Traumatismo anorrectal contuso. Reporte de un caso y revisión bibliográfica / Blunt anorectal trauma. Case reportand literature review

Introducción: El traumatismo anorrectal es una causa poco frecuente de consulta al servicio de emergencias, con una incidencia del 1 al 3%. A menudo está asociado a lesiones potencialmente mortales, por esta razón, es fundamental conocer los principios de diagnóstico y tratamiento, así como los protocolos de atención inicial de los pacientes politraumatizados. Método: Reportamos el caso de un paciente masculino de 47 años con trauma anorrectal contuso con compromiso del esfínter anal interno y externo, tratado con reparación primaria del complejo esfinteriano con técnica de overlapping, rafia de la mucosa, submucosa y muscular del recto. A los 12 meses presenta buena evolución sin incontinencia anal. Conclusión: El tratamiento del trauma rectal, basado en el dogma de las 4 D (desbridamiento, derivación fecal, drenaje presacro, lavado distal) fue exitoso. La técnica de overlapping para la lesión esfinteriana fue simple y efectiva para la reconstrucción anatómica y funcional. (AU)

Introduction: Anorectal trauma is a rare cause of consultation to the Emergency Department, with an incidence of 1 to 3%. It is often associated with life-threatening injuries, so it is essential to know the principles of diagnosis and treatment, as well as the initial care protocols for the polytrau-matized patient. Methods: We present the case of a 47-year-old man with a blunt anorectal trauma involving the internal and external anal sphincter, treated with primary overlapping repair of the sphincter complex and suturing of the rectal wall. At 12 months the patient presents good outcome, without anal incontinence. Conclusion: The treatment of rectal trauma, based on the 4 D ́s dogma (debridement, fecal diversion, presacral drainage, distal rectal washout lavage) was successful. Repair of the overlapping sphincter injury was simple and effective for anatomical and functional reconstruction. (AU)

Tratamiento del cuerpo extraño rectal en un Servicio de Urgencia / Rectal foreign body treatment at an urgency service

Resumen Introducción: El cuerpo extraño rectal (CER) es un problema de difícil manejo para el cirujano general. La vía anal es la puerta de entrada más habitual seguido de la oral. La sospecha clínica es fundamental para el diagnóstico, pudiendo apoyarse de imágenes. El tratamiento es su extracción por vía transanal o por vía anterior. Objetivos: Caracterizar, describir y presentar el tratamiento de los pacientes con CER que consultaron en urgencia del Hospital el Pino (HEP) entre los años 2011 y 2016. Material y Método: Estudio serie de casos. Se realiza revisión de fichas clínicas de pacientes con CER en un periodo de 5 años en el Servicio de Urgencia del HEP. Se identificó a los pacientes tratados en box y a aquellos tratados en pabellón. Se caracterizó según variables demográficas, tratamiento, complicaciones y días de hospitalización. Resultados: Se identificaron 18 pacientes, 13 hombres y 5 mujeres de 45 años (± 36-51) y 34 años (± 23-64) respectivamente. En 1 de ellos fue posible extracción manual transanal en box sin anestesia y en 17 se requirió tratamiento en pabellón, donde 12 fue por vía transanal y 5 por abordaje abdominal. En ningún caso se identificó lesión intestinal. Evolución postoperatoria adecuada. Días de hospitalización promedio 1,8 días. Conclusión: Este es un problema infrecuente y de difícil manejo. Existe mayor frecuencia en hombres de edades media siendo la puerta de entrada la vía anal en todos los casos. En la mayoría se requirió extracción en pabellón bajo anestesia siendo el abordaje transanal el más utilizado y con buenos resultados.

Introduction: The rectal forcing body (RFB) is a problem which involves a difficult management for surgeons. Anal via is the most frequent entrance area, followed by the oral via. Clinical suspicion is fundamental for diagnosis and it is possible to support it using imaging. Treatment considers extraction through transanal or frontal via. Aim: To describe and present the treatment of patients with rectal foreing body in the Urgency Service of El Pino Hospital during years 2011 to 2016. Materials and Method: Case studies. Clinical records revision of patients with rectal foreing body in the Urgency Service of El Pino Hospital considering a 5-year period. Patients are identified as those treated in the box and in a surgical pavilion. Patients were classified according to demographic variables, received treatment, associated complications and hospitalization time. Results: 18 patients are identified, 13 men and 5 women, 45 (± 36-51) and 34 (± 23-64) years respectively. It was possible to manually extract via trans-anal at box, in one of these cases; 17 of them required treatment at surgical pavilion, where 12 were via trans-anal and 5 via abdominal. None of these cases had intestinal injury. Post-surgery evolution was adequate. Average hospitalization was 1.8 days. Conclusion: RFB is a non-frequent problem which requires high diagnose suspicious to be able to carry out proper treatments. It is more frequent in middle age men, with transanal input. In most cases, the extraction was done in surgical pavilion and required anesthesia and were done via trans anal with good results.

