Rodrigo Ambar Pinto

Are There Predictors of Outcome Following Rectovaginal Fistula Repair

BACKGROUND: Rectovaginal fistula is a distressing condition for patients and for physicians who are continuously challenged in providing durable treatment options. The aim of this study is to assess the results of rectovaginal fistula repair and identify predictive factors for poor outcome. METHODS: Retrospective analysis of patients who underwent rectovaginal fistula repair from 1988 to 2008 was performed. &khgr;2 tests and logistical regression analysis were used to study treatment outcomes according to the following fistula characteristics: etiology, size, location, and number of prior attempts at fistula repair. In addition, patient factors such as age, body mass index, smoking history, comorbid condition of diabetes, use of steroid and immunosuppressive medications, number of prior vaginal deliveries, and presence of a diverting stoma were analyzed. RESULTS: A total of 184 procedures were performed in 125 patients. Inflammatory bowel disease was the most common indication for surgery (45.6%), followed by obstetric injury (24%) and surgical trauma (16%). The mean duration of fistula presence was 31.2 months. The procedures performed included endorectal advancement flap (35.3%), gracilis muscle interposition (13.6%), seton placement (13.6%), and transperineal (8.7%) and transvaginal repair (8.1%). The overall success rate per procedure was 60%, with no difference in recurrence rates based on the type of repair. Patients with Crohns disease had more recurrent fistulas (44.2% success per procedure; P < .01), although 78% eventually healed after an average of 1.8 procedures. Patients with obstetric injuries had an 89% success rate after an average of 1.3 procedures per patient, which is similar to the success rate for traumatic fistulas. Pouch vaginal fistulas had a 91% success rate after an average of 1.6 procedures per patient. The overall success rate per patient was 88% after multiple procedures with a mean follow-up of 16.3 months. Age, body mass index, diabetes, use of steroids and immunosuppressive agents, size and location of the fistula, number of vaginal deliveries, time interval between a recurrent episode and subsequent repair, and the presence of fecal diversion did not affect outcomes. The presence of Crohns disease and a smoking history are strongly associated with rectovaginal fistula recurrence (P = .02). CONCLUSIONS: Despite a relatively low initial success rate (60%), most rectovaginal fistulas can be successfully repaired with subsequent operations. Crohns disease and smoking are associated with adverse outcomes.

Surgical resection in Crohn’s disease: is immunosuppressive medication associated with higher postoperative infection rates?

Aim  The aim of this study was to analyse postoperative infection in patients undergoing surgery for Crohn’s disease (CD) according to the use of preoperative immunosuppressants, including infliximab.

Does the radiofrequency procedure for fecal incontinence improve quality of life and incontinence at 1-year follow-up?

PURPOSE: Fecal incontinence is a socially isolating disease that causes physical and psychologic distress. Radiofrequency delivered to the anal canal is a surgical modality for fecal incontinence that has been noted to be safe and potentially effective. The aim of this study was to evaluate improvement in fecal incontinence and quality of life after the radiofrequency procedure at 1-year follow-up. METHODS: After institutional review board approval, patients with fecal incontinence for at least 3 months were prospectively recruited between March 2003 and June 2004. Patients enrolled in the study underwent the Secca procedure. The Cleveland Clinic Florida Fecal Incontinence Score and the Fecal Incontinence Quality of Life Questionnaire were completed at the first visit and then at 12-month follow-up. Wilcoxon signed rank test was used to analyze the difference between baseline and follow-up. RESULTS: A total of 24 patients (23 females) were enrolled in the study, and 16 were available at the 12-month follow-up visit. The main causes of fecal incontinence were either idiopathic or included obstetric injury, aging, and trauma from previous anorectal surgeries. The mean operative time was 45.5 ± 8.3 minutes, and the mean number of radiofrequency lesions in the anal canal was 65.5 ± 13.8. There were 3 self-limited episodes of postoperative bleeding and 1 instance of constipation that was resolved with laxatives. There were no delayed complications. The mean Cleveland Clinic Florida Fecal Incontinence Score improved from a mean of 15.6 (± 3.2) at baseline to 12.9 (± 4.6) at 12 months (P = .035). The mean Fecal Incontinence Quality of Life Questionnaire score improved in all subsets except for the depression subscore. CONCLUSION: Radiofrequency is a safe, minimally invasive tool for treating patients with fecal incontinence. Improvement in fecal incontinence and quality of life was maintained at 12 months without delayed morbidity. The actual significance of this improvement is yet to be determined.

Laparoscopy for recurrent Crohn’s disease: how do the results compare with the results for primary Crohn’s disease?

Aim  To assess the feasibility and outcomes of reoperative laparoscopic‐assisted surgery for recurrent Crohn’s disease compared with index laparoscopic resections.

Ileal pouch-anal anastomosis in elderly patients: is there a difference in morbidity compared with younger patients?

