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La exenteración pélvica total EPT es una intervención que demuestra gran utilidad en la verificación de lesiones en canal vaginal y región anal. Nos permite demostrar, observar la presencia de lesiones en el aparato genital femenino. Siendo de gran utilidad pericial el conocimiento de que esta mujer producto de una muerte violenta a sido también producto de un delito sexual. Colaborando en gran medida al administrador de justicia dentro del "Ministerio Publico" netamente con la autopsia médico legal con EPT. Si bien en nuestro país de Bolivia no se utilizaba esta técnica, el que se haya demostrado la utilidad de la misma hace hincapié de que la EPT puede ser utilizada en caso de muerte violenta de una mujer donde se sospeche agresión sexual, ya que esas lesiones que no se puedan evidenciar al examen externo puedan evidenciarse al examen interno.

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Introducción. La evisceración intestinal transvaginal es consecuencia, en la gran mayoría de casos, de dehiscencia del muñón vaginal posterior a histerectomía en pacientes postmenopáusicas. A través de la dehiscencia vaginal se produce la salida del contenido abdominopélvico, que puede presentarse como una evisceración simple, incarceración, obstrucción, estrangulamiento y perforación de un asa intestinal. Caso clínico. Mujer de 78 años, con antecedente inmediato de colpocleisis y colporrafia con malla de polipropileno por prolapso vaginal, que presentó dehiscencia del muñón vaginal debido a rechazo de la malla, que condicionó la solución de continuidad de la pared vaginal, con prolapso, incarceración, obstrucción y perforación de íleon. Con el diagnóstico de evisceración intestinal transvaginal incarcerada con perforación intestinal se llevó a tratamiento quirúrgico, con abordaje inicial por vía vaginal para liberar el asa intestinal, luego por laparotomía se realizó resección y anastomosis de íleon, sacrocolpopexia con malla y plastia de Douglas. Presentó buena evolución postoperatoria.Conclusión. La evisceración intestinal transvaginal con perforación intestinal es una entidad de muy rara presentación. El órgano más frecuentemente comprometido es el intestino delgado, especialmente el íleon. Puede complicarse con incarceración, obstrucción intestinal, isquemia y perforación. El manejo quirúrgico involucra resección intestinal, cuando hay signos de necrosis, con reparación y fijación del muñón vaginal.

Introduction. Transvaginal intestinal evisceration is a consequence, in the vast majority of cases, of dehiscence of the vaginal stump after hysterectomy in postmenopausal patients. Through vaginal dehiscence, the exit of the abdominopelvic content occurs, which can present as a simple evisceration, incarceration, obstruction, strangulation and perforation of an intestinal loop. Clinical case. A 78-year-old woman with an immediate history of colpocleisis and polypropylene mesh colporrhaphy due to vaginal prolapse, presents dehiscence of the vaginal stump caused by rejection of the mesh that conditioned the solution of continuity of the vaginal wall, prolapse, incarceration, obstruction and perforation of the ileum. Surgical treatment was performed with the diagnosis of incarcerated transvaginal intestinal evisceration with intestinal perforation. The initial approach was to free the intestinal loop vaginally, followed by laparotomy, ileal resection and anastomosis, mesh sacrocolpopexy, and Douglas plasty were performed. He presented good postoperative evolution.Conclussion. Transvaginal intestinal evisceration with intestinal perforation is a very rare entity. The most common organ involved is the small intestine, especially the ileum. It can be complicated by incarceration, intestinal obstruction, ischemia, and perforation. Surgical management involves intestinal resection, when there are signs of necrosis, with repair and fixation of the vaginal stump.

