Publications by authors named "Salvador Navarro-Soto"

71 Publications

How to Learn a Complex Endoscopic Procedure: Knots in Transanal Endoscopic Surgery: Different Skill Among Surgeons.

Surg Laparosc Endosc Percutan Tech 2021 Jul 8. Epub 2021 Jul 8.

Department of Colorectal Surgery and General Digestive Surgery, Parc Tauli University Hospital, Institut d'investigació i Innovació Parc Tauli I3PT, Universitat Autonoma de Barcelona (UAB), Sabadell (Barcelona), Spain.

Purpose: The intrarectal suture is considered a high technically complex procedure. The study's objectives were to assess the feasibility of making an intrarectal knot, through an in vitro study and assessing whether the video tutorial facilitates learning.

Materials And Methods: A detailed description of the technique. A comparative observational cross-sectional study in surgeons with no previous experience in intrarectal knots.

Results: Twenty-one of these 32 participants passed the intrarectal knot test without video tutorial (T1) (65.6%), and 26 (81.2%) after the video tutorial (T2) (P=0.26). The mean time taken to tie the knot fell from 74 seconds (SD=46) in T1 to 41 seconds (SD=41) in T2 (P<0.001). At T1, 26 participants (81.3%) described the technique as difficult, but only 7 (21.9%) at T2 (P<0.001).

Conclusions: Performing the intrarectal knot suture is feasible. Despite the technical difficulty, the video tutorial is sufficient for surgeons to learn the technique.
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http://dx.doi.org/10.1097/SLE.0000000000000969DOI Listing
July 2021

Efficacy and Safety of Non-Antibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study): A Multicentre, Randomised, Open-Label, Non-Inferiority Trial.

Ann Surg 2021 Jun 25. Epub 2021 Jun 25.

Coloproctology Unit. Parc Tauli University Hospital, Sabadell. Institut d'investigació i innovació Parc Tauli I3PT. Despartment of Surgery, Universitat Autonoma de Barcelona Coloproctology Unit, Mataro Hospital Department of Surgery, Hospital Universitari Sant Joan de Reus Department of Surgery, Hospital Sant Joan de Déu de Manresa Coloproctology Unit, Joan XXIII University Hospital (Tarragona) Hospital de Sant Pau i Santa Tecla.

Objective: Mild acute diverticulitis (AD) can be treated safely and effectively on an outpatient basis without antibiotics.

Summary Background Data: In recent years, it have shown no benefit of antibiotics in the treatment of uncomplicated AD in hospitalized patients. Also, outpatient treatment of uncomplicated AD has been shown to be safe and effective.

Methods: A Prospective, multicentre, open-label, non-inferiority, randomized controlled trial, in 15 hospitals of patients consulting the emergency department with symptoms compatible with AD.The Participants were patients with mild AD diagnosed by Computed Tomography meeting the inclusion criteria were randomly assigned to control arm (ATB-Group): classical treatment (875/125 mg/8 h amoxicillin/clavulanic acid apart from anti-inflammatory and symptomatic treatment) or experimental arm (Non-ATB-Group): experimental treatment (anti-inflammatory and symptomatic treatment). Clinical controls were performed at 2, 7, 30, and 90 days.The primary endpoint was hospital admission. Secondary endpoints included number of emergency department revisits, pain control and emergency surgery in the different arms.

Results: Four hundred and eighty patients meeting the inclusion criteria were randomly assigned to Non-ATB-Group (n = 242) or ATB-Group (n = 238). Hospitalization rates were: ATB-Group 14/238 (5.8%) and Non-ATB-Group 8/242 (3.3%) (mean difference 2.58%, 95% CI 6.32 to -1.17), confirming non-inferiority margin. Revisits: ATB-Group 16/238 (6.7%) and Non-ATB-Group 17/242 (7%) (mean difference -0.3, 95% CI 4.22 to -4.83). Poor pain control at 2 days follow up: ATB-Group 13/230 (5.7%), Non-ATB-Group 5/221 (2.3%) (mean difference 3.39, 95% CI 6.96 to -0.18).

Conclusions: Non-antibiotic outpatient treatment of mild AD is safe and effective and is not inferior to current standard treatment.

Trial Registration: ClinicalTrials.gov (NCT02785549); EU Clinical Trials Register (2016-001596-75).
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http://dx.doi.org/10.1097/SLA.0000000000005031DOI Listing
June 2021

Consequencies of therapeutic decision-making based on FAST results in trauma patients with pelvic fracture.

Cir Esp (Engl Ed) 2021 Jun-Jul;99(6):433-439. Epub 2021 May 28.

Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Parc Taulí, Sabadell, Barcelona, Spain.

Introduction: FAST is essential to decide whether trauma patients need laparotomy, but it has a notable decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture.

Methods: Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who died. The FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables.

Results: Over the 13-year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs 14%, P < .05). Patients with positive FAST died more than negative FAST (43% vs 26%); and 4 out of 10 hemodynamically unstable patients who underwent non-therapeutic laparotomy after presenting a false positive FAST died from hypovolemic shock. The mortality rate fell from 60% to 20% when preperitoneal packing was performed before angio-embolization of the pelvis.

Conclusion: FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduced notably by applying preperitoneal packing.
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http://dx.doi.org/10.1016/j.cireng.2021.05.007DOI Listing
May 2021

Is there the same requirement to obtain the PhD degree in all the departments of surgery of the Spanish universities?

Cir Esp (Engl Ed) 2021 May 5. Epub 2021 May 5.

Director del Departamento de Cirugía, Facultad de Medicina, Universidad Autónoma de Barcelona, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Parc Taulí, Sabadell, Barcelona, España.

Introduction: The doctorate is the third cycle of official university studies, which, through the defense of the doctoral thesis leads to the acquisition of the title of doctor or PhD from the Anglo-Saxon countries. Royal Decree law 99/2011 regulates doctoral programs, with a wide margin on quality requirements. The objective of this study is to find out if there is this variation in the requirements of the doctorate programs of the different departments of surgery of the Spanish public universities and to establish a quality scale.

