Resección transmural endoscópica de adenoma colónico residual con fibrosis / Endoscopic full-thickness resection of residual colonic adenoma with fibrosis

Resumen La resección transmural endoscópica es una técnica que permite la resección en bloque de lesiones colónicas en pacientes en los cuales han fracasado los métodos endoscópicos convencionales como la resección mucosa endoscópica o la disección submucosa endoscópica. Presentamos el caso de un hombre de 75 años con antecedentes de adenoma de colon con fibrosis debido a dos intentos previos fallidos de resección endoscópica en otra institución. Realizamos con éxito el procedimiento de resección transmural endoscópica evitando así una cirugía.

Abstract Endoscopic full-thickness resection is a technique that allows in block resection of colonic lesions in patients in whom conventional endoscopic methods such as endoscopic mucosal resection or endoscopic submucosal dissection have failed. We present a case of a 75-year-old man with history of a difficult-to-resect colon adenoma. He had undergone two previous failed attempts of endoscopic mucosal resection due to non-lifting sign in another center. We successfully performed an endoscopic full-thickness resection procedure, avoiding unnecessary surgery.

Surgical and postoperative evaluations of rectal adenomas excised with a rigid proctoscope

Abstract Purpose This study presents the surgical and postoperative results achieved with a rigid proctoscope using the transanal endoscopic technique to excise rectal adenomas. The results are compared to the results obtained with other currently employed transanal techniques. Methods We investigated the medical records of patients who underwent transanal endoscopic operations from April 2000 to June 2018 at two tertiary referral centers for colorectal cancer. Results This study included 99 patients. The mean age was 65.3 ± 13.3 years. The average size of the adenomas was 4.6 ± 2.3 cm, and their average distance to the anal border was 5.6 ± 3.3 cm. The average operative time was 65.3 ± 41.7 min. In 48.5% of the operations, the specimen was fragmented, and in 59.6% of the cases, the microscopic margins were free. The rates of postoperative complications and relapse were 5% and 19%, respectively. The mean follow-up was 80 ± 61.5 months. Conclusions The described proctoscope proved to be a viable technique with results similar to other techniques, with the advantage that it allowed greater accessibility for surgeons. Therefore, its use could be implemented and become widespread in surgical practice.

Adenomas hipofisarios en pacientes añosos / Pituitary adenomas in elderly patients

Se evaluó la presentación clínica, tratamiento y sus resultados durante el seguimiento prolongado de 37 pacientes mayores de 65 años con adenomas hipofisarios, y sus causas de muerte. El estudio fue retrospectivo y transversal. La prevalencia de incidentalomas fue 43% (16), macroadenomas 70.3% (26) y adenomas gigantes 16.2% (6). El fenotipo tumoral más frecuente fue el adenoma no funcionante (76%). La prevalencia de alteraciones en el campo visual y síntomas neurológicos fue 56% y 57% respectivamente. El 54% tuvo función hipofisaria normal, deficiencia parcial el 30% y panhipopituitarismo el 16%. Fueron tratados 32, 5 se perdieron en el seguimiento sin recibir tratamiento. Indicamos cirugía en 18. De los operados por vía transesfenoidal, el 23% tuvo complicaciones postquirúrgicas y el 54% mejoría del campo visual. Por vía transcraneal el 50% sufrió complicaciones post quirúrgicas y el 33% mejoró el campo visual. Durante el seguimiento (55.1 ± 48.7 meses) no observamos recrecimiento tumoral, excepto en un adenoma gigante. Cuatro pacientes operados murieron, dos por causas al tumor. Catorce no fueron operados, 11 con adenomas no funcionantes y campo visual normal fueron controlados periódicamente y 3 con adenomas funcionantes recibieron tratamiento médico. No observamos crecimiento tumoral durante el seguimiento (43.7 ± 38.1 meses). No observamos crecimiento tumoral en adenomas no funcionantes y campo visual normal, por lo que sugerimos conducta expectante y control periódico. Cuando existe alteración del campo visual, la cirugía transesfenoidal es segura y efectiva. En los adenomas secretantes y dependiendo de las comorbilidades, sería apropiado optar por tratamiento médico.

Clinical presentation, treatment and its results were evaluated during long-term follow-up of 37 patients older than 65 years with pituitary adenoma. Causes of death were also evaluated. It was a retrospective and cross-sectional study. Prevalence of incidentalomas was 43% (16), macroadenomas 70.3% (26) and giant adenomas 16.2% (6). The most frequent tumor phenotype was the non-functioning adenoma (76%). The prevalence of visual field defects and neurological symptoms was 56% and 57% respectively. We found normal pituitary function in 54%, partial deficiency in 30% and panhypopituitarism in 16%. Thirty-two patients were treated, 5 were lost to follow-up without receiving treatment. Surgery was indicated in 18. Of those operated by trans-sphenoidal approach, 23% had postsurgical complications and 54% improved the visual field. By trans-craneal approach, 50% had post-surgical complications and 33% visual field improvement. During follow-up (55.1 ± 48.7 months) no tumor regrowth was observed, except in a giant adenoma. Four operated patients died, two due to causes related to tumor. Fourteen were not operated, 11 with non-functioning adenoma and normal visual field were periodically controlled and 3 with secreting adenomas received medical treatment. No tumor growth was observed during follow-up (43.7 ± 38.0 months). We did not observe tumor progression in elderly patients with non-functioning adenoma and normal visual field, so we suggest watchful approach and periodic control. When there are visual field defects, trans-sphenoidal surgery can be considered safe and effective. In secreting adenomas and depending on the associated comorbidities, medical treatment would be the appropriate approach.