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RESUMEN Antecedentes: el uso de la proteína C reactiva (PCR) ha adquirido relevancia como identificador de complicaciones posoperatorias La morbilidad en cirugía colorrectal se estima en un 30% de los pacientes operados, lo que demanda medidas para su temprana identificación y terapéutica. Objetivo: describir las curvas de mediciones sucesivas de PCR y su relación con el desarrollo de complicaciones posoperatorias y niveles de glóbulos blancos en una serie de pacientes operados de cirugía colorrectal. Materiales y métodos: se realizó una revisión retrospectiva sobre un registro prospectivo de 2205 pacientes operados por la División de Cirugía Gastroenterológica del Hospital de Clínicas, entre enero de 2019 y julio de 2020. Se incluyeron 69 pacientes que cumplieron con los criterios de selección. Se consignaron datos del seguimiento clínico y dosaje de PCR, recuento de glóbulos blancos, vía de abordaje y desarrollo de complicaciones. Resultados: el promedio de edad fue de 59 años (DS 13,6; rango 33-85), 31 fueron hombres (43%). La tasa de complicaciones fue del 13,04%; más frecuente fue la fístula anastomótica (fístula, colección), seguida por complicaciones de la herida (hematoma, evisceración). Todos los pacientes mostraron un ascenso inicial del valor de PCR entre el 2° y 3er día, en relación con la lesión quirúrgica, los no complicados presentaron una cinética de descenso y los complicados. curvas de segundo ascenso o no descenso en las mediciones seriadas de PCR, y exhibían valores superiores de PCR cada día Se advirtieron diferencias estadísticamente significativas entre los valores de proteína C reactiva al 5° día posoperatorio en el subgrupo de pacientes complicados con respecto a aquellos con un curso indolente (28 mg/dL vs. 6,1 mg/dL, p < 0,001; IC: 11,24-39,61). hubo diferencia significativa al 5o día entre complicados y no complicados, independientemente de la vía de abordaje. con un valor de corte de PCR de 10,92 mg/dL obtuvimos una sensibilidad del 87,50% y una especificidad del 100% para excluir complicaciones. Conclusiones: la medición de la proteína C reactiva de forma seriada en los posoperatorios de cirugía colorrectal mostró un correlato con la identificación temprana de las complicaciones en nuestra serie, tanto en sus valores absolutos diarios como en la cinética de su comportamiento. se formula el uso de valores de corte para el alta segura.

ABSTRACT Background: The use of C-reactive protein (CRP) has gained relevance as a marker of marker of postoperative complications. As the incidence of complications of colorectal surgery is estimated to be of 30%, measures should for their early identification and treatment. Objective: To describe the performance of consecutive CRP determinations and their relationship with the development of postoperative complications and with white blood cell count in a series of patients undergoing colorectal surgery. Materials and methods: A retrospective review was performed using a prospective registry of 2205 patients operated on at the Department of Digestive Surgery of Hospital de Clínicas, between January 2019 and July 2020. A total of 69 patients fulfilling the selection criteria were included. Clinical follow-up data, CRP levels, white blood cell count, type of approach and development of complications were recorded. Results: Mean age was 59 years (SD 13.6; range 33-85) and 31 were men (43%). The complication rate was 13.04%. Anastomotic leak (fistula, fluid collection) was the most common complication, followed by surgical site complications (hematoma, evisceration). All patients showed an initial increase in CRP values between days 2 and 3, in relation with the surgical lesion, and then decreased in those without complications. Patients with complications had second rise or lack of decrease in serial CRP measurements, and higher CRP values each day. There were statistically significant differences between the CRP levels on postoperative day 5 in the subgroup of patients with complications compared with those with an indolent course (28 mg/dL vs. 6.1 mg/dL, p < 0.001; CI: 11.24-39.61). There was a significant difference on day 5 between patients with and without complications, irrespective of the approach. With a cut-off value of CRP of 10.92 mg/dL on postoperative day 5 we obtained a sensitivity of 87.50% and specificity of 100% to rule out complications. Conclusions: Serial determination of CRP in the postoperative period after colorectal surgery was associated with early identification of complications in our series, both in daily absolute values and in the kinetics of its performance. The use of cut-off values for safe discharge is proposed.

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ABSTRACT Introduction: One of the most remarkable characteristics of urothelial carcinomas is multifocality. However, occurrence of synchronous bladder cancer and upper urinary tract urothelial cancer (UTUC) is exceptional. Minimally invasive approach for these synchronous tumors was just occasionally reported (1-4). The aim of this video article is to describe step-by-step the technique for simultaneous laparoscopic nephroureterectomy and robot-assisted anterior pelvic exenteration with intracorporeal ileal conduit urinary diversion (ICUD). Patients and methods: A 66-year-old female presented with synchronous BCG refractory non-muscle invasive bladder cancer and a right-side UTUC. She was a former smoker and had previously been submitted to multiple transurethral resections of bladder tumor, BCG and right distal ureterectomy with ureteral reimplant. We performed a simultaneous laparoscopic right nephroureterectomy and robot-assisted anterior pelvic exenteration with totally intracorporeal ICUD. Combination of robot-assisted and pure laparoscopic approaches was proposed focusing on optimization of total operative time (TOT). Results: Surgery was uneventful. TOT was of 330 minutes. Operative time for nephroureterectomy, anterior pelvic exenteration and ICUD were 48, 135, 87 minutes, respectively. Estimated blood loss was 150mL. Postoperative course was unremarkable and patient was discharged after 7 days. Histopathological evaluation showed a pT1 high grade urothelial carcinoma plus carcinoma in situ both in proximal right ureter and bladder, with negative margins. Twelve lymph nodes were excised, all of them negative. Conclusion: In our preliminary experience, totally minimally invasive simultaneous nephroureterectomy and cystectomy with intracorporeal ICUD is feasible. Pure laparoscopic approach to upper urinary tract may be a useful tactic to reduce total operative time.

