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Kimura CMS, Kawaguti FS, Horvat N, Nahas CSR, Marques CFS, Pinto RA, de Rezende DT, Segatelli V, Safatle-Ribeiro AV, Junior UR, Maluf-Filho F, Nahas SC. Magnifying chromoendoscopy is a reliable method in the selection of rectal neoplasms for local excision. Tech Coloproctol 2023; 27:1047-1056. [PMID: 36906661 DOI: 10.1007/s10151-023-02773-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/12/2023] [Indexed: 03/13/2023]
Abstract
PURPOSE Adequate staging of early rectal neoplasms is essential for organ-preserving treatments, but magnetic resonance imaging (MRI) frequently overestimates the stage of those lesions. We aimed to compare the ability of magnifying chromoendoscopy and MRI to select patients with early rectal neoplasms for local excision. METHODS This retrospective study in a tertiary Western cancer center included consecutive patients evaluated by magnifying chromoendoscopy and MRI who underwent en bloc resection of nonpedunculated sessile polyps larger than 20 mm, laterally spreading tumors (LSTs) [Formula: see text] 20 mm, or depressed-type lesions of any size (Paris 0-IIc). Sensitivity, specificity, accuracy, and positive and negative predictive values of magnifying chromoendoscopy and MRI to determine which lesions were amenable to local excision (i.e., [Formula: see text] T1sm1) were calculated. RESULTS Specificity of magnifying chromoendoscopy was 97.3% (95% CI 92.2-99.4), and accuracy was 92.7% (95% CI 86.7-96.6) for predicting invasion deeper than T1sm1 (not amenable to local excision). MRI had lower specificity (60.5%, 95% CI 43.4-76.0) and lower accuracy (58.3%, 95% CI 43.2-72.4). Magnifying chromoendoscopy incorrectly predicted invasion depth in 10.7% of the cases in which the MRI was correct, while magnifying chromoendoscopy provided a correct diagnosis in 90% of the cases in which the MRI was incorrect (p = 0.001). Overstaging occurred in 33.3% of the cases in which magnifying chromoendoscopy was incorrect and 75% of the cases in which MRI was incorrect. CONCLUSION Magnifying chromoendoscopy is reliable for predicting invasion depth in early rectal neoplasms and selecting patients for local excision.
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Affiliation(s)
- C M S Kimura
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
- Department of Surgery, Stanford University School of Medicine, Stanford, USA
| | - F S Kawaguti
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Dr. Arnaldo Av, 251, 2nd Floor, São Paulo, Zip Code 01246-000, Brazil.
| | - N Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - C S R Nahas
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - C F S Marques
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - R A Pinto
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - D T de Rezende
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Dr. Arnaldo Av, 251, 2nd Floor, São Paulo, Zip Code 01246-000, Brazil
| | - V Segatelli
- Division of Pathology, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - A V Safatle-Ribeiro
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Dr. Arnaldo Av, 251, 2nd Floor, São Paulo, Zip Code 01246-000, Brazil
| | - U R Junior
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - F Maluf-Filho
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Dr. Arnaldo Av, 251, 2nd Floor, São Paulo, Zip Code 01246-000, Brazil
| | - S C Nahas
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
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Kawaguti FS, Kimura CMS, Moura RN, Safatle-Ribeiro AV, Nahas CSR, Marques CFS, de Rezende DT, Segatelli V, Cotti GCDC, Ribeiro Junior U, Maluf-Filho F, Nahas SC. Impact of a Routine Colorectal Endoscopic Submucosal Dissection in the Surgical Management of Nonmalignant Colorectal Lesions Treated in a Referral Cancer Center. Dis Colon Rectum 2023; 66:e834-e840. [PMID: 36574289 DOI: 10.1097/dcr.0000000000002554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent data show an increasing number of abdominal surgeries being performed for the treatment of nonmalignant colorectal polyps in the West but in settings in which colorectal endoscopic submucosal dissection is not routinely performed. This study evaluated the number of nonmalignant colorectal lesions referred to surgical treatment in a tertiary cancer center that incorporated magnification chromoendoscopy and endoscopic submucosal dissection as part of the standard management of complex colorectal polyps. OBJECTIVE The study aimed to estimate the number of patients with nonmalignant colorectal lesions referred to surgical resection at our institution after the standardization of routine endoscopic submucosal dissection and to describe outcomes for patients undergoing colorectal endoscopic submucosal dissection. DESIGN Single-center retrospective study from a prospectively collected database of endoscopic submucosal dissections and colorectal surgeries performed between January 2016 and December 2019. SETTING Reference cancer center. PATIENTS Consecutive adult patients with complex nonmalignant colorectal polyps were included. INTERVENTIONS Patients with nonmalignant colorectal polyps were treated by endoscopic submucosal dissection or surgery (elective colectomy, rectosigmoidectomy, low anterior resection, or proctocolectomy). MAIN OUTCOMES MEASURES The primary outcome measure was the percentage of patients referred to colorectal surgery for nonmalignant lesions. RESULTS In the study period, 1.1% of 825 colorectal surgeries were performed for nonmalignant lesions, and 97 complex polyps were endoscopically removed by endoscopic submucosal dissection. The en bloc, R0, and curative resection rates of endoscopic submucosal dissection were 91.7%, 83.5%, and 81.4%, respectively. The mean tumor size was 59 (SD 37.8) mm. Perforations during endoscopic submucosal dissection occurred in 3 cases, all treated with clipping. One patient presented with a delayed perforation 2 days after the endoscopic resection and underwent surgery. The mean follow-up period was 3 years, with no tumor recurrence in this cohort. LIMITATIONS Single-center retrospective study. CONCLUSIONS A workflow that includes assessment of the lesions with magnification chromoendoscopy and resection through endoscopic submucosal dissection can lead to a very low rate of abdominal surgery for nonmalignant colorectal lesions. See Video Abstract at http://links.lww.com/DCR/C123 . IMPACTO DE LA DISECCIN SUBMUCOSA ENDOSCPICA COLORRECTAL DE RUTINA EN EL MANEJO QUIRRGICO DE LESIONES COLORRECTALES NO MALIGNAS TRATADAS EN UN CENTRO ONCOLGICO DE REFERENCIA ANTECEDENTES:Datos