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1.
Z Gastroenterol ; 58(2): 137-145, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32050284

RESUMO

PURPOSE: Rectal neuroendocrine tumors are rare with good prognosis. Several endoscopic methods such as endoscopic polypectomy, endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and modified endoscopic mucosal resection (m-EMR) are used in the treatment of rectal neuroendocrine tumors. Although m-EMR is derived from traditional EMR, it has not been widely used in clinical practice. In this study, we compared the efficacy and safety of EMR and m-EMR in the treatment of rectal neuroendocrine tumors by performing a meta-analysis. MATERIALS AND METHODS: We searched PubMed, Web of Science, and EMBASE index up to the end of January 2017 for all published literature about EMR and m-EMR in the treatment of rectal neuroendocrine tumors. RESULTS: A total of 11 studies involving 811 patients were included. The pooled data suggested that there was a significantly higher rate of histologic complete resection and endoscopic complete resection among patients treated with m-EMR than those treated with EMR (histologic complete resection: OR = 0.23, 95 % CI = 0.10-0.51, p < 0.01; endoscopic complete resection: OR = 0.13, 95 % CI = 0.02-0.74, p = 0.02). The procedure time of EMR was longer than m-EMR (MD = 2.40, 95 % CI = 0.33-4.46, p = 0.02). There was a significantly higher rate of vertical margin involvement among patients treated with EMR than those treated with m-EMR; whereas, there was no significant difference of lateral margin involvement between the m-EMR and EMR groups (vertical margin involvement: OR = 5.00, 95 % CI = 2.67-9.33, p < 0.01; lateral margin involvement: OR = 1.44, 95 % CI = 0.48-4.37, p = 0.52). There was no significant difference in mean tumor size among patients treated with m-EMR versus those treated with EMR (MD = -0.30, 95 % CI = -0.75-0.14, p = 0.18); further, there was no significant difference in endoscopic mean sizes of the tumor and pathological mean sizes of the tumor between the m-EMR and EMR groups (endoscopic mean sizes of the tumor: MD = 0.20, 95 % CI = -0.44-0.84, p = 0.43; pathological mean sizes of the tumor: MD = 0.62, 95 % CI = -0.68-1.92, p = 0.05). No significant differences were detected among the treatment groups with regard to complications (bleeding: OR = 0.87, 95 % CI = 0.39-1.95, p = 0.73; complications (bleeding and perforation): OR = 0.87, 95 % CI = 0.40-1.88, p = 0.73). CONCLUSION: The efficacy of m-EMR are better than EMR among patients undergoing endoscopic treatment of rectal neuroendocrine tumors, and the safety of m-EMR is equivalent to EMR treatment.


Assuntos
Ressecção Endoscópica de Mucosa/métodos , Endoscopia Gastrointestinal/efeitos adversos , Tumores Neuroendócrinos/cirurgia , Neoplasias Retais/cirurgia , Humanos , Mucosa Intestinal/patologia , Mucosa Intestinal/cirurgia , Tumores Neuroendócrinos/patologia , Neoplasias Retais/patologia , Estudos Retrospectivos , Resultado do Tratamento
2.
Gut ; 69(2): 295-303, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31331994

RESUMO

BACKGROUND: The duodenum has become a metabolic treatment target through bariatric surgery learnings and the specific observation that bypassing, excluding or altering duodenal nutrient exposure elicits favourable metabolic changes. Duodenal mucosal resurfacing (DMR) is a novel endoscopic procedure that has been shown to improve glycaemic control in people with type 2 diabetes mellitus (T2D) irrespective of body mass index (BMI) changes. DMR involves catheter-based circumferential mucosal lifting followed by hydrothermal ablation of duodenal mucosa. This multicentre study evaluates safety and feasibility of DMR and its effect on glycaemia at 24 weeks and 12 months. METHODS: International multicentre, open-label study. Patients (BMI 24-40) with T2D (HbA1c 59-86 mmol/mol (7.5%-10.0%)) on stable oral glucose-lowering medication underwent DMR. Glucose-lowering medication was kept stable for at least 24 weeks post DMR. During follow-up, HbA1c, fasting plasma glucose (FPG), weight, hepatic transaminases, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), adverse events (AEs) and treatment satisfaction were determined and analysed using repeated measures analysis of variance with Bonferroni correction. RESULTS: Forty-six patients were included of whom 37 (80%) underwent complete DMR and 36 were finally analysed; in remaining patients, mainly technical issues were observed. Twenty-four patients had at least one AE (52%) related to DMR. Of these, 81% were mild. One SAE and no unanticipated AEs were reported. Twenty-four weeks post DMR (n=36), HbA1c (-10±2 mmol/mol (-0.9%±0.2%), p<0.001), FPG (-1.7±0.5 mmol/L, p<0.001) and HOMA-IR improved (-2.9±1.1, p<0.001), weight was modestly reduced (-2.5±0.6 kg, p<0.001) and hepatic transaminase levels decreased. Effects were sustained at 12 months. Change in HbA1c did not correlate with modest weight loss. Diabetes treatment satisfaction scores improved significantly. CONCLUSIONS: In this multicentre study, DMR was found to be a feasible and safe endoscopic procedure that elicited durable glycaemic improvement in suboptimally controlled T2D patients using oral glucose-lowering medication irrespective of weight loss. Effects on the liver are examined further. TRIAL REGISTRATION NUMBER: NCT02413567.


