Importancia de la exploración física y técnicas de imagen en la valoración diagnóstica de las fístulas de ano

Aim

The study was designed to determine the role of clinical examination and imaging techniques in the diagnosis of anorectal fistula.

Material and methods

We performed an observational study with prospective recruiting using the data of 120 patients, by means of clinical evaluation by an experienced coloproctologist surgeon (EE), a surgeon without special training in coloproctology (CE), and examination under anaesthesia (SE), endoanal ultrasound (EAU) and magnetic resonance (MR), using the surgical findings as a reference.

Results

SE was significantly better than EE or CE for detecting an internal opening (IO), primary track and abscess cavities (AC). EAU was significantly more sensitive and accurate than the EE in identifying an IO, and AC, but not compared to the SE. MR was more sensitive than the EE in the identification of the IO, transphincter and suprasphincter tracks and AC with no significant differences compared to EAU, and more sensitive than the SE to detect AC.

Conclusions

Examination under anaesthesia still has a place in the evaluation of anorectal fistula. Imaging methods are an occasional complement to a clinical evaluation that can help the less experienced to decide the appropriate treatment, particularly when a complex fistula is suspected.     

Descripción de los hallazgos de la ecografía endoanal en pacientes con incontinencia fecal mediante un sistema de puntuación

Introduction

The main aim of the study was to apply a severity classification of sphincter lesions detected by endoanal ultrasound using Starck score in patients who suffered faecal incontinence.

Material and method

Data were analysed on 133 patients with faecal incontinence. Those in whom anal sphincter lesions were detected by endoanal ultrasound are described and their corresponding scores according to Starck classification calculated. This system scores severity of detected sphincter lesions from 0 to 16, involving the three axes of the anal canal. Patient demographic characteristics and anorectal manometry results were also analysed. The relationship between this score, patient gender and age, and anorectal manometric results were also analysed.

Results

A total of 83 (62.4%) patients had some type of anal sphincter lesion. The presence of sphincter defects was not related to gender (P=0.172), although it did correlate with younger ages (P=0.028). The severity of anal sphincter damage by Starck score did not show significant correlation to gender (P=0.327) or to the age (P=0.350) of patients. However, a significant correlation was detected between Starck score and anal resting pressure (P=0.008) or anorectal squeeze pressure (P=0.011).

Conclusions

The presence of anal sphincter injuries could be well defined by Starck score in patients with faecal incontinence. Severity of damage scored by Starck correlated with anorectal manometric results.     

Uso de terapia con presión negativa en heridas con fístulas entéricas

Objective

Negative pressure therapy (VAC, vacuum assisted closure) is a method used still in our country. It consists of a system of aspirating a wound by means of a piece of foam and a few adhesive films. It allows the treatment of complex wounds, included (although this is still controversial) those with intestinal fistulas. We present 3 cases of treatment with VAC in this situation and a review of the published literature.

Patients and method

We have treated 10 patients, since VAC therapy was introduced into our centre of which 3 of whom had a fistula in the bed of the surgical wound. We describe the clinical information of the patients and the therapy that followed in each of the cases.

Results

Significant local clinical improvement of the disease, with control of the symptoms, was achieved in all 3 cases. We were able to re-operate to close the fistula in one of the patients, with subsequent good progression of the wound. In the other two cases it gave them a better quality of life although both died due to the overall complexity of their situation.

Conclusions

VAC therapy, although controversial in the treatment of intestinal fistulas, can help to improve the local situation of the wounds, the comfort of the patients and their general situation.     

Empleo,eficacia y repercusión clínica del apoyo radiológico al diagnóstico de la apendicitis aguda

Objective

The aim of this study is to analyze the increasing need of radiological support in the diagnosis of acute appendicitis (AA), the clinical repercussions associated, and the parameters of diagnostic accuracy of ultrasound and computed tomography (CT) scan for AA.

Material and methods

Observational and analytical study. Cohort, patients operated on for suspected AA at a tertiary referral hospital. Pregnancy and <14 years were exclusion criteria. Study group: January 2010-December 2011 (n1 = 419). Control group: set of patients aged 18 to 65 years old operated between October 2001-September 2003 (n2 = 237). Variables analyzed in both groups: 1) percentage of radiological support for diagnosis of acute appendicitis; 2) sensitivity and positive predictive value (PPV) of ultrasound and CT scan; 3) rate of surgical explorations with negative result or with diagnosis other than acute appendicitis. Statistical analysis: SPSS software, χ² test, statistical significance accepted with P<.05, 95% confidence interval (95% CI) for the odds ratio (OR).

