Procedimiento de malone videoasistido en pediatria: primeros dos casos en Uruguay / Laparoscopic malone procedure in pediatrics: first cases in Uruguay / Procedimento de malone videoassistido em pediatria: dois primeiros casos no Uruguai

El procedimiento de apendicostomía continente para la realización de enemas anterógrados ha sido publicado ya hace varios años para el tratamiento de la incontinencia fecal y del estreñimiento de muy difícil manejo. Otra indicación del mismo incluye el estreñimiento severo, en el cual se agotaron las medidas farmacológicas y el único tratamiento efectivo es la realización de enemas. El objetivo principal del procedimiento es ofrecer a los niños y sus familias una alternativa a la hora de realizar los enemas, logrando una mayor adherencia al tratamiento y buscando alcanzar una mejor calidad de vida que permita adecuarse a las actividades con sus pares. Por otra parte permite al niño ir logrando cierta independencia gradual a medida que crezca, preparándolos para el futuro y haciéndolos participes activos de su cuidado. Se describen los primeros casos en donde utilizamos en nuestro medio el abordaje laparoscópico, sus indicaciones, la técnica quirúrgica y los resultados iniciales. Hemos constatado como ventaja principal los beneficios del abordaje mínimamente invasivo, como la exploración completa de la cavidad abdominal, el menor dolor postoperatorio, cicatrices más pequeñas, menor creación de adherencias.

The appendicostomy procedure for performing antegrade enemas has been published several years ago for the treatment of fecal incontinence and constipation that are very difficult to manage. The Malone procedure is performed in our setting, especially in patients with fecal incontinence secondary to neurological disorders such as myelomeningocele using a conventional approach. Other indications of it is severe constipation, in which pharmacological measures have been exhausted and the only effective treatment is enemas. The main objective of the procedure is to offer children and their families an alternative when performing enemas, achieving greater adherence to treatment and seeking to achieve a better quality of life that allows them to adapt to the activities of their peers. On the other hand, it allows the child to achieve a certain gradual independence as they grow, preparing them for the future and making them active participants in their care. The first cases in which we use the laparoscopic approach, its indications, the surgical technique and the initial results are described. We think that its main advantage is the benefits of the minimally invasive approach, such as complete exploration of the abdominal cavity, less postoperative pain, smaller scars, and less creation of adhesions.

O procedimento de apendicostomia continente para a realização de enemas anterógrados foi publicado há vários anos para o tratamento de incontinência fecal e constipação de difícil manejo. Outra indicação inclui constipação grave, na qual as medidas farmacológicas foram esgotadas e o único tratamento eficaz são os enemas. O principal objetivo do procedimento é oferecer às crianças e seus familiares uma alternativa na realização dos enemas, alcançando maior adesão ao tratamento e buscando alcançar uma melhor qualidade de vida que lhes permita adaptar-se às atividades com seus pares. Por outro lado, permite que a criança alcance uma certa independência gradual à medida que cresce, preparando-a para o futuro e tornando-a participante ativa em seus cuidados. São descritos os primeiros casos em que utilizamos a via laparoscópica, suas indicações, a técnica cirúrgica e os resultados iniciais. Confirmamos os benefícios da abordagem minimamente invasiva como principal vantagem, como exploração completa da cavidade abdominal, menos dor pós-operatória, cicatrizes menores e menor formação de aderências.

The Macedo-Malone antegrade colonic enema: A minimal invasive technique that precludes appendix use.

INTRODUCTION: Antegrade continence enema (ACE) is recommended for patients with fecal incontinence/constipation refractory to conservative management. The Malone ACE utilizes the appendix as a catheterizable channel whereas the Macedo-Malone (MM) precludes the use of the appendix. We aimed to illustrate the MM procedure. METHODS: The left colon is brought out through a small transverse incision on the upper left abdomen and a 3-cm transverse flap in a tenia is created. A 12-Fr silicone Foley catheter is placed on the mucosal surface of the flap to allow creating a tubular conduit. After closure of the anterior wall colonic, the continence valve mechanism is produced by embedding the tube over a serous lined tunnel created by interrupted sutures. The distal portion of the tube is anastomosed into a V shape to the skin flap to avoid stoma stenosis. DISCUSSION: The advantage of this technique is the all-the time availability for not requiring the appendix which some authors prefer to use for urinary reconstruction. In a previous study, we have shown that the MM produces a high rate (89%) of fecal continence (Mean follow-up: 75 months). CONCLUSION: We are convinced that this procedure can be incorporated into fecal incontinence/constipation armamentarium.

Use of rectal tissue for reconstruction of an anogenital cleft in a juvenile dog with recurrent rectal prolapse.

CASE DESCRIPTION: A 4-month-old 4.2 kg sexually intact female mixed-breed dog was evaluated for rectal and vesicular tenesmus, intermittent rectal prolapse, fecal incontinence, and an anogenital cleft. CLINICAL FINDINGS: Rectal prolapse and an anogenital cleft were confirmed on physical examination. Results of a CBC and serum biochemical analysis were within respective reference ranges, and abdominal ultrasonography revealed no abnormalities. Urinalysis revealed evidence of a urinary tract infection. TREATMENT AND OUTCOME: An H-perineoplasty was performed and the prolapse was reduced. The repair partially dehisced and was repaired (with concurrent reduction of a recurrent rectal prolapse) but dehisced again. There was limited tissue available for additional reconstruction. In another surgical procedure, the rectum was allowed to prolapse, the most dorsal 40% of the prolapsed rectal tissue was resected, and the rectal tissue margin and skin in this region were apposed. The remaining rectal tissue flap was folded ventrally, and the lateral margins of the aborad aspect were sutured to the dorsolateral vestibular mucosa. In a subsequent surgery, 2.5 to 3 cm of the rectal tissue flap was excised. The remainder was used to create ventral margins for the rectum and vestibular mucosa. The perineal skin between the anus and dorsal vulvar commissure was closed. The patient experienced mild cutaneous partial dehiscence of the repair that healed by second intention. Over an 18-month follow-up period, some fecal incontinence persisted, but straining resolved and urinary tract infection did not recur. CLINICAL RELEVANCE: For the dog of this report, the use of rectal mucosa in surgical repair of an anogenital cleft provided an acceptable clinical outcome.