Methods: Cross-sectional observational study from 2/22/2021 to 3/3/2021, through a survey sent electronically to the professors of the departments of surgery.

Results: Thirty-five departments of surgery were consulted, obtaining a response in 29 of them (82.9%). The observed variation regarding requirements has been basically in the quality of the research project, in fact in 25 (86.2%) there are no regulations on this. When it is presented in the form of a compendium of articles, these are required to be original in 15 (51.7%). Regarding the position as author, the doctoral student must be the preferred author, at least in 2 articles in 14 (48.4%) of the programs. In 14 departments (48.4%) there are no regulations on the position of the articles and quartiles of journals. When scoring the different programs according to their requirements, the variability is high, ranging between 2 and 19 points. Funding for the development of the doctorate is meager.

Conclusions: There is a wide variability in the requirement of doctoral programs. Homogeneous levels of demand must be defined to promote and protect higher-level doctorates.
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http://dx.doi.org/10.1016/j.ciresp.2021.04.006DOI Listing
May 2021

T1 Rectal Adenocarcinoma: a Different Way to Measure Tumoral Invasion Based on the Healthy Residual Submucosa with Its Prognosis and Therapeutic Implications.

J Gastrointest Surg 2021 Feb 24. Epub 2021 Feb 24.

Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Sabadell, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain.

Background: Surgical treatment of early rectal cancer T1 is either local excision or total mesorectal excision. The choice of surgery is based on the risk of metastatic lymph node involvement. The most important factor to consider is the degree of submucosal invasion. We present a different way to measure tumoral invasion derived from the measurement of the healthy residual submucosa with its prognosis and therapeutic implications METHODS: Observational study of tumor submucosal invasion in patients undergoing transanal endoscopic microsurgery was conducted. Parameters evaluated are submucosal invasion, measuring the healthy residual submucosa at the point of maximum invasion; macroscopic morphology of the tumor; presence of muscularis mucosa, muscularis propria, and measurement of submucosa in the tumor area and the healthy area. The classification proposed is compared with the ones previously published.

Results: Eighty consecutive patients diagnosed with T1 rectal cancer underwent transanal endoscopic microsurgery. Seventeen tumors (21.3%) were polypoid. En bloc resection was achieved in 77 (96.3%). The muscularis mucosa was present in 28 (35%), and the muscularis propria in 77 (96.3%) (p < 0.001). The healthy residual submucosa in the tumor area measured 2,343 ± 1,869 μm. Agreement was moderate with the Kikuchi classification (kappa 0.58) and very good with the Kudo classification (kappa 0.87).

Conclusions: We describe a method for measuring submucosal invasion in T1 rectal cancer which does not depend on the morphology of the lesion or on the presence of the muscularis mucosa. It can be applied to all T1 classifications of the digestive tract in which the muscularis propria is present.
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http://dx.doi.org/10.1007/s11605-021-04948-9DOI Listing
February 2021

Transanal Endoscopic Microsurgery: An Alternative Perineal Approach to Treat Rectal Prolapse: A Video Vignette.

Surg Laparosc Endosc Percutan Tech 2021 Feb 17;31(2):277-280. Epub 2021 Feb 17.

Colorectal Unit, Department of General and Digestive Surgery, University Hospital Parc Tauli, Sabadell, Barcelona.

Purpose: Laparoscopic ventral rectopexy is the most favored surgical treatment for rectal prolapse. Perineal approaches are recommended for frail patients and those with major comorbidities, and in young men to avoid genitourinary disorders. There are very few descriptions in the literature of transanal endoscopic surgery to treat complete rectal prolapse. The aim of this article is to describe our experience with this technique.

Patients And Methods: Patients undergoing transanal endoscopic surgery for rectal prolapse repair between 2010 and 2019 were recruited for the study. Preoperative, surgical, and postoperative variables were recorded. Surgical technique, 30-day morbidity and follow-up are described.

Results: Five patients have been included. The postoperative period was uneventful and all patients were discharged in 48 hours without complications. All showed improved symptoms at 1-year control, and none presented recurrence in a mean follow-up period of 6 years.

Conclusions: The transanal endoscopic procedure allows improved endoscopic vision, and the reconstruction is performed transpelvically by fixing the anastomosis suture to the pelvic wall to prevent recurrence. Therefore, we think it is a valid alternative to other perineal procedures in patients in whom abdominal surgery is contraindicated.
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http://dx.doi.org/10.1097/SLE.0000000000000892DOI Listing
February 2021

Minimal invasive surgery for left colectomy adapted to the COVID-19 pandemic: laparoscopic intracorporeal resection and anastomosis, a 'don't touch the bowel' technique.

Colorectal Dis 2021 Jun 22;23(6):1562-1568. Epub 2021 Feb 22.

Colorectal Surgery Unit, General and Digestive Surgery Department, Hospital Universitari Parc, Barcelona, Spain.

Aim: The COVID-19 pandemic has forced surgeons to adapt their standard procedures. The modifications introduced are designed to favour minimally invasive surgery. The positive results obtained with intracorporeal resection and anastomosis in the right colon and rectum prompt us to adapt these procedures to the left colon. We describe a 'don't touch the bowel' technique and outline the benefits to patients of the use of less surgically aggressive techniques and also to surgeons in terms of the lower emission of aerosols that might transmit the COVID-19 infection.

Methods: This was an observational study of intracorporeal resection and anastomosis in left colectomy. We describe the technical details of intracorporeal resection, end-to-end stapled anastomosis and extraction of the specimen through mini-laparotomy in the ideal location.

Results: We present preliminary results of 17 patients with left-sided colonic pathologies, 15 neoplasia and two diverticular disease, who underwent four left hemicolectomies, six sigmoidectomies and seven high anterior resections. Median operating time was 186 min (range 120-280). No patient required conversion to extracorporeal laparoscopy or open surgery. Median hospital stay was 4.7 days (range 3-12 days). There was one case of anastomotic leak managed with conservative treatment.

