Distal resection margins in rectal cancer specimens: differences in assessment between surgeons and pathologists and the influence of neoadjuvant chemoradiation.

To investigate the discrepancy between the distal resection margin (DRM) assessed by surgeons and pathologists, and the impact of neoadjuvant chemoradiotherapy (nCRT) on DRM. This study included 67 rectal cancer patients undergoing elective surgery. DRMs were assessed through four different techniques: in vivo subjective estimative, made by the surgeon before the rectal resection (by palpation and visual estimative); in vivo objective, measured with a ruler before the rectal transection; ex vivo objective, measured right after resection of the specimen; post-fixation objective measurement, conducted by the pathologist. The DRMs subjectively and objectively assessed by the surgeons were not significantly different (3.40 cm vs. 3.45 cm). There was a mean reduction in the length of DRMs of 35.6%, from 3.45 cm objectively measured by the surgeon to 2.20 cm measured by the pathologist. This difference was significant among patients that did not receive nCRT (3.90 cm vs. 2.30 cm, P < 0.001), but not among those who received nCRT (2.30 vs. 2.05 cm). Surgeons are accurate in assessing rectal cancer DRMs. There are significant differences between intraoperative measurements of DRMs and the final pathologic results. However, these differences are not seen when nCRT is used, a finding that may be useful when sphincter preservation is being considered.

Indocyanine green fluorescent dye during bowel surgery: are the blood supply "guessing days" over?

Assessing the blood supply of the bowel is a difficult task even for experienced surgeons. Laser-assisted indocyanine green (ICG) fluorescent dye angiography provides intraoperative visual assessment of blood flow to the bowel wall and surrounding tissues, allowing for modification to the surgical plan, which can reduce the risk of postoperative complications. ICG angiography was prospectively performed in a single center during a 1-year period for small bowel ischemia and left colorectal resections. ICG angiography played a major role in the intraoperative decision making in 4 of 160 patients, whose clinical and operative details are here reported. In case of acute small intestine ischemia, resection is not warranted unless absolute perfusion units are below 19 (relative 21%). When evaluating blood supply to the left colon prior to anastomosing, resection is recommended with absolute units lower than 18 (relative 31%) even if the bowel appears macroscopically perfused.

Intracorporeal ileocolic anastomosis: a review.

This study is a narrative review of the current literature regarding intracorporeal ileocolic anastomosis in laparoscopic right colon resection for benign or malignant diseases of the right colon and terminal ileum. The search strategy included Medline, Embase, CINAHL, ACP Journal Club, and Cochrane databases with laparoscopic right colectomy and intracorporeal anastomosis as keywords. All retrieved references were screened by two independent blinded reviewers. Thirteen papers including 611 patients undergoing laparoscopic right colon resection with intracorporeal ileocolic anastomosis for benign or malignant diseases of the right colon and terminal ileum were identified. There were eight case series and five case control studies. Anastomoses were fashioned as antiperistaltic or isoperistaltic, totally stapled or stapled/handsewn. The mesenteric defect was mostly left open. Overall operating time ranged from 53 to 360 min. The most common specimen extraction site locations were periumbilical, suprapubic, or transvaginal with a median incision length ranging from 3 to 6 cm. The overall rate of surgical site infection was 2.7 %. The anastomotic leak rates varied from 0 to 8.5 %. Postoperative mortality was 0.12 %. Intracorporeal ileocolic anastomosis following laparoscopic resection of the right colon is not commonly performed, but offers potential benefits if carried out by experienced surgeons in selected patients.

[Temporary total fecal diversion--ultimate solution for complex recurrent anal fistula]. / Colostomie terminala temporara--solutie extrema într-un caz de fistula perianala complexa multirecidivata.

Anal fistula is a frequent disease, but complex fistulae are relatively uncommon. The treatment for this pathology remains debated all over the world, and in cases of complex fistulae represents a challenge. We present a 55 years old male, operated more than 40 times in the last 15 years for perianal recurrent fistulas and abscesses. The fistula has had a progressive evolution despite all kind of surgery and has extended finally to entire perineal and gluteal region; more than 30 orifices were founded on skin surface and many internal anorectal orifices as well. The patient is weakened, anemic, in chronic sepsis. As a last resort, we decided to perform a terminal fecal diverting stoma at the level of sigmoid colon, with closure of distal end. There were subsequent operations necessary to resolve perineal and gluteal disease: extensive excisions of altered tissues, various full-thickness skin grafts and covering flaps. After 12 months the perineal region was clean, so remaking of colic continuity was possible. Continuous follow-up until 12 months revealed no sign of recurrence. We conclude that temporary total fecal diversion followed by wide excisions of perianal fistulous tissues represents an ultimate solution to complex recurrent perianal fistula, with good results at least in our case.

Massive zosteriform cutaneous metastasis from rectal carcinoma.

A 44-year-old man presented with a large and rapidly growing skin lesion approximately six months after resection of a rectal carcinoma. The lesion measured 40 cm in size, extended from the suprapubic area to the proximal half of the left groin, and showed a particular zosteriform aspect. Biopsy confirmed a metastatic skin adenocarcinoma. Cutaneous metastases from rectal cancer are very uncommon. Their gross appearance is not distinctive, although the skin tumors are usually solid, small (less than 5 cm) and painless nodules or papules. Early biopsies for suspicious skin lesions are needed in patients with a history of colorectal cancer.

[Magnifying colonoscopy in the diagnosis of colorectal carcinoma invading the submucosa in familial adenomatous polyposis]. / Colonoscopia com magnificação de imagem no diagnóstico de carcinoma colorretal invasivo da submucosa na polipose adenomatosa familiar.

The development of colonoscopy with image magnification has enable to study the colonic mucosa in detail and to do differential diagnosis between neoplastic and non-neoplastic lesions from the observation of pit patterns. The results are comparable to stereomicroscopy being possible to predict the histologic diagnosis. In a patient with familial adenomatous polyposis magnifying colonoscopy was performed and this method demonstrated a wide variation of benign polypoid lesions and the morphological features of early colorectal cancer. In this patient, the evaluation by image magnification, together with indigo carmin 0.4% chromoscopy, showed a wide variety of lesions in the colon and rectum: laterally spreading tumor in the cecum, with IIIL + IV pits, subpediculate polyp in the transverse colon with approximately 2.0 cm diameter and IV + V pits, flat elevated lesions IIIL type, and in the sigmoid colon IIa + IIc lesion with V type of Kudo's classification were observed. The evaluation of pit patterns of the lesions in the transverse and sigmoid colon has enable to do the endoscopic diagnosis of the lesion with submucosal invasion.

[Resection of a laterally spreading tumor by strip biopsy]. / Ressecção de "laterally spreading tumor" por "strip biopsy".

A male white patient 58 years-old was submitted to colonoscopy for follow-up of surgical resection of an advanced colorectal carcinoma 33 months ago. Small polyps were observed in the colons and histopathological examination proved to be tubular adenomas with moderate dysplasia. At the hepatic flexure of the transverse colon a large flat-elevated laterally spreading tumor measuring 2.5 cm in diameter was observed. After spraying of methilene-blue 0.1% the margins of the lesion were demarcated and following saline injection under the lesion it was completely resected in one single procedure. Histologically, the lesion was diagnosed as intramucosal adenocarcinoma.