Prevalence and pathophysiology of functional constipation among women in Catalonia, Spain.

BACKGROUND: Specific treatment of functional bowel disorders requires precise diagnosis. However, prevalence and subtypes of functional constipation among women are not completely understood. OBJECTIVE: Our aim was to assess the prevalence of functional constipation and investigate the subtypes of dyssynergic defecation and slow transit constipation among Spanish women. DESIGN: We performed a prospective epidemiological study in healthy young women and retrospective pathophysiological studies in 2 patient cohorts of women with functional constipation according to Rome II criteria. SETTINGS: Referral centers at Clínica Sagrada Familia, Barcelona, Spain, and Hospital de Mataró, Mataró, Spain. PATIENTS: The epidemiological study included 600 healthy young women, aged 37.1 (SD, 8.2) years. Patient cohort 1 comprised 172 women with functional constipation without symptoms of pelvic floor dysfunction, ranging in age from 18 to 45 years. Patient cohort 2 comprised 106 women with functional constipation and symptoms of dyssynergic defecation, ranging in age from 45 to 65 years. MAIN OUTCOME MEASURES: In healthy women, a questionnaire was used to determine rates of functional constipation, dyssynergic defecation, and slow transit constipation. In patients, results of anorectal manometry, EMG, and colonic transit studies were reviewed to assess subtypes of functional constipation; in addition, results of dynamic videoproctography were reviewed in cohort 2 to assess the role of structural pelvic floor disorders. RESULTS: The prevalence of functional constipation in healthy young women was 28.8%; symptoms of dyssynergic defecation were found in 8.2%, those of isolated slow transit in only 0.17%. In patient cohort 1, a total of 143 patients (83.1%) showed dyssynergic defecation: 117 patients (68.0%) had paradoxical external anal sphincter contraction and 26 (15.1%) had impaired internal anal sphincter relaxation). Slow transit constipation without dyssynergia was observed in 15 (8.7%). Up to 40.2% of patients with dyssynergia also had delayed colonic transit. In the cohort of 106 women with dyssynergic defecation, videoproctography showed impaired puborectal relaxation in 64 patients (60.4%), anterior rectocele in 65 (61.3%), and rectal prolapse in 13 (12.3%). LIMITATIONS: We could not estimate the prevalence and subtypes of irritable bowel syndrome in the epidemiological study. CONCLUSIONS: Functional constipation is extremely prevalent among young, healthy, Spanish women, dyssynergic defecation being the most prevalent subtype. Slow transit constipation without dyssynergic defecation is uncommon. Structural pelvic floor disorders are highly prevalent in middle-aged women with dyssynergic defecation.

A comparative study of structure and function of the longitudinal muscle of the anal canal and the internal anal sphincter in pigs.

PURPOSE: This study aims to compare the physiology of the longitudinal muscle of the anal canal with the internal anal sphincter in pigs. METHODS: Histology and in vitro studies were performed to compare the effect of neural responses induced by electric stimulation and through nicotinic, purinergic, and serotoninergic receptors. RESULTS: The longitudinal muscle and the internal anal sphincter are constituted exclusively by smooth muscle. Strips from the internal anal sphincter a) developed myogenic tone; b) responded to electric stimulation with an "on" relaxation antagonized by nitric oxide synthase inhibitors and purinergic P2Y1 antagonists, and with an "off" contraction antagonized by atropine and phentolamine; and c) responded to stimulation of nicotinic receptors with a relaxation antagonized by nitrergic and purinergic P2Y1 antagonists, responded to stimulation of serotoninergic 5-hydroxytryptamine 3 receptors with a contraction, and relaxed to carbachol and purinergic P2X agonists. Strips from the longitudinal muscle a) did not develop tone, b) responded to electric stimulation with an "on" contraction antagonized by atropine, and c) did not respond to stimulation of nicotinic or serotoninergic 5-hydroxytryptamine 3 receptors, and carbachol and purinergic P2X agonists induced a contraction. CONCLUSIONS: The motility of the internal anal sphincter includes myogenic tone, relaxation mediated by nitric oxide and purinergic P2Y1 receptors, and contraction mediated by cholinergic motor neurons and sympathetic fibers. The motility of the longitudinal muscle is limited to a contraction mediated by cholinergic neurons, suggesting that longitudinal muscle contracts during relaxation of the internal sphincter, shortening the anal canal. Nicotinic, muscarinic, and serotoninergic receptors might be therapeutic targets for anal motor disorders.

