Desgarro perineal con mucosa vaginal íntegra tras primera relación sexual / Perineal tear with intact vaginal mucosa after first sexual intercourse

RESUMEN Las lesiones del tracto genital femenino tras relaciones sexuales son un problema frecuente en las urgencias de ginecología, pero poco estudiado salvo su aspecto médico-legal. Su incidencia es desconocida ya que muchas mujeres no llegan a consultar por miedo o pudor. El reconocimiento precoz de estas lesiones y su correcto tratamiento puede evitar la parición de secuelas que acompañarán a nuestra paciente durante el resto de su vida. Presentamos el caso de una paciente de 18 años con un desgarro perineal con mucosa vaginal íntegra tras su primera relación sexual.

ABSTRACT Injuries to the female genital tract after sexual intercourse are a frequent problem in gynecological emergencies, but little studied except for their medico-legal aspect. Its incidence is unknown since many women do not go to their specialist out of fear or embarrassment. Early recognition of these injuries and their correct treatment may prevent the appearance of sequelae that will accompany our patient for the rest of her life. We present the case of an 18-year-old patient with a perineal tear with intact vaginal mucosa after her first sexual intercourse.

Epidemiological profile of mucosal melanoma in Brazil.

Mucosal melanomas are primary malignant neoplasias originated from melanocytes within mucous membranes in any part of mucosal surface lining, more commonly, in the nasal cavity and accessory sinuses, oral cavity, lips, pharynx, vulvar, vaginal, cervix and anorectal mucosa. Epidemiology data regarding mucosal melanomas in Brazil is scarce, hence the motivation to conduct this research paper. The χ2 test was used to compare categorical variables. Forward stepwise logistic regression method was used in the multivariate analysis to identify independent predictors of early death. A total of 801 patients were included in the analysis. Surgical resection is frequently the first approach to primary tumours (65.3%), even though the utility of lymph node surgery and radiation therapy is not well established. Advanced stage was observed in more than two thirds of patients. Early death was observed in 28.3%. MM cases with regional or distant metastases as well as those located in unusual locations had almost 4 times more risk for early death. Besides that, MM located in lips, oral cavity and pharynx and those receiving chemotherapy had 2 times more risk of early death.

Tilapia Skin for Neovaginoplasty after Sex Reassignment Surgery.

STUDY OBJECTIVE: To describe a new technique of neovaginoplasty after a female sex reassignment surgery using a tilapia skin as a graft. DESIGN: Stepwise demonstration of a new technique with narrated video of a single case report. The patient provided oral and written informed consent. Moreover, this video report is part of a multicenter, Investigational Review Board-approved study. SETTING: Women's university hospital in Campinas, Brazil. INTERVENTIONS: Neovaginoplasty technique using tilapia skin with the following key strategies: (1) corpus cavernosum removal, (2) vagina tunnel creation, (3) mold coating with tilapia skin, (4) mold fixation, and (5) postoperative care. The patient remained with the mold coated with tilapia skin for 5 days; after this time, the mold was removed, and the tissue graft was adhered and incorporated in the new vaginal canal. After 2 months, the tissue resembled a vaginal mucosa, and the vaginal length was 8 cm. The patient has not had intercourse yet. CONCLUSION: We introduce an alternative for low-morbidity neovaginoplasty based on the experience of plastic surgery in burned grafts. The procedure described offers an alternative option to develop an anatomic neovagina with tissue similar to mucosa tissue by a simple, low-morbidity minimally invasive procedure.

Robot-assisted Simple Prostatectomy with Tunnel-Shaped Trigonization (RASP-TST) - A Novel Technique.

