Francisco Sérgio P. Regadas

Importância do ultra-som tridimensional na avaliação anorretal

BACKGROUND Anorectal endosonography is actually the main image exam to evaluate some anorectal diseases. AIM To show the three-dimensional endosonography importance in the anal canal anatomic evaluation and the anorectal diseases diagnosis. METHODS Seventy four anorectal ultrasound were performed, 23 normal individuals (13 women) and 51 patients (33 women) with benign and malignant diseases. All the patients were examined with a 3-D equipment with 360 degrees transducer. Normal individuals were evaluated in midline sagittal plane concerning to the length of the anal canal, the internal anal sphincter, the external anal sphincter and the anatomic defect in the anterior quadrant. RESULTS There were no differences in the anal canal and the internal anal sphincter length between men and women. Otherwise, the external anal sphincter length is longer in men and the anatomic defect is longer in women. In those with anorectal diseases, 11 sphincter injuries, 8 anal fistulas, 7 abscess, 1 perirectal endometriosis, 1 pre-sacral cyst, 3 anal canal and 10 rectal malignant neoplasias were diagnosed. The surgical findings confirmed the ultrasound diagnosis in all the patients. CONCLUSION Three-dimensional endosonography demonstrated the anatomic differences between male and female anal canal, justifying the larger incidence of pelvic floor disorders in female patients. It was possible to diagnose the anorectal diseases, in multi-plane, with high spatial resolution, adding also important informations about the therapeutic decision. Such characteristics become it similar to nuclear magnetic resonance with intra-rectal coil, with the advantages to be easier, quicker, low cost and better tolerated.

Types of pelvic floor dysfunctions in nulliparous, vaginal delivery, and cesarean section female patients with obstructed defecation syndrome identified by echodefecography.

PurposeThis study aims to show pelvic floor dysfunctions in women with obstructed defecation syndrome (ODS), comparing nulliparous to those with vaginal delivery or cesarean section using the echodefecography (ECD).Materials and methodsThree hundred seventy female patients with ODS were reviewed retrospectively and were divided in Group I—105 nulliparous, Group II—165 had at least one vaginal delivery, and Group III—comprised of 100 patients delivered only by cesarean section. All patients had been submitted to ECD to identify pelvic floor dysfunctions.ResultsNo statistical significance was found between the groups with regard to anorectocele grade. Intussusception was identified in 40% from G I, 55.0% from G II, and 30.0% from G III, with statistical significance between Groups I and II. Intussusception was associated with significant anorectocele in 24.8%, 36.3%, and 18% patients from G I, II, and III, respectively. Anismus was identified in 39.0% from G I, 28.5% from G II, and 60% from G III, with statistical significance between Groups I and III. Anismus was associated with significant anorectocele in 22.8%, 15.7%, and 24% patients from G I, II, and III, respectively. Sigmoidocele/enterocele was identified in 7.6% from G I, 10.9% G II, and was associated with significant rectocele in 3.8% and 7.3% patients from G I and II, respectively.ConclusionThe distribution of pelvic floor dysfunctions showed no specific pattern across the groups, suggesting the absence of a correlation between these dysfunctions and vaginal delivery.

TRREMS procedure (transanal repair of rectocele and rectal mucosectomy with one circular stapler): a prospective multicenter trial

CONTEXT Since anorectocele is usually associated with mucosa prolapse and/or rectal intussusceptions, it was developed a stapled surgical technique using one circular stapler. OBJECTIVE To report the results of Transanal Repair of Rectocele and Rectal Mucosectomy with one Circular Stapler (TRREMS procedure) in the treatment of anorectocele with mucosa prolapse in a prospective multicenter trial. METHODS It was conducted by 14 surgeons and included 75 female patients, mean aged 49.6 years, with symptoms of obstructed defecation due to grade 2 (26.7%) and grade 3 (73.3%) anorectocele associated with mucosa prolapse and/or rectal intussusception (52.0%) and an average validated Wexner constipation score of 16. All patients were evaluated by a proctological examination, cinedefecography, anal manometry and colonic transit time. The TRREMS procedure consists of the manual removal of the rectocele wall with circumferential rectal mucosectomy performed with a circular stapler. The mean follow-up time was 21 months. RESULTS All patients presented obstructed defecation and they persisted with symptoms despite conservative treatment. The mean operative time was 42 minutes. In 13 (17.3%) patients, bleeding from the stapled line required hemostatic suture. Stapling was incomplete in 2 (2.6%). Forty-nine patients (65.3%) required 1 hospitalization day, the remainder (34.7%) 2 days. Postoperatively, 3 (4.0%) patients complained of persistent rectal pain and 7 (9.3%) developed stricture on the stapled suture subsequently treated by stricturectomy under anesthesia (n = 1), endoscopic stricturectomy with hot biopsy forceps (n = 3) and digital dilatation (n = 3). Postoperative cinedefecography showed residual grade I anorectoceles in 8 (10.6%). The mean Wexner constipation score decreased significantly from 16 to 4 (0-4: n = 68) (6: n = 6) (7: n = 1) (P<0.0001). CONCLUSION Current trial results suggest that TRREMS procedure is a safe and effective technique for the treatment of anorectocele associated with mucosa prolapse. The stapling technique is low-cost as requires the use of a single circular stapler.

