Functional outcome of autologous anorectal transplantation in an experimental model

BACKGROUND

Although anorectal transplantation is a challenging procedure, it is a promising option for patients who have completely lost anorectal function or in whom it failed to develop, as in congenital malformations. The paucity of animal models with which to test functional outcomes was addressed in this study of anorectal manometry in rats.

METHODS

Wistar rats were assigned randomly to four groups: orthotopic anorectal transplantation, heterotopic transplantation, sham operation, or normal control. Bodyweight and anal pressure were measured immediately before and after operation, and on postoperative days 7 and 14. ANOVA and Tukey's test were used to compare results for bodyweight, anal manometry and length of procedure.

RESULTS

Immediately after the procedure, mean(s.d.) anal pressure in the orthotopic group (n = 13) dropped from 31·4(13·1) to 1·6(13·1) cmH2 O (P < 0·001 versus both sham operation (n = 13) and normal control (n = 15)), with partial recovery on postoperative day 7 (14·9(13·9) cmH2 O) (P = 0·009 versus normal control) and complete recovery on day 14 (23·7(12·2) cmH2 O). Heterotopic rats (n = 14) demonstrated partial functional recovery: mean(s.d.) anal pressure was 26·9(10·9) cmH2 O before operation and 8·6(6·8) cmH2 O on postoperative day 14 (P < 0·001 versus both sham and normal control).

CONCLUSION

Orthotopic anorectal transplantation may result in better functional outcomes than heterotopic procedures. Surgical relevance Patients with a permanent colostomy have limited continence. Treatment options are available, but anorectal transplantation may offer hope. Some experimental studies have been conducted, but available data are currently insufficient to translate into a clinical option. This paper details functional outcomes in a rat model of anorectal autotransplantation. It represents a step in the translational research that may lead to restoration of anorectal function in patients who have lost or have failed to develop it.

Prognostic factors of surgically-treated patients with cancer of the right colon: a ten years' experience of a single universitary institution

BACKGROUND

Colorectal cancer is one of the most common malignancies in the world. There are many controversies in the literature about the prognostic value of primary tumor location. Many studies have shown higher survival rates for tumors in the right colon, and worse prognosis for lesions located more distally in the colon.

AIM

To analyze the results of surgical treatment of right-sided colon cancers patients operated in one decade period and identify the prognostic factors that were associated with lower overall survival in stages I-IV patients.

METHODS

A retrospective review from the prospectively collected database identified 178 patients with right-sided colon cancer surgically treated with curative intent. Demographic factors (gender and age), tumor factors (site, T stage, N stage, M stage, histological type and tumor differentiation), and lymph node yield were extracted to identify those associated with lower overall survival.

RESULTS

Mean age was 65 (± 12) years old, and 105 (56.1%) patients were female. Most common affected site was ascending colon (48.1%), followed by cecum (41.7%) and hepatic flexure (10.2%). Mean length of hospital stay was 14 (± 2.8) days. T stage distribution was T1 (4.8%), T2 (7.5%), T3 (74.9%), and T4 (12.8%). Nodal involvement was present in 46.0%, and metastatic disease in 3.7%. Twelve or more lymph nodes were obtained in 87.2% of surgical specimens and 84.5% were non-mucinous tumors. Mean survival time was 38.3 (± 30.8) months. Overall survival was affected by T stage, N stage, M stage, and final stage. Lymph node involvement (OR=2.06) and stage III/IV (OR=2.81) were independent negative prognostic factors.

CONCLUSION

Right-sided colon cancer presented commonly at advanced stage. Advanced stage and lymph node involvement were factors associated with poor long term survival.

Clinical relevance of positron emission tomography/computed tomography-positive inguinal nodes in rectal cancer after neoadjuvant chemoradiation

AIM

Inguinal nodes may be a possible route for lymphatic spread in patients with distal rectal cancer. The outcome was examined for patients with distal rectal cancer undergoing neoadjuvant chemoradiation (CRT) and having 2-fluorine-18-fluoro-2-deoxy-d-glucose (FDG)-avid inguinal nodes using positron emission tomography/computed tomography (PET/CT) imaging.

METHOD

Ninety-nine consecutive patients with cT2-4N0-2M0 distal rectal adenocarcinoma were enrolled in a clinical trial (NCT00254683) and underwent baseline PET/CT followed by 54 Gy and 5-fluorouracil-based CRT. After CRT, patients underwent 6- and 12-week PET/CT. Patients with positive inguinal node uptake were compared with patients with negative uptake. The inguinal region was not included in the field of radiation therapy.

RESULTS

Seventeen (17%) patients had baseline positive inguinal node FDG uptake. They were more likely to have the tumour closer to the anal verge (2.0 vs 4.2 cm; P = 0.001). Of these, eight (47%) demonstrated a positive inguinal uptake at PET/CT after 12 weeks from CRT. Patients with inguinal node FDG uptake after CRT (positive PET at baseline and 12 weeks) had a significantly worse 3-year overall and disease-free survival (P = 0.02 and P = 0.03). After a median follow-up period of 22 months, none of these patients had developed inguinal recurrence.

CONCLUSION

Uptake of inguinal nodes at PET/CT may be present in up to 17% of patients with distal rectal cancer, particularly with ultra-low tumours. Nearly half of these nodes no longer show uptake after CRT despite the groin area not being included in the radiation field. Persistence of inguinal node uptake 12 weeks after CRT completion may be a marker for worse oncological outcome.

Reduced population of interstitial cells of Cajal in Chagasic megacolon

BACKGROUND/AIMS

In Chagasic megacolon, there is a reduction in the population of interstitial cells of Cajal. It was aimed to evaluate density of Cajal cells in the resected colon of Chagasic patients compared to control patients and to verify possible association between preoperative and postoperative bowel function of megacolon patients and cell count.

METHODOLOGY

Sixteen megacolon patients (12 female; mean age 54.4 (31-73)) were operated on. Pre- and postoperative evaluation using Cleveland clinic constipation score was undertaken. Resected colons were examined. Cajal cells were identified by immunohistochemistry (anti-CD117). The mean cell number was compared to resected colons from 16 patients (7 female; mean age 62.8 (23-84)) with non-obstructive sigmoid cancer. Association between pre- and postoperative constipation scores and cell count for megacolon patients was evaluated using the Pearson test (r).

RESULTS

A reduced number of Cajal cells (per field: 2.84 (0-6.6) vs. 9.68 (4.3-13); p<0.001) were observed in the bowel of megacolon patients compared to cancer patients. No correlation between constipation score before (r=- 0.205; p=0.45) or after surgery (r=0.291; p=0.28) and cell count in megacolon was observed.

CONCLUSIONS

Patients with megacolon display marked reduction of interstitial cells of Cajal. An association of constipation severity and Cajal cells depopulation was not demonstrated.

