FATORES DE RISCO PARA DEISCÊNCIA DA ANASTOMOSE NA RESSECÇÃO ANTERIOR DO RETO: NOSSA EXPERIÊNCIA

Introduction: Anastomotic leakage is a complication of anterior rectum resection, with an incidence up to 20%. Although there ́s no consensus about risk factors for anastomotic leakage, they can be divided into patient/disease/ surgery related. We analyze risk factors in our experience for colorectal anastomosis leakage. Material and Methods: Retrospective review of 105 patients with rectal cancer submitted to anterior rectum resection in the General Surgery Department of a terciaty referral center from 1/1/2018 to 31/12/2019. Statistical analysis was performed using the SPSS, version 25.0. Results: We found an anastomotic leakage incidence of 10.5%. A statistically significant association between anastomotic leakage and previous abdominal surgery and usage of intraabdominal drain was seen, and a tendency to statically significance with intraoperatively red blood cells transfusion. We didn ́t found association with age, sex, cardiovascular risk factors, use of NSAIDs, corticoids, radio chemotherapy, open or laparoscopic surgery, surgeon experience, rectum tumor location and time of surgery. Discussion: Risk factors for anastomotic leakage vary between different studies but it is consensual that it has a multifactorial cause. As there are preoperative factors that increase the risk of anastomotic leakage, an extensive study of the patient previous to the surgery is mandatory in order to minimize the complications. Unlike current literature, we didn’t find any risk factors related to the surgery and the surgeon, and only one risk factor related to the patient (previous abdominal surgery). The association between anastomotic leak and use of pelvic drain is difficult to explain and needs additional studies. Conclusion: In our experience previous abdominal surgery is the only risk factor for anastomotic leakage development in anterior rectum resection for rectal cancerIntrodução: A fístula anastomótica é uma complicação da ressecção anterior do reto, com incidência de até 20%. Embora não haja consenso sobre os fatores de risco para a deiscência da anastomose, estes podem estar relacionados com o doente, com a doença, ou com a cirurgia. Analisámos os fatores de risco para a deiscência da anastomose colorretal na nossa série. Material e Métodos: Realizámos uma revisão retrospetiva de 105 doentes com cancro retal submetidos a ressecção anterior do reto no Departamento de Cirurgia Geral de um centro terciário de referência no período de 01/01/2018 a 31/12/2019. A análise estatística foi realizada com recurso ao programa SPSS, versão 25.0. Resultados: Encontramos uma incidência de deiscência da anastomose de 10,5%. Observou-se associação estatisticamente significativa entre deiscência da anastomose e antecedentes de cirurgia abdominal e a necessidade de colocação de dreno intra-abdominal, observámos uma associação sem significância estatística com a transfusão intraoperatória de eritrócitos. Não encontramos associação com a idade, sexo, fatores de risco cardiovascular, uso de AINEs, corticóides, radioquimioterapia, cirurgia aberta ou laparoscópica, experiência do cirurgião, localização do tumor de reto e a duração da cirurgia. Discussão: Os fatores de risco para fístula anastomótica variam entre os diferentes estudos, mas é consensual que tem uma causa multifatorial. Como existem fatores pré-operatórios que claramente aumentam o risco de deiscência da anastomose, é mandatório o estudo das morbilidades do doente antes da cirurgia, a fim de as mitigar e minimizar as complicações. Ao contrário da literatura, não encontramos nenhum fator de risco relacionado com a técnica cirúrgica e com o cirurgião, apenas a história de cirurgia abdominal prévia revelou uma associação estatisticamente significativa. A associação entre a deiscência da anastomose e uso de dreno pélvico é difícil de explicar e necessita, por esse motivo de estudos adicionais. Conclusão: Na nossa série, a cirurgia abdominal prévia foi o único fator de risco para o desenvolvimento de deiscência da anastomose na ressecção anterior do reto por cancro do reto

