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OBJECTIVES: The purpose of our study was to report the results of the implementation of computed tomography colonography in a university hospital setting serving a Brazilian population at high risk of colorectal cancer. METHODS: After creating a computed tomography colonography service in our institution, 85 patients at high risk of colorectal cancer underwent computed tomography colonography followed by a same-day optical colonoscopy from September 2010 to May 2012. The overall accuracy of computed tomography colonography in the detection of lesions ≥6 mm was compared to that of optical colonoscopy (direct comparison). All colonic segments were evaluated using quality imaging (amount of liquid and solid residual feces and luminal distension). To assess patient acceptance and preference, a questionnaire was completed before and after the computed tomography colonography and optical colonoscopy. Fisher's exact test was used to measure the correlations between colonic distension, discomfort during the exam, exam preference and interpretation confidence. RESULTS: Thirteen carcinomas and twenty-two lesions ≥6 mm were characterized. The sensitivity, specificity and accuracy of computed tomography colonography were 100%, 98.2% and 98.6%, respectively. Computed tomography colonography was the preferred method of investigation for 85% of patients. The preparation was reported to cause only mild discomfort for 97.6% of patients. According to the questionnaires, there was no significant relationship between colonic distension and discomfort (p>0.05). Most patients (89%) achieved excellent bowel preparation. There was a statistically significant correlation between the confidence perceived in reading the computed tomography colonography and the quality of the preparation in each colonic segment (p≤0.001). The average effective radiation dose per exam was 7.8 mSv. CONCLUSION: It was possible to institute an efficient computed tomography colonography service at a university hospital that primarily assists patients from the public health system, with high accuracy, good acceptance and effective radiation doses. Our results seem to be comparable to other centers of excellence and fall within acceptable published guidelines, showing that a successful computed tomography colonography program can be reproduced in a South American population screened in a university hospital.

BACKGROUND: Colorectal cancer is one of the most common types of neoplasia among the worldwide adult population. Among neoplasms of the gastrointestinal tract, it is ranked second in relation to prevalence and mortality, but its etiology is only known in around 5% of the cases. It is believed that 15% of malignant diseases are related to viral oncogenesis. AIM: To correlate the presence of HPV with the staging and degree of cell differentiation among patients with colorectal adenocarcinoma. METHODS: A retrospective case-control study was conducted on 144 patients divided between a test group of 79 cases of colorectal cancer and a control group to analyze 144 patients aged 25 to 85 years (mean, 57.85 years; standard deviation, 15.27 years and median, 58 years). Eighty-six patients (59.7%) were male. For both groups, tissue samples from paraffin blocks were subjected to DNA extraction followed by the polymerase chain reaction using generic and specific primers for HPV 16 and 18. Dot blot hybridization was also performed with the aim of identifying HPV DNA. RESULTS: The groups were shown to be homogenous regarding sex, age and site of HPV findings in the samples analyzed. Out of the 41 patients with HPV, 36 (45.6%) were in the cases and five (7.7%) were in the control group (p

PURPOSE: To evaluate the effects of sustained deep inspiration in the prevention of postoperative pulmonary complications, the hormonal and immunological responses in patients submitted to abdominal surgery. METHODS: This randomized clinical trial study included 75 patients submitted to abdominal surgery, of which 36 were randomly allocated in the experimental group and underwent sustained deep inspiration during five seconds, in three sets of ten repetitions per day. The others 39 patients were allocated in the control group and were not submitted to any breathing exercise. The following parameters were measured preoperatively, 24h and 48h postoperatively: chest x-ray, serum ACTH, cortisol, IL-4, IL-10, TNF-α, forced expiratory volume in first second (FEV1), forced expiratory flow 25-75% (FEF 25-75), forced vital capacity (FVC), paO2 and paCO2. RESULTS: Mean serum cortisol in patients of the experimental and control groups before surgery were 12.8 mcg/dl (4.6-50) and 10.48 mcg/dl (1-29.1), respectively (p=0.414). The experimental group had significantly increase in serum cortisol levels, 23.6 mcg/dl (9.3-45.8), especially 24h postoperatively (p=0.049). CONCLUSION: Sustained deep inspiration in patients submitted to abdominal surgery determined important changes in serum cortisol, however, without significantly influence the postoperative pulmonary complications and the endocrine and immune responses

PURPOSE: To compare the results of rubber band ligation and infrared photocoagulation for the treatment of hemorrhoidal disease through the analysis of the incidence of complications after each treatment and respective success rate. METHODS: Forty-eight patients with first, second or third degree hemorrhoidal disease were randomized to recieve treatment with either rubber band ligation (n=23) or infrared photocoagulation (n=25). Each patient was assessed at 1 week and 4 week intervals after treatment. We compared the incidence of complications and efficiency of each treatment modality and Qui-square, Fisher's Exact Test and Student's t Test were used to statistical analysis. RESULTS: Bleeding occured in eigth (34,7%) patients treated with rubber band ligation and in four (16,0%) after infrared photocoagulation (p=0,243). Thirteen (52,0%) patients felt pain during infrared photocoagulation and 9 (39,1%) after rubber band ligation (p=0,546). After rubber band ligation, 14 (60,8%) required medication for pain relief. One patient (4,0%) required medication after infrared photocoagulation (pOBJETIVO: Comparar os resultados da ligadura elástica com os da fotocoagulação com radiação infravermelha no tratamento da doença hemorroidária através da análise de suas respectivas morbidades e eficácia. MÉTODOS: Foi realizado ensaio clínico casualisado com 48 pacientes portadores de doença hemorroidária graus I, II e III. Após randomização, os pacientes foram submetidos à ligadura elástica (n=23) ou fotocoagulação com radiação infravermelha (n=25). Os pacientes compareceram para consulta ambulatorial 1 semana e 4 semanas após o procedimento. A avaliação foi feita através da análise da incidência de morbidades após cada procedimento e eficácia, com quatro semanas de acompanhamento. As análises estatísticas foram realizadas através do teste do Qui-quadrado, Teste Exato de Fisher e Teste t de Student. RESULTADOS: Dos pacientes submetidos à ligadura elástica, 34,7% (8/23) apresentou sangramento após o procedimento. Após fotocoagulação, 16,0% (4/25) tiveram sangramento (p=0,243). A incidência de pacientes com dor no momento da aplicação do procedimento foi de 52,0% (13/25) após fotocoagulação com radiação infravermelha e 39,1% (9/23) após ligadura elástica (p=0,546). No entanto, ligadura elástica foi mais dolorosa após 48 horas do procedimento (p=0,044). Após ligadura elástica, 60,8% (14/23) dos pacientes necessitaram de analgésicos contra 4,0% (1/25) após fotocoagulação com radiação infravermelha (p

CONTEXT: The relevance of colorectal adenocarcinoma lies in its high incidence, with the liver being the organ most frequently affected by distant metastases. Liver metastases occur in 40 to 50% of patients with colorectal adenocarcinoma, accounting for approximately 80% of deaths in the first three postoperative years. Nevertheless, despite this, they are occasionally susceptible to curative treatment. OBJECTIVE: The present investigation focused on the relationship between the level of carcinoembryonic antigen (CEA) in gallbladder bile and the presence of liver metastases secondary to colorectal adenocarcinoma. DESIGN: Diagnostic test study. SETTING: Surgical Gastroenterology Discipline at the São Paulo Hospital, São Paulo, Brazil. SAMPLE: Forty-five patients with colorectal adenocarcinoma were studied, 30 without liver metastases (group I), and 15 with liver metastases (group II). Diagnosis of liver metastases was made through computed tomography, magnetic resonance imaging and computed tomography during arterial portography. Samples of peripheral blood, portal system blood, and gallbladder bile were collected from patients during the surgical procedure. A control group composed of 18 organ donors underwent the same material collection procedures. CEA level determination was made through fluoroimmunoassay. RESULTS: Mean CEA value in peripheral serum was 2.0 ng/ml (range: 0.7 to 3.8 ng/ml) in the control group, 11.4 ng/ml (range: 0.5 to 110.3 ng/ml) in group I, and 66.0 ng/ml (range: 2.1 to 670 ng/ml) in group II. In the portal system, serum mean values found were 1.9 ng/ml (range: 0.4 to 5.0 ng/ml) in the control group, 15.3 ng/ml (range: 0.8 to 133.3 ng/ml) in group I, and 70.8 ng/ml (range: 1.8 to 725 ng/ml) in group II. Mean values found in gallbladder bile were 4.1 ng/ml (range: 1.0 to 8.6 ng/ml) in the control group, 14.3 ng/ml (range: zero to 93.0 ng/ml) in group I, and 154.8 ng/ml (range: 14.0 to 534.7 ng/ml) in group II. CONCLUSIONS: The CEA level in gallbladder bile is elevated in patients with liver metastases. Determination of CEA both in peripheral serum and in gallbladder bile enabled patients with liver metastases to be distinguished from those without such lesions. The level of CEA in gallbladder bile, however, seems to lead to a more accurate diagnosis of liver metastases secondary to colorectal adenocarcinoma.

