Papel de la reparación muscular en el tratamiento de la incontinencia anal

La incontinencia anal (IA) tiene una alta prevalencia en la sociedad, aumenta con la edad, presenta elevados costes económicos y tiene un importante impacto negativo en la calidad de vida de los pacientes que la padecen. El tratamiento quirúrgico se reserva para aquellos pacientes que no responden a medidas conservadoras. Clásicamente, las técnicas de reparación muscular han jugado un papel principal en el tratamiento de la IA, sobre todo en aquellos casos en los que había un defecto del complejo esfinteriano, siendo la más extendida la esfinteroplastía solapante y reservando técnicas más complejas como la graciloplastía para casos con lesiones esfinterianas catastróficas. Otras técnicas como la reparación total del suelo pélvico se encuentran en desuso por sus pobres resultados.

Anal Incontinence (AI) is a prevalent disease, increases with aging, has high economic costs and a deep impact in the quality of life of the patients who suffer it. Surgical treatment is proposed in patients with no-response to medical therapy. Muscle repair techniques have been the main approach in AI, specially when there is a sphincteric damage. Overlapping sphincteroplasty is the most common technique and graciloplasty is used when there is a wide damage in sphinteric complex. Some other techniques such as postanal or total pelvic floor repair are not used any more because of their poor results.

Cuidados y tratamiento del pioderma gangrenoso periestomal. A propósito de tres casos / Care and treatment of peristomal gangrenous pyoderma. A study of three cases

El pioderma gangrenoso periestomal (PGP) es una enfermedad inflamatoria de la piel con evolución a úlcera dolorosa, muy poco frecuente, que rara vez se asocia con el carcinoma colorrectal.Su diagnóstico es diferencial puesto que puede confundirse con una infección de la piel, absceso, dermatitis de contacto, irritación periestomal o la extensión cutánea periestomal de una enfermedad inflamatoria intestinal (EII).Se presentan tres casos de pacientes intervenidos por carcinoma colorrectal con estoma intestinal, que desarrollaron PGP.Se elaboró un plan de cuidados y curas locales, empleando las taxonomías de la North American Nursing Diagnosis Association (NANDA), la clasificación de resultados de enfermería (NOC) y la clasificación de las intervenciones enfermeras (NIC).Los cuidados del estoma y la adecuación de dispositivos colectores se realizaron con suero fisiológico, pasta, polvos de ostomía y bolsa de dos piezas.Para el tratamiento local básico se utilizó suero fisiológico o la solución de lavado para la limpieza de herida, eosina acuosa (2%), alginato en fase exudativa y pomada con colagenasa en presencia de necrosis esfacelos.El tratamiento local específico (clobetasol propionato, tacrólimus o infiltración de triamcinolona acetónido) y sistémico (corticoterapia) se efectuó de forma secuencial tras el diagnóstico de PGP en función de la respuesta clínica a cada terapia.El primer caso se resolvió a los seis meses con buena respuesta a la infiltración local de triamcinolona. El segundo se recuperó a los 10 meses tras infiltración local con triamcinolona y prednisolona oral. El tercero no tuvo respuesta a los tratamientos locales ni a la corticoterapia sistémica, curándose después de la exéresis tumoral y metastásica con reubicación del estoma a los nueve meses.(AU)

Peristomal gangrenous pyoderma is an inflammatory skin disease with progression to painful ulcer, rare, and rarely associated with colorectal carcinoma.Its diagnosis is differential since it can be confused with skin infection, abscess, contact dermatitis, peristomal irritation or peristomal skin extension of an inflammatory bowel disease.We present three cases of patients operated for colorectal carcinoma with an intestinal stoma, who developed peristomal gangrenous pyoderma.A plan of local care and dressings was developed using the NANDA, NOC and NIC taxonomies.Stoma care and fitting of collecting devices were performed with saline solution, paste, ostomy powders and a two-piece bag.For the basic local treatment, physiological serum or washing solution was used for wound cleaning, aqueous eosin (2%), alginate in the exudative phase, and collagenase ointment in the presence of slough/necrosis.Specific local treatment (clobetasol propionate, tacrolimus, or triamcinolone acetonide infiltration) and systemic treatment (corticosteroid therapy) was given sequentially after the diagnosis of peristomal gangrenous pyoderma depending on the clinical response to each treatment.Case 1 resolved at six months with a good response to local triamcinolone infiltration. Case 2 resolved at 10 months after local infiltration with triamcinolone and oral prednisolone. Case 3 had no response to local treatments or systemic corticosteroid therapy, healing after tumour and metastatic excision with relocation of the stoma at nine months.(AU)

Care and treatment of peristomal gangrenous pyoderma. A study of three cases. / Cuidados y tratamiento del pioderma gangrenoso periestomal. A propósito de tres casos.