Assessing the extent of colon lengthening due to splenic flexure mobilization techniques: a cadaver study

CONTEXT: Failure of a colorectal anastomosis represents a life-threatening complication of colorectal surgery. Splenic flexure mobilization may contribute to reduce the occurrence of anastomotic complications due to technical flaws. There are no published reports measuring the impact of splenic flexure mobilization on the length of mobilized colon viable to construct a safe colorectal anastomosis. OBJECTIVE: The aim of the present study was to determine the effect of two techniques for splenic flexure mobilization on colon lengthening during open left-sided colon surgery using a cadaver model. DESIGN: Anatomical dissections for left colectomy and colorectal anastomosis at the sacral promontory level were conducted in 20 fresh cadavers by the same team of four surgeons. The effect of partial and full splenic flexure mobilization on the extent of mobilized left colon segment was determined. SETTING: University of Sao Paulo Medical School, Sao Paulo, SP, Brazil. Tertiary medical institution and university hospital. PARTICIPANTS: A team of four surgeons operated on 20 fresh cadavers. RESULTS: The length of resected left colon enabling a tension-free colorectal anastomosis at the level of sacral promontory achieved without mobilizing the splenic flexure was 46.3 (35-81) cm. After partial mobilization of the splenic flexure, an additionally mobilized colon segment measuring 10.7 (2-30) cm was obtained. After full mobilization of the distal transverse colon, a mean 28.3 (10-65) cm segment was achieved. CONCLUSION: Splenic flexure mobilization techniques are associated to effective left colon lengthening for colorectal anastomosis. This result may contribute to decision-making during rectal surgery and low colorectal and coloanal anastomosis.

Optimal timing for assessment of tumor response to neoadjuvant chemoradiation in patients with rectal cancer: do all patients benefit from waiting longer than 6 weeks?

PURPOSE

To estimate the metabolic activity of rectal cancers at 6 and 12 weeks after completion of chemoradiation therapy (CRT) by 2-[fluorine-18] fluoro-2-deoxy-d-glucose-labeled positron emission tomography/computed tomography ([(18)FDG]PET/CT) imaging and correlate with response to CRT.

METHODS AND MATERIALS

Patients with cT2-4N0-2M0 distal rectal adenocarcinoma treated with long-course neoadjuvant CRT (54 Gy, 5-fluouracil-based) were prospectively studied (ClinicalTrials.org identifier NCT00254683). All patients underwent 3 PET/CT studies (at baseline and 6 and 12 weeks from CRT completion). Clinical assessment was at 12 weeks. Maximal standard uptake value (SUVmax) of the primary tumor was measured and recorded at each PET/CT study after 1 h (early) and 3 h (late) from (18)FDG injection. Patients with an increase in early SUVmax between 6 and 12 weeks were considered "bad" responders and the others as "good" responders.

RESULTS

Ninety-one patients were included; 46 patients (51%) were "bad" responders, whereas 45 (49%) patients were "good" responders. "Bad" responders were less likely to develop complete clinical response (6.5% vs. 37.8%, respectively; P=.001), less likely to develop significant histological tumor regression (complete or near-complete pathological response; 16% vs. 45%, respectively; P=.008) and exhibited greater final tumor dimension (4.3 cm vs. 3.3 cm; P=.03). Decrease between early (1 h) and late (3 h) SUVmax at 6-week PET/CT was a significant predictor of "good" response (accuracy of 67%).

CONCLUSIONS

Patients who developed an increase in SUVmax after 6 weeks were less likely to develop significant tumor downstaging. Early-late SUVmax variation at 6-week PET/CT may help identify these patients and allow tailored selection of CRT-surgery intervals for individual patients.

Locally advanced colorectal cancer: results of surgical treatment and prognostic factors

OBJECTIVES

To evaluate the incidence surgical results and prognostic factors of locally advanced colorectal cancer.

METHODS

Cohort study including 679 colorectal cancer patients treated from 1997 to 2007. Clinical, surgical and histological data were analyzed.

RESULTS

Ninety patients (females 61%; median age 59 years) were treated for locally advanced carcinomas (13.2%), either in the colon (66%) or rectum (34%). Extended resections most commonly involved the small bowel (19.8%), bladder (16.4%), uterus (12.9%) and ovaries (11.2%). Postoperative morbidity and mortality occurred in 23 (25.6%) and 3 (3.3%) patients, respectively. Survival and recurrence analysis among 76 R0 (84.4%) procedures revealed a 60% 5-year survival and 34% local recurrence rates. Survival curves demonstrated reduced rates for rectal location (45% vs 65%), tumor depth (50% for T4 vs 75% for T3), vascular/ lymphatic/perineural invasion (35% vs 80%) and lymph node metastasis (35% vs 80%).

CONCLUSIONS

Locally advanced carcinomas were found in 13.2% of patients. Survival rates were negatively affected by rectal location and adverse histological features. Number of involved organs and neoplastic adhesions did not influenced chances of survival. A radical R0 extended resection was achieved in a high proportion of cases, resulting in a 60% cancer-free survival under acceptable operative risks.

Accuracy of positron emission tomography/computed tomography and clinical assessment in the detection of complete rectal tumor regression after neoadjuvant chemoradiation: long-term results of a prospective trial (National Clinical Trial 00254683)

BACKGROUND

Neoadjuvant chemoradiation (CRT) therapy may result in significant tumor regression in patients with rectal cancer. Patients who develop complete tumor regression have been managed by treatment strategies that are alternatives to standard total mesorectal excision. Therefore, assessment of tumor response with positron emission tomography/computed tomography (PET/CT) after neoadjuvant treatment may offer relevant information for the selection of patients to receive alternative treatment strategies.

METHODS

Patients with clinical T2 (cT2) through cT4NxM0 rectal adenocarcinoma were included prospectively. Neoadjuvant therapy consisted of 54 grays of radiation and 5-fluorouracil-based chemotherapy. Baseline PET/CT studies were obtained before CRT followed by PET/CT studies at 6 weeks and 12 weeks after the completion of CRT. Clinical assessment was performed at 12 weeks after CRT completion. PET/CT results were compared with clinical and pathologic data.

RESULTS

In total, 99 patients were included in the study. Twenty-three patients were complete responders (16 had a complete clinical response, and 7 had a complete pathologic response). The PET/CT response evaluation at 12 weeks indicated that 18 patients had a complete response, and 81 patients had an incomplete response. There were 5 false-negative and 10 false-positive PET/CT results. PET/CT for the detection of residual cancer had 93% sensitivity, 53% specificity, a 73% negative predictive value, an 87% positive predictive value, and 85% accuracy. Clinical assessment alone resulted in an accuracy of 91%. PET/CT information may have detected misdiagnoses made by clinical assessment alone, improving overall accuracy to 96%.

CONCLUSIONS

Assessment of tumor response at 12 weeks after CRT completion with PET/CT imaging may provide a useful additional tool with good overall accuracy for the selection of patients who may avoid unnecessary radical resection after achieving a complete clinical response. Cancer 2012;3501-3511. © 2011 American Cancer Society.

