Laparoscopic treatment of acquired megacolon / Tratamento laparoscópico do megacolo adquirido

In spite of the large experience acquired in the last 50 years with the surgical treatment of the Chagasic megacolon, the use of colorectal video laparoscopic surgery brought some controversy in several aspects of the treatment that already had been considered as resolved. One of the basic aspects to the establishment of the colorectal video laparoscopic surgery is to maintain the same procedure of the conventional surgery, since the results obtained in this operation were considered as curative. Constipation is only a symptom of a multisymptomatic disease, and the surgical treatment of acquired megacolon must be considered as definitive in the cure of this symptom; recurrence of the constipation or dilatation after a short period of time must be considered deleterious to the patient. Based in 41 years of experience with the Duhamel procedure in the treatment of 912 patients with acquired megacolon, the authors propose to apply the same technique in the surgical laparoscopic approach of acquired megacolon, including the same colon-recto-anal anastomosis. The results obtained in 56 patients operated on by laparoscopic approach showed the same curative results, but with lower morbidity. (AU)

Apesar da vasta experiência adquirida nos últimos 50 anos com o tratamento cirúrgico do megacolo adquirido, a introdução da cirurgia laparoscópica voltou a trazer controvérsia para alguns pontos anteriormente considerados como esclarecidos. Uma das regras básicas para a introdução da videolaparoscopia no tratamento das enfermidades colorretais tem sido a de se manter a técnica original utilizada em cirurgias pela via convencional, desde que os resultados observados na mesma conduzam à cura dos sintomas ou da enfermidade causal. Em especial, no referente ao tratamento cirúrgico do megacolo adquirido a proposta de um tratamento cirúrgico deve ter em mente que diferentemente do que ocorre com a cirurgia para tratamento de outras enfermidades, benignas ou malignas, neste caso não se almeja o tratamento causal da enfermidade, mas essencialmente a cura da manifestação de um de seus sintomas. É, pois, realmente importante que se considere um tratamento que não venha a resultar em bons resultados por apenas um curto espaço de tempo, mas que possibilite ao paciente livrar-se definitivamente de um sintoma, visto que é possível que em curto espaço de tempo ele venha a necessitar tratar outra manifestação sintomatológica (cardíaca ou esofágica) da enfermidade causal. Baseados na experiência adquirida nos últimos 50 anos (912 pacientes) com a técnica de Duhamel, em que o ponto importante é a realização de uma ampla anastomose da parede anterior do cólon abaixado à parede posterior (mucosa) do reto, ao mesmo tempo em que se anastomosa a parede posterior do cólon abaixado ao canal anal, são analisados os resultados obtidos com esta mesma técnica realizada por laparoscopia. Esta mesma incisão no canal anal serve para a retirada do segmento cólico ressecado, sem necessidade de laparotomia auxiliar. Os resultados observados em 56 pacientes quanto à cura da obstipação são similares aos registrados na cirurgia convencional, porém com um menor índice de morbidade, seja intra ou pós-operatória. (AU)

Semi-open hemorrhoidectomy.

The concept that hemorrhoidal disease is a consequence of disorders of the cephalic portion of the anal canal, i.e. weakness of the vascular cushions and the connective tissue, is the basis for modifying the usual surgical technique in many aspects. The two main differences of the method described are: (i) the internal plexus is treated by parceled ligature, avoiding resection of the mucosa, but providing a firm fixation of the submucosa and subsequent fixation of the anal epithelium to the underlying sphincter in the anal canal; (ii) the external plexus is removed preserving as much as possible the anal margin skin, and the resulting wound is partially closed, resulting in a small drainage area; and (iii) a firm fixation of the submucosa and subsequent fixation of the anal epithelium to the underlying sphincter are achieved without mucosa resection.

Laparoscopic total mesorectum excision.

