Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer.

BACKGROUND: Abdominal perineal excision (APE) was originally described with levator ani removal for rectal cancer. An even wider, more aggressive extralevator resection for APE has been proposed. Although some surgeons are performing a very wide 'extralevator APE (ELAPE)', there are few data to recommend it routinely. This multicentre study aimed to compare outcomes of APE and ELAPE. METHODS: A multicentre propensity case-matched analysis comparing two surgical approaches (APE and ELAPE) was performed. All patients who underwent abdominoperineal resection of a rectal tumour were considered for the analysis. Tumour height was defined by magnetic resonance imaging measurement and patients with stage II-III tumours had neoadjuvant radiochemotherapy. Involvement of the circumferential resection margin (CRM) and intraoperative tumour perforation were the main outcome measures. A logistic regression model was used to study the relationship between the surgical approaches and outcomes. RESULTS: From January 2008 to March 2013 a total of 1909 consecutive patients underwent APE or ELAPE, of whom 914 matched patients (457 in each group) formed the cohort for analysis. Intraoperative tumour perforation occurred in 7.9 and 7.7 per cent of patients during APE and ELAPE respectively (P = 0.902), and there was CRM involvement in 13.1 and 13.6 per cent (P = 0.846). There were no differences between APE and ELAPE in terms of postoperative complication rates (52.3 versus 48.1 per cent; P = 0.209), need for reoperation (7.7 versus 7.0 per cent; P = 0.703), perineal wound problems (26.0 versus 21.9 per cent; P = 0.141), mortality rate (2.0 versus 2.0 per cent; P = 1.000) and local recurrence rate at 2 years (2.7 versus 5.6 per cent; P = 0.664). CONCLUSION: ELAPE does not improve rates of CRM involvement, intraoperative tumour perforation, local recurrence or mortality.

Hartmann's operation: how often is it reversed and at what cost? A multicentre study.

AIM: The study evaluated the rate of reversal of Hartmann's operation after the initial surgery and its morbidity. METHOD: A multicentre retrospective study was carried out in seven hospitals in the Valencia area of patients who underwent Hartmann's operation from 2004 to 2008. The incidence of reversal was determined. RESULTS: Four hundred and fifty-two patients of mean age 67.5 ± 15.4 years were included, of whom 78.8% had an emergency operation. The most common diagnosis was cancer (58.6%), although diverticulitis predominated in the emergency setting. At a median follow up of 44 months, 159 (35.2%) patients had undergone reversal, including 16.6% after elective surgery and 40.4% after an emergency Hartmann's procedure (P < 0.001). The most frequent reason why reversal was not done was death (74 [25%] patients). Patients undergoing reversal were younger and had a low ASA risk. Trauma was associated with a higher rate of reversal, followed by diverticular disease. Surgery was performed at a median of 10 months. An open approach with stapled anastomosis was used in most cases. The mortality was 3.5%. Complications occurred in 45.2%, with a 6.2% rate of anastomotic leakage. Complications were associated with age, diabetes mellitus, arteriosclerosis, obesity, smoking, chemotherapy and COPD. CONCLUSION: Hartmann's reversal was performed in a small percentage of patients, mostly including those with benign disease. It had a significant morbidity.

Hematoma espontáneo del músculo psoas-ilíaco. Aporte de 3 casos y revisión de la literatura médica / Spontaneous hematoma of the iliopsoas muscle. The report of three cases and review of the literature

Introducción. Los hematomas del músculo psoas-ilíaco son problemas infrecuentes que veremos en pacientes con factores predisponentes. La presentación clínica es muy variada, lo que puede afectar al mantenimiento de la hemodinamia. Casos clínicos. Presentamos 3 casos clínicos atendidos en nuestro hospital, todos ellos con tratamiento conservador: fue efectivo en 2 casos y una paciente falleció. Comentarios. Los músculos psoas-ilíacos son estructuras fundamentales en el mantenimiento de la postura y la flexión de la cadera. Los hematomas de estos músculos suelen aparecer en pacientes con alteraciones de la coagulación, y causan desde ligeras molestias locales hasta cuadros de shock hipovolémico. Deberán estudiarse mediante pruebas de imagen, como ecografía y tomografía computarizada, que permitirán decidir la actitud terapéutica más adecuada, generalmente requerirán tratamiento conservador con reposo y analgesia, y recuperarán siempre la capacidad coagulante de la sangre (AU)

