A novelty in laparoscopic total colectomy with natural orifice specimen extraction using a plastic cover / Uma novidade na colectomia total laparoscópica com extração de espécime em orifício natural usando uma cobertura plastic

Abstract Introduction: Minimally invasive colectomy has been performed for some years for many patients worldwide without much complications compared to the open approach. In this study we explained our experience regarding a modification in laparoscopic total colectomy and removing the specimen with Natural Orifice Specimen Extraction (NOSE) through rectum using a plastic cover for the first time. Methods and material: This was an experimental study on a new technique of total colectomy with a small modification. Total colectomy was performed based on 7 port laparoscopic approach. Rectum was sparred. Colon was then taken out through the anal canal using a plastic cover. Results: Thirteen patients underwent laparoscopic total colectomy by removal of the specimen through rectum. Mean age of patients was 42.23 ± 8.15 years. Mean duration of operation was 130 ± 32.4 min. All patients had an uneventful postoperative hospitalization. Discussion: Laparoscopic total colectomy has been proven to have superior benefits than the open approach. In NOSE technique, colon is removed from the anal canal without any complication or consuming much time. This technique might have less pain and removes the complications associated with an incision on the skin to remove the specimen. Also, due to low price of a usual plastic cover, it can be used instead of other techniques to remove the specimen through the rectum.

Resumo Introdução: A colectomia minimamente invasiva vem sendo realizada há alguns anos em muitos pacientes no mundo inteiro, apresentando menos intercorrências do que a abordagem aberta. Neste estudo, os autores relatam sua experiência com uma modificação da colectomia total laparoscópica e extração de espécime em orifício natural (NOSE) pelo reto, usando uma cobertura plástica pela primeira vez. Métodos e materiais: Este foi um estudo experimental sobre uma nova técnica de colectomia total com uma pequena modificação. A colectomia total foi realizada com base na abordagem laparoscópica de sete portas. O reto foi poupado. O cólon foi então retirado pelo canal anal usando uma cobertura plástica. Resultados: Treze pacientes foram submetidos a colectomia total laparoscópica por remoção do espécime pelo reto. A idade média dos pacientes foi de 42,23 ± 8,15 anos. A duração média da operação foi de 130 ± 32,4 minutos. Para todos os pacientes, a internação pós-operatória transcorreu sem intercorrências. Discussão: Foi comprovado que a colectomia total laparoscópica apresenta benefícios superiores à abordagem aberta. Na técnica NOSE, o cólon é removido mais rapidamente do canal anal, sem nenhuma intercorrência. Essa técnica pode causar menos dor e remove as complicações associadas a uma incisão na pele para remover o espécime. Além disso, devido ao baixo preço de uma cobertura plástica comum, ela pode ser usada no lugar de outras técnicas para remover o espécime pelo reto.

Extensive colectomy in colorectal cancer and hereditary nonpolyposis colorectal cancer - long-term results / Colectomia extensa em cancro colorretal e cancro colorretal hereditário sem polipose - resultados a longo prazo

ABSTRACT Background: Colorectal cancer survival is better in hereditary nonpolyposis colorectal cancer patients than in sporadic colorectal cancer patients and even for hereditary nonpolyposis colorectal cancer with colorectal cancer is not consensual that extensive colectomy is preferable to partial colectomy. This study analyzes and compares the long-term results of these two groups of patients submitted to curative subtotal colectomy or total colectomy. Methods: Between 2002 and 2018, 68 patients with colorectal cancer without familial adenomatous polyposis were submitted to a total or subtotal colectomy in a single tertiary center. The patients were divided in two groups: hereditary nonpolyposis colorectal cancer patients (with Amsterdam criteria) and sporadic colorectal cancer patients (the others). The presence of Amsterdam criteria for hereditary nonpolyposis colorectal cancer and germline mutation for mismatch repair genes was confirmed by clinical records. Results and survival were analyzed following surgery. Results: We obtained a sporadic colorectal cancer group with 31 patients and a hereditary nonpolyposis colorectal cancer group with 37 patients. The two groups differ in age but not in gender, tumor stage or surgical morbidity. The overall survival and disease-free survival were good in both groups but even better for hereditary nonpolyposis colorectal cancer group with statistical significance when comparing the two groups. Conclusion: Total or subtotal colectomy for colorectal cancer provides a good survival. These surgical procedures should be considered the first option for colorectal cancer in young hereditary non polyposis colorectal cancer patients. In those cases, they provide good long-term results, avoiding the risk of metachronous colorectal cancer and the surveillance is restricted only to the remaining need for rectum.

