Condiloma ano-perineal en una niña de 2 años, 8 meses y tratamiento con podofilina en combinación con ácido glicirricínico y ácido tricloroacético. Reporte de caso / Ano-perineal condyloma in a girl aged 2 years, 8 months and treatment with podophyllin in combination with glycyrrhizinic acid and trichloroacetic acid. Case report

Introducción: Los condilomas o verrugas anogenitales son secundarios a una infección causada por el virus del papiloma humano en sitios específicos, como la piel de la región anogenital, en las mucosas vaginal y anal. Es una infección de transmisión sexual rara en la edad pediátrica, muy frecuente entre los adultos y adolescentes sexualmente activos; la causa en los infantes, sin descartar el abuso sexual podría ser: 1. En el momento del parto, en la etapa neonatal y durante los primeros años; 2. Autoinoculación o hetero-inoculación de los genitales de otros niños, de adultos, familiares como la madre o cuidadores. Podría manifestarse como pequeños papilomas o crecimientos verrugosos en la piel anogenital, en la mucosa de la vagina o el ano. Este caso tiene importancia clínica ya que los tratamientos convencionales presentan recidivas a corto plazo y muchos de ellos no son bien tolerados por los pequeños pacientes. Hay tratamientos agresivos como la criocirugía; el uso de medicamentos costosos como el Imiquimod; sin embargo, las reci-divas son muy frecuentes con estos tratamientos convencionales.Objetivo: Describir el uso de un esquema de terapia de tratamiento con podofilina en combina-ción con ácido glicirricínico y ácido tricloroacético, en una paciente pediátrica con diagnóstico de condiloma ano-perineal, para ayudar a disminuir las recidivas, los costos y sobre todo los efectos psicológicos que provocan los métodos dolorosos en los pequeños pacientes. Presentación del caso: Paciente que presentó lesiones verrucosas, puntiagudos en la región ano-perineal; y, luego de haber sido intervenida en un centro de salud por varios días mediante la topicación sobre las lesiones una solución de ácido tricloro acético a 5% combinada con podofi-lina al 50%; sin embargo, el cuadro se exacerbó extendiéndose las lesiones hasta cerca del área genital. Luego de lo cual acudió a nuestra consulta, donde además de la combinación anterior, más la adición de ácido glicirricinico tópico y logrando a los 30 días la remisión de las lesiones.Conclusiones y recomendaciones: La combinación de una sustancia corrosiva, el ácido tricloro acético, con una sustancia que detiene la multiplicación celular como la podofilina; y el ácido glicirricinico el cual disminuye la replicación de los virus en un estadio temprano, impide la salida del virión de su cápside y con esto su penetración a las células. La aplicación de esta triple terapia mejoró los resultados para condilomatosis en pacientes pediátricos.

Introduction: Anogenital condylomas or warts are secondary to an infection caused by the human papillomavirus in specific sites, such as the skin of the anogenital region, in the vaginal and anal mucosa. It is a rare sexually transmitted infection in pediatric age, very common among sexually active adults and adolescents; The cause in infants, without ruling out sexual abuse, could be: 1. At the time of birth, in the neonatal stage and during the first years; 2. Autoinoculation or he-tero-inoculation of the genitals of other children, adults, family members such as the mother or caregivers. It could manifest as small papillomas or warty growths on the anogenital skin, on the mucosa of the vagina or anus. This case has clinical importance since conventional treatments present short-term recurrences and many of them are not well tolerated by young patients. There are aggressive treatments such as cryosurgery; the use of expensive medications such as Imiqui-mod; However, recurrences are very common with these conventional treatments.Objective: To describe the use of a treatment regimen with podophyllin in combination with glycyrr-hizinic acid and trichloroacetic acid, in a pediatric patient diagnosed with anoperineal condyloma, to help reduce recurrences, costs and, above all, psychological effects. that painful methods cause in young patients.Case presentation: The patient presents sharp, verrucous lesions in the ano-perineal region; and, after having been operated on in a health center for several days by topicalizing a 5% trichloroace-tic acid solution combined with 50% podophyllin on the lesions; However, the condition worsened, with the lesions extending close to the genital area. After which he came to our consultation, where in addition to the previous combination, plus the addition of topical glycyrrhizinic acid and achie-ving remission of the lesions after 30 days.Conclusions and recomendations: The combination of a corrosive substance, trichloroacetic acid, with a substance that stops cell multiplication such as podophyllin; and glycyrrhizinic acid, which decreases virus replication at an early stage, prevents the release of the virion from its cap-sid and thus its penetration into the cells. The application of this triple therapy improved the results for condylomatosis in pediatric patients.

Características clínicas de Soiling en pacientes postoperados de enfermedades anales en el Hospital General San Juan de Dios / Clinical settings of patients with postoperative Soiling at San Juan de Dios Hospital

