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Se presenta un caso poco corriente de prolapso genital, asociado a una enorme procidencia rectosigmoidea, tratados por vía perineal, mediante una rectosigmoidectomía a lo Miles, y una operación de Manchester, en la cual la amplia sutura de los elevadores del ano por vía vaginal, nos han dado excelentes resultados en una enferma que tiene 6 meses de observación.

Chronic constipation in children and adolescents is relatively common and a reason for consultation with pediatricians and proctologists. Most cases respond to medical treatment. Advanced cases of megacolon and megarectum can be treated surgically by Duhamel technique.This case report describes a 15-year-old patient with chronic intestinal constipation refractory to clinical treatment associated with megacolon and megarectum, which was surgically treated. Resumo: A constipação intestinal crônica em crianças e adolescentes é relativamente comum e motivo de consultas a pediatras e coloproctologistas. A maioria dos casos responde ao tratamento clínico. Casos avançados de megacolon e megarreto podem ser tratados cirurgicamente através da cirurgia de Duhamel.Este relato de caso descreve um paciente de 15 anos de idade com quadro de constipação intestinal crônica refratária ao tratamento clínico associada a megacolon e megarreto, o qual foi tratado cirurgicamente. Keywords: Megacolon, Megarectum, Duhamel, Palavras-chave: Megacolon, Megarreto, Duhamel

Background and aim: Several procedures for the treatment of complete rectal prolapse (CRP) exist. These procedures are performed via the abdominal or perineal approach. Perineal procedures for rectal prolapse involve either resection or suspension and fixation of the rectum. The present review aimed to assess the outcomes of the perineal resectional procedures including Altemeier procedure (AP), Delorme procedure (DP), and perineal stapled prolapse resection (PSR) in the treatment of CRP.Patients and methods: A systematic search of the current literature for the outcomes of perineal resectional procedures for CRP was conducted. Databases queried included PubMed/MEDLINE, SCOPUS, and Cochrane library. The main outcomes of the review were the rates of recurrence of CRP, improvement in bowel function, and complications.Results: Thirty-nine studies involving 2647 (2390 females) patients were included in the review. The mean age of patients was 69.1 years. Recurrence of CRP occurred in 16.6% of patients. The median incidences of recurrence were 11.4% for AP, 14.4% for DP, and 13.9% for PSR. Improvement in fecal incontinence occurred in 61.4% of patients after AP, 69% after DP, and 23.5% after PSR. Complications occurred in 13.2% of patients. The median complication rates after AP, DP and PSR were 11.1%, 8.7%, and 11.7%, respectively.Conclusion: Perineal resectional procedures were followed by a relatively high incidence of recurrence, yet an acceptably low complication rate. Definitive conclusions on the superiority of any procedure cannot be reached due to the significant heterogeneity of the studies. (C) 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

To report outcomes of children with constipation refractory to medical management and manometrically proven distal colonic dysmotility, managed with rectosigmoidectomy followed by Duhamel operation (Duhamel). Children who underwent a Duhamel from 2009 onwards for intractable constipation and left colonic dysmotility were retrospectively reviewed. The primary end point was resolution of constipation, and secondary end point was postoperative complications. Continuous data were median (range). 11 patients (4 males) had Duhamel at 11 years (5–16) with constipation started from 2 years (1–8). Hirschsprung’s disease was excluded. All Duhamels were performed with a covering ileostomy: 9 following a Hartmann procedure, one following a previously failed reversal of Hartmann, and one Duhamel performed with a pre-existing ileostomy. All ileostomies were subsequently closed. Median resection length was 22 cm (11–31). Length of stay was 8 days (5–23). Follow-up was 5 years (0.5–7). Age at final review was 15 years (10–18). Resolution of constipation occurred in nine patients (4 required antegrade continence enemas (ACE), 5 with laxative); two had persistent constipation and faecal incontinence despite ACE, ultimately requiring an ileostomy. Two postoperative small bowel obstructions required laparotomy. Duhamel performed in children with manometrically proven distal colonic dysmotility yielded 82% resolution of refractory constipation; half of them subsequently needed ACE.

Perineal approaches for rectal prolapse repair have low complication rates but high recurrence rates, while abdominal approaches that include sigmoidopexy have lower recurrence rates but higher complication rates. To optimize both recurrence and complication rates, we developed a novel procedure that uses transanal endoscopic microsurgery (TEM) to perform a sigmoidopexy via a perineal approach. We created a rectal prolapse model in six swine and two human cadavers using a previously published technique. The rectum was mobilized and eviscerated transanally. After marking the planned point of sigmoid transection, the rectum was returned to the peritoneal cavity. A TEM proctoscope was inserted transanally alongside the rectum, and the lateral sigmoid colon walls were sutured to the sacrum. The sigmoid colon was then transected where previously planned, and a primary sigmoid anastomosis was performed. Total operative time, sigmoidopexy operative time, and suture security were measured and compared to standard rectosigmoidectomy and abdominal sigmoidopexy times. No sigmoid colon, iliac vessel, bladder, or ureteral injuries occurred. At least two sigmoidopexy sutures were secure on inspection in all animals and human cadavers, with increasing success of secure suture placement as experience increased. Operative length was similar to traditional abdominal sigmoidopexy. TEM sigmoidopexy is technically feasible. This approach has the potential to reduce the recurrence rate associated with perineal approaches alone, but further study is needed to confirm this hypothesis.

To reduce bladder function impairment and avert the serious complications of anastomotic leakage after segmental rectosigmoidectomy and to minimize the persistence of endometriotic lesions associated with discoid resection, we used the double circular stapling (DCS) technique. This technique enables excision of bowel endometriosis nodules larger than those that can be removed with the single-load technique of the circular stapler. Of 120 patients who underwent surgery to treat bowel endometriosis, intestinal shaving was performed in 24, discoid resection with single circular stapling in 40, and rectosigmoidectomy in 55. Eleven patients (9.2%) underwent the DCS technique. In the DCS group, the size of the rectosigmoid lesion ranged from 2.2 cm to 4.2 cm. Median operative time for the DCS technique was 100 minutes, compared with 150 minutes for rectosigmoidectomy (p = .04). Only 1 of 11 patients (9%) had urinary retention, compared with postoperative urinary retention in 14 of 55 patients (25%) who had undergone rectosigmoidectomy (difference not significant). Only 1 patient, with a 4.2-cm nodule, had a positive margin in the specimen obtained at the second stapling. DCS is a promising technique and may avert rectosigmoidectomy in selected patients.

Intestinal loop stoma is a common surgical procedure performed for various benign and malignant abdominal problems, but it rarely undergoes spontaneous closure, without surgical intervention. Two male patients presented to our emergency surgical department with acute abdominal pain. One of them was diagnosed as having rectosigmoid perforation and underwent diversion sigmoid loop colostomy after primary closure of the perforation. The other was a known case of carcinoma of the rectum who had already undergone low anterior resection with covering loop ileostomy; the patient underwent second loop ileostomy, this time for complicated intestinal obstruction. To our surprise, both the loop colostomy and ileostomy closed spontaneously at 8 weeks and 6 weeks, respectively, without any consequences. Spontaneous stoma closure is a rare and interesting event. The exact etiology for spontaneous closure remains unknown, but it may be hypothesized to result from slow retraction of the stoma, added to the concept of a tendency towards spontaneous closure of enterocutaneous fistula.

