Colonic preparation before colonoscopy in constipated and non-constipated patients: a randomized study.

AIM: To compare the efficacy of different doses of sodium phosphate (NaP) and polyethylenglicol (PEG) alone or with bisacodyl for colonic cleansing in constipated and non-constipated patients. METHODS: Three hundred and forty-nine patients, older than 18 years old, with low risk for renal damage and who were scheduled for outpatient colonoscopy were randomized to receive one of the following preparations (prep): 90 mL of NaP (prep 1); 45 mL of NaP + 20 mg of bisacodyl (prep 2); 4 L of PEG (prep 3) or 2 L of PEG + 20 mg of bisacodyl (prep 4). Randomization was stratified by constipation. Patients, endoscopists, endoscopists' assistants and data analysts were blinded. A blinding challenge was performed to endoscopist in order to reassure blinding. The primary outcome was the efficacy of colonic cleansing using a previous reported scale. Secondary outcomes were tolerability, compliance, side effects, endoscopist perception about the necessity to repeat the study due to an inadequate colonic preparation and patient overall perceptions. RESULTS: Information about the primary outcome was obtained from 324 patients (93%). There were no significant differences regarding the preparation quality among different groups in the overall analysis. Compliance was higher in the NaP preparations being even higher in half-dose with bisacodyl: 94% (prep 1), 100% (prep 2), 81% (prep 3) and 87% (prep 4) (2 vs 1, 3 and 4, P < 0.01; 1 vs 3, 4, P < 0.05). The combination of bisacodyl with NaP was associated with insomnia (P = 0.04). In non-constipated patients the preparation quality was also similar between different groups, but endoscopist appraisal about the need to repeat the study was more frequent in the half-dose PEG plus bisacodyl than in whole dose NaP preparation: 11% (prep 4) vs 2% (prep 1) (P < 0.05). Compliance in this group was also higher with the NaP preparations: 95% (prep 1), 100% (prep 2) vs 80% (prep 3) (P < 0.05). Bisacodyl was associated with abdominal pain: 13% (prep 1), 31% (prep 2), 21% (prep 3) and 29% (prep 4), (2, 4 vs 1, 2, P < 0.05). In constipated patients the combination of NaP plus bisacodyl presented higher rates of satisfactory colonic cleansing than whole those PEG: 95% (prep 2) vs 66% (prep 3) (P = 0.03). Preparations containing bisacodyl were not associated with adverse effects in constipated patients. CONCLUSION: In non-constipated patients, compliance is higher with NaP preparations, and bisacodyl is related to adverse effects. In constipated patients NaP plus bisacodyl is the most effective preparation.

[Prevalence of serrated adenomas of the colon and association with synchronic and metachronic neoplastic lesions]. / Prevalencia de adenomas serratos de colon y asociación con lesiones neoplásicas sincrónicas y metacrónicas.

OBJECTIVE: To determine the prevalence of serrated adenomas (SA), the frequency of high grade dysplasia (HGD) and adenocarcinoma in these polyps, and the association with synchronic (SNL) and metachronic neoplastic lesions (MNL). METHODS: Reports from patients undergoing colonoscopy and polypectomy from January 2003 to April 2010, were obtained from our electronic database. SA were reanalyzed by two pathologists and classified on the basis of Snover's diagnostic criteria. The prevalence of these polyps and the clinical and endoscopic features were determined. SNL were defined by adenomas, cancer or advanced neoplastic lesions (ANL) (> 1 cm, HGD and/or >75% of villous component) in the same colonoscopy. MNL were identified in patients who underwent surveillance colonoscopies. An univariate and multivariate analysis was performed, looking for independent predictors of HGD/ cancer, SNL and MNL in patients with SA. RESULTS: The prevalence of SA was 0.87%. The mean age was 60 years old and 50.5% of patients were women. Most of the polyps were sessile (67%), small (63%) and located in ceco-ascending colon (47%). We found HGD in 4.4% ofSA and no adenocarcinoma. SNL was found in 31% ofpatients: 46% adenomas, 40.5% ANL and 13.5% adenocarcinoma. MNL was found in 29% of patients: 25% SA, 31% adenomas, 44% ANL and 0% adenocarcinoma. Age over 60 years old was significantly associated with MNL [Odds ratio 3.7 (95% confidence interval 1.16-11.8)] and polyp's size higher than 1 cm with sessile SA histology [Odds ratio 8 (95% confidence interval 1.28-49.4)]. CONCLUSION: The prevalence of SA was low. We found an association with neoplastic lesions. Therefore, it is important to establish specific guidelines for the management of these polyps.

