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2.
J Visc Surg ; 157(5): 395-400, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31954631

RESUMEN

AIM: Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome. PATIENTS AND METHODS: A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. RESULTS: One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P=0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P=0.16), Major (Clavien-Dindo score of 3 or more) complications (P=0.19), Minor (Clavien Dindo 1-2) and no complications (P=0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P=0.4). CONCLUSION: Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.


Asunto(s)
Colostomía/métodos , Diverticulitis del Colon/cirugía , Perforación Intestinal/cirugía , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Puntaje de Propensión , Curva ROC , Estudios Retrospectivos , Factores de Tiempo
3.
World J Surg ; 43(2): 497-503, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30361746

RESUMEN

BACKGROUND: There is debate concerning the need for specialist neurosurgical transfer of patients presenting to Level II trauma centers with a minimal head injury (Glasgow Coma Scale ≥13) and a small non-progressive intracranial bleeding (ICB). METHODS: A retrospective chart analysis was performed assessing the outcomes of adult patients presenting with a minor traumatic ICB on initial CT scan (minimal subarachnoid hemorrhage; small-width subdural hematoma without shift; punctate cerebral contusion). Patients with extradural hematomas and those patients on antiplatelet or anticoagulant therapy were excluded from the protocol. RESULTS: Overall 291 cases were assessed (mean age 69.9 years) with 75% of cases presenting after a fall. There was deterioration of neurological status in 11 patients (3.8%) with 8 hospital transfers and 5 with an abnormal neurological examination (NE). Two patients with an abnormal INR and a worsening head CT were transferred without neurosurgical intervention. Of the 8 transferred cases there were 2 deaths (both >90 years of age with multiple comorbidities) with one craniotomy performed for a subdural hematoma (with full recovery). Three patients meeting transfer criteria were not transferred with one death (patient >90 years of age with severe dementia). The remaining 2 patients were discharged with normal neurological outcomes. CONCLUSIONS: Patients with a minimal traumatic brain injury and a non-progressive minor ICB may be safely managed in a Level II trauma center by an acute care consultant with neurosurgical consultation but without the need for neurosurgical transfer. LEVEL OF EVIDENCE: Retrospective analysis: Level IV.


Asunto(s)
Hemorragia Cerebral Traumática/cirugía , Consultores , Traumatismos Craneocerebrales/cirugía , Centros Traumatológicos , Adulto , Anciano , Anciano de 80 o más Años , Hemorragia Cerebral Traumática/diagnóstico por imagen , Traumatismos Craneocerebrales/diagnóstico por imagen , Femenino , Escala de Coma de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tomografía Computarizada por Rayos X
4.
Tech Coloproctol ; 22(2): 81-87, 2018 02.
Artículo en Inglés | MEDLINE | ID: mdl-29204724

RESUMEN

Hartmann's procedure, colonic resection with an end colostomy and rectal closure, is used in a variety of surgical emergencies. It is a common surgical procedure that is often practiced in patients with colonic obstruction and colonic perforation, resolving the acute clinical situation in the majority of cases. Reversal of Hartmann's procedure with restoration of bowel continuity occurs in a significantly low percentage of patients. There are several reasons contributing to the fact that many patients remain with a permanent colostomy following Hartmann's procedure. These include factors related to the patients' clinical status but also to the significant difficulty and morbidity related to the surgical reversal of Hartmann's procedure. The aim of this study was to review the factors related to the fairly low percentage of patients undergoing Hartmann's reversal as well as surgical techniques that could help surgeons restore intestinal continuity following Hartmann's procedure and deal with the postoperative outcomes.


Asunto(s)
Colectomía/métodos , Colostomía/métodos , Complicaciones Posoperatorias/cirugía , Proctocolectomía Restauradora/métodos , Reoperación/métodos , Adulto , Anciano , Anastomosis Quirúrgica/métodos , Colon/cirugía , Enfermedades del Colon/cirugía , Femenino , Humanos , Obstrucción Intestinal/cirugía , Perforación Intestinal/cirugía , Masculino , Persona de Mediana Edad , Recto/cirugía , Resultado del Tratamiento
5.
Surg Oncol ; 24(3): 145-52, 2015 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-26303826

