Challenges in the diagnosis and treatment of inflammatory bowel disease in Latin America.

The incidence and prevalence of inflammatory bowel disease (IBD), namely Crohn's disease and ulcerative colitis, have increased in Latin America over the past few decades. Although incidence is accelerating in some countries in the region, other areas in Latin America are already transitioning into the next epidemiological stage-ie, compounding prevalence-with a similar epidemiological profile to the western world. Consequently, more attention must be given to the diagnosis and management of IBD in Latin America. In this Review, we provide an overview of epidemiology, potential local environmental risk factors, challenges in the management of IBD, and limitations due to the heterogenity of health-care systems, both public and private, in Latin America. Unresolved issues in the region include inadequate access to diagnostic resources, biological therapies, tight disease monitoring (including treat to target therapy, surveillance and prevention of complications, drug monitoring), and specialised IBD surgery. Local guidelines are an important effort to overcome barriers in IBD management. Advancements in long-term health-care policies will be important to promote early diagnosis, access to new treatments, and improvements in research in Latin America. These improvements will not only affect overall health care but will also lead to optimal prioritisation of IBD-related costs and resources and enhance the quality of life of people with IBD in Latin America.

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)

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.

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.

Overview of colorectal resections in a reference center in Curitiba - Brazil: experience with open and laparoscopic approach / Aspectos gerais da ressecção colorretal em centro de referência em Curitiba, Brasil: experiência com abordagens laparoscópica e a céu aberto

ABSTRACT Introduction: Minimally invasive approach has become the preferential option for the treatment of surgical diseases of the Gastrointestinal Tract, due to its numerous advantages. However, in the Colorectal Surgery field, the acceptance of videolaparoscopy was slower. For example, an American study showed that the percentage of laparoscopic cholecystectomy increased from 2.5% in 1988 to 73.7% in 1992, the rate of laparoscopic sigmoidectomy increased from 4.3% in 2000 to only 7.6% in 2004. Objecties: Our goal was to compare several variables between patients submitted to colorectal resections performed through open surgery or videolaparoscopy. Methods: This is a retrospective observational study performed in a Teaching Private Hospital of the City of Curitiba, Brazil, with the revision of 395 medical charts of patients subjected to colorectal resections from January 2011 through June 2016. Results: 349 patients were included in the study. 243 (69.6%) were subjected to laparoscopic colon resection (LCR) and 106 (30.4%) to open colon resection (OCR). Mean age was 62.2 years for patients undergoing LCR and 68.8 year for OCR (p = 0.0082). Among emergency procedures, 92.5% consisted of OCR and 7.5% were LCRs. Surgery duration was similar in both types of access (196 min in OCR versus 195 min in LCR; p = 0.9864). Diet introduction was earlier in laparoscopic surgery and anastomotic fistula rate was similar in both groups (OCR 7.5% and LCR 6.58%; p = 0.7438). Hospital stay was shorter in patients undergoing laparoscopic resections (7.53 ± 7.3 days) than in the ones undergoing open surgery (17.2 ± 19.3) (p < 0.001). In the OCR group, 70 patients needed ICU admission (66%), and stayed a mean of 12.3 days under intensive care. In the LCR group, however, only 30 needed ICU (12.3%), and the ones who needed it stayed a mean of 5.6 days (p < 0.001). Conclusions Videolaparoscopic approach is a safe and effective option in the treatment of colorectal diseases. Surgery duration and anastomotic fistula rates are similar to the open resections. Hospital stay and ICU stay durations, however, were shorter in patients submitted to laparoscopic colectomies.

