Br. J. Surg. Vol. 63 (1976) 831-835
Chagas’ d i s e a s e of t h e colon
G E R A L D 0 MILTON DA SILVEIRA*
SUMMARY
One hundred cases of’ chagasic megacolon operated
upon in Bahia, Brazil, haue been analysed. The principal theories of the pathological physiology of the
disease are discussed. The pre- and postoperative radiographic features of the colon are presented, and the
surgical treatment as well as the incidence of complications and late results are reported.
CHAGAS’disease or Brazilian trypanosomiasis is an
endemic disease in certain rural areas of Brazil. The
aetiological agent is Trypanosoma cruzi. The Machado
Guerero complement fixation test is specific for this
disease and is positive in 93 per cent of the patients
with megacolon (Fonseca, 1968), which is often one
of the presenting symptoms. The terminal colon and
rectum become markedly dilated. The histopathological and clinical pictures of chagasic megacolon
have been reproduced experimentally by the inoculation of the trypanosomes into mice (Okumura and
Correia Neto, 1961).
Chagas’ disease, however, produces histopathological changes in several organs, most frequently
damaging the heart, the terminal oesophagus, the
sigmoid and rectum.
There are three theories which try to explain the
pathogenesis of Chagas’ disease. These are known
as the ‘focal’, the ‘toxic’ and the ‘allergic’ theories.
Some believe that the megacolon is a result of lesions
of the muscle fibres themselves (Andrade and Andrade,
1965, 1966; Vasconcelos, 1966), whilst others have
proposed that it is due to a decrease in the number of
autonomic nerve cells in the intestinal plexus (Koberle,
1960; Alencar, 1962; Gama, 1966; Rassi, 1967). In
the acute phase of the disease the lesions in the intestinal tract are due to parasites and are composed of
mononuclear interstitial infiltration and degenerative
changes of the muscle fibres and of the neurons in
Meissner’s and Auerbach’s plexuses. In the chronic
phase parasites are rarely found (Fig. l), and there
are foci of chronic myositis and myocarditis with a
decreased number or absence of ganglion cells and
a necrotizing arteritis. The number of ganglion
cells found at autopsy is presented in Table I (Costa,
1968).
In cases of chagasic megacolon the usual findings
are elongation and dilatation of the distal colon,
thickening of the intestinal wall due to muscular
hypertrophy and mucosal ulcers. Electromanometric
studies (Haddad et al., 1965) on patients with chagasic
megacolon have shown changes in motor activity of
the distal portion of the large bowel, characterized
by an increase in frequency, amplitude and duration
of waves. Similar alterations were found 3 years
postoperatively on patients subjected to rectosigmoidectomy, although the clinical symptoms had disappeared. There was n o dilatation of the colon. The
response to metacholin stimulation was similar before
and after surgery.
Following the work of Hiatt (1951) and Swenson
et al. (1951, 1954) on the surgical treatment of congenital megacolon, patients with chagasic megacolon
have been treated by rectosigmoidectomy (Cutait,
Fig. 1. Amastigote forms of T . crrrzi within smooth muscle
cell cytoplasm of the colon in a case of megacolon. HE.
( x 310.)
Table I : NUMBER OF GANGLION CELLS FOUND IN
STUDIES OF AUTOPSY MATERIAL OF NORMAL
INDIVIDUALS AND CHAGASIC PATIENTS
No. of ganglion cells
Grouo
Caecum
Transverse
colon
Sigmoid
Rectum
Normal
Chagasic
4163
189
4941
253
5785
381
4036
163
1953; Luz, 1954). This is now the surgical procedure
most commonly used to treat chagasic megacolon
(Cutait, 1953; Luz, 1954; Pinto, 1960; Raia, 1960;
Haddad et al., 1965 ; Simonsen, 1966; Vasconcelos,
1966; Rassi, 1967; Reis Neto, 1968). The aganglionic
segment of the bowel, which is the part functionally
most affected, is resected. Although other segments
of the colon also show changes, they do not appear
to be sufficient to cause recurrent symptoms (Gama,
1966).
Patients and methods
This report is based on a review of 100 cases of
chagasic megacolon. Ninety-three patients were
* Federal-University
of Bahia, Brazil.
831
Gerald0 Milton da Silveira
highest count was 23 per cent eosinophils and the
average 12.8 per cent.
All the patients in the series were submitted to
abdominoperineal rectosigmoidectomy. In 3 1 cases
Hiatt’s (1951) technique of direct anastomosis was
used and in 69 cases Cutait’s (1960) technique of
delayed anastomosis. In the 31 cases of direct anastomosis the colon was prepared with purgatives, glycerin
enemas, sulpha drugs and antibiotics. Antibiotics and
sulpha drugs were not used in the cases undergoing
t h e delayed type of anastomosis.
45 40
-
35
.
Y
jn
.-5 3 0 Y
a
2s
Age tyr)
Fig. 2. Age distribution of 100 patients with chagasic
megacolon.
Table 11: COMPLICATIONS FOLLOWING COLONIC
SURGERY ON 100 PATIENTS WITH CHAGASIC
MEGACOLON
D e 1ayed
Direct
anastomosis
anastomosis
(69 cases)
(31 cases)
No. of
No. of
Complication
cases
”/,
cases
><;
Infection of presacral
6
19.3
6
8.6
space
12.9
6
86
Partial breakdown of
anastomosis
-.
