Abdominoperineal Excision: Evolution of a Centenary Operation

During the last century, great improvements have been made in rectal cancer management regarding preoperative staging, pathologic assessment, surgical technique, and multimodal therapies. Surgically, there was a move from a strategy characterized by simple perineal excision to complex procedures performed by means of a laparoscopic approach, and more recently with the aid of robotic systems. Perhaps the most important advance is that rectal cancer is no longer a fatal disease as it was at the beginning of the 20th century. This achievement is definitely due in part to Ernest Mile's contribution regarding lymphatic spread of tumor cells, which helped clarify the natural history of the disease and the proper treatment alternatives. He advocated a combined approach with the rationale to clear "the zone of upward spread." The aim of the present paper is to present a brief review concerning the evolution of rectal cancer surgery, focusing attention on Miles' abdominoperineal excision of the rectum (APR) and its controversies and refinements over time. Although APR has currently been restricted to a small proportion of patients with low rectal cancer, recent propositions to excise the rectum performing a wider perineal and a proper pelvic floor resection have renewed interest on this procedure, confirming that Ernest Miles' original ideas still influence rectal cancer management after more than 100 years.

High-frequency TENS in post-episiotomy pain relief in primiparous puerpere: A randomized, controlled trial

Aim: We evaluated the effectiveness of high-frequency transcutaneous electrical nerve stimulation (TENS) as a pain relief resource for primiparous puerpere who had experienced natural childbirth with an episiotomy. Methods: A controlled, randomized clinical study was conducted in a Brazilian maternity ward. Forty puerpere were randomly divided into two groups: TENS high frequency and a no treatment control group. Post-episiotomy pain was assessed in the resting and sitting positions and during ambulation. An 11-point numeric rating scale was performed in three separate evaluations (at the beginning of the study, after 60 min and after 120 min). The McGill pain questionnaire was employed at the beginning and 60 min later. TENS with 100 Hz frequency and 75 mu s pulse for 60 min was employed without causing any pain. Four electrodes ware placed in parallel near the episiotomy site, in the area of the pudendal and genitofemoral nerves. Results: An 11-point numeric rating scale and McGill pain questionnaire showed a significant statistical difference in pain reduction in the TENS group, while the control group showed no alteration in the level of discomfort. Hence, high-frequency TENS treatment significantly reduced pain intensity immediately after its use and 60 min later. Conclusion: TENS is a safe and viable non-pharmacological analgesic resource to be employed for pain relief post-episiotomy. The routine use of TENS post-episiotomy is recommended.

Low-level laser therapy for pain relief after episiotomy: a double-blind randomised clinical trial

Aims and objectives. To evaluate the effectiveness of a low-level laser therapy for pain relief in the perineum following episiotomy during childbirth. Background. Laser irradiation is a painless and non-invasive therapy for perineal pain treatment and its effects have been investigated in several studies, with no clear conclusion on its effectiveness. Design. A double-blind randomised controlled clinical trial. Method. One hundred and fourteen women who underwent right mediolateral episiotomies during vaginal birth in an in-hospital birthing centre in Sao Paulo, Brazil and reported pain =3 on a numeric scale (010) were randomised into three groups of 38 women each: two experimental groups (treated with red and infrared laser) and a control group. The experimental groups were treated with laser applied at three points directly on the episiotomy after suturing in a single session between 656 hours postpartum. We used a diode laser with wavelengths of 660 nm (red laser) and 780 nm (infrared laser). The control group participants underwent all laser procedures, excluding the emission of irradiation. The participants and the pain scores evaluator were blinded to the type of intervention. The perineal pain scores were assessed at three time points: before, immediately after and 30 minutes after low-level laser therapy. Results. The comparison of perineal pain between the three groups showed no significant differences in the three evaluations (p = 0.445), indicating that the results obtained in the groups treated with low-level laser therapy were equivalent to the control group. Conclusions. Low-level laser therapy did not decrease the intensity of perineal pain reported by women who underwent right mediolateral episiotomy. Relevance to clinical practice. The effect of laser in perineal pain relief was not demonstrated in this study. The dosage may not have been sufficient to provide relief from perineal pain after episiotomy during a vaginal birth.

