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Efforts to determine whether metformin can increase the effectiveness of neoadjuvant chemoradiotherapy in rectal cancer have increased in recent years. However, retrospective studies have yielded inconclusive results. Objectives The aim of this study was to compare oncological outcomes and survival after neoadjuvant chemoradiotherapy in patients with rectal cancer taking metformin versus in those not taking metformin. Methods This study analyzed 423 consecutive patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy and curative surgery between January 2010 and May 2020; of these, 59 were taking metformin and 364 were not taking metformin. Results Patients taking metformin had a lower proportion of tumor regression (6.8% versus 22.0%, P = 0.012) as well as a lower proportion of patients achieving a pathological complete response (6.8% versus 20.6%, P = 0.011). In the multivariate analysis, independent predictors of pathologic complete response were not taking metformin (OR: 5.26, 95% CI: 1.12-24.85, P= 0.035) and cT2 stage (OR: 3.49, 95% CI: 1.10-11.07, P= 0.034); the interval was also an independent predictor of tumor regression (OR: 1.78, 95% CI: 1.06-2.96, P= 0.028). No differences were observed in survival between groups. Conclusion Metformin was not associated with better tumor responses or survival after neoadjuvant treatment.

Colorectal cancer is the second-leading oncological cause of death worldwide1. Despite advances in treatment, there is still a risk of local and distant recurrence, which impacts on long-term outcomes This study was awarded a grant by the ‘Asociación Española de Coloproctolgía’ and ‘Col·legi Oficial de Metges de Girona—Joan Bruguera Grant’ in 2021.

Oncological outcomes of self-expanding metallic stent used as a bridge to surgery in potential curative patients with left-sided colonic cancer obstruction remain unclear. The aim of this study was to investigate perioperative and mid-term oncological outcomes of 2 of the currently most commonly performed treatments in left-sided colonic cancer obstruction.This is a retrospective multicenter study including patients with left-sided colonic cancer obstruction treated with curative intent between 2013 and 2017. The presence of metastasis at diagnosis was an exclusion criterion. The primary outcome was to evaluate the noninferiority, in terms of overall survival, of bridge to surgery strategy compared with emergency colonic resection. The secondary outcomes were perioperative morbimortality, disease free survival, local recurrence, and distant recurrence.A total of 564 patients were included, 320 in the emergency colonic resection group and 244 in the bridge to surgery group. Twenty-seven patients of the bridge-to-surgery group needed urgent operation. Postoperative morbidity rates were statistically higher in the emergency colonic resection group (odds ratio [95% confidence interval] 0.37 [0.24-0.55], P.001). There was no difference in 90-day mortality between groups (odds ratio [95% confidence interval] 0.85 [0.36-1.99], P = .702). The median follow-up was 3.80 years (2.29-4.92). The results show the noninferiority of bridge to surgery versus emergency colonic resection in terms of overall survival (hazard ratio [95% confidence interval) 0.78 [0.56-1.07], P = .127). There were no differences in disease free survival, distant recurrence, and local recurrence rates between bridge to surgery and emergency colonic resection groups.Self-expanding metallic stent as bridge to surgery might not lead to a negative impact on the long-term prognosis of the tumor compared with emergency colonic resection in expert hands and selected patients.

Background Low anterior resection syndrome affects 60%–90% of patients with anastomoses after colorectal resection. Consensus regarding the best anastomosis is lacking. Objective To compare outcomes after end-to-end versus side-to-end anastomoses. Design Randomized clinical trial. Settings University hospital (April 2016–October 2017). Patients Patients aged ≥18 years with rectal or sigmoid adenocarcinoma. Interventions Patients were randomized to undergo mechanical end-to-end or side-to-end (n = 33) anastomosis after laparoscopic resection. Main outcome measures Primary outcome was to assess intestinal function (COREFO and LARS questionnaires) 12 months after surgery or ileostomy closure. Secondary outcomes were postoperative complications and intestinal function and quality of life (SF-36® questionnaire) at different time points after surgery or ileostomy closure. Results No significant differences in intestinal function were observed between the two groups 12 months after surgery. Subanalysis of low-mid rectum tumors with end-to-end anastomosis yielded better function at 12 months. Postoperative complications did not differ between the two groups (p = 0.070), but reinterventions were more common in the side-to-end group (p = 0.040). Multivariate analysis found neoadjuvant treatment was independently associated with intestinal dysfunction at 12 months (β = 0.41, p = 0.033, COREFO; β = 0.41, p = 0.024, LARS). Conclusions End-to-end anastomosis yielded low rates of severe complications and reintervention, as well as better intestinal function at 12 months in the subgroup with tumors in the low-mid rectum. Trial registration clinicaltrials.gov identifier: NCT02746224.

