Achieving a Complete Clinical Response After Neoadjuvant Chemoradiation That Does Not Require Surgical Resection: It May Take Longer Than You Think!

BACKGROUND: Patients with rectal cancer who achieve complete clinical response after neoadjuvant chemoradiation have been managed by organ-preserving strategies and acceptable long-term outcomes. Controversy still exists regarding optimal timing for the assessment of tumor response after neoadjuvant chemoradiation. OBJECTIVE: The purpose of this study was to estimate the time interval for achieving complete clinical response using strict endoscopic and clinical criteria after a single neoadjuvant chemoradiation regimen. DESIGN: This was a retrospective review of consecutive patients managed by 54-Gy and consolidation 5-fluorouracil-based chemotherapy. Assessment of response was performed at 10 weeks after radiation. Patients with suspected complete clinical response were offered watch-and-wait strategy and reassessment every 6 to 8 weeks until achievement of strict criteria of complete clinical response or overt residual cancer. SETTINGS: This study was conducted at a single tertiary care center. PATIENTS: Patients with complete clinical response who underwent a successful watch-and-wait strategy until last follow-up were eligible. Dates of radiation completion and achievement of strict endoscopic and clinical criteria (mucosal whitening, teleangiectasia, and no ulceration or irregularity) were recorded. Patients with incomplete response or with initial complete clinical response followed by local recurrence or regrowth were excluded. MAIN OUTCOMES MEASURES: The distribution of time intervals between completion of radiation and achievement of strict complete clinical response was measured. Patients who achieved early complete clinical response (≤16 wk) were compared with late complete clinical response (>16 wk). RESULTS: A total of 49 patients achieved complete clinical response and were successfully managed nonoperatively. A median interval of 18.7 weeks was observed for achieving strict complete clinical response. Only 38% of patients achieved complete clinical response between 10 and 16 weeks from radiation completion. Patients with earlier cT status (cT2/T3a) achieved a complete clinical response significantly earlier when compared with those patients with more advanced disease (T3b-d/4; 19 vs 26 wk; p = 0.03). LIMITATIONS: This was a retrospective study with a small sample size. CONCLUSIONS: Assessment at 10 to 16 weeks may detect a minority of patients who achieve complete clinical response without additional recurrence after neoadjuvant chemoradiation. Patients suspected for a complete clinical response should be considered for reassessment beyond 16 weeks before definitive management when considered for a watch and wait strategy. See Video Abstract at http://links.lww.com/DCR/A901.

Local recurrence after complete clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: impact of salvage therapy on local disease control.

PURPOSE: To review the risk of local recurrence and impact of salvage therapy after Watch and Wait for rectal cancer with complete clinical response (cCR) after chemoradiation therapy (CRT). METHODS AND MATERIALS: Patients with cT2-4N0-2M0 distal rectal cancer treated with CRT (50.4-54 Gy + 5-fluorouracil-based chemotherapy) and cCR at 8 weeks were included. Patients with cCR were enrolled in a strict follow-up program with no immediate surgery (Watch and Wait). Local recurrence-free survival was compared while taking into account Watch and Wait strategy alone and Watch and Wait plus salvage. RESULTS: 90 of 183 patients experienced cCR at initial assessment after CRT (49%). When early tumor regrowths (up to and including the initial 12 months of follow-up) and late recurrences were considered together, 28 patients (31%) experienced local recurrence (median follow-up time, 60 months). Of those, 26 patients underwent salvage therapy, and 2 patients were not amenable to salvage. In 4 patients, local re-recurrence developed after Watch and Wait plus salvage. The overall salvage rate for local recurrence was 93%. Local recurrence-free survival at 5 years was 69% (all local recurrences) and 94% (after salvage procedures). Thirteen patients (14%) experienced systemic recurrence. The 5-year cancer-specific overall survival and disease-free survival for all patients (including all recurrences) were 91% and 68%, respectively. CONCLUSIONS: Local recurrence may develop in 31% of patients with initial cCR when early regrowths (≤ 12 months) and late recurrences are grouped together. More than half of these recurrences develop within 12 months of follow-up. Salvage therapy is possible in ≥ 90% of recurrences, leading to 94% local disease control, with 78% organ preservation.

