RESUMO
A 50-year-old male, with a medical history of Lynch syndrome and transurethral-resection (TUR) secondary to multifocal bladder tumour (pT1-high grade) with normal subsequent follow-ups, consulted for anal pain, rectal tenesmus and fever for 3 weeks. On examination, he presented perianal oedema and, on digital rectal examination, a right lateral orifice was palpable at 6cm from the anal margin. CT scan revealed a defect-in-continuity in the right rectal wall which communicated with bilateral perirectal collections extending towards the puborectalis-levator ani. On the right side, it extended towards the ischiorectal fossa and, on the left side it continued with another collection that displaced the corpus cavernosum. Urgent transanal debridement of abscess with biopsy and cultures was performed. Subsequent evolution was torpid. The clinical history was reviewed, as the patient had undergone repeated bladder catheterizations after TUR and BCG therapy one year before. Abdominal tomography with urethral contrast and cystourethrography were performed, which confirmed the presence of a fistula in the bulbomembranous urethra that communicated with the perirectal abscesses. Cultures and biopsies were negative for mycobacteria and malignancy was ruled out. A new surgical exploration was carried out, enlarging the transanal drainage orifice, making a temporary intestinal stoma and bladder catheterization. After eighteen weeks, the healing of the fistula was verified through of a new cystourethrography. Reconstruction of the intestinal transit has now been scheduled, after radiologically and endoscopically verifying the closure of the rectal orifice.
Assuntos
Fístula , Doenças Retais , Masculino , Humanos , Pessoa de Meia-Idade , Abscesso/diagnóstico por imagem , Abscesso/etiologia , Abscesso/terapia , Uretra , Doenças Retais/etiologia , Doenças Retais/terapia , Reto , Fístula/complicaçõesRESUMO
PURPOSE: Bowel dysfunction after rectal cancer surgery may significantly affect the quality of life. Our study aimed to estimate the incidence and characterize the low anterior resection syndrome (LARS). METHODS: Prospective evaluation of patients treated with anterior resection for rectal cancer at two hospitals followed for 12 months after ileostomy reversal. The assessment was performed at baseline, after neoadjuvant treatment, and 1 month, 6 months, and 12 months after bowel transit reconstruction using several scores (Bristol scale, LARS score, Memorial Sloan Kettering bowel function instrument, Fecal Incontinence Quality of Life, EORTC-QLQ30, and a visual analogue scale). RESULTS: Of 205 patients diagnosed with rectal cancer, 78 were followed for 12 months after the exclusion criteria. "Major LARS" at 1 month, 6 months, and 12 months was 55.6%, 47.3%, and 34.6%, respectively. At 12 months, patients experienced significantly less diarrhea, higher LARS score, more percentage of "major LARS," and worse MSK-BFI score compared to baseline. Regarding the quality of life at 12 months, 77.7% of patients with "major LARS" reported impact according to the anchor question of the LARS score; all FIQL subscales were significantly lower; the overall EORTC-QLQ30 score and the functional subscales significantly correlated with the LARS and the MSK-BFI scores. CONCLUSIONS: Bowel dysfunction with an impact on the quality of life is common after rectal cancer surgery. The knowledge of the potential consequences of the treatments is essential to be able to provide patients with the best possible information.
Assuntos
Enteropatias , Neoplasias Retais , Humanos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Qualidade de Vida , Neoplasias Retais/complicações , Neoplasias Retais/cirurgia , Reto , SíndromeRESUMO
OBJECTIVES: In some patients treated for urinary or fecal incontinence with sacral neuromodulation (SNM) persistence of symptoms, a reduction in efficacy or adverse effects of stimulation can occur. In such situations, further programming of the SNM device can help resolve problems. Infrequently hardware failure is detected. This article aims to provide practical guidance to solve sub-optimal outcomes (troubleshooting) occurring in the course of SNM therapy. MATERIALS AND METHODS: A systematic literature review was performed. Collective clinical experience from an expert multidisciplinary group was used to form opinion where evidence was lacking. RESULTS: Circumstances in which reprogramming is required are described. Actions to undertake include changes of electrode configuration, stimulation amplitude, pulse frequency, and pulse width. Guidance in case of loss of efficacy and adverse effects of stimulation, developed by a group of European experts, is presented. In addition, various hardware failure scenarios and their management are described. CONCLUSIONS: Reprogramming aims to further improve patient symptoms or ensure a comfortable delivery of the therapy. Initial changes of electrode configuration and adjustment of stimulation parameters can be performed at home to avoid unnecessary hospital visits. A logical and stepwise approach to reprogramming can improve the outcome of therapy and restore patient satisfaction.