Uso de prótesis biológica para el tratamiento de fístulas perianales complejas

Antecedentes: El tratamiento de la fístula anal compleja es controvertido. El empleo de tratamientos poco invasivos alternativos a la cirugía convencional disminuye el riesgo de complicaciones y secuelas. Objetivos: Evaluar la factibilidad del procedimiento y los resultados iniciales del uso de una prótesis biológica de origen porcino (PBP) en el tratamiento de la fístula anal compleja. Material y Método: Entre septiembre de 2006 y abril de 2007 se realizó un estudio observacional prospectivo del uso de PBP en pacientes con fístulas complejas. Se excluyeron los pacientes con enfermedad inflamatoria intestinal, fístulas simples superficiales o con procesos supurativos agudos. Todos los pacientes fueron estudiados previamente a la intervención quirúrgica mediante examen proctológico, ecografía endorrectal y manometría. El seguimiento posoperatorio temprano se hizo en el consultorio a los siete y a los quince días de la intervención y posteriormente cada treinta días. Para la evaluación de la incontinencia fecal se utilizó la escala de incontinencia de Jorge y Wexner. Resultados: Se evaluaron 13 pacientes. Siete hombres y seis mujeres. La edad promedio fue de 57 ± 16 años. Los tipos de fístulas a reparar fueron transesfinteriana en 12 (92%) casos y en herradura el restante. La longitud del trayecto fue en promedio 5.1 ± 1.2 cm. El grado de incontinencia prequirúrgica fue 7 ± 1.2 y posquirúrgica de cero. Un paciente presentó más de un trayecto. Tres (23%) fueron tratados con sedal 19 semanas antes del implante. No se registraron complicaciones durante la intervención. La morbilidad fue del 23%. Tres pacientes expulsaron espontáneamente la prótesis. No se registraron recidivas ni incontinencia en los pacientes en que la prótesis permaneció implantada. El éxito en el cierre del trayecto fue del 76.9% (10 pacientes). Conclusión: Los resultados iniciales permiten concluir que el tratamiento con PBP es seguro y eficaz, constituyendo una alternativa válida para el tratamiento de las fístulas complejas.

Background: The treatment of complex anal fístulas is controversial. Using low-invasive treatments as an alternative to conventional surgery reduces the risk of complications and sequels. Objective: To evaluate the feasibility of the procedure and the initial results of using porcine biological prosthe-ses (PBP) for treating complex anal fístulas. Materials and Method: An observational prospective study on the use of PBP in patients with complex anal fístulas was carried out between September 2006 and April 2007. Patients with inflammatory bowel disease, simple fístulas or acute suppurative processes were excluded. Before surgical intervention, all patients were subjected to a proctological examination, endorectal ultrasound and manometry. Early postoperative follow-up was performed 7 and 15 days after surgery, and from then on patients were evaluated every 30 days. The Jorge and Wexner incontinence scale was used to assess fecal continence. Results: A total of 13 patients were evaluated, seven men and six women. The average age was 57 ± 16 years. The repaired fístulas were transsphincteric in 12 cases (92 %) and 1 patient had horseshoe fístula. The mean length of the fistulous tract was 5.1 ± 1.2 cm. The incontinence score previous surgery was 7 ± 1.2, and postsurgical incontinence was zero. One patient presented more than one fistulous tract. Three patients (23%) were treated with setons 19 weeks before the PBP surgery. No complications were registered during surgery and the morbility rate was of 23%. The prosthesis was spontaneously expelled in three patients. No cases of relapse or incontinence were registered among the patients in which (whom ?) the prosthesis remained implanted. The percent of success in closing the fistulous tract was 76.9% (10 patients). ]Conclusion: These initial results allow us to conclude that treatment with PBP is safe and efficient, and is therefore a valid alternative for the treatment of complex fístulas.

[Surveillance colonoscopy before scheduled: is it worthwhile?]. / Vigilancia colonoscópica antes de Lo estipulado: tiene alguna utilidad?

