[A single rectal diclofenac dose reduces post-haemorrhoidectomy urine retention: results of a randomised, controlled clinical study]. / Una sola dosis de diclofenaco intrarrectal reduce la retención urinaria tras la cirugía de las hemorroides. Resultados de un estudio clínico controlado y aleatorizado.

INTRODUCTION: Post-surgical urinary retention requiring a catheter has a mean incidence of 15% (1% to 52%) in the post-operative period after anal surgery. The primary objective of this study was to assess the efficacy of topical rectal Diclofenac in reducing post-surgical haemorrhoidectomy urinary retention. Its impact on the reduced need for post-surgery analgesia has also been assessed as a secondary objective. PATIENTS AND METHOD: The 157 patients intervened for symptomatic haemorrhoids were randomised into two groups: Group with 100 mg diclofenac anal suppository after surgery; and Control group without diclofenac. Haemorrhoidectomy was performed with diathermy, without pedicle ligatures and with hyperbaric spinal anaesthesia. No anal dressings were used and the use of drips was restricted during the post-operative period. Metamizole and diclofenac were used as post-surgical intravenous analgesia in all patients. Meperidine was chosen as rescue analgesia. The descriptive variables evaluated in the patient series were: age, sex, grade and number of haemorrhoid groups, and post-surgical complications. The response variables were: need or not for a urethral catheter, post-surgical pain (Visual Analogue Scale) VAS and rescue analgesia requirements. RESULTS: The 86 males (54.6%) and 71 females (45.4%), with a mean age of 54 years (26-82 years) were randomised into 2 groups: 73 (46.5%) in the diclofenac group and 84 (53.5% in the control group. Of the haemorrhoidectomies performed, 95 were open and 63 were closed. There were no differences as regards the distribution by, age, sex, haemorrhoid grade or in the number of haemorrhoid groups extirpated. Only 1 (1.3%) patient in the diclofenac group and 8 (9.5%) in the control group (p = 0.028) had urine retention. Rescue analgesia was required by 9 (12.3%) patients in the study group compared to 20 (33.3%) in the control group (p = 0.002). The assessment of the magnitude of therapeutic effect of diclofenac gave an RRR of 85.6% (95% CI, 12.3-98.2), RAR, 8.2% (95% CI, 1.3-15) and an NNT of 13 (95% CI, 7-77). CONCLUSIONS: The placing of a 100 mg diclofenac suppository at the end of a haemorrhoidectomy reduces urinary retention and rescue analgesia requirements.

Una sola dosis de diclofenaco intrarrectal reduce la retención urinaria tras la cirugía de las hemorroides. Resultados de un estudio clínico controlado y aleatorizado / A single rectal diclofenac dose reduces post-haemorrhoidectomy urine retention: results of a randomised, controlled clinical study

