Transanal drainage tube for prevention of anastomotic leak after anterior resection for rectal cancer: a meta-analysis / 中华胃肠外科杂志

Objective: To assess the effectiveness of transanal drainage tube (TDT) in reducing the incidence of anastomotic leak following anterior resection in patients with rectal cancer. Methods: We conducted a systematic search for relevant studies published from inception to October 2022 across multiple databases, including PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP. Meta-analysis was performed using Review Manager 5.4 software. The primary outcomes included total incidence of anastomotic leak, grade B and C anastomotic leak rates, reoperation rate, anastomotic bleeding rate, and overall complication rate. Results: Three randomized controlled trials involving 1115 patients (559 patients in the TDT group and 556 in the non-TDT group) were included. Meta-analysis showed that the total incidences of anastomotic leak and of grade B anastomotic leak were 5.5% (31/559) and 4.5% (25/559), respectively, in the TDT group and 7.9% (44/556) and 3.8% (21/556), respectively, in the non-TDT group. These differences are not statistically significant (P=0.120, P=0.560, respectively). Compared with the non-TDT group, the TDT group had a lower incidence of grade C anastomotic leak (1.6% [7/559] vs. 4.5% [25/556]) and reoperation rate (0.9% [5/559] vs. 4.3% [24/556]), but a higher incidence of anastomotic bleeding (8.2% [23/279] vs. 3.6% [10/276]). These differences were statistically significant (P=0.003, P=0.001, P=0.030, respectively). The overall complication rate was 26.5%(74/279) in the TDT group and 27.2% (75/276) in the non-TDT group. These differences are not statistically significant (P=0.860). Conclusions: TDT did not significantly reduce the total incidence of anastomotic leak but may have potential clinical benefits in preventing grade C anastomotic leak. Notably, placement of TDT may increase the anastomotic bleeding rate.

Importance of comprehensive management of anastomotic site after ultra-low anal sphincter-preservation surgery / 中华胃肠外科杂志

Intersphincteric resection (ISR) surgery increases the rate of anal sphincter preservation in patients with ultra-low rectal cancers. However, the anastomotic site of ISR surgery is at risk for structural healing complications such as anastomotic leakage, anastomotic dehiscence, secondary anastomotic stenosis, chronic presacral sinus, rectovaginal fistula, and rectourethral fistula, which can lead to a persistent defunctioning ostomy or a secondary permanent colostomy. This article systematically describes the preoperative high-risk factors and characteristics of anastomotic site structural healing complications after ISR surgery, as well as the management of the anastomotic site during various stages including hospitalization, from discharge to one month after surgery, from one month after surgery to before stoma reversal, and after stoma reversal. This is to provide a clearer understanding of the risks associated with the anastomotic site at different stages of the healing process and to timely detect and actively manage related complications, thereby reducing the rate of permanent colostomy and truly achieving the dual goals of "survival benefit" and "quality of life improvement" in ISR surgery.

McKittrick-Wheelock syndrome secondary to rectal adenocarcinoma

Introduction: McKittrick-Wheelock syndrome is a rare condition that arises from a hypersecretory state secondary to large colorectal tumors, mainly villous adenomas, leading to an electrolytic disorder associated with chronic diarrhea that usually persists for years. It is a relatively unknown disease that can lead to severe complications such as acute kidney injury, severe hyponatremia, and hypokalemia. In fact, it causes death in most untreated cases. Surgical removal of the tumor is the most successful treatment, and symptoms tend to disappear after proper management. Case Report: A 62-year-old man with a 2-year history of mucoid diarrhea preceded by abdominal pain presented with acute kidney injury, hyponatremia, and hypokalemia. A digital rectal examination and sigmoidoscopy were performed, and revealed a large laterally-spreading tumor in the rectum. Further investigation showed a rectal tubulovillous adenoma with secondary McKittrick-Wheelock syndrome. An anterior resection of the rectum with a colonic J-pouch and a diverting ileostomy were performed, and the patient improved with the resolution of the renal failure and electrolyte disturbances. The histopathological analysis revealed an invasive rectal adenocarcinoma. Discussion: McKittrick-Wheelock syndrome is a condition with a low incidence that needs early intervention and proper diagnosis. It is of extreme importance that this disease is included in the differential diagnoses for chronic diarrhea associated with an electrolytic disorder. (AU)

Disfunción ileostómica en pacientes sometidos a resección anterior baja por un cáncer del recto luego de neoadyuvancia / Ileostomic dysfunction in patients undergoing low anterior resection for rectal cancer after neoadjuvant treatment