Conclusion: Intracorporeal resection and end-to-end anastomosis with the possibility of extraction of the specimen by a mini-laparotomy in the ideal location may present benefits and also adapts well to the conditions imposed by the COVID-19 pandemic. Future comparative studies are needed to demonstrate these benefits with respect to extracorporeal anastomosis.
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http://dx.doi.org/10.1111/codi.15562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014247PMC
June 2021

Combined endoscopic and laparoscopic surgery for the treatment of complex benign colonic polyps (CELS): observational study.

Cir Esp (Engl Ed) 2021 Jan 20. Epub 2021 Jan 20.

Unidad de Cirugía Colorrectal, Departamento de Cirugía General y Ap Digestivo, Hospital Universitari Parc Taulí, Universitat Autonoma de Barcelona (UAB), Barcelona, España.

Purpose: Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment.

Method: Observational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated.

Results: Seventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5 - 6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82,4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study.

Conclusion: CELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.
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http://dx.doi.org/10.1016/j.ciresp.2020.12.013DOI Listing
January 2021

Management of intra- and post-operative complications during TEM/TAMIS procedures. A systematic review.

Minerva Chir 2021 Jan 12. Epub 2021 Jan 12.

Colorectal Unit, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain.

Introduction: Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and post-operative complications are low. The information in the literature on the management of these complications is limited, and so their importance may be either under- or overestimated (which may in turn lead to under- or overtreatment). The present article reviews the most relevant series of TEM procedures and their complications and describes various approaches to their management.

Evidence Acquisition: A systematic review of the literature, including TEM series of more than 150 cases each. We analyzed the population characteristics, surgical variables and intraoperative and postoperative complications.

Evidence Gathering: A total of 1043 records were found. After review, 1031 were excluded. The review therefore includes 12 independent cohorts of TEM procedures with a total of 4395 patients. The rate of perforation into the peritoneal cavity was 5.1%, and conversion to abdominal approach was required in 0.8% of cases. The most frequent complications were acute urinary retention (AUR, 4.9%) and rectal bleeding (2.2%). Less common complications included abscesses (0.99%) and rectovaginal fistula (0.62%). Mortality rates were low, with a mean value of 0.29%.

Conclusions: Awareness and knowledge of TEM complications and their management can play an important role in their treatment and patient safety. Here, we present a review of the most important TEM series and their complication rates and describe various approaches to their management.
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http://dx.doi.org/10.23736/S0026-4733.20.08405-9DOI Listing
January 2021

Completion Surgery in Unfavorable Rectal Cancer after Transanal Endoscopic Microsurgery: Does It Achieve Satisfactory Sphincter Preservation, Quality of Total Mesorectal Excision Specimen, and Long-term Oncological Outcomes?

Dis Colon Rectum 2021 02;64(2):200-208

Colorectal Surgery Unit, Department of General and Digestive Surgery, Parc Tauli Hospital Universitari, Institut d'investigació i innovació Parc Tauli I3PT, Universitat Autonoma de Barcelona. Sabadell, Spain.

Background: Unfavorable adenocarcinoma after transanal endoscopic microsurgery requires "completion surgery" with total mesorectal excision. The literature on this procedure is very limited.

Objective: This study aims to assess the percentage of transanal endoscopic microsurgery that will require completion surgery.

Design: This is an observational study with prospective data collection and retrospective analysis from patients who were operated on consecutively.

Settings: The study was conducted at a single academic institution.

Patients: Patients undergoing transanal endoscopic microsurgery from June 2004 to December 2018 who later required total mesorectal excision were included.

Main Outcome Measures: All the patients followed the same protocol: preoperative study, indication of transanal endoscopic microsurgery with curative intent, performance of transanal endoscopic microsurgery, and completion surgery indication 3 to 4 weeks after transanal endoscopic microsurgery.

Results: Seven hundred seventy-four patients underwent transanal endoscopic microsurgery, 622 with curative intent (group I: adenoma, 517; group II: adenocarcinoma, 105). Completion surgery was indicated in 64 of 622 (10.3%) patients: group I, 40 of 517 (7.7%) and group II, 24 of 105 (22.9%). After applying exclusion criteria, completion surgery was performed in 55 patients (8.8%). Abdominoperineal resection was performed in 23 (45.1%); the initial lesion was within 6 cm of the anal verge in 19 of these 23 (82.6%). The clinical morbidity rate (Clavien Dindo> II) was 3 of 51 (5.9%). Total mesorectal excision was graded as complete in 42 of 49 (85.7%). The circumferential resection margin was tumor-free in 47 of 50 (94%). Median follow-up was 58 months. Local recurrence was recorded in 2 of 51 (3.9%) and systemic recurrence was recorded in 7 of 51 (13.7%); 5-year disease-free survival was 86%.

Limitations: The limitations are defined by the study's observational design and the retrospective analysis.

Conclusion: The indication of completion surgery after transanal endoscopic microsurgery is low, but is higher in the indication of adenocarcinoma. Compared with initial total mesorectal excision, completion surgery requires a higher rate of abdominoperineal resection, but has similar postoperative morbidity, total mesorectal excision quality, and oncological results. See Video Abstract at http://links.lww.com/DCR/B423.

