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Papers by Xavier Serra-Aracil

Cirugía Española (english Edition), Oct 1, 2013

Cirugía Española (english Edition), May 1, 2022

Background. Rectal Magnetic Resonance Imaging (MRI) is a key test in advanced rectal cancer and i... more Background. Rectal Magnetic Resonance Imaging (MRI) is a key test in advanced rectal cancer and in the preoperative staging of a lesion suitable for transanal endoscopic surgery (TES). MRI is not operator-dependent, but its results when determining anatomical landmarks are variable. Method. Observational study of inter-observer concordance regarding four diagnostic tests used to establish the anatomical characteristics of rectal lesions: colonoscopy, rectal ultrasound (EUS), rectal MRI, and intraoperative rigid rectoscopy (IRR) in patients scheduled for transanal endoscopic surgery (TES) with curative intent. This inter-observational study assessed the concordance between four expert radiologists regarding the topographic evaluation by means of rectal MRI of lesions under consideration for TES. Results. Fifty-five consecutive rectal tumors were studied. For most of the items, the correlation between IRR and colonoscopy or EUS was generally very good (intraclass correlation coefficient -ICC-)>0.75), although the correlation between MRI and IRR in relation to size by quadrants (ICC=0.092) and location by quadrants (ICC=0.292) was weak. The ICC for the other items obtained excellent correlations: Kappa index >0.80 for all items except for the distance from the peritoneal reflection to the anal verge, where it was merely good (IK=0.606). Conclusions. The anatomical description of rectal lesions that are candidates for TES provided by means of IRR, EUS, colonoscopy and MRI is reliable. The MRI is less reliable, but in the hands of expert radiologists, the anatomical study of rectal lesions is accurate and reproducible.

Revista Espanola De Enfermedades Digestivas, 2017

Introduction: Acute diverticulitis (AD) is increasingly seen in Emergency services. The applicati... more Introduction: Acute diverticulitis (AD) is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management. Objective: To determine whether the combined use of the modified Neff radiological classification (mNeff) and clinical criteria (systemic inflammatory response syndrome [SIRS] and comorbidity) can ensure safe management of AD. Material and methods: Prospective descriptive study in a population of patients diagnosed with AD by computerized tomography (CT). The protocol applied consisted in the application of the mNeff classification and clinical criteria of SIRS and comorbidity to guide the choice of outpatient treatment, admission, drainage or surgery. Results: The study was carried out from February 2010 to February 2016. A total of 590 episodes of AD were considered: 271 women and 319 men, with a median age of 60 years (range: 25-92 years). mNeff grades were as follows: grade 0 (408 patients 70.6%); 376/408 (92%) were considered for home treatment; of these 376 patients, 254 (67.5%) were discharged and controlled by the Home Hospitalization Unit; 33 returned to the Emergency Room for consultation and 22 were re-admitted; the success rate was 91%. Grade Ia (52, 8.9%): 31/52 (59.6%) were considered for outpatient treatment; of these 31 patients, 11 (35.5%) were discharged; eight patients returned to the Emergency Room for consultation and five were re-admitted. Grade Ib (49, 8.5%): five surgery and two drainage. Grade II (30, 5.2%): ten surgery and four drainage. Grade III (5, 0.9%): one surgery and one drainage. Grade IV (34, 5.9%): ten patients showed good evolution with conservative treatment. Of the 34 grade IV patients, 24 (70.6%) underwent surgery, and three (8.8%) received percutaneous drainage. Conclusions: The mNeff classification is a safe, easy-to-apply classification based on CT findings. Together with clinical data and comorbidity data, it allows better management of AD.

Cirugía Española (english Edition), Apr 1, 2017

Introduction: The association of preoperative chemoradiotherapy and transanal endoscopic surgery ... more Introduction: The association of preoperative chemoradiotherapy and transanal endoscopic surgery in T2 and superficial T3 rectal cancers presents promising results in selected patients. The main objective is to evaluate the long-term loco-regional and systemic recurrence and, as secondary objectives, to provide results of postoperative morbidity and the correlation between complete clinical and pathological response. Methods: This is a retrospective observational study including a consecutive series of patients with T2-T3 superficial rectal cancer, N0, M0 who refused radical surgery (2008-2016). The treatment consisted of preoperative chemotherapy (5-fluorouracil or capecitabine) combined with radiotherapy (50, 4 Gy) and transanal endoscopic surgery after 8 weeks. Preoperative, surgical, pathological and long-term oncologic results were analyzed. Results: Twenty-four patients were included in the study. Two of them required rescue radical surgery for unfavorable pathological results. A local recurrence (4.5%) was observed and 2 patients presented systemic recurrence (9%), with a median follow-up of 45 months. A complete clinical tumor response was achieved in 12 patients (50%), and complete pathological tumor response in 9 patients (37.5%). Postoperative complications were observed in 5 patients (20.8%), and they were mild except one. There was no postoperative mortality.

