Transperineal anal sphincter complex evaluation after obstetric anal sphincter injuries: With or without tomographic ultrasound imaging technique?

OBJECTIVES: "Significant" obstetric anal sphincter injuries (OASIS) have been defined as visible defects of at least 30° in at least 4/6 slices using tomographic ultrasound imaging (TUI) with transperineal ultrasound (TPUS). The objective of this study was to assess if TUI is mandatory for the evaluation of OASIS. METHODS: Patients with a history of OASIS were evaluated by performing 3D-endoanal ultrasound (EAUS) and 3D-TPUS with and without TUI. Any damage to the internal (IAS) or external (EAS) anal sphincters was recorded and scored using the Starck's and the Norderval's systems. Intraobserver and inter-techniques correlations were calculated. RESULTS: From September 2012 to May 2015, 63 women, mean age 32.5 ± 4.6 years, with OASIS (3a: 26 pts., 41.3 %; 3b: 26 pts., 41.3 %; 3c: 6 pts., 9.5 %, 4: 4 pts., 6.3 %, "button hole" tear: 1 pt., 1.6 %). Inter-technique and intraobserver correlations were excellent (TUI: k = 0.9; sweeping technique: k = 0.85; EAUS: k = 0.9) in determining OASIS. Using the Starck's Score, excellent correlation was found for both TPUS modalities (TUI: k = 0.86; sweeping technique: k = 0.89). However, for the different individual parameters, the correlation was moderate for EAS depth (TUI: k = 0.44; sweeping technique: k = 0.5) and good for IAS depth (TUI: k = 0.7; sweeping technique: k = 0.78). Similar results were found using the Norderval's classification. CONCLUSIONS: OASIS can be assessed by TPUS without TUI technique, dragging the rendered box and following the anal canal from the anal verge to the anorectal junction in the longitudinal plane and describing findings.

Impact of episiotomy on the urogenital hiatus using transperineal ultrasound.

AIMS: To analyze whether episiotomy affects the urogenital hiatal area and the difference in the hiatus at rest and during contraction, as an indirect measurement of the contractile capacity of the levator ani muscle. METHODS: We performed an observational, comparative, retrospective study of primiparous women who had normal vaginal deliveries. The urogenital hiatal area was compared in women with and without episiotomy. All women underwent transperineal ultrasound scanning after delivery, and all the images were analyzed offline by the principal investigator who was blinded to all clinical data. The urogenital hiatal area was measured at rest and during both Valsalva and contraction manoeuvres. The difference in the hiatus at rest and during contraction was also calculated. These scanning variables were compared between the study groups. RESULTS: In total, 194 women were analysed (101 with, and 93 without, episiotomy). There were no statistically significant differences between the groups regarding the area of the hiatus at rest (P = 0.583), on Valsalva (P = 0.158), and on contraction (P = 0.468), or in the difference in the hiatus at rest and during contraction (P = 0.095). CONCLUSIONS: In normal vaginal delivery, neither the area of the urogenital hiatus nor its difference at rest and during contraction, as measured by ultrasound, were modified by performing an episiotomy.

Circuito asistencial de la paciente con síndrome de vejiga hiperactiva / Care circuit of the patient with overactive bladder syndrome

Objetivo: determinar diferencias asistenciales en las pacientes con síndrome de vejiga hiperactiva en diferentes regiones de España e identificar ámbitos de mejora. Material y métodos: 106 especialistas en ginecología participaron en 12 sesiones regionales dirigidas mediante una metodología de brainstorming estructurado y se agregaron los datos obtenidos. Resultados: el rol de los médicos de atención primaria en la sospecha de la patología, y el de los especialistas en ginecología en el diagnóstico y tratamiento se destacó como relevante en la mayoría de sesiones. Se identificaron diferencias en la accesibilidad a Unidades de Suelo Pélvico y en la disponibilidad de personal de enfermería especializado, entre otros. Se propuso la formación y la generación de nueva evidencia para estandarizar el circuito asistencial. Conclusiones: el circuito asistencial de las pacientes varía entre las distintas regiones de España. La formación del personal asistencial y la creación de nueva evidencia sobre su tratamiento pueden ayudar a mejorarlo (AU)