Introduction: the standard treatment for locally advanced extra-peritoneal rectal adenocar- cinoma, consists of neoadjuvant treatment with radiotherapy and chemotherapy followed by total mesorectal excision.Objective: evaluate, retrospectively, the patients submitted to neoadjuvant therapy and surgery that presents with total remission of the lesion in the anatomopathological examination.Methods: between 2000 and 2010, 212 patients underwent surgery at the Coloproctology Unit at DMAD at FCM–UNICAMP. They were grouped as: rectosigmoidectomy and colorectal anastomosis (n = 54), rectosigmoidectomy with coloanal anastomosis (n = 41), 114 abdomi- noperineal resection of the rectum (n = 114) and other (n = 3).Results: thirty (14.2%) patients (mean age 57.6 years; 60% males) showed complete remis- sion of the rectal lesion. 4 (13.3%) had compromised lymph nodes and/or lymphatic inva- sionAt follow-up (mean 51.9 months), 4 (13.3%) presented with local recurrence (one patient) or distant metastases (two patients had liver metastasis, one had liver and lung, and one had bone metastasis). The mean survival was 86.7%.Conclusion: patients with a complete tumor response show ed an increased survival rate, however, the same patients without evidence of residual tumors could develop local recur- rence or distant metastases on a later follow-up. Resumo: Introdução: o tratamento padrão do adenocarcinoma de reto extra-peritoneal localmente avançado consiste de neoadjuvância com radio e quimioterapia, seguida de cirurgia com excisão total do mesorreto.Objetivo: avaliar, retrospectivamente, os pacientes submetidos à neoadjuvância e cirurgia, que apresentaram remissão completa da lesão no reto no exame anatomopatológico.Métodos: foram avaliados 212 doentes, operados no Serviço de Coloproctologia da DMAD da FCM-Unicamp, entre 2000 e 2010. As cirurgias realizadas foram: retossigmoidectomia e anastomose colorretal (n = 54), retossigmoidectomia com anastomose coloanal (n = 41), amputação abdominoperineal do reto (n = 114) e outras (n = 3).Resultados: trinta (14,2%) pacientes (média de idade de 57,6 anos; 60% do sexo masculino) apresentaram remissão tumoral completa no reto; destes, 4 (13,3%) tinham acometimento linfonodal e/ou invasão linfática. No seguimento pós-operatório (médio de 51,9 meses), 4 (13,3%) apresentaram recidiva local (um doente) ou metástases à distância (dois doentes com metástases hepáticas, uma hepática e pulmonar, e um outro metástase óssea). A so- brevida média do grupo foi de 86,7%.Conclusão: os pacientes com resposta tumoral completa no reto apresentaram elevada taxa de sobrevida, mas mesmo doentes sem evidência de tumor residual, podem apresentar recidiva local ou metástases à distância no seguimento tardio. Keywords: Rectal cancer Neoadjuvant therapy Surgery, Palavras-chave: Câncer retal, Terapia neoadjuvante Cirurgia

Introduction: laparoscopic colorectal surgery has become a viable access route since the beginning of 1990, using Jacobs’ technique. Its outcomes are decrease in hospitalization length, early return to routine activities, better esthetic results and less postoperative pain. Objective: to report a series of patients treated by a team using videolaparoscopic access route in colorectal surgery. Material and methods: retrospective, descriptive study carried out in Salvador, state of Bahia, Brazil, from April of 2010 to May 2012. Results: a total of 81 procedures were analyzed; 59.3% of cases were females, mean age was 58.3 years. Benign illness was treated in 48.1% to the patients. Rectosigmoidectomy was carried out in 41.5% and right colectomy in 21%. Intraoperative complications were observed in 3.7% and postoperative in 21% of cases, with a conversion rate of 6.2%. Conclusion: the laparoscopic procedure showed to be safe and the surgeon's training results in better outcomes in this series. Resumo: Introdução: a cirurgia videolaparoscópica colorretal tem se tornado uma opção de acesso viável, desde o início de 1990, por Jacobs. Tem-se obtido redução dos dias de internação, retorno precoce às atividades, melhor resultado estético e menos dor pós-operatória. Objetivo: relatar a casuística de uma equipe utilizando o acesso videolaparoscópico. Materiais e métodos: estudo retrospectivo, descritivo realizado em Salvador, de abril de 2010 a maio de 2012. Resultados: 81 procedimentos foram analisados, com 59,3% do sexo feminino, média de ida- de de 58,3 anos. Foi tratada doença benigna em 48,1% dos pacientes. A retossigmoidecto- mia foi realizada em 40,7%, e a colectomia direita em 21%. Das complicações encontradas, 3,7% foram transoperatórias e 21% pós-operatórias com uma taxa de conversão de 6,2%. Conclusão: o procedimento videolaparoscópico tem-se mostrado seguro, e a capacitação do cirurgião tem trazido melhores resultados na casuística. Keywords: Laparoscopic colorectal surgery, Colectomy, Laparoscopy, Palavras-chave: Cirurgia laparoscópica colorretal, Colectomia, Laparoscopia

Rectal prolapse represents full thickness protrusion of the rectum through the anal sphincter. Rarely, the prolapsed portion of the rectum can become neoplastic. The exact incidence of rectal prolapse although unknown, it is a rather rare entity. We hereby report a case of a rectal prolapse with neoplastic change. The present study report the case of a 58-year-old woman, without previous major diseases, diagnosed with a rectal prolapse. Eight months later she attended with evident prolapse towards the posterior quadrant of the anal margin with a polypoid lesion of approximately 5 cm × 5 cm. An altemeier’s rectosigmoidectomy is executed. The histopathologic study reports a tubulovillous adenoma with high grade dysplasia.

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.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.

Surgical treatment has been in constant evolution in the search for minimizing incisions regardless of the complexity of the operation. Natural Orifice Translumenal Endoscopic Surgery (NOTES) represents this progression of surgery to less invasive procedures. Transanal endoscopic microsurgery (TEM) is an ideal NOTES platform to access the peritoneal cavity endoscopically through the anus and specifically to allow colorectal resections be performed through smaller, or indeed without, abdominal incisions. Transanal rectosigmoidectomy with total mesorectal excision (TME) using TEM is a feasible and oncologically safe option. Such use of currently available combined hybrid laparoendoscopic systems provides a safe platform to define future clinical applications and advantages of NOTES. Furthermore, it stimulates the active development of technologies that will support and enable it.

