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J. coloproctol. (Rio J., Impr.) ; 41(4): 375-382, Out.-Dec. 2021. tab, graf
Article in English | LILACS | ID: biblio-1356443


Introduction: The literature converges regarding the use of C-reactive protein (CRP) tests between postoperative days (PODs) 3 and 5 of elective procedures. In this period, they have great sensitivity and negative predictive value (NPV) for severe and anastomotic complications about two days before the first clinical sign. The few studies on colorectal urgency suggest that, despite the different initial values according to the surgical indication, following POD 3, the level of CRP is similar to that of elective procedures. However, given the heterogeneity of the studies, there is no consensus on the cutoff values for this use. Objective: To validate the use and propose a PO CRP cut-off value in urgent colorectal procedures as an exclusion criterion for complications of anastomosis or the abdominal cavity. Method: Retrospective analysis of the medical records of 308 patients who underwent urgent colorectal surgical procedures between January 2017 and December 2019. The following data were considered: age, gender, surgical indication, type of procedure performed, complications, CRP levels preoperatively and from POD 1 to 4, and the severity of the complications. We compared the CRP levels and the percentage variations between the preoperative period and PODs 1 to 4 as markers of severe complications using the receiver operating characteristic (ROC) curve. Results: The levels of CRP on POD4, and their percentage drops between PODs 2 to 4 and PODs 3 to 4, were better to predict severe complications. A cutoff of 7.45mg/dL on POD 4 had 91.7% of sensitivity and NPV. A 50% drop between PODs 3 and 4 had 100% of sensitivity and NPV. Conclusion: Determining the level of CRP is useful to exclude severe complications, and it could be a criterion for hospital discharge in POD 4 of emergency colorectal surgery. (AU)

Humans , Male , Female , Adolescent , Adult , Middle Aged , Aged , Aged, 80 and over , Postoperative Complications/diagnosis , C-Reactive Protein , Colorectal Surgery/adverse effects , Emergencies , Anal Canal/surgery , Rectum/surgery
J. coloproctol. (Rio J., Impr.) ; 41(4): 451-454, Out.-Dec. 2021. ilus
Article in English | LILACS | ID: biblio-1356438


The evaluation of preventivemeasures and risk factors for anastomotic leakage has been a constant concern among colorectal surgeons. In this context, the description of a new way to perform a colorectal, coloanal or ileoanal anastomosis, known as transanal transection and single-stapled (TTSS) anastomosis, deserves an appreciation of its qualities, and a discussion about its properties and technical details. In the present paper, the authors review themost recent efforts aiming to reduce anastomotic dehiscence, and describe the TTSS technique in a patient submitted to laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Surgical perception raises important advantages such as distal rectal transection under visualization, elimination of double-stapling lines (with cost-effectiveness and potential protection against suture dehiscence), elimination of dog ears, and the opportunity to be accomplished via a transanal approach after open, laparoscopic, or robotic colorectal resections. Future studies to confirm these supposed advantages are needed. (AU)

Humans , Anal Canal/surgery , Anastomosis, Surgical , Surgical Stapling , Rectum/surgery , Colon/surgery
J. coloproctol. (Rio J., Impr.) ; 41(3): 242-248, July-Sept. 2021. tab
Article in English | LILACS | ID: biblio-1346417


Introduction: There has been conclusive evidence that defunctioning stoma with either transverse colostomy or ileostomy mitigates the serious consequences of anastomotic leakage. However,whether transverse colostomy or ileostomy is preferred for defunctioning a rectal anastomosis remains controversial. The present study was designed to identify the best defunctioning stoma for colorectal anastomosis. Objective: To improve the quality of life in patients with rectal resection and anastomosis and reduce the morbidity before and after closure of the stoma. Patients and Methods The present study included 48 patients with elective colorectal resection who were randomly arranged into 2 equal groups, with 24 patients each. Group I consisted of patients who underwent ileostomy, and group II consisted of patients who underwent colostomy as a defunctioning stoma for a low rectal anastomosis. All surviving patients were readmitted to have their stoma closed and were followed-up for 6 months after closure of their stomas. All data regarding local and general complications of construction and closure of the stoma of the two groups were recorded and blotted against each other to clarify the most safe and tolerable procedure. Results: We found that all nutritional deficiencies, dehydration, electrolytes imbalance, peristomal dermatitis, and frequent change of appliances are statistically more common in the ileostomy group, while stomal retraction and wound infection after closure of the stoma were statistically more common in the colostomy group. There were no statistically significant differences regarding the total hospital stay and mortality between the two groups. Conclusion and Recommendation: Ileostomy has much higher morbidities than colostomy and it also has a potential risk of mortality; therefore, we recommend colostomy as the ideal method for defunctioning a distal colorectal anastomosis. (AU)

Humans , Male , Female , Adult , Middle Aged , Aged , Rectum/surgery , Anastomosis, Surgical/methods , Surgical Stomas/adverse effects , Colostomy , Ileostomy , Treatment Outcome
J. coloproctol. (Rio J., Impr.) ; 41(2): 193-197, June 2021. ilus
Article in English | LILACS | ID: biblio-1286994


Abstract The postoperative outcome of rectal cancer has been improved after the introduction of the principles of total mesorectal excision (TME). Total mesorectal excision includes resection of the diseased rectum and mesorectum with non-violated mesorectal fascia (en bloc resection). Dissection along themesorectal fascia through the principle of the "holy plane" minimizes injury of the autonomic nerves and increases the chance of preserving them. It is important to stick to the TME principle to avoid perforating the tumor; violating the mesorectal fascia, thus resulting in positive circumferential resection margin (CRM); or causing injury to the autonomic nerves, especially if the tumor is located anteriorly. Therefore, identifying the anterior plane of dissection during TME is important because it is related with the autonomic nerves (Denonvilliers fascia). Although there are many articles about the Denonvilliers fascia (DVF) or the anterior dissection plane, unfortunately, there is no consensus on its embryological origin, histology, and gross anatomy. In the present review article, I aim to delineate and describe the anatomy of the DVF inmore details based on a review of the literature, in order to provide insight for colorectal surgeons to better understand this anatomical feature and to provide the best care to their patients.

