Apendicectomía electiva en el manejo de la Colitis ulcerosa refractaria: Reporte de caso

Introducción: La colitis ulcerosa (CU) es una enfermedad inflamatoria intestinal que afecta el colon y el recto de etiología desconocida. Se ha planteado la apendicectomía electiva en pacientes con colitis ulcerosa refractaria como una alternativa de tratamiento. Objetivo: Comunicar el caso clínico de una paciente con CU refractaria a quien la apendicectomía electiva permitió una mejoría de su sintomatología y calidad de vida. Resultados: Se presenta el caso de una paciente de 46 años con antecedentes de hipotiroidismo y colitis ulcerosa de 2 años de evolución, con rectorragia, dolor abdominal y diarrea importante pese a la terapia biológica. Se decide apendicectomía laparoscópica electiva, logrando una mejoría sintomática de la paciente objetivada mediante la aplicación de la encuesta "Inflammatory Bowel Disease Questionnaire". El puntaje preoperatorio de la paciente fue de 60 puntos, y el postoperatorio de 176. Discusión: Se hace evidente que la colitis ulcerosa y el apéndice cecal están íntimamente relacionados. Los desafíos futuros deberían apuntarse a identificar las características clínicas que precisen qué pacientes se benefician de esta intervención.

Introduction: Ulcerative colitis (UC) is an inflammatory bowel disease that affects the colon and rectum of unknown etiology. Elective appendectomy has been proposed as a possible treatment for patients with refractory ulcerative colitis. Objective: To report the clinical case of a patient with refractory UC who showed improvement in symptomatology and quality of life after undergoing elective appendectomy. Results: We present the case of a 46-year-old patient with a 2-year history of hypothyroidism and ulcerative colitis, with rectal bleeding, abdominal pain, and significant diarrhea despite biological therapy. Elective laparoscopic appendectomy was performed, resulting in symptomatic improvement of the patient as measured by the Inflammatory Bowel Disease Questionnaire. The patient's preoperative score was 60 points, and the postoperative score was 176. Discussion: It seems evident that ulcerative colitis and the cecal appendix are intimately related. Future challenges should aim to identify clinical characteristics that determine which patients benefit from this intervention.

Impacto del sitio de extracción en la incidencia de hernias incisionales en pacientes sometidos a cirugía laparoscópica por cáncer colorrectal

Introducción: El objetivo de este estudio fue comparar la tasa de hernia incisional (HI) tras la extracción de piezas operatorias por mini-laparatomia media periumbilical (MM) versus mini-laparotomía transversa suprapúbica (MTS) en pacientes sometidos a cirugía laparoscópica por cáncer colorrectal (CLCC), y evaluar los factores asociados a su ocurrencia. Material y Método: Estudio de cohorte no concurrente. Se incluyen todos los pacientes consecutivos sometidos a CLCC en nuestro centro entre septiembre 2006 y diciembre 2017, cuya pieza operatoria fuese extraída por una MM o MTS y que contaran con un control tomográfico en el seguimiento. El diagnóstico de HI se realizó mediante tomografía computada, evaluada por dos radiólogos de forma independiente. Se agruparon los pacientes en MM y MTS, y se evaluaron las tasas de HI según sitio de extracción. Además, se realizó una regresión logística para identificar factores asociados a HI. Resultados: Se identificaron 1090 pacientes que tuvieron resecciones colorrectales lapa-roscópicas durante el período estudiado. De estos, 254 cumplieron con los criterios de inclusión. La edad media de la serie fue de 63 años (53,5% son hombres) con un IMC de 26,4 kg/m2. El sitio de extracción fue una MTS en un 53,1% y una MM en un 46,9%. Se identificó un total de 41 (34,5%) HI en el grupo de MM versus 17 (12,6%) en MTS (p = 0,001) en la TC de seguimiento realizado en una mediana de 18 meses (RIC 12-32) postoperatorios. En la regresión logística, el sitio de extracción (OR = 3,33, IC 95% 1,72-7,14, p < 0,001) y la presencia de patología bronquial obstructiva se asociaron de manera independiente con HI (OR = 3,45, IC 95% 1,11-11,11, p = 0,03). Conclusión: La MTS se asocia a una menor tasa de HI que la MM en pacientes sometidos a CLCC. Esto se debe tener en consideración al momento de elegir el sitio de extracción de pieza operatoria en CLCC.

Aim: To compare the rate of incisional hernia (IH) according to the extraction site in patients undergoing laparoscopic colorectal cancer surgery (LCCS), and to evalúate the risk factors associated with its occurrence. Material and Method: Cohort study including all consecutive patients undergoing LCCS in our center between September 2006 and December 2017, where the specimen was extracted through a median mini-laparotomy (MM) or transverse suprapubic mini-laparotomy (TSM) and have a tomographic control during follow-up. The diagnosis of IH was made by computed tomography evaluated by two radiologists, independently. The rate of IH was calculated for both groups and a regression analysis were performed to identify factors associated with IH. Results: Some 1090 patients undergoing laparoscopic colorectal resections were identified during the study period; of these, 254 met the inclusion criteria. The mean age of the series was 63 years (53.5% are men) with a BMI of 26.4 kg/m2. The extraction site was a TSM in 53.1% and a MM in 46.9%. A total of 41 (34.5%) IH were identified in the MM group versus 17 (12.6%) in TSM (p = 0.001) in the follow-up CT performed at a median of18 months (IQR 12-32) postoperative. In logistic regression, the extraction site (OR = 3.33, 95% CI 1.72-7.14, p < 0.001) and the presence of obstructive bronchial pathology were independently associated with IH (OR = 3, 45, 95% CI 1.11-11.11, p = 0.03). Conclusión: A TSM is associated with a lower rate of IH compared to a MM as extraction site in patients undergoing LCCS. This must be taken into account when choosing the extraction site in patients having LCCS.

