Dr. Cintia Kimura is a third generation Brazilian-Japanese and a medical doctor from São Paulo, Brazil. She completed her training in general surgery and colorectal surgery at Hospital das Clínicas de São Paulo (Brazil) and is currently a postdoctoral research fellow in the Department of Surgery at Stanford (United States).
Dr. Kimura is member of the Brazilian Society of Coloproctology and Brazilian College of Digestive Surgery. She is also a member of the American Society of Colon and Rectal Surgeons Young Surgeons Committee since 2022.
Her current research focuses on the effect of different diets on the gut microbiome of patients undergoing colorectal surgery and how those diets can affect surgical recovery.
Dr. Kimura’s main professional and scientific interests focus on surgical education and on the intersection between surgery and public health.
You may wonder if negotiation is that important at the point of care. Absolutely yes. Surgeons over the years have realized that they not only need to demonstrate excellent technical skills in the OR but also learn to work in teams and enhance communication skills. Humans tend to be curious but also judgemental, hence the importance of negotiation. Many are the benefits of understanding its basics, including solving disagreements in an operative plan. Having said that, the best option is to discuss, talk and listen in order to try to understand what the other person's thinking is and come to an agreement. In this session we will review a past event part of the Resilient Residents series, focusing on the signs and symptoms calling for negotiation at the point of care. Questions based on the original event were addressed, discussed and solved, enlightening us with the best tips and tricks to identify the needs of negotiation and the strategies and tactics to follow to resolve dirvenges of interests.
Published
Feb 2023
1. HPV (Human Papillomavirus) and anal squamous cell carcinoma (ASCC) Although still rare, the incidence of anal carcinoma has been increasing, having doubled in the last two decades. More than 90% of anal squamous cell carcinoma (ASCC) is caused by HPV infection . There are more than 100 subtypes of HPV, but some were demonstrated to be more carcinogenic, especially 16 and 18. Populations at higher risk for ASCC are: HIV infected patients, men who have sex with men, patients who perform anal receptive intercourse, tobacco smokers, patients with chronic immunosuppression and women with cervical dysplasia. 2. Physiopathology of precursor lesions Most of what is known about the physiopathology of anal dysplasia comes from what is known about cervical dysplasia. Similarly to cervical cancer, which occurs in a transformation zone in the cervix, ASCC also occurs in a transformation zone, the ATZ (anal transformation zone), where the mucosa transitions to nonkeratinized squamous epithelium. The ATZ is located proximal to the dentate line and extends for 0.5 to 1.5 cm distally. Because constant transformation of columnar cells into squamous cells is occurring in this area, this region is very susceptible to HPV infection. The HPV virus integrates into the DNA of the host, disrupting the gene E2, which inhibits proteins E6 and E7, and, consequently, the tumor suppressor gene p53, leading to dysplasia. This dysplasia can be: - initially very mild or mild - and these lesions are called low-grade squamous intraepithelial lesion (LSIL) - or they can evolve to moderate or severe dysplasia or even in situ carcinoma. These lesions are called high-grade squamous intraepithelial lesions (HSIL) . These lesions were initially classified as anal intraepithelial neoplasia (AIN) grades I, II, and III. However, as this led to uncertainty regarding the significance of AIN II lesions, a new standardization was made, in which AIN I corresponds to LSIL and AIN II, IIIand in situ carcinoma, to HSIL. It is believed that treating HSIL may prevent its evolution to invasive carcinoma. 3. Surveillance and screening methods Early detection of ASCC is correlated with higher survival and since precursor lesions can be diagnosed and treated, it is believed that this disease is potentially preventable with adequate preventive measures, as it has been occurring with cervical carcinoma - deaths from cervical carcinoma have decreased remarkably since the introduction of screening methods and, more recently, vaccination. There is actually no consensus regarding what patients should be enrolled in an intensive screening program, but risk factors must be assessed individually, and the following populations should be considered for anal cancer screening: HIV-positive men aged >25 y regardless of sexual orientation HIV-positive women aged >25 y HIV-negative MSM aged >40 y Women with high-grade cervical or vulvar lesions or cancer aged >40 y All men and women with perianal condyloma/high-grade squamous intraepithelial lesion aged >25 y Solid organ transplantation recipients and patients with other forms of immunosuppression aged >25 y Currently, there are some methods employed for screening: Anal Pap smear or anal cytology: is one of the most available methods to identify individuals who might benefit from a more intensive screening program. Sensitivity and specificity of anal cytology is quite limited (50–80% of sensitivity and 40-60% of specificity), but it is a simple and inexpensive method, being justifiable as screening tool for high-risk populations for its cost-effectiveness. Anal cytology can present with 4 different results: normal LSIL HSIL ASCUS (atypical squamous cells of undetermined significance) Patients with all results except for normal should be referred to high resolution anoscopy. High resolution anoscopy (HRA): is performed with a colposcope either in the office or in the operating room and allows visualization of lesions that would go unnoticed under conventional anoscopy. Biopsy guided by HRA is considered the gold-standard method for identifying HSIL. The advantage of this method is that it allows treating the lesions under direct vision at the moment of the exam. HPV testing: The presence of HPV, especially subtypes 16 and 18, is associated with the majority of anal cancers, so screening for the presence of high-risk HPV might estimate the risk for dysplasia. However, due to the high prevalence of various types of HPV among high-risk populations, this strategy is quite limited. 