Association of fecal occult blood tests results with colonoscopic findings in a general hospital and validation of the screening test / Achados colonoscópicos em pacientes submetidos a exame de sangue oculto nas fezes e validacão deste teste de triagem

ABSTRACT Globally, colorectal cancer is the third leading cause of cancer death among men and the second among women, corresponding to about 10% of all cancers. The Brazilian Ministry of Health and National Cancer Institute recommend the screening of colorectal cancer for people over 50 years-old with Fecal Occult Blood Test. Endoscopy is limited to patients with positive screening results. The aim of this study is to evaluate the incidence of malignant or premalignant lesions diagnosed by endoscopy in patients with positive or negative Fecal Occult Blood Test and assess the efficacy of Fecal Occult Blood Test to predict the finding of a malignant colorectal lesion. We carried out a cross-sectional study among patients with a Fecal Occult Blood Test result that were submitted to colonoscopy, in the same hospital, from March 2016 to July 2017. Sensitivity, specificity, positive and negative predictive value of Fecal Occult Blood Test compared to colonoscopy neoplastic findings was calculated. The total of 92 patients were enrolled, 52 (56.5%) were female, Fecal Occult Blood Test was positive in 42.4% of them and in 41 (44.6%) the colonoscopy showed abnormal findings. Polyps were the most frequent alteration, found in 20 patients (21.7%). Among the patients with polyps, 15 (16.3%) had neoplastic and 5 (5.4%) presented non-neoplastic polyps. The Fecal Occult Blood Test sensitivity for detection of neoplastic polyps was 66.7%, specificity 62.3%, positive predictive value 11% and negative predictive value was 94.2%. Considering the need for a screening method, Fecal Occult Blood Test showed to be an effective and reliable screening test that can be applied in public health programs to detect and prevent colorectal cancer.

RESUMO Globalmente, o carcinoma colorretal é a terceira principal causa de morte por neoplasia entre homens e a segunda entre mulheres, correspondendo a 10% de todas as neoplasias. O Ministério da Saúde Brasileiro e o Instituto Nacional do Câncer recomendam a triagem do câncer colorretal para indivíduos acima de 50 anos, utilizando a Pesquisa de Sangue Oculto nas fezes. A endoscopia é reservada para aqueles com Pesquisa de Sangue Oculto nas fezes positiva. O objetivo deste estudo é avaliar a incidência de lesões malignas/pré-malignas diagnósticas na colonoscopia e correlacionar com os resultados prévios da Pesquisa de Sangue Oculto e verificar a eficácia da Pesquisa de Sangue Oculto para predizer uma lesão colorretal maligna. Realizamos um estudo transversal em pacientes que apresentavam resultados positivos ou negativos de Pesquisa de Sangue Oculto nas fezes e foram submetidos à colonoscopia, na mesma instituição, entre março de 2016 e julho de 2017. Dos 92 participantes; 52 (56,5%) eram do sexo feminino, a Pesquisa de Sangue Oculto nas fezes foi positiva em 42,4%; e em 41 (44,6%) a colonoscopia mostrou alterações. Em 20 pacientes (21,7%) havia pólipos; 15 (16,3%) eram neoplásicos e 5 (5,4%) não neoplásicos. A sensibilidade da Pesquisa de Sangue Oculto nas fezes para detecção de pólipos neoplásicos foi 66,7%; a especificidade 62,3%; o valor preditivo positivo 11% e o valor preditivo negativo 94,2%. Considerando a necessidade de um método de triagem, a Pesquisa de Sangue Oculto nas fezes mostrou ser um exame de triagem eficaz e confiável para ser aplicado em programas de saúde pública com o objetivo de detectar e prevenir o carcinoma colorretal.

Crohn's disease versus Yersinia enterocolitica infection - case report - a difficult differential diagnosis / Doença de Crohn's × Yersinia enterocolitica - um difícil diagnóstico diferencial - relato de caso

ABSTRACT The aim of this report is to present an unusual case of Crohn's disease affecting the terminal ileum; whose principal differential diagnosis was Yersinia enterolocolitica infection, as the histological features of the resected ileum was common to both diseases. We also describe how the infectious etiology was discarded and the implications for the patient follow-up.