Assuntos
Terapia por Estimulação Elétrica , Incontinência Fecal , Incontinência Fecal/terapia , Humanos , Plexo Lombossacral , Satisfação do Paciente , Sacro , Resultado do TratamentoRESUMO
Introduction: During the state of alarm established in Spain due to the COVID-19 pandemic, most of the face-to-face outpatient consultations were cancelled and a telephone consultation was established to follow up coloproctological patients. The objective of this study was to analyse the efficacy of telemedicine (by telephone) in monitoring patients in a coloproctology unit, in the context of the COVID-19 pandemic. Method: Prospective descriptive study of consecutive patients in a single centre. The result of the teleconsultation was classified as discharge, resolved visit or reprogramming and was analysed by different diagnostic groups. Results: From March 19th to April 17th, 2020, the teleconsultation of 190 patients was carried out. The response rate was 94.2% (179). The diagnostic categories of the patients attended were: 51 (26.9%) colorectal neoplasia, 48 (25.3%) proctological pathology, 72 (37.9%) pelvic floor dysfunctions and 19 (10%) other benign pathologies. 105 (55.26%) could be recited as if they had come in person. Eleven (5.8%) patients were discharged. No significant differences were found between the different diagnostic categories and the resolution of the teleconsultation. The reasons for reprogramming are analyzed in the study. Conclusion: In the context of a pandemic, teleconsultation has allowed 61% of follow-up visits to be definitively solved, avoiding the reprogramming of 116 patients. The new social and health paradigm after the pandemic will require a rethinking of our healthcare model, and in many aspects, telemedicine can offer tools for this.
RESUMO
BACKGROUND: Bowel disturbances have been identified as the most important risk factor for fecal incontinence (FI). However, few studies have evaluated the impact of fiber supplementation. Our aim was to assess the correlation between the improvement in stool consistency by fiber supplementation and the changes in urgency and number of FI episodes and in the QoL of patients with FI. METHODS: Eighty-three patients who came to our institution with FI and/or fecal urgency associated with loose stools or diarrhea were prospectively included in the study The intervention included dietary advice and methylcellulose 500 mg every 8 h for 6 weeks. All assessments were carried out at baseline and 6 weeks after the start of the intervention, and included a Bristol Stool Scale, a 3-week bowel diary, the St Mark's score, the Fecal Incontinence Quality of Life scale (FIQL) and a bowel satisfaction score. RESULTS: Sixty-one patients completed the study. At baseline 50 reported episodes of urge incontinence, while 11 did not report FI episodes because they rarely left home to avoid leakage. The Bristol score improved to normal stools in 65.6% of patients after treatment. Bowel diaries showed a statistically significant reduction in the number of bowel movements, urge episodes, urge fecal incontinence episodes and soiling per week. The St Mark's score and the bowel satisfaction score significantly improved after methylcellulose and overall deferment time also increased. FIQL significantly improved in two subdomains (lifestyle, coping/behavior). Thirty-one patients (51.7%) were discharged with methylcellulose as the only treatment. CONCLUSIONS: FI may significantly improve with methylcellulose in selected cases. Assessment of fecal consistency and initial treatment with methylcellulose could be started at primary care level to reduce the need for specialist referral.
