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Filotico M, Sancho-Muriel J, Cholewa H, Frasson M, Castro RA, Flor-Lorente B. Perianal extramammary Paget disease: our experience of two cases - a video vignette. Colorectal Dis 2024. [PMID: 38429606 DOI: 10.1111/codi.16928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/11/2024] [Indexed: 03/03/2024]
Affiliation(s)
| | | | - Hanna Cholewa
- Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Matteo Frasson
- Hospital Universitario y Politécnico la Fe, Valencia, Spain
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2
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Giner F, Frasson M, Cholewa H, Sancho-Muriel J, García-Gómez E, Hernández JA, Flor-Lorente B, García-Granero E. A comparison of whole-mount and conventional sections for pathological mesorectal extension and circumferential resection margin assessment after total mesorectal excision. Cir Esp 2024:S2173-5077(24)00049-8. [PMID: 38373616 DOI: 10.1016/j.cireng.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/24/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION The objective of the study is to compare 2 techniques for histological handling of rectal cancer specimens, namely whole-mount in a large block vs conventional sampling using small blocks, for mesorectal pathological assessment of circumferential resection margin status and depth of tumor invasion into the mesorectal fat. METHODS This is a prospective study including 27 total mesorectal excision specimens of rectal cancer from patients treated for primary rectal carcinoma between 2020 and 2022 in a specialized multidisciplinary Colorectal Unit. For each total mesorectal excision specimen, 2 contiguous representative tumoral slices were selected and comparatively analyzed with whole-mount and small blocks macroscopic dissection techniques, enabling comparison between them in the same surgical specimen. The agreement between the 2 techniques to assess the distance of the tumor from the circumferential resection margin as well as the depth of tumor invasion was evaluated with the Student's t-test for paired samples, Pearson's correlation coefficient, and the Bland-Altman method comparison analysis. RESULTS Complete mesorectal excision was observed in 8% of cases. Circumferential resection margin involvement was observed in only one case (4 %). The whole-mount and small block techniques obtained similar results when we assessed the distance to the circumferential resection margin (t-test P = 0.8, r = 0.92) and the depth of mesorectal infiltration (t-test P = 0.6, r = 0.95). CONCLUSIONS Both gross dissection techniques (whole-mount vs multiple small cassettes) are equivalent and reliable to assess the distance to circumferential resection margin and the depth of mesorectal infiltration in the mesorectal fat in rectal cancer staging.
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Affiliation(s)
- Francisco Giner
- Pathology Department, University of Valencia, Valencia, Spain; Pathology Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Matteo Frasson
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain; Surgery Department. University of Valencia, Spain.
| | - Hanna Cholewa
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain
| | - Jorge Sancho-Muriel
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain
| | | | | | - Blas Flor-Lorente
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain; Surgery Department. University of Valencia, Spain
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Cholewa H, Sancho-Muriel J, Flor-Lorente B. Double-Barreled Wet Colostomy After Pelvic Exenteration. Dis Colon Rectum 2024; 67:e13-e14. [PMID: 37656738 DOI: 10.1097/dcr.0000000000002757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Affiliation(s)
- Hanna Cholewa
- Colorectal Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Cerdán-Santacruz C, Cano-Valderrama Ó, Santos Rancaño R, Terés LB, Vigorita V, Pérez TP, Rosciano Paganelli JG, Paredes Cotoré JP, Carre MK, Flor-Lorente B, Antona FB, Martín EY, Tebar JC, Cao IA, Coltell ZB, Alonso MG, Paredes Cotoré JP, Prada López BL, Riesco AB, Cánovas NI, Sánchez CM, Serrat DR, Conde GA, Toscano MJ, Aira AC, Pérez MR, Petit NM, Espín Basany E, Carré MK, Pellino G, Retuerta JM, Saldaña AG, Laso CÁ, Allende IA, Álvarez DH, Cazador AC, Sánchez Bautista WM, Torres Sánchez MT, Bonito AC, Velázquez MC, Díaz OM, Fuentes NS, Olías MDCDLV, Pérez TP, Rosciano Paganelli JG, Lorente BF, Valderrama ÓC, Santos Rancaño R, Terés LB, Santacruz CC. "Long-term oncologic outcomes and risk factors for distant recurrence after pathologic complete response following neoadjuvant treatment for locally advanced rectal cancer. A nationwide, multicentre study". Eur J Surg Oncol 2023; 49:106962. [PMID: 37414628 DOI: 10.1016/j.ejso.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 04/09/2023] [Accepted: 06/15/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Pathologic complete response (pCR) after multimodal treatment for locally advanced rectal cancer (LARC) is used as surrogate marker of success as it is assumed to correlate with improved oncologic outcome. However, long-term oncologic data are scarce. METHODS This retrospective, multicentre study updated the oncologic follow-up of prospectively collected data from the Spanish Rectal Cancer Project database. pCR was described as no evidence of tumour cells in the specimen. Endpoints were distant metastases-free survival (DMFS) and overall survival (OS). Multivariate regression analyses were run to identify factors associated with survival. RESULTS Overall, 32 different hospitals were involved, providing data on 815 patients with pCR. At a median follow-up of 73.4 (IQR 57.7-99.5) months, distant metastases occurred in 6.4% of patients. Abdominoperineal excision (APE) (HR 2.2, 95%CI 1.2-4.1, p = 0.008) and elevated CEA levels (HR = 1.9, 95% CI 1.0-3.7, p = 0.049) were independent risk factors for distant recurrence. Age (years) (HR 1.1; 95%-CI 1.05-41.09; p < 0.001) and ASA III-IV (HR = 2.0; 95%-CI 1.4-2.9; p < 0.001), were the only factors associated with OS. The estimated 12, 36 and 60-months DMFS rates were 96.9%, 91.3%, and 86.8%. The estimated 12, 36 and 60-months OS rates were 99.1%, 94.9% and 89.3%. CONCLUSIONS The incidence of metachronous distant metastases is low after pCR, with high rates of both DMFS and OS. The oncologic prognosis in LARC patients that achieve pCR after neoadjuvant chemo-radiotherapy is excellent in the long term.