Assuntos
Diabetes Mellitus Tipo 2/cirurgia , Duodenoscopia/métodos , Duodeno/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Mucosa Intestinal/cirurgia , Adulto , Idoso , Glicemia/metabolismo , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/tratamento farmacológico , Ressecção Endoscópica de Mucosa/efeitos adversos , Estudos de Viabilidade , Feminino , Hemoglobina A Glicada/metabolismo , Humanos , Hipoglicemiantes/uso terapêutico , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos Prospectivos
3.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(12): 1170-1176, 2019 Dec 25.
Artigo em Chinês | MEDLINE | ID: mdl-31874534

RESUMO

Objective: To evaluate the quality of life after Altemeier and Delorme procedures for rectal prolapse patients. Methods: A retrospective cohort study was performed. Clinical data of patients with full-thickness rectal prolapse undergoing surgical treatment in the Sixth Affiliated Hospital, Sun Yat-sen University from February 2013 to January 2018 were retrospectively analyzed. Patients who had no preoperative imaging data, who suffered from internal rectal intussusception, or who did not undergo Altemeier and Delorme operations were excluded. Sixty-seven patients were enrolled, including 32 males with median age of 20.5 (13, 34) years and 35 females with median age of 65.0 (50, 77) years. According to different procedures, patients were divided into the Altemeier group (48 cases) and the Delorme group (19 cases), who received standard Altemeier and Delorme operations respectively. The maximal prolapse length of preoperative squat position, the Longo constipation score, Wexner incontinence score, EQ-5D-5L score, postoperative complications and recurrence rate were analyzed and compared between two groups. Results: The maximal prolapse length of preoperative squat position in Altemeier group and Delorme group was (7.3±3.3) cm and (4.9±2.1) cm respectively with significant difference (t=2.907, P=0.005). The operations in both groups were successfully completed. The operation time and postoperative hospital stay of Altemeier group were longer than those of Delorme group [(112.3±47.0) minutes vs. (80.7±35.4) minutes, t=2.637, P=0.010; (11.3±5.0) days vs. (8.6±3.0) days, t=2.177, P=0.033]. The median follow-up period was 26 (13, 45) months. In the last follow-up, compared to pre-operation, the Longo constipation score [9.0 (6.0, 14.0) vs 4.0 (1.0, 6.5), Z=-4.989, P<0.001], Wexner incontinence score [0 (0, 5.5) vs. 0 (0, 2.0), Z=-3.325, P<0.001] and EQ-5D-5L score [45.0 (40.0, 57.5) vs. 80.0 (70.0, 87.5), Z=-5.587, P<0.001] were all improved obviously in the Altemeier group, meanwhile Longo constipation score [6.0 (5.0, 14.0) vs. 3.0 (1.0, 7.0), Z=-2.186, P=0.029], Wexner incontinence score [0 (0, 12.0) vs. 0 (0, 4.0), Z=-2.325, P=0.020] and EQ-5D-5L score [50.0 (35.0, 60.0) vs. 75.0 (65.0, 90.0), Z=-3.360, P=0.001] in the Delorme group were all improved obviously as well. The postoperative morbidity of complication between the two groups was not significantly different [10/48 (20.8%) vs. 4/19 (21.1%), χ(2)=0.049, P=0.826]. Sixteen patients (28.0%) relapsed after operation, including 10 patients in the Altemeier group and 6 patients in the Delorme group, without statistically significant difference (P=0.134). Conclusions: Both the Altemeier and Delorme procedures are effective treatments for rectal prolapse, which can improve the postoperative quality of life. Delorme procedure has the advantages of shorter operation time and faster postoperative recovery in patients with mild prolapse.