To describe a technical modifi cation for robotic-assisted simple prostatectomy (RASP) using three-steps reconstructive technique to achieve a 360 trigonization of the bladder mucosa. Through fi ve-trocars transperitoneal access, we perform a longitudinal incision of the bladder wall and prostate capsule. Our technique of RASP is very similar to the standard operative technique described during laparoscopic and robotic removal of adenoma, however, for reconstruction, we propose the Tunnel-Shaped Trigonization (TST). The fi rst step is the advancement of a bladder mucosa fl ap until the posterior part of the prostatic urethra. The second step, a running suture between the advanced mucosa and the prostatic capsule is done bilaterally. At this point, the prostate capsule should be totally isolated from the rest of the urinary tract. Finally, the third step is closing both sides of the capsule and bladder mucosa anteriorly identical to a tunnel conformation. Hiding the prostatic capsule optimizes the patient recovery since hematuria is the most related factor for hospital stay length. This pilot-case has shown satisfactory results without the need for continuous bladder irrigation. The prostate volume in the TRUS was 130 cm3 and the preoperative International Prostate Symptom score was 24. He was discharged at second postoperative day and no late complications were detected. In conclusion, the TST-RASP seems to be a safe and feasible modifi cation of the RASP. We hope that the application of the TST can lead us to lower rates of blood loss, transfusion and postoperative complications in comparison to the standard technique.

Resección endoscópica por tunelización submucosa de un leiomioma de la unión gastroesofágica: reporte de un caso / Submucosal tunneling endoscopic resection of a gastroesophageal junction leiomyoma: report of a case

Resumen Introducción Los tumores submucosos del tracto gastrointestinal alto tienen potencial de malignidad y también pueden ser una carga para el paciente, por lo que se requiere disponer de un tratamiento seguro y eficaz. El surgimiento de la técnica de resección endoscópica por tunelización submucosa (STER) en los últimos años ha mostrado resultados prometedores. Caso clínico Se presenta el caso de un hombre de 47 años asintomático, en quien, en el contexto de un estudio preoperatorio de cirugía bariátrica, se pesquisa una lesión subepitelial en la unión gastroesofágica. La endosonografía alta es compatible con un leiomioma esofágico. Se realiza STER con éxito y sin complicaciones; a las 48 h es dado de alta. El estudio histopatológico confirmó un leiomioma esofágico. Discusión La técnica STER ha demostrado consistentemente ser segura y eficaz en el tratamiento de los tumores submucosos de la unión gastroesofágica. El desafío es difundir la técnica por el resto del país, para mayor beneficio de los pacientes.

Introduction Upper gastrointestinal submucosal tumors are potentially malignant lesions; so safe and efficient treatments are needed. In recent years, submucosal tunneling endoscopic resection (STER) has emerged as a novel therapeutic technique, with promising results. Case report 47-year-old male patient, previously asymptomatic, who was found to have a subepithelial lesion at the gastroesophageal junction. Upper endoscopic ultrasound was compatible with a leiomyoma. He underwent STER to remove the tumor and recovered with any complications. The biopsy confirmed an esophageal leiomyoma. Discussion STER has become a highly feasible and safe therapeutic option for submucosal tumors of the gastroesophageal junction. The challenge is to spread knowledge about this technique, to maximize patient's benefit.

Correção cirúrgica da macrostomia congênita unilateral e bilateral: relato de casos e revisão da literatura / Surgical correction of unilateral and bilateral congenital macrostomia: a case report and literature review

INTRODUÇÃO: A incidência da microssomia craniofacial é de 1 em 5600 nascidos vivos. É a segunda anomalia craniofacial mais comum após as fissuras labiais e palatinas. A fissura número 7 está associada entre 17 a 62% dos casos de microssomia hemifacial e começa na comissura labial, podendo prolongar-se até a linha capilar pré-auricular. As deformidades da orelha externa vão desde excesso de pele pré-auricular até ausência completa da orelha. A comissuroplastia está indicada em pacientes com macrostomia ou fissura facial lateral verdadeira. O objetivo é demonstrar dois casos de macrostomia e fazer uma revisão da literatura sobre o tema. MÉTODOS: Em nosso estudo descrevemos dois casos de macrostomia tratados com retalhos de mucosa e plástica em Z. RESULTADOS: Obtivemos um ótimo reposicionamento das comissuras nos dois pacientes, com excelente resultado estético. CONCLUSÃO: A técnica utilizada é de fácil reprodutibilidade e corrige a macrostomia estética e funcionalmente.