Pituitary adenomas in elderly patients

Clinical presentation, treatment and its results were evaluated during long-term follow-up of 37 patients older than 65 years with pituitary adenomas. Causes of death were also evaluated. It was a retrospective and cross-sectional study. Prevalence of incidentalomas was 43% (16), macroadenomas 70.3% (26) and giant adenomas 16.2% (6). The most frequent tumor phenotype was the non-functioning adenoma (76%). The prevalence of visual field defects and neurological symptoms was 56% and 57%, respectively. We found normal pituitary function in 54%, partial deficiency in 30% and panhypopituitarism in 16%. Thirty-two patients were treated, 5 were lost to follow-up without receiving treatment. Surgery was indicated in 18. Of those operated by trans-sphenoidal approach, 23% had postsurgical complications and 54% improved the visual field. By trans-craneal approach, 50% had post-surgical complications and 33% visual field improvement. During follow-up (55.1 ± 48.7 months) no tumor regrowth was observed, except in a giant adenoma. Four operated patients died, two due to causes related to tumor. Fourteen were not operated, 11 with non-functioning adenomas and normal visual field were periodically controlled, and 3 with secreting adenomas received medical treatment. No tumor growth was observed during follow-up (43.7 ± 38.1 months). We did not observe tumor progression in elderly patients with non-functioning adenomas and normal visual field, so we suggest watchful approach and periodic control. When there are visual field defects, trans-sphenoidal surgery can be considered safe and effective. In secreting adenomas and depending on the associated comorbidities, medical treatment would be the appropriate approach.

Se evaluó la presentación clínica, tratamiento y sus resultados durante el seguimiento prolongado de 37 pacientes mayores de 65 años con adenomas hipofisarios, y sus causas de muerte. El estudio fue retrospecti vo y transversal. La prevalencia de incidentalomas fue 43% (16), macroadenomas 70.3% (26) y adenomas gigantes 16.2% (6). El fenotipo tumoral más frecuente fue el adenoma no funcionante (76%). La prevalencia de alteraciones en el campo visual y síntomas neurológicos fue 56% y 57% respectivamente. El 54% tuvo función hipofisaria normal, deficiencia parcial el 30% y panhipopituitarismo el 16%. Fueron tratados 32, 5 se perdieron en el seguimiento sin recibir tratamiento. Indicamos cirugía en 18. De los operados por vía transesfenoidal, el 23% tuvo complicaciones postquirúrgicas y el 54% mejoría del campo visual. Por vía transcraneal el 50% sufrió complicaciones post quirúrgicas y el 33% mejoró el campo visual. Durante el seguimiento (55.1 ± 48.7 meses) no observamos recrecimiento tumoral, excepto en un adenoma gigante. Cuatro pacientes operados murieron, dos por causas al tumor. Catorce no fueron operados, 11 con adenomas no funcionantes y campo visual normal fueron controlados periódicamente y 3 con adenomas funcionantes recibieron tratamiento médico. No observamos crecimiento tumoral durante el seguimiento (43.7 ± 38.1 meses). No observamos crecimiento tumoral en adenomas no funcionantes y campo visual normal, por lo que sugerimos conducta expectante y control periódico. Cuando existe alteración del campo visual, la cirugía transesfenoidal es segura y efectiva. En los adenomas secretantes y dependiendo de las comorbilidades, sería apropiado optar por tratamiento médico.

Validation of classic and expanded criteria for endoscopic submucosal dissection of early gastric cancer: 7 years of experience in a Western tertiary cancer center

OBJECTIVE: Our aim was to evaluate the Japan Gastroenterological Endoscopy Society criteria for endoscopic submucosal resection of early gastric cancer (EGC) based on the experience in a Brazilian cancer center. METHODS: We included all patients who underwent endoscopic submucosal resection for gastric lesions between February 2009 and October 2016. Demographic data and information regarding the endoscopic resection, pathological report and follow-up were obtained. Statistical calculations were performed with Fisher's exact test and chi-square tests, with 95% confidence intervals. RESULTS: In total, 76% of the 51 lesions were adenocarcinomas, 16% were adenomas, and 8% had other diagnoses. The average size was 19.9 mm (±11.7). The average procedure length was 113.9 minutes (±71.4). The complication rate was 21.3%, with only one patient who needed surgical treatment (transmural perforation). Among the adenocarcinomas, 39.5% met the classic criteria for curability, 31.6% met the expanded criteria and 28.9% met the criteria for noncurative resection. Analysis of the indication criteria and curability revealed differences among cases with "only-by-size" expanded criteria (64.28%), other expanded criteria (40%) and classic criteria (89.47%), with a p-value of 0.049. During follow-up (15.8 months; ±14.3), 86.1% of the EGC patients had no recurrence. When well-differentiated and poorly differentiated lesions or lesions included in the classic and expanded criteria were compared, there were no differences in recurrence. The noncurative group presented a higher recurrence rate than the classic group (p=0.014). CONCLUSION: These results suggest that the Japanese endoscopic submucosal resection criteria might be useful for endoscopic treatment of EGC in Western countries.

Treatment of acromegaly patients at the Federal University of Triângulo Mineiro (UFTM): Experience Report

OBJECTIVE: To evaluate the effectiveness of the treatment of acromegaly patients at the Federal University of Triangulo Mineiro. METHODS: Cross-sectional and retrospective study of thirty cases treated over a period of two decades. RESULTS: 17 men (56.7%) aged 14-67 years and 13 women aged 14-86 years were analyzed. Twenty-one patients underwent transphenoidal surgery, whichwas associated with somatostatin receptor ligands in 11 patients (39.3%), somatostatin receptor ligands + radiotherapyin 5 patients (17.8%), radiotherapy in 3 patients (10.7%), and radiotherapy + somatostatin receptorligands + cabergoline in 1 patient (3.6%). Additionally, 2 patients underwent radiotherapy and surgeryalone. Six patients received somatostatin receptor ligands before surgery, and 2 were not treated due to refusal and death. Nine patients have died, and 20 are being followed; 13 (65%) have growth hormonelevels o1 ng/mL, and 11 have normal insulin-like growth factor 1 levels. CONCLUSION: The current treatment options enable patients seen in regional reference centers to achieve strict control parameters, which allows them to be treated close to their homes.

