Resultados clínicos y funcionales tras el tratamiento de las fístulas perianales complejas con colgajo transanal de avance. Impacto de diferentes modificaciones técnicas.

Tesis titulada “Resultados clínicos y funcionales tras el tratamiento de las fístulas perianales complejas con colgajo transanal de avance. Impacto de diferentes modificaciones técnicas”. El colgajo transanal de avance es la técnica más aceptada para el tratamiento de las fístulas perianales complejas. Sin embargo, la técnica de realización del colgajo varía ampliamente según instituciones y cirujanos, por lo que la valoración de los resultados puede ser contradictoria. Aunque no existe consenso en la forma y espesor del colgajo, el de pared total, incluyendo la totalidad del EAI parece ofrecer mejores resultados en relación a la recidiva, aunque los estudios sobre los cambios presivos en pacientes sometidos a esta técnica son limitados. En relación al tratamiento del trayecto fistuloso, la fistulectomía “core out” es una técnica ampliamente utilizada, con el inconveniente de ser en ocasiones un procedimiento largo, tedioso y difícil, que podría dañar el EAE y provocar cambios manométricos anorrectales que repercutieran sobre la continencia. El simple legrado del trayecto es un método mucho más sencillo, pero podría incrementar el riesgo de recidiva por un insuficiente drenaje. La comparación de estos dos procedimientos no está documentada en la literatura. Los OBJETIVOS del estudio son: 1. Valorar los cambios de la presión basal a lo largo del canal anal tras la realización del colgajo de avance transanal de pared total, especialmente en el tercio distal. 2. Analizar y comparar los resultados manométricos anorrectales tras la realización de fistulectomía tipo “core out” y del legrado del trayecto fistuloso, en el tratamiento mediante colgajo transanal de fístulas complejas de origen criptoglandular. 3. Analizar y comparar los resultados clínicos tras la realización de fistulectomía “core out” y del legrado del trayecto fistuloso, en relación a la recidiva y las alteraciones de la continencia fecal. 4. Proponer pautas de manejo del trayecto fistuloso en el tratamiento mediante colgajo transanal de fístulas complejas. 5. Valorar los factores de riesgo de recidiva e incontinencia. MATERIAL Y MÉTODOS: estudio retrospectivo de una serie de datos prospectiva de 119 pacientes intervenidos con colgajo transanal de avance de pared total por fístulas perianales complejas de origen criptoglandular y con continencia preoperatoria normal (Wexner 0). 78 pacientes fueron tratados con una fistulectomía tipo “core out” (grupo I) y 41 con legrado del trayecto fistuloso (grupo II). La valoración funcional de los pacientes se evaluó pre y postoperatoriamente mediante la escala de continencia de Jorge-Wexner y manometría anorrectal. Se analizaron los siguientes parámetros: la Presión Máxima Basal (PMB) localizada de forma característica en el tercio medio del canal anal y que registra por tanto los cambios provocados tras la realización del colgajo; la Presión Basal a 0.5 cm del margen anal (PBinf) que valora los cambios en el tercio inferior, donde se mantiene la integridad del EAI; y la Presión Máxima de Contracción Voluntaria (PMCV) que refleja la función del EAE. Se realizó un seguimiento postoperatorio mínimo de 12 meses y se consideró recidiva a la presencia de absceso en la misma localización o la evidencia de fistulización. RESULTADOS: Resultados de la presión basal a lo largo del canal anal: Los resultados manométricos muestran un descenso significativo de la PMB del 49.9% tras la cirugía, desde valores preoperatorios de 90,6±31,9 a 45,2±20 mmHg (p<0.001). Los valores de PBinf se mantienen sin cambios significativos (28,2±18,3 a 23,2±13,5 mmHg, p=0,1, NS). Resultados manométricos “core out” vs legrado: En relación a la PMB, en el grupo I (n=55) hubo un descenso significativo de 87,3±27,4 a 47±20,1 mmHg (p<0,001) y en el grupo II (n=38) de 92,8±34,2 a 44,3±20,6 mmHg (p<0,001). Por otro lado, la PMCV se redujo de manera significativa tras la cirugía en el grupo I, de 240,3±99 a 189,9±78,9 mmHg (p<0,001), pero no se demostraron diferencias significativas en el grupo II entre los valores pre y postoperatorios (217,3±74,8 a 203,8±77,6 mmHg)(p=0,1). Resultados sobre la continencia fecal: el 76,5% de los pacientes mantuvieron una continencia completa en el postoperatorio (Wexner 0): 59 (75,6%) en el grupo I y 32 (78%) en el grupo II (p=0,3); 15 pacientes en el grupo I (19,2%) y 9 pacientes en el grupo II (21,9%) mostraron alteraciones menores de la continencia con un incremento de hasta 3 puntos en la escala de Jorge-Wexner. La continencia se vio más afectada con ascenso en 4 o más puntos, en 4 pacientes del grupo I (5,1%) y ninguno en el grupo II. No hemos encontrado diferencias estadísticamente significativas entre ambos grupos. En cuanto a la relación de la PMCV con la continencia anal, es de destacar que en aquellos pacientes con escala de Wexner ≥ 4 (alteraciones mayores de la continencia), la PMCV en el preoperatorio era significativamente más baja que en el resto de pacientes del grupo I (139±29.3 vs 248.2±98.3, p=0,02). Resultados de la recidiva de la fístula perianal: Constatamos recidiva en 7 pacientes (5,9%), 5 pacientes (6,4%) en el grupo I y 2 pacientes (4,8%) en el grupo II, sin diferencias estadísticamente significativas entre ambos grupos (p=0,7). CONCLUSIONES: 1. La realización de un colgajo transanal de pared total provoca un descenso de la PMB en el tercio medio del canal anal, debido a la inclusión del EAI en el colgajo. Si se cuidan detalles técnicos como la preservación del EAI distal, la presión basal en el tercio distal o inferior se mantiene sin cambios, evitando deformidades en el margen anal del tipo “keyhole”, que pueden ser causantes de ensuciamiento o manchado. 2. La técnica de fistulectomia tipo “core out” causa un descenso significativo en la PMCV que refleja el daño producido en el EAE. El legrado es una técnica más simple que no provoca cambios en la PMCV, porque preserva la integridad del EAE. 3. No hemos evidenciado diferencias significativas en las tasas de incontinencia entre el “core out” y el legrado. Sin embargo, el “core out” puede provocar incontinencia en pacientes de alto riesgo, que pueden ser definidos por estudios manométricos preoperatorios. Tampoco hemos constatado diferencias significativas en las tasas de recidiva entre el “core out” y el legrado. 