Resultados terapéuticos en pacientes con traumas de colon y recto tratados con sutura primaria o colostomía / Therapeutic Results in patients with Colon and Rectal Traumas Treated with Primary Suture or Colostomy

RESUMEN Introducción: El trauma de abdomen tiene alta incidencia y con frecuencia afecta el colon y el recto, se aboga por el tratamiento mediante sutura primaria. Objetivo: Identificar diferencias en las características clínico-quirúrgicas y resultados terapéuticos de pacientes con lesiones traumáticas de colon y recto, tratados con sutura primaria y técnicas derivativas. Método: Se realizó un estudio multicéntrico descriptivo ambispectivo para determinar características clínico-quirúrgicas y resultados terapéuticos en pacientes con lesiones traumáticas de colon y recto en los hospitales Carlos J. Finlay, Joaquín Albarrán, Calixto García y Enrique Cabrera de La Habana, en el periodo 2010-2015. El universo estuvo conformado por todos los pacientes intervenidos quirúrgicamente por trauma de colon y/o recto. Resultados: La colostomía fue el proceder más frecuente (53,1 por ciento). Los pacientes en edades medias de la vida (promedio: 43,5 años), sexo masculino (71,4 por ciento), evolución hasta el tratamiento quirúrgico menor de 12 horas (73,4 por ciento); causadas por empalamientos y otros (49 por ciento) y heridas con arma blanca (38,8 por ciento). La magnitud del daño de colon y recto fue baja, con mayor afectación de colon izquierdo. La frecuencia de complicaciones graves y mortalidad fue alta en la colostomía. Conclusiones: La sutura primaria muestra mejores resultados terapéuticos y debe ser la técnica de elección en las lesiones traumáticas de colon y recto intraperitoneal(AU)

ABSTRACT Introduction: Abdominal trauma presents high incidence and often affects the colon and rectum; primary suture is the preferred treatment. Objective: To identify differences between the clinical-surgical characteristics and the therapeutic outcomes in patients with traumatic lesions of the colon and rectum, treated with primary suture and derivative techniques. Method: A multicentric, descriptive and ambispective study was carried out to determine the clinical-surgical characteristics and the therapeutic outcomes in patients with traumatic colon and rectal lesions in Carlos J. Finlay, Joaquín Albarrán, Calixto García and Enrique Cabrera Hospitals in Havana, in the period from 2010 to 2015. The study population was made up of all patients surgically intervened for colon and/or rectal trauma. Results: The colostomy was the most frequent procedure (53.1 percent). Patients in middle ages of life (average: 43.5 years), male sex (71.4 percent), evolution to surgical treatment under 12 hours (73.4 percent); caused by impalement and others (49 percent) and cutting wounds (38.8 percent). The magnitude of colon and rectum damage was low, with greater involvement of the left colon. The frequency of serious complications and mortality was high in the colostomy. Conclusions: Primary suture shows better therapeutic results and should be the technique of choice in traumatic lesions of the intraperitoneal colon and rectum(AU)

Uso de la colostomía en el tratamiento de lesiones traumáticas de colon y recto / Colostomy in the treatment of traumatic lesions of the colon and the rectum

Introducción: El trauma de abdomen tiene una incidencia que varía según las publicaciones, pero el colon y el recto son estructuras anatómicas generalmente comprometidas. Objetivo: Determinar las características clínico-quirúrgicas y los resultados terapéuticos en pacientes con lesiones traumáticas de colon y recto tratados con técnicas derivativas. Método: Se realizó un estudio descriptivo, retrospectivo y multicéntrico en hospitales clínico-quirúrgicos seleccionados de La Habana, desde 2010 hasta 2015. El universo estuvo conformado por todos los pacientes ingresados en las instituciones con trauma rectocolónico único o múltiple tratados quirúrgicamente por colostomía. Resultados: Los pacientes estudiados se caracterizaron por edades: jóvenes (menos de 30), sexo masculino (69,2 por ciento), evolución hasta el tratamiento quirúrgico mayor de 12 horas (46,2 por ciento); causadas por empalamientos y otros (53,8 por ciento) y heridas con arma blanca (23,1 por ciento). Se aplicaron principalmente las técnicas quirúrgicas de colostomía en asa y de Hartman. Tanto el tiempo quirúrgico como la estadía fueron prolongados. La frecuencia de complicaciones graves y la mortalidad fue alta. Los costos fueron elevados. Conclusiones: La colostomía aun es una alternativa quirúrgica viable, pero su selección debe estar basada en la evaluación individualizada de los casos y en los índices pronósticos(AU)

