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The Trousseau syndrome, first described in 1865, is the relationship of venous thromboembolisms and cancer. We present a case with rectal cancer and Trousseau syndrome.Female 40 years old, went to the Coloproctology Service for painless bleeding. A computed tomography report showed a tumor of 5 by 6 cm up 5 cm from the anal margin. Ultra-low anterior resection with colonic reservoir and loop ileostomy surgery was performed. The pathology report showed a semidiferenciate adenocarcinoma of the rectum and we established the stage as T3N0M0. Within 72 hours of her operation, she experienced sudden hypotension and painful abdominal distention. A second surgery was done finding necrosis of the colon from the splenic angle until the colonic reservoir with thrombi in the left colic artery, ischemic signs of bilateral fallopian tubes, ovaries, uterus, pelvic floor and the small intestine, 40 cm before ileostomy and ileon. Left hemicolectomy and colostomy was done. She was taken to intensive care where continuous administration of heparin was given; she died within 5 days because of multiorgan failure.The mechanism for this syndrome was unknown but there are several hypotheses, suggesting that hematological cancer patients are at an increased risk of deep vein thrombosis. Pancreatic cancer is the most common presentation with this syndrome (in 50% of cases). We suggested continuing with the standards of prevention of thromboembolism.antecedentes: el síndrome de Trousseau se describió por primera vez en 1865; es la relación entre tromboembolismo venoso y cáncer. Objetivo: informar el caso de una paciente con cáncer de recto y síndrome de Trousseau. Caso clínico: paciente femenina de 40 años de edad que acudió al servicio de Coloproctología por rectorragia indolora. La TAC reportó un tumor de 5 por 6cm y del margen anal a 5cm. Se efectuó resección anterior ultrabaja, con reservorio colónico e ileostomía de protección. El reporte de patología fue de: adenocarcinoma semidiferenciado del recto, con clasificación T3N0M0. A las 72 horas del postoperatorio tuvo hipotensión arterial súbita y distensión abdominal dolorosa. En la reintervención quirúrgica se encontró: necrosis del colon desde el ángulo esplénico hasta el reservorio colónico, con trombos en meso, signos de isquemia en el útero, trompa de Falopio y ovarios, piso pélvico y 40 cm de intestino delgado, antes de la ileostomía e íleon. Se realizó hemicolectomía izquierda y colostomía. Se trasladó a la unidad de terapia intensiva donde continuó con la administración de heparina; falleció a los cinco días por insuficiencia multiorgánica. Conclusiones: el mecanismo de este síndrome se desconoce pero existen varias hipótesis: se ha sugerido que los cánceres hematológicos son los que tienen mayor riesgo de trombosis venosa profunda. El cáncer de páncreas se relaciona con este síndrome en 50% de los casos. Se sugiere continuar con las normas de prevención del tromboembolismo.

Chordomas are rare, slow-growing tumors that originate in the primitive notochord. The most frequent location is the sacrococcygeal region. It is more frequent in males. Average age is 61 years old. The aim of this study is to report a case of externalization of a chordoma in the sacral region.We present the case of a 62-year-old female whose disease began 4 years before admission, reporting discomfort in the sacral region. In the intergluteal area, the presence of a mass that increased in size during the previous year was noticed and palpated. On proctological examination, a tumor of 6 cm in diameter is found located in the midsacral region 3 cm from the anal canal. On palpation, the tumor is hard and painless with a regular and mobile surface. X-ray of the coccyx was normal. Surgery was performed with total excision and primary closure. Histopathological report was chordoma.Theoretically, notochord in the vertebral bodies is not completely degenerative and the remaining tissue persists, producing chordomas. The most common symptom is local pain. Diagnosis is made by imaging: x-ray of lumbosacral spine, computed tomography and magnetic resonance imaging. The treatment of choice is wide surgical resection.Diagnosis of chordoma is rare but should be kept in mind in patients with pain in lower back or coccyx and, even more so, if accompanied by a mass with years of evolution.

Pathology of the appendix represents50% of surgical activity. It is necessary to consider rare pathologies such as mucoceles. These have a high frequency in females with a F/M ratio of 4:1, as well as in patients50 years of age. The objective of this study is to report on a case of mucinous cystadenoma of the appendix.We present the case of a 34-year-old male with a history of juvenile rheumatoid arthritis diagnosed at 9 years of age. At 22 years of age, the patient underwent bilateral hip arthroplasty. Since 1998, the patient has presented with renal amyloidosis and has been under steroid treatment to date. The current problem evolved 1 year ago during control studies for his disease. Computed tomography (CT) of the abdomen was done, demonstrating a tumor in the right iliac fossa. Colonoscopy confirmed a tumor with smooth edges located in the cecum. Surgery was recommended with a diagnosis of lipoma of the cecum. During surgery, a large tumor was found, indicating a poor prognosis. Right hemicolectomy was done. Surgical specimen was sent to pathology with a report of mucinous cystadenoma.The group of symptoms of cystadenoma is nonspecific. Diagnostic methods include X-rays, ultrasound, CT and colonoscopy. Mucinous cystadenoma is the most common form of mucocele of the appendix. Diagnostic protocols are the same for benign appendix pathology. Treatment is surgical and type of surgery depends on the size of the mucocele. Mucoceles of the appendix are pathologies with a favorable prognosis when appropriate treatment is done.