Assuntos
Defecação , Diarreia/tratamento farmacológico , Fibras na Dieta/uso terapêutico , Incontinência Fecal/tratamento farmacológico , Metilcelulose/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador , Diarreia/complicações , Dieta , Suplementos Nutricionais , Aconselhamento Diretivo , Incontinência Fecal/complicações , Incontinência Fecal/fisiopatologia , Fezes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade da Assistência à Saúde , Índice de Gravidade de Doença , Adulto JovemRESUMO
BACKGROUND: Postoperative rectourethral fistula after radical prostatectomy is an infrequent but very serious problem. OBJECTIVE: We aimed to describe our experience with transperineal repair and unilateral gracilis muscle interposition in patients with rectourethral fistula after radical prostatectomy in nonradiated prostate cancer. DESIGN: This was a cohort study. SETTINGS: All of the procedures were performed at the same hospital by the same multidisciplinary team made up of a senior colorectal surgeon and a senior urologist. PATIENTS: Patients with postoperative rectourethral fistula after laparoscopic prostatectomy were included. INTERVENTION: Transperineal fistula repair and gracilis muscle interposition were included. MAIN OUTCOME MEASURES: Fistula healing rate was measured. RESULTS: Nine patients with postoperative rectourethral fistula were treated between November 2009 and February 2016. Four of them had received other previous treatments without success, and 5 had previously been treated with this technique. Seven patients had a fecal diverting stoma. After a median follow-up of 54 months (range, 2-72), all of the fistulas had successfully healed, and, to date, the patients remain asymptomatic without urinary diversion. Fecal diversion was closed in all but 1 patient. No intraoperative or infectious complications were detected. With the results of our series, we present specific technical details of our technique and hope to provide additional evidence of the low morbidity profile and excellent healing rate of this treatment. Moreover, we note that, although small, this series corresponds with a homogeneous group of patients with rectourethral fistula after radical prostatectomy in nonradiated prostate cancer. LIMITATIONS: This is a small but very homogeneous group of patients. CONCLUSIONS: Simple repair with perineal gracilis muscle interposition is a safe and effective technique for the treatment of postoperative rectourethral fistulas after nonradiated prostate cancer surgery.
Assuntos
Músculo Grácil/transplante , Complicações Pós-Operatórias/cirurgia , Prostatectomia , Neoplasias da Próstata/cirurgia , Fístula Retal/cirurgia , Retalhos Cirúrgicos , Doenças Uretrais/cirurgia , Fístula Urinária/cirurgia , Idoso , Estudos de Coortes , Seguimentos , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: The impact of the low anterior resection syndrome (LARS) on quality of life has underscored the importance of measuring functional outcomes after treatment for rectal cancer. The aim of this study was to evaluate whether the LARS score as a single questionnaire was useful enough in the clinical setting. METHODS: Patients treated by curative anterior resection for rectal cancer were sent the LARS score and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 questionnaires by post. Patients classified as "minor" and "major" LARS according to the LARS score were visited. Assessment included several scores (Vaizey score, Altomare Obstructed Defecation Syndrome score, Bristol scale). Patients with urgency/faecal incontinence also filled in a bowel diary and the FIQL score. RESULTS: Seventy patients returned the questionnaires, 49 of whom ("major LARS" and "minor LARS") were visited and 19 ("no LARS") were assessed by phone. Four different clinical patterns were identified. The group with urgency/faecal incontinence was the largest (33.8 %), whereas 17.7 % referred evacuatory dysfunction. The LARS score did not correctly evaluate 18 patients: 5 who were classified as no LARS but had severe evacuatory dysfunction and 13 patients categorized as LARS but without significant bowel dysfunction, 9 of whom were classified as major LARS. CONCLUSION: The LARS score may overestimate the impact on quality of life in some patients and may underestimate the impact of severe evacuatory dysfunction. Due to the complexity of the LARS, the LARS score as a single questionnaire might not be enough to assess bowel function. A complete clinical evaluation and additional questionnaires might be required.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Neoplasias Retais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fezes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Prevalência , Qualidade de Vida , Procedimentos de Cirurgia Plástica , Inquéritos e Questionários , SíndromeRESUMO
INTRODUCTION: Sacral neuromodulation (SNM) (sacral nerve stimulation SNS) has become an established therapy for functional disorders of the pelvic organs. Despite its overall success, the therapy fails in a proportion of patients. This may be partially due to inadequate electrode placement with suboptimal coupling of the electrode and nerve. Based on these assumptions the technique of sacral spinal neuromodulation has been redefined. All descriptions relate to the only currently available system licensed for all pelvic indications (Medtronic Interstim® ). METHOD: An international multidisciplinary working party of ten individuals highly experienced in performing SNM convened two meetings (including live operating) to standardize the implant procedure. This report addresses the main steps to optimal electrode lead placement in temporal sequence. RESULTS: Key elements of the electrode placement are radiological marking, the use of a curved stylet, the entry of the electrode into the sacral foramen and its progression through the foramen, its placement guided by a combination of a typical appearance in fluoroscopy and achieving specific motor/sensory responses with stimulation. The report describes quadripolar electrode placement and then either insertion of a connecting percutaneous extension lead or permanent implantation of the programmable device. CONCLUSION: Standardization of electrode placement may ensure close electrode proximity to the target nerve providing a higher likelihood for optimal effect with less energy consumption (better battery longevity), more programming options with more electrode contacts close to the nerve and reduced likelihood of side-effects. The potentially better clinical outcome needs to be demonstrated.
