José Hyppólito da Silva

Restaging of colorectal cancer based on the identification of lymph node micrometastases through immunoperoxidase staining of CEA and cytokeratins.

The present study was performed to identify tumor cells in lymph nodes from colorectal adenocarcinomas considered free of disease by the classic hematoxylin-eosin stain, based on the detection of the carcinoembryonic antigen (CEA) and cytokeratins in neoplastic epithelial cells. For this purpose, 603 lymph nodes from 46 lesions were stained by the peroxidase-antiperoxidase technique. Tumor cells were detected in 22 nodes from 12 patients, mainly in the subcapsular sinuses, permitting a restaging of these patients into two groups: those now considered to have metastatic disease and those free of metastases. However, the 5-year follow-up showed no statistical differences in survival between the two groups.

Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial

OBJECTIVE The aims of this study were to evaluate the safety and efficacy of laparoscopic abdominoperineal resection compared to conventional approach for surgical treatment of patients with distal rectal cancer presenting with incomplete response after chemoradiation. METHOD Twenty eight patients with distal rectal adenocarcinoma were randomized to undergo surgical treatment by laparoscopic abdominoperineal resection or conventional approach and evaluated prospectively. Thirteen underwent laparoscopic abdominoperineal resection and 15 conventional approach. RESULTS There was no significant difference (p<0,05) between the two studied groups regarding: gender, age, body mass index, patients with previous abdominal surgeries, intra and post operative complications, need for blood transfusion, hospital stay after surgery, length of resected segment and pathological staging. Mean operation time was 228 minutes for the laparoscopic abdominoperineal resection versus 284 minutes for the conventional approach (p=0.04). Mean anesthesia duration was shorter (p=0.03) for laparoscopic abdominoperineal resection when compared to conventional approach : 304 and 362 minutes, respectively. There was no need for conversion to open approach in this series. After a mean follow-up of 47.2 months and with the exclusion of two patients in the conventional abdominoperineal resection who presented with unsuspected synchronic metastasis during surgery, local recurrence was observed in two patients in the conventional group and in none in the laparoscopic group. CONCLUSIONS We conclude that laparoscopic abdominoperineal resection is feasible, similar to conventional approach concerning surgery duration, intra operative morbidity, blood requirements and post operative morbidity. Larger number of cases and an extended follow-up are required to adequate evaluation of oncological results for patients undergoing laparoscopic abdominoperineal resection after chemoradiation for radical treatment of distal rectal cancer.

Abdominoperineal endoanal pull-through resection

Abdominoperineal endoanal pull-through resection with colorectal anastomosis was performed on 728 patients—primarily those with chagasic megacolon and cancer of the rectum. Intestinal continuity was reestablished through immediate anastomosis (Swenson procedure) in 229 patients and through delayed anastomosis (Cutait-Turnbull procedure) in 499. Comparative studies showed: that the incidence of leakage was 31.9 percent in immediate and only 2.2 percent in delayed anastomosis; that presacral infection occurred in 27.9 percent in immediate and in 6.8 percent in delayed anastomosis; that stenosis was observed in 4.4 percent in immediate and 1.8 percent in delayed anastomosis; that mortality was 6.1 percent in immediate and 2.2 percent in delayed anastomosis; that anal continence was good in both procedures and that sexual disturbances were rare in benign and frequent in malignant lesions in both procedures. The final conclusion is that, in abdominoperineal endoanal pull-through resection with colorectal anastomosis, complications and mortality are less frequent in delayed than in immediate anastomosis and that continence and sexual behavior are identical in both procedures.

Epidermoid carcinoma of the anal canal

Thirty consecutive patients with epidermoid carcinomas of the anal canal larger than 2 cm were treated with the concomitant application of radiation and two cycles of chemotherapy (5FU and mitomycin-C) between January 1982 and January 1988. Twenty-eight patients were treated with curative intention and two for palliation only. All patients were reexamined after a period of one to 2 months, under light general anesthesia, and any residual tumor or scar tissue was biopsied. Control biopsy was positive in eight patients. Three of six patients who had abdominoperineal excision died from locoregional recurrence; the remaining are alive and cancer free after 1 to 4 years. Two patients had local excision; one is alive and the other died of other cancer metastasis four years later. Seventeen patients who had negative biopsies are alive and free of disease after 1 to 5 years; two died of unrelated causes, two died with distant metastasis (present prior to treatment), and one died with locoregional recurrence. Locoregional failures occurred in four patients (13.3 percent) in the entire series. Individualization of each patient, adjustment of doses, and carefully executed radiation and chemotherapy are the most important points for the success of treatment.

Stapled anastomosis in colorectal surgery.

The authors review their experience with stapled anastomosis in colorectal and ileorectal resections for malignant and benign lesions of the large bowel. They describe the technique and results in a series of 49 patients (24 with cancer of the rectum and rectosigmoid junction; six with familial polyposis, associated with cancer in four; 12 with chagastic megacolon; three, Crohn’s disease; two, ulcerative colitis; and one each, diverticular sigmoiditis and ischemic sigmoiditis). Anterior resection was performed in 38 patients and total colectomy with ileorectal anastomosis in 11. Main complications and mortality are presented. They conclude that stapled anastomosis is an efficient method for intestinal reconstruction after resection for malignant and benign lesions of the large bowel

Pouchitis: extracolonic manifestation of ulcerative colitis?