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Affiliation(s)
| | | | | | - Lara Blanco Terés
- Colorectal Surgery Department, Hospital de la Princesa, Madrid, Spain
| | - Vicenzo Vigorita
- Colorectal Surgery Department, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | | | | | - Jesús Pedro Paredes Cotoré
- Colorectal Surgery Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, La Coruña, Spain
| | | | - Blas Flor-Lorente
- Colorectal Surgery Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | | | | | | | - Inés Aldrey Cao
- Complejo Hospitalario Universitario de Ourense, Orense, Spain
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5
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Flor-Lorente B, Noguera-Aguilar JF, Delgado-Rivilla S, García-González JM, Rodriguez-Martín M, Salinas-Ortega L, Casado MÁ, Álvarez M. The economic impact of anastomotic leak after colorectal cancer surgery. Health Econ Rev 2023; 13:12. [PMID: 36795234 PMCID: PMC9933261 DOI: 10.1186/s13561-023-00425-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 02/08/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To determine the economic impact of the incremental consumption of resources for the diagnosis and treatment of anastomotic leak (AL) in patients after resection with anastomosis for colorectal cancer compared to patients without AL on the Spanish health system. METHOD This study included a literature review with parameters validated by experts and the development of a cost analysis model to estimate the incremental resource consumption of patients with AL versus those without. The patients were divided into three groups: 1) colon cancer (CC) with resection, anastomosis and AL; 2) rectal cancer (RC) with resection, anastomosis without protective stoma and AL; and 3) RC with resection, anastomosis with protective stoma and AL. RESULTS The average total incremental cost per patient was €38,819 and €32,599 for CC and RC, respectively. The cost of AL diagnosis per patient was €1018 (CC) and €1030 (RC). The cost of AL treatment per patient in Group 1 ranged from €13,753 (type B) to €44,985 (type C + stoma), that in Group 2 ranged from €7348 (type A) to €44,398 (type C + stoma), and that in Group 3 ranged from €6197 (type A) to €34,414 (type C). Hospital stays represented the highest cost for all groups. In RC, protective stoma was found to minimize the economic consequences of AL. CONCLUSIONS The appearance of AL generates a considerable increase in the consumption of health resources, mainly due to an increase in hospital stays. The more complex the AL, the higher the cost associated with its treatment. INTEREST OF THE STUDY: it is the first cost-analysis study of AL after CR surgery based on prospective, observational and multicenter studies, with a clear, accepted and uniform definition of AL and estimated over a period of 30 days.
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Affiliation(s)
- Blas Flor-Lorente
- Colorectal Surgery Unit. Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | | | | | | | | | - María Álvarez
- Health Economics & Outcomes Research Unit (Medtronic Ibérica, S.A.), Madrid, Spain.
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6
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Sancho-Muriel J, Giner F, Cholewa H, Garcia-Granero Á, Roselló S, Flor-Lorente B, Cervantes A, Garcia-Granero E, Frasson M. The percentage of mesorectal infiltration as a prognostic factor after curative surgery for pT3 rectal cancer. Colorectal Dis 2023. [PMID: 36790134 DOI: 10.1111/codi.16522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/16/2023]
Abstract
AIM The aim of this study is to evaluate the prognostic value of a novel variable - the percentage of mesorectal infiltration (PMI) - in pT3 rectal cancer. METHOD A cohort of 241 patients with pT3 rectal adenocarcinoma, operated on between February 2002 and May 2019, was selected for the analysis. Data concerning patient, treatment and tumour characteristics were collected. The depth of mesorectal infiltration (DMI) and the distance between the deepest invasion and the circumferential resection margin (CRM) were measured. The PMI was calculated using a formula combining these parameters. RESULTS Neoadjuvant therapy was administered in 33.2% of cases. A complete mesorectal excision was achieved in 74% of patients. The CRM was affected in 24 patients (9.9%). The 5-year actuarial local recurrence (LR), overall recurrence (OR) and overall survival (OS) rates were 7.5%, 22.9% and 72.4%, respectively. The PMI was significantly associated with worse oncological outcomes regarding LR (p = 0.009), OR (p = 0.001) and OS (p = 0.016) rates. A cut-off value of PMI >60% had the highest specificity (80%) for LR (p = 0.026), OR (p = 0.04) and OS (p = 0.07). CONCLUSION The PMI has an adverse prognostic impact on the oncological results following surgery for pT3 rectal cancer. It allows prediction of the risk of both LR and distant recurrence with higher accuracy than the DMI or the distance to the CRM. A PMI >60% may be used as a cut off value while subclassifying pT3 rectal tumours. It may influence decision-making while establishing adjuvant treatment and the follow-up schedule.
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Affiliation(s)
| | - Francisco Giner
- University of Valencia, Valencia, Spain.,Department of Pathology, University Hospital La Fe, Valencia, Spain
| | - Hanna Cholewa
- Colorectal Unit, University Hospital La Fe, Valencia, Spain
| | | | - Susana Roselló
- Department of Medical Oncology, Biomedical Research Institute Incliva, University of Valencia, Valencia, Spain
| | - Blas Flor-Lorente
- Colorectal Unit, University Hospital La Fe, Valencia, Spain.,University of Valencia, Valencia, Spain
| | - Andres Cervantes
- University of Valencia, Valencia, Spain.,Department of Medical Oncology, Biomedical Research Institute Incliva, University of Valencia, Valencia, Spain
| | - Eduardo Garcia-Granero
- Colorectal Unit, University Hospital La Fe, Valencia, Spain.,University of Valencia, Valencia, Spain
| | - Matteo Frasson
- Colorectal Unit, University Hospital La Fe, Valencia, Spain.,University of Valencia, Valencia, Spain
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Arencibia-Pérez B, Giner-Segura F, Frasson M, Roselló-Keränen S, Flor-Lorente B, Cervantes-Ruipérez A, García-Granero Ximénez E. Infiltration depth into the mesenteric fat in pT3 colon cancer as a prognostic factor for recurrence and survival. European Journal of Surgical Oncology 2023. [DOI: 10.1016/j.ejso.2022.11.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Martín-Martín GP, Chand M, Flor-Lorente B. Linfadenectomía guiada por fluorescencia en el cáncer de colon. ¿La herramienta llamada a ajustar la radicalidad de la cirugía? Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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9
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Martín-Martín GP, Chand M, Flor-Lorente B. Fluorescence-guided lymphadenectomy in colon cancer. The tool called to adjust the radicality of surgery? Cirugía Española (English Edition) 2022; 101:235-237. [PMID: 35777625 DOI: 10.1016/j.cireng.2022.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/04/2022] [Indexed: 11/27/2022]
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10
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Flor-Lorente B, Rosciano JG, Pérez-Pérez T, Sancho-Muriel J, García-Granero Á, Nohales-Alfonso FJ, Primo-Romaguera V, Simón-Sanz EA. Gender dysphoria: laparoscopic sigmoid vaginoplasty. Another utility of indocyanine green. Colorectal Dis 2021; 23:3272-3275. [PMID: 34653305 DOI: 10.1111/codi.15952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/30/2021] [Accepted: 09/24/2021] [Indexed: 12/24/2022]
Abstract
AIM Gender dysphoria is the disagreement between the gender of birth and the one with which the patient identifies. For its management it is mandatory to have a multidisciplinary team. Gender confirmation surgery with penoscrotal skin flap is the procedure of choice, and a sigmoid vaginoplasty is a feasible alternative. The new technologies and the help of indocyanine green (ICG) fluorescence can help to guarantee a correct neovagina vascularization. The objective of this paper is to present the surgical technique of laparoscopic sigmoid vaginoplasty assisted by ICG. METHODS We present two patients with gender dysphoria and a history of stricture of the penoscrotal skin flap vaginoplasty. We performed sigmoid vaginoplasty by the laparoscopic approach. We began the procedure with the mobilization and section of 30 cm of sigmoid colon, selective ligation of the vessels assisted by ICG, 180° sigmoid rotation, externalized on antiperistaltic position, construction of colovestibular anastomosis and promontory fixation. We finished the procedure with virtual ileostomy construction and drain placement. RESULTS Patients recovered satisfactorily and were discharged on the seventh day after surgery without complications. CONCLUSION Sigmoid vaginoplasty is a safe and feasible procedure. ICG has great value, contributing to the selective ligation of the vessels, allowing 180° sigmoid rotation and guaranteeing the irrigation of the neovagina.
