Cirugía ambulatoria electiva en patología proctológica: experiencia prospectiva de 14 años en un hospital público docente / Elective ambulatory surgery in proctological pathology: 14 years of prospective experience in a public teaching hospital

INTRODUCCIÓN: Se presenta nuestra experiencia en cirugía ambulatoria en patología proctológica. MATERIALES Y MÉTODO: La serie corresponde al análisis de 1.399 pacientes tratados entre agosto de 2003 y diciembre de 2017 en forma prospectiva, RESULTADOS: Fueron intervenidos por fístula anorrectal (20%), enfermedad hemorroidaria (19%), enfermedad pilonidal sacro coccígea (EPSC) (15%), fisura anal (13%), biopsia rectal quirúrgica o resección local endoanal (12%), condilomas (10%) y otras (10%). La morbilidad inmediata es de un caso, por un hematoma luego de una cirugía por EPSC que requirió hemostasia y cierre primario. La tasa de hospitalización inmediata fue de 0,3% y corresponde a 5 casos de retención aguda de orina. La hospitalización tardía fue de un 1,6% y corresponde a 22 pacientes, hospitalizados por sangrado tardío (9), dolor intratable (9) y fiebre (4). Todos fueron tratados en forma conservadora con resolución entre los 2 y 5 días. No se registra morbilidad mayor en esta serie. CONCLUSIONES: La cirugía ambulatoria en patología proctológica es factible y segura.

INTRODUCTION: We present our prospective experience in ambulatory anorectal surgery between August 2003 and December 2017. MATERIALS AND METHOD: The series corresponds to the analysis of 1399 patients treated between August 2003 and December 2017 prospectively. RESULTS: The etiology of the surgerys were anal fistula (20%), hemorrhoidal disease (19%), sacrococcygeal pilonidal disease (15%), anal fissure (13%), rectal surgical biopsy or local resection (12%), condylomata (10%) and others (10%). The immediate morbidity was seen one case, a hematoma after an EPSC surgery that required hemostasis and primary closure. The immediate hospitalization rate was 0.3% and corresponds to 5 cases of acute urinary retention. The late hospitalization was 1.6% and corresponds to 22 patients, due to late bleeding (9), severe pain (9) and fever (4). All were treated conservatively with resolution between 2 and 5 days. No major morbidity is recorded in this series. CONCLUSION: We concluded that outpatient surgery in proctologic pathology is feasible and safe.

Abordaje microquirúrgico transanal. Experiencia inicial. Indicaciones y resultados / Transanal microsurgical approach. Initial experience. Indications and results

Introducción: El tratamiento quirúrgico de las afecciones del recto bajo se encuentra en permanente revisión intentando mantener una adecuada función de continencia y urogenital. Una opción reciente es el abordaje microquirúrgico transanal. El objetivo del trabajo es evaluar una serie de pacientes tratados mediante dicho abordaje, analizando indicaciones, resultados inmediatos y alejados. Material y método: Se seleccionaron 41 pacientes operados en el período comprendido entre febrero de 2009 y febrero de 2015. Resultados: En 41 pacientes, las afecciones tratadas fueron: pólipos, 22; cáncer de recto, 14; estenosis de anastomosis, 2; absceso retrorrectal, 1; endometriosis, 1; poliposis adenomatosa familiar, 1. Los pacientes con pólipos llegaron a consulta: por primera vez, 15; recidivados, 4; segunda recidiva, 2; tercera recidiva, 1. Los procedimientos realizados fueron: resección local, 29; microcirugía transanal transabdominal (TATA), 6; dilatación de estenosis, 4; biopsia transrectal, 3; drenaje de absceso retrorrectal, 1; control de hemorragia, 1; colocación de stent, 1. En cáncer de recto: resección local, 7; biopsia transrectal, 2; TATA, 4; colocación de stent, 1. El tiempo operatorio promedio fue 48,6 minutos, y la estadía hospitalaria promedio 2,21 días. De los 29 pacientes en quienes se realizó resección local, fueron controlados 25 durante un período de 6 a 72 meses. Se complicaron 11 pacientes, sin mortalidad ni recidivas locales. Conclusiones: Este abordaje permite tratar lesiones del recto y último segmento del colon sigmoides. Otorga mejor visión permitiendo una disección más exacta, mejorando resultados postoperatorios inmediatos y alejados en patología benigna y maligna, minimizando la posibilidad de recidivas. (AU)