Cirugía hipofisiaria endoscópica transesfenoidal, con realización de colgajo nasoseptal: evaluación del impacto de la técnica en la olfación:. serie de casos / Endoscopic pitituary surgery transsphenoidal, with nasoseptal flap: assessment of the impact of the technique in the olfaction: cases series

Introducción: La cirugía endoscópica transesfenoidal en la exéresis de patología hipofisaria ha sido ratificada dentro de la mejores opciones para conseguir abordajes exitosos. Para cerrar la brecha ósea, se puede utilizar el colgajo nasoseptal, el cual lograría un cierre adecuado y seguro, evitando complicaciones como persistencia de fístulas de líquido cefalorraquídeo. Dentro de los probables efectos secundarios de este colgajo se señala la presencia de anosmia o hiposmia. Objetivo: Nuestro objetivo es mostrar los resultados obtenidos empleando la técnica del colgajo nasoseptal y la evaluación del olfato posoperatorio. Material y método: Incluimos 14 pacientes con diagnóstico de adenoma hipofisiario intervenidos en nuestro servicio entre diciembre 2014 a diciembre 2015. Se evaluaron diversos parámetros entre otros, olfatometría pre y posoperatorias. A todos se les realizó la técnica endoscópica transesfenoidal. Efectuando la disección del colgajo con la técnica tipo Hadad. La exéresis tumoral fue realizada por neurocirujano, se cubrió la osteotomía con este colgajo. Resultados: De los 14 pacientes, 13 llegaron al estado olfativo preoperatorio. 1 paciente se mantuvo hipósmico mantenidamente. En nuestro estudio, no hemos encontrado deterioro significativo en la calidad del sentido del olfato. Así como tampoco observamos otras complicaciones. Conclusiones: Esta experiencia aún inicial, estimamos que podría ya esbozar una tendencia de mantención de la función olfativa en este tipo de cirugía.

Introduction: Transsphenoidal endoscopic surgery resection of pituitary pathology has been ratified within the best options for successful approaches. To close the gap bone, you can use the nasoseptal flap, which achieved an adequate and secure closure, preventing complications such as persistent cerebrospinal fluid leaks. Among possible side effects of this flap anosmia-hyposmia noted. Aim: Our goal is to show the results obtained using the technique of nasoseptal flap and postoperative evaluation of smell. Material and method: We included 14 patients with a diagnosis of pituitary adenoma surgery in our department between December 2014 to December 2015. Various parameters were evaluated pre and post operative, specially olfactory function. All underwent transsphenoidal endoscopic technique. Performing dissection flap with the technical type Hadad. The tumor resection was performed by neurosurgeon, osteotomy covered with this flap. Results: Of the 14 patients, 13 reached the olfactory preoperative state. 1 patient remained with hyposmia. In our study, we found no significant deterioration in the quality of the sense of smell. Not other complications were found. Conclusions: This is an initial experience, and we estimate that could outline a trend of maintaining olfactory function in this surgery approach.

Endoscopic combined “transseptal/transnasal” approach for pituitary adenoma: reconstruction of skull base using pedicled nasoseptal flap in 91 consecutive cases / O acesso endoscópico transeptal/transnasal em cirurgias de resseção de adenoma de hipófise: reconstrução da base do crânio combinado com a criação do flap naso-septal pediculado em 91 pacientes consecutivos

Objective The purpose of this study was to describe the endoscopic combined “transseptal/transnasal” approach with a pedicled nasoseptal flap for pituitary adenoma and skull base reconstruction, especially with respect to cerebrospinal fluid (CSF) fistula.Method Ninety-one consecutive patients with pituitary adenomas were retrospectively reviewed. All patients underwent the endoscopic combined “transseptal/transnasal” approach by the single team including the otorhinolaryngologists and neurosurgeons. Postoperative complications related to the flap were analyzed.Results Intra- and postoperative CSF fistulae were observed in 36 (40%) and 4 (4.4%) patients, respectively. Among the 4 patients, lumbar drainage and bed rest healed the CSF fistula in 3 patients and reoperation for revision was necessary in one patient. Other flap-related complications included nasal bleeding in 3 patients (3.3%).Conclusion The endoscopic combined “transseptal/transnasal” approach is most suitable for a two-surgeon technique and a pedicled nasoseptal flap is a reliable technique for preventing postoperative CSF fistula in pituitary surgery.

Objetivo O objetivo deste estudo foi descrever o acesso endoscópico transeptal/transnasal combinado com a criação do flap naso-septal pediculado para reconstrução da base do crânio em cirurgias de resseção de adenoma de hipófise, especialmente nos casos que ocorrem fístula líquido cefalorraquidiano (FLC).Método Noventa e um pacientes consecutivos portadores de adenoma de hipófise foram retrospectivamente revisados. Complicações pós-operatórias relacionadas ao flap foram analisadas.Resultados Fístulas líquido cefalorraquidiano intra e pós-operatórias foram observadas em 36 (40%) e 4 (4,4%) dos pacientes, respectivamente. Entre os 4 pacientes, drenagem lombar e repouso absoluto foram suficientes para o fechamento da fístula e intervenção cirúrgica foi necessária em apenas um paciente. Outra complicação relacionada ao flap foi o sangramento em 3 (3,3%) dos pacientes.Conclusão O acesso endoscópico transeptal/transnasal combinado é melhor aplicado quando realizado por dois cirurgiões e o flap naso-septal é uma técnica eficaz para prevenção de fístula pós-operatória em cirurgias de hipófise.

Endoscopic transnasal approach for removing pituitary tumors / Acesso transnasal endoscópico para remoção de tumores da hipófise

To describe a series of 129 consecutive patients submitted to the resection of pituitary tumors using the endoscopic transsphenoidal approach in a public medical center. Method: Retrospective analysis based on the records of patients submitted to the resection of a pituitary tumor through the endoscopic transsphenoidal approach between 2004 and 2009. Results: One hundred and twenty-nine records were analyzed. The tumor was non-secreting in 96 (74.42%) and secreting in 33 patients (22.58%). Out of the secretory tumors, the most prevalent was the growth hormone producer (7.65%), followed by the prolactinoma, (6.98%). Eleven patients developed cerebral spinal fluid (CSF) fistulas, and four of them developed meningitis. One patient died due to intracerebral hemorrhage in the postoperative period. Conclusion: The endoscopic transsphenoidal approach to sellar tumors proved to be safe when the majority of the tumors were non-secreting. The most frequent complication was CSF. This technique can be done even in a public hospital with financial limits, since the health professionals are integrated. .

