Presentaciones de la sífilis anorrectal: la gran simuladora / Anorectal syphilis presentations: the great pretender

Antecedentes: La sífilis es una infección sexualmente transmisible sistémica crónica que afecta a docenas de millones de personas al año. A nivel anorrectal, su manifestación polimórfica obliga al diagnóstico diferencial con enfermedades anorrectales benignas y malignas. Objetivo: Describir las diferentes presentaciones de la sífilis anorrectal a propósito de 5 casos clínicos. Método: Estudio observacional, retrospectivo, descriptivo. Resultados: La mayoría de los pacientes fueron VIH positivos en edad sexual activa. Las manifestaciones registradas, al igual que las reportadas en la bibliografía fueron las fisuras, úlceras perianales y pseudotumores. Conclusiones: La sífilis es considerada "la gran simuladora". En la localización anorrectal se requiere una alta sospecha diagnóstica para diferenciarla de presentaciones similares de otras enfermedades anales benignas, la enfermedad inflamatoria intestinal y el cáncer anorrectal, con el fin de evitar el consiguiente riesgo de sobretratamiento. (AU)

Background: Syphilis is a chronic systemic sexually transmitted infection that affects tens of millions of people annually. At the anorectal level, its polymorphic manifestation requires differential diagnosis with benign and malignant anorectal diseases. Objective: To review the presentation of anorectal syphilis from 5 clinical cases. Methods: Observational, retrospective, descriptive study. Results: Most of the patients were HIV positive in sexually active age. The manifestations recorded and reported in the literature were fissures, perianal ulcers, and pseudotumors. Conclusions: Syphilis is considered "the great pretender". In anorectal syphilis, a high diagnostic suspicion is needed to differentiate it from similar presentations due to other anal conditions, inflammatory bowel disease, and anorectal cancer, to avoid the consequent risk of overtreatment. (AU)

Uso de stent en estenosis colorrectal benigna / Stent utilization in benign colorectal stenosis

Introducción. La estenosis colorrectal benigna hace referencia a una condición anatómica caracterizada por una disminución del diámetro de la luz intestinal distal a la válvula ileocecal, ocasionando una serie de signos y síntomas de tipo obstructivo. Es una entidad poco frecuente, secundaria en la gran mayoría de veces a la realización de anastomosis intestinales al nivel descrito. El objetivo de esta investigación fue determinar la utilidad del stentcolónico en estenosis secundaria a patología colorrectal no neoplásica. Métodos. Estudio descriptivo de una cohorte de pacientes que desarrolló estenosis colorrectal de origen benigna confirmada por colonoscopía, en 3 hospitales de alta complejidad de la ciudad de Medellín, Colombia, entre los años 2007 y 2021. Resultados. Se incluyeron 34 pacientes con diagnóstico de estenosis colorrectal de origen benigno, manejados con stents metálicos autoexpandibles. La mediana de seguimiento fue de 19 meses y se obtuvo éxito clínico en el 73,5 % de los casos. La tasa de complicación fue del 41,2 %, dada principalmente por reobstrucción y migración del stent, y en menor medida por perforación secundaria a la colocación del dispositivo. Conclusión. Los stents metálicos autoexpandibles representan una opción terapéutica en pacientes con obstrucción colorrectal, con altas tasas de mejoría clínica en pacientes con patología estenosante no maligna. Cuando la derivación por medio de estoma no es una opción, este tipo de dispositivos están asociados a altas tasas de éxito clínico y mejoría de la calidad de vida de los pacientes

Introduction. Benign colorectal stenosis refers to an anatomical condition characterized by a decrease in the diameter of the intestinal lumen distal to the ileocecal valve, which might cause a series of obstructive signs and symptoms. It is a rare entity, caused in the vast majority of cases due to intestinal anastomosis at the described level. The purpose of this study is to determine the performance of colonic stents in the management of non-malignant colorectal strictures. Methods. Descriptive study of a cohort of patients who developed a benign colorectal stenosis confirmed by colonoscopy in three high-complexity hospitals in the city of Medellín, Colombia, between 2007 and 2021. Results. Thirty-four patients diagnosed with benign colorectal stenosis managed with self-expanding metal stents were included in the study. Median follow-up was 19 months, obtaining clinical success in 73.5% of cases, with a complication rate of 41.2%, mainly due to reobstruction and migration of the stent, and to a lesser extent due to perforation secondary to device placement.Conclusion. Self-expanding metallic stents represent a therapeutic option in patients with colorectal obstruction caused by non-malignant stenosing pathology. When diversion through a stoma is not an option, this type of device is associated with high rates of clinical success and improvement in the patients' quality of life

Prevalence and predictors of functional evacuation disorder in patients with chronic constipation

