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VOLUME 32

APRIL/JUNE

NUMBER 2

Official Journal of the Brazilan Society of Coloproctology FOUNDER Klaus Rebel - RJ Brazil EDITOR IN CHIEF Eduardo de Paula Vieira - RJ Brazil EXECUTIVE EDITOR Juliana Goncalves dos Reis - RJ Brazil COEDITORS João de Aguiar Pupo Neto - RJ Brazil Francisco Sergio Pinheiro Regadas - CE Brazil Helio Moreira Junior - GO Brazil Olival de Oliveira Junior - PR Brazil EDITORIAL BOARD Angelita Habr-Gama - SP Antonio Booz Senna Silva Ferreira - PE Boris Barone - SP Chuan-Gang Fu ‑ China Cláudio Saddy Rodrigues Coy - SP Elísio Meirelles De Miranda - MG Fang Chia Bin - SP Fernando Zaroni Swaybricker - RJ Feza ‑ EUA Flávio Antonio Quilici - SP Flávio Ferreira Diniz - RS Francisco Lopes Paulo - RJ Francisco Sergio Pinheiro Regadas - CE Galdino José Sitonio Formiga - SP Geraldo Magela Gomes da Cruz - MG Giulio Santoro - Italy Guillermo Rosato - Argentina Hélio Moreira - GO Henrique Sarubbi Fillmann - RS João Francsico Xavier Mussnichi - RS João Gomes Netinho - SP Joaquim José Ferreira - RJ José Alfredo dos Reis Junior - SP José Alfredo Reis Neto - SP Brazilian Society of Coloproctology Av. Marechal Câmara, 160 ‑ Conj. 916 / 917 ‑ Edifício Orly CEP 20020‑080 ‑ Rio de Janeiro ‑ RJ Fax (21) 2220‑5803 * Telefone: (21) 2240‑8927 Homepage: http://www.sbcp.org.br * E-mail: sbcp@sbcp.org.br Editorial Production: Zeppelini Editorial Gráfica Prensa

Jose G. Guillem - EUA José Reinan Ramos - RJ José Ribamar Baldez - MA Julio César M. dos Santos Junior - SP Julio Garcia-Aguilar - EUA Karen Delacoste Pires Mallmann - RS Lusmar Veras Rodrigues - CE Maria Cristina Sartor - PR Marvin Corman ‑ EUA Mauro de Souza Leite Pinho - SC Paulo Gonçalves de Oliveira - DF Paulo Roberto Arruda Alves - SP Peter Marcello ‑ EUA Raul Cutait - SP Renato Araújo Bonardi - PR Robert William de Azevedo Bringel - SP Roberto Misici - CE Rogerio Saad Hossne - SP Rubens Valarini - PR Sergio Carlos Nahas - SP Sidney Nadal - SP Sinara Monica de Oliveira Leite - MG Steven D. Wexner ‑ EUA

Secretary: Janilene Andrade Afonso Sociedade Brasileira de Coloproctologia E-mail: sbcp@sbcp.org.br


BRAZILIAN SOCIETY OF COLOPROCTOLOGY – BOARD 2011/2012 PRESIDENT ELECTED PRESIDENT VICE-PRESIDENT GENERAL SECRETARY FIRST SECRETARY SECOND SECRETARY FIRST TREASURER SECOND TREASURER

Luciana Maria Pyramo Costa (MG) Carlos Walter Sobrado Junior (SP) Paulo Gonçalves de Oliveira (DF) Ronaldo Coelho Salles (RJ) Alice Capobiango (MG) Afonso Henrique da Silva e Souza Junior (SP) Diógenes Guilherme Castro Alvarenga (RJ) David de Lanna (MG)

CONSULTING COUNCIL

COMMITTEE OF THE EXPERT TITLE

Arminda Caetano de Almeida Leite (GO) João de Aguiar Pupo Neto (RJ) Renato Valmassoni Pinho (PR) Karen Delacoste Pires Mallmann (RS) Sergio Carlos Nahas (SP) Francisco Lopes Paulo (RJ) Francisco Sergio Pinheiro Regadas (CE)

André da Luz Moreira (RJ) Afonso Henrique B. Moniz de Aragão (RJ) Antonio Lacerda Filho (MG) Carlos Augusto Real Martinez (SP) Rogerio Saad Hossne (SP) Mauro de Souza Leite Pinho (SC) Sthela Maria Murad Regadas (CE) Odorino Hideyoshi Kagohara (SP) Mario Jorge Jucá (AL) Roberto Misici (CE) Antonio Sergio Brenner (PR) Henrique Sarubbi Fillmann (RS) Magda Maria Profeta da Luz (MG) - RELATORA Ilson Geraldo da Silva (MG) Claudia Rosali Esmeraldo Justo (PE)

SCIENTIFIC COMMITTEE Sinara Monica de Oliveira Leite (MG) José luiz Barbieux (RS) Fabio Guilherme Caserta M. Campos (SP)

TEACHING AND MEDICAL RESIDENCY COMMITTEE JOURNAL COMMITTEE Eduardo de Paula Vieira (RJ) Hélio Moreira Junior (GO) Olival de Oliveira Junior (PR)

CLASS DEFENSE COMMITTEE Luiz Alberto Mendonça de Freitas (DF) Marcelo Rodrigues Borba (SP) Sidney Roberto Nadal (SP)

Galdino José Sitonio Formiga (SP) Fernando Cordeiro (SP) Silvio Augusto Ciquini(SP) Fabio Lopes de Queiroz (MG) César de Paiva Barros (RJ) João Batista de Sousa (DF) Paulo Gustavo kotze (PR) Manoel Alvaro de Freitas Lins Neto (AL) Francisco Luis Altenburg (SC) Juvenal da Rocha Torres Neto (SE) Lusmar Veras Rodrigues (CE) Erico Ernesto Pretzel Fillmann (RS) Fernando Zaroni Sewaybricker (RJ) Marlise Mello Cerato (RS) Rubens Valarini (PR)

SBCP DELEGATES AT SBCP TITULAR Sergio Carlos Nahas (SP) Afonso Henrique da Silva e Souza Junior (SP) ALTERNATES Paulo Fernando de Carvalho (RJ) Flavia Rachel Starling Schwanz (ES)


VOLUME

NUMBER

32

2

CONTENTS

IN MEMORIAM José Hyppolito da Silva (1938–2011) Fábio Guilherme Caserta Maryssael de Campos, Galdino José Sintonio da Silva�����������������������������������������������������������������������103 ORIGINAL ARTICLE Multimodal treatment of peritoneal malignancies – results of the implantation in a tertiary hospital Fernanda Elias Ferreira Rabelo, Fábio Lopes de Queiroz, Rodrigo Soares Napoleão do Rego, Breno Xaia Martins da Costa, Paulo Cesar de Carvalho Lamounier, Teon Augusto Noronha de Oliveira, Antônio Lacerda Filho, Rodrigo de Almeida Paiva������������������106 View of the Public Health System users regarding Proctology Alessandro Andrade Simões, Rafael Felix Schlindwein, Maria Gabriela Lazcano Alves Ferreira, Alynne Genovez, Elisa Koerich������������������������������������������������������������������������� 113 Ileal ulcer in asymptomatic individuals. Is this Crohn? Carlos Henrique Marques dos Santos���������������������������������������119 Colorectal resection without mechanical colon cleansing: experience with 54 patients Marcelo Sepúlveda Magalhães Faria, Cervantes Caporossi, José Eduardo de Aguilar-Nascimento�����������������������������������������������123 Comparative study between the free DNA in peripheral blood and TNM staging in patients with colorectal cancer for prognostic evaluation in the university hospital of the State of Alagoas Victor Cardoso Rocha, Raquel Silva Moreira, Manoel Álvaro de Freitas Lins Neto�����������������������������������������������������������������������127 Transanal rectopexy – twelve case studies Rubens Henrique Oleques Fernandes, Tito Armando Rossi�����132 Clinical and epidemiological evaluation of patients with colorectal cancer from Rio Grande do Sul Michelle Fraga Eisenhardt, Fabrine Huwe, Marcelo Luis Dotto, Cátia Severo, Juliana Jornada Fontella, Andreia Rosane de Moura Valim, Helen Tais da Rosa, Cézane Priscila Reuter, Lia Gonçalves Possuelo����������������������������������������������������������� 136

APRIL / JUNE 2012

Staging of colorectal cancer in the private service versus Brazilian National Public Health System: what has changed after five years? Eduardo Brambilla, Marcos dal Ponte, Leonardo Gilmone Ruschel, Henrique Rasia Bosi, Gustavo Lisbôa de Braga, Pedro Guarise da Silva������������������������������������������������������������������������144 Clinical and manometric evaluation of women with chronic anal fissure before and after internal subcutaneous lateral sphincterotomy Silvana Marques e Silva, Viviane Fernandes Rosa, Romulo Medeiros de Almeida, Marcelo de Melo Andrade Coura, Paulo Gonçalves de Oliveira, João Batista de Sousa��������������������������148 Laparoscopic colorectal surgery: what to expect from an initial experience Fábio Ramos Teixeira, Gustavo Ramos Teixeira, Thiago Costa dos Santos, Juvenal da Rocha Torres Neto��������������������������������������154 Experiencing sexuality after intestinal stoma Maria Angela Boccara de Paula, Renata Ferreira Takahashi, Pedro Roberto de Paula�����������������������������������������������������������������������163 CASE REPORT Laparoscopic total pelvic exenteration and perineal amputation with wet colostomy. A case report Juliano Alves Figueiredo, Gustavo Mareli de Carvalho, Rafael Turano da Mota, Vivian Monteiro de Castro, Matheus Matta Machado Duque Estrada Meyer, André Zucollo Barragat�������������������������������������������������������������������������������������175 Cecal diverticulitis or appendicitis. When should I suspect? A case report Ricardo Pastore, Roberto da Mata Lenza, Flávio Batista Rodrigues, Lucas Vieira Tostes, Natalia Cavasini Guerra, Eduardo Crema����������������������������������������������������������������������180 Fibrogenesis and carcinoid tumor – a case report Eduardo Fonseca Alves Filho, Carlos Ramon Silveira Mendes, Marcelo da Silva Barreto, Rogério Souza Medrado de Alcantara���������������������������������������������������������������184


Intestinal obstruction due to malign breast neoplasm and peritoneal carcinomatosis: a case report Flávia Balsamo, Rafael Ferreira Correia Lima, Rodrigo Rocha Batitsta, Galdino José Sitonio Formiga������������������������������������188 Granular cell tumor of colon: a case report Eduardo Brambilla, Marcos Antonio Dal Ponte, Henrique Rasia Bosi, Rodrigo Paese Capra, Pedro Guarise da Silva�����������������193 Hidradenitis suppurativa: literature review and case report Mônica Mourthé de Alvim Andrade, José Roberto Monteiro Constantino, Daniel Martins Barbosa M. Gomes, Flávia Fontes Faria, Rodrigo Guimarães Oliveira, Renata Magali R. Silluzio Ferreira, Geraldo Magela Gomes da Cruz��������������������������������196

SPECIAL SESSION NEWSLETTER – ALACP�����������������������������������������������������202 SERVICES ACCREDITED���������������������������������������������������203


Indexed: Literatura Latino-Americano e do Caribe em Ciências da Saúde (LILACS), Scientific Electronic Library Online (SciELO), SCOPUS, Directory of Open Access Journals (DOAJ)

INSTRUCTIONS FOR AUTHORS Scope and policy

The Journal of Coloproctology (JCOL) publishes articles that contribute to improvements and developments of the medical practice, research and training in Coloproctology and related specialties. Also published in English version, starting in vol. 31, issue 3, 2011. The guidelines are based on the format proposed by the International Committee of Medical Journal Editors (ICMJE) and published in the article Uniform requirements for manuscripts submitted to biomedical journals, which was updated in April 2010 and can be accessed at http://www.icmje.org.

Manuscript categories:

Editorial: manuscript about themes of interest to the historical moment, with repercussion in Coloproctology and related specialties. Original article: research with unprecedented results that add value to Coloproctology. Clinical information: clinical case report, presentation of techniques, methods and devices. Review article: articles from synthesis – systematic review with or without metaanalysis and integrative review. Special article: articles that do not fit the categories above, but of interest to Coloproctology. They will be produced after an invitation from the Editorial Board.

Manuscript originality

The manuscripts may be in Portuguese and English, and they should be published for the first time, submitted exclusively to the Journal of Coloproctology, not to another journal simultaneously, applicable to their texts, figures or tables, either fully or partially, except for preliminary abstracts or reports published in the Annals of Scientific Meetings.

Authorship criteria:

The inclusion of an author in a manuscript submitted for publication is only justified if he/she has significantly contributed, in an intellectual perspective, to the manuscript elaboration. It is assumed that the author participated in at least one of the following phases: 1) study conception and planning, as well as interpretation of evidences; 2) text elaboration and/or review of preliminary and definitive versions; 3) approval of final version. Data collection and indexing are not authorship criteria. Likewise, authors are not technical assistants that perform routine tasks, physicians that refer patients or interpret routine exams and heads of services or departments not directly involved in the study. Special acknowledgments can be made to these people.

Conflict of interest

We request all authors to declare all forms of conflict of interest. Conflict of Interest Statement (www.jcol.org.br ) The absence of conflict of interest should be declared. The author may refer to: Richard S. Beyond conflict of interest; A common problem; Building a convincing case; What should the BMJ be doing? BMJ. 1998;317.

Records of clinical essays

The Journal of Coloproctology supports the guidelines for clinical essay recording issued by the World Health Organization (WHO) and the International Committee of Medical Journal Editors (ICMJE). Articles on clinical essays will be accepted for publication only if an ID number has been assigned by one of the Clinical Essay Records validated according to the criteria established by the WHO and ICMJE, whose addresses are at http://www.icmje.org. The ID number should be displayed at the end of the abstract.

Ethical considerations

In research involving human beings, the authors should submit a copy of the approval issued by the Research Ethics Committee, recognized by the National Research Ethics Commission (CONEP), following the guidelines of Resolution CNS 196/96 from the National Health Council or equivalent agency in the research country. Researches should indicate whether directly or indirectly involve human beings.

Manuscript ownership

Manuscripts are under the sole responsibility of authors, who should sign and submit the Statement of Authorship and Copyright Transfer.

Description of procedures

Each article submitted to the Journal of Coloproctology is first analyzed regarding

the compliance with the Instructions for Authors, and if any noncompliance is detected, it will be not accepted. If approved, it is submitted to the analysis of two evaluators, who will examine it based on the Instrument of Analysis and Opinion, specifically elaborated for such purpose, and will give their opinion regarding the methodological rigor of the approach used in the article. If the opinions disagree, the manuscript is submitted to a third evaluator. Anonymity is ensured during all the evaluation process. The evaluators’ opinions are analyzed by the Editorial Board, which, if required, will indicate the alterations to be made. The studies will be published only after the final approval of the evaluators and Editorial Board. Flowchart for the procedures. (www.jcol.org.br)

Manuscripts format and preparation The identification page

It should contain: a) The article title, in Portuguese and English, which should be concise and informative; it should express the manuscript content with precision. In addition, the title is important for physicians and investigators to find an article in the bibliographical databases after it is published. Please, be sure the title: - Is not a question. - Does not have colon or any punctuation that separates it in two parts. - Does not reaffirm the article type. Ex.: Case Report, Review. - Does not indicate the type of statistical analysis. Ex.: Multivariate Analysis. - Does not include the institution name. Full name of each author and institutional affiliation. Name of the department and institution to which the paper should be attributed. Name, address, e-mail of the corresponding author in charge. Sources of support to study development. For studies presented in scientific meetings, indicate the meeting name, place, date, type of presentation.

Abstract

The second page should have the abstract, in Portuguese and English, with no more than 200 words. For original and review articles, the abstract structure should highlight the study objectives, methods, main results with significant data and conclusions. For clinical information and special articles, the abstract does not need to be structured as mentioned above, but it should contain important information for the study value recognition, as described in details in the publications: Haynes RB, Mulrow CD, Huth EJ, Altman DG, Gardiner MJ. More informative abstracts revisited. Ann Intern Med 1990;113:69-76 Ad Hoc Working Group for Critical Appraisal of the Medical Literature. A proposal for more informative abstracts of clinical articles. Ann Intern Med 1987;106:598-604

Descriptors

After the abstract, specify three to six terms in Portuguese and English that define the study theme. These terms should be based on the Health Science Descriptors (DeCS) published by Bireme and that can be accessed at http://decs.bvs.br, and the Medical Subject Headings (MeSH) of the National Library of Medicine, at http:// www.nlm.nih.gov/mesh/meshhome.html.

Manuscript presentation limits according to the type of article Type of article and maximum number of authors

Abstract

Main text

Figures and tables

References

Editorial

None

900

Original article (8)

200

3000

5

5 30

Clinical information (6)

200

1500

3

20

Review articles (8)

200

5000

8

60

Special articles

200

2000

30

Editorial: the text should have up to 900 words and 5 references.

Original articles:

The text should have up to 3000 words, not including references and tables. It should have up to 5 tables and/or figures. The number of references should not exceed 30.

Their structure should contain the following:

Introduction: it should be brief, defining the studied problem and highlighting its importance and gaps in knowledge.


Method: the methods employed, the population studied, sources of data and selection criteria should be described in an objective and detailed manner. Insert the protocol number of approval of the Research Ethics Committee and inform that the study was conducted according to the ethical standards required. Results: they should be clearly and objectively presented, describing the obtained data only, without interpretations or comments, and, for a better understanding, they may have tables, charts and figures. The text should complement and not repeat what is described in the illustrations. Discussion: it should be limited to the obtained data and results, emphasizing the new and important aspects observed in the study and discussing the agreements and disagreements with previously published studies. Conclusion: it should correspond to the study objectives or assumptions, based on the results and discussion, aligned with the title, proposition and method.

Clinical information

Figures

The illustrations (pictures, charts, drawings, etc.) should be submitted individually. They should be consecutively numbered, with Arabic numerals, in the order of their appearance in the text, and they should be clear enough to enable their reproduction. Photocopies will not be accepted.

Statistical analysis

The authors should demonstrate that the statistical procedures used in the study were not only appropriate to test the study hypotheses, but also correctly interpreted. The levels of statistical significance (ex. p<0.05; p<0.01; p<0.001) should be mentioned.

Abbreviations

Abbreviations should be indicated when they first appear in the text. After that, the full name should not be repeated.

Clinical case reports, presentation of technical notes, methods and devices. They should address questions of interest to Coloproctology and related specialties.

Drug name

Their structure should contain the following

Acknowledgements

Introduction: it should be brief and show the theme relevance. Presentation of the clinical case, or technique, or method, or device: it should be described with clarity and objectiveness. It should present significant data for Coloproctology and related specialties, and have up to five figures, including tables. Discussion: it should be based on the literature. The text should not exceed 1500 words, not including references and figures. Patients’ initials and dates should be avoided, showing only relevant laboratorial exams for diagnosis and discussion. The total number of illustrations and/or tables should not exceed 3 and the limit of references is 20. When the number of presented cases exceed 3, the manuscript will be classified as a Case Series, and the rules for original articles should be applicable.

Review articles:

Systematic review: broad research method, conducted through a rigorous synthesis of results from original studies, either quantitative or qualitative, with the purpose of clearly answering a specific question of relevance to Coloproctology and related specialties. It should include the search strategy of original studies, the selection criteria for studies included in the review and the procedures used in the synthesis of results obtained from reviewed studies, which may or may not include meta-analysis. Integrative review: research method that presents the synthesis of multiple published studies and enables general conclusions regarding a specific area of study, contributing to enhanced knowledge of the investigated theme. It should follow standards of methodological rigor, clarity of result presentation, enabling the reader to identify the real characteristics of studies included in the review. Integrative review phases: elaboration of a guiding question, search strategy, data collection, critical analysis of included studies, integrative review presentation and result discussion. The text should not exceed 5000 words, not including references and tables. The total number of illustrations and tables should not exceed 8. The number of references should be limited to 60.

Special articles

They should have up to 2000 words and 30 references. In all categories, in-text citation of authors should be numerical and sequential, using superscript Arabic numerals in parentheses, avoiding the indication of authors’ names. In-text citations and references mentioned in legends of tables and figures should be consecutively numbered in the order of their appearance in the text, with Arabic numerals (index numbers). Only the reference number should be included, without further information.

Tables

Each table should be submitted in a separate sheet. The tables should be consecutively numbered, with Arabic numerals, in the order of their appearance in the text, with a proper title. They should be cited in the text, without duplication of information. Tables, with their titles and footnotes, should be self-explanatory. Tables from other sources should bring the original references in footnotes.

The generic names of drugs should be used. They should include collaborations of people, groups or institutions that deserve recognition, but that are not considered authors, as well as acknowledgements for financial and/or technical support, etc.

References

They should be consecutively numbered in the order of their appearance in the text and identified with Arabic numerals. They should be presented according to the “Vancouver Style”. The titles of journals should be abbreviated according to the style presented by the List of Journal Indexed in Index Medicus, of the National Library of Medicine, which can be accessed at http://www.nlm.gov/tsd/serials/lji.html. The authors should be sure that in-text citations of references are included in the list of references with exact dates and correctly spelled names of authors. The accuracy of references is the authors’ responsibility. Personal notes, unprecedented studies or studies in progress may be cited when really required, but should not be included in the list of references; only cited in the text or footnotes. Cite up to six authors for each reference. If any reference has more than six authors, cite the six first names, followed by “et al.”. We request texts with lean writing style. Shorter texts involve shorter revision and formatting times, and have higher chances of quick publication. Checklist (www.jcol.org.br) For improved process and enhanced publication quality, we offer a checklist for your self-evaluation.

Submission

Articles may be submitted using one of the three submission forms below:

Online submission

The article should be sent directly via website http://submission.scielo.br/index. php/jcol/index

2 - Submission via E-mail

The article should be sent with the following: - Checklist - Statement of Authorship and Copyright Transfer - The Research Ethics Committee’s approval - Conflict of Interest statement To: jcoloproctol@sbcp.org.br Via Email to: SBCP Av. Marechal Câmara, 160 - sala 916 - Ed Orly 20020-080 - Rio de Janeiro - RJ – Brasil


In Memoriam

José Hyppolito da Silva (1938–2011) Fábio Guilherme Caserta Maryssael de Campos1, Galdino José Sintonio da Silva2 Full Member of the Sociedade Brasileira de Coloproctologia (SBCP); Associate Professor at the Faculdade de Medicina da Universidade de São Paulo (FMUSP); Discipline of Coloproctology at the Hospital das Clínicas at FMUSP (HC-FMUSP) – São Paulo (SP), Brazil. 2Full Member of the Sociedade Brasileira de Coloproctologia (SBCP); Head of the Service of Coloproctology at the Hospital Heliópolis – São Paulo (SP), Brazil. 1

Campos FGCM, Silva GJS. In memoriam – José Hyppolito Da Silva (1938–2011). J Coloproctol, 2012;32(2): 103-105.

Born on March 7, 1938, in the city of São Roque (SP), José Hyppolito da Silva graduated at (Figure 1) the Faculdade de Medicina da Universidade de São Paulo (FMUSP) in 1963 (CRM 11301). He took the first year of medical residency at the Department of Surgery at the Hospital das Clínicas de São Paulo (HC) in 1964. Then, he took the second year at the Department of Gastroenterology, at the 3rd Division of Surgical Practice, headed by Professor Eurico da Silva Bastos. After that, he participated in the Group of Coloproctology, then headed by Professor Daher Elias Cutait, when he also started to help Drs. Felipe José Figlioni, Angelino Manzione and Massahiro Ishimoto, who, according to him, helped consolidate his knowledge in this specialty. However, José Hyppolito always emphasized that Professor Cutait increased his interest in Coloproctology, which led him to become an specialist. Once approved in a contest for assistant physician at the 3rd Division of Surgical Practice in 1967, he decid-

ed to remain in the Group of Coloproctology. And, in the following year, he was approved as a Specialist by the Sociedade Brasileira de Coloproctologia (SBCP). He traveled to London in 1969 to enrich his knowledge, and he attended a training program at the St. Mark’s Hospital, when he had the chance to meet internally renowned professionals, with important roles in the history of Coloproctology, such as Drs. Milligan e Morgan, Lloyd-Davies, Lockhart-Mummery, Avery Jones, Lennard-Jones, Ian Todd, Bussey, Morson, Charles Mann, Thompson, Peter Hawley, Notaras and York-Mason, among others. In this period, he also had the opportunity to attend the Leeds General Infirmary, headed by legendary Dr. John Goligher, and St. Georges’ Hospital of London, the service of Dr. Brian Brooke, who suggested maturation with eversion of ileostomy. He came back to Brazil in 1969, when he was chosen to organize and head the Service of Coloproctology of the Hospital Heliópolis de São Paulo, where he was responsible for the preparation of around 200 resident physicians and interns in this specialty, who became heads of services in São Paulo and other capitals in Brazil. He simultaneously started to perform professional and educational activities at the HC-FMUSP with Drs. Oscar Simonsen, Jorge Haddad and Angelita Habr-Gama. He has many times the supervisor of the Division of Surgery Practice II at the HC-FMUSP and the director of the Service of Colorectal Surgery in the 1980s, replacing the assistant professor. At the HC, he developed graduation and postgraduate activities at FMUSP. Besides his classes and collaborations

Figure 1. José Hyppolito da Silva in 1963, at his graduation ceremony, at the Faculdade de Medicina da Universidade de São Paulo. Submitted on: 12/06/2011 Approved on: 04/26/2012

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José Hyppolito da Silva (1938–2011) Fábio Guilherme Caserta Maryssael de Campos et al.

to several courses, he became professor in charge of the course of Large Bowel Neoplasm from 1984 to 1996. At this institution, he was also responsible for the Outpatient Clinic of Bowel Neoplasms until some years ago. Among his university degrees, José Hyppolito defended his Doctor’s Degree at the Faculdade de Medicina at USP in 1972, with the dissertation Cisto pilonidal sacrococcígeo — contribuição ao tratamento cirúrgico pela técnica de incisão e curetagem (Sacrococcygeal pilonidal cyst — contribution to surgical treatment by incision and curettage)1,2. Later, in 1996, he became the Associate Professor at the same institution3,4. In the Department of Gastroenterology, he participated for many years in the course of the League for Coloproctology Initiation, the course of Updates in Digestive Tract and Coloproctology (Gastrão) Surgery and the Continuing Course of Coloproctology. Besides his constant participation in infirmary activities at the Service of Colorectal Surgery, visiting patients and taking part in general meetings for the discussion of cases, he also helped resident physicians with pleasure during surgical procedures until some time ago. At the HC-FMUSP, we worked in the last decades under the coordination of several full professors, such as Arrigo Raia, Henrique Walter Pinotti, Joaquim GamaRodrigues and Ivan Cecconello. Specifically at the Service of Surgery of the Colon, Rectum and Anus, he worked under the coordination of Professors Daher Elias Cutait, Angelita Habr-Gama, Desidério Roberto Kiss and Sérgio Carlos Nahas. Among his academic activities, he was an advisor in Master’s and Doctor’s Degree dissertations and collaborated to several studies, and, for this reason, he was honored by his colleagues at the postgraduate program conclusion. To illustrate that, quotations of some of his colleagues and students under his advisor work are presented here. Dr. Renato Lupinacci (master’s degree at the EPM in 1983) thanked him for “being a determinant factor in my professional preparation and for valuable suggestions”. For Dr. Raul Cutait (doctor’s degree at the FMUSP in 1987), José Hyppolito “dedicated fraternal attitudes and guidance”. For Dr. Sylvio de Figueiredo Bocchini (doctor’s degree at the FMUSP in 1990), he dedicated “relevant and manifested support”. Dr. Goes (doctor’s degree at the Universidade Estadual de Campinas – UNI-

Vol. 32 Nº 2

CAMP in 1991), defined him as “a master, discerning and clear friend”. Fábio Campos (master’s degree at the FMUSP in 1992) said that he was a “friend with thought identity”. To Dr. Carlos Brunetti (doctor’s degree at the FMUSP in 1994), he dedicated “lessons and attention during the years at the Service”. Antonio Carlos Donoso defined him as “the professor, friend and advisor, an example of professional and human creature, who always guides my path”. Nadim Chater (master’s degree at the FMUSP in 2003) defined him as the “master of great wisdom”. Besides his position as the head of the Service of Coloproctology at the Hospital Heliópolis since 1969, he also had important functions at other institutions. He was professor-collaborator of Coloproctology at the Department of Surgical Practice at the School of Medicine in Taubaté (1972 and 1973) and assistant professor at the School of Medicine in Santo Amaro in 1973. Besides, he performed important functions at the School of Medical Sciences in Santos (since 1973), the School of Medicine in ABC (1975 to 1976) and in Bragança Paulista (1978). In June 2000, he became the coordinator of the “Digestive Tract Surgery” course at the School of Medical Sciences in Santos, with dedication to the graduation course and resident physician program. At this school, he was honored by the 2001 class after so much dedication (Figure 2). After the results of his study developed for the associate professor degree were published, he received the “Pedro de Souza Campos Award” of Coloproctology from the Associação Paulista de Medicina (APM). Later, because of this award, he was invited to be the head of the Department of Coloproctology from the Associação Paulista de Medicina in 1998 and 1999. At this institution, he organized courses in the city of São Paulo and

Figure 2. “Zezo”, in 2001.

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José Hyppolito da Silva (1938–2011) Fábio Guilherme Caserta Maryssael de Campos et al.

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other cities of the State, such as the Course of Coloproctology Update, held at the head office of the APM and that originated the book “Coloproctology Manual”. He had a dynamic scientific activity, with many studies published in Brazil and in international journals, as well as book chapters, as author and coauthor5-8. He contributed to several medical journals as the member of the SBCP Journal Editorial Council, Gastroenterologia e Endoscopia Digestiva (GED) journal, the Brazilian Medical Association journal and the International Journal of Colorectal Disease. Although he was an active member of various medical associations, he was better known within the sphere of the SBCP. In 1990 and 1991, he intensively dedicated to the chairman position, when a congress organized by him gathered more than 700 participants. He was also a member of the International Society of University Colon and Rectal Surgeons (ISUCRS). In the professional perspective, he saw patients in his private office at Rua Frei Caneca and performed surgeries especially at the Hospital Sírio-Libanês de São Paulo, where he also became assistant of the Board and editor of the Research Center. José Hyppolito was called Zezo by his close friends. Everywhere he developed his activities, he was recognized as a cordial, considerate, correct, honest and delicate man. When he requested his retirement at the Hospital Heliópolis, in 1998, he received many manifestations of recognition from students and

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colleagues, “for the example of work and teaching with competence, ethics and dedication for 30 years”. Although he bravely fought for his health in his last year of life, dear Zezo died on Wednesday, September 14, 2011, and was buried in São Roque, his hometown, where Papelaria Silva (a stationery store) still exists, which was owned by his father, Hyppolito da Silva. José Hyppolito dedicated very much to his family, especially to his wife Rosaly (Figure 3), with whom he used to go dancing in social events, such as wedding and congress parties. They have four children: Vanessa, André, Fábio and Marcos Hyppolito (who is a coloproctologist). José Hyppolito is a name of honor and respect, above all, and he leaves well trained disciples, a happy family and, certainly, many people who miss him. One of the saddest phenomena of modern society, especially in the medical area, is the little attention to individually memories. A human being’s memory should be valued and preserved, and that was the reason of this report.

Figure 3. José Hyppolito in 1991, when he was the Chairman of the Sociedade Brasileira de Coloproctologia, with his wife Rosaly.

REFERENCES

6.

Habr-Gama A, Da Silva e Sousa Júnior AH, Nadalin W, Gansl R, Da Silva JH, Pinotti HW. Epidermoid carcinoma of the anal canal. Results of treatment by combined chemotherapy and radiation therapy. Dis Colon Rectum 1989;32(9):773-7. 7. Habr-Gama A, Campos FG, Ribeiro Júnior U, Gansl R, da Silva JH, Pinotti HW. Primary lymphomas of the large intestine. Rev Hosp Clin Fac Med Sao Paulo 1993;48(6):272-7. 8. Campos FG, Habr-Gama A, Kiss DR, Da Silva EV, Rawet V, Imperiale AR, et al. Adenocarcinoma after ileoanal anastomosis for familial adenomatous polyposis: review of risk factors and current surveillance apropos of a case. J Gastrointest Surg 2005;9(5):695-702.

1. Da Silva JH. Surgical treatment of pilonidal cyst by incision and curettage. Rev Hosp Clin Fac Med Sao Paulo 1974;29(4):199-203. 2. Da Silva JH. Pilonidal cyst: cause and treatment. Dis Colon Rectum 2000;43(8):1146-56. 3. Da Silva JH. Linfocintilografia pélvica. Contribuição ao estadiamento pré-operatório do câncer retal [tese]. São Paulo (SP): Faculdade de Medicina da Universidade de São Paulo; 1996. 4. Da Silva JH. Pelvic lymphoscintigraphy: contribution to the preoperative staging of rectal cancer. Rev Hosp Clin Fac Med Sao Paulo 2002;57(2):55-62 5. Cutait DE, Cutait R, De Silva JH, Manzione A, Lourenção JL, Calache JE, et al. Mechanical suture by stapling in colon or ileo-rectal anastomosis for malignant and benign lesions of the large intestine. Rev Hosp Clin Fac Med Sao Paulo 1980;35(2):72-6.

Correspondence to: Fábio Guilherme C. M. de Campos Rua Padre João Manoel, 222, cj 120 – Cerqueira César CEP: 01411-000 – São Paulo (SP), Brazil E-mail: fgmcampos@terra.com.br

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Original Article

Multimodal treatment of peritoneal malignancies – results of the implantation in a tertiary hospital Fernanda Elias Ferreira Rabelo1, Fábio Lopes de Queiroz2, Rodrigo Soares Napoleão do Rego1, Breno Xaia Martins da Costa1, Paulo Cesar de Carvalho Lamounier3, Teon Augusto Noronha de Oliveira4, Antônio Lacerda Filho5, Rodrigo de Almeida Paiva5 Resident in the Coloproctology Service of Hospital Felício Rocho – Belo Horizonte (MG), Brazil. 2Coordinator of Medical Residency at the Coloproctology Service of Hospital Felício Rocho – Belo Horizonte (MG), Brazil. 3Coordinator of the Coloproctology Service of Hospital Felício Rocho – Belo Horizonte (MG), Brazil. 4Former resident of the Coloproctology Service of Hospital Felício Rocho – Belo Horizonte (MG), Brazil. 5Preceptor at the Coloproctology Service of Hospital Felício Rocho – Belo Horizonte (MG), Brazil.

1

Rabelo FEF, Queiroz FL, Rego RSN, Costa BXM, Lamounier PCC, Oliveira TAN, Lacerda Filho A, Paiva RA. Multimodal treatment of peritoneal malignancies – results of the implantation in a tertiary hospital. J Coloproctol, 2012;32(2): 106-112. ABSTRACT: Introduction: Peritoneal carcinomatosis is a condition that may be present in the natural history of colorectal cancer and some other tumors, such as pseudomyxoma peritonei. It has been associated with poor prognosis. The treatment for patients with this condition, up until recently, was systemic chemotherapy or palliative care to relieve the pain and suffering caused by peritoneal dissemination of certain cancers. Promising results, however, have been reported after the implementation of radical cytoreductive surgery followed by peroperative hyperthermic intraperitoneal chemotherapy. Objective: To evaluate the results of cytoreductive surgery and peroperative hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with peritoneal carcinomatosis secondary to colorectal cancer and pseudomyxoma peritonei. Results: We retrospectively evaluated 24 patients from 2004 to 2011. Mean age was 51.31 years, and 54% were female. The primary diagnosis in 50.01% of the cases was pseudomyxoma peritonei, 41.66%, of colon cancer, and 8.33%, of mesothelioma. The overall complication rate was around 83%, two patients (8%) subsequently died between the 8th and 30th postoperative day. There was an association between the peritoneal carcinomatosis index (PCI) and operative time. The one-year survival rate in the group examined was 60% for colon cancer, and 78.5% for pseudomyxoma. Overall survival was 50% in three years. Conclusion: cytoreductive surgery combined with HIPEC is a treatment option for patients with peritoneal carcinomatosis of colorectal origin and pseudomyxoma. Despite the high rate of peroperative complications (83%), it was possible to achieve a superior survival rate in relation to conventional treatments reported in the literature. Keywords: colorectal cancer; drug therapy; pseudomyxoma peritonei; surgery; peritoneum. RESUMO: Introdução: A carcinomatose peritoneal é uma condição que pode estar presente na história natural do câncer colorretal e de algumas outras neoplasias, como o pseudomixoma peritoneal, sendo associada com um prognóstico desfavorável. O tratamento oferecido aos pacientes portadores dessa condição, até recentemente, era a quimioterapia sistêmica ou apenas os cuidados paliativos para aliviar a dor e o sofrimento causados pela disseminação peritoneal de determinadas neoplasias. Resultados promissores, no entanto, têm sido relatados após a implementação da cirurgia citorredutora radical, seguida da quimioterapia hipertérmica intraperitoneal per-operatória. Objetivo: Avaliar os resultados da cirurgia citorredutora e da quimioterapia intraperitoneal hipertérmica per-operatória (HIPEC) em pacientes portadores da carcinomatose peritoneal, secundária ao câncer colorretal e ao pseudomixoma peritoneal. Resultados: Foram avaliados, retrospectivamente, 24 pacientes de 2004 a 2011. A idade média foi de 51,31 anos, 54% eram do sexo feminino. O diagnóstico primário em 50,01% dos casos foi de pseudomixoma peritoneal, 41,66% de câncer de cólon e 8,33% de mesotelioma. A taxa de complicação global girou em torno de 83%, sendo que dois pacientes (8%) evoluíram para o óbito no pós-operatório, entre 8 e 30 dias. Houve associação entre o índice de carcinomatose peritoneal (PCI) e o tempo operatório. A sobrevida em um ano, no grupo analisado, foi de 60% para o câncer de cólon e de 78,5% para o pseudomixoma. A sobrevida global foi de 50% em 3 anos Conclusão: A cirurgia citorredutora combinada com a HIPEC é uma opção de tratamento para pacientes com carcinomatose peritoneal originária de câncer colorretal e de pseudomixoma. A despeito de uma alta taxa de complicação per-operatória (83%) foi possível alcançar uma sobrevida superior a do tratamento convencional relatado na literatura. Palavras-chave: câncer colorretal; quimioterapia; pseudomixoma peritoneal; cirurgia; peritônio.

Study carried out at the Coloproctology Service of Hospital Felício Rocho – Belo Horizonte (MG), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 05/08/2011 Approved on: 06/09/2011

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INTRODUCTION

MATERIALS AND METHODS

Peritoneal carcinomatosis, which is usually considered as the end-stage of many malignant neoplastic diseases, has few treatment options, leading to suffering and fast aggravation of the general status. Conditions such as intestinal obstruction and cachexia appear, and they accelerate death in patients with this condition. Indeed, a compromised peritoneum leads to a reserved prognosis, with mean survival estimated in up to three months for more aggressive tumors, such as diffuse gastric cancer. This condition happens in 25% of colorectal tumors, being present in 8% of the cases at the moment of diagnosis, leading to a mean survival rate of 5.2 months1, if not treated, and 14 to 20 months, with systemic chemotherapy1. In 1982, Dr. Paul Sugarbaker described the cytoreductive surgery (CRS) followed by the peroperative hyperthermic intraperitoneal chemotherapy (HIPEC), and demonstrated an increased survival for different types of tumors with peritoneal compromise. This technique is currently considered as the standard treatment for pseudomyxoma peritonei (PMP), as well as a treatment option for colorectal carcinomatosis, since it provides increased survival, from 30 to 50% in 5 years. As for the carcinomatosis originating from ovarian tumors, gastric cancer and other intraabdominal neoplasms, there is not a well established benefit, being source for clinical studies. In these cases, prognosis, as well as the response to CRS and HIPEC, depend mainly on the selection of patients, besides other factors, such as the histology of the primary neoplasm, the degree of differentiation, the success of cytoreduction and response to the adjuvant systemic chemotherapy (CT). The therapeutic decision addressed by the histological type and primary location of the neoplasm provides the necessary tools to individualize care and select patients with higher chances of having better results with the cytoreductive surgery, with or without HIPEC. This study aims to evaluate the results obtained from patients with neoplasms that compromise the peritoneum who were treated with CRS and HIPEC, all of whom were referred to treatment after all the possibilities of a conventional treatment had been ruled out. The study was approved by the Ethics Committee of Hospital Felício Rocho (CEP-HFR), protocol number 393/11.

The study was conducted at Hospital Felício Rocho from 2004 to 2011. Twenty four patients were included, all of whom were submitted to complete CRS, with or without hyperthermic intraperitoneal chemotherapy. These patients’ data were registered in a specific protocol for follow-up purposes. Data were collected during admission for surgical treatment, subsequent admissions and postoperative outpatient clinic follow-up. Gender, age group, peritoneal carcinomatosis index (PCI), length of surgery, obtained surgical results, histopathological pattern, morbidity, time of admission to intensive care and hospital, and survival rate of treated patients were analyzed. The patients were submitted to preoperative staging in order to analyze the extension of the disease in the abdomen, as well as to rule out distant disease. The presence of resectable liver metastases was not considered as an isolated criterion to contraindicate the procedure. A computed tomography or a nuclear magnetic resonance (NMR) of abdomen and pelvis was performed to evaluate the extension of the abdominal disease. A thoracic tomography was also used to study the distant disease, and in case of dubious lesions, the positron emission tomography was performed (PET-CT). Surgical procedure At first, a balanced general anesthesia was administered and all hemodynamic parameters were carefully monitored. The procedure was performed with a broad median laparotomy for unrestricted access to the abdominal cavity, thus enabling the complete evaluation and detection of possible contraindications to CRS. Afterwards, PCI was analyzed. When necessary, primary tumor resection was performed according to the oncologic criteria (lymph node excision and proper surgical margins). The peritoneum was resected in compromised sites, with high power electrocautery of the remaining tumor granulation, with the objective to extinguish all macroscopic disease. The liver capsule was also resected, when necessary, after the injection of subcapsular air, in order to facilitate dissection and after chemotherapy. Lesions smaller than 3 mm in loops or on visceral surfaces, which are difficult to resect, were cauterized with argon scalpel. 107


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According to CRS criteria, cytoreduction is considered as complete (CRC-0) when there is no macroscopic implant left. In case implants <2.5 mm remain, cytoreduction is considered as CRC-1. When the remaining implants are between 2.5 mm and 2.5 cm: CRC-2; and when they are >2.5 cm, CRC-3. In the analyzed cases, cytoreduction was complete, and no detectable macroscopic lesion remained (CRC-0).

