Primary rectal mucosaassociated lymphoid tissuelymphoma masquerading asproctitis / Tejido linfoide asociado a la mucosa rectal primarialinfoma disfrazado deproctitis

A 29-year-old male presented with recurrent mucous bloody stools for more than a year. Colonoscopy revealed ill-defined, mildly congested and edematous mucosa with scattered erosion spots in the lower rectum, highly suspicious for proctitis. Histopathology showed diffuse infiltration of small to medium-sized lymphoid cells in the lamina propria. Immunohistochemistry indicated these cells were positive for CD20, CD79a, CD19, kappa and lambda light chains (partial), and negative for CD3, CD5, CD10, cyclin D and BCL-6. These results were consistent with mucosa-associated lymphoid tissue (MALT) lymphoma. Further investigations consisting of upper endoscopy, bone marrow biopsy, and whole-body PET/CT scan did not detect any extrarectal lesions. Based on these findings, the diagnosis of stage I primary rectal MALT lymphoma was made. The patient underwent 15 fractions of radiotherapy with a total dose of 30 Gy. His symptoms were alleviated following the treatment. A follow-up colonoscopy performed 3 months later showed complete resolution of the lesion.(AU)

Validación de la resonancia magnética pélvica como método de elección para determinar la distancia al margen anal en el cáncer de recto / Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer

Introducción: La altura exacta del tumor en el recto y sus relaciones anatómicas contribuyen a determinar la estrategia terapéutica multidisciplinar basada en la combinación de radio-quimioterapia y cirugía radical. Nuestro objetivo es valorar cuál es el método diagnóstico más preciso en la medición preoperatoria de la distancia al margen anal, y si la resonancia magnética pélvica (RM) puede sustituir a los métodos instrumentales clásicos. Métodos: Estudio prospectivo de precisión diagnóstica entre colonoscopia (CF), rectoscopia rígida (RRp) y RM en pacientes con indicación de cirugía radical. La RRp intraoperatoria fue considerada la prueba de referencia. Se analizaron las correlaciones entre las distintas técnicas y su coeficiente de determinación, así como el coeficiente de correlación intraclase y el grado de acuerdo entre los distintos test. Resultados: Se incluyeron 96 pacientes con edad media (DE) de 68 (14,1) años y predominio de varones (65%). Un 72% recibió tratamiento neoadyuvante. La distancia media al margen anal, medida mediante CF=103,5mm, fue significativamente mayor al resto, que obtuvieron valores similares: RRp=81,1, RM=77,4, RRp intraoperatoria=82,9mm (p<0,001). Se objetivó una significativa correlación intraclase y hubo un elevado acuerdo entre todas las mediciones pre e intraoperatorias a excepción de la realizada mediante CF, que sobreestimó el resultado. La RM aportó información más individualizada y precisa. Conclusiones: Existe variabilidad entre los métodos de medición, siendo la colonoscopia el menos fiable. La RM ofrece valores objetivos, comparables, precisos e individualizados que pueden sustituir a los obtenidos por RR en tumores de cualquier localización del recto. (AU)

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. (AU)

Moving the concept associated to laparoscopic intracorporeal rectus aponeuroplasty (LIRA) to lateral hernia / Trasladando el concepto asociado a la aponeuroplastia intracorpórea del recto (LIRA) laparoscópica a la hernia lateral

The surgical repair of lateral hernias is considered a challenge. Laparoscopic intracorporeal rectus aponeuroplasty (LIRA) has been described as a minimally invasive technique for primary incisional ventral hernias of the midline, especially for M2 to M4 ventral hernias but the indications of the concept associated to LIRA are beginning to expand to other complex locations. The aim of this video is to show the surgical steps for lateral hernias where the concept associated to LIRA is followed to repair this type of hernias. (AU)

