Rectal and Pouch Recurrences After Surgical Treatment for Familial Adenomatous Polyposis

Familial adenomatous polyposis (FAP) is a genetic disease characterized by multiple adenomatous colorectal polyps and different extracolonic manifestations (ECM). The present work is aimed to analyze the outcome after surgical treatment regarding complications and cancer recurrence. Charts from patients treated between 1977 and 2006 were retrospectively analyzed. Clinical and endoscopic data, results of treatment, pathological reports and information about recurrence were collected. Eighty-eight patients (41 men [46.6%] and 47 women [53.4%]) were assisted. At diagnosis, associated colorectal cancer (CRC) was detected in 53 patients (60.2%), whose average age was higher than those without CRC (40.0 vs. 29.5 years). At colonoscopy, polyposis was classified as attenuated in 12 patients (14.3%). Surgical treatment consisted in total proctocolectomy with ileostomy (PCI, 15 [17.4%]), restorative proctocolectomy (RPC, 27 [31.4%]), total colectomy with ileal-rectum anastomosis (IRA, 42 [48.8%]), palliative segmental resection (1 [1.2%]) and internal bypass (1 [1.2%]). Two patients were not operated on due to religious reasons and advanced disease. Complications occurred in 25 patients (29.0%), more commonly after RPC (48.1%). There was no operative mortality. Local or distant metastases were detected in six (11.3%) patients with CRC treated to cure. During the follow-up of 36 IRA, cancer developed in the rectal cuff in six patients (16.6%), whose average age was higher than in patients without rectal recurrence (45.8 vs. 36.6 years). Five of them have had colonic cancer in the resected specimen. Among the 26 patients followed after RPC, cancer in the ileal pouch developed in 1 (3.8%). (1) Within the present series, FAP patients presented a high incidence of associated CRC and diagnosis was generally established after the third decade of life; (2) operative complications occurred in about one third of the patients, being more frequent after the confection of an ileal reservoir; (3) rectal cancer after IRA was detected in 16.6% of patients and it was associated with greater age and previous colonic carcinoma; (4) both continuous and long-term surveillance of the rectal stump and ileal pouch are necessary during follow-up.

Colorectal cancer in familial adenomatous polyposis: Are there clinical predictive factors?

Background: Familial Adenomatous Polyposis (FAP) is a hereditary disorder with multiple colorectal polyps that exhibit an almost inevitable risk of colorectal cancer (CRC) in untreated patients. Goals: To evaluate clinical features related to CRC risk at diagnosis. Material and methods: Charts from 88 patients were reviewed to collect information regarding age, family history, symptoms, polyposis severity and association with CRC. Results: 41 men (46.6%) and 47 women (53.4%) were assisted. CRC was detected in 53 patients (60.2%), with a frequency of 9.1% under 20 years, 58% between 21-40 and 85% over 41 years of age. Average age of patients without CRC was lower at treatment (29.5 vs. 40.0 years; p=0.001). Family history was reported by 58 patients (65.9%), whose average age did not differ from those who didn`t report it (33.4 vs. 34.4; p=0.17). Asymptomatic patients comprised 10.2% of the total; in this group, CRC incidence was much lower when compared to those presenting symptoms (1.1% vs. 65.8%; p=0.001). Patients without CRC presented a shorter length of symptoms (15.2 vs. 26.4 months; p=0.03) and less frequent weight loss (11.4% vs. 33.9%; p=0.01). At colonoscopy, polyposis was classified as attenuated in 12 patients (14.3%), who presented greater average age (48.2 vs. 33.3 years; p=0.02) and equal CRC incidence (58.3% vs. 58.3%; p=0.6) when compared to those with classic polyposis. Conclusions: The risk of CRC in FAP patients 1) increases significantly after the second decade; 2) is associated with higher age, weight loss, presence and duration of simptomatology; 3) is similar in patients with attenuated or classic phenotype. (C) 2010 AEC. Published by Elsevier Espana, S.L. All rights reserved.