Introduction: Abdominal trauma has an incidence that varies, according to publications; but the colon and the rectum are generally compromised anatomical structures. Objective: To determine the clinical-surgical characteristics and the therapeutic results in patients with traumatic lesions of the colon and the rectum treated with derivative techniques. Method: A descriptive, retrospective and multicenter study was conducted in selected clinical-surgical hospitals in Havana, from 2010 to 2015. The total sample consisted of all patients admitted with single or multiple rectocolonic trauma and treated with colostomy. Results: The patients studied were characterized by age: young (less than 30), male (69.2 percent), evolution until surgical treatment over 12 hours (46.2 percent); caused by impalements and others (53.8 percent) and stab wounds (23.1 percent). The surgical techniques of loop colostomy and Hartman colostomy were applied, mainly. Both surgical time and stay were prolonged. The frequency of serious complications and mortality was high. The costs were high. Conclusions: Colostomy is still a viable surgical alternative, but its selection must be based on the individualized evaluation of the cases and the prognostic rates(AU)

Sutura primaria en lesiones traumáticas de colon y recto / Primary suture in colon and rectum traumatic lesions

Introducción: en la vida civil la tendencia actual en el tratamiento de las lesiones traumáticas de colon y recto es hacia el cierre primario, pero aún no existe consenso. Objetivo: identificar características y evolución de 36 pacientes con traumatismos de colon a los que se les practicó sutura primaria. Métodos: estudio descriptivo, de cohorte retrospectiva. Se estudiaron pacientes atendidos en hospitales docentes de la provincia de La Habana, desde noviembre de 2008 hasta enero de 2012, así como los factores relacionados con la ocurrencia de complicaciones y los costos. Los datos fueron tomados de la historia clínica y del informe operatorio, en cada hospital. La información fue procesada de forma automatizada (SPSS 15.0). Se utilizó análisis de distribución de frecuencias, y el test de homogeneidad para identificar las variables relacionadas con la ocurrencia de complicaciones. Resultados: la causa más frecuente de las lesiones fue el arma blanca (86,1 por ciento). Los factores relacionados con la ocurrencia de complicaciones fueron el agente causal y la severidad de las lesiones según la escala de Flint (p= 0,02 y p= 0,04). Los costos promedio por tiempo quirúrgico y estadía resultaron ser de: $ 1091,88 y $ 1250,82. Conclusiones: las principales complicaciones por empleo de sutura primaria en los hospitales docentes de La Habana fueron: infección del sitio quirúrgico y sangramiento postoperatorio, y los factores relacionados con ellas: el agente causal y la severidad de las lesiones. El empleo de la sutura primaria es una opción terapéutica que parece razonable y menos costosa que la colostomía(AU)

Introduction: In civilian life, the current trend in the treatment of colon and rectum traumatic lesions is for the primary closure, but there is still no consensus. Objective: to identify the characteristics and outcome of 36 patients with colon trauma colonist who underwent primary suture. Methods: A descriptive study of retrospective cohort was carried out; we studied patients treated in Havana Province teaching hospitals, from November 2008 to January 2012, as well as the factors related to the occurrence of complications and costs. Data were collected from the medical records and the operative report, in each of the hospitals. The information was processed in an automated system (SPSS 15,0). Analysis of frequency distribution and homogeneity test were used to identify variables related to the occurrence of complications. Results: The most frequent cause of injury was stab (86,1 percent). The factors related to the occurrence of complications and the severity of lesions were the causative agents, as measured by the Flint scale (p= 0,02 and p= 0,04). Average costs per surgical and stay time turned out to be: $ 1091,88 and $ 1250,82. Conclusions: The main complications from the use of primary suture in teaching hospitals of Havana are: surgical site infection and postoperative bleeding, and other factors related to them: the causative agent and the severity of lesions. The use of primary suture is a therapeutic option that seems to be reasonable and less expensive than the colostomy(AU)

A case of rectal stricture associated with the use of a fecal management system / Caso de constrição retal associada ao uso de um Sistema de manejo fecal

Fecal management systems are widely used to prevent complications of fecal incontinence such as skin breakdown and pressure ulcers. However they are occasionally associated with complications such as bleeding and pressure necrosis of rectal mucosa. We present a patient with Clostridium difficile colitis with a prolonged hospital stay requiring the use of Flexi-Seal Fecal Management System who developed abdominal pain and distention with obstipation. Computed tomography of abdomen showed dilatation of small and large bowel loops with a transition point at rectosigmoid junction. Flexible sigmoidoscopy revealed the presence of a severe stricture at the rectosigmoid junction that was not amenable to endoscopic dilation. Surgical resection with an end-colostomy was performed to relieve the obstruction. To the best of our knowledge, this is the first reported case of a high-grade stricture due to use of bowel management system that needed bowel resection surgery. (AU)

