A randomized trial comparing transanal irrigation and percutaneous tibial nerve stimulation in the management of low anterior resection syndrome.

AIM: To assess the effectiveness of transanal irrigation (TAI) compared with posterior tibial nerve stimulation (PTNS) in severe and chronic low anterior resection syndrome (LARS). METHOD: A two-group parallel, open-label randomized controlled trial carried out in a single university hospital. The study population included patients with a LARS scale score of more than 29 points who had undergone rectal surgery more than 1 year previously. These were randomly allocated, with a central randomization system, following a 1:1 sequence to TAI or PTNS. The main study outcome was to achieve a reduction of at least one LARS grade in at least 50% of the patients, for each intervention. RESULTS: A total of 27 patients (TAI = 13, PTNS = 14) were randomized. Both groups were similar with regard to confounding factors. Four patients were excluded because of intercurrent disease or early dropout, leaving 23 (TAI, n = 10; PTNS, n = 13) for analysis. Eight out of 10 and 4 out of 13 patients were downgraded with TAI and PTNS, respectively. The median LARS score decreased from 35 [interquartile range (IQR) 32-39] to 12 (IQR 12-26) (P = 0.021) for the TAI group and from 35 (IQR 34-37) to 30 (IQR 25-33) (P = 0.045) for the PTNS group. The Vaizey score fell from 15 (IQR 11-18) to 6 (IQR 4-7) (P = 0.037) and from 14 (IQR 13-17) to 9 (IQR 7-10) (P = 0.007) with TAI and PTNS, respectively, with 80% and 38% of patients, respectively, showing decreases of more than 50%. Improvement in quality of life was observed in both groups. CONCLUSION: Both treatments improved the LARS score in this study but this was only significant in the TAI group.

Non-inferiority multicenter prospective randomized controlled study of rectal cancer T2-T3s (superficial) N0, M0 undergoing neoadjuvant treatment and local excision (TEM) vs total mesorectal excision (TME).

PURPOSE: The standard treatment of rectal adenocarcinoma is total mesorectal excision (TME), in many cases requires a temporary or permanent stoma. TME is associated with high morbidity and genitourinary alterations. Transanal endoscopic microsurgery (TEM) allows access to tumors up to 20 cm from the anal verge, achieves minimal postoperative morbidity and mortality rates, and does not require an ostomy. The treatment of T2, N0, and M0 cancers remains controversial. Preoperative chemoradiotherapy (CRT) in association with TEM reduces local recurrence and increases survival. The TAU-TEM study aims to demonstrate the non-inferiority of the oncological outcomes and the improvement in morbidity and quality of life achieved with TEM compared with TME. METHODS: Prospective, multicenter, randomized controlled non-inferiority trial includes patients with rectal adenocarcinoma less than 10 cm from the anal verge and up to 4 cm in size, staged as T2 or T3-superficial N0-M0. Patients will be randomized to two areas: CRT plus TEM or radical surgery (TME). Postoperative morbidity and mortality will be recorded and patients will complete the quality of life questionnaires before the start of treatment, after CRT in the CRT/TEM arm, and 6 months after surgery in both arms. The estimated sample size for the study is 173 patients. Patients will attend follow-up controls for local and systemic relapse. CONCLUSIONS: This study aims to demonstrate the preservation of the rectum after preoperative CRT and TEM in rectal cancer stages T2-3s, N0, M0 and to determine the ability of this strategy to avoid the need for radical surgery (TME). TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01308190. Número de registro del Comité de Etica e Investigación Clínica (CEIC) del Hospital universitario Parc Taulí: TAU-TEM-2009-01.

