Bernardo Hanan

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.

Resultados do registro de cirurgias colorretais videolaparoscópicas realizadas no Estado de Minas Gerais - Brasil de 1996 a 2009

INTRODUCAO: A partir de 1991, a videolaparoscopia comecou a ser considerada no tratamento de doencas colorretais. O aprimoramento da tecnica cirurgica associado aos beneficios encontrados em diversos estudos publicados levou a modificacoes nas perspectivas da videolaparoscopia. A partir da publicacao do estudo COST as resseccoes oncologicas laparoscopicas foram reconhecidas como alternativa viavel, com resultados semelhantes a cirurgia convencional. PACIENTES E METODOS: Realizou-se pesquisa atraves de formulario especifico e consulta a prontuarios dos principais servicos de coloproctologia de Belo Horizonte. Avaliando-se sexo, idade, indicacao cirurgica, procedimento realizado, tecnica laparoscopica, complicacoes, conversao, estadiamento e recidiva (no caso de neoplasias). RESULTADOS: Foram levantados dados sobre 503 cirurgias colorretais laparoscopicas: 347 (68,9%) em mulheres e 156 (31,1%) homens. A tecnica cirurgica foi totalmente laparoscopica em 137 casos, video-assistida 245 casos. O procedimento mais realizado foi a retossigmoidectomia (41,1%), seguido pela colectomia direita (12,5%), colectomia esquerda (6,9%). Doencas benignas foram responsaveis por 259 (51,5%) casos, destes as principais indicacoes cirurgicas foram endometriose 126 (48,6%), polipos 40 (15,4%), doenca diverticular 30 (11,6%). Das 240 cirurgias realizadas por doencas malignas as mais frequentes foram retossigmoidectomia 102 (42,5%), colectomia direita 46 (19,1%), colectomia esquerda 18 (7,5%), amputacao abdominoperineal 18 (7,5%). Houve 54 conversoes (10.7%) dos casos, 12,9% (31/240) nos casos de neoplasias, 8,5% (22/259) nos de doencas benignas. Complicacoes sistemicas ou cirurgicas ocorreram em 31 (6,1%) e 56 (11,1%) casos, respectivamente. Foram registrados onze (2,18%) obitos nos primeiros 30 dias apos a cirurgia. CONCLUSAO: O estudo atual foi o primeiro levantamento da implantacao de cirurgias colorretais laparoscopicas realizado de forma multicentrica em Minas Gerais. Os dados levantados sao consistentes com registros nacionais de videocirurgia colorretal, mostrando a eficiencia do metodo de aprendizado com realizacao de cirurgias com tutor. Alem disso, que pequena parte das cirurgias colorretais sao realizadas por via laparoscopica no estado, restritos apenas a centros especializados, sobrecarregando esses servicos e limitando o acesso para a populacao.

Pregnancy after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in pseudomyxoma peritonei.

Pseudomyxoma peritonei is usually a benign tumor that is slightly more common in women. However, it requires aggressive surgical treatment and chemotherapy, often compromising future reproductive function. This report presents a case of pregnancy in a 35-year-old woman who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei. The tumor was diagnosed during a laparoscopic examination on a workup for infertility in 2008. Two months later, she underwent a peritonectomy followed by hyperthermic intraperitoneal chemotherapy and, regarding her will to conceive, ovaries and fallopian tubes were preserved. In March 2011, she went through an in vitro fertilization followed by an uneventful pregnancy and delivered a healthy child 39 weeks later. Ovaries are usually resected during the cytoreductive surgery, since they are common sites for neoplastic implants, and, even when not performed, little is known about the effects of local chemotherapy on female fertility. The largest international survey on this matter only describes seven similar cases. This particular report not only describes a rare condition but also adds to the upcoming discussion about whether ovaries can be preserved in specific situations, therefore keeping the prospect of conceiving after this treatment.