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OBJETIVO: El objetivo de este trabajo fue analizar los resultados perioperatorios y a largo plazo de los pacientes sometidos a exenteración pélvica para cáncer de recto en un centro de referencia en la Ciudad de México. MÉTODO: Se incluyeron todos los pacientes que se sometieron a exenteración pélvica por cáncer de recto entre 1995 y 2019. Se analizaron variables demográficas, clínicas, quirúrgicas y patológicas. RESULTADOS: Se incluyeron 18 pacientes operados por cáncer de recto (16 localmente avanzados y 2 recurrentes). La relación hombre: mujer fue de 1:3.5. La morbilidad mayor fue del 27.7%. El sangrado intraoperatorio ≥ 1000 ml se asoció con morbilidad (80 vs. 20%; p = 0,029) y mortalidad posoperatoria (100 vs. 0; p = 0.043). La mediana de sobrevida global fue 102 meses. Las sobrevidas global y libre de enfermedad a los 5 años fueron del 44.4% y el 38.8%, respectivamente. La invasión linfovascular fue un factor de mal pronóstico para sobrevida libre de enfermedad (p = 0.017). CONCLUSIONES: La exenteración pélvica para el cáncer de recto es un procedimiento quirúrgico con altas morbilidad y mortalidad. La invasión linfovascular es un factor de mal pronóstico para la sobrevida libre de enfermedad. INTRODUCTION: Pelvic exenteration is a radical treatment for locally advanced and recurrent pelvic tumors. The aim of this study was to analyze the perioperative and long-term outcomes of patients undergoing pelvic exenteration for rectal cancer at a referral center in Mexico City. METHOD: We included all patients who underwent pelvic exenteration due to rectal cancer between 1995 and 2019. Demographic, clinical, surgical and pathological variables were analyzed. RESULTS: 18 patients were included (16 locally advanced and 2 recurrent). The male-female ratio was 1:3.5. The highest morbidity was 27.7%. Intraoperative bleeding ≥ 1000 ml was associated with postoperative morbidity (80 vs. 20%; p = 0.029) and mortality (100 vs. 0; p = 0.043). The median overall survival was 102 months. Overall survival and disease free survival at 5 years after exenteration were 44.4% and 38.8%, respectively. Lymphovascular invasion of the tumor was a poor prognostic factor for disease free survival (p = 0.017). CONCLUSIONS: Pelvic exenteration for rectal cancer is a surgical procedure with high morbidity and mortality. Lymphovascular invasion is a poor prognostic factor for disease-free survival.

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A exenteração pélvica pode curar pacientes com câncer de colo do útero com recorrência central após radioterapia e quimioterapia. A avaliação pré-operatória é essencial para excluir doença metastática e evitar cirurgias desnecessárias nesse cenário. O objetivo do presente estudo é avaliar a sobrevida de uma série de casos de pacientes submetidas à exenteração pélvica em clínica privada de Teresina. Este é o resultado parcial de um estudo observacional, retrospectivo, transversal e descritivo, realizado em uma clínica privada especializada no tratamento do câncer em Teresina, PI, Brasil, de junho de 2002 a fevereiro de 2020. Cinco pacientes foram incluídas no estudo, com idades entre 29 e 62 anos. No presente estudo, a sobrevida mediana foi de 44,8 meses. Duas pacientes estão vivas e sem doença com seguimento de 201 e 5 meses, respectivamente.(AU)

