Surgical treatment for colorectal cancer: Analysis of the influence of an enhanced recovery programme on long-term oncological outcomes-a study protocol for a prospective, multicentre, observational cohort study

Introduction The evidence currently available from enhanced recovery after surgery (ERAS) programmes concerns their benefits in the immediate postoperative period, but there is still very little evidence as to whether their correct implementation benefits patients in the long term. The working hypothesis here is that, due to the lower response to surgical aggression and lower rates of postoperative complications, ERAS protocols can reduce colorectal cancer-related mortality. The main objective of this study is to analyse the impact of an ERAS programme for colorectal cancer on 5-year survival. As secondary objectives, we propose to analyse the weight of each of the predefined items in the oncological results as well as the quality of life. Methods and analysis A multicentre prospective cohort study was conducted in patients older than 18 years of age who are scheduled to undergo surgery for colorectal cancer. The study involved 12 hospitals with an implemented enhanced recovery protocol according to the guidelines published by the Spanish National Health Service. The intervention group includes patients with a minimum implementation level of 70%, and the control group includes those who fail to reach this level. Compliance will be studied using 18 key performance indicators, and the results will be analysed using cancer survival indicators, including overall survival, cancer-specific survival and relapse-free survival. The time to recurrence, perioperative morbidity and mortality, hospital stay and quality of life will also be studied, the latter using the validated EuroQol Five questionnaire. The propensity index method will be used to create comparable treatment and control groups, and a multivariate regression will be used to study each variable. The Kaplan-Meier estimator will be used to estimate survival and the log-rank test to make comparisons. A p value of less than 0.05 (two-tailed) will be considered to be significant. Ethics and dissemination Ethical approval for this study was obtained from the Aragon Ethical Committee (C.P.-C.I. PI20/086) on 4 March 2020. The findings of this study will be submitted to peer-reviewed journals (BMJ Open, JAMA Surgery, Annals of Surgery, British Journal of Surgery). Abstracts will be submitted to relevant national and international meetings.The present research study was awarded a Ministerio de Ciencia e Innovación health research project grant (PI19/00291) from the Carlos III Institute of the Spanish National Health Service as part of the 2019 call for Strategic Action in Health

Rehabilitación Multimodal en Cirugía Bariátrica

Los protocolos de Rehabilitación Multimodal son una herramienta eficaz para reducir las complicaciones quirúrgicas y la morbilidad postoperativa, lo que se traduce en una menor estancia hospitalaria. De ahí que su aplicación en la cirugía bariátrica es un factor diferencial frente a los cuidados tradicionales.<br /

Neuromonitorización de la profundidad anestésica mediante BIS y su implicación en la incidencia del delirio postoperatorio

INTRODUCCIÓN: El delirio postoperatorio (DPO) se trata de una entidad infradiagnosticada a pesar de su gravedad y elevada incidencia. Estos pacientes precisan una estancia hospitalaria más prolongada y más complicaciones postoperatorias que se traduce además en un incremento de los costes hospitalarios. Dada su importancia, y la ausencia de tratamiento específico, las estrategias preventivas multifactoriales parecen ser la mejor opción actualmente. Nuestra hipótesis es que la realización de una anestesia general evitando el máximo tiempo en planos anestésicos excesivamente profundos gracias a la neuromonitorización guiada por el dispositivo BIS disminuye la incidencia de delirio postoperatorio en pacientes mayores de 65 años y la estancia hospitalaria.MATERIAL Y MÉTODOS: Los pacientes fueron asignados aleatoriamente entre grupo neuromonitorización BIS visible y grupo BIS oculto. El grupo BIS visible mantenía una profundidad anestésica entre 40 y 60 mientras que en el otro grupo la profundidad anestésica era guiada por parámetros hemodinámicos y el valor CAM. Se evaluó a los pacientes en las 72 horas posteriores para determinar el desarrollo de DPO y se realizó un seguimiento de 30días.RESULTADOS: El número de pacientes que desarrolló DPO fue significativamente menor en el grupo BIS visible (39,1%) que en el grupo BIS oculto (60,9%: p = 0,043). Los pacientes del grupo BIS oculto permanecieron 26,6 ± 14,0 minutos en planos BIS 0%; p = 0,01).CONCLUSIONES: La profundidad anestésica guiada mediante BIS disminuye la incidencia de DPO en nuestro medio. Los pacientes neuromonitorizados intraoperatoriamente permanecen menor tiempo en planos anestésicos excesivamente profundos y presentan una menor estancia hospitalaria y mortalidad.PALABRAS CLAVE: Delirio postoperatorio, profundidad anestésica, neuromonitorización,complicaciones neurológicas postoperatorias.<br /

Role of urine immunofixation in the complete response assessment of MM patients other than light-chain-only disease

Response criteria for multiple myeloma (MM) require monoclonal protein (M-protein)–negative status on both serum immunofixation electrophoresis (sIFE) and urine (uIFE) immunofixation electrophoresis for classification of complete response (CR). However, uIFE is not always performed for sIFE-negative patients. We analyzed M-protein evaluations from 384 MM patients (excluding those with light-chain-only disease) treated in the GEM2012MENOS65 (NCT01916252) trial to determine the uIFE-positive rate in patients who became sIFE-negative posttreatment and evaluate rates of minimal residual disease (MRD)–negative status and progression-free survival (PFS) among patients achieving CR, CR but without uIFE available (uncertain CR; uCR), or very good partial response (VGPR). Among 107 patients with M-protein exclusively in serum at diagnosis who became sIFE-negative posttreatment and who had uIFE available, the uIFE-positive rate was 0%. Among 161 patients with M-protein in both serum and urine at diagnosis who became sIFE-negative posttreatment, 3 (1.8%) were uIFE positive. Among patients achieving CR vs uCR, there were no significant differences in postconsolidation MRD-negative (<10−6; 76% vs 75%; P = .9) and 2-year PFS (85% vs 88%; P = .4) rates; rates were significantly lower among patients achieving VGPR. Our results suggest that uIFE is not necessary for defining CR in MM patients other than those with light-chain-only disease.This work was supported by grants from the Fondo de Investigacion Sanitaria (PI1201761 and PI1502062), Red Tematica de Investigación Cooperative en Cáncer, and Centro de Investigacion Biomédica en Cancer of the Instituto de ´Salud Carlos III (Ministry of Science, Innovation and Universities)

Surgeons’ practice and preferences for the anal fissure treatment: results from an international survey

The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons' practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants' demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results