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Affiliation(s)
- Blas Flor-Lorente
- Colorectal Surgery Unit, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | | | - Teresa Pérez-Pérez
- General Surgery Unit, Hospital Lluis Alcanyis de Xativa, Valencia, Spain
| | - Jorge Sancho-Muriel
- Colorectal Surgery Unit, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Álvaro García-Granero
- Colorectal Surgery Unit, Hospital Universitario Son Espases, Palma de Mallorca, Spain
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11
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Sánchez-Guillén L, Frasson M, Pellino G, Fornés-Ferrer V, Ramos JL, Flor-Lorente B, García-Granero Á, Sierra IB, Jiménez-Gómez LM, Moya-Martínez A, García-Granero E. Nomograms for morbidity and mortality after oncologic colon resection in the enhanced recovery era: results from a multicentric prospective national study. Int J Colorectal Dis 2020; 35:2227-2238. [PMID: 32734415 DOI: 10.1007/s00384-020-03692-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Predicting postoperative complications and mortality is important to plan the surgical strategy. Different scores have been proposed before to predict them but none of them have been yet implemented into the routine clinical practice because their difficulties and low accuracy with new surgical strategies and enhanced recovery. The main aim of this study is to identify risk factors for postoperative morbidity and mortality after colonic resection (CR) without protective stomas, in order to develop a comprehensive, up-to-date, simple, reliable, and applicable model for the preoperative assessment of patients with colon cancer. METHODS Multivariable analysis was performed to identify risk factors for 60-day morbidity and mortality. Coefficients derived from the regression model were used in the nomograms to predict morbidity and mortality. RESULTS Three thousand one hundred ninety-three patients from 52 hospitals were included into the analysis. Sixty-day postoperative complications rate was 28.3% and the mortality rate was 3%. In multivariable analysis the independent risk factors for postoperative complications were age, male gender, liver and pulmonary diseases, obesity, preoperative albumin, anticoagulant treatment, open surgery, intraoperative complications, and urgent surgery. Independent risk factors for mortality were age, preoperative albumin anticoagulant treatment, and intraoperative complications. CONCLUSIONS Risk factors for morbidity and mortality after CR for cancer were identified and two easy predictive tools were developed. Both of them could provide important information for preoperative consultation and surgical planning in the time of enhance recovery.
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Affiliation(s)
- Luis Sánchez-Guillén
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - Matteo Frasson
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain.
| | - Gianluca Pellino
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | | | - José Luis Ramos
- Department of General Surgery, Hospital Universitario de Getafe, Getafe, Spain
| | - Blas Flor-Lorente
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - Álvaro García-Granero
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | | | | | | | - Eduardo García-Granero
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
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Garcia-Granero A, Pellino G, Giner F, Frasson M, Fletcher-Sanfeliu D, Romaguera VP, Flor-Lorente B, Gamundi M, Brogi L, Garcia-Calderón D, Gonzalez-Argente FX, Garcia-Granero E. A mathematical 3D-method applied to MRI to evaluate prostatic infiltration in advanced rectal cancer. Tech Coloproctol 2020; 24:605-607. [PMID: 32107687 DOI: 10.1007/s10151-020-02170-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/07/2020] [Indexed: 12/30/2022]
Affiliation(s)
- A Garcia-Granero
- Colorectal Surgery Unit, Hospital Universitario Son Espases, Mallorca, Spain
| | - G Pellino
- Colorectal Surgery Unit, Hospital Vall D'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Naples, Italy.
| | - F Giner
- Department of Pathology Hospital, Universitario y Politéctico la Fe, Valencia, Spain
| | - M Frasson
- Colorectal Surgery Unit, Hospital Universitario y Politéctico la Fe, Valencia, Spain
| | - D Fletcher-Sanfeliu
- Cardiovascular Surgery Department, Hospital, Universitario Son Espases, Mallorca, Spain
| | - V P Romaguera
- Colorectal Surgery Unit, Hospital Universitario y Politéctico la Fe, Valencia, Spain
| | - B Flor-Lorente
- Colorectal Surgery Unit, Hospital Universitario y Politéctico la Fe, Valencia, Spain
| | - M Gamundi
- Colorectal Surgery Unit, Hospital Universitario Son Espases, Mallorca, Spain
| | - L Brogi
- 3D-Reconstruction Unit and Simulation Center, Hospital Universitario Son Espases, Mallorca, Spain
| | | | | | - E Garcia-Granero
- Colorectal Surgery Unit, Hospital Universitario y Politéctico la Fe, Valencia, Spain
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13
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Garcia-Granero A, Primo Romaguera V, Millan M, Pellino G, Fletcher-Sanfeliu D, Frasson M, Flor-Lorente B, Ibañez-Canovas N, Carreño Saenz O, Sánchez-Guillén L, Sancho-Muriel J, Alvarez-Sarrado E, Valverde-Navarro AA. A video guide of five access methods to the splenic flexure: the concept of the splenic flexure box. Surg Endosc 2020; 34:2763-2772. [PMID: 32086618 DOI: 10.1007/s00464-020-07423-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/10/2020] [Indexed: 01/21/2023]
Abstract
AIM The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to show SFM approaches in an easy and practical way to make it easy to learn and teach. METHODS Two different phases. First part: Cadaver-based study of the colonic splenic flexure anatomy. In order to demonstrate the different approaches, a balloon was placed through the colonic hepatic flexure in the lesser sac without sectioning any of the fixing ligaments of the splenic flexure. Second part: A real case series of laparoscopic SFM. RESULTS First part: 11 cadavers were dissected. Five potential approaches to SFM were found: anterior, trans-omentum, lateral, medial infra-mesocolic, and medial trans-mesocolic. The illustrative system developed was named: Splenic Flexure "Box"(SFBox). Second part: One of the types of SFM described in first part was used in five patients with colorectal cancer. Each laparoscopic approach to the splenic flexure was illustrated in a video accompanied by illustration aids delineating the access. CONCLUSION With the cadaver dissection and subsequent demonstration in real-life laparoscopic surgery, we have shown five types of laparoscopic splenic flexure mobilization. The Splenic Flexure "Box" is a useful way to learn and teach this surgical maneuver.