Obstrucción intestinal secundaria a hematoma intramural espontáneo: Caso clínico / Bowel obstruction secondary to a spontaneous intramural hematoma. Report of one case

Spontaneous intramural hematoma (IMH) is an uncommon cause of bowel obstruction, generally secondary to trauma. Even rarer is the spontaneous hematoma, mainly described in anticoagulated patients. We report a 73-year-old female in anticoagulant therapy who presented with a bowel obstruction. A computed tomography (CT) of the abdomen showed a segmentary wall thickening of the distal jejunum, compatible with an IMH which obliterated the lumen and produced dilatation of the proximal bowel loops. Support management was initiated, achieving satisfactory evolution, allowing her discharge 12 days after admission.

Resultados quirúrgicos a corto y mediano plazo por enfermedad de Crohn ileocecal / Short and medium term results of the surgical management of ileocecal Crohn's disease

BACKGROUND: The treatment of Crohn's disease (CD) is based on medical therapy and surgery is reserved for failure of medical management or complications. AIM: To evaluate endoscopic, clinical, and surgical recurrence of CD after surgery. MATERIAL AND METHODS: In a prospectively maintained database, consecutive patients older than 15 years subjected to an ileocecal resection for ileocolic disease from January 2011 to April 2021, were identified. The diagnosis of CD was confirmed with the pathologic report. Patients with less than one year of follow-up were excluded. Information was obtained retrospectively from the database and clinical records. RESULTS: Fourteen patients were identified. The mean age at the time of surgery was 38 years. Surgery was performed at a median of 41.5 months (0-300) after the diagnosis of CD, nine elective and five emergency procedures. In five patients there were four major and two minor postoperative complications, with no anastomotic leakage. Six patients had endoscopic recurrence and seven had clinical recurrence (50%) at a mean of 15 months, one of whom required a second operation. There was no mortality. CONCLUSIONS: After the surgical treatment of CD, the clinical and endoscopic recurrence rate continues to be high.

Abordaje abierto versus laparoscópico para la reconstitución del tránsito luego de la cirugía de Hartmann: resultados de una experiencia de 10 años / Open versus laparoscopic approach for Hartmann's reversal: results of a 10-year retrospective cohort study

Resumen Objetivo: El objetivo de este estudio es comparar los resultados perioperatorios del abordaje abierto (AA) con el abordaje laparoscópico (AL) para la reconstitución de tránsito (RT), y determinar factores de riesgo asociados a morbilidad posoperatoria. Material y Métodos: Se estudiaron pacientes consecutivos sometidos a RT entre enero de 2007 y diciembre de 2016 en nuestro centro. Se excluyeron aquellos con grandes hernias incisionales que requirieran reparación abierta simultánea. Se consignaron variables demográficas y perioperatorias, y se compararon ambos grupos. Además, se realizó una regresión logística para la identificación de factores de riesgo asociados a morbilidad posoperatoria en la serie. Resultados: Se realizaron 101 RT en el período. Se excluyeron 14 casos por hernia incisional, por lo que se analizaron 87 casos (46 AA y 41 AL). Diez pacientes en el grupo AL (24,4%) requirieron conversión, principalmente por adherencias. La morbilidad total de la serie fue de 36,8%, siendo mayor en el AA (50% vs 21,9%, p = 0,007). Hubo una filtración anastomótica en cada grupo. La estadía posoperatoria fue de 5 (3-52) días para el AL y 7 (4-36) días para el AA (p < 0,001). En la regresión logística, sólo el AA fue un factor de riesgo independientemente asociado a morbilidad posoperatoria (OR 2,89, IC 95% 1,11-7,49; p = 0,029). Conclusión: El abordaje laparoscópico se asocia a menor morbilidad y estadía posoperatoria que el abordaje abierto para la reconstitución del tránsito pos-Hartmann. En nuestra serie, el abordaje abierto fue el único factor independientemente asociado a morbilidad posoperatoria.

Introduction: Hartmann's reversal (HR) is considered a technically demanding procedure and is associated with high morbidity rates. Aim: The aim of this study is to compare the perioperative results of the open approach (OA) with the laparoscopic approach (LA) for HR, and to determine the risk factors associated with postoperative morbidity. Material and Methods: Consecutive patients undergoing HR between January 2007 and December 2016 at a university hospital were included. Patients with large incisional hernias that required an open approach a priori were excluded from the analysis. Demographic and perioperative variables were recorded. Analytical statistics were carried out to compare both groups, and a logistic regression was performed to identify risk factors associated with postoperative morbidity in the series. Results: A hundred and one HR were performed during the study period. Fourteen cases were excluded due to large incisional hernias, so 87 cases (46 OA and 41 LA) were analyzed. Ten patients in the LA group (24.4%) required conversion, mainly due to adhesions. The total morbidity of the series was 36.8%, being higher in the OA group (50% vs. 21.9%, p = 0.007). There was one case of anastomotic leakage in each group. The length of stay was 5 (3-52) days for LA and 7 (4-36) days for OA (p < 0.001). In the logistic regression, the OA was the only independent risk factor associated with postoperative morbidity in HR (OR 2.89, IC 95% 1.11-7.49; p = 0.029). Conclusion: A laparoscopic approach is associated with less morbidity and a shorter length of stay compared to the open approach for Hartmann's reversal. An open approach was the only factor independently associated with postoperative morbidity in our series.