Introduction: The surgical treatment of conditions located at the low rectum is in constant review, triying to maintain proper urogenital and continence function. One of the most recent options is the transanal microsurgical. The aim of this paper is to analyze a series of patients treated with this approach, its indications, immediate and long term results. Material and Methods: 41 patients were analyzed retrospectively in the period between February 2009 and February 2015. Results: In these patients, treated conditions were polyps: 22; rectal cancer: 14; anastomotic stricture: 2; retrorectal abscess: 1; endometriosis: 1; familial adenomatous polyposis: 1. Patients affected with polyps reached the first consultation in 15 opportunities; 4 on first recurrence; 2 with second recurrence; 1 with third recurrence. The procedures were 29 local resections; 6 transanal transabdominal resections (TATA); 4 dilations of stenosis; 3 transrectal biopsies; 1 retrorectal abscess drainage; 1 hemorrhage control; 1 stent placement. In rectal cancer were: 7 local resection; 2 transrectal biopsies; 4 TATA; 1 stent placement. Mean operative time was 48.6 minutes and mean hospital stay was 2.21 days. Of the 29 patients in whom local resection was performed, 25 were controlled for a period of 6 to 72 months. 11 patients were complicated; no deaths or local recurrences were registered. Conclusions: This approach allows to treat lesions located throughout the rectum and the last segment of sigmoid colon. A better insight is obtained allowing a more accurate dissection, thus improving the immediate and remote postoperative results and minimizes the possibility of recurrence, particularly when it comes to benign conditions. (AU)

Implementación de un programa de cirugía proctológica en régimen de cirugía mayor ambulatoria: experiencia inicial / Early results of an ambulatory surgery programme for benign anorectal disorders

Introducción: La realización en régimen de cirugía mayor ambulatoria (CMA) de procedimientos proctológicos complejos es aún infrecuente en nuestro medio. El objetivo del presente trabajo es presentar los resultados iniciales de un programa de cirugía proctológica en régimen de CMA que incluye procedimientos complejos tales como esfinteroplastias o colgajos de avance rectal. Material y métodos: Se realizó un estudio descriptivo retrospectivo en el que se incluyeron 186 pacientes intervenidos de patología proctológica en un programa de CMA. El programa se basó en la unión de una Unidad de Coloproctología con amplia experiencia en cirugía proctológica y una Unidad de CMA ya establecida en el centro. Se analizaron los resultados tanto de ingreso como de reintervención en el postoperatorio inmediato y precoz. Resultados: Entre enero de 2014 y diciembre de 2015 se realizaron un total de 197 intervenciones, destacando 105 (53,3%) cirugías de fístula anal, 33 (16,8%) hemorroidectomías y 11 (5,6%) esfinteroplastias. De los pacientes intervenidos por fístula perianal, en 25 (23,8%) se realizó un colgajo de avance rectal. Una paciente (0,5%) requirió ingreso tras la cirugía por haberse realizado un proceso más complejo del inicialmente programado, todos los demás pacientes pudieron ser dados de alta sin complicaciones. Tres pacientes (1,5%) reingresaron en el postoperatorio precoz y fueron reoperados debido a una hemorragia poshemorroidectomía, un absceso perianal y dolor anal. Conclusiones: La implementación de un programa de patología proctológica en régimen de CMA que incluya procedimientos complejos como el colgajo de avance endorrectal o la esfinteroplastia es factible, con una baja tasa de ingresos en hospitalización y reingresos posteriores.

Introduction: Complex procedures for anorectal disorders are uncommonly performed as Ambulatory Surgery (AS). The aim of this study was to describe the early results of an AS program that included complex procedures such as advancement rectal flaps for fistula repair. Material and methods: A retrospective descriptive study was performed with 186 patients who were submitted to AS because of benign anorectal disorders. The AS program for anorectal disorders started when a Colorectal Surgery Unit with broad experience in anorectal surgery joined an AS Unit that was already working in the hospital. Hospital admissions and need of early reoperation were analyzed. Results: One hundred and ninety seven procedures were performed between January 2014 and December 2015. One hundred and five (53.3%) fistula repair surgeries were performed, as well as 33 (16.8%) hemorrhoidectomies and 11 (5.6%) anal sphincter repairs. Among the patients who were operated because of an anorectal fistulae, 25 (23.8%) were submitted to advancement rectal flap. One patient (0.5%) could not be discharged after the surgery because the procedure performed was more complex than previously expected. All other patients were discharged. Three patients (1.5%) were addmited during early postoperative course, all of them had to undergo revisional surgery because of hemorrhage, pain and anorectal abscess respectively. Conclusions: Anorectal procedures, including complex procedures such as advancement rectal flap and sphincter repair, can be performed as AS with a low percentage of patients addmited before or after discharge.