Introducción. La retención urinaria postoperatoria que precisa de sondaje aparece con una incidencia media del 15% (1-52%) en el postoperatorio de la cirugía anal. El principal objetivo de este trabajo ha sido valorar la eficacia del diclofenaco tópico intrarrectal en la reducción de la retención urinaria tras hemorroidectomía quirúrgica. De forma secundaria, también se ha valorado su impacto en la reducción de las necesidades de analgesia postoperatoria. Pacientes y método. Se aleatorizó en dos grupos a 157 pacientes intervenidos de hemorroides sintomáticas: grupo con supositorio de diclofenaco 100 mg vía anal en el postoperatorio y grupo de control sin diclofenaco. En todos los pacientes se realizó una hemorroidectomía con diatermia, sin ligadura de los pedículos y con anestesia raquídea hiperbárica. No se emplearon apósitos anales y durante el postoperatorio se restringió el empleo de sueros. Se empleó metimazol y diclofenaco como analgesia intravenosa postoperatoria en todos los pacientes. Se eligió la meperidina como analgesia de rescate. Se evaluaron como variables descriptivas de la serie: edad, sexo, grado y número de grupos hemorroidales y complicaciones postoperatorias. Las variables respuesta fueron: necesidad de sondaje vesical, escala analógica visual (EAV) del dolor postoperatorio y necesidades de analgesia de rescate. Resultados. Se aleatorizó a 86 varones (54,6%) y 71 mujeres (45,4%), con media de edad de 54 (26-82) años, en dos grupos: 73 (46,5%) al grupo de diclofenaco y 84 (53,5%) al grupo de control. Se realizaron 95 hemorroidectomías abiertas y 63 cerradas. No hubo diferencias en cuanto a la distribución por edad, sexo, grado hemorroidal y número de grupos hemorroidales extirpados. Presentaron retención urinaria 1 (1,3%) paciente del grupo de diclofenaco y 8 (9,5%) del grupo control (p = 0,028). En el grupo de estudio fue precisa la analgesia de rescate en 9 (12,3%) pacientes, frente a 20 (33,3%) en el grupo control (p = 0,002). La valoración de la magnitud del efecto terapéutico del diclofenaco mostró una RRR del 85,6% (intervalo de confianza [IC] del 95%, 12,3-98,2), RAR de 8,2% (IC del 95%, 1,3-15) y un número de pacientes que es necesario tratar de 13 (IC del 95%, 7-77). Conclusiones. La colocación de un supositorio de diclofenaco 100 mg al final de la hemorroidectomía reduce la retención urinaria y la necesidad de analgesia de rescate The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Introduction. Post-surgical urinary retention requiring a catheter has a mean incidence of 15% (1% to 52%) in the post-operative period after anal surgery. The primary objective of this study was to assess the efficacy of topical rectal Diclofenac in reducing post-surgical haemorrhoidectomy urinary retention. Its impact on the reduced need for post-surgery analgesia has also been assessed as a secondary objective. Patients and method. The 157 patients intervened for symptomatic haemorrhoids were randomised into two groups: Group with 100 mg diclofenac anal suppository after surgery; and Control group without diclofenac. Haemorrhoidectomy was performed with diathermy, without pedicle ligatures and with hyperbaric spinal anaesthesia. No anal dressings were used and the use of drips was restricted during the post-operative period. Metamizole and diclofenac were used as post-surgical intravenous analgesia in all patients. Meperidine was chosen as rescue analgesia. The descriptive variables evaluated in the patient series were: age, sex, grade and number of haemorrhoid groups, and post-surgical complications. The response variables were: need or not for a urethral catheter, post-surgical pain (Visual Analogue Scale) VAS and rescue analgesia requirements. Results. The 86 males (54.6%) and 71 females (45.4%), with a mean age of 54 years (26-82 years) were randomised into 2 groups: 73 (46.5%) in the diclofenac group and 84 (53.5% in the control group. Of the haemorrhoidectomies performed, 95 were open and 63 were closed. There were no differences as regards the distribution by, age, sex, haemorrhoid grade or in the number of haemorrhoid groups extirpated. Only 1 (1.3%) patient in the diclofenac group and 8 (9.5%) in the control group (p = 0.028) had urine retention. Rescue analgesia was required by 9 (12.3%) patients in the study group compared to 20 (33.3%) in the control group (p = 0.002). The assessment of the magnitude of therapeutic effect of diclofenac gave an RRR of 85.6% (95% CI, 12.3-98.2), RAR, 8.2% (95% CI, 1.3-15) and an NNT of 13 (95% CI, 7-77). Conclusions. The placing of a 100 mg diclofenac suppository at the end of a haemorrhoidectomy reduces urinary retention and rescue analgesia requirements The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

La respuesta inicial al diltiazem tópico puede predecir la evolución de la fisura anal crónica / Initial response to topical diltiazem can predict outcome of chronic anal fissure

Introducción. Durante los últimos años, el tratamiento médico de la fisura anal crónica (esfinterotomía química) se ha ido implantando en la práctica como consecuencia de la morbilidad atribuida a la esfinterotomía quirúrgica. Sin embargo, el tratamiento médico presenta dos inconvenientes: la moderada eficacia, entre el 30 y el 80% y la necesidad de prolongarlo más de 8 semanas. Objetivo. Valorar la respuesta inicial a diltiazem al 2% tópico como factor de predicción de la curabilidad de la fisura anal crónica. Pacientes y método. Durante el período de febrero de 2004 a diciembre de 2005, todas las fisuras anales de más de 6 semanas de evolución fueron incluidas. Se excluyó a los pacientes con cirugía anal previa, embarazo, enfermedad inflamatoria intestinal, intolerancia al diltiazem y problemas de contacto para el seguimiento. Se empleó una fórmula magistral de gel de diltiazem al 2%, en 3 aplicaciones diarias durante 8 semanas. Se realizaron controles clínicos y medida del dolor mediante escala analógica visual (EAV) al final de la primera, la tercera, sexta y octava semanas. Se compararon los grupos con y sin respuesta al diltiazem mediante las pruebas de la χ2, exacta de Fisher y t de Student. Se realizó una curva ROC (Receiver Operating Characteristic) para valorar la eficacia diagnóstica de la respuesta inicial del dolor al diltiazem, así como la sensibilidad, la especificidad y los valores predictivos. Resultados. Se analizaron 100 pacientes (70 varones), con una media de edad de 43 (22-76) años. Localización posterior en el 87%, anterior en el 11% y lateral en el 2%. Todos tenían dolor; 65, sangrado y 13, prurito. Al final de las 8 semanas de tratamiento se curó el 62%, con una morbilidad del 5% (cefalea leve en el 2% y prurito en el 3%). No hubo diferencias significativas entre los grupos con y sin respuesta al diltiazem al 2% en relación con la edad, el sexo, la localización, el sangrado o el prurito. Hubo diferencias notables en la EAV del dolor al final de la primera, la tercera, la sexta y la octava semanas entre los grupos con y sin respuesta al tratamiento médico (p = 0,00). Con curvas ROC se estableció un punto de corte de 4 en la EAV al final de la primera semana, con un área bajo la curva de 0,925 (intervalo de confianza [IC] del 95%, 0,858-0,989). La capacidad predictora de curabilidad de la respuesta precoz al diltiazem mostró una sensibilidad del 85,5% (IC del 95%, 74,7-92,2%), una especificidad del 92,1% (IC del 95%, 79,2-97,3%), un valor predictivo positivo del 94,6% (IC del 95%, 85,4-98,2%) y un valor predictivo negativo del 79,5% (IC del 95%, 65,5-88,8%). Al final de la primera semana, tan sólo un 9% de los pacientes que no mejoraron con el diltiazem se curaron a las 8 semanas. Y por el contrario, de los que respondieron bien la primera semana, se curó el 94,6%. Conclusiones. La ausencia de respuesta al diltiazem al 2% tópico al final de la primera semana predice con buena fiabilidad el fracaso del tratamiento médico de la fisura anal crónica, y no es necesario prolongarlo hasta las 8 semanas (AU)

