Photodynamic therapy for the treatment of complex anal fistula.

BACKGROUND: Photodynamic therapy (PDT) is a new procedure for the treatment of anal fistula. This preliminary study was designed to investigate the safety and effectiveness of this new technique in the treatment of anal fistula. METHODS: Ten patients were treated with PDT. Intralesional 5-aminolevulinic acid (ALA) 2% was directly injected into the fistula. The internal and external orifices were closed. After an incubation period of 2 h, the fistula was irradiated using an optical fibre connected to a red laser (MULTIDIODE 630 PDT, INTERmedic, Spain) operating at 1 W/cm for 3 min (180 Joules). Patient demographics, operation notes and complications were recorded. RESULTS: There were no complications. The average length of patient follow-up was 14.9 months (range 12-20 months). We could observe primary healing in eight patients (80%). Two patients (20%) showed persistence of suppuration after the operation. No patient reported incontinence postoperatively. CONCLUSIONS: PDT is a potential sphincter-saving procedure that is safe, simple and minimally invasive and has a high success rate.

Sacral nerve stimulation versus percutaneous posterior tibial nerve stimulation in the treatment of severe fecal incontinence in men.

BACKGROUND: Sacral nerve stimulation and percutaneous posterior tibial nerve stimulation have been described previously as effective treatments for fecal incontinence. Nevertheless, there does not exist any study that compares the efficiency of both. The aim of this study was to compare the use of SNS and PPTNS in males with FI. METHODS: We conducted a prospective cohort study on men with FI treated with SNS or PTNS in the Coloproctology Unit of the University General Hospital of Elche and Reina Sofia of Murcia between January 2010 and December 2011. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale. RESULTS: Nineteen patients were included (ten patients SNS and nine PPTNS). SNS improved FI in nine of the ten patients. The mean Wexner score decreased significantly from a median of 14 (12-16) (preoperative) to 4 (1-8) (6-month revision) (p = 0.007). PTNS improved FI in seven of the nine patients. The mean Wexner score decreased significantly from a median of 12 (11-19) (preoperative) to 5 (4-7) (6-month revision) (p = 0.018). Both treatments produced symptomatic improvement without statistical differences between them. CONCLUSIONS: Our study was nonrandomized with a relatively small number of patients. PPTNS had similar efficiency to the SNS in our men population. However, more studies are necessary to exclude selection bias and analyze long-term results.

Prediction of anastomotic leak in colorectal cancer surgery based on a new prognostic index PROCOLE (prognostic colorectal leakage) developed from the meta-analysis of observational studies of risk factors.

PURPOSE: To obtain a prognostic index, which has been named PROCOLE (prognostic colorectal leakage), it can predict the risk that a certain individual may suffer anastomotic leakage. METHODS: The methodology consists of a systematic review to identify potential risk factors for anastomotic leakage and a meta-analysis of studies of each of these factors. In the meta-analysis, the prognostic index integrates factors that are statistically significant, which are weighted according to the estimated value of the effect size. The prognostic index was validated using retrospectively collected data from patients who underwent colorectal cancer surgery anastomosis at our institution. RESULTS: The mean and standard deviation of the PROCOLE prognostic index in patients with anastomotic leakage is 1.9 ± 6.13, whereas in controls, it is 3.63 ± 2.1. The predictive ability of the PROCOLE, assessed by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC), results in an AUC of 0.82 with a 95% confidence interval (CI) (0.75, 0.89) of the AUC, and it can be considered a good prognostic indicator. CONCLUSIONS: The PROCOLE prognostic index predicts the risk of a certain individual developing anastomotic leakage after colorectal cancer surgery. Specifically, the PROCOLE prognostic index establishes a discrimination value threshold of 4.83 for recommending the implementation of a protective stoma. We have developed free software with a simple interface that only requires the selection of risk factors to obtain the PROCOLE value.