Watch and wait approach following extended neoadjuvant chemoradiation for distal rectal cancer: are we getting closer to anal cancer management?

BACKGROUND: No immediate surgery (Watch and Wait) has been considered in select patients with complete clinical response after neoadjuvant chemoradiation to avoid postoperative morbidity and functional disorders after radical surgery. OBJECTIVE: The purpose of this study was to demonstrate the long-term results of patients who had a complete clinical response following an alternative chemoradiation regimen and were managed nonoperatively. DESIGN: This is a prospective study. SETTINGS: This study was conducted at a single center. PATIENTS: Seventy consecutive patients with T2-4N0-2M0 distal rectal cancer were studied. Neoadjuvant chemoradiotherapy included 54 Gy and 5-fluorouracil/leucovorin delivered in 6 cycles every 21 days. Patients were assessed for tumor response at 10 weeks from radiation completion. Patients with incomplete clinical response were referred to immediate surgery. Patients with complete clinical response were not immediately operated on and were monitored. MAIN OUTCOME MEASURES: The primary outcomes measured were the initial complete clinical response rates after 10 weeks and the sustained complete clinical response rates after 12 months from chemoradiotherapy. RESULTS: One patient died during chemoradiotherapy because of cardiac complications. Forty-seven (68%) patients had initial complete clinical response. Of these, 8 developed local regrowth within the first 12 months of follow-up (17%). Thirty-nine sustained complete clinical response at a median follow-up of 56 months (57%). An additional 4 patients (10%) developed late local recurrences (>12 months of follow-up). Overall, 35 patients never underwent surgery (50%). LIMITATIONS: This study is limited by the short follow-up and small sample size. CONCLUSION: Extended chemoradiation therapy with additional chemotherapy cycles and 54 Gy of radiation may result in over 50% of sustained (>12 months) complete clinical response rates that may ultimately avoid radical rectal resection. Local failures occur more frequently during the initial 12 months of follow-up in up to 17% of cases, whereas late recurrences are less common but still possible, leading to 50% of patients who never required surgery. Strict follow-up may allow salvage therapy in the majority of these patients (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A113.).

Prospective multicenter trial comparing echodefecography with defecography in the assessment of anorectal dysfunction in patients with obstructed defecation.

BACKGROUND: Defecography is the gold standard for assessing functional anorectal disorders but is limited by the need for a specific radiologic environment, exposure of patients to radiation, and inability to show all anatomic structures involved in defecation. Echodefecography is a 3-dimensional dynamic ultrasound technique developed to overcome these limitations. OBJECTIVE: This study was designed to validate the effectiveness of echodefecography compared with defecography in the assessment of anorectal dysfunctions related to obstructed defecation. DESIGN: Multicenter, prospective observational study. PATIENTS: Women with symptoms of obstructed defecation. SETTING: Six centers for colorectal surgery (3 in Brazil, 1 in Texas, 1 in Florida, and 1 in Venezuela). INTERVENTIONS: Defecography was performed after inserting 150 mL of barium paste in the rectum. Echodefecography was performed with a 2050 endoprobe through 3 automatic scans. MAIN OUTCOME MEASURES: The κ statistic was used to assess agreement between echodefecography and defecography in the evaluation of rectocele, intussusception, anismus, and grade III enterocele. RESULTS: Eighty-six women were evaluated: median Wexner constipation score, 13.4 (range, 6-23); median age, 53.4 (range, 26-77) years. Rectocele was identified with substantial agreement between the 2 methods (defecography, 80 patients; echodefecography, 76 patients; κ = 0.61; 95% CI = 0.48-0.73). The 2 techniques demonstrated identical findings in 6 patients without rectocele, and in 9 patients with grade I, 29 with grade II, and 19 patients with grade III rectoceles. Defecography identified rectal intussusception in 42 patients, with echodefecography identifying 37 of these cases, plus 4 additional cases, yielding substantial agreement (κ = 0.79; 95% CI = 0.57-1.0). Intussusception was associated with rectocele in 28 patients for both methods (κ = 0.62; 95% CI = 0.41-0.83). There was substantial agreement for anismus (κ = 0.61; 95% CI = 0.40-0.81) and for rectocele combined with anismus (κ = 0.61; 95% CI = 0.40-0.82). Agreement for grade III enterocele was classified as almost perfect (κ = 0.87; 95% CI = 0.66-1.0). LIMITATIONS: Echodefecography had limited use in identification of grade I and II enteroceles because of the type of probe used. CONCLUSIONS: Echodefecography may be used to assess patients with obstructed defecation, as it is able to detect the same anorectal dysfunctions found by defecography. It is minimally invasive and well tolerated, avoids exposure to radiation, and clearly demonstrates all the anatomic structures involved in defecation.

Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy.

Neoadjuvant chemoradiation therapy (CRT) is the preferred treatment option for distal rectal cancer. Complete pathological response after CRT has led to the proposal of nonoperative approach as an alternative treatment for highly selected patients with complete clinical response. However, patterns of failure following this strategy remains undetermined. Three hundred sixty-one patients with distal rectal cancer were managed by neoadjuvant CRT including 5-FU, leucovorin, and 5040 cGy. Tumor response assessment was performed at 8 weeks following CRT. Patients with complete clinical response were not immediately operated on and were closely followed. One hundred twenty-two patients were considered to have complete clinical response after the first tumor response assessment. Of these, only 99 patients sustained complete clinical response for at least 12 months and were considered stage c0 (27.4%) and managed nonoperatively. Mean follow-up was 59.9 months. There were 13 (13.1%) recurrences: 5 (5%) endorectal, 7 (7.1%) systemic, and 1 (1%) combined recurrence. All 5 isolated endorectal recurrences were salvaged. Mean recurrence interval was 52 months for local failure and 29.5 months for systemic failure. There were five cancer-related deaths after systemic recurrences. Overall and disease-free 5-year survivals were 93% and 85%. Even though surgery remains the standard treatment for rectal cancer, nonoperative treatment after complete clinical response following neoadjuvant CRT may be safe and associated with good survival rates in a highly selected group of patients. Survival in these patients is significantly affected by systemic failure. Exclusive local failure occurs late after CRT completion and is frequently amenable to salvage therapy.

Surgical treatment of Chagasic megacolon by abdominal rectosigmoidectomy with immediate posterior end-to-side stapling (Habr-Gama technique).

PURPOSE: Various techniques have been used in the surgical treatment of Chagasic megacolon, including sympathectomy, sphincterotomy, anterior abdominal resection with high or low anastomosis, pull-through procedures, and Duhamel technique. However, results have not been consistently satisfactory, with reportedly high morbidity and mortality rates. The purpose of this study was to assess the technique and results of anterior rectosigmoidectomy with immediate posterior colorectal end-to-side stapled anastomosis for the treatment of Chagasic megacolon. METHODS: A prospective, noncontrolled study between 1989 and 2000 analyzed 49 patients with Chagasic megacolon. Preoperative barium enema confirmed Chagasic megacolon in all patients and preoperative anorectal manometry in 33 patients (67 percent). Rectal stump closure was undertaken by surgical stapling in 41 patients (84 percent); mechanical colorectal anastomosis was accomplished with a circular stapler in all patients. RESULTS: Symptoms of intestinal constipation ranged from 6 months to 40 years, Chagas' serology was positive in 98 percent of patients, 41 percent used bowel enemas for evacuation, and 71 percent had a history of fecaloma. The overall postoperative complication rate was 20 percent. Surgical complications occurred in 18 percent, 2 percent had nonsurgical complications, and there was no mortality. Postoperative barium enema was performed in 82 percent of cases, confirming the absence of disease. Postoperative anorectal manometry demonstrated normal resting pressure and rectal capacity; the inhibitory reflex remained absent and rectal sensitivity was increased. Ninety-three percent of patients were followed for more than 48 months, and all patients reported daily stool elimination without recurrence of constipation. CONCLUSIONS: The current study indicates that our technique is effective for surgical treatment of patients with Chagasic megacolon.

Lymph node micrometastasis in stage II distal rectal cancer following neoadjuvant chemoradiation therapy.