Resumo O resultado pós-operatório do câncer retal foi melhorado após a introdução dos princípios da excisão total do mesorreto (TME, na sigla em inglês). A excisão total do mesorreto inclui a ressecção do reto e do mesorreto afetados com fáscia mesorretal não violada (ressecção em bloco). A dissecção ao longo da fáscia mesorretal pelo princípio do "plano sagrado" minimiza a lesão dos nervos autônomos e aumenta a chance de preservá-los. É importante seguir o princípio da TME para evitar: a perfuração do tumor; a violação da fáscia mesorretal, resultando em margem de ressecção circunferencial (CRM) positiva; ou a lesão aos nervos autônomos, especialmente se o tumor estiver localizado anteriormente. Portanto, a identificação do plano anterior de dissecção durante a TME é importante, pois está relacionada comos nervos autonômicos (fáscia de Denonvilliers). Embora existammuitos artigos sobre a fáscia de Denonvilliers (DVF, na sigla em inglês) ou o plano de dissecção anterior, infelizmente não há consenso sobre sua origem embriológica, histologia e anatomia macroscópica. No presente artigo de revisão, retendo delinear e descrever a anatomia da DVF em mais detalhes com base em uma revisão da literatura, a fim de fornecer subsídios para os cirurgiões colorretais entenderemmelhor esta característica anatômica e fornecer o melhor cuidado para seus pacientes.

Rectal Neoplasms , Fascia/anatomy & histology , Rectum/anatomy & histology , Rectum/surgery , Rectum/pathology
J. coloproctol. (Rio J., Impr.) ; 41(2): 131-137, June 2021. tab, graf
Article in English | LILACS | ID: biblio-1286993


Abstract Background Colorectal resection anastomosis is the commonest cause of rectal strictures. Anastomotic site ischemia, incomplete doughnuts from stapled anastomosis and pelvic infection, are some of the risk factors that play a role in the development of postoperative rectal strictures. However, the role of diverting stoma in the development of rectal strictures has not been studied extensively. Objectives To study the difference in the occurrence of anastomotic strictures (AS) in patients submitted to low anterior resection (LAR) with covering ileostomy (CI), and to LAR without CI for carcinoma rectum. Methods This was a prospective, comparative case control study carried out at a tertiary care referral center. Low anterior resection with covering ileostomy was performed in patients with rectum carcinoma in the study group, while LAR without covering ileostomy was performed in the control group. The study group had 29 patients, while the control group had 33 patients with rectum carcinoma. Results During themean follow-up period of 9.1months, 8 (28%) patients in the study group and 2 (6%) patients in the control group developed AS (p =0.019). Out of these 8 patients with AS in the study group, 50% had Grade-I AS, 25% had Grade-II AS, while 25% of the patients had Grade-III (severe) AS. However, both patients who developed AS in the control group had a mild type (Grade I) of AS. Conclusion Covering ileostomy increases the chances of AS formation after LAR for rectum carcinoma. Also, the SKIMS Clinical Grading of Rectal Strictures is a simple and

Resumo Introdução A anastomose de ressecção colorretal é a causa mais comum de estenoses retais. A isquemia do local da anastomose, donuts (anéis) incompletos de anastomose grampeada e infecção pélvica são alguns dos fatores de risco que desempenham um papel no desenvolvimento de estenoses retais pós-operatórias. No entanto, o papel do estoma de desvio no desenvolvimento de estenoses retais não foi estudado extensivamente. Objetivos Estudar a diferença na ocorrência de estenoses anastomóticas (EA) em pacientes submetidos à ressecção anterior baixa (LAR) com ileostomia de proteção e a LAR sem ileostomia de proteção para carcinoma de reto. Métodos Este foi um estudo prospectivo e comparativo de caso-controle realizado em um centro de referência de atenção terciária. A ressecção anterior baixa com ileostomia de proteção foi realizada em pacientes com carcinoma de reto no grupo de estudo, enquanto LAR sem ileostomia de proteção foi realizada no grupo controle. O grupo de estudo tinha 29 pacientes, enquanto o grupo controle tinha 33 pacientes com carcinoma de reto. Resultados Durante o período de acompanhamento médio de 9, 1 meses, 8 (28%) pacientes no grupo de estudo e 2 (6%) pacientes no grupo controle desenvolveram EA (p=0,019). Destes 8 pacientes com EA no grupo de estudo, 50% tinham EA de Grau I, 25% tinhamEA de Grau II, enquanto 25% dos pacientes tinham EA de Grau III (grave). No entanto, ambos os pacientes que desenvolveram EA no grupo de controle tinham um tipo leve (Grau I) de EA. Conclusão A ileostomia de proteção aumenta as chances de formação de AS após LAR para carcinoma de reto. Além disso, o SKIMS Clinical Grading of Rectal Strictures é uma ferramenta simples e útil disponível para cada cirurgião para graduar, classificar e monitorar as estenoses retais pós-operatórias.

Humans , Anastomosis, Surgical , Ileostomy , Proctectomy , Postoperative Complications , Rectal Neoplasms , Rectum/surgery , Carcinoma , Anastomotic Leak
J. coloproctol. (Rio J., Impr.) ; 41(1): 42-46, Jan.-Mar. 2021. tab
Article in English | LILACS | ID: biblio-1286973


Abstract Introduction Colorectal cancer is the second most common type of cancer and the third leading cause ofmortality due to cancers. Anastomosis leak after proctectomy is a dangerous complication that must be managed carefully. The aim of the present study was to assess the procedure of resection and pull-through of the new rectum after anastomosis leak in patients after proctectomy. Methods and Materials This was a cross-sectional study. Patients who visited the Firoozgar Hospital between 2015 and 2018 for rectal cancer surgery and had anastomosis leak entered the study. All patients underwent resection of the residue of rectum and pull-through of colon. Results In the present study, out of the 110 cases who underwent proctectomy, 12 patients with postoperative anastomosis leak were reported. Five (41.7%) were male and 7 (58.3%) were female. Themean age of the patients was 41.5 ± 4.3 years (33-51). Resection of the new rectum and pull-through anastomosis were performed for these 12 patients. No major intraoperative complication occurred. Postoperative course was uneventful in all patients. Discussion Resection of residue of rectum and pull-through in patients with anastomosis leak can be done after rectal cancer surgery. This method is superior to abdominopelvic resection in many aspects, especially regarding accessibility to the new rectum by rectal exam or endosonography to assess recurrence or a relative continence after closure of ostomy.

Resumo Introdução O câncer colorretal é o segundo tipo de câncer mais comum, e a terceira principal causa de mortalidade por câncer. O vazamento da anastomose após a proctectomia é uma complicação perigosa, que deve ser tratada com cuidado. O objetivo do presente estudo foi avaliar o procedimento de ressecção e abaixamento do novo reto após vazamento de anastomose em pacientes submetidos à proctectomia. Métodos e Materiais Este foi um estudo transversal que incluiu pacientes que compareceram ao Firoozgar Hospital entre 2015 e 2018 submetidos a cirurgia de câncer retal e com vazamento de anastomose. Todos os pacientes foram submetidos a ressecção do resíduo do reto e abaixamento do cólon. Resultados No presente estudo, dos 110 casos submetidos a proctectomia, 12 pacientes tiveram vazamento de anastomose pós-operatório: 5 (41,7%) do sexo masculino e 7 (58,3%) do sexo feminino. A idade média dos pacientes foi de 41,5 ± 4,3 anos (gama: 33 a 51 anos). A ressecção do reto novo e a anastomose por abaixamento foram realizadas nesses 12 pacientes. Nenhuma complicação intraoperatória mais grave ocorreu. No pós-operatório, não houve intercorrências em nenhum dos pacientes. Discussão A ressecção de resíduo retal e o abaixamento em pacientes com vazamento de anastomose pode ser feita após cirurgia de câncer retal. Este método é superior à ressecção abdominopélvica em muitos aspectos, especialmente quanto à acessibilidade ao novo reto por exame retal ou endossonografia para avaliar a recorrência ou uma continência relativa após o fechamento da ostomia.