Resultados de un programa de seguimiento de las prótesis mamarias pip (poly-implant-prothese) / Results of a program to monitor the pip breast prostheses (poly-implant-prothese)

Objective: The rupture of mammary protheses PIP (poly-implant-prothese) caused an alarm, settling in Spain a protocol for the management of patients. As hospital unit of reference for the management, monitoring and treatment of patients carrying PIP breast implants, we propose objective to make a descriptive study of the current situation in our country and compare it to the hitherto described in the literature. Method: We conducted a transversal study of all patients who came during the years 2012 and 2013, to the Unit of Mammary Pathology of the Universitary General Hospital of Elche. Results: With a total of 285 women, we observed a high rate of implant rupture (50.2 percent) asymptomatic most (84.6 percent). Fact that the year 2006 had the highest percentage of breakage and the appearance of siliconomas. Conclusions: Our series confirms rupture rate similar to that described in the literature for PIP breast implants. We observed a higher percentage of breakage from the year 2006, coinciding with the period of manufacture described poorer quality of these implants. Axillary siliconomas were evident in 35.1 percent of patients, the only locally axillary symptoms.

Objetivo: La rotura de las prótesis mamarias PIP (poly-implant-prothese) ha supuesto una alarma, estableciéndose en España un protocolo para el manejo y seguimiento de las pacientes. Como unidad hospitalaria de referencia para el manejo, seguimiento y tratamiento de las pacientes portadoras de prótesis mamarias PIP, nos proponemos como objetivo realizar un estudio descriptivo de la situación actual en nuestro medio y compararlo con lo hasta ahora descrito en la literatura. Método: Realizamos un estudio transversal de todas las pacientes que acudieron durante los años 2012 y 2013, a la Consulta de la Unidad de Patología Mamaria del Hospital General Universitario de Elche. Resultados: Con un total de 285 mujeres, observamos la elevada tasa de ruptura de los implantes (50,2 por ciento) la mayoría asintomáticos (84,6 por ciento). Siendo el año 2006 el de mayor porcentaje de rotura y la aparición de siliconomas. Conclusiones: Se confirma una tasa de ruptura similar a la descrita en la literatura para los implantes mamarios PIP. Observamos un mayor porcentaje de rotura a partir del año 2006, coincidiendo con el período de fabricación descrito de peor calidad de estos implantes. Se evidenciaron siliconomas axilares en el 35,1 por ciento de las pacientes, siendo la única sintomatología a nivel local axilar.

Usefulness of the log odds of positive lymph nodes to predict and discriminate prognosis in gastric carcinomas.

BACKGROUND: The lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) have been proposed to minimize the stage migration phenomenon. The value of the LODDS and LNR staging systems to predict and discriminate prognosis was assessed and compared to the International Union Against Cancer (UICC) TNM classification (pN). METHODS: Three hundred and twenty-six patients with gastric carcinoma were retrospectively studied. Disease-specific survival rates were calculated for every pN, LNR, and LODDS category. RESULTS: Four LNR categories (0, 1-25, 26-75, and >76 %) and four LODDS categories (-5 to -3, > -3 to -1, > -1 to 3, and >3 to 5) were established. In the multivariate analysis, only the stage pT3-4 versus pT1-2 (HR 1.88, 95 % CI 1.11-3.20, p=0.02) and LODDS as continuous variable (HR 1.40, 95 % CI 1.21-1.61, p<0.001) remained as independent prognostic factors. In patients with <16 lymph nodes retrieved, only the LODDS system could discriminate different disease-specific survival curves for every category. LODDS categories were able to discriminate subgroups with different prognoses in pN stages and LNR categories. CONCLUSIONS: The LODDS staging system was superior to the pN classification and LNR system to discriminate risk prognosis especially in patients with an insufficient number of retrieved lymph nodes.