Made available in DSpace on 2019-09-12T16:26:05Z (GMT). No. of bitstreams: 0 Previous issue date: 2011 A intussuscepção intestinal é uma doença rara em adultos, sendo na maior parte dos casos causada por neoplasia maligna. Os sintomas são geralmente inespecíficos e crônicos, na maioria das vezes sugerindo obstrução intestinal. O tratamento consiste na remoção oncológica do tumor. Este artigo relata o caso de uma paciente com quadro de hematoquezia e exteriorização de massa através do ânus que foi submetido à retossigmoidectomia anterior alta em bloco e confirmado o diagnóstico de adenocarcinoma de sigmoide. The intestinal intussusception is a rare disease in adults, and is mostly caused by malignant neoplasm. Symptoms are usually nonspecific and chronic, and in most cases suggesting intestinal obstruction. Treatment consists of removing the malignant tumor. This article reports the case of a patient with hematochezia and apparent mass in the anus who underwent anterior rectosigmoidectomy and had the diagnosis of adenocarcinoma of the sigmoid confirmed. [César, Maria Auxiliadora Prolungatti] Universidade de Taubaté, Brazil Albuquerque, Eduardo Fortes De] Universidade de Taubaté, Brazil Paula, Pedro Roberto De] Universidade de Taubaté, Brazil Silva, Fernanda Perez Adorno Da] Universidade de Taubaté, Brazil

BACKGROUND AND STUDY AIMS: Several reports have demonstrated the safety of pure natural-orifice transluminal endoscopic surgery (P-NOTES) using transanal endoscopic microsurgery (TEM) and embryonic NOTES (E-NOTES; laparoscopic surgery through the umbilicus). This study was performed to compare the safety and applicability of NOTES rectosigmoidectomy between E-NOTES and P-NOTES in a swine model. PATIENTS AND METHODS: E-NOTES was conducted through a single port using laparoscopic instruments (n = 11). P-NOTES was performed using TEM with transgastric endoscopic assistance (n = 11). Gastrotomies were created using a needle knife and the balloon dilatation technique, and closed using T-anchors. Blood samples were collected to evaluate changes in systemic cytokine levels during the preoperative and postoperative periods; operative outcomes were also evaluated and compared between the groups. The necropsy findings were recorded after sacrifice at 1 week after the procedure. RESULTS: The mean operative time for P-NOTES was significantly longer than that for E-NOTES (239 vs. 103 minutes, P < 0.001). The mean distance from the anal verge to colorectal anastomosis in the P-NOTES group was significantly less than that in the E-NOTES group (2.9 vs. 17.6 cm, P < 0.001). On necropsy, the complication rate of P-NOTES was higher than that of E-NOTES, but without statistical significance (54.5 % vs. 18.2 %, P = 0.091). The differences in changes in TNF-α, C-reactive protein, interleukin-6, and interleukin-1β between P-NOTES and E-NOTES were not significant. CONCLUSIONS: E-NOTES rectosigmoidectomy in the swine model is safe, but remains challenging for use in pelvic dissection. P-NOTES rectosigmoidectomy using TEM may be a promising tool for pelvic dissection, but the transgastric approach involves a high degree of risk.

Aim Chagas’ disease is an endemic parasitosis found in Latin America. The disease affects different organs, such as heart, oesophagus, colon and rectum. Megacolon is the most frequent long-term complication, caused by damage to the myoenteric and submucous plexus, ultimately leading to a functional barrier to the faeces. Patients with severe constipation are managed surgically. The study aimed to analyse the 10-year minimum functional outcome after rectosigmoidectomy with posterior end-to-side anastomosis (RPESA). Method A total of 21 of 46 patients were available for follow up. Patients underwent clinical, radiological and manometric evaluation, and the results were compared with preoperative parameters. Results Of the 21 patients evaluated, 81% (17) were female, with a mean age of 60.6 years. Good function was achieved in all patients, with significant improvement in defaecatory frequency (P

Strangled rectal prolapse, the rare disease, is a proctological emergency. Its management is controversial. When it is not reducible and signs of ischemia are present, the Altemeierperineal rectosigmoidectomy remains the best treatment. This study aimed to report our experience on the management of strangled rectal prolapse about 1 case in a 45-year-old man, a holder of a rectal prolapse for 2 years. On admission, he had strangled prolapse for 24 hours with edema. After a vain attempt of manual reduction and installation of necrosis after 48 hours, he had an Altemeier rectosigmo?dectomy. The postoperative course was uneventful and the patient was discharged on the 6th postoperative day. The results were very good, after one year follow-up.

The authors describe an experience with a newly developed technique for the treatment of Hirschsprung's disease (HD)-transanal Swenson pull-through operation (TSPT).The records of 27 children (15 males and 12 females) with HD proven on the basis of rectal biopsy or barium enema who underwent primary TSPT between November 2003 and April 2008 were retrospectively reviewed. Rectosigmoidectomy begins at the level just above dentate line in neonates and approximately 1-cm above dentate line in older children. The full-thickness dissection is performed upward around the rectum. The colon is transected above transition zone and anastomosed to the anus. All patients had postoperative pathologic proof. Data are expressed as mean and SD.Mean age at operation was 29.4 +/- 48.2 months (range, 1-155 months). The operative time averaged 153.5 +/- 85.9 min (range, 65-400 min). There was a statistically significant difference between those younger than 1 month (107.1 +/- 14.8 months) and those greater than 1 month (190.7 +/- 101.1 months). None did receive blood transfusion. Average length of hospital stay was 9.1 +/- 4.1 days (range, 4-21 days). Peri- and postoperative complications included anastomotic stricture (n = 6), enterocolitis (n = 3), and urethral injury (n = 1). Fecal continence (stooling frequency rate of 1-2 times per day) was noted in 70.8% (17/24) and 77.8% (14/18) at 1- and 2-year follow-up, respectively. There was no mortality in the series.Primary TSPT would be an alternative, safe technique in children with HD. The technique is not difficult, and associated with acceptable short-term outcomes. A long-term follow-up will be necessary to assess the real benefit of the technique.

RACIONAL: A literatura médica aceita ressecção local como opção válida em casos selecionados de tumores de reto. A seleção dos pacientes requer exata estimativa dos riscos e avaliação pré-operatória precisa, tanto no aspecto clínico como histopatológico. OBJETIVO: Avaliar os resultados da microcirurgia endoscópica transanal em seguimento de 18 meses. MÉTODOS: De abril de 2002 a abril de 2006, 50 pacientes com tumores de reto foram submetidos a microcirurgia endoscópica transanal, selecionados por suas características clínicas e histopatológicas. Os critérios de inclusão foram: adenomas sésseis maiores do que 3 cm e menores do que 8 cm não-circunferenciais; neoplasia intra-epitelial de alto grau; carcinoma retal pT1, e em casos especiais pT2. Todos esses tumores foram submetidos ao mesmo procedimento cirúrgico. RESULTADOS: O resultado histopatológico final revelou 9 adenomas, 26 neoplasias intra-epiteliais de alto grau, 13 carcinomas (9 pT1 e 4 pT2) e 2 carcinóides. A menor idade foi de 25 anos e a maior de 92. O menor tumor ressecado tinha 64 mm² (carcinóide) e o maior (adenoma) 90 mm². O tempo médio de operação foi de 90 minutos e o de internamento 5 dias. Houve uma morte não relacionada ao método. Um paciente com carcinoma de baixo risco pT1 apresentou recidiva 18 meses após microcirurgia endoscópica transanal e foi submetido a retossigmoidectomia curativa. Foi observado tumor residual em dois pacientes e a complicação mais grave foi uma fístula retovaginal. A taxa de complicação global foi de 9%. CONCLUSÃO: Atualmente a microcirurgia endoscópica transanal é a técnica de escolha para o tratamento de adenomas sésseis, neoplasias intra-epiteliais de alto grau e carcinoma retal pT1 de baixo risco. BACKGROUND: The medical literature accepts local resection as a valuable option in selected cases of rectal tumors. Selection of patients requires an exact perioperative estimation of risks with clinical and histopathological examination. Transanal endoscopic microsurgery aims a safe resection of the tumoral area which leads up to the cure. AIM: To evaluate transanal endoscopic microsurgery results in a follow-up time of 18 months. METHODS: From April 2002 to April 2006, 50 patients with rectal tumors were submitted to transanal endoscopic microsurgery, chosen by clinical history and lesion characteristics. The inclusion criteria were: sessile adenomas larger than 3 cm and smaller than 8 cm, not circumferentially distributed; intra epithelial neoplasia of high degree; and rectal carcinoma pT1, and special cases of pT2. All these rectal tumors were submitted to the same surgical act. RESULTS: The final histopathological results reveal 9 adenoma, 26 intra-epithelial neoplasia of high degree, 13 carcinoma (9 pT1-4 pT2) and 2 carcinoid. The lowest age was 25 and the higher, 92 years-old. The smallest resected tumor had 64 mm² (carcinoid) and the largest (adenoma), 90 cm². Operating time was in average 90 minutes and the overall time statement, 5 days. There was one death not related with the method. One patient with low risk carcinoma pT1 presented recurrence 18 months after transanal endoscopic microsurgery and was submitted to curative rectosigmoidectomy. It was proven a residual tumor after local surgery in two patients and the most important complication was one recto-vaginal fistula. The overall complications rate was 9%. CONCLUSION: Today transanal endoscopic microsurgery is chosen as the ideal technique for the treatment of sessile adenomas, intraepithelial neoplasia of high degree and rectal carcinoma pT1.