Racional - O câncer de canal anal é um tipo raro de neoplasia, sendo responsável por 4% dos tumores de intestino grosso. São descritos os aspectos clínicos e o tratamento dos pacientes com câncer escamoso desta região. Casuística - Analisaram-se, retrospectivamente, 11 pacientes com carcinoma espinocelular de canal anal. Nove pacientes eram do sexo feminino e dois do masculino. A idade média dos pacientes foi de 57,6 anos (variação 35-82 anos). Resultados - Os sintomas mais freqüentes foram sangramento retal, tumoração e dor local. Seis pacientes tinham lesão benigna prévia local e dois tinham doença metastática na ocasião do diagnóstico. Todos foram submetidos a quimioterapia sistêmica com 5-fluorouracil e mitomicina. Após o tratamento quimio e radioterápico, quatro apresentavam doença residual e foram submetidos a ressecção abdômino-perineal. Três pacientes apresentaram recidiva e quatro morreram pela evolução da própria doença. Conclusão - A maioria dos doentes era do sexo feminino. A químio e a radioterapia podem ser tratamentos curativos nos pacientes com doença localizada; no entanto, aqueles com doença residual devem ser submetidos a ressecção abdômino-perineal. Embora o câncer espinocelular de canal anal seja doença curável, quatro pacientes foram a óbito por terem sido diagnosticados em fase avançada.

Corticosteróides são de largo uso na prática médica. Porém, apresentam efeitos colaterais, que condicionam um fator de risco para procedimentos cirúrgicos gastrointestinais. O presente estudo visou avaliar as alterações da mucosa e submucosa em cólon de cães submetidos a administração prolongada de corticosteróides. Quinze cães machos, sem raça definida, 15 kg, randomizados, 6 de grupo controle e 9 de grupo experimental, foram submetidos à aplicação intramuscular de hidrocortisona, 35 mg/Kg/dia, 30 dias. Foi realizada ressecção do segmento distal do cólon, fixado em Bouin, com cortes corados pelos métodos: PAS, alcian blue e HE. Na análise morfométrica, foi realizada contagem de: células caliciformes (CAL), células absortivas (ABS), células totais (TOT = CAL+ABS), mitoses (MIT) e linfócitos (LINF) presentes em cada cripta; mastócitos (MAST) na submucosa. A avaliação histopatológica revelou infiltrado linfoplasmocitário, desorganização das criptas, presença de células picnóticas, ulcerações na mucosa; edema, congestão vascular e linfática na submucosa. Houve diminuição significante do número de CAL, ABS, TOT e LINF, aumento de MIT no grupo experimental e não alteração do número de MAST. Conclui-se que a administração prolongada de corticosteróides em cães induziu alterações histopatológicas e morfométricas significantes na mucosa cólica, que podem se constituir em importante fator de risco cirúrgico.Corticosteroids are largely used in the medical practice. However, they present side effects, that condition a risk factor for gastro-intestinal surgical procedures. The present study seeks to evaluate the histologycal changes of the mucosa and submucosa in colon of dogs submitted to the extended administration of corticosteroids. Fifteen male dogs with no defined pedigree, weighing 15 kg, randomized, being 6 dogs of the control group and 9 dogs of the experimental group, were submitted to the intramuscular application of hydrocortisone, 35 mg/kg/day for 30 days. The colonic distal segment was resected, fixed in Bouin and the courts were stained by the methods: PAS, alcian blue and HE. In the morphometric analysis, was accomplished the counting of: globet cells (GLO), absorptive cells (ABS), total cells (TOT= GLO+ABS), mitosis (MIT) and lymphocytes (LYMP) in each crypt; mast cells (MAST) in the submucosa. The histopathologycal evaluation revealed lymphocytic and plasma cells infiltrated, disorganization of the crypts, presence of pictotic cells, ulcerations in the mucosa; edema, vascular and lymphatic congestion in the submucosa. Analysis revealed: significant decrease of the number of GLO, ABS, TOT and LYMP, increase of MIT in the experimental group and non alteration of the number of MAST. It was concluded that the extended administration of corticosteroids in dogs induced significant histopathologycal and morphometric alterations in the colonic mucosa, that can be constituted important factors of surgical risk.

OBJETIVO: Comparar duas vias cirúrgicas (laparoscópica e convencional) para o tratamento de câncer de reto no que se refere às complicações pós-operatórias, radicalidade oncológica e sobrevida. MÉTODOS: Trata-se de estudo retrospectivo com 84 pacientes com câncer retal que foram admitidos no Hospital do Câncer de Barretos entre 2000 e 2003. Somente os indivíduos que se submeteram à operações eletivas (intenção curativa) foram incluídos. A via cirúrgica foi escolhida subjetivamente e não com base na localização do tumor. RESULTADOS: O acesso laparoscópico foi utilizado por 50% dos pacientes. Não houve diferença (P> 0,05) entre os dois grupos em relação à: idade, sexo, topografia, estádio, tratamento neoadjuvante e adjuvante, número de linfonodos regionais dissecados, tamanho da peça cirúrgica, margens cirúrgicas, transfusões de sangue, taxas de complicações pós-operatórias, dias de hospitalização e a taxa de sobrevida global. O tempo cirúrgico foi maior no grupo laparoscópico (mediana: 210x127,5min, P

OBJECTIVE: To evaluate the protective effect of celecoxib in the esophageal mucosa in rats undergoing esofagojejunostomy. METHODS: Sixty male Wistar rats from the vivarium of the University of Health Sciences of Alagoas were used for the experiment. The animals were divided into four groups: Group I, 15 rats undergoing esofagojejunostomy with the use of celecoxib postoperatively; Group II, 15 rats undergoing esofagojejunostomy without the use of celecoxib; Group III, 15 rats undergoing celiotomy with bowel manipulation; and Group IV, 15 rats without surgery and using celecoxib. The observation period was 90 days. After the death of the animals, the distal segment of the esophagus was resected and sent for microscopic analysis. RESULTS: esofagojejunostomy caused macroscopic and microscopic esophagitis. Esophagitis was equal in both groups I and II. In groups III and IV esophageal lesions were not developed. CONCLUSIONS: celecoxib had neither protective nor inducing effect on esophagitis, but had a protective effect on dysplasia of the animals of group I.

ABSTRACT BACKGROUND: There are cases of colorectal tumors that, although small, show more aggressive evolution than large tumors. This motivated us to study whether there are any proteins capable of alerting about these changes. The aim here was to correlate the immunoexpression of the TS, p53, COX2, EGFR, MSH6 and MLH1 biomarkers in tumors in patients with colorectal adenocarcinoma, with the degree of cell differentiation, tumor staging and clinical-pathological prognostic factors. DESIGN AND SETTING: Retrospective observational study at a public tertiary-level hospital. METHODS: We analyzed tissue-microarray paraffin blocks of tumor tissues that had been resected from 107 patients. We used Fisher’s exact test to study associations between tumor differentiation/staging and the immunoexpression of biomarkers. We also used Kaplan-Meier estimation, the log-rank test and the adjusted Cox regression model to investigate the patients’ overall survival (in months) according to biomarkers and disease-free interval. RESULTS: The degree of tumor differentiation and tumor staging were not associated with the biomarkers, except in cases of patients in stages III or IV, in which there was a correlation with MLH1 expression (P=0.021). Patient survival and disease-free interval were not associated with the biomarkers. CONCLUSION: There were no associations between the degree of tumor differentiation, staging, length of survival or disease-free interval and the immunoexpression of the TS, p53, COX2, EGFR or MSH6 tumor markers. In advanced cases of colorectal adenocarcinoma (stages III and IV), there was a higher percentage of MLH1-negative results.

Abstract Purpose: To analyze gene and protein expression of metalloproteinases 1, 2, 9, 11 and 16 and their correlation with clinicopathological variables in colorectal adenocarcinoma. Methods: A retrospective study of 114 patients with colorectal adenocarcinoma treated surgically in the period 2006 to 2008 in Hospital de Câncer de Barretos - Fundação Pio XII. The evaluation of gene expression was performed by RT-PCR, and protein by immunohistochemistry. The analysis of gene expression was classified as overexpressed genes and poorly expressed (fold change of approximately 2, p

Abstract Background Among the many challenges in cancer diagnosis is the early distinction between metastatic cancer and a secondary tumor. This difficulty stems from the lack of markers that offer high sensitivity and specificity and can be easily applied in routine laboratory work. An example of this challenge is distinguishing gastric metastases originating from breast cancer from a gastric primary tumor. Hepatocyte nuclear factor 4 alpha (HNF4A) has been suggested as a potential marker in these cases. The aim of this study was to analyze the expression of HNF4A, estrogen receptor (ER), progesterone receptor (PR) and gross cystic disease fluid protein 15 (GCDFP-15) in a Brazilian cohort. Methods We performed immunohistochemistry analysis of HNF4A, ER, PR and GCDFP-15 in 126 patients divided into three cohorts: primary breast cancer, primary gastric cancer and both types of tumors. Results Our data confirmed the sensitivity and specificity of the HNF4A marker compared to other currently used clinical markers. Conclusion HNF4A alone could be a gold standard marker for distinguishing primary gastric cancer from breast metastasis, thus validating its potential clinical use, especially in populations with high genetic diversity.

