[Sacral root neuromodulation as treatment for fecal incontinence. Preliminary results]. / Neuromodulación de raíces sacras como tratamiento de la incontinencia fecal. Resultados preliminares.

We present our initial experience in the treatment of fecal incontinence (FI) with sacral root neuromodulation (SRN) by reporting the results of a prospective study with 26 patients where baseline Wexner-Cleveland scale scores and ability to delay defecation were compared to results after one year with SRN. The initial study of patients included history taking, general examination, anal ultrasonography, and manometry, and a three-week diary of continence and quality of life specific for FI was used. Before SRN the mean baseline Wexner-Cleveland score was 15.00 +/- 1.81, and 62.50% of patients could only delay defecation for less than a minute. After a year with NRS the mean Wexner-Cleveland score was 4.87 +/- 2.54 (p = 0.0031), and 75.01% of patients could delay defecation above fifteen minutes (p = 0.0018). We also describe the surgical technique and its indications, and finally review the various therapeutical options for FI and show our algorithm for this condition. SRN is an effective technique for the treatment of FI in properly selected patients with no response to medical therapies (including biofeedback) or anatomic correction (sphincteroplasty), with efficacy, little morbidity, and a short hospital stay.

[Treatment of proctalgia fugax with botulinum toxin: results in 5 patients]. / Tratamiento de la proctalgia fugax con toxina botulínica: resultados en 5 pacientes.

INTRODUCTION: Proctalgia fugax can be defined as transitory but recurrent anal pain. Although its etiology remains unknown, an internal anal sphincter spasm seems to be the most likely, so that the different treatments focus on reducing the pressure of the internal anal sphincter. This study is aimed at evaluating the effectiveness of botulinum A toxin in the treatment of proctalgia fugax. PATIENTS AND METHODS: Prospective clinical trial of patients with proctalgia fugax treated with botulinum A toxin at the Outpatient Clinic attached to the Coloproctogy Unit, University Hospital of Elche, from January 1999 to January 2002. The patients included in the study underwent rectal digital examination, anuscopy, rectoscopy, anal manometry and ultrasonography, barium enema and pelvic CT scan to rule out any organic cause for anal pain. The treatment consisted of 25 IU of botulinum A toxin, with a supplementary dose of 50 IU in those patients with persistence of anal pain episodes within the next two months. The patients were reviewed on the first week, second month, sixth month and first and second year. Anal pain was measured by the patients, using a linear analogue scale from 0 to 10, and continence was assessed at every visit using the Cleveland Continence Grading Scale. RESULTS: Five patients were recluted for the study, with a predominance of females (4 vs. 1). Mean age was 45 years. Length of symptoms prior to the treatment was 13 months (range: 6-18 months). Only one female patient required a second dose of botulinum A toxin to handle the anal pain. All the patients healed and remained free of pain up to finishing the follow-up. There were no local complications. Anal manometry showed an increased MRP (mean resting pressure) in comparison to a control group of patients (114 mmHg vs. 66 mmHg; p < 0.001) that restore to normal values after the treatment (75.65 mmHg). As for the MSP (mean squeeze pressure), it showed no difference with respect to the control group nor did it vary after the treatment. CONCLUSION: Botulinum A toxin offers a high rate of healing with no associate morbidity in the treatment of proctalgia fugax.

Open lateral internal anal sphincterotomy under local anesthesia as the gold standard in the treatment of chronic anal fissures. A prospective clinical and manometric study.