Invasão do reto por carcinoma prostático avançado com disseminação linfática simulando câncer retal: relato de caso

Prostate carcinoma is a frequent disease in the elderly and in advanced cases it can cause rectal invasion mimicking a primary rectal carcinoma. Most of patients present with significant rectal symptoms and mild to absent urinary tract symptoms. We report a case of a patient with a very aggressive locally invasive prostate carcinoma with a concomitant rectal villous tumor which was misdiagnosed and inadequately treated as a rectal cancer. The reported incidence of rectal invasion in advanced prostate cancer has varied between 1 to 11 per cent in different series. The appearance of the prostate tumor with involvement of the rectum causes difficulties in differentiating it from primary rectal carcinoma. Neither radiological nor endoscopic examination of the rectum or lower urinary tract provides a definitive diagnosis. Histopathology in both primary prostate carcinoma invasive to the rectum and primary rectal carcinoma usually is poorly differentiated adenocarcinoma.The differentiation of rectal involvement from prostatic carcinoma is essential, since therapy is quite different for the two diseases. The high incidence of prostatic carcinoma makes it important for all physicians are aware of frequency in which it involves the rectum and mimic a primary rectal neoplasm.

Análise de 33 peças cirúrgicas de colectomias laparoscópicas para câncer, durante a curva de aprendizado inicial: margens oncológicas e número de linfonodos não diferem de colectomias abertas

INTRODUCTION: Colorectal laparoscopic surgery is considered a procedure with long learning curve. Despite surgeons with experience in laparoscopic surgery are able to achieve the same oncological results obtained in open procedures, it is important to evaluate if these good results are sustained during the learning curve. The aim of this study was to evaluate the adequacy of the margins and the lymph nodes harvest in early learning curve of laparoscopic colectomies performed by specialized surgeons compared to open colectomies. METHODS: Thirty-three surgical specimens of laparoscopic resections for colorectal cancer performed during the early learning curve were evaluated. The following data were analyzed: age, sex, tumor location, pathologic classification, lymph node harvest and proximal and distal margins. Data were compared to a control group of 45 open resections for colorectal cancer. RESULTS: Age, tumor location and Dukes classification of laparoscopic and open groups were similar. Laparoscopic group had more female patients. Distal margins were similar between the groups [mean of 7,15 cm (SD ± 9,98) for open and 8,26 cm (SD ± 11,5) for laparoscopic group, p=NS]. There was no difference in the lymph nodes harvest between the groups. The mean of lymph nodes harvest of open and laparoscopic groups were 19 (SD ± 19,41) and 21 (SD ± 14,73), respectively, (p=NS). CONCLUSION: Oncologic margins and lymph nodes harvest obtained during early learning curve of laparoscopic resections were similar to open procedures. Despite the natural difficulties faced during early learning curve, oncologic criteria can be achieved when laparoscopic colorectal resections are performed by specialized surgeons working with gastrointestinal pathology team.

Treatment of Anastomotic Stricture of a Handsewn Coloanal Anastomosis With Transanal Approach

755 DISEASES OF THE COLON & RECTUM VOLUME 60: 7 (2017) This video details the treatment of anastomotic stricture of a handsewn coloanal anastomosis with the transanal approach instead of a combined abdominal and perineal approach. The patient underwent a laparoscopic total mesorectal excision with handsewn side-to-end coloanal anastomosis for rectal cancer. When the ileostomy was being prepared, we realized that the colon in the pelvis was ischemic. A decision to perform another anastomosis with a nonischemic part of the colon was made. Because the nonischemic part did not reach the anus, a laparoscopic Deloyers procedure was performed. A straight handsewn coloanal anastomosis was performed. A diverting loop ileostomy was done. After the discharge, a digital examination showed a stenosis of the anastomosis on day 15 postoperation. On day 60, it was not possible to perform a colonoscopy. With a digital examination, the lumen of the colon was not found. The colonoscope was passed through the anus, but the endoscopist entered into the pelvis. The colon was adherent to the sidewall of pelvis. There were not many adhesions. There was a complete stenosis of the anastomosis with a little retraction. The video presented here shows the treatment of this complication. We decided to perform a transanal down-to-up dissection of the colon using the GelPOINT (Applied Medical, Rancho Santa Margarita, CA) transanal patch applied. A complete mobilization of the colon was performed. The adhesions were resected with blunt and sharp dissection with scissors. After the complete mobilization of the colon, we redid the coloanal anastomosis. The patient had an uneventful postoperative course. The ileostomy was closed 2 months after the transanal approach and redone anastomosis. We visualized the opportunity to treat this complication with a down-to-up dissection of the remaining colon using a new device to permit a laparoscopic approach as occurred in the recently described transanal total mesorectal excision dissection. See Video at http://links.lww.com/DCR/A298.