Introduction. In the last few years, the medical treatment of chronic anal fissure (chemical sphincterotomy) has been introduced as a consequence of the morbidity attributed to surgical sphincterotomy. However, medical treatment has two disadvantages: moderate effectiveness (between 30% and 80%) and the need for treatment to be prolonged for more than 8 weeks. Objective. To evaluate initial response to topical diltiazem 2% topical gel as a predictive factor in the curability of chronic anal fissure. Patients and method. From February 2004 to December 200, all patients with a history of anal fissure of more than 6 weeks were included in this study. Pregnant patients and those with prior anal surgery, inflammatory bowel disease, diltiazem intolerance and problems for maintaining contact during follow-up were excluded. A magistral formula of diltiazem 2% gel was used in three applications daily for 8 weeks. Patients were followed-up clinically and pain was measured through a visual analog scale (VAS) at the end of weeks 1, 3, 6, and 8. Groups with and without response to diliazem were compared through the χ2 test, Fisher's exact test and Student's t-test. A Receiver Operating Characteristic (ROC) curve was used to evaluate the diagnostic efficacy of initial pain response to diliazem, as well as sensitivity, specificity and predictive values. Results. One hundred patients (70 men), with a mean age of 43 years (22-76) were analyzed. Localization was posterior in 87%, anterior in 11% and lateral in 2%. All patients had pain, 65 had bleeding, and 13 had pruritus. At the end of the 8-week treatment, cure was achieved in 62%, with morbidity of 5% (mild headache in 2%, and pruritus in 3%). No significant differences were found between the groups with and without response to diltiazem 2% in terms of age, sex, localization, bleeding, or pruritus. Notable differences were found in the VAS for pain at the end of weeks 1, 3, 6, and 8 between the two groups (p = 0.00). ROC curves established a cut-off point of 4 in the VAS at the end of week 1, with an area below the curve of 0.925 (95% CI, 0.858-0.989). The capacity of early response to diliazem to predict curability showed a sensitivity of 85.5% (95% CI, 74.7%-92.2%), a specificity of 92.1% (95% CI, 79.2%-97.3%), a positive predictive value of 94.6% (95% CI, 85.4%-98.2%), and a negative predictive value of 79.5% (95% CI, 65.5%-88.8%). Among patients who showed no response to diltiazem by the end of week 1, cure was achieved in only 9% at 8 weeks. In contrast, among those with a favorable response in the first week, cure was achieved in 94.6%. Conclusions. Lack of response to topical diltiazem 2% gel at the end of the first week reliably predicts failure of medical treatment for chronic anal fissure, obviating the need to prolong treatment for 8 weeks (AU)

Metástasis cutánea perineal de adenocarcinoma tras cirugía de cáncer colorrectal / Perineal cutaneous metastases from adenocarcinoma after surgery for colorectal cancer

La aparición de metástasis cutáneas en el curso del cáncer colorrectal es un hecho excepcional, sobre todo en ausencia de lesiones viscerales. Presentamos el caso de una mujer de 50 años de edad intervenida de una neoplasia de colon sigmoideo T3N0M0, con resección de una metástasis ovárica a los 12 meses. Fue reintervenida tras 14 meses por recidiva local anastomótica. Cuatro meses tras la cirugía, presentaba lesión nodular ulcerada en periné por metástasis de adenocarcinoma. Tras cirugía local agresiva, la paciente fue dada de alta al quinto año. Se plantea la necesidad de un corecto manejo del muñón rectal o anal mediante lavado con povidona yodada durante las anastomosis instrumentales (AU)

