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1.
Georgian Med News ; (306): 7-10, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33130637

RESUMO

The main treatment for muscle-invasive bladder cancer is radical cystectomy with creation of an artificial intestinal bladder with restoration of transurethral urination is recognized as the best method of urine derivation. Aim - to study the urodynamic features of the artificial bladder. The main study group consisted of 57 patients with invasive bladder cancer who underwent radical cystoprostatectomy with ileocystoplasty in several specialized centers. The artificial bladder, formed from the terminal ileum, shows the original results of an urodynamic study, not similar to the data obtained with various pathologies of the bladder. Patients with severe atony of the neobladder were noted, which potentiated chronic mycotic insufficiency with elements of obstruction and required periodic catheterization. Some patients whose main complaint was urinary incontinence in the daytime and at night, according to the KUDI, demonstrated elements of the lack of overactivity, which can also be the cause of incontinence and requires further study of pathogenetic features and possible correction methods.


Assuntos
Neoplasias da Bexiga Urinária , Coletores de Urina , Cistectomia , Humanos , Íleo/cirurgia , Masculino , Neoplasias da Bexiga Urinária/cirurgia , Urodinâmica
2.
Chirurgia (Bucur) ; 115(4): 493-504, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32876023

RESUMO

Introduction: The laparoscopic approach to right colectomy is gradually gaining a leading role in the surgical treatment of right colonic diseases. However, not all aspects of the procedure are standardized and the method of reconstruction of the digestive tract is still under debate. The present study critically evaluates the extracorporeal (EA) and intracorporeal (IA) techniques used for creation of the ileocolic anastomosis during a laparoscopic right colectomy. Material and Method: The EA and IA anastomotic techniques are described in detail. The peri operative data of a cohort of consecutive patients operated by our surgical team was retrospectively recorded and analyzed regarding type of anastomosis, the path for transition from EA to IA and the incidence of postoperative complications. Furthermore, an analysis of randomized clinical trials, reviews and meta-analyses that provided a comparative evaluation of EA versus IA was performed to provide a more in-depth integration of our own data into the literature. Results: EA was used at the beginning of our experience but was later replaced by IA which became the favorite anastomotic technique. There was no anastomotic fistula recorded in the EA or IA groups but in our cohort IA was unexpectedly associated with higher incidence of peritoneal drainage, prolonged ileus, surgical site infections, anastomotic bleeding and chyloperitoneum. However, IA allows better visualization of the ileal and colonic stumps, avoids twisting of the anastomosis, prevents extraction-related tearing of the mesocolon and reduces the risk of post operative hernia. Data from the literature also shows that IA is generally associated with earlier postoperative return of bowel function, less morbidity and less postoperative pain. Conclusions: Based on this study and the data currently present in the literature it can not be concluded that IA should be considered as the standard of care for laparoscopic right colectomy. The decision for an EA or IA anastomosis ultimately belongs to the surgeon and is influenced by his surgical skill and experience. The results of ongoing randomized controlled trials on large group of patients may bring more clarity on this issue in the future.


Assuntos
Anastomose Cirúrgica/normas , Colectomia/normas , Colo Ascendente/cirurgia , Neoplasias do Colo/cirurgia , Íleo/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/normas , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Colectomia/métodos , Humanos , Laparoscopia , Ensaios Clínicos Controlados Aleatórios como Assunto , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Estudos Retrospectivos , Resultado do Tratamento
4.
N Z Med J ; 133(1521): 102-105, 2020 09 04.
Artigo em Inglês | MEDLINE | ID: mdl-32994641

RESUMO

Foreign body ingestion is not uncommon in patients with mental disorders, alcohol intoxication and for purposes of drug trafficking. Small objects pass spontaneously; however, larger ones may get stuck in the oesophagus, stomach or at narrow areas of the bowel. 'Body packers' is a term used to describe persons who swallow or insert drug-filled packets into a body cavity. They are also called 'swallowers', 'internal carriers', 'couriers' or 'mules'. We report a 37-year-old previous drug abuser who presented with dysphagia. Upper GI endoscopy showed an oblong foreign body covered in plastic in the lower oesophagus. This could not be extracted and hence was pushed into the stomach. Three weeks later, he presented with bowel obstruction that was shown on abdominal radiograph and confirmed by CT indicating multiple dilated small bowel loops with a transition point in the terminal ileum where the ingested package was identified. The package was then removed through a longitudinal enterotomy. Ingested foreign bodies causing dysphagia should ideally be extracted endoscopically. If not possible, then a watch-and-wait policy may be justified. While most ingested objects pass spontaneously, unusual and larger ones may require surgical extraction. The contents, nature and reason for ingesting this strange object remain a mystery. With history of drug abuse and the consistent denial of knowingly swallowing that object, we can only conclude that the patient was trying to transport an illicit drug in the packet.


