Fascitis necrosante como causa de muerte en trauma de recto. Reporte de caso / Necrotizing fasciitis as a cause of death in rectal trauma. Case report

Introducción. La perforación del recto por trauma cerrado es poco frecuente y se asocia a fracturas pélvicas. En pacientes con perforaciones de recto no traumáticas se ha reportado fascitis necrosante en miembros inferiores, en la mayoría de los casos asociada a alta mortalidad. Caso clínico. Hombre de 36 años con trauma cerrado abdomino-pélvico y perforación de recto inferior, quien recibió manejo quirúrgico mediante derivación intestinal y fijación pélvica. Evolucionó con hematoma escrotal sobreinfectado, inestabilidad hemodinámica, signos de fascitis necrosante y choque séptico 4 días posterior a su ingreso. Resultados. Se tomó muestra para cultivo del hematoma escrotal que reportó E. coli. La patología del desbridamiento escrotal informó necrosis de coagulación en toda la muestra. Conclusión. El tacto rectal debe realizarse siempre ante la presencia de enfisema subcutáneo al examen físico o en la tomografía, para un diagnóstico temprano y manejo quirúrgico multidisciplinario oportuno, según el caso. La presencia de enfisema subcutáneo debe aumentar la sospecha de perforación de recto. Hay pocos reportes de fascitis secundaria a perforación de recto por trauma cerrado, por lo que no se conoce con precisión la mortalidad asociada.

Introduction. Rectal perforation due to blunt trauma is rare and associated with pelvic fractures. Signs of necrotizing fasciitis in lower limbs have been reported in non-traumatic rectal perforations, in most cases associated with high mortality. Case report. A 36-year-old man presents blunt abdomino-pelvic trauma and perforation of the lower rectum. Surgical management by intestinal diversion and pelvic fixation is performed. 4 days after admission, evolves with over-infected scrotal hematoma, hemodynamic instability, signs of necrotizing fasciitis and septic shock. Results. A sample for culture was taken from a scrotal hematoma that reported E. coli. Pathology of scrotal debridement reported coagulation necrosis in the entire specimen. Discussion. Digital rectal examination should always be performed in the presence of subcutaneous emphysema on physical examination or CT scan for early and multidisciplinary diagnosis and surgical management as appropriate. Conclusion. The presence of subcutaneous emphysema should raise the suspicion of rectal perforation. There are few reports of rectal perforation due to blunt trauma and fasciitis, so the associated mortality is not precisely known.

Effect of transanal mucosal flap displacement and transanal intersphincterotomy on the treatment of complex anal fistulas and their influence on the pressure of anorectal canal / 临床外科杂志

Objective To explore the effect of Endoanal advancement flap(ERAF)and transanal opening of interphincteric space(TROPIS)in the treatment of complex anal fistula and their impact on anorectal pressure,so as to provide a reference for clinical selection of surgical methods.Methods Eighty-four patients with complex anal fistula admitted from October 2018 to October 2022 were divided into group E received ERAF treatment(n=48)and group T received TROPIS treatment(n=36).The clinical efficacy,operation,wound surface and anorectal pressure of the two groups were compared.Results The effective rate of treatment in Group T was 97.22％,which was higher than that in Group E(87.50％),with no statistically significant difference(P＞0.05).The surgical time[(31.53 ±7.29)minutes],intraoperative bleeding volume[(29.56±7.37)ml],and wound area[(10.03± 0.96)cm2,(8.76±0.87)cm2,(6.20±0.77)cm2]on the day of surgery,7 and 14 days after surgery in Group T were all smaller than those in Group E[(35.36±8.54)min,(36.86±8.04)ml,(12.09± 1.23)cm2,(10.52±1.09)cm2 and(7.36±0.85)cm2](P＜0.05).After surgery,the VAS score and Wexner incontinence score of Group T were(1.38±0.27)and(0.21±0.08),respectively.Group E was(1.56±0.29)and(0.33±0.09),respectively.In group T,the anorectal systolic pressure at 20 mm and 30 mm and the anorectal resting pressure at 20 mm and 30 mm were(138.18±29.58)mmHg,(136.22±35.41)mmHg,(35.47±6.58)mmHg,and(32.97±8.01)mmHg,respectively.In Group E,the data was(152.78±31.53)mmHg,(156.29±32.74)mmHg,(38.29±7.62)mmHg and(36.41±7.63)mmHg,respectively.Both groups showed a decrease in score and anorectal pressure,and group T was lower than group E(P＜0.05).The incidence of adverse reactions in Group E was 20.83％,which was higher than that in Group T(11.11％),but the difference was not statistically significant(P＞0.05).Conclusion TROPIS has a better effect in the treatment of complex anal fistula,which can shorten the operation time,reduce intraoperative bleeding,reduce postoperative pain,and protect anal function.

