The objective of this research was to study the cutaneous branching of the superficial fibular nerve (SFN), with a topographic and biometric focus, aiming to provide further anatomical details for foot and ankle surgery in general. There were analyzed 30 right and left lower limbs of 15 corpses of male adult Brazilian individuals. The cutaneous branching of the nerve was dissected and measurements taken with a tape measure and digital caliper. The nerve emerged at the surface as a single trunk in 66.7% and divided into two branches in 33.3% of the cases. When a single trunk emerged, it appeared at the level of the third distal of the leg in 75%, at the boundary between the middle and distal thirds in 20%, and, in the middle third in 5%. When divided, in most cases (60%), the two branches had the same topography, in general, in the distal third of the leg. The average width of the nerve, at its emergence, when single, was 3.1 ± 0.8 mm, when divided, one of its branches, the medial dorsal cutaneous nerve (MDCn) of the foot, measured 2.4 ± 0.9 mm, and the other, the intermediate dorsal cutaneous nerve (IDCn) of the foot 2.1 ± 0.6 mm. The MDCn communicated with the deep fibular nerve in 53.3%, and the IDCn with the sural nerve in 33.3%. In its distribution in the dorsum of the foot, the MDCn was related mainly with the first metatarsal bone and the first and second interosseous spaces, and the IDCn, in general, with the fourth metatarsal bone and the third and fourth interosseous spaces. There are important variations in the emergence and cutaneous branching of the SFN, which must be known in order to avoid iatrogenic injury during surgical procedures on the foot and ankle.

BACKGROUND: Digital rectal examination (DRE) is part of the physical examination, is also essential for the colorectal surgeon evaluation. A good DRE offers precious information related to the patient’s complaints, which will help in decision making. It is simple, quick and minimally invasive. In many centers around the world, the DRE is still the only method to evaluate the anal sphincter prior to patient’s management. On the other hand, anorectal manometry (ARM) is the main method for objective functional evaluation of anal sphincter pressures. The discrepancy of DRE depending on the examiner to determine sphincter tonus in comparison to ARM motivated this study. OBJECTIVE: To compare the DRE performed by proficient and non-experienced examiners to sphincter pressure parameters obtained at ARM, depending on examiners expertise. METHODS: Thirty-six consecutive patients with complaints of fecal incontinence or chronic constipation, from the anorectal physiology clinic of the University of São Paulo School of Medicine, were prospectively included. Each patient underwent ARM and DRE performed by two senior colorectal surgeons and one junior colorectal surgeon prior to the ARM. Patient’s history was blinded for the examiner’s knowledge, also the impressions of each examiner were blinded from the others. For the DRE rest and squeeze pressures were classified by an objective scale (DRE scoring system) that was compared to the parameters of the ARM for the analysis. The results obtained at the ARM were compared to the DRE performed by the seniors and the junior colorectal surgeons. STATISTICAL ANALYSIS: Descriptive analysis was performed for all parameters. For the rest and squeeze pressures the Gamma index was used for the comparison between the DRE and ARM, which varied from 0 to 1. The closer to 1 the better was the agreement. RESULTS: The mean age was 48 years old and 55.5% of patients were female. The agreement of rest anal pressures between the ARM and the DRE performed by the senior proficient examiners was 0.7 (CI 95%; 0.32-1.0), while for the junior non-experienced examiner was 0.52 (CI 95%; 0.09-0.96). The agreement of squeeze pressures was 0.96 (CI 95%; 0.87-1.0) for the seniors and 0.52 (CI 95%; 0.16-0.89) for the junior examiner. CONCLUSION: More experienced colorectal surgeons used to DRE had a more significant agreement with the ARM, thereafter would have more appropriate therapeutic management to patients with sphincter functional problems. ARM, therefore, persists as an important exam to objectively evaluate the sphincter complex, justifying its utility in the clinical practice.