PURPOSE:To evaluate the protective effects of chilling the bile ducts with cold (5°C) 5% glucose solution (GS) during radiofrequency (RF) administration.METHODS:Twenty male pigs (3 mos. old; 25-30 kg) were subjected to RF delivery with chilling (experimental group, N=10) or without chilling (control group, N=10). Half of the animals in each group were euthanized immediately after the operation, and half were euthanized one week later. The following histological variables in relation to the bile ducts were evaluated by a pathologist (blind examiner): degenerative changes to the epithelium; epithelial necrosis; ulceration, regenerative changes of the epithelium; polymorphonuclear neutrophil infiltration; and thermal effects.RESULTS: The experimental group (88 bile ducts examined) showed reduced thermal damage relative to the control group (86 bile ducts examined) as demonstrated by significant differences in the following histopathological parameters: epithelial detachment of biliary epithelium (84.1% vs. 59.3%; p

PURPOSE: To investigate the effects of preoperative fractioned irradiation using an electron beam on the healing process of colocolonic anastomoses in rats that underwent early and late surgical intervention. METHODS: Thirty Wistar rats, distributed as follows: group A (surgery only), group B (fractionated irradiation for 30 days (if), surgery seven days after the end of it), group C (if for 30 days, and surgery after 30 days of termination). On the seventh postoperative day the anastomotic segment analysis was taken, using tension tests, histology and collagen deposition evaluation by computerized analysis. RESULTS: Regarding the tension resistance of the anastomosis, there were no statistical differences (p=0.42). However, a significant increase in cells number in the inflammatory infiltrate in the group with a longer interval between surgery and pre op radiation (p

The belief that mechanical bowel preparation is related to the reduction of complications in elective colorectal surgery is based on observational studies and expert opinion. This question led the authors to a systematic literature review, with the completion of meta-analysis, followed by three updates. METHOD: The sources of information were EMBASE, LILACS, MEDLINE, IBECS, the Cochrane Controlled Trials Register and letters to the authors. The studies were included according to the randomization criteria. The studied variables were: anastomotic dehiscence, mortality and operatory wound infection. The analysis was divided into two comparisons: one group with mechanical preparation (Group A) compared with a group without preparation (Group B) (Comparison I) and a group submitted to rectal enema (Comparison II). RESULTS: We analyzed 5,805 patients in 20 clinical trials. In comparison I, anastomotic leak occurred in 4.4% (101/2,275 patients) in Group A and 4.5% (103/2,258 patients) in Group B. In comparison II, anastomotic leak occurred in 4.4% (27/601 patients) in Group A and 3.4% (21/609 patients) in Group B. CONCLUSION: Despite the inclusion of more studies, evidences found in studies did not show any benefit obtained from the use of preoperative mechanical bowel preparation or rectal cleansing enemas in elective colorectal surgery.A crença de que o preparo mecânico do cólon está relacionado à diminuição de complicações na cirurgia colorretal eletiva é baseada em estudos observacionais e opinião de especialistas. Seu questionamento motivou os autores na busca sistemática da literatura, com a realização de meta-análise, seguida de três atualizações. MÉTODO: Fontes de informação foram EMBASE, LILACS, MEDLINE, IBECS, Registros de Ensaios Clínicos Casualizados da Colaboração Cochrane e cartas para os autores. Os estudos foram incluídos de acordo com os critérios de casualização. Os desfechos clínicos estudados foram: deiscência anastomótica, mortalidade e infecção da ferida operatória. A análise dos grupos foi dividida em duas comparações: comparação I, grupo submetido a preparo mecânico do cólon (Grupo A) comparado ao grupo sem preparo (Grupo B); comparação II, Grupo A, submetido a preparo do cólon e Grupo B, realizado apenas enema retal. RESULTADOS: Foram analisados 5.805 doentes em 20 ensaios clínicos. Na comparação I, deiscência anastomótica ocorreu em 4,4% (101/2.275 doentes) no Grupo A e 4,5% (103/2.258 doentes) no Grupo B. Na comparação II, deiscência anastomótica ocorreu em 4,4% (27/601 doentes) no Grupo A e 3,4% (21/609 doentes) no Grupo B. CONCLUSÃO: Apesar da inclusão de mais estudos, as evidências encontradas não demonstraram benefício no uso do preparo mecânico pré-operatório do cólon, assim como de enemas de limpeza do reto em cirurgia colorretal eletiva.

CONTEXT: Although the high incidence of gastroesophageal reflux disease (GERD) in the population, there is much controversy in this topic, especially in the surgical treatment. The decision to use of a total or partial fundoplication in the treatment of GERD is still a challenge to many surgeons because the few evidence found in the literature. OBJECTIVE: To bring more clear evidence in the comparison between total and partial fundoplication. DATA SOURCES: A systematic review of the literature and metaanalysis with randomized controlled trials accessed from MEDLINE, LILACS, Cochrane Controlled Trials Database was done. The outcomes remarked were: dysphagia, inability to belch, bloating, recurrence of acid reflux, heartburn and esophagitis. For data analysis the odds ratio was used with corresponding 95% confidence interval. Statistical heterogeneity in the results of the metaanalysis was assessed by calculating a test of heterogeneity. The software Review Manager 5 (Cochrane Collaboration) was utilized for the data gathered and the statistical analysis. Sensitive analysis was applied using only trials that included follow-up over 2 years. RESULTS: Ten trials were included with 1003 patients: 502 to total fundoplication group and 501 to partial fundoplication group. The outcomes dysphagia and inability to belch had statistical significant difference (P = 0.00001) in favor of partial fundoplication. There was not statistical difference in outcomes related with treatment failure. There were no heterogeneity in the outcomes dysphagia and recurrence of the acid reflux. CONCLUSION: The partial fundoplication has lower incidence of obstructive side effects.

CONTEXT: Recent studies have shown that local anesthesia for loop colostomy closure is as safe as spinal anesthesia for this procedure. OBJECTIVES: Randomized clinical trial to compare the results from these two techniques. METHODS: Fifty patients were randomized for loop colostomy closure using spinal anesthesia (n = 25) and using local anesthesia (n = 25). Preoperatively, the bowel was evaluated by means of colonoscopy, and bowel preparation was performed with 10% oral mannitol solution and physiological saline solution for lavage through the distal colostomy orifice. All patients were given prophylactic antibiotics (cefoxitin). Pain, analgesia, reestablishment of peristaltism or peristalsis, diet reintroduction, length of hospitalization and rehospitalization were analyzed postoperatively. RESULTS: Surgery duration and local complications were greater in the spinal anesthesia group. Conversion to general anesthesia occurred only with spinal anesthesia. There was no difference in intraoperative pain between the groups, but postoperative pain, reestablishment of peristaltism or peristalsis, diet reintroduction and length of hospitalization were lower with local anesthesia. CONCLUSIONS: Local anesthesia plus sedation offers a safer and more effective method than spinal anesthesia for loop colostomy closure.CONTEXTO: Estudos recentes têm demonstrado que a anestesia local para o fechamento de colostomia em alça é tão segura quanto a raquianestesia para estes procedimentos. OBJETIVOS: Comparar os resultados do fechamento de colostomia em alça usando essas duas técnicas. MÉTODOS: Cinquenta pacientes foram randomizados para o fechamento de colostomia em alça sob raquianestesia (n = 25) e anestesia local (n = 25). No pré-operatório, o cólon foi avaliado por colonoscopia e o preparo intestinal foi realizado com solução oral de manitol a 10% e limpeza com solução salina fisiológica através do orifício distal da colostomia. Todos os pacientes receberam antibioticoprofilaxia com cefoxitina. Dor, analgesia, restabelecimento do peristaltismo, reintrodução da dieta, tempo de internação e de reinternação foram analisados no pós-operatório. RESULTADOS: Duração da cirurgia e complicações locais foram maiores no grupo da raquianestesia. A conversão para anestesia geral ocorreu somente no grupo da raquianestesia. Em relação á dor intraoperatória, não houve diferença entre os grupos, mas a dor pós-operatória, restabelecimento do peristaltismo, reintrodução da dieta e tempo de hospitalização foram menores no grupo com anestesia local. CONCLUSÃO: A anestesia local associada à sedação ofereceu um método mais seguro e efetivo que a raquianestesia para o fechamento de colostomia em alça.