Resumen Objetivo Los objetivos del trabajo fueron determinar los factores asociados a una estancia postoperatoria (EP) prolongada en pacientes con reseccion intestinal por enfermedad de Crohn (EC) con un protocolo de rehabilitacion multimodal (RM). Metodos Se incluyo a los pacientes intervenidos entre enero de 2013 y diciembre de 2015 por EC. Para la RM se siguio un protocolo de 8 puntos. Las variables estudiadas fueron: edad, sexo, EP, ASA, localizacion y patron de la EC, presencia de enfermedad perianal, indice de Harvey-Bradshaw, reseccion previa, tipo de cirugia actual (minimamente invasiva vs. laparotomia) y Clavien-Dindo. Se realizo un estudio inferencial para identificar los factores asociados a una EP > de 6 dias y un modelo logistico multivariante. Resultados Se intervino a 52 pacientes. La EP mediana fue de 8 dias (RI: 5-11). En el analisis univariante, la localizacion (L1 vs. L2-3), el patron (B2 vs. B3), la existencia de enfermedad perianal, la cirugia previa, el tipo de cirugia realizada, el Harvey-Bradshaw y el grado de Clavien-Dindo se asociaron todos ellos con una EP inferior o superior a 6 dias. El modelo parsimonioso que mejor ajusta para predecir una EP > 6 dias es el que contiene la variable Harvey-Bradshaw (OR: 6,49; IC 95%: 1,46-28,8) y el tipo de cirugia efectuado (OR: 0,23; IC 95%: 0,05-0,95). Conclusiones La estancia prolongada tras cirugia resectiva por EC se relaciona mas con el tipo o gravedad de la enfermedad y de cirugia realizada que con otras caracteristicas del paciente. Los pacientes con EC requieren una buena coordinacion entre prehabilitacion, RM y transferencia de cuidados postoperatorios.

Objective The aim of this study was to determine factors associated with a prolonged postoperative stay (PS) in patients operated on with bowel resection for Crohn's disease (CD) included in an enhanced recovery program (ERP). Methods We included patients operated on for CD between January 2013 and December 2015. ERP was organized following an 8-point protocol. Variables studied were: age, sex, PS, ASA, location and type of CD, presence of perianal disease, Harvey–Bradshaw index, previous resection, type of surgery (minimally invasive vs laparotomy) and Clavien Dindo. An inferential study was performed to identify factors related with a PS>6 days and multivariate analysis. Results A total of 52 patients were operated on. The median PS was 8 days (IR: 5–11). In the univariate analysis, location (L1 vs L2–3), type (B2 vs B3), presence of perianal disease, prior surgery, type of surgery performed, Harvey–Bradshaw index and Clavien-Dindo were associated with a PS > or 6 days contained the variable Harvey–Bradshaw (OR: 6.49; 95% CI: 1.46–28.8) and the type of surgery (OR: 0.23; 95% CI: 0.05–0.95). Conclusion A prolonged postoperative stay after bowel resection for CD is more related to the type or severity of the disease and the type of surgery performed, than with other patient factors. Patients with CD need good coordination between prehabilitation, ERP and postoperative management.

Introduction Recently a score (LARS) has been internationally validated that quantifies the anterior resection syndrome (ARS). The objective of this study is to know the incidence and severity of the ARS using LARS and its correlation with selected variables or risk factors. Methods All operated patients with anterior resection for rectal cancer between October 2007 and February 2014, with curative intention and at least one year of functionality, were sent a LARS questionnaire. The variables studied were age sex, time elapsed since surgery, type of surgical approach, type of anastomosis, derivative ileostomy, postoperative pelvic complication, and radiotherapy regimen. Results Out of 195 patients, 136 (70%) responded, and 132 responded properly. A total of 47% of the patients presented “severe” LARS and 34% did not develop quantifiable ARS. Quality of life was worse in the highest LARS scores ( P =.002). In the univariate analysis, total mesorectal excision, long radiotherapy regimen and derivative stoma were associated to “severe” LARS and the use of a reservoir was associated with minor LARS. In multivariate analysis only the type of resection ( P P =.002) were individual factors related to LARS. Conclusions Half of the operated patients presented high LARS score and only a third did not provide a quantifiable ARS. The overall perception of quality of life was significantly worse in patients with more severe LARS. The absence of the rectum (total mesorectal excision) and the type of anastomosis were the main factors associated with the LARS score.

