Incontinencia fecal posparto. Revisión de conjunto / Postpartum incontinence. Narrative review

El desarrollo de incontinencia fecal tras el parto es un hecho frecuente. Esta incontinencia responde a una etiología multifactorial en la que el elemento más frecuente es la lesión del esfínter anal. Existen diversos factores de riesgo, que es muy importante conocer y evitar. La lesión esfinteriana puede producirse por desgarro perineal o en ocasiones por la realización de una episiotomía de forma incorrecta. Es muy importante reconocer la lesión cuando se produce y repararla de forma adecuada. El traumatismo de los nervios pudendos puede incrementar el efecto de las lesiones esfinterianas directas. Es frecuente la persistencia de incontinencia a pesar de la reparación esfinteriana primaria. La esfinteroplastia quirúrgica es el tratamiento estándar de las lesiones esfinterianas obstétricas, sin embargo, las terapias de estimulación eléctrica sacra o tibial están siendo aplicadas en pacientes con lesiones esfinterianas no reparadas, con resultados prometedores

The development of fecal incontinence after childbirth is a common event. This incontinence responds to a multifactorial etiology in which the most common element is external anal sphincter injury. There are several risk factors, and it is very important to know and avoid them. Sphincter injury may result from perineal tear or sometimes by incorrectly performing an episiotomy. It is very important to recognize the injury when it occurs and repair it properly. Pudendal nerve trauma may contribute to the effect of direct sphincter injury. Persistence of incontinence is common, even after sphincter repair. Surgical sphincteroplasty is the standard treatment of obstetric sphincter injuries, however, sacral or tibial electric stimulation therapies are being applied in patients with sphincter injuries not repaired with promising results

[Postpartum incontinence. Narrative review]. / Incontinencia fecal posparto. Revisión de conjunto.

The development of fecal incontinence after childbirth is a common event. This incontinence responds to a multifactorial etiology in which the most common element is external anal sphincter injury. There are several risk factors, and it is very important to know and avoid them. Sphincter injury may result from perineal tear or sometimes by incorrectly performing an episiotomy. It is very important to recognize the injury when it occurs and repair it properly. Pudendal nerve trauma may contribute to the effect of direct sphincter injury. Persistence of incontinence is common, even after sphincter repair. Surgical sphincteroplasty is the standard treatment of obstetric sphincter injuries, however, sacral or tibial electric stimulation therapies are being applied in patients with sphincter injuries not repaired with promising results.

Changes in anorectal morphologic and functional parameters after fistula-in-ano surgery.

PURPOSE: This study aimed to analyze changes in anal continence and morphologic and functional anorectal variables after fistula-in-ano surgery in a patient series with a high rate of complex fistulas. METHODS: One hundred twenty patients with a mean age of 46.9 (standard deviation, 12.8) years were prospectively analyzed by evaluating anal continence, results of endoanal ultrasound examination and anorectal manometry, and pudendal nerve terminal motor latency before and after fistula-in-ano surgery. RESULTS: Forty-three patients (35.8%) were referred for recurrent fistulas; fistulas in and 70 (58.3%) were considered complex. Preoperatively, 17 patients (14.2%) presented with impaired continence. At follow-up, 59 patients (49.2%) had some degree of incontinence (P < 0.001). The techniques that most affected continence were rectal advancement flap and fistulotomy. Endoanal ultrasound examination showed that the number of patients with internal anal sphincter defects increased from 37 (30.8%) to 78 (74.3%) after surgery (P < 0.001); those with external anal sphincter defects increased from 17 (15.9%) to 34 (32.4%) (P < 0.001). Techniques most associated with increases in internal anal sphincter defects were fistulotomy (P < 0.003) and rectal advancement flap (P < 0.004). Anal manometry showed significant decreases in maximal resting pressure and maximum squeeze pressure in patients with previous incontinence (P < 0.001), and in those with internal anal sphincter defects (P < 0.001). Fistulotomy decreased both resting pressure (P < 0.004) and squeeze pressure (P < 0.007), whereas rectal advancement flap significantly reduced only resting pressure. Pudendal nerve latency did not differentiate continent and incontinent patients, and showed no postoperative change. CONCLUSIONS: Anal continence is significantly affected after fistula-in-ano surgery, mainly because of sphincteric lesions that affect anal canal pressures and that can be imaged with endoanal ultrasound. It is important to preoperatively recognize sphincter defects to allow adequate surgical treatment.

[Mechanical bowel preparation. A necessity or nothing more (or less) than the weight of tradition?]. / Preparar el colon para la cirugía. Necesidad real o nada más (y nada menos) que el peso de la tradición?

