NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Q: How would you manage the following findings? Case Variation 8.28.1. A 0.5-cm-diameter lesion with no local extension and negative lymph nodes ◆ ◆ Superficial, small, mobile lesions warrant treatment with local excision alone, with close follow-up to ensure that the cancer does not recur. Case Variation 8.28.2. A 4-cm-diameter lesion with no local extension and negative lymph nodes ◆ ◆ Surgery is not warranted. Treatment involves the modified Nigro protocol, which consists of chemotherapy and radiation therapy in order to eliminate the cancer. In most cases, chemoradiation treatment is successful. Abdominal perineal resection is used only if there is biopsy-proven residual cancer . However, even in patients with positive inguinal nodes, the modified Nigro protocol usually provides complete local control of the primary cancer (Table 8-5). Table 8-5: Modified Nigro Regimen for Squamous Cell Carcinoma of the Anal Canal Treatment Dose Schedule

External radiation

50 Gy to the primary carcinoma and 35–45 Gy to pelvic inguinal nodes Fluorouracil, 1,000 mg/m 2 /24 hr as a continuous infusion for 4 days

Start day 1 (2 Gy/day, 5 days/week for 5 weeks) Start day 1; repeat 4-day infusion starting day 28

Systemic chemotherapy

Mitomycin C 10–15 mg/m 2 as intravenous bolus Day 1 only From Greenfield LJ, Mulholland MW, Lillemoe KD, et al., eds. Greenfield’s Surgery , 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2010.

Case Variation 8.28.3. A recurrent anal carcinoma ◆ ◆ Abdominoperineal resection plays an important role in recurrent anal cancer. Perineal wound complications are common, as these patients have had radiation to the surgical field. LOWER ABDOMINAL PAIN Critical Surgical Associations If You Hear/See Think Free air Perforation, surgical emergency Rigid abdomen Peritonitis: operate Previous abdominal surgery Adhesions Flatus Obstruction Unintentional weight loss Malignancy RUQ pain Gallbladder RLQ pain Appendix LLQ pain Diverticulitis LLQ, left lower quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant. S MPLE