Doppler ultrasound testing suggests hemorrhoids in females may be a consequence of impaired blood flow Associated with pelvic organ prolapse

Abstract Background It has been observed that there is a high incidence of hemorrhoids in female patients with pelvic organ prolapse. Also, in these patients, hemorrhoidal disease improves after the surgical correction of the pelvic organ prolapse. Objective Our hypothesis was that a cause-effect relationship between pelvic organ prolapse, and hemorrhoids might be the key. The objective of this study was to find an element which connects these two conditions. Study Design We conducted a pilot study which consisted of two parts. An initial part, in which we asked several patients with grades III and IV pelvic organ prolapse and hemorrhoids, who have undergone surgery for prolapse, to determine the impact of the surgical restoration of the prolapsed organs on their hemorrhoidal disease. For the second part, on several patients with uncorrected uterine prolapse grades III and IV, we determined the resistive index of the hemorrhoidal branches within the rectal wall before and after manual reduction of the prolapse. Results First, more than 50% of patients who underwent uterine prolapse correction described an improvement of their hemorrhoidal disease of over 50%. Second, the resistive index of the hemorrhoidal branches was significantly lower after manual reduction of the prolapse. We consider that obstructed veins due to pelvic organ prolapse might induce the dilation of the hemorrhoids. The direct measurement of the resistive index of the hemorrhoidal branches allows us to directly assess the increased resistance in the rectal vascular system. Conclusion Venous stasis and impaired vascular flow might be the pathophysiological explanation for the association between pelvic organ prolapse and hemorrhoids. In these patients, the pathogenic treatment should aim at the restoration of a normal blood flow (prolapse surgical cure) instead of focusing on hemorrhoids only.(AU)

Is there a precise correlation between the lengths of the peritoneal reflection and the middle rectal valve?

Introduction: Pelvic anatomy remains a challenge, and thorough knowledge of its intricate landmarks has major clinical and surgical implications in several medical specialties. The peritoneal reflection is an important landmark in intraluminal surgery, rectal trauma, impalement, and rectal adenocarcinoma. Objectives: To investigate the correlation between the lengths of the middle rectal valve and of the peritoneal reflection determined with rigid sigmoidoscopy and to determine whether there are any differences in the location of the peritoneal reflection between the genders and in relation to body mass index (BMI) and parity. Design: We prospectively investigated the location of the middle rectal valve and of the peritoneal reflection via intraoperative rigid sigmoidoscopy in colorectal cancer patients undergoing elective colorectal surgery. Results: We evaluated 38 patients with a mean age of 55.5 years old (57.5% males) who underwent colorectal surgery at the coloproctology service of the Hospital Santa Marcelina, São Paulo, state of São Paulo, Brazil. There was substantial agreement between the lengths of the middle rectal valve and of the peritoneal reflection (Kappa = 0.66). In addition, the peritoneal reflection was significantly lower in overweight patients (p = 0.013 for women and p < 0.005 for men) and in women with > 2 vaginal deliveries (p = 0.009), but there was no significant difference in the length of the peritoneal reflection between genders (p = 0.32). Conclusion: There was substantial agreement between the lengths of the peritoneal reflection and of the middle rectal valve, and the peritoneal reflection was significantly lower in overweight patients and in women with more than two vaginal deliveries. (AU)

Transanal haemorrhoidal dearterialization with mucopexy (thd-m) for treatment of hemorrhoids: is it applicable in all grades? brazilian multicenter study / A técnica de desarterialização hemorroidária transanal associada à mucopexia (thd-m) é aplicável em todos os graus? estudo multicêntrico brasileiro

ABSTRACT Background: Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades. Aim: To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades. Method: Seven hundred and five consecutive patients with Goligher's grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48). Results: Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively. Conclusion: The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

