[Robot assisted Frykman-Goldberg procedure. Case report]

BACKGROUND

Rectal prolapse is defined as the protrusion of the rectal wall through the anal canal; with a prevalence of less than 0.5%. The most frequent symptoms include pain, incomplete defecation sensation with blood and mucus, fecal incontinence and/or constipation. The surgical approach can be perineal or abdominal with the tendency for minimal invasion. Robot-assisted procedures are a novel option that offer technique advantages over open or laparoscopic approaches.

CASE REPORT

67 year-old female, who presented with rectal prolapse, posterior to an episode of constipation, that required manual reduction, associated with transanal hemorrhage during defecation and occasional fecal incontinence. A RMI defecography was performed that reported complete rectal and uterine prolapse, and cystocele. A robotic assisted Frykman-Goldberg procedure wass performed.

DISCUSSION

There are more than 100 surgical procedures for rectal prolapse treatment. We report the first robot assisted procedure in Mexico. Robotic assisted surgery has the same safety rate as laparoscopic surgery, with the advantages of better instrument mobility, no human hand tremor, better vision, and access to complicated and narrow areas.

CONCLUSION

Robotic surgery as the surgical treatment is a feasible, safe and effective option, there is no difference in recurrence and function compared with laparoscopy. It facilitates the technique, improves nerve preservation and bleeding. Further clinical, prospective and randomized studies to compare the different minimal invasive approaches, their functional and long term results for this pathology are needed.

[Elective laparoscopic right colectomy for caecal volvulus: case report and literature review]

BACKGROUND

Caecal volvulus is an uncommon cause of intestinal obstruction. Its clinical presentation is non-specific, with the diagnosis usually confirmed by barium enema and abdominal computed tomography. Treatment depends on many factors, and minimally invasive approaches are becoming the treatment of choice.

CLINIC CASE

A 54 years old female, admitted to the Emergency Department with clinical symptoms of intestinal obstruction. On physical examination she had a palpable, firm, and tympanitic mass in the right abdomen, with peritoneal irritation. The radiographs of the abdomen, barium enema and abdominal computed tomography showed caecal volvulus. As she showed a full remission after the barium enema, with no clinical or biochemical data of systemic inflammatory response syndrome or peritoneal irritation, she was discharged to her home. Two weeks later, a laparoscopic right hemicolectomy was performed with an ileo-transverse extracorporeal anastomosis. Her progress was satisfactory, and she was discharged 4 days after surgery due to improvement.

CONCLUSION

Caecal volvulus is a rare cause of intestinal obstruction, with high mortality rates, and is caused by excessive mobility of the caecum. Its incidence is increasing. Treatment depends on many factors. Early non-surgical untwisting, followed by an elective laparoscopic surgical procedure offers several advantages and reduces mortality.

Appendiceal diverticulum associated with chronic appendicitis

INTRODUCTION

Appendiceal diverticulosis is a rare entity, with a global incidence between 0.004% and 2.1% of all appendectomies. It has been related with an elevated risk of perforation in comparison to acute appendicitis, as well as an increased risk for synchronic appendicular cancer in 48% of the cases, and colonic cancer in 43%. The incidence of chronic appendicitis has been reported in 1.5% of all appendicitis cases.

PRESENTATION OF CASE

We present a 73-year-old female, with no relevant familial history, who presented due to a four-month-long oppressive, moderate pain in the lower right abdominal quadrant without irradiation or any other accompanying symptoms.

DISCUSSION

The documented incidence of appendiceal diverticula and chronic appendicitis by themselves is low; therefore the presence of both entities at the same time is extremely rare.

CONCLUSION

We present a case in which both diagnoses concurred in the same patient. The relevance of this case relies on the importance of the adequate knowledge of these pathologies, so we can approach them correctly. Although it does not represent an absolute surgical emergency, appendectomy represents the first therapeutic option.

[Pseudomyxoma peritonei. Two-case-report]

BACKGROUND

Pseudomyxoma peritonei is a disease characterized by an intraperitoneal adenomucinous tumor cell disemination, being cecal appendix the most common etiology.

