Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 5.176
Filtrar
1.
Wien Klin Wochenschr ; 132(1-2): 12-18, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31915925

RESUMO

BACKGROUND: The rate of restoration of intestinal continuity after colonic resection and stoma creation in patients with Crohn's disease has not been well-documented in the era of biologics. Thus, the incidence of restoration of intestinal continuity since the introduction of biological drugs was assessed. METHODS: Consecutive patients (n = 43) who underwent colonic resection with ileostomy or colostomy formation for Crohn's disease at a single tertiary referral center between 2002 and 2014 were identified. Data from individual chart review were analyzed retrospectively. Patients were personally contacted for follow-up. RESULTS: Of the 43 patients 8 (18.4%) had a proctectomy leaving 35 patients (81.4%) with the rectum preserved. Of the 30 patients qualifying for final analysis restoration of bowel continuity was finally achieved in 10 patients (33.3%). Permanent stoma rates were comparable in the group of patients with and without biological therapy after surgery (64.3% vs. 60%). The median follow-up period was 7 years (range 3-15 years). Of the patients 20 suffered from perianal disease involvement (66.7%), which was associated with a higher rate of permanent stoma (n = 16/20, 80%) in contrast to patients without perianal disease (n = 4/10, 40%, p = 0.045). CONCLUSION: The overall incidence of stoma formation was low for patients with Crohn's disease; however, once a stoma is created the chance of ending up with a permanent stoma is high even in the era of biologics. Despite the use of new therapeutic agents perianal disease increases the risk of a permanent stoma.


Assuntos
Terapia Biológica , Doença de Crohn , Colostomia , Doença de Crohn/tratamento farmacológico , Doença de Crohn/cirurgia , Feminino , Humanos , Ileostomia , Masculino , Estudos Retrospectivos
2.
Gut ; 69(2): 274-282, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31196874

RESUMO

OBJECTIVES: To better understand the real-world impact of biologic therapy in persons with Crohn's disease (CD) and ulcerative colitis (UC), we evaluated the effect of marketplace introduction of infliximab on the population rates of hospitalisations and surgeries and public payer drug costs. DESIGN: We used health administrative data to study adult persons with CD and UC living in Ontario, Canada between 1995 and 2012. We used an interrupted time series design with segmented regression analysis to evaluate the impact of infliximab introduction on the rates of IBD-related hospitalisations, intestinal resections and public payer drug costs over 10 years among patients with CD and 5 years among patients with UC, allowing for a 1-year transition. RESULTS: Relative to what would have been expected in the absence of infliximab, marketplace introduction of infliximab did not produce significant declines in the rates of CD-related hospitalisations (OR at the last observation quarter 1.06, 95% CI 0.811 to 1.39) or intestinal resections (OR 1.10, 95% CI 0.810 to 1.50), or in the rates of UC-related hospitalisations (OR 1.22, 95% CI 1.07 to 1.39) or colectomies (OR 0.933, 95% CI 0.54 to 1.61). The findings were similar among infliximab users, except that hospitalisation rates declined substantially among UC patients following marketplace introduction of infliximab (OR 0.515, 95% CI 0.342 to 0.777). There was a threefold rise over expected trends in public payer drug cost among patients with CD following infliximab introduction (OR 2.98,95% CI 2.29 to 3.86), suggesting robust market penetration in this group, but no significant change among patients with UC (OR 1.06, 95% CI 0.955 to 1.18). CONCLUSIONS: Marketplace introduction of infliximab has not yielded anticipated reductions in the population rates of IBD-related hospitalisations or intestinal resections, despite robust market penetration among patients with CD. Misguided use of infliximab in CD patients and underuse of infliximab in UC patients may largely explain our study findings.


Assuntos
Fármacos Gastrointestinais/uso terapêutico , Hospitalização/estatística & dados numéricos , Doenças Inflamatórias Intestinais/tratamento farmacológico , /uso terapêutico , Adulto , Colectomia/estatística & dados numéricos , Colectomia/tendências , Colite Ulcerativa/tratamento farmacológico , Colite Ulcerativa/epidemiologia , Colite Ulcerativa/cirurgia , Doença de Crohn/tratamento farmacológico , Doença de Crohn/epidemiologia , Doença de Crohn/cirurgia , Custos de Medicamentos/estatística & dados numéricos , Custos de Medicamentos/tendências , Feminino , Hospitalização/tendências , Humanos , Doenças Inflamatórias Intestinais/epidemiologia , Doenças Inflamatórias Intestinais/cirurgia , Análise de Séries Temporais Interrompida , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Fatores Socioeconômicos
3.
Medicine (Baltimore) ; 98(46): e17510, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31725605

RESUMO

Due to the complexity of Crohn's disease (CD), it is difficult to predict disease course with a single stratification factor or biomarker. A logistic regression (LR) model has been proposed by Guizzetti et al to stratify patients with CD-related surgical risk, which could help decision-making on disease treatment. However, there are no reports on relevant studies on Chinese population. The aim of the study is to present and validate a novel surgical predictive model to facilitate therapeutic decision-making for Chinese CD patients. Data was extracted from retrospective full-mode electronic medical records, which contained 239 CD patients and 1524 instances. Two sub-datasets were generated according to different attribute selection strategies, both of which were split into training and testing sets randomly. The imbalanced data in the training sets was addressed by synthetic minority over-sampling technique (SMOTE) algorithm before model development. Seven predictive models were employed using 5 popular machine learning algorithms: random forest (RF), LR, support vector machine (SVM), decision tree (DT) and artificial neural networks (ANN). The performance of each model was evaluated by accuracy, precision, F1-score, true negative (TN) rate, and the area under the receiver operating characteristic curve (AuROC). The result revealed that RF outperformed all other baseline models on both sub-datasets. The 10 leading risk factors for CD-related surgery returned from RF for attribute ranking were changes of radiology, presence of a fistula, presence of an abscess, no infliximab use, enteroscopy findings, C-reactive protein, abdominal pain, white blood cells, erythrocyte sedimentation rate and platelet count. The proposed machine learning model can accurately predict the risk of surgical intervention in Chinese CD patients, which could be used to tailor and modify the treatment strategies for CD patients in clinical practice.


Assuntos
Doença de Crohn/diagnóstico , Doença de Crohn/cirurgia , Técnicas de Apoio para a Decisão , Endoscopia do Sistema Digestório/estatística & dados numéricos , Modelos Anatômicos , Adulto , Algoritmos , Área Sob a Curva , Grupo com Ancestrais do Continente Asiático/estatística & dados numéricos , China , Árvores de Decisões , Feminino , Humanos , Modelos Logísticos , Aprendizado de Máquina/estatística & dados numéricos , Masculino , Valor Preditivo dos Testes , Curva ROC , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Máquina de Vetores de Suporte
4.
Surg Clin North Am ; 99(6): 1083-1094, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31676049

RESUMO

Patients with ulcerative colitis and Crohn's disease often present to surgery malnourished and on combination immunosuppression. These factors affect operation selection and postoperative outcomes. Corticosteroids have a well-established detrimental effect on postoperative outcomes, whereas the impact of biologic agents is more controversial. In a patient exposed to these medications, and in the presence of other risk factors, temporary intestinal diversion is likely the best choice. Enteral nutrition may help optimize malnourished patients at high risk of adverse postoperative outcomes.


