Victor Edmond Seid

Conservative therapies for hemorrhagic radiation proctitis: a review

Chronic radiation proctitis represents a challenging condition seen with increased frequency due to the common use of radiation for treatment of pelvic cancer. Hemorrhagic radiation proctitis represents the most feared complication of chronic radiation proctitis. There is no consensus for the management of this condition despite the great number of clinical approaches and techniques that have been employed. Rectal resection represents an available option although associated with high morbidity and risk of permanent colostomy. The effectiveness of nonoperative approaches remains far from desirable, and hemorrhagic recurrence represents a major drawback that leads to a need for consecutive therapeutic sessions and combination of techniques. We conducted a critical review of published reports regarding conservative management of hemorrhagic chronic radiation proctitis. Although prospective randomized trials about hemorrhagic radiation proctitis are still lacking, there is enough evidence to conclude that topical formalin therapy and an endoscopic approach delivering an argon plasma coagulation represent available options associated with elevated effectiveness for interruption of rectal bleeding in patients with chronic radiation proctitis.

Robotic surgery for rectal cancer: current immediate clinical and oncological outcomes.

Laparoscopic rectal surgery continues to be a challenging operation associated to a steep learning curve. Robotic surgical systems have dramatically changed minimally invasive surgery. Three-dimensional, magnified and stable view, articulated instruments, and reduction of physiologic tremors leading to superior dexterity and ergonomics. Therefore, robotic platforms could potentially address limitations of laparoscopic rectal surgery. It was aimed at reviewing current literature on short-term clinical and oncological (pathological) outcomes after robotic rectal cancer surgery in comparison with laparoscopic surgery. A systematic review was performed for the period 2002 to 2014. A total of 1776 patients with rectal cancer underwent minimally invasive robotic treatment in 32 studies. After robotic and laparoscopic approach to oncologic rectal surgery, respectively, mean operating time varied from 192-385 min, and from 158-297 min; mean estimated blood loss was between 33 and 283 mL, and between 127 and 300 mL; mean length of stay varied from 4-10 d; and from 6-15 d. Conversion after robotic rectal surgery varied from 0% to 9.4%, and from 0 to 22% after laparoscopy. There was no difference between robotic (0%-41.3%) and laparoscopic (5.5%-29.3%) surgery regarding morbidity and anastomotic complications (respectively, 0%-13.5%, and 0%-11.1%). Regarding immediate oncologic outcomes, respectively among robotic and laparoscopic cases, positive circumferential margins varied from 0% to 7.5%, and from 0% to 8.8%; the mean number of retrieved lymph nodes was between 10 and 20, and between 11 and 21; and the mean distal resection margin was from 0.8 to 4.7 cm, and from 1.9 to 4.5 cm. Robotic rectal cancer surgery is being undertaken by experienced surgeons. However, the quality of the assembled evidence does not support definite conclusions about most studies variables. Robotic rectal cancer surgery is associated to increased costs and operating time. It also seems to be associated to reduced conversion rates. Other short-term outcomes are comparable to conventional laparoscopy techniques, if not better. Ultimately, pathological data evaluation suggests that oncologic safety may be preserved after robotic total mesorectal excision. However, further studies are required to evaluate oncologic safety and functional results.

Distribution of lymph nodes in the mesorectum: how deep is TME necessary?

BackgroundStandardization of total mesorectal excision (TME) had a great impact on decreasing local recurrence rates for the treatment of rectal cancer. However, exact numbers and distribution of lymph nodes (LN) along the mesorectum remains controversial with some studies suggesting that few LNs are present in the distal third of the mesorectum.MethodsEighteen fresh cadavers without a history of rectal cancer were studied. The rectum was removed by TME and then was divided into right lateral, posterior and left lateral sides, which were further subdivided into 3 levels (upper, middle and lower). A pathologist determined the number and sizes of the LNs in each of the nine areas, b linded to their anatomical origin.ResultsOverall, the mesorectum had a mean of 5.7 LNs (SD=3.7) and on average each LN had a maximum diameter of 3.0 mm (SD=2.7). There was no association between the mean number or size of LNs with gender, BMI, or age. There was a significantly higher prevalence of LNs in the posterior location (2.8 per mesorectum) than in the two lateral locations (0.8 and 1.2 per mesorectum; p=0.02). The distribution of LNs in the three levels of the rectum was not significant.ConclusionsThe distribution of LNs reinforces the fact that TME should always include the distal third of the mesorectum. Care must be taken to not violate the posterior aspect of the mesorectum.

