Shock séptico secundario a fascitis necrotizante abdominal tras drenaje de absceso interesfintérico perianal / Septic shock secondary to abdominal necrotizing fascitis after drainage of perianal intersphyteric abscess

Resumen Objetivo: El objetivo de este manuscrito es presentar el caso de un varón de 41 años que debuta con shock séptico y fascitis necrotizante abdominal en el posoperatorio del desbridamiento de un absceso perianal para focalizar la atención del lector en la posible evolución clínica hacia gangrena de Fournier. Materiales y Método: Tras la intervención, el paciente refiere aumento de temperatura y sensación de crepitación subcutánea a nivel abdominal, junto con empeoramiento clínico y hemodinámico, evidenciándose evolución tórpida hacia gangrena de Fournier extendida a región abdominal. Resultados: Tras la reintervención, el paciente presentó una evolución favorable aunque requirió sucesivas curas y desbridamientos quirúrgicos. Conclusiones y Discusión: Cabe destacar la importancia de una exploración clínica completa y detallada previa a cualquier intervención quirúrgica, así como el diagnóstico temprano en situaciones de shock séptico que permitan inicio de antibioterapia precoz y control del foco eficaz.

Aim: The objective of this manuscript is to present the case of a 41-year-old man with septic shock and abdominal necrotizing fasciitis after drainage of an interesphinteric perianal abscess to focus the reader's attention on the possible clinical evolution towards Fournier's gangrene. Materials and Method: After the intervention, the patient reported an increase in temperature and a sensation of subcutaneous crepitus at the abdominal level, with clinical and hemodynamic worsening, showing a torpid evolution towards Fournier's gangrene extended to the abdominal area. Results: After the reoperation, the patient presented a favorable evolution, although he required successive cures and surgical debridements. Conclusions and Discussion: It is worth highlighting the importance of a complete and detailed clinical examination prior to any surgical intervention, as well as the early diagnosis in situations of septic shock that allow early initiation of antibiotic therapy and effective control of the focus.

Anal fistula surgery in an outpatient setting: the Dubai experience / Cirurgia de fístula anal em regime ambulatorial: a experiência Dubai

AIM: To determine whether surgery for transsphincteric and complex fistula-in-ano can be performed safely as a day case. METHOD: This is a retrospective study of 66 patients with transsphincteric and complex anal fistulas, initially managed with preliminary loose Seton followed by fistulectomy and sphincter repair 2-4 months later between March 2011 and March 2014. Patients were seen at the clinic 1 week, 3 months and 1 year post-operatively and were observed for complications and recurrences; incontinence was noted down and was graded according to the Cleveland Clinic score. RESULT: Twenty-five patients (38%) had high or complex fistulas and 32 (48.5%) had a history of previous surgery. All cases were done in an outpatient setting. The Seton was kept in situ for 2-5 months (2.6 months) followed by fistulectomy and sphincter repair. Complete healing was achieved within approximately 3.6 weeks (2-8 weeks). Fifty-one patients were followed up successfully for one year. Two patients had temporary flatus incontinence which had resolved over 2-3 months. Recurrence had occurred in 2 (3.9%) patients. CONCLUSION: Transsphincteric and complex fistulas can safely be operated on as day case surgeries with high patient satisfaction and less complication in the population we studied. (AU)

OBJETIVO: Determinar se cirurgias para fístulas transesfincterianas e para fistulae in ano complexas podem ser realizadas com segurança em ambiente ambulatorial, sem pernoite do paciente no hospital. MÉTODO: Trata-se de um estudo retrospectivo de 66 pacientes com fístulas transesfincterianas e fístulas anais complexas, inicialmente tratados preliminarmente com seton de drenagem, seguido por fistulectomia e reparo do esfíncter 2-4 meses mais tarde, entre março de 2011 e março de 2014. Os pacientes foram reexaminados no ambulatório uma semana, três meses e ano após a cirurgia, tendo sido observados para complicações e recorrências; casos de incontinência foram anotados e classificados de acordo com o escore da Cleveland Clinic. RESULTADO: Vinte e cinco pacientes (38%) apresentaram fístulas altas ou complexas e 32 (48,5%) tinham história de cirurgia prévia. Todos os casos foram tratados em ambiente ambulatorial. O seton foi mantido in situ durante 2-5 meses (2,6 meses), seguido por fistulectomia e reparo do esfíncter. A cura completa se concretizou em cerca de 3,6 semanas (2-8 semanas). Cinquenta e um pacientes foram acompanhados com sucesso ao longo de um ano. Dois pacientes tiveram incontinência temporária para gases, resolvida ao longo de 2-3 meses. Recorrência ocorreu em 2 (3,9%) pacientes. CONCLUSÃO: Fístulas transesfincterianas e fístulas complexas podem ser operadas com segurança como casos ambulatoriais, sem permanência hospitalar noturna, com grande satisfação do paciente e menos complicações na população estudada. (AU)