Assuntos
Corticosteroides/uso terapêutico , Produtos Biológicos/uso terapêutico , Colectomia/métodos , Colite Ulcerativa/tratamento farmacológico , Doença de Crohn/tratamento farmacológico , Progressão da Doença , Tomada de Decisão Clínica , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/cirurgia , Doença de Crohn/diagnóstico , Doença de Crohn/cirurgia , Nutrição Enteral/métodos , Feminino , Humanos , Imunossupressores/uso terapêutico , Doenças Inflamatórias Intestinais/tratamento farmacológico , Doenças Inflamatórias Intestinais/cirurgia , Masculino , Desnutrição/terapia , Período Pré-Operatório , Prognóstico , Resultado do Tratamento
5.
Surg Clin North Am ; 99(6): 1095-1109, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31676050

RESUMO

Treatment of inflammatory bowel disease (IBD) is often multidimensional, requiring both medical and surgical therapies at different times throughout the course of the disease. Both medical and surgical treatments may be used in the acute setting, during a flare, or in a more elective maintenance role. These treatments should be planned as complementary and synergistic. Gastroenterologists and colorectal surgeons should collaborate to create a cohesive treatment plan, arranging the sequence and timing of various treatments. This article reviews the anticipated postoperative recovery after surgical treatment of IBD, possible postoperative complications, and considerations of timing surgery with medical therapy.


Assuntos
Colectomia/efeitos adversos , Colite Ulcerativa/cirurgia , Colostomia/efeitos adversos , Doença de Crohn/cirurgia , Anastomose Cirúrgica , Colectomia/métodos , Colite Ulcerativa/diagnóstico , Bolsas Cólicas/efeitos adversos , Colostomia/métodos , Doença de Crohn/diagnóstico , Feminino , Seguimentos , Humanos , Doenças Inflamatórias Intestinais/diagnóstico , Doenças Inflamatórias Intestinais/cirurgia , Masculino , Monitorização Fisiológica/métodos , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Recidiva , Medição de Risco , Fatores de Tempo
6.
Surg Clin North Am ; 99(6): 1111-1121, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31676051

RESUMO

Patients with inflammatory bowel disease are at an increased risk of cancer secondary to long-standing intestinal inflammation. Surgical options must take into account the significant risk of synchronous disease at other colonic sites. Ileal pouch anal anastomosis is a viable option for patients with ulcerative colitis, but this should be restricted to early cancers that are unlikely to require preoperative or postoperative radiation treatment.


Assuntos
Transformação Celular Neoplásica/patologia , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/patologia , Doenças Inflamatórias Intestinais/epidemiologia , Doenças Inflamatórias Intestinais/cirurgia , Lesões Pré-Cancerosas/patologia , Anastomose Cirúrgica , Colectomia/métodos , Colite Ulcerativa/epidemiologia , Colite Ulcerativa/patologia , Colite Ulcerativa/cirurgia , Neoplasias Colorretais/cirurgia , Comorbidade , Doença de Crohn/epidemiologia , Doença de Crohn/patologia , Doença de Crohn/cirurgia , Feminino , Humanos , Incidência , Doenças Inflamatórias Intestinais/patologia , Masculino , Lesões Pré-Cancerosas/epidemiologia , Prognóstico , Medição de Risco , Estomas Cirúrgicos , Análise de Sobrevida
7.
Surg Clin North Am ; 99(6): 1123-1140, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31676052

RESUMO

Elective abdominal surgery for inflammatory bowel disease is common. Surgery for Crohn's disease is not curative, and treatment must be individualized to the disease process. Surgery for ulcerative colitis generally is curative but consideration of patient-specific factors is important for staging of the procedure and determining whether ileal pouch-anal anastomosis is appropriate.


Assuntos
Colectomia/métodos , Colite Ulcerativa/cirurgia , Doença de Crohn/cirurgia , Procedimentos Cirúrgicos Eletivos/métodos , Anastomose Cirúrgica , Colite Ulcerativa/diagnóstico , Bolsas Cólicas , Doença de Crohn/diagnóstico , Feminino , Humanos , Doenças Inflamatórias Intestinais/diagnóstico , Doenças Inflamatórias Intestinais/cirurgia , Masculino , Proctocolectomia Restauradora/métodos , Prognóstico , Medição de Risco , Resultado do Tratamento
8.
Surg Clin North Am ; 99(6): 1209-1221, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31676059

RESUMO

Short bowel syndrome / intestinal failure (SBS/IF) is a rare and debilitating disease process that mandates a multidisciplinary approach in its management. Inflammatory bowel disease (IBD), in particular Crohn's disease (CD), predisposes patients to development of SBS/IF. This review discusses SBS/IF from the perspective of IBD, with an emphasis on prevention and treatment in the setting of CD. The aims of this review are to emphasize the unique treatment goals of the newly diagnosed SBS/IF patient, and highlight the role of both medical and surgical therapies in the management of IBD-related SBS/IF, including intestinal transplantation.


Assuntos
Doenças Inflamatórias Intestinais/cirurgia , Intestinos/transplante , Síndrome do Intestino Curto/etiologia , Síndrome do Intestino Curto/terapia , Colite Ulcerativa/complicações , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/cirurgia , Tratamento Conservador/métodos , Doença de Crohn/complicações , Doença de Crohn/diagnóstico , Doença de Crohn/cirurgia , Feminino , Humanos , Doenças Inflamatórias Intestinais/complicações , Doenças Inflamatórias Intestinais/patologia , Masculino , Prognóstico , Recuperação de Função Fisiológica , Reoperação/métodos , Medição de Risco , Síndrome do Intestino Curto/fisiopatologia
9.
Dis Colon Rectum ; 62(11): 1371-1380, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31596763