Background Rectum-preserving endoscopic posterior mesorectal resection (EPMR) removes the local lymph nodes in a minimally invasive manner and completes tumour staging after transanal local excision (TE). The aim of this study was to compare the morbidity and mortality of TE and EPMR with those of low anterior resection (LAR) in patients with T1 rectal cancer. Methods Between 1996 and 2006 EPMR was performed 6 weeks after TE in 18 consecutive patients with a T1 rectal cancer. Morbidity and mortality were recorded prospectively and compared with those in a group of 17 patients treated by LAR. Lymph node involvement and local recurrence rate were analysed in both groups. Results Two major and three minor complications were noted after EPMR, and four major and four minor complications after LAR (P = 0·402 for major and P = 0·691 for minor complications). Median number of lymph nodes removed was 7 (range 1–22) for EPMR and 11 (range 2–36) for LAR (P = 0·132). Two of 25 patients with a low-risk rectal cancer were node positive. No patient developed locoregional recurrence. Conclusion EPMR after TE is a safe option for T1 rectal cancer. This two-stage procedure has a lower morbidity than LAR and may reduce locoregional recurrence compared with TE alone.

BACKGROUND: Transanal Endoscopic Microsurgery (TEM) corresponds to one of the most recent advances in treating bening and malignant rectal lesions. AIM: To determine the cost of TEM at the Hospital de Clinicas of the Federal University of Parana, and compare it to the cost of a perineal-abdominal amputation of the rectum and of an anterior rectosigmoidectomy, therefore establishing cost-effective parameters with regards to the "Sistema Unico de Saude”. METHODS: Observational and prospective study pertaining cost evaluation of the three surgical procedures pointed above, focusing on laboratory expenses with drugs and hospitalization. Seventy four patients were included in the study, and of these 27 were submitted to TEM, 29 to anterior rectosigmoidectomy and 18 to perineal-abdominal amputation of the rectum. RESULTS: With regards to age, no significant statistical difference was observed. The group who underwent TEM presented the lowest admission period (5,51 days) when compared to the anterior rectosigmoidectomy (20,41) and to the perineal-abdominal amputation of the rectum (18,33). With regards to laboratory expenses, drug and hospital daily rates, significant statistical differences were observed between the three surgical procedures. The TEM group had the lowest cost, approximately 2.5 to four times smaller in the overall comparison (R$ 1,326.71 vs R$ 5,427.16 vs R$ 4,310.20 respectively). CONCLUSION: TEM advantages are evident through admission and hospital stay costs, with significant reduction when compared to conventional techniques.

No decurso de 31 anos de prática coloproctológica, acumulando um fichário com 24.200 pacientes, 923 (3,8%) portadores de câncer no intestino grosso, dos quais 870 eram adenocarcinomas colorretais e 53 tumores malignos de ânus e margem de ânus. Dos 870 casos de adenocarcinomas colorretais, 490 (56,3%) localizavam-se nos cólons e 380 (43,7%) no reto. O presente trabalho tem como objetivo principal analisar uma casuística de 380 pacientes portadores de câncer retal atendidos de 1965 a 1996, 373 dos quais operados, com ênfase às técnicas cirúrgicas usadas e às 47 complicações decorrentes das cirurgias e suas correções. O CR foi mais comum no terço inferior (172; 45,3%), seguindo o terço superior (126; 33,1%) e o médio (82; 21,6%). A ressecabilidade dos tumores retais de terço superior foi de 88,9% (112 pacientes), e a retossigmoidectomia abdominal com anastomose manual foi a cirurgia mais praticada (76 pacientes; 60,3%). A ressecabilidade dos tumores retais de terço médio foi de 90.2% (72 pacientes), e a retossigmoidectomia abdominal com anastomose manual e mecânica foi a cirurgia mais praticada (40 pacientes; 48,7%). A ressecabilidade dos tumores retais de terço inferior foi de 89,5% (154 pacientes), e a amputação abdominoperineal com colostomia definitiva foi a cirurgia mais praticada (154 pacientes; 74,4%). A ressecabilidade tumoral foi elevada (338 pacientes; 88,9%). As cirurgias mais praticadas foram a AAP (135 ou 35,5%) e a retossigmoidectomia abdominal com anastomose colorretal manual e mecânica (130; 34,3%). A ocorrência de complicações cirúrgicas imediatas maiores foi de 12,6% (47 em 380 casos); e a mortalidade cirúrgica foi de 1,6% (6 casos). As 2 cirurgias mais praticadas apresentaram índices de complicações consideradas baixos: amputação abdominoperineal à Miles com colostomia definitiva - 135 cirurgias com 13 complicações (9,6%) e 2 óbitos (1,5%); e a retossigmoidectomia abdominal tipo Dixon com anastomose manual e mecânica - 130 cirurgias com 19 complicações (14,6%) e 2 óbitos (1,5%). O maior índice de complicações foi da retossigmoidectomia abdômino-endoanal com anastomose cólon-anal mecânica (30,7%); e o menor foi da amputação abdominoperineal (9,6%). O maior índice de mortalidade foi da retossigmoidectomia abdômino-endoanal com anastomose cólon-anal mecânica (7,7%); e o menor foi da amputação abdominoperineal (1,5%). Dentre as 47 complicações, as mais comuns foram as relacionadas à própria anastomose (15 deiscências e 6 estenoses), seguidas dos abscessos (3 abscessos subfrênicos, 4 abscessos pélvicos e 2 abscessos perineais), da necrose de coto abaixado (4 casos), necrose e desabamento de estoma (4 casos), obstrução de intestino delgado (3 casos), hemorragia (4 casos) e lesão cirúrgica do ureter (2 casos). As condutas em cada caso dependeram das condições do paciente, da doença, da evolução e gravidade da complicação e dos recursos técnicos de cada época em que os pacientes foram atendidos.In a 31-year period of practice in Coloproctology, from 1965 to 1996, the author had the opportunity to attend 24,200 patients, bearing 923 (3.8%) cancer of the large bowel. Eight hundred and seventy (870 - 3.6%) of the tumours were colorectal cancer (adenocarcinoma) and 53 (0.2%) were carcinoma of the anus of several hystological types. In 490 cases (56.3%) cancer were localized in the colon and 380 (43.7%) in the rectum. The main purpose of this study was to collect data concerning 380 patients bearing rectal cancer attended from 1965 to 1996, 373 of them undergoing surgery, with enphasis to surgical techniques specially 47 surgical complications. Cancer were far more common in the upper (126; 33.1%) and low (172; 45.3%) than in the middle rectum (82; 21.6%). Resecability of tumours of the upper rectum reached 88.9% (112 patients), being abdominal rectosigmoidectomy with handmade anastomosis the most used surgery (76 patients; 60.3%). Resecability of tumours of the middle rectum reached 90.2% (112 patients), being abdominal rectosigmoidectomy with handmade and stappled anastomosis the most used surgery (40 patients; 48.7%). Resecability of tumours of the low rectum reached 89.5% (112 patients), being abdominaperineal amputation (Miles) the most used surgery (154 patients; 74.4%). Resecability of tumour was very high reaching 88.9% (338 patients). The most used surgical technique was Miles procedure (135 patients; 35.5%) and abdominal rectosigmoidectomy with handmade and stappled anastomosis (130 patients; 34.3%). Immediate major surgical complication rate was 12.6% (47 cases in 380 patients); and mortality rate was 1.6% (6 cases). The two most used surgical techniques presented low complication rate: Miles procedure - 135 surgeries, 13 complications (9.6%) and 2 deaths (1.5%); and abdominal rectosigmoidectomy with hand made and stappled anastomosis - 130 surgeries, 19 complications (14.6%) and 2 deaths (1.5%). The highest immediate major surgical complication rate was caused by endoanal rectosigmoidectomy and stappled colon to anus anastomosis (30.7%); and the lowest was due to Miles procedure (9.6%). The highest mortality rate was caused by endoanal rectosigmoidectomy and stappled colon to anus anastomosis (7.7%); and the lowest was due to Miles procedure (1.5%). The most common among the 47 complications were due to the anastomosis (15 cases of leakage and 6 cases of stenosis), following: abscesses (3 cases of abdominal, 4 cases of pelvic and 2 cases of perineal abscesses), necrosis of the rectal stump (4 cases), necrosis of colostomy (4 cases), small bowell obstruction (3 cases), hemorrhage (4 cases) and surgical lesion of the left urether (2 cases). Surgical procudure in each case of complication depended on conditions of the patient, of the disease, of the evolution and severity of the complication and of the technical resources of each time when the patients were attended.