Resumen Introducción: La resección anterior baja protegida con una ileostomía en asa (IA) luego de neoadyuvancia es el tratamiento estándar del cáncer del recto bajo localmente avanzado. Objetivos: Investigar la incidencia, características clínicas de la disfunción ileostómica (DI) en estos pacientes y, eventualmente, definir un perfil de riesgo. Materiales y Método: Se analizan 103 pacientes consecutivos. La DI se define como la eliminación por la ileostomía de más de 1,5 litros por día durante 3 o más días consecutivos asociado a distensión y dolor abdominal con intolerancia a la alimentación oral en ausencia de una complicación intraabdominal Clavien-Dindo grado III o mayor. Se comparan el grupo con DI del resto (no DI). Resultados: La DI se presentó en el 14,5% de los casos, se resolvió entre 12 y 70 días (en el 50% superó los 30 días), la tasa de reingreso fue 27% y no hubo reoperaciones en este grupo. No hubo diferencias estadísticamente significativas entre ambos grupos salvo en el tiempo de hospitalizarán y la tasa de reingresos. Discusión: La DI corresponde a un tipo de íleo posoperatorio de gravedad y duración variable que paradojalmente se asocia con la eliminación de altos volúmenes de contenido intestinal por la IA, requiere aporte vigoroso de volumen y electrolitos y en los casos más graves apoyo con nutrición parenteral. El cuadro revierte en plazos variables con manejo conservador. En este estudio no se ha logrado definir un perfil del paciente en riesgo de sufrir esta complicación o factores predictivos de ella.

Background: Diverting loop ileostomy (LI) is commonly performed to protect a distal anastomosis after a low anterior resection. Aim: To investigate the frecuency and clinical features of ileostomic dysfunction (ID) and, eventually, to define a profile of patients at risk of this complicaction. Materials and Method: 103 consecutive patients operated on for rectal cancer were included. ID is defined when the maxime output was more than 1,5 lt/day for three or more consecutive days with biochemical disturbances, associated to abdominal distension and the inability to tolerate oral feeding without postoperative severe complication. Patients with ID were compared with noID group. Results: ID developed in 15 patients, lasting between 12 and 70 days (50% for more then 30 days), the readmission rate was 27% without reoperation in this group. Except for inhospital time and readmission rate, no other difference between both groups were founded. Discussion: ID is a kind of paralitic ileus of variable intensity with paradox high output ileostomy leading to depletion of water and electrolyte imbalance. ID requires reposition of high volumen of fluids and electrolytes and sometimes parenteral nutrition with full recovery in variable periods without invasive treatment. In this study it was not possible to define a patient profile at risk or predictive factores of this complication.

Pull-Through in Patients after Pelvic Anastomosis Leak Following Proctectomy: A Cross-Sectional Study / Abaixamento em pacientes após vazamento de anastomose pélvica após proctectomia: Um estudo transversal

Abstract Introduction Colorectal cancer is the second most common type of cancer and the third leading cause ofmortality due to cancers. Anastomosis leak after proctectomy is a dangerous complication that must be managed carefully. The aim of the present study was to assess the procedure of resection and pull-through of the new rectum after anastomosis leak in patients after proctectomy. Methods and Materials This was a cross-sectional study. Patients who visited the Firoozgar Hospital between 2015 and 2018 for rectal cancer surgery and had anastomosis leak entered the study. All patients underwent resection of the residue of rectum and pull-through of colon. Results In the present study, out of the 110 cases who underwent proctectomy, 12 patients with postoperative anastomosis leak were reported. Five (41.7%) were male and 7 (58.3%) were female. Themean age of the patients was 41.5 ± 4.3 years (33-51). Resection of the new rectum and pull-through anastomosis were performed for these 12 patients. No major intraoperative complication occurred. Postoperative course was uneventful in all patients. Discussion Resection of residue of rectum and pull-through in patients with anastomosis leak can be done after rectal cancer surgery. This method is superior to abdominopelvic resection in many aspects, especially regarding accessibility to the new rectum by rectal exam or endosonography to assess recurrence or a relative continence after closure of ostomy.

