Abordaje quirúrgico y evolución posoperatoria en reintervenciones de complicaciones en cirugía colorrectal laparoscópica, 15 años de experiencia / Surgical approach and postoperative clinical course in reinterventions for complications following laparoscopic colorectal surgery: 15 years of experience

Resumen Objetivo: Comparar tres abordajes quirúrgicos (abierto, laparoscópico y laparoscópico convertido) para el manejo de complicaciones posoperatorias en cirugía colorrectal electiva realizadas primariamente por vía laparoscópica. Materiales y Método: Este estudio de cohorte retrospectivo incluyó pacientes reoperados después de una cirugía colorrectal laparoscópica electiva, agrupándose según la vía de abordaje de reoperación: abierta (RVA), laparoscópica (RVL) y laparoscópica convertida (RVLC). Las variables estudiadas fueron: preoperatorias (edad, sexo, puntuación ASA, IMC, comorbilidades e historia quirúrgica); operatorias (causa de reoperación, latencia para reoperación, tiempo operatorio, cirugía realizada y causa de conversión); y posoperatorias (tránsito intestinal, días de hospitalización, días de UCI, complicaciones médicas, infección del sitio quirúrgico, evisceración, transfusión y mortalidad a los 30 días). Resultados: Sin diferencias significativas para las variables preoperatorias y operatorias. En cuanto a las variables posoperatorias, el grupo de reoperaciones por vía laparoscópica, tuvo menos días de hospitalización (p = 0,012), menos días de UCI (p = 0,001) y un tránsito intestinal más rápido para reaparición de gases, heces y retorno a dieta sólida (p = 0,008, p = 0,029, p = 0,030, respectivamente). No hubo diferencias significativas en la infección del sitio quirúrgico, la evisceración, las complicaciones médicas, la transfusión y la mortalidad. Discusión y Conclusión: Este estudio reveló una mejor evolución clínica posoperatoria en el grupo de reoperación laparoscópica, con menor estancia hospitalaria y en UCI, y reducción del íleo posoperatorio, sin aumento de la morbimortalidad. Por lo tanto, la reoperación laparoscópica en cirugía colorrectal podría ser el abordaje más adecuado en pacientes debidamente seleccionados.

Aim: To compare three approaches (laparoscopic, open, and conversion of laparoscopic approach) for the management of intra-abdominal surgical complications after elective laparoscopic colorectal surgery. Materials and Method: This was a retrospective cohort study including patients who required reoperation due to an intra-abdominal surgical complication after initial elective laparoscopic colorectal surgery. Patients were grouped according to the reoperation approach-laparoscopic reoperation, laparoscopic reoperation that required conversion to open surgery, and open reoperation. Pre-operative variables (age, gender, ASA score, BMI, comorbidities, and surgical history), operative variables (cause of reoperation, latency for reoperation, operative time, surgery performed, and cause of conversion), and post-operative variables (intestinal transit, hospital days, ICU days, medical complications, surgical site infection, evisceration, transfusion and 30-day mortality), were compared between groups. Results: There were no significant differences between groups among the pre-operative and operative variables. In terms of post-operative variables, the laparoscopic reoperation group, had fewer hospital days (p = 0.012), fewer ICU days (p = 0.001), and faster intestinal transit regarding gas, stool and return to solid diet (p = 0.008, p = 0.029 and p = 0.030, respectively). However, there were no significant differences in surgical site infection, evisceration, medical complications, transfusion, and mortality. Discussion and Conclusión: This study revealed better post-operative clinical course in the laparoscopic reoperation group, with shorter hospital and ICU stay, and reduced postoperative ileus, without increased morbidity or mortality. Laparoscopic reoperation for complications after elective laparoscopic colorectal surgery may therefore be the preferred approach.

Tratamiento multidisciplinario de la endometriosis profunda grave / Multidisciplinary treatment of severe deep endometriosis

Introducción: La endometriosis es una entidad clínica caracterizada por la presencia de tejido endometrial fuera del endometrio, siendo la afección rectocolónica más agresiva. Diseño: Retrospectivo de grupo único. Objetivos: Evaluar la factibilidad de las resecciones colorrectales, patología compleja que debe abordarse en forma multidisciplinaria y reportar los resultados obtenidos de más de 10 años de trabajo. Material y métodos: Estudio descriptivo y retrospectivo de una serie de casos. En el periodo comprendido entre 2005 y a principios de 2017, se evaluaron 29 pacientes. La evaluación se realizó en forma multidisciplinaria. Resultados: Hemos operado 171 endometriosis profundas. La edad media fue 34,04 años. Veintinueve necesitaron resección de colon, en 27 se realizó una resección anterior con anastomosis colorrectal y 2 sigmoidectomías. Las anastomosis fueron con sutura mecánica, 17 término-terminales colorrectales y 12 término-laterales. Veintiocho anastomosis fueron realizadas entre los 7 y 5 cm del margen anal, 1 fue realizada a 4 cm del margen anal. En este caso se confeccionó una colostomía transversa de protección. El tiempo operatorio medio fue 90 minutos (45-195). El índice de conversión fue del 15%. Las complicaciones fueron hemoperitoneo, fístula anastomótica e infecciones de piel. La estadía institucional la media fue de 5 días. Conclusiones: El tratamiento laparoscópico de esta enfermedad es factible, debido a la distorsión de la anatomía de la pelvis que esta genera, aunque las tendencias actuales enfatizan la necesidad del tratamiento de esta afección de forma mínimamente invasiva. (AU)

