Ex vivo and simulator models teaching therapeutic ERCP and EUS: description of SOBED's first course.

Teaching models in endoscopy are important tools to minimize risks derived from endoscopic procedures, taking into account that therapeutic endoscopy, also known as surgical endoscopy, has greatly developed during the last decade. This results from the fact that minimally invasive procedures present relevant contributions and promote more comfort to patients. In this context, ex vivo teaching models and virtual simulators are important tools to the safe acquisition of abilities. In this article, the Brazilian Society of Digestive Endoscopy presents and describes its first course of therapeutic ERCP and EUS in models of laboratory teaching.

Genetic response of Paspalum plicatulum to genome duplication.

Paspalum plicatulum is a perennial rhizomatous grass with natural diploid and polyploid cytotypes. In this study, we investigated the occurrence of sequence polymorphisms arising immediately after genome autoduplication in this species. Two mixoploid plants (4C and 7D) were previously obtained through colchicine treatment of seeds generated by open pollination of a diploid plant (H14-2x). Diploid and tetraploid sectors from both mixoploids were dissected to generate two ploidy series (4C-2x/4C-4x and 7D-2x/7D-4x). Molecular fingerprints were generated from the maternal plant H14-2x, both ploidy series (4C-2x/4C-4x and 7D-2x/7D-4x), and a tetraploid plant (C1) produced by selfing 7D-4x. Our results indicate that immediately after polyploidization P. plicatulum suffers genetic rearrangements affecting ~28-38 % of the genome. Band gain and loss were equally prevalent at a statistically significant level. At least 5.62 % of the genome experimented recurrent genetic variation in a non-random basis with a confidence of 94.88 %. A significant proportion of novel bands (36 out of 195; 18.4 %) was detected in the C1 tetraploid plant. Half of these bands were not amplified in either H14-2x or 7D-4x, while the remainders were present in H14-2x but absent in 7D-4x. Our results indicate the occurrence of a considerable number of genetic changes in P. plicatulum immediately after polyploidization, some of which were recurrently detected in different independent events. Moreover, we confirmed that after polyploidization, lost ancestral alleles were spontaneously recovered in further generations, a phenomenon previously reported by other research groups.

Analysis of variation for apomictic reproduction in diploid Paspalum rufum.

BACKGROUND AND AIMS: The diploid cytotype of Paspalum rufum (Poaceae) reproduces sexually and is self-sterile; however, recurrent autopolyploidization through 2n + n fertilization and the ability for reproduction via apomixis have been documented in one genotype of the species. The objectives of this work were to analyse the variation in the functionality of apomixis components in diploid genotypes of P. rufum and to identify individuals with contrasting reproductive behaviours. METHODS: Samples of five individuals from each of three natural populations of P. rufum (designated R2, R5 and R6) were used. Seeds were obtained after open pollination, selfing, conspecific interploidy crosses and interspecific interploidy self-pollination induction. The reproductive behaviour of each plant was determined by using the flow cytometric seed screen (FCSS) method. Embryo sacs were cleared using a series of ethanol and methyl salicylate solutions and observed microscopically. KEY RESULTS: In open pollination, all genotypes formed seeds by sexual means and no evidence of apomeiotic reproduction was detected. However, in conspecific interploidy crosses and interspecific interploidy self-pollination induction, variations in the reproductive pathways were observed. While all plants from populations R2 and R6 formed seeds exclusively by sexual means, three genotypes from the R5 population developed seeds from both meiotic and aposporous embryo sacs, and one of them (R5#49) through the complete apomictic pathway (apospory + parthenogenesis + pseudogamy). Cytoembryological observations revealed the presence of both meiotic and aposporous embryo sacs in all the genotypes analysed, suggesting that parthenogenesis could be uncoupled from apospory in some genotypes. CONCLUSIONS: The results presented demonstrate the existence of variation in the functionality of apomixis components in natural diploid genotypes of P. rufum and have identified individuals with contrasting reproductive behaviours. Genotypes identified here can be crossed to generate segregating populations in order to study apomixis determinants at the diploid level. Moreover, analysis of their expression patterns, quantification of their transcript levels and an understanding of their regulation mechanisms could help to design new strategies for recreating apomixis in a diploid genome environment.