Laparoscopic total mesorectal excision: early and late results

BACKGROUND

Laparoscopic colectomy is superior to open colectomy in terms of short-term surgical outcomes. There is solid evidence indicating that laparoscopic and open surgery are equally effective for colon cancer, but for rectal cancer, the issues of neoadjuvant treatment, the need for total mesorectal excision and autonomic nerve preservation, and the technical demands of a well-constructed low colorectal or coloanal anastomosis challenge even the most specialized surgeons. This review discusses the available evidence on short-term and long-term outcomes after laparoscopic total mesorectal excision for rectal cancer.

DATA SOURCES

Systematic MEDLINE and Embase searches of outcomes on laparoscopic total mesorectal excision were conducted and data were retrieved.

CONCLUSIONS

Information on short-term and long-term outcomes after laparoscopic total mesorectal excision remains limited. Data are mainly retrospective and from randomized studies based on few cases that had minimal follow-up. Early non-oncologic surgical outcomes seem improved after laparoscopy, but an increased rate of positive circumferential resection margins has been detected. Though scarce, the available evidence on recurrence and survival does not indicates disadvantages to the laparoscopic approach.

Laparoscopic total mesorectal excision for rectal cancer after neoadjuvant treatment: targeting sphincter-preserving surgery

BACKGROUND/AIMS

Laparoscopic total mesorectal excision for rectal cancer is under scrutiny. This study aimed at analyzing feasibility, adequacy of resection, impact on early outcomes after neoadjuvant chemoradiation therapy, and to investigate trend towards indication of laparoscopy for sphincter-preservation in a single university medical center.

METHODOLOGY

Patients with distal rectal cancer submitted to neoadjuvant treatment followed by laparoscopic total mesorectal excision were prospectively enrolled. The studied parameters were: demographics, previous surgery, BMI, type of operation, rate of sphincter-preserving surgery, duration of surgery, conversion, specimen retrieval, lymphadenectomy, distal and radial margins, intra and postoperative morbidity, reoperations, hospital stay, and mortality.

RESULTS

From January 2000 to July 2010, 68 patients were enrolled. Mean age was 60 (30-87) years. There were 27 anterior and 41 abdominoperineal resections. Six patients underwent a totally laparoscopic resection and coloanal anastomosis. There was a trend (p=0.003) towards more sphincter-preserving surgery. Conversion was 4.5%. Intraoperative complication was 7.4%. Postoperative complications occurred in 15%. Mortality was 3%. Lymph-node harvest was 11 (0-33). Mean distal margin was 2.5cm (1-4). Radial margins were positive in 3 (10%) cases.

CONCLUSIONS

Laparoscopic total mesorectal excision after neoadjuvant treatment is feasible and safe. Sphincter-preserving laparoscopic oncologic rectal surgery has been accomplished more frequently.

Long-term follow up of abdominal rectosigmoidectomy with posterior end-to-side stapled anastomosis for Chagas megacolon

AIM

Chagas' disease is an endemic parasitosis found in Latin America. The disease affects different organs, such as heart, oesophagus, colon and rectum. Megacolon is the most frequent long-term complication, caused by damage to the myoenteric and submucous plexus, ultimately leading to a functional barrier to the faeces. Patients with severe constipation are managed surgically. The study aimed to analyse the 10-year minimum functional outcome after rectosigmoidectomy with posterior end-to-side anastomosis (RPESA).

METHOD

A total of 21 of 46 patients were available for follow up. Patients underwent clinical, radiological and manometric evaluation, and the results were compared with preoperative parameters.

RESULTS

Of the 21 patients evaluated, 81% (17) were female, with a mean age of 60.6 years. Good function was achieved in all patients, with significant improvement in defaecatory frequency (P < 0.0001), usage of enemas (P < 0.0001) and patient satisfaction. Barium enema also showed resolution of the colonic and rectal dilatation in 19 cases evaluated postoperatively.

CONCLUSION

Minimal 10-year follow up of RPESA showed excellent functional results, with no recurrence of constipation.

Influence of perineal prostatectomy on anal continence

OBJECTIVE

Perineal prostatectomy has been proposed as a less invasive and safe procedure, but the risk of anal incontinence has been studied. This study aimed to evaluate the effects of perineal access on anal continence mechanisms after perineal prostatectomy.

METHODS

From August 2008 to May 2009, twenty three patients underwent perineal prostatectomy. These patients were evaluated before surgery and eight months postoperatively using the Cleveland Clinic Anal Incontinence Score, the Fecal Incontinence Quality of Life Score, and anorectal manometry.

RESULTS

The mean age of the subjects was 65 (range, 54-72) years, and the mean prostate weight was 34.5 (range, 24-54) grams. Gleason scores ranged from 6-7, and the mean Cleveland Clinic Anal Incontinence Score (mean±standard deviation) values were 0.9±1.9 and 0.7±1.2 (p>0.05) before and after surgery, respectively. The Fecal Incontinence Quality of Life Score did not change significantly after surgery. The mean values for anal manometric parameters before and after surgery were, respectively: Resting Pressures of 64±23 mmHg and 65±17 mmHg (p = 0.763), Maximum Squeezing Pressures of 130±41 mmHg and 117±40 mmHg (p = 0.259), High Pressure Zones of 3.0±0.9 cm and 2.7±0.8 cm(p = 0.398), Rectal Sensory Thresholds of 76±25 ml and 71±35 ml (p = 0.539), Maximum Tolerated Rectal Volumes of 157±48 ml and 156±56ml (p = 0.836), and Sphincter Asymmetry Indexes 22.4±9% and 14.4±5% (p = 0.003).

CONCLUSION

There was a significant decrease in the sphincter symmetry index after perineal prostatectomy. With the exception of the sphincter asymmetry index, perineal prostatectomy did not affect anal continence parameters.

Videocirurgia no manejo da doença de Crohn intestinal

A doença de Crohn é uma moléstia com um amplo espectro de manifestações. Seu tratamento é complexo e freqüentemente os pacientes portadores desta afecção necessitam de intervenções cirúrgicas. Com o surgimento da laparoscopia e sua popularização no tratamento das afecções intestinais, demonstrando resultados superiores ao acesso convencional e quebrando paradigmas como sua utilização no tratamento do câncer colorretal, passou-se a cogitar se esse acesso seria indicado também nas doenças inflamatórias intestinais. Ainda hoje, a utilização desta via de acesso na doença de Crohn é tema controverso. Devido à natureza inflamatória desta patologia, o grau de dificuldade cirúrgico está aumentado e muitas dúvidas persistem: há benefício para o paciente? A taxa de conversão não está exageradamente aumentada? É possível indicar esse acesso em casos complicados? Qual o grupo de pacientes que se beneficia da técnica? Nesta revisão apresentamos os dados mais recentes e as evidências científicas que sustentam a indicação da via de acesso laparoscópica no tratamento cirúrgico da doença de Crohn.

Depopulation of interstitial cells of cajal in chagasic megacolon: towards tailored surgery?