Assuntos
Corpos Estranhos , Obstrução Intestinal , Adulto , Transtornos de Deglutição/etiologia , Corpos Estranhos/complicações , Corpos Estranhos/diagnóstico por imagem , Corpos Estranhos/cirurgia , Humanos , Íleo/diagnóstico por imagem , Íleo/cirurgia , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Laparotomia , Masculino , Tomografia Computadorizada por Raios X
5.
Ann Surg ; 272(2): 210-217, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675483

RESUMO

OBJECTIVE: This trial aimed to provide randomized controlled data comparing Kono-S anastomosis and stapled ileocolic side-to-side anastomosis. BACKGROUND: Recently, a new antimesenteric, functional, end-to-end, hand-sewn ileocolic anastomosis (Kono-S) has shown a significant reduction in endoscopic recurrence score and surgical recurrence rate in Crohn disease (CD). METHODS: Randomized controlled trial (RCT) at a tertiary referral institution. Primary endpoint: endoscopic recurrence (ER) (Rutgeerts score ≥i2) after 6 months. Secondary endpoints: clinical recurrence (CR) after 12 and 24 months, ER after 18 months, and surgical recurrence (SR) after 24 months. RESULTS: In all, 79 ileocolic CD patients were randomized in Kono group (36) and Conventional group (43). After 6 months, 22.2% in the Kono group and 62.8% in the Conventional group presented an ER [P < 0.001, odds ratio (OR) 5.91]. A severe postoperative ER (Rutgeerts score ≥i3) was found in 13.8% of Kono versus 34.8% of Conventional group patients (P = 0.03, OR 3.32). CR rate was 8% in the Kono group versus 18% in the Conventional group after 12 months (P = 0.2), and 18% versus 30.2% after 24 months (P = 0.04, OR 3.47). SR rate after 24 months was 0% in the Kono group versus 4.6% in the Conventional group (P = 0.3). Patients with Kono-S anastomosis presented a longer time until CR than patients with side-to-side anastomosis (hazard ratio 0.36, P = 0.037). On binary logistic regression analysis, the Kono-S anastomosis was the only variable significantly associated with a reduced risk of ER (OR 0.19, P < 0.001). There were no differences in postoperative outcomes. CONCLUSIONS: This is the first RCT comparing Kono-S anastomosis and standard anastomosis in CD. The results demonstrate a significant reduction in postoperative endoscopic and clinical recurrence rate for patients who underwent Kono-S anastomosis, and no safety issues.ClinicalTrials.gov ID NCT02631967.


Assuntos
Anastomose Cirúrgica/efeitos adversos , Colectomia/métodos , Doença de Crohn/cirurgia , Endoscopia/efeitos adversos , Mesentério/patologia , Prevenção Secundária/métodos , Adulto , Idoso , Anastomose Cirúrgica/métodos , Colo/cirurgia , Doença de Crohn/diagnóstico , Endoscopia/métodos , Feminino , Seguimentos , Humanos , Íleo/cirurgia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Modelos de Riscos Proporcionais , Recidiva , Medição de Risco , Índice de Gravidade de Doença , Centros de Atenção Terciária , Resultado do Tratamento
7.
Lancet Gastroenterol Hepatol ; 5(10): 900-907, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32619413

RESUMO

BACKGROUND: The LIR!C trial showed that laparoscopic ileocaecal resection is a cost-effective treatment that has similar quality-of-life outcomes to treatment with infliximab, an anti-tumour necrosis factor (TNF) drug. We aimed to compare long-term outcomes of both interventions and identify baseline factors associated with the duration of treatment effect in each group. METHODS: In this retrospective follow-up study, we collected data from patients who participated in the LIR!C trial, a multicentre randomised controlled trial that compared quality of life after surgical resection versus infliximab in adult patients with non-stricturing and immunomodulator-refractory ileocaecal Crohn's disease. From Jan 1 to May 1, 2018, we collected follow-up data from the time from enrolment in the LIR!C trial until the last visit at either the gastrointestinal surgeon or gastroenterologist. In this study, outcomes of interest were need for surgery or repeat surgery or anti-TNF therapy, duration of treatment effect, and identification of factors associated with the duration of treatment effect. Duration of treatment effect was defined as the time without need for additional Crohn's disease-related treatment (corticosteroids, immunomodulators, biologics, or surgery). FINDINGS: We collected long-term follow-up data for 134 (94%) of 143 patients included in the LIR!C trial, of whom 69 were in the resection group and 65 were in the infliximab group. Median follow-up was 63·5 months (IQR 39·0-94·5). In the resection group, 18 (26%) of 69 patients started anti-TNF therapy and none required a second resection. 29 (42%) patients in the resection group did not require additional Crohn's disease-related medication, although 14 (48%) of these patients were given prophylactic immunomodulator therapy. In the infliximab group, 31 (48%) of 65 patients had a Crohn's disease-related resection, and the remaining 34 patients maintained, switched, or escalated their anti-TNF therapy. Duration of treatment effect was similar in both groups, with a median time without additional Crohn's disease-related treatment of 33·0 months (95% CI 15·1-50·9) in the resection group and 34·0 months (0·0-69·3) in the infliximab group (log-rank p=0·52). In both groups, therapy with an immunomodulator, in addition to the allocated treatment, was associated with duration of treatment effect (hazard ratio for resection group 0·34 [95% CI 0·16-0·69] and for infliximab group 0·49 [0·26-0·93]). INTERPRETATION: These findings further support laparoscopic ileocaecal resection as a treatment option in patients with Crohn's disease with limited (affected segment ≤40 cm) and predominantly inflammatory terminal ileitis for whom conventional treatment is not successful. FUNDING: None.