Background: Functional evacuation disorder (FED) is the second most common cause of functional constipation (FC) after constipation-predominant irritable bowel syndrome. However, the data on FED is relatively scanty in our region. Hence, the present study was performed to evaluate the demographics of FED and to find out the predictors of FED in patients with chronic constipation. Methods: A total of 134 patients with chronic constipation diagnosed according to the Rome IV criteria who were referred for high-resolution anorectal manometry (HRAM) were retrospectively enrolled in the present study. All FC patients who underwent HRAM were asked to fill a questionnaire and underwent anorectal manometry and were submitted to the balloon expulsion test (BET). Results: The mean age of patients was 43.09 ± 9.32 years old, with a total of 76 (54%) males. The most common symptom was straining during defecation (87%) followed by incomplete evacuation (86%). The prevalence of FED, diagnosed by HRAM and by the BET was 39%. Patients with FED had a significantly higher percentage of straining and sensation of anorectal blockade compared with those without FED (96 versus 82%; p < 0.01; 81 versus 44%; p < 0.001, respectively). On the multivariate regression analysis, straining > 30 minutes (odds ratio [OR] = 3.63; p = 0.03), maximum squeeze pressure (OR = 1.05; p < 0.001), and balloon volume at maximal sensation (OR = 1.06; p < 0.001) were found to be significant independent predictors of FED. Conclusion: Prolonged straining and sensation of anorectal blockade were significant indicators of FED in patients with chronic constipation. (AU)

Tailgut cyst - a case report

Retrorectal hamartoma, also called tailgut cyst, is a congenital lesion resulting from the non-regression of embryo remnants of the hindgut. We describe in this work the case report of a 68-year-old man, previously healthy, complaining of rectal bulging for 4 months, which was diagnosed by nuclear magnetic resonance imaging as a multi-loculated and mucinous lesion, suggestive of tailgut cyst. In view of the finding, the lesion was surgically resected, due to the potential for future complications, and, through the anatomopathological analysis, there were no findings of malignancy in the specimen. (AU)

A prospective cohort study on the clinical value of pelvic peritoneal reconstruction in laparoscopic anterior resection for middle and low rectal cancer / 中华胃肠外科杂志

Objective: To investigate the safety and efficacy of pelvic peritoneal reconstruction and its effect on anal function in laparoscopy-assisted anterior resection of low and middle rectal cancer. Methods: A prospective cohort study was conducted. Consecutive patients with low and middle rectal cancer who underwent laparoscopy-assisted transabdominal anterior resection at Naval Military Medical University Changhai Hospital from February 2020 to February 2021 were enrolled. Inclusion criteria: (1) the distance from tumor to the anal verge ≤10 cm; (2) laparoscopy-assisted transabdominal anterior resection of rectal cancer; (3) complete clinical data; (4) rectal adenocarcinoma diagnosed by postoperative pathology. Exclusion criteria: (1) emergency surgery; (2) patients with a history of anal dysfunction or anal surgery; (3) preoperative diagnosis of distant (liver, lung) metastasis; (4) intestinal obstruction; (5) conversion to open surgery for various reasons. The pelvic floor was reconstructed using SXMD1B405 (Stratafix helical PGA-PCL, Ethicon). The first needle was sutured from the left anterior wall of the neorectum to the right. Insertion of the needle was continued to suture the root of the sigmoid mesentery while the Hemo-lok was used to fix the suture. The second needle was started from the beginning of the first needle, after 3-4 needles, a drainage tube was inserted through the left lower abdominal trocar to the presacral space. Then, the left peritoneal incision of the descending colon was sutured, after which Hemo-lok fixation was performed. The operative time, perioperative complications, postoperative Wexner anal function score and low anterior resection syndrome (LARS) score were compared between the study group and the control group. Three to six months after the operation, pelvic MRI was performed to observe and compare the pelvic floor anatomical structure of the two groups. Results: A total of 230 patients were enrolled, including 58 who underwent pelvic floor peritoneum reconstruction as the study group and 172 who did not undergo pelvic floor peritoneum reconstruction as the control group. There were no significant differences in general data between the two groups (all P>0.05). The operation time of the study group was longer than that of control group [(177.5±33.0) minutes vs. (148.7±45.5) minutes, P<0.001]. There was no significant difference in the incidence of perioperative complications (including anastomotic leakage, anastomotic bleeding, postoperative pneumonia, urinary tract infection, deep vein thrombosis, and intestinal obstruction) between the two groups (all P>0.05). Eight cases had anastomotic leakage, of whom 2 cases (3.4%) in the study group were discharged after conservative treatment, 5 cases (2.9%) of other 6 cases (3.5%) in the control group were discharged after the secondary surgical treatment. The Wexner score and LARS score were 3.1±2.8 and 23.0 (16.0-28.0) in the study group, which were lower than those in the control group [4.7±3.4 and 27.0 (18.0-32.0)], and the differences were statistically significant (t=-3.018, P=0.003 and Z=-2.257, P=0.024). Severe LARS was 16.5% (7/45) in study group and 35.5% (50/141) in control group, and the difference was no significant differences (Z=4.373, P=0.373). Pelvic MRI examination 3 to 6 months after surgery showed that the incidence of intestinal accumulation in the pelvic floor was 9.1% (3/33) in study group and 46.4% (64/138) in control group (χ(2)=15.537, P<0.001). Conclusion: Pelvic peritoneal reconstruction using stratafix in laparoscopic anterior resection of middle and low rectal cancer is safe and feasible, which may reduce the probability of the secondary operation in patients with anastomotic leakage and significantly improve postoperative anal function.

