Abstract Prognostic factors for local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. Background: The standard curative treatment for locally advanced rectal cancer of the middle and lower thirds is long-course chemoradiotherapy followed by total mesorectal excision. Purpose: To evaluate the prognostic factors associated with local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. Methods: Retrospective 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 chemoradio-therapy 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. Results: 270 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). Conclusion: Local 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. Background longcourse Purpose Methods T34N0M0 TNM T3 4N0M0 N M T3–4N0M anyN any 1 border T2N0M chemoradio therapy intent Clinical demographic radiologic collected KaplanMeier Kaplan Meier function analyses Results 27 included 578 57 8 57.8 617 61 7 61. 30‒88 3088 88 (30‒88 years staging 67 6 6.7 I 215 21 21.5 II 718 71 71.8 III 652 65 2 65.2% 781 78 78.1% 3 07 0 0.7% 494 49 4 49. 0.5‒86.1 05861 86 (0.5‒86.1 followup, followup follow up, up follow-up 263 26 26.3 59 9 5.9% HR 911 11 9.11 0.001 0001 001 819 19 8.19 0.001. . Conclusion T34N0M NM 4N0M 57. 30‒8 308 (30‒8 6. 21. 71. 65.2 78.1 0.7 0.5‒86. 0586 (0.5‒86. 26. 5.9 91 9.1 0.00 000 00 81 8.1 30‒ (30‒ 65. 78. 0. 0.5‒86 058 (0.5‒86 5. 9. 0.0 8. (30 0.5‒8 05 (0.5‒8 (3 0.5‒ (0.5‒ ( 0.5 (0.5 (0. (0

Abstract Introduction Appendicitis is the surgical disease with the highest prevalence in emergency rooms. Its clinical and/or surgical complications are associated with the time course of symptoms, age, comorbidities, and stages of the disease. Objectives To analyze the demographic and clinical data of patients who underwent appendectomy for acute appendicitis in a tertiary referral hospital in the city of São Paulo and compare these data between services provided by the Public and Supplementary Health System. Methodology Retrospective analysis of data from electronic medical records of patients over 14 years old who underwent appendectomy for acute appendicitis at Hospital Santa Marcelina, both in the Public and Supplementary Health Systems from January 2015 to December 2017. Results A total of 536 patients were analyzed, 354 (66%) of whom were male with a general mean age of 29.85 years (14-81 years). The mean time from symptoms to seeking medical care was 53.84 hours. Regarding the phases of acute appendicitis, a greater number of cases of complicated disease was observed in patients operated on in the Public Health System (p < 0.0001), as well as the time course of symptoms (p = 0.0005) and Conclusion There was a predominance of male patients undergoing appendectomy for acute appendicitis, with longer time course of symptoms in those operated on in the Public Health System and a predominance of appendicitis in advanced stages (3 and 4) in this group. However, in this group there was no significant increase in the rate of postoperative infection, and the length of stay was shorter than that of patients operated on in the Supplementary Health System. rooms andor or comorbidities 1 Marcelina 201 2017 53 analyzed 35 66% 66 (66% 2985 29 85 29.8 1481 81 (14-8 years. . years) 5384 84 53.8 hours p 0.0001, 00001 0.0001 , 0 0001 0.0001) 0.0005 00005 0005 3 ( 4 However infection 20 5 6 (66 298 2 8 29. 148 (14- 538 53. 0000 0.000 000 (6 (14 0.00 00 (1 0.0 0.

Abstract Introduction Chronic intestinal constipation (CIC) presents an incidence of 2.6 to 30.7% in the overall population and due to the social reality imposed by the coronavirus pandemic, some behavior changes in the Brazilian population occurred that might or not be associated with alterations of CIC prevalence. Objective To assess CIC incidence in medical students before and during the COVID-19 pandemic in Brazil in a private higher educational institution in the city of São Paulo, state of São Paulo. Methods Clinic data were collected through Google Forms software from the same students seeking to analyze the variables before (year of 2019) and during the coronavirus pandemic. The data were: age, sex, body mass index, constipation referred in a subjective way and confirmed through the ROME III criteria, feces consistency and anxiety and/or depression during the pandemic. Results A total of 126 medical students from a private higher education institution from São Paulo, SP were included. The average age was 22.9 years old, 70.6% were female and the average BMI was 23.3 kg/m2. Regarding the ROME III criteria, 32.5% presented > 2 in 2019 and 42.1% during the pandemic. Concerning the feces consistency, 31.75 and 35.71% presented dry Bristol 1 feces or in both periods, respectively. Conclusion It was observed an increase in the prevalence of chronic intestinal constipation in medical students from a private higher education institution from São Paulo, state of São Paulo, during the COVID-19 pandemic, as well as dryness in the feces. (CIC 26 6 2. 307 30 7 30.7 COVID19 COVID 19 COVID-1 Paulo year sex index criteria andor 12 included 229 22 9 22. old 706 70 70.6 233 23 3 23. kgm2 kgm kg m2 m kg/m2 325 32 5 32.5 201 421 42 42.1 3175 31 75 31.7 3571 35 71 35.71 periods respectively 30. COVID1 COVID- 70. kg/m 32. 20 4 42. 317 31. 357 35.7 35.