Descrever uma série de 129 pacientes submetidos à ressecção de tumor de hipófise com acesso endoscópico transesfenoidal em um serviço de público referência em Belo Horizonte. Método: Análise retrospectiva realizada por análise dos prontuários de pacientes submetidos à ressecção de tumor de hipófise com acesso endoscópico transesfenoidal entre os anos 2004 e 2009. Resultados: Foram avaliados 129 prontuários. O tumor era não secretante em 96 (74,42%) e secretante em 33 pacientes (22,58%). Dos tumores secretores, o de maior prevalência foi o produtor de hormônio do crescimento: 15 pacientes (7,65%). Onze pacientes desenvolveram fístula liquórica. Um paciente faleceu devido hemorragia intracerebral no pós-operatório. Conclusão: O acesso endoscópico transfenoidal aos tumores selares mostrou-se seguro numa população em que a maioria dos tumores era não secretante. A principal complicação encontrada foi fístula liquórica. Esta técnica é passível de utilização em hospital público mesmo com limites financeiros desde que haja integração multiprofissional. .

Ressecção endoscópica transesfenoidal de adenomas de hipófise: avaliação preliminar de pacientes consecutivos / Endoscopic endonasal transsphenoidal resection of pituitary adenomas: preliminary evaluation of consecutive cases

Introdução: A cirurgia endoscópica endonasal ganhou aceitação crescente por otorrinolaringologistas e neurocirurgiões. Em muitos centros, esta técnica é agora rotineiramente utilizada para as mesmas indicações que a técnica microcirúrgica convencional. Objetivo: Descrever resultados cirúrgicos relativos à remissão hormonal, ressecção do tumor e complicações de série consecutiva de pacientes com adenoma da hipófise submetidos à ressecção endoscópica. Método: Estudo de série de pacientes consecutivos com adenomas da hipófise, submetidos à cirurgia endoscópica endonasal, avaliados quanto à taxa de tumor residual, remissão funcional, sintomas, complicações e o tamanho do tumor. Resultados: De 47 pacientes consecutivos, 17 eram portadores de adenomas funcionantes, sete produtores de GH, cinco com doença de Cushing e cinco prolactinomas. Dos adenomas funcionantes, 12 foram macroadenomas, cinco microadenomas, e 30 macroadenomas não funcionantes. Dos adenomas funcionantes, 87% melhoraram. Em relação ao déficit visual, 85% melhoraram ao longo do tempo. A maioria dos pacientes que apresentou queixas de cefaléia melhorou (76%). Complicações cirúrgicas ocorreram em 10% dos pacientes, com duas lesões da carótida, duas fístulas liquóricas e uma fatalidade em um paciente com um histórico complicado. Conclusão: A cirurgia hipofisária endoscópica endonasal é uma técnica viável, rendendo bons resultados cirúrgicos e funcionais e baixa morbidade. .

Introduction: Endoscopic endonasal transsphenoidal surgery has gained increasing acceptance by otolaryngologists and neurosurgeons. In many centers throughout the world, this technique is now routinely used for the same indications as conventional microsurgical technique for pituitary tumors. Objective: To present a surgical experience of consecutive endoscopic endonasal trans-sphenoidal resections of pituitary adenomas. Methods: In this study, consecutive patients with pituitary adenomas submitted to endoscopic endonasal pituitary surgery were evaluated regarding the rate of residual tumor, functional remission, symptoms relief, complications, and tumor size. Results: Forty-seven consecutive patients were evaluated; 17 had functioning adenomas, seven had GH producing tumors, five had Cushing's disease, and five had prolactinomas. Of the functioning adenomas, 12 were macroadenomas and five were microadenomas; 30 cases were non-functioning macroadenomas. Of the patients with functioning adenomas, 87% improved. 85% of the patients with visual deficits related to optic nerve compression progressed over time. Most of the patients with complaints of headaches improved (76%). Surgical complications occurred in 10% of patients, which included with two carotid lesions, two cerebrospinal fluid leaks, and one death of a patient with a previous history of complications. Conclusion: Endoscopic endonasal pituitary surgery is a feasible technique, yielding good surgical and functional outcomes, and low morbidity. .

Clinical and laboratorial characterization and post-surgical follow-up of 87 patients with non-functioning pituitary macroadenomas / Caracterização clínica e laboratorial e seguimento pós-cirúrgico de 87 portadores de macroadenomas hipofisários não funcionantes

Objective: It was to assess the main characteristics of patients undergoing pituitary tumor surgery. Method: Eighty-seven patients (44 men; 44.8±13 years old) were included. Results: The main symptoms were visual alterations (87.3%), headache (70.1%), diminished libido (34.4%), galactorrhea (22.9%) and hair loss (19.5%). The axes affected were gonadotropic (72.6%), thyrotropic (48.4%) and corticotropic (38.7%), without significant changes after surgery. The average largest tumor diameter was 3.1 cm before surgery and 1.56 cm after surgery. The most frequent postoperative complications were hydro-electrolyte and acid-base disorders (12%), diabetes insipidus (9%), visual field alterations (9%), liquoric fistula (8%) and nasal obstruction (7%). The patients were affected by more than one complication. Conclusion: Although a decrease in tumor volume was achieved through surgery, hormonal deficiencies persisted in most of the patients and new surgical approaches were necessary for dealing with tumor recurrence or persistence. .

