Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico / Stoma reversal after surgery for complicated acute diverticulitis: A multicentre retrospective study

INTRODUCCIÓN: El objetivo del estudio es analizar la tasa de reconstrucción del estoma tras cirugía por diverticulitis aguda complicada (DAC), su demora, factibilidad, complicaciones y factores de riesgo de mantenerlo. MÉTODOS: Estudio retrospectivo multicéntrico de pacientes intervenidos mediante cirugía urgente por DAC con realización de un estoma en 10 hospitales durante 6 años. Se analiza la frecuencia de reconstrucción del estoma, fundamentalmente de los terminales, y el tiempo en que se produce, así como los factores relacionados con ella. RESULTADOS: De 385 pacientes intervenidos por DAC, a 312 (81%) se les realizó un estoma: 292 fueron colostomías terminales y 20 estomas derivativos. Durante el seguimiento, en 161 (51,6%), se intentó el cierre a una mediana de 9 meses. Las causas más frecuentes de no efectuarlo fueron la comorbilidad y el fallecimiento del paciente. La edad más avanzada se mostró factor adverso en el análisis multivariante y la tasa actuarial de reconstrucción fue mayor en hombres y en quienes no se realizó un Hartmann. La cirugía pudo completarse en todos menos en un paciente y en 4 se asoció un estoma derivativo. La morbimortalidad fue del 35,7 y 1,9%, respectivamente. Hubo un 8,4% de reintervenciones y un 6% de fallos de sutura, quedando 12 pacientes (7,9%) con un estoma tras el intento de reconstrucción. CONCLUSIONES: La cirugía de la DAC se asocia muy frecuentemente a la construcción de un estoma terminal, que en casi un 50% no se reconstruirá. Además, la intervención de reconstrucción tiene una demora notable y está asociada a una morbimortalidad nada despreciable

INTRODUCTION: The aim was to analyse the stoma reversal rate after surgery for complicated acute diverticulitis (CAD), and more specifically the end-stoma-reversal, as well as the delay, feasibility, complications and risk factors for stoma maintenance. METHODS: A multicentre retrospective study of patients who had undergone urgent surgery for CAD with stoma formation in ten hospitals during a period of 6 years. The frequency of reversal over time and the factors affecting the decision for reversal were analysed. RESULTS: Out of 385 patients operated for CAD, 312 underwent stoma creation: 292 end colostomies and 20 diverting stomas. During follow-up, stoma reversal surgery was performed in 161 patients (51.6%) after a median of 9 months. The main causes for not performing stoma reversal were comorbidities and the death of the patient. Advanced age was an adverse factor in the multivariate analysis, and the actuarial rate of reversal was higher in men and in patients with no previous Hartmann's operation. Stoma reversal surgery was completed in all but one patient, and a loop ileostomy was associated in four. Morbidity and mortality rates were 35.7% and 1.9%, respectively. A total of 8.4% of patients underwent re-operation, and 6% experienced an anastomotic leak. Twelve patients remained with a stoma after the attempted reconstruction surgery. CONCLUSIONS: Surgery for CAD is frequently associated with an end stoma, which will ultimately not be reversed in almost 50% of patients. Moreover, reversal surgery is frequently delayed and is associated with significant morbidity and mortality

Stoma reversal after surgery for complicated acute diverticulitis: A multicentre retrospective study. / Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico.

INTRODUCTION THE AIM: was to analyse the stoma reversal rate after surgery for complicated acute diverticulitis (CAD), and more specifically the end-stoma-reversal, as well as the delay, feasibility, complications and risk factors for stoma maintenance. METHODS: A multicentre retrospective study of patients who had undergone urgent surgery for CAD with stoma formation in ten hospitals during a period of 6 years. The frequency of reversal over time and the factors affecting the decision for reversal were analysed. RESULTS: Out of 385 patients operated for CAD, 312 underwent stoma creation: 292 end colostomies and 20 diverting stomas. During follow-up, stoma reversal surgery was performed in 161 patients (51.6%) after a median of 9 months. The main causes for not performing stoma reversal were comorbidities and the death of the patient. Advanced age was an adverse factor in the multivariate analysis, and the actuarial rate of reversal was higher in men and in patients with no previous Hartmann's operation. Stoma reversal surgery was completed in all but one patient, and a loop ileostomy was associated in four. Morbidity and mortality rates were 35.7% and 1.9%, respectively. A total of 8.4% of patients underwent re-operation, and 6% experienced an anastomotic leak. Twelve patients remained with a stoma after the attempted reconstruction surgery. CONCLUSIONS: Surgery for CAD is frequently associated with an end stoma, which will ultimately not be reversed in almost 50% of patients. Moreover, reversal surgery is frequently delayed and is associated with significant morbidity and mortality.