PURPOSE: To evaluate the accuracy and reproducibility of magnetic resonance cholangiopancreatography (MRCP) in the detection of biliary complications in liver transplanted patients. METHODS: A study was conducted, with blinded review of 28 MRCP exams of 24 patients submitted to liver transplantation. The images were reviewed by two independent observers, at two different moments, regarding the degree of biliary tree visualization and the presence or absence of biliary complications. The MRCP results were compared, when negative, to at least 3 months of clinical and biochemical follow-up, and when positive, to the findings at surgery or endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: The degree of intrahepatic biliary tree visualization was considered good or excellent in 78.6% and 82.1% of the exams by the two observers and visualization of the donor duct, recipient duct and biliary anastomosis was considered good or excellent in 100% of the exams, by both observers. Six biliary complications were detected (21.4%), all of them anastomotic strictures. Intra and interobserver agreement were substantial or almost perfect (kappa k values of 0.611 to 0.804) for the visualization of the biliary tree and almost perfect (k values of 0.900 to 1.000) for the detection of biliary complications. MRCP achieved 100% sensitivity, 95.45% specificity, 85.7% positive predictive value and 100% negative predictive value for the detection of biliary complications. CONCLUSIONS: MRCP is an accurate examination for the detection of biliary complications after orthotopic liver transplantation and it is a highly reproducible method in the evaluation of the biliary tree of liver transplanted patients.OBJETIVO: Medir a acurácia e reprodutibilidade da colangiopancreatografia por ressonância magnética (CPRM) na avaliação da visibilização de complicações biliares em pacientes submetidos a transplantes hepáticos ortotópicos. MÉTODOS: Realizado estudo retrospectivo de 28 exames de CPRM de 24 pacientes submetidos a transplantes hepáticos. Os exames foram interpretados por dois observadores independentes, em dois momentos distintos, quanto ao grau de visibilização das estruturas estudadas e quanto à presença ou ausência de alterações nas vias biliares. Os resultados da CPRM foram comparados, nos casos de CPRM negativa, à evolução clínico-laboratorial por pelo menos 3 meses e, nos casos de CPRM alterada, aos achados de colangiopancreatografia retrógrada endoscópica (CPRE) e cirurgia, quando indicados. RESULTADOS: A visibilização das vias biliares intra-hepáticas foi considerada boa ou excelente em 78,6% e 82,1% dos exames pelos dois observadores. A visibilização da via biliar extra-hepática do doador e do receptor, bem como da anastomose biliar, foi considerada boa ou excelente em 100% dos casos por ambos os observadores. Foram detectadas seis complicações biliares (21,4% dos casos), todas elas estenoses anastomóticas. A concordância intra e intra-observador foi substancial ou quase perfeita (índices de kappa- k de 0,611 a 0,804) para a visualização das estruturas estudadas e quase perfeita (k de 0,900 a 1,000) para a detecção das complicações biliares. A CPRM apresentou sensibilidade de 100%, especificidade de 95,45%, valor preditivo positivo de 85,7% e valor preditivo negativo de 100% para a detecção de complicações biliares. CONCLUSÕES: A colangiopancreatografia por ressonância magnética (CPRM) é um exame acurado para a detecção de complicações biliares em pacientes submetidos a transplantes hepáticos ortotópicos por CPRM. Este exame configura-se como um método eficiente e altamente reprodutível para detecção de complicações biliares pós-transplantes hepáticos ortotópicos.

CONTEXT: Search of tumors markers that allow treatment with higher survival rates, and indicate the response to treatment and recurrence of cancer OBJECTIVE: To analyze the immunoexpression of the proteins p53, bcl-2 and Ki-67 in colorectal adenocarcinoma and correlate them with the clinical-pathological prognostic factors. METHOD: Tissue microarray paraffin blocks were made from colorectal adenocarcinoma tissue resected from 82 patients who had undergone surgery but not chemotherapy or radiotherapy, at "Hospital São Paulo", São Paulo, SP, Brazil, between 2002 and 2005. Thin sections (4 µm) were subjected to immunohistochemical reactions, and immunoexpression staining scores were obtained. The scores were correlated with the degree of cell differentiation, staging, disease-free interval, recurrence, survival and specific mortality. The study variables were analyzed using the chi-square and Kaplan-Meier tests to investigate associations with the markers. The significance of the differences between the curves of the disease-free interval and survival was analyzed using the Logrank and Wilcoxon tests. RESULTS: The immunohistochemical expression of p53 was positive in 70 tumors (85.4%) and negative in 12 (14.6%). The expression of bcl-2 was positive in 26 (31.7%) and negative in 56 (68.3%). The expression of Ki-67 was positive in 62 (75.6%) and negative in 20 (24.4%). There was no statistically significant correlation between the expressions of these markers separately or in conjunction, in relation to the degree of cell differentiation, staging, disease-free interval, survival and specific mortality. In relation to recurrence, there was a statistically significant correlation with positive expression of Ki-67 (P = 0.035). CONCLUSION: The immunohistochemical expression of Ki-67 in colorectal cancer is associated with recurrence of this disease.CONTEXTO: Pesquisa de marcadores tumorais que permitam tratamento com maiores índices de sobrevida, além de indicarem a resposta ao tratamento e a recurrência da neoplasia. OBJETIVO: Analisar as expressões imunoistoquímicas das proteínas p53, bcl-2 e Ki-67 no adenocarcinoma colorretal, correlacionando-as com os fatores prognósticos clínico-patológicos. MÉTODO: Foram confeccionados blocos de parafina de TMA com tecido de adenocarcinoma colorretal ressecados cirurgicamente em 82 pacientes no Hospital São Paulo da Universidade Federal der São Paulo, São Paulo, SP, de 2002 a 2005, não submetidos a radio ou quimioterapia. Cortes de 4 µm foram submetidos a reação imunoistoquímica e obtidos escores de intensidade das imunoexpressões, que foram correlacionados com o grau de diferenciação celular, estádio, tempo livre de doença, recidiva, sobrevida e mortalidade específica. As variáveis do estudo foram analisadas pelos testes do qui ao quadrado e de Kaplan-Meier para verificar as associações com os marcadores. A significância das diferenças entre as curvas do tempo livre de doença e da sobrevida foi analisada pelos testes de Logrank e Wilcoxon. RESULTADOS: A expressão imunoistoquímica da p53 foi positiva em 70 tumores (85,4%) e negativa em 12 (14,6%). A bcl-2 foi positiva em 26 tumores (31,7%) e negativa em 56 (68,3%). A expressão imunoistoquímica da Ki-67 foi positiva em 62 tumores (75,6%), sendo em 20 (24,4%) negativa. Não houve correlação estatisticamente significante entre as expressões imunoistoquímicas dos marcadores analisadas separadamente ou em conjunto, envolvendo o grau de diferenciação celular, estádio, tempo livre de doença, sobrevida e mortalidade específica. Com relação à recidiva, observou-se correlação estatisticamente significante com a expressão imunoistoquímica positiva da Ki-67 (P = 0,035). CONCLUSÃO: A expressão imunoistoquímica positiva da Ki-67 no câncer colorretal está relacionada com a incidência de recidiva da doença.

CONTEXT: Studies in the area of health economics are still poorly explored and it is known that the cost savings in this area is becoming more necessary, provided that strict criteria. OBJECTIVE: To perform a cost-effectiveness analysis of spinal anesthesia versus local anesthesia plus sedation for loop colostomy closure. METHODS: This was a randomized clinical trial with 50 patients undergoing loop colostomy closure either under spinal anesthesia (n = 25) or under local anesthesia plus sedation (n = 25). The duration of the operation, time spent in the post-anesthesia recovery room, pain, postoperative complications, length of hospital stay, laboratory and imaging examinations and need for rehospitalization and reoperation were analyzed. The direct medical costs were analyzed. A decision tree model was constructed. The outcome measures were mean cost and cost per local and systemic postoperative complications avoided. Incremental cost-effectiveness ratios were presented. RESULTS: Duration of operation: 146 ± 111.5 min. vs 105 ± 23.6 min. (P = 0.012); mean time spent in post-anesthesia recovery room: 145 ± 110.8 min. vs 36.8 ± 34.6 min. (POBJETIVO: Análise de custo-efetividade entre fechamento de colostomia e m alça sob raquianestesia versus anestesia local associada à sedação. MÉTODOS: Ensaio clínico randomizado com 50 pacientes para fechamento de colostomia em alça, sob raquianestesia (n = 25) e sob anestesia local com sedação (n = 25). Avaliaram-se tempo operatório e de sala de recuperação pós-anestésica, dor, complicações pós-operatórias, tempo de internação, exames laboratoriais e de imagens, reoperações e reinternações. Foi feita análise de custos diretos médicos. A medida de desfecho foi: complicações pós-operatórias locais e sistêmicas. Aplicaram-se razão incremental e árvore de decisão. RESULTADOS: Tempo operatório (146 ± 111,5 min vs 105 ± 23,6 min; P = 0,012), tempo médio de sala de recuperação pós-anestésica (145 ± 110,8 min vs 36,8 ± 34,6 min, P

PURPOSE: To compare histopathological variables and staging in colorectal adenocarcinoma cases with CEA and CA 242 in peripheral and mesenteric blood. METHODS: In 169 individuals underwent surgery for colorectal cancer, CEA and CA 242 were analyzed and compared to mesenteric and peripheral blood and correlated with macroscopic tumor's morphology and size, degree of cell differentiation, venous, neural and lymphatic involvement and TNM classification. RESULTS: There was a difference between the mesenteric (M) and peripheral (P) serum levels of CEA (p=0.020). Higher levels of markers were correlated with venous invasion CEA (P) p=0.013, CEA (M) p=0.05, CA 242 (M) p=0.005 and CA 242 (P) p=0.038; with advanced staging CEA (P) < CEA (M) (p < 0.05); CA 242 (P) < CA 242 (M) (p < 0.05); and with greater dimensions CEA (P) < CEA (M) (p < 0.001); CA 242 (P) < CA 242 (M) (p < 0.001). CA 242 became higher with neural invasion (P): p=0.014, (M): p=0.003). CONCLUSIONS: There were higher mesenteric than peripheral levels of CEA. Both mesenteric and peripheral levels of CEA and CA 242 were higher in neoplasm with venous involvement, greater diameter and advanced stages. There was a correlation between CA 242 and neural invasion.OBJETIVO: Comparar variáveis histopatológicas e graus de estadiamento do adenocarcinoma colorretal com níveis sanguíneos periféricos e mesentéricos de CEA e CA-242. MÉTODOS: Em 169 doentes submetidos ao tratamento cirúrgico por adenocarcinoma colorretal, CEA e CA-242 foram analisados e comparados quanto aos níveis sanguíneos periféricos e mesentéricos e correlacionados com o tamanho e a morfologia macroscópica do tumor, grau de diferenciação celular, invasões venosa, linfática, neural e a classificação TNM. RESULTADOS: Verificou-se diferença significante entre o nível sérico mesentérico e periférico de CEA (p= 0,02). Níveis séricos mais elevados dos marcadores foram observados e correlacionados com invasão venosa, CEA (P) p=0,013, CEA(M), p=0,05, CA-242 (M) p=0,005 e CA-242 (P) p=0,038. Grau de estadiamento TNM avançado foi associado com CEA(P) < CEA(M) p