Peristomal gangrenous pyoderma is an inflammatory skin disease with progression to painful ulcer, rare, and rarely associated with colorectal carcinoma. Its diagnosis is differential since it can be confused with skin infection, abscess, contact dermatitis, peristomal irritation or peristomal skin extension of an inflammatory bowel disease. We present three cases of patients operated for colorectal carcinoma with an intestinal stoma, who developed peristomal gangrenous pyoderma. A plan of local care and dressings was developed using the NANDA, NOC and NIC taxonomies. Stoma care and fitting of collecting devices were performed with saline solution, paste, ostomy powders and a two-piece bag. For the basic local treatment, physiological serum or washing solution was used for wound cleaning, aqueous eosin (2%), alginate in the exudative phase, and collagenase ointment in the presence of slough/necrosis. Specific local treatment (clobetasol propionate, tacrolimus, or triamcinolone acetonide infiltration) and systemic treatment (corticosteroid therapy) was given sequentially after the diagnosis of peristomal gangrenous pyoderma depending on the clinical response to each treatment. Case 1 resolved at six months with a good response to local triamcinolone infiltration. Case 2 resolved at 10 months after local infiltration with triamcinolone and oral prednisolone. Case 3 had no response to local treatments or systemic corticosteroid therapy, healing after tumour and metastatic excision with relocation of the stoma at nine months.

Warthin-like, una variante infrecuente del carcinoma papilar de tiroides / Warthin-like, a rare variant of papillary thyroid cancer

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Impacto del estoma derivativo en un protocolo de rehabilitación multimodal en cirugía de recto / Impact of a diverting stoma in an enhanced recovery programme for rectal cancer

OBJETIVO: La asociación de ileostomía disminuye la gravedad de las complicaciones tras anastomosis rectal baja pero puede alargar la estancia postoperatoria. El objetivo del presente estudio es averiguar si un estoma derivativo modifica la estancia postoperatoria o las complicaciones, en pacientes intervenidos bajo un régimen de rehabilitación multimodal perioperatoria (RHMM). MÉTODOS: Analizamos a 104 pacientes intervenidos de resección con anastomosis por adenocarcinoma rectal con cuidados de RHMM: 66 varones y 38 mujeres, mediana de edad de 64 años (RIQ: 55-75). En el grupo A, se incluyó a los que se asoció ileostomía derivativa y en el B a aquellos sin ileostomía. RESULTADOS: Grupo A = 58, grupo B = 46 pacientes sin diferencias en edad, ASA, IMC, factores de riesgo, ni en el tipo de abordaje, laparoscópico en un 34%, si bien hubo más neoadyuvancia en el grupo A: 77,5 frente a 36,9%. En este grupo, la intervención habitual fue la exéresis total del mesorrecto (96%) y en el B la subtotal (90%). No hubo diferencias en las complicaciones postoperatorias (34,4 frente a 28,2%; p = 0,322) ni en la de dehiscencias anastomóticas (8,3 frente a 10,8%; p = 0,475), o íleo prolongado (20,7 frente a 10,9%; p = 0,140). Tampoco las hubo en la estancia postoperatoria (7,9 frente a 6,9 días; p = 0,058), reingresos (7 frente a 13,6%; p = 0,22), o en la estancia total incluyendo reingresos (8,4 frente a 9,1 días; p = 0,49). CONCLUSIONES: La asociación de una ileostomía no alarga la EP ni incrementa las complicaciones en pacientes intervenidos de resección rectal en régimen de RHMMP