Resumo Introdução O câncer colorretal é o segundo tipo de câncer mais comum, e a terceira principal causa de mortalidade por câncer. O vazamento da anastomose após a proctectomia é uma complicação perigosa, que deve ser tratada com cuidado. O objetivo do presente estudo foi avaliar o procedimento de ressecção e abaixamento do novo reto após vazamento de anastomose em pacientes submetidos à proctectomia. Métodos e Materiais Este foi um estudo transversal que incluiu pacientes que compareceram ao Firoozgar Hospital entre 2015 e 2018 submetidos a cirurgia de câncer retal e com vazamento de anastomose. Todos os pacientes foram submetidos a ressecção do resíduo do reto e abaixamento do cólon. Resultados No presente estudo, dos 110 casos submetidos a proctectomia, 12 pacientes tiveram vazamento de anastomose pós-operatório: 5 (41,7%) do sexo masculino e 7 (58,3%) do sexo feminino. A idade média dos pacientes foi de 41,5 ± 4,3 anos (gama: 33 a 51 anos). A ressecção do reto novo e a anastomose por abaixamento foram realizadas nesses 12 pacientes. Nenhuma complicação intraoperatória mais grave ocorreu. No pós-operatório, não houve intercorrências em nenhum dos pacientes. Discussão A ressecção de resíduo retal e o abaixamento em pacientes com vazamento de anastomose pode ser feita após cirurgia de câncer retal. Este método é superior à ressecção abdominopélvica em muitos aspectos, especialmente quanto à acessibilidade ao novo reto por exame retal ou endossonografia para avaliar a recorrência ou uma continência relativa após o fechamento da ostomia.

Sphincter-saving extrasphincteric rectal dissection and proximal segmental sphincteric excision techniques by using combined abdominal and transvaginal anterior perineal access in female patients who have lower rectal cancer (Transvaginal low anterior rectal resection) / Técnicas de dissecção retal extra-esfincteriana e de excisão esfincteriana segmentar proximal com preservação de esfíncter com o uso de acesso abdominal e perineal anterior transvaginal combinado em mulheres portadoras de câncer retal baixo (Ressecção anterior do reto baixa por via transvaginal)

ABSTRACT Background: Combined abdominal and transvaginal anterior perineal approaches have been used as an alternative surgical method for the surgical treatment of the lower rectal cancer. The main aim of this paper is to describe the surgical stages of the combined abdominal and transvaginal approaches performed for lower rectal cancer, especially in transvaginal anterior perineal stage. Method: We have performed sphincter-saving surgical operations by using transvaginal anterior perineal access by combining with the abdominal access in four female patients who had lower rectal cancer. Results: Sphincter-saving extrasphincteric dissection and proximal segmental sphincteric excision techniques were performed in four female patients operated with combined abdominal and transvaginal anterior perineal approach. All patients were found to have continence. Postoperatively, one patient was converted to abdominoperineal rectal amputation due to the detected distal resection margin positivity. Conclusion: Transvaginal anterior perineal access provides the extrasphincteric rectal dissection possibility in the ischioanal fossa. Therefore, the combined abdominal and transvaginal anterior perineal approaches have been based on the different anatomical and surgical features when compared to intersphincteric dissection technique which is the most common used surgical procedure in lower rectal cancer surgery.

RESUMO Introdução: Uma combinação de abordagens abdominal e perineal anterior transvaginal tem sido empregada como método cirúrgico alternativo para o tratamento cirúrgico do câncer de reto baixo. O principal objetivo do presente artigo é a descrição dos estágios cirúrgicos das abordagens abdominal e transvaginal combinadas realizadas para câncer de reto baixo, especialmente no estágio perineal anterior transvaginal. Método: Realizamos operações cirúrgicas com preservação de esfíncter com o uso do acesso perineal anterior transvaginal, em combinação com o acesso abdominal, em quatro pacientes mulheres portadoras de câncer de reto baixo. Resultados: Realizamos técnicas de dissecção extra-esfincteriana e de excisão esfincteriana segmental proximal com preservação de esfíncter em quatro pacientes operadas com uma combinação de abordagens abdominal e perineal anterior transvaginal. Todas as pacientes estavam continentes. Em uma paciente, houve necessidade de conversão para amputação retal abdominoperineal, por ter sido detectada, no pós-operatório, positividade na margem de ressecção distal. Conclusão: O acesso perineal anterior transvaginal torna possível a dissecção retal extra-esfincteriana na fossa isquioanal. Portanto, as abordagens combinadas abdominal e perineal anterior transvaginal se baseiam em diferentes características anatômicas e cirúrgicas, em comparação com a técnica de dissecção interesfincteriana, que é o procedimento cirúrgico de uso mais comum na cirurgia para câncer de reto baixo.