View of the Public Health System users regarding proctology

Proctology is a specialty of extreme importance due to the high prevalence of anorectal diseases in the population. Despite this fact and its history from the origin of humanity, it is marked by insufficient knowledge, prejudice and teasing. OBJECTIVE: Evaluate the degree of knowledge about Proctology, obtaining data, which may guide and emphasize the need for campaigns to disseminate the specialty. METHOD: An ecological study was conducted on the people's degree of knowledge about the specialty of Proctology. We interviewed 200 patients from August 2008 to January 2009, who came to the outpatient clinic of the Unified Health System, in five different medical specialties in the city of Itajaí (SC). RESULTS: Among the interviewees, 86% did not know what proctology was. Of the 28 (14%) respondents that said they knew it, only 21 (10.5%) answered correctly when they were asked what the specialty was about. CONCLUSION: Despite the high prevalence of anorectal diseases, a great percentage of the population is unaware of the specialty. This fact could be due to the social prejudice and the lack of information provided by health professionals. (AU)

A Proctologia trata-se de uma especialidade de extrema importância devido à alta prevalência de doenças anorretais na população. Apesar de tal fato e de sua história, desde as origens da humanidade, é marcada por déficit de conhecimento, preconceitos e chacotas. OBJETIVO: Avaliar o grau de conhecimento sobre a Proctologia, obtendo dados, os quais poderão guiar e enfatizar a necessidade de campanhas dirigidas para a divulgação da especialidade. MÉTODO: Foi realizado um estudo ecológico sobre o grau de conhecimento das pessoas sobre a especialidade de Proctologia. Foram entrevistados 200 pacientes, no período de agosto de 2008 a janeiro de 2009, que frequentavam o ambulatório do Sistema Único de Saúde da Unidade de Saúde da Família e Comunitária e Posto de Atendimento Médico, em cinco especialidades médicas distintas, no município de Itajaí (SC). RESULTADOS: Dentre os entrevistados, 86% referiram não saber o que é proctologia. Dos 28 (14%) que responderam saber, apenas 21 (10,5%) responderam corretamente quando questionados sobre o que se tratava a especialidade. CONCLUSÃO: Apesar da grande prevalência das doenças anorretais, grande parcela da população desconhece a especialidade. Esse fato pode-se dever ao preconceito da sociedade, bem como a própria falta de informação dos profissionais de saúde. (AU)

Urgencias proctológicas / Proctology emergencies

Las urgencias proctológicas son una causa frecuente de consulta en Servicios de Urgencia. Para los pacientes este tipo de problemas implican, además de los propios síntomas, en muchos casos pudor o vergüenza, lo cual puede redundar en una consulta tardía en relación al inicio del cuadro clínico. Para el médico de urgencia es un desafío poder determinar de forma clara el diagnóstico y el tratamiento adecuado, así como la necesidad de hospitalizar o indicar la consulta por un especialista. Es por esto que se hace necesario el poseer los conocimientos básicos para el diagnóstico y el manejo inicial de las patologías más frecuentes tales como el dolor anal, sangrado vía anal o aumento de volumen en la zona perianal. El objetivo de esta revisión es entregar las bases para un adecuado diagnóstico y manejo de las patologías proctológicas que más frecuentemente requieren una atención de urgencia.

Proctologic emergencies are a frequent cause of consultation in the emergency room. For these patients, such problems involve not only a physical discomfort or pain, but also shame in many cases, which can result in a late consultation in relation of the onset of symptoms. These problems are a chellenge, in order to perform an accurate diagnosis and appropriate treatment. Like wise it is necessary to determine the need for hospitalization or evaluation by a specialist. This is why it is necessary to have the basic knowledge and skills for diagnosis and initial management of most common diseases such as anal pain, rectal bleeding or increased volume in the perianal area. The aim of this review is to provide the basis for a proper diagnosis and management of proctologic pathologies most frequently evaluated in an emergency room.

Instilação de formalina endoluminal como opção terapêutica da retite actínica hemorrágica / Endoluminal formalin instillation as a therapeutic option of radiation-induced hemorrhagic proctitis

A retite actínica hemorrágica é um quadro grave que pode ocorrer em qualquer paciente submetido à radioterapia pélvica, por vezes, sendo necessária terapia transfusional e internação hospitalar. A abordagem terapêutica ainda é bastante controversa. Tanto para o tratamento inicial como para casos refratários, uma das opções é a aplicação de formalina. Este método é barato, facilmente disponível, de simples execução e eficaz no controle da hemorragia. Os autores relatam dois casos de retite actínica hemorrágica de pacientes tratados com instilação de formalina endoluminal, e sua eficácia terapêutica e complicações são discutidas.

