conservative measures in a high percentage of cases. What is known as chemical sphincterotomy aims to achieve a temporary decrease of anal pressures that allows fissures to heal. There are various alternatives such as nitroglycerine or diltiazem ointment and botulinum toxin injections. However, because of collateral effects and recurrences in the medium term, the definitive role of these treatments remains to be elucidated. Nevertheless, chemical sphincterotomy should be the first option in patients with a high risk of incontinence. "Open" or "closed" lateral internal sphincterotomy performed in the ambulatory s…

Prognostic Heterogeneity of Endosonographic T3 Rectal Cancer

PURPOSE: This study aimed to assess the prognostic implications of uT3 rectal carcinomas according to the tumor thickness and to analyze the correlation between this ultrasound-based parameter and other prognostic factors. METHODS: Seventy-four patients with uT3(pM0) rectal tumors underwent primary surgery from 1996 to 2003. Preoperative endorectal ultrasound was used to assess uN stage, maximum tumor perimeter, and maximum tumor thickness. An ultrasound maximum tumor thickness cutoff point for local recurrence subdividing T3 tumors into uT3a and uT3b was established. RESULTS: Median follow-up was 41 months (range, 24-59). The 5-year actuarial local and overall recurrence rates were 9.82 pe…

The changes in resting anal pressure after performing full-thickness rectal advancement flaps.

Background: Advancement flap is an accepted approach for treating complex fistula-in-ano. The purpose was to evaluate the changes in resting pressure along the anal canal after performing a full-thickness flap. Methods: Manometric review of patients who have undergone a full-thickness rectal advancement flap procedure for complex anal fistulas of cryptoglandular origin. Recurrence and continence were evaluated. Resting Anal Pressure was assessed along the anal canal by two measures: maximum resting pressure(MRP) and inferior resting pressure(IRP) at 0.5 cm from the anal verge. Results: 119 patients were evaluated. Overall recurrence rate was5.9%. Anal continence was maintained intact in 76.…

Use of photoplethysmography to determine gastrointestinal perfusion pressure: an experimental canine model.

<i>Objectives:</i> To develop an experimental model to assess the parietal perfusion pressure (PPP) of the digestive tract using photoplethysmography. <i>Materials and Methods:</i> Twenty-two mongrel dogs were used. Progressive external compression was applied to the intestinal wall and the PPP was assessed with photoplethysmography. The study group was divided into two groups. In group 1 PPP was measured at the levels of the stomach, duodenum, jejunum and transverse colon. In group 2 PPP was measured after temporary occlusion of the truncal and marginal circulation of the jejunum to provide further variables. <i>Results:</i> The PPP decreased significant…

The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin.

Aim This technical note describes the use of an endostapler for the definitive treatment of supralevator abscess upward from an intersphincteric origin. Method A two-stage treatment was performed. First an endoanal drainage was performed by inserting a mushroom catheter in the supralevator abscess cavity. In the second stage transanal unroofing of the fistula was performed with an endostapler. Results Since 2011, three patients have been treated in this way. After 2 years of follow up, none of the patients had recurrence of the abscess or been referred for anal incontinence. Conclusion The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin may be an al…

Pelvic exenterations for primary rectal cancer: analysis from a 10-year national prospective database

Aim: to identify short-term and oncologic outcomes of pelvic exenterations (PE) for locally advanced primary rectal cancer (LAPRC) in patients included in a national prospective database. Methods: few studies report on PE in patients with LAPRC. For this study, we included PE for LAPRC performed between 2006 and 2017, as available, from the Rectal Cancer Registry of the Spanish Association of Surgeons [Asociación Española de Cirujanos (AEC)]. Primary endpoints included procedure-associated complications, 5-year local recurrence (LR), disease-free survival (DFS) and overall survival (OS). A propensity-matched comparison with patients who underwent non-exenterative surgery for low rectal canc…

Correlation between fecal calprotectin and inflammation in the surgical specimen of Crohn's disease

Background: An accurate assessment of the inflammatory activity is crucial to establish the most appropriate treatment in Crohn's disease (CD). The present study aimed to evaluate the utility of preoperative fecal calprotectin (FC) measurement in small bowel CD and its relationship with inflammatory activity in surgical pathology specimens. Methods: This was a prospective observational study including all the patients with small bowel CD operated on at our center between March 2011 and September 2013. Preoperative laboratory and stool tests were performed. A meticulous exploration of entire small bowel was performed during surgery, and the resected bowel (or a sample of whole intestinal wal…

Management of intersphincteric abscesses.