Assuntos
Ceco/cirurgia , Doença de Crohn/terapia , Íleo/cirurgia , Laparoscopia/métodos , Corticosteroides/uso terapêutico , Adulto , Ceco/patologia , Análise Custo-Benefício/métodos , Doença de Crohn/etiologia , Feminino , Seguimentos , Fármacos Gastrointestinais/uso terapêutico , Humanos , Íleo/patologia , Fatores Imunológicos/uso terapêutico , Infliximab/uso terapêutico , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Estudos Retrospectivos , Resultado do Tratamento , Fator de Necrose Tumoral alfa/antagonistas & inibidores
8.
Rev. cuba. cir ; 59(2): e911, abr.-jun. 2020.
Artigo em Espanhol | LILACS, CUMED | ID: biblio-1126420

RESUMO

RESUMEN Introducción: Las fístulas aorto-entéricas son una causa infrecuente de hemorragia digestiva. El pronóstico, generalmente ominoso, depende de una alta sospecha clínica y diagnóstico oportuno. Objetivo: Presentar el caso de una hemorragia digestiva por una fístula Aortoentérica diagnosticada y tratada. Presentación del caso: Se reporta el caso de un hombre de 72 años intervenido con el diagnóstico hemorragia digestiva masiva en el preoperatorio; sin embargo, el diagnóstico de la fístula se hizo en el intraoperatorio, sin observar dilatación aneurismática, pero si una aorta ateromatosa y un proceso inflamatorio hacia la fístula. Se realizó reparación quirúrgica urgente con reparación cara anterior aorta infrarrenal cercana a la bifurcación y resección del íleo terminal con ileoascendentostomía termino-lateral. Discusión: Las fístulas aorto-entéricas es una causa potencialmente fatal de hemorragia digestiva. El diagnóstico continúa siendo un desafío debido a su presentación inespecífica y siempre debiese ser considerado frente a una hemorragia digestiva sin causa aparente. Existen varias opciones para el enfrentamiento quirúrgico que deben ser analizadas caso a caso, sin retrasar la reparación. Conclusiones: La fístula aorto-entérica primaria es una causa poco frecuente de hemorragia digestiva, que todo médico y cirujano debe tener en cuenta frente a un paciente con sangrado digestivo de causa no precisada(AU)


ABSTRACT Introduction: Aortoenteric fistulas are a rare cause of gastrointestinal bleeding. The generally ominous prognosis depends on high clinical suspicion and timely diagnosis. Objective: To present a case of gastrointestinal hemorrhage for aortoenteric fistula diagnosed and treated. Case presentation: The case is reported of a 72-year-old man who received surgery after the diagnosis of massive gastrointestinal bleeding during the preoperative period. However, the diagnosis of the fistula was made intraoperatively, without observing aneurysmal dilation, but an atheromatous aorta and an inflammatory process leading to the fistula instead. Urgent surgical repair was performed with repair of anterior infrarenal aorta near the bifurcation and resection of the terminal ileum with end-to-side ascending ileostomy. Discussion: Aortoenteric fistulas are a potentially fatal cause for gastrointestinal bleeding. Diagnosis continues to be a challenge due to its nonspecific presentation and should always be considered for any case of unexplained gastrointestinal bleeding. There are several options for surgical management that must be analyzed case by case, without delaying repair. Conclusions: Primary aortoenteric fistula is a rare cause for gastrointestinal bleeding, which every doctor and surgeon must take into account when dealing with a patient with digestive bleeding of an unspecified cause(AU)


Assuntos
Humanos , Masculino , Idoso , Fístula/cirurgia , Hemorragia Gastrointestinal/diagnóstico por imagem , Íleo/cirurgia
9.
Arch. argent. pediatr ; 118(3): e338-e341, jun. 2020. ilus
Artigo em Espanhol | LILACS, BINACIS | ID: biblio-1117378

RESUMO

La invaginación intestinal ocurre cuando un segmento proximal de intestino se repliega dentro de la luz de un segmento distal adyacente y provoca obstrucción intestinal. Es una causa común de abdomen agudo en los dos primeros años de la vida, pero raro en niños mayores. Un varón de 16 años, con diagnóstico de fibrosis quística, se presentó con un cuadro compatible con síndrome de oclusión intestinal distal. Consultó a la clínica con dolor abdominal y una masa palpable en el hipocondrio derecho. Se realizó ecografía abdominal y tomografía de abdomen contrastada, que demostraron invaginación íleo-colónica con signos de isquemia intestinal, necrosis y neumatosis de la pared intestinal. Fue intervenido: se realizó resección del íleon terminal y hemicolon derecho, y se detectó una tumoración en ciego. La invaginación íleo-colónica es una causa rara de abdomen agudo en pacientes adolescentes con fibrosis quística y puede estar asociada a una causa orgánica subyacente.


