Reitan Ribeiro

Surgical results of pelvic exenteration in the treatment of gynecologic cancer

BackgroundOur aim in the present study was to evaluate surgical outcomes and complications of pelvic exenteration in the treatment of gynecologic malignancy and to compare surgery-related complications associated with different types of exenteration.MethodsWe performed a retrospective analysis of patients who underwent pelvic exenteration for the treatment of gynecologic cancer between January 2008 and August 2011. Patients were divided into two groups for comparison: total pelvic exenteration (TPE) and nontotal pelvic exenteration (NTE, including anterior pelvic exenteration (APE) posterior pelvic exenteration (PPE)). Outcomes are reported according to the modified Clavien-Dindo Classification of Surgical Complications.ResultsTwenty-eight patients were included in the analysis. Eighteen had cervical cancer (64.3%). The prevalence of stage IIIB cervical cancer was 55%. Primary treatment with radiotherapy was performed in 53.3% of patients. Fifty percent of patients underwent TPE, 25% had APE and 25% underwent PPE. Patients who underwent TPE had worse outcomes, with a mean operative time of 367xa0minutes, use of blood transfusion in 93% of patients, ICU stay of 4.3xa0days and total hospital stay of 9.4xa0days. The overall mortality rate was 14.3%, and the surgical site infection rate was 25%. In the TPE group, 78.6% of patients experienced surgical complications. One-fourth of the total patient sample required reoperation, and the leading cause was urinary fistula (57.1%). Urinary leakage occurred in 22.7% of urinary reconstruction patients. Wet colostomy was the most common form of reconstruction with 10% of leakage.ConclusionsPostoperative urinary and infectious complications accounted for 75% of all causes of morbidity and mortality after pelvic exenteration. TPE is a more complex and morbid procedure than NTE.

Endometriose profunda infiltrativa: distribuição anatômica e tratamento cirúrgico

PURPOSEnTo evaluate the anatomical distribution of deep infiltrating endometriosis (DIE) lesions in a sample of women from the South of Brazil.nnnMETHODSnA prospective study was conducted on women undergoing surgical treatment for DIE from January 2010 to January 2012. The lesions were classified according to eight main locations, from least serious to worst: round ligament, anterior uterine serosa/vesicouterine peitoneal reflection, utero-sacral ligament, retrocervical area, vagina, bladder, intestine, ureter. The number and location of the DIE lesions were studied for each patient according to the above-mentioned criteria and also according to uni- or multifocality. The statistical analysis was performed using Statistica version 8.0. The values p<0.05 were considered statistically significant.nnnRESULTSnDuring the study period, a total of 143 women presented 577 DIE lesions: uterosacral ligament (n=239; 41.4%), retrocervical (n=91; 15.7%), vagina (n=50; 8.7%), round ligament (n=50; 8,7%), vesico-uterine septum (n=41; 7.1%), bladder (n=12; 2.1%), and intestine (n=83; 14.4%), ureter (n=11; 1.9%). Multifocal disease was observed in the majority of patients (p<0.0001), and the mean number of DIE lesions per patient was 4. Ovarian endometrioma was present in 57 women (39.9%). Sixty-five patients (45.4%) presented intestinal infiltration on histological examination. A total of 83 DIE intestinal lesions were distributed as follows: appendix (n=7), cecum (n=1) and rectosigmoid (n=75). The mean number of intestinal lesions per patient was 1.3.nnnCONCLUSIONSnDIE has a multifocal pattern of distribution, a fact of fundamental importance for the definition of the complete surgical treatment of the disease.