Application of miniprobe endoscopic ultrasound in endoscopic surgery of small-diameter and low-grade rectum neuroendocrine neoplasm / 局解手术学杂志

Objective To evaluate the value of miniprobe endoscopic ultrasound(EUS)in guiding endoscopic treatment of small-diameter(maximum diameter less than 1 cm)and low-grade(G1 grade)rectum neuroendocrine neoplasm(R-NEN),and to provide evidence and clues for its clinical application and further research.Methods The clinical data of 85 cases of low-grade(G1 grade)R-NEN with a maximum diameter of less than 1 cm who underwent endoscopic treatment in our center from January 2014 to December 2020 were retrospectively analyzed.The patients were divided into the EUS group(37 cases)and control group(48 cases)according to whether EUS was performed before endoscopic treatment.The positive rate of incision margin,the incidence of complications,the recurrence rate,the hospital stay,the cost of hospitalization and endoscopic therapy were compared between the two groups.Results The positive rate of incision margin in the EUS group was significantly lower than that in control group(P<0.05).There was no significant difference in the incidence of complications,tumor recurrence rate,hospital stay or hospital costs between the two groups(P>0.05).There was statistically significant difference in the endoscopic therapy between the two groups(P<0.05).Conclusion Evaluating the lesion depth of small-diameter and low-grade(G1 grade)R-NEN before surgery by miniprobe EUS and selecting endoscopic surgery according to its results of can significantly reduce the residual risk of resection margin tumors.

Reduced Field of View APT Imaging of Rectum (RAPTOR) at 3T MRI Scanner / 生物化学与生物物理进展

ObjectiveThe chemical exchange saturation transfer (CEST) technique has become a valuable tool in diagnosing metabolic changes associated with cerebral and systemic diseases, leveraging the calculation of compounds with exchangeable protons in proximity to water molecules. Specifically, the amide proton transfer (APT) CEST technique has shown promise in diagnosing cerebral strokes and tumors by comparing altered endogenous proteins or peptides with normal tissues. Reduced field of view (rFOV) imaging technology has been widely used in the diagnosis of small organ lesions in the body. In this study, we aim to apply the rFOV imaging to identify CEST signals in the rectum, investigating the potential utility of rFOV technique in clinical diagnosis of rectal diseases and providing metabolic insights for chemoradiotherapy. MethodsMRI images of eleven healthy volunteers were acquired using transverse Full_FOV and rFOV CEST imaging on a 3T scanner. The resolution was set at 2.5×2.5×6 mm³ and 1.5×1.5×6 mm³ for Full_FOV or the rFOV method. Saturation powers of 0.7 μT and 2 μT were applied. For the 2 μT saturation, MTRasym at ±3.5 ppm was employed, while for 0.7 μT saturation, Lorentzian difference was used for CEST quantification of the contrast maps and curves. ResultsThe rFOV method has the advantage of halving the scan time while maintaining the same contrast as the Full_FOV method. When compared to Full_FOV methods, rFOV methods exhibited nearly identical Z_spec and very similar MTRasym curves. Additionally, rFOV with a 1.5 mm×1.5 mm in-plane resolution could be achieved in approximately 3 min. rFOV method displayed better structural details for the entire rectum, including CEST contrast maps and quantitative curves. ConclusionCEST MRI proves valuable in diagnosing rectal diseases, and employing the rFOV technique could provide higher spatial and temporal resolution. CEST MRI should be the preferred choice for offering improved diagnostic capabilities with its potential for rectal disease diagnosis.

Intestinal endometriosis: outcomes from a multidisciplinary specialized referral center / Endometriose intestinal: resultados de um centro de referência multidiscipilinar especializado

ABSTRACT BACKGROUND: Deep penetrating endometriosis (DE) can affect abdominal and pelvic organs like the bowel and bladder, requiring treatment to alleviate symptoms. AIMS: To study and investigate clinical and surgical outcomes in patients diagnosed with DE involving the intestines, aiming to analyze the effectiveness of surgical treatments. METHODS: All cases treated from January 2021 to July 2023 were included, focusing on patients aged 18 years or older with the disease affecting the intestines. Patients without intestinal involvement and those with less than six months of post-surgery follow-up were excluded. Intestinal involvement was defined as direct invasion of the intestinal wall or requiring adhesion lysis for complete resection. Primary outcomes were adhesion lysis, rectal shaving, disc excision (no-colectomy group), and segmental resection (colectomy group) along with surgical complications like anastomotic leak and fistulas, monitored for up to 30 days. RESULTS: Out of 169 patients with DE surgically treated, 76 met the inclusion criteria. No colectomy treatment was selected for 50 (65.7%) patients, while 26 (34.2%) underwent rectosigmoidectomy (RTS). Diarrhea during menstruation was the most prevalent symptom in the RTS group (19.2 vs. 6%, p<0.001). Surgical outcomes indicated longer operative times and hospital stays for the segmental resection group, respectively 186.5 vs. 104 min (p<0.001) and 4 vs. 2 days, (p<0.001). Severe complications (Clavien-Dindo ≥3) had an overall prevalence of 6 (7.9%) cases, without any difference between the groups. There was no mortality reported. Larger lesions and specific symptoms like dyschezia and rectal bleeding were associated with a higher likelihood of RTS. Bayesian regression highlighted diarrhea close to menstruation as a strong predictor of segmental resection. CONCLUSIONS: In patients with DE involving the intestines, symptoms such as dyschezia, rectal bleeding, and menstrual period-related diarrhea predict RTS. However, severe complication rates did not differ significantly between the segmental resection group and no-colectomy group.