Intestinal intussusception occurs when a proximal segment of the intestine telescopes into the lumen of an adjacent distal segment, causing intestinal obstruction. It is a common cause of acute abdomen in the first two years of life, but rare in older children. A 16-year-old male with a diagnosis of cystic fibrosis presented with symptoms compatible with distal intestinal occlusion syndrome. He came at the cystic fibrosis clinic with a 5-day evolution of abdominal pain and a palpable mass in the right hypochondrium. Abdominal ultrasound and abdominal contrasted tomography were performed demonstrating ileo-colonic invagination with signs of intestinal ischemia, necrosis and pneumatosis of the intestinal wall. He underwent surgery with resection of the terminal ileum and right hemicolon, ana tumor in the caecum was found. This is a rare cause of acute abdomen in young patients with cystic fibrosis and may be associated with an underlying organic cause.


Assuntos
Humanos , Masculino , Adolescente , Fibrose Cística , Intussuscepção/diagnóstico por imagem , Dor Abdominal , Íleo/cirurgia , Obstrução Intestinal , Intussuscepção/cirurgia
10.
Ann R Coll Surg Engl ; 102(8): e198-e201, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32538111

RESUMO

Colorectal cancer metastasis to the retroperitoneum, especially solitary metastasis allowing curative resection, is rare. We report a case of complete resection of retroperitoneal metachronous solitary metastasis from caecal cancer without distant metastasis. An 80-year-old woman with caecal cancer underwent laparoscopic ileocaecal resection with regional lymph node dissection. According to the eighth edition of the TNM classification, the pathological diagnosis was stage IIA (T3N0M0). Six months following the surgery, computed tomography revealed a solitary mass of 2cm diameter, dorsal to the right kidney. A second procedure for the removal of the tumour was performed. The lesion was pathologically diagnosed as a metachronous solitary retroperitoneal metastasis from caecal cancer. The patient is surviving and free from recurrence 17 months following the second procedure.


Assuntos
Neoplasias do Ceco/patologia , Ceco , Íleo , Neoplasias Retroperitoneais , Idoso de 80 Anos ou mais , Ceco/diagnóstico por imagem , Ceco/patologia , Ceco/cirurgia , Feminino , Humanos , Íleo/diagnóstico por imagem , Íleo/patologia , Íleo/cirurgia , Laparoscopia , Neoplasias Retroperitoneais/diagnóstico , Neoplasias Retroperitoneais/patologia , Neoplasias Retroperitoneais/secundário , Neoplasias Retroperitoneais/cirurgia
12.
Tunis Med ; 98(2): 164-167, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32395808

RESUMO

INTRODUCTION: Intestinal duplications are rare malformations and hail sites are the most common. Today, the diagnosis is made in antenatal because of the performances of antenatal ultrasound. OBSERVATION: This was a 15-month-old male infant received for constant crying, vomiting and increased abdominal volume that had been evolving for two weeks. An abdominal ultrasound was performed and objectified an intraperitoneal cyst formation of 30 x 27 mm, surrounded by a stratified wall and contiguous to a digestive loop. Surgery was performed and confirmed the existence of non-communicating ileal duplication. CONCLUSION: Intestinal duplication is a rare malformation. Ultrasound is often sufficient for diagnosis based on the presence of a characteristic double-walled cystic mass.


Assuntos
Abdome/patologia , Cistos/diagnóstico , Anormalidades do Sistema Digestório/complicações , Anormalidades do Sistema Digestório/diagnóstico , Íleo/anormalidades , Doenças Peritoneais/diagnóstico , Abdome/diagnóstico por imagem , Abdome Agudo/diagnóstico , Abdome Agudo/etiologia , Abdome Agudo/patologia , Abdome Agudo/cirurgia , Cistos/patologia , Diagnóstico Diferencial , Anormalidades do Sistema Digestório/cirurgia , Humanos , Íleo/cirurgia , Lactente , Masculino , Tamanho do Órgão , Doenças Peritoneais/patologia , Ultrassonografia , Vômito/diagnóstico , Vômito/etiologia , Vômito/cirurgia
13.
J Surg Res ; 252: 116-124, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32278965