Seguridad de la resección con asa fría de lesiones colorrectales no polipoideas (0-IIa y 0-IIb) de hasta 20 mm / [Safety and efficacy of cold snare resection of non-polypoid colorectal lesions (0-IIa and 0-IIb)].

BACKGROUND: Cold polypectomy is a widely used technique for removing small polyps. Little evidence is available regarding its use for removing non-polypoid colorectal lesions (NPCRL). OBJECTIVE: The main aim of this study was to assess the safety of cold snare resection of NPCRL up to 20 mm. METHODS: This was a prospective cohort study carried out from January 2009 to January 2012. Consecutive patients scheduled for colonoscopy who had at least one NPCRL were recruited. Patients undergoing antiaggregation or anticoagulation treatment were excluded. NPCRL of up to 20 mm were removed by means of a cold snare, with or without piecemeal technique. To evaluate the safety of the procedure, the measured outcomes were bleeding and perforation rates. Statistical measures as percentages with their respective confidence intervals of 95

were estimated and the level of significance was set at alpha = 0.03. The calculated interval was unilateral, because the experimental rate was 0

, and was built based on the binomial distribution. Statistix (SX9.0) was used. RESULTS: A total of 171 NPCRL were removed from 124 patients. The mean size of the lesions was 9.22 +/- 4.7 mm (range: 4 to 20 mm). The mean age of patients was 55 +/- 11 years (range: 25 to 81 years) and 56

of them were women. No immediate or delayed complications were recorded. CONCLUSIONS: Cold snare resection could be used to remove LNPCR (0-IIa and 0-IIb) measuring up to 20 mm, without immediate or delayed complications.

Factores asociados a morbilidad precoz en cirugía colorrectal laparoscópica / Factors associated with early morbidity in laparoscopic colorectal surgery

Introduction: different factors have been associated with increased risk of complications in laparosco-pic colorectal surgery. The aim of this study is to identify these factors in our series. Method: retrospective cohort. All patients undergoing laparoscopic colorectal surgery between january 2000 and june 2012 were included. Patients who had postoperative complications until 30 days postoperatively were identified and analyzed by univariate and multivariate logistic regression. A p value less than 0.2 was used was used as a criteria for entry into the multivariate model. Results: the series consists of 848 patients with a median age of 58 +/- 22 years. Main surgical indications were: neoplasia (42.3 percent), diverticular disease (27.8 percent) and inflammatory bowel disease (8.8 percent). Most frecuently-performed procedures were: sigmoidectomy (39.5 percent), anterior resection of the rectum (13.4 percent), right hemicolectomy (13 percent) and total colectomy (8.7 percent). On univariate analysis, factors associated with complications were age over 75 years (OR 1.82, 95 percent CI 1.02 to 3.25) and red blood cell transfusion (OR 8.47, 95 percent CI 3.69 to 19.43). On multivariate analysis, red blood cell transfusion (OR 7.9 95 percent CI 1.78 to 35.88) and ASA III or IV (OR 3.26 95 percent CI 1.01 to 17.23) were independent factors associated with postoperative complications. Conclusion: intraoperative red blood cell transfusion and ASA score III or IV are independent risk factors associated with complications in laparoscopic colorectal surgery.

Introducción: se han descrito factores que se asocian a mayor riesgo de complicaciones en cirugía laparoscópica colorrectal. El objetivo de este trabajo es identificar estos factores en nuestra serie. Método: cohorte histórica. Se incluyeron todos los pacientes sometidos a cirugía colorrectal laparoscópica entre enero de 2000 y junio de 2012. Se identificaron los pacientes que tuvieron complicaciones post operatorias hasta 30 días después de la operación. Se analizaron mediante regresión logística uni y multivariada. Se utilizó como criterio de entrada al modelo multivariado los p < 0,2 y como criterio de significancia un p = 0,05. Resultados: la serie consta de 848 pacientes, con una mediana de edad de 58 +/- 22 años. Las principales indicaciones operatorias fueron: neoplasia (42,3 por ciento), enfermedad diverticular (27,8 por ciento) y enfermedad inflamatoria intestinal (8,8 por ciento). Las operaciones realizadas con mayor frecuencia fueron: sigmoidectomía (39,5 por ciento), resección anterior de recto (13,4 por ciento), hemicolectomía derecha (13 por ciento) y colectomía total (8,7 por ciento). En el análisis univariado, los factores asociados a complicación fueron: la edad sobre 75 años (OR de 1,82; IC 95 por ciento 1,02-3,25) y la transfusión de glóbulos rojos (OR 8,47; IC 95 por ciento 3,69-19,43). En el análisis multivariado, la transfusión de glóbulos rojos (OR 7,9 95 por ciento IC 1,78-35,88) y el ASA III o IV (OR 3,26 95 por ciento IC 1,01-17,23) fueron factores de riesgo independientes de complicaciones en el postoperatorio. Conclusión: la necesidad de transfusión y el ASA III o IV son factores de riesgo independientes asociados a complicaciones en cirugía colorrectal laparoscópica.

