RESUMEN
INTRODUCTION: transanal endoscopic microsurgery (TEM) was developed in 1983 by Büess as a minimally invasive technique to manage rectal villous adenomas and early rectal adenocarcinomas. Many studies have been published worldwide about its excellent results in morbidity and recidive rate, but there are few studies addressing functional results. The objective of this study is to analyze the effect of this technique in the anal anatomy and compare with the manometric results. MATERIAL AND METHODS: we devised a prospective study of 40 patients. 39% female, 61% male. All of them filled an incontinence questionnaire (Pescatori scale) and endoanal ultrasonography and manometry was carried out preoperatively, third month postoperative and at sixth month only if incontinence appeared. RESULTS: 32 patients (80%) had villous adenomas and 8 patients (20%) had adenocarcinomas (uT1). Three patients complained of flatus incontinence at 3rd postoperative month that disappeared with normal continence at 6th month. Anorectal manometric values: mean anal resting pressure (ARP) decreased at 3rd month (from 87.2 mmHg to 70.1 mmHg), as it was for maximal squeeze pressure (MSP) from 152.5 mmHg preoperatively to 142.2 mmHg at 3rd month. Ultrasonography demonstrated internal anal sphincter (IAS) rupture in 3 patients, with a full integrity of the external anal sphincter in all patients. CONCLUSIONS: during TEM, a significant anal dilatation occurs, because of rectoscopy (40 mm wide), what can produce a rupture of IAS, with the consequent decreasing in ARP, and a dilatation without rupture of external sphincter what produces a decreasing of MSP. The fall of anal pressures had minima clinical repercussion when sphincter is intact, but when IAS is broken a temporal incontinence develops.
Asunto(s)
Adenocarcinoma/cirugía , Adenoma Velloso/cirugía , Microcirugia/métodos , Proctoscopía , Neoplasias del Recto/cirugía , Anciano , Canal Anal , Femenino , Humanos , Masculino , Proctoscopía/métodos , Estudios ProspectivosRESUMEN
Introducción: la microcirugía transanal endoscópica (TEM)fue desarrollada en 1983 por Büess como técnica mínimamenteinvasiva para el tratamiento de adenomas y adenocarcinomas enestadio precoz de recto. Son múltiples los estudios realizados entodo el mundo sobre sus resultados de morbimortalidad y tasa derecidiva, pero sin embargo son muy pocos los estudios publicadossobre los resultados funcionales. El objetivo de este estudio fueanalizar el efecto que esta cirugía provoca en la anatomía del canalanal y compararlo con los resultados funcionales.Material y métodos: realizamos un estudio descriptivo prospectivode 40 pacientes: 39% mujeres, 61% hombres. En todosellos se cumplimentó una encuesta de función esfinteriana (test dePescatori) y ecografía endoanal y manometría preoperatoria, al 3ermes postoperatorio, y al 6º sólo si apareció incontinenciaResultados: Treinta y dos pacientes (80%) fueron operados deadenomas y 8 pacientes (20%) de adenocarcinomas uT1. Tres pacientespresentaron incontinencia a gases al 3er mes postoperatorioque se normalizó al 6º mes. Valores de la manometría anorrectal: lapresión media en reposo (PMR) había disminuido a los 3 meses conrespecto al valor preoperatorio de 87,2 a 70,1 mmHg, al igual quela presión máxima de contracción (PMC) de 152,5 mmHg de formapreoperatoria a 142,2 mmHg. Ecográficamente se pudo demostrarrotura del esfínter anal interno en 3 pacientes, estando en todos lospacientes íntegro el esfínter externo.Conclusiones: durante el tiempo quirúrgico de la TEM y debidoal diámetro del rectoscopio (40 mm), existe una dilataciónmantenida del canal anal. Esto unido al hecho de que es frecuenteque haya que modificar la posición del mismo, se traduce, en algunoscasos, en un riesgo de rotura del EAI, con la consiguientecaída en la PMR. En definitiva la caída que se objetiva en las presionesendoanales tiene una mínima repercusión en la clínica amenos que exista una lesión esfinteriana lo que conlleva incontinencia,en cualquier caso siempre temporal