4. El legrado debería ser la técnica de elección en el manejo del trayecto fistuloso, ya que es más simple, preserva el EAE y no aumenta la tasa de recurrencias. 5. Sólo la edad menor a 50 años se ha asociado a un mayor riesgo de recidivas en el estudio univariante. En relación a la incontinencia, la cirugía previa ha sido el único factor implicado. Ninguno ha permanecido como factor independiente en el estudio multivariante.Thesis entitled "Clinical and functional results after treatment of complex fistula-in-ano with transanal advancement flap. Impact of different technical changes ".   Transanal advancement flap is the most accepted approach for treating complex fistula-in-ano. However, the thechnical procedure of the flap varies within institutions and surgeons, so the evaluation of the results may be contradictory. Although there is no consensus about how the shape and thickness of the flap should be, the full-thickness that includes the entire internal sphincter muscle seems to have the best results regarding recurrence, despite this fact, studies on pressive changes in patients undergoing this technique are limited. Related to the treatment of the fistula tract, the fistulectomy "core out" is a widely used approach. Sometimes, it can be a long, tedious and difficult process, which could damage the external sphincter muscle and cause manometric changes affecting continence. The simple curettage of the tract is a much simpler method, nevertheless it may increase the risk of recurrence because of insufficient drainage. The comparison of these two procedures is not reported in the literature. The objectives of the study are: 1. To evaluate the changes in basal pressure along the anal canal, especially in the distal third of it, after performing full-thickness transanal advancement flap. 2. To analyze and compare anorectal manometry results after "core out" fistulectomy with curettage of the tract, in the cryptoglandular complex fistula-in-ano treated with transanal flap. 3. To analyze and compare clinical outcomes after performing fistulectomy "core out" with curettage, in relation to recurrence and faecal continence alterations. 4. To propose management guidelines for treating complex fistula-in-ano with transanal flap. 5. To assess risk factors for recurrence and incontinence. METHODS: This is a retrospective analysis from prospective database. One hundred nineteen consecutive patients with cryptoglandular fistula and normal preoperative continence, underwent full-thickness transanal advancement flap. 78 patients were treated with "core out" fistulectomy (group I) and 41 with curettage (group II). Functional assessment of patients was evaluated pre and postoperatively by Jorge-Wexner Continence Grading Scale and anorectal manometry. The following parameters were analyzed: maximum anal resting pressure (MRP), wich is usually located in the middle third of anal verge and shows the changes cost by the flap performance; inferior resting pressure (IRP), mesure at 0.5 cm from the anal verge, that evidences modifications in the lower third, where internal sphincter integrity remains; and maximum anal squeeze pressure (MSP) that reflects the external sphincter function. All patients had a minimum postoperative follow-up of 12-month. Recurrence was defined as the presence of an abscess arising in the aerea or evidence of fistulization. RESULTS: Results of the resting pressure along the anal canal: Manometric results showed a significant decrease in MRP after surgery of 49.9%, from 90.6±31.9 to 45.2±20 mmHg (p<0.001). IRP values did not differ significantly between pre and postoperative values (28.2±18.3 to 23.2±13.5 mmHg, p=0.1, NS). Manometric results "core out" vs curettage: In group I (n=55), MRP decreased significantly from 87.3±27.4 to 47±20.1 mmHg (p<0.001) and in group II (n=38) decreased from 92.8±34.2 to 44.3±20.6 mmHg (p<0.001). On the other hand, MSP dropped significantly after surgery in group I, from 240.3±99 to 189.9±78.9 mmHg (p<0.001), but no significant differences were demonstrated in the group II (217.3±74.8 to 203.8±77.6 mmHg, p=0.1). Results concerning faecal continence: at postoperative assesment, a Wexner score of 0 was identified in 76.5% of all score patients, 59 patients (75.6%) of group I and 32 (78%) of group II (p=0.3). The proportion of patients with a postoperative minor increase of the Wexner score was 19.2% (15 patients) in group I and 21.9% (9 patients) in group II, while 4 (5.1%) patients of group I and none of group II had a major increased of the Wexner score postoperative. We did not find statistically significant differences between groups. Relation of manometric findings in MSP to anal continence: in particular, in the four patients with a major increase of the Wexner score (Wexner≥4) the preoperative MSP was significantly lower than the other patients in group I (139±29.3 vs 248.2±98.3, p=0.02). Results about recurrence of fistula: We found recurrence in seven patients (5.9%): five patients (6.4%) in group I and two patients (4.8%) in group II without statistical differences significant between groups (p = 0.7). CONCLUSIONS: 1. Conducting a full-thickness transanal flap causes a decrease of the MRP in the middle third of the anal canal, due to the inclusion of the internal sphincter at the flap. It seems crucial to be careful to preserve the distal internal sphincter intact, it allows to keep the resting pressure in the distal or lower third, in order to avoid a "keyhole" deformity of the anal margin that can lead to mucus or stool leakage. 2. Fistulectomy "core out" causes a significant decrease in MSP that reveals damage to the external sphincter. Curettage is a simple technique that does not cause variations in MSP, because it preserves the integrity of it. 3. We have not detected significant differences in the rates of incontinence between "core out" and curettage. However, the "core out" can cause incontinence in high risk patients, which can be defined by preoperative manometric studies. We have not determined significant differences in recurrence rates between the "core out" and curettage. 4. Curettage should be the technique of choice in the management of fistula tract because: it is simpler, preserves the external sphincter and does not increase the recurrence rate. 5. Being under 50 years old has been the only associated factor with an increased risk of recurrence in univariate analysis. Concerning incontinence, previous fistula surgery has been the only factor involved. None of them has remained as an independent factor in the multivariate analysis