Objective  Intersphincteric abscesses are relatively rare, and in some cases of upward extensions in the supralevator plane, can be difficult to manage. The aim of this study was to analyse the type of treatment used in these abscesses. Methods  Twenty-one intersphincteric abscesses treated by endoanal drainage in our colorectal unit between 1992 and 2004 were reviewed from our database; location and extension of the abscess, type of treatment and recurrence rates and the use of endoanal ultrasound were studied. Results  Ninety per cent of patients were male; 10 had a previous history of surgery for perianal abscess and suppuration (48%); 16 (76%) had a posterior location and five were ante…

Prognostic Impact of pT Stage and Peritoneal Invasion in Locally Advanced Colon Cancer

BACKGROUND: TNM stage has been identified as an independent variable for local recurrence and survival after colon cancer resection. It is still unclear whether peritoneal invasion (pT4a) is a risk factor for adverse oncologic outcome or whether these patients have better results compared with contiguous organs infiltration (pT4b), independent from nodal status (pN). OBJECTIVE: The purpose of this study was to analyze whether peritoneal invasion is an independent risk factor for worse oncologic outcome after curative colon cancer resection. DESIGN: This was a retrospective analysis with multivariate regression of a prospective database, according to Strengthening the Reporting of Observatio…

Real-time fluorescence image-guided gastrointestinal oncologic surgery: Towards a new era

Technological improvements are crucial in the evolution of surgery. Real-time fluorescence-guided surgery (FGS) has spread worldwide, mainly because of its usefulness during the intraoperative decision-making processes. The success of any gastrointestinal oncologic resection is based on the anatomical identification of the primary tumor and its regional lymph nodes. FGS allows also to evaluate the blood perfusion at the gastrointestinal stumps after colorectal or esophageal resections. Therefore, a reduction on the anastomotic leak rates has been postulated as one of the foreseeable benefits provided by the use of FGS in these procedures. Although the use of fluorescence in lymph node detec…

Rectal cancer threatening or affecting the prostatic plane: is partial prostatectomy oncologically adequate? Results of a multicentre retrospective study

Aim The management of rectal cancer threatening or affecting the prostatic plane is still under debate. The role of preoperative chemo radiotherapy and the extent of prostatectomy seem to be key points in the treatment of these tumours. The aim of the present study was to evaluate the pathological circumferential margin status and the local recurrence rate following different therapeutic options. Method A multicentre, retrospective study was conducted of patients with rectal cancer threatening or affecting the prostatic plane, but not the bladder, judged by magnetic resonance imaging (MRI). The use of preoperative chemoradiotherapy and the type of urologic resection were correlated with the…

Prospective evaluation of intraoperative peripheral nerve injury in colorectal surgery

Aim  Intraoperative peripheral nerve injury can have permanent neurological consequences. Its incidence is not known and varies according to the location and the surgical specialty. This study was a prospective analysis of intraoperative peripheral nerve injury as a complication of abdominal colorectal surgery. Method  All patients who underwent major colorectal abdominal surgery in our Colorectal Unit between 1996 and 2009 were analyzed. Data on nerve injury were prospectively collected. Results  There were 2304 patients, of whom eight (0.3%) experienced intraoperative peripheral nerve injury. This occurred in 5/2211 (0.2%) open procedures and in 3/93 (3%) laparoscopic procedures. There wa…

Effects of PEEP on Residual Vascularization in Oesophageal Substitution Gastroplasty by Surface Oximetry-Capnometry and Photoplethysmography

<i>Objective:</i> To evaluate the effects of positive end-expiratory pressure (PEEP) on residual vascularization in gastric tubes for oesophageal replacement. <i>Design:</i> Experimental open study. <i>Materials:</i> Eleven mongrel dogs. <i>Methods:</i> Intestinal parietal blood flow was evaluated by photoplethysmography (PPG) and measurement of surface oxygen (PsO<sub>2</sub>) and carbon dioxide (PsCO<sub>2</sub>) tensions under basal conditions. After Akiyama’s tubular gastroplasty, three levels of PEEP were administered. At each level, fluids were infused to counter the drop in cardiac output. PPG, surface gas tensio…

Effect of epidural anesthesia on colorectal anastomosis: a tonometric assessment.

