Carlos Placer

Patterns of local recurrence in rectal cancer after a multidisciplinary approach

Improvements in surgery and the application of combined approaches to fight rectal cancer have succeeded in reducing the local recurrence (LR) rate and when there is LR it tends to appear later and less often in isolation. Moreover, a subtle change in the distribution of LRs with respect to the pelvis has been observed. In general terms, prior to total mesorectal excision the most common LRs were central types (perianastomotic and anterior) while lateral and posterior forms (presacral) have become more common since the growth in the use of combined treatments. No differences have been reported in the current pattern of LRs as a function of the type of approach used, that is, neo-adjuvant therapies (short-term or long-course radiotherapy, or chemoradiotherapy versus extended lymphadenectomy, though there is a trend towards posterior or presacral LR in patients in the Western world and lateral LR in Asia. Nevertheless, both may arise from the same mechanism. Moreover, as well as the mode of treatment, the type of LR is related to the height of the initial tumor. Nowadays most LRs are related to the advanced nature of the disease. Involvement of the circumferential radial margin and spillage of residual tumor cells from lymphatic leakage in the pelvic side wall are two plausible mechanisms for the genesis of LR. The patterns of pelvic recurrence itself (pelvic subsites) also have important implications for prognosis and are related to the potential success of salvage curative approach. The re-operability for cure and prognosis are generally better for anastomotic and anterior types than for presacral and lateral recurrences. Overall survival after LR diagnosis is lower with radio or chemoradiotherapy plus optimal surgery approaches, compared to optimal surgery alone.

Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus.

BackgroundThere are different open healing and primary closure approaches for chronic pilonidal sinus (CPD) that differ in principles and extension.Aims To compare the results of different closure surgical techniques, we performed a meta-analysis of randomized controlled trials (RCT) comparing: (1) open wide excision versus open limited excision (sinusectomy) or unroofing (sinotomy); (2) midline closure (conventional and tension-free) versus off-midline; (3) advancing versus rotation flaps; and (4) sinusectomy/sinotomy versus primary closure.Methods Data extraction and risk of bias assessment were conducted independently by the authors using the Cochrane Collaboration’s tool. Data were pooled using fixed and random-effects models. Primary outcomes were rate of healing, recurrence, wound infection and dehiscence. Twenty-five trials (2,949 patients) were included.Results Four trials compared limited versus radical open healing. Although recurrence rate did not differ, all other outcomes favored the limited approach. Ten studies compared midline versus off-midline primary closure; wound infection and dehiscence were significantly higher after midline closure. Six RCT compared Karydakis/Bascom versus Limberg. No difference was found in recurrence or wound complications rate. Six RCT compared sinusectomy/sinotomy versus primary closure. Recurrence rate was significantly lower after sinusectomy/sinotomy; no significant differences were found in other outcomes.Conclusion Our meta-analysis suggest that some of the questions of which is the best surgical technique for CPD have now been answered: open radical excision and primary midline closure should be abandoned. Sinusotomy/sinectomy or en bloc resection with off midline primary closure are the preferred approaches.

Evaluation of Alpha 1-Antitrypsin and the Levels of mRNA Expression of Matrix Metalloproteinase 7, Urokinase Type Plasminogen Activator Receptor and COX-2 for the Diagnosis of Colorectal Cancer

Background Colorectal cancer (CRC) is the second most common cause of death from cancer in both men and women in the majority of developed countries. Molecular tests of blood could potentially provide this ideal screening tool. Aim Our objective was to assess the usefulness of serum markers and mRNA expression levels in the diagnosis of CRC. Methods In a prospective study, we measured mRNA expression levels of 13 markers (carbonic anhydrase, guanylyl cyclase C, plasminogen activator inhibitor, matrix metalloproteinase 7 (MMP7), urokinase-type plasminogen activator receptor (uPAR), urokinase-type plasminogen activator, survivin, tetranectin, vascular endothelial growth factor (VEGF), cytokeratin 20, thymidylate synthase, cyclooxygenase 2 (COX-2), and CD44) and three proteins in serum (alpha 1 antitrypsin, carcinoembryonic antigen (CEA) and activated C3 in 42 patients with CRC and 33 with normal colonoscopy results. Results Alpha 1-antitrypsin was the serum marker that was most useful for CRC diagnosis (1.79±0.25 in the CRC group vs 1.27±0.25 in the control group, P<0.0005). The area under the ROC curve for alpha 1-antitrypsin was 0.88 (0.79–0.96). The mRNA expression levels of five markers were statistically different between CRC cases and controls: those for which the ROC area was over 75% were MMP7 (0.81) and tetranectin (0.80), COX-2 (0.78), uPAR (0.78) and carbonic anhydrase (0.77). The markers which identified early stage CRC (Stages I and II) were alpha 1-antitrypsin, uPAR, COX-2 and MMP7. Conclusions Serum alpha 1-antitrypsin and the levels of mRNA expression of MMP7, COX-2 and uPAR have good diagnostic accuracy for CRC, even in the early stages.