Resumen Introduccion Recientemente se ha validado una escala internacional de puntuacion (LARS) que cuantifica el sindrome de reseccion anterior (SRA). El objetivo de este estudio es conocer la incidencia y gravedad del SRA utilizando el LARS y su relacion con variables seleccionadas. Metodos A todos los pacientes con reseccion anterior por cancer de recto operados entre octubre de 2007 y febrero de 2014, con intencion curativa y con mas de un ano de funcionalidad, se les envio el cuestionario LARS. Las variables estudiadas fueron: edad, sexo, tiempo transcurrido desde la cirugia, tipo de reseccion, via quirurgica, tipo de anastomosis, realizacion de estoma derivativo, complicacion postoperatoria y regimen de radioterapia. Resultados De 195 pacientes, 136 (70%) respondieron (132 adecuadamente). El 47% de los pacientes presentaba un LARS mayor y el 34% no desarrollo SRA cuantificable. Se relaciono un LARS mayor con peor calidad de vida (p = 0,002). En el analisis univariante, la escision mesorrectal total (ETM), la radioterapia larga y el estoma derivativo se asociaron a un LARS mayor, y la utilizacion de un reservorio, a uno menor. En el analisis multivariante solo el tipo de reseccion (p Conclusiones La mitad de los pacientes operados presentaron un LARS mayor y solo un tercio no presento un SRA cuantificable. La percepcion global de la calidad de vida fue significativamente peor en los pacientes con LARS mayor. La ausencia de recto (ETM) y la forma de reconstruccion anastomotica fueron los principales factores asociados a la puntuacion LARS.

Resumen Introduccion La reseccion completa con margenes libres en los tumores viscerales pelvicos localmente avanzados, primarios o recurrentes, requiere ocasionalmente de una exenteracion pelvica total (EPT). Metodos Revisamos los resultados obtenidos con la EPT en 34 pacientes consecutivos operados entre junio de 2006 y diciembre de 2013. Resultados La mediana de edad fue de 62 (40-82) anos; 24 (70%) eran varones. El origen tumoral mas frecuente fue el avanzado y primitivo de recto (TAPR), con 19 casos (55,9%) y el tipo de exenteracion, la supraelevadora (61,8%). Se logro una reseccion R0 en 24 (70,6%) pacientes y en 16 (85%) de los TAPR. Quince (79%) pacientes con TAPR tenian pT4, y 4 (20%) pN+. La continuidad intestinal y urinaria se realizo con 2 estomas en 17 casos (50%), Bricker y anastomosis colorrectal en 11 (32,3%) y colostomia humeda double barreled en 6 (17,6%). No hubo mortalidad postoperatoria; 23 (67,5%) pacientes tuvieron complicaciones y 5 (14,6%) requirieron una reoperacion en el postoperatorio. La mediana de seguimiento fue de 23 (13-45) meses. La supervivencia global (SG) y libre de enfermedad (SLE) a los 2 anos fueron del 67% y 58% respectivamente, y la mediana de SG y SLE fue de 59 meses (IC 95%: 26 a 110) y de 39 meses (IC 95%: 14 a 64), respectivamente. La SLE de las R0 fue significativamente mejor (p = 0,003) que las R1. Conclusiones La EPT es un procedimiento potencialmente curativo para las neoplasias viscerales avanzadas de la pelvis, con una morbimortalidad similar a otras cirugias exereticas mayores.

Introduction Complete resection with clear margins in locally advanced pelvic visceral tumours, primary or recurrent, occasionally requires total pelvic exenteration (TPE). Methods We reviewed the results of EFA in 34 consecutive patients operated on between June 2006 and December 2013. Results Median age was 62 (40–82) years; 24 (70%) were male. The tumour origin most frequent was advanced primary rectal tumour (APRT), with 19 cases (55.9%) and most common type of exenteration was supraelevator (61.8%). R0 resection was achieved in 24 (70.6%) patients and in 16 (85%) of the APRT. Fifteen (79%) patients had pT4 APRT, and 4 (20%) pN +. Reconstruction of the bowel and bladder was performed with two stomas in 17 cases (50%), colorectal anastomosis and Bricker in 11 (32.3%) and wet double barrelled colostomy in 6 (17.6%). There was no postoperative mortality; 23 (67.5%) patients had complications, and 5 (14.6%) required a postoperative reoperation to solve them. Median follow-up was 23 (13–45) months. Overall survival (OS) and disease free survival (DFS) at 2 years were 67% and 58% respectively, and the median OS and DFS was 59 months (95% CI 26–110) and 39 months (95% CI 14–64), respectively. The DFS of R0 was significantly better (P=.003) than R1. Conclusions TPE is a potentially curative procedure for advanced pelvic visceral malignancies with similar morbi-mortality than other extended excisional surgery.

