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AIM The aim was to investigate the influence of distal resection margin and extent of mesorectal excision on long-term oncological outcomes. METHOD Consecutive patients with upper and middle third rectal cancer from June 2006 to February 2016 were reviewed. Patients were divided into four groups depending on the distal margin considered as a surrogate marker of the extension of mesorectal excision (Q1 ≤10 mm, Q2 11-20 mm, Q3 21-30 mm, Q4 ≥31 mm). Local-recurrence-free survival (LRFS), disease-free survival (DFS) and overall survival (OS) were estimated. Cox regression models were used to investigate the influence of surgical and clinicopathological variables on prognosis by adjusting for confounding factors. RESULTS Two hundred and eleven patients with mid (125) and upper (86) rectal cancer underwent wide mesorectal excision. The median follow-up was 48.64 months (interquartile range 28-63). 17.5% patients developed recurrence. The 5-year LRFS, DFS and OS for all patients were 93.20%, 83.89% and 80.1%, respectively, with no statistically significant differences between groups (LRFS, P = 0.601; DFS, P = 0.487; OS, P = 0.468). In the multivariable analysis the recurrences and survival were associated with the quality of the mesorectum (LRFS, hazard ratio 10.629, 95% CI 2.324-48.610, P = 0.002; DFS, hazard ratio 2.789, 95% CI 1.314-5.922, P = 0.008). CONCLUSION A wide anatomical resection with partial mesorectal excision and shorter distal resection margin does not jeopardize the oncological outcomes.

Introduction Diverting stomata are recommended in patients with low anterior resection and risk factors in order to reduce the severity of anastomotic leaks. Usually, a radiology study is performed prior to the closure of the stoma to detect subclinical leaks. The aim of the present study is to assess the clinical utility of the radiology study. Methods A prospective cohort study of patients undergoing anterior rectal resection for rectal cancer and those who underwent stoma closure without contrast enema. This study was carried out after a retrospective review of radiology study results prior to the closure of the stoma in patients operated from 2007 to 2011. Results Eighty-six patients met the study criteria. Thirteen patients (15.1%) presented pelvic sepsis. Contrast enema before stoma closure was pathological in 8 patients (9.3%). Five out of the 13 patients with pelvic sepsis had a pathological radiological study, compared to only 3 out of the 73 patients without intra-abdominal complications after rectal resection (38.5% vs 4.1%; P=.001). Based on these results, we conducted a prospective study omitting the contrast enema in patients with no postoperative complications. Thirty-eight patients had their stoma closed without a prior radiology study. None of the patients presented pelvic sepsis. Conclusions Radiology studies of the colorectal anastomosis before reconstruction can safely be omitted in patients without pelvic sepsis after the previous rectal resection.

Resumen Introduccion Es recomendable practicar un estoma derivativo en pacientes con reseccion anterior baja y factores de riesgo, para reducir la gravedad de la fuga anastomotica. Habitualmente se realiza un estudio radiologico previo al cierre del estoma para detectar fugas subclinicas. El objetivo del presente estudio es evaluar la utilidad clinica del estudio radiologico. Metodos Estudio prospectivo de una cohorte de pacientes sometidos a reseccion anterior de recto por cancer rectal, y a los que se les realiza cierre del estoma sin enema de contraste. Este estudio se lleva a cabo despues de realizar una revision retrospectiva sobre los resultados del estudio radiologico previo al cierre del estoma en pacientes intervenidos entre 2007 y 2011. Resultados Ochenta y seis pacientes cumplieron los criterios del estudio. Trece pacientes (15,1%) presentaron sepsis pelvica. El enema con contraste antes del cierre del estoma fue patologico en 8 pacientes (9,3%). Cinco de los 13 pacientes con sepsis pelvica mostraron un estudio radiologico patologico, en comparacion con solo 3 de 73 pacientes sin complicaciones intraabdominales despues de la reseccion del recto (38,5% vs 4,1%; p = 0,001). Basandonos en estos resultados, realizamos un estudio prospectivo omitiendo el enema con contraste en pacientes con curso postoperatorio no complicado. A 38 pacientes se les cerro el estoma sin estudio radiologico previo. Ningun paciente presento sepsis pelvica. Conclusiones El estudio radiologico de la anastomosis colorrectal antes de la reconstruccion del transito puede omitirse con seguridad en los pacientes sin sepsis pelvica ni ileo paralitico tras la reseccion anterior de recto.