RESUMO RACIONAL: A endometriose profunda infiltrativa (EP) pode afetar órgãos abdominais e pélvicos, tais como o intestino e a bexiga, necessitando de tratamento para aliviar os sintomas. OBJETIVOS: Estudar e investigar resultados clínicos e cirúrgicos em pacientes com diagnóstico de EP envolvendo o intestino, visando analisar a eficácia dos tratamentos cirúrgicos. MÉTODOS: Foram incluídos todos os casos atendidos de janeiro de 2021 a julho de 2023, com foco em pacientes com 18 anos ou mais com a doença acometendo o intestino. Foram excluídos pacientes sem comprometimento intestinal e aqueles com menos de seis meses de acompanhamento pós-operatório. O envolvimento intestinal foi definido como invasão direta da parede intestinal ou necessidade de lise de aderências para ressecção completa. Os desfechos primários foram lise de aderências, raspagem retal e excisão discóide (grupo não colectomia), e ressecção segmentar (grupo colectomia), juntamente com complicações cirúrgicas como fístulas, monitoradas por até 30 dias. RESULTADOS: Das 169 pacientes com EP tratadas cirurgicamente, 76 preencheram os critérios de inclusão. Não foi indicado colectomia em 50 (65,7%) pacientes, enquanto 26 (34,2%) foram submetidos à retossigmoidectomia (RTS). A diarreia durante a menstruação foi o sintoma mais prevalente no grupo RTS (19,2% vs. 6,0%, p<0,001). Os resultados cirúrgicos indicaram tempos operatórios e internações hospitalares mais longos para o grupo de ressecção segmentar, respectivamente, 186,5 vs. 104 min (p<0,001) e 4 vs. 2 dias, (p<0,001). As complicações graves (Clavien-Dindo ≥3) tiveram prevalência global de 6 (7,9%) casos, sem diferença entre os grupos. Não houve mortalidade relatada. Lesões mais graves e sintomas específicos como disquezia e sangramento retal foram associados a maior probabilidade de indicação de RTS. A regressão bayesiana destacou a diarreia próxima à menstruação como um forte preditor de ressecção segmentar. CONCLUSÕES: Em pacientes com endometriose envolvendo os intestinos, sintomas como disquezia, sangramento retal e diarreia relacionada ao período menstrual predizem a indicação de RTS. No entanto, as taxas de complicações graves não diferiram significativamente entre o grupo de ressecção segmentar e o grupo sem colectomia.

Vegetating lesions that appear in the scar after neoadjuvant therapy for rectal tumors: tumor regrowth or benign neoplasm?

Introduction: After the diagnosis of neoplasm of the middle and distal rectum, patients are often submitted to oncological treatment by neoadjuvant therapy. At the end of this treatment, those patients who show complete clinical response can choose, together with their physician, to adopt the watch-and-wait strategy; although it implies lower morbidity for the patient, this strategy is dependent on strict adherence to treatment follow-up for the early identification of any future local injury. Materials and Methods: Survey of data from medical records and description, and discussion of case reports with a literature review in books and databases. Results: We report the case of a 73-year-old patient diagnosed with moderately differentiated adenocarcinoma of the middle rectum, Stage II (cT3bN0M0), who presented complete clinical response after undergoing treatment with neoadjuvant therapy. Together with the assistant team, the watch-and-wait strategy was chosen. During the follow-up, an endoscopic examination showed a vegetating at the proximal limit of the tumor scar. We chose to perform submucosal endoscopic dissection. The report of the anatomopathological examination evidenced a serrated adenoma with narrow margins free of neoplasia. Conclusion: Patient adherence to cancer treatment using the watch-and-wait strategy is essential for the early identification of new local lesions. After resection of the lesion identified in the tumor scar site as a neoplasm-free lesion, it is consistent to think that this lesion would be the origin of the neoplasm, given the adenomatous origin. (AU)

Valor de la elastografía por patrones de colores en la reestadificación del cáncer de recto / Value of elastography by color patterns in the restaging of rectal cancer i: en

Introducción: La elastografía cualitativa por ecografía endoscópica es una técnica para examinar las propiedades elásticas de los tejidos, que puede distinguir la fibrosis del tumor mediante patrones de colores. Objetivo: Determinar el valor de la elastografía por patrones de colores en la reestadificación del cáncer de recto. Métodos: Se efectuó un estudio observacional y descriptivo (serie de casos) de 54 pacientes con cáncer de recto atendidos en el Centro Nacional de Cirugía de Mínimo Acceso, en La Habana, entre septiembre del 2018 y diciembre del 2022, a quienes se les realizó elastografía por ecografía endoscópica para la reevaluación del tumor. Para determinar el valor de dicha técnica se calculó la sensibilidad, la especificidad, los valores predictivos positivo y negativo, las razones de verosimilitud positiva y negativa, así como el índice de Youden. Se estableció la concordancia diagnóstica según el índice kappa y el estudio histológico de la muestra tomada fue el estándar de referencia. Resultados: La concordancia de la elastografía con el resultado anatomopatológico fue buena (κ=0,84). La especificidad y el índice de validez resultaron ser de 91,7 y 94,4 %, respectivamente; mientras que el valor predictivo negativo fue de 84,6 %. Los 16 pacientes con patrón elastográfico mixto (ye3) tenían tumor residual localizado en alguna de las capas de la pared del recto. El índice de Youden alcanzó valores cercanos a 1. Conclusiones: El valor de esta técnica radica en su especificidad diagnóstica y en el valor predictivo negativo al diferenciar la fibrosis del tumor residual en la pared rectal.

