Importancia de algunos aspectos técnicos del procedimiento de estimulación percutánea del nervio tibial posterior en pacientes con incontinencia fecal / Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence

Introducción: Los resultados de la estimulación percutánea del nervio tibial posterior (PTNS) en el tratamiento de la incontinencia fecal (IF) parecen discretos. El objetivo del estudio es valorar la relación de algunos aspectos técnicos con la respuesta clínica: localización del nervio, respuesta distal (motora o sensitiva) y acomodación. Métodos: Estudio prospectivo de pacientes con IF sometidos a terapia de PTNS. La repuesta clínica se valoró mediante la escala de Wexner, diario defecatorio y manometría anorrectal. Resultados: Se estudiaron 32 pacientes. La intensidad de localización (cercanía al nervio) no se correlacionó con cambios clínicos ni manométricos. La respuesta motora se relacionó con un descenso en la escala de Wexner [12,12 (± 5,39) a 7,71 (± 4,57) p < 0,005], el número de episodios de incontinencia pasiva [8,78 (± 9,64) a 4,11 (± 7,11) p = 0,025], el número total de episodios de incontinencia [16,11 (± 16,03) a 7,78 (± 11,34) p = 0,009] y el número de días con ensuciamiento fecal [6,89 (± 5,53) a 2,56 (± 4,13) p = 0,002] y con un aumento de la longitud del conducto anal manométrico en reposo [4,55 (± 0,596) a 4,95 (± 0,213) p = 0,004]. El incremento de estimulación (acomodación) se correlacionó de forma inversa con la disminución en la escala de Wexner (r = -0,677 p < 0,005) y el número de días con ensuciamiento (r = -0,650 p = 0,022). Conclusiones: La respuesta motora durante la PTNS parece relacionarse con una mejor respuesta clínica. El fenómeno de acomodación podría asociarse con peores resultados. La cercanía del electrodo al nervio no parece tener trascendencia, siempre que se consiga una buena respuesta distal. (AU)

Introduction: The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. Methods: Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. Results: 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (± 5.39) to 7.71 (± 4.57) p < 0.005], the number of episodes of passive incontinence [8.78 (± 9.64) to 4.11 (± 7.11) p = 0.025], the total number of incontinence episodes [16.11 (± 16.03) to 7.78 (± 11.34) p = 0.009] and the number of days with faecal soiling [6.89 (± 5.53) to 2.56 (± 4.13) p = 0.002] and with an increase in the length of the manometric anal canal at rest [4.55 (± 0.596) to 4.95 (± 0.213) p = 0.004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 p < 0.005) and the number of days with soiling (r = -0.650 p = 0.022). Conclusions: The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved. (AU)

Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence.

INTRODUCTION: The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. METHODS: Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. RESULTS: 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (±5.39) to 7.71 (±4.57) P < .005], the number of episodes of passive incontinence [8.78 (±9.64) to 4.11 (±7.11) P = .025], the total number of incontinence episodes [16.11 (±16.03) to 7.78 (±11.34) P = .009] and the number of days with fecal soiling [6.89 (±5.53) to 2.56 (±4.13) P = .002] and with an increase in the length of the manometric anal canal at rest [4.55 (±0.596) to 4.95 (±0.213) P = .004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 P < .005) and the number of days with soiling (r = -0.650 P = .022). CONCLUSIONS: The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.

Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence. / Importancia de algunos aspectos técnicos del procedimiento de estimulación percutánea del nervio tibial posterior en pacientes con incontinencia fecal.

INTRODUCTION: The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. METHODS: Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. RESULTS: 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (± 5.39) to 7.71 (± 4.57) p < 0.005], the number of episodes of passive incontinence [8.78 (± 9.64) to 4.11 (± 7.11) p = 0.025], the total number of incontinence episodes [16.11 (± 16.03) to 7.78 (± 11.34) p = 0.009] and the number of days with faecal soiling [6.89 (± 5.53) to 2.56 (± 4.13) p = 0.002] and with an increase in the length of the manometric anal canal at rest [4.55 (± 0.596) to 4.95 (± 0.213) p = 0.004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 p < 0.005) and the number of days with soiling (r = -0.650 p = 0.022). CONCLUSIONS: The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.