Objective: To describe differences in the care of patients with overactive bladder among the different regions in Spain, as well as to identify fields of improvement. Methods: 106 gynecologists participate in 12 regional meetings run by a structured brainstorming methodology. Data were obtained and shown together. Results: The role of general practitioners in clinical suspicion and the role of gynecologists in diagnoses and treatment were reported as relevant in most of the meetings. Among others, differences in accessibility to units specialized in pelvic floor disorders and in the availability of specialized nurses were identified along the meetings. Training to health professionals in pelvic floor disorders and the creation of new evidence were identified as measures to standardize the healthcare of patients with overactive bladder. Conclusions: The healthcare journey of patients with overactive bladder differs from one to another region in Spain. Training and new evidence may help improve such healthcare (AU)

Three-dimensional translabial ultrasound assessment of urethral supports and the urethral sphincter complex in stress urinary incontinence.

AIMS: The pathophysiological mechanism of incontinence is multifactorial. We evaluated the role of 3D-4D ultrasound in the assessment of the fascial supports of the urethra and the urethral sphincter complex (USC) for diagnosing stress urinary incontinence. METHODS: Observational case-control study in women with and without stress urinary incontinence attending a urogynecology service and a general gynecology service. All women were interviewed, examined, and classified according to the Pelvic Organ Prolapse Quantification (POP-Q) and underwent a 3D-4D translabial ultrasound. Fascial supports of the urethra were assessed by tomographic ultrasound and were considered to be intact or absent if it was possible to identify them at eight levels on each side, urethral mobility was assessed on maximal Valsalva in sagittal section and the length and volume of the USC at rest and on maximal Valsalva were determined using the Virtual Organ Computer-aided Analysis (VOCAL) program. Variables were compared between continent and incontinent women. RESULTS: A total of 173 women were examined, 78 continent and 95 incontinent. There was a significant difference in urethral mobility between continent and incontinent women (12.82 mm vs. 21.85 mm, P < 0.001), but there was no significant difference in the percentage of supports affected (43.27% vs. 35.94%, P < 0.070). The length of the USC at rest was significantly shorter (P < 0.001) ​​in incontinent patients. CONCLUSIONS: Ultrasound evaluation of urethral supports does not discriminate between continent and incontinent women. However, the length of the USC at rest was shorter and urethral mobility was higher in incontinent women. Neurourol. Urodynam. 9999:XX-XX, 2016. © 2016 Wiley Periodicals, Inc.

Can we identify changes in fascial paravaginal supports after childbirth?

BACKGROUND: Defects of anterior vaginal wall fascia are generally assumed to be factors in the aetiology of cystocele. However, to date, there is very little information on diagnosis by imaging. AIM: To document the appearance of vaginal fornices before and after childbirth using 4D ultrasound volume data sets as an aid in diagnosing paravaginal defects of the anterior vaginal wall. MATERIALS AND METHODS: This study was performed by re-analysing data sets obtained in a previously published study involving ante- and postpartum pelvic floor assessment by ultrasound. Two hundred and two nulliparous women had been seen at a mean gestation of 37.2 weeks at two tertiary hospitals. One hundred and sixty-three returned 3 months postpartum. All the participants underwent an interview and 4D translabial ultrasound at both antepartum and postpartum appointments. The integrity of vaginal fornices and levator ani was assessed by tomographic ultrasound. RESULTS: Vaginal fornices were assessed in both ante- and postnatal volumes, and loss of forniceal tenting was found in 85 patients (52%). On average, seven slices were affected (range, 1-16). On multivariate analysis, controlling for potential confounders, including partial/complete avulsion, loss of forniceal tenting remained independently associated with increased cystocele descent (P = 0.005). CONCLUSIONS: Vaginal childbirth is associated with loss of tenting of the vaginal fornices, independent of levator trauma, and also with impaired anterior vaginal wall support. This evidence suggests the existence of paravaginal defects and may imply a role for such defects in the causation of anterior vaginal wall prolapse.

