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The implementation of quality-of-care indicators aiming to improve colorectal cancer (CRC) outcomes has been previously described by Cancer Care Ontario. The aim of this study was to assess the quality-of-care indicators in CRC at a referral centre in a developing country and to determine whether improvement occurred over time.We performed a retrospective study of our prospectively collected database of patients after CRC surgery from 2001 to 2016. We excluded patients who underwent local transanal excision, pelvic exenteration or palliative procedures. We evaluated trends over time using the Cochran-Armitage test for trend.A total of 343 patients underwent surgical resection of CRC over the study period. There was improvement of the following indicators over time: the proportion of patients detected by screening (This study showed the feasibility of applying the Cancer Care Ontario indicators for evaluating outcomes in CRC treatment at a single centre in a developing country. Although there was an improvement of some of the quality-of-care indicators over time, policies and interventions must be implemented to improve the fulfillment of all indicators.Action Cancer Ontario a déjà décrit l’application d’indicateurs de la qualité des soins dans le but d’améliorer l’issue du cancer colorectal (CCR). Le but de cette étude était d’évaluer les indicateurs de la qualité de soins pour le CCR dans un centre de référence d’un pays en voie de développement et de déterminer si des améliorations ont pu être observées avec le temps.Nous avons procédé à une étude rétrospective de notre base de données recueillies prospectivement auprès de patients ayant subi une chirurgie pour CCR entre 2001 et 2016. Nous avons exclu les patients qui ont subi une exérèse transanale locale, une exentération pelvienne ou des traitements palliatifs. Nous avons évalué les tendances au fil du temps à l’aide du test Cochran–Armitage pour dégager les tendances.En tout, 343 patients ont subi une résection chirurgicale de CCR au cours de la période de l’étude. On a noté une amélioration des indicateurs suivants au fil du temps : proportion de patients ayant subi un dépistage (Cette étude a démontré l’applicabilité des indicateurs d’Action Cancer Ontario pour évaluer les résultats du traitement pour CCR dans un seul centre d’un pays en voie de développement. Même si certains des indicateurs de la qualité des soins se sont améliorés au fil du temps, il faut appliquer des politiques et des interventions pour améliorer tous les indicateurs.

Colorectal cancer (CRC) is the third most commonly diagnosed cancer globally and the second cancer in terms of mortality. The prevalence of sarcopenia in patients with CRC ranges between 12%-60%. Sarcopenia comes from the Greek "sarx" for flesh, and "penia" for loss. Sarcopenia is considered a phenomenon of the aging process and precedes the onset of frailty (primary sarcopenia), but sarcopenia may also result from pathogenic mechanisms and that disorder is termed secondary sarcopenia. Sarcopenia diagnosis is confirmed by the presence of low muscle quantity or quality. Three parameters need to be measured: muscle strength, muscle quantity and physical performance. The standard method to evaluate muscle mass is by analyzing the tomographic total cross-sectional area of all muscle groups at the level of lumbar 3rd vertebra. Sarcopenia may negatively impact on the postoperative outcomes of patients with colorectal cancer undergoing surgical resection. It has been described an association between sarcopenia and numerous poor short-term CRC outcomes like increased perioperative mortality, postoperative sepsis, prolonged length of stay, increased cost of care and physical disability. Sarcopenia may also negatively impact on overall survival, disease-free survival, recurrence-free survival, and cancer-specific survival in patients with non-metastatic and metastatic colorectal cancer. Furthermore, patients with sarcopenia seem prone to toxic effects during chemotherapy, requiring dose deescalations or treatment delays, which seems to reduce treatment efficacy. A multimodal approach including nutritional support (dietary intake, high energy, high protein, and omega-3 fatty acids), exercise programs and anabolic-orexigenic agents (ghrelin, anamorelin), could contribute to muscle mass preservation. Addition of sarcopenia screening to the established clinical-pathological scores for patients undergoing oncological treatment (chemotherapy, radiotherapy or surgery) seems to be the next step for the best of care of CRC patients.

Background The aim of this study was to analyze the evidence regarding open versus laparoscopic surgery for the treatment of diverticular colovesical fistula (CVF) in terms of perioperative outcomes. Methods A systematic review was performed using PubMed, Cochrane, Google Scholar, and Web of Science databases for studies comparing laparoscopic versus open surgery for CVF. We pooled odds ratios (OR) and mean differences (MD) using random or fixed effects models. Results Five non-randomized studies with 227 patients met the inclusion criteria. All were retrospective studies, published between 2014 and 2020. For laparoscopic surgery, the pooled rate for conversion to laparotomy was 36%. Laparoscopic and open procedures required similar operative time (MD: -11.62; 95% confidence interval [CI]: -51.41 to 28.16). No difference was found in terms of stoma rates between laparoscopic and open surgery (OR: 1.12; 95% CI 0.44-2.86). Overall, the rate of total postoperative complications was lower in the laparoscopic group (OR: 0.55; 95% CI: 0.30-0.99). The pooled analysis showed equivalent rates of anastomotic leaks (OR: 0.61; 95% CI 0.15-2.45), surgical site infections (OR: 0.44; 95% CI 0.19-1.01), and mortality (OR: 0.18; 95% CI 0.03-1.15). The length of stay was significantly reduced with laparoscopic surgery (MD: -2.89; 95% CI -4.20 to -1.58). Conclusion Among patients with CVF, the laparoscopic approach appears to have shorter hospital length of stay, with no differences in anastomotic leaks, surgical site infections, stoma rates, and mortality, when compared with open surgery.

