Arterias sigmoideas: bases para una nueva clasificación / Sigmoid arteries: bases for a new classification

Las arterias sigmoideas son ramas de la arteria mesentérica inferior e irrigan al colon sigmoideo. Se originan del tronco de las arterias sigmoideas. Esta es la descripción más frecuente según los autores consultados. El objetivo fue analizar las variaciones en el origen y distribución de las arterias sigmoideas mediante disección. Se utilizaron 13 preparados cadavéricos formolizados al 10 %. Se disecó la cavidad abdominal para identificar a las arterias sigmoideas. Se evidenció su bifurcación paralela al colon sigmoideo. Se lo delimitó mediante reparos palpables. Patrón I: 4 casos (30,8 %). Variante de la arcada sigmoidea como rama colateral de la arteria mesentérica inferior. Tipo Ia: 1 caso (25 %). Sin asociaciones. Tipo Ib: 1 caso (25 %). Asociada al tronco sigmoideo. Tipo Ic: 2 casos (50 %). Asociada a arterias sigmoideas accesorias. Patrón II: 6 casos (46,2 %). Variante del tronco común entre arteria cólica izquierda y arterias destinadas al colon sigmoideo. Tipo IIa: 3 casos (50 %). Sin asociaciones. Tipo IIb: 2 casos (33,3 %). Asociado al tronco sigmoideo. Tipo IIc: 1 caso (16,7 %). Asociado a arterias sigmoideas accesorias. Patrón III: 3 casos (23 %). Variante clásica. Se definió por la ausencia del tronco común con la arteria cólica izquierda y de la arcada sigmoidea. Tipo IIIa: 2 casos (66,7 %). Un número variable de arterias sigmoideas nacen como ramas colaterales de la arteria mesentérica inferior, sin asociarse al tronco sigmoideo. Tipo IIIb: 1 caso (33,3 %). La arteria cólica izquierda emite como rama colateral la primera arteria sigmoidea y se asocia al tronco sigmoideo. 1. El patrón II es el prevalente en este trabajo (46,2 %). 2. La variante clásica no es la predominante en esta investigación (23 %). 3. La arcada sigmoidea tiene 53,8 % de incidencia.

SUMMARY: The sigmoid arteries are branches of the inferior mesenteric artery and supply the sigmoid colon. They originate from the trunk of the sigmoids. This is the most frequent description according to the consulted authors. The objective is to analyze the variations in the origin and distribution of the sigmoid arteries through dissection. 13 cadaveric preparations formalized at 10 % and instruments were used. The abdominal cavity was dissected to identify the sigmoid arteries. Its bifurcation parallel to the sigmoid colon is evident. It is delimited by palpable repairs. Pattern I: 4 cases (30.8 %). Variant of the sigmoid arcade as a collateral branch of the inferior mesenteric artery. Type Ia: 1 case (25 %). No associations. Type Ib: 1 case (25 %). Associated with the sigmoid trunk. Type Ic: 2 cases (50 %). Associated with accessory sigmoid arteries. Pattern II: 6 cases (46.2 %). Variant of the common trunk between the left colic artery and arteries destined for the sigmoid colon. Type IIa: 3 cases (50 %). No associations. Type IIb: 2 cases (33.3 %). Associated with the sigmoid trunk. Type IIc: 1 case (16.7 %). Associated with accessory sigmoid arteries. Pattern III: 3 cases (23 %). Classic variant. It was defined by the absence of the common trunk with the left colic artery and the sigmoid arcade. Type IIIa: 2 cases (66.7 %). A variable number of sigmoid arteries arise as collateral branches of the inferior mesenteric artery, without being associated with the sigmoid trunk. Type IIIb: 1 case (33.3 %). The left colic artery gives off the first sigmoid artery as a collateral branch and is associated with the sigmoid trunk. 1. Pattern II is the most prevalent in this study (46.2 %). 2. The classic variant is not the predominant one in this research (23 %). 3. The sigmoid arcade has a 53.8 % incidence.