URINARY DYSFUNCTION AFTER SURGICAL TREATMENT FOR RECTAL CANCER / Disfunção urinária após tratamento cirúrgico do câncer de reto

BackgroundThe impact on quality of life attributed to treatment for rectal cancer remains high. Deterioration of the urinary function is a relevant complication within that context.ObjectiveTo detect the presence of urinary dysfunction and its risk factors among individuals underwent surgical treatment for rectal cancer.MethodsThe present prospective study analyzed 42 patients from both genders underwent surgical treatment for rectal adenocarcinoma with curative intent. The version of the International Prostatic Symptom Score (IPSS) questionnaire validated for the Portuguese language was applied at two time-points: immediately before and 6 months after surgery. Risk factors for urinary dysfunction were analysed by means of logistic regression and Student’s t-test.ResultsEight (19%) participants exhibited moderate-to-severe urinary dysfunction 6 months after surgery; the average IPSS increased from 1.43 at baseline to 4.62 six months after surgery (P<0.001). None of the variables assessed as potential risk factors exhibited statistical significance, i.e., age, gender, distance from tumour to anal margin, neoadjuvant therapy, adjuvant therapy, type of surgery, surgical approach (laparoscopy or laparotomy), and duration of surgery.ConclusionThis study identified an incidence of 19% of moderate to severe urinary dysfuction after 6 months surveillance. No risk factor for urinary dysfunction was identified in this population.

ContextoA perda de qualidade de vida atribuída ao tratamento do câncer retal continua elevada. Neste contexto, a deterioração da função urinária é complicação relevante.ObjetivoIdentificar disfunção urinária e seus fatores de risco em doentes submetidos ao tratamento cirúrgico do câncer de reto.MétodosRealizou-se estudo prospectivo com 42 doentes de ambos os sexos submetidos a tratamento cirúrgico com intenção curativa para adenocarcinoma de reto. Foi utilizado o questionário International Prostatic Symptom Score, validado na língua portuguesa, em dois períodos: imediatamente antes e após 6 meses do procedimento cirúrgico. Os fatores de risco para disfunção urinária foram analisados por regressão logística e teste t de Student.ResultadosApós 6 meses do procedimento cirúrgico, oito (19%) doentes apresentaram disfunção urinária moderada a grave e aumento na média do escore utilizado de 1,43 pontos no pré-operatório para 4,62 pontos no pós-operatório (P<0,001). A análise de fatores de risco para disfunção urinária não mostrou significância para as variáveis estudadas, idade, gênero, distância tumoral da margem anal, neoadjuvância, adjuvância, procedimento cirúrgico realizado, via de acesso cirúrgico (laparoscópica ou laparotômica) e tempo operatório.ConclusãoNos doentes com carcinoma retal operados com intenção curativa, a incidência de disfunção urinária moderada a grave após 6 meses da operação foi de 19%. Não foram identificados fatores de risco para disfunção urinária nesses doentes.

Resección total de mesorrecto robótica por cáncer de recto / [Robotic total mesorectal excision for rectal cancer].

Laparoscopic total mesorectal excision (TME) has proven to be feasible and safe. However, it represents a major technical challenge, since it involves the dissection of the rectum in a confined space such as the bony pelvis using un-ergonomic surgical devices. This difficulty is accentuated in patients with distal tumors and high body mass index (BMI), in which the surgical margins and the hypogastric nerves may be affected. Therefore, robotic surgery aims to overcome these limitations that conspire against the mininvasive surgical approach of rectal cancer. We present an obese (BMI = 32 kg/m2) 82-year-old man with a history of smoking and prostate cancer that was recently diagnosed with a middle rectal adenocarcinoma at 9 cm from the anal verge. Rectal examination evidenced a mobile lesion. Computed tomography scan ruled out metastases and at the local staging by MRI, the tumor was considered as T3-N0 with free circumferential margins. Surgical treatment was decided and a hybrid technique was used combining an initial laparoscopic approach followed by the robotic TME. The patient had a full recovery and was discharged three days after surgery without complications. Pathological examination revealed a low-grade adenocarcinoma with mesorectal invasion, free circumferential and distal margins, and 24 negative lymph nodes (pT3-pN0-pM0/Stage II). Robotic TME was performed safely in an obese patient. It facilitated dissection maneuvers in a confined space with proper identification and preservation of the hypogastric nerves, allowing retrieving an intact mesorectum. Prospective randomized trials will define the role of this new technology.

Prevalencia de adenomas y adenocarcinomas de recto-sigma en pacientes menores de 50 años que consultan por proctorragia / [Prevalence of rectosigmoid adenomas and adenocarcinomas in patients younger than 50 years old referred for proctorrhagia].

