Anal Border Research Articles

Prognostic factors for local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision

Prognostic factors for local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. BackgroundThe standard curative treatment for locally advanced rectal cancer of the middle and lower thirds is long-course chemoradiotherapy followed by total mesorectal excision. PurposeTo evaluate the prognostic factors associated with local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. MethodsRetrospective study including patients with rectal cancer T3–4N0M0 or T (any)N + M0 located within 10 cm from the anal border, or patients with T2N0M0 located within 5 cm, treated by long course chemoradiotherapy followed by total mesorectal excision with curative intent. Clinical, demographic, radiologic, surgical, and anatomopathological data were collected. Local recurrence was estimated using the Kaplan-Meier function, and risk was estimated according to each characteristic using univariate and multivariate analyses. Results270 patients were included, 57.8% male and mean age 61.7 (30‒88) years. At initial staging, 6.7% of patients were stage I, 21.5% stage II, and 71.8% stage III. Open surgery was performed in 65.2%, with sphincter preservation in 78.1%. Mortality within 30 postoperative days was 0.7%. After 49.4 (0.5‒86.1) months of median follow-up, overall and local recurrences were 26.3% and 5.9%. On multivariate analyses, local recurrence was associated with involvement of the mesorectal fascia on restaging MRI (HR = 9.11, p = 0.001) and with pathologic involvement of radial surgical margin (HR = 8.19, p < 0.001). ConclusionLocal recurrence of rectal cancer treated with long-course chemoradiation and total mesorectal excision is low and is associated with pathologic involvement of the radial surgical margin and can be predicted on restaging MRI.

Frozen Pelvis – Stepwise Approach to Multifocal Endometriosis

<h3>Study Objective</h3> To demonstrate the step-by-step approach to the treatment of endometriosis. The idea is to systematize all the steps to make this surgery more reproducible, safe and less time consuming. <h3>Design</h3> Case report for surgical technique and description of the procedure using video. <h3>Setting</h3> Tertiary hospital. <h3>Patients or Participants</h3> A 36-year-old woman with a complaint of metrorrhagia for 2 years. She had one pregnancy with a normal delivery. The patient denied comorbidities and previous surgery. On the bimanual vaginal examination, it was possible to palpate a painful nodule in the retrocervical region as well as bilateral thickening of the uterus sacral ligaments, it was also possible to notice that the uterus had reduced mobility. The vaginal ultrasound described an area of tissue thickening next to the anterior uterus, measuring 1.8 × 0.7 × 1.4cm and another on the posterior measuring 3 × 1 × 2.6cm, determining an adherent process with the rectosigmoid 10cm from the anal border. It was also visualized a hypoechoic thickening on the anterior wall of the rectosigmoid affecting the external muscle itself and involving 15% of the circumference, measuring 2.7 × 0.6 × 1cm and 12 cm from the anal border. Thickening areas are noted near the distal ileum, measuring about 2 × 1.2 × 1.4cm, with signs of impairment of the distal portion of the cecal appendix. <h3>Interventions</h3> We performed a laparoscopic resection of deep endometriosis with bowel shaving and appendectomy. <h3>Measurements and Main Results</h3> We could restore the pelvic anatomy that was distorted by stage 4 endometriosis with bowel involvement without prejudice to the patient's function. <h3>Conclusion</h3> We should be conservative towards function considering that most patients with endometriosis are young and operate only symptomatic lesions.

Restoration of Fertility By Robotic-Assisted Laparoscopic Surgery for Endometriosis and Uterine Myoma: A Case Report