RESUMO Introdução: A sobrevivência do cancro colorretal é melhor em pacientes com cancro colorretal hereditário não associado a polipose do que em pacientes com cancro colorretal esporádico. Mesmo em casos de cancro colorretal hereditário sem polipose, a preferência pela colectomia total em relação à parcial não é consensual na literatura. Este estudo analisa e compara os resultados a longo prazo destes dois grupos de pacientes submetidos à colectomia curativa subtotal ou total. Métodos: Entre 2002 e 2018, 68 pacientes com cancro colorretal sem polipose adenomatosa familiar foram submetidos a colectomia total ou subtotal em um único centro terciário. Os pacientes foram divididos em dois grupos: aqueles com cancro colorretal hereditário sem polipose (de acordo com os critérios de Amsterdão) e os com cancro colorretal esporádico (os demais). Os critérios de Amsterdão para cancro colorretal hereditário sem polipose e a presença de mutação germinativa para os genes de reparação de ADN foram confirmados por consulta dos registros clínicos. Os resultados e a sobrevivência foram analisados após a cirurgia. Resultados: No presente estudo, 31 pacientes foram incluídos no grupo de cancro colorretal esporádico e 37 no grupo de cancro colorretal hereditário sem polipose. Diferenças significativas foram observadas em relação à idade, mas não ao gênero, estadio do tumor ou morbilidade cirúrgica. A sobrevivência global e a sobrevivência livre de doença foram boas em ambos os grupos, mas os resultados foram ainda melhores no grupo de cancro colorretal hereditário sem polipose, com significado estatístico. Conclusão: A colectomia total ou a colectomia subtotal para o cancro colorretal proporcionam uma boa sobrevivência e devem ser consideradas a primeira opção de tratamento em pacientes jovens com cancro colorretal hereditário sem polipose. Nestes pacientes, uma cirurgia cólica mais extensa permite a obtenção de bons resultados a longo prazo; reduz o risco de cancro colorretal metácrono e restringe a vigilância endoscópica ao reto remanescente.

Surgical complications and metachronous rectal cancer risk in patients with classic familial adenomatous polyposis / Complicações cirúrgicas e risco de câncer retal metacrônico em pacientes com polipose adenomatosa familiar clássica

INTRODUCTION: Familial adenomatous polyposis (FAP), an autosomal dominant disease characterized by development of numerous adenomatous polyps in the colon and rectum, is caused by germline mutations in the Adenomatous Polyposis Coli (APC) gene. METHODS: To determine the surgical morbidity in patients with classical familial adenomatous polyposis and determine the incidence of metachronous colorectal cancer (CRC) in those undergoing total colectomy (TC) with ileorectal anastomosis or restorative total proctocolectomy (TPC) and ileal pouch anal anastomosis. We analyzed patients with familial adenomatous polyposis who received treatment and regular follow-up at the A.C. Camargo Cancer Center from 1994 to 2013. RESULTS: Operative complications occurred in 22 patients (34.3%), 16 (25%) being early complications and 8 (12.5%) late complications. No mortality occurred as a result of postoperative complications. The incidence of metachronous rectal cancer after total proctocolectomy was 2.3% and after total colectomy 18.18% (p = 0.044). CONCLUSIONS: In order to provide better quality of life for individuals with familial adenomatous polyposis, total colectomy is commonly offered, as this simple technique is traditionally associated with lower rates of postoperative complications and better functional outcomes. However, it has become a less attractive technique in patients with familial adenomatous polyposis in its classical or diffuse form, since it has a significantly higher probability of metachronous rectal cancer. (AU)