RESUMEN

AIM: Epidemiological studies have shown that the incidence and mortality rates of colorectal cancer (CRC) vary over 10-fold worldwide where within Westernized societies lower rates are observed amongst populations living within the Mediterranean basin, suggesting a significant influence of environment and dietary style in CRC carcinogenesis. Interpretation of the data concerning the benefits of mediterranean (MD) diet is difficult in vivo because of the variability of alimentary regimens used, the differing compliance with dietary supplementation and because of the non-uniform duration of patient cohort observation. Therefore, the aim of this review is to evaluate the in-vitro effects on colorectal cancer cell lines. METHODS: the literature concerning the in-vitro effects of 4 of the principal components symbolizing the MD such as olive oil (polyphenol), red chili (capsaicin), tomato (lycopene) and red grapes (resveratrol) have been systematically reviewed. RESULTS: Several studies have demonstrated that polyphenols form olive oil, lycopene, resveratrol and capsaicin have multiple anticancer properties affecting several metabolic pathways involved in cancerogenesis, apoptosis, and metastasis in CRC cell lines. CONCLUSION: This review summarizes some of the most recent data potentially supportive of the use of MD in CRC chemoprevention, analyzing the in vitro effects of individual components of the MD on CRC cell development, progression, metastasis and apoptosis.


Asunto(s)
Neoplasias Colorrectales/prevención & control , Dieta Mediterránea , Sustancias Protectoras/uso terapéutico , Humanos , Técnicas In Vitro , Pronóstico
6.
Colorectal Dis ; 16(6): 459-68, 2014 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-24450861

RESUMEN

AIM: Abnormalities of one pelvic floor compartment are usually associated with anomalies in the other compartments. Therapies which specifically address one clinical problem may potentially adversely affect other pelvic floor activities. A new comprehensive holistic scoring system defining global pelvic function is presented. METHOD: A novel scoring system with a software program is presented expressing faecal, urinary and gynaecological functions as a geometric polygon based on symptom-specific questionnaires [the three axial pelvic evaluation (TAPE) score] where differences in overall geometric area vary from normal. After validation in healthy volunteers, its clinical performance was tested on patients with obstructed defaecation, genital prolapse and urinary/faecal incontinence treated by the stapled transanal rectal resection (STARR) procedure, colpo-hysterectomy and sacral nerve modulation, respectively. The TAPE score was correlated with the Pelvic Floor Impact Questionnaire 7 quality of life score. RESULTS: There was good inter-observer variation and internal consistency between two observers recording the TAPE score in normal volunteers. In the STARR patients, constipation improved but the TAPE score was unchanged because of deterioration in other pelvic floor functions leading to an unchanged overall postoperative recorded quality of life. Conversely, incontinent patients treated with sacral nerve stimulation improved their function showing concomitant improvements in TAPE scores and quality of life indices. Similar correlative improvements were noted in patients undergoing hysterectomy for genital prolapse. CONCLUSION: The TAPE score defines the impact of symptom-specific treatments on the pelvic floor and may provide an opportunity for comparison of clinical data between units and in clinical trials of specific medical and surgical pelvic floor management.


Asunto(s)
Defecación/fisiología , Incontinencia Fecal/diagnóstico , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Diafragma Pélvico/fisiopatología , Perineo/fisiopatología , Incontinencia Urinaria/diagnóstico , Micción/fisiología , Adulto , Anciano , Incontinencia Fecal/etiología , Incontinencia Fecal/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Pronóstico , Curva ROC , Estudios Retrospectivos , Encuestas y Cuestionarios , Resultado del Tratamiento , Incontinencia Urinaria/etiología , Incontinencia Urinaria/fisiopatología
7.
Colorectal Dis ; 15(8): 1011-8, 2013 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-23489598