RESUMO RACIONAL: A abordagem laparoscópica reduziu consideravelmente a morbidade da cirurgia colorretal quando comparada à abordagem aberta. Entre seus benefícios podemos destacar o menor sangramento intraoperatório, ingestão oral precoce, menor índice de infecção de incisão cirúrgica e hérnia incisional, menor índice de dor pós-operatória e alta hospitalar mais precoce. OBJETIVOS: Comparar a morbidade perioperatória da colectomia direita versus esquerda para câncer e a qualidade da ressecção oncológica laparoscópica. MÉTODOS: Análise retrospectiva de pacientes submetidos à olectomia laparoscópica direit e esquerda entre 2006 e 2016. As complicações pós-operatórias foram classificadas pela escala Clavien-Dindo, 30 dias após a cirurgia. RESULTADOS: Um total de 293 pacientes foram analisados, 97 casos de colectomia direita (33.1%) e 196 de esquerda (66.9%). A idade média foi de 62,8 anos. Os grupos foram comparáveis em termos de idade, comorbidades, índice de massa corporal e classificação da Sociedade Americana de Anestesiologia (ASA). A transfusão pré-operatória foi maior no grupo da colectomia direita (5,1% versus 0,4%, p=0,004, p<0,05). No geral, 233 pacientes (79.5%) não apresentaram complicações. As complicações encontradas foram graus I e II em 62 pacientes (21,1%), egraus III a V em 37 (12,6%). Vinte e três pacientes (7,8%) foram reoperados. A comparação entre a colectomia laparoscópica esquerda e direita não foi estatisticamente diferente para tempo operatório, conversão, reoperação, complicações pós-operatórias graves e tempo de internação. A taxa de fístula anastomótica foi comparável em ambos os grupos (5,6% versus 2,1%, p=0,232, p>0,05). Os resultados oncológicos foram semelhantes nas duas cirurgias. Na regressão logística múltipla, a ASA influenciou estatisticamente os piores resultados (≥ III; p=0,029, p<0,05). CONCLUSÕES: Os resultados cirúrgicos e oncológicos das colectomias laparoscópicas direita e esquerda são semelhantes, tornando esta a abordagem preferida para ambos os procedimentos. RACIONAL aberta intraoperatório precoce incisional pósoperatória pós operatória OBJETIVOS MÉTODOS 200 2016 pósoperatórias operatórias ClavienDindo, ClavienDindo Clavien Dindo, Dindo Clavien-Dindo 3 RESULTADOS 29 analisados 9 33.1% 331 33 1 (33.1% 19 66.9%. 669 66.9% . 66 (66.9%) 628 8 62, anos comorbidades ASA. (ASA) préoperatória pré 5,1% 51 5 (5,1 04 0 4 0,4% p0004 p 004 p=0,004 p<0,05. p005 p<0,05 05 p<0,05) geral 23 79.5% 795 79 (79.5% 6 21,1%, 211 21,1% , 21 (21,1%) 12,6%. 126 12,6% 12 (12,6%) 7,8% 78 7 (7,8% reoperados operatório conversão reoperação internação 5,6% 56 (5,6 2 2,1% p0232 232 p=0,232 p>0,05. p>0,05 p>0,05) cirurgias múltipla ≥ ( p0029 029 p=0,029 CONCLUSÕES procedimentos 20 201 33.1 (33.1 66.9 (66.9% (ASA 5,1 (5, 0,4 p000 00 p=0,00 p00 p<0,0 79.5 (79.5 21,1 (21,1% 12,6 (12,6% 7,8 (7,8 5,6 2,1 p023 p=0,23 p>0,0 p002 02 p=0,02 33. (33. 66. (66.9 5, (5 0, p=0,0 p0 p<0, 79. (79. 21, (21,1 12, (12,6 7, (7, 2, p02 p=0,2 p>0, (33 (66. p=0, p<0 (79 (21, (12, (7 p>0 (3 (66 p=0 p< (21 (12 p> (6 p= (2 (1

