The Relevance of the Excessive Perineal Descent in the Obstructed Defecation Syndrome: A Prospective Study of 141 Patients.

BACKGROUND: Despite the widely accepted association between excessive straining and perineal descent, the clinical significance of perineal descent in patients with obstructed defecation syndrome is still unclear. OBJECTIVE: This study aimed to evaluate the prevalence of pathological perineal descent in patients with obstructed defecation syndrome and the impact of perineal descent on symptoms severity. DESIGN: This was a prospective multicenter uncontrolled study. SETTINGS: The study involved 3 hospital pelvic-care centers and was conducted from January 2018 to January 2022. PATIENTS: The study included 141 consecutive adult patients with an obstructed defecation syndrome score of 9 or more and no evidence of organic GI pathology. All the patients underwent dynamic pelvic MRI and, in case of suspected paradoxical puborectalis contraction, anal manometry. MAIN OUTCOME MEASURES: Main outcome measures were the prevalence of excessive perineal descent and the correlation between perineal descent and obstructed defecation syndrome score. RESULTS: One hundred twenty-eight patients (90.7%) completed magnetic resonance examination and were included in the analysis. Of these, 18 patients (14.1%) had a physiological perineal descent and 110 (85.9%) had an excessive perineal descent. Excessive perineal descent was found in 46.1% of patients (12/26) with MRI signs of paradoxical puborectalis contraction and in 96% of patients (98/102) with normal puborectalis relaxation. In this latter group of patients, a good correlation between obstructed defecation syndrome score and maximum perineal descent during straining was found (Spearman r test: 0.68; p < 0.0001). LIMITATIONS: The study was limited by the small sample size and by the strong selection of the study population. CONCLUSIONS: Excessive perineal descent is a common finding in patients with obstructed defecation syndrome and high symptoms score, occurring almost consistently in patients without paradoxical puborectalis contraction. In these patients, the maximum perineal descent seems to be well correlated with symptoms severity. See Video Abstract at http://links.lww.com/DCR/C135 . LA RELEVANCIA DEL DESCENSO PERINEAL EXCESIVO EN EL SNDROME DE DEFECACIN OBSTRUIDA UN ESTUDIO PROSPECTIVO DE PACIENTES: ANTECEDENTES:A pesar de la asociación ampliamente aceptada entre el esfuerzo excesivo y el descenso perineal, la importancia clínica del descenso perineal en pacientes con síndrome de defecación obstruida aún no está clara.OBJETIVO:Evaluar la prevalencia del descenso perineal patológico en pacientes con síndrome de defecación obstruida y el impacto del descenso perineal en la severidad de los síntomas.DISEÑO:Este fue un estudio prospectivo multicéntrico no controladoENTORNO CLINICO:El estudio involucró a tres centros hospitalarios de atención pélvica y se llevó a cabo entre enero de 2018 y enero de 2022.PACIENTES:El estudio incluyó a 141 pacientes adultos consecutivos con puntuación del síndrome de defecación obstruida ≥ 9 y sin evidencia de patología gastrointestinal orgánica. A todas las pacientes se les realizó resonancia magnética pélvica dinámica y, en caso de sospecha de contracción puborrectal paradójica, manometría anal.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron la prevalencia del descenso perineal excesivo y la correlación entre el descenso perineal y la puntuación del síndrome de defecación obstruida.RESULTADOS:Ciento veintiocho (90,7%) pacientes completaron el examen de resonancia magnética y fueron incluidos en el análisis. De estos, 18 (14,1%) presentaron descenso perineal fisiológico y 110 (85,9%) descenso perineal excesivo. Se encontró descenso perineal excesivo en el 46,1% (12/26) de los pacientes con signos de contracción puborrectal paradójica en la resonancia magnética y en el 96% (98/102) de los pacientes con relajación puborrectal normal. En estos últimos pacientes se encontró una buena correlación entre la puntuación del síndrome de defecación obstruida y el descenso perineal máximo durante el esfuerzo (prueba r de Spearman: 0,68; p < 0,0001).LIMITACIONES:El estudio estuvo limitado por el pequeño tamaño de la muestra y por la fuerte selección de la población de estudio.CONCLUSIONES:El descenso perineal excesivo es un hallazgo común en pacientes con síndrome de defecación obstruida y alto puntaje de síntomas, ocurriendo casi constantemente en pacientes sin contracción puborrectal paradójica. En estos últimos pacientes el descenso perineal máximo parece estar bien correlacionado con la severidad de los síntomas. Consulte Video Resumen en http://links.lww.com/DCRC135 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Safety and effectiveness of minimal sphincterotomy in the treatment of female patients with chronic anal fissure.

