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

Treatment of rectal neoplasia by transanal endoscopic microsurgery - TEM: risk factors for post operative complications

INTRODUÇÃO: A microcirurgia endoscópica transanal (TEM) é uma técnica minimamente invasiva segura e eficiente para o tratamento de neoplasia retal benigna e maligna precoce. As complicações pós operatórias podem ser graves. Existe controvérsia na literatura a respeito da sua incidência e gravidade. OBJETIVOS: Avaliar os fatores de risco relacionados a incidência e gravidade das complicações pós operatórias e seu comportamento temporal em pacientes com neoplasia retal tratados por TEM. MÉTODOS: Estudo prospectivo das complicações pós-operatórias usando a classificação e graduação de Clavien-Dindo. As características estudadas dos pacientes foram: idade, sexo, risco cirúrgico dado pela Associação Americana de Anestesiologia (ASA), quimiorradioterapia neoadjuvante, altura e tamanho da lesão, margens patológicas, histologia do tumor e tipo de sutura: por TEM ou por afastador anal convencional. RESULTADOS: Dentre os cinquenta e três pacientes tratados, a morbidade geral foi de 50%. Incontinência foi a complicação mais frequente (17,3%). Apenas uma paciente teve incontinência persistente. As taxas de complicações pós-operatórias grau I e grau II (GII) foram ambas 21,1%; para grau III (GIII) e IV também foram ambas: 3,8%. Não houve mortalidade. Dos pacientes que tiveram complicações pós-operatórias, 61,54% tinham lesões abaixo da primeira válvula retal, comparado com 38,46% dos pacientes com lesões acima da primeira válvula (p=0.039). Pacientes submetidos à quimiorradioterapia neoadjuvante tiveram 24 vezes mais chance de apresentarem complicações pós-operatórias GII (p=0,002), e 7,03 vezes mais chance de GIII (p=0,098). Quando a sutura da ferida cirúrgica foi realizada por TEM, houve 16 vezes menos chance de ocorrerem complicações pós-operatórias GIII (p=0,043). 53% das complicações pós-operatórias ocorreram em 10 dias e 95%, em 20 dias. CONCLUSÕES: Complicações pós-operatórias pós TEM são frequentes, aceitáveis e geralmente controladas com medicamentos. Pacientes com lesões mais distais têm mais complicações pós-operatórias. Pacientes que receberam quimiorradioterapia neoadjuvante e submetidos a sutura com afastador de ânus convencional tiveram complicações pós operatórias que requereram intervenção médica - cirúrgica ou endoscópica sobre sedação. O comportamento temporal das complicações é progressivo e inespecífico, a maioria ocorrendo nos primeiros 20 diasINTRODUCTION: Transanal endoscopic microsurgery (TEM) is a safe and efficient minimally invasive treatment for rectal benign and early malignant neoplasia. Postoperative complications may be severe. Controversy exists with regard to incidence and severity. OBJECTIVES: Evaluate risk factors related to incidence and severity of postoperative complications, and time course, in patients with rectal neoplasia treated by TEM. METHODS: Prospective study of postoperative complications using the Clavien-Dindo classification and grading system. Patients\' characteristics included age, sex, ASA score, neoadjuvant chemoradiotherapy (CRT), lesion height and size, pathologic margins, tumor histology, and suture type: through TEM or conventional retractor. RESULTS: Among fifty-three patients treated,overall morbidity rate was 50%. Incontinence was the most frequent complication (17.3%). One patient had persistent incontinence. Grade I and Grade II (GII) postoperative complication rates were both 21.1%, and Grade III (GIII) and IV rates were both 3.8%. There was no mortality. Of the patients with postoperative complications, 61.54% had lesions under the first rectal valve, compared with 38.46% of patients with lesions over the first valve (p=0.039). Patients submitted to CRT had a 24-fold greater chance of presenting GII complications (p=0.002), and a 7.03-fold greater chance of GIII (p=0.098). When the surgical defect was treated using the TEM device to perform the suture, there was a 16-fold less chance of having GIII complications (p=0.043). Fifty-three percent of complications occurred in the first 10 days, and 95% within 20 days. CONCLUSIONS: Postoperative complications after TEM for the treatment of rectal neoplasia are frequent, acceptable, and usually controllable with pharmacologic treatment. Patients with more distal lesions have more postoperative complications. Patients receiving neoadjuvant CRT and submitted to suture with a conventional anal retractor have more postoperative complications that require intervention under sedation. Over time the nature of complications is progressive and nonspecific, with most occurring within the first 20 day

Médicos residentes podem realizar com segurança e eficiência técnicas de Milligan-Morgan, Ferguson e grampeadores no tratamento cirúrgico das hemorróidas?

