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Background Several procedures have been proposed to reduce the rates of recurrence in patients with right-sided colon cancer. Different procedures for a radical right colectomy (RRC), including extended D3 lymphadenectomy, complete mesocolic excision and central vascular ligation have been associated with survival benefits by some authors, but results are inconsistent. The aim of this study was to assess the variability in definition and reporting of RRC, which might be responsible for significant differences in outcome evaluation. Methods PRISMA-compliant systematic literature review to identify the definitions of RRC. Primary aims were to identify surgical steps and different nomenclature for RRC. Secondary aims were description of heterogeneity and overlap among different RRC techniques. Results Ninety-nine articles satisfied inclusion criteria. Eight surgical steps were identified and recorded as specific to RRC: Central arterial ligation was described in 100% of the included studies; preservation of mesocolic integrity in 73% and dissection along the SMV plane in 67%. Other surgical steps were inconstantly reported. Six differently named techniques for RRC have been identified. There were 35 definitions for the 6 techniques and 40% of these were used to identify more than one technique. Conclusions The only universally adopted surgical step for RRC is central arterial ligation. There is great heterogeneity and consistent overlap among definitions of all RRC techniques. This is likely to jeopardise the interpretation of the outcomes of studies on the topic. Consistent use of definitions and reporting of procedures are needed to obtain reliable conclusions in future trials. PROSPERO CRD42021241650.

Crohn disease; Artificial intelligence; Three-dimensional imaging Enfermedad de Crohn; Inteligencia artificial; Imagen tridimensional Malaltia de Crohn; Intel·ligència artificial; Imatge tridimensional Aim The aim of this study is to demonstrate the added value of three-dimensional (3D) reconstruction models and artificial intelligence for preoperative planning in complex perianal Crohn's disease. MRI is the gold standard for diagnosis of complex perianal fistulas and abscess due to its high sensitivity, but it lacks high specificity values. This creates the need for better diagnostic models such as 3D image processing and reconstruction (3D-IPR) with artificial intelligence (AI) algorithms. Method This is a prospective study evaluating the utility of 3D reconstruction models from MRI in four patients with perineal Crohn's disease (pCD). Results Four pCD patients had 3D reconstruction models made from pelvic MRI. This provided a more visual representation of perianal disease and made possible location of the internal fistula orifice, seton placement in fistula tracts and abscess drainage. Conclusion Three-dimensional reconstruction in CD-associated complex perianal fistulas can facilitate disease interpretation, anatomy and surgical strategy, potentially improving preoperative planning as well as intraoperative assistance. This could probably result in better surgical outcomes to control perianal sepsis and reduce the number of surgical procedures required in these patients.

AIM Gender dysphoria is the disagreement between the gender of birth and the one with which the patient identifies. For its management it is mandatory to have a multidisciplinary team. Gender confirmation surgery with penoscrotal skin flap is the procedure of choice, and a sigmoid vaginoplasty is a feasible alternative. The new technologies and the help of indocyanine green (ICG) fluorescence can help to guarantee a correct neovagina vascularization. The objective of this paper is to present the surgical technique of laparoscopic sigmoid vaginoplasty assisted by ICG. METHODS We present two patients with gender dysphoria and a history of stricture of the penoscrotal skin flap vaginoplasty. We performed sigmoid vaginoplasty by the laparoscopic approach. We began the procedure with the mobilization and section of 30 cm of sigmoid colon, selective ligation of the vessels assisted by ICG, 180° sigmoid rotation, externalized on antiperistaltic position, construction of colovestibular anastomosis and promontory fixation. We finished the procedure with virtual ileostomy construction and drain placement. RESULTS Patients recovered satisfactorily and were discharged on the seventh day after surgery without complications. CONCLUSION Sigmoid vaginoplasty is a safe and feasible procedure. ICG has great value, contributing to the selective ligation of the vessels, allowing 180° sigmoid rotation and guaranteeing the irrigation of the neovagina.

Resumen Los cirujanos cardiovasculares y del aparato digestivo deberian estar al corriente de las multiples alternativas de abordaje de la aorta abdominal y sus troncos viscerales. Articulo narrativo, ilustrado y dinamico de las diferentes maniobras quirurgicas descritas con este objetivo. Diseccion de 5 cadaveres realizadas durante tres cursos nacionales de Anatomia Quirurgica aplicada a aorta integral, Cirugia hepatobiliopancreatica y Cirugia abdominal digestiva. Maniobras quirurgicas descritas: abordaje aortico inframesocolico longitudinal, abordaje aortico supraceliaco, abordaje del tronco celiaco, tres tipos de abordaje de la arteria mesenterica superior: retroperitoneal tras maniobra de Kocher, supramesocolico e inframesocolico, maniobra de Cattell-Braasch y dos tipos de maniobra de Mattox: retrorrenal y prerrenal. El conocimiento profundo de la anatomia intraabdominal es fundamental para la actuacion quirurgica sobre la aorta abdominal y el entrenamiento en cadaver a partir de la anatomia quirurgica vascular y del tubo digestivo podria ayudar a desarrollar las habilidades quirurgicas de los cirujanos en formacion.