Humans , Male , Female , Adult , Rectum/surgery , Treatment Failure , Colon/surgery , Proctectomy/adverse effects , Rectal Neoplasms/complications , Anastomosis, Surgical , Cross-Sectional Studies
J. coloproctol. (Rio J., Impr.) ; 41(1): 52-57, Jan.-Mar. 2021. tab
Article in English | LILACS | ID: biblio-1286964


Abstract Objective To compare the fecal incontinence status of patients submitted to theAltemeier procedure with or without posterior levatorplasty. Materials and Methods Medical records of the patients who underwent the Altemeier procedure at Shahid Faghihi Hospital (in Shiraz, Iran) from 2014 to 2018 were retrospectively studied. Patients older than 17 years of age who underwent the Altemeier procedure due to complete rectal prolapse were considered. In some cases, the operation was performed with posterior levatorplasty. Rectal prolapse due to collagen or connective tissue disorders, anal/sacral anomalies, immunodeficiency, history of rectal surgery, and pelvic radiotherapy were the exclusion criteria of the present study. In addition to the demographics (including age, gender, and body mass index), the fecal incontinence status of each case was determined through theWexner scale preoperatively and 12 months after the surgery. The incontinence scores were then compared against the baseline values of the two groups of patients: those with and those without posterior levatorplasty. The statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, US), software, version 21. Results In total, 53 patients (17 men and 36 women) with a mean age of 55.23 ± 18.24 years were analyzed. The comparison of the pre- and postoperative scores on theWexner scale between the two groups revealed no statistically significant difference (p >0.05). Conclusion Posterior levatorplasty during the Altemeier procedure did not result in significant improvement of the fecal incontinence outcome of the patients.

Resumo Objetivo Comparar o status de incontinência fecal de pacientes após o procedimento de Altemeier com e sem levatorplastia posterior. Materiais e métodos Os prontuários médicos dos pacientes submetidos ao procedimento de Altemeier no Shahid Faghihi Hospital (em Shiraz, Irã) entre 2014 e 2018 foram avaliados retrospectivamente. Pacientes com idade superior a 17 anos submetidos ao procedimento de Altemeier devido a prolapso retal completo foram considerados. Em alguns casos, a operação foi realizada com levatorplastia posterior. Prolapso retal devido a distúrbios de colágeno ou do tecido conjuntivo, anomalias anais/sacrais, imunodeficiência, histórico de cirurgia retal, e radioterapia pélvica foram os critérios de exclusão deste estudo. Além dos dados demográficos (incluindo idade, sexo, e índice de massa corporal), o status da incontinência fecal de cada caso foi determinado por meio da escala de Wexner antes e doze meses após a cirurgia. Então, as pontuações de incontinência foram comparadas aos valores de referência dos dois grupos de pacientes: com e sem levatorplastia posterior. A análise estatística foi feita usandose o programa Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, EUA), versão 21. Resultados No total, 53 pacientes (17 homens e 36 mulheres) com idade média de 55.23 ± 18.24 anos foramavaliados. A comparação entre os grupos das pontuações na escala de Werner no pré e pós-operatório não revelou diferença estatisticamente significativa (p>0.05). Conclusão Levatorplastia superior durante o procedimento de Altemeier não resultou em melhora significativa do desfecho da incontinência fecal dos pacientes.

Humans , Male , Female , Postoperative Complications/etiology , Rectum/surgery , Rectal Prolapse/complications , Fecal Incontinence/etiology
Rev. Col. Bras. Cir ; 48: e20212977, 2021. tab
Article in English | LILACS | ID: biblio-1287888


ABSTRACT Background: although preservation of bowel continuity is a major goal in rectal cancer surgery, a colorectal anastomosis may be considered an unacceptably high-risk procedure, particularly for patients with multiple comorbidities. We aimed to assess rates of surgical complications in rectal cancer patients according to the type of procedure they had undergone. Materials and Methods: this cohort included all rectal cancer patients undergoing elective resection at a referral academic hospital over 16 years. There were three study groups according to the type of performed operation: (1) rectal resection with anastomosis without defunctioning stoma (DS); (2) rectal resection with anastomosis and DS; and (3) Hartmann's procedure (HP). Postoperative complications and clinical outcomes were assessed. Results: four-hundred and two patients were studied. The 118 patients in group 3 were significantly older (>10 years), had higher Charlson Comorbidity Index scores, and more ASA class ≥3 than patients in the other two groups. Sixty-seven patients (16.7%) had Clavien-Dindo complications grade ≥ III, corresponding to an incidence of 11.8%, 20.9%, and 14.4% in groups 1, 2, and 3, respectively (p=0.10). Twenty-nine patients (7.2%) had major septic complications that required reoperation, with an incidence of 10.8%, 8.2% and 2.5% in groups 1, 2 and 3, respectively (p=0.048). Twenty-one percent of the group 2 patients did not undergo the stoma closure after a 24-month follow-up. Conclusion: HP was associated with a lower incidence of reoperation due to intra-abdominal septic complications. This procedure remains an option for patients in whom serious surgical complications are anticipated.

RESUMO Introdução: embora a preservação do trânsito intestinal seja um dos objetivos principais na cirurgia do câncer retal, a anastomose colorretal pode ser considerada um procedimento de altíssimo risco, particularmente para pacientes com múltiplas comorbidades. Nosso objetivo foi avaliar as taxas de complicações cirúrgicas em pacientes com câncer retal de acordo com o tipo de procedimento a que foram submetidos. Materiais e Métodos: esta coorte incluiu todos os pacientes com câncer retal submetidos a ressecção eletiva em hospital universitário de referência ao longo de 16 anos. Houve três grupos de estudo de acordo com o tipo de operação realizada: (1) ressecção retal com anastomose, sem estoma desfuncionalizante (ED); (2) ressecção retal com anastomose e ED; e (3) procedimento de Hartmann (PH). Avaliamos as complicações pós-operatórias e os resultados clínicos. Resultados: estudamos 402 pacientes. O grupo 3 tinha 118 pacientes, estes sendo significativamente mais idosos (>10 anos), com pontuações mais altas no Índice de Comorbidade de Charlson e mais frequentemente classificados como ASA ≥ 3 do que os pacientes dos outros dois grupos. Sessenta e sete pacientes (16,7%) apresentaram complicações de Clavien-Dindo grau ≥ III, correspondendo à incidência de 11,8%, 20,9% e 14,4% nos grupos 1, 2 e 3, respectivamente (p = 0,10). Vinte e nove pacientes (7,2%) apresentaram complicações sépticas graves, necessitando reoperação, com incidência de 10,8%, 8,2% e 2,5% nos grupos 1, 2 e 3, respectivamente (p = 0,048). Vinte e um por cento dos pacientes do grupo 2 não foram submetidos ao fechamento do estoma após acompanhamento de 24 meses. Conclusão: o PH foi associado à menor incidência de reoperação por complicações sépticas intra-abdominais. Este procedimento continua sendo uma opção para pacientes com alto potencial de desenvolver complicações cirúrgicas graves.