INTRODUÇÃO: Polipose adenomatosa familiar (PAF), uma doença autossômica dominante caracterizada pela formação de numerosos pólipos adenomatosos no cólon e reto, é causada por mutações da linha germinativa no gene da polipose adenomatosa do cólon (PAC). MÉTODOS: Para determinar a morbidade cirúrgica em pacientes com PAF clássica e determinar a incidência de câncer colorretal (CCR) metacrônico naqueles pacientes submetidos à colectomia total (CT) com anastomose íleo-retal ou submetidos à proctocolectomia restaurativa (PCT) e anastomose bolsa ileal-anal, foram analisados pacientes com PAF que foram tratados e tiveram acompanhamento periódico no A. C. Camargo Cancer Center de 1994 até 2013. RESULTADOS: Ocorreram complicações cirúrgicas em 22 pacientes (34,3%); 16 (25%) tiveram complicações precoces e 8 (12,5%) complicações tardias. Não houve mortes como resultado de complicações pós-operatórias. A incidência de câncer de reto metacrônico após PCT foi de 2,3% e após CT foi de 18,18% (p = 0,044). CONCLUSÕES: A fim de proporcionar melhor qualidade de vida para os pacientes com PAF, CT é comumente oferecida, pois esta técnica simples está tradicionalmente associada com menores percentuais de complicações pós-operatórias e melhores resultados funcionais. No entanto, CT se tornou uma técnica menos atraente em pacientes com PAF em sua forma clássica ou difusa, uma vez que traz consigo uma probabilidade significativamente maior de câncer retal metacrônico. (AU)

Diagnosis and treatment of familial adenomatous polyposis combined with adenomas in the common bile duct / 中华消化外科杂志

Familial adenomatous polyposis is characterized by the multiple and adenomatous polyps in the colorectum combined with polyps in the stomach and duodenum, while it is rarely seen in the common bile duct (CBD).In July 2013, 1patient with FAP combined with adenomas in the CBD was admitted to the Fujian Provincial Hospital.The patient underwent laparoscopic CBD exploration and resection of masses due to acute pancreatitis 11 months ago, and was confirmed as with adenoma in the distal CBD by postoperative pathological examination.Multiple polyps were found in the stomach, duodenum,CBD, colorectum after admission to hospital, biopsy confirmed that polyps were tubular adenoma.The patient received pancreaticduodenectomy and was diagnosed as with duodenum-CBD tubular adenoma in postoperative pathological examination.The patient was followed up by telephone interview and outpatient examination and had a full recovery, in addition to the increasing of stools frequency and occasioned hematochezia, and then was treated by total colectomy at postoperative month 7.The tubular adenoma was confirmed by postoperative pathological examination.