Long-term results from modified sphincteroplasty in patients with traumatic sphincter injury: a retrospective study.

BACKGROUND: The results from sphincteroplasty may worsen over time. Reseparation of the rectum and vagina/scrotum in conjunction with sphincteroplasty achieves good results. Improving the surgical effect of sphincteroplasty through perineal body reconstruction is crucial. OBJECTIVE: To evaluate the long-term results from anterior sphincteroplasty and perineal body reconstruction (modified sphincteroplasty) among patients with traumatic sphincter injury. DESIGN AND SETTING: Retrospective study among patients who underwent modified sphincteroplasty in a university hospital between January 2006 and December 2018. Fifty patients were evaluated in detail. METHODS: The following variables were evaluated: gender, age, additional disease status, time interval between trauma and surgery, surgical technique, duration of hospitalization, follow-up period after surgery, manometric values, electromyography results, magnetic resonance imaging scans, Wexner scores, satisfaction levels with surgery and surgical outcomes. RESULTS: The patients' mean age was 44.6 ± 15.1 years. The median follow-up period was 62 months (range, 12-118). The mean Wexner scores preoperatively, postoperatively in first month (M1S) and at the time of this report (AAS) were 15.5 ± 3.2, 1.9 ± 3.15 and 3.9 ± 5.3, respectively. Although improvements in the patients' mean Wexner scores became impaired over time, the postoperative Wexner scores were still significantly better than the preoperative Wexner scores (P = 0.001). CONCLUSION: Good or excellent results were obtained surgically among patients with traumatic sphincter injury. Performing perineal body reconstruction in addition to sphincteroplasty can provide better long-term continence. Surgical outcomes were found to be better, especially among patients younger than 50 years of age and among patients who underwent surgery within the first five years after trauma.

Long-term results from modified sphincteroplasty in patients with traumatic sphincter injury: a retrospective study

ABSTRACT BACKGROUND: The results from sphincteroplasty may worsen over time. Reseparation of the rectum and vagina/scrotum in conjunction with sphincteroplasty achieves good results. Improving the surgical effect of sphincteroplasty through perineal body reconstruction is crucial. OBJECTIVE: To evaluate the long-term results from anterior sphincteroplasty and perineal body reconstruction (modified sphincteroplasty) among patients with traumatic sphincter injury. DESIGN AND SETTING: Retrospective study among patients who underwent modified sphincteroplasty in a university hospital between January 2006 and December 2018. Fifty patients were evaluated in detail. METHODS: The following variables were evaluated: gender, age, additional disease status, time interval between trauma and surgery, surgical technique, duration of hospitalization, follow-up period after surgery, manometric values, electromyography results, magnetic resonance imaging scans, Wexner scores, satisfaction levels with surgery and surgical outcomes. RESULTS: The patients' mean age was 44.6 ± 15.1 years. The median follow-up period was 62 months (range, 12-118). The mean Wexner scores preoperatively, postoperatively in first month (M1S) and at the time of this report (AAS) were 15.5 ± 3.2, 1.9 ± 3.15 and 3.9 ± 5.3, respectively. Although improvements in the patients' mean Wexner scores became impaired over time, the postoperative Wexner scores were still significantly better than the preoperative Wexner scores (P = 0.001). CONCLUSION: Good or excellent results were obtained surgically among patients with traumatic sphincter injury. Performing perineal body reconstruction in addition to sphincteroplasty can provide better long-term continence. Surgical outcomes were found to be better, especially among patients younger than 50 years of age and among patients who underwent surgery within the first five years after trauma.

Anatomical feasibility of peripheral nerve transfer to reestablish external anal sphincter control - cadaveric study.

PURPOSE: Motor deficits affecting anal sphincter control can severely impair quality of life. Peripheral nerve transfer has been proposed as an option to reestablish anal sphincter motor function. We assessed, in human cadavers, the anatomical feasibility of nerve transfer from a motor branch of the tibialis portion of the sciatic nerve to two distinct points on pudendal nerve (PN), through transgluteal access, as a potential approach to reestablish anal sphincter function. METHODS: We dissected 24 formalinized specimens of the gluteal region and posterior proximal third of the thigh. We characterized the motor fascicle (donor nerve) from the sciatic nerve to the long head of the biceps femoris muscle and the PN (recipient nerve), and measured nerve lengths required for direct coaptation from the donor nerve to the recipient in both the gluteal region (proximal) and perineal cavity (distal). RESULTS: We identified three anatomical variations of the donor nerve as well as three distinct branching patterns of the recipient nerve from the piriformis muscle to the pudendal canal region. Donor nerve lengths (proximal and distal) were satisfactory for direct coaptation in all cases. CONCLUSIONS: Transfer of a motor fascicle of the sciatic nerve to the PN is anatomically feasible without nerve grafts. Donor nerve length was sufficient and donor nerve functionally compatible (motor). Anatomical variations in the PN could also be accommodated.

Clinical and physiological efficacy of the application of autologous fat with platelet rich plasma in treating faecal incontinence / Eficácia clínica e fisiológica da aplicação de gordura autóloga com plasma rico em plaquetas no tratamento da incontinência fecal

Abstract Purpose: Faecal incontinence (FI) is a frequent condition that can occur due to different causes; with negative impact on self-esteem and quality of life, secondary morbidity, disability and significant costs. For its treatment there is a wide range of options, being medical treatment, hygienic dietary modifications and biofeedback, the first line of treatment; reserving surgery for patients who do not respond or with severe FI; this with variable success rates and high cost. This study has the primary aim to assess the efficacy and describe the Technique of Application of Autologous Fat with Platelet Rich Plasma (AFPRiP) in patients with faecal incontinence as well as secondary endpoints of quality of life, manometric and ultrasound evaluation, safety of implantation, and complications. Methods: A single-centre prospective, experimental study, was conducted from January 2017 to February 2018 in Domingo Luciani Hospital. Wexner and FIQL scores were filled preoperative and compared at follow-up at 3, 6 and 12 months as well as anorectal manometry and endoanal ultrasound were performed before and 6 months after surgery. Results: Twelve patients were operated, mean time 43 min, no major complications. Wexner finding continence improvement from 10.4 pre to 4 in the 3rd month (p = 0.066) 4.74 at the 6th month (p = 0.001) and 5 at one year (p = 0.001); that is, improvement of >50% in 83.4%. FIQL 50.9 prior to 98.6 at 3rd month (p = 0.001) 95.5 to 6th month (p = 0.001) and 91.3 a year (p = 0.066). Conclusions: We conclude that AFPRiP is innovative, safe and with adequate results.

