RESUMEN

Resumen Introducción La clasificación y el manejo de los tumores neuroendocrinos (TNEs) han cambiado drásticamente en la última década. Se realiza un análisis crítico del manejo de los TENs colorrectales primarios intervenidos en nuestro centro a la luz de la nueva clasificación. Material y Método Análisis retrospectivo de los resultados del tratamiento quirúrgico radical de este tipo de lesiones en un período de 15 años. Resultados Se trata de 10 pacientes, con un promedio de 56 años (extremos 48-76), 6 ubicados cercanos a la válvula ileocecal (VIC) que se presentaron con un cuadro de obstrucción intestinal incompleto y tres en el recto (2 pólipos) y un pólipo en colon sigmoides. La cirugía efectuada incluye cuatro resecciones anteriores y seis colectomías derechas (con resección de una metástasis hepática en 1 caso). La mediana de seguimiento fue de 78,3 meses (extremos 8-180), durante el cual dos pacientes fallecen por metástasis a distancia. Conclusión Los TNEs ubicados en el colon habitualmente se presentaron como grandes masas tumorales cercanos a la VIC, lo que proporcionalmente no ocurre con las lesiones del rectosigmoides que son diagnosticados más precozmente como pólipos o lesiones submucosas. Algunos tumores de bajo grado muestran un compromiso avanzado en la pared y/o los linfonodos regionales lo que justifica la resección radical y/o la quimioterapia adyuvante. A la luz de esta experiencia, es necesario complementar el grado del tumor OMS 2010 (Ki-67 y número de mitosis) con el estadio TNM para caracterizar adecuadamente los TNEs, lo que influye en el manejo multidisciplinario.

Background The nomenclature and staging classification of neuroendocrine tumors (NETs) has changed drastically in the past decade. Objective To do a critical analysis of management of colorectal NETs in our institution in the light of the new classification. Methods We retrospectively reviewed the records of consecutive patients operated on with radical intention due to a colorectal NET in the last 15 years. Results There were 10 patients, median age was 56 years (range 48-76), six of them located near the ileocecal valve, three in the rectum (2 of them polyps) and one polyp in the sigmoid colon. Surgical procedure included four anterior resections and six right colectomy (one with hepatic resection). The median follow up was 78.3 months (range 8-180). Two patients died due to metastatic disease. Conclusion NETs located near de ileocecal valve were diagnosed usually as a big tumor with obstructing symptoms, while NETs of the rectum and sigmoid colon more frequently were detected as polyps or submucosal lesions. Some low grade TENs may invade the colonic wall and/or have metastasis in the regional lymph nodes and those cases need radical resection and/or adjuvant therapy. Combine the grade (Ki-67 and number and/or number of mitosis) of 2010 WHO classification with TNM showed prognostic value for classification and staging colorectal NETs with important therapeutic implications.

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

Objetivo: Presentamos nuestra experiencia en el tratamiento quirúrgico de esta patología con la técnica de la rectosigmoidectomía perineal. Material y método: Se trata de una serie retrospectiva, consecutiva de 17 pacientes. Resultados: Predomina el género femenino y el promedio de edad es de 62 años. La morbilidad alcanza el 23%, aunque casi toda de menor gravedad, con solo un paciente reoperado. La recidiva es del 6%, con mejoría de los síntomas en un 88%. Conclusión: Concluimos que es una técnica segura, con una morbilidad controlada y con buenos resultados a mediano plazo con un adecuado control de la recidiva y mejoría de la continencia en un alto porcentaje de los pacientes.

Aim: We present our experience with perineal rectosigmoidectomy for the treatment of rectal prolapse. Material and method: It is a retrospective, consecutive series of 17 patients. Results: Predominantly female and the average age is 62 years. Morbidity reached 23%, but almost all less serious, with only one reoperation. Recurrence is 6%, and the improvement in continence is 88%. Conclusion: We conclude that it is a safe technique with a controlled morbidity and good results with low recurrence and improvement of continence in a high percentage of patients.