Patients' reactions to digital rectal examination of the prostate

Background:Digital rectal examination (DRE) of the prostate is a simple, fast, cost effective and safe procedure, however, because of previous painful experience, some men may refuse it. Other negative factors include cultural barriers, fear of discovering cancer and embarrassments. However, some men accept DRE because of their symptoms and wishes to contribute to science. The aim of this study was to examine how previous experience of DRE could influence a repeat and to further evaluate their impression before and after DRE including pain score. Patients and Methods:We evaluated one hundred patients who met the inclusion criteria using a structured questionnaire that detailed information on patients biodata, their previous DRE experiences, expectations before and reactions after a repeat. Pain score was also examined using visual analog scale of 0 to 10. Data were collated and analysed using statistical package for social sciences (SPSS) version 20.0. P-value was set at <0.05. Results:Mean age of patients was 64.88±7.53 years ranging from 46 to 82 years. Forty five percent of them complained of pain from previous DRE while 55% reported no pain. Forty one percent of the men anticipated pain before this present procedure but only 8% of them reported that it was painful and humiliating after the procedure. Fifty nine percent had good impression before DRE and after the procedure 92% reported good impression. All patients expressed their willingness to repeat DRE in future if need be and to encourage friends who may need DRE evaluation of their condition. Mean pain score was 0.59± 1.349 (0 ­ 9). Conclusion:Patients previous experience of DRE could negatively influence a repeat procedure because of pain, improper counseling apart from some cultural barriers. DRE in the hands of Urologists has been better tolerated than other clinicians. This calls for proper exposure of medical students to this procedure and need for continuous medical education for other clinicians for skills improvement.

Chinese expert consensus on clinical diagnosis and treatment of fecal incontinence (2022 edition) / 中华胃肠外科杂志

Fecal incontinence is one of the common diseases in the field of colorectal and anal surgery. Its etiology is complex, the treatment response is suboptimal, and there are controversies in clinical care. There is no consensus on the clinical practice of fecal incontinence in China currently. Launched by Anorectal Branch of Chinese Medical Doctor Association, Expert Committee on Anorectal Disease of Anorectal Branch of Chinese Medical Doctor Association, and Clinical Guidelines Committee of Anorectal Branch of Chinese Medical Doctor Association, and organized by the editorial board of Chinese Journal of Gastrointestinal Surgery, Chinese experts on this field were convened to write the Chinese expert consensus on clinical practice of fecal incontinence based on relevant references. After rounds of discussion, the final consensus combines the latest evidence and experts' clinical experience. This expert group suggested that a comprehensive assessment of fecal incontinence should be conducted before treatment, including medical history, relevant scales, physical examination and special examinations. Special examinations include anorectal endoscopy, anorectal manometry, transrectal ultrasound, magnetic resonance, rectal sensation and compliance, balloon ejection test, pelvic floor electromyography, defecography, colonoscopy and pudendal nerve terminal motor latency. Treatment methods include life style modification, medication, surgery, traditional Chinese medicine and other treatments. This consensus aims to standardize the algorithm of fecal incontinence management and improve therapeutic efficacy.

Chinese expert consensus on the diagnosis and treatment of outlet obstructive constipation (2022 edition) / 中华胃肠外科杂志

In recent years, professional societies in China including the Chinese Medical Doctor Association Anorectal Branch have issued many clinical practice guidelines and expert consensus on constipation, which played a positive role in the standardization of diagnosis and surgical treatment of chronic constipation in China. However, the diagnosis and treatment of outlet obstructive constipation (OOC) remain controversial. OOC, the most common subtype of functional constipation, is featured by various clinical symptoms, complex pelvic floor anatomy, functional and psychological aspects. We need a gold standard supported by high-level clinical research evidence. To standardize the diagnosis and treatment process of OOC in China, Chinese Medical Doctor Association Anorectal Branch and its Clinical Guidelines Committee, and jointly sponsored by Professional Committee on Anorectal Diseases of Chinese Society of Integrated Traditional Chinese and Western Medicine, Anorectal Disease Committee of Chinese Medical Women's Association and Chinese Constipation Medical Association, and the Chinese Journal of Gastrointestinal Surgery organized and summoned a Chinese expert taskforce to focus on OOC diagnosis, classification, examination, evaluation, and various treatments (e.g. diet modification, medication, biofeedback therapy, pelvic floor function training, psychological intervention, traditional Chinese medicine and surgical treatment). Based on the latest relevant evidence in China and abroad and experts' clinical experience, the taskforce produced the " Chinese expert consensus on the diagnosis and treatment of outlet obstructive constipation (2022 edition)" after rounds of discussion and revision. The aim is to help anorectal surgeons make clinical decisions, standardize the process of diagnosis and treatment, reduce complications and improve clinical efficacy in OOC.