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The obtained results were compared to data from literature, considering as sources the following online data bases: Medline, Embase, PubMed, Cochrane Database of Systematic Reviews and Database of Abstracts and Reviews. Kaplan-Meier test was used to analyze the global survival (GS) stratified by the base disease. RESULTS

Peritoneal chemotherapy In all cases, the “coliseum technique” was used (open technique)1. Mitomycin was applied for most of the cases1, with perfusion time of 90 minutes, being part of the dose at the beginning and the other part on the second half of the time, with the objective to reach a more stable level of chemotherapy during perfusion, and at the same time, maintaining adequate diuresis and temperature between 41 and 43ºC. Drains were left, and the patients were systematically referred to the Intensive Care Unit (ICU). Abdominal drainage was progressively removed when the drainage was reduced to less than 100 mL in 24 hours. The thorax was drained every time the diaphragm was opened, and then the drainage was removed after the patient was taken out of mechanic ventilation due to the risk of pneumothorax for pleural lesion caused by the chemotherapy. Anastomoses and/or the confection of ostomy were performed as soon as possible, regardless of performing intracavitary CT. When the vagina had to be opened, it was sutured before CT in order to avoid burns caused by extravasation of chemotherapeutics in the perineum. In cases of colorectal tumors, in which PCI was higher than 22, surgical resection was contraindicated, except when this index was not well established in literature. In that case, resection was performed even with PCI higher than 30. For those who underwent surgery for more than12 hours, HIPC was performed afterwards, 2 or 3 days after peritonectomy. In one of these cases, CT was not performed due to the patient’s unstable condition.

Characteristics of the patients The characteristics of 24 patients were related to the treatment and its surgical and postoperative analyzed results from 2004 and 2011, retrospectively. Variables such as the histopathological origin of the lesion, PCI, time of surgery, resected organs, presence of anastomoses, used chemotherapeutic, time of intensive care and hospitalization, postoperative complications and presence of recurrence were factors analyzed in the results. Out of the 24 patients, 54% were females, and 40% underwent cytoreduction due to stage IV colorectal neoplasm. Mean age was 51.31 years (Table 1, Graph 1). Surgical procedure PCI was 18.81, in average, ranging from 3 to 39, and mean operating time was 8h and 33 min (Table 2).

Graph 1. Gender of patients.

Table 1. Description of the patients’ age.

Age

Mean

Median

51.31

51.00

Descriptive statistics Standard deviation 13.01 108

Minimum

Maximum

14

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DISCUSSION

At the end of the surgery, all the 24 patients were CRC-0. There was statistical significance between PCI and operating time (p=0.03). The global complication rate was 83%, and the most common ones were: evisceration (33%), abdominal sepsis (25%), pancreatic fistula (17%) and atrial fibrillation (17%). The mean of complications was 18.8% (Table 3).

Carcinomatosis can occur simultaneously with the primary tumor or with the recurrence after surgical resection. In the first case, the dissemination of malignant cells is spontaneous, after the tumor invades the serous membrane or perforates affected organs. In the second case, carcinomatosis can happen even in the absence of angiolymphatic invasion or hematogenous metastasis. The formation of tumor emboli at the peroperative period can be responsible for the implantation in the peritoneum2,3. The beginning of every treatment is based on the fact that carcinomatosis can be considered as a local dissemination of the disease to the peritoneum, instead of a systemic disease, as it was first considered. Since 1980, new methods to treat patients with tumor dissemination to the peritoneum appeared in literature. These patients are difficult to treat, both therapeutically and emotionally, once they are in a context of therapeutic failure, with progressive loss in quality of life4. The peritoneal dissemination of some tumors should be treated as the locoregional progress of the disease1,4,5. Thus, a therapeutic alternative was developed based on the surgical resection of the macroscopic peritoneal disease, followed by HIPEC to treat the remaining microscopic disease. With this therapeutic approach, the significant increase of 5 years in survival rates was reported, in 30 to 50% of the selected group of patients, who were previously considered as end-stage6.

Chemotherapy HIPEC was performed in 21 patients (84%). Out of these, mitomycin was used in 20 cases (95.2%), and 90-minute perfusion was performed in 85.7% of the time. In one patient, it was 75 minutes, and 60 minutes for another one. For one patient, HIPEC was performed with oxaliplatin and irinotecan for 30 minutes, 1 h after peroperative systemic CT with fluorouracil (5-FU) and leucovorin, as standardized by Elias et al.2. Recurrence and survival There was no statistical significance between the presence of complications and the base disease (p>0.05), nor between complications and PCI (p>0.05). Time of intensive care stay was not statistically correlated with PCI. As to survival, however, PCI seems to establish the inverse relation. That is, for the same base disease, in each case, survival was higher and lower than the PCI. The association between survival and diagnosis was demonstrated based on the Kruskal-Wallis test, through the Kaplan-Meier curve (Graphs 2 and 3).

Table 3. Descriptive statistics: types and rates of complications. Complications Rates (%) Evisceration 33 Abdominal sepsis 25 Pancreatic fistula 17 Atrial fibrillation 17 Anastomotic fistula 12 Bleeding 0.4 SIRS 100 Global rate 83

Table 2. Kolmogorov-Smirnov test. PCI n Mean Standard deviation Kolmogorov-Smirnov p-value

24.00 18.81 12.66 0.70 0.70

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Time of surgery (h) 24 8.33 4.02 0.56 0.91

PCI: peritoneal carcinomatosis index.

SIRS: systemic inflammatory response syndrome.

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However, it is worth to mention that CRS is associated with high morbidity rate, so the selective indication and choice of the patients are necessary. In our series, the morbidity and the mortality have been in accordance with the rates described in literature. Most of the cases led to cytoreduction had been diagnosed for 10 months, in average. PCI, unfavorable compromised locations, presence of liver metastases and complete cytoreduction

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can be understood as independent prognostic factors correlated with survival1,4,7,8. Some studies have shown that PCI>13 (in cases of colorectal cancer) and incomplete cytoreduction have a reserved prognosis. Our experience corroborates with the result of these studies, especially concerning the global survival rate. IN these cases, HIPEC also has minimum benefits as to the increased survival, thus being contraindicated.

Graph 2. Global survival in months.

PMP: pseudomyxoma peritonei; CRCa: colorectal carcinoma. Graph 3. Global survival for base disease (in months)

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Table 4. Descriptive statistics of peritoneal carcinomatosis índex per type of complication. Complications No complications CRC Others PMP General

n 3 0 2 5

% 60.0 0.0 40.0 100.0

Severe complications n 0 0 3 3

% 0.0 0.0 100.0 100.0

Total

Other complications n 9 2 7 18

% 50.0 11.1 38.9 100.0

n 12 2 12 26

% 46.2 7.7 46.2 100.0

CRC: colorectal cancer; PMP: pseudomyxoma peritonei.

CONCLUSION

At the end of one year, global survival in our study was 61.1% (Table 4). Despite the heterogeneous volume of cases throughout the analyzed years, we obtained a curve similar to that of major studies that have already been published. As we do not have the 5-year follow-up of all the 24 patients, we discriminated the number of cases according to the follow-up years for the analysis of survival. In this curve, we were also able to reproduce what has already been published in literature, with mean survival of 50% in 5 years. Systemic CT with 5-FU+leucorovin associated with HIPEC with oxaliplatin and irinotecan was used in one patient, who had not responded well to the conventional adjuvant CT scheme. However, she had already presented good response to irinotecan, which was a decisive factor to indicate cytoreduction, thus motivating the adoption of this new scheme2,3. However, it is worth to mention that this sample is small, and the nature of the analysis is purely empirical, in order to create hypotheses, so no definitive conclusion can be made. The presented results suggest that the selective choice of patients that may really benefit from this treatment is essential. In our service, we follow the criteria adopted at the Peritoneal Surface Oncology Group, in 20066.

Peritoneal carcinomatosis has been characterized as an end-stage disease of limited survival and little response to palliative treatment with systemic CT for a long time1,4,9. We can compare the situation of peritoneal carcinomatosis to that of the isolated liver metastases, in which high survival rates can be obtained with surgical resection of the macroscopic disease and subsequent treatment with systemic CT for the microscopic residual disease. The combination CRS+HIPEC to treat for colorectal peritoneal carcinomatosis leads to a survival rate of 5 years, similar to that published for the resection of liver metastases of the same origin9. The standardization of treatment protocols, as well as multicentric studies, have been proposed to better understand this therapy and to optimize clinical results8. CRS+HIPEC are currently doable procedures that tend to increase survival. They represent the potential cure for selected patients who do not dispose of alternatives1,4,9. The results of this study corroborate with the present status, and validate the applicability of this treatment strategy in our service.

REFERENCES

surgery and intraperitoneal chemotherapy. Eur J Surg Oncol 2010;36(5):456-62. 3. Ducreux M, Elias D. Prolonged survival of initially unresectable hepatic colorectal cancer patients treated with hepatic arterial infusion of oxaliplatin followed by radical surgery of metastases. Ann Surg 2010;251(4):686-91. 4. Spiliotis JD. Peritoneal carcinomatosis cytorreductive surgery and HIPEC: a ray of hope for cure. Hepatogastroenterology 2010;57(102-103):1173-7.

1. Sugarbaker PH. Five reasons why cytorreductive surgery plus hyperthermic intraperitoneal chemotherapy must be regarded as the new standart of care for difuse malignant peritonel. Ann Surg Oncol, 2010; 17(6): 1710-2; author reply 1713-14. 2. Elias D, Gilly F, Quenet F. Pseudomyxoma peritonei: a French multicentric study of 301 pacients treated with cytorreductive

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5. Esquivel J, Averbach A, Chua TC. Laparoscopic cytorreductive surgery and hyperthermic intraperitonoeal chemotherapy in patients with limited peritoneal surface malignances: feasibility, morbidity and outcome in early experience. Ann Surg 2011;253(4):764-8. 6. Esquivel J, Sticca R, Sugarbaker P, Levine E, Yan TD, Alexander R, et al Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: a consensus statement. Society of Surgical Oncology. Ann Surg Oncol 2007;14(1):128-33. 7. Yan TD, Black D, Savady R, Sugarbaker PH. A systematic review on the efficacy of cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei. Ann Surg Oncol 2007;14(2):484-92.

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8. Bretcha-Boix P, Farré-Alegre J, Sureda M, Dussan C, Pérez Ruixo JJ, Brugarolas Masllorens A. Cytoreductive surgery and perioperative intraperitoneal chemotherapy in patients with peritoneal carcinomatosis of colonic origin: outcomes after 7 years’ experience of a new centre for peritoneal surface malignancies. Clin Transl Oncol 2010;12(6):437-42. 9. Sugarbaker PH. Peritonectonectomy procedures. Ann Surg 1995;221:29-42. Correspondence to: Fernanda Elias Ferreira Rabelo Serviço de Coloproctologia do Hospital Felício Rocho Avenida do Contorno, 9530 – Barro Preto CEP: 30110-068 – Belo Horizonte (MG), Brazil E-mail: nand8lias@yahoo.com.br

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Original Article

View of the Public Health System users regarding Proctology Alessandro Andrade Simões1, Rafael Felix Schlindwein2, Maria Gabriela Lazcano Alves Ferreira3, Alynne Genovez4, Elisa Koerich4 Coloproctologist; Full Professor Titular of General Surgery at the Universidade do Vale do Itajaí (UNIVALI); Head of Residency in General Surgery of the Hospital e Maternidade Marieta Konder Bornhausen (HMMKB) – Itajaí (SC), Brazil. 2 Resident physician in Coloproctology at the Universidade Federal de Ciências da Saúde de Porto Alegre, Irmandade da Santa Casa de Misericórdia de Porto Alegre (UFCSPA/ISCMPA) – Porto Alegre (RS), Brazil; Former resident in General Surgery at the HMMKB – Itajaí (SC), Brazil. 3Resident physician in Coloproctology at the Hospital de Clínicas da Universidade Federal do Paraná (HC/UFPR) – Curitiba (PR), Brazil; Former resident in General Surgery at the HMMKB – Itajaí (SC), Brazil. 4Academicians in Medical Sciences at UNIVALI – Itajaí (SC), Brazil. 1

Simões AA, Schlindwein RF, Ferreira MGLA, Genovez A, Koerich E. View of the Public Health System users regarding Proctology. J Coloproctol, 2012;32(2): 113-118. ABSTRACT: Proctology is a specialty of extreme importance due to the high prevalence of anorectal diseases in the population. Despite this fact and its history from the origin of humanity, it is marked by insufficient knowledge, prejudice and teasing. Objective: Evaluate the degree of knowledge about Proctology, obtaining data, which may guide and emphasize the need for campaigns to disseminate the specialty. Method: An ecological study was conducted on the people’s degree of knowledge about the specialty of Proctology. We interviewed 200 patients from August 2008 to January 2009, who came to the outpatient clinic of the Unified Health System, in five different medical specialties in the city of Itajaí (SC). Results: Among the interviewees, 86% did not know what proctology was. Of the 28 (14%) respondents that said they knew it, only 21 (10.5%) answered correctly when they were asked what the specialty was about. Conclusion: Despite the high prevalence of anorectal diseases, a great percentage of the population is unaware of the specialty. This fact could be due to the social prejudice and the lack of information provided by health professionals. Keywords: proctology; Unified Health System; patient care. RESUMO: A Proctologia trata-se de uma especialidade de extrema importância devido à alta prevalência de doenças anorretais na população. Apesar de tal fato e de sua história, desde as origens da humanidade, é marcada por déficit de conhecimento, preconceitos e chacotas. Objetivo: Avaliar o grau de conhecimento sobre a Proctologia, obtendo dados, os quais poderão guiar e enfatizar a necessidade de campanhas dirigidas para a divulgação da especialidade. Método: Foi realizado um estudo ecológico sobre o grau de conhecimento das pessoas sobre a especialidade de Proctologia. Foram entrevistados 200 pacientes, no período de agosto de 2008 a janeiro de 2009, que frequentavam o ambulatório do Sistema Único de Saúde da Unidade de Saúde da Família e Comunitária e Posto de Atendimento Médico, em cinco especialidades médicas distintas, no município de Itajaí (SC). Resultados: Dentre os entrevistados, 86% referiram não saber o que é proctologia. Dos 28 (14%) que responderam saber, apenas 21 (10,5%) responderam corretamente quando questionados sobre o que se tratava a especialidade. Conclusão: Apesar da grande prevalência das doenças anorretais, grande parcela da população desconhece a especialidade. Esse fato pode-se dever ao preconceito da sociedade, bem como a própria falta de informação dos profissionais de saúde. Palavras-chave: proctologia; SUS; assistência ao paciente.

Study carried out at the Department of General Surgery at the Universidade do Vale do Itajaí and the Department of General Surgery at the Hospital e Maternidade Marieta Konder Bornhausen – Itajaí (SC), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 07/04/2011 Approved on: 09/09/2011

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View of the Public Health System users regarding Proctology Alessandro Andrade Simões et al.

INTRODUCTION

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In Brazil, proctologists were not well considered by their colleagues from other specialties, who said they were scientifically limited and frequently made jokes and teased them. The most frequent surgical interventions until the 1940s were abscess drainage, anal skin tag removal and fistula with curettage or cauterization to remove so-called hemorrhoid “warts”9. Today, it is one of the most important specialties10. However, this importance is not recognized by most people, due to poor knowledge of this branch, which is observed not only in non-experts, but also in health professionals. The similarity of procto (from proctology) to prostate many times make physicians “confused” and they mistakenly prescribe a proctologic, rather than a urological, evaluation. This “confusion” incurs costs to the health system and the patient, as it takes the patient more time to receive the proper treatment from the specialist. Considering the importance of this specialty and the poor awareness of the population, as well as the lack of scientific studies analyzing the population’s view of proctology, the purpose of this study was to verify the patients’ knowledge of this specialty.

Proctology, from the Greek proktos that means anus , is a medical specialty that deals with disorders of the anus and rectum. As a medical specialty, its history is 5000 years old, with a number of surgical techniques and several surgical instruments developed by ancient people. The history of proctology is marked by several important names and events that expanded and highlighted the specialty, changing it into a defined and recognized specialty2,3. The disorders that affect the lower segment of the digestive tract were first described in 2750 B.C. through Egyptian hieroglyphs. The medical specialties in those days included the Pharaoh’s Guardian of the Anus. Medical sciences were founded on deities and their God was Thoth, who, according to the legend, became an ibis, so he could use his beak to introduce water in the anus of a physician that bathed in the Nile, showing him the benefits of enemas. In 1300 B.C., the Chester Beatty papyri, written by physician Iri, from the 19th dynasty of Egypt, is the first publication exclusively dedicated to anorectal diseases4,5. The father of Medicine, Greek physician Hippocrates, born in 460 B.C., included the treatment of hemorrhoids and anal fistula in his compendiums. In around 165 A.D., Galen described in his book The epidemics several proctologic topics, highlighting: the description of anal muscles, the treatment of hemorrhoids and the use of a specific scalpel in fistula surgeries6. In the medieval period, in 1349 A.D., John Arderne published his Practica Magistri Johannes de Arderne (in Latin), all about proctologic topics3,7. The period of Modern Medicine started in the 19th century, bringing developments to the proctologic surgery4. In Brazil, Proctology started in 1914, with physician Raul Pitanga Santos, from the state of Pernambuco. Pitanga Santos (1892–1984) was the first Brazilian physician to treat anorectal diseases in the country. In 1930, he created the Faculdade de Ciências Médicas with other renowned professors, when the first cathedra of Proctology was instituted in Brazil. He created and manufactured several instruments for the anal surgery practice, e.g., anuscopes, rectoscopes, specula, sclerosis needles, among others that are still used by specialists8. 1

MATERIALS AND METHODS The purpose of this study was to evaluate the variables related to the population’s knowledge of the specialty of Coloproctology. The study was conducted in the city of Itajaí (SC), between August 2008 and March 2009, interviewing 200 people, 100 of them from the outpatient clinic of the Family and Community Health Service (USFC) at the Universidade do Vale do Itajaí (UNIVALI) and 100 from outpatient clinics of health care facilities, all of them were patients of the Unified Health System. The study was conducted at the Services of General Surgery, Family and Community Medicine, Urology, Gynecology, Gastroenterology of the USFC at the UNIVALI and at outpatient clinics of the same specialties in public health care facilities in Itajaí. In each specialty, 20 individuals were interviewed, totaling 100 individuals from each outpatient clinic. The interviewees were randomly selected to answer the study questionnaire. In the first instance, they were informed about this investigation, and then

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they were invited to answer the questionnaire, voluntarily and anonymously. The inclusion criteria were: patients who came to the outpatient clinic of the specialties described above and who fully answered the questionnaire. The exclusion criteria were: incorrectly or incompletely answered questionnaires, patients who already knew the study, people accompanying any interviewee or who were present during the interview with another patient. Knowledge of the specialty was considered present when the patient mentioned the specialty concept or any related pathology. The ethical principles of the National Health Council established in Resolution 196 of 1996 were observed while conducting this study. Mean and standard deviation values were calculated for the description of quantitative variables. The categorical variables were described through absolute (N) and relative (%) frequencies, using the confidence interval of 95% (95%CI). The association between the specialty knowledge and the studied variables was analyzed using Pearson’s χ2 test or Fisher’ s exact test. The differences were considered significant when the value was p≤0.0511. The analyses were performed using Microsoft Excel and EpiInfo 6.04.

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tion, 6 (85.71%) said it was related to prostate and 1 (14.29%) said it was related to the urinary system. Table 1 shows the profile of the interviewees. The 28 patients who said that they knew the specialty were asked about the source of information (Table 2). The options were: media, physician, health professional, literature or others. Among them, 10 (35.7%) people said they had other sources of information, such as a relative and spouse, and 9 actually knew the specialty concept. Media was the second most mentioned source of information; among the 8 (28.57%) interviewees who mentioned it, only 2 answered it correctly. All interviewees who mentioned physician, health professional and literature as their source of information, i.e. 5, 4 and 1 individuals, respectively (p≤0.001), answered it correctly. Table 1. Profile of users interviewed at the outpatient clinics from the Unified Health System in the city of Itajaí (SC). Age <25 25–40 40–60 >60 Gender Female Male Educational level None Primary education High school Higher education Physician in the family Yes No

RESULTS Among the 200 individuals interviewed, 172 (86%) said that they did not know what proctology was. Among the 28 interviewees who answered that they knew what it was, only 21 (10.5% of total) answered correctly when they were asked what the specialty was about (p≤0.001). Among the 7 individuals who gave an incorrect answer to the ques-

n

%

95%CI

31 51 76 42

15 25.5 38 21

10.8–21.3 19.6–32.1 31.2–45.1 15.6–27.3

126 74

63 37

55.9–69.7 30.3–44.1

8 112 59 21

4 56 29 10.5

1.7–7.7 48.8–63.0 23.3–36.3 6.6–15.6

23 177

11.5 88.5

7.4–16.8 83.2–92.6

Table 2. Relation between the source of information of users interviewed at the outpatient clinics from the Unified Health System in the city of Itajaí (SC) and the knowledge of Proctology. Source of information Media Physician Health professional Literature Others Total

n 2 5 4 1 9 21

Yes

% 25 100 100 100 90 75

n 6 0 0 0 1 7

No

115

% 75 0.00 0.00 0.00 10 25

Total sample n % 8 28.57 5 17.86 4 14.29 1 3.57 10 35.71

p-value (Pearson)

0.004


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View of the Public Health System users regarding Proctology Alessandro Andrade Simões et al.

Among the interviewees, 18 individuals had already seen a proctologist; but only 14 (77.78%; p≤0.001) of them actually knew what Proctology was (Table 3). The interviewees who used the Service of General Surgery and Gynecology were those with better information about Proctology (Table 4), corresponding to 6 (15%) people of each service (p=0.492). In the study, 35 people had previously consulted more than 5 specialties; 6 (17.14%) of them knew what Proctology was. Among the 68 patients who had previously consulted from 2 to 5 specialties, only 7 (10.29%) were aware of the specialty. The patients who had previously consulted only 1 specialty totaled 85 individuals and only 7 (8.24%) of them answered it correctly. Therefore, people who have already consulted more than 5 specialties have two-fold chances of knowing what Proctology is, if compared to those who have consulted up to 2 specialties (p=0.353).

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The relation between the specialty knowledge and the age group was not statistically significant (p=0.322). Among the 200 interviewees, 126 (63%) were females, and 12 (9.52%) of them answered it correctly. Among the 74 (27%) men, 9 (12.16%) knew the specialty (p=0.635). As demonstrated in Table 5, the individuals without school education, 8 (4%) of the interviewees, presented higher chance of knowing what Proctology was, when compared to the 112 (56%) primary education patients. The high school patients represented 59 (29.5%) of the interviewees and the higher education patients represented 21 (10.5%) of the interviewees. Among them, those who actually knew it were: 11 (18.64%) and 4 (19.05%) individuals, respectively (p=0.017). Among the interviewees, 23 (11.5%) had a physician in the family and 5 (21.74%) of them knew

Table 3. Relation between previous appointment with a Proctologist and the knowledge of Proctology among users interviewed at the outpatient clinics from the Unified Health System in the city of Itajaí (SC). Previous appointment with a proctologist Yes No Total

n 14 7 21

Yes

% 77.78 3.85 10.50

n 4 175 179

No

% 22.22 96.15 89.50

Total sample n % 18 9.00 182 91.00 200 100

p-value (Pearson)

<0.001

Table 4. Relation between previously consulted specialties and the knowledge of Proctology among users interviewed at the outpatient clinics from the Unified Health System in the city of e Itajaí (SC). Yes No Total sample Variables p-value Specialty (Pearson) n % n % n % General Surgery 6 15 34 85 40 20 Gynecology 6 15 34 85 40 20 Urology 4 10 36 90 40 20 Gastroenterology 3 7.5 37 92.5 40 20 Family Medicine 2 5 38 95 40 20 Total 21 10.5 179 89.5 200 100 0.513 Table 5. Relation between the knowledge of users interviewed at the outpatient clinics of the Unified Health System in the city of Itajaí (SC) regarding Proctology. Educational level No school education Primary education High school Higher education Total

n 1 5 11 4 21

Yes

% 12.50 4.46 18.64 19.05 10.50

n 7 107 48 17 179 116

No

% 87.50 95.54 81.36 80.95 89.50

Total sample n % 8 4.00 112 56.00 59 29.50 22 10.50 200 100

p-value (Pearson)

0.008


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View of the Public Health System users regarding Proctology Alessandro Andrade Simões et al.

what Proctology was, and these interviewees presented a tendency to have two-fold chances of knowing the concept of Proctology (p=0.062).

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The way scientific and non-expert media help construct symbolic contents in health is a cause of concern, as this situation involuntarily collaborates to disinformation, prejudice and, depending on the circumstances, unnecessary alarmist reactions14. Colorectal cancer is the second most prevalent cancer worldwide, after breast cancer, with estimated 2.4 million alive people with diagnosis in the last 5 years. The tendency shows around 943,000 new cases a year15. As the incidence and prevalence of anorectal diseases are high, requiring the colon cancer screening in all population, a great percentage of this population should, at a certain moment, have at least one appointment with a Coloproctologist. However, having such appointment does not ensure knowledge of this specialty if a good physician-patient relation is not real, based on communication, information and empathy. In our study, the patients who reported previous appointment with a Proctologist (22.22%) said that they did not know what Proctology was. The physical examination at a coloproctologic appointment should include the anus and digital rectal exam, and it is an obligation of the physician to inform the patient how it will be performed and its importance, and the patient should provide the permission. According to article 24 of the Code of Medical Ethics16, the physician should ensure the patient’s right to freely decide about him/herself and his/her well-being and use his/her authority to limit it, as well as the patient’s right to freely decide about it (art. 31) after receiving detailed information (art. 34). Then, the Coloproctologist, during the appointment, should ensure the information to the patient, answering any doubt about the specialty and its related diseases. In this study, the investigators also observed that the patients from the Gynecology and General Surgery outpatient clinics presented better knowledge of the specialty. It can be explained by the fact that evaluating the anus and bowel habit is part of the clinical evaluation performed in these specialties. Although primary education patients had less information about the specialty than patients without school education, most interviewees who actually knew it were high school and higher education patients. This information shows the relevance of school education and access to information of the specialty.

DISCUSSION Proctology was recognized as a specialty much later it should be, despite its 5000-year-old history. In addition, the specialty was marked by prejudice and teasing. This way, the poor knowledge of the specialty, as observed in this study, can be one of the consequences of the history of this specialty3. In this study, 14% of the interviewees said that they knew what Proctology was and only 10.5% answered correctly when they were asked what Proctology was about. This result confirms the population’s lack of knowledge about the specialty that treats very prevalent diseases. And it can be a result of the fact that the health professionals do not have knowledge of the specialty and, therefore, are not prepared to refer patients to the Coloproctologist. Another probable reason is that the most prevalent diseases, such as hemorrhoids and fissures, are clinically treated possibly by a general practitioner, and not necessarily by a specialist. The results of this study can also be attributed to the lack of information among the interviewees. This lack of information can be a result of a communication problem between health professionals and between health professionals and patients. Acquiring information means having it permanently available. Regardless of the acquisition process, the informed individual becomes more complex, with his/her elements better differentiated and organized, promoting a negentropic evolution12. The information cannot be disconnect from its meaning and it is valid only if producing effects on the receptor. But, to make it happen, the receptor has to be prepared to effectively answer the transmitted information13. Obviously, the information should not be transmitted in an exhaustive manner, but otherwise be adjusted to each patient’s needs, to reduce the anxiety about and fear of the unknown. A better informed and less anxious seeks for health services more easily and in a correct manner, and are more collaborative during the treatment13. Most patients who answered incorrectly when they were asked what the specialty was about said that their source of information was the media. 117


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View of the Public Health System users regarding Proctology Alessandro Andrade Simões et al.

Proctology has an old history as a specialty, marked by prejudice and poor knowledge of its real importance. Despite some decades of recognition and statistics confirming the high prevalence of morbimortality of anorectal disease, the poor knowledge of this specialty still remains, due to either prejudice, taboo or low school education level. Regarding taboo, the main prohibition is against touching related not only to the immediate physical contact, mas it has as broad extension as the metaphoric use of the expression ‘get in contact with’. Anything that directs the patient’s thought to the forbidden object, placing it in an intellectual contact, is as forbidden as the direct physical contact17. No other area of the contemporaneous life is so full of prohibitions and taboos as the area that deals with hygiene training and typical behaviors of the anal stage17.

incorrectly about the specialty concept. When analyzing such data, the media, many times prejudicial and alarmist, creates symbolic contents in health, promotes taboos and acts as a means of disinformation, instead of having an educational character. During the study, the investigators observed that the patients had some difficulty in addressing a theme related to the anus. The taboo around this theme ends up in prohibitions and restrictions that contribute to lack of communication freedom and, consequently, education to the population. All patients that said that they had physicians or health professionals as their source of information answered correctly when they were asked about the specialty. This fact shows the importance of communication between health professionals and population, as between the health professionals, who should have a broad view of the service provided to the patient, highlighting the relevance of their role of instructors. This role is only effective when the receptor acquires the knowledge and is prepared to benefit from it. Then, we believe that, to start an education process to the population, taboos should be demystified, first among the health professionals, so they can be able to educate the population through a dialog free of prejudice, with access to questioning and exchange of information between health professionals and the population.

CONCLUSION Based on the analysis of data presented in this study, we can conclude that a great percentage of the patients from the Unified Health Service outpatient clinics in the city of Itajaí (SC) does not know what Proctology is. This result probably reflects the Brazilian population profile. The study indicated that the media was the main source of information of the patients who answered

REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

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11. Kirkwood BR. Essentials of medical statistics. London: Blackwell; 1988. 12. Abreu JL. O espaço e o tempo nos signos. Revista Interacções 1997;5:43-64. 13. Rodrigues VMCP.Transmissão e obtenção de informação em saúde. Ciênc Saúde Coletiva 2010;15(5):2639-46. 14. Castiel LD. Insegurança, ética e comunicação em saúde pública. Rev Saúde Pública 2003;37(2):161-7. 15. Inca. Estimativa 2010: Incidência de câncer no Brasil. Rio de Janeiro: Instituto Nacional do Câncer [cited 2010 Out]. Available from: http://www.inca.gov.br 16. Brasil. Conselho Federal de Medicina. Código de ética médica. Brasília (DF); 2010. 17. Freud S. Edição standard brasileira das obras psicológicas completas de Sigmond Freud. Rio de Janeiro: Imago; 1913.

Rey L. Dicionário de termos técnicos de medicina e saúde. 2a ed. Rio de Janeiro: Guanabara Koogan; 1999. Marti MC. The past and future of proctology. Schweiz Rundsch Med Prax 1990;79:889-91. Entralgo L. História universal de la medicina. Madri: Sanvat; 1976. Quilici FA. Colo-proctologia: estórias da História. Rev Bras Coloproct 1994;14(1):43-8. D’Ávila S. Proctologia como especialidade. Rev Bras Coloproct 1995;15(2):78-80. Inglis B. A history of medicine. New York: World; 1965. Lyons A, Petrucelli R. Historia de la Medicina. Barcelona: Doyma; 1984. Cruz GMG. Nomes que fazem a história da coloproctologia. Rev Bras Coloproct 2009;29(3):98-105. Silveira GM. História da coloproctologia na Bahia. Rev Bras Coloproct 2004;24(1):75-7. Rivera CA. História da coloproctologia. Rev Bras Coloproct 1989;9(1):28-31.

Correspondence to: Rafael Felix Schlindwein Rua Frederico Guilherme Busch, 127, apto 601 – Jardim Blumenau CEP: 89010-360 – Blumenau (SC), Brasil E-mail: rafael.schlindwein@hotmail.com

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Original Article

Ileal ulcer in asymptomatic individuals. Is this Crohn? Carlos Henrique Marques dos Santos Assistant Professor, Universidade Federal de Mato Grosso do Sul (UFMS) – Campo Grande (MS), Brazil; Full Member of the Sociedade Brasileira de Coloproctologia. Santos CHM. Ileal ulcer in asymptomatic individuals. Is this Crohn? J Coloproctol, 2012;32(2): 119-122. ABSTRACT: The endoscopic finding of ileal ulcers, alone or in small number, is not usual, but when it occurs in asymptomatic patients, an impasse may be generated regarding the action to be taken, since the medical literature is unclear as to how to proceed in this situation. Objective: Evaluate patients with ileal ulcers, single or in a small number, asymptomatic, and their follow-up. Methods: The author reports a series of asymptomatic cases (23 patients) of ulcers – single or in small number – found in colonoscopy exams performed for other reasons than typical clinical manifestations of Crohn’s disease. Results: Most patients were not treated and remained asymptomatic during the follow-up period. Conclusions: The patients remained asymptomatic and without treatment in most cases, and, considering the small number of cases and the short observation time, this study does not allow to conclude that this is the best practice in case of asymptomatic patients with ileal ulcer. Keywords: Crohn’s disease; ileal diseases; ileum; ulcer; pathology. RESUMO: O achado endoscópico de úlceras ileais, isoladas ou em pequeno número, não é frequente, mas quando ocorre em pacientes assintomáticos pode gerar um impasse quanto à conduta a ser tomada, já que a literatura médica não é clara quanto a como se proceder nessa situação. Objetivo: Avaliar pacientes que apresentaram úlceras ileais solitárias ou em pequena quantidade, assintomáticos e a evolução clínica dos mesmos. Métodos: O autor relata uma série de casos (23 pacientes) assintomáticos que apresentaram úlceras ileais únicas ou em pequeno número em colonoscopias realizadas por outros motivos que não manifestações clínicas típicas de doença de Crohn. Resultados: A maioria dos pacientes não foi tratada e permaneceu assintomática pelo período de acompanhamento. Conclusões: Os pacientes permaneceram assintomáticos e sem tratamento em sua maioria, salientando-se o reduzido número de casos e o curto tempo de observação, de modo a não permitirem a este estudo concluir ser essa a conduta mais acertada frente à pacientes assintomáticos com achado de úlcera ileal. Palavras-chave: doença de Crohn; doenças do íleo; íleo; úlcera; patologia.

INTRODUCTION

tion. Is it really CD? If the patient is asymptomatic, is it correct to start a treatment with possible adverse effects and for undetermined period? If the option is not treating the patient, wouldn’t we be allowing the disease to develop and maybe appear in the future in more severe forms? The situation described in this study has certainly occurred or will occur one day to physicians dedicated to the treatment of intestinal inflammatory diseases (IID). It is one of the various challenging situations related to IID that we should face in the daily practice and whose answers are vague in the current medical literature.

One patient, at the return appointment, brought a colonoscopy exam showing one or more small ulcers in the terminal ileum, and such finding was a surprise, considering that the reasons for the exam did not include the suspicion of Crohn’s disease (DC). Having discarded the other causes for these ulcers, but, without a convincing histopathological confirmation, how should we proceed? While the patient waits for a definition regarding the diagnosis and the treatment to be adopted, many questions are agitating the assistant physician’s mind in this situa-

Study carried out at the Department of Surgical Practice, Faculdade de Medicina Professor Dr. Hélio Mandetta, Universidade Federal de Mato Grosso do Sul (UFMS) – Campo Grande (MS), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 01/09/2012 Accepted on: 01/13/2012

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OBJECTIVE

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Table 1. Main indications for colonoscopy. Indication for the exam Number of patients Hematochezia 7 Abdominal pain 5 Abdominal distension 3 Anal pain 2 Altered bowel habit 2 Pruritus ani 1 Anal secretion 1 Anal fistula 1 Rectal discomfort 1 Anal lesion 1 Fever 1 Vomiting 1 Total 26*

Evaluate patients with ileal ulcers, single or in a small number, asymptomatic, and their follow-up. METHODS The author reports a case series of patients without CD symptoms, but presenting ileal ulcers at colonoscopy. The records of all patients (all adults) were retrospectively analyzed, regarding gender, age, symptoms and/or factors that required the colonoscopy exam, number of ulcers at colonoscopy, indication or non indication of treatment and follow-up. The study excluded patients that had recently used nonsteroidal anti-inflammatory drugs and those with lesions, signs and/or symptoms suggestive of other specific diseases.

*Some patients presented more than one indication for the exam.

Table 2. Number of ulcers found in the colonoscopy exams. Number of ileal ulcers Number of patients 1 19 2 2 3 or more 2

RESULTS From February 9, 2004 to July 1st, 2011, the study analyzed 23 asymptomatic patients (11 male patients, 27 to 74 years old, mean age: 48 years old), whose colonoscopy exam presented ileal ulcers, not including here those patients that had recently used non-steroidal anti-inflammatory drugs and those with lesions suggestive of any specific diseases. The patientsâ&#x20AC;&#x2122; clinical conditions were not at first suggestive of CD; thus, the indications for colonoscopy were varied, and the endoscopic findings were not compatible with initial signs or symptoms. That was the main aspect that led to the description of this case series. The indications for colonoscopy included: hematochezia, pain and abdominal distension, as well as anal pain (Table 1). Regarding the endoscopic findings, ileal ulcers were found, single or in small number, with biopsy performed for the histological analysis, which resulted in unspecific inflammatory process in all cases (Table 2). One patient presented diverticular disease in the sigmoid colon and one patient presented hemorrhoidal disease. No other concomitant finding was reported. All 23 patients received explanations about the possible diagnosis, including the hypothesis of CD, and about the clinical treatment to be adopted. Only four of them decided to take the treatment. Two patients were

prescribed mesalazine 3 g/day and two patients, azathioprine 150 mg/day. Mesalazine was prescribed in the first cases, of 2004 and 2006, when it was the standard treatment. For more recent cases, the option was azathioprine, according to current protocols. Among the four treated patients, one (treated with mesalazine) did not come back and was not found for a new evaluation. The other three patients were reevaluated six months later. One of them (treated with mesalazine) started to present symptoms compatible with CD, the ileal ulcer remained and the treatment had to be altered. Today, this patient is asymptomatic, taking azathioprine. Another patient continues asymptomatic, but with ileal ulcer at colonoscopy. The treatment was interrupted and the patient has been under observation. And the other patient remained asymptomatic, but presented mild colitis at control colonoscopy, and for this reason, is still taking the treatment with azathioprine. Among the 19 patients who did not decide to take the treatment, 8 have not returned and 11 were 120


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Table 3. Progress of patients with ileal ulcers. Patient Treatment Clinical reevaluation 1 Yes, mesalazine Has not returned 2 Yes, mesalazine Symptomatic 3 Yes, azathioprine Asymptomatic 4 Yes, azathioprine Asymptomatic 5 No Asymptomatic 6 No Asymptomatic 7 No Asymptomatic 8 No Asymptomatic 9 No Asymptomatic 10 No Asymptomatic 11 No Asymptomatic 12 No Asymptomatic 13 No Asymptomatic 14 No Asymptomatic 15 No Asymptomatic 16 No Has not returned 17 No Has not returned 18 No Has not returned 19 No Has not returned 20 No Has not returned 21 No Has not returned 22 No Has not returned 23 No Has not returned reevaluated, initially within 6 months on average, and these patients remained asymptomatic. One patient of this group was submitted to a surgery due to anal fistula and presented good progress. Control colonoscopy was performed and six of them still presented ileal ulcers, with the same initial characteristics. Thus, the option was to keep these 11 patients without treatment and under clinical observation (Table 3).

Endoscopic reevaluation Has not returned Ileal ulcer Ileal ulcer Colitis + ileal ulcer Ileal ulcer Ileal ulcer Ileal ulcer Ileal ulcer Ileal ulcer Ileal ulcer Not performed Not performed Not performed Not performed Not performed Not performed Not performed Not performed Not performed Not performed Not performed Not performed Not performed

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Practice Azathioprine No treatment Azathioprine No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment No treatment

only, with unspecific inflammatory alterations that do not allow the pathologist to define the diagnosis1. That does not enable a fully satisfactory answer when we ask if single ileal ulcers in asymptomatic individuals are really manifestations of CD. If we consider that this is the probable diagnosis, how should be proceed? Today, many specialists defend the idea of complete remission with the treatment of CD to prevent recurrence or the development of severe forms of the disease. In this sense, it sounds reasonable to prescribe the treatment to patients in the situation reported in this article. On the other hand, how to convince an asymptomatic patient to use drugs that may cause side effects and especially for undetermined period? The option in the cases of this study was to share with patients the decision on whether to take the treatment or not. As clearly demonstrated, most patients are not encouraged to take a treatment without a certain diagnosis, and especially without any symptom. Perhaps, this is the proper practice, as the follow-up of these patients showed that most of them

DISCUSSION The literature has few articles addressing this situation of asymptomatic patients with ileal lesions compatible with CD. After discarding differential diagnoses, such as intestinal tuberculosis, ulcers related to the use of non-hormonal anti-inflammatory agents and opportunistic diseases, CD appeared as a very probable hypothesis. Histopathological findings of colonoscopic biopsy are not usually conclusive for CD diagnosis when analyzed individually. The collected material is often representative of the mucosa 121


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did not require a treatment, but pointing out that it involved a small number of patients under observation and a short follow-up period. The main study in the literature addressing this theme, and that somehow agrees with such decision is that conducted by Chang et al.2, which evaluated 93 asymptomatic individuals with ileal ulcers for almost 30 months. Among these, 60 had their condition resolved without any treatment and, although 31 remained with lesions at colonoscopy, only 1 progressed to typical symptoms of CD. Olaison et al.3 observed that 22 among 30 patients submitted to ileocolectomy due to CD had ileal ulcers 3 months after the surgery, and among these, 10 presented early recurrence. The ulcers preceded the disease symptoms and the authors believe that this is a pre-clinical presentation of CD. Then, perhaps the ulcers found in asymptomatic individuals may precede more severe forms of the disease, but additional studies monitoring these individuals for longer periods are required to answer this question. As observed in this study, most patients who presented asymptomatic CD remain with no alterations. However, when symptoms start to appear, they progress to CD4. Cosnes et al.5, in a recent study about the natural history of IIDs, report that many individuals

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present latent ileal CD for many years and may even not present it clinically. However, we should consider an important difference between individuals with inflammatory CD starting in the ileum and in the colon. Among those with inflammatory CD starting exclusively in the colon, 80% remain without alteration for 20 years, while those with the disease starting in the ileum tend to progress to more severe forms, with stenoses and fistulas, and, this way, less than 20% of the patients with ileal CD remain without alteration. Therefore, many questions have not been answered regarding the real diagnosis of CD in endoscopic findings of ileal ulcers in asymptomatic individuals, which may be a latent form of the disease. The practice in this situation is still controversial, and additional well designed studies are required to help answer these questions. CONCLUSION Most patients remained asymptomatic and without treatment, but pointing out that the study involved a small number of cases and a short follow-up period, which did not allow to conclude if this is the best practice in case of asymptomatic patients with findings of ileal ulcer.

