Fístula sigmoido-cervical secundaria a una enfermedad diverticular complicada / Sigmoido-cervical fistula due to diverticular disease

Resumen Introducción: Las fístulas secundarias a una enfermedad diverticular complicada son una indicación formal de cirugía electiva en el 4 a 23% de los casos. Caso Clínico: Se presenta el caso de una mujer de 52 años con antecedentes de una histerectomía subtotal por miomatosis uterina que consulta por cuadro de dolor abdominal en hipogastrio acompañado de fiebre de 4 días de evolución. La tomografía computada (TC) de abdomen y pelvis describe una diverticulitis complicada con absceso peridiverticular. Tratada con antibióticos con buena respuesta clínica consulta a los 3 meses en nuestro servicio por pérdida de material fecal por vagina. Nueva TC confirma la presencia de una colección perisigmoidea y engrosamiento de la pared vesical. La colonoscopía informa una estenosis franqueable a nivel de sigmoides y se constata salida de gases por vagina. La corrección quirúrgica electiva incluyó una sigmoidectomía abierta con traquelectomía en block, cierre de la cúpula vaginal y anastomosis colorrectal mecánica, con buena evolución posoperatoria, sin recidiva a los 12 meses de seguimiento. La fístula sigmoido-cervical es una complicación rarísima de la enfermedad diverticular complicada que puede ocurrir en pacientes sometidas a una histerectomía subtotal previa. Aunque el diagnóstico de la fístula es clínico, la colonoscopía y la TC permiten descartar otras etiologías. La resección radical del segmento afectado es el tratamiento estándar en pacientes aptos.

Introduction: Diverticular disease is complicated by fistulas in 4% to 23% of patients. Case Report: A woman 52 years-old previously operated on with parcial histerectomy was successfully treated with antibiotics due to diverticulitis complicated with an abscess. Three months later the patient presented with vaginal discharge of faeces. Computed tomography showed wall thickening of sigmoid colon and vesical wall. Colonoscopy exclude cancer and confirmed the exit of gas through vagina. En-bloc resection of the sigmoid colon with traquelectomy with primary anastomosis was performed. The postoperative course was good without recurrence after 12 months of follow up. Sigmoido-cervical fistula is a very rare benign fistula due to diverticular disease. Diagnosis is basically clinic, but tomography and colonoscopy are important to exclude other causes of fistulas. Radical surgery with primary anastomosis is the standard treatment.

Hormone treatment as first line therapy is safe and relieves pelvic pain in women with bowel endometriosis / O tratamento hormonal como terapia de primeira linha é seguro e melhora a dor pélvica em mulheres com endometriose intestinal

ABSTRACT Objective: To evaluate clinical features and complications in patients with bowel endometriosis submitted to hormonal therapy. Methods: Retrospective study based on data extracted from medical records of 238 women with recto-sigmoid endometriosis treated between May 2010 and May 2016. Results: Over the course of follow-up, 143 (60.1%) women remained in medical treatment while 95 (39.9%) presented with worsening of pain symptoms or intestinal lesion growth (failure of medical treatment group), with surgical resection performed in 54 cases. Women in the Medical Treatment Group were older (40.5±5.1 years versus 37.3±5.8 years; p<0.0001) and had smaller recto sigmoid lesions (2.1±1.9 versus 3.1±2.2; p=0.008) compared to those who had failed to respond to medical treatment. Similar significant reduction in pain scores for dysmenorrhea, chronic pelvic pain, cyclic dyschezia and dysuria was observed in both groups; however greater reduction in pain scores for dyspareunia was noted in the Surgical Group. Subjective improvement in pain symptoms was also similar between groups (100% versus 98.2%; p=0.18). Major complications rates were higher in the Surgical Group (9.2% versus 0.6%; p=0.001). Conclusion: Patients with recto-sigmoid endometriosis who failed to respond to medical treatment were younger and had larger intestinal lesions. Hormonal therapy was equally efficient in improving pain symptoms other than dyspareunia compared to surgery, and was associated with lower complication rates in women with recto-sigmoid endometriosis. Medical treatment should be offered as a first-line therapy for patients with bowel endometriosis. Surgical treatment should be reserved for patients with pain symptoms unresponsive to hormonal therapy, lesion growth or suspected intestinal subocclusion.