PURPOSE: Epidural anesthesia is believed to benefit colorectal anastomotic blood flow because of the sympathetic blockade it produces. Our purpose is to measure with tonometry the effect of epidural anesthesia on colorectal anastomotic oxygenation. PATIENTS AND METHODS: Fifteen patients operated on for rectal cancer (radical anterior resection) were monitored postoperatively using tonometers placed in the stomach (celiac trunk), transverse colon (superior mesenteric artery), and the anastomotic area during the operation. An epidural catheter was placed at L1-2, and on the first postoperative day, 8 ml of bupivacaine (0.25 percent) was administered. The anesthetic effect extended up to T-4. …

“Near-TME”: proposed standardisation of the technique for proctectomy in male patients with ulcerative colitis

Abstract Background The aim of the present study was to describe in detail an approach to proctectomy in ulcerative colitis (UC), which can be standardized; near-total mesorectal excision (near-TME), to prevent injuries to autonomic pelvic nerves and subsequent sexual dysfunction. Methods We demonstrate the technique ex vivo on a cadaver from a male patient in lithotomy position and on a sagittal section of a male pelvis. We also demonstrate the technique in vivo in two male patients diagnosed with UC, with no history of sexual dysfunction or bowel neoplasia. The study was performed at the Human Embryology and Anatomy Department. University of Valencia, Spain. Results The posterolateral dis…

Impact of surgeon organization and specialization in rectal cancer outcome.

Purpose The present study was designed to assess the differences in the outcome of patients with rectal cancer treated by a group of surgeons before and after being organized as a Coloproctology Unit at the same University Department of Surgery. Methods Comparison of two periods of rectal cancer surgery: I (1986–91) and II (1992–95). Period I: 94 patients were operated on by 14 general surgeons. Period II: 108 patients were operated on by only 4 surgeons of the same group organized as a Colorectal Surgery Unit after visiting referral centres abroad, adopting techniques such as total mesorectal excision (TME) for middle and low rectal cancer and washout of rectal stump. Mean follow-up during…

A Prospective Audit of the Complications of Loop Ileostomy Construction and Takedown

<i>Aim:</i> A prospective review of the complications of ileostomy construction and takedown. <i>Materials and Methods:</i> One hundred twenty-seven consecutive patients undergoing construction of a loop ileostomy were included in a prospective nonrandomized computer database. Complications of the loop ileostomy were assessed prior to and after closure. Three closure techniques were performed [enterotomy suture (25.7%), resection and hand sewn (31.2%) or stapled anastomosis (43.1%)] and compared. <i>Results:</i> One hundred twenty-seven (73 male, 54 female) patients, mean age 54 years were included from 1992 to 2002. Seventy-two patients underwent anterio…

Anal endosonographic evaluation after closed lateral subcutaneous sphincterotomy

PURPOSE: The present study was undertaken to evaluate anal endosonographic results of the transverse and longitudinal extent of internal anal sphincter division after closed lateral subcutaneous sphincterotomy and its relationship to outcome with respect to anal fissure recurrence and postoperative anal incontinence. METHODS: Ten patients selected for symptomatic anal fissure recurrence (mean follow-up, 10.9 months) and 41 asymptomatic control patients (mean follow-up, 15.5 months) were reviewed by anal endosonography after closed lateral subcutaneous sphincterotomy. Clinical evaluation was focused on anal fissure recurrence and postoperative anal incontinence. The anal endosonographic stud…

Robotic transanal total mesorectal excision: Is the future now?

Total mesorectal excision (TME) is the standard surgical treatment for the curative radical resection of rectal cancers. Minimally invasive TME has been gaining ground favored by the continuous technological advancements. New procedures, such as transanal TME (TaTME), have been introduced to overcome some technical limitations, especially in low rectal tumors, obese patients, and/or narrow pelvis. The earliest TaTME reports showed promising results when compared with the conventional laparoscopic TME. However, recent publications raised concerns regarding the high rates of anastomotic leaks or local recurrences observed in national series. Robotic TaTME (R-TaTME) has been proposed as a nove…

Anastomotic leakage after colon cancer resection: does the individual surgeon matter?