Large desmoid tumors in familial adenomatous polyposis: a successful outcome

Desmoid tumors develop from connective tissue, fasciae, and aponeuroses, and may occur in the context of familial adenomatous polyposis or may arise sporadically; also, they may be extra-abdominal, intra-abdominal, or located in the abdominal wall. These benign tumors have a great aggressiveness with a high rate of local recurrence. Familial adenomatous polyposis is an inherited condition with autosomal dominant transmission, and is characterized by the development of multiple colonic and rectal adenomatous polyps, as well as desmoid tumors. We present the case of a 54-year-old woman with germline APC gene mutation, who underwent a total colectomy, subsequently developing two large infiltrative solid intra-abdominal lesions consistent with desmoid tumors. Medical treatment with Cox-2 inhibitors was initiated without result. She was submitted to resection for intestinal obstruction, but developed local recurrence. The lesions were also unresponsive to tamoxifen, and chemotherapy was initiated with dacarbazine plus doxorubicin, switching to vinorelbine plus methotrexate, achieving a good response in all lesions after 12 months. The approach to these intra-abdominal lesions should be progressive, beginning with observation, then a medical approach with non-steroidal anti-inflammatory drugs or with an anti-hormonal agent. Afterwards, if progression is still evident, chemotherapy should be started. Surgery should be reserved for resistance to medical treatment, in palliative situations, or for extra-abdominal or abdominal wall desmoids tumors

Large desmoid tumors in familial adenomatous polyposis

Desmoid tumors develop from connective tissue, fasciae, and aponeuroses, and may occur in the context of familial adenomatous polyposis or may arise sporadically; also, they may be extra-abdominal, intra-abdominal, or located in the abdominal wall. These benign tumors have a great aggressiveness with a high rate of local recurrence. Familial adenomatous polyposis is an inherited condition with autosomal dominant transmission, and is characterized by the development of multiple colonic and rectal adenomatous polyps, as well as desmoid tumors. We present the case of a 54-year-old woman with germline APC gene mutation, who underwent a total colectomy, subsequently developing two large infiltrative solid intra-abdominal lesions consistent with desmoid tumors. Medical treatment with Cox-2 inhibitors was initiated without result. She was submitted to resection for intestinal obstruction, but developed local recurrence. The lesions were also unresponsive to tamoxifen, and chemotherapy was initiated with dacarbazine plus doxorubicin, switching to vinorelbine plus methotrexate, achieving a good response in all lesions after 12 months. The approach to these intra-abdominal lesions should be progressive, beginning with observation, then a medical approach with non-steroidal anti-inflammatory drugs or with an anti-hormonal agent. Afterwards, if progression is still evident, chemotherapy should be started. Surgery should be reserved for resistance to medical treatment, in palliative situations, or for extra-abdominal or abdominal wall desmoids tumors

ATLANTIC EPIPHYTES: a data set of vascular and non-vascular epiphyte plants and lichens from the Atlantic Forest

Epiphytes are hyper-diverse and one of the frequently undervalued life forms in plant surveys and biodiversity inventories. Epiphytes of the Atlantic Forest, one of the most endangered ecosystems in the world, have high endemism and radiated recently in the Pliocene. We aimed to (1) compile an extensive Atlantic Forest data set on vascular, non-vascular plants (including hemiepiphytes), and lichen epiphyte species occurrence and abundance; (2) describe the epiphyte distribution in the Atlantic Forest, in order to indicate future sampling efforts. Our work presents the first epiphyte data set with information on abundance and occurrence of epiphyte phorophyte species. All data compiled here come from three main sources provided by the authors: published sources (comprising peer-reviewed articles, books, and theses), unpublished data, and herbarium data. We compiled a data set composed of 2,095 species, from 89,270 holo/hemiepiphyte records, in the Atlantic Forest of Brazil, Argentina, Paraguay, and Uruguay, recorded from 1824 to early 2018. Most of the records were from qualitative data (occurrence only, 88%), well distributed throughout the Atlantic Forest. For quantitative records, the most common sampling method was individual trees (71%), followed by plot sampling (19%), and transect sampling (10%). Angiosperms (81%) were the most frequently registered group, and Bromeliaceae and Orchidaceae were the families with the greatest number of records (27,272 and 21,945, respectively). Ferns and Lycophytes presented fewer records than Angiosperms, and Polypodiaceae were the most recorded family, and more concentrated in the Southern and Southeastern regions. Data on non-vascular plants and lichens were scarce, with a few disjunct records concentrated in the Northeastern region of the Atlantic Forest. For all non-vascular plant records, Lejeuneaceae, a family of liverworts, was the most recorded family. We hope that our effort to organize scattered epiphyte data help advance the knowledge of epiphyte ecology, as well as our understanding of macroecological and biogeographical patterns in the Atlantic Forest. No copyright restrictions are associated with the data set. Please cite this Ecology Data Paper if the data are used in publication and teaching events. © 2019 The Authors. Ecology © 2019 The Ecological Society of Americ