There is no consensus on the ideal anesthesia for hemorrhoidectomy in ambulatory facilities. Spinal anesthesia and venous propofol associated with local perianal block (combined anesthesia) are frequently used, and their direct costs may be crucial for the anesthesia type selection. The objective of this study was to compare the direct costs of anesthesia-related materials in hemorrhoidectomy between these two anesthetic techniques.Retrospective and cross-section analysis, comparing the direct costs of the materials of spinal and venous anesthesia with propofol associated with local perianal block, in hemorrhoidectomy. Twenty patients were included, ten submitted to each anesthesia type (five from each gender). The mean age in the spinal anesthesia group was 46.5 years and in the combined anesthesia group, 42.5 years (p=0.334). The mean cost of anesthesia-related materials was R$ 58.50 (R$ 36.48 - R$ 85.79) in the first group versus R$ 190.31 (R$ 98.16 - R$ 358.51) in the second - 69.27% difference between them (p<0.001). The mean costs according to gender analysis were R$ 50.32 and R$ 66.69 (p=0.263) in the spinal anesthesia group versus R$ 222.52 and R$ 158.10 (p=0.221) in the combined anesthesia group, respectively. The direct costs of anesthesia-related materials were significantly lower in patients submitted to hemorrhoidectomy using spinal anesthesia. No difference was observed between the genders in each group analyzed.
Não há consenso sobre a técnica anestésica de escolha para hemorroidectomias em regime ambulatorial. A raquianestesia e a anestesia combinada (venosa com propofol + local) são frequentemente utilizadas, e os custos das mesmas podem ser determinantes na escolha do melhor tipo de anestesia. O objetivo deste trabalho foi avaliar e comparar os custos diretos dos materiais anestésicos utilizados em hemorroidectomias entre essas duas técnicas. Foi feito um estudo retrospectivo e transversal, comparativo entre os custos diretos dos materiais anestésicos entre a raquianestesia e a anestesia venosa com poropofol associada ao bloqueio perianal local, em hemorroidectomias. Foram analisados 20 pacientes, 10 operados com cada técnica anestésica (5 de cada gênero). A média de idade do grupo da raquianestesia foi de 46,5 anos e do grupo da anestesia combinada foi de 42,5 anos (p=0,334). O custo médio do procedimento anestésico no primeiro grupo foi de R$ 58,50 (R$ 36,48 - R$ 85,79), no segundo foi de R$ 190,31 (R$ 98,16 - R$ 358,51). A diferença das médias foi de 69,27%, com significância estatística (p<0,001). A média dos custos dos gêneros masculino e feminino no grupo da raquianestesia foi de R$ 50,32 e R$ 66,69 (p=0,263) e no grupo da anestesia combinada foi de R$ 222,52 e R$ 158,10 (p=0,221), respectivamente. Os custos diretos médios dos materiais anestésicos dos pacientes submetidos a hemorroidectomias foram significativamente menores no grupo da raquianestesia. Não houve significância estatística na diferença entre os gêneros em cada grupo

Introduction Since the 1960s, mortality in Crohn's disease and Ulcerative Colitis patients had a significant decrease due to advances in medical and surgical therapy. An important proportion of these patients are submitted to surgical procedures during their disease course, with postoperative mortality between 4 and 10%. Methods 157 inflammatory bowel disease patients submitted to surgical therapy were retrospectively identified and allocated in 2 groups (Crohn's and colitis). Deaths were individually discriminated in detail. Results 281 surgical procedures were performed. In the colitis group, 43 operations were performed in 24 patients; in the abdominal Crohn's subgroup, 127 procedures in 90 patients and in the perineal Crohn's subgroup, 115 in 64 patients, respectively. Nine postoperative deaths were observed (3 in the colitis and 6 in the Crohn's groups). Overall postoperative mortality was 5.7% (4.5% for Crohn's; 6.6% in abdominal Crohn's and 12.5% for Colitis). Most of deaths were related to emergency procedures and previous use of corticosteroids. The cause of death in all patients was sepsis. Conclusions Overall postoperative mortality in inflammatory bowel disease was 5.7%, and it was attributed to the severity of the cases referred.