The complex anatomy surrounding lower rectal cancer, as well as its aggressive biological behavior, creates surgical challenges. Furthermore, patients with lower rectal cancer have a poorer prognosis, compared to tumors in the middle and upper rectum. Thus, it is essential to adopt new strategies to optimize the results of surgical treatment. Magnetic resonance imaging has become a crucial tool for successfully selecting and completing surgery, as it provides a high anatomical resolution and the ability to define the tumor's relationship with the sphincter complex. New surgical techniques based on magnetic resonance imaging can also improve patients' oncological and functional outcomes. This review examines the mo-dern approach to treating lower rectal cancer, and aims to simplify the complex decisions that surgery currently requires. The PubMed database was searched using the terms "lower rectal cancer", "colorectal surgery", and "magnetic resonance imaging". Milestone reports from recent years have been addressed in this review.
Introduction Minimally invasive surgery has revolutionized surgical management in the treatment of colorectal neoplasms, reducing morbidity and mortality, hospitalization, inactivity time and minimizing cost, as well as providing adequate oncological results when compared to the conventional approach. Robotic surgery, with Da Vinci Platform, emerges as a step ahead for its potentials. The objective of this article is to report the single institutional experience with the use of Da Vinci Platform in robotic colorectal surgeries performed at a reference center in oncological surgery in Brazil. Materials and methods A retrospective cohort study was conducted based on the prospective database of patients from the institution submitted to robotic surgery for treatment of colorectal cancer from July 2012 to September 2017. Clinical and surgical variables were analyzed as predictors of morbidity and mortality. Results A total of 117 patients underwent robotic surgery. The complications related to surgery occurred in 33 patients (28%), the most frequent being anastomotic fistula and surgical wound infection, which corresponded to 11% and 3%, respectively. Conversion rate was 1.7%. Median length of stay was 5 days. The only variable associated with increase of complications and death risk was BMI >30, with p -value of 0.038 and 0.027, respectively. Conclusion Robotic surgery is safe and feasible for approaching colorectal cancer surgeries, presenting satisfactory results regarding length of hospital stay and rate of operative complications, as well as presenting a low rate of conversion. Obesity has been shown to be a risk factor for surgical complication in robotic colorectal surgery.
Introduction Robotic transanal surgery (RTS) is the analog of TAMIS and represents a new focus for the advancement of transanal platforms robotic transanal surgery is sometimes referred to as robotic TAMIS. Though limited to only a few centers world-wide, experience with robotic transanal surgery has been encouraging. Most research with robotic transanal surgery has concentrated on local excision of rectal neoplasia, although more complex procedures such as transanal proctectomy are possible using the robotic approach. This article reports the surgical technique of R-TAMIS performed in the Brazilian National Cancer Institute (INCA, Rio de Janeiro). Methods 71-year-old, female with cardiologic disease (heart failure), with a 1.5 cm rectal neoplasm at 4 cm from the anal verge in the right anterolateral position. Biopsy revealed neuroendocrine tumor. A compete colonoscopy revealed no evidence of synchronous lesions. Work-up included 3D endorectal ultrasonography and magnetic resonance imaging, which demonstrated the lesion to be uT1uN0. The patient was counseled about surgical options − local excision versus low anterior resection. Due to the cardiologic condition, the patient was elected to proceed with local excision with robotic transanal surgery. Conclusion Robotic TAMIS is a safe and effective operative procedure for high selected cases of rectal neoplasm. It enhances surgeon ergonomics and facilitates tumor removal and suture in the transanal approach.