Laparoscopy-assisted ileal pouch-anal anastomosis: surgical outcomes after 10 cases.

We analyzed outcomes of laparoscopy-assisted ileal pouch-anal anastomosis (LAIPA) from 10 patients (7 with ulcerative colitis and 3 with familial adenomatous polyposis) operated on between January 1998 and March 2004. Median operating time was 246 minutes. There were no intraoperative complications. There were no conversions. Postoperative complications occurred in 3 (30%) patients: 2 cases of wound infection and 1 case of a foreign body retrieved during pouch endoscopy. There was a 30% reoperation rate due to unsuspected duodenal perforation, a persistent postoperative pain, and 1 case of intestinal obstruction after ileostomy closure. There were no deaths. Median time to resumption of diet was 24 hours. Median hospital stay was 7 days. All ileostomies were closed 6 to 8 weeks after LAIPA. LAIPA is feasible and safe and should be selectively offered to nonobese patients.

Surgical treatment of familial adenomatous polyposis: ileoretal anastomosis or restorative proctolectomy?

CONTEXTO: As controversias quanto a melhor forma de tratamento da polipose adenomatosa familiar confrontam a morbidade da proctocolectomia restauradora contra a suposta mortalidade decorrente de câncer retal apos ileo-reto anastomose. OBJETIVOS: Avaliar as complicacoes operatorias e a evolucao oncologica dos pacientes submetidos a ileo-reto anastomose ou proctocolectomia restauradora. METODOS: Analisaram-se os dados dos doentes tratados entre 1977 e 2006, procedendo ao levantamento de dados clinicos gerais, endoscopicos, resultados do tratamento cirurgico, dados anatomopatologicos e informacoes sobre a evolucao precoce e tardia dos pacientes. RESULTADOS: Foram tratados 88 pacientes, sendo 41 homens (46,6%) e 47 mulheres (53,4%). Por ocasiao do diagnostico, 53 pacientes (60,2%) ja tinham câncer colorretal associado a polipose. Registraram-se complicacoes operatorias em 25 doentes (29,0 %) dentre os 86 operados, sendo 17 (19,7%) precoces e 8 (9,3%) tardias. Houve mais complicacoes apos proctocolectomia restauradora (48,1%) em comparacao as proctocolectomias com ileostomia (26,6%) e ileo-reto anastomose (19,0%) (P = 0,03). Nao houve mortalidade operatoria. O risco cumulativo de câncer retal apos ileo-reto anastomose foi de 17,2% apos 5 anos, 24,1% apos 10 anos e 43,1% apos 15 anos de seguimento pos-operatorio. Ja o risco cumulativo idade-dependente comecou a existir a partir de 30 anos (4,3%), passando para 9,6% aos 40 anos, 20,9% aos 40 anos e 52% aos 60 anos. Entre os pacientes submetidos a bolsa ileal com seguimento (26), apenas 1 doente (3,8%) desenvolveu câncer na bolsa ileal. CONCLUSOES: 1. Ocorreram complicacoes operatorias em cerca de 1/3 dos pacientes, sendo mais frequentes apos a confeccao de bolsa ileal; 2. idade maior, tempo de seguimento e câncer colonico previo se associaram ao desenvolvimento de câncer no coto retal apos ileo-reto anastomose; 3. pacientes tratados por proctocolectomia restauradora nao estao livres do risco de degeneracao na bolsa ileal; 4. a complexidade da doenca e a existencia de diversos fatores de risco envolvidos (clinicos, endoscopicos, geneticos) indicam que a melhor decisao operatoria seja baseada em caracteristicas individuais a serem consideradas por um especialista; 5. todos os pacientes operados requerem vigilância continua e prolongada no seguimento pos-operatorio.CONTEXT Controversy regarding the best operative choice for familial adenomatous polyposis lays between the morbidity of restorative proctocolectomy and the supposed mortality due to rectal cancer after ileorectal anastomosis. OBJECTIVES To