Assuntos
Prolapso Retal/cirurgia , Adolescente , Adulto , Idoso , Colectomia/métodos , Colo Sigmoide/cirurgia , Feminino , Humanos , Mucosa Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Protectomia/métodos , Qualidade de Vida , Reto/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
4.
Acta Gastroenterol Belg ; 82(3): 375-378, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31566324

RESUMO

BACKGROUND: Colorectal recurrent lesions after endoscopic mucosal resection (EMR) often contain severe fibrosis. In such lesions, repeat EMR is often difficult and endoscopic piecemeal mucosal resection (EPMR) has a high risk of repeated recurrence, while surgery is considered overtreatment. Whether ESD can be used safely and reliably to treat such difficult lesions has not been adequately verified. We analyzed the treatment outcomes of ESD for recurrent lesions after EMR. METHODS: Among 653 colorectal ESD conducted in our institution between April 2012 and August 2017, 27 consecutive patients underwent the procedure for recurrent lesions after EMR. Treatment outcomes including en bloc resection rate, R0 resection rate, and curative resection rate; complications were analyzed. RESULTS: Treatment outcomes of the 27 patients were as follows: en bloc resection rate 81.5%, R0 resection rate 74.1%, curative resection rate 74.1%, median procedure time 47 min (range 10‒210 min), perforation rate 0%, and delayed bleeding rate 3.7%. The corresponding rates for 626 patients who underwent colorectal ESD during the same period for lesions other than recurrence after EMR were 97.2%, 95.5%, 88.7%, 37 min (7-225 min), 0.5%, and 2.8%. There were no differences in complication rates. Treatment outcomes including en bloc resection rate were inferior in the recurrence group compared to non-recurrent group, but no local recurrence was found in all patients. CONCLUSIONS: Colorectal ESD is feasible for recurrent colorectal lesions after EMR. The procedure is safe and achieves good treatment outcomes with no local recurrence.


Assuntos
Neoplasias Colorretais/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Mucosa Intestinal/cirurgia , Recidiva Local de Neoplasia/cirurgia , Colonoscopia , Neoplasias Colorretais/patologia , Estudos de Viabilidade , Humanos , Mucosa Intestinal/patologia , Resultado do Tratamento
5.
J Laparoendosc Adv Surg Tech A ; 29(10): 1345-1348, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31532300

RESUMO

Aim: In children, the diameter at the hepaticojejunostomy anastomosis (HJA) can range from 10 mm to less than 5 mm, irrespective of the type of choledochal cyst (CC). We developed a maneuver that involves everting the mucosa (EM) of the Roux-en-Y loop jejunum and the common hepatic duct mucosa circumferentially, to facilitate suturing during laparoscopic HJA (lap-HJA). Otherwise, it is extremely difficult to distinguish between the lumen and the mucosa on the jejunal side. Methods: We used EM to treat 18 consecutive children with CC between 2016 and 2018. After transumbilical, extracorporeal Roux-en-Y loop-plasty, the closed end of the jejunum was incised with a scalpel and bleeding points were coagulated with bipolar diathermy. During lap-HJA, the mucosa at the incision was everted circumferentially by using 7/0 absorbable sutures and anastomosed securely to the common hepatic duct by using 5/0 or 6/0 absorbable sutures. Results: Mean age at surgery was 4.0 years old. HJA diameters were <5 mm (n = 4), 5-9 mm (n = 11), and >9 mm (n = 3). In all cases, EM allowed the lumen at the incision in the Roux-en-Y loop jejunum to be distinguished readily, and suturing proceeded smoothly. After follow-up of a mean of 1.5 years (range 0.5-3.0), no anastomotic leakages or stenoses have been reported. Conclusions: EM greatly facilitated secure anastomosis during lap-HJA, even when the diameter at the anastomosis was <5 mm. The safety and efficiency of lap-HJA in children with CC could be improved by this simple maneuver.