Background: Hemorrhoidal disease is still one of the most prevalent proctological diseases. Pain is the most common complication after surgery but bleeding, urinary retention and perianal infection are also frequent. There is also an important group of patients, such as those with inflammatory bowel disease, pregnancy or immunosuppression, who can present an increased rate or more severe complications. Objective: To describe the complications following different surgical and instrumental techniques for hemorrhoids in a literature review. Special situations were reviewed to determine how they affect the management of the disease. Methods: During August 2019, a narrative review of hemorrhoid surgery complications and special situations was performed using the Pubmed MESH DATABASE. Conclusions: Pain, urinary retention and bleeding remain the most frequent complications after surgery for hemorrhoids; however, special situations must be taken into account in order to choose the best technique to prevent more severe complications.

Extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap is insufficient. We present our experience with eVRAM flap for pelviperineal reconstruction following oncologic resection.A retrospective study was conducted, including all the patients who underwent reconstruction with eVRAM flap after complex pelvic resection, between 2012 and 2020. EVRAM flap was indicated when traditional VRAM was considered deficient to cover or reach the skin defect or to fill the dead space.Forty-four patients were included in the study. Successful reconstruction with eVRAM flap was achieved in 40 patients. There were three flap failures, and one patient died in the second postoperative day because of multiple organ failure. Perineal wound complications occurred in 17 patients (38.6%), eight of them requiring surgical reoperation. Donor site problems were present in five patients (11.4%), and only one patient required surgical closure because of a major dehiscence.The authors found the eVRAM flap to be a useful and reliable flap for reconstruction of complex pelviperineal wounds, with a low rate of donor site morbidity.

Background Below the anterior peritoneal reflection, the anterior rectal wall and mesorectum are separated from the posterior vaginal wall by a virtual rectovaginal space. In this space, the description of a specific and independent rectovaginal septum as a female counterpart of Denonvilliers fascia has been the subject of debate over the years. Objective The aim of this study is to perform an accurate anatomical study of the rectovaginal area in a cadaveric simulation model of total mesorectal excision to evaluate the possible structures and the dissection planes contained within the rectovaginal space. Design and setting This is a cadaveric study performed at the University of Valencia. Patients The pelvises of 25 formalin-preserved female cadavers were dissected. All the included specimens were sectioned in a midsagittal plane, at the level of the middle axis of the anal canal. Main outcome measures Careful and detailed dissection was performed to visualize the anatomical structures and potential dissection planes during anterior mesorectal dissection in cadavers. Histological sections were made of the posterior vaginal wall. Results The rectovaginal space contains loose areolar tissue that allows an easy dissection plane distally. A distinct and independent rectovaginal fascia or septum is not present. The existence of 3 layers fused together in the posterior vaginal wall can be identified more or less precisely because of their different coloration. The histological study confirms this macroscopic arrangement of the posterior vaginal wall in 3 layers: the mucosa, the muscular, and the adventitia. An independent rectovaginal septum can be generated only with a splitting of the adventitia. Limitations The cadaveric pelvic specimens of the oldest donors might have had age-related degeneration. Conclusions The present anatomical study has shown only a plane of loose areolar tissue between the rectal and vaginal wall. We can conclude that there is no independent fascia or septum in the rectovaginal space. See Video Abstract at http://links.lww.com/DCR/B456. ANATOMIA QUIRURGICA DEL ESPACIO RECTOVAGINAL: ?EXISTE UN TABIQUE RECTOVAGINAL INDEPENDIENTE O UNA FASCIA DE DENONVILLIERS EN LAS MUJERES: Debajo del reflejo peritoneal anterior, la pared rectal anterior y el mesorrecto estan separados de la pared vaginal posterior por un espacio rectovaginal virtual. En este espacio, la descripcion de un tabique rectovaginal independiente especifico como contraparte femenina de la fascia de Denonvilliers ha sido objeto de debate a lo largo de los anos.Realizar un estudio anatomico preciso del area rectovaginal en un modelo de simulacion cadaverica de escision mesorrectal total, con el fin de evaluar las posibles estructuras y los planos de diseccion contenidos en el espacio rectovaginal.estudio cadaverico realizado en la Universidad de Valencia.Se disecaron las pelvis de 25 cadaveres femeninos conservados en formalina. Todas las muestras incluidas fueron seccionadas en un plano medio sagital, a la altura del eje medio del canal anal.Se llevo a cabo una diseccion cuidadosa y detallada para visualizar las estructuras anatomicas y los posibles planos de diseccion durante la diseccion mesorrectal anterior en cadaveres. Se realizaron cortes histologicos de la pared vaginal posterior.El espacio rectovaginal contiene tejido areolar laxo que permite un plano de diseccion facil distalmente. No hay fascia o tabique rectovaginal distinto e independiente. La existencia de tres capas fusionadas en la pared vaginal posterior puede identificarse con mayor o menor precision debido a su diferente coloracion. El estudio histologico confirma esta disposicion macroscopica de la pared vaginal posterior en tres capas: la mucosa, la muscular y la adventicia. Un tabique rectovaginal independiente solo se puede generar con una division de la adventicia.Las muestras pelvicas de cadaveres de los donantes mas antiguos pueden haber tenido degeneracion relacionada con la edad.El estudio anatomico actual solo ha mostrado un plano de tejido areolar laxo entre la pared rectal y vaginal. Podemos concluir que no hay fascia o tabique independiente en el espacio rectovaginal. Consulte Video Resumen en http://links.lww.com/DCR/B456. (Traduccion-Dr. Adrian Ortega).