OBJECTIVE: To determine de incidence of colonic polyps in colonoscopies performed before scheduled and to identifY the clinical and endoscopic features that predicted this finding. METHODS: All patients who underwent at least two complete colonoscopies less than three years apart were retrospectively identified in our computerized database. We excluded patients with high risk of colonic neoplasm requiring a new colonoscopy in less than three years. We analyzed the incidence of polyps before the first and third year after the first study, and the clinical and endoscopic features related to this finding by means of multivariate logistic regression. RESULTS: 378 paired colonoscopies fulfilled criteria, 129 were performed less than one year apart (group 1), and 249 less than three years apart (group 2). Regarding surveillance colonoscopies, 19% of patients presented adenomas and 1.5% high grade dysplasia (HGD) in group 1, and 21% presented adenomas and 2% HGD in group 2. In group 1 fair preparation (P = 0.03), and prolonged colonoscopy (P = 0.02) on the first study were independent predictors to find any polyp on the second study before scheduled. In group 2 fair cleansing (P = 0.04), history of sessile polyps (P = 0.01) and 3 or more polyps in the first study (P = 0.01) were independent predictors to find any polyp, while more than 5 polyps in the first study predicate adenomas. CONCLUSION: During the first year incident polyps related to difficult procedures (missed polyps?) while at 3 years the history of previous polyps was also important.

Laparoscopic approach to colonic perforation due to colonoscopy.

BACKGROUND: Iatrogenic perforation due to colonoscopy is the most serious complication of this procedure. Usually, resolution of this event requires segmental resection. The laparoscopic approach could be an option to minimize the outcome of this complication. The aim of the present study was to assess the effectiveness of the laparoscopic approach in treating colonic perforations due to colonoscopy. METHODS: Between July 1997 and November 2008 data were collected retrospectively on all patients who underwent colonoscopy and had a perforation caused by the procedure. Patients with other complications after colonoscopy as well as other colonic perforations were excluded. According to the method employed for the approach, the series was divided in two groups: those treated by the laparoscopic approach (group I; GI) and those treated via laparotomy (group II; GII). Morbidity and recovery parameters were compared between the two groups. Statistical analysis was performed using Student's t-test and the chi square test. RESULTS: A total of 14,713 colonoscopies were performed during the study period. Of these, 10,299 (73 %) were diagnostics and 4,414 (27%) were therapeutics. There were 20 (0.13%) iatrogenic perforations (GI = 14 versus GII = 6). The mean age of the patients was 62 +/- 12.1 years. There were no differences in patient demographics, co-morbidities, and American Society of Anesthesiologists (ASA) grades between the groups. Seventeen patients had segmental colectomy with primary anastomosis (GI: 13 versus GII: 4). One patient in each group had simple suture with diverting ileostomy, and one patient from GII underwent a Hartmann's procedure. Patients from GI had a shorter hospital stay (GI: 4.2 +/- 2.06 days versus GII 11.5 +/- 8.8 days; P = 0.007) and there were no differences in complication rate compared with GII (GI: 3 versus GII: 5; P = 0.058). CONCLUSIONS: Laparoscopic colectomy is effective in resolving colonic perforation due to colonoscopy, and it might offer benefits over the open approach.

Patients with less than three episodes of diverticulitis may benefit from elective laparoscopic sigmoidectomy.

BACKGROUND: This study was designed to asses the predictive factors of postoperative complications in patients who underwent a laparoscopic elective approach for recurrent diverticulitis and to determine the relationship between the number of acute episodes and surgical morbidity. METHODS: A retrospective analysis was performed on patients with colonic diverticular disease treated by an elective laparoscopic approach between July 2000 and November 2007. The variables studied were age, sex, BMI, ASA, number of previous acute episodes, local severity, abdominal surgery history, comorbidity, and laparoscopic training of the surgeon. Logistic regression analysis was used to establish significant results. RESULTS: A total of 137 patients were analyzed; 87 (63.5%) were men with a mean age of 56.7 (range, 27-89) years. Intraoperative and postoperative complications occurred in 2.9% (n = 4) and 12.4% (n = 17) of the patients respectively. Conversion rate was 9.4% (n = 13). Local severity (odds ratio (OR), 16.34; 95% confidence interval (CI), 4.1-64.5, p = 0.00007), history of abdominal surgery (OR, 3.02; 95% CI, 0.8-11.5; p = 0.02), and the training of the operating surgeon (OR, 4.8; 95% CI, 1.02-22.7; p = 0.001) were significant risk factors related to surgery conversion. A history of three or more acute episodes was significantly associated with a high severity of local process and was a risk factor related to conversion (OR, 2.6; 95% CI, 0.5-12.3; p = 0.22). The severity of the local process seems to be a risk factor for perioperative complications. A significant association (chi2, 4.45; p = 0.03) between conversion and postoperative complications also was observed (OR: 3.79, 95% CI, 1.02-14.07; p = 0.04). CONCLUSIONS: A history of three or more acute episodes of diverticulitis with conservative treatment is associated with a high severity of the local process during laparoscopic sigmoidectomy and increases the rate of conversion and perioperative complications.