Nivel de conocimientos de enfermeras sobre intervenciones de enfermería en personas con cirugía ambulatoria por enfermedades anorrectales / Level of Knowledge of Nurses about Nursing Interventions in Outpatient Surgery for Anorectal Diseases

Introducción: Para el desarrollo exitoso de la cirugía ambulatoria de afecciones anorrectales se requiere de profesionales de enfermería con conocimientos juicio y clínico de las intervenciones que realizan. Objetivo: Identificar el nivel de conocimientos de enfermeras sobre intervenciones de enfermería en personas con cirugía ambulatoria por enfermedades anorrectales. Métodos: Estudio descriptivo transversal, contextualizado en los servicios de Cirugía Ambulatoria de hospitales provinciales de Camagüey, desde agosto de 2018 hasta septiembre de 2020. Universo constituido por 52 enfermeras, con más de 5 años de experiencia en esos servicios. Para obtener información sobre nivel de conocimientos se aplicó una encuesta con Alfa de Cronbach de 0,647, lo que confirma su unidimensionalidad y aditividad. Para procesar la información se utilizó el software estadístico IMB SPSS Statistics v23 x64, según los presupuestos establecidos por la estadística descriptiva. Resultados: En cuanto al dominio del instrumental quirúrgico el 48,07 por ciento de las enfermeras identificó el de operar Fístulas, 26,92 por ciento el de fisuras y 19,23 por ciento identificó el instrumental a emplear en la Cirugía Ambulatoria de Hemorroides. Al evaluar los conocimientos básicos, 65,38 por ciento pudo mencionar las principales enfermedades anorrectales, 40,38 por ciento mencionó las complicaciones más frecuentes; los cuidados de enfermería en el preoperatorio fueron identificados por 34,61 por ciento del total de enfermeras evaluadas y solo el 1,92 por ciento pudo definir la conducta a seguir frente a las complicaciones. Conclusiones: Se identificó que el nivel de conocimientos de las enfermeras sobre intervenciones de enfermería en personas con cirugía ambulatoria por enfermedades anorrectales es insatisfactorio(AU)

Introduction: Nursing professionals with judgment and clinical knowledge of the interventions they perform are required for successful development of outpatient surgery for anorectal conditions. Objective: To identify the level of knowledge of nurses about nursing interventions in outpatient surgery for anorectal diseases. Methods: A descriptive cross-sectional study was done in the Ambulatory Surgery services of Camagüey provincial hospitals, from August 2018 to September 2020. A universe was 52 nurses, with more than 5 years of experience in these services. To obtain information on the level of knowledge, a survey with Cronbach's Alpha of 0.647 was applied, which confirmed unidimensionality and additivity. To process the information, the statistical software IMB SPSS Statistics v23 x64 was used, according to the assumptions established by descriptive statistics. Results: Regarding the domain of surgical instruments, 48.07 percent of the nurses identified that of operating fistulas, 26.92 percent that of fissures, and 19.23 percent identified the instruments to be used in outpatient hemorrhoid surgery. When evaluating basic knowledge, 65.38 percent were able to mention the main anorectal diseases, 40.38 percent mentioned the most frequent complications; nursing care in the preoperative period was identified by 34.61 percent of the total number of nurses evaluated and only 1.92 percent were able to define the behavior to follow in the face of complications. Conclusions: The nurses' level of knowledge about nursing interventions in outpatient surgery for anorectal diseases was identified as unsatisfactory(AU)

Anal ultrasonography in monitoring and postoperative evaluation of anorectal malformations

Objectives: We aimed to describe anal ultrasound for monitoring anorectal malformations.Methods: A descriptive and retrospective study of patients diagnosed and/or intervened with anorectal malformations rated by anal ultrasonography, between 2016-2017, was performed. We employed a transducer of 10 megahertz to identify the anatomy of the anal channel.Results: Eight patients, 5 men and 3 women were included, with a mean of 8.37 years old (range, 3-11). Three patients had a diagnosis of an anterior anus (not operated). Surgery was performed in 5 patients: 2 had a rectourethral fistula, 1 had a rectovesical fistula, and 1 had a rectovestibular and a perineal fistula. The most significant ultrasound findings were partial absence of the anterior part of the ex-ternal sphincter, internal sphincter hypertrophy in the middle channel, and absence of internal sphincter in the median and high channel plus the absence of external sphincter in the an-terior region. These results belonged to a patient with clinical incontinence and to 2 patients that were previously diagnosed with an anterior anus.Conclusions: Anal ultrasonography is a non-invasive method, economic, and feasible to be performed without anesthesia. It offers useful anatomical information to establish the best therapeutic option. Its main limitation is the unfeasibility of carrying it out on patients under 3 years old.