Correlation of endoscopic findings with suspected intestinal endometriosis in the distal sigmoid and rectum as observed on transrectal ultrasonography

Introduction: Colonoscopy enables detailed endoscopic evaluation of the interior of the colon. Changes observed via colonoscopy may be subtle or pronounced and can sometimes mimic those of other diseases, such as deep intestinal endometriosis. The diagnosis of endometriosis in the distal sigmoid and rectum by colonoscopy has been described in previous case reports. Objective: We aimed to correlate the endoscopic changes found in the distal sigmoid and rectum with the presence of endometrial deposits confirmed by transrectal ultrasound (TRUS). Methods: We included 50 female patients referred to the endoscopy department at our institution for colonoscopy, rectosigmoidoscopy, or TRUS, who exhibited one or more symptoms associated with endometriosis. Results: The colonoscopic findings were normal in 36 patients but showed alterations in 14 patients. Among the latter, TRUS revealed involvement of the sigmoid and/or rectal wall in 11 patients. Conclusions: The endoscopic changes in the distal sigmoid or rectum described in this study were strongly associated with endometrial deposits confirmed using TRUS. (AU)

Resultados de la cirugía de urgencia en pacientes con cáncer de colon perforado / Results of emergency surgery in patients with perforated colon cancer

RESUMEN: Gran parte de los pacientes con cáncer de colon (CC), son diagnosticados y tratados de forma electiva. Sin embargo, aproximadamente un 20 % de ellos debutará como una emergencia (obstrucción o perforación). El objetivo de este estudio fue determinar morbilidad postoperatoria (MPO) y supervivencia global (SVG) en pacientes resecados por CC perforado (CCP). Serie de casos retrospectiva de pacientes con CCP, sometidos a colectomía y linfadenectomía, de forma consecutiva, en Clínica RedSalud Mayor y Hospital de Temuco, Chile, entre 2010 y 2019. Las variables resultados fueron SVG y MPO. Otras variables de interés fueron: tiempo quirúrgico, resecabilidad, número de linfonodos resecados, estancia hospitalaria, mortalidad operatoria, recurrencia y supervivencia libre de enfermedad (SLE). Los pacientes fueron seguidos de forma clínica. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión; y análisis de SV con curvas de Kaplan Meier. Se intervinieron 15 pacientes (60 % mujeres), con una mediana de edad de 62 años. La localización más frecuente fue sigmoides (6 casos; 40,0 %). La resecabilidad de la serie fue 100 %. La medianas del tiempo quirúrgico, número de linfonodos resecados y estancia hospitalaria; fueron 80 min, 20 y 5 días respectivamente. La MPO fue 26,7 % (4 casos). Con una mediana de seguimiento de 36 meses, se verificó una recurrencia de 40,0 %. Por otra parte, la SVG y SLE a 5 años fue 46,7 % y 33,3 % respectivamente. Los resultados obtenidos, en términos de MPO y SVG, fueron similares a series internacionales.

SUMMARY: Most patients with colon cancer (CC) are diagnosed and treated electively. However, a fifth of them will debut as an emergency (obstruction or perforation). The aim of this study was to determine postoperative morbidity (POM) and overall survival (OS) in patients resected by perforated CC (PCC). Retrospective case series of patients with PCC undergoing colectomy and lymphadenectomy, consecutively, at RedSalud Mayor Clinic and Temuco hospital, Chile, between 2010 and 2019. The outcome variable were POM and OS. Other variables of interest were surgical time, resectability, number of resected lymph nodes, hospital stay, mortality, recurrence, and disease-free survival (DFS). Patients were followed clinically. Descriptive statistics was used (measures of central tendency and dispersion), and OS analysis was applying Kaplan Meier curves.15 patients (60 % women) were intervened, with a median age of 62 years. The most frequent location was the sigmoid colon (6 cases, 40.0 %). Resectability of the series was 100 %. Median surgical time, number of lymph nodes resected, and hospital stay; they were 80 min, 20 and 5 days respectively. POM was 26.7 % (4 cases). With a median follow-up of 36 months, recurrence was 40.0 %. On the other hand, OS and DFS at 5 years were 46.7 % and 33.3 %, respectively. The observed results, in terms of POM and OS, were like international series.

Colo-umbilical enterocutaneous fistula as a rare complication of diverticulitis of the sigmoid colon / Fístula enterocutánea sigmoidea umbilical como una rara complicación de una diverticulitis del colon sigmoide

Abstract The care of patients with enterocutaneous fistula constitutes a significant challenge owing to the alterations it usually brings about. For successful treatment, it is necessary to manage fluids and electrolytes adequately, provide practical nutritional support, and control sepsis until its eradication; thus, many fistulae close spontaneously. We present the case of a 36-year-old male patient with a four-month history of fecal-like umbilical secretion. When performing the fistulogram, we confirmed a fistulous tract of 9 cm, which ended at the level of the sigmoid colon, a rare location. In cases where the enterocutaneous fistula does not close, and surgical treatment is indicated, it is imperative to maximize perioperative care, decrease surgical time, choose the correct surgical technique, and prepare the patient for surgery to avoid complications with a fatal outcome.