RESUMO Racional: A desarterialização hemorroidária transanal associada à mucopexia (THD-M) tem sido indicada como alternativa à hemorroidectomia convencional para o tratamento da doença hemorroidária nos seus variados graus. No entanto, ainda hoje existe controvérsia com relação a sua eficácia para os graus mais avançados. Objetivo: Avaliar a eficácia da técnica THD-M para tratamento doença hemorroidária e comparar os resultados imediatos e tardios nos diferentes graus. Método: Entre julho de 2010 e setembro de 2015, 705 pacientes consecutivos com hemorroidas sintomáticas de graus II, III e IV foram submetidos ao tratamento cirúrgico pelo método THD-M e acompanhados por um período médio de 21 meses (12-48). As operações foram realizadas por seis cirurgiões com experiência em cirurgia colorretal, em três estados brasileiros. Resultados: Complicações intraoperatórias foram observadas em 1,1% dos casos, incluindo quatro casos de hematoma, dois de laceração da mucosa e dois de sangramento. Todos foram controlados com sutura hemostática. As complicações pós-operatórias mais comuns foram: tenesmo transitório (21,4%); dor (7,2%); prolapso mucoso ou hemorroidário (6,4%); plicoma residual (5,6%); impactação fecal (3,2%); trombose hemorroidária (2,8%); sangramento (2,1%); fissura anal (0,7%) e abscesso anal (0,3%). Não houve casos de complicações severas ou mortalidade perioperatória. A recorrência do prolapso e sangramento foi maior na doença hemorroidária grau IV do que nos graus III e II (26.54% e 7.96% vs. 2.31% e 0.92% vs. 2.5% e 1.25%; p<0,001), respectivamente. Conclusão: O método THD-M é seguro e efetivo no tratamento da doença hemorroidária nos graus II e III com baixo índice de complicações. No entanto, para a doença hemorroidária de grau IV essa técnica está relacionada com maior índice de recorrência e complicações tardias, não devendo ser considerada opção eficiente neste estágio de doença.

Establishing the normal ranges of female and male anal canal and rectal wall vascularity with color Doppler anorectal ultrasonography / Estabelecendo padrões normais da vascularização do canal anal e da parede retal em indivíduos do sexo masculino e feminino com ultrassom anorretal com Doppler colorido

ABSTRACT Study objectives: To evaluate blood supply in the anal canal, rectal wall and mesorectal fat of men and women, using color Doppler endorectal sonography to establish normal ranges for vascular parameters. Methods: A prospective cross-sectional study conducted at a tertiary-care hospital recruited asymptomatic volunteers (≤50 years). Vascularity percentage and index were calculated for defined regions. Results: Vascularity percentage and index were significantly higher in the puborectalis, mid-level external and upper internal anal sphincter compared to the low anal canal; these parameters were higher in men than in women at upper and middle levels of the inner anal canal structures. At mid-level, vascularity was greater in the external compared to the internal anal sphincter in both sexes; however, at the upper level it was greater in the puborectalis compared to the internal anal sphincter in women. Vascularity was greater in the rectal wall compared to the mesorectal fat, with no difference between middle and lower levels. Conclusions: Blood supply is highest at upper levels of the anal canal; however, inner structures are better irrigated in men. Moreover, the rectal wall is better irrigated than the mesorectal fat. Establishing normal ranges may permit future comparisons of the studied structures in disease states as well as the hormonal and age related changes.

RESUMO Objetivo: Avaliar vascularização do canal anal, parede retal e gordura mesorretal em homens e mulheres, usando ultrassonografia endorretal com Doppler colorido para estabelecer parâmetros vasculares de normalidade. Métodos: Estudo prospectivo transversal incluindo voluntários assintomáticos com até 50 anos. Medidos os valores da porcentagem e do índice de vascularização foram calculados para regiões escolhidas. Resultados: Valores da porcentagem e do índice foram significativamente maiores no puborretal, esfíncter externo (canal anal médio) e o esfíncter interno (canal anal superior) comparado ao canal anal inferior; esses parâmetros foram maiores em homens que em mulheres no canal anal médio e alto. No médio, a vascularização foi maior no esfíncter externo comparado ao interno em ambos os sexos; contudo, no canal anal superior, foi maior no puborretal comparado ao esfíncter anal interno em mulheres. A vascularização foi maior na parede retal comparada à gordura mesorretal, sem diferenças entre os níveis. Conclusões: O suprimento sanguíneo é maior nos níveis altos do canal anal. As estruturas internas são mais irrigadas nos homens. A parede retal é mais irrigada que a gordura mesorretal. Os parâmetros vasculares estabelecidos permitirá futuras comparações das estruturas estudadas nos casos de doenças, assim como, alterações que ocorrem com a idade e mudanças hormonais.