Mechanical bowel preparation is a traditional procedure for preparing patients for colorectal surgery. This practice aims to reduce the risk of postoperative infectious complications since colonic fecal content has classically been related to stool spillage during surgery and anastomotic disruption. However, increasing evidence against its routine use can be found in experimental studies, clinical observations, prospective studies, and meta-analyses. We performed a review of the literature on mechanical bowel preparation and its consequences. There is no clear evidence that preoperative bowel cleansing reduces the septic complications of surgery and routine use of this procedure may increase anastomotic leaks and morbidity. Therefore, the results suggest that mechanical preparation is not required in elective colon and rectal surgery and that its use should be restricted to specific indications such as small nonpalpable tumors to aid their localization during laparoscopic procedures or to enable intraoperative colonoscopy. The role of mechanical bowel preparation in rectal surgery is not well defined and further trials with a larger number of patients are required.

Preparar el colon para la cirugía. ¿Necesidad real o nada más (y nada menos) que el peso de la tradición? / Mechanical bowel preparation. A necessity or nothing more (or less) than the weight of tradition?

La preparación mecánica del colon es un componente tradicional del preoperatorio de los pacientes sometidos a cirugía colorrectal dirigido a reducir sus complicaciones infecciosas, ya que clásicamente la presencia de heces en el colon se ha asociado a contaminación intraoperatoria y dehiscencias anastomóticas. Sin embargo, en la actualidad, estudios tanto experimentales como de observaciones clínicas, trabajos prospectivos y revisiones sistemáticas de la literatura cuestionan su utilidad. Se efectúa una revisión de conjunto sobre el tema, y se concluye que, con la evidencia disponible, no está claro el beneficio de la preparación mecánica del colon y hay trabajos que muestran incluso una mayor incidencia de complicaciones en la tasa de dehiscencia anastomótica y la morbilidad con su uso sistemático, por lo que puede ser omitida en cirugía electiva y es adecuado restringirla a indicaciones concretas, como pequeños tumores, para facilitar su localización durante un abordaje laparoscópico o cuando se precise hacer una endoscopia intraoperatoria. El papel de la preparación mecánica en la cirugía rectal no está aclarado en la actualidad y se precisa de series más amplias para establecerlo (AU)

Mechanical bowel preparation is a traditional procedure for preparing patients for colorectal surgery. This practice aims to reduce the risk of postoperative infectious complications since colonic fecal content has classically been related to stool spillage during surgery and anastomotic disruption. However, increasing evidence against its routine use can be found in experimental studies, clinical observations, prospective studies, and meta-analyses. We performed a review of the literature on mechanical bowel preparation and its consequences. There is no clear evidence that preoperative bowel cleansing reduces the septic complications of surgery and routine use of this procedure may increase anastomotic leaks and morbidity. Therefore, the results suggest that mechanical preparation is not required in elective colon and rectal surgery and that its use should be restricted to specific indications such as small nonpalpable tumors to aid their localization during laparoscopic procedures or to enable intraoperative colonoscopy. The role of mechanical bowel preparation in rectal surgery is not well defined and further trials with a larger number of patients are required (AU)

Técnicas novedosas en el tratamiento de la incontinencia anal / Novel techniques in the treatment of anal incontinence

La incontinencia fecal es un problema que puede condicionar la vida sociolaboral del paciente. Hasta hace poco, la mayoría de enfermos con incontinencia anal grave, en los que habían fracasado medidas conservadoras y/o quirúrgicas, eran sometidos a una colostomía. Actualmente, estos pacientes pueden beneficiarse de alguna técnica innovadora de reciente aparición. Así, disponemos del esfínter anal artificial y de la graciloplastia dinámica, cada una con sus indicaciones específicas. Ambos procedimientos consiguen buenos resultados funcionales, pero con cifras de complicaciones no despreciables y con reintervenciones en bastantes ocasiones. La neuromodulación sacra ha supuesto un avance importante por su relativa sencillez y porque permite, mediante un test de estimulación temporal, discriminar qué pacientes se beneficiarán definitivamente de su aplicación. Otras técnicas, como la inyección de agentes aumentadores de volumen o la radiofrecuencia, son tan recientes y hay tan poca experiencia que su papel todavía está por definir. Al ser tan novedosas las técnicas descritas, además de su elevado coste económico, conviene utilizarlas en grupos de estudio que dispongan de laboratorio de fisiología anorrectal y dentro de ensayos clínicos, hasta que la experiencia demuestre que puede generalizarse, o no, su aplicación (AU)

Fecal incontinence can negatively affect the patient's occupational and social life. Until recently, most patients with severe anal incontinence unresponsive to conservative medical and/or surgical treatments underwent colostomy. Currently, these patients can benefit from one of the innovative techniques that have recently been developed. Thus, the artificial anal sphincter and dynamic graciloplasty are now available, each with specific indications. Both procedures achieve good functional results but complication and reintervention rates are not inconsiderable. Sacral neuromodulation represents an important advance due to its relative simplicity and because, through a period of test stimulation, patients who can definitively benefit from its application can be identified. Other techniques, such as injectable bulking agents or radiofrequency ablation are so recent that experience is limited and their role remains to be defined. Since these techniques are so novel and their economic cost is high, their use should be restricted to study groups with an anorectal physiology laboratory and within the context of clinical trials until experience shows whether or not their application can become widespread (AU)