La reparación quirúrgica de las hernias laterales se considera un reto. La aponeuroplastia intracorpórea de rectos laparoscópica (LIRA) ha sido descrita como una técnica mínimamente invasiva para tratar las hernias incisionales primarias de la línea media, especialmente para las hernias ventrales M2 a M4, pero las indicaciones del concepto asociado a LIRA comienzan a expandirse a otras localizaciones complejas. El objetivo de este vídeo es mostrar los pasos quirúrgicos de las hernias ÿaterals siguiendo el concepto asociado a LIRA para reparar este hernias. (AU)

Prevalencia de la colonizaciónmaterna intraparto por Estreptococodel Grupo B: análisis epidemiológicoen la provincia de Jaén / Prevalence of maternal intrapartum colonization due to the Group-B Streptococus: epidemiological analysis in the province of Jaén (Spain)

FUNDAMENTOS: La infección por Estreptococo del Grupo B (EGB) sigue siendo a día de hoy, sin profilaxis periparto, la causa más frecuente de infección bacteriana perinatal de transmisión vertical en el mundo occidental. Se estima que la prevalencia de emba-razadas portadoras asintomáticas de EGB en nuestro país oscila entre el 10% y el 20,5%, pero son escasos los estudios realizados al respecto. Con la presente investigación tratamos de establecer la tasa de embarazadas colonizadas por EGB a nivel recto-vaginal en el momento del parto y evaluar la validez de nuestra estrategia para la identificación de embarazadas portadoras de EGB. MÉTODOS: Se seleccionó aleatoriamente una muestra de 290 gestantes, representativa de la población embarazada de la provincia de Jaén. En ella se analizó la presencia o ausencia de EGB en la microbiota recto-vaginal materna el día del parto. Posteriormente se hizo un análisis retrospectivo, caso a caso, con la finalidad de establecer si las técnicas de cribado aplicadas durante la gestación habían sido capaces de identificar correctamente el estado de colonización por EGB en el momento del parto. Se aplicaron técnicas estadísticas para realizar un análisis descriptivo muestral, que se complementó con un análisis de concordancia caso por caso para las dos determinaciones de EGB realizadas en el tiempo a cada sujeto (observaciones repetidas en el tiempo a los individuos de una misma cohorte). RESULTADOS: La tasa de embarazadas portadoras de EGB a nivel recto-vaginal en el momento del parto fue del 23,10%. CONCLUSIONES: En nuestro medio la tasa de embarazadas portadoras de EGB en el momento del parto es superior a lo previamente comunicado en la bibliografía. Además, nuestra estrategia de cribado durante la gestación podría catalogar erróneamente a una de cada ocho mujeres, haciendo que una de cada dieciséis portadoras de EGB no sea adecuadamente identificada.(AU)

BACKGROUND: Group B Streptococcus (GBS) infection remains to datey, without peripartum prophylaxis, the most common cause of vertically transmitted perinatal bacterial infection in the Western world. It is estimated that the prevalence of asymptomatic pregnant women with GBS in our country ranges between 10 and 20.5%, but there are few studies in this regard. With this research, we tried to establish the rate of pregnant women colonized by GBS at the recto-vaginal level at the time of delivery and to evaluate the validity of our strategy for the identification of pregnant women with GBS. METHODS: A 290 women sample representative of pregnant population from the province of Jaén was randomly selected and the presence or absence of GBS in the recto-vaginal microbiota was determined on the day of delivery. Subsequently, a retrospective analysis was made, case by case, in order to establish whether the screening techniques applied during pregnancy had been able to correctly identify the state of GBS colonization at the time of delivery. Statistical techniques were applied to perform a descriptive sample analysis, which was complemented with a case-by-case concordance analysis for the two GBS determinations made over time for each subject (repeated observations over time on individuals from the same cohort). RESULTS: The rate of pregnant women carrying GBS at the recto-vaginal level at the time of delivery was 23.10%. CONCLUSIONS: In our province, the rate of pregnant women with GBS at the time of delivery is higher than previously reported in the literature. Furthermore, our screening strategy during pregnancy could misclassify one of each eight women, causing one in sixteen GBS carriers to not be adequately identified.(AU)