BACKGROUND: The mechanism of constipation in patients with Chagasic megacolon remains partially explained. In these patients, it was recently demonstrated a reduction in the population of interstitial cells of Cajal. AIM: To evaluate density of Cajal cells in the surgically resected colon of Chagasic patients in comparison to control patients, and to verify possible association between preoperative and postoperative bowel function of Chagasic patients and colonic cell count. METHOD: Sixteen patients with Chagasic megacolon were operated on. Clinical pre- and post-operative evaluation using the Cleveland Clinic Constipation Score was undertaken. Resected colons were examined. Cajal cells were identified by immunohistochemistry using anti-CD117 antibody. The mean cell number was compared to resected colons from 16 patients with non-obstructive sigmoid cancer. Association between pre-and post-operative constipation scores and cell count for megacolon patients was evaluated using the Pearson coefficient correlation test (r). RESULTS: A reduced number of Cajal cells [cells per field: 2.84 (0-6.6) vs. 9.68 (4.3-13) - p<0.001] was observed in the resected colon of Chagasic patients when compared to colon cancer patients. No correlation between constipation score before (r=-0.205; p=0.45) or after surgery (r=0,291; p=0.28) and cell count for megacolon patients was observed. CONCLUSIONS: Patients with Chagasic megacolon display marked reduction of interstitial cells of Cajal when compared to non-Chagasic patients. An association of constipation severity and Cajal cells depopulation in Chagasic megacolon could not be demonstrated.

Synchronous collision malignant melanoma and adenocarcinoma of the rectum

"Collision tumors" consist of two independent but coexisting tumors. This uncommon situation might be easily mistaken for a composite tumor where one histogenetic event originates from two apparently distinct neoplasms. Colorectal collisions are particularly unusual; here, we report the exceedingly rare case of a 61-year-old man with malignant melanoma and adenocarcinoma colliding in the rectum. Collision tumors have an idiopathic pathophysiology and in fact "accidental meeting" is accepted by many authors. This article discusses the concepts about cancer development, which are overlooked by this hypothesis, another theory to explain that this rare occurrence involves microenvironment changes.

Surgical outcomes after preceptored laparoscopic colorectal surgery: results of a Brazilian preceptorship program

BACKGROUND/AIMS

Safety of laparoscopic colectomy education methods remains unknown. This study aimed at comparing the outcomes of patients undergoing preceptored laparoscopic colectomy with patients operated on by the same preceptor.

METHODOLOGY

A prospective analysis of 30 pre-ceptored operations performed by nine surgeons (PD group) between 2006 and 2008 was conducted. Data of 30 operations matched for diagnosis and surgery type conducted by the same preceptor (P group) were evaluated.

RESULTS

Median age was 56.2 (26-80) and 55.2 (22-81) respectively in P and PD group (p = 0.804). Eleven (36.7%) were male in P group, 16 (53.3%) in PD group (p = 0.194). Preceptored operations were not significantly longer than operations performed by the preceptor (198 vs. 156 min)--p = 0.072. Length of hospital stay did not differ [4 days (3-12) in P group, and 5 (3-15) in PD group, p = 0.296]. Conversion occurred in 4 cases in PD and in 2 in P group (p = 0.389). Morbidity was similar (23.3% in P and 26.7% in PD group). One patient from P and two from PD group needed reoperation. No deaths occurred.

CONCLUSIONS

Laparoscopic colorectal surgery preceptorship programs in surgeon learner's place are safe. Surgeons' introduction through basic and hands-on courses is required for skills acquisition needed to minimize adverse outcomes.

Quality of life in the late follow-up of ulcerative colitis patients submitted to restorative proctocolectomy with sphincter preservation over ten years ago

OBJECTIVE

To evaluate, by means of the Inflammatory Bowel Disease Questionnaire (IBDQ), the quality of life of ulcerative colitis patients submitted to proctocolectomy with sphincter preservation using J-pouch reconstruction over ten years ago.

METHODS

The study consisted of 36 patients interviewed using the Inflammatory Bowel Disease Questionnaire. The score scale, resulting from the addition of each answer, ranged from 32 to 224, where the highest score indicates the best quality of life. The chi square test was used to verify the existence of meaningful differences between the results of the questionnaire and age, and gender proportion. For each section, as well as for all of them combined, the Kruskal-Wallis test was used to verify if there were differences in the Inflammatory Bowel Disease Questionnaire scores among the groups in relation to the proportions.

RESULTS

After applying the Inflammatory Bowel Disease Questionnaire, it was determined that quality of life was considered excellent for 9 (25%), good for 11 (30.6%), regular for 13 (36.1%), and bad for 3 (8.3%) patients. In our study, we determined that 85% of the patients were pleased with and thankful for the surgery that they underwent.

CONCLUSION

We can conclude that the possibility of sphincter preservation should always be taken into account, since patients remain clinically stable and have a high quality of life even after long periods.

Perianal squamous cell carcinoma with high-grade anal intraepithelial neoplasia in an HIV-positive patient using highly active antiretroviral therapy: case report

CONTEXT

Highly active antiretroviral therapy (HAART) has turned human immunodeficiency virus (HIV) infection into a chronic condition, and this has led to increased incidence of anal dysplasia among HIV-positive patients. Routine anal evaluation including the anal canal and perianal area is recommended for this population, especially for patients infected by oncogenic human papillomavirus (HPV) types.

CASE REPORT

A 54-year-old homosexual HIV-positive man presented with a six-year history of recurrent perianal and anal warts. He had previously undergone incomplete surgical excision and fulguration in another institution on two occasions. He had been using HAART over the past two years. He presented some condylomatous spreading lesions occupying part of the anal canal and the perianal skin, and also a well-demarcated slightly painful perianal plaque of dimensions 1.0 x 1.0 cm. Both anal canal Pap smears and biopsies guided by high-resolution anoscopy revealed high-grade squamous intraepithelial lesion. Biopsies of the border of the perianal plaque also revealed high-grade squamous intraepithelial lesion. HPV DNA testing of the anus detected the presence of HPV-16 type. The patient underwent local full-thickness excision of the lesion. Histological analysis on the excised tissue revealed high-grade squamous intraepithelial lesion with one focus of microinvasive squamous cell cancer measuring 1 mm. No lymph vessel or perineural invasion was detected. The patient showed pathological evidence of recurrent anal and perianal high-grade squamous intraepithelial lesions at the sixth-month follow-up and required further ablation of those lesions. However no invasive squamous cell carcinoma recurrence has been detected so far.

Recent evidences of the use of 18F-fluorodeoxyglucose positron emission tomography in the management of colorectal cancer

Positron emission tomography is considered a potentially useful diagnostic tool in the management of a variety of malignancies. It has been used for staging, evaluation of recurrent and metastatic disease, evaluation of tumoral response to neoadjuvant therapy, and providing prognostic information. However, some data are available about its definitive role in the colorectal cancer population. In this review, the most recent evidences and future perspectives are presented for the use of the 18F-fluorodeoxyglucose positron emission tomography in the management of patients with colorectal cancer.

Colorectal cancer among patients aged 75 years or over

BACKGROUND/AIMS

The aim of this study is to evaluate the risk factors for mortality, morbidity, and long-term survival in elderly patients with colorectal cancer when compared to younger patients.

