RESUMO
Stomas are essential for colorectal surgery and are widely used not only for selected cases for bowel obstructions but also in rectal cancer operations to divert stool away from low rectal anastomosis. On the other hand, complications with stomas/ stomas reversal are not uncommon. In this study, we aimed at studying the frequency and the predictors of temporary stomas being permanent, and the contributing factors of surgical stoma/stoma closure related complications. In our cohort, only about 40% of the patient closed their initially planned temporary stomas. The occurrence of intestinal leak, wound sepsis, or any type of morbidity with 30 days of operation were significant predictors of permanent stomas. In addition, alarmingly although Hartmann's procedure was uncommon in our practice, only 9% of those who underwent Hartmann's have had it reversed. Moreover, the only factor that significantly increased stoma related complications was having an end colostomy. There was a tendency toward late closure of stomas with median 8.2 months, however early closure did not correlate to complications. In conclusion, further studies are needed to delineate the low rate of stoma closure. Patients who develop postoperative complications, even wound sepsis, would be at a higher risk of living with permanent stomas. Hartmann's procedures are commonly associated with stoma problems, and reluctance to reverse the stomas. (AU)
Assuntos
Humanos , Masculino , Feminino , Reto/cirurgia , Neoplasias Colorretais/cirurgia , Estomas Cirúrgicos/efeitos adversos , Perfil de Saúde , Estudos RetrospectivosRESUMO
INTRODUCTION: Hartmann's procedure (HP) is the conventional treatment in patients with complicated diverticulitis. Segmental resection with primary anastomosis (PA) is a treatment alternative for those patients. Our aim was to compare the postoperative results of HP and PA in patients with complicated diverticulitis (Hinchey stage III). METHODS: A case-control study was conducted on patients operated on for purulent Hinchey stage III diverticulitis, within the time frame of 2000 and 2019. RESULTS: Twenty-seven patients that underwent PA were compared with 27 that underwent HP. The patients that underwent HP had a greater probability of morbidity at 30 days (OR 3.5; 95% CI 1.13-11.25), as well as a greater probability of major complications (OR 10.9; 95% CI 1.26-95.05). CONCLUSION: The patients that underwent segmental resection and PA presented with lower morbidity rates and higher stoma reversal rates than the patients that underwent HP.
Assuntos
Doença Diverticular do Colo , Diverticulite , Perfuração Intestinal , Humanos , Doença Diverticular do Colo/cirurgia , Doença Diverticular do Colo/complicações , Estudos de Casos e Controles , Perfuração Intestinal/etiologia , Diverticulite/cirurgia , Diverticulite/complicações , Anastomose Cirúrgica/efeitos adversosRESUMO
RESUMEN Antecedentes: la reconstrucciónn del tránsito intestinal luego de una operación de Hartmann es un procedimiento habitualmente complejo y con alta morbilidad. Objetivo: analizar la tasa de reconstrucción después de la cirugía de Hartmann y resultados posoperatorios en nuestra experiencia. Material y métodos: análisis retrospectivo de pacientes a los que se les practicó la reconstrucción del tránsito intestinal posterior a una cirugía de Hartmann en un período 16 años. Revisamos la bibliografía y nuestra base de datos. Luego traspasamos la información disponible a una grilla de datos construida con variables habitualmente analizadas en la literatura. Finalmente, analizamos los resultados mediante medidas básicas de tendencia central. Resultados: en 16 años realizamos 92 operaciones de Hartmann, de las cuales 69 (75%) llegaron a la reconstrucción. Edad promedio: 58 años. El 52% de los pacientes fueron hombres. La operación de Hartmann fue de urgencia en el 48% y 58% resultaron malignas. Tiempo transcurrido hasta la reconstrucción: en promedio, 9 meses, y el 90% (N 62) de los casos se realizó por vía laparoscópica. Morbilidad general 38% y ajustada a los grados III y IV de Clavien-Dindo fue 11,5%. No hubo mortalidad. Conclusión: los resultados obtenidos son semejantes a los publicados y nuestra experiencia nos motiva a continuar eligiendo el abordaje laparoscópico.
ABSTRACT Background: Background: Stoma reversal after Hartman's operation is usually a complex procedure and is associated high morbidity. Objective: To analyze the rate of reversal after the Hartmann's procedure and the postoperative outcomes in our experience. Material and methods: We conducted a retrospective analysis of patients undergoing reversal after the Hartmann's procedure over a 16-year period with review of the literature and of our database and transferred the available information to a data grid constructed with variables commonly analyzed in the literature. Finally, we analyzed the results using basic measures of central tendency. Results: Over a 16-year period, we performed 92 Hartmann's operations; 69 (75%) reached the reversal stage. Mean age was 58 years and 52% were men. Forty-eight percent of the Hartmann's procedures were emergency surgeries and 58% were due to cancer. Mean time to reversal was 9 months and 90% (n = 62) were laparoscopic procedures. Overall morbidity and adjusted for complications grade III and IV of the Clavien-Dindo classification were 38% and 11.5%, respectively. None of the patients died. Conclusion: The results obtained are similar to those published and our experience motivates us to continue choosing the laparoscopic approach.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Adulto Jovem , Colostomia/estatística & dados numéricos , Ileostomia/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Intestinos/cirurgia , Estudos Retrospectivos , Morbidade , Fístula da Bexiga Urinária/cirurgia , Fístula Intestinal/cirurgiaRESUMO
Resumen Objetivo: El objetivo de este estudio es comparar los resultados perioperatorios del abordaje abierto (AA) con el abordaje laparoscópico (AL) para la reconstitución de tránsito (RT), y determinar factores de riesgo asociados a morbilidad posoperatoria. Material y Métodos: Se estudiaron pacientes consecutivos sometidos a RT entre enero de 2007 y diciembre de 2016 en nuestro centro. Se excluyeron aquellos con grandes hernias incisionales que requirieran reparación abierta simultánea. Se consignaron variables demográficas y perioperatorias, y se compararon ambos grupos. Además, se realizó una regresión logística para la identificación de factores de riesgo asociados a morbilidad posoperatoria en la serie. Resultados: Se realizaron 101 RT en el período. Se excluyeron 14 casos por hernia incisional, por lo que se analizaron 87 casos (46 AA y 41 AL). Diez pacientes en el grupo AL (24,4%) requirieron conversión, principalmente por adherencias. La morbilidad total de la serie fue de 36,8%, siendo mayor en el AA (50% vs 21,9%, p = 0,007). Hubo una filtración anastomótica en cada grupo. La estadía posoperatoria fue de 5 (3-52) días para el AL y 7 (4-36) días para el AA (p < 0,001). En la regresión logística, sólo el AA fue un factor de riesgo independientemente asociado a morbilidad posoperatoria (OR 2,89, IC 95% 1,11-7,49; p = 0,029). Conclusión: El abordaje laparoscópico se asocia a menor morbilidad y estadía posoperatoria que el abordaje abierto para la reconstitución del tránsito pos-Hartmann. En nuestra serie, el abordaje abierto fue el único factor independientemente asociado a morbilidad posoperatoria.