Assuntos
Anastomose Cirúrgica/métodos , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Cisto do Colédoco/cirurgia , Mucosa Intestinal/cirurgia , Jejunostomia/métodos , Laparoscopia/métodos , Adolescente , Anastomose em-Y de Roux , Fístula Anastomótica/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Técnicas de Sutura
6.
Surgery ; 166(6): 1048-1054, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31543322

RESUMO

BACKGROUND: Intestinal inflammation is the predominant contributor to the genesis of postoperative ileus. Janus kinase 1 plays an important role during inflammation. Here, we investigated the role of Janus kinase 1 in postoperative ileus and whether inhibition of Janus kinase 1 could mitigate postoperative ileus. METHODS: A mouse model of postoperative ileus was induced by intestinal manipulation. Janus kinase 1 inhibitor GLPG0634 or placebo was administered orally before intestinal manipulation. At the indicated time points post operation, neutrophil infiltration was assessed by immunohistochemistry and enzyme-linked immunosorbent assay; proinflammatory gene expression was quantified by quantitative reverse-transcriptase polymerase chain reaction and enzyme-linked immunosorbent assay; and Janus kinase 1 activation was detected by Western blot. Functional studies were conducted to evaluate intestinal motility. RESULTS: We found that intestinal manipulation led to marked activation of Janus kinase 1, with increased proinflammatory gene expression and upregulated myeloperoxidase level. Moreover, intestinal manipulation resulted in an impairment of intestinal transit in vivo and inhibition of smooth muscle contractility in vitro. Preoperative administration of GLPG0634 markedly lowered the expression of proinflammatory cytokines, the myeloperoxidase level in the muscularis layer after bowel manipulation, and significantly ameliorated smooth muscle contractile function and intestinal transit ability. CONCLUSION: Our data showed that Janus kinase 1 activation mediated intestinal manipulation-induced resident macrophage activation after intestinal manipulation, and subsequent complex inflammatory cascade and gut dysmotility. Janus kinase 1 inhibition appears to be a prospective and convenient approach for the prevention of postoperative ileus.


Assuntos
Íleus/prevenção & controle , Janus Quinase 1/antagonistas & inibidores , Jejuno/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Piridinas/administração & dosagem , Triazóis/administração & dosagem , Animais , Modelos Animais de Doenças , Motilidade Gastrointestinal/efeitos dos fármacos , Motilidade Gastrointestinal/imunologia , Humanos , Íleus/etiologia , Mediadores da Inflamação/metabolismo , Mucosa Intestinal/efeitos dos fármacos , Mucosa Intestinal/imunologia , Mucosa Intestinal/cirurgia , Janus Quinase 1/metabolismo , Jejuno/efeitos dos fármacos , Jejuno/imunologia , Masculino , Camundongos , Contração Muscular/efeitos dos fármacos , Contração Muscular/imunologia , Músculo Liso/efeitos dos fármacos , Músculo Liso/imunologia , Peroxidase/metabolismo , Complicações Pós-Operatórias/etiologia , Cuidados Pré-Operatórios/métodos , Transdução de Sinais/efeitos dos fármacos , Transdução de Sinais/imunologia , Regulação para Cima/efeitos dos fármacos
7.
Pediatr Surg Int ; 35(10): 1101-1107, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31396740

RESUMO

PURPOSE: To investigate the safety and efficacy of mucous fistula refeeding (MFR) in low-birth-weight infants. METHODS: Between December 2006 and December 2018, medical records of low-birth-weight infants who underwent small bowel enterostomy formation in the neonatal period and subsequent stoma closure at our institution were retrospectively reviewed. Patients were assigned to "refeeding" (RF) and "non-refeeding" (NRF) groups, which were compared for patient characteristics and clinical outcomes. We also cultured the proximal stoma output over time in the RF group and reviewed changes in the flora to evaluate the safety of refeeding. RESULTS: In the RF group, compared with that before refeeding, there was significantly more rapid weight gain after refeeding (17.7 vs 10.6 g/day; P = 0.002). Median total time of parenteral nutrition (PN) was 25 and 87 days in the RF and NRF groups, respectively (P = 0.001). The number of patients who developed PN-associated liver disease (PNALD) was smaller in the RF group (P = 0.12). No complications of MFR were noted and no pathogenic bacteria were cultured. CONCLUSION: MFR was able to diminish the need for PN, which potentially decreased the incidence of PNALD, and was safe as there were no complications of the refeeding process.