Assuntos
Terapia por Estimulação Elétrica/normas , Eletrodos Implantados/normas , Plexo Lombossacral/fisiologia , Equipe de Assistência ao Paciente/normas , Posicionamento do Paciente/normas , Antibioticoprofilaxia/normas , Terapia por Estimulação Elétrica/instrumentação , Terapia por Estimulação Elétrica/métodos , Incontinência Fecal/fisiopatologia , Incontinência Fecal/terapia , Humanos , Pesquisa Interdisciplinar/métodos , Pesquisa Interdisciplinar/normas , Posicionamento do Paciente/instrumentação , Posicionamento do Paciente/métodos , Sacro/inervação , Sacro/fisiologiaRESUMO
INTRODUCTION: Despite its high prevalence, faecal incontinence (FI) is still underrated and underdiagnosed. Moreover, diagnosis and subsequent treatment can be a challenge for the colorectal surgeon because of its associated social taboo and embarrassment, and the wide range of symptoms. The aim of the present study is to describe a new high-resolution circuit (HRC) for FI diagnosis, that was implemented at our center and to evaluate patient satisfaction. METHODS: The structure and organization of the HRC are described. Demographic and clinical data of the patients included in the HRC between February 2014 and June 2016 were collected. Moreover, patients' satisfaction was measured through a structured survey. RESULTS: A total of 321 patients were evaluated in our pelvic floor outpatients clinic during the study period: 65% (210) of them had FI (81% women, median age 66 years). The mean time since FI onset was 24 (range 4-540) months. A total of 79% (165) of the patients were included in the HRC. 62% of them responded to the survey. Of these, only 32% (33) had consulted for FI before coming to our centre. The majority, 88% (90) considered that performing the 2diagnostic tests the same day of the visit was a very good option. And 94% (96) were satisfied with the information received on their FI, with a median satisfaction value of 10 (5-10). CONCLUSION: With the HRC, the patient spends about 2h in the outpatient clinic of the hospital, but leaves with the complete diagnostic process performed. The satisfaction survey confirms that most patients prefer this system.
Assuntos
Incontinência Fecal/diagnóstico , Satisfação do Paciente , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Técnicas de Diagnóstico do Sistema Digestório , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
Phlegmonous gastritis is a rare bacterial infection of the gastric wall, which progress rapidly. It is characterized by a purulent inflammation that can affect the entire gastrointestinal tract and presents a high mortality rate. We are reporting a case of phlegmonous gastritis in an HIV-seropositive man successfully treated with antibiotics. Moreover, a review of the English andSpanish literature is carried out, from 1980 to the present time.The most frequently involved microorganism is Streptococcus spp. (57 %), but the polimicrobial infection is also frequent (17 %). The most important symptom is the intensive epigastric pain associated with vomits and most cases were diagnosed by CT and/or fibrogastroscopy. There are many existing risk factors described.The main one is the immunesuppression, although in 40 % of the cases no risk factors were identified. The global mortality is 27 % without identifying significant differences between antibiotics and surgical treatment, for that reason it is recommended to initiate antibiotic treatment right from the beginning and postponing surgery for the refractory cases and complications.
Assuntos
Abdome Agudo/etiologia , Gastrite/diagnóstico , Adulto , Antibacterianos/uso terapêutico , Gastrite/complicações , Gastrite/tratamento farmacológico , Humanos , MasculinoRESUMO
Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.
