Search

Myasthenia Gravis (MG) and Thymoma have different clinical evolutions and survival. There are few studies grying to describe the prognosis factors in patients with both thymoma and MG. We have evaluated all patients with thymoma and associated MG who were treated in our unit in order to identify possible predictors of survival.There were 108 patients with thymoma and associated MG treated at our center from 1967 to 2000. All data were analyzed by multivariate Cox regression analysis, which allowed quantification of the independent predictive value of prognostic indicators.Median follow-up was 10 years. Mortality was 35.2% (38 patients). In 14 (36.8%) cases, death was related to MG, and 6 (15.8%) patients died from a cause directly related to thymoma. Cox regression analysis found a predictive value for both an age older than 55 years and the need for tracheostomy during the postoperative period.In our series of patients with thymoma and associated MG, age older than 55 years and the need for postoperative tracheostomy were independent predictors of poorer overall survival.

Dear Editor: Diverticulosis is a very common colonic pathology occurring in more than 65% of the population by the age of 80. The inflammatory process involving diverticulosis arises with an inflammatory response that may require surgery for hemorrhage, abscess, perforation, or fistula formation. The pathophysiology of colouterine fistulas includes destruction of two serosas of two epithelialized surfaces in close proximity. We describe the case of an elderly 76-year-old patient who presented within a period of 6 months with two episodes of acute diverticulitis that required endovenous treatment. The patient had already presented with fecal incontinence. At this time, the patient was taken to the emergency room because of the presence of a foul-smelling vaginal discharge with fecaloid flow. Abdominal examination revealed a low tenderness in the left lower quadrant, without palpable mass. The patient had no fever. Laboratory tests did not show any alteration in biological values. Antibiotic treatment was initiated and the patient was studied. A CT scan was performed that showed the presence of a uterus full of air and fecal content. Also, an inflammatory sigmoid colon with the presence of diverticles and a thick sigmoid wall could be seen. An image of malignancy could not be excluded. All these data confirmed the presence of a colouterine fistula. No colonoscopy had been yet performed because of the wish of the patient and their family. Surgery was performed and, at laparotomy, a chronic inflammatory mass was observed. This mass included the whole sigmoid colon and the posterior uterine wall. An en bloc resection was performed with a Hartman’s procedure. Colouterine fistulas were first reported by Lejemtel in 1909. At that time, three main etiologies were described: first, trauma or spontaneous rupture of a gravid uterus in which an intestinal loop impacted on the tear and a subsequent necrosis developed after constricting contractions of the myometrium; second, the presence of abscess rupture into the bowel and the uterus; third, a uterine or sigmoid carcinoma. In later years, radiotherapy has also been involved in colouterine fistula formation. Hawkes described obstetric trauma including curettage of the uterus with simultaneous perforation of the uterus and the colon. The first report of colouterine fistulas related to diverticulitis was by Noecker in 1929. This diagnosis is rare and even rarer is to observe colouterine fistulas related to diverticulitis. Among causes other than diverticulitis, endometriosis, gynecological cancer, and also apex abscesses have been described. Many reasons have been provided in order to explain colouterine fistula formation. Owing to the great thickness of the uterine wall, colouterine fistulas are very rare. The development of diverticulitis episodes may lead to a fistula formation, because of repeated inflammatory response in the tissues, such as in our patient. Repeated acute episodes of diverticulitis may lead to adhesions, local inflammation, with subsequent necrosis and fistula formation. It is usually the fundus of the uterus and the sigmoid colon that are linked. Also, a perforated sigmoid colon in the presence of an abscess may be the cause of the fistula formation, which was the case with our patient. Int J Colorectal Dis (2009) 24:599–600 DOI 10.1007/s00384-008-0630-x

The so-called “burst abdomen” has been described for many years and is a well-known clinical condition, whereas the concept of the “open abdomen” is relatively new. In clinical practice, both nosological entities are characterized by a complex spectrum of symptoms apparently disconnected, which in many cases poses a great challenge for surgical repair. In order to assess the management of these disorders in a more comprehensive and integral fashion, the concept of “acute postoperative open abdominal wall” (acute POAW) is presented, which in turn can be divided into “intentional” or planned acute POAW and “unintentional” or unplanned POAW. The understanding of the acute POAW as a single clinical process not only allows a better optimization of the therapeutic approach in the surgical repair of abdominal wall-related disorders, but also the stratification and collection of data in different patient subsets, favoring a better knowledge of the wide spectrum of conditions involved in the surgical reconstruction of the abdominal wall.

Chagas disease is a frequent cause of acquired megacolon in several countries of Latin America. Several procedures have been described to treat this condition. Recently a report of 147 patients treated with an open rectosigmoidectomy with an ileal loop interposition showed a low rate of complications (8.5 percent) and recurrence (3.1 percent).1 We present the video of a 42-year-old Latin American man who had a diagnosis of chagasic megacolon and was treated with the technique described by Netinho et al. 1 but with the use of laparoscopy. The patient was placed in a supine modified lithotomy position in Allen stirrups; the monitor was placed near the left leg of the patient, and both the surgeon and the assistant stood at the right side of the patient. Four trocars were used. Exploratory laparoscopy was performed. The proximal third of the rectum, sigmoid, and left colon were fully mobilized. Vascular pedicles were sectioned. The rectum was divided by using a linear laparoscopic cutter. A Pfannensteil incision was made and the colon was proximally divided. An ileal loop was interposed isoperistaltically between the descending colon and the rectum. Both the ileoileal and the ileocolic anastomoses were handsewn, and the distal ileorectal anastomoses were performed with a circular stapler under laparoscopic control. The patient is without symptoms or recurrence one year after the surgery. Laparoscopic approach allows the easy and correct dissection of the lateral attachments and offers the advantages of a more cosmetic and less painful procedure. Laparoscopic rectosigmoidectomy with ileal loop interposition is a technique that can be performed by laparoscopy with good results and should be an option in the treatment of chagasic megacolon.

To compare patients with complex abdominal wall hernias undergoing surgical repair using synthetic nonabsorbable or biologic meshes in contaminated fields. Retrospective review of 62 patients with complex abdominal wall hernia with surgical repair in an elective setting and in the context of a clean-contaminated or contaminated fields (January 2009–April 2015). Two groups according to the prosthesis (synthetic nonabsorbable, n = 48 or biologic, n = 14). Mean follow-up was 24.6 (15.8) months. Clean-contaminated wounds were significantly more frequent in the synthetic group. Contaminated wounds were significantly more frequent in the biologic group. Enterocutaneous fistula, recurrent hernia, and removal of chronic infected mesh were significantly more frequently in the biologic group. Differences in postoperative complications and surgical site infections were not found. Recurrence was higher in the biologic group (35.7% vs 8.3%, P = 0.03). In the elective repair of complex hernia, the level of contamination, a recurrent hernia, an enterocutaneous fistula or removal of chronic infected mesh were the factors affecting the choice of prosthesis. In the clean-contaminated setting, the use of a synthetic nonabsorbable mesh versus a biologic mesh did not increase the rate of postoperative infections. Recurrences are significantly higher with biologic meshes.