Assuntos
Enterostomia/métodos , Recém-Nascido de Baixo Peso , Mucosa Intestinal/cirurgia , Intestino Delgado/cirurgia , Nutrição Parenteral Total/métodos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Resultado do Tratamento
8.
World J Gastroenterol ; 25(30): 4148-4157, 2019 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-31435169

RESUMO

Patients with long-standing inflammatory bowel disease (IBD) involving at least 1/3 of the colon are at increased risk for colorectal cancer (CRC). Advancements in CRC screening and surveillance and improved treatment of IBD has reduced CRC incidence in patients with ulcerative colitis and Crohn's colitis. Most cases of CRC are thought to arise from dysplasia, and recent evidence suggests that the majority of dysplastic lesions in patients with IBD are visible, in part thanks to advancements in high definition colonoscopy and chromoendoscopy. Recent practice guidelines have supported the use of chromoendoscopy with targeted biopsies of visible lesions rather than traditional random biopsies. Endoscopists are encouraged to endoscopically resect visible dysplasia and only recommend surgery when a complete resection is not possible. New technologies such as virtual chromoendoscopy are emerging as potential tools in CRC screening. Patients with IBD at increased risk for developing CRC should undergo surveillance colonoscopy using new approaches and techniques.


Assuntos
Neoplasias Colorretais/prevenção & controle , Detecção Precoce de Câncer/normas , Doenças Inflamatórias Intestinais/patologia , Lesões Pré-Cancerosas/patologia , Conduta Expectante/normas , Biópsia , Colonografia Tomográfica Computadorizada/métodos , Colonografia Tomográfica Computadorizada/normas , Colonoscopia/métodos , Colonoscopia/normas , Neoplasias Colorretais/patologia , Progressão da Doença , Detecção Precoce de Câncer/métodos , Ressecção Endoscópica de Mucosa/normas , Humanos , Doenças Inflamatórias Intestinais/diagnóstico por imagem , Doenças Inflamatórias Intestinais/cirurgia , Mucosa Intestinal/diagnóstico por imagem , Mucosa Intestinal/patologia , Mucosa Intestinal/cirurgia , Programas de Rastreamento/métodos , Programas de Rastreamento/normas , Guias de Prática Clínica como Assunto , Lesões Pré-Cancerosas/diagnóstico por imagem , Lesões Pré-Cancerosas/cirurgia
11.
World J Gastroenterol ; 25(23): 2887-2897, 2019 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-31249447

RESUMO

Through the implementation of national bowel cancer screening programmes we have seen a three-fold increase in early pT1 colorectal cancers, but how these lesions should be managed is currently unclear. Local excision can be an attractive option, especially for fragile patients with multiple comorbidities, but it is only safe from an oncological point of view in the absence of lymph node metastasis. Patient risk stratification through careful analysis of histopathological features in local excision or polypectomy specimens should be performed according to national guidelines to avoid under- or over-treatment. Currently national guidelines vary in their recommendations as to which factors should be routinely reported and there is no established multivariate risk stratification model to determine which patients should be offered major resectional surgery. Conventional histopathological parameters such as tumour grading or lymphovascular invasion have been shown to be predictive of lymph node metastasis in a number of studies but the inter- and intra-observer variation in reporting is high. Newer parameters including tumour budding and poorly differentiated clusters have been shown to have great potential, but again some improvement in the inter-observer variation is required. With the implementation of digital pathology into clinical practice, quantitative parameters like depth/area of submucosal invasion and proportion of stroma can be routinely assessed. In this review we present the various histopathological risk factors for predicting systemic spread in pT1 colorectal cancer and introduce potential novel quantitative variables and multivariable risk models that could be used to better define the optimal treatment of this increasingly common disease.


Assuntos
Adenocarcinoma/patologia , Neoplasias Colorretais/patologia , Mucosa Intestinal/patologia , Metástase Linfática/diagnóstico , Guias de Prática Clínica como Assunto , Adenocarcinoma/diagnóstico , Adenocarcinoma/cirurgia , Colectomia/normas , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/cirurgia , Detecção Precoce de Câncer/métodos , Detecção Precoce de Câncer/normas , Humanos , Mucosa Intestinal/cirurgia , Linfonodos/patologia , Programas de Rastreamento/métodos , Programas de Rastreamento/normas , Gradação de Tumores , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Variações Dependentes do Observador , Protectomia/normas , Prognóstico , Medição de Risco/métodos , Fatores de Risco
12.
Acta Biomed ; 90(2): 308-315, 2019 05 23.
Artigo em Inglês | MEDLINE | ID: mdl-31125011

