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The aim of this report is to present an unusual case of Crohn's disease affecting the terminal ileum; whose principal differential diagnosis was Yersinia enterolocolitica infection, as the histological features of the resected ileum was common to both diseases. We also describe how the infectious etiology was discarded and the implications for the patient follow-up. Resumo: O objetivo desse relato é analisar um caso incomum de doença de Crohn, cujo diagnóstico diferencial, com possível infecção por Yersinia enterocilítica, foi dificultado pela presença de alterações histológicas das duas doenças. Descrevemos como foi realizada a exclusão de causas infecciosas e as implicações no acompanhamento do paciente. Keywords: Crohn's disease, Yersinia enterocolitica, Infection, Ileitis, Palavras-chave: Doença de Crohn's, Yersinia enterocolitica, Infecção, Ileíte

Globally, colorectal cancer is the third leading cause of cancer death among men and the second among women, corresponding to about 10% of all cancers. The Brazilian Ministry of Health and National Cancer Institute recommend the screening of colorectal cancer for people over 50 years-old with Fecal Occult Blood Test. Endoscopy is limited to patients with positive screening results. The aim of this study is to evaluate the incidence of malignant or premalignant lesions diagnosed by endoscopy in patients with positive or negative Fecal Occult Blood Test and assess the efficacy of Fecal Occult Blood Test to predict the finding of a malignant colorectal lesion. We carried out a cross-sectional study among patients with a Fecal Occult Blood Test result that were submitted to colonoscopy, in the same hospital, from March 2016 to July 2017. Sensitivity, specificity, positive and negative predictive value of Fecal Occult Blood Test compared to colonoscopy neoplastic findings was calculated. The total of 92 patients were enrolled, 52 (56.5%) were female, Fecal Occult Blood Test was positive in 42.4% of them and in 41 (44.6%) the colonoscopy showed abnormal findings. Polyps were the most frequent alteration, found in 20 patients (21.7%). Among the patients with polyps, 15 (16.3%) had neoplastic and 5 (5.4%) presented non-neoplastic polyps. The Fecal Occult Blood Test sensitivity for detection of neoplastic polyps was 66.7%, specificity 62.3%, positive predictive value 11% and negative predictive value was 94.2%. Considering the need for a screening method, Fecal Occult Blood Test showed to be an effective and reliable screening test that can be applied in public health programs to detect and prevent colorectal cancer. Resumo: Globalmente, o carcinoma colorretal é a terceira principal causa de morte por neoplasia entre homens e a segunda entre mulheres, correspondendo a 10% de todas as neoplasias. O Ministério da Saúde Brasileiro e o Instituto Nacional do Câncer recomendam a triagem do câncer colorretal para indivíduos acima de 50 anos, utilizando a Pesquisa de Sangue Oculto nas fezes. A endoscopia é reservada para aqueles com Pesquisa de Sangue Oculto nas fezes positiva. O objetivo deste estudo é avaliar a incidência de lesões malignas/pré-malignas diagnósticas na colonoscopia e correlacionar com os resultados prévios da Pesquisa de Sangue Oculto e verificar a eficácia da Pesquisa de Sangue Oculto para predizer uma lesão colorretal maligna. Realizamos um estudo transversal em pacientes que apresentavam resultados positivos ou negativos de Pesquisa de Sangue Oculto nas fezes e foram submetidos à colonoscopia, na mesma instituição, entre março de 2016 e julho de 2017. Dos 92 participantes; 52 (56,5%) eram do sexo feminino, a Pesquisa de Sangue Oculto nas fezes foi positiva em 42,4%; e em 41 (44,6%) a colonoscopia mostrou alterações. Em 20 pacientes (21,7%) havia pólipos; 15 (16,3%) eram neoplásicos e 5 (5,4%) não neoplásicos. A sensibilidade da Pesquisa de Sangue Oculto nas fezes para detecção de pólipos neoplásicos foi 66,7%; a especificidade 62,3%; o valor preditivo positivo 11% e o valor preditivo negativo 94,2%. Considerando a necessidade de um método de triagem, a Pesquisa de Sangue Oculto nas fezes mostrou ser um exame de triagem eficaz e confiável para ser aplicado em programas de saúde pública com o objetivo de detectar e prevenir o carcinoma colorretal. Keywords: Colonoscopy, Fecal occult blood test, Polyps, Adenoma, Adenocarcinoma, Palavras-chave: Colonoscopia, Pesquisa de sangue oculto nas fezes, Pólipos, Adenoma, Adenocarcinoma

INTRODUÇÃO: A maioria das mulheres que desenvolvem doença inflamatória intestinal (DII) encontra-se em idade fértil, despertando preocupação dos médicos e mulheres no entendimento desta interação. Avaliamos a influência da DII sobre a fecundidade e gestação e vice- versa. MÉTODOS: Os protocolos de pacientes com doença de Crohn (DC) e retocolite ulcerativa (RC), de 1984 a 2006, em idade fértil, cadastrados no ambulatório de DII, foram revisados. Pacientes foram entrevistados para preenchimento de dados não encontrados nos protocolos. Outros tipos de colites, investigação incompleta, pacientes que não estavam em idade fértil ou sem capacidade cognitiva foram excluídos. Prematuridade, baixo peso ao nascer, anomalias congênitas, natimortalidade, abortamentos, tipos de partos, localização da doença na gestante e uso de medicamentos durante a gestação foram investigados. O método estatístico adotado foi o teste de qui- quadrado e Fisher, com nível de significância de 5%. Nenhum paciente se recusou a participar desta pesquisa. RESULTADOS: 140 gestações em 104 pacientes com DII foram avaliados (RC em 63 gestações e DC em 77). Houve redução da fecundidade após o início dos sintomas relacionados à DII em 41,6%, com influência da doença sobre a opção de não ter filhos em 20,6% (10,3% dos pacientes por medo da doença; 6,5% por orientação médica e 2,2% por más condições clínicas), sem diferenças entre DC e RC. A grande maioria não quis engravidar por já ter filhos, por ser solteira ou estar ter baixa idade (53,3%). A atividade da RC não foi alterada durante a gestação na maioria das pacientes (77,8%; p>0,003). A atividade da doença melhorou durante a gestação mais nas gestantes com DC do que nas com RC (p>0.0007). A incidência de prematuros, baixo peso ao nascer e natimortos foi maior quando todo o cólon estava acometido na RC (p< 0.037). A proporção estimada de prematuros e baixos pesos ao nascer foi de 83,3% [IC 95%: 10,3%; 100,0%]. Não houve diferença estatística quanto à localização da doença e alterações do feto na DC (p> 0,6513). Em 21 gestantes foram administrados aminossalicilatos e em 15, corticosteroides. Em 106 gestações, nenhum medicamento foi administrado. Não houve maior taxa de alterações do concepto quando aminossalicilatos ou corticosteroides foram administrados às gestantes com DII (p> 0,17 and p> 0,1585, respectivamente). CONCLUSÃO: A DII não influenciou diretamente na fecundidade na grande maioria das pacientes. A gestação influenciou positivamente a evolução da DC, independente do uso de medicamentos. A taxa de prematuridade foi maior nas proles de mães com DC. Houve maior taxa de proles com alterações quando todo o cólon estava comprometido na mãe com RC. A DC influenciou o tipo de parto, apenas nos casos de doença perianal extensa associada à doença colônica.INTRODUCTION: Most of women that develops inflammatory bowel disease (IBD) are in fertile age, concerning doctors and patients to understand this interaction. We evaluated the influence of IBD on fecundity and pregnancy and vice-versa. METHODS: the protocols of patients with Crohn's disease (CD) and ulcerative colitis (UC), from 1984 and 2006, in fertile age, followed at the outpatient clinic were reviewed. Patients were interviewed by the research medical doctor, to complete missing data not found in their protocols. Patients with others colitis, incomplete investigation, not in fertile age or without cognitive capacity were excluded from this study. Preterm delivery, low birth weight, congenital anomalies, stillbirth, miscarriages, types of delivery, disease topography in pregnant patients and drug administration during pregnancy were investigated. The statistic method adopted was the chi-square and Fisher test, with significance level of 5%. No patient refused to participate in this study. RESULTS: 140 pregnancies in 104 patients with IBD were evaluated (UC in 63 and CD in 77 pregnancies). : a reduction of 41.6% in fecundity was observed after beginning of symptoms related to IBD, with influence of the disease in 20.6% (10.3% of patients did not want to have children because of fear related to disease; 6.5% because of medical orientation and 2.2% for poor medical conditions). There was no difference between CD and UC. Most of patients did not want to become pregnant because they already had children, were "underage" or "alone" (53.3%) Most of pregnancies did not altered clinic conditions in UC patients (77.8% / p=0.003). Clinical conditions improved during pregnancies more in CD patients than UC patients (p=0.0007). The incidence of preterm delivery, low birth weight and stillbirth was higher when the whole colon was affected in UC (p < 0.037). The estimated rate of preterm delivery low birth weight was 83.3%[IC 95%: 10.29%; 100.00%]. There was no statistic difference between the disease topography and the fetus alteration in CD (p> 0.6513). In twenty-one and fifteen pregnant women, aminosalicilates and corticosteroids were administered, respectively. In 106 pregnancies, no drugs were administered. There were no higher rates of fetus alteration when aminosalicilates or corticosteroids were administered to mothers with IBD (p> 0.17 and p> 0.1585, respectively). CONCLUSIONS: IBD didn´t have any direct influence on fecundity in most of the patients. Pregnancy influenced positively on CD evolution, independently of drug use. The preterm birth rate was higher in children of mothers with CD. There were higher rates of fetus alteration when the whole colon was affected in mothers with UC. CD influenced the type of delivery only when perianal disease was associated to colonic disease.