espanolObjetivos Determinar la incidencia de hernia incisional (HI) en la incision de asistencia (IA) de la pieza en cirugia por neoplasia de colon y recto. Analisis de la relacion de la localizacion de la incision y uso de una malla en la prevencion de la HI en pacientes de alto riesgo. Metodos Revision retrospectiva de la base de datos de cirugia de colon entre enero de 2015 y diciembre de 2016. Se establecieron 2 grupos: incision transversa (IT) e incision media (IM), a su vez este con 2 subgrupos (malla [IMM] y sutura [IMS]). Se categorizaron los pacientes mediante el sistema HERNIAscore. Las hernias se diagnosticaron clinicamente y por TAC. Resultados Se intervino a 210 pacientes, de los que fueron incluidos 182. Tras un seguimiento de 13,0 meses, se detectaron un total de 39 HI (21,9%), de las que 23 (13,4%) fueron en las IA. Estas fueron mucho menos frecuentes en el grupo de IT (3,4%) y en el de IMM (5,9%) que en el de IMS (29,5%; p = 0,007). La probabilidad de aparicion en el grupo IMS de una HI presento una OR = 11,7 (IC 95%: 3,3-42,0) frente a las IT y de 4,3 (IC 95%: 1,1-16,3) frente al grupo IMM. Conclusiones La localizacion de la incision es relevante para disminuir las HI. La IT deberia ser utilizada preferentemente. En los casos en que se utilice una IM, el uso de una malla profilactica en pacientes de alto riesgo puede considerarse, ya que es seguro y con baja morbilidad. EnglishObjectives To determine the incidence of incisional hernia (IH) in the extraction incision (EI) in colorectal resection for cancer. To analyze whether the location of the incision has any relationship with the incidence of hernias and whether mesh could be useful for prevention in high-risk patients. Methods Retrospective review of the colon and rectal surgery database from January 2015 to December 2016. Data were classified into 2 groups, transverse (TI) and midline incision (MI), and the latter was divided into 2 subgroups (mesh [MIM] and suture [MIS]). Patients were classified using the HERNIAscore. Hernias were diagnosed by clinical and/or CT examination. Results A total of 182 out of 210 surgical patients were included. After a median follow-up of 13.0 months, 39 IH (21.9%) were detected, 23 of which (13.4%) were in the EI; their frequency was lower in the TI group (3.4%) and in the MIM group (5.9%) than in the MIS group (29.5%; p = 0.007). The probability of developing IH in the MIS group showed an OR = 11.7 (95%CI: 3.3-42.0) compared to the TI group and 4.3 (IC 95%: 1.1-16.3) versus the MIM group. Conclusions The location of the incision is relevant to avoid incisional hernias. Transverse incisions should be used as the first option. When a midline incision is needed, a prophylactic mesh could be considered in high risk patients because it is safe and associated with low morbidity.

Background Angiogenesis is essential for tumor growth and formation of metastasis. VEGF is the most potent agiogenic citokine. The aim was to investigate the predictive value of postoperative VEGF serum concentration in patients undergoing surgery for colon cancer. Methods Consecutive patients with colon cancer undergoing surgery with curative intent were included. VEGF was measured in serum at 48 h and postoperative day 4. Cox proportional hazards model was used to estimate its contribution with prognosis. Results A total of 94 patients were included. On multivariate analysis VEGF on postoperative day 4 (HR: 1.05; p = 0.011) was independent prognostic factor of decreased DFS and OS. Five-year DFS (57.7% vs. 85%; p = 0.001) and OS (93% vs. 72%; p = 0.005) were significantly lower in patients with postoperative serum VEGF greater than 370 pg/dl. Conclusion Postoperative VEGF serum concentration was an independent predictor of recurrence. These results must be verified in a prospective independent testing cohort.