RESUMO

BACKGROUND: Patients with Crohn's disease are at increased risk of postoperative venous thromboembolism. Historically, extended outpatient prophylaxis has not met conventional measures of societal cost-benefit advantage. However, extended prophylaxis for patients with Crohn's disease may be more cost-effective because of the patients' high thrombotic risk and long life expectancy. OBJECTIVE: This study aimed to assess the cost-effectiveness of extended prophylaxis in patients with Crohn's disease after abdominal surgery. DESIGN: A decision tree model was used to assess the incremental cost-effectiveness and cost per case averted with extended-duration venous thromboembolism prophylaxis following abdominal surgery. SETTING: The risk of a postdischarge thrombotic event, age at surgery, type of thrombotic event, prophylaxis risk reduction, bleeding complications, and mortality were estimated by using existing published sources. PATIENTS: Studied were patients with Crohn's disease versus routine care. INTERVENTION: We constructed a decision analysis to compare costs and outcomes in patients with Crohn's disease postoperatively with and without extended prophylaxis over a lifetime horizon. MAIN OUTCOME MEASURES: Productivity costs ($) and benefits (quality-adjusted life-year) were used to reflect a societal perspective and were time discounted at 3%. Multivariable probabilistic sensitivity analysis accounted for uncertainty in probabilities, costs, and utility weights. RESULTS: With the use of reference parameters, the individual expected societal total cost of care was $399.83 without and $1387.95 with prophylaxis. Preventing a single mortality with prophylaxis would cost $43.00 million (number needed to treat: 39,839 individuals). The incremental cost was $1.90 million per quality-adjusted life-year. Adjusting across a range of scenarios upheld these conclusions 88% of the time. With further sensitivity testing, subpopulations with postdischarge thrombosis rates greater than 4.9% favors postoperative extended-duration venous thromboembolism prophylaxis. LIMITATIONS: Further investigation is needed to determine if specific high-risk individuals can be preemptively identified in the Crohn's surgical population for targeted prophylaxis. CONCLUSION: Extended prophylaxis in patients with Crohn's disease postoperatively is not cost-effective when the cumulative incidence of posthospital thrombosis remains less than 4.9%. These findings are driven by the low absolute risk of thrombosis in this population and the considerable cost of universal treatment. See Video Abstract at http://links.lww.com/DCR/A998. LIMITACIONES DE COSTO-BENEFICIO DE LA PROFILAXIS AMBULATORIA PROLONGADA DEL TROMBOEMBOLISMO VENOSO DESPUÉS DE CIRUGÍA EN CASOS DE ENFERMEDAD DE CROHN:: Los pacientes con enfermedad de Crohn tienen un mayor riesgo de tromboembolismo venoso postoperatorio. Históricamente, la profilaxis ambulatoria prolongada no ha cumplido con las medidas convencionales de ventajas en costo-beneficio para la sociedad. Sin embargo, la profilaxis prolongada en los pacientes con Crohn puede ser más rentable debido al alto riesgo trombótico y a una larga esperanza de vida en estos pacientes.Evaluar la rentabilidad de la profilaxis prolongada en pacientes postoperados de un Crohn.Se utilizó un modelo de árbol de decisión para evaluar el incremento de rentabilidad y el costo por cada caso evitado con la profilaxis prolongada de tromboembolismo venoso después de cirugía abdominal.Se calcularon utilizando fuentes publicadas el riesgo de evento trombótico posterior al alta, la edad del paciente al momento de la cirugía, el tipo de evento trombótico, la reducción del riesgo de profilaxis, las complicaciones hemorrágicas y la mortalidad.Se estudiaron los pacientes de atención rutinaria versus aquellos portadores de Crohn.Construimos un arbol de análisis decisional para comparar costos y resultados de pacientes portadores de Crohn, con y sin profilaxis prolongada en el postoperatorio en un horizonte de por vida.Los costos de productividad ($) y los beneficios (año de vida ajustado por calidad) se utilizaron para reflejar la perspectiva social y se descontaron en el tiempo de un 3%. El análisis de sensibilidad probabilística multivariable dió cuenta de la incertidumbre en las probabilidades, costos y peso de utilidades.Usando parámetros de referencia, el costo total social esperado de la atención individual fue de $ 399.83 sin y $ 1,387.95 con profilaxis. La prevención del deceso de un paciente con profilaxis costaría $ 43.00 millones (valor requerido para tratar: 39,839 individuos). El costo incrementado fue de $ 1.90 millones por año de vida ajustado por la calidad. El ajuste a través de una gama de escenarios confirmó estas conclusiones el 88% del tiempo. Con pruebas de sensibilidad adicionales, las subpoblaciones con tasas de trombosis posteriores al alta fueron superiores al 4,9% y favorecían la profilaxis prolongada del tromboembolismo venoso en el postoperatorio.Se necesita más investigación para determinar si se puede identificar de manera preventiva los individuos específicos de alto riesgo en la población quirúrgica de Crohn en casos de profilaxis dirigida.La profilaxis prolongada en pacientes postoperados de un Crohn no es rentable cuando la incidencia acumulada de trombosis posthospitalaria sigue siendo inferior al 4,9%. Estos hallazgos son impulsados por el bajo riesgo absoluto de trombosis en esta población y el costo considerable del tratamiento universal. Vea el resumen del video en http://links.lww.com/DCR/A998.


Assuntos
Quimioprevenção , Colectomia/efeitos adversos , Doença de Crohn/cirurgia , Complicações Pós-Operatórias , Tromboembolia Venosa , Quimioprevenção/economia , Quimioprevenção/métodos , Colectomia/métodos , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Risco Ajustado , Prevenção Secundária/economia , Prevenção Secundária/métodos , Estados Unidos , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/prevenção & controle
10.
Dis Colon Rectum ; 62(12): 1505-1511, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31580261

RESUMO

BACKGROUND: Controversy in performing hemorrhoidectomy and anal skin tag excision in patients with IBD stems from dated reports of nonhealing wounds resulting in proctectomy. OBJECTIVE: This study aimed to determine the safety of interventional management of hemorrhoids or anal skin tags in patients with Crohn's disease or ulcerative colitis. DESIGN: This study is a retrospective review of patient records from 2000 to 2017. SETTING: The patient records were retrieved from a multistate health system. PATIENTS: Adult patients with IBD undergoing interventional management of hemorrhoids or skin tags were included. MAIN OUTCOME MEASURE: The primary outcome measured was the long-term requirement of proctectomy. RESULTS: Ninety-seven patients (n = 49 Crohn's disease, 48 ulcerative colitis) underwent interventional management of hemorrhoids or anal skin tags (n =35 rubber band ligation, 27 anal skin tag excision, 21 hemorrhoidectomy, 14 excision/incision of thrombosed hemorrhoid). Thirty-day complications were observed in 5 patients (n = 4 urinary retention, 1 perianal abscess). Five patients with Crohn's disease eventually required proctectomy at a median of 7 years after skin tag excision (range, 6 months to 10 years), but none were secondary to impaired wound healing. Two patients with ulcerative colitis who had previously undergone IPAA were subsequently diagnosed with Crohn's disease of the pouch after skin tag excision. No other long-term complications were seen in patients with ulcerative colitis. LIMITATIONS: The study's retrospective design does not allow identification of patients with IBD who underwent only medical management of their hemorrhoids. There is also selection bias in which patients were selected for interventional management of their disease. CONCLUSIONS: The requirement for proctectomy after hemorrhoidectomy/skin tag excision appears to be secondary to the natural disease course of perianal Crohn's disease rather than perianal intervention. Selective hemorrhoidectomy and skin tag excision in patients with well-controlled luminal disease should be considered. See Video Abstract at http://links.lww.com/DCR/B55. HEMORROIDECTOMÍA ASOCIADA A LA EXCISIÓN DE PLICOMAS EN CASOS DE ENFERMEDAD INFLAMATORIA INTESTINAL: ¿ANUNCIO DE FATALIDAD O SIMPLEMENTE EVOLUCIÓN NATURAL DE LA ENFERMEDAD?: Está controvertida la realización de una hemorroidectomía asociada a la excisión de plicomas ano-cutáneos en pacientes con enfermedad inflamatoria intestinal, así lo han demostrado informes detallados sobre la no cicatrisación de las heridas conllevando a una proctectomía.Determinar los margenes de seguridad en casos de tratamiento instrumental de hemorroides asociadas a la excisión de plicomas ano-cutáneos en pacientes portadores de colitis ulcerosa o enfermedad de Crohn.Revisión retrospectiva de historias clinicas de pacientes entre 2000 y 2017.Servicio Multiestatal de Salud.Adultos con enfermedad inflamatoria intestinal sometidos a tratamiento instrumental de hemorroides asociado a la excisión de plicomas ano-cutáneos.Requisitos a largo plazo para una proctectomía.Noventa y siete pacientes (49 con enfermedad de Crohn, 48 con colitis ulcerosa) se sometieron a un tratamiento instrumental de hemorroides asociada a la excisión de plicomas ano-cutáneos (35 ligadura con bandas elásticas, 27 excisión de plicomas ano-cutáneos, 21 hemorroidectomías, 14 excisiones / incisiones de hemorroides trombosadas) Se observaron complicaciones a los 30 días en cinco pacientes (4 con retención urinaria, 1 absceso perianal). Cinco pacientes con enfermedad de Crohn requirieron proctectomía en una media de 7 años después de la excisión de los plicomas ano-cutáneos (rango, 6 meses a 10 años), pero ninguno fue secundario a la mala cicatrización de la herida. Dos pacientes con colitis ulcerosa que previamente se habían sometido a una anastomosis colo-anal protegia por ilestomía fueron diagnosticados posteriormente con enfermedad de Crohn localizada en la ostomía después de la excisión de plicomas ano-cutáneos. No se observaron complicaciones a largo plazo en pacientes con colitis ulcerosa.El diseño retrospectivo del estudio no permite la identificación de pacientes con enfermedad inflamatoria intestinal que se sometieron únicamente al tratamiento médico de las hemorroides. También existe un sesgo de selección de pacientes escogidos para tratamiento instrumental de la enfermedad hemorroidaria.El requisito de proctectomía después de la hemorroidectomía / excisión de plicomas anocutáneos parece ser secundario al curso de la enfermedad natural de la enfermedad de Crohn perianal en el sitio de la intervención perianal. Se debe considerar la hemorroidectomía selectiva y la excisión de plicomas ano-cutáneos solo en pacientes con enfermedad endoluminal controlada. Vea el video del resumen en http://links.lww.com/DCR/B55.