Rectal prolapse is a major challenge for the surgeon who has to resolve the anatomical problem and the functional disturbances in the same procedure. Abdominal procedures are the most appropriate in young patients, and the most common technique is rectopexia with or without resection. The use of mesh or sutures provides the same results and the choice depends on the surgeon's preference. Laparoscopic surgery has been demonstrated to have similar efficacy to conventional surgery and may become the option of the future. The perineal approach is the best option in elderly patients and in those with associated morbidity; the Delorme technique is simple to carry out, but rectosigmoidectomy provides better results.

Aim: To evaluate surgical indications for combined partial rectosigmoidectomy in ovarian cancer with direct invasion of the rectum and sigmoid colon or dissemination into the pouch of Douglas. Methods: Subjects comprised 25 patients with ovarian cancer who underwent primary surgery and rectosigmoidectomy between 1990 and 2002 at our hospital. Federation of Obstetrics and Gynecology staging of tumors was II (n = 6), III (n = 17) or IV (n = 2). The histologic type was serous adenocarcinoma (n = 18), clear cell adenocarcinoma (n = 4), and others (n = 3). Bowel resection was performed during primary surgery in 18 patients, and after neoadjuvant chemotherapy (NAC) in seven patients. Cumulative survival rate was compared between NAC and non-NAC groups. Patients were divided into three groups based on extent of surgical resection to compare survival rates: no residual tumor (n = 19); maximum residual tumor diameter

Selection of an appropriate approach to treat full thickness rectal prolapse remains problematic and controversial. We propose that rectal prolapse may be classified as 'low type' (true rectal prolapse) or 'high type' (intussusception of the sigmoid with a fixed lower rectum). This assessment can be made via a simple clinical test of digital rectal assessment of lower rectal fixity ('the hook test') based on anatomic changes in rectal prolapse to guide the selection process. In cases with the low-type prolapse, a perineal approach is appropriate (either Delorme's procedure, or rectosigmoidectomy with or without pelvic floor repair). For the high type, an abdominal rectopexy with or without high anterior resection is needed. Retrospective analysis of our cases treated over the last 6 years showed a recurrence rate of 6% in perineal procedures and 0% in abdominal rectopexy combined with resection to date. We believe that employing our simple test and classification can contribute to better patient selection for either approach, minimize anaesthetic and surgical risks and also result in lower recurrence rates.

Background: The purpose of this experimental study was to explore if, at this point in modern technology, the predominant techniques used for the treatment of Hirschprung disease (Swenson, Duhamel, and Soave-Boley) can be achieved laparoscopically, without laparotomy. Methods: Sixteen male pigs, weighing 15-25 kg each, were included in our trial experiment. We developed an experimental model and laparoscopically applied the rectosigmoidectomy (Swenson technique), the endorectal pull-through (Soave-Boley technique), and the retrorectal pull-through (Duhamel procedure) as well as the transanal mucosectomy of the rectum. We then recorded the techniques and the outstanding characteristics that evolved during their laparoscopic application. Results: The experimental animals had an uneventful postoperative course. The coloanal anastomosis was free of tension, airtight, and without stenosis regardless of the procedure used, in all the animals. Feeding was started following postoperative normal bowel movements. M...

Background The aim of this study was to compare loop ileostomy and loop transverse colostomy as the preferred mode of faecal diversion following low anterior resection with total mesorectal excision for rectal cancer. Methods Patients who required proximal diversion after low anterior resection with total mesorectal excision were randomized to have either a loop ileostomy or a loop transverse colostomy. Postoperative morbidity, stoma-related problems and morbidity following closure were compared. Results From April 1999 to November 2000, 42 patients had a loop ileostomy and 38 had a loop transverse colostomy constructed following low anterior resection. Postoperative intestinal obstruction and prolonged ileus occurred more commonly in patients with an ileostomy (P = 0·037). There was no difference in time to resumption of diet, length of hospital stay following stoma closure and incidence of stoma-related complications after discharge from hospital. A total of seven patients had intestinal obstruction from the time of stoma creation to stoma closure (six following ileostomy and one following colostomy; P = 0·01). Conclusion Intestinal obstruction and ileus are more common after loop ileostomy than loop colostomy. Loop transverse colostomy should be recommended as the preferred method of proximal faecal diversion.