A clinical-physiological comparative study in dogs with ileoanal pouch anastomosis with and without single and doublé myotomy

Background: Some of the variability in functional results after reconstructive proctocolectomy (RP) may be explained by the excessive intrinsic motility of the ileum and ileoanal pouches. The effect of performing a single or double myotomy on several functional variables after RP was the aim of this prospective, randomized and single blinded experimental study in beagle dogs . Materials and Methods: 33 beagle dogs were randomized in three groups: Group I (12 dogs), a standard RP with a 10 cm ileal J-pouch-anal anastomosis was performed; Group II (10 dogs), a longitudinal myotomy of 8 cm on the wall of the pouch was added to the RP; Group III (11 dogs), same as group II with a further 10 cm longitudinal myotomy in the afferent prepouch ileum loop. Variables studied were daytime and night-time number and characteristics of the stools, as well as their changes over the study period, the intestinal transit time, measured in minutes, and the compliance and capacity of the pouches. Results: No difference in morbidity between groups was found. Mean nocturnal stools were statistically significant lower in groups II and III. Although we observed a trend for lower daytime stool frequency, more percentage of soft-hard stools over the study period, longer intestinal transit time and larger reservoirs in group II, none of these variables reached statistical significant differences. Conclusions. Although the myotomies do not increase the morbidity of the RP, there is no clear clinical evidence of their effectiveness in providing better functional outcomes. Performing two myotomies is not better than only one. Our study do not support a hypothetic use of myotomies for patients with functional failure after a RP

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Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus.

BACKGROUND: There are different open healing and primary closure approaches for chronic pilonidal sinus (CPD) that differ in principles and extension. AIMS: To compare the results of different closure surgical techniques, we performed a meta-analysis of randomized controlled trials (RCT) comparing: (1) open wide excision versus open limited excision (sinusectomy) or unroofing (sinotomy); (2) midline closure (conventional and tension-free) versus off-midline; (3) advancing versus rotation flaps; and (4) sinusectomy/sinotomy versus primary closure. METHODS: Data extraction and risk of bias assessment were conducted independently by the authors using the Cochrane Collaboration's tool. Data were pooled using fixed and random-effects models. Primary outcomes were rate of healing, recurrence, wound infection and dehiscence. Twenty-five trials (2,949 patients) were included. RESULTS: Four trials compared limited versus radical open healing. Although recurrence rate did not differ, all other outcomes favored the limited approach. Ten studies compared midline versus off-midline primary closure; wound infection and dehiscence were significantly higher after midline closure. Six RCT compared Karydakis/Bascom versus Limberg. No difference was found in recurrence or wound complications rate. Six RCT compared sinusectomy/sinotomy versus primary closure. Recurrence rate was significantly lower after sinusectomy/sinotomy; no significant differences were found in other outcomes. CONCLUSION: Our meta-analysis suggest that some of the questions of which is the best surgical technique for CPD have now been answered: open radical excision and primary midline closure should be abandoned. Sinusotomy/sinectomy or en bloc resection with off midline primary closure are the preferred approaches.

Intrapelvic placement of a breast implant to allow deferred ileoanal pouch anastomosis after emergency proctocolectomy.

Restoration of intestinal continuity at a second stage after emergency total proctocolectomy may be difficult or hazardous due to the pelvic cavity being closed off. We present a way of keeping the pelvic cavity open and accessible following total proctocolectomy by insertion of a breast implant that hinders fibrosis and prevents intestinal loops from occupying the space. A 275 ml silicone breast implant was placed in the pelvic cavity after total proctocolectomy and closure of the rectal stump. Three months after the initial surgery, the breast implant had kept the pelvic cavity open, facilitating identification of the rectal stump and creation of an ileoanal J-pouch at this second stage. The use of a breast implant to fill the pelvic cavity may facilitate restoration of intestinal continuity in second-stage surgery and thereby decrease the number of associated complications.

Survival after lung metastasectomy for colorectal cancer: importance of previous liver metastasis as a prognostic factor.