The radiation-induced hemorrhagic proctitis is a serious condition that can occur in any patient undergoing pelvic radiotherapy, sometimes being required hospitalization and transfusion therapy. The therapeutic approach is still very controversial. Both for the initial treatment and for refractory cases, one option is formalin application. This method is cheap, easily available, simple to perform, and effective in controlling bleeding. The authors report two cases of radiation-induced hemorrhagic proctitis treated with endoluminal instillation of formalin, and they discuss its therapeutic efficacy and complications.

Local Perianal Block in Anal Surgery: The Disadvantage of Pain during Injection despite High Patient Satisfaction

PURPOSE: We evaluated the usefulness of anal surgery using local perianal block and assessed patient satisfaction. METHODS: From January to October 2008, a total of 41 consecutive patients consented to anal operation with local perianal block for stapled hemorrhoidopexy (n=15), excisional hemorrhoidectomy (n=9), fistulotomy (n=13), or abscess drainage (n=4). Postoperative pain was evaluated on a visual analogue scale (VAS) from 0 to 10. Patient satisfaction was evaluated through telephone interviews. RESULTS: The mean peak VAS scores on the day of operation were 3.3 after stapled hemorrhoidopexy, 2.9 after excisional hemorrhoidectomy, 2.6 after fistulotomy, and 3.5 after abscess drainage; on postoperative day 1, the scores were 1.3, 1, 0.9, and 2.3, respectively. The majority of patients (31; 86.1%) were satisfied with the postoperative results (very satisfied 12, satisfied 19, only fair 5, unsatisfied 0). More than half of the patients (23; 63.9%) were satisfied with the use of local anesthesia (very satisfied 4, satisfied 19, only fair 12, unsatisfied 1). The mean VAS scores during injection were significantly different between the satisfied group (very satisfied and satisfied) and not-satisfied group (only fair and unsatisfied) treated with the local anesthesia (satisfied group: 3.5 and not-satisfied group: 5.4, P=0.04). Most patients (30; 83.3%) would undergo this anesthetic procedure again if future anal surgeries were necessary. CONCLUSION: Local perianal block is feasible for various anal operations and results in a high degree of satisfaction among patients. However, the pain associated with injection has an adverse effect on patient satisfaction.

Conveniencia de la cirugía ambulatoria en proctología. Análisis retrospectivo de 1031 casos / Ambulatory surgery in proctology: retrospective analysis of 1 031 cases

Introducción: El número de cirugías ambulatorias realizadas en hospitales, como en clínicas particulares, crece a cada día. Este aumento se ha observado principalmente en las últimas dos décadas. En muchos países, como Francia, predominan las cirugías ambulatorias sobre las hospitalarias. Objetivo: Evaluar retrospectivamente 1031 casos de pacientes operados en el Servicio de Cirugía Ambulatoria del H.C. de la Facultad de Medicina de Botucatu. Material y método: Fueron estudiados retrospectivamente 1031 casos clínicos de patologías orificiales operados en el servicio, se analizó la distribución por grupo etario, sexo, patologías y complicaciones posoperatorias. Resultados: Hemos notado predominio de pacientes con edad inferior a los 45 años (56.6%), discreta prevalencia del sexo masculino (51.2%), que la enfermedad hemorroidaria (60%) es la principal afección y el dolor y el sangrado las intercurrencias más frecuentes (3.2%). Conclusiones: Los resultados obtenidos demuestran que los procedimientos ambulatorios en proctología pueden ser realizados de forma sistemática y segura, a bajo costo, con pocas complicaciones y ventajas en relación con los procedimientos realizados en régimen de internación hospitalaria.

Introduction: The number of ambulatory surgeries accomplished in hospitals, as in private clinics, grows eachday, with this increase having been observed principallyin the last two decades. In many countries, such as France, ambulatory surgeries have predominated in relation tothose in hospitals. Objective: To evaluate retrospectively1 031 cases of patients operated on in the Ambulatory Surgery Service of C.H. in the School of Medicine at Botucatu. Material and method: Retrospectively, 1 031clinical cases of orificial pathologies operated on in the service were studied, analyzing the distribution by agegroup, sex, pathologies and postoperative complications. Result: We note predominance of patients aged less than45 years (56.6%), discrete prevalence of males (51.2%), with hemorrhoidal disease (60%) being the principalaffliction, with pain and bleeding being the most frequent complications (3.2%). Conclusions: The results obtained demonstrate that ambulatory procedures in proctologycan be accomplished in a safe and systematic manner at low cost with advantages and fewer complications in relation to procedures completed in a hospitalizationregime.

Care of the patient for surgery of large bowel

This paper deals with an established method of preparing patients for elective surgery of the large bowel, including the anorectum. Preoperative operation, which includes general and local measures, and postoperative care was discussed