Feasibility Study of Transanal Irrigation Using a Colostomy Irrigation System in Patients With Low Anterior Resection Syndrome.

BACKGROUND: Low anterior resection syndrome has a negative impact on quality of life. Intestinal irrigation is a method of lavage consisting of a scheduled evacuation. OBJECTIVE: This study aims to evaluate functional and quality-of-life outcomes in patients with low anterior resection syndrome after transanal irrigation using a colostomy irrigation system. DESIGN: This was a prospective case series. SETTINGS: This study presents a single-center experience at a tertiary oncological center in an upper-middle-income country. PATIENTS: Patients classified as having minor or major low anterior resection syndrome 12 months after their operation were selected. INTERVENTIONS: Transanal irrigation was performed using an ostomy irrigation kit. Questionnaires assessing patients' bowel function (low anterior resection syndrome and Wexner score) and quality of life (Short Form-36 questionnaire) were applied before and after treatment. MAIN OUTCOME MEASURES: The primary outcomes were low anterior resection syndrome score and quality-of-life improvement after a 12-month treatment. RESULTS: Of the 22 patients included, 20 had major and 2 had minor low anterior resection syndrome, with a median score of 39, especially high rates of incontinence for liquid stool (21; 95.5%), clustering (21; 95.5%), and urgency (17; 77.3%). All patients successfully completed the 3-day training, and there were no complications during the treatment. After the 12-month period, the median score was 8, with 90% of the patients classified as having "no syndrome" and great improvement in all domains of this score. The most improved quality-of-life sections were patient vitality (p = 0.025) and physical (p = 0.002), social (p = 0.001), and emotional aspects (p = 0.001). LIMITATIONS: The study was limited by its small sample size and the limited follow-up period. CONCLUSIONS: This study presents a safe implementation protocol of an ostomy irrigation device for transanal irrigation. It also adds to the literature that transanal irrigation is a safe, effective, and easily implemented procedure for patients with low anterior resection syndrome with a significant improvement in quality of life. See Video Abstract at http://links.lww.com/DCR/B563.ESTUDIO DE FACTIBILIDAD DE LA IRRIGACIÓN TRANSANAL UTILIZANDO EL SISTEMA DE IRRIGACIÓN PARA COLOSTOMÍA EN PACIENTES CON SÍNDROME DE RESECCIÓN ANTERIOR BAJAANTECEDENTES:El síndrome de resección anterior baja tiene un impacto negativo en la calidad de vida de los pacientes. La irrigación intestinal es un método de lavado que consiste en evacuaciones programadas.OBJETIVOS:Evaluar los resultados de la funcionalidad e impacto en la calidad de vida de los pacientes con síndrome de resección anterior y baja posterior a la irrigación transanal utilizando un sistema de irrigación de colostomía.DISEÑO:Es estudio prospectivo de una serie de casos.ESCENARIO:En este estudio se muestra la experiencia de un centro oncológico de tercer nivel en un país en vías de desarrollo.PACIENTES:Aquellos clasificados como síndrome con afección en menor o mayor grado doce meses después de la cirugía.METODO:Se efectuó irrigación transanal utilizando un equipo de irrigación de estomas. Se aplicaron cuestionarios para valorar la función intestinal de los pacientes (síndrome de resección anterior baja y la escala de Wexner) y para calidad de vida (Cuestionario Corto-36) antes y después del tratamiento.EVALUACION DE LOS RESULTADOS PRINCIPALES:Los principales resultados se obtuvieron de la escala del síndrome de resección baja y la mejoría en la calidad vida doce meses después de tratamiento.RESULTADOS:De los veintidós pacientes incluidos, veinte presentaron manifestaciones mayores del síndrome de resección baja y dos, manifestaciones menores. Con una media de treinta y nueve, se encontraron, especialmente, altos índices de incontinencia a líquidos (21; 95'5%) hiperdefecación "clustering" (21; 95'5%) y urgencia (17; 77'3%). Todos los pacientes completaron en forma satisfactoria el entrenamiento de tres días sin presentarse complicaciones durante el tratamiento. Al término del mes doce la media fue de ocho, con el 90% de los pacientes clasificados como "sin síndrome" y se observó una mejoría substancial en todos los puntos de la evaluación. Las secciones de calidad de vida que mostraron una mejoría significativa fueron: la vitalidad del paciente (p = 0'025), física (p = 0'002), social (p = 0'001) y emocional (p = 0'001).LIMITACIONES:El tamaño de la muestra es pequeño y el tiempo de seguimiento corto.CONCLUSIONES:Este estudio muestra la implementación de un protocolo seguro para la irrigación de estomas mediante un dispositivo transanal. Además contribuye con el concepto en la literatura de que la seguridad de la irrigación transanal es seguro, efectivo y facilmente reproducible para pacientes con síndrome de resección anterior baja con una mejoría significativa en la calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B563. (Traducción-Dr. Miguel Esquivel-Herrera).