Hidrocele tras diálisis peritoneal: Persistencia del conducto peritoneo-vaginal / Hydrocele after peritoneal dialysis: Persistence of the peritoneal-vaginal duct

No disponible

Resultados a medio plazo en la implementación de la cirugía laparoscópica colorrectal en la práctica clínica tras la realización de un curso intensivo / Medium term results on introducing colorrectal laparoscopic surgery into clinical practice after having an intensive training course

Introducción La cirugía endoscópica posee características que incrementan las dificultades de su aprendizaje. Hace 5 años, se diseñó un curso en cirugía laparoscópica colorrectal para ofrecer de forma intensiva las bases técnicas de este tipo de cirugía. El objetivo de este artículo es conocer el impacto sobre la práctica clínica de un curso de cirugía colorrectal, investigar los factores que limitan su aplicabilidad y las preferencias formativas de los cirujanos. Material y métodos Entre junio de 2005 y diciembre de 2010 se efectuaron 22 cursos, de 4 días de duración, 36 horas lectivas (4 en forma de seminarios y 32 en quirófano) dirigidos a 7 alumnos. En diciembre de 2010 se envió una encuesta para evaluar el impacto del curso sobre la actividad en cirugía laparoscópica colorrectal del alumno, conocer las dificultades encontradas en su aplicación y evaluar las expectativas formativas en cirugía endoscópica de este colectivo de cirujanos. Resultados La encuesta se remitió a 148 cirujanos, obteniendo 74 respuestas (50%). El periodo medio tras el curso fue de 26,5 meses (2-60). Se observó un incremento mensual en más de 5 casos en el 70% de los centros. El curso permitió consolidar la actividad en hospitales comarcales, mientras que en hospitales universitarios y generales sirvió para relanzar una experiencia inicial (..) (AU)

Introduction: Endoscopic surgery has characteristics that increase the difficulties of learning. Five years ago, an intensive colorectal laparoscopic surgery course was designed to offer training in the technical bases of this type of surgery. The aim of this article is to determine the impact of the colorectal surgery course on clinical practice, and to investigate the factors that limit its applicability and the training preferences of the surgeons. Material and methods: Twenty-two courses of four days duration, with 36 hours of lessons (4in seminar form and 32 in the surgery), and with 7 trainees, were held between June 2005 and December 2010. A survey was sent out in December 2010 to assess the impact of the course on the colorectal laparoscopic surgery activity of the trainee, to find out the difficulties encountered in its application, and to evaluate the training expectations in endoscopic surgery in this group of surgeons. Results: The questionnaire was sent to 148 surgeons, with 74 (50%) responses received. The mean period after the course was 26.5 (2-60) months. A monthly increase of more than 5 cases was observed in 70% of the centres. The course enabled them to consolidate the activity in local hospitals, while in university and general hospitals it served to re-launch aninitial experience. Among the obstacles that made it difficult to introduce were care load and the availability of a surgeon, particularly in general and university hospitals (P=.001), and in local hospitals it was the availability of patients. The majority of surgeons (70%) believed that specific training was required, preferring a short period in a hospital with experience. Conclusions: An intensive course on colorectal laparoscopic surgery enabled the activity to be consolidated or increased in this area. Training in colorectal laparoscopic surgery requires additional teaching efforts, which are currently unstructured (AU)

[Medium term results on introducing colorrectal laparoscopic surgery into clinical practice after having an intensive training course]. / Resultados a medio plazo en la implementación de la cirugía laparoscópica colorrectal en la práctica clínica tras la realización de un curso intensivo.