Introduction: Endometriosis is a clinical entity characterized by the presence of endometrial tissue outside the endometrium, being the most aggressive rectocolonic condition. Design: Descriptive, retrospective case series study. Objective: Evaluate the feasibility of colorectal resections in this complex pathology that must be approached in a multidisciplinary way and report the results obtained from more than 10 years of work. Material and methods: In the period between 2005 and early 2017, 29 patients were evaluated in a multidisciplinary way. Results: One hundred and seventy-one patients were operated on for deep endometriosis, mean age 34 years. Twenty-nine patients required colon resection, 27 anterior resection and 2 sigmoidectomies. Seventeen end-to-end and 12 end- to- side stapled anastomoses were performed. Twenty-eight anastomoses were performed between 7 and 5 cm from the anal margin and one at 4 cm. In the latter, a protective transverse colostomy was made. The mean operative time was 90 (45-195) minutes. The conversion rate was 15%. Complications were hemoperitoneum, anastomotic fistula, and wound infections. The average hospital stay was 5 days. Conclusion: Laparoscopic treatment of this disease is feasible. Despite the distortion it generates in the anatomy of the pelvis, the current trend emphasizes the need for minimally invasive treatment. (AU)

Local treatment of colostomy prolapse with the MESH STRIP technique: A novel and highly efficient day hospital technique

OBJECTIVE: Stoma prolapse is an intussusception of the bowel through a mature stoma. It can be caused by increased intra-abdominal pressure, excessively mobile bowel mesentery and/or a large opening in the abdominal wall at the time of stoma formation. It occurs predominantly in loop stomas, and correction methods include conservative modalities, such as local reduction to the prolapsed bowel, or surgical treatment. The purpose of this study was to describe our experience with the treatment of colostomy prolapse using a novel mesh strip technique. METHODS: Between February 2009 and March 2018, ten consecutive male patients underwent correction of colostomy prolapse under local anesthesia by peristomal placement of a polypropylene mesh strip. Operation time, short- and long-term complications, and recurrence rates were recorded and analyzed. RESULTS: No postoperative complications, morbidity or mortality were observed. The median length of the prolapse ranged from 6-20 cm, and the median operative time was 30 minutes. The median duration of follow-up was 25 months (range, 12-89 months). No relapse, mesh strip extrusion, local infection or granuloma formation were found. CONCLUSION: A simple, fast, and low-cost operation under local anesthesia using a mesh strip is a valuable option to treat colostomy prolapse.

Fístulas colónicas de origen diverticular / Colonic fistulas of diverticular origin

INTRODUCCIÓN: La enfermedad diverticular de colon sigmoides representa la principal causa de fistulización del colon a órganos vecinos. OBJETIVO: Describir variables clínicas y terapia quirúrgica de esta entidad. MATERIALES Y MÉTODO: Revisión retrospectiva de los casos de fístulas colónicas de origen diverticular (FCD) operados en forma electiva en un centro terciario. RESULTADOS: En un periodo de 30 años se realizó cirugía resectiva por una FCD en 49 pacientes. Los órganos más afectados fueron la vejiga en 33 casos (68%) y la vagina en 6 (12%). La cirugía efectuada fue la sigmoidectomía en 48 casos (5 con una ileostomía de protección) y una operación de Hartmann. La vía de abordaje fue laparoscópica en 4 pacientes y la morbilidad global de la serie fue 20%, sin mortalidad. Con un seguimiento promedio de 87 meses (extremos 16-178) no hubo casos de recidiva de la fístula. CONCLUSIONES: La FCD representa el 26% de los casos intervenidos por una enfermedad diverticular de colon sigmoides, lo que probablemente refleja un diagnóstico tardío. La fístula colovesical (FCV) es la fístula más común por esta causa y en la mitad de los casos tienen una presentación silenciosa. Las fístulas colovaginales ocurren en mujeres histerectomizadas. La cirugía resectiva del colon en pacientes con riesgo normal es la cirugía estándar con buenos resultados a corto y largo plazo. La cirugía laparoscópica es factible y segura especialmente en los casos de FCV.

BACKGROUND: Fistula formation is a well-known complication of diverticular disease (FCD). AIM: Determine the clinical presentation and surgical management of this kind of fistulas. MATERIALS AND METHODS: Retrospective revision of all consecutive scheduled cases operated on in a terciary public centre in a thirty-years period. RESULTS: Forty-nine patients with a segmental resection of sigmoid colon were analized. Colovesical fistulas were the most common type (n = 33), followed by colovaginal (n = 6). Resection with anastomosis was performed in 48 cases and Hartmann type operation in one. Laparoscopic procedure was made in 4 cases without conversion. Complication rate was 20% and two patients were reoperated on, without mortality in this series. Follow up showed no case of recurrence. CONCLUSIONS: FDC represent 26% of cases operated on in our series. Colovesical fistula is the most common type, followed by colovaginal fistula in histerectomized women. Resection and primary anastomosis should be the treatment of choice in average risk patients with acceptable morbidity and good long-term results. Laparoscopic approach is safe, specifically in patients with colovesical fistulas.

Tratamiento quirúrgico de la endometriosis pélvica profunda con compromiso colorrectal / Surgical treatment of deep pelvic endometriosis with colorectal involvement

INTRODUCCIÓN: En la endometriosis el compromiso intestinal afecta hasta al 12% de las pacientes, comprometiendo al recto y a la unión rectosigmoidea en el 90% de los casos. OBJETIVO: Describir la experiencia del equipo de Coloproctología y Ginecología de Clínica Alemana de Santiago en el tratamiento quirúrgico de la endometriosis pélvica profunda con compromiso colorrectal. MATERIAL Y MÉTODOS: Estudio retrospectivo a partir de la base de datos de pacientes con endometriosis tratados entre enero del año 2015 y abril de 2018. Los criterios de inclusión fueron pacientes con clínica de endometriosis pélvica profunda, que tuviesen compromiso colorrectal y hayan sido tratados con shaving rectal, resección discoide o resección segmentaria. Se revisaron fichas clínicas electrónicas, protocolos operatorios y biopsias definitivas. RESULTADOS: Se reclutaron 25 pacientes con una mediana de edad de 35 años. El síntoma principal de consulta fue dismenorrea y el síntoma digestivo más frecuente fue disquecia. En 8 pacientes se realizó un shaving rectal, en 7 una sigmoidectomía, en 9 una resección discoide y en 1 paciente una tiflectomía. La complicación posoperatoria reportada fue la hemorragia digestiva baja en 4 pacientes (Clavien-Dindo I y IIIa). Con una mediana de seguimiento de 13 meses, a la fecha 3 pacientes se les ha diagnosticado algún tipo de recidiva. CONCLUSIÓN: Es importante que la cirugía a realizar, garantice una morbilidad y recurrencia baja. Los resultados en nuestro centro son alentadores, lo que nos hace creer que el tratamiento quirúrgico podría ser una buena alternativa en la endometriosis pélvica profunda con compromiso colorrectal.