Sistemas de manejo fecal são amplamente utilizados com o objetivo de evitar as complicações da incontinência fecal, além de avarias à pele e úlceras de decúbito. No entanto, ocasionalmente esses sistemas estão associados a complicações, como sangra- mento e necrose por pressão da mucosa retal. Apresentamos um paciente com colite por Clostridium difficile com prolongada permanência no hospital e que necessitou do uso doFlexi-Seal Fecal Management System; esse paciente veio a sofrer dores e distensão abdominal, juntamente com obstipação. A tomografia computadorizada do abdome revelou dilatação de alças de intestine delgado e grosso, com um ponto de transição na junção retossigmóidea. A sigmoidoscopia flexível revelou presença de grande constrição na junção retossigmóidea, que não permitia dilatação endoscópica. Realizamos ressecção cirúrgica com colostomia terminal, com o objetivo de aliviar a obstrução. Até onde vai nosso conhecimento, este é o primeiro caso relatado de constrição de alto grau causada pelo uso de um sistema de manejo intestinal necessitando de cirurgia de ressecção intestinal. (AU)

Dispositivo intrauterino parcialmente migrado e incrustado en serosa de rectosigmoides tras 8 años de inserción / Partially migrated intrauterine device embedded in the rectosigmoid serosa after 8 years of insertion

Se presenta el caso clínico de un dispositivo intrauterino parcialmente migrado a cavidad pélvica e incrustado en serosa de rectosigmoides luego de 8 años de su inserción. El diagnóstico se realizó mediante ecografía transvaginal y retiro del dispositivo por laparoscopia. Se realizó rafia de serosa rectal y de útero. La paciente tuvo un postoperatorio sin complicaciones.

It is shown the clinical case of an intrauterine device partially migrated to the pelvic cavity and embedded in the serous rectosigmoid eight years after insertion. The diagnosis was made by transvaginal ultrasound and laparoscopy removal of the device by laparoscopy. Suture of rectum serous and uterus were performed. The patient had an uneventful postoperative course.

TAMIS with partial excision of mesorectum and primary closure of rectal wound using vloc / TAMIS com excisão parcial do mesorreto e fechamento primário da ferida retal usando vloc

Background: Transanal Minimally Invasive Surgery has proven to be a viable alternative in the treatment of rectal tumors; however, rectal wound closure can be challenging. We describe our experience with this procedure using the vloc suture device. Resume: Eight successful Transanal Minimally Invasive Surgery with primary wound closure using vloc were performed in 5 men, 62 years mean age; all cases had pre-operative diagnosis of adenoma with high-grade dysplasia. The surgical anatomic-pathologic results showed 6 adenomas with high-grade dysplasia and 2 well differentiated adenocarcinomas, limited to the upper third of the submucosa (pT1SM1) without lymphatic or vascular invasion. All lesions were resected with negative margins. No patient reported during follow-up rectal pain, fecal incontinence or bleeding. Conclusion: The use of vloc in rectal wound closure during Transanal Minimally Invasive Surgery is secure and facilitates the procedure. (AU).

Tema: Cirurgia Minimamente Invasiva Transanal (TAMIS) tem provado ser uma alternativa viável para o tratamento de tumores do reto, porém o fechamento da ferida rectal pode ser desafiadante. Nós descrevemos nossa experiência com este procedimento utilizando o dispositivo de sutura vloc. Resumo: Oito TAMIS foram realizados com sucesso com o fechamento primário da ferida usando vloc, cinco homens, com idade média de 62 anos, todos os casos tiveram diagnóstico pré-operatório de adenoma com displasia de alto grau. Os resultados anátomo-patológicos pós-operatório demonstraram: 6 adenomas com displasia de alto grau e 2 adenocarcinomas bem diferenciados, limitado ao terço superior da submucosa (pT1SM1), sem invasão linfática ou vascular. Todas as lesões foram ressecados com margens negativas. Nenhum paciente relatou durante o seguimento dor rectal, incontinência fecal ou sangramento. Conclusão: O uso de vloc no fechamento da ferida retal durante TAMIS é seguro e facilita o procedimento. (AU).

