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Colon cancer in elderly patients is an increasing problem due to its prevalence and progressive aging population. Prehabilitation has experienced a great grown in this field. Whether it is the best standard of care for these patients has not been elucidated yet.A retrospective comparative cohort study of three different standards of care for elderly colon cancer patients (65 years) was conducted. A four-weeks trimodal prehabilitation program (PP), enhanced recovery program (ERP) and conventional care (CC) were compared. Global complications, major complications (Clavien-Dindo ≥ 3), reinterventions, mortality, readmission and length of stay were measured. Optimal recovery, defined as postoperative course without major complications, no mortality, hospital discharge before the fifth postoperative day and without readmission, was the primary outcome measure. The influence of standard of care in optimal recovery and postoperative outcomes was assessed with univariate and multivariate logistic regression models.A total of 153 patients were included, 51 in each group. Mean age was 77.9 years. ASA Score distribution was different between groups (ASA III-IV: CC 56.9%, ERP 25.5%, PP 58.9%; p = 0.014). Optimal recovery rate was 55.6% (PP 54.9%, ERP 66.7%, CC 45.1%; p = 0.09). No differences were found in major complications (p = 0.2) nor reinterventions (p = 0.7). Uneventful recovery favors ERP and PP groups (p = 0.046 and p = 0.049 respectively).PP and ERP are safe and effective for older colon cancer patients. Fewer overall complications and readmissions happened in ERP and PP patients. Major complications were independent of the standard of care used.

Adherence to Enhanced Recovery Protocols (ERPs) is associated with faster functional recovery, better patient satisfaction, lower complication rates and reduced length of hospital stay. Understanding institutional barriers and facilitators is essential for improving adherence to ERPs. The purpose of this study was to identify institutional factors associated with adherence to an ERP for colorectal surgery.A secondary analysis of a nationwide study was conducted including 686 patients who underwent colorectal surgery across twenty-one institutions in Spain. Adherence to ERPs was calculated based upon the components recommended by the Enhanced Recovery After Surgery (ERAS®) Society. Institutional characteristics (i.e., case volume, ERP duration, anesthesia staff size, multidisciplinary meetings, leadership discipline) were captured from each participating program. Multivariable regression was performed to determine characteristics associated with adherence.The median adherence to ERAS was 68.2% (IQR 59.1%-81.8%). Multivariable linear regression revealed that anesthesiologist leadership (+5.49%, 95%CI +2.81% to +8.18%, P 0.01), duration of ERAS implementation (+0.46% per year, 95%CI +0.06% to +0.86%, P 0.01) and the use of regular multidisciplinary meetings (+4.66%, 95%CI +0.06 to +7.74%, P 0.01) were independently associated with greater adherence. Case volume (-2.38% per 4 cases weekly, 95%CI -3.03 to -1.74, P 0.01) and number of anesthesia providers (-1.19% per 10 providers, 95%CI +2.23 to -8.18%, P 0.01) were negatively associated with adherence.Adherence to ERPs is strongly associated with anesthesiology leadership, regular multidisciplinary meetings, and program duration, whereas case volume and the size of the anesthesia staff were potential barriers. These findings highlight the importance of strong leadership, experience and establishing a multidisciplinary team when developing an ERP for colorectal surgery.

Resumen Introduccion Existe un gran interes en los ultimos anos en identificar estandares de calidad en las distintas enfermedades, entre ellas, el cancer de colon debido a su alta prevalencia. El objetivo del presente estudio es definir unos valores estandar de calidad en los resultados de la cirugia del cancer de colon. Metodos Se han utilizado los datos del estudio prospectivo multicentrico nacional «ANACO», que incluye pacientes con cancer de colon intervenidos en 52 hospitales espanoles (2011-2012). Para el presente analisis se han excluido los centros con menos de 30 pacientes y han quedado finalmente 42 hospitales (2.975 pacientes). Se presentan los valores de 4 indicadores de calidad principales a partir de los cuales se ha creado un nomograma que permite definir unos resultados estandar de la cirugia del cancer de colon. Ademas se proporcionan los resultados estandares de otros 10 indicadores de calidad secundarios (5 intraoperatorios y 5 postoperatorios). Resultados La mediana de fuga anastomotica y de mortalidad de los 42 hospitales fue de 8,5% (percentiles 25-75: 6,1-12,4%) y de 2,5% (percentiles 25-75: 0,6-4,7%), respectivamente. La mediana de ganglios aislados fue de 15,1 (percentiles 25-75: 18-14 ganglios). La mediana de estancia hospitalaria postoperatoria fue de 7,7 dias (percentiles 25-75: 6,9-9,2 dias). Basandonos en estos resultados se ha construido un nomograma para la autoevaluacion de los distintos hospitales. Conclusiones El presente analisis ha permitido definir unos resultados quirurgicos estandar tras la reseccion del cancer de colon y se ha creado un instrumento de autoevaluacion para las distintas unidades, de tal forma que cada centro puede identificar posibles areas de mejora en el tratamiento de esta enfermedad.

