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In this single center case series with nine percent primary diversion, 86 of 94 patients alive and with complete follow-up at one year had a functioning anastomosis. Seventy-five of the initial 99 patients never had a stoma. Meaning: Highly selective fecal diversion in combination with proactive leakage management, low anastomoses can be preserved safely, and the majority of patients will be spared all disadvantages of a diverting stoma.

Here, we present a case that highlights the crucial pitfalls related to the presence of morular metaplasia (MM) in endometrioid carcinoma, which are insufficiently recognized in the routine pathology practice. A 45-year-old woman underwent hysterectomy with rectosigmoidectomy due to a 11-cm mass involving uterus, right ovary, and rectosigmoid colon. Histologically, the lesion appeared as a predominantly solid carcinoma with a minor glandular component. Results of the first immunohistochemical analysis suggested a colorectal origin (PAX8-, CK7-, WT1-, hormone receptors-, and CDX2+ in the absence of mucinous features). Subsequent immunohistochemistry (nuclear β-catenin+, CD10+, and low ki67 in the solid areas) supported a diagnosis of endometrioid carcinoma with diffuse MM. This case remarks that morphological and immunohistochemical features of MM may conceal the glandular architecture and the typical immunophenotype of endometrioid carcinomas. Acknowledging the diagnostic issues related to MM appears crucial to avoid misdiagnosis and inappropriate patient management.

The implantation cyst occurs from the imprisonment and subsequent proliferation of the colonic mucosa below the submucosa during mechanical stapling. The understanding and definition of the evaluation protocol of these lesions is important, since they can generate the need for a new complex surgical procedure and cause anxiety in patients and surgeons. This case reports the occurrence of a subepithelial lesion in follow-up imaging of a patient who underwent videolaparoscopic rectosigmoidectomy for adenocarcinoma of the proximal rectum, submitted to an endoscopic attempt to drain/detangle the lesion and subsequent histopathological analysis showing colic mucosa without changes. In line with Katsumata, it is suggested to asymptomatic patients without alteration of the CEA or suspicious imaging signs a follow up with periodic imaging methods. For symptomatic patients with normal CEA, or whose lesions are growing at follow-up exams, it is suggested to continue with the investigation, with biopsy and/or effluent sample for histopathological study in addition to an attempt at symptomatic resolution. Finally, in the presence of an alteration in CEA, despite symptoms, it is suggested that the lesion be managed as a suspected local tumor recurrence. Resumo: O cisto de implantação ocorre a partir do aprisionamento e subsequente proliferação da mucosa colônica abaixo da submucosa durante o grampeamento mecânico. A compreensão e definição do protocolo de avaliação dessas lesões é importante, pois podem gerar a necessidade de um novo procedimento cirúrgico complexo e causar ansiedade em pacientes e cirurgiões. Este caso relata a ocorrência de uma lesão sub-epitelial na imagem de seguimento de um paciente submetido à retossigmoidectomia por via videolaparoscópica devido a adenocarcinoma do reto proximal, submetido a uma tentativa endoscópica de drenar/remover a lesão e subsequente análise histopatológica mostrando a mucosa cólica sem alterações. De acordo com Katsumata, sugere-se que pacientes assintomáticos sem alteração do CEA ou sinais de imagem suspeitos tenham um seguimento com métodos de imagem periódicos. Para pacientes sintomáticos com CEA normal, ou cujas lesões mostrem crescimento nos exames de seguimento, sugere-se continuar a investigação, com biópsia e / ou amostra de efluente para estudo histopatológico, além de uma tentativa de resolução sintomática. Finalmente, na presença de uma alteração no CEA, apesar dos sintomas, sugere-se que a lesão seja tratada como uma suspeita de recorrência local do tumor.

Background Compared to traditional open surgery, laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain, a shorter hospital stay, and better quality of life. In 2007, Whiteford et al reported the first natural orifice trans-anal endoscopic surgery (NOTES) sigmoidectomy using transanal endoscopic microsurgery. To date, all cases of NOTES colorectal resection have included a hybrid laparoscopic approach with the use of established rigid platforms. Aim To introduce a novel technique of peroral external traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis by using only currently available and flexible endoscopic instrumentation in a live porcine model. Methods Three female pigs weighing 25-30 kg underwent NOTES rectosigmoid resection. After preoperative work-up and bowel preparation, general anesthesia combined with endotracheal intubation was achieved. One dual-channel therapeutic endoscope was used. Carbon dioxide insufflation was performed during the operation. The procedure of trans-anal NOTES rectosigmoidectomy included the following eight steps: (1) The rectosigmoid colon was tattooed with India ink by submucosal injection; (2) Creation of gastrostomy by directed submucosal tunneling; (3) Peroral external traction using endoloop ligation; (4) Creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling; (5) Peroral external traction-assisted dissection of the left side of the colon; (6) Trans-anal rectosigmoid specimen transection, where an anvil was inserted into the proximal segment after purse-string suturing; (7) Intracorporeal colorectal end-to-end anastomosis using a circular stapler by a single stapling technique; and (8) Closure of gastrostomy using endoscopic clips. All animals were euthanized immediately after the procedure, abdominal exploration was performed, and the air-under-water leak test was carried out. Results The procedure was completed in all three animals, with the operation time ranging from 193 min to 259 min. Neither major intraoperative complications nor hemodynamic instability occurred during the operation. The length of the resected specimen ranged from 7 cm to 13 cm. With the assistance of a trans-umbilical rigid grasper, intracorporeal colorectal, tension-free, end-to-end anastomosis was achieved in the three animals. Conclusion Peroral traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis is technically feasible and reproducible in an animal model and is worthy of further improvements.