The main controversy of colon-rectal laparoscopic surgery comes from its use as a cancer treatment. Two points deserve special attention: the incidence of port-site tumor implantation and the possibility of performing radical cancer surgery, such as total mesorectum excision. Once these points are addressed, the laparoscopic approach will be used routinely to treat rectal cancer. To clarify these points, 32 patients with cancer of the lower rectum participated in a special protocol that included preoperative radiotherapy and laparoscopic total mesorectum excision. All data were recorded. At the same time, all data recorded from the experience of a multicenter laparoscopic group (Brazilian Colorectal Laparoscopic Surgeons - 130 patients with tumor of the lower rectum) were analyzed and compared with the data provided by our patients. Analysis of the results suggests that a laparoscopic approach allows the same effective resection as that of conventional surgery and that preoperative irradiation does not influence the incidence of intraoperative complications. The extent of lymph nodal excision is similar to that obtained with open surgery, with an average of 12.3 lymph nodes dissected per specimen. The rate of local recurrence was 3.12%. No port site implantation of tumor was noted in this series of patients with cancer of the lower rectum.

Radioterapia preoperatoria del cáncer del recto: evaluación de los efectos de la radiación en las células indiferenciadas y su influencia en el pronóstico / Postoperative radiotherapy in rectal cancer: evolution of radiation effects on undifferentiated cells and their influence on prognosis

Entre 1978-1996, un total de 287 pacientes con adenocarcinoma rectal fueron tratados con radioterapia. El mismo protocolo fue utilizado en todos los pacientes: dosis total de 400cGy; dosis diaria de 200cGy; durante un periodo de 4 semanas y cirugia 10 dias despues. Un análisis de los resultados demostro que la irradiacion aplicada en el preoperatorio disminuyo el numero de celulas carcinomatosas, cambiando significativamente el porcentaje de Broders, al mismo tiempo que redujo la incidencia de recidiva local (3,48 por ciento) y la mortalidad secundaria a la misma (2,43 por ciento). Estadisticamente la radiacion preoperatoria resulto en un aumento significativo de la supervivencia a largo plazo (80,17 por ciento).

Cirugía laparoscópica en cáncer del recto inferior / Laparoscopic surgery for cancer of the lower rectum

La cirugia laparoscopica (CL) colorrectal merece una atencion especial como una alternativa terapeutica segura, asi sea para el tratamiento del cancer, ya que oncologicamente la indicacion y la radicalidad no cambian. Los pasos de la cirugia convencional pueden ser seguidos con precision. La amputacion abdomino-perineal del recto por via laparoscopica permite el mismo grado de radicalidad con relacion a la extirpacion del mesorrecto y de los bordes de reseccion laterales; además, el trauma quirurgico es mucho menor. Se debe hacer enfasis en dos puntos: 1) La recuperacion fisica es mejor: al deambular, al comer, el tiempo necesario para regresar a la actividad fisica habitual es menor. 2) La colostomia se hace en un abdomen libre de cicatrices, permitiendo una mejor manipulacion. La pieza anatómica es retirada con la misma tecnica convencional y su examen anatomopatologico demostro el mismo numero de ganglios resecados. La recidiva a corto y mediano plazo (local y sistemica) fue semejante al porcentaje observado con la cirugia convencional.

Pre-operative radiotherapy in rectal cancer: evaluation of irradiation effects on cellular undifferentiation and its influence on prognosis.

BACKGROUND/AIMS: In spite of the new technology--stapler, antibiotics, anesthesia and new surgical and diagnostic procedures--the prognosis on treatment of cancer of the rectum has not changed in the last 50 years. Survival rates of 50-55% seems immutable in all published series. The main course for those results is the high incidence of recurrence, either local or widespread. Local recurrence is directly related to the number of undifferentiated cells and to the grade of wall invasion. So any kind of treatment that would diminish the number of undifferentiated cells and the size or the tumor wall penetration certainly would decrease the local recurrence rate, lengthening the interval free from cancer and, perhaps, modifying the long-term survival rate. Between 1978-1996, a total of 287 patients with rectal adenocarcinoma were treated by pre-operative RTD. METHODOLOGY: The same RDT protocol was used in all the patients: 400 cGy, 200 cGy/day, during 4 consecutive weeks (anterior and posterior pelvic fields). Surgery was performed 7-10 days after completion of RDT. RESULTS: Statistical analysis of the whole group showed that pre-operative RDT does decrease frequency of undifferentiated cells. Moreover, the incidence of local recurrence diminished after irradiation by 3.48%. Pre-operative RDT reduces tumor volume and wall invasion, as well as the mortality rate due to local recurrence (2.43%) and alters long-term survival rate (80.17%). CONCLUSIONS: Pre-operative radiotherapy is really effective in reducing the number of undifferentiated cells and in diminishing the carcinomatous infiltration of the rectal wall.