BACKGROUND: Rectal bleeding is a sign of colorectal cancer (CRC). Its early diagnosis decreases mortality and improves survival. In young population with no risk factors for the disease, CRC is infrequent. Moreover, benign anorectal disorders are most frequent causes of bleeding and generally, when anal pathology is identified, it is assumed as the origin of the sign. For all these reasons, rectal bleeding sometimes is sub-assessed in young patients. OBJECTIVE: Estimate the prevalence of adenomas and adenocarcinomas in sigmoid and rectum in patients younger than 50 years old referred for proctorrhagia. METHODS: The study design was descriptive, retrospective and cross-sectional. Procedures were performed under sedation and Olympus CF 160 y CF 180 scopes were used. Proctorrhagia was considered as rectal bleeding registered as indication of the procedure. Histology was established according to Vienna classification. Informed consent was signed before the procedures. Colonoscopy reports were reviewed. The study took place in an outpatient clinic in Buenos Aires city, between October 2010 and October 2011. High risk patients for CRC were excluded RESULTS: We included 1,203 from 1,257 reviewed VCC, 49

were female and the median age was 38 years old (range: 18-49 years old). The prevalence of adenomas and adenocarcinomas in sigmoid and rectum was 67

CI): 5.4-8.3] and 1.6

CI 1-2.5), respectively. CONCLUSIONS: Adenocarcinomas and adenomas are infrequent in a young population without risk factors for CRC. However, even when benign anal disorders are the most frequent cause for rectal bleeding, miss evaluation of this sign could have a serious impact in almost 10 of 100 individuals.

The synchronous primary carcinomas of the rectum and prostate.

The diagnosis of synchronous prostatic and rectal carcinomas is uncommon. To make a correct diagnosis, biopsies of both sites are mandatory. Pathological slides should be compared and immunohistochemical staining should be taken into consideration. In this paper, an unexpected case of synchronous rectal and prostatic carcinomas arising in an 84-year-old male with hematemesis and pelvic pain is reported. These two tumoral components have a distinctive histological appearance. Immunohistochemical evaluation confirmed the diagnosis of these synchronous tumors. This case emphasizes that rectal and prostatic carcinomas can arise simultaneously. In this situation, providing clinicopathological correlation and deciding the necessity of intraoperative consultation in proper time are extremely important.

Hemangioma cavernoso rectal: caso clínico / Cavernous hemangioma of the rectum: report of one case

We report a 41 years old male with a history of hematochezia since childhood. A colonoscopy showed a highly vascularized submucosal lesion extending from the pectinate line to the distal sigmoid colon. Magnetic resonance showed a thickening of rectal wall with multiple vascular structures and phleboliths. The lesion was excised surgically. The postoperative period was uneventful. The pathological report disclosed a large rectal hemangioma.

El hemangioma rectal es una entidad infrecuente, con menos de 200 casos publicados en la literatura mundial. Se presenta un caso clínico, que debuta con rectorragia y es documentado con estudios endoscópicos e imagenológicos, siendo resuelto quirúrgicamente.

Metástasis óseas de cáncer de recto / Bone metastases due to rectal cáncer

Objetivo: las metástasis óseas del Cáncer Colorrectal son infrecuentes. Cuando están presentes usualmente corresponden a una manifestación tardía de la enfermedad. Presentamos dos pacientes con metástasis óseas de Adenocarcinoma de Recto, revisando la epidemiología, manifestaciones y manejo de la entidad. Pacientes: Caso 1: hombre de 46 años, operado por Adenocarcinoma de Recto medio, estadio pT3 - pN2 - pM0. Cumplió adyuvancia con Radioterapia y Quimioterapia. 8 meses después de la cirugía consultó por dolor lumbar de 15 días de evolución sin respuesta a analgésicos opiáceos. La Radiografía simple no mostró alteraciones. La TAC evidenció lesión osteolítica a nivel de la segunda vértebra lumbar, sin alteraciones en la cavidad abdominal ni pelviana. Se realizó extirpación de la lesión y descompresión radicular. Evolucionó favorablemente en el postoperatorio inmediato. La anatomía patológica reveló: "Metástasis de Adenocarcinoma moderadamente diferenciado". Cumplió Radioterapia paliativa. 2 meses después refirió dolor lumbar severo, donde la TAC evidenció nueva lesión osteolítica. Se realizó tratamiento paliativo del dolor. Obitó 10 meses luego del diagnóstico de metástasis ósea. Caso 2: hombre de 68 años, operado por Adenocarcinoma de Recto medio, estadio pT3 - pN2 - pM0. Cumplió 2 ciclos de adyuvancia con Quimioterapia. 6 meses después de la cirugía consultó por fractura de cuello del Fémur derecho. La Radiografía demostró la lesión. Se realizó Osteosíntesis con clavo endomedular y toma de biopsia. Evolucionó favorablemente en el postoperatorio inmediato. La anatomía patológica reveló: "Metástasis de Adenocarcinoma moderadamente diferenciado". El paciente se negó a Radioterapia paliativa. Falleció a los 8 meses luego del diagnóstico. Conclusiones: el compromiso óseo como diseminación del Cáncer de Recto es poco habitual. Se desarrolla por vía hemática y las vértebras son el sitio más común...

