Araujo, Sergio Eduardo Alonso

Bocchini, Sylvio Figueiredo

Cecconello, Ivan

Dumarco, Rodrigo Blanco

Kiss, Desidério Roberto

Nahas, Sergio Carlos

Clinics

English

Sergio Eduardo Alonso Araujo

Rodrigo Blanco Dumarco

Sylvio Figueiredo Bocchini

Sergio Carlos Nahas

Desidério Roberto Kiss

Ivan Cecconello

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Recurrence of chagasic megacolon after surgical treatment: clinical, radiological, and functional evaluation

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89CLINICS 2007;62(1):89-92Department of Gastroenterology, São Paulo University Medical School –São Paulo/SP, Brazil.Discipline of Coloproctology, São Paulo University Medical School – SãoPaulo/SP, Brazil.Email: rodrigodumarco@uol.com.brLETTER TO THE EDITORRECURRENCE OF CHAGASIC MEGACOLON AFTERSURGICAL TREATMENT: CLINICAL, RADIOLOGICAL,AND FUNCTIONAL EVALUATIONSergio Eduardo Alonso Araujo, Rodrigo Blanco Dumarco, Sylvio Figueiredo Bocchini, Sergio Carlos Nahas, DesidérioRoberto Kiss, Ivan CecconelloINTRODUCTIONChagas disease is an endemic pathology in many re-gions of Brazil as in most countries of Latin America. TheWorld Health Organization1 estimates that there are 17 mil-lion infected people in Latin America, including 300,000new cases per year, and 2 to 3 million patients with chroniccomplications of the disease. Chagasic megacolon is a latecomplication of this disease and is defined by an increasein diameter and length of the large bowel.2,3Chagasic megacolon is the result of irreversible destruc-tion of the intramural intestinal nervous system that in-cludes the rectum.4,5 A progressive and frequently severeconstipation associated with complications such as sigmoidvolvulus and fecal impaction comprise the clinical picture.6Surgical treatment of chagasic megacolon does not curethe disease; the main objectives are the relief of constipa-tion and abolishment of complication risk. 6 Operations forchagasic megacolon today comprise a myriad of techniquesthat involve different extents of colon resection and anas-tomotic levels, resulting in variable operative morbidity andrecurrence. Partial or total resections of the dilated colonhave proven to be inadequate in the management ofchagasic megacolon due to the preservation of a dyskineticrectum, which continues to act as a functional obstacle tobowel emptying. High complication rates associated withabdominoperineal pull-through procedures prompted thedevelopment of the Habr-Gama technique7 at our institu-tion. This operation is an anterior resection of the dilatedcolon with immediate posterior end-to-side mechanicalextraperitoneal colorectal anastomosis. The good resultsassociated with this technique are due to a functional ex-clusion of the diseased rectum through construction of alarge (33-mm diameter, circular, stapled) colorectal anas-tomosis at the posterior rectal wall, avoiding anterior rec-tal dissection that can offer risk of autonomic nerve dam-age.Removal or exclusion of the rectum for patients withchagasic megacolon through an abdominal or abdomi-noperineal approach is an effective surgical technique.8 Al-though postsurgical recurrent constipation may not be ob-served in some series,9–13 it does occur.14 To the best of ourknowledge, there have been no indexed publications aboutevaluation and treatment of recurrent cases. Therefore, thiscommunication aims to evaluate clinically andradiologically with radiopaque markers the total colonictransit times for patients who presented with symptomaticrecurrence of symptoms after elective surgical treatment ofchagasic megacolon outside our institution.DESCRIPTION OF PATIENTS AND RESULT OFTREATMENTWe were able to revisit data from 10 patients who pre-viously underwent surgery for chagasic megacolon in otherhospitals and had sought medical attention at our institu-tion between January 2001 and January 2003 due to severerecurrence of symptoms.The mean age was 59.8 years (49 to 70 years); 8 pa-tients (80%) were women. We conducted a retrospectiveevaluation of the relevant clinical data. Studied variablesincluded the time interval between surgical treatment andthe relapse of symptoms, the frequency of bowel move-ments, the need