Study Objective To demonstrate the distorted anatomy of the pelvis caused by the coincidence of deep endometriosis and leiomyomas impairing fertility. Also, highlight the robotic approach assisting for a precise landmark identificantion and nerve-sparing dissection in order to perfom a safe procedure. Design Case report for anatomical study and description of the procedure using video. Setting Under general anesthesia, the patient was placed in dorsolithotomy position, arms alongside the body and legs 80o abducted in adjustable stirrups. Legs were dressed under anti-embolism stockings and pneumatic compression. A Foley catheter and a uterine manipulator were placed at the onset of the surgery. Patients or Participants A 40-year-old nulliparous woman presents with infertility along 7 years and unsuccessful previous treatments. She underwent two fibroid embolizations and two in vitro fertilizations (IVF). In the physical examination her uterus was enlarged and partially fixed and she had a painful bulging tumor in the posterior vaginal fornix. The MRI evidenced a 121,7cc uterus with multiple nodular formations, a 2.5 cm retracting retrocervical lesion infiltrating the rectum muscular wall (30%) at 12 cm from the anal border and an endometrioma of 4.7 cm in the left ovary displacing it medially. Despite the infertility she had no other complaints. Interventions We performed a robot-assisted laparoscopic enucleation of multiple fibroids and resection of superficial and deep endometriosis lesions including peritoneum, uterosacral ligaments, left ovarian endometrioma, cecal appendix and rectosigmoid. Measurements and Main Results Patient was discharged in the second postoperative day, with mild abdominal pain. She used dienogest for another five months and three months after stopping the medication she spontaneously became pregnant. Conclusion We were able to achieve a favorable outcome regarding the surgical approach in resecting an extensive disease and the patient's intention of childbearing.

A Novel Perineal Nerve Block Approach for Transperineal Prostate Biopsy: An Anatomical Analysis-based Randomized Single-blind Controlled Trial

OBJECTIVETo develop and validate a novel perineal nerve block approach for transperineal prostate biopsy. PATIENTS AND METHODSFive adult male cadavers were dissected to delineate the superficial and deep branches of the perineal nerve. Afterwards, 90 out of 115 patients were selected and randomly assigned to receive periprostatic, periapical triangle, or branches of perineal nerve (BPN) block. The primary outcome was the maximal pain intensity associated with transperineal prostate biopsy, which was assessed by the 10-point visual analog scale. The secondary outcomes included the number of biopsy with visual analog scale of ≥4 in each biopsy procedure, and the incidences of complications. RESULTSOn the horizontal line of the upper anal border, the locations of the superficial branch of perineal nerve on the left and right sides were 1.87 ± 0.05 cm and 1.86 ± 0.06 cm, respectively; and the deep branch were 2.15 ± 0.07 cm and 2.16 ± 0.06 cm, respectively, from the midline, and lied between the deep layer of superficial fascia and prostate capsule. The number of cases finally enrolled in data analysis in periprostatic block, periapical triangle block, and BPN block groups were 26, 27, and 30, respectively. The maximal pain intensities were 3.4 (3.1-3.7), 3.3 (3.0-3.6), and 1.8 (1.5-2.2) in the 3 groups, respectively, and the numbers of biopsy with the pain intensity of ≥4 were 4.0 (3.2-4.9), 4.2 (3.3-5.2), and 0.7 (0.1-1.2), respectively. There were 4, 3 and 4 cases developing hematuria, and 1, 1 and 2 burdened with urine retention after biopsy in the 3 groups, respectively. CONCLUSIONCollectively, BPN block is a safe, effective and repeatable local anesthesia approach for transperineal prostate biopsy.

Surgical and postoperative evaluations of rectal adenomas excised with a rigid proctoscope.

Purpose This study presents the surgical and postoperative results achieved with a rigid proctoscope using the transanal endoscopic technique to excise rectal adenomas. The results are compared to the results obtained with other currently employed transanal techniques.Methods We investigated the medical records of patients who underwent transanal endoscopic operations from April 2000 to June 2018 at two tertiary referral centers for colorectal cancer.Results This study included 99 patients. The mean age was 65.3 ± 13.3 years. The average size of the adenomas was 4.6 ± 2.3 cm, and their average distance to the anal border was 5.6 ± 3.3 cm. The average operative time was 65.3 ± 41.7 min. In 48.5% of the operations, the specimen was fragmented, and in 59.6% of the cases, the microscopic margins were free. The rates of postoperative complications and relapse were 5% and 19%, respectively. The mean follow-up was 80 ± 61.5 months.Conclusions The described proctoscope proved to be a viable technique with results similar to other techniques, with the advantage that it allowed greater accessibility for surgeons. Therefore, its use could be implemented and become widespread in surgical practice.