Introduction: To report the clinical course of a Chagas’s disease patient with severe intestinal failure after resection of the total colon and terminal ileum.Case Report: The patient underwent rectosigmoidectomy (of the sigmoid volvulus, December 2009) and total colectomy plus partial ileectomy (May 2011). Patient evolved with multiple hospitalizations caused by severe diarrhea (up to 23 stools/day), hydroelectrolyte disturbance and acute renal failure, severe protein-energy malnutrition [loss of 34.9% of usual body weight (uBW)], and multiple episodes of sepsis. Were prescribed parenteral nutrition solutions exclusively or concurrently with very small volumes (e.g., 40ml/day) of semi-elemental diet with low fat and high protein. After several weeks predetermined amounts of carbohydrate-rich foods (potatoes, rice, pasta, cassava), vegetables (chayote, carrots), low-fat meat, cream crackers, coconut water and fruit (watermelon, melon, banana) were progressively introduced. After 36 months, the patient was metabolically stable (BW=67.2 kg, weight recovery of 23.6 kg), with hydroelectrolytic balance. Due to the recovery of the functional capacity, the patient was advised to return to his work activities. Conclusions: Chagas’s disease patient submitted to intestinal resection may have severe intestinal failure and protein-energy malnutrition. Specialized nutritional therapy and clinical and laboratory monitoring by a multidisciplinary team, can contribute to better prognostic.

Transperineal rectosigmoidectomy is a relatively safe operation for the treatment of rectal prolapse; however, it carries a high rate of recurrence. The use of biologic mesh to buttress the repair and support the pelvic floor muscles may decrease the rate of recurrence. The technique for performing an Altemeier procedure with biologic mesh is described.

Laparoscopic colorectal surgery is believed to be technically and oncologically feasible. Robotic surgery is an attractive mode in performing minimally-invasive surgery once it has several advantages if compared to standard laparoscopic surgery. The aim of this paper is to report the first known case of colorectal resection surgery using the robotic assisted surgical device in Brazil. A 35-year-old woman with deep infiltrating endometriosis with rectal involvement was referred for colorectal resection using da Vinci® surgical system. The authors also reviewed the most current series and discussed not only the safety and feasibility but also the real benefits of robotic colorectal surgery

The results of five consecutive perineal rectosigmoidectomies were reviewed to evaluate the role of this approach for complete rectal prolapse. There were two male and three female patients, with a median age of 75 years (range 45–82 years). On average, 23.6 cm (range 15–35 cm) of sigmoid colon and rectum was resected. There was no operation-related mortality. One patient developed postoperative chest infection and another acute retention of urine. No recurrence of the prolapse was detected during a median follow-up period of 25 months (range 6–42 months). Perineal rectosigmoidectomy is an effective and the least invasive procedure for complete rectal prolapse. It is the preferred approach for patients who have had multiple previous abdominal operations and for the frail elderly patient in whom, particularly, constipation is a major associated feature.

This retrospective study reports the results of our 5-year experience in the diagnosis and treatment of rectal prolapse with fecal incontinence by the abdominal (laparotomy or laparoscopy) and perineal approaches. Twenty-five patients (group A; 22 women and 3 men; mean age 57.3 years; range 22-76 years) were operated on by the abdominal approach and ten (group B; 8 women and 2 men; mean age 68.9 years; range 58-84 years) by the perineal approach. All patients were evaluated by clinical examination, proctosigmoidoscopy, pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography preparatory to surgery. In patients of group A, we performed an abdominal rectopexy in 19 cases (7 by laparoscopy) and in the remaining 6 cases, a sigmoid resection-rectopexy (3 of which were by laparoscopy). All patients of group B were treated by a perineal operation using Delorme's mucosectomy in 4 cases and Altemeier's rectosigmoidectomy with total perineoplasty in 6 cases. The mean follow-up was 38.8 months in group A and 25.7 months in group B. The postoperative complication rate was 8% (two cases) in group A, whereas no significant complications occurred in group B. Dyschezia and fecal incontinence improved significantly in both groups (P < 0.05 in group A and P < 0.005 in group B), whereas anoperineal pain was not significantly reduced. At 1-year follow-up, the recurrences rates were 8% in group A and 30% in group B. Rectopexy or resection-rectopexy proved to be a safe and effective procedure for external prolapse, without a discernible difference between the laparotomic and laparoscopic techniques. In selected cases, the perineal approach gives good results regarding fecal incontinence without complications, even if in these patients, the likelihood of recurrence is high.

A case of acute necrotic intestinal ischemia with a rectal cancer is described. A 63-year-old woman was admitted to the hospital because of constipation and abdominal pain with an episode of bloody stool. A rectal cancer was detected by clinical examination, but no other significant changes were seen in the colonic mucosa. After administration of a preoperative laxative, severe abdominal pain occurred. On laparotomy, extensive necrotic bowel ischemia revealed in the colon. Rectosigmoidectomy, total colectomy and ileostomy were performed. But, after massive colectomy this patient died of ischemic necrosis of the lower part of the ileum. Pulsation of the main mesenteric artery and of colonic arterial arcade were preserved at the time of surgical operation. Histological examination showed that multiple fresh fibrin thrombus were observed in mucosal or submucosal small vessels. We think that complicated combination of the vascular and intestinal factors might contribute to the pathogenesis in this case.

This article reports on the surgical procedure in anterior rectosigmoidectomy by laparoscopic approach. We have experience with 10 children. In all of these cases, resection was done according to the pull-through procedure of Swenson with preanal anastomosis of the bowel. In contrast to the Swenson procedure, the sigmoid colon was pulled through by invagination of the colon so that the bowel does not have to be severed intraperitoneally. This leads to a reduction of the operating time and prevents contamination of the abdominal cavity with bowel contents. Several techniques are applied for skeletization of the colon and sigmoid colon (diathermy, endoclips, laser, ligature). The pelvic floor is opened and the rectum is exposed up to 2 cm above the anal sphincter. Invagination of the proximal bowel is then carried out through the rectum and the anus. The exposed bowel is severed directly preanally and anastomosed in a single layer with interrupted sutures. We have performed this procedure 10 times....

Many surgical methods have been described for the treatment of full-thickness rectal prolapse. Rarely, unusually large lengths of colon must be excised, thus resulting in a significant loss of the absorptive function of the remaining colon. We present an unusual case in which an extraordinary length of the colon was excised and a perineal reservoir was created in the form of a colonic J-pouch to improve continence.

Robotic-assisted surgery for the treatment of deep infiltrating bowel endometriosis appears to be feasible, effective, and safe., Background and Objective: Deep infiltrating pelvic endometriosis with bowel involvement is one of the most aggressive forms of endometriosis. Nowadays, robotic technology and telemanipulation systems represent the latest developments in minimally invasive surgery. The aim of this study is to present our preliminary results and evaluate the feasibility of robotic-assisted laparoscopic colorectal resection for severe endometriosis. Methods: Between September 2009 and December 2011, 10 women with colorectal endometriosis underwent surgery with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA). We evaluated the following parameters: short-term complications, clinical outcomes and long-term follow-up, pain relief recurrence rate, and fertility outcomes. Results: Extensive ureterolysis was required in 8 women (80%). Ovarian cystectomy with removal of the cystic wall was performed in 7 women (70%). Torus resection was performed in all women, with unilateral and bilateral uterosacral ligament resection in 1 woman (10%) and 8 women (80%), respectively. In addition to segmental colorectal resection in all cases, partial vaginal resection was necessary in 2 women (20%). An appendectomy was performed in 2 patients (20%). The mean operative time with the robot was 157 minutes (range, 90–190 minutes). The mean hospital stay was 3 days. Six patients had infertility before surgery, with a mean infertility time of 2 years. After a 12-month follow-up period, 4 women (67%) conceived naturally and 2 (33%) underwent in vitro fertilization. Conclusion: We show that robotic-assisted laparoscopic surgery for the treatment of deep infiltrating bowel endometriosis is feasible, effective, and safe.