REFERENCES 1.

Zhou N, Chen W, Chen S, Xu C, Li Y. Inflammatory bowel disease unclassified. J Zhejiang Univ Sci B 2011;12(4):280-6. 2. Chang HS, Lee D, Kim JC, Song HK, Lee HJ, Chung EJ, et al. Isolated terminal ileal ulcerations in asymptomatic individuals: natural course and clinical significance. Gastrointest Endosc 2010;72(6):1226-32. 3. Olaison G, Smedh H, Sjödahl R. Natural course of Crohn’s disease after ileocolic resection: endoscopically visualised ileal ulcers preceding symptoms. Gut 1992;33(3):331-5. 4. Courville EL, Siegel SA, Vay T, Wilcox AR, Suriawinata AA,

5.

Srivistava A. Isolated asymptomatic ileitis does not progress to overt Crohn disease on long-term follow-up despite features of chronicity in ileal biopsies. Am J Surg Pathol 2009;33(9):1341-7. Cosnes J, Gower-Rousseau C, Seksik P, Cortot A. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 2011;140(6):1785-94.

Correspondence to: Carlos Henrique Marques dos Santos Rua XV de Novembro, 1.859 – Vila Esportiva CEP: 79030-200 – Campo Grande (MS), Brazil E-mail: chenriquems@yahoo.com.br

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Colorectal resection without mechanical colon cleansing: experience with 54 patients Marcelo Sepúlveda Magalhães Faria1, Cervantes Caporossi2, José Eduardo de Aguilar-Nascimento3 Associate Professor, Universidade de Cuiabá (UNIC) – Cuiabá (MT), Brazil. 2Assistant Professor, Department of Surgical Practice, Universidade Federal de Mato Grosso (UFMT) – Cuiabá (MT), Brazil. 3Full Professor, Department of Surgical Practice, UFMT – Cuiabá (MT), Brazil.

1

Faria MSM, Caporossi C, Aguilar-Nascimento JE. Colorectal resection without mechanical colon cleansing: experience with 54 patients. J Coloproctol, 2012;32(2): 123-126. ABSTRACT: Introduction: Preoperative mechanical cleansing of the colon has been frequently questioned lately. The purpose of this study was to present the experience of our team with colorectal resection without conventional mechanical preparation of the large bowel. Methods: The study retrospectively evaluated 54 patients (mean age=59 (34–87) years old; 36 (66.7%) females and 18 (33.3%) males) who underwent elective colorectal resections without conventional mechanical preparation of the large bowel at the Hospital Santa Rosa in Cuiabá (MT), from January 2003 to December 2006. Outcome variables were length of stay and postoperative complications. Results: Mortality was 1.8% (one case). Median length of stay was four (2–12) days and mode was three days (n=17; 31.5%). No case of anastomotic dehiscence was observed. Postoperative complications occurred in six patients: serous collection of incision (two cases), partial dehiscence of abdominal wall requiring re-suture (two cases) and prolonged ileus (two cases). Conclusion: As observed in recent literature, routine preoperative mechanical bowel cleansing is no longer justified. Colorectal resection without bowel preparation is safe. Keywords: colorectal surgery; preoperative care; anastomosis, surgical; postoperative complications; intestinal fistula. RESUMO: Introdução: O preparo mecânico pré-operatório do cólon tem sido questionado nos últimos anos. O objetivo deste trabalho foi o de mostrar a experiência do nosso grupo na operação colorretal eletiva sem o uso do preparo convencional do cólon. Métodos: Foram estudados retrospectivamente 54 pacientes (idade mediana=59 anos (34–87 anos), sendo 36 (66,7%) do sexo feminino e 18 (33,3%) do sexo masculino) submetidos a ressecções eletivas do cólon e reto, sem preparo convencional, no Hospital Santa Rosa de Cuiabá (MT), no período de janeiro de 2003 a dezembro de 2006. As variáveis de resultados observadas foram: dias de internação e complicações pós-operatórias. Resultados: A mortalidade foi de 1,8% (um caso). A mediana dos dias de internação foi de quatro (2–12) dias e a moda foi de três dias (n=17; 31,5%). Não foi evidenciado nenhum caso de fístula anastomótica. As complicações pós-operatórias foram evidenciadas em seis (11%) casos: coleção serosa de parede (dois casos), deiscência parcial de parede com ressutura de parede abdominal (dois casos) e íleo prolongado (dois casos). Conclusão: A semelhança dos resultados na literatura recente, a prática mandatória do preparo pré-operatório convencional do cólon pode ser dispensada. A operação de ressecção colorretal sem preparo é segura. Palavras-chave: cirurgia colorretal; cuidados pré-operatórios; anastomose cirúrgica; complicações pós-operatórias; fístula intestinal.

Study carried out at the Hospital Santa Rosa de Cuiabá – Cuiabá (MT) – Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 04/10/2007 Approved on: 04/25/2012

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INTRODUCTION

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biotic prophylaxis with metronidazole (500 mg, oral administration, each 8 hours) and liquid diet without residue. For colorectal lowering surgery, a 500 mL fleet enema was applied at 8 pm. During the induction of anesthesia, 1 g of cefotaxime and 500 mg of metronidazole were infused in all patients and this regimen was kept for 24 hours – cefotaxime each 12 hours and metronidazole each 8 hours. The outcome variables analyzed were: length of stay and postoperative complications. Tables 1 to 3 show the diagnoses and respective procedures.

Colon preparation is largely used as a preoperative procedure for elective colon and rectal surgery. In the United States1, almost 99% of the surgeons use this practice, seeking to reduce the septic content of the colon. The purpose of the mechanical bowel cleansing is to prevent the potential risk of infection with the presence of stool during the surgery and problems affecting the healing process and the anastomotic integrity2,3. Therefore, the preoperative preparation would reduce the chances of stool leakage during the surgical procedure and, consequently, the risk of peritoneal cavity contamination4. However, the preparation is not well tolerated by patients and demands considerable time of the nursing team5. In addition, several randomized studies have shown that mechanical colon cleansing does not improve postoperative morbidity and may increase surgical site infection, anastomotic fistulas and hydroelectrolytic disorders6-9. Also, some randomized studies and meta-analyses have shown results that favor no preparation of the colon in several variables, such as wall infection, septic complications and anastomotic fistulas10-13. A recent randomized and multi-center study conducted in Europe with 250 patients also confirmed inefficiency of preoperative colon preparation in the prevention of postoperative complications. Among us, Santos et al.14 and Fillmann et al.6, in pioneer studies, showed more than ten years ago that colon preparation in colorectal surgery could be dispensable. Although these recent studies show that colorectal preparation may be dispensable in elective surgery, most surgeons are insecure about abolishing the prescription of such procedure. This article shows the experience of our group in elective colorectal surgery without conventional colon preparation.

Table 1. Distribution of cases by indication. Disease or Condition Number of cases (%) Cancer 27 (50) Colonic diverticular disease 20 (37) Crohn’s disease 2 (3.7) Colostomy closure 2 (3.7) Telangiectasia 1 (1.9) Endometriosis 1 (1.9) Colovesical fistula 1 (1.9) Table 2. Surgeries performed and number of cases. Surgeries Number of cases (%) Left colectomy 22 (40.7) Rectosigmoidectomy with 15 (27.8) lowering Right colectomy 11 (20.4) Total colectomy 2 (3.7) Hartman colostomy closure 2 (3.7) Miles surgery 2 (3.7) Table 3. Type of Anastomosis. Anastomosis Number of cases (%) Mechanical 45 (83.3) Manual 4 (7.4) No anastomosis 5 (9.3)

PATIENTS AND METHOD The study retrospectively analyzed 54 patients that were submitted to elective colon and rectal surgery, without conventional preparation, at the Hospital Santa Rosa de Cuiabá (MT), between January 2003 and December 2006. The patients were admitted between 6 pm and 8 pm the day before the procedure, and received anti-

All complications were observed up to day 30 after the surgery. The statistical analysis of data used SSPS 8.0 pack. Comparisons were made between the results from the beginning of the investigation (2003) and the results obtained in the other years (2004–2006). 124


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Length of stay between the two periods was evaluated using the Mann-Whitney test and expressed as median and variation values.

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four days after admission. Thus, no convincing aspect was found based on the results of this study attesting the importance of preoperative colon cleansing in colorectal surgery. Most surgeons that adopt colon cleansing justify that it reduces bacterial colonization and, consequently, the risk of infection and complications in anastomosis, due to the absence of solid stool15. However, several randomized studies6-9,13,14 and meta-analyses10-12 have consistently shown the opposite, i.e., that colon cleansing does not improve the results and that it may even increase the possibility of anastomotic dehiscence. Wille-Jørgensen et al.10, for instance, when analyzing 9 controlled and randomized studies involving total 1,592 patients, 789 of them submitted to surgery without preoperative cleansing and 803 with colon cleansing, observed that the occurrence of anastomotic fistula occurred twice more often in the group submitted to preoperative cleansing (6 versus 3.2%; odds ratio (OR): 2.03; confidence interval (CI) 95%:1.28–3.26; p=0.003). Ram et al.16, after obtaining similar results from 329 patients randomized for cleansing (n=164) or no cleansing (n=165) of the colon, recommend colon cleansing in two situations only: when small (<2 cm) polypoid lesions are present and when intraoperative colonoscopy is required to identify such lesions, and in resections with colorectal lowering. On the other hand, they recommend attention when performing colon cleansing in cases of tumors that occupy more than half the intestinal lumen, due to the risk of distension leading to acute abdomen. In this study, 27.8% of the procedures performed were anterior resection with colorretal lowering, but no case of anastomotic fistula or septic complication was observed. Although not performed in this study, cleansing dehydrates the patient and, for this reason, it may lead to higher infusion of perioperative fluid. Patients that receive more perioperative intravenous fluid tend to have more postoperative complications17. Then, the conclusion of this study is similar to results presented in recent medical literature, which indicate that the practice of preoperative conventional and mechanical cleansing of the colon is dispensable and that colorectal surgery without preparation is safe.

RESULTS Between January 2003 and December 2006, 54 patients were submitted to elective colorectal resection, without conventional colon cleansing, at the Hospital Santa Rosa de Cuiabá (MT). Mean age of patients was 59 years (34–87 years), 36 (66.7%) were females and 18 (33.3%) were males. Malignant neoplasm of the colon (n=27; 50%) was the most frequent indication, followed by colonic diverticular disease (n=20; 37%). The most frequent procedures were: left colectomy in 22 (40.7%) cases, rectosigmoidectomy with lowering in 15 (27.8%) cases and right colectomy in 11 (20.4%) cases. Mechanical anastomosis, with circular and/or linear stapler, was performed in 83.3% (n=45) of the cases. Median length of stay was four (2–12) days and mode was three days (n=17; 31.5%). When comparing the year to length of stay, median of 5.5 days was obtained in 2003 and four days between 2004 and 2006 (p=0.01, Mann-Whitney test). No case of anastomotic fistula was observed. In this study, only one death occurred due to multiple organ failure. Postoperative complications were observed in six (11%) cases: serous collection of incision (two cases), partial dehiscence of abdominal wall requiring re-suture (two cases) and prolonged ileus (two cases). DISCUSSION The results from the initial experience with the group without conventional colon cleaning showed that this practice is dispensable and that good clinical safety is ensured in colon and rectal surgery without using preoperative cleansing, even when involving anastomosis. Indeed, no mortality occurred and the incidence of morbidity was comparable to the current literature. In addition, the hospitalization period was short and patient was discharged from hospital around

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REFERENCES

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11. Slim K, Vicaut E, Panis Y, Chipponi J. Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation. Br J Surg 2004;91(9):1125-30. 12. Bucher P, Mermillod B, Gervaz P, Morel P. Mechanical bowel preparation for elective colorectal surgery. A meta-analysis. Arch Surg 2004;139(12):1359-64. 13. Fa-Si-Oen P, Roumen R, Buitenweg J, van de Velde C, van Geldere D, Putter H, et al. Mechanical bowel preparation or not? Outcome of a multicenter, randomized trial in elective open colon surgery. Dis Colon Rectum 2005;48(8):1509-16. 14. Santos JCM Jr, Batista J, Sirimarco MT, Guimaraes AS, Levy CE. Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery. Br J Surg 1994;81(11):1673-6. 15. Slim K, Panis Y, Chipponi J. [Mechanical colonic preparation for surgery or how surgeons fight the wrong battle]. Gastroenterol Clin Biol 2002;26(8-9):667-9. 16. Ram E; Sherman Y, Weil R, Vishne T, Kravarusic D, Dreznik Z. Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Arch Surg 2005;140(3):285-8. 17. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens. Ann Surg 2003;238(5):641-8.

1.

Zmora O, Wexner SD, Hajjar L, Park T, Efron JE, Nogueras JJ, et al. Trends in preparation for colorectal surgery: survey of the members of the American Society of Colon and rectal surgeons. Am Surg 2003;69(2):150-4. 2. Smith SR, Connolly JC, Gilmore OJ. The effect of faecal loading on colonic anastomótica healing. Br J Surg 1983;70(1):49-50. 3. Nichols RL, Condon RE. Preoperative preparation of the colon. Surg Gynecol Obstet 1971;132(2):323-37. 4. Chung RS, Gurll NJ, Berglund EM. A controlled trial of whole gut lavage as a method of bowel preparation for colonic operations. Am J Surg 1979;137(1):75-81. 5. Hughes ES. Asepsis in large-bowel surgery. Ann R Coll Surg Engl 1972;51(6):347-56. 6. Fillmann EEP, Fillmann HS, Fillmann LS. Cirurgia colorretal eletiva sem preparo. Rev bras Coloproct 1995;15:70-1. 7. Bucher P, Gervaz P, Soravia C, Mermillod B, Erne M, Morel P. Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92(4):409-14. 8. Miettinen RPJ, Laitinen ST, Mäkelä JT, Pääkkönen ME Bowel preparation with oral polyethylene glycol electrolyte solution versus no preparation in elective open colorectal surgery: prospective, randomized study. Dis Colon Rectum 2000;43(5):669-77. 9. Zmora O, Mahajna A, Bar-Zakai B et al. Left-sided anastomosis without mechanical bowel preparation: a randomized, prospective trial. Dis Colon Rectum 2002;45:A7-A8. 10. Wille-Jørgensen P, Guenaga KF, Matos D, Castro AA. Preoperative mechanical bowel cleansing or not? An updated metaanalysis. Colorectal Dis 2005;7(4):304-10.

Correspondence to: José Eduardo de Aguilar-Nascimento Rodovia Helder Candia 2755, Condomínio Country casa 15 – Ribeirão do Lipa CEP: 78048-150 – Cuiabá (MT), Brazil E-mail: aguilar@terra.com.br

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Comparative study between the free DNA in peripheral blood and TNM staging in patients with colorectal cancer for prognostic evaluation in the university hospital of the State of Alagoas Victor Cardoso Rocha1, Raquel Silva Moreira1, Manoel Álvaro De Freitas Lins Neto2 1

Postgraduate (Doctorate) by the Medical School of Universidade Federal de Alagoas (UFAL) – Maceió (AL), Brazil; Professor and Head of the Coloproctology Service, university hospital Professor Alberto Antunes, Medical School of Universidade Federal de Alagoas (UFAL) – Maceió (AL), Brazil.

2

Rocha VC, Moreira RS, Lins-Neto MAF. Comparative study between the free DNA in peripheral blood and TNM staging in patients with colorectal cancer for prognostic evaluation in the university hospital of the State of Alagoas. J Coloproctol, 2012;32(2): 127-131. ABSTRACT: Colorectal neoplasm is one of the most common cancers in developed countries and its incidence has grown progressively. The currently used attempts to prognostic assessment are limited, since they are restricted to the observation of tumor morphology, such as the TNM staging. The quantification of free DNA in peripheral blood aims to find a way to relate it to the clinical status of patients with cancer. Objective: To evaluate the prognosis of patients with colorectal cancer with the quantification of ALU247 fragments in peripheral blood and TNM staging. Methods: We evaluated 79 patients in the following groups: Operated, and Non-Operated and Control as to the ALU247 fragment dosage and its correlation with tumor staging. Results: The amount of ALU247 fragments revealed very different results when comparing the different groups. The mean quantity in the Non-Operated group was 14.62 pg, while the mean was 0.48 pg for the Control Group and 0.93 pg for the Operated Group. Serum levels of ALU247 were higher in more advanced morphofunctional classes of the TNM staging. Conclusions: We suggest there is a relation between the advanced TNM stage and high doses of free DNA in peripheral blood with worse prognosis. Keywords: colorectal neoplasia; colorectal staging; ALU 247; prognosis. RESUMO: A neoplasia colorretal é uma das formas mais comuns de câncer nos países desenvolvidos e sua incidência tem crescido de maneira contínua. As tentativas de avaliação prognóstica usadas atualmente apresentam a grave limitação de se restringirem à observação da morfologia tumoral, como o estadiamento TNM. A quantificação do DNA livre no sangue periférico busca encontrar uma forma de relacioná-lo com o estado clínico dos portadores de câncer. Objetivo: Avaliar o prognóstico dos pacientes portadores do câncer colorretal por meio da quantificação de fragmentos de ALU247 no sangue periférico e do estadiamento TNM. Métodos: Foram avaliados 79 pacientes nos Grupos Operados, Não Operados e Controle quanto à dosagem de fragmento de ALU247 e sua correlação com os estádios dos tumores. Resultados: A quantidade de fragmentos ALU247 revelou resultados bastante distintos quando os diferentes grupos foram comparados. A média da quantificação nos Não Operados foi de 14,62 pg, de 0,48 pg no Grupo Controle e 0,93 pg no Grupo Operados. Os valores séricos do ALU247 encontraram-se mais elevados nas classes morfofuncionais mais avançadas do estadiamento TNM. Conclusões: Sugere-se uma relação entre o avanço do estádio TNM e a dosagem elevada do DNA livre no sangue periférico com pior prognóstico. Palavras-chave: neoplasias colorretais; estadiamento de neoplasias; ALU247; prognóstico.

Study carried out at the Coloproctology Service, university hospital Professor Alberto Nunes, Medical School of Universidade Federal de Alagoas (UFAL) – Maceió (AL), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 02/03/2012 Approved on: 02/29/2012

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search of chromosomal and genetic instabilities, as well as changes in the tissue expression of the proteins codified by these chromosomes and genes, have brought up the possibility of using functional factors as potentially valid variables to better understand the CRC prognosis8. In the past few years, medicine has developed and incorporated advanced technologies, such as the use of molecular biology in order to directly study the DNA, searching for earlier and more precise diagnoses for various diseases, helping to understand the pathogeneses and bringing new perspectives for more efficient treatments or prevention9. In the attempts to establish early diagnosis and better treatment, tumor markers are noticed, which are molecular products secreted by the neoplastic tissue, detectable in cells and organic fluids that are able to indicate the presence, extension, response to treatment and presence of neoplasm recurrence10. The quantification of free DNA in the peripheral blood aims to find a way to relate it to the clinical status of patients with cancer, tumor aggressiveness, and especially a way to early detect the appearance of the first neoplastic cells, or in case of recurrence. Some of these fragments of free DNA are believed to be the proof of the presence of a tumor in the body. Detecting this presence or increase would mean to detect the cancer early11. The results obtained in many studies about cancer have led to a new field of investigation, which indicates that free DNA in the plasma/serum could be the adequate object of study for the development of a diagnostic and prognostic noninvasive diagnostic and follow-up method for cancer11. The potential for molecular and prognostic diagnosis is that human or viral nucleic acids and those deriving from tumors can be obtained through the peripheral blood, by means of a minimally invasive procedure. It can be used as a replacement to protein tumor markers in order to follow-up the course of the disease or to assist in early diagnosis11. By using a method of rapid amplification of specific DNA sequences and in order to establish alternative approaches with high sensitivity and specificity, assays based on polymerase chain reaction (PCR) have been used, since this technique is very sensitive and clinically used to detect cancer markers in circulating tumor cells12.

Colorectal cancer (CRC) is one of the most common cancers in developed countries, and its incidence has been continuously increasing. Even though it is a well established model of carcinogenesis, it is still an important cause of mortality, affecting approximately 782 thousand people throughout the world each year1. Survival rates for CRC are considered good if the disease is diagnosed early. The global mean survival in 5 years is around 55% in developed countries and 40% in developing countries. With this relatively good prognosis, CRC is the second most prevalent type of cancer in the world, with approximately 2.4 million diagnosed living people, coming after breast cancer among women2. According to estimates of the National Cancer Institute (INCA) for 2010, the number of new CRC cases in Brazil was 28,110, being 13,310 among men and 14,800 among women. The tumor node metastasis classification (TNM) is currently used for the postoperative staging. This system was developed and published by the International Union Against Cancer (UICC)3, and is the most used tool to classify malignant tumors. The description of its anatomical extension is provided by the evaluation of tumor aggressiveness and invasibility4. Among all tumor markers, the carcinoembryonic antigen (CEA) is the most used method of prognostic evaluation to follow-up patients with CRC. Some studies have evaluated the prognostic value of CEA serum quantification, correlating it to established morphological variables represented by the different staging forms, also demonstrating the association between high levels of antigen and unfavorable prognosis; however, results are controversial. The attempts that are currently used for the prognostic evaluation have a major limitation, since they are restricted to the observation of tumor morphology, as observed in the TNM staging, even at the microscope, thus not providing information on genetic potential. Therefore, the momentary registration of tumor evolution and biological behavior can be obtained with the evaluation of ALU247, which is related to mechanisms that are inherent to the component cells of that tissue. Recently, after better understanding the genetic changes involved in colorectal carcinogenesis, the re128


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The repeated elements spread in DNA that are more deeply analyzed belong to the Alu family. They have been used as genetic markers in studies of human evolution, due to their particular properties, such as: speed and facility concerning genotyping; and the fact that they are selectively neutral and have a known ancestral state. Besides contributing with the evolution of primate genomics, the Alu elements also contribute with up to 0.4% of the multifactorial genetic human diseases, like cancer.

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order to study the relation between the studied criteria, we used Pearson’s chi square test (χ2) to evaluate the association between ALU247 and TNM staging. Means were obtained with the parametric test to compare means of ANOVA. RESULTS Out of the 79 patients included in the study, 23 belonged to the Operated group; 26 were in the Non-operated group; and 30 were in Control. Fragments of ALU247 were dosed after the peripheral blood draw was performed in all the 79 patients involved. Following data analysis, the mean of ALU247 quantification was analyzed in each group, separately. Results can be observed in Table 1. From the analysis of anatomopathological reports of the surgical pieces, the TNM staging of patients in the Operated group could be defined. All histopathological diagnoses were of CRC. As to the TNM system, the Operated group was separated into stages I, II and III, with the following specifications: “T” refers to the primary tumor, “N” means that regional lymph nodes are compromised, and “M” refers to distant metastasis. Results are demonstrated in Figure 1. Since all cases were M0, there was no stage IV.

METHODS Eighty-six patients were analyzed and divided into three different groups (30 – Non-operated; 26 – Operated; and 30 – Control). They were randomly included in the study, regardless of gender, age or ethnicity. In the Operated group, the blood of patients with CRC was drawn for dosing ALU247 after they had been submitted to curative surgery. The Non-operated group, at the time of dosage, had not been submitted to surgery; meanwhile, the Control group was comprised of patients who did not have CRC. The surgical pieces were obtained by means of therapeutic resections performed at the university hospital Professor Alberto Antunes, at the medical school of Universidade Federal de Alagoas (UFAL), from 2004 to 2010. These surgical pieces went through the standard anatomopathological procedure for TNM staging. Medical reports were taken from the files of the Pathological Anatomy Service of the university hospital Professor Alberto Antunes. Research data were provided by the values obtained with the dosage of free DNA in the peripheral blood of patients with CRC before and after surgery, by means of real-time PCR. This study aimed to assess a prognostic test. The ALU247 is analyzed as a marker for CRC aggressiveness, correlating its presence with TNM staging. In

Figure 1. Distribution of TNM staging in the Operated group.

Table 1. Mean of ALU247 quantification in different groups. Quantity of free DNA (pg) Groups n Minimum Maximum 26 Non-operat­ed group 26 8.02 23.54 23 Operated group 23 0.09 5.95 30 Control 30 0.08 1.55 SD: standard-deviation.

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Mean±SD (pg) 14.62±4.73 0.93±2.45 0.48±0.38


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the absence of tumor in these groups, be it due to the efficacy of the surgical treatment or due to the absence of a neoplasm diagnosis (Figure 2). The quantity of ALU247 fratgments revealed very different results when comparing the Non-operated group with the Operated and Control groups. The mean of quantification in patients with the tumor was 14.62 pg, while the mean among those who did not have the tumor was 0.48 pg in the Control Group and 0.93 pg in the Operated group). The limits demonstrated that those with the tumor (Non-operated grup) presented values of ALU247 much superior to those in the Control and Operated groups, who presented very similar values. TNM staging is the most used prognostic indicator. Its approximated accuracy is 65%, presenting flaws in the estimates of evolution of many patients, especially in clinical stages II and III, which makes it difficult to present a more adequate and consensual therapy indication14. As with other classifications, it is observed that TNM detects the clinical extension of the disease evaluated at the moment of lesion excision, not considering the aggressiveness and power of dissemination resulting of the genotype of the tumor. The quantification of free DNA fragments, such as ALU247, would enable the functional evaluation of the neoplasm related with development, growth and dissemination of the tumor. At the stage I of TNM, the established mean was 0.32 pg, which is lower than the value found in the Control Group and in stages II and III, with means of 0.48, 0.77 and 1.208 pg, respectively. Concerning stage II, the mean was 0.77 pg, superior in relation to the Control group and to stage I, and inferior in rela-

The 23 tumors of the Operated group were analyzed by relating the morphology study by TNM staging with their genotypic features by the ALU247 quantification (Table 2). DISCUSSION The repeated elements spread in DNA that are more deeply studied belong to the Alu family, which has this name because most of its members are cleaved by bacterial restriction endonucleases called Alu I, formerly used in the initial purification of this DNA. ALU247 has been used in cancer investigation and as a genetic marker in studies of human evolution due to its properties, such as speed and facility concerning genotyping, and also because it is selectively neutral3. The expression of these markers, more specifically, ALU247, has been associated with nonapoptotic cells, probably tumor cells. In order to dose ALU247 in the peripheral blood, the PCR technique was used, which consists of amplifying DNA copies in vitro using the basic elements of the natural DNA replication process. This method aims to rapidly amplify specific DNA sequences. The conventional PCR does not present quantitative values. So, the real-time PCR was developed, which is a technique described as quantitative, since it can evaluate the number of molecules produced in each cycle. The relevant characteristics of real-time PCR are speed, specificity, sensitivity and quantification. Using the value of 8.02 pg of ALU247 fragments to evaluate the presence of tumor, which is the minimum value presented by the Non-operated group, we noticed that this value was different among the analyzed groups, which showed that quantities above 8.02 pg of ALU247 are characteristic of those with colorectal tumor11. In the Operated and Control groups, 100% of the patients had values of ALU247 fragmentation below the cut-off point, thus suggesting Table 2. Mean of ALU247 quantification in different stages of the Operated group. Stage n Variance Mean±SD I 5 0.08 0.32±0.28 II 4 2.12 0.772±1.45 III 14 2.87 1.208±1.69

Figure 2. Percentage of patients in different groups that obtained ALU247 inferior to the cut-off point.

SD: standard-deviation.

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tion to stage III, thus establishing intermediate values of ALU247, as well as its TNM staging. Among stage III patients, who present with lymph node invasion by tumor cells, the mean was 1.208 pg, superior to the Control group and stages I and II. In this study, the serum values of ALU247 were higher in more advanced morphofunctional classes of the TNM staging. The suggestion is that different phenotypic expressions of the neoplastic cell, from the morphofunctional point of view, provide larger quantities of ALU247 fragments in the blood flow.

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non-invasive and easy to perform procedure, consisting of a possible mechanism for postoperative follow-up of patients with CRC, once the increased levels of postoperative ALU247 would be related to the possible tumor recurrence. The relation between TNM staging advances, high dose of free DNA in the peripheral blood and the probable worse prognosis is suggested. Thus, it is necessary to incorporate new factors that consider histopathological and functional aspects together. From the combination of morphological variables, which are known to be related to prognosis, TNM staging, together with the dose of tumor markers, such as ALU247, it would be possible to establish the proper stratification of neoplasms in groups of similar biological behavior, thus making the projections related to the prognosis of the disease more reliable.

CONCLUSIONS It is possible to associate the presence of tumor to high levels of ALU247 fragments. The quantification of ALU247, using the real-time PCR, is a

REFERENCES

colorretal baseada em critérios morfofuncionais: correlação com níveis séricos do antígeno carcinoembrionário. Rev Bras Coloproctol 2007;27(4):374-83. 9. Grover D, Mukerji M, Bhatnagar P, Kannan K, Brahmachari SK. Alu repeat analysis in the complete human genome: trends and variation with respect to genomic composition. Bioinformatics 2004;20(6):813-7. 10. Fernandes LC, Matos D. Marcadores tumorais no câncer colorretal. Rev Col Bras Cir 2002;29(2):106-11. 11. Comas D, Plaza S, Calafell F, Sajantila A, Bertranpetit J. Recent insertion of an Alu element within a polymorphic human-specific Alu insertion. Mol Biol Evol 2001;18(1):85-8. 12. Deininger PL, Batzer MA. Alu repeats and human disease. Mol Genet Metab 1999; 67:183-93. 13. 2Zhang J, Fackenthal JD, Huo D, Zheng Y, Olopade OI. Searching for large genomic rearrangements of the BRCA1 gene in a Nigerian population. Breast Cancer Res Treat 2010;124(2):573-7. 14. International Human Genome Sequencing Consortium. Initial sequencing and analysis of the human genome. Nature 2001;409(6846):860-921.

1. Fearon ER, Vogelstein B. A genetic model for colorectal tumorigenesis. Cell 1990;61(5):759-67. Comments in: Cell 2004;118(6):671-4. 2. Silva-Filho BF. Quantificação de fragmentos de DNA livre no sangue periférico de portadores de câncer colorretal. 2009. Dissertação [Mestrado] – Programa de Pós-graduação em Ciências da Saúde da UFAL, Maceió, 2009. 3. Batzer MA, Deininger PL. A human-specific subfamily of Alu sequences. Genomics 1991;9(3):481-7. 4. Huerta S. Recent advances in the molecular diagnosis and prognosis of colorectal cancer. Expert Rev Mol Diagn 2008;8(3):277-88. 5. Le Rouzic A, Deceliere G.. Models of the population genetics of transposable elements. Genet Res 2005;85(3):171-81. 6. SanMiguel P, Tikhonov A, Jin YK, Motchoulskaia N, Zakharov D, Melake-Berhan A, et al. Nested retrotransposons in the intergenic regions of the maize genome. Science 1996;274(5288):765-8. 7. Simmang CL, Senatore P, Lowry A, Hicks T, Burnstein M, Dentsman F, et al. Practice parameters for detection of colorectal neoplasms. The Standards Committee, the American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1999;42(9):1123-9. 8. Priolli DG, Cardinalli IA, Piovesan H, Margarido NF, Martinez CAR. Proposta para estadiamento do câncer

Correspondence to: Manoel Álvaro de Freitas Lins Neto Rua Deputado José Lages, 350 – Ponta Verde CEP: 57035-330 – Maceió (AL), Brazil E-mail: mlinsneto@gmail.com

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Original Article

Transanal rectopexy – twelve case studies Rubens Henrique Oleques Fernandes1, Tito Armando Rossi2 Full Member, Brazilian Society of Coloproctology – Caxias do Sul (RS), Brazil; Residency Preceptor, General Surgery, Hospital Nossa Senhora de Pompeia – Caxias do Sul (RS), Brazil. 2Full Member, Brazilian Society of Coloproctology – Caxias do Sul (RS), Brazil; Head of Gastrocolon Clinic, Hospital Nossa Senhora de Pompeia – Caxias do Sul (RS), Brazil. 1

Fernandes RHO e Rossi TA. Transanal rectopexy – twelve case studies. J Coloproctol, 2012;32(2): 132-135. ABSTRACT: Objectives: This study analyzed the results of transanal rectopexy and showed the benefits of this surgical technique. Method: Twelve patients were submitted to rectopexy between 1997 and 2011. The surgical technique used was transanal rectopexy, where the mesorectum was fixed to the sacrum with nonabsorbable suture. Three patients had been submitted to previous surgery, two by the Delorme technique and one by the Thiersch technique. Results: Postoperative hospital stay ranged from 1 to 4 days. One patient (8.3%) had intraoperative hematoma, which was treated with local compression and antibiotics. One patient (8.3%) had residual mucosal prolapse, which was resected. Prolapse recurrence was seen in one case (8.3%). Improved incontinence occurred in 75% of patients and one patient reported obstructed evacuation in the first month after surgery. No death occurred. Conclusion: Transanal rectopexy is a simple, low cost technique, which has shown good efficacy in rectal prolapse control. Keywords: rectum; rectal prolapse; colorectal surgery. RESUMO: Objetivo: O presente estudo analisou os resultados da retopexia pela via transanal e expôs os benefícios desta técnica cirúrgica. Método: Doze pacientes com prolapso foram operados no período de 1997 a 2011. A técnica cirúrgica usada foi a retopexia transanal, onde o mesorreto foi fixado ao sacro com fio inabsorvível. Três pacientes tinham cirurgia prévia, dois pela técnica de Delorme e um pela técnica de Thiersch. Resultados: A permanência hospitalar pós-operatória variou de 1–4 dias. Uma paciente (8,3%) apresentou hematoma transoperatório que foi tratado com compressão local e antibioticoterapia. Um paciente apresentou prolapso mucoso residual (8,3%), que foi ressecado. Houve recidiva da procidência em um caso (8,3%). A melhora da incontinência ocorreu em 75% dos pacientes e uma paciente apresentou bloqueio evacuatório no primeiro mês após a cirurgia. Não houve mortalidade entre os pacientes operados. Conclusão: A retopexia transanal é uma técnica simples, de baixo custo e apresentou boa eficácia no controle do prolapso retal. Palavras-chave: reto; prolapso de reto; cirurgia colorretal.

INTRODUCTION

duced number of patients with this pathology at each service of Coloproctology is certainly a limitation to studies comparing these surgical techniques. Perineal rectopexy, introduced in 19103, uses gas in the retrorectal space for several days; with high recurrence, the technique has not become popular. Transperineal4, transsacral5 and postanal6 approaches have also been used, but without high acceptance. Transanal rectopexy has been used

Rectal prolapse is the protrusion of all rectal walls through the anal canal. It affects women more often than men, at the ratio of 6:11. Several treatment methods have been proposed, either through abdominal or perineal approach. Few studies have been conducted to guide our practice, and good results have been achieved with both abdominal and perineal techniques2. The re-

Study carried out at the Service of Surgery, Hospital Nossa Senhora de Pompeia, Department of Coloproctology – Caxias do Sul (RS), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 08/24/2011 Approved on: 11/23/2011

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RESULTS

only in association with Altemeier7 e Delorme8 techniques, for reduced recurrence. No utilization of transanal rectopexy as an isolated technique has not been described. The purpose of this study is to present the results of transanal rectopexy and the technical description of the procedure.

The immediate postoperative period was asymptomatic and the patients did not require opioid analgesics. Hospital stay ranged from 1 to 4 days. The only patient hospitalized for 4 days presented retrorectal hematoma after stitching, which was treated with local compression during the surgery and antibiotics for 7 days. The patients were supervised for periods that varied from 6 months to 14 years. Three patients died within one to three years after the surgery, without signs of recurrence. Two patients have not been found anymore, but they were supervised up to one year after the surgery and did not present prolapse recurrence. One patient presented prolapse recurrence 2 months after the surgery (8.3%) and was again submitted to the same surgical technique, with good results. One patient presented residual anterior mucosal prolapse and was treated with local resection 6 moths after rectopexy. The functional result showed partial or total incontinence improvement in 6 patients (75%), and 2 incontinent patients (25%) did not presented alteration to fecal loss. The levator-muscle surgery was recommended to these incontinent patients, but it was not performed, following the decision of patients and their relatives. Patients with incontinence before the surgery did not present any change in this clinical aspect after the transanal rectopexy. Constipation, present in 40% of patients before the surgery, had no change. One patient that had no constipation before rectopexy reported obstructed evacuation in the first preoperative month. She was treated with mini enemas and fiber and presented spontaneous improvement. No mortality was seen with the technique described in this study.

PATIENTS AND METHODS Twelve patients, three males and nine females, aged 34 to 88, were submitted to rectopexy. Prolapse duration ranged from 1 to over 10 years. Three patients had been submitted to previous surgery for prolapse, two by the Delorme technique, with recurrence, and one, with external prolapse and mucosal ischemia, was submitted to urgent Thiersch surgery and subsequently to transanal rectopexy. Table 1 shows the clinical details of patients. The prolapse of patients submitted to rectopexy was 4–10 cm long. Surgical technique All patients were in the lithotomy position during the surgery, and received regional or local anesthesia with sedation (one patient only). After prolapse reduction and rectal retactor placement, the rectum returns to its original position. The following retactors were used: circular anal retactor, vaginal speculum 4 and composite anoscope (130 x 40 mm). With all these instruments, it is possible to perform the surgery. The mucosa is rinsed with physiological saline solution, and, after that, an incision is made in the posterior rectal wall, starting 6 cm and ending 10 cm from the anal margin. As the mesorectum was exposed, it was fixed to the pre-sacral fascia with nonabsorbable suture, using 40 mm atraumatic needles. The needle should be long enough to enable the passage through the pre-sacral fascia and expose the needle tip to end stitching. After 3-4 stitches are made, the threads are tied and the rectal wall is tensioned to test its fixation. It is rinsed again and the rectal wall is closed with absorbable suture #00 or #000. All patients received antibiotic prophylaxis. Figures 1 and 2 show the rectal wall incision and the final aspect after rectopexy and rectal wall suture.

DISCUSSION Abdominal procedures for prolapse treatment are related to lower recurrence1. The current abdominal surgery is based on rectopexy, as other procedures that do not include it have been discarded2. However, rectal dissection is associated with constipation and obstructed evacuation9-11, and the lateral ligament division increases such incidence12. The recurrence rate after rectopexy with or without associated sigmoidectomy is the same13,14. 133


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Tabela 1. Clinical information of patients. Age 34 76 62 64 69 71 73 77 59 44 88 73

Gender M M F F F F F F F M M F

Previous surgery No Delorme No No No Delorme No No No Delorme No No

Comorbidities

Constipation

Incontinence

No Yes No No Yes Yes Yes Yes No No Yes Yes

No No Yes No No Yes Yes Yes No No No Yes

No Yes No Yes Yes Yes Yes Yes No No Yes Yes

Figura 1. Incision on the rectal wall, exposing the mesorectum.

Figura 2. Rectal wall suture.

High morbidity rates of abdominal procedures used in pathologies associated with older age encouraged the development of perineal techniques. The prolapse treatment via perineal procedure has become the preferred choice in elderly and debilitated patients. These surgeries are safe, the anesthetic risk is low and the recovery is fast15, but they have presented higher recurrence rates than abdominal surgery. Published studies present wide discrepancy in terms of recurrence after perineal rectosigmoidectomy, ranging from 0 to 60%1. Functional results were also discouraging at first13, but they improved with

combined levator-muscle repair16-18. The combination of rectopexy with the Altemeier technique described by Prasad et al.7 shows the benefit of fixing the rectum to the sacrum, leading to lower recurrence. Despite the excellent functional results of this study, one death was reported among 25 patients. Anastomotic fistula occurred in another study series, in 16.6% of the patients19; then, resection and anastomosis are associated with high morbimortality20. Another study associated transanal rectopexy with Delorme surgery8, obtaining reduction in the recurrence rate, from 20 to 5%. Rectopexy was 134


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performed only with the placement of absorbable mesh in the retrorectal space. Douglas pouch suture was also associated with this technique. This method also presented high morbidity rate, although not statistically significant. The technical innovation presented in this study shows the benefits of rectopexy, a consolidated technique of lower recurrence rates, and the transanal approach advantages, which make the procedure fast and technically easy to be performed. The possibility of abscess occurrence seems to be discarded, as perirectal tissues are not dissected and synthetic meshes are not used. Hematomas may occur with the needle passing through the sacral fascia, but, in this study, the hematoma did not lead to complications and was

treated with local compression during the surgery. Levator-muscle repair was performed in the patient with persistent incontinence after the prolapse correction.