[Differential diagnosis and management of intramuscular myxomas: A review of our experience]. / Diagnóstico diferencial y manejo de mixomas intramusculares: revisión de nuestra experiencia.

BACKGROUND: Intramuscular myxoma is a rare benign soft tissue tumour of mesenchymal origin, which appears as a painless mass of slow growth. Early diagnosis is important in order to differentiate it from other entities, especially soft tissue sarcoma. CLINICAL CASES: Two cases, both women with a mean age of 52.5 years (range 40-65) are presented. The first was seen due to growth of a gluteal mass, and the second by coccydynia. Computed tomography and nuclear magnetic resonance were the diagnostic tests of choice. In one case, where there was a single but large lesion, radical extirpation of the gluteal muscle was chosen. In the other case, in which the lesions were multiple, individualised excision of cysts was performed. Postoperative functional limitation was low in both types of surgery, with good oncological results being obtained. CONCLUSION: Intramuscular myxomas are benign lesions. There are no cases of malignancy or recurrence due to incomplete resection. It has to be determined whether they are single or multiple, since in the latter case, they could be due to syndromes such as Mazabraud syndrome, which is associated with bone fibrous dysplasia, or Albright syndrome that is also associated with pigmented skin spots.

Melanoma anal, importancia del diagnóstico diferencial con la enfermedad anal benigna / Anal melanoma, the importance of differential diagnosis with benign anal pathology

El melanoma anorrectal, descrito inicialmente por Moore en 1857, es un tumor infrecuente y agresivo, cuyo pronóstico suele ser infausto, con una supervivencia a los cinco años menor de 20 %. La principal importancia de este tumor radica en que suele presentarse como una tumoración anorrectal o producir sangrado, o rectorragia, por lo que el diagnóstico diferencial con la enfermedad anal benigna resulta crucial, pues el pronóstico estará condicionado por el estadio en el momento del diagnóstico. Se presenta el caso de una mujer de 70 años que consultó por sangrado rectal y cuyo diagnóstico inicial fue de trombosis hemorroidal. Tras el diagnóstico de melanoma anorrectal y el estudio de extensión negativo para metástasis, se practicó una amputación abdóminoperineal según la técnica de Miles. Tras nueve años de seguimiento, la paciente se encuentra libre de enfermedad

Anorectal melanoma was first described by Moore in 1857. Is an uncommon and aggresive tumor, with inauspicious prognosis. Five-year survival rates are less than 20%. The main important feature of this tumor is that it usually manifests as a rectal tumor or rectal bleeding; therefore, a diferential diagnosis with benign anal conditions is of utmost importance. Prognosis is conditioned by tumor stage at diagnosis. We present a 70-year-old woman with rectal bleeding with an initial diagnosis of hemorrhoidal trombosis. With the diagnosis of rectal melanoma without distant metastasis, an abdominoperineal resection (Miles operation) was performed. After 9-years follow-up, she is disease free

Tratamiento quirúrgico de la diverticulitis aguda. Estudio retrospectivo multicéntrico / Surgical treatment of acute diverticulitis. A retrospective multicentre study

INTRODUCCIÓN: Se pretende analizar los resultados a corto y medio plazo de diferentes técnicas quirúrgicas en el tratamiento de la diverticulitis aguda complicada (DAC). MÉTODOS: Estudio retrospectivo y multicéntrico de pacientes operados de urgencia o de urgencia diferida por DAC. RESULTADOS: Estudiamos a 385 pacientes: 218 hombres y 167 mujeres, de edad media 64,4 ± 15,6 años, intervenidos en 10 hospitales. La mediana (25-758 percentiles) de evolución desde el inicio de los síntomas hasta la cirugía fue de 48 h(24-72), y su indicación más frecuente, un cuadro peritonítico (66%). El abordaje fue generalmente abierto (95,1%) y los hallazgos más comunes, peritonitis purulenta (34,8%) o absceso pericólico (28,6%). La técnica más habitual fue el procedimiento de Hartmann (PHT) en 278 (72,2%), seguida de resección y anastomosis primaria (RAP) en 69 (17,9%). Se complicaron 205 pacientes (53,2%) y fallecieron 50 (13%). Edad avanzada, inmunodepresión, factores de riesgo quirúrgico y peritonitis fecal se asociaron a mayor mortalidad. El lavado peritoneal laparoscópico (LPL) tuvo elevada tasa de reintervenciones, implicando frecuentemente un estoma, y la RAP se complicó con dehiscencia de sutura en el 13,7% de pacientes, sin diferencias en la morbimortalidad al compararla con el PHT. La mediana de estancia postoperatoria fue de 12 días; su mayor duración se relacionó con la mayor edad, riesgo quirúrgico ASA, hospital y complicaciones postoperatorias. CONCLUSIONES: La cirugía por DAC tiene importante morbimortalidad y se asocia frecuentemente a un estoma terminal. Además, el LPL presenta alta tasa de reintervenciones. LA RAP, aun asociando un estoma de protección, parece de elección en muchos casos