Resultados a largo plazo de la rehabilitación del piso pélvico en pacientes con incontinencia fecal / Long-term results of pelvic floor rehabilitation in patients with fecal incontinence

Resumen Introducción: La rehabilitación del piso pélvico es frecuentemente indicada a los pacientes con incontinencia fecal. Su efectividad a corto plazo ha sido demostrada. Sin embargo, sus resultados en el largo plazo son controversiales. Objetivo: Nuestro objetivo es evaluar los resultados funcionales y calidad de vida a largo plazo de los pacientes con incontinencia fecal tratados mediante rehabilitación del piso pélvico. Materiales y Método: Estudio cuasi-experimental. Se incluyeron los pacientes con incontinencia fecal tratados mediante rehabilitación del piso pélvico entre 2007-2014 en nuestro centro, sin necesidad de cirugía. Se midió el puntaje funcional de Wexner y de calidad de vida (FIQLS) antes (T1) y después del tratamiento (T2). Se realizó encuesta vía correo electrónico para obtener dichos puntajes entre 3-10 años posterior al tratamiento (T3). Resultados: De 215 pacientes, 182 cumplían criterios de inclusión. 96 (52,8%) de ellos respondieron la encuesta en T3. La mediana de seguimiento fue de 4,5 (3-10) años. La edad promedio al tiempo del estudio fue de 60,8 ±13,1 años. 88,4% fueron mujeres. La mediana del puntaje funcional fue 16 (6-20) en T1 y 7 (0-18) en T2, p = 0,000. La calidad de vida mejoró significativamente en sus 4 dimensiones entre T1 y T2. En T3, ambos puntajes presentaron mejores promedios que en T1, p = 0,000. No hubo asociación entre el tiempo de seguimiento y el resultado funcional en T3. Conclusión: Los pacientes con incontinencia fecal tratados mediante rehabilitación del piso pélvico mejoran significativamente su funcionalidad y calidad de vida. El beneficio disminuye en el tiempo, pero persiste mejor que previo al tratamiento.

Introduction: Pelvic floor rehabilitation is often indicated as first-line therapy for patients with fecal incontinence. Its short-term effectiveness has been demonstrated in these patients. However, long-term results are controversial. Aim: Our objective is to evalúate long-term functionality and quality of life in patients with fecal incontinence treated with pelvic floor rehabilitation. Materials and Method: Quasi- experimental study conducted at a single tertiary care center. We included patients with fecal incontinence treated by pelvic floor rehabilitation at our center between 2007-2014 who did not require surgery. Wexner functional score and quality of life using FIQLS were measured pre (T1) and post-treatment (T2). Poste - riorly, an-e-mail survey was conducted to retrieve scores three to 10 years after treatment (T3). Results: Of the 215 patients, 182 met the inclusion criteria. 96 (52.8%) patients responded at T3 and were therefore included. The median follow-up period was of 4.5 years (3-10). The mean age at the time of the study was 60.8 ± 13.1 years and 88.4% were women. The median Wexner score was 16 (6-20) in T1 and 7 (0-18) in T2, (p = 0.000). Quality of life improved significantly in its four dimensions when comparing T1 and T2. In T3, Wexner and the quality of life scores were significantly lower than T2. However, in T3, both scales had better means than T1, (p = 0.000). There was no association between the follow-up time and the functional result in T3. Conclusions: Patients with fecal incontinence treated by pelvic floor rehabilitation improve their functionality and quality of life significantly. This benefit decreases over time but remains above its baseline.

[Short and medium term results of the surgical management of ileocecal Crohn's disease]. / Resultados quirúrgicos a corto y mediano plazo por enfermedad de Crohn ileocecal.

BACKGROUND: The treatment of Crohn's disease (CD) is based on medical therapy and surgery is reserved for failure of medical management or complications. AIM: To evaluate endoscopic, clinical, and surgical recurrence of CD after surgery. MATERIAL AND METHODS: In a prospectively maintained database, consecutive patients older than 15 years subjected to an ileocecal resection for ileocolic disease from January 2011 to April 2021, were identified. The diagnosis of CD was confirmed with the pathologic report. Patients with less than one year of follow-up were excluded. Information was obtained retrospectively from the database and clinical records. RESULTS: Fourteen patients were identified. The mean age at the time of surgery was 38 years. Surgery was performed at a median of 41.5 months (0-300) after the diagnosis of CD, nine elective and five emergency procedures. In five patients there were four major and two minor postoperative complications, with no anastomotic leakage. Six patients had endoscopic recurrence and seven had clinical recurrence (50%) at a mean of 15 months, one of whom required a second operation. There was no mortality. CONCLUSIONS: After the surgical treatment of CD, the clinical and endoscopic recurrence rate continues to be high.

[Bowel obstruction secondary to a spontaneous intramural hematoma. Report of one case]. / Obstrucción intestinal secundaria a hematoma intramural espontáneo: Caso clínico.

Spontaneous intramural hematoma (IMH) is an uncommon cause of bowel obstruction, generally secondary to trauma. Even rarer is the spontaneous hematoma, mainly described in anticoagulated patients. We report a 73-year-old female in anticoagulant therapy who presented with a bowel obstruction. A computed tomography (CT) of the abdomen showed a segmentary wall thickening of the distal jejunum, compatible with an IMH which obliterated the lumen and produced dilatation of the proximal bowel loops. Support management was initiated, achieving satisfactory evolution, allowing her discharge 12 days after admission.

Absceso periostomal secundario a perforación intestinal por cuerpo extraño: presentación de un caso / Periostomal abscess secondary to bowel perforation due to foreign body ingestion: a case report

Resumen Objetivo: Reportar un caso de absceso periostomal, su diagnóstico clínico e imagenológico y manejo. Materiales y Método: Paciente de 77 años usuaria de colostomía con dolor abdominal asociado a aumento de volumen y enrojecimiento de la piel alrededor de la colostomía. Una tomografía computada de abdomen muestra un cuerpo extraño perforante de la pared colónica ostomizada, asociado a formación de un absceso. Resultados: Se practica una incisión de la colección, dando salida a gran cantidad de pus y cuerpo extraño correspondiente a tibia de ave. Se inicia cobertura antibiótica y se instala drenaje Penrose. Controles posteriores muestran regresión del absceso y drenaje sin débito. Discusión: 80%-90% de los cuerpos extraños ingeridos son eliminados sin complicación y < 1% producen perforación. Esto es más común en segmentos intestinales angulados o intervenidos quirúrgicamente. La clínica es inespecífica y el diagnóstico requiere una imagen que identifique signos sugerentes. Conclusión: Un absceso periostomal y la perforación intestinal por cuerpo extraño son cuadros infrecuentes. La alta sospecha diagnóstica y una evaluación imagenológica pueden dar una respuesta precisa. Además del manejo quirúrgico, debe asociarse cobertura antibiótica para enteropatógenos y generalmente un sistema de drenaje.