RACIONAL: A cirurgia para hemorróidas sintomáticas é necessária em quase 10% dos pacientes. Embora, a literatura sobre o tratamento cirúrgico da doença hemorroidária seja muito grande, os dados relativos à hemorroidectomia ou hemorroidopexia realizadas por residentes de treinamento é limitado. OBJETIVO: Analisar os resultados destes procedimentos em uma instituição de ensino. MÉTODOS: Foram analisados retrospectivamente os dados de todos os pacientes que se submeteram ao tratamento cirúrgico para hemorróidas entre1995 e 2007 em uma única instituição. Residentes supervisionados realizaram todos os procedimentos. As técnicas foram comparadas com base no tempo operatório, permanência hospitalar, morbidade e eficácia a longo prazo. RESULTADOS: Trezentos e trinta e três pacientes foram incluídos no estudo, 182 homens (54,6%), com idade média de 45,3 anos (± 12,02). Hemorróidas de terceiro grau foram a principal indicação (81,7%). Milligan-Morgan foi o procedimento mais comumente realizado (57%), seguido por Ferguson e hemorroidopexia grampeada. A média de tempo operatório foi significativamente menor no grupo hemorroidopexia grampeada quando comparado com os procedimentos abertos e fechados: 49,4 ± 29,3 min vs 61,1 ± 26,5 e 67,1 ± 28,3, respectivamente (p=0,0034). Não houve diferença estatisticamente significativa entre os grupos quanto às complicações pós-operatórias ou à taxa de reoperação. O tempo de internação foi significativamente maior no grupo Milligan-Morgan quando comparado com Ferguson e grampeamento (1,41 ± 0,86 dias vs 1,19 ± 0,43 vs 1,16 ± 0,37, respectivamente). Recorrência sintomática, taxas de reoperação e o uso de ligadura elástica foram semelhantes entre os grupos. CONCLUSÃO: Os residentes sob supervisão pode executar Milligan-Morgan, Ferguson e grampeamento hemorroidário com baixa incidência de complicações e bons resultados a longo prazo. O grampeamento foi associado com menor tempo operatório, enquanto Milligan-Morgan foi correlacionada com maior tempo de hospitalização

Perianal squamous cell carcinoma with high-grade anal intraepithelial neoplasia in an HIV-positive patient using highly active antiretroviral therapy: case report

CONTEXT: Highly active antiretroviral therapy (HAART) has turned human immunodeficiency virus (HIV) infection into a chronic condition, and this has led to increased incidence of anal dysplasia among HIV-positive patients. Routine anal evaluation including the anal canal and perianal area is recommended for this population, especially for patients infected by oncogenic human papillomavirus (HPV) types. CASE REPORT: A 54-year-old homosexual HIV-positive man presented with a six-year history of recurrent perianal and anal warts. He had previously undergone incomplete surgical excision and fulguration in another institution on two occasions. He had been using HAART over the past two years. He presented some condylomatous spreading lesions occupying part of the anal canal and the perianal skin, and also a well-demarcated slightly painful perianal plaque of dimensions 1.0 x 1.0 cm. Both anal canal Pap smears and biopsies guided by high-resolution anoscopy revealed high-grade squamous intraepithelial lesion. Biopsies of the border of the perianal plaque also revealed high-grade squamous intraepithelial lesion. HPV DNA testing of the anus detected the presence of HPV-16 type. The patient underwent local full-thickness excision of the lesion. Histological analysis on the excised tissue revealed high-grade squamous intraepithelial lesion with one focus of microinvasive squamous cell cancer measuring 1 mm. No lymph vessel or perineural invasion was detected. The patient showed pathological evidence of recurrent anal and perianal high-grade squamous intraepithelial lesions at the sixth-month follow-up and required further ablation of those lesions. However no invasive squamous cell carcinoma recurrence has been detected so far