Aim Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery. Method This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour character…

Lumbar osteomyelitis and epidural abscess complicating recurrent pilonidal cyst: report of a case.

PURPOSE: This study was conducted to report the rare presentation of lumbar osteomyelitis and epidural abscess as a complication of a pilonidal cyst. METHODS: A case report is presented. RESULTS: We describe the rare case of a male patient with diabetes with a recurring pilonidal cyst who developed a lumbar osteomyelitis and epidural abscess three weeks after pilonidal cyst excision with epidural anesthesia, with a fatal outcome despite emergency treatment. CONCLUSIONS: Life-threatening complications should be kept in mind in high-risk patients with repetitive surgery and neurologic involvement.

Fe de errores de «Evaluación de las fístulas perianales mediante ecografía endoanal tridimensional y correlación con los hallazgos intraoperatorios»

Relevance of dynamic studies with magnetic resonance enterography in Crohn's disease.

A proper quantification of the inflammatory activity in Crohn's disease (CD) lesions is needed to establish the appropriate management for each patient. The aim of this study is to evaluate the inflammatory activity of affected segments in small bowel lesions using dynamic studies of magnetic resonance enterography (MRE) in patients undergoing surgery, and their correlation with the level of inflammation and histological fibrosis of the surgical piece.A prospective, consecutive, observational, clinical study was conducted that included all the patients with small bowel CD that underwent surgery in this center between March 2011 and September 2013. Diagnosis was established according to Lenn…

Modified Wong's Classification Improves the Accuracy of Rectal Cancer Staging by Endorectal Ultrasound and MRI

BACKGROUND: Douglas Wong proposed a new classification of tumor penetration in the rectal wall (T stage) in an attempt to incorporate the prognostic heterogeneity of T3 rectal cancers into the preoperative staging. OBJECTIVE: This study aimed to evaluate if the accuracy of endorectal ultrasound and MRI in predicting rectal cancer T staging improves when using a modified Wong's classification. DESIGN: This prospective series compares local standard TN staging and a modified Wong's classification. SETTINGS: This study was conducted by a specialized Colorectal Multidisciplinary Team at a tertiary teaching hospital. PATIENTS: Seventy patients underwent surgery for middle or low rectal cancer be…

[Evaluation of three-dimensional endoanal endosonography of perianal fistulas and correlation with surgical findings].

Abstract 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 op…

Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study.

Although the early diagnosis of anastomotic leak is a key point in reducing its clinical consequences, in daily practice, anastomotic leak diagnosis is often late.The aim of this study was to determine whether procalcitonin and C-reactive protein are good predictors of anastomotic leak in colorectal surgery.This is a prospective observational study.This study was conducted by a specialized colorectal multidisciplinary team of a tertiary teaching hospital.A series of 205 consecutive patients who underwent elective colorectal surgery in a specialized unit was prospectively analyzed. The following data were collected: demographic, surgical, ASA class, POSSUM, and morbidity. During the first 5 …

The occlusive tourniquet: a simple method for rectal stump washout during open and laparoscopic surgery.

Rectal stump washout with cytolytic agents is recommended and usually performed during anterior rectal or rectosigmoid resection. The use of a linear stapler instrument during ultralow anterior resection makes the placement of pelvic clamps difficult for rectal stump washout prior to resection. The objective of this work is to demonstrate the use of a simple procedure, the occlusive tourniquet for rectal stump washout. Occlusive tourniquet applied to open technique: after complete dissection of the rectum and sigmoid colon according to the usual technique, a simple piece of tubing from an intravenous line is passed behind and around the rectum/sigmoid colon at some point distal to the tumor…

Solitary rectal ulcer: ultrasonographic and magnetic resonance imaging patterns mimicking rectal cancer.