Enterorrhagia due to pelvic hematoma after femoral catheterization / Enterorragia por hematoma pélvico após cateterismo femoral

Arterial puncture, better known as catheterization, has become an important diagnostic tool in recent years. For its realization, generally the option is the Seldinger technique, which is considered today the safest and most often used procedure. This technique allows the insertion of large-caliber or multiple-lumen catheters in the vessel. Arterial catheterization helps in several exams, for instance, mesenteric angiography and cardiac output assessment, and contributes in cineangiocoronariography procedures. We report the case of a 67-year-old male patient who was submitted to cineangiocoronariography and evolved with enterorrhagia due to pelvic hematoma. Throughout the patient's care, a conservative treatment was chosen. The progression of the patient was uneventful and then the patient was discharged. It is very hard to determine which arterial segment was injured; however, as the hematoma was located predominantly in the pelvic region, it is believed that an injury occurred at the internal iliac artery, or directly at the bifurcation of the common iliac artery. Furthermore, it is assumed that a catheter kinking occurred during its progression, due to any tortuosity or to the presence of an atheromatous plaque, thus favoring the occurrence of the more distal lesion, rather than the proximal one. We decided to report this case because of its high degree of rarity, with a scarce number of papers in the literature related to the topic. Thus, with the description of this report we believe that other medical teams will have facilitated their decision-making process, when facing a similar case. (AU)

A punção arterial, mais conhecida como cateterização, tornou-se uma importante ferramenta diagnóstica nos últimos anos. Para sua realização geralmente opta-se pela técnica de Seldinger que é considerada a mais segura e utilizada na atualidade. Esta técnica permite a inserção de cateteres de grosso calibre e ou de múltiplos lúmens em vasos. A cateterização arterial auxilia na realização de exames como arteriografia mesentérica, avaliação do débito cardíaco, além de contribuir na realização da cineangiocoronariografia (CATE). Relata-se um caso de que um paciente masculino de 67 anos que foi submetido ao CATE e evoluiu com enterorragia devido ao hematoma pélvico. Em todo momento foi optado por tratamento conservador. A evolução do paciente ocorreu sem intercorrências e entao o paciente foi de alta. Dificilmente é possível precisar qual segmento arterial foi lesado, entretanto, como o hematoma localizou-se predominantemente na regiao pélvica, acredita-se que ocorreu uma lesão da artéria ilíaca interna ou logo na bifurcação da artéria ilíaca comum. Ademais, supõe-se que aconteceu uma dobra no cateter durante a sua progressão devido a alguma tortuosidade ou mesmo pela presença de placas ateromatosas. Favorecendo, dessa forma, a ocorrência da lesao mais distal e nao proximal. Optou-se por relatar tal caso devido ao alto grau de raridade, e consequentemente, nota-se que há poucos achados na literatura relacionados ao tema. Dessa forma, com a descrição deste relato podem-se ajudar equipes médicas a tomarem condutas quando deparadas com um caso semelhante. (AU)

Manejo actual de las lesiones colorectales traumáticas / Current management of traumatic colo-rectal injuries

El tratamiento de las lesiones traumátcas del colon ha experimentado cambios importantes durante los últmos años, que nos han permitdo ofrecermejores opciones al manejo de éste tpo de trauma y por consiguiente un mejor “confort” para el paciente que, en el pasado, tenía que soportar losefectos indeseables de una cirugía derivatva como la colostomía, y luego someterse a una segunda intervención para su tratamiento defnitvo contodos los riesgos que esto conlleva. Aún existen controversias que están relacionadas con el tempo de evolución principalmente en cuanto al tratamientoprimario retrasado, presencia de shock, lesiones asociadas y grado de contaminación que podrían estar relacionadas con incremento en latasa de morbilidad y mortalidad. Hemos hecho una revisión crítca de la literatura relacionada con estos tópicos que nos ofrecen un mejor panoramade las mejores opciones de tratamiento utlizando una mejor evidencia y en consecuencia ofrecer recomendación adecuada debido a que aún existeincertdumbre acerca de su seguridad.

During recent years, colon injury treatment has experimented important changes that allow us to ofer beter optons for treatng this trauma andconsequently a beter “comfort” for the patents who, in the past, had to deal with the undesirable efects of a derivatve surgery like colostomy, andthen had a second interventon for their defnitve treatment with all the risks that it takes. There are stll controversies related with evoluton tme,mainly concerned the delayed primary treatment, shock presence, associated injuries and contaminaton grade, that could be related with increase ofmorbidity and mortality rates. A critcal literature review related with those topics has been done, that ofers a beter scene of the top treatment choicesusing beter evidence and consequently, ofers an appropriate recommendaton, because there is stll uncertainty about its safety.

