Trauma de recto penetrante: revisión de tema / Penetrating rectal trauma: a comprehensive review

Introducción. En la actualidad, el trauma de recto continúa siendo una situación clínica compleja y temida por ser potencialmente mortal. Su detección y manejo temprano es la piedra angular para impactar tanto en la mortalidad como en la morbilidad de los pacientes. Hoy en día, aún existe debate sobre la aproximación quirúrgica ideal en el trauma de recto y las decisiones de manejo intraoperatorias se ven enormemente afectadas por la experiencia y preferencias del cirujano. Métodos. Se realizó una búsqueda de la literatura en las bases de datos de PubMed, Clinical Key, Google Scholar y SciELO utilizando las palabras claves descritas y se seleccionaron los artículos más relevantes publicados en los últimos 20 años; se tuvieron en cuenta los artículos escritos en inglés y español. Discusión. El recto es el órgano menos frecuentemente lesionado en trauma, sin embargo, las implicaciones clínicas que conlleva pasar por alto este tipo de lesiones pueden ser devastadoras para el paciente. Las opciones para el diagnóstico incluyen el tacto rectal, la tomografía computarizada y la rectosigmoidoscopía. El manejo quirúrgico va a depender de la localización, el grado de la lesión y las lesiones asociadas. Conclusión. El conocimiento de la anatomía, el mecanismo de trauma y las lesiones asociadas permitirán al cirujano realizar una aproximación clínico-quirúrgica adecuada que lleve a desenlaces clínicos óptimos de los pacientes que se presentan con trauma de recto.

Introduction. Currently, rectal trauma continues to be a complex clinical and potentially fatal situation. Its early detection and management is the cornerstone to avoid both mortality and morbidity of patients. Today there is still debate about the ideal surgical approach in rectal trauma, and intraoperative management decisions are greatly affected by the experience and preferences of the surgeon. Methods. A literature search was performed in the PubMed, Clinical Key, Google Scholar and SciELO databases using the keywords described. The most relevant articles published in the last 20 years were selected. Articles written in English and Spanish were considered.Discussion. The rectum is the organ less frequently injured in trauma; however, the clinical implications of overlooking this injury can be devastating for the patient. Options for diagnosis include digital rectal examination, computed tomography and rectosigmoidoscopy. Surgical management will depend on the location, degree of the injury and the associated injuries. Conclusion. Knowledge of the anatomy, the mechanism of trauma and the associated injuries will allow the surgeon to make an adequate clinical-surgical approach that leads to optimal clinical outcomes in patients presenting with rectal trauma.

Is there a precise correlation between the lengths of the peritoneal reflection and the middle rectal valve?

Introduction: Pelvic anatomy remains a challenge, and thorough knowledge of its intricate landmarks has major clinical and surgical implications in several medical specialties. The peritoneal reflection is an important landmark in intraluminal surgery, rectal trauma, impalement, and rectal adenocarcinoma. Objectives: To investigate the correlation between the lengths of the middle rectal valve and of the peritoneal reflection determined with rigid sigmoidoscopy and to determine whether there are any differences in the location of the peritoneal reflection between the genders and in relation to body mass index (BMI) and parity. Design: We prospectively investigated the location of the middle rectal valve and of the peritoneal reflection via intraoperative rigid sigmoidoscopy in colorectal cancer patients undergoing elective colorectal surgery. Results: We evaluated 38 patients with a mean age of 55.5 years old (57.5% males) who underwent colorectal surgery at the coloproctology service of the Hospital Santa Marcelina, São Paulo, state of São Paulo, Brazil. There was substantial agreement between the lengths of the middle rectal valve and of the peritoneal reflection (Kappa = 0.66). In addition, the peritoneal reflection was significantly lower in overweight patients (p = 0.013 for women and p < 0.005 for men) and in women with > 2 vaginal deliveries (p = 0.009), but there was no significant difference in the length of the peritoneal reflection between genders (p = 0.32). Conclusion: There was substantial agreement between the lengths of the peritoneal reflection and of the middle rectal valve, and the peritoneal reflection was significantly lower in overweight patients and in women with more than two vaginal deliveries. (AU)

Trombosis segmentaria sigmoidea consecuente a neoplasia maligna de colon. A propósito de un caso interesante / Sigmoid segmental thrombosis consequent to colon malignant neoplasia. On the purpose of a case

RESUMEN Se presentó un caso de una paciente de 78 años de edad, procedente del municipio de Calimete, con antecedentes patológicos personales de infarto agudo miocárdico sin elevación del segmento ST e hipertensión arterial. Llegó a la Unidad de Cuidados Intensivos de Emergencia, de Colón con un estado toxico infeccioso severo. Fue intervenida quirúrgicamente con el diagnóstico presuntivo de una trombosis mesentérica. Se constató dicho diagnóstico complementario a una neoplasia maligna de colon sigmoides. Falleció producto a un shock séptico refractario a aminas. En la necropsia se reportaron hallazgos de interés.

