Esfinteroplastia anatómica mediante reconstrucción combinada del esfínter anal interno y externo en el tratamiento quirúrgico de la incontinencia anal / Anatomic sphincteroplasty with combined reconstruction of internal and external anal muscles in the anal incontinence surgical treatment

Los estudios que evalúan la efectividad de la esfinteroplastia clásica muestran una mejoría de alrededor del 75% a corto plazo, constatándose un deterioro en el tiempo con resultados satisfactorios a largo plazo de alrededor del 50%. Tras introducir la realización de la reparación por separado del esfínter anal interno y el externo, se publicaron tasas de éxito del 80%, observando que estos resultados se mantenían a largo plazo. Pensamos que la introducción de modificaciones en la técnica quirúrgica desde una mentalidad anatómica y reconstructiva, que hemos denominado «esfinteroplastia anatómica mediante reconstrucción combinada de esfínter anal interno y externo», puede obtener muy buenos resultados clínicos y manométricos en el seguimiento a corto y medio plazo. Asimismo, el aumento de longitud de la barrera presiva generada por la técnica puede colaborar a que estos resultados se mantengan más estables a lo largo del tiempo que con la técnica clásica (AU)

Several groups studying the results of the classic sphincteroplasty show improvement of 75% of patients treated in a short-term follow-up, with a worsening of this data in the long-term follow-up down to an improvement of 50% of the patients. Some other groups published more optimistic results, showing an 80% success rate without any deterioration of the technique over time after introducing a separate repair of the internal and external muscles. We think that the introduction of some modifications in the classic technique, named “anatomic sphincteroplasty with combined reconstruction of external and internal anal sphincter muscles” may obtain very good clinical and anorectal manometric results both in a short and mid-term follow-up. In addition, increasing the pressive length in the anal canal may contribute to maintain more stable results over time (AU)

Magnetic resonance defecography versus videodefecography in the study of obstructed defecation syndrome: Is videodefecography still the test of choice after 50 years?

BACKGROUND: The aim of the present study was to evaluate the diagnostic accuracy of magnetic resonance (MR) defecography and compare it with videodefecography in the evaluation of obstructed defecation syndrome. METHODS: This was a prospective cohort test accuracy study conducted at one major tertiary referral center on patients with a diagnosis of obstructed defecation syndrome who were referred to the colorectal surgery clinic in a consecutive series from 2009 to 2012. All patients underwent a clinical examination, videodefecography, and MR defecography in the supine position. We analyzed diagnostic accuracy for MR defecography and performed an agreement analysis using Cohen's kappa index (κ) for each diagnostic imaging examination performed with videodefecography and MR defecography. RESULTS: We included 40 patients with Rome III diagnostic criteria of obstructed defecation syndrome. The degree of agreement between the two tests was as follows: almost perfect for anismus (κ = 0.88) and rectal prolapse (κ = 0.83), substantial for enterocele (κ = 0.80) and rectocele grade III (κ = 0.65), moderate for intussusception (κ = 0.50) and rectocele grade II (κ = 0.49), and slight for rectocele grade I (κ = 0.30) and excessive perineal descent (κ = 0.22). Eighteen cystoceles and 11 colpoceles were diagnosed only by MR defecography. Most patients (54%) stated that videodefecography was the more uncomfortable test. CONCLUSIONS: MR defecography could become the imaging test of choice for evaluating obstructed defecation syndrome.

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.

Rotura espontánea de aneurisma de la arteria esplénica / Spontaneous rupture of an aneurysm in the splenic artery

Introducción. Los aneurismas de la arteria esplénica son lesiones vasculares infrecuentes, aunque representanel 60% de todos los aneurismas viscerales. Suelen ser clínicamente asintomáticos, pero en caso de rotura espontánease manifiestan como un cuadro de abdomen agudo y shock, requiriendo un diagnóstico temprano y una actitud quirúrgicainmediata. Caso clínico. Varón de 64 años de edad con una rotura de un aneurisma de la arteria esplénica que precisóintervención quirúrgica urgente con su resección y esplenectomía

Introduction. Aneurysms in the splenic artery are rare vascular lesions, although they account for 60% of allvisceral aneurysms. They are usually clinically asymptomatic, but when spontaneous rupture occurs they manifest in theform of acute symptoms in the abdomen and shock, and therefore require an early diagnosis and immediate surgicalintervention. Case report. A 64-year-old male with a ruptured aneurysm in the splenic artery that required urgent surgeryto excise it and a splenectomy

