Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access.

INTRODUCTION: Rectal injury is a rare complication after extraperitoneal laparoscopic radical prostatectomy. The development of rectourethral fistulas (URF) from rectal injuries is one of the most feared and of more complex resolution in urology. MATERIAL AND METHODS: Between 2013 and 2020 we have operated on a total of 5 patients with URF after extraperitoneal endoscopic radical prostatectomy through a perineal access using the interposition of biological material. All fistulas had a diameter of less than 6 mm at endoscopy and were less than 6 cm apart from the anal margin. RESULTS: The mean age of the patients was 64 years old. All patients had a previous bowel and urinary diversion for at least 3 months. Under general anesthesia and with the patient in a forced lithotomy position, fistulorraphy and interposition of biological material of porcine origin (lyophilized porcine dermis [Permacol®]) were performed through a perineal access. Mean operative time was 174 min (140-210). Most patients were discharged on the third postoperative day. The bladder catheter was left in place for a mean of 40 days (30-60). Prior to its removal, cystography and a Gastrografin® barium enema were performed, showing resolution of the fistula in all cases. CONCLUSIONS: The interposition of biological material from porcine dermis through perineal approach is a safe alternative with good results in patients submitted to urethrorectal fistulorraphy after radical prostatectomy.

Tratamiento de las fístulas uretrorrectales tras prostatectomía radical mediante la interposición de material biológico vía perineal / Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access

Introducción: La lesión rectal es una complicación infrecuente de la prostatectomía radical laparoscópica extraperitoneal. El desarrollo de fístulas uretrorrectales (FUR), a partir de lesiones rectales, resulta uno de los problemas más temidos y de más compleja resolución en urología.Material y métodosEntre 2013 y 2020 hemos intervenido a un total de cinco pacientes con FUR tras prostatectomía radical endoscópica extraperitoneal, mediante un abordaje perineal utilizando la interposición de material biológico. Todas las fístulas presentaron un diámetro menor de 6 mm en la endoscopia y se encontraban a menos de 6 cm del margen anal.ResultadosLa media de edad de los pacientes fue 64 años. Todos los pacientes llevaban al menos tres meses de derivación intestinal y urinaria previas. Bajo anestesia general, y con el paciente en posición de litotomía forzada mediante un acceso perineal, se realizó fistulorrafia e interposición de material biológico de origen porcino (dermis porcina liofilizada [Permacol®, Medtronic]). La duración media de la cirugía fue de 174 min (140-210). La mayoría de los pacientes fueron dados de alta al tercer día postoperatorio. La sonda vesical se mantuvo una media de 40 días (30-60). Previa a la retirada de la misma, se realizó cistografía y enema opaco con Gastrografin®, que mostró resolución de la fístula en todos los casos.ConclusionesLa interposición de material biológico procedente de dermis porcina mediante abordaje perineal es una alternativa segura y con buenos resultados en pacientes sometidos a fistulorrafia uretrorrectal tras prostatectomía radical. (AU)

Introduction: Rectal injury is a rare complication after extraperitoneal laparoscopic radical prostatectomy. The development of rectourethral fistulas (URF) from rectal injuries is one of the most feared and of more complex resolution in urology.Material and methodsBetween 2013 and 2020 we have operated on a total of 5 patients with URF after extraperitoneal endoscopic radical prostatectomy through a perineal access using the interposition of biological material. All fistulas had a diameter of less than 6 mm at endoscopy and were less than 6 cm apart from the anal margin.ResultsThe mean age of the patients was 64 years old. All patients had a previous bowel and urinary diversion for at least 3 months. Under general anesthesia and with the patient in a forced lithotomy position, fistulorraphy and interposition of biological material of porcine origin (lyophilized porcine dermis [Permacol®]) were performed through a perineal access. Mean operative time was 174 minutes (140-210). Most patients were discharged on the third postoperative day. The bladder catheter was left in place for a mean of 40 days (30-60). Prior to its removal, cystography and a Gastrografin® barium enema were performed, showing resolution of the fistula in all cases.ConclusionsThe interposition of biological material from porcine dermis through perineal approach is a safe alternative with good results in patients submitted to urethrorectal fistulorraphy after radical prostatectomy. (AU)

Mechanical bowel preparation and antibiotic prophylaxis in colorectal surgery: use by and opinions of Spanish surgeons.