Resumen La atención de los pacientes con fístula enterocutánea constituye un gran reto, por las alteraciones con las que suelen acompañarse. Para lograr un tratamiento exitoso es necesario realizar un adecuado manejo de los líquidos y electrolitos, brindar un apoyo nutricional eficaz y controlar la sepsis hasta lograr su erradicación; de esta manera, muchas fístulas cierran espontáneamente. Se expone el caso de un paciente de 36 años de edad, con un cuadro de secreción umbilical de aspecto fecaloideo de 4 meses de evolución. Al realizar la fistulografía se constató un trayecto fistuloso de 9 cm, el cual terminaba a nivel del colon sigmoide, localización poco frecuente. En los casos en que la fístula enterocutánea no cierre y tenga indicación de tratamiento quirúrgico, es necesario extremar los cuidados perioperatorios, minimizar el tiempo quirúrgico, elegir la técnica quirúrgica correcta y preparar al paciente para la cirugía, de modo que se eviten complicaciones que pueden tener un desenlace fatal.

Respiratory distress and tracheal deviation secondary to sigmoid volvulus / Dificultad respiratoria y desviación traqueal secundaria a vólvulo sigmoideo ­ Un reporte de caso

INTRODUCTION: The trachea is a semiflexible tube of 1.5 to 2 cm in width and 10 to 13 cm in length. Its deviation might be caused by not only diverse thoracic but also abdominal pathologies, which may compromise the airway. We present a case of a severe tracheal deviation due to an abdominal pathology causing displacement of mediastinal structures. CLINICAL CASE: A 78-year-old woman presents with difficulty breathing. History of chronic bedridden and frequently constipated, last stool 5 days prior. On physical examination, cachectic complexion, dry mucous membranes, breathing superficially with scarce wheezing, SatO2 82% on room air. Abdomen distended with an absence of bowel sounds. Chest x-rays show severe tracheal deviation and abdominal x-ray with coffee bean sign. A laparotomy evidences a large sigmoid volvulus. A sigmoidectomy and descending colon colostomy is performed. Room air oxygen saturation improved after extubation to 96%.CONCLUSION: Desaturation and tracheal deviation were caused by a large sigmoid volvulus. Although these pathologies were thoracic, clinicians should suspect different underlying pathologies, in this case, abdominal

INTRODUCCIÓN: La tráquea es un tubo semiflexible de 1-5 a 2 cm de ancho y 10 a 13 cm de longitud. Puede presentar desviaciones en su trayecto, no solo por patologías torácicas, sino también abdominales, las cuales pueden comprometer la vía aérea. Presentamos el caso de una desviación severa de la tráquea por una patología abdominal que ocasionó desplazamiento de las estructuras mediastinales. REPORTE DE CASO: Mujer de 78 años que se presenta por dificultad respiratoria. Antecedente de postramiento crónico en cama y estreñimiento frecuente, con última deposición 5 días previos. En la exploración física presenta complexión caquéctica, mucosas secas, respiración superficial con sibilancias, saturando 82% al aire ambiente. Abdomen distendido con ausencia de ruidos intestinales. Radiografía torácica muestra desviación traqueal severa y la radiografía abdominal muestra signo del grano de café. En el abordaje por laparotomía se evidencia un vólvulo sigmoideo grande. Se realizó sigmoidectomía y colostomía del colon descendiente. La saturación al aire ambiente mejoró después de la extubación a 96%. CONCLUSIÓN: La desaturación y desviación traqueal fueron causadas por un vólvulo sigmoideo grande. Aunque estas patologías eran torácicas, el clínico debe sospechar diferentes patologías de base, como en este caso, abdominales.

Vólvulo cecal y del colon sigmoide como manifestación gastrointestinal de la esclerosis sistémica: reporte de un caso / Cecal and sigmoid colon volvulus as a gastrointestinal manifestation of systemic sclerosis: A case report