Objetivos: Describir la ecografía anal en el seguimiento de malformaciones anorrectales.Material y Métodos: estudio descriptivo y retrospectivo de pacientes diagnosticados y/o in-tervenidos de malformaciones anorrectales, evaluados por ecografía anal, entre 2016-2017. Empleamos un transductor de 10 megahercios, identificando la anatomía del canal anal alto, medio y bajo.Resultados: Se incluyeron ocho pacientes, 5 hombres y 3 mujeres, con una media de 8,37 años (rango, 3-11). Tres pacientes tenían diagnóstico de ano anterior (no operados previa-mente). Se intervinieron 5 pacientes: 2 presentaban fístula recto-uretral, 1 fístula recto-vesi-cal, 1 recto-vestibular y 1 fístula perineal.Los hallazgos ecográficos más significativos fueron: ausencia parcial de la parte anterior del esfínter externo, hipertrofia del esfínter interno en el canal medio en un paciente; y ausencia de esfínter interno en el canal medio y alto más ausencia de esfínter externo en la región anterior, en un paciente con incontinencia clínica, ambos pacientes previamente diagnosticados de ano anterior que posteriormente fueron intervenidos.Conclusiones: La ecografía anal es un método no invasivo, económico, factible de realizarse sin anestesia y ofrece una información anatómica útil para establecer la mejor opción terapéutica. Su principal limitación es la imposibilidad de realizarlo en pacientes menores de 3 años.

Profile of Crohn's disease patients who underwent anorectal examination under anesthesia

Introduction: Crohn's disease (CD) is an inflammatory bowel disease, and in ~ 30% of cases it is associated with perianalmanifestations. To identify the extent of the damage and to implement an appropriate treatment, anorectal examination under anesthesia (EUA) is fundamental. Objective: To describe the profile of patients who underwent anorectal EUA in university and private hospitals in the state of Bahia, Brazil. Methodology: A retrospective, descriptive study with 46 patients who underwent anorectal EUA between March, 2016 and November, 2019. Results: A total of 62 anorectal EUAs were performed in 46 patients. With an average age of 36.8 years, the female gender was predominant (52.2%) among these patients. Anal fistulas were the most frequent findings (83.8%), and in most cases they were treated with a seton placement (69.4%). The main recommended surgical indication was a proper evaluation and identification of perianal disease, followed by drainage of the abscess and therefore immunobiological therapy (59.6%). Conclusion: In the present study, the profile of CD patients was similar to those found in the literature, with a high rate of complex anal fistulas. Additional studies are still necessary to further comprehend and treat this particular and debilitating manifestation of the disease. (AU)

Short- and Long-Term Outcomes of Overlap Anal Sphincter Repair for Fecal Incontinence Following Sphincter Injury / Resultados em curto e longo prazos do reparo por sobreposição do esfíncter anal para incontinência fecal após lesão esfincteriana

Abstract Objective Several techniques are used to repair the anal sphincter following injury. The aim of the present study is to comprehensively analyze the short- and long-term outcomes of overlap repair following anal sphincter injury. Methods A search was conducted in the PubMed, Medline, Embase, Scopus and Google Scholar databases between January 2000 and January 2020. Studies that described the outcomes that are specific to overlap sphincter repair for fecal incontinence with a minimum follow-up period of one year were selected. Results A total of 22 studies described the outcomes of overlap sphincter repair. However, 14 studies included other surgical techniques in addition to overlap repair, and were excluded from the analysis. Finally, data from 8 studies including 429 repairs were analyzed. All studies used at least one objective instrument; however, there was significant heterogeneity among them. Most patients were female (n=407; 94.87%) and the mean age of the included individuals was 44.6 years. The majority of the procedures were performed due to obstetric injuries (n=384; 89.51%). The eight included studies described long-term outcomes, and seven of them demonstrated statistically significant improvements regarding the continence; one study described poor outcomes in terms of overall continence. The long-term scores were significantly better compared with the preoperative scores. However, compared with the shortterm scores, a statistically significant deterioration was noted in the long-term. Conclusion The majority of the studies described good long-term outcomes in terms of anal continence after overlap sphincter repair. However, further studies are needed