INTRODUCTION: Endoscopic surgery has characteristics that increase the difficulties of learning. Five years ago, an intensive colorectal laparoscopic surgery course was designed to offer training in the technical bases of this type of surgery. The aim of this article is to determine the impact of the colorectal surgery course on clinical practice, and to investigate the factors that limit its applicability and the training preferences of the surgeons. MATERIAL AND METHODS: Twenty-two courses of four days duration, with 36 hours of lessons (4 in seminar form and 32 in the surgery), and with 7 trainees, were held between June 2005 and December 2010. A survey was sent out in December 2010 to assess the impact of the course on the colorectal laparoscopic surgery activity of the trainee, to find out the difficulties encountered in its application, and to evaluate the training expectations in endoscopic surgery in this group of surgeons. RESULTS: The questionnaire was sent to 148 surgeons, with 74 (50%) responses received. The mean period after the course was 26.5 (2-60) months. A monthly increase of more than 5 cases was observed in 70% of the centres. The course enabled them to consolidate the activity in local hospitals, while in university and general hospitals it served to re-launch an initial experience. Among the obstacles that made it difficult to introduce were care load and the availability of a surgeon, particularly in general and university hospitals (P=.001), and in local hospitals it was the availability of patients. The majority of surgeons (70%) believed that specific training was required, preferring a short period in a hospital with experience. CONCLUSIONS: An intensive course on colorectal laparoscopic surgery enabled the activity to be consolidated or increased in this area. Training in colorectal laparoscopic surgery requires additional teaching efforts, which are currently unstructured.

Tridimensional sonographic anatomical changes on pelvic floor muscle according to the type of delivery.

INTRODUCTION AND HYPOTHESIS: The aim of the study was to evaluate the association of avulsion and postnatal hiatal dimensions with delivery mode. These anatomical changes on pelvic floor muscle may be assessed by 3-4D ultrasonography. METHODS: This is a prospective observational study that included 164 women: 20 nulliparous, 20 primigravid, and 124 postpartum women (62 at 1 month, 62 at 9 months postpartum). We performed an introital 3-4D ultrasonography to assess levator ani muscle's integrity, levator hiatal area at rest, on Valsalva, and on contraction. RESULTS: Levator ani avulsion was diagnosed in 59.5% of forceps deliveries. There were no statistically significant differences in postnatal hiatal dimensions between normal vaginal deliveries at 9 months postpartum and nulligravid. Levator hiatal area was significantly higher after forceps delivery. CONCLUSION: Low incidence of levator avulsion takes place in normal vaginal deliveries. However, forceps delivery is the riskiest type of delivery for pelvic floor pathology and its recovery.

Thymidylate synthase germline polymorphisms in rectal cancer patients treated with neoadjuvant chemoradiotherapy based on 5-fluorouracil.

PURPOSE: Chemoradiotherapy using 5-fluorouracil has shown to be effective treatment for rectal cancer. Thymidylate synthase (TS) is an important target enzyme for the fluoropyrimidines. However, the predictive role of TS levels in early stage rectal cancer is not yet well understood. We analyzed the value of TS gene polymorphisms as a predictive marker in patients with stage II and III rectal cancer treated with preoperative concomitant radiotherapy and fluoropyrimidine-based chemotherapy. METHODS AND MATERIALS: Between 1998 and 2007, blood samples were obtained from 51 patients with stage II/III rectal cancer. Forty patients were T2-3 (78%), 11 were T4 (22%), and 59% were N+. DNA was extracted from peripheral blood, and the genotypes were analyzed using PCR-restriction fragment length polymorphism and automated sequencing techniques. RESULTS: The *3/*3 thymidylate synthase genotype was associated with a higher response rate (pathological complete remission and microfoci residual tumor; 61 vs. 22% in *2/*2 and *2/*3; P = 0.013). In the multivariate analysis, the *3/*3 thymidylate synthase genotype was also an independent prognostic factor for better survival (P < 0.05). CONCLUSIONS: The thymidylate synthase genotype might help to identify patients with stage II/III rectal cancer who could benefit from pre- and postoperative fluorouracil-based chemotherapy.

