Giovanna Savoy Pazin

Background: Iatrogenic ureteral injuries (IUI) are rare surgical complications in abdominopelvic surgeries, with an incidence varying between 0.15 and 1.0%. Aims: To evaluate the incidence of IUI in elective colorectal surgeries performed in a tertiary university hospital. Methods: This is a retrospective analysis of patients operated from 2004 to 2022, who presented IUI. Demographic data, underlying disease, predisposing factors, surgery access, location of the lesions and their characteristics, diagnosis time, treatment carried out, and follow-up were analyzed. Results: In the period, 2,312 abdominopelvic surgeries were performed, of which 1,998 were open and 314 were laparoscopic, with 19 IUI (0.82%). The mean age was 55.6 years, 57.9% were male, and 89.5% were white. The majority of patients were overweight (52.6%), and 73.7% had a history of abdominal surgery. Primary rectal adenocarcinoma was the most common disease (47.4%), followed by tumor recurrences (21.0%). IUI occurred in 1.91% of laparoscopic surgeries and 0.65% of open surgeries (p=0.053); patients with tumor recurrence presented more IUI than those with primary tumors or benign diseases (p=0.006). They were commonly observed in the left ureter (52.6%) and in the distal portion (89.5%), the main mechanism being the section (57.9%). Intraoperative diagnosis occurred in 12 patients (63.2%). IUI correction was predominant in ureteral reimplantation and end-to-end ureteral anastomosis. Postoperative complications were common (47.4%), and one patient died from causes unrelated to surgery. Conclusions: IUI presented low incidence in colorectal elective surgeries and were more frequent in surgeries for tumor recurrences, in the left ureter and the distal third. Early diagnosis with repair of the injury provided better results.

Juvenile polyposis syndrome (JPS) is an inherited autosomal dominant disease that is distinguished by the emergence of numerous juvenile polyps within the gastrointestinal (GI) tract and has an increased risk of cancer. JPS is associated with germline mutations of the BMPR1A or SMAD4 genes. We aim to describe a case of familial occurrence of the SMAD4 germline pathogenic variant c.403C>T in a Brazilian family. We present a case of an 18‐year‐old female with rectal bleeding and chronic anemia who had a family history of colorectal issues—her mother had a total colectomy due to multiple polyps, and her maternal grandfather died from colorectal cancer (CRC). Despite a negative physical examination for attenuated familial adenomatous polyposis (AFAP) signs, a colonoscopy revealed around 30 proximal colon polyps of juvenile nature. These were systematically removed through multiple sessions, and an upper digestive endoscopy uncovered a few sessile inflammatory polyps. Notably, no polyps were found in the small intestine via double‐balloon enteroscopy. After polyp removal, her bleeding episodes ceased, and her anemia resolved. She now maintains her health through biennial colonoscopies, upper digestive endoscopies, and endoscopic capsule procedures. Genetic testing identified a pathogenic mutation in exon 3 of the SMAD4 gene (c.403C>T), resulting in a truncated SMAD4 protein (p.Arg135   ^∗ ). While previously documented in international databases, this represents the first report of a Brazilian family carrying this variant. Additionally, no mutations were found in the BMPR1A gene during genetic testing. In conclusion, molecular analysis confirmed the familial occurrence of the SMAD4 germline pathogenic variant c.403C>T within this Brazilian family.

Rectal anastomotic stricture (RAS) is a significant complication following rectal resection. Several techniques have been proposed for its management. However, treating complete strictures remains challenging. To describe a simple, safe, and effective technique for the treatment of complete RAS using a circular stapler under ileocolonoscopic guidance. A 43-year-old man underwent laparoscopic anterior resection of the rectum for a 7 cm serrated adenoma located 10 cm from the anal verge. The anastomosis was created 8 cm from the anal verge, and a protective loop ileostomy was fashioned. Histopathological analysis revealed a sessile serrated adenoma confined to the mucosa with foci of intramucosal carcinoma (TisN0). At 2 years postoperatively, delayed follow-up due to the COVID-19 pandemic revealed a complete RAS. Computed tomography (CT) with contrast administered through both the ileostomy efferent loop and the rectum demonstrated a short (< 1 cm) stricture at the anastomosis. The patient underwent transanal correction using a single-port system, assisted by colonoscopy through the ileostomy efferent loop. After circumferential stricturoplasty, a 31 mm circular stapler was used to perform reanastomosis under colonoscopic guidance. The patient had an uneventful recovery and was discharged on postoperative day 1. The ileostomy was closed after 45 days, and the patient presented only minimal symptoms of low anterior resection syndrome. Transanal stricturoplasty followed by circular stapler reanastomosis under endoscopic guidance appears to be a safe, simple, and effective approach for managing complete benign RAS. This technique may be considered in cases refractory to endoscopic dilation, in the place of redo surgery.