ABSTRACT BACKGROUND: The laparoscopic approach considerably reduced the morbidity of colorectal surgery when compared to the open approach. Among its benefits, we can highlight less intraoperative bleeding, early oral intake, lower rates of surgical site infection, incisional hernia, and postoperative pain, and earlier hospital discharge. AIMS: To compare the perioperative morbidity of right versus left colectomy for cancer and the quality of laparoscopic oncologic resection. METHODS: Retrospective analysis of patients submitted to laparoscopic right and left colctomy between 2006 and 2016. Postoperative complications were classified using the Clavien-Dindo scale, 30 days after surgery. RESULTS: A total of 293 patients were analyzed, 97 right colectomies (33.1%) and 196 left colectomies (66.9%). The averageage was 62.8 years. The groups were comparable in terms of age, comorbidities, body mass index, and the American Society of Anesthesiology (ASA) classification. Preoperative transfusion was higher in the right colectomy group (5.1% versus 0.4%, p=0.004, p<0.05). Overall, 233 patients (79.5%) had no complications. Complications found were grade I and II in 62 patients (21.1%) and grade III to V in 37 (12.6%). Twenty-three patients (7.8%) underwent reoperation. The comparison between left and right colectomy was not statistically different for operative time, conversion, reoperation, severe postoperative complications, and length of stay. The anastomotic leak rate was comparable in both groups(5.6% versus 2.1%, p=0.232, p>0.05). The oncological results were similar in both surgeries. In multiple logistic regression, ASA statistically influenced the worst results (≥ III; p=0.029, p<0.05). CONCLUSIONS: The surgical and oncological results of laparoscopic right and left colectomies are similar, making this the preferred approach for both procedures. BACKGROUND benefits bleeding intake infection hernia pain discharge AIMS resection METHODS 200 2016 ClavienDindo Clavien Dindo scale 3 RESULTS 29 analyzed 9 33.1% 331 33 1 (33.1% 19 66.9%. 669 66.9% . 66 (66.9%) 628 8 62. years age comorbidities index (ASA classification 5.1% 51 5 (5.1 04 0 4 0.4% p0004 p 004 p=0.004 p<0.05. p005 p<0.05 05 p<0.05) Overall 23 79.5% 795 79 (79.5% 6 21.1% 211 21 (21.1% 12.6%. 126 12.6% 12 (12.6%) Twentythree Twenty three 7.8% 78 7 (7.8% reoperation time conversion stay groups5.6% groups56 5.6% groups(5.6 2 2.1% p0232 232 p=0.232 p>0.05. p>0.05 p>0.05) surgeries regression ≥ ( p0029 029 p=0.029 CONCLUSIONS procedures 20 201 33.1 (33.1 66.9 (66.9% 5.1 (5. 0.4 p000 00 p=0.00 p00 p<0.0 79.5 (79.5 21.1 (21.1 12.6 (12.6% 7.8 (7.8 groups5 groups5.6 56 5.6 groups(5. 2.1 p023 p=0.23 p>0.0 p002 02 p=0.02 33. (33. 66. (66.9 5. (5 0. p=0.0 p0 p<0. 79. (79. 21. (21. 12. (12.6 7. (7. groups5. groups(5 2. p02 p=0.2 p>0. (33 (66. p=0. p<0 (79 (21 (12. (7 groups( p>0 (3 (66 p=0 p< (2 (12 p> (6 p= (1

RESUMO Racional: Devido à falta de padrões normais de manometria anorretal no Brasil, os dados utilizados estão sujeitos a padrões de normalidade descritos em diferentes nacionalidades . Objetivo: Determinar os valores e a faixa da manometria anorretal de pessoas em idade produtiva, sem distúrbios do assoalho pélvico, comparando os parâmetros obtidos entre homens e mulheres. Métodos: Análise prospectiva de dados clínicos, como gênero, idade, raça, índice de massa corporal (IMC) e manometria anorretal, de voluntários de uma referência universitária brasileira em distúrbios do assoalho pélvico. Resultados: Quarenta pessoas foram incluídas, com idade média de 45,5 anos nos homens e 37,2 nas mulheres (p=0,43). De acordo com homens e mulheres, respectivamente em mmHg, as pressões de repouso foram semelhantes (78,28 vs. 63,51, p=0,40); pressões de contração (153,89 vs. 79,78, p=0,007) e pressão total de compressão (231,27 vs. 145,63, p=0,002). Os homens apresentaram valores significativamente maiores de contração esfincteriana, assim como o comprimento médio do canal anal funcional (2,85 cm nos homens vs. 2,45 cm nas mulheres, p=0,003). Conclusões: Os níveis normais de pressão esfincteriana no Brasil diferem dos utilizados até o momento como padrão normal da literatura. O gênero masculino apresenta maior tônus do esfíncter anal externo em relação ao feminino, além de maior extensão do canal anal funcional

ABSTRACT Background: Due to the lack of normal standards of anorectal manometry in Brazil, data used are subject to normality patterns described at different nationalities. Aim: To determine the values and range of the parameters evaluated at anorectal manometry in people, at productive age, without pelvic floor disorders comparing the parameters obtained between male and female. Methods: Prospective analysis of clinical data, such as gender, age, race, body mass index (BMI) and anorectal manometry, of volunteers from a Brazilian university reference in pelvic floor disorders. Results: Forty patients were included, with a mean age of 45.5 years in males and 37.2 females (p=0.43). According to male and female, respectively in mmHg, resting pressures were similar (78.28 vs. 63.51, p=0.40); squeeze pressures (153.89 vs. 79.78, p=0.007) and total squeeze pressures (231.27 vs. 145.63, p=0.002). Men presented significantly higher values of anorectal squeeze pressures, as well as the average length of the functional anal canal (2.85 cm in male vs. 2.45 cm in female, p=0.003). Conclusions: Normal sphincter pressure levels in Brazilians differ from those used until now as normal literature standards. Male gender has higher external anal sphincter tonus as compared to female, in addition a greater extension of the functional anal canal