Varizes Retais / Rectal Varices

Paciente do sexo feminino, na quinta década de vida, com diagnóstico prévio de cirrose hepática classificação de Child-Pugh C, evoluiu com quadro de hematoquezia intermitente. Foi submetida à colonoscopia, que demonstrou varizes retais calibrosas, conforme mostrado nas figuras A e B.

Desarterialização transanal guiada por doppler associada ao reparo anorretal na doença hemorroidária: a técnica do THD / Transanal desarterialization guided by Doppler associated to anorectal repair in hemorrhoids: THD technic

INTRODUÇÃO: O tratamento cirúrgico para hemorroidas deve ter indicação individual e baseia-se no sintoma predominante (sangramento ou prolapso), na gravidade da doença e na presença ou ausência de componente externo (plicoma). Cabe ao cirurgião conhecer as mais variadas técnicas para que possa encontrar o tratamento mais adequado caso a caso. TÉCNICA: O procedimento THD consiste na ligadura alta seletiva e guiada por Doppler de até seis ramos arteriais submucosos que irrigam as hemorroidas, levando à sua desarterialização, associada à correção do prolapso (reparo anorretal ou lifting). Utiliza equipamento e kit especiais. CONCLUSÃO: A técnica do THD tem mostrado bons resultados iniciais. Por ser técnica cirúrgica em que se respeita a anatomia, ela age diretamente sobre a fisiopatologia da afecção e corrige suas principais consequências, ela parece bastante promissora. Sua aplicação inicial pode ser nos pacientes com doença hemorroidária de II grau, que tenham indicação de tratamento cirúrgico, e de III e IV graus, nestes últimos, podendo ser associada à ressecção de plicomas.

INTRODUCTION: Surgical treatment for hemorrhoids should be indicated individually and is based on the predominant symptom (bleeding or prolapse), severity of disease and the presence or absence of external component (plicoma). Surgeons must choose among varied techniques the one suitable for each case. TECHNIC: The THD procedure consists of Doppler guided high ligation, selective to up six submucosal arterial branches that supply the hemorrhoids, leading to its desarterialization associated with prolapse repair (anorectal repair or lifting). It uses special equipment and kit. CONCLUSION: THD technique has shown good initial results. Because surgical technique respects the anatomy, it acts directly on the pathophysiology of the disease and corrects its principal consequences; it looks quite promising. Its initial application may be in patients with hemorrhoids grade II, which have surgical indication, grades III and IV, the latter being associated with resection of plicomas.

Massive Life-threatening Lower Gastrointestinal Hemorrhage Caused by an Internal Hemorrhoid in a Patient Receiving Antiplatelet Therapy: A Case Report / 대한소화기학회지

A Dieulafoy lesion in the rectum is a very rare and it can cause massive lower gastrointestinal bleeding. An 83-year-old man visited our hospital. He had chronic constipation and had taken aspirin for about 10 years because of a previous brain infarction. He was admitted because of a recent brain stroke. On the third hospital day, he had massive hematochezia and suddenly developed hypovolemic shock. Abdominal computed tomography showed active arterial bleeding on the left side of the mid-rectum. Emergency sigmoidoscopy showed an exposed vessel with blood spurting from the rectal wall. The active bleeding was controlled successfully by an injection of epinephrine and two hemoclippings. On the fourth day after the procedure, he had massive recurrent hematochezia, and his vital signs were unstable. Doppler-guided hemorrhoidal artery band ligation was performed urgently at two sites. However, he rebled on the third postoperative day. Selective inferior mesenteric angiography revealed an arterial pseudoaneurysm in a branch of the superior rectal artery, as the cause of rectal bleeding, and this was embolized successfully. We report a rare case of life-threatening rectal bleeding caused by a Dieulafoy lesion combined with pseudoaneurysm of the superior rectal artery which was treated successfully with embolization.