for oral laxatives or enemas, and the oc-currence of fecal impaction.Anastomotic level was evaluated through proctologicexamination including rectal endoscopy.Barium studies were conducted in all patients. Mobili-zation of the splenic flexure was assumed when a reason-90CLINICS 2007;62(1):89-92Recurrence of chagasic megacolon after surgical treatmentAraujo SEA et al.able distance between the barium inside the distal trans-verse colon/left colon and left diaphragmatic dome couldbe observed associated with a finding of no acute colonicangle at that site. Although subjective, our experience withthis rule held largely true when we performed redo opera-tions, mostly for rectal cancer recurrence.Total colonic transit time with radiopaque markerscould be assessed in 7 patients. Five days after ingestionby mouth of one Sitzmarks® (Konsyl Pharmaceuticals,Edison, NJ, USA) capsule, a flat plate abdominal radio-graph was obtained.15The mean time interval between elective surgical treat-ment and symptomatic recurrence was 17.7 years (11-23years). For those patients with a clinical diagnosis of symp-tomatic recurrence, the frequency of evacuations was 1.2(0-2) bowel movements per week. Use of enemas or orallaxatives was reported by 9 (90%) patients. A highcolorectal anastomosis was observed through endoscopy in4 (40%) patients but could not be identified during rectaldigital examination in any patient. Fecal impaction lead-ing to urgent medical assistance was observed in 5 (50%)patients.Radiological evaluation (barium enema) showed dila-tion of the remnant left colon in 8 (80%) patients, and pan-megacolon in 2 (20%). Mobilization of the splenic flexurecould be radiologically confirmed in only 2 (20%) patients.Total colonic transit time as determined using radio-paque markers could be performed for 7 patients. For allof them, colonic transit time was prolonged. The patternof outlet obstruction was verified in all patients. Since therewas no bowel movement for any patients after a 5-day in-terval, all 24 markers could be observed accumulated inthe left quadrant above the sacral promontory.DISCUSSIONSeveral techniques for surgical treatment of chagasicmegacolon have been developed. Best results have beenobtained when the rectum is partially or totally bypassed,since as is well known, the rectum can act as an obstacleto intestinal transit.8The Duhamel-Haddad technique is probably the mostpopular operation among Brazilian surgeons, although fewinstitutions have significant experience with the techniquefor various reasons.16,17 The procedure avoids pelvic andperineal dissection of the rectum, common to other pull-through procedures such as Swenson´s and Soave´s opera-tions, by making an anastomosis between the nondilatedcolon and the posterior wall of the lower rectum. Thus, theDuhamel-Haddad procedure is an option adopted in accord-ance with the most accepted throry on the pathophysiol-ogy of the disease, namely sigmoid-rectal dyskinesia.3,5,8Recurrence after this operation is quite rare, and compli-cations after it—urinary retention, erectile dysfunction, soil-ing, and rectal stump fecaloma—occur in a profile that isvery similar to, but more rare than that observed after otherpull-through procedures (Cutait and Swenson techniques).7,8Although abdominoperineal retrorectal pull-through re-section with delayed or immediate anastomosis is an ef-fective alternative, significant morbidity and complicationsmay eventually lead to death or permanent colostomy. Thisis probably the main reason why many surgeons have de-cided not to embrace an otherwise popular but technicallydifficult operation. Necrosis of the pulled-through colonsegment and anastomotic site are by far the most commoncomplications, and in our experience, when they occur, per-manent colostomy becomes the ultimate solution.Because of the considerations mentioned above, our in-stitution has adopted (since 1989) as surgical treatment forchagasic megacolonthrough an exclusively abdominal op-eration performed in 1 stage. For patients who do requiresurgery, an anterior resection is performed. Reconstructionis accomplished through an end-to-side mechanicalextraperitoneal posterior colorectal anastomosis