Intra-observer reliability in three-dimensional kinematic analysis of sacroiliac joint mobility.

[Purpose] Physical therapists, osteopathic practitioners, and chiropractors often perform manual tests to evaluate sacroiliac joint (SIJ) mobility. However, the available evidence demonstrates an absence of reliability in these tests and in investigations with kinematic analysis. The aim of this study was to verify the three-dimensional kinematic reliability in SIJ movement measurements. [Subjects] This cross-sectional study analyzed 24 healthy males, aged between 18 and 35 years. [Methods] Three-dimensional kinematic analysis was performed for measurements of posterior superior iliac displacement and greater trochanter (femur) displacement during hip flexion movement in an orthostatic position. The distance variations were measured from a reference point in 3 blocks. The intra-observer reliability was compared with the mean of three 3 blocks using the interclass correlation coefficient (ICC) and a 99% significance level. [Results] The measurements indicated a strong correlation among blocks: ICC = 0.94 for right side SIJ and ICC = 0.91 for left side SIJ. The mean displacement between the reference points was 7.7 mm on the right side and 8.5 mm on the left side. [Conclusion] Our results indicate that three-dimensional kinematic analysis can be used for SIJ mobility analyses. New studies should be performed for subjects with SIJ dysfunction to verify the effectiveness of this method.

Pregnancy after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in pseudomyxoma peritonei.

Pseudomyxoma peritonei is usually a benign tumor that is slightly more common in women. However, it requires aggressive surgical treatment and chemotherapy, often compromising future reproductive function. This report presents a case of pregnancy in a 35-year-old woman who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei. The tumor was diagnosed during a laparoscopic examination on a workup for infertility in 2008. Two months later, she underwent a peritonectomy followed by hyperthermic intraperitoneal chemotherapy and, regarding her will to conceive, ovaries and fallopian tubes were preserved. In March 2011, she went through an in vitro fertilization followed by an uneventful pregnancy and delivered a healthy child 39 weeks later. Ovaries are usually resected during the cytoreductive surgery, since they are common sites for neoplastic implants, and, even when not performed, little is known about the effects of local chemotherapy on female fertility. The largest international survey on this matter only describes seven similar cases. This particular report not only describes a rare condition but also adds to the upcoming discussion about whether ovaries can be preserved in specific situations, therefore keeping the prospect of conceiving after this treatment.

Multiple symmetric lipomatosis.

BACKGROUND: Multiple symmetric lipomatosis (MSL) is a relatively uncommon entity of unknown etiology characterized by symmetrically subcutaneous accumulation of nonencapsulated adipose tissue. Approximately 200 to 300 cases have been published. OBJECTIVES: The aims of this article are to report the case of a 58-year-old Brazilian patient with MSL and provide a comprehensive overview of the current concepts concerning this disease. METHODS: Our search yielded 28 articles on MSL, including case reports and reviews of the literature. RESULTS: MSL predominantly affects Mediterranean males with a history of chronic alcohol abuse. It is usually asymptomatic and may be associated with diabetes mellitus, hyperlipidemia, hyperuricemia, macrocytic anemia, and oral cancer. Surgical resection is the best treatment option. CONCLUSION: The case reported is a classic presentation of MSL; however, it is particularly uncommon owing to the association with immune thrombocytopenic purpura. This association has been described only once in the medical literature.

A simplified rehabilitation program for patients undergoing elective colonic surgery--randomized controlled clinical trial.

BACKGROUND: We have proposed a simplified perioperative rehabilitation program for elective colonic surgery that is focused on early oral nutrition and that could reduce hospital stay and postoperative ileus time without raising complications and readmission rates. PATIENTS AND METHODS: Fifty-four patients admitted for elective colonic surgery were prospectively randomized into two groups: (1) an early feeding group (EFG)-on the first postoperative day, patients initially received a oral liquid diet and were advanced to a regular diet within the next 24 h as tolerated and at their discretion; (2) a traditional care group-patients were managed by nothing per orus until the elimination of the first flatus and then submitted to an oral liquid diet, followed by a regular diet within the next 24 h as described for the EFG. All patients followed a well-defined, simplified rehabilitation program. RESULTS: Patients' baseline characteristics were similar in the two groups. Hospital stay was significantly lower in the EFG (4.0 [±3.7] versus 7.6 [±8.1] days; p = 0.000). Diet tolerance and progression were similar between groups. Time to first flatus after surgery was significantly lower in the EFG (1.5 [±0.5] versus 2.0 [±0.7] days; p = 0.019). Complication and readmission rates were similar in both groups. CONCLUSIONS: Early oral nutrition associated with a simplified perioperative rehabilitation program reduces postoperative length of hospital stay and ileus time after elective colonic resection without increasing rates of complications or readmissions.