Humans , Rectal Neoplasms/surgery , Colostomy , Postoperative Complications/surgery , Postoperative Complications/epidemiology , Rectum/surgery , Reoperation , Anastomosis, Surgical , Retrospective Studies , Cohort Studies , Treatment Outcome , Elective Surgical Procedures
Chinese Journal of Oncology ; (12): 1034-1042, 2021.
Article in Chinese | WPRIM | ID: wpr-920985


Presacral cysts are cystic or cyst-solid lesions between the sacrum and rectum. They are closely connected with adjacent pelvic floor structures such as sacrococcygeal fascia, rectum and anal sphincter. They are usually benign and are believed to be caused by aberrant embryogenesis. Clinically they are rare and its true incidence rate is unknown. Surgical resection remains the major treatment of presacral cysts. Unless the cysts are completely resected, the recurrence are unavoidable. The recurrent cysts even generate hard-to-heal sinus in the sacrococcyx, and cause the patients extreme pain. However, the current knowledge of presacral cysts is vague, even confused with other diseases such as ovarian cysts and perianal abscesses. Moreover, lack of the correct surgical concept or skills leads to palliative treatment of complex presacral cysts and serious complications such as fecal incontinence and massive haemorrhage which were attributed to impairing the function of anal sphincter or important blood vessels and nerves. The consensus summarizes the opinions and experiences of multidisciplinary experts in presacral cysts, and aims to provide clinicians with more detailed concept of the treatment, standardize the surgical approach and improve the resected efficacy of presacral cysts.

China , Consensus , Cysts , Female , Humans , Neoplasm Recurrence, Local , Rectum/surgery
Article in Chinese | WPRIM | ID: wpr-888619


In 1982, total mesorectal excision(TME) was proposed by Professor R. J. Heald, which was a milestone-style for rectal cancer surgery. The concept of TME has reduced the local recurrence rate of mid-low rectal cancer (MLRC) significantly, thus becomes the gold standard for MLRC surgery. However, the incidence of urogenital dysfunction after TME remains high, among which urinary dysfunction reaches 30%-60%, and sexual dysfunction reaches 50%-70%. In recent years, studies have shown that the removal of Denonvilliers' fascia (DVF) during TME is an important cause of postoperative urination and sexual dysfunction. Therefore, DVF preserving total mesorectal excision (iTME) has been recognized by more and more surgical experts. On the basis of existing literature and clinical practice, we organize experts to discuss and vote, put forward recommendations for several issues of iTME, and finally formulate this expert consensus. The formulation of this consensus aims to increase surgeons' awareness of the value and functional protection of DVF during TME surgery, clarify the indications and contraindications of iTME, and standardize the procedure of iTME, so as to reduce postoperative urination and sexual dysfunction and improve the quality of life of patients with MLRC. The level of evidence and recommendation of this consensus is determined by Grading Recommendations, Assessment, Development and Evaluation (GRADE), and the consensus content is determined through expert voting and Delphi method.

China , Consensus , Fascia , Humans , Neoplasm Recurrence, Local , Quality of Life , Rectal Neoplasms/surgery , Rectum/surgery
Article in Chinese | WPRIM | ID: wpr-880391


With the development of surgical techniques, adjuvant and neoadjuvant therapy, the survival of patients with rectal cancer after surgery has improved significantly, while the organ dysfunction remains an important factor affecting quality of life of patients. In order to improve the awareness of Chinese surgeons in organ function protection for the treatment of rectal cancer, standardize the evaluation method and surgical procedure, reduce the incidence of organ dysfunction, and ultimately improve the quality of life of patients, Colorectal and Anal Function Surgeons Committee of China Sexology Association, Organ Function Protection Committee of Chinese College of Colorectal Cancer, and Colon and Rectal Surgeons Committee of Chinese College of Surgeons jointly organized experts in related fields, in combination with domestic and foreign research and clinical practice, to discuss and formulate a Chinese expert consensus on the protection of pelvic organ function in the rectal cancer surgery, including the definition, risk factors, assessment methods, prevention and treatment of organ dysfunction after rectal cancer surgery.

China , Consensus , Humans , Quality of Life , Rectal Neoplasms/surgery , Rectum/surgery
J. coloproctol. (Rio J., Impr.) ; 40(3): 265-268, July-Sept. 2020. tab, ilus
Article in English | LILACS | ID: biblio-1134982


Abstract Up to 80 % of the rectal injuries reported in US trauma centers occur secondary to firearm injuries. Rectal gunshot wounds are associated with significant morbidity and mortality. Diverse surgical approaches and techniques have been described; however, controversy persists regarding the best management for these complex injuries. Nowadays, no single approach has proven to provide optimal results when dealing with these injuries. We present a case of a young male that suffered a combined (intra-extraperitoneal) gun shot gun to the rectus and the use of a transanal platform to repair it.

Resumo Até 80 % das lesões retais relatadas nos centros de trauma dos EUA ocorrem secundariamente às lesões por armas de fogo. Ferimentos retais por arma de fogo estão associados a significativa morbimortalidade. Foram descritas diversas abordagens e técnicas cirúrgicas; no entanto, ainda há controvérsias quanto qual é o melhor tratamento para essas lesões complexas. Atualmente, nenhuma abordagem isolada provou ótimos resultados ao lidar com essas lesões. Apresentamos um caso de um jovem do sexo masculino que sofreu um ferimento de pistola combinada (intra-extraperitoneal) no reto e o uso de uma plataforma transanal para repará-la.