INTRODUÇÃO: A maioria das mulheres que desenvolvem doença inflamatória intestinal (DII) encontra-se em idade fértil, despertando preocupação dos médicos e mulheres no entendimento desta interação. Avaliamos a influência da DII sobre a fecundidade e gestação e vice- versa. MÉTODOS: Os protocolos de pacientes com doença de Crohn (DC) e retocolite ulcerativa (RC), de 1984 a 2006, em idade fértil, cadastrados no ambulatório de DII, foram revisados. Pacientes foram entrevistados para preenchimento de dados não encontrados nos protocolos. Outros tipos de colites, investigação incompleta, pacientes que não estavam em idade fértil ou sem capacidade cognitiva foram excluídos. Prematuridade, baixo peso ao nascer, anomalias congênitas, natimortalidade, abortamentos, tipos de partos, localização da doença na gestante e uso de medicamentos durante a gestação foram investigados. O método estatístico adotado foi o teste de qui- quadrado e Fisher, com nível de significância de 5%. Nenhum paciente se recusou a participar desta pesquisa. RESULTADOS: 140 gestações em 104 pacientes com DII foram avaliados (RC em 63 gestações e DC em 77). Houve redução da fecundidade após o início dos sintomas relacionados à DII em 41,6%, com influência da doença sobre a opção de não ter filhos em 20,6% (10,3% dos pacientes por medo da doença; 6,5% por orientação médica e 2,2% por más condições clínicas), sem diferenças entre DC e RC. A grande maioria não quis engravidar por já ter filhos, por ser solteira ou estar ter baixa idade (53,3%). A atividade da RC não foi alterada durante a gestação na maioria das pacientes (77,8%; p>0,003). A atividade da doença melhorou durante a gestação mais nas gestantes com DC do que nas com RC (p>0.0007). A incidência de prematuros, baixo peso ao nascer e natimortos foi maior quando todo o cólon estava acometido na RC (p< 0.037). A proporção estimada de prematuros e baixos pesos ao nascer foi de 83,3% [IC 95%: 10,3%; 100,0%]. Não houve diferença estatística quanto à localização da doença e alterações do feto na DC (p> 0,6513). Em 21 gestantes foram administrados aminossalicilatos e em 15, corticosteroides. Em 106 gestações, nenhum medicamento foi administrado. Não houve maior taxa de alterações do concepto quando aminossalicilatos ou corticosteroides foram administrados às gestantes com DII (p> 0,17 and p> 0,1585, respectivamente). CONCLUSÃO: A DII não influenciou diretamente na fecundidade na grande maioria das pacientes. A gestação influenciou positivamente a evolução da DC, independente do uso de medicamentos. A taxa de prematuridade foi maior nas proles de mães com DC. Houve maior taxa de proles com alterações quando todo o cólon estava comprometido na mãe com RC. A DC influenciou o tipo de parto, apenas nos casos de doença perianal extensa associada à doença colônica.

PURPOSE: Carcinoembriogenic antigen (CEA) is the most frequently used tumor marker in rectal cancer. A decrease in carcinoembriogenic antigen after radical surgery is associated with survival in these patients. Neoadjuvant chemoradiotherapy may lead to significant primary tumor downstaging, including complete tumor regression in selected patients. Therefore, we hypothesized that a decrease in CEA after neoadjuvant chemoradiotherapy could reflect tumor response to chemoradiotherapy, affecting final disease stage and ultimately survival. METHODS: Patients with distal rectal cancer managed by neoadjuvant chemoradiotherapy and available pretreatment and postchemoradiotherapy levels of CEA were eligible for the study. Outcomes studied included final disease stage, relapse, and survival, and these were compared according to initial CEA level, postchemoradiotherapy CEA level, and the reduction in CEA. RESULTS: Overall 170 patients were included. Postchemoradiotherapy CEA levels

O desenvolvimento de técnicas minimamente invasivas é um dos mais importantes avanços da cirurgia colorretal. A assistência robótica integra o arsenal de técnicas em cirurgia minimamente invasiva, e vem sendo aplicado em cirurgia colorretal por um restrito grupo de cirurgiões em alguns centros ao redor do mundo com resultados iniciais que merecem atenção. O objetivo do presente estudo é analisar os resultados do emprego da assistência robótica em videocirurgia colorretal. Dentre as vantagens associadas ao emprego de robôs em videocirurgia colorretal, figuram o incremento na precisão dos movimentos e a visão tridimensional. A experiência clínica é ainda pequena, e advém de uma série de casos e estudos comparativos com a videocirurgia colorretal sem assistência robótica com ainda pequeno número de casos. A dissecção pélvica com incremento da preservação autonômica parece ser a maior vantagem associada à assistência robótica em videocirurgia colorretal. Somente através do treinamento de um número mais representativo de cirurgiões colorretais, bem como com a expansão da experiência clínica será possível prever com maior precisão o papel da assistência robótica em videocirurgia colorretal.The development of minimally invasive surgical techniques represents an important aspect of modern surgical research. Robot-assisted minimally invasive colorectal surgery represents a way of assisting laparoscopic colorectal procedures. Robotic technology overcomes some of these limitations by successfully providing intuitive motion and enhanced precision and accuracy, in an environment that is much more ergonomic. A restrict number of surgeons in specialized centers around the world have been applying robotics. In this review, current evidence about different technologies and its place in colorectal surgery is evaluated. The feasibility of performing robot-assisted colorectal operations has been demonstrated though case series and small case-controlled trials. The potential for enhancing autonomic nerve preservation during proctectomy may be the most remarkable advantage associated to robotic assistance during laparoscopic colorectal surgery. Colorectal surgeons should seize the opportunity to begin to use surgical robotic systems. Only through widespread surgeon training and increasing clinical experience with these systems, further technological developments, and continuous research, robotic technology will be routinely incorporated into surgical procedures on the colon and rectum.