Diagnosis of colorectal cancer (CRC) after emergency presentation is associated with a worse prognosis.The aim of the study was to determine the sociodemographic factors related with emergency CRC surgery at our institution.From January 2009 to December 2017, patients that underwent CRC surgery at our institution were included in the study. Univariate and multivariate logistic regression were used to determine the effect of the potential risk factors on the rate of emergency surgery.A total of 247 patients underwent CRC surgery at our institution. The rate of emergency surgery was 7.7%. On univariate analysis, patients without a family history of cancer (odds ratio [OR]: 4.95), living in a rural area (OR: 3.7), and late clinical cancer stage (OR: 5.06) were associated with emergent surgery. Mid-income status was a protective factor for emergency surgery (OR: 0.14, p = 0.003). On multivariate analysis, late clinical cancer stage (OR: 4.41, 95% CI 1.21-16.05, p = 0.024) and mid-income economic status (OR: 0.41, 95% CI 0.04-0.55, p = 0.004) were identified as independent risk factors for emergency surgery.Social, economic, and demographic factors were identified as predictors for emergent CRC surgery.El diagnóstico de cáncer colorrectal (CCR) en el contexto de urgencia está asociado a un mal pronóstico.Determinar los factores sociodemográficos asociados a cirugía de urgencia en el CCR en nuestra institución.De enero de 2009 a diciembre de 2017 se incluyeron los pacientes operados de CCR y se realizaron análisis univariado y multivariado para determinar los potenciales factores de riesgo.Se incluyeron en el estudio 247 pacientes operados de CCR. El 7.7% de las cirugías fueron de urgencia. En el análisis univariado, los pacientes sin antecedentes familiares de cáncer (odds ratio [OR]: 4.95), los habitantes de zonas rurales (OR: 3.7) y aquellos en etapas avanzadas del cáncer (OR: 5.06) se asociaron a cirugía de urgencia. Los pacientes con nivel socioeconómico medio tuvieron menos probabilidad de que su cirugía fuera de urgencia (OR: 0.14; p = 0.003). En el análisis multivariado, debutar con una etapa clínica avanzada (OR: 4.41; intervalo de confianza del 95% [IC95%]: 1.21-16.05; p = 0.024) y tener un nivel socioeconómico medio (OR: 0.41; IC95%: 0.04-0.55; p = 0.004) fueron factores independientes para cirugía de urgencia por CCR.Los factores sociales, económicos y demográficos se encontraron relacionados con la necesidad de cirugía de urgencia por CCR.

Background Muscle mass and visceral fat may be assessed at the level of the third lumbar vertebra (L3) in computed tomography (CT). Both variables have been related with adverse surgical outcomes. Objective The objective of the study was to study the association of skeletal muscle index (SMI) and visceral fat area (VFA) with 30-day mortality in colorectal surgery. Methods This is a retrospective cohort study conducted at a tertiary referral hospital in Mexico City. Patients who underwent colorectal surgery with primary anastomosis from January 2007 to December 2018 were included in the study. Their preoperative CT scans were analyzed with the NIH ImageJ software at the level of the third lumbar vertebra to determine their SMI (L3-SMI) and the VFA. Logistic regression analysis (adjusted by surgery anatomical location) was used to determine the association between these variables and surgical 30-day mortality. Results A total of 548 patients were included; 30-day mortality was 4.18% (23 patients). On univariable analysis, L3-SMI, low SMI, anastomosis leak, pre-operative albumin, estimated blood loss, age, steroid use, Charlson comorbidity index score >2, and type of surgery were associated with 30-day mortality. On multivariable analysis, low SMI remained an independent risk factor with an odds ratio of 4.74, 95% confidence interval 1.22-18.36 (p = 0.02). Conclusion Low SMI was found to be an independent risk factor for 30-day mortality in patients submitted to colorectal surgery with a primary anastomosis, whether for benign or malignant diagnosis. VFA was not associated with 30-day mortality.

Clostridium difficile is an increasingly common source of in-patient morbidity and mortality. We aim to assess the effects of diverting loop ileostomy (DLI) versus total abdominal colectomy (TAC) for Clostridium difficile colitis (CDC), in terms of mortality and morbidity. Systematic literature search was performed using PubMed, Embase, Cochrane, and Web of Science databases for randomized and non-randomized studies comparing DLI and TAC for fulminant CDC. Meta-analysis was carried out for mortality and postoperative complications. Five non-randomized studies qualified for inclusion in the quantitative synthesis. In total, 3683 patients were allocated to DLI (n = 733) or TAC (n = 2950). The overall mortality was equivalent (OR 0.73; 95% CI 0.45–1.20; P = 0.22). Regarding secondary outcomes, the pooled analysis revealed the following equivalent rates of postoperative events: thromboembolism (OR 0.45; 95% CI 0.14–1.43; P = 0.18), acute renal failure (OR 1.71; 95% CI 0.91–3.23; P = 0.10), surgical site infection (OR 0.95; 95% CI 0.11–8.59; P = 0.97), pneumonia (OR 0.98; 95% CI 0.36–2.66; P = 0.97), urinary tract infection (OR 0.81; 95% CI 0.26–2.52; P = 0.72), and reoperation (OR 0.95; 95% CI 0.50–1.82; P = 0.78). The ostomy reversal rate was significantly higher in DLI (OR 12.55; 95% CI 3.31–47.55; P = 0.0002). The overall morbidity and mortality rates between DLI and TAC for the treatment of CDC seemed to be equivalent. Evidence from a randomized controlled trial is needed to clarify the timing and understand the impact of DLI for CDC.