Background Anastomotic leakage is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. The aim was to investigate the inflammatory and angiogenic responses in patients undergoing surgery for colorectal cancer who had postoperative intra-abdominal infection, and to compare the results with patients without complications. Methods Consecutive patients undergoing surgery for colorectal cancer with curative intent were included. Patients who had an anastomotic leak or intra-abdominal abscess were included in the infection group and matched with patients who had an uncomplicated postoperative course. IL-6 and VEGF were measured in serum and peritoneal fluid. Results Serum concentration of IL-6 was higher in the infection group (n = 30) compared with the control group (n = 30) on day 4 (infection: 42.3 [27.6–1473.2] versus control: 0.6 [0.6–17.1] pg/ml; p = 0.008). IL-6 in peritoneal fluid was higher in the infection group at 48 h and day 4 (infection: 1000.2 [995.4–1574.0] versus control: 90.3 [35.2.6–106.1] pg/ml; p = 0.001). Serum VEGF was higher in the infection group on day 4 (infection: 1128.6 [427.3–10000.0] versus control: 438.3 [214.1–677.6] pg/ml; p = 0.001). Peritoneal VEGF concentration was higher in the infection group at 48 h and day 4 (infection: 10000.0 [2563.0–10000.0] versus control: 477.8 [313.5–814.4] pg/ml; p = 0.001). Two-year recurrence rate was higher in patients with infection (infection: 30% versus control: 4%; p = 0.001). Conclusions Intra-abdominal infection increases IL-6 and VEGF after surgery for colorectal cancer. Amplification of inflammation and angiogenesis might be one of the mechanisms responsible for the higher recurrence rate observed in patients with anastomotic leakage or intra-abdominal abscess.

Objectives To determine the incidence of incisional hernia (IH) in the extraction incision (EI) in colorectal resection for cancer. To analyze whether the location of the incision has any relationship with the incidence of hernias and whether mesh could be useful for prevention in high-risk patients. Methods Retrospective review of the colon and rectal surgery database from January 2015 to December 2016. Data were classified into 2 groups, transverse (TI) and midline incision (MI), and the latter was divided into 2 subgroups (mesh [MIM] and suture [MIS]). Patients were classified using the HERNIAscore. Hernias were diagnosed by clinical and/or CT examination. Results A total of 182 out of 210 surgical patients were included. After a median follow-up of 13.0 months, 39 IH (21.9%) were detected, 23 of which (13.4%) were in the EI; their frequency was lower in the TI group (3.4%) and in the MIM group (5.9%) than in the MIS group (29.5%; P=.007). The probability of developing IH in the MIS group showed an OR=11.7 (95% CI: 3.3–42.0) compared to the TI group and 4.3 (IC 95%: 1.1–16.3) vs the MIM group. Conclusions The location of the incision is relevant to avoid incisional hernias. Transverse incisions should be used as the first option. When a midline incision is needed, a prophylactic mesh could be considered in high risk patients because it is safe and associated with low morbidity.

Introduction Although the conventional treatment of patients with stage IV colorectal cancer involves resection of the primary tumour followed by chemotherapy, several studies suggest that in patients with few symptoms the first and only treatment should be chemotherapy. The objective of this study is to analyse the complications related to the primary tumour in a series of patients with unresectable metastatic colorectal cancer treated with chemotherapy without surgery. Materials and methods Retrospective descriptive study. The study included all patients with unresectable metastatic colorectal cancer treated with chemotherapy without resection of the primary tumour (January 2007–February 2011). Results The mean age of the 61 patients analysed was 67±13 years and the performance status was 0-1 in 53 (87%). Twenty (33%) patients developed complications during follow-up. The most common complication was intestinal obstruction in 15 (25%) patients followed by perforation. Complications required surgery in 6 (10%) cases. We did not find differences in patient characteristics between those who had a complication and those without, although the complication rate in patients with a colonic stent (53%) was twice that of other patients (26%). Conclusions Chemotherapy without surgery is a good option in most patients with unresectable metastatic colorectal cancer. However, although the percentage of patients requiring surgery is low, the total number of complications related to the primary tumour is not negligible. Studies are needed to identify those patients in whom a prophylactic colectomy could be indicated.

