Sacral nerve stimulation for the treatment of faecal incontinence following low anterior resection for rectal cancer.

AIM: The aim of this study was to assess the effectiveness of sacral nerve stimulation (SNS) in the management of faecal incontinence following neoadjuvant therapy and low anterior resection (LAR) for rectal cancer. METHOD: In a prospective single-centre study, 15 patients (12 men, median age 72 years) were enrolled between 2005 and 2008. All had severe incontinence after total mesorectal excision, and 14 had received preoperative full-course chemoradiotherapy. The patients were followed up for a median of 50 (range: 24-144) months. There was no recurrence (local or distal). Incontinence was evaluated using the Cleveland Clinic Florida Fecal Incontinence (CCF-FI) scoring system. Quality of life (QoL) was evaluated using the Fecal Incontinence Quality of Life (FIQL) questionnaire. SNS was performed in three stages. RESULTS: During percutaneous nerve evaluation (PNE), a good response was observed in seven patients, all of whom received a permanent implant. The median follow up was 12 (range: 1-44) months. The mean CCF-FI score was reduced from 19.2 [standard deviation (SD) 1.2] to 6.2 (SD 1.7) (P < 0.01). The mean number of days per week with an incontinent episode decreased from 7 (SD 0) to 0.2 (SD 0.3) (P < 0.01), and the mean number of defaecations per week decreased from 42.5 (SD 13.7) to 13.2 (SD 7.4) (P < 0.01). In the five patients with a permanent implant who were followed up for longer than 6 months, all FIQL scores improved. An increase in the mean resting and squeeze pressures was seen in four patients with a permanent implant. CONCLUSIONS: SNS is a treatment option for faecal incontinence after LAR for rectal cancer.

Randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano.

BACKGROUND: The aim of this randomized study was to compare the results of anal fistula plug and endorectal advancement flap in the treatment of high fistula in ano of cryptoglandular origin. METHODS: Consecutive patients with high trans-sphincteric fistula in ano of cryptoglandular aetiology were randomized to treatment with either an anal fistula plug or endorectal advancement flap. Patients agreed to participate in a follow-up programme, which included scheduled visits at 2, 4, 8, 12 and 24 weeks and at 1 year after surgery. The primary endpoint was effectiveness in fistula healing. Recurrence was defined as the presence of an abscess arising in the same area, or obvious evidence of fistulation. RESULTS: A large number of recurrences in the fistula plug group led to premature closure of the trial. After 1 year, fistula recurrence was noted in 12 of 15 patients treated with an anal fistula plug compared with two of 16 treated with an endorectal advancement flap (relative risk 6.40 (95 per cent confidence interval 1.70 to 23.97); P < 0.001). CONCLUSION: Contrary to other published studies, an anal fistula plug was associated with a low rate of fistula healing, particularly in patients with a history of fistula surgery.

Comparative study to determine the need for intraoperative colonic irrigation for primary anastomosis in left-sided colonic emergencies.

OBJECTIVE: To compare the outcome of resection and primary anastomoses in patients undergoing emergency surgery of the left colon with and without intraoperative colonic irrigation. METHOD: From January 2004 to December 2006, 102 consecutive patients with acute occlusion or perforation of the left colon were operated on an emergency basis in two Coloproctology units. According to the sample size calculation, 61 patients from one unit underwent surgery with intraoperative colonic irrigation, whereas 41 patients from the second unit underwent surgery without intraoperative colonic irrigation. The endpoints were mortality and morbidity. RESULTS: Thirty (49.2%) patients with intraoperative colonic irrigation and 8 (19.5%) without colonic irrigation developed one or more complications postoperatively (odds ratio 4.0, 95% CI 1.6-10.0, P = 0.002). An increased number of wound infections was seen in the group managed with colonic irrigation 15 vs 3 (P = 0.034). The postoperative mortality rate and the occurrence of dehiscence of the anastomoses were similar in both study groups. CONCLUSION: The present findings indicate that resection and primary anastomosis in patients undergoing emergency surgery of the left colon can be safely performed without intraoperative colonic irrigation.