Tumores extramucosos de colon: diagnóstico diferencial / Extramucosal colon tumors: differential diagnosis

Los tumores estromales o mesenquimáticos derivan de la pared extramucosa del tubo digestivo y constituyen un grupo raro de tumores originados del tejido conectivo. Presentamos dos casos clínicos, en lo que la sospecha diagnóstica inicial era GIST pero tras intervención quirúrgica y resultado anatomo-patológico se evidenció la existencia de tumor fibroso solitario y lipoma, descartando por tanto la existencia de GIST. Es fundamental, por tanto, llevar a cabo un diagnóstico diferencial de estos tumores extramucosos ya que el tratamiento y el seguimiento dependeran de la entidad

Mesenchymal or stromal tumors derived from extramucosal gut wall and are a rare group of tumors caused connective tissue. We present two cases in which the initial diagnostic suspicion was but after GIST surgery and anatomy-pathological result was evidence of solitary fibrous tumor and lipoma, thus ruling out the existence of GIST. It is essential therefore to carry out a differential diagnosis of these tumors extramucosal as treatment and monitoring depend on the entity

Perforación vaginal iatrogénica tras colonoscopia virtual / Latrogenic vaginal perforation after computed tomographic colonography

La colonoscopia virtual o colonografía por tomografía computarizada (TC) es una alternativa potencial a la colonoscopia convencional para la detección de pólipos y cáncer colorrectal. Presentamos un caso inusual de perforación iatrogénica vaginal durante una colonoscopia virtual. El paciente fue tratado con medidas conservadoras sin complicaciones. El presente caso es el primero en la literatura de perforación vaginal iatrogénica debido a la introducción del catéter de Foley a través de la vagina durante la realización de una colonografía por TC. La perforación vaginal es una complicación rara, fácilmente evitable con una correcta exploración clínica

Computed tomographic colonography is a potential alternative to conventional colonoscopy for the detection of colorectal polyps and cancers. We present an unusual case of iatrogenic vaginal perforation during a computed tomographic colonography. The patient was managed with conservative treatment without complications. The present case is the first in the literature of iatrogenic vaginal perforation due to the introduction of the Foley's catheter through vagina during the accomplishment of a computed tomographic colonography. Vaginal perforation is a rare complication, easily avoidable with a correct clinical exploration

Hernia paraduodenal izqueirda gigante / Giant left paraduodenal hernia

Introducción: las hernias internas causan el 0,9% de las obstrucciones intestinales y de estas entre 50-55% son hernias paraduodenales. La edad media de diagnóstico es 38.5 años y son tres veces más comunes en el varón. El riesgo de desarrollar una obstrucción intestinal es del 50% en estos pacientes y puede alcanzar una mortalidad del 20 al 50%. Caso clínico: varón de 36 años con dolor abdominal tipo cólico y mal definido con vómitos de 24 horas de evolución. En la radiografía simple de abdomen presentaba dilatación de asas de intestino delgado. Una tomografía computada abdominal evidenció: encapsulación de las asas intestinales con dilatación desde unión duodeno-yeyunal hasta íleon terminal, con signos de sufrimiento intestinal. Por laparotomía exploradora urgente se observó una hernia mesocólica izquierda gigante, donde el intestino delgadose encuentra compartimentalizado en un saco peritoneal y los vasos mesentéricos desplazados a la derecha y la vena mesentérica inferior se encuentra malposicionada formando un ojal a través del que pasa íleon terminal. El saco peritoneal fue resecado, liberando la vena mesentérica inferior hasta su origen, pasando por el ojal el paquete intestinal, quedando este y el ciego a la derecha de la vena mesentérica inferior. El paciente evolucionó satisfactoriamente, siendo dado de alta al 4º día postoperatorio. Conclusión: la hernia paraduodenal gigante es una patología infrecuente, con elevado riesgo de obstrucción. Donde la tomografía computada se convierte en la prueba de imagen por excelencia que aporta datos concluyentes que ayudan al diagnóstico