REFERENCES

study. Br J Surg 1991;78:1431-3. 13. Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S. The management of procidentia: 30 years experience. Dis Colon Rectum 1985;28:96-102. 14. Mc Kee RF, Lauder JC, Poon FW, Aitchinson MA, Finlay IG. A prospective randomized study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse. Surg Gynecol Obstet 1992;174:145-8. 15. Beck DE, Roberts PL, Rombeau JL, Stamos MJ, Wexner SD. The ASCRS Textbook of colon and rectal surgery. New York: Springer Science and Business Media; 2007. 16. Ramanujam PS, Venkatesh KS. Perineal excision of rectal prolapse with posterior levator ani repair in elderly high risk patients. Dis Colon Rectum 1988;31:704-6. 17. Bueno RN, Rocha JJR, Rodrigues RG, Feres O, Koga DY, Veneziano SG, et al. Proctossigmoidectomia via perineal no tratamento do prolapso retal. Acta Cir Bras 2001;16(Suppl 1):82-3. 18. Altemeier WA, Culbertson WR, Schowengerdt CJ, Hunt J. Nineteen years` experience with one stage perineal repair of rectal prolapse. Ann Surg 1971;173:993-1006. 19. Sobrado CW, Kiss DR, Nahas SC, Araujo SEA, Seid VE, Cotti G, et al. Surgical treatment of rectal prolapse: experience and late results with 51 patients. Rev Hosp Clin Fac Med S Paulo 2004;59:168-71. 20. Gordon PH. Rectal procidentia. In: Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum and anus. St Louis, Missouri: Quality Medical Publisher; 1992. p. 449-81.

CONCLUSION Transanal rectopexy uses the sphincter hypotonia, an anatomical aspect in patients with rectal prolapse, which makes it a relatively easy procedure. The recurrence rate was low, with minimum morbidity. Even treating patients at older ages, no mortality was seen with the technique described in this study. This is also a low cost technique. However, the comparison of this technique to other methods requires additional prospective studies.

1.

Henry MM, Swash M. Coloproctology and the pelvic floor. 2nd ed. Oxford: Butterworth – Heinemann Ltd.; 1996. 2. Nicholls RJ, Banerjee A. Rectal prolapse and solitary rectal ulcer syndrome. In: Nicholls RJ, Dozois RR (Eds). Surgery of the colon & rectum. New York: Churcill Livingstone; 1997. p. 709-37. 3. Lockhart Mummery JP. A new operation for prolapse of the rectum. Lancet 1910;1:641. 4. Wyatt AP. Perineal rectopexy for rectal prolapse. Br J Surg 1981;68:717-19. 5. Davidian VA, Thomas CG. Trans-sacral repair of rectal prolapse. Am J Surg 1972;123:231-5. 6. Rogers J, Jeffery PJ. Intersphincteric repair and Ivalon sponge rectopexy for the treatment of rectal prolapse. Br J Surg 1987;74:384-6. 7. Prasad ML, Pearl RK, Abcarian H, Orsay CP, Nelson RL. Perineal proctectomy, posterior rectopexy, and postanal levator repair for the treatment of rectal prolapse. Dis Colon Rectum 1986;29:547-52. 8. Lechaux JP, Lechaux D, Perez M. Results of Delorme`s procedure for rectal prolapse. Dis Colon Rectum 1995;38:301-7. 9. Holmström B, Brodén G, Dolk A. Results of the Ripstein operation in the treatment of rectal prolapse and internal rectal procidentia. Dis Colon Rectum 1986;29:845-8. 10. Allen-Mersh TG, Turner MJ, Mann CV. Effect of abdominal Ivalon rectopexy on bowel habit and rectal wall. Dis Colon Rectum 1990;33:550-3. 11. Mann VC, Hofman C. Complete rectal prolapse: the anatomical and functional results of treatment by an extended abdominal rectopexy. Br J Surg 1988;75:34-7. 12. Speakman CT, Madden MV, Nicholls RJ, Kamm MA. Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized

Correspondence to: Rubens Henrique Oleques Fernandes Rua Pinheiro Machado 2.321, sala 51 CEP: 95020-172 – Caxias do Sul (RS), Brazil E-mail: olequesfernandes@terra.com.br

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Original Article Clinical and epidemiological evaluation of patients with colorectal cancer from Rio Grande do Sul Michelle Fraga Eisenhardt1, Fabrine Huwe1, Marcelo Luis Dotto2, Cátia Severo3, Juliana Jornada Fontella3, Andreia Rosane De Moura Valim4, Helen Tais Da Rosa5, Cézane Priscila Reuter6, Lia Gonçalves Possuelo4 Academician, School of Pharmacy, Universidade de Santa Cruz do Sul (UNISC) – Santa Cruz do Sul (RS), Brazil. Oncologist, Centro de Oncologia Integrado, Hospital Ana Nery – Santa Cruz do Sul (RS), Brazil. 3Nurse, Centro de Oncologia Integrado, Hospital Ana Nery – Santa Cruz do Sul (RS), Brazil. 4Post-Graduation Program of Health Promotion, Universidade de Santa Cruz do Sul (UNISC) – Santa Cruz do Sul (RS), Brazil. 5Academician, Course of Biological Sciences, UNISC – Santa Cruz do Sul (RS), Brazil. 6Pharmacist, attending postgraduate program (master’s degree) in Health Promotion, UNISC – Santa Cruz do Sul (RS), Brazil. 1

2

Eisenhardt MF, Huwe F, Dotto ML, Severo C, Fontella JJ, Moura Valim AR. Clinical and epidemiological evaluation of patients with colorectal cancer from Rio Grande do Sul. J Coloproctol, 2012;32(2): 136-143. ABSTRACT: Colorectal cancer has a high incidence in Brazil, with the South and Southeast regions presenting the largest number of cases. Objective: Identify the epidemiological characteristics and the regimens used as first-line treatment of patients with colorectal cancer treated at a cancer center in Santa Cruz do Sul (RS, Brazil) from 2006 to 2011. Methods: The records of 130 patients were retrospectively evaluated. Clinical and epidemiological characteristics, such as age, gender, ethnic group, stage of disease, primary site of disease and first-line treatment, were evaluated. The association of significance was evaluated using the chi-square and Fischer exact tests. The confidence interval used was 95% (p<0.05). Results: The mean age of patients with colorectal cancer in this study was 60.8 years, with higher incidence of the disease in men. At diagnosis, 40% of the patients had advanced disease stage IV. The regimen of 5-fluorouracil/folic acid (68.5%) was used as first-line treatment. Conclusion: This study showed high prevalence of colorectal cancer in patients of advanced age with the diagnosis made in the later stage of the disease. This fact demonstrates the importance of prevention campaigns that encourage periodic examinations in patients over 50 years of age. Keywords: colorectal neoplasms; incidence; drug toxicity; 5-fluorouracil/folic acid. RESUMO: No Brasil, o câncer colorretal apresenta uma elevada incidência, sendo as Regiões Sul e Sudeste as com maior número de casos. Objetivo: Identificar as características epidemiológicas e os esquemas terapêuticos utilizados como primo-tratamento dos pacientes portadores de câncer colorretal atendidos em um centro especializado em oncologia em Santa Cruz do Sul (RS) no período de 2006 a 2011. Método: Foram avaliados retrospectivamente 130 prontuários de pacientes portadores de câncer colorretal. Características clínicas e epidemiológicas como idade, sexo, cor da pele, estádio da doença, sítio primário da doença e primo-tratamento foram avaliadas. A associação de significância foi avaliada pelos testes do qui-quadrado e exato de Fischer. O intervalo de confiança utilizado foi de 95% (p<0,05). Resultados: A idade média dos pacientes encontrada neste estudo foi de 60,8 anos com incidência maior da doença entre os homens. No momento do diagnóstico, 40% dos pacientes estavam com a doença no estádio IV. Como primo-tratamento o esquema terapêutico mais utilizado foi o 5-fluoracil/ácido folínico (68,5%). Conclusão: Este estudo ratificou a alta prevalência do câncer colorretal em pacientes com idade mais avançada, com o diagnóstico realizado na fase mais avançada da doença. Esse fato evidencia a importância da realização de campanhas de prevenção que estimulem a realização de exames periódicos nos pacientes com idade acima de 50 anos. Palavras-chave: neoplasias colorretais; incidência; toxicidade de drogas; 5-fluoracil/ácido folínico.

Study carried out at the Department of Biology and Pharmacy, Universidade de Santa Cruz do Sul (UNISC) – Santa Cruz do Sul (RS), Brazil Financing source: Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS). Conflict of interest: nothing to declare. Submitted on: 02/09/2012 Approved on: 03/12/2012

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(IFL) was largely accepted as the first-line treatment for the metastatic colorectal cancer (mCRC), producing better results than those obtained with 5-FU/LV17. When selecting the therapeutic regimen, an effective, well-tolerated and convenient therapy is desirable18. Goldberg et al.19 demonstrated that FOLFOX presents significantly lower rates of nauseas, vomiting, diarrhea, febrile neutropenia and dehydration when compared to IFL. And, when compared to FOLFIRI, the occurrence of diarrhea and febrile neutropenia is also higher in patients treated with IFL20. The regimen of 5-FU/LV is associated with adverse drug reactions (ADRs), such as diarrhea, leukopenia, neutropenia, mucositis and vomiting, but at significantly lower rates than IFL21. The fact that innumerous pharmacological agents are not effective in the treatment of advanced CRC or present high toxicity raises an important question about what really constitutes the standard treatment for this disease and about how the active agents for such disease should be combined22,23. Thus, the purpose of this study was to identify the epidemiological characteristics of patients with CRC treated at a cancer center in Santa Cruz do Sul (RS) and the main therapeutic regimens used as the first-line treatment and their ADRs.

Colorectal cancer (CRC) is one of the most common types of cancer worldwide, with predominance in more industrialized and economically richer countries. In Brazil, CRC has a high incidence, with the South and Southeast regions presenting the largest number of cases1,2. CRC is a disease that predominates in individuals over 50 years of age, only 10% of people with CRC are under 50 years old, with 2% to 10.6% of the diagnoses made in patients under 40 years old and only 2.4% of the diagnoses made in patients under 30 years old3,4. CRC is a disease that can be treated and frequently healed; with the treatment usually involving surgery, radiotherapy and chemotherapy. Surgery is the main type of treatment, which, alone or combined with chemotherapy, can offer long survival and, consequently, healing, since diagnosed in its early stage5. The treatment selection is basically dependent on the tumor size, location and extension, and the patient’s general health, and the different forms of treatment can be used individually or combined6. Adjuvant chemotherapy is habitually used in the treatment of high-risk stage III and stage II CRC to reduce recurrences after the initial treatment with surgery, eliminating residual tumor cells and increasing the number of patients that obtain long-term disease-free survival and increased overall survival (OS)7. The chemotherapeutic treatment for CRC has become increasingly complex in the last years8. The combination of 5-fluorouracil and folic acid (5-FU/LV) became the standard treatment for CRC many years ago, and remains as the standard treatment for stage II CRC and one of the options for stage III CRC9-11. However, stage III e IV CRC may be treated with different therapeutic regimens that incorporate new agents, such as irinotecan and oxaliplatin12,13. Examples of these combinations include: irinotecan, 5-FU (continuous bolus infusion) and folic acid (FOLFIRI) and oxaliplatin, 5-FU (continuous bolus infusion) and folic acid (FOLFOX)13. These therapeutic regimens present different toxicity profiles, but both are considered first-line therapeutic options for the treatment of advanced CRC14-16. Before the introduction of these regimens, the combination of irinotecan, 5-FU (bolus) and folic acid

METHODS Study design and data collection A retrospective descriptive study was conducted, which analyzed patients with CRC treated at the Centro de Oncologia Integrado (COI) at the Hospital Ana Nery, in the city of Santa Cruz do Sul, 155 km from the State capital, Porto Alegre, in the central region of the State of Rio Grande do Sul. Hospital Ana Nery is a hospital of medium complexity, with a cancer center that is a reference to Vale do Rio Pardo and Centro-Serra, a region of 458,238 inhabitants. Selection of patients and data collection The medical records of patients over 18 years of age diagnosed with CRC confirmed by biopsy between March 2006 to April 2011 were evaluated. The patients’ data were collected between October 2010 and December 2011. 137


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Table 1. Epidemiological characteristics of patients with colorectal cancer treated at the Oncology Center at the Hospital Ana Nery from 2006 to 2011. Total Characteristics p-value n=130* (%) Mean age 60.8 (±12.6) Gender 71 (54.6) Male 0.29 59 (45.4) Female Marital status 97 (74.6) With a companion <0.001 32 (24.6) Alone Skin color White 128 (98.5) <0.001 Other than white 2 (1.5) Occupation Retired 39 (30) Housewife 30 (23.1) 0.83 Agriculturist 30 (23.1) Others 31 (23.8) Medical care SUS (public system) 125 (96.2) <0.001 Private medical care 5 (3.8)

During the analysis of medical records, clinical and epidemiological data were evaluated and transcribed to a previously elaborated data form. The epidemiological data included age, gender, occupation, marital status and ethnic group. The clinical data included disease stage, primary site of the disease, metastases at the diagnosis, lymph node invasion, chemotherapeutic regimen adopted as the first-line treatment, ADRs and therapeutic response. Ethical considerations This study was approved by the Research Ethics Committee of the Universidade de Santa Cruz do Sul (UNISC), under protocol number 2.523/10. Statistical analysis Clinical and epidemiological data were stored and analyzed in a database created with the software Statistical Package for the Social Science (SPSS, Chicago, IL), version 18.0. The association of significance was evaluated using the chi-square and Fischer exact tests. The confidence interval used was 95% (p<0.05). Descriptive statistics were calculated and univariate comparisons were performed.

*The difference in percentage is due to the number of cases without such information in the patient’s records. SUS: Unified Health System (public system).

RESULTS Characteristics of patients The medical records of 130 patients were analyzed; 53 (40.8%) of them were of patients from the city of Santa Cruz do Sul. This number refers to the total patients treated at COI in the studied period; 125 (96.2%) of them were treated under the government’s Unified Health System (SUS). Table 1 shows the epidemiological characteristics of patients. The mean age of patients at the diagnosis was 60.8 years (±12.6), with 6 (4.6%) patients under 40 years of age. In terms of gender, 71 (54.6%) were male patients, but the difference between male and female patients was not statistically significant (p=0,29). Regarding the tumor site, 85 (65.4%) patients had colon cancer and 45 (34.6%) had rectal cancer. Regarding the TNM staging system, at the diagnosis, 52 (40%) patients presented stage IV CRC, 32 (24.6%) stage III CRC and 42 (32.3%) stage II CRC and, regarding the lymphatic invasion, 67 (51.5%) patients did not present metastasis in regional lymph

nodes. In this group of patients, the most frequent metastatic site at the diagnosis was the liver (23.8%). Chemotherapeutic treatment Regarding the chemotherapeutic treatments, the most frequent first-line treatment was 5-FU/LV (68.5%). The second most frequent treatment was IFL, used by 13 (10%) patients, followed by FLOX (5-FU bolus infusion, LV and oxaliplatin), used by 9 (6.9%) patients. Table 2 correlates the most frequent therapeutic regimen with the patients’ clinical characteristics. The regimen of 5-FU/LV was used in the treatment of 40 (95.2%) patients with stage II CRC and 27 (84.4%) patients with stage III CRC. Sixty-nine patients (71.9%) that used this regimen had moderately differentiated tumors. The level of carcinoembryonic antigen (CEA) above 5 ng/mL before starting the treatment was observed in 50 (83.3%) patients. 138


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Table 2. Clinical characteristics of patients associated with the therapeutic regimen adopted as the first-line treatment. 5FU/LV Others** Total Characteristics p-value n=89 (%) n=41 (%) n=130 (%) Primary tumor site Rectum 31 (68.9) 14 (31.1) 45 (34.6) 0.90 Colon 58 (68.2) 27 (31.8) 85 (65.4) TNM stage system* II 40 (95.2) 2 (4.8) 42 (32.4) III 27(84.4) 5 (15.6) 32 (24.6) <0.001 IV 21 (40.4) 31 (59.6) 52 (40) Pathology Well differentiated 3 (75) 1 (25) 4 (3.1) Poorly differentiated 69 (71.9) 27 (28.1) 7 (5.4) <0.001 Moderately differentiated 6 (85.7) 1 (14.3) 96 (73.8) CEA baseline*/*** <5 ng/mL 50 (83.3) 10 (16.7) 60 (46.2) <0.001 >5 ng/mL 13 (48.1) 14 (51.9) 23 (20.8) Metastatic site* Liver 8 (25.8) 23 (74.2) 31 (23.8) <0.001 Others 81 (81.8) 18 (18.2) 17 (13.1) Lymph node invasion Yes 39 (61.9) 24 (38.1) 63 (48.5) 0.17 No 50 (74.6) 17 (25.4) 67 (51.5) Death* Yes 30 (56.6) 23 (43.4) 53 (40.8) 0.026 No 59 (76.6) 18 (23.4) 77 (59.2) ADR* Yes 46 (71.9) 18 (28.1) 64 (49.2) 0.23 No 9 (52.9) 8 (47.1) 17 (13.1) Purpose of treatment* Adjuvant 77 (89.5) 9 (10.5) 86 (66.2) <0.001 Palliative 12 (27.9) 31 (72.1) 43 (33.1) Response rate* Complete remission 5 (71.4) 2 (28.6) 7 (5.4) Partial remission 3 (75) 1 (25) 4 (3.1) 0.059 Stable disease 26 (86.7) 4 (13.3) 30 (23.1) Progressive disease 14 (53.8) 12 (46.2) 26 (20) *The difference in percentage is due to the number of cases without such information in the patientâ&#x20AC;&#x2122;s records; **IFL: 13 (10%) patients, FLOX (5-FU bolus infusion, LV and oxaliplatin): 9 (6.9%) patients, capecitabine: 7 (5.4%) patients, FOLFOX: 6 (4.2%) patients, XELOX (capecitabine and oxaliplatin): 3 patients (2.3%), imatinib mesilate: 2 (1.5%) patients and BFOL to only 1 (0.8%) patient. ***CEA baseline refers to the level of CEA in the beginning of the treatment, with cutoff between normal and altered 5ng/mL. 5FU/LV: 5-fluorouracil/folic acid.

The purpose of the 5-FU/LV treatment was to act as an adjuvant therapy for 77 (89.5%) patients, while the other therapeutic regimens were used in only 9 (10.5%) patients with the same purpose (p<0.001).

The patients who, according to the analyzed medical records, reported any ADR during the chemotherapeutic treatment totaled 64 (49.2%). Fortysix (71.9%) of these received the 5-FU/LV treat139


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ment. Reported ADRs included diarrhea (62.3%), mucositis (50.8%), leukopenia (7.5%), thrombopcytopenia (11.7%), nauseas (11.3%), neutropenia (10.5%) and vomiting (7.5%). Regarding the treatment response rate, the disease remained stable in 30 (23.1%) patients, 26 (86.7%) of them were treated with 5-FU/LV. Complete remission occurred in only 7 (5.4%) patients and partial remission in 26 (20%) patients, 14 (53.8%) of them were treated with 5-FU/LV. The analysis of medical records identified 53 (40.8%) deaths, 30 (56.6%) of them were treated with 5-FU/LV as the first-line treatment.

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the liver, which is in agreement with the studies conducted by Roits et al.27 and Adachi et al.4. The cellular differentiation degree is the most frequent histological variable in association with the TNM staging system, attributing a more careful prognosis to little differentiated adenocarcinomas32. In this study, only 3.1% of the tumors were well differentiated, which agrees with findings reported in previous studies28,30. Evidences show that the presence of metastatic lymph node invasion at the diagnosis is related to factors of worse prognosis, such as advanced disease and presence of distant metastasis33. Such identification is extremely important for the prognosis, but the macroscopic access to lymph nodes is not viable, as a considerable part of lymph node metastasis (more than 30%) have maximum diameter of 3 mm34. In this study, most patients (51.5%) did not present lymph node metastasis at the diagnosis, just as demonstrated by other authors33,34. Only 23 (20.4%) patients presented levels of CEA above 5ng/mL at the diagnosis. These values confirm the idea that this antigen does not have a diagnostic value, it is beneficial only for prognosis and treatment monitoring28-30. Regarding the occurrence of ADRs during the chemotherapeutic treatment, 64 (49.2%) patients mainly had diarrhea, mucositis and leukopenia, but some medical records (37.7%) did not have information about ADR occurrences, making the analysis and calculation of ADR frequency in oncological patients more difficult. In terms of first-line chemotherapeutic treatment, the 5-FU/LV regimen is indicated by two meta-analyses as the treatment of option to patients with stage II CRC10,11. In this study, 95.2% of the patients in this stage received 5-FU/LV as adjuvant therapy. In this study, 27 (84.4%) stage III patients received 5-FU/LV, which is considered by some authors a generally well-tolerated adjuvant regimen and effective for the treatment of CRC35,36. The study conducted by Twelves et al. demonstrated that oral capecitabine is a highly effective alternative to 5-FU/LV for the treatment of stage III CRC, with disease-free survival equivalent to that of 5-FU/LV with less ADRs18. On the other hand, the study conducted by Van Cutsem et al. shows capecitabine as

DISCUSSION CRC is usually affects men more often, regardless of their age24-27. In this study, the disease frequency in male patients was 54.6%, in agreement with the world tendency4. In the United States and the European Union, the disease is diagnosed in patients over 70 years old26. In this study, the mean age at the diagnosis was 60 years old, in agreement with other studies described in the literature27,28. In addition, the risk of cancer increases with the age â&#x20AC;&#x201C; 50% of the cases affect individuals over 60 years old1. Regarding the ethnic origin, most patients with CRC are known to have a Caucasian origin, also in agreement with this study, as 98.5% of the patients were white12,29. Colon was the primary tumor site in 65.4% of the analyzed patients, confirming what has been demonstrated by other investigators12,27. On the other hand, the rectum is more frequently indicated in other studies as the primary tumor site18,30. Today, the CRC staging at the diagnosis is considered an important factor of prognosis, as it is directly related to OS. Once the disease staging is known, it is possible to define the best therapy. Through the TNM system, proposed by the Union for International Cancer Control (UICC), the analysis observed that 40% of the patients had stage IV CRC at the diagnosis. This is the most severe stage, which may indicate delayed diagnosis in most patients, who, for this reason, presented more advanced neoplasms, making prognosis more difficult28. Unlike this study, other authors show stages II and III as the most frequent at the diagnosis31. In this study, the site most frequently affected by metastasis was 140


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an alternative to mCRC treatment37, where it was used as the first-line treatment by 7 (5.4%) patients, all with stage IV CRC. Other therapeutic options to treat stage II and III CRC were considered by Twelves et al., Thierry et al. and Cassidy et al. better than 5-FU/LV, as they significantly increase the overall survival of patients, such as XELOX, FOLFOX and FLOX9,18,38. In this study, these therapeutic options were used in 5 (15.6%) patients, and the regimens were FLOX and FOLFOX. The therapeutic regimen used as the first-line treatment of 21 (40.4%) stage IV patients was 5-FU/LV. The other stage IV patients (59.6%) received other therapeutic regimens, including the IFL, used by 13 (10%) patients. For the treatment of the disease at a more advanced stage, FOLFOX and FOLFIRI, in the presence or absence of monoclonal antibodies – bevacizumab (an anti-VEGF antibody) or cetuximab (an anti-EGFR antibody) – are considered first-line treatment for mCRC, as both regimens offer similar OS and disease-free survival, with different toxicity profiles14,15. However, XELOX, FOLFOXIRI, 5-FU/LV and capecitabine are also considered alternatives to first-line treatment for mCRC37-40. Regarding the utilization of IFL regimen, studies have demonstrated that FOLFIRI, FOLFOX and 5-FU/LV are related to less ADRs, such as neutropenia and gastrointestinal effects, when compared to IFL18-20. However, the adoption of chemotherapeutic regimens that use 5-FU in continuous infusion, such as FOLFIRI and FOLFOX, require the implantation of a long-term catheter (Port-A-Cath). As a result, typical complications of this type of device occur, especially thrombosis of superior vena cava and infection, both very serious and with risk of death. However, as demonstrated in this study, IFL is used as the first-line treatment for mCRC. As described above, there are many treatment options for CRC, but the selection of the best treatment to each patient is made by the oncologist based on international regulations, such as the National Comprehensive Cancer Guideline. However, this selection is many times limited, as most patients are treated under SUS, which has specific

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protocols. But, regardless of the therapeutic regimens available, the treatment option should be always selected on an individual basis, considering the best to each patient, based on his/her clinical characteristics. In addition, it should be noted that, in stage IV CRC, as the treatment is usually palliative, it is not always interesting to use the whole therapeutic arsenal in the first intervention. Not using a drug in the first-line treatment may represent the possibility of using it in the future, as the second- or third-line treatment, depending on the  response rate expected to alleviate the symptoms caused by the disease. CONCLUSION The epidemiological characteristics showed higher frequency of CRC in male patients, over 60 years of age. This study demonstrated that the most frequent primary tumor site is the colon, and that patients are diagnosed with CRC at a more advanced clinical stage of the disease, which leads to lower possibility of healing and more indefinite prognosis. Regarding the first-line treatment, the most frequent therapeutic regimen was 5-FU/LV. The treatment selection is based on international protocols, according to the patient’s clinical characteristics and the availability of the therapeutic regimen at the hospital. Most patients (49.2%) reported, at one point of the treatment, any type of ADR, regardless of the therapeutic regimen. And the most frequent ADRs were diarrhea, mucositis and leukopenia. This study demonstrates the importance of prevention campaigns that encourage periodic examinations to prevent the disease development through the identification of CRC precursor lesions. ACKNOWLEDGEMENTS We would like to thank the nursing team, physicians and other staff members of the Oncology Center at the Hospital Ana Nery for their technical support and help in the collection of data used in this article.

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1. Habr-Gama A. Câncer colorretal – A importância de sua prevenção. Arq Gastroenterol 2005;42(1):2-3. 2. Instituto Nacional de Câncer (INCA). Estimativa 2010: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2009. 3. Born LJ, Imperiale TF, Kahi CJ, Stuart JS, Qi R, Glowinski EA et al. Risk factors for advanced sporadic colorectal neoplasia in persons younger than age 50. Cancer Detect Prev 2008;32(1):33-8. 4. Adachi CT, Nadal LRM, Nunes MAA, Ishiy CAA, Bobotis VC, Andreotti AP et al. Evolução do Carcinoma Colorretal, Comparando Doentes com Idades Acima e Abaixo de 40 Anos, Quanto à Diferenciação Tumoral e ao Estádio do Tumor. Rev bras Coloproct 2009;29(3):351-7. 5. Jin L, Inoue N, Sato N, Matsumoto S, Kanno K, Hashimoto Y, et al. Comparison between surgical outcomes of colorectal cancer in younger and elderly patients. World J Gastroenterol 2011;17(12):1642-8. 6. Brasil. Ministério da Saúde. Secretaria de Assistência à Saúde. Instituto Nacional de Câncer. Falando sobre câncer do intestino/Instituto Nacional de Câncer, Sociedade Brasileira de Coloproctologia, Colégio Brasileiro de Cirurgiões, Associação Brasileira de Colite Ulcerativa e Doença de Crohn, Colégio Brasileiro de Cirurgia Digestiva, Sociedade Brasileira de Endoscopia Digestiva, Sociedade Brasileira de Cancerologia, Sociedade Brasileira de Oncologia Clínica. Rio de Janeiro: INCA, 2003. 7. Cattell E, Tebbutt NC, Midgley R, Cunningham D, Kerr D, Systemic treatment of colorectal cancer. Euro J Cancer 2002;38(7):1000-15. 8. Board RE, Valle JW. Metastatic colorectal cancer: current systemic treatment options. Drugs 2007;67:1851-67. 9. Thierry A, Boni C, Navarro M, Tabernero J, Hickish T, Topham C, et al. Improved Overall Survival With Oxaliplatin, Fluorouracil, and Leucovorin As Adjuvant Treatment in Stage II or III Colon Cancer in the MOSAIC Trial. J Clin Oncol 2009:27(19):3109-16. 10. Figueredo A, Charette ML, Maroun J, Brouwers MC, Zuraw L. Adjuvant therapy for stage II colon cancer: a systematic review from the Cancer Care Ontario Program in evidencebased care’s gastrointestinal cancer disease site group. J Clin Oncol 2004;22(16):3395-407. 11. Quasar. Adjuvant chemotherapy versus observation in patients with colorectal cancer: a randomised study. Lancet 2007;370(9604):2020-9. 12. Obeidat NA, Pradel FG, Zuckerman IH, Delisle S, Mullins D. Outcomes of Irinotecan-Based Chemotherapy Regimens in Elderly Medicare Patients With Metastatic Colorectal Cancer. Am J Geriatr Pharmacother 2009;7(6):343-54. 13. Palomaki GE, Bradley LA, Douglas MP, Kolor K, Dotson D. Can UGT1A1 genotyping reduce morbidity and mortality in patients with metastatic colorectal câncer

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26. Hall N. Colorectal cancer: features and investigation. Medicine 2011;39(5):250-3. 27. Rouits E, Charasson V, Petain A, Boisdron-Celle M, Delord, JP, Fonck M, et al. Pharmacokinetic and pharmacogenetic determinants of the activity and toxicity of irinotecan in metastatic colorectal cancer patients. Br J Cancer 2008;99(8):1239-45. 28. Saad-Hossne R, Prado RG, Neto AB, Lopes OS, Nascimento SM, Santos CRV, et al. Estudo retrospectivo de pacientes portadores de câncer de colorretal atendidos na faculdade de medicina de Botucatu no período de 2000-2003. Rev bras Coloproct 2005;25(1);31-7. 29. Innocenti F, Undevia SD, Iyer L, Chen PX, Das S, Kocherginsky M, et al. Genetic variants in the UDPglucuronosyltransferase 1A1 gene predict the risk of severe neutropenia of irinotecan. J Clin Oncol 2004;22(8):1382-8. 30. Carneiro Neto JD, Barreto JBP, Freitas NS, Queiroz MA. Câncer colorretal: características clínicas e anatomopatológicas em pacientes com idade inferior a 40 anos. Rev bras Coloproct 2006;26(4):430-5. 31. Ychou M, Raoul JL, Douillard JY, Bourgade SG, Mineur BL, Viret F, et al. A phase III randomised trial of LV5FU2 1 irinotecan versus LV5FU2 alone in adjuvant high-risk colon câncer (FNCLCC Accord02/FFCD9802). Annals of Oncology 2009; 20:674-680 32. Lupinacci RM, Campos FGCM, Araújo SEA, Imperiale AR, Seid VE, et al. Análise comparativa das características clínicas, anátomo-patológicas e sobrevida entre pacientes com câncer colo-retal abaixo e acima de 40 anos de idade. Rev bras Coloproct 2003;23(3):155-62. 33. Pereira JrT, Torres RAB, Nogueira AMMF. Acometimento metastático linfonodal no câncer colorretal. Arq Gastroenterol 2006;43(2)89-93. 34. Cserni G. The influence of nodal size on the staging of colorectal carcinomas. J Clin Pathol 2002;55(5):386-90. 35. Wolmark N, Rockette H, Fisher B, Wickerham DL, Redmond C, Fisher ER, et al. The benefit of leucovorin-modulated fluorouracil as postoperative adjuvant therapy for primary

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colon cancer: results from National Surgical Adjuvant Breast and Bowel Project protocol C-03. J Clin Oncol 1993;11(10):1879-87. 36. Efficacy of adjuvant fluorouracil and folinic acid in colon câncer. International Multicentre Pooled Analysis of Colon Cancer Trials (IMPACT) Investigators. Lancet 1995;345(8955):939-44. Comments in: Lancet 1995;345(8955):938; Lancet 1995;345(8964):1582. 37. Van Cutsem E, Hoff PM, Harper P, Bukowski RM, Cunningham D, Dufour P, et al. Oral capecitabine vs intravenous 5-fluorouracil and leucovorin: integrated efficacy data and novel analyses from two large, randomised, phase III trials. Br J Cancer 2004;90(6):1190-7. 38. Cassidy J, Clarke S, Díaz-Rubio E, Scheithauer W, Figer A, Wong R, et al. Randomized Phase III Study of Capecitabine Plus Oxaliplatin Compared With Fluorouracil/Folinic Acid Plus Oxaliplatin As First-Line Therapy for Metastatic Colorectal Cancer. J Clin Oncol 2008;26(12):2006-12. 39. Souglakos J, Androulakis N, Syrigos K, Polyzos A, Ziras N, Athanasiadis A, et al. FOLFOXIRI (folinic acid, 5-fluorouracil, oxaliplatin and irinotecan) vs FOLFIRI (folinic acid, 5-fluorouracil and irinotecan) as first-line treatment in metastatic colorectal cancer (MCC): a multicentre randomised phase III trial from the Hellenic Oncology Research Group (HORG). Br J Cancer 2006;94(6):798-805. 40. Emmanuel Mitry E, Fields ALA, Bleiberg H, Labianca R, Portierg, Tu D, et al. Adjuvant chemotherapy after potentially curative resection of metastases from colorectal cancer: a pooled analysis of two randomized trials. J Clin Oncol 2008;26(30):4906-11.

Correspondence to: Lia Gonçalves Possuelo Avenida Independência, 2293, bloco 35, sala 3504 CEP: 96815-900 – Santa Cruz do Sul (RS), Brazil E-mail: liapossuelo@unisc.br

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Original Article

Staging of colorectal cancer in the private service versus Brazilian National Public Health System: what has changed after five years? Eduardo Brambilla1, Marcos dal Ponte2, Leonardo Gilmone Ruschel3, Henrique Rasia Bosi3, Gustavo Lisbôa de Braga3, Pedro Guarise da Silva3 Assistant Professor, Department of Surgical Practice, Center of Biological and Health Sciences, Universidade de Caxias do Sul (UCS) – Caxias do Sul (RS), Brazil.2Resident, Service of General Surgery, Hospital Geral at the UCS – Caxias do Sul (RS), Brazil.3Academician, Medical Sciences, UCS – Caxias do Sul (RS), Brazil.

1

Brambilla E, dal Ponte M, Ruschel LG, Bosi HR, Braga GL, Silva PG. Staging of colorectal cancer in the private service versus Brazilian National Public Health System: what has changed after five years? J Coloproctol, 2012;32(2): 144-147. ABSTRACT: Introduction: Cancer is a disease that affects a large population, being the colorectal cancer one of the most prevalent. The early diagnosis of these neoplasms represents a better life expectancy. The high cost of diagnostic tests and the low socioeconomic status are considered factors leading to delayed diagnosis. Objectives: Assess the difference between colorectal cancer staging in patients of private clinics and patients of the Brazilian National Health Service (SUS) and assess the changes in cancer staging in the past five years. Methods: This retrospective study was conducted with 53 patients divided in two groups (SUS and private clinic) diagnosed with colorectal cancer and treated in 2009. Staging of patients diagnosed in 2009 was compared with data from patients diagnosed in 2004, already published in 2005. Results: Both groups were similar in gender and age. Regarding the staging of patients, no statistical difference was observed between the two groups (p=0.147). When comparing the staging of patients diagnosed in 2009 with that of patients studied in 2004, patients diagnosed in 2009 presented early stages (II and III) in relation to patients analyzed in 2004 (III and IV), p<0.001. Conclusion: No significant difference was observed in cancer staging between SUS and private clinic patients. The patients analyzed in 2009 were diagnosed with early stage tumors when compared to patients diagnosed in 2004. Keywords: neoplasm staging; colorectal neoplasms; unified health system; private health care, clinical evolution. RESUMO: Introdução: O câncer é uma doença que afeta grande parte da população, sendo o câncer colorretal um dos mais prevalentes. O diagnóstico precoce dessas neoplasias resulta em uma melhor expectativa de vida. O alto custo dos exames diagnósticos e o baixo nível socioeconômico são apontados como fatores que levam ao atraso no diagnóstico. Objetivos: Avaliar a diferença no estadiamento de câncer colorretal no momento do diagnóstico de pacientes oriundos da clínica privada e pacientes do Sistema Único de Saúde (SUS), assim como, avaliar as mudanças no estadiamento nos últimos cinco anos. Métodos: Estudo retrospectivo envolvendo 54 pacientes divididos em dois grupos (SUS e clínica privada) diagnosticados no ano de 2009. Os estadiamentos dos pacientes diagnosticados em 2009 foram comparados com os dados de pacientes diagnosticados em 2004, já publicados em 2005. Resultados: Ambos os grupos eram similares em gênero e idade. Em relação ao estadiamento dos pacientes não houve diferença estatística entre os dois grupos (p=0,147). Na comparação entre os pacientes de 2009 e os pacientes estudados em 2004 se evidencia que os pacientes de 2009 apresentaram-se com estádios mais precoces (II e III) em relação aos pacientes de 2004 (III e IV), p<0,001. Conclusão: Não há diferença no estadiamento dos pacientes do SUS comparado ao estadiamento dos pacientes da clínica privada. Os pacientes tratados no ano de 2009 se apresentaram com estádios mais precoces em relação aos tratados em 2004. Palavras-chave: estadiamento de neoplasias; neoplasias colorretais; sistema único de saúde; convênios particulares; evolução clínica.

Study carried out at the Service of Coloproctology at the Hospital Geral – Caxias do Sul, RS, Brazil. Conflict of interest: nothing to declare. Financial source: no declare. Submitted on: 05/17/2011 Approved on: 06/03/2011

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INTRODUCTION

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and if any change was observed in the disease staging of patients in the last five years.

Cancer is one of the main public health problems worldwide. It is a chronic and degenerative disease that affects several dimensions of human life and causes important economic impact on society, requiring a specialized, long and expensive treatment. In addition, it causes reduced labor and increased mortality1. Over 15 million new cases of cancer are expected for 2025 around the globe2. In Brazil, estimates suggested approximately 30,000 new cases of colon and rectal cancer in 2010. These numbers correspond to around 15 new cases in each 100,000 men and 16 in each 100,000 women3. It is known that the earlier the diagnosis of colorectal cancer, the better the patient’s life expectancy. Mean cumulative survival for colorectal cancer in 5 years is 40–50%, not showing great difference between developed and developing countries4. Many factors are considered determining that lead to delayed diagnosis of colorectal cancer in Brazil, such as lack of health policies that alert the population to the importance of early diagnosis, patients’ non-awareness of signs and symptoms, high cost of exams and low socioeconomic level5,6. Due to lack of resources and investments, mainly in public health, it is believed that, in Brazil, the diagnosis may be delayed in users of the Unified Health System (SUS) when compared to users of private clinics. To evaluate this question, Brambilla et al.7 conducted a retrospective study based on the analysis of staging data of patients diagnosed and treated through the SUS at the Hospital Geral of Caxias do Sul (HG-UCS) in comparison to patients from private clinics of the same medical team, in the same city. The findings showed no difference in disease staging between the two groups7. Thus, the purpose of this study was to analyze if there is any difference in the disease staging of SUS patients in relation to patients treated at private clinics

METHODS Retrospective study based on the analysis of staging data from patients diagnosed and treated through SUS at the HG-UCS and patients from private clinics of the same medical team, in the same city, in 2009. In total, 54 patients were included in the study. The patients were divided in groups, according to their health care plan (SUS and private clinic): 26 patients in the private group and 28 in the SUS group. Both groups were staged by the HG-UCS proctology team. The disease staging was based on the TNM classification (AJCC/ UICC). The comparison of staging from 2004 and 2009 used current data and data published in 20057. Statistical analysis The categorical variables, such as gender and number of patients in each stage between SUS and private clinics and between 2004 and 2009 studies, were presented as proportion, and age, as mean and standard deviation. A bivariate analysis using the chi-squared test was performed to observe staging differences between SUS and private clinics and between 2004 and 2009 studies. Statistical significance was considered when p≤0.05 was obtained, with alpha error of 0.05 and beta error of 0.20. For data storage and analysis, IBM SPSS® 18.0 for Windows (IBM, Chicago, IL, USA) was used. RESULTS Among total 54 patients, 30 (55.6%) were males and 24 (44.4%) were females; mean age was 63.4±13.8 years old. Mean age in the group of patients from private clinics was 65.6±15.0 years old and 61.46±12.72 in the SUS group. Both groups were similar in gender and age, p>0.05 (Table 1).

Table 1. Characteristics of studied groups. Total (n=54) Females 44.4% Males 55.6% Age (years) 63.44±13.8

SUS (n=28) 51.85% 53.6% 61.46±12.72

SUS: Unified Health System (public system).

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Private clinics (n=26) 48.15% 57.7% 65.58±15.00


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Regarding the disease staging, the study observed that the patients from private clinics showing stages II (50%) and III (34.6%) were predominant. In the group of SUS patients, stages II (25.9%) and III (37%) were also more frequent (Table 2). No statistical difference was observed in relation to staging between the two groups (p=0.147). The article published in 2005 showed more patients diagnosed with the disease in advanced stages – III (46.3%) and IV (36.6%). The article published in 2009 showed patients with the disease in earlier stages at the diagnosis – II (37.7%) and III (35,8%), with only 7 patients (13.2%) diagnosed with stage IV (p<0.001) (Figure 1). Table 3 shows the number of patients in each stage in 2004 and 2009.

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have a late diagnosis in relation to patients from private clinics. At private clinics, the patients usually have higher socioeconomic levels and can be submitted to complementary exams more quickly. However, we observed that the SUS patients present the same staging as those from private clinics at the diagnosis, a fact that had been observed before7. When comparing the results of our study published in 2005 to current results, we observed that, in the last five years, the predominant stages were different – III and IV in 2004 (82.9% of the patients) and II and III (73.6% of the patients) in 20097. Such data show that in the last five years, the patients were diagnosed earlier; which is an extremely important fact, since patients diagnosed in early stages present survival rate in five years of around 80%11-13. We believe that such improvement in the disease staging of patients in the last five years is a result of greater awareness of the population in general and the medical community regarding the importance of early diagnosis of colorectal cancer, higher number ofscreening exams performed and shorter time between exam request and execution; although we have no concrete data to confirm this hypothesis. In addition, it is important to observe that the Brazilian government does not have any public policy that encourages the prevention of colorectal cancer and the digital rectal exam – which is a low-cost exam that can be performed by any physician at the Basic Health Units.