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Affiliation(s)
| | - Vicent Primo Romaguera
- Hospital Universitari i Politècnic La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain.
| | - Monica Millan
- Hospital Universitari i Politècnic La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | | | | | - Matteo Frasson
- Hospital Universitari i Politècnic La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Blas Flor-Lorente
- Hospital Universitari i Politècnic La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | | | | | | | - Jorge Sancho-Muriel
- Hospital Universitari i Politècnic La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Eduardo Alvarez-Sarrado
- Hospital Universitari i Politècnic La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain
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14
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Sánchez-Guillén L, Frasson M, García-Granero Á, Pellino G, Flor-Lorente B, Álvarez-Sarrado E, García-Granero E. Risk factors for leak, complications and mortality after ileocolic anastomosis: comparison of two anastomotic techniques. Ann R Coll Surg Engl 2019; 101:571-578. [PMID: 31672036 PMCID: PMC6818057 DOI: 10.1308/rcsann.2019.0098] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION There are no definitive data concerning the ideal configuration of ileocolic anastomosis. Aim of this study was to identify perioperative risk factors for anastomotic leak and for 60-day morbidity and mortality after ileocolic anastomoses (stapled vs handsewn). MATERIALS AND METHODS This is a STROBE-compliant study. Demographic and surgical data were gathered from patients with an ileocolic anastomosis performed between November 2010 and September 2016 at a tertiary hospital. Anastomoses were performed using standardised techniques. Independent risk factors for anastomotic leak, complications and mortality were assessed. RESULTS We included 477 patients: 53.7% of the anastomoses were hand sewn and 46.3% stapled. Laterolateral anastomosis was the most common configuration (93.3%). Anastomotic leak was diagnosed in 8.8% of patients and 36 were classified as major anastomotic leak (7.5%). In the multivariate analysis, male sex (P = 0.014, odds ratio, OR, 2.9), arterial hypertension (P = 0.048, OR 2.29) and perioperative transfusions (P < 0.001, OR 2.4 per litre) were independent risk factors for major anastomotic leak. The overall 60-day complication rate was 27.3%. Male sex (31.3% vs female 22.3%, P = 0.02, OR 1.7), diabetes (P = 0.03 OR 2.0), smoking habit (P = 0.04, OR 1.8) and perioperative transfusions (P < 0.001, OR 3.3 per litre) were independent risk factors for postoperative morbidity. The 60-day-mortality rate was 3.1% and no significant risk factors were identified. CONCLUSION Anastomotic leak after ileocolic anastomosis is a relevant problem. Male sex, arterial hypertension and perioperative transfusions were associated with major anastomotic leak. Conversion to open surgery was more frequently associated with perioperative death.
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Affiliation(s)
| | - M Frasson
- Colorectal Surgery, University Hospital La Fe, Valencia, Spain
| | | | - G Pellino
- Colorectal Surgery, University Hospital La Fe, Valencia, Spain
| | - B Flor-Lorente
- Colorectal Surgery, University Hospital La Fe, Valencia, Spain
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Flor-Lorente B, Sánchez-Guillén L, Pellino G, Frasson M, García-Granero Á, Ponce M, Domingo S, Paya V, García-Granero E. “Virtual ileostomy” combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report. Langenbecks Arch Surg 2019; 404:375-383. [DOI: 10.1007/s00423-019-01776-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 03/08/2019] [Indexed: 12/11/2022]
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Pellino G, Frasson M, García-Granero A, Granero-Castro P, Ramos Rodríguez JL, Flor-Lorente B, Bargallo Berzosa J, Alonso Hernández N, Labrador Vallverdú FJ, Parra Baños PA, Ais Conde G, Garcia-Granero E. Predictors of complications and mortality following left colectomy with primary stapled anastomosis for cancer: results of a multicentric study with 1111 patients. Colorectal Dis 2018; 20:986-995. [PMID: 29920911 DOI: 10.1111/codi.14309] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 05/14/2018] [Indexed: 12/16/2022]
Abstract
AIM Reports detailing the morbidity-mortality after left colectomy are sparse and do not allow definitive conclusions to be drawn. We aimed to identify risk factors for anastomotic leakage, perioperative mortality and complications following left colectomy for colonic malignancies. METHOD We undertook a STROBE-compliant analysis of left colectomies included in a national prospective online database. Forty-two variables were analysed as potential independent risk factors for anastomotic leakage, postoperative morbidity and mortality. Variables were selected using the 'least absolute shrinkage and selection operator' (LASSO) method. RESULTS We analysed 1111 patients. Eight per cent of patients had a leakage and in 80% of them reoperation or surgical drainage was needed. A quarter of patients (24.9%) experienced at least one minor complication. Perioperative mortality was 2%, leakage being responsible for 47.6% of deaths. Obesity (OR 2.8, 95% CI 1.00-7.05, P = 0.04) and total parenteral nutrition (TPN) (OR 3.7, 95% CI 1.58-8.51, P = 0.002) were associated with increased risk of leakage, whereas female patients had a lower risk (OR 0.36, 95% CI 0.18-0.67, P = 0.002). Corticosteroids (P = 0.03) and oral anticoagulants (P = 0.01) doubled the risk of complications, which was lower with hyperlipidaemia (OR 0.3, P = 0.02). Patients on TPN had more complications (OR 4.02, 95% CI 2.03-8.07, P = 0.04) and higher mortality (OR 8.7, 95% CI 1.8-40.9, P = 0.006). Liver disease and advanced age impaired survival, corticosteroids being the strongest predictor of mortality (OR 21.5, P = 0.001). CONCLUSION Requirement for TPN was associated with more leaks, complications and mortality. Leakage was presumably responsible for almost half of deaths. Hyperlipidaemia and female gender were associated with lower rates of complications. These findings warrant a better understanding of metabolic status on perioperative outcome after left colectomy.