INTRODUCTION: In endometriosis, intestinal involvement affects up to 12% of patients, compromising the rectum and the rectosigmoid junction in 90% of cases. AIM: Describe the experience of the Coloproctolgy and Gynecology Team of the Clínica Alemana de Santiago in the surgical treatment of deep pelvic endometriosis with colorectal involvement. MATERIAL AND METHODS: Retrospective study based on the database of patients with endometriosis treated between January 2015 and April 2018. The inclusion criteria were patients with deep pelvic endometriosis clinic, who had colorectal involvement and who had been treated with rectal shaving, discoid resection or segmental resection. Electronic clinical records, operative protocols and definitive biopsies were reviewed. RESULTS: Twenty-five patients with a median age of 35 years were recruited. The main symptom of consultation was dysmenorrhoea and the most frequent digestive symptom was dyschezia. In 8 patients a rectal shaving was performed, in 7 a sigmoidectomy, in 9 a discoid resection and in 1 patient a tiflectomy. The only reported post-operative complication was low gastrointestinal bleeding in 4 of the 25 patients (Clavien-Dindo I and IIIa). A median follow-up of 13 months was achieved, to date 3 patients have been diagnosed with some type of recurrence. CONCLUSION: It is important that the surgery to be performed guarantees low morbidity and recurrence. The results in our center are encouraging, which makes us believe that surgical treatment could be a good alternative in deep pelvic endometriosis with colorectal involvement.

A novel simplified scoring system for predicting mortality in emergency colorectal surgery: prediction model development

ABSTRACT BACKGROUND: Despite advances in surgical approaches, emergency colorectal surgery has high mortality and morbidity. OBJECTIVE: We aimed to create a simple and distinctive scoring system, for predicting mortality among patients undergoing emergency colorectal surgery. DESIGN AND SETTING: Prediction model development study based on retrospective data-gathering. METHODS: Patients who underwent emergency colorectal surgery between March 2014 and December 2016 at a single tertiary-level referral center were included in our study. Patient demographics, comorbidities, type of surgery, etiology and laboratory and radiological findings were collected retrospectively and analyzed. A new clinical score (named the Numune emergency colorectal resection score) was constructed from the last logistic regression model, in which one point was assigned for the presence of each predictive factor. RESULTS: 138 patients underwent emergency colorectal surgery. These comprised 64 males (46.4%) and 74 females (53.6%), with a mean age of 64 years. Multivariate analysis revealed that blood urea nitrogen level > 65 mg/dl (odds ratio, OR: 8.03; 95% confidence interval, CI: 2.16-15.77), albumin level < 0.7 ­mg/­dl (OR: 4.43; 95% CI: 1.96-14.39) and American Society of Anesthesiologists score ≥ 3 (OR: 3.47; 95% CI: 0.81-9.18) were associated with postoperative complications. The Numune score was graded from I to III. The risk of mortality was found to be 63.2% in the group with grade III, which accounted for 35.2% of the subjects. There were 37 postoperative deaths. CONCLUSIONS: Surgeons need scoring systems, especially to predict postoperative mortality. We propose the Numune emergency colorectal resection score for emergency surgical procedures as a practical, usable and effective system for predicting postoperative morbidity.

Adoption rates of laparoscopic techniques for colorectal resections among Brazilian surgeons: limiting factors affecting incorporation into daily practice / Adoção de técnicas laparoscópicas em ressecções colorretais entre cirurgiões brasileiros. Fatores limitantes que afetam a incorporação na prática diária

ABSTRACT Routine adoption of laparoscopy in clinical practice and Medical Residency has not been widely evaluated in Brazil so far. Aim: To take an overview on the adoption and limitations concerning the use of laparoscopic techniques among Brazilian colorectal surgeons. Methods: A questionnaire was sent to 1870 SBCP filiated members, containing personal and professional data such as sex, age, length and local of practice, SBCP filliation, number of procedures, treatment of cancer and laparoscopy limitations. Results: 418 members (22.4%) sent their response (80% men and 20% women). 110 members (26.3%) affirmed they don't perform any laparoscopic procedure, while 308 (73.7%) have already adopted laparoscopy as a routine. An average number of 7.6 laparoscopic colorectal procedures were declared to be performed per month (1 to 40 procedures). Laparoscopic adoption rates were favourably influenced by young age members (46% vs. 28%) and affiliation to University hospitals (p = 0.01). Conversely, surgeons from private clinic showed a greater tendency of no adoption. Among the 308 responders, 106 (34.4%) have already surpassed more than 100 laparoscopic cases, and 167 (54.2%) reported an experience of more than 50 operated patients. The group of surgeons not using minimally invasive techniques incriminated lack of training (73.6%) and laparoscopic instruments availability (27.3%) as the main reasons for no adoption. Conclusions: Adoption rate of laparoscopic techniques to treat colorectal diseases is still low (at least 17%). Future efforts should focus on providing supervised training, proctorship during the initial experience and help instrumental acquisition in centers willing to change their routine and perspectives.