Doble engrapado en cirugía colorrectal / Double stapler technique in colorectal surgery

BACKGROUND: Colorectal surgery has evolved significantly during the last 35 years. The circular stapler and the double stapler techniques have favored the development of very low rectal anastomoses with reduction in anastomotic leakage. The objective of this study is to evaluate the functional results and complication rate of this surgical technique in the Department of Colorectal Surgery at the Hospital de Especialidades, Centro Medico Nacional Siglo XXI and at the Hospital Angeles del Pedregal, both located in Mexico City. METHODS: Clinical records of patients who underwent surgery from May 1995 to December 2005 using the double stapler technique and performed by the authors were reviewed. RESULTS: The study included 142 patients, 55 of whom had rectosigmoid cancer resections. Average age was 60.1 years (male predominance 52.05%). The circular stapler most frequently used was CDH 33 (Johnson & Johnson). Average distance between the anal margin and the anastomoses for extended low anastomoses was 3.21 cm (low 7.8 cm and high 13.7 cm), and the rate of anastomoses leak was 3.52%. CONCLUSIONS: Double stapler technique used to treat rectosigmoid pathology is safe, secure and assures intestinal continuity in low anterior as well as extended low anterior resections with primary anastomoses. In those patients with associated risk factors and low extended low anterior resection with primary anastomoses, we recommend performing a protective stoma (ileostomy).

Cirurgia ambulatorial em proctologia: análise retrospectiva de 437 casos / Outpatient surgery for anorectal diseases: the experience of the Clinics Hospital of the Medical School, Botucatu, SP, Brazil, in 437 cases

RACIONAL: O número de cirurgias ambulatoriais realizadas em hospitais, como em clínicas particulares, cresce a cada dia. Hoje, em alguns países, como a França, há predomínio das cirurgias ambulatoriais em relação às hospitalares. OBJETIVO: Avaliar retrospectivamente os pacientes operados no Serviço de Cirurgia Ambulatorial do Hospital das Clínicas da Faculdade de Medicina de Botucatu, SP. CASUíSTICA E MÉTODO: Foram estudados retrospectivamente 437 casos clínicos de patologias orificiais, analisando a distribuição por faixa etária, por sexo, por patologias e as complicações pós-operatórias. RESULTADOS: Notou-se predomínio de pacientes com idade inferior a 45 anos (62,8 por cento), prevalência do sexo feminino (56 por cento), sendo a doença hemorroidária (45,1 por cento) a principal patologia e a dor e sangramento as complicações mais freqüentes (9,8 por cento e 7,3 por cento). CONCLUSÕES: Os resultados satisfatórios observados demonstram a possibilidade de realização, em ambulatório, de diversos procedimentos simples em patologias anorretais freqüentes, a baixo custo e poucas complicações, sendo estas não superiores às observadas em cirurgia hospitalar.

Cirurgia laparoscópica colorretal: resultados do inquérito nacional brasileiro - 2001 / Laparoscopic colorectal surgery

Este trabalho multicêntrico reúne a experiência de 14 equipes brasileiras em cirurgia laparoscópica colorretal. No período de 1992 a 2001, foram operados 1843 pacientes, sendo 896 homens e (48,6 por cento) e 947 mulheres (51,4 por cento) cuja idade variou de 1 a 94 anos (média de 56,4 anos). Doenças beniginas foram diagnosticadas em 1109 pacientes (60,2 por cento). A maioria das afecções (60,5 por cento) localizava-se no cólon esquerdo e sigmóide, 21,3 por cento no reto e canal anal e 9,5 por cento no cólon direito. Houve 73 (4,0 por cento) complicações intra-operatórias (variaçäo de 2,0 por cento a 6,2 por cento), a maioria delas (54-73,9 por cento) registradas nos primeiros 50 casos operados por equipe. Foram relatadas 199 (10,66 por cento) conversões para laparotomia (0 a 23,5 por cento), que também foram mais freqüentes nos primeiros 50 casos operados (n=119-59,8 por cento). Complicações pós-operatórias foram registradas em 367 (19,9 por cento) (8,0 a 29,6 por cento). Ocorreram 29 óbitos (1,6 por cento). Foram operados 734 (39,8 por cento) pacientes portados de tumores malignos, tendo sido informados os tipos histológicos de 685 tumores, assim distribuídos: 652(95,2 por cento) adenocarcinoma 23 (3,4 por cento) carcinomas espinocelulares e outros tipos histológicos em 10 (1,5 por cento) pacientes

