Francisco Puig Blanco

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.

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.

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 therefore analyzed for this study. Endorectal ultrasound was performed in all six patients and rectal cancer was diagnosed in five of them; MRI was performed in four patients and a diagnosis of rectal cancer was assessed in three of them; rectal cancer was finally ruled out in all cases by deep-forceps macrobiopsies. The incidence of misdiagnosis between SRUS and rectal cancer does not decrease with the regular use of imaging methods. Clinical judgment and deep-forceps macrobiopsies are essential in avoiding an erroneous diagnosis.

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 to form an occlusive tourniquet. Occlusive tourniquet applied to laparoscopic technique: similar to the open technique, tubing is passed through the left iliac fossa trocar and passed behind the sigmoid mesocolon. This simple procedure allows easy exposure and dissection of the mesorectum, without traumatizing the rectum/sigmoid colon or the tumor and lavage can be performed without the need for clamps or other instruments which may traumatize the rectum and provoke anastomotic failure. In conclusion, the occlusive tourniquet is a simple method for rectal stump washout so this step can be done.