Transanal local excision with the use of endoscopic microsurgical approach may result in significant postoperative morbidity, wound dehiscence, and readmission rates, in particular, because of rectal pain secondary to wound dehiscence. In this setting, the benefits of this minimally invasive approach either for diagnostic or therapeutic purposes become significantly restricted to highly selected patients that can potentially avoid a major operation but will still face a significantly morbid and painful procedure.

Therefore, in the setting of a complete tumor regression after neoadjuvant CRT, surgeons have searched for alternative management of patients in order to avoid the potential consequences of TME with or without abdominal perineal resection. 2. Factors associated with tumor response after CRT Tumor response to neoadjuvant chemoradiation is not uniform and seems to be related to many factors such as specific treatment regimen, timing after CRT completion, tumor/patient characteristics and tumor biology. 2.1 Chemoradiation regimen Fractionated long course chemoradiation followed by surgery after 6-8 weeks or pelvic short-course irradiation with 25Gy in five fractions followed by immediate surgery (shortcourse) have been the two most frequent regimens used in the preoperative treatment of patients with resectable T3-4 rectal cancer. Even though the benefits in local disease control seem to be equivalent between short-course RT and long-course chemoradiation therapy,(Bujko et al. 2006) there are significant differences in terms of tumor downstaging between patients undergoing these two regimens. In patients undergoing short-course RT, the rates of pCR are significantly lower when compared with patients undergoing long-course neoadjuvant chemoradiation. Two aspects should be considered; first, the long-course regimen includes chemotherapy, second, cancer cells damaged after radiotherapy need time to undergo necrosis and usually in patients undergoing short-course RT, surgery is performed within 1 week after RT completion whereas long-course CRT is followed by radical surgery after at least 6-8 weeks. The addition of chemotherapy to radiation in the neoadjuvant setting has resulted not only in improvements in local disease control (ie, lower recurrence rates) but also in tumor downstaging.(Jose G Guillem et al. 2008) In a randomized trial of patients undergoing RT with or without 5-FU-based chemotherapy, patients in the CRT group more frequently had a complete pathologic responses less lymph node metastases as well as vascular invasion. Additionally, patients treated by CRT had fewer overall lymph nodes recovered in the resected specimens and decreased tumor size. (Bosset 2005) A review of phase II and III studies using different neoadjuvant CRT regimens for rectal cancer identified several predictive factors for complete pathologic response, including the dose of radiation therapy delivered, the method of 5-FU infusion, and the use of additional drugs to standard 5-FU based regimens. After reviewing 71 studies with over 4,000 patients treated with different regimens, complete pathologic response ranged from 0% to 42% and was significantly associated with the delivery of radiation doses higher than 45-Gy, 5-FU regimens with continous infusion, and the use of a second drug, most frequently oxaliplatin. (Sanghera et al. 2008) Despite the suggestion that the use of additional drugs (other than 5-FU) could enhance tumor response to CRT, recently reported results from a prospective randomized trial showed that the addition of...

<b><i>Introduction:</i></b> Abdominal surgery in patients with Crohn’s disease (CD) is challenging, especially in the biologic era. The aim of this study was to evaluate factors associated with increased risk for postoperative complications in CD. <b><i>Methods:</i></b> A retrospective study was conducted with consecutive patients who underwent abdominal surgery for CD from January 2012 to January 2018. <b><i>Results:</i></b> Of 103 patients, 32% had postoperative complications. Gender, age, disease location and phenotype, hemoglobin and albumin levels, previous abdominal surgery, and preoperative optimization did not differ between the groups with or without complications. Thirty-five percent of the patients were under anti-TNF therapy, and this medication was not associated with increased risk for postoperative complications. Time since the onset of the disease was significantly higher in patients with complications (12.9 vs. 9.4, <i>p</i> = 0.04). In multivariate analysis, creation of ostomy and urgent surgery were the only variables independently associated with increased risk for complications (OR 3.2, 95% CI 1.12–9.46 and OR 2.94, 95% CI 0.98–9.09, respectively). <b><i>Conclusion:</i></b> Urgent surgery for CD should preferably be performed in specialized centers, and creation of stoma is not necessarily associated with lower rate of postoperative complications but rather less severe complications.

Introduction. Central pontine myelinolysis is characterized by the occurrence of acute demyelinating lesions of cells in the pons secondary to abrupt oscillations of serum osmolarity. Its exact incidence is not well defined, but studies show a prevalence of 0.25 to 0.5% in the general population, 2.5% in the intensive care unit, and up to 10% in patients with risk factors, such as chronic liver disease and hepatic transplantation, alcoholism, malnutrition, diuretic therapy, electrolyte imbalance, hypoglycemia, and hyperglycemia. Case Report. A 70-year-old white female with extranodal diffuse large B-cell non-Hodgkin’s lymphoma (extensive mass on the left anterior chest wall), stage IVA, developed pontine myelinolysis secondary to hypovolemic acute hypernatremia, which occurred due to diarrhea caused by chemotherapy (rituximab, cyclophosphamide, doxorubicin, and vincristine). Discussion. Pontine myelinolysis occurs most often due to the rapid correction of chronic hyponatremia. But here, we describe a case of the disease secondary to the occurrence of hypovolemic acute hypernatremia in a patient with a hematological malignancy under treatment, who was on chronic treatment with thiazide diuretics and who presented with other electrolyte disturbances as risk factors for the development of pontine myelinolysis.

INTRODUÇÃOO tratamento convencional da doença de Crohn (DC) é muitas vezes desapontador. Apesar da variedade de drogas disponíveis para o seu tratamento, tais como: salicilatos e seus derivados, corticosteróides, antibióticos e imunossupressores, nenhuma destas mostrou ser totalmente eficaz ou definitiva para o tratamento da doença e seus surtos de exacerbação. As drogas biológicas foram desenvolvidas com o objetivo de serem mais específicas para esse tipo de tratamento.Sabe-se que o fator de necrose tumoral (TNF) alfa está elevado nas fezes, mucosa e sangue dos doentes com DC, e que o desequilíbrio entre secreção e sua inibição está relacionado com a patogênese da doença 13 . Neste contexto, algumas drogas foram desenvolvidas com a estratégia de bloqueá-lo e, demonstraram potente atividade clínica, confirmando o seu papel na patogênese da DC e no tratamento de doentes de difícil manejo clínico 5,15,17 .Entre os variados tipos de anti-TNF alfa que surgiram para o tratamento da DC podemos citar: infliximabe, adalimumabe, CDP870, CDP571, etanercept e ornecept 17 . O infliximabe é um anticorpo monoclonal IgG1 quimérico constituído de 75% de proteína humana e 25% de proteína de camundongo. A porção de camundongo contém o sítio de ligação para o fator de necrose tumoral (TNF) alfa, enquanto a porção humana é responsável pela função efetora. O infliximabe liga-se ao TNF alfa solúvel e TNF ligado à membrana bloqueando as atividades biológicas da citocina 2,3 .O presente estudo visa avaliar os resultados obtidos com o uso do infliximabe no tratamento dos doentes com DC e observar se houve diferença na resposta clínica entre os grupos de doentes que variaram quanto ao tempo de doença e tratamento cirúrgico prévio relacionado. MÉTODO