Ciruga Complementaria En Cncer De Recto Desfavorable Despus De Una Tem Se Obtiene Satisfactoriamente Preservacin Del Esfnter, Calidad De Muestra De Etm Y Resultados Oncolgicos A Largo Plazo: ANTECEDENTES:El adenocarcinoma con evolución desfavorable luego de una de microcirugía endoscópica transanal (TEM) requiere "cirugía de finalización" con la excisión total del mesorecto. La literatura sobre este procedimiento es muy limitada.OBJETIVO:Evaluar el porcentaje de microcirugía endoscópica transanal que requerió cirugía completa.DISEÑO:Estudio observacional con recolección prospectiva de datos y análisis retrospectivo de pacientes operados consecutivamente.AJUSTES:El estudio se realizó en una sola institución académica.PACIENTES:Aquellos pacientes sometidos a microcirugía endoscópica transanal desde junio de 2004 hasta diciembre de 2018 que luego requirieron excisón toztal del mesorecto.PRINCIPALES MEDIDAS DE RESULTADO:Todos los pacientes siguieron el mismo protocolo: estudio preoperatorio, indicación de microcirugía endoscópica transanal con intención curativa, realización de microcirugía endoscópica transanal e indicación de cirugía complementaria 3-4 semanas después de la microcirugía endoscópica transanal.RESULTADOS:Setecientos setenta y cuatro pacientes fueron sometidos a microcirugía endoscópica transanal, 622 con intención curativa (grupo I, adenoma: 517, grupo II, adenocarcinoma: 105). la cirugía complementaria fué indicada en 64/622 (10.3%), grupo I: 40/517 (7.7%) y grupo II 24/105 (22.9%). Después de aplicar los criterios de exclusión, la cirugía complementaria se realizó en 55 pacientes (8,8%). La resección abdominoperineal fué realizada en 23 (45,1%); en 19 de estos casos 23 (82,6%) la lesión inicial se encontraba dentro los 6 cm del margen anal. La tasa de morbilidad clínica (Clavien-Dindo > II) fue de 3/51 (5,9%). La excisión total del mesorecto se calificó como completa en 42/49 (85,7%). El margen de resección circunferencial se encontraba libre de tumor en 47/50 (94%). La mediana de seguimiento fue de 58 meses. La recurrencia local se registró en 2/51 (3.9%) y la recurrencia sistémica en 7/51 (13.7%); La supervivencia libre de enfermedad a 5 años fue del 86%.LIMITACIONES:Todas definidas por el diseño observacional y el análisis retrospectivo del mismo.CONCLUSIÓN:La indicación de completar la cirugía después de una TEM es baja, pero es más alta cuando la indicación es por adenocarcinoma. En comparación con la excisión total del mesorecto inicial, la cirugía complementaria requiere una tasa más alta de resección abdominoperineal, pero tiene una morbilidad postoperatoria, una calidad de excisión total del mesorecto y resultados oncológicos similares. ConsulteVideo Resumen en http://links.lww.com/DCR/B423. (Traducción-Dr. Xavier Delgadillo).
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http://dx.doi.org/10.1097/DCR.0000000000001730DOI Listing
February 2021

Urinary catheter in colorectal surgery: current practices and improvements in order to allow prompt removal. A cross-sectional study.

Minerva Surg 2021 Feb 25;76(1):72-79. Epub 2020 Sep 25.

Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona (UAB), Sabadell, Spain.

Background: Despite the publication of the guidelines for enhanced recovery after surgery (ERAS), attitudes to urinary catheter (UC) management vary widely in colorectal surgery. The aim of the present study was to define current practices in UC management in colorectal surgery.

Methods: Cross-sectional observational study carried out in March-April 2019, based on the responses to a survey administered to public hospitals in Catalonia. Respondents were asked about their observance of ERAS programs, the percentage of laparoscopic procedures performed, and the time of UC withdrawal in surgery of the colon and rectum.

Results: Forty-three of 45 hospitals contacted eventually responded (95.6%). As two hospitals reported that they did not perform colorectal surgery, the study is based on the results from 41 centers. Thirty-five (85.4%) reported following ERAS programs; 30 (73.2%) have coloproctology units, and 39 (95.1%) perform more than 70% of colorectal surgeries by laparoscopy. In colon surgery, 27 (65.9%) remove the UC at 24 h, and 12 (29.3%) on day 2 or day 3. In rectal surgery, 17 (58.6%) remove the UC on day 2-3.

Conclusions: Management of UC in colon and rectal surgery varies widely. There is clearly room for improvement in UC management, but needs to be thoroughly assessed in randomized multicenter studies.
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http://dx.doi.org/10.23736/S0026-4733.20.08341-8DOI Listing
February 2021

Consequencies of therapeutic decision-making based on FAST results in trauma patients with pelvic fracture.

Cir Esp 2021 Jun-Jul;99(6):433-439. Epub 2020 Sep 21.

Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España.

Introduction: FAST is essential to decide if trauma patients need laparotomy, but has a notably decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture.

Methods: Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who were fallecimiento. FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables.

Results: Over the 13-year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs. 14%, p <0.05). Patients with positive FAST died more than negative FAST (43% vs. 26%); and 4 of 10 hemodynamically unstable patients who underwent non therapeutic laparotomy after presenting a false positive FAST died from hypovolemic shock. The mortality rate fell from 60% to 20% when preperitoneal packing was performed before angio-embolization of the pelvis.

Conclusion: FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduce notably applying a preperitoneal packing.
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http://dx.doi.org/10.1016/j.ciresp.2020.08.002DOI Listing
September 2020

Botulinum toxin A as an adjunct to giant inguinal hernia reparation.

Cir Cir 2020 ;88(Suppl 1):71-73

Unidad de Cirugía Gastroesofágica. Corporació Sanitária Parc Taulí, Sabadell, Barcelona, España.

La toxina botulínica se ha aplicado en la reparación de defectos ventrales, pero la literatura sobre su aplicación en hernias inguinoescrotales es escasa. Presentamos el caso de un paciente con hernia inguinoescrotal gigante. Se realiza tomografía computada basal y otra a las 4 semanas de la administración de toxina botulínica en la musculatura oblicua y en el recto abdominal (reducción de grosor e incremento de longitud de la musculatura). Se repara la pared abdominal mediante la colocación de una malla tipo BioA intraperitoneal y otra tipo DynaMesh retromuscular. La toxina puede tener un papel importante como adyuvante en la reparación de hernias inguinoescrotales con pérdida de domicilio.

