Evaluation of the anorectal motor response after percutaneous stimulation of the posterior tibial nerve in patients with fecal incontinence.

BACKGROUND: The effect of posterior tibial nerve stimulation (PTNS) on the mechanisms of anal continence has not been fully demonstrated. The aim of this study was to assess the anal manometric response after percutaneous PTNS in patients with fecal incontinence (FI). METHODS: This was a prospective study in patients with FI undergoing 1 weekly session of percutaneous PTNS for 8 weeks. A clinical assessment (Wexner scale) and a complete study of up to 22 manometric parameters were carried out prior to treatment and 2-4 weeks after the end of treatment. RESULTS: A total of 32 patients were evaluated. After therapy, there was a decrease in the average Wexner score [12.6 (± 5.2) to 9.5 (± 5.2) (P < 0.005)] and an increase in the "anal canal length at rest" [4.55 (± 0.60) to 4.95 (± 0.21) P = 0.004], without observing variations in other manometric parameters. The decrease in the Wexner score was significantly correlated with an increase in the "pressure at 5 cm at rest" after therapy (r = 0.464 P = 0.030). CONCLUSIONS: In our study, PTNS was associated with a significant decrease in the Wexner score and with an increase in the functional length of the anal canal at rest. The improvement in the Wexner scale was correlated with an increase in pressure at rest in the theoretical area of the anorectal junction.

Factors related to lymph node harvest: does a recovery of more than 12 improve the outcome of colorectal cancer?

AIM: The nodal harvest was studied to identify factors that affected the number of lymph nodes (LNs) retrieved in patients undergoing curative surgery for colorectal cancer. The influence of predictive factors on overall and disease-free 5-year survival was analysed. METHOD: All patients diagnosed with colorectal cancer who underwent oncological resection consecutively from January 1996 to December 2011 in a single institution have been studied. Factors influencing LN retrieval were analysed. A logistic regression analysis was performed to determine the factors that predicted a recovery of more than 12 LNs. A Cox regression analysis was made to identify the predictive factors of overall and disease-free 5-year survival. RESULTS: A total of 1166 patients were included in the study. The factors associated with the number of LNs harvested in surgical resections were age, colorectal surgeon, right colectomy, total colectomy, year of surgery, number of LN metastases and lymphocyte response. The factors that predicted a recovery of ≥ 12 LNs were age < 60 years, right colectomy, year of surgery and expert pathologist. A recovery of ≥ 12 LNs did not show significant differences in overall and disease-free 5-year survival, but the factor of colorectal surgeon did. CONCLUSION: Number of LN metastases, lymphocyte response, type of surgical resection, age of patient and colorectal surgeon can predict the LN harvest. Survival in colorectal cancer, however, is probably more influenced by the performance of the operation by an expert surgeon than by recovery of more than 12 LNs.

Long-term results of artificial bowel sphincter for the treatment of severe faecal incontinence. Are they what we hoped for?

OBJECTIVE: This study evaluates the long-term morbidity, functional results and quality of life (QOL) after treatment of severe faecal incontinence (FI) with the Acticon Neosphincter (American Medical Systems, Minneapolis, Minnesota, USA). METHOD: Between 1996 and 2002, 17 consecutive patients (14 female, 3 male; median age 46) underwent sphincter implantation. Clinical evaluation, incontinence severity and QOL were assessed. Anorectal manometry, endoanal ultrasound and pudendal nerve latency were performed preoperatively and at several stages of follow-up. The study was completed in December 2007. RESULTS: Mean follow-up was 68 months (range: 3-133). Morbidity occurred in 100% of patients from which 65% required at least one re-operation. After the first implant, 11 devices had to be removed (65%). Seven patients had a new implant. At the final stage, Acticon was activated in 9 cases (53%). Severity of FI improved from a median of 17.5 preoperatively to 9 (P = 0.005), 5.5 (P = 0.005) and 10 (P = 0.092) at 6, 12 months and at the end of follow-up, respectively. There was a significant improvement in QOL in all postoperative controls (P < 0.05). Severity of FI did not show a correlation with QOL in the preoperative period, but did at 6, 12 months and at the end of follow-up. Mean maximum resting pressure significantly increased with the full anal cuff. CONCLUSION: There is a high rate of morbidity, surgical re-interventions and explants after Acticon implant. Patients should be clearly informed about this before surgery. However, patients who have not had Acticon Neosphincter explanted, experience a significant improvement in anal continence and QOL.

Experience and results on the surgical and medical treatment of ischaemic colitis.