Radioterapia pré-operatória em câncer do reto baixo: avaliaçäo dos efeitos da irradiaçäo nas células indiferenciadas e sua influência no prognóstico / Preoperative radiotherapy in lower rectal cancer: an evaluation of the effect of radiation on the unaffected cells, and its influence on the prognosis

Entre 1978-1996, um total de 287 pacientes com adenocarcinoma retal foi tratado com radioterapia pré-operatória. O mesmo protocolo foi utilizado em todos os pacientes: dose total 4.000 cGy; dose diária 200 cGy; período de quatro semanas; cirurgia 10 dias (em média) após o término da irradiaçäo. A análise dos resultados demonstrou que a irradiaçäo aplicada pré-operatoriamente diminui o número de células carcinomatosas, mudando significativamente o percentual de Broders, ao mesmo tempo que reduz a incidência de recidiva local (3,48 por cento) e a mortalidade decorrente da mesma (2,43 por cento). Estatisticamente a irradiaçäo pré-operatória resultou em um aumento significativo da sobrevida a longo prazo (80,17 por cento)

Videolaparoscopia em câncer do reto baixo / Laparoscopy in lower rectal cancer

A cirurgia videolaparoscópica colorretal merece uma atençäo especial como uma alternativa terapêutica segura, mesmo para o tratamento do câncer. Entretanto, a indicaçäo e a radicalidade oncológica näo muda. Os padröes da cirurgia convencional podem ser seguidos com precisäo. A amputaçäo abdômino-perineal do reto por videolaparoscopia permite o mesmo grau de radicalidade quanto as margens laterais e longitudinais (excisäo total do mesorreto). O trauma cirúrgico é, todavia, menor. Dois pontos devem ser enfatizados: 1. A recuperaçäo física é melhor: o andar, o comer e o retorno a atividade física habitual se faz em um tempo menor; 2. A colostomia se faz em um abdômen virgem de cicatrizes, permitindo uma melhor manipulaçäo. A peça é removida pelo períneo em técnica igual à realizada em cirurgia convencional. O exame anatomopatológico do espécimen revelou o mesmo número, comparativamente, de linfonodos ressecados. A recidiva a curto e médio prazo (local e geral) mostrou-se absolutamente similar, em percentagem, à obtida por via convencional

Laparoscopically assisted colorectal anastomose post-Hartmann's procedure.

We present 20 cases (10 men, 10 women) of laparoscopically assisted colorectal anastomose. The patients' mean age was 52.8 years. The mean length of procedure was 130 min. There were two transoperative complications, a rectal perforation with the stapler and an incomplete anastomose. Six (35.2%) patients said they had no postoperative pain. Bowel sounds occurred in a mean time of 18.2 h, flatus in 26.4 h, and bowel movement in an average of 2.5 postoperative days. Liquid diet was started after an average of 1.5 days, and the mean hospital stay was 4 days. There were three (15%) conversions because of excessive pelvic adherence, pelvic neoplastic invasion, and rectal perforation with a stapler. Postoperative complications occurred in seven (41.1%) cases: an incisional hernia, two wound infections, one wound bleeding, an acute renal failure, an undetermined peritonitis, and a small pelvic abscess. No mortality occurred in these cases.

Open versus semi-open hemorrhoidectomy: a random trial.

Three hundred patients with hemorrhoidal disease were randomly allocated to either a semi-open hemorrhoidectomy (group A) or to an open procedure (group B). The aims of the trial were to investigate the healing time in both groups, to analyse and compare the incidence of post-operative complications and the use of analgesics. A secondary aim was to investigate the period of time required to reestablish the normal bowel habit. All patients had a follow-up of at least three months. The wound was observed daily in the first week and then, twice a week, till complete healing occurred. The dosage, route and amount of analgesic demanded by each patient was noted. Any observed complication and its consequent treatment were written down. As to healing time there was a statistically significant difference between both groups: whereas for group A the average healing time was 12.38 days, for group B it was 25.22 days. The incidence of post-operative complication such as granuloma and pruritus was higher in group B; urinary disturbances were similar in both groups. The patients of group A demanded a small amount of analgesics, statistically significant (p = 0.01), in the early as well as in the late post-operative period. The normal bowel habit was re-established earlier in group A and this was also statistically significant.

