LAPAROSCOPIC RIGHT AND LEFT COLECTOMY: WHICH PROVIDES BETTER POSTOPERATIVE RESULTS FOR ONCOLOGY PATIENTS?

BACKGROUND: The laparoscopic approach considerably reduced the morbidity of colorectal surgery when compared to the open approach. Among its benefits, we can highlight less intraoperative bleeding, early oral intake, lower rates of surgical site infection, incisional hernia, and postoperative pain, and earlier hospital discharge. AIMS: To compare the perioperative morbidity of right versus left colectomy for cancer and the quality of laparoscopic oncologic resection. METHODS: Retrospective analysis of patients submitted to laparoscopic right and left colctomy between 2006 and 2016. Postoperative complications were classified using the Clavien-Dindo scale, 30 days after surgery. RESULTS: A total of 293 patients were analyzed, 97 right colectomies (33.1%) and 196 left colectomies (66.9%). The averageage was 62.8 years. The groups were comparable in terms of age, comorbidities, body mass index, and the American Society of Anesthesiology (ASA) classification. Preoperative transfusion was higher in the right colectomy group (5.1% versus 0.4%, p=0.004, p<0.05). Overall, 233 patients (79.5%) had no complications. Complications found were grade I and II in 62 patients (21.1%) and grade III to V in 37 (12.6%). Twenty-three patients (7.8%) underwent reoperation. The comparison between left and right colectomy was not statistically different for operative time, conversion, reoperation, severe postoperative complications, and length of stay. The anastomotic leak rate was comparable in both groups(5.6% versus 2.1%, p=0.232, p>0.05). The oncological results were similar in both surgeries. In multiple logistic regression, ASA statistically influenced the worst results (≥ III; p=0.029, p<0.05). CONCLUSIONS: The surgical and oncological results of laparoscopic right and left colectomies are similar, making this the preferred approach for both procedures.

Comparing three-dimensional endorectal ultrasound and magnification chromoendoscopy for early rectal neoplasia invasion depth assessment.

INTRODUCTION: Accurate assessment of invasion depth of early rectal neoplasms is essential for optimal therapy. We aimed to compare three-dimensional endorectal ultrasound (3D-ERUS) with magnification chromoendoscopy (MCE) regarding their accuracy in assessing parietal invasion depth (T). METHODS: Patients with middle and distal rectum neoplasms were prospectively included. Two providers blinded to each other's assessment performed 3D-ERUS and MCE, respectively. The T stage assessed through ERUS was compared to the MCE evaluation. The results were compared to the surgical specimen anatomopathological report. Sensitivity, specificity, accuracy, positive (PPV), and negative (NPV) predictive values were calculated for the T stage and for the final therapy (local excision or radical surgery). RESULTS: In 8 years, 70 patients were enrolled, and all underwent both exams. MCE and ERUS showed an accuracy of 94.3% and 85.7%, sensitivity of 83.7 and 93.3%, specificity of 96.4 and 83.6%, PPV of 86.7 and 60.9%, and NPV of 96.4 and 97.9%, respectively. Kappa for T stage assessed through ERUS was 0.64 and 0.83 for MCE. CONCLUSION: MCE and 3D-ERUS had good diagnostic performance, but the endoscopic method had higher accuracy. Both methods reliably assessed lesion extension, circumferential involvement, and distance from the anal verge.

The Role of Probe-Based Confocal Laser Endomicroscopy (pCLE) in the Diagnosis of Sustained Clinical Complete Response Under Watch-and-Wait Strategy After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Adenocarcinoma: a Score Validation.

BACKGROUND: Watch-and-wait strategy has been increasingly accepted for patients with clinical complete response (cCR) after multimodal treatment for locally advanced rectal adenocarcinoma. Close follow-up is essential to the early detection of local regrowth. It was previously demonstrated that probe-based confocal laser endomicroscopy (pCLE) scoring using the combination of epithelial and vascular features might improve the diagnostic accuracy of cCR. AIM: To validate the pCLE scoring system in the assessment of patients with cCR after neoadjuvant chemoradiotherapy (nCRxt) for advanced rectal adenocarcinoma. METHODS: Digital rectal examination, pelvic magnetic resonance imaging (MRI), and pCLE were performed in 43 patients with cCR, who presented either a scar (N = 33; 76.7%) or a small ulcer with no signs of tumor, and/or biopsy negative for malignancy (N = 10; 23.3%). RESULTS: Twenty-five (58.1%) patients were men, and the mean age was 58.4 years. During the follow-up, 12/43 (27.9%) patients presented local regrowth and underwent salvage surgery. There was an association between pCLE diagnostic scoring and final histological report (for patients who underwent surgical resection) or final diagnosis at the latest follow-up (p = 0.0001), while this association was not observed with MRI (p = 0.49). pCLE sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 66.7%, 93.5%, 80%, 88.9%, and 86%, respectively. MRI sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 66.7%, 48.4%, 66.7%, 78.9%, and 53.5%, respectively. CONCLUSIONS: pCLE scoring system based on epithelial and vascular features improved the diagnosis of sustained cCR and might be recommended during follow-up. pCLE might add some valuable contribution for identifying local regrowth. Trial Registration This protocol was registered at the Clinical Trials (ClinicalTrials.gov identifier NCT02284802).