Splenic metastases from mucinous neoplasms of the appendix and colon.

AIMS AND BACKGROUND: Splenic metastases associated with mucinous intraabdominal tumors have been an enigma in the radiologic and oncology literature. These focal parenchymal defects from a non-metastasizing malignancy within an organ that rarely develops metastatic foci, even with high-grade cancer, were studied. METHODS: Information on 9 patients who underwent splenectomy with intraparenchymal splenic masses associated with appendiceal or colorectal mucinous tumors with peritoneal dissemination was collected. The CT scan, the histopathology and the clinical parameters of these patients were studied. A literature review searching for prior reports of this subject was performed. RESULTS: Eight of these patients had mucinous appendiceal tumors and 1 a mucinous sigmoid colon cancer. All patients had mucinous carcinomatosis at some time in their clinical course. These splenic tumor masses had a CT image compatible with metastases and not compatible with mucinous tumor layered out of the splenic capsule. None of the patients had evidence of metastases to other sites such as liver or lymph nodes. All patients had a mucinous histopathology. Splenectomy may be associated with prolonged survival. CONCLUSIONS: From our review of the clinical information available on these 9 patients, these splenic lesions were thought to be an entrapment of mucinous tumor within splenic surface trabeculae, which expand into the splenic parenchyma resembling metastatic disease. These CT findings may be more accurately referred to as splenic pseudometastases.

Limited survival in the treatment of carcinomatosis from rectal cancer.

PURPOSE: Carcinomatosis from colon and rectal cancer has always been regarded as a lethal condition. Recently, numerous reports suggest that long-term survival is possible in selected patients if a definitive management strategy is used. An important task involves the clear description of the clinical features that influence prognosis in these patients. METHODS: From June 1981 to November 2004, 156 patients with peritoneal carcinomatosis secondary to colorectal cancer underwent cytoreductive surgery with perioperative intraperitoneal chemotherapy. Among these patients, 11 had rectal cancer with carcinomatosis and are the focus of the present study. The survival of patients with peritoneal carcinomatosis of rectal cancer origin was compared with patients with colon cancer. In the data analysis, patients were classified by completeness of cytoreduction score. RESULTS: The mean follow-up for 11 patients with rectal cancer was 15.7 (range, 3-51) months. At the end of the cytoreductive surgery, the cytoreduction was complete in six patients, nearly complete in two patients, and there was gross disease in three patients. The median survival of the six rectal cancer patients with complete cytoreduction was 17 (range, 12-29) months and 35 (range, 3-241) months for 64 colon cancer patients with complete cytoreduction (P = 0.126). The five-year survival for patients with rectal cancer with complete cytoreduction was 0 percent and for patients with colon cancer was 33 percent. CONCLUSIONS: Patients with peritoneal carcinomatosis secondary to rectal cancer treated by cytoreductive surgery combined with intraperitoneal chemotherapy have a poor prognosis. Some improvement in these poor results may occur if resection of a rectal cancer with carcinomatosis is delayed until definitive treatment of the primary cancer plus the carcinomatosis is possible.

Recurrence of pseudomyxoma peritonei within the inguinal canal.

AIM AND BACKGROUND: Tumor appearing in an inguinal hernia sac indicates widespread carcinomatosis with ascites. A new onset hernia is a common clinical presentation of pseudomyxoma peritonei syndrome arising in an appendiceal mucinous tumor. Recurrence of pseudomyxoma peritonei within the inguinal region was previously reported in only a single patient. We present five patients with a recurrence of pseudomyxoma peritonei tumor nodules in the inguinal region following cytoreductive surgery and attempt to understand the etiology of this treatment failure. METHODS AND STUDY DESIGN: From a database of 910 patients with mucinous appendiceal tumors with peritoneal dissemination who had definitive treatment, five patients who had disease recurrence within the inguinal region were identified. The clinical histories were studied and presented in order to make future recommendations regarding the management of these patients. RESULTS: Five patients with ages ranging 39 to 67 years had a mucinous tumor in the inguinal region as a recurrence after a previous cytoreductive surgery combined with perioperative intraperitoneal chemotherapy. One of them had separate recurrence in both right and left inguinal regions. All these patients were made disease-free by the reoperative surgery with a sacrifice of the testicle in four. None have evidence of a recurrence of an inguinal hernia despite the lack of formal repair. CONCLUSION: At the time of initial cytoreductive surgery the surgeon should be aware of the inguinal region as a possible site of relapse. This may be more problematic in patients who have had prior surgery with mucoid fluid in a hernia as the presenting sign of pseudomyxoma peritonei. Inguinal recurrences should be removed with clear margins even if orchiectomy is required.