Length of follow-up after fistulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano.

BACKGROUND: The length of follow-up required after surgical repair of cryptoglandular fistula in ano has not been established. This prospective study determined the follow-up time needed to establish that an anal fistula has been cured after elective fistulotomy or fistulectomy associated with endorectal advancement flap (ERAF) repair. METHODS: Between January 2001 and June 2004, consecutive patients with anal fistula of cryptoglandular aetiology were included provided that they lived within the catchment area of the hospital and agreed to participate in a follow-up programme, which comprised scheduled visits every month until complete wound healing and annually thereafter. RESULTS: Some 206 of 219 eligible patients were evaluable; fistulotomy was performed in 115 and ERAF repair in 91. Median follow-up was 42 (range 24-65) months. Eighteen patients had recurrence of the fistula during follow-up, with a median time to relapse of 5.0 (range 1.0-11.7) months. There were no recurrences after 1 year. CONCLUSION: Recurrence of fistula in ano of cryptoglandular origin treated by means of fistulotomy or ERAF repair occurs within the first year of operation.

Simultaneous presentation of oesophageal and renal cancer.

Oesophageal cancer has been documented to be often associated with other primary tumours. However, concurrent oesophageal and renal cell carcinoma is extremely uncommon. We report a case of synchronous oesophageal and kidney cancer that was successfully treated at our hospital by a one-stage surgical procedure. The patient is doing well and without recurrence 54 months after the operation.

[Treatment of perianal Crohn's disease]. / Tratamiento de la enfermedad de Crohn perianal.

Perianal affectation due to Crohn's disease includes a wide spectrum of lesions involving different management and prognosis. A thorough exploration of the patient, under anaesthetic if necessary, a rectoscope to evaluate the possible affectation of the rectum by the disease, and on occasions evaluation through endoanal echography or magnetic resonance, are the bases for a correct diagnostic and therapeutic focus. Pharmacology and surgery must be complementary in the treatment of perianal Crohn's disease and must pursue a double aim: to alleviate the symptomology of the patient and prevent possible complications. Except in situations of emergency due to perianal sepsis, medical treatment is the first step in managing perianal Crohn's disease, and on many occasions it will control the disease, making surgery unnecessary. When surgery is required, with the aim of a definitive treatment of the perianal lesion, the risk of developing complications, especially incontinence, must be contrasted.

Congenital esophageal cysts--two cases in adult patients.

Esophageal cysts are a rare clinicopathological condition. They usually cause respiratory symptoms in children, while they are often asymptomatic in adults. Two cases of esophageal cysts in adults, recently diagnosed and treated in our department, are reported. In the 1st case (a 52 year-old woman) dysphagia was the main symptom. In the 2nd one (a 39 year-old woman) the patient was asymptomatic. Both were surgically excised by enucleation, with no post-operative complications. The histological study showed both cysts to be lined with ciliated cylindrical epithelium, and they were therefore considered to be congenital. Smooth muscle was only seen in the cyst wall in the 2nd case, but it was not organized in 2 layers, as is typical of duplication cysts. Cartilage or respiratory glands, the pathognomonic features of bronchogenic cysts, were not identified in either of them. Therefore, the diagnosis was inclusion cysts in both cases.

The value of D1 lymphadenectomy as prognostic marker in gastric cancer.

BACKGROUND/AIMS: To assess if the study on the involvement of perigastric lymph nodes, the only ones resected in D1 lymphadenectomy, is a valid prognostic marker in patients undergoing curative resection for gastric cancer. METHODOLOGY: A retrospective study was performed in 101 patients with gastric cancer, 34 women and 67 men, with a mean age of 61 years, undergoing curative resection by gastrectomy and D1 lymphadenectomy. Tumor size, the depth of tumoral invasion of the wall, nodal involvement and 5-year survival were assessed. RESULTS: Both tumor size and the depth of tumoral invasion of the wall were significantly related to metastatic involvement of perigastric lymph nodes. Similarly, tumoral involvement of the first-level lymph nodes was significantly associated with survival. CONCLUSIONS: D1 lymphadenectomy can provide adequate prognostic information in patients with gastric cancer undergoing curative resection.