Resumen Introduccion Aunque el tratamiento convencional de los pacientes con cancer colorrectal en estadio iv ha consistido en la reseccion del tumor primario seguida de quimioterapia, varios estudios defienden que en pacientes poco sintomaticos el primer y unico tratamiento debe ser quimioterapia. El objetivo es analizar las complicaciones relacionadas con el tumor primario en una serie consecutiva de pacientes con cancer colorrectal y metastasis irresecables tratados con quimioterapia sin cirugia. Material y metodos Estudio descriptivo retrospectivo. Se ha incluido a todos los pacientes con cancer colorrectal y metastasis irresecables en los que se decidio realizar quimioterapia sin reseccion del tumor primario durante el periodo enero 2007-febrero 2011. Resultados La edad media de los 61 pacientes analizados era de 67 ± 13 anos. Veinte (33%) pacientes presentaron alguna complicacion durante el seguimiento. La complicacion mas frecuente fue la obstruccion intestinal en 15 (25%) seguida de la perforacion. Las complicaciones precisaron cirugia en 6 (10%). No hemos encontrado diferencias estadisticamente significativas en las caracteristicas de los pacientes entre aquellos que presentaron una complicacion y los que no, aunque el porcentaje de complicaciones entre los portadores de protesis colonica (53%) doblo el del resto de pacientes (26%). Conclusiones La quimioterapia sin cirugia es una buena opcion en la mayoria de los pacientes con cancer colorrectal y metastasis irresecables. Sin embargo, aunque el porcentaje de pacientes que precisan cirugia es bajo, el numero de complicaciones relacionadas con el tumor primario no es despreciable. Se necesitan estudios que permitan identificar a aquellos pacientes en los que estaria indicada una colectomia profilactica.

Resumen Introduccion Los programas de rehabilitacion multimodal (RHMM) en cirugia han demostrado un beneficio en la recuperacion funcional de los pacientes. Nuestro objetivo fue evaluar el impacto de un programa de RHMM en los costes hospitalarios. Material y metodos Estudio prospectivo comparativo de cohortes consecutivas de pacientes intervenidos de cirugia colorrectal electiva. En la primera cohorte analizamos 134 pacientes que recibieron un control postoperatorio convencional (grupo control). En la segunda cohorte se incluye a 231 pacientes tratados con un programa de RHMM (grupo RHMM). Se analiza el cumplimiento del protocolo y la recuperacion funcional de los pacientes del grupo RHMM. Se comparan las complicaciones postoperatorias, la estancia hospitalaria y los reingresos en ambos grupos. El analisis de costes se ha basado en la contabilidad analitica del centro. Resultados Las caracteristicas demograficas y clinicas de los pacientes fueron similares entre grupos. No encontramos diferencias en la morbimortalidad global. La estancia media postoperatoria fue 3 dias menor en el grupo RHMM. No se observaron diferencias significativas en la tasa de reingresos. Los costes totales por paciente fueron significativamente menores en el grupo RHMM (RHMM: 8.107 ± 4.117 euros vs. control: 9.019 ± 4.667 euros; p = 0,02). El principal factor que contribuyo a la reduccion de los costes fue el descenso de los gastos de la Unidad de Hospitalizacion. Conclusiones La aplicacion de un protocolo de RHMM en cirugia electiva colorrectal reduce, no solo la estancia hospitalaria, sino tambien los costes hospitalarios, sin aumentar la morbilidad postoperatoria ni el porcentaje de reingresos.

Introduction Multimodal rehabilitation (MMRH) programmes in surgery have proven to be beneficial in functional recovery of patients. The aim of this study is to evaluate the impact of a MMRH programme on hospital costs. Method A comparative study of 2 consecutive cohorts of patients undergoing elective colorectal surgery has been designed. In the first cohort, we analysed 134 patients who received conventional perioperative care (control group). The second cohort included 231 patients treated with a multimodal rehabilitation protocol (fast-track group). Compliance with the protocol and functional recovery after fast-track surgery were analysed. We compared postoperative complications, length of stay and readmission rates in both groups. The cost analysis was performed according to the system “full-costing”. Results There were no differences in clinical features, type of surgical excision and surgical approach. No differences in overall morbidity and mortality rates were found. The mean length of hospital stay was 3 days shorter in the fast-track group. There were no differences in the 30-day readmission rates. The total cost per patient was significantly lower in the fast-track group (fast-track: 8107 ± 4117 euros vs control: 9019 ± 4667 euros; P =.02). The main factor contributing to the cost reduction was a decrease in hospitalisation unit costs. Conclusion The application of a multimodal rehabilitation protocol after elective colorectal surgery decreases not only the length of hospital stay but also the hospitalisation costs without increasing postoperative morbidity or the percentage of readmissions.

