Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer

INTRODUCTION

Distance from anal verge of rectal tumours and their anatomical relationships contribute to determine the multidisciplinary therapeutic strategy based on the combination of radio-chemotherapy and radical surgery. Our aims are to investigate which is the most accurate method for the preoperative measuring of the distance from the anal verge in rectal tumours and if the pelvic MRI can substitute the classical instrumental methods.

METHODS

Prospective study of diagnostic precision between flexible colonoscopy (FC), preoperative rigid rectosigmoidoscopy (pRR) and pelvic MRI in patients scheduled to radical surgery. Rigid intraoperative rectoscopy (iRR) was considered the reference test. The correlations between the different techniques and their determination coefficient as well as the intraclass correlation coefficient and the degree of agreement between the different tests were analyzed.

RESULTS

96 patients (65% males), mean age (SD): 68 (14.1) years were included. 72% received neoadjuvant treatment. The mean distance to the anal margin measured by FC = 103.5 mm, was significantly greater than others, which had similar values: pRR = 81.1; MRI = 77.4; iRR = 82.9 mm (P < .001). A significant intraclass correlation was observed and there was high agreement between all pre- and intraoperative measurements except for the performed by FC, which overestimated the results. MRI provided more individualized and accurate information.

CONCLUSIONS

There is variability between the measurement methods, being colonoscopy the least reliable. MRI offers objective, comparable, accurate and individualized values that can replace those obtained by pRR for tumours of any location in the rectum.

Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer

INTRODUCTION

Distance from anal verge of rectal tumors and their anatomical relationships contribute to determine the multidisciplinary therapeutic strategy based on the combination of radio-chemotherapy and radical surgery. Our aims are to investigate which is the most accurate method for the preoperative measuring of the distance from the anal verge in rectal tumors and if the pelvic MRI can substitute the classical instrumental methods.

METHODS

Prospective study of diagnostic precision between flexible colonoscopy (FC), preoperative rigid rectosigmoidoscopy (pRR) and pelvic MRI in patients scheduled to radical surgery. Rigid intraoperative rectoscopy (iRR) was considered the reference test. The correlations between the different techniques and their determination coefficient as well as the intraclass correlation coefficient and the degree of agreement between the different tests were analyzed.

RESULTS

96 patients (65% males), mean age (SD): 68 (14.1) years were included. 72% received neoadjuvant treatment. The mean distance to the anal margin measured by FC=103.5mm, was significantly greater than others, which had similar values: pRR=81.1; MRI=77.4; iRR=82.9mm (P<.001). A significant intraclass correlation was observed and there was high agreement between all pre- and intraoperative measurements except for the performed by FC, which overestimated the results. MRI provided more individualized and accurate information.

CONCLUSIONS

There is variability between the measurement methods, being colonoscopy the least reliable. MRI offers objective, comparable, accurate and individualized values that can replace those obtained by pRR for tumors of any location in the rectum.

[Accreditation and dedication in coloproctology is associated with good perioperative care]

Complex data analysis methods require optimisation techniques such as evolutionary algorithms in order to generate reliable results. The objective of this study is to analyse the relationships of particular perioperative care in colorectal surgery (CRS) with surgeon epidemiological data, performing partition grouping to look for significant relationships.

METHODS

Data were used from a survey of members of Spanish coloproctology associations on perioperative care in colorectal surgery, and analysing the responses associated with mechanical bowel preparation (MBP), nasogastric intubation (NGI), drainages (D), and early feeding (EF), over the existing scientific evidence (SE) which shows that the first ones are unnecessary and the importance of the last one. We applied a variant of particle swarm optimization (PSO), to group data conglomerates, optimising variables with statistical grouping criteria.

RESULTS

A total of 130 surveys were analysed, finding 2 clear groups which included 21.5% and 78.5% of the sample, respectively. Sixty eight per cent of the surgeons in Group A belonged to the European Board in Coloproctology, compared to none in Group B, and the former performed 80% of the coloproctology activity, compared to 60% of the rest. A responded homogeneously to questions on MBP, NGI, D and EF, those of group A following the SE, while the others did it randomly and without following it. Age, work position or academic range were not significant in the grouping.