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Affiliation(s)
- G Pellino
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain.,Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, Università della Campania 'Luigi Vanvitelli', Naples, Italy
| | - M Frasson
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | - A García-Granero
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain.,Human Anatomy and Embryology Department, University of Valencia, Valencia, Spain
| | - P Granero-Castro
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | - B Flor-Lorente
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | | | | | | | | | - E Garcia-Granero
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
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Garcia-Granero A, Sánchez-Guillén L, Fletcher-Sanfeliu D, Flor-Lorente B, Frasson M, Sancho Muriel J, Alvarez Serrado E, Pellino G, Grifo Albalat I, Giner F, Roca Estelles MJ, Esclapez Valero P, Garcia-Granero E. Application of three-dimensional printing in laparoscopic dissection to facilitate D3-lymphadenectomy for right colon cancer. Tech Coloproctol 2018; 22:129-133. [PMID: 29353427 DOI: 10.1007/s10151-018-1746-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/20/2017] [Indexed: 12/30/2022]
Affiliation(s)
- A Garcia-Granero
- Colorectal Surgery Unit, Hospital Universitario y Politecnico La Fe, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain.
| | - L Sánchez-Guillén
- Colorectal Surgery Unit, Hospital Universitario y Politecnico La Fe, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - D Fletcher-Sanfeliu
- Cardiovascular Surgery Department, University Hospital Son Espases, Palma de Mallorca, Spain
| | - B Flor-Lorente
- Colorectal Surgery Unit, Hospital Universitario y Politecnico La Fe, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - M Frasson
- Colorectal Surgery Unit, Hospital Universitario y Politecnico La Fe, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - J Sancho Muriel
- Colorectal Surgery Unit, Hospital Universitario y Politecnico La Fe, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - E Alvarez Serrado
- Colorectal Surgery Unit, Hospital Universitario y Politecnico La Fe, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - G Pellino
- Colorectal Surgery Unit, Hospital Universitario y Politecnico La Fe, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - I Grifo Albalat
- Colorectal Surgery Unit, Hospital Universitario y Politecnico La Fe, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - F Giner
- Department of Pathology, University Hospital La Fe, Valencia, Spain
| | | | - P Esclapez Valero
- Colorectal Surgery Unit, Hospital Universitario y Politecnico La Fe, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - E Garcia-Granero
- Colorectal Surgery Unit, Hospital Universitario y Politecnico La Fe, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
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García-Granero E, Navarro F, Cerdán Santacruz C, Frasson M, García-Granero A, Marinello F, Flor-Lorente B, Espí A. Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: An institutional analysis of 800 patients. Surgery 2017; 162:1006-1016. [PMID: 28739093 DOI: 10.1016/j.surg.2017.05.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 05/14/2017] [Accepted: 05/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Our aim was to assess whether the individual surgeon is an independent risk factor for anastomotic leak in double-stapled colorectal anastomosis after left colon and rectal cancer resection. METHODS This retrospective analysis of a prospectively collected database consists of a consecutive series of 800 patients who underwent an elective left colon and rectal resection with a colorectal, double-stapled anastomosis between 1993 and 2009 in a specialized colorectal unit of a tertiary hospital with 7 participating surgeons. The main outcome variable was anastomotic leak, defined as leak of luminal contents from a colorectal anastomosis between 2 hollow viscera diagnosed radiologically, clinically, endoscopically, or intraoperatively. Pelvic abscesses were also considered to be an anastomotic leak. Radiologic examination was performed when there was clinical suspicion of leak. RESULTS Anastomotic leak occurred in 6.1% of patients, of which 33 (67%) were treated operatively, 6 (12%) with radiologic drains, and 10 (21%) by medical treatment. Postoperative mortality rate was 2.9% for the whole group of 800 patients. In patients with anastomotic leak, mortality rate increased up to 16% vs 2.0% in patients without anastomotic leak (P < .0001). At multivariate analysis, rectal location of tumor, male sex, bowel obstruction preoperatively, tobacco use, diabetes, perioperative transfusion, and the individual surgeon were independent risk factors for anastomotic leak. The surgeon was the most important factor (mean odds ratio 4.9; range 1.0 to 13.5). The variance of anastomotic leak between the different surgeons was 0.56 in the logit scale. CONCLUSION The individual surgeon is an independent risk factor for leakage in double-stapled, colorectal, end-to-end anastomosis after oncologic left-sided colorectal resection.
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Affiliation(s)
- Eduardo García-Granero
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Francisco Navarro
- Department of General Surgery, Colorectal Surgery Unit. Hospital de Manises, Manises, Valencia, Spain
| | - Carlos Cerdán Santacruz
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain.
| | - Matteo Frasson
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Alvaro García-Granero
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Franco Marinello
- Department of General Surgery, Colorectal Surgery Unit, Hospital Vall D´Hebrón, Barcelona, Spain
| | - Blas Flor-Lorente
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Alejandro Espí
- Department of General Surgery, Hospital Clínico Universitario, Valencia, Spain
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Cerdán Santacruz C, Frasson M, Flor-Lorente B, Ramos Rodríguez JL, Trallero Anoro M, Millán Scheiding M, Maseda Díaz O, Dujovne Lindenbaum P, Monzón Abad A, García-Granero Ximenez E. Laparoscopy may decrease morbidity and length of stay after elective colon cancer resection, especially in frail patients: results from an observational real-life study. Surg Endosc 2017; 31:5032-5042. [PMID: 28455773 DOI: 10.1007/s00464-017-5548-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advantages of laparoscopic approach in colon cancer surgery have been previously demonstrated in controlled, randomized trials and in retrospective analysis of large administrative databases. Nevertheless, evidence of these advantages in prospective, observational studies from real-life settings is scarce. METHODS This is a prospective, observational study, including a consecutive series of patients that underwent elective colonic resection for cancer in 52 Spanish hospitals. Pre-/intraoperative data, related to patient, tumor, surgical procedure, and hospital, were recorded as well as 60-day post-operative outcomes, including wound infection, complications, anastomotic leak, length of stay, and mortality. A univariate and multivariate analysis was performed to determine the influence of laparoscopy on short-term post-operative outcome. A sub-analysis of the effect of laparoscopy according to patients' pre-operative risk (ASA Score I-II vs. III-IV) was also performed. RESULTS 2968 patients were included: 44.2% were initially operated by laparoscopy, with a 13.9% conversion rate to laparotomy. At univariate analysis, laparoscopy was associated with a decreased mortality (p = 0.015), morbidity (p < 0.0001), wound infection (p < 0.0001), and post-operative length of stay (p < 0.0001). At multivariate analysis, laparoscopy resulted as an independent protective factor for morbidity (OR 0.7; p = 0.004), wound infection (OR 0.6; p < 0.0001), and length of post-operative stay (Effect-2 days; p < 0.0001), compared to open approach. These advantages were more relevant in high-risk patients (ASA III-IV), even if the majority of them were operated by open approach (67.1%). CONCLUSIONS In a real-life setting, laparoscopy decreases wound infection rate, post-operative complications, and length of stay, especially in ASA III-IV patients.