RESUMO Racional: A realização de procedimentos minimamente invasivos para o manejo de distúrbios colorretais, possibilitou ampliar a indicação de laparoscopia para o manuseio de diversas complicações pós-operatórias precoces e tardias. Objetivo: Apresentar a experiência com reoperações laparoscópicas para complicações precoces após ressecções colorretais laparoscópicas. Métodos: Foram incluídos pacientes submetidos a ressecções colorretais laparoscópicas que apresentaram complicações cirúrgicas no pós-operatório abordadas por via laparoscópica. Os pacientes selecionados foram aqueles com diagnóstico precoce de complicações, estabilidade hemodinâmica sem distensão abdominal significativa e sem comorbidades clínicas que impedissem o procedimento. Resultados: Em quatro anos, nove de 290 (3,1%) pacientes submetidos a ressecções colorretais laparoscópicas foram reabordados pela mesma via de acesso. Havia cinco pacientes do sexo masculino e idade média foi de 40,67 anos. Os diagnósticos de doença primária incluíram adenocarcinoma (n=3), polipose adenomatosa familiar (n=3), colite ulcerativa (n=1), inércia colônica (n=1) e megacólon chagásico (n=1). Os procedimentos iniciais incluíram quatro proctocolectomias totais com anastomose íleo-anal em bolsa ileal; três ressecções anteriores; uma totalização de colectomia total; e uma hemicolectomia direita. A deiscência da anastomose foi a complicação mais comum que resultou em reoperação (n=6). Houve apenas um caso de desfecho desfavorável, com óbito no 40º dia da primeira abordagem após complicações consecutivas. Os demais casos tiveram desfecho favorável . Conclusão: Em casos selecionados, o acesso laparoscópico pode representar alternativa de abordagem segura e minimamente invasiva para complicações da ressecção colorretal. No entanto, a reoperação laparoscópica deve ser cuidadosamente selecionada, considerando o tipo de complicação, a condição clínica do paciente e a experiência da equipe cirúrgica.

ABSTRACT Background: Recently, with the performance of minimally invasive procedures for the management of colorectal disorders, it was allowed to extend the indication of laparoscopy in handling various early and late postoperative complications. Aim: To present the experience with laparoscopic reoperations for early complications after laparoscopic colorectal resections. Methods: Patients undergoing laparoscopic colorectal resections with postoperative surgical complications were included and re-treated laparoscopically. Selection for laparoscopic approach were those cases with early diagnosis of complications, hemodynamic stability without significant abdominal distention and without clinical comorbidities that would preclude the procedure. Results: In four years, nine of 290 (3.1%) patients who underwent laparoscopic colorectal resections were re-approached laparoscopically. There were five men. The mean age was 40.67 years. Diagnoses of primary disease included adenocarcinoma (n=3), familial adenomatous polyposis (n=3), ulcerative colitis (n=1), colonic inertia (n=1) and chagasic megacolon (n=1). Initial procedures included four total proctocolectomy with ileal pouch anal anastomosis; three anterior resections; one completion of total colectomy; and one right hemicolectomy. Anastomotic dehiscence was the most common complication that resulted in reoperations (n=6). There was only one case of an unfavorable outcome, with death on the 40th day of the first approach, after consecutive complications. The remaining cases had favorable outcome. Conclusion: In selected cases, laparoscopic access may be a safe and minimally invasive approach for complications of colorectal resection. However, laparoscopic reoperation must be cautiously selected, considering the type of complication, patient’s clinical condition and experience of the surgical team.

RESUMO CONTEXTO: Exame anorretal digital (EAD) faz parte do exame físico, também é essencial para a avaliação do cirurgião colorretal. Um bom EAD oferece informações preciosas relacionadas às queixas do paciente, que auxiliam na tomada de decisões. Sua realização é simples, rápida e minimamente invasiva. Em diversos centros ao redor do mundo, o toque retal ainda é o único método para avaliar o esfíncter anal antes do tratamento. Por outro lado, a manometria anorretal (MAR) é o principal método para avaliação funcional objetiva das pressões esfincterianas. A discrepância entre o EAD, dependendo do examinador para determinar o tônus esfincteriano em comparação à MAR motivou este estudo. OBJETIVO: Comparar o EAD com os parâmetros de pressão esfincteriana obtidos na MAR, dependendo da experiência dos examinadores. MÉTODOS: Trinta e seis pacientes consecutivos com queixas de incontinência fecal ou constipação crônica, do ambulatório de Fisiologia Anorretal da Faculdade de Medicina da Universidade de São Paulo, foram prospectivamente incluídos. Cada paciente foi submetido a MAR e EAD realizados por dois cirurgiões colorretais seniores e um júnior antes da MAR. A história dos pacientes propositalmente omitida dos examinadores, e os resultados de cada examinador foram cegos dos demais. Para o EAD, as pressões de repouso e contração foram classificadas por uma escala objetiva (EAD Scoring System), realizada pelos examinadores seniores e pelo júnior em todos os pacientes, que foi comparada com os parâmetros da MAR para a análise. ANÁLISE ESTATÍSTICA: A análise descritiva foi feita para todos os parâmetros. Para as pressões de repouso e contração, o índice Gamma foi utilizado para a comparação entre o EAD e a MAR, que variou de 0 a 1. Quanto mais próximo de 1 melhor a concordância entre os dois métodos de avaliação. RESULTADOS: A idade média foi de 48 anos e 55,5% dos pacientes eram do sexo feminino. A concordância das pressões anais de repouso entre a MAR e o EAD realizadas pelos examinadores seniores, proficientes, foi de 0,7 (IC 95%; 0,32-1,0), enquanto para o examinador júnior, menos experiente, foi de 0,52 (IC95%; 0,09-0,96). A concordância das pressões de contração foi de 0,96 (IC 95%; 0,87-1,0) para os examinadores seniores e de 0,52 (IC 95%; 0,16-0,89) para o júnior. CONCLUSÃO: Cirurgiões colorretais mais experientes, o EAD teve concordância mais significativa com a MAR, o que poderia levar a um manejo terapêutico mais adequado aos pacientes portadores de doença anorretais funcionais. A manometria anorretal permanece, portanto, como método de avaliação objetiva da função esfincteriana.