MRI-based radiomic score increased mrTRG accuracy in predicting rectal cancer response to neoadjuvant therapy.

PURPOSE: To develop a magnetic resonance imaging (MRI)-based radiomics score, i.e., "rad-score," and to investigate the performance of rad-score alone and combined with mrTRG in predicting pathologic complete response (pCR) in patients with locally advanced rectal cancer following neoadjuvant chemoradiation therapy. METHODS: This retrospective study included consecutive patients with LARC who underwent neoadjuvant chemoradiotherapy followed by surgery from between July 2011 to November 2015. Volumes of interest of the entire tumor on baseline rectal MRI and of the tumor bed on restaging rectal MRI were manually segmented on T2-weighted images. The radiologist also provided the ymrTRG score on the restaging MRI. Radiomic score (rad-score) was calculated and optimal cut-off points for both mrTRG and rad-score to predict pCR were selected using Youden's J statistic. RESULTS: Of 180 patients (mean age = 63 years; 60% men), 33/180 (18%) achieved pCR. High rad-score (> - 1.49) yielded an area under the curve (AUC) of 0.758, comparable to ymrTRG 1-2 which yielded an AUC of 0.759. The combination of high rad-score and ymrTRG 1-2 yielded a significantly higher AUC of 0.836 compared with ymrTRG 1-2 and high rad-score alone (p < 0.001). A logistic regression model incorporating both high rad-score and mrTRG 1-2 was built to calculate adjusted odds ratios for pCR, which was 4.85 (p < 0.001). CONCLUSION: Our study demonstrates that a rectal restaging MRI-based rad-score had comparable diagnostic performance to ymrTRG. Moreover, the combined rad-score and ymrTRG model yielded a significant better diagnostic performance for predicting pCR.

Mucinous Degeneration on MRI After Neoadjuvant Therapy in Patients With Rectal Adenocarcinoma: Frequency and Association With Clinical Outcomes.

BACKGROUND. Patients with nonmucinous rectal adenocarcinoma may develop mucinous changes after neoadjuvant chemoradiotherapy, which are described as mucinous degeneration. The finding's significance in earlier studies has varied. OBJECTIVE. The purpose of this study was to assess the frequency of mucinous degeneration on MRI after neoadjuvant therapy for rectal adenocarcinoma and to compare outcomes among patients with nonmucinous tumor, mucinous tumor, and mucinous degeneration on MRI. METHODS. This retrospective study included 201 patients (83 women, 118 men; mean age, 61.8 ± 2.2 [SD] years) with rectal adenocarcinoma who underwent neoadjuvant chemoradiotherapy followed by total mesorectal excision from October 2011 to November 2015, underwent baseline and restaging rectal MRI examinations, and had at least 2 years of follow-up. Two radiologists independently evaluated MRI examinations for mucin content, which was defined as T2 hyperintensity in the tumor or tumor bed, and resolved differences by consensus. Patients were classified into three groups on the basis of mucin status: those with nonmucinous tumor (≤ 50% mucin content on baseline and restaging examinations), those with mucinous tumor (> 50% mucin content on baseline and restaging examinations), and those with mucinous degeneration (≤ 50% mucin content on baseline examination and > 50% content on restaging examination). The three groups were compared. RESULTS. Interreader agreement for mucin content, expressed as a kappa coefficient, was 0.893 on baseline MRI and 0.890 on restaging MRI. Of the 201 patients, 156 (77.6%) had nonmucinous tumor, 34 (16.9%) had mucinous tumor, and 11 (5.5%) had mucinous degeneration. Mucin status was not significantly associated with complete pathologic response (p = .41) or local or distant recurrence (both p > .05). The death rate during follow-up was not significantly different (p = .21) between patients with nonmucinous tumor (23.1%), those with mucinous tumor (29.4%), and those with mucinous degeneration (9.1%). In adjusted Cox regression analysis, with mucinous degeneration used as reference, the HR for the overall survival rate for the mucinous tumor group was 4.7 (95% CI, 0.6-38.3; p = .14), and that for the nonmucinous tumor group was 8.0 (95% CI, 0.9-59.9; p = .06). On histopathologic assessment, all 11 patients with mucinous degeneration showed acellular mucin, yet 10 of 11 patients showed viable tumor (i.e., in nonmucinous portions of the tumors). CONCLUSION. Mucinous degeneration on MRI is not significantly associated with pathologic complete response, recurrence, or survival. CLINICAL IMPACT. Mucinous degeneration on MRI is uncommon and should not be deemed an indicator of pathologic complete response.