BACKGROUND: Chronic anal fissure is one of the most frequent proctological disorders in Western populations. Open lateral internal sphincterotomy is one of the therapeutic options accepted as the treatment of choice for chronic anal fissure, since it reduces the hypertonia of the internal anal sphincter (the main etiopathogenic mechanism of fissures), decreases anal pain, and allows the fissure to heal. MATERIAL AND METHODS: We carried out a prospective study of 120 patients operated on for chronic anal fissure with open sphincterotomy under local anesthesia at our Proctology Outpatient Unit from 1998 to 2001. No preoperative studies, bowel preparation, or antibiotic prophylaxis were carried out. All patients were followed up after 1 week, 2 months, 6 months, and 1 year, and underwent an anal manometry before and after surgery. RESULTS: Early complications: 3 hematoma-ecchymosis of the wound (2.5%), 3 self-limited hemorrhage events (2.5%). No hemorrhoidal thrombosis, fistulas, or perianal abscesses occurred. Fissures recurred in nine patients (7.5%) within one year. The initial rate of incontinence of 7.5% at two months dropped down to 5% at six months. The mean resting pressure (MRP) in incontinent patients was lower than in continent patients (55 +/- 7 mmHg versus 80.7 +/- 21 mmHg). The difference in mean squeeze pressure (MSP) between incontinent patients and continent patients was not statistically significant. CONCLUSIONS: Open sphincterotomy under local anesthesia has a long-term rate of healing and a morbidity rate similar to other techniques. It may therefore be considered an effective treatment for chronic anal fissure.

Effectiveness of rubber band ligation in haemorrhoids and factors related to relapse.

PURPOSE: to assess the effectiveness of ambulatory rubber band ligation (RBL) in the treatment of symptomatic internal haemorrhoids and to identify factors related to relapse. PATIENTS AND METHODS: prospective study of 232 patients treated with rubber band ligation for symptomatic haemorrhoids (grade I-III or grade IV with severe contraindication for surgery) from November 1996 to November 2000 at the outpatient clinic. Ligation was performed with a Stille AB (Comedic) ligator and suction pump, placing 1-3 bands per session and with up to three sessions per patient. Effectiveness of treatment was defined as the absence of symptoms and was confirmed by anoscopy by checking the residual scar after the cushions' detachment. Categorical variables were compared using the shi-squared test, whereas Student's t-test was used for continuous variables. Logistic regression was employed to identify clinical factors related to relapse. RESULTS: a total of 331 bands were placed during 235 sessions in the 163 patients who completed follow-up (70%). Mean age was 45.6 years, with males accounting for 64.4%. Most patients (86.5%) had grade II or grade III haemorrhoids. Overall morbidity was 6%. The most frequent complications were rectal tenesmus (11%), slight or mild anal pain (7.4%), dysuria (4.3%) and transient anal bleeding (3.7%). The treatment was effective in 86% of patients after a mean follow-up of 32 months. Efficacy was high for grades I and II (100% and 97.4% ) but decreased for grade III (69.8%; p<0.001) and grade IV (0%; p<0.001). Most relapses occurred within the first 24 months (87%) and were not significantly related to age, gender, duration of symptoms, itching, bleeding, pain, tenesmus or bowel habit, but were significantly related to the presence of prolapse and its grade (p<0.001), and to the involvement of left posterior, right lateral and anterior pedicles (p<0.05). CONCLUSIONS: ambulatory RBL is a safe and effective treatment for grade I, II and III symptomatic haemorrhoids, and is associated with low morbidity. Recurrence is uncommon and occurs mainly within the first 24 months, being related to the presence and grade of prolapse as well as to its location, but bears little relation to the rest of factors analysed.

[Management of colostomies with plug: clinical aspects and patient evaluation]. / Manejo de las colostomías mediante obturador: aspectos clínicos y evaluación de los pacientes.

AIM: To assess the effectiveness of the one-piece disposable plug device Conseal (Coloplast A/S, Espergaerd, Denmark) in colostomy patients, considering clinical and social aspects. PATIENTS AND METHODS: Twenty patients with definitive (perineal-abdominal amputation 17 cases) or transitory (Hartmann in 3 cases) colostomy were studied prospectively. No patient used self-irrigations. All of them completed the study. After obtaining the patient's consent, we analyzed for comfort, leaks, security, easy handling and skin conditions by means of personal interview and clinical examination. RESULTS: Sixteen patients (80%) had previously used conventional colostomy bags, 4 (20%) started to use the plug device during the postoperative period (average 8.7 days). Fifteen patients (75%) preferred to use the plug, whereas 5 (25%) considered the plug was insecure. CONCLUSIONS: Our study suggests that the one-piece disposable plug device improves the quality of life in patients with colostomy, although adequate selection of patients and previous training are mandatory.