OBJECTIVE: Antibiotic prophylaxis (AP) and mechanical bowel preparation (MBP) previous to surgery have classically been regarded as important in colorectal surgery. The latter has recently been questioned. We evaluated opinion of Spanish surgeons about the use of these measures. METHOD: E-mail survey among all members of Spanish Coloproctologic Associations. RESULTS: Of 413 participants in the survey, 131 (31.7%) responded; 87% of surgeons used cathartics (70%), enemas (2%) or both (28%) for MBP. MBP was used 60% in right colon surgery, 90% in left colon and 99% in rectal surgery. Surgeons with more case load or those who specialized in colorectal surgery used significantly less MBP; 60% of the surgeons thought that MBP made surgery easier and reduced contamination; 35% thought that it decreased wound infection (WI) and 17% thought that it prevented anastomotic leaks. For 77%, it was regarded as useful or very useful. AP was used by 99.3% of surgeons including systemic alone in 86.2% and combined with oral in 16.8%. The first dose was given 2 h before surgery by 20.2% of the surgeons, at the anaesthetic induction by 78.3% and postoperatively by 1.5%; 43% used single dose only, 44.5% extended to 24 h and 12.5% for two or more days; 95% thought that AP reduced WI and 96% considered that it was useful. CONCLUSION: There is general agreement on AP. MBP remained a common practice among Spanish colorectal surgeons except for right colonic resection. Surgeons with more case load and specialization used it significantly less.

Evidencia de la alimentación enteral precoz en la cirugía colorrectal / No disponible

los pacientes intervenidos de cirugía colorrectal, incluso en muchasocasiones estos pacientes se mantienen con sonda nasogástricaen el postoperatorio, con el supuesto de prevenir complicacionescomo la dehiscencia, evisceración o eventración.Realizamos una revisión de la evidencia clínica sobre el empleode sonda nasogástrica y alimentación precoz consultando las basesdel PubMed, Embase y la Cochrane.Encontramos evidencia Ia, Ib a partir de meta-análisis y estudiosrandomizados prospectivos donde se desaconseja el uso sistemáticode la sonda de descompresión gástrica y se recomienda elinicio de una alimentación precoz en la cirugía colorrectal. La dietaabsoluta no aporta ningún beneficio después de una cirugíagastrointestinal y con la sonda nasogástrica no disminuyen lascomplicaciones postoperatorias. Sin embargo, una cirugía menosinvasiva y los avances en la anestesia y analgesia contribuyen a reducirel íleo postoperatorio

There is much variability regarding time to start of enteral nutritionin patients undergoing colorectal surgery. In many instancessuch patients are postoperatively maintained with nasogastricintubation with the aim of preventing complications suchas dehiscence, evisceration or eventration.We examine the clinical evidence regarding nasogastric tubeplacement and early feeding with reference to the PubMed, Embase,and Cochrane databases.Ia and Ib evidence was obtained from meta-analyses andprospective randomized studies, where the systematic use of agastric decompression catheter is advised against and initiation ofearly feeding for colorectal surgery is recommended. Fasting doesnot provide any benefit after gastrointestinal surgery, and the useof nasogastric tubes does not decrease postoperative complications.However, less invasive surgery and new advances in anesthesiaand analgesia are contributing to a reduction in postoperativeileus (AU)

[Evidence of early oral feeding in colorectal surgery]. / Evidencia de la alimentación enteral precoz en la cirugía colorrectal.