The optimal operation for rectal prolapse is unclear. Various options exist. Broadly, one can carry out the operation via a perineal or abdominal approach. If perineal, should it be a Delormes or rectosigmoidectomy combined with a levatorplasty or not? If abdominal, should it be open or laparoscopic and should the rectum be simply mobilised or fixed? If fixed, what with and where from and to? Should the lateral ligaments be divided or preserved and should the redundant sigmoid be resected? With such a huge variation in techniques, what is the evidence that will tell us what the best approach for prolapse surgery is? Unfortunately, the literature is full of poor quality data mainly from case series and expert opinion. So the first step must be to concentrate on only the quality comparative data in the form of randomised controlled trials. Can this data tell us anything? The next step is to decide what outcome to assess. The obvious outcome is recurrence. When considering the two broad approaches, there is a perception that an abdominal procedure will result in a lower incidence of recurrence. Indeed, the recurrence rate for any perineal procedure may be greater than 40 % if the patient is followed up for long enough [1]. Is there good quality comparative data to back up this perception that the abdominal procedure is more robust? Two randomised trials have taken on this comparison [1, 2]. Both have inadequate numbers of patients to reach any meaningful conclusion, but for the numbers that have been examined no difference in recurrence was seen for either approach. The most recent trial failed to recruit adequate numbers despite the trial being multicentre, indeed multinational, and running for many years. Herein lies the problem with such trials. Surgeons are inclined to individualise when it comes to approach, with the perineal procedure, perhaps done under regional anaesthetic, reserved for elderly frail patients, and the abdominal approach indicated for younger patients who can tolerate a more invasive procedure and have potentially many more years of life. Equipoise does not therefore exist, and any trial becomes very difficult to recruit to. But perhaps it is time for a readjustment of this surgical dogma; the advent of laparoscopic techniques means that elderly patients can undergo abdominal procedures without an increase in complications [3]. If we assume the decision has been made to carry out an abdominal approach, is there any evidence to suggest how to carry out the operation? In terms of recurrence there probably is not. However, one large reasonably welldesigned trial has shown that the rectum cannot simply bemobilised; it has to be fixed to reduce recurrence [4]. However, recurrence is not the only important outcome. For instance, in terms of recovery, it is clear that a laparoscopic approach results in shorter postoperative stay and actually reduces overall costs [5]. Constipation is another important outcome, and the common perception is that abdominal rectopexy alone will increase the incidence of constipation in many patients, justifying the need for resection to be combined with the rectopexy [6]. Is this true? Is the added possibility of anastomotic breakdown, even if rare, really worth the risk? The study by El Muhtaseb et al. [7] would suggest it is not, with resection rectopexy failing to correct abnormal transit Comment on El Muhtaseb et al.: Colonic transit before and after resection rectopexy for full-thickness rectal prolapse (doi:10.1007/s10151-013-1053-4).

We report a pure natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and the Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) rectosigmoidectomy in animal models using transgastric endoscopic inferior mesenteric artery (IMA) dissection and transanal rectal mobilization.Ten live animals (2 pigs weighing 35-40 kg each and 8 dogs weighing 25-30 kg each) were used. A gastrotomy was made using a needle-knife puncture and the balloon dilatation technique or following the creation of a submucosal tunnel. A circular stapler shaft was transanally inserted up to the sigmoid colon for spatial orientation and traction of the mesocolon. The IMA was endoscopically dissected using a Coagrasper™ (Olympus, Tokyo, Japan) and then clipped. Endoscopic division of the sigmoid mesocolon was conducted laterally toward the marginal artery. Transanal full-thickness circumferential rectal and mesorectal dissections were performed, and a colorectal anastomosis was performed using a circular stapler with a single stapling technique. During the transanal approach, the gastrotomy was closed using four endoscopic clips.Endoscopic dissection of the IMA was successful in all cases, but minor bleedings occurred in 3 cases. The mean time from dissection and clipping to division of the IMA was 36.7 minutes (range, 25-45 minutes). The mean operation time was 180.5 minutes (range, 145-210 minutes). There were no intraoperative complications or hemodynamic instability. The mean length of the resected specimen was 11.2 cm (range, 9-17 cm).A pure NOTES approach to rectosigmoid resection using transgastric endoscopic IMA dissection is technically feasible in animal models.

s / Clinical Nutrition ESPEN 13 (2016) e55ee74 e58 ileostomy patients lose large amounts of sodium and fluid through their stoma effluent. Fluid and electrolyte abnormalities appear to be a common problem in this group of patients. Aim: The aim of the study was to assess the efficacy of an oral rehydration solution (isotonic drink) on electrolyte profile of patients with a temporary ileostomy. Materials and methods: Patients meeting inclusion criteria were both male and female patients who had undergone a rectosigmoidectomy procedure resulting or not in an ileostomy formation. A total of 48 rectosigmoidectomy patients were recruited for this prospective randomized controlled study, 31 of which had an ileostomy being constructed. The arms of the study were divided as follows: 1st arm included group A (ileostomy patients who received an intervention solution) and group B (ileostomy patients who did not receive a rehydration solution). The 2nd arm of the study comprised of patients who had undergone colorectal resection surgery without an ileostomy creation andwere used as a control group. Serum electrolyte levels as well as renal function markers were assessed preoperatively and at 20 and 40 days postoperatively. Results: According to the statistical analysis mean blood sodium, urea and creatinine levels were significantly different between groups A and B (p1⁄4 .046, p1⁄4 .021 and p1⁄4 .018 respectively). Moreover statistically significant differences were also noted between group B (no intervention solution) and the control group (p< .05). Conclusion: Administration of an isotonic oral rehydration solution seems to improve biochemical markers indicative of dehydration and renal impairment in this category of patients. The study will continue to recruit participants in order improve sample size and reach more valid and concise conclusions. «EAT HEALTHY LIVE LIKE SCOUT», A NUTRITION BEHAVIOUR CHANGE PROGRAM IN SCOUTS, AGED 12-15 YEARS Stella Chortiatinou, Grigoris Risvas, Antonis Zampelas. Department of Food Science and Human Nutrition, Agricultural University of Athens, Athens

Anastomotic leakage is a dreaded complication of gastrointestinal surgery. The complication is difficult to manage and is associated with prolonged hospitalizations and increased morbidity and mortality. We present the nonsurgical management and the use of a fibrin sealant for an anastomotic leak that followed rectosigmoid resection and anastomosis for Stage IV endometriosis. This approach requires a clinically stable patient who is willing to follow-up over a prolonged period of time until the leak is completely sealed. Tissue sealants can be considered when an air leak or fistulous tract persists despite drainage and antibiotics.