La respuesta inicial al diltiazem tópico puede predecir la evolución de la fisura anal crónica

INTRODUCTION In the last few years, the medical treatment of chronic anal fissure (chemical sphincterotomy) has been introduced as a consequence of the morbidity attributed to surgical sphincterotomy. However, medical treatment has two disadvantages: moderate effectiveness (between 30% and 80%) and the need for treatment to be prolonged for more than 8 weeks. OBJECTIVE To evaluate initial response to topical diltiazem 2% topical gel as a predictive factor in the curability of chronic anal fissure. PATIENTS AND METHOD From February 2004 to December 200, all patients with a history of anal fissure of more than 6 weeks were included in this study. Pregnant patients and those with prior anal surgery, inflammatory bowel disease, diltiazem intolerance and problems for maintaining contact during follow-up were excluded. A magistral formula of diltiazem 2% gel was used in three applications daily for 8 weeks. Patients were followed-up clinically and pain was measured through a visual analog scale (VAS) at the end of weeks 1, 3, 6, and 8. Groups with and without response to diliazem were compared through the chi2 test, Fishers exact test and Students t-test. A Receiver Operating Characteristic (ROC) curve was used to evaluate the diagnostic efficacy of initial pain response to diliazem, as well as sensitivity, specificity and predictive values. RESULTS One hundred patients (70 men), with a mean age of 43 years (22-76) were analyzed. Localization was posterior in 87%, anterior in 11% and lateral in 2%. All patients had pain, 65 had bleeding, and 13 had pruritus. At the end of the 8-week treatment, cure was achieved in 62%, with morbidity of 5% (mild headache in 2%, and pruritus in 3%). No significant differences were found between the groups with and without response to diltiazem 2% in terms of age, sex, localization, bleeding, or pruritus. Notable differences were found in the VAS for pain at the end of weeks 1, 3, 6, and 8 between the two groups (p = 0.00). ROC curves established a cut-off point of 4 in the VAS at the end of week 1, with an area below the curve of 0.925 (95% CI, 0.858-0.989). The capacity of early response to diliazem to predict curability showed a sensitivity of 85.5% (95% CI, 74.7%-92.2%), a specificity of 92.1% (95% CI, 79.2%-97.3%), a positive predictive value of 94.6% (95% CI, 85.4%-98.2%), and a negative predictive value of 79.5% (95% CI, 65.5%-88.8%). Among patients who showed no response to diltiazem by the end of week 1, cure was achieved in only 9% at 8 weeks. In contrast, among those with a favorable response in the first week, cure was achieved in 94.6%. CONCLUSIONS Lack of response to topical diltiazem 2% gel at the end of the first week reliably predicts failure of medical treatment for chronic anal fissure, obviating the need to prolong treatment for 8 weeks.

Ventral rectal sacropexy (colpo-perineal) in the treatment of rectal and rectogenital prolapse

Abstract Introduction Ventral sacral-rectopexy with mesh corrects rectal prolapse and minimises rectal dissection. Subsequent colpopexy corrects apical and posterior prolapses of the vagina. The combination of both procedures can lead to the simultaneous correction of pelvic organ prolapses (POP). Objective To present the results of a patient series with several types of POP treated using the same approach and operation. Material and method A total of 57 patients diagnosed with any type of POP were operated on between January 2005 and August 2008 using ventral rectal-colpo-sacropexy, who were grouped into 3 types: A, total rectal prolapse isolated or combined with a hysterocele or colpocele (11 patients); B, rectoenterocele with internal rectal invagination and/or descending perineum (4 patients); and C, middle and posterior genital compartment prolapse (42 patients). The laparoscopic approach was used in the 15 patients of groups A and B and 11 from group C. A biological mesh was used in 41 patients and a macroporous synthetic one in the rest. Results The mean age of the patients in the series was 66 (19–81) years, with 55 females and 2 males. The median follow up was 25 (4–48) months. There were no major post-surgical complications. A recurrence of prolapse was recorded in one patient in group A (1/11); the 7 patients who suffered from incontinence improved after the surgery, no case of de novo constipation being recorded and an improvement in 8 of the 9 patients from groups A and B with obstructive defecation. There were 9 (21%) recurrences detected in group C, but only 4 (9%) required reintervention. In all the recurrences a biological mesh had been used. Conclusions Laparoscopic ventral rectal-colpo-pexy is an effective technique to correct POP. Although safe and innocuous, the results with biological meshes did not last as long.