AIMS: To analyse patient survival after the resection of lung metastases from colorectal carcinoma and specifically to verify whether presence of liver metastasis prior to lung metastasectomy affects survival. METHODS: All patients who, between 1998 and 2008, underwent lung metastasectomy due to colorectal cancer were included in the study. Kaplan-Meier survival analysis was performed with the log-rank test and Cox regression multivariate analysis. RESULTS: During this period, 101 metastasectomies were performed on 84 patients. The median age of patients was 65.4 years, and 60% of patients were male. The 30-day mortality rate was 2%, and incidence of complications was 7%. The overall survival was 72 months, with 3-and 5-year survival rates of 70% and 54%, respectively. A total of 17 patients (20%) had previously undergone resection of liver metastasis. No significant differences were found in the distribution of what were supposed to be the main variables between patients with and without previous hepatic metastases. Multivariate analysis identified the following statistically significant factors affecting survival: previous liver metastasectomy (p = 0.03), tumour-infiltrated pulmonary lymph nodes (p = 0.04), disease-free interval ≥ 48 months (p = 0.03), and presence of more than one lung metastasis (p < 0.01). In patients with previous liver metastasis, the shorter the time between primary colorectal surgery and the hepatectomy, the lower the survival rate after pulmonary metastasectomy (p = 0.048). CONCLUSIONS: A previous history of liver metastasis shortens survival after lung metastasectomy. The time between hepatic resection and lung metastasectomy does not affect survival; however, patients with synchronous liver metastasis and colorectal neoplasia have poorer survival rates than those with metachronous disease.

¿Se puede mejorar el postoperatorio de la hemorroidectomía? Estudio comparativo del dispositivo Ligasure® frente a la hemorroidectomía con diatermia / Can posthemorrhoidectomy pain be improved? Ligasure® vs diathermy hemorrhoidectomy

Introducción. La hemorroidectomía es una técnica de uso frecuente y con una importante morbilidad, fundamentalmente en forma de dolor postoperatorio.El presente trabajo tiene el objetivo de comparar, en términos de dolor postoperatorio, un nuevo tipo de hemorroidectomía mediante el empleo del sellador de vasos Ligasure®.Pacientes y métodos. Cincuenta pacientes consecutivos intervenidos de hemorroides grados II, III y IV fueron aleatorizados en 2 grupos: en 24 pacientes se realizó una hemorroidectomía abierta con Ligasure®y en 26, como grupo control, una hemorroidectomía con diatermia. Se valoró el dolor postoperatorio mediante escala analógica visual en el primer, tercer y séptimo días, en la tercera semana y en el tercer mes.Un investigador independiente realizó una encuesta de satisfacción al final del estudio.Resultados. Treinta y tres mujeres (66 por ciento) y 17 varones (34 por ciento) con una edad media de 54 años fueron intervenidos de hemorroides: 24 con el dispositivo Ligasure® y 26 con técnica de diatermia. La distribución por grados fue de 4 pacientes con grado II, 28 con grado III y 18 con grado IV. El número de paquetes intervenidos fue de un paquete en 2 pacientes, dos en 7 pacientes, tres en 39 y cuatro en 2. No se detectaron diferencias entre los grupos en relación con la edad (p = 0,724), el sexo (p = 0,556), el grado hemorroidal (p = 0,39), el número de paquetes (p = 0,25), el tiempo de intervención (p = 0,122), la escala analógica visual al primer, tercer y séptimo días postoperatorios (p = 0,850, 0,595 y 0,969, respectivamente), el tacto rectal a la tercera semana y el tercer mes (p = 0,931) así como el número y el tipo de complicaciones.Conclusiones. En nuestra experiencia, en términos de dolor postoperatorio, no hay diferencias entre la cirugía hemorroidal con diatermia y el empleo del Ligasure® (AU)

Meckel's diverticulum adenocarcinoma: a rare malignant degeneration.

The case of a 40 year old male that, after the etiological study performed due to rectorrhages that was the only symptom he presented, was referred to an exploratory laparotomy. A disseminated adenocarcinoma arising in Meckels diverticulum was detected and palliative segmentary resection of the small bowel was performed. The lack of previous symptoms lead to the dissemination of the disease and to the impossibility of curative surgical resection of the tumor.

