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Doctoral Thesis
DOI
10.11606/T.5.2005.tde-06102014-113422
Document
Author
Full name
Antonio Henrique Oliveira Poletto
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2005
Supervisor
Committee
Lopes, Ademar (President)
Barros, Alfredo Carlos Simoes Dornellas de
Rodrigues, Consuelo Junqueira
Caboclo, Jose Liberato Ferreira
Pereira, Paulo Roberto Bueno
Title in Portuguese
Exenteração pélvica e preservação dos esfíncteres: análise de 96 casos
Keywords in Portuguese
Ânus
Estudos retrospectivos
Exenteração pélvica
Neoplasias pélvicas
Prognóstico
Abstract in Portuguese
A exenteração pélvica é método efetivo no tratamento de tumores pélvicos localmente avançados. As cirurgias mais conservadoras, com preservação funcional dos esfíncteres e reconstrução continente dos tratos intestinal e urinário podem melhorar a qualidade de vida e estimular os pacientes a aceitar a cirurgia. O objetivo deste estudo foi avaliar os resultados da exenteração pélvica no tratamento dos tumores pélvicos localmente avançados em relação à preservação dos esfíncteres e fatores associados ao prognóstico. Analisou-se retrospectivamente os fatores relacionados à preservação dos esfíncteres bem como os fatores associados ao prognóstico em pacientes submetidos à exenteração pélvica. Dos 96 pacientes submetidos à exenteração pélvica, preservou-se pelo menos um dos esfíncteres em 36 (37,5%). Na década de 1990 a taxa de preservação esfincteriana foi significativamente maior do que na década de 1980 (47,6 versus 18,2%) (p = 0,005). As variáveis independentemente relacionadas à preservação de esfíncter foram tratamento realizado na década de 1990 e tumor de origem coloproctológica. A taxa de complicação pós-operatória não foi influenciada pela preservação dos esfíncteres (p = 0,276). Não se observou diferença estatisticamente significativa nas taxas de morbidade entre as décadas de 1990 e 1980 (55,6% versus 75,8%; p = 0,075). Na década de 1990 houve redução da taxa de mortalidade pós-operatória em relação à década de 1980 (9,5% versus 27,3%; p = 0,023). Em nove pacientes, as margens de ressecção estavam microscopicamente comprometidas (R1) e, em cinco macroscopicamente comprometidas (R2). As margens de ressecção não foram influenciadas pelo tipo de cirurgia (p = 0,104), nem pela preservação dos esfíncteres (p = 0,881). A taxa de sobrevida livre de doença em cinco anos foi de 40,5%. Observou-se associação da recorrência com perda de peso (p = 0,006), índice de Karnofsky (p = 0,035) e a topografia do tumor (p = 0,027). No modelo multivariado, a perda de peso e os tumores de origem ginecológica foram as variáveis independentes para recorrência. Pacientes portadores de tumores ginecológicos ou com perda de peso foram considerados de alto risco para recorrência e os pacientes portadores de tumores não ginecológicos e sem perda de peso, de baixo risco. O grupo de alto risco apresentou chance de recorrência cerca de sete vezes maior do que o de baixo risco. A sobrevida livre de doença em 5 anos para os grupos de baixo e de alto risco foram, respectivamente, de 78,0% e 21,2%. As variáveis associadas ao óbito foram a idade superior a 60 anos (p = 0,007), a perda de peso (p = 0,004), radioterapia pré-operatória (p = 0,043), década de trata mento (p = 0,050) e preservação de esfíncter (p=0,026). No modelo multivariado as variáveis associadas ao óbito foram tratamento realizado na década de 1980, a idade superior a 60 anos e a perda de peso. Com os resultados deste estudo podemos concluir que houve aumento significante da preservação dos esfíncteres na década de 1990 sem aumento da freqüência de margens cirúrgicas comprometidas nem prejuízo na sobrevida dos pacientes submetidos à exenteração pélvica com preservação dos esfíncteres
Title in English
Pelvic exenteration and sphincter preservation: an analysis of 96 cases
Keywords in English
Anus
Pelvic exenteration
Pelvic neoplasm
Prognostic
Retrospective study
Abstract in English
Pelvic exenteration (PE) is an effective method for treating locally advanced pelvic tumors. More conservative surgeries, preserving sphincters and continent reconstruction of the intestinal and urinary tract, which could contribute to a better quality of life and encourage patients to accept this procedure. The objective of this study was to evaluate the results of PE in the treatment of locally advanced pelvic tumors, mainly considering sphincter preservation and factors associated to the prognosis. Between 1980 and 2000, 96 PE were performed. Factors related to sphincter preservation as well as factors associated to prognosis were respectively analyzed. Of the 96 patients treated with pelvic exenteration, at least one sphincter in 36 patients was preserved (37.5%). In the 1990's, the sphincter preservation rate was significantly higher than in the 1980's (47.6 vs. 18.2 %) (p = 0.005). Independent variables related to the sphincter preservation were decades from the realization of surgery 1990's and coloproctological tumors. The postoperative complication rate was not influenced by sphincter preservation (p = 0.276). Statistically, there was no differentiation between the morbidity rates during the 1980's and 1990's (55.6% versus 75.8%, p = 0.075). In the 1990's, there was a reduction in the post-operative mortality rate compared to the 1980s' rate (9.5% versus 27.3%; p = 0.023). In nine patients, the resection margins were compromised microscopically (R1) and in five patients, macroscopically compromised (R2). The resection margins were not influenced by the type of surgery (p = 0.104), nor by the preservation of sphincters (p = 0.881). Disease free survival at five years was 40.5%. Among the clinical variables, there was an association between recurrence and weight loss (p = 0.006) and the Karnofsky index (p = 0.035). The topography of the tumor showed links with recurrence (p = 0.027). In the multivariable model, the independent variables related to recurrence were weight loss and gynecological tumors. Patients with gynecological tumors or with weight loss were considered high risk for recurrence, while patients with no gynecological tumors and without weight loss were considered low risk. The high risk group showed 7 times more chance of recurrence than the low risk group. Survival rates of patients, who remained disease-free, after 5 years, for the low and high risk group were 78.0% and 21.2% respectively. Death was linked to ages over 60 (p = 0.007), weight loss (p = 0.004), pre-surgery radiotherapy (p = 0.043), decades from the realization of surgery (p = 0.050) and the sphincter preservation (p = 0.026). The independent variables related to death were treatments in the 1980's, ages over 60 and weight loss. Taking into account the results in this research, we conclude that there was a significant increase of sphincter preservation during the 1990's and neither the type of surgery nor sphincter preservation were associated to a higher number of surgeries with compromised margins allows pelvic exenteration to be performed with sphincter preservation, without harming survival rates
 
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Publishing Date
2014-10-07
 
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