This study was designed to identify the mucosa-associated microflora in patients with severe ulcerative colitis before and after restorative proctocolectomy with ileoanal pouch construction in comparison with historic controls.Ten patients with a diagnosis of ulcerative colitis were evaluated. Mucus was collected during colonoscopy from all segments of the colon and terminal ileum before surgery, and from the ileal pouch two and eight months after ileostomy closure. The prevalence and mean concentration of the mucosa-associated microflora were compared over time and with historic controls.Veillonella sp was the most prevalent bacterium in patients and controls. Klebsiella sp was significantly more prevalent in the ileum of controls, was not found in patients with ulcerative colitis, and after proctocolectomy returned to values found in controls. Some bacteria such as Enterobacter sp, Staphylococcus sp (coag-), Bacteroides sp (npg), Lactobacillus sp, and Veillonella sp had higher mean concentrations in the ileal pouch of patients after surgery than in controls.No bacterium was identified that could be exclusively responsible for the maintenance of the inflammatory process. The mucosa-associated microflora of patients with ulcerative colitis underwent significant changes after proctocolectomy with ileal pouch construction and returned to almost normal values for some bacteria.

The number of retrieved lymph nodes during radical surgery has been considered of great importance to ensure adequate staging and radical resection. However, this finding may not be applicable after neoadjuvant therapy in which, not only is there a decrease in lymph nodes recovered, but also a subgroup of patients with absence of lymph nodes in the resected specimen.Patients with absence of lymph nodes were compared with patients with ypN0 disease and patients with ypN+ disease.Thirty-two patients (11 percent) had absence of lymph nodes, 171 patients (61 percent) had ypN0 disease, and 78 patients (28 percent) had ypN+ disease. Patients with absence of lymph nodes had significantly lower ypT status (ypT0-1, 40 vs. 13 percent; P0.001) and decreased risk of perineural invasion (6 vs. 21 percent; P=0.04) compared with ypN0 patients. Five-year disease-free survival (74 percent) was similar to patients with ypN0 (59 percent; P=0.2), and both were significantly better than patients with ypN+ disease (30 percent; P0.001).Absence of lymph nodes retrieved from the resected specimen is associated with favorable pathologic features (ypT and perineural invasion status) and good disease-free survival rates. In this setting, absence of retrieved lymph nodes may reflect improved response to neoadjuvant chemoradiation therapy rather than inappropriate or suboptimal oncologic radicality.

Wereport a case of a perianal verrucous lesions that was ini-tially suspected to be anal neoplasia, but was revealed tobe a herpes infection. The patient required surgical resec-tion after antiviral therapy failure. This article reviews theliterature in order to describe the main characteristics ofpatients with verrucous perineal herpes infection and theoutcomes of different treatment modalities.

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.

INTRODUÇÃO: Existe uma grande prevalência de manifestações extra-intestinais(MEI) em portadores de doença de Crohn(DC) e de retocolite ulcerativa(RCU), variando de 24 a 65%. OBJETIVO: Determinar a prevalência de MEI em RCU e DC, correlacionando com diagnóstico do tipo de doença inflamatória intestinal, extensão, tempo de evolução e atividade da doença. MÉTODOS: Mil pacientes foram avaliados no Hospital das Clínicas da FMUSP no período de 1984 a 2004. Foram estudadas manifestações articulares, dermatológicas, oftalmológicas, urológicas, hepáticas, pulmonares e vasculares. RESULTADOS: Foram estudados 468 pacientes com DC(46,8%) e 532 com RCU(53,2%). Encontrados 627 pacientes (59,2% com RCU e 66,7% com DC) com pelo menos uma forma de MEI. A média de tempo de doença dos pacientes com MEI foi de 10 anos. As MEI foram mais freqüentes após o início dos sintomas intestinais. CONCLUSÕES: Tanto na RCU quanto na DC,quanto maior a extensão da doença no cólon, maior a incidência de MEI. As manifestações urológicas foram mais freqüentes na DC. As manifestações articulares e dermatológicas foram mais prevalentes no sexo feminino nos dois grupos. Manifestações hepáticas foram mais prevalentes na DC. As manifestações articulares, dermatológicas e vasculares tiveram correlação com a atividade da doença intestinal em ambos os grupos.INTRODUCTION: There is great prevalence of extra-intestinal manifestations (EIM) in Crohn's disease(CD) and ulcerative rectocolitis (UR), varying from 24 to 65%. AIM: To determine the prevalence of EIM in UR and CD, establishing a correlation with the diagnosis of the kind of intestinal inflammatory disease, extension, evolution time and disease activity. METHODS: One thousand patients were evaluated at the Hospital das Clínicas da FMUSP, along the 1984 to 2004 period. Articular, dermatological, ophthalmologic, urologic, hepatic, pulmonary and vascular manifestations were studied. RESULTS: 468 patients were studied with CD (46.8%) were studied and 532 with UR (53.2%). 627 patients found (59.2% with UR and 66.7% with CD) with at least one form of EIM. The average disease time of the EIM patients was of 10 years. EIM were more frequent after the beginning of the intestinal symptoms. CONCLUSIONS: Both in UR as in CD, the greater the extension of the disease in the colon, the greater is the EIM incidence. Urologic manifestations were more frequent in CD. Articular and dermatological manifestations were more prevalent in the feminine sex in both groups. Hepatic manifestations were more prevalent in CD. Articular, dermatological and vascular manifestations were related with the activity of the intestinal disease in both groups.

INTRODUÇÃO: Existe uma grande prevalência de manifestações extra-intestinais(MEI) em portadores de doença de Crohn(DC) e de retocolite ulcerativa(RCU), variando de 24 a 65%. OBJETIVO: Determinar a prevalência de MEI em RCU e DC, correlacionando com diagnóstico do tipo de doença inflamatória intestinal, extensão, tempo de evolução e atividade da doença. MÉTODOS: Mil pacientes foram avaliados no Hospital das Clínicas da FMUSP no período de 1984 a 2004. Foram estudadas manifestações articulares, dermatológicas, oftalmológicas, urológicas, hepáticas, pulmonares e vasculares. RESULTADOS: Foram estudados 468 pacientes com DC(46,8%) e 532 com RCU(53,2%). Encontrados 627 pacientes (59,2% com RCU e 66,7% com DC) com pelo menos uma forma de MEI. A média de tempo de doença dos pacientes com MEI foi de 10 anos. As MEI foram mais freqüentes após o início dos sintomas intestinais. CONCLUSÕES: Tanto na RCU quanto na DC,quanto maior a extensão da doença no cólon, maior a incidência de MEI. As manifestações urológicas foram mais freqüentes na DC. As manifestações articulares e dermatológicas foram mais prevalentes no sexo feminino nos dois grupos. Manifestações hepáticas foram mais prevalentes na DC. As manifestações articulares, dermatológicas e vasculares tiveram correlação com a atividade da doença intestinal em ambos os grupos. INTRODUCTION: There is great prevalence of extra-intestinal manifestations (EIM) in Crohn's disease(CD) and ulcerative rectocolitis (UR), varying from 24 to 65%. AIM: To determine the prevalence of EIM in UR and CD, establishing a correlation with the diagnosis of the kind of intestinal inflammatory disease, extension, evolution time and disease activity. METHODS: One thousand patients were evaluated at the Hospital das Clínicas da FMUSP, along the 1984 to 2004 period. Articular, dermatological, ophthalmologic, urologic, hepatic, pulmonary and vascular manifestations were studied. RESULTS: 468 patients were studied with CD (46.8%) were studied and 532 with UR (53.2%). 627 patients found (59.2% with UR and 66.7% with CD) with at least one form of EIM. The average disease time of the EIM patients was of 10 years. EIM were more frequent after the beginning of the intestinal symptoms. CONCLUSIONS: Both in UR as in CD, the greater the extension of the disease in the colon, the greater is the EIM incidence. Urologic manifestations were more frequent in CD. Articular and dermatological manifestations were more prevalent in the feminine sex in both groups. Hepatic manifestations were more prevalent in CD. Articular, dermatological and vascular manifestations were related with the activity of the intestinal disease in both groups.

