Incontinencia fecal posparto. Revisión de conjunto / Postpartum incontinence. Narrative review

El desarrollo de incontinencia fecal tras el parto es un hecho frecuente. Esta incontinencia responde a una etiología multifactorial en la que el elemento más frecuente es la lesión del esfínter anal. Existen diversos factores de riesgo, que es muy importante conocer y evitar. La lesión esfinteriana puede producirse por desgarro perineal o en ocasiones por la realización de una episiotomía de forma incorrecta. Es muy importante reconocer la lesión cuando se produce y repararla de forma adecuada. El traumatismo de los nervios pudendos puede incrementar el efecto de las lesiones esfinterianas directas. Es frecuente la persistencia de incontinencia a pesar de la reparación esfinteriana primaria. La esfinteroplastia quirúrgica es el tratamiento estándar de las lesiones esfinterianas obstétricas, sin embargo, las terapias de estimulación eléctrica sacra o tibial están siendo aplicadas en pacientes con lesiones esfinterianas no reparadas, con resultados prometedores

The development of fecal incontinence after childbirth is a common event. This incontinence responds to a multifactorial etiology in which the most common element is external anal sphincter injury. There are several risk factors, and it is very important to know and avoid them. Sphincter injury may result from perineal tear or sometimes by incorrectly performing an episiotomy. It is very important to recognize the injury when it occurs and repair it properly. Pudendal nerve trauma may contribute to the effect of direct sphincter injury. Persistence of incontinence is common, even after sphincter repair. Surgical sphincteroplasty is the standard treatment of obstetric sphincter injuries, however, sacral or tibial electric stimulation therapies are being applied in patients with sphincter injuries not repaired with promising results

[Postpartum incontinence. Narrative review]. / Incontinencia fecal posparto. Revisión de conjunto.

The development of fecal incontinence after childbirth is a common event. This incontinence responds to a multifactorial etiology in which the most common element is external anal sphincter injury. There are several risk factors, and it is very important to know and avoid them. Sphincter injury may result from perineal tear or sometimes by incorrectly performing an episiotomy. It is very important to recognize the injury when it occurs and repair it properly. Pudendal nerve trauma may contribute to the effect of direct sphincter injury. Persistence of incontinence is common, even after sphincter repair. Surgical sphincteroplasty is the standard treatment of obstetric sphincter injuries, however, sacral or tibial electric stimulation therapies are being applied in patients with sphincter injuries not repaired with promising results.

Perianal versus endoanal application of glyceryl trinitrate 0.4% ointment in the treatment of chronic anal fissure: results of a randomized controlled trial. Is this the solution to the headaches?

BACKGROUND: Application of nitroglycerin (glyceryl trinitrate) ointment with perianal administration is a widely used treatment for chronic anal fissure. However, headache occurs after application in 20% to 70% patients and leads to withdrawal in 10% of patients. OBJECTIVE: The aim of the study was to investigate whether endoanal application of the ointment may lower the frequency of headaches without sacrificing effectiveness. compare the effects of perianal versus endoanal administration of nitroglycerin ointment on frequency of headache and rate of healing in the treatment of chronic anal fissure. DESIGN: This was a prospective randomized clinical trial (ClinicalTrial.gov, NCT01132391). SETTINGS AND PATIENTS: Study participants were consecutive patients with a diagnosis of chronic anal fissure treated at a university teaching hospital in Elche, Alicante, Spain. INTERVENTION: Patients were randomly assigned to receive perianal (n = 26) or endoanal (n = 26) administration of 0.4% nitroglycerin ointment (375 mg of ointment containing 1.5 mg of glyceryl trinitrate), applied every 12 hours over an 8-week period. MAIN OUTCOME MEASURES: The primary endpoint of the study was the number of patients with headache within 3 hours after application of the ointment, analyzed with the intention-to-treat principle. Intensity of headache pain was rated on a 10-point visual analog scale. Secondary endpoints included frequencies of fissure healing, anorectal pain, rectal bleeding, pruritus, and incontinence. RESULTS: Headaches were reported in 14 (54%) patients with perianal treatment and in 6 patients (23%) with anorectal treatment (p = 0.003). The median headache pain score was 6 (range, 0-10) in the perianal group and 4.5 (range, 0-10) in the endoanal group (p = 0.03). Disabling headaches led to crossover from perianal to endoanal treatment in 4 patients (15%), and from endoanal to perianal treatment in 1 patient (4%) (p = 0.004). Of the 4 patients who switched from perianal to endoanal treatment, 2 reported improvement in headaches and 2 stopped treatment. The patient who switched from endoanal to perianal treatment also showed no improvement and stopped treatment. The healing rate at 24-week follow-up was 62% (16 patients) with perianal treatment and 77% (20 patients) with endoanal treatment (p < 0.05). LIMITATIONS: Effects on sphincter pressure were not evaluated because manometric measurements were not available. CONCLUSIONS: Endoanal application significantly reduces the frequency of headaches due to treatment with 0.4% nitroglycerin ointment and results in a higher healing rate compared with perianal administration. However, roughly 1 in 4 patients still experiences headaches. Our data suggest that endoanal application may be a better option for treatment of anal fissure with nitroglycerin ointment.

