Tracking precursor lesions of anal squamous cell carcinoma in individuals with HIV

INTRODUÇÃO: O carcinoma espino-celular do canal anal é doença que atinge os adultos de meia idade e corresponde a 4% dos cânceres do trato gastrointestinal baixo. Na população geral a incidência é de 1 em 100.000 habitantes, e entre os homens que fazem sexo com homens essa incidência atinge 35 por 100.000 habitantes, sendo que os portadores de HIV têm esse risco duplicado (70 por 100.000 habitantes). MÉTODO: Foi realizada revisão da literatura com consulta nos periódicos das bases Medline/Pubmed, Scielo e Lilacs cruzando os descritores Rastreamento, Lesões pré-cancerosas, Neoplasias do ânus e HIV. Além da revisão bibliográfica, foi adicionada a este trabalho a experiência pessoal dos autores, e a obtida no Departamento de Gastroenterologia - Divisão Cirúrgica, no ICESP - Instituto do Câncer do Estado de São Paulo Octávio Frias de Oliveira, no Departamento de Moléstias Infeciosas - Casa da AIDS e no Serviço de Coloproctologia do Hospital das Clínicas da Universidade de São Paulo, SP, Brasil. CONCLUSÕES: HIV+ é um grande fator de risco no desenvolvimento de carcinoma espino-celular anal em indivíduos infectados por HPV. A avaliação desses pacientes não deve se restringir à erradicação de condilomas, mas principalmente incluir o rastreamento de lesões displásicas subclínicas potencialmente neoplásicas. Apesar dos métodos de rastreamento ainda não serem ideais, o grande benefício do rastreamento baseia-se no fato de oferecer acompanhamento rigoroso, tornando possível à prevenção ou detecção cada vez mais precoce do carcinoma espino-celular anal.INTRODUCTION: Squamous cell carcinoma of the anal canal is a disease that affects the middle-aged adults and accounts for 4% of cancers of the gastrointestinal tract below. In the general population the incidence is 1 in 100,000, and among men who have sex with men the incidence is 35 per 100,000 inhabitants, those with HIV have doubled this risk (70 per 100,000 inhabitants). METHODS: Was performed literature review in consultation with periodic Medline / Pubmed, Lilacs and Scielo crossing Trackingm, Precancerous conditions, Anus neoplasms and HIV descriptors. Besides the review,was added to this work the authors'personal experiences, and obtained at the Department of Gastroenterology - Surgical Division, in ICESP - Cancer Institute of the State of São Paulo Octavio Frias de Oliveira, in Department of Diseases Infectious - House of AIDS and in the Department of Coloproctology, Hospital das Clinicas, University of São Paulo, Brazil. CONCLUSIONS: HIV + is a major risk factor in developing squamous cell carcinoma anal in individuals infected with HPV. The evaluation of these patients should not restrict itself to the eradication of warts, but mainly include the screening of subclinical dysplastic lesions potentially neoplastic. Despite the screening methods are still not ideal, the great benefit of screening is based on the fact offer closely monitored, making possible the prevention or detection of increasingly early anal squamous cell carcinoma

Tratamento cirúrgico da estenose anal: resultados de 77 anoplastias

PURPOSE: Anal stenosis is a rare, incapacitating, and challenging condition, occurring mainly after hemorrhoidectomy, for which several surgical techniques have been devised. The purpose of this study was to describe early and late (1 year) results of 77 anoplasty operations performed in the Colorectal Unit of our institution. METHODS: From 1977 to 2002, 77 patients with moderate to severe anal stenosis underwent surgery using two sliding graft techniques: 58 underwent Sarner's operation and 19 underwent Musiari's technique. Bilateral flaps were used in 7 patients. RESULTS: Early morbidity was due to pruritus occurring in 2 patients, urinary infection in 1, and temporary incontinence in 1 patient. One patient needed early reoperation following suture line dehiscence. Late results (1 year) were classified as good in 67 cases (87%). There was no reoperation due to recurrence of stenosis. CONCLUSION: The ease of performance, good functional results, and lack of severe complications show that Sarner's and Musiari's flap advancement techniques are effective and safe methods for surgical correction of anal stenosis, particularly when cutaneous fibrosis plays a major role in its etiology.OBJETIVO: A estenose anal é uma condição rara, incapacitante e desafiadora que ocorre principalmente após hemorroidectomia, para a qual diversas técnicas cirúrgicas reparadoras foram desenvolvidas. O objetivo deste estudo é descrever os resultados precoces e tardios (um ano) de 77 anoplastias realizadas no Serviço de Cirurgia Colorretal. MÉTODOS: No período de 1977 a 2002, 77 pacientes com estenose anal moderada ou grave foram operados, utilizando-se duas técnicas diferentes de avanço de retalho: 58 foram submetidos à técnica de Sarner e 18 submetidos à Técnica de Musiari. Avanços bilaterais foram utilizados em sete pacientes. RESULTADOS: As complicações precoces foram: prurido em dois pacientes, infecção urinária em um paciente e incontinência fecal temporária em outro. Um paciente necessitou reoperação precoce por deiscência de linha de sutura. Os resultados tardios foram classificados como bons em 67 (87%). Não houve reoperação por recorrência de estenose. CONCLUSÃO: A facilidade técnica, os bons resultados funcionais e a ausência de complicações graves demonstraram que as técnicas de avanço de retalho de Sarner e Musiari são efetivas e seguras para correção de estenose anal, particularmente nos casos em que a fibrose cutânea é o principal fator etiológico