Introduction: Hartmann's reversal (HR) is considered a technically demanding procedure and is associated with high morbidity rates. Aim: The aim of this study is to compare the perioperative results of the open approach (OA) with the laparoscopic approach (LA) for HR, and to determine the risk factors associated with postoperative morbidity. Material and Methods: Consecutive patients undergoing HR between January 2007 and December 2016 at a university hospital were included. Patients with large incisional hernias that required an open approach a priori were excluded from the analysis. Demographic and perioperative variables were recorded. Analytical statistics were carried out to compare both groups, and a logistic regression was performed to identify risk factors associated with postoperative morbidity in the series. Results: A hundred and one HR were performed during the study period. Fourteen cases were excluded due to large incisional hernias, so 87 cases (46 OA and 41 LA) were analyzed. Ten patients in the LA group (24.4%) required conversion, mainly due to adhesions. The total morbidity of the series was 36.8%, being higher in the OA group (50% vs. 21.9%, p = 0.007). There was one case of anastomotic leakage in each group. The length of stay was 5 (3-52) days for LA and 7 (4-36) days for OA (p < 0.001). In the logistic regression, the OA was the only independent risk factor associated with postoperative morbidity in HR (OR 2.89, IC 95% 1.11-7.49; p = 0.029). Conclusion: A laparoscopic approach is associated with less morbidity and a shorter length of stay compared to the open approach for Hartmann's reversal. An open approach was the only factor independently associated with postoperative morbidity in our series.
Assuntos
Humanos , Complicações Pós-Operatórias/epidemiologia , Neoplasias Colorretais/cirurgia , Laparoscopia/métodos , Cirurgia Colorretal/métodos , Laparotomia/métodos , Complicações Pós-Operatórias/fisiopatologia , Anastomose Cirúrgica/métodos , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/patologia , Distribuição de Qui-Quadrado , Análise de Sobrevida , Laparoscopia/efeitos adversos , Cirurgia Colorretal/efeitos adversos , Laparotomia/efeitos adversosRESUMO
La diverticulosis puede presentarse en cualquier sector del tubo digestivo. La topografía de intestino delgado es infrecuente, se presenta sobre todo a nivel del yeyuno y en un 35% de los casos se asocia con diverticulosis colónica. Es más frecuente en mayores de 40 años. Los divertículos van disminuyendo de tamaño y número hacia el sector distal. Habitualmente el diagnóstico es incidental, sin embargo, pueden presentar complicaciones de las cuales se destacan por frecuencia el sangrado gastrointestinal y la diverticulitis. Se plantea que la deficiencia de fibra dietética generaría anomalías en el peristaltismo intestinal, lo que junto con fenómenos pseudo-obstructivos y alta presión intraluminal, actuaría en áreas de debilidad focal provocando la lesión. Presentamos el caso de una paciente de 88 años con una oclusión de colon a la cual se le realizó una cirugía de Hartmann, en el intraoperatorio se identificó divertículos de yeyuno sin elementos complicaciones.
Assuntos
Humanos , Feminino , Idoso de 80 Anos ou mais , Divertículo/diagnóstico , Colo/cirurgia , Obstrução Intestinal/cirurgia , Jejuno , Octogenários , Complicações IntraoperatóriasRESUMO
Research has shown that longitudinal chromatic aberration (LCA) of the human eye is generated across all of the eye's optical surfaces. However, it may not be necessary to measure the LCA from the first surface of the cornea to the retina, as it is known that most of the changes that can modify the path of light occur from the first surface of the cornea to the last surface of the crystalline lens. This investigation presents the study of an objective technique that allows the measurement of longitudinal chromatic aberration (LCA) on the last crystalline lens surface by developing a pulse width wavefront system using a Hartmann test, Purkinje image, and Zernike polynomial. A blue pulse (440-480 nm) and a red pulse (580-640 nm) were used to generate a pattern of spots in the human eye. This pattern generated on the posterior surface of the crystalline lens of the human eye allows the reconstruction of the wavefront via a modal method with Zernike polynomials. Once the wavefront is reconstructed, Zernike coefficients can be used to quantify the LCA. The methodology and objective measurements of the magnitude of the longitudinal chromatic aberration of five test subjects are explained in this article.
Assuntos
Cristalino , Erros de Refração , Algoritmos , Córnea , Humanos , Visão OcularRESUMO
Abstract Background The reestablishment of continuity after Hartmann operation is considered a major surgical procedure with high morbidity and mortality. The optimal interval time between the Hartman procedure and reversal is controversial. Our study aimed to evaluate the effectiveness of laparoscopic Hartmann reversal and to determine the optimal timing of operation. Methods All patients who underwent laparoscopic Hartmann reversal from 2008 to 2019 (11 years) at the University Medical Center (UMC) in Ho Chi Minh City were recruited and divided into 2 groups according to the interval time (≤ 4 or > 4 months). The short-term operative outcomes of these groups were compared. Results There were 66 patients who underwent laparoscopic Hartmann reversal (mean age: 63.2 years old); ~ 77% of them had colorectal cancer, and 17% had complicated diverticular disease. Themortality rate, anastomotic leakage rate, and overall complication rate were 0%, 1.5%, and 13.2%, respectively. Early operation was performed in 36 patients, and late reversal in 28 patients. There was no difference in mortality, anastomotic leakage, operative complications, and hospital stay between the two groups. Conclusion Laparoscopic Hartmann reversal was effective with acceptable morbidity and mortality at the UMC. There was no observed impact of the interval time between the Hartmann procedure and laparoscopic Hartmann reversal on the short-term operative outcomes.