Comparison of postoperative complication rates between a novel endoluminal balloon-assisted drainage and diverting stoma after low rectal cancer

AimTo introduce a novel endo-luminal balloon-assisted drainage (EBAD) and compare postoperative complication rates between EBAD and diverting stoma (DS) groups.MethodsThe single center prospective non-random cohort study included a total of 163 patients in convenience patients with rectal cancer between January 2019 and January 2021. Out of 163 patients, 83 underwent DS and 80 EBAD. Primary endpoints were postoperative complication rate.ResultsThe total number of complications was 28 in the DS group vs. 22 in the EBAD group (P = 0.388). 18 patients (21.7%) in the DS group and 14 patients (17.5%) in the EBAD group developed postoperative complication (P = 0.501). There were no differences identified for anastomotic leak rates between the two groups (P = 0.677). The rate of the pelvic abscess was lower in the EBAD group (1/80, 1.3%) than in the DS group (4/83, 4.8%) but with no statistical significance (P = 0.386). Compared with the DS group, the median operative time was shorter in the EBAD group (225 vs. 173.5 min, P < 0.001). Regarding incomplete small bowel obstruction, a higher prevalence was observed in the DS group compared to the EBAD group (7.2% vs 2.5%, P = 0.301). 7 patients (11.3%) in the DS group developed a para-stomal hernia, while no patient suffered a catheter-related complication. The median postoperative hospital stay was shorter in the DS groups than in the EBAD group (7 vs 8 days, P = 0.009). The median residence time of endo-luminal balloon-assisted drainage was 5.41 days. The median average and total volume of drainage were 51.57 ml/day and 255 ml, respectively.ConclusionEBAD is feasible and safe with similar postoperative complications when compared with a DS. EBAD may replace DS after rectum resection.

Preliminary results of a vaginal constraint for reducing G2 late vaginal complications after postoperative brachytherapy in endometrial cancer: a prospective analysis

PurposeTo evaluate the preliminary results of the use of 68 Gy EQD2(α/β=3 Gy) as a dose limit to the lowest dose in the most exposed 2 cm3 of the vagina in order to reduce G2 late vaginal problems in postoperative endometrial carcinoma (EC).MethodsFrom November 2016 to October 2019, 69 postoperative EC patients receiving vaginal brachytherapy (VBT) ± external beam radiotherapy (EBRT) were prospectively analyzed. The median EBRT dose was 45 Gy (range: 44–50.4 Gy), 1.8−2 Gy/day, 5 fractions(Fr)/week. VBT was administered with the following schedule: 1Fr of 7 Gy after EBRT and 2 daily Fr × 7.5 Gy in exclusive VBT. The dose was prescribed at 0.5 cm from the applicator surface with an active length of 2.5 cm; 56 patients were treated with vaginal cylinders (49–3.5 cm, 6–3 cm, and 1–2.5 cm) and 13 with the colpostat technique. The overall VBT dose was adjusted to meet the vaginal restriction of < 68 Gy EQD2(α/β=3 Gy) at 2 cm3. Late toxicity was prospectively assessed using RTOG scores for bladder and rectum, and the objective LENT-SOMA criteria for vagina.ResultsWith a median follow-up of 31.0 months, no vaginal-cuff recurrences were found. Late toxicity: only 1G1(1.4%) rectal toxicity; 21G1(30.4%) and 3G2(4.3%) vaginal complications. Only one (1.4%) of 3 G2 manifested as vaginal shortening.ConclusionsIn postoperative EC patients treated with VBT, only one developed G2 vaginal stenosis with the use of 68 Gy EQD2(α/β=3 Gy) as a dose constraint. These preliminary results seem to indicate the value of this dose limit for reducing G2 vaginal stenosis. Nonetheless, these findings should be confirmed in a larger number of patients with longer follow-up.