Aim  The aim of this study was to review the recent results of ileal pouch–anal anastomosis (IPAA) in elderly patients compared with younger patients.

Short‐term outcome of infliximab and other medications on patients with inflammatory bowel disease undergoing ileostomy reversal

Aim  We evaluated the impact of immunosuppressive drugs on the short‐term outcome following loop ileostomy closure in patients with inflammatory bowel disease.

Synchronous collision malignant melanoma and adenocarcinoma of the rectum

Abstract“Collision tumors” consist of two independent but coexisting tumors. This uncommon situation might be easily mistaken for a composite tumor where one histogenetic event originates from two apparently distinct neoplasms. Colorectal collisions are particularly unusual; here, we report the exceedingly rare case of a 61-year-old man with malignant melanoma and adenocarcinoma colliding in the rectum. Collision tumors have an idiopathic pathophysiology and in fact “accidental meeting” is accepted by many authors. This article discusses the concepts about cancer development, which are overlooked by this hypothesis, another theory to explain that this rare occurrence involves microenvironment changes.

The Abdominal Approach to Rectal Prolapse

Numerous approaches have been described for the treatment of rectal prolapse. The two basic categories of operation are transabdominal and perineal. The former type tends to be more durable with lower recurrence rates but at the expense of higher morbidity. The latter group tends to be safer but is associated with higher recurrence rates and less functional recovery. More recently, the abdominal approaches have been modified to be laparoscopically accomplished in most cases. The indications for, technical details of, and results following these abdominal operations will be described and discussed.

Médicos residentes podem realizar com segurança e eficiência técnicas de Milligan-Morgan, Ferguson e grampeadores no tratamento cirúrgico das hemorróidas?

BACKGROUND: Surgery for symptomatic hemorrhoids is needed in almost 10% of the patients. Although, literature about the surgical management of hemorrhoidal disease is vast, data concerning hemorrhoidectomy or hemorrhoidopexy performed by training residents is limited. AIM: To analyze the results of these procedures in a teaching institution. METHODS: Data from all patients who underwent surgical treatment for hemorrhoids from 1995 to 2007 in a single institution were retrospectively analyzed. Residents supervised by assisting doctors performed all procedures. Techniques were compared based on operative time, hospital stay, morbidity, and long-term efficacy. RESULTS: Three hundred thirty three patients were included in the study, 182 males (54.6%), with a mean age of 45.3 years (± 12.02). Third degree hemorrhoids were the main indication (81.7%). Milligan-Morgan was the most commonly performed procedure (57%), followed by Ferguson and stapled hemorrhoidopexy. Mean operative time was significantly lower in the stapled hemorrhoidopexy group when compared to the open and closed procedures: 49,4 ± 29.3 min vs. 61.1 ± 26.5 and 67.1 ± 28.3, respectively (p=0.0034). There was no statistically significant difference among the groups regarding postoperative complications or reoperation rate. Length of stay was significantly higher in the Milligan-Morgan group when compared to Ferguson and stapled hemorrhoidopexy (1.41 ± 0.86 days vs. 1.19 ± 0.43 vs. 1.16 ± 0.37 respectively). Symptomatic recurrence, reoperation rates and band ligation usage were similar among groups. CONCLUSION: Residents under supervision can perform Milligan-Morgan, Ferguson and stapled hemorrhoidopexy with low incidence of complications and good long-term results. Stapled hemorrhoidopexy technique was associated with a shorter operative time, while Milligan-Morgan correlated with a longer length of stay.

Cistoadenocarcioma mucinoso de ovário e esclerose sistêmica

O câncer de ovario e a terceira causa de morte entre as neoplasias malignas em mulheres e o cistoadenocarcinoma mucinoso e uma neoplasia maligna originaria do epitelio ovariano e que pode adquirir grandes dimensoes. Alguns estudos sugerem um aumento do risco de neoplasia em pacientes com esclerose sistemica (ES), mas a associacao com neoplasia de ovario, principalmente do subtipo mucinoso, nao e comum. Os autores descrevem um caso de cistoadenocarcinoma mucinoso de ovario em uma mulher branca de 52 anos com diagnostico de ES difusa ha seis anos, tratada previamente com D-penicilamina e ciclofosfamida, que procurou o servico medico com queixa de dor e aumento do volume abdominal ha tres meses. Ao exame fisico apresentava facies esclerodermica, membros superiores com diminuicao da elasticidade e enxerto bitibial em membros inferiores; no abdome havia a presenca de uma massa endurecida estendendo-se da regiao suprapubica ate o epigastrio. Foi realizada laparotomia exploradora onde se encontrou uma massa cistica no ovario direito, com peso de 3.300 gramas. Em seguida procedeu-se exerese do tumor com histerectomia total e ooforectomia bilateral. O exame histologico confirmou tratar-se de um cistoadenocarcinoma mucinoso sem invasao de capsula.