Marta Pascual

Postoperative peritoneal infection enhances migration and invasion capacities of tumor cells in vitro: an insight into the association between anastomotic leak and recurrence after surgery for colorectal cancer.

Objective:The aim of this study was to investigate the effect of postoperative peritoneal infection on proliferation, migration, and invasion capacities of cancer cells lines in vitro after surgery for colorectal cancer. Background:Anastomotic leakage is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. We hypothesized that the infection-induced inflammatory response may enhance tumor progression features of residual cancer cells. Methods:Prospective matched cohort study. Patients undergoing surgery for colorectal cancer with curative intent (January 2008—March 2012) were included. Patients who had an anastomotic leak or intra-abdominal abscess were included in the infection group (n = 47). For each case patient, another patient with an uncomplicated postoperative course was selected for the control group (n = 47).In vitro treatments on cancer cell lines (MDA-MB-231 and SW620) were performed using baseline and postoperative serum and peritoneal fluid samples to determine cell proliferation and cell migration/invasion activities. Results:Postoperative peritoneal fluid from infected patients enhanced both cell migration (infection: 140 ± 85 vs control: 94 ± 30; P = 0.016) and cell invasion (infection: 117 ± 31 vs control: 103 ± 16; P = 0.024) capacities of cancer cell lines. With serum samples, these effects were only observed in cell migration assays (infection: 98 ± 28 vs control: 87 ± 17; P = 0.005). Some minor activation of cell proliferation was observed by treatment with serum from infection group. Two-year cumulative disease-free survival was significantly lower in patients with postoperative peritoneal infection (infection: 77.6% vs control: 90.6%; P = 0.032). Conclusions:Our results suggest that postoperative peritoneal infection enhances the invasive capacity of residual tumor cells after surgery, thus facilitating their growth to recurrent tumors.

Postoperative intra-abdominal infection increases angiogenesis and tumor recurrence after surgical excision of colon cancer in mice

BACKGROUND Recent reports have suggested that anastomotic leakage is associated with greater rates of tumor recurrence and cancer-specific mortality after surgery for colorectal cancer. The impact of postoperative intra-abdominal infection on long-term oncologic results, however, is still controversial, and no direct causal relationship has been found between both processes. Our aim was to investigate the influence of postoperative intraabdominal infection on angiogenesis and tumor growth in an animal model of colon cancer. METHODS Balb/c mice were randomized immediately after injection of 5x10(6) B51LiM cells into the cecal wall into 2 groups: cecal resection without postoperative infection (group 1), and cecal resection with postoperative intra-abdominal infection (group 2). A total of 18 days after cell injection, cecectomy was performed, and infection was induced in group 2 by intraperitoneal injection of 3x10(8) colony-forming units of Bacteroides fragilis. On postoperative day 12, the mice were killed. RESULTS Comparing group 1 with group 2, tumor recurrence was more frequent in animals with intraabdominal infection (65% vs 100%, respectively; P=02). VEGF serum levels were greater at the time of sacrifice in the group with infection (11+/-10 vs 30+/-23 pg/mL; P<.05). Tumor angiogenesis was also increased in the postoperative infection group. The mean (+/-standard deviation) microvessel density was 16+/-7 versus 28+/-11 vessels per high-power field (P<.05). CONCLUSION We concluded that postoperative intra-abdominal infection increases angiogenesis and tumor recurrence after operative excision of a colon cancer in mice.