The objective of this study was to analyze a series of solitary rectal ulcer syndrome (SRUS) cases initially diagnosed as rectal cancer. We analyzed all the patients (1996-2008) initially referred to our colorectal unit with a diagnosis of rectal cancer but with a final diagnosis of SRUS. Demographic data, the diagnostic work-up, and treatment details were collected in a prospective database and analyzed retrospectively. Out of the 5035 patients registered in the colorectal unit database, 14 (0.28%) had a final diagnosis of SRUS. Nine of them had an initial diagnosis of rectal cancer. Out of these, six were preoperatively staged with endorectal ultrasound and/or magnetic resonance and were …

Peritoneal invasion and metachronous peritoneal metastases after colon cancer surgery: The role of homogeneous, reliable assessment and confounders

UTILIDAD DE LA LATENCIA MOTORA TERMINAL DE NERVIOS PUDENDOS EN PACIENTES CON INCONTINENCIA ANAL

Antecedentes El examen de la Latencia Motora Terminal de Nervios Pudendos (LMTNP) se utiliza habitualmente para valorar la existencia o no de Neuropatia Pudenda (NP). Sin embargo, la utilidad de esta tecnica es motivo de controversia dado que unicamente evalua las fibras nerviosas de conduccion rapida. Objetivos Establecer la prevalencia de NP medida mediante la LMTNP en pacientes con Incontinencia anal (IA) y evaluar la relacion existente entre NP y funcion ano-rectal en estos pacientes. Metodos Se revisaron un total de 380 pacientes con IA, 348 (91,6%) mujeres, con edad media de 59 anos (rango 15–84 anos). Todos ellos fueron estudiados mediante ecografia endoanal, manometria ano- rectal, …

Randomized clinical trial to evaluate the effects of perioperative supplemental oxygen administration on the colorectal anastomosis

Abstract Background Perioperative supplemental oxygen therapy may have beneficial effects on wound healing following colorectal surgery. The aim of this study was to evaluate the effects of such therapy on colorectal anastomotic pH and partial pressure of carbon dioxide (Pco2) gap. Methods Forty-five patients undergoing anterior resection for rectal or sigmoid cancer were randomized to receive 30 or 80 per cent perioperative oxygen. Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. Intragastric and anastomotic tonometric catheters were placed in each patient and intramucosal pH (pHi) was measured immediately after operation, and 6 and 24 h lat…

Relaxation of the isolated human internal anal sphincter by sildenafil.

Abstract Background Hypertonicity of the internal anal sphincter (IAS) appears to be involved in the pathogenesis of anal fissure. The relaxant effects of sildenafil, a selective phosphodiesterase 5 (PDE5) inhibitor, on isolated human IAS were investigated. Methods The efficacy (maximal effect, Emax) and potency (−log IC50, where IC50 is half-maximal inhibitory concentration) of the PDE5 inhibitors, sildenafil and zaprinast, and of nitric oxide donors, sodium nitroprusside and glyceryl trinitrate, as relaxants of histamine (0·1 mmol/l)-induced tone were examined in IAS strips under isometric contraction. The presence of PDE5 isoenzymes and changes in intracellular calcium and cyclic nucleot…

Adhesive Small Bowel Obstruction: Predictive Factors of Lack of Response in Conservative Management with Gastrografin

<b><i>Background:</i></b> Gastrografin represents a useful tool in the diagnosis and management of adhesive small bowel obstruction (ASBO). The aim of this study is to identify variables with negative influence in nonoperative management with gastrografin. <b><i>Methods:</i></b> From August 2008 to March 2013, 223 consecutive patients with 235 episodes of ASBO were included and received gastrografin. A protocol for prospective data collection was developed. In order to explore factors related to the failure of nonoperative treatment, univariate and multivariate analysis were performed. <b><i>Results:</i></b> One hundred…

Tratamiento quirúrgico y resultados del cáncer de recto

Resumen Las experiencias acumuladas en los ultimos anos han modificado la tactica y la tecnica quirurgicas en el tratamiento del cancer de recto, existiendo una evidencia cientifica en la mejoria de los resultados en grupos especializados. El objetivo del presente trabajo es describir las distintas opciones tecnicas, indicaciones y los resultados del tratamiento quirurgico actual del cancer de recto. El cancer de recto puede tratarse con intencion curativa con cualquiera de las siguientes opciones quirurgicas: reseccion local, reseccion anterior con sus distintas variantes y amputacion abdominoperineal. Se deben mantener unos criterios de seleccion correctos, fundamentalmente en relacion co…

Evaluation of Mesorectal Fascia in Mid and Low Anterior Rectal Cancer Using Endorectal Ultrasound Is Feasible and Reliable

Accuracy of MRI in assessing mesorectal fascia and predicting circumferential resection margin decreases in low anterior rectal tumors.The purpose of this work was to evaluate the accuracy of endorectal ultrasound in predicting the pathologic circumferential resection margin in low rectal anterior tumors and to compare it with MRI findings.This was a prospective series comparing the preoperative circumferential resection margin assessed by endorectal ultrasound and MRI with pathologic examination.The study was conducted by a specialized colorectal multidisciplinary team at a tertiary teaching hospital.Between 2002 and 2008, 76 patients with mid to low rectal cancer were preoperatively evalu…

Estomas de protección en cirugía colorrectal. ¿Cuándo y cómo realizarlos?