Harnessing apomictic reproduction in grasses: what we have learned from Paspalum.

BACKGROUND: Apomixis is an alternative route of plant reproduction that produces individuals genetically identical to the mother plant through seeds. Apomixis is desirable in agriculture, because it guarantees the perpetuation of superior genotypes (i.e. heterotic hybrid seeds) by self-seeding without loss of hybrid vigour. The Paspalum genus, an archetypal model system for mining apomixis gene(s), is composed of about 370 species that have extremely diverse reproductive systems, including self-incompatibility, self-fertility, full sexual reproduction, and facultative or obligate apomixis. Barriers to interspecific hybridization are relaxed in this genus, allowing the production of new hybrids from many different parental combinations. Paspalum is also tolerant to various parental genome contributions to the endosperm, allowing analyses of how sexually reproducing crop species might escape from dosage effects in the endosperm. SCOPE: In this article, the available literature characterizing apomixis in Paspalum spp. and its use in breeding is critically reviewed. In particular, a comparison is made across species of the structure and function of the genomic region controlling apomixis in order to identify a common core region shared by all apomictic Paspalum species and where apomixis genes are likely to be localized. Candidate genes are discussed, either as possible genetic determinants (including homologs to signal transduction and RNA methylation genes) or as downstream factors (such as cell-to-cell signalling and auxin response genes) depending, respectively, on their co-segregation with apomixis or less. Strategies to validate the role of candidate genes in apomictic process are also discussed, with special emphasis on plant transformation in natural apomictic species.

Comparison between clinical trials and real-world evidence studies on biologics for severe asthma.

In recent years, the more widespread availability of biological drugs with specific mechanisms of action has led to significant breakthroughs in the management of severe asthma. Over time, numerous randomised clinical trials have been conducted to evaluate the efficacy and safety of these biologics and define the eligibility criteria of patients suitable for various therapeutic options. These studies were conducted under controlled conditions not always applicable to real life. For this and other reasons, real-world evidence and pragmatic studies are required to provide useful information on the effectiveness of biological drugs and their safety, even in the long term. Because differences in outcomes have sometimes emerged between clinical trials and real-life studies, it is important to clarify the causes of these discrepancies and define the significance of the results of studies conducted in the course of daily clinical practice. Thus, a scientific debate is ongoing, and no consensus has been reached. The purpose of this narrative review is to analyse the differences between randomised trials and real-world evidence studies, focusing on their roles in guiding clinicians among different therapeutic options and understanding the reasons for the large discrepancies often found in the results obtained.

Patterns of cytotype variation of Turnera sidoides subsp. pinnatifida (Turneraceae) in mountain ranges of central Argentina.

Cytogeographical variability among 564 plants from 26 populations of Turnera sidoides subsp. pinnatifida in mountain ranges of central Argentina was analysed with meiotic chromosome counts and flow cytometry and is described at regional and local scales. Populations were primarily tetraploids (2n = 4x = 28), although diploid (2n = 2x = 14), hexaploid (2n = 2x = 42), and mixed populations of diploids and triploids (2n = 3x = 21) were also found. Diploids, triploids, and hexaploids were fewer in number and restricted to narrow areas, while tetraploids were the most common and geographically widespread cytotype. Diploids grew at higher altitudes and in colder and wet locations; tetraploids had the broadest ecological spectrum, while hexaploids occurred at the lowest altitudes and in drier conditions. The cytotypes were also spatially segregated at a microgeographical scale. Diploids grew in the piedmont, tetraploids were in the adjacent valley, and in the contact zone of both cytotypes, patches of diploids and triploids were found. At a regional scale, the distribution of the cytotypes may be governed by a combination of ecological and historical variables, while segregation in the contact zone may be independent of the selective environment because the cytotypes are unable to coexist as a result of reproductive exclusion. The role of triploids is also discussed.

Predictive factors of low anterior resection syndrome following anterior resection of the rectum. / Síndrome da ressecção anterior do reto: fatores preditivos.