Associação entre endometrioma ovariano e endometriose profunda infiltrativa

PURPOSEnTo evaluate the association between ovarian endometrioma and the presence of deep infiltrating endometriosis (DIE) lesions in a sample of women of the South of Brazil.nnnMETHODSnA retrospective study was conducted in all women undergoing surgical treatment of endometriosis from January 2010 to June 2012. Patients were divided into 2 groups according to the presence or not of ovarian endometrioma. Patients presenting an ovarian endometrioma were subsequently divided into 2 groups according to the diameter of the endometrioma (<40 and ≥40 mm). The following parameters were compared between the groups: cancer antigen (CA) 125 level, size of the endometrioma, presence and number of deep lesions. The statistical analysis was performed with Statistica version 8.0 using Fishers exact test, Students t-test and Mann-Whitney test, when needed. The p values of <0.05 were considered statistically significant.nnnRESULTSnDuring the study period, a total of 201 women underwent laparoscopic surgical treatment of endometriosis. Fifty-five patients (27.9%) presented ovarian endometrioma and 180 patients (89.5%) presented DIE confirmed by pathologic examination. Women presenting an ovarian endometrioma had higher CA 125 levels (39.5 versus 24.1 U/mL; p<0.01) and stronger association with the presence of DIE lesions (98.2 versus 86.2%; p=0.01) and intestinal DIE (57.1 versus 37.9%; p=0.01). There was no difference between the groups with endometriomas <40 and ≥40 mm.nnnCONCLUSIONSnOvarian endometrioma is a marker for the presence of DIE lesions, including intestinal DIE.

Retrocervical Deep Infiltrating Endometriotic Lesions Larger than Thirty Millimeters are Associated with an Increased Rate of Ureteral Involvement

STUDY OBJECTIVEnTo estimate the presence of ureteral involvement in deep infiltrating endometriosis (DIE) affecting the retrocervical area.nnnDESIGNnRetrospective study of women undergoing laparoscopic treatment of DIE affecting the retrocervical area.nnnDESIGN CLASSIFICATIONnCanadian Task Force classification II-3.nnnSETTINGnTertiary referral private hospital.nnnPATIENTSnWe evaluated 118 women who underwent laparoscopy for the treatment of retrocervical DIE lesions between January 2010 and March 2012.nnnINTERVENTIONSnAll women underwent laparoscopic surgery for the complete treatment of DIE. After surgery all specimens were sent for pathologic examination to confirm the presence of endometriosis.nnnMEASUREMENTSnPatients with pathologically-confirmed retrocervical DIE were divided into 2 groups according to the size of the lesion (group 1: lesions ≥ 30 mm; group 2: lesions < 30 mm) and the rate of ureteral endometriosis was compared between both groups.nnnMAIN RESULTSnUreteral involvement was present in 17.9% (95% confidence interval [CI] 10%-29.9%) of women with retrocervical lesions ≥ 30 mm whereas in only 1.6% (95% CI 0.4%-8.5%) of those with lesions <30 mm (odds ratio = 13.3 [95% CI 1.6-107.3]).nnnCONCLUSIONnPatients undergoing surgery for retrocervical DIE lesions ≥ 30 mm in diameter have a greater risk of having ureteral involvement (17.9%).

Laparoscopic promontofixation for the treatment of recurrent sigmoid neovaginal prolapse: case report and systematic review of the literature.

Prolapse of a sigmoid neovagina, created in patients with congenital vaginal aplasia, is rare. In correcting this condition, preservation of coital function and restoration of the vaginal axis should be of primary interest. A 34-year-old woman with vaginal agenesis underwent vaginoplasty using sigmoid colon. Almost 6 years after the initial operation, she started complaining of a bearing-down sensation and an increase in vaginal discharge. She underwent 2 open surgeries and one vaginal surgery to treat the prolapse with no success. She came to our service and at vaginal examination the neovagina protruded approximately 5 cm beyond the hymen. The prolapse was treated successfully using a laparoscopic approach to suspend the neovagina to the sacral promontory (laparoscopic promontofixation). Prolapse of an artificially created vagina is a rare occurrence, without a standard treatment. Laparoscopy may be an alternative approach to restore the neovagina without compromising its function.

Laparoscopic Double Discoid Resection With a Circular Stapler for Bowel Endometriosis