Introduction. Hematomas of the iliopsoas muscle are uncommon problems that are seen in patients withpredisposing factors. They have a varied clinical presentation which may even alter hemodynamics maintenance. Case reports. We present 3 clinical cases reports on patients treated conservatively at our hospital. The outcome was successful in two of them and resulted in death in the other. Comments. Iliopsoas muscles are essential structures in the maintenance of posture and hip flexion. Hematomas of these muscles usually occur in patients with coagulation disorders, causing from mild local discomfort to hypovolemic shock. They can be diagnosed by imaging tests such as ultrasound and computed tomography, which enable us to decide the most appropriate therapeutic approach, usually requiring conservative management that includes rest and analgesia, together to the recover of blood clotting ability (AU)

Management of colonic volvulus. Experience in 75 patients.

BACKGROUND: the diagnostic and therapeutic management of colonic volvulus remains nowadays controversial. The election of the type of surgery, its timing, or the use of non-operative decompression must be based on the experience of a multidisciplinary team, the clinical condition of the patient, and the type of volvulus. OBJECTIVES: the purpose of this study is to review our experience and results in the treatment of patients with colonic volvulus. MATERIAL AND METHODS: we performed a retrospective study of patients diagnosed of colonic volvulus between January 1990 and September 2008 in our institution. RESULTS: we included a total of 75 patients with a mean age of 72.7 years and, in most cases, with associated comorbidities and constipation. The most frequently involved segment was sigmoid colon (85.3%). A rectal tube insertion was used as the only therapeutic measure in 17 patients (22.4%), colonoscopic decompression in 17 (22.4%), and surgery in 41 patients (55.2%). Intestinal resection with primary anastomosis was the most common surgical option. Postoperative morbidity was 43%, being wound infections the most frequent complication. In the group of non-surgical treatment morbidity was 26.4%, albeit with a higher and early rate of recurrences. CONCLUSIONS: treatment of colonic volvulus present important morbidity and mortality rates, and its treatment must be individualized. Resective surgery with primary anastomosis in clinically stable patients is the most appropriate therapeutic option, offering the lower recurrence rates.

Manejo del vólvulo de colon. Experiencia en 75 pacientes / Management of colonic volvulus. Experience in 75 patients

Introducción: el manejo diagnóstico-terapéutico del vólvulode colon continúa siendo un tema controvertido en la actualidad.En base a la situación clínica del paciente, a la experiencia de unequipo multidisciplinar, deben elegirse el tipo de cirugía, momentode su realización y el empleo de otras opciones descompresivas.Objetivos: los objetivos del presente trabajo son revisar nuestraexperiencia y resultados en el tratamiento de los pacientes convólvulo de colon.Material y métodos: hemos realizado un estudio retrospectivodescriptivo de los pacientes diagnosticados de vólvulo de colonentre enero de 1990 y septiembre de 2008 en nuestro centro.Resultados: se han incluido un total de 75 pacientes, de edadmedia 72,7 años y, en su mayoría, con comorbilidades asociadasy estreñimiento. La zona de volvulación más frecuentemente implicadafue el sigma (85,3%). La sonda rectal fue utilizada comoúnica medida terapéutica en 17 pacientes (22,4%), el tratamientoendoscópico en otros 17 (22,4%), y la cirugía en 41 (55,2%). Laresección intestinal con anastomosis primaria fue la opción quirúrgicamás empleada. La morbilidad postoperatoria fue del 43%,siendo las infecciones de herida la complicación más frecuente.En el grupo de tratamiento no quirúrgico la morbilidad fue del26,4%, aunque con una mayor y más precoz tasa de recidivas.Conclusiones: el vólvulo de colon presenta una elevada tasade morbimortalidad asociada, debiendo realizarse su tratamientode forma individualizada. La cirugía resectiva con anastomosis primariaen pacientes clínicamente estables es la opción terapéuticadefinitiva más adecuada y con menores tasas de recidiva(AU)

