Laparoscopic versus open total mesorectal excision for stage I-III mid and low rectal cancer: a retrospective 5 years analysis

Introduction. Total mesorectal excision (TME) is the cornerstone of a correct surgical therapy for extraperitoneal rectal cancer. Aim of the study is to evaluate our 5 years experience confronting retrospectively laparoscopic (lap) TME in respect to its laparotomic (open) counterpart. Patients and Methods. 30 patients were treated laparoscopically for stage I-III extraperitoneal rectal cancer and retrospectively compared to a homogeneous group, stratified for sex, age, comorbidities and stage of disease. Results. 30 days mortality was zero for both groups, while morbidity was 20% for the lap group and 36.6% for the open group. Mean lymph nodes harvested was 24 ± 12 for the lap group, 26 ± 14 for the open group (p > 0.05). Five years overall and disease free survival was respectively 82.2% and 81.4% in the lap group, 79.9% and 79.6% in the open group, without statistical significance (p>0.05). Discussion. Minimally invasive TME resulted a safe, effective and oncologically adequate procedure when retrospectively compared to its laparotomic counterpart, with 5 years overall survival and disease free survival reaching no statistical significance compared to the open approach, but with all the advantages of the laparoscopy such as less pain and blood loss, faster recovery, less morbidity and better cosmetics. Conclusions. Our study has retrospectively demonstrated that laparoscopic TME is feasible and oncologically effective, even if it remains a complex minimally invasive procedure, requiring adequate skill. More prospective, randomized studies are necessary to define such a procedure as the new gold standard in treatment of stage I-III extraperitoneal rectal cancer.

3531: Neoadjuvant radiotherapy (RT) combined with capecitabine (Cape) and sorafenib (Sor) in patients (pts) with locally advanced, k-ras-mutated rectal cancer (LARC): A phase I/II trial SAKK 41/08

Background: K-ras mutation is found in up to 40% of LARC. Sor is a multitarget tyrosine kinase inhibitor including raf and VEGFR and has demonstrated radiosensitizing effects. Sor might improve outcome of standard preoperative radio-chemotherapy in patients with k-ras mutated LARC. Methods: Pts with k-ras mutated T3-4 and/or N+, M0 disease by MRI were included. Recommended doses from phase I part consisted of RT 1.8 Gy/day x25 with Cape 825mg/m2bid x 33 in combination with Sor 400mg/d. The primary endpoint for the phase II part was pathological complete response (pCR) prospectively defined as grade 3 (near complete regression) or 4 (complete regression) in the histological grading system according to Dworak (DC). A pCR rate of 8% or lower was considered uninteresting and of 22% or higher was promising. Secondary endpoints included sphincter preservation, R0 resection, downstaging and safety. Results: 54 pts were treated in 18 centers in Switzerland und Hungary, 40 pts were included into the single arm phase II part. Median dose intensity per day was 100.0% for RT, 98.6% for Cape and 100.0% for Sor respectively. pCR rate was 60.0% (95%CI: 43.3%, 75.1%) by central independent pathological review (15.0% DC grade 4; 45.0% DC grade 3). Sphincter preservation was achieved in 89.5%, R0 resection in 94.7% and downstaging in 81.6% of the pts. The most common grade 3 toxicities included diarrhea (15.0%), skin toxicity outside of the RT field (12.5%), pain (7.5%), skin toxicity in RT field, proctitis, fatigue and cardiac ischemia (each 5.0%). Laboratory AEs grade 3/4 were neutropenia (1 pt grade 4; 1 grade 3), creatinine elevation (1 pt grade 3). Conclusions: The combination of Sor to standard RCT with Cape in k-ras mutated LARC tumors is highly active with acceptable toxicity and deserves further investigation.