[Should hernia operations be carried out on elderly patients? ]. / Se debe operar de hernia a los pacientes mayores?

BACKGROUND: To evaluate whether treatment of the inguinal hernia in patients over 70 years has different connotations with respect to patients of a lower age. MATERIAL AND METHODS: Prospective study of 299 patients who had undergone intervention for an uncomplicated unilateral inguinal hernia during the year 2002. Group 1 included 90 patients with an age equal to, or higher than 70 years, and group 2 included the 209 patients who did not exceed this age. The variables studied in the two groups of patients were: type of hernia following the classification of Gilbert - Rutkow-Robbins, percentage of first cases-relapses, technique of repair, type of anaesthesia employed in the intervention, index of substitution in outpatient major surgery and post-operational complications. RESULTS: The two groups were similar with regard to type of hernia, surgical techniques of repair employed and type of anaesthesia employed in the intervention. In spite of the significantly greater anaesthetic risk in the group of patients of greater age (54.4% vs. 7.6% of patients ASA III; p<0.0005), significant differences were not registered between the two groups, either in the index of substitution in out-patient major surgery (80.0% vs. 81.8%) or in the development of complications (3.3% vs. 1.4%). CONCLUSION: Age is not a factor that alters the good results of the elective inguinal hernioplasty. We would thus not advise against this intervention in elderly patients.

Tratamiento de la enfermedad de Crohn perianal / Treatment of perianal Crohn’s disease

La afectación perianal por enfermedad de Crohn comprende un amplio espectro de lesiones de diferente manejo y pronóstico. Una exploración minuciosa del paciente, si es preciso bajo anestesia, una rectoscopia para valorar la posible afectación del recto por la enfermedad, y en ocasiones la valoración mediante ecografía endoanal o resonancia magnética, son las bases para un correcto enfoque diagnóstico y terapéutico. Farmacología y cirugía han de complementarse en el tratamiento de la enfermedad de Crohn perianal y perseguir un doble objetivo: aliviar la sintomatología del paciente y prevenir posibles complicaciones. Salvo en situaciones de urgencia por sepsis perianal, el tratamiento médico es el primer escalón en el manejo de la enfermedad de Crohn perianal, y en muchas ocasiones se controlará la enfermedad haciendo innecesaria la cirugía. Cuando se precisa de ésta, al propósito de un tratamiento definitivo de la lesión perianal, ha de contraponerse el riesgo de desarrollar complicaciones, muy especialmente incontinencia

Perianal affectation due to Crohn’s disease includes a wide spectrum of lesions involving different management and prognosis. A thorough exploration of the patient, under anaesthetic if necessary, a rectoscope to evaluate the possible affectation of the rectum by the disease, and on occasions evaluation through endoanal echography or magnetic resonance, are the bases for a correct diagnostic and therapeutic focus. Pharmacology and surgery must be complementary in the treatment of perianal Crohn’s disease and must pursue a double aim: to alleviate the symptomology of the patient and prevent possible complications. Except in situations of emergency due to perianal sepsis, medical treatment is the first step in managing perianal Crohn’s disease, and on many occasions it will control the disease, making surgery unnecessary. When surgery is required, with the aim of a definitive treatment of the perianal lesion, the risk of developing complications, especially incontinence, must be contrasted

¿Se debe operar de hernia a los pacientes mayores? / Should hernia operations be carried out on elderly patients?

