Enrique Pellicer-Franco

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.

Colonografía tomográfica computarizada frente a enema opaco en el estudio preoperatorio del cáncer colorrectal en pacientes con colonoscopia incompleta

BACKGROUND AND OBJECTIVE: The complete preoperative evaluation of the colon is necessary in colorectal cancer owing to the frequency of synchronous tumors. The objective of this paper was to evaluate the utility of the computed tomography colonography (CTC) as opposed to barium enema (BEDC) when the colonoscopy was incomplete or impossible to perform. PATIENTS AND METHOD: Group A: 50 patients with colorectal cancer with subsequent incomplete colonoscopy and BEDC. Group B: 40 patients with colorectal cancer with subsequent incomplete colonoscopy and CTC. As gold standard to match the tests, we carried out the pathological study of the surgical piece and the colonoscopy 3 months after surgery. In addition, we studied the degree of satisfaction, indirect effect and cost by test. RESULTS: There were no synchronous tumors. For the detection of colonic polyps, we obtained for the CTC the following values: Sensitivity = 85.7%, Specificity = 96.1%, PPV = 92.3%, NPV = 92.6%, CPP = 21,97 and CPN =0,15. And for BEDC, the values were: Sensitivity = 23.5%, Specificity = 92.8%, PPV = 80%, NPV = 71.7%, CPP = 3.26 and CPN = 0.82 (p < 0.001). The degree of satisfaction was greater with CTC than with BEDC (p < 0.05). There were no differences as far as indirect effect was concerned. The cost of CTC was 33.18 Euros and it was 42.42 Euros for BEDC. CONCLUSION: CTC is better than BEDC both to confirm the presence of polyps in colon and to rule out the absence of them in patients in whom a complete the study of the colon by colonoscopy has not been possible.

Mejora de la calidad de vida en los pacientes con incontinencia fecal tratados con estimulación de raíces sacras

INTRODUCTION Faecal incontinence (FI) is a highly prevalent disorder that severely affects the health related quality of life (HRQOL) of the patients who suffer from it. Neuromodulation is a minimally invasive treatment that has demonstrated its efficacy in the treatment of FI symptoms over the past 10 years. The aim of this study is to check whether there is an improvement in the quality of life, using EuroQuol (EQ-5D), in patients with faecal incontinence treated with sacral root neuromodulation. METHODOLOGY An observational study with prospective recording of quality of life data, before and after, using the EQ-5D on a series of patients diagnosed with moderate to severe FI with a complete or repaired sphincter who had a definitive MEDTRONIC Interstim(®) 3023 implant after a subchronic stimulation phase with a good response. RESULTS The initial mean number of leaks was 3.1±1, and the final was 0.5±0.6. The mean number of escapes per week decreased to 2.6 escapes (CI 95%: 2.1-3.1) after the definitive implant of the sacral root stimulator (P<.001). The mean baseline health status score was 55.9±13, and after neuromodulation it was 63.1±13. Thus, the visual analogue scale score increased by 7.1 points (CI 95%: 0.37-14) after the definitive implant of the sacral root stimulator (P<.05). In the HRQOL variables studied with the EQ-5D questionnaire, we found an improvement with neuromodulation in the mobility and the presence of anxiety and/or depression variables. On the other hand we found an improvement with the neurostimulator implant, which was not significant, in personal care, performing daily activities and the presence of pain and/or discomfort. The current health was better in 11 patients (57.9%), the same in 7 (36.8%) and worse in 1 (5.3%). CONCLUSIONS Neuromodulation is a therapy that has demonstrated a significant improvement in HRQOL measured with the EQ-5D.

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.

Schwannoma en colon descendente: presentación de una neoplasia en rara localización

Presentamos un varón de 67 años en el que la colonoscopia de cribado evidenció, a 35 cm del margen anal, una lesión polipoidea ulcerada. La biopsia fue inespecífica. La TC y la colonografía virtual mostraron una masa polipoidea en colon izquierdo de 4,5x3,6x3,7 cm con adenopatías regionales, sin metástasis a distancia. El paciente acudió a urgencias por rectorragia y dolor abdominal. La ecografía mostró una invaginación cólico-cólica originada por la masa polipoidea. Se intervino mediante laparotomía media objetivándose una invaginación en colon descendente, sin observar infiltración ni diseminación a distancia. Se realizó una colectomía segmentaria con anastomosis latero-lateral mecánica. El paciente evolucionó favorablemente. El estudio anatomopatológico informó de una tumoración blanco-amarillenta submucosa bien delimitada constituida por células fusiformes que formaban empalizadas, un infiltrado linfoide intratumoral con nódulos periféricos y escasa actividad mitótica. La inmunohistoquímica dio positividad para S-100 y CD68, no habiendo reactividad para CD117, CD34, actina y CD10 (Fig. 1). El diagnóstico definitivo fue de schwannoma de colon. En 3 años de seguimiento no se ha evidenciado recidiva.