Impact of a Routine Colorectal Endoscopic Submucosal Dissection in the Surgical Management of Nonmalignant Colorectal Lesions Treated in a Referral Cancer Center.

BACKGROUND: Recent data show an increasing number of abdominal surgeries being performed for the treatment of nonmalignant colorectal polyps in the West but in settings in which colorectal endoscopic submucosal dissection is not routinely performed. This study evaluated the number of nonmalignant colorectal lesions referred to surgical treatment in a tertiary cancer center that incorporated magnification chromoendoscopy and endoscopic submucosal dissection as part of the standard management of complex colorectal polyps. OBJECTIVE: The study aimed to estimate the number of patients with nonmalignant colorectal lesions referred to surgical resection at our institution after the standardization of routine endoscopic submucosal dissection and to describe outcomes for patients undergoing colorectal endoscopic submucosal dissection. DESIGN: Single-center retrospective study from a prospectively collected database of endoscopic submucosal dissections and colorectal surgeries performed between January 2016 and December 2019. SETTING: Reference cancer center. PATIENTS: Consecutive adult patients with complex nonmalignant colorectal polyps were included. INTERVENTIONS: Patients with nonmalignant colorectal polyps were treated by endoscopic submucosal dissection or surgery (elective colectomy, rectosigmoidectomy, low anterior resection, or proctocolectomy). MAIN OUTCOMES MEASURES: The primary outcome measure was the percentage of patients referred to colorectal surgery for nonmalignant lesions. RESULTS: In the study period, 1.1% of 825 colorectal surgeries were performed for nonmalignant lesions, and 97 complex polyps were endoscopically removed by endoscopic submucosal dissection. The en bloc, R0, and curative resection rates of endoscopic submucosal dissection were 91.7%, 83.5%, and 81.4%, respectively. The mean tumor size was 59 (SD 37.8) mm. Perforations during endoscopic submucosal dissection occurred in 3 cases, all treated with clipping. One patient presented with a delayed perforation 2 days after the endoscopic resection and underwent surgery. The mean follow-up period was 3 years, with no tumor recurrence in this cohort. LIMITATIONS: Single-center retrospective study. CONCLUSIONS: A workflow that includes assessment of the lesions with magnification chromoendoscopy and resection through endoscopic submucosal dissection can lead to a very low rate of abdominal surgery for nonmalignant colorectal lesions. See Video Abstract at http://links.lww.com/DCR/C123 . IMPACTO DE LA DISECCIN SUBMUCOSA ENDOSCPICA COLORRECTAL DE RUTINA EN EL MANEJO QUIRRGICO DE LESIONES COLORRECTALES NO MALIGNAS TRATADAS EN UN CENTRO ONCOLGICO DE REFERENCIA: ANTECEDENTES:Datos recientes muestran un número cada vez mayor de cirugías abdominales realizadas para el tratamiento de pólipos colorrectales no malignos en Occidente, pero no en los entornos donde la disección submucosa endoscópica colorrectal se realiza de forma rutinaria. El estudio evaluó el número de lesiones colorrectales no malignas referidas a tratamiento quirúrgico en un centro oncológico terciario, que incorporó cromoendoscopia de aumento y disección submucosa endoscópica como parte del manejo estándar de pólipos colorrectales complejos.OBJETIVO:Estimar el número de pacientes con lesiones colorrectales no malignas referidos para resección quirúrgica en nuestra institución, después de la estandarización de la disección submucosa endoscópica de rutina y describir los resultados para los pacientes sometidos a disección submucosa endoscópica colorrectal.DISEÑO:Estudio retrospectivo de un solo centro, a partir de una base de datos recolectada prospectivamente de disecciones submucosas endoscópicas y cirugías colorrectales realizadas entre enero de 2016 y diciembre de 2019.AJUSTE:Centro oncológico de referencia.PACIENTES:Pacientes adultos consecutivos con pólipos colorrectales no malignos complejos.INTERVENCIONES:Pacientes con pólipos colorrectales no malignos tratados mediante disección submucosa endoscópica o cirugía (colectomía electiva, rectosigmoidectomía, resección anterior baja o proctocolectomía).PRINCIPALES MEDIDAS DE RESULTADO:La medida de resultado primario fue el porcentaje de pacientes remitidos a cirugía colorrectal por lesiones no malignas.RESULTADOS:En el período, 1,1% de 825 cirugías colorrectales fueron realizadas por lesiones no malignas y 97 pólipos complejos fueron extirpados por. disección submucosa endoscópica. Las tasas de resección en bloque, R0 y curativa de disección submucosa endoscópica fueron 91,7%, 83,5% y 81,4%, respectivamente. El tamaño tumoral medio fue de 59 (DE 37,8) mm. Se produjeron perforaciones durante la disección submucosa endoscópica en 3 casos, todos tratados con clipaje. Un paciente presentó una perforación diferida 2 días después de la resección endoscópica y fue intervenido quirúrgicamente. El seguimiento medio fue de 3 años, sin recurrencia tumoral en esta cohorte.LIMITACIONES:Estudio retrospectivo de un solo centro.CONCLUSIONES:Un flujo de trabajo que incluye la evaluación de las lesiones con cromoendoscopia de aumento y resección a través de disección submucosa endoscópica, puede conducir a una tasa muy baja de cirugía abdominal para lesiones colorrectales no malignas. Consulte Video Resumen en http://links.lww.com/DCR/C123 . (Traducción-Dr. Fidel Ruiz Healy ).