Colectomías totales videolaparoscópicas / Videolaparoscopic total colectomy

Introducción: la resección laparoscópica del colon fue informada por primera vez en 1990 por Moisés Jacobs y Gustavo Plascencia. Las colectomías totales son procedimientos complejos indicados en pacientes con enfermedades como la poliposis múltiple familiar y la colitis ulcerativa idiopática. El abordaje laparoscópico ofrece beneficios importantes al paciente con respecto a la cirugía convencional, incluyendo menor riesgo de recurrencia del tumor en los casos con cáncer. Objetivo: describir los resultados quirúrgicos obtenidos con colectomía total videolaparoscópica. Métodos: se realizó un estudio descriptivo de una serie consecutiva de 14 pacientes a los cuales se les practicó colectomías totales videolaparoscópicas en el Centro Nacional de Cirugía de Mínimo Acceso, en el período comprendido entre enero de 2005 a agosto de 2012. Las variables en estudio fueron: la edad, sexo, indicación quirúrgica, tiempo quirúrgico, necesidad de transfusión intraoperatoria, estadía hospitalaria, complicaciones transoperatorias y postoperatorias. La información se obtuvo de las historias clínicas individuales. Se emplearon porcentajes, promedios y desviación estándar, mediana y rango intercuartílico para muestras asimétricas, como medidas de resumen de las variables empleadas. Resultados: las indicaciones quirúrgicas fueron: poliposis múltiple familiar y colitis ulcerativa idiopática. Predominó el sexo femenino. El rango de edad estuvo comprendido de 16 a 76 años. El tiempo quirúrgico promedio fue de 265 ± 54,7 minutos. No existieron complicaciones transoperatorias. Hubo seis pacientes con complicaciones posoperatorias, cuatro de ellas requirieron reintervención para su corrección, los pacientes evolucionaron favorablemente. Conclusiones: la colectomía total videolaparoscópica constituye un procedimiento factible y seguro para el tratamiento quirúrgico de la poliposis múltiple familiar y colitis ulcerativa idiopática(AU)

Introduction: laparoscopic colon resection was reported for first time in 1990 by Moisés Jacobs and Gustavo Plascencia. Total colectomy is a complex procedure for patients with Familial Multiple Polyposis (FMP) and Idiopathic Ulcerative Colitis(IUC). The laparoscopic approach provides important benefits to the patient as compared to the conventional surgery, including lower risk of tumor recurrence in cancer cases. Objective: to describe the surgical results from the used of the videolaparoscopic total colectomy. Methods: a descriptive study of a consecutive series of 14 patients who underwent videolaparoscopic total colectomy in the National Center of of Minimal Access Surgery in the period of January 2005 through August 2012. The study variables were age, sex, surgical indication, surgical time, transfusional requirements during surgery, stay at hospital, and transoperative and postoperative complications. The information was drawn from the individual medical histories. Percentages, means and standard deviations, medians and interquartile range were taken for asymmetric samples, in terms of summary measures of the used variables. Results: the surgical indications were familial multiple polyposis and idiopathic ulcerative colitis. Females predominated. The age range was 16 to 76 years. The average surgical time was 265.0 ± 54.7 minutes, with no transoperative complications. There were six patients with postoperative complications, four of them were reoperated on to correct the disorders, the patients successfully recovered. Conclusions: videolaparoscopic total colectomy is a feasible and safe procedure for the surgical treatment of familial multiple polyposis and for idiopathic ulcerative colitis(AU)

Poliposis adenomatosa familiar / Family adenomatous polyposis

La Poliposis Adenomatosa Familiar (PAF) es una enfermedad hereditaria autosómica dominante, se caracteriza por el desarrollo de pólipos adenomatosos en el intestino grueso (más de 100), que invariablemente evolucionan al cáncer. Los pólipos aparecen a partir de la pubertad y el cáncer sobreviene antes de los 50 años, por tanto requieren diagnóstico temprano y tratamiento inmediato. La proctocolectomía total es el tratamiento de elección. Se presentan una serie de seis casos atendidos desde febrero de 2012 a julio del 2013.

Familial Adenomatous Polyposis (FAP) is an autosomal dominant inherited disease, characterized by the development of adenomatous polyps in the large intestine (over 100), which invariably evolving cancer. Polyps appear after puberty and cancer occurs before age 50, thus requiring early diagnosis and immediate treatment. Total proctocolectomy is the treatment of choice. A series of six cases treated from February 2012 to July 2013 are presented.

