Rafael Alós

Prevalence of pudendal neuropathy in fecal incontinence

PURPOSE: A prospective study was made of the prevalence and associations of pudendal neuropathy in 96 patients with fecal incontinence (72 females and 24 males). METHODS: Clinical exploration, perineal level measurement, anorectal manometry, and electrophysiologic evaluations (pudendal nerve terminal motor latency (PNTML) and external sphincter fiber density (FD)) were performed. RESULTS: Pudendal neuropathy (defined as PNTML>2.2 ms or FD>1.65) was found in 67 patients (69.8 percent) and was more common in females (75 percent) than in males (50 percent;P= 0.05). Pudendal neuropathy was also more frequent in patients with pathologic perineal descent (85 percentvs.55 percent;P<0.01) or exhibiting risk factors such as difficult labor or excessive defecatory straining (P<0.01). Perineal level at straining correlated inversely with both PNTML and FD (P<0.01). Manometric findings suggested greater external anal sphincter damage in patients with pudendal neuropathy than in those suffering fecal incontinence but no neuropathy (P<0.05). Pressure caused by the striated anal sphincter was also inversely correlated to PNTML. Pudendal neuropathy was encountered in 37 of 63 (58.7 percent) patients with sphincter injuryvs.in 31 of 33 (93.9 percent) patients with idiopathic fecal incontinence (P< 0.01). CONCLUSIONS: Pudendal neuropathy is an etiologic or associated factor often present in patients with fecal incontinence. In this sense, clinical, perineometric, and manometric findings correlate with pudendal neuropathy, though such explorations do not suffice to detect it.

Quality of mesorectum after laparoscopic resection for rectal cancer - results of an audited teaching programme in Spain.

Objective  The aim of this prospective observational study was to compare the quality of total mesorectal excision between laparoscopic and open surgery for rectal cancer.

Fistulectomy and sphincteric reconstruction for complex cryptoglandular fistulas

Objective  Complex anal fistulas (CFs) are difficult to treat. Endoanal advancement flap (EAF) is one of the standard treatment options for such clinical conditions. Immediate sphincter repair after fistulectomy (ISR) is not commonly performed because of the fear of causing postoperative incontinence. The objective of this study was to compare the results of both techniques.

Hypoxic macrophages impair autophagy in epithelial cells through Wnt1: relevance in IBD

A defective induction of epithelial autophagy may have a role in the pathogenesis of inflammatory bowel diseases. This process is regulated mainly by extracellular factors such as nutrients and growth factors and is highly induced by diverse situations of stress. We hypothesized that epithelial autophagy is regulated by the immune response that in turn is modulated by local hypoxia and inflammatory signals present in the inflamed mucosa. Our results reveal that HIF-1α and Wnt1 were co-localized with CD68 in cells of the mucosa of IBD patients. We have observed increased protein levels of β-catenin, phosphorylated mTOR, and p62 and decreased expression of LC3II in colonic epithelial crypts from damaged mucosa in which β-catenin positively correlated with phosphorylated mTOR and negatively correlated with autophagic protein markers. In cultured macrophages, HIF-1 mediated the increase in Wnt1 expression induced by hypoxia, which enhanced protein levels of β-catenin, activated mTOR, and decreased autophagy in epithelial cells in co-culture. Our results demonstrate a HIF-1-dependent induction of Wnt1 in hypoxic macrophages that undermines autophagy in epithelial cells and suggest a role for Wnt signaling and mTOR pathways in the impaired epithelial autophagy observed in the mucosa of IBD patients.

Proceso docente auditado del tratamiento del cáncer de recto en España: resultados del primer año

