Sérgio Alexandre da Conceição

Perianal fistula: retrospective study of surgical treatment of 241 cases

Perianal fistula, usually has a criptoglandular etiology, developing from a perianal abscess and communicating the anal mucosa with the perianal skin. The aim of this paper is to study retrospectively 241 cases of perianal fistula (172 men and 69 women; 2,5:1) aging from 7 and 80 years old (average: 37,4 years), operated on at the Hospital da Clinicas - UFMG, from 1977 to 1996. The surgical techniques and post-operative outcome have been analysed. Perianal abscesses with spontaneous drainage were the predominant etiology (132 patients; 54,8%). Eighty percent were submitted to fistulectomy as the first surgical treatment. Among early complications (78; 32,4%), local pain was the most frequent (60; 24,9%). Among the late complications (136; 56,4%) fistula recurrence (101; 41,9%) was the most frequent. There were 141 reoperations in 80 patients. Fistulectomy was the predominant surgical technique employed for the treatment (101; 71,6%). The average hospitalization time was 6,3 days until 1990 and 1,5 day from 1991 to 1996, after the advent of day-surgery beds in HC-UFMG. The surgical treatment of perianal fistula has a significant rate of post-operative complications and a high recurrence rate, in spite of the short stay in hospital.

Reconstrução de trânsito intestinal após confecção de colostomia à Hartmann

OBJECTIVE To study was to investigate the associated morbidity and mortality of the restoration of intestinal continuity after Hartmanns procedure. METHODS Hospital records of 29 patients undergoing surgery to restoration of intestinal continuity after Hartmanns procedure at Hospital das Clínicas da Universidade Federal de Minas Gerais between January 1998 and December 2006 were retrospectively analyzed. Demographic, morbidity and mortality data were colleted. RESULTS There were 16 men and 13 women with mean age of 52.6 years. The median time between the Hartmanns procedure and the attempt of closure of colostomy was 17.6 months (range,1-84 months). The median operation time was 300 minutes (range, 180-720 min). The restoration of the continuity was successful in 27 patients (93%). Two patients had anastomotic leakage (7%) and 7 had wound infection (22%). The mortality rate was of 3.4% (1/29 patients). There were association between unsuccessful restoration of intestinal continuity and previous attempt of closure (p=.007), chemotherapy (p=.037) and long term stay with colostomy (p =.007). CONCLUSION The interval between the Hartmanns procedure and the restoration of intestinal continuity should not be long. The patients should be aware that in some circumstances the restoration of intestinal continuity after Hartmanns procedure is not possible due to local conditions of the rectum.

Morbidity and mortality assessment of modified Duhamel operation with immediate mechanical end-to-side colorectal anastomosis for chagasic megacolon: the role of the diverting stoma.

Dear Editor, Sepsis secondary to anastomotic leakage is the most important surgical complication of rectal surgery. Anastomosis performed close to the anal sphincter is considered in high risk for leakage. The lower the anastomosis is in the rectum, the higher the risk of leakage. In total mesorectal excisions for rectal cancer, the rate of anastomotic leakage varied from 3% to 17%. Therefore, in this procedure, either a defunctioning ileostomy or a colostomy is still routinely performed in many specialized centers. In Brazil, Chagas’ disease affects people in the rural area with poor living conditions. Megacolon is the most common complication in the gastrointestinal tract. Surgery is indicated to treat patients with severe constipation. Several techniques have been reported in the surgical treatment for chagasic megacolon. All of them have high morbidity and mortality rates. The Duhamel–Haddad operation with delayed coloanal anastomosis was popular amongBrazilian surgeons. However, this time-consuming procedure has been abandoned in most centers in Brazil. To avoid a two-stage procedure, abdominal retosigmoidectomy with immediate posterior end-to-side colorectal mechanical anastomosis was proposed as a new technique for chagasic megacolon (modified Duhamel operation or Habr–Gama operation). The anastomosis is situated at the lower third of the posterior wall of the rectum. As occurs in rectal cancer surgery, the anastomosis is placed just above the anorectal ring. Therefore, intuitively, one should expect problems with this anastomosis. Another variable that could increase the risk for dehiscence in this group of patients is malnutrition; a usual finding in this group of patients. Therefore, a high rate of dehiscence should have been observed in this technique. However, a diverting stoma to avoid pelvic sepsis has not been recommended. Over the past 9 years, our own experience with chagasic megacolon has been based on 26 patients (11 females and 15 males) with a mean age of 56.0 years (range, 40–74 years) who underwent abdominal retosigmoidectomy with immediate posterior end-to-side colorectal mechanical anastomosis. After mechanical and systemic antibiotic preoperative preparation, all operations were performed through a median laparatomy. The dilated colon was excised. The rectum was sectioned at the level of anterior peritoneal reflection and closed with hand-sewn or mechanical suture. The posterior dissection of the rectum was performed to clean the posterior wall of the mesorectum. Therefore, the mesorectum was not incorporated at the anastomotic site. The mechanical endto-side colorectal anastomosis was performed in all patients just above the anorectal ring. The final result was quite similar to the Duhamel technique. The diverting stoma was performed according to the preference of the surgeon. Pelvic tubular drains were used in all operations. A diverting stoma was performed in 10 (38.5%) patients. Among them, eight were an ileostomy and two were a transverse colostomy. All patients had the stoma closed until August 2006. The groups with and without diverting stoma were comparable in terms of preoperative characteristics, Int J Colorectal Dis (2008) 32:215–216 DOI 10.1007/s00384-007-0297-8