4. Assessing precursor lesions Fortunately the rate of progression of HSIL to invasive carcinoma is relatively low, about 1.3-2% per year and around 10% in a 5-year period. For this reason, it is still debatable whether HSIL lesions should always be treated or if expectant management with close follow-up is acceptable in specific situations. Treatment options include ablative therapy and use of topical agents (imiquimod, fluoracil, trichloroacetic acid). There are various algorithms for anal cancer screening, as the University of California San Francisco Anal Neoplasia Clinic, Research, and Education Center (ANCRE). 5. Vaccination The vaccines currently available protect against either two, four or nine types of HPV. All of them protect against types 16 and 18, the most carcinogenic ones. The Centers for Disease Control and Prevention (CDC) recommends: Two doses of the HPV vaccine for all boys and girls at ages 11-12; Vaccination through age 26 for women, 21 for men, if they did not get vaccinated when they were younger. Vaccination of people through age 26, if they did not get vaccinated when they were younger: Young men who have sex with men Young adults who are transgender Young adults with weakened immune systems Although the vaccines are for some specific types of HPV, many studies suggest that crossed-protection against other types of HPV are developed with vaccination. Also, some studies have shown that the nonavalent HPV vaccine may be helpful in preventing recurrent HSIL and the progression to anal SCC, so vaccination might also have a role in secondary prevention of anal cancer.
Published
Sep 2019
Clinical Case Trocar site hernias (TSH) tend to develop more frequently – around 25% of them - at umbilical and midline port sites due to a natural weakness of the linea alba. Most hernias develop in the first month after surgery, especially during the first 10 days. About 70-80% of trocar site hernias require surgical management and one of the most feared complications of trocar site hernias is small bowel strangulation. Ritcher’s hernia is particularly frequent in TSH. It is defined by a protrusion of the antimesenteric wall of the intestine through a defect in the abdominal wall, so it can cause small bowel strangulation without causing obstructive symptoms. The incidence of Ritcher’s hernia reaches 47.6% in early onset TSH. About 80-90% of trocar site hernias occur at incisions that are 10 mm or larger, so an incision size larger than or equal to 10 mm is a significant risk factor. Other associated risk factors are: prolonged surgical time manipulation of the incision number of trocars incomplete closure of fascia at the trocar site midline trocars organ retrieval through the trocar site partial vacuum during port withdrawal, drawing the omentum and intestine into the fascial defect wound infection at trocar site reinsertion of the port host factors: obesity, poor nutrition, advanced age, gender, diabetes, steroid therapy The clinical presentation of TSH is variable, as is the time of onset. Usually, it presents as swelling and pain at the incision site and may be hard to differentiate from a hematoma or wound infection, especially in the first post-operative days. Especially in obese patients, diagnosis by physical examination can be tricky, so CT scans can be helpful. Careful postoperative management is recommended, especially in patients with the risk factors mentioned. Bowel occlusion is often insidious, as in the case of a partial Richter's hernia, which typically presents with vomiting or nausea and a distended and painful abdomen, especially in the first 14 days after surgery. When resolution of postoperative ileus after laparoscopic surgery is not achieved after 7–14 days, a differential diagnosis with mechanical occlusion should be obtained by means of a CT scan. TSHs are classified into 3 types , originally described by Tanouchi: Type 1, early-onset: indicates dehiscence of the anterior fascial plane, posterior fascial plane, and peritoneum. It often presents as a small-bowel obstruction. Type 2, late-onset: develops several months after surgery and is frequently related to complications of the trocar insertion. It indicates dehiscence of the anterior fascial plane and posterior fascial plane. The hernia sac of the late-onset type is in the peritoneum. Type 3, special type: indicates dehiscence of the whole abdominal wall, with protrusion of the intestine and other tissue (eg, greater omentum). Trocar site hernias are directly related to the size of the trocar, being more common at > 10mm sizes rather than in 5mm. Therefore, it is recommended that all incisions > 10mm be closed, if possible. When active manipulation through a 5-mm port has occurred during prolonged procedures, the fascial defect should be closed to avoid complications. Many authors have recommended the deflation of the pneumo-peritoneum prior to port removal , so the omentum and intestines are not drawn into the fascial defect. According to most authors, despite the evidence that some types of trocars or incisions may prevent or are better at avoiding trocar site herniation, closure of both the fascia and the peritoneum should be performed when possible.