Resumo Objetivo Diversas técnicas são usadas no reparo do esfíncter anal após lesões. O objetivo deste estudo é fazer uma análise completa dos desfechos nos curto e longo prazos do reparo por sobreposição após lesão do esfíncter anal. Métodos Realizou-se uma busca nas bases de dados PubMed, Medline, Embase, Scopus e Google Scholar entre janeiro de 2000 e janeiro de 2020. Estudos que descreviam desfechos específicos do reparo de esfíncter por sobreposição para incontinência fecal, com um mínimo de 1 ano de seguimento, foram selecionados. Resultados No total, 22 estudos descreviam os desfechos do reparo de esfíncter por sobreposição. No entanto, 14 estudos incluíam outras técnicas cirúrgicas além do reparo por sobreposição, e foram excluídos da análise. Por fim, dados de 8 estudos que incluíam 429 reparos foram analisados. Todos os estudos usaram pelo menos um instrumento objetivo, mas havia uma heterogeneidade significativa entre eles. A maioria dos pacientes era do sexo feminino (n=407; 94,87%), e a idade média dos indivíduos incluídos foi de 44,6 anos. A maioria das cirurgias foi realizada devido a lesões obstétricas (n=384; 89,51%). Os oito estudos incluídos descreveram os desfechos no longo prazo, e sete deles demonstraram melhoras estatisticamente significativas com relação à continência; um estudo descreveu resultados ruins em termos gerais com relação à continência. As pontuações no longo prazo foram significativamente melhores em comparação com as pontuações no pré-operatório. No entanto, em comparação com as pontuações no curto prazo, percebeu-se uma piora estatisticamente significativa no longo prazo. Conclusão A maioria dos estudos descrevia bons resultados no longo prazo em termos de continência anal depois do reparo do esfíncter por sobreposição. Entretanto mais estudos são necessários para que se identifiquem os fatores associados aos desfechos ruins para auxiliar na seleção de pacientes para o reparo por sobreposição.

Manejo de la fístula anorrectal compleja: LIFT, colgajo de avance y otras técnicas / Management of complex anorectal fistula: LIFT, endorectal advancement flap and others techniques

Resumen Las fístulas anorrectales complejas son un desafío para el coloproctólogo. Son una patología frecuente que afecta la calidad de vida de los pacientes. La patogénesis aún no está clara, estarían involucradas citoquinas y el proceso de transición de epitelio a mesénquima. El gold standard para su estudio es la resonancia nuclear magnética, su uso por sí mismo disminuye la recurrencia. El objetivo del tratamiento es lograr la curación sin afectar la función del esfínter evitando las recidivas. Existen múltiples técnicas, siendo la de mayor aceptación la ligadura interesfinteriana del trayecto fistuloso, con tasa de curación sobre el 70%, con mínimo impacto en continencia. Esta revisión incluye otras técnicas como el colgajo endorrectal de avance, uso de sellante, permacol, células madres, Anal fistula plug, Video asisted anal fistula treatment, Over the scope clip y fistula laser closure.

Complex anal fistula are a challenge for colorectal surgeons. It is a common pathology in population. Pathogenesis is still unclear, it would be involved citokines and the process of epitelial to eesenchymal transition. The gold standard for study is MRI, its use reduces recurrences. The goal of treatment is heal the fistula without damaging the function of the sphincter and avoid recurrences. There are multiple techniques, the most accepted is ligation of intersphincteric fistula tract with cure rate over 70%, with minimal impact in continence. This review includes other techniques like rectal advancement flap, fibrin glue, permacol, stem cells, anal fistula plug, video asisted anal fistula treatment, over the scope clip and fistula laser closure.

One hundred citation classics in benign anorectal disease: a bibliometric analysis of seven decades (1950-2019) / Cem clássicos de citações em doença anorretal benigna: uma análise bibliométrica de sete décadas (1950-2019)

ABSTRACT Background & aim Bibliometric analysis is used to explore the historical development in a particular field. The aim is to identify and analyse most cited papers in benign anorectal disease in the last 7 decades (1950-2018). Method Thomson Reuters Web of Science database was used to find the top 100 cited articles in benign anorectal conditions. Papers were independently extracted by two investigators. The top 100 cited articles were identified and ranked according to number of citations. The articles were then sorted by author, journal, institution, country and publication date. The study subject was divided into 5 groups. Results The most frequently cited article received 1307 citations whereas the least cited received 154 citations. The earliest recorded article was published in 1960 and the most recent was from 2010. More than half of the articles addressed faecal incontinence and sphincter related literature (n = 54). The articles were published in 29 different journals. A majority (69%) of manuscripts originated from the USA (n = 35; 9221 citations) and UK (n = 34; 7796 citations). The origin of these top 100 classic papers was from 53 different institutions. St. Mark's Hospital in the UK had the highest number of articles (n = 21), followed by Cleveland clinic (n = 5) and University of Minnesota (n = 5). Conclusion The most highly cited manuscripts in benign anorectal disease cover a wide range of topics. Faecal incontinence and sphincter related articles had the highest number of citations. This review serves as a reference for researchers to find the influential papers in this field.