Fundamento. Valorar si el tratamiento de la hernia inguinal en pacientes mayores de 70 años posee unas connotaciones distintas respecto a los pacientes de menor edad. Material y métodos. Estudio prospectivo sobre 299 pacientes intervenidos por hernia inguinal unilateral no complicada durante el año 2002. En el grupo 1, se incluyeron 90 pacientes con edad igual o superior a 70 años, y en el grupo 2 los 209 pacientes que no superaban esa edad. Las variables estudiadas en los dos grupos de pacientes fueron: tipo de hernia según la clasificación de Gilbert - Rutkow-Robbins, porcentaje de primarias-recidivadas, técnica de reparación, tipo de anestesia bajo la que se realizó la intervención, índice de sustitución en cirugía mayor ambulatoria y complicaciones postoperatorias. Resultados. Los dos grupos fueron similares en cuanto al tipo de hernia, técnicas quirúrgicas de reparación empleadas y tipo de anestesia bajo el que se realizó la intervención. A pesar de que el riesgo anestésico fue significativamente mayor en el grupo de pacientes de mayor edad (54,4 por ciento vs 7,6 por ciento de pacientes ASA III; p<0,0005), no se registraron diferencias significativas entre los dos grupos ni en el índice de sustitución en cirugía mayor ambulatoria (80,0 por ciento vs 81,8 por ciento), ni en el desarrollo de complicaciones (3,3 por ciento vs 1,4 por ciento).Conclusión. La edad no es un factor que altere los buenos resultados de la hernioplastia inguinal electiva.No debemos por tanto desaconsejar esta intervención en pacientes mayores (AU)

Simultaneous presentation of oesophageal and renal cancer

Oesophageal cancer has been documented to be often associated with other primary tumours. However, concurrent oesophageal and renal cell carcinoma is extremely uncommon. We report a case of synchronous oesophageal and kidney cancer that was successfully treated at our hospital by a one-stage surgical procedure. The patient is doing well and without recurrence 54 months after the operation (AU)

Oclusión intestinal por actinomicosis abdominal. Una infrecuente forma de presentación de la enfermedad / Intestinal occlusion due to abdominal actinomycosis. A rare presentation of the disease

La actinomicosis abdominal es una enfermedad poco frecuente producida por Actinomyces israelii, un germen usual del tracto gastrointestinal alto. Produce lesiones tumorales con abscesos y fístulas. Su forma de presentación clínica es muy variada. El diagnóstico preoperatorio correcto es inferior al 10 por ciento. Presentamos un caso de actinomicosis abdominal que se inició como obstrucción intestinal y que obligó a la resección quirúrgica con el diagnóstico preoperatorio de cáncer de colon izquierdo ocluido. La actinomicosis abdominal es una enfermedad que, aunque poco frecuente, debe tenerse en cuenta en el diagnóstico diferencial de pacientes con masas-abscesos abdominales (AU)

Cáncer de muñón gástrico: resultados del tratamiento quirúrgico / Gastric stump cancer: results of surgical treatment

Introducción. El pronóstico de cáncer de muñón gástrico, en general, es peor que el de cáncer gástrico primario. Métodos. Un total de 33 pacientes con cáncer de muñón tratados en nuestro servicio desde 1984 a 1999, 31 varones y 2 mujeres, con una edad media de 69,6 años. La primera intervención fue por úlcera gástrica en 14 casos, y duodenal o pilórica en 19. Presentaban gastrectomía Billroth II 22 pacientes y Billroth I 11 pacientes. El intervalo medio entre la primera operación y el diagnóstico del tumor fue de 30,6 años. Resultados. Fueron operados 27 pacientes; el índice de resecabilidad fue del 66,6 por ciento. Se realizaron 16 gastrectomías totales, 6 de ellas ampliadas y 2 casi totales. Predominó el adenocarcinoma tipo intestinal (22 casos); 4 pacientes presentaban tumores precoces (early) y en 13 (72,2 por ciento) existía afección de la serosa (pT3-pT4). La supervivencia actuarial global a los 5 años es del 22 por ciento, un 41,4 por ciento en los pacientes resecados (p < 0,001). Fue significativa la supervivencia de los casos resecados según el tamaño del tumor (p < 0,05).Conclusiones. En los pacientes gastrectomizados parece aconsejable el control endoscópico a partir de los 15 años para mejorar la resecabilidad y la supervivencia mediante un diagnóstico más precoz. La supervivencia obtenida en los casos tratados con gastrectomía total justifica este tratamiento quirúrgico agresivo. Hubo diferencias significativas en la supervivencia según el tamaño del tumor (AU)