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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.

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.

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 neoplasia intraepitelial anal es una lesion precursora del carcinoma escamoso anal. Se considera poblacion en riesgo de padecer esta lesion a los pacientes con condilomas anogenitales, historia previa de displasia de cervix, infeccion por VIH y en general los pacientes con infeccion por el VPH. El objetivo de este estudio es analizar los resultados de la aplicacion de un protocolo diagnostico de neoplasia intraepitelial anal en poblacion de riesgo mediante el empleo de citologia anal. Material y metodo El protocolo diagnostico de neoplasia intraepitelial anal consistio en realizar una anamnesis estructurada, exploracion fisica y citologia anal, la cual se interpreto mediante los criterios de Bethesda. En este estudio observacional de corte transversal se analizan los resultados de diagnostico de neoplasia intraepitelial anal y su asociacion con factores de riesgo. Resultados Se incluyo a 64 pacientes en los que se diagnosticaron 25 alteraciones citologicas: 9 alteraciones citologicas de significado incierto o ASCUS, 15 casos de neoplasia intraepitelial anal de bajo grado y 1 de alto grado. Al relacionar la presencia de alteraciones en la citologia anal con los factores de riesgo conocidos, no hubo asociacion estadisticamente significativa con la presencia de condilomas (p=0,22), infeccion por VPH de alto riesgo (p=0,84), infeccion por VIH (p=0,98) o tabaquismo (p=0,14). Conclusiones La aplicacion de un protocolo de deteccion de neoplasia intraepitelial anal en poblacion de riesgo ha permitido detectar un 25% de pacientes con lesiones precursoras de carcinoma anal.

Although limited haematochezia with the first bowel movement is frequent in patients undergoing colorectal resection, postoperative life-threatening lower gastrointestinal bleeding is very rare. The purpose of this study was to review our results in the management of this complication. We analysed the cases of patients with severe lower gastrointestinal bleeding after colorectal surgery from 2000 to 2006 in our hospital. We studied the general characteristics, diagnostic data, therapeutic management and outcome. We also reviewed the published articles regarding this issue. This complication appeared in 7 (0.5%) of 1,389 colorectal procedures in the study period. In all the patients the anastomosis was stapled. In six of the seven patients bleeding resolved with conservative treatment including endoscopy. However, one patient required surgical treatment. There was no mortality and there were no anastomotic leaks in these seven patients. Severe lower gastrointestinal bleeding after colorectal resection and stapled anastomosis is a rare complication. Only in unstable patients or failure of conservative measures is surgery indicated.

Introduction Anal intraepithelial neoplasia is a precursor condition of squamous anal carcinoma. The groups at risk of this lesion are patients with anogenital condylomata, cervical dysplasia, human immunodeficiency virus infection and, in general, patients with HPV infection. The aim of this study was to analyse the results of a diagnostics protocol of anal intraepithelial neoplasia in high risk population using anal cytology. Patients and method The protocol is based on a visit in the outpatient department, clinical interview, physical examination, and anal cytology evaluated by Bethesda criteria. The cross-sectional observational study was designed to study the anal smear results and their relationship with risk factors. Results A total of 64 patients were included from January 2005 to December 2006. In the overall series, 25 patients have been diagnosed with abnormal anal cytology: 9 atypical squamous cells of undetermined significance (ASCUS), 15 low-grade, and 1 highgrade squamous intraepithelial lesions. There were no significant associations between abnormal cytology results and the presence of anal condyloma ( P = .22). Neither were there statistical associations found with high risk-HPV infection ( P = .84), HIV infection ( P = .98), or tobacco use ( P = .14). Conclusions Our diagnostic protocol of anal intraepithelial neoplasia revealed 25% of patients with pre-invasive lesions of squamous anal cancer.