Purpose The authors describe a modified technique of primary transanal rectosigmoidectomy for Hirschsprung's disease (HD), using a Swenson like procedure to perform the anastomosis between the colon and the rectum, and the preliminary results from this in children. Methods Twenty children, of whom, 90% were boys and 10% girls, 50% white and 50% nonwhite, aged 15 days to 10 years and with HD proven via biopsy, underwent a transanal pull-through procedure over a 29-month period. Postoperative follow-up ranged from 29 to 5 months. The proximal cut edge of the mucosal and submucosal cuff was tagged with multiple polypropylene 4-0 sutures, which were used for traction of the intestinal layers outside. The rectal mucosa was incised circumferentially using cautery, to perform rectal dissection approximately 1.5 cm from the dentate line, except in newborn case, in which the proximal cut edge was 0.5 cm from the dentate line. The dissection extended in an upward direction around the entire rectal circumference as far as the opening of the peritoneal reflection. The full thickness of rectum and sigmoid were mobilized outside through the anus, with division and coagulation of the rectal and sigmoid vessels using cautery or ligatures with cotton 4-0. The dissected colon then was divided above the transition zone, which was confirmed via full-thickness biopsy sections and with frozen section confirmation of ganglion cell presence. The authors performed a modified Swenson anastomosis technique, using a seromuscular polyglactin 4-0 separate-stitch suture. No drains were used. Results Normal bowel movements were displayed by all patients at the follow-up. All patients underwent a defecogram and anorectal computerized manometry at 3 months after surgery that showed an absence of stenosis and good anorectal sphincter muscle complex function. The incidence of complications in our series was 10%. Conclusions During the follow-up period of 29 months, all patients had normal bowel movements and normal anorectal manometric pressure profiles.

Background. Natural orifice transluminal endoscopic surgery (NOTES) and single access surgery are emerging techniques that reduce surgical invasiveness. This study was performed to evaluate the feasibility of NOTES transanal rectosigmoidectomy using a single port in a swine model. Methods. Ten male pigs were used to conduct 2 studies, 4 for a nonsurvival study and 6 for a survival study. After anesthesia, the rectum was occluded transanally with a purse-string suture, and then a single port was placed. CO2 gas was insufflated, and full-thickness rectal dissection was extended using laparoscopic instruments as far cephalad as possible. A 5-mm trocar was placed on the abdominal wall for transabdominal laparoscopic view, and then further colonic mobilization was performed using the endoscope through the anus. When the dissection was completed, the specimen was exteriorized and colorectal anastomosis was performed using a circular stapler. In the survival study, necropsies were performed on postoperative day 7. Results. Full-thickness circumferential rectosigmoid mobilization was achieved in all cases. The mean length of resected colon was 10 cm (range = 8-15 cm). No anastomotic defects were noted. All resected rectosigmoid specimens were grossly intact. No mortality or significant postoperative complications was observed in the survival group. On necropsy, a small abscess in the pelvic cavity was noted in 1 case and bladder distention was noted in 3 cases. Conclusions. NOTES transanal rectosigmoidectomy using the single port is feasible and safe. Further experimental studies are warranted, especially in human cadaver model.

Complete rectal prolapse was relatively uncommon disease, but a number of different methods of surgical treatment for prolapse of the rectum had been devised. There were transperineal, transabdominal and their combined method. The same surgical treatments of complete rectal prolapse were reported recurrence of the disease. Here we report a case of complete rectal prolapse in a 77-year-old woman whose rectal wall was fixed with bilateral internal iliac artery branches, with good postoperative condition for one year and six months. New surgical method that we have devised was as follows: 1) Rectosigmoid and rectum are mobilized anterioly and posterioly 2) Suture of rectal wall with bilateral internal iliac artery branches 3) Incised peritoneum is sutured to the rectal wall 4) Rectosigmoidectomy, mattress placed to approximate walls of anal cuff and sigmoid. This new devised procedure will promise to prevent recurrence as well as to keep healthy bowel movement after the operation, if it is indicated for selected candidates who are able to undergo laparotomy.

We report a case of a 75-year-old man submitted to a rectosigmoidectomy and partial cystectomy because of a sigmoid cancer and colovesical fistula. Seven months later and after four cycles of adjuvant chemotherapy, a lesion was detected in the kidney. Histology revealed tubular adenocarcinoma, which meant sigmoid cancer metastasis. Kidney metastases are very rare in colorectal cancer (CRC), but may be generally associated with an unfavorable prognosis. Thus, patients with metastatic CRC and kidney tumors are a diagnostic and therapeutic challenge.

A transrectal (TR) approach for natural orifice translumenal endoscopic surgery (NOTES) makes sense for colorectal surgery because the colotomy can be incorporated into subsequent anastomosis. Because cancer is a primary indication for left-sided colon resection, oncologic standards will have to be met by a NOTES procedure. This study aimed to assess whether pure TR rectosigmoidectomy can be performed with strict adherence to oncologic principles compared with a conventional laparoscopically assisted approach (LAP).Human male cadavers were allocated to either TR (n = 4) or LAP (n = 2). A simulated sigmoid lesion was created at 25 cm. Transrectal retrograde mobilization of the rectosigmoid was performed using conventional transanal endoscopic microsurgery (TEM) instrumentation. After ligation of the superior hemorrhoidal artery and further mobilization, the specimen was delivered transanally and divided extracorporeally. Using a circular stapler, NOTES colorectal anastomosis was performed. Lymph node yield, adequate resection margins, and operative time were compared with LAP.Transrectal retrograde rectosigmoid dissection was achieved in all attempts (4/4) and showed numbers of lymph nodes (median, 5; range, 3-6) similar to the LAP group (median, 4.5; range, 2-7). One pure TR approach failed to resect the lesion. Three TR procedures required additional mobilization via an abdominal approach to provide adequate margins. The mean length of TR specimens was 16 ± 4 cm compared with 31 ± 9 cm achieved by LAP (p0.01). The TR operative time was significantly longer (247 ± 15 vs 110 ± 14 min).Lymph node yield during TR rectosigmoidectomy was similar to that achieved by the LAP approach. However, conventional TEM instrumentation alone did not permit adequate colon mobilization. This indicates a need for flexible instrumentation or other technical solutions to perform true NOTES colectomies.

Background Rectosigmoidectomy (RR) with primary anastomosis or pelvic peritonectomy (PP) are often part of an optimal en bloc tumor resection in advanced ovarian cancer (AOC) patients with contiguous extension to or encasement of the reproductive organs, peritoneum of the cul-de-sac and sigmoid colon. We report our experience with two different surgical approaches in optimally cytoreduced AOC patients evaluating oncologic outcome and surgically associated morbidities Methods Data from all consecutive AOC patients undergoing PP or RR as part of the surgical procedure during primary cytoreduction from 2004 through 2009 were extrapolated and analyzed using the chi-squared test, Cox proportional hazard model and Kaplan-Meier method including log-rank test. Results During the study period, we identified 187 AOC patients, fitting the inclusion criteria: 71 (38%) were submitted to RR and 116 (62%) were managed with PP. The estimated mean disease-free survival (DFS) was 30.7 months (95% CI 24.6–36.8) in the RR arm vs. 25.9 months in the PP arm (95% CI 21.9–29.9) (p 0.299); similarly, the estimated mean overall survival (OS) was 38.8 months (95% CI 33.4–44.2) in the RR arm and 48.2 months in the PP arm (95% CI 43.1–53.3) (p = 0.122). No statistically significant differences were found in terms of DFS and OS according to the mesocolic lymphnode status (p = 0.65 and p = 0.81, respectively). Conclusions In conclusion, the current study clearly supports evidence that survival rates are similar for patients who achieved optimal residual tumor (RT), independent to whether they had RR or PP.