Peritumoral inflammatory response has been considered a good prognostic factor for colorectal cancer. However, this has not been evaluated in patients submitted to neoadjuvant therapy for distal rectal cancer. For this reason, we decided to study the effect of the presence of this pathological finding on disease recurrence and survival.The peritumoral inflammatory infiltrate from recovered pathological specimens of patients operated after neoadjuvant therapy for distal rectal cancer was graded (positive or negative). Patients were compared according to the presence of peritumoral inflammatory response.Of the 168 patients, 63 (37%) patients had a peritumoral inflammatory response. The lack of peritumoral inflammatory response was significantly associated with the presence of mucinous component (13 vs 3%; p = 0.02). Five-year overall survival (91 vs 81%) and disease-free survival (57 vs 48%) were not significantly different between patients with and without peritumoral inflammatory response (p = 0.5 and 0.3, respectively).Peritumoral inflammatory response is not a favorable prognostic factor in patients with distal rectal cancer after neoadjuvant chemoradiation therapy. Possibly, the immunosuppressive action of chemoradiation therapy may lead to a loss of function of the immunological response, which may represent a disadvantage of the neoadjuvant approach for the management of distal rectal cancer.

A obstrução intestinal constitui complicação freqüente, de etiologia multifatorial, apresentação clínica variável e alta morbidade. Uma vez esgotados os recursos conservadores em casos específicos, a laparotomia exploradora é empregada para o diagnóstico final e tratamento em grande número de pacientes. Apesar do sucesso da via laparoscópica no manuseio de diversas afecções, a utilização desta via na abordagem inicial da obstrução do intestino delgado tem sido bastante limitada e alvo de numerosas críticas. Entretanto, o acúmulo de experiência com o método nos últimos anos, aliado ao avanço tecnológico e instrumental, têm permitido tratar número cada vez maior de pacientes obstruídos por meio do acesso laparoscópico. Assim, o surgimento de novos instrumentos como grampeadores laparoscópicos, pinças e trocáteres menos traumáticos ajudaram a tornar a videolaparoscopia factível e segura nestes pacientes. Neste artigo, os autores apresentam uma revisão sobre o papel da vídeo-cirurgia em casos selecionados de obstrução intestinal, ressaltando a contribuição dos métodos minimamente invasivos para o arsenal diagnóstico e terapêutico desta importante complicação.Bowel obstruction is a frequent complication that exhibits variable clinical presentation and high morbidity. After conservative measures, laparotomy is performed for final diagnosis and treatment in a large number of patients. Besides the benefits of the laparoscopic approach in the management of many diseases, its use during the initial evaluation of bowel obstruction has been limited and has raised some criticism. However, experience with method and technological-instrumental advances in recent years has facilitated the treatment of a greater number of patients with obstruction. Thus, the development of new instruments such as laparoscopic staplers, less traumatic clamps and trocars had an important role in the feasibility and safety of the laparoscopic approach in this setting. In this article, the authors present a revision about the use of video-surgery in selected cases of intestinal obstruction, standing out the contribution of minimally invasive methods for the diagnosis and therapeutics of this important complication.

Diverting stomas are commonly performed during ileoanal and coloanal anastomoses. We studied a series of patients after loop ileostomy closure to determine risk factors and the impact of the interval from primary operation on morbidity. Ninety-three consecutive patients undergoing loop ileostomy closure at a single institution after coloanal or ileoanal anastomosis were retrospectively reviewed. Complications were classified as medical or surgical according to its treatment requirements. Results were correlated to clinical and operative features. Of the 93 patients, 43 were male and 50 were female with mean age of 56 years. Overall, complication rate was 17.2 percent. The most common complication was small-bowel obstruction. Complications required operative management in 3.2 percent and medical management alone in 14 percent. There was no mortality. There was no correlation between complication occurrence and age, gender, type of suture (manual or mechanical), and operative time. Complications were significantly associated with primary disease and shorter interval between primary operation and ileostomy closure. Regarding the optimal interval between primary surgery and ileostomy closure, the cutoff value for increased risk of developing postoperative complications was 8.5 weeks, below which the risk of such occurrence was significantly higher with a sensitivity rate of 88 percent. Diverting loop ileostomy adds little cumulative morbidity to the primary operation and is a safe option for diversion to protect a low colorectal anastomosis. To further reduce morbidity, the interval between primary operation and ileostomy closure should be no shorter than 8.5 weeks.

Objective To prospectively compare immediate postoperative results of the surgical treatment of haemorrhoidal disease (HD) by Milligan–Morgan technique using either the CO2 laser or cold scalpel. Methods Forty patients with grade III/IV HD were prospectively randomized to undergo surgical treatment (Milligan–Morgan) using either the CO2 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 CO2 laser or cold scalpel regarding postoperative pain, complications, healing time, return to normal activities or patient satisfaction.

Background/aims Cowden syndrome (CS) is a rare and complex disease inherited through an autosomal dominant trait associated with germline mutations of the PTEN gene. Objective This article reports 2 female patients with classic features of the syndrome and reviews the current guidelines regarding diagnosis and surveillance. Review Although it exhibits variable clinical expressivity, the diagnosis is based on characteristic mucocutaneous alterations such as multiple facial trichilemmomas, oral mucosal papillomatosis, and acral and palmoplantar keratoses. These manifestations often precede systemic involvement. Extracutaneous lesions include fibrocystic disease of the breast, thyroid goiters or adenomas, multiple polyposis of the gastrointestinal tract, and ovarian cysts. Gastrointestinal polyps are usually asymptomatic, and the risk of gastrointestinal cancer is not greatly increased. Otherwise, an important feature of Cowden's disease is the greater risk of breast and thyroid cancer. Conclusions Because of the potentially serious associations with internal malignancy, early and accurate diagnosis of CS is essential. For this reason, all patients must be screened for occult malignancies and undergo close surveillance throughout lifetime.

Perineal hernia (PH) is formed by the protrusion of intra-abdominal viscera through a defect in the pelvic floor. This is a rare complication after conventional abdominoperineal resection, pelvic exanteration, proctectomy, and other pelvic procedures. The purpose of the present paper is to report 4 cases of PH after laparoscopic abdominoperineal resection for rectal cancer and to review literature data about the incidence, predisposing factors, and treatment of this challenging problem. When added to other 3 cases previously reported in the Brazilian series of laparoscopic surgery, this group of 7 cases comprises a PH incidence of 3.5% after rectal resection procedures. Surgical treatment is indicated only in symptomatic patients with no signs of cancer recurrence. Proposed methods of surgical repair include abdominal, perineal, or combined approaches to the hernia in association with the use of autologous tissues or prosthetic meshes. Preventive measures are represented by closure of the pelvic peritoneum whenever possible, primary perineal suture and wound care to avoid infection.

Colorectal cancer invading adjacent organs is a frequent event occurring in 5.5% to 12% of all colorectal malignancies. Colon cancer directly invading the duodenum and pancreas is rare and may require combined resection of the colon, pancreas, and duodenum, which represents a complex operation with significant morbidity and mortality rates. In this article, a case of a 41-year-old patient with a right colon cancer directly infiltrating the duodenum and head of the pancreas is presented. The patient was treated by radical combined resection of the colon, duodenum, and pancreas. Pathological examination confirmed neoplastic invasion of the adjacent organs and absence of lymph node metastasis (T4N0). The patient recovered uneventfully. Patients with colorectal cancer infiltrating adjacent organs such as the duodenum and the pancreas should be treated by radical en bloc resection of the tumor. This procedure is the preferred treatment strategy because it seems to be associated with improved overall survival rates.