RESUMO Justificativa e objetivo A análise bibliométrica é usada para explorar o desenvolvimento histórico em um campo específico. O objetivo é identificar e analisar os artigos mais citados em doença anorretal benigna nas últimas 7 décadas (1950-2018). Método A base de dados Thomson Reuters Web of Science foi usada para encontrar os 100 artigos mais citados em doenças anorretais benignas. Os artigos foram extraídos de forma independente por dois pesquisadores. Os 100 artigos mais citados foram identificados e classificados de acordo com o número de citações. Os artigos foram classificados por autor, revista médica, instituição, país e data de publicação. Os sujeitos do estudo foram divididos em cinco grupos. Resultados O artigo mais citado recebeu 1.307 citações, enquanto o menos citado recebeu 154 citações. O artigo mais antigo foi publicado em 1960 e o mais recente a partir de 2010. Mais da metade dos artigos abordou a incontinência fecal e a literatura relacionada ao esfíncter (n = 54). Os artigos foram publicados em 29 revistas diferentes. A maioria (69%) dos manuscritos é originária dos EUA (n = 35; 9.221 citações) e do Reino Unido (n = 34; 7.796 citações). Os 100 artigos clássicos mais citados são originários de 53 instituições diferentes. O St. Mark's Hospital, no Reino Unido, teve o maior número de artigos (n = 21), seguido pela Clínica de Cleveland (n = 5) e pela Universidade de Minnesota (n = 5). Conclusão Os manuscritos mais citados em doença anorretal benigna abrangem uma grande variedade de tópicos. Os artigos relacionados à incontinência fecal e ao esfíncter tiveram o maior número de citações. Esta revisão serve de referência para os pesquisadores encontrarem os artigos influentes nesse campo.

Use of local anesthetic for the resolution of benign anorectal pathology in the Social Security Institute of Guatemala (IGSS) / Uso de anestésico local para resolução de patologia anorretal benigna no Instituto Guatemalteco de Seguridade Social

Abstract Introduction The use of regional anesthetic block has increased, along with the reduction of the use of spine anesthetic in this particular field of surgical activity. In the last decade ambulatory surgery and local anesthetic have lower surgical time, complications of the anesthetic itself, and hospital stay. Objective Presenting the results obteained with the use of local anesthesic and analgesic in the resolution of benign anorectal pathology. Methods A prospective, longitudinal, study, from January 2017 to December 2017, patients were classified according to surgical procedures performed using analogical visual scale to determine the pain tolerance, during the procedure, 24 h later and in the 5th post operative day. Results 253 procedures were performed with 116 local analgesia, 116 were male (45.86%) years 137 female (54%), Milligan-Morgan hemorroidectomy with Ligasure and fistulotomy were the most frequently performed procedures 32% each, followed by biopsy 16%, left lateral esfinterotomy 13% and cutaneous appendix 12%. Females presented better pain tolerance than males patients (92 vs. 81), 68% referred good tolerance through the procedure. Conclusions 68% of all the patients obtained good pain tolerance through anal anesthetic block, females manifested better pain tolerance than males, in non-complicated anorectal pathology local block ha shown to be safe and reproductible for the treatment of benign anorectal pathology in the Guatemalan Institute for Social Security.

Resumo Introdução O uso de bloqueio anestésico regional aumentou ao mesmo tempo em que diminuiu o uso do anestésico espinhal nesse campo específico da atividade cirúrgica. Na última década, a cirurgia ambulatorial e o anestésico local apresentaram um tempo cirúrgico menor, menos complicações associadas ao próprio anestésico e redução da permanência hospitalar. Objetivo Apresentar os resultados obtidos com o uso de anestésico local e analgésico na resolução da patologia anorretal benigna. Métodos Estudo prospectivo, longitudinal, realizado no período de janeiro a dezembro de 2017. Com o uso de uma escala visual analógica, os pacientes foram classificados para determinar a tolerância à dor durante o procedimento, 24 horas após a cirurgia e no quinto dia de pós-operatório. Resultados No total, 253 procedimentos foram realizados com 116 analgesias locais; 116 pacientes eram do sexo masculino (4586%) e 137 do sexo feminino (54%). A técnica de Milligan-Morgan para hemorroidectomia com ligadura e a fistulotomia foram os procedimentos realizados com mais frequência (32% cada), seguidos de biópsia (16%), esfincterotomia lateral esquerda (13%) e apêndice cutâneo (12%). As mulheres apresentaram melhor tolerância à dor que os homens (92 vs. 81), e 68% apresentaram boa tolerância durante o procedimento. Conclusões De todos os pacientes, 68% apresentaram boa tolerância à dor com o uso de bloqueio anestésico por via retal; as mulheres manifestaram melhor tolerância à dor que os homens. Na patologia anorretal não complicada, o bloqueio local mostrou ser seguro e reprodutível para o tratamento da patologia anorretal benigna no Instituto Guatemalteco de Seguridade Social.