Background Strong agreement exists concerning the standards of pathologic reporting for total mesorectal excision and complete mesocolic excision. It represents a quality standard that correlates with survival. However, no agreed standards of reporting are available to define D3 lymphadenectomy for right colectomy. Objective The purpose of this study was to define anatomopathological standards of specimen quality obtained from the surgical specimen when an oncologic right hemicolectomy with D3 lymphadenectomy has been correctly performed. Design This study was conducted in 2 different phases. The first part consisted of a cadaver-based study of right colon anatomy, and the second part consisted of a prospective assessment of a series of surgical specimens obtained after right hemicolectomy for cancer. Settings The anatomic phase of the study was performed in collaboration with the University of Valencia Department of Anatomy and Embryology. The second part was performed at a colorectal unit of a tertiary hospital. Patients Seventeen cadavers were used for the first phase, and 65 surgical specimens were examined for the second part of the study. Main outcome measures In each specimen, the pathologists looked for anatomic structures defined as markers of quality standards of the D3 lymphadenectomy during the first phase. Specimens were classified as complete, partial, and incomplete D3 lymphadenectomy. Results Twenty percent of specimens were classified as incomplete D3 lymphadenectomy, 31% as partial, and 49% as complete. A median number of 14 (6-64), 22 (11-47), and 29 (14-55) lymph nodes were isolated (p = 0.01). Similarly, the median numbers of lymph nodes isolated in the area of D3 lymphadenectomy were 0 in incomplete, 1 (0-5) in Partial, and 3 (0-8) in Complete D3 lymphadenectomy specimens (p = 0.0001). Limitations A large multicenter study with adequate power is needed. Conclusions We propose the right mesocolic sail and trunk of superior right colic vein as new and reproducible anatomopathologic standards of D3 lymphadenectomy in oncologic right hemicolectomy. See Video Abstract at http://links.lww.com/DCR/B149. PROPUESTA PARA NUEVOS ESTANDARES HISTOPATOLOGICOS EN LA LINFADENECTOMIA D3 EN EL CANCER DE COLON DERECHO: LA VELA MESOCOLICA Y LA VENA COLICA DERECHA SUPERIOR: Existe un claro acuerdo sobre los estandares de calidad patologicos para la escision total del mesorrecto y la escision completa del mesocolon. Son considerados "estandar de calidad" que se correlaciona con la supervivencia. Sin embargo, no se dispone de estandares de calidad para definir la linfadenectomia D3, en la colectomia derecha.Definir los estandares anatomopatologicos de calidad obtenidos de una muestra quirurgica, cuando se ha realizado correctamente una hemicolectomia derecha oncologica, con linfadenectomia D3.Dos fases diferentes. La primera parte consistio en un estudio basado en la anatomia del colon derecho, realizado en cadaveres, y la segunda parte consistio en una evaluacion prospectiva de una serie de muestras quirurgicas obtenidas despues de la hemicolectomia derecha para cancer.La fase anatomica del estudio se realizo en colaboracion con el Departamento de Anatomia y Embriologia de la Universidad de Valencia. La segunda parte se realizo en la Unidad Colorrectal de un hospital terciario.Se utilizaron diecisiete cadaveres para la primera fase y se examinaron 65 muestras quirurgicas para la segunda parte del estudio.En cada muestra, los patologos buscaron estructuras anatomicas definidas, como marcadores de los estandares de calidad de la linfadenectomia D3, durante la primera fase. Las muestras se clasificaron como linfadenectomia D3 completa, parcial e incompleta.El veinte por ciento de las muestras se clasificaron como "Linfadenectomia D3 Incompleta", el 31% como "Parcial" y el 49% como "Completa." Se aislo una media de 14 (6-64), 22 (11-47) y 29 (14-55) ganglios linfaticos respectivamente (p = 0,01). Del mismo modo, el numero medio de ganglios linfaticos aislados en el area de la linfadenectomia D3 fue 0 en "Incompleta", 1 (0-5) en "Parcial" y 3 (0-8) en muestras de "Linfadenectomia D3 Completa" (p = 0,0001).Se necesita un estudio multicentrico con potencia adecuada.Proponemos la vela mesocolica derecha y el tronco de la vena colica derecha superior, como estandares anatomopatologicos nuevos y reproducibles de linfadenectomia D3, en hemicolectomia derecha oncologica. Consulte Video Resumen en http://links.lww.com/DCR/B149.