17-Week Delay Surgery after Chemoradiation in Rectal Cancer with Complete Pathological Response

Neoadjuvant chemoradiation (CRT) followed by curative surgery still remains the standard of care for locally advanced rectal cancer (LARC). The main purpose of this multimodal treatment is to achieve a complete pathological tumor response (ypCR), with better survival. The surgery delay after CRT completion seems to increase tumor response and ypCR rate. Usually, time intervals range from 8 to 12 weeks, but the maximum tumor regression may not be seen in rectal adenocarcinomas until several months after CRT. About this issue, we report a case of a 52-year-old man with LARC treated with neoadjuvant CRT who developed, one month after RT completion, an acute myocardial infarction. The need to increase the interval between CRT and surgery for 17 weeks allowed a curative surgery without morbidity and an unexpected complete tumor response in the resected specimen (given the parameters presented in pelvic magnetic resonance imaging (MRI) performed 11 weeks after radiotherapy completion).

Histologic response after neoadjuvant chemoradiotherapy in locally advanced rectal adenocarcinoma: experience from Sudan.

Background: Locally advanced rectal cancer can be down staged by neoadjuvant therapy and the resultant tumor response can be quantified histologically. This study aimed to assess pathological response of neoadjuvant chemoradiation in patients with locally advanced rectal cancers treated in Wad Medani Teaching Hospital (WMTH) and National Cancer Institute (NCI), Wad Medani, Sudan. Patients and Methods: A total of 36 consecutive patients with locally advanced rectal cancer that were managed in WMTH and NCI during the period from 2006-2011 were reviewed. Preoperative pelvic radiotherapy was delivered. Total of 46 Gray were delivered concurrently with 5- fluorouracil (5-FU) on the first and last week of radiation. Total mesorectal excision of the rectal tumour either by anterior or abdominoperineal resections was planned at 6-8 weeks from completion of preoperative treatment. The pathological response to therapy was assessed by histopathology examination of the surgical specimen. Results: Initial clinical staging of patients revealed 58.3% of them were stage T3/T4N2M0 and 41.7% were stage T3N0M0. Down-staging to stage T1/T2N0M0 was found in 36.1% and stage T3N0M0 in 30.6%. No response was seen in 8.3% of cases with stage T3/T4N2M0 while complete clinical response (no residual) was seen in 25.0%. Complete histological response was observed in 13.8%. Positive lymph-nodes metastasis was confirmed in 8.3% of cases. Conclusion: Neoadjuvant chemoradiation is a reasonable option for cases of rectal cancer and deserves further evaluation.

Rectal inflammatory fibroid polyp in a Nigerian: case report & brief review of literature.

Background: Inflammatory fibroid polyps are very unusual gastrointestinal tumours. Furthermore, their occurrence in the rectum is a rarity indeed. Objective: To document this very rare pathologic entity in a patient from our region of Africa and highlight some pertinent clinical and pathologic aspects of the disease. Case report: We present a 59 year old Nigerian who had neither significant previous medical history nor current complaint and had a routine colonoscopy done. The finding in the rectum was of a small polypoidal mass which was excised whole and whose histopathologic findings were consistent with a diagnosis of inflammatory fibroid polyp. Conclusion: A unique case of rectal inflammatory fibroid polyp in a Nigerian is hereby presented. This, to the best of our knowledge, is the first such documented case from our region of the world. Hence, the entity should be considered in the differential diagnosis of colonic polyps from the continent.

Medición de la eficiencia entre el diagnóstico del chequeo reproductivo por palpación rectal, ecografía y niveles séricos de progesterona

Tesis (Médico Veterinario). -- Universidad de La Salle. Facultad de Ciencias Agropecuarias. Programa de Medicina Veterinaria, 2014

Validación del antígeno prostático específico [PSA] y densidad del PSA [PSAD] en el diagnóstico precoz del cáncer de próstata: Determinación del PSA sérico y PSAD, en correlación con el tacto rectal y ecografía transrectal de próstata para el diagnóstico precoz del cáncer de próstata, Hospital Vicente Corral Moscoso,1999 - 2001. Cuenca-Ecuador