CONTEXT: Identification of risk factors for requiring transfusions during surgery for colorectal cancer may lead to preventive actions or alternative measures, towards decreasing the use of blood components in these procedures, and also rationalization of resources use in hemotherapy services. This was a retrospective case-control study using data from 383 patients who were treated surgically for colorectal adenocarcinoma at "Fundação Pio XII", in Barretos-SP, Brazil, between 1999 and 2003. OBJECTIVE: To recognize significant risk factors for requiring intraoperative blood transfusion in colorectal cancer surgical procedures. METHODS: Univariate analyses were performed using Fisher's exact test or the chi-squared test for dichotomous variables and Student's t test for continuous variables, followed by multivariate analysis using multiple logistic regression. RESULTS: In the univariate analyses, height (P = 0.06), glycemia (P = 0.05), previous abdominal or pelvic surgery (P = 0.031), abdominoperineal surgery (POBJETIVO: Identificar fatores de risco de indicação de transfusão sanguínea intraoperatória em doentes submetidos a tratamento cirúrgico por adenocarcinoma colorretal. MÉTODOS: Estudo retrospectivo, tipo caso-controle, realizado na Fundação Pio XII, em Barretos, SP, utilizando-se base de dados de prontuários de 383 pacientes admitidos entre 1999 e 2003. Utilizou-se teste exato de Fischer ou qui ao quadrado para variáveis dicotômicas e t de Student para variáveis contínuas, na análise univariada, adotando-se nível de significância de 10% (P

PURPOSE: To analyze the expression of metalloproteinase-1, metalloproteinase-7 and vascular endothelial growth factor (VEGF) in colorectal adenocarcinoma, and to correlate these with the clinical-pathological prognostic factors. METHODS: Tumor tissue from 82 patients was fixed in formalin and embedded in paraffin blocks. These samples were analyzed by means of the streptavidin-biotin immunohistochemical method, using the tissue microarray technique. Marker positivity was evaluated using categorical scores that determined cutoff percentages of stained tumor cells. Protein tissue expression was correlated with the variables of degree of cell differentiation, staging, disease-free interval, recurrence, survival and specific mortality. The Fisher exact and Kaplan-Meier tests were used to assess associations between the markers and the study variables. The log-rank and Wilcoxon tests were used to assess the significance of differences between curves of disease-free interval and survival. RESULTS: All tumors were positive for metalloproteinase-1; 50 (61%) were positive and 32 (39%) were negative for metalloproteinase-7; and 60 (74.1%) were positive and 21 (25.9%) were negative for VEGF. Correlation of marker expression, both in groups and individually, did not show statistical significance in relation to the degree of cell differentiation, staging, disease-free interval, survival or specific mortality. Recurrence showed a statistically significant correlation with positive expression of the three markers, when analyzed as a group (p = 0.038). CONCLUSION: The associated expression of metalloproteinase-1, metalloproteinase-7 and VEGF in colorectal adenocarcinoma is related to the incidence of disease recurrence.OBJETIVO: Analisar as expressões da metaloproteinase-1, metaloproteinase-7 e do fator de crescimento endotelial vascular no adenocarcinoma colorretal e correlacionar com os fatores prognósticos clínico-patológicos. MÉTODOS: Foram analisados tecidos fixados em formol e dispostos em blocos de parafina dos tumores de 82 pacientes, por imunohistoquímica, pelo método da estreptavidina-biotina, usando-se a técnica de arranjo em matriz de amostras teciduais (tissue microarray). Na avaliação da positividade dos marcadores foi utilizado um escore categórico, que predeterminou o valor de corte na percentagem de células coradas do tumor. As expressões teciduais das proteínas foram correlacionadas com as varáveis representadas pelo grau de diferenciação celular, estadiamento, tempo livre de doença, recidiva, sobrevida e mortalidade específica. Foram empregados os testes exato de Fisher e de Kaplan-Meier para verificar as associações dos marcadores com as varáveis estudadas. Para testar a significância das diferenças entre as curvas do tempo livre de doença e da sobrevida foram utilizados os testes de longrank e Wilcoxon. RESULTADOS: A metaloproteinase-1 foi positiva em todos os tumores. A metaloproteinase-7 foi positiva em 50 (61%) e negativa em 32 (39%) tumores. O fator de crescimento endotelial vascular foi positivo em 60 (74,1%) e negativo em 21 (25,9%) tumores. A correlação das expressões dos marcadores realizada separadamente e em conjunto não apresentou significância estatística com o grau de diferenciação celular, estadiamento, tempo livre de doença, sobrevida e mortalidade específica. A recidiva apresentou correlação estatística significante com a expressão positiva dos três marcadores, quando foram analisados em conjunto (p = 0,038). CONCLUSÃO: As expressões associadas da metaloproteinase-1, metaloproteinase-7 e do fator de crescimento endotelial vascular no adenocarcinoma colorretal se relacionam com a incidência de recidiva da doença.

PURPOSE: To compare morbidity, mortality, recurrence and 5-year survival between D1 and D2 or D3 for treatment of gastric cancer. METHODS: Systematic review and meta-analysis of RCTs. Metaview in RevMan 4.2.8 for analysis; statistical heterogeneity by Cochran's Q test (P50%). Estimates of effect were calculated using random effects model. RESULTS: D2 or D3 was associated with higher in-hospital mortality, with RR = 2.13, p=0.0004, 95% CI, 1.40 to 3.25, I²=0%, P=0.63; overall morbidity showed higher incidence in D2 or D3, RR = 1.98, pOBJETIVO: Comparar a morbidade, mortalidade, recidiva e sobrevida de cinco anos entre linfadenectomia D1 e D2 ou D3 no tratamento do câncer gástrico. MÉTODOS: Revisão sistemática metanálise de ensaios clínicos randomizados, programa Metaview, Revman 4.2.8. Heterogeneidade estatística pelo teste Q de Cochrane (P50%). Estimativas dos efeitos pelo modelo randômico. RESULTADOS: Maior mortalidade hospitalar em D2 ou D3, RR = 2.13, p=0.0004, 95% IC, 1.40 a 3.25, I²=0%, P=0.63; maior morbidade geral em D2 ou D3, RR = 1.98, p

PURPOSE: The controversy regarding whether loop ileostomy or loop transverse colostomy is a better method for temporary decompression of colorectal anastomosis motivated this review. METHODS: Five randomized trials were included, with 334 patients: 168 in the loop ileostomy group and 166 in the loop transverse colostomy group. The outcomes analyzed were: 1. Mortality; 2. Wound infection; 3. Time of stoma formation; 4. Time of stoma closure; 5. Time interval between stoma formation and closure; 6. Stoma prolapse; 7. Stoma retraction; 8. Parastomal hernia; 9. Parastomal fistula; 10. Stenosis; 11. Necrosis; 12. Skin irritation; 13. Ileus; 14. Bowel leakage; 15. Reoperation; 16. Patient adaptation; 17. Length of hospital stay; 18. Colorectal anastomotic dehiscence; 19. Incisional hernia; 20. Postoperative bowel obstruction. RESULTS: Stoma prolapse was statistically significant (p = 0.00001), but with statistical heterogeneity; the sensitive analysis was applied, excluding the trials that included emergency surgery, and this showed: p = 0.02, with I² = 0% for the heterogeneity test. CONCLUSIONS: The outcomes reported were not statistically or clinically significant except for stoma prolapse. Better evidence for making the choice between loop ileostomy or loop colostomy requires large-scale randomized controlled trials.OBJETIVO: A controvérsia entre ileostomia em alça ou colostomia em alça como a melhor forma para a descompressão temporária da anastomose colorretal motivou a realização desta revisão. MÉTODOS: Cinco ensaios clínicos casualizados foram incluídos com 334 pacientes: 168 no grupo de ileostomia e 166 no grupo de colostomia. Os resultados analisaram: 1. Mortalidade; 2. Infecção da ferida; 3. Tempo de formação do estoma; 4. Tempo de fechamento do estoma; 5. Intervalo de tempo entre a formação e o fechamento do estoma; 6. Prolapso do estoma; 7. Retração do estoma; 8. Hérnia parastomal; 9. Fistula parastomal; 10. Estenose; 11. Necrose; 12. Irritação de pele; 13. Íleo; 14. Fístula entérica; 15. Reoperação; 16. Adaptação do paciente; 17. Tempo de internação hospitalar; 18. Deiscência da anastomose colorretal; 19. Hérnia de Incisional; 20. Obstrução intestinal pós-operatória. RESULTADOS: Prolapso do estoma: p = 0.00001, mas com heterogeneidade estatística; a análise de sensibilidade foi aplicada excluindo os estudos que incluíram cirurgias de emergência: p = 0.02 e teste de heterogeneidade: I²=0%. CONCLUSÕES: Os resultados encontrados não foram estatística ou clinicamente significantes, exceto prolapso do estoma. A melhor evidência para a escolha entre ileostomia em alça ou colostomia em alça necessita de maior número de ensaios clínicos.