Aim: The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to show SFM approaches in an easy and practical way to make it easy to learn and teach. Methods: Two different phases. First part: Cadaver-based study of the colonic splenic flexure anatomy. In order to demonstrate the different approaches, a balloon was placed through the colonic hepatic flexure in the lesser sac without sectioning any of the fixing ligaments of the splenic flexure. Second part: A real case series of laparoscopic SFM. Results: First part: 11 cadavers were dissected. Five potential approaches to SFM were found: anterior, trans-omentum, lateral, medial infra-mesocolic, and medial trans-mesocolic. The illustrative system developed was named: Splenic Flexure “Box”(SFBox). Second part: One of the types of SFM described in first part was used in five patients with colorectal cancer. Each laparoscopic approach to the splenic flexure was illustrated in a video accompanied by illustration aids delineating the access. Conclusion: With the cadaver dissection and subsequent demonstration in real-life laparoscopic surgery, we have shown five types of laparoscopic splenic flexure mobilization. The Splenic Flexure “Box” is a useful way to learn and teach this surgical maneuver.

Objective: Intra-abdominal septic complications (IASC) affect short-term outcomes after surgery for colon cancer. Blood transfusions have been associated with worse short-term results.The role of IASC and blood transfusions on long-term oncologic results is still debated. This study aims to assess the impact of these two variables on survival after curative colon cancer resection. Patients and methods: Retrospective analysis of a prospectively maintained database of patients who underwent curative surgery for colon cancer at a university hospital, between 1993 and 2010. Cox regression was used to identify the role of IASC and transfusions (alone and combined) on local recurrence (LR), disease-free survival (DES), and cancer-specific survival (CSS). Results: Out of the 1686 patients analyzed, 1277 fit in the inclusion criteria. Colorectal surgeons performed the procedure in 82.2% of the patients. Blood transfusions were administered to 25.8% of the patients. Thirty-day complication and mortality rates were 34.5% and 6.1%. IASC occurred in 9.9%. The mean follow-up was 66 months. The 5-year rates of LR, DES, and CSS were 7%, 79.8%, and 85.1%. The year of surgery and pT (Hazard ratio 9.35, 95% CI 1.23-70.9, for T4) and pN (Hazard ratio 2.57, 95% CI 1.39-4.72, for N2) stages were independent risk factors for LR. The same variables, bowel obstruction and surgeries performed by surgeons not specialized in colorectal surgery, were also associated with worse DES and CSS. IASC and blood transfusions were not associated with LR, DFS, and CSS, whether alone or combined. Conclusions: IASC and transfusions were not associated with worse oncological outcomes after curative colon cancer surgery per se. Other factors were more important predictors of survival. (C) 2019 Published by Elsevier Espana, S.L.U.

The extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap could be insufficient. To compare the dimensions of VRAM and eVRAM flaps an anatomical study was performed. Ten VRAM and ten eVRAM flaps were dissected in ten fresh adult cadavers. Length, width and volume of all the flaps were measured. Length and volume were significantly larger in eVRAM flap compared to VRAM flap (36.55 cm vs. 30.15, p=.005; and 315.5 vs. 244 mL, p=.012, respectively). No differences were observed in flap width. The eVRAM flap could be a better option than traditional VRAM for reconstruction of big pelviperineal defects when bulkier tissue, larger skin paddle and/or longer arch of rotation are needed for reconstruction.