Introduction Lately there has been an increasing interest in identifying quality standards in different pathologies, among them colon cancer due to its great prevalence. The main goal of this study is to define the quality standards of colon cancer surgery based on a large prospective national study dataset. Methods Data from the prospective national study ANACO were used. This study included a consecutive series of patients operated on for colon cancer in 52 Spanish hospitals (2011–2012). Centers with less than 30 patients were excluded. The present analysis finally included 42 centers (2975 patients). Based on the results obtained in 4 main indicators from each hospital (anastomotic leak, lymph-nodes found in the specimen, mortality and length of stay), a nomogram that allows the evaluation of the performance of each center was designed. Standard results for further 5 intraoperative and 5 postoperative quality indicators were also reported. Results Median of anastomotic leak and mortality rate was 8.5% (25th–75th percentiles 6.1%–12.4%) and 2.5% (25th–75th percentiles 0.6%–4.7%), respectively. Median number of nodes found in the surgical specimen was 15.1 (25th–75th percentiles 18–14 nodes). Median length of postoperative stay was 7.7 days (25th–75th percentiles 6.9–9.2 days). Based on these data, a nomogram for hospital audit was created. Conclusions Standard surgical results after colon cancer surgery were defined, creating a tool for auto-evaluation and allowing each center to identify areas for improvement in the surgical treatment of colon cancer.

Introduction Laparoscopic appendectomy is probably the technique of choice in acute appendicitis. Single port laparoscopic surgery (SILS) has been proposed as an alternative technique. The objective of this study is to compare the safety and efficacy of SILS against conventional laparoscopic appendectomy (LA). Material and methods From January 2011 to September 2012, 120 patients with acute appendicitis were prospectively randomized; 60 for SILS and 60 for LA. Patients between 15 and 65 years were selected, with onset of symptoms less than 48 h. We compared BMI, surgery time, start of oral intake, hospital stay, postoperative pain, pathology, and costs. Results The median age, BMI, sex, and time of onset of symptoms to diagnosis were similar. There were no statistically significant differences in the operative time, start of oral intake, or hospital stay. There was a significant difference in postoperative pain being higher in SILS (4±1.3) than in LA (3.3±0.5) with a P =.004. Flemonous appendicitis predominated in both groups in a similar percentage. A total of 3 cases with intra-abdominal abscess (SILS 2, LA 1) required readmission and resolved spontaneously with intravenous antibiotic treatment. One case of SILS required assistance by a 5 mm trocar in the RLC for drainage placement. The cost was higher in SILS due the single port device. Conclusion SILS appendectomy is safe, effective, and has similar results to LA in selected patients, and although the cost is greater, the long term results will determine the future of this technique.

Resumen Introduccion La apendicectomia laparoscopica es probablemente en la actualidad la tecnica de eleccion en las apendicitis agudas. La cirugia laparoscopica por puerto unico (PU) ha intentado instalarse como tecnica alternativa. El objetivo de este estudio es comparar la seguridad y eficacia del PU frente a la apendicectomia laparoscopica convencional (LC). Material y metodos De enero del 2011 a septiembre del 2012 se aleatorizo prospectivamente a 120 pacientes con apendicitis aguda (PU 60, LC 60). Se selecciono a pacientes entre 15 y 65 anos con inicio de sintomas Resultados La edad media, IMC, sexo y tiempo de inicio de sintomas hasta el diagnostico fueron similares. No se encontraron diferencias del tiempo operatorio, inicio de ingesta ni estancia hospitalaria. Se evidenciaron diferencias en el dolor postoperatorio siendo mayor en el PU (4 ± 1,3) que en la LC (3,3 ± 0,5) con una p = 0,004. La apendicitis flemonosa predomino para ambos grupos. Hubo 3 reingresos por absceso intraabdominal (PU 2, LC 1) que requirieron tratamiento antibiotico intravenoso. Un caso del PU requirio asistencia intraoperatoria de un trocar de 5 mm en FID por necesidad de drenaje. El coste fue mayor en el PU debido al dispositivo empleado. Conclusion La apendicectomia por PU es segura, eficaz con resultados similares a la LC en pacientes seleccionados y, aunque el coste es mayor, seran los resultados obtenidos a largo plazo los que determinen el futuro de esta tecnica.