Two new species of Helicopsyche Siebold 1856 (Insecta: Trichoptera: Helicopsychidae) from Pará State, northern Brazil.

Two new species of Helicopsychidae from Pará State, Brazil, are described and illustrated: male of Helicopsyche (Feropsyche) carajas n. sp. is characterized by segment X having 8 pairs of subequal megasetae distributed in a pair of longitudinal rows; the primary branch of each gonocoxite, in lateral view, with its basal half nearly as broad as its median part and parallel-sided, its posterior apex directed slightly ventrad and slender and strongly pointed; the dorsal lobes of the endotheca posteriorly protruding, and the lateral lobes of the endotheca well developed. Helicopsyche (Feropsyche) inflata n. sp. is characterized by the hind wings each having very long fringes along the anal border; the primary branch of each gonocoxite having a pointed apex in lateral view and its basimesal lobe being triangular in lateral and ventral views and bearing eight megasetae; and the dorsal lobe of the endotheca being very well developed in lateral view.

Clinical value of carbon nanoparticles marker for neoadjuvant chemoradiotherapy of rectal cancer

Objective To explore the clinical value of carbon nanoparticles marker before neoadjuvant chemoradiotherapy (NACRT) of locally advanced rectal cancer. Methods Clinical data of 18 patients (11 male and 7 female) with locally advanced rectal cancer admitted to Fuzhou General Hospital from July 2015 to December 2015 was analyzed retrospectively. Patients were 45.8±12.5 (35-68) years old. Before NACRT, carbon nanoparticles were injected through an endoscope. The multiple-point injection was 1 cm from the lesion (4 quadrants of the upper, lower, left and right) to avoid direct injection into the tumor. The injection suspension of carbon nanoparticles was 5 mg per point. After endoscopic marking, the duration of NACRT plus rest was 8±2 (5-11) weeks, and then the surgery was performed. Effects of endoscopic carbon nanoparticles markers on judgment of the tumor size, the distance from the lower margin of the tumor to the anal border, the intraoperative condition and the rate of anus preservation were observed. Results The operation time was 10.0±3.5(5-15)min. No adverse reactions, and bleeding, perforation or other complications occurred. After NACRT, all tumors were reduced, completely disappeared in 7 cases (38.9%), and pathologically respond in 6 cases (33.3%). The distance between the lower margin of the tumor and the margin of the anal border was 6.4±1.8 (4.5-10.0)cm. In the operation, 100% lesions were found to be stained black outside the intestine, with clear location and partial lymph node dysphasia. Eight cases received anus preserving operation, and the rate of anus preservation was 44.4%. Conclusion The carbon nanoparticles marker can accurately position the tumor and label the lymph node for locally advanced rectal cancer before NACRT. The dyeing effect is lasting, conducive to the surgery or follow-up observation. Key words: Colorectal neoplasms; Antineoplastic combined chemotherapy protocols; Carbon nanoparticles; Tumor markers

&lt;b&gt;A new species of sea squirt &lt;I&gt;Rhopalaea bilobata&lt;/I&gt; (Ascidiacea: Diazonidae) from the Andaman Islands, India&lt;/b&gt;

Rhopalaea bilobata, a new species of the class Ascidiacea, under the family Diazonidae has been described from the Andaman Islands of Andaman &amp; Nicobar, India. The species was found in sandy bottoms, reef areas and artificial structures at a depth range of 10–40 m. This species has bilobed anal border, six lobed branchial and atrial siphons, transparent thorax with pigmented spots at the anus, between the two siphons and at the anterior end of endostyle, and ramified basal test. The species is closely related to R. idoneta, R. macrothorax and R. tenuis in several sets of anatomical and morphological features.

Magnifying endoscopy with narrow-band imaging is more accurate for determination of horizontal extent of early gastric cancers than chromoendoscopy.