recientes muestran un número cada vez mayor de cirugías abdominales realizadas para el tratamiento de pólipos colorrectales no malignos en Occidente, pero no en los entornos donde la disección submucosa endoscópica colorrectal se realiza de forma rutinaria. El estudio evaluó el número de lesiones colorrectales no malignas referidas a tratamiento quirúrgico en un centro oncológico terciario, que incorporó cromoendoscopia de aumento y disección submucosa endoscópica como parte del manejo estándar de pólipos colorrectales complejos.OBJETIVO:Estimar el número de pacientes con lesiones colorrectales no malignas referidos para resección quirúrgica en nuestra institución, después de la estandarización de la disección submucosa endoscópica de rutina y describir los resultados para los pacientes sometidos a disección submucosa endoscópica colorrectal.DISEÑO:Estudio retrospectivo de un solo centro, a partir de una base de datos recolectada prospectivamente de disecciones submucosas endoscópicas y cirugías colorrectales realizadas entre enero de 2016 y diciembre de 2019.AJUSTE:Centro oncológico de referencia.PACIENTES:Pacientes adultos consecutivos con pólipos colorrectales no malignos complejos.INTERVENCIONES:Pacientes con pólipos colorrectales no malignos tratados mediante disección submucosa endoscópica o cirugía (colectomía electiva, rectosigmoidectomía, resección anterior baja o proctocolectomía).PRINCIPALES MEDIDAS DE RESULTADO:La medida de resultado primario fue el porcentaje de pacientes remitidos a cirugía colorrectal por lesiones no malignas.RESULTADOS:En el período, 1,1% de 825 cirugías colorrectales fueron realizadas por lesiones no malignas y 97 pólipos complejos fueron extirpados por. disección submucosa endoscópica. Las tasas de resección en bloque, R0 y curativa de disección submucosa endoscópica fueron 91,7%, 83,5% y 81,4%, respectivamente. El tamaño tumoral medio fue de 59 (DE 37,8) mm. Se produjeron perforaciones durante la disección submucosa endoscópica en 3 casos, todos tratados con clipaje. Un paciente presentó una perforación diferida 2 días después de la resección endoscópica y fue intervenido quirúrgicamente. El seguimiento medio fue de 3 años, sin recurrencia tumoral en esta cohorte.LIMITACIONES:Estudio retrospectivo de un solo centro.CONCLUSIONES:Un flujo de trabajo que incluye la evaluación de las lesiones con cromoendoscopia de aumento y resección a través de disección submucosa endoscópica, puede conducir a una tasa muy baja de cirugía abdominal para lesiones colorrectales no malignas. Consulte Video Resumen en http://links.lww.com/DCR/C123 . (Traducción-Dr. Fidel Ruiz Healy ).
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Affiliation(s)
- Fábio S Kawaguti
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Cintia Mayumi Sakurai Kimura
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Renata Nobre Moura
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | | | - Caio Sergio Rizkallah Nahas
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | | | - Daniel Tavares de Rezende
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Vanderlei Segatelli
- Division of Pathology, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | | | - Ulysses Ribeiro Junior
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Fauze Maluf-Filho
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Sergio Carlos Nahas
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
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Miranda J, Pinto PVA, Kinochita F, Garcia CM, El Homsi M, Vilela de Oliveira C, Pandini RV, Nahas CSR, Nahas SC, Gollub MJ, Horvat N. Mucinous Degeneration on MRI After Neoadjuvant Therapy in Patients With Rectal Adenocarcinoma: Frequency and Association With Clinical Outcomes. AJR Am J Roentgenol 2023; 221:206-216. [PMID: 36919880 PMCID: PMC10777341 DOI: 10.2214/ajr.23.29002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND. Patients with nonmucinous rectal adenocarcinoma may develop mucinous changes after neoadjuvant chemoradiotherapy, which are described as mucinous degeneration. The finding's significance in earlier studies has varied. OBJECTIVE. The purpose of this study was to assess the frequency of mucinous degeneration on MRI after neoadjuvant therapy for rectal adenocarcinoma and to compare outcomes among patients with nonmucinous tumor, mucinous tumor, and mucinous degeneration on MRI. METHODS. This retrospective study included 201 patients (83 women, 118 men; mean age, 61.8 ± 2.2 [SD] years) with rectal adenocarcinoma who underwent neoadjuvant chemoradiotherapy followed by total mesorectal excision from October 2011 to November 2015, underwent baseline and restaging rectal MRI examinations, and had at least 2 years of follow-up. Two radiologists independently evaluated MRI examinations for mucin content, which was defined as T2 hyperintensity in the tumor or tumor bed, and resolved differences by consensus. Patients were classified into three groups on the basis of mucin status: those with nonmucinous tumor (≤ 50% mucin content on baseline and restaging examinations), those with mucinous tumor (> 50% mucin content on baseline and restaging examinations), and those with mucinous degeneration (≤ 50% mucin content on baseline examination and > 50% content on restaging examination). The three groups were compared. RESULTS. Interreader agreement for mucin content, expressed as a kappa coefficient, was 0.893 on baseline MRI and 0.890 on restaging MRI. Of the 201 patients, 156 (77.6%) had nonmucinous tumor, 34 (16.9%) had mucinous tumor, and 11 (5.5%) had mucinous degeneration. Mucin status was not significantly associated with complete pathologic response (p = .41) or local or distant recurrence (both p > .05). The death rate during follow-up was not significantly different (p = .21) between patients with nonmucinous tumor (23.1%), those with mucinous tumor (29.4%), and those with mucinous degeneration (9.1%). In adjusted Cox regression analysis, with mucinous degeneration used as reference, the HR for the overall survival rate for the mucinous tumor group was 4.7 (95% CI, 0.6-38.3; p = .14), and that for the nonmucinous tumor group was 8.0 (95% CI, 0.9-59.9; p = .06). On histopathologic assessment, all 11 patients with mucinous degeneration showed acellular mucin, yet 10 of 11 patients showed viable tumor (i.e., in nonmucinous portions of the tumors). CONCLUSION. Mucinous degeneration on MRI is not significantly associated with pathologic complete response, recurrence, or survival. CLINICAL IMPACT. Mucinous degeneration on MRI is uncommon and should not be deemed an indicator of pathologic complete response.