Laparoscopic right and left colectomy: which provides better postoperative results for oncology patients? / Colectomia laparoscópica, direita ou esquerda: qual apresenta melhores resultados pós-operatórios para pacientes oncológicos?

ABSTRACT BACKGROUND: The laparoscopic approach considerably reduced the morbidity of colorectal surgery when compared to the open approach. Among its benefits, we can highlight less intraoperative bleeding, early oral intake, lower rates of surgical site infection, incisional hernia, and postoperative pain, and earlier hospital discharge. AIMS: To compare the perioperative morbidity of right versus left colectomy for cancer and the quality of laparoscopic oncologic resection. METHODS: Retrospective analysis of patients submitted to laparoscopic right and left colctomy between 2006 and 2016. Postoperative complications were classified using the Clavien-Dindo scale, 30 days after surgery. RESULTS: A total of 293 patients were analyzed, 97 right colectomies (33.1%) and 196 left colectomies (66.9%). The averageage was 62.8 years. The groups were comparable in terms of age, comorbidities, body mass index, and the American Society of Anesthesiology (ASA) classification. Preoperative transfusion was higher in the right colectomy group (5.1% versus 0.4%, p=0.004, p<0.05). Overall, 233 patients (79.5%) had no complications. Complications found were grade I and II in 62 patients (21.1%) and grade III to V in 37 (12.6%). Twenty-three patients (7.8%) underwent reoperation. The comparison between left and right colectomy was not statistically different for operative time, conversion, reoperation, severe postoperative complications, and length of stay. The anastomotic leak rate was comparable in both groups(5.6% versus 2.1%, p=0.232, p>0.05). The oncological results were similar in both surgeries. In multiple logistic regression, ASA statistically influenced the worst results (≥ III; p=0.029, p<0.05). CONCLUSIONS: The surgical and oncological results of laparoscopic right and left colectomies are similar, making this the preferred approach for both procedures.

RESUMO RACIONAL: A abordagem laparoscópica reduziu consideravelmente a morbidade da cirurgia colorretal quando comparada à abordagem aberta. Entre seus benefícios podemos destacar o menor sangramento intraoperatório, ingestão oral precoce, menor índice de infecção de incisão cirúrgica e hérnia incisional, menor índice de dor pós-operatória e alta hospitalar mais precoce. OBJETIVOS: Comparar a morbidade perioperatória da colectomia direita versus esquerda para câncer e a qualidade da ressecção oncológica laparoscópica. MÉTODOS: Análise retrospectiva de pacientes submetidos à olectomia laparoscópica direit e esquerda entre 2006 e 2016. As complicações pós-operatórias foram classificadas pela escala Clavien-Dindo, 30 dias após a cirurgia. RESULTADOS: Um total de 293 pacientes foram analisados, 97 casos de colectomia direita (33.1%) e 196 de esquerda (66.9%). A idade média foi de 62,8 anos. Os grupos foram comparáveis em termos de idade, comorbidades, índice de massa corporal e classificação da Sociedade Americana de Anestesiologia (ASA). A transfusão pré-operatória foi maior no grupo da colectomia direita (5,1% versus 0,4%, p=0,004, p<0,05). No geral, 233 pacientes (79.5%) não apresentaram complicações. As complicações encontradas foram graus I e II em 62 pacientes (21,1%), egraus III a V em 37 (12,6%). Vinte e três pacientes (7,8%) foram reoperados. A comparação entre a colectomia laparoscópica esquerda e direita não foi estatisticamente diferente para tempo operatório, conversão, reoperação, complicações pós-operatórias graves e tempo de internação. A taxa de fístula anastomótica foi comparável em ambos os grupos (5,6% versus 2,1%, p=0,232, p>0,05). Os resultados oncológicos foram semelhantes nas duas cirurgias. Na regressão logística múltipla, a ASA influenciou estatisticamente os piores resultados (≥ III; p=0,029, p<0,05). CONCLUSÕES: Os resultados cirúrgicos e oncológicos das colectomias laparoscópicas direita e esquerda são semelhantes, tornando esta a abordagem preferida para ambos os procedimentos.

ANORECTAL MANOMETRY STANDARD OF A BRAZILIAN POPULATION AT PRODUCTIVE AGE WITHOUT PELVIC FLOOR DISORDERS: A PROSPECTIVE VOLUNTEERED STUDY.