Resumen Introduccion El tratamiento ambulatorio de la diverticulitis aguda no complicada es seguro y eficaz. El objetivo de este estudio es cuantificar el impacto que el tratamiento ambulatorio tiene en la reduccion de costes sanitarios. Pacientes y metodos Estudio comparativo de cohortes retrospectivo. Grupo ambulatorio: pacientes diagnosticados de diverticulitis aguda no complicada tratados con antibioticos via oral de forma ambulatoria. Grupo de tratamiento hospitalario: pacientes que cumplian criterios de tratamiento ambulatorio pero que fueron ingresados con tratamiento antibiotico intravenoso. La valoracion de costes se ha realizado a traves del sistema de contabilidad analitica del hospital, basado en costes totales: suma de todos los costes variables (costes directos) mas el conjunto de costes generales repartidos por actividad (costes indirectos). Resultados Se incluyo a 136 pacientes, 90 en el grupo ambulatorio y 46 en el grupo de ingreso. No hubo diferencias en las caracteristicas de los pacientes entre los 2 grupos. No hubo diferencias en el porcentaje de fracaso del tratamiento entre los 2 grupos (5,5 vs. 4,3%; p = 0,7). El coste global por episodio fue de 882 ± 462 euros en el grupo ambulatorio frente a 2.376 ± 830 euros en el grupo hospitalario (p = 0,0001). Conclusiones El tratamiento ambulatorio de la diverticulitis aguda no solo es seguro y eficaz sino que tambien reduce mas de un 60% los costes sanitarios.

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.

Resumen Introduccion La implantacion de la cirugia de preservacion esfinteriana en el cancer de recto ha hecho incrementar el numero de resecciones bajas protegidas con una ileostomia en asa. Esto obliga a un posterior cierre del estoma mediante un acto quirurgico no desprovisto de morbilidad ni mortalidad. Los objetivos del estudio fueron analizar los resultados clinicos de la cirugia de reconstruccion del transito y conocer el intervalo entre ambas cirugias, asi como el papel que la quimioterapia determina en el mismo. Pacientes y metodo Se utilizo retrospectivamente la base de datos prospectiva de los pacientes intervenidos previamente de cancer de recto a los que se les cerro la ileostomia entre mayo de 2004 y septiembre de 2008. Se recogieron y analizaron los datos relativos a indicacion de quimioterapia, intervalo entre cirugias, y complicaciones. Resultados Se analizaron 54 pacientes consecutivos con edad media de 66 anos. El intervalo medio entre cirugias fue de 178 dias siendo significativamente menor en el grupo de pacientes que no recibio quimioterapia (p=0,008). La estancia postoperatoria fue de 6,3 dias (DE=4,1). La mortalidad fue del 1,8% por causa respiratoria y la morbilidad fue del 22,2% con un porcentaje de reintervenciones del 7,4%. Conclusiones La mortalidad y morbilidad del cierre de las ileostomia, no son despreciables, si bien sus ventajas en la proteccion del estoma justifican su uso. El intervalo de reconstruccion de la ileostomia, se ve afectado significativamente por la quimioterapia postoperatoria.

Resumen Introduccion El objetivo es evaluar la influencia del aprendizaje en la aplicacion de un programa de rehabilitacion multimodal (RHMM) sobre el cumplimiento del protocolo y la recuperacion de los pacientes intervenidos de cirugia electiva colorrectal. Material y metodos Estudio prospectivo comparativo de 3 cohortes consecutivas de 100 pacientes (P1, P2 y P3) intervenidos de cirugia de colon o recto. En todos los casos se aplico el mismo protocolo de RHMM. Se ha analizado el cumplimiento del protocolo, tolerancia a la dieta y deambulacion. Tambien se han comparado los porcentajes de alta hospitalaria precoz. Resultados El cumplimiento mejoro progresivamente alcanzando la significacion estadistica entre P1 y P3: el inicio de la dieta el dia 1 del postoperatorio fue de 52 vs. 86% (p=0,0001) y la retirada de sueros fue de 21 vs. 40% (p=0,005). Esta diferencia se mantuvo durante los dias 2 y 3. La tolerancia a la dieta en el dia 1 (P1: 34 vs. P3: 66%; p=0,0001) y la deambulacion en el dia 2 (P1: 41 vs. P3: 68%; p=0,0002) tambien fueron mayores en el tercer periodo. No encontramos diferencias en la morbilidad entre los 3 periodos. El porcentaje de altas hospitalarias en el dia 3 (P1: 1 vs. P3: 15%; p=0,0003), dia 4 (P1: 12 vs. P3: 32%; p=0,001) y dia 5 (P1: 30 vs. P3: 50%; p=0,002) fue mayor en el tercer periodo. Conclusiones El cumplimiento del protocolo y los resultados de la aplicacion de un programa de RHMM mejoran significativamente con la mayor experiencia de los profesionales implicados.