RESUMO Durante as últimas décadas, a incorporação de técnicas minimamente invasivas no tratamento de doenças colorretais testemunhou um progresso lento e firme, principalmente após o reconhecimento da segurança oncológica e melhor evolução. A adoção rotineira na prática clínica e na Residência Médica no Brasil ainda não amplamente avaliada até agora. Objetivos: O presente estudo visou avaliar a adoção e as limitações relativas ao uso de técnicas laparoscópicas entre cirurgiões colorretais brasileiros. Métodos: um questionário foi enviado a 1870 membros filiados à Sociedade Brasileira de Coloproctologia (SBCP) em 2006. As questões foram enviadas por email, incluindo dados pessoais (sexo, idade) e profissionais (tempo e local de prática, filiação à SBCP, número mensal de procedimentos laparoscópicos, tratamento de câncer e limitações para realizar laparoscopia na rotina. Resultados: Entre os 1870 membros, 418 (22.4%) mandaram sua resposta, com uma maior participaçãoo de homens (80%) em comparação às mulheres (20%). A idade média foi de 43 (28-80) anos. A distribuição entre membros titulares e não titulares foi semelhantes (48% vs. 52%). As atividades profissionais foram desenvolvidas em clínica privada (84%), hospitais privados (73%), hospitais públicos (50%) e hospitais universitários (53%). Entre os que responderam (418), 110 (26.3%) não realizavam procedimentos laparoscópicos, enquanto 308 (73.7%) já haviam adotado o acesso laparoscópico rotineiramente na prática clínica. Um número médio de 7.6 procedimentos colorretais laparoscópicos são realizados por mês (1-40). Cerca de 13% dos cirurgiões iniciaram sua experiência laparoscópica diretamente com procedimentos colorretais, enquanto a maioria (87%) começaram por outros procedimentos no trato digestivo. A adoção da laparoscopia foi positivamente influenciada pela idade jovem dos membros (46% vs. 28%) e pela filiação a hospitais universitários (p = 0,01). Inversamente, cirurgiões trabalhando na prática privada demonstraram uma menor tendência em adotar o método. A maioria dos cirurgiões (93%) que adoraram a laparoscopia afirmou incluir pacientes com câncer colorretal em suas indicações operatórias. Entre os que responderam 106 (34,4%) já realizaram mais de 100 procedimentos laparoscópicos, e 167 (54,2%) reportaram experiência maior que 50 casos. Dentre aqueles que não adotaram técnicas minimamente invasivas, a falta de treinamento (73,6%) ou a indisponibilidade de instrumental laparoscópico (27,3%) foram incriminadas como os principais fatores limitantes. Conclusões: o índice de adoção de técnicas laparoscópicas no tratamento de doenças intestinais ainda é baixo (pelo menos 17%) entre cirurgiões colorretais brasileiros. Esforços futuros de nossa Sociedade Médica devem focar na provisão de treinamento supervisionado, na criação de oportunidades para preceptoria durante a experiência inicial e na obtenção de instrumental em centros que queiram mudar sua rotina e perspectivas.

Coloanal intussusception in adults due to lipoma / Intussuscepção colo-anal decorrente de lipoma em adulto

ABSTRACT Adult intussusception is a rare condition. But coloanal intussusception is an exception. Malignant lesions are the most common cause of colonic intussusception, and in this aspect, differ from childhood intussusception. We present a case wherein the patient had a lipoma of the sigmoid colon that caused an immense prolapse through the anus. Very few cases of coloanal intussusception are reported in adults, and we discuss the diagnostic tools and the management of this rare surgical entity.

RESUMO A intussuscepção no adulto é uma entidade rara. Mas a intussuscepção colo-anal é uma exceção. Lesões malignas são a causa mais comum de intussuscepção colônica e, neste aspecto, difere da intussuscepção infantil. Apresentamos um caso de lipoma do cólon sigmoide que causou um prolapso imenso através do ânus. Muito poucos casos de intussuscepção colo-anal foram relatados em adultos e discutimos as ferramentas diagnósticas e o tratamento dessa entidade cirúrgica rara.

Impact of hypotension and global hypoperfusion in postoperative delirium: a pilot study in older adults undergoing open colon surgery / Impacto da hipotensão e hipoperfusão global sobre o delírio pós-operatório: um estudo piloto com idosos submetidos à cirurgia aberta do cólon

Abstract Background: Post-operative delirium is a serious complication in patients undergoing major abdominal surgery. It remains unclear whether peri-operative hemodynamic and perfusion variables affect the risk for postoperative delirium. The objective of this pilot study was to evaluate the association between perfusion and hemodynamics peri-operative with the appearance of post-operative delirium. Methods: Prospective cohort study of adults 60 years or older undergoing elective open colon surgery. Multimodal hemodynamic and perfusion variables were monitored, including central venous oxygenation (ScvO2), lactate levels, and non-invasive cerebral oxygenation (rSO2), according to a standard anesthesia protocol. Fisher's exact test or Student's t-test were used to compare patients who developed post-operative delirium with those who did not (p < 0.05). Results: We studied 28 patients, age 73 ± 7 years, 60.7% female. Two patients developed post-operative delirium (7.1%). These two patients had fewer years of education than those without delirium (p = 0.031). None of the peri-operative blood pressure variables were associated with incidence of post-operative delirium. In terms of perfusion parameters, postoperative ScvO2 was lower in the delirium than the non-delirium group, without reaching statistical significance (65 ± 10% vs. 74 ± 5%; p = 0.08), but the delta-ScvO2 (the difference between means post-operative and intra-operative) was associated with post-operative delirium (p = 0.043). Post-operative lactate and rSO2 variables were not associated with delirium. Conclusions: Our pilot study suggests an association between delta ScvO2 and post-operative delirium, and a tendency to lower post-operative ScvO2 in patients who developed delirium. Further studies are necessary to elucidate this association.

