Use of the gluteus maximus muscle as the neosphincter for restoration of anal function after abdominoperineal resection.

BACKGROUND: Our aim was to evaluate complications and long-term functional outcome in patients who had sphincter reconstruction using the gluteus maximus muscle as the neosphincter after abdominoperineal resection for rectal cancer treatment. METHODS: Seven patients underwent reconstruction from 2000 to 2010. First, the sigmoid colon was brought down to the perineum as a perineal colostomy, with the procedure protected by a loop ileostomy. Reconstruction of the sphincter mechanism using the gluteus maximus took place 3 months later, and after another 8-12 weeks, the loop ileostomy was closed. We studied the functional outcome of these interventions with follow-up interviews of patients and objectively assessed anorectal function using manometry and the Cleveland Clinic Florida (Jorge-Wexner) fecal incontinence score. RESULTS: The mean follow-up was 56 months (median 47; range 10-123 months). One patient had a perianal wound infection and another had fibrotic stricture in the colocutaneous anastomosis that required several digital dilatations. Anorectal manometry at 3-month follow-up showed resting pressures from 10 to 18 mm Hg and voluntary contraction pressures from 68 to 187 mm Hg. Four patients had excellent sphincter function (Jorge-Wexner scores ≤5). CONCLUSIONS: Our preliminary results show that sphincter reconstruction by means of gluteus maximus transposition can be effective in restoring gastrointestinal continuity and recovering fecal continence in patients who have undergone APR with permanent colostomy for rectal cancer. Furthermore, the reconstruction procedure can be performed 2-4 years after the APR.

Ligaduras de hemorroides internas con bandas elásticas / Elastic band ligature of internal hemorrhoids

En 1964 uno de nosotros (J.E.R.) inicio el uso de ligaduras con bandas elasticas para el tratamiento de hemorroides internas. En esta oportunidad revisamos una muestra de 439 ligaduras realizadas en 114 pacientes desde 1992 a 1997 (3,8 ligaduras por paciente). La edad promedio fue de 50 años, y 60 por ciento de los pacientes eran hombres. La indicacion fundamental fue sangrado indoloro y ano humedo. Todos los procedimientos fueron realizados en forma ambulatoria. En 16 casos seleccionados se practicó) mas de una ligadura por sesion. Hubo 9 complicaciones, siendo la mas frecuente la trombosis de hemorroides externas. Concluimos que las ligaduras de hemorroides internas con bandas elasticas son una alternativa valida en el tratamiento de esta entidad. Este procedimiento tiene baja morbilidad y costo, con alta efectividad y satisfaccion del paciente; prolongada, ocasiona complicaciones y secuelas importantes y el costo es alto. Las consideraciones anteriores han estimulado el desarrollo de alternativas, una de las cuales es la ligadura con bandas elasticas. Este procedimiento fue introducido por BLAISDELL (1958) y mejorado y popularizado por BARRON (1963). Es una alternativa ambulatoria para el tratamiento de todos los grados de hemorroides internas. Se han publicado multiples trabajos que demuestran las enormes ventajas de esta tecnica. Es de anotar que la hemorroidectomía quirurgica sigue siendo la conducta de eleccion para algunos casos. En agosto de 1997 presentamos en el XXIV Congreso Nacional de Cirugia un informe preliminar, el cual queremos ahora complementar.

Laparoscopic ultrasonography: a training model.

PURPOSE: The purpose of this study was to develop a surgical training program and to test the accuracy of laparoscopic ultrasound in detecting injected lesions in pig livers. METHODS: Pig livers were divided into eight segments and injected with Surgilube "malignant" and silicone "benign" lesions. All were examined by laparoscopic ultrasound followed by liver explantation to confirm results. First, a pilot study was conducted on six swine by injecting Surgilube lesions and performing laparoscopic ultrasound through 3 different ports (left upper quadrant (I), umbilicus (II), and right lower quadrant (III)) to determine per-segment accuracy and to optimize port placement. Second, blinded injection of Surgilube and silicone implants was done on 18 pigs with laparoscopic ultrasound conducted through the two most accurate ports from the pilot study. This model was then tested during a resident training workshop. RESULTS: In the pilot study, per-lesion and per-segment sensitivity was 96 percent, with no difference among the three ports used. Ports I and II were chosen for the blinded study for their convenience in performing laparoscopic colectomy. In the blinded study, per-segment sensitivity, specificity, and accuracy were 97 percent, 94 percent, and 96 percent and 99 percent, 94 percent, and 97 percent for ports I and II, respectively. At the conclusion of a pilot workshop, trainee per-segment sensitivity, specificity, and accuracy were 60 percent, 80 percent, and 70 percent, respectively. The major difficulty was differentiating benign from malignant lesions. CONCLUSIONS: A useful liver laparoscopic ultrasound training model for surgeons was developed with good preliminary results. It is anticipated that further training will enhance laparoscopic ultrasound accuracy rates before application of this modality in humans.

Tratamiento del paciente con sospecha de coledocolitiasis: contribución de la colangioscopia flexible / Management of the patient with suspected choledocholithiasis: value of flexible cholangioscopy

Se realizo un estudio observacional, descriptivo y prospectivo en el "Hospital General de Medellin ", desde octubre de 1993 hasta septiembre de 1995. Se practico exploracion de la via biliar y colocacion de tubo en T a 113 pacientes en quienes se sospechaba Coledocolitiasis. A todos se les hizo seguimiento clinico y colangiografia postoperatoria de conrol. La incidencia global de litiasis residual fue 8.8 por ciento (n=0). Los pacientes se dividieron en tres grupos de acuerdo con la ayuda diagnostica utilizada durante la cirugia, asi: 17 con colangioscopia flexible; 49 con colangiografia, y 26 ayuda diagnostica. El grupo con colangioscopia demostró tener la menor incidencia (n= 1:2.6 por ciento) de coledocolitiasis residual (p= 0.0745). La colangioscopia demostro ser de fácil manejo y sirvio, además, para la extraccion de calculos retenidos, a traves del trayecto del tubo en T. El ilangioscopio flexible parece ser un avance importante para el tratamiento y postoperatorio de la coledocolitiasis.

Early enteral nutrition in gastrointestinal surgery: a pilot study.

There is still some concern about the safety of early enteral nutrition (EN) to patients with recent anastomoses. A pilot trial was carried out on a prospective basis to evaluate the tolerance and clinical outcome of 56 patients who received early EN following gastrointestinal (GI) surgery. A continuous infusion of an elemental, peptide-based diet was administered using a nasointestinal feeding tube placed beyond the pylorus by the operating surgeon. Tube feeds were started at 6.07 +/- 4.99 h after surgery and advanced as tolerated to a rate of 60 mL/h on the third postoperative day. Patients received the diet either proximal or distal (in the case of gastrectomies) to their recent anastomosis. Forty-six patients met the inclusion criteria and were included in the analysis. EN was well tolerated with a low incidence of side effects (19.5%), nausea and vomiting being the most frequent. Oral feeding was started 2.89 +/- 1.28 d after surgery. There was one case of small bowel suture leakage, but no relationship to the tube feeding was established. Early EN appears to be a useful and safe therapeutic alternative for the postoperative management of patients undergoing GI surgery. It may contribute to faster recovery of bowel function and lead to a shorter hospital stay. Careful selection of patients is necessary in order to obtain the greatest benefit of early enteral feeding in this patient population.