Procedimentos cirúrgicos em pacientes proctológicos selecionados, sob anestesia local: estudo de 150 casos / Surgical procedures in proctological selected patients, with local anesthesia: study of 150 cases

Experience in the treatment of 150 patients with anorectal disorders and disorders of the sacrococcygeal region who were operated on with local anesthesia at the University Hospital, ABC Medical School, Sao Bernardo do Campo, SP, Brazil, from March 1995 to March 1998. The anesthesia technique, the operations carried out and the tolerance to the procedure are reported. Intraoperative morbidity was 10.6 per cent (16 patients), and postoperative morbidity was 6 per cent (nine patients). The age of patients was between 15 and 92 years old, with mean age 42 years old; 58 per cent of patients were male and 42 per cent female. Surgical mean time was 45 minutes and the patients remained in the hospital for a mean time of 8 hours. All of patients was instructed about the anesthesia technique, their advantages and disadvantages, and only with their permit the surgery was programmed. Hospitalization was required in five patients (3.3 per cent). The anesthesia technique employed was the same for all patients. Upon survey, 96.7 per cent of the patients stated they did not feel pain during the surgery and that they would go through the procedure again. The authors conclude the surgical treatment of anorectal disorders and disorders of the sacrococcygeal region with local anesthesia is viable and safe, and in addition, is well accepted by the patients

Rectorragia como complicación del síndrome de Klippel-Trenaunay / Rectal bleeding as a complication of Klippel-Trenaunay syndrome

Objetivo: describir la presentación clínica y el tratamiento de dos pacientes con síndrome de Klippel-Trenaunay referidos a nuestro hospital por rectorragia y revisar la literatura para establecer las modalidades actuales de diagnóstico y tratamiento que se le pueden ofrecer a estos pacientes. Caso 1: paciente masculino de 15 años de edad con síndrome de Klippel-Trenaunay y antecedente de anemia crónica. Internado por cuadro de rectorragia severa. Caso 2: paciente femenino de 19 años de edad con el mismo síndrome y dos años de evolución con rectorragia intermitente, anemia y trombocitopenia. El protocolo diagnóstico de cada paciente mostró várices colónicas como la causa de la rectorragia además de otras alteraciones vasculares propias del síndrome. Tratamiento: el primer caso fue tratado con hemicolectomía izquierda y colorrecto anastomosis. Cuatro años después volvió a presentar rectorragia leve y se realizó esclerosis de várices rectales residuales con formol al 40 por ciento. El segundo caso fue tratado con hemicolectomía izquierda y colostomía. Se le han realizado dos sesiones de esclerosis con alcohol absoluto en las várices del muñón rectal y se encuentra en espera del cierre de la colostomía. Conclusión: el síndrome de Klippel-Trenaunay es una enfermedad poco frecuente, con afección vascular en varios niveles. Un porcentaje bajo de pacientes presenta hemorragia a través de las várices colónicas que puede condicionar anemia crónica o hemorragia aguda con compromiso hemodinámico. Esta complicación amerita tratamiento quirúrgico con resección del segmento afectado, complementado con alguna medida local para las várices residuales en el recto

Surgery for severe idiopathic constipation: a report of personal experience

Discute-se protocolo para estudo de tratamento de constipacao idiopatica severa (CIS); 108 pacientes foram assim classificados: 58 com constipacao colica cronica, 30 com transito lento, quatro com megacolon idiopatico, 24 com sindrome de intestino irritavel, 45 com constipacao retal, 21 com obstrucao intestinal baixa, 12 com megareto e 12 com hipertonia do esfincter anal interno, alem de cinco casos de formas mistas. Em sete pacientes com CIS colica (cinco com transito lento e dois com megacolon idiopatico) foi indicado tratamento cirurgico, com realizacao de colectomia subtotal e anastomose ileo-retal. Todos esses doentes evoluiram satisfatoriamente no pos-operatorio...