Eduardo García-Granero

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 A (BOTOX®) on each side of the anal sphincter (total dose, 10 U) constituted the first group. In a second group 27 patients were injected as previously described, with an additional 5-U injection below the fissure (total dose, 15 U). The 19 patients constituting the third group received a 7-U injection on each side of the anus and below the fissure (total dose, 21 U). All patients were followed up for at least six months. RESULTS: Pain relief one month after treatment was more evident in the second and the third group (48 percent of patients in the first group, 74 percent in the second group, and 100 percent in the third group). A significant reduction of the mean resting pressure was demonstrated only in Groups II and III (P<0.05), whereas the mean squeeze pressure significantly decreased in the three groups (P<0.01 in Group I andP<0.001 in Groups II and III). Fifty-two percent of the patients in the first group, 30 percent in the second group, and 37 percent in the third group were reinjected during the follow-up period, because of persistence of symptomatology or early relapse. The need for surgery was similar in the first and the second group (17 and 19 percent, respectively) and clearly lower in the last group (5 percent). No serious complications or incontinence attributable to this therapeutic modality developed in any patient. CONCLUSIONS: Intrasphincteric injection of botulinum toxin is a reliable new option in the treatment of uncomplicated chronic anal fissure. The healing rate is related to the dose and probably to the number of puncture sites. No permanent damage to the continence mechanism was detected in these patients.

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

Aim: A prospective review of the complications of ileostomy construction and takedown. Materials and Methods: 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. Results: One hundred twenty-seven (73 male, 54 female) patients, mean age 54 years were included from 1992 to 2002. Seventy-two patients underwent anterior resection for low rectal carcinoma, 30 an ileoanal pouch for ulcerative colitis and 25 for miscellaneous conditions. Fifty-nine pre-takedown complications occurred in 50 (39.4%) patients. The most common were dermatitis (12.6%) and erythema (7.1%). The most severe were dehydration in 1 patient and stomal prolapse in 4 patients. Closure was associated with a complication rate of 33.1% and a mortality rate of 0.9%. Wound infection occurred in 18.3% and small bowel obstruction in 4.6%. Anastomotic leak requiring reanastomosis occurred in 2.8% and enterocutaneous fistula treated conservatively in 5.5%. There were no statistically significant differences in morbidity between closure techniques (p = 0.892). There were no statistically significant differences in complications (p = 0.516) between patients with ulcerative colitis and those with neoplasia (39.29% vs. 32.2%). Conclusions: Loop ileostomy construction and takedown is associated with considerable morbidity, mostly minor. No differences exist between technique used for closure or the baseline pathology of the patient.

Risk Factors for Anastomotic Leak After Colon Resection for Cancer: Multivariate Analysis and Nomogram From a Multicentric, Prospective, National Study With 3193 Patients.

OBJECTIVE To determine pre-/intraoperative risk factors for anastomotic leak after colon resection for cancer and to create a practical instrument for predicting anastomotic leak risk. BACKGROUND Anastomotic leak is still the most dreaded complication in colorectal surgery. Many risk factors have been identified to date, but multicentric prospective studies on anastomotic leak after colon resection are lacking. METHODS Fifty-two hospitals participated in this prospective, observational study. Data of 3193 patients, operated for colon cancer with primary anastomosis without stoma, were included in a prospective online database (September 2011-September 2012). Forty-two pre-/intraoperative variables, related to patient, tumor, surgical procedure, and hospital, were analyzed as potential independent risk factors for anastomotic leak (60-day follow-up). A nomogram was created to easily predict the risk of anastomotic leak for a given patient. RESULTS The anastomotic leak rate was 8.7%, and widely varied between hospitals (variance of 0.24 on the logit scale). Anastomotic leak significantly increased mortality (15.2% vs 1.9% in patients without anastomotic leak, P < 0.0001) and length of hospitalization (median 23 vs 7 days in uncomplicated patients, P < 0.0001). In the multivariate analysis, the following variables were independent risk factors for anastomotic leak: obesity [P = 0.003, odds ratio (OR) = 2.7], preoperative serum total proteins (P = 0.03, OR = 0.7 per g/dL), male sex (P = 0.03, OR = 1.6), ongoing anticoagulant treatment (P = 0.05, OR = 1.8), intraoperative complication (P = 0.03, OR = 2.2), and number of hospital beds (P = 0.04, OR = 0.95 per 100 beds). CONCLUSIONS Anastomotic leak after colon resection for cancer is a frequent, relevant complication. Patients, surgical technique, and hospital are all important determining factors of anastomotic leak risk.