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Affiliation(s)
- Carlos Cerdán Santacruz
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain.
| | - Matteo Frasson
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | - Blas Flor-Lorente
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | - Marta Trallero Anoro
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | | | | | | | - Eduardo García-Granero Ximenez
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
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Sancho-Muriel J, Frasson M, Hervás D, Flor-Lorente B, Ramos Rodriguez JL, Romero Simó M, Escoll Rufino J, Santamaría Olabarrieta M, Viñas Martinez J, López Bañeres M, García-Granero E. Resultados quirúrgicos estándar tras resección oncológica de colon. Creación de un nomograma para la autoevaluación. Cir Esp 2017; 95:30-37. [DOI: 10.1016/j.ciresp.2016.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 11/15/2022]
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Marinello FG, Baguena G, Lucas E, Frasson M, Hervás D, Flor-Lorente B, Esclapez P, Espí A, García-Granero E. Anastomotic leakage after colon cancer resection: does the individual surgeon matter? Colorectal Dis 2016; 18:562-9. [PMID: 26558741 DOI: 10.1111/codi.13212] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 08/01/2015] [Indexed: 12/13/2022]
Abstract
AIM Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery. METHOD This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour characteristics, surgical procedure and operating surgeons were analysed. A logistic regression model was used to discriminate statistical variation and identify risk factors for anastomotic leakage. RESULTS A total of 1045 patients underwent elective colon cancer resection with primary anastomosis. Anastomotic leakage occurred in 6.4% of patients. Ileocolic anastomosis had an anastomotic leakage rate of 7.2%, colo-colonic/colorectal anastomosis 5.2% and ileorectal anastomosis 12.7%, with intersurgeon variability. The independent risk factors associated with anastomotic leakage were the use of perioperative blood transfusion (OR 2.83, CI 1.59-5.06, P < 0.0001) and the individual surgeon performing the procedure (OR up to 8.44, P < 0.0001). CONCLUSION In addition to perioperative blood transfusion, the individual surgeon was identified as an important risk factor for anastomotic leakage. Efforts should be made to reduce performance variability amongst surgeons.
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Affiliation(s)
- F G Marinello
- Department of Surgery, University of Valencia, Valencia, Spain
| | - G Baguena
- Department of Surgery, University of Valencia, Valencia, Spain
| | - E Lucas
- Department of Surgery, University of Valencia, Valencia, Spain
| | - M Frasson
- Department of Surgery, University of Valencia, Valencia, Spain
| | - D Hervás
- Department of Biostatistics, IIS La Fe, Valencia, Spain
| | - B Flor-Lorente
- Department of Surgery, University of Valencia, Valencia, Spain
| | - P Esclapez
- Department of Surgery, University of Valencia, Valencia, Spain
| | - A Espí
- Department of Surgery, University of Valencia, Valencia, Spain
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Garcia-Granero A, Granero-Castro P, Frasson M, Flor-Lorente B, Carreño O, Espí A, Puchades I, Garcia-Granero E. Management of cryptoglandular supralevator abscesses in the magnetic resonance imaging era: a case series. Int J Colorectal Dis 2014; 29:1557-64. [PMID: 25339133 DOI: 10.1007/s00384-014-2028-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2014] [Indexed: 02/04/2023]
Abstract
AIM The aim of this study is to describe the diagnostic performance of magnetic resonance imaging in the management of supralevator abscess, regarding its origin, location, drainage route, subsequent treatment of the fistula, and long-term results. METHODS A retrospective case series including thirteen consecutive patients with cryptoglandular supralevator abscess treated between 2001 and 2011 at a colorectal unit of a tertiary referral center. A magnetic resonance imaging was performed in all patients before surgical drainage, and its usefulness in assessing supralevator abscess origin was analyzed. Short- and long-term results after drainage were also evaluated. RESULTS The final diagnosis of supralevator abscess and the location described in the magnetic resonance were confirmed intraoperatively in all patients. An ischiorectal origin was identified in nine patients, and perineal translevator drainage was performed placing a mushroom catheter through the ischiorectal or the postanal space. Four patients underwent secondary treatment of anal fistula: two rectal advancement flap and two non-cutting seton. In the other four patients, an intersphincteric origin was identified and transanal surgical drainage was performed placing a long-term mushroom catheter. Several weeks later, transanal unroofing of the residual cavity was performed and the fistula lay open to the anorectal lumen. In the long-term follow-up (median 61 months), only patients with supralevator abscess of ischiorectal origin in whom fistula was not subsequently treated presented a recurrence of the anal sepsis. CONCLUSIONS Magnetic resonance imaging seems essential to clarify the location of supralevator abscess, its origin, and choice of the right drainage route. Subsequent treatment of the fistula is necessary to avoid recurrence.
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Affiliation(s)
- Alvaro Garcia-Granero
- Department of General Surgery, Hospital Arnau de Vilanova, University of Valencia, C/Pizarro 5, 46004, Valencia, Spain,
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García-Granero A, Granero-Castro P, Frasson M, Flor-Lorente B, Carreño O, Garcia-Granero E. The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin. Colorectal Dis 2014; 16:O335-8. [PMID: 24853735 DOI: 10.1111/codi.12670] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 04/23/2014] [Indexed: 12/13/2022]
Abstract
AIM This technical note describes the use of an endostapler for the definitive treatment of supralevator abscess upward from an intersphincteric origin. METHOD A two-stage treatment was performed. First an endoanal drainage was performed by inserting a mushroom catheter in the supralevator abscess cavity. In the second stage transanal unroofing of the fistula was performed with an endostapler. RESULTS Since 2011, three patients have been treated in this way. After 2 years of follow up, none of the patients had recurrence of the abscess or been referred for anal incontinence. CONCLUSION The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin may be an alternative to decrease the risk of recurrence and incontinence.