OBJECTIVE: The objective was to determine the presence and frequency of micrometastasis in lymph nodes of patients with rectal cancer treated by preoperative chemoradiation followed by curative resection. PATIENTS AND METHODS: All 56 patients included were treated with 5-FU and leucovorin plus 5,040 cGy, followed by radical surgery and were diagnosed with stage II distal rectal adenocarcinoma after complete pathological examination (ypT3-4N0M0). Immunohistochemistry was assessed with cytokeratin monoclonal antibody AE1/AE3. Three 4-microm paraffin sections were obtained from each lymph node, cut at 50 microm apart from each other. The results were reviewed by two independent pathologists. RESULTS: Mean number of lymph nodes was 9.6 per patient. Four patients (7%) and seven lymph nodes (1.35%) were positive for micrometastasis. Three patients had pT3 and one a pT4 tumor. One of the patients had positive micrometastasis and the presence of mucinous deposits. One other patient had mucinous deposits without any micrometastasis. All four patients are alive with no evidence of recurrent disease. Fourteen patients negative for micrometastasis had recurrent disease (25%), eight systemic (14.7%) and six locoregional (10.3%). There were two cancer-related deaths. The mean follow-up period was 39 months. CONCLUSION: Patients with rectal cancer treated by preoperative chemoradiation showed a surprisingly low rate of micrometastasis detection (7%), even in high-risk patients (T3 and T4 tumors). Lymph node micrometastasis was not associated with decreased overall or disease-free survival. The identification of mucinous deposits on lymph nodes with no viable tumor cells may be direct evidence of lymph node downstaging. The downstaging effect of preoperative chemoradiation therapy may be significant in reducing even micrometastasis detection in low rectal cancer managed by this treatment strategy.

New surgical options for fecal incontinence in patients with imperforate anus.

INTRODUCTION: Anorectal malformations are among the various etiologic factors causing fecal incontinence. Patients with imperforate anus are difficult to treat, specifically those with high lesions. The artificial bowel sphincter and electrically stimulated gracilis neosphincter are two relatively new techniques that have been used for the treatment of patients with severe refractory fecal incontinence. The aim of this study was to evaluate the results of these technologies in the treatment of patients with chronic fecal incontinence due to imperforate anus. METHODS: All patients with imperforate anus who had fecal incontinence and underwent either the artificial bowel sphincter procedure or the gracilis neosphincter procedure between February 1995 and December 2000 were evaluated. Preoperative and postoperative incontinence score (Cleveland Clinic Florida Incontinence Score; 0 = perfect continence; 20 = complete incontinence), quality of life, (Fecal Incontinence Quality of Life Scale, 29 items forming 4 scales), and manometric sphincter pressure results were compared. RESULTS: Eleven patients had artificial bowel sphincter and five had the gracilis neosphincter (one nonstimulated) procedure. There were 11 males and 5 females of a mean age of 25.3 (range, 15-45) years. The mean follow-up time was 1.7 years (5 months to 5.7 years). Eight (50 percent) complications occurred in six patients, including three with fecal impaction (all artificial bowel sphincter), three with device migration (two gracilis neosphincter, one artificial bowel sphincter), and two patients with concomitant wound infection (one gracilis neosphincter, one artificial bowel sphincter); no patients had the devices explanted. Fourteen patients had manometric data (10 artificial bowel sphincter and 4 gracilis neosphincter) available. The overall incontinence score decreased from a preoperative mean of 18.5 to a postoperative mean of 7.5 in the artificial bowel sphincter group (P < 0.01) and from 17.4 to 9.4 in the gracilis neosphincter group (P = 0.06). All four Fecal Incontinence Quality of Life scales increased in both the artificial bowel sphincter (lifestyle and depression/self-perception, P = 0.02; coping/behavior and embarrassment, P = 0.03) and the gracilis neosphincter (lifestyle and coping, P = 0.06; depression and embarrassment, P = 0.05) patients. As well, the mean resting and squeeze pressures increased with both techniques (artificial bowel sphincter: P = 0.008 and P = 0.02, respectively; gracilis neosphincter: P = 0.4 and P = 0.1, respectively). All results were statistically significant in the artificial bowel sphincter group. CONCLUSIONS: Artificial bowel sphincter and gracilis neosphincter are efficient methods to treat patients with imperforate anus. These techniques should be considered for patients with imperforate anus and severe fecal incontinence.

Biofeedback therapy in the colon and rectal practice.