Botulinum toxin has been used in ventral defects repair, but literature on its application in inguinoscrotal hernias is scarce. Patient with giant inguinoscrotal hernia. A baseline CT scan is performed and it is repeated four weeks after botulinum toxin injection in oblique musculature and in the abdominal rectum (reduction in thickness and increase in muscle length is observed). The abdominal wall is repaired by placing an intraperitoneal BioA mesh and a retromuscular DynaMesh mesh. The toxin can have an important role as an adjuvant in the reparation of inguinoscrotal hernias with loss of domain.
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http://dx.doi.org/10.24875/CIRU.20001553DOI Listing
January 2020

[Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons].

Cir Esp (Engl Ed) 2020 Oct 29;98(8):433-441. Epub 2020 Apr 29.

Servicio de Cirugía, Hospital Universitario Virgen del Rocío, Sevilla, España.

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients.
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http://dx.doi.org/10.1016/j.ciresp.2020.04.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188641PMC
October 2020

A randomized controlled noninferiority trial comparing radiofrequency with stripping and conservative hemodynamic cure for venous insufficiency technique for insufficiency of the great saphenous vein.

J Vasc Surg Venous Lymphat Disord 2021 01 28;9(1):101-112. Epub 2020 Apr 28.

Department of Vascular Surgery, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain.

Objective: The quality of available evidence regarding new minimally invasive techniques to abolish great saphenous vein reflux is moderate. The present study assessed whether radiofrequency ablation (RFA) was noninferior to high ligation and stripping (HLS) and conservative hemodynamic cure for venous insufficiency (CHIVA) for clinical and ultrasound recurrence at 2 years in patients with primary varicose veins (VVs) due to great saphenous vein (GSV) insufficiency.

Methods: We performed a randomized, single-center, open-label, controlled, noninferiority trial to compare RFA and 2 surgical techniques for the treatment of primary VVs due to GSV insufficiency. The noninferiority margin was set at 15% for absolute differences. Patients aged >18 years with primary VVs and GSV incompetence, with or without clinical symptoms, C2 to C6 CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) clinical class, and GSV diameter >4 mm were randomized with a 1:1:1 ratio to RFA, HLS, or CHIVA. The rate of clinical recurrence at 24 months was the primary endpoint and was analyzed using a delta noninferiority margin of 15%. Ultrasound recurrence, safety, and quality of life were secondary endpoints.

Results: From December 2012 to June 2015, 225 limbs had been randomized to RFA, HLS, or CHIVA (n = 74, n = 75, and n = 76). Clinical follow-up and Doppler ultrasound examinations were performed at 1 week and 1, 6, 12, and 24 months postoperatively. No differences in postoperative complications or pain were observed among the three groups. RFA was noninferior to HLS and CHIVA for clinical recurrence at 24 months, with an estimated difference in recurrence of 3% (95% confidence interval [CI], -4.8% to 10.7%; noninferiority P = .002) and -7% (95% CI, -17% to 3%; P < .001), respectively. For ultrasound recurrence, RFA was noninferior to CHIVA, with an estimated difference of -34% (95% CI, -47% to -20%; noninferiority P < .001) at 24 months. However, noninferiority could not be demonstrated compared with HLS (5.9%; 95% CI, -4.1 to 15.9; P = .073). No differences were found in quality of life among the three groups.

Conclusions: RFA was shown to be noninferior in terms of clinical recurrence to HLS and CHIVA in the treatment of VVs due to GSV insufficiency.
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http://dx.doi.org/10.1016/j.jvsv.2020.04.019DOI Listing
January 2021

Is obesity a factor of surgical difficulty in transanal endoscopic surgery?

Am J Surg 2020 09 20;220(3):687-692. Epub 2020 Jan 20.

Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain.

Background: The aim of this study is to assess the feasibility of transanal endoscopic surgery (TES) in obese patients.

Methods: Observational descriptive study evaluating the feasibility of TES in obese rectal tumors between June 2004 and January 2019. Patients were assigned to two groups: body mass index (BMI) < 30 kg/m and BMI ≥30 kg/m, the latter defined as obese.

Results: From 775 patients, 681 were enrolled in the study, 145 (21.3%) of them obese. No statistically significant differences between groups were found with respect to overall morbidity (27, 18.6%).The obese patients presented trends towards shorter mean surgical time (65 min, IQR 48 min), less perforation in the peritoneal cavity (eight, 5.5%), and 133 (91.7%) presented a lower rate of lesion fragmentation.

Conclusion: There were no significant differences in postoperative outcomes in obese patients (BMI ≥30 kg/m). TES in those obese patients does not represent a factor of surgical difficulty.
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http://dx.doi.org/10.1016/j.amjsurg.2020.01.027DOI Listing
September 2020

How to start and develop a multicenter, prospective, randomized, controlled trial.

Cir Esp (Engl Ed) 2020 Mar 10;98(3):119-126. Epub 2020 Jan 10.

Comité Científico AEC, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Parc Taulí, Universidad Autónoma de Barcelona, Sabadell, Barcelona, España.

Our main goal is to describe how to start and develop a multicenter, prospective, randomized, controlled trial. The first step is to have an idea that will become the hypothesis and a main objective. A bibliographic search should be done to check for clinical interest and originality. Moreover, the study must be feasible and should be finished within 4 years. In order to start the multicenter study, a protocol should be written (in accordance with the SPIRIT guidelines Standard Protocol items: Recommendations for Interventional Trials), including the design type, sample size and participating hospitals. Randomization is key to the design and, therefore, the CONSORT (Consolidated Standards of Reporting Trials) guidelines must be followed. However, if the study cannot be randomized, the TREND (Transparent Reporting of Evaluations with Non-Randomized Designs) guidelines are recommended. When the protocol is approved by the Ethics Committee for Clinical Investigation of the hospital, we ought to create visibility. It is suggested to register the trial on ClincalTrials.gov and submit its publication to indexed magazines. Financial resources are necessary to execute the study and maintain an online database. This allows the registry to be updated and accessible to all the participants in the study. What is more, randomization can be done immediately. And last, but not least, is motivation. Multicentricity equals to participation of all the chosen medical centers. Updating and motivating them by sending a newsletter every 1-3 months keeps participants engaged in the study.
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http://dx.doi.org/10.1016/j.ciresp.2019.11.012DOI Listing
March 2020

Is Local Resection of Anal Canal Tumors Feasible with Transanal Endoscopic Surgery?