OBJETIVO: Avaliar a relação de duas proteínas que participam do mecanismo de adesão celular com o grau de diferenciação celular e os estadiamentos TNM (T: tumor, N: linfonodo, M: metástase) I e IV no câncer de cólon e reto. MÉTODOS: Foram estudados cem pacientes (54 homens e 46 mulheres) tratados por adenocarcinoma colorretal, estádios I (44) e IV (56). Os cortes histológicos do tecido tumoral foram examinados por técnica de imuno-histoquímica em relação à imunoexpressão das proteínas caderina-E e delect in colon cancer (DCC), sendo classificados como positivos quando se detectou a imunoexpressão dessas proteínas em 50% ou mais das células tumorais. RESULTADOS: Para o TNM, imunoexpressão da caderina-E estádio I: positiva em 72,7 % e negativa em 35,7% ; estádio IV: positiva em 64,3% e negativa em 35,7%. Proteína DCC: 43,2% positiva e 56,8% negativa no estádio I, e 50% positiva e 50% negativa no estádio IV. Em relação ao grau de diferenciação celular, imunoexpressão da caderina-E - GI: positiva em 70% e negativa em 30%; GII: positiva em 68,4% e 31,6% negativa; GIII: 63,6% positiva e 36,4% negativa. Imunoexpressão da DCC - GI: 40% positiva e 60% negativa; GII: 46,8% positiva e 53,2% negativa; GIII: 54,5% positiva e 45,5% negativa. Não houve diferença significativa entre os grupos. CONCLUSÃO: Os resultados dessa pesquisa permitem concluir que não há relação da imunoexpressão das proteínas caderina-E e DCC com o estadiamento TNM (I e IV) e o grau de diferenciação celular no carcinoma colorretal.OBJECTIVE: Evaluate the relationship of two proteins, which take part in the same mechanism of cell adhesion, with the cell differentiation degree and TNM staging I and IV in colorectal cancer. METHODS: One-hundred patients (54 men and 46 women), who have received treatment for colorectal cancer, stages I (44) and IV (56), have been studied. Histological cuts of tumor tissue were examined by the immunohistochemical technique as to the expression of E-cadherin and delect in colon cancer (DCC) proteins, being classified as positive whenever it was detected immunoexpression of such proteins in 50% or more tumor cells. RESULTS: For TNM, E-cadherin immunoexpression for stage I: positive in 72.7% and negative in 35.7%; stage IV: positive in 64.3% and negative in 35.7%. For DCC protein: 43.2% positive and 56.8% negative in stage I, and 50% positive and 50% negative in stage IV. Regarding the cell differentiation degree, the immunoexpression of E-cadherin - GI: positive in 70% and negative in 30%; GII: positive in 68.4% and negative in 31.6%; GIII: positive in 63.6% and negative in 36.4%. The immunoexpression of DCC - GI: 40% positive and 60% negative; GII: 46.8% positive and 53.2% negative; GIII: 54.5% positive and 45.5% negative. There was no significant difference among groups. CONCLUSION: The results of this research make it possible to come to the conclusion that there is no relationship between the immunoexpression of E-cadherin and DCC proteins with TNM staging (I and IV) and cell differentiation degree in colorectal cancer.

PURPOSE: To quantify the degree of angiogenesis by conventional method (microvessel density, MVD) and computerized method (endothelial area, EA), and to evaluate their relationships with the prognosis of patients operated on for colorectal adenocarcinoma. METHODS: Tumoral angiogenesis was studied by means of an immunohistochemical technique, using CD 34, on 126 patients; to quantify the angiogenesis, MVD (defined as number of microvessels per mm²) and EA measurement (defined as the area occupied by EA in the microscope field). A computerized method, IMAGELab software was utilized to quantify endothelial area. RESULTS: The mean number of microvessels was 128.6 MV/mm² (SD = 44.5) and the mean EA was 4.3% (SD = 2.1). The Pearson method demonstrated a low correlation coefficient between MVD and EA (r = 0.429). No relationship between MVD and EA was observed with regard to relapse-free interval and overall survival. CONCLUSION: The histological analysis of angiogenesis expression in patients with colorectal adenocarcinoma can be performed either by computer-assisted image analysis of endothelial area or by conventional microvessels counting. Both methods did not show any significant relationship between these angiogenesis parameters with relapse-free interval and overall survival.OBJETIVO: Quantificar a intensidade da angiogênese pelo método convencional (densidade microvasal, DMV) e pelo método informatizado, área endothelial (AE) e avaliar a sua correlação com o prognóstico de doentes operados por adenocarcinoma colorretal. MÉTODOS: A angiogênese tumoral foi investigada por meio de técnica imuno-histoquímica, utilizando-se CD-34, em 126 doentes; para quantificar a angiogênese, a microdensidade vascular, definida como o número de microvasos por mm² e a medida da área endotelial, definida como a área ocupada pelo endotélio vascular identificada no campo microscópico foram empregadas. Um programa computadorizado, o IMAGELab foi empregado para a quantificação da área endothelial. RESULTADOS: A media do número de microvasos foi de 128,6 MV/mm ² (d esvio padrão de 44,5). O método do coeficiente de Pearson demonstrou uma baixa correlação entre a DMV e a AE (r=0,429). Nenhuma correlação entre a DMV e AE com o intervalo livre de doença e tempo global de sobrevida foi observada. CONCLUSÃO: A análise histológica da expressão angiogênica em doentes com adenocarcinoma colorretal pode ser realizada tanto da forma informatizada, na quantificação da área endotelial, como pela convencional, na contagem dos microvasos. Ambos métodos não demonstraram relação estatisticamente significante entre estes parâmetros de angiogênese e o intervalo livre de doença e a sobrevida global.

OBJETIVO: Verificar a associação entre o uso da circulação extracorpórea e o desenvolvimento de colelitíase. MÉTODO: Foram estudados 135 pacientes coronariopatas acompanhados na Disciplina de Cardiologia da Universidade Federal de São Paulo - Escola Paulista de Medicina, no período de janeiro de 2000 a setembro de 2002, distribuídos em três grupos: Grupo 1 - 51 pacientes tratados clinicamente; Grupo 2 - 43 pacientes revascularizados sem circulação extracorpórea e Grupo 3 - 41 pacientes revascularizados com circulação extracorpórea. Foram controladas as variáveis sexo, idade, índice de massa corpórea e doenças associadas entre os grupos e foi realizada ultra-sonografia total de abdome em todos os pacientes, aos doze meses de tratamento (clínico ou cirúrgico), para verificar a existência de colelitíase. RESULTADOS: A prevalência de colelitíase encontrada nos grupos foi: Grupo 1 - 7,84 %; Grupo 2 - 11,62 % e Grupo 3 - 19,51 %. Não houve diferença estatisticamente significante entre os grupos quanto à existência de colelitíase (p=0,248). CONCLUSÃO: Baseado neste estudo não se pode afirmar que o uso da circulação extracorpórea predisponha a maior prevalência de colelitíase.OBJECTIVE: The objective of the present study was to clarify the relationship between cardiopulmonary bypass with the use of a heart-lung machine and gallstones in a short-term follow-up. METHOD: A total of 135 patients with ischaemic heart disease were included in this study. All were followed up by the Cardiology Department of Hospital São Paulo, Federal University of São Paulo. They were divided into three groups: Group 1 - 51 patients who were treated clinically; Group 2 - 43 patients who underwent coronary artery grafting bypass without cardiopulmonary bypass; and Group 3 - 41 patients who underwent coronary artery grafting bypass with cardiopulmonary bypass and the use of a heart-lung machine. There were no statistically significant differences between the groups in relation to gender, age, body mass index or associated diseases (p

PURPOSE: To analyze the correlation between p53 and bcl-2 expression and colorectal adenocarcinoma staging and prognosis. METHODS: This was a retrospective series of 125 colorectal adenocarcinoma patients (67 women and 58 men; ages 30-87 years) who underwent surgery with curative intent. The mean follow-up was 28.5 months (range: 2-96 months). TNM staging, tumor recurrence, survival and cancer-related mortality were analyzed. Immunoreactivity was evaluated using DO7 (Dako) for p53 and K492 (Dako) for bcl-2. Tumors with accumulation of staining for cytoplasmic bcl-2 or nuclear p53 in more than 10% of cells were considered positive. Statistical analysis utilized Pearson chi-squared, log-rank and Wilcoxon tests, and Kaplan-Meier survival estimation (significance level: p