Pouchitis is the most frequent complication of ileal pouch-anal anastomosis for treatment of ulcerative colitis. There are several possible explanations. Among them, we focus on the one that considers pouchitis as an extracolonic manifestation of ulcerative colitis. The aim of this study was to investigate the association between pouchitis and extra-intestinal manifestations (EIM), which are frequent in these patients. Sixty patients underwent restorative proctocolectomy with an ileal J pouch (IPAA) from September 1984 to December 1998. Pouchitis was defined by clinical, endoscopic, and histologic criteria. The following extra-intestinal manifestations were studied: articular, cutaneous, hepatobiliary, ocular, genitourinary, and growth failure. Thirteen patients, of which 10 were female (76.9%), developed one or more episodes of pouchitis. Twelve patients of this group (92.3%) presented some kind of extra-intestinal manifestation, 4 pre-operatively (exclusively), 2 post-operatively (exclusively), and 6 both pre- and post-operatively (1.7 per patient). Twenty patients (42.7%) of the 47 without pouchitis did not present extra-intestinal manifestations; 10/35 (28. 5%) of females had pouchitis, compared to 3/35 (12.0%) of men. Pouchitis was more frequent among females, though not statistically significant. EIM increases the risk of pouchitis. Pouchitis is related to EIM in 92.3 % of cases, corroborating the hypothesis that it could be an extracolonic manifestation of ulcerative colitis.

Intestinal intussusception and occlusion caused by small bowel polyps in the Peutz-Jeghers syndrome. Management by combined intraoperative enteroscopy and resection through minimal enterostomy: case report

UNLABELLED The Peutz-Jeghers syndrome is a hereditary disease that requires frequent endoscopic and surgical intervention, leading to secondary complications such as short bowel syndrome. CASE REPORT This paper reports on a 15-year-old male patient with a family history of the disease, who underwent surgery for treatment of an intestinal occlusion due to a small intestine intussusception. DISCUSSION An intra-operative fiberscopic procedure was included for the detection and treatment of numerous polyps distributed along the small intestine. Enterotomy was performed to treat only the larger polyps, therefore limiting the intestinal resection to smaller segments. The postoperative follow-up was uneventful. CONCLUSION We point out the importance of conservative treatment for patients with this syndrome, especially those who will undergo repeated surgical interventions because of clinical manifestation while they are still young.

Pelvic lymphoscintigraphy: contribution to the preoperative staging of rectal cancer

PURPOSE Preservation of the anal sphincter in surgery for cancer of the distal rectum in an attempt to avoid colostomy has been a main concern of colorectal surgeons. Various proposed procedures contradict oncological principles, especially with respect to pelvic lymphadenectomy. Therefore, prior knowledge of pelvic lymph node involvement is an important factor in choosing the operative technique, i.e., radical or conservative resection. Introduction of ultrasound, computerized tomography, and magnetic resonance have made preoperative study of the area possible. Nevertheless, these resources offer information of an anatomical nature only. Lymphoscintigraphy enables the morphological and functional evaluation of the pelvic area and contributes toward complementing the data obtained with the other imaging techniques. The objective of this prospective study is twofold: to standardize the lymphoscintigraphy technique and to use it to differentiate patients with rectal cancer from those with other coloproctologic diseases. CASUISTIC AND METHODS Sixty patients with various coloproctologic diseases were studied prospectively. Ages ranged from 21 to 96 years (average, 51 and median, 55 years). Twenty-six patients were male and 34 were female. Thirty patients had carcinoma of the distal rectum as diagnosed by proctologic and anatomic-pathologic examinations, 20 patients had hemorrhoids, 5 had chagasic megacolon, 2 had diverticular disease, 2 had neoplasm of the right colon, and 1 had ulcerative colitis as diagnosed by proctologic exam and/or enema. The lymphoscintigraphy method consisted of injecting 0.25 mL of a dextran solution marked with radioactive technetium-99m into the right and left sides of the perianal region and obtaining images with a gamma camera. The results were analyzed statistically with a confidence level of 95% (P <.05) using the following statistical techniques: arithmetic and medium average, Fisher exact test, chi-square test corrected for continuity according to Yates, and distribution tables for the number of patients. RESULTS In rectal cancer, the tracer progresses unilaterally or is absent; in other patients, the progress of the tracer is bilateral and symmetrical, although its progress may be slow. Statistical tests showed with high significance that the agreement index between the clinical diagnosis and the result of the lymphoscintigraphic exam was 93%. CONCLUSIONS Lymphoscintigraphy is a standardized, painless, and harmless test that can be performed in all cases; it differentiates patients with rectal cancer from those with other coloproctological diseases.

Tratamento cirúrgico do megacólon chagásico: retocolectomia abdominal com anastomose colorretal mecânica término-lateral

Thirty five patients with chagasic megacolon were operated on by the technique of recto-colectomy with colo-rectal mechanical end-to-side anastomosis, anterior or posterior during the period of 1993 to 1997. Twenty (57.14%) patients were female and 15 (42.85%) male. The age ranged from 27 to 76 years, with a mean of 51years. The operation consisted of resection of the dilated colon, closure of the rectal stump at the level of the peritoneal reflexion, dissection of the rectrorectal space down to the level of the levator ani and posterior end to side colo-rectal mechanical anastomosis. Four (11.42%) patients had the anastomosis made anteriorly. Three (8.57%) patients had a positive test of the anastomosis integrity and demanded suture in two (5.71%) and suture and ostomy in one (2.85%). There were seven postoperative early complications, four (11.42%) considered important and four late complications. There was one (2.85%) death due to clinical complication. Patients that underwent colostomy were reoperated in order to close it with no problems. The totality of patients has normal bowel function. There were no complaints of sexual, urinary disturbances or fecal incontinence. The anastomosis was examined in all patients. There was no case of fecaloma in the rectal stump. Although the initial results are good, a long follow up is necessary to evaluate the possibility of recurrence.