In coloproctology, biofeedback has been used for more than 20 years to treat patients with fecal incontinence, constipation, and rectal pain. It can be performed in a number of conditions with minimal risk and discomfort. However, it does require the presence of some degree of sphincter contraction and rectal sensitivity. Biofeedback can be time-consuming and demands motivation. The purpose of this paper is to review the indications, methodology, and results of anorectal biofeedback in the treatment of these disorders. Mean success rates for biofeedback range from 72.3% for fecal incontinence of diverse etiology, 68.5% for constipation attributable to paradoxical puborectalis syndrome, and 41.2% for idiopathic rectal pain. However, criteria to define success vary tremendously among researchers and there is a tendency to indicate biofeedback in a myriad of conditions when other therapeutic options, including surgery, fail or are inappropriate. These factors make comparison of the results difficult and reinforce the need for randomized controlled trials and studies assessing long-term follow-up. In summary, biofeedback is a simple, cost-effective, and morbidity-free technique and remains an attractive option, especially considering the complexity of the functional disorders of the colon, rectum, anus, and pelvic floor.

Avaliação computadorizada do esvaziamento retal em voluntários assintomáticos / Computerized evaluation of the rectal evacuation in assymptomatic volunteers

O esvaziamento retal adequado, proporcionando satisfação do paciente, é o principal objetivo no processo de defecação, daí a grande importância de sua mensuração durante o exame de defecografia. Tal parâmetro é normalmente avaliado apenas de forma qualitativa e o presente trabalho propõe método objetivo de quantificação do esvaziamento retal por computador, a partir de imagens digitalizadas da fluoroscopia, e analisa os valores obtidos em vinte voluntários assintomáticos. A média do percentual de esvaziamento retal foi de 58,2por cento(13,9), o tempo de evacuação médio foi de 43,3 (27,3)segundos e o número médio de contrações foi de 4,6 (2,2). Esses resultados foram discutidos e comparados com resultados obtidos em outros trabalhos na literatura. O método computadorizado descrito neste trabalho permite a avaliação do esvaziamento retal, de forma quantitativa, sem a necessidade de radiografias e os resultados obtidos em indivíduos assintomáticos são comparáveis aos da literatura.

Inflammatory bowel diseases: principles of nutritional therapy.

Inflammatory Bowel Diseases - ulcerative colitis and Crohn's disease- are chronic gastrointestinal inflammatory diseases of unknown etiology. Decreased oral intake, malabsorption, accelerated nutrient losses, increased requirements, and drug-nutrient interactions cause nutritional and functional deficiencies that require proper correction by nutritional therapy. The goals of the different forms of nutritional therapy are to correct nutritional disturbances and to modulate inflammatory response, thus influencing disease activity. Total parenteral nutrition has been used to correct and to prevent nutritional disturbances and to promote bowel rest during active disease, mainly in cases of digestive fistulae with high output. Its use should be reserved for patients who cannot tolerate enteral nutrition. Enteral nutrition is effective in inducing clinical remission in adults and promoting growth in children. Due to its low complication rate and lower costs, enteral nutrition should be preferred over total parenteral nutrition whenever possible. Both present equal effectiveness in primary therapy for remission of active Crohn's disease. Nutritional intervention may improve outcome in certain individuals; however, because of the costs and complications of such therapy, careful selection is warranted, especially in patients presumed to need total parenteral nutrition. Recent research has focused on the use of nutrients as primary treatment agents. Immunonutrition is an important therapeutic alternative in the management of inflammatory bowel diseases, modulating the inflammation and changing the eicosanoid synthesis profile. However, beneficial reported effects have yet to be translated into the clinical practice. The real efficacy of these and other nutrients (glutamine, short-chain fatty acids, antioxidants) still need further evaluation through prospective and randomized trials.

[Immunonutrition in experimental colitis: beneficial effects of omega-3 fatty acids]. / Imunonutrição em colite experimental: efeitos benéficos dos ácidos graxos ômega-3.