INTRODUCTION: The incidence of craniofacial microsomia is 1 in 5600 live births. This is the second most common craniofacial anomaly after cleft lip and palate. Tessier cleft 7 is associated with 17% to 62% of cases of hemifacial microsomia. It begins on the labial commissure and may extend to the pre-auricular capillary line. Deformities of the external ear range from excessive pre-auricular skin to complete absence of the ear. Commissuroplasty is indicated in patients with macrostomia or true lateral facial cleft. The objective is to present two cases of macrostomia and perform a review of related literature. METHODS: In this study, we describe two cases of macrostomia treated with mucous flaps and zetaplasty. RESULTS: We obtained optimal repositioning of labial commissures in two patients, with excellent aesthetic results. CONCLUSION: The technique used is easily reproducible, and aesthetically and functionally corrects macrostomia.

Esophageal mucosal resection versus esophagectomy: a comparative study of surgical results in patients with advanced megaesophagus.

BACKGROUND: The surgical treatment of advanced megaesophagus has no consensus, being esophagectomy the more commonly used method. Since it has high morbimortality--inconvenient for benign disease -, in recent years an alternative has been introduced: the esophageal mucosal resection. AIM: To compare early and late results of the two techniques evaluating the operative time, length of ICU stay; postoperative hospitalization; total hospitalization; intra- and postoperative complication rates; mortality; and long-term results. METHODS: Were evaluated retrospectively 40 charts, 23 esophagectomies and 17 mucosectomies. In assessing postoperative results, interviews were conducted by using a specific questionnaire. RESULTS: Comparing the means of esophagectomy and mucosal resection, respectively, the data were: 1) surgical time--310.2 min and 279.7 min (p > 0.05); 2) length of stay in ICU--5 days and 2.53 days (p <0.05); 3) total time of hospitalization--24.25 days and 20.76 days (p> 0.05); 4) length of hospital stay after surgery--19.05 days and 14.94 days (p> 0.05); 5) presence of intraoperative complications--65% and 18% (p <0.05); 6) the presence of postoperative complications - 65% and 35% (p> 0.05). In the assessment of late postoperative score (range 0-10) esophagectomy (n = 5) obtained 8.8 points and 8.8 points also got mucosal resection (n = 5). CONCLUSIONS: Esophageal mucosal resection proved to be good alternative for surgical treatment of megaesophagus. It was advantageous in the immediate postoperative period by presenting a lower average time in operation, the total hospitalization, ICU staying and complications rate. In the late postoperative period, the result was excellent and good in both operations.

Oestrogen receptor alpha expression in neovaginal tissue of women following modified Abbé-McIndoe technique and in premenopausal women.

The aim of the study was to compare the expression of oestrogen receptor alpha (ERα) in neovaginal tissue of patients with vaginal agenesis following neovaginoplasty using regenerated, oxidised cellulose in premenopausal women. A prospective, observational case-control study was performed on eight patients with vaginal agenesis following modified Abbé-McIndoe neovaginoplasty and 10 control premenopausal women following benign gynaecologic surgery. 6F11 monoclonal antibody was used to determine ERα expression in the vaginal mucosa. Quantitative and qualitative evaluations were performed, respectively, in vaginal epithelium and stroma. The thickness of the vaginal epithelium was determined as the vertical distance between the basal layer cells and the apical surface of the superficial layer. The percentage of ERα-expressing cells was higher in the control group, except in the superficial zone of the epithelium. In the stromal tissue, ERα was detected in only one patient from the neovagina group compared with nine women in the control group. The neovagina group had a statistically thinner epithelium. Our study suggests that women with vaginal agenesis following modified Abbé-McIndoe neovaginoplasty using regenerated oxidised, cellulose experience relatively local hypo-oestrogenism in the first year after surgery, with repercussion in vaginal trophism.

