[Treatment of chronic anal fissure with botulinic toxin type A]. / Tratamiento de la fisura anal crónica con toxina botulínica tipo A.

UNLABELLED: Anal fissure is a disease that generally affects to young people, but it can present at any age. PURPOSE: To show our experience in the treatment of chronic anal fissure with botulinum toxin type A. MATERIAL AND METHODS: This is a prospective, experimental and longitudinal study realized in the Coloproctology Unit in the General Hospital of Mexico City and in Medical North of Monterrey, Mexico, between June 2002 and November 2004. Direct variable was healing with 25 units of botulinum toxin. Secondary variables: age, sex, symptomatology, evolution time, localization of fissure, evolution after application of botulinum toxin, complications and time ofhealing. RESULTS: 35 (67.30%) were female and 17 (32.69%), male; age range, 21 to 64 years, with a medium of 43. At twelve months of toxin, application of 34 (65.38%) patients were asymptomatic, but in four fissure persisted. The other 18 patients were operated on due to persistence of the fissure. In a follow up of 18 months, 30 patients cured (57.69%), 4 improved (7.69%) and 18 (34.61%) were failures; one died by myocardial infarction and there were no recurrences. CONCLUSIONS: Botulinum toxin type A is a good alternative in the treatment of chronic anal fissure. Healing or improved with the application of 25 units of botulinum toxin was 65.38%.

[Results and analysis of Ferguson-type hemorrhoidectomy]. / Resultados y análisis de la hemorroidectomía tipo Ferguson.

BACKGROUND: We undertook this study to demonstrate the experience with Ferguson hemorrhoidectomy in the Coloproctology Unit in the Gastroenterology Service of the General Hospital in Mexico City. METHODS: A prospective, descriptive and observational study was designed and included patients with hemorrhoidal disease submitted to hemorrhoidectomy with Ferguson technique, from May 1999 to April 2004. Preoperative data included in the patient's chart was as follows: sex, age, time of evolution of symptoms, classification of hemorrhoids, associated disease, operative duration, immediate and late surgical complications and their management and healing duration. RESULTS: Five hundred eighty six patients fulfilled the inclusion criteria; 342 were male (58.36%) and 244 (41.69%) female. Average age was 43 years (range: 20-78 years). Occupation was not reported. Classification of hemorrhoids was 46 (7.85%), grade II; 396 (67.57%), grade III; 82 (13.99%), grade IV; and 62 (10.59%), massive hemorrhoid thrombosis. CONCLUSIONS: Results of this series conclude that perioperative morbidity is lower than reported in other series and that hemorrhoidectomy with Ferguson technique continues as the gold standard for treatment of this disease.

[Incidence, diagnosis and treatment of colovesical fistula]. / Incidencia, diagnóstico y tratamiento de la fístula colovesical.

BACKGROUND: Enterovesical fistula, also known as vesicoenteric fistula, is an abnormal communication of the vesical bladder with a segment of the digestive tract. We undertook this study to describe diagnostic and therapeutic methods to treat colovesical fistula (CVF) in patients who attended the Coloproctology Unit of the Gastroenterology Service of the General Hospital in Mexico City. METHODS: This is a descriptive study in CVF patients carried out from January 2001 to June 2006; descriptive statistics were used for analysis of information. RESULTS: Eleven patients were identified (10 males and 1 female). Average age was 54.72 years (range: 39-73 years). Time from onset of symptoms to diagnosis was on average 11.9 months. The most frequent signs and symptoms were fecaluria, pneumaturia, dysuria, hematuria and chronic abdominal pain in hypogastric and left iliac regions. Nine patients were submitted to sigmoidectomy and primary colorectal anastomosis. Hartmann procedure was carried out in one patient with restoration of intestinal transit 6 weeks later. In one patient, a loop colostomy was built as a first operation, with sigmoidectomy with fistula resection as a second operation, and restoration of intestinal transit as the third. CONCLUSIONS: Surgery is the only treatment that assures cure and avoids relapses. Sigmoidectomy and primary anastomosis must be considered as the treatment of choice. Mortality, although low, continues being a negative factor when surgery is indicated in these patients.