RESUMO

BACKGROUND: Proximal (duodenal) small bowel adenocarcinomas have a worse prognosis than distal (jejuno-ileal) tumors, but differences in patient, tumor, and treatment factors between locations remain unclear. METHODS: Patients in the National Cancer Database with surgically resected pathologic stage I-IV small bowel adenocarcinomas between 2004 and 2015 were analyzed. Clinical stage IV patients were excluded. RESULTS: Proximal tumors (n = 3767) were more likely to be higher grade (OR 1.52, CI 1.22-1.85 for moderately; OR 1.83, CI 1.49-2.33 for poorly differentiated, P < 0.01 for both) and have positive lymph nodes (OR 2.04, CI 1.30-3.23, P < 0.01), while distal tumors (n = 3252) were likely to be larger (OR 1.31, CI 1.07-1.60 for size > 5 cm, P < 0.01). Proximal tumors were associated with worse overall survival (OS) and stage-specific survival compared with distal tumors (all P < 0.01). Cox regression analysis of the entire cohort showed worse survival with community versus academic cancer programs, higher comorbidity scores, pathologic stage IV, poorly differentiated histology, positive nodal or margin status, and proximal location, while female gender, larger tumor size, and chemotherapy predicted better survival. On separate Cox regression analyses of each location, neoadjuvant chemotherapy was associated with better OS in the proximal cohort (HR 0.70, CI 0.55-0.88, P < 0.01), while adjuvant chemotherapy was associated with better OS for both proximal (HR 0.49, CI 0.42-0.57, P < 0.01) and distal tumors (HR 0.68, CI 0.57-0.81, P < 0.01). CONCLUSIONS: Proximal small bowel adenocarcinomas are associated with worse overall and stage-specific survival. This may be due to tumor biologic differences as proximal tumors were more likely to have higher grade. Future studies should further investigate differences between proximal and distal tumors to guide targeted treatment algorithms.


Assuntos
Adenocarcinoma/mortalidade , Neoplasias Duodenais/mortalidade , Neoplasias do Íleo/mortalidade , Neoplasias do Jejuno/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Idoso , Quimiorradioterapia Adjuvante , Neoplasias Duodenais/patologia , Neoplasias Duodenais/terapia , Duodeno/patologia , Duodeno/cirurgia , Feminino , Humanos , Neoplasias do Íleo/patologia , Neoplasias do Íleo/terapia , Íleo/patologia , Íleo/cirurgia , Neoplasias do Jejuno/patologia , Neoplasias do Jejuno/terapia , Jejuno/patologia , Jejuno/cirurgia , Estimativa de Kaplan-Meier , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Terapia Neoadjuvante , Gradação de Tumores , Estadiamento de Neoplasias , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Taxa de Sobrevida , Resultado do Tratamento
14.
J Anim Sci ; 98(4)2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-32206780

RESUMO

In order to further increase the stability of the cannula behind the ribs and to facilitate cannula exteriorization in growing pigs, the present study aimed to evaluate whether elongation of the cannula flange could increase the stability of the cannula behind the ribs and to develop a tool to improve the exteriorization of the cannula through the ribs. Moreover, it was assessed whether a special skin protection paste and soft polyurethane foam material used in daily skin care could prevent erythema around the fistula. The feasibility of both, the modified simple T-cannula and daily skin care procedure, was evaluated in a digestibility experiment. Simple T-cannulae were made of high-molecular-weight polyethylene and inserted into the distal ileum of eight growing pigs (average body weight at surgery 30 kg). Modifications in the cannula design included a longer flange (11 cm) that was narrowed from the center to the ends and a bending of the flange to adapt it to the curve of the costal arch. In order to reduce the damage to the thread on the outer cannula barrel during surgery, a special surgical plug in conjunction with a screw thread on the inside of the barrel was developed. With respect to the daily cleaning of the fistula, a special skin protection paste was applied on the skin around the fistula to create a waterproof film that entirely sealed the skin. Additionally, foam material was inserted between the retaining ring and the skin to absorb the leaking digesta. Monitoring of the pigs throughout the trial showed that modifications in cannula design proved to be useful as they facilitated exteriorization of the cannula through the ribs and stability of the cannula behind the ribs. Moreover, the use of the skin protection paste and foam material during postsurgical treatment of growing pigs effectively prevented skin irritation around the flank area.


Assuntos
Cânula/veterinária , Cateterismo/veterinária , Íleo/cirurgia , Higiene da Pele/veterinária , Suínos/cirurgia , Ração Animal , Animais , Peso Corporal , Cateterismo/métodos , Digestão/fisiologia
15.
Am J Case Rep ; 21: e920384, 2020 Feb 14.
Artigo em Inglês | MEDLINE | ID: mdl-32054825

RESUMO

BACKGROUND Intestinal obstruction secondary to internal hernia is a rare phenomenon in adults particularly in patients with history of pulmonary tuberculosis, but commonly seen in pediatric population. Mostly it occurs along the duodenum in the paraduodenal recesses. The patient might be misdiagnosed as having obstruction secondary to strictures formed as a result of intestinal tuberculosis and pose delay in exploration. CASE REPORT We describe an adult patient who presented with intestinal obstruction by a tourniquet or ring formed between the tip of appendix and ileocecal junction through which small bowel herniated, strangulated and finally perforated before exploration, initially thought to be due to intestinal tuberculosis. He underwent exploratory laparotomy and was release of obstruction, appendectomy and resection of bowel. The patient tolerated the procedure well and discharged in stable condition. CONCLUSIONS Intestinal obstruction due to internal hernia is rare in adults. Computed tomography abdomen can diagnose the condition; however, exploration of the abdomen can give the definite diagnosis and tailor the appropriate therapy.