Preventing complications in colorectal anastomosis: results of a randomized controlled trial using bioabsorbable staple line reinforcement for circular stapler.

BACKGROUND: Anastomotic complications, including leaks, stenoses, and bleeding, cause considerable mortality and morbidity after colorectal surgery. OBJETIVE: The purpose of this work was to evaluate the effectiveness of bioabsorbable staple line reinforcement in reducing colorectal anastomotic complications. DESIGN: This was a prospective randomized clinical study. SETTINGS: This study was conducted at a university hospital within a specialized colorectal unit. PATIENTS: Patients undergoing left colon resection for a benign or malignant condition were eligible. A total of 302 patients participated, including 154 control subjects and 148 with reinforcement. INTERVENTION: Patients were prospectively randomly assigned to reinforcement of circular stapled anastomosis with a bioabsorbable device versus stapled circular anastomosis without reinforcement. MAIN OUTCOME MEASURES: The primary end point was the rate of pooled incidences of anastomotic complications (leakage, bleeding, or stenosis). Secondary outcomes were the rate of reoperations and the length of hospital stay. RESULTS: Baseline characteristics were similar between both groups. Intention-to-treat analysis revealed that there were no significant differences in the pooled incidences of anastomotic complications (p = 0.821). Regarding individual complications, we did not observe statistical differences between groups, including leakage (6.6% vs 4.8%; p = 0.518), hemorrhage (1.4% vs 1.3%; p = 0.431), or stenosis (2.9% vs 6.8%; p = 0.128). Again, no significant differences were observed in length of stay (7 days; p = 0.242) or rate of reoperation (7.3% vs 9.6%; p = 0.490). A patient (0.3%) in the control group died. LIMITATIONS: Sample size calculation was performed including all 3 of the complications, which may render it underpowered to detect differences regarding a specific complication. Anastomoses located within 5 cm from the anal verge were excluded from the study. CONCLUSIONS: The results obtained show that bioabsorbable staple line reinforcement in a colorectal anastomosis >5 cm from the anal verge does not reduce the rate of pooled anastomotic complications (ie, leaks, bleeding, or stenosis).

Proctitis actínica, hemorrágica crónica y refractaria. Experiencia con formaldehído al 4%

INTRODUCTION Bleeding is a common complication of proctitis secondary to radiotherapy of pelvic tumours. Between 5 and 10% may become severe and refractory to topical and endoscopic treatment. Experience with the application of 4% formaldehyde is presented. PATIENTS AND METHOD A retrospective and descriptive study was performed on a patient cohort with severe radiation proctitis admitted to the Hospital Universitario Donostia between January 2003 and September 2009. All patients were diagnosed by colonoscopy and admitted due to the severity of their treatment. Both 4% formaldehyde and the gauze technique were used, as well as using enemas, in cases refractory to topical and endoscopic treatment with argon. The technique was performed in theatre with regional anaesthetic. Clinical and endoscopic follow up was carried out. RESULTS The study included 25 males (73.5%) and 9 women (26.5%), with a mean age of 69 years (32-80) who had rectal bleeding due to radiation proctitis and required admission. All treatments failed in 6 (28.5%) patients, and 4% formaldehyde was used, with a complete response to the bleeding in all 6 patients, with 3 cases requiring one session, and the 3 others 2 sessions. The gauze technique was used in 4 patients and another 2 were given a formaldehyde enema due to the presence of stenosis. Pain appeared as the main complication in 2 (33.3%) patients. The median follow up was 60 months (interquartile range 26 to 67 months). CONCLUSIONS The use of 4% formaldehyde in bleeding due to radiation proctitis is an effective, easy to reproduce technique, with a low morbidity.