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Affiliation(s)
- Joao Miranda
- Department of Radiology, University of Sao Paulo, Sao Paulo, Brazil
| | | | | | | | - Maria El Homsi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY 10065
| | - Camila Vilela de Oliveira
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY 10065
| | | | | | - Sergio C Nahas
- Department of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY 10065
| | - Natally Horvat
- Department of Radiology, University of Sao Paulo, Sao Paulo, Brazil
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY 10065
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Miranda J, Horvat N, Assuncao AN, de M Machado FA, Chakraborty J, Pandini RV, Saraiva S, Nahas CSR, Nahas SC, Nomura CH. MRI-based radiomic score increased mrTRG accuracy in predicting rectal cancer response to neoadjuvant therapy. Abdom Radiol (NY) 2023; 48:1911-1920. [PMID: 37004557 PMCID: PMC10942660 DOI: 10.1007/s00261-023-03898-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE To develop a magnetic resonance imaging (MRI)-based radiomics score, i.e., "rad-score," and to investigate the performance of rad-score alone and combined with mrTRG in predicting pathologic complete response (pCR) in patients with locally advanced rectal cancer following neoadjuvant chemoradiation therapy. METHODS This retrospective study included consecutive patients with LARC who underwent neoadjuvant chemoradiotherapy followed by surgery from between July 2011 to November 2015. Volumes of interest of the entire tumor on baseline rectal MRI and of the tumor bed on restaging rectal MRI were manually segmented on T2-weighted images. The radiologist also provided the ymrTRG score on the restaging MRI. Radiomic score (rad-score) was calculated and optimal cut-off points for both mrTRG and rad-score to predict pCR were selected using Youden's J statistic. RESULTS Of 180 patients (mean age = 63 years; 60% men), 33/180 (18%) achieved pCR. High rad-score (> - 1.49) yielded an area under the curve (AUC) of 0.758, comparable to ymrTRG 1-2 which yielded an AUC of 0.759. The combination of high rad-score and ymrTRG 1-2 yielded a significantly higher AUC of 0.836 compared with ymrTRG 1-2 and high rad-score alone (p < 0.001). A logistic regression model incorporating both high rad-score and mrTRG 1-2 was built to calculate adjusted odds ratios for pCR, which was 4.85 (p < 0.001). CONCLUSION Our study demonstrates that a rectal restaging MRI-based rad-score had comparable diagnostic performance to ymrTRG. Moreover, the combined rad-score and ymrTRG model yielded a significant better diagnostic performance for predicting pCR.
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Affiliation(s)
- Joao Miranda
- Department of Radiology, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA.
| | - Antonildes N Assuncao
- Department of Radiology, University of Sao Paulo, Sao Paulo, SP, Brazil
- Research and Education Institute, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil
| | | | - Jayasree Chakraborty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Samya Saraiva
- Department of Radiology, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil
| | | | | | - Cesar Higa Nomura
- Department of Radiology, University of Sao Paulo, Sao Paulo, SP, Brazil
- Department of Radiology, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil
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de Paiva ACM, Nahas SC, Kimura CMS, Moniz CMV, Marques CFS, Júnior UR, Nahas CSR. Salvage Surgery for Anal Squamous Cell Carcinoma: Still a Difficult Challenge. J Gastrointest Surg 2022:10.1007/s11605-022-05486-8. [PMID: 36509896 DOI: 10.1007/s11605-022-05486-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/20/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Aline Costa Mendes de Paiva
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Sergio Carlos Nahas
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Cintia M S Kimura
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Camila Motta Venchiarutti Moniz
- Division of Clinical Oncology, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Carlos Frederico Sparapan Marques
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Ulysses Ribeiro Júnior
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil
| | - Caio Sergio Rizkallah Nahas
- Division of Gastrointestinal Surgery, Instituto Do Câncer Do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP-ICESP), São Paulo, Brazil.