Cirugía Española (english Edition), Jun 1, 2013

Background: Adhesions are the most important cause of intestinal obstruction. Approximately 25% o... more Background: Adhesions are the most important cause of intestinal obstruction. Approximately 25% of surgical admissions for acute abdominal conditions are due to intestinal obstruction. Better diagnostic and treatment methods of intestinal obstruction could potentially reduce mortality rate to 5%-10%. Gastrografin 1 could contribute to this achieve this. Aim: To present a protocol to treat adhesion intestinal obstruction with Gastrografin 1 that is safe, and allows shorter hospital stays and shorter time between admission and surgery. Material and methods: All patients with adhesion intestinal obstruction without symptoms of strangulation were treated with Gastrografin 1 , intravenous fluids and nasogastric tube. Those in whom contrast reach the colon in 8, 12 or 24 h were considered to have partial obstruction, and were fed orally. If Gastrografin 1 failed in the following 24 h, a laparotomy was performed. Results: Out of a total of 211 episodes (164 patients), 170 episodes received contrast and in 142 cases Gastrografin 1 reached the colon (104 episodes at 8 h, 11 at 12 h, and 27 at 24 h). A laparotomy was required in 28 patients because of failed treatment, and in another 5 for other causes. Conclusions: A management protocol for adhesion intestinal obstruction with Gastrografin 1 is safe, reduces morbidity and mortality, and leads to a shorter hospital stay.

Cirugia Espanola, Dec 1, 2020

Resumen Introduccion Se ha disenado un protocolo de prehabilitacion trimodal con el objetivo de v... more Resumen Introduccion Se ha disenado un protocolo de prehabilitacion trimodal con el objetivo de valorar si contribuye a disminuir la morbilidad postoperatoria, valorar el efecto de la prehabilitacion en la estancia hospitalaria global y analizar la evolucion de la capacidad funcional antes y despues de cirugia. Metodos Estudio observacional unicentrico con pacientes con cancer colorrectal intervenidos quirurgicamente con intencion curativa despues de un protocolo de prehabilitacion trimodal. Se recoge morbilidad postoperatoria segun el Comprehensive Complication Index y estancia hospitalaria, y se compara con una matriz historica. Tambien se recoge capacidad funcional antes y despues de la aplicacion del protocolo de prehabilitacion. Resultados En comparacion con la poblacion historica se consigue disminuir el Comprehensive Complication Index global de forma estadisticamente significativa de 13,2 a 11,5. Desglosando por tipo de morbilidad, todas disminuyen en porcentaje sin conseguir significacion (infeccion espacio quirurgico del 11,7 al 8,4%; infeccion nosocomial del 15,8 al 10%, y morbilidad medica del 8,6 al 4,2%). La estancia hospitalaria global pasa de 6 a 4 dias y el porcentaje de pacientes que se preparan en casa disminuye de forma estadisticamente significativa en ambos casos. Conclusiones La prehabilitacion trimodal puede contribuir a disminuir la morbilidad postoperatoria y la estancia hospitalaria global de los pacientes intervenidos de neoplasia colorrectal.

International Journal of Surgery, 2015

To evaluate the impact of Transanal Endoscopic Microsurgery (TEM) on anorectal function, using cl... more To evaluate the impact of Transanal Endoscopic Microsurgery (TEM) on anorectal function, using clinical and manometric assessments. To identify subgroups likely to develop incontinence after TEM, by stratifying the sample. Descriptive, prospective study. Between December 2004 and May 2011, 222 patients were operated on at our hospital, of whom 21 were excluded from the study. Patients underwent anal manometry and answered a clinical incontinence questionnaire (the Wexner scale) prior to surgery, one month post-surgery, and then at four months post-surgery. There were no statistically significant differences between preoperative Wexner questionnaire scores and values at one month and four months post-surgery. Preoperative baseline pressure (BP) values were 64 mmHg±26.18, falling to 44.26 mmHg±20.11 at one month and to 48.86 mmHg±21.14 at four months. Voluntary Contraction Pressure (VCP) reached preoperative values of 200.49 mmHg±88.85, falling to 169.5 mmHg±84.95 and to 173.6±79 at four months. The differences in BP and VCP were statistically significant. The sample was stratified in order to identify subsets susceptible to incontinence after surgery, but no at-risk subgroups were found. Multivariate analysis did not detect any predictors of incontinence. The sustained, controlled anal dilatation produced with TEM caused statistically significant decreases in VCP and BP one month and four months after surgery. However, the Wexner questionnaire scores did not show any association with clinical incontinence. No predictors of postoperative incontinence were observed. We conclude that TEM is a safe technique and does not affect continence.

