Search

Resumen Introduccion Los resultados de la estimulacion percutanea del nervio tibial posterior (PTNS) en el tratamiento de la incontinencia fecal (IF) parecen discretos. El objetivo del estudio es valorar la relacion de algunos aspectos tecnicos con la respuesta clinica: localizacion del nervio, respuesta distal (motora o sensitiva) y acomodacion. Metodos Estudio prospectivo de pacientes con IF sometidos a terapia de PTNS. La repuesta clinica se valoro mediante la escala de Wexner, diario defecatorio y manometria anorrectal. Resultados Se estudiaron 32 pacientes. La intensidad de localizacion (cercania al nervio) no se correlaciono con cambios clinicos ni manometricos. La respuesta motora se relaciono con un descenso en la escala de Wexner [12,12 (± 5,39) a 7,71 (± 4,57) p Conclusiones La respuesta motora durante la PTNS parece relacionarse con una mejor respuesta clinica. El fenomeno de acomodacion podria asociarse con peores resultados. La cercania del electrodo al nervio no parece tener trascendencia, siempre que se consiga una buena respuesta distal.

The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation.Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry.32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (± 5.39) to 7.71 (± 4.57) p0.005], the number of episodes of passive incontinence [8.78 (± 9.64) to 4.11 (± 7.11) p = 0.025], the total number of incontinence episodes [16.11 (± 16.03) to 7.78 (± 11.34) p = 0.009] and the number of days with faecal soiling [6.89 (± 5.53) to 2.56 (± 4.13) p = 0.002] and with an increase in the length of the manometric anal canal at rest [4.55 (± 0.596) to 4.95 (± 0.213) p = 0.004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 p0.005) and the number of days with soiling (r = -0.650 p = 0.022).The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.

Resumen Introduccion Los resultados de la reparacion de la hernia paraestomal (HP) basados en datos provenientes de registros son escasos. El objetivo del presente trabajo es analizar los datos recogidos sobre la HP en el Registro Nacional de Hernia Incisional (EVEREG) y asi evaluar las practicas actuales y resultados en la reparacion de una HP. Metodos Se analizan los datos de la cohorte de HP registradas en el periodo desde julio de 2012 hasta junio de 2018. Se analizan las complicaciones, recidivas y factores asociados a ellas de la cohorte completa de HP, independientemente del tipo de estoma al que se asocian. Posteriormente, se realiza el mismo analisis del grupo de HP con relacion a una colostomia (grupo mas numeroso). Resultados Se estudiaron 353 HP. De estas, 259 (73%) fueron HP en el contexto de una colostomia terminal, 74 (21%) en el de una ileostomia terminal y 20 (6%) en el de una ureteroileostomia (Bricker). La edad media global fue de 68,7 ± 11,1 anos y 135 (38%) pacientes fueron del sexo femenino. El abordaje abierto y la cirugia electiva fueron predominantes (78% y 92%, respectivamente). El 99% se reparo con una malla sintetica no absorbible. Las complicaciones postoperatorias globales fueron altas (30,6%), asi como la recurrencia global (27,5%) tras un seguimiento medio de 9,4 meses. Conclusiones La reparacion de la HP es poco frecuente comparada con el conjunto de reparaciones de la hernia incisional. La cirugia de la HP parece relacionarse con un porcentaje elevado de complicaciones postoperatorias y recidiva.

The Gastrointestinal (GI) tract is the most frequent site of extranodal lymphoma involvement. Most GI lymphomas are non-Hodgkin’s mature B-cell lymphomas, being diffuse large B-cell lymphoma one of the most common histologic subtypes. About 7% of GI lymphomas are located in the colon, usually at the ileocecal valve, and may grow into the terminal ileum. Abdominal pain and weight loss are common presenting symptoms, although complications such as intestinal obstruction may occur. Abdominal CT scan and barium enema are the most frequently used imaging tests for diagnosis, although colonoscopy with biopsies is required to confirm the diagnosis. Treatment includes surgery and chemotherapy with or without rituximab. Keywords: Primary colonic lymphoma; Diffuse large B-Cell Lymphoma; Obstruction; Surgery; Management.