Introduction: The qualitative elastography by endoscopic echography is a technique to examine the elastic properties of tissues that can distinguish the fibrosis of the tumor by means of color patterns. Objective: To determine the value of elastography by color patterns in the reestadification of the rectum cancer. Methods: An observational and descriptive study (serial cases) of 54 patients with rectum cancer was carried out, who were assisted in the National Center of Minimum Access Surgery, in Havana, between September, 2018 and December, 2022 to whom elastography by endoscopic echography were carried out for the reevaluation of the tumor. To determine the value of this technique the sensibility, specificity, the predictive positive and negative values, the positive and negative true ratio, as well as the index of Youden were calculated. The diagnostic consistency was established according to the kappa index and the histologic study of the sample was the reference standard. Results: The elastography consistency with the pathologic result was good (ĸ=0.84). The specificity and the index of validity were 91.7 and 94.4%, respectively; while the negative predictive value was 84.6%. The 16 patients with mixed elastographic pattern (ye3) had residual tumor located in some of the layers of the rectum wall. The Youden index reached values close to 1. Conclusions: The value of this technique resides in its diagnostic specificity and negative predictive value when differentiating fibrosis from the residual tumor in the rectal wall.

Ghost ileostomy release down: our initial experience

Background: Many publications describe the advantages of the creation of ghost ileostomy (GI) to prevent the need for formal covering ileostomy in more than 80% of carcinoma rectum patients. However, none of the papers describes exactly how to ultimately remove the GI in these 80% of patients in whom it doesn't need formal maturation. Aim: To describe and evaluate the ghost ileostomy release down (GIRD) technique in terms of feasibility, complications, hospital stay, procedure time etc. in patients with low anterior resection/ultra-low anterior resection (LAR/uLAR) with GI for carcinoma rectum. Method: The present was a prospective cohort study of patients with restorative colorectal resections with GI for carcinoma rectum, Postoperatively the patients were studied with respect to ease and feasibility of the release down of GI and its complications. The data was collected, analyzed and inference drawn. Results: A total of 26 patients needed the GIRD and were included in the final statistical analysis of the study. The procedure was done between 7th to 16th postoperative days (POD) and was successful in all patients without the need of any additional surgical procedure. None of the patients required any local anesthetic injection or any extra analgesics. The average time taken for procedure was 5-minutes and none of the patients had any significant difficulty in GI release. There were no immediate postprocedure complications. Conclusion: The GIRD technique is a simple, safe, and quick procedure done around the 10th POD that can easily be performed by the bedside of patient without the need of any anesthesia or additional analgesics. (AU)

Capsaicin fails to produce changes in contractile tension in large gut of neonate rats

Objectives: Capsaicin, the most pungent constituent of chilli pepper (Capsicum annuum L.), is known to alter the physiological activity of the gut. Capsaicin mediates its action through a transient receptor potential vanilloid type 1 (TRPV1) channel. The action of capsaicin on gut smooth muscle varies from segment to segment in different species. The earlier studies were carried out in adult animals only, and its status in the neonate gut, which is in a development stage, is not known. Objective: Therefore, the present study was done to assess the effect of capsaicin on the large gut of neonates. Materials and Methods: In an organ bath preparation, isometric contractions were recorded from segments of dissected rat colon and rectum. The gut segments were exposed to cumulative concentrations of capsaicin (0.01 nM–3 µM) and a capsaicin-induced contractile response was observed. TRPV1 receptor antagonist capsazepine (1 µM) and a nitric oxide synthase inhibitor, L-NAME (100 µM), were used to assess their blocking effect on capsaicin-induced contractile response. Results: Capsaicin raised contractile tension in the colon and rectum of adult rats but not in neonate rats. In adult rats, capsazepine pre-treatment (1 µM) failed to block the capsaicin-induced response in the colon, but in the lower concentrations, it increased contractile tension in the rectum. Pre-application of L-NAME (100 µM) potentiated capsaicin-induced response in the adult rectum and neonate’s colon but had no effect in the neonate rectum and adult colon. Capsaicin with a low concentration (0.01 nM–0.01 µM) increased contractile frequency in both the colon and rectum of adult rats. However, the effect of capsaicin on frequency was abolished at higher concentrations (0.01 µM–3 µM). A capsaicin-evoked change in contractile frequency in adult rats was blocked by capsazepine and L-NAME. At lower concentrations (0.01 nM–0.01 µM), capsaicin did not show any change in frequency in the neonatal colon, while a decrease in contractile frequency was observed with the higher concentrations (0.1 µM–3 µM) of capsaicin. In neonates, capsazepine pre-treatment produced changes in frequency for both the colon and rectum. However, pre-application of L-NAME decreased frequency in the neonate rectum but not in the colon. Conclusion: Capsaicin-induced changes in contractile activity may or may not involve TRPV1 or the Nitric Oxide (NO) pathway, depending on the part of the large gut and developmental maturity.