Objective: osseous metastases from colorectal cancer are infrequent. When it shows it is usually a late manifestation of the disease. We present two patients with rectal carcinoma who presented osseous involvement, whit a review its epidemiology, symptoms and treatment. Patients: Case 1: a 46 year-old man had a low anterior resection for a pT3 - pN2 - pM0 rectal adenocarcinoma and received adjuvant with radio and chemotherapy. Eight months later he developed lumbar pain, X-ray was normal. A bone CT scan showed only a destructive lesion in L2. He underwent laminectomy and radicular decompression with significant relief of symptoms. Pathology reported Metastasis of moderate differentiated adenocarcinoma. He received palliative radiotherapy. Two months later he developed severe lumbar pain and CT scan showed another osteolytic lesion. Finally he received palliative treatment. His physical condition gradually deteriorated and died ten months later. Case 2: a 68 year-old man had a low anterior resection for a pT3 - pN2 - pM0 rectal adenocarcinoma. He received 2 cycles of adjuvant chemotherapy. Six months later he suffered a right femur pathological fracture, X-ray showed the bone fracture. He underwent bone biopsy and endomedular fixation resulting in partial pain relief. Pathologist reported Metastasis of moderate differentiated Adenocarcinoma. There was no palliative treatment and he died eight months later. Conclusions: bone involvement by colorectal metastatic cancer is uncommon. The most common sites with lesion are the vertebrae through blood-bone way. Bone scanning in probably more effective in the early detection of osseous metastases then radiographic skeletal survey. Usually they are osteolytic lesions. The treatment modalities are palliative. The prognosis is poor.

Tumor rectal como presentación de sífilis primaria / Rectal tumor as a presentation of primary syphilis

In the era of HIV infection there is a resurgence of syphilis. Without a doubt it is still a diagnostic dilemma in various clinical situations such as anorectal syphilis in HIV patients. When a patient HIV-positive presents with a rectal tumor, syphilis must be considered in the differential diagnosis. We present a case report of an HIV positive patient who consulted due to rectal tenesmus associated to rectal bleeding, being diagnosed a rectal tumor and treated secondary to primary syphilis.

En la era de la infección por VIH, ha habido un resurgimiento de enfermedades en franca disminución en el mundo occidental como sífilis. Sin lugar a dudas siguen siendo un dilema diagnóstico algunas manifestaciones clínicas como sífilis rectal en pacientes portadores de VIH. Frente a un tumor rectal en un paciente VIH se debe tener en cuenta en el diagnóstico diferencial a esta patología. Presentamos un caso de un paciente portador de VIH que consultó por tenesmo rectal asociado a rectorragia, siendo diagnosticado un tumor rectal secundario a sífilis primaria.

Melanoma anorrectal primario: una causa infrecuente de rectorragia en el adulto mayor / Primary anorectal melanoma: an uncommon source of rectal bleeding in the elderly

El melanoma anorrectal primario es un tumor maligno muy infrecuente y con un pobre pronóstico. Se presenta un paciente de 66 años con rectorragia, en el cual el diagnóstico de melanoma anorrectal se efectuó por colonoscopia e histología. Se trató mediante una resección abdominoperineal. Se efectúa revisión de la literatura.

Primary anorectal melanoma is a very rare malignant tumor, with poor prognosis. A 66 years old man presenting with rectal bleeding is reported. The diagnosis of anorectal melanoma was confirmed by colonoscopy and histological findings. An abdominoperineal resection was performed. A review of the literature is presented.