Laparoscopic total colectomy for familial adenomatous polyposis with a report of 9 cases / 局解手术学杂志

Objective To explore the feasibility and safety of laparoscopic total colectomy for familial adenomatous polyposis. Methods All 9 patients with familial adenomatous polyposis received laparoscopic total colectomy were analyzed. Results Laparoscopic total colecto-my was successfully performed in all the 9 patients. The operative time,blood loss,flatus and hospitalization were respectively 230~310 min, 80~210 mL,2~3 days and 12~14 days. All patients were followed up for 6~36 months. The postoperative recovery was good. Conclusion Total colectomy can be successfully perfomed with laparoscopic assisted in treating familial adenomatous poliposis. It is a feasible and safe surgical procedure and can significantly improve the quality life.

Laparoscopically Assisted Total Colectomy with J-pouch Formation for Intractable Chronic Constipation due to Hypoganglionosis: A Case Report / 대한내시경복강경외과학회지

Chronic constipation has been successfully treated with specific medications and bio-feedback therapy. Surgical manipulation for this condition can be an option when non-surgical interventions fail. We report here on a patient who was diagnosed as having intractable chronic constipation with hypoganglionosis. The patient was a 60 year-old male with the history of seizure and diabetes. This patient did not gain any clinical benefits from non-surgical regimens. Therefore, we performed a laparoscopically assisted total colectomy with J-pouch ileorectal anastomosis on this patient. The patient recovered from the surgery without complications and he had normal bowel functions. The postoperative anatomical pathology revealed a hypogaglionosis. In conclusion, a laparoscopically assisted total colectomy for a patient with intractable chronic constipation with hypoganglionosis is a good option and it may be a curative method.

Complications, Mortality and Functional Outcome following a Total Colectomy and Ileo-rectal Anastomosis

PURPOSE: This study reviews the feasibility of a total colectomy with ileo-rectal anastomosis (TCIRA) and the functional outcome following the operation. METHODS: The cases of a total of 50 patients (31 men and 19 women) with a median age of 61 who underwent a TCIRA were reviewed retrospectively. The median follow-up time was 28 months (4~72). The clinical records were reviewed to analyze the postoperative complications and bowel function. The clinical outcomes were examined directly from patients' scoring. RESULTS: The indications of TCIRA were metachronous or synchronous colorectal cancer (34 percent), multiple polypoid lesions (22 percent), malignant colon obstruction (24 percent), ischemic colitis (2 percent), Crohn's disease (6 percent), and tuberculosis colitis (2 percent). The overall mortality and morbidity rates were 0 and 31 percent, respectively. The morbidity included postoperative bleeding, obstruction, intra-abdominal abscess formation, pneumonia, and wound complications. We used the CCIS index to evaluate postoperative functional bowel habit change. The CCIS index evaluation revealed perfect continence in 57 percent of the patients with short-term follow up (<6 months) and in 83 percent of the patients who had undergone a TCIRA more than 2 years ago. CONCLUSIONS: Most patients were satisfied with their bowel function on long-term follow up, and we think the TCIRA is a safe operation, and the clinical outcomes are relatively satisfactory.

Total colectomy and proctocolectomy under laparoscopy for familial adenomatous polyposis with can-cerization / 中华消化内镜杂志

Objective To evaluate the safety, feasibility and efficacy of treating familial adenoma-tous polyposis (FAP) with cancerization by total colectomy and proctocolectomy under laparoscopv. Methods Perioperative data and surgical outcomes of 3 FAP patients who underwent laparoscopic total colectomy and proctocolectomy were analyzed retrospectively and compared with those of 8 patients performed conventional open surgery between Autumn 2001 and December 2002. Results All of the 3 patients were received laparoscopic total colectomy or proctocolectomy successfully without severe complications. The operative times were longer in the laparoscopic group when compared with the conventional group (243. 33 vs. 168. 75 minutes) , (P= 0.028). The mean operative blood loss, flatus and hospital stay in the laparoscopic group were 146. 66 ml, 1. 33 days and 14 days respectively without significant difference when compared with those of the conventional group. The incision length was significantly shorter in the laparoscopic group (4. 33 vs. 19. 38cm) , ( P

Ileostomia continente com preservação da papila íleo-cecal

The authors report three cases of patients submitted to definitive continent ileostomy and three cases of temporary continent ileostomy. Five of them had inflammatory bowel disease and one had familial adenomatous polyposis associated to lower rectal cancer. It was used the continent ileostomy technique, keeping the ileocecal sphincter and a small border of cecal wall. The ileal flow in the first week of post operative does not overflow 430 ml per day. They conclude that the continent ileostomy is useful procedure in selected cases when we need to keep an efficient control of the intestinal effluent.