Resumen En los ultimos anos, el empleo de estomas de proteccion en cirugia colorrectal se ha incrementado, y tiene fundamentalmente tres grandes indicaciones: 1) traumatismos ano-recto-colicos graves; 2) enfermedad de Crohn con importante afectacion anorrectal y perineal, y 3) prevencion de complicaciones derivadas del fracaso anastomotico, fundamentalmente tras reseccion anterior baja por neoplasia de recto y tras proctocolectomia restauradora por colitis ulcerosa o poliposis colica familiar. En cuanto al tipo de estoma a realizar, en los casos de enfermedad o traumatismo anorrectal, lo habitual sera realizar una sigmoidostomia en asa, por lo que la derivacion se situa inmediatamente proxi…

Opciones quirúrgicas en el cáncer de recto del tercio distal localmente avanzado. Necesidad de una superespecialización. Introducción

Pathological Evaluation of Mesocolic Resection Quality and Ex Vivo Methylene Blue Injection

BACKGROUND: Although the National Quality Forum has endorsed the harvest of ≥12 lymph nodes as a standard quality indicator for colon cancer surgery, this minimum quantity is not reached in many centers. OBJECTIVE: The aim of this study was to assess the impact of the implementation of a mesocolon evaluation pathological protocol and ex vivo arterial methylene blue injection on the number of nodes harvested after colon cancer resection. DESIGN: A prospective series was compared with a historical group. SETTINGS: This study was conducted by a specialized colorectal multidisciplinary team at a tertiary teaching hospital. PATIENTS: From June 2009 to December 2009, all the specimens after colon…

A Proposal for Novel Standards of Histopathology Reporting for D3 Lymphadenectomy in Right Colon Cancer: The Mesocolic Sail and Superior Right Colic Vein Landmarks

Background Strong agreement exists concerning the standards of pathologic reporting for total mesorectal excision and complete mesocolic excision. It represents a quality standard that correlates with survival. However, no agreed standards of reporting are available to define D3 lymphadenectomy for right colectomy. Objective The purpose of this study was to define anatomopathological standards of specimen quality obtained from the surgical specimen when an oncologic right hemicolectomy with D3 lymphadenectomy has been correctly performed. Design This study was conducted in 2 different phases. The first part consisted of a cadaver-based study of right colon anatomy, and the second part consi…

A systematic review and meta-analysis comparing surgical and oncological outcomes of upper rectal, rectosigmoid and sigmoid tumours.

Abstract Aim Management paradigms for tumours from the sigmoid colon to the lower rectum vary significantly. The upper rectum (UR) represents the transition point both anatomically and in treatment protocols. Above the UR is clearly defined and managed as colon cancer and below is managed as rectal cancer. This study compares outcomes between sigmoid, rectosigmoid and UR tumours to establish if differences exist in operative and oncological outcomes. Methods Electronic databases were searched for published studies with comparative data on peri-operative and oncological outcome for upper rectal and sigmoid/rectosigmoid (SRS) tumours treated without neoadjuvant radiation. The search adhered t…

Real-Time Quantification in Plasma of Human Telomerase Reverse Transcriptase (hTERT) mRNA: A Simple Blood Test to Monitor Disease in Cancer Patients

Real-Time Quantification in Plasma of Human Telomerase Reverse Transcriptase (hTERT) mRNA: A Simple Blood Test to Monitor Disease in Cancer Patients

Simple technique for the intraoperative detection of Crohn's strictures with a calibration sphere.

Several methods have been used to detect and evaluate small-bowel strictures in Crohn's disease. We describe a simple technique for the calibration of strictures using a 2.5-cm medical plastic sphere. This method provides an aseptic, safe, and effective calibration of the entire small bowel.