METHODOLOGY

Patients operated on with colorectal cancer were divided into 2 groups according to age: Group 1 (75 years old or older, n=90) and group 2 (<75 years, n=430).

RESULTS

Preoperative hemoglobin levels were lower in group 1 (p = 0.008). Poorer clinical status defined by ASA score (p = 0.008) results and blood transfusions (p = 0.003) were more frequent in group 1 when compared to group 2. Group 1 had a significantly higher operative mortality rate than group 2 (p = 0.01). Regarding cancer-related survival after 1, 2, and 4 years, there was no significant difference between the 2 groups.

CONCLUSIONS

Poorer clinical conditions with special regard to anemia are more frequent among patients of 75 years and older and this finding may lead to an increase in operative mortality when compared to younger patients. Even though, senior patients with colorectal cancer should not be denied surgical and adjuvant therapy on account of age alone since cancer-related survival remains comparable to younger patients' results.

Early results of the treatment of internal hemorrhoid disease by infrared coagulation and elastic banding: a prospective randomized cross-over trial

BACKGROUND

Rubber band ligation (RBL) is probably the most commonly performed nonsurgical therapy for hemorrhoidal disease. Infrared coagulation (IRC) is one of the most recent advances based on the use of "heat". Recent studies have demonstrated similar efficacy for both modalities. This prospective randomized crossover trial compared IRC and RBL for pain, complications, effectiveness, and patient satisfaction and preference in the treatment of internal hemorrhoids (IH).

METHODS

Patients were randomized to receive either RBL (Group A) or IRC (Group B) for treatment of the first hemorrhoid; in a second procedure two weeks later, patients underwent the other procedure on the second hemorrhoid, thereby serving as their own control. The procedure preferred by the patient was employed two weeks later for the third hemorrhoid. Post-treatment pain was evaluated on a visual analog scale and on the basis of the percentage of patients requiring analgesics. Bleeding and early outcome of treatment were also recorded, together with the patient's satisfaction.

RESULTS

A total of 94 patients were included in this study (47 patients in each group). At 30 minutes and 6 hours after treatment, pain scores were significantly higher in patients treated with RBL than in those treated with IRC (p<0.01). There was no significant difference in pain scores between the two procedures immediately and 24 hours after the procedures (p<0.05). After 72 hours and one week, the pain scores for RBL and IRC were similar. The percentage of patients using analgesics was significantly higher in RBL group than in IRC group at 6 hours (29.6% vs. 19.2%, respectively; p<0.05) and 24 hours (22.5% vs. 13.5%, respectively; p<0.05) after treatment. However, significant differences were not noted at 72 hours (12.7% vs. 6.4%; p<0.05) and one week (5.6% vs. 7.1%; p>0.05) after the procedures. There were significantly higher incidences of bleeding immediately, 6 hours, and 24 hours after RBL compared to IRC (immediate: 32.4% vs. 4.3%; 6 hours: 13.4% vs. 3.6%, 24 hours: 26.8% vs. 10.2%, respectively; p<0.01). However, there were no significant differences noted regarding the incidence of bleeding between the two groups at 72 hours. Complications were more likely after RBL than IRC, however this difference was not significant (p>0.05). Overall, 91 patients (96.8%) were successfully treated and 93 patients (99%) were very satisfied with the treatment. In the third treatment session, 50% of patients selected RBL and 50% chose IRC.

CONCLUSIONS

Both RBL and IRC were well-accepted and highly efficacious methods for the treatment of IH; in addition, both procedures were associated with relatively minor complications. However, RBL was associated with more pain than IRC in the 24-hour postoperative period.

Surgical treatment of haemorrhoidal disease with CO2 laser and Milligan-Morgan cold scalpel technique

OBJECTIVE

To prospectively compare immediate postoperative results of the surgical treatment of haemorrhoidal disease (HD) by Milligan-Morgan technique using either the CO(2) laser or cold scalpel.

METHODS

Forty patients with grade III/IV HD were prospectively randomized to undergo surgical treatment (Milligan-Morgan) using either the CO(2) laser (group A) or the cold scalpel method (group B). Data were compared regarding postoperative pain, complications, healing time, return to normal activity and patient satisfaction. Patients were blinded to treatment method until the completion of the study. Postoperative outcomes were assessed by patient questionnaire and outpatient follow-up visits. Pain was assessed by Visual Analogue Scale and analgesic consumption.

RESULTS

Twenty patients were randomized into each group and were comparable relative to mean age, gender and grade of HD. There were no statistically significant differences regarding postoperative pain measured (P =0.17) or consumption of oral (P = 0.741) and parenteral analgesics (P = 0.18) between the two groups. Mean pain score at the first bowel movement was significantly higher in group A (P = 0.035), although the use of analgesics was similar in both the groups. There were no differences regarding complications, mean healing time, return to normal activities and patient satisfaction.

CONCLUSION

There were no differences in the immediate results after Milligan-Morgan haemorrhoidectomy using either the CO(2) laser or cold scalpel regarding postoperative pain, complications, healing time, return to normal activities or patient satisfaction.

Concurrent development of Crohn disease and myelodysplastic syndrome in a child: case report and literature review

A small number of cases of Crohn disease associated with myelodysplastic syndromes or leukemia have been reported in adults in the last 25 years in the English-language medical literature. The authors report a case of a 9-year-old boy who developed Crohn disease and myelodysplastic syndrome concurrently. Analysis of his bone marrow showed a chromosome 20 abnormality. Although chromosome 20 abnormalities have been reported in a minority of these patients, the significance of this association remains unclear at the present time.

Laparoscopy-Assisted Ileal Pouch-Anal Anastomosis

We analyzed outcomes of laparoscopy-assisted ileal pouch-anal anastomosis (LAIPA) from 10 patients (7 with ulcerative colitis and 3 with familial adenomatous polyposis) operated on between January 1998 and March 2004. Median operating time was 246 minutes. There were no intraoperative complications. There were no conversions. Postoperative complications occurred in 3 (30%) patients: 2 cases of wound infection and 1 case of a foreign body retrieved during pouch endoscopy. There was a 30% reoperation rate due to unsuspected duodenal perforation, a persistent postoperative pain, and 1 case of intestinal obstruction after ileostomy closure. There were no deaths. Median time to resumption of diet was 24 hours. Median hospital stay was 7 days. All ileostomies were closed 6 to 8 weeks after LAIPA. LAIPA is feasible and safe and should be selectively offered to nonobese patients.

[Colonoscopy as a diagnostic and therapeutic method of the large bowel diseases: analysis of 2,567 exams]

BACKGROUND

Since the sixties, when the optic fibers were reported, colonoscopy had emerged as the first line imaging investigation of the colon.

AIM

To review the results of diagnostic and therapeutic colonoscopy at the Discipline of Coloproctology of the University of São Paulo Medical School, São Paulo, SP, Brazil, respecting the characteristics of an institution of medical education.