ABSTRACT The authors present the case of a 78-years-old female patient from the municipality of Calimete, with personal pathological antecedents of acute myocardial infarct without ST segment elevation and arterial hypertension. She arrived to the Emergency Intensive Care Unit of Colon with a severe toxic-infectious status. She underwent a surgery with a presumptive mesenteric thrombosis. It was stated that diagnosis, complementary to a sigmoid colon malignant neoplasia. She died as a product of an amine-refractory septic shock. The autopsy showed findings of interest.

Oncologic Outcomes of Organ Preserving Approaches in Patients With Rectal Cancer Treated With Preoperative Chemoradiotherapy

PURPOSE: We evaluated the oncologic outcomes of organ-preserving strategies in patients with rectal cancer treated with preoperative chemoradiotherapy (PCRT). METHODS: Between January 2008 and January 2013, 74 patients who underwent wait-and-watch (WW) (n = 42) and local excision (LE) (n = 32) were enrolled. Organ-preserving strategies were determined based on a combination of magnetic resonance imaging, sigmoidoscopy, and physical examination 4–6 weeks after completion of PCRT. The rectum sparing rate, 5-year recurrence-free survival (RFS), and overall survival (OS) were evaluated. RESULTS: The rectum was more frequently spared in the LE (100% vs. 87.5%, P = 0.018) at last follow-up. Recurrence occurred in 9 (28.1%) WW and 7 (16.7%) LE (P = 0.169). In the WW, 7 patients had only luminal regrowth and 2 had combined lung metastasis. In the LE, 2 (4.8%) had local recurrence only, 4 patients had distant metastasis, and 1 patient had local and distant metastasis. Among 13 patients who indicated salvage surgery (WW, n = 7; LE, n = 11), all in the WW received but all of LE refused salvage surgery (P = 0.048). The 5-year OS and 5-year RFS in overall patients was 92.7% and 76.9%, respectively, and were not different between WW and LE (P = 0.725, P = 0.129). CONCLUSION: WW and LE were comparable in terms of 5-year OS and RFS. In the LE group, salvage treatment was performed much less among indicated patients. Therefore, methods to improve the oncologic outcomes of patients indicated for salvage treatment should be considered before local excision.

Anastomotic Sinus That Developed From Leakage After a Rectal Cancer Resection: Should We Wait for Closure of the Stoma Until the Complete Resolution of the Sinus?

PURPOSE: The aims of this study were to identify the clinical characteristics of an anastomotic sinus and to assess the validity of delaying stoma closure in patients until the complete resolution of an anastomotic sinus. METHODS: The subject patients are those who had undergone a resection of rectal cancer from 2011 to 2017, who had a diversion ileostomy protectively or therapeutically and who developed a sinus as a sequelae of anastomotic leakage. The primary outcomes that were measured were the incidence, management and outcomes of an anastomotic sinus. RESULTS: Of the 876 patients who had undergone a low anterior resection, 14 (1.6%) were found to have had an anastomotic sinus on sigmoidoscopy or a gastrografin enema before their ileostomy closure. In the 14 patients with a sinus, 7 underwent ileostomy closure as scheduled, with a mean closure time of 4.1 months. The remaining 7 patients underwent ileostomy repair, but it was delayed until after the follow-up for the widening of the sinus opening by using digital dilation, with a mean closure time of 6.9 months. Four of those remaining seven patients underwent stoma closure even though their sinus condition had not yet been completely resolved. No pelvic septic complications occurred after closure in any of the 14 patients with an anastomotic sinus, but 2 of the 14 needed a rediversion due to a severe anastomotic stricture. CONCLUSION: Patients with an anastomotic sinus who had been carefully selected underwent successful ileostomy closure without delay.