Objetivo: Avaliar as principais características de pacientes operados de tumor de hipófise. Método: Foram incluídos 87 pacientes (44 homens; 44,8±13 anos). Resultados: Os principais sintomas foram alterações visuais (87,3%), cefaleia (70,1%), diminuição da libido (34,4%), galactorreia (22,9%) e queda de pelos (19,5%). Os eixos afetados foram gonadotrófico (72,6%), tireotrófico (48,4%) e corticotrófico (38,7%). Não houve mudanças significativas após a cirurgia. A média do maior diâmetro do tumor foi 3,1 cm antes da cirurgia e 1,56 cm após a cirurgia. As complicações pós-cirúrgicas mais frequentes foram distúrbios hidroeletrolíticos e ácido-básicos (12%), diabetes insipidus (9%), alterações do campo visual (9%), fístula liquórica (8%) e obstrução nasal (7%). Ocorreu mais de uma complicação no mesmo paciente. Conclusão: Embora tenha obtido diminuição da massa tumoral com a cirurgia, as deficiências hormonais persistiram na maioria dos pacientes e ocorreu necessidade de novas abordagens por recidiva ou persistência do tumor. .

La secuencia adenoma-carcinoma, consideraciones clínicas, patológicas y de vigilancia endoscópica / The adenoma-carcinoma sequence. Clinical, pathological and endoscopic surveillance

A case of a 84 year-old woman with a history of colonoscopy performed in May 2008, where a 5 mm polyp was detected from the hepatic flexure. It was removed by biopsy and histology showed a tubular adenoma with low-grade dysplasia. In May 2011, the patient consulted due to mild to moderate pain in both hypochondria of 6 months of duration accompanied by bloating and belching. A control colonoscopy was indicated, which was held in June 2011, and showed a 2 cm polyp in ascending colon, this was resected with polypectomy snare. In the vicinity there was a 3-mm polyp that was removed with biopsy forceps. Histological examination showed in the bigger lesion a moderately differentiated grade 2 invasive tubular adenocarcinoma, with superficial and focal invasion of the submucosa, developed in adenoma with free surgical margin (1.7 mm), no vascular, lymphatic invasion or tumor budding were found. The smaller lesion was reported as tubular adenoma with low grade dysplasia. Colorectal cancer epidemiology, indications for controls after colonoscopic polypectomy of adenomas, especially those at high risk, histopathological risk factors for adenocarcinomas developed in adenomas and the need to monitor these patients annually with occult blood test stool are discussed between the control colonoscopies indicated.

Se presenta el caso de una mujer de 84 años, con antecedentes de colonoscopia efectuada en mayo de 2008 donde se le detectó un pólipo de 5 mm del ángulo hepático del colon, el que fue extraído por biopsia y cuyo estudio histológico demostró un adenoma tubular con displasia de bajo grado. En mayo de 2011, consulta por dolor leve a moderado en ambos hipocondrios de 6 meses de evolución acompañados de meteorismo y eructos. Se indicó ileocolonoscopia, la que se realizó en junio de 2011 y demostró un pólipo del colon ascendente de 2 cm, que fue resecado con asa de polipectomía; y cercano a éste, un pólipo de 3 mm que se extirpó con pinza biopsia. El examen histológico informó adenoma tubular con displasia moderada en la lesión de menor tamaño y adenocarcinoma tubular invasor moderadamente diferenciado grado 2 de Broders, con invasión focal superficial de la submucosa, desarrollado en adenoma. Límites quirúrgicos libres de lesión, sin invasión vascular sanguínea, linfática ni budding tumoral con límite quirúrgico profundo a 1,7 mm de la lesión. Se comentan la epidemiología del cáncer rectocolónico, la indicación de los controles colonoscópicos luego de la polipectomía de los adenomas, en especial de aquellos de alto riesgo, los factores de riesgo anatomopatológicos de carcinomas desarrollados en adenomas, y la necesidad de controlar anualmente a estos pacientes con colonoscopias de vigilancia.

Endoscopic endonasal transsphenoidal approach for pituitary adenomas: technical aspects and report of casuistic / Abordagem endoscópica endonasal para adenomas de hipófise: aspectos técnicos e relato de casuística

OBJECTIVE: Analyse technical aspects, effectiveness and morbidity of the endoscopic endonasal transphenoidal approach for pituitary adenomas. METHOD: From January 2005 to September 2008, 30 consecutive patients underwent endoscopic endonasal resection of pituitary adenomas with a follow up from 3 to 36 months. Their medical charts were retrospectively analysed. RESULTS: There were 18 women and 12 men, mean age 44 years (range 17-65 yr). Among the 30 patients, 23 had macroadenomas and 7 microadenomas. Twelve patients had non-functioning tumors, 9 had ACTH-secreting tumors, 8 had GH-secreting tumors and 1 prolactinoma. Complete resection and hormonal control was achieved in all microadenomas. Macroadenomas were completely removed in 6 patients, subtotal resection in 6 and partial resection in 11. Three patients had diabetes insipidus and 5 had CSF leaks treated with lumbar drainage. CONCLUSION: The endonasal endoscopic approach for pituitary tumors is effective and has low morbidity.

OBJETIVO: Analisar aspectos técnicos, eficácia e morbidade do acesso transesfenoidal endonasal endoscópico para adenomas hipofisários. MÉTODO: Estudo retrospectivo de trinta pacientes consecutivos submetidos à ressecção endoscópica endonasal de adenomas hipofisários, entre janeiro de 2005 e setembro de 2008, com seguimento pós-operatório entre três e 36 meses. RESULTADOS: Foram operados 18 mulheres e 12 homens com idades variando entre 17 e 65 anos (média 44 anos). Entre os 30 casos operados, 23 eram macroadenomas e sete microadenomas. Doze pacientes apresentavam adenomas não-funcionantes, nove tumores secretores de ACTH, oito tumores secretores de GH e um prolactinoma. Ressecção macroscópica completa e controle endócrino foram conseguidos em todos microadenomas. Ressecção dos macroadenomas foi completa em seis pacientes, subtotal em seis e parcial em seis casos. Três pacientes desenvolveram diabetes insipidus e cinco tiveram fístula liqüórica pós-operatória controlada com drenagem lombar. CONCLUSÃO: A abordagem endoscópica endonasal para adenomas de hipófise é eficaz e apresenta baixa morbidade.