Resumo Introdução O reestabelecimento da continuidade após a cirurgia de Hartmann é considerado um procedimento cirúrgico de grande porte com altas morbidade e mortalidade. O tempo ideal de intervalo entre a cirurgia de Hartmann e a reversão é controverso. Nosso estudo teve como objetivo avaliar a eficácia da reversão da cirurgia de Hartmann e determinar o momento ideal para a cirurgia. Métodos Todos os pacientes submetidos à reversão laparoscópica da cirurgia de Hartmann entre 2008 e 2019 (11 anos) no Centro Médico Universitário (UMC, na sigla em inglês) na cidade de Ho Chi Minh foram recrutados e divididos em 2 grupos de acordo como tempo de intervalo (≤ 4 or > 4 meses). Os resultados pós-operatórios de curto prazo destes grupos foram comparados. Resultados Um total de 66 pacientes foram submetidos à reversão laparoscópica da cirurgia de Hartmann (mediana de idade: 63.2 anos); ~ 77 deles tinha câncer colorretal, e 17% tinham doença diverticular complicada. As taxas de mortalidade, de vazamento, e de complicações em geral foram de 0%, 1,5%, e 13,2%, respectivamente. Cirurgia precoce foi realizada em 36 pacientes, e reversão tardia foi realizada em 28 pacientes. Não houve diferença em mortalidade, vazamento anastomótico, complicações operatórias e duração da internação entre os dois grupos. Conclusão A reversão laparoscópica da cirurgia de Hartmann foi eficaz, com morbidade e mortalidade aceitáveis no UMC. Não foi observado qualquer impacto no tempo de intervalo entre a cirurgia de Hartmann e a reversão laparoscópica nos resultados pós-operatórios de curto prazo.
Assuntos
Humanos , Masculino , Feminino , Laparoscopia , Cirurgia Colorretal/métodos , Complicações Pós-Operatórias , Reoperação , Resultado do TratamentoRESUMO
OBJECTIVE: We aimed to define indication of Hartmann procedure (HP) under emergency conditions, analyze, and present in which cases this procedure should be used. METHODS: The patients who underwent emergency surgery for colorectal cancer were analyzed. Rates of mortality, overall, and disease-free survival of the patients were evaluated. The colostomy closure rate, operative mortality, and surgical complications of the secondary operation performed after the HP were also assessed. RESULTS: Fifty-seven patients who underwent HP were included in the study. The indications were obstruction (n = 37) or perforation (n = 20). The post-operative mortality and morbidity rates were 21.1% and 63.2%, respectively. The 1-, 3-, and 5-year survival rates for all patients were 54%, 49%, and 45%. CONCLUSION: HP can be a life-saving procedure in cases of high risk, emergency colorectal disease. Surgeons create a temporary stoma as a part of this procedure that is generally closed with a second operation. However, it is not possible to close the stoma in some cases, and the potential physical and emotional issues related to the stoma should be a part of the surgeon's considerations.
OBJETIVO: Definir la indicación del procedimiento de Hartmann en condiciones de emergencia y en qué casos debe utilizarse. MÉTODO: Se analizaron los pacientes sometidos a cirugía colorrectal de emergencia. Se evaluaron las tasas de mortalidad y de supervivencia global y libre de enfermedad. También se evaluaron la tasa de cierre de la colostomía, la mortalidad operatoria y las complicaciones quirúrgicas de la operación secundaria. RESULTADOS: Fueron incluidos en el estudio 57 pacientes sometidos a un procedimiento de Hartmann. Las indicaciones fueron obstrucción (n = 37) o perforación (n = 20). Las tasas de mortalidad y de morbilidad posoperatorias fueron del 21,1% y el 63,2%, respectivamente. Las tasas de supervivencia a 1, 3 y 5 años para todos los pacientes fueron del 54%, el 49% y el 45%. CONCLUSIÓN: El procedimiento de Hartmann puede salvar vidas en casos de enfermedad colorrectal de emergencia de alto riesgo. Los cirujanos crean un estoma temporal como parte de este procedimiento, que generalmente se cierra con una segunda operación. Sin embargo, en algunos casos no es posible cerrar la estoma, y los posibles problemas físicos y emocionales relacionados con este deberían ser parte de las consideraciones del cirujano.
Assuntos
Doenças do Colo , Neoplasias Colorretais , Anastomose Cirúrgica , Neoplasias Colorretais/cirurgia , Colostomia , Emergências , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologiaRESUMO
Resumen Objetivo: Conocer las diferentes conductas que realizan los cirujanos coloproctólogos latinoamericanos en relación con las urgencias colónicas. Materiales y Método: Estudio transversal, utilizando encuesta vía web con preguntas de selección múltiple. La encuesta fue enviada a las distintas Sociedades Coloproctológicas Latinoamericanas, así como a la Asociación Latinoamericana de Coloproctología (ALACP), para su distribución. La encuesta fue escrita en español neutro y traducida al portugués. Se utilizó análisis estadísticos descriptivos y analítico. Resultados: 441 encuestas respondidas completamente de 16 países diferentes. El 85% realiza resección y anastomosis sin ostomía de protección en obstrucciones de colon derecho. En las perforaciones del colon izquierdo, se realiza operación de Hartmann en el 63,3% de los casos que presentan peritonitis purulentas y en el 94,5% de las peritonitis fecaloideas. Discusión: En las obstrucciones colónicas, la resección con anastomosis primaria, es una conducta poco discutida en colon derecho, a diferencia de las obstrucciones del lado izquierdo, en donde realizar una operación de Hartmann es una conducta tan válida como la resección y anastomosis. En los cuadros de perforación, la decisión de resección y anastomosis primaria es multifactorial, tomando relevancia la estabilidad hemodinámica del paciente. En estos últimos casos, realizar una resección con ostomía, es la respuesta de gran parte de los encuestados. Conclusiones: Los resultados de cada situación, en su mayoría, presentan una tendencia clara hacia una conducta en particular; solo en el caso de obstrucción de colon izquierdo, se observan dos conductas (operación de Hartmann o anastomosis primaria) ambas validadas por la literatura internacional.
