[Results of long-term follow-up after local excision for well-selected low rectal cancers]. / Resultados alejados de la resección local transanal para cánceres de recto bajo bien seleccionados.

OBJECTIVE: to evaluate our results about local failure, total recurrence and survival. METHOD: twenty-one patients underwent a complete local transanal excision for low rectal cancer in our institution during an 18-year period (1985-2003). Preoperative staging included clinical, endoscopic, CT, EUSR, and histopathological findings; pathological specimens were 4 T1, 13 T2 and 4 T3 tumors. None of the T1 patients received another treatment; 6 out of 13 T2 and all of T3 cases were treated with chemoradiotherapy. None of the latter underwent radical surgery. RESULTS: follow-up (median 74 months) proved 23.8% for total recurrence and 19.0% for local failure (out of all 3 T2 cases only one received chemoradiotherapy, and one T3 received adjuvant treatment). Five-year survival is 95.2%. CONCLUSIONS: this experience allows us to assert that local excision is a good choice in well-selected low rectal cancer patients; for T2 tumors chemoradiotherapy is necessary; in T3 patients radical surgery must be prompt.

Lomas-Cooperman technique for rectal prolapse in the elderly patient.

BACKGROUND: A variety of surgical procedures is used to correct complete rectal prolapse (RP). We analysed the immediate and long-term results of the Lomas-Cooperman technique in the management of symptomatic RP in elderly patients with severe concomitant diseases. METHODS: Across a 13-year period, all patients with RP having undergone surgery with this procedure were retrospectively evaluated. The technique consisted in placing a triply folded piece of polypropylene mesh encircling the anal canal through a perineal approach. RESULTS: A total of 22 patients (20 female) with a mean age of 84 years (range, 72-93 years) with severe concomitant pathologies were assessed. Four patients were classified as ASA II and 18 as ASA III. Mean Karnofsky score was 50%, ranging between 40% and 60%. All patients were operated on under regional anaesthesia without incidents. Mean operative time was 35 min(range, 20-60 min) and mean hospital stay was 4.5 days (range, 2-17 days). The most common immediate postoperative complication was urinary tract infection, found in 18% of the cases. Mean follow-up was 32 months (range, 4-84 months). During follow-up, 4 cases (18%) of mesh exteriorisation were detected, requiring mesh trimming at the outpatient clinic. Rectal prolapse recurred in 2 patients; one of them was managed with a new cerclage reaching a satisfactory outcome. Thus, by intention-to-treat basis, the recurrence rate was 4.5%. Constipation was resolved in three out of 4 patients, but in 18% of the cases late faecal impact was recorded. Mean preoperative incontinence score improved from 5.1+/-0.62 to 3.4+/-1.61 (p<0.0001) after surgery. CONCLUSION: Anal cerclage with the Lomas-Cooperman technique constitutes a simple and reproducible surgical technique with an acceptable morbidity and recurrence rate in high-risk elderly patients with RP.

Posterior pelvic exenteration for primary rectal cancer.

BACKGROUND: Indications for and the prognosis of posterior pelvic exenteration (PPE) in rectal cancer patients are not clearly defined. The aim of this study was to analyse the indications, complications and long-term results of PPE in patients with primary rectal cancer. METHODS: A retrospective review included patient demographics, tumour and treatment variables, and morbidity, recurrence, and survival statistics. These results were compared with a group of female patients who underwent standard resection for primary rectal cancer in the same period (non PPE group). RESULTS: The series included 30 women with an average age of 56.7 years (range 22-78). Tumour location was recorded in three cases in the upper rectum, 13 cases in the medium rectum and 14 cases in the lower rectum. A sphincter-preserving procedure was performed in 70% of the patients. Mean operative time was 4.2 h (range 2-7.5 h). Overall major morbidity rate in this series was 50% and mean hospital stay was 19.7 days (range 9-60 days). There was no hospital mortality. Pathological reports showed direct invasion of uterus, vagina or rectovaginal septum in 19 cases, involvement of perirectal tissue in 25 cases and positive lymph nodes in 18 cases. Comparison between PPE and non PPE groups showed no differences in mean tumour diameter, histological grade and tumour stage, but patients in the first group were younger. Although low tumours were seen more frequently in the PPE group (P = 0.003), the rate of sphincter-preserving procedure was comparable in both groups. Operative time was longer (P = 0.04) and morbidity was higher (P = 0.0058) in the PPE group. Local recurrence with or without distant metastases for the whole series was 30%. Five-year survival rate for patients who underwent curative resections (TNM I-III) was 48% in the PPE group vs 62% in the non PPE group (P = 0.09). CONCLUSIONS: In the present series, PPE prolonged operative time, increased postoperative complications and showed a trend toward poor prognosis in recurrence and survival. However, PPE offers the only hope for cure to patients with a primary rectal cancer that is adherent or invades reproductive organs.

