Os pólipos colorretais são estruturas que se projetam na superfície da camada mucosa do intestino grosso, podendo ser neoplásicos ou não. Foi Morson, em 1976, quem melhor estabeleceu uma classificação para os diversos tipos de pólipos e a importância da progressão adenoma-câncer. Os pólipos foram divididos em: pólipos neoplásicos, caracterizados pelos adenomas e os carcinomas, e os pólipos não-neoplásicos, que incluem os tipos epiteliais hamartomatosos, inflamatórios, hiperplásicos ou metaplásicos. Os pólipos adenomatosos, que correspondem a cerca de 70% de todos os pólipos, são conhecidamente lesões pré-malignas que antecedem, em 10 a 15 anos, o câncer colorretal. Por conta dessa progressão lenta, a detecção de lesões pré-neoplásicas no intestino grosso é relevante na prevenção do surgimento e complicações do câncer colorretal. Os pólipos podem ser ressecados (polipectomia) antes da sua malignização, diminuindo sobremaneira a taxa de morbimortalidade do câncer colorretal.
A colonoscopia é o padrão-ouro para o diagnóstico do câncer colorretal e para a detecção e ressecção endoscópica das lesões precursoras. A realização de polipectomias e biópsias permite, através da histopatologia, avaliar o tipo histológico, o grau de displasia e as margens de ressecção a fim de quantificar seu potencial de malignização. O câncer colorretal é a quinta neoplasia maligna mais frequente no Brasil, e se estima que 26.990 novos casos tenham sido diagnosticados no ano de 2008, o que evidencia sua alta frequência. Estes valores correspondem a um risco estimado de 13 casos novos a cada 100 mil homens e 15 para cada 100 mil mulheres. Associado a isso, a grande maioria dos tumores malignos se origina dos adenomas, e a detecção e retirada precoces evitam a progressão para o câncer.
Surgical site infections (SSIs) are a common surgical complication that affects between 2% and 5% of the 30 to 40 million operations that occur in the United States per year. SSIs are the most common nosocomial infection among surgical patients and are consistently the second most common healthcare-associated infection overall. Mortality rates after SSI are markedly higher when compared with patients without an SSI, as are the patient’s length of stay (mean, 7 days), hospital readmission rates, and direct patient costs ($500 to $3000 per infection).
Development of an SSI requires microorganism contamination at the surgical site. During an operative procedure in which skin is incised, endogenous skin flora, the most common source of pathogens, are introduced into the exposed tissue. Additional sources of bacteria include patient colonization, mucous membrane or hollow viscous pathogens encountered during the operation, surgical personnel, operative instruments, and the operating room environment. An accepted surrogate for bacterial contamination at the surgical site is the wound classification. The risk of SSI increases with the degree of contamination and higher wound classifications. Wounds are classically defined as clean, clean-contaminated, contaminated, or dirty/infected. The NHSN developed a risk index by which the risk of an SSI can be predicted based on three major criteria: wound classification, American Society of Anesthesiologists (ASA) score, and duration of the operation. The SSI risk category is based on the number of factors present at the time of operation, including a wound class of 3 (contaminated) or 4 (dirty), an ASA class of 3 or greater, and an operation lasting longer than the 75th percentile of the duration of the specific operation. Each independent factor is given a single point if present, which determines the NHSN risk index category (0 to 3).
- 1. Smoking
- 2. Diabetes
- 3. COPD: Chronic obstructive pulmonary disease
- 4. CAD: coronary artery disease
- 5. Nutritional status
- 6. Immunosuppression
- 7. Chronic corticosteroid use
- 8. Low serum albumin
- 9. Obesity
- 10. Advanced age
An incisional hernia is usually deﬁned as a chronic postoperative defect of the abdominal wall through which intra-abdominal viscera protrude. Progress in surgical techniques, even with laparoscopic surgery, has not led to the elimination of incisional hernias. On the contrary, the incidence of this complication seems to be increasing as more major and lengthy operations are being performed, especially in elderly patients with concomitant organic disease. The incidence of this condition has been reported to be as high as 11% of all laparotomies. Surgical repair is difﬁcult in the patient with a large abdominal wall defect, especially if the herniated viscera has “lost its right of domain” in the abdominal cavity. It must be remembered that surgical repair of an incisional hernia is not the same thing as closure of a laparotomy. Weakening of the abdominal wall and the consequences of decreased abdominal pressure on diaphragmatic mobility and respiratory function must also be considered. Placement of a prosthetic mesh is essential because without mesh, the recurrence rate is prohibitive, varying from 30% to 60%. The which is the subject of this article, was popularized by Jean Rives and has been used in our department since 1966.
Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden. Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended. Rather, a more individualized approach, taking into account frequency, severity of the attacks and their impact on quality of life, should guide the indication for surgery. On the other hand, complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation. Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis. There is not sufficient evidence supporting any changes in the approach to management in younger patients. Conversely, the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals.