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Kimura CMS, Kawaguti FS, Nahas CSR, Marques CFS, Segatelli V, Martins BC, de Paulo GA, Cecconello I, Ribeiro-Junior U, Nahas SC, Maluf-Filho F. Long-term outcomes of endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors. J Gastroenterol Hepatol 2021; 36:1634-1641. [PMID: 33091219 DOI: 10.1111/jgh.15309] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/28/2020] [Accepted: 10/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Endoscopic submucosal dissection and transanal endoscopic microsurgery are good options for the treatment of rectal adenomas and early rectal carcinomas, but whether long-term outcomes of these procedures are comparable is not known. The aim of this study was to address this question. METHODS A retrospective single-center study evaluating 98 consecutive procedures between June 2008 and December 2017 was performed in a tertiary cancer center. Consecutive patients who had undergone either endoscopic submucosal resection or transanal endoscopic microsurgery for rectal adenomas and early rectal carcinomas were evaluated, and long-term recurrence and complication rates were compared. RESULTS Both groups were similar regarding sex, age, preoperative surgical risk, and en bloc resection rate (95.7% in the endoscopic and 100% in the surgical group, P = 0.81). Mean follow-up period was 37.6 months. Lesions resected endoscopically were significantly larger (68.5 mm) than those resected by transanal resection (44.5 mm), P = 0.003. Curative resections occurred in 97.2% of endoscopic resections and 85.2% of the surgical ones (P = 0.04). Comparing resections that fulfilled histologic curative criteria, there were no recurrences in the endoscopic group (out of 69 cases) and two recurrences in the transanal group (8.3% of 24 cases), P = 0.06. Late complications occurred in 12.7% of endoscopic procedures and 25.9% of surgical procedures (P = 0.13). CONCLUSIONS In our experience, endoscopic submucosal resection seems to have advantages over transanal endoscopic microsurgery, with similar en bloc resection rate and lower rate of late complications and recurrences. Multicenter randomized controlled trials are needed to support our findings.
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Affiliation(s)
| | | | | | | | | | | | | | - Ivan Cecconello
- Division of Gastrointestinal Surgery, Institute of Cancer of São Paulo, São Paulo, Brazil
| | - Ulysses Ribeiro-Junior
- Division of Gastrointestinal Surgery, Institute of Cancer of São Paulo, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Division of Gastrointestinal Surgery, Institute of Cancer of São Paulo, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Division of Endoscopy, Institute of Cancer of São Paulo, São Paulo, Brazil
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Sobrado LF, Nahas CSR, Marques CFS, Cotti GCDC, Imperiale AR, Averbach P, de Meira JD, Horvat N, Ribeiro-Júnior U, Cecconello I, Nahas SC. Is it Safe to Perform Elective Colorectal Surgical Procedures during the COVID-19 Pandemic? A Single Institution Experience with 103 Patients. Clinics (Sao Paulo) 2021; 76:e2507. [PMID: 33787677 PMCID: PMC7955150 DOI: 10.6061/clinics/2021/e2507] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 02/01/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Since the outbreak of the novel coronavirus disease 2019 (COVID-19), all health services worldwide underwent profound changes, leading to the suspension of many elective surgeries. This study aimed to evaluate the safety of elective colorectal surgery during the pandemic. METHODS This was a retrospective, cross-sectional, single-center study. Patients who underwent elective colorectal surgery during the COVID-19 pandemic between March 10 and September 9, 2020, were included. Patient data on sex, age, diagnosis, types of procedures, hospital stay, mortality, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) preoperative screening tests were recorded. RESULTS A total of 103 colorectal surgical procedures were planned, and 99 were performed. Four surgeries were postponed due to positive preoperative screening for SARS-CoV-2. Surgical procedures were performed for colorectal cancer (n=90) and inflammatory bowel disease (n=9). Laparoscopy was the approach of choice for 43 patients (43.4%), 53 (53.5%) procedures were open, and 3 (3%) procedures were robotic. Five patients developed COVID-19 in the postoperative period, and three of them died in the intensive care unit (n=3/5, 60% mortality). Two other patients died due to surgical complications unrelated to COVID-19 (n=2/94, 2.1% mortality) (p<0.01). Hospital stay was longer in patients with SARS-CoV-2 infection than in those without (38.4 versushttps://doi.org/10.3 days, respectively, p<0.01). Of the 99 patients who received surgical care during the pandemic, 94 were safely discharged (95%). CONCLUSION Our study demonstrated that elective colorectal surgical procedures may be safely performed during the pandemic; however, preoperative testing should be performed to reduce in-hospital infection rates, since the mortality rate due to SARS-CoV-2 in this setting is particularly high.