Introducción: El soiling es el escape inconsciente de pequeñas cantidades de materia fecal después de una evacuación normal. Se ha reportado una prevalencia del 7-23% en otros países y se ha observado una alta incidencia después de esfinterotomías y fistulotomías (35-45%). Material y Métodos: Se realizó un estudio observacional que incluyó 80 pacientes con patologías anales que acudieron a la consulta externa del Hospital General San Juan de Dios donde se aplicó un cuestionario de 8 ítems. Resultados: Se evaluaron 80 pacientes, la mayoría son hombres, de la quinta década. La enfermedad anal más frecuente son las hemorroides y el tratamiento quirúrgico más frecuente la hemorroidectomía. La incidencia de soiling definitivo (presencia de manchado a los 6 meses) es del 22.5%. Las variables asociadas fueron el género masculino, el tipo de enfermedad y procedimiento quirúrgico, el enrojecimiento, la picazón anal, el uso de protector en la región anal, la sensación de materia fecal y la limpieza en región anal. El ser hombre presenta un riesgo 6 veces mayor y el presentar enrojecimiento en la región anal aumenta el riesgo de 27 veces de presentar soiling definitivo. Conclusión: El soiling se presenta en un quinto de los pacientes que son operados de patologías anales en el Hospital General San Juan de Dios. La presencia de eritema, picazón anal, el uso de protector en la región anal, la sensación de materia fecal y la limpieza en región anal son variables estadísticamente asociadas al mismo. (AU)

Introduction: Soiling is the unconscious escape of small amounts of fecal matter after a normal bowel movement. A prevalence of 7-23% was reported in other countries and a high incidence was observed after sphincterotomies and fistulotomies (35-45%). Material and Methods: A observational study that included 80 patients with anal pathologies who attended the outpatient clinic of the San Juan de Dios General Hospital during 2018-2019, where an 8-item questionnaire was applied. Results: Eighty patients were evaluated, the majority are men, in their fifth decade. The most common anal disease is hemorrhoids, and the most common surgical treatment is hemorrhoidectomy. The incidence of definitive soiling (presence of spotting at 6 months) is 22.5%. The variables associated with definitive soiling were male gender, type of disease and surgical procedure, redness, anal itching, use of a protector in the anal region, the sensation of fecal matter, and cleanliness in the anal region. Being male presents a 6 times greater risk of definitive soiling and having redness in the anal region presents a 27 times greater risk of definitive soiling. Conclusion: Soiling occurs in a fifth of the patients operated for anal pathologies at the San Juan de Dios General Hospital. The presence of erythema, anal itching, the use of a protector in the anal region, the sensation of stool, and cleanliness in the anal region are statistically associated variables with soiling. (AU)

Sirenomelia associated with VACTERL and VACTERL-H syndrome / Sirenomelia asociaciada con síndrome de VACTERL y VACTERL-H

Sirenomelia or mermaid syndrome is an extremely rare congenital lethal malformation with a frequency between 1.5 and 4.2 per 1 000 000 pregnancies.The association of sirenomelia with the VACTERL association is very rare, with twenty cases reported in the literature and only two cases with VACTERL-H. We present two cases of sirenomelia, type I and type II associated with VACTERL-H and VACTERL syndromes and we review the literature. First time pregnancy women aged 15 and 40 years, without harmful habits and diseases, where between 25-27 gestational week (GW) the prenatal study identifies malformative fetus and the pregnancy is interrupted by medical evidence. The fetopathological examination in the first case identified sirenomelia type I associated with myelomeningocele, hydrocephalus, anal imperforation, single umbilical artery, bilateral renal agenesis, ureteral and bladder agenesis, tracheo-esophageal fistule, agenesis of external genitals, monkey fold of the left palm of the hand - VACTERL-H. In the second case, where genetic testing is normal, sirenomelia type II associated with agenesis of external genitalia, anal imperforation, myelomeningocele, dolichocrania, macroglossia, low set ears, left preauricular skin tag, long philtrum, lung hypoplasia, split cadiac apex, single umbilicalis artery, blind end colon, hepatomegaly, accessory spleen, polycystic horseshoe kidney, uterine and vaginal agenesis, presence of two ovaries and duodenal stenosis - VACTERL association. This two cases, lead us to believe that sirenomelia and the VACTERL association are probably different manifestations of a pathogenetic process leading to disorders of blastogenesis at different levels during embryonic development.

La sirenomelia es una malformación congénita y excepcionalmente rara, con una frecuencia entre 1,5 y 4,2 en un millón de embarazos. La combinación de la sirenomelia con el síndrome de VACTERL es igualmente rara. La literatura especializada informa sobre la existencia de una veintena de casos solamente; en lo que respecta a su asociación con el síndrome de VACTERL-H se conocen solo dos casos. Luego de realizar una revisión de la literatura presentamos dos casos de sirenomelia asociada con los síndromes de VACTERL-H y de VACTERL En el estudio se analizaron los primeros embarazos de dos mujeres, edad de 15 y de 40 años, respectivamente, ambas mujeres completamente sanas y sin hábitos viciosos. Entre la vigésima quinta y la vigésima séptima semana gestacional (SG) del embarazo ambas mujeres, el análisis prenatal comprueba la existencia de malformación del feto debido a lo cual los embarazos fueron interrumpidos por prescripción médica. El análisis fetopatológico del primer caso comprueba la existencia de sirenomelia de tipo I asociada con mielomeningocele, hidrocefalia, atresia anal, arteria umbilical única, agenesia bilateral de los riñones y de los ureteres que transportan la orina desde los riñones hasta la vejiga, fístula traqueoesofágica, agenesia de los órganos genitales externos, línea simiesca en la palma de la mano izquierda - VACTERLH. En el segundo caso, en que el análisis genético ha resultado normal, se observó la presencia de sirenomelia de tipo II asociada con agenesia de los órganos genitales externos, atresia anal, mielomeningocele, dolicocrania, macroglosia, orejas bajas, filtrum alargado, hipoplasia pulmonar, ápice cardíaco escindido, arteria umbilical única, colon terminado en ciego, bazo accesorio, poliquistosis renal, riñón en herradura, agenesia vaginal y de útero, presencia de dos ovarios y estenosis duodenal - VACTERL asociación. Los dos casos investigados permiten llegar a la conclusión de que la sirenomelia y su combinación con el síndrome de VACTERL probablemente sean manifestaciones diferentes de un proceso patogenético que conlleva la alteración de la blastogénesis en distintos niveles durante el proceso del desarrollo embrionario.