Temperature-controlled radiofrequency (RF) energy delivery to the sphincter complex has been proposed as an option for those patients not susceptible to a major surgical procedure for fecal incontinence (FI). The aim of the study was to evaluate the long-term (15 years) functional outcomes obtained after RF procedure for FI. This was a retrospective analysis of our prospectively collected database of patients that underwent RF procedure for FI. Primary outcomes measured were the Cleveland Clinic Florida Fecal Incontinence scale (CCF-FI), Fecal Incontinence-related Quality of Life Score (FIQLS), the 36-Item Short Form survey (SF-36), endoanal ultrasound, and anorectal manometry. Evaluations were compared at baseline and at 15 years of follow-up. Ten patients were followed up 15 years after RF procedure. There was no significant improvement in the CCF-FI score (13.8 vs. 12.4, p = 0.24). No significant changes in the FIQLS were observed including lifestyle (2.39 vs. 2.13, p = 0.23), coping (1.91 vs. 1.92, p = 0.96), and embarrassment (1.66 vs. 1.86; p = 0.43). However, significant worsening was found in the depression category (2.47 vs. 1.60, p = 0.001). The SF-36 showed significant worsening in the mental (36.7 vs. 25.8, p

Despite the advantages of diverting loop ileostomy construction, it is related to complications.The aim of the study was to determine the risk factors for complications after loop ileostomy closure.Patients who underwent loop ileostomy closure from January 2010 to March 2018 were retrospectively analyzed. Multivariate logistic regression was used to determine the effect of the potential risk factors on the rate of each complication.A total of 136 patients underwent reversal. Indications for the initial operation were colorectal cancer (39.7%), diverticulitis (25.7%), idiopathic chronic ulcerative colitis (ICUC) (8.1%), familial adenomatous polyposis (FAP) (7.4%), and others (19.1%). Multivariate analysis identified the following risk factors: type of incision (midline laparotomy) (odds ratio [OR] = 6.5) for wound infection; treatment with immunomodulator (OR = 12.5) for anastomotic leak; history of FAP (OR = 9.8) for intestinal obstruction; previous use of immunomodulator (OR = 10.0) and performing reversal through midline incision (OR = 18.9) for reoperation; and ≥ 65 years old (OR = 3.5) for medical complications. The rate of incisional hernia was 11%, and the risk factors were time to closure3 months (OR = 6.4) and parastomal hernia (OR = 13.2).Several patient-related and surgical technique factors should be considered at the time of loop ileostomy closure to reduce post-operative morbidity.A pesar de las ventajas de la ileostomía en asa de derivación, múltiples complicaciones se han asociado a su uso.Determinar los factores de riesgo para presentar complicaciones tras el cierre de una ileostomía en asa.Se realizó un análisis retrospectivo de los pacientes sometidos a cierre de ileostomía en asa de enero de 2010 a marzo de 2018. Se determinaron los factores de riesgo utilizando regresión multivariable.Se incluyeron 136 pacientes. Las indicaciones para cirugía fueron cáncer colorrectal (39.7%), diverticulitis (25.7%), colitis ulcerosa crónica idiopática (CUCI) (8.1%), poliposis adenomatosa familiar (PAF) (7.4%) y otras (19.1%). Se identificaron los siguientes factores de riesgo: incisión en línea media (OR: 6.5) para infección de herida; tratamiento inmunomodulador (OR: 12.5) para fuga de anastomosis; antecedente de PAF (OR: 9.8) para oclusión intestinal; tratamiento inmunomodulador (OR: 10) e incisión en línea media (OR: 18.9) para reintervención; y edad ≥ 65 años (OR: 3.5) para complicaciones médicas. La frecuencia de hernia incisional fue del 11%:3 meses para el cierre (OR: 6.4) y hernia parastomal (OR: 13.2).Numerosos factores relacionados con el paciente y con la técnica quirúrgica deben de ser considerados al momento del cierre de la ileostomía en asa para reducir la morbilidad posoperatoria.

BACKGROUND Despite the potential benefits of fecal diversion after low pelvic anastomosis in colorectal surgery, diverting loop ileostomy construction is related to significant rates of complications. AIM To determine potential predictors of high output related complications in patients with diverting loop ileostomy creation after colorectal surgery. METHODS Patients who underwent open and laparoscopic colorectal surgery requiring a diverting loop ileostomy from January 2010 to March 2018 were retrospectively analyzed. We included patients older than 18 years, who underwent colorectal surgery with primary low pelvic anastomosis, and with the creation of a diverting loop ileostomy, at elective or emergency settings for the treatment of benign or malignant conditions. Univariate and multivariate logistic regression analysis was used to determine the effect of the potential predictors on the rate of high output related complications. The high output related complications were dehydration and acute renal failure that required visits to the emergency department and hospitalizations. RESULTS Of the 102 patients included in the study, 23.5% (n = 24) suffered high output related complications. In this group of patients at least one visit to the emergency department (mean 1.6), and at least one readmission to the hospital was needed. The factors associated with high-output ileostomy, in the univariate analysis, were: urgent surgical intervention (OR = 2.6; P = 0.047), the development of postoperative complications (OR = 3; P = 0.024), have ulcerative colitis (OR = 4.8; P = 0.017), use of steroids (OR = 4.3; P = 0.010), mean output at discharge greater than 1000 mL/24 h (OR = 3.2; P = 0.016), and use of loperamide at discharge (OR = 2.8; P = 0.032). Multivariate logistic regression analysis identified two independent risk factors for high output related complications: ulcerative colitis [OR = 7.6 (95%CI: 1.81-31.95); P = 0.006], and ileostomy output at discharge ≥ 1000 mL/24 h [OR = 3.3 (1.18-9.37); P = 0.023]. CONCLUSION In our study, patients with ulcerative colitis and those with an ileostomy output above 1000 mL/24 h at discharge, were at increased risk of high output related complications.