Objective: Learn about the different management options performed by latin american colon and rectal surgeons, in relation to colonic emergencies. Materials and Method: Cross-sectional study, using web survey with multiple-choice questions. The survey was sent to the different Latin America Coloproctological Societies, as well as to ALACP, for distribution. The survey was written in neutral Spanish and translated into Portuguese. Descriptive and analytical statistical analysis was used. Results: 441 complete surveys, from 16 different countries. 85% perform resection and anastomosis without diverting ostomy in obstructions of the right colon. In perforations of the left colon, Hartmann's procedure is performed in 63.3% of case with purulent peritonitis and in 94.5% of fecaloid peritonitis. Discussion: In colonic obstructions, resection with primary anastomosis, is little discussed behavior in the right colon, unlike obstructions on the left side, where performing a Hartmann operation is a behavior as valid as resection and anastomosis. In colonic perforation, the decision of resection and primary anastomosis is multifactorial, taking into account the hemodynamic stability of the patient. In the latter cases, performing an ostomy is the response of a large part of the surveyed. Conclusions: The results in each situation, for the most part, present a clear tendency towards a particular behavior; only in the case of left colon obstruction, two behaviors (Hartmann procedure or primary anastomosis) are both validated by international literature.
Assuntos
Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Cirurgiões/tendências , Obstrução Intestinal/cirurgia , Perfuração Intestinal/cirurgia , Complicações Pós-Operatórias , Resultado do Tratamento , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Perfuração Intestinal/etiologia , Perfuração Intestinal/mortalidadeRESUMO
ABSTRACT We report on the management of three cases of rectal stump leak and sepsis following urgent Hartmann's procedure for perforated sigmoid diverticulitis or large bowel obstruction. Two patients had significant risk factors for poor tissue healing. All patients developed features of sepsis and computer tomography scans demonstrated rectal stump leak with adjacent collections. All patients required reoperation for drainage and washout of abscess. An intraperitoneal catheter system was introduced together with drains in order to continue on the ward until tract was formed. There was no mortality and minimal morbidity. The key to management of rectal stump leak is the early and aggressive drainage of the associated collection and continued irrigation of the stump.
RESUMO Relatamos o tratamento de três casos de vazamento de coto retal e sepse após o procedimento de urgente de Hartmann para diverticulite sigmoide perfurada ou obstrução do intestino grosso. Dois pacientes apresentaram fatores de risco significativos para uma má cicatrização tecidual. Todos os pacientes desenvolveram características de sepse e tomografia computadorizada demonstraram vazamento de coto retal com coleções adjacentes. Todos os pacientes necessitaram de reoperação para drenagem e lavagem do abscesso. Um sistema de cateter intraperitoneal foi introduzido junto com os drenos para continuar na enfermaria até a formação do trato. Não houve mortalidade e morbidade mínima. A chave para o gerenciamento do vazamento de coto retal é a drenagem precoce e agressiva da coleta associada e a irrigação contínua do coto.
Assuntos
Humanos , Masculino , Idoso , Doenças do Colo Sigmoide/patologia , Doença Diverticular do Colo/patologia , Protectomia/efeitos adversos , Complicações Pós-Operatórias , Drenagem/métodosRESUMO
PURPOSE: We analyzed the morbidity and mortality associated with Hartmann's reversal (HR) and the risk factors for major complications and mortality. METHODS: The subjects of this retrospective study were patients who underwent HR in a high-volume center. We evaluated complications as categorical variables using univariate analyses. RESULTS: Between 2003 and 2018, 199 patients underwent HR at our hospital [56.5 years; body mass index (BMI): 26.3 kg/m2; American Society of Anesthesiology score (ASA) 3: 7.5%; 36.2% had hernias]. The mean time to HR was 20.2 months and the mean operation time was 302 min. The anastomosis was stapled in 71.4% and was performed in the low/medium rectum in 21.6%. Midline hernias were repaired with mesh in 80.1%. The mean hospitalization period was 10.1 days. Surgical site infection (SSI) developed in 27.1% of the patients, 94.4% of whom were treated at the bedside. BMI was a risk factor for SSI (27.8 vs. 25.6; p = 0.047). Major complications (Clavien-Dindo III-V) developed in 27 patients (13.5%), including anastomosis dehiscence in 2.5%. ASA, BMI, age, hernia repair, and rectal stump size were not associated with major complications. The mortality rate was 2.5%. An ASA of 3 was associated with high mortality (p = 0.03). CONCLUSION: Hartmann's reversal remains challenging but can have low complication and mortality rates if performed on selected patients in a reference center. An ASA of 3 was the only predictor of mortality.