Ischemic Colitis Associated with Rhabdomyolysis and Heat Stroke after an Intense Exercise in Young Adult / 대한소화기병학회잡지

Ischemic colitis primarily affects the elderly with underlying disease, but it rarely occurs in young adults with risk factors, such as coagulopathy or vascular disorder. Moreover, it is extremely rare in the very young without risk factors. This paper presents a patient with ischemic colitis associated with heat stroke and rhabdomyolysis after intense exercise under high-temperature conditions. A 20-year-old man presented with mental deterioration after a vigorous soccer game for more than 30 minutes in sweltering weather. He also presented with hematochezia with abdominal pain. The laboratory tests revealed the following: AST 515 U/L, ALT 269 U/L, creatine kinase 23,181 U/L, BUN 29.1 mg/dL, creatinine 1.55 mg/dL, and red blood cell >50/high-power field in urine analysis. Sigmoidoscopy showed ischemic changes at the rectum and rectosigmoid junction. A diagnosis of ischemic colitis and rhabdomyolysis was made, and the patient recovered after conservative and fluid therapy. This case showed that a diagnosis of ischemic colitis should be considered in patients who present with abdominal pain and bloody diarrhea after intense exercise, and appropriate treatment should be initiated immediately.

Rectal Ulcer Developed in Systemic Lupus Erythematosus without Ischemic Colitis / 대한소화기병학회잡지

Rectal involvement by systemic lupus erythematosus (SLE) is quite rare. Approximately 14 cases have been reported worldwide, but only one with ischemic colitis has been reported in Korea. A 17-year-old female patient was hospitalized with abdominal pain and hematochezia. Sigmoidoscopy revealed only a simple rectal ulcer without ischemic colitis. cytomegalovirus and bacterial infections were excluded. A sigmoidoscopic rectal biopsy indicated a rectal invasion by SLE, but the patient showed an acute worsening conditions that did not respond to treatment. This paper reports a case of rectal ulcer that developed in SLE without ischemic colitis with a review of the relevant literature.

Ischemic Colitis Associated with Rhabdomyolysis and Heat Stroke after an Intense Exercise in Young Adult / 대한소화기학회지

Ischemic colitis primarily affects the elderly with underlying disease, but it rarely occurs in young adults with risk factors, such as coagulopathy or vascular disorder. Moreover, it is extremely rare in the very young without risk factors. This paper presents a patient with ischemic colitis associated with heat stroke and rhabdomyolysis after intense exercise under high-temperature conditions. A 20-year-old man presented with mental deterioration after a vigorous soccer game for more than 30 minutes in sweltering weather. He also presented with hematochezia with abdominal pain. The laboratory tests revealed the following: AST 515 U/L, ALT 269 U/L, creatine kinase 23,181 U/L, BUN 29.1 mg/dL, creatinine 1.55 mg/dL, and red blood cell >50/high-power field in urine analysis. Sigmoidoscopy showed ischemic changes at the rectum and rectosigmoid junction. A diagnosis of ischemic colitis and rhabdomyolysis was made, and the patient recovered after conservative and fluid therapy. This case showed that a diagnosis of ischemic colitis should be considered in patients who present with abdominal pain and bloody diarrhea after intense exercise, and appropriate treatment should be initiated immediately.

Rectal Ulcer Developed in Systemic Lupus Erythematosus without Ischemic Colitis / 대한소화기학회지

Rectal involvement by systemic lupus erythematosus (SLE) is quite rare. Approximately 14 cases have been reported worldwide, but only one with ischemic colitis has been reported in Korea. A 17-year-old female patient was hospitalized with abdominal pain and hematochezia. Sigmoidoscopy revealed only a simple rectal ulcer without ischemic colitis. cytomegalovirus and bacterial infections were excluded. A sigmoidoscopic rectal biopsy indicated a rectal invasion by SLE, but the patient showed an acute worsening conditions that did not respond to treatment. This paper reports a case of rectal ulcer that developed in SLE without ischemic colitis with a review of the relevant literature.

A Rare Case of Eosinophilic Gastroenteritis in a Neonate with Fever

Eosinophilic gastroenteritis is a member of eosinophilic gastrointestinal (GI) diseases and is characterized by the accumulation of eosinophils within the GI tract. Common symptoms of eosinophilic gastroenteritis are vomiting, abdominal pain, dysphagia, and weight loss, but rare fever in neonate. This report describes a 10-day-old boy who developed fever, bloody mucoid stool, and bilious vomiting resulting from eosinophilic gastroenteritis, mimicking sepsis. Sigmoidoscopy and pathologic findings revealed mucosal edema, small hemorrhagic spot, and segmental erythemoid edema in the colon and increased number of eosinophils in the lamina propria with intraepithelial eosinophils. After breast milk feeding with restriction of milk from the mother for 6 months, specific immunoglobulin to milk was class 0 (class 3, previous). The boy restarted formula feeding, and he had no fever and GI symptoms.