METHODS

Retrospective analysis of basis related to 2,567 fibro colonoscopies between 1984 and 2002. The procedure was performed in hospitalized and in outpatients. The most common indications for colonoscopy were investigation of rectal bleeding and anemia (22.4%), change of bowel habit (14.76%), inflammatory bowel disease (8.65%) and carcinoma (7.25%). Bowel preparation with manitol was used by most of the patients. Sedation, when not contra-indicated, was administered. The most common combination was meperidine and benzodiazepine. All the exams were monitored with pulse oximeter. A normal colonoscopy to the point of maximum insertion was reported in 42.42% of procedures. The most common diagnosis was polyps (15.47%), followed by diverticular disease (12.86%). Inflammatory disease was recorded in 11.88% and carcinoma in 10.21%. Polypectomy was undertaken in 397 patients (2.21 polypectomy per patient with polyps). Colonoscopy was considered incomplete (when the colonoscope did not pass to the cecum or terminal ileum) in 181 (7.05%) cases. Perforation was reported in one patient who had a subestenosing retossigmoid tumor. In 0.42%, reasons for failing to complete the procedure included complication related to sedation, with no further prejudice for the patients.

CONCLUSIONS

Colonoscopic examination of the entire colon remains the standard for visualization, biopsy and treatment of colonic affections. The incidence of complication of endoscopy of the large bowel is quite low, even in a school hospital.

Surgical treatment of anal stenosis: assessment of 77 anoplasties

PURPOSE

Anal stenosis is a rare, incapacitating, and challenging condition, occurring mainly after hemorrhoidectomy, for which several surgical techniques have been devised. The purpose of this study was to describe early and late (1 year) results of 77 anoplasty operations performed in the Colorectal Unit of our institution.

METHODS

From 1977 to 2002, 77 patients with moderate to severe anal stenosis underwent surgery using two sliding graft techniques: 58 underwent Sarner's operation and 19 underwent Musiari's technique. Bilateral flaps were used in 7 patients.

RESULTS

Early morbidity was due to pruritus occurring in 2 patients, urinary infection in 1, and temporary incontinence in 1 patient. One patient needed early reoperation following suture line dehiscence. Late results (1 year) were classified as good in 67 cases (87%). There was no reoperation due to recurrence of stenosis.

CONCLUSION

The ease of performance, good functional results, and lack of severe complications show that Sarner's and Musiari's flap advancement techniques are effective and safe methods for surgical correction of anal stenosis, particularly when cutaneous fibrosis plays a major role in its etiology.

Stapled hemorrhoidectomy for the treatment of hemorrhoids

BACKGROUND

The use of circular staplers in the treatment of hemorrhoidal disease is known as a simple procedure, with low morbidity, less post-treatment pain and with the same efficacy when compared to the classical hemorrhoidectomy.

AIM

Analyze the operative technique, intra-operative and immediate postoperative complications and late results in 100 patients treated for hemorrhoid disease by stapling technique.

PATIENTS AND METHODS

The group included 53 males and 47 females with mean age of 49.8 years, operated during the period June 2000 to June 2002 in the "Hospital Universitário" (São Paulo University Hospital) and "Hospital Sírio Libanês", in São Paulo, SP, Brazil.

RESULTS

The majority of patients (78%) were discharged on the first post-operative day. Eight patients required supplementary analgesia and were given intramuscular diclofenac sodium and four of them received intramuscular tramadol. One intraoperative complication was bleeding which was difficult to control and required a blood transfusion. One patient was reoperated on the first postoperative day due to intermittent and persistent bleeding, however without hemodynamic changes or a drop in hematocrit. Two patients presented hemorrhoidal thrombosis in the early postoperative stage. The postoperative follow-up displayed: recurrence of prolapse, five cases (5%); anal sub-stenosis, two cases (2%); anal fissure, one case (1%); persistent pain, two cases (2%). Seven reoperations were performed: one due to bleeding, one due to sub-stenosis and five due to recurrence of hemorrhoidal prolapse and persistence of symptoms.

CONCLUSIONS

Stapling is simple to accomplish, has low postoperative pain and rate of complications, however, the incidence of late reoperations is rather high and therefore major follow-up for better analysis is required.

Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial

OBJECTIVE

The aims of this study were to evaluate the safety and efficacy of laparoscopic abdominoperineal resection compared to conventional approach for surgical treatment of patients with distal rectal cancer presenting with incomplete response after chemoradiation.

METHOD

Twenty eight patients with distal rectal adenocarcinoma were randomized to undergo surgical treatment by laparoscopic abdominoperineal resection or conventional approach and evaluated prospectively. Thirteen underwent laparoscopic abdominoperineal resection and 15 conventional approach.

RESULTS

There was no significant difference (p<0,05) between the two studied groups regarding: gender, age, body mass index, patients with previous abdominal surgeries, intra and post operative complications, need for blood transfusion, hospital stay after surgery, length of resected segment and pathological staging. Mean operation time was 228 minutes for the laparoscopic abdominoperineal resection versus 284 minutes for the conventional approach (p=0.04). Mean anesthesia duration was shorter (p=0.03) for laparoscopic abdominoperineal resection when compared to conventional approach : 304 and 362 minutes, respectively. There was no need for conversion to open approach in this series. After a mean follow-up of 47.2 months and with the exclusion of two patients in the conventional abdominoperineal resection who presented with unsuspected synchronic metastasis during surgery, local recurrence was observed in two patients in the conventional group and in none in the laparoscopic group.

CONCLUSIONS

We conclude that laparoscopic abdominoperineal resection is feasible, similar to conventional approach concerning surgery duration, intra operative morbidity, blood requirements and post operative morbidity. Larger number of cases and an extended follow-up are required to adequate evaluation of oncological results for patients undergoing laparoscopic abdominoperineal resection after chemoradiation for radical treatment of distal rectal cancer.

Radiation-induced total regression of a highly recurrent giant perianal condyloma: report of case

We report a case of a highly recurrent giant perianal condyloma, or Buschke-Lowenstein tumor, which was successfully treated by telecobalt therapy. We conclude that radiation therapy is an optional treatment modality for the management of giant perianal condylomata in selected cases.

Colorectal cancer screening

Colorectal cancer (CRC) is the third most common cancer in the world, and mortality has remained the same for the past 50 years, despite advances in diagnosis and treatment. Because significant numbers of patients present with advanced or incurable stages, patients with pre-malignant lesions (adenomatous polyps) that occur as result of genetic inheritance or age should be screened, and patients with long-standing inflammatory bowel disease should undergo surveillance. There are different risk groups for CRC, as well as different screening strategies. It remains to be determined which screening protocol is the most cost-effective for each risk catagory. The objective of screening is to reduce morbidity and mortality in a target population. The purpose of this review is to analyze the results of the published CRC screening studies, with regard to the measured reduction of morbidity and mortality, due to CRC in the studied populations, following various screening procedures. The main screening techniques, used in combination or alone, include fecal occult blood tests, flexible sigmoidoscopy, and colonoscopy. Evidence from the published literature on screening methods for specific risk groups is scanty and frequently does not arise from controlled studies. Nevertheless, data from these studies, combined with recent advances in molecular genetics, certainly lead the way to greater efficacy and lower cost of CRC screening.