6.4
-Total breakdown of
anastomosis
6.4
2
2-8
Stercoraceous fistula
.3.2
Vesicorectal fistula
3.2
Peritonitis
3
4.3
Necrosis with retraction
of pull-through
4
12.9
3
4.3
Stenosis of anastomosis
3.2
I
Haemorrhage
10
14.4
Non-stenotic narrowing
3
9.6
I
I.4
Postoperative mortality
operated upon in the Hospital Prof. Edgard Santos,
Faculty of Medicine, Federal University of Bahia,
Brazil. Seven patients were operated upon in other
hospitals. There were 59 males and 41 females. The
age distribution is shown in Fig. 2. The youngest
patient was 22 years old and the oldest 76. The main
complaint was progressive constipation. The length
of time between the initial symptoms and surgery
varied from 1 to 25 years. Periods without bowel
movements varied from 5 days to 7 months. The
incidence of faecaloma in the series was 26 per cent.
There was associated mega-oesophagus in 36 per cent
of the cases. Chagasic myocarditis with abnormal
electrocardiogram findings was seen in 52 per cent
of the cases. Routine laboratory studies showed no
specificalterations related to the disease, except eosinophilia occurring in 40 per cent of the patients. The
832
Results
With the direct anastomosis (Hiatt technique) there
was a higher incidence of complications. Temporary
transverse colostomy was performed in 61.2 per cent
of the cases. Of these, 41.9 per cent were done simultaneously with rectosigmoidectomy and 19 per cent
during the early postoperative period.
Among the 69 patients in whom the surgical technique of delayed anastomosis was used (Cutait technique), only 7.2 per cent of the colostomies were
done in the early postoperative period.
The postoperative complications are shown in
Table II. With direct anastomosis there was a higher
percentage of partial or total breakdown of the anastomosis leading to infection in the presacral space, peritonitis or fistula formation. The incidence of stenosis
of the anastomosis, secondary haemorrhage and postoperative mortality was also higher, whereas in
delayed anastomosis there was more necrosis due to
retraction of the pull-through which caused some
narrowing.
The causes of death in 3 cases (9.6 per cent) with
direct anastomosis were peritonitis in one, haemorrhage in another and vesicorectal fistula in the remaining case. The single death (1.4 per cent) in the delayed
anastomosis group resulted from necrosis and retraction of the pull-through.
Urinary infection occurred in many cases as prolonged catheterization was needed.
All the cases in which delayed anastomosis was
used had temporary anal sphincteric incontinence.
This was due to the eversion of the rectum and consequent dilatation of the anal orifice produced by the
sigmoid loop which was pulled through the anal
orifice and remained in situ for 10-12 days. The
longest period of time for total recovery of sphincteric
function was 35 days.
ln the present series no sexual impotence was
recorded.
Based upon our experience we conclude that abdominoperineal rectosigmoidectomy is the most useful
therapeutic method for the treatment of chagasic
megacolon. This is in agreement with the opinion of
most Brazilian surgeons (Cutait, 1953; Luz, 1954;
Pinto, 1960; Raia, 1960; Haddad et al., 1965; Simonsen, 1966; Rassi, 1967; Reis Neto, 1968). In order to
obtain satisfactory results we feel it is necessary to
follow these principles :
1. The anastomosis should be performed 2-4 cm
from the pectinate line.
Chagas’ disease of the colon
a
b
Fig. 3. n, Preoperative barium enema film showing marked dilatation and elongation o f the sigmoid colon. h, Appearance
o f the left colon 3 years after abdominoperineal rectosigmoidectomy.
a
Fig. 4. Raritcm enema films.
after surgery.
IF,
b
Preoperative view of the rectosigmoid and sigiiioid Nith marked dilatation.
/I,
Seven years
833
Geraldo Milton da Silveira
a
b
Fig. 5. a, Typical barium enema appearances in chagdsic megacolon. 6, Eighteen years after surgery there is no dilatation
of the colon.
2. The diameter of the bowel at the proximal line
of resection should be normal or near normal.
3. Mobilization of the left colon, including the
splenic flexure, should be performed whenever necessary in order to obtain an intestinal anastomosis
without tension.
4. The pelvic dissection and ligation of the middle
haemorrhoidal vessels should be performed close to
the rectal wall.
Immediate results of the surgical treatment of
chagasic megacolon were satisfactory and all the
preoperative symptoms disappeared.
Late follow-up studies could not be obtained in
the majority of cases. After discharge from hospital
most of the patients returned to their homes, which
were usually many miles away. The socio-economic
status of the patients as rural workers prevented them
from returning to the hospital for periodic examinations. Thus, late follow-up results are available for
only 12 patients, for periods varying from 3 to 18
years. At the time of the follow-up 1 1 had daily
bowel movements needing no laxatives. One had
spontaneous bowel movements every other day. No
morphological alterations of the colon were demontrated by barium enemas. Our findings are similar to
other published series of cases (Figs. 3-5).
Conclusions
Surgery is indicated in cases of chagasic megacolon,
and abdominoperineal rectosigmoidectomy with delayed anastomosis (Cutait, 1960) is the technique of
choice. The late postoperative results are satisfactory.
834
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