Aim: To report a case of periostomal abscess, its clinical and imaging diagnosis and management. Materials and Method: 77-year-old patient, user of a colostomy with abdominal pain associated to swelling and redness of the skin next to the colostomy. A computed tomography of the abdomen showed a foreign body perforating the ostomized bowel associated to the formation of an abscess. Results: An incision of the gathering was performed, giving out a great quantity of pus and the foreign body, which corresponded to a bird's tibia. Antibiotic therapy was given, and a Penrose drainage installed. Further controls showed regression of the abscess and no flux from drainage. Discussion: 80%-90% of ingested foreign bodies are eliminated without complications and < 1% produce perforation. This is more common in angled intestinal segments or surgically intervened ones. Clinical features are unspecific, and diagnosis requires suggesting imaging signs. Conclusion: Periostomal abscesses and bowel perforation due to foreign body are infrequent. High diagnostic suspicion and an imaging evaluation may give a precise answer. Besides surgical management, antibiotic coverage for enteropathogens must be associated and a drainage system too in most cases.

Diagnóstico de divertículo de Meckel mediante cápsula endoscópica / Diagnose of Meckel's diverticulum through endoscopic capsule

Meckel's diverticulum can be present in up to 1.2% of the population. It is usually diagnosed as an imaging finding, but it can present with complications such as digestive bleeding, intestinal obstruction, diverticulitis, ulcers, and perforation, more frequently in childhood or infancy. The diagnosis workup for this condition will depend on their clinical manifestation, the most frequent being gastrointestinal bleeding of obscure origin or small intestinal bleeding. In this context, although capsule endoscopy is the preferred technique, its diagnostic yield for the detection of Meckel's diverticulum is not entirely clear and it has not been compared in a controlled studies with other diagnostic methods. Here we report the diagnosis of a Meckel diverticulum and its intestinal complications by means of capsule endoscopy in a patient with iron deficiency anemia and gastrointestinal bleeding

El divertículo de Meckel puede estar presente en el 1,2% de la población general. Usualmente es diagnosticado como un hallazgo, pero puede presentarse con mayor frecuencia en la niñez o infancia por sus complicaciones como hemorragia digestiva, obstrucción intestinal, diverticulitis, úlceras y perforación. El enfrentamiento diagnóstico de esta condición dependerá de la manifestación clínica, siendo lo más frecuente hemorragia digestiva de origen oscuro o de intestino delgado. En este contexto, si bien la cápsula endoscópica es la técnica de elección, su rendimiento diagnóstico para la detección del divertículo de Meckel no es del todo claro y no ha sido comparado de forma controlada con otras técnicas diagnósticas. En el presente caso se reporta el diagnóstico de un divertículo de Meckel y sus complicaciones intestinales mediante cápsula endoscópica en una paciente con anemia ferropriva y hemorragia digestiva.

Contracción paradojal del puborrectal como causa de defecación obstructiva: resultados a corto plazo del tratamiento con biofeedback y rehabilitación pelviperineal / Puborectal paradoxical contraction as a cause of obstructive defecation: short-term outcomes of treatment with biofeedback and pelviperineal rehabilitation

Resumen Introducción: En pacientes constipados crónicos por obstrucción de salida, la contracción paradojal del puborrectal (CPP) o "anismo" es frecuente. El tratamiento con Biofeedback y rehabilitación pelviperineal presenta resultados exitosos entre el 40-90%. Objetivo: Evaluar el resultado del tratamiento con Biofeedback y rehabilitación pelviperineal en pacientes con CPP a corto plazo. Materiales y Método: Serie de casos. Datos obtenidos prospectivamente de la Unidad de Piso Pelviano. Se incluyó pacientes entre 2008 y 2015 que cumplían criterios de constipación crónica secundaria a CPP, confirmado por manometría anorrectal y/o defeco-resonancia. Se analizaron datos demográficos, frecuencia de evacuaciones, uso de laxantes, enemas, pujo, Score de Altomare y Score de constipación de Wexner pre y post-tratamiento. Resultados: 43 pacientes, de los cuales 39 son mujeres. Edad media de 40 años (rango: 14-84). Duración de síntomas fue ≥ 5 años en el 72,5%. Mediana de sesiones de Biofeedback de 8 (6-10). El 62,8% presenta ≤ 2 evacuaciones semanales y disminuye a un 29,3% post-tratamiento (p < 0,001). El 76,2% requiere laxantes orales y el 42,9% enemas, disminuyendo a 35,1% (p < 0,001) y 5,4% (p < 0,001) respectivamente post-tratamiento. Sensación de evacuación incompleta/fragmentada en todos los intentos mejoró de 67,4% a 14,6% (p < 0,001) y el pujo excesivo en más de la mitad de intentos mejoró de 76,1% a 10,8% (p < 0,001). Score de Wexner para constipación y Altomare mejoró de 18 a 7 (p < 0,001) y de 16 a 5 (p < 0,001) respectivamente. Conclusión: El biofeedback y la rehabilitación pelviperineal son efectivas en el tratamiento de la CPP.