RESUMO Objetivo: Avaliar características clínicas e complicações em pacientes com endometriose intestinal submetidos ao tratamento hormonal. Métodos: Dados de prontuários de 238 pacientes com endometriose de retossigmoide tratadas entre maio de 2010 e maio de 2016 foram coletados para este estudo retrospectivo. Resultados: Durante o período de acompanhamento, 143 (60,1%) mulheres mantiveram tratamento clínico, enquanto 95 (39,9%) tiveram piora dos sintomas de dor ou aumento da lesão intestinal (grupo falha de tratamento clínico), sendo 54 submetidas ao tratamento cirúrgico. As mulheres no Grupo Tratamento Clínico eram mais velhas (40,5±5,1 anos versus 37,3±5,8 anos; p<0,0001) e tinham lesões intestinais menores (2,1±1,9 versus 3,1±2,2; p=0,008) em comparação ao grupo falha de tratamento clínico. Redução significativa e semelhante do escore de dor na dismenorreia, dor pélvica crônica, disquezia cíclica e disúria cíclica foi observada nos Grupos Tratamento Clínico e Cirúrgico. Dispareunia, no entato, teve uma redução maior no Grupo Cirurgia. A redução subjetiva dos sintomas dolorosos também foi semelhante entre os Grupos Clínico e Cirúrgico (100% versus 98,2%; p=0,18). O Grupo Tratamento Cirúrgico foi relacionado a uma maior taxa de complicações graves (9,2% versus 0,6%; p=0,001) em comparação ao Grupo Tratamento Clínico. Conclusão: Falha no tratamento clínico em pacientes com endometriose de retossigmoide foi observada em mulheres mais jovens que tinham lesões intestinais maiores. O tratamento clínico hormonal foi igualmente eficaz na melhora dos sintomas de dor, exceto dispareunia, em comparação ao tratamento cirúrgico em mulheres com endometriose intestinal, mas com menor taxa de complicações. O tratamento clínico deve ser oferecido como primeira opção em pacientes com endometriose intestinal, enquanto o tratamento cirúrgico deve ser reservado para pacientes sem melhora nos sintomas de dor com tratamento hormonal, progressão das lesões ou suspeita de suboclusão intestinal.

Megacolon andino y vólvulo del sigmoides de la altura: Presentación de 418 casos entre 2008 - 2012 en el hospital C. Monge - Puno, Perú / Andean megacolon and sigmoid volvulus in the high altitude: Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru

Objetivo: El presente estudio describe el manejo médico y quirúrgico del vólvulo de sigmoides debido a dolicomegacolon andino en un hospital a una altitud mayor a 3000 msnm. Material y métodos: Estudio descriptivo, observacional, transversal de 418 pacientes con diagnóstico de vólvulo de sigmoides; admitidos inicialmente por cuadros de obstrucción intestinal, en el Hospital de Juliaca Carlos Monge - Puno, Perú, durante el periodo 2008-2012. Los datos fueron procesados a través del programa SPSS versión 21. Resultados: Se registraron 418 pacientes, la media de edad fue de 60 años, rango 18-89 años, con una proporción hombre/mujer de 3,5/1. El manejo no quirúrgico se hizo en 64 (15,4%), el tratamiento empleado fue de enema salino 20 casos 31% y sonda rectal 44 (69%), se presentó recurrencia en 27 pacientes (45%), los cuales tuvieron cirugía con resección anastomosis primaria, de estos la mortalidad correspondió a 8 pacientes (30%). De los 354 pacientes sometidos a manejo quirúrgico de emergencia 325 fueron sometidos a sigmoidectomia con anastomosis primaria (92%), mientras 29 tuvieron colostomía a lo Hartmann (8%), la morbilidad para ambos procedimientos fue de 52 casos (14,7%), la mortalidad para ambos procedimientos fue de 45 casos (12,7%). Conclusiones: El vólvulo sigmoides debido a megacolon andino tuvo una edad media de 60 años. El 15,4% tuvo manejo no quirúrgico, la tasa de recurrencia fue de 45%, mortalidad de 30%. El 84,7% tuvo manejo quirúrgico; el 92% tuvo resección anastomosis primaria y 8% colostomía a lo Hartmann, la morbilidad fue de 14,7% y la mortalidad de 12,7%.

Objective: The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m. Material and methods: A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21. Results: A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%). Conclusions: In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.