PURPOSE: To analyze the effects of sodium hyaluronate and carboxymethylcellulose membrane on collagen and fibroblast formation in bowel suture healing in rats. METHODS: 48 male Wistar rats, weighing 250 to 343g, were randomized into two groups: group I - bowel suture without applying a biologically absorbable membrane and group II - bowel suture with application of an absorbable membrane. The two groups were divided into subgroups of 3, 14 and 30 days of observation, with 8 rats in each subgroup. All were sacrificed after the end of the observation period. RESULTS: No morbidity or mortality was observed during the experiment. The amounts of collagen in group I were 23.4%, 72.1% and 67.6% and in group II were 22.5%, 52.5% and 51.6%, for the subgroups of 3, 14 and 30 days, respectively. Comparison between groups showed that the 14-day (p=0.0013) and 30-day (p=0.0587) subgroups had significant variance, with larger collagen zones in animals in which the membrane was not applied. However, with regard to fibroblasts, group I had 2%, 13% and 8% and group II had 2%, 10% and 8%, for the 3-day (p=1.0), 14-day (p=0.3184) and 30-day (p=0.5995) subgroups, respectively, showing no significant variance. CONCLUSION: The use of the biologically absorbable membrane cause a decrease in collagen formation, while not altering the number of fibroblasts, in bowel suture healing in rats, without increased morbidity and mortality.OBJETIVO: Analisar os efeitos da membrana de hialuronato de sódio e carboximetilcelulose, na formação de colágeno e fibroblastos na colorrafia de ratos. MÉTODOS: Foram utilizados 48 ratos machos da linhagem Wistar, com peso entre 250 e 343g, distribuídos em dois grupos: grupo I colorrafia sem aplicação de membrana bioabsorvível e grupo II colorrafia com aplicação de membrana bioabsorvível; tendo sido divididos em subgrupos de 3, 14 e 30 dias de observação, com 8 animais em cada um dos subgrupos, todos submetidos à eutanásia após o período correspondente. RESULTADOS: Não foi observada morbimortalidade. A quantidade de colágeno no grupo I foi de 23,4%, 72,1% e 67,6%; no grupo II 22,5%, 52,5% e 51,6%, ambos os grupos nos 3, 14 e 30 dias, respectivamente, tendo na comparação intergrupos demonstrado que os subgrupos 14 (p=0,0013) e 30 (p=0,0587) obtiveram variância significativa, apresentando zona de colágeno maior nos animais nos quais não se usou a membrana; entretanto, em relação à quantidade de fibroblastos, o grupo I obteve 2%, 13% e 8%; o grupo II obteve 2%, 10% e 8%, ambos os grupos nos 3 (p=1,0), 14 (p=0,3184) e 30 (p=0,5995) dias, respectivamente, demonstrando não haver variância significativa. CONCLUSÃO: A utilização da membrana bioabsorvível determinou diminuição da formação de colágeno e não alterou o número de fibroblastos na cicatrização de colorrafias, sem apresentar morbi-mortalidade, em ratos.

Spontaneous development of perineal hernias is a very rare condition and many techniques have been described for repairing the floor defect. The authors describe the use of a combined approach in the surgical treatment of primary perineal hernias, by reconstructing the muscle pelvic floor and restoring the rectum to its sacral position with mesh repair. The case of one patient with a huge primary perineal hernia is reported, with clinical manifestations of progressive bulging in the buttock area, obstipation and fecal incontinence. Long-term follow-up has shown no recurrence of the condition and normal bowel function. It is concluded that primary perineal hernia can be repaired by a combined surgical approach, by using prosthetic material.O desenvolvimento espontâneo de hérnia perineal representa uma condição patológica muito rara.Várias técnicas têm sido descritas para a correção da falha no assoalho muscular pélvico. Os autores descrevem um acesso cirúrgico combinado para o tratamento das hérnias perineais primárias, pela reconstrução do assoalho pélvico muscular e reposicionamento do reto com reforço utilizando-se tela. O caso de uma paciente com uma volumosa hérnia na região perineal, caracterizada como primária, é relatado, evidenciando-se manifestações clínicas de aumento progressivo do saco herniário, dificuldades para evacuar e incontinência fecal. O seguimento clínico a longo prazo, após a correção cirúrgica, demonstrou que não houve recidiva da hérnia, normalizando-se a função intestinal. Conclui-se que as hérnias perineais primárias podem ser tratadas por este acesso combinado, utilizando-se próteses.

OBJETIVO: Comparar os resultados precoces entre anastomoses colorretais realizadas com anel biofragmentável e com grampeador circular após irradiação pélvica. MÉTODOS: Foram utilizados 40 cães beagle, em dois grupos de 20 animais, submetidos ou não à irradiação gama pré-operatória, com dose única de 500 cGy. Cada grupo foi dividido em dois subgrupos de dez animais, sendo denominado A o grupo em que se utilizou o anel biofragmentável e B aquele em que se empregou o grampeador. Os animais foram submetidos à secção completa do intestino grosso ao nível da junção retossigmóide, com reconstrução do trânsito sendo efetuada por uma das técnicas, após sorteio. Os animais foram sacrificados no sétimo dia de período pós-operatório. RESULTADOS: Houve dois óbitos antes da reoperação: um em animal do grupo teste, por ruptura da anastomose realizada com anel biofragmentável; outro por peritonite generalizada em animal do grupo controle com anastomose efetuada por grampeador. Aderências e infecções de parede ocorreram de forma similar. A análise histológica convencional e a análise morfométrica realizada por computador das áreas de cicatrização anastomótica identificaram comportamento análogo entre os grupos e subgrupos estudados. CONCLUSÃO: Os resultados precoces das técnicas empregadas para anastomose intestinal foram semelhantes nas condições de risco estudadas.PURPOSE: To compare the early results of colorectal anastomosis with the biofragmentable ring and with stapler after preoperative gamma irradiation with a 500 cGy single dose. METHODS: Forty beagle dogs were distributed in 2 groups of 20 animals submitted or not to preoperative gamma irradiation and named test(II) and control (I) groups respectively. Two subgroups of 10 animals were created: group A in which the biofragmentable ring was used and group B in which the stapler was used. The animals were submitted to full division of the large bowel at the rectosgmoid junction and the intestinal tube has been reconstructed by one of the two techniques randomly assigned. In the seventh postoperative day the animals were killed and histological specimens were collected for macro and microscopic analysis. RESULTS: Two deaths occurred before reoperation: one in the biofragmentable anastomosis group and the other in the stapler anastomosis group, due to generalized peritonitis. Adhesions and wound infection have occurred equally in all groups. The standard histological analysis and computorized morphometric study showed no significant differences between the groups. CONCLUSION: The early results of the two anastomosis technique under risk conditions were alike.

To evaluate the relationship between the expression profiles of 84 extracellular matrix (ECM) genes and the prognosis of patients with colorectal cancer (CRC).This retrospective study included 114 patients with stage I-IV CRC who underwent primary tumour resection. Quantitative real-time PCR and immunohistochemistry assays were conducted using primary tumour samples. Kaplan-Meier survival curves were also generated to identify differences in global survival (GS) and disease-free survival (DFS) for the hypo- or hyperexpression status of each marker. The log-rank test was used to verify whether the differences were significant. Stepwise Cox regression models were also used to identify the risk factors associated with GS and DFS in a multivariate mode, and then were used to score the risk of death associated with each marker, either independently or in association.In the univariate analyses, significant differences in GS in relation to the expression profiles of ITGAV (p = 0.001), ITGA3 (p = 0.002), ITGA6 (p = 0.001), SPARC (p = 0.036), MMP9 (p = 0.034), and MMP16 (p = 0.038) were observed. For DFS, significant differences were observed in associated with ITGAV (p = 0.004) and ITGA3 (p = 0.001). However, only the ITGAV and ITGA6 gene markers for GS (hazard ratio (HR) = 3.209, 95% confidence interval (CI) = 1.412-7.293, p = 0.005 and HR = 3.105, 95% CI = 1.367-7.055, p = 0.007, respectively), and ITGA3 for DFS (HR = 3.806, 95% CI = 1.573-9.209, p = 0.003), remained in the final Cox regression models. A scoring system was developed to evaluate the risk of patient death based on the number of markers for the components of the final GS model. Scores of 0, 1, or 2 were associated with the following mean survival rates [CI]: 47.162 [44.613-49.711], 39.717 [35.471-43.964], 30.197 [24.030-36.327], respectively.Multivariate mathematical models demonstrated an association between hyperexpression of the ITGAV and ITGA6 integrins and GS, and also between the ITGA3 integrin and DFS, in patients with colorectal tumours. A risk scoring system based on detected hyperexpression of 0, 1, or 2 markers (e.g., ITGAV and/or ITGA6) was also found to accurately correlate with the GS curves generated for the present cohort.

Colorectal cancer dissemination depends on extracellular matrix genes related to remodeling and degradation of the matrix structure. This investigation intended to evaluate the association between FN-1, ITGA-3, ITGB-5, MMP-2, and MMP-9 gene and protein expression levels in tumor tissue with clinical and histopathological neoplastic parameters of cancer dissemination. The expression associations between ECM molecules and selected epithelial markers EGFR, VEGF, Bcl2, P53, and KI-67 have also been examined in 114 patients with colorectal cancer who underwent primary tumor resection. Quantitative real-time PCR and immunohistochemistry tissue microarray methods were performed in samples from the primary tumors. The gene expression results showed that the ITGA-3 and ITGB-5 genes were overexpressed in tumors with lymph node and distant metastasis (III/IV-stage tumors compared with I/II tumors). The MMP-2 gene showed significant overexpression in mucinous type tumors, and MMP-9 was overexpressed in villous adenocarcinoma histologic type tumors. The ECM genes MMP9 and ITGA-3 have shown a significant expression correlation with EGFR epithelial marker. The overexpression of the matrix extracellular genes ITGA-3 and ITGB-5 is associated with advanced stage tumors, and the genes MMP-2 and MMP-9 are overexpressed in mucinous and villous adenocarcinoma type tumors, respectively. The epithelial marker EGFR overactivity has been shown to be associated with the ECM genes MMP-9 and ITGA-3 expression.