Neuraxial analgesia in a parturient with the VACTERL association undergoing labor and vaginal delivery / Analgesia neuraxial em uma parturiente com síndrome de Vacterl em trabalho de parto normal

Abstract Introduction: The term VACTERL is an acronym for an association of congenital malformations: including vertebral, anal, cardiac, tracheo-esophageal, renal and limb anomalies. VACTERL anomalies pose a formidable challenge to anesthesiologists. We describe the anesthetic management of a parturient with VACTERL association, who underwent neuraxial analgesia for labor and vaginal delivery. Case report: A 23 year old primigravida at 39 weeks gestation presented in labor at 4 cm cervical dilatation, completely effaced, requesting labor analgesia. Past medical history included VACTERL association with an imperforate anus and a partial endocardial cushion defect, both repaired in early childhood. She also had significant dorso-lumbar scoliosis with an extra lumbar vertebra. An MRI performed at 14 years age revealed the above findings with no spinal cord abnormalities. With a normal neurologic exam, a combined spinal epidural technique was performed. Despite significant scoliosis, the epidural space was identified at approximately the L3-L4 interspace at a depth of 5 cm. Spinal Fentanyl 25 mcg was administered followed by continuous patient-controlled epidural analgesia. The patient experienced excellent pain relief throughout her labor, and had an uneventful vaginal delivery 5 h after epidural placement. Discussion: The rarity of VACTERL association in the obstetric population with its extensive anomalies mandates a multidisciplinary approach in the prenatal period as it can pose major challenges to all health care providers, including airway, ventilatory, cardiac and neuraxial problems. This is the first reported case of a successful and safe neuraxial technique in a laboring patient with the VACTERL association with albeit limited vertebral and spinal cord anomalies.

Resumo Introdução: O termo Vacterl é um acrônimo para uma associação de malformacões congênitas que inclui anomalias vertebral, anal, cardíaca, traqueal, esofágica, renal e dos membros (Limbs em inglês). As anomalias Vacterl representam um enorme desafio para os anestesiologistas. Descrevemos o manejo anestésico de uma parturiente com síndrome de Vacterl submetida à analgesia neuraxial para parto normal. Relato de caso: Paciente primípara, 23 anos, 39 semanas de gestação, apresentava em trabalho de parto 4 cm de dilatação cervical, apagamento completo, exigiu analgesia de parto. A história médica incluía síndrome de Vacterl com ânus imperfurado e defeito parcial do coxim endocárdico, ambos corrigidos na primeira infância. A paciente também apresentava escoliose dorso-lombar acentuada com uma vértebra lombar adicional. Uma RM feita aos 14 anos revelou os achados mencionados acima sem anormalidades na medula espinhal. Com um exame neurológico normal, a técnica anestésica combinada raquiperidural (CRP) foi usada. Apesar de escoliose significativa, o espaço peridural foi identificado próximo ao interespaço L3-L4 a uma profundidade de 5 cm. Fentanyl (25 mcg) foi administrado por via espinhal, seguido de analgesia peridural contínua controlada pela paciente. A paciente sentiu grande alívio da dor durante todo o trabalho de parto; o parto vaginal ocorreu 5 horas após a anestesia CRP sem intercorrências. Discussão: A raridade da síndrome de Vacterl na população obstétrica com suas extensas anomalias exige uma abordagem multidisciplinar no pré-natal porque pode representar grandes desafios para todos os prestadores de cuidados de saúde, inclusive problemas respiratórios, de ventilação, cardíacos e do neuroeixo. Este é o primeiro caso relatado de uma técnica neuraxial bem-sucedida e segura em uma paciente em trabalho de parto com síndrome de Vacterl, embora com anomalias limitadas da coluna vertebral e medula espinhal.

A novel four quadrant laser sphincterotomy for idiopathic severe anal stenosis / Nova esfincterotomia a laser nos quatro quadrantes para estenose anal idiopática grave

ABSTRACT Anal stricture or stenosis, though uncommon, is disabling condition. It affects the quality of life due to pain, bleeding and difficulty in defecation, incontinence or increased frequency. It occurs when the normally pliable anoderm is replaced with fibrotic connective tissue, leading to an abnormally tight and inelastic anal canal. Mostly it occurs secondary to trauma, iatrogeny, inflammatory diseases, radiation or neoplasia. The treatment of anal stricture is generally considered to be difficult and various methods of treatment have been suggested. It is often unresponsive to conservative medical management. The surgical procedures such as dilatations and anoplasty are associated with significant complications which make it a difficult treatment challenge. Several good treatment options are available currently. Through this case, we report and explore a new medical treatment for anal strictures with four quadrant laser sphincterotomy.

RESUMO A estritura ou estenose anal, embora incomum, é problema incapacitante. Essa condição afeta a qualidade de vida por causa da dor, do sangramento e da dificuldade de defecação, de incontinência ou aumento da frequência. A estenose anal ocorre quando o anoderma, normalmente flexível, foi substituído por tecido conjuntivo fibrótico, e o resultado é um canal anal anormalmente estenosado e inelástico. Na maioria dos casos, a estenose anal ocorre secundariamente a trauma, por causa iatrogênica, por doença inflamatória, radiação ou neoplasia. Em geral, se considera que o tratamento dessa condição é tarefa difícil, tendo sido sugeridos diversos métodos de tratamento. Com frequência a estenose anal não responde ao tratamento clínico conservador. Procedimentos cirúrgicos como as dilatações ou a anoplastia estão associados a complicações significativas, implicando difícil desafio terapêutico. Atualmente, o cirurgião conta com várias opções terapêuticas satisfatórias. No presente caso, relatamos e exploramos um novo tratamento clínico para estenoses anais, por meio da esfincterotomia a laser nos quatro quadrantes.