Assuntos
Terapia por Estimulação Elétrica , Incontinência Fecal , Humanos , Terapia por Estimulação Elétrica/métodos , Incontinência Fecal/diagnóstico , Incontinência Fecal/terapia , Canal Anal , Medicina Baseada em EvidênciasRESUMO
INTRODUCTION: During the state of alarm established in Spain due to the COVID-19 pandemic, most of the face-to-face outpatient consultations were cancelled and a telephone consultation was established to follow up coloproctological patients. The objective of this study was to analyse the efficacy of telemedicine (by telephone) in monitoring patients in a coloproctology unit, in the context of the COVID-19 pandemic. METHOD: Prospective descriptive study of consecutive patients in a single centre. The result of the teleconsultation was classified as discharge, resolved visit or reprogramming and was analysed by different diagnostic groups. RESULTS: From March 19th to April 17th, 2020, the teleconsultation of 190 patients was carried out. The response rate was 94.2% (179). The diagnostic categories of the patients attended were: 51 (26.9%) colorectal neoplasia, 48 (25.3%) proctological pathology, 72 (37.9%) pelvic floor dysfunctions and 19 (10%) other benign pathologies. 105 (55.26%) could be recited as if they had come in person. Eleven (5.8%) patients were discharged. No significant differences were found between the different diagnostic categories and the resolution of the teleconsultation. The reasons for reprogramming are analyzed in the study. CONCLUSION: In the context of a pandemic, teleconsultation has allowed 61% of follow-up visits to be definitively solved, avoiding the reprogramming of 116 patients. The new social and health paradigm after the pandemic will require a rethinking of our healthcare model, and in many aspects, telemedicine can offer tools for this.
Assuntos
COVID-19 , Doenças do Colo , Doenças Retais , Consulta Remota/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/epidemiologia , Doenças do Colo/diagnóstico , Cirurgia Colorretal , Feminino , Unidades Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doenças Retais/diagnóstico , Espanha/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: To determine whether the Thiel cadaveric model is better and more realistic than other surgical simulation techniques for learning pelvic floor and perineal surgical procedures according to the opinions of urogynecologists and surgeons participating in international postgraduate pelvic floor surgery courses using cadavers embalmed by the Thiel method. STUDY DESIGN: An observational prospective study was performed in urogynecologists and surgeons attending international postgraduate pelvic floor and perineal surgery courses using cadavers embalmed by the Thiel method. A survey was completed by the participants after finishing the course. Based on the answers collected, we analyzed the differences, including in the satisfaction degree and teaching level for each surgical procedure, between different surgical simulation models that the participants had already used and the Thiel simulation method employed. RESULTS: The students recognized that Thiel cadavers present more similarities to patients than other simulation methods. The Thiel cadaveric method was considered by most responders to be the best for the simulation of surgical procedures on the pelvic floor and perineum. Most of the surgeons surveyed recommended conducting these courses with Thiel cadavers for different colleagues in other specialties as a reliable simulation method for training for difficult surgical procedures. CONCLUSIONS: Participants in the course on pelvic floor surgery in Thiel cadavers recognized that this is the most realistic model for surgical simulation and the best way to gain confidence, self-determination and precise surgical skills for performing pelvic floor and perineal surgery.
Assuntos
Diafragma da Pelve , Treinamento por Simulação , Cadáver , Embalsamamento , Humanos , Diafragma da Pelve/cirurgia , Estudos ProspectivosRESUMO
AIM: The aim of this study is to analyze whether fast-track (FT) recovery protocols can be applied to single-port laparoscopic surgery for colon resection, as they are in multiport laparoscopic surgery. MATERIALS AND METHODS: Retrospective study comparing single-port laparoscopic surgery (SP-FT) versus multiport laparoscopic surgery (MP-FT) for colon resection, and the applicability of our FT recovery protocol in all patients between 2013 and 2014. Variables evaluated were American Society of Anesthesiologists (ASA) score, tumor size, number of nodes, surgery performed, postoperative morbidity, and length of hospital stay. RESULTS: A total of 83 patients (28 SP-FT group and 55 MP-FT group) underwent FT recovery. The median age was 62 (11-85) years in SP-FT group and 72 (57-84) in MP-FT group. ASA score showed no significant difference (P = .973). The surgical procedures performed were as follows: SP-FT group 20 right hemicolectomy, 5 left hemicolectomy, and 3 subtotal colectomy and MP-FT group were 26 right hemicolectomy, 28 left hemicolectomy, and 1 subtotal colectomy. Mean operative time (minutes) was shorter in SP-FT group (151 ± 47.9 versus 182 ± 50.7), but no significant difference was observed. Regarding the tumor size (SP-FT 4.2 [2-7] cm versus MP-FT 4 [3-12] cm) and postoperative morbidity Clavien-Dindo ≥2 (SP-FT 10 patients versus MP-FT 20 patients), there were no significant differences (P = .535; P = .383). The median length of hospital stay was statistically significant: SP-FT 4.5 (3-53) days versus MP-FT 7 (4-33) days (P = .005). CONCLUSIONS: FT rehabilitation is safe and reproducible in single-port laparoscopic surgery for colon pathologies, with postoperative results comparable with conventional laparoscopic surgery.