Results

Age, gender, percentage of atypical locations and gangrenous/perforated episodes were similar in both groups. The number of radiological examinations needed for diagnosis was significantly higher in the study group (78.8% vs. 30.4%, P<.0,000). Sensitivity was significantly superior for CT than for ultrasound scan (97% vs. 86%), but PPV was similar in both tests (92% vs. 94%). Surgical exploration percent values with diagnosis of acute appendicitis was significantly higher in the study group (94.5% vs. 88.6%; P<.006, OR 2.2; CI 95% 1.25-4).

Conclusions

CT and ultrasound scan are excellent diagnostic tools for acute appendicitis, and have contributed to a significant increase in surgical explorations with correct diagnosis.     

Utilidad de la tomografía computarizada para el diagnóstico de lesiones intestinales y mesentéricas en el trauma abdominal cerrado

Background

The frequency of bowel and mesenteric injuries is increasing. They are difficult to diagnose and delays in their diagnosis leads to a significantly increased morbidity and mortality. The aim of this study is to evaluate the usefulness of the computed tomography (CT) in the detection of blunt bowel and mesenteric injuries.

Method

Between January 2000 and October 2007, 79 patients with blunt abdominal trauma (60 men and 19 women) were included in our study. They underwent laparotomy after performing the abdominal CT. The CT findings were compared with the findings at laparotomy in order to determine the accuracy of the CT in the detection of bowel and mesenteric injuries.

Results

For the detection of bowel and mesenteric injuries we obtained for the CT: Sensitivity=84.2%, Specificity=75.6%, Positive Predictive Value =76.2%, Negative Predictive Value =83.8%, Positive Probability Value=3.45 and Negative Probability Value =0.21. Accuracy: 79.7%.

Conclusion

The abdominal CT is suitable for detecting bowel and mesenteric injuries following blunt abdominal trauma.     

Aplicación de las nuevas tecnologías en la enseñanza de la cirugía en la licenciatura de medicina

Introduction

The new methods of teaching, based on new technologies, already available in other educational and professional fields are gradually being introduced in our Medical Schools. The aim of our study is to present our initial experience in the introduction of a subject on the principles of surgery in our university.

Material and methods

The subject was offered voluntary to undergraduate students, with a maximum of 65 students per course during two consecutive academic years, while maintaining the traditional teaching with a formal lecture program with a different lecturer. The subject was designed with 60% virtuality on a WebCT platform and later in Moodle. The virtual subject was structured into teaching units, academically directed activities and communication tools. The subject was assessed in a report prepared by Cadiz University Department of Evaluation and Quality.

Results

There were 32 students in the 2005-2006 course and 62 in the following course. The mean activity of the students was: 602 accesses, 13 subjects for discussion forums and 20 e-mails between students and teachers. The students who participated in the Virtual subject have remarked that virtualisation make it more attractive and is an aid in the acquisition of knowledge. The data obtained from the report showed better results than the mean obtained in other subjects of the Department, School of Medicine and Cadiz University.

Conclusions

The virtual subject of principles of surgery has been well evaluated in our university campus. We believe that the provision of teaching tools and new communication models make an effective contribution to the teaching of surgery as a subject in the school of medicine curriculum.     

Mamoplastia de reducción en la cirugía del cáncer de mama

Reduction mammaplasty techniques enable the breast cancer surgeon to provide an integral surgical treatment, thus significantly increasing and improving surgical options. These techniques are used to correct problems after the conservative treatment of type 1 breast cancer and to achieve symmetry between the breasts after mastectomy. They are also the basis of cosmetic reconstruction techniques in conservative oncoplastic surgery.     

Neoplasia intraepitelial anal: resultados de la aplicación de un protocolo diagnóstico en pacientes de riesgo mediante el uso de citología anal

Introduction

Anal intraepithelial neoplasia is a precursor condition of squamous anal carcinoma. The groups at risk of this lesion are patients with anogenital condylomata, cervical dysplasia, human immunodeficiency virus infection and, in general, patients with HPV infection. The aim of this study was to analyse the results of a diagnostics protocol of Anal Intraepithelial Neoplasia in high risk population using anal cytology.

Patients and method

The protocol is based on a visit in the outpatient department, clinical interview, physical examination and anal cytology evaluated by Bethesda criteria. The cross-sectional observational study was designed to study the anal smear results and their relationship with risk factors.

Results

A total of 64 patients were included from January 2005 to December 2006. In the overall series, 25 patients have been diagnosed with abnormal anal cytology: 9 atypical squamous cells of undetermined significance (ASCUS), 15 low-grade and 1 high-grade squamous intraepithelial lesions. There were no significant associations between abnormal cytology results and the presence of anal condyloma (p=0.22). Neither were there statistical associations found with high risk-HPV infection (p=0.84), HIV infection (p=0.98) or tobacco use (p=0.14).