Differences in patient postoperative and long-term outcomes between obstructive and perforated colonic cancer.

BACKGROUND: The aim of this observational study was to analyze the differences between patients with obstructive and perforated colonic cancer who managed with emergency curative surgery. METHODS: Between January 1994 and December 2000, patients deemed to have undergone curative resection for complicated colonic cancer were considered for inclusion in the study. They were classified into 2 groups: patients with obstructive cancer (OC) and patients with perforated cancer (PC). The main end points were postsurgical outcomes and long-term overall survival, cancer-related survival, and tumor recurrence. RESULTS: Of the 236 patients, surgery was deemed to be radical and performed with intent to cure in 155 patients (65.7%): 117 patients in the OC group and 38 patients in the PC group. No statistical differences were observed between the percentage of radical surgery between the 2 groups (P = .63). The overall postsurgical mortality rate was 12.2%: 14 patients in the OC group and 5 patients in the PC group (P = .839). Overall survival, probability of being free of recurrence, and cancer-related survival of the entire series were 64.57%, 67.72% and 73.03%, respectively. There were no differences between the 2 groups with respect to tumor recurrence, type of recurrence, overall survival, probability of being free of recurrence, and cancer-related survival at 5 years. CONCLUSIONS: In our experience, patients with perforated colonic cancer do not seem to show worse long-term outcomes than those with OC. Studies with larger series are needed for further investigations.

Caspase-3 activity, response to chemotherapy and clinical outcome in patients with colon cancer.

BACKGROUND AND AIMS: The prognostic value of the degree of apoptosis in colorectal cancer is controversial. This study evaluates the putative clinical usefulness of measuring caspase-3 activity as a prognostic factor in colonic cancer patients receiving 5-fluoracil adjuvant chemotherapy. MATERIALS AND METHODS: We evaluated caspase-3-like protease activity in tumours and in normal colon tissue. Specimens were studied from 54 patients. These patients had either stage III cancer (Dukes stage C) or high-risk stage II cancer (Dukes stage B2 with invasion of adjacent organs, lymphatic or vascular infiltration or carcinoembryonic antigen [CEA] >5). Median follow-up was 73 months. Univariate analysis was performed previously to explore the relation of different variables (age, sex, preoperative CEA, tumour size, Dukes stage, vascular invasion, lymphatic invasion, caspase-3 activity in tumour and caspase-3 activity in normal mucosa) as prognostic factors of tumour recurrence after chemotherapy treatment. Subsequently, a multivariate Cox regression model was performed. RESULTS: Median values of caspase-3 activity in tumours were more than twice those in normal mucosa (88.1 vs 40.6 U, p=0.001), showing a statistically significant correlation (r=0.34). Significant prognostic factors of recurrence in multivariate analysis were: male sex (odds ratio, OR=3.53 [1.13-10.90], p=0.02), age (OR=1.09 [1.01-1.18], p=0.03), Dukes stage (OR=1.93 [1.01-3.70]), caspase-3 activity in normal mucosa (OR=1.02 [1.01-1.04], p=0.017) and caspase-3 activity in tumour (OR=1.02 [1.01-1.03], p=0.013). CONCLUSION: Low caspase-3 activity in the normal mucosa and tumour are independent prognostic factors of tumour recurrence in patients receiving adjuvant 5-fluoracil-based treatment in colon cancer, correlating with poor disease-free survival and higher recurrence rate.

[Long-term results of emergency surgery for colon cancer compared with elective surgery]. / Resultados a largo plazo de la cirugía urgente y electiva del cáncer de colon. Estudio comparativo.