OBJECTIVE: to identify predictors of low anterior resection syndrome (LARS) that can contribute to its early diagnosis and treatment. METHODS: we conducted a retrospective cohort study of patients undergoing anterior resection of the rectum between 2007 and 2017 in the Coloproctology Service of the Federal University of Parana Clinics Hospital. We performed Receiver Operating Characteristic Curve (ROC) analysis to identify LARS predictive factors. RESULTS: we included 64 patients with complete data. The men's age was 60.1±11.4 years and 37.10% were male. Twenty patients (32.26%) had LARS. The most reported symptoms were incomplete evacuation (60%) and urgency (55%). In the univariate analysis, the distance from the anastomosis to the anal margin (p<0.001), neoadjuvant therapy (p=0.0014) and ileostomy at the time of resection (p=0.0023) were predictive of LARS. The ROC curve analysis showed a 6.5cm cut-off distance from the anastomosis to the anal margin as a predictor of LARS. CONCLUSION: distance between the anastomosis and the anal margin, neoadjuvant therapy history and preparation of stoma are conditions that can help predict the development of LARS. Guidance and involvement in patient education, as well as early management, can potentially reduce the impact of these symptoms on patients' quality of life.

OBJETIVO: identificar fatores preditivos da síndrome da ressecção anterior do reto (SRAR) que podem contribuir para o seu diagnóstico e tratamento precoces. MÉTODOS: estudo de coorte retrospectivo de pacientes submetidos à ressecção anterior do reto entre 2007 e 2017 no Serviço de Coloproctologia do Hospital de Clínicas da Universidade Federal do Paraná. Foram realizadas análises de curva ROC (Receiver Operating Characteristic Curve Analysis) ou COR (Característica de Operação do Receptor) para identificar os fatores preditivos da SRAR. RESULTADOS: foram incluídos 64 pacientes com dados completos. A idade dos homens foi de 60,1±11,4 anos e 37,10% eram do sexo masculino. Vinte pacientes (32,26%) apresentaram SRAR. Os sintomas mais relatados foram evacuação incompleta (60%) e urgência (55%). Na análise univariada, a distância da anastomose à margem anal (p<0,001), terapia neoadjuvante (p=0,0014) e confecção de ileostomia no momento da ressecção (p=0,0023) foram preditivos da SRAR. Análise da curva ROC mostrou um ponto de corte de 6,5cm na distância da anastomose à margem anal como preditor da SRAR. CONCLUSÃO: distância entre anastomose e margem anal, história de terapia neoajuvante e confecção de estoma são condições que podem ajudar a predizer o desenvolvimento da SRAR. A orientação e o envolvimento na educação do paciente, bem como, o manejo precoce podem reduzir potencialmente o impacto desses sintomas na qualidade de vida dos pacientes.

Inflammatory proteins are altered in chronic fatigue syndrome-A systematic review and meta-analysis.

Immune dysfunction has been posited as a key element in the aetiology of chronic fatigue syndrome (CFS) since the illness was first conceived. However, systematic reviews have yet to quantitatively synthesise inflammatory biomarkers across the literature. We undertook a systematic review and meta-analysis to quantify available data on circulating inflammatory proteins, examining studies recruiting patients with a CFS diagnosis and a non-affected control group. Results were meta-analysed from 42 studies. Patients with CFS had significantly elevated tumour necrosis factor (ES = 0.274, p < 0.001), interleukin-2 (ES = 0.203, p = 0.006), interleukin-4 (ES = 0.373, p = 0.004), transforming growth factor-ß (ES = 0.967, p < 0.001) and c-reactive protein (ES = 0.622, p = 0.019). 12 proteins did not differ between groups. These data provide some support for an inflammatory component in CFS, although inconsistency of results indicates that inflammation is unlikely to be a primary feature in all those suffering from this disorder. It is hoped that further work will elucidate whether there are subgroups of patients with clinically-relevant inflammatory dysfunction, and whether inflammatory cytokines may provide a prognostic biomarker or moderate treatment effects.

Usefulness of endoscopic ultrasound for perianal fistula in Crohn's disease. / Papel da ultrassonografia endoscópica na avaliação da fístula perianal na doença de Crohn.