Assuntos
Colostomia/métodos , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Colostomia/mortalidade , Feminino , Hospitais/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Deiscência da Ferida Operatória/epidemiologia , Deiscência da Ferida Operatória/etiologia , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Adulto JovemRESUMO
Resumen Antecedentes: Descrito hace casi 100 años, el procedimiento de Hartmann sigue vigente y es una conducta clásica para el manejo del colon izquierdo en la urgencia. La restitución del tránsito intestinal proporciona una importante mejora en la calidad de vida de los pacientes, sin embargo, la elevada morbimortalidad del procedimiento hace que solo la mitad de ellos se reconstruyan. La restitución del Hartmann laparoscópica ofrece las ventajas de los procedimientos mínimamente invasivos con morbimortalidad comparable a la cirugía convencional. Objetivos: Analizar la técnica quirúrgica y los resultados de una serie de pacientes en los cuales se realizó la restitución de Hartmann laparoscópica. Material y métodos: Revisión retrospectiva realizada entre marzo de 2002 y enero de 2017. La población pertenece a las Clínicas Quirúrgicas 2 y 3 del Hospital Maciel, Facultad de Medicina UDELAR, Montevideo, Uruguay. Resultados: Se operaron 29 pacientes: 10 mujeres y 19 hombres. Las enfermedades más frecuentes que determinaron el Hartmann estuvieron vinculadas a enfermedad diverticular (37,93%) u oncológica (34,48%). El tiempo mínimo transcurrido entre el Hartmann y la reconstrucción fue de 4 meses. Los tiempos operatorios variaron entre 107 y 240 min. El porcentaje de conversión fue del 24,1%. Ocurrieron complicaciones mayores en el 6,90% y menores en el 13,79%. No hubo fallas de sutura. La estadía hospitalaria fue de 5,57 días. La mortalidad fue del 3,45%. Conclusiones: Nuestros resultados concuerdan con la literatura internacional, la restitución del Hartmann laparoscópica es un procedimiento exigente pero factible, seguro y que otorga al paciente los beneficios de la cirugía mínimamente invasiva.
Abstract Background: Described almost 100 years ago, the Hartmann procedure is still valid, being the classical behavior adopted for the management of the left colon in the emergency room. The restitution of the intestinal transit provides an important improvement in the quality of life of the patients, nevertheless given the high morbimortality, only half is reconstructed. Laparoscopic Hartmann restitution offers all the advantages of minimally invasive procedures with morbidity and mortality comparable to conventional surgery. Objectives: Analyze surgical technique and the results of a series of patients in whom laparoscopic Hartmann restitution was performed. Material and methods: Retrospective review was conducted between March 2002 and January 2017. The population belongs to the Surgical Clinics of the Maciel Hospital ('Q2' and 'Q3'), UDELAR Medical School, Montevideo, Uruguay. Results: Twenty-nine patients were operated: 10 women and 19 men. The most frequent pathologies that determined the Hartmann were linked to diverticular pathology (37.93%) or oncological (34.48%). The minimum time elapsed between the Hartmann and the reconstruction was 4 months. The operative times ranged from 107 to 240 min. The conversion rate was 24.1%. Major complications occurred in 6.90% and minor complications in 13.79%. There was no anastomotic leak. The hospital stay was 5.57 days. The mortality rate was 3.45%. Conclusions: Our results are consistent with the international literature, laparoscopic Hartmann restitution is a demanding but feasible, safe procedure that gives the patient the benefits of minimally invasive surgery.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Colostomia/métodos , Laparoscopia/métodos , Trânsito Gastrointestinal , Estudos Retrospectivos , Resultado do TratamentoRESUMO
ABSTRACT Introduction: The objective of our study was to describe surgical outcomes of Deloyers procedure in our referral center, and to compare the results of patients with and without protective ileostomy. Methods: Patients undergoing a Deloyers procedure from 2013 to 2016 were prospectively included. General characteristics, intraoperative variables, postoperative course, and functional outcomes were analyzed. Patients were compared into two groups: group (1) patients undergoing Deloyers procedure without ileostomy, and group (2) Deloyers procedure with protective ileostomy. Results: Sixteen patients undergoing isoperistaltic transposition of the right colon remnant were included, of which 9 (63%) were males with a median age of 47 (range 22-76) years. The main surgical indication was the restoration of bowel transit (62.5%). There was higher major morbidity rate in the Deloyers procedure with protective ileostomy group, but without statistical significance (20% vs. 9%, p = 0.92). No leaks or deaths were reported. The length of hospital stay was 7 days. The mean number of bowel movements per day was 4 at 18 months of follow up. Only four (25%) patients used irregularly loperamide. Conclusions: The Deloyers procedure has satisfactory results and is reproducible with low morbidity. The major and minor morbidity rates were similar between groups, suggesting that the costs and risks of a second procedure can be avoided by providing a safe primary anastomosis.
RESUMO Introdução: O objetivo de nosso estudo foi descrever os resultados cirúrgicos do procedimento de Deloyer em nosso centro de referência e comparar os resultados de pacientes com e sem ileostomia de proteção. Métodos: Pacientes submetidos ao procedimento de Deloyer de 2013 a 2016 foram incluídos prospectivamente. Foram analisadas as características gerais, as variáveis intraoperatórias, o curso pós-operatório e os desfechos funcionais. Os pacientes foram comparados em dois grupos: Grupo 1) pacientes submetidos ao procedimento de Deloyer (PD) sem ileostomia, e grupo 2) procedimento de Deloyer com ileostomia de proteção (IP). Resultados: Foram incluídos 16 pacientes submetidos à transposição isoperistáltica da porção remanescente do cólon direito, dos quais 9 (63%) eram do sexo masculino com idade média de 47 anos (variação de 22-76) anos. A principal indicação cirúrgica foi a restauração do trânsito intestinal (62,5%). Houve maior morbidade maior no grupo IP, mas sem significância estatística (20% vs. 9%, p = 0,92). Nenhum vazamento ou óbito foi relatado. A duração da hospitalização foi de 7 dias. O número médio de evacuações por dia foi 4, aos 18 meses de seguimento. Apenas quatro (25%) pacientes utilizaram irregularmente a loperamida. Conclusões: O procedimento de Deloyer tem resultados satisfatórios e é reprodutível com baixa morbidade. As taxas de morbidades maiores e menores foram semelhantes entre os grupos, sugerindo que os custos e riscos de um segundo procedimento podem ser evitados proporcionando-se uma anastomose primária segura.