Uso de stent en estenosis colorrectal benigna / Stent utilization in benign colorectal stenosis

Introducción. La estenosis colorrectal benigna hace referencia a una condición anatómica caracterizada por una disminución del diámetro de la luz intestinal distal a la válvula ileocecal, ocasionando una serie de signos y síntomas de tipo obstructivo. Es una entidad poco frecuente, secundaria en la gran mayoría de veces a la realización de anastomosis intestinales al nivel descrito. El objetivo de esta investigación fue determinar la utilidad del stentcolónico en estenosis secundaria a patología colorrectal no neoplásica. Métodos. Estudio descriptivo de una cohorte de pacientes que desarrolló estenosis colorrectal de origen benigna confirmada por colonoscopía, en 3 hospitales de alta complejidad de la ciudad de Medellín, Colombia, entre los años 2007 y 2021. Resultados. Se incluyeron 34 pacientes con diagnóstico de estenosis colorrectal de origen benigno, manejados con stents metálicos autoexpandibles. La mediana de seguimiento fue de 19 meses y se obtuvo éxito clínico en el 73,5 % de los casos. La tasa de complicación fue del 41,2 %, dada principalmente por reobstrucción y migración del stent, y en menor medida por perforación secundaria a la colocación del dispositivo. Conclusión. Los stents metálicos autoexpandibles representan una opción terapéutica en pacientes con obstrucción colorrectal, con altas tasas de mejoría clínica en pacientes con patología estenosante no maligna. Cuando la derivación por medio de estoma no es una opción, este tipo de dispositivos están asociados a altas tasas de éxito clínico y mejoría de la calidad de vida de los pacientes

Introduction. Benign colorectal stenosis refers to an anatomical condition characterized by a decrease in the diameter of the intestinal lumen distal to the ileocecal valve, which might cause a series of obstructive signs and symptoms. It is a rare entity, caused in the vast majority of cases due to intestinal anastomosis at the described level. The purpose of this study is to determine the performance of colonic stents in the management of non-malignant colorectal strictures. Methods. Descriptive study of a cohort of patients who developed a benign colorectal stenosis confirmed by colonoscopy in three high-complexity hospitals in the city of Medellín, Colombia, between 2007 and 2021. Results. Thirty-four patients diagnosed with benign colorectal stenosis managed with self-expanding metal stents were included in the study. Median follow-up was 19 months, obtaining clinical success in 73.5% of cases, with a complication rate of 41.2%, mainly due to reobstruction and migration of the stent, and to a lesser extent due to perforation secondary to device placement.Conclusion. Self-expanding metallic stents represent a therapeutic option in patients with colorectal obstruction caused by non-malignant stenosing pathology. When diversion through a stoma is not an option, this type of device is associated with high rates of clinical success and improvement in the patients' quality of life

Escisión meso-rectal total por vía trans anal (TaTME). Experiencia institucional / Trans anal total meso-rectal excision (TaTME). Institutional experience

Introducción. La cirugía es la base del tratamiento curativo del cáncer de recto. La escisión meso-rectal total ha permitido mejorar los desenlaces oncológicos, disminuyendo las tasas de recurrencia locorregional e impactando en la supervivencia global. El empleo de esta técnica en los tumores de recto medio o distal es un reto quirúrgico, en el que la vía trans anal, permite superar las dificultades técnicas. Método. Se realizó un estudio observacional retrospectivo, recolectando la información de los pacientes con cáncer de recto medio y distal llevados a cirugía con esta técnica, en dos instituciones de cuarto nivel en Medellín, Colombia, entre enero de 2017 y marzo de 2022. Se analizaron sus características demográficas, la morbilidad perioperatoria y la pieza quirúrgica. Resultados. Se incluyeron 28 pacientes sometidos al procedimiento trans anal y laparoscópico de forma simultánea; al 57 % se les realizó una ileostomía de protección. Hubo complicaciones en el 60,7 % de los pacientes; ocurrieron cuatro casos de fuga anastomótica. No se presentó ninguna mortalidad perioperatoria. Conclusiones. La tasa de morbilidad perioperatoria es acorde con lo reportado en la literatura. Se resalta la importancia de la curva de aprendizaje quirúrgica y de incluir la calificación de la integridad meso-rectal dentro del informe patológico. Se requiere seguimiento a largo plazo para determinar el impacto en desenlaces oncológicos, calidad de vida y morbilidad

Introduction. Surgery is the pillar of curative treatment for rectal cancer. Total meso-rectal excision has improved oncological outcomes, decreasing locoregional recurrence rates and impacting overall survival. The use of this technique in tumors of the middle or distal rectum is a surgical challenge, in which the trans anal route allows overcoming technical difficulties. Method. A retrospective observational study was carried out, collecting information from patients with middle and distal rectal cancer undergoing surgery with this technique, in two level 4 institutions in Medellín, Colombia, between January 2017 and March 2022. Results. Twenty-eight patients were included; their demographic characteristics, perioperative morbidity, and surgical specimen were analyzed. All patients underwent the trans anal and laparoscopic procedures simultaneously; 57% underwent a protective ileostomy. There was no perioperative mortality. Complications occurred in 60.7% of the patients. Only four cases of anastomotic leak occurred. Conclusions. The perioperative morbidity rate is consistent with that reported in the literature; the importance of the surgical curve and to include the qualification of the meso-rectal integrity within the pathological report is highlighted. Long-term follow-up is required to determine the impact on oncological outcomes, quality of life, and morbidity