Resumen Introduccion La perforacion del colon es una complicacion poco frecuente, aunque grave, de la endoscopia digestiva baja. El tratamiento es controvertido, aunque en la mayoria de los casos es quirurgico. Los objetivos de este estudio fueron determinar la incidencia de las perforaciones por colonoscopia en nuestro centro y conocer los resultados de las opciones terapeuticas empleadas. Material y metodos Estudio retrospectivo de las perforaciones producidas por colonoscopia entre enero de 2004 y octubre de 2009. Las variables analizadas fueron las siguientes: caracteristicas demograficas, indicacion de la colonoscopia, manifestaciones clinicas, pruebas diagnosticas utilizadas, tiempo entre la perforacion y el diagnostico, tipo de tratamiento, estancia hospitalaria y complicaciones. Resultados Durante el periodo de estudio se realizaron 13.493 colonoscopias. En 13 pacientes (0,1%) se produjo una perforacion del colon. Nueve perforaciones ocurrieron durante la realizacion de una colonoscopia diagnostica (0,08%) y las restantes 4 despues de una colonoscopia terapeutica (0,16%). En 10 casos, el diagnostico se realizo durante las primeras 12 h y en 5 de ellos, la perforacion se identifico durante el mismo procedimiento. La localizacion mas frecuente fue el sigma en 7 casos. En 11 pacientes se realizo tratamiento quirurgico y en 2 pacientes se resolvio con tratamiento conservador. La tecnica quirurgica mas utilizada fue la sutura simple seguida de la reseccion con anastomosis. Un paciente fallecio por sepsis intraabdominal. Conclusion Las perforaciones causadas por colonoscopia son complicaciones poco frecuentes, aunque graves. La mayoria de estos pacientes precisaran tratamiento quirurgico, y quedara reservado el tratamiento conservador para pacientes seleccionados.

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=.0001) and the removal of drips was 21% vs 40% (P=.005). This difference remained during days 2 and 3. Tolerance to the diet on day 1 (P1: 34% vs P3: 66%; P=.0001) and walking on day 2 (P1: 41% vs P3: 68%; P=.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=.0003), day 4 (P1: 12% vs P3: 32%; P=.001) and day 5 (P1: 30% vs P3: 50%; P=.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.

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=.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.

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.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.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).We concluded that postoperative intra-abdominal infection increases angiogenesis and tumor recurrence after operative excision of a colon cancer in mice.

Aim Evidence supporting outpatient treatment with oral antibiotics in patients with uncomplicated diverticulitis is limited. Our aim was to evaluate the safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis. Method All patients diagnosed with uncomplicated diverticulitis based on abdominal computed tomography findings from June 2003 to December 2008 were considered for outpatient treatment. Admission was indicated in patients not able to tolerate oral intake and those with comorbidity or without adequate family support. Treatment consisted of oral antibiotics for 7 days (amoxicillin-clavulanic or ciprofloxacin plus metronidazole in patients with penicillin allergy). Patients were seen again at between 4 and 7 days after starting treatment to confirm symptom improvement. Results Ninety-six patients were diagnosed with uncomplicated acute diverticulitis and 26 presented at least one criterion for admission. Ambulatory treatment was initiated in 70 (73%) patients. Only two (3%) required admission because of persisting abdominal pain and vomiting, respectively. Intravenous antibiotics resolved the inflammatory process in both cases. In the remaining 68 (97%), ambulatory treatment was completed without complication. Conclusion Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective and applicable to most patients with tolerance to oral intake and without severe comorbidity and having appropriate family support.