Anastomotic complications, including leaks, stenoses, and bleeding, cause considerable mortality and morbidity after colorectal surgery.The purpose of this work was to evaluate the effectiveness of bioabsorbable staple line reinforcement in reducing colorectal anastomotic complications.This was a prospective randomized clinical study.This study was conducted at a university hospital within a specialized colorectal unit.Patients undergoing left colon resection for a benign or malignant condition were eligible. A total of 302 patients participated, including 154 control subjects and 148 with reinforcement.Patients were prospectively randomly assigned to reinforcement of circular stapled anastomosis with a bioabsorbable device versus stapled circular anastomosis without reinforcement.The primary end point was the rate of pooled incidences of anastomotic complications (leakage, bleeding, or stenosis). Secondary outcomes were the rate of reoperations and the length of hospital stay.Baseline characteristics were similar between both groups. Intention-to-treat analysis revealed that there were no significant differences in the pooled incidences of anastomotic complications (p = 0.821). Regarding individual complications, we did not observe statistical differences between groups, including leakage (6.6% vs 4.8%; p = 0.518), hemorrhage (1.4% vs 1.3%; p = 0.431), or stenosis (2.9% vs 6.8%; p = 0.128). Again, no significant differences were observed in length of stay (7 days; p = 0.242) or rate of reoperation (7.3% vs 9.6%; p = 0.490). A patient (0.3%) in the control group died.Sample size calculation was performed including all 3 of the complications, which may render it underpowered to detect differences regarding a specific complication. Anastomoses located within 5 cm from the anal verge were excluded from the study.The results obtained show that bioabsorbable staple line reinforcement in a colorectal anastomosis5 cm from the anal verge does not reduce the rate of pooled anastomotic complications (ie, leaks, bleeding, or stenosis).

Mujer de 69 años, sin antecedentes reseñables, remitida a consultas de cirugía colorrectal por rectorragia y proctalgia asociada a aparición de tumoración perianal. Presenta a la exploración una lesión nodular perianal no pigmentada, de consistencia dura, ulcerada y friable, con base de implantación a nivel del canal anal bajo. Se biopsia y se completa el estudio con una colonoscopia, que resulta normal, y pruebas de imagen mediante RMN y TC de extensión. En el informe anatomopatológico presenta fragmentos de mucosa escamosa con infiltración del tejido subepitelial por proliferación celular atípica con inmunohistoquímica compatible para melanoma maligno. El TC de extensión es negativo y la RMN pélvica descarta afectación del aparato esfinteriano.

Introduction. The objective of this study was to determine the recurrence rate and associated risk factors of full-thickness rectal prolapse in the long term after Delorme’s procedure.Patients and Methods. The study involved adult patients with rectal prolapse treated with Delorme’s surgery between 2000 and 2012 and followed up prospectively in an outpatient unit. We assessed epidemiological data, Wexner constipation and incontinence score, recurrence patterns, and risk factors. Data were analyzed by univariate and multivariate studies and follow-up was performed according to Kaplan-Meier technique. The primary outcome was recurrence.Results. A total of 42 patients, where 71.4% (n=30) were women, with a median age of 76 years (IQR 66 to 86), underwent Delorme’s surgery. The median follow-up was 85 months (IQR 28 to 132). There was no mortality, and morbidity was 9.5%. Recurrence occurred in five patients (12%) within 14 months after surgery. Actuarial recurrence at five years was 9.9%. According to the univariate analysis, constipation and concomitant pelvic floor repair were the only factors found to be associated with recurrence. Multivariate analysis showed no statistically significant differences among variables studied. Kaplan-Meier estimate revealed that constipation was associated with a higher risk of recurrence (log-rank test,p=0.006).Conclusions. Delorme’s procedure is a safe technique with an actuarial recurrence at five years of 9.9%. The outcomes obtained in this study support the performance of concomitant postanal repair and levatorplasty to reduce recurrences. Also, severe constipation is associated with a higher recurrence rate.