BACKGROUND: Due to the lack of normal standards of anorectal manometry in Brazil, data used are subject to normality patterns described at different nationalities. AIM: To determine the values and range of the parameters evaluated at anorectal manometry in people, at productive age, without pelvic floor disorders comparing the parameters obtained between male and female. METHODS: Prospective analysis of clinical data, such as gender, age, race, body mass index (BMI) and anorectal manometry, of volunteers from a Brazilian university reference in pelvic floor disorders. RESULTS: Forty patients were included, with a mean age of 45.5 years in males and 37.2 females (p=0.43). According to male and female, respectively in mmHg, resting pressures were similar (78.28 vs. 63.51, p=0.40); squeeze pressures (153.89 vs. 79.78, p=0.007) and total squeeze pressures (231.27 vs. 145.63, p=0.002). Men presented significantly higher values of anorectal squeeze pressures, as well as the average length of the functional anal canal (2.85 cm in male vs. 2.45 cm in female, p=0.003). CONCLUSIONS: Normal sphincter pressure levels in Brazilians differ from those used until now as normal literature standards. Male gender has higher external anal sphincter tonus as compared to female, in addition a greater extension of the functional anal canal.

Is it Safe to Perform Elective Colorectal Surgical Procedures during the COVID-19 Pandemic? A Single Institution Experience with 103 Patients.

OBJECTIVES: Since the outbreak of the novel coronavirus disease 2019 (COVID-19), all health services worldwide underwent profound changes, leading to the suspension of many elective surgeries. This study aimed to evaluate the safety of elective colorectal surgery during the pandemic. METHODS: This was a retrospective, cross-sectional, single-center study. Patients who underwent elective colorectal surgery during the COVID-19 pandemic between March 10 and September 9, 2020, were included. Patient data on sex, age, diagnosis, types of procedures, hospital stay, mortality, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) preoperative screening tests were recorded. RESULTS: A total of 103 colorectal surgical procedures were planned, and 99 were performed. Four surgeries were postponed due to positive preoperative screening for SARS-CoV-2. Surgical procedures were performed for colorectal cancer (n=90) and inflammatory bowel disease (n=9). Laparoscopy was the approach of choice for 43 patients (43.4%), 53 (53.5%) procedures were open, and 3 (3%) procedures were robotic. Five patients developed COVID-19 in the postoperative period, and three of them died in the intensive care unit (n=3/5, 60% mortality). Two other patients died due to surgical complications unrelated to COVID-19 (n=2/94, 2.1% mortality) (p<0.01). Hospital stay was longer in patients with SARS-CoV-2 infection than in those without (38.4 versushttps://doi.org/10.3 days, respectively, p<0.01). Of the 99 patients who received surgical care during the pandemic, 94 were safely discharged (95%). CONCLUSION: Our study demonstrated that elective colorectal surgical procedures may be safely performed during the pandemic; however, preoperative testing should be performed to reduce in-hospital infection rates, since the mortality rate due to SARS-CoV-2 in this setting is particularly high.

Long-term outcomes of endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors.

BACKGROUND AND AIM: Endoscopic submucosal dissection and transanal endoscopic microsurgery are good options for the treatment of rectal adenomas and early rectal carcinomas, but whether long-term outcomes of these procedures are comparable is not known. The aim of this study was to address this question. METHODS: A retrospective single-center study evaluating 98 consecutive procedures between June 2008 and December 2017 was performed in a tertiary cancer center. Consecutive patients who had undergone either endoscopic submucosal resection or transanal endoscopic microsurgery for rectal adenomas and early rectal carcinomas were evaluated, and long-term recurrence and complication rates were compared. RESULTS: Both groups were similar regarding sex, age, preoperative surgical risk, and en bloc resection rate (95.7% in the endoscopic and 100% in the surgical group, P = 0.81). Mean follow-up period was 37.6 months. Lesions resected endoscopically were significantly larger (68.5 mm) than those resected by transanal resection (44.5 mm), P = 0.003. Curative resections occurred in 97.2% of endoscopic resections and 85.2% of the surgical ones (P = 0.04). Comparing resections that fulfilled histologic curative criteria, there were no recurrences in the endoscopic group (out of 69 cases) and two recurrences in the transanal group (8.3% of 24 cases), P = 0.06. Late complications occurred in 12.7% of endoscopic procedures and 25.9% of surgical procedures (P = 0.13). CONCLUSIONS: In our experience, endoscopic submucosal resection seems to have advantages over transanal endoscopic microsurgery, with similar en bloc resection rate and lower rate of late complications and recurrences. Multicenter randomized controlled trials are needed to support our findings.