Introduction: Internal hernias cause 0.9% of intestinal obstructions and of these 50-55% are paraduodenal hernias. The average age at diagnosis is 38.5 years and are three times more common in men. Paraduodenal risk of developing intestinal obstruction is 50% in these patients and may reach 20 mortality at 50%. Clinical case: A 36 year old male with poorly defined abdominal and vomiting of 24 hours history. Abdominal radiography showed dilated small bowel loops. A computed tomography scan revealed; encapsulation dilated bowel loops from duodenal-jejunal junction to terminal ileum with signs of intestinal distres. For urgent laparotomy showed a giant left mesocolic hernia, where the small intestine was compartmentalized in a peritoneal sac and mesenteric vessels and displaced right inferior mesenteric vein was poorly positioned forming an eyelet through which passes terminal ileum. Peritoneal sac was resected, releasing the inferior mesenteric vein to its origin, through the intestinal buttonhole, leaving the blind and the inferior mesenteric vein to the right. The patient progressed satisfactorily, being discharged on postoperative day 4. Conclusion: The giant paraduodenal hernia is an uncommon condition with high risk of blockage. Where the computed tomography becomes the quintessential image test that provides conclusive data that help the diagnosis

Effect on anal pressure of percutaneous posterior tibial nerve stimulation for faecal incontinence.

AIM: Previous studies on percutaneous posterior tibial nerve stimulation (PTNS) for faecal incontinence do not report anal pressure changes. In the present study the effect of percutaneous PTNS on anal manometry was determined. METHOD: This was a prospective observational study of patients with faecal incontinence. They underwent one 30-min session of PTNS weekly for 12 consecutive weeks. Patients who showed improvement were given six more sessions at 2-weekly intervals. Anal manometry was performed before and after treatment. Clinical data including the Wexner score, psychological testing, quality of life using the Fecal Incontinence Quality of Life Score and the contents of a continence diary were recorded before and after the procedure. RESULTS: Twenty-four patients were included in the study of whom 17 (70.83%) demonstrated some degree of clinical or manometric improvement at 3 months. Before treatment 18 patients had urgency of <1 min. At 3 and 6 months this had risen to 5 min in 62.5% and 70.83% (P < 0.001). The anal resting pressure increased from 21.7 to 37.6 mmHg (P = 0.021), the maximum squeeze pressure from 58.2 to 72.2 mmHg (P = 0.045) and the Wexner score fell from 15 to 10 (P = 0.018) at 6 months. Predictive factors for a response included fewer than three incontinent episodes per week (P = 0.027). Negative predictive factors included episiotomy and an initial Wexner score of > 12 (P = 0.035). CONCLUSION: Percutaneous PTNS was effective in over 70% of patients in the present study with improvements in urgency, anal pressures and Wexner score.

Sacral nerve stimulation in the treatment of severe faecal incontinence: long-term clinical, manometric and quality of life results.

BACKGROUND: Faecal incontinence (FI) is a complex and multifactorial health problem. Treatment has to be individualised, analysing the aetiology and gravity in every case. Sacral nerve stimulation (SNS) has been shown to effectively improve treatment of FI. METHODS: Fifty patients with severe FI treated with SNS between March 2002 and December 2010 were analysed. Preoperative assessment included physical examination, anorectal manometry and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale (FIQLS). Follow-up appointments were scheduled at 1, 6 and 12 months and annually thereafter. Wexner score, FIQLS and the ability to defer defecation were assessed at each visit. RESULTS: Fifty patients underwent a permanent implant. The overall mean follow-up period was 55.52 ± 31.84 months. After 6 months, SNS significantly improved FI and positively impacted quality of life, as evidence by significant improvements in all 4 scales of the FIQLS. Anorectal manometry showed a trend towards an increase in maximum resting pressure and maximum pressure. After the first assessment at 6 months, Wexner score and FIQLS remained stable. Ability to defer defecation was also maintained. During follow-up, 3 patients (6 %) experienced implant site pain and episodes of extremity pain and paresthesias that were refractory to medical management and required device explantation. The implant site infection rate was 2 %. CONCLUSIONS: Analysis of our long-term results confirms the safety and effectiveness of SNS in the management of patients with FI.

Prognosis for gastric carcinomas with an insufficient number of examined negative lymph nodes.