Restorative proctocolectomy has become the most common surgical option for familial adenomatous polyposis (FAP) patients, based on the premise that it provides good functional results and reduces colorectal cancer risk. But several adenomas may develop in the pouch mucosa over the years, and even cancer at the anastomosis or in the pouch mucosa has been reported rarely. This article aims to describe a case of pouch cancer after restorative proctocolectomy for FAP, reviewing the possible causes of this unfortunate outcome. A 40-year-old man started presenting with fecal blood loss 12 years after restorative proctocolectomy with mucosectomy and hand-sewn anastomosis for FAP. Proctologic examination revealed an elevated mass 3 cm from the anal margin, which biopsy determined to be a mucinous adenocarcinoma. The patient underwent pouch excision and terminal ileostomy. Histologic analysis showed a 2.2 cm mucinous adenocarcinoma between the ileal and anal mucosa (T2N0Mx) and multiple tubular microadenomas in the ileal pouch. The present case and the data presented here suggest that restorative proctocolectomy is not a "cancer-free" alternative to ileorectal anastomosis, because it does not remove the risk of metachronous intestinal neoplasia. Although the long-term risk of malignancy is not known, lifelong follow-up seems to be necessary after restorative proctocolectomy. Current recommendations for pouch surveillance are presented.

The objective was to determine the presence and frequency of micrometastasis in lymph nodes of patients with rectal cancer treated by preoperative chemoradiation followed by curative resection.All 56 patients included were treated with 5-FU and leucovorin plus 5,040 cGy, followed by radical surgery and were diagnosed with stage II distal rectal adenocarcinoma after complete pathological examination (ypT3-4N0M0). Immunohistochemistry was assessed with cytokeratin monoclonal antibody AE1/AE3. Three 4-microm paraffin sections were obtained from each lymph node, cut at 50 microm apart from each other. The results were reviewed by two independent pathologists.Mean number of lymph nodes was 9.6 per patient. Four patients (7%) and seven lymph nodes (1.35%) were positive for micrometastasis. Three patients had pT3 and one a pT4 tumor. One of the patients had positive micrometastasis and the presence of mucinous deposits. One other patient had mucinous deposits without any micrometastasis. All four patients are alive with no evidence of recurrent disease. Fourteen patients negative for micrometastasis had recurrent disease (25%), eight systemic (14.7%) and six locoregional (10.3%). There were two cancer-related deaths. The mean follow-up period was 39 months.Patients with rectal cancer treated by preoperative chemoradiation showed a surprisingly low rate of micrometastasis detection (7%), even in high-risk patients (T3 and T4 tumors). Lymph node micrometastasis was not associated with decreased overall or disease-free survival. The identification of mucinous deposits on lymph nodes with no viable tumor cells may be direct evidence of lymph node downstaging. The downstaging effect of preoperative chemoradiation therapy may be significant in reducing even micrometastasis detection in low rectal cancer managed by this treatment strategy.

Neoadjuvant chemoradiation treatment (CRT) has resulted in significant tumor downstaging and improved local disease control for distal rectal cancer. The purpose of the present study was to determine the correlation between final stage and survival in these patients regardless of initial disease stage. Two hundred sixty patients with distal (0-7 cm from anal verge) rectal adenocarcinoma considered resectable were treated by neoadjuvant CRT with 5-FU and leucovorin plus 5040 cGy. Patients with incomplete clinical response 8 weeks after CRT completion were treated by radical surgical resection. Patients with complete clinical response were managed by observation alone. Overall survival and disease-free survival were compared according to Kaplan-Meier curves and log-rank tests according to final stage. Seventy-one patients (28%) showed complete clinical response (clinical stage 0). One hundred sixty-nine patients showed incomplete clinical response and were treated with surgery. In 22 of these patients (9%), pathologic examination revealed pT0 N0 M0 (stage p0), 59 patients (22%) had stage I, 68 patients (26%) had stage II, and 40 patients (15%) had stage III disease. Overall survival rates were significantly higher in stage c0 (P=0.01) compared with stage p0. Disease-free survival rate showed better results in stage c0, but the results were not significant. Five-year overall and disease-free survival rates were 97.7% and 84% (stage 0); 94% and 74% (stage I); 83% and 50% (stage II); and 56% and 28% (stage III), respectively. Cancer-related overall and disease-free survival may be correlated to final pathologic staging following neoadjuvant CRT for distal rectal cancer. Also, stage 0 is significantly associated with improved outcome.

RACIONAL: A incontinência anal acarreta incapacitação física e psicológica, determinando impacto na qualidade de vida. Para quantificar esse impacto em nosso meio, não existem instrumentos específicos validados. OBJETIVOS: Avaliar a qualidade de vida na incontinência anal, através da validação do questionário "Fecal Incontinence Quality of Life" (FIQL), que é composto por 29 questões distribuídas em 4 domínios: estilo de vida, comportamento, depressão e constrangimento, sua escala de pontuação varia de 1 a 4 com exceção das questões 1 e 4 que variam de 1 a 5 e 1 a 6, respectivamente. MATERIAL E MÉTODO: Após tradução e adaptação cultural, estudou-se a validação do instrumento através das propriedades de medida de reprodutibilidade e validade. Para a avaliação da reprodutibilidade aplicou-se o questionário em 50 pacientes com incontinência anal por dois examinadores, sendo reaplicado por um dos examinadores após período de 7 a 10 dias. A validade construtiva foi testada através da comparação do FIQL e o SF-36, questionário genérico de qualidade de vida e entre o FIQL e um índice de incontinência anal. O índice de incontinência anal utilizado foi o de Jorge-Wexner, que varia de 0 (continência perfeita) a 20 (incontinência total). A validade discriminativa foi avaliada através da aplicação do FIQL em dois grupos controle: indivíduos voluntários hígidos e portadores de constipação intestinal. RESULTADOS: Verificou-se que o FIQL apresentou correlação significativa com outros instrumentos (SF-36 e índice de incontinência) e que a qualidade de vida no portador de incontinência anal está comprometida em todos os domínios: estilo de vida: 2,4 comportamento: 2,0, depressão: 2,5 e constrangimento: 1,9, quando comparado com os indivíduos voluntários hígidos (3,9, 3,9, 4,1 e 4,0), e pacientes com constipação intestinal (3,7, 3,8, 3,6 e 3,8), respectivamente. CONCLUSÃO: O FIQL é útil para a avaliação da qualidade de vida na incontinência anal em nossa população. BACKGROUND: Anal incontinence causes physical and psychological incapacity, determining impact on quality of life. However, there are no specific tools to quantify this impact in our population. AIM: The evaluation of quality of life in anal incontinence, through validation of the FIQL ("Fecal Incontinence Quality of Life Scale"). FIQL is a questionnaire composed of 29 questions, grouped into four domains: lifestyle, behavior, depression and embarrassment. For each question, the scale ranges from 1 to 4, except questions 1 and 4, which ranges from 1-5 and 1-6, respectively. MATERIAL AND METHOD: FIQL scale underwent both translation and cultural adaptation processes, giving rise to a final Portuguese version. This version was then used in a validation study to test measurement properties (reproducibility and validity). The reproducibility was tested through application of FIQL questionnaire by two observers in 50 patients with anal incontinence. After a period of 7 to 10 days, the questionnaire was applied again by one of the observers. The constructive validity was assessed by correlating the FIQL questionnaire results with both, a generic questionnaire for quality of life (SF-36) and the Jorge-Wexner incontinence score results. The discriminative validity was evaluated comparing the results of the FIQL to incontinence group with two other groups: healthy volunteers and patient with chronic idiopathic constipation. RESULTS: The correlation among results domains of FIQL questionnaire and results of short form-36 and the incontinence score were statistically significant. The quality of life is impaired in all of domains of FIQL for incontinent patients: lifestyle: 2.4 behaviour:2.0, depression:2.5 and embarrassment:1.9, when compared to healthy volunteers (3.9, 3.9, 4.1 and 4.0), and patients with chronic constipation (3.7, 3.8, 3.6 and 3.8), respectively. CONCLUSION: The FIQL questionnaire is effective and reproducible in its measuring properties, and it can be useful as an instrument to assess quality of life in anal incontinence in our population.