Resumo Justificativa: O delírio pós-operatório é uma complicação séria em pacientes submetidos à cirurgia abdominal de grande porte. Ainda não está claro se as variáveis hemodinâmicas e de perfusão no período perioperatório afetam o risco de delírio pós-operatório. O objetivo deste estudo piloto foi avaliar a associação entre perfusão e hemodinâmica no perioperatório com o surgimento de delírio pós-operatório. Métodos: Estudo prospectivo de coorte de adultos com 60 anos ou mais, submetidos à cirurgia eletiva aberta do cólon. As variáveis multimodais de hemodinâmica e perfusão foram monitoradas, inclusive oxigenação venosa central (ScvO2), níveis de lactato e oxigenação cerebral não invasiva (rSO2), de acordo com um protocolo-padrão de anestesia. O teste exato de Fisher ou o teste t de Student foram usados para comparar os pacientes que desenvolveram delírio pós-operatório com aqueles que não desenvolveram p < 0,05. Resultados: Avaliamos 28 pacientes, 73 ± 7 anos, 60,7% do sexo feminino. Dois pacientes desenvolveram delírio pós-operatório (7,1%). Esses dois pacientes tinham menos anos de escolaridade do que aqueles sem delírio pós-operatório (p = 0,031). Nenhuma das variáveis de pressão arterial no perioperatório foi associada à incidência de delírio. Quanto aos parâmetros de perfusão, ScvO2 foi menor no grupo que apresentou delírio pós-operatório do que no grupo que não apresentou delírio, sem atingir significância estatística (65 ± 10% vs. 74 ± 5%; p = 0,08), mas o delta-ScvO2 (a diferença entre as médias no pós-operatório e intraoperatório) foi associado ao delírio (p = 0,043). As variáveis de lactato e rSO2 no pós-operatório não foram associadas ao delírio. Conclusões: Nosso estudo piloto sugere uma associação entre delta-ScvO2 e delírio e uma tendência à diminuição da ScvO2 no pós-operatório de pacientes com delírio. Estudos adicionais são necessários para elucidar essa associação.

Laparoscopic nephrectomy outside gerota fascia and en bloc ligation of the renal hilum for management of inflammatory renal diseases

ABSTRACT Objectives This study aims to improve laparoscopic nephrectomy techniques for inflammatory renal diseases (IRD) and to reduce complications. Materials and Methods Thirty-three patients underwent laparoscopic nephrectomy for IRD, with a method of outside Gerota fascia dissection and en-bloc ligation and division of the renal pedicle. Operative time, blood loss, complications, analgesia requirement, post-operative recovery of intestinal function and hospital stay were recorded. The degrees of perinephric adhesion were classified based on the observation during operation and post-operative dissection of the specimen, and the association of different types of adhesion with the difficulty of the procedures was examined. Results Among 33 cases, three were converted to hand-assisted laparoscopy, and one was converted to open surgery. Mean operative time was 99.6±29.2min, and blood loss was 75.2±83.5 mL. Postoperative recovery time of intestinal function was 1.6±0.7 days and average hospital stay was 4.8±1.4 days. By classification and comparison of the perinephric adhesions, whether inflammation extending beyond Gerota fascia or involving renal hilum was found to be not only an important factor influencing the operative time and blood loss, but also the main reason for conversion to hand-assisted laparoscopy or open surgery. Conclusions In laparoscopic nephrectomy, outside Gerota fascia dissection of the kidney and en-bloc ligation of the renal pedicle using EndoGIA could reduce the difficulty of procedure and operative time, with satisfactory safety and reliability. Inflammation and adhesion extending beyond Gerota fascia or involving renal hilum is an important predictor of the difficulty related to laparoscopic nephrectomy for IRD.

Perioperative approach of patient with takotsubo syndrome / Abordagem perioperatória de doente com síndrome de takotsubo

Abstract Introduction: Takotsubo cardiomyopathy (TCM) is a stress-induced cardiomyopathy. It is characterized by an acute onset of symptoms and electrocardiographic abnormalities mimicking an acute coronary syndrome in the absence of obstructive coronary artery disease. Any anesthetic-surgical event corresponds to a stressful situation, so the anesthetic management of patients with TCM requires special care throughout the perioperative period. We describe the anesthetic management of a patient with a confirmed diagnosis of TCM undergoing segmental colectomy. Case report: Female patient, 55 years old, ASA III, with history of takotsubo syndrome diagnosed 2 years ago, scheduled for segmental colectomy. The patient, without other changes in preoperative evaluation, underwent general anesthesia associated with lumbar epidural and remained hemodynamically stable during the 2 h of surgery. After a brief stay in the Post-Anesthesia Care Unit, she was transferred to the Intermediate Care Unit (IMCU), with epidural analgesia for postoperative period. Conclusion: TCM is a rare disease which true pathophysiology remains unclear, as well as the most appropriate anesthetic-surgical strategy. In this case, through a preventive approach, with close monitoring and the lowest possible stimulus, all the perioperative period was uneventful. Because it is a rare disease, this report could help to raise awareness about TCM.

Resumo Introdução: A miocardiopatia takotsubo (MT) é uma miocardiopatia induzida pelo estresse. Caracteriza-se por um início agudo de sintomas e alterações eletrocardiográficas que mimetizam uma síndrome coronária aguda na ausência de doença arterial coronária obstrutiva. Qualquer evento anestésico-cirúrgico corresponde a uma situação de estresse, pelo que a abordagem anestésica dos doentes com MT exige um cuidado especial em todo o período perioperatório. Descrevemos a abordagem anestésica de uma doente com diagnóstico confirmado de MT submetida a colectomia segmentar. Caso clínico: Paciente do sexo feminino, 55 anos, ASA III, com antecedentes de síndrome de takotsubo diagnosticada havia dois anos, encaminhada para colectomia segmentar. A paciente, sem outras alterações na avaliação pré-operatória, foi submetida a anestesia geral associada a epidural lombar e manteve-se hemodinamicamente estável durante as duas horas do procedimento cirúrgico. Após uma breve permanência na Unidade de Cuidados Pós-Anestésicos foi transferida para a Unidade de Cuidados Intermédios (UCIM) com analgesia peridural para o pós-operatório. Conclusão: A MT é uma doença rara, cuja verdadeira fisiopatologia continua por esclarecer, assim como a estratégia anestésico-cirúrgica mais apropriada. Nesse caso, por causa de uma abordagem preventiva, com monitoração rigorosa e o menor estímulo possível, todo o perioperatório decorreu sem intercorrências. Sendo uma doença rara, o seu relato poderá contribuir para o avanço do conhecimento sobre a MT.