Background Rectal prolapse (RP) is an uncommon perineal disease. It is defined as a complete protrusion or intussusception of the rectum through the anus. Strangulation of the RP is rare. This complication presents requires an emergent surgery. This case presentation aims to report the therapeutic management and results of this condition. Observation A 29-year-old men, who consulted for a sudden, painful, irreducible rectal prolapse. At the anus, there was an irreducible, edematous, without signs of ischemia or necrosis rectal prolapse measuring 25*10 cm wide. The laboratory data showed a high white blood cell count and elevated C-reactive protein. After a failure of external manual reduction under general anesthesia, the patient underwent emergent surgery. The procedure consisted of a rectosigmoidectomy with coloanal anastomosis using a perineal approach according to the Altemeier technique associated to a diverting ileostomy. The postoperative follow-up was uneventful. The patient was discharged at post-operative day five. Conclusion Strangulated RP is a rare complication. Altemeier procedure remains the intervention of choice in this situation., Highlights • An uncommon perineal disease. • Therapeutic surgical management and issues. • Socio-psychological impact of this disease.

Introduction: The development of internal hernias due to the mesocolon defect after laparoscopic colectomy is a rare complication with only 39 cases described. There are controversies whether the closure of the defect of the mesocolon after resection of the colon could prevent the development of this complication. Objective: To describe a case of intestinal obstruction due to internal hernia through the mesocolon defect after laparoscopic rectosigmoidectomy and to perform a literature review. Case report: A 59-year-old woman was hospitalized for laparoscopic rectosigmoidectomy due to an adenocarcinoma located in the rectosigmoid junction. She underwent a rectosigmoidectomy by laparoscopy, with an extracorporeal mechanical anastomosis, without closure of the mesocolon defect. In the fifth postoperative day the patient presented an intestinal obstruction due to an internal hernia through the mesocolon defect confirmed by computerized tomography. During the exploratory laparotomy approximately 120 cm jejunum was identified through the mesocolon defect. The reduction of herniated small bowel was done without the need of intestinal resection. The mesocolon defect was corrected by continuous suture. After the reoperation, the patient presented a favorable recovery being discharged on the fifth day. Conclusion: Intestinal obstruction due to internal hernia after laparoscopic rectosigmoidectomy is a rare postoperative complication that can be avoided by the adequate closure of the mesocolon defect. Resumo: Introdução: O desenvolvimento de hérnias internas pelo defeito mesocólico após a realização de colectomia laparoscópica é uma complicação rara com apenas 39 casos descritos. Existem controvérsias se fechamento do defeito após a ressecção do cólon preveniria o desenvolvimento desta complicação. Objetivo: Descrever um caso de obstrução intestinal por hérnia interna pelo defeito mesocólico, após retossigmoidectomia laparoscópica e revisar a literatura relacionada ao tema. Relato do caso: Mulher, 59 anos foi internada para realizar ressecção cirúrgica de adenocarcinoma localizado na junção retossigmoideana. Foi submetida à retossigmoidectomia laparoscópica, com confecção de anastomose mecânica extracorpórea. O defeito mesocólico não foi corrigido no final do procedimento. No quinto dia de pós-operatório, a doente apresentou quadro de obstrução intestinal cuja tomografia computadorizada identificou presença de hérnia interna pelo defeito do mesocólon. Na laparotomia exploradora identificou-se que aproximadamente 120 cm de alças jejunais estavam herniadas através do defeito mesocólico. Realizou-se a redução do intestino delgado herniado sem necessidade de ressecção intestinal. O defeito foi corrigido por sutura contínua. Após a reoperação a doente apresentou evolução favorável recebendo alta no quinto dia. Conclusão: Obstrução intestinal após retossigmoidectomia laparoscópica consequente à formação de hérnia interna é complicação pós-operatória rara, com alta mortalidade, que pode ser evitada pelo fechamento criterioso do defeito do mesocólico. Keywords: Hernia/complications, Intestinal obstruction, Laparoscopy, Mesocolon, Colonic neoplasm, Palavras-chave: Hérnia/complicações, Obstrução intestinal, Laparoscopia, Mesocolon, Neoplasias do colo