Rectum/surgery , Wounds and Injuries , Transanal Endoscopic Surgery , Wounds, Gunshot
Arq. bras. med. vet. zootec. (Online) ; 72(5): 1742-1750, Sept.-Oct. 2020. tab, ilus
Article in Portuguese | LILACS, VETINDEX | ID: biblio-1131554


Objetivou-se, com este estudo, avaliar o processo de cicatrização da musculatura reto-abdominal em coelhos submetidos à laparorrafia, utilizando-se o fio de sutura à base de quitosana, comparando-o aos fios de categute cromado e poliglactina 910. Foram utilizados 24 coelhos adultos, divididos aleatoriamente em quatro grupos: quitosana e categute 15 dias (QC-15dias), quitosana e categute 30 dias (QC-30 dias), quitosana e poliglactina 910 15 dias (QP-15 dias) e quitosana e poliglactina 910 30 dias (QP-30 dias). Cada grupo foi composto por seis coelhos, nos quais foram realizadas duas incisões, uma do lado direito e outra do lado esquerdo e, posteriormente, a laparorrafia, com o fio de quitosana de um lado e o categute cromado ou poliglactina 910 do outro. Realizou-se análise clínico-cirúrgica, histológica e avaliação de achados de necropsia, além de testes de citotoxicidade e de mecânica no fio de quitosana. Ele apresentou baixa resistência mecânica e citotóxica. O fio de quitosana não proporcionou uma cicatrização satisfatória em coelhos, pois desencadeou uma resposta inflamatória acentuada.(AU)

The objective of this study was to evaluate the healing process of the recto-abdominal muscles in rabbits submitted to laparorrhaphy using chitosan-based suture yarn, comparing it to chrome catgut and polyglactin 910 yarns. Twenty-four adult rabbits were divided in to four random groups: chitosan and polyglactin 910 15 days (QP-15 days) and chitosan and polyglactin 910 30 days (QC-30 days), chitosan and polyglactin 910 15 days (QP-15 days) QP-30 days). Each group consisted of six rabbits, in which two incisions were made, one on the right side and one on the left side, and later the laparorraphy with the chitosan yarn on one side and chromed catgut or polyglactin 910 on the other. Clinical-surgical, histological and necropsy findings were evaluated, as well as cytotoxicity and mechanical tests on the chitosan wire. It presented low mechanical and cytotoxic resistance. Chitosan thread did not provide satisfactory healing in rabbits, as it triggered a marked inflammatory response.(AU)

Animals , Rabbits , Polyglactin 910/analysis , Sutures/veterinary , Wound Healing , Catgut/veterinary , Chitosan , Rectum/surgery , Suture Techniques/veterinary , Laparoscopy/veterinary , Guided Tissue Regeneration/veterinary , Abdomen/surgery
ABCD arq. bras. cir. dig ; 33(2): e1507, 2020. graf
Article in English | LILACS | ID: biblio-1130531


ABSTRACT Background: Abdominoperineal excision of the rectum (APR) remains the only potential curative treatment for very low rectal adenocarcinoma and squamous cell carcinoma of the anus. Yet, it implies a significant perineal exenteration and has set the attention on the perineal reconstruction. Aim: To present technique used in one case of APR for anal cancer, with resection of the vaginal posterior wall with large perineal defect which has called for the necessity of a flap for reconstruction Method: To cover the large perineal defect and reconstruct the posterior vaginal wall was perform a standardized and reproducible surgical technique using oblique rectus abdominis myocutaneous (ORAM) flap. The overlying skin of this flap is thick and well vascularized by both superficial branches and perforators of the superior epigastric artery and the deep inferior epigastric artery which serves as the vascular pedicle for the ORAM flap. Results: This procedure was applied in a 65-year-old woman with recurrent squamous cell carcinoma of the anus infiltrating the posterior wall of the vagina. Was performed an APR with en-bloc resection of the vaginal posterior wall in order to achieve tumor-free margins. Postoperative course was uneventful and she was discharged home at postoperative day 9. Final pathological report confirmed the oncological adequacy of the procedure (R0) and showed a rypT4N0 lesion. Conclusion: Flap reconstruction is an effective way to cover the perineal wound reducing both perineal complication rate and wound healing delay. The ORAM is particularly interesting for female whose tumors require resection and subsequent reconstruction of the posterior wall of the vagina.

RESUMO Racional: A amputação abdominoperineal do reto (APR) continua sendo o único tratamento curativo nos casos de adenocarcinoma retal muito baixo e carcinoma espinocelular do ânus. No entanto, implica em exenteração perineal significativa e exige atenção na reconstrução perineal. Objetivo: Propor, ilustrando com um caso clinico, proposta de APR para câncer anal com ressecção da parede posterior da vagina com cobertura do grande defeito perineal através de reconstrução com retalho miocutâneo oblíquo do reto abdominal (ORAM). Método: Para cobrir o defeito e reconstruir a parede vaginal posterior, realizou-se técnica de retalho miocutâneo oblíquo do reto abdominal (ORAM). A pele subjacente desse retalho por ser espessa e bem vascularizada por ramos perforantes superficiais da artéria epigástrica superior e pela artéria epigástrica inferior profunda serviu como pedículo vascular. Resultado: Este procedimento foi aplicado em uma mulher de 65 anos com recidiva de carcinoma espinocelular do ânus infiltrado na parede posterior da vagina. Foi realizada APR com ressecção em bloco da parede posterior vaginal com o objetivo de obter margens livres de tumor. O pós-operatório transcorreu sem intercorrências e a paciente recebeu alta hospitalar no 9° dia pós-operatório. O relatório patológico final confirmou a adequação oncológica do procedimento (R0) e mostrou uma lesão rypT4N0 de 6,5 cm. Conclusão: A reconstrução perineal com utilização de retalho é maneira eficaz de fechar a ferida operatória, reduzindo a taxa de complicações perineais e o atraso na cicatrização. O retalho de tipo ORAM é particularmente interessante para mulheres cujos tumores requerem ressecção e subsequente reconstrução da parede posterior da vagina.

Humans , Female , Aged , Rectal Neoplasms/surgery , Reconstructive Surgical Procedures , Myocutaneous Flap , Proctectomy , Perineum/surgery , Rectum/surgery , Rectus Abdominis/surgery , Neoplasm Recurrence, Local
ABCD arq. bras. cir. dig ; 33(2): e1504, 2020. tab
Article in English | LILACS | ID: biblio-1130521


ABSTRACT Background: Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades. Aim: To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades. Method: Seven hundred and five consecutive patients with Goligher's grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48). Results: Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively. Conclusion: The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