Aim Due to the altered bowel habits after bariatric surgery (BS), we hypothesize that there is a high frequency of benign anal diseases (BAD) in these patients. We aimed to assess the incidence of BAD in patients that underwent BS and the factors associated with its development. Method A retrospective review of the patient's records with morbid obesity that underwent BS at a single institution from 2010 to 2016 was conducted. Results Two-hundred thirty-five patients who underwent BS were included. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) was performed in 210 (89.4%) and 25 (10.6%) patients, respectively. The total follow-up was 804.3 person-years. The mean postoperative follow-up was 41 months (95% CI: 38–44.1). At follow-up, normal bowel habits were found in 186 (79.2%) patients, constipation in 36 (15.3%), and diarrhea in 13 (5.5%). BAD occurred in 9 (3.8%) patients; hemorrhoids were diagnosed in 6 (2.5%) and abscess/fistulae in 3 (1.3%). There was no predominance of BAD regarding sex (2.9% females Vs. 6.2% males, p = 0.237) or BS performed (3.8% RYGB Vs. 4% SG, p = 0.963). Postoperative weight change was not associated with BAD. Patients who developed BAD after BS were older (median 52 Vs. 45 years, p = 0.011) and had fewer bowel movements per day (median 1 Vs. 2, p Conclusion The frequency of BAD after BS was 3.8% over a mean follow-up time of 41 months. The estimated incidence density of BAD after BS was 11.1 events per 1000 person-years. Older age was associated with its occurrence.

Neutropenic enterocolitis (NEC) is a severe complication of neutropenia. NEC is characterized by segmental ulceration, intramural inflammation, and necrosis. Factors present in patients who underwent colectomy have never been studied. The present study aimed to describe the clinical factors present in patients who underwent emergent colectomy for the treatment of neutropenic enterocolitis. Patients admitted with neutropenic enterocolitis from November 2009 to May 2018 were retrospectively analyzed. Logistic regression analysis was used to determine clinical factors associated with emergent colectomy. Thirty-nine patients with NEC were identified. All patients had a hematological disorder. Medical treatment was the only management in 30 (76.9%) patients, and 9 (23.1%) patients underwent colectomy. No differences were found between the treatment groups regarding sex, age, or comorbidities. Patients were more likely to undergo colectomy if they developed abdominal distention (OR = 12, p = 0.027), hemodynamic failure (OR = 6, p = 0.042), respiratory failure (OR = 17.5, p = 0.002), multi-organic failure (OR = 9.6, p = 0.012), and if they required ICU admission (OR = 11.5, p = 0.007). Respiratory failure was the only independent risk factor for colectomy in multivariable analysis. In-hospital mortality for the medical and surgical treatment groups was 13.3% (n = 4) and 44.4% (n = 4), respectively (p = 0.043). In our study, most NEC patients were treated conservatively. Patients were more likely to undergo colectomy if they developed organ failures or required ICU admission. Early surgical consultation is suggested in all patients with NEC.

Pelvic floor reconstruction with pedicled vertical rectus abdominis myocutaneous flap has been popularized in patients undergoing pelvic exenteration due to locally advanced rectal carcinoma. Abdominal wall fascial dehiscence and incisional hernia may occur as a result of large skin and fascia islands as well as muscle required to close these large defects. The purpose of this paper was to describe a novel technique, consisting of VRAM flap donor-site closure with component separation technique, performed on the contralateral side as the flap harvest, allowing for a lower tension closure between ipsilateral external oblique/internal oblique/transverse abdominis muscles complex and contralateral rectus abdominis muscle. In 10 patients undergoing this technique, no abdominal fascial dehiscence, incisional hernia, or parastomal hernia occurred during a mean follow-up of 15 months. Overall 3-year patient survival rate was 80% with abdominal hernia free-survival rate of 100%. The addition of this technique represents an advance in overall patient care to provide a more successful outcomes in this complex scenario.

To assess the functional outcomes and quality of life in patients with laparoscopic total colectomy for slow-transit constipation (STC). All patients undergoing laparoscopic colectomy with ileorectal anastomosis for colonic inertia at two referral centers were analyzed. Their preoperative, intraoperative and postoperative details were recorded with a one-year follow-up. Their quality of life was assessed using the SF-36 questionnaire. Between 2004 and 2007, 710 patients were evaluated. Eight female patients (1.1 %) fulfilled the criteria for STC without obstructive defecation syndrome. Their mean age was 38 years ± 15 (range from 22 to 62). The conversion rate was 12.5 %. The morbidity rate was 37.5 %, and mortality was nil. The preoperative abdominal pain was 6.6 ± 0.3 and had decreased to 3.6 ± 2.3 postoperatively (P = 0.008). At 1 year, the defecation frequency per week had increased from 0.84 ± 0.24 to 6.75 ± 3.4 (P = 0.001). Three patients developed nocturnal leakage (37.5 %). Eighty-eight percent of the patients recommend the procedure. All parameters of the SF-36 questionnaire had improved at the one-year follow-up examination. Laparoscopic colectomy for slow-transit constipation is safe and increased the number of evacuations per week. Although nocturnal leakage may occur, these patients experience improvements in their quality of life.

