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In the treatment of colorectal cancer, from 1982 Heald proposed standardization of the total mesorectal excision, with a significant reduction in the recurrence rate. But the treatment of lower rectal lesions is still a challenge.
To describe the association of robotic low anterior resection- TATA (Transanal Abdominal Transanal Resection), with transanal access using Transanal Endoscopic Operations - TEO in the treatment of lower rectal cancer.
The TATA performs robotic abdominal approach and the TEO performs the perineal approach, developing total mesorectal excision (TME) transanally (TaETM).
The TaETM technique was applied in a woman with rectal adenocarcinoma 5 cm from the anal verge that had been submitted to chemoradiation. The procedure was performed with satisfatory operative time and favorable oncological outcome (grade 3 mesorectal excision).
This is a promising minimally invasive procedure in the armamentarium of rectal cancer treatment, specially in challenging scenarios such as narrow pelvis, obesity and very low rectal tumors.
Association between esophageal achalasia/ gastroesophageal reflux disease (GERD) and cholelithiasis is not clear. Epidemiological data are controversial due to different methodologies applied, the regional differences and the number of patients involved. Results of concomitant cholecistectomy associated to surgical treatment of both diseases regarding safety is poorly understood.
To analyze the prevalence of cholelithiasis in patients with esophageal achalasia and gastroesophageal reflux submitted to cardiomyotomy or fundoplication. Also, to evaluate the safety of concomitant cholecistectomy.
Retrospective analysis of 1410 patients operated from 2000 to 2013. They were divided into two groups: patients with GERD submitted to laparocopic hiatoplasty plus Nissen fundoplication and patients with esophageal achalasia to laparoscopic cardiomyotomy plus partial fundoplication. It was collected epidemiological data, specific diagnosis and subgroups, the presence or absence of gallstones, surgical procedure, operative and clinical complications and mortality. All groups/subgroups were compared.
From 1,229 patients with GERD or esophageal achalasia, submitted to laparoscopic cardiomyotomy or fundoplication, 138 (11.43%) had cholelitiasis, occurring more in females (2.38:1) with mean age of 50,27 years old. In 604 patients with GERD, 79 (13,08%) had cholelitiasis. Lower prevalence occurred in Barrett's esophagus patients 7/105 (6.67%) (p=0.037). In 625 with esophageal achalasia, 59 (9.44%) had cholelitiasis, with no difference between chagasic and idiopathic forms (p=0.677). Complications of patients with or without cholecystectomy were similar in fundoplication and cardiomyotomy (p=0.78 and p=1.00).There was no mortality or complications related to cholecystectomy in this series.
Prevalence of cholelithiasis was higher in patients submitted to fundoplication (GERD). Patients with chagasic or idiopatic forms of achalasia had the same prevalence of cholelithiasis. Gallstones occurred more in GERD patients without Barrett's esophagus. Simultaneous laparoscopic cholecystectomy was proved safe.
The choledocolithiasis has an incidence of 8-20% in patients with cholecystolithiasis. The preoperative diagnosis guides the interventional treatment on the bile duct
To evaluate the sensitivity and specificity of the laboratory markers and imaging studies for choledocholithiasis preoperatively.
The study comprised 254 patients divided into two groups: the control group (207 patients), patients without choledocholithiasis intraoperatively and cases group (47 patients), that enrolled the patients with choledocholithiasis intra-operatively. Were evaluated the laboratory markers, image exams and intra-operative diagnostic aspects.
The sample was homogeneous for age and gender. It was observed that 47% of the cases the patients did not show comorbidities. Hospitalization showes in cases group acute pancreatitis in12.8%, jaundice in 30%, fever in 30% and pain in the right hypochondrium in 95%. By comparing them, was observed that fever and jaundice were the signs and symptoms with statistical significance. Patients with choledocholithiasis had transaminases, alkaline phosphatase, gamma-glutamyl transferase and higher bilirubin with statistical significance (p<0.001). In regard to imaging studies, ultrasound was fairly accurate for cholelithiasis and choledocholithiasis (p<0.001).
Changes in canalicular and transaminase enzymes are suggestive for preoperative choledocholithiasis; GGT showed better sensitivity and alkaline phosphatase greater specificity; ultrasonography and nuclear magnetic resonance cholangiopancreatography showed high specificity.
In the surgical treatment of colorectal cancer, a lymphadenectomy is considered adequate when at least 12 lymph nodes are removed.
To evaluate whether videolaparoscopic surgery positively affects the rates of adequate lymphadenectomy.