Introducción. La esclerosis sistémica es una enfermedad del colágeno de etiología autoinmune, con manifestaciones gastrointestinales hasta en un 90 % de los pacientes. Aunque es infrecuente, se han descrito algunos casos de vólvulos colónicos, pero es extremadamente rara la presentación de vólvulo cecal y del colon sigmoide en un mismo paciente. Caso clínico.Paciente femenina de 65 años, con antecedente de esclerosis sistémica, quien consultó a urgencias por dolor y distensión abdominal, asociados a emesis, con ausencia de flatos y deposiciones. Por imágenes sugestivas de obstrucción intestinal con zona de transición en el colon sigmoide se indicó laparotomía exploratoria, con hallazgo de vólvulo del sigmoide. Posteriormente reingresó por sintomatología similar, con imágenes sugestivas de vólvulo cecal. Se realizó hemicolectomía derecha con ileostomía y posterior cierre de ileostomía en misma hospitalización. Discusión. El vólvulo del colon sigmoide y ciego en un mismo paciente es una condición muy infrecuente. Existen pocos casos reportados en la literatura. Conclusión. La resección del segmento colónico afectado es el estándar de manejo quirúrgico.

Introduction. Systemic sclerosis is a collagen disease of autoimmune etiology, with gastrointestinal manifestations in up to 90% of patients. Although infrequent, some cases of colonic volvulus have been described, but the presentation of cecal and sigmoid colon volvulus in the same patient is extremely rarely. Clinical case. A 65-year-old female patient, with a history of systemic sclerosis, who consulted the emergency room due to abdominal pain and distension, associated with emesis and absence of flatus and stools. Due to images suggestive of intestinal obstruction with a transition zone in the sigmoid colon, an exploratory laparotomy was indicated, with the finding of a sigmoid volvulus. She was later readmitted for similar symptoms, with images suggestive of cecal volvulus. Right hemicolectomy was performed with ileostomy and subsequent closure of the ileostomy in the same hospitalization. Discussion. Volvulus of the sigmoid and cecum in the same patient is a very rare condition. There are few cases reported in the literature. Conclusion. Resection of the affected colonic segment is the standard of care management.

Unusual Case Report of Synchronous Caecal and Sigmoid Volvulus / Reporte de un caso inusual de presentación sincrónica de vólvulo cecal y de sigmoide

Abstract In the spectrum of patients with intestinal obstruction, volvulus is one of the least frequent etiologies (5-15 %). Synchronous volvulus of two colonic segments in a patient is regarded as rare, with few cases reported in the literature. The present report of synchronous cecal and sigmoid volvulus documents one of them: a patient who underwent subtotal colectomy and formation of ileostomy. Although the preoperative diagnosis of this entity is rare, it should be considered in these intraoperative findings for both intraoperative management, with resection and anastomosis or resection and stoma, and postoperative management. It has a significant impact on mortality if patients are treated with broad-spectrum antibiotic coverage, given the bacterial translocation and sepsis that they experience.

Resumen En el espectro de los pacientes con obstrucción intestinal, el vólvulo es una de las etiologías menos frecuentes, siendo esta del 5 % al 15 %. La presentación sincrónica de dos segmentos colónicos volvulados en el mismo paciente se considera una entidad rara, con pocos casos reportados en la literatura. El presente caso de vólvulo sincrónico del ciego y del sigmoide documenta uno de ellos, en un paciente que se llevó a colectomía subtotal con ileostomía. Aunque el diagnóstico preoperatorio de esta entidad es poco frecuente, se debe tener en cuenta a la hora de encontrarse estos hallazgos intraquirúrgicos para el manejo tanto intraoperatorio, con resección y anastomosis o resección y estoma, como posoperatorios, lo que tiene un impacto importante en la mortalidad, si se manejan los pacientes con cubrimiento antibiótico de amplio espectro, dada la translocación bacteriana y septicemias con los que cursan estos pacientes.

Elective laparoscopic sigmoidectomy with preservation of the superior rectal artery prior to endoscopic decompression in sigmoid volvulus

Sigmoid volvulus is a frequent cause of intestinal obstruction. Its management has evolved with the use of laparoscopic surgery, achieving an elective sigmoid resection with anastomosis after a flexible endoscopic detorsion. A female patient was admitted to the emergency room with abdominal pain, distention, and constipation. The abdominal computed tomography showed a whirled sigmoid mesentery in addition to dilated sigmoid loops, and coffee bean sign. The patient successfully underwent a flexible endoscopic detorsion and was scheduled for elective sigmoid colectomy with rectal superior artery preservation and primary anastomosis. During the sigmoid resection, the superior rectal artery preservation is related to a better prognostic, with less bleeding, anastomotic leakage, and hospital stay. Currently, there are few reports of the laparoscopic preservation of the superior rectal artery in patients with sigmoid volvulus. (AU)

Hemangioma cavernoso de colon en un paciente joven / Cavernous hemangioma of the colon in a young patient

