Oscar Cano-Valderrama

Background: Prehabilitation has become an essential component of perioperative care in colorectal surgery, aiming to improve postoperative outcomes through multimodal interventions. However, its real-world implementation remains heterogeneous. This study aimed to evaluate the degree of implementation and variability of prehabilitation programs across colorectal surgery units in Spain. Methods: A national multicenter cross-sectional survey (VAPPER Survey) was conducted among colorectal surgery units. The questionnaire included 83 items addressing organizational structure, nutritional assessment, frailty screening, and multidisciplinary collaboration. Data were analyzed descriptively and expressed as frequencies and percentages. Results: A total of 104 hospitals participated. Prehabilitation programs were present in 79% (n = 82) of centers, while 21% (n = 22) reported no program. Nutritional screening was not performed in 21% (n = 22) of hospitals. Among those performing screening, MUST was the most frequently used tool (68%, n = 56), although considerable variability existed. Systematic use of GLIM criteria was reported in only 24% (n = 20), whereas 35% (n = 28) did not use GLIM and 41% (n = 34) applied it selectively. Frailty screening in patients ≥70 years was absent in 54% (n = 44) of centers, and geriatric involvement was limited and non-standardized. Conclusions: Prehabilitation is widely implemented in Spain but remains highly heterogeneous across all dimensions. The most relevant deficits are concentrated in systematic nutritional assessment, malnutrition diagnosis using standardized criteria, geriatric integration, and psychological support. Standardization of protocols, strengthening of multidisciplinary teams, and enhanced training in perioperative nutrition are priorities for optimizing outcomes in colorectal surgery.

PT4 colon tumors are associated with worse oncologic prognosis. Although minimally invasive surgery (MIS) improves postoperative recovery, concerns remain regarding its long‑term oncologic safety. This is a secondary analysis of a retrospective, multicenter national cohort including patients with pT4 colon cancer treated with curative intent in 50 hospitals. We compared oncologic outcomes (local, peritoneal and systemic recurrence, disease‑free survival [DFS] and overall survival [OS]) between open surgery and MIS. Variables associated with surgical approach were incorporated into a propensity score (PS) to adjust outcomes. A total of 1850 patients were analyzed: 725 (39.2%) underwent MIS and 1125 (60.8%) open surgery. Patients selected for MIS more frequently had favorable clinical and tumor characteristics. After PS adjustment, MIS was associated with fewer postoperative complications, including fewer major complications (OR 2.4, p < 0.01). The mean number of resected lymph nodes and margin involvement were similar between groups. After a median follow‑up of 42.1 months, overall recurrence rates did not differ between MIS and open surgery, including peritoneal and systemic metastases. Although overall mortality was lower in the MIS group, cancer‑specific mortality was similar. MIS was associated with better DFS (HR 1.2, p = 0.018) and OS (HR 1.3, p = 0.024) after adjustment. MIS can be safely performed in well-selected patients with T4 colon cancer-specifically those with ASA I-II, screen-detected disease, right-sided tumors, elective surgery, tumors not adherent to adjacent structures, no need for extended resection, absence of tumor perforation, pT4a stage, and low-grade histology-reducing postoperative complications without compromising oncological outcomes.

Background/Objectives: Female trans-sphincteric anterior anal fistula is one of the most challenging fistulae because of the inherent risk of postoperative incontinence. The objective of this study is to analyze current surgical practices in these patients and their results. Methods: This study is a nationwide cohort retrospective study of all female patients with trans-sphincteric anterior anal fistula that were operated on in 2019. The primary outcomes measured were the analysis of the different techniques used in this type of patient and the results in terms of healing, persistence and recurrence. Results: We analyzed 139 patients that were operated on in 2019 because of an anterior trans-sphincteric fistula. The most usual technique performed was fistulotomy (29.5%), followed by ligation of the inter-sphincteric fistula tract (22.3%). The overall healing rate was 60.4%, taking into account that this rate was higher for fistulotomy (87.8%) than for sphincter-preserving techniques such as ligation of the inter-sphincteric fistula tract, advanced flap and fistulotomy plus sphincterography (51.8%). The main protective factors for healing that have been identified are the absence of current smoking and the realization of a fistulotomy. The overall postoperative incontinence rate is 12.6%, which is higher in patients with higher fistula (25%). It is important to highlight that in low fistula, the rate of incontinence in techniques different from fistulotomy is about 25%. The only risk factor for incontinence that has been identified is obesity. Conclusions: The treatment of this type of fistula is still a big challenge with high diversity in terms of surgical techniques, even though, fistulotomy still remains safe and with good results in terms of healing and incontinence in low fistulas and medium fistulas with strict selection criteria. In these cases, fistulotomy is the indicated procedure.