Asunto(s)

RESUMEN

Objetivo: El objetivo de este estudio es mostrar los resultados inmediatos y alejados de la exenteración pélvica total (EPT) en el manejo de tumores primarios de recto localmente avanzados. Se describe una alternativa técnica en los casos de EPT supraelevador. La EPT puede ser la única oportunidad de curación en pacientes con tumores pélvicos de gran volumen. Material y método: Se incluyen tumores T4 por la estadificación clínica o los hallazgos operatorios sometidos a una EPT con intención curativa. Resultados: En un periodo de 16 años se intervienen con esta técnica 10 pacientes, 6 de los cuales recibieron radioquimioterapia neoadyuvante. La técnica clásica se empleó en 3 pacientes y la EPT supraelevador, en 6. El promedio de hospitalización fue de 36 días (rango, 18-97) y la morbilidad alcanzó el 80%. El estudio de la pieza operatoria confirmó un tumor T4 en 6 pacientes, T3 en 3 y T0 en uno. Los 6 pacientes con neoadyuvancia son 1 ypT0N0M0, 2 ypIIA, 2 ypIIC y 1 ypIIIB. El resto eran 2 pIIC y 2 pIIIC. En el seguimiento hay 5 pacientes vivos entre 30 y 180 meses, y 3 fallecen por metástasis a distancia sin recidiva local. Conclusión: La EPT es una intervención asociada a una elevada morbilidad y larga estadía hospitalaria. La EPT supraelevador protegida mediante una ileostomía transitoria evitó una colostomía definitiva en 6 de 10 casos. La ileostomía urinaria muestra resultados funcionales satisfactorios en el largo plazo. La sobrevida prolongada en la mitad de los pacientes justifica la indicación de la técnica en casos seleccionados.

Aim: To report the results of total pelvic exenteration (TPE) in patients with locally advanced primary rectal tumors. Material and method: We report 10 patients with stage 4 rectal tumors subjected to a potentially curative TPE in a period of 16 years. Results: Six patients received also adjuvant chemoradiotherapy. A classic technique was used in 3 patients and a supra-elevator technique in 6. Mean hospitalization length was 36 days, and 80% of patients had complications. The pathological study of the surgical piece confirmed a T4 tumor in 6 patients, T3 in 3 and T0 in one. Among patients who received chemoradiotherapy, one was in stage ypT0N0M0, 2 in ypIIA, 2 in ypIIC, one in ypIIIB, 2 in pIIC and 2 in pIIIC. During follow up 3 patients survived between 30 and 180 months and three died due to distant metastases without local relapse. Conclusion: TPE requires long hospital stays and has a high rate of complications. Supra-elevator TPE protected with a transitory ileostomy avoided definitive colostomy in 6 of 10 cases. Urinary ileostomy had satisfactory long term functional results. The prolonged survival of half of the patients justifies the use of this surgical technique.

Asunto(s)

RESUMEN

BACKGROUND: There are no clear guidelines for the indication of elective surgery in sigmoid diverticular disease. AIM: To analyze the indications and long term results of elective surgery in sigmoid diverticular disease. MATERIAL AND METHODS: Retrospective review of 100 patients (age range 25-86 years, 51 male) with sigmoid diverticular disease, operated in a lapse of 22 years. Sixty seven patients answered a survey about their disease at the end of follow up. RESULTS: Among patients aged more than 70 years, there was a higher proportion of women. The main indication for surgery was recurrent diverticulitis in 54 patients, followed by diverticular fistula in 19. A sigmoidectomy was performed in 91 patients. Stapled anastomosis was performed in half of these patients. No patient died or required reoperation in the immediate postoperative period. During a follow up ranging from 8 to 280 months, 28 patients died for causes not associated with diverticular disease and five were lost. Those patients that answered the survey were free of symptoms related to diverticular disease and did not require new operations. CONCLUSIONS: In patients with sigmoid diverticular disease and recurrent diverticulitis or with fistulae, the long term results of surgery are satisfactory.

Asunto(s)

RESUMEN

The incidence, risk factors, and clinical relevance of stenosis of stapled colorectal anastomosis (CRA) were studied prospectively. Anastomotic stricture was defined as the inability of traversing the anastomosis with the rigid proctoscope. The population studied consisted of 179 patients (94 males) with an average age of 59.3 years (range: 20 to 91 years). The main indication for surgery was colorectal cancer in 59% of the cases, followed by diverticular disease in 23%. The first endoscopic control was performed before 4 months in 25% of the patients, between 5 and 10 months in 50%, and during the following 10 months in 25%. Stenosis was verified with the rigid instrument in 21.1% of the cases and with the flexible colonoscope in 4.4%. The barium enema performed in 12 cases confirmed a punctiform stenosis in 5 patients, 4 of whom had been asymptomatic. An endoscopic dilatation was performed on 5 of the 8 symptomatic patients, with one relapse that required an additional dilatation. In the univariate analysis only the lesser 4-month interval was statistically significant (p = 0.033; odds ratio (OR) = 2.3; confidence interval (CI) 95% = 1.06 to 4.97). Male patients (p = 0.057; OR = 2.08; IC 95% = 0.97-4.44) show a tendency to CRA stricture that does not reach statistically significant levels. In the multivariate analysis, only sex (p = 0.04; OR = 4.11; IC 95% = 1.03 to 5.41) and the time interval (p = 0.012; OR = 2.87; IC 95% = 1.25 to 6.57) appear as independent variables in stenosis risk of a stapled CRA. The incidence of this complication depends on the criteria used for defining it. It is clinically relevant in no more than 5% of the patients. Five out of eight patients in category II were treated successfully with an endoscopic dilatation, while the other three improved spontaneously. Early stenosis, although frequent, is generally asymptomatic and disappears spontaneously. Considering the lack of correlation between the degree of stricture and its symptomatology, it is convenient to combine both the anatomic and the clinical criteria in the selection of candidates for an eventual therapeutic procedure.