ABSTRACT BACKGROUND: Digital rectal examination (DRE) is part of the physical examination, is also essential for the colorectal surgeon evaluation. A good DRE offers precious information related to the patient’s complaints, which will help in decision making. It is simple, quick and minimally invasive. In many centers around the world, the DRE is still the only method to evaluate the anal sphincter prior to patient’s management. On the other hand, anorectal manometry (ARM) is the main method for objective functional evaluation of anal sphincter pressures. The discrepancy of DRE depending on the examiner to determine sphincter tonus in comparison to ARM motivated this study. OBJECTIVE: To compare the DRE performed by proficient and non-experienced examiners to sphincter pressure parameters obtained at ARM, depending on examiners expertise. METHODS: Thirty-six consecutive patients with complaints of fecal incontinence or chronic constipation, from the anorectal physiology clinic of the University of São Paulo School of Medicine, were prospectively included. Each patient underwent ARM and DRE performed by two senior colorectal surgeons and one junior colorectal surgeon prior to the ARM. Patient’s history was blinded for the examiner’s knowledge, also the impressions of each examiner were blinded from the others. For the DRE rest and squeeze pressures were classified by an objective scale (DRE scoring system) that was compared to the parameters of the ARM for the analysis. The results obtained at the ARM were compared to the DRE performed by the seniors and the junior colorectal surgeons. STATISTICAL ANALYSIS: Descriptive analysis was performed for all parameters. For the rest and squeeze pressures the Gamma index was used for the comparison between the DRE and ARM, which varied from 0 to 1. The closer to 1 the better was the agreement. RESULTS: The mean age was 48 years old and 55.5% of patients were female. The agreement of rest anal pressures between the ARM and the DRE performed by the senior proficient examiners was 0.7 (CI 95%; 0.32-1.0), while for the junior non-experienced examiner was 0.52 (CI 95%; 0.09-0.96). The agreement of squeeze pressures was 0.96 (CI 95%; 0.87-1.0) for the seniors and 0.52 (CI 95%; 0.16-0.89) for the junior examiner. CONCLUSION: More experienced colorectal surgeons used to DRE had a more significant agreement with the ARM, thereafter would have more appropriate therapeutic management to patients with sphincter functional problems. ARM, therefore, persists as an important exam to objectively evaluate the sphincter complex, justifying its utility in the clinical practice.

RESUMO Racional: Desde 1990, foi proposto que a localização distal e proximal do câncer de cólon pode seguir diferentes aspectos biológicos, epidemiológicos, patológicos e prognósticos. Essas diferenças podem ter consequências para o tratamento de pacientes com câncer colorretal. Objetivo: Comparar as características entre pacientes com câncer de cólon direito e esquerdo, com gravidade e características tumorais que influenciam na sobrevida desses pacientes. Método: Avaliação dos resultados do tratamento cirúrgico dos pacientes com câncer de cólon em longo prazo com dados coletados retrospectivamente. Resultados: O lado do tumor não influenciou o tempo de sobrevida (p=0,112) no modelo de regressão. Apenas o estágio da doença influencia no tempo de sobrevida. Os pacientes com câncer de cólon direito apresentam estadiamento mais avançado (III ou IV) e apresentam risco de morte 3,23 vezes maior. Conclusão: O prognóstico do câncer de cólon localizado no lado esquerdo é melhor comparado ao direito. Os pacientes com câncer de cólon direito têm estágio e idade mais avançados e tumor mucinoso.

ABSTRACT Background: Since 1990 it was proposed that distal and proximal location of colon cancer might follow different biological, epidemiology, pathology and prognosis, probably due to embryologic different development of the two segments of the colon, which may represent two separate disease entities. These differences might have consequences for the treatment of patients with colorectal cancer. Aim: To compare the characteristics between patients with right and left colon cancer, with severity and tumor characteristic that influence in the survival of these patients. Method: Were evaluated the outcomes of surgical treatment of patients with colon cancer with data collected retrospectively from prospectively collected database. Results: The tumor’s side did not influence survival time of patients with colon cancer (p=0.112) in the regression model. Only the diseases stage leads to influence on survival time; patients with right colon cancer have more advanced staging (III or IV) and present a risk of death greater in 3.23 times. Conclusion: This analysis provides evidence that the prognosis of localized left-sided colon cancer is better compared to right-sided colon cancer. Also, the patients with right colon cancer have more advanced stage, mucinous tumor and are older.