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Affiliation(s)
- Lucas Faraco Sobrado
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mails: /
| | - Caio Sergio Rizkallah Nahas
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Carlos Frederico Sparapan Marques
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Guilherme Cutait de Castro Cotti
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Antônio Rocco Imperiale
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Pedro Averbach
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - José Donizeti de Meira
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Natally Horvat
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Departamento de Radiologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Ulysses Ribeiro-Júnior
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ivan Cecconello
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Sergio Carlos Nahas
- Divisao de Cirurgia Gastrointestinal e Colorretal, Departamento de Gastroenterologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Nahas SC, Nahas CSR, Bustamante-Lopez LA, Pinto RA, Marques CFS, Cecconello I. Outcomes of surgical treatment for patients with distal rectal cancer: A retrospective review from a single university hospital. Rev Gastroenterol Mex (Engl Ed) 2020; 85:180-189. [PMID: 32057523 DOI: 10.1016/j.rgmx.2019.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/19/2019] [Accepted: 05/30/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND AIM Surgery for distal rectal cancer (DRC) can be performed with or without sphincter preservation. The aim of the present study was to analyze the outcomes of two surgical techniques in the treatment of DRC patients: low anterior resection (LAR) and abdominoperineal resection (APR). METHODS Patients with advanced DRC that underwent surgical treatment between 2002 and 2012 were evaluated. We compared the outcomes of the type of surgery (APR vs LAR) and analyzed the associations of survival and recurrence with the following factors: age, sex, tumor location, lymph nodes obtained, lymph node involvement, and rectal wall involvement. Patients with distant metastases were excluded. RESULTS A total of 148 patients were included, 78 of whom were females (52.7%). The mean patient age was 61.2years. Neoadjuvant chemoradiation therapy was performed in 86.5% of the patients. APR was performed on 86 (58.1%) patients, and LAR on 62 (41.9%) patients. No differences were observed between the two groups regarding clinical and oncologic characteristics. Eighty-seven (62%) patients had pT3-4 disease, and 41 patients (27.7%) had lymph node involvement. In the multivariate analysis, only poorly differentiated tumors (P=.026) and APR (P=.009) correlated with higher recurrence rates. Mean follow-up time was 32 (16-59.9) months. Overall 5-year survival was 58.1%. The 5-year survival rate was worse in patients that underwent APR (46.5%) than in the patients that underwent LAR (74.2%) (P=.009). CONCLUSIONS Patients with locally advanced DRC that underwent APR presented with a lower survival rate and a higher local recurrence rate than patients that underwent LAR. In addition, advanced T/stage, lymph node involvement, and poor tumor differentiation were associated with recurrence and a lower survival rate, regardless of the procedure.
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Affiliation(s)
- S C Nahas
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - C S R Nahas
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - L A Bustamante-Lopez
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil.
| | - R A Pinto
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - C F S Marques
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - I Cecconello
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
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Nahas CSR, Nahas SC, Bustamante-Lopez L, Sparapan CMF, Ortega C, Azambuja R, Ribeiro U, Cotti GC, Imperiale AR, Cecconello I. T≤2N0 TRG1-2 in Post-Chemoradiation Therapy MRI: What can it Predict? Surg Technol Int 2019; 35:161-168. [PMID: 31687781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Total mesorectal excision is the standard radical operation after neoadjuvant chemoradiotherapy for patients with middle/low locally advanced rectal cancer. However, it carries significant rates of morbidity, sexual/urinary dysfunction, fecal impairment and permanent stoma. The ability to identify patients with a complete or nearly-complete response could help steer patients to less-invasive surgery or a watch-and-wait strategy. OBJECTIVE To assess the ability to predict good responders and a favorable prognosis among rectal cancer patients by post-chemoradiation therapy MRI. PATIENTS Consecutive patients stage T3-4N0M0 or T(any)N+M0 located within 10cm from the anal verge were enrolled. Patients were staged and re-staged 8.8 weeks after the completion of chemoradiation by digital exam, colonoscopy, pelvic-MRI, and thorax and abdominal CT scans. All patients underwent total mesorectal excision with curative intent. RESULTS Of the total 309 patients, 275 were eligible, and 199 (72.4%) of these were stage III. Restaging-MRI identified 59 (21.4%) T=2N0/TRG1-2. Specimen pathologic evaluation revealed 43 (15.6%) patients with a complete pathologic response. Estimates of the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of MRIyT=2N0/TRG1-2 for the identification of ypT0N0 were 79.7%, 84.5%, 53.5%, 39%, and 90.7%, respectively. Estimates for the identification of ypN0 were 48.4%, 27.8%, 92%, 88.1%, and 48.4%, respectively. In a multivariate analysis, the only pre-CRT/MRI variables that were associated with an increased risk of lymph node involvement at the specimen were N+ (OR=2.22) and extramural vascular invasion (OR=2.28). MRI yT=2N0/TRG1-2 patients showed improved estimated 5-year disease-free survival, but no difference in estimated 5-year survival. CONCLUSION Although MRIyT=2N0/TRG1-2 cannot predict all cases of a complete pathologic response, it can effectively predict a low rate of lymph node involvement and a better prognosis in patients who undergo total mesorectal excision.