Transanal minimally-invasive surgery (TAMIS): technique and results from an initial experience / Cirurgia transanal minimamente invasiva (TAMIS): técnica e resultados em experiência inicial

Transanal endoscopic microsurgery is a minimally-invasive approach for rectal lesions. Superior exposure and access to the entire rectum result in lesser risk of compromised margins and lower recurrence rates, when compared to conventional transanal excision. The aim of this study was to describe a single institution's initial experience with transanal minimally invasive surgery (TAMIS). This was a prospective review of our database. Eleven procedures from January 2012 to June 2013 were analyzed. Results: eleven operations were completed. Five men were evaluated. Mean age was 62.9 (40-86). Mean follow-up was 9.3 (2-17) months. Average tumor size was 3.8 (1.8-8) cm. Mean distance from anal verge was 6.3 (3-12) cm. Mean operating time was 53.73 (28-118) min. Postoperative complication rate was 9.1%. There were no readmissions. Mortality was null. Operative pathology disclosed the presence of adenoma in four patients, invasive adenocarcinoma in two, neuroendocrine carcinoma in three, and no residual lesion in one case. TAMIS is a minimallyinvasive procedure with low postoperative morbidity at the initial experience. TAMIS is a curative procedure for benign lesions and for selected early cancers. It is useful after neoadjuvant therapy for strictly selected cancers, pending the results of multi-institutional trials. (AU)

Microcirurgia endoscópica transanal é uma abordagem minimamente invasiva para lesões retais. Apresenta menor risco de margem comprometida e menores taxas de recorrência em comparação com excisão transanal convencional. Objetivou-se descrever a experiência inicial, de uma única instituição, com cirurgia minimamente invasiva transanal (TAMIS). Avaliação prospectiva de nosso banco de dados. Onze procedimentos de janeiro de 2012 a junho de 2013, foram analisados. Resultados: onze operações foram concluídas. Havia cinco homens. A média de idade foi de 62,9 (40-86). O acompanhamento médio foi de ww9,3 (2-17) meses. O tamanho médio do tumor foi de 3,8 (1,8-8 cm). Distância média de borda anal foi de 6,3 (3-12) cm. O tempo médio de operação foi de 53,73 (28-118) min. Taxa de complicação pós-operatória foi de 9,1%. Não houve readmissões. A mortalidade foi nula. Achados patológicos foram de adenoma em 4, adenocarcinoma invasivo em 2, carcinoma neuroendócrino em três, e nenhuma lesão residual em um caso. TAMIS é um procedimento minimamente invasivo, com baixa morbidade pós-operatória durante a experiência inicial. TAMIS é curativo para as lesões benignas e de cânceres selecionados. É útil após a terapia neoadjuvante para casos de câncer rigorosamente selecionados, enquanto os resultados de estudos multi-institucionais são aguardados. (AU)

Rectal impalement with bladder perforation: a review from a single institution

Impalement injuries of the rectum with bladder perforation have been rarely reported. Such lesions have been associated with increased postoperative morbidity. A well-conducted preoperative evaluation of the lesions tends to prevent such complications. To increase awareness about patients with rectal impalement that involve bladder injuries and to examine the significance of thorough clinical examination and complementary investigation for these patients' management. Retrospectively, we identified three patients with rectal impalement and bladder perforation treated in University Hospital Hassan 2, Fez, Morocco. We recorded the symptoms, subsequent management, and further follow-up for each patient. All available variables of published cases were reviewed and analyzed. Evident urologic symptoms were present in only one patient. Bladder perforation was suspected in two other patients on the basis of anterior rectal perforation in digital exam. Retrograde uroscanner could definitely confirm the diagnosis of bladder perforation. Fecal and urine diversion was the basis of the treatment. No postoperative complications were noted. We have reviewed 14 previous reports. They are presented mainly with urine drainage through the rectum. Radiologic investigation [retrograde cystography and retrograde uroscanner] confirmed bladder perforation in 10 patients [71.4%]. Unnecessary laparotomy was performed in six patients [42.8%]. Fecal diversion and urinary bladder decompression using urethral catheter were the most performed procedures in bladder perforation [6/14 patients [42.8%]]. No specific postoperative complications were reported. A high index of clinical suspicion is required to make the diagnosis of bladder perforation while assessing patients presenting with rectal impalement. Meticulous preoperative assessment is the clue of successful management

Amputación abdominoperineal cilíndrica: racionalidad y aspectos técnicos / Cylindric Abdominoperineal Resection: rational and technique

La resección quirúrgica sigue siendo la piedra angular de la terapia curativa en el cáncer de recto. La amputación abdominoperineal implica la remoción en bloque del recto, mesorrecto, aparato esfinteriano y el ano; con la creación de una colostomía definitiva. Esta cirugía es la propuesta para pacientes sin posibilidad de conservación esfinteriana. Este grupo representa aproximadamente el 80% de los pacientes con lesiones a menos de 5 cm del margen anal y aquellos con una continencia preoperatoria deficiente. Recientemente una modificación de la técnica denominada “Amputación abdominoperineal extraelevador” destinada a la ampliación del margen circunferencial sugiere mejores resultados oncológicos que la técnica clásica. El siguiente trabajo tiene por objetivo caracterizar y describir a la amputación abdominoperineal cilíndrica en comparación a la técnica clásica.