Assuntos
Colite Ulcerativa/complicações , Doença de Crohn/complicações , Hemorroidas/cirurgia , Pele/patologia , Adulto , Colite Ulcerativa/cirurgia , Doença de Crohn/cirurgia , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Feminino , Hemorroidectomia/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Protectomia , Estudos Retrospectivos , Tempo para o Tratamento , Adulto Jovem
11.
Dis Colon Rectum ; 62(11): 1352-1362, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31567927

RESUMO

BACKGROUND: The evidence regarding the association of preoperative biologic exposure and postoperative outcomes remains controversial for both antitumor necrosis factor agents and vedolizumab and largely unknown for ustekinumab. OBJECTIVE: The purpose of this study was to determine differences in the rates of 30-day postoperative overall infectious complications and intra-abdominal septic complications among the 3 classes of biologic therapies as compared with no biologic therapy. DESIGN: This was a retrospective review. SETTINGS: The study was conducted at an IBD referral center. PATIENTS: Adult patients with Crohn's disease who received an antitumor necrosis factor, vedolizumab, ustekinumab, or no biologic therapy within 12 weeks of a major abdominal operation between May 20, 2014, and December 31, 2017, were included. MAIN OUTCOMES MEASURES: Thirty-day overall postoperative infectious complications and intra-abdominal septic complications were measured. RESULTS: A total of 712 patients with Crohn's disease were included; 272 patients were exposed to an antitumor necrosis factor agents, 127 to vedolizumab, 38 to ustekinumab, and 275 to no biologic therapy within the 12 weeks before an abdominal operation. Patients exposed to a biologic were more likely to be taking a concurrent immunomodulator, but there was no difference in concurrent corticosteroid usage. The particular class of biologic was not independently associated with total overall infectious complications. Vedolizumab was associated with an increased rate of intra-abdominal sepsis on univariate analysis but not on multivariable analysis. Combination immunosuppression was associated with both an increased rate of overall postoperative infectious complications and intra-abdominal sepsis. LIMITATIONS: The study was limited by its retrospective design and single-center data. CONCLUSIONS: The overall rate of total infectious complications or intra-abdominal septic complications was not increased based on preoperative exposure to a particular class of biologic. Rates increased with combination immunosuppression of biologic therapy with corticosteroids and previous abdominal resection. See Video Abstract at http://links.lww.com/DCR/B24. BIOLÓGICOS Y COMPLICACIONES POSTOPERATORIAS DE 30 DÍAS DESPUÉS DE LAS OPERACIONES ABDOMINALES PARA LA ENFERMEDAD DE CROHN: ¿EXISTEN DIFERENCIAS EN LOS PERFILES DE SEGURIDAD?:: La evidencia sobre la asociación de la exposición biológica preoperatoria y los resultados postoperatorios sigue siendo controvertida controversial tanto para los agentes del factor de necrosis tumoral (anti-TNF) como para el vedolizumab, y en gran parte desconocida para el ustekinumab.Determinar las diferencias en las tasas de complicaciones infecciosas generales postoperatorias de 30 días y complicaciones sépticas intraabdominales entre las tres clases de terapias biológicas en comparación con ninguna terapia biológica.Revisión retrospectiva.centro de referencia de la enfermedad inflamatoria intestinal.Pacientes adultos con enfermedad de Crohn que recibieron un factor de necrosis antitumoral, vedolizumab, ustekinumab o ningún tratamiento biológico dentro de las 12 semanas de una operación abdominal mayor entre el 5/20/2014 y el 12/31/2017.Complicaciones infecciosas postoperatorias generales de 30 días, complicaciones sépticas intraabdominales.Se incluyeron setecientos doce pacientes con enfermedad de Crohn; 272 pacientes fueron expuestos a un anti-TNF, 127 a vedolizumab, 38 a ustekinumab y 275 a ninguna terapia biológica dentro de las 12 semanas previas a una operación abdominal. Los pacientes expuestos a un producto biológico tenían más probabilidades de tomar un inmunomodulador concurrente, pero no hubo diferencias en el uso simultáneo de corticosteroides. La clase particular de productos biológicos no se asoció de forma independiente con las complicaciones infecciosas totales. Vedolizumab se asoció con una mayor tasa de sepsis intraabdominal en el análisis univariable, pero no en el análisis multivariable. La inmunosupresión combinada se asoció tanto con una mayor tasa de complicaciones infecciosas postoperatorias generales como con sepsis intraabdominal.Diseño retrospectivo, datos de centro único.La tasa general de complicaciones infecciosas totales o complicaciones sépticas intraabdominales no aumentó en función de la exposición preoperatoria a una clase particular de productos biológicos. Las tasas aumentaron con la combinación de inmunosupresión de la terapia biológica con corticosteroides y resección abdominal previa. Vea el Resumen del Video en http://links.lww.com/DCR/B24.