Microbiological spectrum of the intraperitoneal surface after elective right-sided colon cancer: are there differences in the peritoneal contamination after performing a stapled or a handsewn anastomosis?

BACKGROUND: Although colonic surgery is performed with strict aseptic measures, some contamination is nearly impossible to avoid. In stapled anastomosis, the hole opened in the colon is minimum, just necessary for introducing the parts of the mechanical devices. In handsewn anastomosis, the colonic lumen is more exposed to the peritoneum, despite colonic occlusion with clamps while the suture is performed. PATIENTS AND METHODS: A prospective, randomized study was performed between October 2009 and June 2011. Inclusion criteria were a diagnosis of right-sided colon cancer and having undergone an elective surgery with curative aims. The patients were divided into two groups: those patients undergoing a stapled ileocolonic anastomosis (group 1) and those undergoing a handsewn anastomosis (group 2). A microbiological sample was obtained from the peritoneal surface before opening the colon and after finishing the anastomosis in each group. Data were correlated with the wound infection and intra-abdominal infection rates. RESULTS: Eighty-four patients were included in the study: 42 patients in each group. There were two intra-abdominal abscesses (5 %) in each group (NS). Wound infection rate was 10 % in group 1 and 7 % in group 2 (NS). Mean operative time was 98.8 min in the stapled group and 105.2 min in the handsewn one (P = 0.013). Positive cultures were obtained in 79 % of the cases after stapled anastomosis and 73 % after handsewn ones (NS). CONCLUSION: Peritoneal contamination appears in over 70 % of cases after ileocolonic anastomosis. Significant differences in peritoneal contamination, wound infection, and intra-abdominal abscess between stapled and handsewn anastomoses could not be demonstrated.

Effect of peritoneal lavage with clindamycin-gentamicin solution on infections after elective colorectal cancer surgery.

BACKGROUND: Colorectal surgery may lead to infections because despite meticulous aseptic measures, extravasation of microorganisms from the colon lumen is unavoidable. STUDY DESIGN: A prospective, randomized study was performed between January 2010 and December 2010. Patient inclusion criteria were a diagnosis of colorectal neoplasms and plans to undergo an elective curative operation. Patients were divided into 2 groups: Group 1 (intra-abdominal irrigation with normal saline) and Group 2 (intraperitoneal irrigation with a solution of 240 mg gentamicin and 600 mg clindamycin). The occurrence of wound infections and intra-abdominal abscesses were investigated. After the anastomosis, a microbiologic sample of the peritoneal surface was obtained (sample 1). A second sample was collected after irrigation with normal saline (sample 2). Finally, the peritoneal cavity was irrigated with a gentamicin-clindamycin solution and a third sample was obtained (sample 3). RESULTS: There were 103 patients analyzed: 51 in Group 1 and 52 in Group 2. There were no significant differences between the groups in age, sex, comorbidities, or type of colorectal surgery performed. Wound infection rates were 14% in Group 1 and 4% in Group 2 (p = 0.009; odds ratio [OR] 4.94; 95% CI 1.27 to 19.19). Intra-abdominal abscess rates were 6% in Group 1 and 0% in Group 2 (p = 0.014; OR 2.14; 95% CI 1.13 to 3.57). The culture of sample 1 was positive in 68% of the cases, sample 2 was positive in 59%, and sample 3 in 4%. CONCLUSIONS: Antibiotic lavage of the peritoneum is associated with a lower incidence of intra-abdominal abscesses and wound infections.

