Inflamación del remanente rectal (Cuffitis) posterior a una proctocolectomía total con reservorio ileal: reporte de caso y enfoque actual de tratamiento / Rectal cuff inflammation (Cuffitis) after total proctoclectomy with ileal pouch anal anastomosis: case report and current approach to treatment

La alternativa quirúrgica de elección para los pacientes con colitis ulcerosa (CU) refractaria al tratamiento médico es la proctocolectomía total con una reconstrucción a través de la confección de un reservorio ileal y una anastomosis ileo-anal. Esta cirugía permite la curación de la enfermedad con buen resultado funcional. A pesar de las demostradas ventajas, no está exenta de complicaciones. Una de las complicaciones es la inflamación sintomática del remanente rectal o cuffitis. Esta genera controversias importantes acerca de la técnica que debe utilizarse para la anastomosis ileo-anal debido a la asociación que presenta con la preservación de mucosa rectal en técnicas de sutura mecánica. El presente trabajo propone la revisión del tema y el análisis del enfoque actual de tratamiento, basada en un caso clínico.

Restorative proctocolectomy with ileal pouch is the treatment of choice in the majority of patients with ulcerative colitis (UC) refractory to medical treatment. This surgery can cure the disease with good functional outcome. Despite the proven benefits, is not without complications. One of the complications is symptomatic inflammation of the rectal remnant or cuffitis. This generates significant controversy about the technique to be used for the Ileo-anal anastomosis because of the association presented to the preservation of rectal mucosa in mechanical suture techniques. This paper proposes the review of the topic and analysis of the current approach to treatment based on one case.

Rectitis actínica / Radiation induced proctitis

El aumento del uso de la radioterapia en la enfermedad oncológica pelviana ha conducido a un aumento en la incidencia de la rectitis actínica crónico. El objetivo del trabajo es analizar en una institución privada, la prevalencia de Rectitis Actínica crónico.

Tratamento endoscópico de lesões sangrantes do trato gastrointestinal por meio de eletrocoagulação com argônio / Endoscopic treatment of bleeding lesions of the gastrointestinal tract by argon plasma coagulation

Introdução e objetivos: A eletrocoagulação com argônio (APC) é um método térmico de não-contato que pode ser utilizado como alternativa ao laser em endoscopia. Um amplo espectro de indicações têm sido propostas para tratamento através de APC, desde a introdução do uso em endoscopia, em 1991. O objetivo deste estudo é avaliar a eficácia do uso do APC na hemostasia endoscópica de lesões sangrantes do esôfago, estômago, duodeno, cólon e reto. Metodologia: Um total de 22 pacientes consecutivos (14M/8F, média de idade 66,7 anos) foram submetidos ao tratamento com APC entre 1998 e fevereiro de 2002. As causas de sangramento incluíam retite actínica (12 pacientes), ectasia vascular do antro gástrico (GAVE) ­ watermelon stomach (6 pacientes), angiodisplasias de esôfago, estômago e cólon (2 pacientes), gastrite actínica (1 paciente) e síndrome de Osler-Weber-Rendu (1 paciente). Resultados: Um total de 49 sessões foram realizadas (média de 2,2 sessões por paciente). Sucesso no tratamento endoscópico foi obtido em 18 pacientes (85,8%). Complicações foram observadas em 3 pacientes: 2 apresentaram dor local após as sessões de APC e um paciente desenvolveu estenose retal tratada com sucesso em uma sessão de dilatação endoscópica. Não houve mortalidade relacionada ao método. Conclusões: APC é um método seguro, efetivo, de relativo baixo custo e boa aceitação pelos pacientes para o tratamento de lesões sangrantes do trato gastrointestinal. Deve, portanto, ser considerado método de primeira escolha no tratamento dessas afecções (AU)

Background and aims: Argon plasma coagulation (APC) is an innovative non-touch electrocoagulation technique. A broad spectrum of indications has been proposed for APC since its introduction into endoscopy in 1991. The aim of this study is to evaluate the efficacy of utilizing APC in the endoscopic hemostasis of bleeding lesions of the esophagus, stomach, duodenun, colon and rectum. Methodology: A total of 22 consecutive patients (14M/ 8 F, mean age 66.7 years) underwent APC treatment between 1998 and february 2002. Causes of bleeding included radiation colitis (12 patients), gastric antral vascular ectasia ­ watermelon stomach (6 patients), esophagus,stomach and colon angiodysplasia (2 patients), radiation gastritis (1 patient) and Osler-Weber-Rendu Syndrome (1 patient). Results: A total of 49 sessions were performed (mean 2.2 sessions / patient). Succesful endoscopic APC treatment was achieved in 18 patients (85,8%). Complications were observed in 2 patients that referred local pain after therapy and 1 patient that developed a rectal stenosis succesfully reversed in one session of endoscopic dilation. No mortality related to APC was observed. Conclusions: APC is a safe, effective, and relative low-cost hemostatic modality for bleeding vascular lesions of the gastrointestinal tract. Therefore, APC should be considered as a first-line therapy for these conditions (AU)

Treatment of severe actinic rectitis

Background: The authors report the treatment of three female patients with severe actinic rectitis, with stenosis of perforation, submitted to anterior proctosigmoidectomy and transanal coloanal anastomosis. methods: In all cases surgery consisted of total proctosigmoidectomy, mucosectomy of the anal canal, lowering of the left colon through the pelvis and tansanal anastomosis performed manually at the level of the pectineal line using separate absorbable sutures. A protective intestinal shunt was performed in all cases. Results: The three patients did not present transoperative or immediate postoperative complications, but the first patient developed deep venous thrombosis of the leg that was submitted to successful clinical treatment. The intestinal shunts were later closed in all three cases. Sphincter function was considered very good in the first case and regular in the remaining two. Conclusion: The surgical technique utilized was considered to be adequate for the cases reported and is the first option for the maintenance of transit in patients with severe actinic rectitis since the anastomosis is performed using non-irradiated colon with the pectineal line, practically outside the pelvis.