performed5 to 7 cm above the anal verge. A laparoscopic access iscommonly used at our institution. Since we initiated ourexperience with this operation, we have observed virtuallyno recurrences; it must however be pointed out that an in-complete follow-up may have occurred for some patients,because Brazil is a large country and many patients leaveSão Paulo after improvement of their bowel function, re-sulting in loss of follow-up.7Recurrence after elective surgical treatment of chagasicmegacolon represents a clinically complex situation. To thebest of our knowledge, there are no indexed publicationsthat address the issue of recurrence after it; moreover, thereare no standard protocols for the evaluation of patients withrecurrent constipation after surgical treatment of chagasicmegacolon. For instance, patients who present with symp-tomatic recurrence are no longer young, and clinicalcomorbidities that may or may not be related to chagasicstatus (such as cardiac disease, for instance) contribute toan additional risk for a surgical solution. Furthermore,reoperation incurs the need for pelvic dissection; eventhough this occurs in the clinical scenario of a benign dis-ease, construction of a safe distal colorectal or coloanalanastomosis may not be a simple task.In order to better understand the clinical picture, we ret-rospectively evaluated a cohort of patients with chagasicmegacolon who underwent elective surgical treatment andpresented with symptomatic recurrence.We could not obtain accurate data regarding the type91CLINICS 2007;62(1):89-92 Recurrence of chagasic megacolon after surgical treatmentAraujo SEA et al.of operation and extent of resected colon segment for thesepatients, since they did not undergo the first surgical treat-ment in our institution.According to our results, the mean time interval until di-agnosis of recurrence was 17.7 years (range, 11-23 years).This result indicates that sigmoidectomy may be an effec-tive option only for older patients with chagasic megacolon(which seems to be the case for this cohort of patients), sinceit is an operation associated with less morbidity than abdomi-noperineal operations, and recurrence is a late complication.Although patients could tolerate poor bowel functionsuch as 1 bowel movement per week leading to the needfor laxative and enema practice in 90% of cases, fecal im-paction usually demanded medical assistance and was a fre-quent complication for 50% of the studied population. Infact, fecal impaction was the most important single reasonthat drove these patients to nonurgent medical attention.Information obtained from the proctologic evaluationled to the conclusion that for this cohort of patients, therectum was neither resected nor bypassed. A high colorectalanastomosis could be identified at proctoscopic evaluationin 4 (40%) patients, and for none of the 10 patients wasthe anastomosis within reach of an examining finger.Radiological evaluation confirmed the clinical suspicionof recurrence, since findings of dilated colon with no evi-dence of anastomotic stenosis were observed in all cases.Dilation of the left colon above the presumed anastomosiswas the most common finding, although pan-megacolon wasalso observed. Observation of an intact splenic left flexurein most (80%) of the patients confirmed suspicion of a pre-vious economic left colon resection. Colonoscopic evalua-tion could be performed for only 2 (20%) patients, since itwas judged not routinely necessary for this analysis.In order to obtain an objective picture regarding the rea-son for recurrent constipation, we performed a colonic tran-sit time study, even though there is no published experi-ence with this matter. For our patients, total colonic tran-sit time was available for 7 patients and was significantlyprolonged, being longer than 5 days. There was no bowelmovement for any of these patients, and an accumulationin the left colon of the radiopaque markers was observed.This observation in patients with recurrent chagasic mega-colon is similar as that for patients with the condition priorto surgical treatment, indicating that sigmoidectomy rep-resents an option that is undertaken with physiologic un-derstanding of the