[Fournier's disease]. / Enfermedad de Fournier.

Fournier's disease or perineal gangrene is a severe necrotizing process affecting the ano-rectal, perineal and scrotal region which is usually secondary to ano-rectal pathology and periurethral or cutaneous processes. Ample surgical debridement, wide spectrum systemic antibiotics and general supportive measures are essential for survival in this very serious disease.

[Intermittent cecal volvulus. Report of 2 cases]. / Vólvulo cecal intermitente. Comunicación de 2 casos.

In our country, acute cecal volvulus is responsible of 3.3% of mechanical large bowel obstructions. More than half of these cases have a history compatible with intermittent cecal volvulus, an usually overlooked diagnosis. The author reports two cases of intermittent cecal volvulus, treated in the last ten years. Both patients are female, aged 45 and 71 years old, with a history of 3 and 5 years of recurrent abdominal distention located in the right lower quadrant, that relieves spontaneously after the expulsion of gases or defecation. The symptomatology of the first cases was erroneously attributed to a concomitant colonic diverticulosis and the patient was subjected to a elective sigmoidectomy. The right colon and cecum was observed located in the right lower quadrant during the operation, and an appendectomy and a tube cecostomy for cecopexia were performed. The postoperative evolution was uneventful, and the patient is asymptomatic nine years later. The diagnosis in the second case was performed with a barium enema and a cecostomy for cecopexia was performed. The patient is asymptomatic two years later. The anatomical prerequisite for this condition is a lack of fusion of ascending colon to parietal peritoneum, which allows free rotation of this segment. The diagnosis must be suspected in patients with chronic and recurrent abdominal distention and must be confirmed with a barium enema. The surgical treatment consist in the fixation of the ascending colon.

[Surgical treatment of intestinal complications of pelvic radiotherapy]. / Tratamiento quirúrgico de las complicaciones intestinales de la radioterapia pélvica.

One hundred forty patients treated for intestinal complications of pelvic irradiation are presented. The most common clinical expression was radiation rectitis, complicated with rectovaginal fistulas in 58% of cases. These patients were subjected to Parks procedure for fistula repair with satisfactory results. Half the operated patients remained with an ostomy as a definitive sequel and overall perioperative mortality in these patients was 10%. Radiation enteritis has a high operative mortality due to delays in diagnosis and to severe septic complications. It must be suspected in irradiated patients presenting with chronic diarrhea and weight loss. Urological complications and involvement of several intestinal segments are bad prognostic factors. Resections and anastomoses with undamaged segments are the safest surgical procedures. Improvements of radiation techniques and the use of a reabsorbable mesh to seal the pelvis during radiation therapy are adequate preventive measures.

[Abdominal actinomycosis]. / Actinomicosis abdominal.

Actinomycosis is a non opportunistic chronic infection caused by a superior bacteria that forms grains in the pus or affected organs. Fifty four cases have been reported in the last 50 years in the chilean literature, 51% were abdominal actinomycoses, 25.5% pelvic and 18.5% pulmonary. Fourteen cases have been treated in the last 9 years at San Borja Arriaran. Of these 7 were abdominal (1 parietal and 6 visceral forms) and four involved the rectosigmoid; two were ileocecal and occurred after an appendicectomy. The presenting picture was of a giant abdominal mass in two cases (one with a colocutaneous fistula), rectal stricture in one case, tubo-ovarian abscess with colonic involvement in one case, parietal mass in one case and a fistula after an appendicectomy in two cases. Actinomyces Israelli was found in the histopathological study in three cases and in the bacteriological study in two. All visceral forms were treated with penicillin plus tetracycline or amoxicillin during 6 to 12 months with complete and permanent recovery. Two patients required a colonic resection due to a iatrogenic damage and an associated diverticular disease. Three patients required a colostomy to overcome the obstruction, all of them are asymptomatic and without colostomy 18 months to 8 years later. Due to its different presentation forms, actinomycosis has been called "the great pretender" and in several occasions the histological or bacteriological diagnosis is not achieved.

[Colonic perforation secondary to ileocecal tuberculosis. Report of one case]. / Perforación del colon secundaria a tuberculosis ileocecal. Caso clínico.