Assuntos
Anticorpos Monoclonais Humanizados , Colectomia , Doença de Crohn , Infecções Intra-Abdominais , Complicações Pós-Operatórias , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Ustekinumab , Adulto , Anti-Inflamatórios/efeitos adversos , Anti-Inflamatórios/uso terapêutico , Anticorpos Monoclonais Humanizados/efeitos adversos , Anticorpos Monoclonais Humanizados/uso terapêutico , Produtos Biológicos/efeitos adversos , Produtos Biológicos/uso terapêutico , Colectomia/efeitos adversos , Colectomia/métodos , Doença de Crohn/tratamento farmacológico , Doença de Crohn/imunologia , Doença de Crohn/cirurgia , Monitoramento de Medicamentos/métodos , Feminino , Seguimentos , Humanos , Interleucina-12/antagonistas & inibidores , Interleucina-23/antagonistas & inibidores , Infecções Intra-Abdominais/diagnóstico , Infecções Intra-Abdominais/epidemiologia , Infecções Intra-Abdominais/etiologia , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Período Pré-Operatório , Estados Unidos , Ustekinumab/efeitos adversos , Ustekinumab/uso terapêutico
13.
Chirurgia (Bucur) ; 114(4): 487-493, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31511135

RESUMO

Introduction: Crohn disease (CD) has seen a steady increase in incidence over the years in Romania. Laparoscopy had a slow evolution as a feasible therapeutic option for patients with CD. Material and Method: The study is retrospective. The period on which the data was gathered spread over 8 years (01.01.2011-01.01.2019). Data was retrieved from three Clinical Hospitals in Bucharest, Romania Results: the preoperative diagnosis of an intestinal fistula (p = 0,02), sepsis (p = 0.01 ) or increased age should be regarded as a limitation for a laparoscopic approach in CD complications. Also in emergency settings an open approach should be the mainstay treatment (approach p = 0.000001). Conclusion: Laparoscopy is a feasible surgical option in the treatment of surgical complication in CD. In order to increase the safety of the intervention, correct selection of patients is important.


Assuntos
Doença de Crohn/epidemiologia , Doença de Crohn/cirurgia , Fatores Etários , Doença de Crohn/complicações , Humanos , Fístula Intestinal/epidemiologia , Fístula Intestinal/cirurgia , Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Seleção de Pacientes , Estudos Retrospectivos , Romênia/epidemiologia , Sepse/epidemiologia , Sepse/etiologia , Sepse/cirurgia , Resultado do Tratamento
14.
Cochrane Database Syst Rev ; 9: CD013210, 2019 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-31513295

RESUMO

BACKGROUND: Crohn's disease (CD) is a chronic disease of the gut. About 75% of people with CD undergo surgery at least once in their lifetime to induce remission. However, as there is no known cure for the disease, patients usually experience a recurrence even after surgery. Different interventions are routinely used in maintaining postsurgical remission. There is currently no consensus on which treatment is the most effective. OBJECTIVES: To assess the effects and harms of interventions for the maintenance of surgically induced remission in Crohn's disease and rank the treatments in order of effectiveness. SEARCH METHODS: We searched the Cochrane IBD Group Specialized Register, CENTRAL, MEDLINE, and Embase from inception to 15 January 2019. We also searched reference lists of relevant articles, abstracts from major gastroenterology meetings, ClinicalTrials.gov, and the WHO ICTRP. There was no restriction on language, date, or publication status. SELECTION CRITERIA: We considered for inclusion randomised controlled trials (RCTs) that compared different interventions used for maintaining surgically induced remission in people with CD who were in postsurgical remission. Participants had to have received maintenance treatment for at least three months. We excluded studies assessing enteral diet, diet manipulation, herbal medicine, and nutritional supplementation. DATA COLLECTION AND ANALYSIS: Two review authors independently selected relevant studies, extracted data, and assessed the risk of bias. Any disagreements were resolved by discussion or by arbitration of a third review author when necessary. We conducted a network meta-analysis (NMA) using a Bayesian approach through Markov Chain Monte Carlo (MCMC) simulation. For the pairwise comparisons carried out in Review Manager 5, we calculated risk ratios (RR) with their corresponding 95% confidence intervals (95% CI). For the NMA, we presented hazard ratios (HR) with corresponding 95% credible intervals (95% CrI) and reported ranking probabilities for each intervention. For the NMA, we focused on three main outcomes: clinical relapse, endoscopic relapse, and withdrawals due to adverse events. Data were insufficient to assess time to relapse and histologic relapse. Adverse events and serious adverse events were not sufficiently or objectively reported to permit an NMA. We used CINeMA (Confidence in Network Meta-Analysis) methods to evaluate our confidence in the findings within networks, and GRADE for entire networks. MAIN RESULTS: We included 35 RCTs (3249 participants) in the review. The average age of study participants ranged between 33.6 and 38.8 years. Risk of bias was high in 18 studies, low in four studies, and unclear in 13 studies. Of the 35 included RCTs, 26 studies (2581 participants; 9 interventions) were considered eligible for inclusion in the NMA. The interventions studied included 5-aminosalicylic acid (5-ASA), adalimumab, antibiotics, budesonide, infliximab, probiotics, purine analogues, sulfasalazine, and a combination of sulfasalazine and prednisolone. This resulted in 30 direct contrasts, which informed 102 mixed-treatment contrasts.The evidence for the clinical relapse network (21 studies; 2245 participants) and endoscopic relapse (12 studies; 1128 participants) were of low certainty while the evidence for withdrawal due to adverse events (15 studies; 1498 participants) was of very low certainty. This assessment was due to high risk of bias in most of the studies, inconsistency, and imprecision across networks. We mainly judged individual contrasts as of low or very low certainty, except 5-ASA versus placebo, the evidence for which was judged as of moderate certainty.We ranked the treatments based on effectiveness and the certainty of the evidence. For clinical relapse, the five most highly ranked treatments were adalimumab, infliximab, budesonide, 5-ASA, and purine analogues. We found some evidence that adalimumab (HR 0.11, 95% Crl 0.02 to 0.33; low-certainty evidence) and 5-ASA may reduce the probability of clinical relapse compared to placebo (HR 0.69, 95% Crl 0.53 to 0.87; moderate-certainty evidence). However, budesonide may not be effective in preventing clinical relapse (HR 0.66, 95% CrI 0.27 to 1.34; low-certainty evidence). We are less confident about the effectiveness of infliximab (HR 0.36, 95% CrI 0.02 to 1.74; very low-certainty evidence) and purine analogues (HR 0.75, 95% CrI 0.55 to 1.00; low-certainty evidence). It was unclear whether the other interventions reduced the probability of a clinical relapse, as the certainty of the evidence was very low.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing endoscopic relapse. Whilst there might be some evidence of prevention of endoscopic relapse with adalimumab (HR 0.10, 95% CrI 0.01 to 0.32; low-certainty evidence), no other intervention studied appeared to be effective.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing withdrawal due to adverse events. Withdrawal due to adverse events appeared to be least likely with sulfasalazine (HR 1.96, 95% Crl 0.00 to 8.90; very low-certainty evidence) and most likely with antibiotics (HR 53.92, 95% Crl 0.43 to 259.80; very low-certainty evidence). When considering the network as a whole, two adverse events leading to study withdrawal (i.e. pancreatitis and leukopenia) occurred in more than 1% of participants treated with an intervention. Pancreatitis occurred in 2.8% (11/399) of purine analogue participants compared to 0.17% (2/1210) of all other groups studied. Leukopenia occurred in 2.5% (10/399) of purine analogue participants compared to 0.08% (1/1210) of all other groups studied. AUTHORS' CONCLUSIONS: Due to low-certainty evidence in the networks, we are unable to draw conclusions on which treatment is most effective for preventing clinical relapse and endoscopic relapse. Evidence on the safety of the interventions was inconclusive, however cases of pancreatitis and leukopenia from purine analogues were evident in the studies. Larger trials are needed to further understand the effect of the interventions on endoscopic relapse.