SEOM-GEMCAD-TTD clinical guidelines for localized rectal cancer (2021)

The management of localized rectal cancer requires a multidisciplinary approach to optimize outcomes, reduce morbidity and prevent under or overtreatments. While early stages may obtain benefit of local resections without any additional therapies, locally advanced rectal cancer becomes a challenge defining the better sequential strategy of surgery, radiotherapy and chemotherapy. The latest results of international phase III studies have positioned the total neoadjuvant therapy as a potential new standard of care in high risk rectal cancers, however, the best schedule is still not well defined.

Diagnostic value of transrectal combined scrotal ultrasonography in acquired obstructive azoospermia / Valor diagnóstico de la ecografía transrectal y escrotal en la azoospermia obstructiva adquirida

Objective: To investigate the transrectal and scrotal ultrasonographic features of acquired obstructive azoospermia and evaluate the role of ultrasonography in the location diagnosis of acquired obstructive azoospermia patients.Methods: Retrospectively analysis of 92 cases of acquired obstructive azoospermia in recent years. All the patients underwent transrectal and scrotal ultrasonography. The ultrasonographic features were observed of testis, epididymis, scrotal segment of vas deferens, seminal vesicle, ejaculatory duct and prostate. Eighty cases with normal semen were taken as control group.Results: Among the 92 cases of acquired obstructive azoospermia, 28 cases were prostate midline cyst, 32 cases were stone or calcification of the ejaculation duct and 21 cases were chronic seminal vesicle inflammation, which were found through transrectal ultrasonography; 27 cases were vas deferens dilation, 30 cases had abnormal mass of epididymis tail, 31 cases were epididymis thickness with reticular change, 8 cases were cystic dilatation of rete testis, which were found through scrotal ultrasonography. Compared with the control group, ultrasound examination increased the detection rate of distal seminal duct lesions and epididymal lesions in acquired obstructive azoospermia patients (p<.01). Comparison of testicular volume between case group and control group did not reveal significant difference (p>.05). The thickness of the head, body and tail of epididymis in case group was significantly bigger than that in control group (p<.01). (AU)

Objetivo: Investigar las características ecográficas transrectales y escrotales de la azoospermia obstructiva adquirida y evaluar el rol de la ecografía en el diagnóstico de localización de los pacientes con azoospermia obstructiva adquirida.Métodos: Análisis retrospectivo de 92 casos de azoospermia obstructiva adquirida en los últimos años. Todos los pacientes fueron sometidos a ecografía transrectal y escrotal, observándose las características ecográficas en los testículos, epidídimo, segmento escrotal de los conductos deferentes, vesícula seminal, conducto eyaculatorio y próstata. Se tomaron ocho casos con semen normal, como grupo control.Resultados: Entre los 92 casos de azoospermia obstructiva adquirida, se detectaron mediante ecografía transrectal 28 casos de quiste prostático de línea media, 32 casos de cálculo o calcificación del conducto eyaculatorio y 21 casos de inflamación crónica de la vesícula seminal; también se detectaron mediante ecografía escrotal 27 casos de dilatación de los conductos deferentes, 30 casos de masa anormal en el tallo del epidídimo, 31 casos de grosor del epidídimo con cambio reticular y ocho casos de dilatación quística de la rete testis. En comparación con el grupo control, el examen ecográfico incrementó la tasa de detección de las lesiones del conducto seminal distal y las lesiones epididímicas en los pacientes con azoospermia obstructiva adquirida (p < 0,01). La comparación entre el volumen testicular entre el grupo de casos y el grupo control, no reveló ninguna diferencia significativa (p > 0,05). El espesor de la cabeza, cuerpo y cola del epidídimo en el grupo de casos fue significativamente mayor que en el grupo control (p < 0,01). (AU)