[Complex anal fistula treated with cutting seton]. / Setón de corte en el tratamiento de la fístula anal compleja.

BACKGROUND: Anorectal sepsis is a frequent condition presenting in the office of colorectal specialists. The acute phase presents as an abscess and the chronic phase as a fistula. We undertook this study to report the experience of the Coloproctology Unit of the General Hospital of Mexico in the management of complex anal fistula with cutting seton. METHODS: From May 1999 to April 2004, 11,731 clinical cases were reviewed. Inclusion criteria were patients with complex anal fistula treated using the cutting seton technique and 6 months minimum follow-up after withdrawal of seton. RESULTS: There were 742 fistulous patients among which 50 fulfilled inclusion criteria. There were 44 males and 6 females. Fistulas were classified as high transsphincteric in 41 patients, suprasphincteric in 8 patients, and high intersphincteric in one patient. On average, patients were followed-up during 9.67 postoperative examinations and on average there were 4.55 adjustments. The average permanence of seton was 7.02 months. CONCLUSIONS: Management of complex anal fistula continues to be a challenge for surgeons. Cutting seton is an appropriate surgical option for patients with no alteration of continence and is useful for patients with high transsphincteric, suprasphincteric and, in some cases, extrasphincteric fistula. In women with low anterior transsphincteric fistula, this option must be considered as an alternative.

[Hidradenitis suppurativa]. / Hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa is an inflammatory, chronic and recurrent disease of appocrine glands, located in inguinal, axillar, perineal, perianal areas and scalp. OBJECTIVE: To determine the frequency and therapeutic management. METHODS: A retrospective, transverse, and descriptive study was carried out. All patients with hidradenitis suppurativa, and who were managed by the Coloproctology Unit from the Gastroenterology Service of the General Hospital of Mexico City from January 1995 to December 2004, were included. RESULTS: We reviewed 12,689 files and identified 15 patients (0.12%) with hidradenitis suppurativa; nine fulfilled inclusion criteria. CONCLUSIONS: This is a complex disease with a diagnostic and therapeutic challenge.

[Non-surgical alternative management of hemorrhoidal disease]. / Manejo alternativo no quirúrgico de la enfermedad hemorroidaria.

UNLABELLED: Clinical manifestations of hemorrhoidal disease depend on its location (internal or external) and the presence or not of complications. PURPOSE: To describe the results of the three most common alternatives for non-surgical procedures treating internal hemorrhoids: rubber band ligation, esclerotherapy and infrared photocoagulation. MATERIALS AND METHODS: A retrospective, longitudinal and descriptive study from January 1998 to December 2002 was carried out, including variables like age, gender, clinical manifestations and date of initiation, type of non-surgical alternative treatment, complications, management and stage of the illness. RESULTS: In 9,103 charts reviewed this study included 2,701 patients with hemorrhoidal disease, with an annual incidence of 540.20 patients; 1,388 (51.39%) were male and 1,313 (48.62%) were female; ages between 17 and 78 years, 44.10 as a mean age. Rubber band ligation was used in 516 patients (67.45%), esclerotherapy in 177 (23.13%) and infrared photocoagulation in 72 cases (9.41%). CONCLUSIONS: Rubber band ligation is mainly indicated for internal hemorrhoids II degree, the esclerotherapy is indicated in the suppression of acute hemorrhage, but in the long term, this method has the poorest results. Infrared photocoagulation has its best results in internal hemorrhoids I degree because it causes less pain and complications and patients accept it better.

[Surgical alternatives in the treatment of anal abscesses]. / Alternativas en el tratamiento quirúrgico de los abscesos anales.