The "best" surgical technique for the management of complete rectal prolapse remains unknown. Due to its low incidence, it is very difficult to achieve a representative number of cases, and there are no large prospective randomized trials to attest to the superiority of one operation over another. PURPOSE: Analyze the results of surgical treatment of complete rectal prolapse during 1980 and 2002. METHOD: Retrospective study. RESULTS: Fifty-one patients underwent surgical treatment during this period. The mean age was 56.7 years, with 39 females. Besides the prolapse itself, 33 patients complained of mucous discharge, 31 of fecal incontinence, 14 of constipation, 17 of rectal bleeding, and 3 of urinary incontinence. Abdominal operations were performed in 36 (71%) cases. Presacral rectopexy was the most common abdominal procedure (29 cases) followed by presacral rectopexy associated with sigmoidectomy (5 cases). The most common perineal procedure was perineal rectosigmoidectomy associated with levatorplasty (12 cases). Intraoperative bleeding from the presacral space developed in 2 cases, and a rectovaginal fistula occurred in another patient after a perineal rectosigmoidectomy. There were 2 recurrences after a mean follow-up of 49 months, which were treated by reoperation. CONCLUSION: Abdominal and perineal procedures can be used to manage complete rectal prolapse with safety and good long-term results. Age, associated medical conditions, and symptoms of fecal incontinence or constipation are the main features that one should bear in mind in order to choose the best surgical approach.A técnica cirúrgica mais apropriada para a correção da procidência retal permanece motivo de controvérsia. Por se tratar de afecção pouco freqüente, há dificuldade de avaliação de número adequado de pacientes em estudos randomizados e existe pouca evidência para comprovar a superioridade de alguma das técnicas. OBJETIVO: Analisar os resultados de eficácia e segurança do tratamento cirúrgico da procidência retal em pacientes operados entre 1980 e 2002. MÉTODO: Estudo retrospectivo. RESULTADOS: Cinqüenta e um pacientes foram operados. A idade média foi de 56,7 anos e 39 eram mulheres. Além do prolapso, 33 pacientes queixavam-se de eliminação de muco, 31 tinham incontinência anal, 14 apresentavam constipação, 17 com sangramento retal e 3 incontinência urinária. Operações abdominais foram realizadas em 36 (71%) casos, sendo a retopexia sem prótese a operação mais realizada (29 casos) seguida pela retossigmoidectomia com retopexia (5 casos). A operação perineal mais realizada foi a retossigmoidectomia com plastia dos elevadores (12 casos). O sangramento sacral foi a única complicação intra-operatória e ocorreu em dois casos. Como complicação pós-operatória, houve um caso de fístula retovaginal após operação de retossigmoidectomia perineal. Após seguimento médio de 49 meses, observamos recidiva da procidência em 2 casos. CONCLUSÕES: Operações abdominais e perineais podem ser utilizadas com segurança e eficácia no tratamento cirúrgico da procidência do reto. A idade, a presença de afecções associadas, comorbidades e os sintomas de constipação e incontinência são as principais variáveis envolvidas na escolha da operação. As operações de retopexia abdominal e retossigmoidectomia perineal estão associadas a bons resultados.

Gastrointestinal mesenchymal tumors comprise a rare group of gastrointestinal tract wall tumors that have long been a source of confusion and controversy, especially in terms of pathological classification, preoperative diagnosis, management strategies, and prognosis. This report describes the clinical manifestations and management of 2 rectal leiomyomas and reviews the pertinent literature. Case 1: A 44-year-old woman was admitted reporting a nodule in the right para-anal region for the previous 2 years. At proctological examination, a 4-cm diameter fibrous mass situated in the para-anal region that produced an arch under the smooth muscle on the right rectal wall just above the anorectal ring was noted. Computed tomography and magnetic resonance imaging of the abdomen and pelvis showed the lesion and detected no other abnormalities. Surgical treatment consisted of wide local resection of the tumor through a para-anal incision, with no attempts to perform lymphadenectomy. Case 2: A 40-year-old male patient was admitted reporting constant anal pain for 4 months. He presented a 3-cm submucosal nodule at the anterior rectal wall just above the dentate line. After 2 inconclusive preoperative biopsies, transanal resection of the tumor was performed. Histological analysis of the specimen showed a benign leiomyoma. A review of the literature is presented, emphasizing some clinical and therapeutic aspects of this unusual rectal tumor.Os tumores mesenquimais gastrointestinais constituem um grupo raro de neoplasias que têm sido fonte de confusão e controvérsia, especialmente quanto à classificação patológica, diagnóstico pré-operatório, manuseio e prognóstico. O presente artigo descreve as manifestações clínicas e o tratamento de dois pacientes com leiomioma retal e revê a literatura pertinente. Caso 1: Uma mulher de 44 anos foi admitida referindo um nódulo na região paranal direita nos últimos 2 anos. Ao exame físico notou-se uma massa fibrosa de 4 centímetros de diâmetro situada na região paranal que produzia um discreto abaulamento na musculatura lisa da parede retal, logo acima do anel ano-retal. As imagens de tomografia computadorizada e ressonância magnética do abdômen e pelve confirmaram a lesão e não detectaram outras anormalidades. O tratamento cirúrgico consistiu de ressecção alargada do tumor através de uma incisão paranal, sem se realizar linfadenectomia. Caso 2: Outro paciente com 40 anos foi admitido com história de dor anal constante há 4 meses. Este homem apresentava nódulo submucoso de 3 cm na parede retal anterior, logo acima da linha pectínea. Após duas biópsias inconclusivas, realizou-se a ressecção transanal do tumor. A análise histológica do espécime demonstrou tratar-se de um leiomioma benigno. Uma breve revisão da literatura é apresentada, enfatizando alguns aspectos clínicos e terapêuticos deste tumor retal pouco comum.

OBJETIVO: Comparar os resultados de eficacia e seguranca do emprego da operacao de amputacao do reto por via laparoscopica e por via convencional no tratamento cirurgico de pacientes com câncer do reto distal que apresentaram resposta incompleta a quimioirradiacao pre-operatoria. METODO: Vinte e oito pacientes com adenocarcinoma de reto distal foram randomizados para se submeter a amputacao do reto por via laparoscopica ou a amputacao do reto por via convencional. Treze pacientes submeteram-se a amputacao do reto por via laparoscopica e 15 a amputacao do reto por via convencional. RESULTADOS: Nao houve diferenca significativa (p