DISCUSSION Colorectal cancer is a common malignant tumor, with around 28,000 new cases a year in Brazil3,8,9. This number has increased in Brazil, partially due to the increased life expectancy of the Brazilian population. Survival in this neoplasm is around 50% in five years4. Despite high investments in research on colorectal cancer, the impact on mortality has been small, which leads to studies focusing on new aspects: prevention and early diagnosis10. Exams for colorectal cancer diagnosis, such as colonoscopy and imaging exams, involve relatively high cost. As Brazil has low financial resources, mainly in health, it was believed that SUS users would

Table 2. Stage of colorectal cancer in the Unified Health System and private clinics. Stage 0 I II III IV

SUS Private clinics 0 (0%) 1 (3.8%) 5 (18.5%) 1 (3.8%) 7 (25.9%) 13 (50%) 10 (37%) 9 (34.6%) 5 (18.5%) 2 (7.7%)

p=0.147

Table 3. Comparison of 2004 staging to 2009 patients. Stage 0 I II III IV

Figure 1. Comparison of disease stages of patients treated in 2005 and 2009.

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2004 1 (2.4%) 6 (14.6%) 0 (0%) 19 (46.3%) 15 (36.6%)

2009 1 (1.9%) 6 (11.3%) 20 (37.7%) 19 (35.8%) 7 (13.2%)

p<0.001


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Staging of colorectal cancer in the private service versus Brazilian National Public Health System: what has changed after five years? Eduardo Brambilla et al.

CONCLUSION

when comparing 2004 and 2009 studies. In this period, the predominant stages were different; today, the patients are diagnosed earlier, with stages III and IV predominating in 2004 and stages II and III in 2009.

No difference was observed in the disease staging between SUS patients and patients from private clinics REFERENCES 1. 2. 3.

5.

6.

7.

8.

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Instituto Nacional de Câncer. Coordenação de Prevenção e Vigilância de Câncer. Estimativas 2008: Incidência de Câncer no Brasil. Rio de Janeiro: INCA; 2007. p. 94. 9. Brasil. Ministério da Saúde. Coordenação de Prevalência e Vigilância. Estimativa 2005: incidência do câncer no Brasil. Rio de Janeiro: INCA; 2004. 10. Vianna JN, Althoff JL. Perfil epidemiológico e anatomopatológico dos pacientes com câncer colorretal no município de Criciúma [tese de Mestrado]. Criciúma: Universidade do Extremo Sul Catarinense; 2008. 11. Winawer S, Fletcher R, Miler L, Godlee F, Stolar MH, Mulrow CD, et al. Colorectal cancer screening: clinical guideline and rationale. Gastroenterology 1997;112(2):594-642. 12. Tizler R. Colorectal cancer screening. Bloomington: Institute for Clinical Systems Improvement; 2000. p. 24-35. 13. Benson AB 3rd, Desch C, Flynn P, Krause C, Loprinzi CL, Minsky BD. 2000 update of American Society of Clinical Oncology colorectal cancer surveillance guidelines. J Clin Oncol 2000;18(20):3586-8.

Secoli SR. Perfil epidemiológico do câncer no adulto: panorama brasileiro. Ambito Hosp 2005;17(171):59-62. Organization WH. Cancer. [cited 2012 Apr 10]. Available from: http://www.emro.who.int/ncd/cancer.htm Brasil. Ministério da Saúde. Instituto Nacional do Câncer. Estimativa 2012: Incidência de câncer de colon e reto. 2012. [cited 2012 Apr 10]. Available from: http://www.inca.gov. br/estimativa/2012/index.asp?ID=5 4. Brasil. Ministério da Saúde. Sistema Único de Saúde. Datasus. Taxas de mortalidade específica por neoplasias malignas – cólon reto e ânus, por sexo, segundo faixa etária em 2002. [cited 2005 May 13]. Available from: http://tabnet.datasus.gov.br/cgi/ tabcgi.exe?idb2004/c10.def Câncer INd. Câncer do Intestino Grosso: fique de olho. Introdução à campanha de conscientização sobre câncer do intestino grosso. [cited 2002 Jun 22]. Available from: http:// www.abrapreci.org/index2.htm Santos Jr JCM. Contribuição à campanha nacional de conscientização sobre o câncer do intestino grosso. Prevenção e diagnóstico precoce. Rev Bras Coloproct 2003;23(1):32-40. Brambilla E, Chiele Neto C, Passarin TL, Pante SR, Dal Ponte M, Santos PC. Pacientes que possuem plano de saúde realizam diagnóstico mais precoce do câncer colorretal? Rev Bras Coloproct 2005;25(3):223-5. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde.

Correspondence to: Prof. Dr. Eduardo Brambilla Rua General Arcy da Rocha Nobrega, 401, sala 705 – Madureira CEP: 95040-000 – Caxias do Sul (RS), Brasil E-mail: brambilla.procto@gmail.com

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Original Article Clinical and manometric evaluation of women with chronic anal fissure before and after internal subcutaneous lateral sphincterotomy Silvana Marques e Silva1, Viviane Fernandes Rosa2, Romulo Medeiros de Almeida3, Marcelo de Melo Andrade Coura4, Paulo Gonçalves de Oliveira5, João Batista de Sousa5 Attending Postgraduate Program (PhD) in Medical Sciences, School of Medicine, Universidade de Brasília – Brasília (DF), Brazil. 2Resident Physician, University Hospital, Universidade de Brasília – Brasília (DF), Brazil 3MD, Assistant Professor, Surgical Clinics, University of Brasília School of Medicine – Brasília (DF), Brazil. 4Staff surgeon – Federal District Health Department – Brasília (DF), Brazil. 5PhD, Associate Professor, Surgical Clinics, School of Medicine, Universidade de Brasília – Brasília (DF) Brazil. 1

Silva SM, Rosa VF, Almeida RM, Coura MMA, Oliveira PG, Sousa JB. Clinical and manometric evaluation of women with chronic anal fissure before and after internal subcutaneous lateral sphincterotomy. J Coloproctol, 2012;32(2):148-153. ABSTRACT: Objective: To evaluate clinical and manometric parameters of chronic anal fissure females undergoing lateral internal sphincterotomy (LIS). Methods: A total of eight women with chronic anal fissure who underwent LIS were included in this study. The preoperative assessment was performed one week before surgery and included general and anorectal examination, anorectal manometry, and Jorge Wexner questionnaire. The post operative follow up was made every 15 days until complete healing. Jorge Wexner questionnaires and anorectal manometry were repeated at 1 month and 3 months after the surgery. Time to healing, manometric changes and complications were assessed. Results: All patients had preoperative increased anal resting pressure. The resting pressures and anal canal length were significantly decreased 3 months after surgery. Patients’ complaints of itching and bleeding were also reduced. Fissures healed in 7 patients and median healing time was 45 days. No complications were observed due to the procedure. One patient had transient incontinence to flatus. Conclusion: Lateral internal sphincterotomy provided clinical improvement and reduced resting pressure of the internal anal sphincter in women with chronic anal fissure. Keywords: anal fissure; anal canal; manometry; wound healing. RESUMO: Objetivo: Avaliar a evolução clínica e manométrica de mulheres com fissura anal crônica submetidas à esfincterotomia lateral interna subcutânea. Métodos: Estudo prospectivo com oito pacientes. A avaliação inicial foi realizada por meio de questionários, exame físico e manometria anorretal na semana anterior ao procedimento cirúrgico. Durante o período pós-operatório, as pacientes foram avaliadas clinicamente a cada 15 dias, até a cicatrização completa. Os questionários e a manometria anorretal foram repetidos 1 mês e 3 meses após a operação. Foi avaliado o tempo para cicatrização da fissura, as alterações manométricas e as complicações decorrentes do procedimento. Resultados: Todas as pacientes apresentavam hipertonia esfincteriana interna no período pré-operatório. Após 3 meses da operação, as pressões de repouso e o comprimento do canal anal funcional diminuíram de modo estatisticamente significante. Houve redução das queixas de prurido e sangramento. A cicatrização completa da fissura ocorreu em sete pacientes. A mediana do tempo de cicatrização foi de 45 dias. Não houve complicações decorrentes do procedimento. Uma paciente apresentou incontinência transitória para flatos. Conclusões: A esfincterotomia lateral interna subcutânea proporcionou melhora clínica e diminuição das pressões de repouso dos esfíncteres anais em mulheres com fissura anal crônica. Palavras-chave: fissura anal; esfíncter anal; manometria; cicatrização.

Study carried out at the Division of Colorectal Surgery, School of Medicine, Universidade de Brasília – Brasília (DF), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 01/15/2012 Approved on: 01/17/2012

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INTRODUCTION

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with an eight-channel water perfusion system manometry device. More specifically the catheter was initially placed 6 cm from the anal verge and subsequent evaluations were made considering 1 cm intervals. High anal resting pressure was defined as an anal resting pressure greater than 70 mmHg. The surgical procedure was performed by the same surgical team. The patient was positioned in the left lateral decubitus position and a proper antisepsis was performed with povidone-iodine. Local anesthesia was made using lidocaine 2% with vasoconstrictor and a 1.5 cm medium lateral incision was made around 1 cm from the anal verge. The internal anal sphincter was then isolated and sectioned using a bovie cautery up to the dentate line. The incision was finally loosely closed with 2-0 catgut chromic stitches. Postoperatively, patients were clinically evaluated each 15 days until complete anal fissure healing. The Jorge Wexner questionnaire and anorectal manometric evaluation were repeated one and three months after the surgery. Time to complete healing, early and late complications, manometric changes resulting from the procedure and patient’s satisfaction degree were assessed. The statistical analysis was made with Statistical Package for the Social Sciences (SPSS) 17.0. The Mann-Whitney’s test was used to evaluate the postoperative changes in manometric parameters. The Fisher’s exact test was used to comparer the pre and postoperative symptoms. A p value less than 0.05 was considered statistically significant. This study was approved by the University of Brasília School of Medicine Research and Ethics Committee. All patients signed an informed consent form before they were enrolled in this study.

Anal fissure was recognized as a disease in 19341. It is one of the most frequent causes of anal pain and bleeding, affecting around 10% of the patients coming to an outpatient colorectal clinic2. It can be defined as a vertical wound extending from the anal verge to the dentate line3 often becoming chronic and causing significant pain. Its prevalence is similar in both genders and more commonly affects younger patients, although it can affect old patients as well4. The majority of the anal fissure patients will report hard bowel movements and consequent local trauma, and, although there is no consensus regarding the anal fissure etiology, according to the most believed theory, this local trauma would result in internal sphincter spasm and consequent increased anal resting pressure which in turn would cause a posterior anal skin ischemia resulting in an unhealed wound5,6,7. Currently, lateral internal sphincterotomy (LIS) is the “gold standard” for the surgical treatment of anal fissure patients8. Described in 1835, this procedure results in a 95% healing rate with up to 10% patients developing some degree of anal incontinece9. The aim of this study was to evaluate clinical and manometric changes in females with chronic anal fissure undergoing LIS. METHODS This was a prospective single center study including female patients with chronic anal fissure undergoing LIS. The following exclusion criteria were considered: presence of acute anal fissure, clinical evidence of sepsis, inflammatory bowel disease or malignant neoplasm, history of prior anorectal surgery, use of immunosuppressant agents or inability to answer questionnaires. The chronic anal fissure was characterized by the presence of fibrosis at the fissure base, exposing the internal anal sphincter fibers, associated or not with hypertrophied anal papilla and/or a sentinel skin tag. The preoperative evaluation was made through general and anorectal physical examination and the Jorge Wexner questionnaire. All patients were submitted to anorectal manometry one week before surgery

RESULTS A total of 8 patients with a median age of 46 (range 21–49) years were included in this study. Median of symptom time was approximately 60 weeks. The preoperative characteristics of patients are summarized in Table 1. A statistically significant reduction in the number of patients complaining of anal itching and bleeding at defecation was observed 3 months after the surgery (Table 2). 149


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Table 1. Preoperative characteristics of patients submitted to internal subcutaneous lateral sphincterotomy. Characteristic Number of patients % Fissure location Anterior 2 25.0 Posterior 6 75.0 Sentinel skin tag Present 7 87.5 Absent 1 12.5 Prior clinical treatment Yes 7 87.5 No 1 12.5 Table 2. Symptoms and signs of patients submitted to internal subcutaneous lateral sphincterotomy: preoperative evaluation and 3 months after the surgery. Preoperative period 3 months after the surgery Symptom/signs p-value (number of patients) (number of patients) Hard bowel movements 4 1 0.11 Pain at evacuation 8 5 0.20 Bleeding 7 3 0.05 Itch 7 3 0.05 Tenesmus 5 1 0.13 Skin tag 6 3 0.15

Table 3. Values of functional anal canal length and resting pressure and contraction pressure at the preoperative manometric evaluation and 1 month after the surgery. Parameter Preoperative period 1 month after the surgery p-value Resting pressure (mmHg) 115.28 111.52 0.50 Contraction pressure (mmHg) 195.31 178.71 0.50 Functional anal canal (cm) 3.25 2.50 0.08

Table 4. Values of functional anal canal length and resting pressure and contraction pressure at the preoperative manometric evaluation and 3 months after the surgery. Parameter Preoperative period 3 months after the surgery p-value Resting pressure (mmHg) 115.28 75.15 0.007 Contraction pressure (mmHg) 195.31 176.9 0.279 Functional anal canal (cm) 3.25 1.88 0.003

Table 5. Self-perception of health condition before and after internal subcutaneous lateral sphincterotomy. 1 month after 3 months after Preoperative period Health condition the surgery the surgery (number of patients) (number of patients) (number of patients) Good or excellent 4 8 8 Tolerable or bad 4 0 0 p=0.04.

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Table 6. Postoperative patients satisfaction regarding lateral internal sphincterotomy. 1 month after the surgery 3 months after the surgery Degree of satisfaction (number of patients) (number of patients) Very satisfied 5 8 Satisfied 2 0 Not satisfied 1 0

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p-value 0.50 0.50 0.08

DISCUSSION

Preoperatively all patients had high anal resting pressure. A reduction of these values was observed in seven patients at the final evaluation, becoming normal or close to the normal reference. In one patient the 3 months postoperative resting anal was higher than the preoperative values. However, this patient achieved complete anal fissure healing. Maximum voluntary contraction pressures (MVCP) had variable alterations. Three patients had 3 months postoperative MVCP values higher than the preoperative values. All the remaining patients had a reduction in MVCP values. All of them kept final values above 100 mmHg, i.e., within the range of normal parameters. The preoperative and 1 month postoperative resting anal pressure, contraction pressure and length of functional anal canal were statistically similar (Table 3). However, the three months postoperative resting anal pressure and length of functional anal canal were significantly lower then the preoperative values (Table 4). Seven patients had complete anal fissure healing with a median time of of 45 (range 15â&#x20AC;&#x201C;90) days. One patient did not progress with complete wound healing, however, she had a reduction in resting anal pressure, from 99 to 59 mmHg, and significant improvement of her symptoms. The only patient that had incontinence to flatus right after surgery fully recovered her anal continence at the final evaluation. The median Jorge and Wexner score was zero in the preoperative period and 1 and 3 months after the surgery. No early or late complication was observed resulting from the procedure. Each patientâ&#x20AC;&#x2122;s perception of her own health condition had a statistically significant improvement at the end of the treatment (Table 5). All patients reported satisfaction with the treatment 3 months after the surgery (Table 6) and they said they would be willing to undergo the procedure again if necessary.

LIS performed with local anesthesia in an outpatient setting is a safe and effective method for chronic anal fissure treatment11. In this study, the patients were young and most of them had a fissure in the posterior midline, what is in agreement with the literature. In a recent study involving chronic anal fissure patients, only 25% of women and 8% of men had anterior fissures, while in 3% of the cases the two positions coexisted12. It is important to note that the presence of unusual locations or multiple lesions may indicate the diagnosis of other diseases, such as HIV, inflammatory bowel disease and other infectious causes5. Only one patient did not had intestinal constipation at the preoperative evaluation. Constipation used to be considered an essential factor in anal fissure etiology. More specifically the anal trauma following a bowel movement would cause pain which in turn would increase anal resting pressure provoking more constipation and establishing a vicious circle. However, some studies have shown that a high resting anal pressure may not be caused by pain, as it does not respond to topical anesthetics13. In addition, 25% of the patients with chronic anal fissure do not present history of intestinal constipation12,14. According to the most accepted theory regarding anal fissure etiology relies on a relative ischemia of the posterior anal midline. At a glance, the average blood pressure of the terminal arteries that cross the internal sphincter is 85 mmHg. This pressure would not be great enough to overcome the high resting anal pressure (90 mmHg) observed in anal fissure patients. As a result, the blood flow to fistula area would be decreased, preventing its healing15. Schouten et al.16 defined an inverted correlation between irrigation of the posterior midline and maximum resting anal pressure in both health and anal 151


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fissure patients. In the evaluation of these authors, healthy individuals had lower perfusion at the posterior midline when compared to other studied quadrants. Patients with anal fissure had greater resting anal pressures and lower perfusions. In our study, all patients had high resting anal pressure at the preoperative manometric evaluation. Currently LIS is the most commonly used surgical technique for chronic anal fissure treatment as it is associated with high healing rate and significantly improvement in patient quality of life17-19. It provides permanent reduction of resting pressure of the anal canal in more than 95% of the patients20,21 and the healing rate is also over 95%21,22. In our study, seven out of eight patients achieved complete fissure healing with a median time of 45 days. Almost all patients had, at the final evaluation, decreased resting and squeezing anal pressure. Moreover, self-perception of their health condition improved in the postoperative period, and all patients said they were satisfied or very satisfied with the treatment in the last evaluation. Other authors evaluated 487 patients, with an average of 72 months follow-up after sphincterotomy. The overall healing rate was 96% and the median healing time was 3 weeks. Although some degree of incontinence during the follow-up occurred in 45% of the patients; most of them were of mild intensity and transient duration. Finally, 95% of the patients were happy with the surgical outcomes23. Alper et al.24 evaluated patients submitted to sphincterotomy, hemorrhoidectomy and compared

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them to patients with regular manometric evaluations. As expected, anal fissure patients had a greater baseline values of resting anal pressure than the others. Anal fissure patients also had a reduction in resting anal pressure 1 month after sphincterotomy. Moreover, 12 months after surgery, the resting anal pressure values remained significantly lower than the preoperative values. Ram et al.25 evaluated 50 patients submitted to sphincterotomy. Mean baseline pressure was 138±28 mmHg. A statistically significant reduction was observed in these values 1 month after the surgery, with subsequent gradual increase up to 12 months after the surgery, but yet still lower than the preoperative values. In our study, no patient presented complications related to the surgical procedure. But complications have already been described after sphincterotomy, such as bleeding, abscess formation and hematomas26. Only one patient had transient incontinence to flatus, recovering complete continence 8 weeks after the procedure. Fecal incontinence has been described in up to 16% of the patients submitted to LIS9,27, being more common in the first 5 weeks with the recovery rate varying in the literature23. However, its incidence may alter according to the surgical technique, length of sphincterotomy and follow-up period20,28. CONCLUSION In this study, LIS provided improved clinical status and reduced resting anal pressure values in women with chronic anal fissure.

REFERENCES

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Lockhart-Mummery JP. Diseases of the rectum and colon and their surgical treatment. Toronto: MacMillan; 1934. 2. Pescatori M, Interisano A. Annual report of the Italian coloproctology units. Tech Coloproctol 1995;3(29-30). 3. Orsay C, Rakinic J, Perry WB, Hyman N, Buie D, Cataldo P, Newstead G, Dunn G, Rafferty J, Ellis CN, Shellito P, Gregorcyk S, Ternent C, Kilkenny J 3rd, Tjandra J, Ko C, Whiteford M, Nelson R; Standards Practice Task Force; American Society of Colon and Rectal Surgeons. Practice parameters for the management of anal fissures (revised). Dis Colon Rectum 2004;47(12):2003-7. 4. Lindsey I, Jones OM, Cunningham C, Mortensen NJ. Chronic anal fissure. Br J Surg 2004;91(3):270-9.

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Herzig DO, Lu KC. Anal fissure. Surg Clin North Am 2010;90(1):33-44, Table of Contents. Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum 1994;37(5):424-9. Xynos E, Tzortzinis A, Chrysos E, Tzovaras G, Vassilakis JS. Anal manometry in patients with fissure-in-ano before and after internal sphincterotomy. Int J Colorectal Dis 1993;8(3):125-8. Altomare DF, Binda GA, Canuti S, Landolfi V, Trompetto M, Villani RD. The management of patients with primary chronic anal fissure: a position paper. Tech Coloproctol 2011;15(2):135-41. Elsebae MM. A study of fecal incontinence in patients with chronic anal fissure: prospective, randomized, controlled trial


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of the extent of internal anal sphincter division during lateral sphincterotomy. World J Surg 2007;31(10):2052-7. Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993;36(1):77-97. Sousa JB, Oliveira PG, Santos ACN, Guilherme Filho J, Wurmbauer IFS. Subcutaneous lateral internal sphincterotomy for chronic anal fissure in outpatient under local anesthesia. Arq Bras Cir Dig 2003;16(3):124-6. Hananel N, Gordon PH. Re-examination of clinical manifestations and response to therapy of fissure-in-ano. Dis Colon Rectum 1997;40(2):229-33. Minguez M, Tomas-Ridocci M, Garcia A, Benages A. [Pressure of the anal canal in patients with hemorrhoids or with anal fissure. Effect of the topical application of an anesthetic gel]. Rev Esp Enferm Dig 1992;81(2):103-7. Article in Spanish. Lock MR, Thomson JP. Fissure-in-ano: the initial management and prognosis. Br J Surg 1977;64(5):355-8. McCallion K, Gardiner KR. Progress in the understanding and treatment of chronic anal fissure. Postgrad Med J 2001;77(914):753-8. Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum 1994;37(7):664-9. Mentes BB, Tezcaner T, Yilmaz U, Leventoglu S, Oguz M. Results of lateral internal sphincterotomy for chronic anal fissure with particular reference to quality of life. Dis Colon Rectum 2006;49(7):1045-51.18. Ortiz H, Marzo J, Armendariz P, De Miguel M. Quality of life assessment in patients with chronic anal fissure after lateral internal sphincterotomy. Br J Surg 2005;92(7):881-5. Nelson R. Operative procedures for fissure in ano. Cochrane Database Syst Rev 2005(2):CD002199. Madoff RD, Fleshman JW. AGA technical review on the diagnosis and care of patients with anal fissure. Gastroenterology 2003;124(1):235-45.

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21. Nelson RL. A review of operative procedures for anal fissure. J Gastrointest Surg 2002;6(3):284-9. 22. Wiley M, Day P, Rieger N, Stephens J, Moore J. Open vs. closed lateral internal sphincterotomy for idiopathic fissurein-ano: a prospective, randomized, controlled trial. Dis Colon Rectum 2004;47(6):847-52. 23. Nyam DC, Pemberton JH. Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum 1999;42(10):1306-10. 24. Alper D, Ram E, Stein GY, Dreznik Z. Resting anal pressure following hemorrhoidectomy and lateral sphincterotomy. Dis Colon Rectum 2005;48(11):2080-4. 25. Ram E, Alper D, Stein GY, Bramnik Z, Dreznik Z. Internal anal sphincter function following lateral internal sphincterotomy for anal fissure: a long-term manometric study. Ann Surg 2005;242(2):208-11. 26. Khan JS, Tan N, Nikkhah D, Miles AJ. Subcutaneous lateral internal sphincterotomy (SLIS)--a safe technique for treatment of chronic anal fissure. Int J Colorectal Dis 2009;24(10):1207-11. 27. Renzi A, Izzo D, Di Sarno G, Talento P, Torelli F, Izzo G, et al. Clinical, manometric, and ultrasonographic results of pneumatic balloon dilatation vs. lateral internal sphincterotomy for chronic anal fissure: a prospective, randomized, controlled trial. Dis Colon Rectum 2008;51(1):121-7. 28. Garcia-Aguilar J, Belmonte Montes C, Perez JJ, Jensen L, Madoff RD, Wong WD. Incontinence after lateral internal sphincterotomy: anatomic and functional evaluation. Dis Colon Rectum 1998;41(4):423-7.

Correspondence to: Silvana Marques e Silva SQS 405 bloco B, apto. 205 CEP: 70239-020 – Brasília (DF), Brazil E-mail: silvismarques@yahoo.com.br

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Original Article

Laparoscopic colorectal surgery: what to expect from an initial experience Fábio Ramos Teixeira1, Gustavo Ramos Teixeira2, Thiago Costa dos Santos3, Juvenal da Rocha Torres Neto4 Resident Physician in Coloproctology, Hospital Universitário da Universidade Federal de Sergipe (UFS) – São Cristóvão (SE), Brazil. 2Academician in Medicine, Universidade Federal de Alagoas (UFAL) – Maceió (AL), Brazil. 3 Resident Physician in Coloproctology, UFS – São Cristóvão (SE), Brazil. 4Doctor and Head of the Service of Coloproctology, UFS – São Cristóvão (SE), Brazil. 1

Teixeira FR, Teixeira GR, Santos TC, Torres Neto JR. Laparoscopic colorectal surgery: what to expect from an initial experience. J Coloproctol, 2012;32(x):154-162. ABSTRACT: Laparoscopic colorectal surgery is less traumatic when compared to traditional surgery techniques, with well-established advantages. The objective of this study was to report the experience in laparoscopic surgical treatment of colorectal diseases. Method: Catalog all patients submitted to laparoscopic colorectal surgery performed by one surgeon and perform a descriptive analysis of key data from these records. Results: The study analyzed data from 43 patients who underwent laparoscopic colorectal surgery. Most were females (n=30; 69.77%) in relation to males (n=13; 30.23%), mean age of 57.21 years old. Among the indications for surgery, diverticular disease was the most frequent (n=20; 46.51%), followed by malignancy (n=13; 30.23%). Most patients underwent rectosigmoidectomy (n=28; 65.12%), followed by right hemicolectomy (n=6; 13.95%), with conversions in five cases (11.63%). The study observed a tendency towards increased number of surgeries, reduced average operative time as well as decreased conversions to laparotomy along the studied period. Conclusion: Laparoscopic colorectal surgery is a safe procedure, and with the technical development of the team, the results have been increasingly good. Keywords: surgery; colorectal surgery; laparoscopy. RESUMO: A videolaparoscopia colorretal apresenta-se como uma tática operatória menos traumática com vantagens bem-estabelecidas. O objetivo deste trabalho foi apresentar a experiência no tratamento cirúrgico videolaparoscópico das afecções colorretais. Método: Catalogar todos os pacientes submetidos à cirurgia colorretal videolaparoscópica realizadas por um único cirurgião e realizar uma análise descritiva dos principais dados a partir dos prontuários destes. Resultados: O estudo analisou dados de 43 pacientes que foram submetidos à cirurgia colorretal por videolaparoscopia. A maioria era do gênero feminino (n=30; 69,77%) em relação ao masculino (n=13; 30,23%) com média de idade de 57,21 anos. Dentre as indicações cirúrgicas, doença diverticular foi a mais frequente (n=20; 46,51%), seguido de doença maligna (n=13; 30,23%). A maioria dos pacientes foi submetida a retossigmoidectomia (n=28; 65,12%), seguido de colectomia direita (n=6; 13,95%), com conversões em cinco casos (11,63%). Houve uma tendência crescente no número de cirurgias, na proporção de cânceres removidos por laparoscopia ao longo dos anos em estudo, assim como uma diminuição crescente na média do tempo operatório e nas conversões para laparotomia. Conclusão: A videolaparoscopia colorretal é um procedimento seguro e, com a evolução técnica da equipe, os resultados vão se tornando cada vez mais satisfatórios. Palavras-chave: cirurgia; cirurgia colorretal; laparoscopia.

Study carried out at the Centro de Ciências Biológicas e da Saúde, Departamento de Medicina da Universidade Federal de Sergipe (UFS) – São Cristóvão (SE), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 03/01/2012 Approved on: 03/06/2012

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INTRODUCTION

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surgery performed by only one surgeon and treated at the Service of Coloproctology at Torres Centro Médico. The information was collected according to a protocol (Annex I), with the following main variables: type of site of treated diseases, procedures performed, surgery duration and hospitalization period, conversion rate and causes, intraoperative and postoperative complications, anatomopathological data of tumors, mortality and recurrence rates. The information was collected from the patients’ records, after obtaining the authorization from the institution’s management, through a document (Annex II) ensuring secrecy of the patients’ identity and no damage to the institution. The Informed Consent Term signed by the patients was not required, as the study only collected data contained in the patients’ medical records. A descriptive analysis of main data was performed using spreadsheets elaborated in Microsoft Excel® 2007. The study was approved by the Research Ethics Committed of the Universidade Federal de Sergipe.

In the 1990s, the laparoscopic access was introduced in colorectal surgeries. Of reduced indications, limited to a small group of surgeons at the time, the access is today employed by innumerous coloproctologists, and the indications have been expanded to any type of colorectal procedure1-4. The advantages of laparoscopic colorectal surgery have been consolidated by innumerous scientific studies, as this method involves a minimally invasive technique and reduced surgical trauma. Less postoperative pain, shorter hospitalization and earlier return to activities have been some of the great benefits leading to the selection of this access4-8. However, some factors make it difficult to expand this technique to an even greater number of coloproctologists, such as: learning curve, voluminous tumors or tumors infiltrating into adjacent structures, multiple intracavitary adhesions, voluminous incisional hernias, preservation of oncological principles, among others9. In cancer, laparoscopic resections were postponed, and were adopted only after surgeons acquired more experience. Published studies that presented implantation due to trocar injury criticized at first the adoption of this access in oncological surgeries10, but other studies demonstrated similar incidence of implantation in the abdominal wall when using laparotomy11. With the improvements in surgical techniques and materials, the principles of oncological radicality have been really preserved, as indicated in several publications comparing specimens resected through laparoscopy and laparotomy6,8,12. With this new access, new complications appeared, not only regarding the surgery itself, but also related to the pneumoperitoneum and puncture and trocars. Some authors report greater incidence of complications in the surgeon’s initial experience, with the frequency of complications inversely proportional to the medical team’s experience13. The purpose of this study was to report the experience in laparoscopic colorectal surgery.

RESULTS From May 2007 to October 2011, 43 patients were submitted to laparoscopic colorectal surgery. Most of them were females (n=30; 69.77%) in relation to males (n=13; 30.23%). Age varied from 17 to 83 years old, with mean age of 57.21, and, most of them were from Aracaju (n=36; 83.72%). A growing number of surgeries was observed along the years (3 in 2007; 7 in 2008; 8 in 2009; 11 in 2010; 14 in 2011) (Figure 1), as well as an increasing proportion of cancer removed through laparoscopy (1 in 2008; 1 in 2009; 5 in 2010; 6 in 2011) (Figure 2). The mean period of hospitalization was 7.63 days (varying from 3 to 33 days) and the mean duration of surgery was 229.30 minutes (varying from 105 to 450 minutes). The most frequent surgical indication was diverticular disease (n=20; 46.51%), followed by malignant disease (n=13; 30.23%), endometriosis (n=3; 6.98%), Crohn’s disease (n=2; 4.65%), adenocarcinoma of the descending colon (n=1; 2.33%), lipoma in the ascending colon (n=1; 2.33%) and intestinal

PATIENTS AND METHODS This is a retrospective observational study of all patients submitted to laparoscopic colorectal 155


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2

2 2

3 20

13

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Diverticular disease Mallignant neoplasm Endometriosis Inflammatory bowel disease Benign tumors Others

Figure 3. Distribution by surgical indication. Figure 1. Number of surgeries performed between 2007 and 2011.

3 3 6

2 2 11 28

Rectosigmoidectomy Right colectomy Total colectomy Left colectomy Transversectomy Intestinal reconstruction Rectal amputation

Figure 4. Distribution of surgical procedures performed.

total colectomy (n=3; 6.98%), left colectomy (n=2; 4.65%), transversectomy (n=2; 4.65%), intestinal reconstruction after a Hartmann intervention (n=1; 2.33%) and rectal amputation (n=1; 2.33%) (Figure 4). Five cases (11.63%) presented conversion and the causes were: presacral bleeding, anastomotic bleeding, tumor in the left ureter and left external iliac artery, lesion in the left ureter and adhesions with lesions in the small bowel. Besides these five intraoperative complications, three other occurred but no conversion was required: fault in mechanical suture, peripancreatic bleeding and another with lesion in the small bowel, totaling eight cases with intraoperative complications (18.60%). Postoperative complications were observed in 12 patients (27.91%), which were: 1) rectal bleeding associated with wall hematoma and deep venous thrombosis; 2) respiratory failure associated with hemodynamic instability and extended ileum; 3) wall hematoma progressing to incisional hernia; 4) anastomotic bleeding; 5) obstruction with small bowel necrosis, with reoperation required for resection, and progressing to short-bowel syndrome; 6) necrosis of

Figure 2. Number of surgeries for malignant neoplasm removal from 2007 to 2011.

reconstruction after Hartmann intervention (n=1; 2.33%) (Figure 3). Two cases (4.65%) presented two simultaneous indications: one case with diverticular disease associated with endometriosis and one case with diverticular disease associated with adenocarcinomas of the ascending and transverse colon. The tumor site distribution in colorectal diseases showed that most of them occurred in the sigmoid colon (n=24; 55.81%), followed by the ascending colon (n=4; 9.30%), rectosigmoid junction (n=3; 6.98%), rectum (n=3; 6.98%), diffuse disease (n=3; 6.98%), descending colon (n=2; 4.65%), transverse colon (n=2; 4.65%), cecum (n=1; 2.33%) and cecal appendix (n=1; 2.33%). Regarding the procedures performed, most patients were submitted to rectosigmoidectomy (n=28; 65.12%), followed by right colectomy (n=6; 13.95%), 156


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the lowered colon associated with intracavitary collections and non-lithiasic cholecystitis; 7) bowel obstruction due to recurrent neoplasm with carcinomatosis; 8) obstruction due to adhesion and stenotic anastomosis, with recurrent neoplasm; 9) hernia at the trocar site, as well as stenotic colorectal anastomosis; 10) rectal bleeding; 11) rectal bleeding, progression to stenotic anastomosis; 12) anastomotic dehiscence and peritonitis, requiring multiple surgeries, progressing to death on the 33rd hospitalization day. When analyzing the groups of 2 most frequent surgical indications, we have the following results: in patients that had diverticular disease as the surgical indication, the mean period of hospitalization was 6 days (ranging from 3 to 21 days) and the mean duration of surgery was 237.95 minutes (ranging from 105 to 400 minutes). The most frequent surgical procedure in this group of patients was rectosigmoidectomy (n=20), followed by total colectomy (n=2). Conversion to laparotomy was required in 3 patients. In patients with malignant neoplasm, the mean hospitalization was 11.85 days (ranging from 4 to 33 days) and the mean duration of surgery was 232.69 minutes (ranging from 150 to 450 minutes). The most frequent surgical procedure was rectosigmoidectomy (n=6), followed by right colectomy (n=4), left colectomy (n=1), transversectomy (n=1) and rectal amputation (n=1). Conversion was required in two patients, two presented recurrent neoplasm and one died after surgical complications. The most frequent histological type was adenocarcinoma (n=12), followed by carcinoid tumor (n=1). It was possible to obtain information regarding the degree of differentiation and complete disease staging in 10 cases; 80% were moderately differentiated and 20% well differentiated. Regarding the disease staging, 50% were stage II, 40% stage III and 10% stage I. Mean resected ganglia were 16.33 (ranging from 8 to 38). When dividing all 43 patients into 3 groups of 14 first surgeries (group 1), 14 intermediate surgeries (group 2) and 15 last surgeries (group 3), we obtained the following results: 1) growing reduction was observed in the mean duration of surgery (Figure 5), group 1 presenting 246.07 minutes (ranging from 170 to 450 minutes), group 2 with 225.36 minutes (105 to 400 min.) and group 3 with 217.33 minutes (105 to 360 min.); 2) growing number of surgeries for malig-

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nant neoplasm removal was observed in all 3 groups (Figure 6), group 1 with 2 cases, group 2 with 5 cases and group 3 with 6 cases; 3) reduced number of conversion to laparotomy (Figure 7), group 1 with 3 cas-

Figure 5. Mean duration of surgery in the three groups of surgery.

Figure 6. Number of surgeries for malignant neoplasm removal in the three groups.

Figure 7. Number of conversions to laparotomy in the three groups of surgery.

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Table 1. Mean duration of surgery and number of conversions in the procedures of rectosigmoidectomy and right colectomy.

es, group 2 with 1 case and group 3 with 1 case. Mean hospitalization was 6.07 days in group 1, 10.29 days in group 2 and 6.60 in group 3. When dividing the groups of the 2 most frequent surgical procedures into subgroups, we had the following results: from total 28 rectosigmoidectomy procedures, the 14 first interventions (subgroup  1) had mean duration of surgery of 250.36 minutes (ranging from 170 to 450 minutes), while the 14 last interventions (subgroup 2) presented mean duration of 206.79 minutes (105 to 300 minutes). Subgroup 1 had 3 conversions, while subgroup 2 had no conversion. From total 6 right colectomy procedures, the 3 first interventions (subgroup 1) had mean duration of surgery of 186.67 minutes (ranging from 170 to 210 minutes), while the 3 last interventions (subgroup 2) presented mean duration of 171.67 minutes (120 to 200 minutes). No conversions were performed in this group of surgeries (Table 1).

Mean duration of 228.57 minutes rectosigmoidectomy 14 first surgeries 250.36 min 14 last surgeries 206.79 min Conversions in 3 rectosigmoidectomy 14 first surgeries 3 14 last surgeries 0 Mean duration of right colectomy 179.17 min 3 first surgeries 186.67 min 3 last surgeries 171.67 min Conversions in right colectomy 0

Ceará and at the Hospital São Carlos, in the City of Fortaleza7, cancer treatment occurred in 141 cases (35.1%), with this as the most frequent indication, followed by diverticular disease in 107 (26.7%). The national Brazilian record of colorectal videosurgery in 20073 also showed malignant disease (n=2,389; 49.6%) as the most frequent indication, with diverticular disease in 961 cases (20.2%). Among the surgical procedures, rectosigmoidectomy was the most frequent intervention (n=28; 65.12%), followed by right colectomy (n=6; 13.95%). A similar pattern was observed in national records3,4. Results of records from laparoscopic colorectal surgeries performed in the State of Minas Gerais – Brazil, from 1996 to 20094, showed rectosigmoidectomy as the most frequent procedure (n=207; 41.1%), followed by right colectomy (n=63; 12.5%). Conversion was observed in five cases (11.63%) out of eight cases with intraoperative complications (18.60%) in our study. One analysis performed in Singapore14, the rate of conversions was 10.5%. The Brazilian medical literature3 reports conversions to laparotomy in 5.5%, with rates ranging from 0 to 16.5% among the medical teams. When analyzing the group of patients with malignant neoplasm, the most frequent histological type was adenocarcinoma (n=12; 92.31%), followed by carcinoid tumor (n=1; 7.69%). Most of

DISCUSSION The study analyzed 43 patients submitted to laparoscopic colorretal surgery in the State of Sergipe. Most were females (n=30; 69.77%) in relation to males (n=13; 30.23%); age varied from 17 to 83 years old, with mean age of 57.21. The national Brazilian record of colorectal videosurgery in 20073, which gathered data from 28 medical teams from different Brazilian states, also presented a greater number of female patients (n=2,750; 58.6%), at similar mean age (57.7 years old). The study observed increasing number of surgeries along the years, which is also demonstrated in this national record of 2007, as well as in studies conducted in other countries14. Most patients had benign disease, with malignant neoplasm leading to surgery observed in 13 cases (30.23%). The study also observed increased number of cancer removed through laparoscopy during the analyzed period, also reported in other national and international studies3,14. Diverticular disease was the most frequent indication (n=20; 46.51%), and 2 other cases had diverticular disease associated with another pathology, totaling 22 cases (51.16%). At the Service of Coloproctology at the Hospital das Clínicas da Universidade Federal do 158


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them were moderately differentiated (80%) and were classified as stage II (50%) and III (40%) of the disease. Mean resected ganglia were 16.33 (ranging from 8 to 38). The record of surgeries performed in Minas Gerais4, the national record of colorectal videosurgery in 20073 and the international medical literature14 report similar results in their studies. Our study enabled to analyze the learning curve in several evaluations. When dividing all 43 patients into 3 groups of 14 first surgeries (group 1), 14 intermediate surgeries (group 2) and 15 last surgeries (group 3), we observed growing reduction in the mean duration of surgery, growing proportion of surgeries for malignant neoplasm removal and reduced number of conversions to laparotomy. When dividing the groups of two most frequent surgical procedures into subgroups with the first half of surgeries (subgroup 1) and the second half of surgeries (subgroup 2), we observed reduced mean duration of surgery and reduced rate of conversions. In the study conducted by Bruch

et al.15, the learning curve in laparoscopic colorectal surgery was analyzed by dividing 300 patients into 3 groups of 100, for the period of 5 years. Conversion was observed in 22 cases (7.3%). The incidence of conversion reduced from 8.0% (first and second groups) to 6.0% (third group), and the mean duration of surgeries also reduced in the 3 groups: from 251.4 to 213.5 minutes (first and second groups) and to 196.9 minutes (third group).

REFERENCES

Rectum 1996;39(10 Suppl):S35-46. 7 Regadas FSP, Regadas SMM, Rodrigues LV, Lima D, Silva FR, Regadas Filho FSP. Cirurgia colorretal laparoscópica. Experiência com 401 casos. Rev bras videocir. 2005;3(4):191-5 8 Reis Neto JA, Cordeiro F, Quilici FA, Reis JA Jr. Cirurgia colorretal por videolaparoscopia versus cirurgia convencional. In: Ramos JR, Regadas FSP e Souza JS. Cirurgia colorretal por videolaparoscopia. Revinter: Rio de Janeiro; 1997. p. 29-33. 9 Pinho M. Por que a cirurgia colorretal por via laparoscópica ainda não se consolidou? In: Tópicos em gastroenterologia 11. Avanços em coloproctologia; 2001. p. 287-95. 10 Wexner SD, Cohen SM. Port site metastases after laparoscopic colorectal surgery for cure of malignancy. Br J Surg 1995;82:295-8. 11 Ramos JM, Gupta S, Anthone GJ, Ortega AE, Simons AJ, Beart RW Jr. Laparoscopy and colon cancer: is the port site at risk? A preliminary report. Arch Surg 1994;129(9):897-9. 12 Buchmann P, Christen D, Flury R, Luthy A, Bischofberger U. Does laparoscopic colonic carcinoma surgery satisfy the radicality criteria of open surgery? Schweiz Med Wochenschr 1995;125(39):1825-9.

CONCLUSION Based on the results of this study, we concluded that laparoscopic colorretal surgery is a safe and comprehensive procedure. The preservation of oncological principles is possible in this approach, with low complication and tumor recurrence rates. This study showed the learning curve as an initial obstacle to complete utilization of laparoscopy in colorectal surgery, but, with the technical development of the team, the results have been increasingly good.

1

Corman ML, Sackier JM. Laparoscopic-assisted colon e rectal surgery. In: Corman ML, editor. Colon & Rectal Surgery. Philadelphia: Lippincott-Raven; 1998. 2 Regadas FSP, Averbach M, Campos FGCM, Pandini LC, Reis Neto AJ, Ramos JR. Experiência brasileira em cirurgia laparoscópica colorretal: [Mesa-redonda]. Rev bras videocir 2004;2(2):93-97. 3 Valarini R, Campos FGCM. Resultados do registro nacional brasileiro em vídeo-cirurgia colorretal 2007. Rev Bras Coloproct 2008;28(2):145-55. 4 Queiroz FL, Cortes MGW, Neto PR, Alves AC, Freitas AHA, Lacerda-Filho A, et al. Resultados do registro de cirurgias colorretais videolaparoscópicas realizadas no Estado de Minas Gerais – Brasil de 1996 a 2009. Rev Bras Coloproct 2010;30(1):61-7. 5 Chen HH, Wexner SD, Iroatulam AJ, Pikarsky AJ, Alabaz O, Nogueras JJ, et al. Laparoscopic colectomy compares favorably with colectomy by laparotomy for reduction of postoperative ileus. Dis Colon Rectum 2000;43(1):61-5. 6 Franklin ME Jr, Rosenthal D, Abrego-Medina D. Prospective comparison of open versus laparoscopic colon surgery for carcinoma: five-year results. Dis Colon

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13 Pandini LC, Gonçalves CA, Neto RC. Complicações da cirurgia colorretal laparoscópica. Tópicos em gastroenterologia 11. Avanços em coloproctologia; 2011. p. 319-27. 14 Wong MTC, Ng KH, Lim JF, Ooi BS, Tang CL, Eu KW. 418 cases of laparoscopic colorectal resections: a singleinstitution experience and literature review. Singapore Med J 2010;51(8):650-4. 15 Bruch H, Schiedeck Th, Schwandner O. Laparoscopic

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colorectal surgery: a five-year experience. Dig Surg 1999;16(1):45-54.

Correspondence to: Fábio Ramos Teixeira Avenida Oceânica, 1077, apt. 401, bloco A – Atalaia Velha CEP: 49035-000 – Aracaju (SE), Brazil E-mail: teixeirafr15@gmail.com

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Annex I RESEARCH Protocol LAPAROSCOPIC COLORRETAL SURGERY: iniTial EXPERIENCE Name: Registration: Age: Birth Date: Gender: Marital Status: Occupation: Origin: Place of Birth: Date of Surgery: Hospitalization period: Duration of Surgery: 1. Surgical indication: ( ) Malignant neoplasm ( ) Inflammatory bowel disease ( ) Intestinal reconstruction after Hartmann procedure ( ) Others:____________________

( ) Diverticular disease ( ) Benign tumors

2. Tumor site: ( ) Cecum ( ) Ascending colon ( ) Transverse colon ( ) Descending colon ( ) Sigmoid colon ( ) Rectum ( ) Cecal appendix ( ) Anal canal 3. Surgery performed: ( ) Rectosigmoidectomy ( ) Left colectomy ( ) Rectal amputation

( ) Right colectomy ( ) Total colectomy ( ) Others:____________________

4. Conversion: ( ) Yes ( ) No 4.1. Conversion causes: ( ) Technical difficulty ( ) Fixed tumor ( ) Adhesions ( ) Visceral lesion ( ) Bleeding ( ) Others:____________________ 5. Intraoperative complications: ( ) Lesion of the ureter ( ) Lesion of the small bowel ( ) Fault in mechanical suture ( ) Others:____________________

( ) Vascular lesion ( ) Lesion in the colon ( ) Hypercapnia

6. Postoperative complications: ( ) Infection in surgical injury ( ) Anastomotic dehiscence or fistula ( ) Extended ileum ( ) Bowel obstruction ( ) Bleeding ( ) Peritonitis ( ) Others:____________________ 7. Anatomopathological analysis: 7.1. Diverticular Disease of Colons: ( ) Yes ( ) No ( ) Diverticulitis 161

( ) Diverticulosis

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Annex I - Continuation 7.2. Cancer: Histological type: ____________________________________ 7.2.1. Degree of differentiation: ( ) Well differentiated ( ) Moderately differentiated

( ) Poorly differentiated ( ) Undifferentiated

7.2.2. Number of dissected ganglia:________ ( ) Negative ( ) Positives How many:_____ 7.2.3. Staging: TNM (primary tumor extension, metastasis in regional lymph node, distant metastasis) _________________ ___________________________ 8. Mortality: ( ) Yes ( ) No 8.1. Cause of surgical mortality: ( ) Intra-abdominal sepsis ( ) Acute anemia (bleeding) ( ) Others:____________________

( ) Heart failure ( ) Respiratory infection

9. Recurrent neoplasm: ( ) Yes ( ) No Annex II AUTHORIZATION I, head of the _____________________, authorize chief investigator Dr. Fábio Ramos Teixeira to perform data search in the records of patients submitted to laparoscopic colorretal surgery. The investigator guarantees that the execution of this study will not bring any type of damage to this institution, and that the identify and moral integrity of the patients, whose records will be analyzed in this study, will be preserved. Under no circumstance should public disclosures mention names. The researcher will clarify any doubt about the study, and for this reason, should always be found at the address and telephone number below. ________________________________________________ HEAD OF THE INSTITUTION _________________________________________________________________ FÁBIO RAMOS TEIXEIRA HOSPITAL UNIVERSITÁRIO Address: Rua Cláudio Batista, S/N – 49060-100 – Aracaju (SE), Brazil – Tel.: (55 79) 2105-1700, Fax: (55 79) 2105-1743 ATTENTION: For this study, no Informed Consent Term will be required, as the study has no direct contact with the patients, only having the access to data from their medical records! 162


Original Article Experiencing sexuality after intestinal stoma Maria Angela Boccara de Paula1, Renata Ferreira Takahashi2, Pedro Roberto de Paula3 Assistant Professor and Doctor, Department of Nursing, Universidade de Taubaté (UNITAU) – Taubaté (SP), Brazil; Master and Doctor in Nursing, School of Nursing, Universidade de São Paulo (USP) – São Paulo (SP), Brazil; Full Member, Sociedade Brasileira de Enfermagem em Estomaterapia; 2Associate Professor, Department of Nursing in Collective Health, School of Nursing, USP – São Paulo (SP), Brazil; 3Assistant Professor and Doctor, Department of Medicine, UNITAU – Taubaté (SP), Brazil; Doctor in Surgical Gastroenterology, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp); Full Member, Sociedade Brasileira de Coloproctologia (SBCP) – São Paulo (SP), Brazil. 1

Paula MAB, Takahashi RF, Paula PR. Experiencing sexuality after intestinal stoma. J Coloproctol, 2012;32(2): 163-174. ABSTRACT: Objective: Identify the Social Representations (SR) of ostomized people in terms of sexuality after the stoma. Methods: An exploratory, descriptive, qualitative study using the Social Representation Theory with 15 ostomized people (8 females), mean age of 57.9 years, between August and September 2005. Data obtained from transcribed interviews were submitted to content analysis, resulting in the thematic unit “Giving new meaning to sexuality” and subthemes. Results: The study demonstrated that the intestinal stoma interferes in the sexuality experience, showing that the meanings attributed to this experience are based on individual life stories, quality of personal relationships established in practice and perception of sexuality, despite the stoma. Conclusions: The Social Representations, in terms of experiencing sexuality after the stoma, are based on meanings attributed to the body, associated with daily life and present in the social imaginary. It is influenced by other factors, such as physiological changes resulting from the surgery and the fact of having or not a partner. Care taken during sexual practices provide greater security and comfort in moments of intimacy, resembling the closest to what ostomized people experienced before the stoma. The self-irrigation technique associated or not with the use of artificial occluder, has been attested by its users as a positive element that makes a difference in sexual practice after the stoma. The support to ostomized people should be comprehensive, not limited to technical care and disease, which are important, but not sufficient. The interdisciplinary health team should consider all aspects of the person, seeking a real meeting between subjects. Keywords: colostomy; sexuality; subjectivity. RESUMO: Objetivo: Identificar as Representações Sociais (RS) da pessoa estomizada intestinal sobre vivência da sexualidade após confecção do estoma. Métodos: Estudo exploratório, descritivo, qualitativo do ponto de vista do referencial da Representação Social. Participaram 15 estomizados, sendo 8 mulheres, com idade média de 57,9 anos, entre agosto e setembro de 2005. Dados obtidos por entrevistas, transcritas, foram submetidos à análise de conteúdo, originando a unidade temática “Ressignificando a sexualidade” e subtemas. Resultados: Demonstrou-se que o estoma intestinal interfere na dinâmica da vivência da sexualidade, desvelando que os significados a ela atribuídos estão ancorados nas histórias individuais de vida, na qualidade das relações pessoais/conjugais estabelecidas na prática e na percepção da sexualidade, apesar do estoma. Conclusões: Representações Sociais sobre vivência da sexualidade após estoma estão ancoradas nos significados atribuídos ao corpo, veiculadas no cotidiano e presentes no imaginário social. É influenciada por outros fatores, como alterações fisiológicas decorrentes do ato cirúrgico e da existência de parceiro. Cuidados adotados nas práticas sexuais propiciam maior segurança e conforto nos momentos de intimidade, tornando-as mais próximas daquilo que vivenciavam antes do estoma. A autoirrigação, associada ou não ao oclusor, constituiu estratégia facilitadora para melhor aceitação do estoma, sendo essencial para vida sexual mais prazerosa. A assistência à pessoa estomizada deve ser integral, não se limitando apenas à doença e ao cuidado técnico, que são importantes, mas não únicos. O trabalho interdisciplinar da equipe de saúde deve vislumbrar a pessoa em sua totalidade, buscando real encontro entre sujeitos. Palavras-chave: colostomia; sexualidade; subjetividade.

Study carried out at the Department of Nursing and Department of Medicine, Universidade de Taubaté (UNITAU) – Taubaté (SP), Brazil; and at the School of Nursing, Universidade de São Paulo (USP) – São Paulo (SP), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 01/18/2012 Approved on: 02/24/2012

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INTRODUCTION

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People with stoma considers they have an imperfect, and for this reason, different body, without the characteristics regarded by the society as normal attributes11. Unsatisfied with their body, they may present low self-esteem, as well as feelings of self-exclusion11,12, involving feelings of inadequacy, guilt or shame or loss of confidence and self-appreciation, affecting their selfimage and self-esteem, elements that are part of the human identity and subjectivity, which are partially based on symbolic representations2. The production of a stoma is a milestone in the life of those undergoing this surgical procedure, determining singular ways to face the situation, according to each one’s particularities and world view, in the different aspects of life, also regarding sexuality. The identification of personal values, the way to perceive the world, life and the disease treatment are especially important when confronted with the possibilities or impossibilities that the stoma may impose to the person. The ostomized people’s approach to sexuality is poorly explored or limited to aspects such as having or not an active sex life. The reasons for having this lifestyle many times result from difficulties faced by both assisted people and professionals, either for personal aspects that involve the practice of one’s own sexuality or due to gaps in the professional training, considering that sexuality is still not sufficiently discussed in undergraduate courses in the area of health. Thus, the purpose of this study was to identify Social Representations of people with intestinal stoma regarding how they experience sexuality before and after the stoma production.

Intestinal stoma is an opening of intestine on the anterior abdominal wall. It may have different names, according to the exposed segment1,2. Colostomy and ileostomy are some of the common therapeutic procedures to treat physical traumas and several intestinal and anal diseases, such as: colorretal cancer, inflammatory bowel diseases, diverticular disease of the colon, ischemic colitis, familial polyposis, megacolon, anal incontinence and severe anoperineal diseases3. The production of an intestinal stoma leads to uncontrolled elimination of gas and stool, a condition that causes indirect effects on the life in society, and that may lead to psychological and social isolation, interfering in relationships with family, sexual partners, friends and work colleagues, almost always involving negative feelings, such as anxiety, fear and doubts4-7. The surgery that produces a stoma may represent invasion of physical and psychological intimacy, generating changes in the daily life and lifestyle of ostomized people and their family, with different levels of intensity and types of repercussion5. In the presence of a stoma, the anatomical position of the anus is changed and eliminations are not controlled, influencing these people’s body image reorganization. Besides the surgical treatment of the stoma, these people have to carry the fecal collection bag attached to their abdomen. Their body image is gradually renewed with the experiences and experiments with their body, enabling to build new meanings and images concerning this matter2. Along the health-disease process, people’s relations and actions are not only cognitive or social; they also have great symbolic, subjective influences, and are directly related to affectivity. In people with stoma, alterations to body image are considered key elements that determine aspects of their trajectory and quality of life, in the different phases of the rehabilitation process2. A healthy and attractive look plays an important role in the life in society, constituting everyone’s object of desire. The consumer market has intensified and popularized the representation of an “ideal body” through repetition and normalization, something almost intolerable and useless, which favors the self-perception of ostomized people as “different” in terms of physical aspect2,8-10.

METHODS An exploratory, descriptive, qualitative study was performed, using the Social Representation (SR) Theory, which analyzes the phenomena of a specific group and the imaginary processes of the members of this group13, through categories that explain, justify and question the actions and feelings of those experiencing such reality14. The study project was approved by the Research Ethics Committee at the Universidade de Taubaté (UNITAU), under protocol # 326/05. Data were collected in individual interviews, performed in Taubaté (SP), from 164


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August to September 2005. The study analyzed 15 ostomized people, who fulfilled the inclusion criteria in terms of time since stoma production (1 year or more) and who, after receiving explanations about the study purpose, signed the Informed Consent Term. The interviews, privately performed, started with the collection of data about the person’s identification and characterization and at what health services he/she was treated. After that, the study questions were made: What can you say about your sexuality after the stoma? What about now, how is it now? All interviews were recorded and fully transcribed; the content was analyzed using a group of techniques for communication analysis, seeking explicit or hidden, manifested or latent signification15, and knowledge behind the words, other realities not clearly expressed in the messages. After exhaustively reading the transcribed interviews, key expressions were identified to examine the literality of speeches and select the focus of the analysis of all speeches, which originated the first categorization. Speech cutting was the next phase, as well as the verification of how often the speeches fitted the categories, and then they were sorted into initial subgroups, for subsequent definitive categorization in the next phase, resulting in the thematic unit: “Giving new meaning to sexuality” and subthemes.

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one (14.3%) was a widower and one (14.3%) was single. Among the married men, 4 had been married for over 20 years; 3 between 5 and 9 years; 2 between 10 and 15 years, 1 between 16 and 20 years. Regarding the participants’ education level, two (13.3%) were illiterate, seven (46.8%) had incomplete primary education, one (6.6%) had complete primary education, four (26.7%) had complete high school and one (6.6%) had incomplete higher education. Regarding their occupation, six (40%) were retired, three (20%) were housewives, three (20%) were storekeepers, one (6.6%) was unemployed, one (6.6%) was a commercial employee and one (6.6%) was a babysitter. Regarding the stoma time, 4 people (26.7%) had the stoma from 2 to 5 years, 2 (13.3%) from 6 to 10 years, 4 (26.7%) from 11 to 15 years, 2 (13.3%) from 16 to 20 years and 3 (20%) for 21 years or more. Thematic unit I Giving new meaning to sexuality Having a definitive stoma means living with this body alteration until the end of life. Adaptations in several aspects of life are required, also in terms of experiencing sexuality, which usually involves intimacy and body exposure. These adaptations, in this thematic unit, include changes in how to experience sexuality after the stoma, new concerns related to the sexual act, strategies to adapt moments of intimacy, the technique of irrigation and use of intestinal occluder as factors that facilitate the sexual act, the concern about not damaging the stoma, the sexual disorders or dysfunctions resulting from the surgery, the possibility of fully experiencing sexuality despite the stoma and the distance kept form sex as an option. The excerpts from speeches presented below show the changes in sexuality after the stoma:

RESULTS AND DISCUSSION Characterization of studied population All interviewees were ostomized and were registered in the service to ostomized people in Taubaté, 12 (80%) of them presented definitive left colostomy due to intestinal cancer; 2 (13.4%) had ileostomy due to chronic inflammatory bowel diseases; and 1 (6.6%) had loop transversostomy. Eight (53.3%) were females. Regarding their age group, 8 (53.3%) were between 50 and 69 years old: 4 (26.6%) females and 4 males; 5 (33.3%) were 70 years old or older: 3 (20%); and 2 (13.4%) were between 30 and 49 years old: 1 female and 1 male. From total females, five (62.5%) were married, two (25%) were widows and one (12.5%) was divorced. From total males, five (71.4%) were married,

[...] we get apprehensive [...] (A1). It used to be effervescent [...] everything was fun [...]. Now, I almost have no relation. Before, we had nothing [...], I used to be more active [...] (A4). [...] after this surgery, it was all over (A10). Falling sick causes discontinuity of daily routine and contributes to reanalysis and restructuring of values, priorities and projects in life, many times leading 165


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to deep reflections on what is really important to each person16. This is a process that directly or indirectly affects other people, especially close family members, in particular, partner and children, who also go through processes of resignification and adaptations in their routines, once they share their life stores. The diagnosis of cancer, whose treatment requires a large surgical intervention and, many times, the production of a definitive intestinal stoma, triggers a process of addressing the situation, characterized by required adaptations and elaboration of strategies for the new situation and not expected or planned instances. Such strategies are handled in many ways, considering that the experiences are particular of each person, and that everyone finds unique answers and alternatives to the situations experienced, as observed in the excerpts of speeches. The speeches showed apprehensiveness in the practice of sexuality after the stoma, characterized by fear and discouragement, which resulted, to some, in repression and, to others, discovery of alternatives that enabled, some time later, the return to practices in sexuality. Ostomized people and their partners experience moments of insecurity and uncertainty in relation to sexuality, which may lead to changes in their practices. It was not possible to state that the reported changes occurred only as a result of the stoma, as other factors, such as fear, pain, widow(er)hood, among others, were concomitant and influenced the sexuality experience, but the stoma appeared, in the context of speech excerpts, as an element that influenced such alterations. Getting old, the development of maturity, the several forms of experiencing relations with the family and spouse, among other factors, are parts of life process and can influence how sexuality is perceived, how it is manifested and how it is experienced. In addition, other physical, sociocultural and psycho-spiritual changes that may occur in the people’s daily life should taken into account.

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The process of getting old is a determinant to be considered in sexual practices, as the possibilities and expectations change with the age. However, neither age nor most diseases automatically imply the end of sex life17. The health professional, when considering and analyzing the feasible possibilities of attention and care in the process of providing support to an old ostomized person, should investigate and appreciate complaints or statements regarding sexuality, as they are important for the adaptation and resolution of physical, emotional and conflicting problems, aiming at the maintenance of their quality of life. Instructions and information related to sexuality concerning the attention to people with intestinal stoma should be provided during the entire process of support, based on healthy ways to live, thus, helping achieve the maximum potential of health, in all life phases6. The excerpt below shows new concerns considered by the interviewees, especially related to the sexual act after the stoma, such as the presence of a bag, effluent, noise, odor and changes in the body image. I had nothing to worry about, and now, it is [...] now, we got used to it, but in the beginning [...] I was traumatized about it [...] there’s this bag, it’s more complicated (A1). Years ago, I had nothing to worry about (A13). Adapting, adjusting and reinventing situations, creating moments and elaborating new approaches were attitudes required for the practice of sexuality after the stoma, which certainly generated new meanings and representations, especially about experiencing moments of intimacy. After the colostomy, I’ve done many things, I even had ‘extramarital relations’. I got another husband, who taught me things I didn’t know hehehe (A2). Today, the symbolization of an ideal body involves signs of youth, beauty, vigor and health; thus, a fertile and healthy body. Body significations and representations based on populations of the modern world make people seek these socially established models, which end up influencing their way of perceiving and appreciating their own figures and how others perceive and appreciate them2.

[...] I was younger, seeking to be horny, to have best horny feeling [...] (A12). The excerpt above refers to the age factor, and not exactly the stoma, showing that it was not the only condition for the changes in behavior and sexuality experience. 166


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These meanings of a young, slim and sensual body are part of the SRs about sexuality valid in the contemporaneous society. The ostomized people have their body image changed not only by the stoma, but also by the devices used to collect the effluent. Despite the technological progress for the creation of several types and models of collecting bags, the ostomized person fears the possibility of having accidental losses of gas or feces, especially in situations of friction, during the sexual act.

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direct exposure. This way, she feels more comfortable to manage the situation of intimacy and face body alteration, not allowing to be observed, protecting herself and avoiding unpleasant and embarrassing situations, neither for her nor for her partner. Shame and the need to hide are emphasized in this speech excerpt. According to Lucia18, shame is “[...] an explosion of the impossibility to react” (p. 346) that paralyzes and uses concealmente as an attempt to preserve the secret part (in this case, the body image altered by the presence of the stoma, to continue being accepted). The body image is that perceived from outside the body and, thus, it is characterized by the image that another person (a peer) transmits to the person19. Such image is full of affective values that make sense to the person. Hiding the stoma contributes to keep the sexual body veiled, under the imaginary idea of that was captured from outside. On the other hand, the multiple character of the body can be understood based on the singularity and articulations of thought that determine how the body is established in the world, or based on the how the world imposes itself and the body only defends itself, reacting to the “threats”. For this purpose, a group of subjective elements have to be activated, which are always correlated with the personal history of each ostomized person and the cultural context in which the person lives20. The exposure of the “altered” body is also a situation that can generate discomfort, regardless of the time with the stoma e the partner, as seen in the case we have just mentioned. The different aspect still seems to disturb, which confirms the idea of Turano21 that “the same causes do not always lead to the same effects” (p. 21), as essential human themes, such as sexuality, are immersed in the universe of feelings, which does not enable to theorize the reality as it is, then allowing to change certainty for probability, which characterizes each one’s individual reality. The elaboration of strategies to face the new situations, difficulties and new limits are present in the daily life of ostomized people. Regarding the questions of sexuality, part of the group of ostomized people created strategies to adapt their moment of intimacy, inserting additional care, especially concerning the use of collecting devices.

When we have a new bag is one thing, two days later [sic] it’s another thing, it doesn’t have the same [...] smell [...] and everything [...] no matter if you clean it, it’s not the same thing, we get apprehensive. It’s not evident, but we get apprehensive, you see? I’m afraid it gets dirty, there’s no freedom, the smell is not the same thing [...] (A1). The occurrence of any of these events in moments of intimacy makes the ostomized person and his/her partner embarrassed, especially during an intimate relation immediately after the stoma. The possible loss of gas and feces caused by the absence of occluder in the stoma, remains even after many years with the stoma, causing impacts along the person’s life, as observed in the speech excerpt below: Ah, I’ll never make sex if I’m not clean and neat (A15). This excerpt is from the speech of a person that had been ostomized for 18 years, who reported full adaptation to the situation and more intense sexuality experience after the surgery, as her stoma resulted from complications of an inflammatory bowel disease that limited her life in several aspects, including sexual relations. However, it shows her concern about privacy regarding the stoma and the ritual before moments of intimacy with her partner, in this case, in pre- and post-stoma phases. [...] but there’s one thing [...] I never leave the lights on, I’ve never wanted him to see the stoma very well [...] (A15). Care taken to make the stoma less visible act as a defense mechanism, through which the person avoids 167


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The bag is what most disturbed [...] (A1 and A12). [...] if we do it in the missionary position, the bag plastic material disturbs a lot [...] (A12).

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In general, health professionals have small or no preparation to deal with complaints regarding sexuality, and few of them have some kind of training in sexology or sex education. According to Maldonado and Canella22, these professionals usually ignore the problem and provide “false” support with very superficial and unspecific information, such as: “that happens to most people undergoing this type of surgery, it will soon return to normal”, “you’ll get used to the bag, it’s a question of time”, and many of them soon end up sending the person to other professionals, without eliminating their doubts and/or providing satisfactory answers to their questions. The development of an “ethical view” that considers the need for recognition of the person in the relation23, as well as his/her subjectivity, may help enable to feel the other one’s situation and elaborate new possibilities in shared worlds24. Then, it will favor the creation of viable strategies to each person, according to each one’s particularities, and strengthen the health professional-patient relation. Addressing sexuality while providing support to ostomized people through active listening may promote information sharing, which is required to improve the quality of life, thus, constituting the dimension of this much desired comprehensive support that associates theory with practice. The excerpts below show some of the alternations found by the ostomized people to facilitate their sexual practices.

There are innumerous collecting devices and accessories available in the market, and, no matter how good the product plastic is, the friction between the bodies produces noises, disturbs and may even cause some type of allergic reaction in the person and/or partner, especially in the presence of sweat, a secretion almost always present in moments of intimacy and during the sexual act. The speech excerpts above explain the inconveniences of this situation and show that the health professionals and companies that produce stoma devices should dedicate more attention to these aspects, seeking for instance, alternative materials to product the bags. Investigations addressing the people’s adaptation to products, their difficulties in using these devices, and the reasons for accepting or rejecting them, are essential for the process to find solutions, propose changes and elaborate specific instructions, to minimize discomfort and suggest optional devices, enabling to expand the possibilities and promoting better and less concerning experience of sexuality. The speech excerpt below shows that, at times, simple instructions can help overcome difficulties/ limitations involved in the sexual act. [...] the adaptations are positions at the sexual relation moment, just place the bag to the side, and then it doesn’t disturb (A12).

When the bag is loose, of course, it disturbs a little, it gets stuck, it’s too bad, it disturbs, so [...] I have SOMETHING LIKE A BELT that I put on much before, it doesn’t let the bag disturb. It doesn’t let the bag loose, it doesn’t disturb at all (A9). [...] at the moment of sex, I LET THE BAG CLEAN AND WRAP IT WITH MICROPORE, then, it doesn’t disturb at all (A14).

The health professional may, in turn, provide practical instructions while providing support to ostomized people, addressing the subject when noticing that the person requires it, and then, contribute to the fastest possible adaptation process. It is important to emphasize that, regarding sexuality, most professionals that provide support to ostomized people rarely address these aspects spontaneously, except when questioned by such people or their partners. The participation in update courses and especially in stoma therapy trainings showed that professionals from the area and other professionals do not spontaneously address aspects of sexuality, but only when questioned by ostomized people or their partners.

The strategies reported are simple and may be considered examples of adaptation during the sexual act, provided in nursing consultation to ostomized person or shared in group meetings or meeting of ostomized people associations. These experiences are relevant, as they can help other people face similar difficulties. 168


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Sharing these experiences with the manufacturers of stoma devices may help develop new accessories to be used by the ostomized people in their sexual practices, that reduce or eliminate their current difficulties. The techniques of irrigation and intestinal occluder are practices that seem to be relevant and beneficial to the sexuality experience and improvement of the quality of life of ostomized people. The intestinal irrigation is a mechanical method to control the fecal elimination. It consists in the application of an enema each 24, 48 or 72 hours, in the stoma itself. It is indicated to people with definitive left colostomy and without complications, such prolapses, hernias and important retractions25-27. The intestinal occluder or obturator for colostomy is a plug-like flexible and disposable device that controls the fecal elimination, reducing noises and odors. It may be combined or not with the irrigation technique, but it is for users with left terminal colostomy, and the stoma diameter should be between 20 and 45 mm, with max. 25 mm protrusion26-28. The use of intestinal irrigation or occluder is indicated by the physician. The requirements for both are specific and precise. The results are effective, ensuring the ostomized people that correctly use them a satisfactory intestinal control, not requiring, many times, the collecting bag for reasonably long periods. People who adopt the intestinal irrigation associated with the occluder may have effluent control for an average period that varies from 16 to 24 hours, securing the practice of daily activities, without being concerned about losses and stool leaking, also during the sexual act. The possibility of evacuation control was a positive factor, bringing the perspective of having practices resembling those before the disease, and contributing a milder and less limiting connotation of the stoma. This way, despite the stoma, the irrigation combined with the occluder helped establish new and positive SRs about being ostomized. Among all 15 participants of this study, 12 (80%) had left terminal colostomy and, among these, 33.33% (4) used the intestinal irrigation. Only 16.4% (2) used this method combined with the occluder. The indication of these techniques and products is very important to ostomized people with definitive left colostomy; however, physicians do not recommend them very often. On the other hand, stoma ther-

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apy nurses frequently recommend them, but, as these procedures require doctor’s prescription, they do not always get to effect them in practice. The following speech excerpts clearly show the benefits of using self-irrigation, especially when associated with the occluder. After the irrigation my life changed considerably and, with the occluder, it improved much more; if I don’t mention, nobody knows I am ostomized (A13). At first, I didn’t accept it, now I perform the irrigation and use the occluder, then, no problems, everything is normal! Really normal! I perform the irrigation each 24 hours and use the plug, it’s 100% good. With the bag, I had to clean it three times a day. Now, I do it and remain [sic] for 24 hours. It’s 100% good. No problem at all (A5). The first speech excerpt showed that the self-irrigation benefits were important for the person not to feel different from non-ostomized people. The association with the occluder was an additional incentive, as, when definitively suppressing the collecting bag, a full experience was enabled, not only of sexuality, but also of other aspects in life related to social, work and family interactions. The second speech excerpt shows that the change in how to perceive the ostomized condition occurred between the period before and after the adoption of self-irrigation. It changed from non receptivity to acceptance of a situation, which helped overcome anxieties and control the stoma and its effluents and to new meanings involving the stoma. The person was happy for not having to face embarrassing situations, such as stool leaking, odors, and for not having to use collecting devices that were visible through tight clothes, making the person feel secure and self-confident to experience sexuality. In terms of sexuality, these procedures seemed to be essential for sexual practices, allowing a more pleasant intimate contact, probably not so timidly, especially due to the security they provided, as well as reduced flatulence and increased comfort for not having to use the collecting bag. Such aspects reduced the sensation of being different. Body care is essential to keep its integrity. For the intestinal stoma, such integrity is violated, since 169


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an intestinal loop is outside the abdominal wall, exposing the intestinal mucosa and, given its fragility, bleeding and inflammation may occur after intense friction, such as the oral mucosa. This a factor that may have helped prevent intimate contacts, reducing the frequency, mainly of more intense contacts, as the person was concerned about not damaging the stoma.

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including loss of ejaculation, partial erectile dysfunction or even complete impotence30. This situation is illustrated in the speech excerpt below: Now I have erection, but no ejaculation. Only this is different now, the rest is the same (A5). Erectile dysfunction and dyspauremia are frequently reported complaints of ostomized people, as indicated in the excerpt above. The correct information about possible alterations and complications that may occur after the surgery should be provided, and the doubts should be properly clarified, to make the person aware of all possible consequences of this surgery. This way, the person will be prepared to face the challenges that appear and effectively collaborate to his/her treatment.

[...] I get worried about not damaging the colostomy (A13). Any type of lesion and bleeding generates insecurity and fear, which may be aggravated by the fact that the digestive tract anatomy is unknown. The presence of blood in the device, due to excessive friction during the sexual act, may produce embarrassment and apprehensiveness to both the ostomized person and his/her partner. The intestinal mucosa, just as the oral mucosa, is highly vascularized and friable, causing small bleedings when any type of injury occurs, although no pain is felt. Such small bleedings are common and are not important problems, but blood involves some concern to most people, being related to situations of urgency/ emergency, requiring prompt actions or care. Thus, knowing these characteristics of the stoma may help minimize excessive concern about small lesions and bleedings of the stoma. Another factor that limits the sexuality experience of ostomized people is related to possible sexual disorders or dysfunctions resulting from the surgery.

[...] 9 months after the surgery, it returned to what was before the surgery, it returned to normal, thank God, so far, everything has been normal [...] (A9). Analyses and questioning help the person think of what is required to face the unexpected, in case of sexual disorders and dysfunctions that may occur. On the other hand, when questioning and informing the person, the health professional, with clinical attitude, shows interest in the person’s situation, helping him/her demystify beliefs that many times do not correspond to the reality and seek strategies to address these problems, according to the reality of each person and situation22.

After the ostomy, I didn’t have sex for one year [...] because this surgery might have affected any nerve under it (A9). The surgery, although it was in the intestine, involved the front part, because it was already affected, and, in the sexual act, it hurt a little (A8).

After the colostomy, I’ve done many things, I even had ‘extramarital relations’. I got another husband. I’ve lived more, you know!!! I’ve learned many things [...] (A9). A new reality is possible when the person is open to changes. The speech excerpt above shows that, indicating that the stoma was not an obstacle in her life, who was open to learn and experience new things. Then, the same experience does not produce the same effects, and there is no linearity in causes and consequences, as something bad for some people may not be bad to everyone. There are many ways to understand and interpret experiences, which occurs as a result of the specific reality of

The surgery of abdominoperineal amputation is the curative treatment of distal rectal cancer, but, due to its radicality, it produces a stoma and may cause several disorders or dysfunctions, including those related to sex29-32. Injuries in nerves of the autonomic nervous system that run from the pelvis to the sex organs may occur, leading to implications also in the sexual activity, 170


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each person, based on the interaction with others, the significations of the experiences and perception of phenomena21. The stoma, in the case above, does not seem to be a limiting factor to this person, as her speech shows that, after the stoma, her sexl life was renewed. She says that she learned new things and broke barriers and concepts pre-established by the society. The stoma was not a factor that limited her; otherwise, it was part of the changes and the process of building a new phase of her life. The speech excerpt above pulls down barriers that are often present in the society, such as the idea that a stoma prevents someone from performing some physical, social, labor and sexual activities, among others. Pre-established concepts may permeate, influence and even determine ways of living and experiencing situations, as in the case of a stoma, usually negative and even paralyzing, preventing the person from experiencing moments of pleasure and freedom. The speech above shows exactly the opposite, full experience of sexuality, despite the stoma; therefore, an example of how it is possible to accept and live someone’s current condition, considering it a possibility of renewal. People often stick to models of “romantic love” and forget that “each one’s love is invented each new relationship”, each new situation, as experienced by A9. New situations can encourage people to mobilize efforts and seek possibilities and ways that maybe have not been sufficiently or properly been explored. Then, these people will find out that it is possible to fully experience their sexuality in pleasant relationships, despite the stoma in the abdomen, and that a new situation may even cause these discoveries to effectively occur and positively transform some relationships. It is important to emphasize that these actions are produced based on needs or a system of reasons that are intrinsically associated with the person’s emotional status. They correspond to emotional processes that follow the person’s actions in various contexts of his/her life, in this case, the subjective sense of sexuality for the person, and translate the expression of a new synthesis, which can be understood only within the constant changes of private meanings and emotions20.

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The speech excerpts below clearly show this situation: I think it’s better than before (A13). [...] I’m more excited and very active now in all senses (A15). On the other hand, some of the interviewees indicate that extramarital sex experiences are not possible, as illustrated in the speech excerpt below: I have nothing to complain about it, but if I had a relation with someone other than my partner, then I believe I would have problems [...] (A12). The contact with an abnormality in the body, in this case, the intestinal stoma, may generate embarrassment between the people and affect the different areas of social life and sexuality. These difficulties can be more intense in the initial phase of relationships. The speech below illustrates one of these difficulties, which are not common to non-ostomized people. People are not used to what they will see in the sexual act [...] the stoma (A12). Speaking of the presence of something different in the body may be embarrassing not only in new relationships, but also in stable relations, in which the partners, despite being together for a long time, are reserved, especially regarding their bodies. The psychological problems of these people may often be more intense than the physical difficulties, affecting the relations with their partners. Adjustments in the relation may be performed using strategies involving the partner, using the dialog, to clarify doubts and eliminate uncertainties. The efficiency of the strategies depends on flexibility, stability and mutuality of both individuals in the relation. Today I sit and talk about it [...] more openly (A13). Sharing expectations, being supportive and especially the empathy and love are essential and indispensable factors to enable sexuality manifested in various forms. Sexual partnership is considered the key that shapes the details in the relationship 171


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and may contribute positively to a successful relation, or negatively to a failed relation. Experiencing sexuality involves individual well-being and wellbeing of the couple33-35.

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The option of being distant from or giving up sexual practices may become a system of reference to these people, when incorporated into their life. It appears as images that condense a group of significations that enable to interpret the facts and even give a sense to the unexpected. It is changed into categories to classify the circumstances, phenomena and individuals, resulting in opinions about themselves, that is, they are representations of the individuals characterized by subjectivity, thus permeating the construction of knowledge37.

[...] some times he reaches out, but no way in [...] the [...] we hardly talk about it (A10). I avoid doing only what he wants, if I don’t feel well [...] only wants to benefit from me [...] (A10). These excerpts illustrate relations with difficulties, which seems to have no pleasure, dialog, respect between the partners. They feel they are only the other one’s object of pleasure, without any exchange, even before the stoma. These characteristics remained or were intensified after the stoma. This way, the stoma became a justification to effectively establish the distance from sexual practices. The speech excerpts below illustrate these situations.

FINAL CONSIDERATIONS The SRs, in terms of experiencing sexuality after the stoma, are based on meanings attributed to the body, associated with daily life and present in the social imaginary. It is influenced by other factors, such as physiological changes resulting from the surgery, the fact of having or not a partner and relationship quality. Care taken during sexual practices provide greater security and comfort in moments of intimacy, resembling the closest to what ostomized people experienced before the stoma. The self-irrigation technique associated or not with the use of artificial occluder, has been attested by its users as a positive element that makes a difference in sexual practice after the stoma. The elaboration of support projects shared with the person receiving the support is an essential health service, which should involve the ethical and esthetical aspects, once its practice is directed to subjects, and not only to the technical axis that builds support objects. This way, health professionals that work with ostomized people, to achieve this objective, have to seek knowledge that enables to establish suitable support projects to each individual in particular. The support to ostomized people should be comprehensive, not limited to technical care and disease, which are important, but not sufficient. The interdisciplinary health team should consider all aspects of the person, seeking a real meeting between subjects (health professional-assisted person). Sexuality of both ostomized and general people is determined by multiple interconnected factors

[...] today, there’s only affection without sex life [...] and we live well this way (A3). I’ve had no sex life after the divorce and I’m fine this way” (A11). [...] I’m fine this way, I have no relation (A8). Establishing contact, communication and connection through the body is essential, not only for social relations, but also for the practice of sexuality36, which assumes an important meaning in the historical and cultural context of people. Then, when the body connection is, for any reason, weakened or ceased, recovering it is very complex, as it is determined by multiple factors based on the social elaboration of roles impregnated by feelings and emotions of each partner and molded by themselves in the couple’s daily life. The sex life is directly related to emotion, which, according to Rey20, represents an “essential moment in the definition of a person’s subjective sense of processes and relations” (p. 247), once that even one’s own reflections are sources of emotional production. The way the ostomized people adapt to the new situation, their own altered body image, affects their capability to establish personal relations, experience, express their sexuality and go through the rehabilitation process16. 172


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that will influence their experience and often define their way. The capability to understand the reality, pull down obstacles, beliefs, symbols, perceptions

and values, the quality of the couple’s relation and the access to qualified health information, products and services are essential to determine it.

REFERENCES 1.

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Martins Jr A, Rocha JJR. Tipos de estomas intestinais. In: Crema E, Silva E. Estomas: uma abordagem interdisciplinar. Uberaba: Pinti; 1997. p. 41-64. Santos VLCG. Representações do corpo e a ostomia. Estigma. In: Santos VLCG, Cesaretti IUR. Assistência em estomaterapia: cuidando do ostomizado. São Paulo: Atheneu; 2000. p. 89-102. Habr-Gama A, Araújo SEA. Estomas intestinais: aspectos conceituais e técnicos. In: Santos VLCG, Cesaretti IUR. Assistência em estomaterapia: cuidando do ostomizado. São Paulo: Atheneu; 2000. p. 39-54. Santos VLCG. A bolsa na mediação “estar ostomizado” “estar profissional” análise de uma estratégia pedagógica [tese]. São Paulo: Escola de Enfermagem da USP; 1996. Cesaretti IUR, Leite MG. Bases para o cuidar em enfermagem. In: Santos VLCG, Cesaretti IUR. Assistência em estomaterapia: cuidando do ostomizado. São Paulo: Atheneu; 2000. p. 19-37. Pereira MLD. A (re)invenção da sexualidade feminina após a infecção pelo HIV [tese]. São Paulo: Escola de Enfermagem da USP; 2001. Cascais AFMV, Martini JG, Almeida PJS. O impacto da ostomia no processo de viver humano. Texto & Contexto Enferm 2007;16(1):163-7. Salter MJ. Aspects of sexuality for patients with stomas and continent pouches. JET Nurs 1992;19:126-30. Salter MJ. If you can help somebody: nursing interventions to facilitate adaptation to an altered body image. World Counc Enterostom Ther J 1999;19:28-32. Rocha EF. Corpo deficiente: em busca da reabilitação? Uma reflexão a partir da ética das pessoas portadoras de deficiência física [dissertação]. São Paulo: Instituto de Psicologia da USP; 1991. Silva AL, Shimizu HE. O significado da mudança no modo de vida da pessoa com estomia intestinal definitiva. Rev Latino-Am Enfermagem 2006;14(4):483-90. Souza RHS, Montovani MF, Lenard T. Significados do corpo: reflexão teórica. Cogitare Enferm 2001;6(2):25-30. Bison RAP. Representações sociais dos estudantes de enfermagem sobre sexualidade, numa experiência de ensino [dissertação]. Ribeirão Preto: Escola de Enfermagem da USP; 1998. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 1994. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2010. Petuco VM, Martins CL. A experiência da pessoa estomizada

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com câncer: uma análise segundo o Modelo de Trajetória da Doença Crônica proposto por Morse e Johnson. Rev Bras Enferm 2006;59(2):134-41. Butler RN, Lewis MI. Sexo e amor na terceira idade. São Paulo: Summus; 1985. Lucia MCS. Sexualidade do ostomizado. In: Santos VLCG, Cesaretti IU. Assistência em estomaterapia: cuidando do estomizado. São Paulo: Atheneu; 2000. p. 335-53. Droguett JG. Corpo, imagem e cultura. In: Lyra B, Garcis W. Corpo & imagem. São Paulo: Arte & Ciência; 2002. p. 287-92. Rey FG. Sujeito e subjetividade. São Paulo: Pioneira Thompson Learning; 2003. Turato ER. Métodos científicos: aspectos históricos e epistemológicos. In: Turato ER. Psicologia da saúde: estudos clínicos-qualitativos. Taubaté: Cabral; 2003. p. 19-25. Maldonado MT, Canella P. Recursos de relacionamento para profissionais de saúde. Rio de Janeiro: Reichmann & Affonso, 2003. Bellato R, Araújo Neto LFS. Ética: substantivo agregador da cidadania e dos direitos no trabalho em saúde e em enfermagem. In: Oliveira AGB, organizador. Ensino de enfermagem: temas e estratégias interdisciplinares. Cuiabá: UFMT; 2006. Ayres JRCM. Sujeito, intersubjetividade e práticas de saúde. Cienc Saúde Coletiva 2001;6(1):63-72. Santos VLCGS. Estudos sobre os resultados da irrigação em colostomizados submetidos a um processo de treinamento sistematizado [dissertação]. São Paulo: Escola de Enfermagem da USP; 1989. Santos VLCG, Cesaretti IUR, Ribeiro AM. Métodos de “controle” intestinal em ostomizados: auto-irrigação e sistema oclusor. In: Santos VLCG, Cesaretti IUR. Assistência em estomaterapia: cuidando do ostomizado. São Paulo: Atheneu; 2000. p. 245-62. Santos RMT, Luz CM, Oliveira PS. Ensinando técnicas para o controle de eliminação intestinal do colostomizado: irrigação e uso do oclusor intestinal. In: Cesaretti IUR, Bocara de Paula MA, Paula PR. Estomaterapia: temas básicos em estomas. Taubaté: Cabral; 2006. p. 159-85. Lucia MCS. Sexualidade do ostomizado. In: Santos VLCG, Cesaretti IU. Assistência em estomaterapia: cuidando do estomizado. São Paulo: Atheneu; 2000. p. 335-53. Goligher J. Cirurgia do ânus, reto e colo. São Paulo: Manole; 1990. Souza JB, Oliveira PG, Ginani FP. Implicações sexuais na cirurgia do estoma intestinal. In: Crema E, Silva R. Estomas: uma abordagem interdisciplinar. Uberaba: Pinti; 1997. p. 177-92.


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31. Corman ML. Colon & rectal surgery. Philadelphia: Ppippincott-Raven; 1998. 32. Saad SS. Câncer de reto. In: Matos D, Saad AS, Fernandes LC. Coloproctologia - guias de medicina ambulatorial e hospitalar. São Paulo: Manole; 2004. p. 271-86. 33. Hogan RM. Human sexuality: a nursing perspective 2ª ed. Connecticut: Appeton Century Crofts; 1991. 34. Freitas MRI, Pelá NTR. Subsídios para a compreensão da sexualidade do parceiro do sujeito portador de colostomia definitiva. Rev Latino-Am Enfermagem 2000;8(5):28-33. 35. Rosa GF. O corpo feito cenário. In: Louro GL, Goellner SV, Neckel JF. Corpo, gênero e sexualidade. Porto Alegre: Mediação; 2004.

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36. Jodelet D. As representações sociais. Rio de Janeiro: UERJ; 2001. Representações sociais: um domínio em expansão. 37. Jodelet D. La representación social: fenómeno, concepto e teoria. In: Moscovici S, org. Psicologia social. Buenos Aires: Paidós; 1986.

Correspondence to: Maria Angela Boccara de Paula Avenida Itália, 1.551 – R1 Rua 1, 234 – Jardim das Nações CEP: 12031-540 – Taubaté (SP), Brazil E-mail: boccaradepaula@hotmail.com

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Laparoscopic total pelvic exenteration and perineal amputation with wet colostomy. A case report Juliano Alves Figueiredo1, Gustavo Mareli de Carvalho2, Rafael Turano da Mota3, Vivian Monteiro de Castro3, Matheus Matta Machado Duque Estrada Meyer3, André Zucollo Barragat3 Member of the Brazilian Society of Coloproctology and the Brazilian Society of Digestive Endoscopy; in Doctor’s Degree Program in Surgery, School of Medical Sciences, Universidade Federal de Minas Gerais (UFMG) – Belo Horizonte (MG), Brazil. 2Urologist at the Hospital da Baleia – Belo Horizonte (MG), Brazil. 3Resident in General Surgery, Hospital da Baleia – Belo Horizonte (MG), Brazil.

1

Figueiredo JA, Carvalho GM, Mota RT, Castro VM, Meyer MMMDE, Barragat AZ. Laparoscopic total pelvic exenteration and perineal amputation with wet colostomy. A case report. J Coloproctol, 2011;32(2): 175-179. ABSTRACT: Advanced rectal tumors can be treated with curative intent by surgical resection of the rectum including other pelvic organs. The reconstruction of the urinary and gastrointestinal tracts depends on the distance between the tumor and the anus, the patient’s status and the experience of the surgical team. This is a case of a male patient with a locally advanced low rectal tumor that underwent a laparoscopic pelvic exenteration. The anus and the tumor and other organs were excised by peritoneal approach. The uretero-colic anastomosis was performed extra-abdominally. The patient was discharged on the 14th postoperative day and remains healthy six months after the surgery. This approach has shown to be feasible and safe. The aesthetical result was well accepted by the patient. The laparoscopic route should be considered as an alternative approach to pelvic exenteration in the treatment of locally advanced low rectal tumors that demand perineal amputation. Keywords: rectal neoplasm; pelvic exenteration; laparoscopy. RESUMO: O tumor de reto localmente avançado pode ser tratado com intenção curativa com uma operação ampliada que inclua outros órgãos da pelve. A reconstrução do trânsito urinário e do trânsito intestinal dependerá da distância do tumor em relação à margem do ânus, da experiência da equipe de cirurgiões, assim como das morbidades associadas do paciente. Apresentou-se neste artigo o caso de um paciente do sexo masculino, com tumor de reto baixo localmente avançado que foi submetido à exenteração pélvica por laparoscopia. Houve indicação para ressecção do ânus e a peça cirúrgica foi retirada por via perineal. A anastomose uretero-colônica foi confeccionada de maneira extracorpórea. O paciente recebeu alta hospitalar após 14 dias e encontra-se com seis meses pós-operatórios. O método se mostrou factível e seguro. O resultado estético foi bem aceito pelo paciente. A via de acesso laparoscópica pode ser considerada uma alternativa para a exenteração pélvica no tratamento do tumor de reto baixo avançado que necessita de amputação anoperineal. Palavras-chave: neoplasia de reto; exenteração pélvica; laroscopia.

INTRODUCTION

Total pelvic exenteration is a surgical procedure used in the treatment of locally advanced or recurrent colorectal and cervical cancer within the pelvis. This treatment is adopted when the tumor is extended to other organs, such as prostate, seminal vesicle and bladder trigone1. Despite the considerable morbidity

A locally advanced rectal tumors is a challenging situation in the clinical practice. Only complete surgical resection can offer the possibility of long-term disease control.

Study carried out at the Hospital da Baleia – Belo Horizonte (MG), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 05/04/2010 Approved on: 05/19/2010

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of pelvic exenteration, it is possible to have good survival rates within five years2,3. Laparoscopy has shown to be an alternative to the treatment of locally advanced neoplasms within the pelvis, with some reports and series of cases published in the world literature4,5,6. The purpose of this study was to describe, with emphasis on the surgical approach, the case of a patient with locally advanced rectal tumor, treated with pelvic exenteration and wet colostomy by laparoscopy.

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tion started with the endopelvic fascia opening, with the venous complex controlled with 2-0 silk suture, incision of the urethra and rectourethralis near the pelvic musculature. Denovilliers’ (rectoprostatic) fascia was not opened, and the single vesicoprostatic specimen was laterally dissected until the pelvic floor. A pelvic drain was placed through the right iliac fossa trocar incision. The greater omentum, keeping the vascular nutrition through the left gastroepiploic artery, was placed in the pelvis to fill the empty space and between the ureters after the wet colostomy placement. No metastatic lesion was observed in the surgery. No lymphadenectomy of internal iliac vessels or obturator fossa was performed. The surgical specimen was extracted through the perineum by two surgeons, at the same time, and part of the team performed the anastomosis of ureters with the distal segment of the descending colon. That was an extracorporeal anastomosis (Figure 2). The patient remained hospitalized for 14 days after the surgery. No supplementary nutrition was required, as the patient did not tolerate feeding for the maximum period of four days. No blood transfusion was required. Leucocytosis occurred after

CASE REPORT A 43-year-old male patient, with body mass index of 19, presented hematochezia and tenesmus three months ago. Low rectal cancer was confirmed near the pectineal line, as well as moderately differentiated adenocarcinoma, with fistula directed to the anus margin. The computed tomography showed invasion of prostate. Tomographic exams showed no signs of hepatic or pulmonary metastasis. The neoadjuvant treatment with chemotherapy was indicated (5-Fluorouracil 675 mg and Leucovorin 50 mg) and radiotherapy. The preoperative bowel preparation was performed with polyethylene glycol. Total pelvic exenteration was performed using six trocars: umbilical (10 mm), right hypochondrium (5 mm), right iliac fossa (12 mm), two in left iliac fossa (5 mm) and hypogastric (5 mm) trocars (Figure 1). The patient remained in dorsal decubitus position, with lower limbs extended, during the laparoscopic exams of rectosigmoidectomy and cystoprostatectomy. The patient’s lower limbs were placed on stirrups only during the perineal surgical time. The colorectal surgery was performed before the bladder and prostate surgery. A double-barrel stroma was placed in the left iliac fossa trocar incision (Figure 1). As the patient had the preoperative stoma marking, it was used for one of the trocars. A monopolar cautery was coupled to the laparoscopic curved scissors for the surgery and the 400 clips were used for hemostasia of mesenteric, vesical and prostatic vessels. The vesicoprostatic dissection started with the Retzius space opening. The vascular pedicles were posterolaterally connected with the 400 clips and Hemolock. The ureters were distally identified, released above the iliac vessels. The prostate dissec-

Figure 1. Image of the anterior abdominal wall. Incisions for the trocars, wet colostomy (arrow) in the left iliac fossa and pelvic drain in the right iliac fossa.

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for primary rectal cancer is between 28 and 64%1,2,7. Pelvic oncologic surgery is also performed for the treatment of advanced cervical cancer, with radical hysterectomy and aortic and pelvic lymphadenectomy8. Anterior pelvic exenterations can be performed with the urinary tract reconstruction, using a uretersigmoid anastomosis4. Surgeries such as radical cystectomy and prostatectomy, via laparoscopic route, are performed by trained surgeons9. In this study, the urologist had already conclude the learning curve in laparoscopic urologic surgery. The colorectal surgeon had already performed more than 40 colorectal surgeries via laparoscopy and participated in a number of cases with wet colostomy via conventional access10. In this case report, the option of pelvic exenteration via laparoscopic route was considered due to the possibility of complete extraction of the surgical specimen through the perineum, as it is, according to the tomographic exams, a tumor close to the pectineal line and that invaded the prostate. The urology team performed the rectal touch examination and cystoscopy and kept the indication of pelvic exenteration. It is desirable to have the definition about the pelvic exenteration before the surgery, although it is known that some cases are only defined during the surgery3. The survival of patients with locally advanced rectal tumor without lymph nodes is better than when metastatic lymph nodes are present, and it is an independent variable for survival2. In locally advanced rectal tumors, the prostate is the second most frequently involved organ3. The neoadjuvant treatment is well accepted in the treatment of locally advanced rectal cancer with indication of pelvic exenteration (R0)11, although some renowned authors prefer not to use neoadjuvant chemoradiotherapy. There is also some debate on the use of lymphadenectomy near the internal iliac vessels in cases of pelvic exenteration either via laparotomy12 or laparoscopy6. The authors of this study preferred to use preoperative chemotherapy and radiotherapy and did not use lymphadenectomy near the internal iliac vessels during the surgery. Possible advantages of the laparoscopic surgery are: reduced blood loss, reduced postoperative pain and better cosmetic effect without affecting the oncologic radicality13. Pelvic exenteration via laparoscopic route should not affect the oncologic radi-

Figure 2. Exteriorization of right and left ureters (arrows) and colon loop, in the left iliac fossa incision, for the extracorporeal ureterocolonic anastomosis.

the sixth postoperative day, secondary to a left iliac fossa wall collection near the colostomy. This collection was treated with percutaneous drainage guided by ultrasound and use of Vancomycin and Meropenem. Histology showed an adenocarcinoma that invaded the muscularis propria, and the lymph nodes were free of neoplasm. In the prostate, fibrotic tissue was identified, but no signs of adenocarcinoma after the adjuvant treatment. The margins were not affected (R0). Four postoperative chemotherapy cycles were scheduled. The total surgical time was seven hours and thirty minutes, with five hours and thirty minutes only for the laparoscopic procedure. The procedure was well tolerated by the patient, without any significant reduction of hemoglobin or blood transfusion. He remained 14 days hospitalized after the surgery due to a purulent collection near the stoma. He is in the 10-month follow-up. There is no evidence of recurrent hydronephrosis and no sign of metastatic disease. DISCUSSION Pelvic exenteration for the treatment of advanced pelvic tumors alleviates symptoms of refractory pain, lower limb edema, urinary sepsis and recurrent hemorrhage7. It is estimated that 6 to 10% of the rectal tumors invade adjacent organs2. The prostate involvement changes the primary treatment into a total pelvic exenteration1,2,7. The survival rate within five years after the total pelvic exenteration 177


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cality and the complete excision of the tumor, and lymphadenectomy should follow the same parameters of the open technique. Urinary derivation, combined with total pelvic exenteration, affects the patient’s quality of life, and some options could be the Bricker procedure or double-barrel wet colostomy14,15. Double-barrel wet colostomy is an option for patients that require simultaneous urinary and fecal derivation16. It presents two derivations that drain to a single stoma17,18. It is considered a technique of low complexity, without intestinal anastomosis, involving reduced surgical time and acceptable quality of life10. The published series about urinary derivations via laparoscopic route have few case of wet colostomy, due to the difficult production of the reservoir and increased surgical time4,6,8. The extracorporeal production described in this case report had the double-barrel configuration, using a larger incision in one of the trocars in the left lower quadrant of

the abdomen; thus, promoting reduced surgical time without increasing surgical morbidity. The authors know only few cases in the international literature with total pelvic exenteration combined with perineal amputation and ureterocolonic anastomosis for the treatment of advanced rectal tumor. The laparoscopic procedure, combined with wet colostomy, was feasible and safe and it enabled reduced blood loss and prevented abdominal incision. However, a greater number of patients is required, as well as a longer postoperative follow-up, for a better acceptance of this access route in the treatment of locally advanced rectal tumor.

REFERENCES

7. Kecmanovic D M, Pavlov M J, Kovacevic P A, Sepetkovski A V, Ceranic M S, Stamenkovic A B. Management of advanced pelvic cancer by exenteration. Eur J Surg Oncol 2003;29(9):743-6. 8. Spirtos NM, Schlaerth JB, Kimball RE, Leiphart VM, Ballon SC. Laparoscopic radical hysterectomy (type III) with aortic and pelvic lymphadenectomy. Am J Obstet Gynecol 1996;174(6):1763-8. 9. Gupta NP, Gill IS Fergany A, Nabi G. Laparoscopic radical cystectomy with intracorporeal ileal conduit diversion: five cases with a 2-year follow-up. BJU Int 2002;90(4):391-6. 10. Queiroz FL, Barbosa-Silva T, Costa LMP, Werneck-Cortes BJ, Figueiredo JA, Guerra F, et al. Double-barrelled wet colostomy with simultaneous urinary e faecal diversion: results in 9 patients and review of the literature. Colorectal Disease 2006;8(4):353-9. 11. Bedrosian I, Giacco G, Penderson L, Rodrigues-Bigas MA, Feig B, Hunt KK et al. Outcome after curative resection for locally recurrent rectal cancer. Dis Colon Rectum 2006;49(2):175-82. 12. Costa SR, Antunes RC, Paula RP, Pedroso MA, Farah JF, Lupinacci RA. A exenteração pélvica no tratamento do câncer de reto estádio T4: A experiência de 15 casos operados. Arq Gastroenterol 2007;44(4):284-8.

CONCLUSION The laparoscopic route is an alternative for the treatment of locally advanced rectal tumor in male patients that require pelvic exenteration, anoperineal amputation and wet colostomy.

1. Koda K, Tobe T, Takiguchi N, Oda K, Ito H, Miyazaki M. Pelvic exenteration for advanced colorectal cancer with reconstruction of urinary and sphincter functions. Brit J Surg 2002;89(10):1286-9. 2. Costa SRP, Teixeira ACP, Lupinacci RA. A exenteração pélvica para o câncer de reto: Avaliação dos fatores prognósticos de sobrevida de 27 pacientes operados. Rev Bras Coloproct 2008;28(1):7-18. 3. Moriya Y, Akasu T, Fujita S, Yamamoto S. Aggressive surgical treatment for patients with T4 rectal cancer. Colorectal Dis 2003;5(5):427-31. 4. Puntambekar S, Kudchadkar R J, Gurjar AM, Sathe RM, Chaudhari YC, Agarwal GA, et al. Laparoscopic pelvic exenteration for advanced pelvic cancer: a review of 16 cases. Gynecol Oncol 2006;102(3):513-6. 5. Ferron G, Querleu D, Martel P, Chopin N, Soulié M. Laparocopy-assisted vaginal pelvic exenteration. Gynecol Obst Fertil 2006;34(12):1134-6. 6. Lin MY, Fan EW, Chiu AW, Tian YF, WU MP, Liao AC. Laparoscopy-assisted transvaginal total exenteration for locally advanced cervical cancer with bladder invasion after radiotherapy. J Endourol 2004;18(10):867-70.

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13. Leroy J, Forbes L, Jamali F, Smith M, Rubino F, Mutter D, Marescaux J et al. Laparoscopic total mesorectal excision (TME) for rectal câncer surgery long-term outcomes. Surg Endosc 2004;18(2):281-9. 14. Takada H, Yoshioka K, Boku T, Yoshida R, Nakagawa K, Matsuda T et al. Double-barreled wet colostomy. A simple method of urinary diversion for patients undergoing pelvic exenteration. Dis Col Rectum 1995;38(12);1325-6. 15. Díez AB, Rosado EF, Castelo LA, Rodrígues-Losada JS, Abal VC, Castro SN et al. Colostomía húmeda em doble barra: análisis de una derivación. Actas Urol Esp 2003;27(8):611-7. 16. Gullón AO, Oca J, Costea MAL, Virgili J, Ramos E, Rio C, et al. Double-barreled wet colostomy: a safe and simple method after pelvic exenteration. Int J Colorectal Dis 1997;12(1):37-41.

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17. Carter MF, Dalton DP, Garnett J.E. Simultaneous diversion of the urinary and fecal streams utilizing a single abdominal stoma: the double-barreled wet colostomy. J Urol 1989;141(5):1189-91. 18. Guimarães GC, Ferreira FO, Rossi BM, Aguiar SJ, Zequi SC, Bachega W et al. Double-barreled wet colostomy is a safe option for simultaneous urinary and fecal diversion. Analysis of 56 procedures from a single institution. J Surg Oncol 2006;93(3):206-11. Correspondence to: Juliano Alves Figueiredo Rua Barcelona, 226, apto. 304 – Santa Lúcia CEP: 30360-260 – Belo Horizonte (MG), Brazil E-mail: julianofigueiredo@ig.com.br

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Cecal diverticulitis or appendicitis. When should I suspect? A case report Ricardo Pastore1, Roberto da Mata Lenza2, Flávio Batista Rodrigues3, Lucas Vieira Tostes3, Natalia Cavasini Guerra3, Eduardo Crema4 Professor, Discipline of General Surgery and Surgical Technique at the Universidade Federal do Triângulo Mineiro (UFTM) – Uberaba (MG), Brazil. 2Digestive Tract Surgeon and Physician at the Emergency Service at the UFTM – Uberaba (MG), Brazil. 3Academicians of Medicine at the UFTM – Uberaba (MG), Brazil. 4Full Professor, Discipline of Digestive Tract Surgery at the UFTM – Uberaba (MG), Brazil. 1

Pastore R, Lenza RM, Rodrigues FB, Tostes LV, Guerra NC, Crema E. Cecal diverticulitis or appendicitis. When should I suspect? A case report. J Coloproctol, 2011;32(2): 180-183. ABSTRACT : The objective of this article was to report a case of cecal diverticulitis and point out the differential diagnosis of acute appendicitis. The clinical manifestations of these pathological conditions are similar, and the accurate diagnosis of cecal diverticulitis before the surgery is difficult. Therefore, most diagnoses are made during the surgery. Moreover, cecal diverticulum is uncommon in western countries, but it is prevalent in Asian people and their descendants. We report a case of a 55-year-old female patient, whose imaging exams (ultrasonography and computed tomography) and blood tests were not enough to diagnose the affection, requiring laparotomy and pathological exams for the final diagnosis. Some studies suggesting the best practice in case of diverticulum of the cecum were revised, as the diagnosis usually occurs during the surgery. Keywords: appendicitis; diverticulitis; cecum; diverticulum. RESUMO: O objetivo deste trabalho foi relatar um caso de diverticulite no ceco e chamar a atenção para o diagnóstico diferencial com apendicite aguda. As manifestações clínicas das duas afecções são semelhantes, dificultando o diagnóstico exato de diverticulite cecal, além de ser incomum, em nosso meio, o aparecimento de divertículo em cólon direito, sendo essa entidade mais comum em asiáticos e em seus descendentes. Relata-se atendimento a uma paciente de 55 anos, cujos exames de imagem (ultrassonografia e tomografia computadorizada) e de sangue não foram suficientes para o diagnóstico. Houve necessidade de realizar-se laparotomia exploradora e exames anatomopatológicos para a confirmação. Também foram revisados alguns trabalhos que sugerem qual a melhor conduta a ser tomada quando se encontra divertículo cecal no perioperatório, já que, na maioria das vezes, o diagnóstico é feito neste momento. Palavras-chave: apendicite; diverticulite; ceco; divertículo.

INTRODUCTION

of the times during the surgery2,9,11-13 and confirmed only with an anatomopathological exam1.

Cecal diverticulitis is a rare condition1,2,3, with prevalence of 0.004 to 2.1%4, affecting more often the Asian people3,5,6 and their descendants1,7,8. The first description was reported in 18633. The preoperative diagnosis is difficult, as its signs and symptoms can be confused with the signs and symptoms of acute appendicitis1,5,7,9-12. Consequently, the diagnosis is most

CASE REPORT M.A.C., female, 55 years old, came to the emergency service at the Hospital das Clínicas da Universidade Federal do Triângulo Mineiro complaining of pain in the right iliac fossa and gradual worsening for

Study carried out at the Discipline of General Surgery, Universidade Federal do Triângulo Mineiro (UFTM) – Uberaba (MG), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 10/14/2010 Approved on: 11/18/2010

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a week. She said she had no nauseas, vomiting or alteration to bowel habits. She presented anorexia and no fever since the beginning of this condition. The physical examination showed peritoneal reaction in the right iliac fossa (positive Blumberg sign). Pelvic ultrasonography (US) showed fecalith in the right iliac fossa, with peritoneal reaction around it (Figure 1) and no collections. The report suggested appendicitis as the most probable diagnosis or focal diverticulitis near the cecum. Abdominal computed tomography (CT) showed a tubular shape posterolaterally to the cecum. The lesion area was highlighted after the intravenous infusion of contrast medium and calcified focus in its proximal segment, as well as densification of surrounding mesenteric fat. No colonic diverticular formations with evidence of acute inflammatory were observed. Then, based on CT, the patientâ&#x20AC;&#x2122;s condition was compatible with acute appendicitis. Two complete blood tests were performed, which did not present alterations. Infraumbilical median exploratory laparotomy was the selected method and a tumor mass was found in the cecum. Then, segmental colectomy was performed, with removal of the cecum and the mass involving it, as well as the appendix, which presented unaltered aspect. In addition, termino-terminal ileocolic anastomosis was performed. The anatomopathological exam showed ulcerated and abscessed diverticulum in the wall of the large bowel and contained by the peri-intestinal adipose tissue (Figure 2).

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Figure 1. Ultrasonography of the patient, showing fecalith (smaller arrow) in the right iliac fossa. The larger arrow shows the acoustic shadow of the dense material.

Figure 2. Picture of anatomopathological exam.

cecal

diverticulum

at

the

topic pregnancy, ovarian cyst rupture, pelvic inflammatory disease and, especially, acute appendicitis2,17. The clinical presentation of cecal diverticulitis with fever and abdominal pain in the right lower quadrant is practically indistinguishable from acute appendicitis1, but there are some differences: the pain in diverticulitis starts directly in the right iliac fossa, instead of starting vaguely in the periumbilical region, as it occurs in appendicitis. Diverticulitis is more insidious and extended, and its systemic toxic signs are mild, with rare nauseas and vomiting7. A case has been reported of cecal diverticulitis initially causing pain in the periumbilical region, and the patient presented recurrent abdominal pain for six months, without alteration to bowel habits or systemic toxic signs3, compatible with the clinical condition suggested for cecal diverticulitis. The blood test may show elevated white blood cell count1,9. However, in our case, no alteration was observed in the absolute number of leucocytes. US and CT are very helpful, enabling the correct diagnosis and preventing unexpected findings

DISCUSSION The (false) left colon diverticulosis occurs predominantly in the sigmoid and affects the western population more often9,14,15, while the (true) right colon diverticulosis occurs predominantly in the cecum and affects the young population and descendants of Asians more often1,9. Cecal diverticulitis is rare in western population, but it is prevalent in Asian countries.6,7,14. The preoperative diagnosis is difficult9 and infrequent, despite de use of radiological imaging. The diagnostic certainty is obtained only with the anatomopathological exam16. The differential diagnoses are: Crohnâ&#x20AC;&#x2122;s disease, actinomycosis, perforation by a strange body, amebiasis, carcinoid tumor, tuberculosis, gastroenteritis, ureteral colic, ec181


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during the surgery2. A study that analyzed 934 patients18 with pain of undetermined nature in the right iliac fosse showed that US presented 100% accuracy when distinguishing diverticulitis from appendicitis. However, this is a limited exam, as it depends on the examiner’s experience, a fact that becomes a problem, particularly in western countries, where the experience with cecal diverticulitis is low2. CT offers good cost-benefit ratio at the differential diagnosis of abdominal pain conditions involving suspicion of acute appendicitis19. Helical CT may suggest or define the diagnosis of cecal diverticulitis18. In this report, only ultrasonography suggested that it was cecal diverticulitis. When the diagnosis of cecal diverticulitis is secured, antibioticotherapy can be applied in patients without signs of peritonitis1,9,20,21. As the right colonic diverticulitis is benign, the conservative treatment with minimal surgical intervention should be the best therapeutic option10. Exploratory laparotomy is suggested in cases without diagnostic certainty1. However, the greatest di-

lemma is what to do when cecal diverticulitis is incidentally found during appendicectomy3. There is no standard procedure for the treatment of solitary cecal diverticulitis3. The surgical resection of diverticulum is recommended9 plus colectomy, if the histopathological exam shows the presence of neoplasm9. When the diagnosis is secured, the procedure of diverticulectomy combined with appendicectomy is suggested3. Otherwise, colectomy is suggested3. In this case, the second approach was selected, with segmental colectomy. A successful clinical treatment was reported in a case whose diagnosis was made without laparotomy, but the patient had history of appendicectomy for 15 years and no pain at rapid decompression1. In addition, emergency colectomy is well accepted in the treatment of complicated diverticulitis10. Two cases have been reported in which right hemicolectomy was performed, without complications in both cases2,3. Laparoscopy could be applied for diagnostic purposes, but it involves the risk of not detecting diverticula in the posterior wall of the cecum22.

REFERENCES

patients presenting with appendicitis. World J Surg 1999;23(7):713-6. 7. Shyung LR, Lin SC, Shih SC, Kao CR, Chou SY. Decision making in right-sided diverticulitis. World J Gastroenterol 2003;9(3):606-8. 8. Ruiz-Tovar J, Reguero-Callejas ME, Gonzáles FP. Inflammation and perforation of a solitary divericulum of the cecum. A report of 5 cases and literature review. Rev Esp Enferm Dig 2006;98(11):875-80. 9. Karatepe O, Gulcicek OB, Adas G, Battal M, Ozdenkaya Y, Kurtulus I, et. al. Cecal diverticulitis mimicking acute appendicitis: a report of 4 cases. World J Emerg Surg 2008;3:16-4. 10. Leung WW, Lee JF, Liu SY, Mou JW, Ng SS, Yiu RY, et al. Critical appraisal on the role and outcome of emergency colectomy for uncomplicated right-sided colonic divericulitis. World J Surg 2007;31(2):383-7. 11. Connolly D, Mcgookin RR, Gidwani A, Brown MG. Inflamed solitary caecal diverticulum – it is not appendicitis, what

1. Chedid AD, Domingues LA, Chedid MF, Villwock MM, Mondelo AR. Divertículo único do ceco: experiência de um hospital geral brasileiro. Arq Gastroenterol 2003;40(4):216-9. 2. Griffiths EA, Date RS. Acute presentation of a solitary caecal diverticulum: a caser report. J Med Case Reports 2007;1:129. 3. Kurer MA. Solitary caecal diverticulitis as an unusual cause of a right iliac fossa mass: a case report. J Med Case Reports 2007;1:132. 4. Barría C, Pujado B, Zepeda N, Beltrán MA. Diveriticulitis apendicular como causa de apendicectomía: reporte de un caso. Rev child Cir 60(2):154-7. 5. Fontes D, Luz MMP, Andrade Jr JCCG, Santos BMR, Andrade DC. Doença diverticular no apêndice cecal. Rev bras Coloproct 2006;23(1):25-7. 6. Poon RT, Chu KW. Inflammatory cecal masses in

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should I do? Ann R Coll Surg Engl 2006;88(7):672-4. 12. Griffiths EA, Bergin FG, Henry JA, Mudawi AM. Acute inflammation of a congenital cecal diverticulum mimicking appendicitis. Med Sci Monit 2003; 9(12):CS107-9. 13. Papapolychroniadis C, Kaimakis D, Fotiadis P, Karamanlis E, Stefopoulou M, Kouskouras K, et al. Perforated diverticulum of the caecum. A difficult preoperative diagnosis. Report of 2 cases and review of the literature. Tech Coloproctol 2004;(Suppl l):116-8. 14. Hildebrand P, Kropp M, Stellmacher F, Roblick UJ, Bruch HP, Schwandner O. Surgery for right-sided colonic diverticulitis: results of a 10-year-observation period. Langenbecks Arch Surg 2007;392(2):143-7. 15. Paulino F, Roselli A, Martins U. Pathology of diverticular disease of the colon. Surgery 1971;69(1):63-9. 16. Nunes FC, Mattos MP, Silva AL. Divertículo do apêndice vermiforme. Rev Col Bras Cir 2004;31(5):342-3. 17. Rasmussen I, Enblad P. Acute solitary diverticulitis of the caecum. Case report. Acta Chir Scand 1988;154(5-6):399-401. 18. Chou YH, Chiou HJ, Tiu CM, Chen JD, Hsu CC, Lee CH, et al. Sonography of acute right side colonic diverticulitis. Am J Surg 2001;181(2):122-7.

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19. Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998;338(3):141-6. 20. Abogunrin FA, Arya N, Somerville JE. Case report solitary caecal diverticulitis – a rare cause of right iliac fossa pain. Ulster Med J 2005;74(2):132-3. 21. Jang HJ, Lim HK, Lee SJ, Lee WJ, Kim EY, Kim SH. Acute diverticulitis of the cecum and ascending colon: the value of thin-section helicoidal CT findings in excluding colonic carcinoma. ARJ Am J Roentgenol 2000;174(5):1397-402. 22. Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2004;(4):CD001546. Correspondence to: Dr. Eduardo Crema Disciplina de Cirurgia Geral Universidade Federal do Triângulo Mineiro (UFTM) Avenida Frei Paulino, 30 – Abadia CEP: 38025-180 – Uberaba (MG), Brazil E-mail: cremaUFTM@mednet.com.br

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Fibrogenesis and carcinoid tumor – a case report Eduardo Fonseca Alves Filho1, Carlos Ramon Silveira Mendes2, Marcelo Da Silva Barreto3, Rogério Souza Medrado De Alcantara4 Coordinator, Service of Coloproctology, Hospital Português da Bahia – Salvador (BA), Brazil; Full member, Sociedade Brasileira de Coloproctologia (TSBCP) – Salvador (BA), Brazil. 2Service of Coloproctology, Hospital Português da Bahia – Salvador (BA), Brazil; Member of the Sociedade Brasileira de Coloproctologia (ASBCP) – Salvador (BA), Brazil. 3 Service of Coloproctology, Hospital Português da Bahia – Salvador (BA), Brazil; TSBCP – Salvador (BA), Brazil. 4Service of Coloproctology, Hospital Português da Bahia – Salvador (BA), Brazil; ASBCP – Salvador (BA), Brazil. 1

Alves Filho EF , Mendes CRS, Barreto MS, Alcantara RSM. Fibrogenesis and carcinoid tumor – a case report. J Coloproctol, 2012;32(2): 184-187. ABSTRACT: Carcinoid tumors are rare. They may appear in the entire gastrointestinal and respiratory tracts, with single or multiple occurrences. Prognosis is dependent on the size and location. Symptoms may appear in carcinoid syndrome, related to active substances, especially serotonin. One important aspect associated with these tumors and usually ignored is fibrogenesis. This is a case report of a patient with carcinoid tumor of the terminal ileum, treated by laparoscopy, associated with fat and fibrosis infiltration. Keywords: carcinoid tumor; colectomy; laparoscopy. RESUMO: Tumores carcinoides são pouco frequentes, podem surgir em todo o trato gastrointestinal e respiratório, podem ser únicos ou múltiplos. O prognóstico depende do tamanho e da localização do tumor. Podem ocorrer sintomas relacionados à síndrome carcinoide, decorrente da produção de substâncias ativas, em especial serotonina. Um aspecto comumente ignorado associado a estes tumores é a estimulação da fibrogênese. Relatamos um caso de tumor carcinoide de íleo, tratado por videolaparoscopia, associado à infiltração fibroadiposa. Palavras-chave: tumor carcinoide; colectomia; laparoscopia.

INTRODUCTION

CASE REPORT

Carcinoid tumors are infrequent neuroendocrine neoplasms that may occur in the entire gastrointestinal, and outside it as well1. They may be single or multiple tumors and are associated with secretion of several active substances that can lead to many specific or nonspecific symptoms, particularly related to carcinoid syndrome. The presentation, although frequent but not always remembered, is the fibrous reaction that the tumor may cause. The purpose of this study was to report a case of carcinoid tumor of the terminal ileum, treated by videolaparoscopy, associated with fat and fibrosis infiltration of the abdominal cavity and the cecum.

A 68-year-old female patient, asymptomatic, was submitted to routine ileocolonoscopy for colorectal neoplasm screening four years ago, which showed submucosal tumor in the ileum of around 1 cm and two sessile polyps of 0.5 cm in the rectum, and polypectomy of rectal polyps (tubular adenomas) was performed. The patient remained without supervision for four years. A new ileocolonoscopy was performed (Figures 1 and 2), which showed ileocecal valve bulge and submucosal tumor of the terminal ileum of around 2 cm, involving 50% of the lumen. The abdominal computed tomography (CT) showed no anomalies and imaging and laboratorial exams showed no alterations.

Study carried out at the Service of Coloproctology at the Hospital Português da Bahia – Salvador (BA), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 09/30/2010 Approved on: 11/15/2010

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Figure 1. Colonoscopy: ileocecal valve bulge. Figure 3. Surgical specimen; product of laparoscopic right hemicolectomy: ileum, cecum, ascending colon and mesocolon, pointing to a tumor in the ileum.

At the pathological anatomy, a carcinoid tumor of 2 cm was observed in the ileum, limited to the muscularis propria, and 23 neoplasm-free lymph nodes, as well as lipomatosis of the ileocecal valve and fat and fibrosis infiltration of the cecal appendix. The patient was taken to the service of oncology, which did not prescribe any adjuvant treatment. DISCUSSION The term karzinoid tumor was first used in 1907, by Oberndorfer, to describe tumors less aggressive than adenocarcinomas2. Carcinoid tumors derive from enterochromaffin cells, which are part of the diffuse endocrine system (amine precursor uptake and decarboxylation â&#x20AC;&#x201C; APUD); although usually occurring in the form of subepithelial lesions, they are histologically considered epithelial tumors3. According to their embryological origin, carcinoid tumors can be classified as: foregut (thymus, respiratory system, stomach, duodenum, pancreas and ovaries), midgut (jejunum, ileum, appendix and proximal colon); hindgut (distal colon and rectum)2. The most frequently affected structures are: appendix, ileum, rectum and bronchi1-5.

Figure 2. Ileoscopy showing a 2-cm tumor of the ileum.

Considering the future risk of obstruction, impossibility of endoscopic treatment and involvement of malignancy, the surgical intervention was the adopted therapy. At the surgical inventory, performed by laparoscopy, a high amount of fibrous adherence in the abdominal cavity was observed, with no evidence of metastases. Adhesiolysis and laparoscopic right hemicolectomy were performed, with laterolateral ileotransverse lymphadenectomy and extracorporeal mechanical anastomosis (Figure 3). The patient was discharged from the hospital on the third postoperative day. 185


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In a clinical perspective, they can be classified as functioning or non-functioning, depending on the production of substances, such as amines (serotonin and histamine), proteins (hormones and kinins) and prostaglandins. The first type causes carcinoid syndrome associated with vasomotor symptoms: hot flashes, alterations to systemic arterial pressure, bronchospasm and diarrhea6,7. The syndrome invariably occurs associated with liver metastases or tumors outside the hepatic portal system1. Metastases are more common in tumors in the jejunum and ileum. Tumors smaller than 1 cm rarely cause metastases, while around 10% of the tumors up to 2 cm and 70% of tumors over 2 cm are associated with metastases. Insulin-like growth factor (IGRF) and vascular endothelial growth factor (VEGF) are related to pulmonary and intestinal carcinoid tumors, and the increased expression of these factors is associated with tumor growth due to increased angiogenesis, which seems to be related to metastases and reduced survival1. Another aspect related to the production of substances by the tumor, especially serotonin and the transforming growth factor-beta 1 (TGF-β1), is the occurrence of fibrogenesis, mainly in tumors of the ileum and jejunum, which many times leads to bowel obstruction3,4. Fibrosis usually occurs in the mesentery, called desmoplastic reaction. Fibrosis occurs less frequently in the retroperitoneum, pleura, skin and endocardium, leading to heart valve lesions, particularly in the right side. Serotonin regulates the production of TGF–β, which, in turn, promotes the collagen synthesis by stimulating fibroblasts in the extracellular matrix. Tachykinins promote the DNA synthesis in fibroblasts and neurokinins are involved in heart valve fibrosis4,8. Studies show that high serum levels of serotonin bound with platelets and high urinary levels of 5-hydroxy-indole-acetic acid (5-HIAA – the serotonin metabolite produced in the kidneys) are commonly associated with liver metastases; whereas the peritoneal mass associated with fibrosis is only related to high levels of serotonin bound with platelets1.

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The preoperative diagnosis is not always possible. The urinary excretion of 5-HIAA above 8 mg/24 h presents sensitivity and specificity of 73% and 100%, respectively2. Hindgut and foregut tumors are not associated with high urinary levels of 5-HIAA, neither with serum serotonin, but the serum level of platelet serotonin is more sensitive in the detection of these tumors. Imaging exams are more useful when associated with methods that detect metabolites secreted by the tumor, such as: scintillography and positron emission tomography (PET). Fibrous tumors smaller than 1.5 cm are identified in tomography in 50 to 75% of midgut tumors2. The treatment is surgical, depending on the tumor location and size. Tumors of the appendix smaller than 1 cm can be treated through appendicectomy and tumors over 2 cm, with right hemicolectomy. Tumors of intermediate size should be individualized. Small bowel tumors are treated with resections of both primary and secondary lesions. Colon tumors should be resected depending on their location. Rectal tumors smaller than 1 cm can be treated with local resections, for 1 to 2 cm, the treatment is individualized, over 2 cm, with rectosigmoidectomy, if possible, or rectal amputation6. The drug treatment I used to relieve the symptoms related to carcinoid syndrome, such as octeocride, lanreotide, H2 blockers, phenothiazine, corticosteroids, serotonin blockers2. Chemotherapy is ineffective in advanced stages of the diseases. Substances that inhibit angiogenesis and tumor growth, such as endostatin, sunitinib, sorafenib and bevacizumab, seem to bring promising results1. Prognosis is dependent on both tumor staging and location, and tumors of the ileum and jejunum present the worst prognosis. CONCLUSION A high level of suspicion for carcinoid tumors should be taken into account, especially in the presence of systemic symptoms and signs of local or distant fibrosis.

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REFERENCES

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thearchives of the AFIP: benign fibrous tumors and tumorlikelesions of the mesentery: radiologic-pathologic correlation. Radiographics 2006;26(1):245-64. 6. Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoid tumors. Cancer 2003;97(4):934-59. 7. Modlin IM, Champaneria MC, Chan AK, Kidd M. A three decade analysis of 3,911 all intestinal neuroendocrine tumors: the rapid pace of no progress. Am J Gastroenterol 2007;102(7):1464-73. 8. Leask A, Abraham DJ. TGF-beta signaling and the fibrotic response. FASEB J 2004;18(7):816-27.