Resumen El hemangioma cavernoso de colon es una neoplasia vascular benigna, muy poco frecuente. Se realiza una breve descripción del cuadro clínico, diagnóstico y tratamiento de un paciente joven con un hemangioma cavernoso en el sigmoides. Se trata de un paciente de 18 años de edad quien consultó al servicio de urgencias por un cuadro clínico consistente en sangrado rectal indoloro asociado con disnea, astenia y adinamia; el paciente ingresó con signos vitales estables, posteriormente, se realizaron estudios complementarios, entre ellos un hemograma, que reportó un síndrome anémico grave que lleva al estudio de su causa. Se realizó una colonoscopia que reportó una lesión a nivel del sigmoides compatible con hemangioma colónico. El paciente es llevado a cirugía (laparotomía), se realizó una hemicolectomía y se confirmó el diagnostico por estudio de patología.

Abstract Cavernous hemangioma of the colon is a very rare benign vascular neoplasm. The following is a brief description of the symptoms, diagnosis, and treatment of a young patient with a cavernous hemangioma of the sigmoid colon. An 18-year-old man consulted the emergency department due to painless rectal bleeding associated with dyspnea, asthenia, and adynamia. The patient was admitted with stable vital signs, and complementary studies, including a blood count, reported severe anemic syndrome leading to the study of the cause of the disease. A colonoscopy was performed, finding a sigmoid lesion compatible with colon hemangioma. The patient was taken to surgery (laparotomy), a hemicolectomy was performed, and the diagnosis was confirmed by pathology study.

Colectomía por colitis ulcerativa grave / Colectomy for severe ulcerative colitis

La Colitis Ulcerativa (CU) es una enfermedad crónica multifactorial de etiología desconocida caracterizada por la presencia de inflamación difusa en la mucosa colónica en presencia de diarrea sanguinolenta asociada con urgencia y tenesmo rectal. Una mujer de 51 años, acudió al Servicio de Urgencias por rectorragia con molestias en hipogastrio y tenesmo, además un mes y medio de deposiciones liquidas, sensación febril intermitente, anorexia, nauseas sin vómitos y pérdida de peso de aprox. 10 kilos en 1 mes, con un abdomen distendido, levemente depresible, doloroso en hipogastrio. La colonoscopía y anatomía patológica informan una Rectocolitis Ulcerativa Pancolónica. La paciente continua con mala evolución a pesar de tratamiento médico, por lo que se decide el manejo quirúrgico con una colectomía subtotal con confección de ileostomía y fístula mucosa de sigmoides por colitis aguda grave refractaria al tratamiento. El manejo médico previo al manejo quirúrgico en este caso se vio limitado por la disponibilidad de fármacos. Esto resalta la necesidad del conocimiento del manejo multidisciplinario de las patologías colorectales.

Ulcerative Colitis (UC) is a multifactorial chronic disease of unknown etiology characterized by the presence of diffuse inflammation in the colonic mucosa and often the presence of bloody diarrhea associated with rectal urgency. A 51-year-old woman came to the emergency room due to rectal bleeding with hypogastric pain and tenesmus, in addition to a month and a half of diarrhea, intermittent fever, anorexia, nausea without vomiting and weight loss of approx. 10 kilos in 1 month, with a distended abdomen, slightly depressible, painful in the hypogastrium. Colonoscopy and pathological anatomy report a Pancolonic Ulcerative Rectocolitis. The patient continues with poor evolution despite medical treatment, so a surgical approach is decided with a subtotal colectomy, terminal ileostomy and sigmoid fistula due to severe acute colitis refractory to treatment. Medical treatment prior to a surgical approach in this case was limited by the availability of drugs. This highlights the need for a multidisciplinary management of colorectal pathologies.

Irreducible Indirect Inguinal Hernia Caused by Sigmoid Colon Cancer Entering Right Groin:A Case Report / 中国医学科学院学报

We reported a case of irreducible indirect inguinal hernia caused by sigmoid colon cancer entering the right groin.The patient complained about a right groin mass for more than 60 years with progressive enlargement for 3 years and pain for half a month.Abdominal CT examination at admission showed rectum and sigmoid colon hernia in the right inguinal area and thickening of sigmoid colon wall.Electronic colonoscopy and pathological diagnosis showed sigmoid colon cancer.Therefore,the result of preliminary diagnosis was irreducible indirect inguinal hernia caused by sigmoid colon cancer entering the right groin.We converted laparoscopic exploration to laparotomy followed by radical sigmoidectomy and employed end-to-end anastomosis of descending colon and rectum in combination with repair of right inguinal hernia.The patient recovered well after operation and was discharged.