RESUMO CONTEXTO: Esclerodermia ou esclerose sistêmica progressiva caracteriza-se por um processo inflamatório crônico com proliferação e fibrose do tecido conjuntivo e uma deposição excessiva de colágeno e matriz extracelular na pele, musculatura lisa e vísceras. A musculatura lisa mais envolvida é a esofágica e a disfagia é o sintoma mais comumente relatado. Entretanto, o esfíncter anal interno também pode ser acometido por essa degeneração e fibrose ocasionando incontinência anal nos pacientes portadores de esclerodermia. Isso pode ser omitido pelo paciente, exceto quando questionado de forma direta. OBJETIVO: Analisar a função e anatomia anorretal através do escore de incontinência anal de Cleveland Clinic Florida, manometria anorretal e ultrassom endoanal em pacientes do sexo feminino portadoras de esclerodermia e sintomas de incontinência anal atendidas no ambulatório de Fisiologia Colorretoanal no Hospital das Clínicas da Universidade de São Paulo (HC-FMUSP). RESULTADOS: Treze pacientes do sexo feminino foram avaliadas com média de idade de 55,77 anos (±16,14; 27-72 anos) e duração média da doença de 10,23 anos (±6,23; 2-23 anos). O índice de incontinência anal teve variação de 1-15, sendo que sete (53,8%) pacientes apresentavam índice inferior a 7; três (23,1%) entre 8 e 13; e três (23,1%) superior a 14, correspondendo à incontinência anal leve, moderada e grave, respectivamente. Dez (76,92%) pacientes apresentavam hipotonia do esfíncter anal interno. O estudo da ultrassonografia endoanal de três dimensões demonstrou afilamento com atrofia do esfíncter anal interno em seis casos e defeito muscular em três pacientes. CONCLUSÃO: O prejuízo funcional e anatômico do complexo esfincteriano anorretal é um importante fator a ser analisado em pacientes portadores de esclerose sistêmica progressiva e isso não pode ser subestimado.

ABSTRACT BACKGROUND: Scleroderma or progressive systemic sclerosis is characterized by a chronic inflammatory process with proliferation of fibrous connective tissue and excessive deposition of collagen and extracellular matrix in the skin, smooth muscle, and viscera. The smooth muscle most involved in scleroderma is that of the esophagus, and dysphagia is the most commonly reported symptom. However, the internal anal sphincter may also be impaired by degeneration and fibrosis, leading to concomitant anal incontinence in scleroderma patients. These patients may neglect to complain about it, except when actively questioned. OBJECTIVE: To assess anorectal function and anatomy of female scleroderma patients with symptoms of anal incontinence through Cleveland Clinic Florida Fecal Incontinence Score (CCFIS), anorectal manometry and endoanal ultrasound at the outpatient clinic of colorectal and anal physiology, Clinics Hospital, University of São Paulo Medical School (HC-FMUSP). METHODS: Female scleroderma patients were prospectively assessed and questioned as to symptoms of anal incontinence. The anorectal manometry and endoanal ultrasound results were correlated with clinical data and symptoms. RESULTS: In total, 13 women were evaluated. Their mean age was 55.77 years (±16.14; 27-72 years) and their mean disease duration was 10.23 years (±6.23; 2-23 years). All had symptoms of fecal incontinence ranging from 1 to 15. Seven (53.8%) patients had fecal incontinence score no higher than 7; three (23.1%) between 8 and 13; and three (23.1%) 14 or higher, corresponding to mild, moderate, and severe incontinence, respectively. Ten (76.92%) patients had hypotonia of the internal anal sphincter. Three-dimensional endoanal ultrasound showed tapering associated with muscle atrophy of the internal sphincter in six cases and previous muscle defects in three cases. CONCLUSION: A functional and anatomical impairment of the sphincter is an important factor to assess in patients with progressive systemic sclerosis and it should not be underestimated.

RESUMO O objetivo deste trabalho foi avaliar os consensos de sociedade de especialistas e guidelines publicados sobre o diagnóstico e tratamento da constipação intestinal crônica em adultos, e confrontar com a experiência dos autores, a fim de padronizar condutas que auxiliem o raciocínio e a tomada de conduta do médico. Foi realizada busca na literatura científica, mais precisamente nas bases de dados eletrônicos Medline/Pubmed, Scielo, EMBASE and Cochrane, tendo sido utilizado os seguintes descritores: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Pode-se concluir que constipação crônica é condição comum em adultos, ocorrendo com maior frequência em idosos e mulheres. Identificar com precisão a fisiopatologia presente na constipação crônica funcional é complexo, requerendo a realização de testes funcionais nos casos refratários. O entendimento da motilidade intestinal e do mecanismo defecatório é importante para o manejo da constipação intestinal crônica funcional, sendo o tratamento cirúrgico indicado para casos selecionados, onde à abordagem medicamentosa não surtiu efeito. As informações contidas neste artigo de revisão devem ser submetidas à avaliação e à crítica do médico especialista responsável pela conduta a ser tomada, frente à sua realidade e ao estado clínico de cada paciente.

ABSTRACT The aim of this study was to evaluate the published professional association guidelines regarding the current diagnosis and treatment of functional intestinal constipation in adults and to compare those guidelines with the authors' experience to standardize actions that aid clinical reasoning and decision-making for medical professionals. A literature search was conducted in the Medline/PubMed, Scielo, EMBASE and Cochrane online databases using the following terms: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Conclusively, chronic intestinal constipation is a common condition in adults and occurs most frequently in the elderly and in women. Establishing a precise diagnosis of the physiopathology of functional chronic constipation is complex and requires many functional tests in refractory cases. An understanding of intestinal motility and the defecatory process is critical for the appropriate management of chronic functional intestinal constipation, with surgery reserved for cases in which pharmacologic intervention has failed. The information contained in this review article is subject to the critical evaluation of the medical specialist responsible for determining the action plan to be followed within the context of the conditions and clinical status of each individual patient.

