Antonio Salvador

Rehabilitación mutimodal en cirugía colorrectal. Sobre la resistencia al cambio en cirugía y las demandas de la sociedad

Resumen El manejo perioperatorio es uno de los campos de la cirugia mas sujetos a la tradicion, y es dificil modificar actitudes clasicas incluso con la evidencia cientifica. Uno de los avances que mas ha contribuido a mejorar el resultado tras cirugia colorrectal es la rehabilitacion multimodal o fast-track, programa que pretende acelerar la recuperacion, reduciendo la morbilidad y acortando las estancias. Se basa en la actuacion conjunta de cirujanos, anestesistas y personal a cargo del paciente con el objetivo de disminuir la respuesta a las alteraciones fisiopatologicas inducidas por la agresion quirurgica. Aspectos como la ingesta preoperatoria de carbohidratos, evitar la preparacion de colon, reducir la fluidoterapia o mantener la normotermia son de gran importancia. Del mismo modo, la analgesia epidural, eliminacion de sondas y drenajes, alimentacion precoz o una cirugia menos invasiva pueden mejorar el ileo postoperatorio y otras complicaciones. Existe importante evidencia de que el uso conjunto de estas y otras medidas contribuye a una mejor recuperacion posquirurgica, aunque se sigue utilizandolas muy poco en la practica.

Recurrent pericarditis in a patient with ulcerative proctitis due to mesalazine suppositories

Dear Editor: Pericarditis is rarely reported in inflammatory bowel disease (IBD). The most frequent presentation is as acute pericarditis. It can arise as a true extraintestinal IBD event or as a secondary effect due to drug employment. We present a case of a recurrent pericarditis related to ulcerative colitis (UC) and induced with suppositories of mesalazine. A 54-year-old male was seen as an outpatient with scarce bloody diarrhea during the past 6 months. Clinical history reported hypertension, colecystectomy with adenocarcinoma in situ 7 years ago, upper gastrointestinal bleeding treated medically due to gastritis and a lupus-like reaction 20 years ago. Recently, diagnosed and treated with metformine due to diabetes type 2. The performance of a colonoscopy revealed a continuously inflamed mucosa up to the rectosigmoid junction and proven histology of UC without displastic lesions. Corticoid foamwas initiated for 2 weeks and then switched to mesalazine 1.5 g orally a day. After 3 weeks, he was admitted to hospital with chest pain, fatigue, and fever as high as 39oC. With the diagnosis of viral pericarditis, a chest X-ray was ordered and revealed an enlarged cardiac silhouette. Electrocardiogram was normal but echocardiogram detected pericardic effusion in the anterior and posterior space. Among the laboratory data of interest were hemoglobin 15.2 g, leucocytes 9.900 (51.6% neutrophils), eosinophils 0.9%, albumin 41.6 g/L globulin 32.2 g/L (albumin/globulin ratio=1.29), and ferritin 180.7 ng/ml. C-reactive protein 7.89 mg/L (slightly elevated) and erythrocyte sedimentation rate 10 mm. Treatment was commenced with 3 g daily for 7 days of acetilsalycilic acid. Oral mesalazine was stopped in the meanwhile. After the cardiac episode, the patient was managed with 500 mg mesalazine in suppository as maintenance therapy. After 3 weeks, he presented with a second episode of pericarditis. A chest CT revealed a thickened pericardium. Rheumatoid factor, antinuclear, anti-DNA, and antimitochondrial antibodies were negative or in normal range. Complement C3 143 mg/dl, complement C4 23.5 mg/dl, complement CH50 55.5U/mL was in normal ranges. Since the withdrawal of mesalazine no further pericarditis episode developed. Cardiac involvement can be associated with IBD especially with UC being pericarditis the most frequent cardiac feature, although it may affect the myocardium or even both structures. Both cutaneous test with mesalazine and test for linfoblastic proliferation were negative, but do not exclude the diagnosis of drug-induced pericarditis. The gold standard for the diagnosis of drug allergy is a provocation test with the potential agent. This method of course would not be ethical at all and implies a great risk for the patient. J. C. Bernal-Sprekelsen (*) European Board of Coloproctology, Department of General Surgery, Hospital General de Requena, Pasaje Casablanca s/n, 46340 Requena, Spain e-mail: jcbernal@comv.es

Preparación intestinal selectiva en un programa de rehabilitación multimodal. Influencia en el confort preoperatorio y resultados tras cirugía colorrectal

INTRODUCTION Despite there being no evidence of the advantages of its use, mechanical bowel preparation (MBP) continues to be routine in colorectal surgery. Our objective is to analyse the impact of its selective use, as regards patient comfort and results, comparing a perioperative multimodal rehabilitation program (MMRH) with conventional care (CC). MATERIAL AND METHODS A prospective study of 108 patients proposed for elective surgery, assigned consecutively 2:1 to an MMRH protocol which only included MBP in rectal surgery with low anastomosis, or to CC in whom MBP was used except in right colon surgery. We also studied two Groups (A and B) with and without the use of MBP. Their tolerance, results and postoperative recovery variables were analysed. RESULTS Thirty-nine patients were included in Group A, and 69 in Group B. A MMRH protocol was used in another 69 patients. The Group A patients had more abdominal pain, anal discomfort, nausea and thirst, but there were no differences as regards, death, overall or local complications, whilst there was less complications, suture failures and death in the MMRH when compared with CC Group (P<.05). There were no advantages observed in the use of MBP as regards the start of bowel movements, tolerance to diet or hospital stay, but these parameters were favourable to the MMRH when compared with CC Group. CONCLUSIONS The restriction of MBP is safe, and associated with an MMRH program, contributes to a faster and more comfortable recovery, without increasing complications.

Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico

INTRODUCTION THE AIM: was to analyse the stoma reversal rate after surgery for complicated acute diverticulitis (CAD), and more specifically the end-stoma-reversal, as well as the delay, feasibility, complications and risk factors for stoma maintenance. METHODS A multicentre retrospective study of patients who had undergone urgent surgery for CAD with stoma formation in ten hospitals during a period of 6 years. The frequency of reversal over time and the factors affecting the decision for reversal were analysed. RESULTS Out of 385 patients operated for CAD, 312 underwent stoma creation: 292 end colostomies and 20 diverting stomas. During follow-up, stoma reversal surgery was performed in 161 patients (51.6%) after a median of 9 months. The main causes for not performing stoma reversal were comorbidities and the death of the patient. Advanced age was an adverse factor in the multivariate analysis, and the actuarial rate of reversal was higher in men and in patients with no previous Hartmanns operation. Stoma reversal surgery was completed in all but one patient, and a loop ileostomy was associated in four. Morbidity and mortality rates were 35.7% and 1.9%, respectively. A total of 8.4% of patients underwent re-operation, and 6% experienced an anastomotic leak. Twelve patients remained with a stoma after the attempted reconstruction surgery. CONCLUSIONS Surgery for CAD is frequently associated with an end stoma, which will ultimately not be reversed in almost 50% of patients. Moreover, reversal surgery is frequently delayed and is associated with significant morbidity and mortality.