Published
Feb 2018
Clinical Case A parastomal hernia (PH) is defined as the herniation of any abdominal cavity content other than the ostomy itself through the ostomy orifice. It should be distinguished, however, from mucosal prolapse, which is a full-thickness protrusion of intestine through the stoma. Parastomal hernias are a fairly common complication in patients with a definitive stoma, being observed in 30-50% of them. Thus they are more frequent overall than incisional ventral hernias . Most parastomal hernias occur within the first years after their stoma is created, but may arise much later, as the patients grow older and the abdominal wall may become weaker. Parastomal hernias occur as a result of weakness in the abdominal wall which may or may not be associated with elevated intraabdominal pressure, or be due to a technical failure when the stoma is created. Consequently, the main risk factors for parastomal hernias are: Advanced age Obesity Malnutrition Steroid use or other immunodeficience Smoking and/or COPD Wound infection The diagnosis is established on the basis of clinical history and physical examination . The most frequent complaints are discomfort and difficulty in adapting ostomy appliances. The physical examination will show a bulge under the skin beside the ostomy, which is increased by Valsalva’s maneuver and may be completely or partially reducible. In obese patients, the diagnosis of parastomal hernias by physical examination may be difficult. In these cases, when there is a complaint, a CT scan or ultrasound can be helpful for diagnosis. Moreover, these exams are helpful in evaluating the size of the hernia, as well as its contents. Several classifications have been created over the years, until in 2014, the European Hernia Society created a consensus classification in order to improve the ability to compare different studies and their results, in addition to facilitating data collection. The classification divides hernias into four types and distinguishes between primary and recurrent hernias. Hernias are rated according to size ( ≤ or > 5 cm) and presence or not of incisional hernia (cIH). Type I: PH ≤5 cm with no cIH. Type II: PH ≤5 cm with cIH. Type III: PH >5 cm with no cIH. Type IV: PH >5 cm with cIH. P: primary PH. R: recurrence after previous PH treatment. There is no consensus on the timing of elective surgical treatment for parastomal hernias. Treatment should be tailored according to the patient’s symptoms and complaints and should take into consideration the patient’s comorbidities, quality of life and clinical status, as well as the risk associated with watchful waiting. The main symptoms leading to surgery are discomfort, pain, bowel obstruction and/or strangulation, and difficulty in proper fixation of ostomy appliances, leading to peristomal dermatitis and physical deformity. There are some clinical measures that can be taken to minimize symptoms, such as use of support garments, losing weight and follow-up with stomal nurses. Many techniques have been proposed, from Sugarbaker to repositioning of the colostomy, open vs laparoscopic, biological or synthetic mesh vs no mesh. One of the most frequently employed techniques is the Sugarbaker technique, which consists of applying an intraperitoneal mesh covering the ostomy. There are some intra and post-operative measures that can help to prevent the development of parastomal hernias, such as: Correct positioning, placing the orifice through the rectus muscle Avoiding excessive opening of the fascia (as small as possible, as long as it doesn’t compromise stoma perfusion) Wearing a support garment (belt or underwear) Avoiding heavy lifting and straining Avoiding being overweight and maintaining a normal body mass index when possible – being overweight can place additional strain on your abdominal muscles.
Published
Feb 2018
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