Intestinal mucosa-associated microflora in ulcerative colitis patients before and after restorative proctocolectomy with an ileoanal pouch

PURPOSE: This study was designed to identify the mucosa-associated microflora in patients with severe ulcerative colitis before and after restorative proctocolectomy with ileoanal pouch construction in comparison with historic controls. METHODS: Ten patients with a diagnosis of ulcerative colitis were evaluated. Mucus was collected during colonoscopy from all segments of the colon and terminal ileum before surgery, and from the ileal pouch two and eight months after ileostomy closure. The prevalence and mean concentration of the mucosa-associated microflora were compared over time and with historic controls. RESULTS: Veillonella sp was the most prevalent bacterium in patients and controls. Klebsiella sp was significantly more prevalent in the ileum of controls, was not found in patients with ulcerative colitis, and after proctocolectomy returned to values found in controls. Some bacteria such as Enterobacter sp, Staphylococcus sp (coag-), Bacteroides sp (npg), Lactobacillus sp, and Veillonella sp had higher mean concentrations in the ileal pouch of patients after surgery than in controls. CONCLUSION: No bacterium was identified that could be exclusively responsible for the maintenance of the inflammatory process. The mucosa-associated microflora of patients with ulcerative colitis underwent significant changes after proctocolectomy with ileal pouch construction and returned to almost normal values for some bacteria.

Evolução dos doentes com citologia oncótica alterada e colposcopia anal normal

A citologia anal vem sendo usada para rastreamento do carcinoma anal e suas lesões precursoras nas populações de risco. Quando o raspado do canal anal mostra alterações citológicas está indicada o exame com colposcópio e ácido acético para identificar e realizar biópsia para confirmar o achado. Poucos estudos mostram o seguimento dos doentes tratados de condilomas acuminados perianais. Temos usado os métodos em associação e encontrado lesões subclínicas em metade dos doentes, cujo exame proctológico não revelava doença HPV induzida. Essas lesões são tratadas com tópicos. Entretanto, algumas citologias estavam alteradas e a colposcopia anal não revelou doença HPV induzida. O objetivo deste estudo foi observar o comportamento dessas lesões no seguimento semestral, durante 12 meses, e avaliar se a periodicidade da reavaliação foi suficiente para evitar o aparecimento das lesões de alto grau ou superior. Encontramos 58 (21%) entre 273 doentes nessas condições. As reavaliações de 22 deles após um ano mostraram que as colposcopias permaneceram normais em 17 (74%), sendo que em cinco (22%) a citologia voltou aos padrões normais e 12 (52%) persistiram com alterações. Os outros seis (26%) desenvolveram lesões clínicas ou subclínicas provocadas pelo HPV. As contagens de linfócitos T CD4 dos doentes HIV-positivos foram inferiores nos doentes cujas lesões progrediram. Os resultados permitiram concluir que as alterações podem progredir ou regredir neste grupo distinto de doentes, sendo relacionada à imunidade, e que o intervalo de seis meses é suficiente para cada reavaliação.

Linfoma ileal primário como uma causa de intussuscepção ileocecal recorrente

INTRODUÇÃO: A intussuscepção ocorre quando um segmento proximal do intestino invagina para dentro do lúmen do segmento distal adjacente. Esta patologia é relativamente comum em crianças, sendo geralmente idiopática, diferentemente do que é evidenciado em adolescentes e adultos, os quais apresentam uma causa orgânica comprovada na maioria dos casos. O linfoma intestinal como etiologia desta patologia é extremamente raro. RELATO DE CASO: Um paciente de 16 anos, masculino, referindo dor abdominal em quadrante inferior direito há 36 horas associada a vômitos e fezes com sangue vivo compareceu em nosso serviço. O exame físico se apresentava dentro da normalidade exceto por uma massa palpável no quadrante inferior direito. A ultra-sonografia abdominal revelou intussuscepção ileocecal. A colonoscopia demonstrou uma massa protuberante proveniente do orifício da válvula ileocecal que foi reduzida, tendo o paciente um alívio completo dos sintomas. Três semanas após, o paciente retornou ao nosso hospital com recorrência dos sintomas. Uma laparotomia exploradora foi realizada evidenciando uma massa polipóide no íleo terminal com intussuscepção para dentro do ceco. Uma colectomia direita ampliada foi realizada. Após exame patológico da peça e estadiamento tumoral, um linfoma de Burkitt primário foi diagnosticado. A recuperação pós-operatória não apresentou intercorrências e o paciente foi encaminhado para quimioterapia adjuvante.