El adenocarcinoma de próstata, es una patología que ha ido ganando espacio en nuestro medio, por esta razón este trabajo de investigación se dedicó al estudio del PSA sérico, importante marcador tumoral y a su método alternativo de interpretación PSAD, para el diagnóstico como son el tacto digital y la ecografía transrectal, de próstata [ETRP]. Se incluyeron en este estudio 63 pacientes hombres mayores de 45 años, con síntomas y signos de protatismo, con PSA igual o mayor a 10 ng/ml, PSAD igual o mayor a 0.15, con alteraciones sospechosas al tacto rectal y a la ecografía transrectal, todos se sometieron a biopsia transrectal de próstata. Se trata de un estudio comparativo cuasi experimental entre los diferentes procedimientos para el diagnóstico precoz del cáncer de próstata. La selección de los pacientes se realizó durante dos años [1999-2000], en la consulta externa de urología del Hospital Vicente Corral Moscoso, valorados por el autor de esta tesis y sus análisis realizados en un solo laboratorio clínico [Hospital de Solca ], y en mismo centro radiológico. De este total de pacientes el 25.39 por ciento presentaron cáncer de próstata, la sensibilidad y especificidad de la PSAD supera en forma significativa a la del PSA sérico, ya que sus valores aumentan en pacientes con lesiones sospechosas al tacto rectal y la ETRP, siendo de utilidad sobre todo en pacientes con PSA entre 4-10 ng/ml reduciendo así el número de biopsias prostáticas negativas. Al relacionar niveles de PSA y PSAD con biopsia prostática se determinó que el PSA tiene una sensibilidad del 87.5 por ciento y una especificidad del 63.82 por ciento, siendo superado por la PSAD que presenta una sensibilidad del 93.75 por ciento y una especificidad del 65.95 por ciento para el diangóstico precoz del cáncer de próstata. Importante decir que toda próstata sospechosa al tacto rectal y a la ETRP, independiente de los resultados del PSA y PSAD debería realizarse biopsia prostática para descartar neoplasia, ya que cerca del 20 por ciento de pacientes con cáncer de próstata localizado presenta un PSA por debajo de 4 ng/ml

Carbapenemase producing enterobacteriacae rectal colonization in dialysis patients: a large monocentric retrospective analysis

Carbapenemase-producing Enterobacteriaceae (CPE) represent a growing global public health concern due to their increasing prevalence and resistance to carbapenems, a group of last-resort antibiotics. Dialysis patients, who often have compromised immune systems, are particularly vulnerable to infections that represent the second cause of death in dialysis’ cohorts. Presenting a rectal colonization by CPE has a significative impact on patients in dialysis? Are there factors that can help us understand which patients are at a higher risk of developing CPE colonization? How can we treat a CPE colonized patient who develop fever? Our study aim to reviews the challenges posed by CPE in dialysis settings and explores current diagnostic, therapeutic, and infection control strategies on a large cohort of dialyzed patients.

Hemorrhagic Shock Secondary To Button Battery Ingestion.

Button battery ingestion is a frequent pediatric complaint. The serious complications resulting from accidental ingestion have increased significantly over the last two decades due to easy access to gadgets and electronic toys. Over recent years, the increasing use of lithium batteries of diameter 20 mm has brought new challenges, because these are more detrimental to the mucosa, compared with other types, with high morbidity and mortality. The clinical complaints, which are often nonspecific, may lead to delayed diagnosis, thereby increasing the risk of severe complications. A five-year-old boy who had been complaining of abdominal pain for ten days, was brought to the emergency service with a clinical condition of hematemesis that started two hours earlier. On admission, he presented pallor, tachycardia and hypotension. A plain abdominal x-ray produced an image suggestive of a button battery. Digestive endoscopy showed a deep ulcerated lesion in the esophagus without active bleeding. After this procedure, the patient presented profuse hematemesis and severe hypotension, followed by cardiorespiratory arrest, which was reversed. He then underwent emergency exploratory laparotomy and presented a new episode of cardiorespiratory arrest, which he did not survive. The battery was removed through rectal exploration. This case describes a fatal evolution of button battery ingestion with late diagnosis and severe associated injury of the digestive mucosa. A high level of clinical suspicion is essential for preventing this evolution. Preventive strategies are required, as well as health education, with warnings to parents, caregivers and healthcare professionals.