Background and study aims: Although magnifying endoscopy with narrow-band imaging (ME-NBI) is reported to be useful for delineating the horizontal extent of early gastric cancers (EGCs), there are few reports which have objectively demonstrated the superiority of ME-NBI over chromoendoscopy with indigo carmine for this purpose. We conducted an exploratory comparison of the diagnostic accuracy of both modalities for the delineation of EGCs using prospectively collected data, and clarified the clinicopathological features related to inaccurate evaluation of the horizontal extent of EGCs. Patients and methods: EGCs were assigned to the oral narrow-band imaging (O-NBI) group or the oral chromoendoscopy (O-CE) group before endoscopic submucosal dissection (ESD). The oral border was observed according to assignment, and the anal border with the other modality. The horizontal extent of the tumor was evaluated by each modality and a marking dot was placed on the visible delineation line. After ESD, the marking dots were identified pathologically and defined as “accurate evaluation” if they were located within 1 mm of the pathological tumor border. We compared the rate of accurate evaluation of ME-NBI and chromoendoscopy, and analyzed the clinicopathological features related to inaccurate evaluation. Results: A total of 113 marking dots evaluated by ME-NBI and 116 evaluated by chromoendoscopy were analyzed. The rate of accurate evaluation by ME-NBI was significantly higher than that by chromoendoscopy (89.4 % vs 75.9 %, P = 0.0071). The EGCs with flat borders and large EGCs were significantly related to inaccurate evaluation using ME-NBI. There were no significant factors related to inaccurate evaluation with chromoendoscopy. Conclusions: The accurate evaluation rate of the horizontal extent of EGCs by ME-NBI is significantly higher than that by chromoendoscopy.Study registration: UMIN000007641

Neophalloplasty to congenital aphallia using two transverse skin-flaps: An alternative approach

Penile agenesis is a rare congenital abnormality with an incidence of 1 in 30 million births. We want to demonstrate in this video a new technique of neophalloplasty based on two transverse skin flaps from lower abdominal wall. The patient was placed into a prone position; the urethral meatus was found inside the rectum, 2 cm from the anal border. An Anterior Sagittal Transrectal Approach (ASTRA) approach was performed; the urethra was isolated and repositioned as a perineal urethrostomy. We created the neophallus based on two flaps, each measuring 7 × 3 cm. After incision, flaps were rotated 90° and sutured to each other creating the neophallus. We also created a Mitrofanoff channel to secure bladder emptying in cases of urethrostomy stricture. The patient had an uneventful immediate postoperative evolution, but later showed some degree of penile retraction. He voids preferably through the urethrostomy and his mother uses the Mitrofanoff once a day. The current follow-up is 18 months. We acknowledge limited clinical experience with this technique. However, the same principle has been used to create catheterizable urinary channels, with favorable results and longer follow-up. The use of transverse skin flaps might be an interesting alternative for neophalloplasty in aphallia.

Styela cearense n. sp. (Ascidiacea: Styelidae) from the Northeastern Brazilian Coast.

The species Styela cearense n. sp. is described from material collected in shallow waters at the Ceará State, Northeastern Brazil. Discussion includes several other species with one gonad on each side of the body, and a tabular key is provided. A set of important anatomical features and their intraspecific variability within the genus is considered, including the number of branchial and stomach folds, the presence of endocarps, and anal border shape.

Laparoscopic Discoid Anterior Rectal Excision with the Circular Stapler for Rectosigmoid Endometriosis, Performed by the Gynecologic Surgeon

