Resumo em Inglês:

Abstract Objective Despite all the technological advances, successful management of complex fistula-in-ano is still a challenge due to recurrence and incontinence. The present study evaluates the outcomes of a novel technique, Interception of Fistula Track with Application of Ksharasutra (IFTAK) in terms of success rate and degree of incontinence. Methods In the present prospective study, 300 patients with complex fistula-inano were treated by the IFTAK technique, whose surgical steps include: incision at the anterior or posterior midline perianal area, identification and interception of the fistulous track at the level of the external sphincter, rerouting the track (and extensions) at the site of interception, and application of a ksharasutra (medicated seton) in the proximal track (from the site of interception to the internal opening) that is laid open gradually, with the resulting wound healing with minimum scarring. The distal track is allowed to heal spontaneously. Results There were 227 transsphincteric and 73 intersphincteric varieties of fistula with supralevator extension in 23 cases, of which 130 were recurrent fistulas, 29 had horseshoe track, while 25 had blind fistula with no cutaneous opening. The mean duration of the ksharasutra application was 8.11 ± 3.86 weeks with an overall success rate of 93.33% at the 1-year follow-up. A total of 3.67% of the cases reported with a mild impairment of continence on the Wexner incontinence scoring system. Pre- and postoperative anal manometry evaluation showed minimal reduction in median basal and squeeze pressures. Conclusion The IFTAK technique is a minimally invasive, daycare surgical procedure for the management of complex fistula-in-ano with low recurrence and minimal sphincter damage.

Resumo em Inglês:

Abstract Background Despite several improvements in surgical techniques, the intracorporeal division of the distal end of the rectum is still challenging, particularly when it is too deep in a narrow pelvis. Even though it helps avoid spillage, the double-stapling technique (DST) raises concerns regarding safety and anastomotic leakage if multiple stapler firings are essential to complete the rectal division. Objective To assess the feasibility of vertically dividing the rectum and its impact in reducing the number of reloads essential for that division in non-low rectal cancer patients undergoing total mesorectal excision (TME). Materials and Methods A retroprospective study. Results From January 2017 to November 2021, a total of 123 patients with sigmoid and rectal cancers were enrolled in the present study; their data were collected and analyzed, and 21 patients were excluded. The remaining sample of 102 subjects was composed of 47 male (46%) and 55 female (54%) patients with a median age of 54 years (range: 30 to 78 years). Only 1 reload was enough to complete the rectal division in 82 (80.39%) cases, and 2 reloads were used in the remaining 20 (19.61%) patients. Anastomotic leakage was clinically evident in 4 cases (3.9%). No statically significant difference was observed when firing one or two staplers. No 30-day mortality was recorded in this series. Conclusion Our early experience indicates that this type of division has a real advantage in terms of decreasing the number of reloads needed and, in turn, lowering the incidence of anastomotic leakage after partial mesorectal excision (PME) or TME when applied with proper patient selection.

Resumo em Inglês:

Abstract Objective To evaluate the prevalence of polyps and their treatments. Materials and Method This is a retrospective study conducted in our department over 20 years and 3 months between January 2000 and March 2021. All patients with colorectal polyps who underwent endoscopic resection were included. We evaluated the resection techniques and the management of complications. Results The total number of patients was 273, with a mean age of 57.26 ± 14.058 (18–90) and a M/W sex ratio of 2. The prevalence was 3.35% and the mean number of polyps was 1.33 ± 0.69. The most frequent symptoms were rectal bleeding (23.5%) and constipation (12.1%). The median size was 6 mm (4–12 mm). The left colonic location was the most frequent site (43%). All polyps were classified according to the Paris classification, with a predominance of sessile polyps in 45.75%, followed by pedunculated polyps, representing 42.4%. Endoscopic resection was performed either by biopsy forceps, polypectomy, or mucosectomy in 30.2%, 27.4%, and 25.4% of cases, respectively. Our study noted immediate bleeding in 1.5% of cases, and no perforations or late complications. All complications were treated endoscopically, and no patient required blood transfusion or surgical intervention. Conclusion Endoscopic resection of rectocolic polyps is the ideal treatment for these lesions. In our department, the prevalence was 3.35%, the most used resection techniques were forceps resection and polypectomy, and the complication rate was 1.5%.