Introduction There are no definitive data concerning the ideal configuration of ileocolic anastomosis. Aim of this study was to identify perioperative risk factors for anastomotic leak and for 60-day morbidity and mortality after ileocolic anastomoses (stapled vs handsewn). Materials and methods This is a STROBE-compliant study. Demographic and surgical data were gathered from patients with an ileocolic anastomosis performed between November 2010 and September 2016 at a tertiary hospital. Anastomoses were performed using standardised techniques. Independent risk factors for anastomotic leak, complications and mortality were assessed. Results We included 477 patients: 53.7% of the anastomoses were hand sewn and 46.3% stapled. Laterolateral anastomosis was the most common configuration (93.3%). Anastomotic leak was diagnosed in 8.8% of patients and 36 were classified as major anastomotic leak (7.5%). In the multivariate analysis, male sex (P = 0.014, odds ratio, OR, 2.9), arterial hypertension (P = 0.048, OR 2.29) and perioperative transfusions (P < 0.001, OR 2.4 per litre) were independent risk factors for major anastomotic leak. The overall 60-day complication rate was 27.3%. Male sex (31.3% vs female 22.3%, P = 0.02, OR 1.7), diabetes (P = 0.03 OR 2.0), smoking habit (P = 0.04, OR 1.8) and perioperative transfusions (P < 0.001, OR 3.3 per litre) were independent risk factors for postoperative morbidity. The 60-day-mortality rate was 3.1% and no significant risk factors were identified. Conclusion Anastomotic leak after ileocolic anastomosis is a relevant problem. Male sex, arterial hypertension and perioperative transfusions were associated with major anastomotic leak. Conversion to open surgery was more frequently associated with perioperative death.

Access to the abdominal aorta and its visceral trunks is possible through several approaches. Dissections of five cadavers performed during three National Surgical Anatomy courses applied to Aorta, Hepatobiliopancreatic and Digestive Surgery. Videos and pictures were taken throughout the dissections and showed different abdominal aorta approaches. Abdominal aorta and visceral trunks approaches: longitudinal inframesocolic access, supraceliac clamping, celiac trunk dissection, superior mesenteric artery approaches (retroperitoneal after Kocher menoeuvre, supramesocolic or inframesocolic), Cattell-Braasch manoeuvre and mattox manoeuvre: retrorenal and prerenal. Correct knowledge of the intraabdominal anatomy is necessary to perform all the abdominal aorta surgical approaches. Cadaveric dissection could help to achieve this objective. Cardiovascular and digestive surgeons need to know the possible strategies in order to choose the one which is best suited for each patient.

Introduction To explore the reported variability in the surgical management of ileocolonic Crohn’ s disease and identify areas of standard practice, we present this study which aims to assess how different colorectal surgeons with a subspecialty interest in inflammatory bowel disease (IBD) surgery may act in different clinical scenarios of ileocolonic Crohn’s disease. Methods Anonymous videos demonstrating the small bowel walkthrough and anonymised patients’ clinical data, imaging and pathological findings were distributed to the surgeons using an electronic tool. Surgeons answered on operative strategy, bowel resections, management of small bowel mesentery, type of anastomosis and use of stomas. Results Eight small bowel walkthrough videos were registered and 12 assessors completed the survey with a questionnaire completion rate of 87.5%. There was 87.7% agreement in the need to perform an ileocolonic resection. However, the agreement for the need to perform associated surgical procedures such as strictureplasties or further bowel resections was only 57.4%. When an anastomosis was fashioned, the side to side configuration was the most commonly used. The preferred management of the mesentery was dissection close to the bowel. Conclusions The decision on the main procedure to be performed had a high agreement amongst the different assessors, but the treatment of multifocal disease was highly controversial, with low agreement on the need for associated procedures to treat internal fistulae and the use of strictureplasties. At the same time, there was significant heterogeneity in the decision on when to anastomose and when to fashion an ileostomy.

Background D3-Lymphadenectomy, together with complete mesocolic excision (CME), were introduced to provide oncological results after right colon cancer. The aim of this systematic review with meta-analysis was to assess the short and long-term outcomes of right-sided hemicolectomy with CME + D3 as compared with classic right hemicolectomy. Secondary aims included the prevalence of D3-metastasis and skip metastasis when performing CME + D3. Material and methods A systematic review with meta-analysis was conducted, according to PRISMA methodology. Results 29 studies were enrolled (2592 patients). No differences were accounted in morbidity variables associated with the measured techniques. CME + D3 was significantly associated with a greater distance between the tumour and the closest vascular tie, a longer colonic resection, a wider resection of mesentery and an increased number of harvested lymph nodes. Regarding to long-terms outcomes, we found a significant decrease in local recurrence in patients undergoing CME + D3 (HR:0.17) and a significant improvement in 3-year and 5-year overall survival rates (HR:0.53 vs. HR:0.57, respectively), as well as an improving survival in patients with stage II and III disease. Overall prevalence of patients with lymphatic metastases in D3-territory was of 8.6% and 2.2% of skip metastases. Conclusions CME + D3 is a feasible surgical procedure that allows to obtain specimens with higher quality oncological resection, without greater associated morbidity, thus improving survival in patients with stage II and III right colon cancer.