Massive Life-threatening Lower Gastrointestinal Hemorrhage Caused by an Internal Hemorrhoid in a Patient Receiving Antiplatelet Therapy: A Case Report / 대한소화기학회지

A Dieulafoy lesion in the rectum is a very rare and it can cause massive lower gastrointestinal bleeding. An 83-year-old man visited our hospital. He had chronic constipation and had taken aspirin for about 10 years because of a previous brain infarction. He was admitted because of a recent brain stroke. On the third hospital day, he had massive hematochezia and suddenly developed hypovolemic shock. Abdominal computed tomography showed active arterial bleeding on the left side of the mid-rectum. Emergency sigmoidoscopy showed an exposed vessel with blood spurting from the rectal wall. The active bleeding was controlled successfully by an injection of epinephrine and two hemoclippings. On the fourth day after the procedure, he had massive recurrent hematochezia, and his vital signs were unstable. Doppler-guided hemorrhoidal artery band ligation was performed urgently at two sites. However, he rebled on the third postoperative day. Selective inferior mesenteric angiography revealed an arterial pseudoaneurysm in a branch of the superior rectal artery, as the cause of rectal bleeding, and this was embolized successfully. We report a rare case of life-threatening rectal bleeding caused by a Dieulafoy lesion combined with pseudoaneurysm of the superior rectal artery which was treated successfully with embolization.

Letter to the Editor: A Case of Behcet's Disease with Massive Lower Gastrointestinal Bleeding / 대한소화기학회지

No abstract available.

Involvement of Splenic Hemangioma and Rectal Varices in a Patient with Klippel - Trenaunay Syndrome / 대한소화기학회지

Klippel - Trenaunay syndrome (KTS) is characterized by a cutaneous vascular nevus of the involved extremity, bone and soft tissue hypertrophy of the extremity and venous malformations. We present a case of KTS with splenic hemangiomas and rectal varices. A 29-year-old woman was referred for intermittent hematochezia for several years. She had history with a number of operations for cutaneous and soft tissue hamangiomas since the age of one year old and for increased circumference of her left thigh during the last few months. Abdominal CT revealed multiple hemangiomas in the spleen, fusiform aneurysmal dilatation of the deep veins and soft tissue hemangiomas. There was no evidence of hepatosplenomegaly or liver cirrhosis. Colonoscopy revealed hemangiomatous involvement in the rectum. There were rectal varices without evidence of active bleeding. Upon venography of the left leg, we also found infiltrative dilated superficial veins in the subcutaneous tissue and aneurysmal dilatation of the deep veins. The patient was finally diagnosed with KTS, and treated with oral iron supplementation only, which has been tolerable to date. Intervention or surgery is not required. When gastrointestinal varices or hemangiomatous mucosal changes are detected in a young patient without definite underlying cause, KTS should be considered.

Rincones olvidados de la gastroenterología III: la compleja interacción entre la musculatura recto-anal y la circulación / Forgotten corners of the gastrointestinal tract III: the complex interaction between anorectal muscles an blood supply

Our medical education does not emphatize the study of the lower GI tract physiology. This results in a biased view of the importance of knowing both the syndromes and the pathologies arising from local derangements. When diseases of the lower GI tract do occur, our approach is too local, with excessive emphasis in topical therapy, while neglecting the causal factors. Therefore, we cannot educate our patients into correcting their habits and lifestyle, usually the responsible factors for the pathology. Because of little prevention and inadequate treatments, these problems derive into chronic conditions that may finally result in surgical therapies. In this review we aim to analize the importance of the vascular structures of the lower GI tract and of the irrigation of the rectal and anal muscles, describing the complex interaction that exists between vessels and muscles both in the physiology of continence and in ano-rectal pathology, detailing which derangements are causal and which are consequences, with the intention of leading us into a different approach based on physiology.

Nuestra formación no profundiza en la fisiología del tubo digestivo bajo. Ello nos lleva a una visión sesgada de la importancia de conocer los síndromes y las patología derivadas de los problemas en esa zona. Cuando se genera patología orificial o del recto distal, nuestro enfoque suele ser, erróneamente, muy localista, con mucho énfasis en terapias tópicas, olvidando de abordar los factores causales. Con ello no podemos educar bien a los pacientes en corregir los hábitos y costumbres, responsables, casi siempre, de la patología. La consecuencia es que hacemos poco por prevenir y hacemos terapias inadecuadas, desembocando los cuadros en patología crónicas que finalmente pueden terminar en resolución quirúrgica. En la presente revisión se analiza la importancia de las alteraciones de las estructuras vasculares y de la irrigación de la musculatura recto-anal, describiendo la interacción que existe entre vasos y músculos, tanto en la fisiología de la continencia como en la patololgía ano-rectal, examinando cuales alteraciones son causa y cuales son consequencia. La intención es cambiar nuestro enfoque hacia un abordaje basado en la fisiopatología.