Colovesical fistulas in two-thirds of the cases are due to diverticular disease. In recent years, a minimally invasive approach has shown advantages over the traditional open approach. The goal of this study was to evaluate the surgical results and safety of the laparoscopic procedure in patients with colovesical fistula.We retrospectively evaluated 24 patients who underwent surgery for colovesical fistula in a referral center from 2005 to 2011. Patients were divided into two groups: (i) laparoscopic approach, and (ii) open approach.The laparoscopic and open groups had similar characteristics with respect to age and gender distribution. There were a higher number of bladder repairs in the open approach group (83.3 vs. 16.6%; p = 0.01). The operative time (212 ± 74 min vs. 243 ± 69 min; p = 0.313) and intraoperative bleeding (268 ± 222 ml vs. 327 ± 169 ml; p = 0.465) were similar in both groups. The conversion rate of the laparoscopic approach to open surgery was 25%. There was no difference in morbidity (41.1 vs. 25%; p = 0.414), although the laparoscopic group had a shorter hospital stay (9 ± 4 days vs. 15 ± 11 days; p = 0.083) without statistical significance.The treatment of colovesical fistula by a laparoscopic approach is safe and is associated with less bladder repairs and a shorter hospital stay.

The use of temporary stomas has been demonstrated to reduce septic complications, especially in high-risk anastomosis; therefore, it is necessary to reduce the number of complications secondary to ostomy takedowns, namely wound infection, anastomotic leaks, and intestinal obstruction.To compare the rates of superficial wound infection and patient satisfaction after pursestring closure of ostomy wound vs conventional linear closure.Patients undergoing colostomy or ileostomy closure between January 2010 and February 2011 were randomly assigned to linear closure (n = 30) or pursestring closure (n = 31) of their ostomy wound. Wound infection within 30 days of surgery was defined as the presence of purulent discharge, pain, erythema, warmth, or positive culture for bacteria. Patient satisfaction, healing time, difficulty managing the wound, and limitation of activities were analyzed with the Likert questionnaire.The infection rate for the control group was 36.6% (n = 11) vs 0% in the pursestring closure group (p0.0001). Healing time was 5.9 weeks in the linear closure group and 3.8 weeks in the pursestring group (p = 0.0002). Seventy percent of the patients with pursestring closure were very satisfied in comparison with 20% in the other group (p = 0.0001).This study was limited by the heterogeneity in the type of stoma in both groups.The pursestring method resulted in the absence of infection after ostomy wound closure (shorter healing time and improved patient satisfaction).

Background: Steroids can alleviate symptoms long enough for the patient to stop the compulsive pruritus-scratch cycle and allow for healing excoriated perianal skin, owing to potent anti-inflammatory and anti-proliferative effects. This systematic review was designed to evaluate the use of topical steroids for the treatment of primary pruritus ani.Methods: Studies were retrieved after searching the electronic databases Medline, Google Scholar, and Co-chrane Central. The search terms, pruritus ani, anal itching, idiopathic pruritus ani, primary pruritus ani and topical steroids were used. Outcomes were efficacy in reduction of pruritus and side-effects.Results: A total of 7 studies met our inclusion criteria accounting for 181 total of cases of primary pruritus ani treated with topical steroids between 1982 and 2007. On regard of the 181 cases, mean age of patients ranged from 35.4 to 49.5 years old, and similar proportion of males (51.6%) and females (48.4%) was found. Mean duration of symptoms (pruritus ani) varies widely among the studies, with a minimum 5.2 weeks to a maximum 6.5 years. The majority of studies employed hydrocortisone ointment at different concentrations (0.25% and 1%) as the primary therapy. On regard of the overall effectiveness of topical steroid therapy in patients with primary pruritus ani, it ranges between 73.9% to 100%. Few or no side effects were reported in the studies.Conclusions: This systematic review found a lack of high-quality studies on the efficacy of topical steroids in the treatment of primary pruritus ani.

Patients with Systemic Lupus Erythematosus (SLE) that present with acute abdominal pain (AAP) represent a challenge for the general surgeon. The purpose of this study was to identify the major causes of AAP among these patients and to define the role of disease activity scores and the APACHE II score in identifying patients with an increased perioperative risk. We conducted a prospective study of patients admitted to the ER with AAP and SLE in an 11-year period. Demographic, diagnostic, and treatment data were recorded. Systemic lupus erythematosus disease activity index (SLEDAI), systemic lupus international collaboration clinics damage index (SLICC/DI), and APACHE II Score were analyzed. The main outcome variables were morbidity and mortality within 30 days of admission. Seventy-three patients were included. Ninety-three percent were female. Most common causes of AAP were: pancreatitis (29%), intestinal ischemia (16%), gallbladder disease (15%), and appendicitis (14%). Most causes of AAP in patients with LES were not related to the disease. APACHE II score > 12 was statistically associated with the diagnosis of intestinal ischemia compared to other causes. No relationship was observed between SLEDAI and outcome. Furthermore, this index did not have impact on diagnosis or decision making. Overall morbidity was 57% and overall mortality 11%. On multivariate analysis, only APACHE II > 12 was associated with mortality (P = 0.0001). This is one of the largest series of AAP and SLE. Most common causes of AAP were pancreatitis and intestinal ischemia. APACHE II score in patients with intestinal ischemia was higher than those with serositis; further studies are needed to examine whether this score may help to differentiate these ethiologies when CT findings are inconclusive. APACHE II score was the most important factor associated with mortality. Furthermore, a prompt diagnosis and an appropriate surgical management are essential in order to improve patient outcome.