Pulmonary embolism typically occurs from deep venous thrombosis (DVT). However, not always a DVT can be identified, and 'in situ' generation of pulmonary embolism has been considered, referred to in the literature as 'De novo pulmonary embolism' (DNPE). The objective of the study is to assess risk factors, comorbidities, clinic characteristics and long-term evolution of patients with pulmonary embolism in the absence of an identified source. Retrospective study of 280 patients with pulmonary embolism, 190 pulmonary embolisms with DVT group and 90 (32%) pulmonary embolism without DVT (DNPE group), admitted to an Internal Medicine Department of a tertiary hospital from January 2012 to December 2015. In the DNPE group, segmental and subsegmental arteries were more frequently affected (P = 0.01). As compared with pulmonary embolisms with DVT group: older age, female sex, sedentary lifestyle, diabetes mellitus, arterial hypertension, heart failure, respiratory infections and chronic obstructive pulmonary disease (COPD) were significantly more frequent in DNPE. In multivariate analysis, respiratory infection [odds ratio (OR) 12.2, P < 0.0001], COPD (OR 8.7, P < 0.0001) and female sex (OR 3.0, P = 0.003) were independently associated risk factors. Long-term mortality (median follow-up 15 months) was also higher in DNPE group (34 vs. 16%, P = 0.01). De novo pulmonary embolism occurred in 32% of cases of pulmonary embolisms and was more frequent in female and COPD patients or those with respiratory infections as compared with pulmonary embolisms in which DVT was identified as a source of embolism.

Objective. To determine the factors related with diverting ileostomy performance after colorectal resection and anastomosis, in advanced ovarian cancer cytoreductive surgery. Methods. We have previously demonstrated the risk factors associated with anastomotic leak after colorectal anastomosis: Advanced age at surgery, low serum albumin level, additional bowel resections, manual anastomosis and distance of the anastomosis from the anal verge. However, use of diverting ileostomy is strongly variable and depends on individual surgeon preferences and training. Eight hospitals participated in this retrospective study. Data of 695 patients operated for ovarian cancer with primary colorectal anastomosis were included (January 2010-June 2018). Fourteen pre-/intraoperatively defined variables were identified and analysed as justification factors for use of diverting ileostomy. Results. The rate of diverting ileostomy in the entire cohort was 19.13% (133/695; range within individual centers 4.6-24.32%). Previous treatment with bevacizumab [OR 2.8 (1.3-6.1); p=0.01]; additional bowel resections [OR 3.0 (1.8-5.1); p

Background The aim of this study was to analyze the quality of life (QoL), low anterior resection syndrome (LARS) and fecal incontinence after surgery for mid to low rectal cancer and its relationship with the type of surgical procedure performed. Methods A cross-sectional cohort survey study of 358 patients operated on for mid to low rectal cancer. Patients were included in three groups: abdominoperineal resection (APR), low mechanical colorectal anastomosis (CRA) and hand-sewn coloanal anastomosis (CAA). The QLQ-C30/CR29 questionnaires, LARS and Vaizey scores were used to study QoL and defecatory dysfunction. Multivariable analysis was used to estimate the prognostic effect of the variables on QoL and LARS scores. Results 62.6% of the patients answered the survey. The global QoL score was similar among APR, CRA and CAA. Patients' body image perception was significantly worse after APR than after CRA or CAA. LARS score was better in CRA group (p = 0.002). A major LARS was observed in 83.3% of the patients who underwent CAA and in 56.6% of the patients who underwent CRA. No relationship between surgical procedures and the global QoL score was observed. Neoadjuvant radiotherapy (p = 0.048) and CAA (p = 0.005) were associated with a major LARS. The Vaizey score was higher for CAA than for CRA (p = 0.036). Conclusions Though CAA group presents worse LARS and higher faecal incontinence scores respect CRA patients, and APR is related with a worse body image, global QoL was similar in the three groups.