Reparación de las fístulas vaginales rádicas mediante cierre e interposición de tejido bulbocavernoso (Técnica de Martius) / Radical vaginal fistula repair involving closure and interposition of bulbocavernous tissue (the Martius technique)

Introducción. Se describe el tratamiento de la fístula vaginal rádica mediante la interposición de tejido bulbocavernoso (técnica de Martius).Pacientes y métodos. Desde 1990 hasta 1998 se han intervenido 6 pacientes (5 fístulas rectovaginales y una vesicovaginal), en 4 casos la enfermedad inicial fue cáncer de cérvix, en uno un cáncer de endometrio y en otro un adenocarcinoma de recto medio. En 4 pacientes, la aparición de la fístula fue espontánea, y en el resto inducida tras manipulación instrumental. En todos los casos, antes de la reparación quirúrgica se realizó detección de enfermedad tumoral recurrente o persistente mediante biopsias y estudio de extensión, y colostomía derivativa previa durante al menos 6 meses. En 5 casos se realizó interposición de tejido bulbocavernoso excepto en uno en el que se realizó una modificación de la técnica original mediante autoinjerto pediculado miocutáneo. Resultados. Todas las fístulas cerraron y permanecen cerradas tras un seguimiento medio de 34 meses. En 3 fístulas con más de 4 años de seguimiento no se han observado recurrencias tardías. Todas las pacientes con fístulas rectovagina les permanecen libres de enfermedad tumoral. La paciente con fístula vesicovaginal también curó, aunque falleció a los 14 meses por progresión metastásica de su enfermedad. Entre las complicaciones locales destacan 2 hematomas bulbares y una infección de herida quirúrgica. Conclusiones. La técnica de Martius es una excelente solución para pacientes bien seleccionadas con fístulas vaginales de origen actínico, con una mínima morbilidad y escasas secuelas posquirúrgicas (AU)

Implicaciones de la coexistencia de hidrosadenitis supurativa y enfermedad de Crohn perianal / Implications of the coexistence of suppurative hidrosadenitis and perianal Crohn's disease

La hidrosadenitis supurativa perianal puede asemejarse a las lesiones anales de la enfermedad de Crohn. La coexistencia de una hidrosadenitis perianal y una enfermedad de Crohn puede ser más frecuente de lo que se cree. Así mismo, la existencia de esta enfermedad dual puede complicar el diagnóstico y el tratamiento de los enfermos en los que ocurre: los pacientes con una enfermedad de Crohn perianal diagnosticados como una hidrosadenitis supurativa pueden recibir un tratamiento quirúrgico agresivo innecesario o bien, como en el caso que presentamos, el no reconocimiento de una hidrosadenitis supurativa en un paciente con enfermedad de Crohn puede conducir a retrasar la cirugía o a aplicar una medicación in adecuada y potencialmente de riesgo. Presentamos a un paciente con enfermedad de Crohn y lesiones perianales de una hidrosadenitis supurativa tratado con buen resultado mediante escisión amplia y cierre por primera intención con colgajos bilaterales de traslación (AU)

The value of Hughes-Cardiff classification in the management of perianal Crohn's disease.

PURPOSE: The aim of this study was to assess the value of Hughes' pathogenic classification in the prognosis and management of perianal Crohn's disease (CD). PATIENTS AND METHODS: This classification differentiates between purely inflammatory lesions and their mechanical or septic complications, and defines the presence of ulceration (U), fistula (F) and stricture (S), which are assigned a score of 0, 1 or 2 according to the severity and associated conditions, proximal intestinal involvement and disease activity (A, P and D). Of a series of 96 patients with CD, 12 underwent 16 procedures involving anesthesia to treat symptomatic anal lesions. Patients presenting with severe pain were explored and treated by surgical drainage or, in cases in which there was no demonstrable sepsis, by gentle dilation or infiltration with steroids. For superficial, non-specific fistulas, conventional fistulotomy was performed, and long-term seton drainage was implanted for complex fistulas. Strictures were treated by gentle dilation. Uncontrolled sepsis or proctocolitis was managed by proximal stoma creation or proctocolectomy. RESULTS: The association of cavitating ulcers (U2) and contiguous active rectal involvement (P1) was a contraindication for rectal preservation, making proctectomy or stoma creation the most feasible therapeutic option. The etiology of most, but not all, complex fistulas (F2) was the progressive cavitation of U2, whilst F1 was either of cryptoglandular origin or the result of epithelialized fissures (U1). The treatment was also adjusted to this association, and it was confirmed that most of the severe lesions (F2) and S2) were secondary to U2. CONCLUSIONS: Hughes' pathogenic classification: 1) makes it possible to set up an easily stored registry of anal and perianal Crohn's disease; 2) identifies predefined lesions, allowing the individualization of therapeutic procedures and the comparison of results, and 3) provides prognostic information.