INTRODUCTION: Currently, the mechanisms that worsen the prognosis of complicated colon cancers are still not well known. Moreover, the possible effect of using sound oncological principles in emergency surgery on long-term prognosis has not been studied in detail. AIMS: The aim of the present study was to analyze the 5-year efficacy of curative oncological surgery for complicated colon cancer performed in an emergency setting in terms of tumor recurrence and survival compared with elective surgery of uncomplicated tumors. PATIENTS AND METHOD: We performed a prospective observational cohort study in patients who underwent emergency surgery for complicated colon cancer (group 1) and patients who underwent elective surgery (group 2). Exclusion criteria were tumors of less than 15 cm from the anal verge, palliative surgery, and distant metastases. RESULTS: During the study period, 646 patients underwent surgery: there were 165 (25.5%) emergency surgeries and 481 (74.5%) elective interventions. Surgery was considered curative in 456 (70.6%) patients: 102 (22.4%) emergency and 354 (77.6%) elective surgeries. Significant differences were found in disease stage between the 2 groups (P = 0.003). The postoperative mortality rate was 12.7% in group 1 and 3.4% in group 2 (P = 0.001). When patients were stratified by TNM stage, worse 5-year cancer-related and disease-free survival rates were observed in group 1 patients with stage II tumors. No differences were found in cancer-related survival rates in stage III patients (P = 0.178). There were no significant differences in overall survival, cancer-related survival or tumor recurrence rates when group 1 was compared with a subgroup of patients in group 2 with factors of poor prognosis. CONCLUSIONS: Complicated colon cancer presents in more advanced stages and had a worse overall long-term prognosis than uncomplicated tumour. These differences decrease when patients are subclassified by tumoral stage. Overall survival and cancer-related survival rates similar to those of elective surgery can be achieved in emergency surgery when curative oncological resection is performed.

Resultados a largo plazo de la cirugía urgente y electiva del cáncer de colon. Estudio comparativo / Long-term results of emergency surgery for colon cancer compared with elective surgery

Introducción. Actualmente no se sabe con exactitud cuáles son los mecanismos que gravan con un peor pronóstico el tratamiento del cáncer de colon complicado. Por otra parte, no se ha estudiado en detalle la aplicación de los principios de cirugía oncológica al tratamiento del cáncer de colon en situación de urgencia. Objetivos. Los objetivos del presente estudio fueron analizar la eficacia a 5 años de la cirugía oncológica curativa del cáncer de colon complicado, realizada en urgencias en términos de recurrencia tumoral y supervivencia, en comparación con la cirugía electiva de los tumores no complicados. Pacientes y método. Estudio analítico observacional de cohortes prospectivo entre pacientes operados en urgencias por cáncer de colon complicado (grupo 1) y pacientes intervenidos en cirugía (..) (AU)

Introduction. Currently, the mechanisms that worsen the prognosis of complicated colon cancers are still not well known. Moreover, the possible effect of using sound oncological principles in emergency surgery on long-term prognosis has not been studied in detail. Aims. The aim of the present study was to analyze the 5-year efficacy of curative oncological surgery for complicated colon cancer performed in an emergency setting in terms of tumor recurrence and (..) (AU)

Respuesta de los autores: Cirugía en el cáncer de colon complicado / Authors’ response: Rupture of a splenic artery aneurism

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Surgical resection of colorectal liver metastases in patients with expanded indications: a single-center experience with 501 patients.

PURPOSE: This study was designed to investigate survival after curative resection of colorectal liver metastases in patients with expanded indications. METHODS: A total of 501 patients had 545 liver resections for metastatic colorectal cancer. There were no predefined criteria for resectability with regard to the number or size of the tumors, locoregional invasion, or extrahepatic disease, except that resection had potential to be complete and macroscopically curative. All patients who had curative hepatic resection were advised to start postoperative adjuvant chemotherapy. RESULTS: A total of 259 patients had expanded indications (52 percent), including 14 with liver metastases >10 cm, 194 with bilateral deposits, 140 with four or more liver metastases, and 73 with extrahepatic disease. The overall actuarial survival rates at one, three, five, and ten years were 88, 67, 45, and 36 percent, respectively, for patients with classic indications and 84, 53, 34, and 24 percent, respectively, for patients with expanded indications (P = 0.0009). In the group of expanded indications, there were more patients who received preoperative than postoperative chemotherapy: 72 (28 percent) vs. 18 (7 percent; P < 0.0001), and 148 (70 percent) vs. 131 (61 percent; P = 0.0466). In a multivariate analysis, four or more liver metastases and extrahepatic disease were independent predictors of poor outcome. Adjuvant chemotherapy significantly improved survival (P = 0.0002). CONCLUSIONS: This study suggested that liver resection should be indicated in patients with expanded indications. The extent of the benefits of preoperative and postoperative chemotherapy needs to be quantitated.