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

D3-lymphadenectomy enhances oncological clearance in patients with right colon cancer. Results of a meta-analysis

D3-Lymphadenectomy, together with complete mesocolic excision (CME), were introduced to provide oncological results after right colon cancer. The aim of this systematic review with meta-analysis was to assess the short and long-term outcomes of right-sided hemicolectomy with CME&nbsp;+&nbsp;D3 as compared with classic right hemicolectomy. Secondary aims included the prevalence of D3-metastasis and skip metastasis when performing CME&nbsp;+&nbsp;D3

“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 &lt; 0.001) and ASA III-IV (HR = 2.0; 95%-CI 1.4-2.9; p &lt; 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

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study (vol 46, pg 2021, 2022)

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Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2

Delayed colorectal cancer care during covid-19 pandemic (decor-19). Global perspective from an international survey

Background The widespread nature of coronavirus disease 2019 (COVID-19) has been unprecedented. We sought to analyze its global impact with a survey on colorectal cancer (CRC) care during the pandemic. Methods The impact of COVID-19 on preoperative assessment, elective surgery, and postoperative management of CRC patients was explored by a 35-item survey, which was distributed worldwide to members of surgical societies with an interest in CRC care. Respondents were divided into two comparator groups: 1) ‘delay’ group: CRC care affected by the pandemic; 2) ‘no delay’ group: unaltered CRC practice. Results A total of 1,051 respondents from 84 countries completed the survey. No substantial differences in demographics were found between the ‘delay’ (745, 70.9%) and ‘no delay’ (306, 29.1%) groups. Suspension of multidisciplinary team meetings, staff members quarantined or relocated to COVID-19 units, units fully dedicated to COVID-19 care, personal protective equipment not readily available were factors significantly associated to delays in endoscopy, radiology, surgery, histopathology and prolonged chemoradiation therapy-to-surgery intervals. In the ‘delay’ group, 48.9% of respondents reported a change in the initial surgical plan and 26.3% reported a shift from elective to urgent operations. Recovery of CRC care was associated with the status of the outbreak. Practicing in COVID-free units, no change in operative slots and staff members not relocated to COVID-19 units were statistically associated with unaltered CRC care in the ‘no delay’ group, while the geographical distribution was not. Conclusions Global changes in diagnostic and therapeutic CRC practices were evident. Changes were associated with differences in health-care delivery systems, hospital’s preparedness, resources availability, and local COVID-19 prevalence rather than geographical factors. Strategic planning is required to optimize CRC care