Antônio Lacerda-Filho

Intussusception in adults: a retrospective study

Objective  Intestinal intussusception in adult patients is rare. In contrast with paediatric patients, it is usually secondary to a definable lesion, often malignant. The purpose of this study was to determine the causes and the management of intussusception in adult patients.

Stapled hemorrhoidectomy: present status

AIM To evaluate cost-effectiveness of stapled hemorrhoidectomy comparing its results with conventional technique. SOURCE OF DATA We retrospectively analyzed the MEDLINE data basis from 2000 to 2004 studying randomized clinical trials which compared pain intensity, recovery period, return to work and occurrence of anal incontinence, in addition to postoperative complications and costs evaluation between stapled and conventional hemorrhoidectomy during different periods of follow-up. CONCLUSIONS Stapled hemorrhoidectomy provides lesser postoperative pain and earlier return to work than conventional hemorrhoidectomy. However, its efficacy could not be determined, since rigorous prospective and randomized clinical trials with long-term follow-up periods and large size samples are not available at this time.

Idiopathic encapsulating peritonitis: Report of two cases

This report presents two cases of young males who developed the rare idiopathic form of sclerosing encapsulating peritonitis (SEP) presented as partial bowel obstruction, both diagnosed during surgical treatment, with satisfactory outcomes. Sclerosing encapsulating peritonitis is a rare and enigmatic condition, characterized by intraperitoneal fibrosclerosis, which causes intestinal obstruction. It is a chronic entity with a poorly elucidated pathophysiology, leading to the constitution of a thick white nacreous fibrosis membrane that wraps the bowel in a concertina-like fashion with some adhesions configuring an intra-abdominal cocoon. Sclerosing encapsulating peritonitis is reported in a wide variety of patients, including those who have undergone peritoneal dialysis, young adolescent girls, cirrhotic patients after peritoneal-venous shunting, and patients treated with β-blockers. Nevertheless, the etiology of SEP remains obscure. This entity presents many difficulties in preoperative diagnosis because of its peculiar characteristics. Recognition of the SEP results in proper management and prevents unnecessary bowel resection. Regardless of cause, the treatment of the obstruction is surgical, with dissection of the encasing membrane from the intestine and separation of adherent loops of small bowel until they are laid free and returned to their normal configuration. The prognosis after appropriate surgical therapy is good, but depends on coexisting diseases.

IMMEDIATE PREOPERATIVE NUTRITIONAL STATUS OF PATIENTS WITH COLORECTAL CANCER: a warning

CONTEXT Weight loss and malnutrition are disorders observed in colorectal cancer patients. OBJECTIVES We sought to evaluate the immediate preoperative nutritional status of patients with colorectal cancer. METHODS This is a cross-sectional clinical study conducted at a single center. Sixty-six consecutive patients in preoperative for elective surgical treatment were studied. The clinical history, socio-demographic data and nutritional status of the patients were evaluated using Subjective Global Assessment and objective (anthropometry) methods. The primary outcome measures were nutritional status classification as nourished or malnourished and the relationship between nutritional status and socio-demographic and clinical features. RESULTS Most of patients exhibited left colon tumors and disease stage II. According to the Subjective Global Assessment, 36.4% of patients were malnourished. Malnutrition ranged from 7.6% to 53% depending on the evaluation method used, with poor correlation to Subjective Global Assessment. The prevalence of malnutrition was significantly greater in females and non-married patients and in those with two or more symptoms of colorectal cancer. CONCLUSIONS More than a third of patients in the immediate preoperative period for colorectal cancer exhibited malnutrition. Therefore, routine nutritional assessment is highly advisable so that appropriate measures may be taken to minimize the potential postoperative complications.