Objective: To demonstrate the standardization of deep endometriosis surgery with intestinal involvement. Methods: Prospective study evaluating 74 women undergoing standardized surgery for deep intestinal endometriosis. Divided into two groups, according to the findings of three-dimensional anorectal ultrasound, Group I with lesions affecting perirectal fat and Group II with lesions affecting at least the muscular layer of the rectum. Results: There was no statistically significant difference between the groups in relation to the size of the focus and the distance of the lesion to the puborectalis muscle (p > 0.05). The type of surgery performed was laparoscopy without lesions in one patient (1.35%), disk resection in 13 patients (17.56%), shaving in 45 patients (60.81%), and rectosigmoidectomy in 15 patients (20.27%). The complications were bleeding from the drain with conservative treatment in three patients (4.05%), fistula in two patients submitted to the shaving method (2.70%), and three patients (4.05%) with lower anterior recession syndrome (LARS), with improvement from conservative treatment. Lesions in other organs were also observed during videolaparoscopy. Conclusion: Surgical standardization is important to guide the general/colorectal surgeon in the effective approach of intestinal endometriosis. Resumo: Objetivo: Demonstrar a padronização da cirurgia de endometriose profunda com acometimento intestinal. Métodos: Estudo prospectivo que avaliou 74 mulheres submetidas à cirurgia padronizada para endometriose profunda intestinal. Divididas em dois grupos, segundo os achados da ultrassonografia anorretal tridimensional, o Grupo I com lesões acometendo a gordura perirretal e o Grupo II com lesões acometendo, pelo menos, a camada muscular própria do reto. Resultados: Não houve diferença estatisticamente significativa entre os grupos em relação ao tamanho do foco e à distância da lesão ao músculo puborretal (p > 0,05). O tipo de cirurgia realizada foi laparoscopia sem achados da lesão em um paciente (1,35%), ressecção em disco em 13 pacientes (17,56%), Shaving em 45 pacientes (60,81%) e retossigmoidectomia em 15 pacientes (20,27%). As complicações encontradas foram sangramento pelo dreno com tratamento conservador em 3 pacientes (4,05%), fístula em 2 pacientes submetidas ao método de shaving (2,70%), 3 pacientes (4,05%) com Síndrome da Ressecção Anterior do Reto (LARS), com melhora ao tratamento conservador. Lesões em outros órgãos também foram observadas durante a videolaparoscopia. Conclusão: A padronização cirúrgica é importante para orientar o cirurgião geral/colorretal na abordagem eficaz na endometriose intestinal. Keywords: Endometriosis, Ultrasonography, Laparoscopy, Colorectal surgery, Palavras-chave: Endometriose, Ultrassonografia, Laparoscopia, Cirurgia colorretal

Background/aims Suboptimal bowel function can negatively affect colon cleansing for colonoscopy after surgery. Very few studies have compared the relationship between the colorectal resection and the bowel preparation quality. We postulated that the colon cleansing quality in patients with a history of colorectal surgery might not be inferior to that of patients with no resection history. Materials and methods Overall, 200 patients were enrolled in the study and distributed into two groups: the resection group (RG) and the control group. The surgical maneuvers were classified as right colectomy, left colectomy, and rectosigmoidectomy. The bowel preparation was performed using 2-L low-volume or 4-L high-volume regimens, and the preparation quality was evaluated using the modified Boston Bowel Preparation Scale (BBPS). Results There were no significant differences in achieving adequate cleansing observed between the RG and the control group (modified BBPS of 6-9; 88% vs. 88%). According to the logistic regression analysis of the RG, patients with a left colon resection had an odds ratio (OR) of 0.27 (p=0.003) for achieving a successful cleansing, and the low-volume preparation (OR=3.092, p=0.023) was the main predictor of a successful cleansing procedure. However, a longer time between colonoscopy and surgery was not related to unsuccessful bowel cleansing. Conclusion Our study demonstrates that a history of colorectal surgery is not a risk factor for inadequate colon cleansing.

INTRODUCTION Transanal total mesorectal excision (TaTME) for rectal cancer offers a better vision of the dissection planes and facilitates the distal transection of the rectum. The aim of this study was to compare functional outcomes, local recurrence rate y 2-years overall survival and disease free survival rates of TaTME and laparoscopic total mesorectal excision (LPC TME). MATERIAL AND METHODS From December 2016 to October 2018, 50 patients (36 males and 14 females) with low rectal cancer and an age of 67 (55.7-75.2) years underwent TME (20 TaTME and 30 LPCTME). RESULTS Clinical features and quality indicators for rectal cancer surgery were similar in both groups. After a median follow-up of 35 (30-40) months, low anterior resection syndrome rate was 14% (15% vs 13%, p = 0.043), fecal incontinence rate was 8% (15% vs 3%, p = 0.017) and sexual dysfunction was 8% (15% vs 3%, p = 0.017). Systemic recurrence rate was 10% (15% vs 6%, p = 0.377). One patient presented local recurrence 2 years after TATME. 2-years overall survival rate was 98% (95% vs 100%, p = 0.400) and 2-years disease free survival rate was 90 % (85% vs 93%, p = 0.377). CONCLUSION Although 2-years overall survival and disease free survival rates were similar in TaTME and LPC TME group, functional outcomes were worse after TATME in our study.