Introduction The main aim of the study was to apply a severity classification of sphincter lesions detected by endoanal ultrasound using Starck score in patients who suffered faecal incontinence. Material and method Data were analysed on 133 patients with faecal incontinence. Those in whom anal sphincter lesions were detected by endoanal ultrasound are described and their corresponding scores according to Starck classification calculated. This system scores severity of detected sphincter lesions from 0 to 16, involving the three axes of the anal canal. Patient demographic characteristics and anorectal manometry results were also analysed. The relationship between this score, patient gender and age, and anorectal manometric results were also analysed. Results A total of 83 (62.4%) patients had some type of anal sphincter lesion. The presence of sphincter defects was not related to gender (P = .172), although it did correlate with younger ages (P = .028). The severity of anal sphincter damage by Starck score did not show significant correlation to gender (P = .327) or to the age (P = .350) of patients. However, a significant correlation was detected between Starck score and anal resting pressure (P = .008) or anorectal squeeze pressure (P = .011). Conclusions The presence of anal sphincter injuries could be well defined by Starck score in patients with faecal incontinence. Severity of damage scored by Starck correlated with anorectal manometric results.

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.

Anorectal pressure studies have demonstrated internal anal sphincter (IAS) hypertonia in patients with chronic anal fissure. It is unknown however, if these changes in IAS function are associated with any abnormality in sphincter morphology. The first aim was to investigate the clinical characteristics and the manometric and endosonographic findings of the IAS in a cohort of patients with chronic anal fissure. The second aim was to investigate the association between these findings and the outcome with topical Glyceryl trinitrate (GTN) therapy.All patients who presented with chronic anal fissure from November 1999 to May 2004 were included after failure of conservative therapy. Anorectal manometry and anal endosonography were performed before treatment with 0.2% GTN ointment twice daily was initiated. Patients were evaluated after 8 weeks.One hundred and twenty-four patients (66 women, mean age, 45.2 +/- 14.8 years) were included. Hypertonia of the IAS was found in 84 (68%) patients. The mean maximum IAS thickness was 3.6 +/- 0.76 mm (1.6-5.5). An abnormally thick IAS, adjusted by age, was observed in 113 (91.1%) patients. We found no correlation between resting pressure and IAS thickness (r = 0.074; p = 0.41). At 8 weeks, 52 patients (42%) had healed with complete symptoms resolution. No statistically significant differences were observed when clinical features and manometric and endosonographic findings were compared between healing and no-healing fissures.The majority of patients with chronic anal fissure present an abnormally thick IAS. Clinical, manometric and endosonographic features had no association with outcome after GTN treatment.

Resumen Introduccion El aumento de la presion en reposo es uno de los factores implicados en la patogenia de la fisura anal cronica. Se desconoce, sin embargo, si esta anormalidad en la funcion del esfinter anal interno (EAI) se corresponde con alteraciones en su morfologia. Los objetivos son determinar el grosor del EAI en pacientes con fisura anal cronica e investigar la correlacion entre el grosor del EAI y la presion en reposo. Pacientes y metodo Estudio observacional prospective (noviembre de 1999-diciembre de 2002). Se incluyo a pacientes con fisura anal cronica y se excluyo a los que tenian antecedentes de enfermedad inflamatoria, cirugia anal y tratamiento previo con nitroglicerina topica o toxina botulinica. Se practicaron una ecografia endoanal y una manometria. Se considero que el grosor del EAI estaba aumentado cuando era > 2,5 mm en pacientes 3 mm en pacientes ≥ 50 anos. Se considero que la presion en reposo estaba aumentada cuando superaba los 80 mmHg. Resultados Se analizo a 63 pacientes. El EAI estaba aumentado de grosor en 58 (92%) pacientes. El grosor medio del EAI fue de 3,7 ± 0,7 mm. La presion en reposo estaba aumentada en 47 (66%) pacientes. La presion en reposo media fue de 91 ± 28 mmHg. No encontramos ninguna correlacion positiva entre el grosor del EAI y la presion en reposo (r = 0,05; p Conclusiones La mayoria de los pacientes con fisura anal presenta una hipertrofia del EAI. El aumento del grosor del EAI no se correlaciona con un aumento de la presion en reposo.