OBJECTIVE: to determine the role of endoscopic ultrasonography (EU) in comparison with nuclear magnetic resonance imaging (MRI) and examination under anesthesia (EUA) in the management of patients with perianal fistulizing Crohn's disease. METHODS: we conducted a cross-sectional, observational study with patients with perianal Crohn's disease evaluated at a tertiary center in Curitiba, Paraná, Brazil, from February 2016 to March 2017. All patients underwent EU, MRI and EUA. We evaluated the degree of agreement between the three methods by obtaining the Kappa coefficient. A Kappa value of 0.7 or greater indicated good agreement. We used the Friedman's non-parametric test to compare the number of fistulous paths detected in each modality. We set the level of statistical significance at p<0.05. RESULTS: we included 20 patients. There was agreement between the three exams in 11 patients. The level of Kappa agreement between the three exams was 0.53 (moderate - p<0.001). There was no statistically significant difference in relation to the number of fistulous trajectories detected in the three exams (p=0.641). EU failed to identify a fistulous pathway in three patients; MRI failed in three; and EUA failed in two. CONCLUSION: EU was comparable to MRI and EUA for the evaluation of perianal fistulizing Crohn's disease, and can be considered a valid exam for preoperative investigation of such patients.

OBJETIVO: determinar o papel da ultrassonografia endoscópica (UE) em relação à ressonância magnética nuclear (RMN) e ao exame sob anestesia (ESA) no manejo de pacientes com doença de Crohn fistulizante perianal. MÉTODOS: estudo observacional transversal com pacientes com doença de Crohn perianal, avaliados em um centro terciário de Curitiba, Paraná, Brasil, de fevereiro de 2016 a março de 2017. Todos os pacientes foram submetidos à UE, RMN e ESA. O grau de concordância entre os três métodos foi avaliado através da obtenção do coeficiente de Kappa. Um valor de Kappa de 0,7 ou maior indicou boa concordância. O teste não paramétrico de Friedman foi utilizado para comparar o número de trajetos fistulosos detectados em cada modalidade. Considerou-se o nível de significância estatística como p<0,05. RESULTADOS: vinte pacientes foram incluídos. Houve concordância entre os três exames em 11 pacientes. O nível de concordância de Kappa entre os três exames foi 0,53 (moderado) (p<0,001). Não houve diferença estatisticamente significativa em relação ao número de trajetos fistulosos detectados nos três exames (p=0,641). Houve falha na identificação de um trajeto fistuloso em três pacientes com a UE, em três pacientes com a RMN e em dois pacientes com o ESA. CONCLUSÃO: a UE foi comparável à RMN e ao ESA para avaliação da doença de Crohn fistulizante perianal, e pode ser considerada um exame válido para investigação pré-operatória desses pacientes.

Vegetating lesions that appear in the scar after neoadjuvant therapy for rectal tumors: tumor regrowth or benign neoplasm?

Introduction: After the diagnosis of neoplasm of the middle and distal rectum, patients are often submitted to oncological treatment by neoadjuvant therapy. At the end of this treatment, those patients who show complete clinical response can choose, together with their physician, to adopt the watch-and-wait strategy; although it implies lower morbidity for the patient, this strategy is dependent on strict adherence to treatment follow-up for the early identification of any future local injury. Materials and Methods: Survey of data from medical records and description, and discussion of case reports with a literature review in books and databases. Results: We report the case of a 73-year-old patient diagnosed with moderately differentiated adenocarcinoma of the middle rectum, Stage II (cT3bN0M0), who presented complete clinical response after undergoing treatment with neoadjuvant therapy. Together with the assistant team, the watch-and-wait strategy was chosen. During the follow-up, an endoscopic examination showed a vegetating at the proximal limit of the tumor scar. We chose to perform submucosal endoscopic dissection. The report of the anatomopathological examination evidenced a serrated adenoma with narrow margins free of neoplasia. Conclusion: Patient adherence to cancer treatment using the watch-and-wait strategy is essential for the early identification of new local lesions. After resection of the lesion identified in the tumor scar site as a neoplasm-free lesion, it is consistent to think that this lesion would be the origin of the neoplasm, given the adenomatous origin. (AU)

COLORECTAL CANCER: factors related to late diagnosis in users of the public health system treated at an Universitary Hospital in Curitiba, Paraná State, Brazil.