Surgery, Feb 1, 2007

Acute pancreatitis is one of the main causes of intra-abdominal hypertension, which may lead to m... more Acute pancreatitis is one of the main causes of intra-abdominal hypertension, which may lead to multiple physiologic alterations. The aim of this study was to determine the relationship between acute pancreatitis and intra-abdominal hypertension, and to evaluate the utility of intra-abdominal pressure (IAP) as a marker of severity in acute pancreatitis. From July 2002 to July 2004, 45 patients admitted for acute pancreatitis were included in this prospective, observational study. The diagnostic criteria for acute pancreatitis were compatible clinical manifestations and a 3-fold increase in serum amylase levels. Severe pancreatitis was defined as Apache II score >or=8. IAP was determined every 12 hours, and the maximum and the mean values were used for analysis and correlated with prognostic factors of acute pancreatitis. A statistical relationship was observed between maximum IAP and the typical prognostic factors of acute pancreatitis. Maximum IAP had a significant relationship with the computed tomography severity index and the number of complementary tests required. The maximum IAP was significantly greater in patients who died and in patients requiring vasoactive drugs, total parenteral nutrition, or operative treatment related to complications. The maximum IAP was also greater in patients who developed systemic inflammatory response syndrome, multiorgan failure, increase in number and/or volume of intra-abdominal collections, those who required aspiration of the necrosis for suspected infection, those who demonstrated the presence of microorganisms, and those with positive blood cultures. The maximum IAP is a useful, inexpensive, and easy method to measure prognostic marker of the evolution and complications of acute pancreatitis.

Colorectal Disease, Jun 8, 2012

A 32-year-old male presented at the Emergency Service for intense proctalgia following impalement... more A 32-year-old male presented at the Emergency Service for intense proctalgia following impalement with a 15-cm metal bar after an accidental fall. On arrival the patient was haemodynamically stable, with normal temperature and a Glasgow Scale score of 15. Abdominal examination was uneventful; in the perianal region he presented rectal haemorrhage and an incision wound 3 cm to the right of the anal verge. No alterations were observed on chest and abdominal X-rays. Abdominal-pelvic CT scan (Fig. 1a) revealed penetrating trauma in the right ischiorectal fossa with gas adjacent to the mesorectal fat and intraluminal bleeding in the rectum. The intra-abdominal organs were unaffected. In view of these findings and the short time since the trauma (< 12 h) we decided to carry out examination under anaesthetic followed by rectoscopy, and then repaired the lesion using transanal endoscopic operation-TEO [3] (Karl Storz GmbH, Tüttlingen, Germany). Two penetrating wounds were seen in the rectum: one 4 cm posterolaterally to the right of the anal verge and the other 9 cm anterolaterally to the right, both approximately 1 cm in length (RIS = II) [1] (Fig. 1b). A simple suture of the entire thickness of the rectal wall was performed at the height of the lesion, followed by debridement of the perineal wound. Postoperative evolution was favourable. The patient was discharged on day 3 after surgery.

Journal of Hospital Infection, 2011

Background: Accounting for time-dependency and competing events are strongly recommended to estim... more Background: Accounting for time-dependency and competing events are strongly recommended to estimate excess length of stay (LOS) and risk of death associated with healthcare-associated infections. Aim: To assess the effect of organ/space (OS) surgical site infection (SSI) on excess LOS and in-hospital mortality in patients undergoing elective colorectal surgery (ECS) Methods: A multicentre prospective adult cohort undergoing ECS, January 2012 to December 2014, at 10 Spanish hospitals was used. SSI was considered the time-varying exposure and defined as incisional (superficial and deep) or OS. Discharge alive and death were the study endpoints. The mean excess LOS was estimated using a multistate model which provided a weighted average based on the states patients passed through. Multivariate Cox regression models were used to assess the effect of OS-SSI on risk of discharge alive or in-hospital mortality. Findings: Of 2 778 patients, 343 (12.3%) developed SSI: 194 (7%) OS-SSI and 149 (5.3%) incisional-SSI. Compared to incisional-SSI or no infection, OS-SSI prolonged LOS by 4.2 days (95% CI, 4.1-4.3) and 9 days (95% CI, 8.9-9.1), respectively, reduced the risk of discharge alive [adjusted hazard ratio (aHR), 0.36 (95%CI, 0.28-0.47) and aHR, 0.17 (95%CI, 0.14-0.21), respectively], and increased the risk of in-hospital mortality [aHR, 8.02 (95%CI, 1.03-62.9) and aHR, 10.7 (95%CI, 3.7-30.9), respectively]. Conclusion: OS-SSI substantially extended LOS and increased risk of death in patients undergoing ECS. These results reinforce OS-SSI as the SSI with the highest health burden in ECS.

Cirugia Espanola, Apr 1, 2022

PURPOSE Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for... more 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.