Interposição jejunal após gastrectomia total radical por adenocarcinoma gástrico

Realizamos um estudo retrospectivo do tratamento cirurgico do adenocarcinoma gastrico por uma gastrectomia total radical, com reconstrucao do trânsito esofagoduodenal pela interposicao de uma alca jejunal pediculada. Revisao de trabalhos nacionais e estrangeiros relacionados ao tratamento do adenocarcinoma gastrico pela gastrectomia total radical. De acordo com a operabilidade relacionada ao paciente e a ressecabilidade, a lesao primaria e sua evolucao, 126 pacientes foram submetidos a interposicao de um segmento de alca jejunal apos gastrectomia total radical. Resseccao oncologica total do estomago e sistematizada reconstrucao tecnica do reservatorio gastrico e do trânsito esofagoduodenal. Nossos casos evoluiram de maneira satisfatoria, nao fugindo daqueles estudados na literatura. Enfase especial foi dada ao procedimento tecnico, mais anatomico e muito mais funcional, restituindo ao operado um neoestomago e um trânsito esofago-intestinal atraves do duodeno. A interposicao de uma alca jejunal pediculada entre o esofago terminal e a segunda porcao do duodeno age como neo-reservatorio gastrico. Evita o refluxo esofagico e direciona o bolo alimentar para o delgado atraves do duodeno, trânsito anatomico e funcional capaz de proporcionar melhor qualidade de vida ao gastrectomizado total.

Cistoadenoma de apêndice: relato de caso e revisão da literatura sobre tumores mucinosos do apêndice vermiforme

INTRODUCAO: Mucocele do apendice (MA) e uma lesao rara, caracterizada pelo acumulo de secrecao mucoide em sua luz. Diagnostico precoce e fundamental para evitar o extravasamento de secrecao mucoide na cavidade peritoneal, causando pseudomixoma peritoneal. RELATO DE CASO: Paciente sexo masculino, 62 anos com historia de dor abdominal em fossa iliaca direita ha cerca de 6 meses. Realizou uma ultra-sonografia do abdome que evidenciou no flanco direito pequena estrutura cistica compativel com MA. Colonoscopia, exames laboratoriais e dosagem do CEA encontravam-se sem alteracoes. O paciente foi submetido a laparotomia exploradora com resseccao do apendice e do seu meso em monobloco. O exame histologico mostrou tratar-se de cistoadenoma do apendice vermiforme. O paciente evoluiu sem intercorrencias. DISCUSSAO: A MA e um achado raro. As principais causas patologicas incluem cisto de retencao, mucocele secundaria a epitelio hiperplasico, cistoadenomas e cistoadenocarcinomas. A doenca e geralmente assintomatica e o diagnostico pre-operatorio e raro. O tratamento para mucocele do apendice e cirurgico e a preocupacao principal do cirurgiao e evitar o extravasamento do conteudo da mucocele na cavidade abdominal. CONCLUSAO: A MA e uma entidade incomum e com alto potencial de complicacao, usualmente curavel com tratamento cirurgico adequado.