Resumo Objetivo: A incontinência fecal é uma condição frequente que pode ocorrer devido a diferentes causas, com impacto negativo na autoestima e qualidade de vida, morbidade secundária, incapacidade e custos significativos. Existem várias opções para o manejo da incontinência fecal; o tratamento médico, as modificações higiênicas da dieta e o biofeedback, são os de primeira linha. A cirurgia é recomendada apenas para pacientes que não respondem ao tratamento de primeira linha ou aqueles com incontinência fecal grave; as taxas de sucesso são variáveis e o custo do tratamento cirúrgico é elevado. Este estudo teve como objetivo principal avaliar a eficácia e descrever a técnica de aplicação de gordura autóloga com plasma rico em plaquetas (AFPRiP) em pacientes com incontinência fecal; o estudo também avaliou parâmetros secundários de qualidade de vida, manométricos e ultrassonográficos, bem como a segurança da implantação e suas complicações. Métodos: Um estudo experimental prospectivo, de centro único, foi realizado de janeiro de 2017 a fevereiro de 2018 no Hospital Domingo Luciani. A escala de Wexner e o FIQL foram preenchidos no pré-operatório e comparados no seguimento de três, seis e 12 meses; manometria anorretal e ultrassonografia endoanal foram realizadas antes e seis meses após a cirurgia. Resultados: Doze pacientes foram operados; o tempo médio da cirurgia foi de 43 minutos, sem maiores complicações. Na escala de Wexner, observou-se melhora na continência: de 10,4 pré-operatório a 4 no terceiro mês (p = 0,066), 4,74 no sexto mês (p = 0,001) e 5 em um ano (p = 0,001), uma melhoria de 83,4%. Já o FIQL evoluiu de 50,9 no período pré-operatório para 98,6 no terceiro mês (p = 0,001), 95,5 no sexto mês (p = 0,001) e 91,3 em um ano (p = 0,066). Conclusões: A AFPRiP é uma técnica inovadora, segura e que apresenta resultados adequados.

In-hospital resource utilization, outcome analysis and radiation exposure in children undergoing appendicostomy vs cecostomy tube placement.

INTRODUCTION AND OBJECTIVES: Continence enemas for the purpose of bowel management may be delivered via trans-anal retrograde irrigations, and via antegrade conduits including surgical appendicostomy or placement of cecostomy tube (CT). An appreciation of the relative advantages and disadvantages of each antegrade continence enema (ACE) procedure allows clinicians, parents and children to make an informed decision regarding which procedure is most appropriate in individual cases. The objective of this study was to evaluate the differences in in-hospital resource utilization, surgical outcomes and radiation exposure between children undergoing appendicostomy creation and CT placement at our institution. METHODS: We conducted a retrospective chart review of children undergoing these procedures at our institution over a 10-year period. All patients 0-18 years of age undergoing either procedure for any indication were included. Data on demographics, length of stay (LOS), radiation exposure events (REE), and surgical outcomes were collected. RESULTS: One hundred fifteen (63 appendicostomy/52 CT) patients were included. Those undergoing CT placement had significantly increased post-procedural LOS, catheter exchanges and REE compared to those undergoing appendicostomy (see Table). Reported rates of bowel control were similar between the two groups, and there was no significant difference in rates of surgical complications, although each group had unique, procedure-specific complications. DISCUSSION AND CONCLUSION: In our study, appendicostomy holds a clear advantage over CT in terms of post-procedural LOS, as well as REE. In general, children with CTs require more planned and unplanned device maintenance procedures than those with appendicostomy. These findings aside, the rates of success for bowel control between the two groups are similar, and the incidence of complications does not differ significantly between the two groups. CT remains a safe and effective conduit for delivery of ACEs, and is a particularly good option in patients whose appendix has been lost or used for another conduit. However, patients wishing to avoid repeated procedures and radiation exposure may find the option of appendicostomy more attractive.

LONG-TERM OUTCOMES OF LIGATION OF INTERSPHINCTERIC FISTULA TRACT FOR COMPLEX FISTULA-IN-ANO: MODIFIED OPERATIVE PROCEDURE EXPERIENCE.

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.

Technique and results of the first six cases of anal sphincteroplasty with Deoti's flap for complex anatomical deformity of the perineum / Técnica e resultados dos primeiros seis casos de esfincteroplastia anal com retalho Deoti para deformidade anatômica complexa do períneo

ABSTRACT Objectives: Anal sphincteroplasty with Deoti's flap is a recently published procedure for the treatment of fecal incontinence with severe perineal deformity. The aim of this study is to report six cases of patients, analyzing their results in fecal incontinence questionnaires and proposing a new scale to better assess our technique's main objective, the reconstruction of the perianal anatomy. Methods: Six patients were submitted to anal sphincteroplasty with Deoti's flap and follow-up was performed every six months. Functional results and Quality of Life were measured by Wexner Score and Fecal Incontinence Quality of Life Scale, respectively. Results: All operations were carried out without failure to perform Deoti's flap rotation. The sample presented medians of 18.5 and 3.5 on Wexner Score, before and after surgery, respectively. In the Fecal Incontinence Quality of Life Scale, the medians before and after surgery are, respectively, 1.75 and 3.35 (Scale 1), 1.54 and 2.60 (Scale 2), 2.35 and 3.28 (Scale 3), 1.49 and 3.33 (Scale 4). The p-values were 0.0173 for Wexner Score and 0.0260, 0.0411, 0.0368 and 0.0952 for Scales 1, 2, 3 and 4 of Fecal Incontinence Quality of Life Scale, respectively. All patients presented sustained improvement in Wexner Score and in quality of life questionnaire (in all scales of Fecal Incontinence Quality of Life Scale). Conclusions: Deoti's surgical flap with sphincteroplasty successfully reconstructs complex anatomical deformities of the perineum. Current questionnaires to assess fecal incontinence may not evaluate properly the anatomical result of the technique, thus we propose a visual scale. In addition, sphincteroplasty with Deoti's flap may have longer-term outcomes in functional results than sphincteroplasty alone.