We report a 44 years old male, presenting with an eight months history of right lower quadrant pain, diarrhea and weight loss. Colonoscopy showed a proliferative and ulcerated lesion in the cecum, with necrotic areas. Barium enema showed an extensive irregular stenosis with rigidity of cecum and ascending colon. The endoscopic biopsy showed numerous granulomas with giant multinucleated cells of Langhans type. A right colectomy was performed with a good postoperative evolution. Anti tuberculosis treatment was started two weeks later and was well tolerated. The patient is currently asymptomatic after two years of followup.

[Toxic megacolon secondary to ischemic colitis. Report of a case]. / Megacolon tóxico secundario a colitis isquémica en un caso.

We report a 67 years old male that consulted due to bloody diarrhea of several months of evolution and emaciation. According to endoscopic and radiological findings, the diagnosis of severe ulcerative colitis was made. Fifteen days after admission, the patient was subjected to an emergency total colectomy due to a toxic megacolon. The pathological study showed an ischemic colitis with extensive longitudinal ulcers in the antimesenteric border, presence of granulation tissue with inflammation and transmural fibrosis. Intestinal transit was reconstituted six months later and after 12 months of follow up the patient is in good conditions.

[Colonic volvulus during pregnancy: 2 clinical cases]. / Vólvulos del colon durante el embarazo: 2 casos clínicos.

Two clinical cases of volvulus of the colon in pregnant women are presented. Both were operated on with success and the pregnancies continued without problems.

[Results of surgical treatment and prognosis of colonic neoplasms complicated by perforation]. / Resultados del tratamiento quirúrgico y pronóstico del cáncer del colon complicado con perforación.

Twenty two patients (13 males), whose ages ranged between 25 and 94 years, were subjected to surgical treatment for perforative carcinoma of the colon in a period of 10 years. Seventy three percent of tumors were localized in rectum and sigmoid colon. The perforation lied within the tumor in half of the patients and proximal to the tumor, specially in the cecum, in the rest. The perforation produced a local abscess in 5 patients and a diffuse peritonitis in 17 patients. Fifteen patients were subjected to segmental resections with a 40% operative mortality rate and 5 to a fecal diversion procedure with a 57% operative mortality. Tumor staging was similar to that of patients subjected to elective surgery. Crude 5 year survival was 18% and, excluding operative mortality, 57%.

[Pseudomyxoma peritonei secondary to cystadenocarcinoma on the cecal appendix. Clinical case]. / Pseudomixoma peritoneal secundario a cistoadenocarcinoma del apéndice cecal. Caso clínico.

We report a 40 years old female that presented with an ovarian tumor and ascites. The exploratory laparotomy revealed a mucocele of the appendix that was informed as a cystadenoma of the appendix in the fast biopsy. The definitive pathological diagnosis, a cystadenocarcinoma of the appendix, motivated a second intervention, performing a right hemicolectomy, left adnexectomy and omentumectomy. Three years later she presented with an abdominal mass and was subjected to a total hysterectomy and right adnexectomy. The pathological diagnosis was a mucinous cystadenocarcinoma with peritoneal involvement. The patient completed five years of follow up since the first intervention and is free of tumor. Pseudomyxome peritoneai generally is a tumor of ovarian origin, followed by the appendix. Surgical treatment must include the excision of neighboring compromised organs. The follow up must be lengthy considering the possibility of late recurrences.

[Radical resective surgery for the management of rectosigmoidal endometriosis. Clinical case]. / Cirugía resectiva radical en el manejo de la endometriosis rectosigmoidea. Caso clínico.

We report a 35 years old female with a profound rectosigmoidal endometriosis, who had been subjected to multiple laparoscopic procedures and open surgery due to infertility in the last five years. Main presenting symptoms were cyclic hematochezia during the menstrual periods associated to pelvic pain. Colonoscopy was inconclusive, barium enema showed a marked stenosis of the zone, appearing as an extrinsic compression. CAT scan showed a homogeneous, solid parauterine mass. During surgery, an inflammatory mass with multiple endometriotic foci was found. A low anterior resection with mechanical anastomosis was done, preserving the uterus and left adnexa. Two months later, the patient became pregnant and an elective cesarean section was done at 38 weeks of gestation, giving birth to a healthy newborn. Radical resective surgery for rectosigmoidal endometriosis is indicated in patients with intense and recurrent symptoms in whom hormonal treatment has failed and when a tumor cannot be discarded. The fertility rate, when adnexa and uterus are preserved, is 40% and symptomatic improvement is achieved in 85% of patients.