Eccrine glands (sweat glands) appear in all sites of the skin and are more abundant in hands and feet. Nodular hidradenocarcinoma (NH) is a rare malignant and aggressive tumor of the eccrine glands. The objective of this study is to report a case of perianal hidradenocarcinoma.We present the case of a 75-year-old female with diabetes, hypertension, and hypothyroidism. Physical examination revealed a small perianal tumor that was palpated near the anal canal. Biopsy was done. Pathology report revealed perianal hidradenoma. Rectosigmoidoscopy was normal. Computed tomography showed 1-cm adenopathies in inguinal and right iliac regions. Extensive resection of the tumor was done. Definitive pathology report was malignant eccrine acrospiroma. The patient underwent adjuvant chemotherapy in the Oncology Service and died 1 month later.In patients with a first symptom of metastases in the inguinal region, suspicion must be directed to the anal canal.

The presacral space, which contains different types of embryonic tissue, is a potential site for several tumors including epidermoid cyst. Presacral cysts are divided into two major groups: teratomas and developmental cysts. Presacral developmental cysts are rare congenital injuries with significant manifestations in the adult. Our objective was to report a case of a giant epidermoid presacral and retrorectal cyst.We present the case of a 28-year-old female whose clinical feature was the presence of a perianal mass and difficult micturition of 8 years. Rectosigmoidoscopy and videocolonoscopy were normal. Simple and contrast abdominal and pelvic tomography (CT) were ordered as well as nuclear magnetic resonance (NMR) imaging to determine extension and location of the tumor. These studies demonstrated three tumors in the presacral space. Surgery using a combined abdominal and perianal approach was done. Pathological report was epidermoid cysts. The patient had a favorable evolution with no reports of fecal incontinence.The accepted definition describing epidermoid cyst is squamous stratified epithelium with keratohyaline grains, but with no other skin structures. Developmental cysts are slow growing due to their unique location, despite being congenital. Diagnosis is confirmed by ultrasound, CT, and NMR. Biopsy is contraindicated. Three described approaches are abdominal, combined or abdominoposterior, and transsacral, each with its specific indications.

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.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.The appendix was affected in 12-16% of all patients with Crohn's disease who had intestinal resection.If the cecum is not affected, appendectomy using laparascopic procedure with soft tissue drainage is adequate.

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.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.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 (JohnsonJohnson). 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%.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).

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.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.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.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.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.

Introducción: Moschowitz propuso que el prolapso rectal era una hernia deslizante de la pared anterior del recto a través de un defecto de la fascia pélvica. En 1969, Frykman y Goldberg publicaron su técnica, que era exactamente igual a la fase abdominal de la operación de Milles. Material y métodos: Se revisaron los expedientes de los pacientes operados de prolapso rectal entre enero de 1995 y diciembre de 2004, en el Servicio de Cirugía de Colon y Recto del Hospital de Especialidades, Centro Médico Nacional Siglo XXI. Resultados: De 55 pacientes con diagnóstico de prolapso rectal, a 16 (29.09 %) se le realizó procedimiento de Frykman- Goldberg: 14 mujeres y dos hombres, edad promedio de 54 años, tiempo quirúrgico promedio de 193.2 minutos, sangrado promedio de 250 ml; hubo complicaciones posoperatorias en dos (12.5 %). Conclusiones: Las técnicas perineales para el tratamiento del prolapso rectal tienen mayor tasa de recidiva que la vía abdominal, sin embargo, se opta por éstas como alternativa en pacientes con contraindicación para cirugía abdominal. Consideramos que el procedimiento es seguro y fisiológico para el manejo de prolapso rectal, y si bien el número de paciente fue bajo, los resultados fueron alentadores.