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Doença de Crohn/prevenção & controle , Quimioterapia de Manutenção/métodos , Anti-Inflamatórios não Esteroides/uso terapêutico , Antimetabólitos/uso terapêutico , Doença de Crohn/tratamento farmacológico , Doença de Crohn/cirurgia , Humanos , Imunossupressores/uso terapêutico , Meta-Análise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Indução de Remissão , Prevenção Secundária
15.
Dis Colon Rectum ; 62(10): 1222-1230, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31490831

RESUMO

BACKGROUND: Surgical treatment of ileosigmoid fistulas in Crohn's disease is poorly characterized. OBJECTIVE: The purpose of this study was to identify differences in patient postoperative outcomes for isolated ileosigmoid fistulas by surgical approach (laparoscopic versus open) and sigmoid colon repair type (sigmoid resection versus primary repair). DESIGN: Using a prospectively collected database, we gathered perioperative data from chart reviews to calculate differences and associations between treatment groups. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients with Crohn's disease who underwent surgery for isolated ileosigmoid fistulas between July 1, 2010, and June 30, 2016 were included. RESULTS: We identified 84 patients, with an average age of 37 years. A total of 51 were men and 33 were women; 34 underwent a sigmoid resection, whereas 50 had a primary repair of the sigmoid. All of the patients underwent an ileocolic resection. A total of 67 surgeries were initially attempted laparoscopically, of which 17 (25.4%) were converted to open, with 50 (59.5%) completed laparoscopically. There were no significant differences in length of stay or incidence of postoperative complications by surgical approach (laparoscopic versus open). For patients who underwent a primary sigmoid repair versus a sigmoid resection, there were no significant differences in postoperative complications, but there was a significant difference in the length of stay (6.36 vs 9.56 d for primary repair versus resection; multivariate p value of 0.022). MAIN OUTCOME MEASURES: Postoperative complications and length of stay were measured. LIMITATIONS: The study was limited by its small sample size, cross-sectional nature of the data, and limited information about preoperative outpatient medical treatment. CONCLUSIONS: Laparoscopic surgery for isolated ileosigmoid fistulas in Crohn's disease is safe and does not result in a different length of stay or incidence of postoperative complications. Primary repair (rather than resection) of the sigmoid colon in these cases, when feasible, appears to be safe and is likely to be cost-effective given the reduced length of stay. See Video Abstract at http://links.lww.com/DCR/A993. TÉCNICAS QUIRÚRGICAS Y DIFERENCIAS EN LOS RESULTADOS POSTOPERATORIOS PARA LOS PACIENTES CON ENFERMEDAD DE CROHN CON FÍSTULAS ILEO-SIGMOIDEAS: UNA EXPERIENCIA EN UNA SOLA INSTITUCIÓN, 2010-2016: El tratamiento quirúrgico de las fístulas ileo-sigmoideas en la enfermedad de Crohn está mal caracterizado. OBJETIVO: Identificar las diferencias en los resultados postoperatorios de los pacientes para las fístulas ileo-sigmoideas aisladas por abordaje quirúrgico (laparoscópica versus abierta) y tipo de reparación de colon sigmoide (resección sigmoidea versus reparación primaria). DISEÑO:: Utilizando una base de datos recopilada de forma prospectiva, se recopilaron datos perioperatorios de las revisiones de los gráficos para calcular las diferencias y las asociaciones entre los grupos de tratamiento. AJUSTE: Un solo centro de atención terciaria. PACIENTES: Pacientes con enfermedad de Crohn que se sometieron a una cirugía para fístulas ileo-sigmoideas aisladas entre el 1 de julio de 2010 y el 30 de junio de 2016. RESULTADOS: Se identificaron 84 pacientes, con una edad promedio de 37 años. Un total de 51 eran hombres y 33 mujeres; 34 se sometieron a una resección sigmoidea, mientras que 50 tuvieron una reparación primaria del sigmoide. Todos los pacientes fueron sometidos a resección ileocólica. Inicialmente, un total de 67 círugias se intentaron por vía laparoscópica, de las cuales 17 (25,4%) se convirtieron en cirugías abiertas, y 50 (59,5%) se completaron por vía laparoscópica. No hubo diferencias significativas en la duración de la estancia o la incidencia de complicaciones postoperatorias por abordaje quirúrgico (laparoscópica versus abierta). Para los pacientes que se sometieron a una reparación sigmoidea primaria versus una resección sigmoidea, no hubo diferencias significativas en las complicaciones postoperatorias, pero sí hubo una diferencia significativa en la duración de la estancia hospitalaria (6,36 versus a 9,56 días para la reparación primaria frente a la resección; p multivariable -valor de 0.022). PRINCIPALES MEDIDAS DE RESULTADOS: Complicaciones postoperatorias y duración de la estancia. LIMITACIONES: Tamaño de muestra pequeño, naturaleza transversal de los datos e información limitada sobre el tratamiento médico ambulatorio preoperatorio del paciente. CONCLUSIONES: La cirugía laparoscópica para fístulas ileo-sigmoideas aisladas en la enfermedad de Crohn es segura y no ocasiona una duración diferente de la estancia hospitalaria ni una incidencia diferente de complicaciones postoperatorias. La reparación primaria (en lugar de la resección) del colon sigmoide en estos casos, cuando es posible, parece ser segura y es probable que sea rentable, dada la duración reducida de la estancia. Vea el Resumen del Video en http://links.lww.com/DCR/A993.