[Multimodal rehabilitation in colorectal surgery. On resistance to change in surgery and the demands of society]. / Rehabilitación mutimodal en cirugía colorrectal. Sobre la resistencia al cambio en cirugía y las demandas de la sociedad.

Perioperative management is one of the fields of surgery most hide bound by tradition and conventional attitudes are difficult to modify even in the face of strong scientific evidence. One of the advances that has most helped to improve the results of colorectal surgery is multimodal or fast-track rehabilitation, which aims to enhance recovery, reduce morbidity, and shorten the length of hospital stay. This modality is based on a multidisciplinary approach provided by surgeons, anesthesiologists and other staff and aims to decrease the response to physiopathological changes induced by surgical aggression. There is evidence to support the use of preoperative oral carbohydrate therapy and oral bowel preparation, the avoidance of intraoperative fluid excess, and the maintenance of normothermia on postoperative recovery. Other factors that can also reduce complications are epidural analgesia, avoidance of drainage and nasogastric decompression, early oral feeding, and minimally invasive surgery. There is strong evidence that the combined use of these and other measures enhances postsurgical recovery, although many of these measures are currently little used in daily practice.

Rehabilitación mutimodal en cirugía colorrectal. Sobre la resistencia al cambio en cirugía y las demandas de la sociedad / Multimodal rehabilitation in colorectal surgery. On resistance to changein surgery and the demands of society

El manejo perioperatorio es uno de los campos de la cirugía más sujetos a la tradición, y es difícil modificar actitudes clásicas incluso con la evidencia científica. Uno de los avances que más ha contribuido a mejorar el resultado tras cirugía colorrectal es la rehabilitación multimodal o fast-track, programa que pretende acelerar la recuperación, reduciendo la morbilidad y acortando las estancias. Se basa en la actuación conjunta de cirujanos, anestesistas y personal a cargo del paciente con el objetivo de disminuir la respuesta a las alteraciones fisiopatológicas inducidas por la agresión quirúrgica. Aspectos como la ingesta preoperatoria de carbohidratos, evitar la preparación de colon, reducir la fluidoterapia o mantener la normotermia son de gran importancia. Del mismo modo, la analgesia epidural, eliminación de sondas y drenajes, alimentación precoz o una cirugía menos invasiva pueden mejorar el íleo postoperatorio y otras complicaciones. Existe importante evidencia de que el uso conjunto de estas y otras medidas contribuye a una mejor recuperación posquirúrgica, aunque se sigue utilizándolas muy poco en la práctica (AU)

Perioperative management is one of the fields of surgery most hidebound by tradition and conventional attitudes are difficult to modify even in the face of strong scientific evidence. One of the advances that has most helped to improve the results of colorectal surgery is multimodal or fast-track rehabilitation, which aims to enhance recovery, reduce morbidity, and shorten the length of hospital stay. This modality is based on a multidisciplinary approach provided by surgeons, anesthesiologists and other staff and aims to decrease the response to physiopathological changes induced by surgical aggression. There is evidence to support the use of preoperative oral carbohydrate therapy and oral bowel preparation, the avoidance of intraoperative fluid excess, and the maintenance of normothermia on postoperative recovery. Other factors that can also reduce complications are epidural analgesia, avoidance of drainage and nasogastric decompression, early oral feeding, and minimally invasive surgery. There is strong evidence that the combined use of these and other measures enhances postsurgical recovery, although many of these measures are currently little used in daily practice (AU)

[Mechanical bowel preparation. A necessity or nothing more (or less) than the weight of tradition?]. / Preparar el colon para la cirugía. Necesidad real o nada más (y nada menos) que el peso de la tradición?