Management of lower gastrointestinal bleeding after colorectal resection and stapled anastomosis

BackgroundAlthough limited haematochezia with the first bowel movement is frequent in patients undergoing colorectal resection, postoperative life-threatening lower gastrointestinal bleeding is very rare. The purpose of this study was to review our results in the management of this complication.MethodsWe analysed the cases of patients with severe lower gastrointestinal bleeding after colorectal surgery from 2000 to 2006 in our hospital. We studied the general characteristics, diagnostic data, therapeutic management and outcome. We also reviewed the published articles regarding this issue.ResultsThis complication appeared in 7 (0.5%) of 1,389 colorectal procedures in the study period. In all the patients the anastomosis was stapled. In six of the seven patients bleeding resolved with conservative treatment including endoscopy. However, one patient required surgical treatment. There was no mortality and there were no anastomotic leaks in these seven patients.ConclusionSevere lower gastrointestinal bleeding after colorectal resection and stapled anastomosis is a rare complication. Only in unstable patients or failure of conservative measures is surgery indicated.

Cuál es la calidad metodológica de los artículos sobre procedimientos terapéuticos publicados en Cirugía Española

Introduccion. El objetivo de este estudio fue determinar la calidad metodologica de los articulos publicados sobre procedimientos terapeuticos en la revista Cirugia Espanola y su asociacion con el ano de publicacion, su procedencia y el area tematica estudiada. Material y metodo. Estudio bibliometrico que analiza todos los articulos publicados en Cirugia Espanola entre los anos 2001 y 2004 relacionados con procedimientos terapeuticos. Se analizo cualquier tipo de diseno, excluyendo editoriales, articulos de revision, cartas al director y estudios experimentales. Las variables que se consideraron fueron: ano de publicacion, procedencia, area tematica, diseno y calidad metodologica. Se aplico un analisis de calidad metodologica que empleo una escala valida y confiable. Se utilizo estadistica descriptiva (calculo de promedios, desviacion estandar y medianas) y analitica (?² de Pearson, no parametricos, ANOVA y Bonferroni). Resultados. Se estudiaron 244 articulos (197 [81%] series de casos, 28 [12%] estudios de cohortes, 17 [7%] ensayos clinicos y 1 estudio de corte transversal y otro de casos y controles [0,8%]). Los estudios provenian preferentemente de Cataluna y Murcia, con un 22 y un 16%, respectivamente. Las areas tematicas con mayor numero de publicaciones fueron la cirugia de partes blandas y la hepatobiliopancreatica, con un 23 y un 19%, respectivamente. El promedio y mediana de la calidad metodologica de la totalidad de la serie fueron 10,2 ± 3,9 puntos y 9,5 puntos, respectivamente. Se verifico un incremento significativo de la calidad metodologica por ano de publicacion (p < 0,001). Se observo una asociacion entre la calidad metodologica y el area tematica. Sin embargo, no se verifico asociacion alguna con la procedencia ni con el caracter universitario del centro generador de las publicaciones. Conclusiones. Se constato una tendencia significativa al alza en la calidad metodologica de los estudios relacionados con los procedimientos terapeuticos publicados en Cirugia Espanola entre los anos 2001 y 2004. Sin embargo, su calidad media es mejorable.

Tratamiento de la fístula rectouretral tras prostatectomía radical mediante la exposición transesfinteriana posterior de York Mason

Resumen Introduccion La fistula rectouretral tras prostatectomia radical es una complicacion poco frecuente que ocurre en menos de un 2% de los casos. El objetivo es analizar nuestra experiencia en el tratamiento de la fistula rectouretral mediante la exposicion transesfinteriana posterior de York Mason. Pacientes y metodo Estudio retrospectivo. Se ha incluido a todos los pacientes intervenidos en nuestro hospital de fistula rectouretral tras prostatectomia radical. En todos los casos se realizo la tecnica de York Mason. Resultados Durante los ultimos 6 anos, 5 pacientes han precisado tratamiento quirurgico de fistula rectouretral tras prostatectomia radical. Los sintomas (fecaluria y/o emision de orina por ano) aparecieron entre el cuarto dia y las 7 semanas tras la intervencion, y la fistula fue confirmada mediante cistografia. En 3 pacientes se practico una colostomia sigmoidea derivativa en el momento del diagnostico, mientras que en los otros 2 el diagnostico fue tardio y se realizo la derivacion fecal mediante ileostomia en el momento de la reparacion de la fistula. La reparacion transesfinteriana posterior se realizo entre 5 y 10 meses despues del diagnostico. Dos pacientes presentaron infeccion de la herida que no afecto a la reconstruccion esfinteriana y otros 2 presentaron dehiscencia cutanea sin infeccion. Ninguno de los pacientes ha tenido recidiva tras un seguimiento medio de 22 (4-40) meses, y la continencia, una vez cerrados los estomas, es completa en todos los casos. Conclusiones La reparacion mediante la via de abordaje transesfinteriana posterior de York Mason proporciona excelentes resultados en el tratamiento de la fistula rectouretral.