A new genus and two new species of Stevardiinae (Characiformes: Characidae) with a hypothesis on their relationships based on morphological and histological data

Lepidocharax, new genus, and Lepidocharax diamantina and L. burnsi new species from eastern Brazil are described herein. Lepidocharax is considered a monophyletic genus of the Stevardiinae and can be distinguished from the other members of this subfamily except Planaltina, Pseudocorynopoma, and Xenurobrycon by having the dorsal-fin origin vertically aligned with the anal-fin origin, vs. dorsal fin origin anterior or posterior to anal-fin origin. Additionally the new genus can be distinguished from those three genera by not having the scales extending over the ventral caudal-fin lobe modified to form the dorsal border of the pheromone pouch organ or to represent a pouch scale in sexually mature males. In this paper, we describe these two recently discovered species and the ultrastructure of their spermatozoa.

Avaliação manométrica anal de crianças com encoprese

INTRODUÇÃO: A constipação crônica é doença comum na infância, ocorrendo em 5 a 10% dos pacientes pediátricos, considerada a segunda maior causa de procura nos consultórios de pediatria, sendo a encoprese decorrente de constipação grave associada à impactação fecal no reto. Dentre os exames diagnósticos, a manometria anal é utilizada para a avaliação de pacientes com distúrbios funcionais, como a constipação intestinal e a incontinência fecal, em alguns serviços para a avaliação de pacientes com encoprese, pois pode trazer informações sobre o mecanismo evacuatório e possíveis lesões esfincterianas anais. OBJETIVO: Verificar alterações manométricas em pacientes com encoprese. MÉTODOS: Foi realizado estudo de 40 manometrias anais de crianças constipadas com encoprese (G1) e 12 crianças constipados sem encoprese (G2). Foram obtidos os seguintes dados: pressões de repouso, contração e evacuação do canal anal e ampola retal, ponto de maior pressão, reflexo inibitório anal e sensibilidade retal. As manometrias foram realizadas com o aparelho Alacer de perfusão com 8 canais. RESULTADOS: Não foram encontradas diferenças nas pressões de repouso, contração e evacuação do canal anal entre os grupos. Chamou-nos a atenção a ausência de necessidade de maior volume retal para desencadear o reflexo inibitório anal. Não houve diferença da incidência de anismus entre os dois grupos, demonstrando que não se trata de fator importante na manutenção da encoprese, mas sim da constipação. CONCLUSÃO: Não houve necessidade de maior volume para desencadear o reflexo inibitório anal. O anismus não foi diferente entre os dois grupos, não sendo importante na manutenção da encoprese.

Early morphological and histochemical alterations in rats subjected to ileocystoplasty

PURPOSE: To study morphologic and histochemical alterations arising at the ileocystoplasty site. METHODS: Sixteen Wistar female rats were subjected to ileocystoplasty and sacrificed after eight weeks. Material collected was divided into four groups for histological and histochemical studies: Group I (control) - isolated ileum segment removed during ileocystoplasty; Group II - ileoileal anastomosis; Group III - ileovesical anastomosis and Group IV - ileal segment from the neobladder. Histological and histochemical study assessed dysplasia, metaplasia, acute and chronic inflammation, fibrosis, atrophy, hypertrophy, total mucins, sialomucins and sulfomucins. The non-parametric Wilcoxon and Mann-Whitney tests were employed in statistical analysis. RESULTS: None of the groups presented dysplasia. Acute inflammation and atrophy occurred in Groups II, III and IV, not reaching statistical significance. Metaplasia was significant only in Group III (p=0.012). Chronic inflammation, fibrosis and hypertrophy were significant in Groups II, III and IV. There was a significant increase in total mucin content in Group IV (p=0.014) and a reduction in Group III (p=0.016). Increases in sialomucins were observed in samples for Groups III (p=0.003) and IV (p=0.002) along with reduced sulfomucins in samples from Groups III (p=0.013) and IV (p=0.008). CONCLUSION: Ileocystoplasty in female rats caused squamous metaplasia, chronic inflammatory infiltration, fibrosis, hypertrophy, increase in sialomucin content, reduction in sulfomucins, and alterations in total mucin content with statistical significance, as well acute inflammatory infiltration and muscular atrophy with less intensity.