Mensuração e caracterização da dor após episiotomia e sua relação com a limitação de atividades

Trata-se de um estudo descritivo realizado com cinquenta mulheres em pós-parto vaginal com episiotomia. Objetivou-se mensurar e caracterizar a dor perineal em primíparas submetidas ao parto normal com episiotomia e verificar as atividades limitadas pela dor. Para avaliação da dor foi utilizada a Escala Numérica e o Questionário McGill, bem como um formulário para analisar as atividades que estavam limitadas. A média de dor perineal encontrada foi cinco. As categorias sensorial e avaliação subjetiva foram as mais selecionadas no Questionário McGill. A dor perineal foi caracterizada como latejante, que repuxa, que esquenta, ardida, dolorida, chata, incômoda, que prende e que deixa tensa. Sentar, deitar e deambular foram as atividades mais limitadas. Em conclusão, foi possível verificar a presença de dor perineal nas puérperas causada pela episiotomia e identificar que as atividades de sentar, deitar e deambular estavam limitadas por este sintoma.

Proctocolectomy and ileal J-pouch anal anastomosis on the surgical treatment of familial adenomatous polyposis and ulcerative colitis: analysis of 49 cases

OBJECTIVE: To evaluate the results of ileal J-pouch anal anastomosis in ulcerative colitis and familial adenomatous polyposis. METHOD: Retrospective analysis of medical records of 49 patients submitted to ileal J-pouch anal anastomosis. RESULTS: Ulcerative colitis was diagnosed in 65% and familial adenomatous polyposis in 34%. Mean age was 39.5 years. 43% were male. Among familial adenomatous polyposis, 61% were diagnosed with colorectal cancer. Thirty-one percent of patients with ulcerative colitis was submitted to a previous surgical approach and 21% of these had toxic megacolon. Average hospital stay was 10 days. Post-operative complications occurred in 50% of patients with ulcerative colitis and 29.4% with familial adenomatous polyposis. Intestinal diversion was performed in 100% of ulcerative colitis and 88% of familial adenomatous polyposis. Pouchitis occurred in eight cases (seven ulcerative colitis and one FAP), requiring excision of the pouch in three ulcerative colitis. Mortality rate was 7.6%: two cases of carcinoma on the pouch and two post-operative complications. Late post-operative complications occurred in 22.4%: six familial adenomatous polyposis and five ulcerative colitis). Two patients had erectile dysfunction, and one retrograde ejaculation. One patient with severe perineal dermatitis was submitted to excision of the pouch. Incontinence occurred in four patients and two reported soil. Mean bowel movement was five times a day. CONCLUSION: Ileal J-pouch anal anastomosis is a safe surgery with acceptable morbidity and good functional results, if well indicated and performed in referral centers.

Fistole retto-vaginali Crohn-relate trattate mediante trasposizione del muscolo gracile: risultati a lungo termine e qualità della vita

OBIETTIVO: Le fistole retto-vaginali Crohn-relate hanno un impatto significativo sulla qualità della vita. Quando il canale anale è alterato da ulcerazioni e stenosi o in pazienti con difetti estesi del perineo, la chirurgia locale produce risultati insoddisfacenti. Lo scopo di questo studio è quello di valutare l'efficacia della trasposizione del muscolo gracile nelle fistole retto-vaginali Crohn-relate e determinare i suoi effetti sulla qualità della vita. MATERIALI E METODI: Da gennaio 2012 a ottobre 2014 sono state trattate 10 pazienti; sono state raccolte alcune variabili (età, BMI, il fumo, CDAI, setone perioperatorio, precedenti procedure, uso di immunomodulatori e steroidi). Tutte le pazienti sono state sottoposte ad ileostomia temporanea prima della graciloplastica. La percentuale di successo è stata misurata come numero di pazienti con fistola guarita dopo la chiusura della stomia. Sono stati utilizzati tre questionari prima della graciloplastica e 3 mesi dopo la chiusura della stomia al fine di valutare la qualità della vita (SF-36), l’ incontinenza fecale e la funzione sessuale. RISULTATI: La fistola retto-vaginale è stata chiusa in 9 pazienti su 10 dopo graciloplastica, con un follow-up medio di chiusura della stomia di 19 mesi (range 4 -34). È stata documentata una recidiva di RVF. Il tempo operatorio era 90-150 minuti (media, 120). La degenza postoperatoria era 7-16 giorni (media 10). Complicanze postoperatorie precoci includevano deiscenza delle suture perineali in 2 casi. Le complicanze a lungo termine includevano disestesia della cicatrice perineale. Nei dati post-operatori abbiamo riportato un miglioramento della qualità di vita, della funzione sessuale e della continenza fecale. CONCLUSIONI: La chiusura della fistola retto-vaginale utilizzando la trasposizione del muscolo gracile è associata a morbidità minima e un alto tasso di successo.