Introduction: In patients with chronic constipation by obstructive defecation syndrome Paradoxical Puborectalis Contraction or "anismus" is important. Successful results for Biofeedback treatment and Pelviperineal Rehabilitation it described between 40-90%. Aim: To evaluate the outcome of biofeedback and pelviperineal rehabilitation in patients with CPP in the short-term. Materials and Method: Case series. Data was obtained from the prospective database of Pelvic Floor Unit of Universidad Católica de Chile. Patients with anismus were included between 2008 and 2015. Diagnostic criteria were chronic constipation patients by anismus with anorectal manometry and/or defecoresonancy that confirms this disorder and discards other causes of obstruted defecation síndrome. Demographic variables, frequency of bowel movements, use of laxatives, enemas, pushing, Altomare Score and Wexner constipation Score were analyzed pre and post-treatment. Results: Series of 43 patients, 39 of whom where women. Median age: 40 years (range: 14-84). Duration of symptoms ≥ 5 years in 72.5%. Median of Biofeedback sessions: 8 (range 6-10). Pre-treatment, 62.8% had ≤ 2 evacuations weekly and 29.3% post-treatment (p < 0.001). Oral laxatives were required in 76.2% and 42.9% enemas, decreasing to 35.1% (p < 0.001) and 5.4% (p < 0.001) post-treatment respectively. Feeling of incomplete/evacuation fragmented all the time improved from 67.4% to 14.6% (p < 0.001) and excessive pushing in more than half of time improved from 76.1% to 10.8% (p < 0.001). Wexner Score for and Altomare Score improved from 18 to 7 (p < 0.001) and 16 to 5 (p < 0.001) respectively. Conclusion: Adult with chronic constipation by anismus can be treated effectively with Biofeedback and Pelviperineal Rehabilitation.

Desarrollo y evaluación de modelo ex vivo para entrenamiento de anastomosis intracorpórea en hemicolectomía derecha laparoscópica / Development and assessment of an ex vivo simulated model for intracorporeal anastomosis training in laparoscopic right hemicolectomy

Resumen Introducción: Si bien la anastomosis intracorpórea (AI) ha demostrado beneficios clínicos sobre la anastomosis extracorpórea (AE) en la hemicolectomía derecha laparoscópica (HDL), su aplicación ha sido limitada por su dificultad técnica y curva de aprendizaje más larga. El presente estudio busca desarrollar y evaluar un modelo simulado para entrenar este procedimiento. Materiales y Método: Se desarrolló un modelo en base a tejido ex vivo, con colon porcino e intestino bovino, montados en un simulador de laparoscopía. Este se modificó sucesivamente en base a entrevistas semiestructuradas a cirujanos hasta lograr el modelo final. Para evaluar apariencia y reacción al modelo, coloproctólogos, cirujanos y residentes previamente expuestos a entrenamiento simulado, realizaron una ileotransverso anastomosis mecánica en el modelo y luego contestaron una encuesta. Resultados: Doce sujetos participaron. Cuatro coloproctólogos, 4 residentes de coloproctología, 2 residentes de cirugía general, 1 cirujano general y 1 cirujano digestivo. El 91,6% valoró positivamente la ergonomía lograda, mientras que el 83,3% y 75% valoraron positivamente el uso del instrumental y la relación anatómica entre estructuras, respectivamente. Todos los participantes consideraron el modelo útil para entrenar sutura manual laparoscópica, el 91,6% para entrenar enterotomías y 83,3% para entrenar el uso de endograpadora. Todos declararon que el módulo permite entender y reflexionar sobre la técnica propuesta. Conclusión: Este modelo desarrollado sería útil para entrenar habilidades críticas para realizar una AI en HDL. Su incorporación a un programa de entrenamiento en laparoscopía avanzada podría contribuir a acortar la curva de aprendizaje de este procedimiento.

Introduction: Although intracorporeal anastomosis has demonstrated clinical benefits over extracorporeal anastomosis in laparoscopic right hemicolectomy, its application has been limited due to its technical difficulty and longer learning curve. The present study aims to develop and evaluate a simulated model to train this procedure. Materials and Method: An ex vivo tissue model was developed with porcine colon and bovine small bowel mounted in a laparoscopic simulator. This was subsequently modified based on semi-structured interviews to experts until the final model was achieved. To evaluate appearance and reaction to the model, the participants performed an ileocolic mechanical anastomosis in the model and answered a survey. Results: Twelve subjects participated. Four colorectal surgeons, 4 colorectal surgery fellows, 2 residents of general surgery, 1 general surgeon and 1 upper digestive surgeon. Of all subjects, 91.6%, 83.3% and 75% deemed ergonomics achieved, the use of instruments, and the anatomical relationship between structures as similar to reality, respectively. All participants deemed the model useful to train laparoscopic manual suturing, while 91.6% and 83.3% of them considered it useful to train enterotomies and the use of an endostapler, respectively. All declared that the model allows to understand the proposed technique. Conclusion: This model would be useful to train critical skills to perform an intracorporeal anastomosis in laparoscopic right hemicolectomy. Its incorporation into an advanced simulated laparoscopy training program could help shorten the learning curve of this procedure.

[Outcome of surgery for Crohn's colitis. Review of 28 cases]. / Colitis de Crohn: resultados del tratamiento quirúrgico y evolución alejada.

BACKGROUND: Exclusive involvement of the colon or rectum in Crohn's disease, called Crohn's colitis, (CC) occurs in about 25% of these patients. AIM: To analyze early surgical results and long-term outcomes of patients undergoing surgery for CC. MATERIAL AND METHODS: Review of a prospective database, identifying patients with Crohn's disease operated between 2003 and 2015 and excluding those with ileocecal disease. We analyzed demographic data, pre and postoperative pharmacological treatment, operations, morbidity and the need for a second bowel resection at follow-up. RESULTS: We reviewed data from 28 patients aged 17 to 72 years (15 men). Twenty-seven (96.4%) had previous pharmacological treatment, 11 received monoclonal antibodies. The most common indications for surgical treatment were failure of medical treatment in 15 cases, acute severe colitis in 12 and anemia/malnutrition in eight. Total colectomy was performed in 17 (61%) patients, proctocolectomy in 8 (29%) and segmental colectomies in 3 (11%). Sixteen (57%) were operated laparoscopically. Major postoperative complications were observed in 5 (18%). Four needed a reintervention. There was no operative mortality. During a 55 months median follow-up of 27 patients, seven (26%) required a second bowel resection, one of them for recurrence. Nineteen (70%) patients had an ostomy, which was permanent in 11. Fifteen patients are without medical treatment. CONCLUSIONS: Most of the reviewed patients required total colectomy for the control of the disease with a low surgical morbidity. Two-thirds required an ileostomy, which became permanent in half of them.