CONCLUSIONS

The evolutionary algorithm was shown to be able to identify groups according to the use of perioperative care in CRS. Accreditation and dedication was associated with behaviour based on the SE.

[Use of nasogastric tubes and drains after colorectal surgery. Have attitudes changed in the last 10 years?]

OBJECTIVE

To evaluate attitudes and opinions of Spanish surgeons on the use of nasogastric tubes (NGT) and drainages after colorectal surgery.

MATERIAL AND METHOD

E-mail survey to the members of the Spanish Association of Coloproctology, and Coloproctology Division of the Spanish Surgical Association comparing the results with a previous survey from 1996.

RESULTS

Of the 413 surveys sent out, 131 (31.7%) were returned, this compared with 190 from 1996. NGT is routinely used by 22%, selectively by 35% and never by 43%, vs 62%, 31% and 7% in 1996 (p < 0.001). Experience and accreditation in colorectal surgery was associated with its lower use. NGT is removed by 16% 24 hours after surgery, 9% later and 51% when peristalsis begins vs. 6%, 21% and 66% in 1996 (p < 0.001). Of the total, 76% believe that the ileus is not reduced by NGT and 89% that it does not increase comfort vs 27% and 48% (p < 0.001). Drainages are routinely used by 38.5% and selectively by a 57.7%, more than in 1996 (25% and 63%) (p < 0.05). Board-Certification in colorectal surgery was associated with a lower use of drains (p < 0.0001). Drains are not used by 46% in right colon surgery; 22% in left colon and 3.1% in rectal surgery. A total of 66% believe that its used reduce fluid collections and 43% that they drain anastomosis leaks without any differences from previous survey. Drains are considered very useful by 16% in colon surgery and by 52% in rectal surgery.

CONCLUSIONS

There is a tendency to decrease the use of NGT. However, drainages continue to be widely employed.

[Short-term and long-term evolution of deep vein thrombosis treated by a health care unit]

INTRODUCTION AND OBJECTIVES

Deep vein thrombosis (DVT) is a common disease, with a high risk of complications persisting for years. Until recently, the treatment of this condition was on an hospitalary basis. Nevertheless, there is growing evidence suggesting an adequate management on an ambulatory basis with low molecular weight heparin (LMWH). Based upon these observations, and observational study was performed to determine short-term ad long-term complications of DVT treated by a Home Care Unit (HCU).

METHODS

A total of 125 patients diagnosed of DVT by means of Doppler echography were treated on an ambulatory basis with subcutaneous nadroparine followed by oral anticoagulants (OAC) or LMWH alone, when a contraindication for acenocumarol use was present. The characteristics of the study population and their risk factors were studied, as well as the presence of bleeding or relapse during the acute period. Once the acute period with surveillance and treatment by the DHU was over, patients were followed at the Outpatient Clinics of the Internal Medicine Department. At each visit, the long-term complications were assessed: relapse, postflebitis syndrome (PFS), or death.

RESULTS

The most common short-term complications were bleeding (3.2%) and relapse (7.3%). Eighteen percent of patients showed liver toxicity (increase of at least a 1.5 fold in the basal values of transaminases) secondary to the use of nadroparine. Nevertheless, this toxicity was mild in all cases and subsided when the medication was stopped. With a mean follow-up of 15.4 months, an overall 16.5% of patients relapsed, 25.8 % of patients had a PFS, and 23.7% of patients died. Death was associated with the presence of some risk factors (32.7% versus 7.69%; p = 0.004), and particularly when this risk factor was a tumor (75% versus 12%; p < 0.001).

CONCLUSIONS

Deep vein thrombosis is a condition associated with common complications, both in the acute period and in the long-term. Nevertheless, it can be treated safely and efficiently by a HCU. This disease is associated with a high risk of mortality, particularly because it is usually associated with severe diseases.