Background: the diagnostic and therapeutic management ofcolonic volvulus remains nowadays controversial. The election ofthe type of surgery, its timing, or the use of non-operative decompressionmust be based on the experience of a multidisciplinaryteam, the clinical condition of the patient, and the type of volvulus.Objectives: the purpose of this study is to review our experienceand results in the treatment of patients with colonic volvulus.Material and methods: we performed a retrospective studyof patients diagnosed of colonic volvulus between January 1990and September 2008 in our institution.Results: we included a total of 75 patients with a mean age of72.7 years and, in most cases, with associated comorbidities andconstipation. The most frequently involved segment was sigmoidcolon (85.3%). A rectal tube insertion was used as the only therapeuticmeasure in 17 patients (22.4%), colonoscopic decompressionin 17 (22.4%), and surgery in 41 patients (55.2%). Intestinalresection with primary anastomosis was the most common surgicaloption. Postoperative morbidity was 43%, being wound infectionsthe most frequent complication. In the group of non-surgicaltreatment morbidity was 26.4%, albeit with a higher and earlyrate of recurrences.Conclusions: treatment of colonic volvulus present importantmorbidity and mortality rates, and its treatment must be individualized.Resective surgery with primary anastomosis in clinically stablepatients is the most appropriate therapeutic option, offeringthe lower recurrence rates(AU)

Fistulectomy and sphincteric reconstruction for complex cryptoglandular fistulas.

OBJECTIVE: Complex anal fistulas (CFs) are difficult to treat. Endoanal advancement flap (EAF) is one of the standard treatment options for such clinical conditions. Immediate sphincter repair after fistulectomy (ISR) is not commonly performed because of the fear of causing postoperative incontinence. The objective of this study was to compare the results of both techniques. METHOD: We retrospectively analysed a prospectively entered database composed of 146 patients (112 M; 34 F), undergoing operations for CF of cryptoglandular origin. The patients were divided in two groups: Group A: (EAF); n = 71 patients; Group B: (ISR); n = 75 patients. RESULTS: Forty-two fistulas (28.7%) were recurrent, 98 trans-sphincteric (TS) and 37 suprasphincteric (SS). Twenty-six (17.7%) patients had some degree of preoperative continence disturbances, 11 in Group A vs 15 in Group B (P = 0.47). After a mean follow up of 13 months (12-60), fistula persisted or recurred in 13 (18.3%) patients in Group A vs eight (10.6%) in Group B (P = 0.19) irrespective of the fistula type (TS or SS). Thirty-one (43.6%) patients in Group A vs 16 (21.3%) in Group B presented postoperative continence disturbances (P < 0.001). No changes were observed with the Faecal Incontinence Quality of Life Scale (FIQLS). Group A patients had a significant reduction of maximal rest pressure after surgery. After ISR, no significant changes in pressures were observed. CONCLUSION: Immediate sphincter repair can be a therapeutic option in selected cases of CF, mainly when associated with incontinence or increased risk factors.

Risk factors for recurrence and incontinence after anal fistula surgery.

OBJECTIVE: Fistula-in-ano continues to raise problems that require important therapeutic decisions. Our aim was to evaluate its recurrence and incontinence risk factors. METHOD: We analysed a series of 279 patients who had undergone anal fistula surgery with long-term follow-up. RESULTS: 42.7% of the fistulae were considered complex and 46% had been referred from other institutions. There was delayed healing or recurrence in 7.2% patients, which appeared at a median of 4 months. The factors associated with recurrence were the type of fistula (extrasphincteric/suprasphincteric), nonidentification of internal opening (IO), recurrent or complex fistulae (CF), and associated chronic abscess. Only CF and nonidentification of IO were statistically significant in the multivariate analysis. Preoperative incontinence was a risk factor for postoperative incontinence, as were suprasphincteric, recurrent and CF. The age and gender of the patient did not influence postoperative continence, nor did the surgeon or surgical technique appear as a risk factor, although after excluding preoperative incontinent patients, fistulotomy was the technique that showed a higher risk of incontinence. Multivariate analysis only confirmed previous incontinence as a RF. CONCLUSION: The overall recurrence rate is acceptable, but high fistulae continue to be difficult to treat. IO identification is also essential for obtaining good results. It is important to identify the patients with preoperative incontinence as they are at a greater risk of deterioration after surgery.