Pelvic exenteration can heal patients with cervical cancer with central recurrence after radiotherapy and / or chemotherapy. Preoperative evaluation is essential to exclude metastatic disease and to avoid unnecessary surgery in this scenario. The objective of the present study is to evaluate the survival of a series of cases of patients submitted to pelvic exenteration in a private clinic in Teresina. This is the partial result of an observational, retrospective, cross-sectional and descriptive study, conducted at a private clinic specialized in cancer treatment in Teresina, Brazil, from June 2002 to February 2020. Five patients were included in the study, aged between 29 and 62 years. In the present study, the median survival was 44,8 months. Two patients are alive and without disease with a follow-up of 201 and 5 months, respectively.(AU)

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ABSTRACT Pelvic exenteration has showed to be beneficial therapeutically and palliatively in locally advanced colorectal cancer. Reconstruction of urinary transit posterior to a cystectomy has always been challenging with many associated complications. We present a 58-year-old male with locally advanced rectal cancer in which a pelvic exenteration and a double-barreled wet colostomy (DBWC) was created for urinary reconstitution. We present the surgical technique of DBWC. DBWC is a good alternative to other urinary reconstructions because fecal and urinary derivation occurs in only one stoma, the stoma output is easier to manage, and fewer complications are seen compared to other urinary reconstructions. Long-term surveillance is mandatory in patients with a DBWC because there is an increased risk of neoplasm in the reservoir.

RESUMO A exenteração pélvica mostrou-se benéfica, tanto terapêutica quanto paliativamente, em casos de câncer colorretal localmente avançado. A reconstrução do trânsito urinário após uma cistectomia sempre foi desafiadora, com muitas complicações associadas. Os autores apresentam o caso de um homem de 58 anos de idade com câncer retal localmente avançado, submetido a uma exenteração pélvica e uma colostomia úmida em dupla-boca (CUDB) para reconstituição urinária. Os autores apresentam a técnica cirúrgica da CUDB, uma boa alternativa para outras reconstruções urinárias, já que a derivação fecal e urinária ocorre em apenas um estoma, a saída do estoma é mais fácil de gerenciar e o método apresenta menos complicações em comparação com outras reconstruções urinárias. A vigilância a longo prazo é obrigatória em pacientes com CUDB, pois há um risco aumentado de neoplasia no reservatório.

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Introducción: la evisceración vaginal después de una cirugía pélvica es una emergencia quirúrgica extremadamente rara. La dehiscencia laparotómica consiste en la desunión y separación precoz de los bordes de una herida quirúrgica suturada, con exteriorización o sin ella del contenido de la cavidad abdominal. Presentación de caso: el caso que aquí se reporta es el de una mujer de 36 años con antecedentes de hipertensión arterial. Intervenida hacia 3 meses de histerectomía abdominal por fibromiomas, sin prolapso uterino. Acude al cuerpo de guardia del hospital por dolor abdominal, sensación de ocupación vaginal y estreñimiento. Niega distensión abdominal y síntomas respiratorios. Ya en el cuerpo de guardia refiere deseos de defecar y al pujar ocurre una protrusión de intestino delgado de más o menos 3 cm, irreductible a través de orificio vaginal. Se realizó laparatomía, revisión por vía vaginal, reducción de las asas intestino delgado y ampliación del orificio por donde se produjo la evisceración. Discusión: se localizaron los bordes del peritoneo parietal, se sutura la cúpula vaginal con puntos continuos y se colocó una malla en el fondo de la pelvis recubierta por peritoneo. Se utilizaron los datos provenientes de la historia clínica hospitalaria. Exámenes complementarios, la entrevista y el examen físico de la paciente, a pesar las probables complicaciones no hubo perdida de tiempo y la operación fue un éxito. Conclusiones: la evolución fue satisfactoria, gracias a la labor del personal médico que estuvo a cargo del caso(AU)

Introduction: vaginal evisceration after pelvic surgery is an extremely rare surgical emergency. Laparotomic dehiscence consists of disunity and early separation of the edges of a sutured surgical wound, with or without externalization of the contents of the abdominal cavity. Case presentation: the case reported here is that of a 36-year-old woman with a history of high blood pressure. She underwent 3 months of abdominal hysterectomy for fibromyomas, without uterine prolapse. She comes to the hospital guard corps for abdominal pain, a feeling of vaginal occupation and constipation. He denies abdominal bloating and respiratory symptoms. Already in the body of guard it refers desires to defecate and when pushing a protrusion of small intestine of more or less 3 cm occurs, irreducible through the vaginal opening. Laparatomy, vaginal revision, reduction of the small intestine loops and enlargement of the hole through which evisceration occurred were performed. Discussion: the edges of the parietal peritoneum were located, the vaginal dome was sutured with continuous stitches, and a mesh was placed at the bottom of the pelvis covered by peritoneum. The data from the hospital medical history were used. Complementary examinations, the interview and the physical examination of the patient, despite the probable complications, there was no loss of time and the operation was successful. Conclusions: the evolution was satisfactory, thanks to the work of the medical personnel who were in charge of the case(EU)

