Prospective multicenter trial comparing echodefecography with defecography in the assessment of anorectal dysfunction in patients with obstructed defecation.

BACKGROUND: Defecography is the gold standard for assessing functional anorectal disorders but is limited by the need for a specific radiologic environment, exposure of patients to radiation, and inability to show all anatomic structures involved in defecation. Echodefecography is a 3-dimensional dynamic ultrasound technique developed to overcome these limitations. OBJECTIVE: This study was designed to validate the effectiveness of echodefecography compared with defecography in the assessment of anorectal dysfunctions related to obstructed defecation. DESIGN: Multicenter, prospective observational study. PATIENTS: Women with symptoms of obstructed defecation. SETTING: Six centers for colorectal surgery (3 in Brazil, 1 in Texas, 1 in Florida, and 1 in Venezuela). INTERVENTIONS: Defecography was performed after inserting 150 mL of barium paste in the rectum. Echodefecography was performed with a 2050 endoprobe through 3 automatic scans. MAIN OUTCOME MEASURES: The κ statistic was used to assess agreement between echodefecography and defecography in the evaluation of rectocele, intussusception, anismus, and grade III enterocele. RESULTS: Eighty-six women were evaluated: median Wexner constipation score, 13.4 (range, 6-23); median age, 53.4 (range, 26-77) years. Rectocele was identified with substantial agreement between the 2 methods (defecography, 80 patients; echodefecography, 76 patients; κ = 0.61; 95% CI = 0.48-0.73). The 2 techniques demonstrated identical findings in 6 patients without rectocele, and in 9 patients with grade I, 29 with grade II, and 19 patients with grade III rectoceles. Defecography identified rectal intussusception in 42 patients, with echodefecography identifying 37 of these cases, plus 4 additional cases, yielding substantial agreement (κ = 0.79; 95% CI = 0.57-1.0). Intussusception was associated with rectocele in 28 patients for both methods (κ = 0.62; 95% CI = 0.41-0.83). There was substantial agreement for anismus (κ = 0.61; 95% CI = 0.40-0.81) and for rectocele combined with anismus (κ = 0.61; 95% CI = 0.40-0.82). Agreement for grade III enterocele was classified as almost perfect (κ = 0.87; 95% CI = 0.66-1.0). LIMITATIONS: Echodefecography had limited use in identification of grade I and II enteroceles because of the type of probe used. CONCLUSIONS: Echodefecography may be used to assess patients with obstructed defecation, as it is able to detect the same anorectal dysfunctions found by defecography. It is minimally invasive and well tolerated, avoids exposure to radiation, and clearly demonstrates all the anatomic structures involved in defecation.

Colostomía perineal pseudocontinente / Pseudocontinent perineal colostomy

Presentar la técnica quirúrgica de la colostomía perineal continente, como una alternativa en la operación de Miles, realizada en el Servicio de Cirugía II del Hospital Domingo Luciani. IVSS-Caracas. Se trata de un paciente masculino de 63 años, quien consultó por sangrado rectal y trastornos evacuatorios. Al examen físico se evidenció una lesión exofítica y friable a 1,5 cms del margen anal y que ocupaba el 50 por ciento de la luz. La biopsia reportó un adenocarcinoma de recto moderadamente diferenciado infiltrante. Diagnóstico: adenocarcinoma del canal anal T3N2M0. Recibió neoadyuvancia. Se practicó en un primer tiempo quirúrgico resección abdónimo-perineal más una colostomía perineal y en un segundo tiempo la maduración de la colostomía. Evoluciona satisfactoriamente con un manejo adecuado de la colostomía. La colostomía perianeal es una buena alternativa en la operación de Miles. Se debe reservar para pacientes jóvenes o mayores, en buenas condiciones físicas, buen nivel cognoscitivo y sin radioterapia postoperatoria.