Anastomosis coloanal, operación de Parks, para el tratamiento de la rectitis actínica grave / Coloanal anastomosis coloanal, Parks surgery, in the treatment of severe radiation rectitis

Aim: To assess inmediate and late results of Prks operation in the treatment of severe radiation rectitis. Patients and methods: Retrospective review of clinical histories of 35 patients with uterine cervical cancer, 5 with endometrial cancer and 1 with vaginal cancer that received radiotherapy. Two years as a mean after radiotherapy, 14 women had rectal bleeding, 19 fistulae, 7 stenosis and 1 rectal ulceration. All were initially treated with a discharge colostomy and after a mean interval of 1.6 years, a Parks operation was performed. Results: One patient died after surgery (2.4 percent) due to peritonitis and sepsis. Early surgical complications were necrosis of descended colon in 2, intra-abdominal sbscess in 1, splenic rupture in 1 and postoperative bleeding in 1. Colostomy was closed in 37 patients 3 months after surgery. During late follow up (ranging from 3 to 64 months) rectal continence has been assessed as good in 30 patients, fair in 5 and bad in 2. Three women required a new colostomy. Conclusion: Parks operation is a viable therapeutic alternative for severe radiation rectitis

Resultados inmediatos y alejados del tratamiento quirúrgico de la rectitis actínica grave / Inmediate and later results of surgical treatment in severe actinic rectitis

Se define la rectitis actínica grave como la secuela de radioterapia que requiere de cirugía para su corrección y/o paliación. En un período de 12 años hemos tratado 30 pacientes por esta complicación, 28 mujeres y 2 hombres con un promedio etario de 60 años, extremos 35-78; 70 por ciento de ellos portador de una neoplasia ginecológica. La dosis promedio recibida fue de 5.200 Rads, extremos 4000-7000. La complicación más relevante fue la fístula rectovaginal, 17 casos; seguida de la estenosis con hemorragia iterativa, 10. Al momento del diagnóstico 21 pacientes presentan 25 complicaciones actínicas de la esfera urológica, de las cuales 16 requieren cirugía. Excluidas éstas, se efectuaron 60 intervenciones en 30 pacientes, destacando la colostomía en 36, cierre de colostomía en 12 y operación de Parks en 9. La morbilidad operatoria global fue de 40 por ciento, falleciendo 3 pacientes: embolia pulmonar, aspiración masiva y peritonitis postoperatoria. La mortalidad quirúrgica fue específica fue de 3,3 por ciento. El seguimiento promedio es de 7 años, margen 18 meses-12 años. De los 20 pacientes actualmente vivos, 8 están sin colostomía y 4 presentan una fístula urológica compleja, 3 de ellas metacrónicas. La operación de Parks es una técnica valiosa en la reparación de graves injurias actínicas del recto, con baja mortalidad y buenos resultados funcionales en cuanto a la continencia

Actinic rectitis--the role of colostomy

From 4132 patients treated with radiation therapy due to gynecological malignancy from 1974 to 1988, 527 (12.75%) developed some grade of actinic rectitis with clinical manifestation. The authors analyzed the efficacy of colostomy in the management of 10 women with actinic rectitis grades I and II (Sherman classification) submitted to clinical treatment without response. Pelvic radiation therapy, clinical findings, proctoscopy and rectal biopsy were the basis for the diagnosis and staging of the actinic rectitis. All colostomies were made in the transverse colon and the median follow up from colostomy to last review was 53 months. Eight patients had complete remission of clinical findings after colostomy, but one had recurrence of symptoms 2 years later. One patient had incomplete remission but with clinical improvement and one patient had tumor recurrence. From 8 patients with complete clinical remission, 2 had the colostomies closed, but in 1 was restored 3 months later due to rectum-vaginal fistula

Rectitis actínica: evolución y tratamiento / Actinic rectitis: evolution and treatment

Se presentan 164 casos de rectitis actínica tratadas por el equipo de coloproctología del departamento de cirugía del Hospital Clínico de la Universidad de Chile entre los años 1965 y 1983. Todos los casos corresponden a mujeres irradiadas por cáncer cérvicouterino a excepción de dos hombres portadores de cancer vesical. La mayor incidencia se observó entre la quinta y sexta década de la vida. Los síntomas fundamentales fueron la rectorragia y el dolor anorrectal. La mayor incidencia de acuerdo a los grados de Sherman correspondió a los grados I y II (91,7%). El diagnóstico fue fácil por el antecedente de irradiación previa y el estudio proctológico. El tratamiento médico es beneficioso y dabuenos resultados en los grados I y II. El tratamiento quirúrgico se realizó por fracaso del tratamiento médico, la hemorragia incoercible, la estenosis rectal franca, las fístulas y perforaciones rectales. La mortalidad fue de 3%