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Enhanced recovery after surgery (ERAS) programs provide a framework to standardize care processes and improve outcomes. The results of this multimodal and multidisciplinary approach based on actions focused on reducing physiological surgical stress in the preoperative, intraoperative, and postoperative periods are beneficial in reducing morbidity and hospital stay, without increasing readmissions across different surgical settings. The implementation of ERAS in resection procedures of esophageal and gastric cancer has been challenging due to the complexity of these surgical techniques and the high risk of complications. Despite the limited evidence of ERAS in esophagectomy operations, systematic reviews and meta-analysis have confirmed a reduction of pulmonary complications and hospital stay without increasing readmissions. In gastrectomy operations, the implementation of ERAS reduces the use of nasogastric tubes and intraabdominal drains, facilitates early diet, and reduces the length of hospital stay, without increasing complications. There is, however, wide heterogeneity and absence of standardization in the number and definition of the ERAS components. The development of ERAS consensus guidelines including procedure-specific components may reduce this variability. Regardless growing evidence of the effectiveness of ERAS, the adherence rate is still low. The commitment of the multidisciplinary team and leadership is critical in the application and refinement of ERAS protocols in parallel with periodic audits. Pre- and post-habilitation methods are emerging concepts to be incorporated in ERAS protocols.

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.

Background Surgical strategies are being adapted to face the COVID‐19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X‐ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P, The COVID‐19 pandemic required reorganization of surgical services, affecting patients with common surgical diseases including acute appendicitis. No evidence is available on the topic. This study found global variation in screening policies, use of personal protective equipment and intraoperative directives. There has been increased adoption of non‐operative management and open appendicectomy. Hands off

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.

Peritoneal infection after colorectal cancer surgery is associated with a higher rate of tumor relapse. We have recently proposed that soluble inflammatory factors released in response to a postoperative infection enhance tumor progression features in residual tumor cells. In an effort to set up models to study the mechanisms of residual tumor cell activation during surgery-associated inflammation, we have analyzed the phenotypic response of colon cancer cell lines to the paracrine effects of THP-1 and U937 differentiated human macrophages, which release an inflammatory medium characteristic of an innate immune response. The exposure of the colon cancer cell lines HT-29 and SW620 to conditioned media isolated from differentiated THP-1 and U937 macrophages induced a mesenchymal-like phenotypic shift, involving the activation of in vitro invasiveness. The inflammatory media activated the β-catenin/TCF4 transcriptional pathway and induced the expression of several mesenchymal (e.g., FN1 and VIM) and TCF4 target genes (e.g., MMP7, PTGS2, MET, and CCD1). Similarly, differential expression of some transcription factors involved in epithelial-to-mesenchymal transitions (i.e. ZEB1, SNAI1, and SNAI2) was variably observed in the colon cancer cell lines when exposed to the inflammatory media. THP-1 and U937 macrophages, which displayed characteristics of M1 differentiation, overexpressed some cytokines previously shown to be induced in colorectal cancer patients with increased rates of tumor recurrence associated with postoperative peritoneal infections, thus suggesting their pro-tumoral character. Therefore, the environment created by inflammatory M1 macrophages enhances features of epithelial-to-mesenchymal transition, and may be useful as a model to characterize pro-inflammatory cytokines as putative biomarkers of tumor recurrence risk.

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.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most common bariatric technique. Laparoscopic sleeve gastrectomy (LSG) is a restrictive procedure; the metabolic and endocrine effects of which remain unknown. We compared the effects of both procedures on glucose metabolism and fasting and meal-stimulated gut hormone levels.Seven patients were randomised to LRYGB and eight to LSG. All patients were evaluated before and at 3 and 12 months postoperatively. Plasma levels of glucose, insulin, ghrelin, leptin, peptide YY (PYY), GLP-1 and pancreatic polypeptide were measured before and after 10 and 60 min of a standard test meal ingestion.Age, body mass index and preoperative hormone levels were similar in both groups. A significant reduction of plasma glucose and insulin levels was observed after surgery. Moreover, a normalisation of homeostatic model assessment for insulin resistance value was also seen after both procedures. The fasting and postprandial leptin levels were significantly lower in the LRYGB group. LSG was followed by a significant reduction in fasting ghrelin levels. In the LRYGB group, GLP-1 levels increased significantly after the test meal.LRYGB and LSG markedly improved glucose homeostasis. Only LSG decreased fasting and postprandial ghrelin levels, whereas GLP-1 and PYY levels increased similarly after both procedures.

Summary De novo cholangiocarcinoma associated with recurrent primary sclerosing cholangitis in the transplanted liver is rare. This case report reviews the literature and highlights the need to consider cholangiocarcinoma in transplanted patients with PSC that clinically/biochemically deteriorate.

