Aims:The prognosis on treatment of the cancer of the rectum has not changed in the last fifty years. Survival rates of 50% to 55% seems immutable in several published series. The main cause for those results is the high incidence of recurrence, either local or widespread. Local recurrence is directly related to the number of undifferentiated cells and to the grade of wall invasion. Widespread recurrence depends specifically on the lymphatic and vascular spreading. So any kind of treatment that would diminish the number of undifferentiated cells and the size or the tumor wall penetration would certainly decrease the local recurrence rate, lengthening the interval free from cancer and, perhaps, modifying the long term survival rate. Between 1978 and 2009, a total of 538 patients with adenocarcinoma of the lower rectum (from the pectinate line to 10 cm above) were treated by preoperative radiotherapy. Methodology: The same protocol was used in all the patients -400 cGy, 200 cGy/day, during 4 consecutive weeks (anterior and posterior pelvic fields) by means of a Linear Megavoltage Accelerator (25 MeV). Surgery was performed 2 months after completion of the radiotherapy. Results: Statistical analysis of the whole group showed that preoperative radiotherapy does decrease frequency of undifferentiated cells. Moreover, the incidence of local recurrence diminished after irradiation by 3.4%. Preoperative radiotherapy reduces tumor volume (ERUS) and wall invasion, as well as the mortality rate due to local recurrence (2.4%) and alters long-term survival rate (80.1%). Conclusion: Preoperative radiotherapy is really effective in reducing the number of undifferentiated cells and in diminishing the tumor volume and the carcinomatous infiltration of the rectal wall.

Purpose The goal of a rubber band ligature is to promote fibrosis of the submucosa with subsequent fixation of the anal epithelium to the underlying sphincter. Following this principle, a new technique of ligature was developed based on two aspects:1. macro banding: to have a better fibrosis and fixation by banding a bigger volume of mucosa and2. higher ligature: to have this fixation at the origin of the hemorrhoidal cushion displacement. Methods 1634 patients with internal hemorrhoidal disease grade II or III were treated by the technique called high macro rubber band. There was no distinction as to age, gender or race. To perform this technique a new hemorrhoidal device was specially designed with a larger diameter and a bigger capacity for mucosal volume aspiration. It is recommended to utilize a longer and wider anoscope to obtain a better view of the anal canal, which will facilitate the injection of submucosa higher in the anal canal and the insertion of the rubber band device. The hemorrhoidal cushion must be banded higher in the anal canal (4 cm above the pectinate line). It is preferable to treat all the hemorrhoids in one single session (maximum of three areas banded). Results The analysis was retrospective without any comparison with conventional banding. The period of evaluation extended from one to twelve years. The analysis of the results showed perianal edema in 1.6% of the patients, immediate tenesmus in 0.8%, intense pain (need for parenteral analgesia) in 1.6%, urinary retention in 0.1% of the patients and a symptomatic recurrence rate of 4.2%. All patients with symptomatic recurrence were treated with a new session of macro rubber banding. None of the patients developed anal or rectal sepsis. Small post-ligature bleeding was observed only in 0.8% of the patients. Conclusions The high macro rubber banding technique represents an alternative method for the treatment of hemorrhoidal disease grades II or III, with good results at a low cost. The analysis of the observed results showed a small incidence of minor complications, with a high index of symptomatic relief.

Kagohara OH, Costa SL. Influence of pneumoperitoneum on tumor implantation in parietal incision: a comparative study of trocar incision and laparotomy in rats. J Coloproctol, 2012;32(3): 214-222. ABSTRACT:Videolaparoscopic surgery has enabled great progress in surgical procedures. However, the literature shows great controversy concerning its indication in oncological surgery for possibly increasing the implantation of metastases. This experimental study was carried out to help solve this controversy and analyze the influence of pneumoperitoneum as a cause of this implantation. A comparative study between incisions of trocars of videolaparoscopy and conventional laparotomy was conducted. For this analysis, 30 Wistar rats were divided into two equal groups: laparotomic group (A), that underwent a 5 cm laparotomy, which was left exposed for 15 minutes; and another (B), in which a 3 mmHg pneumoperitoneum was created with CO 2 and two more trocars were inserted, maintaining the insufflation for the same period. In both groups, the tumor, Walker 256 carcinosarcoma, was inoculated in the surgical procedure. The evaluation was performed within the fifth and the seventh postoperative days. The result of the macroscopic evaluation indicated that the tumor invasion in group A reached 93.33% and the implantation in the laparoscopy incision reached 73.33%. Nevertheless, the histopathological exam showed tumor implantation in all incisions of both groups (100%). The study concluded that parietal tumor implantation is not influenced by pneumoperitoneum in incisions of trocars when compared with conventional laparotomy in rats.Keywords: laparoscopy; laparotomy; neoplasm metastasis; implantation; carcinosarcoma. RESUMO:A cirurgia videolaparoscópica proporcionou grande avanço nas técnicas cirúrgicas. No entanto, há controvérsia na literatura sobre sua indicação na cirurgia oncológica por possivelmente aumentar a implantação tumoral de metástases. No intuito de contribuir para esclarecer essa controvérsia, realizou-se este estudo experimental visando analisar a influência do pneumoperitônio como causa dessa implantação. Realizou-se um estudo comparativo entre incisões dos trocartes da videolaparoscopia e da laparotomia convencional. Para isso, foram utilizados 30 ratos Wistar divididos em dois grupos iguais: um laparotômico (A), que foi submetido à laparotomia com 5 cm de extensão, a qual ficou exposta por 15 minutos; e outro (B), no qual se efetuou pneumoperitônio de 3 mmHg com CO 2 e colocaram-se mais dois trocartes, mantendo-se insuflado pelo mesmo período. Em ambos os grupos, inoculou-se o tumor no ato operatório, o carcinossarcoma 256 de Walker. A avaliação deu-se entre o quinto e sétimo dia de pós-operatório. Como resultado na avaliação macroscópica, há invasão tumoral no grupo A de 93,33% e implantação na incisão laparoscópica de 73,33%. No exame histopatológico, porém, revelou-se implantação tumoral em todas as incisões de ambos os grupos (100%). Conclui-se que a implantação tumoral não sofre influência do pneumoperitônio...

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The concept that hemorrhoidal disease is a consequence of disorders of the cephalic portion of the anal canal, i.e. weakness of the vascular cushions and the connective tissue, is the basis for modifying the usual surgical technique in many aspects. The two main differences of the method described are: (i) the internal plexus is treated by parceled ligature, avoiding resection of the mucosa, but providing a firm fixation of the submucosa and subsequent fixation of the anal epithelium to the underlying sphincter in the anal canal; (ii) the external plexus is removed preserving as much as possible the anal margin skin, and the resulting wound is partially closed, resulting in a small drainage area; and (iii) a firm fixation of the submucosa and subsequent fixation of the anal epithelium to the underlying sphincter are achieved without mucosa resection.