INTRODUCTION: Anal abscess is a pus collection localized in some of the regions around the anus and rectum. We reviewed the experience in the management of abscesses in Coloproctology Unit at the Gastroenterology Service in the General Hospital of Mexico. MATERIAL AND METHODS: This is a retrospective, longitudinal and descriptive study in patients diagnosed as carriers of an anal abscess during the period from January 1998 to December 2002. RESULTS: During this period, 9,233 first consultations took place, 241 fulfilled inclusion criteria: 197 (81.74%) were male and 44 (18.25%) were female. Perianal abscesses affected 156 patients (64.73%), 51 ischiorectal abscesses (21.16%), 17 horseshoe (7.05%), 14 intersphincteric (5.80%) and 3 has supralevator abscesses (1.24%). CONCLUSIONS: There were 96.68% nonspecific anal abscesses. Simple drainage is an initial adequate management. Most patients (73%) were attended in the office. Pain was the most common symptom (99%). Perianal and ischiorectal localizations were the most frequently classified and there was no mortality.

[Surgical management of anal fistula]. / Manejo quirúrgico de la fístula anal.

UNLABELLED: Anal fistula has been known since the beginning of medical history and is defined as a duct of fibrous infected walls that runs from anal crypt to skin or rectal lumen. Internal orifice is called primary or internal, while cutaneous orifice is referred to as secondary or external. Several techniques have been developed for surgical management of anal fistula, including fistulotomy, fistulectomy with or without sphincter repair, placement of sedal cutting or seton drainage, endorectal advancement flap, and fibrin glue, among others. GENERAL OBJECTIVE: Our aim was to demonstrate the experience in management of anal fistula at the Coloproctology Unit, Gastroenterology Service, of the Mexico City General Hospital. MATERIALS AND METHODS: We conducted a retrospective, longitudinal, and descriptive study in patients with anal fistula. All patients had complete clinical and proctologic studies and pre-operative laboratory analysis. RESULTS: A total of 8,816 files were reviewed from January 1997 to December 2001; 642 (7.28%) patients were carriers of a fistula, but only 595 satisfied inclusion criteria; 500 (84.03%) were male and 95 (15.97%), female, with annual incidence of 119. Average global age was 34 years (37 years in males and 28 years in females). Age range was 17 to 80 years; most frequent decades were 31 to 40 years in 197 patients (33.11%) and 41 to 50 years in 140 patients (23.53%). Anal fistula was intersphincteric in 351 (59%) and transsphincteric in 149 (25.04%). Fistulectomy was carried out in 422 patients (70.92%), fistulotomy in 108 (18.15%), seton division in 22 (3.69%), sedal in 10 (1.68%), seton drainage in two (0.33%), endorectal advancement flap in five (0.84%), fistulectomy with sphincter repair in 14 (2.35%) patients, and in 12 (2.0%) patients it was impossible to know what type of treatment had been carried out. DISCUSSION: The fundamental aims to accomplish in treatment of anal fistula include curing, preserving anal continence, minimizing healing defects, and offering to the patient a quick recovery.

[Hemorrhoidal desarterialization guided by Doppler. A surgical alternative in hemorrhoidal disease management]. / Desarterialización hemorroidaria guiada por Doppler. Una alternativa quirúrgica en el manejo de la enfermedad hemorroidaria.

BACKGROUND: Hemorrhoidal disease is a common condition that includes 30% of patients seen for the first time at the Colon and Rectal Unit of the Gastroenterology Service, Hospital General in Mexico City. This study shows experience with hemorrhoidal desarterialization guided by Doppler in patients with internal hemorrhoidal disease stages II or III in the Coloproctology Units of the Hospital General in Mexico City and at the North Medical Unit in Monterrey, Nuevo Leon, Mexico. MATERIALS AND METHODS: A prospective, longitudinal, and descriptive study was performed in 56 patients with diagnosis of internal hemorrhoids stages II or III, not complicated, and treated by hemorrhoidal artery ligation guided by Doppler between July 1, 2002 and April 31, 2003. RESULTS: 49 patients were included, 32 male (66%) and 17 female (34%), aged between 21 and 75 years with mean age of 43.5 years; 40 patients had internal hemorrhoids stage II (82%) and nine, stage III (18%). With a follow-up of 4 months or longer, all patients were symptomless: bleeding and hemorrhoidal prolapse disappeared. CONCLUSIONS: Doppler-Guided hemorrhoidal desarterialization is indicated in patients with internal hemorrhoids stages II or III; it is a simple technique that requires a short learning curve, minimal anesthetic and surgical materials, and pain after the procedure is mild and short-lived in the majority of patients.