[Cecal pseudotumoral endometriosis: a rare cause of massive lower digestive hemorrhage. A clinical case]. / Endometriosis pseudotumoral del ciego: una causa infrecuente de hemorragia digestiva baja masiva. Caso clínico.

A 45 year old female, with massive intestinal bleeding was subjected to barium enema disclosing a large lobulated mass in the caecum. A right hemicolectomy was performed. Gross pathological examination showed an infiltrative lesion of the caecum with superficial mucosal ulcerations. Histologically the cecal wall was studded with endometrial implants penetrating to the submucosal layer. No invasion of the mucosa was demonstrated. Recovery was uneventful. After 1 year of follow up the patient remain asymptomatic.

[Non familial juvenile multiple polyposis. A case report]. / Poliposis múltiple juvenil no familiar. Caso clínico.

We report a 15 years old girl presenting with severe hematochezia with secondary anemia and hemodynamic decompensation, rectal prolapse and spontaneous anal elimination of polyps. She had no family history of polyposis and a search for the disease in her close relatives was negative. A complete diagnostic work up did not find polyps in other segments of the digestive tract. Colonoscopy showed more than 200 polyps between the cecum and the rectum. Pathological analysis confirmed the presence of retention polyps with adenomatous areas and mild atypia. The patient was subjected to a proctocolectomy with ileal pouch and sphincteric preservation, using a mechanical suture. Postoperative evolution was uneventful and after 24 months of follow up, the patient is asymptomatic, with two stool movements per day and without incontinence.

[Colon and rectum cancer complicated with obstruction: immediate results and long-term follow-up]. / Cáncer de colon y recto complicado con obstrucción: resultados immediatos y seguimiento a largo plazo.

Colorectal cancer is the leading cause of large bowel obstruction in Chile. The aim of this work was to assess the immediate results and long term survival of the surgical treatment of this complication. The clinical features of 113 patients (48 male and 65 female) with a mean age of 65 years, operated in a period of 10 years, were reviewed. The follow up was made by clinic appointments or home visits. The tumor was localized in the right colon in 30 cases, transverse colon in 20, splenic angle in 14, left colon in 39 and rectum in 10. Operative mortality was 34% for tumors of the right colon and 14% form tumors of the left colon. The follow up of the 89 survivors was accomplished in 97% with a mean follow up of 54 months (range 6 months-10 years). The principal prognostic factor was the initial stage of the tumor; survival was 87% for Dukes-Turnbull stage A, 70% for stage B and 32% for stage C1. The maximal survival period for stages D was 28 months. Patients subjected to an initial resective surgical procedure fared better, although not significantly, than colostomized patients. Present tendency is to perform one surgical procedure, avoiding colostomies that worsen patients quality of life and require a second intervention that increases surgical morbidity.

[Non-specific cecal ulcer in a patient with chronic renal failure in hemodialysis treatment. Case report]. / Ulcera cecal inespecífica en una paciente con insuficiencia renal crónica en programa de hemodiálisis. Caso clínico.

We report a 65 years old female undergoing hemodialysis, presenting with intense pain in the lower right quadrant and moderate hematochezia. Since symptoms did not abate after an appendectomy, a colonoscopy and barium enema were performed, whose results suggested an advanced cecal carcinoma. Biopsies were negative for cancer. A new surgical abdominal exploration disclosed a cecal inflammatory and transmural lesion. A right colectomy was performed and the patient had a satisfactory postoperative evolution. Pathological study of the surgical piece showed a six cm perforated profound ulceration and a two cm ulcer. Both had precise limits. Unspecific cecal ulcers are rare entities that must be born in mind in the differential diagnosis of abdominal pain or hematochezia, specially in patients undergoing chronic hemodialysis.

[Results of the surgical treatment of colorectal cancer: analysis of recurrence and survival in 400 patients]. / Resultados del tratamiento quirúrgico del cáncer colorrectal: análisis de la recurrencia y sobrevida en 400 pacientes.

We analyzed retrospectively the long term survival and recurrence of 400 patients with colorectal cancer operated in a period of 13 years. Kaplan Meier curves were used for survival analysis and Cox's regression for multivariate analysis. Ninety eight percent of 377 surviving patients were followed for a mean period of 34 +/- 36 months (range 12-156). Global recurrence was 32% and higher for rectal than colon cancer. Sixty five percent of recurrences were distant. The main prognostic parameter for recurrence was peritumoral lymph node involvement. The initial tumoral stage was the main prognostic factor for survival. Five years survival probability was 94.4% in stage A, 81.3% in stage B, 63.8% in stage C1, 41.3% in stage C2 and 3.1% in stage D. Preoperative radiation therapy did not improve survival or recurrence. Postoperative radiation therapy prolonged the lapse between surgery and recurrence, without changing overall survival. The prolonged survival of some patients in stage D justifies palliative surgery in this stage.