Introdução: O dermatofibrossarcoma protuberante (DFSP) é um tumor fibrohistiocítico de origem dérmica raro, que acomete a pele, representando 1% dos sarcomas de partes moles e menos de 0,1% de todas malignidades. A principal característica deste tipo de tumor é a sua elevada taxa de recidiva local após excisão cirúrgica. Decidir a margem cirúrgica adequada para a ressecção completa é um desafio. Relato de caso: 24 anos, apresenta lesão tumoral vegetante avermelhada no ombro esquerdo, assintomática. Possui história familiar positiva de DFSP em membro inferior. O laudo histopatológico definitivo confirmou Dermatofibrossarcoma protuberans. Discussão: A característica histológica do tumor é a presença de projeções tipo tentáculos de células neoplásicas na periferia que se estendem através do tecido subcutâneo até a fáscia muscular. Certamente, o fator de maior importância para o controle local é a obtenção de margens cirúrgicas livres. A excisão através da cirurgia micrográfica de Mohs é uma ótima opção em regiões onde a excisão ampla não é desejável, como na face. A margem padrão estabelicida em grande parte da literatura é de 3 cm com ressecção até a fáscia muscular, podendo ser diminuida para 2 cm em locais em que a excisão ampla prejudique a conformação do local, como na face
Background: All available treatments for achalasia are palliative and aimed to eliminate the flow resistance caused by a hypertensive lower esophageal sphincter. Aim:To analyze the positive and negative prognostic factors in the improvement of dysphagia and to evaluate quality of life in patients undergoing surgery to treat esophageal achalasia by comparing findings before, immediately after, and in long follow-up. Methods:A total of 84 patients who underwent surgery for achalasia between 2001 and 2014 were retrospectively studied. The evaluation protocol with dysphagia scores compared preoperative, immediate (up to three months) postoperative and late (over one year) postoperative scores to estimate quality of life. Results:The surgical procedure was Heller-Dor in 100% of cases, with 84 cases performed laparoscopically. The percent reduction in pre- and immediate postoperative lower esophageal sphincter pressurewas 60.35% in the success group and 32.49% in the failure group. Regarding the late postoperative period, the mean percent decrease was 60.15% in the success group and 31.4% in the failure group. The mean overall drop in dysphagia score between the pre- and immediate postoperative periods was 7.33 points, which represents a decrease of 81.17%. Conclusions:Reduction greater than 60% percent in lower esophageal sphincter pressurebetween the pre- and postoperative periods suggests that this metric is a predictor of good prognosis for surgical response. Surgical treatment was able to have a good affect in quality of life and drastically changed dysphagia over time.
Background Anastomotic leaks after esophagectomy can lead to severe complications and account for 40% of postoperative deaths. During the last decades, several types of endoscopic treatments have became available, such as the use of esophageal stent and the use of vacuum therapy. In this paper we report one case of cervical anastomotic fistulas after esophagectomy treated with vacuum therapy and two cases treated with stent. Methods Three cases of cervical anastomotic fistulas after esophagectomy treated with an endoscopic aproach (stent and vacuum therapy) are reported. Results Case 1 61-year-old male with an mid-esophagus adenocarcinoma was treated with neoadjuvant chemotherapy and minimally invasve esophagectomy. On the 10th post-operative day (POD) a partial dehiscence of the anastomosis with communication with the mediastinum was identified, forming a cavity with a large amount of purulent secretion. A sponge attached to a nelaton probe, similar to the VAC device, was positioned inside the mentioned cavity and coupled to a continuous aspiration system. There was a gradual clinical improvement and on the 30th POD the sponge was finally removed. The patient was discharged on the 50th POD. Case 2: A 62-year-old male with a adenocarcinoma in the thoracic esophagus received neoadjuvant chemoradiotherapy and a minimally invasive esophagectomy. On the 7th POD, an anastomotic fistula draining by the chest tube was diagnosed. A stent that was positioned over the fistula area. The patient was discharged on the 28th POD with the stent, that was removed six weeks later. Case 3: 58 years old male patient presented with a superficial squamous cell carcinoma of the mid-thoracic esophagus. A minimally invasive esophagectomy was performed.On the 7th POD, a EGD was performed and showed a fistulous orifice in the esophagogastric anastomosis. A metal stent that was positioned over the fistula area. The patient evolved with empyema and a pulmonary decortication was performed by on the 17th POD. After progressive clinical improvement he was discharged on the 34th POD. Conclusion Esophageal stent has been successful used in treating this surgical complication. Recently, VAC therapy, is becoming an promising therapy for this complication, with lower morbidity and mortality rates and greater success in the closure of the anastomotic fistula when compared to the esophageal stent. Disclosure All authors have declared no conflicts of interest.
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