Long-term outcomes of ligation of intersphincteric fistula tract for complex fistula-in-ano: modified operative procedure experience / Resultados em longo prazo da ligadura da fístula interesfincteriana no complexo das fístulas perianais: modificação técnica de procedimento cirúrgico

ABSTRACT Background: It is important but difficult to treat complex fistula-in-ano due to the high recurrent rate and following incontinence. Ligation of the intersphincteric fistula tract (LIFT), a novel surgical procedure with the advantage of avoiding anal incontinence, has a variable success rate of 57-94.4 %. Aim: To evaluate the long-term outcomes of modified LIFT operative procedure - ligation of intersphincteric fistula tract - to treat complex fistula-in-ano. Methods: Retrospective analysis of 62 cases of complex fistula-in-ano. The group was treated with the modified approach of LIFT (curved incision was made in the anal canal skin; purse-string suture was performed around the fistula; the residual fistulas were removed in a tunnel-based way) and had a follow-up time of more than one year. Patient´s preoperative general condition, postoperative efficacy and their anal function were compared. Results: The median age of the participants was 34, and 43 (69.4%) cases were male. Forty-one (66.1%) cases were of high transsphincteric fistula, four (6.5%) cases of high intrasphincter fistula, and 17 (27.4%) cases of anterior anal fistula in female. The median follow-up duration was 24.5 (range, 12-51) months. The success rate in the end of follow-up was 83.9% (52/62). The anorectal pressure and Cleveland Clinic Florida Fecal Incontinence (CCF-FI) evaluated three months before and after the operation did not find apparent changes. Conclusions: Compared with LIFT, the modified LIFT remarkably reduces postoperative failure and the recurrence rate of complex fistula with acceptable long-term outcomes.

RESUMO Racional: É importante, mas difícil de se tratar fístula anal complexa devido à alta taxa de recorrência e de incontinência pós-operatória. A ligadura do trajeto da fístula interesfincteriana (LIFT) - um novo procedimento cirúrgico com a vantagem de evitar a incontinência anal - tem taxa de sucesso variável entre 57-94,4%. Objetivo: Avaliar os resultados em longo prazo do procedimento cirúrgico LIFT modificado - ligadura do trato interesfincteriano com fístula - para tratar fístula complexa anal. Métodos: Análise retrospectiva de 62 casos de fístula complexa no ânus tratados com abordagem modificada de LIFT (incisão curva na pele do canal anal; sutura em bolsa realizada em torno da fístula; as fístulas residuais removidas em um túnel) e teve tempo de acompanhamento de mais de um ano. A condição geral pré-operatória dos pacientes, a eficácia pós-operatória e a função anal foram comparadas. Resultados: A mediana de idade dos participantes foi de 34 anos, e 43 (69,4%) dos casos eram de homens. Quarenta e um (66,1%) casos eram de fístula transesfincteriana alta, quatro (6,5%) de fístula intra-esfincteriana alta e 17 (27,4%) de fístula anal anterior em mulheres. A mediana da duração do acompanhamento foi de 24,5 meses (12-51). A taxa de sucesso no final do acompanhamento foi de 83,9% (52/62). A pressão anorretal e a Incontinência Fecal da Cleveland Clinic Florida (CCF-FI) avaliadas três meses antes e após a operação não encontraram alterações aparentes. Conclusões: Comparado com o LIFT, o LIFT modificado reduz notavelmente a falha pós-operatória e a taxa de recorrência de fístula complexa com resultados aceitáveis em longo prazo.

Fístulas perianales: caracterización con resonancia magnética / Perianal fistulas: magnetic resonance classification

Las fístulas perianales constituyen una problemática frecuente en la consulta médica actual, con un gran impacto en la morbilidad. Su tratamiento no está exento de complicaciones, como la recurrencia local y la incontinencia fecal. La resonancia magnética (RM) cumple un rol fundamental en la planificación preoperatoria de estos casos, ya que la notable resolución espacial de los equipos de última generación permite generar un mapa de la anatomía de la pelvis menor, señalando el número y la relación de los trayectos con el esfínter anal. El objetivo del presente trabajo es identificar los distintos tipos de fístulas en base a sus características por RM, haciendo énfasis en la anatomía de la región y la técnica de estudio de esta entidad.

Perianal fistulas are a prevalent problem in current medical practice, with a high impact on morbidity. The treatment is not exempt from complications, such as local recurrence and faecal incontinence. Magnetic resonance imaging (MRI) performs an essential role insurgical planning of these patients, since the high spatial resolution of the latest equipment provides more precise information of the pelvis anatomy, indicating the number and relationship of the fistulous tracks with the anal sphincter. The aim of this work is to identify the different types of fistulas based on MRI classification, with particular emphasis on the local anatomy and study techniques.