Mean intrasellar pressure, visual field, headache intensity and quality of life of patients with pituitary adenoma / Pressão intra-selar média, campo visual, intensidade de cefaléia e qualidade de vida em portadores de adenoma hipofisário

Intrasellar pressure (ISP) measurement technique has recently opened a new line of research in neuroendocrinology. The absolute and mean ISP values were investigated in 25 patients consecutively operated at the Brasilia University Hospital (DF). These data were correlated with serum prolactin levels, number of visual quadrant affected, tumor size, quality of life (measured through the SF-36 scale) and graded headache (measured through the HIT-6 scale). No correlation was observed. The p values were 0.887; 0.137; 0.892; 0.812 and 0.884; respectively. The HIT-6 values were inversely and moderately correlated with total RAND SF-36 and its mental and physical dimensions.

A técnica da medida da pressão intra-selar (PIS) abriu, recentemente, uma nova linha de pesquisa em neuroendocrinologia. O objetivo deste estudo foi aferir os valores absolutos da PIS e calcular a pressão intra-selar média (PIM) em uma população de 25 pacientes operados consecutivamente no Hospital Universitário de Brasília (DF). Não se observou correlação significativa entre a PIM e o número de quadrantes visuais comprometidos (p=0,137), área do tumor (p=0,892), nível de qualidade de vida mensurado pela escala SF-36 (p=0,812) e a presença e a intensidade da cefaléia mensurada pela escala HIT-6 (p=0,884). Contudo, o HIT-6 correlacionou-se de forma inversa e intensidade moderada com os valores de HIT-6 e suas dimensões mental e física.

Non-functioning pituitary adenomas: clinical feature, laboratorial and imaging assessment, therapeutic management and outcome / Adenomas hipofisários não-secretores: avaliações clínica, laboratorial, neuro-radiológica e evolução após tratamento

OBJECTIVE: This study is an updated review of a Southeast Brazilian experience NFPA, emphasizing clinical features, laboratorial and imaging assessment, therapeutic management and outcome. DESIGN AND METHODS: Retrospective study, in which 104 patients with NFPA were evaluated by the same team of endocrinologists and neurosurgeon. Patients underwent biochemical evaluation, radiological studies and visual field assessment. RESULTS: Hypopituitarism and neuro-ophthalmological defects were observed in 89 percent. We observed GH deficiency (81.4 percent), hypogonadism (63.3 percent), adrenal hypofunction (59.5 percent), hypothyroidism (20.4 percent), high (38.5 percent) and low (16.7 percent) prolactin levels. Preoperative imaging classified 93 percent of the tumors as macroadenomas. Extra-sellar expansion was observed in 83.8 percent. Varying degrees of visual disturbance were observed in 74 percent. Primary treatment was transsphenoidal surgery (75 percent). Clinical control was achieved with one surgery in 37.5 percent of patients. The majority of patients needed a second therapeutic approach, radiotherapy or other surgeries. Immunohistochemistry resulted negative for pituitary hormones in 43 percent. Improvement of neuro-ophthalmological symptoms was observed in 61 percent of the patients after treatment. CONCLUSIONS: Our data confirm elevated prevalence of mass effect and hypopituitarism in patients harboring NFPA. Recurrence due to invasion or incomplete resection of the tumor is quite common, which frequently leads to a second therapeutic option.

OBJETIVOS: Esse estudo é uma revisão atualizada em adenomas hipofisários não-secretores (AHNS), enfatizando características clínicas, avaliações laboratorial e neuro-radiológica, manejo terapêutico e desfecho. MÉTODOS: Estudo retrospectivo, em que 104 pacientes com AHNS foram avaliados pela mesma equipe de endocrinologistas e neurocirurgião. Os pacientes foram submetidos à avaliação bioquímica, a estudos radiológicos e à avaliação de campo visual. RESULTADOS: Hipopituitarismo e distúrbios neuro-oftalmológicos foram observados em 89 por cento. Observou-se deficiência de GH (81,4 por cento), hipogonadismo (63,3 por cento), hipofunção adrenal (59,5 por cento), hipotireoidismo (20,4 por cento), concentrações elevadas (38,5 por cento) e baixas (16,7 por cento) de prolactina. Imagens pré-operatórias classificaram os tumores em sua maioria como macroadenomas (93 por cento). Expansão extra-selar foi observada em 83,8 por cento. Graus variados de distúrbios visuais foram observados em 74 por cento. O tratamento de escolha foi a cirurgia transesfenoidal (75 por cento). O controle clínico foi alcançado com cirurgia em 37,5 por cento dos pacientes. A maioria dos pacientes precisou de segunda abordagem terapêutica, radioterapia ou outras cirurgias. A imunoistoquímica resultou negativa para hormônios hipofisários em 43 por cento. Melhora de sintomas neuro-oftalmológicos foi observada em 61 por cento dos pacientes após o tratamento. CONCLISÕES: Os dados do estudo confirmam elevada prevalência de efeitos de massa e hipopituitarismo em pacientes com AHNS. Recorrência causada por invasão ou ressecção incompleta do tumor é comum, levando frequentemente à segunda opção terapêutica.