Presentamos el caso de un paciente varón de 80 años de edad sin alergias conocidas y con antecedentes de riesgo cardiovascular, diabetes mellitus tipo II, insuficiencia renal (IR) crónica estadio III, nefropatía diabética, colon irritable de dos años de evolución e ingreso previo por insufiencia renal aguda de causa prerrenal, hiperpotasemia y acidosis metabólica que precisó diálisis.

This prospective, two-centre study was designed to evaluate long-term outcomes when using a collagen plug to treat cryptoglandular anal fistulae. Over 3 years, 60 consecutive patients with cryptoglandular fistulae were treated using an anal fistula plug by experienced surgeons. Preoperative, postoperative and follow-up data were collected in a dedicated database. Success was defined as the closure of all fistula openings and the absence of discharge. Faecal incontinence scores were administered at baseline and at 6 months follow-up. Eleven patients had multiple fistula tracts. All fistulae treated in this series were classified as complex. Seventeen fistulae were anterior tracts in females, and the remaining tracts were trans-sphincteric in nature. Thirty-eight tracts were recurrent. Mean operative time was 26 ± 10 min. No major complications, active sepsis or mortality were observed. Success rate with a mean follow-up of 13 months was 60% of patients and 70% of tracts. Mean time for recurrence was 5.7 months. Two recurrent patients were successfully treated with a redo plug procedure, and five were successfully closed with a post-plug fistulotomy, leading to a global 72% success rate without continence impairment. Of the patients with a minimum follow-up of 6 months (mean, 18.5 months; range, 6–34 months), 29 in 32 (90.6%) were healed at final evaluation. In these patients, the mean preoperative CCF incontinence score was 0.73. This was reduced to 0.14 at 6-month follow-up. The mean reduction of CCF incontinence score was −0.6 (95% CI, 1.3 to −0.1; p = 0.01). Fistula tract treatment with the anal fistula plug is a safe and viable surgical option that should be offered to complex fistula patients. The reasons and risk factors for recurrence remain to be explored.

ResumenLa reparación de la hernia incisional gigante requiere una técnica de disección compleja, con un alto riesgo de complicaciones posoperatorias.Presentamos un caso de eventración recidivada en el que se realizó una técnica de separación de componentes para su cierre primario. El caso se complicó con un sangrado posoperatorio secundario a la lesión inadvertida de un vaso perforante, por lo que tuvo que ser reintervenido de urgencias. A los 3 días fue dado de alta sin más complicaciones. A los pocos días reingresó por isquemia intestinal con síndrome compartimental abdominal asociado, que se trató mediante laparotomía descompresiva dejando el abdomen abierto. Posteriormente se realizó el cierre primario diferido con una segunda técnica de separación de componentes, controlando las presiones de cierre aponeurótico mediante un dinamómetro digital. Al año de seguimiento el paciente mantiene una buena calidad de vida, y se descarta recidiva herniaria mediante tac de control.A pesar de tratarse de una dolencia benigna, no debemos menospreciar las importantes complicaciones que pueden aparecer en el posoperatorio, sobre todo cuando se trata de una hernia incisional de gran tamaño que ha precisado una disección considerable de la pared abdominal.En el contexto de cualquier posoperatorio de cirugía abdominal, cuando un paciente presenta distensión y dolor abdominal hay que descartar la existencia de hipertensión intraabdominal para evitar la progresión al síndrome compartimental agravado con una alta mortalidad a la que este se asocia.AbstractLarge incisional hernia repair requires a laborious dissection and it is associated with a high risk of postoperative complications.We present a case of recurrent incisional hernia in which an anatomic component separation technique was performed for primary closure. The patient presented complications with postoperative bleeding due to a perforant vessel undetected damage so he had to be reoperated. After 3 days he was discharged without complications. Afterwards he was readmitted to the hospital because of an intestinal ischaemia associated with abdominal compartment syndrome that was treated by decompressive laparotomy leaving an open abdomen. Subsequently, a delayed primary closure with a second separating components technique was carried out, controlling the tension strength edge while aponeurotic closure was performed using a digital dynamometer. After one year, the patient maintains a good quality of life with no recurrence shown in a CT scan.Although it is a benign disease, the serious complications that can occur in the postoperative setting should not be underestimaed, especially when a large incisional hernia is present and an important dissection of the abdominal wall has been performed.In the context of any postoperative abdominal surgery, when a patient has bloating and abdominal pain, it is mandatory to rule out the existence of intra-abdominal hypertension to prevent the development of a compartment syndrome, thus reducing the risk of mortality.