Association of endothelial function and vascular data with LDL-c and HDL-c in a homogeneous population of middle-aged, healthy military men: Evidence for a critical role of optimal lipid levels.

BACKGROUND: Modifying lipids levels underpins atherosclerosis prevention. Flow-mediated dilation (FMD) could advise which patients to treat and to what extent. Little is known about the influence of near-normal lipid levels on the endothelium and the mechanisms related to different lipid fractions. We studied associations between FMD and lipids, focusing on normal lipid levels. METHODS: An age-homogeneous sample of 171 healthy, untreated military men (mean age 35.5+/-1.1 years) was studied: serum lipid determination and brachial artery ultrasound with a forearm ischemia cuff and automated measurement were performed. NCEP-ATP III groups were used. RESULTS: Significantly smaller vessel diameters were found among individuals with high HDL-c (4.10 mm vs. 4.24 mm), optimal LDL-c (4.00 mm vs. 4.22 mm), and normal triglycerides (<150 mg/dl) (4.15 mm vs. 4.31 mm). Basal diameter correlated significantly with HDL-c and triglycerides. There were significant differences in FMD between low HDL-c compared to the rest (4.13% vs. 5.07%) and between optimal and near-optimal LDL-c compared to the rest (5.28% vs. 4.56%). HDL-c and LDL-c correlated with FMD. The inverse relation of high LDL-c and FMD is partially due to a decreased stimulus. Besides, stimulus heterogeneity may mask HDL-c link with FMD. CONCLUSION: Those subjects naturally (not pharmacologically) in the healthy tail-end of the lipid distributions have the best endothelial function and smaller vessels. Functional vascular remodeling might precede anatomical remodeling and, in early stages, vessel size should be considered a risk indicator rather than an atherosclerotic sign. Furthermore, controlling the stimulus seems necessary for detecting the relationship between HDL-c and FMD, and should be performed regularly.

Detailed exploration of the endothelium: parameterization of flow-mediated dilation through principal component analysis.

Endothelial dysfunction is associated with cardiovascular diseases and their risk factors (CVRF), and flow-mediated dilation (FMD) is increasingly used to explore it. In this test, artery diameter changes after post-ischaemic hyperaemia are classically quantified using maximum peak vasodilation (FMDc). To obtain more detailed descriptors of FMD we applied principal component analysis (PCA) to diameter-time curves (absolute), vasodilation-time curves (relative) and blood-velocity-time curves. Furthermore, combined PCA of vessel size and blood-velocity curves allowed exploring links between flow and dilation. Vessel diameter data for PCA (post-ischaemic: 140 s) were acquired from brachial ultrasound image sequences of 173 healthy male subjects using a computerized technique previously reported by our team based on image registration (Frangi et al 2003 IEEE Trans. Med. Imaging 22 1458). PCA provides a set of axes (called eigenmodes) that captures the underlying variation present in a database of waveforms so that the first few eigenmodes retain most of the variation. These eigenmodes can be used to synthesize each waveform analysed by means of only a few parameters, as well as potentially any signal of the same type derived from tests of new patients. The eigenmodes obtained seemed related to visual features of the waveform of the FMD process. Subsequently, we used eigenmodes to parameterize our data. Most of the main parameters (13 out of 15) correlated with FMDc. Furthermore, not all parameters correlated with the same CVRF tested, that is, serum lipids (i.e., high LDL-c associated with slow vessel return to a baseline, while low HDL-c associated with a lower vasodilation in response to similar velocity stimulus), thus suggesting that this parameterization allows a more detailed and factored description of the process than FMDc.