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BACKGROUND AND OBJECTIVES: The primary treatment for locally advanced cases of cervical cancer is chemoradiation followed by high-dose brachytherapy. When this treatment fails, pelvic exenteration (PE) is an option in some cases. This study aimed to develop recommendations for the best management of patients with cervical cancer undergoing salvage PE. METHODS: A questionnaire was administered to all members of the Brazilian Society of Surgical Oncology. Of them, 68 surgeons participated in the study and were divided into 10 working groups. A literature review of studies retrieved from the National Library of Medicine database was carried out on topics chosen by the participants. These topics were indications for curative and palliative PE, preoperative and intraoperative evaluation of tumor resectability, access routes and surgical techniques, PE classification, urinary, vaginal, intestinal, and pelvic floor reconstructions, and postoperative follow-up. To define the level of evidence and strength of each recommendation, an adapted version of the Infectious Diseases Society of America Health Service rating system was used. RESULTS: Most conducts and management strategies reviewed were strongly recommended by the participants. CONCLUSIONS: Guidelines outlining strategies for PE in the treatment of persistent or relapsed cervical cancer were developed and are based on the best evidence available in the literature.

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La hernia incisional es una complicación frecuente de la cirugía abdominal, se presenta entre el 2 al 20 por ciento de los pacientes laparotomizados. Entre sus complicaciones se describen la incarceración aguda, el atascamiento y la estrangulación. Objetivo: Describir el caso inusual de una paciente portadora de hernia incisional eviscerada. Reporte de caso: Anciana de 78 años, diabética tipo II, con vitíligo, hipertensión arterial controlada, presentó además hernia incisional voluminosa recidivada, la cual sufrió ruptura espontánea de pared y piel con evisceración. Fue tratada mediante hernioplastia con prótesis preperitoneal de polipropileno y cierre aponeurótico parcial. A los tres años de seguimiento posoperatorio los resultados fueron excelentes. Conclusiones: Es inusual esta complicación y se comparó con reportes similares que justifican y avalan la conducta asumida. La ruptura espontánea de la cubierta y piel de una hernia incisional recidivada y su evisceración a través del defecto es infrecuente, se le realizó hernioplastia protésica preperitoneal con favorables resultados posoperatorios(AU)

The incisional hernia is a frequent complication of the abdominal surgery; it is presented between the 2 to 20 percent of the patients with laparotomy. Among their complications they are described: Incarcerated hernia, blockage or obstruction and strangulation. Objective: To describe the unusual case of a patient carrier with an incisional hernia with evisceration. Case report: A 78 years old, aged woman, type II diabetic, with vitiligo, controlled hypertension, carrier of incisional hernia too, voluminous, recurrent, which suffered spontaneous rupture of wall and skin, with evisceration. She was treated by hernioplasty with a polypropylene preperitoneal prosthesis and partial aponeurotic closure. At three years post-operative follow-up the results were excellent. Conclusions: It is an unusual complication that is compared with similar reports that justify and support the assumed behavior. The spontaneous rupture of the cover and skin of a recurrent incisional hernia and its evisceration through the defect are uncommon, preperitoneal hernioplasty prosthesis with favorable postoperative results was performed(AU)

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BACKGROUND: Pelvic exenteration is one of the most mutilating surgical procedures with high post-operative morbidity. The laparoscopic technique aims to reduce perioperative complications and reduce post-surgical recovery. OBJECTIVE: We present the first case of laparoscopic anterior exenteration for locally advanced melanoma, held at the National Cancer Institute and published in Mexico. CASE REPORT: Patient 60 years of age diagnosed with invasive vulvar melanoma with bladder extension upon whom laparoscopic anterior pelvic exenteration with external urinary reconstruction was performed. Time in surgery was 505minutes and estimated blood loss was 400ml. No complications occurred during or immediately after surgery. The final histopathological study reported: nodular lesion that completely replaces the clitoris and spreads to the left labia majora, measures 3×2.5×2cm and is located relative to the free margins with perineural invasion intraepithelial spread in space and urethra and bladder trigone. CONCLUSIONS: The laparoscopic anterior pelvic exenteration is a safe alternative in well-selected patients, with acceptable time in surgery, surgical complications and recovery time.