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

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

BACKGROUND: 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. OBJECTIVE: The aim of this study was to determine whether procalcitonin and C-reactive protein are good predictors of anastomotic leak in colorectal surgery. DESIGN: This is a prospective observational study. SETTINGS: This study was conducted by a specialized colorectal multidisciplinary team of a tertiary teaching hospital. PATIENTS: 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 postoperative days, procalcitonin, C-reactive protein, leukocytes, platelets, and vital signs were evaluated daily. INTERVENTIONS: Daily assessment of clinical variable and serological data were conducted in the first 5 postoperative days. MAIN OUTCOME MEASURES: The primary outcome measure was the area under the curve at receiving operating characteristic curve analysis of the different variables in relation to the anastomotic leak. RESULTS: Anastomotic leak was detected in 17 (8.3%) patients; 11(5.4%) of the patients had a major anastomotic leak (need for drainage or reoperation). None of the variables evaluated were shown to be reliable in the early detection of anastomotic leak, considering both minor and major (maximum area under the curve <0.80). In contrast, when considering only major anastomotic leaks, procalcitonin and C-reactive protein were reliable predictors on postoperative days 3 to 5 (p < 0.0001, area under the curve >0.80). The best combination was procalcitonin at postoperative day 5 (area under the curve = 0.86), with a cutoff of 0.31 ng/mL, resulting in a 100% sensitivity, 72% specificity, 100% negative predictive value, and 17% positive predictive value. LIMITATIONS: Only symptomatic patients were investigated to rule out anastomotic leakage. CONCLUSIONS: Procalcitonin and C-reactive protein are both reliable predictors of major anastomotic leak after colorectal resection, although procalcitonin is more accurate. Raised procalcitonin and C-reactive protein serum concentration on postoperative days 3 to 5 renders necessary a careful evaluation of the patient before discharge.

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

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.

Real time quantification in plasma of human telomerase reverse transcriptase (hTERT) mRNA in patients with colorectal cancer

Background  Increased telomerase activity can be found in almost 90% of colorectal tumours. We aim to describe the preliminary results for quantification in plasma of hTERT mRNA in colorectal cancer patients.

Early Prediction of Anastomotic Leak in Colorectal Cancer Surgery by Intramucosal pH

PurposeAdequate oxygenation is necessary for anastomotic healing, and ischemia has been found to be one of the most important factors in anastomotic leakage. This study was designed to assess the value of early postoperative intramucosal pH measurements for the prediction of anastomotic leakage in patients with colorectal anastomosis.MethodsA prospective study of 90 patients with rectal or sigmoid cancer with primary anastomosis was conducted. In all patients intramucosal pH was determined by using tonometry at the anastomotic and gastric levels during the first 24 and 48 hours postoperatively. Seven other variables also were tested by univariate and multivariate analysis for any association with anastomotic leakage.ResultsThe rate of clinical anastomotic leakage was 6.6 percent. Multivariate analysis showed that only the intramucosal pH at the anastomosis was an independent factor for the development of anastomotic leakage. The risk of leakage was 22 times higher in patients with an anastomotic intramucosal pH < 7.28 in the first 24 hours after surgery.ConclusionsMeasurement of anastomotic intramucosal pH in the early postoperative period can more accurately predict the risk of anastomotic leakage and benefit those patients who would need additional measures to improve the viability of the anastomosis.

Impact of surgeon organization and specialization in rectal cancer outcome.

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.

Macroscopic Assessment of Mesorectal Excision in Rectal Cancer: A Useful Tool for Improving Quality Control in a Multidisciplinary Team

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.