An observational study was conducted with patients undergoing either open or videolaparoscopic surgery for colorectal cancer between 2008 and 2013. The following variables were collected: gender, age, tumor site, histology, degree of differentiation, tumor stage, number of lymph nodes removed, and number of lymph nodes affected by the disease.
A total of 62 patients with colorectal cancer were included; 42 (67.7%) received open surgery, and 20 (32.3%) laparoscopic surgery. Regarding lymphadenectomy, a mean of 13 lymph nodes (95% CI: 10-16) were removed in the group that received open surgery, while 19 lymph nodes were removed (95% CI: 14-24) in the laparoscopic surgery group (p=0.021). Adequate lymphadenectomy (removal of at least 12 lymph nodes) was achieved in 58.1% of the total cases, in 50.0% of the patients who received open surgery, and in 75% of those who received laparoscopic surgery. Non-elderly patients and those with an advanced disease stage were more likely to receive an adequate lymphadenectomy (p=0.004 and p=0.035, respectively).
Disease stage and patient age were the factors that had the greatest influence on achieving an adequate lymphadenectomy. The type of surgery did not affect the number of lymph nodes removed.
Only few studies have examined the impact of racial differences on the age of onset, course and outcomes of diverticulitis.
To provide data about the epidemiology of diverticulitis in northern Israel, and to determine whether ethnicity is a predictor of age of onset, complications, and need for surgery.
Was conducted a retrospective review of the charts of all patients diagnosed with a first episode of diverticulitis in our hospital between 2005 and 2012.
Were found 638 patients with a first episode of acute diverticulitis in the eight year interval. Israeli Arabs developed a first episode of diverticulitis at a younger age compared to Jews (51.2 vs 63.8 years, p<0.01). Arabs living in rural areas developed diverticulitis at a younger age than Arabs living in urban centers (49.4 vs 54.5 years, P=0.03). Jewish and Arabic men developed diverticulitis at younger age compared to their female counterparts (59.9 vs 66.09, p<0.01, and 47.31 vs 56.93, p<0.01, respectively). Arabs were more likely [odds ratio (OR)=1.81 ,95% confidence interval (CI)1.12-2.90, p=0.017] than Jews to require surgical treatment (urgent or elective) for diverticulitis.
Israeli Arabs tend to develop diverticulitis at a younger age and are more likely to require surgical treatment for diverticulitis compared to Jews. Arabs living in rural areas develop diverticulitis at a younger age than Arabs living in urban centers. These findings highlight a need to address the root cause for ethnic differences in onset, course and outcome of acute diverticulitis.
Idiopathic esophageal achalasia is an inflammatory disease of unknown origin, characterized by aperistalsis of the esophageal body and failure of the lower esophageal sphincter in response to swallowing, with consequent dysphagia.
To demonstrate the results of surgical therapy in these patients, evaluating the occurred local and systemic complications.
Were studied retrospectively 32 patients, 22 of whom presented non-advanced stage of the disease (Stage I/II) and 10 with advanced disease (Stage III/IV). All of them had the clinical conditions to be submitted to surgery. The diagnoses were done by clinical, endoscopic, cardiological, radiological and esophageal manometry analysis. Pre-surgical evaluation was done with a questionnaire based on the most predisposing factors in the development of the disease and the surgical indication was based on the stage of the disease.
The patients with non-advanced stages were submitted to cardiomyotomy with fundoplication, wherein in the post-surgical early assessment, only one (4,4%) presented pulmonary infection, but had a good outcome. In patients with advanced disease, seven were submitted to esophageal mucosectomy preserving the muscular layer, wherein one patient (14,2%) presented dehiscence of gastric cervical esophagus anastomosis as well as pulmonary infection; all of these complications were resolved with proper specific treatment; the other three patients with advanced stage were submitted to transmediastinal esophagectomy; two of them presented hydropneumothorax with good evolution, and one of them also presented fistula of the cervical esophagogastric anastomosis, but with spontaneous healing after conservative treatment and nutritional support. The two patients with fistula of the cervical anastomosis progressed to stenosis, with good results after endoscopic dilations. In the medium and long term assessment done in 23 patients, all of them reported improvement in life quality, with return to swallowing.
The strategy proposed for the surgical treatment of idiopathic esophageal achalasia according to the stages of the disease was of great value, due to post-surgical low morbidity complications and proper recovery of swallowing.
The esophageal cancer is one of the most common and aggressive worldwide. Recently, the AJCC changed the staging system, considering, among others, the important role of the lymph node metastasis on the prognosis.
To discuss the applicability of different forms of lymph node staging in a western surgical center.
Four hundred eighty seven patients with esophageal cancer were enrolled. Three staging systems were evaluated, the 6th and the 7th AJCC editions and the Lymph Node Metastatic Ratio.
