Pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema after endoscopic submucosal dissection of a rectal lateral spreading tumor / Pneumorretroperitônio, pneumomediastino e enfisema subcutâneo após dissecção endoscópica da submucosa de lesão retal de crescimento lateral

Introduction: Endoscopic submucosal dissection (ESD) is an already established procedure in the treatment of gastric and esophageal cancer in its early stages. Colorectal lesions, initially approached by endoscopic mucosal resection en bloc or in fragments, are the current focus for submucosal approach, especially for superficial lateral spreading tumor of 20 mm-diameter. The experience of Japanese centers, which are reference in therapeutic endoscopy, demonstrates reduction in the rate of disease recurrence with this approach and, according to specific histopathological criteria, may avoid colectomy in some cases of malignant neoplasia. Case report: The patient was 50-year-old female. She underwent endoscopic submucosal dissection of a rectal lateral spreading tumor measuring 50 mm, located 8 cm from the anal margin. The procedure was performed without major complications, with just two points for muscle layer detachment, without gross perforation and closed with metal clips. However, the patient developed air leakage to the peritoneum, retroperitoneum, mediastinum and subcutaneous tissue, being only treated with clinical procedures and without additional intervention. Conclusion: It is vital to know and be able to apply the technique of ESD, in addition to addressing its complications, since despite the numerous benefits compared to surgery, ESD can result in serious outcomes. (AU)

Introdução: A dissecção endoscópica da submucosa (ESD) já é procedimento consagrado no tratamento do câncer gástrico e esofagiano em suas fases precoces. As lesões colorre-tais, inicialmente abordadas por mucossectomia, em bloco ou em fragmentos, são o foco atual para a abordagem submucosa, principalmente para os tumores de crescimento lateral superficial a partir de 20 mm de diâmetro. A experiência de centros japoneses, referências em endoscopia terapêutica, demonstram redução no índice de recidiva da doença com esta abordagem e, segundo critérios histopatológicos específicos, podem evitar uma colectomia em alguns casos de neoplasia maligna. Relato de caso: Trata-se de paciente de 50 anos, submetida à dissecção endoscópica da submucosa de lesão de crescimento lateral, com 50 mm, localizada no reto, a 8 cm da margem anal. O procedimento foi realizado sem maiores intercorrências, com apenas dois pontos de afastamento da muscular, sem perfuração grosseira, fechados com clipe. Entretanto, a paciente evoluiu com escape aéreo para peritônio, retroperitônio, mediastino e subcútis, sendo tratada sem intervenção adicional, apenas com manejo clínico. Conclusão: É de fundamental importância conhecer e saber aplicar a técnica da ESD, além de abordar suas complicações, uma vez que, mesmo repleta de benefícios em relação à cirurgia, ela pode apresentar desfechos graves. (AU)

Safe multidisciplinary approach in deeply infiltrating endometriosis (DIE): is it feasible?

OBJECTIVE: Evaluate the type and incidence of postoperative complications after surgery for deep infiltrative endometriosis at Biocor Hospital. METHODS: Our observational study involved a multidisciplinary surgical team that performed laparoscopy on 154 patients suffering from pelvic pain. Surgical complications occurring up to the 30th postoperative day were recorded. RESULTS: Mean age patient age was 34.1 years. Infertility was present in 69 (45%) although 31% had not attempted to get pregnant. Dysmenorrhea was the most frequent symptom (79.3%) followed by chronic pelvic pain (59.7%) and deep dyspareunia (48,7%). Most cases required extensive surgery as the majority (n=117; 76.9%) were classified as severe endometriosis (ASRM grade IV). The most frequent surgical procedures were: 136 adhesiolysis, 100 intestinal surgeries (85 retosigmoidectomies), 92 peritonal lesion excision, 39 vaginal resections, 19 myomectomies, 21 hysterectomies and 5 partial bladder resections. Postoperative complications were recorded in 14 (9.59%) patients: 8 (5.48%) major complications and 6 (4.11%) minor. Major complications included blood transfusion (n=2) retosigmoid anastomosis dehiscence (1), rectovaginal fistula (n=1), urinary fistula (n=1), deep vein thrombosis (n=1), lower limb compartment syndrome with motor deficit (n=1) and one intestinal obstruction (n=1). Minor complications were abdominal wall infection (n=3), peripheral neuropathy (n=3), bladder atony (n=1) and bladder perforation (n=1). No deaths were observed. All major complication cases underwent retosigmoidectomy associated with vaginal resection (n=6), uterosacral ligament excision (n=5) or hysterectomy (n=3). CONCLUSION: The surgical treatment of DIE is complex and subject to complications. The surgical expertise of a multidisciplinary team plays a vital role in this setting.