Mechanical and manual anastomoses of the extraperitoneal rectum: experimental comparative study in dogs

E objeto de controversia na literatura a escolha da tecnica cirurgica nas anastomoses baixas no reto extraperitoneal com preservacao do mecanismo esfincteriano. Este estudo comparativo randomizado entre as anastomoses mecanica e manual no reto de caes abaixo da reflexao peritoneal, permitiu contribuir para o adequado posicionamento destas tecnicas na metodologia cirurgica. Para isso, submeteram-se 20 animais a retocolectomia, efetuando-se a reconstrucao do transito intestinal por dois metodos: em um grupo de dez caes, pela sutura mecanica e no outro, pela manual. As suturas foram avaliadas aos 5 e 15 dias do pos-operatorio, com especial atencao a concentracao do tecido colageno na linha de sutura, alem dos exames macro e microscopicos e das complicacoes atribuiveis as anastomoses. A analise desse estudo permitiu concluir: 1) na analise microscopica ao quinto dia do pos-operatorio, o grupo da sutura mecanica, apresentou melhor evolucao cicatricial; 2) na avaliacao bioquimica houve maior concentracao do tecido colageno no grupo da mecanica; 3) a estenose foi mais intensa no grupo submetido a sutura mecanica; 4) a resistencia a insuflacao gasosa, no quinto dia, foi maior na sutura mecanica, e 5) ambos os metodos foram validos para cirurgias no reto extraperitoneal de caes.

A comparison of nonoperative vs. preoperative radiotherapy in rectal carcinoma. A 10-year randomized trial.

From 1978 to 1980, 68 patients with rectal cancer were randomly allocated to either preoperative irradiation plus surgery or surgical treatment without any preoperative measures. The primary aim of the trial was to investigate the 5-year survival rate in both groups; a secondary aim was to analyze the local recurrence rate and finally the anatomopathologic tumoral classification after surgery. All patients were followed at least 8 years. The preoperative irradiation group (Group A) was submitted to 4000 cGy for 4 weeks and surgery was performed 1 week after irradiation. All tumors were classified anatomically and pathologically according to Broders' and Dukes' classifications. The results indicated that there is a significant difference in the five-year survival rates in both groups: group A had a corrected survival rate of 80 percent; group B (nonirradiated) had a corrected survival rate of 80 percent; group B (nonirradiated) had a corrected survival rate of 34.4 percent. The local recurrence rate was 2.9 percent in group A and 23.5 percent in group B. Regarding tumor regression, before radiotherapy 64.6 percent of the tumors were Broders' Grades 3 and 4; after radiotherapy these were reduced to 20.5 percent. As to Dukes' classification, 26.4 percent of the tumors were type C in group A and, in group B, 47 percent were considered as Dukes' C.

Estudo analitico de um novo fio sintetico em sutura gastrintestinal. / Analytic study of a new sinthetic kind in gastrointestinal suture

Com o intuito de observar um novo fio sintetico de sutura, considerado de absorcao lenta, os AA realizaram cirurgias gastrintestinais em 20 caes, divididos em lotes iguais de cinco animais cada um. Os animais de cada lote respectivamente, foram sacrificados 48 horas, cinco dias, 10 dias e 15 dias apos a cirurgia. As zonas de anastomoses foram estudadas do ponto de vista macro e microscopico, observando-se fundamentalmente a coaptacao das bordas anastomosadas, a espessura das paredes na zona de anastomose, a cicatrizacao na linha de sutura e as alteracoes histopatologicas atribuidas ao fio de sutura. A analise dos resultados obtidos permite concluir que o fio desperta minima reacao granulomatosa tipo corpo estranho, nao interferindo no processo de cicatrizacao nem produzindo reacao alergica local. Em animal algum houve ruptura das bordas anastomosadas ou ulceracao de mucosa provocada pelo fio