BACKGROUND: - The fourth most frequent tumor in the world, colorectal cancer is commonly diagnosed at an advanced stage. OBJECTIVE: - To analyze factors that interfere in the diagnosis of colorectal cancer in users of the Public Health System treated at an universitary hospital in Curitiba, Paraná State, Brazil. METHODS: - Cross-sectional, quantitative and descriptive study with 120 patients treated at the institution between 2012 and 2013. Data collection, carried out by means of medical record appointments and patients' interviews, addressed sociodemographic variables; clinical profile; timespan between symptoms, examination, diagnosis, treatment onset and difficulties encountered. Statistical analyses were performed by means of Stata 8.0. RESULTS: - Abdominal pain was the most frequent complaint and rectal bleeding presented the highest chance of advanced colorectal cancer diagnosis. From 52.5% of patients with late diagnosis of colorectal cancer, 81% reported difficulties in the health system. CONCLUSION: - Results suggest that late diagnosis is due to symptom absence in the early stage of the disease, patients' lack of perception about the severity of the symptoms, need of better of health teams to search early diagnosis. Educational interventions are deemed necessary to the population and health teams, besides actions prioritizing the access to diagnostic testing for serious illnesses.

Prevalence of anal intraepithelial lesions in patients with inflammatory bowel disease

Introduction: Anal intraepithelial neoplasia (AIN) is a premalignant lesion of the anal canal associated with HPV, with a higher prevalence in immunosuppressed individuals. Patients with inflammatory bowel disease (IBD) are at potential risk for their development, due to the use of immunosuppressants and certain characteristics of the disease. Method: This is a prospective, cross-sectional, and interventional study that included 53 patients with IBD treated at a tertiary outpatient clinic, who underwent anal smear for cytology in order to assess the prevalence of AIN and associated risk factors. Results: Forty-eight samples were negative for dysplasia and 2 were positive (4%). Both positive samples occurred in women, with Crohn's disease (CD), who were immunosuppressed and had a history of receptive anal intercourse. Discussion: The prevalence of anal dysplasia in IBD patients in this study is similar to that described in low-risk populations. Literature data are scarce and conflicting and there is no evidence to recommend screening with routine anal cytology in patients with IBD. Female gender, history of receptive anal intercourse, immunosuppression and CD seem to be risk factors. (AU)

Síndrome da ressecção anterior do reto: fatores preditivos / Predictive factors of low anterior resection syndrome following anterior resection of the rectum

RESUMO Objetivo: identificar fatores preditivos da síndrome da ressecção anterior do reto (SRAR) que podem contribuir para o seu diagnóstico e tratamento precoces. Métodos: estudo de coorte retrospectivo de pacientes submetidos à ressecção anterior do reto entre 2007 e 2017 no Serviço de Coloproctologia do Hospital de Clínicas da Universidade Federal do Paraná. Foram realizadas análises de curva ROC (Receiver Operating Characteristic Curve Analysis) ou COR (Característica de Operação do Receptor) para identificar os fatores preditivos da SRAR. Resultados: foram incluídos 64 pacientes com dados completos. A idade dos homens foi de 60,1±11,4 anos e 37,10% eram do sexo masculino. Vinte pacientes (32,26%) apresentaram SRAR. Os sintomas mais relatados foram evacuação incompleta (60%) e urgência (55%). Na análise univariada, a distância da anastomose à margem anal (p<0,001), terapia neoadjuvante (p=0,0014) e confecção de ileostomia no momento da ressecção (p=0,0023) foram preditivos da SRAR. Análise da curva ROC mostrou um ponto de corte de 6,5cm na distância da anastomose à margem anal como preditor da SRAR. Conclusão: distância entre anastomose e margem anal, história de terapia neoajuvante e confecção de estoma são condições que podem ajudar a predizer o desenvolvimento da SRAR. A orientação e o envolvimento na educação do paciente, bem como, o manejo precoce podem reduzir potencialmente o impacto desses sintomas na qualidade de vida dos pacientes.