STUDY OBJECTIVEnTo demonstrate the technique of laparoscopic double discoid resection with a circular stapler for bowel endometriosis.nnnDESIGNnCase report (Canadian Task Force classification III).nnnSETTINGnPrivate hospital in Curitiba, Paraná, Brazil.nnnPATIENTnA 33-year-old woman was referred to our service complaining about cyclic dysmenorrhea, dyspareunia, chronic pelvic pain, and cyclic dyschezia. Transvaginal ultrasound with bowel preparation showed a 6-cm endometriotic nodule at the retrocervical area, uterosacral ligaments, posterior vaginal fornix, and anterior rectal wall, infiltrating up to the submucosa, 5 cm far from the anal verge.nnnINTERVENTIONSnUnder general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. Pneumoperitoneum was achieved using a Veres needle placed at the umbilicus. Four trocars were placed: a 10-mm trocar at the umbilicus for the zero-degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions, and all implants in the anterior compartment of the pelvis were resected. The lesions located at the ovarian fossae were completely removed. The ureters were identified bilaterally, and both para-rectal fossae were dissected. The right hypogastric nerve was released from the disease laterally. The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum. The lesion was shaved off the anterior rectal wall using a harmonic scalpel. A x-shaped stitch was placed at the anterior rectal wall using 2-0 mononylon suture. A 33-mm circular stapler was placed transanally under laparoscopic control, and once it reached the area to be resected, it was opened. A gap was created between the envil and the stapler. The anterior rectal wall was placed inside this gap with the aid of the stitch at the anterior rectal wall. The stapler was fired, and a piece of the anterior rectal wall was resected. The same procedure was performed using a 29-mm circular stapler, which allowed for the complete removal of the lesion. We usually perform the second discoid resection using a 29-mm circular stapler to allow an easy progression of the stapler through the rectum beyond the first stapler line, so not to put too much pressure on it. In our experience, the first discoid resection removes most of the disease, and the second discoid resection is only needed to remove a small amount of residual disease, along with the first staple line.nnnMEASUREMENTS AND MAIN RESULTSnThe procedure took 177 min, and the estimated blood loss was 100 mL. The patient started clear liquids 6 hours after the procedure, and was discharged 19 hours after that [1]. Pathological examination of the 2 strips of the anterior rectal wall revealed infiltration of the bowel wall by endometriotic tissue. She had an uneventful postoperative course, and was able to re-start sexual intercourse 50 days after surgery. Between January 2010 and January 2015, 315 women underwent laparoscopic surgery for the treatment of bowel endometriosis in our service. Among them, 16 (5.1%) were operated on by using the double discoid resection technique. Median age of the patients was 34 years, and median body mass index was 25.9 kg/m(2). Median preoperative cancer antigen-125 level was 26.5 U/mL (normal value is <35 U/mL). Median size of the rectosigmoid nodule was 35 mm (range: 30-60), and median distance from the anal verge was 10.5 cm (range: 5-15 cm). Median surgical time was 160 min (range: 54-210 min). Concomitant procedures included hysterectyomy (n = 5), partial cystectomy (n = 3), resection of the posterior vaginal fornix (n = 4), and appendectomy (nxa0= 1). Median estimated intraoperative bleeding was 32.5 mL (range: 30-100), and median time of hospitalization was 19 hours (range: 10-41). Median American Fertility Society score was 46 (10-102). Two minor complications (12.5%) occurred in this initial series: 1 patient required bladder catheterization for urinary retention; and 1 patient developed a urinary tract infection that required oral antibiotic treatment. One major complication (6.2%) was observed; the patient developed fever and abdominal pain on the fourth postoperative day. She was re-operated, and the intraoperative diagnosis was pelviperitonitis. The abdominal cavity was inspected for any dehiscence of the bowel and then washed. She was discharged on the second day after re-operation with oral antibiotic therapy. In our daily practice, we are used to discharging our patients soon in the postoperative setting (19 hours for rectal shaving or discoid resection and 28 hours for segmental bowel resection) [1] because the rate of postoperative fistula seems to be low [2]. Because we still have not seen any fistulas after conservative surgery (rectal shaving, discoid resection, and double discoid resection), we usually prefer to perform this type of surgery compared with segmental bowel resection, when possible.nnnCONCLUSIONSnLaparoscopic double discoid resection with circular stapler may be an alternative to segmental bowel resection in selected patients with bowel endometriosis.

Spontaneous Healing of a Rectovaginal Fistula Developing after Laparoscopic Segmental Bowel Resection for Intestinal Deep Infiltrating Endometriosis

The surgical treatment of intestinal deep infiltrating endometriosis has an associated risk of major complications such as dehiscence of the intestinal anastomosis, pelvic abscess, and rectovaginal fistula. The management of postoperative rectovaginal fistula frequently requires a reoperation and the construction of a stoma for temporary fecal diversion. In this paper we describe a 27-year-old woman undergoing laparoscopic treatment of deep infiltrating endometriosis (extramucosal cystectomy, resection of the uterosacral ligaments, resection of the posterior vaginal fornix, and segmental bowel resection) complicated by a rectovaginal fistula, which healed spontaneously with nonsurgical conservative treatment.

Fast-track surgery in intestinal deep infiltrating endometriosis.

STUDY OBJECTIVEnTo evaluate the length of hospital stay (LOS) and the readmission rate in patients undergoing laparoscopic surgery to treat intestinal deep infiltrating endometriosis (DIE) with application of the concepts of fast-track surgery.nnnDESIGNnRetrospective study of women undergoing laparoscopic treatment of intestinal DIE (Canadian Task Force classification II-3).nnnSETTINGnTertiary referral private hospital.nnnINTERVENTIONSnWe evaluated 161 women who underwent laparoscopic surgery between January 2010 and April 2013 for complete treatment of intestinal DIE, via either conservative surgery (rectal shaving, mucosal skinning, or anterior disk resection) or radical surgery (segmental bowel resection). After surgery, all specimens were sent for pathologic examination to confirm the presence of endometriosis.nnnMEASUREMENTS AND MAIN RESULTSnPatients were divided into 2 groups according to type of surgery (conservative [n = 102] or radical [n = 59]), and LOS and readmission rate were measured in both groups. Median LOS was shorter in the conservative group compared with the segmental bowel resection group (19 vs 28 hours; p < .001). Ninety-two patients (90.2%) in the conservative surgery group were discharged to home on the first postoperative day, compared with only 38 patients (64.4%) in the segmental bowel resection group. Overall, the readmission rate was low (3.1%): 6.8% in the segmental bowel resection group and 1% in the conservative group (p = .04; odds ratio, 7.34; 95% confidence interval, 0.8-67.3); however, the need for repeat operation was similar in both groups (3.4% vs 1%; p = .28; odds ratio, 3.54; 95% confidence interval, 0.31-39.95).nnnCONCLUSIONnImplementation of fast-track concepts in the laparoscopic treatment of intestinal DIE resulted in a short LOS and low readmission rate in both the segmental bowel resection and conservative surgery groups.

Laparoscopic Treatment of Deep Infiltrating Endometriosis Affecting the Rectosigmoid Colon: Nodulectomy or Segmental Resection?

Intestinal Deep Infiltrating Endometriosis (DIE) is defined as the lesion infiltrating at least the muscular layer of the bowel and it usually affects the rectosigmoid colon. Medical treatment plays an important role in terms of pain relief in women with such lesions, but has a temporary effect. Surgical treatment is considered the gold standard for symptomatic patients and may be conducted by the means of conservative or radical procedures. The former may be called “nodulectomy” and include the rectal shaving, the mucosal skinning and the full-thickness anterior rectal wall excision/disc resection. The latter is called segmental bowel resection. Each type of procedure has different indications, outcomes, and complications. In this paper, we provide the rationale for the surgical treatment of intestinal DIE affecting the rectosigmoid colon.

Uterine transposition: technique and a case report

OBJECTIVEnTo report the first uterine transposition for fertility preservation in a patient with rectal cancer.nnnDESIGNnCase report.nnnSETTINGnCommunity hospital.nnnPATIENT(S)nA 26-year-old patient with stage cT3N1M0 rectal adenocarcinoma located 5xa0cm from the anal margin.nnnINTERVENTION(S)nLaparoscopic transposition of the uterus to the upper abdomen, outside of the scope of radiation, was performed to preserve fertility. After the end of radiotherapy, rectosigmoidectomy was performed and the uterus was repositioned into the pelvis.nnnMAIN OUTCOME MEASURE(S)nUterine and ovarian function preservation.nnnRESULT(S)nThe patient had two menstrual periods and exhibited normal variation in ovarian hormones throughout the course of neoadjuvant therapy. Menstruation began 2xa0weeks after reimplantation into the pelvis, and the cervix exhibited a normal appearance on clinical examination after 6xa0weeks. Eighteen months after the surgery, the uterus was normal and there was no sign of disease.nnnCONCLUSION(S)nUterine transposition might represent a valid option for fertility preservation in women who require pelvic radiotherapy and want to bear children. However, studies that assess its viability, effectiveness, and safety are required.