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The treatment of patients with vulvar cancer remains challenging for gynecologic oncologists. Up to 30 % of the cases are diagnosed in a clinical condition of irresectability, and some kind of strategy has to be taken into account beyond surgery. In this regard, a common and standard definition is critical to maximize oncological results and minimize complications after treatments. Each patient treatment must be tailored individually according to their clinical and biological features and to the setting in which they are dealing with.

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OBJECTIVE: to evaluate the profile of morbidity and mortality and its predictors related to extensive pelvic resections, including pelvic exenteration, to optimize the selection of patients and achieve better surgical results. METHODS: we performed 24 major resections for anorectal pelvic malignancy from 2008 to 2015 in the Instituto do Câncer do Ceará. The factors analyzed included age, weight loss, resected organs, total versus posterior exenteration, angiolymphatic and perineural invasion, lymph node metastasis and overall and disease-free survival. RESULTS: the median age was 57 years and the mean follow-up was ten months. Overall morbidity was 45.8%, with five (20.8%) serious complications. There were no deaths in the first 30 postoperative days. The median overall survival was 39.5 months, and disease-free survival, 30.7 months. Concomitant resection of the bladder was an isolated prognostic factor for higher risk of complications (87.5% vs. 26.7%, p = 0.009). Angiolymphatic invasion and lymph node metastasis did not reach significance with respect to disease-free survival. CONCLUSION: treatment of advanced anorectal tumors is challenging, often requiring combined resections, such as cystectomy and sacrectomy, and complex reconstructions. The magnitude of the operation still carries a high morbidity rate, but is a procedure considered safe and feasible, with a low mortality and adequate locoregional tumor control when performed in referral centers. OBJETIVOS: avaliar o perfil de morbimortalidade e seus fatores preditivos relacionados às ressecções pélvicas extensas, incluindo a exenteração pélvica, com o intuito de otimizar a seleção dos pacientes e obtenção de melhores resultados cirúrgicos. MÉTODOS: foram realizadas 24 grandes ressecções pélvicas por neoplasia maligna anorretal de 2008 a 2015 no Instituto do Câncer do Ceará. Os fatores analisados incluíram idade, perda de peso, órgão ressecados, exenteração total versus posterior, invasão angiolinfática e perineural, metástase linfonodal e sobrevida global e livre de doença. RESULTADOS: a mediana de idade foi 57 anos e o tempo médio de seguimento foi dez meses. A morbidade global foi 45,8%, com cinco (20,8%) complicações graves. Não houve óbito nos primeiros 30 dias de pós-operatório. A sobrevida global média foi 39,5 meses e a sobrevida livre de doença foi 30,7 meses. A ressecção concomitante da bexiga foi fator prognóstico isolado com maior risco para complicações (87,5% vs. 26,7%, p=0.009). Invasão angiolinfática e metástase linfonodal não alcançaram significância com relação à sobrevida livre de doença. CONCLUSÃO: o tratamento dos tumores anorretais avançados é desafiador, necessitando frequentemente de ressecções combinadas, como a cistectomia e sacrectomia, além de reconstruções complexas. A magnitude da cirurgia ainda carrega uma elevada taxa de morbidade, porém é um procedimento considerado seguro e factível, com uma baixa mortalidade e adequado controle locorregional tumoral quando realizado em centros de referência.

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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.

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ABSTRACT Objective: to evaluate the profile of morbidity and mortality and its predictors related to extensive pelvic resections, including pelvic exenteration, to optimize the selection of patients and achieve better surgical results. Methods: we performed 24 major resections for anorectal pelvic malignancy from 2008 to 2015 in the Instituto do Câncer do Ceará. The factors analyzed included age, weight loss, resected organs, total versus posterior exenteration, angiolymphatic and perineural invasion, lymph node metastasis and overall and disease-free survival. Results: the median age was 57 years and the mean follow-up was ten months. Overall morbidity was 45.8%, with five (20.8%) serious complications. There were no deaths in the first 30 postoperative days. The median overall survival was 39.5 months, and disease-free survival, 30.7 months. Concomitant resection of the bladder was an isolated prognostic factor for higher risk of complications (87.5% vs. 26.7%, p = 0.009). Angiolymphatic invasion and lymph node metastasis did not reach significance with respect to disease-free survival. Conclusion: treatment of advanced anorectal tumors is challenging, often requiring combined resections, such as cystectomy and sacrectomy, and complex reconstructions. The magnitude of the operation still carries a high morbidity rate, but is a procedure considered safe and feasible, with a low mortality and adequate locoregional tumor control when performed in referral centers.