PURPOSE: The association of a loop ileostomy decreases the severity of complications after rectal surgery but can increase the postoperative stay. The aim of this study is to investigate if a diverting ileostomy influences the postoperative outcomes in a series of patients included in a multimodal rehabilitation program (MMRP). METHODS: We analyzed a series of 104 patients that underwent elective surgery with primary anastomosis for rectal adenocarcinoma using a MMRP: 66 men and 38 women, with a median age of 64 (IQR: 55-75) years. Group A included patients with an associated loop ileostomy, and Group B, those without a protective stoma. RESULTS: Group A = 58, group B = 46 patients without differences in age, ASA, BMI and other risk factors, nor in the surgical approach (laparoscopic in 34%), although there were more neoadjuvant treatments in group A: 77.5 vs. 36.9%; P=.001. In group A, the most common operation was total mesorectal excision (96%) and in the B, a subtotal mesorectal excision (90%). There were no differences in postoperative complications (Group A 34.4 vs. group B28.2%; P=.322), anastomotic leaks (8.3 vs. 10.8%; P=.475), or postoperative ileus (20.7 vs. 10.9%; P=.140), neither in postoperative stay (7.9 vs. 6.9 days; P= .058, readmissions (7 vs. 13.6%; P= .22), or postoperative stay, including readmissions (8.4 vs. 9.1 days; P= .49). CONCLUSIONS: The association of a loop ileostomy does not extend the length of stay nor increases the rate of complications in patients that underwent a rectal resection with anastomosis included in a MMRP

Impact of a diverting stoma in an enhanced recovery programme for rectal cancer.

PURPOSE: The association of a loop ileostomy decreases the severity of complications after rectal surgery but can increase the postoperative stay. The aim of this study is to investigate if a diverting ileostomy influences the postoperative outcomes in a series of patients included in a multimodal rehabilitation program (MMRP). METHODS: We analyzed a series of 104 patients that underwent elective surgery with primary anastomosis for rectal adenocarcinoma using a MMRP: 66 men and 38 women, with a median age of 64 (IQR: 55-75) years. Group A included patients with an associated loop ileostomy, and Group B, those without a protective stoma. RESULTS: Group A = 58, group B = 46 patients without differences in age, ASA, BMI and other risk factors, nor in the surgical approach (laparoscopic in 34%), although there were more neoadjuvant treatments in group A: 77.5 vs. 36.9%; P=.001. In group A, the most common operation was total mesorectal excision (96%) and in the B, a subtotal mesorectal excision (90%). There were no differences in postoperative complications (Group A 34.4 vs. group B28.2%; P=.322), anastomotic leaks (8.3 vs. 10.8%; P=.475), or postoperative ileus (20.7 vs. 10.9%; P=.140), neither in postoperative stay (7.9 vs. 6.9 days; P= .058, readmissions (7 vs. 13.6%; P= .22), or postoperative stay, including readmissions (8.4 vs. 9.1 days; P= .49). CONCLUSIONS: The association of a loop ileostomy does not extend the length of stay nor increases the rate of complications in patients that underwent a rectal resection with anastomosis included in a MMRP.

Análisis de nuestra experiencia mediante el uso de resonancia magnética dinámica pelviana en la evaluación del síndrome de defecación obstructiva / Analysis of experience in the use of dynamic pelvic magnetic resonance imaging in the assessment of obstructive defaecation syndrome

Introducción El diagnóstico etiológico del síndrome de defecación obstructiva (DO) requiere, entre otros, de métodos de imagen El objetivo del presente estudio es analizar y comparar descriptivamente con la exploración clínica los hallazgos de la resonancia magnética pelviana dinámica (RMPD) en pacientes con DO. Material y métodos Se efectúa un estudio prospectivo comparativo entre la exploración física y la RMPD, analizando los resultados de forma descriptiva. Se incluyeron 30 pacientes (2 hombres y 28 mujeres), con una mediana de edad de 60 años (rango 23-76), con sintomatología de DO a los que se efectuó anamnesis y exploración física detalladas y una RMPD. Se analizaron alteraciones funcionales (anismo) y morfológicas (rectocele, enterocele, intususcepción, etc.).ResultadosLa exploración física no objetivó anomalías en 6 pacientes (20%). En 21 (70%) se diagnosticó un rectocele y en 2 (6,7%) un prolapso mucoso rectal. La RMPD evidenció laxitud del suelo pelviano en 22 casos (73,3%), enterocele en 4 (13,3%), sigmoidocele en 2 (6,7%), intususcepción en 8 (26,7%), prolapso mucoso rectal en 4 (13,3%), anismo en 3 (10%) y cistocele en 4 (13,3%). El rectocele fue el diagnóstico más frecuente, dándose en 26 pacientes (86,6%).Conclusiones La resonancia magnética ofrece una evaluación pelviana global con gran definición de los tejidos, no utiliza radiaciones ionizantes, es bien tolerada y nos aporta información complementaria para llegar al diagnóstico y plantear el mejor tratamiento en el síndrome de DO. Son necesarios estudios comparativos amplios frente a videodefecografía, considerada actualmente la técnica gold standard, que demuestren su superioridad o no respecto a esta (AU)

