[Show abstract][Hide abstract] ABSTRACT: Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are minimally invasive procedures that can be used to treat early rectal cancer.
The aim of this study was to compare clinical efficacy between ESD and TEM for the treatment of early rectal cancer.
Between July 2008 and August 2011, 24 patients with early rectal cancers were treated by ESD (11) or TEM (13) at the Cancer Institute of São Paulo University Medical School (São Paulo, Brazil). Data were analyzed retrospectively according to database and pathological reports, with respect to en bloc resection rate, local recurrence, complications, histological diagnosis, procedure time and length of hospital stay.
En bloc resection rates with free margins were achieved in 81.8 % of patients in the ESD group and 84.6 % of patients in the TEM group (p = 0.40). Mean tumor size was 64.6 ± 57.9 mm in the ESD group and 43.9 ± 30.7 mm in the TEM group (p = 0.13). Two patients in the TEM group and one patient in the ESD group had a local recurrence. The mean procedure time was 133 ± 94.8 min in the ESD group and 150 ± 66.3 min in the TEM group (p = 0.69). Mean hospital stay was 3.8 ± 3.3 days in the ESD group and 4.08 ± 1.7 days in the TEM group (p = 0.81).
This was a non-randomized clinical trial with a small sample size and selection bias in treatment options.
ESD and TEM are both safe and effective for the treatment of early rectal cancer.
[Show abstract][Hide abstract] ABSTRACT: Prostatic artery embolization (PAE) is an alternative treatment for benign prostatic hyperplasia. Complications are primarily related to non-target embolization. We report a case of ischemic rectitis in a 76-year-old man with significant lower urinary tract symptoms due to benign prostatic hyperplasia, probably related to nontarget embolization. Magnetic resonance imaging revealed an 85.5-g prostate and urodynamic studies confirmed Inferior vesical obstruction. PAE was performed bilaterally. During the first 3 days of follow-up, a small amount of blood mixed in the stool was observed. Colonoscopy identified rectal ulcers at day 4, which had then disappeared by day 16 post PAE without treatment. PAE is a safe, effective procedure with a low complication rate, but interventionalists should be aware of the risk of rectal nontarget embolization.
CardioVascular and Interventional Radiology 10/2013; · 2.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Postoperative pelvic abscesses in patients submitted to colorectal surgery are challenging. The surgical approach may be too risky, and image-guided drainage often is difficult due to the complex anatomy of the pelvis. This article describes novel access for drainage of a pelvic collection using a minimally invasive natural orifice approach.
A 37 year-old man presented with sepsis due to a pelvic abscess during the second postoperative week after a Hartmann procedure due to perforated rectal cancer. Percutaneous drainage was determined by computed tomography to be unsuccessful, and another operation was considered to be hazardous. Because the pelvic fluid was very close to the rectal stump, transrectal drainage was planned. The rectal stump was opened using transanal endoscopic microsurgery (TEM) instruments. The endoscope was advanced through the TEM working channel and the rectal stump opening, accessing the abdominal cavity and pelvic collection.
The pelvic collection was endoscopically drained and the local cavity washed with saline through the scope channel. A Foley catheter was placed in the rectal stump. The patient's recovery after the procedure was successful, without the need for further intervention.
Transrectal endoscopic drainage may be an option for selected cases of pelvic fluid collection in patients submitted to Hartmann's procedure. The technique allows not only fluid drainage but also visualization of the local cavity, cleavage of multiloculated abscesses, and saline irrigation if necessary. The use of TEM instrumentation allows safe access to the peritoneal cavity.
[Show abstract][Hide abstract] ABSTRACT: RACIONAL: A cirurgia para hemorróidas sintomáticas é necessária em quase 10% dos pacientes. Embora, a literatura sobre o tratamento cirúrgico da doença hemorroidária seja muito grande, os dados relativos à hemorroidectomia ou hemorroidopexia realizadas por residentes de treinamento é limitado. OBJETIVO: Analisar os resultados destes procedimentos em uma instituição de ensino. MÉTODOS: Foram analisados retrospectivamente os dados de todos os pacientes que se submeteram ao tratamento cirúrgico para hemorróidas entre1995 e 2007 em uma única instituição. Residentes supervisionados realizaram todos os procedimentos. As técnicas foram comparadas com base no tempo operatório, permanência hospitalar, morbidade e eficácia a longo prazo. RESULTADOS: Trezentos e trinta e três pacientes foram incluídos no estudo, 182 homens (54,6%), com idade média de 45,3 anos (± 12,02). Hemorróidas de terceiro grau foram a principal indicação (81,7%). Milligan-Morgan foi o procedimento mais comumente realizado (57%), seguido por Ferguson e hemorroidopexia grampeada. A média de tempo operatório foi significativamente menor no grupo hemorroidopexia grampeada quando comparado com os procedimentos abertos e fechados: 49,4 ± 29,3 min vs 61,1 ± 26,5 e 67,1 ± 28,3, respectivamente (p=0,0034). Não houve diferença estatisticamente significativa entre os grupos quanto às complicações pós-operatórias ou à taxa de reoperação. O tempo de internação foi significativamente maior no grupo Milligan-Morgan quando comparado com Ferguson e grampeamento (1,41 ± 0,86 dias vs 1,19 ± 0,43 vs 1,16 ± 0,37, respectivamente). Recorrência sintomática, taxas de reoperação e o uso de ligadura elástica foram semelhantes entre os grupos. CONCLUSÃO: Os residentes sob supervisão pode executar Milligan-Morgan, Ferguson e grampeamento hemorroidário com baixa incidência de complicações e bons resultados a longo prazo. O grampeamento foi associado com menor tempo operatório, enquanto Milligan-Morgan foi correlacionada com maior tempo de hospitalização.