Prognostic factors affecting outcomes in multivisceral en bloc resection for colorectal cancer

OBJECTIVES: This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer. METHODS: Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155. RESULTS: The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement. CONCLUSIONS: Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes

Modelo de treinamento cadavérico de baixo custo em videolaparoscopia sem pneumoperitônio

A laparoscopia consiste em acesso cirúrgico realizado por meio de diminutas incisões na parede abdominal seguidas de estabelecimento de pneumoperitônio, representando um avanço na recuperação pós-operatória em relação a cirurgia aberta. Modelos de treinamento em cirurgia videolaparoscópica utilizando de modelos inanimados, animados e envolvendo uso de realidade virtual (RV) foram desenvolvidos para facilitar a curva de aprendizado. Esses modelos procuram permitir aos cirurgiões em treinamento adquirir competências básicas em laparoscopia, tais como a coordenação mão-olho, destreza na utilização das pinças e melhora da percepção de profundidade na imagem bidimensional (2D). Os elevados custos dos modelos de treinamento têm levado instituições e cirurgiões a procurarem modelos menos onerosos, tais como caixa de treinamento e simuladores de RV. No entanto, não oferecem a mesma experiência de aprendizado que o treinamento VLP em porcos ou em cadáveres. Os custos para realização do pneumoperitônio e para utilização de equipamentos do set de vídeo são elevados. Buscando reduzir esses custos e a complexidade do treinamento VLP em cadáveres, desenvolveu-se um modelo de polietileno sem a necessidade de estabelecimento de pneumoperitônio.Laparoscopy consists of surgical access performed using diminutive incisions in the abdominal wall followed by the establishment of pneumoperitoneum, representing an advance in postoperative recovery compared to open surgery. Models of training in laparoscopic surgery were developed to accelerate the technique’s learning. The main ones are inanimate models, animated simulators, and virtual reality (VR). These models seek to allow surgeons in training to acquire basic skills in laparoscopy, such as hand-eye coordination, dexterity in using tweezers, and improvement of depth perception in two-dimensional (2D). The high costs of training models have led institutions and surgeons to look for less expensive models, such as training boxes and VR simulators. However, they do not offer the same learning experience as VLP training on pigs or corpses. Performing the pneumoperitoneum and using video set equipment is expensive. A polyethylene model was developed without establishing pneumoperitoneum to reduce these costs and the complexity of VLP training in cadavers

Laparoscopic Ureterocalicostomy Technique

ABSTRACT Purpose: Ureterocalicostomy is a technique that was first described by Neuwirt in 1948 (1) The laparoscopic access was initiated in 2003 by Cherullo et al. (2), following the established principles of open surgery. In 2004, Gill et al. had two patients with UPJO treated with laparoscopic ureterocalicostomy, with success (3). In 2014, Arap et. al. presented a case series with good results in adults and children in our service (4). There are factors that prepare the surgeon for an ureterocalicostomy, such as the renal cortex thickness, although the decision is mainly taken during the procedure (5). Material and Methods: A 24 years-old female patient with right lumbar pain was referred to our institution. She already had a right open pyeloplasty two years ago. The CT scan presented a right hydronephrotic kidney, DMSA scan with 30% of relative function and a DTPA scan with an obstructive pattern. Results: A laparoscopic ureterocalicostomy was performed due to the intra-operative findings (inferior kidney pole thickness and challenging access to the uretero-pelvic junction). The overall time was 130 minutes with no complications. The patient was discharged in two days and the double J was withdrawn in four weeks. The CT scan within one year demonstrates a reduction of the hydronephrosis. She had no more lumbar pain. Conclusion: In complex cases, the laparoscopic ureterocalicostomy proves to be a safe and efficient procedure, with a free tension-free anastomosis and the advantages of the laparoscopic access