RESUMO

BACKGROUND: The aim of the study was to assess safety and efficacy of pre-operative assessment for internal mucosal rectal prolapse (IMRP) in internal hemorrhoids, in order to achieve a tailored transanal stapled surgery. METHODS: All consecutive patients (January 2011 to December 2014; age 18-80 years), affected by prolapses with II-IV degrees hemorrhoids that underwent Longo procedure with EEA® Auto Suture stapler (Covidien) were included in the present study. RESULTS: A total of 100 consecutive patients (38 females) were enrolled in the study. Preoperative Visual Analogue Scale pain assessment was 7.33±2.68. The mean duration of the procedure was 34.1±17.8 min, and the median hospital stay was 2 days (range 2-6). No major complication occurred, including relapses of mucosal prolapse. Preoperative prolapse measurement with EEA® EEA® Auto Suture stapler (2.3±0.5 cm) was well correlated direct assessment (2.4±0.6, p<0.001), but a proportional bias was identified, with significant preoperative underestimation of IMRP, particularly for lesions larger than 3 cm (around 10% of actual extent). CONCLUSIONS: EEA® Auto Suture stapler seems to be safe and effective for a tailored approach to anorectal prolapse due to hemorrhoids. However, it reasonable that its actual impact may have been overestimated, beneficing of the repetitive, direct assessment of the operatory field guaranteed by preoperative IMRP measurement.


Assuntos
Ressecção Endoscópica de Mucosa/métodos , Hemorroidectomia/métodos , Hemorroidas/cirurgia , Prolapso Retal/cirurgia , Grampeadores Cirúrgicos , Adulto , Estudos de Coortes , Comorbidade , Seguimentos , Hemorroidas/diagnóstico , Hemorroidas/epidemiologia , Humanos , Mucosa Intestinal/cirurgia , Cuidados Intraoperatórios/métodos , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Prolapso Retal/diagnóstico , Prolapso Retal/epidemiologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento
13.
J Surg Res ; 242: 111-117, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31075655

RESUMO

BACKGROUND: Mucosal appendicitis is a controversial entity that is histologically distinct from transmural appendicitis. There is mixed opinion regarding mucosal inflammation as a spectrum of appendicitis versus a negative appendectomy. The ability to distinguish these diagnoses preoperatively is of importance to prevent unnecessary surgery. We hypothesize that patients with mucosal appendicitis can be discriminated from those with transmural disease based on specific preoperative clinical and imaging findings. MATERIALS AND METHODS: After IRB approval, all patients who underwent laparoscopic appendectomy at our institution during 2015 were reviewed in the electronic medical record. Patients with mucosal appendicitis were identified and matched 2:1 to a random cohort of nonperforated transmural appendicitis cases. Demographic and clinical data were collected, including history, examination, laboratory, and imaging findings. Preoperative factors associated with mucosal appendicitis were modeled using binomial logistic regression analysis. RESULTS: Of 1153 appendectomies performed during 2015, 103 patients had pathologic diagnosis of mucosal appendicitis. When compared with patients with mucosal infection, leukocytosis >10,000 per microliter led to 5.9 times higher likelihood of transmural pathology (P = 0.000). Noncompressibility on ultrasound was associated with 7.3 times higher likelihood of transmural disease (P = 0.015). Echogenic changes were predictive of transmural appendicitis, conferring 3.9 times the risk (P = 0.007). Presence of free fluid led to 2.3 times the rate of transmural pathology (P = 0.007). Finally, for every millimeter decrease in appendiceal diameter, patients were half as likely to exhibit transmural disease (P = 0.000). Together, these variables can successfully predict presence of mucosal appendicitis on final pathology report at a rate of 82.1%, and explain 60% of the variance in diagnosis of mucosal versus transmural appendicitis (P = 0.000). CONCLUSIONS: Mucosal appendicitis remains a controversial pathologic entity, but is not associated with greater complications compared with transmural appendicitis when treated with laparoscopic appendectomy. Transmural disease can be predicted by leukocytosis, noncompressible appendix, presence of free fluid, larger appendiceal diameter and echogenicity.