occurrence of constipation in such pa-tients. After this case study, we still cannot recommend aroutine colonic transit time study for patients with recur-rent chagasic megacolon, since its results may not alter thesurgical strategy for a redo operation of construction of alow colorectal anastomosis.Clinical, radiological, and functional evidence obtainedfor 10 patients with recurrent chagasic megacolon afterelective surgical treatment indicate that symptomatic recur-rence was a late complication after elective surgical treat-ment and could be radiologically confirmed in all cases.The combination of an intact left flexure with an anasto-mosis that was not reachable by digital examination wasobserved in most (80%) of patients who entered this study,indicating that sigmoidectomy was the surgical option of-fered to these patients. Although associated with low mor-bidity and temporary good results, sigmoidectomy did notmodify the results of the colonic transit time study for thesepatients with chagasic megacolon.REFERENCES1. OMS. Wkly Epidemiol Rec. Chagas disease, Brazil. 2000;75:153-5.2. Jorge JMN, Habr-Gama A, Yusuf SA, Bocchini SF, Araujo SEA.Physiologic investigation of constipated patients with chagas disease.Colorectal Disease Supplement 2001; 3 (Suppl 1):86.3. Raia AA. Pathogenesis and treatment of acquired megacolon. Surg GynObstet. 1955;101:69-74.4. Meneghelli UG. Chagasic enteropathy. Rev Soc Bras Med Trop.2004;37:252-60.5. Ribeiro U Jr, Safatle-Ribeiro AV, Gama-Rodrigues JJ, Sohn J, ReynoldsJC. Effect of Chagas’ disease on nitric oxide-containing neurons inseverely affected and unaffected intestine. Dis Colon Rectum.1998;41:1411-7.6. Kiss DR: An electron microscope study of the smooth muscle cell inacquired and congenital megacolon. Rev Inst Med Trop São Paulo.1972;14:178-90.7. Habr-Gama A, Kiss DR, Bocchini SF, Teixeira MG, Pinotti HW. Chagasicmegacolon. Treatment by abdominal recto-sigmoidectomy withmechanical colo-rectal termino-lateral anastomosis. Preliminary results.Rev Hosp Clin Fac Med São Paulo. 1994;49:199-203 (In Portuguesewith English abstract).8. Cutait DE, Cutait R. Surgery of chagasic megacolon. World J Surg.1991;15:188–97.9. Moreira H. Tratamento cirúrgico do megacólon chagásico pela técnicade Duhamel-Haddad: experiência pessoal. Arq Gastroenterol.1971;8:185-90 (In Portuguese with English abastract).10. Reis Neto JA. Resultados tardios da operação de Duhamel no tratamentodo megacólon adquirido. Rev Med Bras. 1972;18:57 (In Portuguese).11. Habr-Gama A, Bocchini SF, Kiss DR, Sousa Jr AHS.Retossigmoidectomia abdominal com anastomose mecânica colorretalna parede anterior do reto para cirurgia do megacólon. Rev Bras Proct.1990;10:38 (Suppl. 1) (In Portuguese with English abstract).92CLINICS 2007;62(1):89-92Recurrence of chagasic megacolon after surgical treatmentAraujo SEA et al.12. Gama RC, Costa JH, Azevedo IF. Tratamento cirúrgico do megacólonchagásico pela técnica de Duhamel-Haddad. Experiência no HospitalGeral de Goiânia. Rev Bras Colo-Proct. 1986;6:84-8 (In Portuguesewith English abstract).13. Pinheiro HB. Abordagem cirúrgica do megacólon chagásico –experiência pessoal. Rev Bras Colo-Proct, 1990;35:21-4 (In Portuguesewith English abstract).14. Lins Neto MAF. Duhamel modified surgery with immediate colorectalanastomosis for the treatment of the chagasic megacolon: techniqueand results. Rev Bras Colo-Proct. 1999;19:263-2.15. Jorge JMN, Habr-Gama A. Tempo de trânsito colônico total e segmentar:análise crítica dos métodos e estudo em indivíduos normais commarcadores radiopacos. Rev Bras Colo-Proct. 1991;11:55-60 (InPortuguese with English abstract).16. Kiss DR, Habr-Gama A, Pinotti HW. Chagas’megacolon: considerationson new physiopathological perspectives. Rev Paul Med, 1986;104:145-55 (In Portuguese with English abstract).17. Netinho JG, Cunrath GS, Ronchi LS. Rectosigmoidectomy with ilealloop interposition: a new surgical method for the treatment of chagasicmegacolon. Dis Colon Rectum. 2002;45:1387–92.

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Recurrence of chagasic megacolon after surgical treatment: clinical, radiological, and functional evaluation

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