[Endolifter, a new tool for safe and rapid submucosal endoscopic dissection]. / Endolifter, una nueva herramienta para una segura y rápida disección endoscópica submucosa.

BACKGROUND: The effectiveness of endoscopic submucosal dissection (ESD) is similar to that of surgery in the treatment of early lesions. The technique requires a high level of technical skill. Training on biologic models and the mastering of accessories facilitate ESD. AIMS: The aim was to evaluate the usefulness of the Endolifter in facilitating tissue exposure during ESD in an in vivo porcine model performed at the experimental surgery laboratory of the School of Medicine at the Universidad de São Paulo in Brazil. MATERIAL AND METHOD: A study with an experimental design employing an in vivo porcine model was conducted on 5 Yorkshire pigs weighing 20-25kg. ESDs were performed using the Endolifter. Mucosal layer dissection was carried out with a dual knife and IT knife and all the endoscopic procedures were performed by a single expert endoscopist. RESULTS: A total of 25 ESDs were performed, with a technical success rate of 100%. The mean dissection time was 12.34min (range: 10.40-14.50 min) and the mean lesion size was 2.7cm (range: 2.3-3.2cm). There were no episodes of bleeding or perforations during the procedures. CONCLUSIONS: The Endolifter enables rapid and effective ESDs to be carried out. It is an applicable and easy-to-use device that can be manipulated by a single operator.

A new system to classify submucous myomas: a Brazilian multicenter study.

OBJECTIVE: To evaluate 2 different predicting scores of submucous myoma removal, fluid balance, and operative time in woman undergoing hysteroscopic myomectomy. DESIGN: A multicenter and prospective study (Canadian Task Force classification II-2). SETTING: Six hysteroscopy centers in Brazil. PATIENTS: A total of 191 women who underwent hysteroscopic resection of 205 submucous myomas. INTERVENTION: Resection of submucous myomas (hysteroscopic myomectomy). Myomas were scored according to the European Society for Gynaecological Endoscopy (ESGE) and STEPW (size, topography, extension, penetration, and wall) classifications. The validation of the 2 classifications was assessed with sensitivity and specificity of each classification, with their best cutoff point. MAIN OUTCOME MEASURES: To correlate ESGE and STEPW classifications with complete or incomplete removal of submucous myoma, length of surgery, surgical complications, and fluid balance. RESULTS: Removal of the myoma was complete in 190 (92.7%) of 205 myomectomies, and incomplete in 15 (7.3%). All 140 (100%) of 140 myomas with a score ≤ 4 in the STEPW classification were completely removed, and 50 (76.9%) of 65 myomas with a score >4 were removed. All 15 (100%) cases of incomplete hysteroscopic myomectomy had a STEPW score >4. With the ESGE classification, 156/164 (95.1%) cases of type 0 and type 1 myomas, and 34/41 (82.9%) of type 2 were completely resected. STEPW scores >4 were statistically associated with longer duration of surgery, surgical complications, higher levels of fluid balance, and use of gonadotropin releasing hormone analogue if compared with lower scores. The ESGE scores were not associated with any of these variables. CONCLUSION: Classifying submucous myomas with the STEPW classification allows better prediction of myoma removal, fluid balance, length of surgery and surgical complications in hysteroscopic myomectomy than ESGE classification.

To be or not to be: disección endoscópica submucosa o resección endoscópica de la mucosa en el tratamiento de las neoplasias gastrointestinales / To be or not to be: endoscopic sub-mucosal dissection or endoscopic mucosal resection for treatment of gastrointestinal neoplasia

Endoscopic treatment of early gastrointestinal neoplasias has become the standard treatment in Japan and other Asia-Pacific countries, while it is still a developing technology in the West. The advent of endoscopic mucosal resection and endoscopic sub-mucosal dissection in the last decade has allowed early treatment of malignancies in a manner that preserves the organ, avoiding major surgery with less morbidity and mortality, and overall survival rates compared to standard surgery. In Japan and other Asia-Pacific countries, submucosal dissection has shifted over endoscopic mucosal resection as the technique of choice in the recent years, because of the possibility of treating deeper and larger lesions, with higher rates of bloc and curative resections, and lower recurrence rates, but with a higher rate of complications and a longer learning curve.