RESUMO O objetivo desse relato é analisar um caso incomum de doença de Crohn, cujo diagnóstico diferencial, com possível infecção por Yersinia enterocilítica, foi dificultado pela presença de alterações histológicas das duas doenças. Descrevemos como foi realizada a exclusão de causas infecciosas e as implicações no acompanhamento do paciente.

Locally advanced colorectal cancer: results of surgical treatment and prognostic factors.

OBJECTIVES: To evaluate the incidence surgical results and prognostic factors of locally advanced colorectal cancer. METHODS: Cohort study including 679 colorectal cancer patients treated from 1997 to 2007. Clinical, surgical and histological data were analyzed. RESULTS: Ninety patients (females 61%; median age 59 years) were treated for locally advanced carcinomas (13.2%), either in the colon (66%) or rectum (34%). Extended resections most commonly involved the small bowel (19.8%), bladder (16.4%), uterus (12.9%) and ovaries (11.2%). Postoperative morbidity and mortality occurred in 23 (25.6%) and 3 (3.3%) patients, respectively. Survival and recurrence analysis among 76 R0 (84.4%) procedures revealed a 60% 5-year survival and 34% local recurrence rates. Survival curves demonstrated reduced rates for rectal location (45% vs 65%), tumor depth (50% for T4 vs 75% for T3), vascular/ lymphatic/perineural invasion (35% vs 80%) and lymph node metastasis (35% vs 80%). CONCLUSIONS: Locally advanced carcinomas were found in 13.2% of patients. Survival rates were negatively affected by rectal location and adverse histological features. Number of involved organs and neoplastic adhesions did not influenced chances of survival. A radical R0 extended resection was achieved in a high proportion of cases, resulting in a 60% cancer-free survival under acceptable operative risks.

Locally advanced colorectal cancer: results of surgical treatment and prognostic factors / Câncer colorretal localmente avançado: resultados do tratamento cirúrgico e fatores prognósticos

OBJECTIVES: To evaluate the incidence surgical results and prognostic factors of locally advanced colorectal cancer. METHODS: Cohort study including 679 colorectal cancer patients treated from 1997 to 2007. Clinical, surgical and histological data were analyzed. RESULTS: Ninety patients (females 61 percent; median age 59 years) were treated for locally advanced carcinomas (13.2 percent), either in the colon (66 percent) or rectum (34 percent). Extended resections most commonly involved the small bowel (19.8 percent), bladder (16.4 percent), uterus (12.9 percent) and ovaries (11.2 percent). Postoperative morbidity and mortality occurred in 23 (25.6 percent) and 3 (3.3 percent) patients, respectively. Survival and recurrence analysis among 76 R0 (84.4 percent) procedures revealed a 60 percent 5-year survival and 34 percent local recurrence rates. Survival curves demonstrated reduced rates for rectal location (45 percent vs 65 percent), tumor depth (50 percent for T4 vs 75 percent for T3), vascular/ lymphatic/perineural invasion (35 percent vs 80 percent) and lymph node metastasis (35 percent vs 80 percent). CONCLUSIONS: Locally advanced carcinomas were found in 13.2 percent of patients. Survival rates were negatively affected by rectal location and adverse histological features. Number of involved organs and neoplastic adhesions did not influenced chances of survival. A radical R0 extended resection was achieved in a high proportion of cases, resulting in a 60 percent cancer-free survival under acceptable operative risks.

OBJETIVOS: Avaliar a incidência, os resultados operatórios e os fatores prognósticos relacionados aos tumores colorretais localmente avançados. MÉTODOS: A população deste estudo foi constituída por 679 pacientes com câncer colorretal tratados entre 1997 e 2007. Dados clínicos, cirúrgicos e histológicos foram analisados. RESULTADOS: Noventa pacientes (mulheres 61 por cento; idade media 59 anos) foram tratados por câncer colorretal localmente avançados (13.2 por cento) no cólon (66 por cento) ou no reto (34 por cento). As ressecções alargadas mais frequentemente envolveram o intestino delgado (19.8 por cento), bexiga (16.4 por cento), útero (12.9 por cento) e ovários (11.2 por cento). Houve morbidade e mortalidade pós-operatórias em 23 (25.6 por cento) e 3 (3.3 por cento) pacientes, respectivamente. Análise de sobrevida e recidiva entre 76 ressecções R0 (84.4 por cento) mostraram sobrevida de 5 anos em 60 por cento e índice de recidiva local em 34 por cento. As curvas de sobrevida demonstraram índices menores para localização retal do tumor (45 por cento vs 65 por cento), grau de penetração (50 por cento para T4 vs 75 por cento para T3), invasão vascular, linfática ou perineural (35 por cento vs 80 por cento) e metástases linfonodais (35 por cento vs 80 por cento). CONCLUSÕES: Carcinomas localmente avançados foram diagnosticados em 13.2 por cento dos pacientes. Os índices de sobrevida foram negativamente afetados pela localização retal e fatores histológicos adversos. O número de órgãos envolvidos e aderências neoplásicas não influenciaram as chances de cura. Foi possível realizar ressecções alargadas R0 em grande proporção de casos, resultando em sobrevida livre de doença em 60 por cento dos doentes, em condições de risco cirúrgico aceitável.