Surgery remains the cornerstone in rectal cancer treatment. Abdominoperineal resection involves the en bloc removal of the rectum, mesorectum, sphincters and anus with confection of a definitive colostomy. This surgery is indicated in patients without the possibility of sphincter preservation. This group represents approximately 80% of patients with lesions <5 cm from the anal verge and those with preoperative incontinence. Recently “Extralevator Abdominoperineal Excision” has been described to improve rates of circumferential margin positivity suggesting better oncological outcomes compared to the standard procedure. The objective of this paper is to provide a technical description and compare available data of both Extralevator and Standard techniques.

Evisceración omental transanal posterior a lesión de recto / Omental evisceration through a rectal perforation: case report

Rectal perforation rarely occurs spontaneously. We report a 44 years old male consulting for abdominal pain lasting 12 hours. Abdominal muscular resistance was observed on physical examination. A plain abdominal X ray film showed a pneumoperitoneum. The patient was operated finding a perforation in the lower rectum, with omentum sliding through it and exiting through the anus. The omentum was sectioned and ligated and a derivative colostomy was performed. The cause of the rectal perforation was not ascertained.

La perforación de recto se produce como resultado de una complicación bajo condiciones patológicas que comprometen la pared rectal. Rara vez ocurre espontáneamente. En casi todos los casos reportados de lesión rectal asociada a evisceración intestinal, el intestino delgado es el órgano involucrado. Las técnicas de reparación son variables, desde una rafia primaria en lesiones poco extensas, hasta resección de segmento lesionado y colostomía para los casos más graves. La decisión de la técnica a utilizar dependerá de la extensión y otras características de la lesión, del compromiso de estructuras vecinas, del tiempo de evolución y del grado de contaminación. El cirujano general debe estar preparado para el manejo de estas lesiones ya que son de resolución en los servicios de urgencias. Presentamos un caso, poco frecuente, de evisceración del epiplón mayor, transanal, posterior a lesión rectal de dudosa etiología.

Pólipos colorrectales no hereditarios / Non hereditary colorectal polyps

Antecedentes: La mayoría de los pólipos colorrectales son pequeños, no neoplásicos, asintomáticos y hallados durante la pesquisa o en forma incidental. Algunos de mayor tamaño pueden causar sangrado u obstrucción, aunque su verdadera importancia radica en que los adenomatosos preceden en más del 90 por ciento, al cáncer colorrectal (CCR), siguiendo en la mayoría de los casos una secuencia adenoma-carcinoma de lenta progresión que involucra múltiples alteraciones en genes supresores y oncogenes. En los últimos años una creciente evidencia demuestra otra vía de carcinogénesis a partir de los pólipos aserrados. Estos son precursores de cánceres colorrectales con inestabilidad microsatélite alta y extensa metilación del ADN, alteraciones genéticas diferentes a las de la vía tradicional que presenta inestabilidad cromosómica. El prolongado lapso de la clásica secuencia adenoma-carcinoma permite la realización de pruebas para la pesquisa de los pólipos adenomatosos y, ante su hallazgo el tratamiento endoscópico, como una forma efectiva de prevenir el CCR. Alrededor del 5 por ciento de los pólipos extirpados endoscópicamente presentan un adenocarcinoma invasor de la submucosa. La pesquisa ha llevado a encontrar más frecuentemente estos pólipos malignos que son por definición carcinomas tempranos T1. La polipectomía endoscópica se considera segura si es completa y el pólipo no tiene factores histológicos de riesgo para presentar metástasis linfáticas y recurrencia local. Sin embargo, hay cierta controversia en la literatura sobre cuáles son estos factores que permiten definir a los pólipos de alto riesgo para un resultado desfavorable con la polipectomía sola y que requieren una resección quirúrgica oncológica. Varios adelantos tecnológicos, algunos surgidos muy recientemente, pueden ayudar en la decisión terapéutica diferenciando las lesiones benignas de las malignas...

