RISK FACTORS FOR EARLY POSTOPERATIVE COMPLICATIONS IN ACUTE COLITIS IN THE ERA OF BIOLOGIC THERAPY.

BACKGROUND: Despite major advances in the clinical treatment of inflammatory bowel disease, some patients still present with acute colitis and require emergency surgery. AIMS: To evaluate the risk factors for early postoperative complications in patients undergoing surgery for acute colitis in the era of biologic therapy. METHODS: Patients with inflammatory bowel disease admitted for acute colitis who underwent total colectomy at a single tertiary hospital from 2012 to 2022 were evaluated. Postoperative complications were graded according to Clavien-Dindo classification (CDC). Patients with more severe complications (CDC≥2) were compared with those with less severe complications (CDC<2). RESULTS: A total of 46 patients underwent surgery. The indications were: failure of clinical treatment (n=34), patients' or surgeon's preference (n=5), hemorrhage (n=3), toxic megacolon (n=2), and bowel perforation (n=2). There were eight reoperations, 60.9% of postoperative complications classified as CDC≥2, and three deaths. In univariate analyses, preoperative antibiotics use, ulcerative colitis diagnosis, lower albumin levels at admission, and preoperative hospital stay longer than seven days were associated with more severe postoperative complications. CONCLUSIONS: Emergency surgery for acute colitis was associated with a high incidence of postoperative complications. Preoperative use of antibiotics, ulcerative colitis, lower albumin levels at admission, and delaying surgery for more than seven days were associated with more severe early postoperative complications. The use of biologics was not associated with worse outcomes.

Pathologic Complete Response in Rectal Cancer: Can We Detect It? Lessons Learned From a Proposed Randomized Trial of Watch-and-Wait Treatment of Rectal Cancer.

BACKGROUND: Chemoradiotherapy has the potential to downsize and downstage tumors before surgery, decrease locoregional recurrence, and induce a complete sterilization of tumor cells for middle and low locally advanced rectal cancer. A watch-and-wait tactic has been proposed for patients with clinical complete response. OBJECTIVE: The purpose of this study was to verify our ability to identify complete clinical response in patients with rectal cancer based on clinical and radiologic criteria. DESIGN: This was a prospective study. SETTINGS: The study was conducted at a single institution, in the setting of a watch-and-wait randomized trial. PATIENTS: Consecutive patients with stage T3 to T4N0M0 or T(any)N+M0 cancer located within 10 cm from anal verge or T2N0 within 7 cm from anal verge were included in the study. Patients were staged and restaged 8 weeks after completion of chemoradiation (5-fluorouracil, 5040 cGy) by digital examination, colonoscopy, pelvic MRI, and thorax and abdominal CT scans. MAIN OUTCOME MEASURES: Clinical and radiologic judgments of tumor response were compared with pathologic response of patients treated by total mesorectal excision or clinical follow-up of patients selected for nonoperative treatment. RESULTS: A total of 118 patients were treated. Six patients were considered clinic complete responders (2 randomly assigned for surgery (1 ypT0N0 and 1 ypT2N0) and 4 patients randomly assigned for observation (3 sustained clinic complete response and 1 had tumor regrowth)). The 112 clinic incomplete responders underwent total mesorectal excision, and 18 revealed pathologic complete response. These 18 patients were not considered complete responders at restaging because they presented at least 1 of the following conditions: mucosal ulceration and/or deformity and/or substenosis of rectal lumen at digital rectal examination and colonoscopy (n = 16), ymrT1 to T4 (n = 16), ymrN+ (n = 2), involvement of circumferential resection margin on MRI (n = 3), extramural vascular invasion on MRI (n = 4), MRI tumor response grade 2 to 4 (n = 15), and pelvic side wall lymph node involvement on MRI (n = 1). Sensitivity for identification of ypT0N0 or sustained clinic complete response was 18.2%. LIMITATIONS: This study has a short follow-up and small sample size. Radiologists who reviewed the restaging examination were not blinded to the pretreatment stage. Only 1 radiologist read the images of each patient. CONCLUSIONS: Evaluation of clinic complete response according to current adopted criteria has low sensitivity because pathologic complete response more frequently presented as clinic incomplete response (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A221).

Cirurgia ambulatorial sob anestesia local em proctologia: experiência e análise do resultado de 503 operações / The outpatient surgery under local anesthesia at proctology: experience and analysis about the results of 503 operations

No período de outubro de 1992 a janeiro de 2000, quinhento e três pacientes portadores de doenças orificiais diversas foram submetidos a tratamento cirúrgico ambulatorial sob anestesia local. Em 49 intervenções cirúrgicas a anestesia foi realizada pela técnica do anzol (hook-needle puncture) e no restante, as anestesias foram realizadas pela clássica punçäo bilateral da regiäo anal.Doença hemorroidária, fístula, fissura, cisto pilonidal e condiloma anal foram as afecções mais freqüentes nesta casuística (85,8 por cento). A incidência global de complicações precoces e tardias foi, respectivamente, 16,1 por cento e 4,8 por cento. Dor intensa, durante o procedimento ou no pós-operatório, foi a complicaçäo mais freqüente, sendo relatada por 57 pacientes desta casuística (11,3 por cento). Cinco pacientes (1,0 por cento) necessitaram de internaçäo hospitalar para tratamento de complicações pós-operatórias. Quatrocentos e quarenta e dois pacientes (88 por cento) revelaram-se satisfeitos com o método empregado, referindo como principal vantagem do método o retorno precoce ao ambiente domiciliar, propiciando uma recuperaçäo mais confortável e com maior privacidade. Cada hemorroidectomia realizada em nível ambulatorial proporcionou uma economia de 170 dólares americanos quando comparado com o mesmo procedimento sob regime de internaçäo de um dia, ou seja, foi 31,5 por cento mais econômica. A cirurgia proctológica (orificial) ambulatorial sob anestesia local pode ser realizada com segurança e baixa morbidade, sendo uma boa alternativa para diminuiçäo dos custos hospitalares e liberaçäo de leitos para intervenções cirúrgicas mais complexas

Bowel preparation for colonoscopy: comparison of mannitol and sodium phosphate: results of a prospective randomized study

METHOD: Eighty patients were prospectively randomized for precolonoscopic cleansing either with 750ml of 10 percent mannitol (Group M) or 180ml of a sodium phosphate preparation (Group NaP). Laboratory examinations before and after preparation on all patients included hemoglobin, hematocrit, sodium, potassium, phosphorous, calcium and serum osmolarity. A questionnaire was used to assess undesirable side effects and patient tolerance to the solution. The quality of preparation was assessed by the endoscopist who was unaware of the solution employed. RESULTS: Statistically significant changes were verified in serum sodium, phosphorous, potassium and calcium between the two groups, but no clinical symptoms were observed. There were no significant differences in the frequency of side effects studied. Six of the eight patients in Group NaP who had taken mannitol for a previous colonoscopy claimed better acceptance of the sodium phosphate solution. The endoscopic-blinded trial reported excellent or good bowel preparation in 85 percent prepared with sodium phosphate versus 82.5 percent for mannitol (p=0.37). CONCLUSIONS: Quality of preparation and frequency of side effects was similar in the two solutions. The smaller volume of sodium phosphate necessary for preparation seems to be related to its favorable acceptance. Nevertheless, the retention of sodium and phosphate ions contraindicates the use of sodium phosphate in patients with renal failure, cirrhosis, ascites, and heart failure.

Cirurgia proctologica ambulatorial sob anestesia local: analise de 351 operacoes / Ambulatory anorectal surgery under local anesthesia: results in 351 procedures

Trezentos e vinte e oito pacientes portadores de doencas orificiais diversas foram submetidos a tratamento cirurgico ambulatorial sob anestesia local, sendo realizados um total de 351 procedimentos cirurgicos em um periodo de tres anos. Em 37 intervencoes cirurgicas a anestesia foi realizada pela tecnica do anzol (Hook-Needle puncture) e no restante, as anestesias foram realizadas pela classica puncao bilateral da regiao anal. Hemorroidas, fistulas, fissuras e cistos pilonidais foram as afeccoes mais frequentes nesta casuistica (71,6 por cento). A incidencia global de complicacoes precoces e tardias foi, respectivamente, 19,6 por cento e 4,8 por cento. Dor intensa, durante o procedimento ou no pos-operatorio, foi a complicacao mais frequente, sendo relatada por 53 pacientes desta casuistica (16,1 por cento)...

Cisto esplenico verdadeiro tratado por videolaparoscopia: relato de caso e revisao da literatura / A true splenic cyst treated by videolaparoscopy: case report and survey of the literature

Os cistos esplenicos verdadeiros nao parasitarios sao raros, sua real incidencia e dificil de ser estimada uma vez que mais de 30 por cento sao assintomaticos. O correto diagnostico desses cistos raramente e feito no pre-operatorio, sendo em muitos casos achado de exames. A esplenectomia parcial ou total e o tratamento de eleicao apos ser afastada a hidatidose esplenica, visto que respondem por dois tercos da incidencia mundial. Mais recentemente com os avancos tecnologicos ocorridos na cirurgia, especialmente na videolaparoscopia, alguns autores tem proposto a cistectomia parcial ou a esplenectomia por este metodo. Os autores apresentam caso de cisto esplenico verdadeiro (epidermoide) que foi ressecado por videolaparoscopia, e discutem aspectos relativos ao diagnotico, e a conduta empregada