Seis doentes foram submetidos a ileostomia continente com preservação da papila íleo-cecal, como tempo cirúrgico complementar à proctocolectomia e à colectomia totais, para tratamento de doença inflamatória intestinal e polipose adenomatosa familiar, associada a pólipo degenerado no reto inferior. A técnica utilizada de ileostomia continente preserva a papila íleo-cecal e uma pequena borda circular de parede cecal exteriorizados na parede abdominal. O débito ileal, na primeira semana pós-operatória, não ultrapassou 430 ml/dia, não houve complicações do procedimento e o aspecto estético ficou excelente. Conclui-se que a ileostomia continente com preservação da papila íleo-cecal, definitiva ou temporária, é um procedimento cirúrgico eficiente, em casos selecionados, quando se deseja manter um controle eficaz do efluente intestinal.

Clinical Analysis of Total Colectomy for Chronic Idiopathic Constipation

The aim of this study was to analyse clinical feature and outcome of patients following total abdominal colectomy and ileorectal anastomosis. METHODS: All of 8 patients subjected to surgery during 5 year period from May 1995 to December 1999 were reviewed using retrospective method. RESULTS: All patients had slow colonic transit and 7 patients (male to female, 1:1.6) with a mean age of 54 (range, 27~70) years underwent total abdominal colectomy and ileorectal anastomosis and one patient had right hemicolectomy. Major symptoms were abdominal pain and bloating and mean bowel action was 18.5 days, mean suffered time before operation was 26.3 years. Colonic transit study, defecography and rectal manometry were done in all cases. Pelvic floor dysfunction was combined in 5 patients. Median follow up was 2.7 years. There was one mortality case due to postoperative pneumonia and ARDS in a 70 year old patient. Except one mortality case, there was significant success rate, overall 71%. CONCLUSIONS: Colectomy with ileorectal anastomosis produces a satisfactory outcome in the majority of patients undergoing surgery for chronic idiopathic constipation.

Clinical Significance of Subtotal or Total Colectomy in Obstructing Left Side Colon Cancer

PURPOSE: Although the cancer of the right side colon is usually managed by primary anastomosis following resection, but the optimal management of obstructing left side colon cancer is controversial. So, we performed this study to evaluate the feasibility and safety of subtotal or total colectomy as a method of one-stage operation in malignant obstruction of left side colon. METHODS: We analyzed retrospectively 35 patients with obstructing left side colon cancer among 74 cases of obstructing colorectal carcinoma who were treated surgically at the Wallace Memorial Baptist Hospital from January 1989 to December 1998. RESULTS: One-stage operation was performed in 16 patients (subtotal colectomy in 13, total colectomy in 3). Staged operation was performed in 15 patients (two-stage operation in 10, three-stage operation in 5). Palliative colostomy was performed in 4 patients. Postoperative complications had been developed in 6 patients (37.5%) with subtotal or total colectomy group and in 7 patients (46.7%) with staged operation group. The postoperative frequent bowel movement was shown in 13 patients (81.2%) with subtotal or total colectomy group and in 7 patients (70.0%) with staged operation group. Frequent bowel movement was improved with antidiarrheal medications within 3 months. Operative mortality was 6.3% (1 patient) in subtotal or total colectomy group and 13.3% (2 patients) in staged operation group. There was no significant difference in morbidity and mortality statistically between two groups. CONCLUSIONS: We believe that subtotal or total colectomy as a method of one-stage operation can be performed with acceptable morbidity and mortality in selected patients with obstructing left side colon cancer.