La cirugía en el cáncer de colon complicado / Surgery in complicated colorectal cancer

El cáncer colorrectal (CCR) sigue manteniendo un importante impacto social, y en un elevado porcentaje de casos en el momento del diagnóstico se manifiesta en un estadio avanzado. Un tercio de los pacientes con cáncer de colon se presentará de manera urgente con un tumor complicado, una situación de alta mortalidad que implica, además, un peor pronóstico a largo plazo. La oclusión y la perforación son las formas más frecuentes de complicación, y la hemorragia masiva es rara. La capacidad de curación de una intervención, urgente o electiva, depende, entre otros factores, de la radicalidad de la resección realizada. En la bibliografía que estudia el tratamiento de la enfermedad urgente de colon, son muy escasas las referencias a los criterios oncológicos de la resección. La incertidumbre acerca del tratamiento óptimo de una enfermedad se traduce en una amplia variación en el tratamiento de la afección urgente del colon. El objetivo del presente artículo es realizar un análisis crítico de las controversias que existen a propósito del papel de la cirugía y de su impacto en el cáncer de colon complicado (AU)

Colorectal cancer continues to have a serious social impact. A large proportion of patients are diagnosed at an advanced stage of the disease. Approximately one-third of patients with colorectal cancer will undergo emergency surgery for a complicated tumor, with a high risk of mortality and poorer long-term prognosis. The most frequent complications are obstruction and perforation, while massive hemorrhage is rare. The curative potential of surgery, whether urgent or elective, depends on how radical the resection is, among other factors. In the literature on the management of urgent colorectal disease, there are few references to the oncological criteria for resection. Uncertainly about the optimal treatment has led to wide variability in the treatment of this entity. The present article aims to provide a critical appraisal of the controversies surrounding the role of surgery and its impact on complicated colorectal cancer (AU)

[Surgery in complicated colorectal cancer]. / La cirugía en el cáncer de colon complicado.

Colorectal cancer continues to have a serious social impact. A large proportion of patients are diagnosed at an advanced stage of the disease. Approximately one-third of patients with colorectal cancer will undergo emergency surgery for a complicated tumor, with a high risk of mortality and poorer long-term prognosis. The most frequent complications are obstruction and perforation, while massive hemorrhage is rare. The curative potential of surgery, whether urgent or elective, depends on how radical the resection is, among other factors. In the literature on the management of urgent colorectal disease, there are few references to the oncological criteria for resection. Uncertainly about the optimal treatment has led to wide variability in the treatment of this entity. The present article aims to provide a critical appraisal of the controversies surrounding the role of surgery and its impact on complicated colorectal cancer.

Incontinencia fecal. Valoración del paciente. Tratamientos clásicos / Fecal incontinence. Patient assessment and classical treatments

La incontinencia fecal es una afección muy frecuente, aunque su prevalencia exacta no es muy bien conocida. Es causante de un estigma social y personal que significa una carga insoportable para el paciente y puede producirse por un amplio abanico de enfermedades. Por estas razones, hay un gran número de tratamientos. En este artículo se revisan la incidencia y la etiología de esta afección; la exploración física e instrumental con la descripción de los diversos componentes del laboratorio anorrectal; el tratamiento médico y quirúrgico más habitual, y finalmente, los resultados de estos últimos (AU)

Fecal incontinence is a very common disease but its exact prevalence is largely unknown. The condition gives rise to personal and social stigma with severe repercussions for the patient. It can be caused by a large number of physiopathologic disorders and consequently there is a wide variety of treatments. In this article we review the incidence and etiology of fecal incontinence, physical and instrumental examinations (with description of the components of the anorectal laboratory), traditional medical and surgical treatments and, lastly, the results of sphincteroplasties (AU)