EARLY FUNCTIONAL RESULTS OF BIOFEEDBACK AND ITS IMPACT ON QUALITY OF LIFE OF PATIENTS WITH ANAL INCONTINENCE

CONTEXT Biofeedback has been used successfully in the treatment of fecal incontinence, working mainly on rehabilitation of the sphincter muscle. However, there are few studies presenting objective results of biofeedback, in terms of functional results and those related to the quality of life. OBJECTIVES The aims of this study was to evaluate the immediate results of biofeedback in the treatment of fecal incontinence and its impact on the quality of life of patients by using validated questionnaires, correlating the results with those related to functional parameters of quality of life and clinical variables. METHODS We analyzed and compared the results of biofeedback in 52 patients with fecal incontinence before the start of the sessions and immediately after the end of them, by applying validated questionnaires assessing the degree of intensity of fecal incontinence (FISI - Fecal Incontinence Severity Index) and evaluation of quality of life related to fecal incontinence (FIQL - Faecal Incontinence Quality of Life Scale) as compared to clinical variables (age, onset of symptoms, etiology of the fecal incontinence, number of sessions of biofeedback and number and types of deliveries). RESULTS The evaluation of the results of FISI showed a significant increase in the number of individuals who had low severity scores of symptoms before and after the biofeedback (from 48.1 to 65.4%) with P = 0.004. There was significant improvements in domains of the FIQL, behavior (P = 0.008), depression (P = 0.006) and embarrassment (P = 0.008) after biofeedback. There was no significant correlation between the improvement of functional parameters evaluated by FISI and the improvement of quality of life. Positive correlation was found between the improvements of the domains of FIQL. There was no significant correlation between the results obtained using the FISI and FIQL with clinical variables assessed. CONCLUSIONS Biofeedback has proven to be an effective therapy in the treatment of fecal incontinence, improving symptoms and/or quality of life for most patients, regardless of clinical presentation of this functional disorder.

Small-cell Neuroendocrine Carcinoma Associated with Non Adenoma-like Raised Lesion in a Patient with Long-standing Ulcerative Colitis.

Long-standing cases of ulcerative colitis [UC] are associated with a high risk of colorectal cancer [CRC]. The oncological prognosis is usually favourable in cases of adenocarcinomas diagnosed in surveillance testing,1,2 but the growth of other rare malignancies related to UC, such as aggressive neuroendocrine tumours [NET] implies poor outcomes.3,4 We report a case of a 61-year-old female patient who presented with UC, characterised as pancolitis for over 25 years. In surveillance colonoscopy, non adenoma-like raised lesions with high-grade dysplastic areas (former Dalm) were found in the ascending, transverse, and sigmoid colon. The patient underwent total proctocolectomy with ileoanal reservoir, diverting ileostomy, and bilateral oophorectomy, due to involvement of ovaries. She …

Reconstrução de trânsito intestinal após confecção de colostomia à Hartmann

OBJECTIVE To study was to investigate the associated morbidity and mortality of the restoration of intestinal continuity after Hartmanns procedure. METHODS Hospital records of 29 patients undergoing surgery to restoration of intestinal continuity after Hartmanns 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 Hartmanns 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%). Two patients had anastomotic leakage (7%) and 7 had wound infection (22%). The mortality rate was of 3.4% (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 Hartmanns 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 Hartmanns procedure is not possible due to local conditions of the rectum.

Neuropathic pain after stapled hemorrhoidopexy

Sir, Stapled haemorrhoidopexy (SH) has been considered as an effective surgical intervention for the treatment of hemorrhoids, mainly for third degrees as stated by the Guidelines of the Italian Society of Colorectal Surgery [1]. Despite some recent reviews and meta-analysis have shown more recurrences of disease and the need for additional operations compared with conventional hemorrhoidectomy [2], SH continues to be offered as a less painful operation. This great advantage, which implies in quick recovery, has been demonstrated in many studies [3]. However, some patients suffer acute or chronic postoperative pain related to several causes. We report an unexpected case of very severe postoperative pain after an uneventful SH, which responded only when treated as a neuropathic pain (NP). A 25-year-old man presented to our department complaining of chronic hemorrhoidal prolapse with the necessity of manual replacement and bleeding. Proctoscopic evaluation revealed a very large circumferential hemorrhoidal complex and SH was recommended. We performed an uneventful surgery under spinal block using a PPH-03 circular stapler (Ethicon Endo-Surgery, Cincinnati, OH, USA) with a circular anal dilator. The staple line was located 5 cm from the dentate line and no immediate bleeding was observed. A slight smooth muscle strip was incorporated to the doughnut as we have observed in some cases. After 6 h, patient started to complain of severe anorectal pain unresponsive to dypirone and ketorolac tromethamine. Only intravenous morphine alleviated the pain and patient was discharged 36 h after surgery with recommendations to remain in contact with our team. In the third postoperative day, patient went back to the hospital complaining of severe pain, not alleviated with regular analgesic prescription. Patient reported no fever or other complaints. Owing to the severity of pain, a rectal examination was performed under narcotic anesthesia. We observed only a very small hematoma into the stapled line, with no other alterations. Despite the continuous use of morphine and non-steroidal anti-inflammatory drugs (ketoprophen), patient sustained excruciating shooting anorectal pain with no relation to the bowel movements. At 12th postoperative day, we decided to repeat rectal examination under anesthesia that showed an unremarkable stapled line with complete reabsorption of hematoma. Patient was also undergone to a pelvic CT scan, which revealed no alterations beyond the stapled line. At that point, we requested a consultation from Pain Management Department. They diagnosed NP and started with gabapentin (1,200 mg/day) and amitriptyline (25 mg/ day). After a week under this new treatment, a progressive relief of pain was obtained and patient was discharged under this medication. In both one and two weeks of evaluation on outpatient clinic, patient was feeling very well with no pain. A 3–6-month treatment was planned with progressive withdrawn of medication. In an excellent review of SHs complications published recently in Techniques in Coloproctology, Pescatori & Gagliardi [4] have considered postoperative pain as an important complication of PPH besides bleeding. They A. Lacerda-Filho T. A. N. de Oliveira Department of Coloproctology, Felicio Rocho Hospital, Belo Horizonte, Brazil