Functional outcome of anorectal malformations and associated anomalies in era of Krickenbeck classification

Objective: To describe the management and functional outcome of anorectal malformations and associated anomalies according to Krickenbeck classification. Study Design: Case series. Place and Duration of Study: The Aga Khan University Hospital, Karachi, from January 2002 to December 2012

Methodology: Anorectal anomalies were classified according to Krickenbeck classification. Data was collected and proforma used regarding the primary disease associated anomalies, its management and functional outcome, according to Krickenbeck classification. Cases included were: all those children with imperforate anus managed during the study period. Qualitative variables like gender and functional outcome were reported as frequencies and percentages. Quantitative variables like age were reported as medians with interquartile ranges

Results: There were 84 children in study group. Most common associated anomaly was cardiac [38%], followed by urological anomaly [33%]. All children were treated by Posterior Sagittal Anorectoplasty [PSARP]. Fistula was present in 64 out of 84 [76%] cases. The most common fistula was rectourethral [33%], followed by recto vestibular [31%]. According to Krickenbeck classification, continence was achieved in 62% children; however 27% children were constipated, followed by 12% children having fecal soiling

Conclusion: Functional outcome of anorectal malformation depends upon severity of disease. A thorough evaluation of all infants with ARM should be done with particular focus on cardiovascular [38%] and genitourinary abnormalities [33%]

Asociación de fistula rectovaginal congénita con ano normal (Fístulas Tipo H) y atresia rectal en una paciente. Reporte de un caso y breve revisión de la literatura / Congenital recto-vaginal fistula associated with a normal anus (type H fistula) and rectal atresia in a patient. Report of a case and a brief revision of the literature.

Las malformaciones ano-rectales del tipo de fístulas recto-urogenitales congénitas con ano normal y atresia rectal son anomalías poco frecuentes. Se discute el caso de una niña con la asociación de estas dos entidades, acompañada además de una vagina doble, quien fue llevada a la consulta a los siete días de vida por la expulsión de heces a través de los genitales. Las malformaciones fueron corregidas a través de un abordaje sagital posterior, con descenso del recto hasta el ano sin disección perineal. El tabique vaginal fue resecado a través de la vulva. En la actualidad no hay evidencia de recurrencia de la fístula recto-vaginal.

Congenital recto-urogenital type fistulas with a normal anus and rectal atresia, represent both anorectal malformations that are infrequently seen in clinical practice. We describe the case of a girl with an association of these two anomalies, together with a double vagina who, on her seventh day of life, expelled feces through her genitals. The malformations were corrected by means of a posterior sagittal approach, descending from the rectum to the anus without perineal dissection. The vaginal septum was resected thru the vulva. There is no evidence of recurrence of the recto-vaginal fistula.

Is it possible folic acid reduce anorectal malformations ethylenethiourea induced in rats?

PURPOSE: To investigate the effect of folic acid (FA) in an experimental model of anorectal malformations (ARMs) ethylenethiourea (ETU) induced.METHODS:Eight female Wistar rats were divided randomly in two groups. Group A - ETU; Group B - FA+ETU; Dams from group B received daily, since two weeks before pregnancy to the end of pregnancy, FA (50mg/kg) by gavage. Dams from groups A and B, received 1% ETU (125mk/kg) by gavage on gestational day (GD) 11. Their fetuses were harvested by cesarean section on GD21 and were examined looking for ARMs. The thickness of anal stratified squamous epithelium (ASSE) and intestinal epithelium (IE) were analyzed. p<0.05*.RESULTS:One hundred and one embryos were harvested. The number of embryos; number of ARMs; mean statistical % (± SD) were determined to be, respectively: ETU - 49 [30;65% (±24%)] versus FA+ETU - 52 [1;02% (±3%)] (p=0.025). AMRs were significantly lower in FA+ETU group than in ETU group (p=0.025). The thickness (µm) of ASSE (± SD) and IE (± SD) were measured, respectively: ETU - [27.75 (±0.56) and 18.88 (±0.93)] versus FA+ETU - [28.88 (±0.61) and 21.11 (±0.16)] (p=0.001). The thickness of IE was significantly enlarged when FA was given (p=0.001).CONCLUSION:Folic acid reduces the number and enlarged the IE of ARMs ETU-induced.

Surco perineal en ginecología infantil: reporte de 2 casos clínicos / Perineal groove in pediatric gynecology: a report of 2 cases

Introduction: the perineal groove is a very uncommon anorectal anomaly. It is the result of an unknown embryology anomaly. The perineal groove is a wet sulcus extending from de fourchette to the anus. It is a benign pathology and tends to resolve spontaneously. Objective: We report two cases of girls diagnosed with perineal groove and their follow up. Cases reports: The first case is an 18 days old baby girl, that during her first clinical examination there was found a painless lineal lesion in the perineum from the fourchette to the anus, which created a big anxiety in her family. She was cared at the Pediatric Gynecology Unit, with local lubrication, doing well with the epithelization of it. The second case is an 8 year-old girl who consulted because, when being a child, she was diagnosed with a perineal lesion, but she didn't receive any special treatment and now she feels some aches in the perineum. Conclusions: The perineal groove is a benign entity pretty unknown by general practitioners or pediatricians. It is important to be up to date with this condition to avoid alarming misinterpretations.