There is much variability regarding time to start of enteral nutrition in patients undergoing colorectal surgery. In many instances such patients are postoperatively maintained with nasogastric intubation with the aim of preventing complications such as dehiscence, evisceration or eventration. We examine the clinical evidence regarding nasogastric tube placement and early feeding with reference to the PubMed, Embase, and Cochrane databases.Ia and Ib evidence was obtained from meta-analyses and prospective randomized studies, where the systematic use of a gastric decompression catheter is advised against and initiation of early feeding for colorectal surgery is recommended. Fasting does not provide any benefit after gastrointestinal surgery, and the use of nasogastric tubes does not decrease postoperative complications. However, less invasive surgery and new advances in anesthesia and analgesia are contributing to a reduction in postoperative ileus.

[Experimental study of the immunomodulator effect of pentoxifylline in bacterial translocation produced by lipid-free parenteral nutrition]. / Estudio experimental sobe la influencia inmunomoduladora de la pentoxifilina en la translocación bacteriana producida por la nutrición parenteral sin lípidos.

INTRODUCTION: Bacterial translocation (BT) leads to sepsis of intestinal origin and, despite current advances, there is a high level of mortality and morbidity as a result of this. We have attempted to investigate whether such an immunity modulating substance as Pentoxiphylline (PX) might diminish or inhibit BT. We have chosen PX because it has immunity modulation actions and inhibits the synthesis and action of TNF-alpha, which seems to be linked to the progress of these conditions towards multiple organ failures. MATERIAL AND METHOD: An experimental study was performed with 4 groups of 20 Wistar rats subjected to lipid-free parenteral nutrition (PN) over 7 days. Group A: PN; group B: PN + 50 mg/kg of PX; group C: PN + 100 mg/kg; and group D: PN + 134 mg/kg. On day 7, a sterile extraction was effected to remove the mesenteric ganglial chain, liver, blood and intestine, and these samples were processed for the quantitative and qualitative microbiological study, the histological study of the intestinal mucosa and the quantification of TNF-alpha. The data obtained were subsequently analyzed statistically. RESULTS: The quantitative microbiological study revealed that, with statistically significant differences, more colonies grew in the lymphatic ganglion, liver and blood of animals belonging to group A. The germ most frequently identified was E. Coli. In the study of TNF-alpha, the greatest value corresponded to group A, again with statistically significant differences. In the histological study, it was observed that group A showed the greatest atrophy. CONCLUSIONS: Our experimental model is valid as a model of BT, in group A, without PX, a total of 16 BT occurred while in the groups with PX the number of BT fell, as did the serum figures for TNF-alpha.

La arginina favorece la cicatrización de las anastomosis cólicas experimentales / Arginine favors wound healing in experimental colonic anastomoses

Introducción. Se ha demostrado que la L-arginina mejora la cicatrización de las heridas cutáneas. Sin embargo, no hay estudios que reflejen la influencia de este aminoácido en la cicatrización de las anastomosis cólicas. El presente estudio pretende averiguar si la suplementación de arginina en la nutrición parenteral total mejora la cicatrización de las anastomosis cólicas experimentales. Material y método. Se estudian tres grupos de ratas Wistar (20 animales por grupo), a los que se realizó una anastomosis término-terminal de colon izquierdo y se administró nutrición parenteral isocalórica e isonitrogenada, con distintas concentraciones de L-arginina: A (nutrición estándar) = 4,3 g/l, B (suplementada) = 7,3 g/l y C (suplementada) = 10,3 g/l. El séptimo día postoperatorio se estudió la anastomosis cólica (complicaciones locales, presión de rotura, histología e hidroxiprolina). Se realizó un análisis descriptivo, ANOVA de una vía, test de Newman-Keuls, regresión múltiple y prueba de la *2 de las variables. Resultados. La presión de rotura, la hidroxiprolina, así como el grado de epitelización, fibrosis y neovascularización de las anastomosis fueron mayores de forma significativa en los grupos que recibieron mayor concentración de L-arginina en la nutrición (p < 0,005).Conclusión. El suplemento de L-arginina en la nutrición parenteral de ratas Wistar mejora de forma significativa la cicatrización de las anastomosis cólicas experimentales, como se demuestra con las medidas de presión, la concentración de hidroxiprolina y los criterios histológicos (AU)

Tratamiento del bocio cervicomediastínico / Management of cervicomediastinal goiter