Microcirurgia endoscópica transanal no tratamento dos tumores do reto: estudo prospectivo em 50 pacientes / Transanal endoscopic microsurgery in the treatment of rectal tumors: a prospective study in 50 patients

RACIONAL: A literatura médica aceita ressecção local como opção válida em casos selecionados de tumores de reto. A seleção dos pacientes requer exata estimativa dos riscos e avaliação pré-operatória precisa, tanto no aspecto clínico como histopatológico. OBJETIVO: Avaliar os resultados da microcirurgia endoscópica transanal em seguimento de 18 meses. MÉTODOS: De abril de 2002 a abril de 2006, 50 pacientes com tumores de reto foram submetidos a microcirurgia endoscópica transanal, selecionados por suas características clínicas e histopatológicas. Os critérios de inclusão foram: adenomas sésseis maiores do que 3 cm e menores do que 8 cm não-circunferenciais; neoplasia intra-epitelial de alto grau; carcinoma retal pT1, e em casos especiais pT2. Todos esses tumores foram submetidos ao mesmo procedimento cirúrgico. RESULTADOS: O resultado histopatológico final revelou 9 adenomas, 26 neoplasias intra-epiteliais de alto grau, 13 carcinomas (9 pT1 e 4 pT2) e 2 carcinóides. A menor idade foi de 25 anos e a maior de 92. O menor tumor ressecado tinha 64 mm² (carcinóide) e o maior (adenoma) 90 mm². O tempo médio de operação foi de 90 minutos e o de internamento 5 dias. Houve uma morte não relacionada ao método. Um paciente com carcinoma de baixo risco pT1 apresentou recidiva 18 meses após microcirurgia endoscópica transanal e foi submetido a retossigmoidectomia curativa. Foi observado tumor residual em dois pacientes e a complicação mais grave foi uma fístula retovaginal. A taxa de complicação global foi de 9 por cento. CONCLUSÃO: Atualmente a microcirurgia endoscópica transanal é a técnica de escolha para o tratamento de adenomas sésseis, neoplasias intra-epiteliais de alto grau e carcinoma retal pT1 de baixo risco.

BACKGROUND: The medical literature accepts local resection as a valuable option in selected cases of rectal tumors. Selection of patients requires an exact perioperative estimation of risks with clinical and histopathological examination. Transanal endoscopic microsurgery aims a safe resection of the tumoral area which leads up to the cure. AIM: To evaluate transanal endoscopic microsurgery results in a follow-up time of 18 months. METHODS: From April 2002 to April 2006, 50 patients with rectal tumors were submitted to transanal endoscopic microsurgery, chosen by clinical history and lesion characteristics. The inclusion criteria were: sessile adenomas larger than 3 cm and smaller than 8 cm, not circumferentially distributed; intra epithelial neoplasia of high degree; and rectal carcinoma pT1, and special cases of pT2. All these rectal tumors were submitted to the same surgical act. RESULTS: The final histopathological results reveal 9 adenoma, 26 intra-epithelial neoplasia of high degree, 13 carcinoma (9 pT1-4 pT2) and 2 carcinoid. The lowest age was 25 and the higher, 92 years-old. The smallest resected tumor had 64 mm² (carcinoid) and the largest (adenoma), 90 cm². Operating time was in average 90 minutes and the overall time statement, 5 days. There was one death not related with the method. One patient with low risk carcinoma pT1 presented recurrence 18 months after transanal endoscopic microsurgery and was submitted to curative rectosigmoidectomy. It was proven a residual tumor after local surgery in two patients and the most important complication was one recto-vaginal fistula. The overall complications rate was 9 percent. CONCLUSION: Today transanal endoscopic microsurgery is chosen as the ideal technique for the treatment of sessile adenomas, intraepithelial neoplasia of high degree and rectal carcinoma pT1.

Prospective evaluation of transsphenoidal pituitary surgery in 108 patients with Cushing's disease

Transsphenoidal pituitary surgery (TSS) remains the treatment of choice for Cushing's disease (CD). Despite the widespread acceptance of this procedure as the first line treatment in CD, the indication of a second TSS in not cured or relapsed DC patients is not consensus. We report the results of TSS in 108 patients with CD (a total of 117 surgeries). The mean postoperative follow-up period was 6 years. Remission was defined as clinical and laboratorial signs of adrenal insufficiency, period of glucocorticoid dependence, serum cortisol suppression on oral 1-mg dexamethasone overnight suppression test and clinical remission of hypercortisolism. We evaluated 103 patients with CD by the time of the first TSS. Fourteen patients underwent second TSS (5 had already been operated in others centers; in 5 patients the first surgery was not curative; in 4 patients CD relapsed). Remission rates were 85.4 percent and 28.6 percent (p < 0.001) after first and second TSS, respectively. In microadenomas, remission rates were higher than macroadenomas (94.9 percent vs. 73.9 percent; p = 0.006). In patients with negative pituitary imaging remission rates were 71.4 percent (p = 0.003; vs. microadenomas). Postoperative complications were: transient diabetes insipidus, definitive diabetes insipidus, hypopituitarism, stroke and one death. Only hypopituitarism was more frequent after second TSS (p = 0.015). In conclusion, TSS for CD is an effective and safe treatment. The best remission rates were observed at the first surgery and in microadenomas. The low remission rates after a second TSS suggest that this approach could not be a good therapeutic choice when the first one was not curative.

O tratamento de escolha para a doença de Cushing (DC) ainda é a cirurgia transesfenoidal (CTE) para ressecção do adenoma hipofisário produtor de ACTH. Porém, a indicação de uma segunda CTE representa uma questão controversa, tanto nos pacientes não curados após a primeira cirurgia quanto nos casos de recidiva. Neste trabalho, relatamos os resultados da CTE em 108 pacientes com DC (totalizando 117 cirurgias). O tempo médio de seguimento foi de 6 anos. Critérios de cura: ocorrência de insuficiência adrenal (clínica ou laboratorial), período de dependência ao glicocorticóide, supressão do cortisol sérico pós-1 mg de dexametasona overnight e remissão clínica do hipercortisolismo. Foram avaliados 103 pacientes com DC submetidos à primeira CTE. Quatorze pacientes foram submetidos a uma segunda CTE (5 já tinham sido operados em outros centros; a primeira cirurgia não fora curativa em 5; 4 pacientes com recidiva da DC). Índices de cura: 85,4 por cento e 28,6 por cento (p < 0,001) após a primeira e segunda CTE, respectivamente. Nos microadenomas, remissão maior que nos macroadenomas (94,9 por cento vs. 73,9 por cento; p = 0,006). Nos pacientes com imagem hipofisária negativa, cura foi de 71,4 por cento (p = 0,003; vs. micro). Complicações pós-operatórias: diabetes insipidus transitório e definitivo, hipopituitarismo, acidente vascular cerebral e um óbito. Apenas a ocorrência de hipopituitarismo foi mais freqüente após a segunda CTE (p = 0,015). Assim sendo, a CTE para a DC representa uma terapêutica efetiva e segura. Os melhores índices de cura foram obtidos na primeira cirurgia e em microadenomas. O baixo índice de cura após a segunda CTE sugere que esta abordagem não deve ser considerada uma boa opção terapêutica quando a primeira cirurgia não for curativa.