BACKGROUND: Recent data have given emphasis to the benefits of immunonutrition with omega-3 fatty acids (n-3 FA) in various clinical situations. This work presents the results of parenteral administration of different lipid emulsions in experimental acute colitis and reviews the pertinent literature. METHODS: Seventy-four adult male Wistar rats were randomized in six groups that had 10% acetic acid-induced colitis (except CS). During 7 days, control groups CS (without colitis) and CC (with colitis) received physiological solution and the others received specific lipid emulsion by a central venous catheter (0.5 mL/h). The n-3/n-6 FA ratio and lipidic compositions were: group L--1:7.7 (LCT, n = 12), M--1:7.0 (MCT and LCT, n = 12), LW-3--1:4.5 (LCT plus FO, n = 12) and MW-3--1:3.0 (MCT and LCT plus FO, n = 13). Rats were evaluated to assess abdominal and intestinal alterations, macrophage cellularity and colonic concentrations of LTB4, LTC4, PGE2 and TXB2. RESULTS: N-3 FA treated rats (LW-3 and MW-3) presented less inflammatory abdominal alterations than CC rats. Mucosal ulcer formation in MW-3 group was the only comparable to CS group. Only CS, M and MW-3 rats presented smaller cellularity than CC group. Comparing to CC group, there were found smaller averages of LTB4 in CS, LW-3 and MW-3 groups, of PGE2 in CS, M and MW-3 groups, and of TXB2 in CS and MW-3 groups. LTC4 averages were not different. CONCLUSIONS: 1) LCT-containing lipid emulsion with low n-3/n-6 ratio do not modify inflammatory colitis derived manifestations; 2) the association of MCT/LCT-containing lipid emulsion with fish oil with high n-3/n-6 ratio impels great beneficial impact, attenuating morphological and inflammatory consequences and decreasing colonic concentrations of proinflammatory mediators.

Inflammatory bowel diseases: principles of nutritional therapy

Inflammatory Bowel Diseases - ulcerative colitis and Crohn's disease- are chronic gastrointestinal inflammatory diseases of unknown etiology. Decreased oral intake, malabsorption, accelerated nutrient losses, increased requirements, and drug-nutrient interactions cause nutritional and functional deficiencies that require proper correction by nutritional therapy. The goals of the different forms of nutritional therapy are to correct nutritional disturbances and to modulate inflammatory response, thus influencing disease activity. Total parenteral nutrition has been used to correct and to prevent nutritional disturbances and to promote bowel rest during active disease, mainly in cases of digestive fistulae with high output. Its use should be reserved for patients who cannot tolerate enteral nutrition. Enteral nutrition is effective in inducing clinical remission in adults and promoting growth in children. Due to its low complication rate and lower costs, enteral nutrition should be preferred over total parenteral nutrition whenever possible. Both present equal effectiveness in primary therapy for remission of active Crohn's disease. Nutritional intervention may improve outcome in certain individuals; however, because of the costs and complications of such therapy, careful selection is warranted, especially in patients presumed to need total parenteral nutrition. Recent research has focused on the use of nutrients as primary treatment agents. Immunonutrition is an important therapeutic alternative in the management of inflammatory bowel diseases, modulating the inflammation and changing the eicosanoid synthesis profile. However, beneficial reported effects have yet to be translated into the clinical practice. The real efficacy of these and other nutrients (glutamine, short-chain fatty acids, antioxidants) still need further evaluation through prospective and randomized trials

Imunonutrição em colite experimenta: efeitos benéficos dos ácidos graxos ômega-3 / Immunonutrition in experimental colitis: benefical effects of omega-3 fatty acids