El tratamiento endoscópico de las neoplasias gastrointestinales precoces se ha convertido en el estándar de tratamiento en Japón y otros países del Asia-Pacífico, siendo aún una técnica en desarrollo en occidente. La aparición de la resección endoscópica de la mucosa y la disección endoscópica submucosa en la última década, ha permitido tratar las neoplasias precoces, logrando preservar el órgano, y evitando así una cirugía mayor, con menor morbi-mortalidad y cifras de sobrevida comparables con el tratamiento quirúrgico convencional. En Japón y otros países del Asia-Pacífico, la disección sub-mucosa ha desplazado en los últimos años a la resección endoscópica de la mucosa como técnica de elección, debido a la posibilidad de resecar lesiones más profundas y de mayor tamaño, con mayor tasa de resección en bloque y curativa, y menor recidiva. Sin embargo, con una mayor tasa de complicaciones y una curva de aprendizaje más larga.

Mucosal bridge of the vocal fold: difficulties in the diagnosis and treatment.

SUMMARY: Mucosal bridges are rare laryngeal lesions probably of genetic origin. They may cause dysphonia of varying degrees, especially when associated with other laryngeal lesions such as vocal sulci and cysts. Reports on mucosal bridges are rare, and the better treatment is inconclusive. AIM: To report the authors' experience in 14 cases of mucosal bridge showing details on endoscopic examinations and treatment. STUDY DESIGN: Retrospective study. METHODS: We reviewed the medical records of 14 patients with a diagnosis of mucosal bridge confirmed by videolaryngostroboscopy and direct laryngoscopy who attended the Outpatient Clinic of Voice Disorders of the Discipline of Otorhinolaryngology, Botucatu Medical School, São Paulo State University, São Paulo. Data collected included information on gender, age, symptoms, time of onset, history of intubation, smoking status, alcohol intake, associated laryngeal lesions, treatment, and GRBAS (grade of hoarseness, roughness, breathiness, asthenia, and stress) scale ratings. RESULTS: Of 14 patients, 10 were females and four were males. There was a prevalence of adults (n=12), with only two of the patients being younger than 13 years (10 and 13 years). Mucosal bridges showed no correlations with smoking, alcohol intake, or gastroesophageal and sinonasal symptoms. Voice abuse was reported in 50% of the cases that consisted of patients who had high-voice demand occupations. In seven cases, mucosal bridges were associated with other laryngeal lesions, particularly vocal cysts and sulci. All patients who underwent surgery and phonotherapy showed improved vocal quality. CONCLUSIONS: We documented 14 patients with dysphonia caused by mucosal bridge. Promising results were obtained with surgery.

Augmentation of the porcine vocal fold using autologous composite cervical fascia and fat graft. Comparison between the transmuscular and submuscular approaches.

OBJECTIVES: To assess the integration of an autologous composite fascia and fat graft implanted into the lamina propria of a porcine vocal fold using two different approaches. STUDY DESIGN: An experimental prospective study on the porcine larynx was conducted at a tertiary research institution. METHODS: An external cervical approach was used to expose the thyroid cartilage of 24 healthy minipigs under general anesthesia. The composite fascia/fat graft was implanted through two distinct approaches, transmuscular and submuscular. Animals were sacrificed at 7, 30, 90, and 180 days for macroscopic and histological study of the larynx. Graft integration and local inflammatory response were studied. RESULTS: The survival rate of the experimental model was 100% and all animals had local inflammatory response to the surgical procedure. Only 41.7% of the grafts placed inside the thyroarytenoid (TA) muscle fibers were identified postmortem, whereas 83.3% of the submuscular grafts remained intact. CONCLUSIONS: Graft incorporation was better and there was less inflammation when the architecture of the TA muscle fibers was preserved. Graft extrusion was observed in the most of the cases where it was placed inside the muscle.

