[Robot assisted Frykman-Goldberg procedure. Case report]. / Procedimiento de Frykman-Goldberg asistido por robot. Reporte de caso.

BACKGROUND: Rectal prolapse is defined as the protrusion of the rectal wall through the anal canal; with a prevalence of less than 0.5%. The most frequent symptoms include pain, incomplete defecation sensation with blood and mucus, fecal incontinence and/or constipation. The surgical approach can be perineal or abdominal with the tendency for minimal invasion. Robot-assisted procedures are a novel option that offer technique advantages over open or laparoscopic approaches. CASE REPORT: 67 year-old female, who presented with rectal prolapse, posterior to an episode of constipation, that required manual reduction, associated with transanal hemorrhage during defecation and occasional fecal incontinence. A RMI defecography was performed that reported complete rectal and uterine prolapse, and cystocele. A robotic assisted Frykman-Goldberg procedure wass performed. DISCUSSION: There are more than 100 surgical procedures for rectal prolapse treatment. We report the first robot assisted procedure in Mexico. Robotic assisted surgery has the same safety rate as laparoscopic surgery, with the advantages of better instrument mobility, no human hand tremor, better vision, and access to complicated and narrow areas. CONCLUSION: Robotic surgery as the surgical treatment is a feasible, safe and effective option, there is no difference in recurrence and function compared with laparoscopy. It facilitates the technique, improves nerve preservation and bleeding. Further clinical, prospective and randomized studies to compare the different minimal invasive approaches, their functional and long term results for this pathology are needed.

[Initial experience in robot-assisted colorectal surgery in Mexico]. / Experiencia inicial en cirugía colorrectal asistida por robot en México.

BACKGROUND: Colorectal surgery has advanced notably since the introduction of the mechanical suture and the minimally invasive approach. Robotic surgery began in order to satisfy the needs of the patient-doctor relationship, and migrated to the area of colorectal surgery. An initial report is presented on the experience of managing colorectal disease using robot-assisted surgery, as well as an analysis of the current role of this platform. MATERIAL AND METHODS: A retrospective study was conducted in order to review five patients with colorectal disease operated using a robot-assisted technique over one year in the initial phase of the learning curve. Gender, age, diagnosis and surgical indication, surgery performed, surgical time, conversion, bleeding, post-operative complications, and hospital stay, were analysed and described. A literature review was performed on the role of robotic assisted surgery in colorectal disease and cancer. RESULTS: The study included 5 patients, 3 men and 2 women, with a mean age of 62.2 years. Two of them were low anterior resections with colorectal primary anastomoses, one of them extended with a loop protection ileostomy, a Frykman-Goldberg procedure, and two left hemicolectomies with primary anastomoses. The mean operating time was 6hours and robot-assisted 4hours 20minutes. There were no conversions and the mean hospital stay was 5 days. CONCLUSION: This technology is currently being used worldwide in different surgical centres because of its advantages that have been clinically demonstrated by various studies. We report the first colorectal surgical cases in Mexico, with promising results. There is enough evidence to support and recommend the use of this technology as a viable and safe option.

[Biofeedback effectiveness in patients with fecal incontinence]. / Efectividad del biofeedback en pacientes con incontinencia fecal.

BACKGROUND: Fecal incontinence is defined as an involuntary bowel movement through the anal canal in inadequate time and place. There are different types of therapies for the management of fecal incontinence, being biofeedback therapy one of the most effective techniques. The aim of this study was to evaluate the necessary number of sessions of biofeedback electromyographyc therapy to achieve the maximum sphincteric complex contraction. METHODS: Descriptive, retrospective and longitudinal study. 65 patients with fecal incontinence were included. Weekly electromyographyc biofeedback therapies were applied, with a maximum of 6, in which the sphincteric complex contraction was measured. A two ways Friedman analysis was made to determine the significant differences between the sessions. RESULTS: A total of 65 patients were evaluated for fecal incontinence. The values for pelvic floor contraction were significantly higher in the third session, and did not show any significant difference in posterior sessions. CONCLUSION: The maximum contraction of the sphicnteric complex was achieved in the third weekly biofeedback session, without any significant differences in the posterior sessions.