Perioperative care in colorectal surgery: current practice patterns and opinions.

Objective Evidence regarding perioperative care in colorectal surgery has recently increased, leading to changes in classical clinical procedures that make the perioperative period safer and shorter. This survey aimed to evaluate the opinions of Spanish colorectal surgeons on the perioperative management of their patients. Method Emailed surveys submitted to the members of Spanish Coloproctological Associations. Results One hundred and thirty-one (31.7%) of the 413 members participated in the study and responded thus: 21% use clinical pathways and 8% use fast track (FT); 36% use epidural analgesia in colonic surgery and 57% in rectal; 40% use warm air and 23% warm fluids to maintain intraoperative normothermia; 53% prescribe >/= 3000 ml. of iv fluids on the first postoperative day and 6.2%

Mechanical bowel preparation and antibiotic prophylaxis in colorectal surgery: use by and opinions of Spanish surgeons.

OBJECTIVE: Antibiotic prophylaxis (AP) and mechanical bowel preparation (MBP) previous to surgery have classically been regarded as important in colorectal surgery. The latter has recently been questioned. We evaluated opinion of Spanish surgeons about the use of these measures. METHOD: E-mail survey among all members of Spanish Coloproctologic Associations. RESULTS: Of 413 participants in the survey, 131 (31.7%) responded; 87% of surgeons used cathartics (70%), enemas (2%) or both (28%) for MBP. MBP was used 60% in right colon surgery, 90% in left colon and 99% in rectal surgery. Surgeons with more case load or those who specialized in colorectal surgery used significantly less MBP; 60% of the surgeons thought that MBP made surgery easier and reduced contamination; 35% thought that it decreased wound infection (WI) and 17% thought that it prevented anastomotic leaks. For 77%, it was regarded as useful or very useful. AP was used by 99.3% of surgeons including systemic alone in 86.2% and combined with oral in 16.8%. The first dose was given 2 h before surgery by 20.2% of the surgeons, at the anaesthetic induction by 78.3% and postoperatively by 1.5%; 43% used single dose only, 44.5% extended to 24 h and 12.5% for two or more days; 95% thought that AP reduced WI and 96% considered that it was useful. CONCLUSION: There is general agreement on AP. MBP remained a common practice among Spanish colorectal surgeons except for right colonic resection. Surgeons with more case load and specialization used it significantly less.

Complicaciones tras la inyección de silicona líquida como mamoplastia de aumento / No disponible

La silicona líquida está formada por polímeros de dimetilsiloxano.El uso de esta sustancia para el aumento de tejidosblandos como es la mamoplastia de aumento, puede ocasionarla aparición de granulomas, entre otros efectos indeseables.También dificulta posteriormente el diagnóstico tempranodel cáncer de mama. La técnica diagnóstica más aceptadaes la resonancia magnética. El tratamiento sintomático y etiológicode las complicaciones (eliminar la sustancia inyectada)presenta problemas difíciles de resolver. Presentamos dos casosde complicación aguda por reacción a cuerpo extraño trasinyección intramamaria de silicona líquida(AU)

Liquid silicone is derived from dimethylsiloxane polymers.The use of this substance to augment soft tissues as breastaugmentation is associated with the appearance of granulomas,among other undesirable effects. Its use also leads toenormous difficulty in the early diagnosis of breast cancer.Magnetic resonance has become the most accepted test fordiagnosis. The symptomatic and etiological treatment (removalof injected substance) presents problems that are difficult tosolve. We present two cases of foreign body reactions as anacute complication after intramammary injection of liquid silicone(AU)

Review of the anatomic concepts in relation to the retrorectal space and endopelvic fascia: Waldeyer's fascia and the rectosacral fascia.

