Yolanda Saralegui

Preventing complications in colorectal anastomosis: results of a randomized controlled trial using bioabsorbable staple line reinforcement for circular stapler.

BACKGROUND: Anastomotic complications, including leaks, stenoses, and bleeding, cause considerable mortality and morbidity after colorectal surgery. OBJETIVE: The purpose of this work was to evaluate the effectiveness of bioabsorbable staple line reinforcement in reducing colorectal anastomotic complications. DESIGN: This was a prospective randomized clinical study. SETTINGS: This study was conducted at a university hospital within a specialized colorectal unit. PATIENTS: Patients undergoing left colon resection for a benign or malignant condition were eligible. A total of 302 patients participated, including 154 control subjects and 148 with reinforcement. INTERVENTION: Patients were prospectively randomly assigned to reinforcement of circular stapled anastomosis with a bioabsorbable device versus stapled circular anastomosis without reinforcement. MAIN OUTCOME MEASURES: The primary end point was the rate of pooled incidences of anastomotic complications (leakage, bleeding, or stenosis). Secondary outcomes were the rate of reoperations and the length of hospital stay. RESULTS: Baseline characteristics were similar between both groups. Intention-to-treat analysis revealed that there were no significant differences in the pooled incidences of anastomotic complications (p = 0.821). Regarding individual complications, we did not observe statistical differences between groups, including leakage (6.6% vs 4.8%; p = 0.518), hemorrhage (1.4% vs 1.3%; p = 0.431), or stenosis (2.9% vs 6.8%; p = 0.128). Again, no significant differences were observed in length of stay (7 days; p = 0.242) or rate of reoperation (7.3% vs 9.6%; p = 0.490). A patient (0.3%) in the control group died. LIMITATIONS: Sample size calculation was performed including all 3 of the complications, which may render it underpowered to detect differences regarding a specific complication. Anastomoses located within 5 cm from the anal verge were excluded from the study. CONCLUSIONS: The results obtained show that bioabsorbable staple line reinforcement in a colorectal anastomosis >5 cm from the anal verge does not reduce the rate of pooled anastomotic complications (ie, leaks, bleeding, or stenosis).

Exenteración pélvica total en el tratamiento de las neoplasias avanzadas, primarias o recurrentes, de vísceras pélvicas

INTRODUCTION Complete resection with clear margins in locally advanced pelvic visceral tumors, primary or recurrent, occasionally requires total pelvic exenteration (TPE). METHODS We reviewed the results of EFA in 34 consecutive patients operated on between June 2006 and December 2013. RESULTS Median age was 62 (40-82) years; 24 (70%) were male. The tumor origin most frequent was advanced primary rectal tumor (APRT), with 19 cases (55.9%) and most common type of exenteration was supraelevator (61.8%). R₀ resection was achieved in 24 (70.6%) patients and in 16 (85%) of the APRT. Fifteen (79%) patients had pT₄ APRT, and 4 (20%) pN +. Reconstruction of the bowel and bladder was performed with two stomas in 17 cases (50%), colorectal anastomosis and Bricker in 11 (32.3%) and wet double barreled colostomy in 6 (17.6%). There was no postoperative mortality; 23 (67,5%) patients had complications, and 5 (14.6%) required a postoperative reoperation to solve them. Median follow-up was 23 (13-45) months. Overall survival (OS) and disease free survival (DFS) at 2 years were 67% and 58% respectively, and the median OS and DFS was 59 months (95% CI 26-110) and 39 months (95% CI 14-64), respectively. The DFS of R₀ was significantly better (p=0.003) than R₁. CONCLUSIONS TPE is a potentially curative procedure for advanced pelvic visceral malignancies with similar morbi-mortality than other extended excisional surgery.

Delorme’s Procedure for Complete Rectal Prolapse: A Study of Recurrence Patterns in the Long Term

Introduction. The objective of this study was to determine the recurrence rate and associated risk factors of full-thickness rectal prolapse in the long term after Delormes procedure. Patients and Methods. The study involved adult patients with rectal prolapse treated with Delormes surgery between 2000 and 2012 and followed up prospectively in an outpatient unit. We assessed epidemiological data, Wexner constipation and incontinence score, recurrence patterns, and risk factors. Data were analyzed by univariate and multivariate studies and follow-up was performed according to Kaplan-Meier technique. The primary outcome was recurrence. Results. A total of 42 patients, where 71.4% (n = 30) were women, with a median age of 76 years (IQR 66 to 86), underwent Delormes surgery. The median follow-up was 85 months (IQR 28 to 132). There was no mortality, and morbidity was 9.5%. Recurrence occurred in five patients (12%) within 14 months after surgery. Actuarial recurrence at five years was 9.9%. According to the univariate analysis, constipation and concomitant pelvic floor repair were the only factors found to be associated with recurrence. Multivariate analysis showed no statistically significant differences among variables studied. Kaplan-Meier estimate revealed that constipation was associated with a higher risk of recurrence (log-rank test, p = 0.006). Conclusions. Delormes procedure is a safe technique with an actuarial recurrence at five years of 9.9%. The outcomes obtained in this study support the performance of concomitant postanal repair and levatorplasty to reduce recurrences. Also, severe constipation is associated with a higher recurrence rate.

Interposición de intestino delgado entre el colon y el recto como forma de lograr una anastomosis pélvica sin tensión

PURPOSE There are some circumstances in which the descending colon does not reach the pelvis to complete a colorectal anastomosis without tension. Re-establishing intestinal continuity by interposing small bowel as a bridge between the colon and the rectum could be an acceptable surgical alternative. METHODS We describe the interposition of one or two segments of small bowel as a way of restoring continuity of the colon and rectum in three patients in whom it was not possible to perform a colorectal anastomosis without tension due to ischaemic colon, synchronous cancer or difficulty in accessing the supramesocolic space, respectively. RESULTS Intestinal continuity was re-established in all patients with no significant morbidity and good intestinal function. CONCLUSION The interposition of small bowel segments between the colon and the rectum should be considered a valid surgical option when it is not possible to achieve a well-perfused, tension-free pelvic colorectal anastomosis.