Inhibition Of Tumor Necrosis Factor-alpha And Cyclooxigenase-2 By Isatin: A Molecular Mechanism Of Protection Against Tnbs-induced Colitis In Rats.

Isatin, an indole alkaloid has been shown to have anti-microbial, anti-tumor and anti-inflammatory effects. Due to its findings, we evaluated whether this alkaloid would have any effect on TNBS-induced colitis. Animals (male Unib:WH rats, aged 8 weeks old) were induced colitis through a rectal administration of 2,4,6-trinitrobenzene sulphonic acid using a catheter inserted 8 cm into the rectum of the animals. The rats were divided into two major groups: non-colitic and colitic. The colitic group was sub-divided into 6 groups (10 animals per group): colitic non-treated, Isatin 3; 6; 12.5; 18.75 and 25 mg/kg. Our main results showed that the oral treatment with Isatin 6 and 25 mg/kg were capable of avoiding the increase in TNF-α, COX-2 and PGE₂ levels when compared to the colitic non-treated group. Interestingly, the same doses (6 and 25 mg/kg) were also capable of preventing the decrease in IL-10 levels comparing with the colitic non-treated group. The levels of MPO, (an indirect indicator of neutrophil presence), were also maintained lower than those of the colitic non-treated group. Isatin also prevented the decrease of SOD activity and increase of GSH-Px and GSH-Rd activity as well as the depletion of GSH levels. In conclusion, both pre-treatments (6 and 25 mg/kg) were capable of protecting the gut mucosa against the injury caused by TNBS, through the combination of antioxidant and anti-inflammatory properties, which, together, showed a protective activity of the indole alkaloid Isatin.

Resultados da cirurgia de reservatórios ileais em pacientes com doença de Crohn

BACKGROUND: Total rectocolectomy and ileal pouch-anal anastomosis is the choice surgical procedure for patients with ulcerative colitis. In cases of Crohn's disease post-operative diagnosis, it can be followed by pouch failure. AIM: To evaluate ileal pouch-anal anastomosis long-term outcome in patients with Crohn's disease. METHODS: Between February 1983 and March 2007, 151 patients were submitted to ileal pouch-anal anastomosis by Campinas State University Colorectal Unit, Campinas, SP, Brazil, 76 had pre-operative ulcerative colitis diagnosis and 11 had post-operative Crohn's disease diagnosis. Crohn's disease diagnosis was made by histopathological biopsies in nine cases, being one in surgical specimen, two cases in rectal stump, small bowel in two cases, ileal pouch in three and in perianal abscess in one of them. The median age was 30.6 years and eight (72.7%) were female. RESULTS: All patients had previous ulcerative colitis diagnosis and in five cases emergency colectomy was done by toxic megacolon. The mean time until of Crohn's disease diagnosis was 30.6 (6-80) months after ileal pouch-anal anastomosis. Ileostomy closure was possible in 10 cases except in one that had ileal pouch fistula, perianal disease and small bowel involvement. In the long-term follow-up, three patients had perineal fistulas and one had also a pouch-vaginal fistula. All of them were submitted to a new ileostomy and one had the pouch excised. Another patient presented pouch-vaginal fistula which was successfully treated by mucosal flap. Three patients had small bowel involvement and three others, pouch involvement. All improved with medical treatment. Presently, the mean follow-up is 76.5 months and all patients are in clinical remission, and four have fecal diversion. The remaining patients have good functional results with 6-10 bowel movements/day. CONCLUSION: Crohn's disease diagnosis after ileal pouch-anal anastomosis for ulcerative colitis may be usual and later complications such fistulas and stenosis are common. However, when left in situ ileal pouch is associated with good function.