Assuntos
Apendicite/diagnóstico , Apêndice/diagnóstico por imagem , Mucosa Intestinal/patologia , Leucocitose/diagnóstico , Adolescente , Apendicectomia/efeitos adversos , Apendicectomia/estatística & dados numéricos , Apendicite/complicações , Apendicite/cirurgia , Apêndice/patologia , Apêndice/cirurgia , Criança , Diagnóstico Diferencial , Feminino , Humanos , Mucosa Intestinal/diagnóstico por imagem , Mucosa Intestinal/cirurgia , Laparoscopia/efeitos adversos , Laparoscopia/estatística & dados numéricos , Contagem de Leucócitos , Leucocitose/sangue , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Estudos Retrospectivos , Ultrassonografia
14.
World J Gastroenterol ; 25(13): 1618-1627, 2019 Apr 07.
Artigo em Inglês | MEDLINE | ID: mdl-30983821

RESUMO

BACKGROUND: Chronic radiation proctitis (CRP) is a complication which occurs in 1%-5% of patients who undergo radiotherapy for pelvic malignancies. Although a wide range of therapeutic modalities are available, there is no literature to date showing any particularly appropriate therapeutic modality for each disease stage. Argon plasma coagulation (APC) is currently recommended as the first-choice treatment for hemorrhagic CRP, however, its indication based on long-term follow-up is still unclear. On the hypothesis that the long-term efficacy and safety of APC are not fully understood, we reviewed APC treatment for patients with hemorrhagic CRP from a single center. AIM: To assess the long-term efficacy and safety of APC for hemorrhagic CRP. METHODS: This is a retrospective study of consecutive patients treated with APC for hemorrhagic CRP from January 2013 to October 2017. Demographics, clinical variables, and typical endoscopic features were recorded independently. Success was defined as either cessation of bleeding or only occasional traces of bloody stools with no further treatments for at least 12 mo after the last APC treatment. We performed univariate and multivariate analyses to identify factors associated with success and risk factors for fistulas. RESULTS: Forty-five patients with a median follow-up period of 24 mo (range: 12-67 mo) were enrolled. Fifteen (33.3%) patients required blood transfusion before APC. Successful treatment with APC was achieved in 31 (68.9%) patients. The mean number of APC sessions was 1.3 (1-3). Multivariate analysis showed that APC failure was independently associated with telangiectasias present on more than 50% of the surface area [odds ratio (OR) = 6.53, 95% confidence interval (CI): 1.09-39.19, P = 0.04] and ulcerated area greater than 1 cm2 (OR = 8.15, 95%CI: 1.63-40.88, P = 0.01). Six (13.3%) patients had severe complications involving rectal fistulation. The only factor significantly associated with severe complications was ulcerated area greater than 1 cm2 (P = 0.035). CONCLUSION: The long-term efficacy of APC for hemorrhagic CRP is uncertain in patients with telangiectasias present on > 50% of the surface area and ulceration > 1 cm2.


Assuntos
Coagulação com Plasma de Argônio/efeitos adversos , Hemorragia Gastrointestinal/cirurgia , Complicações Pós-Operatórias/epidemiologia , Proctite/cirurgia , Lesões por Radiação/cirurgia , Telangiectasia/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Hemorragia Gastrointestinal/etiologia , Humanos , Mucosa Intestinal/irrigação sanguínea , Mucosa Intestinal/patologia , Mucosa Intestinal/efeitos da radiação , Mucosa Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Neoplasias Pélvicas/radioterapia , Complicações Pós-Operatórias/etiologia , Proctite/etiologia , Proctite/patologia , Lesões por Radiação/etiologia , Lesões por Radiação/patologia , Reto/irrigação sanguínea , Reto/patologia , Reto/efeitos da radiação , Reto/cirurgia , Estudos Retrospectivos , Fatores de Risco , Telangiectasia/etiologia , Telangiectasia/patologia , Resultado do Tratamento
15.
Turk J Gastroenterol ; 30(4): 350-356, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30945645

RESUMO

BACKGROUND/AIMS: Colorectal laterally spreading tumors (LSTs) are large and superficial neoplasms. Most are adenomatous lesions. Endoscopic mucosal resection (EMR) is a standard technique of removing precursor colorectal lesions. The aim of the present study was to assess the factors associated with the clinical outcomes of EMR for LSTs. MATERIALS AND METHODS: A total of 275 patients with LSTs who underwent EMR were enrolled in the study. The clinical outcomes of the patients were analyzed by retrospectively reviewing their medical records. RESULTS: The en bloc resection and R0 resection rates were 86.9% and 80.4%, respectively. The bleeding and perforation rates were 7.6% and 0.4%, respectively. The frequency of high-grade dysplasia and adenocarcinoma histology was significantly higher, and the procedure time was significantly longer in LSTs >20 mm than in those ≤20 mm. The R0 resection rate was significantly higher in LSTs ≤20 mm than in those >20 mm. The frequency of piecemeal resection was significantly higher in LSTs with an adenomatous and cancerous pit pattern than in those with a non-neoplastic pit pattern. The frequency of piecemeal resection was significantly higher in LSTs with adenocarcinoma than in those with low-grade dysplasia. Multivariate analysis revealed that adenomatous pit pattern, high-grade dysplasia, or adenocarcinoma was a significant independent risk factor of LSTs for piecemeal resection after EMR. CONCLUSION: EMR is useful for treating ≤20 mm LSTs with regard to curative resection and procedure time. LSTs with an adenomatous pit pattern, high-grade dysplasia, or adenocarcinoma are significant independent risk factors for piecemeal resection after EMR.