[Management of the rectovaginal fistula. A review of five years at the Colon and Rectal Unit of the General Hospital of Mexico City]. / Manejo de la fístula rectovaginal. Revisión de cinco años en la unidad de coloproctología del Hospital General de México.

BACKGROUND: Rectovaginal fistula, although infrequent, produces considerable discomfort to the patients and disables them in their social life. OBJECTIVES: To review and report the experience in the management of rectovaginal fistula in the Colon and Rectal Unit of the General Hospital of Mexico City, from January 1997 to December 2001. MATERIAL AND METHODS: A retrospective, observational and descriptive study was designed including all patients diagnosed with rectovaginal fistula, who had not been previously operated for this condition in the Colon and Rectal Unit of the General Hospital of Mexico City from January 1977 to December 2001. RESULTS: Thirty-eight patients were included, aged between 17 and 70 years with a mean age of 24. The etiology of the rectovaginal fistulas was: obstetric trauma in 21 patients (55.2%), post-surgical in 5 (13.1%), traumatic in 5 (13.1%), after radiotherapy in 5 (13.1%) and malignant in 2 (5.2%). DISCUSSION: Rectovaginal fistula treatment relies on fistula classification (simple or complex), its location, and damage or not to the sphincter mechanisms and prior surgical repair. CONCLUSIONS: The most frequent surgical approach was the creation of a fourth degree perineum laceration and reconstruction (45.7%), followed by the advancement flap (25.7%). Complex fistulas were handled with a stoma. The surgical approach of rectovaginal fistula must rely on etiologic, anatomic and physiologic basis.

Hidradenitis suppurativa / Hidradenitis suppurativa

Introducción: la hidradenitis supurativa es una enfermedad inflamatoria, crónica, recurrente, originada en las glándulas apocrinas; se puede localizar en axila, ingle, periné, región anoperineal y cuero cabelludo. Objetivo: conocer la frecuencia y el manejo terapéutico. Material y métodos: se trató de un estudio retrospectivo, transversal y descriptivo, Se incluyeron los pacientes portadores de hidradenitis supurativa atendidos en la Unidad de Coloproctología del Servicio de Gastroenterología, Hospital General de México, de enero de 1995 a diciembre de 2004. Resultados: se revisaron 12,689 expedientes clínicos y se identificaron 15 pacientes (0.12 %), de los cuales nueve cumplieron los criterios de inclusión. Conclusiones: la hidradenitis supurativa es una enfermedad compleja que constituye un reto diagnóstico y terapéutico.

BACKGROUND: Hidradenitis suppurativa is an inflammatory, chronic and recurrent disease of appocrine glands, located in inguinal, axillar, perineal, perianal areas and scalp. OBJECTIVE: To determine the frequency and therapeutic management. METHODS: A retrospective, transverse, and descriptive study was carried out. All patients with hidradenitis suppurativa, and who were managed by the Coloproctology Unit from the Gastroenterology Service of the General Hospital of Mexico City from January 1995 to December 2004, were included. RESULTS: We reviewed 12,689 files and identified 15 patients (0.12%) with hidradenitis suppurativa; nine fulfilled inclusion criteria. CONCLUSIONS: This is a complex disease with a diagnostic and therapeutic challenge.

