Manifestaciones clínicas y anoscópicas de las lesiones ecamosas intraepiteliales de alto grado anales / Clinical and anoscopic manifestations of high-grade anal squamous intraepithelial lesions

Introducción: Las lesiones escamosas intraepiteliales de alto grado anales (H-ASIL) son consideradas el precursor del carcinoma escamoso anal. Es por esto que distintas Sociedades recomiendan su pesquisa y tratamiento en poblaciones de alto riesgo. El objetivo del trabajo es describir las manifestaciones de H-ASIL en la anoscopía de alta resolución (AAR) en nuestros pacientes. Diseño: Retrospectivo, descriptivo. Pacientes y métodos: Revisión de historias clínicas e imágenes de AAR de pacientes con diagnóstico de H-ASIL entre enero de 2016 y julio de 2017. La evaluación anoscópica incluyó la unión escamocolumnar, el conducto anal distal y el área perianal. Frente al hallazgo de una lesión sospechosa de ASIL, se tomaron biopsias. Resultados: Entre enero de 2016 y julio de 2017 se realizaron 184 AAR. Se biopsiaron 143 lesiones sospechosas de ASIL. Veintiséis de ellas, presentes en 13 pacientes fueron H-ASIL. Once hombres (diez hombres que tienen sexo con hombre (HSH) con infección por VIH). Todas las lesiones eran subclínicas y se encontraron a nivel endoanal; eran en su totalidad acetoblancas. Se buscaron áreas con puntillado y/o mosaico sugestivas de ASIL. El uso de Lugol nos permitió aumentar el grado de sospecha y delimitar las lesiones. Se tomaron biopsias para anatomía patológica bajo visión directa. Conclusiones: Las H-ASIL son consideradas en la actualidad las precursoras del carcinoma escamoso anal; su detección y tratamiento prevendrían su desarrollo. En nuestra casuística, todos los pacientes se encontraban en al menos un grupo de riesgo. Las lesiones fueron subclínicas y requirieron de la anoscopía de alta resolución para su hallazgo, lo que permitió realizar un tratamiento dirigido. Es importante que los profesionales de la salud consideren la pesquisa de H-ASIL en población de riesgo. (AU)

Introduction: The high-grade anal intraepithelial lesions (H-ASIL) are considered the precursor of the anal squamous cell carcinoma. This is why different societies recommend the screening and treatment in high-risk populations. The objective of this paper is to describe H-ASIL manifestations in the high resolution anoscopy (HRA) in our patients. Design: Retrospective, Descriptive Patients and Methods: Review of clinical histories and pictures of HRA of patients with H-ASIL diagnosis between January 2016 and July 2017. The anoscopic evaluation included the squamocolumnar junction, the distal anal duct and the perianal area. In case of the finding of a suspicious lesion of ASIL, biopsies were taken. Results: Between January 2016 and July 2017 184 HRA were performed. 143 ASIL suspicious lesion were biopsied. Twentysix of them, in 13 patients, were H-ASIL. Eleven were men (10 men who have sex with men with HIV infection). All lesions were subclinical and found at endoanal level. The totality of them were acetowhite. Areas with coarse punctation and a mosaic pattern were suggestive of ASIL. The use of lugol´s iodine allows us to increase the grade of suspect and delimit the lesions. Biopsies were taken for pathology under direct vision. Conclusion: The H-ASIL are considered at the present the precursors of the anal squamous carcinoma. Its development could be prevented with de proper detection and treatment of the H-ASIL. In our casuistic, all patients are in at least one risk group. The lesions were subclinical and required of the high resolution anoscopy for their finding, which allows to perform a directed treatment. It is important that health professionals consider the H-ASIL screening in risk population. (AU)

Hemorroidopexia. Nuestra experiencia. Análisis descriptivo de las complicaciones de la técnica de hemorroideopexia con sutura mecánica y el grado de satisfacción / Hemorroidopexy Our experience. Descriptive analysis of the complications of the hemorrhoidepexy technique with mechanical suture and the degree of satisfaction