Study ObjectiveTo demonstrate the technique of laparoscopic discoid anterior rectal wall resection using a circular stapler, feasible in the case of rectosigmoid endometriosis lesions measuring ≤3 cm. DesignCase report (Canadian Task Force classification III). SettingPrivate practice hospital in São Paulo, Brazil. PatientThirty-four-year-old woman with pelvic deep endometriosis including a 2-cm lesion in the rectosigmoid situated 11 cm proximally to the anal border. She had chronic pelvic pain, dysmenorrhea, dyspareunia, and constipation. She had undergone no previous surgical procedures. InterventionsStandard 4-puncture laparoscopy was performed, and all visible endometriosis lesions were first removed before proceeding to rectal resection. The avascular rectovaginal space was identified, and the rectosigmoid was mobilized cranially, releasing the vagina and increasing the final distance of the bowel anastomosis to the anal border. The rectosigmoid nodule was isolated in its entire circumference and remained restricted to the anterior wall of the bowel. It was then transfixed using a 2-0 polyglycolic suture, with the healthy proximal and distal limits of the bowel included in the suture. A 33-cm endoscopic circular stapler was introduced via the anus up to the distal limit of the lesion and opened inside the bowel lumen. By pulling the edges of the suture, the rectosigmoid nodule was introduced inside of the circular stapler. It was fired to resect the anterior rectal wall, and the anastomosis was situated at the anterior and lateral walls of the bowel. Integrity of the bowel was checked via infusion of saline solution with methylene blue dye. Gynecologic surgeons performed all of the procedures. Measurements and Main ResultsBowel resection took 20 minutes, and the entire surgical procedure lasted 120 minutes. The patient was discharged after 48 hours. There were no intercurrent events, either early or late postoperatively. The patient was symptom-free at 2 years of follow-up. ConclusionLaparoscopic discoid excision of an anterior rectal nodule using the circular stapler is an effective option for treating selected cases of rectosigmoid endometriosis. The technique might be reproducible by gynecologic surgeons after proper training.

The Real Distance between Rectosigmoid Endometriosis (RSGend) Lesions to the Anal Border (AB): A Descriptive Study Correlating Different Surgical Techniques and Related Complications

The Real Distance between Rectosigmoid Endometriosis (RSGend) Lesions to the Anal Border (AB): A Descriptive Study Correlating Different Surgical Techniques and Related Complications

Transvaginal US after Bowel Preparation for Deeply Infiltrating Endometriosis: Protocol, Imaging Appearances, and Laparoscopic Correlation

Deeply infiltrating endometriosis (DIE) is a common gynecologic disease that is characterized by a difficult and delayed diagnosis. Radiologic mapping of the DIE lesion sites is crucial for case management, patient counseling, and surgical planning. Transvaginal ultrasonography (US) is the initial imaging modality for investigating DIE and has been the focus of several recent studies. DIE typically manifests at imaging as hypoechogenic nodules throughout the affected sites and thickening of the intestinal wall, with some lesions showing a mixed pattern due to cystic areas. Transvaginal US performed after bowel preparation improves the ability to diagnose intestinal lesions and provides invaluable details, including which layers of the intestine are affected and the distance between the lesion and the anal border. It is vital that radiologists be familiar with the technical aspects of this modality and with the US manifestations of DIE lesions. Transvaginal US performed after bowel preparation should be the first-line imaging modality for the evaluation of women with suspected endometriosis.

Transvaginal ultrasound after bowel preparation to assist surgical planning for bowel endometriosis resection

up 3 as those more than The rectosigmoid colon (RSC) is involved in up to 93% of all endometriotic lesions of the bowel [1]. Preoperative diagnosis of bowel endometriosis is very important for surgical planning and patient counseling. In this context, estimation of the distance from endometriotic lesions to the anal border hasmajor surgical implications because the risk of complications is greater for gastrointestinal anastomosis performed below the peritoneal reflection, in the lower rectum (less than 5 cm from the anal border) [2]. From the authors’ personal experience (MOCG and LPC), transvaginal ultrasound after bowel preparation (TVS-BP) improves the detection and characterization of intestinal lesions, permitting identification of the affected layers and the distance between the lower margin of the lesions and the anal border. Fifty-one patients who presented with endometriosis-associated infertility at the Huntington Medicina Reprodutiva Sao Paulo, Brazil, from October 2005 to October 2006 underwent TVS-BP measurement of the distance between RSC lesions to the anal border, and laparoscopic excision of endometriosis. Eighteen bowel lesions were resected in 16 women. During surgery, the actual distances between the endometriotic lesions and the anal border were recorded as the distance from the insertion of an endoscopic stapler at the anal border up to where the tip of the stapler touched the lesion. Lesions were divided into 3 groups based on their distance from the anal border, with group 1 categorized as those from1–5 cm (1/18; 5.6%); group 2 as those 6–10 cm (9/18; 50%); and gro