Although the conventional treatment of patients with stage iv colorectal cancer involves resection of the primary tumor 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 analyze the complications related to the primary tumor in a series of patients with unresectable metastatic colorectal cancer treated with chemotherapy without surgery.Retrospective descriptive study. The study included all patients with unresectable metastatic colorectal cancer treated with chemotherapy without resection of the primary tumor (January 2007-February 2011).The mean age of the 61 patients analyzed 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%).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 tumor is not negligible. Studies are needed to identify those patients in whom a prophylactic colectomy could be indicated.

Background Outpatient treatment of uncomplicated acute diverticulitis is safe and effective. The aim of this study was to determine the impact of outpatient treatment on the reduction of healthcare costs. Patients and methods A retrospective cohort study comparing two groups was performed. In the outpatient treatment group, patients diagnosed with uncomplicated acute diverticulitis were treated with oral antibiotics at home. In the hospital treatment group, patients met the criteria for outpatient treatment but were admitted to hospital and received intravenous antibiotic therapy. Cost estimates have been made using the hospital cost accounting system based on total costs, the sum of all variable costs (direct costs) plus overhead expenses divided by activity (indirect costs). Results A total of 136 patients were included, 90 in the outpatient treatment group and 46 in the hospital group. There were no differences in the characteristics of the patients in both groups. There were also no differences in the treatment failure rate in both groups (5.5% vs 4.3%; p =0.7). The total cost per episode was significantly lower in the outpatient treatment group (882±462 vs 2376±830 euros; p =0.0001). Conclusions Outpatient treatment of acute diverticulitis is not only safe and effective but also reduces healthcare costs by more than 60%.

Multimodal rehabilitation (MMRH) programs 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 program on hospital costs.A comparative study of 2 consecutive cohorts of patients undergoing elective colorectal surgery has been designed. In the first cohort, we analyzed 134 patients that 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 analyzed. We compared postoperative complications, length of stay and readmission rates in both groups. The cost analysis was performed according to the system «full-costing».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: 8.107 ± 4.117 euros vs. control: 9.019 ± 4.667 Euros; P=.02). The main factor contributing to the cost reduction was a decrease in hospitalization unit costs.The application of a multimodal rehabilitation protocol after elective colorectal surgery decreases not only the length of hospital stay but also the hospitalization costs without increasing postoperative morbidity or the percentage of readmissions.

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.

Recto-urethral fistula is an uncommon complication after radical prostatectomy, occurring in less than 2% of patients. Our aim is to review our experience for repairing these fistulas with the posterior trans-sphincter approach of York Mason.Retrospective review. All patients who underwent repair of postoperative recto-urethral fistula in our unit were included. The procedure described by York Mason was performed in all cases.During the last 6 years, 5 patients with recto-urethral fistulas after radical prostatectomy were repaired by using this method. Symptoms, including faecaluria and/or passing of urine via the anus, appeared between the postoperative day 4 and 7 weeks after surgery, and confirmation was obtained by cystography. Initial faecal diversion with sigmoid loop colostomy was performed in 3 cases, whereas in the other 2 patients a loop ileostomy was performed at the time of surgical repair. The posterior trans- sphincter approach and fistula repair was performed between 5 and 10 months after diagnosis. Morbidity included wound infection in 2 cases and skin dehiscence in another 2 patients. Successful fistula closure was achieved in all cases with complete faecal continence. No recurrence has been observed after a mean follow-up of 22 (4-40) months.The posterior trans-sphincter approach of York Mason is effective for the repair of recto-urethral fistulas after radical prostatectomy with minor morbidity and no impairment of continence.

The aim of this study was to evaluate the applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis.All patients diagnosed with uncomplicated acute diverticulitis based on abdominal computed tomography findings during a 2-year period were prospectively included. Patients with vomiting, severe comorbidities, or without an appropriate family environment were excluded. Ambulatory treatment consisted of oral antibiotics for 1 week (amoxicillin-clavulanic 1 g t.i.d. or ciprofloxacin 500 mg b.i.d. plus metronidazole 500 mg t.i.d. in patients with penicillin allergy). A clear liquid diet for the first 2 days and pain control with oral acetaminophen 1 g t.i.d. were also recommended.Fifty-three patients were diagnosed with uncomplicated acute diverticulitis and 13 patients were excluded. Therefore, ambulatory treatment was initiated in 40 patients. Only two patients (5%) required admission after outpatient therapy was started due to vomiting and persistent abdominal pain, respectively. In both patients, the inflammatory process was successfully resolved by intravenous antibiotic treatment. In the remaining 38 patients (95%), ambulatory treatment was completed without complications.Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective and applicable in most patients with tolerance to oral intake and with an appropriate family environment.