RESUMO Racional: O câncer colorretal é o terceiro câncer mais comum no mundo. No Brasil é a principal causa no trato gastrointestinal. Objetivo: Avaliar os fatores de riscos pré, peri e pós-operatório para recorrência e sobrevida global de pacientes com câncer de cólon esquerdo operado durante um período de dez anos. Métodos: Os pacientes com câncer de cólon esquerdo operados foram retrospectivamente avaliados. Os seguintes fatores foram estudados: gênero, idade, localização do tumor, estádio T, número de linfonodos, estágio N, estágio M, tipo histológico e diferenciação tumoral. Foi analisada a influência desses fatores na sobrevida global de cinco anos. Resultados: 173 pacientes foram submetidos à colectomia para câncer de cólon esquerdo. O gênero masculino predominou com 50,9%. A média de idade foi de 60,8 anos. Quinze (8,7%) tumores foram localizados no ângulo esplênico, 126 (72,8%) no sigmóide e 32 (18,5%) e no descendente. A média do tempo de internação foi de sete dias. A sobrevida média foi de 47,5 meses. Aos 60 meses sete doentes (4%) perderam o seguimento, 38 (21,9%) faleceram e 135 (78%) estavam vivos. O tempo de sobrevida global foi de 48 meses. Conclusão: Os estádios avançados (T3-T4, N e M+) foram os únicos fatores associados à menor sobrevida em longo prazo em câncer de cólon esquerdo.

ABSTRACT Background: Colorectal cancer is the third most common cancer in the world. In Brazil, it is the leading cause of cancer in the gastrointestinal tract. Aim: To evaluate the preoperative, perioperative, and postoperative risk factors for recurrence and overall survival of patients with left colon cancer operated during a ten-year period. Methods: Patients with left colon cancer surgically treated underwent clinical preoperative workout and cancer staging. The following factors were studied: gender, age, tumor location, T stage, lymph node yield, N stage, M stage, histological type, and tumor differentiation. It was analyzed the influence in five-year overall survival. Results: A total of 173 patients underwent left colectomy for colon cancer. There was a slight predominance of male gender with 50.9%. The mean age was 60.8 years old. Fifteen (8.7%) tumors were located at splenic flexure, 126 (72.8%) at sigmoid colon, and 32 (18.5%) at descending colon. The median length of hospital stay was seven days. Mean survival was 47.5 months. At 60 months seven patients (4%) lost follow-up, 38 patients (21.9%) deceased and 135 patients (78%) were alive. Overall survival time was 48 months. Conclusion: Advanced stages (T3-T4, N+ and M+) were the only factors associated with poor long term survival in left colon cancer.

OBJECTIVES: This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer. METHODS: Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155. RESULTS: The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement. CONCLUSIONS: Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes.

RACIONAL: Câncer colorretal é o tipo mais comum das neoplasias gastrointestinais. Há muitas controvérsias na literatura acerca do valor prognóstico do sítio da neoplasia. Muitos estudos revelam maiores taxas de sobrevida para tumores em cólon direito, com piora do prognóstico à medida que as lesões se situam mais distalmente. OBJETIVO: Analisar os resultados do tratamento cirúrgico de pacientes com câncer de cólon direito estádios I-IV operados em um período de dez anos e identificar os fatores prognósticos que foram associados com menor sobrevida global. MÉTODOS: Em 10 anos, 187 pacientes foram submetidos à colectomia direita com intenção curativa. Foram estudados os seguintes fatores: gênero, idade, localização do tumor, o número de linfonodos obtidos no espécime, comprometimento linfonodal, estádio T e presença de metástases à distância. Estes fatores foram avaliados quanto à possibilidade de serem indicadores prognósticos na sobrevida em cinco anos. RESULTADOS: A idade média foi de 65 (±12) anos e 105 (56,1%) eram mulheres. A localização, mas comum foi o cólon ascendente (48,1%), seguido do ceco (41,7%) e o ângulo hepático (10,2%). A média de tempo de internação hospitalar foi 14 (±2.8) dias. A distribuição do estádio T foi T1 (4,8%), T2 (7,5%), T3 (74,9%) e T4 (12,8%). Acometimento linfonodal ocorreu em 46,0% e metástases à distância em 3,7%. Um mínimo de 12 linfonodos ressecados foram obtidos em 87,2% dos espécimes cirúrgicos. Em 84.5% os tumores eram não-mucinosos. A média de sobrevida foi de 38,3 (±30.8) meses. A sobrevida geral foi afetada pelo estádio T, N, M e pelo estádio final. O acometimento linfonodal (RR=2,06) e os estádios III/IV (RR=2,81) foram fatores prognósticos negativos independentes. CONCLUSÕES: Estádio avançado e envolvimento linfonodal foram os fatores associados com a pior sobrevida em longo prazo.