Evaluation of a clinical pathway to improve colorectal cancer outcomes.

The aims of this preintervention and postintervention study were to monitor and evaluate the clinical pathway (CP) for colorectal cancer (CRC) over a 5-year period and to compare 2 groups of patients (before and after the intervention) with regard to different variables of effectiveness. Group I comprised 68 patients who underwent planned surgery between January 2002 and January 2003. Group II comprised a sample of 202 patients who underwent surgery between January 2004 and December 2008. No significant differences were found in the majority of the parameters measured: postoperative stay, compliance with antibiotic prophylaxis, compliance with the staging study, mortality, rate of infection, and reoperations. The mean length of stay (±standard deviation) for patients without complications was reduced significantly (9.2 ± 3.6 in group I versus 7.7 ± 1.7 in group II, P = .031). The CP for CRC did not achieve most of the objectives for which it was designed.

Population-based screening improves histopathological prognostic factors in colorectal cancer

IntroductionDiagnosis 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 methodsThe 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.ResultsCompared 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).ConclusionsCRC diagnosed through a population-based screening programme presents more favourable histopathological characteristics than that diagnosed from the appearance of symptoms.

Single-port transanal endoscopic microsurgery: a developing technique.

Introduction: Transanal endoscopic microsurgery is a widely used and valid technique with established indications. However, the cost of surgical anoscopes is not available in all centers. Many authors have described transanal resection of rectal tumors through a single laparoscopy port such as the SILS system. Materials and Methods: We analyzed 5 cases of patients undergoing transanal resection with an SILS device. The clinical, surgical, and oncological data were assessed. Results: The median distance to the anal margin was 7.2 cm (range, 5 to 10 cm) and median tumor size was 3 cm (range, 1 to 6 cm). Median operating time was 75 minutes (range, 60 to 120 min). A postsurgical rectorrhagia occurred in 1 of the case. Two cases were adenocarcinoma, 2 were adenomas, and the other was a mucosa without any tumor remnants. The margins were negative in all cases. Conclusions: Transanal resection of rectal tumors using the SILS technique is a feasible procedure. Longer series and prospective studies are necessary.

Sobre la productividad científica de los médicos residentes de cirugía general y digestiva

Recently, an interesting and important Letter to the Editor was published in which Parés called attention to the low scientific productivity of resident physicians of our specialty. The scientific activity of our residents, measured as written publications and contributions to congresses, does not meet the standards set by the program of our specialty, as demonstrated in a previous study by Serra-Aracil et al. Probable solutions and incentives are proposed, such as stimulating critical review of the literature, increasing the conversion of previous oral communications into publications, structured and progressive planning of scientific activity and practical training in this part of clinical research through workshop courses. A word of necessary advice is also given: what is truly important is not to publish for the sake of publishing, but to generate knowledge. There is no doubt that Dr. Parés’s letter shows wisdom and excellent timing. Every now and then a voice arises to preach in this wilderness. But more should still be said. It is essential for there to have a leadership in general surgery departments, both in clinical practice and in research. To this end, department heads, unit directors and medical resident tutors all need to be able to demonstrate sufficient scientific background. Although generalizations are unfair, one must admit that the current system of promotion or selection of these positions is frequently capricious, arbitrary or even nonexistent. We could say the same about the Spanish Association of Surgeons or the regional societies with regards to some committee-member positions. When selecting department heads and directors, objective requirements and indicators should be used to assess potential researchers, such as the possession of a doctorate, impact factor, h index or the number of publications that meet quality criteria. This experience or research potential should complement clinical or management needs. Research and clinical practice are inseparable, but in a large number of cases the routine of patient care consumes all the resources or is used as a weak excuse to justify the lack of research activities. Other times, there may even be open resentment toward scientific work. Resident doctors will do as they see being done, reproducing these learned behaviors in many cases. The low research profile of many chiefs, coordinators and those with similar positions makes it nearly impossible to stimulate the scientific production that Parés and Serra-Aracil find lacking. If those in charge do not encourage, require, facilitate or award research, it will languish. Another unresolved problem is the sufficient, fair and necessary recognition of the research work done by residents when later promoted to a work position. It is the responsibility of all of us but especially those in leadership positions on tribunals, commissions and committees that have the possibility to demand not unattainable excellence but instead a minimal objective and simple threshold of merits in the designation or selection of heads of Spanish general surgery units. Furthermore, surgical teaching departments should be rewarded or penalized depending on the scientific and research activity demonstrated by their residents. One way of doing so would be to increase the teaching capabilities of productive departments and reduce that of those which are not. c i r e s p . 2 0 1 4 ; 9 2 ( 4 ) : 2 9 7 – 2 9 8