Impacto de la subespecialización en los resultados de la sigmoidectomía laparoscópica por diverticulitis perforada Hinchey III / Outcomes of emergent laparoscopic sigmoid resection for Hinchey III diverticulitis: Does specialization matter?

Introducción: La sigmoidectomía por diverticulitis perforada es una cirugía de urgencia comúnmente realizada por cirujanos generales. Está descripta la correlación positiva entre el volumen del cirujano y los mejores resultados postoperatorios. Sin embargo, existe escasa evidencia de la influencia de la especialización en cirugía colorrectal sobre los resultados de la sigmoidectomía laparoscópica por diverticulitis perforada. Objetivo: Evaluar el impacto de la especialización en cirugía colorrectal en los resultados postoperatorios de la sigmoidectomía laparoscópica por diverticulitis Hinchey III. Diseño: Estudio retrospectivo sobre una base de datos cargada de forma prospectiva. Material y métodos: Se incluyeron pacientes sometidos a sigmoidectomía laparoscópica por diverticulitis perforada Hinchey III. La muestra fue dividida en dos grupos: pacientes operados por un cirujano colorrectal (CC) y aquellos operados por un cirujano general (CG). Las variables demográficas, operatorias y postoperatorias fueron comparadas entre los grupos. El objetivo primario fue determinar si existían diferencias en la proporción de anastomosis primaria, morbilidad y mortalidad a 30 días entre los grupos. Resultados: Se incluyeron 101 pacientes en el análisis; 58 operados por CC y 43 por CG. Los pacientes operados por CC presentaron una mayor proporción de anastomosis primaria (CC: 98,3% vs. CG: 67,4%, p<0,001). Los CG realizaron más estomas (CC: 13,8% vs. CG: 46,5%, p<0,001), presentaron un mayor índice de conversión (CC: 20,6% vs. CG: 39,5%, p=0,03) y una mayor estadía hospitalaria (CC: 6,2 vs. CG: 10,8 días, p<0,001). La morbilidad global (CC: 34,4% vs. CG: 46,5%, p=0.22), dehiscencia anastomótica (CC: 3,5% vs. CG: 6,8%, p=0.48) y la mortalidad (CC: 1,7% vs. CG: 9,3 %, p=0,08) fueron similares entre ambos grupos. Conclusión: La sigmoidectomía laparoscópica de urgencia realizada por CG presenta similar morbilidad y mortalidad postoperatoria que la realizada por CC. Sin embargo, la participación del especialista se asoció a una mayor frecuencia de anastomosis primarias, menos estomas y una estadía hospitalaria más corta.

Background: Sigmoid resection for perforated diverticulitis is one of the most common emergency surgeries and often performed by general surgeons. Relationship between high-volume surgeons and improved postoperative outcomes is well established. However, the influence of colorectal specialization on outcomes after emergency laparoscopic sigmoidectomy for perforated diverticulitis is not well described. Aim: Evaluate the impact of colorectal surgery training on the outcomes after emergency laparoscopic sigmoid resection for Hinchey III diverticulitis. Design: Retrospective analysis of prospectively collected database.Method: Patients undergoing emergent laparoscopic sigmoid resection for perforated (Hinchey III) diverticulitis were identified and stratified by involvement of colorectal or general surgeon. This study was conducted from 2000 to 2018 at a teaching hospital. Primary outcome measures were primary anastomosis, postoperative morbidity and mortality.Results: A total of 101 patients were identified; 58 by colorectal and 43 by general surgeons. Patients in the colorectal surgeon group had higher rates of primary anastomosis (CS: 98, 2% vs. GS: 67, 4%, p<0.001). General surgeons performed more ostomies (CS: 13, 8% vs. GS: 46, 5%, p<0.001), had a higher conversion rate (CS: 20, 6% vs. GS: 39, 5%, p=0.03) and longer mean length of hospital stay (CS: 6, 2 vs. GS: 10, 8 days, p<0.001). Overall morbidity (CS: 34, 4% vs. GS: 46, 5%, p=0.22), anastomotic leak rate (CC: 3,5% vs. CG: 6,8%, p=0.48) and mortality (CS: 1, 7% vs. GS: 9,3 %, p=0.08) were similar between groups. Conclusion: Emergency laparoscopic sigmoid resection by general surgeons wasn ́t associated with higher rates of postoperative morbidity, anastomotic leakage or mortality. However, patients operated by colorectal surgeons had higher rates of primary anastomosis, lower rates of ostomy, conversion and shorter length of hospital stay.