Because definitive long-term results are not yet available, the oncologic safety of laparoscopic surgery in rectal cancer remains controversial. Laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME). However, few prospective randomized studies have been performed. The main purpose of our study was to evaluate whether relevant differences in safety and efficacy exist after elective LTME for the treatment of rectal cancer compared with OTME in a tertiary referral medical center. This comparative nonrandomized prospective study analyzes data in 56 patients with middle and lower rectal cancer treated with low anterior resection or abdominoperineal resection from November 2005 to November 2007. Follow-up was determined through office charts or direct patient contact. Statistical analysis was performed using χ2 test and Student's t test. Twenty-eight patients underwent LTME and 28 patients were in the OTME group. No conversion was required in the LTME group. Mean operating time was shorter in the laparoscopic group (LTME) (181.3 vs 206.1 min, P < 0.002). Less intraoperative blood loss and fewer postoperative complications were seen in the LTME group. Return of bowel motility was observed earlier after laparoscopic surgery. There was no 30-day mortality and the overall morbidity was 17 per cent in the LTME group versus 32 per cent in the OTME group. The mean number of harvested lymph nodes was greater in the laparoscopic group than in the OTME group (12.1 ± 2 vs 9.3 ± 3). Mean follow-up time was 12 months (range 9-24 months). No local recurrence was found. LTME is a feasible procedure with acceptable postoperative morbidity and low mortality, however it is technically demanding. This series confirms its safety, although oncologic results are at present comparable with the OTME published series with the limitation of a short follow-up period. Further randomized studies are necessary to evaluate long-term clinical outcome.

Recently, there have been new antiseptics for surgical scrub that do not require brushing. One of them contains 1% chlorhexidine gluconate and 61% ethyl alcohol; within its benefits, it may offer a low potential for skin sensitization, as well as cost savings and less use of water.To evaluate satisfaction levels, washing time, safety, cost and amount of water between the traditional surgical scrub technique (group A) and brush-free surgical scrub procedure (group B).One hundred clean and clean-contaminated surgeries with four hundred members of surgical teams were included. Satisfaction levels, hand-washing time, skin disorders and problems associated with placement of gloves were evaluated. Hands cultures were taken in 20% of the population and the amount of water used by patients in group A was measured. Total costs and wound infections were analyzed.Satisfaction scale in group A was 9.1 +/- 1.39 and 9.5 +/- 1.54 in group B (p = 0.004). The mean hand-washing time was 3.9 +/- 1.07 min in group A and 2.0 +/- 0.47 min in group B (p = 0.00001). Thirteen patients had dry skin in group A and four in group B (6.5% vs. 2%; p = 0.02). There were ten positives cultures in group A and five in group B (25% vs. 12.5%, p = 0.152). Wound infection rate was 3%. On average, five-hundred eighty liters of water were used by the former group, and the estimated hand-washing cost was lower in the second group.The handwashing technique with CGEA is as effective as traditional surgical scrub technique, and it is associated with less washing time, dry skin, cost and use of water.

A protective loop ileostomy for a distal anastomosis of the rectum or anus, decreases the risk of sepsis secondary to anastomotic leak or dehiscence. This study examines whether the surgical technique employed in the construction of the anastomosis (open vs. laparoscopic) alters the subsequent closure of ileostomy.The goal of this study is to determine whether at the time of a protective ileostomy closure, the fact of doing an initial laparoscopic surgery has advantages over those who underwent open surgery.This is a comparative and retrospective analysis of the results of an ileostomy closure with prior open surgery (ICPOS) vs those performed with a prior laparoscopic surgery (ICPLS). Demographic and surgical results were analyzed. Fisher's test and Chi square tests were used. A statistically significant results was defined as p0.05.A total of 71 patients were included: 42 (59.2%) ICPOS and 29 (40.8%) ICPLS. Surgical time and hospital stay were less in the ICPLS group when compared with the ICPOS group. 79 vs. 133 min (p = 0.0001) and 3 vs. 5 days (p = 0.0001). Four patients (66.7%) from the ICPOS group developed ileum, whereas only 2 (33.3% from the ICPLS presented it (p = 0.04). Six patients had surgical wound infection, 5 (83.3%) of them represented the ICPOS group and only 1 (16.7%) represented the ICPLS group (p = 0.01). Four patients (5.6%) had anastomotic dehiscence, all of them were from the ICPOS group (p = 0.0037). On the ICPOS group 6 patients were reinterveined after the ileostomy closure, whereas none from the ICPLS required it (p = 0.01).An ICPLS seems to have advantages over a ICPOS when analyzing surgical time, hospital stay and surgical ileum development, a lesser infection rate and a lesser re intervention rate at last.