Resumen Introduccion La creencia popular propugna el uso de banos de asiento con agua fria para el tratamiento del dolor anal agudo, pero las guias de practica clinica recomiendan el uso de agua caliente por su efecto conocido sobre la presion anal de reposo. Objetivo El objetivo fue estudiar el efecto analgesico, sobre la calidad de vida, datos de manometria y evolucion clinica, de 2 temperaturas en los banos de asiento en enfermos con dolor anal. Material y metodos Ensayo clinico aleatorizado en pacientes con dolor anal agudo por enfermedad hemorroidal o fisura anal divididos en Grupo 1: banos de asiento con agua a T a inferior a 15 °C y Grupo 2: banos con agua a T a superior a 30 °C. La analgesia fue la misma en ambos grupos. Se analizo: el dolor durante 7 dias (escala visual analogica), calidad de vida (SF-36), presion anal de reposo y evolucion de la enfermedad. Resultados De 27 pacientes elegibles, 24 fueron aleatorizados (Grupo 1: n=12 y Grupo 2: n=12). El dolor no mostro diferencias estadisticamente significativas, pero se mantuvo estable en el Grupo 1 y por el contrario fue disminuyendo progresivamente en los pacientes del Grupo 2, siendo la diferencia en los valores del dolor del primer dia respecto al septimo superior en el Grupo 2 (p=0,244). El resto de variables fueron similares. Conclusion No hubo diferencias estadisticamente significativas en el control del dolor del 1. er al 7 dia en el Grupo con banos de asiento con agua caliente. (ISRCTN numero 50105150).

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.

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 popular belief advocates the use of sitz (sitting) baths with cold water for the treatment of acute anal pain, but clinical practice guides recommend the use of hot water for its known effect on the at-rest anal pressure. Aim The objective of the study was to examine the analgesic effect on the quality of life, manometer data and clinical progress, of the two temperatures in sitz baths in patients with anal pain. Material and methods A randomised clinical trial on patients with acute anal pain due to haemorrhoids or anal fissures, divided into Group 1: Sitz baths with water at a temperature of less than 15°C, and Group 2: Baths with a water temperature above 30°C. The analgesia was the same in both groups. An analysis was made of the pain at 7 days (visual analogue scale), quality of life (SF-36), anal at-rest pressure and disease progress. Results Of the 27 eligible patients, 24 were randomised (Group 1: n=12 y Group 2: n=12). There were no statistical differences in pain, but it remained stable in Group 1, but gradually decreased in the patients of Group 2, the difference being in the pain scores on the first day compared to the seventh in Group 2 (P=.244). The rest of the variables were similar. Conclusion There were no statistically significant differences in pain control from day 1 to day 7 in the Group with sitz baths with hot water.

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.

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 El conocimiento de los factores que predisponen a la aparicion de complicaciones tras cirugia herniaria urgente es de gran importancia tanto para la priorizacion de la cirugia electiva como para seleccionar los casos que pueden ser susceptibles de seguimiento clinico. Objetivos Analizar los factores que condicionan la morbilidad y la mortalidad de la reseccion intestinal asociada a la reparacion herniaria urgente. Pacientes y metodo Revision retrospectiva de las historias clinicas de los pacientes intervenidos urgentemente por afeccion herniaria desde enero de 2000 hasta diciembre de 2005. Se compararon los resultados obtenidos en funcion de si fue o no necesaria una reseccion intestinal. Resultados De un total de 2.367 pacientes intervenidos por hernias en ese periodo, en 362 (15,3%; media de edad, 69,5 anos; 146 varones y 216 mujeres) fue de forma urgente. Precisaron reseccion intestinal 60 (16,6%). Presentaron complicaciones 108 (29,8%) y 17 (4,7%) fallecieron tras la intervencion. El limite de 70 anos discrimino una mortalidad significativamente mayor (el 7 frente al 2%, entre mayores y menores de 70 anos, respectivamente; p = 0,01). El grupo de pacientes que preciso reseccion intestinal tenia una media de edad mayor (75,4 frente a 68,3 anos; p = 0,002), mas prevalencia de complicaciones totales (el 40,7 frente al 6,2%; p Conclusiones La morbilidad y la mortalidad de la cirugia herniaria urgente que precisa reseccion intestinal son muy elevadas, especialmente en pacientes de edad avanzada y cuando se trata de hernias crurales.

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 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%.

De novo cholangiocarcinoma associated with recurrent primary sclerosing cholangitis in the transplanted liver is rare. This case report reviews the literature and highlights the need to consider cholangiocarcinoma in transplanted patients with PSC that clinically/biochemically deteriorate.

Knowledge of the risk factors that may lead to complications after emergency hernia repair is of great importance, as much for the prioritisation of the elective surgery, as selecting those cases that require clinical follow up.To analyse the factors conditioning the morbidity and mortality of bowel resection associated to emergency hernia repair.A retrospective review was carried out on the clinical histories of patients who had emergency operations for hernia problems from January 2000 to December of 2005. The clinical results obtained were compared based on whether or not a bowel resection was required.A total of 2367 patients were operated for hernia in this period, 362 of them (15.3%); for a complicated hernia (mean age 69.5 years; 146 males/216 females); 60 patients needed bowel resection. Complications appeared in 108 patients (29.8%) and 17 (4.7%) died after operation. The limit of 70 years discriminated a significantly greater mortality (70: 7% vs70 2%; p = 0.01). The group of patients who needed bowel resection showed differences in statistical analysis both in age (75.4 vs 68.3 years; p = 0.002), prevalence of complications (40.7% vs 6.2%; p0.0001), and mortality (20% vs 1.6%; p0.0001). The discriminant analysis identified bowel resection as the only predictive independent variable of mortality (lambda Wilks = 0.89; p = 0.0001; predictive value, 85%).Morbidity and the mortality of urgent hernia surgery, when bowel resection was required, are elevated; especially in older patients, and in crural hernias.

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.