Resumo em Inglês:

Abstract Objective To develop a low-cost simulator model and a colonoscope with materials that are easily accessible to offer training on colonoscopy skills during undergraduate studies. Since this is the procedure of choice for colorectal cancer screening, the general practitioner must be able to recognize its main indications, preparation, and complications. Methods Using materials such as a mannequin, a vehicle inspection camera, a conduit, polyvinyl chloride (PVC) pipe, acrylic, wood, and red paint, we built a simulator and a 150-cm long and 20-to-25-mm thick colonoscope. The colonoscope’s handle and handhold were made of acrylic, the colonoscope’s mobile end was made with articulated PVC rings, and the up and down movements were performed according to the traction of the steel cables. The camera attached to its distal end enables connection to a smartphone to view the image. In the simulator, the conduit was inserted into the mannequin to simulate the curvatures of the colon. Red spray paint was used to simulate the staining of the colonic mucosa in the inner region of the mannequin and the adventitial layer in the outer region. Results We were able to build a simulator and a colonoscope with a total amount of R $ 182.82 (roughly US$ 36.50). Both were tested and proved to be useful in the acquisition of psychomotor and cognitive skills in colonoscopy. Conclusion The simulator and colonoscope developed by us are cost-effective, useful in the acquisition of psychomotor and cognitive skills in colonoscopy, and can facilitate the structuring of a training program for undergraduate students.

Resumo em Inglês:

Abstract Introduction Right colon diverticulitis (RCD) is an uncommon condition in Western populations, but its incidence has increased over the last decades. Due to its rarity, many surgeons are unfamiliar with this disease, which is often mistakenly diagnosed as acute appendicitis. The lack of data about the diagnosis and management of RCD in Western populations makes it difficult to establish the optimal therapeutic strategy. Objective To evaluate the outcomes of patients treated for acute RCD and to propose a therapeutic algorithm for the diagnosis and treatment. Methods A retrospective analysis of the medical records of patients treated for acute RCD between 2008 and 2020 by a single experienced colorectal surgeon was performed. Results In total, 12 patients were identified, 8 male and 4 female subjects, with a mean age of 49.6 years; 9 of these patients were of Western origin. The median follow-up time was of 49 months (range: 12 to 144 months). The most frequent symptoms were abdominal pain (100%) and fever (66%). Diagnostic errors in imaging exams occurred in four patients. A total of 6 patients were managed clinically, and the other 6 underwent surgical treatment with right colectomy (n = 5) and total colectomy (n = 1), 2 via laparoscopy and 4 through a laparotomy. The anatomopathological examination confirmed RCD in all operated patients. There was no incidental finding of neoplasia and there were no deaths during the study period. Conclusion Uncomplicated RCD can be treated conservatively with a high success rate. Recurrent cases that impact quality of life or complicated forms of RCD should undergo surgical treatment, preferably through a right laparoscopic colectomy. The authors present a diagnostic and therapeutic algorithm to facilitate the diagnosis and to guide the management of this uncommon disease.

Resumo em Inglês:

Abstract Background The surgery with total mesorectal excision recommended by R. J. Heald in 1982 is the gold standard. Rectal cancer (RC) surgery has a morbidity rate ranging from 6 to 35%, and it can cause functional issues such as sexual, urinary, and bowel dysfunction in the long term. Neoadjuvant chemoradiotherapy (CRT) has been gaining ground in patients with lesions in the middle and lower rectum. The aim of the present study is to present the experience of a reference service in the treatment of RC. Patients and Methods A retrospective study involving 53 patients diagnosed with RC between January 2017 and December 2019 with follow-up until December 2020. We examined tumor location, disease stage, digital rectal exam findings, carcinoembryonic antigen (CEA), therapeutic modality offered, and follow-up time. Results A total of 32% of the patients were men and 68% were women, with a mean age of 60 years old. Location: upper rectum in 6 cases, middle rectum in 21 cases, and lower rectum in 26 cases with evolution from 9.8 to 13.5 months. The most frequent complaints were hematochezia and constipation. A total of 36 patients underwent neoadjuvant therapy: 11 complete clinical response (CCR) (30.5%), 20 (55.5%) partial clinical response (PCR), and no response in 5 patients (14%). The follow-up ranged from 12 to 48 months, with a mean of 30.5 months. A total of 25% of the patients had RC that went beyond the mesorectal fascia, and 22.64% had metastases in other parts of the body when they were diagnosed. Conclusion Neoadjuvant radio and chemotherapy present themselves as an alternative in the treatment of rectal cancer. In 36 patients, 30.5% had a complete clinical response, 55.5% had a partial clinical response, and 14% had no response. It was worth doing the “Watch and Wait” (W&W) to sample. A definitive colostomy was avoided. However, it is necessary to expand the study to a larger follow-up and more patients. Additionally, it is necessary to implement a multicenter study.