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Affiliation(s)
- Caio Sergio Rizkallah Nahas
- Instituto do Cãncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICESP-HCFMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Instituto do Cãncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICESP-HCFMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Leonardo Bustamante-Lopez
- Instituto do Cãncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICESP-HCFMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Marques Frederico Sparapan
- Instituto do Cãncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICESP-HCFMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Cinthia Ortega
- Instituto do Cãncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICESP-HCFMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Rodrigo Azambuja
- Instituto do Cãncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICESP-HCFMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Ulysses Ribeiro
- Instituto do Cãncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICESP-HCFMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Guilherme Cutait Cotti
- Instituto do Cãncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICESP-HCFMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Antonio Rocco Imperiale
- Instituto do Cãncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICESP-HCFMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Ivan Cecconello
- Instituto do Cãncer do Estado de São Paulo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICESP-HCFMUSP), Universidade de São Paulo, São Paulo, Brazil
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Nahas SC, Nahas CSR, Cama GM, de Azambuja RL, Horvat N, Marques CFS, Menezes MR, Junior UR, Cecconello I. Diagnostic performance of magnetic resonance to assess treatment response after neoadjuvant therapy in patients with locally advanced rectal cancer. Abdom Radiol (NY) 2019; 44:3632-3640. [PMID: 30663025 DOI: 10.1007/s00261-019-01894-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Our study aimed to evaluate the diagnostic performance of rectal magnetic resonance imaging (MRI) for local restaging in patients with non-metastatic locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (CRT) using surgical histopathology of total mesorectal excision as the reference standard. METHODS Ninety-five patients with LARC who underwent rectal MRI after CRT between January 2014 and December 2016 were included. Accuracy, sensitivity, specificity, positive, and negative predictive value for local staging regarding T-stage, N-stage, circumferential resection margin, and MRI tumor regression grade (ymriTRG) were calculated, and inter-test agreements were assessed. RESULTS 22/95 (23.2%) patients had radiological complete response (rCR), whereas 20/95 (21.1%) had pathological complete response (pCR). Among the patients with pCR, 11/20 (55%) had rCR. Fair agreement was demonstrated between ymriTRG and pathological TRG (ypTRG) (κ = 0.255). The sensitivity and specificity for detection of pCR were 61.1% (95% CI 35.7-82.7) and 89.6% (95% CI 80.6-95.4). For the detection of ypTRG grades 1 and 2, the corresponding values were 67.2% (95% CI 54.3-78.4) and 51.6 (95% CI 33.1-69.8). The accuracy of ymriTRG was 24.2% (95% CI 15.6-32.8). Inter-test agreement in TRG between MRI and pathology was overall fair (κ = 0.255) and slight (κ = 0.179), if TRG 1 + 2. CONCLUSION Qualitative assessment on MRI for diagnosing pCR showed moderate sensitivity and high specificity, whereas the diagnosis of TRG had moderate sensitivity and low specificity with slight to fair inter-test agreement when compared with pathological specimens.
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Souza JLDCAD, Nahas CSR, Nahas SC, Marques CFS, Ribeiro Júnior U, Cecconello I. HEALTH-RELATED QUALITY OF LIFE ASSESSMENT IN PATIENTS WITH RECTAL CANCER TREATED WITH CURATIVE INTENT. Arq Gastroenterol 2018; 55:154-159. [PMID: 30043865 DOI: 10.1590/s0004-2803.201800000-27] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/28/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The treatment of median and distal rectal cancer has evolved a lot in the last decades due to the dissemination of the technique of total mesortal excision and the use of neoadjuvant chemotherapy and radiotherapy. However, this multidisciplinary approach can affect patients' quality of life in a number of ways that deserve to be adequately assessed. OBJECTIVE To evaluate immediate and late health related quality of life in patients with rectal cancer treated with curative intent. METHODS Prospective study including patients with non-metastatic mid or low rectal cancer. EORTC QLQ-C30 and EORTC-CR38 questionnaires were applied before, 3 months and 12 months after treatment. The mean scores of the questionnaires were stratified into 4 categories for the purpose of comparing the results at different moments. RESULTS Twenty nine patients completed the 1st and 2nd questionnaires and 12 completed the three questionaries. Patient´s mean age was 50.8 years and 62% were female. Sphincter preservation was possible in 89.6%. Overall health scores and quality of life improved after three months after 12 months. After three months, sexual satisfaction, female sexual problems and future perspective were worsen, but gastrointestinal symptoms, sphincter problems, and weight loss were improved. After 12 months the Future Perspective deteriorated, but there was improvement of the problems related to stoma, sphincter problems and body image. CONCLUSION Despite the complexity of the treatment of rectal cancer within a specialized service, quality of life was preserved and was satisfactory in most of the studied aspects.
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Affiliation(s)
- José Luís da Costa Alves de Souza
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer Divisão Cirúrgica, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Caio Sergio Rizkallah Nahas
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer Divisão Cirúrgica, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Sergio Carlos Nahas
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer Divisão Cirúrgica, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Carlos Frederico Sparapan Marques
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer Divisão Cirúrgica, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Ulysses Ribeiro Júnior
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer Divisão Cirúrgica, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Ivan Cecconello
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer Divisão Cirúrgica, Departamento de Gastroenterologia, São Paulo, SP, Brasil
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Bustamante-Lopez LA, Nahas CSR, Nahas SC, Marques CFS, Pinto RA, Cotti GC, Imperiale AR, de Mello ES, Ribeiro U, Cecconello I. Pathologic complete response implies a fewer number of lymph nodes in specimen of rectal cancer patients treated by neoadjuvant therapy and total mesorectal excision. Int J Surg 2018; 56:283-287. [PMID: 29981939 DOI: 10.1016/j.ijsu.2018.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/30/2018] [Accepted: 07/02/2018] [Indexed: 12/26/2022]
Abstract
Studies have suggested that the use of neoadjuvant chemoradiation results in a lower lymph nodes yield in rectal cancer patients. OBJECTIVE To evaluate factors associated with less than 12 lymph nodes harvested on patients with rectal cancer treated with preoperative chemoradiotherapy followed by total mesorectal excision. PATIENTS This was a cohort/retrospective single cancer center study. Low and mid locally advanced rectal cancer or T2N0 under risk of sphincter resection underwent chemoradiotherapy followed by total mesorectal excision with curative intent. Chemotherapy consisted of 5-FU and leucovorin IV. Total dose of pelvic radiation was 5040 Gys. All patients were staged and restaged by digital rectal examination, proctoscopy, colonoscopy, CT of abdomen and chest, and MRI of the pelvis. Patients were stratified in two groups: ≥12 and < 12 L N retrieved. The possible factors affecting number of LN were analyzed. RESULTS 95 patients met the inclusion criteria. Mean LN harvest was 23.2 (3-67). 81 patients (85%) had ≥12 L N. Gender, age, tumor size, tumor stage, tumor location, length of specimen, presence of LN involvement, type of surgery, and surgical access showed no association with number of LN retrieved. Only pathological complete response showed a statistically significant association with <12 L N on univariate (p = 0.004) and multivariate analyses (p = 0.002). LIMITATIONS Data were collected retrospectively. The number of patients disparity between the two groups. CONCLUSIONS Complete pathologic response is associated with <12 L N harvested. Thus, the number of lymph nodes should not be used as a surrogate for oncologic adequacy of resection in patients with pathologic complete response.