Prospective study on the safety and feasibility of early ileostomy closure 2 weeks after lower anterior resection for rectal cancer

PURPOSE: Transient loop ileostomies in rectal cancer surgery are generally closed after 2 or more months to allow adequate time for anastomotic healing. Maintaining the ileostomy may cause medical, surgical, or psychological complications; it also reduces the quality of life, and increase treatment costs. We performed this study to evaluate the safety and feasibility of early ileostomy closure 2 weeks postoperatively. METHODS: If a patient who underwent total mesorectal excision had 2 or more risk factors for anastomotic leakage, a loop ileostomy was created. After confirmation of intact anastomosis via sigmoidoscopy and proctography 1 week postoperatively, the patient was enrolled and ileostomy was closed 2 weeks postoperatively. The primary endpoint was the frequency of complication after ileostomy repair. RESULTS: Thirty patients were enrolled in the study and 6 were excluded due to anastomotic leakage. Except for 1 case of wound infection (4.2%), no patient experienced any complication including newly developed leakage after the ileostomy closure. The mean duration to repair was 13.1 days (range, 8–16 days) and mean duration to the start of adjuvant treatment after radical surgery was 5.37 weeks (range, 3.0–8.1 weeks). CONCLUSION: Transient loop ileostomy, which is confirmed to be intact endoscopically and radiologically, can be safely closed 2 weeks postoperatively without requiring a significant delay in adjuvant chemotherapy.

Acute Suppurative Appendicitis Diagnosed by Acute Lower Gastrointestinal Hemorrhage / 대한소화기학회지

A 49-year-old man visited the emergency room of Korea University Ansan Hospital with hematochezia starting the day before the visit. Recently, he was on anti-platelet medication due to hypertension. The patient had no definite symptoms other than hematochezia. Digital rectal exam was positive and laboratory tests showed severe anemia. Sigmoidoscopy was initiated and almost no fecal material was observed in the intestinal tract, allowing insertion into the cecum. Active bleeding from the appendiceal opening was noted. On abdominal CT, contrast enhancement was observed at the tip of the appendix. Under suspicion of acute appendicitis, we consulted with a surgeon. The patient underwent appendectomy with partial cecal resection. Pathologic examination revealed a diagnosis of appendix bleeding due to acute suppurative appendicitis. The patient had no further bleeding after surgery and was discharged in a stable state. Careful observation by the endoscopist is necessary for accurate diagnosis of lower gastrointestinal hemorrhage. Appendiceal hemorrhage is very rarely reported, but it has various pathophysiologies. CT scan is useful when appendiceal hemorrhage is confirmed by endoscopic findings. Surgical treatment was needed in almost all cases reported worldwide. If bleeding from the appendix is confirmed, surgical treatment should be considered for both therapeutic and diagnostic purposes.

Endoscopic Band Ligation to Treat a Massive Hemorrhoidal Hemorrhage Following a Transrectal Ultrasound-Guided Prostate Biopsy

Prostate cancer is commonly diagnosed by using a transrectal ultrasound (TRUS)-guided biopsy. Although this procedure is usually well tolerated, rarely it may be complicated by massive rectal bleeding. We report a case of a 77-year-old male who underwent a TRUS biopsy and subsequently developed recurrent episodes of rectal bleeding with syncope and anemia requiring the transfusion of multiple units of blood. A sigmoidoscopy revealed the source of the bleeding: a large hemorrhoid on the anterior wall of the rectum with an overlying ulceration. We successfully applied a band to ligate the hemorrhoid, and the patient's condition improved. To our knowledge, this case represents the first report of a successful band ligation to treat massive bleeding from a hemorrhoid that had been punctured in the course of the TRUS biopsy procedure.

Transanal Tube Drainage as a Conservative Treatment for Anastomotic Leakage Following a Rectal Resection