Retroneumoperitoneo y celulitis retroperitoneal: complicaciones inusuales de la enfermedad diverticular del colon / Pneumoretroperitoneum and retroperitoneal cellulitis: unusual complications of colonic diverticular disease

Se reporta dos casos de retroneumoperitoneo con neumo-mediastino, consecuencias de perforaciones diverticulares en el espacio retroperitoneal, en pacientes portadores de diverticulitis aguda y septicemia. En ambos casos no se comprobó contaminación peritoneal alguna, siendo sometidos a Colectomia parcial tipo Hartmann con buena evolución; al momento del reporte ambos han sido sometidos al restablecimiento del tránsito colo-rectal. Se discuten los problemas diagnósticos y los posibles mecanis-mos del paso del aire - y gérmenes bacterianos - al mediastino.

We report two cases of retropneumoperitoneum with pneumomediastinum, as a result of diverticular perforations in the retroperitoneal space, in patients with acute diverticulitis and septicemia. In both cases the patients underwent partial colectomy (Hartmann procedure) with good evolution, and no sign of peritoneal contamination was found. Currently both patients have undergone colorectal transit restoration. We discuss problems with the diagnosis and possible mechanism of the air and bacterial germ passage to the mediastinum.

Morbilidad global asociada a ileostomías en asa temporales / Morbidity associated to ileostomies

Introduction: The main indications for a loop ileostomy are to protect a distal anastomosis or to management of an anastomotic leak. However, it is a procedure with complications arising from its confection, function or closure. There are sparse local data on this topic. Objective: To describe the global morbidity from loop ileostomies. Method: Patients who underwent a loop ileostomy between January 2009 and January 2012 were retrospectively included. Demographics, indications, complications from the making, function and closure of the ileostomy was recorded. Results: The series consists of 64 patients. The total percentage of complications was 40.3 percent. Complications arising from the confection, function and closure were 4.7 percent, 18.7 percent and 16.9 percent respectively. Two patients were readmitted for dehydration with a total of 4 readmissions. Four patients were reoperated for morbidity of ileostomy closure, two intestinal obstructions, one leak and one enterotomy. Conclusion: In this study, loop ileostomy complications are present in a substantial proportion of patients. It should be take in consideration at the moment of making it.

Introducción: Las principales indicaciones de ileostomías en asa son proteger una anastomosis distal de alto riesgo o el manejo de una complicación séptica derivada de una filtración. Sin embargo, es un procedimiento que no está exento de complicaciones derivadas de la confección, función o cierre. En este contexto, existen escasas publicaciones que incluyen la morbilidad sumatoria. Objetivo: Describir la morbilidad global derivada de las ileostomías en asa. Método: Se incluyó en forma retrospectiva los pacientes a quienes se les practicó una ileostomía en asa de protección de una anastomosis distal entre enero de 2009 y enero de 2012. Se registraron datos demográficos, indicaciones y complicaciones derivadas de la confección, función y cierre de la ostomía. Resultados: La serie consta de 64 pacientes. Un 40,3 por ciento de los pacientes tuvieron una o más complicaciones. Complicaciones derivadas de la confección, función y cierre de la ileostomía fueron 4,7 por ciento, 18,7 por ciento y 16,9 por ciento respectivamente. Se rehospitalizaron por deshidratación 2 pacientes con un total de 4 rehospitalizaciones. Se reoperaron 4 pacientes por morbilidad del cierre de la ileostomía, 2 por obstrucción intestinal, 1 filtración y 1 enterotomía inadvertida. Conclusión: Las ileostomías en asa presentan complicaciones en un importante porcentaje de los pacientes, lo que debe ser tomado en cuenta al decidir su confección.

Israeli Arabs develop diverticulitis at a younger age and are more likely to require surgery than Jews / Árabes israelitas desenvolvem diverticulite em idade mais jovem e estão mais sujeitos ao tratamento cirúrgico do que os judeus

BACKGROUND: Only few studies have examined the impact of racial differences on the age of onset, course and outcomes of diverticulitis. AIM: To provide data about the epidemiology of diverticulitis in northern Israel, and to determine whether ethnicity is a predictor of age of onset, complications, and need for surgery. METHODS: Was conducted a retrospective review of the charts of all patients diagnosed with a first episode of diverticulitis in our hospital between 2005 and 2012. RESULTS: Were found 638 patients with a first episode of acute diverticulitis in the eight year interval. Israeli Arabs developed a first episode of diverticulitis at a younger age compared to Jews (51.2 vs 63.8 years, p<0.01). Arabs living in rural areas developed diverticulitis at a younger age than Arabs living in urban centers (49.4 vs 54.5 years, P=0.03). Jewish and Arabic men developed diverticulitis at younger age compared to their female counterparts (59.9 vs 66.09, p<0.01, and 47.31 vs 56.93, p<0.01, respectively). Arabs were more likely [odds ratio (OR)=1.81 ,95% confidence interval (CI)1.12-2.90, p=0.017] than Jews to require surgical treatment (urgent or elective) for diverticulitis. CONCLUSIONS: Israeli Arabs tend to develop diverticulitis at a younger age and are more likely to require surgical treatment for diverticulitis compared to Jews. Arabs living in rural areas develop diverticulitis at a younger age than Arabs living in urban centers. These findings highlight a need to address the root cause for ethnic differences in onset, course and outcome of acute diverticulitis. .

