Desgarros obstétricos Iatrógenos. Una entidad más frecuente de lo que desearíamos.

Se presenta el caso clínico de una mujer de 34 años con antecedente de dos partos vaginales, el último de ellos hace 2 años. Se trató de un parto distócico instrumentado que le causó un desgarro obstétrico. La paciente acude a la consulta de coloproctología con clínica de incontinencia fecal, dispareunia e infecciones urinarias de repetición. A la exploración física se observa ausencia de tabique rectovaginal y al tacto rectal atonía esfinteriana

Diagnostic Accuracy of Abdominal CT for Locally Advanced Colon Tumors: Can We Really Entrust Certain Decisions to the Reliability of CT?

Many different options of neoadjuvant treatments for advanced colon cancer are emerging. An accurate preoperative staging is crucial to select the most appropriate treatment option. A retrospective study was carried out on a national series of operated patients with T4 tumors. Considering the anatomo-pathological analysis of the surgical specimen as the gold standard, a diagnostic accuracy study was carried out on the variables T and N staging and the presence of peritoneal metastases (M1c). The parameters calculated were sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios, as well as the overall accuracy. A total of 50 centers participated in the study in which 1950 patients were analyzed. The sensitivity of CT for correct staging of T4 colon tumors was 57%. Regarding N staging, the overall accuracy was 63%, with a sensitivity of 64% and a specificity of 62%; however, the positive and negative likelihood ratios were 1.7 and 0.58, respectively. For the diagnosis of peritoneal metastases, the accuracy was 94.8%, with a sensitivity of 40% and specificity of 98%; in the case of peritoneal metastases, the positive and negative likelihood ratios were 24.4 and 0.61, respectively. The diagnostic accuracy of CT in the setting of advanced colon cancer still has some shortcomings for accurate diagnosis of stage T4, correct classification of lymph nodes, and preoperative detection of peritoneal metastases

Anomalías de la vena cava y trombosis venosa profunda

Estudio prospectivo de 116 pacientes menores de 50 años con trombosis venosa profunda (TVP) de los miembros inferiores, en el que se valora la presencia de anomalías de la vena cava inferior (VCI) como factor de riesgo de la TVP. Se practicó a todos una eco-Doppler; cuando tenían afección ilíaca se realizaba también flebografía, y cuando el drenaje a la VCI era deficiente, se completaba el estudio con resonancia magnética o tomografía computarizada. En todos los pacientes también se realizaron las siguientes determinaciones: antitrombina, déficit de proteína C y S, factor V Leiden, protrombina G20210A y anticuerpos antifosfolipídicos. También se valoraron los factores de riesgo adquiridos. De los 37 pacientes con afección ilíaca, 6 presentaron anomalías de VCI: 4 hipoplasias y 2 duplicaciones. Todos ellos eran menores de 30 años, 2 tenían anticuerpos antifosfolipídicos y 1 protrombina G20210A. Dos presentaron recidiva trombótica tras la suspensión de la anticoagulación. En conclusión, el 16,2% (intervalo de confianza [IC] del 95%, 6,2-32) de los pacientes con trombosis ilíaca presentaba anomalía de la VCI

"Virtual ileostomy" combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report

Despite the benefits of a loop ileostomy after total mesorectal excision (TME), it carries a significant associated morbidity. A "virtual ileostomy" (VI) has been proposed to avoid ileostomies in low-risk patients, which could then be converted into a real ileostomy (RI) in the event of anastomotic leak (AL). The aim of the present study is to evaluate safety and efficacy of VI associated with early endoscopy in patients undergoing rectal surgery with anastomosis to detect subclinical AL prior to the onset of clinical symptoms for sepsis. METHODS: This is a single-center, retrospective study of a consecutive series of patients undergoing elective or emergent colorectal surgery with low or ultralow colorectal or ileorectal anastomosis between September 2015 and September 2016. RESULTS: We included 44 consecutive, unselected patients. Eight patients (18.2%) required conversion into RI and one required terminal colostomy because of AL, of whom 44.4% were asymptomatic and AL was detected with early endoscopy. Fashioning of RI was not associated with further morbidity. All patients with AL converted into RI (n = 8/9) (88.9%), had adequate healed anastomosis, and later underwent stoma closure with no complications. A stoma was avoided in 79.6% of VI. Endoscopy was associated with 55% sensitivity and 100% specificity, with a global accuracy of 88%. CONCLUSIONS: The combination of VI with early postoperative endoscopy could avoid unnecessary ileostomies in patients with low or ultralow anastomoses and reveal AL before the onset of symptoms, thus reducing associated morbidity