Preoperative administration of erythropoietin stimulates tumor recurrence after surgical excision of colon cancer in mice by a vascular endothelial growth factor-independent mechanism.

BACKGROUND It has been suggested that preoperative administration of erythropoietin (Epo) in patients with gastrointestinal cancer reduces transfusional needs and is also associated with lower morbidity. On the other hand, experimental and clinical studies show that Epo might enhance tumor growth and angiogenesis. Our aim was to ascertain whether preoperative administration of Epo has any effect on tumor recurrence after curative surgery using an experimental model of colon cancer. MATERIALS AND METHODS We induced tumors by injecting B51LiM colon cancer cells into the cecal wall of Balb/c mice. We randomized the animals into three groups of treatment with (1) recombinant human Epo, (2) recombinant mouse Epo, or (3) vehicle alone, for 12 d until cecectomy. On postoperative day 12, we killed mice and analyzed tumor recurrence. We measured serum levels of vascular endothelial growth factor and determined vascular endothelial growth factor expression and tumor microvessel density by immunohistochemistry. We also investigated the in vitro effect of Epo on B51LiM cell line proliferation. RESULTS All three groups displayed tumor recurrence, but the final tumor load score and total tumoral weight were higher in the two groups that included Epo. The differences were statistically significant when we compared the recombinant mouse Epo group with the control group. We found no evidence of increased angiogenesis or enhanced cell proliferation as possible mechanisms of Epo-induced recurrence. CONCLUSIONS Preoperative administration of Epo stimulates tumor recurrence in an animal model of colon cancer. Our results point to the need for further research on the mechanisms of tumor growth enhancement by Epo, to better understand the benefits or disadvantages of Epo treatment.

Estándares de calidad de la cirugía del cáncer de recto

Resumen Los resultados en cirugia del cancer de recto se han medido clasicamente mediante indicadores como la morbilidad, la mortalidad y la estancia hospitalaria. En los ultimos anos se han incluido otros parametros que valoran la calidad asistencial, como los resultados funcionales de la tecnica quirurgica y la calidad de vida. La exeresis total del mesorrecto, realizada por cirujanos con experiencia, es la tecnica quirurgica de eleccion. En la actualidad es posible preservar los esfinteres en mas del 70% de los casos. La dehiscencia anastomotica despues de una reseccion anterior de recto es la complicacion mas grave y el factor de riesgo mas importante es la altura de la anastomosis. En conjunto, la tasa global de dehiscencias debe ser inferior al 15% y la mortalidad operatoria entre el 2 y el 3%. El reservorio colonico mejora el resultado funcional por lo que es el procedimiento de eleccion para reconstruir el transito tras una reseccion anterior baja. La recurrencia local debe ser inferior al 10% y la supervivencia a los 5 anos, entre el 70 y el 80%. En general, la calidad de vida es superior despues de una reseccion anterior de recto en comparacion con la amputacion abdominoperineal a pesar del deterioro funcional que presentan algunos pacientes.