RACIONAL: Somente poucos estudos examinaram o impacto das diferenças raciais na idade de início, curso e os resultados da diverticulite. OBJETIVO: Fornecer dados sobre a epidemiologia da diverticulite no norte de Israel, e determinar se a etnia é preditor de idade de início, complicações e necessidade de tratamento cirúrgico. MÉTODOS: Foi realizado estudo retrospectivo dos prontuários de todos os pacientes diagnosticados com um primeiro episódio de diverticulite em nosso hospital entre 2005 e 2012. RESULTADOS: Foram encontrados 638 pacientes com um primeiro episódio de diverticulite aguda no intervalo de oito anos. Os árabes israelenses desenvolveram o primeiro episódio de diverticulite em idade mais jovem em comparação com os judeus (51,2 vs 63,8 anos, p<0,01). Árabes que vivem em áreas rurais a diverticulite foi desenvolvida em idade mais jovem do que os árabes que vivem em centros urbanos (49,4 vs 54,5 anos, p=0,03). Homens judeus e árabes desenvolveram diverticulite em idade mais jovem em comparação com os seus homólogos do sexo feminino (59,9 vs 66,09, p<0,01, e 47,31 vs 56,93, p<0,01, respectivamente). Os árabes eram mais prováveis ​​do que os judeus de necessitar de tratamento cirúrgico (urgência ou eletiva) para a diverticulite [odds ratio (OR)=1,81, intervalo de confiança de 95% (CI) 1,12-2,90, p=0,017]. CONCLUSÕES: Os árabes israelenses tendem a desenvolver diverticulite em idade mais jovem e são mais propensos a necessitar de tratamento cirúrgico para a diverticulite em comparação com os judeus. Árabes que vivem em áreas rurais desenvolvem diverticulite em idade mais jovem do que os árabes que vivem em centros urbanos. Estes resultados destacam a necessidade de abordar a causa raiz para diferenças étnicas em início, o curso e o resultado da diverticulite aguda. .

Clinical Efficacy of Endoscopic Treatment for Benign Colorectal Stricture: Balloon Dilatation versus Stenting

BACKGROUND/AIMS: There has been a lack of research comparing balloon dilatation and self-expandable metal stent (SEMS) placement to determine which is better for long-term clinical outcomes in patients with benign colorectal strictures. We aimed to compare the clinical efficacy and complication rates of balloon dilatation and SEMS placement for benign colorectal strictures from a variety of causes. METHODS: Between January 1999 and January 2012, a total of 43 consecutive patients who underwent endoscopic treatment for benign colorectal stricture (balloon only in 29 patients, SEMS only in seven patients, and both procedures in seven patients) were retrospectively reviewed. RESULTS: Thirty-six patients underwent endoscopic balloon dilatation, representing 65 individual sessions, and 14 patients received a total of 17 SEMS placements. The initial clinical success rates were similar in both groups (balloon vs SEMS, 89.1% vs 87.5%). Although the reobstruction rates were similar in both groups (balloon vs SEMS, 54.4% vs. 57.1%), the duration of patency was significantly longer in the balloon dilatation group compared with the SEMS group (65.5+/-13.3 months vs. 2.0+/-0.6 months, p=0.031). CONCLUSIONS: Endoscopic balloon dilatation is safe and effective as an initial treatment for benign colorectal stricture and as an alternative treatment for recurrent strictures.

Benign Colorectal Stricture: An Answer to the Balloon or Stent Question?

No abstract available.

Laparoscopic management of cholecystocolic fistula / Abordagem laparoscópica da fístula colecistocólica

INTRODUCTION: Cholecystocolic fistula is a rare complication of gallbladder disease. Its clinical presentation is variable and nonspecific, and the diagnosis is made, mostly, incidentally during intraoperative maneuver. Cholecystectomy with closure of the fistula is considered the treatment of choice for the condition, with an increasingly reproducible tendency to the use of laparoscopy. AIM: To describe the laparoscopic approach for cholecystocolic fistula and ratify its feasibility even with the unavailability of more specific instruments. TECHNIQUE: After dissection of the communication and section of the gallbladder fundus, the fistula is externalized by an appropriate trocar and sutured manually. Colonic segment is reintroduced into the cavity and cholecystectomy is performed avoiding the conversion procedure to open surgery. CONCLUSION: Laparoscopy for resolution of cholecystocolic fistula isn't only feasible, but also offers a shorter stay at hospital and a milder postoperative period when compared to laparotomy. .

INTRODUÇÃO: A fístula colecistocólica é rara complicação das doenças calculosas do trato biliar. Sua apresentação clínica é variável e inespecífica, sendo o diagnóstico realizado, na maioria das vezes, incidentalmente durante o intraoperatório de sua causa base. A colecistectomia com fechamento da fístula é considerada o tratamento de escolha para a condição, sendo a videolaparoscopia cada vez mais reprodutível. OBJETIVO: Descrever a abordagem laparoscópica da fístula colecistocólica e ratificar a sua factibilidade mesmo diante da indisponibilidade de instrumentos mais específicos. TÉCNICA: Após dissecção da comunicação e secção do polo vesicular, a fístula é exteriorizada por uma cânula adequada e rafiada manualmente. Reintroduzido o segmento colônico na cavidade, a colecistectomia é realizada evitando-se a conversão do procedimento para a operação aberta. CONCLUSÃO: A videolaparoscopia para resolução de fístula colecistocólica é viável, com menor tempo de internação hospitalar e melhor pós-operatório quando comparada à laparotomia. .