Evidencia de la alimentación enteral precoz en la cirugía colorrectal / No disponible

los pacientes intervenidos de cirugía colorrectal, incluso en muchasocasiones estos pacientes se mantienen con sonda nasogástricaen el postoperatorio, con el supuesto de prevenir complicacionescomo la dehiscencia, evisceración o eventración.Realizamos una revisión de la evidencia clínica sobre el empleode sonda nasogástrica y alimentación precoz consultando las basesdel PubMed, Embase y la Cochrane.Encontramos evidencia Ia, Ib a partir de meta-análisis y estudiosrandomizados prospectivos donde se desaconseja el uso sistemáticode la sonda de descompresión gástrica y se recomienda elinicio de una alimentación precoz en la cirugía colorrectal. La dietaabsoluta no aporta ningún beneficio después de una cirugíagastrointestinal y con la sonda nasogástrica no disminuyen lascomplicaciones postoperatorias. Sin embargo, una cirugía menosinvasiva y los avances en la anestesia y analgesia contribuyen a reducirel íleo postoperatorio

There is much variability regarding time to start of enteral nutritionin patients undergoing colorectal surgery. In many instancessuch patients are postoperatively maintained with nasogastricintubation with the aim of preventing complications suchas dehiscence, evisceration or eventration.We examine the clinical evidence regarding nasogastric tubeplacement and early feeding with reference to the PubMed, Embase,and Cochrane databases.Ia and Ib evidence was obtained from meta-analyses andprospective randomized studies, where the systematic use of agastric decompression catheter is advised against and initiation ofearly feeding for colorectal surgery is recommended. Fasting doesnot provide any benefit after gastrointestinal surgery, and the useof nasogastric tubes does not decrease postoperative complications.However, less invasive surgery and new advances in anesthesiaand analgesia are contributing to a reduction in postoperativeileus (AU)

The effect of surgery on quality of life in patients with faecal incontinence of obstetric origin.

OBJECTIVE: To evaluate the results of surgery in the treatment of faecal incontinence of obstetric origin and assess the effect of treatment on the quality of life of these patients. PATIENTS AND METHODS: A consecutive series of 43 patients, who had undergone surgery for severe faecal incontinence of obstetric aetiology between March 1990 and March 2004, was studied. The following studies were carried out: clinical evaluation, anorectal manometry, anal endosonography (from 1996 on) and measurement of the pudendal nerve terminal motor latency. The degree of incontinence, both preoperative and at the end of follow-up was evaluated using the Cleveland Clinic Score (CCS). Quality of life assessment was made using the Fecal Incontinence Quality of Life Scale (FIQL). RESULTS: The study was completed on 35 (87%) of the 43 patients. The mean age in the series was 53 years, (range 28-73). After an average follow-up of 50.4 months (range 4-132) the mean CCS had reduced significantly, passing from 16 (range 8-20) to 6 (range 0-18; P < 0.001). Pudendal neuropathy was found to be a factor of poor prognosis. The results of the quality of life questionnaire at the end of follow-up were: lifestyle 3.5 (SD 0.65), coping/behaviour 3.1 (SD 0.81), depression/self perception 3.7 (SD 0.75) and embarrassment 3.3 (SD 0.91). There is a statistically significant linear relationship between incontinence measured on the CCS and quality of life. For the 14 patients undergoing surgery since the publication of the FIQL questionnaire, it was possible to complete the questionnaire preoperatively, with significant improvement found on each of the four scales (lifestyle 1.7 vs 3.5; coping/behaviour 1.4 vs 3.2; depression 2.2 vs 3.8; embarrassment 1.8 vs 3.2; P < 0.001). CONCLUSION: Surgical treatment of faecal incontinence of obstetric origin achieves good results in a high percentage of patients and has a positive effect on their quality of life. The existence of prolonged preoperative pudendal nerve motor latency indicates a poor prognosis.

[Evidence of early oral feeding in colorectal surgery]. / Evidencia de la alimentación enteral precoz en la cirugía colorrectal.

There is much variability regarding time to start of enteral nutrition in patients undergoing colorectal surgery. In many instances such patients are postoperatively maintained with nasogastric intubation with the aim of preventing complications such as dehiscence, evisceration or eventration. We examine the clinical evidence regarding nasogastric tube placement and early feeding with reference to the PubMed, Embase, and Cochrane databases.Ia and Ib evidence was obtained from meta-analyses and prospective randomized studies, where the systematic use of a gastric decompression catheter is advised against and initiation of early feeding for colorectal surgery is recommended. Fasting does not provide any benefit after gastrointestinal surgery, and the use of nasogastric tubes does not decrease postoperative complications. However, less invasive surgery and new advances in anesthesia and analgesia are contributing to a reduction in postoperative ileus.

Controversias en el tratamiento quirúrgico del tumor carcinoide rectal / Controversy in the surgical treatment of the rectal carcinoid tumor

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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)

Carcinoma insular de tiroides / Insular thyroid cancer

Se presenta un nuevo caso de carcinoma insular de tiroides. Este término fue descrito por Carcangiu et al( 1) en 1984 para definir un tipo histológico de tumores pobremente diferenciados, y desde entonces se han publicado menos de un centenar de casos. Se trata de una paciente que consulta por sintomatología compresiva causada por una masa mediastínica, que durante la intervención se evidencia un lóbulo tiroideo izquierdo tumoral íntimamente adherido a estructuras vecinas, que resultó ser un carcinoma insular de tiroides. Tras la tiroidectomía total, la paciente ha recibido tratamiento con I131, y se halla asíntomática tras un año de segumiento. Se analiza el proceso diagnóstico y terapeútico y se lleva a cabo un diagnóstico diferencial con otros tumores tiroideos, poniéndose de manifiesto la rareza del caso y la necesidad de diagnóstico para realizar un tratamiento correcto y un exhaustivo seguimiento en este tipo de tumores, dada la agresividad y el mal pronóstico del mismo comparado con los tumores diferenciados de tiroides (AU)

Comentario / Commentary

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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)

[Insular thyroid carcinoma]. / Carcinoma insular de tiroides.

A new case of insular carcinoma of the thyroid gland is presented. It was described by Carcangiu et al(1) in 1984 as a poorly differentiated carcinoma, less of one hundred cases were published after its description. We report a case of a patient who was referred for compressive symptoms caused by a mediastinal mass. It was found a tumor of left thyroid lobe strongly adherent to adjacent structures, which was informed as a poorly differentiated insular carcinoma. She underwent total thyroidectomy and posterior treatment with an ablative dose of 1311. She is currently free of disease after one year of follow-up. The diagnosis, treatment, differential diagnosis with another thyroid carcinomas and the rarety of this type of tumors are analyzed. The importance of a correct diagnosis is fundamental in order to carry out an aggressive treatment and a more exhaustive follow-up in these patients, taken account its behavior and its poor prognosis when compared with well-differentiated carcinomas.

[The mucosal electrosensitivity of the anal canal following restorative proctocolectomy for ulcerative colitis]. / Electrosensibilidad mucosa del canal anal tras proctocolectomía restauradora por colitis ulcerosa.

The aim of this study was to investigate the mucosal electrosensitivity of the anus in 23 patients following restorative proctocolectomy for ulcerative colitis. In 16 cases mechanical anastomosis was performed 2 cm above the pectineal line conserving the transitional anal mucosa and in 7 cases distal rectal mucosectomy and manual anastomosis was performed to the pectineal line. In these patients and in those of the control group of 21 patients without previous anorectal disease, the threshold of sensitivity of the lower, middle and upper anus segment was determined. A clinical questionnaire was made in the patients with ileoanal reservoir to evaluate the existence of alterations in continence, and in the capacity to discriminate between gases and stools. The sensitivity thresholds obtained were significantly higher than those in the control group. A significantly greater sensitivity threshold (p = 0.01) was found in the upper anus segment in patients with mucosectomy (median 18.5 mA) with respect to the patients with mechanical anastomosis (median 11 mA). A significantly greater threshold was also observed (p = 0.03) globally in the patients with some alteration in continence (median 15 mA; 57.1% mucosectomy and 18.8% mechanical anastomosis) with respect to completely continent patients (median 11 mA). The results demonstrate the importance of conserving the transitional anal mucosa during surgery with the aim of improving the functional results during the follow of the functioning ileoanal reservoir.