Introduction. Large resections may be necessary in cytoreductive surgery for endometriosis, which present risk of urinary and bowel complications. Presentation of Case. A 29-year-old woman underwent multidisciplinary laparoscopy for endometriosis in a private practice setting for acyclic pelvic pain and cyclic abdominal distension with changes in bowel habits and frequent sensation of incomplete defecation. After surgery, urodynamics remained normal and bowel function improved subjectively and objectively per dynamic magnetic resonance defecography (DMRD). The five-month follow-up found improvements in pain scores, bowel function, and health-related quality of life (assessed by the full versions of the Short Form 36 and Endometriosis Health Profile 30 scales). Discussion. Animus may contribute to the bowel symptoms in women with endometriosis. DMRD provides additional objective parameters for comparing pre- and postoperative functions. Conclusion. A nerve-sparing segmental rectosigmoidectomy for endometriosis carefully executed by a multidisciplinary team can preserve the function of different pelvic organs.

You may wonder why a minor operation like rectal prolapse repair is included in this book on major gastrointestinal operations. We include it because it provides a good opportunity to understand the rectal anatomy by viewing it from a different angle. This chapter describes an established rectosigmoidectomy procedure via the perineal approach, commonly known as the Altemeier procedure. The operation time is 1 h.

Study Objective The objective of the study is to show that a qualified team and the systematization of the surgical technique help to decrease the number of complications in laparoscopic surgery for deep endometriosis. Design Retrospective cohort during the period between 2017 to 2020. Setting Laparoscopic operating room with patient in semi-gynecological position. Patients or Participants 355 women with deep endometriosis. Interventions Surgeries were performed by the same team, with the same systematization. In all cases were performed cavity review, oophoroplasty and ovarian fixation, ureterolysis, hypogastric nerves identification and bowel disease treatment, and endometrial nodules exeresis. Postoperative complications, hospitalization time, fistulas, etc. were evaluated. Measurements and Main Results Of all the 355 surgery patients of the group, 86,98% had bowel disease, 40,82% had urinary tract disease, 24,85% ovary disease, 1,77% diaphragmatic disease, 3,55% parametrium injuries, concurrent or not. A percentage of 15,97% hysterectomies were performed, out of the total of 355 patients. The techniques used to treat bowel disease were rectosigmoidectomy in 15,38% of the cases, shaving in 39,05% of the cases, circular stapling in 14,79% of the cases, appendectomy in 17,15% of the cases, and right colectomy in 0,59% of the cases. Only one protective colostomy was performed in one of the cases (0,59%) due to the height of the wound when compared to the anal verge, and no drains were used in any of the cases. The average hospitalization time was 3 days (2 to 10), and no blood transfusions were required. On postoperative, there were 0,59% of cases with rectovaginal fistulas and 0,59% of cases with intestinal perforation. Conclusion The data showcased in our group review showed that deep endometriosis surgery is a high complexity procedure and should be performed by surgeons with a comprehensive experience in anatomy, together with multidisciplinary surgeons and systematizing the surgery technique, to achieve better results.

Study Objective Report surgical approach in a difficult case of Giant Ovarian Endometrioma. Design Case report with imaging exams and description of the surgical approach, with narrated surgical video. Setting The prevalence of endometrioma is unknown, but it is expected to affect around 17-44% of women with endometriosis. The surgical management is recommended in cases as the large endometriomas. Usually, the endometrioma is adhered to the surrounding structure, therefore it is fundamental the surgeon's anatomic landmark knowledge and their experience in deep endometriosis surgery. Patients or Participants Female, 40 years old with previous nephrectomy and a giant ovarian endometrioma associated with deep endometriosis. Interventions Patient was submitted to laparoscopic surgery. A giant ovarian endometrioma occupied all the pelvis. The first step was to drain it, to make it possible to view the pelvis. Adhesiolysis was performed followed by left oophorectomy. It was primordial to dissect and visualize her only ureter. Her ureter was enlarged due to its adherence with a paracervical endometriosis nodule. After the ureterolysis and endometriosis nodule removal, there was no sign of ureter dilatation anymore. To perform a complete treatment for deep endometriosis, segmental rectosigmoidectomy and appendicectomy were done. Measurements and Main Results The patient was stable after the procedure, with hospital discharge on the 5th day after surgery. In the follow-up, the diet was slowly re-introduced, with good response. The pathology reports showed endometriosis in all specimens. The renal labs remained normal. Conclusion Giant ovarian endometrioma cases are challenging due to its requirement of surgical treatment. The imaging exams as magnetic resonance and ultrasound would give the surgeon a clue, but the final aspect of the pelvis is only known during the surgery. Therefore, it is very relevant to start the procedure with a strategy in mind.