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Affiliation(s)
| | - Caio Sergio Rizkallah Nahas
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Rodrigo Ambar Pinto
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Guilherme Cutait Cotti
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Antonio Rocco Imperiale
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Evandro Sobroza de Mello
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
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Nahas CSR, Nahas SC, Ribeiro-Junior U, Bustamante-Lopez L, Marques CFS, Pinto RA, Imperiale AR, Cotti GC, Nahas WC, Chade DC, Piato DS, Busnardo F, Cecconello I. Prognostic factors affecting outcomes in multivisceral en bloc resection for colorectal cancer. Clinics (Sao Paulo) 2017; 72:258-264. [PMID: 28591336 PMCID: PMC5439112 DOI: 10.6061/clinics/2017(05)01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/20/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES: This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer. METHODS: Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155. RESULTS: The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement. CONCLUSIONS: Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes.
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Affiliation(s)
- Caio Sergio Rizkallah Nahas
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Sergio Carlos Nahas
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ulysses Ribeiro-Junior
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Leonardo Bustamante-Lopez
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Carlos Frederico Sparapan Marques
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rodrigo Ambar Pinto
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Antonio Rocco Imperiale
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Guilherme Cutait Cotti
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - William Carlos Nahas
- Servico de Urologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Daher Cezar Chade
- Servico de Urologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Dariane Sampaio Piato
- Servico de Ginecologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fabio Busnardo
- Servico de Cirurgia Plastica, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ivan Cecconello
- Servico de Cirurgia Gastrointestinal, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Nahas SC, Nahas CSR, Bustamante-Lopez LA, Pinto RA, Marques CFS, Campos FG, Ceconello I. Prognostic factors of surgically-treated patients with cancer of the right colon: a ten years' experience of a single universitary institution. Arq Bras Cir Dig 2016; 28:3-7. [PMID: 25861059 PMCID: PMC4739258 DOI: 10.1590/s0102-67202015000100002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/11/2014] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Sergio Carlos Nahas
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Rodrigo Ambar Pinto
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Fabio Guilherme Campos
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ivan Ceconello
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Nahas CSR, Nahas SC, Marques CFS, Schmerling R, Bustamante-Lopez LA, Ribeiro U, Cecconello I. Gastrointestinal stromal tumor of the rectum treated with neoadjuvant Imatinib followed by transanal endoscopic microsurgery. Arq Bras Cir Dig 2016; 28:87-9. [PMID: 25861079 PMCID: PMC4739257 DOI: 10.1590/s0102-67202015000100022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 11/25/2014] [Indexed: 12/12/2022]
Affiliation(s)
| | - Sergio Carlos Nahas
- Clinic Hospital, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Rafael Schmerling
- Clinic Hospital, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Ulysses Ribeiro
- Clinic Hospital, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Ivan Cecconello
- Clinic Hospital, School of Medicine, University of São Paulo, São Paulo, Brazil
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Kawaguti FS, Martins BC, Nahas CSR, Marques CFS, Ribeiro U, Nahas SC, Maluf-Filho F. Endoscopic radial incision and cutting procedure for a colorectal anastomotic stricture. Gastrointest Endosc 2015; 82:408-9. [PMID: 25957477 DOI: 10.1016/j.gie.2015.03.1975] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 03/25/2015] [Indexed: 02/08/2023]
Affiliation(s)
| | | | | | | | - Ulysses Ribeiro
- Cancer Institute, São Paulo University Medical School, São Paulo, Brazil
| | | | - Fauze Maluf-Filho
- Cancer Institute, São Paulo University Medical School, São Paulo, Brazil
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Moreira AM, Marques CFS, Antunes AA, Nahas CSR, Nahas SC, de Gregorio Ariza MÁ, Carnevale FC. Transient Ischemic Rectitis as a Potential Complication after Prostatic Artery Embolization: Case Report and Review of the Literature. Cardiovasc Intervent Radiol 2013; 36:1690-1694. [DOI: 10.1007/s00270-013-0739-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 08/25/2013] [Indexed: 12/20/2022]
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Araujo SEA, Bammann RH, Seid VE, Nahas SC, Nahas CSR, Cecconello I. Neoadjuvant chemoradiation therapy followed by curative transanal endoscopic microsurgery (TEM) for rectal cancer complicated by major suture dehiscence: avoiding ileostomy through hyperbaric oxygen therapy. Int J Colorectal Dis 2011; 26:1359-61. [PMID: 21249373 DOI: 10.1007/s00384-011-1131-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2011] [Indexed: 02/04/2023]
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Nahas SC, Pinto RA, Dias AR, Nahas CSR, Araújo SEA, Marques CFS, Cecconello I. Long-term follow up of abdominal rectosigmoidectomy with posterior end-to-side stapled anastomosis for Chagas megacolon. Colorectal Dis 2011; 13:317-22. [PMID: 19906053 DOI: 10.1111/j.1463-1318.2009.02128.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- S C Nahas
- Division of Colorectal Surgery, School of Medicine, University of São Paulo, São Paulo, Brazil.