World J Surg 2020 03;44(3):939-946

Coloproctology Unit, General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain.

Background: An important drawback of local surgery for lesions in the anal canal is the difficulty of achieving en bloc full-thickness resections. The aim of this study is to evaluate TEM/TEO in lesions of this type from the point of view of morbidity, mortality and the quality of the pathology specimen.

Methods: This is an observational study with prospective data collection from June 2004 to July 2018. Two groups are defined: group A (rectal tumors with proximal margin between 0 and ≤4 cm from anal verge) and group B (distal margin > 4 cm from anal verge). A technical description is provided; resections and postoperative complications in both groups are compared.

Results: During the study period, 757 patients underwent TEM/TEO. Finally, 692 patients were included, 192 patients in group A and 500 patients in group B. An en bloc surgical specimen was obtained in 176/192 patients (91.7%), although the defect was completely sutured in 132 (68.8%). In the comparative analysis, group A did not present significantly greater fragmentation of the resected piece [16/192 (8.3%) vs. 36/500 (7.2%), p = 0.630], although group A was associated with greater involvement of the surgical margin [28/192 (14.6%), 32/500 (6.4%), p = 0.001] and clinically relevant morbidity [16/192 (8.3%), 20/500 (4%), p = 0.034]. There was no mortality.

Conclusions: The use of TEM/TEO to remove lesions originating in the anal canal is feasible. But we have to take into account that there is an increase in complications, technical difficulties and affected margins resection.
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http://dx.doi.org/10.1007/s00268-019-05262-xDOI Listing
March 2020

TEO-Transanal Intersphincteric Intramesorectal and Laparoscopic Approach in Proctosigmoidectomy for Benign Disease.

Surg Laparosc Endosc Percutan Tech 2019 Oct;29(5):e76-e78

Coloproctology Unit, General and Digestive Surgery Service.

Purpose: Completion proctectomy is the traditional approach in the rectal stump remaining after subtotal colectomy for benign disease. It is associated with high morbidity and urinary and sexual dysfunction. To reduce this risk, a minimally invasive approach is presented, intersphincteric intramesorectal proctosigmoidectomy by transanal endoscopic operation and laparoscopy.

Patients And Methods: Patients who had undergone total or subtotal colectomy for benign disease, those with a rectosigmoid stump who had rejected intestinal reconstruction and with refractory symptoms or risk of degeneration were selected. The technique proposed and the morbidity outcomes are described.

Results: Three patients underwent this minimally invasive approach, operative time was 130 to 150 minutes. The median postoperative hospital stay was 6.6 days. Genitourinary and sexual tests performed in the male patient showed no dysfunction.

Conclusions: This minimally invasive technique, with intersphincteric resection and dissection close to the rectal wall, theoretically reduces morbidity and the damage to the autonomic pelvic nerves.
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http://dx.doi.org/10.1097/SLE.0000000000000690DOI Listing
October 2019

Dissection of the inferior mesenteric vein versus of the inferior mesenteric artery for the genitourinary function after laparoscopic approach of rectal cancer surgery: a randomized controlled trial.

BMC Urol 2019 Aug 5;19(1):75. Epub 2019 Aug 5.

Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain.

Background: Total Mesorectal Excision (TME) is the standard surgical technique for the treatment of rectal cancer. However, rates of sexual dysfunction ofup to 50% have been described after TME, and rates of urinary dysfunction of up to 30%. Although other factors are involved, the main cause of postoperative genitourinary dysfunction is intraoperative injury to the pelvic autonomic nerves. The risk is particularly high in the inferior mesenteric artery (IMA). The aim of this study is to compare pre- and post-TME sexual dysfunction, depending on the surgical approach usedin the inferior mesenteric vessels: either directly on the IMA, or from the inferior mesenteric vein (IMV) to the IMA.

Methods: Prospective, randomized,controlled study of patients with rectal adenocarcinoma with neoadjuvant chemoradiotherapy, who will be randomly assigned to one of two groups depending on the surgical approach to the inferior mesenteric vessels. The main variable is pre- and postoperative sexual dysfunction; secondary variables are visualization and preservation of the pelvic autonomic nerves, pre- and postoperative urinary dysfunction, and pre- and postoperative quality of life. The sample will comprise 90 patients, 45 per group.

Discussion: The aim is to demonstrate that the dissection route from the IMV towards the IMA favors the preservation of the pelvic autonomic nerves and thus reducesrates of sexual dysfunction post-surgery.

Trial Registration: Ethical and Clinical Research Committee, Parc Taulí University Hospital: ID 017/315. ClinicalTrials.gov TAU-RECTALNERV-PRESERV-2018 (TRN: NCT03520088 ) (Date of registration 04/03/2018).
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http://dx.doi.org/10.1186/s12894-019-0501-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683580PMC
August 2019

Diagnostic tests for preoperative staging of esophagogastric junction tumors: performance and evidence-based recomendations.

Cir Esp (Engl Ed) 2019 Oct 26;97(8):427-431. Epub 2019 Jun 26.

Unidad Esofagogástrica, Servicio de Cirugía General y Digestiva, Parc Taulí Hospital Universitari, Sabadell, Barcelona, España.