Is a laparoscopic approach useful for treating complications after primary laparoscopic colorectal surgery?

PURPOSE: Although the use of laparoscopy for the management of postoperative complications has been previously well documented for different pathologies, there is scarce information regarding its use after laparoscopic colorectal surgery. METHODS: Data were prospectively collected from all patients undergoing laparoscopic colorectal surgery between June 2000 to October 2007. Patients were divided into two groups according to the approach used for the reoperation: laparoscopy (Group I) or laparotomy (Group II). Data were statistically analyzed by using Student's t-test and chi-squared test. RESULTS: In all, 510 patients were analyzed. Twenty-seven patients (5.2 percent), 14 men and 13 women (men/women Group I: 10/7 vs. Group II: 4/6; P = not significant (NS)), required a second surgery because of postoperative complications (Group I: 17 (63 percent); Group II: 10 (37 percent)). Mean age was 60 +/- 17 years (Group I: 61.7 +/- 17.7 vs. Group II: 57.1 +/- 16 years; P = NS). Fifteen patients (55.5 percent) had anastomotic leaks (Group I 13/17 (76.5 percent) vs. Group II 2/13 (15 percent); P = 0.004). The were no differences between the groups regarding the length of stay or postoperative complications (Group I: 11.9 +/- 9.6 vs. Group II: 18.1 +/- 19.7 days: P = NS; Group I: 1 vs. Group II: 3; P = NS). CONCLUSIONS: Laparoscopic approach is a useful tool for treating complications after laparoscopic colorectal surgery, especially anastomotic leaks. Randomized, controlled trials are necessary to validate these findings.

Laparoscopic colectomy: medial versus lateral approach.

BACKGROUND: Laparoscopic colectomy can be performed using 2 approaches: lateral or medial. However, it is unknown if one of these techniques provides better results. Thus, the object of the present study is to assess whether one of the approaches has any potential benefits over the other. METHODS: A comparative, retrospective study was performed that included all patients scheduled for left and right laparoscopic colon resection for both neoplastic and benign diseases between June 2000 and June 2006. The following factors were assessed: operation time, recovery variables (bowel sounds, passage of gases, intake of liquids and solids), length of hospital stay, and morbidity and mortality rates. The population was divided into 4 groups: right colectomy using a lateral approach (RL); right colectomy using a medial approach (RM); left colectomy using a lateral approach (LL); and left colectomy using a medial approach (LM). RESULTS: A total of 202 patients were evaluated: RL: 16 (8%); RM: 37 (18.3%); LL: 110 (54.4%); LM: 39(19.3%). No differences in recovery parameters were observed between the right colectomies. However, the presence of bowel sounds and solid intake was significantly earlier in the patients subjected to left colectomies using a medial approach. A tendency toward a higher conversion rate was observed in left colectomies with lateral approach (LL: 18 vs. LM: 1, P=0.052). The operation time was significantly shorter when a medial approach was used for both right and left colectomies (RL: 185.6 min vs. RM: 148.6 min, P=0.009; LL: 205.5 min vs. LM: 139.9 min, P<0.0001). No differences in the morbidity and mortality rates were found between lateral and medial approach in both types of colectomy. CONCLUSIONS: The use of a medial approach in a laparoscopic colectomy provides short-term benefits compared with a lateral approach.