Infecciones severas del periné luego de radioterapia en cáncer de recto / Severe perineal infections due to radiotherapy in rectal cancer

Introducción: Las infecciones severas del periné constituyen un conjunto de infecciones entre las que se destaca la gangrena de Fournier o sinérgica. Es una fascitis necrotizante del periné y área genital, de etiología polimicrobiana. El foco puede estar localizado en el tubo digestivo distal, el tracto genitourinario o la piel. Objetivo: Analizar los hallazgos clínicos, imagenológicos y factores de riesgo y conducta terapéutica en pacientes con infecciones del periné luego de radioterapia por cáncer de recto. Diseño: Análisis retrospectivo. Revisión de la literatura. Métodos: Revisión de bases MEDLINE, LILACS, AMA, AAC y SACP. Pacientes: 3 casos en 15 días. Resultados: Caso 1: masculino, 46 años; cáncer de recto en tratamiento adyuvante. Al finalizar radioterapia presenta celulitis perineal y absceso profundo por perforación adyacente del tumor rectal. Laparotomía, colostomía definitiva por tumor localmente avanzado y drenaje de absceso y celulitis. Egreso. Falleció por progresión de su enfermedad de base. Caso 2: masculino, 40 años. Tumor de recto irresecable por metástasis hepática en tratamiento con radioterapia paliativa por sangrado persistente, presentó gangrena de Fournier por perforación del tumor. Drenaje del foco séptico. Evoluciona con insuficiencia respiratoria progresiva, disfagia y hemorragia digestiva. Óbito. Caso 3: masculino, 33 años. Tumor de recto localizado, de diagnóstico reciente, en tratamiento neoadyuvante con radio y quimioterapia. Durante la radioterapia presentó gangrena de Fournier por perforación de recto retroperitoneal. Evolucionó con sepsis a pesar del tratamiento. Óbito. Discusión y conclusiones: El manejo se basa en el debridamiento quirúrgico, drenaje y curaciones programadas, asociados a antibióticos de amplio espectro y sostén de los parámetros vitales. El diagnóstico precoz es fundamental... (TRUNCADO)

Introduction: Perineal severe infections are unfrequent and the most common presentation is Fournier's Disease. This disease compromise genital and perineal areas with necrosis of the muscular fascia and does not involve the muscle. Primary focus can come from digestive tract, urinary tract of skin. Objective: To analyze clinical, radiological, risk factors and treatment of Founier’s Disease in patients with rectal cancer and external radiotherapy. Design: Retrospective serie. Literature review. Patients: 3 cases in last 15 days. Results: Case 1: male, 46y, rectal cancer and adyuvant radiotherapy. During treatment, rectal lateral abscess appeared as consequence of rectal perforation. Laparotomy, definitive colostomy and drainage were performed. He died because of neoplastic disease. Case 2: male, 40y. Rectal tumor with hepatic metastasis was under palliative radiotherapy due to low rectal bleeding. Fournier's Disease was diagnosed due to tumor perforation. In spite of surgical treatment, he developed pulmonary insuficiency, disfagia and digestive bleeding and died. Case 3: male, 33y. Lower rectal tumor in neoadyuvant protocol of radiotherapy. Fournier's Disease was presented during this period due to rectal perforation to retroperitoneum. He presented sepsis and died. Discussion and conclusions: Early surgical debridement, elective and periodic surgical wound care and broad spectrum antibiotics should be applied. Early diagnosis is mandatory. Mortality is nearly 20 per cent. Perforated rectal tumor associated with radiotherapy in males younger than 50y presented as Fournier's Disease is first reported.

A Case of Pseudomembranous Colitis Associated with Rifampicin Therapy in a Patient with Rectal Cancer and Gastrointestinal Tuberculosis / 대한소화기학회지

Pseudomembranous colitis (PMC) is known to be associated with the administration of antibiotics which alter normal gastrointestinal flora and allow overgrowth of Clostridium difficile. Most cases of rifampicin-induced PMC are seen in patients with pulmonary tuberculosis, but not with gastrointestinal tuberculosis. We report a case of PMC associated with rifampicin therapy in a patient with gastrointestinal tuberculosis. A 65-year-old female patient with rectal cancer and gastrointestinal tuberculosis was admitted due to abdominal pain and diarrhea. She was treated with anti-tuberculosis agents containing rifampicin. On colonoscopic examination, mucoid exudates and yellowish plaque lesions were observed. Anti-tuberculosis agents were stopped, and the patient was treated with metronidazole. Symptoms were relieved and did not recur when all the anti-tuberculosis agents except rifampicin were started again. When a patient complains of abdominal pain or diarrhea while taking rifampicin, the physician should consider the possibility of rifampicin-associated PMC.