Introduction/Background: Patients with locally advanced rectal cancer (LARC) with pathological complete response (pCR) after neoadjuvant chemo-radiotherapy (NCRT) are a privileged group because of the favorable progression of their disease. However, their follow-up patterns after surgery are similar to those of other groups with worse prognosis, with the consequent psychological and economic impact. Methods: This is a retrospective observational multicenter study with data obtained from the Spanish Rectal Cancer Project. Patients with LARC who underwent surgery with curative intent after NCRT and achieved pCR were selected. The last follow-up update was conducted in December 2021. A conditional survival model was used to analyze oncological outcomes during follow-up. Recurrence-free survival (RFS) was analyzed for the entire cohort of patients and for those who survived at one, two, and three years. Results: A total of 815 patients from 32 hospitals were included. Their mean age was 65.1 years, and 36.1% of them were women. Of the 815 patients, 35 died or experienced recurrence (local or systemic) in the first postoperative year, and 780 were included in the conditional survival analysis one year after surgery. The probability of RFS at 5 years was 86.5% in the whole cohort and 89.4%, 92.9%, and 95.2% for survivors at one, two, and three years, respectively. The probability of recurrence in these same groups was 6.5%, 4.3%, 1.8%, and 0.6%. Conclusions: Follow-up of patients with LARC and pCR after NCRT followed by surgery could be adapted based on conditional survival data showing that the probability of RFS increases as patients remain recurrence-free, and recurrences more than 3 years after treatment are exceptional.

PURPOSE: Organ preservation has become an attractive alternative to surgery (total mesorectal excision [TME]) among patients with rectal cancer after neoadjuvant therapy who achieve a clinical complete response (cCR). Nearly 30% of these patients will develop local regrowth (LR). Although salvage resection is frequently feasible, there may be an increased risk for development of subsequent distant metastases (DM). The aim of this study is to compare the risk of DM between patients with LR after Watch and Wait (WW) and patients with near-complete pathologic response (nPCR) managed by TME at the time of reassessment of response. METHODS: Data from patients enrolled in the International Watch & Wait Database (IWWD) with cCR managed by WW and subsequent LR were compared with patients managed by TME (with ≤10% cancer cells—nPCR) from the Spanish Rectal Cancer Project (VIKINGO project). The primary end point was DM-free survival at 3 years from decision to WW or TME. The secondary end point was possible risk factors associated with DM. RESULTS: Five hundred and eight patients with LR were compared with 893 patients with near-complete response after TME. Overall, DM rate was significantly higher among LRs (22.8% v 10.2%; P ≤ .001). Independent risk factors for DM included LR ( v TME at reassessment; P = .001), ypT3-4 status ( P = .016), and ypN+ status ( P = .001) at the time of surgery. 3-year DM-free survival was significantly worse for patients with LR (75% v 87%; P = .001). When stratified for pathologic stage, patients with LR did significantly worse through all stages ( P ≤ .009). CONCLUSION: Patients with LR appear to have a higher risk for subsequent DM development than patients with nPCR managed by TME at restaging irrespective of final pathology. Leaving the primary undetectable tumor in situ until development of LR may result in worse oncologic outcomes.

Background/Objectives: Colon cancer presents as an obstruction in almost 30% of patients. Self-expandable metallic stents emerged as an alternative to emergency surgery, despite early controversies around their use. Improved techniques led to stent incorporation in clinical guidelines. Our objective is to compare colectomies performed after the insertion of self-expandable metallic stents versus emergency surgeries in pT4 obstructive left colon cancer, analysing postoperative and oncological outcomes. Methods: This is an observational retrospective multicentre study involving 50 hospitals and analysing data from patients with pT4 obstructive tumours treated for curative intent between 2015 and 2017. Patients with left-sided obstructive colon cancer were included, with exclusion criteria being palliative surgery or incomplete resection. Primary outcomes were local, peritoneal, and systemic recurrence rates, overall survival (OS), and disease-free survival (DFS). Secondary outcomes were postoperative complications and the rate of surgeries without major complications. Results: In total, 196 patients were analysed, 128 undergoing emergency surgery and 68 receiving colonic stents. Stents more frequently allowed for minimally invasive surgeries: 33.8% vs. 4.7% (p < 0.01). The stent group showed fewer major complications (Clavien–Dindo ≥ 3) at 4.5% vs. 22.4% (p < 0.01), fewer infectious complications at 13.2% vs. 23.1% (p = 0.1), and fewer organ-space infections at 3.3% vs. 15.9% (p = 0.03). No significant differences in recurrence rates, 29.4% vs. 28.1% (p = 0.8); disease-free survival, 44.5 vs. 44.3 months (p = 0.5); or overall survival, 50.5 vs. 47.6 months (p = 0.4), were found between groups. Conclusions: Self-expandable metallic stents are a safe alternative for pT4 obstructive left colon cancer, improving postoperative outcomes without compromising short- and medium-term oncological results. Consideration of experienced clinicians and potential referral to centres with advanced stenting capabilities may enhance patient care.