Resumen Introduccion El cancer de recto (CR) es uno de los tumores con resultados terapeuticos mas dispares, tanto por recidiva local (RL) como por supervivencia. En Espana desconocemos las tasas generales de RL, pero diferentes estudios europeos han demostrado que la implantacion de programas nacionales formativos han disminuido la tasa de RL y aumentado la supervivencia. El objetivo de este trabajo es presentar un analisis descriptivo de los primeros resultados de un programa nacional docente sobre la escision total del mesorrecto (ETM). Material y metodo La Asociacion Espanola de Cirujanos inicio la organizacion del proceso docente y su comite cientifico fue el encargado de seleccionar al grupo que inicio el proyecto mediante equipos multidisciplinarios y que a la vez cumplieran los requisitos programados. Se diseno una base de datos en la que se recogian todas las variables estudiadas. Resultados En el periodo de un ano se registro a 346 pacientes afectos de CR; el tumor se localizaba en el tercio superior en 109 pacientes; en el tercio medio en 150 pacientes y en el tercio inferior en 87 pacientes. Se realizo ecografia endoanal en 222 pacientes (64,1%) y resonancia magnetica en 237 (68,5%); 313 pacientes fueron tributarios de cirugia mayor, al 69,3% de los pacientes se los opero por via laparotomica, y al 30,7%, por via laparoscopica; la tasa de conversion fue del 21,9%. Se realizo cirugia conservadora de esfinteres en 224 pacientes (71,5%). La morbilidad fue del 37% y la mortalidad del 3%. La calidad del mesorrecto fue satisfactoria en el 76% de los casos e insatisfactoria en el 7%. Conclusiones Por los resultados obtenidos durante este primer ano, consideramos que la implantacion de un proceso docente nacional sobre la ETM es viable y factible y, ademas, repercutira en una mejora de los resultados quirurgicos.INTRODUCTION Rectal cancer (RC) is one of the tumors showing the greatest discrepancies in outcomes, both in terms of local recurrence (LR) and survival. In Spain, the overall LR rates are unknown, but several European studies have demonstrated that the introduction of national training programs have decreased these rates and have increased survival. The aim of the present study was to present a descriptive analysis of the first results of a national teaching program in total mesorectal excision (TME). MATERIAL AND METHOD The Spanish Association of Surgeons initiated the organization of the teaching process and its scientific committee was made responsible for selecting the group that started the project, based on multidisciplinary teams that met the established requirements. A database containing all the variables studied was designed. RESULTS Over the 1-year period, data on 346 patients with RC were gathered. Of these, the tumor was located in the upper third of the rectum in 109 patients, in the middle third in 150, and in the lower third in 87 patients. Endoanal ultrasonography was performed in 222 patients (64.1%) and magnetic resonance imaging in 237 (68.5%). A total of 313 patients were suitable for surgery; 69.3% underwent open surgery and 30.7% underwent laparoscopy. The conversion rate was 21.9%. Sphincter-preserving surgery was performed in 224 patients (71.5%). Morbidity was 37% and mortality was 3%. The quality of the mesorectum was satisfactory in 76% and unsatisfactory in 7%. CONCLUSIONS Based on the results obtained during the first year, we believe that the implementation of a national teaching program on TME is feasible and, moreover, that it would improve surgical outcomes.

Tratamiento quirúrgico y resultados del cáncer de colon

Resumen El tratamiento quirurgico del cancer de colon no se ha modificado en las ultimas decadas y sigue siendo la base de la terapeutica de esta enfermedad. Se han demostrado pronosticos el estadio anatomopatologico, seguido de la variable cirujano, cuya especializacion determina los resultados de la reseccion primaria, y estos, el pronostico del paciente. Cuando la intervencion tiene caracter curativo, el margen distal debera ser al menos de 5 cm, y el proximal dependera de la reseccion vasculolinfatica, que determinara la extension de la colectomia. Si el tumor se encuentra adherido a otras visceras, se practicara la reseccion en bloque. No se ha demostrado que la tecnica de no tocar el tumor aporte beneficio. En este articulo se revisan las diferentes tecnicas quirurgicas clasicas, actualizando aspectos concretos de cada una. La cirugia laparoscopica del cancer de colon se esta demostrando como una tecnica segura y cada vez mas empleada en pacientes seleccionados. La busqueda continua de la calidad obliga a plantear estandares de referencia y analisis de resultados en estos pacientes. Finalmente se tratan problemas especiales, que no resultan infrecuentes en la practica diaria, como son el polipo degenerado, el cancer asociado a enfermedad inflamatoria intestinal y el cancer en el seno de sindromes geneticos.

Preparar el colon para la cirugía. ¿Necesidad real o nada más (y nada menos) que el peso de la tradición?

Resumen La preparacion mecanica del colon es un componente tradicional del preoperatorio de los pacientes sometidos a cirugia colorrectal dirigido a reducir sus complicaciones infecciosas, ya que clasicamente la presencia de heces en el colon se ha asociado a contaminacion intraoperatoria y dehiscencias anastomoticas. Sin embargo, en la actualidad, estudios tanto experimentales como de observaciones clinicas, trabajos prospectivos y revisiones sistematicas de la literatura cuestionan su utilidad. Se efectua una revision de conjunto sobre el tema, y se concluye que, con la evidencia disponible, no esta claro el beneficio de la preparacion mecanica del colon y hay trabajos que muestran incluso una mayor incidencia de complicaciones en la tasa de dehiscencia anastomotica y la morbilidad con su uso sistematico, por lo que puede ser omitida en cirugia electiva y es adecuado restringirla a indicaciones concretas, como pequenos tumores, para facilitar su localizacion durante un abordaje laparoscopico o cuando se precise hacer una endoscopia intraoperatoria. El papel de la preparacion mecanica en la cirugia rectal no esta aclarado en la actualidad y se precisa de series mas amplias para establecerlo.