[Scalp metastasis from small cell carcinoma of the rectum: an unusual case]

Cutaneous metastasis of rectal carcinoma is a rare event. It occurs in 4%of all patients with rectal cancer. Skin metastasis of rectal cancer are usually detected near the initial tumor. especially in the periumbilical region; but they rarely occur in the scalp. To report a new case of scalp metastases from rectal tumor. Our patient was a 63-year old male with a history small cell carcinoma of the rectum who subsequently developed s single nodule of the scalp of 4cm. Histopathological analysis revealed a small cell carcinoma infiltrating the dermis am subcutaneous tissue. The patient underwent palliative chemotherapy but his disease continued to progress. In contrast to the prior cases of scalp metastases reported in the literature, ours is the first documentation of such occurrence from rectal small cell carcinoma. The early diagnosis of skin metastases in these patients is very important because it can alter treatment

Microcirurgia endoscópica transanal no tratamento dos tumores do reto: estudo prospectivo em 50 pacientes / Transanal endoscopic microsurgery in the treatment of rectal tumors: a prospective study in 50 patients

RACIONAL: A literatura médica aceita ressecção local como opção válida em casos selecionados de tumores de reto. A seleção dos pacientes requer exata estimativa dos riscos e avaliação pré-operatória precisa, tanto no aspecto clínico como histopatológico. OBJETIVO: Avaliar os resultados da microcirurgia endoscópica transanal em seguimento de 18 meses. MÉTODOS: De abril de 2002 a abril de 2006, 50 pacientes com tumores de reto foram submetidos a microcirurgia endoscópica transanal, selecionados por suas características clínicas e histopatológicas. Os critérios de inclusão foram: adenomas sésseis maiores do que 3 cm e menores do que 8 cm não-circunferenciais; neoplasia intra-epitelial de alto grau; carcinoma retal pT1, e em casos especiais pT2. Todos esses tumores foram submetidos ao mesmo procedimento cirúrgico. RESULTADOS: O resultado histopatológico final revelou 9 adenomas, 26 neoplasias intra-epiteliais de alto grau, 13 carcinomas (9 pT1 e 4 pT2) e 2 carcinóides. A menor idade foi de 25 anos e a maior de 92. O menor tumor ressecado tinha 64 mm² (carcinóide) e o maior (adenoma) 90 mm². O tempo médio de operação foi de 90 minutos e o de internamento 5 dias. Houve uma morte não relacionada ao método. Um paciente com carcinoma de baixo risco pT1 apresentou recidiva 18 meses após microcirurgia endoscópica transanal e foi submetido a retossigmoidectomia curativa. Foi observado tumor residual em dois pacientes e a complicação mais grave foi uma fístula retovaginal. A taxa de complicação global foi de 9 por cento. CONCLUSÃO: Atualmente a microcirurgia endoscópica transanal é a técnica de escolha para o tratamento de adenomas sésseis, neoplasias intra-epiteliais de alto grau e carcinoma retal pT1 de baixo risco.

BACKGROUND: The medical literature accepts local resection as a valuable option in selected cases of rectal tumors. Selection of patients requires an exact perioperative estimation of risks with clinical and histopathological examination. Transanal endoscopic microsurgery aims a safe resection of the tumoral area which leads up to the cure. AIM: To evaluate transanal endoscopic microsurgery results in a follow-up time of 18 months. METHODS: From April 2002 to April 2006, 50 patients with rectal tumors were submitted to transanal endoscopic microsurgery, chosen by clinical history and lesion characteristics. The inclusion criteria were: sessile adenomas larger than 3 cm and smaller than 8 cm, not circumferentially distributed; intra epithelial neoplasia of high degree; and rectal carcinoma pT1, and special cases of pT2. All these rectal tumors were submitted to the same surgical act. RESULTS: The final histopathological results reveal 9 adenoma, 26 intra-epithelial neoplasia of high degree, 13 carcinoma (9 pT1-4 pT2) and 2 carcinoid. The lowest age was 25 and the higher, 92 years-old. The smallest resected tumor had 64 mm² (carcinoid) and the largest (adenoma), 90 cm². Operating time was in average 90 minutes and the overall time statement, 5 days. There was one death not related with the method. One patient with low risk carcinoma pT1 presented recurrence 18 months after transanal endoscopic microsurgery and was submitted to curative rectosigmoidectomy. It was proven a residual tumor after local surgery in two patients and the most important complication was one recto-vaginal fistula. The overall complications rate was 9 percent. CONCLUSION: Today transanal endoscopic microsurgery is chosen as the ideal technique for the treatment of sessile adenomas, intraepithelial neoplasia of high degree and rectal carcinoma pT1.