Alejandro Barrera

Predictive factors of stenosis after stapled colorectal anastomosis: prospective analysis of 179 consecutive patients.

The incidence, risk factors, and clinical relevance of stenosis of stapled colorectal anastomosis (CRA) were studied prospectively. Anastomotic stricture was defined as the inability of traversing the anastomosis with the rigid proctoscope. The population studied consisted of 179 patients (94 males) with an average age of 59.3 years (range: 20 to 91 years). The main indication for surgery was colorectal cancer in 59% of the cases, followed by diverticular disease in 23%. The first endoscopic control was performed before 4 months in 25% of the patients, between 5 and 10 months in 50%, and during the following 10 months in 25%. Stenosis was verified with the rigid instrument in 21.1% of the cases and with the flexible colonoscope in 4.4%. The barium enema performed in 12 cases confirmed a punctiform stenosis in 5 patients, 4 of whom had been asymptomatic. An endoscopic dilatation was performed on 5 of the 8 symptomatic patients, with one relapse that required an additional dilatation. In the univariate analysis only the lesser 4-month interval was statistically significant (p = 0.033; odds ratio (OR) = 2.3; confidence interval (CI) 95% = 1.06 to 4.97). Male patients (p = 0.057; OR = 2.08; IC 95% = 0.97–4.44) show a tendency to CRA stricture that does not reach statistically significant levels. In the multivariate analysis, only sex (p = 0.04; OR = 4.11; IC 95% = 1.03 to 5.41) and the time interval (p = 0.012; OR = 2.87; IC 95% = 1.25 to 6.57) appear as independent variables in stenosis risk of a stapled CRA. The incidence of this complication depends on the criteria used for defining it. It is clinically relevant in no more than 5% of the patients. Five out of eight patients in category II were treated successfully with an endoscopic dilatation, while the other three improved spontaneously. Early stenosis, although frequent, is generally asymptomatic and disappears spontaneously. Considering the lack of correlation between the degree of stricture and its symptomatology, it is convenient to combine both the anatomic and the clinical criteria in the selection of candidates for an eventual therapeutic procedure.

Resultados alejados de la resección local transanal para cánceres de recto bajo bien seleccionados

OBJECTIVE to evaluate our results about local failure, total recurrence and survival. METHOD twenty-one patients underwent a complete local transanal excision for low rectal cancer in our institution during an 18-year period (1985-2003). Preoperative staging included clinical, endoscopic, CT, EUSR, and histopathological findings; pathological specimens were 4 T1, 13 T2 and 4 T3 tumors. None of the T1 patients received another treatment; 6 out of 13 T2 and all of T3 cases were treated with chemoradiotherapy. None of the latter underwent radical surgery. RESULTS follow-up (median 74 months) proved 23.8% for total recurrence and 19.0% for local failure (out of all 3 T2 cases only one received chemoradiotherapy, and one T3 received adjuvant treatment). Five-year survival is 95.2%. CONCLUSIONS this experience allows us to assert that local excision is a good choice in well-selected low rectal cancer patients; for T2 tumors chemoradiotherapy is necessary; in T3 patients radical surgery must be prompt.

Lomas-Cooperman technique for rectal prolapse in the elderly patient

AbstractBackgroundA variety of surgical procedures is used to correct complete rectal prolapse (RP). We analysed the immediate and long-term results of the Lomas-Cooperman technique in the management of symptomatic RP in elderly patients with severe concomitant diseases.MethodsAcross a 13-year period, all patients with RP having undergone surgery with this procedure were retrospectively evaluated. The technique consisted in placing a triply folded piece of polypropylene mesh encircling the anal canal through a perineal approach.ResultsA total of 22 patients (20 female) with a mean age of 84 years (range, 72–93 years) with severe concomitant pathologies were assessed. Four patients were classified as ASA II and 18 as ASA III. Mean Karnofsky score was 50%, ranging between 40% and 60%. All patients were operated on under regional anaesthesia without incidents. Mean operative time was 35 min(range, 20–60 min) and mean hospital stay was 4.5 days (range, 2–17 days). The most common immediate postoperative complication was urinary tract infection, found in 18% of the cases. Mean follow-up was 32 months (range, 4–84 months). During follow-up, 4 cases (18%) of mesh exteriorisation were detected, requiring mesh trimming at the outpatient clinic. Rectal prolapse recurred in 2 patients; one of them was managed with a new cerclage reaching a satisfactory outcome. Thus, by intention-to-treat basis, the recurrence rate was 4.5%. Constipation was resolved in three out of 4 patients, but in 18% of the cases late faecal impact was recorded. Mean preoperative incontinence score improved from 5.1±0.62 to 3.4±1.61 (p<0.0001) after surgery.ConclusionAnal cerclage with the Lomas-Cooperman technique constitutes a simple and reproducible surgical technique with an acceptable morbidity and recurrence rate in high-risk elderly patients with RP.