Obstrucción colónica por cálculo / Colonic obstruction by gallstone

El íleo biliar es una rara complicación de la colelitiasis, que se caracteriza por presentar clínicamente una obstrucción intestinal mecánica intraluminal, secundaria a la impactación de un cálculo biliar en el tubo digestivo, debido a la existencia de una fístula bilio-entérica. El diagnóstico preoperatorio es difícil, ya que presenta síntomas y signos de obstrucción intestinal, los cuales son muy inespecíficos para sospechar un íleo biliar. El tratamiento de elección en el manejo del íleo biliar es el quirúrgico. Habitualmente se realiza una cirugía en dos tiempos, enterolitotomía como único gesto, sin embargo no hay una técnica quirúrgica definitiva estandarizada. Presentamos el caso de una paciente de 70 años que acude al Departamento de Urgencias con el diagnóstico clínico de obstrucción intestinal mecánica baja, de cuatro días de evolución, como consecuencia de un cálculo impactado en colon sigmoides.

Gallstone ileus is a rare complication of cholelithiasis, which is characterized by clinically presenting as an intraluminal mechanical intestinal obstruction secondary to the impaction of a gallstone in the digestive tract, due to the existence of a biliary-enteric fistula. The preoperative diagnosis is difficult, since it presents symptoms and signs of intestinal obstruction, which are very unspecific to suspect a Biliary Ileus. The treatment of choice in the management of gallstone ileus is surgery; usually is performed in two stages, whole lithotomy as the only gesture, however there is no standardized definitive surgical technique. We present the case of a 70-year-old patient, who attended the emergency department with the clinical diagnosis of low mechanical bowel obstruction, four days of evolution, as a result of a stone impacted in the sigmoid colon.

Comparative study of collagen deposition in the colon wall of patients operated for sigmoid diverticular disease

PURPOSE: To investigate the deposition of collagen in the colon wall of patients with sigmoid diverticulitis.METHODS: Samples of sigmoid tissue from 15 patients (disease group), seven men and eight women aged 37-77 years who underwent surgery for the treatment of diverticulitis, were selected. For the control group, specimens from five patients, three men and two women aged 19-58 years undergoing emergency surgery for sigmoid trauma were selected. These subjects had no associated diseases. The histological study of the surgical specimens was performed by staining with hematoxylin-eosin and picrosirius and using a histochemical method for collagen quantification.RESULTS: Collagen deposition in the colon wall in terms of area (F), glandular epithelium (E) and total area was significantly higher in the disease group compared to control (p=0.003, p=0.026 and p=0.010, respectively). The collagen volume fraction (F fraction) and muscle tissue (M fraction) were also significantly higher compared to control (p=0.044 and p=0.026, respectively). The muscle (M area) and volume fraction of glandular epithelium (E fraction) did not differ significantly between the two groups, (p=0.074 and p=1.000, respectively).CONCLUSION: In this study, collagen deposition in the colon wall of the patients operated for sigmoid diverticulitis was higher compared to patients without the disease.

Oclusión intestinal por nudo ileosigmoideo / Intestinal occlusion by Ileosigmoid Knot

La oclusión intestinal es una causa frecuente de abdomen agudo quirúrgico. Dentro de sus múltiples casusas se encuentra el nudo ileosigmoideo, entidad rara en el mundo, pero puede verse con relativa frecuencia en algunas latitudes geográficas como Asia, Medio Oriente y otros países del continente africano. El objetivo de este trabajo es presentar cuatro casos de pacientes con oclusión intestinal por nudo ileosigmoideo en los hospitales Souro Sanu de Bobo Diulaso, Burkina Faso y Wa Regional Hospital, de Gana. Se intervinieron quirúrgicamente, se hizo resección en bloque de los segmentos ileales y sigmoideos gangrenados con anastomosis íleo-ascendente y colostomía de tipo Hartman. Los pacientes evolucionaron satisfactoriamente y luego de tres meses se restableció definitivamente el tránsito intestinal. Se realizó una revisión de la literatura(AU)

Intestinal occlusion is a frequent cause of surgical acute abdomen. Among its multiple causes are the ileosigmoid knot, a rare entity worldwide, which is relatively frequent in some geographic areas such as Asia, Middle East and Africa. The objective of this paper was to present four patients with intestinal occlusion due to ileosigmoid knot in Souro Sanu of Bobo Diulaso hospitals in Burkina Faso and Wa Regional Hospital in Ghana. They were operated on through block resection of gangrenous ileal and sigmoid segments with ascending ileoanastomosis and Hartrman-type colostomy. The patients recovered satisfactorily and three months later, the intestinal transfer was finally re-established. A literature review on the topic was made(AU)

Ileosigmoid Knot: A Rare Cause of Intestinal Obstruction.