Do transsexuals have micturition disorders?

OBJECTIVE: Transsexualism occurs with an estimated prevalence of 2.4:100,000 male-to-female (MTF) and 1:100,000 female-to-male (FTM) transsexuals. As sex reassignment surgery involves surgery of the urethra and transsexuals are substituted life-long with the cross gender hormones there could possibly arise micturition disorders. Aim of the study was to determine if transsexuals have an increased risk of micturition disorders and if so which. STUDY DESIGN: Between January and July 2003 we examined 25 transsexuals whereof 18 were MTF and 7 were FTM transsexuals using King's Health Questionnaire, visual analogue scale for patient's well being, perineal and transabdominal ultrasound, urine dipstick and uroflow measurement. RESULTS: 17 out of 25 patients considered themselves very happy. In MTF transsexuals, a diverted stream, overactive bladder and stress urinary incontinence was a common problem. Prostate volume was small with 20 g and palpation did not confirm and solid or suspicious lesions. None of the patients had significant residual urine but MTF transsexuals had a reduced urinary flow. We could not detect a current urinary tract infections in any of the patients. CONCLUSION: Transsexuals have an increased risk for the development of micturition disorders including stress urinary incontinence and overactive bladder compared to age-matched control groups and should be counselled preoperatively. Reasons for the development of incontinence might be surgery including pudendal nerve damage, hormonal reasons and ageing.

Iatrogenic sciatic nerve injury in eighteen dogs and nine cats (1997-2006)

OBJECTIVE: To report clinical features associated with iatrogenic peripheral nerve injury in dogs and cats admitted (1997-2006) to a referral teaching hospital. STUDY DESIGN: Retrospective study. ANIMALS: Dogs (n=18), 9 cats. METHODS: Patients had acute signs of monoparesis attributable to sciatic nerve dysfunction that developed after treatment. Neurologic examination and electrodiagnostic testing were performed. Surgical therapy was used for nerve entrapment and delayed reconstructive surgery used in other cases. RESULTS: Of 27 nerve injuries, 25 resulted from surgery (18 with treatment of pelvic injuries). Iliosacral luxation repair resulted in tibial (4 cats) and peroneal (3 dogs) nerve dysfunction. Other causes were intramedullary pinning of femoral fractures (3), other orthopedic surgery (cemented hip prosthesis [2] and tibial plateau-leveling osteotomy [1]), and perineal herniorrhaphy [1]. Nerve injury occurred after intramuscular injection (1 cat, 1 dog). Immediate surgical treatment was removal of intramedullary nails, extruded cement, or entrapping suture. Delayed nerve transplantation was performed in 2 dogs. Within 1 year, 13 patients recovered completely, clinical improvement occurred in 7, and there was no improvement in 7. Five of the 7 dogs that did not recover had acetabular or ilium fracture. CONCLUSION: Iatrogenic sciatic nerve injury occurred most commonly during treatment of pelvic orthopedic diseases and had a poor prognosis. Clinical variation in sciatic nerve dysfunction in dogs and cats can be explained by species anatomic differences. CLINICAL RELEVANCE: Iatrogenic sciatic nerve injury leads to severely debilitating locomotor dysfunction with an uncertain prognosis for full-functional recovery.

Development of an ultrasound-guided technique for pudendal nerve block in cat cadavers.

The objective of this prospective experimental cadaveric study was to develop an ultrasound-guided technique to perform an anaesthetic pudendal nerve block in male cats. Fifteen fresh cadavers were used for this trial. A detailed anatomical dissection was performed on one cat in order to scrutinise the pudendal nerve and its ramifications. In a second step, the cadavers of six cats were used to test three different ultrasonographic approaches to the pudendal nerve: the deep dorso-lateral, the superficial dorso-lateral and the median transperineal. Although none of the approaches allowed direct ultrasonographical identification of the pudendal nerve branches, the deep dorso-lateral was found to be the most advantageous one in terms of practicability and ability to identify useful and reliable landmarks. Based on these findings, the deep dorso-lateral approach was selected as technique of choice for tracer injections (0.1 ml 1% methylene blue injected bilaterally) in six cat cadavers distinct from those used for the ultrasonographical study. Anatomical dissection revealed a homogeneous spread of the tracer around the pudendal nerve sensory branches in all six cadavers. Finally, computed tomography was performed in two additional cadavers after injection of 0.3 ml/kg (0.15 ml/kg per each injection sites, left and right) contrast medium through the deep dorso-lateral approach in order to obtain a model of volume distribution applicable to local anaesthetics. Our findings in cat cadavers indicate that ultrasound-guided pudendal nerve block is feasible and could be proposed to provide peri-operative analgesia in clinical patients undergoing perineal urethrostomy.