Treatment of acute lower gastrointestinal hemorrhage by superselective transcatheter embolization.

AIM: To evaluate the technical feasibility, success of hemostasis and complications of transcatheter embolization in the treatment of acute lower gastrointestinal (GI) bleeding. METHODS: Retrospective review of 63 patients with acute lower GI bleed who had undergone transcatheter selective embolization of mesenteric arteries over a two-year period. Embolization was carried out only if the arteria recta leading to the bleed could be successfully catheterized (n=52). The lesions treated were located in the jejunum (n=13), ileum and ileo-cecal region (n=9), appendicular region (n=2) and colon (n=28). Embolization was performed with only polyvinyl alcohol particles (PVA) (250-500 microns) in 23 patients, only microcoils in 16 patients and both PVA particles and microcoils in 13 patients. Twenty-eight patients were evaluated for objective evidence of ischemia by colonoscopy (n=21) and/or histologic evidence in the surgical specimen (n=7); 23 patients were followed up clinically. RESULTS: Immediate hemostasis was achieved in 61 of 63 patients; of the remaining 2 patients, one underwent surgery whereas the other died during the procedure. Recurrent bleeding occurred in 9 patients - 6 were managed surgically and 3 medically. Endoscopic evaluation showed mucosal ischemia in 7 patients but they remained asymptomatic on follow up. Embolization was the sole modality of treatment in 41 patients (78.9%). CONCLUSION: Transcatheter superselective embolization is an effective and safe modality of treatment for acute lower GI bleeding.

Frequency of rectal varices in patients with cirrhosis

To document the frequency of rectal varices in patients with cirrhosis of liver and compare it with that of oesophageal varices in liver and to compare the frequency of rectal varices with non-cirrhotic controls. Design: A cross-sectional analytical survey. Place and Duration of Study: The study was conducted in the medical wards of Civil Hospital, Karachi from August 2000 to July 2001. Patients and All patients of confirmed cirrhosis of liver, presenting during the study period, were selected for initial workup. On the basis of upper gastrointestinal [GI] endoscopy, patients were segregated into those with oesophageal varices [Group-A] and those without them [Group-B]. A matched control group [Group-C] was added, which consisted of patients of irritable bowel syndrome [IBS] who underwent sigmoidoscopic/colonoscopic examination during the study period. Fiberoptic sigmoidoscopy was done in all selected patients. Statistical analysis for continuous variables was done by student's 't' test while non-continuous variables were analyzed by Mann-Whitney-U test. A total of 104 patients [males 61; females 43] were included. Hepatic encephalopathy grade was significantly lower in Group-B [p < 0.0001]. Grade-I varices were seen in 13 patients, Grade-II in 38 and Grade-III in 33 patients of Group-A. Rectal varices were present in 59.9% of patients in Group-A as compared to Group-B in which no one had them [p<0.0001]. Rectal varices are common in patients of portal hypertention

Consideraciones anatómicas sobre la anastomosis arterial recto-sigmoídea / Anatomical considerations of the recto-sigmoid arterial anastomosis

El conocimiento de la circulación colateral abdominal es importante en las cirugías de la región. Con la finalidad de esclarecer la capacidad de flujos de la anastomosis recto-sigmoídea, su localización y las eventuales variaciones anatómicas, estudiamos las arterias componentes de ella en 43 cadáveres de individuos adultos, brasileños, a los que se inyectó una mezcla de alginato con agua y teñida de tal manera de visualizar su recorrido. Los resultados obtenidos mostraron que la anastomosis recto-sigmoídea está presente en 86.1 por ciento del total de casos; se observó permeable en 70,3 por ciento y se presentó sin permeabilidad en 29,7 por ciento. Estos datos permiten asegurar que esta anastomosis está presente y es funcional en más de la mitad de los casos

Tratamiento de várices rectales a través de ligadura elástica endoscópica / Treatment of rectal varices using endoscopic elastic ligation

Las várices rectales sangrantes son raras y cuando aparecen representan un riesgo muy alto para estos pacientes. Relatamos el caso de un paciente de 50 años con cirrosis, que presentó sangrado por várices rectales y fue tratado con ligadura elástica endoscópica con excelente resultado

Cardiac nociception induced rectal response: relation with haemodynamic changes.