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Araujo SEA, Seid VE, Dumarco RB, Nahas CSR, Nahas SC, Cecconello I. Surgical outcomes after preceptored laparoscopic colorectal surgery: results of a Brazilian preceptorship program. Hepatogastroenterology 2009; 56:1651-1655. [PMID: 20214211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
- Sergio Eduardo Alonso Araujo
- Discipline of Coloproctology, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo, Brazil.
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Chang AJBA, Nahas CSR, Araujo SEA, Nahas SC, Marques CFS, Kiss DR, Cecconello I. Early rectal cancer: local excision or radical surgery? J Surg Educ 2008; 65:67-72. [PMID: 18308284 DOI: 10.1016/j.jsurg.2007.11.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Accepted: 11/06/2007] [Indexed: 05/26/2023]
Abstract
BACKGROUND Sphincter preservation, disease control, and long-term survival are the main goals in the treatment of rectal cancer. Although transanal local excision is attractive because it is a sphincter sparing procedure, some contradictory data exist in the literature about its ability to locally control disease and provide overall survival comparable with radical procedures, even for patients with early stage tumor. PURPOSE To compare transanal local excision and radical surgery treatment results based on the appropriate data in literature. METHODS We reviewed the literature to identify the current recurrence and survival rates of both techniques as well as the salvage surgery success. A PubMed search of the last 10 years was performed, and a total of 10 nonrandomized studies were identified; only 1 study was prospective, 5 were comparative, and 5 were case reports. RESULTS Five-year overall survival rate varied from 69% to 83% in the local excision group versus 82% to 90% for the radical excision group. Local recurrence rates ranged from 9% to 20% for local excision and from 2% to 9% for radical surgery. Systemic recurrence rates ranged from 6% to 21% for local excision and from 2% to 9% for radical surgery. CONCLUSION Radical surgery is the more definitive cancer treatment; however, it does not eliminate local excision as a reasonable choice for many patients, who will have lesser procedure-related morbidity and will accept an increased risk of tumor recurrence, a prolonged period of postoperative cancer surveillance, and a decreased success rate by salvage surgery.
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Affiliation(s)
- Alexandre Jin Bok Audi Chang
- Department of Gastroenterology, Surgical Division, University of São Paulo, School of Medicine, São Paulo, Brazil
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Nahas SC, Nahas CSR, Silva Filho EVD, Levi JE, Atui FC, Marques CFS. Perianal squamous cell carcinoma with high-grade anal intraepithelial neoplasia in an HIV-positive patient using highly active antiretroviral therapy: case report. SAO PAULO MED J 2007; 125:292-4. [PMID: 18094898 DOI: 10.1590/s1516-31802007000500009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Accepted: 09/21/2007] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Sergio Carlos Nahas
- Surgical Division of Gastroenterology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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Dias AR, Nahas SC, Camargo EE, Nahas CSR. Recent evidences of the use of 18F-fluorodeoxyglucose positron emission tomography in the management of colorectal cancer. J Surg Educ 2007; 64:114-9. [PMID: 17462214 DOI: 10.1016/j.jsurg.2006.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2006] [Revised: 11/07/2006] [Accepted: 11/08/2006] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- Andre Roncon Dias
- Surgical Division, Gastroenterology Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Marques CFS, Nahas SC, Nahas CSR, Sobrado CW, Habr-Gama A, Kiss DR. Early results of the treatment of internal hemorrhoid disease by infrared coagulation and elastic banding: a prospective randomized cross-over trial. Tech Coloproctol 2006; 10:312-7. [PMID: 17115317 DOI: 10.1007/s10151-006-0299-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Accepted: 02/14/2006] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- C F S Marques
- Colorectal Unit, Department of Gastroenterology, School of Medicine University of São Paulo, São Paulo, Brazil
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Abstract
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.
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Affiliation(s)
- L C Pandini
- Department of Digestive Surgery, University of Sao Paulo, Sao Paulo, Brazil.
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Nahas SC, Nahas CSR, Marques CF, Borba MR, Helito AS, Odoni V. Concurrent development of Crohn disease and myelodysplastic syndrome in a child: case report and literature review. Pediatr Hematol Oncol 2006; 23:477-83. [PMID: 16849278 DOI: 10.1080/08880010600803214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Sergio Carlos Nahas
- Department of Gastroenterology-Digestive Surgery Division, Hospital das Clínicas, Medical School, University of São Paulo, São Paulo, Brazil.
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Abstract
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.
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Affiliation(s)
- Angelita Habr-Gama
- Colorectal Unit, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
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Abstract
BACKGROUND Metastases may be the first manifestation of adenocarcinoma. Up to 60% are cutaneous and present in advanced stage neoplasms. Research for the primary site is costly and requires endoscopy, imaging and immunohistochemical exams. The primary site becomes obvious in only 15% to 20% of live patients and is detected mainly at autopsy. AIM To report a case of metastatic cutaneous moderately differentiated adenocarcinoma of unknown primary site, located in the lower left abdomen. RESULTS The lesion was surgically resected. Primary site was not found by any imaging or endoscopy exams. The immunohistochemistry was negative for CEA, CK20, PSA and positive for CK7. Based on these exams, prostate and colorectal cancer were excluded. The pancreas and biliary tract were considered as the probable primary site. CONCLUSION The research for the primary site still is difficult, expensive and is not effective to the treatment of metastatic adenocarcinomas.
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Affiliation(s)
- Caio Sergio Rizkallah Nahas
- Serviço de Cirurgia de Emergência, Divisão Cirúrgica III, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Botucatu, SP.
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