evaluate operative complications and oncological outcome after ileorectal anastomosis and restorative proctocolectomy. METHODS Charts from patients treated between 1977 and 2006 were retrospectively analyzed. Clinical and endoscopic data, results of treatment, pathological reports and information regarding early and late outcome were recorded. RESULTS Eighty-eight patients - 41 men (46.6%) and 47 women (53.4%) - were assisted. At diagnosis, 53 patients (60.2%) already had associated colorectal cancer. Operative complications occurred in 25 patients (29.0 %), being 17 (19.7%) early and 8 (9.3%) late complications. There were more complications after restorative proctocolectomy (48.1%) compared to proctocolectomy with ileostomy (26.6%) and ileorectal anastomosis (19.0%) (P = 0,03). There was no operative mortality. During the follow-up of 36 ileorectal anastomosis, cancer developed in the rectal cuff in six patients (16,6%). Cumulative cancer risk after ileorectal anastomosis was 17.2% at 5 years, 24.1% at 10 years and 43.1% at 15 years of follow-up. Age-dependent cumulative risk started at 30 years (4.3%), went to 9.6% at 40 years, 20.9% at 40 years and 52% at 60 years. Among the 26 patients followed after restorative proctocolectomy, it was found cancer in the ileal pouch in 1 (3.8%). CONCLUSIONS 1. Operative complications occurred in about one third of the patients, being more frequently after the confection of ileal reservoir; 2. greater age and previous colonic carcinoma were associated with the development of rectal cancer after ileorectal anastomosis; 3. patients treated by restorative proctocolectomy are not free from the risk of pouch degeneration; 4. the disease complexity and the various risk factors (clinical, endoscopic, genetic) indicate that the best choice for operative treatment should be based on individual features discussed by a specialist; 5. all patients require continuous and long-term surveillance during postoperative follow-up.

Laparoscopic total mesorectal excision for rectal cancer after neoadjuvant treatment: targeting sphincter-preserving surgery.

BACKGROUND/AIMS Laparoscopic total mesorectal excision for rectal cancer is under scrutiny. This study aimed at analyzing feasibility, adequacy of resection, impact on early outcomes after neoadjuvant chemoradiation therapy, and to investigate trend towards indication of laparoscopy for sphincter-preservation in a single university medical center. METHODOLOGY Patients with distal rectal cancer submitted to neoadjuvant treatment followed by laparoscopic total mesorectal excision were prospectively enrolled. The studied parameters were: demographics, previous surgery, BMI, type of operation, rate of sphincter-preserving surgery, duration of surgery, conversion, specimen retrieval, lymphadenectomy, distal and radial margins, intra and postoperative morbidity, reoperations, hospital stay, and mortality. RESULTS From January 2000 to July 2010, 68 patients were enrolled. Mean age was 60 (30-87) years. There were 27 anterior and 41 abdominoperineal resections. Six patients underwent a totally laparoscopic resection and coloanal anastomosis. There was a trend (p=0.003) towards more sphincter-preserving surgery. Conversion was 4.5%. Intraoperative complication was 7.4%. Postoperative complications occurred in 15%. Mortality was 3%. Lymph-node harvest was 11 (0-33). Mean distal margin was 2.5cm (1-4). Radial margins were positive in 3 (10%) cases. CONCLUSIONS Laparoscopic total mesorectal excision after neoadjuvant treatment is feasible and safe. Sphincter-preserving laparoscopic oncologic rectal surgery has been accomplished more frequently.