Introducción: La hemorroidopexia con sutura mecánica, es una técnica eficaz para los prolapsos hemorroidales grado III y IV. Objetivo: Describir nuestra experiencia con dicho método. Material y métodos: Se realizó un análisis descriptivo, retrospectivo sobre una base de datos cargada en forma prospectiva. Se analizaron pacientes con hemorroides grado III y IV, en quienes se realizó hemorroidopexia con PPH- 03, desde enero del 2010 hasta diciembre de 2017. Se evaluaron las variables demográficas, las complicaciones y el grado de satisfacción. Se realizó seguimiento postoperatorio semanal, a los 15 días, al mes, a los 6 meses y finalmente un control telefónico. Resultados: Se estudiaron 452 pacientes. La edad media fue de 46 años (rango: 20-75), siendo el 63% (n=291) del sexo masculino. El 84% (n=387) presentaban hemorroides grado III. El índice de complicación fue del 25% (n=115) durante el periodo de seguimiento, en el postoperatorio inmediato, 60 (52%) pacientes presentaron un evento considerado como complicación, y 55 (48%) pacientes presentaron complicaciones mediatas y tardías. Las complicaciones más frecuentes fueron: dolor en 37 (8%) de los pacientes, seguida por proctorragía en 18 casos (4%) y trombosis hemorroidal externa en 15 pacientes (3,3%). (AU)

Background: Hemorrhoidopexy with mechanical suture is an effective technique for hemorrhoidal prolapses grade III and IV. Objective: Describe our experience with this method. Material and methods: A descriptive, retrospective analysis was performed on a prospectively loaded database. Patients with grade III and IV hemorrhoids were analyzed, in whom hemorrhoidopexy was performed with PPH-03, from January 2010 to December 2017. Demographic variables, complications and degree of satisfaction were evaluated. Weekly postoperative follow-up was performed at 15 days, at month, at 6 months and finally a telephone control. Results: 452 patients were studied. The average age was 46 years (range,: 20 - 75), being 63% (n = 291) of the male sex. 84% (n = 387) had grade III hemorrhoids. The complication rate was 25% (n = 115) during the follow-up period, in the immediate postoperative period, 60 (52%). The most frequent complications were: pain in 37 (8%) patients, follow-up by proctorrhagia in 18 cases (4%) and hemorrhoidal thrombosis external in 15 patients (3.3%). (AU)

[Sacral neuromodulation. Long-term results]. / Neuromodulación. sacra. Resultados a largo plazo.

Sacral neuromodulation involves electrical stimulation of af­ferent nerve roots to restore the balance between inhibitory and excitatory reflexes who improve the functional activity of the pelvic floor. With benefits in patients with fecal inconti­nence, constipation and chronic anorectal pain. Objective. The aim of this study is present the results obtained with sacral neuromodulation for the treatment of patients with fecal incontinence, severe and intractable chronic constipa­tion and chronic anorectal pain. Patients and methods. 33 patients had indication for transitory electrical sacral stimu­lation, 25 patients performed transitory electrical stimula­tion for fecal incontinence, 5 with refractary constipation and 3 with chronic anorectal pain. In cases of fecal inconti­nence, the patients performed previous anorectal manometry and ultrasonography examination of anal sphincters. When the constipation is the indication, we performed stimulation in patients with severe and refractary constipation like step before total colectomy. In cases of chronic anorectal pain, the electrical transitory test was performed according to our treatment algorithm for management of functional anorectal pain. In all cases, if the patients had satisfactory results after 2 weeks period the definitive implant was placed. Results. Mean follow-up was 69 months (range 6-130). Definitve implant was placed for treatment of fecal incontinence in 23 patients with a decrease in fecal incontinence scores in 98%, with an average success rate of 66% (range: 45-92). In cases of constipation, 3 definitive implants were placed, the mean follow-up was 77 months (range: 51-96) with a success rate between 50%-80% as measured by bowel frequency. We performed definitive electrical stimulation in 3 patients wit chronic and intractable anorectal pain. Response rates as measured by visual analog scale were between 40%-70%. Conclusions. Sacral neuromodulation is an area in constant growth, with more indications. The success depends on the correct indication and the patients need to be treated with other therapeutic options before sacral neuromodulation.