Resumen Introduccion El uso de un stent metalico autoexpandible como puente a la cirugia del cancer de colon izquierdo en oclusion se ha senalado como tratamiento alternativo a la cirugia de urgencia. El objetivo del presente estudio fue comparar la morbimortalidad, el coste-beneficio y los resultados oncologicos a largo plazo de ambas opciones terapeuticas. Metodos Se trata de un estudio prospectivo, comparativo, controlado y no aleatorizado (2005-2010) realizado en una unidad especializada. El estudio agrupo a 82 pacientes con cancer de colon izquierdo en oclusion tratados mediante stent como puente a la cirugia (n = 27) o cirugia de urgencia (n = 55), intervenidos con intencion curativa local. Las principales variables del estudio (morbimortalidad postoperatoria, coste-beneficio, tasa de estomas y resultados oncologicos a largo plazo) fueron comparados sobre la base de un analisis «con intencion de tratar». Resultados No se encontraron diferencias estadisticamente significativas entre los dos grupos en terminos de datos preoperatorios y caracteristicas tumorales. La tasa de exito tecnico en la colocacion de la endoprotesis fue del 88,9% (con un 11,1% de perforaciones derivadas del stent), y el exito clinico fue del 81,4%. No se observo diferencia alguna en cuanto a los indices de morbimortalidad postoperatoria. La tasa de anastomosis primaria fue superior en el grupo «stent como puente a la cirugia», en comparacion al grupo «cirugia de urgencia» (77,8% frente a 56,4%; p = 0,05). Los costes medios por paciente en el grupo «cirugia de urgencia» resultaron ser mas elevados (+1.391,9 €) que en el grupo «stent como puente a la cirugia». No se produjeron diferencias estadisticamente significativas en cuanto a resulados oncologicos a largo plazo. Conclusiones El uso de stents metalicos autoexpandibles como puente a la cirugia constituye una opcion segura para el tratamiento urgente del cancer de colon izquierdo en oclusion, con resultados oncologicos similares a largo plazo en comparacion a la cirugia de urgencia, con menor coste economico y una tasa superior de anastomosis primarias, evitando numerosos estomas.

Introduction: The use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost-benefit and long-term oncological outcomes of both therapeutic options. Methods: This is a prospective, comparative, controlled, non-randomized study (2005-2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n = 27) or emergency surgery (n = 55) operated with local curative intention. The main outcome measures (postoperative morbimortaliy, cost-benefit, stoma rate and long-term oncological outcomes) were compared based on an "intention-to-treat'' analysis. Results: There were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs. 56.4%; P =.05). The mean costs in the emergency surgery group resulted to be (Sic)1,391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes. Conclusions: The use of self-expanding metalllic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis. (C) 2017 AEC. Published by Elsevier Espanna, S.L.U. All rights reserved.

Access to the abdominal aorta is possible through several routes and with different manoeuvres. Each approach has associated advantages and shortcomings. There is no ideal, one-size-fits-all access to treat diseases of the abdominal aorta or to expose it; rather approaches are complementary and choice should be made based on several factors, including disease-related, surgeon-related and patient-related factors. Cardiovascular surgeons need to know the possible strategies in order to choose the one which is best suited for each individual patient.

ObjectiveAnastomotic leak remains the main concern after colorectal anastomosis in ovarian cancer. Our objective was to compare the use of three different management approaches after colorectal resection and anastomosis in patients with ovarian cancer.MethodsBetween January 2010 and June 2018, a total of 133 patients with International Federation of Gynecology and Obstetrics (FIGO) stage II–IV ovarian cancer who underwent colorectal resection and anastomosis were included. According to the approach followed after colorectal anastomosis and during the post-operative period, patients were stratified into three groups: conservative management and observation, diverting ileostomy, or ghost ileostomy technique. Univariate analyses were performed for quantitative variables by applying Student’s t test or Mann-Whitney U test and for qualitative variables by using the χ2 test (or Fisher’s test according to the sample size).ResultsA total of 145 patients underwent colorectal resection during cytoreduction for FIGO stage II–IV ovarian cancer. Twelve patients were excluded because a colostomy was required. Thus, 133 patients were included in the final analysis. Modified posterior pelvic exenteration was performed in 121 (91%) patients and recto-sigmoid resection in 12 (9%) patients with relapse. The approach after anastomosis was wait-and-see in 72 patients (54.1%), diverting ileostomy in 19 patients (14.4%), and ghost ileostomy in 42 patients (31.5%). There were no differences in diagnosis, age, body mass index, ECOG (Eastern Cooperative Oncology Group), histology, tumor grade, FIGO stage, or type of surgery between the groups. No differences were found regarding the anastomosis leak related factors or the rate of anastomotic leak between the three groups (5.6% vs 5.3% vs 4.8%; p=0.98). Two patients died because of the anastomotic leak in the wait-and-see group, and none died in the diverting ileostomy or ghost ileostomy group. In the diverting ileostomy group, a higher number of patients had complications compared with the ghost ileostomy group (78.9% vs 7.1%; p1500 mL) causing electrolyte imbalance in the diverting ileostomy group, and one patient (2.4%) in the ghost ileostomy group (p=0.03). The stoma reversal rate was 73.7% for the diverting ileostomy group and 100% for the ghost ileostomy group.ConclusionsThere were no differences found in the rate of anastomotic leak among the three groups of patients. The use of ghost ileostomy avoids the drawbacks of diverting ileostomy and seems to have advantages over routine diverting ileostomy and wait-and-see approaches for ovarian cancer patients undergoing colorectal anastomosis. Rates of stoma reversal are lower after diverting ileostomy when compared with ghost ileostomy.