British Journal of Surgery, Oct 13, 2022

Background Transanal total mesorectal excision (TaTME) is a minimally invasive surgical technique... more Background Transanal total mesorectal excision (TaTME) is a minimally invasive surgical technique that tries to avoid conversion to open surgery. However, specific intraoperative complications and local recurrences have cast some doubt on the suitability of the technique. The primary endpoint of the present study was a composite outcome of conversion surgery. Secondary objectives were to assess postoperative recovery, and pathological and oncological outcomes. Methods This was a prospective, multicentre, randomized, controlled open-label study of patients diagnosed with mid and low rectal adenocarcinoma who underwent laparoscopic TaTME or laparoscopic total mesorectal excision (LaTME). The TaTME technique comprised intracorporeal resection and anastomosis. Main outcomes were conversion to open surgery. Secondary outcomes were postoperative morbidity, mortality, pathological, oncological results, and survival. Modified intention-to-treat (mITT) and per-protocol analyses were performed. Results The study was conducted between April 2015 and May 2021. Patients were randomized to the LaTME (57 patients) or TaTME (59) group. Fifty patients from the LaTME group and 55 from the TaTME group were eligible for mITT analysis. The procedure was converted to open surgery in 11 patients (11 per cent): 10 (20 per cent) in the LaTME group and 1 (2 per cent) in the laparoscopic TaTME group (difference 18.8, 95 per cent c.i. 30 to 7; P = 0.003). No significant differences were found in terms of postoperative recovery and morbidity at 30 days; nor were there significant differences in anastomotic leakage, although it was less common in laparoscopic TaTME. With a median follow-up of 39 months, there were three instances of local recurrence (6.1 per cent) in the LaTME group and one (1.8 per cent) in the laparoscopic TaTME group (95 per cent c.i. 60 to 69; P = 0.3). Registration number: NCT02550769 (http://www.clinicaltrials.gov). Conclusion The conversion rate was significantly lower in laparoscopic TaTME than in LaTME. At centres with experienced surgeons, laparoscopic TaTME can avoid conversion to open surgery.

Surgical Endoscopy and Other Interventional Techniques, Nov 18, 2019

Background Since the introduction of screening for colorectal cancer, the use of transanal endosc... more Background Since the introduction of screening for colorectal cancer, the use of transanal endoscopic surgery (TEM) has become increasingly popular. However, the technical difficulty of this surgery varies widely. The few studies of learning curve in TEM have produced very disparate results. The aim of this study is to distinguish between straightforward and complex procedures, in order to refer more difficult cases to centers with greater experience. Method Observational study with prospective data collection and retrospective analysis was carried out between June 2004 and January 2019. All TEMs performed on rectal tumors were included. The complexity of the procedure was defined according to the weighted mean surgical time for each surgeon. A predictive model of complexity was established, with a score higher than 5 indicating a complex lesion. Results During the study period, 773 TEMs were performed, 708 of which met the study's inclusion criteria. One hundred and three tumors were defined as complex. Predictors of complexity were as follows: male sex (OR: 1.

Techniques in Coloproctology, Feb 27, 2020

In recent decades, adenomatous colonic polyps have been removed endoscopically to prevent their m... more In recent decades, adenomatous colonic polyps have been removed endoscopically to prevent their malignant degeneration. However, a significant proportion of colonic polyps (up to 10–15%) are unsuitable for endoscopic removal [1]. Combined endoscopic and laparoscopic surgery (CELS) has recently emerged as a method for managing complex lesions that are likely to be benign (no evidence of malignancy is found in approximately 80% of patients) and that would otherwise require major colonic resection [2]. In this video presentation, we highlight several variations of the CELS technique that are available for use depending on the polyp’s characteristics [3, 4].

Techniques in Coloproctology, Aug 28, 2019

Background Transanal endoscopic microsurgery (TEM) has become the treatment of choice for benign ... more Background Transanal endoscopic microsurgery (TEM) has become the treatment of choice for benign rectal lesions and early rectal cancer (T1). The size classification of rectal polyps is controversial. Some articles define giant rectal lesions as those larger than 5 cm, which present a significantly increased risk of complications. The aim of this study was to evaluate the feasibility of TEM in these lesions. Methods An observational descriptive study with prospective data collection evaluating the feasibility of TEM in large rectal adenomas was performed between June 2004 and September 2018. Patients were assigned to one of the three groups according to size: < 5 cm, very large (5-7.9 cm) and ultra-large (≥ 8 cm). Descriptive and comparative analyses between groups were performed. Results TEM was indicated in 761 patients. Five hundred and seven patients (66.6%) with adenoma in the preoperative biopsy were included in the study. Three hundred and nine out of 507 (60.9%) tumors < 5 cm, 162/507 (32%) very large tumors (5-7.9 cm) and 36/507 (7.1%) ultra-large tumors (≥ 8 cm) were reviewed. Morbidity increased with tumor size: 17.5% in tumors < 5 cm, 26.5% in those 5-7.9 cm, and 36.1% in those > 8 cm. Peritoneal perforation, fragmentation, free margins and stenosis were also more common in very large and ultra-large tumors (p < 0.001). There were no statistical differences between the groups in the definitive pathology (p = 0.38). Conclusions TEM in these large tumors is associated with higher rates of morbidity, peritoneal perforation, free margins and stenosis. Although these tumors do not require total mesorectal excision and are eligible for TEM, the surgery must be carried out by experienced surgeons.

Techniques in Coloproctology, Jun 22, 2022

Cirugía Española (english Edition), Apr 1, 2022

PURPOSE Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for... more 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.

Clinics in oncology, Nov 30, 2018

The results of intracorporeal laparoscopic anastomosis in the literature vary widely, but the lat... more The results of intracorporeal laparoscopic anastomosis in the literature vary widely, but the latest publications report low rates of morbidity and of surgical space infection (SSI) [5,7]. The aim of the present study is to assess whether laparoscopic right hemicolectomy, with intracorporeal anastomosis, obtains better results than a laparoscopic approach with extracorporeal anastomosis or open surgery, in terms of overall morbidity, SSI, AL, re-interventions and hospital stay.