Introducción: el origen anómalo de la arteria coronaria izquierda del seno coronario derecho (ACAOS) se caracteriza porque la arteria coronaria principal izquierda se origina anómalamente del seno de valsalva aórtico coronario derecho y cuyo trayecto puede seguir cuatro diferentes caminos hacia el lado izquierdo del corazón. Caso clínico: masculino de 73 años de edad, que ingresó al hospital por dolor precordial de tipo opresivo, intensidad 10/10 con irradiación a brazo izquierdo y cuello, acompañado de diaforesis y nausea. El diagnóstico fue de un síndrome isquémico coronario agudo sometido a terapia trombolítica Su evolución posterior fue no satisfactoria debido a diferentes complicaciones que lo llevaron a la muerte. Conclusiones: el diagnóstico del origen anómalo de la arteria coronaria izquierda del seno opuesto (ACAOS), se establece únicamente a través de métodos de diagnósticos como la angiotomografía computada cardiaca o un cateterismo cardiaco como parte del abordaje de un síndrome isquémico coronario agudo que permiten establecer las características morfológicas de las arterias coronarias como las diferentes variantes anatómicas y sus características particulares respecto a las estructuras adyacentes.

Appendiceal diverticulum associated with chronic appendicitis.

INTRODUCTION: Appendiceal diverticulosis is a rare entity, with a global incidence between 0.004% and 2.1% of all appendectomies. It has been related with an elevated risk of perforation in comparison to acute appendicitis, as well as an increased risk for synchronic appendicular cancer in 48% of the cases, and colonic cancer in 43%. The incidence of chronic appendicitis has been reported in 1.5% of all appendicitis cases. PRESENTATION OF CASE: We present a 73-year-old female, with no relevant familial history, who presented due to a four-month-long oppressive, moderate pain in the lower right abdominal quadrant without irradiation or any other accompanying symptoms. DISCUSSION: The documented incidence of appendiceal diverticula and chronic appendicitis by themselves is low; therefore the presence of both entities at the same time is extremely rare. CONCLUSION: We present a case in which both diagnoses concurred in the same patient. The relevance of this case relies on the importance of the adequate knowledge of these pathologies, so we can approach them correctly. Although it does not represent an absolute surgical emergency, appendectomy represents the first therapeutic option.

Intussusception secondary to a carcinoid tumor in an adult patient.

INTRODUCTION: Intussusception in adult patients represents 5% of all intussusceptions and 1-5% of bowel obstructions in adults. In contrast to pediatric patients, 90% of the time, in adults, it's caused by well-established pathologic mechanisms, such as carcinoma, polyps, diverticula, Meckel diverticula, stenosis, or benign neoplasms. Small intestine intussusceptions are more frequent, but colonic intussusceptions are caused 50% of the time by malignant neoplasms, especially adenocarcinoma. PRESENTATION OF CASE: We present a 70-year-old woman, with no relevant familial history, who presented with a 3-day symptomatology consisting of epigastric, colic, diffuse, abdominal pain of moderate intensity, which progressed till reaching a severe intensity, also referring abdominal distension, nausea, and gastrointestinal-content vomits. DISCUSSION: In adult patients, the exact mechanism of intussusception is unknown in 8-20% of the cases, however, secondary intussusception can occur with any lesion of the intestinal wall or any irritant factor in its lumen that alters normal peristaltic activity and that could serve as a trigger to start an intussusception of one bowel segment over another the most common site is the small intestine. CONCLUSION: Intussusception represents an unusual problem in adult patients; it requires a high clinical suspicion, mainly as a differential diagnosis in patients with intestinal obstruction, and it clinically presents as a subacute or chronic illness. CT represents the most useful diagnostic tool. An attempt to perform reduction procedures in small intestine intussusceptions can be done, however, in ileocolic or colonic intussusceptions, a formal resection of the segment is recommended.

Colonic tuberculosis in an immunocompetent patient.

INTRODUCTION: One-third of the world's population is infected with tuberculosis (TB), with intestinal TB representing the sixth most common presentation of extrapulmonary TB. The diagnosis of intestinal TB is a challenge for physicians due to its diverse clinical manifestations that mimic other infectious, autoimmune, and neoplastic disorders, and is thus rarely considered as the causative agent of disease. PRESENTATION OF CASE: We present a 55-year-old male with no relevant familial history, who presented due to a loss of 10kg of weight in 2 months accompanied by nocturnal diaphoresis and continuous abdominal distension. DISCUSSION: The incidence and the severity of intestinal TB are increased in immunosuppressed patients and more rapidly progress due to deficient immune response. However, our immunocompetent had severe progression resulting in surgery less than a month after the diagnosis was made. CONCLUSION: While the diagnosis of intestinal TB, and specifically colonic TB, is difficult and is almost never the first diagnosis entertained outside the immunocompromised population, we present a rare case in which the disease presents in an immunocompetent patient.