Assuntos
Apêndice/anormalidades , Apêndice/cirurgia , Hérnia/complicações , Íleo/cirurgia , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Apendicectomia , Constrição Patológica , Herniorrafia , Humanos , Laparotomia , Masculino , Adulto Jovem
16.
Dis Colon Rectum ; 63(4): 504-513, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32015288

RESUMO

BACKGROUND: Outcomes after total abdominal colectomy with ileosigmoid or ileorectal anastomosis for Crohn's colitis and risk factors for requirement of a permanent ileostomy remain poorly understood, particularly in the biologic era. OBJECTIVE: This study aimed to determine long-term ostomy-free survival after ileosigmoid or ileorectal anastomosis for Crohn's colitis and potential risk factors for requirement of an ileostomy. DESIGN: This is a retrospective cohort study. SETTING: This study was conducted at a single-institution IBD tertiary referral center. PATIENTS: Patients diagnosed with Crohn's disease and undergoing ileosigmoid or ileorectal anastomosis between 2006 and 2018 were selected. MAIN OUTCOME MEASURE: Long-term ostomy-free survival and hazard ratios of potential predictors of ileostomy requirement were the primary outcomes measured. RESULTS: One hundred nine patients (56% female) underwent ileosigmoid or ileorectal anastomosis for Crohn's disease. The majority of surgical procedures were completed in 2 or 3 stages (53%). The indication for total abdominal colectomy was predominantly medically refractory disease (77%), with dysplasia the second leading indication (13%). At an overall mean follow-up of 3 years, 16 patients had undergone either proctectomy or diversion with the rectum in situ. This resulted in ostomy-free survival estimates at 5 and 10 years of 78% (95% CI, 68-90) and 58% (95% CI, 35-94). A positive distal microscopic margin was the only risk factor for later requirement of a permanent ileostomy (HR, 5.4; 95% CI, 1.7-17.2). LIMITATIONS: This study is limited because it is a retrospective study at a tertiary referral center. CONCLUSIONS: Long-term ostomy-free survival can be achieved in the majority of patients who undergo restoration of intestinal continuity after total abdominal colectomy for Crohn's colitis. A positive distal microscopic margin was independently associated with long-term anastomotic failure, and it should be accounted for when risk stratifying patients for postoperative prophylactic medical therapy. See Video Abstract at http://links.lww.com/DCR/B111. ¿QUÉ FACTORES ESTÁN ASOCIADOS CON LA EVENTUAL NECESIDAD DE UNA ILEOSTOMÍA DESPUÉS DE UNA COLECTOMÍA ABDOMINAL TOTAL Y UNA ANASTOMOSIS ILEOSIGMOIDEA O ILEORRECTAL PARA LA COLITIS DE CROHN EN LA ERA BIOLÓGICA?: Los resultados después de la colectomía abdominal total con anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo para el requerimiento de una ileostomía permanente siguen siendo poco conocidos, particularmente en la era biológica.Determinar la supervivencia a largo plazo sin ostomía después de una anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo potenciales para la necesidad de una ileostomía.Estudio de cohorte retrospectivo.Centro de referencia de tercel nivel para enfermedad inflamatoria intestinal de una sola institución.Pacientes diagnosticados con enfermedad de Crohn y sometidos a anastomosis ileosigmoidea o ileorrectal entre 2006 y 2018Supervivencia a largo plazo sin ostomías y cocientes de riesgo de predictores potenciales de requerimiento de ileostomía109 pacientes (56% mujeres) se sometieron a anastomosis ileosigmoidea o ileorrectal por enfermedad de Crohn. La mayoría de los procedimientos quirúrgicos se completaron en 2 o 3 etapas (53%). La indicación de colectomía abdominal total fue predominantemente enfermedad médicamente refractaria (77%), con displasia la segunda indicación principal (13%). En un seguimiento medio general de 3 años, 16 pacientes se habían sometido a una proctectomía o a una derivación con el recto in situ. Esto dio como resultado estimaciones de supervivencia sin ostomía a los 5 y 10 años de 78% (intervalo de confianza del 95%: 68-90) y 58% (intervalo de confianza del 95%: 35-94), respectivamente. Un margen microscópico distal positivo fue el único factor de riesgo para el requerimiento posterior de una ileostomía permanente (razón de riesgo: 5.4; intervalo de confianza del 95%, 1.7-17.2).Estudio retrospectivo en un centro de referencia de tercer nivel.La supervivencia a largo plazo sin ostomía se puede lograr en la mayoría de los pacientes que se someten a la restauración de la continuidad intestinal después de la colectomía abdominal total por colitis de Crohn. Un margen microscópico distal positivo se asoció de forma independiente con la insuficiencia anastomótica a largo plazo, y debe tenerse en cuenta cuando se trata de pacientes con estratificación de riesgo para el tratamiento médico profiláctico postoperatorio. Consulte Video Resumen en http://links.lww.com/DCR/B111.