RESUMO Objetivos: A esfincteroplastia anal com retalho Deoti é um procedimento publicado recentemente para o tratamento de deformidade perineal grave. O objetivo deste estudo é relatar seis pacientes, analisando seus resultados em questionários de incontinência fecal e propondo uma nova escala para avaliar melhor o objetivo principal da nossa técnica, a reconstrução da anatomia perianal. Métodos: Seis pacientes foram submetidos à esfincteroplastia anal com retalho de Deoti e o acompanhamento foi realizado a cada seis meses. Os resultados funcionais e a qualidade de vida foram medidos pelas Escalas Wexner Score e FIQL, respectivamente. Resultados: Não houve falhas na rotação do retalho Deoti. A amostra apresentou medianas de 18,5 e 3,5 na Wexner Score, antes e depois da cirurgia, respectivamente. Na Escala FIQL, as medianas antes e depois da cirurgia são, respectivamente, 1,75 e 3,35 (Escala 1); 1,54 e 2,60 (Escala 2); 2,35 e 3,28 (Escala 3); 1,49 e 3,33 (Escala 4). Os valores de p foram 0,0173 para Wexner Score e 0,0260; 0,0411; 0,0368 e 0,0952 para Escalas 1; 2; 3 e 4 de FIQL, respectivamente. Todos os pacientes apresentaram melhora sustentada na pontuação de Wexner e no questionário de qualidade de vida (em todas as escalas do FIQL). Conclusões: O retalho de Deoti com esfincteroplastia reconstrói com sucesso as deformidades anatômicas complexas do períneo. Os questionários atuais para avaliar a incontinência fecal podem não avaliar adequadamente o resultado anatômico da técnica, por isso propomos uma escala visual. Além disso, a esfincteroplastia com retalho de Deoti pode apresentar resultados funcionais mais duradouros do que a esfincteroplastia isolada.

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.

Deoti surgical flap and sphincteroplasty for treatment of severe perineal deformity / Retalho cirúrgico de Deoti mais esfincteroplastia para tratamento de deformidade perineal grave

ABSTRACT Purpose: Anal incontinence is a very stigmatizing condition, which affects biopsychosocially the patient. It is a neglected, but quite common complication of obstetric and anorectal surgery, however it has treatment options. None of the treatment options have exceptional efficacy rates and still associated with risk of recurrence. The surgery techniques known are: anterior and posterior shortening procedure; post-anal repair; anterior elevator plasty and external sphincter plication; total pelvic floor repair and sphincter repair. None of them use a flap rotation of adipose tissue. The purpose is to propose a new surgery technique of anal sphincteroplasty, which uses flap rotation, for severe perineal deformity associated with anal incontinence. Methods: Patient with severe perineal deformity and anal incontinence treated with a new surgery technique of sphincteroplasty with flap rotation. Results: The severe perineal deformity was corrected with both esthetic and functional results. Anal continence measured by Wexner and Jorge assessment in a follow-up period of 2 years after the intervention. Pictures and video show esthetic and functional aspects. Conclusion: This is the first time that a flap rotation is used to treat a severe perineal deformity. And the technique presented promising outcomes, which allows perineum reconstruction that is similar to the original anatomy. Therefore, this technique is justified to better evaluate its efficiency and the impact on patients' prognosis.

RESUMO Objetivo: A incontinência anal é uma condição muito estigmatizante, que afeta biopsicossocialmente o paciente. É uma complicação negligenciada, mas bastante comum da cirurgia obstétrica e anorretal, no entanto, tem opções de tratamento. Nenhuma das opções de tratamento tem taxas de eficácia excepcionais e ainda está associada ao risco de recorrência. As técnicas cirúrgicas conhecidas são: procedimento de encurtamento anterior e posterior; reparação pós-anal; plástica do elevador anterior e plicatura externa do esfíncter; reparo total do assoalho pélvico e reparo do esfíncter. Nenhum deles utiliza uma rotação de retalho de tecido adiposo. O objetivo é propor uma nova técnica cirúrgica de esfincteroplastia anal, que utiliza a rotação de retalho, para deformidade perineal grave associada à incontinência anal. Métodos: Paciente com deformidade perineal grave e incontinência anal tratada com nova técnica cirúrgica de esfincteroplastia com rotação de retalho. Resultados: A deformidade perineal grave foi corrigida com resultados estéticos e funcionais. Continência anal medida pela avaliação de Wexner & Jorge em um período de seguimento de 2 anos após a intervenção. Imagens e vídeo mostram aspectos estéticos e funcionais. Conclusão: Esta é a primeira vez que uma rotação de retalho é usada para tratar uma deformidade perineal grave. E a técnica apresentou resultados promissores, o que permite a reconstrução do períneo semelhante à anatomia original. Portanto, esta técnica é justificada para melhor avaliar sua eficiência e o impacto no prognóstico dos pacientes.

Long-term evaluation of fecal continence and quality of life in patients operated for anorectal malformations.

INTRODUCTION:: Patients operated for correction of anorectal malformations (ARM) can develop fecal incontinence, constipation, and soiling, with loss in quality of life. OBJECTIVE:: To evaluate, through the use of questionnaires, fecal continence, and quality of life of children in the late postoperative follow-up of ARM correction, both high and low. In addition, the levels of fecal continence and quality of life were compared with those of a control group. METHOD:: A Fecal Continence Index Questionnaire (ICF) and a Questionnaire for Assessment of Quality of Life Related to Fecal Continence in Children and Adolescents (QQVCFCA) were administered to 63 patients with ARM, aged from 7 to 19 years, whose surgical treatment had been completed for at least 6 months. The patients were compared to a control group of 59 children. RESULTS:: In the control group, 25 (42.4%) patients had good continence and 34 (57.6%), normal continence. We found that the quality of life in children with ARM is compromised globally, in all areas and in the ICF questionnaire, compared to controls (p<0.001). There was no difference between patients with high and low defects. Thirty-two (50.8%) patients had other associated anomalies. CONCLUSION:: In patients operated for ARM correction, quality of life and ICF were compromised, and there was no difference between patients with high-type and low-type of the disease. In about half the cases there are other associated malformations.