Colitis de Crohn: resultados del tratamiento quirúrgico y evolución alejada / Outcome of surgery for Crohn's colitis: review of 28 cases

Background: Exclusive involvement of the colon or rectum in Crohn's disease, called Crohn's colitis, (CC) occurs in about 25% of these patients. Aim: To analyze early surgical results and long-term outcomes of patients undergoing surgery for CC. Material and Methods: Review of a prospective database, identifying patients with Crohn's disease operated between 2003 and 2015 and excluding those with ileocecal disease. We analyzed demographic data, pre and postoperative pharmacological treatment, operations, morbidity and the need for a second bowel resection at follow-up. Results: We reviewed data from 28 patients aged 17 to 72 years (15 men). Twenty-seven (96.4%) had previous pharmacological treatment, 11 received monoclonal antibodies. The most common indications for surgical treatment were failure of medical treatment in 15 cases, acute severe colitis in 12 and anemia/malnutrition in eight. Total colectomy was performed in 17 (61%) patients, proctocolectomy in 8 (29%) and segmental colectomies in 3 (11%). Sixteen (57%) were operated laparoscopically. Major postoperative complications were observed in 5 (18%). Four needed a reintervention. There was no operative mortality. During a 55 months median follow-up of 27 patients, seven (26%) required a second bowel resection, one of them for recurrence. Nineteen (70%) patients had an ostomy, which was permanent in 11. Fifteen patients are without medical treatment. Conclusions: Most of the reviewed patients required total colectomy for the control of the disease with a low surgical morbidity. Two-thirds required an ileostomy, which became permanent in half of them.

Morbilidad global asociada a ileostomías en asa temporales / Morbidity associated to ileostomies

Introduction: The main indications for a loop ileostomy are to protect a distal anastomosis or to management of an anastomotic leak. However, it is a procedure with complications arising from its confection, function or closure. There are sparse local data on this topic. Objective: To describe the global morbidity from loop ileostomies. Method: Patients who underwent a loop ileostomy between January 2009 and January 2012 were retrospectively included. Demographics, indications, complications from the making, function and closure of the ileostomy was recorded. Results: The series consists of 64 patients. The total percentage of complications was 40.3 percent. Complications arising from the confection, function and closure were 4.7 percent, 18.7 percent and 16.9 percent respectively. Two patients were readmitted for dehydration with a total of 4 readmissions. Four patients were reoperated for morbidity of ileostomy closure, two intestinal obstructions, one leak and one enterotomy. Conclusion: In this study, loop ileostomy complications are present in a substantial proportion of patients. It should be take in consideration at the moment of making it.

Introducción: Las principales indicaciones de ileostomías en asa son proteger una anastomosis distal de alto riesgo o el manejo de una complicación séptica derivada de una filtración. Sin embargo, es un procedimiento que no está exento de complicaciones derivadas de la confección, función o cierre. En este contexto, existen escasas publicaciones que incluyen la morbilidad sumatoria. Objetivo: Describir la morbilidad global derivada de las ileostomías en asa. Método: Se incluyó en forma retrospectiva los pacientes a quienes se les practicó una ileostomía en asa de protección de una anastomosis distal entre enero de 2009 y enero de 2012. Se registraron datos demográficos, indicaciones y complicaciones derivadas de la confección, función y cierre de la ostomía. Resultados: La serie consta de 64 pacientes. Un 40,3 por ciento de los pacientes tuvieron una o más complicaciones. Complicaciones derivadas de la confección, función y cierre de la ileostomía fueron 4,7 por ciento, 18,7 por ciento y 16,9 por ciento respectivamente. Se rehospitalizaron por deshidratación 2 pacientes con un total de 4 rehospitalizaciones. Se reoperaron 4 pacientes por morbilidad del cierre de la ileostomía, 2 por obstrucción intestinal, 1 filtración y 1 enterotomía inadvertida. Conclusión: Las ileostomías en asa presentan complicaciones en un importante porcentaje de los pacientes, lo que debe ser tomado en cuenta al decidir su confección.

Intervenciones realizadas por residentes de cirugía general / Surgical procedures performed by general surgery residents

Introduction: The national Society of Surgery has defined the minimum number of surgical procedures that must be performed by general surgeons in trainee, however, there is no national data reporting this accomplishment. The aim of this study is to report on detail the surgical interventions performed by General Surgery Residents at the Pontificia Universidad Catolica de Chile (PUC) as lead surgeons. Methods: Retrospective analysis of surgical procedures performed by 26 Residents of the General Surgery Program (GSP) at PUC who graduated between the years 2012 and 2014. A total of 10.102 registered surgeries were reviewed and summarized. Results: The mean number of interventions performed by surgery residents was 481 (20% of them on the first year). The most frequently performed procedures were (mean per resident) laparoscopic cholecystectomy (115;24%), open appendectomy (89;19%), classic hernioplasty (43;9%), laparoscopic appendectomy (34;7%) and open cholecystectomy (25;5%). Regarding complex/sub-specialty interventions, partial/ total colectomy (12;2%), thyroidectomy-parathyroidectomy (9;2%), vascular access (8;2%), thoracotomy-VATS-sternotomy (5;1%) and breast surgery (4;1%) were the most commonly performed. Fifty three percent of all procedures were done in an emergency setting. The proportion of emergency procedures increased through the GSP training (elective vs emergency: 62 vs 38% at first year and 34 vs 66% at third year, respectively; p < 0.002). Interventions were mainly performed in the capital city of Chile, Santiago (74%) and the remaining were done in other provinces. Regarding only abdominal interventions (mean per resident: 366), 42% was performed by laparoscopy. Conclusions: Residents of the PUC-GSP execute a considerable large amount of interventions as resident surgeons throughout their 3-years-training program, exceeding the minimum recommendations established by the national Society of Surgery.