Assuntos
Colectomia/efeitos adversos , Colo Sigmoide/cirurgia , Doença de Crohn/terapia , Ileostomia/métodos , Íleo/cirurgia , Complicações Pós-Operatórias/cirurgia , Reto/cirurgia , Adulto , Anastomose Cirúrgica/métodos , Produtos Biológicos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos
17.
Dis Colon Rectum ; 63(3): 357-364, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32045400

RESUMO

BACKGROUND: Ileocolectomy is the most common surgery performed for Crohn's disease, and postoperative complications occur frequently. There has been minimal evaluation of complications after ileocolectomy as a function of both clinical and genetic factors. OBJECTIVE: The purpose of this study was to evaluate both genetic and clinical factors associated with complications after Crohn's ileocolectomy. DESIGN: This was a retrospective clinical and genetic cohort study. SETTINGS: This study was conducted at a high-volume tertiary care center. PATIENTS: We identified 269 patients with Crohn's disease who had undergone 287 ileocolectomies at our institution between July 2008 and October 2018. MAIN OUTCOME MEASURES: We measured the association of complications with a combination of clinical factors and 6 Crohn's-associated single nucleotide polymorphisms in NOD2 (rs2076756, rs2066844, and rs2066845), IRGM (rs4958847 and rs13361189), and ATG16L1 (rs2241880). RESULTS: There were 86 ileocolectomies of 287 (30%) with complications requiring intervention. The single nucleotide polymorphism rs13361189 in the gene IRGM was significantly associated with complications on univariate and multivariate analysis. There were 61 patients with a variant at the rs13361189 single nucleotide polymorphism and 26 of them had complications, although only 55 of the 208 wild-type patients had complications (43% vs 26%; OR = 2.1; p = 0.02). Other significant factors associated with complication after ileocolectomy were open surgery, placement of a proximal ileostomy, and a greater perioperative decrease in hematocrit. LIMITATIONS: This study was limited by its retrospective design and inherent selection bias. CONCLUSIONS: In addition to clinical risk factors, the rs13361189 single nucleotide polymorphism in the IRGM gene was independently associated with complications after ileocolectomy for Crohn's disease. The use of such genetic determinants may identify patients at increased risk for surgical complications after ileocolectomy. See Video Abstract at http://links.lww.com/DCR/B124. FACTORES CLÍNICOS Y GENÉTICOS ASOCIADOS CON COMPLICACIONES DESPUÉS DE LA ILEOCOLECTOMÍA DE CROHN: La ileocolectomía es la cirugía más común realizada para la enfermedad de Crohn y con frecuencia ocurren complicaciones postoperatorias. Ha habido una evaluación mínima de complicaciones después de la ileocolectomía, en función de factores clínicos y genéticos.Evaluar factores genéticos y clínicos asociados con complicaciones, después de la ileocolectomía por Crohn.Estudio retrospectivo de cohorte clínico y genético.Este estudio se realizó en un centro de atención terciaria de alto volumen.Identificamos a 269 pacientes con enfermedad de Crohn, sometidos a 287 ileocolectomías en nuestra institución, entre julio de 2008 y octubre de 2018.La asociación de complicaciones con una combinación de factores clínicos y seis polimorfismos de un solo nucleótido asociados a Crohn en NOD2 (rs2076756, rs2066844 y rs2066845), IRGM (rs4958847 y rs13361189) y ATG16L1 (rs2241880).Hubieron 86 ileocolectomías en 287 (30%) pacientes con complicaciones que requirieron intervención. El polimorfismo de un solo nucleótido rs13361189 en el gen IRGM se asoció significativamente con complicaciones en el análisis univariado y multivariado. Hubieron 61 pacientes con una variante en el polimorfismo de un solo nucleótido rs13361189 y 26 de ellos tuvieron complicaciones, mientras que solo 55 de los 208 pacientes de tipo salvaje (WT) tuvieron complicaciones (43% vs 26%, OR 2.1, p = 0.02). Otros factores significativos asociados con las complicaciones después de la ileocolectomía fueron, la cirugía abierta, la colocación de una ileostomía proximal y una mayor disminución perioperatoria del hematocrito.Este estudio estuvo limitado por su diseño retrospectivo y sesgo de selección inherente.Además de los factores de riesgo clínicos, el polimorfismo de un solo nucleótido rs13361189 en el gen IRGM se asoció independientemente con complicaciones después de la ileocolectomía, para la enfermedad de Crohn. El uso de tales determinantes genéticos puede identificar a los pacientes con mayor riesgo de complicaciones quirúrgicas, después de la ileocolectomía. Consulte Video Resumen en http://links.lww.com/DCR/B124.


Assuntos
Colectomia , Doença de Crohn/genética , Doença de Crohn/cirurgia , Proteínas de Ligação ao GTP/genética , Íleo/cirurgia , Complicações Pós-Operatórias/genética , Adulto , Proteínas Relacionadas à Autofagia/genética , Feminino , Humanos , Masculino , Proteína Adaptadora de Sinalização NOD2/genética , Pennsylvania , Polimorfismo de Nucleotídeo Único , Estudos Retrospectivos , Fatores de Risco
18.
Updates Surg ; 72(2): 325-333, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32048178

RESUMO

Ulcerative colitis (UC) is a chronic inflammatory disorder of poorly understood aetiology. While medical treatment is first-line management, approximately 10% of patients with UC will require a colectomy either as an emergency or elective procedure. There are multiple surgical options available in the current era and the choice of operation(s) is highly dependent on the clinical presentation, patient preference and individual surgeon or institutional practice. We present a review of modern surgical practices in ulcerative colitis, addressing some current controversies and diversities.