Introduction: transanal endoscopic microsurgey (TEM) wasdeveloped in 1983 by Büess as a minimally invasive technique tomanage rectal villous adenomas and early rectal adenocarcinomas.Many studies have been published worldwide about its excellentresults in morbidity and recidive rate, but there are few studiesaddressing functional results. The objective of this study is to analyzethe effect of this technique in the anal anatomy and comparewith the manometric results.Material and methods: we devised a prospective study of40 patients. 39% female, 61% male. All of them filled an incontinencequestionnaire (Pescatori scale) and endoanal ultrasonographyand manometry was carried out preoperatively, third monthpostoperative and at sixth month only if incontinence appeared.Results: 32 patients (80%) had villous adenomas and 8 patients(20%) had adenocarcinomas (uT1). Three patients complainedof flatus incontinence at 3rd postoperative month that disappearedwith normal continence at 6th month. Anorectalmanometric values: mean anal resting pressure (ARP) decreasedat 3rd month (from 87.2 mmHg to 70.1 mmHg), as it was formaximal squeeze pressure (MSP) from 152.5 mmHg preoperativelyto 142.2 mmHg at 3rd month. Ultrasonography demonstratedinternal anal sphincter (IAS) rupture in 3 patients, with a full integrityof the external anal sphincter in all patients.Conclusions: during TEM, a significant anal dilatation occurs,because of rectoscopy (40 mm wide), what can produce a ruptureof IAS, with the consequent decreasing in ARP, and a dilatationwithout rupture of external sphincter what produces a decreasingof MSP. The fall of anal pressures had minima clinical repercussionwhen sphincter is intact, but when IAS is broken a temporalincontinence develops
Asunto(s)
Masculino , Femenino , Anciano , Humanos , Microcirugia/métodos , Adenocarcinoma/cirugía , Adenoma Velloso/cirugía , Proctoscopía , Neoplasias del Recto/cirugía , Estudios Prospectivos , Canal AnalRESUMEN
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Asunto(s)
Femenino , Adulto , Humanos , Enfermedades del Colon/complicaciones , Colon Transverso , Obstrucción Intestinal/etiología , Vólvulo Intestinal/complicacionesRESUMEN
INTRODUCTION: Proctalgia fugax (PF) is a benign, self-limiting disease characterized by episodes of intense anorectal pain at frequent intervals in the absence of organic proctological disease. Even though PF was described more than a century ago, its etiology remains unclear. Currently there is no information available. Few papers quoting many ways of management have been published. The aim of this study was to investigate patients complaining of this condition and to treat them with sequential therapy. PATIENTS AND METHODS: We devised a descriptive, prospective study of patients complaining of acute perianal pain--duration less than 30 minutes--without organic disease or previous perianal surgery since 1996 to 2002 in our Department. We treated these patients using a three-step treatment (1: information, hip bath, benzodiazepines; 2: sublingual nifedipine 10 mg, or topic 0.1% nitroglycerin on demand; 3: internal anal sphincterotomy if hypertrophy of the internal anal sphincter was demonstrated by anal ultrasonography and no improvement was confirmed with the previous steps of treatment). We defined remarkable improvement as a decrease in the number of episodes by half or in pain intensity by 50%. RESULTS: Fifteen patients with an average follow-up of 4 years. Anal endosonography confirmed a grossly thickened internal anal sphincter (IAS) in 5 cases. After the first step of treatment 7 patients improved and 1 patient was cured; after the second step of treatment 3 patients improved and 1 was cured; the third step was applied to 3 patients with a thickened IAS; 1 patient improved and 1 patient was cured. CONCLUSION: A total resolution of PF is not always possible, but we may improve symptoms and their frequency. Almost 50% of patients in our series improved with the first step of treatment; 30% of our patients had IAS hypertrophy. Anal endosonography can help in the diagnosis of organic diseases or IAS hypertrophy, for which we can perform an internal anal sphincter myectomy.