Introducción. Los bocios cervicomediastínicos son una enfermedad infrecuente, con un crecimiento lento y en su evolución pueden ocasionar clínica compresiva de estructuras vecinas. Es importante resaltar su asociación a neoplasias (3-15 por ciento). Actualmente persiste la controversia en el manejo terapéutico del mismo. Pacientes y método. En un estudio retrospectivo de los últimos 7 años se han intervenido 26 bocios endotorácicos. Se estudiaron la edad, sexo, antecedentes personales, sintomatología, diagnóstico, vía de abordaje y tipo de cirugía, histopatología, estancia hospitalaria, evolución y control de los casos. Resultados. Fueron 26 los bocios cervicomediastínicos, 18 en mujeres y 8 en varones. La sintomatología fue variada, solapándose varios síntomas; en el 35 por ciento de los casos fue asintomático. La forma de presentación más frecuente fue la subaguda o crónica. La localización del bocio fue predominante en el lado izquierdo. La exploración que mejor reveló el diagnóstico y la topografía fue la TAC. La vía de abordaje empleada fue en 21 casos la cervicotomía y en tres se asoció una esternotomía. En dos casos se realizó una mediastinotomía diagnóstica. Se practicaron 17 lobectomías, 7 tiroidectomías subtotales, una biopsia y una exéresis de restos tiroideos mediastínicos. La estancia media postoperatoria fue de 4,72 días. Entre las complicaciones destaca una hemorragia muscular y 2 disfonías.Conclusiones. El bocio endotorácico posee un crecimiento lento, se presenta en una edad avanzada, aumenta la incidencia de cáncer y en su evolución puede desarrollar complicaciones. El abordaje, por vía cervical, puede realizarse en la mayoría de los casos. Por todo esto opinamos que ante el bocio cervicomediastínico se debe indicar su tratamiento quirúrgico, dada la nula mortalidad y la escasa morbilidad (AU)

Multiple colon tumors. Diagnosis and follow-up of 450 patients with colorectal carcinoma.

OBJECTIVE: Failure to diagnose synchronous tumors leads to errors in patient treatment and prognosis. The existence of metachronous tumors requires strict patient follow-up to ensure early identification of the second tumor. The present study evaluates the results obtained in the application of a structured procedure for the diagnosis and follow-up of multiple colorectal carcinoma. MATERIALS AND METHODS: A structured procedure was used to follow for 5 years a group of 12 patients with multiple colorectal tumors (7 synchronous and 5 metachronous) of a series of 450 colorectal neoplasms. RESULTS: Six synchronous tumors were diagnosed preoperatively and one intraoperative. Of the 5 metachronous neoplasms, 4 strictly adhered to the follow-up protocol, as a result of which the second tumor was detected at an early stage. The remaining case involved no follow-up, and the second tumor was diagnosed in an advanced stage as a result of bowel occlusion. The left colon was predominantly involved; polyps were detected in 9 cases, while two patients had 3 malignancies detected by histopathological study. COMMENTS: We emphasize the need for a full evaluation of the colon in all patients with colorectal carcinoma. In the case of incomplete preoperative evaluation, intraoperative colonoscopy is to be considered; if this is not feasible it should be performed one month after surgery. A structured follow-up procedure permits the early detection of these tumors, there by improving patient prognosis.

[The effect of intravenous amino acids in total parenteral nutrition on the healing of experimental colonic anastomoses in the rat]. / Efecto de los aminoácidos intravenosos en nutrición parenteral total en la cicatrización de las anastomosis cólicas experimentales en la rata.

The authors present a study in two groups of Wistar rats, which were given two different parenteral nutritions with two different amounts of proteins, during different periods of time (4, 7 and 11 days), with the objective of evaluating their influence on the healing of a colonic anastomosis which was performed prior to the initiation of the TPN. To asses the condition of the colonic anastomosis, we studied the rupture pressure of the colon containing the anastomosis, the hydroxyproline concentration of said anastomosis, and the histological study of the same. The results indicate that the group of animals which were fed with a hyperproteinic diet during a longer period of time, showed a better degree of healing than the rest of the study groups.