Long-term evaluation of fecal continence and quality of life in patients operated for anorectal malformations / Avaliação tardia da continência fecal e da qualidade de vida em pacientes operados por malformações anorretais

Summary Introduction: Patients operated for correction of anorectal malformations (ARM) can develop fecal incontinence, constipation, and soiling, with loss in quality of life. Objective: To evaluate, through the use of questionnaires, fecal continence, and quality of life of children in the late postoperative follow-up of ARM correction, both high and low. In addition, the levels of fecal continence and quality of life were compared with those of a control group. Method: A Fecal Continence Index Questionnaire (ICF) and a Questionnaire for Assessment of Quality of Life Related to Fecal Continence in Children and Adolescents (QQVCFCA) were administered to 63 patients with ARM, aged from 7 to 19 years, whose surgical treatment had been completed for at least 6 months. The patients were compared to a control group of 59 children. Results: In the control group, 25 (42.4%) patients had good continence and 34 (57.6%), normal continence. We found that the quality of life in children with ARM is compromised globally, in all areas and in the ICF questionnaire, compared to controls (p<0.001). There was no difference between patients with high and low defects. Thirty-two (50.8%) patients had other associated anomalies. Conclusion: In patients operated for ARM correction, quality of life and ICF were compromised, and there was no difference between patients with high-type and low-type of the disease. In about half the cases there are other associated malformations.

Resumo Introdução: os pacientes operados para correção de malformações anorretais (MAR) podem evoluir com incontinência fecal, constipação e soiling, com prejuízo na qualidade de vida. Objetivo: avaliar pela aplicação de questionários a continência fecal e a qualidade de vida de crianças no seguimento pós-operatório tardio de correção de MAR, formas altas e baixas. Também foram comparados os índices de continência fecal e qualidade de vida com um grupo controle de crianças. Método: foram utilizados o Questionário para o Índice de Continência Fecal (ICF) e o Questionário para Avaliar a Qualidade de Vida Relativa à Continência Fecal em Crianças e Adolescentes (QQVCFCA). Os questionários foram aplicados em 63 pacientes de 7 a 19 anos com MAR, com tratamento cirúrgico finalizado há pelo menos 6 meses. Os pacientes foram comparados com um grupo controle de 59 crianças. Resultados: nos pacientes do grupo controle, 25 (42,4%) apresentaram boa continência e 34 (57,6%), normal. A qualidade de vida nas crianças com MAR está comprometida globalmente, em todos os domínios e no ICF, quando comparada com a dos controles (p<0,001). Não houve diferença entre os pacientes com anomalias altas e anomalias baixas. Trinta e dois (50,8%) pacientes apresentaram outras anomalias associadas. Conclusão: nos pacientes operados para correção de MAR, qualidade de vida e ICF foram comprometidos, não havendo diferença entre os pacientes com as formas altas ou baixas da doença. Em cerca de metade dos casos existem outras malformações associadas.

Using amniotic membrane for anal sphincter repair in animal model / Uso de membrana amniótica para reparo de esfíncter anal em modelo animal

Purpose: Sphincter repair is the primary management for fecal incontinence especially in traumatic causes. Regardless of progression in the method and material of sphincter repair, the results are still disappointing. This study evaluates the efficacy of using amniotic membrane during sphincteroplasty regarding its effects in healing of various tissues. Methods: Rabbits undergone sphincterotomy and after three weeks end to end sphincteroplasty was done. Animals divided to three groups: classic sphincteroplasty, sphincteroplasty with fresh amniotic membrane and sphincteroplasty with decellularized amniotic membrane. Three weeks after sphincteroplasty animals were sacrificed and sphincter complex was sent for histopathologic evaluation. Sphincter muscle diameter and composition of sphincter was evaluated. Before sphincterotomy, before and after sphincteroplasty electromyography of sphincter at the site of repair were recorded. Results: No statistical significant difference was seen between groups even in histopathology or electromyography. Conclusion: Although amniotic showed promising effects in the healing of different tissue in animal and human studies it was not effective in healing of injured sphincter.

Objetivo: Reparo do esfíncter é o tratamento primário para casos de incontinência fecal, especialmente em causas traumáticas. Independentemente da progressão no método e do material de reparo do esfíncter, os resultados são ainda desapontadores. Esse estudo avalia a eficácia do uso da membrana amniótica durante a esfincteroplastia, com relação aos seus efeitos na cura de diversos tecidos. Métodos: Coelhos foram submetidos a um procedimento de esfincterotomia e, depois de transcorridas três semanas, foi realizada uma esfincteroplastia término-terminal. Os animais foram divididos em três grupos: esfincteroplastia clássica, esfincteroplastia com membrana amniótica fresca, e esfincteroplastia com membrana amniótica descelularizada. Três semanas após a realização da esfincteroplastia, os animais foram sacrificados e o complexo esfinctérico foi encaminhado para avaliação histopatológica. O diâmetro do músculo esfinctérico e a composição do esfíncter foram avaliados. Antes da esfincterotomia, e antes e depois da esfincteroplastia, foi registrada a eletromiografia do esfíncter no local do reparo. Resultados: Não foi observada diferença estatisticamente significativa entre os grupos, mesmo na histopatologia, ou na eletromiografia. Conclusão: Embora a membrana amniótica tenha demonstrado efeitos promissores em termos da cicatrização dos diferentes tecidos em estudos com animais e em humanos, não foi observada eficácia na cura do esfíncter lesionado.

[Treatment of severe fecal incontinence with artificial sphincter. Report of two cases]. / Tratamiento de la incontinencia fecal severa con esfinter artificial. Reporte de dos casos.