Because definitive long-term results are not yet available, the oncologic safety of laparoscopic surgery in rectal cancer remains controversial. Laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME). However, few prospective randomized studies have been performed. The main purpose of our study was to evaluate whether relevant differences in safety and efficacy exist after elective LTME for the treatment of rectal cancer compared with OTME in a tertiary referral medical center. This comparative nonrandomized prospective study analyzes data in 56 patients with middle and lower rectal cancer treated with low anterior resection or abdominoperineal resection from November 2005 to November 2007. Follow-up was determined through office charts or direct patient contact. Statistical analysis was performed using chi2 test and Student's t test. Twenty-eight patients underwent LTME and 28 patients were in the OTME group. No conversion was required in the LTME group. Mean operating time was shorter in the laparoscopic group (LTME) (181.3 vs 206.1 min, P0.002). Less intraoperative blood loss and fewer postoperative complications were seen in the LTME group. Return of bowel motility was observed earlier after laparoscopic surgery. There was no 30-day mortality and the overall morbidity was 17 per cent in the LTME group versus 32 per cent in the OTME group. The mean number of harvested lymph nodes was greater in the laparoscopic group than in the OTME group (12.1 +/- 2 vs 9.3 +/- 3). Mean follow-up time was 12 months (range 9-24 months). No local recurrence was found. LTME is a feasible procedure with acceptable postoperative morbidity and low mortality, however it is technically demanding. This series confirms its safety, although oncologic results are at present comparable with the OTME published series with the limitation of a short followup period. Further randomized studies are necessary to evaluate long-term clinical outcome.

Because definitive long-term results are not yet available, the oncologic safety of laparoscopic surgery in rectal cancer remains controversial. Laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME). However, few prospective randomized studies have been performed.The main purpose was to evaluate whether there are relevant differences in safety and efficacy after elective LTME for the treatment of rectal cancer compared with OTME in a tertiary academic medical center.This comparative non-randomized prospective study analyzes data of 20 patients with middle and low rectal cancer treated with low anterior resection (LAR) or abdomino perineal resection (APR) from November 2005 to April 2006. Follow-up was determined through office charts or direct patient contact. Statistical analysis was performed using chi2 test and Student's t-test.Ten patients underwent LTME and 10 patients underwent OTME. No conversion was required in the LTME group. Mean operating time was shorter in the laparoscopic group (LTME) (186.7 vs. 204.4 min, p0.007). Less intraoperative blood loss and fewer postoperative complications were seen in the LTME group. An earlier return of bowel motility was achieved after laparoscopic surgery. There was no 30-day mortality and the overall morbidity was 20% in the LTME group vs. 40% in the OTME group. The mean number of harvested lymph nodes was greater in the laparoscopic group than in OTME group (10.2 +/- 2.5 vs. 8.3 +/- 3). Mean follow-up time was 12 months (range 9-15 months). No local recurrence was found.LTME is a feasible procedure with acceptable postoperative morbidity and low mortality, however it is technically demanding. This series confirms its safety, while oncologic results are at present comparable to the OTME published series, with limitation of a short follow-up period though. Further randomized studies are necessary to evaluate long-term clinical outcome.

Haemorrhoidal disease is a frequent entity worldwide. The surgical management is indicated in third or fourth degree internal hemorrhoidal disease. The conventional hemorrhoidectomy has showed good results but the severe postoperative pain is an important complain. Currently diverse surgical alternatives have been described, mainly to avoid the postoperative pain that follows surgical hemorrhoidectomy. One of these new options is the stapled hemorrhoidectomy using the PPH stapler. This procedure may produce less postoperative pain, with a shorter inpatient stay and faster return to work.The aim of this paper is to analyze the results of using the Procedure for Prolapsed Hemorrhoids (PPH) as treatment in Hemorrhoidal Disease.This is an observational and descriptive study, where 17 patients underwent stapled hemorrhoidectomy with PPH procedure, between March 2000 and August 2003.52.8% of this patients presented grade three internal hemorrhoids and 47.2% grade four; 52.9% presented mild postoperative pain; 41.2% moderate and 5.9% severe pain. In a short and median follow up, due to the persistence of hemorrhoidal disease symptoms two patients required surgical re-intervention. Two more patients presented incontinency. One patient presented stenosis in the line of staples treated satisfactory with an anal dilatation session.The use of PPH is a feasible and safe procedure and it could be a surgical alternative in the treatment of hemorrhoidal disease, even before than conventional hemorrhoidectomy.

Since the introduction of laparoscopic colectomy in 1991, experience in laparoscopic bowel surgery has gradually increased. Several reports from specialized centers have demonstrated that laparoscopic colorectal resections are feasible and safe, providing an acceptable alternative to laparotomy for a variety of diseases. Some studies have shown the feasibility, safety, and good functional outcome of the minimally invasive procedures for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). No known studies have investigated laparoscopic proctocolectomy in Mexico. This report aims to describe the first laparoscopic proctocolectomies with ileal pouch anal anastomosis (IPAA) performed at the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran (INCMNSZ). All the patients in the authors’ institution who underwent a one- or two-stage laparoscopic total proctocolectomy with IPAA between June 2005 and December 2006 were included in the study. All the operations were performed by the same surgeon, who had already completed the learning curve for colorectal laparoscopic procedures. For the study, 10 patients underwent a laparoscopic proctocolectomy with IPAA by a single surgeon. Eight of the patients underwent a one-stage procedure, whereas two patients with severe colitis underwent a two-step procedure. All the cases were managed with a diverting loop ileostomy. Six patients underwent a standard double-stapled IPAA anastomosis, and two patients with FAP underwent a mucosectomy with a manual IPAA anastomosis. The mean operative time was 187 min, and the mean blood loss was 46 ml. There were two postoperative complications. One patient presented with an early small bowel obstruction due to an internal hernia, which required reoperation. The other complication was a wound infection. The mean return to oral intake was 1.5 days, and the mean length of hospital stay was 3.4 days. Although this was not a comparative study and although sample size imposed limitations, with this preliminary data, we conclude that the laparoscopic approach to UC and FAP at our institution is safe, feasible, and effective. However, to achieve the benefits in postoperative outcome, this procedure should be performed only by experienced laparoscopic surgeons.