Ileosigmoid knotting also known as compound volvulus or double volvulus is a rare cause of intestinal obstruction. Here, we present a case of acute intestinal obstruction in shock. The patient was resuscitated taken up for an emergency exploratory laparotomy, which revealed a large volume of hemorrhagic fluid and dilated gangrenous loops of ileum and sigmoid. A loop of ileum had encircled the base of sigmoid to form a knot resulting in gangrene of both the ileum and the sigmoid colon. Resection of gangrenous ileum and sigmoid colon with ileo-ileal and colorectal anastomosis with a temporary diversion colostomy was done.

Lower gastrointestinal bleeding as a result of fistula between the iliac artery and sigmoid colon in patient with advanced testicular cancer

Fistula between arteries and the gastrointestinal tract are a rare cause of gastrointestinal bleeding, but potentially fatal. The recognition and early treatment can modify the patient prognosis. We report a case of a patient with previous surgery for seminoma of cryptorchidic testicle, with massive lower gastrointestinal bleeding. We performed the diagnosis and surgical treatment of the fistula between left external iliac artery and sigmoid colon. The patient was successfully treated by external iliac artery ligation and left colectomy.

Stercolith Perforation

A 62-year-old diabetic bed ridden woman, presented to the emergency department with symptoms suggestive of peritonitis. She had been taking oral laxatives and enemas to relieve her chronic constipation for last 6 years. Hard impacted stools and pelvic tenderness were found on digital rectal examination. Her X-ray abdomen showed soft tissue shadows in the colon but there was no gas under the diaphragm on chest X-ray. Sonography found free fluid in pelvis. She was resuscitated, and her hyperglycemia was controlled by use of regular insulin as per sliding scale. Operative findings revealed free fluid in pelvis and very hard faecalomas lying free in peritoneal cavity. There was a 2 x 3 cm perforation at the anterior wall of the recto-sigmoid junction. Peritoneal toilet was carried out followed by Hartmann's procedure. Histopathology of perforation side showed no evidence of malignancy

Colectomía parcial laparoscópica electiva por enfermedad diverticular / Elective laparoscopic colectomy for diverticular disease

Background: Colorectal colectomy is a less invasive technique that can be used for the treatment of diverticular disease, recently in younger patients. Aim: To report the experience with laparoscopic colectomy for diverticular disease. Material and Methods: All patients with indication for elective surgical resolution for diverticular disease were subjected to laparoscopic surgery from 1997 to 2009. The surgical protocols of these patients were analyzed. Results: Sixty patients with average age 53,8 (31 males) were operated in the period. Forty six were subjected to a sigmoidectomy and 14 to left hemicolectomy. Operative average time was 173 minutes and hospital stay 4,16 days. Three patients had to be converted to open surgery and three had complications that were managed without need of reoperation. During a median follow up of 38 months, the disease relapsed in two patients, which did not require a new intervention. Conclusions: Elective laparoscopic colectomy for diverticular disease is feasible and safe.

La cirugía laparoscópica colorrectal, aunque de desarrollo lento, ha presentado en los últimos años ventajas con respecto a la cirugía abierta. Hay escasas publicaciones nacionales sobre esta técnica en enfermedad diverticular. Objetivo: Presentar nuestra experiencia en enfermedad diverticular en una serie consecutiva de pacientes con indicación quirúrgica electiva resueltos por vía laparoscópica. Material y Método: Se analizan los protocolos prospectivos de cirugía laparoscópica de colon con diagnóstico de enfermedad diverticular para resolución electiva, desde junio de 1997, hasta diciembre de 2009. Todo paciente con indicación quirúrgica electiva por esta patología fue resuelto por vía laparoscópica. Se estudian edad, sexo, tipo de resección, evolución postoperatoria inmediata y tardía. Resultados: Se operaron 60 pacientes, con edad promedio de 53,8 años. De éstos 46 fueron sigmoidectomías y 14 hemicolectomías izquierdas. El tiempo operatorio promedio fue de 173 minutos y la hospitalización de 4,16 días. Se convirtieron 3 pacientes (5 por ciento) y hubo 3 complicaciones (5 por ciento), que fueron manejadas médicamente. Hubo 1 estenosis de anastomosis tratada endoscópicamente como complicación tardía. Seguimiento promedio de 37,9 meses. Hubo 2 recidivas (3,3 por ciento), tratadas médicamente y no hubo mortalidad en esta serie. Conclusión: La cirugía laparoscópica para la enfermedad diverticular electiva es factible de realizar en la gran mayoría de los pacientes, con baja morbilidad y rápida recuperación.