RESUMO Racional: A desarterialização hemorroidária transanal associada à mucopexia (THD-M) tem sido indicada como alternativa à hemorroidectomia convencional para o tratamento da doença hemorroidária nos seus variados graus. No entanto, ainda hoje existe controvérsia com relação a sua eficácia para os graus mais avançados. Objetivo: Avaliar a eficácia da técnica THD-M para tratamento doença hemorroidária e comparar os resultados imediatos e tardios nos diferentes graus. Método: Entre julho de 2010 e setembro de 2015, 705 pacientes consecutivos com hemorroidas sintomáticas de graus II, III e IV foram submetidos ao tratamento cirúrgico pelo método THD-M e acompanhados por um período médio de 21 meses (12-48). As operações foram realizadas por seis cirurgiões com experiência em cirurgia colorretal, em três estados brasileiros. Resultados: Complicações intraoperatórias foram observadas em 1,1% dos casos, incluindo quatro casos de hematoma, dois de laceração da mucosa e dois de sangramento. Todos foram controlados com sutura hemostática. As complicações pós-operatórias mais comuns foram: tenesmo transitório (21,4%); dor (7,2%); prolapso mucoso ou hemorroidário (6,4%); plicoma residual (5,6%); impactação fecal (3,2%); trombose hemorroidária (2,8%); sangramento (2,1%); fissura anal (0,7%) e abscesso anal (0,3%). Não houve casos de complicações severas ou mortalidade perioperatória. A recorrência do prolapso e sangramento foi maior na doença hemorroidária grau IV do que nos graus III e II (26.54% e 7.96% vs. 2.31% e 0.92% vs. 2.5% e 1.25%; p<0,001), respectivamente. Conclusão: O método THD-M é seguro e efetivo no tratamento da doença hemorroidária nos graus II e III com baixo índice de complicações. No entanto, para a doença hemorroidária de grau IV essa técnica está relacionada com maior índice de recorrência e complicações tardias, não devendo ser considerada opção eficiente neste estágio de doença.

Humans , Anal Canal/blood supply , Rectum/blood supply , Digestive System Surgical Procedures/methods , Hemorrhoids/surgery , Anal Canal/surgery , Arteries , Rectum/surgery , Severity of Illness Index , Brazil , Treatment Outcome , Hemorrhoidectomy , Hemorrhoids/classification , Ligation/methods
Rev. cir. (Impr.) ; 71(2): 136-144, abr. 2019. tab, graf, ilus
Article in Spanish | LILACS | ID: biblio-1058246


INTRODUCCIÓN: La dehiscencia anastomótica (DA) es una complicación severa en cirugía colorrectal con una incidencia que oscila entre 2 y 19%. La literatura internacional muestra numerosos estudios sobre la identificación de factores de riesgo (FR), mientras que en la nacional existen solo dos series que analizan esta complicación. OBJETIVO: Realizar una caracterización descriptiva de resultados institucionales y establecer la tasa de DA, sus factores de riesgo asociados y la mortalidad. MATERIALES Y MÉTODO: Serie de casos no concurrente, cuya muestra son pacientes consecutivos intervenidos de patología colorrectal con anastomosis primaria con o sin ostoma derivativo entre los años 2004 y 2016. Se realiza modelo de regresión logística univariable y multivariable. RESULTADOS: Se obtuvieron 748 pacientes, 50,5% mujeres, media de edad fue 56,2. Las indicaciones quirúrgicas más frecuentes fueron cáncer colorrectal en 381 (50,9%) pacientes y enfermedad diverticular en 163 (21,8%). La DA fue de 5,6% (42/748) y la mortalidad fue de 2% (15/748), siendo de 1% para los electivos (7/681). En el análisis univariado encontramos que los FR que tuvieron significancia estadística fueron la albúmina (p < 0,001), altura anastomosis (p < 0,001), transfusión (p < 0,001), localización (colon derecho > izquierdo) (p = 0,011), mientras que en el análisis multivariado fueron la albúmina (p = 0,002) con un OR 3,64 (IC 95% 1,58-8,35) y transfusión (p = 0,015) con un OR 7,15 (IC 95% 1,46-34,91). CONCLUSIÓN: Nuestra serie es la más grande reportada en Chile, con resultados similares a estudios internacionales y nacionales. Establecemos que la hipoalbuminemia y la presencia de transfusiones intraoperatorias se asocian a alta tasa de DA.

INTRODUCTION: Anastomotic leakage (AL) is a severe complication in colorectal surgery, its incidence ranges from 2 to 19%. In international literature, we found numerous studies on the identification of risk factors (RF), while in the national there are only two series that analyze this complication. AIM: Perform a descriptive characterization of institutional results and establish the AL rate, its associated risk factors and mortality. MATERIALS AND METHOD: Non-concurrent series of cases, whose sample is consecutive patients operated for colorectal pathology with primary anastomosis with or without a derivative ostoma between 2004 and 2016. Univariate and multivariable logistic regression model was performed. RESULTS: There were 748 patients, 50.5% women, mean age was 56.2. The most frequent surgical indications were colorectal cancer in 381 (50.9%) patients and diverticular disease in 163 (21.8%). The AL was 5.6% (42/748) and the mortality was 2% (15/748), being 1% for the electives (7/681). In the univariate analysis, we found that the RF that had statistical significance were albumin (p < 0.001), anastomosis height (p < 0.001), transfusion (p < 0.001), location (right colon > left) (p = 0.011), while that in the multivariate analysis were albumin (p = 0.002) with an OR 3.64 (IC 95% 1.58-8.35) and transfusion (p = 0.015) with an OR 7.15 (IC 95% 1.46-34.91). CONLUSION: Our series is the largest reported in Chile, with similar results to international and national studies. We establish that hypoalbuminemia and the presence of intraoperative transfusions are associated with a high rate of AL.

Humans , Male , Female , Middle Aged , Aged , Surgical Wound Dehiscence/diagnosis , Anastomosis, Surgical/adverse effects , Colorectal Surgery/adverse effects , Rectum/surgery , Digestive System Surgical Procedures/adverse effects , Surgical Wound Dehiscence/surgery , Surgical Wound Dehiscence/mortality , Colorectal Neoplasms/surgery , Logistic Models , Multivariate Analysis , Retrospective Studies , Risk Factors , Colon/surgery
J. coloproctol. (Rio J., Impr.) ; 39(2): 127-131, Apr.-June 2019. tab, ilus
Article in English | LILACS | ID: biblio-1012584