Estimulación de raíces sacras para el dolor anal intratable

Chronic anal pain is a common condition related to several pathologies, from proctalgia fugax to coccydynia or anismus. Its presentation usually causes psychosocial disturbance to patients, which leads to a poor quality of life. The etiology continues to be unknown, although some findings, such as increased anal canal pressure,myopathy of the internal anal sphincter or neuropathy of the pudendal nerve caused by entrapment or perineal descent, have been described associated to certain patient groups. Psychological factors have also been considered as a possible etiologic factor of these symptoms, although most patients demonstrate associated depression as a result of several months of untreatable anal pain. To date, no treatment has been shown effective for chronic anal or perianal pain. There have been reports using lateral internal sphincterotomy, nitroglycerin or botulinum toxin injection with no significant improvements reproducible by other authors. Sacral nerve stimulation (SNS) was first used in 2007 to treat a case of idiopathic chronic anal pain and another study was later published to demonstrate its usefulness. We present 3 cases of patients with chronic idiopathic anal pain that was resistant to treatment and was treated with sacral root stimulation. The 3 patients (Table 1) were assessed by endoanal ultrasound and rectoscopy to rule out organic pathologies responsible for the symptoms. We also ruled out suppurative disease, anal fissure, hemorrhoids or other pathologies that would explain the symptoms. Patients were assessed and treated by the Pain Management Unit and were once again referred to our department because they did not respond to medical treatment and required high doses of opioid analgesics that failed to control their symptoms. The SNS surgical technique has been previously published by the authors and it consists of the first stage of acute stimulation done under local anesthesia and placement of a quadripolar electrode (R 3889-28, Medtronic, Minneapolis, USA). Responses to stimulation were assessed at different voltages, leaving the stimulation electrode in the sacral foramina of the root that obtained the best sensory-motor response, which was then connected to an external currentgenerating device. During the second stage of subchronic stimulation, patients evaluated the effectiveness of the stimulation current using the EQ-5D and visual analog scale (VAS). The third stage, or permanent stimulation, was performed only if the results were satisfactory and involved the placement of an internal battery in a subcutaneous space in the buttocks, which is also done under local anesthesia. Definitive neuromodulator placement was decided upon when there was an improvement of at least 50% in the perception of quality of life and VAS pain scale. The stimuli ranged from 0.5 to 1.5 V, and the pulse width and frequency were constant (210 ms and 25 Hz, respectively). Stimulation was initially done in continuous mode and, at times, in discontinuous mode if the response was not sufficient. In order to measure the effectiveness of the treatment, 3 patients were given the self-administered visual analog pain scale (1 no pain, 10 maximum pain) and also the selfadministered EuroQol-5D (EQ-5D) questionnaire before the intervention and one and six months after it (in the 2 patients with definitive implants). The EQ-5D questionnaire consists of 2 parts: the first allows the patient to define health status according to the EQ-5D multi-attribute classification system (5 dimensions: mobility, personal care, daily activities, pain/ discomfort and anxiety/depression); the second part is a visual analog scale (VAS) graded from 0 (‘‘worst imaginable health state’’) to 100 (‘‘best imaginable health state’’). One-digit numbers (1, 2 or 3) are obtained to express the level selected for each dimension. Two of the 3 patients (Table 2) obtained improvement in the perception of pain (VAS) of more than 50% and an improvement in perceived health status of more than 50% that has continued to date after a follow-up of 24 months in the first patient and 18 months in the second patient. The third patient experienced no improvement in these or other parameters; therefore, the intensity, frequency and amplitude parameters were changed, but, after no response in pain perception was detected, the placement of the definitive stimulator was not performed.