Inflamación del remanente rectal (Cuffitis) posterior a una proctocolectomía total con reservorio ileal: reporte de caso y enfoque actual de tratamiento / Rectal cuff inflammation (Cuffitis) after total proctoclectomy with ileal pouch anal anastomosis: case report and current approach to treatment

La alternativa quirúrgica de elección para los pacientes con colitis ulcerosa (CU) refractaria al tratamiento médico es la proctocolectomía total con una reconstrucción a través de la confección de un reservorio ileal y una anastomosis ileo-anal. Esta cirugía permite la curación de la enfermedad con buen resultado funcional. A pesar de las demostradas ventajas, no está exenta de complicaciones. Una de las complicaciones es la inflamación sintomática del remanente rectal o cuffitis. Esta genera controversias importantes acerca de la técnica que debe utilizarse para la anastomosis ileo-anal debido a la asociación que presenta con la preservación de mucosa rectal en técnicas de sutura mecánica. El presente trabajo propone la revisión del tema y el análisis del enfoque actual de tratamiento, basada en un caso clínico.

Restorative proctocolectomy with ileal pouch is the treatment of choice in the majority of patients with ulcerative colitis (UC) refractory to medical treatment. This surgery can cure the disease with good functional outcome. Despite the proven benefits, is not without complications. One of the complications is symptomatic inflammation of the rectal remnant or cuffitis. This generates significant controversy about the technique to be used for the Ileo-anal anastomosis because of the association presented to the preservation of rectal mucosa in mechanical suture techniques. This paper proposes the review of the topic and analysis of the current approach to treatment based on one case.

Resultados de la pesquisa del cáncer colorrectal mediante videocolonoscopía en una población cerrada / Results of the colonoscopic colorectal cancer screening a community hospital

Antecedentes: La detección de lesiones preneoplásicas y del cáncer colorrectal a través de distintos estudios es efectiva para la prevención y el tratamiento de la enfermedad. Objetivo: Evaluar los resultados obtenidos con videocolonoscopías efectuadas a pacientes asintomáticos, sin riesgo de enfermedad neoplásica colorrectal. Diseño: Estudio retrospectivo. Población: Pacientes sometidos a videocolonoscopías, cuyo motivo de estudio fue pesquisa. Método: Se analizaron características demográficas, tipo y localización de los hallazgos patológicos. Resultados: De 1788 videocolonoscopías realizadas entre Marzo de 2005 y Marzo de 2006. 214 (12 %) fueron por pesquisa. 115 (54 %) pacientes fueron hombres y 99 (46 por ciento) mujeres, con una edad promedio de 59.6 (50-79) años. El estudio fue completo en el 96,7 por ciento. En 71 (33 %) estudios se halló patología. En el 60 por ciento de éstos se encontraron pólipos. La prevalencia de pólipos en esta población fue del 20 por ciento y de cáncer colorrectal del 1,4 %. Se hallaron 59 pólipos en 43 pacientes. 42,4 % fueron hiperplásicos, 52.5 por ciento adenomatosos y el 5,1 % cánceres. El 76.3 % de los pólipos se localizaron en colon izquierdo y recto y el 23,7 % en colon derecho. De los 31 pólipos adenomatosos, 7 (22,6 %) se hallaron en colon derecho (3 con displasia) y 24 (77.4 %) en el izquierdo (19 con diplasia). Los 3 cánceres se localizaron en el colon derecho. 7/59 pólipos midieron más de 10 mm, 5 en rectosigma (adenomatosos con displasía) y 2 en colon derecho (cánceres). No hubo complicaciones ni mortalidad asociadas al método. Conclusión: La videocolonoscopía es eficaz como método de pesquisa en una población cerrada.

Background: Colonoscopy is considered the most effective screening tool for detecting premalignant lesions and early colorectal cancer (CRC). Aim: To evaluate the results with colonoscopy for colorectal cancer screening in average risk patients. Design: Retrospective study. Patients and Methods: All patients that underwent colonoscopy for screening were included. Screening was defined as colonoscopic examination in asymptomatic patients, older than 50 years, within family history of CRC and within history of colon diseases. Demographic characteristics, type and location of pathological findings were analyzed. Results: From 1788 colonoscopies achieved between March 2005 and March 2006, 214 (12 %) were for screening. The mean age of the patients was 59,6 (50-79) years, and 54 % (115) were men. Colonoscopy to the level of the cecum was completed in 96,7 % of the patients. 71 (33 %) procedures showed some pathological finding. 60 per cent of them were polyps, 33per cent diverticular disease and other things in 7 per cent. The prevalence of polyps was 20 %, adenomas 11,2 % and CRC 1.4 %. We found 59 polyps in 43 patients, 76,3 % in the left colon, 31 were adenomas, 25 hyperplastic polyps and 3 CRC. 7 (22,6 %) of 31 adenomas were found in the proximal colon. And all (3) CRC were situated in the right colon. 7/59 polyps had a diameter of at least 10 mm, five of them were adenomas with some grade of dysplasia and two CRC. There were no morbidity and mortality associated with this procedure. Conclusion: Colonoscopy is an effective tool for colorectal cancel' screening in a Community Hospital.