Introducción: Se han definido objetivos mínimos para la formación de Cirujanos Generales, pero no existen publicaciones que den cuenta del cumplimiento de los mismos. El objetivo de este trabajo es comunicar un análisis descriptivo de las intervenciones quirúrgicas realizadas por los residentes del Programa de Cirugía General (PCG) de la Pontificia Universidad Católica de Chile (PUC) en rol de primer cirujano. Material y Método: Se solicitó el registro de operaciones realizadas en rol de 1er cirujano a los 26 egresados entre 2012-2014 del PCG. Se realizó un análisis descriptivo de las 10.102 operaciones registradas. Resultados: El promedio de intervenciones realizadas por residente fue de 481 (20 por ciento en 1er año). Las más frecuentes fueron: colecistectomía laparoscópica (115;24 por ciento), apendicectomía clásica (89;19 por ciento), hernioplastía (43;9 por ciento), apendicectomía laparoscópica (34;7 por ciento) y colecistectomía clásica (25;5 por ciento). Las operaciones de especialidades derivadas que más se realizaron: colectomía (12;2 por ciento); tiroidectomía-paratiroidectomía (9;2 por ciento), accesos vasculares (8;2 por ciento), toracotomía-VATS-esternotomía (5;1 por ciento) y cirugía mamaria (4;1 por ciento). Un 53 por ciento de las intervenciones fueron de urgencia, observándose una inversión de la proporción entre procedimientos electivos vs de urgencia a lo largo de la formación (62 vs 38 por ciento en 1ro y 34 vs 66 por ciento en 3ro; p < 0,002). De las intervenciones abdominales (366), 58 por ciento fue por laparotomía y 42 por ciento por laparoscopia. Un 74 por ciento y 26 por ciento de todas las intervenciones se realizaron en centros de Santiago y regiones, respectivamente. Conclusiones: Los residentes de la PUC completan un volumen importante de intervenciones en rol de primer cirujano durante los 3 años de su PCG, superando las exigencias mínimas establecidas.

Resección de lesión neoplásica rectal mediante cirugía transanal mínimamente invasiva-técnica de TAMIS / Rectal neoplasm lesion resected by Transanal Minimally Invasive Surgery – TAMIS technique

We present a clinical case with a stage T1 rectal neoplasm lesion; resection was performed with transanal minimally invasive surgery-TAMIS procedure without complications. Anatomical pathology results showed invasion of the muscular layer, i.e. stage T2. The TAMIS technique, recently described by the coloproctology group of Orlando Hospital (USA), consists of using a single port device to generate a pneumorectum and resect the rectal lesion by means of regular laparoscopic tools. It has low morbidity and has gained general acceptance basically because the use of standard laparoscopic instrumentation, which reduces costs, allows one-block resections, without fragmentation of the surgical specimen and the learning curve not that long. The indication of local resection in cases of rectal cancer is still for T1 lesions, without nodal involvement and without histological factors leading to poor prognosis. Local relapse in these cases is acceptable and conservation of the rectum ensures good life quality for patients. Incorrect staging once the sample has been analyzed is indication of radical surgery and does not affect the prognosis.

Se presenta un caso clínico de una lesión neoplásica rectal etapificada como T1 la cual fue resecada con cirugía transanal mínimamente invasiva (transanal minimally invasive surgery-TAMIS) sin complicaciones. La anatomía patológica evidenció invasión hasta la túnica muscular, es decir T2. La técnica TAMIS, descrita recientemente por el grupo de coloproctología del Hospital de Orlando (EE.UU.), consiste en utilizar un dispositivo de puerto único para generar un neumorrecto y resecar la lesión rectal mediante instrumentos de laparoscopía tradicional. Tiene baja morbilidad y ha ganado aceptación principalmente por utilizar instrumental laparoscópico estándar, lo que disminuye el costo, permite resecciones transmurales, en bloque, sin fragmentar la pieza operatoria y su curva de aprendizaje no es larga. La indicación de resección local en cáncer de recto sigue siendo lesiones T1, sin compromiso nodal y sin factores de mal pronóstico histológico. La recidiva local en estos casos es aceptable y la conservación del recto permite una buena calidad de vida de los pacientes. La incorrecta etapificación una vez analizada la pieza operatoria es indicación de cirugía radical y no afecta el pronóstico.

Factores asociados a morbilidad precoz en cirugía colorrectal laparoscópica / Factors associated with early morbidity in laparoscopic colorectal surgery

Introduction: different factors have been associated with increased risk of complications in laparosco-pic colorectal surgery. The aim of this study is to identify these factors in our series. Method: retrospective cohort. All patients undergoing laparoscopic colorectal surgery between january 2000 and june 2012 were included. Patients who had postoperative complications until 30 days postoperatively were identified and analyzed by univariate and multivariate logistic regression. A p value less than 0.2 was used was used as a criteria for entry into the multivariate model. Results: the series consists of 848 patients with a median age of 58 +/- 22 years. Main surgical indications were: neoplasia (42.3 percent), diverticular disease (27.8 percent) and inflammatory bowel disease (8.8 percent). Most frecuently-performed procedures were: sigmoidectomy (39.5 percent), anterior resection of the rectum (13.4 percent), right hemicolectomy (13 percent) and total colectomy (8.7 percent). On univariate analysis, factors associated with complications were age over 75 years (OR 1.82, 95 percent CI 1.02 to 3.25) and red blood cell transfusion (OR 8.47, 95 percent CI 3.69 to 19.43). On multivariate analysis, red blood cell transfusion (OR 7.9 95 percent CI 1.78 to 35.88) and ASA III or IV (OR 3.26 95 percent CI 1.01 to 17.23) were independent factors associated with postoperative complications. Conclusion: intraoperative red blood cell transfusion and ASA score III or IV are independent risk factors associated with complications in laparoscopic colorectal surgery.