Morbidity and mortality assessment of modified Duhamel operation with immediate mechanical end-to-side colorectal anastomosis for chagasic megacolon: the role of the diverting stoma.

Dear Editor, Sepsis secondary to anastomotic leakage is the most important surgical complication of rectal surgery. Anastomosis performed close to the anal sphincter is considered in high risk for leakage. The lower the anastomosis is in the rectum, the higher the risk of leakage. In total mesorectal excisions for rectal cancer, the rate of anastomotic leakage varied from 3% to 17%. Therefore, in this procedure, either a defunctioning ileostomy or a colostomy is still routinely performed in many specialized centers. In Brazil, Chagas’ disease affects people in the rural area with poor living conditions. Megacolon is the most common complication in the gastrointestinal tract. Surgery is indicated to treat patients with severe constipation. Several techniques have been reported in the surgical treatment for chagasic megacolon. All of them have high morbidity and mortality rates. The Duhamel–Haddad operation with delayed coloanal anastomosis was popular amongBrazilian surgeons. However, this time-consuming procedure has been abandoned in most centers in Brazil. To avoid a two-stage procedure, abdominal retosigmoidectomy with immediate posterior end-to-side colorectal mechanical anastomosis was proposed as a new technique for chagasic megacolon (modified Duhamel operation or Habr–Gama operation). The anastomosis is situated at the lower third of the posterior wall of the rectum. As occurs in rectal cancer surgery, the anastomosis is placed just above the anorectal ring. Therefore, intuitively, one should expect problems with this anastomosis. Another variable that could increase the risk for dehiscence in this group of patients is malnutrition; a usual finding in this group of patients. Therefore, a high rate of dehiscence should have been observed in this technique. However, a diverting stoma to avoid pelvic sepsis has not been recommended. Over the past 9 years, our own experience with chagasic megacolon has been based on 26 patients (11 females and 15 males) with a mean age of 56.0 years (range, 40–74 years) who underwent abdominal retosigmoidectomy with immediate posterior end-to-side colorectal mechanical anastomosis. After mechanical and systemic antibiotic preoperative preparation, all operations were performed through a median laparatomy. The dilated colon was excised. The rectum was sectioned at the level of anterior peritoneal reflection and closed with hand-sewn or mechanical suture. The posterior dissection of the rectum was performed to clean the posterior wall of the mesorectum. Therefore, the mesorectum was not incorporated at the anastomotic site. The mechanical endto-side colorectal anastomosis was performed in all patients just above the anorectal ring. The final result was quite similar to the Duhamel technique. The diverting stoma was performed according to the preference of the surgeon. Pelvic tubular drains were used in all operations. A diverting stoma was performed in 10 (38.5%) patients. Among them, eight were an ileostomy and two were a transverse colostomy. All patients had the stoma closed until August 2006. The groups with and without diverting stoma were comparable in terms of preoperative characteristics, Int J Colorectal Dis (2008) 32:215–216 DOI 10.1007/s00384-007-0297-8

The role of lymph node revealing solution on the improvement of lymph node harvest in colorectal cancer specimens

The correct analysis of lymph node status is one of the most important parameters for the accurate pathological diagnosis of colorectal cancer. Our aim was to evaluate the number of lymph nodes among the specimens obtained from colorectal resections due to colorectal cancer, before and after the routine use of a lymph node revealing solution (LNRS).