Fistulas perianales. Artículo de revisión / Late results and treatment of anal fistulas: a revision

La fístula perianal es una entidad con alta incidencia. En general es la consecuencia de una infección perianal previa. La presente revisión incluye aspectos generales del examen clínico, métodos diagnósticos complementarios y se revisan, con mayor énfasis, las opciones terapéuticas clásicas y las más novedosas con sus respectivos resultados. Por último se aborda el manejo de la fístula perineal vinculada a la enfermedad de Crohn.

Laparoscopic-assisted proctocolectomy using complete intracorporeal dissection.

PURPOSE: Although many studies have demonstrated good results using laparoscopic proctocolectomy in patients with ulcerative colitis (UC), most surgical procedures require at least one additional incision larger than 5 cm to complete the surgery. The aim of this study was to evaluate the use of laparoscopic proctocolectomy with ileoanal J pouch, with a complete intracorporeal dissection using a 4-5 cm right lower quadrant (RLQ) incision. METHODS: Data were collected prospectively from all patients with UC that were subjected to a proctocolectomy with ileoanal J pouch between August 2003 and December 2006. The dissection was performed completely by laparoscopy using a medial-lateral approach for the colon and a total mesorectal excision for the rectum. Once the rectum was resected laparoscopically, a 4-5 cm incision in the RLQ was performed to resect the specimen and then an end or a loop ileostomy was implanted at the RLQ wound. The surgery was performed in two (proctocolectomy with ileoanal J pouch and loop ileostomy) or three steps (subtotal colectomy and end ileostomy with sigmoid fistula; proctectomy with ileoanal J pouch; and loop ileostomy). RESULTS: A total of 47 surgical procedures were performed in 32 patients with a mean age of 34.5 +/- 15.7 years, of which 56% were male. The mean body mass index was 21 +/- 16 kg/m(2); 50% of patients underwent surgery in two steps and the other 50% in three steps. Surgery was converted in five (10.6%) cases due to megacolon in one case, narrow pelvis in two, and difficult rectal dissection in two; the overall morbidity rate was 14.9%. Two patients required reoperation and no mortality was registered. The mean operative time was 248 +/- 62 min; proctocolectomy 292 +/- 61 min, subtotal colectomy 203 +/- 43 min, and proctectomy 248 +/- 47 min. The mean hospital stay was 4.8 +/- 1.9 days, and the mean interval time to close loop ileostomies was 64 +/- 12 days. CONCLUSIONS: A complete laparoscopic proctocolectomy dissection is feasible and safe for surgical treatment of UC.

Resección local en cáncer de recto: ¿es una estrategia oncológica adecuada? / Local excision for rectal cancer: is it an adquate oncologic strategy?

La aplicación de protocolos de pesquisa ha resultado en que el némero de tumores rectales diagnosticados tempranamente aumente de manera exponencial. Los avances en el terreno del diagnóstico y la selección de pacientes con neoplasias en fases iniciales de crecimiento han permitido implementar la resección local como una alternativa menos cruenta que mantiene la intención curativa. Inicialmente, esta táctica mostró resultados oncológicos similares a los obtenidos con cirugía convencional. Sin embargo recientmente, distintos estudios cuestionan su indicación a la luz de resultados oncológicos adversos. El presente artículo analiza los puntos controvertidos del tratamiento local para las neoplasias malignas del recto.