To present two cases of severe fecal incontinence handled in EsSalud Almenara Hospital in Lima, Peru, with successful results using new technologies, in this case Artificial Anal sphincter. Observational study of first two cases of patients, who were selected randomly throughout 2006, and had a diagnosis of severe fecal incontinence. In these patients were placed on Artificial Anal Sphincter Neosphincter. The first patient with fecal incontinence neurological etiology after 2 months of implant the device was activated, with satisfactory results. In the second case, the etiologic factor was the severe injury to the anal sphincter, he had colostomy which, after implanted the device was closed, there were some difficulties in activating the second device that were resolved with a review, then activated with satisfactory results alternative for definitive treatment of severe fecal incontinence.

Experiencia inicial del impacto de la reparación con colgajos de cloaca traumática postparto en la calidad de vida / Initial experience, of the impact of the repair, with postpartum traumatic cloaca flaps, on the quality of life

Introducción: La incontinencia fecal mayor es un trastorno que modifica significativamente la calidad devida. Un grupo particularmente afectado son las mujeres con antecedentes de trauma obstétrico. Dentrode ellos, los más graves son los de cuarto grado que involucran la totalidad de las capas del tabique rectovaginal, produciendo una comunicación completa entre la luz rectal y la vagina, generando una cloaca. Sibien la incidencia de éstas, es de alrededor del 0,3% de los partos, el efecto que tiene sobre las pacienteses devastador. El único tratamiento efectivo para este tipo de lesiones es la reparación quirúrgica.Objetivo: Evaluar el impacto que presenta la corrección quirúrgica de la cloaca por trauma obstétrico en lacalidad de vida de las afectadas.Material y Métodos: Análisis prospectivo secundario y ampliado de una serie consecutiva de pacientestratadas por desgarro perineal completo tipo cloaca durante el año 2013. Se evaluó la demografía de lamuestra, la paridad de las pacientes, el tiempo medio hasta la consulta desde el último parto, la manometríapre y postoperatoria, la evaluación de incontinencia fecal pre y postoperatorio. Para valorar la severidad dela incontinencia fecal se utilizó el índice CCF-FIS y el índice de severidad de incontinencia fecal (FISI). Parala evaluación de calidad de vida se utilizó la encuesta FIQLS de la Sociedad Americana de Cirujanos delColon y Recto (ASCRS).Resultados: Tres pacientes fueron intervenidas entre enero de 2013 y diciembre de 2013. En el examenfísico, el 100% de las pacientes presentaron una cloaca perineal. El score CCF-FIS preoperatorio fue del16,7 (16 a 18 puntos). El puntaje de FISI pre-operatorio fue de 54,3 (52 a 57). Las tres pacientes refirieronalteraciones en su actividad social y sexual. Se reevaluaron las pacientes al tercer mes de postoperatorio yluego del cierre de la colostomía...

Introduction: The major fecal incontinence is a disorder that significantly change the quality of life. Aparticularly affected group are women with a history of obstetric trauma and presenting demonstrationsimmediately. Among them, the most serious are the fourth degree involving all the layers of the rectovaginalseptum, producing a complete communication between the rectal lumen and vagina, creating a sewer.Although their incidence is about 0.3% of births, the effect on patients is devastating.Objective: To evaluate the impact making the surgical correction of the cloaca by obstetrical trauma in thequality of life of those affected.Material and Methods: Secondary and expanded Prospective analysis of a consecutive series of patientstreated by complete perineal tear type cloaca in 2013. The demographics of the sample was evaluated theparity of the patients, the median time to the query from the last delivery, pre and postoperative manometry,assessment of pre-and postoperative fecal incontinence. To assess the severity of fecal incontinence CCFFISindex and the severity of fecal incontinence (FISI) was used. The FIQLS survey by the American Societyof Colon and Rectal Surgeons (ASCRS) was used for the evaluation of quality of lifeResults: Three patients were operated between January 2013 and December 2013 on physical examination, 100% of patients had a perineal cloaca. The CCF-FIS preoperative score was 16.67 (16-18 points). Thescore FISI pre-surgery was 54.33 (52-57). The three patients reported changes in their social and sexualactivity. Patients at the third month after surgery and after colostomy closure were reassessed...

Incontinência urinária e fecal: estudo sobre o uso de fraldas e insumos auxiliares / Fecal and urinary incontinence: study on the use of diapers and auxiliary products / Incontinencia fecal y incontinencia urinaria: estudio acerca de la utilización de pañales y productos auxiliares