Estudio Multicéntrico Nacional. Análisis de las complicaciones de colonoscopías realizadas por coloproctólogos / National Multicentric Study. Analysis of complications of colonoscopy performed by colorectal surgeons

Introducción: la colonoscopía es el método estándar para el diagnóstico y tratamiento de la patología colorrectal. Su incidencia a nivel nacional entre los cirujanos es desconocido. Objetivo: analizar las complicaciones de la videocolonoscopía en series institucionales. Pacientes y Métodos: se analizaron las videocolonoscopías realizadas entre enero 2009 y diciembre de 2010 Variables: complicaciones, patología previa, sexo y edad, indicación, tipo de endoscopía, complicación, número y sitio de la complicación, clínica, metodología y momento del diagnóstico, tratamiento y evaluación de complicaciones. Resultados: de 6629 colonoscopías, el 58% fueron del sexo femenino. Hubo un 94,7% de llegadas al ciego. El tiempo fue de 28,7’ (20’-45’). La edad promedio fue de 53,5 años (13-92). Fueron ambulatorias en el 90,1%. Se hicieron 4057 (61,2%) estudios diagnósticos y 2572 (38,8%) terapéuticos. Se registraron 17 lesiones (0,25%), 12 (0,18%) estaban relacionadas al procedimiento. Las complicaciones luego de colonoscopías diagnósticas fueron del 0,12% y del 0,31% en procedimientos terapéuticos. Las complicaciones fueron resueltas con expectación en 4, cirugía en 7 y endoscopia en 1. No hubo mortalidad ni morbilidad asociadas. Existieron resultados similares entre los diferentes centros participantes. Discusión: la incidencia de complicaciones, luego de colonoscopía, fue baja. Las más frecuentes fueron la perforación y la hemorragia. La incidencia fue similar tanto en estudios diagnósticos como en terapéuticos. Fue evidente que cuando el diagnóstico fue precoz y el tratamiento oportuno, la morbi-mortalidad fue baja o nula. La relación de equivalencia de resultados entre centros de referencia y centros del interior infiere que la calidad del estudio fue similar entre ambos. Cuando se considera que fueron entrenados en centros similares al de referencia es dable atribuir a la colonoscopía realizada por coloproctólogos los mismos resultados... (TRUNCADO).

Background: colonoscopy is diagnostic standard of colorectal diseases. Its adoption by proctologists is unknown. Objective: to analyze nationwide colonoscopic complications performed by colorectal surgeons. Method: all colonoscopies performed between January 2009 and December 2010 were analyzed by type of colonoscopy and complication, previous pathology, age and gender, number and site of complication, diagnosis and treatment. Results: 6629 colonoscopies were performed, 58% of them were female. Cecum visualization was possible in almost 95% in 20 to 45 minutes. Average age was 53,5 years. Almost 91% were ambulatory. 62% of them were diagnostic procedures. There were 17 complications, 12 after diagnostic procedures. Complications were treated by expectation in 4 and surgery in 7. There was neither morbidity nor mortality in this series. Similar results were found in different centers. Discussion: incidence of complications after colonoscopy is low. Perforation and hemorrhage are the most frequent and its incidence is similar in diagnostic and therapeutic scopes. In early diagnosis, morbidity and mortality were lower. Relation of incidence between high and low volume hospitals were similar, even between colorectal surgeons with same results. Conclusion: colonoscopy is a safe procedure performed by colorectal surgeons, either diagnostic or therapeutic, supported for the first time by nationwide data.

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

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

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

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

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

Preparación Mecánica del Colon para la Cirugía. ¿Es Necesaria? / Mechanical bowel preparation for surgery. Is it necessary?

Antecedentes: la preparación mecánica del colon (PMC) para la cirugía ha sido de práctica habitual durante décadas. Recientemente han sido publicados muchos trabajos con resultados adversos de la PMC y se ha puesto en duda la necesidad de la misma. Objetivo: evaluar la PMC en una serie consecutiva de enfermos operados en tiempo electivos por patología colónica benigna y maligna. Lugar de aplicación: Sanatorio Dupuytren y Clínica Colegiales. Diseño: estudio prospectivo. Serie consecutiva randomizada y comparativa. Población: n= 251 pacientes randomizados en dos grupos, A=132 pacientes con PMC y B=119 paciente sin PMC. Método: ambos grupos fueron similares en cuanto a sexo, edad y patología (benigna y maligna). Todos fueron operados por el mismo equipo quirúrgico y se excluyeron patologías rectales o cuando hubo anastomosis colo-rectales. Se evaluaron complicaciones inmediatas como infección del sitio quirúrgico, de la pared y dehiscencia anastomótica y la mortalidad. Resultados: no hubo diferencias significativas con respecto a la morbilidad entre el colon derecho y el colon izquierdo: con PMC colon derecho 9.83% y colon izquierdo 7.75%, y sin PMC colon derecho 5.73% vs. colon izquierdo 4.65%. La mortalidad fue de 2 pacientes (1.5%), reoperados con dehiscencia anastomótica, 1 con PMC y 1 sin PMC. Conclusiones: en esta serie no hubo ventajas significativas en los resultados postoperatorios cuando se realizó PMC.

Background: mechanical bowel preparation (MBP) has been the standard practice during decades. Recently, numerous papers with some adverse events related to MBP, have been published raising doubts about the need for its application. Objective: to assess a consecutive series of patients operated on for elective malignant and benign pathology. Setting: Sanatoriums Dupuytren and Colegiales. Design: Prospective, randomized study. Population: two-hundred fifty-one patients of both genders, randomized in 2 groups. A) With MBP: 132 and B) Without MBP: 119. Methods: both groups were similar with regard to age, gender, and pathology. All patients were operated on by the same surgical team. Rectal disease and rectal anastomoses were excluded. Early complications such as anastomotic leakage, abdominal abscesses, and wound infection, and mortality were analyzed. Results: there were not significant differences in morbidity between the right colon (RC), and the left colon (LC) in both groups. Group A) CD: 9,83% vs. CI: 7,75%. Group B) CD: 5.73 % vs. CI: 4,65%. Mortality was 1.5% (2 patients), one with and the other without MBP, both reoperated on for LC anastomotic leakage. Conclusions: in the present series there were not any significant advantages in postoperative outcome when MBP was performed.