A NOTES Modification of the Transanal Pull-Through

Transanal endorectal pull-through (TAEPT) surgery is primarily performed for rectosigmoid aganglionosis, generally with excellent results. There is evidence that overstretching the anus and tension traction in the sigmoid during the procedure could impair the final continence of the patient. Many researchers suggest the use of small umbilical or laparoscopic access to aid in colon mobilization, thus preventing excessive handling within the anal canal. We assumed that transabdominal mobilization of the sigmoid could be prevented by utilizing the NOTES (natural orifices transluminal endoscopic surgery) technique. We performed a TAEPT with NOTES access of the sigmoid vascular pedicle, keeping the surgery exclusively transanal, which prevented scars in the abdomen and minimized the stretching of perineal structures.

Does bilioenteric anastomosis impair results of liver resection in primary intrahepatic lithiasis?

AIM: To evaluate the long-term results of liver resection for the treatment of primary intrahepatic lithiasis. Prognostic factors, especially the impact of bilioenteric anastomosis on recurrence of symptoms were assessed. METHODS: Forty one patients with intrahepatic stones and parenchyma fibrosis/atrophy and/or biliary stenosis were submitted to liver resection. Resection was associated with a Roux-en-Y hepaticojejunostomy in all patients with bilateral stones and in those with unilateral disease and dilation of the extrahepatic biliary duct (> 2 cm). Late results and risk factors for recurrence of symptoms or stones were evaluated. RESULTS: There was no operative mortality. After a mean follow-up of 50.3 mo, good late results were observed in 82.9% of patients; all patients submitted to liver resection alone and 58.8% of those submitted to liver resection and hepaticojejunostomy were free of symptoms (P = 0.0006). Patients with unilateral and bilateral disease showed good late results in 94.1% and 28.6%, respectively (P < 0.001). CONCLUSION: Recurrence of symptoms in patients with hepaticojejunostomy showed that this may not be the ideal solution. Further studies are needed to establish the best treatment for patients with bilateral stones or unilateral disease and a dilated extrahepatic duct. (C) 2010 Baishideng. All rights reserved.

Prospective randomized controlled trial comparing 2 versions of laparoscopic ileal interposition associated with sleeve gastrectomy for patients with type 2 diabetes with BMI 21-34 kg/m(2)

Background: The objective of the present study was to prospectively evaluate the results of 2 versions of laparoscopic ileal interposition (II) and sleeve gastrectomy (SG) for the treatment of patients with type 2 diabetes mellitus and body mass index of 21-34 kg/m(2). Methods: The laparoscopic procedures were prospectively and randomly performed in 38 patients. Of the 38 patients, 18 underwent the first version (II-SG) and 20 underwent the second version in which a diversion of the second portion of the duodenum was applied (II-DSG) and a segment of ileum was interposed into the proximal duodenum. The groups were comparable regarding age (56 and 50 years); gender (13 men and 5 women and 14 men and 6 women); weight (78 and 86 kg); mean BMI (27 and 29 kg/m(2)); duration of type 2 diabetes mellitus (10.1 and 9.2 years); the presence of dyslipidemia (12 and 8 patients), micro- and macroalbuminuria (9 and 9 patients), hypertension (8 and 15 patients), and retinopathy (5 and 8 patients); and the use of antidiabetic medications and the hemoglobin A1c level (8.6% and 8.4%). All patients were followed up for >= 2 years. Results: The mean hospital stay was 3.4 days for the II-SG and 3.5 days for the II-DSG group. No patient required reoperation. All patients in both groups achieved lower levels of hemoglobin A1c. In the II-SG group. the mean hemoglobin A 1c level was 6.35% (range 4.9-8.1). In the II-DSG group, the mean hemoglobin A 1c level was 5.39% (range 4.2-6.5%). The mean BMI decreased in both groups to 22.2 kg/m(2) in the II-SG group and 22.7 kg/m(2) in the II-DSG group. Normal cholesterol levels (<200 mg/dL) were observed in 95% of the II-SG group and 100% of the II-DSG group. The triglycerides were lower than 150 mg/dL in 73% of the II-SG group and 90% of the II-DSG group after 24 months. Conclusion: Laparoscopic II-SG and II-DSG were safe and effective operations for controlling type 2 diabetes mellitus in a nonobese (BMI 21-34 kg/m(2)) population. (Surg Obes Relat Dis 2010;6:296-305.) (C) 2010 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Improvement in Insulin Sensitivity and B-Cell Function Following Ileal Interposition with Sleeve Gastrectomy in Type 2 Diabetic Patients: Potential Mechanisms