Exenteración pélvica total en el tratamiento de las neoplasias avanzadas, primarias o recurrentes, de vísceras pélvicas

INTRODUCTION Complete resection with clear margins in locally advanced pelvic visceral tumors, primary or recurrent, occasionally requires total pelvic exenteration (TPE). METHODS We reviewed the results of EFA in 34 consecutive patients operated on between June 2006 and December 2013. RESULTS Median age was 62 (40-82) years; 24 (70%) were male. The tumor origin most frequent was advanced primary rectal tumor (APRT), with 19 cases (55.9%) and most common type of exenteration was supraelevator (61.8%). R₀ resection was achieved in 24 (70.6%) patients and in 16 (85%) of the APRT. Fifteen (79%) patients had pT₄ APRT, and 4 (20%) pN +. Reconstruction of the bowel and bladder was performed with two stomas in 17 cases (50%), colorectal anastomosis and Bricker in 11 (32.3%) and wet double barreled colostomy in 6 (17.6%). There was no postoperative mortality; 23 (67,5%) patients had complications, and 5 (14.6%) required a postoperative reoperation to solve them. Median follow-up was 23 (13-45) months. Overall survival (OS) and disease free survival (DFS) at 2 years were 67% and 58% respectively, and the median OS and DFS was 59 months (95% CI 26-110) and 39 months (95% CI 14-64), respectively. The DFS of R₀ was significantly better (p=0.003) than R₁. CONCLUSIONS TPE is a potentially curative procedure for advanced pelvic visceral malignancies with similar morbi-mortality than other extended excisional surgery.

Estenosis anastomóticas benignas en la cirugía radical del cáncer de recto. Resultados del tratamiento con dilatación hidrostática

INTRODUCTION Benign anastomotic strictures after rectal cancer surgery are common and their treatment can vary from conservative measures to surgical resection. PATIENTS AND METHODS Between March 2001 and August 2008, 422 patients with rectal cancer underwent anterior resection and 83.8% were treated with primary anastomosis. Anastomotic stricture has been defined as the inability to pass a colonoscope. Hydrostatic balloon dilation was performed. Results of success and failure dilation were assessed. RESULTS Twenty-six patients (7.34%) with anastomotic stricture were treated; 16 men and 10 women, with a median age of 66 years (57-74). A total of 26 anterior resections were performed, as well as 10 end-to-end anastomosis, 10 side-to-end, 4 j-pouch and 2 pouch coloplasties. The median stricture height was 10cms (4-12). Thirteen patients had preoperative radiotherapy (50%), and 9 patients had an ileostomy (34.7%). The median time of diagnosis was 6 months (3-10). The diagnosis was made by: rectal digital examination in 19.2%, colonoscopy 23.1% and clinical symptoms in 57.7%. The median number of dilation sessions required was 2 (1-4). The median of follow-up was 39 months (23 to 49). Results were successful 88.5,% and unsuccessful in 11.5%. Morbidity was 3.8% (one perforation after dilation). There was no mortality. CONCLUSIONS Benign anastomotic strictures after rectal cancer surgery are frequent (7.05%), develop symptoms (52.9%) and can be successfully treated by hydrostatic dilation in more than 88% patients.

Fístula coloseminal sintomática tras radioquimioterapia y cirugía de cáncer de recto

Aunque las lesiones de las vesiculas seminales no son raras durante la cirugia del recto, la formacion de una fistula coloseminal es un hecho excepcional. Varon de 60 anos, sin antecedentes de interes. Diagnosticado de adenocarcinoma de recto a 4 cm del margen anal uT3N0. Con criterio preservador de esfinteres se trato con radioquimioterapia preoperatoria. Tras 6 semanas de intervalo, se realizo una reseccion anterior baja asistida por laparoscopia, con exeresis mesorrectal total, anastomosis coloanal con reservorio en J e ileostomia de proteccion. El estudio patologico no evidencio tumor residual y 14 ganglios negativos para tumor. Previa defecografia, a la 8. semana se cerro la ileostomia con alta al cuarto dia. Al decimo dia reingresa con dolor y engrosamiento del testiculo derecho, neumaturia y fecaluria. Con el diagnostico de orquiepididimitis por posible fistula colovesical o colouretral. se realizaron tomografia computarizada y enema opaco, sin hallazgos. La resonancia magnetica (fig. 1) mostro aire en vejiga y burbujas en vesicula seminal derecha con trayecto fistuloso entre el reservorio colonico y la vesicula seminal. Se instauro tratamiento con metronidazol, ciprofloxacino y finasteride durante 4 semanas; desaparecio la clinica y se normalizaron las pruebas de imagen. Tras 27 meses de control el paciente se encuentra asintomatico. Las lesiones seminales tras cirugia y radioterapia del cancer de recto no son tan infrecuentes; sin embargo, es excepcional su repercusion clinica, con sepsis pelviana, urinaria o testicular. La resonancia magnetica es el mejor metodo diagnostico. Se puede iniciar un tratamiento medico en ausencia de sepsis. Si fracasa, el drenaje percutaneo, la vasovasostomia y la colostomia de descarga son las opciones terapeuticas ensayadas. El finasteride anadido al tratamiento antibiotico reduce la secrecion seminal y puede favorecer su curacion.