Assuntos
Colectomia/métodos , Doença de Crohn/cirurgia , Doenças do Íleo/cirurgia , Fístula Intestinal/cirurgia , Laparoscopia/métodos , Complicações Pós-Operatórias/epidemiologia , Doenças do Colo Sigmoide/cirurgia , Adulto , Doença de Crohn/complicações , Estudos Transversais , Feminino , Humanos , Doenças do Íleo/etiologia , Incidência , Fístula Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Doenças do Colo Sigmoide/etiologia , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
16.
J Laparoendosc Adv Surg Tech A ; 29(11): 1397-1404, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31414963

RESUMO

Aim: There is still no consensus on whether laparoscopic surgery can be routinely recommended as a safe approach for complex Crohn's disease (CD). Methods: PubMed, Embase, and Cochrane library databases were searched (up to February 2019). Comparative studies reporting laparoscopic surgery for complex CD (LC group) comparing with simple CD (LS group) were included. The outcomes were blood loss, operative time, conversion rate, length of hospital stay, postoperative complications, and reoperation rate within 30 days after surgery. Results: Thirteen retrospective studies with 1120 participants were included. The LC group has significantly more blood loss (weighted mean difference [WMD] 43.64 mL; 95% confidence interval (CI) 8.37-78.91; P = .020), longer operative time (WMD 17.59 minutes; 95% CI 6.38-28.81; P = .002), higher conversion rate (WMD 2.04%; 95% CI 1.43-2.91; P < .001), and longer length of hospital stay (WMD 0.86 day; 95% CI 0.53-1.19; P < .001). Overall postoperative complication rates (WMD 0.98; 95% CI 0.71-1.34; P = .90) did not differ significantly between the 2 groups. Conclusions: LC is safe and feasible with comparable postoperative complications, although there is a more blood loss, longer operative time, higher conversion rate, and longer length of hospital stay.


Assuntos
Doença de Crohn/complicações , Doença de Crohn/cirurgia , Laparoscopia , Perda Sanguínea Cirúrgica , Conversão para Cirurgia Aberta , Humanos , Laparoscopia/efeitos adversos , Tempo de Internação , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Reoperação , Resultado do Tratamento
17.
Cochrane Database Syst Rev ; 8: CD010233, 2019 08 06.
Artigo em Inglês | MEDLINE | ID: mdl-31425621

RESUMO

BACKGROUND: Crohn's disease (CD) is a chronic relapsing inflammatory condition and maintenance of remission is a major issue as many patients fail to achieve remission with medical management and require surgical interventions. Purine analogues such as azathioprine (AZA) and 6-mercaptopurine (6-MP) have been used to maintain surgically-induced remission in CD, but the effectiveness, tolerability and safety of these agents remains controversial. OBJECTIVES: To assess the efficacy and safety of purine analogues (AZA and 6-MP) for maintenance of surgically-induced remission in CD. SEARCH METHODS: We searched PubMed, MEDLINE, Embase, CENTRAL, and the Cochrane IBD Group Specialized Register from inception to 26 July 2018 (and from inception to 31 July 2019). In addition, we searched reference lists of all included studies and relevant reviews, conference proceedings and trials registers. SELECTION CRITERIA: Randomised controlled trials (RCTs) with a duration of at least three months that enrolled adults and children with surgically-induced remission of CD and compared AZA or 6-MP to no treatment, placebo or any other active intervention were considered for inclusion. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial eligibility, extracted data, assessed the risk of bias and assessed the certainty of the evidence using GRADE. The primary outcome was clinical relapse. Secondary outcomes included endoscopic relapse, radiologic and surgical relapse, adverse events (AEs), serious adverse events (SAEs), withdrawal due to AEs and health-related quality of life. MAIN RESULTS: Ten RCTs with a total of 928 participants were included. Study participants were adults recruited from university clinics and gastroenterology hospitals who received interventions post-surgery for a duration between 12 to 36 months. Most study participants were recruited less than three months after surgery in all except one study where participants were recruited between 6 to 24 months post-surgery. One study was rated as low risk of bias, six studies were rated high risk of bias and three were rated unclear risk of bias.There was moderate certainty evidence that purine analogues are more efficient for preventing clinical relapse than placebo. At 12 to 36 months, 51% (109/215) of AZA/6-MP participants relapsed compared to 64% (124/193) of placebo participants (RR 0.79; 95% CI 0.67 to 0.92; 408 participants; 3 studies; I² = 0%; moderate certainty evidence). The certainty of the evidence regarding the efficacy of AZA or 6-MP for maintaining postoperative clinical remission compared to 5-ASA compounds was low. At 12 to 24 months , 64% (113/177) of purine analogue participants relapsed compared to 59% (101/170) of 5-ASA participants (RR 1.05; 95% CI 0.89 to 1.24; 347 participants; 4 studies; I² = 8%; low certainty evidence). The certainty of evidence that purine analogues are inferior for preventing postsurgical clinical relapse compared to tumour necrosis factor alpha agents (anti-TNF-α) was very low. At 12 to 24 months, 43% (29/67) of AZA participants relapsed compared to 14% (10/72) of anti-TNF-α participants (RR 2.89; 95% CI 1.50 to 5.57; 139 participants; 3 studies; I² = 0%; very low certainty evidence).The effect of purine analogues compounds on AEs compared to placebo or any active treatment was uncertain, as the quality of evidence ranged from very low to low. After 12 to 24 months, 14% (12/87) of purine analogue participants experienced an AE compared to 10% (8/81) of placebo participants (RR 1.36; 95% CI 0.57 to 3.27; 168 participants; 2 studies; I² = 0%; low certainty evidence). The effect of purine analogues on AEs compared to 5-ASA agents was uncertain. After 12 to 24 months, 41% (73/176) of purine analogue participants had an AE compared to 47% (81/171) of 5-ASA participants (RR 0.89; 95% CI 0.74 to 1.07; 346 participants; 4 studies; I² = 15%; low certainty evidence). The effect of purine analogues on AEs in comparison to anti TNF-α agents was uncertain. At 12 to 24 months, 57% (32/56) of AZA participants had an AE compared to 51% (31/61) of anti-TNF-α participants (RR 1.13; 95% CI 0.83 to 1.53; 117 participants; 2 studies; I² = 0%; low certainty evidence). Purine analogue participants were more like than 5-ASA participants to have a SAE (RR 3.39, 95% CI 1.26 to 9.13, 311 participants; 3 studies; I² = 9%; very low certainty evidence), or to withdraw due to an AE (RR 2.21, 95% CI 1.28 to 3.81; 425 participants; 5 studies; I² = 0%; low certainty evidence). Commonly reported AEs across all studies included leucopenia, arthralgia, abdominal pain or severe epigastric intolerance, elevated liver enzymes, nausea and vomiting, pancreatitis, anaemia, nasopharyngitis and flatulence. AUTHORS' CONCLUSIONS: Moderate certainty evidence suggests that AZA and 6-MP may be superior to placebo for maintenance of surgically-induced remission in participants with CD. There was no clear difference in the number of clinical relapses when purine analogues were compared with 5-ASA agents, however this is based on low certainty evidence. There was very low certainty evidence that AZA and 6-MP are more likely to result in more serious adverse events (SAEs) and withdrawals due to an AE (low certainty) when compared to 5-ASA agents. Very low certainty evidence suggests that purine analogues may be inferior to anti-TNF-α agents, however, no firm conclusions can be drawn. Further research investigating the efficacy and safety of AZA and 6-MP in comparison to other active medications in surgically-induced remission of CD is warranted.