Severe Myalgia Associated with Adalimumab Treatment in a Patient with Crohn's Disease

Objective: To report a case of severe myalgia associated with adalimumab in a patient with Crohns disease. Case Summary: A 44-year-old woman was diagnosed as having ileocecal Crohns disease with perianal fistula lesions. She was treated with 3 infusions of infliximab 5 mg/kg, which stabilized her condition. However, when reactivation of Crohns disease occurred, Infliximab was discontinued. Eight weeks after infliximab was suspended, treatment with adalimumab was started, with an initial dose of 160 mg followed by 80 mg in week 2; 46 hours after the first dose, the woman complained of generalized severe pain in her upper and lower extremities. Results of all laboratory tests were within normal limits. A diagnosis of severe drug-related myalgia was made. We suspected that adalimumab was the causative agent since it was the only drug that had been added before the musculoskeletal symptoms appeared. Adalimumab was stopped and treatment with Ibuprofen and tramadol was started. Fifteen days after stopping adalimumab, the patient reported complete resolution of her muscle pain. Discussion: Myalgia following administration of adalimumab Is uncommon. This adverse reaction rarely is severe enough to result in cessation of the drug. In our patient, the most likely cause of the severe myalgias was considered to be adalimumab. The onset and resolution of the signs and symptoms followed a reasonable temporal sequence following drug initiation and discontinuation. In accordance with the data obtained and based on the Naranjo algorithm, the adverse reaction could be considered probable. Conclusions: This case documents the importance of recognizing the possibility of musculoskeletal adverse reactions even with medications like adalimumab, which have a good safety profile. These findings should further alert clinicians to the potential for myalgias associated with adalimumab administration.

Progastrin represses the alternative activation of human macrophages and modulates their influence on colon cancer epithelial cells.

Macrophage infiltration is a negative prognostic factor for most cancers but gastrointestinal tumors seem to be an exception. The effect of macrophages on cancer progression depends on their phenotype, which may vary between M1 (pro-inflammatory, defensive) to M2 (tolerogenic, pro-tumoral). Gastrointestinal cancers often become an ectopic source of gastrins and macrophages present receptors for these peptides. The aim of the present study is to analyze whether gastrins can affect the pattern of macrophage infiltration in colorectal tumors. We have evaluated the relationship between gastrin expression and the pattern of macrophage infiltration in samples from colorectal cancer and the influence of these peptides on the phenotype of macrophages differentiated from human peripheral monocytes in vitro. The total number of macrophages (CD68+ cells) was similar in tumoral and normal surrounding tissue, but the number of M2 macrophages (CD206+ cells) was significantly higher in the tumor. However, the number of these tumor-associated M2 macrophages correlated negatively with the immunoreactivity for gastrin peptides in tumor epithelial cells. Macrophages differentiated from human peripheral monocytes in the presence of progastrin showed lower levels of M2-markers (CD206, IL10) with normal amounts of M1-markers (CD86, IL12). Progastrin induced similar effects in mature macrophages treated with IL4 to obtain a M2-phenotype or with LPS plus IFNγ to generate M1-macrophages. Macrophages differentiated in the presence of progastrin presented a reduced expression of Wnt ligands and decreased the number and increased cell death of co-cultured colorectal cancer epithelial cells. Our results suggest that progastrin inhibits the acquisition of a M2-phenotype in human macrophages. This effect exerted on tumor associated macrophages may modulate cancer progression and should be taken into account when analyzing the therapeutic value of gastrin immunoneutralization.

Defecación obstructiva. Métodos diagnósticos y tratamiento

Resumen La existencia de defecacion obstructiva se observa en torno a la mitad de los pacientes con estrenimiento funcional. Se ha relacionado al estrenimiento funcional, con alteraciones de la motilidad intestinal (estrenimiento de transito lento) y con disfunciones en el suelo pelviano que provocan defecacion obstructiva, asociado a una alteracion anatomica del suelo pelviano (rectocele, hernia perineal posterior, enterocele y sigmoidocele, intususcepcion interna rectal, prolapso mucoso oculto, ulcera rectal solitaria y syndrome del perine descendente) o defecacion obstructive sin existencia de alteracion anatomica (disinergia del suelo pelviano o anismo). Se analizan los metodos diagnosticos empleados (anamnesis y exploracion fisica, tiempo de transito colico, test de expulsion de balon, estudios proctograficos, manometria anorrectal y electromiografia), asi como el tratamiento medico conservador y las indicaciones y los resultados del tratamiento quirurgico.