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

METHOD

Eighty patients were prospectively randomized for precolonoscopic cleansing either with 750ml of 10% mannitol (Group M) or 180ml of a sodium phosphate preparation (Group NaP). Laboratory examinations before and after preparation on all patients included hemoglobin, hematocrit, sodium, potassium, phosphorous, calcium and serum osmolarity. A questionnaire was used to assess undesirable side effects and patient tolerance to the solution. The quality of preparation was assessed by the endoscopist who was unaware of the solution employed.

RESULTS

Statistically significant changes were verified in serum sodium, phosphorous, potassium and calcium between the two groups, but no clinical symptoms were observed. There were no significant differences in the frequency of side effects studied. Six of the eight patients in Group NaP who had taken mannitol for a previous colonoscopy claimed better acceptance of the sodium phosphate solution. The endoscopic-blinded trial reported excellent or good bowel preparation in 85% prepared with sodium phosphate versus 82.5% for mannitol (p=0.37).

CONCLUSIONS

Quality of preparation and frequency of side effects was similar in the two solutions. The smaller volume of sodium phosphate necessary for preparation seems to be related to its favorable acceptance. Nevertheless, the retention of sodium and phosphate ions contraindicates the use of sodium phosphate in patients with renal failure, cirrhosis, ascites, and heart failure.

Polypectomies: colonic endoscopic resections

The authors present their experience with 924 colonoscopic polypectomies in 549 patients. Postpolypectomy bleeding was 0.36% without perforations. Complications associated with the procedure are analyzed; evaluating the risk, diagnosis and treatment based on a survey of the literature and personal experience.

Orifice Diseases Project--experience of the "Hospital das Clínicas" University of São Paulo Medical Center in day-hospital of anorectal disease

The treatment of malignant or benign colorectal pathologies that require more complex management are priorities in tertiary hospitals such as "Hospital das Clínicas" University of São Paulo Medical Center (HCFMUSP). Therefore, benign, uncomplicated orifice conditions are relegated to second place. The number of patients with hemorrhoids, perianal fistulas, fissures, condylomas and pilonidal cysts who seek treatment at the HFMUSP is very great, resulting in over-crowding in the outpatient clinics and a long waiting list for recommended surgical treatment (at times over 18 months). The authors describe the experience of the HCFMUSP over an eight-day period with day-hospital surgery in which 140 patients underwent surgery. Data was prospectively taken on the patients undergoing surgery for benign orifice pathologies including age, sex, diagnosis, surgery performed, immediate and late postoperative complications, and follow-up, 140 patients operated on over eight days were studied, 68 were males (48.75%) with ages ranging from 25 to 62 (mean 35.2 yrs.). Hemorrhoids was the most frequent condition encountered (82 hemorrhoidectomies, 58.6%), followed by perineal fistula (28 fistula repairs, 20.0%). The most common complication was headache secondary to rachianesthesia occurring in 9 patients (6.4%). One patient (0.7%) developed bleeding immediately PO that required reoperation. Mean follow-up was 104 days. Day-surgery characterized by quality care and low morbidity is feasible in tertiary public hospitals, permitting surgery for benign orifice pathologies on many patients within a short period of time.

Diagnostic colonoscopy

Colonoscopy is employed in prevention, diagnosis, follow-up and treatment of colorectal diseases. The technological advancement of colonoscopes and supplementary equipment, has broadened indications for colonoscopy. However, since it is an invasive method with potential complications and hazards it should be performed by specialists capable of preventing, recognizing and treating them. The authors report their personal experience with 1,234 colonoscopies. The most frequent indications were changes in bowel habits and rectal bleeding in 35.1% and 30.5% cases respectively. The patients were given 10% mannitol for bowel cleansing and inadequate bowel cleansing in only 15 (1.2%) so that the colonoscopy could not be completed. The overall incidence of perforation was 0.16%. Three hundred and one polypectomies were performed and two cases (0.75%) of bleeding were noted.

Experimental injury to the spleen study of interaction: contamination/preservation

Ablation of the spleen leads to a significant risk of postsplenectomy invasive sepsis. This concept has become very important in the last three decades because of awareness of the spleen's important role in immunological functions. Hence, this has led many research centers to study hemostasis of the injured spleen in order to preserve its function. The objective of this study is to analyze the use of nylon mesh for preservation of the wounded spleen in the presence or absence of local contamination. Twenty dogs were operated, randomly divided into two groups and followed postoperatively for eight weeks. A standard splenic injury was produced in all animals and hemostasis accomplished by attaching nylon mesh to the organ. Postoperatively, in one of the groups the "wounded organ + mesh" was contaminated with a bacterial count proportional to the animal's weight. The other group was not contaminated, maintaining it as control. Both groups were studied as to interaction of contamination/preservation, i.e., body weight, surgical findings, splenic size and histology, blood and tissue culture and hematological data. The dogs adequately withstood the standardized trauma regardless of local contamination. And the nylon mesh effectively arrested bleeding in all animals. At sacrifice inoculated germs were confirmed in the contaminated group by histological methods or tissue cultures. A cellular infiltrate of lymphocytes and plasmocytes was present close to the mesh only in the latter. The mesh attached to the injured spleen did not lead to abscesses, intrasplenic or intraperitoneal fluid collections. Based on analysis of the data, we can infer that local contamination of the injured spleen and the presence of non-absorbable material (nylon mesh) did not markedly alter the overall behavior of the dogs compared to the uncontaminated group.

[Ambulatory anorectal surgery under local anesthesia: analysis of 351 procedures]

Three hundred and twenty-eight patients with anorectal diseases were submitted ambulatory surgery, under local anesthesia, in a three-year period. Three hundred and fifty one operations were performed in outpatient service. Local anesthesia by Hook-Needle Puncture technique was used in 37 operations and the rest of them by classical technique through infiltration of both lateral anal quadrants. Hemorrhoids, fistulas, fissures and pilonidal cysts were the most frequent diseases treated (71.6%). The incidence of early and late complications was 19.6% and 4.8%, respectively. The most common complication was severe pain (16.1%). Five patients (1.5%) required hospitalization due postoperative complications. The surgery on an outpatient basis was a well-accepted procedure for two hundred eighty-eight patients (88%). The main benefit reported by patients was the possibility of recovery at home, which is more comfortable. The ambulatory anorectal surgery under local anesthesia is a safe and effective method, with the additional advantage of the costs saved and increase of available beds for more complex surgery.

[Transsacral rectopexy for treatment of bleeding rectal prolapse in a patient with severe liver disease: case report]

Rectal procidentia is an uncommon but debilitating condition that often affects elderly patients with significant medical problems. Fecal incontinence is usually frequent. Abdominal rectopexy with or without sigmoid resection repeatedly demonstrate lower recurrence rates (2-4%) but in high-risk patients, morbidity and mortality may be significant. Perineal or transacral approaches may be used in these patients to avoid the complications of abdominal procedures and general anesthesia. The lack of experience with transacral approach has limited your utilization by colon and rectal surgeons. We describe a case of rectal procidentia in patient with severe liver disease (Child C) sucssefull treated with transacral rectopexy, detailing the technique used.