Mechanical bowel preparation is a traditional procedure for preparing patients for colorectal surgery. This practice aims to reduce the risk of postoperative infectious complications since colonic fecal content has classically been related to stool spillage during surgery and anastomotic disruption. However, increasing evidence against its routine use can be found in experimental studies, clinical observations, prospective studies, and meta-analyses. We performed a review of the literature on mechanical bowel preparation and its consequences. There is no clear evidence that preoperative bowel cleansing reduces the septic complications of surgery and routine use of this procedure may increase anastomotic leaks and morbidity. Therefore, the results suggest that mechanical preparation is not required in elective colon and rectal surgery and that its use should be restricted to specific indications such as small nonpalpable tumors to aid their localization during laparoscopic procedures or to enable intraoperative colonoscopy. The role of mechanical bowel preparation in rectal surgery is not well defined and further trials with a larger number of patients are required.

Preparar el colon para la cirugía. ¿Necesidad real o nada más (y nada menos) que el peso de la tradición? / Mechanical bowel preparation. A necessity or nothing more (or less) than the weight of tradition?

La preparación mecánica del colon es un componente tradicional del preoperatorio de los pacientes sometidos a cirugía colorrectal dirigido a reducir sus complicaciones infecciosas, ya que clásicamente la presencia de heces en el colon se ha asociado a contaminación intraoperatoria y dehiscencias anastomóticas. Sin embargo, en la actualidad, estudios tanto experimentales como de observaciones clínicas, trabajos prospectivos y revisiones sistemáticas de la literatura cuestionan su utilidad. Se efectúa una revisión de conjunto sobre el tema, y se concluye que, con la evidencia disponible, no está claro el beneficio de la preparación mecánica del colon y hay trabajos que muestran incluso una mayor incidencia de complicaciones en la tasa de dehiscencia anastomótica y la morbilidad con su uso sistemático, por lo que puede ser omitida en cirugía electiva y es adecuado restringirla a indicaciones concretas, como pequeños tumores, para facilitar su localización durante un abordaje laparoscópico o cuando se precise hacer una endoscopia intraoperatoria. El papel de la preparación mecánica en la cirugía rectal no está aclarado en la actualidad y se precisa de series más amplias para establecerlo (AU)

Mechanical bowel preparation is a traditional procedure for preparing patients for colorectal surgery. This practice aims to reduce the risk of postoperative infectious complications since colonic fecal content has classically been related to stool spillage during surgery and anastomotic disruption. However, increasing evidence against its routine use can be found in experimental studies, clinical observations, prospective studies, and meta-analyses. We performed a review of the literature on mechanical bowel preparation and its consequences. There is no clear evidence that preoperative bowel cleansing reduces the septic complications of surgery and routine use of this procedure may increase anastomotic leaks and morbidity. Therefore, the results suggest that mechanical preparation is not required in elective colon and rectal surgery and that its use should be restricted to specific indications such as small nonpalpable tumors to aid their localization during laparoscopic procedures or to enable intraoperative colonoscopy. The role of mechanical bowel preparation in rectal surgery is not well defined and further trials with a larger number of patients are required (AU)

Actitud ante los quistes tiroideos recidivantes con citología benigna / Approach cytologically-benign recurrent thyroid cysts