BACKGROUND: The optimal system for lymph node (LN) staging in gastric cancer is still a subject of debate. The aim of our study was to analyse the probability of error in negative LN (pN0) gastric carcinomas when a low number of LNs were harvested using a probabilistic model. METHODS: Patients with gastric carcinoma who underwent R0 resection at three university hospitals between 2004 and 2009 were retrospectively included. A Bayesian model was used to analyse the probability of error for negative LNs (pN0) gastric carcinomas. Kaplan-Meier survival curves and the log-rank test were used to compare the overall and specific mortality of prognosis groups. RESULTS: Of the 291 patients included, 123 were classified as pN0 (42%). A significant correlation was found between the extent of the LN dissection performed and the number of the LNs retrieved. According to the Bayesian model the carcinomas with 9 or fewer negative lymph nodes were considered to have a high risk (HR) of misclassification, whereas patients with 10-25 LNs analysed and those with more than 26 negative lymph nodes were considered to have a moderate risk (MR) and low risk (LR), respectively. The log-rank test showed a significant improvement in the disease-specific survival for the MR pN0 (p < 0.001) and LR pN0 (p < 0.04) but not for the HR pN0 patients compared to pN1 patients. CONCLUSIONS: The proposed probabilistic model is clinically useful for differentiating the prognosis in pN0 gastric carcinomas when an insufficient number of negative lymph nodes are retrieved.

Neumoperitoneo secundario al lavado quirúrgico de absceso isquiorrectal con agua oxigenada / Pneumoperitoneum secondary to ischiorectal abscess surgical scrub with hydrogen peroxide

El agua oxigenada es una sustancia usada frecuentemente como un agente seguro e inocuo; sin embargo, se han descrito diversas complicaciones que establecen la voz de alarma sobre su uso. Presentamos un caso de neumoperitoneo secundario al lavado quirúrgico con agua oxigenada en un paciente con diagnóstico de absceso isquiorrectal. Ante las complicaciones observadas del uso de una sustancia tan ampliamente extendida en cirugía, debería replantearse su uso o al menos darle un empleo más restringido, en cavidades o espacios semicerrados y usar en su lugar sustancias más seguras que hasta ahora no hayan mostrado efectos tan nocivos (AU)

Hydrogen peroxide is a substance often used as a safe and harmless agent, various complications have been described that set the alarm on their use. We present a case of pneumoperitoneum secondary to surgical scrub with hydrogen peroxide in a patient with ischiorectal abscess. Given the complications of the use of a substance as widespread in surgery, we should rethink their use or at least give it more restricted use, in cavities or semi-enclosed spaces and instead use other safer chemicals (AU)

Factores asociados a mayor débito de drenaje tras linfadenectomía axilar por cáncer de mama / Factors associated with greater debit drainage after axillary lymphadenectomy for breast cancer

Introduction: axillary lymph node dissection (ALND) is still a usual procedure in the treatment of breast cancer. A drain is normally placed in the surgical bed and maintained several days until obtaining a daily discharge of 30-50 ml, in order to reduce the appearance of seroma. The aim of this study was to analyze possible factors associated with an increased drainage volume. Patients and Methods: a retrospective study of all the patients undergoing ALND for breasts cancer at our institution between 2011 and 2012 was performed. Results: 40 females were included. There were no complications or mortality. Median hospital stay was 2 days. Median day of drainage removal was the 5th postoperative day. Mean total drainage volume was 298.9 +/- 240.1 ml. High blood pressure associated with an increased drainage volume (550 ml vs 217.5 ml; p = 0.001) and a later removal (8th vs 4th day; p = 0.002). Similar happened with age > 65 years (420.8 ml vs 24.6 ml; p = 0.003) and (7th vs 5th day; p = 0.009). The number of metastatic lymph nodes showed a direct correlation with total drainage volume (Pearson 0.503; p = 0.017) and removal day (Spearman 0.563; p = 0.006), similar to the primary tumour size: total drainage volume (Pearson 0.447; p = 0.042) and removal day (Spearman 0.556; p = 0.009). Conclusion: age over 65 years, high blood pressure, number of metastatic lymph nodes and primary tumour size associated with a higher drainage volume and time to remove the drain.