Rectal carcinoma with synchronous liver metastases

Introduction: Colorectal cancer is amongst the most prevailing malignancies in the world and it is associated with a relatively high mortality rate. Rectal cancer occurs in 20–30% of all colorectal cancer cases, and 25% of this present synchronous metastatic disease. This study aims to review the current treatment approaches for rectal cancer patients with synchronous liver metastases, as there are no specific guidelines for the management of this group of patients. Methods: A systematic literature search was performed on Pubmed database with a 10 year timeline limitation from 2008 to 2018. Results: Currently, the only potentially curative approach remains to be the surgical resection. Conventionally, the classical strategy of these patients involves resection of rectal tumor, followed by liver resection, with chemotherapy sessions between the two procedures. However, recent studies have reported no inferiority, in safety and survival outcomes, when compared with other approaches (liver-first resection or simultaneous resection), except when symptoms of primary tumor are present. Hence, treatment strategy should be individualized based on the assessment of metastatic extent, primary tumor symptoms and the patient's overall clinical status. Chemotherapy and targeted agents have substantially contributed to overall survival improvements, allowing enhanced tumor down staging. Conclusion: Complete resection of liver metastases is considered the major condition for a potential survival outcome in these patients. Management of these patients should include a multidisciplinary team with consideration of each individual specificities. Prospective randomized trials are needed to elucidate the optimal treatment strategy. Resumo: Introdução: O câncer colorretal está entre as neoplasias mais prevalentes no mundo, apresentando a uma taxa de mortalidade relativamente alta. Ele corresponde a 20% a 30% de todos os casos de câncer colorretal; 25% dos casos apresentam doença metastática síncrona. Este estudo teve como objetivo revisar as abordagens atuais de tratamento para pacientes com câncer retal com metástases hepáticas síncronas, uma vez que não existem diretrizes específicas para o manejo deste grupo de pacientes. Métodos: Uma busca sistemática da literatura foi realizada no banco de dados PubMed com uma limitação temporal de 10 anos (2008 a 2018). Resultados: Atualmente, a ressecção cirúrgica ainda é a única abordagem potencialmente curativa. Tradicionalmente, a estratégia clássica para o tratamento desses pacientes envolve a ressecção do tumor retal, seguida de ressecção hepática, com sessões de quimioterapia entre os dois procedimentos. No entanto, ao comparar a abordagem tradicional com outras técnicas (ressecção em primeiro plano do fígado ou ressecção simultânea), estudos recentes não relataram inferioridade nos desfechos de segurança e sobrevida, exceto quando sintomas de tumor primário estão presentes. Portanto, a estratégia de tratamento deve ser individualizada com base na avaliação da extensão metastática, nos sintomas primários do tumor e no estado clínico geral do paciente. A quimioterapia e os agentes dirigidos contribuíram substancialmente para as melhorias gerais na sobrevida, permitindo uma maior redução do estadiamento tumoral. Conclusão: A ressecção completa de metástases hepáticas é considerado o principal requisito para um possível resultado de sobrevida nesses pacientes. O manejo desses pacientes deve incluir uma equipe multidisciplinar e considerar as características específicas de cada paciente. Estudos prospectivos randomizados são necessários para elucidar a estratégia de tratamento ideal. Keywords: Rectal neoplasms, Neoplasm metastasis, Liver, Chemoradiotherapy, Neoadjuvant therapy, Palavras-chave: Neoplasias retais, Metástase neoplásica, Fígado, Quimiorradioterapia, Terapia neoadjuvant