Ileal pouch-anal anastomosis was an important advancement in the treatment of ulcerative colitis. The aim of this study was to determine whether early complications of ileal pouch-anal anastomosis in patients with ulcerative colitis are associated with poor late functional results. PATIENTS AND METHODS: Eighty patients were operated on from 1986 to 2000, 62 patients with ileostomy and 18 without. The early and late complications were recorded. Specific emphasis has been placed on the incidence of pouchitis with prolonged follow-up. RESULTS: The ileostomy was closed an average of 9.2 months after the first operation. Fourteen patients were excluded from the long-term evaluation; 6 patients were lost to regular follow-up, 4 died, and 4 patients still have the ileostomy. Of the 4 patients that died, 1 died from surgical complications. Early complications after operation (41) occurred in 34 patients (42.5%). Late complications (29) occurred in 25 patients as follows: 16 had pouchitis, 3 associated with stenosis and 1 with sexual dysfunction; 5 had stenosis; and there was 1 case each of incisional hernia, ileoanal fistula, hepatic cancer, and endometriosis. Pouchitis occurred in 6 patients (9.8%) 1 year after ileal pouch-anal anastomosis, 9 (14.8%) after 3 years, 13 (21.3%) after 5 years, and 16 (26.2%) after more than 6 years. The mean daily stool frequency was 12 before and 5.8 after operation. One pouch was removed because of fistulas that appeared 2 years later. CONCLUSIONS: Ileal pouch-anal anastomosis is associated with a considerable number of early complications. There was no correlation between pouchitis and severe disease, operation with or without ileostomy, or early postoperative complications. The incidence of pouchitis was directly proportional to duration of time of follow-up. A anastomose íleo-anal com reservatório ileal foi um importante avanço no tratamento da retocolite ulcerativa. O objetivo deste trabalho foi determinar se os maus resultados funcionais tardios estariam relacionados às complicações precoces da anastomose íleo-anal com reservatório ileal em doentes com retocolite ulcerativa. MATERIAL E MÉTODO: Oitenta doentes foram operados entre 1986 e 2000, 60 com ileostomia de proteção e 18 sem. Os doentes foram avaliados quanto a incidência de complicações pós-operatórias precoces e tardias. Enfatizou-se a incidência de bolsite no pós-operatório prolongado. RESULTADO: A ileostomia foi fechada em média 9,2 meses após a primeira operação. Quatorze doentes foram excluídos da avaliação tardia: seis perderam o seguimento e quatro faleceram. Quatro doentes permanecem com a ileostomia. Trinta e quatro doentes (42,5%) apresentaram 41 complicações precoces. Vinte e cinco apresentaram 29 complicações tardias: 16 bolsites, três associadas a estenose e uma a disfunção erétil; cinco estenoses e uma de cada das seguintes: hérnia incisional, fístula íleoanal, câncer hepático e endometriose. Seis doentes apresentaram bolsite um ano após a anastomose íleoanal com reservatório ileal (9,8%), nove (14,8%) após três anos, 13 (21,3%), após cinco anos e 16 (26,2%) após seis anos.A freqüência diária média de evacuação era de 12 antes e de 5,8 após a operação.Um reservatório foi removido devido ao aparecimento de fístulas dois anos depois. CONCLUSÃO: A anastomose íleoanal com reservatório ileal está associada com número considerável de complicações. Não há correlação entre bolsite e doença grave, operação com ou sem ileostomia ou complicações pós-operatórias imediatas. A incidência de bolsite foi diretamente proporcional ao tempo de seguimento.

Chronic radiation proctitis represents a challenging condition seen with increased frequency due to the common use of radiation for treatment of pelvic cancer. Hemorrhagic radiation proctitis represents the most feared complication of chronic radiation proctitis. There is no consensus for the management of this condition despite the great number of clinical approaches and techniques that have been employed. Rectal resection represents an available option although associated with high morbidity and risk of permanent colostomy. The effectiveness of nonoperative approaches remains far from desirable, and hemorrhagic recurrence represents a major drawback that leads to a need for consecutive therapeutic sessions and combination of techniques. We conducted a critical review of published reports regarding conservative management of hemorrhagic chronic radiation proctitis. Although prospective randomized trials about hemorrhagic radiation proctitis are still lacking, there is enough evidence to conclude that topical formalin therapy and an endoscopic approach delivering an argon plasma coagulation represent available options associated with elevated effectiveness for interruption of rectal bleeding in patients with chronic radiation proctitis.A retite actínica crônica é uma condição cada vez mais freqüentemente observada como resultado do crescente emprego da radioterapia no tratamento do câncer de órgãos pélvicos. A manifestação hemorrágica da retite actínica é a complicação mais comum dessa doença e seu tratamento é desafiador. Diversas técnicas foram empregadas para o tratamento dessa condição e não há evidência satisfatória acerca da melhor forma de controlar os episódios de sangramento de forma eficaz e duradoura. A necessidade de se realizar múltiplas sessões de tratamento conservador bem como a associação de técnicas freqüentemente observada no manejo desses pacientes dificulta a interpretação dos resultados. O objetivo dessa revisão foi avaliar a segurança e a eficácia das alternativas clínicas mais freqüentemente empregadas no controle da retite actínica hemorrágica. Ainda que a falta de estudos prospectivos e randomizados comparando duas ou mais alternativas terapêuticas impeça uma conclusão mais definitiva, concluímos que existe suficiente evidência acerca de elevada eficácia e segurança associadas ao emprego da formalina tópica e da coagulação por plasma de argônio no controle do sangramento em pacientes com retite actínica crônica.

The case of a patient with blue rubber bleb nevus syndrome who is infected by acquired immunodeficiency syndrome virus due to multiple blood transfusions is presented. This case shows that although it is a rare systemic disorder, blue rubber bleb nevus syndrome has to be considered in the differential diagnosis of chronic anemia or gastrointestinal bleeding. Patients should be investigated by endoscopy, which is the most reliable method for detecting these lesions. The patient underwent gastroscopy and enteroscopy via enterotomy with identification of all lesions. Minimal resection of the larger lesions and string-purse suture of the smaller ones involving all the layers of the intestine were performed. The string-purse suture of the lesions detected by enteroscopy proved to be an effective technique for handling these lesions, avoiding extensive intestinal resection and stopping the bleeding. Effective management of these patients demands aggressive treatment and should be initiated as soon as possible to avoid risks involved in blood transfusions, as occurred in this case.

OBJECTIVE: The aims of this study were to evaluate the safety and efficacy of laparoscopic abdominoperineal resection compared to conventional approach for surgical treatment of patients with distal rectal cancer presenting with incomplete response after chemoradiation. METHOD: Twenty eight patients with distal rectal adenocarcinoma were randomized to undergo surgical treatment by laparoscopic abdominoperineal resection or conventional approach and evaluated prospectively. Thirteen underwent laparoscopic abdominoperineal resection and 15 conventional approach. RESULTS: There was no significant difference (pOBJETIVO: Comparar os resultados de eficácia e segurança do emprego da operação de amputação do reto por via laparoscópica e por via convencional no tratamento cirúrgico de pacientes com câncer do reto distal que apresentaram resposta incompleta a quimioirradiação pré-operatória. MÉTODO: Vinte e oito pacientes com adenocarcinoma de reto distal foram randomizados para se submeter à amputação do reto por via laparoscópica ou à amputação do reto por via convencional. Treze pacientes submeteram-se à amputação do reto por via laparoscópica e 15 à amputação do reto por via convencional. RESULTADOS: Não houve diferença significativa (p

A defecografia é exame de imagem valioso no estudo da fisiologia anorretal e, portanto, com extensa aplicação na avaliação e diagnóstico de diversas afecções coloproctológicas que cursam com sintomas de constipação, sensação de evacuação incompleta, incontinência fecal, dor pélvica obscura, proctalgia e tenesmo, entre outras. Além disso, em algumas situações após cirurgia anorretocólica, pode ser utilizada como método de avaliação do resultado e acompanhamento pós-operatório. Nas últimas décadas tem-se observado aumento do interesse da comunidade médica pelo exame, em parte, pelo melhor entendimento da fisiopatologia dos distúrbios colorretais e, também, pelo aprimoramento da técnica, como é o exemplo da videodefecografia dinâmica computadorizada, que permitiu maior difusão e melhora na qualidade do exame. Diversos aspectos da defecografia são discutidos neste artigo, desde indicações para o exame, metodologia, até interpretação dos resultados. A técnica do exame, incluindo princípios básicos e os avanços mais recentes, também foi abordada.Defecography is a valuable imaging method to assess changes within the pelvis and rectum during evacuation. Therefore, it has been extensively used to evaluate colorectal complaints such as constipation, dyschezia, faecal incontinence, interrupted defecation, anorectal pain and others. Furthermore, the technique can be used to evaluate the postoperative results and follow-up. In the last years, physicians' interest in this examination has greatly increased, in part due to the better understanding of the pathophysiology of colorectal disorders and also to the advances of the technique (e.g. computerized dynamic videodefecography extended the access to the test reducing radiation and improving the image quality). We discuss several aspects of defecography including the indications for the test and the methodology and interpretation of the results. The technique, including the basic principles and advances, are also discussed.