The development of cutaneous metastases in the context of colorectal cancer is exceptional, especially in the absence of visceral lesions. We present the case of a 50-year-old woman who underwent surgery for a T3N0M0 tumor in the sigmoid colon, with resection of ovarian metastases at 12 months. Reoperation was performed 14 months later for local anastomotic recurrence. Four months after surgery, a nodular ulcerated lesion was observed in the perineum due to metastases from adenocarcinoma. Aggressive local surgery was performed and the patient has presented no recurrences after a 5-year follow-up. We discuss the need for correct management of the rectal or anal stump (through the use of iodine povidone wash solution) during instrumental anastomoses (AU)

[Initial response to topical diltiazem can predict outcome of chronic anal fissure]. / La respuesta inicial al diltiazem tópico puede predecir la evolución de la fisura anal crónica.

INTRODUCTION: In the last few years, the medical treatment of chronic anal fissure (chemical sphincterotomy) has been introduced as a consequence of the morbidity attributed to surgical sphincterotomy. However, medical treatment has two disadvantages: moderate effectiveness (between 30% and 80%) and the need for treatment to be prolonged for more than 8 weeks. OBJECTIVE: To evaluate initial response to topical diltiazem 2% topical gel as a predictive factor in the curability of chronic anal fissure. PATIENTS AND METHOD: From February 2004 to December 200, all patients with a history of anal fissure of more than 6 weeks were included in this study. Pregnant patients and those with prior anal surgery, inflammatory bowel disease, diltiazem intolerance and problems for maintaining contact during follow-up were excluded. A magistral formula of diltiazem 2% gel was used in three applications daily for 8 weeks. Patients were followed-up clinically and pain was measured through a visual analog scale (VAS) at the end of weeks 1, 3, 6, and 8. Groups with and without response to diliazem were compared through the chi2 test, Fisher's exact test and Student's t-test. A Receiver Operating Characteristic (ROC) curve was used to evaluate the diagnostic efficacy of initial pain response to diliazem, as well as sensitivity, specificity and predictive values. RESULTS: One hundred patients (70 men), with a mean age of 43 years (22-76) were analyzed. Localization was posterior in 87%, anterior in 11% and lateral in 2%. All patients had pain, 65 had bleeding, and 13 had pruritus. At the end of the 8-week treatment, cure was achieved in 62%, with morbidity of 5% (mild headache in 2%, and pruritus in 3%). No significant differences were found between the groups with and without response to diltiazem 2% in terms of age, sex, localization, bleeding, or pruritus. Notable differences were found in the VAS for pain at the end of weeks 1, 3, 6, and 8 between the two groups (p = 0.00). ROC curves established a cut-off point of 4 in the VAS at the end of week 1, with an area below the curve of 0.925 (95% CI, 0.858-0.989). The capacity of early response to diliazem to predict curability showed a sensitivity of 85.5% (95% CI, 74.7%-92.2%), a specificity of 92.1% (95% CI, 79.2%-97.3%), a positive predictive value of 94.6% (95% CI, 85.4%-98.2%), and a negative predictive value of 79.5% (95% CI, 65.5%-88.8%). Among patients who showed no response to diltiazem by the end of week 1, cure was achieved in only 9% at 8 weeks. In contrast, among those with a favorable response in the first week, cure was achieved in 94.6%. CONCLUSIONS: Lack of response to topical diltiazem 2% gel at the end of the first week reliably predicts failure of medical treatment for chronic anal fissure, obviating the need to prolong treatment for 8 weeks.

[Perineal cutaneous metastases from adenocarcinoma after surgery for colorectal cancer]. / Metástasis cutánea perineal de adenocarcinoma tras cirugía de cáncer colorrectal.

The development of cutaneous metastases in the context of colorectal cancer is exceptional, especially in the absence of visceral lesions. We present the case of a 50-year-old woman who underwent surgery for a T3N0M0 tumor in the sigmoid colon, with resection of ovarian metastases at 12 months. Reoperation was performed 14 months later for local anastomotic recurrence. Four months after surgery, a nodular ulcerated lesion was observed in the perineum due to metastases from adenocarcinoma. Aggressive local surgery was performed and the patient has presented no recurrences after a 5-year follow-up. We discuss the need for correct management of the rectal or anal stump (through the use of iodine povidone wash solution) during instrumental anastomoses.

Esofagectomía mínimamente invasiva / Minimally-invasive esophagectomy

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