The sentinel lymph node biopsy in breast cancer can be used instead of axillary dissection when the node is negative because the sentinel lymph node (SLN) represents the first node that receive lymphatic drainage and may predict the tumor status of the entire lymph node group, so it may avoid a more morbid procedure. The objective of this study was to determinate the accuracy of this procedure and to evaluate techniques using blue dye, radiocolloid or both.Sixty-one women underwent sentinel lymphadenectomy followed by axillary lymph node dissection. Thirty-one patients underwent breast conserving surgery and 30 modified radical mastectomy. We studied three groups of patients: the first group was injected with isosulfan blue dye, the second group was injected with technetium-99m-labeled sulfur colloid and the third received both. From the patients marked with isosulfan blue, twenty two patients were injected subareolar (43.2%) and 29% into the breast parenchyma immediately surrounding the primary tumor or biopsy cavity (56.8%). Technetium-99m-labeled sulfur colloid was injected into the breast parenchyma immediately surrounding the primary tumor. Standard axillary lymphadenectomy including level I and level II was performed in all patients. Statistical analysis was performed with the SPSS 10.0 statistical software. Significance was considered at p0.05.At least one SLN was identified in all patients (100%). The SLN predicted the tumor status of the entire lymph node group in 59 patients (96.77%). There were two false negative sentinel nodes (3.3%), each one using isosulfan blue dye injected subareolar and surrounding a primary tumor. The mean number of SLNs removed were 1.06 in the group 1, 2.2 in the group 2 and 2.37 in the group 3 (p = 0.0001 for group 1 vs. 2 and 3). The sensitivity and negative predictive value were 91 and 95%, respectively.This procedure has enough accuracy to justify avoidamce of standard axillary lymphadenectomy when the sentinel node is negative for me- tastases. Both isosulfan blue dye injected techniques may be used indistinctly. When the radiocolloid technique is used there are an increase in the mean number of SLNs removed per patient.

Broadly, complex fistulas are those that are not low transsphincteric or intersphincteric. The objectives of surgical management are to achieve fistula healing, prevent recurrences and maintain continence. The risk of incontinence associated with treatment ranges from 10% to 57%. The objective of this manuscript is to review the current literature to date on the ligation of the intersphincteric fistula tract procedure (LIFT procedure) as a treatment option in these types of fistula. A search was conducted in Medline, PUBMED, EMBASE and ISI Web of Knowledge, and studies published from January 2009 to May 2013 were included. The primary outcomes were fistula healing rates, mean healing time and patient satisfaction with this surgical technique. Eighteen studies were included in this review. The total number of patients included was 592 (65% male). The median age reported was 42.8 years. The most common type of fistula included was transsphincteric (73.3% of cases). The mean healing rate reported was 74.6%. The risk factors for failure discovered were obesity, smoking, multiple previous surgeries and the length of the fistula tract. The mean healing time was 5.5 wk, and the mean follow-up period was 42.3 wk. The patient satisfaction rates ranged from 72% to 100%. No de novo incontinence developed secondary to the LIFT procedure. There is not enough evidence that variants in the surgical technique achieve better outcomes (Bio-LIFT, LIFT-Plug, LIFT-Plus). This review indicates that the LIFT procedure is primarily effective for transsphincteric fistulas with an overall fistula closure of 74.6% and has a low impact on fecal continence. This procedure produces better outcomes at the first surgical attempt.

AIM: To assess the prevalence and clinical value of p-ANCA in a sample of Mexican ulcerative colitis (UC) pa- tients. METHODS: In a prospective, IRB-approved protocol, p-ANCA was determined in 80 patients with UC (mean age, 32 ± 12.9 years). The severity and extension of dis- ease were determined by clinical methods, searching a statistical association with p-ANCA status. RESULTS: p-ANCA were detected in 41 (51%) patients. Severity of disease was the only clinical variable statisti- cally associated with their presence (P < 0.0001; OR = 9; CI 95% = 3.2-24.7). CONCLUSION: The prevalence of p-ANCA was similar to that reported in other countries. Their presence was associated to UC severity, but offered no more informa- tion than the obtained by clinical methods.

Introduction Gastrocolic fistula is a rare complication of adenocarcinoma of the colon. Despite radical resections, these patients usually have a poor prognosis with a mean survival of 23 months and long-term survival is rarely reported. Case presentation A 48-year-old Latino-American man presented with watery diarrhea, diffuse abdominal pain and weight loss for 3 months. A computed tomography scan revealed a mass in the splenic flexure that had infiltrated his stomach and diaphragm. Panendoscopy and colonoscopy confirmed the presence of a fistula between the distal transverse colon and the stomach, which was secondary to a colon cancer. His colon, stomach and left diaphragm were resected en bloc. A histological examination revealed a moderately differentiated adenocarcinoma of the colon that had infiltrated the full width of the gastric wall with 37 negative lymph nodes and clear surgical margins. Adjuvant chemotherapy with capecitabine and oxaliplatin was administered after surgery. Our patient is alive and without any recurrence 5 years after surgery. Conclusions En bloc resection with adjuvant chemotherapy offers the best treatment option for gastrocolic fistulas. This is one of the patients with greater survival reported in the medical literature.