RESUMEN

AIM: Successful anal fistula care is aided by specialized imaging accurately defining the site of the internal opening and fistula type. Imaging techniques are complementary, designed to answer specific anatomical questions. There are limited data concerning the clinical value of transperineal ultrasound (TP-US) in both cryptogenic fistula-in-ano and perianal Crohn's disease (PACD). The aim of the study was to assess the accuracy of TP-US compared with operative findings in patients with perirectal sepsis. METHOD: Patients with recurrent cryptogenic anal fistula and PACD referred for sonography were examined using TP-US by a single examiner blinded to the operative results. Fistulae were categorized by the Parks classification predicting the site of the internal fistula opening. Ancillary horseshoe collections, abscesses and secondary tracks were defined. RESULTS: Fourteen patients with PACD and 27 patients with recurrent cryptogenic fistula-in-ano were analysed with comparative images and operative data. Correlation of fistula type for cryptogenic and PACD patients respectively was 23/27 (85.2%) and 12/14 (85.7%), with a correlative internal opening site (when found at surgery) of 16/22 (72.3%) and 12/14 (85.7%). Misclassification of fistula type in cryptogenic cases occurred in the presence of ancillary abscesses with associated acoustic shadowing. In PACD patients, TP-US was used when anal stenosis precluded endoanal ultrasonography, assisting in the diagnosis of recto-vaginal fistulae. CONCLUSION: TP-US is a useful complementary technique to assess fistula-in-ano and has special advantage when there is anal canal distortion, complex fistula type or suspicion of a recto-vaginal fistula.


Asunto(s)
Canal Anal/diagnóstico por imagen , Enfermedad de Crohn/diagnóstico por imagen , Endosonografía/métodos , Fístula Rectal/diagnóstico por imagen , Fístula Rectovaginal/diagnóstico por imagen , Adolescente , Adulto , Anciano , Niño , Preescolar , Enfermedad de Crohn/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fístula Rectal/cirugía , Recurrencia , Estudios Retrospectivos
10.
Tech Coloproctol ; 16(3): 187-99, 2012 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-22534832

RESUMEN

The main serious risks of anastomotic construction in the colon and rectum include dehiscence and stricture formation. There is a resurgence of interest in sutureless anastomoses formed by compression elements since the introduction of shape memory alloy (SMA) systems, which evoke minimal early inflammatory response whilst maintaining anastomotic integrity. Currently, the most commonly used SMA is the nickel-titanium (NiTi) alloy that is highly biocompatible, returning to its pre-deformed stable (austenite) shape under different mechanical and thermal loads for use in humans. Pre-clinical data for shape memory alloy systems in colorectal anastomoses are limited, but it appears to be safe in porcine and canine models with limited leakage and reduced stricture formation. There does not appear to be any difference in tissue biochemistry of inflammatory markers when compared with conventional stapled techniques, although the few studies available show a markedly reduced early inflammatory response at the anastomotic site with the NiTi device. The majority of the clinical data concerning compression anastomoses are derived from the biofragmentable anastomotic ring device. This device has fallen out of use because of reported leaks, instrumental failure and problems with device expulsion. A novel SMA device, the NiTi anastomotic ring, permits construction of a low rectal anastomosis construction during open or laparoscopic procedures. The preliminary data demonstrate a safety comparable to conventional staple technology. This device also provides the potential of benefit of reduced anastomotic inflammation, because the compression ring results in direct serosa-to-serosa (or alternatively serosa-to-muscularis propria) apposition without the persistence of residual foreign material. This type of construction could lead to a reduced incidence of early anastomotic leakage and/or the development of anastomotic stenosis. Randomized clinical trials employing a NiTi arm for elective, emergency and high-risk colorectal anastomoses are required to determine its indications and clinical profile as well as to assess whether such technology may selectively obviate the need for proximal diversion in low colorectal anastomoses.


Asunto(s)
Anastomosis Quirúrgica/instrumentación , Colon/cirugía , Recto/cirugía , Aleaciones , Anastomosis Quirúrgica/métodos , Animales , Humanos
12.
Tech Coloproctol ; 15(2): 159-64, 2011 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-21538014

RESUMEN

BACKGROUND: The etiology of anal incontinence (AI) is often multifactorial. There is little data on the relationship between the etiology of AI, symptom severity, and the need for surgery. The aim of our study was to investigate this association in a large number of unselected patients with AI referred to a tertiary specialist coloproctological practice. METHODS: Patients with AI seen at our unit between 1983 and 2008 were analyzed. The main etiologies were categorized as congenital, traumatic, neurologic, idiopathic, post-operative, post-obstetric, secondary to rectal prolapse, or inflammatory bowel disease. The severity of AI was graded using the validated Pescatori incontinence scale. RESULTS: Overall, 1,046 patients were studied. The AI score was higher in patients with congenital (4.7 ± 1.1), traumatic (4.6 ± 1.4), and neurological (4.4 ± 1.2) incontinence. Surgical treatment was indicated in 214 cases (20.5%). Patients with AI related to trauma and congenital anomalies required surgery in 43.5 and 31.4% of cases, respectively, a percentage significantly higher than that for patients with other etiologies (P = 0.002). Prolapse-related AI usually responded to correction of the prolapse. CONCLUSIONS: Patients with congenital, traumatic, and neurological AI tend to have greater symptom severity. Traumatic, rectal prolapse-related, and congenital AI cases more often require surgery.