Introducción: la linfadenectomía axilar (LA) sigue siendo un procedimiento frecuente en el tratamiento del cáncer de mama. Habitualmente se coloca un drenaje en el hueco axilar, que se mantiene varios días, hasta que tiene un débito diario de 30-50 ml, con el fin de reducir la aparición de seroma. El objetivo del presente estudio es analizar posibles factores asociados a un mayor volumen de drenaje. Pacientes y Métodos: realizamos un estudio retrospectivo de todas las pacientes intervenidas de LA por cáncer de mama en nuestro centro durante los años 2011 y 2012. Resultados: incluimos 40 mujeres en el estudio. No hubo complicaciones ni mortalidad. La mediana de estancia hospitalaria fue de 2 días. El día mediano de retirada de drenaje fue el 5° postoperatorio. El volumen medio total del drenaje fue 298,9 +/- 240,1 ml. La hipertensión arterial se asocia a un mayor volumen de drenaje (550 ml vs 217,5 ml; p = 0,001) y a una retirada más tardía del mismo (8° día vs 4° día; p = 0,002). Al igual ocurre con la edad > 65 años (420,8 ml vs 24,6 ml; p = 0,003) y (7° vs 5° día; p = 0,009). El número de ganglios metastásicos también se correlaciona con el volumen total de drenaje (coeficiente de correlación de Pearson 0,503; p = 0,017) y con el día de retirada (Spearman 0,563; p = 0,006), lo mismo que el tamaño del tumor primario: volumen total de drenaje (Pearson 0,447; p = 0,042) y día de retirada (Spearman 0,556; p = 0,009). Conclusión: la edad mayor de 65 años, la hipertensión arterial, el número de ganglios metastásicos y el tamaño del tumor primario se asocian con mayor volumen por el drenaje axilar y días necesarios hasta la retirada.

Complicaciones durante la neuromodulación de raíces sacras en el tratamiento de la incontinencia fecal grave / Complications during sacral nerve stimulation in the treatment of severe fecal incontinence

Objective: to evaluate the complications of sacral nerve stimulation for the treatment of fecal incontinence. Background: sacral nerve stimulation is considered to be nowadays an effective treatment for fecal incontinence in selected patients. Many authors have reported excellent results and indication for his use have increased. Nevertheless, even being a simple technique, not it exempts this from complications. Methods: fifty-two patients with severe faecal incontinence, treated with sacral nerve stimulation between january 2002 and december 2010, were analysed. All adverse events during follow-up were recorded. Results: there was not surgical complication during peripheral neural evaluation test. In our series, with an average follow-up to 55.52 +/- 31.84 months (range: 12-121), we had a rate of adverse effects of 14 percent, infection of surgical wound in two patients, break of electrode in two patients and the presence of pain in the place of the implant, with episodes of extremity pain and paresthesias in low members in 3 patients. Conclusions: sacral nerve stimulation in severe fecal incontinence is a safe treatment, with a low index of complications.

Objetivo: evaluar las complicaciones de la neuromodulación de raíces sacras en el tratamiento de la incontinencia fecal. Introducción: la neuromodulación de raíces sacras ha sido descrita como un tratamiento quirúrgico eficaz en pacientes con incontinencia fecal grave. Muchos autores han comunicado excelentes resultados y las indicaciones en su uso han aumentado. Sin embargo, a pesar de ser una técnica quirúrgica sencilla, no está exenta de complicaciones. Material y Método: 52 pacientes con incontinencia fecal grave, tratados mediante neuromodulación de raíces sacras entre enero de 2002 y diciembre de 2010, fueron analizados. Todas las complicaciones, tanto durante la implantación del dispositivo como durante el seguimiento, fueron registradas. Resultados: no se registraron complicaciones durante la prueba de estimulación. En nuestra serie, con un seguimiento de 55,52 +/- 31,84 meses, observamos un 14 por ciento de efectos adversos, infección de la herida quirúrgica en dos pacientes, rotura o movilización del electrodo en 2 pacientes y dolor y parestesias en 3 pacientes. Discusión: la neuroestimulación de raíces sacras en el tratamiento de la incontinencia fecal es un tratamiento seguro, con un bajo índice de complicaciones.