Trastorno del suelo pélvico / Pelvic floor disease

El suelo pélvico es una de las estructuras más complejas del cuerpo humano. Históricamente, el abordaje de sus enfermedades ha sido «vertical», con el compartimiento anterior abordado por urólogos, el medio por ginecólogos con frecuentes incursiones en el compartimiento anterior femenino, y el posterior reservado a los cirujanos. Durante los últimos años se ha producido un cambio en la filosofía del manejo de estas enfermedades gracias la aparición de un concepto integrador «transversal» que afecta a la fisiología, la fisiopatología y la propia definición de estas enfermedades como una estructura integrada, en la que se incluyen la incontinencia urinaria, la incontinencia fecal, el prolapso de órganos pélvicos, las alteraciones de la percepción y del vaciamiento del tracto urinario, el estreñimiento crónico, las disfunciones sexuales y varios síndromes de dolor crónico del área perineal. Creemos que se deberían aunar los esfuerzos de los diferentes profesionales relacionados con el tratamiento de estas enfermedades y crear unidades de suelo pélvico. Parece importante que se establezca un concepto de multidisciplinariedad, ya que las habilidades y los conocimientos necesarios para el abordaje de los problemas de las pacientes requieren equipos formados por múltiples dominios profesionales (AU)

The pelvic floor is one of the most complex structures of the human body. Historically, the approach to pelvic floor disease has been «vertical»: the anterior compartment was the domain of urologists, the middle compartment was the domain of gynecologists with frequent incursions into the female anterior compartment, and the posterior compartment was reserved for surgeons. In the last few years, a change has occurred in the philosophy underpinning the management of these diseases with the development of an integrative «cross sectional» approach which affects the physiology, physiopathology, and the definition of these diseases as an integrated structure, and which includes urinary and fecal incontinence, pelvic organ prolapse, alterations in the perception of urinary tract emptying, chronic constipation, sexual dysfunctions, and several chronic pain syndromes in the perineal area. We believe that the efforts of the various professionals involved in the treatment of these disorders should be pooled and that pelvic floor units should be created. These units should be characterized by a multidisciplinary approach, since the skills and knowledge necessary for the management of these patients requires teams composed of professionals with a broad range of competencies (AU)

A prospective study of outcomes of emergency and elective surgeries for complicated colonic cancer.

BACKGROUND: Although a significantly decreased long-term survival has been observed in patients undergoing surgery for complicated colorectal tumors compared with uncomplicated ones, the role of radical oncologic surgery on emergency colonic cancer is not defined clearly. The aim of this study was to analyze the efficacy of a curative emergency surgery in terms of tumor recurrence and cancer-related survival compared with elective colonic surgery. METHODS: Between January 1996 and December 1998, all patients with colonic cancer deemed to have undergone a curative resection were considered for inclusion in this prospective study. Patients were classified into 2 groups: group 1, after emergency surgery for complicated colonic cancer, and group 2, patients undergoing elective surgery. The main end points were cancer-related survival and the probability of being free from recurrence at 3 years. RESULTS: Of the 266 patients included in the study, 59 patients (22.2%) were in group 1 and 207 patients (77.8%) were in group 2. Postoperative mortality was higher in group 1 (P=.0004). After patients were stratified by the tumor node metastasis system, differences between the groups with respect to overall survival of stage II tumors (P=.0728), the probability of being free from recurrence (P=.0827), and cancer-related survival (P=.1071) of stage III cancers did not reach statistical significance. Differences were observed for the overall survival in stage III tumors (P=.0007), and for the probability of being free from recurrence (P=.0011) and cancer-related survival (P=.0029) in stage II cancers. When patients with elective stage II tumors presenting 1 or more negative prognostic factor were compared with emergency patients affected by a stage II colonic cancer, no differences were observed. CONCLUSION: Curative surgeries for complicated colonic cancer are acceptable in emergency conditions. Cancer-related survival and recurrence in patients with complicated colonic cancers may approach that of elective surgery if a surgical treatment with radical oncologic criteria is performed.

