José Manuel Díaz-Pavón

Evaluation of a new synthetic plug in the treatment of anal fistulas: results of a pilot study.

BACKGROUND: The treatment of anal fistulas using plugs is a very promising method because of its simplicity and ability to be carried out on an ambulatory basis. If unsuccessful, it does not compromise subsequent alternative surgical techniques and/or products. However, success rates are variable. OBJECTIVE: This pilot study was designed to investigate the safety and effectiveness of a new synthetic plug in the treatment of transsphincteric anal fistulas. DESIGN: This was a prospective observational study. SETTING: Patients were treated at 2 colorectal surgery centers in Spain (Seville and Huelva). INTERVENTIONS: Anal fistulas were treated with a fistula plug made of bioabsorbable polymers (67% polyglycolide, 33% trimethylene carbonate). PATIENTS: Starting in January 2009, consecutive adult patients with transsphincteric anal fistulas were evaluated. MAIN OUTCOME MEASURES: Outcome measures included rates of successful fistula closure, complications, and continence (Jorge-Wexner incontinence score), assessed postoperatively at 1 week and again at 1, 3, 6, and 12 months. Healing was determined by clinical examination by a surgeon blinded for the intervention. RESULTS: A total of 19 patients (18 men, 1 woman) with transsphincteric anal fistulas were included in the study. The median age was 49 (range, 33–65) years. Of these patients, 12 presented with fistula relapse. The median time from onset of symptoms to surgery was 12 (range, 6–120) months. Three patients had previously placed setons. The follow-up duration was 12 months. Relapse occurred in 16 patients (with a perianal abscess in 1), and successful closure was observed in 3 patients (15.8%). LIMITATIONS: The number of patients was small, and time was needed for the learning curve of the technique. CONCLUSIONS: This study indicates that the new synthetic plug is safe, but the fistula closure rate was low. Randomized studies are needed to further determine the role of the bioabsorbable synthetic plug in the management of anal fistulas.

The Rabbit as an Animal Model for Proctology Research: Anatomical and Histological Description

ABSTRACT Purpose: This study was designed to describe the surgical anatomy and histology of the rabbit anorectum comparing it to that of humans, in order to decide whether it can be a good experimental model for research in proctology. Material and Methods: This study of the anorectal region was performed on six female New Zealand white rabbits, weighting between 2.5–2.9 kg. An autopsy was performed immediately after sacrificing the animal and an anatomical and histological description was performed. Results: The mean rectum and anal canal lengths were of 7.2 cm and 0.9 cm, respectively. The macroscopic study showed that the musculature of the anal canal is formed by the coccygeus muscle, which serves as puborectalis in humans. It also defined an external anal sphincter with a deep and superficial portion. The histological evaluation showed similarity to that of humans, with mucosa of simple columnar type, muscularis mucosae, a small submucosa, with a muscular wall divided into internal and external layers, separated by the myenteric plexus. Conclusion: The great similarity to both the anatomy and the histology of humans, appropriate size and easy-handling and care, make the rabbit an attractive animal for the use as experimental and research model in proctology.

A New Perspective on Vacuum-Assisted Closure for the Treatment of Anastomotic Leak Following Low Anterior Resection for Rectal Cancer, Is It Worthy?:

Background. Anastomotic dehiscence is a common complication of anterior resection. In this work, we evaluate the management of the pelvic cavity after low rectal resection using vacuum closure (VAC) with a gastroscope, and we establish factors that determine the success of closure and analyzed the rate of ileostomy closure after leakage was resolved. Patients and Methods. This is a descriptive case series analysis conducted at a tertiary hospital. Twenty-two patients with low colorectal anastomosis leakage or opening of the rectal stump after anterior resection for rectal cancer were included. They were treated with VAC therapy. Results. The total number of endoscopic sessions was 3.1 ± 1.9 in the anterior resection with anastomosis group and 3.2 ± 1.8 in the Hartmann group. In 11 patients the therapy was administered in an ambulatory setting. The mean time to healing was 22.3 ± 14.7 days. Full resolution was achieved in 19 patients (followed-up 1 year). Ileostomy closure was carried out in 5 patients (38.46%) during follow-up. None of these patients showed leakage signs. Statistically significant differences were obtained depending on the onset of therapy, with better results in patients who underwent earlier vacuum-assisted therapy (before the sixth week after initial surgery), P = .041. Conclusions. VAC therapy is an alternative to surgery that can be safely administered in an ambulatory setting. Early administration in the 6 weeks following surgery is an independent predictive factor for successful closure; however, colonic transit was only recovered in a small percentage of patients.