Perforación de sigma secundaria a migración de prótesis biliar / Sigma Perforation Secondary to Migration of Biliary Prosthesis

RESUMEN Introducción: La migración de una prótesis en la vía biliar es una complicación muy poco frecuente que normalmente se expulsa de forma natural, pero en raras ocasiones puede cursar con complicaciones severas. Objetivo: Describir una complicación rara por migración de una prótesis biliar. Caso clínico: Se presenta un paciente de sexo masculino de 75 años, portador de stent biliar que presenta una perforación de sigma secundaria a migración de la prótesis. Conclusiones: Las migraciones protésicas deben vigilarse y si no se eliminan de manera espontánea o el paciente presenta síntomas, se debe proceder a su retirada endoscópica o quirúrgica(AU)

ABSTRACT Introduction: Migration of a prosthesis in the bile duct is a very rare complication normally expelled in a natural way, but on rare occasions it can lead to severe complications. Objective: To describe a rare complication due to migration of biliary prosthesis. Clinical case: A case is presented of a 75-year-old male patient with a biliary stent who presented a sigmoid perforation secondary to migration of the prosthesis. Conclusions: Prosthetic migrations should be monitored and, if they are not eliminated spontaneously or the patient presents with symptoms, they should be removed endoscopically or surgically(AU)

Concurrent urinary and bowel diversion: Surgical modification with sigmoid colon that avoids a bowel anastomosis

ABSTRACT Objective: Cystectomy with urinary diversion is the gold standard for muscle invasive bladder cancer. It also may be performed as part of pelvic exenteration for non-urologic malignancy, neurogenic bladder dysfunction, and chronic conditions that result in a non-functional bladder (e.g., interstitial cystitis, radiation cystitis). Our objective is to describe the surgical technique of urinary diversion using large intestine as a conduit whilst creating an end colostomy, thereby avoiding a primary bowel anastomosis and to show its applicability with respect to urologic conditions. Materials and Methods: We retrospectively reviewed five cases from a single institution that utilized the described method of urinary diversion with large intestine. We describe operative times, hospital length of stay (LOS), and describe post-operative complications. Results: Five patients with a variety of urologic and oncologic pathology underwent the described procedures. Their operative times ranged from 5 hours to 11 hours and one patient experienced a Clavien III complication. Conclusion: We describe five patients who underwent this procedure for various medical indications, and describe their outcomes, and believe dual diversion of urinary and gastrointestinal systems with colon as a urinary conduit to be an excellent surgical option for the appropriate surgical candidate.

Hartmann procedure or resection with primary anastomosis for treatment of perforated diverticulitis? systematic review and meta-analysis / Procedimento de hartmann ou ressecção com anastomose primária para tratamento da diverticulite perfurada? revisão sistematizada e metanálise

ABSTRACT Background: The Hartmann procedure remains the treatment of choice for most surgeons for the urgent surgical treatment of perforated diverticulitis; however, it is associated with high rates of ostomy non-reversion and postoperative morbidity. Aim: To study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment. Method: Systematic search in the literature of observational and randomized articles comparing resection with primary anastomosis vs. Hartmann's procedure in the emergency treatment of perforated diverticulitis. Analyze as primary outcomes the mortality after the emergency operation and the general morbidity after it. As secondary outcomes, severe morbidity after emergency surgery, rates of non-reversion of the ostomy, general and severe morbidity after reversion. Results: There were no significant differences between surgical procedures for mortality, general morbidity and severe morbidity. However, the differences were statistically significant, favoring primary anastomosis in comparison with the Hartmann procedure in the outcome rates of stoma non-reversion, general morbidity and severe morbidity after reversion. Conclusion: Primary anastomosis is a good alternative to the Hartmann procedure, with no increase in mortality and morbidity, and with better results in the operation for intestinal transit reconstruction.