INTRODUCTION: To analyze short and medium-term results of different surgical techniques in the treatment of complicated acute diverticulitis (CAD). METHODS: Multicentre retrospective study including patients operated on as surgical emergency or deferred-urgency with the diagnosis of CAD. RESULTS: A series of 385 patients: 218 men and 167 women, mean age 64.4 ± 15.6 years, operated on in 10 hospitals were included. The median (25th-75th percentile) time from symptoms to surgery was 48 (24-72) h, being peritonitis the main surgical indication in a 66% of cases. Surgical approach was usually open (95.1%), and the commonest findings, a purulent peritonitis (34.8%) or pericolonic abscess (28.6%). Hartmann procedure (HP) was the most used technique in 278 (72.2%) patients, followed by resection and primary anastomosis (RPA) in 69 (17.9%). The overall postoperative morbidity and mortality was 53.2% and 13% respectively. Age, immunosupression, presence of general risk factors and faecal peritonitis were associated with increased mortality. Laparoscopic peritoneal lavage (LPL) was associated with an increased reoperation rate frequently involving a stoma, and anastomotic leaks presented in 13.7 patients after RPA, without differences in morbimortality when compared with HP. Median postoperative length of stay was 12 days, and was correlated with age, surgical risk, ASA score, hospital and postoperative complications. CONCLUSIONS: Surgery for CAD has important morbidity and mortality and is frequently associated with an end-stoma. Moreover LPL presented high reoperation rates. It seems better to resect and anastomose in most cases, even with an associated protective stoma

Surgical treatment of acute diverticulitis. A retrospective multicentre study. / Tratamiento quirúrgico de la diverticulitis aguda. Estudio retrospectivo multicéntrico.

INTRODUCTION: To analyze short and medium-term results of different surgical techniques in the treatment of complicated acute diverticulitis (CAD). METHODS: Multicentre retrospective study including patients operated on as surgical emergency or deferred-urgency with the diagnosis of CAD. RESULTS: A series of 385 patients: 218 men and 167 women, mean age 64.4±15.6 years, operated on in 10 hospitals were included. The median (25th-75th percentile) time from symptoms to surgery was 48 (24-72) h, being peritonitis the main surgical indication in a 66% of cases. Surgical approach was usually open (95.1%), and the commonest findings, a purulent peritonitis (34.8%) or pericolonic abscess (28.6%). Hartmann procedure (HP) was the most used technique in 278 (72.2%) patients, followed by resection and primary anastomosis (RPA) in 69 (17.9%). The overall postoperative morbidity and mortality was 53.2% and 13% respectively. Age, immunosupression, presence of general risk factors and faecal peritonitis were associated with increased mortality. Laparoscopic peritoneal lavage (LPL) was associated with an increased reoperation rate frequently involving a stoma, and anastomotic leaks presented in 13.7 patients after RPA, without differences in morbimortality when compared with HP. Median postoperative length of stay was 12 days, and was correlated with age, surgical risk, ASA score, hospital and postoperative complications. CONCLUSIONS: Surgery for CAD has important morbidity and mortality and is frequently associated with an end-stoma. Moreover LPL presented high reoperation rates. It seems better to resect and anastomose in most cases, even with an associated protective stoma.

Prospective Randomized Study Comparing a Single-Cuff Self-Locating Catheter with a Single-Cuff Straight Tenckhoff Catheter in Peritoneal Dialysis.