To evaluate the outcome of a left lateral internal sphincterotomy extended for 20% of total sphincter length in female patients with chronic anal fissure, high anal resting pressure and normal preoperative anal continence. Between January 2014 and January 2018 all the female patients with chronic anal fissure showing failure of medical therapy, perfect anal continence (Cleveland Clinic Florida incontinence score = 0) and high anal resting pressure underwent a lateral internal sphincterotomy extended for 1/5 of total lateral sphincter length, basing on the preoperative measurements by three-dimensional endoanal ultrasound. Postoperative follow-up included clinical assessment at 3, 6 and 12 months associated with manometric and ultrasonographic evaluation at 6 months. Thirty-two patients, [median age 45 (range 19-68)] were included and, of these, 2 (6.2%) were lost to follow-up. At 6 month follow-up success rate was 93.3% (28/30) and continence score was 0 in all the patients. Two patients (6.2%) with poor outcome showed incomplete sphincterotomy at EAUS and underwent re-surgery. At three-dimensional endoanal ultrasound the median length of sphincterotomy was 6 mm (5-8.2). At 12 month follow-up the success rate was 100% and Cleveland Clinic Florida incontinence score remained 0 in all the cases. Open left lateral internal sphincterotomy extended for about 20% of total left lateral internal sphincter length seems to be safe and effective in the treatment of chronic anal fissure in suitable female patients achieving a high success rate without compromising anal continence.

Penetrating cardiac injuries. Two case reports.

INTRODUCTION: Penetrating cardiac injuries is still a diagnostic problem at this time. Their management requires immediate surgical intervention and excellent surgical critical care postoperatively. PRESENTATION OF CASES: A 15-year old male patient was stabbed with a knife to the right chest. The chest radiograph showed an haemothorax and the angiography showed an intercostals artery and a right auricle injury. After an emergency operation the patient was released home in good condition after the toracotomy had healed. A 19-year old male patient was stabbed with a knife to the chest more than once. By a left toracotomy we sutured the lesion of the left ventricle with multiple single stitch in non-absorbable suture, we covered the suture with a sealant. The patient released home in 24 days. DISCUSSION: Penetrating cardiac injuries is one of the leading cause of death from urban violence. To evaluate a thoracic trauma with cardiac injury it's clear the use of thorax X-ray and multislice angio-Tc scan. Echocardiography has clearly emerged for the diagnosis in patients haemodynamically stable. When the patient is haemodynamically unstable the emergency thoracotomy is mandatory. CONCLUSION: Despite the high mortality of penetrating cardiac injuries new surgical and radiological tecniques may help surgeon to save this patients.

[Mesenteric Castleman's disease and inflammatory fibroid polyp of the stomach: a case report and review of the literature]. / Malattia di Castelman mesenterica e polipo fibroide infiammatorio dello stomaco: associazione in un caso clinico e revisione della letteratura.

Castleman's disease is a very rare disease that causes many problems both in diagnosis and therapy. It is often associated with other diseases and can develop in any part of the body. Castleman's disease can be classified as uni-centric or multicentric based on clinical and radiological findings, as hyaline-vascular or plasma-cell based on the histological aspect, and as HIV-related or non-HIV-related, based on the HIV status of the patient. An inflammatory fibroid polyp is a very rare benign lesion that can develop anywhere in the gastrointestinal tract. Such polyps are most commonly found in the gastric antrum and usually occur in 50- to 60-year-old people. The authors report the unusual finding of mesenteric Castleman's disease and an inflammatory fibroid polyp of the stomach in a 41-year-old woman.