[True splenic cyst treated with++videolaparoscopy. Case report and review of the literature]

True non-parasitic splenic cysts are uncommon, their real incidence is difficult to determine since over 30% are asymptomatic. Preoperatively these cysts are rarely diagnosed correctly and they are often findings on examinations. Partial or total splenectomy is the treatment of choice after ruling out splenic hydatidosis, since it is responsible for two thirds of global incidence. Currently, with the technological advances of surgery, especially of videolaparoscopy, some authors have proposed its use for partial cystectomy or splenectomy. The authors present the case of a true splenic cyst (epidermoid) which was resected videolaparoscopically and they discuss aspects of diagnosis and management.

Genetics and colorectal cancer (HNPCC) in adolescence. A case report

The authors report a case of non-polyposis colon cancer in a seventeen year old female without prior polyposis or family history. Since it was the first case in this family, HNPCC was suspected. The polymerase chain reaction (PCR) of the tumor revealed changes in four polymorphic regions. Analysis of two of them, indicated the loss of genetic material confirming instability suggestive of HNPCC. The patient underwent ileorectal anastomosis and adjuvant chemotherapy with a good outcome. The authors discuss the importance of family history, genetic and immunohistochemistry studies, and the instability of microsatellites in adolescents with colorectal cancer.

[Penetrating trauma of the neck: prospective study of 53 cases]

The treatment of penetrating injuries of the neck is still controversial nowadays, especially when there is doubt concerning the existence of any anatomic structure lesion. The delay to indicate surgical cervical exploration may predispose the patient to have serious sequels when the esophagus or the trachea are injured. The infection which may occur in this eventuality progresses rapidly to the mediastinum, determining the patient's death. The purpose of this work was to identify and to analyze the parameters which suggest the best treatment indicated for patients with penetrating injuries of the neck. This is a non-randomized prospective study which gathered 53 patients, victims of penetrating wounds of the neck, treated at the Emergency Surgical Service of the Hospital das Clínicas, University of São Paulo School of Medicine, during a three-year period, starting in October, 1990. All the patients were evaluated by the surgical team on call who elected the selective exploration approach for the cases that did not present clear evidence of injuries in the cervical structures nor hemodynamic alterations. For the fifteen carriers of evident injuries, immediate surgical exploration was the treatment adopted. All the patients had epidemiologic data, evaluation results, hospitalization period, complications, morbidity and mortality rates, besides trauma indexes, collected. For patients whose clinical observation was allowed, endoscopic studies were also performed and compared. In order to evaluate variable correlations, statistical analysis were performed using Q square test, Student test and Z statistics, which leaded to the following conclusions: 1. Penetrating wounds of the neck were most frequent in white people aged from 20 to 30 years. They were mostly located in the right side of cervical zone II and were caused by gunshot. 2. Trauma indexes correlated with patients' clinical evolution. 3. In cases when there was doubt about the effective presence of injuries, complementary digestive and respiratory evaluations were indicated. These exams contributed for reducing the rate of unnecessary surgical explorations.

[Villous and tubulovillous adenomas of the colon and rectum. Results in 30 patients]

Colorectal adenomas precede carcinomas as much as they become larger and present villous histology. Since colonoscopic polypectomy cannot remove all polyps, surgical options include local resection as well as segmental colectomy. Significant morbidity and high recurrence rates may occur following individual and polyp-related characteristics. This paper focuses the clinical aspects of colorectal tubulo-villous adenomas and the results of the surgical treatment.

PATIENTS AND METHODS

Hospital charts from 30 patients who underwent surgical treatment of colorectal tubulovillous adenomas between 1980 and 1997 were retrospectively reviewed.

RESULTS

Rectal bleeding, urgency and mucus discharge were the most frequent clinical findings. Proctologic examination (digital and rigid rectosigmoidoscopy) diagnosed the lesion for the majority of cases. Seventy per cent of the polyps were in the distal rectum and 60% were larger than 4 cm. Transanal resection was the surgical option for one half of the patients and segmental colectomy for the other. Fourty-two per cent of the polyps that were considered benign as result of preoperative biopsy showed malignant transformation when the whole polyp was examined. Recurrence rate was 26.7% and 6.7% for patients who underwent local resection and segmental colectomy respectively. Postoperative complication rate was similar for the two surgical groups.

CONCLUSIONS

Recurrence may occur frequently after standard local resection. Preoperative biopsy examination has no role for the diagnosis of malignant transformation. Office proctologic examination diagnoses majority of colorectal polyps that may be elected for surgical resection.

[Muscle-aponeurotic transposition for treatment of anal incontinence]

The management of anal incontinence varies. It can be treated either clinically or surgically depending on its etiology and the intensity of the signs and symptoms. The variety of procedures and techniques employed in its treatment is proof of the incomprehension of the pathophysiological mechanisms involved as well as their diversity. Sphincteroplasties are indicated for those patients with well-defined muscle injury, usually resulting from obstetrical trauma, iatrogenic surgery or vehicular accidents. In cases of persistent anal incontinence after previous sphincteroplasty or those in which extensive destruction of the sphincteric musculature is confirmed, muscle-aponeurotic transpositions are an attractive option. A detailed survey of the literature of the chief techniques utilized and their results is presented.

[Colonoscopy as a diagnostic and therapeutic method in large intestine diseases. Results of 1715 exams]

Widespread use of colonoscopy in clinical practice results from the continuous progress of the techniques developed for exam completion and from the therapeutic perspective for several colorectal conditions. This paper analyses in a retrospective basis the results associated to the employment of fibrocolonoscopy between 1984 and 1995 at Discipline of Coloproctology from the University of São Paulo School of Medicine. For this period, 1,715 exams were realized. More than 50% of the patients were between the 50th and 70th decade. Habit change of hemorrhage were indications for the exam in more than 35%. Inflammatory bowel disease and cancer follow-up were indications, respectively, in 18% and 16%. "Express mannitol" bowel prep resulted satisfactory in more than 97% but precluded complete exam for seven (0.4%) patients. In 42.5%, colonoscopic examination was normal. Polyps were found in 248 (14.5%) patients for whom 376 polypectomy procedures were done successfully. Endoscopists could not reach the cecum in 68 (3.9%) patients. Incidence of hemorrhage and perforation was nill for this series. Authors conclude that fibrocolonoscopy remains as a safe and efficient method for the diagnosis and treatment (polypectomy) of common colorectal conditions.

[Colonoscopy: indications, contraindications and complications]

The bioengeneering technological development associated with new medical information transformed colonscopy today in one of the most complete method of investigation on colorrectal diseases. The authors aim to describe the use of colonoscopy as a diagnostic and therapeutic method, its main indications and limitations. The wide utilization of colonoscopy as therapy is emphasized in the polipectomy, the identification of bleeding areas and the hemostasy. Some intervening facts are discussed as copious bleeding, perfuration and post polipectomy syndrome. Finally, the authors report the low morbidity and mortality rates in their personal experience with colonoscopy during the last decade.