Laparoscopic treatment for appendicitis during pregnancy: Retrospective cohort study.

BACKGROUND: Acute appendicitis is the most frequent non-obstetric surgical emergency during pregnancy. The benefits of laparoscopy during pregnancy are well known, but complications can occur, and these can affect both the mother and/or the foetus.We present results of laparoscopic surgical treatment of acute appendicitis in pregnant women, analysing the occurrence of adverse postoperative, obstetric and foetal outcomes and reviewing literature. MATERIALS AND METHODS: Retrospective observational study on pregnant women with a preoperative diagnosis of acute appendicitis. RESULTS: n = 63, mean age 28.4 years, average gestational age of 17.7 weeks (3-30 weeks). 6.4 % exploratory laparoscopies, 92 % laparoscopic appendectomies and one right colectomy were performed. Conversion rate was 3.2 %. When symptoms begun within 48 hours prior to surgery, a perforated appendicitis was found in 11 %; whereas when the time from symptom onset to surgery was greater than or equal to 48 hours, it was evident in 31 % of the cases (p 0.008). The only independent variable associated with the presence of postoperative complications was symptom duration prior to surgery greater than or equal to 48 hours (OR 4.8; 95 % CI 1.1-16.2; p 0.04). Seven minor and 2 mayor postoperative complications were observed. Patients with complications spent, on average, twice as many days hospitalized (p < 0.001); and had 8 times more risk of preterm delivery (p 0.03). Obstetric complications were more frequent in pregnant women operated during the first trimester. Foetal mortality was 1.6 %. CONCLUSION: Surgical morbidity of acute appendicitis in pregnant women is linked to the delay in the diagnosis and treatment of the inflammatory condition. Laparoscopic appendectomy during pregnancy is not exempt from postoperative, obstetric and foetal complications. It is necessary to standardize the definitions of "complication" in order to collate reliably the outcomes presented in the literature.

Added value of dynamic magnetic resonance images in pelvic floor dysfunction / Valor agregado das imagens de ressonância magnética dinâmica na disfunção do assoalho pélvico

ABSTRACT Purpose Pelvic floor dysfunction has a high prevalence in the adult population. The Dynamic and Multiplanar Evaluation of the Pelvic Floor (DMRIPF) represents an ideal tool for multidisciplinary management. The purpose of this analysis is to evaluate the added value of the Dynamic and Multiplanar Evaluation of the Pelvic Floor in patients with suspected pelvic floor disorders. Methods Retrospective analysis of a consecutive series of patients who underwent a DMRIPF due to suspected pelvic floor disorders between April 2005 and July 2019. Results 359 patients were included. The average number of diagnoses achieved by physical examination was 1.2 vs. 2.5 by the Dynamic and Multiplanar Evaluation of the Pelvic Floor (p < 0.001). Physical examination found a single pathology in 80.8 % of cases. Anterior rectocele (AR) was the most frequent isolated diagnosis on physical examination (68 %). On the Dynamic and Multiplanar Evaluation of the Pelvic Floor, anterior rectocele was diagnosed as an isolated condition in 10.9 %. In 231 cases, anterior rectocele was associated with up to 5 other pelvic floor disorders. The number of individuals with associated pathologies of the posterior and anterior compartments tripled. It modified physical examination findings in 17 % of individuals and, in 63.5 %, allowed the identification of additional pelvic floor pathologies that were missed by physical examination. The Dynamic and Multiplanar Evaluation of the Pelvic Floor had greater added value in patients with anterior rectocele (59.6 % vs. 20.9 %; p < 0.001). Female gender was also associated with a greater diagnostic yield (p < 0.001). Conclusion The Dynamic and Multiplanar Evaluation of the Pelvic Floor allows the detection of multi-compartment defects that could otherwise go undetected, or even alter the initial clinical diagnosis, representing an ideal tool for multidisciplinary approach of pelvic floor dislocations, allowing a comprehensive therapeutic planning.

RESUMO Objetivo A disfunção do assoalho pélvico tem alta prevalência na população adulta. A avaliação dinâmica e multiplanar do assoalho pélvico (DMRIPF) representa uma ferramenta ideal para o gerenciamento multidisciplinar. O objetivo desta análise é avaliar o valor agregado da avaliação dinâmica e multiplanar do assoalho pélvico em pacientes com suspeita de distúrbios do assoalho pélvico. Métodos Análise retrospectiva de uma série consecutiva de pacientes submetidos à avaliação dinâmica e multiplanar do assoalho pélvico por suspeita de distúrbios do assoalho pélvico entre Abril de 2005 e Julho de 2019. Resultados 359 pacientes foram incluídos. O número médio de diagnósticos alcançados pelo exame físico foi de 1,2vs. 2,5 pela avaliação dinâmica e multiplanar do assoalho pélvico p < 0,001. O exame físico encontrou uma única patologia em 80.8 % dos casos. A retocele anterior (RA) foi o diagnóstico isolado mais frequente no exame físico (68 %). Na avaliação dinâmica e multiplanar do assoalho pélvico, a retocele anterior foi diagnosticada como uma condição isolada em 10.9 %. Em 231 casos, a retocele anterior foi associada a até 5 outros distúrbios do assoalho pélvico. O número de indivíduos com patologias associadas dos compartimentos posterior e anterior triplicou. Modificou os achados do exame físico em 17 % dos indivíduos e em 63.5 %; permitiu a identificação de outras patologias do assoalho pélvico que foram esquecidas pelo exame físico. A avaliação dinâmica e multiplanar do assoalho pélvico teve maior valor agregado em pacientes com retocele anterior (59.6 % vs.20.9 %; p < 0,001. O sexo feminino também foi associado a um maior rendimento diagnóstico p < 0,001. Conclusão A avaliação dinâmica e multiplanar do assoalho pélvico permite a detecção de defeitos multicompartimentários que, de outra forma, poderiam não ser detectados, ou mesmo alterar o diagnóstico clínico inicial, representando uma ferramenta ideal para a abordagem multidisciplinar das luxações do assoalho pélvico, permitindo um planejamento terapêutico abrangente.