Introducción: La enfermedad de Crohn fue descrita por primera ocasión en 1932; la asociación de apendicitis aguda con esta enfermedad es muy rara y ante afectación del ciego el riesgo de fístula es muy alto. El objetivo fue informar un caso de apendicitis aguda en un paciente con diagnóstico de enfermedad de Crohn. Caso clínico: Mujer de 48 años de edad, con diagnóstico reciente de enfermedad de Crohn quien presentó cuadro clínico de dolor abdominal intenso en fosa iliaca derecha con tratamiento médico inicial sin mejoría, por lo cual fue necesaria la resolución quirúrgica por vía laparoscópica. Conclusiones: La incidencia de la enfermedad de Crohn que afecta el apéndice varía de 12 a 16 % en pacientes con enfermedad de Crohn sometidos a resección intestinal. Si no afecta el ciego se debe realizar solo apendicectomía con colocación de drenaje blando, y el abordaje laparoscópico es adecuado

Approximately 10% of all colorectal adenomas are constituted by villous adenomas. Their relationship with hydroelectrolytic depletion is rare. We report two cases with villous adenoma that presented hydroelectrolytic depletion with clinical and surgical management, exclusively.Case 1. Patient was a 76-year-old female with hypertension and 3 months evolution of symptoms such as asthenia, adynamia, unexplained weight loss, and abundant mucus with diarrhea. Serum potassium value was 2.2 mEq/l . Upon rectal exam we found a sessile, exophitic soft tumor with irregular surface of approximately 10 cm in diameter. We also performed a transanal resection of tumor reporting villous adenoma. The patient was discharged from the hospital at the 4th postoperative day with potassium values within normal limits. Case report 2. Patient was a 76-year-old female with diabetes and hypertension of long evolution. She reported a 4-month clinical evolution with non-bloody diarrhea and abundant mucus. She reported nausea, vomiting and no unexplained weight loss. Serum potassium value was 2.1 mEq/l . During the rectal exam we identified a sessile, polypoid, 5-cm diameter tumor that did not involve deep planes. In addition, we carried out a transanal resection of the polyp. The patient was discharged from the hospital on the 5th postoperative day. Potassium value was 4.3 mEq/l.Size and location of the villous adenoma are related to the production of mucus secretory diarrhea. The inhibiting well-known indomethacin of the prostaglandins has been used to decrease the mucus secretion. In every patient with presence of mucus, persistent diarrhea and occasional rectal bleeding of 1 month, it is necessary to carry out lower endoscopy to rule out the presence of villous adenoma.

To report for the first time in Mexico a case of anorectal tuberculosis as well as the revision of world-wide literature.In recent years the tuberculosis has had a significant increase, caused mainly by the epidemic of acquired immunodeficiency syndrome. The anorectal tuberculosis is a very rare presentation, their diagnosis requires a high index of suspicion since it can be confused with an infectious disease.Female of 50 years old, with atipic annal ulcers, treated at the being like perianal Crohn disease, the treatment with mesalazina and prednisona do not improve the disease. Thorax x-ray was made. The biopsies reported tuberculosis, initiating treatment with triple antifimic scheme, with good results at one month of medical treatment. COMENT: The biopsy is the main diagnostic method specific, the medical triple or quadruple treatment is the main management and surgical treatment is reserved for anal abscess and fistula.

Nonsteroidal antiinflammatory Drugs (NSAIDS) are the most widely prescribed medication in the world, with a high complication rate including gastrointestinal damage.To present two clinical cases of intestinal damage associated to the chronic ingestion of NSAIDs.A clinical case with inflammatory bowel disease and jejunum enteropathy and another case associated with clinical symptoms of digestive hemorrhage and endoscopic demostration of ulcers in the right colon.Patients with previous ingestion of NSAIDs presenting diarrhea, gastrointestinal bleeding, malnutrition or anemia need to discard intestinal damage.

Anal fistula is an abnormal tract or cavity originating in a cryoglandular infection, whose primary internal opening is in the anorectal junction. Secondary orifice is located in the perianal skin, perineum or vagina. We undertook this study to use an electrosurgery complementary procedure that treats multiple tracts without sectioning the anal sphincter.We reviewed the files of 1354 patients who were operated on for anal fistula in the Regional Hospital of the Ecuadorian Institute of Social Security, Guayaquil, Ecuador, from January 1978 to December 2002. We selected only 79 patients with diagnoses of double anal fistula. Study design was descriptive, retrospective, and longitudinal.Seventy one patients were male (89.8%). The age average was 42.5 years. The symptomatic period had an average of 14 months. The period of wound healing and incapacity from work was 3.3 weeks. The procedure failed in seven patients (8.8%) and eight patients presented partial incontinence to gases (10.12%).Fulguration is a coagulation method in which the active electrode is maintained near the tissue (1-10 mm distance) and the energy dissipated in the area by means of sparks. Fulguration has greater penetration capability and reaches a greater degree of dehydration of the tissue than electrocoagulation. Factors that influence recurrence and anal incontinence are, for recurrence: type of fistula, horseshoe extension, identification of the primary orifice, previous anal surgery and surgeon's experience. Incontinence has been related to female gender, high anal fistulas, and type of previous surgery (fistulectomy/fistulotomy).In complex double anal fistulas, it is preferable to resect the tract and use complementary thermo-obliteration. In this way, anal continence is not altered substantially.