OBJECTIVE

To report a surgeon's group experience and a detailed up to date literature review.

CLINICAL CASES

1. A 74 year old woman with a history of four days with mesogastrium and right lower quadrant abdominal pain associated with diarrhea and fever was admitted to our institution. Upon admission she presented with signs of peritoneal irritation and muscular rigidity, leukocytosis of 14,500 cels/mm(3), 89% neutrophils and 1% bands. An acute appendicitis diagnosis was established, being scheduled for diagnostic laparoscopy, during procedure, significant bowel distention was found, so conversion to laparotomy was required. Case 2. A 73 year old male with a history of one year with intermittent abdominal pain at right iliac fossa and hypogastrium was admitted to our institution. Dyspnea, constipation alternating with periods of diarrhea, gastric fullness and heartburn occurred. On physical examination only a palpable tumor occupying mesogastrium and both iliac fossae was noticed, therefore, a laparotomy was performed. In both cases diagnoses were made during procedure, finding multiple scattered multilobulated mucinous tumor implants within the peritoneal cavity. Histopathological studies confirmed a pseudomyxoma peritonei diagnoses.

CONCLUSIONS

Peritoneal pseudomyxoma is a rare malignant tumor with a difficult diagnosis characterized by copious production of mucinous ascites and multiple tumors implants on serosa of intracavitary viscera. The gold standard treatment consists of cytoreductive surgery and perioperative intraperitoneal chemotherapy and/or adjuvant chemotherapy.

[Traumatic diaphragmatic injury diagnosed preoperatively. A Case report]

Traumatic diaphragmatic rupture represents a diagnostic challenge to any physician dealing with polytraumatized patients. This uncommon injury must be suspected in certain types of accidents, making knowledge of trauma mechanisms vital for its diagnosis. In this paper we present a case of traumatic diaphragmatic rupture with intrathoracic herniation of abdominal contents, which was surgically repaired. We also present a review of the clinical characteristics, diagnosis and treatment of this entity, emphasizing the importance of keeping a high index of suspicion in order to achieve a correct diagnosis.

[Colon transverse volvulus; a case report]

BACKGROUND

Colon transverse volvulus is an uncommon pathology which is associate with alterations of the colonic motility, mental disorders and congenital anomalies of the fixation of the colon sistem. Up to 1994, 72 cases has been reported in world-wide literature.

AIM

To report a case of colon transverse volvulus and the treatment.

CASE REPORT

A female 46 years old who show intense abdominal pain 2 days of evolution. The physical exploration show important abdominal distension and pain in left inferior quadrant. The Rx of abdomen with gas absence in rectal descendent colon and ampula with level and important distension of proximal colon. Colonoscopic study with impossibility to advance endoscopy throw colon transverse by zone of stenosis, wasn't made a contrast study, underwent laparotomy of urgency, it was done right hemicolectomy and ileocoloanastomosis with good evolution and given of discharge fourth postsurgical day.

CONCLUSIONS

This possibility is due to have in mind diagnoses, the treatment is surgical secondary to a high index of recidivate, nevertheless recommends the colonoscopy study accomplishment in order to discard obstructive injuries mainly cancer.

[Anal malignant melanoma. Case report and literature review]

OBJECTIVE

To present two cases of anorectal malignant melanoma as due to its non specific presentation and rarity they are often misdiagnosed like hemorrhoids.

BACKGROUND

Anal melanomas are rare tumors that constitute less than 1% of the malignant colorectal tumors and represent both a diagnostic and therapeutic challenge to physicians. They are generally pigmented but could be amelanotic in 29% of the cases and they are associated with poor prognosis, regardless of the surgical procedure used. Melanomas are often misdiagnosed by a lot of anorectal conditions and diagnosis must be suspected in patients with an anal mass.

CASE REPORT

We present two anorectal cases of malignant melanoma treated by wide local excision, the principal complain in both patients was the presence of an anal mass and bleeding. Both patients were treated by local excision since survival rates are comparable to those of patients treated by abdomino perineal resections (with a high morbility and mortality rates) and a better quality of life is achieved with control of the symptoms.

CONCLUSIONS

Anal melanoma is a rare entity with a poor prognosis. The overall treatment goal should be to optimize the quality of life.