Management of viable sigmoid volvulus by mesosigmoidoplasty

Mesosigmoidoplasty is a non-resective procedure for viable sigmoid volvulus. It corrects the main pathogenetic factor, the narrow but long mesosigmoid. This study was conducted to know the outcome of mesosigmoidoplasty in cases of viable sigmoid volvulus. This prospective study was conducted from July 2004 to June 2008 at District Headquarter Teaching Hospital D.I.Khan, on patients admitted with large gut obstruction due to viable sigmoid volvulus. After initial investigations and resuscitation, non-operative decompression was tried in all cases. Successfully decompressed patients underwent elective laparotomy and the rest had emergency laparotomy and mesosigmoidoplasty. After their discharge from hospital, patients were followed up for 6 months. Thirty-nine patients presented with viable sigmoid volvulus; 35 males and 4 females, with male to female ratio of 8.7:1. Age range was 48-70 years. Thirteen [33%] patients had successful decompression. Two patients refused surgery after successful non-operative decompression and were dropped from the study. Out of the remaining 37 patients 11[30%] patients had mesosigmoidoplasty on elective list and 26[70%] had emergency operation for mesosigmoidoplasty. Average hospital stay was 4 days [2-6 days]. Post-operative complications were wound infection in 1[2.7%] and paralytic ileus in 3[8%] cases. During 6 months follow-up, only 1[2.7%] patient had recurrence. Mesosigmoidoplasty is a definitive procedure for viable sigmoid volvulus with low rates of mortality, morbidity

Ileosigmoid knot: a case report and literature review of 280 cases

Ileosigmoid knotting, also known as compound volvulus or double volvulus, is a rare cause of intestinal obstruction. In this condition the ileum wraps around the base of the sigmoid colon and forms a knot. Ileosigmoid knotting is an unusual entity in the West, but is comparatively common in certain Africa, Asian and Middle Eastern nations. The condition is serious, generally progressing rapidly to gangrene. Awareness of the condition is essential for prompt diagnosis and optimal management. This report describes a case in a 60-year-old male and describes the management of this rare condition. An additional 280 recent cases in the English literature are reviewed as to etiopathogenesis, presentation, diagnostic modalities, surgical interventions and outcome

Postmenopausal intestinal obstructive endometriosis: case report and review of the literature / Endometriose intestinal obstrutiva na pós-menopausa: relato de caso e revisão da literatura

CONTEXT: Endometriosis is characterized by the presence of endometrial tissue outside the uterine cavity, which is commonly detected in gynecological practice but rarely reported as a coloproctological disorder. The objective of the present report was to discuss a rare case of postmenopausal intestinal endometriosis simulating a malignant lesion, following a review of the literature. CASE REPORT: A 74-year-old woman with complaints of hematochezia and tenesmus of two months' duration accompanied by liquid feces and pelvic pain, but with no other gastrointestinal or gynecological complaints, was referred to our service. She had been menopausal for 22 years, with no hormone replacement treatment, and had undergone panhysterectomy three years before the referral to us, due to endometrial thickening and a right adnexal cyst. Five months before this referral, she had undergone laparotomy due to acute obstructive abdomen, which revealed a tumor mass involving the small bowel. Anatomopathological examination of the enterectomy suggested a hypothesis of intestinal endometriosis. A proctological examination was normal. Computed tomography of the pelvis revealed thickening of the rectosigmoid transition and colonoscopy revealed friable tumor formation in the rectum. A biopsy of the lesion revealed mucosal fragments of endometrial type, which led to a review of the previous anatomopathological examination. The patient underwent rectosigmoidectomy with protective transversotomy, with a good postoperative course, and anatomical examination confirmed the intestinal endometriosis. The patient subsequently suffered a stenosing recurrence of the lesion and has undergone colostomy since then.