Cirugía Española (english Edition), Oct 1, 2013

Cirugía Española (english Edition), May 1, 2022

Background. Rectal Magnetic Resonance Imaging (MRI) is a key test in advanced rectal cancer and i... more Background. Rectal Magnetic Resonance Imaging (MRI) is a key test in advanced rectal cancer and in the preoperative staging of a lesion suitable for transanal endoscopic surgery (TES). MRI is not operator-dependent, but its results when determining anatomical landmarks are variable. Method. Observational study of inter-observer concordance regarding four diagnostic tests used to establish the anatomical characteristics of rectal lesions: colonoscopy, rectal ultrasound (EUS), rectal MRI, and intraoperative rigid rectoscopy (IRR) in patients scheduled for transanal endoscopic surgery (TES) with curative intent. This inter-observational study assessed the concordance between four expert radiologists regarding the topographic evaluation by means of rectal MRI of lesions under consideration for TES. Results. Fifty-five consecutive rectal tumors were studied. For most of the items, the correlation between IRR and colonoscopy or EUS was generally very good (intraclass correlation coefficient -ICC-)&gt;0.75), although the correlation between MRI and IRR in relation to size by quadrants (ICC=0.092) and location by quadrants (ICC=0.292) was weak. The ICC for the other items obtained excellent correlations: Kappa index &gt;0.80 for all items except for the distance from the peritoneal reflection to the anal verge, where it was merely good (IK=0.606). Conclusions. The anatomical description of rectal lesions that are candidates for TES provided by means of IRR, EUS, colonoscopy and MRI is reliable. The MRI is less reliable, but in the hands of expert radiologists, the anatomical study of rectal lesions is accurate and reproducible.

Revista Espanola De Enfermedades Digestivas, 2017

Introduction: Acute diverticulitis (AD) is increasingly seen in Emergency services. The applicati... more Introduction: Acute diverticulitis (AD) is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management. Objective: To determine whether the combined use of the modified Neff radiological classification (mNeff) and clinical criteria (systemic inflammatory response syndrome [SIRS] and comorbidity) can ensure safe management of AD. Material and methods: Prospective descriptive study in a population of patients diagnosed with AD by computerized tomography (CT). The protocol applied consisted in the application of the mNeff classification and clinical criteria of SIRS and comorbidity to guide the choice of outpatient treatment, admission, drainage or surgery. Results: The study was carried out from February 2010 to February 2016. A total of 590 episodes of AD were considered: 271 women and 319 men, with a median age of 60 years (range: 25-92 years). mNeff grades were as follows: grade 0 (408 patients 70.6%); 376/408 (92%) were considered for home treatment; of these 376 patients, 254 (67.5%) were discharged and controlled by the Home Hospitalization Unit; 33 returned to the Emergency Room for consultation and 22 were re-admitted; the success rate was 91%. Grade Ia (52, 8.9%): 31/52 (59.6%) were considered for outpatient treatment; of these 31 patients, 11 (35.5%) were discharged; eight patients returned to the Emergency Room for consultation and five were re-admitted. Grade Ib (49, 8.5%): five surgery and two drainage. Grade II (30, 5.2%): ten surgery and four drainage. Grade III (5, 0.9%): one surgery and one drainage. Grade IV (34, 5.9%): ten patients showed good evolution with conservative treatment. Of the 34 grade IV patients, 24 (70.6%) underwent surgery, and three (8.8%) received percutaneous drainage. Conclusions: The mNeff classification is a safe, easy-to-apply classification based on CT findings. Together with clinical data and comorbidity data, it allows better management of AD.

Cirugía Española (english Edition), Apr 1, 2017

Introduction: The association of preoperative chemoradiotherapy and transanal endoscopic surgery ... more Introduction: The association of preoperative chemoradiotherapy and transanal endoscopic surgery in T2 and superficial T3 rectal cancers presents promising results in selected patients. The main objective is to evaluate the long-term loco-regional and systemic recurrence and, as secondary objectives, to provide results of postoperative morbidity and the correlation between complete clinical and pathological response. Methods: This is a retrospective observational study including a consecutive series of patients with T2-T3 superficial rectal cancer, N0, M0 who refused radical surgery (2008-2016). The treatment consisted of preoperative chemotherapy (5-fluorouracil or capecitabine) combined with radiotherapy (50, 4 Gy) and transanal endoscopic surgery after 8 weeks. Preoperative, surgical, pathological and long-term oncologic results were analyzed. Results: Twenty-four patients were included in the study. Two of them required rescue radical surgery for unfavorable pathological results. A local recurrence (4.5%) was observed and 2 patients presented systemic recurrence (9%), with a median follow-up of 45 months. A complete clinical tumor response was achieved in 12 patients (50%), and complete pathological tumor response in 9 patients (37.5%). Postoperative complications were observed in 5 patients (20.8%), and they were mild except one. There was no postoperative mortality.