Comparative study of two autogenous graft techniques using piezosurgery for sinus lifting.

PURPOSE: Maxillary sinus lifting is a technique, in which, a possible complication is sinus membrane perforation. The aim of this study was to compare two techniques using ultrasound surgery to perform autogenous graft for maxillary sinus lifting. METHODS: Ten rabbits were used in the study, one of them did not undergo surgery. The other nine rabbits had their maxillary sinuses filled with autogenous bone grafts collected from the external skull diploe in particulate form on the right side, and shaved on the left side, both with ultrasonic device. Data on bone density in left and right maxillary sinus, obtained by computed tomography in transverse and longitudinal sections, recorded 90 days after the grafts, were statistically compared. RESULTS: There were no statistically significant differences between the two techniques that used shaved and particulate bone collected by means of ultrasonic device from rabbit skulls. CONCLUSION: Assessment of operative procedures led to the conclusion that piezoelectric ultrasound was shown to be a safe tool in the surgical approach to the maxillary sinus of rabbits, allowing sinus membrane integrity to be maintained during surgical procedures.

Comparative study of two autogenous graft techniques using piezosurgery for sinus lifting / Estudo comparativo de duas técnicas de enxerto autógeno utilizando piezocirurgia para levantamento de seio maxilar

PURPOSE: Maxillary sinus lifting is a technique, in which, a possible complication is sinus membrane perforation. The aim of this study was to compare two techniques using ultrasound surgery to perform autogenous graft for maxillary sinus lifting. METHODS: Ten rabbits were used in the study, one of them did not undergo surgery. The other nine rabbits had their maxillary sinuses filled with autogenous bone grafts collected from the external skull diploe in particulate form on the right side, and shaved on the left side, both with ultrasonic device. Data on bone density in left and right maxillary sinus, obtained by computed tomography in transverse and longitudinal sections, recorded 90 days after the grafts, were statistically compared. RESULTS: There were no statistically significant differences between the two techniques that used shaved and particulate bone collected by means of ultrasonic device from rabbit skulls. CONCLUSION: Assessment of operative procedures led to the conclusion that piezoelectric ultrasound was shown to be a safe tool in the surgical approach to the maxillary sinus of rabbits, allowing sinus membrane integrity to be maintained during surgical procedures.

OBJETIVO: A técnica de levantamento de seio maxilar apresenta como possível complicação a perfuração da membrana sinusal. O presente trabalho teve por objetivo comparar duas técnicas que utilizam a cirurgia ultrassônica para realização de enxerto autógeno para levantamento de seio maxilar. MÉTODOS: Dez coelhos foram utilizados no estudo, sendo que um deles não foi submetido a procedimento cirúrgico. Os nove coelhos operados tiveram os seios maxilares preenchidos com enxertos autógenos coletados de díploe externa de calota craniana, nas formas particulado do lado direito e raspado do lado esquerdo, ambos com aparelho ultrassônico. Os dados de densidade óssea nos seios maxilares esquerdo e direito, obtidos por meio de tomografia computadorizada nos sentidos transversal e longitudinal, registrados 90 dias após a realização dos enxertos foram comparados estatisticamente. RESULTADOS: não houve diferenças estatisticamente significantes entre as técnicas de enxerto que utilizaram osso raspado e particulado coletado por meio de dispositivo ultrassônico da calota craniana de coelhos. CONCLUSÃO: A avaliação clínica dos procedimentos nos levou a concluir que o ultrassom piezoelétrico mostrou-se um instrumento clinicamente seguro na abordagem cirúrgica do seio maxilar de coelhos, permitindo a manutenção da integridade da membrana sinusal durante as manobras de ostectomia da parede lateral da maxila e divulsão da membrana sinusal.

Clinical and functional evaluation of patients with rectocele and mucosal prolapse treated with transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS).