Introducción. El surco perineal es una malformación poco frecuente, de etiología desconocida, consiste en una ranura en la línea media del periné desde la horquilla vulvar al ano, es benigna y tiende a la resolución espontánea. Objetivos: Reportar el diagnóstico y evolución de dos pacientes con surco perineal. Casos clínicos: Caso 1. Recién nacida de 18 días que previo al alta de maternidad se pesquisó una lesión lineal no dolorosa desde la horquilla vulvar al ano, lo que generó gran inquietud en su familia. En Ginecología Infantil se confirmó el diagnóstico, se manejó con lubricación del área genital evolucionando a la epitelización del surco. Caso 2. Niña de 8 años consultó por que en controles de salud se diagnosticó una "fisura" entre la horquilla vulvar y el ano que no fue tratada y presentaba molestias inespecíficas en el periné. Se indicó resección quirúrgica, pero paciente evolucionó satisfactoriamente con lubricación de la zona. Conclusiones. El surco perineal es una entidad benigna que debe ser conocida por médicos de atención ambulatoria debido a la alarma que pueden generar sus diagnósticos diferenciales.

Duplicación rectal extrofiada asociada a malformación anorrectal y transposición pene-escrotal con hipospadias perineal: Reporte de un caso clínico / Exstrophy of rectal duplication associated with anorectal malformation and penoscrotal transposition with perineal hypospadias: A case report

Se presenta el caso de un paciente masculino quien requirió tratamiento por agenesia anorrectal con fístula rectouretral y transposición pene-escrotal con hipospadias perineal, acompañados de una masa perineal. La tumoración perineal se encontró íntimamente adherida y en continuidad al recto, lo que la hace compatible con una duplicación rectal extrofiada. La reconstrucción quirúrgica de la anomalía se realizó en etapas hasta lograr resultados funcionales y estéticos aceptables.

We present the case of a male patient who required treaatment due to anorectal agenesis with recto urethral fistula and penoscrotal transposition with perineal hypospadias, associated with a perineal tumor. The perineal tumor was found strongly adhered and contiguous to the rectum which makes it compatible with an exstrophy of rectal duplication. Surgical reconstruction of the birth defect was performed in stages until acceptable biological function and esthetic results were obtained.

Endoanal ultrasound assessment of sphincter defects and thinning – Correlation with anal manometry

This study aims to determine if anal sphincter defects/thinning observed at endoanal ultrasound correlates with anal pressures recorded at anal manometry. A total of 30 consecutive patients with history suggestive of anal sphincter pathology underwent anal endosonography with documentation of internal and external sphincter defects/ thinning. The same patients underwent anal manometry with documentation of maximum resting and maximum squeeze pressures. Patients with a sphincter defect [SD] were compared to patients without a sphincter defect [NSD] and both groups were compared with respect to findings in manometry. The Mann-Whitney U test was used for statistical analysis. This study was approved by the Institutional Ethics Committee. A statistically significant correlation was found between decreased maximal resting pressure and decreased internal anal sphincter [IAS] thickness or an IAS defect. The correlation between MSP and external sphincter pathology was significantly less consistent in our study. Our study showed a statistically significant correlation between maximum resting pressure and observation of internal sphincter defects at endoanal ultrasound. The patients with documented internal sphincter defects have significantly reduced maximum resting pressures. There was however, no correlation between external sphincter defects and decrease in maximum squeeze pressure as has been observed in other studies. Until a manometry cut-off can be set to discriminate between the absence and presence of defects, both manometry and ultrasound should be offered to patients with history suggesting anal sphincter pathology

Acesso sagital transretal anterior (ASTRA) para vaginoplastia após complicação de anoretoplastia sagital posterior / Anterior sagittal transrectal approach (ASTRA) for vaginoplasty after complications of posterior sagittal anorectoplasty

A exposição transperineal de altas vaginas é limitada. Essas limitações podem ser contornadas usando ASTRA (anterior sagital transrectal approach). Relatamos o uso desta estratégia cirúrgica para o tratamento de um caso de atresia vaginal adquirida, após anorretoplastia posterior, em caso de malformação anorretal.

Transperineal exposure of the high portion of the vagina is limited. These limitations can be circumvented using ASTRA (anterior sagittal transrectal approach). We report the use of this surgical strategy for the treatment of a case of acquired vaginal atresia after posterior anorectoplasty due to anorectal malformation.

Anatomical and physiological changes in pelvic diaphragm in patients with chagasic megacolon submitted to Duhamel surgery / Avaliação das alterações anatômicas e funcionais do diafragma pélvico de pacientes portadores de colopatia chagásica submetidos a cirurgia de Duhamel

ORIGINAL CONTRIBUTION: understand the reasons why Duhamel surgery results in clinical improvement of constipation in patients with Chagasic colopathy. BACKGROUND: Duhamel surgery is one of the most widespread techniques for the treatment of Chagasic megacolon, with low rates of recurrence of constipation. OBJECTIVE: evaluate the anatomical and physiological changes in the pelvic diaphragm of patients with chagasic colopathy, as well as changes occurring after undergoing Duhamel surgery. DESIGN: clinical data and results of cinedefecography, electromanometry and anorectal ultrasound of the anal canal were evaluated in patients with Chagasic colopathy, before and after Duhamel surgery. LOCATION: Service of Coloproctology - Departament of Surgery, Faculdade de Medicina da Universidade Federal de Goiás. Patients: patients with positive serology for Chagas Disease, with constipation and radiological megacolon, who presented consecutively to the Chagas outpatient clinic and freely agreed to participate in this study, were prospectively included. RESULTS: a total of 20 patients were included, with a mean age of 53.2 years, of which 16 were women. The following parameters were observed in the postoperative period: change in bowel frequency, of, on average, one evacuation every ten days to daily bowel movement; 16 patients used laxatives preoperatively and only one did, intermittently, in postoperative period. Electromanometry showed, postoperatively, a decrease in anal resting pressure (60.88 to 37.2 mmHg p < 0.001) and anal squeeze pressures (244.3 mL to 161.25 p = 0.01), whereas ultrasound showed that 75% of the patients had abnormalities of the internal anal sphincter in the posterior anal canal juxtaposed to the pulled-through colon. Postoperative rectal emptying observed in cinedefecographic tests occurred more quickly and with less effort when compared with the preoperative findings. There was a change in the anorectal angle postoperatively, which became more obtuse, both during rest, straining and during evacuation. CONCLUSIONS: the anatomical and functional changes in the pelvic diaphragm are significant after Duhamel surgery and together, they result in clinical improvement of patients. (AU)