ABSTRACT Objective: to identify predictors of low anterior resection syndrome (LARS) that can contribute to its early diagnosis and treatment. Methods: we conducted a retrospective cohort study of patients undergoing anterior resection of the rectum between 2007 and 2017 in the Coloproctology Service of the Federal University of Parana Clinics Hospital. We performed Receiver Operating Characteristic Curve (ROC) analysis to identify LARS predictive factors. Results: we included 64 patients with complete data. The men's age was 60.1±11.4 years and 37.10% were male. Twenty patients (32.26%) had LARS. The most reported symptoms were incomplete evacuation (60%) and urgency (55%). In the univariate analysis, the distance from the anastomosis to the anal margin (p<0.001), neoadjuvant therapy (p=0.0014) and ileostomy at the time of resection (p=0.0023) were predictive of LARS. The ROC curve analysis showed a 6.5cm cut-off distance from the anastomosis to the anal margin as a predictor of LARS. Conclusion: distance between the anastomosis and the anal margin, neoadjuvant therapy history and preparation of stoma are conditions that can help predict the development of LARS. Guidance and involvement in patient education, as well as early management, can potentially reduce the impact of these symptoms on patients' quality of life.

Postoperative topical analgesia of hemorrhoidectomy with policresulen and cinchocaine: a prospective and controlled study.

OBJECTIVE: To evaluate the effects of topical policresulen and cinchocaine in the postoperative pain behavior of open hemorrhoidectomy. METHODS: We conducted a prospective, double-blinded, controlled study. The control group received the usual guidelines with oral medications. The topical treatment group received, in addition, the application of the ointment and was comprised of two subgroups (policresulen + cinchocaine, and placebo). Pain intensity was recorded with the visual analogue scale. RESULTS: 43 patients were operated on: control group - n = 13, one excluded; placebo - n = 15; and policresulen + cinchocaine - n = 15. The mean age was 45.98 years and 37.2% were men. The average pain intensity was 4.09 (immediate postoperative), 3.22 (hospital discharge), 5.73 (day 1) , 5.77 (day 2), 5.74 (day 3), 5.65 (day 7), 5.11 (day 10), 2.75 (day 15) and 7.70 (first bowel movement), with no difference between groups in all periods. CONCLUSION: This study showed no reduction in pain after hemorrhoidectomy with the use of topical policresulen and cinchocaine.

Adalimumab for maintenance therapy for one year in Crohn's disease: results of a Latin American single-center observational study.

CONTEXT: Adalimumab is a fully-human antibody that inhibits TNF alpha, with a significant efficacy for long-term maintenance of remission. Studies with this agent in Latin American Crohn's disease patients are scarce. OBJECTIVES: The objective of this study was to outline clinical remission rates after 12 months of adalimumab therapy for Crohn's disease patients. METHODS: Retrospective, single-center, observational study of a Brazilian case series of Crohn's disease patients under adalimumab therapy. Variables analyzed: demographic data, Montreal classification, concomitant medication, remission rates after 1, 4, 6 and 12 months. Remission was defined as Harvey-Bradshaw Index ≤ 4, and non-responder-imputation and last-observation-carried-forward analysis were used. The influence of infliximab on remission rates was analyzed by Fischer and Chi-square tests (P<0.05). RESULTS: Fifty patients, with median age of 35 years at therapy initiation, were included. Remission rates after 12 months of therapy were 54% under non-responder-imputation and 88% under last-observation-carried-forward analysis. After 12 months, remission on patients with previous infliximab occurred in 69.23% as compared to 94.59% in infliximab-naïve patients (P = 0.033). CONCLUSIONS: Adalimumab was effective in maintaining clinical remission after 12 months of therapy, with an adequate safety profile, and was also more effective in infliximab naïve patients.

Papel da ultrassonografia endoscópica na avaliação da fístula perianal na doença de Crohn / Usefulness of endoscopic ultrasound for perianal fistula in Crohn's disease