[Anterior rectal duplication in adult patient: a case report]

OBJECTIVE

To report a case of rectal duplication in the adult and make a literature review.

BACKGROUND

The intestinal duplications are injuries of congenital origin that can exist from the base of the tongue to the anal verge, being the most frequent site at level of terminal ileum (22%) and at the rectal level in 5% To date approximately exist 80 reports in world-wide Literature generally in the pediatric population being little frequent in the adult age. Its presentation could be tubular or cystic. The recommended treatment is the surgical resection generally in block with coloanal anastomosis.

METHOD

A case review of rectal duplication in the adult and the conducted treatment.

RESULT

The case of a patient appears with diagnose of rectal duplication with tubular type,whose main symptom was constipation and fecal impactation. In the exploration was detect double rectal lumen (anterior and posterior) that it above initiates by of the anorectal ring with fibrous ulcer of fibrinoid aspect of 3 approx cm of length x 1 cm wide, at level of the septum that separates both rectal lumina.

CONCLUSIONS

The rectal duplication is a rare pathology in the adult nevertheless is due to suspect before the existence of alterations in the mechanics of the defecation, rectal prolapse and rectal bleeding,the election treatment is a protectomy with colonic pouch in "J" and coloanal anastomosis.

[Acute appendicitis without Crohn's disease in a patient with inflammatory bowel disease. Case report]

BACKGROUND

Crohn's disease was described for the first time in 1932. The association of acute appendicitis with this disease is very rare and when the cecum is involved, risk of fistula is very high.

CASE REPORT

We present the case of a 48-year-old female who had been diagnosed with Crohn's disease several months earlier. The patient complained of intense abdominal pain in the right lower quadrant and was treated medically without improvement. Thus, laparascopic surgery was decided upon.

DISCUSSION

The appendix was affected in 12-16% of all patients with Crohn's disease who had intestinal resection.

CONCLUSIONS

If the cecum is not affected, appendectomy using laparascopic procedure with soft tissue drainage is adequate.

[Double stapler technique in colorectal surgery]

BACKGROUND

Colorectal surgery has evolved significantly during the last 35 years. The circular stapler and the double stapler techniques have favored the development of very low rectal anastomoses with reduction in anastomotic leakage. The objective of this study is to evaluate the functional results and complication rate of this surgical technique in the Department of Colorectal Surgery at the Hospital de Especialidades, Centro Medico Nacional Siglo XXI and at the Hospital Angeles del Pedregal, both located in Mexico City.

METHODS

Clinical records of patients who underwent surgery from May 1995 to December 2005 using the double stapler technique and performed by the authors were reviewed.

RESULTS

The study included 142 patients, 55 of whom had rectosigmoid cancer resections. Average age was 60.1 years (male predominance 52.05%). The circular stapler most frequently used was CDH 33 (Johnson & Johnson). Average distance between the anal margin and the anastomoses for extended low anastomoses was 3.21 cm (low 7.8 cm and high 13.7 cm), and the rate of anastomoses leak was 3.52%.

CONCLUSIONS

Double stapler technique used to treat rectosigmoid pathology is safe, secure and assures intestinal continuity in low anterior as well as extended low anterior resections with primary anastomoses. In those patients with associated risk factors and low extended low anterior resection with primary anastomoses, we recommend performing a protective stoma (ileostomy).

[Quality of life after restorative proctocolectomy with ileo-anal J pouch in patients with ulcerative colitis]

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the most common treatment in patients with ulcerative colitis. This procedure removes the entire colon, conserving the sphincteric complex and, therefore, preserving continence. The most important goal of this surgery is to improve quality of life.

METHODS

We reviewed the files of patients who underwent restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis from January 1995 to December 2004 . We administered questionnaire SF-36 to evaluate quality of life. We used an observational, retrospective, and transversal method.

RESULTS

Twenty "J" pouch procedures were done, of which files of 14 patients were reviewed. As far as quality of life, we were able to interview only eight patients and the average was as follows: physical function 75, physical status 50, corporal pain 51, general health 77, vitality 47.5, social function 62.50, emotional status 83 and mental health 74.