1. Kidd M, Modlin IM, Shapiro MD, Camp RL, Mane SM, Usinger W, et al. CTGF, intestinal stellate cells and carcinoid fibrogenesis. World J Gastroenterol 2007;13(39):5208-16. 2. Druce M, Rockall A, Grossman AB. Fibrosis and carcinoid syndrome: from causation to future therapy. Nat Rev Endocrinol 2009;5(5):276-83. 3. Jackson LN, Chen LA, Larson SD, Silva SR, Rychahou PG, Boor PJ, et al. Development and characterization of a novel in vivo model of carcinoid syndrome. Clin Cancer Res 2009;15(8):2747-55. 4. Bowen KA, Silva SR, Johnson JN, Doan HQ, Jackson LN, Gulhati P, et al. An analysis of trends and growth factor receptor expression of GI carcinoid tumors. J Gastrointest Surg 2009;13(10):1773-80. 5. Levy AD, Rimola J, Mehrotra AK, Sobin LH. From

Correspondence to: Eduardo Fonseca Alves Filho Avenida Princesa Isabel, 914, sala 316 – Barra Avenida CEP: 40144-900 – Salvador (BA), Brazil E-mail: eduardoalvesfh@hotmail.com

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Case Report

Intestinal obstruction due to malign breast neoplasm and peritoneal carcinomatosis: a case report Flávia Balsamo1, Rafael Ferreira Correia Lima2, Rodrigo Rocha Batitsta2, Galdino José Sitonio Formiga3 Assistant, Service of Coloproctology, Hospital Heliópolis – São Paulo (SP), Brazil. Permanent Member, Sociedade Brasileira de Coloproctologia. 2Resident, Service of Coloproctology, Hospital Heliópolis – São Paulo (SP), Brazil. 3Head of the Service of Coloproctology, Hospital Heliópolis – São Paulo (SP), Brazil; Permanent Member, Sociedade Brasileira de Coloproctologia. 1

Balsamo F, Lima RFC, Batitsta RR, Formiga GJS. Intestinal obstruction due to malign breast neoplasm and peritoneal carcinomatosis: a case report. J Coloproctol, 2012;32(2): 188-192. ABSTRACT: Peritoneal carcinomatosis due to breast cancer is rare and gastrointestinal tract involvement is also unusual. Symptoms are unspecific and can begin many years after the primary tumor. Investigation of carcinomatosis origin is mandatory as breast cancer carcinomatosis can relieve partially or totally with chemo and hormonal therapy. A case of colonic obstruction due to carcinomatosis secondary to breast cancer is reported, emphasizing its diagnostic aspects and treatment. Keywords: intestinal obstruction; /secondary; breast neoplasms; carcinoma; abdomen, acute. RESUMO: A carcinomatose peritoneal secundária ao câncer de mama é entidade rara e o comprometimento do trato gastrointestinal é pouco frequente. A sintomatologia bastante inespecífica dificulta o diagnóstico e os sintomas podem surgir vários anos após o aparecimento do tumor primário. O diagnóstico da origem da carcinomatose é fundamental, pois quando a doença é secundária à neoplasia de mama, pode ocorrer remissão parcial e até total da doença com quimio e hormonioterapia. Relata-se caso de obstrução colônica devido a carcinomatose peritoneal secundária a neoplasia maligna de mama, com ênfase em seu diagnóstico e tratamento. Palavras-chave: obstrução intestinal; /secundário; neoplasias da mama; carcinoma; abdome agudo.

INTRODUCTION

The lobular type of the disease is more associated with metastases in the gastrointestinal tract, genital organs and peritoneum1-4. The purposes of this report were to describe a case of colonic obstruction due to peritoneal carcinomatosis secondary to malignant breast neoplasm and make a literature review.

Breast cancer is the most frequent malignant tumor in women1-4, but peritoneal carcinomatosis due to breast cancer is rare1, accounting from 6 to 8% of breast adenocarcinoma cases4,5. Metastatic lesion of breast cancer usually affects lymphatic ganglions, bones, lungs, brain and liver1-3. More rarely, it may also affect the gastrointestinal tract, peritoneum and genital organs1,4. Its very unspecific symptoms make diagnosis more difficult and they may appear several years after the primary tumor1,3. The investigation of carcinomatosis origin is mandatory, as breast cancer carcinomatosis can relieve partially or totally with proper chemo and hormonal therapy1.

CASE REPORT A 62-year-old female patient, born in Salto Grande (SP) and living in Santo André (SP), retired, presented for three months changes in the bowel habit – one in three days, associated with distension and abdominal pain like cramps and loss of 20 kilos in the period. The patient presented history of hy-

Study carried out at the Service of Coloproctology, Hospital Heliópolis – São Paulo, SP, Brazil. Conflict of interest: nothing to declare. Financial source: none. Submitted on: 02/25/2011 Approved on: 08/25/2011

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pothyroidism, treated with Puran T4 100 mcg/day and right mastectomy and hormonal therapy due to malignant breast neoplasm ten years before. The physical examination detected globus and tympanic abdomen, a little distended, no pain at superficial and deep palpation, no palpable mass and bowel sounds were present and normal. The proctologic exam was performed until 20 cm from the anal canal, with normal mucosa. The colonoscopic study was performed until the transverse colon with luminal stenosis and preserved mucosa, blocking the device progression. Biopsies were made with samples from the site, whose histopathological result showed unspecific chronic inflammatory process. Abdominal tomography showed liver without alter-

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ations and colonic dilatation, with abrupt interruption at the transverse colon level, as well as greater omentum thickening (Figure 1). Tomography of thorax was normal (Figure 2). As illustrated in Figure 3, the opaque enema showed free progression of rectal contrast until distal transverse colon, with inadequate filling at this level. High digestive endoscopy until the second duodenal portion showed mild enanthematous gastritis. The serum level of carcinoembryonic antigen (CEA) was 2.7 ng/dL. The patient was submitted to exploratory laparotomy, which showed peritoneal carcinomatosis (Figure 4) and involvement of distal transverse colon, with the omentum full of carcinomatosis nodules.

A

B Figure 1. Abdominal tomography showing colonic dilatation.

Figure 3. Opaque enema with inadequate filling in transverse colon.

Figure 2. Normal tomography of thorax.

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A small portion of the omentum was resected for derivative transversostomy proximally to stenosis. The histopathological analysis of the omentum showed adenocarcinoma infiltrating adipose tissues (Figure 5) and the immunohistochemical analysis showed 90% of the

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cells positive to markers SP1 (estrogen receptor) and PgR636 (progesterone receptor), as well as presence of positiveness to cytokeratin 7 (CK7), showing primary breast adenocarcinoma (Figure 6). The patient was submitted to adjuvant chemotherapy with Adriamycin 60 mg/m2 and Paclitaxel 175 mg/m2 and hormonal therapy with Anastrozole (Arimidex®) 1 mg/day, showing improved general conditions and weight gain. Control exams showed absence of omentum thickening, normal liver and unspecific distribution of intestinal loops (Figure 7) In Figure 8, the opaque enema shows persistent stenosis of transverse colon, with difficult progression of rectal contrast until the colostomy. The patient was submitted to a new exploratory laparotomy, without evidence of carcinomatosis,

A

B

A

C

B

Figure 4. Peritoneal carcinomatosis with distal transverse colon obstruction.

A

Figure 5. Histopathological analysis: adenocarcinoma infiltrating adipose tissues.

B

Figure 6. Immunohistochemical analysis with positive markers of breast cancer.

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DISCUSSION

which found the cicatricial stenosis of transverse colon, and a segmental colectomy was performed involving the area of stenosis, as well as colostomy with reconstruction of intestinal flow and termino-terminal colonic anastomosis (Figures 9 and 10). The histopathological study of the specimen showed no evidence of neoplasm, only cicatricial tissue. The patient presented good progress and was discharged from hospital six days after the surgery. Today, the patient is in 27-month follow-up, without symptoms and free from the disease.

The infrequent occurrence of peritoneal carcinomatosis due to breast adenocarcinoma and its unspecific symptoms make its diagnosis more difficult4. In the case reported, despite the endoscopic and contrast radiological and tomographic investigations in the preoperative period, it was not possible to diagnose it on this occasion, but only confirm the site with the probable obstruction, which has also been found by other authors1. The definitive diagnosis was only achieved after the histopathological and immunohistochemical analysis of a fragment of the omentum obtained through exploratory laparotomy. In cases of history of breast neoplasm with any gastrointestinal tract manifestation, the secondary involvement due to breast neoplasm should be con-

A

B

Figure 7. (A) thorax X-ray and (B) abdominal tomography with normal aspect after chemotherapy and hormonal therapy.

Figure 8. Free progression of contrast, with difficult progression until the stoma.

Figure 9. Absence of carcinomatosis.

Figure 10. Surgical specimen (colostomy and stenosis).

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sidered as one of the hypotheses and, whenever possible, confirm the finding with immunohistochemical exams6. The immunohistochemical markers that can help in this diagnosis are the expression of cytokeratin 7, estrogen and progesterone receptors and negativity to cytokeratin 201,6, also used in this case. The interval between the primary disease appearance and the peritoneal carcinomatosis may vary from months to 30 years, average interval of 6 years1; in this case, this interval was 10 years. It was not possible to identify the histological type of breast adenocarcinoma that affected the patient in question and, therefore, we cannot correlate the finding of carcinomatosis to lobular or ductal type. Surgical interventions are used only to resolve complications, considering that this is a disease with systemic dissemination4, as performed here, with exploratory lap-

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arotomy required for intestinal derivation due to partial bowel occlusion and to help achieve the diagnosis. The patient remains fully asymptomatic, 27 months after the secondary disease diagnosis, as she presented a good response when submitted to chemotherapy and hormonal treatment. This finding agrees with the average survival presented in these cases, which is 24 to 36 months4. CONCLUSION In cases of peritoneal carcinomatosis and history of breast adenocarcinoma, the investigation of the carcinomatosis origin is essential, as good alleviation can be obtained with a specific treatment. Chemotherapy associated with conservative surgeries can also provide good quality of life.

REFERENCES

5.

1.

Priego PJ, Rodriguez GV, Reguero MEC, Cabañas JM, Lisa EC, Peromingo RF, et al. Carcinomatosis peritonial secundaria a carcinoma lobulillar de mama. Rev Chil Cir 2007;59(3):223-8. 2. Araújo LHL, Melo AC, Moreira MML,Gomes CAS, Noronha Jr H, Cunha WML, et al. Metástase gástrica de câncer de mama: relato de caso e revisão de literatura. Rev Bras Cancerol 2007;53(3):365-8. 3. Fillmann LS, Pinho CM, Fillmann HS, Fillmann EEP. Relato de caso: metástase de carcinoma de mama para o intestino grosso. Rev Bras Coloproct 2007;27(4):50-2. 4. McLemore EC, Pockaj BA, Reynolds C, Gray RJ, Hernandez JL, Grant CS, et al. Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis. Ann Surg Oncol 2005;12(11):886-94.

6.

Hewitt MJ, Hall GD, Wilkinson N, Perren TJ, Lane G, Spencer JA. Image-guided biopsy in women with breast cancer presenting with peritoneal carcinomatosis. Int J Gynecol Cancer 2006;16 Suppl 1:108-10. Schwartz RE, Klimstra DS, Turnbull ADM. Metastatic breast cancer masquerading as gastrointestinal primary. Am J Gastroenterol 1998;93(1):111-4.

Correspondence to: Flávia Balsamo Serviço de Coloproctologia do Hospital Heliópolis Rua Cônego Xavier, 276 – Vila Heliópolis CEP: 04231-030 – São Paulo (SP), Brazil E-mail: flabal@uol.com.br

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Case Report Granular cell tumor of colon: a case report Eduardo Brambilla¹, Marcos Antonio Dal Ponte², Henrique Rasia Bosi³, Rodrigo Paese Capra³, Pedro Guarise da Silva³ ¹Full Professor, Department of Surgical Practice, Discipline of Coloproctology, Center of Health Sciences at the Universidade de Caxias do Sul (UCS) – Caxias do Sul (RS), Brazil. ²Resident physician, Service of General Surgery at the Hospital Geral, UCS – Caxias do Sul (RS), Brazil. 3Academician, Medical Sciences at the UCS – Caxias do Sul (RS), Brazil.

Brambilla E, Dal Ponte MA, Bosi HR, Capra RP, Silva PG. Granular cell tumor of colon: a case report. J Coloproctol, 2012;32(2): 193-195. ABSTRACT: Granular cell tumor rarely affects the gastrointestinal tract. The symptoms are often unspecific and the diagnosis is reached accidentally by colonoscopy. We report the case of a 42-year-old patient diagnosed with granular cell carcinoma of the colon based on an incidental finding in colonoscopy, who was treated successfully by endoscopic excision of the tumor. Keywords: colon; colonoscopy; granular cell tumor; endoscopy. RESUMO: O tumor de células granulares raramente acomete o trato gastrointestinal. Os sintomas muitas vezes são inespecíficos e o diagnóstico é feito ao acaso através da colonoscopia. Nós reportamos o caso de um paciente de 42 anos diagnosticado com tumor de células granulares de cólon devido a um achado incidental da colonoscopia e tratado com sucesso com remoção endoscópica. Palavras-chave: colo; colonoscopia; tumor de células granulares; endoscopia.

INTRODUCTION

CASE REPORT

Granular cell tumor, also known as granular cell myoblastoma1, is a rare soft tissue tumor that affects any anatomical site, more commonly the oral cavity and tongue (33%), subcutaneous tissues (10%) and the musculoskeletal system (5%)2,3. In the gastrointestinal tract, it affects most commonly the esophagus, followed by the stomach and duodenum2. Its histogenesis is uncertain3; however, it is known to be a benign tumor that appears as a submucosal nodule, and which may be accidentally found during the endoscopic exam4. We report the case of a patient with granular cell tumor, diagnosed and treated by endoscopy, with good progress after 24-month follow-up.

A 42-year-old man came to the outpatient clinic complaining of rectal prolapse, bleeding and pain at evacuation. At the physical examination, mixed hemorrhoids were observed, with no additional findings. In the preoperative period, laboratorial exams were performed and the patient was submitted to colonoscopy. This examination showed the presence of three submucosal lesions in the cecum and ascending colon, which were resected after infiltration of the submucosa with saline solution, with no complication during the procedure. Macroscopically, the lesions presented around 5 mm diameter, were hardened and whitish. The material was sent for histopathological analysis, which showed lesions compatible with granular cell

Study carried out at the Service of Coloproctology, Hospital Geral de Caxias do Sul – Caxias do Sul (RS), Brazil. Conflict of interest: nothing to declare. Financial source: none. Submitted on: 05/17/2011 Approved on: 05/30/2011

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tumor, presenting dystrophic calcifications (Figure 1). The lesions were removed by endoscopic excision, with observational management. After 24-month follow-up, the patient remains asymptomatic and with normal colonoscopy.

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The tumor symptoms are unspecific. In most cases, the lesions are asymptomatic; and they may simulate other pathologies that affect the colon, such as hematochezia and abdominal discomfort1,7. At colonoscopy, the aspect is similar to that of a sessile polyp, preferably located in the anorectal area and the ascending colon4. The endoscopic biopsy is not the best option, as in most cases, the tumor is covered by normal mucosa. The endoscopic ultrasound may suggest the diagnosis, but it does not always allow it to be distinguished from malign neoplasms8. The best diagnostic option is the mass surgical excision and histopathological analysis7. Diagnosis is rarely difficult at the histopathological analysis, as the presence of nests of large cells with abundant cytoplasm and small and round nucleus is typical. The immunohistochemical analysis confirms the diagnosis when demonstrating positivity to S-100 protein, neuron specific enolasis and vimentin, and negativity to alpha smooth muscle actin and desmin1. As this is a benign pathology, the recommended treatment is the endoscopic excision of the lesion by extensive biopsy when the tumor diameter is smaller than 2 cm and not adherent to the muscularis propria, preventing complications such as perforation and bleeding6. In cases of multiple tumors, total colostomy is recommended. For single location of the tumor, but with diameter above 4 cm, colectomy is suggested, as tumors of this size present higher risk of malignity and metastasis4.

Figure 1. Histological exam showing dystrophic calcifications, compatible with the presence of granular cell tumor.

DISCUSSION Granular cell tumor rarely affects the gastrointestinal tract. The cellular origin of this entity is uncertain. In the beginning, it was believed to have a myoblastic origin, and for this reason, it was named granular cell myoblastoma. However, as it is positive to S-100 protein, it is thought to be a tumor of neural origin, more precisely, of Schwann cells5. The incidence of this neoplasm has not been defined, but it is supposed to affect more often men in his 40s or 50s2. When affecting the gastrointestinal tract, this tumor is usually located in the submucosa, covered by normal mucosa6. The tumor diameter varies from 1 to 2 cm, but tumors of 4 cm diameter have been reported, and it may be a single tumor or multiple tumors.

CONCLUSION This report described a case of granular cell tumors in the ascending colon and cecum. The patient presented unspecific symptoms, which is typical of this pathology, and the disease was accidentally diagnosed during colonoscopy. The endoscopic excision is the recommended treatment and was successfully performed in the patient, with good clinical progress after 24-month follow-up.

REFERENCES

2.

1. Yamada T, Fujiwara Y, Sasatomi E, Nakano S, Tokunaga O. Granular cell tumor in the ascending colon. Intern Med 1995;34(7):657-60.

3.

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Sohn DK, Choi HS, Chang YS, Huh JM, Kim DH, Kim DY, et al. Granular cell tumor of colon: report of a case and review of literature. World J Gastroenterol 2004;10(16):2452-4. Corman M. Colon and rectal surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 1089-1170: Less common


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tumors and tumor-like lesions of colon, rectum and anus. 4. Santoni BALM, Pinto FES, Machado L, Ferraz ED, Cueto GG, Quintas CM, et al. Tumor de células granulares no canal anal: relato de caso e revisão de literatura. Rev Bras Coloproct 2006;26(4):454-8. 5. Berry MA. Granular cell tumor of the colon. Am J Gastroenterol 1995;90(4):684-5. 6. Yasuda I, Tomita E, Nagura K, Nishigaki Y, Yamada O, Kachi H. Endoscopic removal of granular cell tumors. Gastrointest Endosc 1995;41(2):163-7. 7. Ebecken R, Ebecken K, Motta RN, Basilio CA. Multiple colonic

8.

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granular cell tumors. Gastrointest Endosc 2002;55(6):718. Hwang JH, Saunders MD, Rulyak SJ, Shaw S, Nietsch H, Kimmey MB. A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses. Gastrointest Endosc 2005;62(2):202-8.

Correspondence to: Prof. Dr. Eduardo Brambilla Rua General Arcy da Rocha Nobrega, 401, sala 705 – Madureira CEP: 95040-000 – Caxias do Sul (RS), Brazil E-mail: brambilla.procto@gmail.com

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Case Report

Hidradenitis suppurativa: literature review and case report Mônica Mourthé de Alvim Andrade1, José Roberto Monteiro Constantino2, Daniel Martins Barbosa M. Gomes1, Flávia Fontes Faria1, Rodrigo Guimarães Oliveira1, Renata Magali R. Silluzio Ferreira2, Geraldo Magela Gomes da Cruz3 Attending postgraduate program in Coloproctology at Faculdade de Ciências Médicas de Minas Gerais (FCMMG) – Belo Horizonte (MG), Brazil. 2Assistants of the Group of Coloproctology (GCP), Santa Casa de Belo Horizonte (SCBH) – Belo Horizonte (MG), Brazil. 3Coordinator of the GCP-SCBH – Belo Horizonte (MG), Brazil.

1

Andrade MMA, Constantino JRM, Gomes DMBM, Faria FF, Oliveira RG, Ferreira RMRS, Cruz GMG. Hidradenitis suppurativa: literature review and case report. J Coloproctol, 2012;32(2): 196-201. ABSTRACT: Hidradenitis suppurativa (HS) is a chronic, recurrent and debilitating disease, affecting mainly women, especially in their second and third decades of life. Its most common incidence is in the axillary, inguinal, perianal and inframammary regions. Its complications include chronic fistulizing processes, with involvement of important adjacent structures, such as the sacrum and coccyx, the anal sphincter, urethra and great-caliber vessels, such as the groin vessels. The proportions of some cases of HS requiring extensive surgical procedures at several moments and the application of flaps and grafts, justify unusual cases reports, like this one. The authors present a case of extensive involvement of the perianal and gluteal regions, which required extended resection with flap in the first approach and fistulectomy in a second surgical moment, with good result for the patient. Keywords: hidradenitis suppurativa; buttocks; surgical flaps. RESUMO: A hidradenite supurativa (HS) é uma doença crônica, recorrente e debilitante, que afeta principalmente mulheres, sobretudo na segunda e terceira décadas de vida. Incide mais nas regiões axilar, inguinal, perianal e inframamária. Dentre suas complicações crônicas, são descritos processos fistulizantes com comprometimento de estruturas importantes, como o sacro e o cóccix, aparelho esfincteriano, uretra e vasos calibrosos, como os inguinais. As proporções de alguns casos de HS, exigindo intervenções alargadas, em vários tempos e com aplicação de retalhos e enxertos justificam relatos de casos que fogem da rotina, como o atual. Os autores apresentam um caso de comprometimento extenso da região glútea e perianal, que exigiu ressecção alargada com retalho e fistulectomia em um segundo tempo cirúrgico, com bom resultado para a paciente. Palavras-chave: hidradenite supurativa; nádegas; retalhos cirúrgicos.

INTRODUCTION

factors1,2,4-6,8,10,11. Its chronic complications include chronic fistulizing processes, with involvement of important adjacent structures, such as the sacrum and coccyx, the anal sphincter, urethra and greatcaliber vessels, such as the groin vessels10. The proportions of some cases of HS requiring extensive surgical procedures at several moments and the application of flaps and grafts, justify unusual cases reports, like this one2. Report a case of perianal and gluteal hidradenitis suppurativa treated with radical resection and rotation flaps.

Hidradenitis suppurativa (HS) is a chronic, recurrent and debilitating disease, affecting mainly women, especially in their second and third decades of life1-8. Its most common incidence is in the axillary, inguinal, perianal and inframammary regions3,9,7. Its cause has been attributed to apocrine duct occlusion caused by keratin plugs, involving some triggering factors – friction of adipose tissue, sudoresis, heat, stress, tight clothes – and some facilitating factors – genetic and hormonal

Study carried out at the Santa Casa de Misericórdia de Belo Horizonte – Belo Horizonte (MG), Brazil. Financing source: none. Conflict of interest: nothing to declare. Submitted on: 09/22/2009 Approved on: 10/22/2009

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CASE DESCRIPTION

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Blood exams: routine exams, as well as hepatic function tests, VHS and PCR, did not show alterations. Diagnostic hypothesis: hidradenitis suppurativa. Conduct: radical excision of skin and subcutaneous tissue affected by the disease. First surgery: a radical excision of affected skin and subcutaneous tissue was performed using seton of a perianal fistula. The bleeding area reconstruction was performed using rotation of subcutaneous skin and muscular fascia flaps (Figures 2 and 3A and B). The final aspect of the surgery was according to expected patterns, with proper skin approximation (Figure 4). Histopathology examination (HPE): the specimen HPE showed fistulous courses in the subcutaneous tissue, suggesting hidradenitis suppurativa (Figure 5). Second surgery: the approach to the fistula channeled by seton in the first surgery was performed 40 days later, with excellent surgical result. Patient control: the patient was examined two and four months after the second surgery, and at these two moments, the final aspect of the surgery was documented (Figures 6 and 7).

Clinical examination: MAMN, female, 45 years old, with three years of purulent secretion drainage in the gluteal and perianal regions. Proctologic examination: at the inspection, several fistulous orifices are observed, with palpable courses through the skin with purulent secretion drainage, located in the gluteal and perianal regions (Figure 1). No anomalies were detected with rectal touch examination and rectosigmoidoscopy. Colonoscopy: performed until the terminal ileum, without alterations. Intestinal flow: no alterations.

LITERATURE Other names Hidradenitis Suppurativa, Hidrosadenitis Suppurativa, Acne Inversa, Acne Conglobata, Verneuil’s Disease, Velpeau’s Disease1,3,12,13.

Figure 1. Panoramic view of hidradenitis suppurativa.

History HS was first described by Velpeau (1839), who reported unusual processes related to the peculiar locations of axillary, mammary and perianal abscesses. For this reason, it was named “Velpeau’s disease”. After some time, Velpeau was not included in the references, despite his classical study of 1839 13. However, that was Verneuil, through his several publications on the subject in the 1850’s, who most contributed to the knowledge of this disease, until then known as “Velpeau’s disease”. For this reason, “Verneuil’s disease” was also established, recognizing the importance of his publications12.

Figure 2. Panoramic view of the bleeding area of surgical resection and seton insertion to concomitantly approach the anal fistula.

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B

Figure 3. Internal view (A) and external view (B) of the resected surgical specimen.

But the relation of HS with sweat glands was made only about 30 years after that, by Dubreuilh (1893), in his classical study of almost 120 years14. Pollitzer, also in 1893, repeated the studies made by Dubreuilh, and the first case of HS was published on around 40 years after Brunsting (1939). General HS is a chronic, recurrent and debilitating disease, affecting mainly women, especially in their second and third decades of life2-8. Its most common incidence is in the axillary, inguinal, perianal and inframammary regions1,3,5,7,9. Its cause has been attributed to apocrine duct occlusion caused by keratin plugs, involving some triggering factors – friction of adipose tissue, sudoresis, heat, stress, tight clothes – and some facilitating factors – genetic and hormonal factors1,2,4-6,8,10,11.

Figure 4. Panoramic view of the immediate result of the surgery, after using cutaneous flaps.

Diagnosis The diagnosis is eminently clinical, based on symptoms reported by the patient and signs observed by the physician. The initial symptoms include discomfort, pruritus, erythema and hyperhidrosis in the affected area 7. With the disease progress, the symptoms are more evident. The physical examination detects lesions in the form of multiple diffused abscesses, with chronic drainage in the form of multiple fistulas through fistulous orifices of varied aspects. The skin and subcutaneous tissue in the affected area become

Figure 5. Panoramic view of a plate at the histopathology examination showing cryptic formations in the epithelium and dense conjunctive tissue with perifollicular inflammatory infiltrete.

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cases of perianal Crohn’s disease, tuberculous ulcer and carcinoma. The association with spinocellular carcinoma, in case of long-term progress, is very rare1,7,15,16. The most important acute complication is characterized by an inflammatory and later infectious process, affecting superficial and deep tissues with cellulitis, abscesses and suppuration. Its chronic complications result from fistulas and the involvement of important structures, such as the sacrum and coccyx, the anal sphincter, urethra and great-caliber vessels, such as the groin vessels1,4. Complementary exams are required in the presence of extensive suppurative areas, deep fistulas and involvement of noble structures. Bacterioscopy and culture of secretions, radiography of the sacrum and coccyx, fistulography and computed tomography of the pelvis can be performed. The histopathology exam shows a cellular reaction into the lumen of apocrine sweat glands, with distention by leukocytes and cellular infiltration of adjacent conjunctive tissue. In the macroscopic perspective, the subcutaneous tissues have higher density, skin purple discoloration and fistulous orifices with little purulent secretion8. The secretion culture can isolate Streptococcus milleri, Stasphylococcus aureus, anaerobic Streptococcus and bacteroids7,8.

Figure 6. Final panoramic view of the surgery two months after the surgical intervention.

Differential diagnoses The diseases that should be considered and ruled out as differential diagnoses include (Figure 8): Crohn’s disease (Figure 8A), anorectal fistulas (Figure 8B), perianal fistulas (Figure 8C), cutaneous tuberculosis (Figure 8D), lymphogranuloma venereum (Figure 8E), pilonidal cyst, as well as other rarer diseases, such as anthrax, epidermoid cyst (infected dermoid cyst), erysipelas, furuncle, granuloma inguinale, steatocystoma multiplex and actinomycosis5,7,8,15.

Figure 7. Final panoramic view of the surgery four months after the surgical intervention.

hardened, fixed and fibrotic, welding the dermis and epidermis layers together, keeping them from sliding apart 4,7,8,11. The clinical condition is characterized by long-term symptoms and signs that may reach 30 years of progress, with recurrent abscesses and fistulas, which, after the inflammatory phase, leave sequelae such as areas of fibroses, fistulous orifices and scarce purulent secretion1,4,10,11. When the disease affects the perianal area, it rarely involves the anal sphincter8,10. The diagnosis, in the chronic form of the disease, is clinical and easily performed, depending the coloproctologist’s experience. In certain situations, a biopsy is required to confirm the diagnosis, such as in the atypical

Associated conditions The conditions that can be associated with hidradenitis suppurativa include: acanthosis nigricans, certain forms of arthritis, Crohn’s disease, Down’s syndrome, Graves’ disease, Hashimoto’s thyroiditis, herpes simplex, hyperandrogenism, irritable bowel syndrome and Sjögren’s syndrome15. 199


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A

B

C

D

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E

Figure 8. Some morbid entities that should be considered as differential diagnoses of hidradenitis suppurativa: Crohn’s disease (A), multiple non-specific anorectal fistulas (B), non-specific perianal fistulas (C), cutaneous tuberculosis (D) and lymphogranuloma venereum (E).

Anogenital hidradenitis suppurativa It affects more frequently the groin, involving the inguinal region, pubic region, internal face of the thigh and lateral scrotum. The perineum, buttocks and

perianal folds are frequently included; the fistulas may deeply dissect in the tissue, involving the musculature, fascia and bowel. In the perianal form, biopsies are indicated to remove coexisting cancer and perianal 200


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CONCLUSION

Crohn’s disease. It rarely affects the anal canal, but if involved, it is never above the pectineal line7,8,15.

The approach used in the treatment of hidradenitis suppurativa remains challenging to physicians and frustrating to patients. As the number of randomized studies is insufficient, due to the lack of long series of cases, comparing the several types of treatment, the best approach is based on the patient’s clinical condition, results from prior nonsurgical treatments and the physician’s experience. The radical excision is considered the gold standard, and it should be the treatment of choice, since it is well indicated. Leaving the surgical wound resulting from enlarged resection of skin and subcutaneous tissue to heal at a second moment should not taken as the best alternative, although this is an option in certain patients; with flap rotations, when well indicated and performed, as an important factor in the immediate quality of life of the patient.

Treatment Multiple treatment options are available, including antibioticotherapy, systemic retinoids, intralesional corticosteroids, hormonal therapy, immunosuppressors, radiotherapy, cryotherapy, local care of the lesion, laser therapy and surgical treatment. No isolated treatment was effective to the patients1-4,6-9,17. The surgical approach still seems to be the ideal option, and it may vary from simple incision and acute abscess drainage to radical excision of the whole tissue with apocrine glands. The radical excision of the whole affected tissue is the definitive and gold-standard treatment, as the recurrence rate is inversely proportional to the surgical radicality: the recurrence rate ranges from 100% in three months (isolated drainage) to 25% (cases of surgical radicality in 20 months after the radical excision)1-5,8,11. REFERENCES

11. Mandal A, Watson J. Experience with different treatment modules in hidradenitis suppurativa: a study of 106 cases. Surgeon 2005;3(1):23-6. 12. Verneuil AS. Études sur les tumeurs de la peau: de quelque maladies des glandes sudoripares. Arch Gen Med 1854;94:693-9. 13. Velpeau A. Dictionnaire de Medicine. Un Repertoire des Sciences Medicales sons le Rapport. Theorique et Pratique. 2nd ed. Paris. France; 1839. 91 p. 14. Dubreuilh W. Des hidrosadénites suppurées disséminées Archives de médecine expérimentale et d’anatomie pathologique. 1er Janvier 1893;1. 15. Church JM, Fazio VW, Lavery IC, Oakley JR, Milsom JW. The differential diagnosis and comorbidity of hidradenitis suppurativa and perianal Crohn’s disease. Int J Colorectal Dis 1993;8(3):117-9. 16. Rosenzweig LB, Brett AS, Lefaivre JF, Vandersteenhoven JJ. Hidradenitis suppurativa complicated by squamous cell carcinoma and paraneoplastic neuropathy. Am J Med Sci 2005;329(3):150-2. 17. Bong JL, Shalders K, Saihan E. Treatment of persistent painful nodules of hidradenitis suppurativa with cryotherapy. Clin Exp Dermatol 2003;28(3):241-4.

1. Jansen I, Altmeyer P, Piewig G. Acne inversa (alias hidradenitis suppurativa). J Eur Acad Dermatol Venereol 2001;15(6):532-40. 2. Mitchell KM, Beck DE. Hidradenitis suppurativa. Surg Clin North Am 2002;82(6):1187-97. 3. Rompel R, Petres J. Long-term results of wide surgical excision in 106 patients with hidradenitis suppurativa. Dermatol Surg 2000;26(7):638-43. 4. Slade DE, Powell BW, Mortimer PS. Hidradenitis suppurativa: pathogenesis and management. Br J Plast Surg 2003;56(5):451-61. 5. Wiltz O, Schoetz DJ Jr, Murray JJ, Roberts PL, Coller JA, Veidenheimer MC. Perianal hidradenitis suppurativa. The Lahey Clinic experience. Dis Colon Rectum 1990;33:731-4. 6. Kraft JN, Searles GF. Hidradenitis suppurativa in 64 female patients: retrospective study comparing oral antibiotics and antiandrogen therapy. J Cutan Med Surg 2007;11(4):125-31. 7. Sohail N, Spencer JP, Mather R. Chronic, draining perianal sinuses. Am Fam Physician 2006;74(12):2089-90. 8. Mortimer PS, Lunniss PJ. Hidradenitis suppurativa. J R Soc Med 2000;93(8):420-2. 9. Mekkes JR, Bos JD. Long-term efficacy of a single course of infliximab in hidradenitis suppurativa. Br J Dermatol 2008;158(2):370-4. 10. Culp CE. Chronic hidradenitis suppurativa of the anal canal. A surgical skin disease. Dis Colon Rectum 1983;26(10):669-76.

Correspondence to: Dra. Mônica Mourthé de Alvim Andrade Avenida do Contorno, 9921 sala 804 – Barro Preto CEP: 30110-945 – Belo Horizonte (MG), Brazil E-mail: monicamourtheaa@yahoo.com.br

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NEWSLETTER – ALACP

ALACP Management – 2011-2013 President: José Victor Rodrigues Mendoza (El Salvador) 1st Vice President: Ricardo Alfonzo Nunes (Venezuela) 2nd Vice President: Ricardo Fretes (Paraguay) Secretary General: Eduardo de Paula Vieira (Brazil) Vice Secretary: Viviane Castro Souza Passos (Brazil) Treasurer: Andrés Pessôa Pandelo (Brazil) 1st Vice Treasurer: Andréa Povedano (Brazil)

______________________________________________________________________

• The 22nd Congress of the Latin American Association of Coloproctology was held in Mendoza, Argentina, from August 8 to 11, 2011, presenting high scientific level and with the significant presence of specialists, also from Brazil.

• The next congress will be in El Salvador, from July 8 to 11, 2013. The link for this event will be opportunely posted on this page.

ALACP Administration Av. Marechal Câmara, 160/916 – Ed. Orly, Centro 20020-080 – Rio de Janeiro (RJ), Brasil Tel: 55(21)22408927/Fax: 55(21)22205803 Eduardo de Paula Vieira Secretary General

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Hospital das Clínicas Faculdade de Medicina da Universidade de São Paulo - SP Av. Dr. Eneas de Carvalho Aguiar, 255 Cerqueira Cesar 05403-000 - São Paulo - SP Tel. (11)3069-6000 203


J Coloproctol April/June, 2012

Services accredited by SBCP for the improvement in coloproctology

Hospital de Base do Distrito Federal S M H S , 101 BL. A Setor Hospitalar Sul 70335-900 - Brasília - DF Tel. (61) 3325-5050

Hospital do Andaraí Rua Leopoldo, 280 - 2º andar -Andaraí 20541-170 - Rio de Janeiro - RJ (21) 2562-2719 Hospital Municipal São José Av. Getúlio Vargas, 233 89202-001 - Joinville - SC (47) 3441-6666

Real e Benemérita Sociedade Portuguesa de Beneficência Hospital São Joaquim Rua Maestro Cardim, 769 01323-001 - São Paulo - SP Tel: (11) 3253-5022

Hospital Geral de Goiânia Dr. Alberto Rassi Av. Anhanguera , 6379 - Setor Oeste 74043-011 - Goiânia - GO Tel: (62) 3221-6031

Hospital Universitário Evangélico de Curitiba Al. Augusto Stellfeld, 1908 80730-150 - Curitiba - PR Tel. (41) 3222-0727 / 3322-4141

Santa Casa de Misericórdia - Fortaleza - CE Serviço de Coloproctologia Rua Barão do Rio Branco, 1816 60025-061 - Fortaleza - CE Tel: (85) 3211-1911

Hospital do Servidor Público Estadual de São Paulo – “FMO” Serviço de Gastroenterologia Cirúrgica e Coloproctologia Rua Pedro de Toledo, 1800 - 11º andar - Ala Central 04029-000 - São Paulo - SP Tel. (11) 5088-8117 / 5088-8119

Hospital do Serviço Público Municipal - SP Serviço de Coloproctologia Rua Castro Alves nº 60 - Liberdade 01532 - São Paulo - SP Tel: (11) 3208-2211

Hospital Geral Roberto Santos MEC/CNRM - PARECER Nº 98/99 Est. do Saboeiro, S/N - Cabula 41180-780 - Salvador - BA Tel. (71) 3372-2849

Hospital Nossa Senhora das Graças Serviço de Coloproctologia Rua Alcides Munhoz, 433 - Mêrces 80810-040 Curitiba - PR Tel: (41) 3240-6706 Fax. (41) 3240-6500

Centro de Colo-Proctologia do Ceará Av. Pontes Vieira, 2551 (2º andar) 60130-241 - Fortaleza - CE Tel. (85) 3257-6588 - 257-7728

Serviço de Coloproctologia Hospital das Clínicas da Faculdade de Medicina Universidade Federal de Goiás 1ª Avenida, s/nº 74650-050 - Goiânia - GO Tel.: (62) 3202-1800 ramal 1094 - COREME Tel.: (62) 3202-4443

Hospital de Base da Faculdade de Medicina de São José do Rio Preto Av. Brigadeiro Faria Lima, 5416 15090-000 - São José do Rio Preto - SP Tel. (17) 3201-5000 Hospital Felício Rocho Av. Contorno, 9.530 30110-130 - Belo Horizonte - MG Tel. (31) 3339-7142

Hospital Universitário Prof. Alberto Antunes Av. Lourival Melo Mota, s/n Tabuleiro do Martins 57072-900 - Maceió - AL Tel.: (82) 3322-2494

Hospital de Jacarepaguá Av. Menezes Cortes, 3245 20715-190 - Rio de Janeiro - RJ Tel. (21) 2425-2255 - R. 200 Hospital Sírio Libanês CNRN / MEC Nº 23/2002 Rua Dona Adma Jafet, 91 01308-050 - São Paulo - SP Tel. (11) 3155-0200

Vol. 32 Nº 2

Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP Av. Bandeirantes, 3900 14048-900 - Ribeirão Preto - SP Tel. (16) 3602-1000 / 3602-2509 204


J Coloproctol April/June, 2012

Services accredited by SBCP for the improvement in coloproctology

Hospital Universitário da Universidade Federal de Sergipe Rua Cláudio Batista s/nº Sanatório 49060-100 - Aracajú - SE Tel. (79) 3218-1738

Hospital São Rafael Serviço de Coloproctologia Av. São Rafael, 2152 - São Marcos 41256-900 - Salvador - BA Tel.: (71) 3281-6400

Hospital das Clínicas -UFMG Instituto Alfa de Gastroenterologia Av. Prof. Alfredo Balena, 110 , 2º andar Sta. Efigênia 30130-100, Belo Horizonte, MG Tel. (31) 3248-9403 / (31) 3248-9251

Vitória Apart Hospital Serviço de Coloproctologia Rod. BR 101 Norte Km 2 - Carapina 29101-900 - Serra - ES Tel.: (27) 3201-5555

Vol. 32 Nº 2

Hospital Municipal Dr. Mário Gatti Serviço de Coloproctologia Av. Prefeito Faria Lima, 340 - Parque Itália 13036-902 - Campinas - SP Tel.: (19) 3772-5700

Clínica Reis Neto Rua General Osório, 2273 12025-155 - Cambuí - Campinas - SP Tel.: (19) 3252-5611 Hospital Universitário Cajuru - Serviço de Coloproctologia Reg. Mec. Parecer 43/06 Av. São José, 300 80050-350 - Cristo Rei - Curitiba - PR Tel.: (41) 3271-3009

Serviço de Coloproctologia Hospital de Clínicas de Porto Alegre Universidade Federal do Rio Grande do Sul Rua Ramiro Barcelos, 2.350 / sala 600 90035-903 - Porto Alegre - RS Tel.: (51) 3359-8232

We require the Coloproctology services that have medical residency or internships related to this specialty to send their program and schedule to the Society, so they can be publicized. This section will be available to publicize rules and dates of selection. MINIMUM PROGRAM TO BE ACCREDITED BY THE BRAZILIAN SOCIETY OF COLOPROCTOLOGY Staff – Participation of at least two full members of SBCP. Surgeries – Monthly mean of at least three colorectal surgeries and six anoperineal surgeries. Ambulatory – Monthly mean of at least 50 appointments. Endoscopies – Monthly mean of at least 20 rectosigmoidoscopies and five colonoscopies. Available supporting units: Radiology, pathological anatomy, endoscopy, clinical analysis laboratory, ICU, Oncology, Radiotherapy, Statistical and Medical Files. Teaching – a) Weekly meetings of the service to discuss cases and also published articles; b) To estimulate the production of scientific papers to be presented at the annual congress of the Brazilian Society of Coloproctology and possible publication in the SBCP journal; c) To send at least one original article per year for possible publication in the SBCP journal. 205


Journal of Coloproctology, Vol 32 N 2  

Apr/Jun 2012

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