Asunto(s)
Incontinencia Fecal/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Incontinencia Fecal/congénito , Incontinencia Fecal/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Adulto Joven
13.
Tech Coloproctol ; 14(2): 107-12, 2010 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-20174849

RESUMEN

BACKGROUND: Chronic anal pain is relatively common as a presentation to specialist physicians and surgeons. Currently, it is regarded as a functional disorder upon the exclusion of occult intersphincteric sepsis. Our study assessed an unselected cohort of patients presenting with chronic previously undiagnosed anal pain using routine ultrasonography. METHODS: All patients referred to a tertiary gastroenterology service between January 2005 and January 2008 with a diagnosis of chronic anal pain (>3 months duration with no clinical anorectal signs) underwent endoanal and static and dynamic transperineal ultrasound to assess for the frequency and pattern of occult intersphincteric sepsis. RESULTS: Of 1,580 patients referred, there were 146 presenting with chronic anal pain as a main symptom. Of these, 37 (25.3%) had intersphincteric sepsis (ISS) diagnosed with ultrasound examination with 17 undergoing evaluable surgery. There was a male preponderance (70.3%) with the diagnosis being made in 46% of cases after 6 months of symptoms and with 80.8% having posteriorly located sepsis. This occurred on a background of 62% having previous acute proctological conditions. There was complete ultrasonographic and operative concordance with 15 becoming asymptomatic after surgery at a mean follow-up of 6 months. CONCLUSION: Occult intersphincteric sepsis is not uncommon and is diagnosed using routine ultrasonography at the time of clinical presentation. Endoanal and transperineal ultrasound is recommended as part of the investigative armamentarium to exclude categorization as functional anorectal pain. This is currently not part of the Rome III coding for such a diagnosis suggesting a revision of these diagnostic criteria for the ultimate diagnosis of functional proctalgia.


Asunto(s)
Canal Anal , Endosonografía , Dolor/diagnóstico por imagen , Dolor/etiología , Enfermedades del Recto/diagnóstico por imagen , Sepsis/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Clínicas de Dolor , Valor Predictivo de las Pruebas , Enfermedades del Recto/complicaciones , Enfermedades del Recto/patología , Derivación y Consulta , Estudios Retrospectivos , Sepsis/complicaciones , Sepsis/patología , Adulto Joven
14.
Br J Surg ; 96(11): 1373-4; author reply 1374, 2009 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-19847853
15.
Acta Chir Iugosl ; 56(2): 9-16, 2009.
Artículo en Inglés | MEDLINE | ID: mdl-19780324

RESUMEN

The trend towards preoperative adjuvant and neoadjuvant therapies in selected patients with rectal cancer has led to increases in sphincter preservation with a limited understanding of the factors governing unsatisfactory functional outcomes. Data would suggest the need for a more selective use of standard radiotherapeutic fields in low- to intermediate-risk cases where there appears to be limited survival or locoregional recurrence benefit and where there is under-reported toxicity. This article discusses the complex factors which impact on functional outcome following open rectal cancer surgery particularly when it is accompanied by adjuvant therapy.


Asunto(s)
Neoplasias del Recto/cirugía , Reservorios Cólicos , Terapia Combinada , Humanos , Proctocolectomía Restauradora , Neoplasias del Recto/terapia , Recto/cirugía
16.
Tech Coloproctol ; 13(3): 185-8, 2009 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-19626415

RESUMEN

The life and times of the coloproctologist David Henry Goodsall (1843-1906) is presented outlining his contribution to surgery in general and to the field of colorectal surgery, in particular giving a reassessment of his well-known rule regarding anal fistulae.