Introduction The aetiological diagnosis of obstructive defaecation syndrome (ODS) requires, among others, imaging tests. The purpose of this study is to descriptively analyse and compare the findings of dynamic pelvic magnetic resonance imaging (DPMRI) with the clinical examinations in patients with ODS. Material and methods A prospective comparative study was made between the physical examination and the DPMRI, with a descriptive analysis of the results. A total of 30 patients were included (2 males and 28 females), with a median age of 60 (range 23-76) years, with symptoms of ODS. An anamnesis and detailed physical examination and a DPMRI were performed on all of them. Functional (anismus) and morphological changes (rectocele, enterocele, intussusception, etc.), were analysed. Results The physical examination did not detect anomalies in 6 (20%) patients. A rectocele was diagnosed in 21 (70%) of the cases, and 2 (6.7%) a rectal mucosal prolapse. The DPMRI showed evidence of pelvic floor laxity in 22 (73.3%) cases, an enterocele in 4 (13.3%), a sigmoidocele in 2 (6.7%), intussusception in 8 (26.7%), rectal mucosal prolapse in 4 (13.3%), anismus in 3 (10%), and a cystocele in 4 (13.3%). The rectocele was the most frequent diagnosis, being given in 26 (86.6%) patients. Conclusions Magnetic resonance imaging provides an overall pelvic assessment with good definition of the tissues, and does not use ionising radiation, is well tolerated, and provides us with complementary information to arrive at the diagnosis, and establish the best treatment for ODS. Larger studies comparing videodefaecography (VD), currently considered the Gold Standard technique, are needed to be able to demonstrate whether it is superior or not to DPMRI (AU)

[Analysis of experience in the use of dynamic pelvic magnetic resonance imaging in the assessment of obstructive defaecation syndrome]. / Análisis de nuestra experiencia mediante el uso de resonancia magnética dinámica pelviana en la evaluación del síndrome de defecación obstructiva.

INTRODUCTION: The aetiological diagnosis of obstructive defaecation syndrome (ODS) requires, among others, imaging tests. The purpose of this study is to descriptively analyse and compare the findings of dynamic pelvic magnetic resonance imaging (DPMRI) with the clinical examinations in patients with ODS. MATERIAL AND METHODS: A prospective comparative study was made between the physical examination and the DPMRI, with a descriptive analysis of the results. A total of 30 patients were included (2 males and 28 females), with a median age of 60 (range 23-76) years, with symptoms of ODS. An anamnesis and detailed physical examination and a DPMRI were performed on all of them. Functional (anismus) and morphological changes (rectocele, enterocele, intussusception, etc.), were analysed. RESULTS: The physical examination did not detect anomalies in 6 (20%) patients. A rectocele was diagnosed in 21 (70%) of the cases, and 2 (6.7%) a rectal mucosal prolapse. The DPMRI showed evidence of pelvic floor laxity in 22 (73.3%) cases, an enterocele in 4 (13.3%), a sigmoidocele in 2 (6.7%), intussusception in 8 (26.7%), rectal mucosal prolapse in 4 (13.3%), anismus in 3 (10%), and a cystocele in 4 (13.3%). The rectocele was the most frequent diagnosis, being given in 26 (86.6%) patients. CONCLUSIONS: Magnetic resonance imaging provides an overall pelvic assessment with good definition of the tissues, and does not use ionising radiation, is well tolerated, and provides us with complementary information to arrive at the diagnosis, and establish the best treatment for ODS. Larger studies comparing videodefaecography (VD), currently considered the Gold Standard technique, are needed to be able to demonstrate whether it is superior or not to DPMRI.

Hemoperitoneo por divertículo solitario de sigma / Hemoperitoneum due to solitary sigmoid diverticulum

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