Cirugía de la colitis ulcerosa. Necesidad de una adecuada técnica quirúrgica. Presentación de un caso y revisión de la literatura / Surgery for ulcerative colitis. Need of an appropiate surgical technique. Case report and literature review

Los pacientes sometidos a proctocolectomía y reservorio ileal por colitis ulcerosa raramente desarrollan cambios inflamatorios, displasia o procesos neoplásicos en la mucosa rectal remanente. Comunicamos el caso de una paciente de 18 años que presentaba una colitis ulcerosa activa en el muñón rectal extremadamente largo, al cual se había anastomosado el reservorio ileal. Enfatizamos la necesidad de realizar la anastomosis al nivel de la linea dentada, o en la zona de transición anal.

Factibilidad de la colectomía laparoscópica en pacientes obesos / Feasibility of laparoscopic colectomy in obese patients

Antecedentes: Según algunos autores, los pacientes obesos podrían no verse beneficiados con el abordaje laparoscópico de la patología colónica, presentando un mayor número de complicaciones y un índice de conversión más elevado cuando se los compara con la población no obesa. Objetivo: Evaluar los resultados de la cirugía laparoscópica del colon en pacientes obesos y si estos son equiparables a los pacientes no obesos. Diseño: Análisis retrospectivo. Pacientes y Método: Se incluyeron todos los pacientes con patología colorrectal operados por vía laparoscópica. Se excluyeron las cirugías de urgencia, las paliativas y las combinadas. Se dividió la serie en dos grupos. I) Obesos: índice de masa corporal (IMC) > 30. II) No Obesos: IMC < 30. Se analizaron: índice de conversión, morbimortalidad perioperatoria, recuperación y estadía hospitalaria. Para el análisis estadístico se utilizaron el test t de Student y el Chi cuadrado. Resultados: De los 142 pacientes operados, 26 (18,3 por ciento) eran obesos y 116 (81,7 por ciento) no obesos. No se presentaron diferencias significativas entre ambos grupos en cuanto al tiempo operatorio, recuperación, ni morbilidad postoperatoria. El índice de conversión fue: Grupo I: 19 por ciento; Grupo II: 16 por ciento (P = NS) y la estadía hospitalaria de 3 ± 1 días para el Grupo I, y 3,6 ± 2 días para el Grupo II (P = NS). Conclusiones: Los pacientes obesos pueden beneficiarse con el abordaje laparoscópico en la patología colónica con resultados similares a los pacientes no obesos.

Background: Some authors think that obese patients do not obtain benefits with laparoscopic colonic surgery, and that they have more complications and an elevated conversion rate, when compare with non-obese patients. Aim: To evaluate the results of laparoscopic colon surgery in obese patients and compare them with the non-obese population. Design: Retrospective analysis. Patients and Methods: All patients who underwent elective laparoscopic colorectal surgery were included in the study. Patients operated on for emergency, palliative, and combined procedures were excluded. Patients were divided into two groups: Group I: body mass index (BMI) > 30 (Obese). Group II: BMI < 30 (Non-obese). Conversion rate, per-operative morbidity and mortality, recovery and length of hospital stay were assessed. Statistical analysis was performed using the Student t test and Chi-square test. Results: One hundred-forty-two patients were evaluated. There were 26 (18,3 per cent) in Group I and 116 (81,7 per cent) in Group II. There were no differences in operating time, recovery parameters, and postoperative complications between the groups. The conversion rate was 19 per cent in Group I and 16 per cent in Group II (P = NS) and the length of stay was 3 ± 1 days in Group I vs. 3,6 ± 2 days in Group II (P = NS). Conclusions: Laparoscopic colorectal surgery is feasible in obese patients, with the same benefits achieved in non-obese patients.

Estricturoplastia en pacientes con enfermedad de Crohn / Strictureplasty in patients with crohn's disease

Antecedentes: Desde su introducción en 1982 la estricturoplastia se ha convertido en una opción válida en el manejo quirúrgico de la enfermedad de Crohn obstructiva del intestino delgado. Objetivo: Análisis de la experiencia y evaluación de los resultados obtenidos en estricturoplastias. Diseño: Serie de casos. Estudio retrospectivo. Pacientes y métodos: Se incluyeron 17 pacientes a quienes se les realizó estricturoplastias por enfermedad de Crohn obstructiva del intestino delgado entre septiembre de 1992 y junio de 2005. Se analizó el tipo de cirugía, la morbilidad y la recurrencia. Resultados: Se realizaron 81 estricturoplastias, con una media de 4,7 (rango, 1-14) por paciente. En 73 (90,1 por ciento) pacientes se utilizó la técnica de Heineke-Mikuliczy en 8 (9,9 por ciento) la técnica de Finney. En 9 (52,9 por ciento) casos se realizó resección intestinal y estricturoplastia en forma simultánea. La morbilidad postoperatoria fue del 11,7 por ciento (un síndrome febril y una dehiscencia de la estricturoplastia). Presentaron recurrencia quirúrgica 3 (17,6 por ciento) pacientes luego de un seguimiento promedio de 36,4 (rango, 4-155) meses. Conclusiones: La estricturoplastia es eficaz y segura en pacientes con estenosis intestinal por enfermedad de Crohn.