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Affiliation(s)
- A García-Granero
- Department of General Surgery, Hospital Arnau de Vilanova, Valencia, Spain
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Navarro-Vicente F, García-Granero A, Frasson M, Blanco F, Flor-Lorente B, García-Botello S, García-Granero E. Prospective evaluation of intraoperative peripheral nerve injury in colorectal surgery. Colorectal Dis 2012; 14:382-5. [PMID: 21689319 DOI: 10.1111/j.1463-1318.2011.02630.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
AIM Intraoperative peripheral nerve injury can have permanent neurological consequences. Its incidence is not known and varies according to the location and the surgical specialty. This study was a prospective analysis of intraoperative peripheral nerve injury as a complication of abdominal colorectal surgery. METHOD All patients who underwent major colorectal abdominal surgery in our Colorectal Unit between 1996 and 2009 were analyzed. Data on nerve injury were prospectively collected. RESULTS There were 2304 patients, of whom eight (0.3%) experienced intraoperative peripheral nerve injury. This occurred in 5/2211 (0.2%) open procedures and in 3/93 (3%) laparoscopic procedures. There was no association between intraoperative peripheral nerve injury and age, gender, body mass index, surgeon, operation time, American Society of Anesthesiology (ASA) score and urgent surgery. The use of Allen-type stirrups and a vacuum bag (in laparoscopic surgery) seemed to be protective for nerve injury in the lower and upper limbs respectively. CONCLUSION Adequate positioning and the use of pressure-free positioning devices may prevent intraoperative peripheral nerve injury, particularly during laparoscopy.
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Affiliation(s)
- F Navarro-Vicente
- Coloproctology Unit, Department of General Surgery, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
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Frasson M, Garcia-Granero E, Roda D, Flor-Lorente B, Roselló S, Esclapez P, Faus C, Navarro S, Campos S, Cervantes A. Preoperative chemoradiation may not always be needed for patients with T3 and T2N+ rectal cancer. Cancer 2011; 117:3118-3125. [DOI: 10.1002/cncr.25866] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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García-Granero E, Faiz O, Flor-Lorente B, García-Botello S, Esclápez P, Cervantes A. Prognostic implications of circumferential location of distal rectal cancer. Colorectal Dis 2011; 13:650-7. [PMID: 20236143 DOI: 10.1111/j.1463-1318.2010.02249.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM This study evaluated the prognostic importance of circumferential tumour position of mid and low rectal cancers. METHOD All uT2, uT3 and uT4 tumours of the middle and lower rectum that underwent total mesorectal excision (TME) with curative intent between 1996 and 2006 were included. The predominant circumferential tumour position (anterior, posterior or circumferential) was defined on preoperative endorectal ultrasound examination (ERUS). The relationships between tumour position and other characteristics and recurrence were explored. RESULTS Two hundred and five patients with distal rectal cancer were operated on for a uT2-T4 tumour. Median follow up was 49 months. The location of the tumour was predominantly anterior, posterior or circumferential in 128, 49 and 27 patients, respectively. Anterior tumours were more likely to receive neoadjuvant therapy (P = 0.016) and perioperative blood transfusion (P = 0.012). No significant differences were observed between circumferential position and pT or pN stage, circumferential resection margin involvement or mesorectal excision quality. Sixty-three (30.7%) patients developed recurrence, which was local only in 16 (7.8%). Although tumours involving 360° of the rectal wall had a higher risk of local recurrence (P = 0.048), those with a predominant anterior or posterior position were not related to a higher risk of local or overall recurrence. CONCLUSION Anterior rectal tumours do not differ in pathological characteristics from posterior tumours, and their prognosis is no worse when circumferential resection is complete.
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Affiliation(s)
- E García-Granero
- Department of General Surgery, Coloproctology Unit, Hospital Clínico Universitario, University of Valencia, Valencia, Spain.
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Faus C, Roda D, Frasson M, Roselló S, García-Granero E, Flor-Lorente B, Navarro S. The role of the pathologist in rectal cancer diagnosis and staging and surgical quality assessment. Clin Transl Oncol 2010; 12:339-45. [PMID: 20466618 DOI: 10.1007/s12094-010-0515-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Since the introduction of the total mesorectal excision by Heald, many changes in the therapeutic management of rectal cancer have been incorporated. The multidisciplinary approach to colorectal cancer, integrated in a team of different specialists, ensures individualised treatment for each patient with rectal cancer. Therefore the role of the pathologist has acquired an important relevance, not only in diagnosing but also managing and evaluating the surgical specimen. The knowledge of preoperative staging, distance between tumour and anal verge or in patients subjected to a neoadjuvant treatment is necessary for the pathologist to make a detailed, accurate and good-quality report. Parameters such as the macroscopic quality of the mesorectum, the status of the circumferential resection margin and the lymph node harvest are considered basic criteria recommended by the current guidelines for the multidisciplinary team audit.
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Affiliation(s)
- Carmen Faus
- Department of Pathology, Hospital Clínico Universitario, University of Valencia. INCLIVA, Valencia, Spain.
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Abstract
OBJECTIVE Intersphincteric abscesses are relatively rare, and in some cases of upward extensions in the supralevator plane, can be difficult to manage. The aim of this study was to analyse the type of treatment used in these abscesses. METHODS Twenty-one intersphincteric abscesses treated by endoanal drainage in our colorectal unit between 1992 and 2004 were reviewed from our database; location and extension of the abscess, type of treatment and recurrence rates and the use of endoanal ultrasound were studied. RESULTS Ninety per cent of patients were male; 10 had a previous history of surgery for perianal abscess and suppuration (48%); 16 (76%) had a posterior location and five were anterolateral. Twelve patients had low intersphincteric abscesses and were treated by laying open the abscess and dividing the internal sphincter. Nine were found to have high extensions into the intermuscular planes and were treated by staged procedures: a temporary transanal mushroom catheter was used in seven patients. Endoanal ultrasound was used initially in seven patients (33.3%) and for the evaluation of definitive treatment in 11 (52%). CONCLUSIONS Low intersphincteric abscesses should be treated by de-roofing of the abscess and division of the internal sphincter up to a level of the dentate line. High intersphincteric abscesses are relatively frequent and mostly require staged surgery with a temporary mushroom (de Pezzer) catheter. Accurate anatomical ultrasound localization and proper drainage become important to avoid recurrences or extrasphincteric fistulas.
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Affiliation(s)
- M Millan
- Colorectal Surgery Unit, Department of Surgery, Clinic University Hospital, University of Valencia, Valencia, Spain.