Conclusions

Our diagnostic protocol of anal intraepithelial neoplasia revealed 25% of patients with pre-invasive lesions of squamous anal cancer.     

Nuevos avances en el diagnóstico y el tratamiento de la displasia y el adenocarcinoma precoz en el esófago de Barrett

Periodic endoscopic follow-up is recommended after the diagnosis of Barrett's oesophagus, particularly in patients with dysplasia. The new endoscopic techniques show promising results in identifying areas suspected of housing high grade dysplasia and adenocarcinoma. Endoscopic resection of the mucosa has become a fundamental technique for the complete histological assessment of these lesions and is able to establish appropriate therapeutic decisions. Likewise, this technique may be the therapeutic option in patients with high grade dysplasia and adenocarcinoma, although its application must be complemented with ablation techniques such as radiofrequency to eliminate the residual Barrett's metaplasia. Oesophagectomy associated with lymphadenectomy is the option of choice in patients with submucosal adenocarcinoma. The diagnosis and treatment of patients with early onset high grade dysplasia and adenocarcinoma must be carried out with multidisciplinary teams who can evaluate each case individually. This strategy will enable the oesophagus to be preserved in many patients with high grade dysplasia and indicate oesophagectomy in selected cases.     

Carcinoma broncogénico en pacientes con trasplante de órgano sólido. Papel de la cirugía

Background

The incidence of neoplastic diseases is higher in patients undergoing solid organ transplant. However, the incidence of bronchogenic carcinoma (BC) is controversial. The objective of our study was to determine the incidence of BC in a large cohort of transplant patients and the role of surgery.

Material and methods

Until December 2006, 3596 patients underwent solid organ transplant at our institution; 24 (0.7%) patients subsequently developed BC, of which 6 (24%) were classified as clinical stage I and submitted to surgical treatment. Survival was estimated by the Kaplan-Meier method.

Results

Three patients received a liver transplant, two a kidney transplant and one a heart transplant. All were male and all had a smoking history. Mean age was 58.6 years. Two patients had cough, one accompanied by bloody expectoration, and BC was an incidental finding in the remaining cases. The interval between transplant and diagnosis of BC was 38.1 months. Epidermoid carcinoma was the most frequent histological type. Mean tumour size was 3.6 cm (range, 1.3-6). One tumour was classified as pathological stage IA, four as stage IB and one as IIB due to parietal pleural invasion. No patient died during the perioperative period and only one had a haemothorax which resolved with chest tube drainage. Mean hospital stay was 8.5 days (range, 7-11). The immunosuppression regimen was maintained continuously. In subsequent follow-up, one patient died from BC metastasis, one from sepsis, one from chronic renal failure, and three remained alive. The probability of survival at 5 years was 40%, and median survival was established at 5 years.

Conclusions

The incidence of BC in patients undergoing solid organ transplant and the proportion of patients diagnosed in early stages does not differ from non-transplant patients diagnosed with BC, which questions the role of immunosuppression in the genesis and aggressiveness of BC in transplant patients. Surgery may offer acceptable results in early stages, with acceptable rates of perioperative morbidity and mortality.     

Elegir a la cirugía como especialidad: Opiniones de los estudiantes de la Universidad de Buenos Aires sobre la cirugía y los cirujanos

Introduction

Since the number of applicants to residencies in general surgery in Argentina seems to be decreasing, we designed this work with the objective of studying the factors considered undesirable by students when choosing surgery as a specialty.

Material and methods

Between March and April 2012, one-hundred students were surveyed with a structured questionnaire with true/false binary answers in an observational case-control design. The survey contained 26 statements that made reference to characteristics of surgery as a specialty, or about the personality and lifestyle of surgeons, as they could be perceived by students. As a control group the same survey was applied to 20 surgeons who were in contact with the students and that could represent a role model for them during their rotation in surgery.

Results

Comparison between students and surgeons showed no difference in most answers, except in «surgery has poor reimbursement» (OR: 8,9; P=.0001), «there is not enough job demand» (OR: 8,1; P=.015), «surgery restrains intellectual development» (OR: 17,5; P=.014), «surgeons have too many non-scheduled activities» (OR: 9,36; P=.024), «they have a limited patient-physician relationship» (OR: 3,61; P=.009), «they have little time for family» (OR: 4,27; P=.036) and «they are exposed to infectious diseases» (OR: 5,90; P=.007).