Introducción: se han descrito factores que se asocian a mayor riesgo de complicaciones en cirugía laparoscópica colorrectal. El objetivo de este trabajo es identificar estos factores en nuestra serie. Método: cohorte histórica. Se incluyeron todos los pacientes sometidos a cirugía colorrectal laparoscópica entre enero de 2000 y junio de 2012. Se identificaron los pacientes que tuvieron complicaciones post operatorias hasta 30 días después de la operación. Se analizaron mediante regresión logística uni y multivariada. Se utilizó como criterio de entrada al modelo multivariado los p < 0,2 y como criterio de significancia un p = 0,05. Resultados: la serie consta de 848 pacientes, con una mediana de edad de 58 +/- 22 años. Las principales indicaciones operatorias fueron: neoplasia (42,3 por ciento), enfermedad diverticular (27,8 por ciento) y enfermedad inflamatoria intestinal (8,8 por ciento). Las operaciones realizadas con mayor frecuencia fueron: sigmoidectomía (39,5 por ciento), resección anterior de recto (13,4 por ciento), hemicolectomía derecha (13 por ciento) y colectomía total (8,7 por ciento). En el análisis univariado, los factores asociados a complicación fueron: la edad sobre 75 años (OR de 1,82; IC 95 por ciento 1,02-3,25) y la transfusión de glóbulos rojos (OR 8,47; IC 95 por ciento 3,69-19,43). En el análisis multivariado, la transfusión de glóbulos rojos (OR 7,9 95 por ciento IC 1,78-35,88) y el ASA III o IV (OR 3,26 95 por ciento IC 1,01-17,23) fueron factores de riesgo independientes de complicaciones en el postoperatorio. Conclusión: la necesidad de transfusión y el ASA III o IV son factores de riesgo independientes asociados a complicaciones en cirugía colorrectal laparoscópica.

Respuesta patológica completa en pacientes sometidos a neoadyuvancia en cáncer de recto / Pathologic complete response in patients with neoadjuvant chemoradiotherapy for rectal cancer

Background: the standard treatment of locally advanced rectal cancer (RC) of the middle and lower third of the rectum is neoadjuvant chemoradiotherapy (XRQT) follow by oncologic resection. After this treatment in 15-25 percent of the cases, the pathologist reports complete pathological response (pCR). Aim: to describe demographic, clinical and survival data of patients with pCR undergoing chemoradiotherapy and radical resection for RC. Material and Methods: historic cohort study. In a prospectively maintained database between 2000 and 2010, we identified patients with RC, who underwent neoadjuvant chemoradiotherapy according to protocol, followed by radical resection. The preoperative staging was obtained by clinical examination, endoscopy, rectal ultrasound, CT scan of chest, abdomen and pelvis and pelvic MRI. Demographic data, tumor location, time between the end of XRTQ and surgery, postoperative staging (according AJCC) and survival, were collected. Results: 119 patients received preoperative XRTQ, 65 percent male, with a mean age of 58 years. The most frequent tumor site was the lower third (63 percent). Surgery was performed 8 weeks after the end of XRTQ. Of 119 patients with XRTQ, 15.1 percent had a pCR. Overall survival was 75 percent, and cancer-specific survival was 80.4 percent at 5 years in patients without pCR. For patients with pCR, the 5 year survival estimates for overall and cancer specific survival was 100 percent. We did not identify factors associated with pCR. Conclusions: in this study, pCR was comparable to other larger series reported elsewhere. No factors associated with pCR were identified.

Introducción: el cáncer de recto (CR) de tercio medio e inferior localmente avanzado se trata con radio-quimioterapia (XRTQ) preoperatoria. Luego XRQT y resección quirúrgica, 15-25 por ciento presentan respuesta patológica completa (RPC) de la lesión. Objetivo: comparar características demográficas, clínicas y sobrevi da de pacientes con RPC y respuesta parcial sometidos XRTQ preoperatoria y resección radical. Materiales y Métodos: estudio cohorte concurrente. En la base de datos de pacientes con CR mantenida prospectivamente, entre 2000-2010, se identificaron pacientes con CR tercio medio e inferior, sometidos XRTQ preoperatoria según protocolo, seguidos de resección radical. Etapificación preoperatoria según: examen clínico, endoscopia, endosonografía rectal, TAC tórax abdomen pelvis y resonancia nuclear magnética de pelvis. Se registraron datos demográficos, localización tumoral, lapso entre término de XRTQ y cirugía, etapificación post operatoria (AJCC), seguimiento y sobrevida. Resultados: 119 pacientes recibieron XRTQ preoperatoria por CR, 65 por ciento hombres. Edad promedio: 58 años. Localización tumoral más frecuente: tercio inferior (63 por ciento). Cirugía se realizó 8 semanas después del término de XRTQ. Etapificación post operatoria: Etapa I 26,1 por ciento, II 34,5 por ciento, III 16,8 por ciento, IV 5 por ciento y RPC 15,1 por ciento. Sobrevida global 75 por ciento, sobrevida específica por cáncer 80,4 por ciento a 5 años. Sobrevida pacientes con RPC fue 100 por ciento a 5 años. No se identificaron factores asociados a RPC. Conclusiones: en este estudio no se logró reconocer factores asociados a RPC. Con las limitaciones que impone el número de pacientes y el seguimiento, se reproducen hallazgos vistos en series más extensas.