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Martínez-García F, Mayordomo-Aranda E, Flor-Lorente B, García-Fuster MJ. [Hypogammaglobulinemia secundary to actinic enteritis]. Med Clin (Barc) 2006; 127:518. [PMID: 17043010 DOI: 10.1157/13093278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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García-Fuster MJ, Forner MJ, Flor-Lorente B, Soler J, Campos S. [Inferior vena cava malformations and deep venous thrombosis]. Rev Esp Cardiol 2006; 59:171-5. [PMID: 16540040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
We carried out a prospective study of 116 patients under 50 years of age who had deep venous thrombosis of the lower extremities to determine whether the presence of congenital anomaly of the inferior vena cava (IVC) was a risk factor for the disease. All patients were investigated by Doppler echography. Some 37 patients who had iliac vein occlusion also underwent phlebography. In 10 patients in whom the IVC was difficult to image, magnetic resonance angiography or computerized axial tomography was carried out. In all patients, studies of antithrombin, protein C and protein S deficiency, factor V Leiden, prothrombin G20210A, antiphospholipid antibodies, and acquired risk factors were also performed. Of the 37 patients who had iliac vein occlusion, six had an IVC anomaly. Two of these patients had antiphospholipid antibodies, while another had prothrombin G20210A. Two patients with an anomaly had recurrent thrombotic occlusion. In conclusion, congenital IVC anomalies were present in 16.2% (95% confidence interval, 6.2-32%) of young patients with iliac thrombosis.
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Affiliation(s)
- María J García-Fuster
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valencia, Valencia, España.
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García-Botello S, Calvete-Chornet J, Sabater-Ortí L, Flor-Lorente B, Cassinello-Fernández N, March-Villalba JA, Lledó-Matoses S. [A single gallbladder calculus occupying the entire gallbladder]. Cir Esp 2006; 78:202. [PMID: 16420824 DOI: 10.1016/s0009-739x(05)70917-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sabater-Ortí L, Antonio March-Villalba J, Flor-Lorente B, Calvete-Chornet J, Camps-Vilata B, García-Granero E, Lledó-Matoses S. La imagen del mes. Cir Esp 2004. [DOI: 10.1016/s0009-739x(04)72300-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Garcia-Granero E, Garcia SA, Alos R, Calvete J, Flor-Lorente B, Willatt J, Lledo S. Use of photoplethysmography to determine gastrointestinal perfusion pressure: an experimental canine model. Dig Surg 2003; 20:222-8. [PMID: 12759502 DOI: 10.1159/000070389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2002] [Accepted: 11/05/2002] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To develop an experimental model to assess the parietal perfusion pressure (PPP) of the digestive tract using photoplethysmography. MATERIALS AND METHODS Twenty-two mongrel dogs were used. Progressive external compression was applied to the intestinal wall and the PPP was assessed with photoplethysmography. The study group was divided into two groups. In group 1 PPP was measured at the levels of the stomach, duodenum, jejunum and transverse colon. In group 2 PPP was measured after temporary occlusion of the truncal and marginal circulation of the jejunum to provide further variables. RESULTS The PPP decreased significantly for each successive distal section. Correlation coefficients and indices for PPP and mean arterial pressures were statistically significant (p < 0.005). Truncal occlusion provoked a drop in PPP whereas marginal occlusion scarcely modified the basal results. CONCLUSIONS Photoplethysmography, through measurements of the residual arterial wave amplitude, is a valid method of determining quantitatively the PPP of the digestive tract and could be useful in a clinical environment.
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Affiliation(s)
- E Garcia-Granero
- Department of General Surgery and Coloproctology Unit, Hospital Clínico Universitario, University of Valencia, Valencia, Spain.
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del Olmo JA, Flor-Lorente B, Flor-Civera B, Rodriguez F, Serra MA, Escudero A, Lledó S, Rodrigo JM. Risk factors for nonhepatic surgery in patients with cirrhosis. World J Surg 2003; 27:647-52. [PMID: 12732995 DOI: 10.1007/s00268-003-6794-1] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cirrhosis of the liver appears to have an unfavorable prognosis in the surgical patient. The aim of this study was to determine risk factors for morbidity and mortality in patients with cirrhosis undergoing nonhepatic surgery. We studied 135 patients with liver cirrhosis undergoing nonhepatic procedures and 86 controls matched by age, sex, and preoperative diagnosis. Preoperative, intraoperative, and postoperative variables associated with 30-day mortality and morbidity were assessed by univariate and multivariate analyses. Patients with cirrhosis showed higher blood transfusion requirements, longer length of hospital stay, and a higher number of complications than controls. The mortality rate was 16.3% in cirrhotics and 3.5% in controls. By univariate analysis, the need for transfusions, prothrombin time, and Child-Pugh score were significantly associated with postoperative liver decompensation, whereas duration of surgery, prothrombin time, Child-Pugh score, cirrhosis-related complications, and general complications were significantly associated with mortality. In the multivariate analysis, Child-Pugh score (odds ratio [OR] 24.4; 95% confidence interval [CI] 5.5 to 106); duration of surgery (OR 5; 95% CI 1.2 to 15.6), and postoperative general complications (OR 3.7; 95% CI 3.4 to 6.4) were independent predictors of mortality. Patients with cirrhosis undergoing nonhepatic operations are at significant risk of perioperative complications leading to death. Independent variables associated with perioperative mortality include preoperative Child-Pugh score, the duration of surgery, and the presence of postoperative general complications.
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Affiliation(s)
- Juan A del Olmo
- Service of Hepatology, Hospital Clinico Universitario, Avenida Blasco Ibáñez 17, E-46010 Valencia, Spain.
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Hernández V, Flor-Lorente B, Burgués O, Flor-Civera B, Oliver V. [Anasarca as presentation of lobular breast carcinoma]. Gastroenterol Hepatol 2000; 23:338-40. [PMID: 11002535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Metastatic tumors in the small intestine are rare. The most commonly implicated primitive tumors are malignant melanoma, lung cancer and colon cancer. Few cases of metastasis to the intestine as the first manifestation of metastasis have been described. We present a case of metastasis to the intestine of lobular breast carcinoma 9 years after surgical resection of the primary tumor. Metastasis presented as anasarca. Ray small bowel series revealed ileal stenosis. Diagnosis was confirmed by histopathologic analysis following surgical resection of the affected intestinal segment.
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Affiliation(s)
- V Hernández
- Servicio de Medicina Interna, Hospital Clínico, Universitat de Valencia
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