Leiomiosarcoma colorrectal: reporte de dos casos / Colorectal leiomyosarcoma: report of two cases

Casi todos los sarcomas colorrectales son leiomiosarcomas, que se originan en las células del músculo liso de la pared intestinal. Los síntomas de presentación y los hallazgos endoscópicos no son específicos, por lo que se requiere exploración quirúrgica para su diagnóstico. La resección completa es posible en el 50 a 60 por ciento de los casos. Las metástasis a la cavidad peritoneal e hígado son comunes. Sólo en 10 a 20 por ciento de los casos en quienes se practica resección completa presentan curación. Los pacientes con tumores de grado bajo de malignidad presentan una mayor supervivencia. A pesar de que los rangos de curación son bajos, la resección radical es un buen método paliativo. Ni la radioterapia ni la quimioterapia han mostrado ser efectivas como terapias adyuvantes. El papel de la resección preservadora de esfínteres y la excisión local en sarcomas rectales no es claro. El tratamiento convencional de las lesiones del tercio medio e inferior del recto es la resección abdominoperineal. En los tumores del colon, la resección segmentaria está indicada. La excisión local se fundamenta en la baja incidencia de metástasis a ganglios linfáticos locales en sarcomas colorrectales, pero la mayoría de los datos existentes sugieren que los rangos de recurrencia con excisión local son altos. Se presentan dos casos de pacientes masculinos atendidos en la Unidad de Coloproctología del Hospital General de México, los cuales presentaron rectorragia, pérdida de peso y marcadores inmunohistoquímicos positivos, con diagnóstico definitivo de leiomiosarcoma. La resección abdominoperineal para leiomiosarcoma del recto y la sigmoidectomía para leiomiosarcoma de sigmoides fueron los tratamientos quirúrgicos.Palabras clave: Leimiosarcoma colorrectal.

Fístulas anales complejas / Complex anal fistulae

Antecedentes: Las fístulas anorrectales ponen a prueba la experiencia de los cirujanos del colon y recto. Objetivo: Este artículo de revisión se realizó para discutir los avances más recientes en el diagnóstico y tratamiento de las fístulas anales complejas. Resultados: Las fallas en el tratamiento de las fístulas anorrectales pueden ser minimizadas mediante el conocimiento completo de la anatomía anorrectal y de los múltiples trayectos que pueden ocacionar las fístulas. Su complejidad está determinada por su tipo, especialmente con relación al aparato esfinteriano, que obliga a extremar el cuidado para su identificación correcta y la diferenciación de su origén. La planeación del tratamiento debe individualizarse a cada paciente que las padece. Conclusiones: El papel de las diferentes alternativas quirúrgicas dependerá de las características y relaciones del trayecto fistuloso y el esfínter

La fotocoagulación por rayos infrarrojos en el tratamiento de la enfermedad hemorroidaria / Infrared photocoagulation in hemorrhoidal disease treatment

Propósitos. Evaluar la eficacia de la fotocoagulación por rayos infrarrojos en el tratamiento de la enfermedad hemorroidaria grados I y II, en el Servicio de Coloproctología del Hospital General de México de la SSa. Material y métodos. Se incluyeron 60 pacientes con hemorragia transanal como síntoma único, sin patología anorrectal agregada. Fueron 30 pacientes del sexo femenino y 30 del sexo masculino, con una edad media de 39.9 años. Cada paciente recibió de 1 o 4 sesiones de fotocoagulación de acuerdo con los resultados que se obtuvieron en cada una. Se utilizó el fotocoagulador marca Redfield. Técnica. La aplicación de los disparos fue en forma de diamante o en arco iris, con una duración de 1.5 segundos cada uno. El tiempo de seguimiento fue de 24 meses. Resultados. Se obtuvo respuesta favorable en el 66.6 por ciento de los casos a partir de la segunda aplicación, y del 93.4 por ciento al término del estudio; en 4 pacientes (6.6 por ciento no hubo respuesta favorable y fueron tratados quirúrgicamente. Conclusiones. El tratamiento de la enfermedad hemorroidaria con fotocoagulación por rayos infrarrojos ofrece una buena alterantiva en los grados I y II, es indoloro, no requiere hospitalización y su costo es bajo