Anorectal diseases in patients with Antiphospholipid syndrome: a cross-sectional study

Abstract Background: Hemorrhoid disease (HD) is one of the most common gastrointestinal complaints worldwide, affecting 4.4% of the general population in the United States. Since antiphospholipid syndrome (APS) may lead to intra-abdominal thrombosis, one may expect that this condition can impact the risk for HD development. Additionally, as APS patients are more prone to thrombosis and treatment with anticoagulants may increase risk of bleeding, one may also infer that rates of HD complications may be higher in this scenario. Nevertheless, no data in these regards have been published until now. The objective of the present study is to evaluate frequency of HD and describe its complications rates in antiphospholipid syndrome APS patients. Methods: We consecutively invited patients who fulfilled APS criteria to undergo proctological examination. After examination, patients were divided in two groups, based on the presence of HD, and compared regarding different clinical manifestations and antiphospholipid profile. We performed the analysis of the data, using chi-square and Mann Whitney U when applicable and considering a significance level of 0.05. Multivariate regression analysis included age and variables with p < 0.10 in the bivariate analysis. Results: Forty-one APS patients agreed to undergo proctological examination. All were female and overall median age was 43 (36-49). Seventeen (41.4%) patients were diagnosed with HD, with the following frequency distribution: 7 internal (41.2%), 4 external (23.5%) and 5 mixed hemorrhoids (29.4%). Of the internal hemorrhoids, 5 patients were classified as grade I (71.4%), 1 grade II (14.3%), and 1 grade IV (14.3%). Prior gestation ( p = 0.067) and constipation ( p = 0.067) correlated with a higher frequency of HD. In multivariate analysis, constipation remained as an important risk factor (OR 3.92,CI95% 1.03-14.2, p = 0.037). Five out of 17 patients (29.4%) reported anal bleeding, but it did not correlate with warfarin dose ( p = 0.949). Surgical treatment was indicated for 10 patients (58.8%). Other anorectal findings were anal fissure, plicoma, condyloma and one chlamydial retitis. Conclusion: We found an unexpected high frequency of hemorrhoids in APS patients, with a great proportion requiring surgical treatment.(AU)

Cirugía ambulatoria electiva en patología proctológica: experiencia prospectiva de 14 años en un hospital público docente / Elective ambulatory surgery in proctological pathology: 14 years of prospective experience in a public teaching hospital

INTRODUCCIÓN: Se presenta nuestra experiencia en cirugía ambulatoria en patología proctológica. MATERIALES Y MÉTODO: La serie corresponde al análisis de 1.399 pacientes tratados entre agosto de 2003 y diciembre de 2017 en forma prospectiva, RESULTADOS: Fueron intervenidos por fístula anorrectal (20%), enfermedad hemorroidaria (19%), enfermedad pilonidal sacro coccígea (EPSC) (15%), fisura anal (13%), biopsia rectal quirúrgica o resección local endoanal (12%), condilomas (10%) y otras (10%). La morbilidad inmediata es de un caso, por un hematoma luego de una cirugía por EPSC que requirió hemostasia y cierre primario. La tasa de hospitalización inmediata fue de 0,3% y corresponde a 5 casos de retención aguda de orina. La hospitalización tardía fue de un 1,6% y corresponde a 22 pacientes, hospitalizados por sangrado tardío (9), dolor intratable (9) y fiebre (4). Todos fueron tratados en forma conservadora con resolución entre los 2 y 5 días. No se registra morbilidad mayor en esta serie. CONCLUSIONES: La cirugía ambulatoria en patología proctológica es factible y segura.

INTRODUCTION: We present our prospective experience in ambulatory anorectal surgery between August 2003 and December 2017. MATERIALS AND METHOD: The series corresponds to the analysis of 1399 patients treated between August 2003 and December 2017 prospectively. RESULTS: The etiology of the surgerys were anal fistula (20%), hemorrhoidal disease (19%), sacrococcygeal pilonidal disease (15%), anal fissure (13%), rectal surgical biopsy or local resection (12%), condylomata (10%) and others (10%). The immediate morbidity was seen one case, a hematoma after an EPSC surgery that required hemostasis and primary closure. The immediate hospitalization rate was 0.3% and corresponds to 5 cases of acute urinary retention. The late hospitalization was 1.6% and corresponds to 22 patients, due to late bleeding (9), severe pain (9) and fever (4). All were treated conservatively with resolution between 2 and 5 days. No major morbidity is recorded in this series. CONCLUSION: We concluded that outpatient surgery in proctologic pathology is feasible and safe.