Anorectal manometry standard of a brazilian population at productive age without pelvic floor disorders: a prospective volunteered study / Valores manométricos anorretais para a população brasileira eutrófica em idade produtiva e sem distúrbios do assoalho pélvico: estudo prospectivo com voluntários

ABSTRACT Background: Due to the lack of normal standards of anorectal manometry in Brazil, data used are subject to normality patterns described at different nationalities. Aim: To determine the values and range of the parameters evaluated at anorectal manometry in people, at productive age, without pelvic floor disorders comparing the parameters obtained between male and female. Methods: Prospective analysis of clinical data, such as gender, age, race, body mass index (BMI) and anorectal manometry, of volunteers from a Brazilian university reference in pelvic floor disorders. Results: Forty patients were included, with a mean age of 45.5 years in males and 37.2 females (p=0.43). According to male and female, respectively in mmHg, resting pressures were similar (78.28 vs. 63.51, p=0.40); squeeze pressures (153.89 vs. 79.78, p=0.007) and total squeeze pressures (231.27 vs. 145.63, p=0.002). Men presented significantly higher values of anorectal squeeze pressures, as well as the average length of the functional anal canal (2.85 cm in male vs. 2.45 cm in female, p=0.003). Conclusions: Normal sphincter pressure levels in Brazilians differ from those used until now as normal literature standards. Male gender has higher external anal sphincter tonus as compared to female, in addition a greater extension of the functional anal canal

RESUMO Racional: Devido à falta de padrões normais de manometria anorretal no Brasil, os dados utilizados estão sujeitos a padrões de normalidade descritos em diferentes nacionalidades . Objetivo: Determinar os valores e a faixa da manometria anorretal de pessoas em idade produtiva, sem distúrbios do assoalho pélvico, comparando os parâmetros obtidos entre homens e mulheres. Métodos: Análise prospectiva de dados clínicos, como gênero, idade, raça, índice de massa corporal (IMC) e manometria anorretal, de voluntários de uma referência universitária brasileira em distúrbios do assoalho pélvico. Resultados: Quarenta pessoas foram incluídas, com idade média de 45,5 anos nos homens e 37,2 nas mulheres (p=0,43). De acordo com homens e mulheres, respectivamente em mmHg, as pressões de repouso foram semelhantes (78,28 vs. 63,51, p=0,40); pressões de contração (153,89 vs. 79,78, p=0,007) e pressão total de compressão (231,27 vs. 145,63, p=0,002). Os homens apresentaram valores significativamente maiores de contração esfincteriana, assim como o comprimento médio do canal anal funcional (2,85 cm nos homens vs. 2,45 cm nas mulheres, p=0,003). Conclusões: Os níveis normais de pressão esfincteriana no Brasil diferem dos utilizados até o momento como padrão normal da literatura. O gênero masculino apresenta maior tônus ​​do esfíncter anal externo em relação ao feminino, além de maior extensão do canal anal funcional

Is it Safe to Perform Elective Colorectal Surgical Procedures during the COVID-19 Pandemic? A Single Institution Experience with 103 Patients

OBJECTIVES: Since the outbreak of the novel coronavirus disease 2019 (COVID-19), all health services worldwide underwent profound changes, leading to the suspension of many elective surgeries. This study aimed to evaluate the safety of elective colorectal surgery during the pandemic. METHODS: This was a retrospective, cross-sectional, single-center study. Patients who underwent elective colorectal surgery during the COVID-19 pandemic between March 10 and September 9, 2020, were included. Patient data on sex, age, diagnosis, types of procedures, hospital stay, mortality, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) preoperative screening tests were recorded. RESULTS: A total of 103 colorectal surgical procedures were planned, and 99 were performed. Four surgeries were postponed due to positive preoperative screening for SARS-CoV-2. Surgical procedures were performed for colorectal cancer (n=90) and inflammatory bowel disease (n=9). Laparoscopy was the approach of choice for 43 patients (43.4%), 53 (53.5%) procedures were open, and 3 (3%) procedures were robotic. Five patients developed COVID-19 in the postoperative period, and three of them died in the intensive care unit (n=3/5, 60% mortality). Two other patients died due to surgical complications unrelated to COVID-19 (n=2/94, 2.1% mortality) (p<0.01). Hospital stay was longer in patients with SARS-CoV-2 infection than in those without (38.4 versushttps://doi.org/10.3 days, respectively, p<0.01). Of the 99 patients who received surgical care during the pandemic, 94 were safely discharged (95%). CONCLUSION: Our study demonstrated that elective colorectal surgical procedures may be safely performed during the pandemic; however, preoperative testing should be performed to reduce in-hospital infection rates, since the mortality rate due to SARS-CoV-2 in this setting is particularly high.

IS LAPAROSCOPIC REOPERATION FEASIBLE TO TREAT EARLY COMPLICATIONS AFTER LAPAROSCOPIC COLORECTAL RESECTIONS?