Assuntos
Azatioprina/uso terapêutico , Doença de Crohn/tratamento farmacológico , Imunossupressores/uso terapêutico , Quimioterapia de Manutenção/métodos , Mercaptopurina/uso terapêutico , Doença de Crohn/prevenção & controle , Doença de Crohn/cirurgia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Indução de Remissão/métodos , Prevenção Secundária
18.
Surgery ; 166(4): 670-677, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31420214

RESUMO

BACKGROUND: The aim of this study was to assess the association of the mode of surgery on female fertility after restorative proctocolectomy with ileal pouch-anal anastomosis. METHODS: All female patients aged 18 to 44 years who underwent restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis, familial adenomatous polyposis, or Crohn's disease at the Cleveland Clinic Ohio or the Cleveland Clinic Florida from 1983 to 2012 were sent a standardized fertility questionnaire. Infertility was defined as lack of pregnancy after 1 year of unprotected sexual intercourse. Patients who had attempted to conceive after restorative proctocolectomy with ileal pouch-anal anastomosis were compared based on the surgical approach: laparoscopic ileal pouch-anal anastomosis versus open ileal pouch-anal anastomosis. RESULTS: A total of 890 female patients were surveyed, of which 519 (58.3%) responded. Of these, 161 (31%) had attempted pregnancy after surgery: 18 (12%) had laparoscopic ileal pouch-anal anastomosis and 143 (88%) had open ileal pouch-anal anastomosis. There were no significant differences regarding demographics between groups. There was no difference in reported infertility rates (61.1% vs 65%, respectively, P = 0.69) between the laparoscopic ileal pouch-anal anastomosis and open ileal pouch-anal anastomosis groups. The median time to pregnancy (3.5 months vs 9 months, respectively, log-rank P = 0.01) was reduced in patients who underwent laparoscopic ileal pouch-anal anastomosis compared with those who underwent open ileal pouch-anal anastomosis. CONCLUSION: Postoperative infertility rates were higher after ileal pouch-anal anastomosis regardless of mode of surgery. However, laparoscopy was associated with a significantly reduced time to conceive compared with the open approach.


Assuntos
Infertilidade Feminina/etiologia , Doenças Inflamatórias Intestinais/patologia , Doenças Inflamatórias Intestinais/cirurgia , Laparoscopia/efeitos adversos , Laparotomia/efeitos adversos , Proctocolectomia Restauradora/métodos , Centros Médicos Acadêmicos , Adolescente , Adulto , Estudos de Coortes , Colectomia/métodos , Colite Ulcerativa/patologia , Colite Ulcerativa/cirurgia , Doença de Crohn/patologia , Doença de Crohn/cirurgia , Feminino , Seguimentos , Humanos , Incidência , Infertilidade Feminina/epidemiologia , Laparoscopia/métodos , Laparotomia/métodos , Proctocolectomia Restauradora/efeitos adversos , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Inquéritos e Questionários , Adulto Jovem
19.
Int J Colorectal Dis ; 34(9): 1585-1590, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31377853

RESUMO

PURPOSES: Bowel resection in patients with Crohn's disease (CD) has a high reported rate of postoperative complications and surgical recurrence. A macroscopically normal resection margin is recommended in CD surgery as wider margins do not translate in reduced recurrence rates. The aim of this study was to evaluate the association between resection margin status and anastomotic complications following ileocaecal resection for primary CD. METHODS: All patients treated with ileocaecal resection for primary CD from 2010 to 2018 were included in this retrospective observational study. Emergency operations and recurrent CD were excluded. Patients in whom an anastomosis was not fashioned at the time of the surgery were also excluded. Histopathology data collected included macroscopic description, presence of macroscopic and microscopic involvement of the proximal and distal resection margins. The primary outcome was the rate of positive resection margin in patients who developed anastomotic complications (anastomotic leaks and intra-abdominal collections), and the secondary outcomes were overall complications rate, length of hospital stay, reoperations and rehospitalisation within 30 days. RESULTS: A total of 104 patients were included. The proximal resection margin was microscopically involved in 19 patients (18.2%). Ten patients (9.6%) developed intra-abdominal anastomotic related complications, with 5 patients out of 10 (50%) in the group of postoperative anastomotic complications having a positive microscopic proximal margin at histology, compared to 14 patients (14.9%) in the group that did not develop anastomotic complications (p < 0.0001). CONCLUSIONS: Microscopic involvement of the proximal resection margin is more frequent in patients who develop postoperative anastomotic complications following elective ileocaecal resection for primary CD.


Assuntos
Ceco/cirurgia , Doença de Crohn/cirurgia , Íleo/cirurgia , Margens de Excisão , Complicações Pós-Operatórias/etiologia , Adulto , Anastomose Cirúrgica/efeitos adversos , Ceco/patologia , Doença de Crohn/patologia , Feminino , Humanos , Íleo/patologia , Masculino , Resultado do Tratamento
20.
Eur J Pediatr ; 178(9): 1413-1421, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31327075

RESUMO

Psychosocial and functional outcomes after intestinal resection in pediatric Crohn's disease (CD) are lacking. Therefore, we (I) assessed health-related quality of life (HRQOL), colorectal function, and satisfaction with surgery and (II) investigated their relationship with surgical outcomes, after ileocecal resection for CD. Crohn's patients that underwent ileocecal resection during childhood were included. HRQOL and colorectal function were assessed using SF-36 and COREFO, respectively, and compared with reference values. Satisfaction was scored on a 5-point Likert scale. In total, 80 patients (50% male, median age 23.0 years) were included. Physical HRQOL was impaired (SF-36 [mean]: CD, 47 vs. general, 54; p < 0.001), while mental HRQOL was similar to that in the general population. Overall colorectal function was impaired (COREFO [mean]: CD, 12.6 vs. normal, 7.2; p < 0.001). Worse colorectal function was associated with increasing clinical disease activity and longer interval since resection. Majority of patients was satisfied with surgery (81% satisfied/very satisfied, 11% neither satisfied nor dissatisfied, 8% dissatisfied/very dissatisfied). Decreased satisfaction with surgery was associated with increased clinical disease activity but not related to colorectal function.Conclusions: Physical HRQOL and colorectal function in CD patients who underwent ileocecal resection during childhood seem impaired and related to adverse surgical outcomes. This emphasizes the need for post-operative monitoring and prophylactic therapies. What is Known: • Up to 25% of pediatric-onset Crohn's disease (CD) patients undergo an intestinal resection within 5 years from diagnosis. • Many children and adults with CD experience disruption of their daily activities and health-related quality of life (HRQOL). What is New: • Physical HRQOL and colorectal function are impaired in patient with CD that underwent ileocecal resection during childhood. • Increasing clinical disease activity, a longer interval since surgery, severe complications related to surgery, and recurrent surgeries are all associated with worse colorectal function.


Assuntos
Ceco/cirurgia , Doença de Crohn/cirurgia , Íleo/cirurgia , Satisfação do Paciente/estatística & dados numéricos , Qualidade de Vida , Adolescente , Adulto , Criança , Doença de Crohn/fisiopatologia , Estudos Transversais , Feminino , Indicadores Básicos de Saúde , Humanos , Masculino , Recuperação de Função Fisiológica , Resultado do Tratamento , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA