Fístulas rectoneovaginales en pacientes tras cirugía de reasignación de sexo. Descripción de nuestra experiencia y revisión de la literatura / Rectoneovaginal fistula after sex reassignment surgery. Description of our experience and literature review

La cirugía de reasignación de sexo masculino a femenino o vaginoplastia incluye aquellos procedimientos quirúrgicos cuyo objetivo es recrear un perineo femenino funcional y estéticamente aceptable con una formación mínima de cicatrices. La técnica de elección en nuestro centro es la vaginoplastia con inversión peneana con o sin injertos escrotales. Presentamos 4 casos diagnosticados con fístulas rectoneovaginales tratados en nuestro centro con evolución favorable. La primera paciente fue diagnosticada en el postoperatorio tardío durante las dilataciones. Se sometió a 2 intentos de reparación vaginal sin éxito. Finalmente, se realizó una colostomía temporal y un colgajo rectal. La segunda paciente fue diagnosticada 2 semanas después de la cirugía inicial debido a una dilatación agresiva, siendo tratada con una colostomía temporal y cierre por segunda intención. La tercera paciente se diagnostica en el quinto día postoperatorio, después de la extracción del taponamiento vaginal. Se indicó restricción dietética y se realizó un colgajo rectal. Una cuarta paciente fue diagnosticada durante el postoperatorio tardío, realizando una exploración quirúrgica y un colgajo de pared rectal. Las fístulas rectoneovaginales después de la cirugía de reasignación de sexo tienen una incidencia de alrededor del 2-17%, siendo el tipo más común de fístulas después de este procedimiento. La causa más común es secundaria a lesiones rectales durante la cirugía inicial. Para el manejo de estas fístulas se plantean opciones que van desde el cierre primario a las colostomías de descarga, pasando por un manejo conservador o la confección de colgajos. Se recomienda el abordaje por un equipo multidisciplinario para el diagnóstico y tratamiento de esta complicación. (AU)

Male-to-female reassignment surgery or vaginoplasty includes those surgical procedures that aim to recreate a functional and cosmetically acceptable female perineum with minimal scarring. The technique of choice at our center is penile inversion vaginoplasty with or without scrotal skin grafts. We present 4 cases diagnosed with rectoneovaginal fistulas treated at our center with favorable evolution. The first patient was diagnosed in the late postoperative period during dilation. She underwent 2 failed vaginal repair attempts. Finally, a temporary colostomy and a rectal flap were performed. The second patient was diagnosed 2 weeks after the initial surgery due to aggressive dilation and was treated with a temporary colostomy and secondary wound closure. The third patient was diagnosed on the fifth post-operative day after removal of the vaginal packing. Dietary restriction was indicated, and a rectal flap was performed. A fourth patient was diagnosed within the late postoperative period; she was submitted to surgical exploration and a rectal wall flap was created. Rectoneovaginal fistulas after sex reassignment surgery has an incidence of about 2-17% and they are the most common type of fistula after this procedure. In most cases, it is secondary to rectal injury during the initial surgery. The management of these fistulas ranges from primary closure, diverting colostomies, conservative management, or the performance of flaps. A multidisciplinary team approach is recommended for the diagnosis and treatment of this complication. (AU)

Rectoneovaginal fistula after sex reassignment surgery. Description of our experience and literature review. / Fístulas rectoneovaginales en pacientes tras cirugía de reasignación de sexo. Descripción de nuestra experiencia y revisión de la literatura.

Male-to-female reassignment surgery or vaginoplasty includes those surgical procedures that aim to recreate a functional and cosmetically acceptable female perineum with minimal scarring. The technique of choice at our center is penile inversion vaginoplasty with or without scrotal skin grafts. We present 4 cases diagnosed with rectoneovaginal fistulas treated at our center with favorable evolution. The first patient was diagnosed in the late postoperative period during dilation. She underwent 2 failed vaginal repair attempts. Finally, a temporary colostomy and a rectal flap were performed. The second patient was diagnosed 2 weeks after the initial surgery due to aggressive dilation and was treated with a temporary colostomy and secondary wound closure. The third patient was diagnosed on the fifth post-operative day after removal of the vaginal packing. Dietary restriction was indicated, and a rectal flap was performed. A fourth patient was diagnosed within the late postoperative period; she was submitted to surgical exploration and a rectal wall flap was created. Rectoneovaginal fistulas after sex reassignment surgery has an incidence of about 2-17% and they are the most common type of fistula after this procedure. In most cases, it is secondary to rectal injury during the initial surgery. The management of these fistulas ranges from primary closure, diverting colostomies, conservative management, or the performance of flaps. A multidisciplinary team approach is recommended for the diagnosis and treatment of this complication.

Transanal minimal invasive surgery for rectal lesions: should the defect be closed?

AIM: Transanal minimal invasive surgery (TAMIS) of rectal lesions is increasingly being used, but the technique is not yet standardized. The aims of this study were to evaluate peri-operative complications and long-term functional outcome of the technique and to analyse whether or not the rectal defect needs to be closed. METHOD: Consecutive patients undergoing TAMIS using the SILS port (Covidien) and standard laparoscopic instruments were studied. RESULTS: Seventy-five patients (68% male) of mean age 67 (± 15) years underwent single-port transanal surgery at three different centres for 37 benign lesions and 38 low-risk cancers located at a mean of 6.4 ± 2.3 cm from the anal verge. The median operating time was 77 (25-245) min including a median time for resection of 36 (15-75) min and for closure of the rectal defect of 38 (9-105) min. The defect was closed in 53% using interrupted (75%) or a running suture (25%). Intra-operative complications occurred in six (8%) patients and postoperative morbidity was 19% with only one patient requiring reoperation for Grade IIIb local infection. There was no difference in the incidence of complications whether the rectal defect was closed or left open. Patients were discharged after 3.4 (1-21) days. At a median follow-up of 12.8 (2-29) months, the continence was normal (Vaizey score of 1.5; 0-16). CONCLUSION: Transanal rectal resection can be safely and efficiently performed by means of a SILS port and standard laparoscopic instruments. The rectal defect may be left open and at 1 year continence is not compromised.

Transanal access for rectal tumors: the simultaneous use of a flexible endoscope and SILS.

The authors report that TEM with a single-incision laparoscopic surgery (SILS) port can be facilitated by the use of a colonoscope instead of a conventional laparoscopic camera. The colonoscope can be inserted through one of the SILS channels and has the added benefit of flexibility, insufflation, irrigation, suction, and an operative port.

Tetraparesia como primera manifestación de un carcinoma hepatocelular / No disponible

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Perianal metastases from lobular breast carcinoma.

Breast cancer gastrointestinal and soft tissue metastases are extremely rare. We present the case of a woman with perianal metastases from a primary lobular breast carcinoma 11 years after mastectomy and local radiotherapy.

Perianal metastases from lobular breast carcinoma

Breast cancer gastrointestinal and soft tissue metastases are extremely rare. We present the case of a woman with perianal metastases from a primary lobular breast carcinoma 11 years after mastectomy and local radiotherapy (AU)

Near infrared reflectance spectroscopy as a tool for the control of sheep leather defatting.

The fat content is one of the variables to be controlled by the tanning industry with a view to obtaining leather for various commercial purposes. Ensuring the production of quality leather products frequently entails using some defatting treatment, particularly when the raw skin is rich in natural fat. The official method for determining fat in leather, IUC 4, is rather slow; also, it uses polluting reagents and involves powdering samples for Soxhlet extraction with low-polarity solvents. The combination of NIR diffuse reflectance spectroscopy as implemented with a fibre-optic probe and multivariate calibration is probably the best choice for the direct determination of fat in leather and the monitoring of leather defatting. In this work, a method for the determination of fat in leather and the control of the defatting process in an expeditious manner and with no sample treatment was developed. Defatting tests were conducted on leather specimens from lambs of various breeds and origins in order to span as wide as possible a range of variability in their properties and natural fat content. The NIR spectra used to construct the calibration matrices were recorded directly on the leather samples prior to and after defatting. Fat contents were determined by partial least-squares regression (PLSR), using the values obtained with the official method as references. Notwithstanding the complex nature of leather, the calibration models used provided good external predictions: the largest overall relative error, obtained by using a single calibration matrix for natural and defatted specimens, was 10%. The proposed method is therefore an advantageous alternative to the official method.

Systematic review of laparoscopic versus open surgery for colorectal cancer.

BACKGROUND: This study compares the efficacy and safety of laparoscopic surgery (LS) and open surgery (OS) for colorectal cancer. METHODS: An electronic search of the literature was undertaken to identify primary studies and systematic reviews. Information on the efficacy and safety of LS versus OS was analysed. A meta-analysis was conducted to examine long-term outcomes. RESULTS: A systematic review published in 2000 and 12 more recent randomized clinical trials were identified. Compared with OS, LS reduced blood loss and pain, and resulted in a faster return of bowel function and earlier resumption of normal diet. Hospital stay was up to 2 days shorter after LS. No significant differences between the techniques were noted in the incidence of complications or postoperative mortality. The time required to complete LS was significantly longer (0.5-1.0 h more). No significant differences were found between the two procedures in terms of overall mortality, cancer-related mortality or disease recurrence. CONCLUSION: LS takes longer than OS but offers several short-term benefits. However, complication rates are similar for both procedures and no differences were found in long-term outcomes.

Prognostic value of the quantified expression of p185 in non-small cell lung cancer.

BACKGROUND: We sought to assess the relationship between tissue concentration of erb -b-2 or neu oncogene-encoded protein (p185(neu)) with overall survival in patients with non-small cell lung cancer. METHODS: Levels of protein p185(neu) were determined in 102 patients with the diagnosis of non-small cell lung cancer. Concentration of p185(neu) protein was determined by using enzyme immunoassay and evaluated by using several variables. The relative prognostic importance of this marker and its influence on other prognostic factors was evaluated by using the Cox regression model. RESULTS: The mean p185(neu) value in these samples was 250 +/- 200 U/mg (95% confidence interval, 210-290). This distinguished two groups within the tumoral population: those with less than 350 U/mg and those with 350 U/mg or greater (80th percentile). Multivariable analysis established an independent prognostic value for protein p185(neu). Patients with p185(neu) values of the 80th percentile or greater had a risk of death that was 2.11-fold (95% confidence interval, 1.10-4.05) that of patients with values of less than 350 U/mg (P =.03), and increases in the neu oncogene of 100 U/mg increased the probability of death by 17% (P =.02; 95% confidence interval, 1.04-1.31). CONCLUSION: This study shows that the p185(neu) expression is an objective and comparable variable for the assessment of phenotypic aggressivity in non-small cell lung cancer, and in the future, it could be included in daily clinical practice.

Rotura intramural espontánea de la pared esofágica. Una entidad poco frecuente / Spontaneous rupture of the esophageal wall. A rare entity

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Use of possible synergistic expression of p53 and p185 as a prognostic tool for stage I non-small-cell lung cancer.

The possible interaction between the quantified overexpression of the oncoproteins p53 and p185 was evaluated. These proteins have already been independently defined as prognostic factors in non-small-cell lung cancer (NSCLC). p53 and p185 levels were determined in stage I patients (n = 40) from a sample of 102 NSCLC sufferers who underwent surgery for precocious disease during the period October 1991 to June 1994. The resected tumors were histologically classified and included 15 adenocarcinomas (37.5%), 1 large-cell carcinoma (2.5%), and 24 epidermoid (60%) carcinomas. The p53 concentration of tumor specimens was determined by luminescence immunoanalysis and was defined as positive if it was above the minimum value detectable by the method (0.01 ng/mg). The p185 protein was quantified by enzyme-linked immunoassay, and the 80th percentile of the frequency distribution was used as the reference cutoff value (348.8 U/mg). Survival and disease-free-survival (DFS) rates were estimated at 24 months after intervention. There were no significant differences in survival or DFS of patients with adenocarcinoma-type tumors for subjects with independent p185 values < 348.8 U/mg and those showing values >/= 348.8 U/mg. Neither were there differences observed between patients with positive and negative p53 values. In patients with epidermoid-type tumors the cumulative survival was significantly higher in p53-negative than in p53-positive patients (p = 0.03) and was also higher in patients with p185 levels < 348.8 U/mg than in those with values >/= 348.8 U/mg (p = 0.00001). These patients showed no significant differences with respect to recurrence rate. The possible synergistic behavior of p53 and p185 levels as a prognostic factor was evaluated in patients with epidermoid-type tumors. p53-negative and p53-positive patients were grouped according to a p185 level of less than or more than 348.8 U/mg. Significant differences were seen in both survival rates and DFS between groups. Individual analysis of relative risks showed an increased risk of death and greater recurrence rate in patients with p185 levels >/= 348.8 U/mg and a greater recurrence rate in patients with p53-positive values. Multivariate analysis established that the multiplicative, synergistic, prognostic effect of p53 and p185 was not significant. The existence of a significant, synergistic, prognostic effect of the p185 and p53 proteins in NSCLC could not be proven. However, a greater prognostic potential of the quantified overexpression of p185 with respect to that of p53 was established. An additive effect in the prognostic potential of both proteins was also observed (stratified analysis).

Palliative treatment of esophageal cancer: self-expanding metal stents versus Postlethwait technique.

BACKGROUND/AIMS: The development of new techniques for palliation of esophageal carcinoma with lower morbidity and mortality than surgical procedures. METHODOLOGY: Between 1981 and 1994, 258 patients with esophageal and cardiac cancer were treated in our Department. We selected two groups: Group A, 25 patients underwent a by-pass with an isoperistaltic gastric tubular (Postlethwait technique) and, group B, in 30 patients we placed 35 autoexpandable esophageal stents. We subsequently performed a retrospective study. RESULTS: In group A, dysphagia was not relieved in 6 patients (24%) and we found no complications in 18 patients (72%). The hospitalization period ranged from 18-50 days. Hospital mortality rate was 24% (6 patients). Mean survival was 5.4 months (range: 3-9 months). All patients in group B, except for 2, were relieved of dysphagia. Two patients (6.6%) died in the immediate post-intubation period though none of the deaths were related to technical complications. Hospitalization period ranged from 5-12 days. Mean survival was 6 months (range: 12 days to 9 months). CONCLUSIONS: Currently, surgical by-pass procedures are restricted to the patient with an incurable disease not identified until operation time.