Resultados y factores pronósticos de mortalidad en la intervención de Hartmann / Results and prognostic factors in the Hartmann procedure

Introducción. La introducción, hace ya muchos años, de la cirugía cólica urgente en un tiempo ha relegado la intervención de Hartmann para los pacientes más graves. Este hecho ha conducido a que las tasas de morbimortalidad asociadas a la técnica de Hartmann sean elevadas. El objetivo de nuestro estudio fue analizar los resultados obtenidos con la intervención de Hartmann en el período de estudio y analizar los factores pronósticos de mortalidad postoperatoria en este grupo de pacientes. Pacientes y métodos. Durante el período comprendido entre enero de 1995 y diciembre de 2000 se intervino quirúrgicamente a 79 pacientes (34 varones y 45 mujeres), con una edad media de 71,5 años, a los que se les realizó una intervención de Hartmann. Casi la totalidad de los pacientes (91,1%) tenía una o más enfermedades asociadas. En este grupo de pacientes se analizaron retrospectivamente los resultados de morbimortalidad y, mediante un estudio de regresión logística multivariable, los factores pronósticos de mortalidad postoperatoria. Resultados. En toda la serie, la indicación de cirugía fue: peritonitis aguda (77,2%), oclusión intestinal (18,9%) y hemorragia digestiva baja (3,7%). La causa etiológica más frecuente fue la diverticulitis aguda complicada (36 casos) y el cáncer colorrectal complicado (18 casos). El 70,9% de los pacientes (56 casos) presentó 1 o más complicaciones durante el postoperatorio;15 casos fueron reintervenidos (18,9%), y la mortalidad postoperatoria fue del 45,5%. La insuficiencia renal (creatinina ≥ 120 µmol/l) y el riesgo quirúrgico ASA avanzado (III o IV) alcanzaron significación estadística cómo factores predictivos de mortalidad en estos pacientes (p = 0,001 y 0,005, respectivamente). Conclusión. Los pacientes a los que se les practicó una intervención de Hartmann y que tenían un mayor riesgo quirúrgico anestésico (ASA) y/o una alteración de la función renal tuvieron un riesgo de mortalidad significativamente más elevado (AU)

Introduction. The introduction of one-stage procedures in emergency colonic surgery many years ago has relegated the use of the Hartmann procedure to the most seriously-ill patients, which has led to the high morbidity and mortality rates associated with this surgical technique. The aim of our study was to investigate our results using Hartmann’s procedure and to evaluate several prognostic factors of postoperative mortality in this group of patients. Patients and methods. From January 1995 to December2000, 79 patients (34 men and 45 women) with a mean age of 71.5 years underwent Hartman’s operation. Almost all the series (91.1%) had comorbidities. In this group of patients, morbidity and mortality were analyzed retrospectively, and a multivariate logistic regression analysis was performed to study prognostic factors of postoperative mortality. Results. The indications for surgery were acute peritonitis(77.2%), intestinal obstruction (18.9%), and lower gastrointestinal hemorrhage (3.7%). The most frequent etiology was acute diverticulitis (36 patients),followed by complicated colorectal carcinoma (18 patients). In 70.9% of the patients (56 patients) one or more postoperative complications was observed. Reoperation was performed in 15 patients (18.9%) and overall postoperative mortality was 45.5%. Renal failure (creatinine ≥ 120 µmol/l) and high surgical ASA score (III or IV) reached statistical significance as predictive factors of mortality in these patients(p=.001 and p=.005, respectively). Conclusion. The patients who underwent Hart-mann’s procedure with high surgical ASA score and/or renal failure were at significantly higher risk of mortality (AU)

[Fecal incontinence. Patient assessment and classical treatments]. / Incontinencia fecal. Valoración del paciente. Tratamientos clásicos.

Fecal incontinence is a very common disease but its exact prevalence is largely unknown. The condition gives rise to personal and social stigma with severe repercussions for the patient. It can be caused by a large number of physiopathologic disorders and consequently there is a wide variety of treatments. In this article we review the incidence and etiology of fecal incontinence, physical and instrumental examinations (with description of the components of the anorectal laboratory), traditional medical and surgical treatments and, lastly, the results of sphincteroplasties.

[Results and prognostic factors in the Hartmann procedure]. / Resultados y factores pronósticos de mortalidad en la intervención de Hartmann.