Introducción. El objetivo de este estudio ha sido determinar la incidencia de carcinoma en los quistes recidivantes citológicamente benignos y evaluar la indicación quirúrgica en estos pacientes. Pacientes y método. Revisión de todos los pacientes intervenidos por recidiva tras la aspiración de un nódulo tiroideo quístico, solitario o dominante en un bocio multinodular (BMN), con estudio citológico preoperatorio benigno, desde enero de 1992 hasta diciembre 2002. Se han excluido los nódulos mixtos. Resultados. Se ha intervenido a 34 pacientes con una edad media de 43 años (rango, 18-76; 5 varones y 29 mujeres). En el 75% de los casos se trataba de nódulos únicos y en el 25% eran nódulos dominantes en el seno de un bocio multinodular. El número medio de citologías con drenaje completo fue de 2,3 (rango, 23) por paciente, y se observó contenido hemorrágico en el 35% de los casos. Se realizó tiroidectomía total en los casos de BMN y lobectomía con itsmectomía en los nódulos solitarios. La biopsia extemporánea fue benigna en el 91% de los casos y no concluyente en el resto; no se identificó en ningún caso la presencia de carcinoma. En el estudio anatomopatológico definitivo se evidenció un carcinoma papilar en 3 pacientes (8,8%) y un carcinoma papilar oculto separado del quiste en 4 (11,8%). En todos estos casos, la biopsia peroperatoria fue benigna. En los quistes mayores de 3 cm, el riesgo de malignidad ha sido más elevado (el 23 frente al 0%; p < 0,05). Conclusiones. Dada la incidencia de carcinomas, se debe considerar la realización de una tiroidectomía en los quistes tiroideos recidivantes, especialmente en los mayores de 3 cm, con independencia del resultado del estudio citológico (AU)

Introduction. The aim of this study was to determine the incidence of carcinoma in cytologically-benign recurrent thyroid cysts and to evaluate the surgical indications in these patients. Patients and method. We reviewed all patients undergoing thyroid surgery between January 1992 and December 2002 for cytologically-benign solitary or dominant cystic nodules in multinodular goiter that recurred after aspiration. Mixed nodules were excluded. Results. Thirty-four patients (29 women and five men) with a mean age of 43 years (18-76) underwent surgery. Seventy-five percent were solitary nodules and 25% were dominant nodules within a multinodular goiter. The mean number of fine needle aspirations with complete drainage was 2.3 (2-3) per patient with hemorrhagic aspirate in 35%. Total thyroidectomy was performed in multinodular goiters and lobectomy with isthmectomy in solitary nodules. Intraoperative biopsy revealed benign lesions in 91% and was inconclusive in the remainder; no cases of carcinoma were identified. Definitive pathologic findings revealed the nodule to be a papillary carcinoma in 3 patients (8.8%) and occult papillary carcinoma separate from the cyst in 4 patients (11.8%). In all these patients intraoperative biopsy showed benign disease. The risk of malignancy was higher in cysts larger than 3 cm (23% vs 0%; p < 0.05). Conclusions. Given the incidence of carcinoma, surgical resection should be considered in recurrent cystic thyroid nodules, especially in those larger than 3 cm, regardless cytological study (AU)

[Approach to cytologically-benign recurrent thyroid cysts]. / Actitud ante los quistes tiroideos recidivantes con citología benigna.

INTRODUCTION: The aim of this study was to determine the incidence of carcinoma in cytologically-benign recurrent thyroid cysts and to evaluate the surgical indications in these patients. PATIENTS AND METHOD: We reviewed all patients undergoing thyroid surgery between January 1992 and December 2002 for cytologically-benign solitary or dominant cystic nodules in multinodular goiter that recurred after aspiration. Mixed nodules were excluded. RESULTS: Thirty-four patients (29 women and five men) with a mean age of 43 years (18-76) underwent surgery. Seventy-five percent were solitary nodules and 25% were dominant nodules within a multinodular goiter. The mean number of fine needle aspirations with complete drainage was 2.3 (2-3) per patient with hemorrhagic aspirate in 35%. Total thyroidectomy was performed in multinodular goiters and lobectomy with isthmectomy in solitary nodules. Intraoperative biopsy revealed benign lesions in 91% and was inconclusive in the remainder; no cases of carcinoma were identified. Definitive pathologic findings revealed the nodule to be a papillary carcinoma in 3 patients (8.8%) and occult papillary carcinoma separate from the cyst in 4 patients (11.8%). In all these patients intraoperative biopsy showed benign disease. The risk of malignancy was higher in cysts larger than 3 cm (23% vs 0%; p<0.05). CONCLUSIONS: Given the incidence of carcinoma, surgical resection should be considered in recurrent cystic thyroid nodules, especially in those larger than 3 cm, regardless cytological study.