Resultados clínicos del cierre de ileostomías en asa en pacientes intervenidos de cáncer de recto. Efecto de la quimioterapia en el tiempo de espera

INTRODUCTION The introduction of sphincter preservation surgery in rectal cancer has led to an increase in the number of low resections protected with a loop ileostomy. This requires subsequent closure of the stoma, a surgical procedure which is not devoid of morbidity or mortality. The aims of the study were to analyse the clinical results of the passage reconstruction surgery and to find out the interval between both surgeries, as well as the role chemotherapy plays in this. PATIENTS AND METHOD The prospective data of patients previously operated on for rectal cancer were used retrospectively with those whose ileostomy was closed between May 2004 and September 2008. Data associated to chemotherapy indication, interval between surgeries and complications were collected and analysed. RESULTS A total of 54 consecutive patients with a mean age of 66 years were analysed. The mean interval between surgeries was 178 days, being significantly less in the patient group that did not receive chemotherapy (p=0.008). The post-operative stay was 6.3 days (SD=4.1). Mortality due to respiratory failure was 1.8% and the morbidity was 22.2%, with 7.4% requiring further surgery. CONCLUSIONS The mortality and morbidity of ileostomy closures are not inconsiderable, although its advantages in the protection of the stoma justify its use. The ileostomy construction interval appears to be significantly affected by post-operative chemotherapy.

Rehabilitación multimodal en cirugía electiva colorrectal: evaluación de la curva de aprendizaje con 300 pacientes

INTRODUCTION The aim of this paper is to assess the learning curve on compliance to the application of a multimodal rehabilitation program (MMRP) protocol and patient recovery after elective colorectal surgery. MATERIAL AND METHODS A comparative prospective study of 3 consecutive cohorts of 100 patients (P1, P2 and P3) who had colonic or rectal surgery. The same MMRP protocol was applied in all cases. Compliance to the protocol, tolerance to the diet and walking have been analysed. The percentages of early hospital discharges have also been compared. RESULTS Compliance gradually improved, reaching statistical significance between P1 and P3. Starting the diet on day 1 post-surgery was 52% vs 86% (p=0.0001) and the removal of drips was 21% vs 40% (p=0.005). This difference remained during days 2 and 3. Tolerance to the diet on day 1 (P1: 34% vs. P3: 66%; p=0.0001) and walking on day 2 (P1: 41% vs. P3: 68%; p=0.0002) were also better in the third period. No differences in morbidity were found between the three periods. The percentage of hospital discharges on day 3 P1: 1% vs. P3: 15%; p=0.0003), day 4 (P1: 12% vs. P3: 32%; p=0.001) and day 5 (P1: 30% vs. P3: 50%; p=0.002) was higher in the third period. CONCLUSIONS The compliance to the protocol and the results of applying the MMRP improved significantly with the greater experience of the professionals involved.

Descripción de los hallazgos de la ecografía endoanal en pacientes con incontinencia fecal mediante un sistema de puntuación

INTRODUCTION The main aim of the study was to apply a severity classification of sphincter lesions detected by endoanal ultrasound using Starck score in patients who suffered faecal incontinence. MATERIAL AND METHOD Data were analysed on 133 patients with faecal incontinence. Those in whom anal sphincter lesions were detected by endoanal ultrasound are described and their corresponding scores according to Starck classification calculated. This system scores severity of detected sphincter lesions from 0 to 16, involving the three axes of the anal canal. Patient demographic characteristics and anorectal manometry results were also analysed. The relationship between this score, patient gender and age, and anorectal manometric results were also analysed. RESULTS A total of 83 (62.4%) patients had some type of anal sphincter lesion. The presence of sphincter defects was not related to gender (P=0.172), although it did correlate with younger ages (P=0.028). The severity of anal sphincter damage by Starck score did not show significant correlation to gender (P=0.327) or to the age (P=0.350) of patients. However, a significant correlation was detected between Starck score and anal resting pressure (P=0.008) or anorectal squeeze pressure (P=0.011). CONCLUSIONS The presence of anal sphincter injuries could be well defined by Starck score in patients with faecal incontinence. Severity of damage scored by Starck correlated with anorectal manometric results.