DISCUSSION

Previous reports exist showing that proctocolectomy is a safe and effective procedure for patients with ulcerative colitis and where ileostomy is accompanied by one definitive, independent continent or pouch.

CONCLUSIONS

The presence of stoma and fecal incontinence are factors that contribute to deterioration of quality of life after proctocolectomy; thus, both should be avoided. Of the patients who we interviewed, 87.5% consider that their health status has improved during 1 year.

[Rectal diverticula. Case report]

BACKGROUND

The presence of rectal diverticula is extremely rare; nevertheless, diverticular disease is considered a greater problem. We report a case of rectal diverticula in a patient with diverticular disease of the sigmoid.

CLINICAL CASE

An 88-year-old male presented to the emergency room with hematochezia of several days evolution. During colonoscopy two diverticula were seen at 5 cm from the anal verge.

DISCUSSION

Two theories exist to explain why rectal diverticula are rare, but other authors indicate its relationship to genetic alterations. Rectal diverticula are generally asymptomatic and surgical treatment only becomes necessary when these lesions progress to ulceration and abscess formation.

[Ischemic colitis in patients submitted to aortic replacement surgery. Risk factors]

Ischemic colitis (IC) is an important clinical problem, and may present after aortic surgical procedures. The aim of this work was to establish risk factors for IC presentation in aortic surgical replacement patients.

MATERIAL AND METHODS

A retrospective study of patients with aortic surgical replacement in a 3-year period was carried out. Patients were divided into two groups: patients without IC and patients with IC, the later group subdivided into patients with gangrenous ischemic colitis and without gangrenous ischemic colitis. Multiple logistic regressions was used to obtain the variables for possible risk factor for IC.

RESULTS

We included 101 patients in the study; ischemic colitis was present in 16.8% of all cases, with 47.1% of gangrenous type. Metabolic acidosis was the most frequent alteration. Diagnosis was made by endoscopy in 94.1%. Mortality in IC group was 18.2% with an increase in the gangrenous group to 62.5%. Identified risk factors were disrupted aneurysm, previous colonic surgery, emergency surgery, and hemodynamic instability.

CONCLUSIONS

Ischemic colitis is most frequent in emergency surgery for disrupted aneurysm in the hemodynamically unstable patient with retroperitoneal hematoma. We must entertain a high suspicion index for IC in all patients with aortic surgical procedures for early detection and adequate treatment.

[Surgical treatment of unspecific chronic ulcerative colitis. A 5-year experience]

BACKGROUND

Treatment of ulcerative colitis depends on clinical stage of disease and have precise surgical indications. The aim of this work was to review surgical indications and present data related to our experience.

MATERIAL AND METHODS

Retrospective, descriptive, and transversal study. We reviewed records of all patients who underwent a surgical procedure for ulcerative colitis at our service from March 1996 to March 2001.

RESULTS

Twenty two patients, 13 males and nine females, ages range 21 to 72 years. Main indication for surgery was no response to medical treatment (50%). Surgical procedures was subtotal colectomy with ileostomy in one patient, intersphincteric proctocolectomy with ileostomy in four intersphincteric proctectomy with ileostomy in three ileorectalanastomosis in three proctocolectomy with ileoanal "J" pouch in six and proctectomy with ileoanal J pouch in five. We had the following complications: oral candidiasis; phlebitis; eventration; pouchitis, and anal fissure in one patient, respectively, pouch-skin fistula in two patients (9%), and retrograde ejaculation in one of these. Follow-up was for 5 years.

CONCLUSIONS

Surgical indications for ulcerative colitis are precise. We recommend early surgical evaluation. Ileoanal pouch is now considered the gold standard for surgical procedure because it eliminates disease, neoplasm development, and permanent extra-colonic manifestations, and restores continence.

[Perianal leukemic infiltration. Case report]

BACKGROUND

Leukemic infiltration of perianal skin (leukemia cutis) is quite uncommon, and may consist of no diffuse infiltration, erythema, ulceration, fistula, and abscess. Diagnosis may be established by biopsy and adequate hematologic studies. Treatment must be conservative in patients with poorly controlled disease (sitz baths, antibiotics, radiotherapy), and surgical in patients with risk of fulminant sepsis and death.