Tratamiento quirúrgico de la enfermedad de Crohn abdominal / Surgical treatment of abdominal Crohn´s disease

Antecedentes: La mayoría de los pacientes con enfermedad de Crohn abdominal requieren de al menos una intervención quirúrgica durante la historia de la enfermedad. La incidencia de la enfermedad de Crohn es baja en los países subdesarrollados por lo cual es difícil obtener experiencia en el tratamiento de esta afección. Objetivo: Evaluar los resultados del tratamiento quirúrgico en pacientes con enfermedad de Crohn abdominal. Lugar de aplicación: Hospital de referencia. Diseño: Serie de casos. Estudio retrospectivo. Población: Se realizaron 52 cirugías en 42 pacientes entre abril de 1989 y abril de 2005. Método: Evaluación de indicación quirúrgica, tipo de cirugía, morbilidad y recurrencia de la enfermedad. Para el análisis estadístico se utilizó el test de chi cuadrado y el test de Student. Resultados: Treinta (71,4 por ciento) pacientes fueron hombres. La edad promedio fue de 37,1 (17-80) años. Se realizaron 35 cirugías en forma primaria y 17 por recurrencia de la enfermedad. Treinta y nueve (75 por ciento) fueron cirugías programadas y trece (25 por ciento) de urgencia. 8 procedimientos fueron efectuados por vía laparoscópica con 2 conversiones. Se realizaron 44 resecciones en 38 pacientes (25 ileocequectomías, 16 enterectomías, 1 colectomía subtotal, 1 colectomía izquierda, 1 resección segmentaria de sigmoides). Fueron realizadas un total de 93 estricturoplastías en 17 pacientes. El promedio de estricturoplastías por paciente fue de 5,4 (1-14). En 85 (91,4 por ciento) casos la técnica empleada fue la de Heinecke-Mickulicz mientras que en 8 (8,6 por ciento) se utilizó la técnica de Finney. En 10 (59 por ciento) casos se realizó resección y estricturoplastía en forma simultánea. El tiempo promedio de internación fue de 6,7 (2-21) días. La morbilidad temprana fue del 11,7 por ciento. Dos (3,9 por ciento) pacientes presentaron complicaciones alejadas, uno de ellos con síntomas de intestino corto. La mortalidad fue del 2 por ciento. Con un seguimiento promedio...

Tratamiento laparoscópico de la colitis ulcerosa: experiencia inicial / Results of laparoscopic technique in ulcerative colitis: preliminary experience

Antecedentes: La cirugía de la colitis ulcerosa comprende desde la realización de la colectomía subtotal hasta procedimientos más complejos como la proctocolectomía con realización de pouch ileal. Con el perfeccionamiento de la técnica laparoscópica es factible realizar estos procedimientos en forma segura. Objetivo: Analizar los resultados de la técnica laparoscópica en el tratamiento quirúrgico de pacientes con colitis ulcerosa. Lugar de aplicación: Sección Coloproctología. Servicio de Cirugía y Servicio de Gastroenterología. Hospital de comunidad. Diseño: Estudio retrospectivo. Población: Pacientes con diagnóstico de colitis ulcerosa operados por vía laparoscópica entre agosto de 2003 y agosto de 2004. Método: Se realizaron 12 procedimientos en 9 pacientes. El tiempo operatorio promedio fue de 287,5 minutos. Se registró una complicación intraoperatoria (8,3 por ciento). No hubo conversiones. El promedio de estadia hospitalaria fue de 5,5 días. La tasa de complicaciones postoperatorias fue de 25 por ciento y el índice de reoperaciones del 8,3 por ciento. Conclusión: La proctocolectomía con pouch ileal es factible de realizar por vía laparoscópica