A new proctoscope for transanal endoscopic operations

Transanal access is one of many currently used procedures for rectal cancer treatment. The techniques used for local excision include conventional transanal excision, posterior access, therapeutic colonoscopy and transanal endoscopic approaches. The aim of the present study was to present a new surgical proctoscope for the endoscopic transanal excision of rectal lesions. A cylindrical proctoscope with a diameter of 4 cm was devised and built. The end inserted into the anus has a bevelled aspect and rounded borders, allowing correct exposure of the anal lesion. The rectoscope is fixed to the anal border with surgical thread through perforations in the external end. A base screw holds a fibre-light which illuminates the operative field. Part of the equipment is a guide which is positioned inside the rectoscope on insertion into the anus. In operations utilizing this proctoscope, 17 adenomas, 25 adenocarcinomas, 1 carcinoid and 1 endometrioma were excised. The diameter of the lesions varied from 1 to 6 cm. The range of procedures that are possible with this new proctoscope are similar to those achieved with conventional techniques which, however, require more expensive equipment. Hence, the present study demonstrates that this newly devised low-cost proctoscope is an efficient tool for the transanal endoscopic excision of rectal lesions.

ENDOSCOPIC SNARE PAPILLECTOMY FOR TUMORS OF THE MAJOR DUODENAL PAPILLA

Safer procedures for performing endoscopic papillectomy on papillary tumors should be established. Fourteen patients underwent endoscopic papillectomy between January 2000 and February 2007. Before papillectomy, tumors were slightly elevated by submucosal injection of glycerol, followed by semi‐circular mucosal incision of the anal border of the lesion in five cases. In nine cases, balloon‐catheter‐assisted endoscopic snare papillectomy was performed. All patients routinely underwent endoscopic nasobiliary drainage tube placement in the bile duct. A pancreatic stent was inserted only in patients with non‐patent minor papilla. The rate of positive margins was lower in patients who received balloon‐catheter‐assisted papillectomy than in patients who received papillectomy without a balloon catheter. Of three patients with local recurrence, only one patient required surgery. Post‐procedural complications included hemorrhage in eight patients, pancreatitis in one patient, and perforation in one patient. No perforation occurred after submucosal injection and mucosal incision. In three of four patients with early hemorrhage, bleeding was noticed as hemobilia through the nasobiliary drainage tube; this appears to be useful for early diagnosis of bleeding. No pancreatitis occurred in patients with patent minor papilla, suggesting that pancreatic stent placement is unnecessary in patients with patent minor papilla.

Endoscopic submucosal resection with ligation of rectal carcinoids: 3 years experience

To assess the value of endoscopic submucosal resection with ligation (ESMRL) in rectal carcinoids. 45 patients with rectal carcinoids, 20 males and 25 females, aged 58 +/- 18 (19 - 73), were treated with ESMRL from April, 2002 to April, 2006. The radical resection rate, complication rate, relapse rate, and metastasis rate were analyzed. Carcinoids accounted for 1.8% of the 24,600 cases undergoing colonoscopy at the same time. All the carcinoids were located 2 - 15 cm from anal border, with a mean diameter of (1.4 +/- 0.3) cm (0.3 - 2.0 cm). The endoscopic ultrasonographic (EUS) characteristic was a hypoechoic solid tumor in the superficial submucosa (24 cases, 53%) or in both the mucosa and submucosa (21 cases, 47%) without involvement of the muscularis propria. All patients received ESMRL of the rectal carcinoids, of which 34 cases (75.6%) needed more hemostasis of the incision margin. The mean operation time was (25 +/- 4) min. 7 cases (15.6%) with tardy bleeding 2 - 7 days after ESMRL needed endoscopic re-hemostasis, of which 3 cases (43%) showed oozing of blood from the muscle layer and another 4 showed oozing of blood or arterial bleeding from the incision border. No perforation or inflammatory was reported. 39 cases (86.7%) had negative margin in pathological examination, and the incision margins of the other 6 patients, as normal submucosal layer could not be seen outside the tumor envelope, could not be evaluated. But the tumor envelope was integrated without involvement of tumor and other biopsy results 7 days after ESMRL was negative. So no more therapies were selected. All 45 patients were followed up for 31 months (6 - 52 months), there was no metastasis, relapse and dead cases. ESMRL is an effective, safe, and minimally invasive method to deal with rectal carcinoids.