BACKGROUND: Recently, with the performance of minimally invasive procedures for the management of colorectal disorders, it was allowed to extend the indication of laparoscopy in handling various early and late postoperative complications. AIM: To present the experience with laparoscopic reoperations for early complications after laparoscopic colorectal resections. METHODS: Patients undergoing laparoscopic colorectal resections with postoperative surgical complications were included and re-treated laparoscopically. Selection for laparoscopic approach were those cases with early diagnosis of complications, hemodynamic stability without significant abdominal distention and without clinical comorbidities that would preclude the procedure. RESULTS: In four years, nine of 290 (3.1%) patients who underwent laparoscopic colorectal resections were re-approached laparoscopically. There were five men. The mean age was 40.67 years. Diagnoses of primary disease included adenocarcinoma (n=3), familial adenomatous polyposis (n=3), ulcerative colitis (n=1), colonic inertia (n=1) and chagasic megacolon (n=1). Initial procedures included four total proctocolectomy with ileal pouch anal anastomosis; three anterior resections; one completion of total colectomy; and one right hemicolectomy. Anastomotic dehiscence was the most common complication that resulted in reoperations (n=6). There was only one case of an unfavorable outcome, with death on the 40th day of the first approach, after consecutive complications. The remaining cases had favorable outcome. CONCLUSION: In selected cases, laparoscopic access may be a safe and minimally invasive approach for complications of colorectal resection. However, laparoscopic reoperation must be cautiously selected, considering the type of complication, patient's clinical condition and experience of the surgical team.

Is laparoscopic reoperation feasible to treat early complications after laparoscopic colorectal resections? / é possível reoperar por laparoscopia as complicações precoces das ressecções colorretais laparoscópicas?

ABSTRACT Background: Recently, with the performance of minimally invasive procedures for the management of colorectal disorders, it was allowed to extend the indication of laparoscopy in handling various early and late postoperative complications. Aim: To present the experience with laparoscopic reoperations for early complications after laparoscopic colorectal resections. Methods: Patients undergoing laparoscopic colorectal resections with postoperative surgical complications were included and re-treated laparoscopically. Selection for laparoscopic approach were those cases with early diagnosis of complications, hemodynamic stability without significant abdominal distention and without clinical comorbidities that would preclude the procedure. Results: In four years, nine of 290 (3.1%) patients who underwent laparoscopic colorectal resections were re-approached laparoscopically. There were five men. The mean age was 40.67 years. Diagnoses of primary disease included adenocarcinoma (n=3), familial adenomatous polyposis (n=3), ulcerative colitis (n=1), colonic inertia (n=1) and chagasic megacolon (n=1). Initial procedures included four total proctocolectomy with ileal pouch anal anastomosis; three anterior resections; one completion of total colectomy; and one right hemicolectomy. Anastomotic dehiscence was the most common complication that resulted in reoperations (n=6). There was only one case of an unfavorable outcome, with death on the 40th day of the first approach, after consecutive complications. The remaining cases had favorable outcome. Conclusion: In selected cases, laparoscopic access may be a safe and minimally invasive approach for complications of colorectal resection. However, laparoscopic reoperation must be cautiously selected, considering the type of complication, patient's clinical condition and experience of the surgical team.

RESUMO Racional: A realização de procedimentos minimamente invasivos para o manejo de distúrbios colorretais, possibilitou ampliar a indicação de laparoscopia para o manuseio de diversas complicações pós-operatórias precoces e tardias. Objetivo: Apresentar a experiência com reoperações laparoscópicas para complicações precoces após ressecções colorretais laparoscópicas. Métodos: Foram incluídos pacientes submetidos a ressecções colorretais laparoscópicas que apresentaram complicações cirúrgicas no pós-operatório abordadas por via laparoscópica. Os pacientes selecionados foram aqueles com diagnóstico precoce de complicações, estabilidade hemodinâmica sem distensão abdominal significativa e sem comorbidades clínicas que impedissem o procedimento. Resultados: Em quatro anos, nove de 290 (3,1%) pacientes submetidos a ressecções colorretais laparoscópicas foram reabordados pela mesma via de acesso. Havia cinco pacientes do sexo masculino e idade média foi de 40,67 anos. Os diagnósticos de doença primária incluíram adenocarcinoma (n=3), polipose adenomatosa familiar (n=3), colite ulcerativa (n=1), inércia colônica (n=1) e megacólon chagásico (n=1). Os procedimentos iniciais incluíram quatro proctocolectomias totais com anastomose íleo-anal em bolsa ileal; três ressecções anteriores; uma totalização de colectomia total; e uma hemicolectomia direita. A deiscência da anastomose foi a complicação mais comum que resultou em reoperação (n=6). Houve apenas um caso de desfecho desfavorável, com óbito no 40º dia da primeira abordagem após complicações consecutivas. Os demais casos tiveram desfecho favorável . Conclusão: Em casos selecionados, o acesso laparoscópico pode representar alternativa de abordagem segura e minimamente invasiva para complicações da ressecção colorretal. No entanto, a reoperação laparoscópica deve ser cuidadosamente selecionada, considerando o tipo de complicação, a condição clínica do paciente e a experiência da equipe cirúrgica.

IS THERE A DIFFERENCE BETWEEN RIGHT- VERSUS LEFT-SIDED COLON CANCERS? DOES SIDE MAKE ANY DIFFERENCE IN LONG-TERM FOLLOW-UP?