UNLABELLED: ♦ OBJECTIVES: Peritoneal dialysis (PD) catheters are critical to the success of the technique. However, few studies provide evidence about which design helps to reduce complications. Self-locating catheters (SLCs) are used to avoid displacement of the catheter tip. The incidence of mechanical and infectious complications and catheter survival rate were assessed in Tenckhoff PD catheters. ♦ DESIGN: The prospective randomized study compared drainage problems in 40 incident PD patients using a single-cuff SLCs and 38 patients using a single-cuff, straight Tenckhoff catheter (TC). ♦ RESULTS: No significant differences were observed in the number of complications in the Pre period (from the insertion of the catheter to the start of the technique); however, the number of complications was lower in the SLC group during Post (p = 0.021) and Total period (p = 0.048). The number of problems related to catheter malfunction for each period: Pre, Post, and Total, was significantly lower with SLCs vs TCs (p = 0.018, p = 0.001 and p = 0.003, respectively). Problems were solved more easily with SLCs, using laxatives, with less need for fluoroscopic placement and no need for surgical replacement, as opposed to the TC group: Pre (not significant), Post (p = 0.007), and Total (p = 0.011).Median survival was 39.6 months (30.9 - 48.3) for SLCs and 30.1 months (22.6 - 37.5) for TCs, which is not a significant difference. However, SLCs have a higher malposition-free survival rate. Multivariate logistic regression models only included the variable "type of catheter" as a predictor of malfunction during the Pre period (odds ratio [OR] = 4.154). The Post period included the variables, "type of catheter" (OR = 7.701) and "age" (OR = 1.047), and the Total period only included the variable "type of catheter" (OR = 4.487), which indicates an increased probability of malfunction with the use of TCs vs SLCs. The variables (gender, previous intra-abdominal surgery, body mass index (BMI) and diabetes mellitus) did not add predictive value to the models (p > 0.05). ♦ CONCLUSION: The study confirms the hypothesis that TCs have more malfunctions and a lower malposition-free survival rate than SLCs, and TCs are considered as the highest risk factor for malfunction during all study periods.

[Functional recovery of Oddi's sphincter after balloon dilatation of the papilla of Vater. An experimental study in rabbits]. / Recuperación funcional del esfínter de Oddi tras dilatación con balón de la papila de Vater. Estudio experimental en conejos.

INTRODUCTION: Balloon dilatation of the papilla of Vater is used to treat biliary lithiasis. The results and complications rate of this technique are excellent. Published data indicate that this procedure does not significantly alter the physiology of the sphincter of Oddi and that normal function is maintained. Papillary balloon dilatation would therefore provide an advantage over other techniques in which sphincteric function is abolished. The objective of this study was to evaluate the functional status of the sphincter of Oddi after balloon dilatation of the papilla of Vater. MATERIAL AND METHODS: Twenty-four New Zealand albino rabbits were used. All animals underwent laparotomy and duodenotomy with balloon dilatation of the papilla of Vater. Manometric study of the biliary tract and of the sphincter of Oddi was also performed before, shortly after, and 21 days after dilatation. Biliary and sphincter of Oddi pressures and phasic activity of the sphincter (frequency, amplitude and duration of waves) were used as measuring variables for each of the stages of the experiment. RESULTS: Papillary balloon dilatation immediately provoked substantial sphincter relaxation. Comparison of the values of basal biliary and sphincter of Oddi pressures with those found 21 days after dilatation showed no statistically significant differences. No significant differences were found when the variables related to phasic activity of the sphincter (frequency, amplitude and duration) were compared between the distinct phases of the experiment. CONCLUSIONS: The results of the present study suggest complete recovery of sphincter function 21 days after balloon dilatation.

Recuperación funcional del esfínter de Oddi tras dilatación con balón de la papila de Vater. Estudio experimental en conejos / Functional recovery of Oddi’s sphincter after balloon dilatation of the papilla of Vater. An experimental study in rabbits