Anal canal squamous carcinoma

AbstractBackgroundAnal canal carcinoma is a rare neoplasm, representing 2% of the digestive tumors, and the most common is squamous cell carcinoma, with an increasing incidence.ObjectiveThe study aims to elucidate the pathogenesis of an increasingly prevalent disease, as well as to update treatment and prognosis.MethodsA literature search in Pubmed database, including articles from 2005 to 2015 and cross-research articles with the initial research.ResultsSeveral studies prove the role of HPV as a major risk factor in the development of squamous cell carcinoma of anal canal, as well as a greater prevalence of this neoplasia in HIV-positive people and in those who practice receptive anal intercourse. In the last two decades chemoradiotherapy remains the treatment of choice, and abdominoperineal resection is reserved for those cases of treatment failure or recurrence. Evidence advances in order to adapt the treatment to each patient, taking into account individual prognostic factors and biological tumor characteristics.ConclusionsSquamous cell carcinoma of the anal canal is a neoplasm associated with HPV; therefore, screening and vaccination programs of male individuals, by way of prevention, should be started. Many studies are needed in order to achieve development in the treatment as well as in the evaluation of the biological characteristics of the tumor

Ischemic colitis: risk factors, diagnosis and prognosis in patients undergoing surgery

Objective: To identify risk factors, diagnosis and prognosis associated with ischemic colitis, focusing mainly on patients undergoing surgery. Materials and methods: This retrospective study included all patients admitted to the Centro Hospitalar de São João - E. P. E., diagnosed with ischemic colitis during the period from 2012 to 2013. Results: The study included 154 patients; 118 were undergoing medical treatment, with a 12% mortality rate, and 36 were undergoing surgery, with a 61% associated mortality rate. Hypertension was the most common risk factor in both groups. The presence of a large num- ber of cardiovascular risk factors in both groups, such as hypertension and dyslipidemia, was recorded, but we still found no direct relationship with development of ischemic coli- tis. Comorbidities that affect blood flow, such as the presence of thrombi or aneurysms, do provide a worse prognosis and therefore require a more aggressive treatment. Conclusion: The diagnosis of ischemic colitis is not always immediately established due to a nonspecific presentation. Surgical treatment should be reserved for severe cases with a worse prognosis associated

Coloretal cancer in pregnant women

Background: Colorectal cancer in pregnancy is a rare pathology with limited high-grade evidence available for guidance. The diagnosis of CRC in pregnant women is usually delayed, and once diagnosis is made, challenges exist as treatment options may be limited. Objective: The study aims to highlight the importance of early investigation of symptomatic patients during pregnancy, as well as to update treatment and prognosis in CRC. Methods: A literature search in PubMed database, including articles from 2006 to 2016 and cross-research articles with the initial research. Results: Pregnancy can limit and contraindicate the utilization of standard diagnostic and therapeutic tools, which in particular can hamper the liberal use of colonoscopy and CT. Physical evaluation and abdominal US are first recommended; besides, MRI or CT may be used, only in indicated cases. Surgery is the main stay of treatment but radiotherapy and chemotherapy have significant role in posterior management of tumour. Conclusions: Many studies are needed in order to achieve development in CRC pathogenesis during pregnancy as well as in treatment outcomes. The potential curative treatment of the disease should be the main aim of treatment when considering CRC in pregnancy. However, it is crucial to adapt the treatment to each patient, taking into account conscious decision on pregnancy further management. Resumo: Introdução: O cancro colorretal na gravidez é uma patologia rara, com limitada evidência científica para orientação terapêutica. O diagnóstico de cancro coloretal em mulheres grávidas é tardio e, quando o diagnóstico é feito, as opções de tratamento podem ser limitadas. Objetivo: O objetivo deste estudo é ressalvar a importância da investigação precoce de pacientes sintomáticas durante a gravidez, assim como avaliar os atuais métodos de tratamento e prognóstico no CCR. Métodos: A pesquisa bibliográfica foi realizada na base de dados PubMed, incluindo artigos a partir de 2006 até 2016, assim como artigos de pesquisa cruzada com os artigos iniciais. Resultados: A gravidez pode limitar e contra-indicar a utilização de ferramentas de diagnóstico e terapêuticas convencionais, assim como dificultar o uso indiscriminado de colonoscopia e tomografia computadorizada. A avaliação física e a ecografia abdominal são a primeira linha para diagnóstico. No entanto, em casos selecionados, a ressonância magnética ou a tomografia computadorizada também podem ser usadas. A cirurgia é o gold-standard mas a radioterapia e a quimioterapia assumem um papel cada vez mais relevante no tratamento multidisciplinar destes tumores. Discussão: Como os sintomas abdominais são comuns na gravidez e cancro coloretal pode simulá-los, o diagnóstico diferencial entre estas duas patologias é crucial, já que intervenções precoces podem ser curativas. Após diagnóstico, o seguimento das grávidas deve ser individualizado, dependendo de vários fatores. Porém, já que atualmente o tratamento do cancro é possível na gravidez, a probabilidade de sobrevivência da paciente não deve ser diminuída devido ao diagnóstico tardio. Conclusões: Mais estudos são necessários para saber mais acerca da patogénese do cancro coloretal na gravidez, assim como os resultados após tratamento. O potencial objetivo é o tratamento oncológico do cancro coloretal. No entanto, é crucial adaptar o tratamento a cada paciente, tendo em conta a sua decisão consciente acerca da continuação da gravidez. Keywords: Colon cancer, Rectal cancer, Pregnancy, Cancer diagnosis, Cancer treatment, Palavras-chave: Cancro do cólon, Cancro do reto, Gravidez, Diagnóstico do cancro, Tratamento do cancr

