A novel approach for the treatment of pelvic abscess: transrectal endoscopic drainage facilitated by transanal endoscopic microsurgery access.

BACKGROUND: Postoperative pelvic abscesses in patients submitted to colorectal surgery are challenging. The surgical approach may be too risky, and image-guided drainage often is difficult due to the complex anatomy of the pelvis. This article describes novel access for drainage of a pelvic collection using a minimally invasive natural orifice approach. METHODS: A 37 year-old man presented with sepsis due to a pelvic abscess during the second postoperative week after a Hartmann procedure due to perforated rectal cancer. Percutaneous drainage was determined by computed tomography to be unsuccessful, and another operation was considered to be hazardous. Because the pelvic fluid was very close to the rectal stump, transrectal drainage was planned. The rectal stump was opened using transanal endoscopic microsurgery (TEM) instruments. The endoscope was advanced through the TEM working channel and the rectal stump opening, accessing the abdominal cavity and pelvic collection. RESULTS: The pelvic collection was endoscopically drained and the local cavity washed with saline through the scope channel. A Foley catheter was placed in the rectal stump. The patient's recovery after the procedure was successful, without the need for further intervention. CONCLUSIONS: Transrectal endoscopic drainage may be an option for selected cases of pelvic fluid collection in patients submitted to Hartmann's procedure. The technique allows not only fluid drainage but also visualization of the local cavity, cleavage of multiloculated abscesses, and saline irrigation if necessary. The use of TEM instrumentation allows safe access to the peritoneal cavity.

Squamous cell carcinoma of the esophagus and multiple primary tumors of the upper aerodigestive tract.

Squamous cell carcinoma of the esophagus is frequently associated with other, synchronous or metachronous tumors, in the upper aerodigestive tract. All 264 patients with squamous cell carcinoma of the esophagus, treated in the Gastrointestinal Surgery, Esophagus section, of the "Hospital das Clínicas" (São Paulo University Medical School, Brazil), between 1979 and 1989 were analyzed retrospectively with regards to the occurrence of multiple primary tumors in the upper aerodigestive tract. Multiple primary tumors were encountered in 10 (3.8%) patients. All patients were male and the mean age at the time of the first primary was 52.2 years. Tobacco smoke and alcohol were the principal carcinogens in these patients (n = 10). The sites of the tumors were: larynx (n = 4), tongue (n = 4), lung (n = 2), and oral cavity (n = 1). Two simultaneous, three synchronous and five metachronous multiple primary carcinomas were detected. The esophagus was the second primary tumor in nine patients. The mean overall survival after the diagnosis of the second primary was 2.8 months (SD = 0.89). Inquiry regarding other malignancies, associated with panendoscopy should be carry out prior to the treatment of the first primary to diagnose simultaneous or synchronous primary tumors, and careful follow-up should be performed after treatment of the first primary to detect new tumors in these high-risk patients.

Gastric stump mucosa: is there a risk for carcinoma?

BACKGROUND: Patients who underwent partial gastric resections are at an increased risk for the development of cancer in the gastric remnant. AIM: To assess the long-term patients who underwent surgical treatment for peptic ulcer disease through endoscopic and pathologic evaluation of the gastric stump mucosal alterations. PATIENTS AND METHODS: Between 1987 and 1990, 154 patients (mean = 20.4 years after gastrectomy) were evaluated by upper digestive endoscopy with multiple biopsies and pathological examination. RESULTS: Endoscopic alterations were present in 111 patients (72.1%). The commonest pathologic alterations were foveolar hyperplasia, intestinal metaplasia and cystic dilation. Severe dysplasia was noted in two (1.25%) and carcinoma in 13 (8.4%) of the cases. In four patients (3.8%) the endoscopic findings did not show any evidence of tumors, however they were detected due to multiple biopsies and histologic studies. CONCLUSIONS: Surveillance of these patients with endoscopy and multiple biopsies may provide the means to diagnose tumors at an early stage, but the cost benefit ratio of surveillance requires further study.

Synchronous primary malignant lymphoma and carcinoma of the stomach.

A case of synchronous concurrent carcinoma and primary malignant lymphoma developing as two independent tumors of the stomach is presented. The clinical and pathological diagnosis and therapeutic problems associated with synchronous tumors of the stomach are discussed. A possible relationship between the two tumors and the role of Helicobacter pylori are also reviewed.

Double pylorus: case report and review of the literature.