Assuntos
Colectomia/métodos , Colectomia/tendências , Colite Ulcerativa/cirurgia , Endoscopia Gastrointestinal/métodos , Laparoscopia/métodos , Proctocolectomia Restauradora/métodos , Anastomose Cirúrgica/métodos , Anastomose Cirúrgica/tendências , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos do Sistema Digestório/tendências , Emergências , Endoscopia Gastrointestinal/tendências , Humanos , Íleo/cirurgia , Laparoscopia/tendências , Proctocolectomia Restauradora/tendências , Reto , Grampeamento Cirúrgico/métodos , Grampeamento Cirúrgico/tendências
19.
J Gastroenterol Hepatol ; 35(9): 1503-1508, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32003060

RESUMO

BACKGROUND AND AIM: Intubation of the terminal ileum (TI) demonstrates a complete colonoscopy, but its clinical value during screening exams is unknown. We aimed to determine whether TI intubation during screening colonoscopy is associated with colonoscopy quality measures or identifies subclinical pathology. METHODS: We performed a retrospective cohort study examining average-risk screening colonoscopies performed at an academic health system between July 2016 and October 2017. Data were extracted from an internal colonoscopy quality registry and the electronic health record. Appropriate statistical tests were used for group comparisons, to correlate TI intubation rate (TIIR) with measures of colonoscopy quality and to examine factors associated with the likelihood of TI intubation. RESULTS: There were 7799 colonoscopies performed with adequate prep quality by 28 gastroenterologists. Most patients were female (56.4%) with a median age of 58. The median TIIR was 37.0%, with significant variability among physicians (2-93%). The detection rates for all polyps, adenomas, and sessile serrated polyps were 62.1%, 45.5%, and 7.2%, respectively, and none correlated with TIIR. Intubation of the TI was associated with significantly longer withdrawal times. In a random 10% sample of cases with TI intubation, no clinically significant pathology was found. CONCLUSIONS: There is wide variability in TIIR among endoscopists. Except to provide photodocumentation of exam extent when other images may be difficult to obtain, the lack of correlation between TI intubation and meaningful clinical outcomes together with the associated time costs suggest routine TI intubation during screening colonoscopy may not be warranted.


Assuntos
Adenoma/diagnóstico , Colonoscopia/métodos , Íleo/cirurgia , Neoplasias Intestinais/diagnóstico , Pólipos Intestinais/diagnóstico , Intubação/métodos , Programas de Rastreamento/métodos , Avaliação de Resultados em Cuidados de Saúde , Garantia da Qualidade dos Cuidados de Saúde , Qualidade da Assistência à Saúde , Idoso , Estudos de Coortes , Feminino , Humanos , Intubação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
20.
Ann R Coll Surg Engl ; 102(4): e1-e4, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31928361

RESUMO

While appendiceal intussusception is an uncommon pathological condition, mucinous cystadenoma of the appendix is a particularly rare entity. We report a case of appendiceal intussusception induced by a mucinous cystadenoma presenting as acute appendicitis. A 37-year-old woman was admitted with a one-day history of acute onset, right lower abdominal pain. Computed tomography showed swelling of the appendix, a pathological mass in the ileocolic region and oedematous pericolonic fat stranding. Emergency laparotomy via a McBurney incision revealed that the base of the appendix was swollen and intussuscepting into the caecum. Palpation of the caecum demonstrated an intraluminal mass, 6cm in size, at the appendicocaecal junction. After extension of the McBurney incision, a caecotomy was performed to investigate the mass, following which a cauliflower-like tumour started to protrude. En bloc excision was undertaken of both the appendix and the tumorous mass with a clear surgical margin to send for frozen section analysis. The biopsy samples indicated a mucinous neoplasm. Ileocaecal resection was therefore performed with ileocolic anastomosis. The resected specimen contained a tumour arising from the appendix. The tumour measured 5.3cm x 5cm x 3cm in the caecal cavity and the appendix had invaginated into the caecum at its base. The cut surface of the appendix showed the mucinous tumour projecting into the caecal cavity. Microscopic examination revealed a low grade mucinous cystadenoma.


Assuntos
Neoplasias do Apêndice/diagnóstico , Apendicite/diagnóstico , Colectomia , Cistadenoma Mucinoso/diagnóstico , Intussuscepção/cirurgia , Adulto , Neoplasias do Apêndice/complicações , Neoplasias do Apêndice/cirurgia , Apêndice/diagnóstico por imagem , Apêndice/patologia , Biópsia , Ceco/cirurgia , Cistadenoma Mucinoso/complicações , Cistadenoma Mucinoso/cirurgia , Diagnóstico Diferencial , Feminino , Humanos , Íleo/cirurgia , Intussuscepção/etiologia , Tomografia Computadorizada por Raios X
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