Conclusions

Women would be as interested as men in working as surgeons; a remarkable fact when considering that the surgical specialties have been predominantly filled by men. The fact that surgeons mostly coincide with the views of students means that role models should be reviewed to promote vocations.     

Estudio prospectivo controlado y aleatorizado sobre la necesidad de la preparación mecánica de colon en la cirugía programada colorrectal

Introduction

Mechanical preparation of the colon (MPC) in colorectal surgery has been a dogma that has been questioned over the last few years. The objective of this study is to demonstrate that morbidity in scheduled colorectal surgery is the same or lower without MPC.

Material and method

Patients subjected to scheduled left colon and rectal surgery with primary anastomosis randomised into two groups. The “Preparation” group (MPC) received MPC and the “non-preparation” group (No-MPC) had only cleaning enemas. The variables collected were: demographic, oncological, nutritional, risk prediction models and morbidity-mortality.

Results

Of the 193 patients included: 69 received MPC and 71 did not; 89 patients with colocolic anastomosis (MPC, 38; no MPC, 51) and 50 colorectal (MPC, 31; no MPC, 19). Statistically significant differences were seen in the overall analysis in favour of “no preparation” as regards morbidity (43.55 % with MPC and 27% with No MPC) and nosocomial infection (27.5% and 11.4%). There was 11.6% wound infections in the MPC compared to 5.7% in the no MPC, which was not statistically significant. The only mortalities were in the MPC group 2/69 (2.9% of patients). As regards the location of the anastomosis, in the colocolics the differences were more pronounced, with statistically significant differences in the morbidity, anastomosis dehiscence, and nosocomial infection variables. The effect of no MPC was not so evident in colorectal anastomosis.

Conclusions

Our results suggest that there is no benefit in MPC before surgery in colocolic anastomosis. No-MPC is not associated with a higher morbidity in wound infection or anastomotic dehiscence. In colorectal anastomosis the differences are not so evident, therefore a much bigger series needs to be studied.     

Posición operatoria en cirugía colorrectal. La importancia de lo básico

Intra-operative positioning in colorectal surgery is very important from three points of view: the proper surgical approach and exposure, adequate anaesthetic requirements with maintenance of the airway, and the potential complications related to the position. In the present study, we analyse the indications, positioning, advantages and disadvantages of each operative position, their potential complications and how to avoid them. These complications can be of a diverse nature, the most common being injuries related to stretching or compression of peripheral nerves, followed by thromboembolic, haemodynamic, and ischaemic or compartmental syndromes related to ischaemia-reperfusion after a long time in the Trendelenburg position. Anaesthetists and surgeons should coordinate and take responsibility for the position of surgical patients.     

Invaginación intestinal en el adulto: presentación de un caso y revisión de la literatura médica española

Introduction

Intestinal invagination in the adult is an uncommon condition, often manifested by non-specific chronic or sub-acute symptoms. In the majority of occasions there is an organic lesion. There are currently no large patient series published in the literature to help define the management of these patients.

Material and method

A review of case series published in the Spanish literature. A data base of patients over 15 years old was designed. Data was extracted from national clinical cases using Internet resources. Our own recent clinical case is added.

Results

A series of 30 adults with intestinal invagination was obtained (29 cases from the review and one own). The median age was 45 years (19–84 years) and 17/30 (57%) were males. A total of 27/30 patients had abdominal pain and 8/30 (28%) cases had established intestinal obstruction. The preoperative diagnosis of invagination was made in 25/30 (83%) of patients. The invaginations were; enteroenteric, 61%; colocolic, 12%; enterocolic, 21%; and gastrojejunal, 6%. A total of 85% of the invaginations were associated with a proliferative lesion and 43% of the latter were malignant.

Conclusions

The diagnosis of invagination in the adult is usually made preoperatively. There are no data to support intestinal resection without performing a reduction. Resection must be the norm and the presence of lymph nodes is no argument to perform large resections.     

25 años de cirugía laparoscópica en España

Introduction

The introduction of laparoscopic surgery (LS) can be considered the most important advancement in our specialty in the past 25 years. Despite its advantages, implementation and consolidation has not been homogenous, especially for advanced techniques. The aim of this study was to analyse the level of development and use of laparoscopic surgery in Spain at the present time and its evolution in recent years.

Material and methods

During the second half of 2012 a survey was developed to evaluate different aspects of the implementation and development of LS in our country. The survey was performed using an electronic questionnaire.