BACKGROUND: The aim of the present study was to make a preoperative and postoperative clinical and functional evaluation of patients who underwent transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS procedure) as treatment for obstructed defecation syndrome (ODS) caused by rectocele and rectal mucosal prolapse (RMP). METHODS: This prospective study included 35 female patients, 34 multiparous and one nulliparous, with an average age of 47.5 years (range 31-67 years), rectocele grade II (n = 13/37.1%) or grade III (n = 22/62.9%), associated with RMP. The study parameters included ODS, constipation, functional continence scores and pre- and postoperative cinedefecographic findings. RESULTS: The average preoperative ODS score, the constipation score and the functional continence score were significantly reduced after surgery from 10.63 to 2.91 (p = 0.001), 15.23 to 4.46 (p = 0.001) and 2.77 to 1.71 (p = 0.001), respectively. Between the first and the eighth postoperative day, the average visual analog scale pain score fell from 5.23 to 1.20 (p = 0.001). Satisfaction with treatment outcome was 79.97, 86.54, 87.65 and 88.06 at 1, 3, 6 and 12 months, respectively. Cinedefecography revealed average reductions in rectocele size from 19.23 ± 8.84 mm (3-42) to 6.68 ± 3.65 mm (range 0-7) at rest and from 34.89 ± 12.30 mm (range 20-70) to 10.94 ± 5.97 mm (range 0-25) during evacuation (both P = 0.001). CONCLUSION: The TRREMS procedure is a safe and efficient technique associated with satisfactory anatomic and functional results and with a low incidence of postoperative pain and complications.

[Endoscopic mucosal resection due to adenocarcinoma of the esophagus caused by Barrett's esophagus.]. / Resección endoscópica de la mucosa debido a adenocarcinoma de esófago originado en un esófago de Barrett.

The endoscopic therapy has been used in the treatment of early stage neoplastic esophageal lesions with great success. The endoscopic ultrasound is a useful tool for the correct staging of these lesions. The staging accuracy of esophageal cancer with endoscopic ultrasound reaches 80% for T stage and 77% for N stage. The endoscopic approach provides complete resection of lesions confined to the mucosal layer, is a safety procedure with complications reported to occur from 3% to 13%. The morbidity and mortality rates after an endoscopic mucosal resection have been reported to be less than those posterior to esophagectomy. We present a case of a patient with high surgical risk, who underwent an upper endoscopy because of long history of gastroesophageal reflux disease and uncontrollable hiccup with successful endoscopic mucosal resection with plastic cap and polipectomy loop of an early stage esophageal adenocarcinoma derived of Barrett s esophagus.

p53 and Ki-67 in Barrett's carcinoma: is there any value to predict recurrence after circumferential endoscopic mucosal resection? / p53 e Ki-67 no carcinoma do esôfago de Barrett: algum valor na predição da recurrência após mucosectomia endoscópica circunferencial?

BACKGROUND: There are situations in which the specimens obtained after endoscopic mucosal resection of superficial adenocarcinoma arising from Barrett's esophagus are not adequate for histopathological assessment of the margins. In these cases, immunohistochemistry might be an useful tool for predicting cancer recurrence. AIM: To evaluate the value of p53 and Ki-67 immunohistochemistry in predicting the cancer recurrence in patients with Barrett's esophagus-related cancer referred to circumferential endoscopic mucosal resection. METHODS: Mucosectomy specimens from 41 patients were analyzed. All endoscopic biopsies prior to endoscopic mucosal resection presented high-grade dysplasia and cancer was detected in 23 of them. Positive reactions were considered the intense coloration in the nuclei of at least 90 percent of the cells in each high-power magnification field, and immunostaining could be classified as superficial or diffuse according to the mucosal distribution of the stained nuclei. RESULTS: Endoscopic mucosal resection samples detected cancer in 21 cases. In these cases, p53 immunohistochemistry revealed a diffuse positivity for the great majority of these cancers (90.5 percent vs. 20 percent), and Ki-67 showed a diffuse pattern for all cases (100 percent vs. 30 percent); conversely, patients without cancer revealed a superficial or negative pattern for p53 (80 percent vs. 9.5 percent) and Ki-67 (70 percent vs. 0 percent). During a mean follow-up of 31.6 months, 5 (12.2 percent) patients developed six episodes of recurrent cancer. Endoscopic mucosal resection specimens did not show any significant difference in the p53 and Ki-67 expression for patients developing cancer after endoscopic treatment. CONCLUSIONS: p53 and Ki-67 immunohistochemistry were useful to confirm the cancer; however, they had not value for predicting the recurrent carcinoma after circumferential endoscopic mucosal resection of Barrett's carcinoma.