Ingesta de cuerpos extraños / Ingest of foreign bodies

La ingesta de cuerpos extraños supone una consulta habitual en los servicios de urgencias. En la mayoría de los casos, eltratamiento médico es suficiente, pero existe una pequeña proporción de casos en los que es necesario recurrir a la cirugía. Presentamos dos casos de ingesta de cuerpo extraño (AU)

The ingestion of foreign bodies supposes a habitual consultation in the services of urgencies. In most cases, the medical treatment is sufficient, but there exists a small proportion of cases in which it is necessary to resort to the surgery. We present two cases of ingestion of foreign body (AU)

Ileitis tras ileostomía / Bleeding ileitis following ileostomy

Background: The incidence of ileitis following ileostomy is 5 percent. Material and Method: We report a 79 years old male with a sigmoid cancer presenting with an intestinal obstruction. Results: Patient required a subtotal colectomy, leaving a terminal ileostomy in the right lower flank. Three days after the intervention, the patient had a profuse bleeding through the ileostomy. An emergency endoscopy showed multiple bleeding ulcers in the ileostomy. The patient did not respond to medical treatment and required a new intervention, excising 20 cm of distal ileum and performing a new ileostomy. The pathological study of the excised segment showed multiple superficial ulcers with abundant inflammatory cells.

Introducción: La ileitis tras ileostomía es una entidad poco frecuente, pero que conlleva una importante morbilidad. Objetivo: Describir un caso de ileitis postileostomía sin respuesta al tratamiento médico y revisar la literatura sobre el tema. Material y Método: Presentamos el caso de un varón de 79 años con sangrado agudo por ileostoma tras colectomía subtotal. Resultados: Tras fracaso de la terapia médica fue necesario realizar resección de segmento de íleon terminal afecto. Conclusiones: Se debe pensar en ileitis postileostomía en caso de ileostomías muy productivas o ileorragias y comenzar tratamiento esteroideo temprano y realizar ileoscopia precoz. La cirugía se reserva para aquellos casos en los que no es eficaz el tratamiento médico.

Applicability, safety and efficiency of outpatient treatment in uncomplicated diverticulitis.

BACKGROUND: In most cases of diverticulitis, inflammation is mild, and the only treatment required is a clear liquid diet and antibiotics. Until recently, patients were given this treatment as inpatients with the consequent expenditure of resources. The aim of this study was to assess the safety and efficacy of an outpatient treatment protocol with oral antibiotics in selected patients with uncomplicated acute diverticulitis in comparison with inpatient intravenous treatment. METHODS: We conducted a prospective non-randomized study between January 2007 and December 2009. We included all patients diagnosed with uncomplicated acute diverticulitis, at the Emergency Department of the University General Hospital of Elche. We compared the efficacy, safety and costs of hospital treatment with intravenous antibiotics and outpatient treatment with oral antibiotics. Seventy-six patients were included in the study. Forty-four of them underwent intravenous treatment with Metronidazole 500 mg/8 h + Ciprofloxacin 400 mg/12 h (hospital treatment group) and 32 took oral antibiotics Metronidazole 500 mg/8 h and Ciprofloxacin 500 mg/12 h (outpatient group). RESULTS: Outpatient treatment is viable in almost 95 % of those patients suffering from uncomplicated acute diverticulitis. Treatment was effective in resolving inflammation, and there were no complications in the majority of cases (94 %). Only 2 patients (6 %) required admission after outpatient treatment. The results further reflect complications and relapse rates similar to those of patients admitted to hospital and treated with intravenous antibiotics. There are no significant statistical differences (p = 0.86) between inpatients and outpatients. It is possible to save approximately 1,600 € per patient with outpatient treatment (p < 0.05). CONCLUSIONS: Outpatient treatment has demonstrated a safety and efficiency similar to inpatient treatment, producing an important reduction in expenses and medical resources.