Effect of atropine and truncal vagotomy on the exocrine pancreatic function in dogs stimulated with intraduodenal tryptophan.

The purpose of this experimental study was to analyze the effect of different doses of atropine and bilateral transthoracic truncal vagotomy on pancreatic secretion. We chose the dog as our experimental model and used the modified Thomas method to obtain gastric juice, removing the gastric acid with a gastric cannula. An additional duodenal cannula was used for the selective intubation of the greater pancreatic duct in order to obtain pure pancreatic juice. To stimulate pancreatic secretion the pancreas was stimulated with intravenous secretin at a constant dose and intraduodenal tryptophan at gradually increasing doses. The juice was collected at 10-min intervals and volume, output of bicarbonate and protein were determined. The results obtained show that low doses of atropine (0.65, 1.25 and 5 micrograms/kg/h) strengthen the suppressive effect of truncal vagotomy on the hydrobicarbonate secretion. Greatest suppression was found in the highest dosage of atropine in response to the intraduodenal tryptophane at gradually increasing doses. The above results suggest the possible existence of local enteropancreatic cholinergic reflexes that are readily suppressed by atropine and vagotomy. Suppression is not global though, since there is no significant reduction in the pancreatic protein secretion, which shows a dosage-effect curve in response to the gradually increasing doses of intraduodenal tryptophan released by the action of endogenous cholecystokinin. Our hypothesis is that there exists a nonvagal enteropancreatic cholinergic reflex.

[Hepatocarcinoma: a rare form of presentation]. / Hepatocarcinoma: forma infrecuente de presentación.

A case of acute abdomen presenting with pain in the right upper abdomen, pyrexia and leukocytosis is presented. At laparotomy, hepatocarcinoma with necrosis and associated acute cholecystitis was found. This is apparently an unusual report of hepatocarcinoma presenting as acute cholecystitis.

[Immuno-nutritional prognostic factors in acute cholecystitis]. / Estudio de factores pronósticos inmunonutricionales en la colecistitis aguda.

A set of parameters that could be used to identify possible immunonutritional disturbances and serve as clinical evolution markers were measured in 210 patients diagnosed of acute cholecystitis (136 females and 74 males, 64.8 and 35.2% respectively) who were admitted into the Surgery Service of the Hospital General de 1++Elche. The prognostic evaluation indices were: a) Nutritional: hematocrit, hemoglobin, total protein, albumin, transferrin; b) Immunological: total lymphocytes and delayed hypersensitivity reaction test. The results obtained were analyzed and compared to those of the literature in this field.

[Bacteriologic findings as a prognostic factor in the course of acute cholecystitis]. / Hallazgos bacteriológicos como factor pronóstico en la evolución de la colecistitis aguda.

We made a bacteriological study of bile in a consecutive study of 210 patients studied in the General Surgery Department of the General Hospital of Elche (Spain) who underwent cholecystectomy for acute lithiasic cholecystitis, as a prognostic factor in the clinical evolution of these patients. The results obtained led us to the following conclusions. 1. The presence of positive bile culture is a risk factor predisposing to postoperative septic complications. 2. Bile cultures were more frequently positive in patients over 60-years-old. 3. In the early stages of the disease, positive cultures were more frequent. 4. The organism most often isolated was E. coli, so antibiotic treatment should be directed mainly against this agent.

[Primary adenocarcinoma of the duodenum]. / Adenocarcinoma primitivo del duodeno.

Two cases are presented of primitive adenocarcinoma of the duodenum diagnosed and treated in the General Surgery Department of General Hospital of Elche (Spain) during the 10 years of its existence. The two patients were women, one a 45-year-old who consulted for pain, epigastric discomfort and melenas, and the other a 76-year-old who consulted for paraneoplastic syndrome and a palpable mass in the right lower quadrant. Radical resection was performed, with cephalic duodenopancreatectomy in the first case and atypical local resection of the first and second duodenal portions, gastric antrum and gallbladder in the second case. Six and 4 years after operation, respectively, the two patients are alive and asymptomatic. We comment the most important aspects of this rare disease in relation to the pecularities of our cases. We insist on the appropriateness of surgical resection as an effective therapeutic option.