BACKGROUND: Since 1990 it was proposed that distal and proximal location of colon cancer might follow different biological, epidemiology, pathology and prognosis, probably due to embryologic different development of the two segments of the colon, which may represent two separate disease entities. These differences might have consequences for the treatment of patients with colorectal cancer. AIM: To compare the characteristics between patients with right and left colon cancer, with severity and tumor characteristic that influence in the survival of these patients. METHOD: Were evaluated the outcomes of surgical treatment of patients with colon cancer with data collected retrospectively from prospectively collected database. RESULTS: The tumor's side did not influence survival time of patients with colon cancer (p=0.112) in the regression model. Only the diseases stage leads to influence on survival time; patients with right colon cancer have more advanced staging (III or IV) and present a risk of death greater in 3.23 times. CONCLUSION: This analysis provides evidence that the prognosis of localized left-sided colon cancer is better compared to right-sided colon cancer. Also, the patients with right colon cancer have more advanced stage, mucinous tumor and are older.

T≤2N0 TRG1-2 in Post-Chemoradiation Therapy MRI: What can it Predict?

BACKGROUND: Total mesorectal excision is the standard radical operation after neoadjuvant chemoradiotherapy for patients with middle/low locally advanced rectal cancer. However, it carries significant rates of morbidity, sexual/urinary dysfunction, fecal impairment and permanent stoma. The ability to identify patients with a complete or nearly-complete response could help steer patients to less-invasive surgery or a watch-and-wait strategy. OBJECTIVE: To assess the ability to predict good responders and a favorable prognosis among rectal cancer patients by post-chemoradiation therapy MRI. PATIENTS: Consecutive patients stage T3-4N0M0 or T(any)N+M0 located within 10cm from the anal verge were enrolled. Patients were staged and re-staged 8.8 weeks after the completion of chemoradiation by digital exam, colonoscopy, pelvic-MRI, and thorax and abdominal CT scans. All patients underwent total mesorectal excision with curative intent. RESULTS: Of the total 309 patients, 275 were eligible, and 199 (72.4%) of these were stage III. Restaging-MRI identified 59 (21.4%) T=2N0/TRG1-2. Specimen pathologic evaluation revealed 43 (15.6%) patients with a complete pathologic response. Estimates of the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of MRIyT=2N0/TRG1-2 for the identification of ypT0N0 were 79.7%, 84.5%, 53.5%, 39%, and 90.7%, respectively. Estimates for the identification of ypN0 were 48.4%, 27.8%, 92%, 88.1%, and 48.4%, respectively. In a multivariate analysis, the only pre-CRT/MRI variables that were associated with an increased risk of lymph node involvement at the specimen were N+ (OR=2.22) and extramural vascular invasion (OR=2.28). MRI yT=2N0/TRG1-2 patients showed improved estimated 5-year disease-free survival, but no difference in estimated 5-year survival. CONCLUSION: Although MRIyT=2N0/TRG1-2 cannot predict all cases of a complete pathologic response, it can effectively predict a low rate of lymph node involvement and a better prognosis in patients who undergo total mesorectal excision.

Diagnostic performance of magnetic resonance to assess treatment response after neoadjuvant therapy in patients with locally advanced rectal cancer.

PURPOSE: Our study aimed to evaluate the diagnostic performance of rectal magnetic resonance imaging (MRI) for local restaging in patients with non-metastatic locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (CRT) using surgical histopathology of total mesorectal excision as the reference standard. METHODS: Ninety-five patients with LARC who underwent rectal MRI after CRT between January 2014 and December 2016 were included. Accuracy, sensitivity, specificity, positive, and negative predictive value for local staging regarding T-stage, N-stage, circumferential resection margin, and MRI tumor regression grade (ymriTRG) were calculated, and inter-test agreements were assessed. RESULTS: 22/95 (23.2%) patients had radiological complete response (rCR), whereas 20/95 (21.1%) had pathological complete response (pCR). Among the patients with pCR, 11/20 (55%) had rCR. Fair agreement was demonstrated between ymriTRG and pathological TRG (ypTRG) (κ = 0.255). The sensitivity and specificity for detection of pCR were 61.1% (95% CI 35.7-82.7) and 89.6% (95% CI 80.6-95.4). For the detection of ypTRG grades 1 and 2, the corresponding values were 67.2% (95% CI 54.3-78.4) and 51.6 (95% CI 33.1-69.8). The accuracy of ymriTRG was 24.2% (95% CI 15.6-32.8). Inter-test agreement in TRG between MRI and pathology was overall fair (κ = 0.255) and slight (κ = 0.179), if TRG 1 + 2. CONCLUSION: Qualitative assessment on MRI for diagnosing pCR showed moderate sensitivity and high specificity, whereas the diagnosis of TRG had moderate sensitivity and low specificity with slight to fair inter-test agreement when compared with pathological specimens.