Adenoma paratiroideo ectopico mediastinal: diagnostico por sonda de deteccion gamma y reseccion por videotoracoscopia / Ectopic mediastinal parathyroid adenoma: detection with a radioisotopic probe and resolution with videothoracoscopy

Presentamos el caso de una mujer de 66 años con diagnóstico de hiperparatiroidismo primariopor adenoma paratiroideo ectópico mediastinal realizado por gammagrafía paratiroidea con 99mtcmetoxi-isobutil-isonitrito (Tc99-MIBI). Fue intervenida exitosamente mediante la técnica de videotoracoscopia.Durante el procedimiento se utilizó la medición de parathormona y a los 10 minutos de extirpado el adenoma seobtuvo un descenso mayor del 50% del basal. La sonda de detección gamma no fue efectiva in situ por la superposicióndel radioisótopo con el miocardio pero confirmó la radioactividad dentro del quirófano una vez extirpadoel adenoma. La paciente normalizó los valores de calcemia y parathormona en el postoperatorio y permaneciónormocalcémica luego de 9 meses de seguimiento. En nuestro caso, la localización prequirúrgica y elmonitoreo de parathormona intraoperatoria fueron de gran utilidad para el éxito quirúrgico, la sonda detectora marcada con Tc99-MIBI no fue efectiva in situ pero confirmó la radioactividad una vez extirpado el adenoma. El tratamiento quirúrgico endoscópico por videotoracoscopia fue bien tolerado, menos doloroso que la toracotomía y acortó el tiempo de internación

We report a 66 years old woman with a diagnosis of primary Hyperparathyroidism. Localization to mediastinum was obtained with parathyroid scintigraphy using 99mtc-methoxyisobutyl-isonitrite (Tc99-MIBI). The patient was successfully operated upon by means of a videothora-coscopicapproach. During the procedure serum parathormone was measured before and 10 minutes after adenomectomy,showing a more than 50% reduction from the basal level. An attempt to detect the precise site of the adenomawith a Tc99-MIBI probe was unsuccessful because of its proximity to the myocardium, but radioactivity was confirmed on the surgical specimen after resection. The patient's calcemia and parathormone levels became normalduring the postoperative course and she remains normocalcemic 9 months after the procedure. In our case,preoperative localization and intraoperative parathormone measurements were both very useful for confirming surgical success; the intraoperative localization with a radioactive probe was not useful, but radioactivity was confirmedafter resection on the surgical specimen. The endoscopic surgical procedure with videothoracoscopy waswell tolerated, less painful than a thoracotomy, and it shortened the hospitalization period

Reseccion toracoscopica de una glandula paratiroidea hipersecretante mediastinal / Thoracoscopic resection of mediastinal hypersecretant parathyroid gland

In general experienced hands, the inferior parathyroid glands, localized in the thymus or low extrathymus are the main cause or surgical therapeutic failure. When they could not be approached through cervicotomy, or when they were diagnosed after surgery the sternotomy or the angiographic ablation were chosen as treatment. The limited number of thoracoscopic approach whit good results published so far, moved us to use this method. MATERIAL AND METHOD: Patient of 49 years with a 7 year secondary hiperprathyroidism due to CRI. After a sub total parathyroidectomy with bilateral thimectomy, the patient did not present clinical or laboratory improvement. Through a thoracic centellogram sixth MIBI, NMR and CAT, a tumor in the middle mediastinum was fond. The mediastinal structures have been easily identified through a left thoracoscopic approach. At the level of the aortopulmonary window, a tumoral mass is located and, with a simple dissection, et is easily extracted in bag. The biopsy through freezing confirms the parathyroid etiology of the gland. RESULT: Clinical and laboratory evolution has been favorable, with hospital discharged at the 3 day, and being asymptomatic after two years. CONCLUSION: The hipersecretant parathyroid glands, located in middle mediastinum, that can not be approach through cervicotomy, can be successfully approach through thoracoscopic technique.

Por lo general en manos experimentadas las paratiroides inferiores. de localización tímica o extratímica baja, son la principal causa de fracaso terapéutico quirúrgico. Cuando no son accesibles por cervicotomía o bien se diagnosticaron posteriormente. la esternotomía o la ablación angiográfica eran considerados como los tratamientos de elección. El haberse publicado limitadas experiencias de abordaje toracoscópico con buenos resultados nos motivo al empleo de esta VÍa. Material y método: paciente de 49 años con hiperparatiroidismo secundario por IRC de 7 años de evolución. Luego de una paratiroidectomía sub-total con timectomía bilateral. no presenta mejoría clínica ni de laboratorio. Al ser estudiada con centellograma sesta-MIBI. RMN y TAC torácica es localiza un tumor en mediastino meido. Abordaje toracoscópico izquierdo. identificándose con facilidad las estructuras mediastinales. A nivel de la ventana aortopulmonar se localiza una masa tumoral que con simples maniobras de disección es fácilmente extraída en bolsa. La biopsia por congelación confirma la etiología paratiroidea de la misma. Resultado: Evolución clínica y de laboratorio favorable con alta de sala al 3- día. encontrándose a los dos años asintomático. Conclusión: vemos con entusiasmo el abordaje toracoscópico de glándulas paratiroideas hipersecretantes ubicadas en medias tino medio que no hayan podido ser extraídas por cervicotomía.