Cirugía Española (english Edition), Jun 1, 2013

Background: Adhesions are the most important cause of intestinal obstruction. Approximately 25% o... more Background: Adhesions are the most important cause of intestinal obstruction. Approximately 25% of surgical admissions for acute abdominal conditions are due to intestinal obstruction. Better diagnostic and treatment methods of intestinal obstruction could potentially reduce mortality rate to 5%-10%. Gastrografin 1 could contribute to this achieve this. Aim: To present a protocol to treat adhesion intestinal obstruction with Gastrografin 1 that is safe, and allows shorter hospital stays and shorter time between admission and surgery. Material and methods: All patients with adhesion intestinal obstruction without symptoms of strangulation were treated with Gastrografin 1 , intravenous fluids and nasogastric tube. Those in whom contrast reach the colon in 8, 12 or 24 h were considered to have partial obstruction, and were fed orally. If Gastrografin 1 failed in the following 24 h, a laparotomy was performed. Results: Out of a total of 211 episodes (164 patients), 170 episodes received contrast and in 142 cases Gastrografin 1 reached the colon (104 episodes at 8 h, 11 at 12 h, and 27 at 24 h). A laparotomy was required in 28 patients because of failed treatment, and in another 5 for other causes. Conclusions: A management protocol for adhesion intestinal obstruction with Gastrografin 1 is safe, reduces morbidity and mortality, and leads to a shorter hospital stay.

Cirugia Espanola, Dec 1, 2020

Resumen Introduccion Se ha disenado un protocolo de prehabilitacion trimodal con el objetivo de v... more Resumen Introduccion Se ha disenado un protocolo de prehabilitacion trimodal con el objetivo de valorar si contribuye a disminuir la morbilidad postoperatoria, valorar el efecto de la prehabilitacion en la estancia hospitalaria global y analizar la evolucion de la capacidad funcional antes y despues de cirugia. Metodos Estudio observacional unicentrico con pacientes con cancer colorrectal intervenidos quirurgicamente con intencion curativa despues de un protocolo de prehabilitacion trimodal. Se recoge morbilidad postoperatoria segun el Comprehensive Complication Index y estancia hospitalaria, y se compara con una matriz historica. Tambien se recoge capacidad funcional antes y despues de la aplicacion del protocolo de prehabilitacion. Resultados En comparacion con la poblacion historica se consigue disminuir el Comprehensive Complication Index global de forma estadisticamente significativa de 13,2 a 11,5. Desglosando por tipo de morbilidad, todas disminuyen en porcentaje sin conseguir significacion (infeccion espacio quirurgico del 11,7 al 8,4%; infeccion nosocomial del 15,8 al 10%, y morbilidad medica del 8,6 al 4,2%). La estancia hospitalaria global pasa de 6 a 4 dias y el porcentaje de pacientes que se preparan en casa disminuye de forma estadisticamente significativa en ambos casos. Conclusiones La prehabilitacion trimodal puede contribuir a disminuir la morbilidad postoperatoria y la estancia hospitalaria global de los pacientes intervenidos de neoplasia colorrectal.

International Journal of Surgery, 2015

To evaluate the impact of Transanal Endoscopic Microsurgery (TEM) on anorectal function, using cl... more To evaluate the impact of Transanal Endoscopic Microsurgery (TEM) on anorectal function, using clinical and manometric assessments. To identify subgroups likely to develop incontinence after TEM, by stratifying the sample. Descriptive, prospective study. Between December 2004 and May 2011, 222 patients were operated on at our hospital, of whom 21 were excluded from the study. Patients underwent anal manometry and answered a clinical incontinence questionnaire (the Wexner scale) prior to surgery, one month post-surgery, and then at four months post-surgery. There were no statistically significant differences between preoperative Wexner questionnaire scores and values at one month and four months post-surgery. Preoperative baseline pressure (BP) values were 64 mmHg±26.18, falling to 44.26 mmHg±20.11 at one month and to 48.86 mmHg±21.14 at four months. Voluntary Contraction Pressure (VCP) reached preoperative values of 200.49 mmHg±88.85, falling to 169.5 mmHg±84.95 and to 173.6±79 at four months. The differences in BP and VCP were statistically significant. The sample was stratified in order to identify subsets susceptible to incontinence after surgery, but no at-risk subgroups were found. Multivariate analysis did not detect any predictors of incontinence. The sustained, controlled anal dilatation produced with TEM caused statistically significant decreases in VCP and BP one month and four months after surgery. However, the Wexner questionnaire scores did not show any association with clinical incontinence. No predictors of postoperative incontinence were observed. We conclude that TEM is a safe technique and does not affect continence.