RESUMO Objetivo: determinar o papel da ultrassonografia endoscópica (UE) em relação à ressonância magnética nuclear (RMN) e ao exame sob anestesia (ESA) no manejo de pacientes com doença de Crohn fistulizante perianal. Métodos: estudo observacional transversal com pacientes com doença de Crohn perianal, avaliados em um centro terciário de Curitiba, Paraná, Brasil, de fevereiro de 2016 a março de 2017. Todos os pacientes foram submetidos à UE, RMN e ESA. O grau de concordância entre os três métodos foi avaliado através da obtenção do coeficiente de Kappa. Um valor de Kappa de 0,7 ou maior indicou boa concordância. O teste não paramétrico de Friedman foi utilizado para comparar o número de trajetos fistulosos detectados em cada modalidade. Considerou-se o nível de significância estatística como p<0,05. Resultados: vinte pacientes foram incluídos. Houve concordância entre os três exames em 11 pacientes. O nível de concordância de Kappa entre os três exames foi 0,53 (moderado) (p<0,001). Não houve diferença estatisticamente significativa em relação ao número de trajetos fistulosos detectados nos três exames (p=0,641). Houve falha na identificação de um trajeto fistuloso em três pacientes com a UE, em três pacientes com a RMN e em dois pacientes com o ESA. Conclusão: a UE foi comparável à RMN e ao ESA para avaliação da doença de Crohn fistulizante perianal, e pode ser considerada um exame válido para investigação pré-operatória desses pacientes.

ABSTRACT Objective: to determine the role of endoscopic ultrasonography (EU) in comparison with nuclear magnetic resonance imaging (MRI) and examination under anesthesia (EUA) in the management of patients with perianal fistulizing Crohn's disease. Methods: we conducted a cross-sectional, observational study with patients with perianal Crohn's disease evaluated at a tertiary center in Curitiba, Paraná, Brazil, from February 2016 to March 2017. All patients underwent EU, MRI and EUA. We evaluated the degree of agreement between the three methods by obtaining the Kappa coefficient. A Kappa value of 0.7 or greater indicated good agreement. We used the Friedman's non-parametric test to compare the number of fistulous paths detected in each modality. We set the level of statistical significance at p<0.05. Results: we included 20 patients. There was agreement between the three exams in 11 patients. The level of Kappa agreement between the three exams was 0.53 (moderate - p<0.001). There was no statistically significant difference in relation to the number of fistulous trajectories detected in the three exams (p=0.641). EU failed to identify a fistulous pathway in three patients; MRI failed in three; and EUA failed in two. Conclusion: EU was comparable to MRI and EUA for the evaluation of perianal fistulizing Crohn's disease, and can be considered a valid exam for preoperative investigation of such patients.

Colonic phytobezoar / Fitobezoar cólico

ABSTRACT Bezoars, although rare, represent a small part of the etiologies of intestinal obstructions. They are indigestible masses formed in human beings consisting of hair, seeds, plant fibers, fruits, and even medications. The present report concerns a male patient with a complaint of interrupted flatus passage and feces elimination and pain in the left iliac fossa, initially suspected as a neoplasia of the sigmoid colon. However, analysis of the surgical specimen revealed that the condition was characterized by intestinal obstruction due to an encapsulated phytobezoar. This fact demonstrates the importance of a differential diagnosis, with emphasis on the relevance of considering the presence of bezoars despite their rare occurrence.

RESUMO Os bezoares, embora raros, representam uma pequena parte das etiologias das obstruções intestinais. São massas indigestíveis formadas em seres humanos que consistem em cabelo, sementes, fibras vegetais, frutas e até mesmo medicamentos. O presente relato retrata um paciente do sexo masculino com uma queixa de parada de eliminação de flatos e fezes somado à dor na fossa ilíaca esquerda, que inicialmente suspeitou-se como neoplasia do cólon sigmoide. No entanto, a análise das peças cirúrgicas revelaram que a obstrução intestinal ocorreu devido à presença de um fitobezoar encapsulado. Este fato demonstra a importância do diagnóstico diferencial, com ênfase em considerar a presença de bezoares apesar de sua rara ocorrência.

Appendico-cutaneous fistula following hysterectomy: first case report / Fístula apêndico-cutanea pós histerectomia: primeiro relato de caso

ABSTRACT Appendico-cutaneous fistulas not related to acute appendicitis or cancer are rare and show spontaneous resolution after conservative treatment, mainly when they show low output, absence of obstruction or sepsis and in patients with good nutritional status. We found no report in the literature on appendico-cutaneous fistula after hysterectomy. The evolution of this case shows that this type of fistula can have low, but persistent debt, requiring definitive surgery.