CONTRIBUIÇÃO ORIGINAL: compreender os motivos pelos quais a cirurgia de Duhamel resulta na melhora clínica da obstipação intestinal de pacientes com colopatia chagásica. ANTECEDENTES: a cirurgia de Duhamel é uma das técnicas mais difundidas para o tratamento do megacólon chagásico, com baixos índices de recidiva dos sintomas de obstipação intestinal. OBJETIVO: avaliar as alterações anatômicas e fisiológicas do diafragma pélvico de pacientes portadores de colopatia chagásica e as mudanças ocorridas após serem submetidos à cirurgia de Duhamel. DESENHO DO ESTUDO: foram avaliados os dados clínicos e os resultados de exames de cinedefecografia, eletromanometria anorretal e o ultrassom do canal anal de pacientes portadores de colopatia chagásica, no pré e pós-operatório da cirurgia de Duhamel. LOCALIZAÇÃO: Serviço de Coloproctologia - Departamento de Cirurgia Faculdade de Medicina da Universidade Federal de Goiás. PACIENTES: foram inclusos, prospectivamente, pacientes com sorologia positiva para Doença de Chagas, com obstipação intestinal e megacólon radiológico, que se apresentaram consecutivamente ao ambulatório de Chagas e que livremente aceitaram participar desse estudo. RESULTADOS : foram incluídos 20 pacientes, com média de idade de 53,2 anos, sendo 16 mulheres. Observou-se, no pós-operatório, uma mudança do ritmo intestinal de, em média, uma evacuação a cada dez dias para uma evacuação diária; 16 pacientes faziam uso de laxantes no pré-operatório e somente um o fazia, intermitentemente, no pós-operatório. A eletromanometria evidenciou, no pós-operatório, uma diminuição das pressões anais de repouso (60,88 para 37,2 mmHg com p < 0,001), e da capacidade retal (244,3 para 161,25 mL, p = 0,01) e o ultrassom revelou que em 75% dos pacientes haviam alterações anatômicas do esfíncter interno na porção posterior do canal anal, justaposto ao local de abaixamento do cólon. O esvaziamento da ampola retal, observado durante a cinedefecografia pós-operatória, se processou mais rapidamente e com menor esforço quando comparado com os achados pré-operatórios. Houve mudança do ângulo anorretal no pós-operatório, que se tornou mais obtuso, tanto durante o repouso como durante o esforço evacuatório. CONCLUSÕES: as alterações anatômicas e funcionais do diafragma pélvico são significativas após a cirurgia de Duhamel e que ela determina, em conjunto, a melhoria clínica dos pacientes. (AU)

Penile duplication and two anal openings; report of a very rare case

Penile duplication [diphallus] is an extremely rare disorder. It is almost always associated with other malformations like double bladder, exstrophy of the cloacae, imperforate anus, duplication of the rectosigmoid and vertebral deformities. Meanwhile anal canal duplication, the most distal and least common duplication of the digestive tube and is a very rare congenital malformation. A 21 days old Egyptian neonate is reported with complete penile duplication and two scrotums with each one carrying two palpable testes. Both penises have normal shaft with normally located meatus. Clear urine voids from both meati spontaneously. The child had also a fold of redundant skin about 4x5 cm at the anal region in which two separate anal openings are present. In rectal examination we found two normal anuses passing stool spontaneously. Ascending [voiding] cystourethrography revealed two penises with two separate meatuses and one bladder from which the two urethras go out separately. Intravenous pyelogram [IVP] revealed two normal kidneys and ureters. Barium study revealed duplication of rectum and colon, otherwise normal GIT. In our review of the literature, we did not come across any other case of this variety of the penile duplication and congenital presence of two anuses. Unfortunately the patient expired before any surgical correction

Anomalia anorretal e cuidados maternos / Anorectal anomaly and maternal care / Anormalidades anorectales y la atención materna

O objetivo deste artigo foi realizar um estudo de revisão bibliográfica sobre anomalia anorretal e cuidados maternos. O assunto foi abordado por meio de revisão integrativa realizada em consulta de artigos publicados nas bases de dados indexados na Biblioteca Virtual em Saúde. Foram identificadas 25 publicações que atenderam aos critérios de inclusão e exclusão pré-estabelecidos. Nos estudos analisados observaram-se distintos desenhos metodológicos demonstrando que algumas crianças nascidas com anomalia anorretal necessitam de cirurgia de urgência. Os profissionais de saúde, juntamente aos pais, precisam desenvolver parcerias que possibilitem um acompanhamento a longo prazo e orientações cuidadosas. Faz-se necessário que novas pesquisas sejam realizadas sobre o tema, com propostas metodológicas que retratem melhor a essência do cuidado com as crianças estomizadas.