Safety and effectiveness of laparoscopic peritoneal lavage in Hinchey III diverticulitis

Introduction: The management of Hinchey III diverticulitis has been subject to investigation over the years. Hartmann's procedure is widely referred as the standard treatment. However, this option is associated with relevant morbidity and mortality which motivated the arise of alternative interventions such as the laparoscopic peritoneal lavage. Aim: The aim of this review is to synthesize the evidence on the safety and effectiveness of laparoscopic peritoneal lavage in the management of diverticulitis with generalized purulent peritonitis in comparison to resection procedures. Materials and methods: The bibliographic research was conducted using the electronic database Medline from Pubmed. Of the 358 articles identified, our criterious selection resulted in a total of 27 articles for review. Results: Overall, laparoscopic lavage revealed low mortality rates with no remarkable differences between procedures. The non-randomized studies tended to show lower recurrence and morbidity rates comparatively to the latest RCTs, in the lavage groups, however, no significant differences have been found. Discussion and conclusion: In this review, laparoscopic peritoneal lavage proved to be safe and comparatively effective, although not superior to resection, reaching mixed results. We believe it can be applied as a damage control operation to treat or as a bridge to elective resection. Still, more studies are needed to determine indications and factors for the success of laparoscopic lavage. Resumo: Introdução: O tratamento da diverticulite por Hinchey III tem sido objeto de investigação ao longo dos anos. A operação tipo Hartmann é amplamente referida como o tratamento padrão. No entanto, esta opção está associada à morbilidade e mortalidade relevante, o que motivou o surgimento de intervenções alternativas, como a lavagem peritoneal laparoscópica. Objetivo: O objetivo desta revisão é sintetizar a evidência sobre a segurança e a eficácia da lavagem peritoneal laparoscópica no tratamento da diverticulite com peritonite generalizada purulenta em comparação com os procedimentos de ressecção. Materiais e métodos: A pesquisa bibliográfica foi realizada na base de dados eletrónica Medline da Pubmed. Dos 358 artigos identificados, a nossa seleção criteriosa resultou num total de 27 artigos para revisão. Resultados: No geral, a lavagem laparoscópica revelou baixas taxas de mortalidade sem diferenças significativas entre os procedimentos. Os estudos não randomizados tenderam a mostrar menores taxas de recorrência e morbilidade comparativamente aos últimos ensaios clínicos randomizados, nos grupos submetidos à lavagem, no entanto, nenhuma diferença significativa foi encontrada. Discussão e conclusão: Nesta revisão, a lavagem peritoneal laparoscópica mostrou-se segura e comparativamente eficaz, embora não superior à ressecção, não alcançando resultados constantes. Nós acreditamos que pode ser aplicada como um procedimento de controlo de danos para tratamento ou como ponte para cirurgia eletiva. Ainda assim, são necessários mais estudos para determinar indicações e fatores para o sucesso da lavagem laparoscópica