Preoperative clinical staging is critical to select those patients whose disease is localized and may benefit from surgery with curative intent. Ideally, such staging should predict tumor invasion, lymphatic involvement and distant metastases. With the cTNM, we are able to select patients who could benefit from endoscopic resection, radical surgery or less radical treatment in patients with distant metastasis. The initial diagnosis of adenocarcinomas of the esophagogastric junction requires endoscopy with biopsies. For clinical staging, thoracoabdominal-pelvic CT scan, endoscopic ultrasound and PET or PET/CT are used. Other useful explorations are: barium swallow, endoscopic mucosal resection or endoscopic submucosal dissection (for assessment in initial stages) and staging laparoscopy. Once the resectability of the tumor has been established, the operability of the tumor should be assessed according to the patient's condition.
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http://dx.doi.org/10.1016/j.ciresp.2019.03.015DOI Listing
October 2019

The Effectiveness of Contralateral Drainage in Reducing Superficial Incisional Surgical Site Infection in Loop Ileostomy Closure: Prospective, Randomized Controlled Trial.

World J Surg 2019 07;43(7):1692-1699

Unidad de Coloproctología. Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Parc Taulí, Universidad Autónoma de Barcelona, Parc Tauli, 1, 08208, Sabadell, Barcelona, Spain.

Background: Loop ileostomy reduces the rates of morbidity due to colorectal anastomotic dehiscence. For its part, ileostomy closure is associated with low mortality (0-4%) but substantial morbidity (11-37%). Incisional surgical site infection (SSI) is one of the most frequent complications (2-40%).

Methods: A single-center, prospective, randomized controlled clinical trial of two study groups: control (conventional primary skin closure) and experimental (primary skin closure with a contralateral Penrose drain).

Results: Seventy patients undergoing loop ileostomy closure between April 2013 and June 2017 were included (35 per branch). Four were later removed from the study. Six of the remaining 66 patients (per protocol analysis) were diagnosed with incisional SSI (9.1%); there were no statistically significant differences between the two groups (control group: 9.7%; experimental group: 8.6%) or between the risk factors associated with incisional SSI. Rates of overall and relevant morbidity (Clavien ≥ III) were considerable (28.1% and 9.1%, respectively), and there were no statistically significant differences between the two groups. No patients died.

Conclusion: Contralateral drainage does not significantly affect the results of primary ileostomy closure. The rate of incisional SSI was similar in the drainage and non-drainage groups, and the overall rate of 9.1% was in the low range of those reported in the literature. The absence of mortality (0%) and the non-negligible rates of overall and relevant morbidity (28.1% and 9.1%, respectively) in our series suggest that loop ileostomy is a safe procedure. However, the bowel reconstruction involves risks that must be borne in mind.

Clinical Trial Registration: The study was registered and approved by the clinical research ethics committee of the study center (reference number 2012076). Clinical trial was registered in ClinicalTrial.gov (identification number NCT02574702 and reference: ILEOS-ISS_2013).
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http://dx.doi.org/10.1007/s00268-019-04972-6DOI Listing
July 2019

The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain.

Cir Esp (Engl Ed) 2019 Jan 8;97(1):3-10. Epub 2018 Nov 8.

Hospital General Universitario Gregorio Marañón, Madrid, España.

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.
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http://dx.doi.org/10.1016/j.ciresp.2018.09.015DOI Listing
January 2019

Importance of Resection Margins in the Treatment of Rectal Adenomas by Transanal Endoscopic Surgery.

J Gastrointest Surg 2019 09 10;23(9):1874-1883. Epub 2018 Oct 10.

Department of General and Digestive Surgery, Department of Colorectal Surgery, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona (UAB), Parc Taulí Street s/n, 08208, Sabadell, Barcelona, Spain.

Background: Polypectomy is the gold standard for treating colorectal adenomas up to 2 cm in size. For larger lesions, various procedures ranging from endoscopy to transanal surgery can be performed and achieve varying results for en bloc resection and recurrence. There are no clear guidelines for dealing with involved resection margins. We assess the recurrence of rectal adenomas operated using TEM with full-thickness wall excision with or without free resection margins and define optimal endoscopic follow-up.

Method: Observational study with prospective data collection, including patients undergoing TEM between 6/2004 and 11/2017, with definitive diagnosis of rectal adenoma. Data on epidemiological, preoperative, surgical, postoperative, pathological, and follow-up variables were recorded. Univariate analysis, follow-up risk function, and multivariate logistic regression analysis were performed to detect risk factors for recurrence.

Results: TEM was indicated in 736 patients; 481 adenomas were identified in the preoperative biopsy, of which 95 were infiltrating adenocarcinomas (19.8%) in the definitive pathology study. With a minimum follow-up of 1 year, 372 patients were included. Pathology study showed free margins in 324 (87%). Recurrences were recorded in 15 patients (4%), up to 18 months in the free margins group and up to 24 months in the involved margins group. Thirteen patients with recurrence (86.6%) were treated with TEM. No predictors of recurrence were found in the multivariate analysis.

Conclusion: TEM is the technique of choice for treating rectal adenomas and recurrences, achieving a low relapse rate. Follow-up must be adapted to resection margins and should be extended to 24 months.
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http://dx.doi.org/10.1007/s11605-018-3980-xDOI Listing
September 2019

Giant lumbar incisional hernia reparation by «sandwich» technique.

Cir Esp (Engl Ed) 2019 Mar 10;97(3):177-178. Epub 2018 Sep 10.

Unidad de Cirugía Gastroesofágica, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España.

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http://dx.doi.org/10.1016/j.ciresp.2018.07.007DOI Listing
March 2019

Morbidity after transanal endoscopic microsurgery: risk factors for postoperative complications and the design of a 1-day surgery program.

Surg Endosc 2019 05 10;33(5):1508-1517. Epub 2018 Sep 10.

Coloproctology Unit, General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain.