The term angiokeratoma is applied to several diseases with cutaneous vascular lesions.A 26-year-old male presented with an intergluteal tumor from childhood until the present time, which was treated on several occasions without results. The patient presented to the hospital complaining of a painful and bleeding intergluteal tumor.Five types of angiokeratomas have been described (angiokeratoma corporis diffusum, angiokeratoma of Mibelli, angiokeratoma of Fordyce, solitary angiokeratoma and angiokeratoma corporal circumscriptum). This patient was identified with an angiokeratoma circumscriptum by pathological and physical characteristics of the tumor. Differential diagnosis is with verrucous hemangioma and the Fabry disease type II (angiokeratoma corporis diffusum).Pathogenesis is unknown and surgery is the recommended treatment.

Introducción: La proctocolectomía restaurativa con reservorio ileoanal en J se ha convertido en el tratamiento más común para los pacientes con colitis ulcerativa. Esta operación remueve todo el colon y el recto enfermo conservando el complejo esfintérico y, por lo tanto, la continencia. Uno de los objetivos de esta cirugía es mejorar la calidad de vida. Material y métodos: Se revisaron los expedientes de los pacientes sometidos a cirugía de reservorio ileoanal por colitis ulcerativa crónica inespecífica, de enero de 1995 a diciembre de 2004, y se aplicó el cuestionario SF-36 para valorar calidad de vida. El método usado fue observacional, retrospectivo, transversal. Resultados: Se realizaron 20 reservorios ileoanales en J, de los cuales sólo se encontraron los expedientes de 14 pacientes. En cuanto a la calidad de vida, se logró entrevistar a ocho pacientes, la media fue: función física 75, rol físico 50, dolor corporal 51, salud general 77, vitalidad 47.5, función social 62.5, rol emocional 83 y salud mental 74. Discusión: Existen informes previos que han mostrado que la proctocolectomía es un procedimiento seguro y eficaz para los pacientes con colitis ulcerativa crónica inespecífica, independientemente de que se acompañe de ileostomía definitiva, continente o un reservorio. Conclusiones: La presencia de un estoma y la incontinencia fecal resultan en deterioro de la calidad de vida después de la proctocolectomía, por lo cual ambas deben evitarse; 87.5 % de los pacientes encuestados consideró que su estado de salud ha mejorado en un año.

Report for first time in Mexico a case of hereditary mixed polyposis and review the literature.The hereditary mixed polyposis syndrome (HMPS) is an uncommon condition, distinguished by presence of a different histological pattern of polyps in digestive tract, clinically manifested by diarrhea, anemia and weight loss.Male patient, 38 years old, with familiar antecedent (dead sister) with polyps and gastric cancer. With history of a 1 year with bleeding and mucous diarrhea, and weight loss of a 28.6 pounds. Pale at physical examination, without abdominal signs. At blood test with hemoglobin of 9.7 g/dL, and colonoscopy with multiple polyps within colon and rectum, upper endoscopy with a big esophageal polyp and multiple polyps in gastric and duodenal lining smaller than 1 cm. Contrast study of intestine was normal. Histopathologic study of the polyps report mixed pattern of polyps: (hyperplasic-adenomatous, juvenile-adenomatous, adenoma-inflammatory-hyperplasic, hyperplasic-adenomatous with a high degree dysplasia); juvenile in esophagus, and hyperplasic in stomach and duodenum. Patient was undergone to totalproctocolectomy and reconstruction by "J" ileoanal pouch with good outcome, and endoscopic esophageal polypectomy, with actual surveillance.

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.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.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.

Introducción: la presencia de divertículos en el recto es extremadamente rara, sin embargo, la enfermedad diverticular se considera un problema mayor. Nuestro objetivo es informar el caso de un hombre con enfermedad diverticular del sigmoides y divertículos rectales. Caso clínico: hombre de 88 años quien acudió al área de urgencias por hematoquecia de varios días de evolución. Se le realizó colonoscopia, con la que a 5 cm del margen anal se observaron dos orificios diverticulares. Discusión: existen dos teorías que tratan de explicar por qué son raros los divertículos en el recto, pero existen otros autores que indican que están relacionados con alteraciones genéticas. Generalmente no producen síntomas y el tratamiento quirúrgico se realiza cuando se ulceran o se forma un absceso.