Asunto(s)

RESUMEN

BACKGROUND: CEA is widely used in the follow up of patients with colorectal carcinoma. AIM: To study the value of preoperative CEA as an independent prognostic factor in colorectal carcinoma. PATIENTS AND METHODS: Analysis of 373 operated patients (204 females, age range 21-92 years) with colorectal carcinoma and a mean follow up of 53 months. The cutoff value for CEA was 5 ng/ml. Ninety four percent of patients had an excisable tumor, 79% had involvement of perirectal/pericolonic adipose tissue and 46% had lymph node involvement. Staging was done using Dukes-Turnbull and TNM classifications. RESULTS: CEA was normal in 61% of cases, over 5 ng/ml in 39% and over 15 ng/ml in 22%. There was a strong correlation between mean preoperative CEA and tumor stage, depth and lymph node involvement. During the follow up, 140 patients died, 57 with normal and 83 with elevated CEA. Cancer mortality in patients subjected to a curative excision of the tumor (Dukes A-C2/TNM I-III) was 9% for colonic tumors and 36% for rectal tumors (p < 0.001). There were no survival differences in patients with Dukes B/TNM II tumors according to preoperative CEA. Among Dukes C/TNM III tumors, survival difference was only significant for rectal tumors. A Cox model disclosed tumor stage, location and preoperative CEA as independent prognostic factors for survival. CONCLUSIONS: CEA is an independent prognostic factor for survival in colorectal carcinoma and high levels suggest an advanced disease.

Asunto(s)

RESUMEN

BACKGROUND: Ten to 22% of lower gastrointestinal bleedings require emergency surgery. The overall mortality of the procedure is 22%. AIM: To report our experience in the management of patients with massive lower gastrointestinal bleeding. PATIENTS AND METHODS: Retrospective analysis of 20 patients (10 male) aged 19 to 79 years old, with lower gastrointestinal bleeding. RESULTS: Nine patients were operated on after the bleeding stopped and 11 were operated while still bleeding. In ten, the cause of bleeding was diverticular disease or angiodysplasia. In four, the bleeding originated in the small bowel and in 7 it was of vascular origin. Two patients with a torrential bleeding, were operated on without prior study. Colonoscopy, done in 18 patients, identified the bleeding site in 66% of cases. Scintigraphy was performed in 7 patients and it was positive in five without operative mortality. Selective angiography was done in four patients and was positive in three. A partial intestinal resection was performed in 15 patients and a total colectomy in five without operative mortality. Six patients had major postoperative complications and mean hospital stay was 18 days. Patients have been followed for 9 to 144 months and six have died. Eleven patients were reassessed and all have complete fecal continence. CONCLUSIONS: In this series, the main causes of massive lower gastrointestinal bleeding were diverticulosis and angiodysplasia. In a high percentage of patients, the bleeding originated in the small bowel.

Asunto(s)

RESUMEN

Severe chronic constipation is defined as less than two bowel movements per week, hard stools, non productive urgency and the need of digital maneuvers in more than 25% of bowel evacuations. The best studied causes of chronic severe constipation are slow bowel transit constipation and pelvic floor dysfunction. However, there are mixed forms that cross link with irritable colon syndrome. The main diagnostic tests are anorrectal manometry, bowel evacuation, X-ray studies and anorrectal sphincteromyomectomy, that can be therapeutic. Five percent of patients are surgical candidates. In cases of slow bowel movement, total colectomy with ileorectal anastomosis has satisfactory results in 80 to 90% of patients. Some patients with pelvic floor dysfunction have an occult rectal prolapse, rectocele or sigmoidocele and obtain benefits with the correction of these conditions. The remaining patients require a training of bowel evacuation, known as biofeedback. We have performed a total colectomy in 10 patients with slow bowel movements with good functional results in 80%. After 56 months of follow-up, a mean 2.6 bowel movements per day is reported by the patients. Four patients were also operated due to a solitary rectal ulcer and two patients due to a sigmoidocele, with satisfactory results.

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)