OBJETIVO: Avaliar a relação da expressão da caderina-E com o intervalo livre de doença (ILD), com a sobrevida (S) e com o estadiamento de doentes operados por adenocarcinoma colorretal. MÉTODO: Foram estudados 89 doentes (41 homens e 48 mulheres) com média de idade de 62,3 anos. A distribuição segundo o estadiamento TNM foi: estádio I - 13 (14,6%) doentes, estádio II - 29 (32,6%), estádio III - 23 (25,8%) e estádio IV - 24 (27,0%). Sessenta e sete doentes foram submetidos à operação radical e acompanhados por um período médio de 37,9 meses. Os tumores foram examinados por técnica imuno-histoquímica e classificados como positivos ou negativos em relação à expressão da caderina-E. RESULTADOS: A caderina-E foi positiva em 49,4% e negativa em 50,6% dos doentes. A recidiva ocorreu em 22,4% dos doentes e não esteve relacionada à expressão da caderina-E. Não foi observada relação da caderina- E com intervalo livre de doença e com a sobrevida. Também não foi verificada a associação da caderina-E (p = 0,958) com o estadiamento TNM. CONCLUSÃO: Os resultados verificados nesta pesquisa não permitem relacionar a expressão tissular da caderina-E com o estadiamento e o prognóstico do adenocarcinoma colorretal.

CONTEXT: The interest in the results from comparisons between handsewing and stapling in colorectal anastomoses has been reflected in the progressive increase in the number of clinical trials. These studies, however, do not permit conclusions to be drawn, given the lack of statistical power of the samples analyzed. OBJECTIVE: To compare stapling and handsewing in colorectal anastomosis, testing the hypothesis that in colorectal anastomosis the technique of stapling is superior to that of handsewing. DESIGN: A systematic review of randomized controlled trials. SURVEY STRATEGY: Systematic revision of the literature and meta-analysis were used, without restrictions on language, dates or other considerations. The sources of information used were Embase, Lilacs, Medline, Cochrane Controlled Clinical Trials Database, and letters to authors and industrial producers of staples and thread. SELECTION CRITERIA: Studies were included in accordance with randomization criteria. The external validity of the studies was investigated via the characteristics of the participants, the interventions and the variables analyzed. An independent selection of clinical studies focusing on analysis of adult patients attended to on an elective basis was made by two reviewers. DATA COLLECTION AND ANALYSIS: The methodological quality of the studies was assessed by the same reviewers. In addition to the randomization criteria, the masking, treatment intention, losses and exclusions were also analyzed. The meta-analysis was performed using risk difference and weighted average difference, with their respective 95% confidence intervals. The variables studied were mortality, clinical and radiological anastomotic dehiscence, anastomotic stricture, hemorrhage, reoperation, wound infection, time taken to perform the anastomosis and hospital stay. RESULTS: Nine clinical trials were selected. After verifying that it was possible to perform one of the two techniques being compared, 1,233 patients were included, of whom 622 underwent stapling and 611 the handsewing technique. No statistical difference was found between the variables, except for stenosis, which was more frequent in stapling (p < 0.05), and the time taken to perform the anastomosis, which was greater in handsewing (p < 0.05). CONCLUSION: The evidence found was insufficient to demonstrate superiority of the stapling method over handsewing, independent of the level of colorectal anastomosis.

OBJETIVO: Avaliar o efeito da colostomia proximal na cicatrização de anastomoses colocólicas em ratos com obstrução intestinal. MÉTODO: 72 ratos foram divididos em três grupos: grupo controle (C), submetido à anastomose colocólica e à colostomia proximal na ausência de oclusão intestinal; grupo sem colostomia (SC), submetido à oclusão intestinal de 72 horas e à anastomose colocólica primária; grupo com colostomia (CC) submetido à oclusão intestinal de 72 horas, à anastomose colocólica primária e à colostomia proximal. A cicatrização anastomótica foi avaliada em dois períodos, nos 2º e 7º dias de pós-operatório, em relação à deiscência anastomótica, aderências, epitelização mucosa, pressão de ruptura e a variáveis histológicas por estudo convencional e informatizado. RESULTADOS: verificou-se maior tendência a deiscência anastomótica no grupo SC (12,5%), e elevada incidência de complicações da colostomia no grupo CC (13%), entretanto tais resultados não apresentaram diferença estatística significante. No que se refere às demais variáveis analisadas para verificação da cicatrização anastomótica deve-se considerar que houve equivalência entre os três grupos nos dois períodos analisados. CONCLUSÃO: Não há diferença entre a cicatrização de anastomoses colocólicas associadas ou não à colostomia proximal, em ratos com obstrução intestinal.

A anastomose com sutura é método consagrado, apresentando desvantagens teóricas representadas pelo trauma tecidual, edema e alteração da microcirculação. Além disso, o fio de sutura, sendo corpo estranho, determina reação inflamatória, propiciando a aderência e a proliferação de bactérias, assim como de células neoplásicas que seriam evitadas ao se usar método de anastomose sem sutura. A procura por método de anastomose em que não se utilizasse fio de sutura vem sendo realizada desde o início deste século. Com o advento das novas aquisições tecnológicas foi desenvolvido método de anastomose sem sutura através do anel biofragmentável. Esse anel sofre desintegração por hidrólise, sendo eliminado com a evacuação, não permanecendo corpo estranho na anastomose. Esse instrumento permite a realização de anastomose sem sutura, por meio da compressão das paredes intestinais justapostas. O objetivo desse estudo prospectivo e casualizado, foi o de comparar os resultados clínicos e endoscópicos de anastomoses colocólicas, eletivas e de baixo risco, realizadas com anel biofragmentável e com fio de sutura não absorvível. CASUÍSTICA E MÉTODOS: A casuística foi composta por 36 doentes, divididos em dois grupos de 18, que foram denominados Grupo I (anel biofragmentável ) e Grupo II (sutura com fio não absorvível ), constituídos de doentes comparáveis. RESULTADOS: Os parâmetros de avaliação do período intra-operatório, revelaram que a anastomose com anel biofragmentável despende menor tempo para sua realização. Não se detectou diferença estatisticamente significante entre os dois grupos com relação à incidência de complicações pós-operatórias, mortalidade e avaliação clínica ambulatorial. A incidência de deiscência anastomótica só ocorreu no Grupo I. A análise endoscópica da anastomose no período pós-operatório não demonstrou diferença quanto à perviedade, contratilidade, elasticidade e grau de epitelização. O Grupo II apresentou maior incidência de fio de sutura na anastomose em relação ao Grupo I sendo esta diferença estatística significante. CONCLUSÕES: O anel biofragmentável permite a realização de anastomose de colo mais rápida do que aquela realizada com fio de sutura. Este método de anastomose determinou, na análise global da complicações clínicas, resultados semelhantes ao uso de fio de sutura. O método de anastomose sem sutura apresentou o inconveniente de determinar maior incidência de deiscência anastomótica e como vantagem estabeleceu presença de corpo estranho na anastomose em menor porcentagem.

Colorectal cancer is a clinical entity of a persistent relevance in clinical practice and its early diagnosis is a determinant factor to obtain better therapeutic results. Tumor markers are helpful means for a better approach to individuals with such neoplasm. In the present review, the authors analyze the phases in which surgical-clinical treatment markers must be used: diagnosis, determination of tumor stage, establishment of prognosis and detection of recurrence. Current and future markers and the consensus on their use are discussed. Causal factors for errors in diagnosis with markers and perspectives of use are also presented.

ABSTRACT BACKGROUND: Irritable bowel syndrome (IBS) is a complex gastrointestinal disorder, whose understanding is relatively uncertain, and the treatment guidance decision still represents a challenge. OBJECTIVE: To identify and critically appraise systematic reviews (SRs) published in the Cochrane Database of SRs (CDSR) on the effects of interventions (pharmacological and non-pharmacological) for the treatment of IBS. METHODS: The search was conducted at the Cochrane Library in May 2020. The methodological quality of the SRs was evaluated by the AMSTAR-2 tool. RESULTS: Eight SRs with moderate to high quality were included, which addressed the treatments: (a) pharmacological: volume agents, antispasmodics, antidepressants and tegaserod; and (b) non-pharmacological: homeopathy, acupuncture, phytotherapy, biofeedback, psychological interventions and hypnotherapy. The results were favorable to antispasmodic drugs and antidepressants regarding the improvement of clinical symptoms. There was no difference between volume agents or tegaserod when compared to placebo. Acupuncture and homeopathy showed a little improvement in symptoms compared to placebo, but the certainty of this evidence was considered low to very low. Psychological interventions seem to improve the overall assessment of the patient and relief symptoms such as abdominal pain. However, there was no long-term follow-up of these patients. The results of the other treatments were considered uncertain due to the high risk of bias. CONCLUSION: Considering the low quality of the studies included in the SRs, pharmacological treatment with antispasmodics and antidepressants seems to be beneficial for patients with IBS. Among non-pharmacological interventions, psychological interventions seem to be beneficial. However, further clinical trials are recommended with greater methodological rigor to prove these findings.

Littré's hernia is an extremely rare surgical event. It is characterized by the presence of Meckel's diverticulum in the hernial sack. The authors report one case of Littré's hernia in a 42 year-old male who had the diagnosis accomplished in the intraoperative. The diverticulum presented no signs of complications and was treated conservatively , without exeresis.