[Total anorectal reconstruction after proctocolectomy: surgical results and functional outcome]. / Reconstrucción anorrectal total luego de una coloproctectomía: resultados funcionales.

The aim of this report is to describe a novel technical approach to total anorectal reconstruction and show surgical results and functional outcome. The technique is an innovative surgery to restore gastrointestinal perineal continuity after coloproctectomy in patients with familial adenomatous polyposis. We made the internal anal sphincter replacement with demucosated small bowel plication, the external anal sphincter replacement with an artificial bowel sphincter (ABS) and the restitution of intestinal transit with and ileal "S" pouch. After 12 months follow-up the control of gas is irregular, normal continence to solid stool was achieved with only occasional minimal soiling after defecation. The Jorge-Wexner incontinence score is 6 (moderate incontinence). The fecal incontinence quality of life (FIQL) comparing stoma vs. non-stomas, shows a relevant clinical difference, with improvement in all scales. This study has limitations because it is preliminary, observational and with no control group. We conclude that this recent surgical technique requires expertise in pelvic floor surgery and management of fecal incontinence. The surgeon should be able not only to introduce an artificial anal sphincter, but also to make the plication of intestinal muscle layer to create a zone of high pressure in anal canal and the ileal pouch.

Reconstrucción anorrectal total luego de una coloproctectomía: resultados funcionales / [Total anorectal reconstruction after proctocolectomy: surgical results and functional outcome].

The aim of this report is to describe a novel technical approach to total anorectal reconstruction and show surgical results and functional outcome. The technique is an innovative surgery to restore gastrointestinal perineal continuity after coloproctectomy in patients with familial adenomatous polyposis. We made the internal anal sphincter replacement with demucosated small bowel plication, the external anal sphincter replacement with an artificial bowel sphincter (ABS) and the restitution of intestinal transit with and ileal "S" pouch. After 12 months follow-up the control of gas is irregular, normal continence to solid stool was achieved with only occasional minimal soiling after defecation. The Jorge-Wexner incontinence score is 6 (moderate incontinence). The fecal incontinence quality of life (FIQL) comparing stoma vs. non-stomas, shows a relevant clinical difference, with improvement in all scales. This study has limitations because it is preliminary, observational and with no control group. We conclude that this recent surgical technique requires expertise in pelvic floor surgery and management of fecal incontinence. The surgeon should be able not only to introduce an artificial anal sphincter, but also to make the plication of intestinal muscle layer to create a zone of high pressure in anal canal and the ileal pouch.

Reconstrucción anorrectal total luego de una coloproctectomía: resultados funcionales. / [Total anorectal reconstruction after proctocolectomy: surgical results and functional outcome].

The aim of this report is to describe a novel technical approach to total anorectal reconstruction and show surgical results and functional outcome. The technique is an innovative surgery to restore gastrointestinal perineal continuity after coloproctectomy in patients with familial adenomatous polyposis. We made the internal anal sphincter replacement with demucosated small bowel plication, the external anal sphincter replacement with an artificial bowel sphincter (ABS) and the restitution of intestinal transit with and ileal "S" pouch. After 12 months follow-up the control of gas is irregular, normal continence to solid stool was achieved with only occasional minimal soiling after defecation. The Jorge-Wexner incontinence score is 6 (moderate incontinence). The fecal incontinence quality of life (FIQL) comparing stoma vs. non-stomas, shows a relevant clinical difference, with improvement in all scales. This study has limitations because it is preliminary, observational and with no control group. We conclude that this recent surgical technique requires expertise in pelvic floor surgery and management of fecal incontinence. The surgeon should be able not only to introduce an artificial anal sphincter, but also to make the plication of intestinal muscle layer to create a zone of high pressure in anal canal and the ileal pouch.