Introducción. La dilatación con balón de la papila de Vater es utilizada para el tratamiento de la ocupación litiásica de la vía biliar con resultados e índice de complicaciones buenos. Los datos publicados apuntan a que tras esta técnica la fisiología del esfínter de Oddi podría verse poco alterada tendiendo a una función normal. Este hecho aportaría una ventaja en relación con otras técnicas utilizadas en las que el mecanismo esfinteriano queda destruido y su función, abolida. El objetivo del estudio es valorar el estado funcional del esfínter tras realizar la técnica de dilatación con balón de la papila de Vater. Material y métodos. Se usaron 24 conejos de raza neozelandés albino que fueron sometidos, tras laparotomía y duodenotomía, a una dilatación con balón de la papila de Vater. Se realizó un estudio manométrico biliar y del esfínter de Oddi previo a la dilatación, inmediatamente después de ésta y a los 21 días. Se analizaron como variables los valores de presión de la vía biliar y el esfínter, así como los valores de las variables de actividad fásica del esfínter (frecuencia, duración y amplitud de las ondas de presión). Resultados. La dilatación con balón de la papila produjo de forma inmediata una relajación importante del esfínter. La comparación de los valores de presión intrabiliar y del esfínter de Oddi basales con los encontrados a los 21 días posdilatación no ha mostrado diferencias significativas. Tampoco se han encontrado diferencias al comparar las variables de actividad fásica del esfínter (frecuencia, duración y amplitud de ondas) entre una y otra fase del experimento. Conclusiones. Los resultados de nuestro trabajo sugieren la recuperación total de la función del esfínter tras ser sometido a una dilatación con balón después de un período de 21 días (AU)

Introduction. Balloon dilatation of the papilla of Vater is used to treat biliary lithiasis. The results and complications rate of this technique are excellent. Published data indicate that this procedure does not significantly alter the physiology of the sphincter of Oddi and that normal function is maintained. Papillary balloon dilatation would therefore provide an advantage over other techniques in which sphincteric function is abolished. The objective of this study was to evaluate the functional status of the sphincter of Oddi after balloon dilatation of the papilla of Vater. Material and methods. Twenty-four New Zealand albino rabbits were used. All animals underwent laparotomy and duodenotomy with balloon dilatation of the papilla of Vater. Manometric study of the biliary tract and of the sphincter of Oddi was also performed before, shortly after, and 21 days after dilatation. Biliary and sphincter of Oddi pressures and phasic activity of the sphincter (frequency, amplitude and duration of waves) were used as measuring variables for each of the stages of the experiment. Results. Papillary balloon dilatation immediately provoked substantial sphincter relaxation. Comparison of the values of basal biliary and sphincter of Oddi pressures with those found 21 days after dilatation showed no statistically significant differences. No significant differences were found when the variables related to phasic activity of the sphincter (frequency, amplitude and duration) were compared between the distinct phases of the experiment. Conclusions. The results of the present study suggest complete recovery of sphincter function 21 days after balloon dilatation (AU)

Trombosis venosa profunda como manifestación clínica inicial de un aneurisma de la arteria femoral común / Deep vein thrombosis as the initial clinical symptom of an aneurysm in the common femoral artery

Introducción. Los aneurismas femorales, junto con los de localización poplítea, constituyen el grupo de aneurismas periféricos más frecuentes (80%). La compresión de estructuras vecinas por efecto masa es frecuente, pero rara vez tiene lugar la aparición de una trombosis venosa profunda como manifestación inicial. Caso clínico. Varón de 55 años que ingresó de urgencias por presentar cuadro clínico compatible con trombosis venosa profunda de miembro inferior izquierdo. Como antecedentes personales refería hipertensión arterial y obesidad mórbida. En la exploración física presentaba edema de toda la extremidad, pulsos femoral y poplíteo presentes; los distales eran difíciles de valorar. El estudio eco-Doppler puso de manifiesto la presencia de un aneurisma en la arteria femoral común y la trombosis del sector venoso femoroilíaco. El paciente sufrió un cuadro de isquemia arterial distal aguda, por lo que se le intervino de urgencia; se realizaron una aneurismectomía e interposición de prótesis iliofemoral con anastomosis terminoterminal

INTRODUCTION. Femoral, together with popliteal, aneurysms constitute the most frequent group of peripheral aneurysms (80%). The compression of neighbouring structures due to the mass effect is frequent, but deep vein thrombosis rarely appears as the initial symptom. CASE REPORT. A 55-year-old male who was urgently admitted to hospital with a clinical picture that was compatible with deep vein thrombosis in the left lower limb. His personal history included arterial hypertension and morbid obesity. The physical examination revealed oedema of the entire extremity, femoral and popliteal pulses were present, but the distal pulses were difficult to evaluate. A Doppler ultrasound recording showed the presence of an aneurysm in the common femoral artery and thrombosis of the femoral-iliac vein segment. The patient suffered symptoms of acute distal arterial ischaemia, and had to be submitted to an emergency surgical intervention involving an aneurysmectomy and placement of an iliofemoral graft with end-to-end anastomosis

Peritonitis por quiste mesentérico / Peritonitis due to a mesenteric cyst

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