ABSTRACT Objective: To describe the partial results of a study in patients with rectal cancer who underwent neoadjuvant treatment with chemotherapy and radiotherapy regarding the rate of complete clinical response, disease-free survival, anorectal function, and quality of life. Material and methods: This was a prospective study from June 2015 to June 2018, in patients with low- or mid-rectum adenocarcinoma and clinical stage II or III, treated with radiotherapy and chemotherapy (IMRT 54 Gy for six weeks) concomitant with 5-fluorouracil (5-FU) 380 mg/m2 and folinic acid (LV) 20 mg/m2 for five days in the first and fifth weeks and two cycles after radiotherapy (5-FU 400 mg/m2 and LV 20 mg/m2) every 28 days. After the treatment, clinical examination, rectosigmoidoscopy, pelvic magnetic resonance imaging, chest and upper abdomen computed tomography, and CEA testing were performed. Resection surgery was performed in those with incomplete clinical response (iCR). Those with complete clinical response (cCR) are under observation (wait-and-see policy). Manometry and scintigraphic function and quality of life scales were collected before treatment and at 30 and 90 days after the end of treatment. Results: As of June 2018, 11 patients were recruited. One was excluded from the analysis for presenting severe toxicity, suggestive of dihydropyrimidine dehydrogenase (DPD) deficiency, after the first chemotherapy cycle. All others completed the treatment. Two patients presented toxicity grade 3/4 related to chemotherapy and had their doses reduced. Seven patients (70%) presented iRC; three underwent rectosigmoidectomy, and the anatomopathological evaluation indicated complete pathological response in two cases (28.5%). Three (30%) presented cCR and did not present evidence of disease after a mean follow-up of 19 months. Patients presented improvement of anorectal function and quality of life. Conclusions: Advances in the neoadjuvant treatment of rectal tumors contributed to better rates of complete pathological responses. New paradigms promote an increase in the complete clinical response rates, which would allow organ preservation and consequent reduction of surgical morbidity.

RESUMO Objetivo: Descrever os resultados parciais de estudo em pacientes com câncer de reto submetidos a tratamento neoadjuvante com quimioterapia e radioterapia quanto à taxa resposta clínica completa, sobrevida livre de doença, função anorretal e qualidade de vida. Material e métodos: Estudo prospectivo desde junho 2015 até junho de 2018, em paciente com adenocarcinoma de reto baixo ou médio e estadio clínico II ou III tratados com RT/QT (IMRT 54 Gy em 6 semanas) concomitante a 5-Fuorouracil (5-FU) 380 mg/m2 e ácido folínico (LV) 20 mg/m2 por 5 dias nas primeira e quinta semanas e dois ciclos após RT (5-FU 400 mg/m2 e LV 20 mg/m2) a cada 28 dias. Após o tratamento, realizou-se exame clínico, retossigmoidoscopia, RNM de pelve, TC de tórax e abdômen superior e dosagem de CEA. Naqueles com Resposta Clínica Incompleta (iRC) procedeu-se à cirurgia de ressecção. Aqueles com Resposta Completa (cRC) estão em observação (wait and see policy). Manometria e escalas de função esfincteriana e qualidade de vida foram obtidas antes e após 30 e 90 dias do término do tratamento. Resultados: Até junho de 2018, recrutaram-se 11 pacientes. Um foi excluído da análise, pois apresentou toxicidade severa sugestiva de deficiência de DPD após o primeiro ciclo de QT. Todos os demais concluíram o tratamento. Toxicidades graus 3/4 relacionadas à QT ocorreram dois pacientes, reduzindo-se sua dose. Sete (70%) apresentaram iRC, submetendo três à retossigmoidectomia cuja avaliação anatomopatológica evidenciou Resposta Completa (pRC) em dois casos (28,5%). Três (30%) apresentaram cRC e estão sem evidência de doença com seguimento médio de 19 meses. Houve melhora da função anorretal e da qualidade de vida. Conclusões: Avanços no tratamento neoadjuvante dos tumores de reto contribuíram para melhores taxas de pRC. Novos paradigmas promovem crescentes índices de cRC, o que possibilitaria a preservação do órgão e consequente redução da morbidade cirúrgica.

Humans , Male , Female , Rectal Neoplasms/drug therapy , Rectal Neoplasms/radiotherapy , Neoadjuvant Therapy , Quality of Life , Rectum/surgery
Rev. argent. coloproctología ; 30(1): 1-10, mar. 2019. tab, ilus
Article in Spanish | LILACS | ID: biblio-1023345


La morbilidad y alteración de la calidad de vida asociadas a la resección anterior del recto y amputación abdominoperineal determinaron un gran interés en el desarrollo del abordaje transanal. En los últimos años se ha visto un marcado desarrollo tecnológico en los dispositivos disponible para este abordaje. La cirugía por vía transanal ofrece ventajas en cuanto a sus resultados y complicaciones cuando se la compara a la cirugía por vía abdominal. La cirugía transanal mini-invasiva surge como una alternativa de abordaje videoendoscópico del recto. La resección local por cirugía endoscópica para los pólipos grandes de recto se ha convertido en un nuevo estándar de tratamiento en la mayoría de los centros, obteniendo piezas no fragmentadas con una alta tasa de márgenes negativos. En el presente estudio realizamos una revisión sobre la aplicación de TAMIS (TransAnal Minimally Invasive Surgery) al tratamiento de los pólipos de recto. (AU)

A great interest has developed in implementing trans anal minimally invasive surgery for the treatment of rectal adenomas and early rectal tumors. It present advantages when compare to radical surgery and peace meal endoscopic resections. TAMIS delivers non-fragmented specimens with clear resection margin in the majority of the cases. Such good technical results are mirrored with a low recurrence rate when evaluating rectal adenomas. This is a review of the application of TAMIS for the treatment of rectal adenomas. (AU)

Humans , Middle Aged , Rectum/surgery , Intestinal Polyps/surgery , Intestinal Polyps/epidemiology , Transanal Endoscopic Surgery/instrumentation , Transanal Endoscopic Surgery/methods , Postoperative Complications , Quality of Life , Rectal Neoplasms/surgery , Rectal Neoplasms/epidemiology , Morbidity , Treatment Outcome , Survivors , Fecal Incontinence/epidemiology
J. coloproctol. (Rio J., Impr.) ; 39(1): 27-32, Jan.-Mar. 2019. tab, graf
Article in English | LILACS | ID: biblio-984638


ABSTRACT Routine adoption of laparoscopy in clinical practice and Medical Residency has not been widely evaluated in Brazil so far. Aim: To take an overview on the adoption and limitations concerning the use of laparoscopic techniques among Brazilian colorectal surgeons. Methods: A questionnaire was sent to 1870 SBCP filiated members, containing personal and professional data such as sex, age, length and local of practice, SBCP filliation, number of procedures, treatment of cancer and laparoscopy limitations. Results: 418 members (22.4%) sent their response (80% men and 20% women). 110 members (26.3%) affirmed they don't perform any laparoscopic procedure, while 308 (73.7%) have already adopted laparoscopy as a routine. An average number of 7.6 laparoscopic colorectal procedures were declared to be performed per month (1 to 40 procedures). Laparoscopic adoption rates were favourably influenced by young age members (46% vs. 28%) and affiliation to University hospitals (p = 0.01). Conversely, surgeons from private clinic showed a greater tendency of no adoption. Among the 308 responders, 106 (34.4%) have already surpassed more than 100 laparoscopic cases, and 167 (54.2%) reported an experience of more than 50 operated patients. The group of surgeons not using minimally invasive techniques incriminated lack of training (73.6%) and laparoscopic instruments availability (27.3%) as the main reasons for no adoption. Conclusions: Adoption rate of laparoscopic techniques to treat colorectal diseases is still low (at least 17%). Future efforts should focus on providing supervised training, proctorship during the initial experience and help instrumental acquisition in centers willing to change their routine and perspectives.