Recent data have given emphasis to the benefits of immunonutrition with omega-3 fatty acids (n-3 FA) in various clinical situations. This work presents the results of parenteral administration of different lipid emulsions in experimental acute colitis and reviews the pertinent literature. METHODS: Seventy-four adult male Wistar rats were randomized in six groups that had 10% acetic acid-induced colitis (except CS). During 7 days, control groups CS (without colitis) and CC (with colitis) received physiological solution and the others received specific lipid emulsion by a central venous catheter (0.5 mL/h). The n-3/n-6 FA ratio and lipidic compositions were: group L--1:7.7 (LCT, n = 12), M--1:7.0 (MCT and LCT, n = 12), LW-3--1:4.5 (LCT plus FO, n = 12) and MW-3--1:3.0 (MCT and LCT plus FO, n = 13). Rats were evaluated to assess abdominal and intestinal alterations, macrophage cellularity and colonic concentrations of LTB4, LTC4, PGE2 and TXB2. RESULTS: N-3 FA treated rats (LW-3 and MW-3) presented less inflammatory abdominal alterations than CC rats. Mucosal ulcer formation in MW-3 group was the only comparable to CS group. Only CS, M and MW-3 rats presented smaller cellularity than CC group. Comparing to CC group, there were found smaller averages of LTB4 in CS, LW-3 and MW-3 groups, of PGE2 in CS, M and MW-3 groups, and of TXB2 in CS and MW-3 groups. LTC4 averages were not different. CONCLUSIONS: 1) LCT-containing lipid emulsion with low n-3/n-6 ratio do not modify inflammatory colitis derived manifestations; 2) the association of MCT/LCT-containing lipid emulsion with fish oil with high n-3/n-6 ratio impels great beneficial impact, attenuating morphological and inflammatory consequences and decreasing colonic concentrations of proinflammatory mediators

Cirurgia ambulatorial sob anestesia local em proctologia: experiência e análise do resultado de 503 operações / The outpatient surgery under local anesthesia at proctology: experience and analysis about the results of 503 operations

No período de outubro de 1992 a janeiro de 2000, quinhento e três pacientes portadores de doenças orificiais diversas foram submetidos a tratamento cirúrgico ambulatorial sob anestesia local. Em 49 intervenções cirúrgicas a anestesia foi realizada pela técnica do anzol (hook-needle puncture) e no restante, as anestesias foram realizadas pela clássica punçäo bilateral da regiäo anal.Doença hemorroidária, fístula, fissura, cisto pilonidal e condiloma anal foram as afecções mais freqüentes nesta casuística (85,8 por cento). A incidência global de complicações precoces e tardias foi, respectivamente, 16,1 por cento e 4,8 por cento. Dor intensa, durante o procedimento ou no pós-operatório, foi a complicaçäo mais freqüente, sendo relatada por 57 pacientes desta casuística (11,3 por cento). Cinco pacientes (1,0 por cento) necessitaram de internaçäo hospitalar para tratamento de complicações pós-operatórias. Quatrocentos e quarenta e dois pacientes (88 por cento) revelaram-se satisfeitos com o método empregado, referindo como principal vantagem do método o retorno precoce ao ambiente domiciliar, propiciando uma recuperaçäo mais confortável e com maior privacidade. Cada hemorroidectomia realizada em nível ambulatorial proporcionou uma economia de 170 dólares americanos quando comparado com o mesmo procedimento sob regime de internaçäo de um dia, ou seja, foi 31,5 por cento mais econômica. A cirurgia proctológica (orificial) ambulatorial sob anestesia local pode ser realizada com segurança e baixa morbidade, sendo uma boa alternativa para diminuiçäo dos custos hospitalares e liberaçäo de leitos para intervenções cirúrgicas mais complexas

Bowel preparation for colonoscopy: comparison of mannitol and sodium phosphate: results of a prospective randomized study

METHOD: Eighty patients were prospectively randomized for precolonoscopic cleansing either with 750ml of 10 percent mannitol (Group M) or 180ml of a sodium phosphate preparation (Group NaP). Laboratory examinations before and after preparation on all patients included hemoglobin, hematocrit, sodium, potassium, phosphorous, calcium and serum osmolarity. A questionnaire was used to assess undesirable side effects and patient tolerance to the solution. The quality of preparation was assessed by the endoscopist who was unaware of the solution employed. RESULTS: Statistically significant changes were verified in serum sodium, phosphorous, potassium and calcium between the two groups, but no clinical symptoms were observed. There were no significant differences in the frequency of side effects studied. Six of the eight patients in Group NaP who had taken mannitol for a previous colonoscopy claimed better acceptance of the sodium phosphate solution. The endoscopic-blinded trial reported excellent or good bowel preparation in 85 percent prepared with sodium phosphate versus 82.5 percent for mannitol (p=0.37). CONCLUSIONS: Quality of preparation and frequency of side effects was similar in the two solutions. The smaller volume of sodium phosphate necessary for preparation seems to be related to its favorable acceptance. Nevertheless, the retention of sodium and phosphate ions contraindicates the use of sodium phosphate in patients with renal failure, cirrhosis, ascites, and heart failure.