Resumen Introduccion El objetivo principal del estudio fue la aplicacion de una clasificacion de gravedad de las lesiones esfinterianas halladas en ecografias endoanales mediante el sistema de puntuacion de Starck en pacientes con incontinencia fecal (IF). Material y metodos Se analizaron los datos de 133 enfermos con IF, en los que se describio la presencia ecografica de lesiones esfinterianas, y su puntuacion segun el sistema de Starck. Este sistema asigna un valor entre 0 y 16 puntos a la lesion detectada segun su gravedad en los 3 ejes del espacio del canal anal. Se estudio tambien la relacion entre la gravedad de estas lesiones, el sexo, la edad de los pacientes y los hallazgos de la manometria anorrectal. Resultados Ochenta y tres pacientes (62,4%) presentaron algun tipo de lesion esfinteriana. Estas lesiones no se asociaron de manera significativa al sexo de los pacientes (p=0,172), aunque si se presentaron en edades mas tempranas (p=0,028). La gravedad de las lesiones segun Starck no se correlaciono con el sexo (p=0,327) ni con la edad (p=0,350) de los pacientes. Los pacientes con lesiones ecograficas mas graves presentaron una menor presion anal basal (p=0,008) y de contraccion voluntaria (p=0,011) en la manometria anorrectal. Conclusiones La presencia ecografica de lesiones en el complejo esfinteriano en pacientes con IF se pudo caracterizar con el sistema de puntuacion de Starck. La gravedad de las lesiones se correlaciono con los valores de la manometria anorrectal.

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.

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.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.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.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).Our results suggest that postoperative peritoneal infection enhances the invasive capacity of residual tumor cells after surgery, thus facilitating their growth to recurrent tumors.

Background Several studies have suggested that laparoscopy might confer an oncological advantage in patients undergoing surgery for colonic cancer. A decreased inflammatory and angiogenic response has been proposed. This study compared the local and systemic inflammatory and angiogenic responses after open and laparoscopic surgery for colonic cancer. Methods Some 122 patients with colonic cancer were randomized to open or laparoscopic colectomy. Levels of interleukin (IL) 6 and vascular endothelial growth factor (VEGF) were measured in serum and peritoneal fluid at baseline, then at 4, 12, 24 and 48 h and on day 4 after surgery. Samples obtained on day 4 were tested in an in vitro angiogenesis assay, with measurement of number of capillaries per field and capillary length. Results The serum IL-6 level was lower in the laparoscopic group at 4 h (mean(s.d.) 124(110) versus 244(326) pg/dl after open colectomy; P = 0·027). The serum VEGF concentration was also lower in the laparoscopic group at 48 h and day 4 (430(435) versus 650(686) pg/dl; P = 0·001). Overall, local IL-6 and VEGF levels were significantly higher than serum levels but there were no differences between groups. In vitro, postoperative serum and peritoneal fluid samples were potently angiogenic but there were no differences between open surgery and laparoscopy. Rates of tumour recurrence and survival were similar in the two groups. Conclusion Despite differences in postoperative serum levels of IL-6 and VEGF after open and laparoscopic surgery in patients with colonic cancer, the angiogenic response is comparable in both surgical approaches. Registration number: ISRCTN55624793 (http://www.controlled-trials.com).

Introduction Colon perforation is a fairly uncommon, but serious, complication during endoscopy of the lower gastrointestinal tract. Treatment is controversial, although surgery is used in the majority of cases. The aims of this study were to determine the incidence of perforations due to colonoscopy in our hospital and to find out the results of the treatment options used. Material and methods Retrospective study of perforations caused by colonoscopy between January 2004 and October 2008. The variables analysed were: demographic characteristics, colonoscopy indication, clinical signs and symptoms, diagnostic tests used, time between perforation and the diagnosis, treatment type, hospital stay and complications. Results A total of 13,493 colonoscopies were performed during the study period. A perforation of the colon was found in 13 (0.1%) patients. Nine perforations occurred whilst performing a diagnostic colonoscopy (0.08%) and the remaining 4 after a therapeutic colonoscope (0.16%). In 10 of the cases the diagnosis was made within the first 12 h, and in 5 of these the perforation was identified during the procedure itself. The most common location was the sigmoid, in 7 cases. Surgical treatment was carried out on 11 patients, and in the other two it was resolved by conservative treatment. The most used surgical technique was simple suture followed by resection with anastomosis. One patient died due to intra-abdominal sepsis. Conclusion Perforations caused by colonoscopy are rare, but serious, complications. The majority of these patients required surgical treatment, with conservative treatment being reserved for selected patients.