RESUMO Durante as últimas décadas, a incorporação de técnicas minimamente invasivas no tratamento de doenças colorretais testemunhou um progresso lento e firme, principalmente após o reconhecimento da segurança oncológica e melhor evolução. A adoção rotineira na prática clínica e na Residência Médica no Brasil ainda não amplamente avaliada até agora. Objetivos: O presente estudo visou avaliar a adoção e as limitações relativas ao uso de técnicas laparoscópicas entre cirurgiões colorretais brasileiros. Métodos: um questionário foi enviado a 1870 membros filiados à Sociedade Brasileira de Coloproctologia (SBCP) em 2006. As questões foram enviadas por email, incluindo dados pessoais (sexo, idade) e profissionais (tempo e local de prática, filiação à SBCP, número mensal de procedimentos laparoscópicos, tratamento de câncer e limitações para realizar laparoscopia na rotina. Resultados: Entre os 1870 membros, 418 (22.4%) mandaram sua resposta, com uma maior participaçãoo de homens (80%) em comparação às mulheres (20%). A idade média foi de 43 (28-80) anos. A distribuição entre membros titulares e não titulares foi semelhantes (48% vs. 52%). As atividades profissionais foram desenvolvidas em clínica privada (84%), hospitais privados (73%), hospitais públicos (50%) e hospitais universitários (53%). Entre os que responderam (418), 110 (26.3%) não realizavam procedimentos laparoscópicos, enquanto 308 (73.7%) já haviam adotado o acesso laparoscópico rotineiramente na prática clínica. Um número médio de 7.6 procedimentos colorretais laparoscópicos são realizados por mês (1-40). Cerca de 13% dos cirurgiões iniciaram sua experiência laparoscópica diretamente com procedimentos colorretais, enquanto a maioria (87%) começaram por outros procedimentos no trato digestivo. A adoção da laparoscopia foi positivamente influenciada pela idade jovem dos membros (46% vs. 28%) e pela filiação a hospitais universitários (p = 0,01). Inversamente, cirurgiões trabalhando na prática privada demonstraram uma menor tendência em adotar o método. A maioria dos cirurgiões (93%) que adoraram a laparoscopia afirmou incluir pacientes com câncer colorretal em suas indicações operatórias. Entre os que responderam 106 (34,4%) já realizaram mais de 100 procedimentos laparoscópicos, e 167 (54,2%) reportaram experiência maior que 50 casos. Dentre aqueles que não adotaram técnicas minimamente invasivas, a falta de treinamento (73,6%) ou a indisponibilidade de instrumental laparoscópico (27,3%) foram incriminadas como os principais fatores limitantes. Conclusões: o índice de adoção de técnicas laparoscópicas no tratamento de doenças intestinais ainda é baixo (pelo menos 17%) entre cirurgiões colorretais brasileiros. Esforços futuros de nossa Sociedade Médica devem focar na provisão de treinamento supervisionado, na criação de oportunidades para preceptoria durante a experiência inicial e na obtenção de instrumental em centros que queiram mudar sua rotina e perspectivas.

Humans , Male , Female , Laparoscopy , Colorectal Surgery/methods , Rectum/surgery , Colonic Diseases/surgery , Minimally Invasive Surgical Procedures
Rev. Col. Bras. Cir ; 46(6): e20192361, 2019. tab, graf
Article in Portuguese | LILACS | ID: biblio-1057183


RESUMO Objetivo: identificar fatores preditivos da síndrome da ressecção anterior do reto (SRAR) que podem contribuir para o seu diagnóstico e tratamento precoces. Métodos: estudo de coorte retrospectivo de pacientes submetidos à ressecção anterior do reto entre 2007 e 2017 no Serviço de Coloproctologia do Hospital de Clínicas da Universidade Federal do Paraná. Foram realizadas análises de curva ROC (Receiver Operating Characteristic Curve Analysis) ou COR (Característica de Operação do Receptor) para identificar os fatores preditivos da SRAR. Resultados: foram incluídos 64 pacientes com dados completos. A idade dos homens foi de 60,1±11,4 anos e 37,10% eram do sexo masculino. Vinte pacientes (32,26%) apresentaram SRAR. Os sintomas mais relatados foram evacuação incompleta (60%) e urgência (55%). Na análise univariada, a distância da anastomose à margem anal (p<0,001), terapia neoadjuvante (p=0,0014) e confecção de ileostomia no momento da ressecção (p=0,0023) foram preditivos da SRAR. Análise da curva ROC mostrou um ponto de corte de 6,5cm na distância da anastomose à margem anal como preditor da SRAR. Conclusão: distância entre anastomose e margem anal, história de terapia neoajuvante e confecção de estoma são condições que podem ajudar a predizer o desenvolvimento da SRAR. A orientação e o envolvimento na educação do paciente, bem como, o manejo precoce podem reduzir potencialmente o impacto desses sintomas na qualidade de vida dos pacientes.

ABSTRACT Objective: to identify predictors of low anterior resection syndrome (LARS) that can contribute to its early diagnosis and treatment. Methods: we conducted a retrospective cohort study of patients undergoing anterior resection of the rectum between 2007 and 2017 in the Coloproctology Service of the Federal University of Parana Clinics Hospital. We performed Receiver Operating Characteristic Curve (ROC) analysis to identify LARS predictive factors. Results: we included 64 patients with complete data. The men's age was 60.1±11.4 years and 37.10% were male. Twenty patients (32.26%) had LARS. The most reported symptoms were incomplete evacuation (60%) and urgency (55%). In the univariate analysis, the distance from the anastomosis to the anal margin (p<0.001), neoadjuvant therapy (p=0.0014) and ileostomy at the time of resection (p=0.0023) were predictive of LARS. The ROC curve analysis showed a 6.5cm cut-off distance from the anastomosis to the anal margin as a predictor of LARS. Conclusion: distance between the anastomosis and the anal margin, neoadjuvant therapy history and preparation of stoma are conditions that can help predict the development of LARS. Guidance and involvement in patient education, as well as early management, can potentially reduce the impact of these symptoms on patients' quality of life.

Humans , Male , Female , Anal Canal/physiopathology , Rectal Neoplasms/diagnosis , Rectum/physiopathology , Anal Canal/surgery , Rectal Neoplasms/surgery , Rectal Neoplasms/etiology , Rectum/surgery , Anastomosis, Surgical , Predictive Value of Tests , Risk Factors , Longitudinal Studies , Surgical Stomas , Middle Aged