RESUMO Fístulas apendico-cutâneas não relacionadas à apendicite aguda ou neoplasias são raras e de resolução espontânea após tratamento conservador, sobretudo quando se apresentam com baixo débito, ausência de obstrução ou sepse e em pacientes em bom estado nutricional. Não encontramos relato na literatura de fístula apendico-cutânea após histerectomia. A evolução desse caso demonstra que a esse tipo de fístula pode apresentar débito baixo, mas persistente, demandando cirurgia definitiva.

Colorectal cancer: factors related to late diagnosis in users of the public health system treated at an Universitary Hospital in Curitiba, Paraná State, Brazil

ABSTRACT Background - The fourth most frequent tumor in the world, colorectal cancer is commonly diagnosed at an advanced stage. Objective - To analyze factors that interfere in the diagnosis of colorectal cancer in users of the Public Health System treated at an universitary hospital in Curitiba, Paraná State, Brazil. Methods - Cross-sectional, quantitative and descriptive study with 120 patients treated at the institution between 2012 and 2013. Data collection, carried out by means of medical record appointments and patients' interviews, addressed sociodemographic variables; clinical profile; timespan between symptoms, examination, diagnosis, treatment onset and difficulties encountered. Statistical analyses were performed by means of Stata 8.0. Results - Abdominal pain was the most frequent complaint and rectal bleeding presented the highest chance of advanced colorectal cancer diagnosis. From 52.5% of patients with late diagnosis of colorectal cancer, 81% reported difficulties in the health system. Conclusion - Results suggest that late diagnosis is due to symptom absence in the early stage of the disease, patients' lack of perception about the severity of the symptoms, need of better of health teams to search early diagnosis. Educational interventions are deemed necessary to the population and health teams, besides actions prioritizing the access to diagnostic testing for serious illnesses.

RESUMO Contexto - Quarto tumor mais frequente no mundo, o câncer colorretal comumente é diagnosticado em estádio avançado. Objetivo - Analisar fatores que interferem no diagnóstico do câncer colorretal de usuários do Sistema Único de Saúde, atendidos em hospital universitário de Curitiba. Métodos - Estudo transversal, quantitativo e descritivo com 120 pacientes atendidos na instituição em 2012 e 2013. A coleta de dados, realizada por meio de consulta ao prontuário e entrevista aos pacientes, abordou variáveis sociodemográficas; perfil clínico; tempo decorrido entre sintomas, atendimento, diagnóstico e início do tratamento e dificuldades encontradas. As análises estatísticas foram feita com pelo Stata 8.0. Resultados - Dor abdominal foi a queixa mais frequente e sangramento retal representou maior chance de diagnóstico avançado de câncer colorretal. Dos 52,5% dos pacientes que diagnosticaram a doença tardiamente, 81% relataram dificuldades com o serviço de saúde. Conclusão - Os resultados sugerem que o diagnóstico tardio é devido à ausência de sintomas na fase inicial da doença, falta de percepção dos pacientes sobre a gravidade dos sintomas, necessidade de maior preparo das equipes de saúde para o diagnóstico precoce. São necessárias intervenções educativas junto à população e equipes de saúde, além de ações que priorizem o acesso a exames diagnósticos de doenças graves.

Ex vivo and simulator models teaching therapeutic ERCP and EUS: description of SOBEDs first course

Teaching models in endoscopy are important tools to minimize risks derived from endoscopic procedures, taking into account that therapeutic endoscopy, also known as surgical endoscopy, has greatly developed during the last decade. This results from the fact that minimally invasive procedures present relevant contributions and promote more comfort to patients. In this context, ex vivo teaching models and virtual simulators are important tools to the safe acquisition of abilities. In this article, the Brazilian Society of Digestive Endoscopy presents and describes its first course of therapeutic ERCP and EUS in models of laboratory teaching.

Los modelos de enseñanza en endoscopía son herramientas importantes para minimizar los riesgos de los procedimentos endoscópicos. En la última década la endoscopía terapéutica o también llamada endoscopía-quirúrgica, tuvo gran desarollo debido a que los procedimentos minimamente invasivos tienen mejores resultados para la calidad de vida del paciente. En este contexto, los modelos experimentales y animales son herramientas muy importantes para los alumnos. En este artículo de revisión y presentación, los miembros de la Sociedad Brasilera de Endoscopía Digestiva presentan el primer Curso Taller en Ecoendoscopía terapéutica y CPRE en el Congreso Nacional del 2015.