TECNOLOGIA: Fraldas geriátricas e insumos auxiliares. INDICAÇÃO: Incontinência urinária e fecal. CARACTERIZAÇÃO DAS TECNOLOGIAS: Fralda geriátrica é um produto de higiene íntima usado por adultos, principalmente idosos, que não têm (ou perderam) o controle de suas necessidades fisiológicas. Insumos auxiliares são preparações utilizadas para prevenção e/ou tratamento de problemas decorrentes do uso das fraldas. PERGUNTA: Quais as indicações de uso de fraldas geriátricas e insumos auxiliares, quais são as alternativas terapêuticas a esses produtos e qual é o custo estimado da sua utilização crônica em comparação com alternativas terapêuticas disponibilizadas no SUS? Métodos: As indicações de uso das fraldas geriátricas, bem como de outras alternativas para o controle/tratamento das incontinências foram encontradas em busca na literatura científica e em guias de tratamento nacionais e estrangeiros. Para se ter uma noção do gasto público atual com fraldas geriátricas os preços desses produtos foram levantados de acordo com dados do Banco de preços em Saúde. Também foram pesquisados os preços de fraldas em 57 sítios eletrônicos de farmácias e drogarias, além de sites de compras coletivas e o Sistema de Atendimento ao Consumidor (SAC) dos fabricantes. Os tipos e preços dos insumos auxiliares foram pesquisados em três grandes redes de drogarias privadas, das quais uma está presente apenas no Estado de Minas Gerais. Além disso, como forma de contemplar aqueles produtos mais judicializados foram pesquisados os principais insumos auxiliares solicitados no JusBrasil. RESULTADOS: O gasto do SUS com procedimentos cirúrgicos e fisioterápicos é bem menor que o próprio subsídio dado à compra de fraldas geriátricas no programa "Aqui tem Farmácia Popular" e, portanto, deveriam ser recomendados com maior frequência, dependendo da condição de incontinência de cada indivíduo. Nesse parecer, constatou-se a necessidade do uso de produtos de barreira e hidratantes na prevenção e cuidado de dermatites e úlceras associadas à condição de incontinência, evidenciando a necessidade de maior financiamento por parte do SUS para garantir acesso a cremes, pomadas e loções (preventivas e/ou curativas), os quais, pela análise aqui conduzida, são bastante onerosos para o paciente. De acordo com os dados levantados nesse parecer, os valores estimados de gasto individual anual com fraldas geriátricas foram de R$1.674,04; R$1.827,81; R$1.439,31; e R$1.123,72, respectivamente para as fraldas tamanho extragrande, grande, médio e pequeno. Os produtos considerados auxiliares foram cremes, loções, pomadas, óleos e pastas, com propriedades oclusivas, hidratantes e de restauração da pele afetada por assaduras, decorrentes do uso de fraldas geriátricas. O gasto médio anual com insumos auxiliares foi estimado em R$2.255,78. Como alternativas terapêuticas foram consideradas a terapia medicamentosa, fisioterapia e procedimentos cirúrgicos, de acordo com levantamento bibliográfico e guias de tratamento da incontinência nacionais e estrangeiros. Os principais medicamentos foram a oxibutinina, tolterodina, darifenacina e toxina botulínica, os quais apresentaram valores estimados de custo anual médio de R$988,20; R$4.355,05; R$4.322,40; e R$3.979,14, respectivamente. Os procedimentos cirúrgicos ofertados pelo Sistema Único de Saúde foram pesquisados no SIGTAP (Sistema de Gerenciamento da Tabela de Procedimentos, Medicamentos e OPM do SUS) e apresentaram valores de ressarcimento que variaram de R$372,54 a R$457,67. De acordo com o SIGTAP o preço da sessão de fisioterapia para fins de controle da incontinência é R$4,67, sendo recomendadas 20 sessões por semana. CONSIDERAÇÕES FINAIS: Observou-se que a estimativa de gasto médio de pacientes com uso de fraldas e insumos auxiliares para o cuidado e tratamento das incontinências é elevado, podendo atingir R$2.255,78 por ano. O uso de fralda será necessário em caso de incontinência fecal e condicional no caso de incontinência urinária (IU). Na IU, o uso de fralda irá depender do tipo e gravidade da incontinência, estado físico e funcional da pessoa e se foram utilizadas opções de tratamento (reeducação, ingestão controlada de líquidos, fisioterapia, terapia ocupacional, medicamentos e cirurgias). De acordo com as evidências levantadas por esse PTC, parece haver uma subutilização de terapia medicamentosa, da fisioterapia e de procedimentos cirúrgicos e uma superutilização de fraldas geriátricas, as quais podem, em caso de uso desnecessário, contribuir para manter ou instituir a incontinência. De toda forma o SUS ainda não dispensa medicamentos recomendados para IU, insumos auxiliares ao tratamento e o valor do subsídio econômico fornecido aos pacientes é insuficiente para cobrir os gastos com as incontinências, nas situações onde o uso da fralda está adequadamente recomendado.(AU)

TECHNOLOGY: Adult diapers and auxiliary inputs. INDICATION: Urinary and fecal incontinence. TECHNOLOGY CHARACTERIZATION: Geriatric diaper is a hygiene product used by adults, especially the elderly, who do not have (or lost) control of your physiological needs. Auxiliary products are preparations and equipment used for prevention and / or treatment of problems emerging from the use of diapers. MAIN QUESTION: What are the indications for use of geriatric diapers and auxiliary products, which are therapeutic alternatives to these products and what is the estimated cost of its chronic use in comparison with therapeutic alternatives available through the Unified Health System (SUS ­ Sistema Único de Saúde)? METHODS: Indications for use of adult diapers, as well as other alternatives for the control / treatment of incontinence were found after search of scientific literature and national and international treatment guidelines. To get a sense of current public spending on adult diapers the prices of these products were raised in accordance with the Health price Bank. Also diaper prices were surveyed in 57 electronic sites of pharmacies and sites of collective shopping and the System of Customer Service of the manufacturers. The types and prices of auxiliary products were surveyed in three major networks of private drugstores, one of which is present only in the state of Minas Gerais. Furthermore, most solicited auxiliary products where searched in JusBrasil website. RESULTS: SUS spends with surgical and physical therapy procedures is much less than own subsidy given to the purchase of diapers in the program "Aqui tem farmácia popular" and therefore should be recommended more often, depending of each individual incontinence condition. Thus, there is the need for the use of barrier products and moisturizers in the prevention and care of dermatitis and ulcers associated with incontinence condition, highlighting the need for greater financial effort by the SUS in ensuring access to creams, ointments and lotions (preventive and / or curative), which, by the analysis undertaken here, are quite costly to the patient. According to our data, the estimated annual individual expenditure values with adult diapers were R$ 1674.04 ± 722.89; R$ 1827.81 ± 1179.24; R$ 1439.31 ± 724.88; and 1123.72 ± 521.21 respectively for the extra-large, large, medium and small size diapers. Auxiliary products are creams, lotions, ointments, oils and pastes, with occlusive properties, moisturizing and restoring the skin affected by diaper rash. Antifungal creams such as nystatin, were also classified as an auxiliary product. The estimated average annual expenditure on auxiliary products was R$ 2255.78 ± 3096.36. According to literature, national and foreign incontinence guides, drug therapy, physical therapy and surgical procedures were considered therapeutic alternatives. The main drugs are oxybutynin, tolterodine, darifenacin and botulinum toxin, which showed estimated annual average cost of R$ 988.20; R$ 4,355.05; R$ 4,322.40; and 3979.14, respectively. Surgical procedures offered by the Brazilian Public Health system were surveyed in SIGTAP (Management System of SUS Procedures) and had compensation values ranging from R$ 372.54 to R$ 457.67. According to the SIGTAP, the price of a single physiotherapy procedure for incontinence control purposes is R$ 4.67; the recommended are 20 sessions per week. CONCLUSIONS: We observed that the average spending estimation patients using diapers and auxiliary inputs for the care and treatment of incontinence is high, reaching R $ 2255.78 per year. The diaper use will be necessary in case of fecal incontinence and conditional in the case of urinary incontinence (UI). UI, use diaper will depend on the type and severity of incontinence, physical and functional condition of the person and were used treatment options (reeducation, controlled fluid intake, physical therapy, occupational therapy, medication and surgery). According to the evidence raised by this PTC, there seems to be an underspend of drug therapy, physical therapy and surgical procedures and overuse of adult diapers, which can, in case of unnecessary use, contribute to maintain or establish incontinence. Anyway SUS does not dispense drugs recommended for UI and auxiliary products to the treatment; moreover the value of the subsidy provided to patients is insufficient to cover the costs of the incontinences, in situations where the use of the diaper is properly recommended. (AU)