Resumo em Inglês:

Abstract Survival in rectal cancer has been related mainly to clinical and pathological staging. Recurrence is the most challenging issue when surgical treatment of rectal cancer is concerned. This study aims to establish a recurrence pattern for rectal adenocarcinoma submitted to surgical treatment between June 2003 and July 2021. After applying the exclusion criteria to 305 patients, 166 patients were analyzed. Global recurrence was found in 18.7% of them, while 7.8% have had local recurrence. Recurrences were diagnosed from 5 to 92 months after the surgical procedure, with a median of 32.5 months. Follow-up varied from 6 to 115 months. Recurrence, in literature, is usually between 3 and 35% in 5 years and shows a 5-year survival rate of only 5%. In around 50% of cases, recurrence is local, confined to the pelvis. This study was consonant with the literature in most aspects evaluated, although a high rate of local recurrence remains a challenge in seeking better surgical outcomes.

Resumo em Inglês:

Abstract Background A common acquired anorectal condition is anal fistula. The treatment approaches that have been employed have been linked to erratic outcomes and sometimes life-threatening consequences. Video-assisted anal fistula treatment (VAAFT), a minimally invasive method, was introduced for adult patients in 2011. Objective To know the efficacy of the VAAFT procedure in treating high anal fistulas and to compare it to open methods in the Basrah province. Methods The present study was performed on 200 patients with high fistulas in ano in Basrah province. We divided the patients into 2 groups: Group A: treated by the VAAFT technique and Group B: treated by open fistulotomy Results The patients treated with VAFFT revealed no occurrence of the following postoperative complication: Infection, incontinence, recurrence, anal stenosis, and bleeding. There was lower incidence of pain, short time for wound healing, rapid return to work, and more patient satisfaction compared with open fistulotomy Conclusion An innovative method for managing ano fistula is VAAFT. Compared with traditional methods, it has a lot of benefits. It is day case surgeryno open wound.no damage to anal sphincter and no risk of incontinence, it is more affordable.it allow for clear identification of internal office, whole tract and its associated branches and cavity. The instrument can be used for multiple patients after good sterilization and disinfection.

Resumo em Português:

Resumo A pandemia de SARS-Cov-2 e suas imediatas consequências para a saúde coletiva causaram enormes restrições ao atendimento médico-hospitalar normal. A despeito disso, os riscos de morbimortalidade relacionados a outras doenças e agravos à saúde são incessantes. E é razoável de presumi-los como aumentados pela falta de atendimento regular no período restrições mais severas decorrentes das medidas sanitárias contra a epidemia. A retomada do atendimento é necessária, ainda que o vírus permaneça uma ameaça. Portanto, é crítico que esta seja feita de forma estruturada e segura, sob pena de causar mal adicional aos nossos pacientes e a nós mesmos. O presente artigo se propõe a servir como guia para a retomada e manutenção dos atendimentos eletivos ambulatorial, cirúrgico e endoscópico baixo, auxiliando o coloproctologista a identificar os riscos, avaliar a suas dimensões e implementar medidas de controle de forma pragmática e eficaz.

Resumo em Inglês:

Abstract The SARS-Cov-2 pandemic and its immediate public health impact has caused severe disruption of regular medical care provision. The morbimortality of other diseases continues to affect people regardless of the viral infection. Indeed, it would be reasonable to assume that they have been aggravated by the period of most restrictive public health measures that were adopted against the virus. Recovery and maintenance of healthcare provision is required despite the ongoing threat. Therefore, it is critical to resume services in a structured and safe way, otherwise greater harm could come to our patients and to ourselves. The present article proposes to be a broad guide to the recovery and maintenance of elective outpatient, surgical and lower endoscopic services, aiding the colorectal surgeon in identifying risks, assessing their multiple dimensions, and implementing risk management strategies in a pragmatic and efficacious way.

