José Andrés García-Marín

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.

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.

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.

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.

Úlcera de Marjolin: experiencia de 10 años en una unidad de pie diabético

BACKGROUND Marjolins ulcer is defined as the appearance of a neoplasm within a chronic wound. The most common histological type is squamous. A total of 2 cases treated in our hospital are presented. CLINICAL CASE Case 1. A 71 year old man who presented with redness and suppuration from the wounds he had in his right foot after an electric shock 40 years earlier. The radiology showed involvement of the 4° and 5° metatarsal. Supracondylar amputation was performed, showing a well-differentiated invasive squamous cell carcinoma. CASE 2 A 56 year old male, paraplegic for 20 years. He was treated due to an infected right heel ulcer, with partial improvement, but the ulcers persisted. Biopsy was performed, reporting as epidermoid carcinoma. Infracondylar amputation was performed. The diagnosis was a well-differentiated squamous cell carcinoma infiltrating the dermis. CONCLUSION The prevalence of Marjolins ulcer is 1.3-2.2% of all ulcers. Diagnosis is difficult, so biopsy is recommended on any suspicious lesion or ulcer that has received conservative treatment for one month without improvement, although this time limit is not clear. The treatment is the surgery. Local excision with a margin of an inch is enough. If the ulcer is extensive, amputation is required. Survival is estimated between 66 and 80% at 2 years, with recurrence rates of 23%. Unfavourable factors are poor tumour differentiation and metástasis, appearing in 20% of cases.

Chylous Fistula following Axillary Lymphadenectomy: Benefit of Octreotide Treatment.

Chyle leak following axillary lymph node clearance is a rare yet important complication. The treatment of postoperative chyle fistula still remains unclear. Conservative management is the first line of treatment. It includes axillary drains on continuous suction, pressure dressings, bed rest, and nutritional modifications. The use of somatostatin analogue is well documented as a treatment for chylous fistulas after neck surgery. We present a case of chylous fistula after axillary surgery resolved with the use of octreotide.

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.

Venous intestinal ischemia due to G20210A mutation of prothrombin gene

Venous intestinal ischemia is a relatively rare disease, which has some predisposing factor up to 80 % of cases. These factors may be temporary or permanent. Cancer, immobilization, trauma, intraabdominal infections, or oral contraceptives are temporary factors. Paroxysmal nocturnal hemoglobinuria and hypercoagulability states as factor V Leiden, G20210A mutation in prothrombin gene, C677T methylene-tetrahydrofolate reductase, protein C and S deficiency, antithrombine III deficiency or antiphospholipid syndrome are permanent factors. We report a case diagnosed and treated in our center.