Complicaciones infecciosas graves luego de la ligadura con banda elástica para hemorroides: reporte de un caso y revisión de la literatura / Acute infectious complications after ligation with elastic band for hemorrhoids: a case report and literature review

Introducción: La ligadura con banda elástica es un procedimiento efectivo y de bajo costo, para el manejo de hemorroides grado I-III, que no requiere internación. Sus complicaciones, cuando presentes, son habitualmente leves. Aunque poco comunes, existen complicaciones graves asociadas a este procedimiento. El objetivo de este estudio es realizar una revisión de las complicaciones infecciosas pelvi-perineales de la ligadura con banda elástica, características comunes de presentación y alternativas de tratamiento en aquellos que sufren estas complicaciones. Descripción del caso: Se expone el caso de un hombre de 71 años de edad que presentó una sepsis pelviana severa posterior a la realización de una ligadura con banda elástica. A las 48 horas del procedimiento consulta por dolor perianal, dificultad miccional y fiebre. Se realiza el drenaje quirúrgico de ambas fosas isquiorrectales, luego de lo cual intercurre con shock séptico, realizándose una laparotomía, drenaje de retroperitoneo, colostomía sigmoidea. Posteriormente, debido al desarrollo de un síndrome compartimental abdominal, el abdomen se dejó abierto y contenido con una malla. Discusión: Se han descripto complicaciones sépticas posteriores a escleroterapia y crioterapia hemorroidal, ligadura con banda elástica, hemorroidectomia convencional y con sutura mecánica. Se exponen 20 casos de sepsis pelviana post-ligadura con banda elástica. La relación hombre:mujer fue de 3:1, con un amplio rango de edad (27-82 años). Sólo 2 tenían antecedentes de inmunosupresión. La progresión o la persistencia del dolor asociado a fiebre, dificultad miccional, edema perineal y/o genital fueron signos y síntomas comunes que se manifestaron dentro de los 14 días posteriores a la ligadura. Tal como en el caso aquí referido como en otros ya publicados, la realización de imágenes ayudó al diagnóstico y a la planificación quirúrgica. Todos recibieron antibioticoterapia de amplio espectro y 13 requirieron además cirugía. El espectro de tratamientos quirúrgicos fue desde el drenaje incisional hasta la amputación rectal. Ante la progresión del cuadro séptico, la realización de una ostomía fue la conducta más usual. Cinco pacientes requirieron más de una cirugía, y 8 fallecieron. Conclusión: Es importante conocer las complicaciones infecciosas mayores y su presentación clínica, para realizar un diagnóstico y tratamiento precoz de las mismas, con el fin de disminuir su elevada morbilidad o mortalidad. (AU)

Background: Rubber band ligation is an effective, low-cost procedure for grade I-III hemorrhoids, and does not require hospitalization. Its complications, when present, are usually mild. Although rare, there are serious complications associated with this procedure. The purpose of this review was to identify common presenting features and treatment alternatives in those who suffer pelviperineal infectious complications after rubber band ligation. Case Report: The present case is that of a 71-year-old man who presented severe pelvic sepsis after rubber band ligation. He complained of perianal pain, voiding difficulties and fever 48 hours after the procedure. Surgical drainage of both ischiorectal fossae was carried out. He developed septic shock. Laparotomy, retroperitoneal drainage and sigmoid loop colostomy were performed. In a subsequent operation due to abdominal compartment syndrome, the abdomen was left open and contained with a mesh. Discussion: Septic complications have been described after sclerotherapy, cryotherapy, rubber band ligation, conventional hemorrhoidectomy and stapled haemorrhoidopexy. We describe 20 cases of pelvic sepsis after rubber band ligation. The male: female ratio was 3: 1, with a wide age range (27- 82 years). Only 2 had a history of immunosuppression. The progression or persistence of pain associated with fever, voiding difficulties, perineal and / or genital edema were common signs and symptoms that appeared within 14 days after rubber band ligation. In the case here referred to as in others already published, imaging studies helped the diagnosis and surgical planning. All received broad spectrum antibiotic therapy and 13 required surgery. The spectrum of surgical treatments ranged from incisional drainage to rectal amputation. In view of the progression of the septic condition, performing an ostomy was the most usual conduct. Five patients required more than one surgery, and 8 died. Conclusion: It is important to acknowledge the major infectious complications and their clinical presentation, to help with an early diagnosis and treatment, in order to reduce their high morbidity and mortality. (AU)