Migración de catéter distal a nivel del recto como complicación de derivación ventriculoperitoneal. Reporte de caso / Catheter Migration Through the Rectum as Ventricular Peritoneal Shunt Complication. Case Report

Resumen La hidrocefalia es una entidad nosológica común que en muchos casos tiene como tratamiento de elección la derivación ventricular hacia cualquier cavidad. Dentro de las complicaciones más frecuentes, tenemos las abdominales con formación de colecciones, así como irrupción a sistema intestinal con posterior migración del mismo con presentación de sintomatología a este nivel. Presentamos el caso de un paciente con nula sintomatología abdominal y migración del catéter distal hacia el recto.

Abstract Hydrocephalus is a common nosological entity, with ventricular shunting towards any cavity as the treatment of choice in many cases. Among the most frequent complications, we have the abdominal ones with the formation of collections, as well as irruption to the intestinal system with subsequent migration of the same with presentation of symptoms at this level. We present the case of a patient with no abdominal symptoms and migration of the distal catheter towards the rectum.

Analysis of the rectum and bladder changes in prostate precise radiotherapy under the bowel and bladder preparation / 中华放射肿瘤学杂志

Objective:To analyze the clinically acceptable and reproducible bladder and rectum volumes of prostate cancer patients during radiotherapy under bladder and bowel preparation, aiming to provide quantitative indicators for bowel and bladder preparation before and after radiotherapy.Methods:Clinical data of 275 prostate cancer patients with strict bladder and bowel preparation and completion of whole course radical radiotherapy at Sun Yat-sen University Cancer Center from April 2015 to December 2020 were retrospectively analyzed. Patients were scanned with cone beam CT (CBCT) before each treatment and the setup error was recorded. Sixty-six patients were selected by simple random sampling and the bladder and rectum on daily CBCT was outlined using MIM software. The relationship between the ratio of daily bladder or rectum volume to the planned bladder or rectum volume (relative value of volume) and setup error was analyzed. Quantitative data were expressed as mean±SD. Normally distributed data were analyzed by paired t-test while non-normally distributed data were assessed by Kruskal-Wallis test.Results:The bladder and rectum volume on planning CT were (370.87±110.04) ml and (59.94±25.07) ml of 275 patients. The bladder and rectum volumes on planning CT were (357.51±107.38) ml and (65.28±35.37) ml respectively of the 66 selected patients with 1611 sets of CBCT images. And the bladder and rectum volumes on daily CBCT were (258.96±120.23) ml and (59.95 ± 30.40) ml. The bladder volume of patients was decreased by 3.59 ml per day on average during the treatment and 0.37 ml for the rectum volume. According to the bladder volume on planning CT, all patients were divided into three groups: <250 ml, 250-450 ml and >450 ml groups. The relative value of volume in the 250-450 ml group during the course of radiotherapy was the smallest. And the setup error in the superior and inferior (SI) direction was (0.28±0.24) cm and (0.19±0.17) cm in the left and right (LR) direction, significantly lower than those in the other two groups (both P≤0.027). According to the rectum volume on planning CT, all patients were divided into four groups: <50 ml, 50-<80 ml, 80-120 ml and >120 ml groups. The <50 ml group had the smallest relative value of volume during radiotherapy, and the setup error in the SI direction was (0.26±0.22) cm and (0.24±0.22) cm in the anterior and posterior (AP) direction, significantly smaller than those in the other groups (both P≤0.003). The setup errors in the SI, LR, AP directions of the enrolled 66 patients were (0.30±0.25) cm, (0.20±0.18) cm and (0.28±0.27) cm, respectively. Among them, the relative value of bladder volume in the AP direction was (0.73±0.37) in the setup error <0.3 cm group, which was statistically different from those in the setup error 0.3-0.5 cm and >0.5 cm groups (both P<0.05). Conclusion:Under the bladder and bowel preparation before planning CT, the appropriate bladder and rectum volumes are in the range of 250-450 ml and <50 ml, which yields higher reproducibility and smaller setup error.

Application of C-type incision to endoscopic submucosal dissection for the treatment of rectal neuroendocrine tumors / 中华消化内镜杂志