Prospective study of morphologic and functional changes with time in the mucosa of the ileoanal pouch: functional appraisal using transmucosal potential differences.

PURPOSE: This study was undertaken to investigate the morphologic and functional changes with time in the mucosa of the ileoanal pouch. METHODS: A morphologic study by histopathologic analysis, mucosal morphometry, and mucin histochemistry and a functional study by analysis of transmucosal potential difference were performed in 27 patients with an ileoanal J-pouch after restorative proctocolectomy for ulcerative colitis. In 19 patients with a normal ileoanal pouch, two prospective follow-up analyses were performed after median functional pouch times of 14 and 39 months. We also evaluated eight patients with the diagnosis of pouchitis (median follow-up, 52.5 months). RESULTS: In the normal i…

Prognostic implications of circumferential location of distal rectal cancer

Aim  This study evaluated the prognostic importance of circumferential tumour position of mid and low rectal cancers. Method  All uT2, uT3 and uT4 tumours of the middle and lower rectum that underwent total mesorectal excision (TME) with curative intent between 1996 and 2006 were included. The predominant circumferential tumour position (anterior, posterior or circumferential) was defined on preoperative endorectal ultrasound examination (ERUS). The relationships between tumour position and other characteristics and recurrence were explored. Results  Two hundred and five patients with distal rectal cancer were operated on for a uT2-T4 tumour. Median follow up was 49 months. The location of …

Risk factors for recurrence and incontinence after anal fistula surgery

Objective: Fistula-in-ano continues to raise problems that require important therapeutic decisions. Our aim was to evaluate its recurrence and incontinence risk factors. Method: We analysed a series of 279 patients who had undergone anal fistula surgery with long-term follow-up. Results: 42.7% of the fistulae were considered complex and 46% had been referred from other institutions. There was delayed healing or recurrence in 7.2% patients, which appeared at a median of 4 months. The factors associated with recurrence were the type of fistula (extrasphincteric/suprasphincteric), nonidentification of internal opening (IO), recurrent or complex fistulae (CF), and associated chronic abscess. On…

Macroscopic assessment of mesorectal excision in rectal cancer

BACKGROUND: High quality of surgical technique and the use of descriptive measures to assess and report surgical proficiency have been shown to influence locoregional tumor control in patients with rectal cancer. In this study, the authors have aimed to audit the implementation of a macroscopic assessment of mesorectal excision (MAME) and to investigate factors that influenced surgical quality and disease recurrence. METHODS: All curative resections for rectal cancer were prospectively evaluated for MAME between 1998 and 2007. Mesorectal specimens were graded into 3 types: complete, nearly complete, and incomplete categories. Univariate and multivariate analyses identified independent risk …

Standard Outcome Indicators After Colon Cancer Resection. Creation of a Nomogram for Autoevaluation

Abstract Introduction Lately there has been an increasing interest in identifying quality standards in different pathologies, among them colon cancer due to its great prevalence. The main goal of this study is to define the quality standards of colon cancer surgery based on a large prospective national study dataset. Methods Data from the prospective national study ANACO were used. This study included a consecutive series of patients operated on for colon cancer in 52 Spanish hospitals (2011–2012). Centers with less than 30 patients were excluded. The present analysis finally included 42 centers (2975 patients). Based on the results obtained in 4 main indicators from each hospital (anastomo…

La resonancia magnética y el índice MaRIA en la valoración preoperatoria de la enfermedad de Crohn ileal

Abstract Introduction Accurate quantification of the inflammatory activity in Crohn’s Disease is essential to decide the adequate treatment for each patient. The aim of the present study is to assess the correlation between the pre-operative Magnetic Resonance Index of Activity (MaRIA) and the histologic degree of inflammation from surgically resected intestinal Crohn’s Disease lesions. Methods This is a prospective study including a consecutive case series of patients with small bowel Crohn’s Disease, who underwent surgical resection. A Magnetic Resonance Enterography was performed during the three months prior to surgery, applying a pre-established protocol. Relative contrast enhancements…

Selective approach for upper rectal cancer treatment: total mesorectal excision and preoperative chemoradiation are seldom necessary.