Epicardial application of nicotine (200 micrograms/ml) over the left ventricle or occlusion of the left anterior descending coronary artery (LAD) in lightly anaesthetised cats resulted a biphasic change in rectal motility-initial relaxation followed by contraction along with biphasic changes of blood pressure (B.P.) with epicardial nicotine and only hypotension with LAD occlusion. Desensitisation of ventricular receptors by epicardial application of 2% lignocaine abolished the rectal response and the biphasic blood pressure response but not the LAD occlusion induced hypotension. Sectioning of left inferior cardiac nerve (LICN) abolished such cardiorectal reflex but not the B.P. changes. Stimulation of central cut end of LICN elicited similar cardiorectal reflex keeping the B.P. unaltered. Atropinization (1 mg/kg) abolished only the contractile phase of the cardiorectal reflex and also the hypotension induced by epicardial nicotine. Intra-arterial NG-nitro-L-Arginine (LNNA) at a dose of 2 mg/kg abolished the relaxation phase of such cardiorectal reflex keeping the B.P. changes unaltered. LAD occlusion induced hypotension was neither counteracted by atropine nor by LNNA pretreatment. These indicate that though the cardio-rectal reflexes are associated with B.P. changes, they do not have any direct correlation.

Investigación anatómica de las vías linfáticas del recto y sus implicacias quirúrgicas / Anatomy research of lymphatic routes of the rectum

Se presentan los resultados de un trabajo de investigación anatómica sobre las vías linfáticas del recto. Fue realizado sobre 36 fetos fallecidos con 7 o más meses de vida intrauterina. La masa de Gerota se inyectó separadamente en cada tercio del recto y en el canal anal. En el tercio superior del recto sólo se coloreó la vía linfática ascendente (vía de la mesentérica inferior). En los especímenes inyectados en el tercio medio e inferior del recto y en el canal anal, la masa de Gerota coloreó tanto la vía ascendente como la lateral (vía de la hemorroidal media). En dos ejemplares, inyectados en el tercio medio, además de las dos vías recién mencionadas, fue observado un fino canal linfático ascendiendo por el espacio retrorrectal hasta terminar en un ganglio localizado sobre el ala derecha del sacro. No se hallaron comunicaciones linfáticas entre el recto y los órganos genitourinarios ni tampoco con el grupo ganglionar inguinal

A vascularizaçäo arterial do cólon terminal (anatomia cirúrgica da artéria mesentérica inferior) / The arterial vascular supply of the terminal colon (surgical anatomy of the inferior mesenteric artery)

Recorda, o autor, a evoluçäo dos conhecimentos em torno da vascularizaçäo do cólon sigmoide e recto, aplicada à cirurgia desse segmento intestinal. Menciona as primeiras operaçöes de amputaçäo abdómino-perineal do recto e ressecçöes cólicas com anastomose das extremidades intestinais e os primeiros estudos em torno do problema cirúrgicoda vascularizaçäo, feito por SUDECK e ARCHIBALD, em 1908. Após a revisäo dos trabalhos básicos, no assunto, menciona os autores nacionais que têm se interessado pelo estudo da vascularizaçäo do cólon termina, através da contribuiçäo anatômica ou cirúrgica à literatura médica nacional. Descreve a distribuiçäo e as variedades dos ramos da artéria mesentérica inferior. Apresenta o resultado de suas observaçöes, feitas em 100 indivíduos, pós-mortem, relacionando o comprimento do cólon terminal e o número das artérias sigmóideas. Baseado na observaçäo pessoal, apresenta uma classificaçäo e variaçöes das artérias sigmoideas, segundo o número e origem das mesmas, excluídas aquelas que, por suas características especiais possam ser consideradas como anomalias. Descreve a variedade de tipos das artérias sigmoideas, passando depois aos ramos terminais representados nas hemorroidárias superiores e às arcadas marginais. Faz, depois, um estudo da artéria sigmoidea ima e de seu valor anatomo-cirúrgico, esclarecendo e apoiando as razöes que levaram GREGOIRE a substituir a noçäo do "ponto crítico de Sudeck" pela de "zona crítica". O trabalho é ilustrado com vários esquemas e desenhos anatômicos, e acompanhado de vasta bibliografia