Introductions: Optimum operation for rectal prolapse is not established yet. Laparoscopic procedures are gaining popularity and on the other hand, proponents of perineal procedures are also not scarce. Methods: Rectal prolapse cases operated during five years in a tertiary care hospital regarding immediate post-surgical outcome of abdominal and perineal procedures were reviewed. Results: Total 30 patients of rectal prolapse were operated during the study period. Over the years, Altemiere's rectosigmoidectomy outnumbered abdominal procedures. Immediate postoperative complications were similar except for one case in perineal group needing laparotomy for intraperitoneal bleed. Conclusions: Altemiere's rectosigmoidectomy was safe and increasingly acceptable procedure at our center for patients with rectal prolapse. Keywords : abdominal rectopexy, Altemiere's rectosigmoidectomy, rectal prolapse

Introduction: Diverticular disease of the colon (DDC) is the fifth most common gastrointestinal disease in developed Western countries, with mortality rates of 2.5 per 100,000 inhabitants per year. Objective: The objective of this study is to compare the occurrence of complications, conversion rate, use of stoma, deaths and time of hospitalization among patients undergoing rectosigmoidectomy for DDC and patients undergoing the same surgery for other reasons. Method: This was an observational retrospective comparative study. This study was approved by the ethics committee of the Hospital Felicio Rocho – Minas Gerais, Brazil – and the data were obtained from the same hospital database. Results: The groups were classified according to age, gender, presence of comorbidities, and ASA classification. There was no evidence indicating a significant difference between groups. In this analysis, no perioperative complications were observed and there was no need for a stoma, and no deaths or fistulas occurred. Conclusion: Elective laparoscopic surgical treatment of DDC in the analyzed group showed no difference in complications, duration of surgery and hospitalization time versus control group. Therefore, the laparoscopic surgical treatment of diverticular disease translates into an excellent tool for both the surgeon and the patient. Resumo: Introdução: A Doença Diverticular do Cólon (DDC) é a quinta doença gastrointestinal mais frequente nos países desenvolvidos do ocidente com índices de mortalidade de 2,5 por 100.000 habitantes por ano. Objetivo: O objetivo desse estudo é comparar a ocorrência de complicações, taxa de conversão, utilização de estoma, óbito e tempo de internação entre pacientes submetidos a retossigmoidectomia por DDC e pacientes submetidos ao mesmo procedimento cirúrgico por outras causas. Método: Trata-se de um estudo comparativo, retrospectivo observacional. Este estudo foi aprovado pelo comitê de ética do Hospital Felício Rocho - Minas Gerais, Brasil - e os dados foram obtidos no banco de dados do mesmo hospital. Resultados: Os grupos foram classificados em relação à idade, sexo, presença ou não de comorbidades e classificação ASA. Observou-se que não existem evidências indicando diferença significativa entre os grupos. Não houveram complicações per-operatórias, necessidade de estoma, bem como óbitos ou fístulas nesta análise. Conclusão: O tratamento cirúrgico eletivo videolaparoscópico da DDC no grupo analisado não apresentou diferença quanto às complicações, o tempo de cirurgia e o tempo de internação em relação ao grupo controle. Portanto, o tratamento cirúrgico laparoscópico da doença diverticular traduz-se em excelente ferramenta tanto para o cirurgião quanto para o paciente. Keywords: Disease diverticular, Colorectal cancer, Videolaparoscopy, Palavras-chave: Doença diverticular, Câncer colorretal, Videolaparoscopia

Introduction/Background The present study was designed to evaluate the effect of the peritoneal stripping method termed ‘wide resection of the pelvic peritoneum (WRPP)’ on eliminating disseminated tumors in the pelvic peritoneum and whether there is any survival benefit for patients with epithelial ovarian cancer. Methodology From January 2000 to December 2018, 460 patients with epithelial ovarian cancer were treated surgically at Kumamoto University Hospital. The clinical and surgical records of these patients were reviewed retrospectively, and 225 patients with ovarian cancer who underwent standard definitive surgery were included in this study. Eligible patients with ovarian cancer were divided into 3 groups according to surgical approach. Patients in the standard surgery group underwent cytoreduction with standard surgical techniques (n=65). The WRPP group consisted of patients who underwent standard surgery plus WRPP (n=125). The RS group included patients who required standard surgery plus rectosigmoidectomy (RS) (n=35). The primary outcome measure was overall survival. The secondary endpoint was recurrence-free survival. Results Overall survival was significantly longer in the WRPP group than in the standard surgery group for patients with stage III–IV disease (P Conclusion WRPP is an effective procedure that should be a part of the skill set of any gynecological surgeon performing surgical cytoreduction in patients with advanced ovarian cancer. The addition of this surgical technique has the potential to improve patient outcomes. Disclosure Nothing to disclose.

Laparoscopic surgery is performed worldwide, even for cases of rectal cancer close to the anus, and advances in surgical instruments and techniques have increased the number of cases for which anastomosis can be performed, even those cases for which abdominoperineal resection was performed previously. Consequently, as a measure to avoid complications in the event of suture failure after surgery, the number of cases of establishing diverting stoma has also increased. Diverting ostomy may require a closure operation earlier than planned due to colostomy complications, cases requiring a long period of time until closure due to postoperative complications, and cases in which closure operation cannot be performed. Herein, we report cases that took more than 36 months to allow closure of the diverting stoma.