Post-Operative Functional Outcomes in Early Age Onset Rectal Cancer

Background: Impairment of bowel, urogenital and fertility-related function in patients treated for rectal cancer is common. While the rate of rectal cancer in the young (<50 years) is rising, there is little data on functional outcomes in this group. Methods: The REACCT international collaborative database was reviewed and data on eligible patients analysed. Inclusion criteria comprised patients with a histologically confirmed rectal cancer, <50 years of age at time of diagnosis and with documented follow-up including functional outcomes. Results: A total of 1428 (n=1428) patients met the eligibility criteria and were included in the final analysis. Metastatic disease was present at diagnosis in 13%. Of these, 40% received neoadjuvant therapy and 50% adjuvant chemotherapy. The incidence of post-operative major morbidity was 10%. A defunctioning stoma was placed for 621 patients (43%); 534 of these proceeded to elective restoration of bowel continuity. The median follow-up time was 42 months. Of this cohort, a total of 415 (29%) reported persistent impairment of functional outcomes, the most frequent of which was bowel dysfunction (16%), followed by bladder dysfunction (7%), sexual dysfunction (4.5%) and infertility (1%). Conclusion: A substantial proportion of patients with early-onset rectal cancer who undergo surgery report persistent impairment of functional status. Patients should be involved in the discussion regarding their treatment options and potential impact on quality of life. Functional outcomes should be routinely recorded as part of follow up alongside oncological parameters

Screening anal dysplasia in HIV-infected patients : is there an agreement between anal pap smear and high resolution anoscopy guided biopsy?

OBJETIVO: O objetivo deste estudo foi analisar a concordância entre o esfregaço anal e a biópsia guiada por anuscopia de alta resolução no diagnóstico da displasia anal em pacientes infectados pelo HIV. MÉTODO: Conduzimos uma análise transversal de pacientes infectados pelo HIV submetidos a rastreamento de displasia anal rotineiro. A concordância entre mensurações foi estimada por índice de kappa ponderado através de sistema de avaliação citológica e histológica de três categorias (normal, displasia de baixo grau, e displasia de alto grau). Estimativas de sensibilidade, especificidade e valores preditivos foram calculados através de sistema de avaliação citológica e histológica de duas categorias (ausência de displasia e displasia de qualquer grau). Estimativas foram calculadas também para a detecção de displasia de alto grau. RESULTADOS: No decorrer de um ano, 222 pacientes foram submetidos a 330 esfregaços anais seguidos de biópsias guiadas por anuscopia de alta resolução. Trezentos e onze (311) esfregaços com biópsias concomitantes foram satisfatórios. Considerando-se a histologia como padrão, a freqüência de displasia anal foi de 46%. O índice kappa ponderado para concordância entre o esfregaço anal e a biópsia foi de 0,20. Para detecção de displasia anal de qualquer grau, o esfregaço anal demonstrou sensibilidade de 61%, especificidade de 60%, valor preditivo positivo de 56% e valor preditivo negativo de 64%. Para displasia de alto grau, o esfregaço anal demonstrou sensibilidade de 16% e especificidade de 97%. CONCLUSÃO: Os resultados obtidos no presente estudo, em que comparamos os achados da citologia dos esfregaços com os achados histológicos das biópsias dirigidas pela anuscopia de alta resolução em pacientes infectados pelo HIV permitiram concluir que houve baixa concordância entre elesPurpose: To analyze the agreement between anal Pap smear and high resolution anoscopy guided biopsy to diagnose anal dysplasia in HIV-infected patients. Methods: Cross sectional analysis of HIV-infected patients receiving anal dysplasia screening as part of routine care. Agreement between measures was estimated by weighted kappa-statistics, using 3-tiered cytologic and histologic grading system (normal, low grade dysplasia, and high grade dysplasia). Estimates of sensitivity, specificity, and predictive values were calculated using a 2-tiered cytologic and histologic grading system (without dysplasia, and with dysplasia of any grade). Estimates were also calculated for the detection of high grade dysplasia. Results: Two hundred and twenty-two patients underwent 330 anal Pap smears followed by high resolution anoscopy guided biopsies in one year period. There were 311 satisfactory Pap smears with concurrent biopsy. Considering histology the standard, the frequency of anal dysplasia was 46 percent (95 percent confidence interval: 40-51 percent). Kappa-agreement between anal Pap smear and biopsy was 0.20 (95 percent confidence interval: 0.10 0.29). Anal Pap smear showed sensitivity of 61 percent, specificity of 60 percent, positive predictive value of 56 percent, and negative predictive value of 64 percent for detection of anal dysplasia of any grade. For high grade dysplasia, anal Pap smear showed sensitivity of 16 percent, and specificity of 97 percent. Conclusion: The present study showed a low concordance between anal Pap smears and high resolution anoscopy-guided biops