Medical factors in the morbidity and mortality associated with emergency colorectal cancer surgery.

OBJECTIVE: To review the results of the analysis and quantification of the influence of medical factors on the morbidity and mortality associated with emergency surgery for colorectal cancer. PATIENTS AND METHODS: We analyze retrospectively the data for 51 patients who underwent emergency surgery: 34 (67%) to treat acute obstruction and 17 (33%) for perforation. The median follow-up period was 18.5 months (3 to 62 months). RESULTS: The main tumor was located in the right colon in 13 patients (25%), in the left colon in 35 (69%) and in, the rectum in 3 (6%). Primary resection was performed in 94% of the patients: without anastomosis in 35% (18 of 51) and with primary anastomosis in 59% (30 of 51); 6% of the tumors were not resectable. The postoperative morbidity was 41%: 29% (10 of 34) occurring in obstructions and 65% (11 of 17) in perforations. The mortality rate was 14% (9% and 23%, respectively). There were statistically significant associations between mortality and the American Society of Anesthesia grading (p < 0.01) and between both the mortality and morbidity and the score for the acute physiology component of APACHE II (p = 0.01, respectively) and the total APACHE II score (p < 0.01 in both cases). The rate of actuarial disease-free survival was 26% at 36 months. Overall survival was 15% at 62 months. A recurrence rate of 48% (14 of 29) has been recorded. CONCLUSIONS: Emergency surgery for colorectal cancer is associated with a high postoperative morbidity and mortality rate, which correlate with the medical status and, particularly, with the acute physiology score of the APACHE II risk stratification system.

[Hepatocellular carcinoma as an incidental hepatic finding: approach to incidental focal hepatic lesions]. / Carcinoma hepatocelular como incidentaloma hepático: actitud frente a la lesión focal hepática incidental.

Nowadays incidental focal hepatic lesions are detected rather frequently by abdominal imaging. A 12 cm diameter liver mass was incidentally found in an abdominal ultrasound in a 26 years old man. Despite an extensive diagnostic workup, the diagnosis of hepatocellular carcinoma could only be attained through the histological study of the surgical specimen. Differential diagnosis of a focal hepatic lesion is reviewed. Radiological assessment and biopsy procedures should follow a protocol. Where doubt exists about the presence of malignancy after fulfilling the diagnostic protocol we believe that it is justified to remove the lesion. This policy allowed to treat successfully our patient. Hepatocellular carcinoma in noncirrhotic occurs much less frequently than in cirrhotic liver, and moreover, it is specially rare to find at such a young age a non fibrolamellar hepatocarcinoma non associated with cirrhosis or a chronic viral infection. Diagnosis, treatment and prognosis of hepatocellular carcinoma are reviewed.

Traumatic anal incontinence. Role of unilateral gluteus maximus transposition supplementing and supporting direct anal sphincteroplasty.

PURPOSE: This study was designed to describe the surgical technique and discuss the possible beneficial role of unilateral gluteus maximus transposition supplementing and supporting a tensile-direct anal sphincteroplasty. METHODS: Based on our experience with bilateral gluteus transposition, direct apposition of the remaining muscular ends combined with unilateral gluteus transposition (to avoid the tendency of the sphincter ends to separate) was undertaken in two patients with severe destruction of more than half of the anal muscular ring. RESULTS: Both postoperative courses were uneventful. Three months after colostomy closure, both patients were classified as Pescatori's B1. CONCLUSION: As with any other combined surgical technique, the benefit derived may be attributed entirely to one of the procedures, but it is our impression that the gluteus transposition was worthwhile in achieving satisfactory repair.