Renewed public attention is being paid to ethics today. There are governmental ethics commissions, research ethics boards, and corporate ethics committees. Some of these institutional entities are little more than window dressing, whereas others are investigative bodies called into being, for example, on suspicion that financial records have been altered or data have been presented in a deceptive manner. However, many of these groups do important work, and the fact that they have been established at all suggests that we are not as certain as we once were, or thought we were, about where the moral boundaries are and how we would know if we overstepped them. In search of insight and guidance, we turn to ethics. In the professions, which are largely self-regulating, and especially in the medical profession, whose primary purpose is to be responsive to people in need, ethics is at the heart of the enterprise.
Responsibility to the patient in contemporary clinical ethics entails maximal patient participation, as permitted by the patient’s condition, in decisions regarding the course of care. For the surgeon, this means arriving at an accurate diagnosis of the patient’s complaint, making a treatment recommendation based on the best knowledge available, and then talking with the patient about the merits and drawbacks of the recommended course in light of the patient’s life values. For the patient, maximal participation in decision making means having a conversation with the surgeon about the recommendation, why it seems reasonable and desirable, what the alternatives are, if any, and what the probable risks are of accepting the recommendation or pursuing an alternative course.
This view of ethically sound clinical care has evolved over the latter half of the 20th century from a doctor-knows-best ethic that worked reasonably well for both patients and physicians at a time when medical knowledge was limited and most of what medicine could do for patients could be carried in the doctor’s black bag or handled in a small, uncluttered office or operating room. What practical steps can be taken by clinicians to evaluate patient attitudes and behavior relative to the patient’s cultural context so that the physician and patient together can reach mutually desired goals of care? Marjorie Kagawa-Singer and her colleagues at the University of California, Los Angeles, developed a useful tool for ascertaining patients’ levels of cultural influence. It goes by the acronym RISK:
Resources: On what tangible resources can the patient draw, and how readily available are they?
Individual identity and acculturation: What is the context of the patient’s personal circumstances and her degree of integration within her community?
Skills: What skills are available to the patient that allow him to adapt to the demands of the condition?
Knowledge: What can be discerned from a conversation with the patient about the beliefs and customs prevalent in her community and relevant to illness and health, including attitudes about decision making and other issues that may affect the physician-patient relationship.
A doença hemorroidária é uma afecção bastante comum, contudo sua prevalência é subestimada. A taxa de prevalência pode chegar até 20% da população geral. Ocorre mais usualmente nos caucasianos, sexo masculino e a partir da 3a década de vida.
A trombose hemorroidária é uma complicação aguda que ocorre tanto nas hemorróidas externas como internas, caracterizada pela presença de isquemia e trombo nos coxins vasculares submucosos do canal anal. As hemorróidas ocorrem como resultado da degeneração dos tecidos de sustentação e suporte dos coxins vasculares anais. As hemorróidas internas, externas e mistas são diferenciadas por sua origem anatômica no canal anal.
FATORES DE RISCO
Os principais fatores de risco para o desenvolvimento da doença hemorroidária complicada são: dieta Industrializada, Hereditariedade, Constipação intestinal, Obesidade, Gravidez / Pós-parto imediato e Trauma local (Fezes Ressecadas).
Os sintomas mais freqüentes são: dor anal aguda (proctalgia aguda) e constante, tumor anal com ou sem prolapso mucoso, e ás vezes sangramento (hematoquezia) na roupa íntima ou no papel higiênico. A dor tem maior intensidade nas primeiras 72 horas podendo regredir após esse período, assim que o trombo organizar-se, ocorrendo a involução espontânea em 7 a 10 dias. Muitas vezes a dor não é proporcional ao volume da trombose hemorroidária.
Dependendo da extensão da trombose poderá ser clínico ou operatório.
5.1 Tratamento Clínico: Associa-se o uso de analgésicos por via oral, pomada heparinóide aplicada sobre a tumoração, medicamentos mucilaginosos, se houver obstipação intestinal e banhos de assento com água morna.
5.2 Tratamento Operatório: A indicação operatória criteriosa, a anestesia apropriada, a técnica utilizada e os cuidados pós-operatórios adequados, são comemorativos importantes no sucesso do tratamento. Para as tromboses hemorroidárias localizadas preferimos a hemorroidectomia à Milligan-Morgan (técnica aberta) ou Ferguson (técnica fechada) com anestesia local com ou sem sedação endo-venosa; ou a trombectomia, que é a retirada do trombo somente, com anestesia local, em caráter ambulatorial. Para as tromboses hemorroidárias grandes e/ou extensas, preferimos a hemorroidectomia à Milligan-Morgan com anestesia raque e internação por 24 horas .