BACKGROUND: Colorectal cancer is one of the most common malignancies in the world. There are many controversies in the literature about the prognostic value of primary tumor location. Many studies have shown higher survival rates for tumors in the right colon, and worse prognosis for lesions located more distally in the colon. AIM: To analyze the results of surgical treatment of right-sided colon cancers patients operated in one decade period and identify the prognostic factors that were associated with lower overall survival in stages I-IV patients. METHODS: A retrospective review from the prospectively collected database identified 178 patients with right-sided colon cancer surgically treated with curative intent. Demographic factors (gender and age), tumor factors (site, T stage, N stage, M stage, histological type and tumor differentiation), and lymph node yield were extracted to identify those associated with lower overall survival. RESULTS: Mean age was 65 (±12) years old, and 105 (56.1%) patients were female. Most common affected site was ascending colon (48.1%), followed by cecum (41.7%) and hepatic flexure (10.2%). Mean length of hospital stay was 14 (±2.8) days. T stage distribution was T1 (4.8%), T2 (7.5%), T3 (74.9%), and T4 (12.8%). Nodal involvement was present in 46.0%, and metastatic disease in 3.7%. Twelve or more lymph nodes were obtained in 87.2% of surgical specimens and 84.5% were non-mucinous tumors. Mean survival time was 38.3 (±30.8) months. Overall survival was affected by T stage, N stage, M stage, and final stage. Lymph node involvement (OR=2.06) and stage III/IV (OR=2.81) were independent negative prognostic factors. CONCLUSION: Right-sided colon cancer presented commonly at advanced stage. Advanced stage and lymph node involvement were factors associated with poor long term survival.

RACIONAL: A cirurgia para hemorróidas sintomáticas é necessária em quase 10% dos pacientes. Embora, a literatura sobre o tratamento cirúrgico da doença hemorroidária seja muito grande, os dados relativos à hemorroidectomia ou hemorroidopexia realizadas por residentes de treinamento é limitado. OBJETIVO: Analisar os resultados destes procedimentos em uma instituição de ensino. MÉTODOS: Foram analisados retrospectivamente os dados de todos os pacientes que se submeteram ao tratamento cirúrgico para hemorróidas entre1995 e 2007 em uma única instituição. Residentes supervisionados realizaram todos os procedimentos. As técnicas foram comparadas com base no tempo operatório, permanência hospitalar, morbidade e eficácia a longo prazo. RESULTADOS: Trezentos e trinta e três pacientes foram incluídos no estudo, 182 homens (54,6%), com idade média de 45,3 anos (± 12,02). Hemorróidas de terceiro grau foram a principal indicação (81,7%). Milligan-Morgan foi o procedimento mais comumente realizado (57%), seguido por Ferguson e hemorroidopexia grampeada. A média de tempo operatório foi significativamente menor no grupo hemorroidopexia grampeada quando comparado com os procedimentos abertos e fechados: 49,4 ± 29,3 min vs 61,1 ± 26,5 e 67,1 ± 28,3, respectivamente (p=0,0034). Não houve diferença estatisticamente significativa entre os grupos quanto às complicações pós-operatórias ou à taxa de reoperação. O tempo de internação foi significativamente maior no grupo Milligan-Morgan quando comparado com Ferguson e grampeamento (1,41 ± 0,86 dias vs 1,19 ± 0,43 vs 1,16 ± 0,37, respectivamente). Recorrência sintomática, taxas de reoperação e o uso de ligadura elástica foram semelhantes entre os grupos. CONCLUSÃO: Os residentes sob supervisão pode executar Milligan-Morgan, Ferguson e grampeamento hemorroidário com baixa incidência de complicações e bons resultados a longo prazo. O grampeamento foi associado com menor tempo operatório, enquanto Milligan-Morgan foi correlacionada com maior tempo de hospitalização.

BACKGROUND: Surgery for symptomatic hemorrhoids is needed in almost 10% of the patients. Although, literature about the surgical management of hemorrhoidal disease is vast, data concerning hemorrhoidectomy or hemorrhoidopexy performed by training residents is limited. AIM: To analyze the results of these procedures in a teaching institution. METHODS: Data from all patients who underwent surgical treatment for hemorrhoids from 1995 to 2007 in a single institution were retrospectively analyzed. Residents supervised by assisting doctors performed all procedures. Techniques were compared based on operative time, hospital stay, morbidity, and long-term efficacy. RESULTS: Three hundred thirty three patients were included in the study, 182 males (54.6%), with a mean age of 45.3 years (± 12.02). Third degree hemorrhoids were the main indication (81.7%). Milligan-Morgan was the most commonly performed procedure (57%), followed by Ferguson and stapled hemorrhoidopexy. Mean operative time was significantly lower in the stapled hemorrhoidopexy group when compared to the open and closed procedures: 49,4 ± 29.3 min vs. 61.1 ± 26.5 and 67.1 ± 28.3, respectively (p=0.0034). There was no statistically significant difference among the groups regarding postoperative complications or reoperation rate. Length of stay was significantly higher in the Milligan-Morgan group when compared to Ferguson and stapled hemorrhoidopexy (1.41 ± 0.86 days vs. 1.19 ± 0.43 vs. 1.16 ± 0.37 respectively). Symptomatic recurrence, reoperation rates and band ligation usage were similar among groups. CONCLUSION: Residents under supervision can perform Milligan-Morgan, Ferguson and stapled hemorrhoidopexy with low incidence of complications and good long-term results. Stapled hemorrhoidopexy technique was associated with a shorter operative time, while Milligan-Morgan correlated with a longer length of stay.