Assuntos
Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Idoso , Canal Anal/cirurgia , Reto/cirurgia , Anastomose Cirúrgica/efeitos adversos , Ileostomia/estatística & dados numéricos , Colectomia/métodos , Colo/cirurgia , Período Pós-Operatório , Resultado do TratamentoRESUMO
BACKGROUND: It is possible to resect the perforated segment and reestablish intestinal continuity with adequate morbidity and mortality results in patients with complicated diverticulitis. AIMS: To evaluate the type of surgery performed at our center and the results of the procedures in patients with complicated diverticulitis. MATERIAL AND METHODS: All patients that underwent sigmoidectomy due to complicated diverticulitis within the time frame of 2005-2012 were included in the study. The primary objective was to evaluate the type of surgery performed. The secondary objective was to evaluate patient morbidity and mortality after 30 postoperative days. RESULTS: The study included 77 patients with a mean age of 51.17±12.80 years. The majority of the patients were men (64.9%) (n=50) and the mean BMI was 28.24±4.06kg/m2. A total of 63.6% (n=49) patients presented with a Hinchey iii-iv classification. Sigmoidectomy with primary anastomosis was performed in 58.4% (n=45) of the patients, 48.8% (22/45) of whom presented with Hinchey iii-iv. Primary anastomosis was more frequently performed in patients that had Hinchey i-ii(P=.001). Open surgery was carried out in 85.7% (n=66) of the cases. The mean surgery duration was longer in the patients with primary anastomosis (181.73±68.2min vs. 152.13±65.8min) (P>.05). Colorectal surgeons performed the procedures in 44.2% (n=34) of the cases. Complications presented in 23.4% (n=18) of the patients and there was a tendency toward more complications in patients that underwent the Hartmann's procedure. The mortality rate was 2.6% (n=2). CONCLUSIONS: Sigmoidectomy with primary anastomosis is a frequent surgery in patients with complicated diverticulitis at our hospital. There was no difference in morbidity and mortality, compared with the Hartmann's procedure.
Assuntos
Colectomia/métodos , Colo Sigmoide/cirurgia , Doença Diverticular do Colo/cirurgia , Doenças do Colo Sigmoide/cirurgia , Adulto , Idoso , Anastomose Cirúrgica , Colectomia/mortalidade , Doença Diverticular do Colo/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Doenças do Colo Sigmoide/complicações , Doenças do Colo Sigmoide/mortalidade , Resultado do TratamentoRESUMO
Introduction: colonic diverticulosis, as diverticulitis, is a frequent disease in different stages of evolution. There is uncertainty about treatment options that are used in secondary peritonitis. The aim of this study is to determine the best treatment option for patients with peritonitis secondary to diverticulitis of the left colon in terms of postoperative morbidity (POM) and mortality, comparing Hartmann's procedure (HP) and resection with primary anastomosis (RPA). Material and Methods: systematic review. Studies in adults with peritonitis secondary to diverticulitis of the left colon treated with HP and RPA published between 1990 and 2011 were analyzed. TRIPDATABSE, IWO, MEDLINE, SciELO and LILACS databases were consulted and search strategies were applied using MeSH and free terms. Selected studies were analyzed using a score of methodological quality (MQ). The following variables were considered: mortality, POM, hospital stay, percentage of bowel transit reconstitution in patients undergoing HP and MQ of primary studies. Results: 26 primary studies were analyzed (47 series). There were no significant differences in the variable mortality (p = 0.0805), but significant difference was observed in POM (incompletely reported) (p = 0.0187). The median of MQ of the studies was 11 points for HP series and 10 for RPA series. Conclusion: the available evidence to determine the best treatment option in terms of mortality and POM in this kind of patients is insufficient. Studies with better level evidence and MQ are needed to clarify the uncertain.
Introducción: la enfermedad diverticular del colon es una entidad frecuente, como también la diverticulitis en sus diferentes estadios de evolución. Existe incertidumbre respecto de las opciones terapéuticas que se utilizan en el tratamiento de la peritonitis diverticular de colon izquierdo (PDCI). El objetivo de este estudio es determinar la mejor opción de tratamiento para pacientes con PDCI entre procedimiento de Hart-mann (PH) y resección con anastomosis primaria (RAP), en términos de mortalidad y morbilidad postoperatoria (MPO). Material y Método: revisión sistemática de la literatura. Se analizaron estudios realizados en adultos con PDCI tratados con PH y RAP, publicados entre 1990 y 2011. Se consultó en las bases de datos TRIPDATABSE, IWO, MEDLINE, SciELO y LILACS, utilizando estrategias de búsqueda con términos MeSH, palabras libres y operadores booleanos. Los estudios seleccionados fueron analizados mediante un escore de calidad metodológica (CM). Se consideraron las variables mortalidad, MPO, estadía hospitalaria, porcentaje de reconstitución de tránsito en pacientes sometidos a PH y CM de los estudios primarios. Resultados: se analizaron 26 estudios primarios (47 series de pacientes). No se encontraron diferencias significativas respecto de la variable mortalidad (p = 0,0805); pero sí en la variable MPO, reportada de forma incompleta (p = 0,0187). La mediana de la CM de los estudios primarios fue de 11 puntos para las series de PH y de 10 para las de RAP. Conclusión: la evidencia disponible no permite determinar la mejor alternativa terapéutica en términos de mortalidad y MPO en este tipo de pacientes. Se requieren estudios de mejor nivel de evidencia y CM para aclarar esta incertidumbre.
Assuntos
Humanos , Doença Diverticular do Colo/cirurgia , Doença Diverticular do Colo/complicações , Peritonite/cirurgia , Peritonite/etiologia , Anastomose Cirúrgica , Doença Diverticular do Colo/mortalidade , Complicações Pós-Operatórias , Peritonite/mortalidadeRESUMO
En este artículo se muestran tres aplicaciones de la prueba de Hartmann en Ciencias de la Visión, desarrolladas en el laboratorio de diseño óptico del Departamento de Física de la Universidad Nacional de Colombia: lensómetro para lentes de adición progresiva, topógrafo corneal y aberrómetro tipo Hartmann-Shack. Primero se describe brevemente la prueba clásica de Hartmann para espejos astronómicos y luego se presentan tres variaciones de la prueba de Hartmann para optometría y oftalmología. En cada caso se describe el sistema óptico empleado y la geometría para deducir la aberración de frente de onda a partir de las aberraciones de rayo (patrones de Hartmann). En los tres casos se obtienen relaciones matemáticas similares, por lo que el frente de onda se puede determinar en cada caso empleando el mismo método de integración. Posteriormente, se calculan las cantidades de interés, a saber: en lensometría, los mapas de potencia refractiva cilíndrica y esférica; en topografía, el mapa de curvatura tangencial; y en aberrometría, el mapa de elevación de frente de onda y la psf. Finalmente, se hace un breve comentario sobre la implementación de la prueba de Hartmann por parte de algunas compañías comerciales.