(1) Background: For normo-nourished colorectal cancer patients, the need for immunonutrients after elective surgery is not known. (2) Methods: Multicenter, randomized, double-blind, phase III clinical trial comparing the postoperative diet with 200 mL oligomeric hyperproteic normocaloric (OHN; experimental arm) supplement vs. 200 mL immunonutritional (IN) (active comparator) supplement twice a day for five days in 151 normo-nourished adult colorectal-resection patients following the multimodal rehabilitation ERAS protocol. The proportions of patients with complications (primary outcome) and those who were readmitted, hospitalized for

ResumenObjetivoEvaluamos la utilidad de un cuestionario postal en el seguimiento de la cirugía de la eventración.Pacientes y métodoSe analiza prospectivamente una cohorte de 285 pacientes intervenidos por una eventración entre 1998 y 2003 mediante una técnica con malla prefascial y que recibieron un cuestionario de 6 preguntas e ideogramas, con estrategia de reenvíos y llamada telefónica para aumentar la respuesta. Se citaron a examen clínico a los pacientes sin inconveniente a ser visitados. Se revisaron todas las hojas operatorias. Se estudia la respuesta al cuestionario y hallazgos de la visita (test exacto de Fisher y Chi cuadrado), la concordancia con los datos operatorios (índices Kappa de Cohen y de Fleiss) y el valor predictivo del cuestionario.ResultadosUn total de 215 pacientes devolvieron el cuestionario después de tres envíos, con lo que se recogió información de un 75.4% de la cohorte, que aumentó al 94% después de la llamada telefónica. Un total de 168 pacientes (el 78.2%) aceptaron ser visitados, aunque finalmente solo acudieron 62 (el 36.9%). La concordancia entre las respuestas al cuestionario e ideogramas y los datos de las hojas operatorias fue baja (índice Kappa de Cohen de 0.065 e índice Kappa de Fleiss de 0.170).ConclusionesUn cuestionario postal con medidas para aumentar la respuesta puede ser efectivo para recoger información básica sobre la cirugía de la hernia incisional. La utilidad de dicha información resulta cuestionable por falta de cumplimiento de los pacientes en los controles y por dificultades en la comprensión del cuestionario, aunque este sea corto y/o en forma de ideograma.AbstractAimTo assess the usefulness of a short postal questionnaire as a method of follow-up in incisional hernia repair.Patients and methodAll consecutive patients (n=285) undergoing open mesh repair of incisional hernia using an onlay technique between 1998 and 2003 received a six-item self-administered questionnaire complemented with ideograms. Non-responders received two successive new questionnaires and a telephone call. All patients’ operation forms were reviewed. Patients with no objections to physical examination were contacted by phone for an appointment. The Fisher's exact test or the chi-square (χ2) tests were used to compare categorical variables between clinical visits and response to questionnaire. Agreement between response to the questionnaire and data on the operation forms was measured with the Cohen's kappa index and the Fleiss kappa index. The predictive values of the questionnaire were calculated.Results215 patients returned questionnaires after three reminders, allowing us to reach 75.4% of the study cohort, which in turn increased to 94% after the telephone call. A total of 168 (78.2%) patients were willing to come for a physical examination. Finally 62 (36.9%) patients were examined. The overall agreement between response to the questionnaire and data on the operation forms was poor (Cohen's kappa coefficient = 0.065 and Fleiss kappa coefficient = 0.170).ConclusionsA postal questionnaire can be effective to gather information. However, the usefulness of this information in the follow-up was low due to the small percentage of patients examined and difficulties in comprehension despite making the questionnaire short and illustrated by ideograms.

Prevention of parastomal hernia represents an important aim when a permanent stoma is necessary. The objective of this work is to assess whether implantation of a prophylactic prosthetic mesh during laparoscopic abdominoperineal resection contributed to reduce the incidence of parastomal hernia. Rectal cancer patients undergoing elective laparoscopic abdominoperineal resection with permanent colostomy were randomized to placement of a large-pore lightweight mesh in the intraperitoneal/onlay position by the laparoscopic approach (study group) or to the control group (no mesh). Parastomal hernia was defined radiologically by a CT scan performed after 12 months of surgery. The usefulness of subcutaneous fat thickness measured by CT to discriminate patients at risk of parastomal hernia was assessed by ROC curve analysis. Thirty-six patients were randomized, 19 to the mesh group and 17 to the control group. Parastomal hernia was detected in 50 % of patients in the mesh group and in 93.8 % of patients in the control group (P = 0.008). The AUC for thickness of the subcutaneous abdominal was 0.819 (P = 0.004) and the optimal threshold 23 mm. Subcutaneous fat thickness ≥23 mm was a significant predictor of parastomal hernia (odds ratio 15.7, P = 0.010), whereas insertion of a mesh was a protective factor (odds ratio 0.06, P = 0.031). Use of prophylactic large-pore lightweight mesh in the intraperitoneal/onlay position by a purely laparoscopic approach reduced the incidence of parastomal hernia formation. Subcutaneous fat thickness ≥23 mm measured by CT was an independent predictor of parastomal hernia.