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo). 09/2011; 24(3):210-214.
[Show abstract][Hide abstract] ABSTRACT: INTRODUÇÃO: O carcinoma espino-celular do canal anal é doença que atinge os adultos de meia idade e corresponde a 4% dos cânceres do trato gastrointestinal baixo. Na população geral a incidência é de 1 em 100.000 habitantes, e entre os homens que fazem sexo com homens essa incidência atinge 35 por 100.000 habitantes, sendo que os portadores de HIV têm esse risco duplicado (70 por 100.000 habitantes). MÉTODO: Foi realizada revisão da literatura com consulta nos periódicos das bases Medline/Pubmed, Scielo e Lilacs cruzando os descritores Rastreamento, Lesões pré-cancerosas, Neoplasias do ânus e HIV. Além da revisão bibliográfica, foi adicionada a este trabalho a experiência pessoal dos autores, e a obtida no Departamento de Gastroenterologia - Divisão Cirúrgica, no ICESP Instituto do Câncer do Estado de São Paulo Octávio Frias de Oliveira, no Departamento de Moléstias Infeciosas Casa da AIDS e no Serviço de Coloproctologia do Hospital das Clínicas da Universidade de São Paulo, SP, Brasil. CONCLUSÕES: HIV+ é um grande fator de risco no desenvolvimento de carcinoma espino-celular anal em indivíduos infectados por HPV. A avaliação desses pacientes não deve se restringir à erradicação de condilomas, mas principalmente incluir o rastreamento de lesões displásicas subclínicas potencialmente neoplásicas. Apesar dos métodos de rastreamento ainda não serem ideais, o grande benefício do rastreamento baseia-se no fato de oferecer acompanhamento rigoroso, tornando possível à prevenção ou detecção cada vez mais precoce do carcinoma espino-celular anal.
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo). 06/2011; 24(2):168-172.
[Show abstract][Hide abstract] ABSTRACT: INTRODUÇÃO: O tratamento cirúrgico do câncer do reto passou por grande refinamento técnico após a incorporação da excisão total do mesorreto. A possibilidade de tratamento por laparoscopia ainda permanece como motivo de controvérsia. Assim, uma revisão atualizada do assunto é pertinente para ajudar a orientar a conduta aos pacientes com esse tumor. MÉTODO: Foram consultadas as bases de dados disponíveis pelo Medline/Pubmed, Scielo e Lilacs cruzando os seguintes unitermos: câncer colorretal, laparoscopia, cirurgia. CONCLUSÃO: Até a presente data, ainda permanece motivo de controvérsia se o tratamento do câncer de reto deve ser realizado de forma rotineira por laparoscopia. Não existem dados na literatura que suportem a realização minimamente invasiva da excisão total do mesorreto para o tratamento do câncer de reto fora de protocolo de pesquisa, especialmente pela ausência de índices de sobrevida e de recidiva local com pelo menos cinco anos de seguimento.
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo). 03/2011; 24(1):64-67.
[Show abstract][Hide abstract] ABSTRACT: Transanal endoscopic microsurgery (TEM) provides a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. TEM aims to provide an alternative to conventional abdominal surgery (low anterior resection or abdominoperineal amputations), which carries not inconsiderable morbidity and mortality. Based on review of the literature and in the authors experience, this review present the method and indications for TEM.
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo). 03/2010; 23(1).
[Show abstract][Hide abstract] ABSTRACT: 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).
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.
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.
Minimal 10-year follow up of RPESA showed excellent functional results, with no recurrence of constipation.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to analyze the agreement between anal Pap smear and high-resolution anoscopy-guided biopsy in diagnosing anal dysplasia in HIV-infected patients.