CONTEXTO: A endometriose caracteriza-se pela presença de tecido endometrial fora da cavidade uterina, e a etiopatogenia ainda apresenta controvérsias. O objetivo desta publicação é apresentar e discutir, após revisão da literatura, um raro caso de endometriose intestinal na pós-menopausa que simulava uma lesão maligna. RELATO DE CASO: Mulher de 74 anos apresentou-se com queixas de hematoquezia e tenesmo há dois meses. Relatou também aparecimento de fezes líquidas e dor pélvica no mesmo período, negando outras queixas gastrointestinais ou ginecológicas. Como antecedentes de interesse, revelou que era menopausada há 22 anos, sem terapia de reposição hormonal e realizou uma pan-histerectomia há três anos por espessamento endometrial e cisto anexial direito. Há cinco meses foi submetida a laparotomia exploradora por abdome agudo obstrutivo, com o achado de uma massa tumoral envolvendo alças de delgado. O exame anatomopatológico da enterectomia sugeriu a hipótese de endometriose intestinal. O exame proctológico era normal. A tomografia computadorizada da pelve mostrou um espessamento da transição retossigmóide e a colonoscopia, uma tumoração friável e estenosante no reto alto. A biópsia da lesão revelou fragmentos de mucosa tipo endometrial, que motivou a revisão do anatomopatológico anterior. A paciente foi submetida a retossigmoidectomia abdominal com transversostomia protetora, tendo boa evolução no pós-operatório. O anatomopatológico confirmou endometriose intestinal. Evoluiu com recidiva estenosante da lesão e pemanece colostomizada desde então.

Resultados de la cirugía laparoscópica en el tratamiento electivo de la enfermedad diverticular de colon / Results of laparoscopic surgery for the treatment of diverticular disease of the colon

The laparoscopic approach is an alternative for the elective treatment of diverticular colon disease (DCD). Aim: To analyze the results of patients electively operated for DCD using a laparoscopic technique. Material and Methods: Data of patients with DCD operated using laparoscopy at the Catholic University of Chile Clinical Hospital were prospectively recorded from January 1999 to August 2006. Indications for surgery were repetitive crises of acute diverticulitis, the persistence of the symptoms or anatomic deformity after the first crisis and complicated diverticulitis (Hinchey 1-2) that responded to the medical treatment. The laparoscopic technique used five ports and the surgical specimen was extracted through a suprapubic approach. Results: One hundred and six patients aged 32 to 82 years (49 percent females) were operated in the study period. Fifty five percent had a previous abdominal surgery. The mean operative time was 213 minutes (range: 135-360). Four patients were converted to open surgery (3.7 percent). One or more early post-operative complications were observed in five patients (4.7 percent). The mean time for passing gases and reinitiate liquid diet was 1.7 and 2.4 days respectively. The median post operative stay after surgery was 4 days. There was no operative mortality. Mean follow-up time was 27 months and only one patient (0.9 percent) had a new episode of acute diverticular disease, with a satisfactory response to medical treatment. No patient has developed bowel obstruction. Conclusions: The laparoscopic approach is a safe alternative in the elective surgical treatment of DCD.

Results of primary closure in the management of gangrenous and viable sigmoid volvulus

To compare the outcome of primary repair, both in viable and gangrenous cases of Sigmoid Volvulus. Retrospective study conducted from August 2001 to April 2006. District Headquarter Hospital, Bannu, North West Frontier Province. All patients admitted with large gut obstruction due to Sigmoid Volvulus. After initial investigations and resuscitation, the patients were shifted to the operation theatre where the vascular status of the sigmoid colon was noted, and resection and primary anastomosis was done in all the cases. Patients were allowed orally after 3-5 days, when their bowel sounds returned and they were able to pass flatus and/ or faeces. All patients were discharged home after recovery, and were followed up for a minimum of four months. The outcome of both the gangrenous and the viable gut patients was compared in terms of anastomotic leakage, wound infection, hospital stay and long term complications. The findings were entered onto a proforma and the results compiled and analyzed. Amongst the total 83 patients, there were 72 [86.7%] males and 11[13.3%] females, with an age range of 35-80 years [mean 55 years]. All patients presented with the typical symptoms of intestinal obstruction. Local and systemic signs of toxicity were more common in the gangrenous group. Postoperatively 17 [53.12%] patients in the gangrenous group and 9 [17.64%] cases in the viable group developed paralytic ileus; 2 [6.25%] patients in the gangrenous group developed anastomotic leakage leading to peritonitis; 2 [6.25%] patients in the gangrenous group and one [1.96%] in the viable group developed intra abdominal abscess; eight patients in the gangrenous group and five in the viable group developed wound infection, two of these patients late on developed incisional hernia. The mean hospital stay in the gangrenous group was 10 days as compared to eight days in the viable group. The difference in the outcome of primary anastomosis in both the viable and non viable groups was insignificant. Primary anastomosis can be safely done for acute sigmoid volvulus in both gangrenous and viable gut