Management of patients with rectocele, multiple pelvic floor dysfunctions and obstructed defecation syndrome

CONTEXT Management of patients with obstructed defecation syndrome is still controversial. OBJECTIVE To analyze the efficacy of clinical, clinical treatment followed by biofeedback, and surgical treatment in patients with obstructed defecation, rectocele and multiple dysfunctions evaluated with echodefecography. METHODS The study included 103 females aged 26-84 years with obstructed defecation, grade-II/III rectocele and multiple dysfunctions on echodefecography. Patients were distributed into three treatment groups and constipation scores were assigned. Group I: 34 (33%) patients with significant improvement of symptoms through clinical management only. Group II: 14 (14%) with improvement through clinical treatment plus biofeedback. Group III: 55 (53%) referred to surgery due to treatment failure. RESULTS Group I: 20 (59%) patients had grade-II rectocele, 14 (41%) grade-III. Obstructed defecation syndrome was associated with intussusception (41%), mucosal prolapse (41%), anismus (29%), enterocele (9%) or 2 dysfunctions (23%). The average constipation score decreased significantly from 11 to 5. Group II: 11 (79%) grade-II rectocele, 3 (21%) grade-III, associated with intussusception (7%), mucosal prolapse (43%), anismus (71%) or 2 dysfunctions (29%). There was significant decrease in constipation score from 13 to 6. Group III: 8 (15%) grade-II rectocele, 47 (85%) grade-III, associated with intussusception (42%), mucosal prolapse (40%) or 2 dysfunctions (32%). The constipation score remained unchanged despite clinical treatment and biofeedback. Twenty-three underwent surgery had a significantly decrease in constipation score from 12 to 4. The remaining 32 (31%) patients which 22 refused surgery, 6 had low anal pressure and 4 had slow transit. CONCLUSIONS Approximately 50% of patients with obstructed defecation, rectocele and multiple dysfunctions presented a satisfactory response to clinical treatment and/or biofeedback. Surgical repair was mainly required in patients with grade-III rectocele whose constipation scores remained high despite all efforts.

Influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions

CONTEXT The correlation between vaginal delivery, age and pelvic floor dysfunctions involving obstructed defecation is still a matter of controversy. OBJECTIVES To determine the influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions in women with obstructed defecation syndrome. METHODS Four hundred sixty-nine females with obstructed defecation syndrome were retrospectively evaluated using dynamic 3D ultrasonography to quantify posterior pelvic floor dysfunctions (rectocele grade II or III, rectal intussusception, paradoxical contraction/non-relaxation of the puborectalis and entero/ sigmoidocele grade III). In addition, sphincter damage was evaluated. Patients were grouped according to age (≤50y x >50y) and stratified by mode of delivery and parity: group I (≤50y): 218 patients, 75 nulliparous, 64 vaginal delivery and 79 only cesarean section and group II (>50y): 251 patients, 60 nulliparous, 148 vaginal delivery and 43 only caesarean section. Additionally, patients were stratified by number of vaginal deliveries: 0 - nulliparous (n = 135), 1 - vaginal (n = 46), >1 - vaginal (n = 166). RESULTS Rectocele grade II or III, intussusception, rectocele + intussusception and sphincter damage were more prevalent in Group II (P = 0.0432; P = 0.0028; P = 0.0178; P = 0.0001). The stratified groups (nulliparous, vaginal delivery and cesarean) did not differ significantly with regard to rectocele, intussusception or anismus in each age group. Entero/sigmoidocele was more prevalent in the vaginal group <50y and in the nulliparous and vaginal groups >50y. No correlation was found between rectocele and the number of vaginal deliveries. CONCLUSION Higher age (>50 years) was shown to influence the prevalence of significant rectocele, intussusception and sphincter damage in women. However, delivery mode and parity were not correlated with the prevalence of rectocele, intussusception and anismus in women with obstructed defecation.