OBJECTIVE

To report a case of leukemic perianal infiltration with atypical ulcerated lesion.

CASE REPORT

Female patient, 21 years of age with diagnosis of AML M7, began with perianal pain posterior to evacuation associated with bleeding; at perianal examination we found anterior atypical ulcerated lesion. We carried out a biopsy under suspicion of leukemic infiltration corroborated by histopathology. The patient received conservative treatment.

CONCLUSIONS

We must suspect leukemic infiltration in patients with anal symptoms and effect close surveillance. Prognosis depends on control of hematologic disease.

Experience in management of Fournier's gangrene

We report our experience and results in the management of Fournier's gangrene. Fournier's gangrene is a synergistic infective necrotizing fasciitis, which involves perianal, perineal and genital regions, originated mostly from colorectal and genitourinary sources. Charts and records from 28 patients with Fournier's gangrene diagnosed between 1993 and 1997 were reviewed. The mean patients age was 57.8 years (range, 22-82 years); mean hospital stay was 19 days. Eighteen patients (64.3%) were diabetic. The most common source of gangrene was ischiorectal abscess in 22 patients (78.6%). Colostomy was performed on 14 patients (50%) and cystostomy on 7 patients (25%). Ten patients (35.7%) died because of sepsis. In conclusion, medical and surgical treatment should be aggressive. Colostomy should only be performed if sphincter complex is damaged. Multidisciplinary management is mandatory, because of high morbidity and mortality.

[Colonic primary lymphoma]

Primary colon lymphomas (PCL) are very rare tumors of the gastrointestinal tract, and represent 0.2-0.5% of all colon primary tumors. They appear principally PCL in adult population. Almost all are non-Hodgkin's lymphomas; first however, one must discard lymph node origin. The most frequent sites of presentation are the cecum and rectum. Treatment of choice is surgical, plus adjuvant chemotherapy. Radiotherapy is reserved for specific cases.

OBJECTIVE

To inform on two cases of PCL.

METHOD

Review two of cases of cecum lymphomas and their treatment.

RESULTS

We inform the cases of two patients with the diagnosis of cecum lymphoma. The main patient complaints were abdominal pain, palpable mass, and hemorrhage. Both patients were treated with right extended hemicolectomy and ileum-transverse anastomosis. The outcome was unremarkable. Both patients received chemotherapy and remain free of disease at 1.5 and 5 years of follow-up.

CONCLUSIONS

Primary colon lymphomas are very uncommon gastrointestinal tumors, with cecum localization as one of the most frequent sites of presentation in the colon. Treatment of choice must be surgical, with chemotherapy as an adjuvant therapy to improve survival.

[Toxic megacolon secondary to pseudomembranous colitis]

BACKGROUND

Toxic megacolon is a rare complication of pseudomembranous colitis.

OBJECTIVE

The aim of this paper is to present a rare case of toxic megacolon secondary to pseudomembranous colitis.

METHODS

The chart of a 75-year-old male, who developed a toxic megacolon secondary to pseudomembranous colitis no was reviewed.

RESULTS

The clinical features and outcome of a 75-year-old male with pseudomembranous colitis are depicted. The main symptoms were no ever, abdominal distention, bloody and diarrhea; the man suddenly developed a toxic megacolon and taken was to surgery. Total colectomy with proximal rectal closure was performed. The patient died within 24 hours of the abdominal procedure.

CONCLUSIONS

Toxic megacolon is a rare complication of pseudomembranous colitis. Its presence should be suspected when these patients develop no colonic dilatation with associated systemic toxicity. Aggressive surgical intervention is indicated.

[Anorectal surgery in patients infected with human immunodeficiency virus]

OBJECTIVE

The aim of this study was to describe the clinical characteristics of the patients infected with the human immunodeficiency virus (HIV), who were submitted to anorectal surgery with emphasis on healing time and complications.