This purpose of the article was to make a bibliographic review about anorectal malformations and maternal cares. The matter was addressed through an integrative review undertaken in consultation of articles published in the databases indexed in the Virtual Health Library. We identified 25 publications that met the inclusion and exclusion criteria pre-established. In the studies reviewed, there were different study designs, demonstrating that some children born with anorectal anomalies requiring urgent surgery. Health professionals, along with the parents, need to develop partnerships that would enable a long-term monitoring and careful guidance. It is necessary to do more research on the subject, with methodological proposals that reflect the essence of the best care of an ostomized child.

El objetivo de este artículo fue realizar un estudio de revisión bibliográfica sobre anomalía ano retal y cuidados maternos. El asunto fue abordado por medio de una revisión integral realizada por consulta de artículos publicados en las bases de datos indexados en la Biblioteca Virtual en Salud. Fueron identificadas 25 publicaciones que atendieron a los criterios de inclusión y exclusión pre-establecidos. En los estudios analizados se observaron distintos dibujos metodológicos demostrando que algunos niños nacidos con anomalía ano retal necesitan de cirugía de urgencia. Los profesionales de salud, juntamente con los padres, necesitan desarrollar grupos que posibiliten un acompañamiento a largo plazo y orientaciones cuidadosas. Se hace necesario que nuevos estudios sean realizados sobre el tema, con propuestas metodológicas que retraten mejor la esencia del cuidado con los niños con ostomía.

Injectable anal bulking agent for the management of faecal incontinence

This study was conducted to determine the safety and efficacy of injectable bulking agents. A total of 13 procedures were performed on 11 patients with faecal incontinence during 2002 to 2007. Patients with internal anal sphincter defect and low incontinence score [Cleveland score < 10] revealed improvement. Patients with higher incontinence score and external sphincter defect secondary to obstetric damage required further intervention. At a median follow-up of 43 months, 7 [63%] patients showed improvement in incontinence score and 4 [32%] showed marked improvement in their symptoms. Fifty six percent of the patients described this as an effective procedure, though the level of effectiveness varied from person to person. Anal injectable collagen was found safe and effective in the management of faecal incontinence. Long-term follow-ups are required to re assess and consider definitive procedure in failed cases

Análisis de 200 casos pediátricos de malformaciones anorectales / Analysis of 200 cases of pediatric anorectal malformation

Las malformaciones anorectales son una patología frecuente en el Servicio de Cirugía General del Hospital Nacional de Niños, sin embargo, en Costa Rica las publicaciones sobre el tema han sido pocas. El objetivo de este trabajo es analizar los pacientes operados netre 1998 y 2008, para conocer el detalle de los tratamientos usados y determinar cuál ha sido la experiencia, algo muy recomendable para que, con base en los hallazgos, se procesen las sugerencias para mejorar. Material y métodos: Se revisaron los expedientes y se examinaron los pacientes con malformaciones anorectales operados entre 1990 y 2008, controlados en la sección especializada de la Consulta Externa del Servicio de Cirugía General del Hospital Nacional de Niños. Los pacientes fueron agrupados de acuerdo con su tipo de anomalía, y fueron examinados para determinar: malformaciones congénitas asociadas, tipo de malformación anorectal, tipo de cirugía, complicaciones, y resultados de los siguientes exámenes: ultrasonido de abdomen, CUMS, colografía distal y sus resultados funcionales, después de los tres años de edad. Los datos de los pacientes se digitaron en una base de datos del programa Excel, para analizarlos y tener una clara visión de los procedimientos empleados con cada grupo y de los resultados obtenidos. Resultados: Se controlaron 200 casos operados entre 1998 y 2008; en todos se estudiaron las malformaciones congénitas asociadas y su malformación anal, y se encontraron distintos tipos que fueron clasificados de la siguiente forma: los que tenían fístula, que se agruparon por el sitio donde la fístula desembocaba: a cuello vesical, 12 casos, uretra prostática, 12 casos, uretra bulbar, 18 casos, vestibular, 26 casos, perineal, 92 casos, estenosis anal, 12 casos; los que no tenían fístula: altos, 16 casos, o bajos, 3 casos, y finalmente, las malformaciones cloacales, tanto las altas, 2 casos, como las bajas, 7 casos. Todos los pacientes fueron operados con la técnica...

Despite the high frequency of anorectal malformations treated at the General Surgery Service of the National Children’s Hospital, there exists a dearth of national medical publications related to this pathology. The aim of this investigation is to verify the treatment details of 200 patients who underwent anorectal surgery between 1998 and 2008 as well as to determine our experience. Any recommendations will be based on the findings of this study.Materials and methods: Two hundred patients of the Dr. Carlos Sáenz National Children’s Hospital were studied. This group presented anorectal malformations, were treated between 1998 and 2008 and received follow up care at the General Surgery outpatient clinic.The patients were grouped according to their type of anomaly and were examined for the following: associated congenital malformations, type of anorectal anomaly, type of surgery, complications and the results of the following tests: abdominal ultrasound, CUMS, distal colography and the functional results after three years of age. All of the data was collected from the patients’ medical files. This information was then transferred to an Excel data sheet for further analysis and in order to have a clear picture of the conduct that was followed with each group of patients. Results:The groups were made using the following classification: those patients with a fistula were grouped according to the location of the opening: bladder neck (12 cases), prostate (12 cases), bulbar (18 cases), vestibular (26 cases), perineal (92 cases), anal stenosis (12 cases). Those who had no fistula: high (16 cases) or low (3 cases). Finally, the cloacae malformations, both high cases (2 cases) and low cases (7cases). All of the patients underwent surgery using the Peña technique with the corresponding modifications. No patients were treated with the laparoscopic technique. Conclusion: Because we consider these cases to be highly complex...