Cirurgia proctologica ambulatorial sob anestesia local: analise de 351 operacoes / Ambulatory anorectal surgery under local anesthesia: results in 351 procedures

Trezentos e vinte e oito pacientes portadores de doencas orificiais diversas foram submetidos a tratamento cirurgico ambulatorial sob anestesia local, sendo realizados um total de 351 procedimentos cirurgicos em um periodo de tres anos. Em 37 intervencoes cirurgicas a anestesia foi realizada pela tecnica do anzol (Hook-Needle puncture) e no restante, as anestesias foram realizadas pela classica puncao bilateral da regiao anal. Hemorroidas, fistulas, fissuras e cistos pilonidais foram as afeccoes mais frequentes nesta casuistica (71,6 por cento). A incidencia global de complicacoes precoces e tardias foi, respectivamente, 19,6 por cento e 4,8 por cento. Dor intensa, durante o procedimento ou no pos-operatorio, foi a complicacao mais frequente, sendo relatada por 53 pacientes desta casuistica (16,1 por cento)...

Cisto esplenico verdadeiro tratado por videolaparoscopia: relato de caso e revisao da literatura / A true splenic cyst treated by videolaparoscopy: case report and survey of the literature

Os cistos esplenicos verdadeiros nao parasitarios sao raros, sua real incidencia e dificil de ser estimada uma vez que mais de 30 por cento sao assintomaticos. O correto diagnostico desses cistos raramente e feito no pre-operatorio, sendo em muitos casos achado de exames. A esplenectomia parcial ou total e o tratamento de eleicao apos ser afastada a hidatidose esplenica, visto que respondem por dois tercos da incidencia mundial. Mais recentemente com os avancos tecnologicos ocorridos na cirurgia, especialmente na videolaparoscopia, alguns autores tem proposto a cistectomia parcial ou a esplenectomia por este metodo. Os autores apresentam caso de cisto esplenico verdadeiro (epidermoide) que foi ressecado por videolaparoscopia, e discutem aspectos relativos ao diagnotico, e a conduta empregada

Importância da glutamina em nutriçäo na prática clínica / The role of glutamine in clinical nutrition

O suporte nutricional empregando nutrientes com propriedades farmacológicas tem sido motivo inúmeras publicaçoes nos últimos anos. Dentre esses nutrientes, a glutamina, que é o aminoácido circulante mais abundante no sangue dos mamíferos, tem merecido especial destaque. Apesar de ser aminoácido nao essencial, a glutamina tem sido considerada nutriente nao dispensável, principalmente em estados catabólicos, quando ocorrem alteraçoes do fluxo inter-orgânico de glutamina, com diminuiçao de suas concentraçoes plasmáticas e na musculatura esquelética. Constitui-se no principal combustível oxidativo das células epiteliais, razao pela qual desempenha papel importante na manutençao da estrutura e das funçoes intestinais. Além disso, a glutamina tem efeitos benéficos na manutençao das funçoes do sistema imunológico, melhora o balanço nitrogenado e os parâmetros nutricionais de pacientes desnutridos em pós-operatório e também reduz a degradaçao protéica em pacientes em estado de intenso catabolismo. Por esses motivos, o enriquecimento de dietas com glutamina deve ser considerado no suporte nutricional de diversas afecçoes e novos estudos controlados, prospectivos e randomizados, devem ser realizados para definir quais grupos de pacientes podem se beneficiar da suplementaçao de glutamina.

Diverticulo do colon transverso: descriçao de dois casos e revisao da literatura / Diverticulim of the transverse colo: report of two cases and review of the literature

Dois pacientes com diverticulo de angulo hepatico do colon foram operados em nosso Serviço. Em ambos foi possivel diagnostico pre-operatorio atraves de enema opaco. Foram submetidos a colectomia total com ileorreto-anastomose primaria. Esta conduta foi assumida, pois apresentavam diverticulos de distribuiçao universal e espamo no colon sigmoide. Apesar de rara, esta e uma condiçao que deve ser sempre lembrada no diagnostico diferencial, especialmente com apendicite aguda, ulcera perfurada ou neoplasia de colon.