METHODS

The patients were evaluated prospectively from July 1998 to July 1999; there was a total of 23 patients HIV (+) (Group 1). They were compared to a control group of randomly chosen HIV (-) patients (Group II) to establish the characteristics of each group, the morbidity, and the time of healing. The statistical analysis was performed with the student T test.

RESULTS

In Group I, the diagnosis were fistula in the anus, anal fissure, anal abscess, condylomata acuminata, anal ulcer, and cutaneous flaps. Seven patients had a fistulotomy, a drainage of abscess in one, resection of different skin lesions in 12, electrofulguration of condylomata in two, fisturectomy in three and solely biopsy in three. The average healing time was 26.087 days for Group I and 23.21 days for Group II. A comparison between healing time and complications in these two groups was carried out to determine a whether significant difference exists in these parameters. There was no significant difference between these groups, but there were unequal rates of healing (26.087, DE +/- 10.778 days vs 23.21 DE +/- 6.259 days; p = not significant) and complications for the similar procedures.

CONCLUSIONS

The healing in time HIV (+) patients submitted to anorectal surgery may not vary important when compared with HIV (-) patients.

[Colonoscopy. Analysis of 2,000 procedures]

BACKGROUND

During the last 3 decades, colonoscopy has become the diagnostic study with greatest sensitivity and acuity in colonic pathology.

AIMS

To know the most frequent diagnostic and colonoscopic disorders, and the pathology found, to establish certainty of the colonoscopic procedure.

METHOD

Between 1987 and 1997, a descriptive, transversal, retrospective and observational study of the 2,000 colonoscopies that were carried out at on service was done, making a registry of the endoscopic search in colorectal pathology and their characteristics in on patients.

RESULTS

Colonoscopies were done in 967 men (47.3%) and 1,053 women (52.6%) with a median age of 55.8 years (10 range (-) 93 years). In 1,780 of them (89.%), it was possible to arrive to cecum; 1,150 (57.5%) were pathologic. The most frequent finding was hemorrhage of the lower digestive tube in 525 (26.2%) patients; in addition cancer in 402 (20.1%), suspicion of intestinal inflammatory disease 292 (14.6%) and colorectal polyps 199 (10%) were found. The most frequent endoscopic diagnosis was colorectal polyps in 405 (35.7%) patients; in additions diverticular disease was found in 404 (35.1%) patients intestinal inflammatory disease in 185 (16%), colorectal cancer in 85 (7.4%), and vascular ectasias in 52 (4.5%) patients. There were four complicated cases (0.25%), three by resolved therapeutic colonoscopy and one diagnostically.

CONCLUSION

The most frequent colonoscopic were findings hemorrhage of the lower digestive tube and the finding of cancer. The most frequent diagnoses were colorectal polyps and diverticular disease. Colonoscopy is a safe diagnostic and therapeutic procedure.

[Synchronous neoplasias in colorectal cancer]

OBJECTIVE

The aim of this study was to show the incidence of synchronous lesions in colorectal cancer patients treated surgical at our service.

SUMMARY BACKGROUND DATA

Many studies have shown different incidences of synchronous lesions in colorectal cancer, mainly due to variations in the accuracy of the diagnostic methods used and the intentional search for associated lesucosal.

METHOD

Fifty-eight clinical records of patients operated on for colorectal cancer were retrospectively reviewed from August 1995 to March 1999. The synchronous lesions were classified as benign or malignant lesions based on its histological classification. Statistical analysis was carried out by the Spearman coefficient correlation.

RESULTS

Fifteen patients (25.8%) had 28 synchronous lesions, nine were male (60%), and six females (20%). The average age was 63.2 years with a range of 26 to 83 years. The endoscopic diagnosis of synchronous lesions was performed preoperatively in 12 patients (80%). The most frequent localization's of primary tumor was the sigmoid colon in six patients (40%). The more frequent localization of synchronous lesions was the rectum (35.7%). Benign lesions were most commonly found in synchronous lesions (89.3%).

CONCLUSIONS

The patient with colorectal cancer has an unstable epithelium and an uncommon predisposition to develop several mucosal alterations. This predisposition is prone to grow benign or malignant lesions. For this reason, we advise all that patient with colorectal cancer be fully studied endoscopically.