Surgery, Feb 1, 2007

Acute pancreatitis is one of the main causes of intra-abdominal hypertension, which may lead to m... more Acute pancreatitis is one of the main causes of intra-abdominal hypertension, which may lead to multiple physiologic alterations. The aim of this study was to determine the relationship between acute pancreatitis and intra-abdominal hypertension, and to evaluate the utility of intra-abdominal pressure (IAP) as a marker of severity in acute pancreatitis. From July 2002 to July 2004, 45 patients admitted for acute pancreatitis were included in this prospective, observational study. The diagnostic criteria for acute pancreatitis were compatible clinical manifestations and a 3-fold increase in serum amylase levels. Severe pancreatitis was defined as Apache II score &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=8. IAP was determined every 12 hours, and the maximum and the mean values were used for analysis and correlated with prognostic factors of acute pancreatitis. A statistical relationship was observed between maximum IAP and the typical prognostic factors of acute pancreatitis. Maximum IAP had a significant relationship with the computed tomography severity index and the number of complementary tests required. The maximum IAP was significantly greater in patients who died and in patients requiring vasoactive drugs, total parenteral nutrition, or operative treatment related to complications. The maximum IAP was also greater in patients who developed systemic inflammatory response syndrome, multiorgan failure, increase in number and/or volume of intra-abdominal collections, those who required aspiration of the necrosis for suspected infection, those who demonstrated the presence of microorganisms, and those with positive blood cultures. The maximum IAP is a useful, inexpensive, and easy method to measure prognostic marker of the evolution and complications of acute pancreatitis.

Colorectal Disease, Jun 8, 2012

A 32-year-old male presented at the Emergency Service for intense proctalgia following impalement... more A 32-year-old male presented at the Emergency Service for intense proctalgia following impalement with a 15-cm metal bar after an accidental fall. On arrival the patient was haemodynamically stable, with normal temperature and a Glasgow Scale score of 15. Abdominal examination was uneventful; in the perianal region he presented rectal haemorrhage and an incision wound 3 cm to the right of the anal verge. No alterations were observed on chest and abdominal X-rays. Abdominal-pelvic CT scan (Fig. 1a) revealed penetrating trauma in the right ischiorectal fossa with gas adjacent to the mesorectal fat and intraluminal bleeding in the rectum. The intra-abdominal organs were unaffected. In view of these findings and the short time since the trauma (< 12 h) we decided to carry out examination under anaesthetic followed by rectoscopy, and then repaired the lesion using transanal endoscopic operation-TEO [3] (Karl Storz GmbH, Tüttlingen, Germany). Two penetrating wounds were seen in the rectum: one 4 cm posterolaterally to the right of the anal verge and the other 9 cm anterolaterally to the right, both approximately 1 cm in length (RIS = II) [1] (Fig. 1b). A simple suture of the entire thickness of the rectal wall was performed at the height of the lesion, followed by debridement of the perineal wound. Postoperative evolution was favourable. The patient was discharged on day 3 after surgery.

Journal of Hospital Infection, 2011

Background: Accounting for time-dependency and competing events are strongly recommended to estim... more Background: Accounting for time-dependency and competing events are strongly recommended to estimate excess length of stay (LOS) and risk of death associated with healthcare-associated infections. Aim: To assess the effect of organ/space (OS) surgical site infection (SSI) on excess LOS and in-hospital mortality in patients undergoing elective colorectal surgery (ECS) Methods: A multicentre prospective adult cohort undergoing ECS, January 2012 to December 2014, at 10 Spanish hospitals was used. SSI was considered the time-varying exposure and defined as incisional (superficial and deep) or OS. Discharge alive and death were the study endpoints. The mean excess LOS was estimated using a multistate model which provided a weighted average based on the states patients passed through. Multivariate Cox regression models were used to assess the effect of OS-SSI on risk of discharge alive or in-hospital mortality. Findings: Of 2 778 patients, 343 (12.3%) developed SSI: 194 (7%) OS-SSI and 149 (5.3%) incisional-SSI. Compared to incisional-SSI or no infection, OS-SSI prolonged LOS by 4.2 days (95% CI, 4.1-4.3) and 9 days (95% CI, 8.9-9.1), respectively, reduced the risk of discharge alive [adjusted hazard ratio (aHR), 0.36 (95%CI, 0.28-0.47) and aHR, 0.17 (95%CI, 0.14-0.21), respectively], and increased the risk of in-hospital mortality [aHR, 8.02 (95%CI, 1.03-62.9) and aHR, 10.7 (95%CI, 3.7-30.9), respectively]. Conclusion: OS-SSI substantially extended LOS and increased risk of death in patients undergoing ECS. These results reinforce OS-SSI as the SSI with the highest health burden in ECS.

Cirugia Espanola, Apr 1, 2022

PURPOSE Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for... more 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.