In this paper, we present three applications of the Hartmann test in vision science, developed atthe optical design laboratory of the Physics Department at the National University of Colombia:lensmeter for progressive addition lenses, corneal topography, and Hartmann-Shack aberrometer.First we briefly describe the classical Hartmann test for astronomical mirrors, and later threevariations of the Hartmann test for optometry and ophthalmology are done. In each case the opticalsystem and geometry used to derive the wavefront aberration from ray aberrations (Hartmann patterns) are described. In all three cases similar mathematical relationships are obtained, so that the wavefront can be determined in each case using the same method of integration. Afterwards,the quantities of interest are calculated in order to find out: in lensometry, maps of cylindrical and spherical refractive power; in topography, the map of tangential curvature; and in aberrometry,the wavefront elevation map and psf. Finally, a brief comment is made on the implementation of the Hartmann test by some commercial companies.
Assuntos
Aberrometria , Topografia da CórneaRESUMO
ANTECEDENTES: La operación de Hartmann continúa siendo una alternativa válida en el tratamiento de la patología colónica de urgencia. Su atractivo se debe a la aparente simplicidad de su técnica, pero sin embargo. no está exenta de complicaciones, y entre el 20% al 70% de los casos, nunca llega a reconstruirse el tránsito intestinal. Hipótesis: La operación de Hartmann está sobreindicada en pacientes sin repercusión sistémica y con hallazgos quirúrgicos favorables. LUGAR DE APLlCACION: Hospital público de la Ciudad de Buenos Aires. DISEÑO: Retrospectivo, observacional. POBLACION: Todos los pacientes a los que se efectuó una operación de Hartmann entre enero del 2000 a marzo del 2009. METODO: Revisión de historias clínicas y de base de datos del servicio. Se utilizó el Mannheim Peritonitis Index (MPI) para clasificar los pacientes según los hallazgos intraoperatorios y la repercusión sistémica. RESULTADOS: 44 pacientes. 24 varones (45%) y 20 mujeres (65%). La edad promedio fue 44 años. 34 (77%1) cirugías de urgencia y 10 (23%) programadas. Según el MPI, 30 pacientes (68%) tuvieron un score = a 21; 12 pacientes (27%) entre 22 y 28 y 2 pacientes (5%) un score mayor a 28. En ocho pacientes (25%) se reconstruyó el tránsito intestinal en un tiempo medio de 284 días La morbilidad fue de 32% y la mortalidad de 27%. CONCLUSIONES: La operación de Hartmann está asociada a una alta morbi-mortalidad. Sólo un 25% de nuestra serie se reconstruyó el tránsito intestinal. Si analizamos a los pacientes según el MPI, el 68% tuvieron un puntaje = 21, por lo que concluimos que la operación de Hartmann está sobreindicada en nuestro medio.
BACKGROUND: Hartmann's procedure is widely used for treatment of acute colonic dísease. It's apparent simplicity is what makes it attractive, however, there are many postoperative complications and Hartmann's reversal is done in 20% to 70%. Hypothesis: Hartmann' s procedure is too often performed in patients without systemic disease and with a favorable surgical outcome. METHODS: Retrospective reviews of all patients who underwent Hartmann's procedure from January 2000 to January 2009. Patients were classified into three groups according to the general status and intraoperative findings using the Mannheim Peritonitis Index (MPI). RESULTS: 44 patients underwent Hartmann's procedure (24 men and 20 women). The mean age was 44 years. Ten out of 44 surgeries were elective. Nineteen patients (43%) had cancer, while 25 patients (57%) had a benign disease. Thirty patients (68%) had an MPI = 21; 12 patients (27%) had an MPI between 22 and 28 (25%), and 2 patients an MPI > 28. Twenty five percent underwent Hartmann' s reversal in a mean period of 284 days (Range 79-419 days). The morbidity was 32% and mortality 27%. CONCLUSION: Hartmann's procedure is associated with high morbidity and mortality. Only 25% underwent Hartmann's reversal. According to the Mannheim Peritonitis Index, 68% had scored less or equal to 21, so we can conclude that Hartmann's procedure is often unnecessarily performed in our Hospital.
Assuntos
Humanos , Masculino , Adulto , Feminino , Colo/cirurgia , Tratamento de Emergência , Doenças do Colo/cirurgia , Anastomose Cirúrgica , Colostomia/métodos , Colostomia/mortalidade , Emergências , Doenças do Colo/mortalidade , Hospitais Municipais , Morbidade , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
OBJETIVO: O objetivo desse estudo foi avaliar as taxas de morbidade e de mortalidade da tentativa de reversão do procedimento de Hartmann. MÉTODOS: Foram estudados retrospectivamente 29 pacientes submetidos à operação para reconstrução do trânsito intestinal após procedimento de Hartmann no Hospital das Clínicas da Universidade Federal de Minas Gerais no período de janeiro de 1998 a dezembro de 2006. Foram avaliados dados pré-operatório, intra-operatórios e pós-operatórios. RESULTADOS: A média de idade dos pacientes submetidos à operação para reconstrução de trânsito intestinal após realização de colostomia a Hartmann foi de 52,6 anos, sendo 16 pacientes do sexo masculino (55,2 por cento). O tempo médio da permanência da colostomia foi de 17,6 meses (variando de 1 a 84 meses). O tempo operatório médio foi de 300 minutos (variando de 180 a 720 minutos). O sucesso na reconstrução do trânsito intestinal foi alcançado em 27 pacientes (93 por cento). Dois pacientes apresentaram fístula anastomótica (7 por cento) e seis tiveram infecção de parede (22 por cento). Ocorreu um óbito (3,4 por cento) em paciente com fístula anastomótica e sepse abdominal. Dentre os fatores relacionados ao insucesso na reconstrução da colostomia a Hartmann observou-se associação estatisticamente significativa com a tentativa prévia de reconstrução (p = 0,007), a utilização prévia de quimioterapia (p = 0,037) e o longo tempo de permanência da colostomia (p = 0,025) CONCLUSÃO: O intervalo entre a confecção e a tentativa de reversão não deve ser muito longo e os pacientes devem ser alertados que, numa pequena porcentagem dos casos, a reconstrução do trânsito intestinal pode ser impossível devido às condições locais do reto excluído.