Objetivo: Dissertar sobre um caso de paciente senil, com câncer colorretal, múltiplos pólipos adenomatosos, tumor renal e COVID-19. Analisar as terapêuticas propostas e a relevância da retossigmoidectomia e nefrectomia como tratamento ao adenocarcinoma retal e carcinoma renal. Detalhamento do caso: Paciente, masculino, 82 anos, admitido em 2019 com crises álgicas abdominais, equimose extensa em membro superior direito, petéquia em lábio inferior, calafrios, diaforese, hematúria e melena. À colonoscopia observou-se lesão retal vegetante, pólipos e diverticulose em cólon. Em junho de 2020 evoluiu com dispneia, febre, fraqueza e mal estar generalizado, confirmando COVID-19 em exames laboratoriais, evoluindo com cura 2 semanas após tratamento. Em agosto de 2020, em nova colonoscopia, observou-se diversos pólipos sésseis e lesão polipoide de 5cm em reto. À biópsia, indicado adenocarcinoma retal. À tomografia computadorizada de abdome e à ecografia de abdome total foi identificado tumor renal à direita. Paciente foi então submetido a retossigmoidectomia com anastomose colorretal e nefrectomia à direita. Considerações finais: A colonoscopia ainda é considerada um exame de rastreio excelente para os pólipos intestinais. Com relação ao adenocarcinoma retal, a retossigmoidectomia é considerada um tratamento curativo eficaz. Contudo, a COVID-19 é considerada um fator de risco com alta mortalidade em pacientes com câncer.

Full-thickness rectal prolapse is a painful and debilitating condition that often responds well to surgical intervention. The best method of surgical repair is a matter of debate. Historically, perineal approaches have been thought to have inferior outcomes and were therefore reserved for elderly and unfit patients. Despite recent data calling that into question, perineal approaches are still commonly performed and have their role. We present risks and benefits along with a description of perineal approaches for surgical treatment of rectal prolapse.

Modelo de estudo: Relato de caso. Objetivo do estudo: Relatar o caso de uma paciente com prolapso de tumor colorretal localizado no sigmoide. Metodologia: Relato de caso obtido de prontuario. Resultados: E relatado o caso de uma paciente que aguardava cirurgia para resseccao oncologica de um tumor colorretal, quando foi encaminhada ao servico de urgencias medicas com episodio de prolapso retal contendo massa tumoral pos-evacuacao, sem reducao espontânea. A paciente foi encaminhada a cirurgia de urgencia e submetida a uma abordagem transabdominal, na qual o prolapso foi reduzido, em seguida realizada retossigmoidectomia segundo procedimento de Hartamann com colostomia terminal no colon descendente. Conclusoes: No caso relatado, por tratar-se de um paciente portador de tumor de sigmoide prolapsado, a abordagem de escolha foi a retosigmoidectomia abdominal, seguindo os preceitos oncologicos, com ligadura da arteria mesenterica inferior em sua origem. Importância do problema: O prolapso de tumor de sigmoide, uma situacao clinica relativamente incomum na populacao adulta, e uma complicacao mais rara quando se trata dos tumores colorretais, deve ser tratado imediatamente apos o diagnostico para se diminuir o risco de isquemia do segmento prolapsado e sempre que possivel oferecer a cirurgia que siga os preceitos oncologicos de tratamento. Comentarios: No caso relatado, foi necessario uma abordagem cirurgica de urgencia, sendo a via abdominal escolhida por respeito aos principios da cirurgia oncologica e ao menor tempo cirurgico

The absence of residual disease remains the strongest predictor for disease free and overall survival in patients with advanced stage or relapsed ovarian cancer. However in most cases this desiderates is achieved after performing multiple visceral resections. Extended pelvic disease usually involves the surrounding pelvic viscera and leads to the necessity of digestive resections such as rectosigmoidectomy. In other cases other digestive resections such as right ileocolectomy might be needed. We present the case of a 64 year old patient in which an R0 resection was feasible after association of rectosigmoidectomy, right ileocolectomy and segmental ileal resection.

Study Objective The purpose of this video is to demonstrate the technical bases of a new laparoscopic technique for segmental resection of the rectosigmoid without intestinal exteriorization. Design 19 patients with indication for segmental resection of the rectosigmoid, due to infiltrative endometriosis, underwent this less invasive technique compared to classic techniques, which involves the externalization of the bowel through minilaparotomy or vaginally for intestinal resection and anvil placement. Setting The insertion of the endoscopic linear stapler and anvil, as well as the removal of the surgical specimen, were carried out through the vaginal route using intentional colpotomy or opportunely during the hysterectomy or resection of endometriosis infiltrating the posterior vaginal fornix. Patients or Participants Between June 2019 and January 2020, 19 patients underwent total laparoscopic rectosigmoidectomy to treat deep endometriosis. Interventions A 0˚ optic was introduced in a 10mm trocar and 3 auxiliary 5mm punctures were used in the inferior abdomen. Lesions located in the rectosigmoid were identified. The segment was prepared and isolated. A linear endoscopic stapler vaginally inserted was used to section the bowel. The proximal stump had its suture line opened with scissors and a purse-string suture was used to fix the anvil vaginally inserted into the abdominal cavity. A transanal circular stapler was used together with the anvil for anastomosis. Measurements and Main Results There were no intraoperative complications. At postoperative, there was no evidence of leakage, need for transfusion nor readmissions for a period of up to 60 days. Conclusion The total laparoscopic technique prevents traction and externalization of the intestinal loop through minilaparotomy or the vagina. There was a decrease in surgical time, less traction of the mesentery, preserving of vascularization and innervation, thus improving the quality of the anastomosis and protecting the nerves of the intestinal segment.