British Journal of Surgery, Oct 13, 2022

Background Transanal total mesorectal excision (TaTME) is a minimally invasive surgical technique... more Background Transanal total mesorectal excision (TaTME) is a minimally invasive surgical technique that tries to avoid conversion to open surgery. However, specific intraoperative complications and local recurrences have cast some doubt on the suitability of the technique. The primary endpoint of the present study was a composite outcome of conversion surgery. Secondary objectives were to assess postoperative recovery, and pathological and oncological outcomes. Methods This was a prospective, multicentre, randomized, controlled open-label study of patients diagnosed with mid and low rectal adenocarcinoma who underwent laparoscopic TaTME or laparoscopic total mesorectal excision (LaTME). The TaTME technique comprised intracorporeal resection and anastomosis. Main outcomes were conversion to open surgery. Secondary outcomes were postoperative morbidity, mortality, pathological, oncological results, and survival. Modified intention-to-treat (mITT) and per-protocol analyses were performed. Results The study was conducted between April 2015 and May 2021. Patients were randomized to the LaTME (57 patients) or TaTME (59) group. Fifty patients from the LaTME group and 55 from the TaTME group were eligible for mITT analysis. The procedure was converted to open surgery in 11 patients (11 per cent): 10 (20 per cent) in the LaTME group and 1 (2 per cent) in the laparoscopic TaTME group (difference 18.8, 95 per cent c.i. 30 to 7; P = 0.003). No significant differences were found in terms of postoperative recovery and morbidity at 30 days; nor were there significant differences in anastomotic leakage, although it was less common in laparoscopic TaTME. With a median follow-up of 39 months, there were three instances of local recurrence (6.1 per cent) in the LaTME group and one (1.8 per cent) in the laparoscopic TaTME group (95 per cent c.i. 60 to 69; P = 0.3). Registration number: NCT02550769 (http://www.clinicaltrials.gov). Conclusion The conversion rate was significantly lower in laparoscopic TaTME than in LaTME. At centres with experienced surgeons, laparoscopic TaTME can avoid conversion to open surgery.

Surgical Endoscopy and Other Interventional Techniques, Nov 18, 2019

Background Since the introduction of screening for colorectal cancer, the use of transanal endosc... more Background Since the introduction of screening for colorectal cancer, the use of transanal endoscopic surgery (TEM) has become increasingly popular. However, the technical difficulty of this surgery varies widely. The few studies of learning curve in TEM have produced very disparate results. The aim of this study is to distinguish between straightforward and complex procedures, in order to refer more difficult cases to centers with greater experience. Method Observational study with prospective data collection and retrospective analysis was carried out between June 2004 and January 2019. All TEMs performed on rectal tumors were included. The complexity of the procedure was defined according to the weighted mean surgical time for each surgeon. A predictive model of complexity was established, with a score higher than 5 indicating a complex lesion. Results During the study period, 773 TEMs were performed, 708 of which met the study's inclusion criteria. One hundred and three tumors were defined as complex. Predictors of complexity were as follows: male sex (OR: 1.

Techniques in Coloproctology, Feb 27, 2020

In recent decades, adenomatous colonic polyps have been removed endoscopically to prevent their m... more In recent decades, adenomatous colonic polyps have been removed endoscopically to prevent their malignant degeneration. However, a significant proportion of colonic polyps (up to 10–15%) are unsuitable for endoscopic removal [1]. Combined endoscopic and laparoscopic surgery (CELS) has recently emerged as a method for managing complex lesions that are likely to be benign (no evidence of malignancy is found in approximately 80% of patients) and that would otherwise require major colonic resection [2]. In this video presentation, we highlight several variations of the CELS technique that are available for use depending on the polyp’s characteristics [3, 4].

Techniques in Coloproctology, Aug 28, 2019

Background Transanal endoscopic microsurgery (TEM) has become the treatment of choice for benign ... more Background Transanal endoscopic microsurgery (TEM) has become the treatment of choice for benign rectal lesions and early rectal cancer (T1). The size classification of rectal polyps is controversial. Some articles define giant rectal lesions as those larger than 5 cm, which present a significantly increased risk of complications. The aim of this study was to evaluate the feasibility of TEM in these lesions. Methods An observational descriptive study with prospective data collection evaluating the feasibility of TEM in large rectal adenomas was performed between June 2004 and September 2018. Patients were assigned to one of the three groups according to size: < 5 cm, very large (5-7.9 cm) and ultra-large (≥ 8 cm). Descriptive and comparative analyses between groups were performed. Results TEM was indicated in 761 patients. Five hundred and seven patients (66.6%) with adenoma in the preoperative biopsy were included in the study. Three hundred and nine out of 507 (60.9%) tumors < 5 cm, 162/507 (32%) very large tumors (5-7.9 cm) and 36/507 (7.1%) ultra-large tumors (≥ 8 cm) were reviewed. Morbidity increased with tumor size: 17.5% in tumors < 5 cm, 26.5% in those 5-7.9 cm, and 36.1% in those > 8 cm. Peritoneal perforation, fragmentation, free margins and stenosis were also more common in very large and ultra-large tumors (p < 0.001). There were no statistical differences between the groups in the definitive pathology (p = 0.38). Conclusions TEM in these large tumors is associated with higher rates of morbidity, peritoneal perforation, free margins and stenosis. Although these tumors do not require total mesorectal excision and are eligible for TEM, the surgery must be carried out by experienced surgeons.

Techniques in Coloproctology, Jun 22, 2022

Cirugía Española (english Edition), Apr 1, 2022

PURPOSE Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for... more 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.

Clinics in oncology, Nov 30, 2018

The results of intracorporeal laparoscopic anastomosis in the literature vary widely, but the lat... more The results of intracorporeal laparoscopic anastomosis in the literature vary widely, but the latest publications report low rates of morbidity and of surgical space infection (SSI) [5,7]. The aim of the present study is to assess whether laparoscopic right hemicolectomy, with intracorporeal anastomosis, obtains better results than a laparoscopic approach with extracorporeal anastomosis or open surgery, in terms of overall morbidity, SSI, AL, re-interventions and hospital stay.