Ultrassom anorretal tri-dimensional pode selecionar pacientes com tumor no reto após neoadjuvância para cirurgia de preservação esfincteriana?

ABSTRACT: Proposal:Evaluate the post-chemoradiotherapy response for treatment of rectal tumor using three-dimensionalanorectal ultrasound-3D-US to determine the best surgical approach Methods:32 patients with lower and middle rectal cancerwere prospectively staged using 3D-US to identify anal canal invasion and the distance(cm) between tumor and the internal analsphincter-IAS, Group l:with anal canal invasion; Group II-with distance =2cm; Group III-with distance >2. They were submittedto neoadjuvant chemoradiation-CR T and the 3-D US was r epeated 50-55 days later . The choice of the surgical appr oach was basedon the post-chemoradiation response identified by the 3D-US comparing with pathologic findings. Results:The post-chemoradiation/3D-US findings were concordant with pathologic results in 31/32(97%). It was identified residual tumors in 26/27(96% sensibility), 19(59%) with partial response and 7(22%) without response. Complete response was demonstrated in 5/5 by3D-US, with specificity and predictive valor in 100%. Negative predictive valor in 83% since one(3%) case was inconclusive.Sphincter-saving resection was performed in 16 patients, 5 with complete response, 10 with partial response and one inconclusive,with distal margin >2cm. The pathologic findings confirmed distal margins without tumor. It was demonstrated highconcordance(87.5%) concerning the lymph nodes evaluation(Kappa test). Conclusion: 3D-US can be useful to determine thepatients who should be submitted to sphincter-saving resections.Key words: Rectal Cancer; Endorectal Ultrasonography; Radiotherapy; Surgery Treatment.

Utilização do método videolaparoscopico na reconstituição do trânsito intestinal após a operação de Hartmann

O objetivo e apresentar a padronizacao da tecnica operatoria e os resultados obtidos com a utilizacao do acesso videolaparoscopico na reconstituicao do trânsito intestinal em pacientes previamente submetidos a operacao de Hartmann por causas diversas. Foram analisados prospectivamente 32 pacientes, no periodo de dezembro de 1991 a junho de 1997, com distribuicao semelhante com relacao ao sexo e com idade media de 42,4 anos. Todos os pacientes foram submetidos ao mesmo preparo pre-operatorio e a mesma tecnica cirurgica. Ocorreram tres (9,3%) complicacoes transoperatorias. Uma (3,1 %) anastomose mecânica incompleta, necessitando de endossutura manual, uma (3,1 %) laceracao do reto com o grampeador mecânico e uma (3,1 %) lesao da arteria epigastrica direita. Ocorreram ainda tres (9,3%) conversoes, sendo uma (3,1 %) devido a laceracao do reto com o grampeador mecânico, outra (3.1 %) pela invasao tumoral na pelve e outra (3,1 %) pela presenca de excessivas aderencias intraperitoneais. O tempo operatorio variou de 30 a 240 minutos, na media de 126,2 minutos (2,1 horas). A evolucao clinica pos-operatoria foi satisfatoria. Nove (31,0%) pacientes nao referiram dor, enquanto 13 (44,8%) a referiram em pequena intensidade, e apenas sete (24,0%) queixaram-se de dor com maior intensidade. A dieta liquida via oral foi instituida no periodo medio de 1,6 dias, e a primeira evacuacao ocorreu na media de 3,2 dias de pos-operatorio. O periodo medio de hospitalizacao foi de 4,7 dias. Ocorreram complicacoes pos-operatorias em oito (27,5%) pacientes. Duas (6,8%) infeccoes da ferida do estoma, dois pacientes (6,8%) com dor no ombro direito, uma (3,4%) deiscencia de anastomose, um (3,4%) caso de peritonite por provavel contaminacao do material cirurgico, uma colecao liquida pelvica e uma hernia incisional. Em conclusao, a reconstituicao do trânsito intestinal por videolaparoscopia apresentou-se segura e eficaz, podendo constituir-se no metodo cirurgico de escolha, pois foi utilizada com sucesso em 90,6% dos pacientes.