Sandra Alonso

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.

Laparoscopic Pancreas-Sparing Subtotal Duodenectomy

CONTEXT Primary adenocarcinoma of the duodenum is a rare digestive malignancy which is commonly treated by radical surgical resection, pancreaticoduodenectomy being the technique of choice. Complete tumor resection obtaining free margins should be the standard of treatment for primary adenocarcinoma of the duodenum. Segmental duodenal resection is an appropriate operation for selected cases of primary adenocarcinoma of the duodenum of the 3rd and 4th portions of the duodenum. CASE REPORT We present the case of a 67-year-old woman suffering from an infra-ampullary large villous polypoid mass affecting the 3rd portion of the duodenum. Multiple endoscopic biopsies did not disclose any malignancy, and abdominal CT and endoscopic ultrasound found no extraduodenal involvement. A 3rd and 4th portion pancreas-sparing duodenectomy was carried out using a totally laparoscopic approach. Intra-operatory duodenoscopy was done to safeguard the papilla of Vater. Recovery was uneventful and the patient was discharged on the 7th postoperative day. The final diagnosis was primary adenocarcinoma of the duodenum (free resection margins). After forty-five months of follow-up, the patient is free of disease. CONCLUSIONS We recommend this procedure for treatment of an infra-ampullary benign and pre-malignant duodenal pathology; it can also be a treatment option and an alternative to a pancreaticoduodenectomy in very selected cases of tumors confined to the duodenum. Expertise in both pancreatic surgery and laparoscopic techniques is required.

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.

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.

Tratamiento ambulatorio de la diverticulitis aguda no complicada: impacto sobre los costes sanitarios

BACKGROUND Outpatient treatment of uncomplicated acute diverticulitis is safe and effective. The aim of this study was to determine the impact of outpatient treatment on the reduction of healthcare costs. PATIENTS AND METHODS A retrospective cohort study comparing 2 groups was performed. In the outpatient treatment group, patients diagnosed with uncomplicated acute diverticulitis were treated with oral antibiotics at home. In the hospital treatment group, patients met the criteria for outpatient treatment but were admitted to hospital and received intravenous antibiotic therapy. Cost estimates have been made using the hospital cost accounting system based on total costs, the sum of all variable costs (direct costs) plus overhead expenses divided by activity (indirect costs). RESULTS A total of 136 patients were included, 90 in the outpatient treatment group and 46 in the hospital group. There were no differences in the characteristics of the patients in both groups. There were also no differences in the treatment failure rate in both groups (5.5% vs. 4.3%; P=.7). The total cost per episode was significantly lower in the outpatient treatment group (882 ± 462 vs. 2.376 ± 830 euros; P=.0001). CONCLUSIONS Outpatient treatment of acute diverticulitis is not only safe and effective but also reduces healthcare costs by more than 60%.

Expression of estrogen and progesterone receptors in the anal canal of women according to age and menopause.

PURPOSE: Fecal incontinence is highly prevalent, especially in menopausal women. The aim of this study was to analyze the expression of estrogen and progesterone receptors in the anal canal of women in relation to menopausal status and age. METHODS: Samples of hemorrhoidal tissue were obtained from 34 women undergoing hemorrhoidectomy. The patients were divided into 2 groups: group 1 consisted of women with a menstrual cycle (n = 17) and group 2 consisted of postmenopausal women (n = 17). Immunostaining of hormone receptors was performed using specific antibodies (DAKO, Copenhagen, Denmark) in cells from the internal anal sphincter, the vascular epithelium, and the squamous epithelium. The percentage of positivity of receptors and the association between age and receptor positivity were compared between the 2 groups. RESULTS: Estrogen receptors were found in the internal anal sphincter in 23.5% in group 1 vs 11.8% in group 2 (P = .656). Progesterone receptors were found in 41.2% in group 1 vs 11.8% of group 2 (P = .118). Squamous epithelium showed estrogen receptors in 52.9% in group 1 vs 64.7% of group 2 (P = .388) and progesterone receptors in 17.6% and 0% in groups 1 and 2, respectively (P = .227). Vascular endothelium showed no receptors. Receptor positivity was not associated with age. CONCLUSION: No significant differences were found in the detection of estrogen and progesterone receptors in structures of the anal canal in women in relation to menopausal status and age.