Assessing the extent of colon lengthening due to splenic flexure mobilization techniques: a cadaver study

CONTEXT Failure of a colorectal anastomosis represents a life-threatening complication of colorectal surgery. Splenic flexure mobilization may contribute to reduce the occurrence of anastomotic complications due to technical flaws. There are no published reports measuring the impact of splenic flexure mobilization on the length of mobilized colon viable to construct a safe colorectal anastomosis. OBJECTIVE The aim of the present study was to determine the effect of two techniques for splenic flexure mobilization on colon lengthening during open left-sided colon surgery using a cadaver model. DESIGN Anatomical dissections for left colectomy and colorectal anastomosis at the sacral promontory level were conducted in 20 fresh cadavers by the same team of four surgeons. The effect of partial and full splenic flexure mobilization on the extent of mobilized left colon segment was determined. SETTING University of Sao Paulo Medical School, Sao Paulo, SP, Brazil. Tertiary medical institution and university hospital. PARTICIPANTS A team of four surgeons operated on 20 fresh cadavers. RESULTS The length of resected left colon enabling a tension-free colorectal anastomosis at the level of sacral promontory achieved without mobilizing the splenic flexure was 46.3 (35-81) cm. After partial mobilization of the splenic flexure, an additionally mobilized colon segment measuring 10.7 (2-30) cm was obtained. After full mobilization of the distal transverse colon, a mean 28.3 (10-65) cm segment was achieved. CONCLUSION Splenic flexure mobilization techniques are associated to effective left colon lengthening for colorectal anastomosis. This result may contribute to decision-making during rectal surgery and low colorectal and coloanal anastomosis.

Advantages of the robotic approach to deep infiltrating rectal endometriosis: because less is more.

For symptomatic deep infiltrating endometriosis, surgery is often required to achieve symptom relief and restore fertility. A minimally invasive approach using laparoscopy is considered the gold standard. However, specific limitations of the laparoscopic approach deep in the pelvis keep challenging even surgeons with a solid experience with minimally invasive techniques. Robotic surgery has the potential to compensate for technical drawbacks inherent in conventional laparoscopic surgery, such as limited degree of freedom, two-dimensional vision, and the fulcrum effect. In the present report, we aim at demonstrating the central role of robotic surgery for deep infiltrating endometriosis, with special emphasis in the ability to practice organ (rectal) preservation. A 45-year-old white female with a 4-month history of chronic pelvic pain, dyschezia, and dysmenorrhea, refractory to hormonal therapy was referred to our unit. MRI findings were diagnostic of deep infiltrating endometriosis (retrocervical and rectovaginal) extending to the anterior rectal serosal layer (partial-thickness rectal invasion). Using a fully robotic approach, appropriate dissection of the rectovaginal septum and of the extraperitoneal rectum followed by complete excision of the endometriotic rectal nodule with organ (rectal) preservation was undertaken. It is our belief that using a robotic approach, the potential to boost rectal preservation might be established. Moreover, it is possible that in many cases, a robotic operation may allow the surgeon to perform the intervention with greater accuracy and comfort. As a result, more patients with deep infiltrating endometriosis may benefit from rectal sparing procedures.

Neoadjuvant chemoradiation therapy followed by curative transanal endoscopic microsurgery (TEM) for rectal cancer complicated by major suture dehiscence: avoiding ileostomy through hyperbaric oxygen therapy