Tratamento do câncer colorretal em idosos extremos: relato de caso e revisão da literatura

Because the elderly population in Brasil is rapidly increasing, the colorectal surgeron will always manage extremely old patients, aged 75 or 85 years or older, with the diagnosis of colorectal cancer. The management of such cases is controversial. This paper reports the treatment of a 97-year-old patient with diagnosis of rectum adenocarcinoma, and presents a literature review on the best approach for old-age patients with colorectal cancer. The patient underwent a palliative laparoscopic retossigmoidectomy and colorectal anastomosis, as the specimen was resected through supra-pubic transverse incision. She was included in the fast-track rehabilitation program for colorectal surgery and had good recovery, being discharged in good clinical conditions on the third postoperative day. Pathologic examination of surgical specimen showed a rectum adenocarcinoma with invasion of the muscularis propria and metastasis in 2 of 12 dissected lymph nodes. According to the literature, in selected individuals older than 75 years, elective colorectal surgery for primary colorectal cancer can be performed with morbidity and mortality rates comparable to those of younger individuals, achieving favorable disease-free and overall long-term survival. Prognosis or contraindications to the procedure are not defined by isolate comorbidities.

Intussuscepção intestinal em adultos

A intussuscepcao intestinal em adultos e rara. Ao contrario do que ocorre na faixa pediatrica, e, na maioria das vezes, secundaria a uma lesao definida com potencial significativo de malignidade. O objetivo deste estudo e avaliar retrospectivamente os aspectos diagnosticos e terapeuticos da intussuscepcao intestinal em adultos. Foram estudados, retrospectivamente, os dados relativos as causas, a apresentacao clinica, ao diagnostico e ao manejo da doenca em 16 pacientes, sendo 10 do sexo feminino (62%) e com media de idade de 49 anos (variacao de 19-76 anos). Os principais achados clinicos foram: dor abdominal (100%), nauseas e vomitos (62,5%), massa palpavel (62,5%), distensao abdominal (37,5%) e hemorragia digestiva baixa (31,25%). Sete pacientes (43,75%) apresentaram quadro agudo, sendo seis por obstrucao intestinal (37,5%). O diagnostico pre-operatorio foi firmado em 8 pacientes (50%), atraves de exame clinico associado a ultra-sonografia, tomografia computadorizada, trânsito intestinal ou colonoscopia. Todos os pacientes foram submetidos a tratamento cirurgico. Em cinco pacientes (31,25%) o segmento acometido foi o intestino delgado; em seis (37,5%) o ileo terminal e a valva ileocecal e em cinco (31,25%) havia acometimento colonico. Causa anatomica patologica foi identificada em 14 pacientes (87,5%), sendo que oito (50%) eram portadores de neoplasias malignas. Os procedimentos de resseccao realizados foram enterectomia (18,75%), hemicolectomia direita com anastomose primaria (31,25%) ou ileostomia e fistula mucosa (12,5%), retossigmoidectomia a Hartmann (12,5%), retossigmoidectomia com anastomose primaria (6,25%) e colectomia total com anastomose ileo-retal (6,25%). Dois pacientes (12,5%) foram tratados com reducao sem resseccao. Complicacoes pos-operatorias ocorreram em 3 pacientes (seroma, abscesso de parede abdominal e arritmia cardiaca). Nao houve nenhum obito. Embora incomum, a intussuscepcao deve ser suspeitada em casos de dor abdominal cronica e recorrente ou de obstrucao intestinal. A resseccao esta indicada na maioria dos casos devido a presenca de lesao potencialmente maligna, como causa da invaginacao intestinal.