Nearly all chronic anal fissures occur in the posterior midline of the anal canal. However, some of them are in the anterior midline and are rarely double or in the lateral anal walls. The aim of this study was to determine if the clinical, manometric and endosonographic characteristics in patients with chronic anal fissure varied according to topography of the fissure. The patients included in this prospective study were divided according to a fissure site in posterior midline location (Group A, n = 84) and anterior midline location (Group B, n = 30). No differences were found regarding clinical data except that anterior fissures were more common in females. Mean maximal anal resting pressure and internal anal sphincter thickness was higher in Group A. However, these differences were not statistically significant. We found correlation between mean maximal anal resting pressure and internal anal sphincter thickness in patients suffering from anterior chronic anal fissure.

High anal resting pressures have been implicated in the pathophysiology of chronic anal fissure. It is not known, however, whether altered function is associated with any morphological abnormalities of the internal anal sphincter (IAS). The aims of the present study were to determine IAS thickness in patients with chronic anal fissure and to investigate the correlation between IAS thickness and anal resting pressure.Patients with chronic anal fissure were prospectively included between November 1999 and December 2002. Patients with a history of inflammatory bowel disease, anal surgery, and those previously treated with nitroglycerine ointment or botulinum toxin were excluded. Anal endosonography and manometry were performed. IAS thickness was considered to be increased when it was2.5 mm in patients50 years and3 mm in patientsor = 50 years. Anal resting pressure was considered to be increased when it was higher than 80 mmHg.Sixty-three patients were analyzed. An abnormally thick IAS was observed in 58 patients (92%). The mean IAS thickness was 3.7 +/- 0.7 mm. IAS hypertonia was found in 47 patients (66%). The mean anal resting pressure was 91 +/- 28 mmHg. No correlation was found between IAS thickness and anal resting pressure (r = 0.05; p0.68).Most of the patients with chronic anal fissure had an abnormally thick IAS. However, increased thickness of the IAS did not correlate with increased anal resting pressure.

Aim: To investigate the influence of a screening program on the short-term outcome of patients undergoing surgery for colorectal cancer. Methods: Between April 2010 and December 2012 patients diagnosed with colorectal cancer via the screening program (n = 80) were compared with patients diagnosed elsewhere (n = 106). Only patients of ≥ 50 and ≤ 69 years of age diagnosed outside the program were selected as controls. The clinical variables included age, sex, American Society of Anesthesiologists (ASA) status, Charlson index, preoperative hemoglobin and serum albumin levels, surgical approach, tumor location and stage, perioperative transfusion and postoperative morbidity. A multivariate analysis was used to identify variables independently associated with outcome. Results: There were no significant differences with regard to age, sex and ASA status. Preoperative hemoglobin (14.1 ± 1.6 g/ dl vs 12.3 ± 2.3 g/dl; p < 0.001) and serum albumin (4.45 ± 0.26 g/dl vs 4.0 ± 0.6 g/dl; p < 0.001) levels were significantly higher in the screening group. The overall morbidity was significantly lower in the screening group (38.8% vs 63.2; p < 0.001) and mainly related to a higher rate of Clavien-Dindo grade II complications in controls. There were no differences with regard to wound infection, postoperative ileus, anastomotic leakage or reoperations. The median length of hospital stay was shorter in the screening group (6 vs 9 days; p = 0.003). Multivariate analysis showed that diagnosis outside the screening program, type of surgical procedure, open surgery and Charlson index were independent risk factors for postoperative complications. Conclusions: The diagnosis of colorectal cancer via the screening program is associated with a lower rate of postoperative minor complications and a shorter hospital stay.