Francisco Pérez-Vicente

Prospective Randomized Clinical Trial Comparing Two Different Circular Staplers for Mucosectomy in the Treatment of Hemorrhoids

BackgroundThe main objections against circular stapled mucosectomy have been anal pain and rectal bleeding during the surgical procedure or in the immediate postoperative follow-up. To avoid these consequences, a new stapler (PPH33-03) has been developed. The aim of this trial was to compare the intraoperative and short-term postoperative morbidity of stapled mucosectomy with PPH33-01 versus PPH33-03 in the treatment of hemorrhoids.MethodsWe conducted a prospective randomized clinical trial comparing hemorrhoidectomy with PPH33-01 (group 1, n = 30) versus PPH33-03 (group 2, n = 30) for grade III–IV symptomatic hemorrhoids. For the follow-up, the patients underwent examination and proctoscopy at 4 weeks, 3 months, and 6 months. We recorded anal pain (linear analog scale from 0 to 10), intraoperative hemorrhage, postoperative bleeding, and continence (Wexner Continence Grading Scale).ResultsDemographic and clinical features showed no differences between the two groups. More patients required suture ligation to stop anastomotic bleeding at surgery when the PPH33-01 stapler was used (15 versus 4, P < 0.05). Rectal bleeding during the first postoperative 4 weeks was similar (P > 0.05). The postoperative pain scores during the first week were similar (P > 0.05). Patients with pain on defecation were fewer in the PPH-03 group (15 versus 2, P < 0.05). Six patients from group 1 and none from group 2 (P < 0.05) had granulomas along the line of staples at the sites of the reinforcing stitches; the granulomas were associated with postoperative anal discomfort and rectal bleeding. One patient in group 1 complained of persistent pain that resolved within 3 months. Of all the intraoperative or preoperative variables analyzed, only the presence of granuloma was associated with postoperative bleeding and anal discomfort. We have not found any recurrence or incontinence during the 6-month follow-up.ConclusionsIntraoperative bleeding along the stapled line and tenesmus or discomfort during defecation were less frequent after circular stapled mucosectomy with PPH33-03. Therefore, circular stapled mucosectomy with PPH33-03 decreases the risk of immediate complications and thus allows implantation with more safety as a day surgery procedure.

Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results.

Objective:To evaluate the long-term clinical and manometric results of fistulotomy and sphincter reconstruction for the treatment of complex fistula-in-ano. Background:Complex fistula-in-ano is difficult to treat due to the occurrence of postoperative anal incontinence and the high rate of recurrence. Methods:Seventy patients who were diagnosed with complex fistula-in-ano and underwent fistulotomy and sphincter reconstruction between October 2000 and October 2006 were analyzed in the present study. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Appointments were scheduled every 6 months during the first and second year of treatment and every 2 years thereafter. Recurrence and incontinence were evaluated during each visit. Continence was assessed according to the Wexner continence grading scale. Anal manometry was performed 3 and 12 months after treatment and every 2 years thereafter. Anal endosonography was conducted 6 months after treatment. Results:Fistulas were classified as medium-high trans-sphincteric in 64 patients (91.42%) and were recurrent in 22 patients (32%). Before surgery, 22 patients (32%) reported fecal incontinence, which improved after surgery in 15 cases (70%), from 6.75 to 1.88 (P < 0.005) on the Wexner Scale. Eight preoperative continent patients (16.6%) reported postoperative incontinence (Wexner Score < 3), and 6 patients (8.5%) had recurrent incontinence. Among these patients, 2 developed recurrent incontinence 6 months after treatment, 2 developed recurrent incontinence 1 year after treatment, 1 developed recurrent incontinence 2 years after treatment, and 1 developed incontinence 5 years after treatment. Conclusions:Fistulotomy with sphincter reconstruction is an effective technique for the treatment of complex fistula-in-ano. Continence and anal manometry results were improved in incontinent patients and were not jeopardized in continent ones. Fistulotomy with sphincter reconstruction is an especially suitable technique for incontinent patients with recurrent fistulas.

Tratamiento de la fisura anal crónica

Resumen La fisura anal cronica es una afeccion con una alta incidencia en nuestro medio que causa una grave incapacidad sociolaboral en el paciente, lo que nos obliga a buscar una solucion rapida y eficaz. Por ello, hemos revisado los diferentes tratamientos descritos en la bibliografia con el objetivo de establecer un protocolo terapeutico adecuado ante el paciente con fisura anal cronica que acude a la consulta. Recomendamos la esfinterotomia quirurgica (preferiblemente esfinterotomia lateral interna realizada indistintamente con una tecnica abierta o cerrada) como primera opcion terapeutica en la fisura anal cronica. Sin embargo, en pacientes > 50 anos con incontinencia previa, factores de riesgo de incontinencia (cirugia anal previa, multiples partos vaginales, diabetes, enfermedad inflamatoria intestinal, etc.) o fisura anal sin hipertonia asociada, la esfinterotomia quimica (preferiblemente con toxina botulinica) se convierte en la tecnica de eleccion ya que, a pesar de la alta tasa de recidiva en los tratamientos medicos, evita el elevado porcentaje de incontinencia residual descrito en la bibliografia con la esfinterotomia quirurgica en este grupo de pacientes.

Proctitis complicating stapled hemorrhoidectomy: report of a case

Dear Editor: Stapled mucosectomy has proved to be an effective technique for the treatment of hemorrhoids, rectal prolapse, and rectocele. There seems to be minimal postoperative pain and early recovery compared with traditional hemorrhoidectomy. It has been described as a safe technique that can be performed as an outpatient procedure with local or regional anaesthesia. However, urinary retention, bleeding, thrombosis, incontinence, persistent pain and fecal urgency have been reported as the most frequent complications of stapled hemorrhoidectomy, yet few cases have been published. Severe pelvic sepsis has been found to be the most life-threatening complication. We describe the first published case of proctitis secondary to stapled hemorrhoidectomy and review the possible causes and treatment. A 45-year-old man with an unremarkable past medical history, presented with grade III hemorrhoidal prolapse, with anal bleeding during defecation as the only symptom. Preoperative studies and full colonoscopy were normal. After dietetic/hygienic measures and unsuccessful treatment with rubber band ligation, the patient was operated on using stapled hemorrhoidectomy with PPH-33. There were no intraoperative complications. The suture line was 4 cm from the dentate line, and neither electrocautery nor suture was necessary to control bleeding. There were no complications during the immediate postoperative period. At follow-up 1 month after the operation, there was clinical healing and proctoscopic examination was normal. The patient reported a daily sense of urgency to defecate, but no incontinence or other associated symptoms. The patient returned after 3 months complaining of proctalgia and rectal tenesmus, with no fever or other abdominal symptoms. He reported no change in his normal dietetic/hygienic habits or significant clinical changes during the postoperative months. On examination, anal fissure and hemorrhoidal recurrence were ruled out, and on proctoscopy, there was proctitis or erythema of the mucosa, which was friable from the anal verge to the line of staples, but normal above this. The study was completed with a normal pelvic CT scan and colonoscopy. Biopsy of the zone distal to the affected zone of staples suggested a non-specific inflammatory condition. Smears and culture of the rectal wall for bacterial, fungal, and viral pathogens, Tzanck test for microscopic recognition of multinucleate giants cells, serologic test for syphilis, and stool evaluation for Clostridium difficile were negative and ruled out other infectious etiologies. A. Arroyo . F. Perez-Vicente . P. Serrano . F. Candela . M. T. Perez-Vazquez . R. Calpena Coloproctology Unit, Department of Surgery, University Hospital of Elche, C/Huertos y Molinos s/n., 03203 Elche (Alicante), Spain

Giant splenic metastasis due to lung adenocarcinoma

Lung cancer is the most prevalent malignancy in western countries and most of the patients present at advanced stages, but single splenic metastasis is exceptional instead. We report on a case of a seventy-three-year old male presenting with non-hemoptoic productive cough, constitutional syndrome and pain in the left lower quadrant. Physical examination and complementary radiological and hystologycal procedures revealed the presence of an adenocarcinoma of the left lung with probable splenic metastasis. The patient underwent splenectomy, which confirmed the diagnose of splenic metastasis of lung adenocarcinoma and, secondly, lung resection was performed. Topics about lung cancer metastasis are discussed.

Importancia de la curva de aprendizaje de la anopexia con PPH-33 para el tratamiento quirúrgico de las hemorroides

Resumen Introduccion Los resultados publicados de la mucosectomia circular mecanica con PPH-33 (MCM) para el tratamiento de las hemorroides de grados IIIIV ofrecen ventajas en terminos de postoperatorio inmediato e incorporacion a la actividad normal frente a las tecnicas clasicas, siendo similares a largo plazo. Los malos resultados iniciales y su implante sin el debido aprendizaje han causado el abandono de la MCM en muchos centros. El objetivo del presente trabajo consiste en describir la importancia de la curva de aprendizaje a traves de su influencia en los resultados. Pacientes y metodo Estudio retrospectivo de los primeros 100 pacientes intervenidos de hemorroides de grados III-IV mediante MCM por los mismos cirujanos (octubre 1999-mayo 2002). La muestra se dividio en 2 grupos, correspondientes a 2 periodos cronologicos, de 50 pacientes cada uno. Resultados La edad media fue de 48,7 anos, con un predominio de varones (62 varones frente a 38 mujeres); 56 pacientes tenian hemorroides de grado III y 44 de grado IV. El seguimiento medio fue de 21,4 meses (minimo, 12 meses). No hubo diferencias en las variables clinicas y poblacionales entre grupos, que fueron homogeneos y comparables. Tras la cirugia se observaron diferencias significativas en la distancia de la anastomosis a la linea pectinea (3,04 frente a 3,37 cm; p Conclusiones Hay una curva de aprendizaje donde los resultados y complicaciones pueden no ser los esperados, tras la cual mejoran, sobre todo en terminos de dolor postoperatorio, lo que hace necesaria una adecuada puesta en marcha de la tecnica y la evaluacion de los resultados.

Aneurisma de arteria mesentérica superior

La cirugía del cáncer de mama ha evolucionado asombrosamente, desde las traumáticas amputaciones de miembro superior hasta la detección y la exéresis del ganglio centinela. La evolución se debió a la aceptación del cáncer de mama como enfermedad sistémica, con lo que su manejo se centró en la quimioterapia adyuvante y en técnicas quirúrgicas conservadoras. Presentamos el caso de una paciente de 66 años que consultó por la presencia de una lesión ulcerada de 1,5 cm (fig. 1) en el extremo inferior de la cicatriz de una mastectomía radical modificada que había sido practicada hacía 40 años por un adenocarcinoma de mama de 2 cm y que posteriormente recibió radioterapia adyuvante. La biopsia confirmó la recidiva del adenocarcinoma. El estudio de extensión descartó metástasis a distancia. Se extirpó la lesión alcanzando el plano costal y se procedió a la reconstrucción con un colgajo cutáneo romboidal. Las recidivas tras una mastectomía radical o radical modificada asientan sobre tejido mamario residual, sustrato de la recidiva local de la enfermedad. El porcentaje de recidivas tras una mastectomía radical varía desde el 2 al 35% y aparecen como media a los 3 años de la intervención; están directamente relacionadas con el tamaño del tumor primario, los ganglios afectados y grado de indiferenciación tumoral. Se han descrito recidivas tardías, la mayoría en torno a los 10-15 años, aunque las recidivas a los 40 años o más son extremadamente raras. La localización suele ser paracicatrizal (80%), paraesternal (13%) y axilar (7%). La presencia de recidiva local en ausencia de metástasis a distancia no indica una afección sistémica de la enfermedad, y la cirugía radical con reconstrucción miocutánea posterior es el tratamiento de elección, al que puede asociarse radioquimioterapia o ablación hormonal posterior.