Background: Most colorectal polyps are small, non neoplastic, asymptomatic, and are found during screening or incidentally. Some larger polyps may cause bleeding or obstruction, however, their real importance is based on the fact that colorectal cancer (CRC) is preceded in more than 90 per cent by adenomatous polyps, in most cases through a slow progression of the adenoma-carcinoma sequence, involving multiple alterations in suppressor genes and oncogenes. In latest years, accumulative evidence shows that there is another pathway to carcinogenesis, arising in serrated polyps. These polyps are the precursors of CRCs with high microsatellite instability, and extensive DNA metylation, genetic alterations different from those seen in the traditional pathway, which presents chromosomal instability. The long period of time of the classical adenoma-carcinoma sequence allows performance of screcning tests for adenomatous polyps, and their endoscopic treatment when found, as an elective way to CRC prevention. Nearly 5 per cent of polyps removed endoscopically have an adenocarcinoma invading into the submucosa. The screening has lead to find these malignant polyps, early carcinomas T1 by definition, more frequently. Endoscopic polypectomy is considered safe if complete, and the polyp lack histological risk factors for lymphatic metastases and local recurrence. However, there is some controversy in the literature regarding which are these factors that define the high risk polyps for an unfavorable outcome with polypectomy only, and require an oncologic resection. Several technological advances, some very recently aroused, can assist in the therapeutic decision, by differentiating benign from malignant lesions. Others, like transanal endoscopic microsurgery, or laparoscopic technique, have contributed with the advantages of minimally invasive surgery...

Experiencia en el manejo de la gangrena de fournier: Servico de Cirugía I / Experience in the management of fournier's gangrene: Servico de Cirugía I

Presentar la experiencia de nuestro servicio en el manejo de la gangrena de Fournier entre los años 1996 a 2006. Estudio retrospectivo y descriptivo. Se estudiaron a todos los pacientes ingresados por gangrena de Fournier en el Servicio de Cirugía Uno del Hospital Vargas de Caracas, entre enero de 1996 y diciembre 2006. Se estudiaron un total de 10 pacientes que habían presentado gangrena de Fournier, todos pertenecían al género masculino. El grupo etario más afectado fue el grupo entre 51 y 60 años con un 40 por ciento (cuatro casos). En cuanto al foco primario se observó con más frecuencia el de origen anorrectal con un 50 por (cinco casos). El número de limpiezas realizadas fue entre uno y cinco, con promedio de 2,7 limpiezas quirúrgicas por pacientes. Se realizaron colostomías derivativas al 80 por ciento de los pacientes, cistostomías al 30 por ciento, se manejo la vía urinaria al 70 por ciento con sonda de Foley, se realizaron injertos al 70 por ciento de los enfermos. No hubo decesos en esta serie de pacientes. La gangrena de Fournier debe ser diagnósticada en forma rápida, manejada en forma agresiva y con medidas de soporte que permitan un adecuado control metabólico e infeccioso.

Instrumentação anal erótica: um problema médico-cirúrgico / Anal erotic instrumentation: a medical problem

A inclusão do ânus na esfera sexual e a utilização de objetos fálicos para prática auto-erótica, descrito na literatura médica desde o século 16, é freqüente na sociedade moderna. O problema social traz consigo, além do aspecto curioso, o risco de lesões ano-retais traumáticas de graves repercussões. Nesse artigo destacamos esses aspectos, reunindo 20 pacientes do sexo masculino, dos quais 6 (30 por cento) foram atendidos com o objeto retido no reto, e 14 (70 por cento) com lesão ano-retal ocorrida durante a prática erótica e provocada pelo corpo fálico. Dentre os pacientes com lesão ano-retal, 10 (71,4 por cento) estavam com o reto perfurado. As lesões ano-retais foram tratadas cirurgicamente, e 7 desses pacientes (50 por cento) evoluíram com complicações que incluem 2 óbitos (20 por cento entre os que tinham perfuração do reto), o que representa para o grupo todo o índice de 10,5 por cento de mortalidade. A prática do erotismo anal com emprego de objetos fálicos, pelo alto índice de morbi-mortalidade, constitui-se em grave problema médico cirúrgico.

Anorectal injuries and colorectal foreign bodies due to anal erotic instrumentation or transanal autoerotism are a common fact of modern homosexual relationship making both a social and surgical problem. Severe anorectal injuries caused by foreign bodies during sexual practice and sexual autostimulation are reported occuring in 20 male patients. These patients are allocated in two different groups. Group 1: patients referred to the hospital with retained like-penis rectal foreign body without anorectal lesions(30 percent). Group 2: patients admitted to the hospital with anorectal lesions (70 percent) due to foreign body inserted into the rectum for sexual stimulation. Among them, 10 patients (71,4 percent) had rectal perforation. Fifty per cent exhibited several complications following surgical management of injuries. Among patients of the group 2 there were 20 percent of mortality. We emphasize the severity of such lesions and claim for judicious assessment of those patients.