RESUMO Introdução: Abordagens minimamente invasivas passaram a ser a opção preferencial para tratamento de doenças cirúrgicas do trato gastrointestinal, graças às suas numerosas vantagens. Contudo, no campo da cirurgia colorretal, a aceitação da videolaparoscopia foi mais lenta. Exemplificando, um estudo norte-americano demonstrou que o percentual de colecistectomias laparoscópicas aumentou de 2,5% em 1988 para 73,7% em 1992, enquanto que o percentual de sigmoidectomias laparoscópicas aumentou de 4,3% em 2000 para somente 7,6% em 2004. Objetivos: Nosso objetivo foi comparar diversas variáveis entre pacientes submetidos a ressecções colorretais realizadas por cirurgia a céu aberto, ou por videolaparoscopia. Métodos: Este é um estudo observacional retrospectivo realizado em um Hospital-Escola privado em Curitiba, Brasil, com revisão de 395 prontuários clínicos de pacientes submetidos a ressecções colorretais de janeiro de 2011 até junho de 2016. Resultados: 349 pacientes foram incluídos no estudo. 243 (69,6%) foram submetidos à ressecção laparoscópica de cólon por laparoscopia (RLC) e 106 (30,4%) foram tratados com ressecção de cólon a céu aberto (RCCA). A média de idade foi de 62,2 anos para os pacientes tratados com RLC e de 68,8 anos para RCCA (p = 0,0082). Entre os procedimentos de emergência, 92,5% dos pacientes foram tratados com RCCA e 7,5% com RLC. A duração da cirurgia foi similar para os dois tipos de acesso (196 min para RCCA versus 195 min para RLC; p = 0,9864). A introdução da alimentação ocorreu mais cedo nos pacientes tratados com a cirurgia laparoscópica, e o percentual de fístulas anastomóticas foi similar para os dois grupos (RCCA 7,5% e RLC 6,58%; p = 0,7438). A permanência no hospital foi mais curta para os pacientes tratados por ressecção laparoscópica (7,53 ± 7,3 dias) versus pacientes tratados com cirurgia a céu aberto (17,2 ± 19,3 dias) (p< 0,001). No grupo RCCA, 70 pacientes precisaram ser internados na UTI (66%), com permanência média de 12,3 dias em terapia intensiva. Mas no grupo RLC, apenas 30 pacientes necessitaram de internação na UTI (12,3%), e sua permanência em terapia intensiva foi de, em média, 5,6 dias (p < 0,001). Conclusões: A abordagem videolaparoscópica é opção segura e efetiva no tratamento de doenças colorretais. A duração da cirurgia e os percentuais de confecção de fístula anastomótica são similares ao observado nas ressecções a céu aberto. No entanto, a permanência no hospital e o tempo de permanência na UTI foram mais curtos para os pacientes tratados com colectomia laparoscópica.

Surgical Management of Solid Pseudopapillary Tumor of the Pancreas.

BACKGROUND AND OBJECTIVES: Although solid pseudopapillary tumor (SPT) of the pancreas is rare, its diagnosis has increased severalfold in the past decades. We present our experience in the management of SPT, including a patient who experienced tumor rupture during laparoscopy pancreatic resection. METHODS: Data on all patients with SPT who were subjected to surgical treatment were retrospectively obtained. RESULTS: Of 20 patients evaluated, 17 (85%) were females. The mean age was 31 years. Tumor size varied from 2.7 × 1.5 to 13.5 × 10.0 cm, with a mean of 6.4 × 7.6 cm. The most common location was the tail and/or body of the pancreas (14 patients [70%]). Pancreatic tumor resection was performed in 19 patients (50%). The type of resection depended on tumor location and size: distal pancreatectomy (n = 13), pancreatoduodenectomy (n = 5), and central pancreatectomy (n = 1) Pancreatic resection was performed via laparoscopy in 7 patients who underwent distal pancreatectomy. Tumor resection was not performed in only 1 patient (5%), due to invasion of mesenteric vessels and presence of liver metastases. One patient had tumor rupture during laparoscopic resection, with no apparent macroscopic dissemination of the tumor. All 19 patients who underwent SPT resection had no tumor recurrence, including a patient with capsule invasion and another patient with tumor rupture during surgical dissection. The mean follow-up time was 38 months (range, 6-72 months). CONCLUSION: Complete SPT resection is possible in most patients, with a low recurrence rate. Because of its large size, laparoscopic resection of SPT's should be performed only by experienced surgeons to avoid tumor rupture.