RESUMO Objetivos: avaliar o perfil de morbimortalidade e seus fatores preditivos relacionados às ressecções pélvicas extensas, incluindo a exenteração pélvica, com o intuito de otimizar a seleção dos pacientes e obtenção de melhores resultados cirúrgicos. Métodos: foram realizadas 24 grandes ressecções pélvicas por neoplasia maligna anorretal de 2008 a 2015 no Instituto do Câncer do Ceará. Os fatores analisados incluíram idade, perda de peso, órgão ressecados, exenteração total versus posterior, invasão angiolinfática e perineural, metástase linfonodal e sobrevida global e livre de doença. Resultados: a mediana de idade foi 57 anos e o tempo médio de seguimento foi dez meses. A morbidade global foi 45,8%, com cinco (20,8%) complicações graves. Não houve óbito nos primeiros 30 dias de pós-operatório. A sobrevida global média foi 39,5 meses e a sobrevida livre de doença foi 30,7 meses. A ressecção concomitante da bexiga foi fator prognóstico isolado com maior risco para complicações (87,5% vs. 26,7%, p=0.009). Invasão angiolinfática e metástase linfonodal não alcançaram significância com relação à sobrevida livre de doença. Conclusão: o tratamento dos tumores anorretais avançados é desafiador, necessitando frequentemente de ressecções combinadas, como a cistectomia e sacrectomia, além de reconstruções complexas. A magnitude da cirurgia ainda carrega uma elevada taxa de morbidade, porém é um procedimento considerado seguro e factível, com uma baixa mortalidade e adequado controle locorregional tumoral quando realizado em centros de referência.

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Objetivo: analizar las causas más frecuentes de reingreso de las pacientes posthisterectomía del Servicio de Ginecología del Hospital México, entre enero 2009 y diciembre 2011.Métodos:se realizó un estudio retrospectivo descriptivo en 70 pacientes, las cuales reingresaron luego de que se les practicara una histerectomía, con el fin de analizar las principales causas de reingreso, así como los principales factores de riesgo asociados.Resultados:la principal causa de reingreso de las pacientes posthisterectomía fue la infección de la herida quirúrgica 74,3% (n=52), seguida por el absceso de la cúpula vaginal 11,4% (n=8), la evisceración y la dehiscencia de la herida quirúrgica, ambas con un 2,9% (n=2) de los casos. Los principales factores de riesgo encontrados fueron: tiempo quirúrgico prolongado, obesidad, cáncer y diabetes mellitus. La minoría de las participantes requirió ser llevada a sala de operaciones al reingreso. Conclusiones: en el estudio, la infección del sitio quirúrgico fue la principal causa de reingreso de las pacientes histerectomizadas. De las causas infecciosas, las más frecuentes fueron: infección de la herida quirúrgica y absceso de cúpula vaginal, hematoma de cúpula vaginal y evisceración.

Objective: To analyze the most frequent reasons for readmission of patients after a hysterectomy at the Department of Gynecology of the Mexico Hospital between January 2009 and December 2011.Methods: A retrospective descriptive study was conducted in 70 patients that were readmitted after a hysterectomy surgery in order to analyze the main causes of readmission and the main associated risk factors.Results: The main causes of readmission of patients after hysterectomy were infection of the surgical wound, in 74.3% of the cases (n52), followed by vaginal vault abscess in 11.4% (n8) of the cases and evisceration and dehiscence of the surgical wound, both accounting for 2.9% (n2) of cases. The main risk factors found were prolonged surgical time, obesity, cancer and diabetes mellitus. A minority of participants required reentry to the surgery room.Conclusions: Surgical site infection was the leading cause of readmission of hysterectomy patients in this study. The most common infectious causes were the infection of the surgical wound and abscess of the vaginal vault, followed by vaginal vault hematoma and evisceration.

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