Current aspects and future prospects of total anorectal reconstruction - a critical and comprehensive review of the literature

PURPOSE: Many rectal cancer patients undergo abdominoperineal excision worldwide every year. Various procedures to restore perineal (pseudo-) continence, referred to as total anorectal reconstruction, have been proposed. The best technique, however, has not yet been defined. In this study, the different reconstruction techniques with regard to morbidity, functional outcome and quality of life were analysed. Technical and timing issues (i.e. whether the definitive procedure should be performed synchronously or be delayed), oncological safety, economical aspects as well as possible future improvements are further discussed. METHODS: A MEDLINE and EMBASE search was conducted to identify the pertinent multilingual literature between 1989 and 2013. All publications meeting the defined inclusion/exclusion criteria were eligible for analysis. RESULTS: Dynamic graciloplasty, artificial bowel sphincter, circular smooth muscle cuff or gluteoplasty result in median resting and squeezing neo-anal pressures that equate to the measurements found in incontinent patients. However, quality of life was generally stated to be good by patients who had undergone the procedures, despite imperfect continence, faecal evacuation problems and a considerable associated morbidity. Many patients developed an alternative perception for the urge to defecate that decisively improved functional outcome. Theoretical calculations suggested cost-effectiveness of total anorectal reconstruction compared well to life with a permanent colostomy. CONCLUSIONS: Many patients would be highly motivated to have their abdominal replaced by a functional perineal colostomy. Given the considerable morbidity and questionable functional outcome of current reconstruction technique improvements are required. Tissue engineering might be an option to design an anatomically and physiologically matured, and customised continence organ.

Empresas familiares

El presente trabajo de investigación se encuentra destinado a determinar y analizar los factores claves para la supervivencia, profesionalización y crecimiento de las empresas familiares en Mendoza, otorgando herramientas a las mismas para poder lograr el traspaso generacional en forma exitosa. Con esto se pretende ofrecer un análisis sobre qué están haciendo bien las empresas del medio, como así también qué afecta su continuidad. En la actualidad, la mayor parte de las empresas que se encuentran en la región son empresas familiares. Muy poco se ha estudiado sobre las mismas, por ello es que no se conocen las razones de éxito de las empresas, o, en su defecto, las razones de fracaso para tomarlo como base que las empresas no deben hacer a la hora de emprender un negocio o realizar el traspaso a las siguientes generaciones. El conocimiento de la información mencionada con anterioridad, ayudaría sin duda a muchas empresas a analizar la información que se detalla como impulsora del éxito, para así realizar determinados cambios en sus empresas y poder, sin tanta dificultad, realizar el cambio generacional en forma ordenada y sin problemas. Otra de las razones por la cual se considera importante el desarrollo del presente trabajo, es el hecho de que facilitará a las empresas comprender la mirada de las entidades financieras y realizar unadecuado estudio sobre la situación actual de su insti tución y sus posibilidades de acceso al crédito. De esta manera se aseguraran que el dinero solicitado podrá ser devuelto en tiempo y forma. Asimismo podrán buscar la mejor forma de combinar los distintos productos, buscando lograr una mayor rentabilidad con el menor costo posible.