Study Objective To illustrate a technique of robotic vesicovaginal fistula repair in a patient with a prior history of pelvic radiation therapy and multiple abdominal surgeries. Design Stepwise demonstration of the technique with narrated video footage. Setting Barretos Cancer Hospital, Brazil. Patient A 59-year-old woman presenting with vesicovaginal fistula, who had a past history of rectosigmoidectomy followed by pelvic radiotherapy for Stage III colon cancer 23 years before, and robotic hysterectomy, bilateral salpingo-oophorectomy, omentectomy with bilateral pelvic and para-aortic lymphadenectomy for stage II Mixed Cell Endometrial carcinoma, which needed surgical reintervention because of a pelvic hematoma and complete vaginal cuff dehiscence. Interventions Robotic vesicovaginal fistula repair. Measurements and Main Results We performed a robotic approach to vesicovaginal fistula with several key strategies to perform the fistula repair and maintain the integrity of the abdominopelvic structures: 1-Careful bowel adhesiolysis involving multiple segments of the intestine to the abdominal and pelvic peritoneum. 2-Cystotomy using a vaginal probe guidance. 3-Fistulectomy by monopolar scissors, after ureteral orifices visualization. 4-Dissection of the retropubic space of Retzius, taking off bladder tension. 5-Transverse sutures to coapt the raw surfaces on the vaginal side and the bladder in two layers with minimal tension. 6-Transurethral instillation of methylene blue into the bladder. Conclusions Traditionally, patients with vesicovaginal fistula after pelvic radiation therapy and multiple abdominal surgeries are managed by laparotomy. This video demonstrates a feasible robotic approach to vesicovaginal fistula repair, with superior imaging affording a three-dimensional vision and stabilization of instruments allowing wrist-like movements.

Background At the severe end of the idiopathic constipation spectrum exist patients with chronic idiopathic constipation associated with an enormous megarectosigmoid, among whom few require surgery. We performed transanal proximal rectosigmoidectomy, involving preservation of a 5 cm rectal reservoir, to ameliorate inconsistent and unpredictable outcomes and fecal incontinence occurring in some patients operated on with other techniques. Methods We retrospectively observed patients with chronic idiopathic constipation with megarectosigmoid who underwent transanal proximal rectosigmoidectomy during July 2017–May 2018. We analyzed sex, age, operation indication, complications, functional outcome, and time of follow-up. We statistically compared the dosage of laxative before and after the procedure. Results Thirteen patients were included in the study. Median age during surgery was 8 years. In 9 cases, the indication for surgery was chronic intake of a daily high dose of Senna with failed weaning trials, and 4 had persistent fecal impaction with laxative-intolerance and refusal of rectal enemas. No intra/postoperative complications occurred. Currently, all 13 patients have daily voluntary bowel movements and no fecal accidents. Laxative dosage was significantly reduced (p = 0.007). Follow-up ranged 6–16 months. Conclusion Preliminary results suggest transanal proximal rectosigmoidectomy as an adequate alternative for patients requiring surgery for chronic idiopathic constipation with megarectosigmoid. Type of study Clinical research. Level of evidence Level III.

To outline the demographic and clinical characteristics of patients with deep intestinal endometriosis submitted to surgical treatment at a tertiary referral center with a multidisciplinary team, and correlate those characteristics with the surgical procedures performed and operative complications. A prospective cohort from February 2012 to November 2016 of 32 women with deep intestinal endometriosis operations. The variables analyzed were: age; obesity; preoperative symptoms (dysmenorrhea, dyspareunia, acyclic pain, dyschezia, infertility, urinary symptoms, constipation and intestinal bleeding); previous surgery for endometriosis; Enzian classification; size of the intestinal lesion; and surgical complications. The mean age was 37.75 (±5.72) years. A total of 7 patients (22%) had a prior history of endometriosis. The mean of the largest diameter of the intestinal lesions identified intraoperatively was of 28.12 mm (±14.29 mm). In the Enzian classification, there was a predominance of lesions of the rectum and sigmoid, comprising 30 cases (94%). There were no statistically significant associations between the predictor variables and the outcome complications, even after the multiple logistic regression analysis. Regarding the size of the lesion, there was also no significant correlation with the outcome complications ( The studied sample consisted of highly symptomatic women. A high prevalence of deep infiltrative endometriosis lesions was found located in the rectum and sigmoid region, and their size correlated directly with the extent of the surgical resection performed. Delinear as características das pacientes portadoras de endometriose profunda intestinal submetidas a tratamento cirúrgico em centro de referência com equipe multidisciplinar, e correlacionar tais achados com a extensão de doença e com os procedimentos cirúrgicos realizados. MéTODOS: Tratamento cirúrgico no período de fevereiro de 2012 a novembro de 2016 em 32 mulheres portadoras de endometriose profunda intestinal. Variáveis analisadas: idade; obesidade; queixas pré-operatórias: dismenorreia, dispareunia, dor acíclica, disquezia, sangramento uterino anormal, infertilidade, sintomas urinários, constipação, e sangramento intestinal; cirurgia prévia para tratamento de endometriose profunda; classificação de Enzian; técnica cirúrgica aplicada; tamanho da lesão intestinal; e complicações operatórias. A média de idade foi de 37,75 (±5,72) anos. Um total de 7 (22%) pacientes tinha histórico de abordagem prévia da endometriose. A média do maior diâmetro das lesões intestinais foi de 28,12 mm (±14,29 mm). Na classificação de Enzian, houve predomínio das lesões da região de reto ou retossigmoide no compartimento posterior, num total de 30 casos (94%). Não foi observada associação estatística significativa entre as variáveis preditivas e o desfecho da complicação, mesmo após análise de regressão logística múltipla. Quanto ao tamanho da lesão, também não houve correlação significativa com o desfecho complicação (