[Laparoscopic treatment of rectal prolapse]. / Tratamiento laparoscópico del prolapso rectal.

INTRODUCTION: Rectal prolapse is an uncommon disease mainly seen in patients of advanced age. It is treated surgically, although there is still significant controversy as regards the most appropriate technique. In the last few years the laparoscopic route has been shown to be feasible and has the advantage of being a minimally invasive technique. OBJECTIVE: To present the preliminary results of a series of patients with rectal prolapse, the majority of whom were treated by performing a laparoscopic posterior rectopexy. MATERIAL AND METHOD: Between February 1998 and February 2008, 17 patients diagnosed with total rectal prolapse were operated on. In 15 cases, a Wells type posterior rectopexy was performed and in the other two a sigmoidectomy was done. The pre-surgical characteristics, as well as the immediate post-surgical results and the long-term follow up results were analysed. RESULTS: The mean age of the series was 63 (21-87) years, with a mean operation time of 186 (105-240) min and a conversion index of 6.6%. There was no post-surgical morbidity and mortality and the mean hospital stay was 5.2 (3-8) days. The mean follow-up was 39 (6-96) months with no relapses seen. One patient had an intralumen migration of the mesh which was expulsed via the rectum, two years after the surgery. One patient died during follow-up due to his underlying severe cardio-respiratory disease. The prolapse re-occurred in one patient after a sigmoidectomy. Eight patients (53%) previously had constipation and in six cases (40%), incontinence. In the post-surgical reviews, constipation persisted in three patients (20%) and a it was seen de novo in one case (6.6%). The incontinence was resolved in four cases (26%) and persisting in two patients (13%). CONCLUSIONS: Laparoscopic rectopexy is a good technical option with a low morbidity-mortality and a reduced hospital stay, as well as good results in the long-term.

Tratamiento laparoscópico del prolapso rectal / Laparoscopic treatment of rectal prolapse

Introducción. El prolapso rectal es una enfermedad infrecuente que predomina en edades extremas de la vida. Su tratamiento es quirúrgico, aunque continúa habiendo una importante controversia en cuanto a la técnica más adecuada. En los últimos años la aplicación de la vía laparoscópica se ha demostrado factible y se acompaña de las ventajas de una técnica mínimamente invasiva. Objetivo. Presentar los resultados preliminares de una serie de pacientes afectos de prolapso rectal que fueron abordados por laparoscopia; en la mayoría de ellos se practicó una rectopexia posterior laparoscópica. Material y método. Entre febrero de 1998 y febrero de2008, se ha intervenido a 17 pacientes diagnosticados de prolapso rectal total. En 15 casos se realizó una rectopexia posterior tipo Wells por laparoscopia y en los otros dos, una sigmoidectomía. Se analizaron las características preoperatorias y los resultados en el postoperatorio inmediato y el seguimiento a largo plazo. Resultados. La media de edad de la serie es 63 (21-87) años y la del tiempo operatorio, 186 (105-240) min; el índice de conversión fue del 6,6%. La morbimortalidad postoperatoria fue nula, con una media de estancia hospitalaria de 5,2 (3-8) días. La media del seguimiento fue de 39 (6-96) meses, y no se han objetivado recidivas. En 1 paciente se produjo la (..) (AU)

Introduction. Rectal prolapsed is an uncommon disease mainly seen in patients of advanced age. It is treated surgically, although there is still significant controversy as regards the most appropriate technique. In the last few years the laparoscopic route has-been shown to be feasible and has the advantage of being a minimally invasive technique. Objective. To present the preliminary results of a series of patients with rectal prolapse, the majority of whom were treated by performing a laparoscopic posterior rectopexy. Material and method. Between February 1998 and February2008, 17 patients diagnosed with total rectal prolapsed were operated on. In 15 cases, a Wells type (..) (AU)

Energy sources for laparoscopic colectomy: a prospective randomized comparison of conventional electrosurgery, bipolar computer-controlled electrosurgery and ultrasonic dissection. Operative outcome and costs analysis.