Changes in ruminal fermentation and mineral serum level in animals kept in high temperature environments

In order to evaluate the effect of environmental temperature on ruminal fermentation and on mineral levels of growing ruminants, it was used 12 male calves (initial average weight 82.9 ± 7.7 kg, 100 days of age), were employed in a randomized block design (by weight) experiment, with repeated weight measurement and two environmental temperatures: thermoneutral (24ºC) and heat-stressed (33ºC), during 38 days. The animals exposed to 33ºC presented lower dry matter ingestion, lower T3 (triiodothyronine) serum level, higher ammoniacal nitrogen (NH3-N) level in the rumen liquid, and higher rectal and body temperatures during all the experimental period when compared to the animals kept in thermoneutral environment (24ºC). The animals kept under heat stress environment (33ºC) presented higher calcium serum level, which was the highest on 31st day and the lowest on the 38th day of the experiment; phosphorus level was the lowest during all the experimental period; sodium level was lower on the 17th, 31st and 38th experimental days. Potassium and zinc levels were lower after 24 days; copper level was lower until the 24th day; magnesium level was higher until the 17th day, if compared to the ones from the animals kept in thermoneutral environment (24ºC). The heat-stressed animals presented higher levels of ammoniacal nitrogen in the ruminal liquid and a decrease in the phosphorus, sodium, potassium and zinc serum levels. These results show the necessity of changes on feed management to ruminants in temperatures over the thermal comfort limits so that performance loss is decreased.

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.

Fatores associados à realização dos exames de rastreamento para o câncer de próstata: um estudo de base populacional

O objetivo deste estudo foi analisar a prevalência da realização dos exames de rastreamento para o câncer de próstata em homens com 50 anos ou mais de idade, segundo variáveis socioeconômicas, demográficas, de comportamentos relacionados à saúde e presença de morbidade. O estudo foi do tipo transversal, de base populacional, e as análises estatísticas consideraram o delineamento da amostra. Os fatores associados à não realização dos exames de rastreamento do câncer de próstata, foram: ter de idade menor que 70 anos, ter escolaridade de até 8 anos, renda familiar per capita menor que 0,5 salário mínimo, não ter diabetes, ter limitação visual e não ter ido ao dentista no último ano. O SUS foi responsável pela realização de 41% dos exames de rastreamento do câncer de próstata referidos. Este estudo apontou que apesar da controvérsia sobre e efetividade do toque retal e da dosagem do Antígeno Específico Prostático (PSA) para a detecção do câncer de próstata, parcela significativa da população masculina vem realizando estes exames para os quais existem significativas desigualdades socioeconômicas quanto ao acesso.

Modelo de suprimento sanguíneo do intestino grosso do tamanduá bandeira (Myrmecophaga tridactyla)

Em seis animais adultos Myrmecophaga tridactyla estudou-se o modelo de suprimento sanguíneo do intestino grosso, que é dependente das artérias mesentérica cranial (AMCr) e caudal (AMC). Os espécimes coletados conforme as normas do IBAMA (Instituto Brasileiro do Meio Ambiente e dos Recursos Naturais Renováveis) foram perfundidos com água (40 C), injetados com látex corado, fixados em formol e conservados em solução alcoólica (50%). O mesocólon está disposto na linha sagital mediana e fixa o intestino grosso à parede dorsal do abdome. Derivaram da AMC: a artéria retal cranial, sete a 14 artérias cólicas e uma ou duas artérias ileocólicas, que apresentaram anastomoses de irrigação com a AMCr. A AMC finaliza-se na borda mesocólica das alças intestinais, emitindo ramos cólicos retos a partir das arcadas justacólicas, que penetram na intimidade da musculatura longitudinal. Ao longo do trajeto da AMC foram observadas ilhas arteriais, e a região ileocólica apresentou maior densidade vascular.