This prospective, two-centre study was designed to evaluate long-term outcomes when using a collagen plug to treat cryptoglandular anal fistulae. Over 3 years, 60 consecutive patients with cryptoglandular fistulae were treated using an anal fistula plug by experienced surgeons. Preoperative, postoperative and follow-up data were collected in a dedicated database. Success was defined as the closure of all fistula openings and the absence of discharge. Faecal incontinence scores were administered at baseline and at 6 months follow-up. Eleven patients had multiple fistula tracts. All fistulae treated in this series were classified as complex. Seventeen fistulae were anterior tracts in females, and the remaining tracts were trans-sphincteric in nature. Thirty-eight tracts were recurrent. Mean operative time was 26 ± 10 min. No major complications, active sepsis or mortality were observed. Success rate with a mean follow-up of 13 months was 60% of patients and 70% of tracts. Mean time for recurrence was 5.7 months. Two recurrent patients were successfully treated with a redo plug procedure, and five were successfully closed with a post-plug fistulotomy, leading to a global 72% success rate without continence impairment. Of the patients with a minimum follow-up of 6 months (mean, 18.5 months; range, 6–34 months), 29 in 32 (90.6%) were healed at final evaluation. In these patients, the mean preoperative CCF incontinence score was 0.73. This was reduced to 0.14 at 6-month follow-up. The mean reduction of CCF incontinence score was −0.6 (95% CI, 1.3 to −0.1; p = 0.01). Fistula tract treatment with the anal fistula plug is a safe and viable surgical option that should be offered to complex fistula patients. The reasons and risk factors for recurrence remain to be explored.

The use of prophylactic antibiotics in addition to mechanical cleansing is the current standard of care prior to colonic surgery. The question of whether the antibiotics should be administered intravenously or orally, or by both routes, remains controversial. Our aim was to compare three methods of prophylactic antibiotic administration in elective colorectal surgery. Three hundred consecutive elective colorectal resections were studied. All patients had preoperative mechanical colon cleansing with oral sodium phosphate and intravenous antibiotic prophylaxis with cefoxitin (one dose before skin incision and two postoperative doses). Patients were randomised to one of the following three groups: group A: three doses of oral antibiotic (neomycin and metronidazole) at the time of mechanical colon cleansing; group B: one dose of oral antibiotic; group C: no oral antibiotics. All patients were followed during their hospital stay and at 7, 14 and 30 days post-surgery. Vomiting occurred in 31%, 11% and 9% of the studied patients (groups A, B and C, respectively) (p

The use of a sublay mesh in open surgery has been probed to be an efficient strategy for the prevention of parastomal hernia. Based on these previous reports, placing a composite mesh (polypropylene/cellulose) in an intraperitoneal fashion seems to be a good technique when a laparoscopic approach is performed. This technique is easy to perform. Mesh is kept in place with the help of tackers, normal intra-abdominal pressure, and the colon itself. We report the description of a laparoscopic technique for placing an intraperitoneal mesh for the prevention of a parastomal hernia.

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).1We 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.

The most frequent tumors that grow in the retrorectal space are embryological. Their management requires adequate knowledge of the characteristics of these lesions. We present five cases of retrorectal tumors.

We report the case of a 48-year-old man who was admitted to the intensive care unit for acute respiratory distress. After discharge, the patient showed massive pneumoperitoneum. None of the complementary investigations provided information on the cause. The patient underwent surgery but no intraoperative diagnosis was reached. We believe that this case is of interest since pneumoperitoneum is a frequent entity that often leads to emergency laparotomy. The cause is usually perforation, although in a substantial proportion of cases the pneumoperitoneum is non-surgical, or idiopathic.

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.