Quality of life in the late follow-up of ulcerative colitis patients submitted to restorative proctocolectomy with sphincter preservation over ten years ago.

OBJECTIVE: To evaluate, by means of the Inflammatory Bowel Disease Questionnaire (IBDQ), the quality of life of ulcerative colitis patients submitted to proctocolectomy with sphincter preservation using J-pouch reconstruction over ten years ago. METHODS: The study consisted of 36 patients interviewed using the Inflammatory Bowel Disease Questionnaire. The score scale, resulting from the addition of each answer, ranged from 32 to 224, where the highest score indicates the best quality of life. The chi square test was used to verify the existence of meaningful differences between the results of the questionnaire and age, and gender proportion. For each section, as well as for all of them combined, the Kruskal-Wallis test was used to verify if there were differences in the Inflammatory Bowel Disease Questionnaire scores among the groups in relation to the proportions. RESULTS: After applying the Inflammatory Bowel Disease Questionnaire, it was determined that quality of life was considered excellent for 9 (25%), good for 11 (30.6%), regular for 13 (36.1%), and bad for 3 (8.3%) patients. In our study, we determined that 85% of the patients were pleased with and thankful for the surgery that they underwent. CONCLUSION: We can conclude that the possibility of sphincter preservation should always be taken into account, since patients remain clinically stable and have a high quality of life even after long periods.

Interação da gestação na atividade da doença inflamatória intestinal e sua influência sobre o prognóstico gestacional e na fecundidade / Interaction of pregnancy on inflammatory bowel disease activity and its influence on pregnancy outcome and fecundity

INTRODUÇÃO: A maioria das mulheres que desenvolvem doença inflamatória intestinal (DII) encontra-se em idade fértil, despertando preocupação dos médicos e mulheres no entendimento desta interação. Avaliamos a influência da DII sobre a fecundidade e gestação e vice- versa. MÉTODOS: Os protocolos de pacientes com doença de Crohn (DC) e retocolite ulcerativa (RC), de 1984 a 2006, em idade fértil, cadastrados no ambulatório de DII, foram revisados. Pacientes foram entrevistados para preenchimento de dados não encontrados nos protocolos. Outros tipos de colites, investigação incompleta, pacientes que não estavam em idade fértil ou sem capacidade cognitiva foram excluídos. Prematuridade, baixo peso ao nascer, anomalias congênitas, natimortalidade, abortamentos, tipos de partos, localização da doença na gestante e uso de medicamentos durante a gestação foram investigados. O método estatístico adotado foi o teste de qui- quadrado e Fisher, com nível de significância de 5 por cento. Nenhum paciente se recusou a participar desta pesquisa. RESULTADOS: 140 gestações em 104 pacientes com DII foram avaliados (RC em 63 gestações e DC em 77). Houve redução da fecundidade após o início dos sintomas relacionados à DII em 41,6 por cento, com influência da doença sobre a opção de não ter filhos em 20,6 por cento (10,3 por cento dos pacientes por medo da doença; 6,5 por cento por orientação médica e 2,2 por cento por más condições clínicas), sem diferenças entre DC e RC. A grande maioria não quis engravidar por já ter filhos, por ser solteira ou estar ter baixa idade (53,3 por cento). A atividade da RC não foi alterada durante a gestação na maioria das pacientes (77,8 por cento; p>0,003). A atividade da doença melhorou durante a gestação mais nas gestantes com DC do que nas com RC (p>0.0007). A incidência de prematuros, baixo peso ao nascer e natimortos foi maior quando todo o cólon estava acometido na RC (p< 0.037). A proporção estimada de prematuros e baixos...