The development of operative laparoscopic surgery is linked to advances in ancillary surgical instrumentation. Ultrasonic energy devices avoid the use of electricity and provide effective control of small- to medium-sized vessels. Bipolar computer-controlled electrosurgical technology eliminates the disadvantages of electrical energy, and a mechanical blade adds a cutting action. This instrument can provide effective hemostasis of large vessels up to 7 mm. Such devices significantly increase the cost of laparoscopic procedures, however, and the amount of evidence-based information on this topic is surprisingly scarce. This study compared the effectiveness of three different energy sources on the laparoscopic performance of a left colectomy. The trial included 38 nonselected patients with a disease of the colon requiring an elective segmental left-sided colon resection. Patients were preoperatively randomized into three groups. Group I had electrosurgery; vascular dissection was performed entirely with an electrosurgery generator, and vessels were controlled with clips. Group II underwent computer-controlled bipolar electrosurgery; vascular and mesocolon section was completed by using the 10-mm Ligasure device alone. In group III, 5-mm ultrasonic shears (Harmonic Scalpel) were used for bowel dissection, vascular pedicle dissection, and mesocolon transection. The mesenteric vessel pedicle was controlled with an endostapler. Demographics (age, sex, body mass index, comorbidity, previous surgery and diagnoses requiring surgery) were recorded, as were surgical details (operative time, conversion, blood loss), additional disposable instruments (number of trocars, EndoGIA charges, and clip appliers), and clinical outcome. Intraoperative economic costs were also evaluated. End points of the trial were operative time and intraoperative blood loss, and an intention-to-treat principle was followed. The three groups were well matched for demographic and pathologic features. Surgical time was significantly longer in patients operated on with conventional electrosurgery vs the Harmonic Scalpel or computed-based bipolar energy devices. This finding correlated with a significant reduction in intraoperative blood loss. Conversion to other endoscopic techniques was more frequent in Group I; however, conversion to open surgery was similar in all three groups. No intraoperative accident related to the use of the specific device was observed in any group. Immediate outcome was similar in the three groups, without differences in morbidity, mortality, or hospital stay. Analysis of operative costs showed no significant differences between the three groups. High-energy power sources specifically adapted for endoscopic surgery reduce operative time and blood loss and may be considered cost-effective when left colectomy is used as a model.

Mesh in the hiatus: a controversial issue.

OBJECTIVE: To analyze the experience acquired to date on the use of prosthetic mesh to prevent recurrence after laparoscopic repair of paraesophageal hernia. DATA SOURCES: Current English-language literature review. STUDY SELECTION: Case reports, series, and opinion articles on the use of mesh for paraesophageal hernia repair. DATA EXTRACTION AND SYNTHESIS: Study type and results were analyzed. Most articles were short case series. Few comparative or randomized trials assessing the procedure have been published to date. The information available showed that the use of a mesh for hiatal repair was safe and prevented recurrence. However, data on the long-term results were lacking, and infrequent but severe complications may arise. CONCLUSIONS: The mesh should be used selectively, and the decision to proceed should be based on clinical experience. In light of the evidence available, however, it appears to be safe, and the fears expressed in the past have not been confirmed.

The massive hiatal hernia: dealing with the defect.