RESUMO Racional: O procedimento a Hartmann permanece sendo o tratamento de escolha da maioria dos cirurgiões para o tratamento cirúrgico de urgência da diverticulite perfurada, entretanto está associado com altas taxas de não reversão da ostomia e de morbidade pós-operatória. Objetivo: Estudar os resultados após o procedimento de Hartmann vs. ressecção com anastomose primária, com ou sem ileostomia, para o tratamento da diverticulite perfurada com peritonite purulenta ou fecal (grau de Hinchey III ou IV), e comparar as vantagens entre as duas formas de tratamento. Método: Busca sistemática na literatura de artigos observacionais e randomizados comparando ressecção com anastomose primária vs. procedimento de Hartmann no tratamento de urgência da diverticulite perfurada. Analisar como desfechos primários a mortalidade após a operação de urgência e a morbidade geral após ela; como desfechos secundários, a morbidade severa após a operação de urgência, as taxas de não reversão da ostomia, a morbidade geral e severa após a reversão. Resultados: Não houve diferenças significativas entre os procedimentos cirúrgicos para mortalidade, morbidade geral e morbidade severa. Contudo, as diferenças foram significativas estatisticamente favorecendo anastomose primária na comparação com procedimento de Hartmann nos desfechos taxas de não reversão do estoma, morbidade geral e morbidade severa após reversão. Conclusão: A anastomose primária apresenta-se como boa alternativa ao procedimento de Hartmann, sem aumento de mortalidade e morbidade, e com melhores resultados na operação de reconstrução do trânsito intestinal.

Prevalencia y características histológicas de los pólipos diminutos del recto y del sigmoides en una población colombiana / Prevalence and histological characteristics of tiny rectal and sigmoid polyps in a Colombian population

Resumen Introducción: el cáncer de colon y recto (CCR) se origina a partir de pólipos adenomatosos y serrados. Por tanto, se recomienda que todos los pólipos colónicos sean resecados y enviados a patología. Sin embargo, en los pólipos diminutos (<5 mm) del recto y del sigmoides existe controversia sobre esta conducta, razón por la cual se ha planteado la estrategia de resecar y descartar o dejar in situ, a partir de la utilización de endoscopios avanzados (con una imagen de banda angosta [Narrow Band Imaging, NBI] u otras), y se logre concordancia con la histopatología, superior al 90 %. En nuestro medio, no hay estudios prospectivos con luz blanca sobre la prevalencia y las características histológicas de estos pólipos en el recto y el sigmoides. Por esta razón, se desarrolló este trabajo. Materiales y métodos: estudio de prevalencia analítica, prospectivo. Se incluyeron las colonoscopias de tamización realizadas en la Unidad de Gastroenterología de la Clínica Fundadores de Bogotá, entre enero y julio de 2018. Resultados: se incluyeron 719 pacientes. La prevalencia de pólipos diminutos en el recto y el sigmoides fue del 27 % (intervalo de confianza [IC], 95 %: 23,7-30,2 %). El 50 % eran pólipos adenomatosos, mientras que en 8 casos se presentó una displasia de alto grado (DAG). Entre los pólipos diminutos, 3 fueron tumores neuroendocrinos. No hubo cáncer en ninguna de las lesiones. Conclusiones: la mitad de los pólipos diminutos encontrados fueron adenomatosos y 8 (0,83 %) tuvieron DAG. Recomendamos resecar todos los pólipos diminutos hasta que los estudios locales realizados con NBI u otra tecnología demostrasen la capacidad para discriminar en más del 90 % los pólipos hiperplásicos (dejarlos in situ) o adenomatosos (resecarlos).

Abstract Introduction: Because colorectal cancer (CRC) originates from adenomatous and serrated polyps, it is recommended that all colonic polyps be resected and sent to pathology. However, there is controversy over this recommendation in the case of rectal and sigmoid polyps measuring less than 5 mm. Strategies using advanced NBI endoscopes to either "resect and discard" or leave "in situ" have been proposed. Concordance with histopathology of over 90% has been achieved. No prospective studies of the prevalence and histological characteristics of these rectal and sigmoid polyps had been done with white light in this country, so we undertook this study. Materials and methods: This is an analytical and prospective prevalence study. Screening colonoscopies performed in the gastroenterology unit of Clínica Fundadores in Bogotá between January and July 2018 were included. Results: Seven hundred nineteen patients were included. The prevalence of tiny polyps in the rectum and sigmoid colon was 27% (95% CI: 23.7 to 30.2%). Fifty percent were adenomatous, but eight cases had high grade dysplasia. Among the tiny polyps, three were neuroendocrine tumors. There was no cancer in any of the lesions. Conclusions: Half of the tiny polyps found were adenomatous, and eight (0.83%) had high grade dysplasia. We recommend resecting all tiny polyps until local studies conducted with NBI or other technology demonstrate the ability to discriminate between the more than 90% hyperplastic polyps (leaving them in situ) and adenomatous polyps (resect them).