Asunto(s)
Canal Anal , Enfermedades del Ano/terapia , Enfermedad Aguda , Adulto , Canal Anal/diagnóstico por imagen , Canal Anal/patología , Canal Anal/cirugía , Ansiolíticos/administración & dosificación , Ansiolíticos/uso terapéutico , Enfermedades del Ano/diagnóstico por imagen , Enfermedades del Ano/tratamiento farmacológico , Enfermedades del Ano/patología , Enfermedades del Ano/cirugía , Baños , Benzodiazepinas/administración & dosificación , Benzodiazepinas/uso terapéutico , Endosonografía , Femenino , Estudios de Seguimiento , Humanos , Hipertrofia , Masculino , Persona de Mediana Edad , Nifedipino/administración & dosificación , Nifedipino/uso terapéutico , Nitroglicerina/administración & dosificación , Nitroglicerina/uso terapéutico , Dolor/tratamiento farmacológico , Dolor/etiología , Manejo del Dolor , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento , Vasodilatadores/administración & dosificación , Vasodilatadores/uso terapéuticoRESUMEN
Introducción: la proctalgia fugaz (PF) es una patología benigna,autolimitada, caracterizada por dolor anorrectal intenso, a intervalosfrecuentes, sin causa orgánica aparente. Su etiología noestá clara, a pesar de ser conocida desde hace un siglo y existenpocos artículos publicados sobre esta patología, con escaso númerode pacientes, aplicando tratamientos variados con mayor o menorfortuna. El propósito de este trabajo ha sido estudiar a una seriede pacientes aquejados de esta patología y aplicar a todos ellosun tratamiento de manera secuencial en dependencia de su respuestaal mismo.Material y métodos: realizamos un estudio descriptivo prospectivode pacientes aquejados de dolor perianal brusco, < 30min de duración, sin lesión orgánica concomitante ni intervenciónprevia perianal desde 1996-2002 en nuestro Servicio, sometiéndolesa un tratamiento de manera secuencial, basado en 3 escalonesterapéuticos (1. información, baños de asiento, tranquilizantes;2. nifedipino 10 mg sublingual, o nitroglicerina tópica 0,1%en el momento de la crisis; y 3. esfinterotomía lateral interna si hipertrofiadel esfínter anal interno y no mejoría con los otros escalones).Definimos mejoría significativa cuando se producía un importantedistanciamiento de los episodios (disminución nº crisis ala mitad) y/o disminución del dolor en un 50%.Resultados: quince pacientes con un seguimiento medio de 4años. Mediante ecografía endoanal se pudo demostrar la existenciade hipertrofia del esfínter anal interno (EAI) en 5 casos. Tras laaplicación del escalón 1 mejoraron 7 pacientes y curó 1 paciente;con el escalón 2 mejoraron 3 pacientes y 1 curó, y se aplicó el escalón3 a 3 pacientes que presentaban hipertrofia del EAI mejorando1 y curando otro paciente.Conclusión: la curación de la PF no siempre es factible, perosí es posible aliviar los síntomas, así como su frecuencia. Casi el50% de los pacientes de nuestra serie mejoró con el escalón 1 deltratamiento. Un tercio de nuestros pacientes presentaban hipertrofiadel EAI. La ecografía endoanal ayudará tanto a descartar lesionesorgánicas concomitantes como a diagnosticar una hipertrofiadel EAI, que se beneficiaría de una esfinterotomía lateral interna
disease characterized by episodes of intense anorectal pain at frequentintervals in the absence of organic proctological disease.Even though PF was described more than a century ago, its etiologyremains unclear. Currently there is no information available.Few papers quoting many ways of management have been published.The aim of this study was to investigate patients complainingof this condition and to treat them with sequential therapy.Patients and methods: we devised a descriptive, prospectivestudy of patients complaining of acute perianal pain durationless than 30 minutes without organic disease or previous perianalsurgery since 1996 to 2002 in our Department. We treatedthese patients using a three-step treatment (1: information, hipbath, benzodiazepines; 2: sublingual nifedipine 10 mg, or topic0.1% nitroglycerin on demand; 3: internal anal sphincterotomy ifhypertrophy of the internal anal sphincter was demonstrated byanal ultrasonography and no improvement was confirmed withthe previous steps of treatment). We defined remarkable improvementas a decrease in the number of episodes by half or in painintensity by 50%.Results: Fifteen patients with an average follow-up of 4 years.Anal endosonography confirmed a grossly thickened internal analsphincter (IAS) in 5 cases. After the first step of treatment 7 patientsimproved and 1 patient was cured; after the second step oftreatment 3 patients improved and 1 was cured; the third stepwas applied to 3 patients with a thickened IAS; 1 patient improvedand 1 patient was cured.Conclusion: a total resolution of PF is not always possible,but we may improve symptoms and their frequency. Almost 50%of patients in our series improved with the first step of treatment;30% of our patients had IAS hypertrophy. Anal endosonographycan help in the diagnosis of organic diseases or IAS hypertrophy,for which we can perform an internal anal sphyncter myectomy