Local excision is currently being considered as an alternative strategy for ypT0-2 rectal cancer. However, patient selection is crucial to rule out nodal disease and is performed by radiologic studies that consider size as a surrogate marker for positive nodes. The purpose of this study was to determine the difference in size between metastatic and nonmetastatic nodes and the critical lymph node size after neoadjuvant chemoradiation therapy.The 201 lymph nodes available from 31 patients with ypT0-2 rectal cancer were reviewed and measured. Lymph nodes were compared according to the presence of metastases and size.There was a mean of 6.5 lymph nodes per patient and 12 positive nodes of the 201 recovered (6%). Ninety-five percent of all lymph nodes were5 mm, whereas 50% of positive lymph nodes were3 mm. Metastatic lymph nodes were significantly greater in size (5.0 vs. 2.5mm; P = 0.02). Lymph nodes4.5 mm had a greater risk of harboring metastases (P = 0.009).Patients with ypT0-2 rectal cancer following neoadjuvant chemoradiation have very small perirectal nodes. Individual metastatic lymph nodes are significantly larger. However, a significant number of lymph nodes after neoadjuvant chemoradiation (negative and positive) are3 mm. Individual lymph node size is not a good predictor of nodal metastases and may lead to inaccurate radiologic staging.

Background. This study aimed to evaluate manometric parameters that may explain improvement in anal incontinence using a silicone bulking agent. Methods. Incontinent patients having internal sphincter defects were prospectively selected and injected with a silicone bulking agent. Manometry and endoanal ultrasound were performed before and 3 months after injections. Twenty continent healthy volunteers were used only for manometric comparison. Results. Thirty-five patients (28 females; mean age 60.3 years) and 20 controls entered this study. Patients had lower resting and squeeze pressures compared with controls ( P < .05). Length of the high-pressure zone increased from 1 to 1.7 cm postinjection ( P = .002). Asymmetry index showed a significant change postinjection ( P < .001). Conclusion. Despite considerable clinical improvement, no significant increase in manometric pressures was noted posttreatment. There was significant improvement in both high-pressure zone and asymmetry index, and these findings may explain the mechanism of action of the bulking agent injected.

OBJECTIVE: To evaluate, by means of the Inflammatory Bowel Disease Questionnaire (IBDQ), the quality of life of ulcerative colitis patients submitted to proctocolectomy with sphincter preservation using J-pouch reconstruction over ten years ago. METHODS: The study consisted of 36 patients interviewed using the Inflammatory Bowel Disease Questionnaire. The score scale, resulting from the addition of each answer, ranged from 32 to 224, where the highest score indicates the best quality of life. The chi square test was used to verify the existence of meaningful differences between the results of the questionnaire and age, and gender proportion. For each section, as well as for all of them combined, the Kruskal-Wallis test was used to verify if there were differences in the Inflammatory Bowel Disease Questionnaire scores among the groups in relation to the proportions. RESULTS: After applying the Inflammatory Bowel Disease Questionnaire, it was determined that quality of life was considered excellent for 9 (25%), good for 11 (30.6%), regular for 13 (36.1%), and bad for 3 (8.3%) patients. In our study, we determined that 85% of the patients were pleased with and thankful for the surgery that they underwent. CONCLUSION: We can conclude that the possibility of sphincter preservation should always be taken into account, since patients remain clinically stable and have a high quality of life even after long periods.

O desenvolvimento de técnicas minimamente invasivas é um dos mais importantes avanços da cirurgia colorretal. A assistência robótica integra o arsenal de técnicas em cirurgia minimamente invasiva, e vem sendo aplicado em cirurgia colorretal por um restrito grupo de cirurgiões em alguns centros ao redor do mundo com resultados iniciais que merecem atenção. O objetivo do presente estudo é analisar os resultados do emprego da assistência robótica em videocirurgia colorretal. Dentre as vantagens associadas ao emprego de robôs em videocirurgia colorretal, figuram o incremento na precisão dos movimentos e a visão tridimensional. A experiência clínica é ainda pequena, e advém de uma série de casos e estudos comparativos com a videocirurgia colorretal sem assistência robótica com ainda pequeno número de casos. A dissecção pélvica com incremento da preservação autonômica parece ser a maior vantagem associada à assistência robótica em videocirurgia colorretal. Somente através do treinamento de um número mais representativo de cirurgiões colorretais, bem como com a expansão da experiência clínica será possível prever com maior precisão o papel da assistência robótica em videocirurgia colorretal. The development of minimally invasive surgical techniques represents an important aspect of modern surgical research. Robot-assisted minimally invasive colorectal surgery represents a way of assisting laparoscopic colorectal procedures. Robotic technology overcomes some of these limitations by successfully providing intuitive motion and enhanced precision and accuracy, in an environment that is much more ergonomic. A restrict number of surgeons in specialized centers around the world have been applying robotics. In this review, current evidence about different technologies and its place in colorectal surgery is evaluated. The feasibility of performing robot-assisted colorectal operations has been demonstrated though case series and small case-controlled trials. The potential for enhancing autonomic nerve preservation during proctectomy may be the most remarkable advantage associated to robotic assistance during laparoscopic colorectal surgery. Colorectal surgeons should seize the opportunity to begin to use surgical robotic systems. Only through widespread surgeon training and increasing clinical experience with these systems, further technological developments, and continuous research, robotic technology will be routinely incorporated into surgical procedures on the colon and rectum.

Familial adenomatous polyposis (FAP) is a genetic disease characterized by multiple adenomatous colorectal polyps and different extracolonic manifestations (ECM). The present work is aimed to analyze the outcome after surgical treatment regarding complications and cancer recurrence. Charts from patients treated between 1977 and 2006 were retrospectively analyzed. Clinical and endoscopic data, results of treatment, pathological reports and information about recurrence were collected. Eighty-eight patients (41 men [46.6%] and 47 women [53.4%]) were assisted. At diagnosis, associated colorectal cancer (CRC) was detected in 53 patients (60.2%), whose average age was higher than those without CRC (40.0 vs. 29.5 years). At colonoscopy, polyposis was classified as attenuated in 12 patients (14.3%). Surgical treatment consisted in total proctocolectomy with ileostomy (PCI, 15 [17.4%]), restorative proctocolectomy (RPC, 27 [31.4%]), total colectomy with ileal-rectum anastomosis (IRA, 42 [48.8%]), palliative segmental resection (1 [1.2%]) and internal bypass (1 [1.2%]). Two patients were not operated on due to religious reasons and advanced disease. Complications occurred in 25 patients (29.0%), more commonly after RPC (48.1%). There was no operative mortality. Local or distant metastases were detected in six (11.3%) patients with CRC treated to cure. During the follow-up of 36 IRA, cancer developed in the rectal cuff in six patients (16.6%), whose average age was higher than in patients without rectal recurrence (45.8 vs. 36.6 years). Five of them have had colonic cancer in the resected specimen. Among the 26 patients followed after RPC, cancer in the ileal pouch developed in 1 (3.8%). (1) Within the present series, FAP patients presented a high incidence of associated CRC and diagnosis was generally established after the third decade of life; (2) operative complications occurred in about one third of the patients, being more frequent after the confection of an ileal reservoir; (3) rectal cancer after IRA was detected in 16.6% of patients and it was associated with greater age and previous colonic carcinoma; (4) both continuous and long-term surveillance of the rectal stump and ileal pouch are necessary during follow-up.