Graciela Valero-Navarro

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.

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.

Necrosis intestinal segmentaria en paciente joven

Segmental ischemic colitis is an uncommon disease in young patients, being usually associated to drug abuse, infectious or autoimmune diseases. We present a case that, in spite of a complete diagnostic study, had repeatedly two attacks of intestinal necrosis during his admission.

Surgical management of appendiceal adenocarcinoid: case report and literature review

Adenocarcinoid tumour of the appendix is a rare entity characterised by the presence of a double component (neuroendocrine and glandular). It originates in the neuroendocrine cells of the appendicular mucosa. A preoperative diagnosis of a primary appendiceal tumour is uncommon and more so one suggesting an adenocarcinoid pathology. Optimal treatment is debated between a simple appendectomy and a more extensive resection, which occasionally includes hysterectomy and bilateral ovariectomy. Our aim is to report this rare entity and conduct a review of the literature on the different treatment options.

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.

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.