Results

The global response rate was 16% and 103 heads of Department answered the survey. A total of 92% worked in the public system. A total of 99% perform basic laparoscopic surgery and 85,2% advanced LS. Most of the responders (79%) consider that the instruments they have available for LS are adequate and 71% consider that LS is in the right stage of development in their environment.

Conclusions

Basic laparoscopic surgery has developed in our country to be considered the standard performed by most surgeons, and forms part of the basic surgical training of residents. With regards to advanced LS, although it is frequently used, there are still remaining areas of deficit, and therefore, opportunities for improvement.     

Programa de formación del residente de cirugía en un laboratorio experimental de cirugía minimamente invasiva (CENDOS)

Introduction

The rapid development of laparoscopic surgery makes resident training programmes necessary.

Objective

To analyse the results of a structured programme of laparoscopic training in an experimental laboratory.

Material and method

From 2003 until 2007, we trained 11 general surgery residents for 20 h every 3 months, for three years. The practice consisted of suture and anastomosis in Endo-Trainer with animal organs, as well as laparoscopic techniques in live animals. In the Endo-Trainer practice we evaluated the time and quality of anastomosis performance. In laparoscopic techniques (cholecystectomy and anti-reflux surgery) a task table was evaluated, from 0 (no errors) to 100 (severe lesion).

Results

In total, 314 anastomosis were performed by the 11 residents, with a median of 28.5 per resident (24-42). The mean time for the first gastro-jejunal anastomosis was 135 min (100-140) and 65 min (57.5-105) for the first jejunal-jejunal anastomosis. Maximum learning was achieved after 45 training hours. There wer no appreciable ifferences between both types of anastomosis. There was inadequate anastomosis quality due to leakage in 17.1% during the learning period and 13.7% during the consolidation period. In the animal, 172 procedures were performed. In cholecystectomy and anti-reflux surgery the mean scores were 2.4 and 5.6 points, respectively. In the remaining procedures, subjectively evaluated by the monitors, the quality was adequate in 65%, deficient in 22% and highly deficient in 13%.

Conclusions

This structured programme of laparoscopic skills based on intestinal anastomosis allows for quicker resident training.     

Evolución del cierre de ileostomía en una unidad de cirugía colorrectal. Análisis comparativo según la técnica

Introduction

The objective of this study is to assess whether the results of loop ileostomy closure in terms of morbidity and hospital stay are influenced by the type of anastomosis and suture used.

Method

All patients who underwent loop ileostomy closure were reviewed. A retrospective cohort study comparing morbidity and hospital stay according to the type of anastomosis (TT/LL) and the type of suture (hand sewn/mechanical) was performed.

Results

From January 2003 to November 2011 a total of 167 loop ileostomy closures were analized. The groups were: type of anastomosis (TT 95/LL 72) and type of suture (manual 105/stapled 62). In 76% of the observed population the underlying disease was cancer. Mortality occurred in one case. The stratified morbidity analysis by type of complications showed no significant differences between the groups in terms of local (7.4% TT, LL 8.3%, 6.7% hand sewn, stapled 9.7%), general (TT 9.5%, 16.7% LL, hand sewn 6.7%, 6.5% stapled) and surgical (TT 15.8%, 19.4% LL, hand sewn 17.1%, 17.7% stapled) complications, nor in the rate of reoperations (TT 6.3%, 6.9% LL, hand sewn 6.7%, 6.5% stapled) and hospital stay in days (TT 7.8, 8 LL, hand sewn 8.6, stapled 6.7)

Conclusions

Closure of loop ileostomy can be performed regardless of the type of suture or anastomosis used, with the same rate of morbidity and hospital stay.     

Impacto de los colgajos transanales de avance en la continencia fecal

Objective

The aim of this study was the prospective evaluation of the functional results of a series endorectal advancement flaps in the treatment of complex anal fistulas.

Material and methods

A total of 90 patients were operated on for a complex anal fistula by means of fistulectomy and endorectal advancement flap. The functional results were evaluated using the Wexner continence scale and an anorectal manometry study before and after surgery.

Results

There were seven patients with fistula recurrence (7.7%) and the same surgical procedure was performed on five of them, resulting in healing in all cases. Significant reductions in maximum resting pressure (83.85±30.96 vs 46.51±18.67; p<0.001) and maximum squeeze pressure (220.97±100.21 vs 183.06±75.36; p<0.001) were seen 3 months after surgery. On the continence scale, 80% of patients had a normal continence with a value of 0 on thepostoperative Wexner scale, while 20% recorded changes in continence values, most of them lower than 3 points.

Conclusions

Endorectal advancement flap is an effective surgical procedure in complex anal fistulas treatment, with a low recurrence rate. Only 20% of the patients showed changes in the continence value.