Double pylorus is an unusual condition in which a double communication between the gastric antrum and the duodenal bulb occurs. It may be congenital, or it may be acquired complication of peptic ulcer disease. We present a case of double pylorus in a gentleman with epigastric pain and previous history of peptic ulcer disease. The relationship between Helicobacter pylori and this disease was assessed. A review of the literature, the role of associated diseases and the role of H. pylori are discussed.

[Primary lymphomas of the large intestine]. / Linfomas primários do intestino grosso.

Primary colorectal lymphomas are rare tumors that comprise 0.5 to 2% of large bowel malignancies and 10 to 20% of gastrointestinal lymphomas. Between 1982-1993 ten patients were treated in the Colorectal Unit of the "Hospital das Clínicas" of the University of São Paulo, representing 2% of the neoplasms in this period. Age varied from 22 to 76 years, with median around 50 years, and male/female ratio 8:2. Weight loss, right iliac palpable mass and bowel habit alterations were the most common symptoms. Definitive diagnostic was only set with histological evaluation of the surgical specimen in all colon tumors. Four patients had advanced disease classified as stages III or IV. The tumors were located in ileocecal region (7 cases), transverse colon (1 case), sigmoid colon (1 case) and rectum (1 case). Colon lymphomas were treated by radical surgical resection and chemotherapy; the patient with rectal lymphoma received radiotherapy and chemotherapy because of local tumor spread. Histological data showed 6 large cell lymphomas and 4 small cleaved cells lymphomas. Lymphnodal involvement and tumor size were the main prognostic factors in the series: 80% of the patients in advanced stage (III or IV) and 66% of those with tumors larger than 10 cm died during the first year of the follow-up.

[The laparoscopy method in preoperative evaluation of patients with malignant stomach neoplasm]. / O método laparoscópico na avaliação pré-operatória de pacientes com neoplasia maligna do estômago.

In 190 patients with malignant gastric neoplasia the value of laparoscopy for diagnosing intra-abdominal metastases was investigated. At the laparoscopic examination the presence of tumoral tissue was appraised on the serosal coat of the stomach, epiploons, parietal and visceral peritoneum, and in the liver. On hand of laparoscopic findings (peritoneal or hepatic metastases) the surgical treatment was discarded in 34 patients (70.6%). In the remaining 29.4% of patients a bad general condition or concomitant diseases contra-indicated surgical intervention. A comparison of laparoscopic and surgical findings showed that correct diagnosis was established by laparoscopy in 61.4% of cases with tumoral invasion of gastric serosa, in 21.4% of cases with involvement of epiploon, in 27% of parietal peritoneum, and in 33.3% of the liver. Falsely positive findings were rare (5% of examinations).

Morphologic, histologic, and molecular similarities between adenocarcinomas arising in the gastric stump and the intact stomach.

BACKGROUND: Patients with gastric remnants resulting from partial resections have an increased risk for carcinoma. It is unclear whether adenocarcinoma arising in the gastric stump (GSca) differs from intact stomach carcinoma (Gca). The goal of this study was to examine the pathologic and molecular features of GSca and compare them with Gca. METHODS: Adjacent nonmalignant areas and tumors from 14 patients who were 19-55 years postgastrectomy (mean, 32.1 years) were compared with 14 Gca by pathologic and molecular analysis. Formalin fixed, paraffin embedded specimens were immunohistochemically stained for p53 followed by topographic genotyping. Exons 5-8 were amplified by the polymerase chain reaction and directly sequenced. RESULTS: No differences were noted between the two groups regarding gender, types of metaplasia, dysplasia, morphology, or histologic tumor type. However, a higher incidence of cystic dilatation and foveolar hyperplasia were present in GSca. p53 gene point mutations occurred in 5 of 14 (35.7%) GSca patients. GSca p53 mutations included missense point mutations (G:A transitions in four patients and G:C transversion in one patient) with allelic loss. In four of the five patients with p53 mutations, the same mutation was also observed in the adjacent area. p53 point mutations were present in 4 of 14 Gca (28.6%), in exons 5, 6, and 8. In one case, the same mutation was also detected in the adjacent nonmalignant mucosa. CONCLUSIONS: Similarities in clinical, pathologic, and molecular features between GSca and Gca suggest the possibility that they share similar mechanisms of carcinogenesis. p53 gene alterations in premalignant areas may denote a possible early role of this gene in gastric carcinoma.