ASSESSMENT OF RISK FACTORS FOR SURGERY TREATMENT OF CROHN'S DISEASE: A HOSPITAL COHORT.

BACKGROUND: New therapies have revolutionized the treatment of Crohn's disease (CD), but in some countries, the surgery rate has not changed, the frequency of emergency surgery is underestimated, and surgical risk is poorly studied. AIMS: The aim of this study was to identify risk factors and clinical indications for primary surgery in CD patients at the tertiary hospital. METHODS: This was a retrospective cohort of a prospectively collected database of 107 patients with CD from 2015 to 2021. The main outcomes were the incidence of surgery treatment, types of procedures performed, surgical recurrence, surgery free time, and risk factors for surgery. RESULTS: Surgical intervention was performed in 54.2% of the patients, and most of the procedures were emergency surgeries (68.9%). The elective procedures (31.1%) were performed over 11 years after diagnosis. The main indications for surgery were ileal stricture (34.5%) and anorectal fistulas (20.7%). The most frequent procedure was enterectomy (24.1%). Recurrence surgery was most common in emergency procedures (OR 2.1; 95%CI 1.6-6.6). Montreal phenotype L1 stricture behavior (RR 1.3; 95%CI 1.0-1.8, p=0.04) and perianal disease (RR 1.43; 95%CI 1.2-1.7) increased the risk of emergency surgeries. The multiple linear regression showed age at diagnosis as a risk factor for surgery (p=0.004). The study of surgery free time showed no difference in the Kaplan-Meier curve for Montreal classification (p=0.73). CONCLUSIONS: The risk factors for operative intervention were strictures in ileal and jejunal diseases, age at diagnosis, perianal disease, and emergency indications.

Assessment of risk factors for surgery treatment of crohn's disease: a hospital cohort / Avaliação dos fatores de risco para tratamento cirúrgico na doença de crohn: uma coorte hospitalar

ABSTRACT BACKGROUND New therapies have revolutionized the treatment of Crohn's disease (CD), but in some countries, the surgery rate has not changed, the frequency of emergency surgery is underestimated, and surgical risk is poorly studied. AIMS: The aim of this study was to identify risk factors and clinical indications for primary surgery in CD patients at the tertiary hospital. METHODS: This was a retrospective cohort of a prospectively collected database of 107 patients with CD from 2015 to 2021. The main outcomes were the incidence of surgery treatment, types of procedures performed, surgical recurrence, surgery free time, and risk factors for surgery. RESULTS: Surgical intervention was performed in 54.2% of the patients, and most of the procedures were emergency surgeries (68.9%). The elective procedures (31.1%) were performed over 11 years after diagnosis. The main indications for surgery were ileal stricture (34.5%) and anorectal fistulas (20.7%). The most frequent procedure was enterectomy (24.1%). Recurrence surgery was most common in emergency procedures (OR 2.1; 95%CI 1.6-6.6). Montreal phenotype L1 stricture behavior (RR 1.3; 95%CI 1.0-1.8, p=0.04) and perianal disease (RR 1.43; 95%CI 1.2-1.7) increased the risk of emergency surgeries. The multiple linear regression showed age at diagnosis as a risk factor for surgery (p=0.004). The study of surgery free time showed no difference in the Kaplan-Meier curve for Montreal classification (p=0.73). CONCLUSIONS: The risk factors for operative intervention were strictures in ileal and jejunal diseases, age at diagnosis, perianal disease, and emergency indications.

RESUMO RACIONAL Novas terapias revolucionaram o tratamento da Doença de Crohn, mas em alguns países a taxa de cirurgias não se modificou, a frequência de cirurgias de emergência é subestimada e o risco cirúrgico é pouco estudado. OBJETIVOS Analisar fatores de risco e as indicações para cirurgia primária em pacientes com doença de Crohn, em Hospital terciário. MÉTODOS: Análise de banco de dados coletado prospectivamente, de 107 pacientes com doença de Crohn de 2015 a 2021. Os principais desfechos foram a incidência de tratamento cirúrgico, tipos de procedimentos realizados, recidiva cirúrgica, tempo livre de cirurgia e fatores de risco. RESULTADOS: A intervenção cirúrgica foi realizada em 54.2% dos pacientes, sendo a maioria dos procedimentos cirúrgicos de urgência (68.9%). Os procedimentos eletivos (31.1%) foram realizados mais de 11 anos após o diagnóstico. As principais indicações cirúrgicas foram estenose ileal (34,5%) e fístula anorretal (20,7%), sendo o procedimento mais frequente a enterectomia (24,1%). As cirurgias para recidiva foram mais comuns em procedimentos de urgência (OR 2,1; IC95% 1,6-6,6). O fenótipo de comportamento estenosante Montreal L1 (RR = 1,3; IC 95%: 1,0-1,8, p=0,04) e a doença perianal (RR 1,43; IC95% 1,2-1,7) aumentaram o risco de cirurgias de emergência. A regressão linear múltipla mostrou a idade ao diagnóstico como fator de risco para cirurgia (p=0,004). O estudo do tempo livre de cirurgia não mostrou diferença na curva de Kaplan Meier para a classificação Montreal (p=0,73). CONCLUSÕES: Os principais fatores de risco para intervenções cirúrgicas foram estenoses em doenças ileais e jejunais, idade ao diagnóstico, doença perianal e indicações de urgência.

Accuracy of Oral 67Gallium Citrate Scintigraphy in assessment of inflammatory activity of Crohn's disease.

AIM: The main goal in Crohn´s disease (CD) is a sustained suppression of inflammatory activity associated with mucosa healing in endoscopic evaluation. During clinical routine, there are small numbers of good markers to monitor inflammatory activity under treatment. We postulated that Oral 67Gallium Citrate Scintigraphy is able to mark inflammatory disease in mucosa and deep inflammation in CD, when used in oral form. OBJECTIVE: Measure the accuracy of Oral 67Gallium Citrate Scintigraphy in intestinal inflammatory activity of Crohn´s disease. PATIENTS AND METHODS: In a prospective consecutive cross-sectional study from January 2018 to June 2019, the ileocolonic region of 32 patients with CD were studied by dividing into four regions of interest (ROI) from the ileum to the rectum. A total of 128 intestinal segments were analyzed in cluster data. Accuracy values of Oral 67Gallium Scintigraphy and colonoscopy tests were evaluated with the histological reference test. Values of the respective receiver operating characteristic (ROC) curves were obtained  and compared. The reliability between the tests was evaluated by Kappa statistical with the segment-level analyses using variance adjustments. All statistical analyses were performed with a test significance level of 0.05. RESULTS: The study population included 32 patients with CD (10 men, 22 women; average age 39 years). Disease time was five years on average. Anti-TNFs treatment was found in 71%. The most found phenotype of the Montreal classification was L3. Differences in ROC curves for colonoscopy (0.94) and Oral 67Ga Scintigraphy (0.96) did not show significant value (p = 0.32). The sensitivity of scintigraphy to detect intestinal inflammatory activity in CD was 64%, specificity of 96% and accuracy of 84%. A high agreement was found between oral scintigraphy and histological measurements with kappa = 0.64. CONCLUSIONS: Oral 67Ga Scintigraphy had similar accuracy and agreement compared to colonoscopy in the identification of inflammatory activity in Crohn´s Disease. This new approach may be useful and less invasive for long term follow-ups.

Scintigraphic evaluation of colonic transit in children with constipation using 67Ga-citrate.

The aim of this study was to assess the colonic transit in children and teenagers with chronic constipation. Twenty patients from 1.5 to 16 years old were included (mean age = 6.9 years). Chronic constipation etiologies were as follows: congenital megacolon in 6; surgical treatment in 5 (imperforate anus 2, hip dysplasia 1, sacral teratoma 1, and paraspinal neuroblastoma 1); idiopathic chronic constipation in 5; sacral myelomeningocele in 3; and intestinal duplication in 1. Static images on the anterior projection of the abdomen were performed 1, 6, 24, 48, and 72 h after the radiotracer oral administration. Doses were 3.7 MBq of 67Ga-citrate. The images were visually analyzed and classified by the observers as normal, diffuse slow transit, right slow transit, and left slow transit. Patients' dosimetric estimation was performed also. There were four cases of diffuse slow transit that responded well to the clinical treatment, 3 of them being chronic idiopathic constipation. From five patients with right slow transit, 4 were submitted to appendicostomy (Malone surgery) with good results. There were 11 cases of left slow transit (ten at the rectosigmoid level). Five of the 6 patients with congenital megacolon had left slow transit. Patients' dose estimation was 1.9 mSv to the whole body, 1.8 mSv to the ovaries, and 1.4 mSv to the testicular. This method is simple, safe, noninvasive, provides helpful functional information, and allows therapeutic decision regarding chronic constipation.

Expressão citofotométrica do marcador CD-34 no adenocarcinoma de cólon / CD-34 cytophotometric expression in colon adenocarcinoma

A angiogênese é uma das responsáveis pelo equilíbrio homeostático entre as células. Durante o desenvolvimento do processo de degeneração maligna celular o seu desequilíbrio é considerado um importante marco neoplásico e o CD-34 parece ser um bom marcador de angiogênese. OBJETIVOS - Avaliar qual a expressão citofotométrica do CD-34 no adenocarcinoma de cólon; se apresenta alterações nas diferentes fases evolutivas na classificação modificada de Dukes; e como se expressa no cólon direito e esquerdo. MÉTODOS - Utilizaram-se 19 casos submetidos à técnica imunoistoquímica com anticorpo anti CD-34. Após, as lâminas foram lidas pelo sistema SAMBA com o software Immuno 4, analisando dois índices: marcação e densidade óptica. Os parâmetros foram marcação e expressão do marcador, quer individual quer relacionado à classificação de Dukes e lado. RESULTADOS - A média do índice de marcação foi 66,54 e densidade óptica 43,60. Em relação à classificação de Dukes, 12 do tipo B, tiveram índice de marcação 67,95 e densidade óptica 43,21 e, para os sete do tipo C, índice de marcação 64,12 e densidade óptica 44,27. Não foi possível identificar diferença em relação à classificação de Dukes. Quanto ao lado do tumor, os 11 esquerdos tiveram índice de marcação 72,08 e densidade óptica 46,70, e os oito direitos, índice de marcação 58,93 e densidade óptica 39,44. Em relação ao índice de marcação houve diferença significante, mas quanto à densidade óptica não. CONCLUSÕES - O CD-34 apresentou expressão discreta como marcador de angiogênese; sem diferença entre tipos B e C de Dukes mostrando atividade angiogênica maior à direita do que à esquerda.

Angiogenesis is considered to be one of the mechanisms responsible for the homeostatic balance among cells. During cell malignant degeneration, the unbalanced cell proliferation mechanisms demonstrate to be an important factor in cancer evolution and CD-34 is one important marker. OBJECTIVE - To evaluate CD-34 biomarker expression through cytophotometric analysis of colon adenocarcinoma samples; to verify the presence of tumor marker expression in different stages of tumor samples according to Dukes modified classification; to determine eventual difference in CD-34 expression while tumor location is either in right or left colon. METHODS - Nineteen samples were submitted to an immunohistochemical method, using anti-CD-34 monoclonal antibody. Marked slides were analyzed by SAMBA system using Immuno 4 software. Biomarker expression consisted in label index and optical density. The parameters considered under investigation were tumor expression, its intensity, correlations to Dukes' classification and tumor's side. RESULTS - The mean rate of CD-34 expression was 66.54, and optical density 43.60. Regarding Dukes' classification, 12 samples B-type presented label index 67.95 and optical density 43.21; seven C-type, label index was 64.12 and optical density 44.27. It was not possible to identify any difference related to Dukes' classification. Tumor side reflected significant difference in label index, but not in optical density. Eleven samples on the left presented 72.08 of label index and 46.70 of optical density. Eight right, demonstrated label index of 58.93 and optical density of 39.44. CONCLUSIONS - CD-34 marker presented a low expression as an angiogenesis marker in colon tumors with no difference between Duke's tumors type-B and type-C. The tumor had higher angiogenic activity in the right than in left colon.

Estudo da expressão citofotométrica do marcador tumoral Caspase-3 no adenocarcinoma de cólon / Citophotometric expression study of tumoral marker Caspase-3 on colon adenocarcinoma

RACIONAL: O adenocarcinoma de cólon é a segunda causa mais comum de morte por câncer em homens e mulheres, sendo responsável por mais de cinco milhões de mortes por ano. No momento do diagnóstico apenas 70% dos tumores são ressecáveis, 75% são curáveis e 25% poderão ter recorrência da doença. A apoptose é uma das responsáveis pelo equilíbrio homeostático entre as células. Durante o desenvolvimento do processo de degeneração maligna celular o desequilíbrio na apoptose é considerado um dos principais marcos neoplásicos. A caspase-3 é uma das mais importantes moléculas na apoptose, sendo sua efetora principal. Sua expressão e prognóstico têm sido relatados em vários estudos e revisões com seu papel valorizado desde o surgimento do pólipo até a sua transformação maligna, com a taxa de apoptose diminuindo progressivamente. OBJETIVOS: Avaliar a expressão citofotométrica computadorizada do marcador Caspase-3 no adenocarcinoma de cólon; avaliá-lo nas fases evolutivas na classificação modificada de Dukes e comparar sua expressão nos tumores do lado direito e esquerdo do cólon. MÉTODOS: Utilizaram-se 19 casos de câncer recuperados de blocos de parafina confirmados por hematoxilina-eosina e submetidos à técnica imunoistoquímica da estreptavidina-biotina com anticorpo policlonal anti-caspase-3. Após este processo as lâminas marcadas foram submetidas à leitura pelo sistema SAMBA com o software IMUNNO 4.00. Foram analisados três índices: marcagem (Label index), heterogeneidade e densidade óptica. Utilizaram-se a marcagem individual, avaliação da expressão do marcador e grupos definidos de tumores com classificação Dukes e pelo lado do tumor. RESULTADOS: A média do índice de marcagem da caspase-3 foi de 85,24 e da densidade óptica de 39,55. Na classificação Dukes de 12 tipos B tiveram índice de marcagem de 86,20 e a densidade óptica de 37,72 e para os 7 tipos C a área de marcagem foi de 85,66 e a densidade óptica foi de 42,71 não sendo possível identificar diferença em relação a classificação de Dukes. Quanto ao lado do tumor os 11 tumores à esquerda tiveram índice de marcagem de 86,65 e densidade óptica de 43,29 e os 8 à direita tíndice de marcagem de 83,29 e densidade óptica de 39,44 não sendo possível observar diferença estatística significante. CONCLUSÕES: A caspase-3 possui alta expressão individual revelando-se marcador de boa utilidade no estudo do adenocarcinoma de cólon e da fase pró-apoptóica da sua tumorigênese pelo seu alto grau de índice de marcagem e densidade óptica. Em relação à classificação Dukes não houve diferença entre os tipos B e C, como também em relação ao lado direito e esquerdo do cólon.

BACKGROUND: Colon adenocarcinoma is the second cause of cancer death in men and women, responsible for more than five million deaths each year. At the diagnosis, only 70% of tumors are resectable, 75% curative and 25% might have disease recurrence. Apoptosis is responsible for homeostatic equilibrium among cells. During the development of the cellular malignant degeneration, an abnormal apoptosis plays an important role in the neoplasm transformation. Caspase-3 is one of the most important molecules in apoptosis, considered as the principal executioner. Caspase-3 expression and its prognosis have been mentioned in a variety of study and revision as its role being emphasized since the onset of polyp formation until the malignant transformation, as apoptosis declines progressively. AIM: To evaluate the computerized image cytophotometric expression of Caspase-3 in colon adenocarcinoma; to evaluate in the respective phases of Dukes-modified Classification and to compare its expression on right-sided and left-sided colon tumors. METHODS: Nineteen recovery of sampled-tissue in paraffin blocks confirmed by hematoxylin-eosin and submitted to immunohistochemistry estreptavidin-biotin method using antibody polyclonal anti-caspase-3. Following this process, marked slides were submitted SAMBA reading using software IMUNNO 4.00. Three indexes were analyzed: label index, heterogeneity and optical density. Individual labeling, marker expression evaluation and predefined tumors groups under Dukes Classification and side of tumor occurrence were considered. RESULTS: The average labeling index for caspase-3 was 85,24, where as for optical density was 39,55 pixels. According to Dukes Classification, 12 type B presented labeling index of 86,20 and optical density of 37,72 and for 7 samples type C labeling index corresponded to 85,66 and optical density equals to 42,71, unable to identify the difference regarding to Dukes Classification. Regarding to the side of tumor occurrence, 11 left-sided tumors had labeling index of 86,65 and optical density of 43,29 and the 8 right-sided tumors had labeling index of 83,29 and optical density of 39,44, unable to observe significant statistical difference. CONCLUSION: Caspase-3 presents a distinct value expression, revealing as useful marker in colon adenocarcinoma study and its proapoptotic phase at the tumorigenesis due to its high labeling index and optical density. Regarding to Dukes Classification there was no difference between types B and C, as well as right and left sided-related colon tumor occurrence.

Estudo citofotométrico da expressão dos marcadores tumorais Caspase-3 e Ki-67 no adenocarcinoma gástrico / Cytophotometric study of the expression of tumoral markers Caspase-3 and Ki-67 in gastric adenocarcinoma

RACIONAL: A carcinogênese gástrica é processo complexo e depende de fatores genéticos, ambientais e infecciosos. Nos últimos anos, houve grandes avanços nos campos da genética e da biologia molecular, sobre o desenvolvimento dos tumores. Os marcadores tumorais são substâncias ausentes nos tecidos normais e que podem ser identificadas em tecidos com câncer. Através de procedimentos imunoistoquímicos eles podem ser estudados. OBJETIVOS: Descrever a expressão citofotométrica do marcador tumoral Ki-67 analisando a densidade óptica e o índice de marcagem no adenocarcinoma de estômago. Descrever a expressão citofotométrica do marcador tumoral Caspase-3 analisando a densidade óptica e o índice de marcagem no adenocarcinoma de estômago. Comparar o índice de marcagem e densidade óptica dos marcadores tumorais Ki-67 e Caspase-3 no adenocarcinoma de estômago. MÉTODO: Foram selecionados, inicialmente, 58 blocos com espécime de adenocarcinoma gástrico coletados nos Serviços de Anátomo-Patologia do Hospital do Gama - Brasília (DF) e Hospital Dom Orione - Araguaina (TO), e analizados no Laboratório de Citologia e Histopalogia Ltda - CITOLAB, Curitiba (PR). Foram aproveitados 31 blocos para o estudo histológico e imunoistoquímico realizado pelo sistema de análise computarizado SAMBA 4000. RESULTADOS: Das 31 lâminas estudas, 15 (48%) foram marcadas pelo marcador Ki-67, 22 (71%) foram marcadas pelo marcador Caspase-3 e 14 (45%) marcaram com os dois marcadores. CONCLUSÕES: A expressão citofométrica do marcador Ki-67 foi observada em 15 lâminas da amostra estudada e apresentaram média do índice de marcagem de 36,85%, enquanto a densidade óptica apresentou média de 29,33 pixels. A expressão citofotométrica do marcador Caspase-3 foi observada em 22 lâminas da amostra estudada e apresentaram média do índice de marcagem de 87,71% e 60,74 pixels de média para a densidade óptica. Na comparação do índice de marcagem dos marcadores Ki-67 e Caspase-3 com a leitura de 14 lâminas, observamos que existe diferença significativa (P<0,001) em favor do marcador Caspase-3, o mesmo aconteceu para a densidade óptica também com diferença significativa (P<0,001).

BACKGROUND: Gastric tumorigenesis is a complex mechanism where genetic, enviromental and infeccious interferences may occur. In the last few years, advances in molecular biology brought a new way in the research of the malignancies using tumoral markers and imunohistochemistry. AIM: To describe the cytophotometric expression of tumoral markers Ki-67 and caspase-3, analyzing optical density and labeling index as parameters in gastric adenocarcinoma. To compare the labeling index and optical density of Ki-67 and Caspase-3 in gastric adenocarcinoma. METHODS: Fifty eight paraffin blocks containing gastric adenocarcinomas specimens were collected in the Serviços de Anátomo-Patologia do Hospital do Gama - Brasília (DF) and Hospital Dom Orione - Araguaina (TO), being analyzed at CITOLAB - Cytology and Hystopathology Laboratory Ltda, in Curitiba (PR). A total of 31 of the blocks were used for hystological studies. Immunohistochemistry was performed utilizing the SAMBA 4000 computerized analysis system. RESULTS: Of the 31 slides studies, 15 (48%) were marked by Ki-67, 22 (71%) were marked by Caspase-3 and 14 (45%) were marked by both of the tumoral markers. CONCLUSIONS: Cytophotometric expression of Ki-67 was observed in 15 of the slides studied, presenting an average labeling index of 36,85%, where as the optical density showed an average of 29,33 pixels. Cytophotometric expression of Caspase-3 was observed in a total of 22 slides, presenting an average labeling index of 87,71% and optical density of 60,74 pixels. When comparing the labeling indexes of both of the tumoral markers Ki-67 and Caspase-3 concerning the 14 slides analyzed, a significant difference (P<0,001).

Revisão sobre infecção de sítio cirúrgico e recomendações de antibioticoprofilaxia em clínicas cirúrgicas / Review on Surgical Site Infection and Prophylactic Recommendations in Surgical Clinics

Este trabalho trata de revisão da literatura abordando os fatores de risco pré e intra-operatório, os microorganismos mais prevalentes e as medidas para diminuir a ocorrência de infecções de sítio cirúrgico. Enfoca o uso correto da antibioticoprofilaxia e sua relação com o problema da resistência bacteriana para as principais cirurgias de diversas especialidades.