[Prognostic factors in colorectal neoplasm. Multivariate analysis in 224 patients]. / Factores pronósticos en el cáncer colorrectal. Análisis multivariado de 224 pacientes.

BACKGROUND: Staging of colorectal carcinoma has prognostic value and allows to take decisions about adjuvant therapy and follow up. Prognostic factors are not universally accepted and there are different staging classifications. AIM: To assess the prognostic value of clinical and pathological variables in 224 patients subjected to a curative resection of a colorectal carcinoma. PATIENTS AND METHODS: A retrospective analysis of 99 men and 125 women, aged 23 to 91 years old subjected to a curative resection of a colorectal carcinoma and followed up for a mean of 72 months. RESULTS: Global survival at 60 months was 72%. Univariate analysis showed that tumor localization, vascular permeation, wall infiltration and number of involved lymph nodes had an influence on survival. A Cox regression model disclosed tumor localization (colon versus rectum), a carcino-embryonic antigen over 30 ng/ml, vascular permeation, presence of 1 to 4 involved lymph nodes, or 5 or more lymph nodes and the presence of an apical lymph node as variables with significant prognostic value. CONCLUSIONS: Our series confirms the prognostic importance of lymph node involvement. This parameter is incorporated in Jass, GITSG (both modifications of Dukes classIfication) and TNM staging scores.

Resultados alejados de la resección local transanal para cánceres de recto bajo bien seleccionados / Results of long-term follow-up after local excision for well-selected low rectal cancers

Objetivo: evaluar nuestros resultados alejados en términos de recidiva local, rescate y sobrevida libre de enfermedad. Método: veintiún pacientes con un cáncer de recto bajo fueron sometidos a una resección transanal completa en un periodo de 18 años (1985-2003). La estadificación preoperatoria incluyó hallazgos clínicos y endoscópicos, estudios por imágenes e histopatológicos. Los especímenes resecados correspondieron a 4 tumores T1, 13 T2 y 4 T3. Los 4 pacientes T1 sólo fueron tratados con cirugía; 6 de los 13 T2 y todos los T3 recibieron quimiorradioterapia postoperatoria. Ninguno de ellos recibió una cirugía radical secuencial. Resultados: el seguimiento (media 75 meses) registró 5 casos (23,8%) de recidiva total y 4 (19%) con falla local (3 T2 de los cuales sólo uno había recibido terapia coadyuvante y un T3 también tratado con quimiorradioterapia). Los cuatro pacientes con recidiva local accedieron a cirugía de rescate, una amputación abdominoperineal en dos casos y a una re-resección local en los otros. Dos de ellos volvieron a recidivar. La sobrevida a 5 años fue de 95,2%, y la sobrevida libre de enfermedad en el mismo periodo alcanzó a un 90,4%. En el periodo de observación hasta agosto de 2006 hay dos pacientes que fallecieron diseminados, y sólo un paciente vivo está recidivado. Conclusiones: esta experiencia confirma que la resección local transanal para cáncer de recto bajo es una buena alternativa en pacientes adecuadamente seleccionados. En tumores T2, la quimiorradioterapia adyuvante será necesaria; en tumores T3, la cirugía radical de rescate debería ser realizada oportunamente

Objective: to evaluate our results about local failure, total recurrence and survival. Method: twenty-one patients underwent a complete local transanal excision for low rectal cancer in our institution during an 18-year period (1985-2003). Preoperative staging included clinical, endoscopic, CT, EUSR, and histopathological findings; pathological specimens were 4 T1, 13 T2 and 4 T3 tumors. None of the T1 patients received another treatment; 6 out of 13 T2 and all of T3 cases were treated with chemoradiotherapy. None of the latter underwent radical surgery. Results: follow-up (median 74 months) proved 23.8% for total recurrence and 19.0% for local failure (out of all 3 T2 cases only one received chemoradiotherapy, and one T3 received adjuvant treatment). Five-year survival is 95.2%. Conclusions: this experience allows us to assert that local excision is a good choice in well-selected low rectal cancer patients; for T2 tumors chemoradiotherapy is necessary; in T3 patients radical surgery must be prompt