Objective. To determine pre-/intraoperative risk factors for anastomotic leak after modified posterior pelvic exenteration (MPE) or colorectal resection in ovarian cancer and to create a practical instrument for predicting anastomotic leak risk. Background. In advanced ovarian cancer surgery, there is rather limited published evidence, drawn from a small sample, providing information about risk factors for anastomotic leak. Methods. Eight hospitals participated in this retrospective study. Data on 695 patients operated for ovarian cancer with primary anastomosis were included (January 2010-June 2018). Twelve pre-/intraoperative variables were analysed as potential independent risk factors for anastomotic leak. A predictive model was created to stablish the risk of anastomotic leak for a given patient. Results. The anastomotic leak rate was 6.6% (46/695; range 1.7%-12.5%). A total of 457 patients were included in the final multivariate analysis. The following variables were found to be independently associated with anastomotic leakage: age at surgery (OR 1.046, 95% CI 1.013-1.080, p = 0.005), serum albumin level (OR 0.621, 95% CI 0.407-0.948, p = 0.027), one or more additional small bowel resections (OR 3.544, 95% CI 1.228-10.23, p = 0.019), manual anastomosis (OR 8.356, 95% CI 1.777-39.301, p = 0.007) and distance of the anastomosis from the anal verge (OR 0.839, 95% CI 0.726-0.971, p = 0.018). Conclusions. Due to the low incidence of AL in ovarian cancer patients, a restrictive stoma policy based on the presence of risk factors should be the actual recommendation. Hand-sewn anastomosis should be avoided. Crown Copyright (C) 2019 Published by Elsevier Inc. All rights reserved.

Introduction The only curative treatment of pelvic recurrence of rectal cancer is radical resection. The aim of this paper is to analyze our experience in surgery for local recurrence of rectal cancer. Methods We performed a descriptive retrospective analysis of patients treated with curative intent for local recurrence of rectal cancer from May 2000 to January 2014. The presence of resectable liver or lung metastases was not an exclusion criterion. The descriptive results, overall survival and disease free survival are presented. Results A total of 35 patients were included. In 18 patients an abdominoperineal resection of the remaining rectum was performed. Two of them included excision of lower sacral vertebrae, while in 17 patients, sphincter sparing surgery was performed. The most frequent postoperative complications were pelvic collection and postoperative ileus. Seven patients required reoperation and one patient died. Overall survival at 1 year was 91.2%, at 2 years 75.6% and at 5 years 37%. Conclusions Local recurrence of rectal cancer is a disease with high curability rate. The only curative option is radical surgery, with acceptable mortality.

Resumen Introduccion Actualmente, el unico tratamiento curativo de la recurrencia pelvica del cancer de recto es la reseccion radical. El objetivo de este trabajo es realizar un analisis de nuestra experiencia en la cirugia de la recidiva local del cancer de recto. Metodos Realizamos un analisis descriptivo retrospectivo de los pacientes intervenidos con intencion curativa por recidiva local de cancer recto desde mayo de 2000 hasta enero de 2014. La presencia de metastasis hepaticas o pulmonares resecables no fue criterio de exclusion. Se presentan los resultados descriptivos y los tiempos de supervivencia y libres de enfermedad. Resultados Se incluyo a 35 pacientes. En 18 pacientes se realizo una amputacion del remanente del recto, en 2 de ellos con exeresis de vertebras sacras inferiores, y en 17 pacientes se realizo cirugia preservadora de esfinteres. Las complicaciones postoperatorias mas frecuentes fueron la coleccion pelvica y el ileo paralitico postoperatorio. Siete pacientes requirieron reintervencion y uno fallecio. La supervivencia global al ano fue del 91,2%, a los 2 anos del 75,6% y a los 5 anos del 37%. Conclusiones La recidiva local del cancer de recto es una enfermedad con alta tasa de curabilidad. La unica opcion curativa es la cirugia radical, con una mortalidad aceptable.