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.

Long-term follow-up of chronic anal fissure (CAF) on diltiazem 2% using a telephone questionnaire. Do results change?

INTRODUCTION: Calcium channel blockers have an excellent effectiveness in the conservative management of chronic anal fissure (CAF). OBJECTIVES: To assess the long-term results of management with diltiazem 2% ointment using a telephone questionnaire. METHODS: A descriptive, retrospective study from March 2004 to March 2011 in patients with CAF on diltiazem 2%, 3 applications daily for 4-6 weeks. Starting at 12 months a questionnaire was administered over the phone by medical staff outside the surgery department to record socio-demographic data, predominant manifestations, and response to diltiazem on a 5-point scale measuring symptom relief (1 = poorest, 5 = best). Patients with therapy failure were referred to surgery. RESULTS: The study was completed for 166 patients with a mean age of 54.1 years. CAF was posterior in 82.3% of subjects. Diltiazem tolerability was excellent with only 4 adverse event cases (3 skin irritation, 1 hypotension). We obtained symptom relief in 62.1% of patients and CAF healing in 51.2%, and referred 33.7% to surgery. The questionnaire showed that 74.1% of patients had used only 2 applications daily, and that results were better with an increased number of applications, albeit without statistical significance. CONCLUSIONS: The telephone questionnaire showed symptom relief for 62% and healing for 51.2% of patients with CAF on diltiazem 2%, which should be considered first-choice for the conservative management of this condition.

Seguimiento a largo plazo de la fisura anal crónica (FAC) tratada con diltiazem 2% mediante un cuestionario telefónico. ¿Cambian los resultados? / Long-term follow-up of chronic anal fissure (CAF) on diltiazem 2% using a telephone questionnaire. Do results change?

INTRODUCCIÓN: los antagonistas del calcio son fármacos con una excelente efectividad en el tratamiento conservador de la fisura anal crónica (FAC). OBJETIVOS: evaluar los resultados a largo plazo del tratamiento con pomada de diltiazem al 2% mediante un cuestionario telefónico. MÉTODOS: estudio descriptivo y retrospectivo desde marzo de 2004 a marzo de 2011 de pacientes con FAC y tratados con diltiazem 2%, 3 aplicaciones diarias, durante 4-6 semanas. A partir de los 12 meses se efectuó un cuestionario telefónico por personal médico ajeno al Servicio de Cirugía recogiendo datos sociodemográficos de los pacientes, sintomatología predominante, respuesta al diltiazem mediante una escala de alivio sintomático del 1 al 5 (1 = muy malo, 5 = muy bueno). Los pacientes con fracaso terapéutico se derivaron a cirugía. RESULTADOS: el estudio se completó en 166 pacientes con una edad media de 54,1 años. La localización de la FAC fue posterior en el 82,3%. La tolerancia al diltiazem fue excelente, con sólo 4 casos de efectos adversos (3 por irritación dérmica y 1 por hipotensión). Obtuvimos un alivio sintomático del 62,1% y curación de la FAC en un 51,2%, remitiendo un 33,7% a cirugía. El cuestionario evidenció que el 74,1% de los pacientes utilizó sólo dos aplicaciones al día y que a mayor número de aplicaciones mejoraban los resultados, sin alcanzar significación estadística. CONCLUSIONES: el cuestionario telefónico evidencia un alivio sintomático del 62% y una curación del 51,2% de la FAC con diltiazem 2% debiendo ser considerada como primera opción en el manejo conservador de la misma

INTRODUCTION: Calcium channel blockers have an excellent effectiveness in the conservative management of chronic anal fissure (CAF). OBJECTIVES: To assess the long-term results of management with diltiazem 2% ointment using a telephone questionnaire. METHODS: A descriptive, retrospective study from March 2004 to March 2011 in patients with CAF on diltiazem 2%, 3 applications daily for 4-6 weeks. Starting at 12 months a questionnaire was administered over the phone by medical staff outside the surgery department to record socio-demographic data, predominant manifestations, and response to diltiazem on a 5-point scale measuring symptom relief (1 = poorest, 5 = best). Patients with therapy failure were referred to surgery. RESULTS: The study was completed for 166 patients with a mean age of 54.1 years. CAF was posterior in 82.3% of subjects. Diltiazem tolerability was excellent with only 4 adverse event cases (3 skin irritation, 1 hypotension). We obtained symptom relief in 62.1% of patients and CAF healing in 51.2%, and referred 33.7% to surgery. The questionnaire showed that 74.1% of patients had used only 2 applications daily, and that results were better with an increased number of applications, albeit without statistical significance. CONCLUSIONS: The telephone questionnaire showed symptom relief for 62% and healing for 51.2% of patients with CAF on diltiazem 2%, which should be considered first-choice for the conservative management of this condition

Linfoma rectal primario: caso clínico y revisión de la literatura médica / Primary rectal lymphoma: Clinical case and a review of the literature

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Evisceración vaginal. Abordaje abdominal y reparación con malla sintética / Vaginal evisceration. Abdominal approach and synthetic mesh repair

La evisceración vaginal espontánea es un fenómeno raro en la práctica clínica diaria. Se han publicado más de 70 casos hasta la actualidad desde que McGregor comunicara el primer caso a comienzos del siglo pasado. La situación ocurre generalmente en pacientes posmenopáusicas con hipoestrogenismo asociado a cirugía ginecológica previa. Recientemente, se ha descrito también en situaciones no ginecológicas tras una proctectomía perineal. Presentamos un nuevo caso de evisceración vaginal espontánea en una mujer posmenopáusica con cirugía ginecológica previa. La reparación se efectuó con malla a través de una laparotomía convencional (AU)

Spontaneous vaginal evisceration is a rare phenomenon in daily clinical practice. Since McGregor reported the first case at the beginning of the past century, more than 70 cases have been reported to date. Spontaneous vaginal evisceration usually occurs in patients with postmenopausal hypoestrogenism associated with previous gynecologic surgery. This entity has recently been described in non-gynecological conditions after perineal proctectomy. We present a new case of spontaneous vaginal evisceration in a postmenopausal woman with previous gynecological surgery. Surgical mesh repair was performed through conventional laparotomy (AU)