Rosa María Jiménez-Rodríguez

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.

Is the interval from surgery to ileostomy closure a risk factor for low anterior resection syndrome

Low anterior resection syndrome (LARS) comprises a collection of symptoms affecting patients after restorative surgery for rectal cancer. The aim of the present study was to analyse the incidence of LARS in patients undergoing rectal cancer surgery with and without subsequent ileostomy and to determine whether the interval to ileostomy closure is a factor associated with its occurrence.

A new technique to close open abdomen using negative pressure therapy and elastic gums.

‘‘Open abdomen’’ is a routine surgical procedure in patients presenting with abdominal compartment syndrome, polytrauma requiring a second look and abdominal sepsis. In these cases, free access to the abdominal cavity may be necessary to drain fluid collections or to solve postoperative complications [1–3]. Several techniques for temporary abdominal closure have been described in the literature, but we observe a lack of experience as regards definitive closure techniques [4]. Here we present a kit which combines the use of a mesh, negative pressure therapy and elastic gums to attain definitive closure of the open abdomen in patients requiring a previous temporary closure and in whom it is impossible to accomplish primary closure of abdominal fascia, subcutaneous tissue and skin.

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.

Anal encirclement: a surgical technique for faecal incontinence in patients who are not good candidates for more invasive surgery - a video vignette

Dear Sir, Faecal incontinence (FI) is a complex and debilitating condition. Prevalence is between 1.4% and 19.5% but it can be up to 50% in institutional patients [1]. The Thiersch procedure was first described in 1981 for rectal prolapse; in this technique, the anus is encircled with a silver wire [2], and its indications are mainly patients who cannot tolerate other procedures. The method has been modified and described in different publications. Most modifications are related to the material used for encircling the anus (fascia, silicone, silastic mesh etc.) [3]. It is an easy and low cost procedure but the technique is not frequently used probably due to the high frequency of sling break and faecal impaction. Devesa and Vicente [4] described anal encirclement in 33 patients with FI. Complications included infection, erosion of the skin and breakage of the sling. Explantation was performed in 39.4%. Despite these complications, 97% of the patients presented improvement in functional scores and in all four of the FI Quality of Life scale. Zutshi et al. [5] reported anal encirclement in 13 patients with FI due to anal sphincter defect. No complications were seen. Incontinence severity scores and quality of life scales showed improvement. The aim of the video is to describe and show the modified Thiersch procedure for FI. Faecal incontinence is a problem that affects between 1.4% and 19.5% of the population [1]. There is consensus that, when medical treatment and/or biofeedback fails, surgery is the only option [6]. Surgical procedures include sphincteroplasty, bulking agents, sacral nerve stimulation – or a colostomy when everything else fails [7]. Most of these techniques require a high and specific surgical specialization, a general anaesthesia or at least spinal anaesthesia and have a significant rate of complications. Anal encirclement, also called the Thiersch modified procedure, could be an option for elderly patients with socioeconomic limitations due to its low cost, low complexity and improvement in FI.

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.

Feasibility and safety of surgical wound remote follow-up by smart phone in appendectomy: A pilot study

Introduction The objective of the present study is to assess the safety and feasibility of the use of telemedicine-based services for surgical wound care and to measure patient satisfaction with telemedicine-based follow-up. Material and methods 24 patients were included, they were provided with a corporate mail address. On day 7 after surgery patients sent, via email, an image of their surgical wound together with a completed questionnaire in order to obtain an early diagnosis. Two independent physicians studied this information and the histologic analysis of the specimen. On day 8, all patients underwent face-to-face office examination by a third physician and all of them completed a satisfaction questionnaire at the end of the study. Results The use of telemedicine-based services showed a sensitivity of 100%, a specificity of 91.6%, a positive predictive value of 75% and a negative predictive value of 100%. Degree of concordance between the two physicians, as regards the necessity of face-to-face follow-up yielded a kappa coefficient of 0.42 (standard error 0.25 and confidence interval 95% (0.92–0.08), which means a moderate agreement between the two evaluations. 94% of patients were satisfied with telemedicine-based follow-up and 93% showed their preference for this procedure over conventional methods. Conclusions The telemedicine-based follow-up, has proven to be feasible and safe for the evaluation of early postoperative complications. Patients reported high levels of satisfaction with the procedure. Telemedicine-based follow-up could become standard practice with the development of a specific mobile application.