Bariatric surgery in morbidly obese type 2 diabetic (T2DM) patients is associated with high rates of diabetes remission. We investigated the mechanisms of the anti-diabetic effect of the laparoscopic ileal interposition with sleeve gastrectomy (LII-SG) in normal weight (NW), overweight (OW) and obese (OB) T2DM patients. Ninety-four patients (aged 54 +/- 8 years) with long-standing (median 10 years), treated diabetes (median HbA(1c) = 8.6%), who were NW (15), OW (64) or OB (15) based on BMI, underwent LII-SG. Insulin sensitivity and parameters of -cell function were measured from an Oral Glycaemic Tolerance Test pre- and post-operatively. At a median of 13.4 months post-operatively, weight loss averaged 9.4 +/- 1.3, 16.8 +/- 0.8 and 23.2 +/- 1.7 kg in NW, OW and OB subjects, respectively (p < 0.0001). Insulin sensitivity was fully restored (395 [108] vs 208 [99] ml min(-1) m(-2)), fasting insulin secretion rate decreased (68 [52] vs 146 [120] pmol min(-1) m(-2)) and total insulin output increased (52 [26] vs 39 [28] nmol m(-2), all p a parts per thousand currency signaEuro parts per thousand 0.001). -cell glucose sensitivity doubled (37 [33] vs 18 [24] mol min(-1) m(-2) mM(-1), p < 0.0001). The only parameter predicting remission of diabetes was a lower baseline insulin sensitivity (p = 0.005). LII-SG induced changes on T2DM by mechanisms in part distinct from weight loss, principally involving restoration of insulin sensitivity and improvement of -cell function.

Surgical Treatment of Morbid Obesity: Mid-term Outcomes of the Laparoscopic Ileal Interposition Associated to a Sleeve Gastrectomy in 120 Patients

The aim of this study was to evaluate the mid-term outcomes of the laparoscopic ileal interposition associated to a sleeve gastrectomy (LII-SG) for the treatment of morbid obesity. The procedure was performed in 120 patients: 71 women and 49 men with mean age of 41.4 years. Mean body mass index (BMI) was 43.4 +/- 4.2 kg/m(2). Patients had to meet requirements of the 1991 NIH conference criteria for bariatric operations. Associated comorbidities were observed in all patients, including dyslipidemia in 51.7%, hypertension in 35.8%, type 2 diabetes in 15.8%, degenerative joint disease in 55%, gastroesophageal reflux disease in 36.7%, sleep apnea in 10%, and cardiovascular problems in 5.8%. Mean follow-up was 38.4 +/- 10.2 months, range 25.2-61.1. There was no conversion to open surgery nor operative mortality. Early major complications were diagnosed in five patients (4.2%). Postoperatively, 118 patients were evaluated. Late major complications were observed in seven patients (5.9%). Reoperations were performed in six (5.1%). Mean postoperative BMI was 25.7 +/- 3.17 kg/m(2), and 86.4% were no longer obese. Mean %EWL was 84.5 +/- 19.5%. Hypertension was resolved in 88.4% of the patients, dyslipidemia in 82.3%, and T2DM in 84.2%. The LII-SG provided an adequate weight loss and resolution of associated diseases during mid-term outcomes evaluation. There was an acceptable morbidity with no operative mortality. It seems that chronic ileal brake activation determined sustained reduced food intake and increased satiety over time. LII-SG could be regularly used as a surgical alternative for the treatment of morbid obesity.