Background: Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure with low morbidity. The definition of risk factors for postoperative complications would help to identify the patients likely to require more care and surveillance in an ambulatory or 1-day surgery (A-OdS) program. The main endpoints are overall 30-day morbidity and relevant morbidity. The secondary objectives are to detect risk factors for complications, rehospitalization, and the time of occurrence of the postoperative complications, and to describe the adverse effects following hospitalization that the A-OdS program would avoid.

Methods: This is an observational study of consecutive patients undergoing TEM between June 2004 and December 2016. Overall and relevant morbidity based on the Clavien-Dindo (Cl-D) classification were recorded, as were demographic, preoperative, surgical, and pathology variables. Univariate and multivariate analyses of the risk factors were carried out.

Results: Six hundred and ninety patients underwent surgery, of whom 639 were included in the study. Overall morbidity rate was 151/639 patients (23.6%); the clinically relevant morbidity rate was 36/639 (Cl-D > II) (5.6%) and mortality 2/639 (0.3%). The most frequent complication was rectal bleeding, recorded in 16.9% (108/639 patients) and grade I in 86/108 patients (78. 9%). The period with the greatest risk of complications was the first 2 days. The rehospitalization rate after 48 h was 7%. The risk factors for complications were as follows: tumor size > 6 cm (OR 3.2, 95% CI 1.3-7.8), anti-platelet medication (OR 2.3, 95% CI 1.1-5.1), and surgeon's experience < 150 procedures (OR 2.0, 95% CI 1-4.1).

Conclusions: TEM is a safe procedure. The low rates of morbidity, re-hospitalization, and postoperative complications in the first 2 days after surgery make the procedure suitable for A-OdS.
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http://dx.doi.org/10.1007/s00464-018-6432-5DOI Listing
May 2019

[Functional impairment and quality of life after rectal cancer surgery].

Cir Cir 2018 ;86(2):140-147

Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Parc Taulí, Universidad Autónoma de Barcelona, Sabadell (Barcelona), España.

Objective: This study determines the quality of life and the anorectal function of these patients.

Method: Observational study of two cohorts comparing patients undergoing rectal tumor surgery using TaETM or conventional ETM after a minimum of six months of intestinal transit reconstruction. EORTC-30, EORTC-29 quality of life questionnaires and the anorectal function assessment questionnaire (LARS score) are applied. General variables are also collected.

Results: 31 patients between 2011 and 2014: 15 ETM group and 16 TaETM. We do not find statistically significant differences in quality of life questionnaires or in anorectal function. Statistically significant general variables: longer surgical time in the TaETM group. Nosocomial infection and minor suture failure in the TaETM group.

Conclusion: The performance of TaETM achieves the same results in terms of quality of life and anorectal function as conventional ETM.
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http://dx.doi.org/10.24875/CIRU.M18000022DOI Listing
January 2019

The use of the Shock Index as a predictor of active bleeding in trauma patients.

Cir Esp (Engl Ed) 2018 Oct 31;96(8):494-500. Epub 2018 May 31.

Departamento de Cirugía General, Hospital Universitario Parc Taulí, Sabadell, Barcelona, España.

Introduction: Vital signs indicate the presence of bleeding only after large amounts of blood have been lost, with high morbidity and mortality. The Shock Index (SI) is a hemorrhage indicator with a cut-off point for the risk of bleeding at 0.9. The aim of this study is to assess whether a cut-off of≥0.8 is more sensitive for detecting occult bleeding, providing for early initiation of therapeutic maneuvers.

Methods: SI analytical validation study of severe trauma patients older than 16 years of age. Vital signs were recorded, and scales for predicting bleeding included: SI, Assessment of Blood Consumption score, and Pulse Rate Over Pressure score. The relationship between the SI and 5 markers for bleeding was analyzed: need for massive transfusion, angiographic embolization, surgical bleeding control, death due to hypovolemic shock, and the overall predictor «active bleeding» (defined as the presence of at least one of the 4 markers above).

Results: Data from 1.402 trauma patients were collected prospectively over a period of 10 years. The mean Injury Severity Score was 20.9 (SD 15.8). The mortality rate was 10%. The mean SI was 0.73 (SD 0.29). «Active bleeding» was present in 18.7% of patients. The SI area under the ROC curve for «active bleeding» was 0.749.

Conclusions: An SI cut-off point≥0.8 is more sensitive than≥0.9 and allows for earlier initiation of resuscitation maneuvers in patients with occult active bleeding.
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http://dx.doi.org/10.1016/j.ciresp.2018.04.004DOI Listing
October 2018

How to deal with rectal lesions more than 15 cm from the anal verge through transanal endoscopic microsurgery.

Am J Surg 2019 01 22;217(1):53-58. Epub 2018 Apr 22.

Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain.

Background: The aim of this study is to assess postoperative morbidity and mortality in tumors with a proximal margin 15 cm or more from the anal verge operated with transanal endoscopic microsurgery (TEM).

Methods: This observational study of consecutive rectal tumor patients undergoing TEM was carried out from July 2004 to June 2017. We compared the results of rectal tumors at distances of ≥15 cm (group A) and <15 cm (group B) from the anal verge.

Results: During the study period 667 patients were included: 118 in group A and 549 in group B. In the comparative analysis there were no significant differences in morbidity (p = 0.23), mortality (p = 0.32) or free margin involvement (p = 0.545). Differences were observed in terms of lesion size (p < 0.001), surgical time (p < 0.001) and peritoneal cavity perforation, which were all increased in group A.

Conclusion: TEM for lesions in the rectosigmoid junction is feasible and is not associated with higher morbidity or mortality.
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http://dx.doi.org/10.1016/j.amjsurg.2018.04.014DOI Listing
January 2019

Reply by the Authors.

Urology 2018 05 5;115:194-195. Epub 2018 Feb 5.

General and Digestive Surgery Service, University Hospital Parc Taulí, Sabadell, Barcelona, Spain.

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http://dx.doi.org/10.1016/j.urology.2018.01.032DOI Listing
May 2018