Asunto(s)
Cirugía Colorrectal/historia , Fístula Rectal/cirugía , Historia del Siglo XIX , Humanos , Fístula Rectal/historia , Reino Unido
18.
Crit Rev Oncol Hematol ; 72(1): 65-75, 2009 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-19147371

RESUMEN

Colorectal cancer (CRC) caused nearly 204,000 deaths in Europe in 2004. Despite recent advances in the treatment of advanced disease, which include the incorporation of two new cytotoxic agents irinotecan and oxaliplatin into first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the integrated use of targeted monoclonal antibodies, the 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with colorectal liver metastases, liver resection offers the only potential for cure. This review, based on the outcomes of a meeting of European experts (surgeons and medical oncologists), considers the current treatment strategies available to patients with CRC liver metastases, the criteria for the selection of those patients most likely to benefit and suggests where future progress may occur.


Asunto(s)
Neoplasias Colorrectales/patología , Hepatectomía , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Antineoplásicos/uso terapéutico , Ensayos Clínicos como Asunto , Neoplasias Colorrectales/mortalidad , Terapia Combinada , Humanos , Terapia Neoadyuvante , Guías de Práctica Clínica como Asunto
19.
Colorectal Dis ; 11(4): 410-9, 2009 May.
Artículo en Inglés | MEDLINE | ID: mdl-18637923

RESUMEN

OBJECTIVE: Many procedures are used to treat internal (IRP) and external rectal prolapse (ERP). We report the outcome of surgery tailored in accordance with an evolving Unit algorithm over a 21-year period. METHOD: Two hundred and sixty-eight patients (151 IRP and 117 ERP) are reported. Perineal procedures (Delorme's mucosectomy, Altemeier's perineal rectosigmoidectomy) were used in frail elderly patients with ERP with abdominal sacrorectopexy or the Frykman-Goldberg procedure in fit patients. In IRP, prolapsectomy was most common with anterior hemi-Delorme's procedures for rectocele and levatorplasty for coincident faecal incontinence. Clinical and functional outcome was assessed over a median of 61 months (range 4-184 months). RESULTS: Postoperative mortality was 0.4%. For ERP, a perineal procedure was carried out in 75 (61.4%) cases with a 7.2% complication rate, postoperative incontinence in 20 (26.7%), constipation in four (5.3%) and recurrence in 12 (16%). For 42 abdominal procedures, the complication rate was 5% with incontinence in 7.1%, constipation in eight (19%) and recurrence in five (11.9%). A perineal operation was used in 89.4% of patients with IRP with incontinence in 10.6%, persistent constipation in 48 (52.7%) and recurrence in 25 (27.5%). The overall incontinence rate was 11% following abdominal and 24% following perineal procedures (P < 0.05). Recurrence of ERP was significantly higher following a perineal operation (P < 0.05). CONCLUSION: Tailored surgery for ERP achieves satisfactory results in terms of recurrence and functional outcome. For patients with IRP, perineal procedures are associated with a high incidence of recurrence and residual evacuatory difficulty.


Asunto(s)
Colectomía/métodos , Prolapso Rectal/cirugía , Recto/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estreñimiento/etiología , Incontinencia Fecal/etiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Prolapso Rectal/complicaciones , Estudios Retrospectivos , Adulto Joven
20.
Tech Coloproctol ; 12(3): 191-200, 2008 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-18679577

RESUMEN

Following the untimely death of Professor Ahmed Shafik, the authors decided to analyse his published work on the anatomy and physiology of the anorectal area, reconciling this body of data with current imaging and physiological techniques. All available papers as indexed by PubMed pertaining to the anorectal area were obtained and reviewed. The anatomical data was compared with historical representations and current new imaging modalities. The original 'triple-loop' theory of the anatomical disposition of the external anal sphincter has been confirmed by coronal and coronally reconstructed imaging modalities. There is variance between the Shafik and other descriptions of the anatomy of the longitudinal muscle and its importance in the definition of perianal spaces which are important in the spread of perirectal sepsis and in intersphincteric rectal dissection. Current dynamic defaecography would suggest a more complex levator plate function in squeeze and straining than that originally suggested by Shafik as a primary defaecatory role for the levator muscle. The body of work by Professor Shafik has reorganized our understanding of the external anal sphincter and the function of the levator during defaecation. Future studies should assess anatomical and physiological variances using new technology in health and in specific disease states.


Asunto(s)
Canal Anal/anatomía & histología , Canal Anal/fisiología , Recto/anatomía & histología , Recto/fisiología , Cirugía Colorrectal/historia , Defecación/fisiología , Electromiografía , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Manometría , Contracción Muscular/fisiología , Músculo Liso/anatomía & histología , Músculo Liso/fisiología , Enfermedades del Recto/fisiopatología
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