OBJECTIVE: To study was to investigate the associated morbidity and mortality of the restoration of intestinal continuity after Hartmann's procedure. METHODS: Hospital records of 29 patients undergoing surgery to restoration of intestinal continuity after Hartmann's procedure at Hospital das Clínicas da Universidade Federal de Minas Gerais between January 1998 and December 2006 were retrospectively analyzed. Demographic, morbidity and mortality data were colleted. RESULTS: There were 16 men and 13 women with mean age of 52.6 years. The median time between the Hartmann's procedure and the attempt of closure of colostomy was 17.6 months (range,1-84 months). The median operation time was 300 minutes (range, 180-720 min). The restoration of the continuity was successful in 27 patients (93 percent). Two patients had anastomotic leakage (7 percent) and 7 had wound infection (22 percent). The mortality rate was of 3.4 percent (1/29 patients). There were association between unsuccessful restoration of intestinal continuity and previous attempt of closure (p=.007), chemotherapy (p=.037) and long term stay with colostomy (p =.007). CONCLUSION: The interval between the Hartmann's procedure and the restoration of intestinal continuity should not be long. The patients should be aware that in some circumstances the restoration of intestinal continuity after Hartmann's procedure is not possible due to local conditions of the rectum.
Assuntos
Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Colostomia/métodos , Intestino Grosso/cirurgia , Estudos Retrospectivos , Adulto JovemRESUMO
El presente artículo resume la tarea de fundamentación apriorística trascendental desarrollada por la ética del discurso elaborada por Karl-Otto Apel. Desde una postura personal, acude a esta propuesta teórica y a los aportes que en idéntico sentido realizó durante el pasado siglo el filósofo Nicolai Hartmann, en el ánimo de proponer una ética convergente como variante y complementación de la ética discursiva apeliana.
The present article sums up the task of the transcendental a priori basis developed by the ethics of discourse elaborated by Karl-Otto Apel. From a personal position, he resorts to this theoretical proposal and the contributions that were realized in parallel by Nicolai Hartmann, during the last century in the spirit of proposing a convergent ethics as a variation and complement to Apel´s ethics of discourse.
O presente artigo resume a tarefa de fundamentação apriorística transcendental desenvolvida pela ética do discurso elaborada por Karl-Otto Apel. A partir de uma postura pessoal, acode a esta proposta teórica e às contribuições que igualmente realizou durante o século passado o filósofo Nicolai Hartmann, ao propor uma ética convergente como variante e complementação da ética discursiva de Apel.
Assuntos
ÉticaRESUMO
Introducción: el procedimiento de Hartmann es una alternativa de tratamiento para cirugías colorrectales de emergencia, sin embargo, su reconexión es difícil y propensa a complicaciones. Se ha propuesto que un periodo de tiempo mayor entre el procedimiento inicial y la reconexión puede disminuir las complicaciones. El objetivo de esta investigación es determinar la morbilidad y mortalidad de la reconexión posHartmann, y analizar la presencia de factores de riesgo para complicaciones. Material y métodos: se analizaron retrospectivamente 48 pacientes cuyas edades oscilaron entre 57 ± 16 años, de los cuales 19 (40 %) eran mayores de 65 años y 21 (44 %) tenían enfermedades crónicas concomitantes. Se buscaron factores de morbilidad y mortalidad con prueba U de Mann- Whitney y prueba exacta de Fisher. Resultados: la indicación más frecuente del procedimiento fue la diverticulitis aguda (42 %). El periodo entre el procedimiento de Hartmann y la reconexión fue de ocho meses, con un rango de 1 a 46 meses. La duración aproximada de la cirugía de reconexión fue de 267 minutos (rango de 120 a 540). Se presentaron complicaciones en 29 pacientes (60 %), incluyendo fístulas de la anastomosis en seis (12 %) y muerte en cuatro (8 %). No se asociaron mayores complicaciones o más tiempo quirúrgico, con un intervalo de tiempo menor entre el procedimiento de Hartmann y la reconexión. Conclusiones: la reconexión posHartmann es un procedimiento con alta morbilidad y mortalidad, sin que se asocie al intervalo de tiempo entre el procedimiento y la reconexión.
BACKGROUND: Hartmann's operation is an alternative for emergency colorectal surgeries, but its reversal may be difficult and prone to complications. A longer interval for its reversal has been recommended to decrease complications. METHODS: In order to determine rates of morbi-mortality and to ascertain the association between the time interval for its reversal and presence of complications, we undertook a retrospective analysis of 48 patients with a mean age of 57 +/- 16 years. Nineteen patients (40%) were >65 years, and 21 (44%) had one or more underlying chronic disease. Perioperative factors associated with morbi-mortality were determined by means of the Mann-Whitney U test and Fisher exact test. RESULTS: Acute diverticulitis was the most frequent indication (42%). Mean interval between Hartmann's operation and its reversal was 8 months (range: 1 to 46 months). Mean duration of the reversal operation was 267 min (range: 120 to 540 min). There were complications in 29 patients (60%) including anastomotic leaks in 6 (12%) and operative deaths in 4 (8%). A shorter interval between Hartmann's operation and its reversal was not associated with more complications or longer surgical time. CONCLUSIONS: Hartmann's reversal operation has high rates of morbidity and mortality that are not influenced by the time interval from the original operation.