INTRODUCTION: Most of women that develops inflammatory bowel disease (IBD) are in fertile age, concerning doctors and patients to understand this interaction. We evaluated the influence of IBD on fecundity and pregnancy and vice-versa. METHODS: the protocols of patients with Crohn's disease (CD) and ulcerative colitis (UC), from 1984 and 2006, in fertile age, followed at the outpatient clinic were reviewed. Patients were interviewed by the research medical doctor, to complete missing data not found in their protocols. Patients with others colitis, incomplete investigation, not in fertile age or without cognitive capacity were excluded from this study. Preterm delivery, low birth weight, congenital anomalies, stillbirth, miscarriages, types of delivery, disease topography in pregnant patients and drug administration during pregnancy were investigated. The statistic method adopted was the chi-square and Fisher test, with significance level of 5 percent. No patient refused to participate in this study. RESULTS: 140 pregnancies in 104 patients with IBD were evaluated (UC in 63 and CD in 77 pregnancies). : a reduction of 41.6 percent in fecundity was observed after beginning of symptoms related to IBD, with influence of the disease in 20.6 percent (10.3 percent of patients did not want to have children because of fear related to disease; 6.5 percent because of medical orientation and 2.2 percent for poor medical conditions). There was no difference between CD and UC. Most of patients did not want to become pregnant because they already had children, were "underage" or "alone" (53.3 percent) Most of pregnancies did not altered clinic conditions in UC patients (77.8 percent / p=0.003). Clinical conditions improved during pregnancies more in CD patients than UC patients (p=0.0007). The incidence of preterm delivery, low birth weight and stillbirth was higher when the whole colon was affected in UC (p < 0.037). The estimated rate of preterm delivery...

Rectal and pouch recurrences after surgical treatment for familial adenomatous polyposis.

BACKGROUND: Familial adenomatous polyposis (FAP) is a genetic disease characterized by multiple adenomatous colorectal polyps and different extracolonic manifestations (ECM). The present work is aimed to analyze the outcome after surgical treatment regarding complications and cancer recurrence. METHODS: Charts from patients treated between 1977 and 2006 were retrospectively analyzed. Clinical and endoscopic data, results of treatment, pathological reports and information about recurrence were collected. RESULTS: Eighty-eight patients (41 men [46.6%] and 47 women [53.4%]) were assisted. At diagnosis, associated colorectal cancer (CRC) was detected in 53 patients (60.2%), whose average age was higher than those without CRC (40.0 vs. 29.5 years). At colonoscopy, polyposis was classified as attenuated in 12 patients (14.3%). Surgical treatment consisted in total proctocolectomy with ileostomy (PCI, 15 [17.4%]), restorative proctocolectomy (RPC, 27 [31.4%]), total colectomy with ileal-rectum anastomosis (IRA, 42 [48.8%]), palliative segmental resection (1 [1.2%]) and internal bypass (1 [1.2%]). Two patients were not operated on due to religious reasons and advanced disease. Complications occurred in 25 patients (29.0%), more commonly after RPC (48.1%). There was no operative mortality. Local or distant metastases were detected in six (11.3%) patients with CRC treated to cure. During the follow-up of 36 IRA, cancer developed in the rectal cuff in six patients (16.6%), whose average age was higher than in patients without rectal recurrence (45.8 vs. 36.6 years). Five of them have had colonic cancer in the resected specimen. Among the 26 patients followed after RPC, cancer in the ileal pouch developed in 1 (3.8%). CONCLUSIONS: (1) Within the present series, FAP patients presented a high incidence of associated CRC and diagnosis was generally established after the third decade of life; (2) operative complications occurred in about one third of the patients, being more frequent after the confection of an ileal reservoir; (3) rectal cancer after IRA was detected in 16.6% of patients and it was associated with greater age and previous colonic carcinoma; (4) both continuous and long-term surveillance of the rectal stump and ileal pouch are necessary during follow-up.