A multifaceted individualized pneumoperitoneum strategy for laparoscopic colorectal surgery: a multicenter observational feasibility study

Background: While guidelines for laparoscopic abdominal surgery advise using the lowest possible intra-abdominal pressure, commonly a standard pressure is used. We evaluated the feasibility of a predefined multifaceted individualized pneumoperitoneum strategy aiming at the lowest possible intra-abdominal pressure during laparoscopic colorectal surgery. Methods: Multicenter prospective study in patients scheduled for laparoscopic colorectal surgery. The strategy consisted of ventilation with low tidal volume, a modified lithotomy position, deep neuromuscular blockade, pre-stretching of the abdominal wall, and individualized intra-abdominal pressure titration; the effect was blindly evaluated by the surgeon. The primary endpoint was the proportion of surgical procedures completed at each individualized intra-abdominal pressure level. Secondary endpoints were the respiratory system driving pressure, and the estimated volume of insufflated CO2 gas needed to perform the surgical procedure. Results: Ninety-two patients were enrolled in the study. Fourteen cases were converted to open surgery for reasons not related to the strategy. The intervention was feasible in all patients and well-accepted by all surgeons. In 61 out of 78 patients (78%), surgery was performed and completed at the lowest possible IAP, 8 mmHg. In 17 patients, IAP was raised up to 12 mmHg. The relationship between IAP and driving pressure was almost linear. The mean estimated intra-abdominal CO2 volume at which surgery was performed was 3.2 L. Conclusion: A multifaceted individualized pneumoperitoneum strategy during laparoscopic colorectal surgery was feasible and resulted in an adequate working space in most patients at lower intra-abdominal pressure and lower respiratory driving pressure. ClinicalTrials.gov (Trial Identifier: NCT03000465)

“Long-term oncologic outcomes and risk factors for distant recurrence after pathologic complete response following neoadjuvant treatment for locally advanced rectal cancer. A nationwide, multicentre study”

Background: Pathologic complete response (pCR) after multimodal treatment for locally advanced rectal cancer (LARC) is used as surrogate marker of success as it is assumed to correlate with improved oncologic outcome. However, long-term oncologic data are scarce.Methods: This retrospective, multicentre study updated the oncologic follow-up of prospectively collected data from the Spanish Rectal Cancer Project database. pCR was described as no evidence of tumour cells in the specimen. Endpoints were distant metastases-free survival (DMFS) and overall survival (OS). Multivariate regression analyses were run to identify factors associated with survival.Results: Overall, 32 different hospitals were involved, providing data on 815 patients with pCR. At a median follow-up of 73.4 (IQR 57.7-99.5) months, distant metastases occurred in 6.4% of patients. Abdominoperineal excision (APE) (HR 2.2, 95%CI 1.2-4.1, p = 0.008) and elevated CEA levels (HR = 1.9, 95% CI 1.0-3.7, p = 0.049) were independent risk factors for distant recurrence. Age (years) (HR 1.1; 95% CI 1.05-41.09; p < 0.001) and ASA III-IV (HR = 2.0; 95%-CI 1.4-2.9; p < 0.001), were the only factors associated with OS. The estimated 12, 36 and 60-months DMFS rates were 96.9%, 91.3%, and 86.8%. The estimated 12, 36 and 60-months OS rates were 99.1%, 94.9% and 89.3%.Conclusions: The incidence of metachronous distant metastases is low after pCR, with high rates of both DMFS and OS. The oncologic prognosis in LARC patients that achieve pCR after neoadjuvant chemoradiotherapy is excellent in the long term. (c) 2023 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved