Management of obstructed defecation

The management of obstructed defecation syndrome(ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy. According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an "iceberg syndrome", with "emerging rocks", rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has "underwater rocks" or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment. Rectal prolapse excision or obliterative suture, rectoceleand/or enterocele repair, retrograde Malone's enema and partial myotomy of the puborectalis muscle are effective in selected cases. Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception. A multidisciplinary approach to ODS provides the best results.

Transanal endoscopic surgery in rectal cancer

Total mesorectal excision(TME) is the standard treatment for rectal cancer, but complications are frequent and rates of morbidity, mortality and genitourinary alterations are high. Transanal endoscopic microsurgery(TEM) allows preservation of the anal sphincters and, via its vision system through a rectoscope, allows access to rectal tumors located as far as 20 cm from the anal verge. The capacity of local surgery to cure rectal cancer depends on the risk of lymph node invasion. This means that correct preoperative staging of the rectal tumor is necessary. Currently, local surgery is indicated for rectal adenomas and adenocarcinomas invading the submucosa, but not beyond(T1). Here we describe the standard technique for TEM, the different types of equipment used, and the technical limitations of this approach. TEM to remove rectal adenoma should be performed in the same way as if the lesion were an adenocarcinoma, due to the high percentageof infiltrating adenocarcinomas in these lesions. In spite of the generally good results with T1, some authors have published surprisingly high recurrence rates; this is due to the existence of two types of lesions, tumors with good and poor prognosis, divided according to histological and surgical factors. The standard treatment for rectal adenocarcinoma T2N0M0 is TME without adjuvant therapy. In this type of adenocarcinoma, local surgery obtains the best results when complete pathological response has been achieved with previous chemoradiotherapy. The results with chemoradiotherapy and TEM are encouraging, but the scientific evidence remains limited at present.

Presacral venous bleeding during mobilization in rectal cancer

To analyze the anatomy of sacral venous plexus flow, the causes of injuries and the methods for controlling presacral hemorrhage during surgery for rectal cancer.METHODSA review of the databases MEDLINE® and Embase™ was conducted, and relevant scientific articles published between January 1960 and June 2016 were examined. The anatomy of the sacrum and its venous plexus, as well as the factors that influence bleeding, the causes of this complication, and its surgical management were defined.RESULTSThis is a review of 58 published articles on presacral venous plexus injury during the mobilization of the rectum and on techniques used to treat presacral venous bleeding. Due to the lack of cases published in the literature, there is no consensus on which is the best technique to use if there is presacral bleeding during mobilization in surgery for rectal cancer. This review may provide a tool to help surgeons make decisions regarding how to resolve this serious complication.CONCLUSIONA series of alternative treatments are described; however, a conventional systematic review in which optimal treatment is identified could not be performed because few cases were analyzed in most publications.

Role of endoglin and VEGF family expression in colorectal cancer prognosis and anti-angiogenic therapies

Colorectal cancer(CRC)is one of the cancer models and most of the carcinogenic steps are presently well understood.Therefore,successful preventive measures are currently used in medical practice.However,CRC is still an important public health problem as it is the third most common cancer and the fourth most frequent cause of cancer death worldwide.Nowadays,pathologic stage is a unique and well-recognized prognostic indicator,however,more accurate indicators of the biologic behavior of CRC are expected to improve the specificity of medical treatment.Angiogenesis plays an important role in the growth and progression of cancer but its role as a prognostic factor is still controversial.Probably the most important clinical implication of tumor angiogenesis is the development of anti-angiogenic therapy.The goal of this review is to critically evaluate the role of angiogenic markers,assessed by either endoglin-related microvessel density or expression of vascular endothelial growth factor family members in the CRC setting and discuss the role of these angiogenic markers in antiangiogenic therapies.

Long-term outcomes after stenting as a"bridge to surgery"for the management of acute obstruction secondary tocolorectal cancer

Obstructive symptoms are present in 8% of cases at the time of initial diagnosis in cases of colorectal cancer. Emergency surgery has been classically considered the treatment of choice in these patients. However, in the majority of studies, emergency colorectal surgery is burdened with higher morbidity and mortality rates than elective surgery, and many patients require temporal colostomy which deteriorates their quality of life and becomes permanent in 10%-40% of cases. The aim of stenting by-pass to surgery is to transform emergency surgery into elective surgery in order to improve surgical results, obtain an accurate tumoral staging and detection of synchronous lesions, stabilization of comorbidities and performance of laparoscopic surgery. Immediate results were more favourable in patients who were stented concerning primary anastomosis, permanent stoma, wound infection and overall morbidity, having the higher surgical risk patients the greater benefit. However, some findings laid out the possible implication of stenting in long-term results of oncologic treatment. Perforation after stenting is related to tumoral recurrence. In studies with perforation rates above 8%, higher recurrences rates in young patients and lower disease free survival have been shown. On the other hand, after stenting the number of removed lymph nodes in the surgical specimen is larger, patients can receive adjuvant chemotherapy earlier and in a greater percentage and the number of patients who can be surgically treated with laparoscopic surgery is larger. Finally, there are no consistent studies able to demonstrate that one strategy is superior to the other in terms of oncologic benefits. At present, it would seem wise to assume a higher initial complication rate in young patients without relevant comorbidities and to accept the risk of local recurrence in old patients(> 70 years) or with high surgical risk(ASA Ⅲ/Ⅳ).

Failed stapled rectal resection in a constipated patient with rectal aganglionosis

A rare case of a severely constipated patient with rectal aganglionosis is herein reported.The patient,who had no megacolon/megarectum,underwent a STARR,i.e.,stapled transanal rectal resection,for obstructed defecation,but her symptoms were not relieved.She started suffering from severe chronic proctalgia possibly due to peri-retained staples fibrosis.Intestinal transit times were normal and no megarectum/megacolon was found at barium enema.A diverting sigmoidostomy was then carried out,which was complicated by an early parastomal hernia,which affected stoma emptying.She also had a severe diverting proctitis,causing rectal bleeding,and still complained of both proctalgia and tenesmus.A deep rectal biopsy under anesthesia showed no ganglia in the rectum,whereas ganglia were present and normal in the sigmoid at the stoma site.As she refused a Duhamel procedure,an intersphincteric rectal resection and a refashioning of the stoma was scheduled.This case report shows that a complete assessment of the potential causes of constipation should be carried out prior to any surgical procedure.

Ultrastructural Findings, at Micrometric and Nanometric Scales, in Rectal and Muscular Mucosa of Patients with HIV/AIDS and Anorectal Pathology

Objective: To determine the ultrastructural findings on Rectal Mucosa (RM) of patients with HIV/AIDS and anorectal pathologies (ARP), at micrometric and nanometric scales. Materials and methods: 5 patients were evaluated, 18 - 55 years old, with ARP (HIV co-infection with HPV, n = 4, and HIV-negative patient with HPV infection) (control n = 1), who were referred to the Coloproctology Unit of the HUC, and subjected to rectoscopy and biopsy. RM samples were identified, placed in a sterile plastic bottle with 1 mL of 2% glutaraldehyde and immediately transported for routine processing of fine cut (60 - 90 nm) to be evaluated via Transmission Electron Microscopy (TEM). They were fixed with Karnovsky solution with Millonig phosphate buffer (pH 7.4 and 320 mOsm) and post-fixed with OsO4 under the same conditions of pH and osmolarity. Results: Ultrastructural findings, at 10−6 scale: 1) Intestinal mucosa: vacuoles of mucus of different sizes that seem to be fused. 2) Smooth muscle cells: loss of definition of contractile myofilaments mass. 3) Unmyelinated axons and terminals of Schwann cells (SC): Edema and loss of their plasma membranes in some areas of association with axon terminals as well as abundant collagen fibers associated with SC. Ultrastructural findings, at 10−9 scale: 1) Smooth muscle cells: folded wrapper cores and edema of mitochondria and rough endoplasmic reticulum cisterns (RER). 2) Myelinated axon terminals: Loss of synaptic vesicles. 3) Fibroblasts: One observes mitochondria and cisterns of RER with alterations. All these alterations can generate intestinal and anorectal dysfunction in these patients. Conclusions: The HIV causes changes in rectal and muscular mucosa despite HAART treatment with undetectable viral load.

吻合器痔固定术后发生并发症或失败后的再干预

BACKGROUND: Stapled hemorrhoidopexy has become increasingly popular over the past five years, mainly because of the assumption that it is associated with less pain. However, persistent tags and recurrence might represent a problem, because piles are not excised and severe complications requiring surgery have been occasionally reported. The aim of the present study is to analyze the causes for and the outcome of reintervention following either severely complicated or failed stapled hemorrhoidopexy. METHODS: A total of 232 primary stapled hemorrhoidopexies and 65 reinterventions after stapled hemorrhoidopexy were performed by the authors in five centers devoted to colorectal surgery. Twelve patients of the latter group had the stapled hemorrhoidopexy performed in one of these centers. Thirty-five were males and 30 were females. The mean age was 50 (range, 29-81) years. In all cases the primary indication for stapled hemorrhoidopexy was either third-degree or fourth-degree symptomatic hemorrhoids. In all patients submitted to reoperation the diagnosis of either severely complicated or failed stapled hemorrhoidopexy was made. The clinical history of all of these patients was carefully studied and all underwent inspection, digital exploration, and proctoscopy. After the reintervention, proctoscopy was performed in 61 patients (92 percent) after a median followup of 5.5 (range, 1-36) months. RESULTS: Our reoperation rate after stapled hemorrhoidopexy was 11 percent. The most frequent indications for reintervention were persistent, severe anal pain (visual analog pain score higher than 7) in 29 patients (45 percent), severe postoperative bleeding in 20 (31 percent), anal fissure in 16 (21 percent), pro-lapsing piles in 12 (18 percent), rectal polyp in 11 (16 percent), anorectal sepsis in 11 (16 percent), and fecal incontinence in 7 (11 percent). Thirteen different types of reintervention were needed. Excisional hemorrhoidectomy, removal of staples, and fissurectomy and/or internal sphincterotomy were the most frequent operation (n = 41). A decrease in anal pain, as measured by visual analog pain score, was observed one month after reintervention, compared with that measured preoperatively (from 5.6 ±3.6 to 3.0 ±2.9)(P < 0.001). Bleeding requiring treatment occurred in six cases (10 percent), anal stricture requiring dilation occurred in three (5 percent), and fecal incontinence in three (5 percent). Proctoscopy showed no recurrences in 52 cases (80 percent) after the reintervention. CONCLUSION: Pain and bleeding mostly caused by piles, fissures, and retained staples were the most frequent causes for reoperation after stapled hemorrhoidopexy. Reintervention was associated with a high bleeding and soiling rate, but was effective in treating pain and other symptoms in the majority of patients. Because of the wide spectrum of different interventions required, a failed or complicated stapled hemorrhoidopexy might be better treated by an experienced colorectal surgeon.

Sphincteroplasty for anal incontinence

Sphincteroplasty(SP)is the operation most frequently performed in patients suffering from moderate-to-severe anal incontinence(AI)who do not respond to conservative treatment.Other costly surgeries,such as artificial bowel sphincter(ABS)and electro-stimulated graciloplasty,have been more or less abandoned due to their high morbidity rate.Minimally invasive procedures are widely used,such as sacral neuromodulation and injection of bulking agents,but both are costly and the latter may cure only mild incontinence.The early outcome of SP is usually good if the sphincters are not markedly denervated,but its effect diminishes over time.SP is more often performed for post-traumatic than for idiopathic AI.It may also be associated to the Altemeier procedure,aimed at reducing the recurrence rate of rectal prolapse,and may be useful when AI is due either to injury to the sphincter,or to a narrowed rectum following the procedure for prolapse and haemorrhoids(PPH)and stapled transanal rectal resection(STARR).The outcome of SP is likely to be improved with biological meshes and post-operative pelvic floor rehabilitation.SP is more effective in males than in multiparous women,whose sphincters are often denervated,and its post-operative morbidity is low.In conclusion,SP,being both low-cost and safe,remains a good option in the treatment of selected patients with AI.

Gastric cancer treated with pressurized intraperitoneal aerosol chemotherapy:revising an option for peritoneal carcinomatosis

Aim:Gastric cancer is the cancer with the highest rate of peritoneal metastization and this type of spread is associated with a higher death rate compared to dista nt orga n metastasis.The systemic chemotherapy has a mini mal effect in peritoneal metastasis so new types of treatment have emerged.The authors revised the main studies done in pressurized in traperit on eal aerosol chemotherapy(PIPAC)and prese nted the main con clusi ons.Methods:A PubMed search was con ducted focus ing on PIPAC in gastric can cer.The MeSH database was searched with the terms:"Gastric can cer[MeSH]and in traperit on eal aerosol chemotherapy".Results:Seve n studies were an alyzed.All the studies performed the tech nique with aerosol of doxorubic in and cisplat in.All cases were well tolerated,with minor adverse effects.Patients presented resolution of their abdominal symptoms and regression of macroscopic carcinomatosis.Cytoreductive surgery or hypertermic intraperitoneal chemotherapy could be performed in some patients with good response to PIPAC.The peritonitis caused by the chemotherapy was well tolerated.Conclusion:PIPAC can induce remission in end-stage and resistant disease with acceptable side effects,good safety levels for patients and health professionals,and quality of life improvement.