Quality of life in the late follow-up of ulcerative colitis patients submitted to restorative proctocolectomy with sphincter preservation over ten years ago

OBJECTIVE: To evaluate, by means of the Inflammatory Bowel Disease Questionnaire (IBDQ), the quality of life of ulcerative colitis patients submitted to proctocolectomy with sphincter preservation using J-pouch reconstruction over ten years ago. METHODS: The study consisted of 36 patients interviewed using the Inflammatory Bowel Disease Questionnaire. The score scale, resulting from the addition of each answer, ranged from 32 to 224, where the highest score indicates the best quality of life. The chi square test was used to verify the existence of meaningful differences between the results of the questionnaire and age, and gender proportion. For each section, as well as for all of them combined, the Kruskal-Wallis test was used to verify if there were differences in the Inflammatory Bowel Disease Questionnaire scores among the groups in relation to the proportions. RESULTS: After applying the Inflammatory Bowel Disease Questionnaire, it was determined that quality of life was considered excellent for 9 (25 percent), good for 11 (30.6 percent), regular for 13 (36.1 percent), and bad for 3 (8.3 percent) patients. In our study, we determined that 85 percent of the patients were pleased with and thankful for the surgery that they underwent. CONCLUSION: We can conclude that the possibility of sphincter preservation should always be taken into account, since patients remain clinically stable and have a high quality of life even after long periods.

Videocirurgia colorretal com assistência robótica: o próximo passo? / Robotic assisted colorrectal surgery

O desenvolvimento de técnicas minimamente invasivas é um dos mais importantes avanços da cirurgia colorretal. A assistência robótica integra o arsenal de técnicas em cirurgia minimamente invasiva, e vem sendo aplicado em cirurgia colorretal por um restrito grupo de cirurgiões em alguns centros ao redor do mundo com resultados iniciais que merecem atenção. O objetivo do presente estudo é analisar os resultados do emprego da assistência robótica em videocirurgia colorretal. Dentre as vantagens associadas ao emprego de robôs em videocirurgia colorretal, figuram o incremento na precisão dos movimentos e a visão tridimensional. A experiência clínica é ainda pequena, e advém de uma série de casos e estudos comparativos com a videocirurgia colorretal sem assistência robótica com ainda pequeno número de casos. A dissecção pélvica com incremento da preservação autonômica parece ser a maior vantagem associada à assistência robótica em videocirurgia colorretal. Somente através do treinamento de um número mais representativo de cirurgiões colorretais, bem como com a expansão da experiência clínica será possível prever com maior precisão o papel da assistência robótica em videocirurgia colorretal.

The development of minimally invasive surgical techniques represents an important aspect of modern surgical research. Robot-assisted minimally invasive colorectal surgery represents a way of assisting laparoscopic colorectal procedures. Robotic technology overcomes some of these limitations by successfully providing intuitive motion and enhanced precision and accuracy, in an environment that is much more ergonomic. A restrict number of surgeons in specialized centers around the world have been applying robotics. In this review, current evidence about different technologies and its place in colorectal surgery is evaluated. The feasibility of performing robot-assisted colorectal operations has been demonstrated though case series and small case-controlled trials. The potential for enhancing autonomic nerve preservation during proctectomy may be the most remarkable advantage associated to robotic assistance during laparoscopic colorectal surgery. Colorectal surgeons should seize the opportunity to begin to use surgical robotic systems. Only through widespread surgeon training and increasing clinical experience with these systems, further technological developments, and continuous research, robotic technology will be routinely incorporated into surgical procedures on the colon and rectum.

Early rectal cancer: local excision or radical surgery?

BACKGROUND: Sphincter preservation, disease control, and long-term survival are the main goals in the treatment of rectal cancer. Although transanal local excision is attractive because it is a sphincter sparing procedure, some contradictory data exist in the literature about its ability to locally control disease and provide overall survival comparable with radical procedures, even for patients with early stage tumor. PURPOSE: To compare transanal local excision and radical surgery treatment results based on the appropriate data in literature. METHODS: We reviewed the literature to identify the current recurrence and survival rates of both techniques as well as the salvage surgery success. A PubMed search of the last 10 years was performed, and a total of 10 nonrandomized studies were identified; only 1 study was prospective, 5 were comparative, and 5 were case reports. RESULTS: Five-year overall survival rate varied from 69% to 83% in the local excision group versus 82% to 90% for the radical excision group. Local recurrence rates ranged from 9% to 20% for local excision and from 2% to 9% for radical surgery. Systemic recurrence rates ranged from 6% to 21% for local excision and from 2% to 9% for radical surgery. CONCLUSION: Radical surgery is the more definitive cancer treatment; however, it does not eliminate local excision as a reasonable choice for many patients, who will have lesser procedure-related morbidity and will accept an increased risk of tumor recurrence, a prolonged period of postoperative cancer surveillance, and a decreased success rate by salvage surgery.