Purpose: Many different operations have been proposed for treating rectal prolapse, with varying recurrence rates and functional outcome. The main purpose of this study was to assess long-term results of surgery for prolapse of the rectum. Methods: We carried out a retrospective study to evaluate changing trends in surgical strategies and outcome in all patients treated in our hospital over 19 years. Results: Ninety-three patients were operated and 30 (32%) experienced recurrence of external prolapse during a median (range) follow-up time of 82 (2–231) months. There were 37 reoperations for recurrence, bringing the total number of operations to 130. From 1998 to 2010, laparoscopic posterior suture rectopexy was the preferred abdominal procedure with Delorme’s operation as the perineal alternative. Observed recurrence rates were 15/49 (31%) and 8/15 (53%) during a median observation time of 84 and 9 months, respectively. From 2011 to 2017, these procedures were replaced by ventral mesh rectopexy and Altemeier’s rectosigmoidectomy. The observed recurrence rate for ventral mesh rectopexy was 3/22 (14%) during a median observation time of 29 months. The 30-day mortality rate was 3% and complication rate 14%. Conclusions: The recurrence rates were high after all procedures, with no significant difference between posterior suture rectopexy and ventral mesh rectopexy, but the short observation time for the latter procedure is a limitation of the study. Both procedures had low complication rates, and ventral mesh rectopexy had no mortality.

The guideline for the treatment of rectal prolapse recommends that surgeons select appropriate surgical procedures individually based on each patient’s overall status. However, in cases of irreducible or incarcerated rectal prolapse, surgical options are quite limited. Here we present a case of an elderly woman with massive chronic irreducible rectal prolapse. An 87-year-old woman presented to our hospital with a complaint of massive rectal prolapse. The prolapsed rectum was over 20 cm long, and completely irreducible. She underwent perineal rectosigmoidectomy with levatorplasty known as Altemeier’s procedure. More than 30 cm of rectosigmoid colon was resected. After the operation, rectal prolapse was resolved completely. Her postoperative course was uneventful, and her quality of life and bowel movements improved. She has since been healthy without recurrence for over 2 years. Altemeier’s procedure is applicable even in cases of irreducible rectal prolapse and features acceptable safety and a satisfactory outcome.

Introduction Rectal prolapse is the complete protrusion of the rectum through the anal canal, incarceration rarely complicates rectal prolapse. Even more rarely, it becomes strangulated and gangrenous, necessitating emergency surgery. Case presentation We present the first reported case of strangulated acute rectal prolapse as the first manifestation of rectal prolapse. The patient was a 26-year-old man who presented with a 20×6 cm semi-spherical mass extra-anally. Rectosigmoidectomy with sacral rectopexy was performed, resecting 20 cm of the incarcerated rectum and sigmoid colon. The postoperative course was uneventful with a good final result after colostomy closure and continuity restoration. Conclusion The successful treatment of this patient illustrates the value of surgery in this difficult and unusual case scenario of rectal incarceration.

We present the case of a 75-year-old patient presenting with nausea, faecal emesis and intense abdominal meteorism, symptoms that began three before presentatiton and accentuated within the last 12 hours. Clinical examination revealed an incresead volume of the abdomen, painfully diffused on palpation. Abdominal radiography highlights multiple hydroaeric levels. Computerized tomography: Parietal, circumferential thickening with spiked contours of the middle sigmoid, associating the important distension of the overlying sigmoid, and, at the level of the stenosis, endoluminal, a linear image of 3mm thick and 24mm in length, spontaneous hyperdensity (180UH), important densification of neighboring fat. A rectosigmoidectomy with left flank colostomy – Hartmann’s operation, is performed. The opening of the lumen of the resected colonic portion reveals a foreign body (wooden fragment) impacted at this level. Histopathological diagnosis is colonic adenocarcinoma with a high degree of cellular differentiation (G1) invasively up to serum pT3N0. The particularity of the case consists in the difficulty of the pre- and intraoperative differential diagnosis between a neoplasia requiring an oncological visa management and an inflammatory pseudotumoral formation with a more limited surgical management. In emergency, the intraoperative macroscopic examination of the resection piece is essential. Differentiation between tumor and inflammatory aspects is difficult, which is why the presumptive diagnosis and the surgical decision must be inclined to the lesion with the most severe evolutionary potential.