Estimación de escenarios de contaminación por coliformes fecales en una microcuenca de la Pampa Ondulada de Argentina mediante el empleo de un modelo predictivo

Se evaluó la dinámica de contaminación biológica en una microcuenca con uso ganadero de la Pampa Ondulada de Argentina, mediante el coeficiente de partición bacteriano (BactKdQ) del modelo SWAT (Soil and Water Assessment Tool). Se simularon escenarios de contaminación para dos cargas ganaderas (0,5 y 1 equivalente vaca por ha), utilizando dos valores de BactKdQ: el propuesto por el SWAT (175 m3 Mg-1) y uno real medido in situ (10 m3 Mg-1). Para el escenario real se corroboró la íntima relación entre los eventos de precipitaciones - escurrimientos y la contaminación biológica de los cursos de agua. Los valores reales de BactKdQ, aún siendo bajos, incidieron de forma significativa en la dinámica de transporte de coliformes fecales. Por ende, es de interés la inclusión de parámetros como el BactKdQ medidos localmente y no de aquellos que el modelo SWAT incluye por defecto. Además, se pudo observar una importante concentración de coliformes fecales en la microcuenca, señalándola como un ambiente de alto riesgo de contaminación biológica, ya que para esta aplicación del SWAT todos los niveles guías fueron sobrepasados. Este trabajo destaca la relevancia de la utilización de modelos computacionales como soporte de decisiones productivas y ambientales.

¿Le temía Claudio a la muerte? (Suetonio, Claudio 43-46)

Todas las fuentes antiguas presentan el ascenso al poder de Claudio como un evento fortuito. De acuerdo con ellas, Claudio fue emperador por casualidad y todo su imperio se caracterizó por la inseguridad y la inestabilidad. Tan gran inestabilidad caracterizó todo su gobierno que era natural que él sintiera miedo. Pero este defecto, el temor, aparece notablemente exagerado por Suetonio, quien dedica varios capítulos a su descripción. Sin embargo, cuando llega el momento de narrar la muerte de Claudio y su decisión de favorecer a su hijo Británico en su ascenso al trono y el coraje que esta decisión implicó, Suetonio presenta una narración de los hechos simple y reducida. Suetonio ha disminuido intencionalmente la importancia de este último acto de Claudio, narrándolo de una manera muy simple y concisa, sin comentarios, sin interpretación, a la vez que ha enfatizado y exagerado los defectos del emperador, el miedo y la crueldad. El propósito de este artículo es, por lo tanto, mostrar la tendenciosidad del relato de Suetonio y rescatar la imagen del emperador injustamente vilipendiado

¿Le temía Claudio a la muerte? (Suetonio, Claudio 43-46)

Todas las fuentes antiguas presentan el ascenso al poder de Claudio como un evento fortuito. De acuerdo con ellas, Claudio fue emperador por casualidad y todo su imperio se caracterizó por la inseguridad y la inestabilidad. Tan gran inestabilidad caracterizó todo su gobierno que era natural que él sintiera miedo. Pero este defecto, el temor, aparece notablemente exagerado por Suetonio, quien dedica varios capítulos a su descripción. Sin embargo, cuando llega el momento de narrar la muerte de Claudio y su decisión de favorecer a su hijo Británico en su ascenso al trono y el coraje que esta decisión implicó, Suetonio presenta una narración de los hechos simple y reducida. Suetonio ha disminuido intencionalmente la importancia de este último acto de Claudio, narrándolo de una manera muy simple y concisa, sin comentarios, sin interpretación, a la vez que ha enfatizado y exagerado los defectos del emperador, el miedo y la crueldad. El propósito de este artículo es, por lo tanto, mostrar la tendenciosidad del relato de Suetonio y rescatar la imagen del emperador injustamente vilipendiado

¿Le temía Claudio a la muerte? (Suetonio, Claudio 43-46)

Todas las fuentes antiguas presentan el ascenso al poder de Claudio como un evento fortuito. De acuerdo con ellas, Claudio fue emperador por casualidad y todo su imperio se caracterizó por la inseguridad y la inestabilidad. Tan gran inestabilidad caracterizó todo su gobierno que era natural que él sintiera miedo. Pero este defecto, el temor, aparece notablemente exagerado por Suetonio, quien dedica varios capítulos a su descripción. Sin embargo, cuando llega el momento de narrar la muerte de Claudio y su decisión de favorecer a su hijo Británico en su ascenso al trono y el coraje que esta decisión implicó, Suetonio presenta una narración de los hechos simple y reducida. Suetonio ha disminuido intencionalmente la importancia de este último acto de Claudio, narrándolo de una manera muy simple y concisa, sin comentarios, sin interpretación, a la vez que ha enfatizado y exagerado los defectos del emperador, el miedo y la crueldad. El propósito de este artículo es, por lo tanto, mostrar la tendenciosidad del relato de Suetonio y rescatar la imagen del emperador injustamente vilipendiado