PURPOSE: We evaluate the role of transanal tube drainage (TD) as a conservative treatment for patients with anastomotic leakage (AL). METHODS: Patients treated for AL who had undergone a low or an ultralow anterior resection with colorectal or coloanal anastomosis for the treatment of rectal cancer between January 2013 and January 2017 were enrolled in this study. The data were collected prospectively and analyzed retrospectively. The primary outcomes were the diagnosis and the management of AL. RESULTS: Two hundred thirteen consecutive patients, 122 males and 91 females, were included. The mean age was 66.91 ± 11.15 years, and the median body mass index was 24 kg/m2 (range, 20–35 kg/m2). The median tumor distance from the anal verge was 8 cm (range, 4–12 cm). Ninety-three patients (44%) received neoadjuvant therapy for nodal disease and/or locally advanced rectal cancer. Only 13 patients (6%) developed AL. Six patients developed subclinical AL as they had a defunctioning ileostomy at the time of the initial procedure. They were treated conservatively with TD under endoscopic guidance in the endoscopy unit and received intravenous antibiotics. Six weeks after discharge, these 6 patients underwent follow-up flexible sigmoidoscopy which showed a completely healed anastomotic defect with no residual stenosis. Seven patients developed a clinically significant AL and required reoperation with pelvic abscess drainage and Hartmann colostomy formation. CONCLUSION: These results suggest that TD for management of patients with AL is safe, cheap, and effective. Salvaging the anastomosis will help decrease the need for Hartmann colostomy formation. Proper patient selection is important.

Is Clostridium difficile infection a real threat in patients with ulcerative colitis? A prospective, multicenter study in Korea

BACKGROUND/AIMS: Clostridium difficile infection (CDI) has been reported to be a cause of flare-ups in patients with ulcerative colitis (UC). We evaluated the prevalence and clinical outcomes of CDI in patients with UC hospitalized for flare-ups. METHODS: This was a prospective, multicenter study including 7 academic teaching hospitals in Korea. All consecutive patients with UC admitted for disease flare-up were enrolled. We detected the presence of CDI by using enzyme immunoassay, real-time polymerase chain reaction (RT-PCR) for toxin genes, and sigmoidoscopy. RESULTS: Eighty-one consecutive patients with UC were enrolled from January 2014 to December 2015. Among 81 patients, 8 (9.9%) were diagnosed with CDI. Most of the cases were identified by RT-PCR. Enzyme immunoassay was positive in 3 of 8 patients, and only 1 had typical endoscopic findings of pseudomembranous colitis. There were no differences in demographic data, length of hospital stay, or colectomy rate between patients with and without CDI. CONCLUSIONS: CDI was not a rare cause of flare-up in patients with UC in Korea. However, CDI did not appear to affect the course of UC flare-up in Korean patients. RT-PCR was sensitive in detecting CDI and can be considered a diagnostic tool in patients with UC flare-up.

A case of ulcerative colitis presenting with cerebral venous thrombosis

Patients with inflammatory bowel disease (IBD) have been reported to have an increased risk of thromboembolism. Cerebral venous thrombosis (CVT) is a rare but serious extraintestinal manifestation of IBD. Due to its highly variable manifestation and low incidence, CVT is not usually readily recognized by physicians. Herein, we report a case of a 35-year-old male presenting with CVT associated with ulcerative colitis (UC). The patient was admitted with chief complaints of bloody diarrhea that had started 3 days prior. Sigmoidoscopy showed hyperemic and edematous mucosa, friability, and shallow ulcers from the sigmoid colon to the rectum suggestive of IBD. Three days later, the patient started complaining of a headache, and gradually developed a decreased level of consciousness. Magnetic resonance imaging of the brain revealed CVT with hemorrhagic infarctions. An angiogram was obtained to evaluate the extent of CVT, and anticoagulation therapy was initiated with intravenous heparin. During hospitalization, he was diagnosed with UC and treated with 5-aminosalicylic acid. After discharge, the patient was recovered without neurological deficit, and remission of UC was also obtained. The presence of headache or acute worsening of neurological status in a patient with IBD should alert the health professionals about the possibility of CVT.

Pyoderma Gangrenosum of the Preauricular Area with Ulcerative Colitis: A Case Report and Review

Pyoderma gangrenosum (PG) is primarily, a sterile, inflammatory, neutrophilic dermatosis, characterized by recurrent cutaneous ulceration with mucopurulent or hemorrhagic exudate. The incidence of PG is uncertain, but it is estimated to be about 3-10 patients per million per year. It occurs most commonly on the lower legs, but has been reported at other sites of the body as well. The causes of PG are unknown, but about 50-70% of cases are associated with other diseases, mainly inflammatory bowel disease. We hereby report a case of PG in a 21-year-old male, with a history of ulcerative colitis (UC). After appropriate diagnostic methods including biopsy for pathologic confirmation, sigmoidoscopy and computed tomography, we excluded other diseases and the lesion was diagnosed as PG. We then carried out regular dressing of the wound, while UC was treated with steroid and immunosuppressant medication, with inputs from the department of gastroenterology during the hospital stay. There occurred recurrence of the skin lesion, 7 months after discharge, after which they improved. UC has been in the remission state as per the follow-up, since 2 years.