TECNOLOGÍA: Pañales geriátricos y entradas auxiliares. INDICACIÓN: Incontinencia urinaria y fecal. CARACTERIZACIÓN DEL TECNOLOGÍA: Pañal geriátrica es un producto de higiene íntima utilizado por adultos, especialmente los ancianos, que no tienen (o han perdido) el control de sus necesidades fisiológicas. Productos auxiliares son preparaciones utilizadas para la prevención y / o tratamiento de los problemas derivados del uso de los pañales. PREGUNTA: ¿Cuáles son las indicaciones para el uso de los pañales geriátricos y de los productos auxiliares, que son las alternativas terapéuticas para estos productos y cuál es el costo estimado de su uso crónico en comparación con las alternativas terapéuticas disponibles en el Sistema Único de Salud (SUS ­ Sistema Único de Saúde)? MÉTODOS: Las indicaciones de uso de pañales para adultos, así como otras alternativas para el control / tratamiento de la incontinencia se encontraron en la búsqueda de la literatura científica y directrices nacionales e internacionales de tratamiento. Los precios de pañales se buscaron en el Banco de los Precios en Salud de Brasil, para tener una idea del actual gasto público en pañales para adultos. Además, los precios de pañales fueron encuestados en 57 sitios electrónicos de las farmacias y droguerías, así como los sitios de compra en grupo y el Servicio de Atención al Consumidor (SAC) de los fabricantes. Los tipos y precios de productos auxiliares fueron encuestados en tres grandes redes de farmacias privadas, en el que uno se encuentra sólo en el Estado de Minas Gerais. Además, a fin de contemplar aquellos principales productos demandados en los tribunales, los productos auxiliares se buscaran en sitio electrónico JusBrasil. RESULTADOS: El gasto del SUS con procedimientos quirúrgicos y de terapia física es mucho menos que la propia subvención dada a la compra de pañales en el programa "Aqui tem Farmácia Popular" y por lo tanto se debe recomendar más veces, dependiendo de la condición de incontinencia individual. En este estudio, se constató la necesidad de la utilización de productos de barrera y humectantes en la prevención y cuidado de la dermatitis y úlceras asociadas con la condición de pañales, destacando la necesidad de mayor esfuerzo financiero por el SUS en garantizar el acceso a cremas, ungüentos y lociones (preventivo y / o curativo), que, por la análisis hecha aquí, son bastante costosos para el paciente. De acuerdo con los datos recogidos, los valores estimados anuales de gastos individuales con pañales para adultos fueron de R$ 1.674,04 ± 722,89; R$ 1827,81 ± 1179,24; R$ 1.439,31 ± 724,88; y R$ 1.123,72 ± 521,21, respectivamente, para los pañales extra grandes, grandes, medianas y pequeños. Productos considerados auxiliares son cremas, lociones, ungüentos, aceites y pastas, con propiedades oclusivas, hidratante y de restauración de la piel afectada por la utilización del pañal. El gasto estimado medio anual con productos auxiliares fue de R$ 2.255,78 ± 3.096,36. Se consideraron alternativas terapéuticas la terapia con medicamentos, fisioterapia y procedimientos quirúrgicos, de acuerdo con la literatura y las guías nacionales y extranjeras para la incontinencia. Los principales fármacos son oxibutinina, tolterodina, darifenacina y la toxina botulínica, que mostraron coste estimado medio anual de R$ 988,20; R$ 4,355.05; R$ 4,322.40; y R$ 3.979,14, respectivamente. Los procedimientos quirúrgicos ofrecidos por el Sistema Único de Salud fueron buscados en SIGTAP (tabla de Procedimientos del SUS) y tenían valores de compensación que van desde R$ 372,54 a R $ 457,67. Según el SIGTAP, el precio de la sesión de fisioterapia para el control de la incontinencia es de R $ 4,67; son recomendadas 20 sesiones por semana. CONSIDERACIONES FINALES: Se observó que el gasto promedio estimado de los pacientes utilizando pañales y productos auxiliares para el cuidado y tratamiento de la incontinencia es alta, alcanzando R $ 2.255,78 por año. El uso del pañal será necesario en el caso de la incontinencia fecal y condicional en el caso de la incontinencia urinaria (UI). En la UI, el uso de pañales dependerá del tipo y la gravedad de la incontinencia y de la condición física y funcional de la persona y se fueron utilizadas opciones de tratamiento (reeducación, la ingestión controlada de líquidos, fisioterapia, terapia ocupacional, medicamentos y cirugía). De acuerdo con las evidencias de este PTC, parece que hay una infrautilización del tratamiento farmacológico, fisioterapia y los procedimientos quirúrgicos y el uso excesivo de pañales para adultos, que pueden, en caso de uso innecesario, contribuir a mantener o establecer la incontinencia. De todos modos SUS no dispensa fármacos recomendados para UI y productos auxiliares para el tratamiento, además el valor del subsidio económico prestado a los pacientes es insuficiente para cubrir los costos de las incontinencias, en situaciones donde se recomienda adecuadamente el uso del pañal.(AU)