OBJECTIVE: A precise anatomical study of the fascias within the retrorectal space is reported, analyzing and clarifying the anatomical concepts previously employed to describe Waldeyer's and the rectosacral fascia. METHOD: The pelvis was dissected in 15 cadavers (10 males and five females). All specimens were divided in the median sagittal plane including the middle axis of the anal canal, to allow a correct visualization of and access to the retrorectal space. RESULTS: The retrorectal space was limited anteriorly by the rectum and posterior mesorectum covered by a fine visceral fascia, and posteriorly by the sacrum covered by the parietal presacral fascia. The rectosacral fascia divided the retrorectal space into inferior and superior portions in 80% of the male and 100% of the female specimens. It originated from the presacral parietal fascia at the level of S2 in 15%, S3 in 38% and S4 in 46% of specimens. In all cases it passed caudally to join the rectal visceral fascia 3-5 cm above the anorectal junction. As described by Waldeyer, the floor of the retrorectal space is formed by the fusion of the presacral parietal fascia and the rectal visceral fascia and lies above the levator ani muscle at the level of the anorectal junction. CONCLUSION: The rectosacral fascia divides the retrorectal space into inferior and superior portions. This must be differentiated from Waldeyer's description of the fascia lying in the inferior limit of the retrorectal space, formed by the fusion of the rectal visceral and parietal fascias.

Efecto beneficioso de itraconazol en mastodinia / No disponible

El sistema enzimático del citocromo P-450 es el principalresponsable del metabolismo hepático de hormonas sexuales.Presentamos el caso de una paciente de 39 años que acude aconsultas externas de Cirugía por presentar mastalgia cíclicaintensa desde hace meses, que cede coincidiendo con la tomade itraconazol y recidiva al dejar este tratamiento. Se trata deun efecto paradójico puesto que, en este caso, el itraconazolse comporta como un inductor de la isoenzima CYPA3A4 aumentandola eliminación del estradiol y no como el inhibidorque es habitualmente(AU)

The enzymatic system of the cytochrome P-450 is the mainresponsible for the hepatic metabolism of sexual hormones.We present the case of a 39 year-old patient. She went to SurgeryService because she suffered recurrent intense cyclic breastpain during several months. She started itraconazol therapyand breast pain improved, but it relapsed when sheleaved the treatment with itraconazol. This is supposed to be aparadoxical effect because in this case itraconazole behaved asan inductor of the CYPA3A4 isoenzyme increasing the eliminationof the estradiol, and it did not behave as an inhibitor ofCYPA3A4, as habitually(AU)

Adenocarcinoma primitivo de intestino delgado con presentación de novo / Primary smal bowel adenocarcinoma de novo

No disponible

No disponible

Cáncer de mama en varones / Breast cancer in men

El cáncer mamario en varones es una enfermedad infrecuente,que representa menos del 1% de la patología tumoral malignaen los pacientes de este sexo. Es difícil establecer criterios y guíasde diagnóstico y terapéutica sobre esta enfermedad, por lo quese utilizan los procedimientos empleados en el manejo del cáncerde mama en mujeres también para los hombres. Hemos realizadoun estudio retrospectivo de los 33 casos diagnosticados en losúltimos 40 años y seguidos durante un largo periodo en nuestraunidad, analizando en global los resultados y extrayendo ciertascaracterísticas particulares diferentes a las mujeres

The breast cancer in men is an infrequent disease, that representsless of 1% of the malignant tumorlike pathology inthe patients of this sex. It is difficult to establish criteria andguides of therapeutic and diagnosis on this disease, reasonwhy the procedures used in the handling of the breast cancerin women are also used for the men. We have made a retrospectivestudy of the 33 cases diagnosed in the last 40 yearsand followed for a long period in our unit, analyzing in globalthe results and extracting certain particular characteristics differentfrom the women