The majority of the cases were squamous cell carcinoma. The mean lymph node sample was eight. Considering the survival, there was no significant difference between the patients when they were classified by the 7th AJCC edition. Analysis of the Lymph Node Metastatic Ratio, just on the group of patients with 0 to 25%, has shown significant difference (p=0,01). The 6th AJCC edition shows the major significant difference between among the classifications evaluated.
In this specific population, the 7th AJCC edition for esophageal cancer was not able to find differences in survival when just the lymph node analysis was considered.
The use of laparoscopy for the treatment of gastric cancer suffered some resistance among surgeons around the world, gaining strength in the past decade. However, its oncological safety and technical feasibility remain controversial.
To describe the results from the clinical and anatomopathological point of view in the comparative evaluation between the surgical videolaparoscopic and laparotomic treatments of total gastrectomy with linphadenectomy at D2, resection R0.
Retrospective analyses and comparison data from patients submitted to total gastrectomy with D2 linphadenectomy at a sole institution. The data of 111 patients showed that 64 (57,7%) have been submitted to laparotomic gastrectomy and 47 (42,3%) to gastrectomy entirely performed through videolaparoscopy. All variables related to the surgery, post-operative follow-up and anatomopathologic findings have been evaluated.
Among the studied variables, videolaparoscopy has shown a shorter surgical time and a more premature period for the introduction of oral and enteral nourishment than the open surgery. As to the amount of dissected limph nodes, there has been a significant difference towards laparotomy with p=0,014, but the average dissected limph nodes in both groups exceed 25 nodes as recommended by the JAGC. Was not found a significant difference between the studied groups as to age, ASA, type of surgery, need for blood transfusion, stage of the disease, Bormann classification, degree of differentiation, damage of the margins, further complications and death.
The total gastrectomy with D2 lymphadenectomy performed by laparoscopy presented the same benefits known of laparotomy and with the advantages already established of minimally invasive surgery. It was done with less surgical time, less time for re-introduction of the oral and enteral diets and lower hospitalization time compared to laparotomy, without increasing postoperative complications.
Large number of surgical services use laparoscopy to approach the colon. One of the concerns on the resection using this way is the high rate of cancer relapse at in- and outlet site of the surgical instruments.
To describe a protective device for surgical isolation in laparoscopic colectomy.
The device is made of sterile polyethylene plastic cover used to protect the fiber optic cable in laparoscopic surgery and one 20 Fr. urethral catheter working as a conduit.
The device was used in six laparoscopic colectomies, three for adenocarcinoma of the colon and three for intestinal endometriosis. It was effective to avoid contact of the specimen with the abdominal wall, in order to reduce the risk of implantation of cancer or endometriotic cells and surgical site infection. The device was made intraoperative at all surgeries and allowed good visualization in laparoscopy and maintenance of the pneumoperitoneum. It cost R$ 22,00 (approximately US$ 10), R$14.50 related to the plastic cover and R$7.50, the urethral tube. The production time of the device and its installation in the abdominal cavity was measured in each procedure and was, on average, respectively, of 66 s and 25 s.
The device proved to be feasible, not requiring any special training and can be performed by the surgical team itself, even at institutions with limited resources.
Patients presenting upper gastrointestinal obstruction, difficulty or inability in swallowing, may need nutritional support which can be obtained through gastrostomy and jejunostomy.
To describe the methods of gastrostomy and jejunostomy video-assisted, and to compare surgical approaches for video-assisted laparoscopy and laparotomy in patients with advanced cancer of the esophagus and stomach, to establish enteral nutritional access.
Were used the video-assisted laparoscopic techniques for jejunostomy and gastrostomy and the same procedures performed by laparotomies. Comparatively, were analyzed the distribution of patients according to demographics, diagnosis and type of procedure.
There were 36 jejunostomies (18 by laparotomy and 17 laparoscopy) and 42 gastrostomies (21 on each side). In jejunostomy, relevant data were operating time of 132 min vs. 106 min (p=0.021); reintroduction of diet: 3.3 days vs 2.1 days (p=0.009); discharge: 5.8 days vs 4.3 days (p= 0.044). In gastrostomy, relevant data were operative time of 122.6 min vs 86.2 min (p= 0.012 and hospital discharge: 5.1 days vs 3.7 days (p=0.016).
The comparative analysis of laparotomy and video-assisted access to jejunostomies and gastrostomies concluded that video-assisted approach is feasible method, safe, fast, simple and easy, requires shorter operative time compared to laparotomy, enables diet start soon in compared to laparotomy, and also enables lower length of stay compared to laparotomy.
Developed by Surya MKT