Estudio de factibilidad y seguridad del plug de colágeno (PICS-AF™) en el tratamiento de la fístula anal criptoglandular☆

INTRODUCTION The PICS-AF™ (Curaseal Inc.) device is a new plug made of collagen that has a retention system in the internal orifice. This pilot study was designed to assess both the feasibility and safety of this plug in the treatment of trans-sphincteric anal fístulas. METHODS A total of 44 patients (34 men), with a mean age of 54.68±7.3, with trans-sphincteric anal fístulas were included in the study; 34 of them were analyzed. All patients were examined according to a strict preoperative protocol and until 6 months after surgery. The feasibility of the procedure and the adverse events were analyzed. RESULTS Finally, 34 patients were operated on, and in 30 of them the plug was used. Therefore, the feasibility was calculated at 88%. There was a total of 16 adverse events, 4recorded as not related (3 mild and one moderate) and 12 related to the procedure or to the device implanted. Of these, 5were mild, 5moderate and 2severe. The majority of the events reported were related to proctalgia (4 patients) or infection at the implant site (4 patients). CONCLUSIONS The present study indicates that the new collagen plug can be placed effectively and with an acceptable complication rate.

Hereditary nonpolyposis colorectal cancer (Lynch syndrome I) in a 15-year-old male

Dear Editor: Lynch syndrome, or hereditary nonpolyposis colorectal cancer (HNPCC), is a dominantly inherited syndrome characterised by the development of a variety of cancers in the colorectum, endometrium and, less frequently, small bowel, stomach, urinary tract, ovaries, and brain. HNPCC is caused by a single mutation of a DNA mismatch repair gene (MMR), mainly MSH2 and MLH1. Defects in this pathway lead to changes in the length of nucleotide repeat sequences of DNA, termed microsatellite instability. We report a case of a male, 15 years old, with a family background of Lynch syndrome who sought attention for episodes of fever with 4 months of evolution, accompanied in the last month by urinary symptoms that persisted after several cycles of antibiotics, along with constitutional syndrome. During the abdominal ultrasound, we observed a retrovesical mass, so we decided to perform a thoracoabdominal CT scan, which revealed a large heterogeneous lesion that resembled a tumour (14×10×10 cm) with a gas-filled interior that appeared to have continuity with the bladder, obstructing the distal segment of the left ureter with prostatic invasion. It was also accompanied by retroperitoneal and iliac bilateral adenopathies. We did not observe metastasis into other organs nor lesions in the rest of the colon. We completed the examination with a colonoscopy, which evidenced important extrinsic compression and ulceration of the anterior face of the rectum, as well as a large vegetative neoformation of 40–45 cm that occupied the entire tube, with necrotic areas that impeded the passage of the endoscope. The carcinoembryonic antigen test revealed a level of 12 ng/dl. We decided on a surgical intervention, performing a complete pelvic exenteration with pelvic and aortocaval lymphadenectomy, after which the patient was moved to the intensive care unit, with good evolution and discharge from this unit on the fifth day after the operation. During his stay in the postoperative recovery wing, the patient progressed favourably with adequate adaptation to the ostomy, and was discharged from the hospital 10 days after the operation. The histopathological analysis of the surgical specimen revealed adenocarcinoma of the sigmoid colon with G2 histological tumour grade and stage IV (pT4b N1a M1b) TNM. The immunohistochemical study performed by PCR detects the mutation at codon 12ASP of Kras gene. Typically, colorectal cancer (CRC) is a disease of ageing, with the majority of cases arising after 50 years of age. Approximately 10–15% of patients with colorectal cancer have a family history of CRC, and in 17–30% of young-onset cases of CRC, DNAMMR defects will account for the younger age of onset of CRC, although the remainingmajority of young-onset MSS CRC cases occur for unknown reasons. CRC patients initially qualify as having HNPCC/Lynch syndrome if they meet Amsterdam criteria, which includes at least three relatives with CRC: one individual must be a first-degree relative of the other two, at least two successive generations should be affected, and one should have been affected before 50 years of age. They are usually in the right side of the colon (66%) compared with sporadic cancers (30%). Polyps are not F. de la Portilla (*) : I. Ramallo : S. Pardo : J. M. Díaz-Pavón Coloproctology Unit, Gastrointestinal Surgery Department, Virgen del Rocio University Hospital, Avda. Manuel Siurot s/n, 41013 Seville, Spain e-mail: delaportilla@ya.com

Lesión perineal en recién nacidos durante la cesárea

Bhat et al1 + + + – + Septicemia por Defuncion a los 15 dias Pseudomonas Lickstein et al4 + + + – + Sin complicaciones Sin incidencias Patel et al5 + + + – – Sin complicaciones Sin incidencias Caso 1 + + + + + Sin complicaciones Sin fistulas. Continencia normal Caso 2 + + + – – Sin complicaciones Sin fistulas. Continencia normal Fig. 1. Lesiones perineales. A: en el primer caso fue precisa una colostomia. B: en el segundo caso se realizo sutura directa. A B 217.250