Objective:To evaluate the clinical efficacy of C-type endoscopic submucosal dissection (C-ESD) for rectal neuroendocrine tumors (NEN).Methods:The retrospective analysis was performed on data of 55 patients who underwent ESD for rectal NEN at the Department of Endoscopy in Quanzhou First Hospital from January 2018 to July 2021. Patients were divided into the C-ESD group ( n=28) and the conventional ESD group ( n=27). The dissection time, the dissection speed, the number of submucosal injections, the enbloc resection rate, the curative resection rate and the rate of postoperative complications of the two groups were compared. Results:There were no statistically significant differences in basic information between the two groups ( P>0.05). The dissection time was 13.8±4.2 min in the C-ESD group and 19.9±3.9 min in the conventional ESD group with statistically significant difference ( t=5.649, P<0.001). The dissection speed in the C-ESD group was 0.08±0.04 cm 2/min, which was faster than 0.06±0.04 cm 2/min in the conventional ESD group ( t=2.218, P=0.031). The number of submucosal injections in the C-ESD group was less than that in the conventional ESD group [2 (1, 2) VS 3 (2, 3), Z=-8.701, P<0.001]. The lesions were enbloc resected in both groups. The curative resection rate in the C-ESD group was 100.0% (28/28) and 88.9% (24/27) in the conventional ESD group with statistically significant difference ( P=0.011). There were 7 cases of postoperative complications in the conventional ESD group, including 1 delayed bleeding, 5 delayed perforation and 1 muscularis propria injury, while no postoperative complications occurred in the C-ESD group ( P=0.004). Conclusion:C-ESD is a safe and effective treatment strategy for colorectal NEN, which can shorten the dissection time, improve the dissection speed, reduce the number of submucosal injections, improve the curative resection rate, and reduce complications.

Application of magnetic compression anastomosis to colorectal anastomosis and reconstruction / 中华消化内镜杂志

Clinical cases treated by magnetic compression anastomosis (MCA) for different causes and types of intestinal stenosis/ atresia to successfully achieve intestinal recanalization were reviewed, so as to explore the clinical application of MCA. From May 2019 to August 2022, 4 patients underwent colorectal MCA for intestinal recanalization in the First Affiliated Hospital of Xi'an Jiaotong University and Northwest Women and Children's Hospital. All operations went well, and the intestinal anastomosis was recanalized. The magnetic ring was discharged in 7-15 days, and the postoperative colonoscopy or radiography showed that the anastomosis was intact. MCA can be used to treat different types of colorectal stenosis and atresia due to different reasons, and can also be used to assist intestinal anastomosis in colorectal surgery.

Application of intestinal fluid reinfusion after anterior resection of rectum and preventive ileostomy in patients with low rectal cancer / 中国医师进修杂志

Objective:To analyze the effect of intestinal fluid reinfusion after anterior resection of rectum and preventive ileostomy in patients with low rectal cancer.Methods:A prospective research method was used, and 60 patients with low rectal cancer in Zhejiang Jinhua Guangfu Tumor Hospital from January 2021 to June 2022 were enrolled. The patients were divided into control group (treated with anterior resection of rectum and preventive ileostomy) and observation group (treated with anterior resection of rectum and preventive ileostomy combined with intestinal fluid infusion) by random number table method with 30 cases each. On the next day and 3 months after surgery, the low anterior resection syndrome (LARS) scale was used to evaluate anal function, the patient-generated subjective global assessment (PG-SGA) method was used to evaluate nutritional status, the stoma-quality of life (stoma-QOL) was used to evaluate the quality of life. The complications were recorded.Results:Both groups of patients were successfully completed the scheduled surgery. There were no statistical differences in LARS score and incidence of LARS on the next day after surgery between the two groups ( P>0.05); the LARS score and incidence of LARS 3 months after surgery in observation group were significantly lower than those in control group: (18.63 ± 3.15) scores vs. (24.90 ± 6.11) scores and 23.33% (7/30) vs. 46.67% (14/30), and there were statistical differences ( P<0.01 or <0.05). There were no statistical differences in PG-SGA score and incidence of malnutrition on the next day after surgery between the two groups ( P>0.05); the PG-SGA score and incidence of malnutrition 3 months after surgery in observation group were significantly lower than those in control group: (3.07 ± 0.82) scores vs. (5.13 ± 1.01) scores and 26.67% (8/30) vs. 46.67% (14/30), and there were statistical differences ( P<0.01 or <0.05). There were no statistical differences in the scores of psychological burden, social interaction, stoma management and daily living of stoma-QOL on the next day after surgery between the two groups ( P>0.05); the scores 3 months after surgery in observation group were significantly higher than those in control group: (27.70 ± 4.28) scores vs. (21.47 ± 5.16) scores, (14.33 ± 2.03) scores vs. (11.90 ± 1.64) scores, (14.87 ± 1.92) scores vs. (11.57 ± 2.38) scores and (15.30 ± 1.03) scores vs. (12.37 ± 2.11) scores, and there were statistical differences ( P<0.01). The incidence of complications in observation group was significantly lower than that in control group: 30.00% (9/30) vs. 60.00% (18/30), and there was statistical difference ( χ2 = 5.45, P<0.05). Conclusions:For the patients with low rectal cancer, the anterior resection of rectum and preventive ileostomy combined with intestinal fluid reinfusion can reduce LARS, improve nutritional status, improve quality of life, and also reduce complications.