INTRODUCTION: The introduction of one-stage procedures in emergency colonic surgery many years ago has relegated the use of the Hartmann procedure to the most seriously-ill patients, which has led to the high morbidity and mortality rates associated with this surgical technique. The aim of our study was to investigate our results using Hartmanns procedure and to evaluate several prognostic factors of postoperative mortality in this group of patients. PATIENTS AND METHODS: From January 1995 to December 2000, 79 patients (34 men and 45 women) with a mean age of 71.5 years underwent Hartmanns operation. Almost all the series (91.1%) had comorbidities. In this group of patients, morbidity and mortality were analyzed retrospectively, and a multivariate logistic regression analysis was performed to study prognostic factors of postoperative mortality. RESULTS: The indications for surgery were acute peritonitis (77.2%), intestinal obstruction (18.9%), and lower gastrointestinal hemorrhage (3.7%). The most frequent etiology was acute diverticulitis (36 patients), followed by complicated colorectal carcinoma (18 patients). In 70.9% of the patients (56 patients) one or more postoperative complications was observed. Reoperation was performed in 15 patients (18.9%) and overall postoperative mortality was 45.5%. Renal failure (creatinine > or = 120 micromol/l) and high surgical ASA score (III or IV) reached statistical significance as predictive factors of mortality in these patients (p=.001 and p=.005, respectively). CONCLUSION: The patients who underwent Hartmanns procedure with high surgical ASA score and/or renal failure were at significantly higher risk of mortality.

[Pelvic floor disease]. / Trastornos del suelo pélvico.

The pelvic floor is one of the most complex structures of the human body. Historically, the approach to pelvic floor disease has been "vertical": the anterior compartment was the domain of urologists, the middle compartment was the domain of gynecologists with frequent incursions into the female anterior compartment, and the posterior compartment was reserved for surgeons. In the last few years, a change has occurred in the philosophy underpinning the management of these diseases with the development of an integrative "cross sectional" approach which affects the physiology, physiopathology, and the definition of these diseases as an integrated structure, and which includes urinary and fecal incontinence, pelvic organ prolapse, alterations in the perception of urinary tract emptying, chronic constipation, sexual dysfunctions, and several chronic pain syndromes in the perineal area. We believe that the efforts of the various professionals involved in the treatment of these disorders should be pooled and that pelvic floor units should be created. These units should be characterized by a multidisciplinary approach, since the skills and knowledge necessary for the management of these patients requires teams composed of professionals with a broad range of competencies.

Large bowel obstruction: predictive factors for postoperative mortality.

PURPOSE: The aims of this study were to assess the prognostic value for mortality of several factors in patients with colonic obstruction and to study the differences between proximal and distal obstruction. METHODS: Two-hundred and thirty-four consecutive patients who underwent emergency surgery for colonic obstruction were studied. Patients with an obstructive lesion distal to the splenic flexure were assessed as having a distal colonic obstruction. Resection and primary anastomosis was the operation of choice in selected patients. Alternative procedures were Hartmann's procedure in high-risk patients, subtotal colectomy in cases of associated proximal colonic damage, and colostomy or intestinal bypass in the presence of irresectable lesions. Obstruction was considered proximal when the tumor was situated at the splenic flexure or proximally and a right or extended right colectomy was performed. A range of factors were investigated to estimate the probability of death: gender, age, American Society of Anesthesiologists score, nature of obstruction (benign vs. malign), location of the lesion (proximal vs. distal), associated proximal colonic damage and/or peritonitis, preoperative transfusion, preoperative renal failure, and laboratory data (hematocrit < or = 30 percent, hemoglobin < or = 10 g/dl, and leukocyte count >15,000/mm3). Univariate and multivariate forward steptwise logistic regression analysis was used to study the prognostic value of each significant variable in terms of mortality. RESULTS: One or more complications were detected in 109 patients (46.5 percent). Death occurred in 44 patients (18.8 percent). No differences were observed between proximal and distal obstruction. Age (>70 years), American Society of Anesthesiologists III-IV score, preoperative renal failure, and the presence of proximal colon damage with or without peritonitis were significantly associated with postoperative mortality in the univariate analysis. Only American Society of Anesthesiologists score, presence of proximal colon damage, and preoperative renal failure were significant predictors of outcome in multivariate logistic regression. CONCLUSION: Large bowel obstruction still has a high of mortality rate. An accurate preoperative evaluation of severity factors might allow stratification of patients in terms of their mortality risk and help in the decision-making process for treatment. Such an evaluation would also enable better comparison between studies performed by different authors. Principles and stratification similar to those of distal lesions should be considered in patients with proximal colonic obstruction.