Perianal approach to ischiorectal fossa tumours - a video vignette.

Dear Sir, The ischiorectal fossa is defined superiorly by the levator ani and medially by the external sphincter muscles. Laterally its limits are the obturator internus muscle and the obturator fascia, anteriorly the superficial and deep transverse perineal muscles and inferiorly the skin of perineum [1]. Tumours in this location are very rare and only case reports and small case series [2–7] such as that published by Buchs et al. [7] have been reported. There are two matters of importance regarding tumours in this anatomical region, including the role of percutaneous biopsy and the approach to achieve a complete resection. Anecdotal publications report a perineal approach as the only route to achieve complete resection for these neoplasms avoiding an abdominal incision. We report a case of an 81-year-old patient who experienced pain in both thighs and a bulging mass in the right gluteal muscle. The MRI appearances were indicative of a leiomyosarcoma and this was confirmed by examination of a needle biopsy. This video illustrates the perineal approach technique without an abdominal phase for the complete excision of the leiomyosarcoma. We conclude that the perineal approach could be a technical option to perform complete excision for tumours in the ischiorectal fossa avoiding intraabdominal extension.

La imagen del mesRuptura pancreática y reconstrucción en Y de Roux tras traumatismo abdominalPancreatic rupture and Roux-en-Y reconstruction after abdominal trauma

Mujer de 20 anos sin antecedentes de interes es trasladada al servicio de urgencias tras sufrir accidente de trafico. Refiere un golpe en region epigastrica. A pesar de no encontrar alteraciones en la ecografia de urgencias se mantiene en observacion. A las 48 h, el dolor epigastrico aumenta gradualmente de intensidad y se asocia a nauseas y vomitos. En la exploracion abdominal se objetiva dolor epigastrico sin signos de peritonismo. Ante este cuadro clinico se decide realizacion de ecaner donde aparece una lesion lineal hipodensa que atraviesa cuerpo de pancreas, compatible con laceracion o rotura pancreatica junto con liquido libre intraabdominal (fig. 1). Se realiza laparotomia exploradora urgente, donde se confirma rotura pancreatica del 75% de la glandula a nivel istmico con desgarro completo del conducto de Wirsung. Se procede a al cierre del Wirsung y sellado del munon proximal y reconstruccion del munon distal en Y de Roux transmesocolica. Buena evolucion en UCI y planta, con normalizacion de parametros analiticos, fue alta 23 dias despues de la cirugia, encontrandose en la actualidad asintomatica. c i r e s p . 2 0 1 2 ; 9 0 ( 1 0 ) : e 3 9

[Pancreatic rupture and Roux-en-Y reconstruction after abdominal trauma].

Mujer de 20 anos sin antecedentes de interes es trasladada al servicio de urgencias tras sufrir accidente de trafico. Refiere un golpe en region epigastrica. A pesar de no encontrar alteraciones en la ecografia de urgencias se mantiene en observacion. A las 48 h, el dolor epigastrico aumenta gradualmente de intensidad y se asocia a nauseas y vomitos. En la exploracion abdominal se objetiva dolor epigastrico sin signos de peritonismo. Ante este cuadro clinico se decide realizacion de ecaner donde aparece una lesion lineal hipodensa que atraviesa cuerpo de pancreas, compatible con laceracion o rotura pancreatica junto con liquido libre intraabdominal (fig. 1). Se realiza laparotomia exploradora urgente, donde se confirma rotura pancreatica del 75% de la glandula a nivel istmico con desgarro completo del conducto de Wirsung. Se procede a al cierre del Wirsung y sellado del munon proximal y reconstruccion del munon distal en Y de Roux transmesocolica. Buena evolucion en UCI y planta, con normalizacion de parametros analiticos, fue alta 23 dias despues de la cirugia, encontrandose en la actualidad asintomatica. c i r e s p . 2 0 1 2 ; 9 0 ( 1 0 ) : e 3 9