The implementation of preoperative chemoradiation combined with total mesorectal excision has reduced local recurrence rates in rectal cancer. However, the use of both types of treatment in upper rectal cancer is controversial.The purpose of this work was to assess oncological results after radical resection of upper rectal cancers compared with sigmoid, middle, and lower rectal cancers and to determine risk factors for local recurrence in upper rectal cancer.This was a retrospective analysis of prospectively collected data.This study was conducted in a tertiary care referral hospital in Valencia, Spain.Analysis included 1145 patients who underwent colorectal resection with primary curative…

Evaluación de las fístulas perianales mediante ecografía endoanal tridimensional y correlación con los hallazgos intraoperatorios

Resumen Objetivo Evaluar la fiabilidad diagnostica de la ecografia tridimensional (ECO 3D) vs. la bidimensional (ECO 2D) y la exploracion fisica en el diagnostico de las fistulas perianales correlacionandolo con los hallazgos intraoperatorios. Material y metodo Estudio prospectivo, observacional con pacientes incluidos de forma consecutiva entre diciembre 2008 y agosto 2009. Se incluyen 29 pacientes diagnosticados de fistula perianal subsidiarios de tratamiento quirurgico. Se realizo una exploracion fisica, ECO 2D, ECO 3D comparandolos con los hallazgos intraoperatorios. Cuando el orificio fistuloso externo se encuentra abierto, se repiten ambas exploraciones instilando agua oxigenada. Resu…

Fistulectomy and sphincteric reconstruction for complex cryptoglandular fistulas

Objective  Complex anal fistulas (CFs) are difficult to treat. Endoanal advancement flap (EAF) is one of the standard treatment options for such clinical conditions. Immediate sphincter repair after fistulectomy (ISR) is not commonly performed because of the fear of causing postoperative incontinence. The objective of this study was to compare the results of both techniques. Method  We retrospectively analysed a prospectively entered database composed of 146 patients (112 M; 34 F), undergoing operations for CF of cryptoglandular origin. The patients were divided in two groups: Group A: (EAF); n = 71 patients; Group B: (ISR); n = 75 patients. Results  Forty-two fistulas (28.7%) were recurren…

Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: An institutional analysis of 800 patients

Background. Our aim was to assess whether the individual surgeon is an independent risk factor for anastomotic leak in double-stapled colorectal anastomosis after left colon and rectal cancer resection. Methods. This retrospective analysis of a prospectively collected database consists of a consecutive series of 800 patients who underwent an elective left colon and rectal resection with a colorectal, double-stapled anastomosis between 1993 and 2009 in a specialized colorectal unit of a tertiary hospital with 7 participating surgeons. The main outcome variable was anastomotic leak, defined as leak of luminal contents from a colorectal anastomosis between 2 hollow viscera diagnosed radiologic…

Integrating Downstaging in the Risk Assessment of Patients With Locally Advanced Rectal Cancer Treated With Neoadjuvant Chemoradiotherapy: Validation of Valentini's Nomograms and the Neoadjuvant Rectal Score

Abstract Background Adjuvant chemotherapy is controversial in patients with locally advanced rectal cancer after preoperative chemoradiation. Valentini et al developed 3 nomograms (VN) to predict outcomes in these patients. The neoadjuvant rectal score (NAR) was developed after VN to predict survival. We aimed to validate these tools in a retrospective cohort at an academic institution. Patients and Methods VN and the NAR were applied to 158 consecutive patients with locally advanced rectal cancer treated with chemoradiation followed by surgery. According to the score, they were divided into low, intermediate, or high risk of relapse or death. For statistical analysis, we performed Kaplan-M…

Relaxation by β3-adrenoceptor agonists of the isolated human internal anal sphincter

In this study, responses of beta(3)-adrenoceptor agonists were examined on human isolated internal anal sphincter (IAS) in order to explore their relaxant effects on hypertonicity of IAS.The relaxant efficacy (E(max)) and potency (-logIC(50)) of BRL37344 and SR58611A, beta(3)-adrenoceptor agonists, were examined in contracted IAS muscle strips. The presence of beta(3)-adrenoceptors, and changes in intracellular calcium and cyclic nucleotide levels in IAS muscle were tested by Western blotting, epifluorescence microscopy and enzyme immunoassay, respectively.BRL37344 and SR58611A relaxed contracted IAS muscle (E(max)=27+/-3% and 35+/-3%; -logIC(50)=6.26+/-0.24 and 4.87+/-0.13; respectively). …