The success of laparoscopic fundoplication has extended the use of the laparoscopic approach to treating more difficult situations such as paraesophageal hernias (PEHs) or type III (mixed) hiatal hernia. The results have shown that laparoscopic repair is feasible and safe. However, several series have shown recurrence rates of up to 42% as a result of difficulty in the closure of the hiatal gap. Some authors recommend the use of prosthetic mesh to reinforce the hiatal closure. This review analyses the different techniques proposed to prevent recurrence after laparoscopic repair of PEHs. The information currently available shows that the use of a mesh for hiatal repair is safe and prevents recurrence. However, data on the long-term results are lacking, and infrequent but severe complications may arise. The mesh should be used selectively, and the decision to proceed should be based on clinical experience.

Minimally invasive treatment for obstructive tumors of the left colon: endoluminal self-expanding metal stent and laparoscopic colectomy. Preliminary results.

BACKGROUND: Obstruction of the left colon may be the first manifestation of colorectal cancer. Resection of the colonic segment involved and the construction of an end colostomy (Hartman's procedure) is the most frequent treatment. Alternatives to the placement of a stoma are subtotal colectomy or intraoperative lavage of the colon and primary anastomosis, but their application depends on intraoperative findings and the availability of a skilled surgeon. The use of an expandable stent (SEMS) can enhance the feasibility of laparoscopic colectomy, avoiding the need for a colostomy and offering the advantages of a combination of two minimally invasive procedures. STUDY DESIGN: Between 1997 and 2004, an SEMS was placed in 11 cases of left colonic obstruction due to cancer, the obstruction being successfully resolved in each case. Seven patients were approached by laparoscopy to attempt the definitive colectomy. We evaluated the location and pathological characteristics of the tumor, effectiveness and complications of SEMS insertion, time interval between the insertion of SEMS and laparoscopic surgery, and postoperative data. RESULTS: The tumors were situated in the recto-sigma (1 case), sigma (3 cases) and descending colon (3 cases). Immediate relief of the obstruction was achieved in all cases after SEMS insertion of the stent, and oral diet was started at 24 h. The 7 patients were operated on an average of 8 days (range 6-14) after insertion of the stent. Conversion to open surgery was necessary in one case for reasons not related to the stent. CONCLUSIONS: Preliminary results of the combination of SEMS and elective laparoscopic surgery demonstrate that the procedure is feasible and that it presents all the clinical advantages of a minimally invasive approach. The procedure is a valid alternative to traditional major urgent surgery.

Laparoscopic surgery in situs inversus: a literature review and a report of laparoscopic sigmoidectomy for diverticulitis in situs inversus.

BACKGROUND: Situs inversus (SI) is a rare autosomal recessive congenital defect in which the position of abdominal and/or thoracic organs is a "mirror image" of the normal one, in the sagittal plain. In 25% of these cases, SI is part of the Kartagener syndrome, together with bronchiectasis and chronic sinusitis. METHODS: We present a case of a patient with Kartagener syndrome and complete SI that was laparoscopically operated on for diverticulitis. We also review the published English information available on this rare condition. RESULTS: A review of the literature revealed another single case of laparoscopic sigmoidectomy and 27 cases of other laparoscopic interventions in the presence of SI. Those laparoscopic procedures included basic procedures such as explorations and cholecystectomies, as well as advanced procedures such as gastrectomy and gastric bypass. CONCLUSION: The laparoscopic approach is feasible in cases of SI, although technically more complicated because of the different position of the organs and the different laparoscopic view of the anatomy.