Defecación obstructiva. Métodos diagnósticos y tratamiento / Obstructive defecation. Diagnostic methods and treatment

La existencia de defecación obstructiva se observa en torno a la mitad de los pacientes con estreñimiento funcional. Se ha relacionado el estreñimiento funcional con alteraciones de la motilidad intestinal (estreñimiento de tránsito lento) y con disfunciones en el suelo pelviano que provocan defecación obstructiva, asociado a una alteración anatómica del suelo pelviano (rectocele, hernia perineal posterior, enterocele y sigmoidocele, intususcepción interna rectal, prolapso mucoso oculto, úlcera rectal solitaria y síndrome del periné descendente) o defecación obstructiva sin existencia de alteración anatómica (disinergia del suelo pelviano o anismo). Se analizan los métodos diagnósticos empleados (anamnesis y exploración física, tiempo de tránsito cólico, test de expulsión de balón, estudios proctográficos, manometría anorrectal y electromiografía), así como el tratamiento médico conservador y las indicaciones y los resultados del tratamiento quirúrgico (AU)

Obstructive defecation is observed in approximately half of all patients with functional constipation. Functional constipation has been related to alterations in intestinal motility (slow transit constipation) and to pelvic floor disorders leading to obstructive defecation associated with anatomical alterations of the pelvic floor (rectocele, posterior perineal hernia, enterocele and sigmoidocele, internal rectal intussusception, occult mucosal prolapse, solitary rectal ulcer and descending perineum syndrome), or obstructive defecation without anatomical alterations (pelvic floor dyssynergy or anismus). The diagnostic methods used (history and physical examination, colonic transit time, balloon expulsion test, proctography, anorectal manometry and electromyography) are reviewed. Conservative medical treatment and the indications for surgical treatment and its results are also discussed (AU)

[Novel techniques in the treatment of anal incontinence]. / Técnicas novedosas en el tratamiento de la incontinencia anal.

Fecal incontinence can negatively affect the patient's occupational and social life. Until recently, most patients with severe anal incontinence unresponsive to conservative medical and/or surgical treatments underwent colostomy. Currently, these patients can benefit from one of the innovative techniques that have recently been developed. Thus, the artificial anal sphincter and dynamic graciloplasty are now available, each with specific indications. Both procedures achieve good functional results but complication and reintervention rates are not inconsiderable. Sacral neuromodulation represents an important advance due to its relative simplicity and because, through a period of test stimulation, patients who can definitively benefit from its application can be identified. Other techniques, such as injectable bulking agents or radiofrequency ablation are so recent that experience is limited and their role remains to be defined. Since these techniques are so novel and their economic cost is high, their use should be restricted to study groups with an anorectal physiology laboratory and within the context of clinical trials until experience shows whether or not their application can become widespread.

[Obstructive defecation. Diagnostic methods and treatment]. / Defecación obstructiva. Métodos diagnósticos y tratamiento.

Obstructive defecation is observed in approximately half of all patients with functional constipation. Functional constipation has been related to alterations in intestinal motility (slow transit constipation) and to pelvic floor disorders leading to obstructive defecation associated with anatomical alterations of the pelvic floor (rectocele, posterior perineal hernia, enterocele and sigmoidocele, internal rectal intussusception, occult mucosal prolapse, solitary rectal ulcer and descending perineum syndrome), or obstructive defecation without anatomical alterations (pelvic floor dyssynergy or anismus). The diagnostic methods used (history and physical examination, colonic transit time, balloon expulsion test, proctography, anorectal manometry and electromyography) are reviewed. Conservative medical treatment and the indications for surgical treatment and its results are also discussed.

Tratamiento quirúrgico y resultados del cáncer de colon / Surgical treatment and results of colon cancer

El tratamiento quirúrgico del cáncer de colon no se ha modificado en las últimas décadas y sigue siendo la base de la terapéutica de esta enfermedad. Se han demostrado pronósticos el estadio anatomopatológico, seguido de la variable cirujano, cuya especialización determina los resultados de la resección primaria, y éstos, el pronóstico del paciente.Cuando la intervención tiene carácter curativo, el margen distal deberá ser al menos de 5 cm, y el proximal dependerá de la resección vasculolinfática, que determinará la extensión de la colectomía. Si el tumor se encuentra adherido a otras vísceras, se practicará la resección en bloque. No se ha demostrado que la técnica de no tocar el tumor aporte beneficio.En este artículo se revisan las diferentes técnicas quirúrgicas clásicas, actualizando aspectos concretos de cada una. La cirugía laparoscópica del cáncer de colon se está demostrando como una técnica segura y cada vez más empleada en pacientes seleccionados.La búsqueda continua de la calidad obliga a plantear estándares de referencia y análisis de resultados en estos pacientes. Finalmente se tratan problemas especiales, que no resultan infrecuentes en la práctica diaria, como son el pólipo degenerado, el cáncer asociado a enfermedad inflamatoria intestinal y el cáncer en el seno de síndromes genéticos (AU)