Dear Editor: The modern approach for the treatment of distal rectal cancer is multidisciplinary, including chemotherapy, radiotherapy, and surgery. Preoperative chemoradiation therapy may result in significant tumor downstaging, higher rates of sphincterpreserving surgeries, better local control, and improvement of overall survival. Treating rectal cancer lies in conflicting aims: a successful and low morbidity associated eradication of the disease and preservation of sphincter function, with a good quality of life and preservation of autonomic nerve function. The concept of total mesorectal excision (TME) in rectal cancer surgery was introduced by Heald in 1979 and represents the most important surgical principle to be addressed during open or laparoscopic approach. In the Dutch TME trial, local recurrence after a median follow-up of 2 years was reduced to 2.4% after radiation therapy and TME and to 8.2% after TME alone. However, low anterior rectal resections and the abdominoperineal resection are associated with early and late postoperative morbidity. Septic complications after TME represent a feared complication of surgery for rectal cancer due to its association with postoperative mortality. Moreover, low anterior resection may result in significant morbidity, with sexual and urinary dysfunction commonly experienced (20–70%). Surgeons consider local excision techniques an appealing option in rectal cancer management because they result in no mortality, less frequent and rarely life-threatening morbidity, shorter operation time, and a shorter hospital stay. In addition, they allow rectum preservation and avoid the risk of stoma. The introduction of transanal endoscopic microsurgery (TEM) has renewed the interest. The use of TEM techniques for local excision after neoadjuvant therapy represents an alternative therapeutic option to radical resection for distal rectal adenocarcinomas. However, the use of this strategy for the curative approach of distal rectal non-early tumors is currently investigational. The concept that TEM is a minimally invasive and low morbidity procedure is widespread. Whether this concept persists after neoadjuvant treatment is a concern especially regarding wound healing after radiation therapy. During radical surgery, a segment of non-radiated proximal colon is brought into the field, whereas during a local excision, two segments of irradiated rectum are sutured. The dehiscence of the rectal suture represents a minor acute complication after transanal endoscopic-assisted or conventional local excisions of benign or malignant rectal lesions. However, there has been some evidence and it is our unpublished perception that the fate of the sutured rectal wound after TEM following external radiation therapy is different when compared to non-irradiated patients. Our preliminary data S. E. A. Araujo :V. E. Seid : S. C. Nahas : C. S. R. Nahas : I. Cecconello Discipline of Digestive Surgery and Coloproctology, Department of Gastroenterology, University of Sao Paulo Medical School, Eneas de Carvalho Aguiar 255, Suite 9074, Sao Paulo, SP 05403–900, Brazil

[Colorectal cancer in familial adenomatous polyposis: Are there clinical predictive factors?].

Abstract Background Familial Adenomatous Polyposis (FAP) is a hereditary disorder with multiple colorectal polyps that exhibit an almost inevitable risk of colorectal cancer (CRC) in untreated patients. Goals To evaluate clinical features related to CRC risk at diagnosis. Material and methods Charts from 88 patients were reviewed to collect information regarding age, family history, symptoms, polyposis severity and association with CRC. Results 41 men (46.6%) and 47 women (53.4%) were assisted. CRC was detected in 53 patients (60.2%), with a frequency of 9.1% under 20 years, 58% between 21–40 and 85% over 41 years of age. Average age of patients without CRC was lower at treatment (29.5 vs 40.0 years; P=.001). Family history was reported by 58 patients (65.9%), whose average age did not differ from those who didn’t report it (33.4 vs 34.4; P=.17). Asymptomatic patients comprised 10.2% of the total; in this group, CRC incidence was much lower when compared to those presenting symptoms (1.1% vs 65.8%; P=.001). Patients without CRC presented a shorter length of symptoms (15.2 vs 26.4 months; P=.03) and less frequent weight loss (11.4% vs 33.9%; P=.01). At colonoscopy, polyposis was classified as attenuated in 12 patients (14.3%), who presented greater average age (48.2 vs 33.3 years; P=.02) and equal CRC incidence (58.3% vs 58.3%; P=.6) when compared to those with classic polyposis. Conclusions The risk of CRC in FAP patients 1) increases significantly after the second decade; 2) is associated with higher age, weight loss, presence and duration of simptomatology; 3) is similar in patients with attenuated or classic phenotype.