Vesico-appendiceal fistula in a mucinous adenocarcinoma of the appendix / Fístula vésico-apendicular em adenocarcinoma mucinoso do apêndice

BACKGOUND: A rare case of vesicoappendiceal fistula secondary to mucinous adenocarcinoma of the appendix is presented. CASE REPORT: A 62-year-old man with a one year history of recurrent urinary tract infections. After two months he developed pneumaturia and fecaluria. An abdominal and pelvic computed tomography demonstrated a trans-mural mass in the posterior wall of the bladder with a vesicoenteric fistula leading to the terminal ileum. Laparotomy revealed a tumor arising from the appendix contiguous with the bladder posterior wall. The bladder was opened and a large fistula and tumor on the posterior bladder wall near the trigone was identified. Frozen pathological analysis showed a mucinous adenocarcinoma. En-bloc right hemicolectomy and partial cystectomy, preserving bladder trigone was performed. After manipulating the tumor, grossly leakage of mucinous materials occurred into the pelvic cavity. A peritoneal washing with a mytomicin solution at 42º C was then performed, to prevent peritoneal seeding. The patient had a prolonged postoperative ileus and was discharged at the 15th day. Five months after the procedure the patient was recieving chemotherapy with 5-fluoracil and leucovorin and there was no signs of recurrent disease. CONCLUSION: The presentation with vesico-appendiceal fistula is extremely rare with only a few cases reported in the literature. Knowledge of different types of neoplasm and appropriate treatment allows the surgeon to provide patients optimal care referring to specialized centers whenever appropriate.

INTRODUÇÃO: Apresenta-se raro caso de fístula vésico-apendicular secundária a adenocarcinoma mucinoso do apêndice. RELATO DE CASO: Paciente masculino de 62 anos com história de um ano de infecções urinárias de repetição. Após dois meses desenvolveu pneumatúria e fecalúria, sendo indicada tomografia computadorizada de abdômen que mostrou massa trans-mural na parede da bexiga, com fistula vésico-entérica para região do íleo terminal. A laparotomia revelou tumoração surgindo do apêndice cecal, em continuidade com a parede posterior da bexiga. A mesma foi aberta, sendo identificada grande fistula e material tumoral até próximo ao trígono vesical. A biópsia de congelação identificou adenocarcinoma mucinoso. Realizada hemicolectomia associada à cistectomia parcial em bloco, com preservação do trígono vesical. Houve extravasamento de mucina para a cavidade pélvica pela manipulação. Optado por lavagem peritoneal com solução de mitomicina a 42º C para prevenir disseminação peritoneal. O paciente evoluiu com íleo prolongado pós-operatório, tendo alta hospitalar no15º dia. Cinco meses após o procedimento encontrava-se em quimioterapia com 5-fluouracil e leucovorin, sem sinais de doença recidivante. CONCLUSÃO: A presença de fístula vésico-apendicecal é extremamente rara, tendo poucos casos relatados na literatura. O conhecimento dos diferentes tipos de neoplasias e seus tratamentos adequados permite ao cirurgião oferecer melhor cuidado ao paciente.

Manifestações extra-intestinais em doença de Crohn e retocolite ulcerativa: prevalência e correlação com o diagnóstico, extensão, atividade, tempo de evolução da doença / Extra-intestinal manifestations Crohn disease and ulcerative rectocolitis: prevalence na correlation with diagnosis, extension, activity, disease evolution time

INTRODUÇÃO: Existe uma grande prevalência de manifestações extra-intestinais(MEI) em portadores de doença de Crohn(DC) e de retocolite ulcerativa(RCU), variando de 24 a 65 por cento. OBJETIVO: Determinar a prevalência de MEI em RCU e DC, correlacionando com diagnóstico do tipo de doença inflamatória intestinal, extensão, tempo de evolução e atividade da doença. MÉTODOS: Mil pacientes foram avaliados no Hospital das Clínicas da FMUSP no período de 1984 a 2004. Foram estudadas manifestações articulares, dermatológicas, oftalmológicas, urológicas, hepáticas, pulmonares e vasculares. RESULTADOS: Foram estudados 468 pacientes com DC(46,8 por cento) e 532 com RCU(53,2 por cento). Encontrados 627 pacientes (59,2 por cento com RCU e 66,7 por cento com DC) com pelo menos uma forma de MEI. A média de tempo de doença dos pacientes com MEI foi de 10 anos. As MEI foram mais freqüentes após o início dos sintomas intestinais. CONCLUSÕES: Tanto na RCU quanto na DC,quanto maior a extensão da doença no cólon, maior a incidência de MEI. As manifestações urológicas foram mais freqüentes na DC. As manifestações articulares e dermatológicas foram mais prevalentes no sexo feminino nos dois grupos. Manifestações hepáticas foram mais prevalentes na DC. As manifestações articulares, dermatológicas e vasculares tiveram correlação com a atividade da doença intestinal em ambos os grupos.

INTRODUCTION: There is great prevalence of extra-intestinal manifestations (EIM) in Crohn's disease(CD) and ulcerative rectocolitis (UR), varying from 24 to 65 percent. AIM: To determine the prevalence of EIM in UR and CD, establishing a correlation with the diagnosis of the kind of intestinal inflammatory disease, extension, evolution time and disease activity. METHODS: One thousand patients were evaluated at the Hospital das Clínicas da FMUSP, along the 1984 to 2004 period. Articular, dermatological, ophthalmologic, urologic, hepatic, pulmonary and vascular manifestations were studied. RESULTS: 468 patients were studied with CD (46.8 percent) were studied and 532 with UR (53.2 percent). 627 patients found (59.2 percent with UR and 66.7 percent with CD) with at least one form of EIM. The average disease time of the EIM patients was of 10 years. EIM were more frequent after the beginning of the intestinal symptoms. CONCLUSIONS: Both in UR as in CD, the greater the extension of the disease in the colon, the greater is the EIM incidence. Urologic manifestations were more frequent in CD. Articular and dermatological manifestations were more prevalent in the feminine sex in both groups. Hepatic manifestations were more prevalent in CD. Articular, dermatological and vascular manifestations were related with the activity of the intestinal disease in both groups.

Prevenção e tratamento das complicações em operações colorretais / Prevention and treatment of complications in colorectal operations

As operações sobre o cólon e reto têm particularidades relacionadas às características clínicas dos doentes, às afecções intestinais e à flora bacteriana local exuberante. O presente artigo destina-se a revisar e discutir as medidas de prevenção e tratamento das complicações mais comuns após a realização de procedimentos colorretais, destacando aspectos importantes sobre o adequado preparo pré-operatório, emprego racional de antibioticoterapia, técnica cirúrgica apurada e na evolução pós-operatória. São discutidos as causas e o manuseio de complicações infecciosas, da obstrução intestinal, de complicações hemorrágicas, lesões iatrogênicas e complicações relacionadas aos estomas.

A videolaparoscopia no diagnóstico e tratamento da obstrução intestinal / Laparoscopic disgnosis and treatment of intestinal obstruction

A obstrução intestinal constitui complicação freqüente, de etiologia multifatorial, apresentação clínica variável e alta morbidade. Uma vez esgotados os recursos conservadores em casos específicos, a laparotomia exploradora é empregada para o diagnóstico final e tratamento em grande número de pacientes. Apesar do sucesso da via laparoscópica no manuseio de diversas afecções, a utilização desta via na abordagem inicial da obstrução do intestino delgado tem sido bastante limitada e alvo de numerosas críticas. Entretanto, o acúmulo de experiência com o método nos últimos anos, aliado ao avanço tecnológico e instrumental, têm permitido tratar número cada vez maior de pacientes obstruídos por meio do acesso laparoscópico. Assim, o surgimento de novos instrumentos como grampeadores laparoscópicos, pinças e trocáteres menos traumáticos ajudaram a tornar a videolaparoscopia factível e segura nestes pacientes. Neste artigo, os autores apresentam uma revisão sobre o papel da vídeo-cirurgia em casos selecionados de obstrução intestinal, ressaltando a contribuição dos métodos minimamente invasivos para o arsenal diagnóstico e terapêutico desta importante complicação.

Bowel obstruction is a frequent complication that exhibits variable clinical presentation and high morbidity. After conservative measures, laparotomy is performed for final diagnosis and treatment in a large number of patients. Besides the benefits of the laparoscopic approach in the management of many diseases, its use during the initial evaluation of bowel obstruction has been limited and has raised some criticism. However, experience with method and technological-instrumental advances in recent years has facilitated the treatment of a greater number of patients with obstruction. Thus, the development of new instruments such as laparoscopic staplers, less traumatic clamps and trocars had an important role in the feasibility and safety of the laparoscopic approach in this setting. In this article, the authors present a revision about the use of video-surgery in selected cases of intestinal obstruction, standing out the contribution of minimally invasive methods for the diagnosis and therapeutics of this important complication.

Colorectal cancer among patients aged 75 years or over.

BACKGROUND/AIMS: The aim of this study is to evaluate the risk factors for mortality, morbidity, and long-term survival in elderly patients with colorectal cancer when compared to younger patients. METHODOLOGY: Patients operated on with colorectal cancer were divided into 2 groups according to age: Group 1 (75 years old or older, n=90) and group 2 (<75 years, n=430). RESULTS: Preoperative hemoglobin levels were lower in group 1 (p = 0.008). Poorer clinical status defined by ASA score (p = 0.008) results and blood transfusions (p = 0.003) were more frequent in group 1 when compared to group 2. Group 1 had a significantly higher operative mortality rate than group 2 (p = 0.01). Regarding cancer-related survival after 1, 2, and 4 years, there was no significant difference between the 2 groups. CONCLUSIONS: Poorer clinical conditions with special regard to anemia are more frequent among patients of 75 years and older and this finding may lead to an increase in operative mortality when compared to younger patients. Even though, senior patients with colorectal cancer should not be denied surgical and adjuvant therapy on account of age alone since cancer-related survival remains comparable to younger patients' results.

A expressão de genes reparadores do DNA nos tumores sincrônicos de câncer colorretal esporádico / DNA repair gene expression in synchronic tumors of sporadic colorectal cancer

RACIONAL: Um dos mecanismos genéticos presentes em aproximadamente 80% dos pacientes com síndrome hereditária não-polipóide do câncer colorretal (HNPCC) são os defeitos nos genes reparadores de DNA, como o MSH2, MSH6 e MLH1, onde os tumores sincrônicos são relativamente freqüentes. Já no câncer colorretal esporádico as lesões sincrônicas são raras. OBJETIVO: Verificar se o mesmo mecanismo genético presente no HNPCC está presente no câncer colorretal esporádico que apresentam com lesões sincrônicas. MÉTODOS: Foram incluídos no estudo todos os pacientes com câncer colorretal sincrônico não HNPCC. Imunoistoquímica com anticorpos para MSH2,MSH6, e MLH1 foi realizada para cada tumor. RESULTADOS: Todos os pacientes apresentaram expressão normal de MSH2 e MLH1. O único gene com imunoexpressão alterada foi o MSH6. CONCLUSÃO: Possivelmente outro mecanismo genético seja responsável pelo surgimento de dois tumores sincrônicos no câncer colorretal esporádico.

BACKGROUND: Mismatch repair genes (such as MSH2, MLH1 and MSH6) mutations are present in over 80% of hereditary non-polyposis colorectal cancer (HNPCC) tumors, which frequently exhibit synchronous lesions. Sporadic colorectal cancer is rarely associated with synchronous lesions. AIM: To investigate the role of mismatch repair gene mutation in synchronous sporadic colorectal cancer. METHODS: Patients with sporadic synchronous colorectal adenocarcinomas were included in the study. Immunohistochemistry was performed using MSH2, MLH1 and MSH6 antibodies. RESULTS: All patients had two synchoronous lesions. None of them had altered MSH2 or MLH1 expression. One patient had altered MSH6 expression in both tumors. CONCLUSION: Possibly, other molecular mechanisms are involved in carcinogenesis of sporadic synchronous colorectal cancer.