OBJECTIVE: To analyse differences between patients with transient forms of ischemic colitis managed with medical treatment and those developing gangrenous forms subsidiaries of surgical treatment. MATERIAL AND METHODS: Retrospective study (1991-1998) of the ischemic colitis cases occurred in our center separating into two groups according to treatment received (A group: medical, 19 patients; B group: surgical, 10 patients). RESULTS: Hypertension mainly appear in B group being average age higher in this group than in A group (p < 0.05). Other risk factors analysed such as diabetes, cardiovascular disease, renal failure or consume of different drugs appear in similar way in both groups. In A group patients clinical presentation hematochezia is typical while B group use to start with acute abdomen associated to abdominal distension and hyperleukocytosis (p < 0.05). In group B average estance, morbidity and mortality have been higher than in A (17.4 vs 8.6 days 70 vs 5%, 40 vs 0%, respectively). CONCLUSION: Hypertension and advanced age are associated risk factors of gangrenous ischemic colitis. The classic clinical presentation of abdominal pain and hematochezia is typical in transient forms. Patients who need a surgical operation for ischemic colitis have a high morbimortality.

Experiencia y resultados en el tratamiento quirúrgico y conservador de la colitis isquémica / Experience and results on the surgical and medical treatment of ischaemic colitis

Objetivo: analizar las diferencias entre los pacientes con formas transitorias de colitis isquémicas (CI) resueltas con tratamiento médico y aquéllos que desarrollan formas gangrenosas subsidiarias de tratamiento quirúrgico. Material y métodos: se estudian retrospectivamente (19911998) los casos de CI en nuestro centro dividiéndolos en dos grupos según el tratamiento recibido (grupo A: conservador, 19 pacientes; grupo B: quirúrgico, 10 pacientes).Resultados: la hipertensión arterial aparece mayoritariamente en el grupo B siendo en éste la edad media superior respecto al grupo A (p<0,05). Otros factores de riesgo analizados como diabetes, patología cardiovascular, insuficiencia renal o consumo de diversos fármacos aparecen de forma similar en ambos grupos. En la presentación clínica de los pacientes del grupo A es típica la hematoquecia mientras que los del grupo B suelen debutar con abdomen agudo asociado a distensión abdominal y leucocitosis (p<0,05). En el grupo B han sido superiores la estancia media, la morbilidad y la mortalidad respecto al grupo A (17,4 vs 8,6 días, 70 vs 5 por ciento y 40 vs 0 por ciento, respectivamente). Conclusiones: la HTA y la edad avanzada son factores de riesgo asociados a CI gangrenosas. La presentación clínica clásica de dolor abdominal con hematoquecia es típica de las formas transitorias. Los pacientes que requieren intervención quirúrgica por CI tienen una elevada morbimortalidad (AU)

Nuestra experiencia en el tratamiento de los traumatismos anorrectales y sus secuelas / Our experience in the treatment of anorectal trauma and its sequelae

Introducción. El objetivo de este trabajo es describir nuestra experiencia y resultados en el tratamiento de los traumatismos anorrectales accidentales y de sus secuelas. Pacientes y métodos. Se describen el manejo y los resulta dos funcionales de un grupo con 23 casos de traumatismo anorrectal de etiología accidental (grupo I) y otro con 18 casos de secuelas rectoanales postraumáticas (grupo II). Se excluyen iatrogenia y traumatismo obstétrico. Resultados. El tratamiento en las perforaciones rectales extraperitoneales fue principalmente (67 por ciento) sutura primaria, colostomía derivativa, lavado rectal distal y drenaje presacro, y en las intraperitoneales varió según las condiciones locales. La morbilidad fue del 17 por ciento. La lesión esfinteriana fue tratada con sutura primaria en un 82 por ciento de casos. No hubo en este grupo alteraciones tardías de la continencia. El estudio funcional en el grupo II consistió en manometría anorrectal, latencias de nervios pudendos o ecografía endoanal en función del tipo de secuela (incontinencia, fístulas, estenosis), y el tratamiento fue en un 50 por ciento la esfinteroplastia, con resultados funcionales satisfactorios en un 79 por ciento. Conclusiones. El tratamiento de un traumatismo anorrectal debe ser individualizado, pero prevaleciendo las reglas básicas descritas para este tipo de traumatismos (lavado del recto distal, drenaje presacro, etc.). Los estudios funcional y ecográfico esfinterianos son necesarios en la evaluación de las secuelas anorrectales postraumáticas, con la finalidad de realizar un enfoque más correcto de su tratamiento y conseguir mejores resultados (AU)