Mallas en el hiato: una controversia no solucionada / Mesh repair of hiatal hernia: an ongoing controversy

El éxito de la funduplicatura laparoscópica ha extendido el abordaje laparoscópico al tratamiento de las hernias de hiato paraesofágicas o mixtas. Los resultados demuestran que la reparación es factible y segura, aunque con una incidencia de recidivas elevada, por lo que algunos autores recomiendan el uso de prótesis para reforzar el cierre hiatal. El objetivo de esta revisión ha sido analizar la experiencia publicada con el uso de mallas para prevenir la recidiva después de la reparación laparoscópica de la hernia de hiato paraesofágica. Existen escasos estudios comparativos o aleatorizados en los que se compare el uso de mallas con el cierre convencional. Sin embargo, el uso de mallas previene la recidiva herniaria y se acompaña de un bajo índice de complicaciones. La información disponible permite concluir que el uso de mallas para la reparación hiatal es seguro y previene la recidiva. Sin embargo, la información sobre los resultados a largo plazo es escasa, y pueden presentarse complicaciones graves. Por ello, es recomendable su uso selectivo basado en la experiencia clínica del cirujano (AU)

Esplenectomía laparoscópica: resultados a largo plazo de una serie prospectiva de 257 pacientes en función del diagnóstico hematológico / Laparoscopic splenectomy: long-term results of a prospective series of 257 patients according to hematological diagnosis

Introducción. El abordaje laparoscópico ha demostrado ser un procedimiento seguro y eficaz en el tratamiento de las enfermedades hematológicas que requieren la realización de una esplenectomía, especialmente en las que el bazo mantiene un tamaño dentro de la normalidad. Sin embargo, aunque los resultados inmediatos son prometedores, no existe suficiente información sobre la evolución a largo plazo. Objetivo. Evaluar los resultados a largo plazo en una serie prospectiva de 257 pacientes a los que se ha realizado una esplenectomía laparoscópica (EL), en función de la indicación hematológica por la que se indicó la cirugía. Material y métodos. Desde febrero de 1993 hasta octubre de 2003, se han realizado 257 EL, en 100 varones y 157 mujeres, con una edad media de 45 ñ 19 años. La información clínica fue recopilada de forma prospectiva en una base de datos. Las indicaciones de esplenectomía incluyeron los siguientes diagnósticos: púrpura trombocitopénica idiopática (PTI) (n = 115), PTI asociada al virus de la inmunodeficiencia humana (VIH) (n = 9), síndrome de Evans (n = 6), anemia hemolítica autoimmune (AHAI) (n = 13), esferocitosis hereditaria (EH) (n = 19), patología hematológica maligna (n = 66), púrpura trombocitopénica trombótica (PTT) (n = 1) y otros (n = 26). Se han analizado los resultados inmediatos (tiempo operatorio, conversión, morbilidad y estancia), así como en el seguimiento a largo plazo (resultados analíticos, cursos clínicos del hematólogo de referencia, así como entrevistas telefónicas tanto con el paciente como con el hematólogo de referencia).Resultados. El tiempo operatorio medio fue de 137 ñ 56 min, con un índice de conversión del 6,7 por ciento, una mortalidad postoperatoria del 0,8 por ciento y una estancia media de 5 días. Se consigió el seguimiento a largo plazo en 188 casos (75 por ciento) durante un período medio de 35 meses: PTI, seguimiento de 87 pacientes (76 por ciento) con remisión en el 89 por ciento de los casos; PTI-VIH, 6 pacientes seguidos (86 por ciento) con remisión completa en el 83 por ciento; síndrome de Evans, 4 pacientes seguidos (67 por ciento) con remisión completa en el 100 por ciento; PTT, el único paciente con este diagnóstico fue controlado durante el seguimiento y presentó una remisión completa; AHAI, 9 pacientes seguidos (82 por ciento) con remisión completa en el 67 por ciento, EH: 13 pacientes seguidos (76 por ciento) con remisión completa en el 100 por ciento; patología hematológica maligna, 47 pacientes seguidos (73 por ciento) con una mortalidad del 22 por ciento; otros: 18 pacientes seguidos (78 por ciento) sin presentar mortalidad. Durante el seguimiento no se han detectado casos de sepsis relacionada con la esplenectomía. Conclusiones. La EL es aplicable en todas las indicaciones hematológicas de esplenectomía, con resultados satisfactorios a largo plazo (AU)