Fístula colovesical secundaria a la migración de una endoprótesis biliar: reporte de un caso / Colovesical fistula secondary to the migration of a biliary stent: case report

Introducción: la colocación endoscópica de stents para descomprimir una obstrucción biliar es un tratamiento comúnmente utilizado para enfermedades malignas de la vía biliar y para estenosis benignas de la misma. Se han descrito complicaciones inusitadas derivadas de la colocación de endoprótesis biliares, incluyendo la migración. Se presenta un caso clínico con el objetivo de compartir con la comunidad científica una rara complicación y la única publicada, secundaria a la migración de un stent biliar. Caso clínico: mujer de 47 años de edad, con estenosis de ámpula de Vater benigna, a quien se le colocó endoprótesis biliar, con la cual mejoró clínicamente. Posterior a la colocación del stent se le realizó colecistectomía abierta con exploración de vías biliares. Al año y medio posterior a la colocación del stent, la paciente presentó dolor vago en abdomen bajo y disuria; se le practicaron estudios de imagen donde se observó un extremo del stent biliar en colon sigmoides y otro en vejiga. Se realizó intervención quirúrgica encontrando fístula colovesical, la cual se resolvió en un solo tiempo quirúrgico. La paciente fue egresada con resultados satisfactorios.

BACKGROUND: The endoscopic placement of endoprostheses to decompress biliary obstruction is a commonly used treatment for malignant biliary diseases and is also used in the treatment of benign biliary strictures. Unusual complications of endoprosthesis placement have been described and include the migration of the stent. We present a case to share with the scientific community, an unusual complication secondary to the migration of a biliary stent that has not previously been reported to our knowledge. CASE REPORT: We present the case of a 47-year-old female with a diagnosis of benign papillary stenosis. The patient received a biliary endoprosthesis with clinical improvement. Later she underwent open cholecystectomy and common duct exploration. At consultation 18 months later, the patient presents with indistinct lower abdominal pain and dysuria. We performed imaging studies where the biliary stent was observed, partly in the sigmoid colon and partly in the bladder. The patient underwent surgery where a colovesical fistula was found and treated during the same surgical event. The patient was discharged succesfully.

Indicaciones resultados alejados del tratamiento quirúrgico electivo de la enfermedad diverticular del colon sigmoides / Indications and long term results of elective surgery for sigmoid diverticular disease

Background: There are no clear guidelines for the indication of elective surgery in sigmoid diverticular disease. Aim: To analyze the indications and long term results of elective surgery in sigmoid diverticular disease. Material and Methods: Retrospective review of 100 patients (age range 25-86 years, 51 male) with sigmoid diverticular disease, operated in a lapse of 22 years. Sixty seven patients answered a survey about their disease at the end of follow up. Results: Among patients aged more than 70 years, there was a higher proportion of women. The main indication for surgery was recurrent diverticulitis in 54 patients, followed by diverticular fistula in 19. A sigmoidectomy was performed in 91 patients. Stapled anastomosis was performed in half of these patients. No patient died or required reoperation in the immediate postoperative period. During a follow up ranging from 8 to 280 months, 28 patients died for causes not associated with diverticular disease and five were lost. Those patients that answered the survey were free of symptoms related to diverticular disease and did not require new operations. Conclusions: In patients with sigmoid diverticular disease and recurrent diverticulitis or with fistulae, the long term results of surgery are satisfactory.

Primary perineal posterior hernia: an abdominoperineal approach for mesh repair of the pelvic floor

O desenvolvimento espontâneo de hérnia perineal representa uma condição patológica muito rara.Várias técnicas têm sido descritas para a correção da falha no assoalho muscular pélvico.