Clinical characteristics and factors influencing the prognosis of patients with mucosal melanoma / 肿瘤研究与临床

Objective:To investigate clinical characteristics and factors influencing the prognosis of patients with mucosal melanoma.Methods:The clinical data of 49 patients with mucosal melanoma in Fujian Cancer Hospital from March 2012 to March 2022 were retrospectively analyzed, and their clinical characteristics and prognostic influencing factors were observed. Kaplan‐Meier method was used for survival analysis and Cox proportional risk model was used to analyze the prognostic influencing factors.Results:Female accounted for 61.2% (30/49) of all 49 patients with mucosal melanoma and the median age was 56 years (42-79 years). The most frequent primary tumor sites occurred in head and neck (42.9%, 21/49), followed by the reproductive system (32.7%, 16/49). At the time of initial diagnosis, 81.6% (40/49) of patients had no distant metastasis and 79.6% (39/49) of patients had normal levels of peripheral blood lactate dehydrogenase. The median overall survival time of 49 patients with mucosal melanoma was 39.5 months (95% CI 23.1-55.9 months). The median overall survival time of patients without distant metastasis at the time of initial diagnosis was significantly longer than that of patients with distant metastasis [46.5 months (95% CI 31.6-61.4 months) vs. 19.2 months (95% CI 0-42.2 months, P = 0.025]. There were no statistically significant differences in median overall survival time of patients with different gender, age at the time of initial diagnosis, primary tumor site, and the level of lactate dehydrogenase in peripheral blood at the time of initial diagnosis (all P > 0.05). The presence of distant metastasis at the time of initial diagnosis was an independent risk factor for the prognosis of patients with mucosal melanoma ( HR = 0.379, 95% CI 0.157-0.918, P = 0.032). Conclusions:Mucosal melanoma is more common in female. The most frequent primary tumor sites occur in head and neck. At the time of initial diagnosis, most patients have non‐distant metastasis and the normal level of peripheral blood lactate dehydrogenase. At the time of initial diagnosis, whether there is distant metastasis is an independent influencing factor for the prognosis of patients with mucosal melanoma.

Signet ring cell carcinoma of the rectal stump in a known ulcerative colitis patient

ABSTRACT Colorectal carcinoma (CRC) is the third most commonly diagnosed cancer worldwide and is the second most common cause of cancer-related deaths. However, the Omani population shares the major burden as the most prevalent carcinoma. The disease is comparatively higher in males than females. Patients with pre-existing risk factors, including inflammatory bowel disease, are at increased risk of developing neoplasia. Among the various histopathological subtypes of adenocarcinoma in the rectum, signet ring cell carcinoma is the rarest and accounts for approximately 1% of the cases. Given the aggressive nature of this tumor, advanced presentation, stage, and poor prognosis, regular endoscopic surveillance is essential. Hereby, we report a rare case of signet ring cell carcinoma arising in the rectal stump in an already diagnosed and operated patient of Ulcerative colitis.

Watch and wait, worth It?

Background: The surgery with total mesorectal excision recommended by R. J. Heald in 1982 is the gold standard. Rectal cancer (RC) surgery has a morbidity rate ranging from 6 to 35%, and it can cause functional issues such as sexual, urinary, and bowel dysfunction in the long term. Neoadjuvant chemoradiotherapy (CRT) has been gaining ground in patients with lesions in the middle and lower rectum. The aim of the present study is to present the experience of a reference service in the treatment of RC. Patients and Methods: A retrospective study involving 53 patients diagnosed with RC between January 2017 and December 2019 with follow-up until December 2020. We examined tumor location, disease stage, digital rectal exam findings, carcinoembryonic antigen (CEA), therapeutic modality offered, and follow-up time. Results: A total of 32% of the patients were men and 68% were women, with a mean age of 60 years old. Location: upper rectum in 6 cases, middle rectum in 21 cases, and lower rectum in 26 cases with evolution from 9.8 to 13.5 months. The most frequent complaints were hematochezia and constipation. A total of 36 patients underwent neoadjuvant therapy: 11 complete clinical response (CCR) (30.5%), 20 (55.5%) partial clinical response (PCR), and no response in 5 patients (14%). The follow-up ranged from 12 to 48 months, with a mean of 30.5 months. A total of 25% of the patients had RC that went beyond the mesorectal fascia, and 22.64% had metastases in other parts of the body when they were diagnosed. Conclusion: Neoadjuvant radio and chemotherapy present themselves as an alternative in the treatment of rectal cancer. In 36 patients, 30.5% had a complete clinical response, 55.5% had a partial clinical response, and 14% had no response. It was worth doing the "Watch and Wait" (W&W) to sample. A definitive colostomy was avoided. However, it is necessary to expand the study to a larger follow-up and more patients. Additionally, it is necessary to implement a multicenter study. (AU)

Boerhaave Syndrome: An Uncommon Cause of Hydropneumothorax

We report the case of a 52-year-old patient with type 2 diabetes mellitus diagnosed with adenocarcinoma rectum, presenting with the complaint of breathlessness to the emergency department. Chest radiograph done showed a left-sided hydropneumothorax with mediastinal shift to the right side. Tube thoracostomy was done. Pleural fluid was exudative; there was no evidence of malignancy. The patient developed a right-sided pleural effusion; anaerobic bacteria were grown on pleural fluid culture. Computed tomography (CT) of the chest was done in view of the new onset empyema on the right side. The CT showed pneumomediastinum and periesophageal air pockets. Orally administered methylene blue had appeared in the pleural drain confirming the diagnosis. The patient was taken up for feeding jejunostomy and repair of tear was planned for a later date. He succumbed to sepsis due to empyema.