RACIONAL: Há situações nas quais o material obtido após mucosectomia endoscópica do adenocarcinoma superficial do esôfago de Barrett é inadequado para avaliação histopatológica de suas margens. Nesses casos, a imunoistoquímica poderia ser de auxílio para predição da recurrência tumoral. OBJETIVO: Avaliar o valor da detecção imunoistoquímica da p53 e do Ki-67 na predição da recurrência tumoral após mucosectomia endoscópica circunferencial do câncer no esôfago de Barrett. MÉTODOS: Foi analisado o material proveniente de mucosectomias de 41 pacientes. Todas as biopsias endoscópicas pré-mucosectomia apresentavam displasia de alto grau e câncer foi detectado em 23 casos. A imunorreatividade foi definida pela coloração de, pelo menos, 90 por cento dos núcleos em cada campo de grande aumento, podendo ser classificada como superficial ou difusa, conforme a distribuição celular dos núcleos corados. RESULTADOS: A mucosectomia detectou o câncer em 21 casos. Nesses casos, a p53 revelou padrão difuso de positividade para a maioria dos casos (90,5 por cento vs. 20 por cento) e o Ki-67 demonstrou padrão difuso para todos os portadores de câncer (100 por cento vs. 30 por cento). Por sua vez, pacientes sem câncer revelaram padrão negativo ou apenas superficial para a p53 (80 por cento vs. 9,5 por cento) e para o Ki-67 (70 por cento vs. 0 por cento). Durante seguimento médio de 31,6 meses, cinco (12,2 por cento) pacientes apresentaram seis episódios de câncer recurrente. Neste grupo, os fragmentos de mucosectomia não demonstraram nenhuma diferença significativa na expressão imunoistoquímica da p53 e do Ki-67 nos pacientes desenvolvendo câncer após o tratamento endoscópico. CONCLUSÕES: A imunoistoquímica da p53 e do Ki-67 é útil na confirmação do câncer; contudo não demonstra nenhum valor na predição da recurrência tumoral após mucosectomia endoscópica circunferencial do esôfago de Barrett com adenocarcinoma.

Experience with staged mucosal advancement anoplasty for high trans-sphincteric fistula-in-ano / Experiencia con la anoplastia por avance de colgajo de mucosa para la fístula anal transesfintérica

Successful eradication of a complicated, recurrent fistula-in-ano with maintenance of anal continence, requires a specialized surgical approach. Mucosal advancement anoplasty is associated with acceptably low rates of recurrence and continence and is reported in this small series of 11 patients where it followed preliminary deployment of a loose guiding and drainage seton. The technique was also supplemented by internal anal sphincter repair at the time of the advancement anoplasty. Success was achieved in nine cases without any effect on reported continence.

La erradicación exitosa de la fístula anal complicada, recurrente, con mantenimiento de la continencia anal, requiere un abordaje quirúrgico especializado. La anoplastia por avance de colgajo de mucosa esta asociada con tasas aceptablemente bajas de recurrencia y continencia, y se reporta en esta pequeña serie de 11 pacientes, en la que a continuación se produjo el uso preliminar de un sedal (setón) de drenaje y laxo de guía. La técnica fue también complementada por la reparación del esfínter anal interior en el momento de la anoplastia de avance. Se logró éxito en nueve casos sin efectos sobre la continencia reportada.