We conducted cross-sectional analysis of HIV-infected patients receiving anal dysplasia screening as part of routine care. Agreement between measures was estimated by weighted kappa statistics, using a three-tiered cytologic and histologic grading system (normal, low-grade dysplasia, and high-grade dysplasia). Estimates of sensitivity, specificity, and predictive values were calculated using a two-tiered cytologic and histologic grading system ("without dysplasia" and "with dysplasia of any grade"). Estimates were also calculated for the detection of high-grade dysplasia.
During a one-year period, 222 patients underwent 330 anal Pap smears followed by high-resolution anoscopy-guided biopsies. There were 311 satisfactory Pap smears with concurrent biopsies. Considering histology the standard, the frequency of anal dysplasia was 46%. Kappa agreement between anal Pap smear and biopsy was 0.20. For detection of anal dysplasia of any grade, anal Pap smear showed sensitivity of 61%, specificity of 60%, positive predictive value of 56%, and negative predictive value of 64%. For high-grade dysplasia, anal Pap smear showed sensitivity of 16% and specificity of 97%.
Anal Pap smears alone were not sensitive enough to rule out anal dysplasia. We recommend that high-resolution anoscopy-guided biopsy be incorporated as a complementary screening test for anal dysplasia in high-risk patients. Following baseline high-resolution anoscopy, these individuals could be followed with serial anal cytology to dictate the need for future high-resolution anoscopy-guided biopsies.
Diseases of the Colon & Rectum 11/2009; 52(11):1854-60. · 3.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Transanal endoscopic microsurgery (TEM) was introduced in 1983 as a minimally invasive technique allowing the resection of adenomas and early rectal carcinomas unsuitable for local or colonoscopic excision which would otherwise require major surgery. After 25 years, there is still much debate about the procedure. This article presents the TEM technique, indications, results and complications, focusing on its role in rectal cancer. The controversial points addressed include long-term results, TEM in high-risk T1 lesions, TEM associated with combined modality therapy (CMT) for invasive rectal cancer and salvage therapy after TEM. The future perspectives for TEM are promising and its association with CMT will probably expand the select group of patients who will benefit from the procedure.
Techniques in Coloproctology 07/2009; 13(2):105-11. · 1.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients with locally advanced rectal cancer may present with synchronous distant metastases. Choice of optimal treatment--neoadjuvant chemoradiation versus systemic chemotherapy alone--depends on accurate assessment of distant disease. We prospectively evaluated the ability of [18F]fluorodeoxyglucose ([18F]FDG) positron emission tomography (PET) to detect distant disease in patients with locally advanced rectal cancer who were otherwise eligible for combined modality therapy (CMT).
Ninety-three patients with locally advanced rectal cancer underwent whole-body [18F]FDG PET scanning 2-3 weeks before starting CMT. Sites other than the rectum, mesorectum, or the area along the inferior mesenteric artery were considered distant and were divided into nine groups: neck, lung, mediastinal lymph node (LN), abdomen, liver, colon, pelvis, peripheral LN, and soft tissue. Two nuclear medicine physicians blinded to clinical information used PET images and a five-point scale (0-4) to determine certainty of disease. A score greater than 3 was considered malignant. Confirmation was based on tissue diagnosis, surgical exploration, and subsequent imaging.
At a median follow-up of 34 months, the overall accuracy, sensitivity, and specificity of PET in detecting distant disease were 93.7%, 77.8%, and 98.7% respectively. Greatest accuracy was demonstrated in detection of liver (accuracy = 99.9%, sensitivity = 100%, specificity = 98.8%) and lung (accuracy = 99.9%, sensitivity = 80%, specificity = 100%) disease; PET detected 11/12 confirmed malignant sites in liver and lung. A total of 10 patients were confirmed to have M1 stage disease. All 10 were correctly staged by pre-CMT PET; abdominopelvic computed tomography (CT) scans accurately detected nine of them.
Baseline PET in patients with locally advanced rectal cancer reliably detects metastatic disease in liver and lung. PET may play a significant role in defining extent of distant disease in selected cases, thus impacting the choice of neoadjuvant therapy.
Annals of Surgical Oncology 04/2008; 15(3):704-11. · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
To compare transanal local excision and radical surgery treatment results based on the appropriate data in literature.
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.
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.
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.
Journal of Surgical Education 01/2008; 65(1):67-72. · 1.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Positron emission tomography (PET) is considered a potentially useful diagnostic tool in the management of a variety of malignancies.
It has been used for staging, evaluating recurrent and metastatic disease and tumoral response to neoadjuvant therapy, and
providing prognostic information. However, some data are available about its definitive role in the colorectal cancer (CRC)
population. In this chapter, the most recent evidence and future perspectives are presented for [18F]fluorodeoxyglucose PET in managing patients with CRC.