Resumo em Inglês:

Abstract Introduction Sacrococcygeal pilonidal disease (SPD) is a chronic suppurative condition of the sacrococcygeal region causing chronic sinus tract or cyst. It is an acquired complex disease more common in young adult males, causing considerable morbidity and long periods of interruption in work or education. From simple conservative techniques to complex flap reconstruction, many debatable treatment options are offered; however clear dynamics toward the widespread use of minimally invasive methods and off-midline flap reconstruction are suggested in all guidelines, which recommend the Karydakis and Limberg flap modification. The plethora of literature compares procedures for identification of a single best treatment approach, which has proven to be difficult. The surgical outcome of both techniques is compared in the present study. Objective To compare the surgical outcomes of the modified Karydakis flap (MKF) versus the modified Limberg flap (MLF) in SPD. Materials and Methods The present study was conducted at the general surgery department on SPD patients who were ≥18 years old. A total of 67 participants were included after obtaining the informed consent, with group A comprising 33 patients undergoing the MLF procedure and group B comprising 34 patients undergoing the MKF procedure. Results The mean patient age was 28.85 (range, 18–44) years old. For the MKF and MLF methods, the average operating duration was 32.5 (range, 25–40) and 54.5 (range, 45–65) minutes, respectively. The MKF approach was found to significantly improve pain score, mean sitting painless time, return to normal activity, wound healing time, and patient satisfaction. Conclusion Comparative outcomes were seen between both MKF and MLF; however, our findings show that MKF is a more favourable method than MLF with superior outcomes.

Resumo em Inglês:

Abstract Background Patients with colorectal cancer may seek the emergency department for symptoms related to chemotherapy and radiotherapy side effects as well as those from the disease itself and from surgery complications. Objectives To establish the epidemiological and clinical profile of colorectal cancer patients that look for consultations in the emergency department. Methods Retrospective study of emergency room charts from colorectal cancer patients that consulted in a single oncological hospital for the period of 1 year. Results Four hundred and forty-six consultations were identified (49.5% males and 50.5% females) with a mean age of 63 years and with advanced disease (most with tumor, node, metastases [TNM] stages III and IV). The most common complaint was abdominal pain (27.5%), followed by nausea (4.7%; more commonly seen in females with p =0.03) and bladder symptoms (4.7%; more commonly seen in males, with p =0.003). Infections (10.3%) and acute abdominal pain (9.1%) were the most frequent diagnoses. About 18% of them were admitted to the hospital and 80% were discharged home. Conclusion The profile of patients with colorectal cancer seeking the emergency department comprises patients with advanced disease and a similar proportion of males and females. Symptom-driven complaints were the most frequent reason for consultations.

Resumo em Inglês:

Abstract Introduction Inverse psoriasis affects the skin of flexural areas, such as the groin, axillae, umbilicus, intergluteal fold, and external genitalia. Clinical Case We herein report the case of a man who presented with anal pruritus and, upon physical examination, a perianal dermatosis was found, which was characterized by erythematous plaques, with fine scaling. The case was initially managed with zinc oxide, and when no improvement was observed, we decided to take an incisional biopsy, which indicated histological changes suggestive of psoriasiform dermatitis. Discussion Inverse psoriasis affects 3% to 7% of patients with psoriasis, and it manifests with erythematous plaques without the classic scaling appearance. The skin in these areas is susceptible to maceration, irritation, and ulceration, which alter the classic clinical picture. It may present with typical lesions or, less frequently, in isolation in the anogenital region. In the anogenital presentation only, the diagnosis should be made by biopsy, looking for the classic histopathological features of psoriasis. As for the first-line treatment, low- or medium-potency topical steroids are used for short periods of time; the second-line treatment is with emollients and tar-based products; and the third-line treatment uses an immunomodulator. Conclusion This presentation is infrequent, and it requires a high index of suspicion for the diagnosis, always supported by biopsies, in search of the classic histopathological features of psoriasis.

Resumo em Inglês:

Abstract Objective Laparoscopic colectomy has gained acceptance as a standard treatment for benign and malignant colorectal disease, such as diverticular disease and cancer, among others. Same as in open surgery, the laparoscopic approach carries a low risk of small bowel obstruction in the postoperative period, but in laparoscopic surgery, internal hernia after laparoscopic left colectomy may be a cause of small bowel obstruction with a significant risk of morbidity and mortality. This rare complication may be prevented with routine closure of the mesenteric defects created during the colectomy. Methods We present four cases of internal herniation after laparoscopic colectomy. Two cases were after laparoscopic left colectomy and two after laparoscopic low anterior resection. All four cases had full splenic flexure mobilization. Routine closure of the mesenteric defect was not performed in the initial surgery. Results The four patients were treated by laparoscopic reintervention with closure of the mesenteric defect. In two of them, conversion to open surgery was necessary. One of the patients developed recurrent internal herniation after surgical reintervention with mesenteric closure of the defect. All patients were managed without need for bowel resection, and mortality rate was 0%. Conclusion Internal herniation after laparoscopic colorectal surgery is a highly morbid complication that requires prompt diagnosis and management and should be suspected in the early postoperative period. Additional studies with extended follow-up are required to establish recommendations regarding its prevention and management.