Assuntos
Adenocarcinoma/cirurgia , Adenoma/cirurgia , Neoplasias Colorretais/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Enteropatias/cirurgia , Lesões Pré-Cancerosas/cirurgia , Adenocarcinoma/patologia , Adenoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Colorretais/patologia , Feminino , Humanos , Enteropatias/patologia , Mucosa Intestinal/patologia , Mucosa Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Lesões Pré-Cancerosas/patologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
16.
World J Gastroenterol ; 25(12): 1502-1512, 2019 Mar 28.
Artigo em Inglês | MEDLINE | ID: mdl-30948913

RESUMO

BACKGROUND: Risk factors for local recurrence after polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD) have not been identified. Additionally, the appropriate interval for endoscopic surveillance of colorectal tumors at high-risk of local recurrence has not been established. AIM: To clarify the clinicopathological characteristics of recurrent lesions after endoscopic colorectal tumor resection and determine the appropriate interval. METHODS: Three hundred and sixty patients (1412 colorectal tumors) who underwent polypectomy, EMR, or ESD and received endoscopic surveillance subsequently for more than one year to detect local recurrence were enrolled in this study. The clinicopathological factors associated with local recurrence were determined via univariate and multivariate analyses. RESULTS: Local recurrence was observed in 31 of 360 (8.6%) patients [31 of 1412 (2.2%) lesions] after colorectal tumor resection. Piecemeal resection, tumor size of more than 2 cm, and the presence of villous components were associated with colorectal tumor recurrence after endoscopic resection. Of these three factors, the piecemeal resection procedure was identified as an independent risk factor for recurrence. Colorectal tumors resected into more than five pieces were associated with a high risk of recurrence since the average period from resection to recurrence in these cases was approximately 3 mo. The period to recurrence in cases resected into more than 5 pieces was much shorter than that in those resected into less than 4 pieces (3.8 ± 1.9 mo vs 7.9 ± 5.0 mo, P < 0.05). CONCLUSION: Local recurrence of endoscopically treated colorectal tumors depends upon the outcome of first endoscopic procedure. Piecemeal resection was the only significant risk factor associated with local recurrence after endoscopic resection.


Assuntos
Pólipos do Colo/cirurgia , Colonoscopia/métodos , Neoplasias Colorretais/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Recidiva Local de Neoplasia/epidemiologia , Assistência ao Convalescente/métodos , Assistência ao Convalescente/estatística & dados numéricos , Colo/diagnóstico por imagem , Colo/patologia , Colo/cirurgia , Pólipos do Colo/diagnóstico por imagem , Pólipos do Colo/patologia , Colonoscopia/estatística & dados numéricos , Neoplasias Colorretais/diagnóstico por imagem , Neoplasias Colorretais/patologia , Ressecção Endoscópica de Mucosa/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Mucosa Intestinal/diagnóstico por imagem , Mucosa Intestinal/patologia , Mucosa Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Conduta Expectante
17.
Dig Liver Dis ; 51(6): 774-781, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31014942

RESUMO

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is commonly used to treat early-stage digestive cancer because it results in a higher frequency of en-bloc resection and a lower frequency of local recurrence. However, the efficacy and safety of duodenal ESD remain unclear. Therefore, present study is aimed at evaluating clinical outcomes of duodenal ESD. METHODS: To evaluate the efficacy and safety of duodenal ESD, electronic databases (MEDLINE, CENTRAL and EMBASE) were searched by two independent reviewers. The authors were contacted for additional information. A meta-analysis was performed to evaluate the efficacy and safety of duodenal ESD. RESULTS: A total of 7 studies (203 patients) were included in the quantitative synthesis analysis. The pooled proportions of the frequencies of en-bloc resection, need for surgical intervention, bleeding, intraoperative perforation and delayed perforation were 87%, 4%, 2%, 15% and 2%, respectively. The quality of evidence regarding on surgical intervention outcomes was rated as moderate, whereas that of en-bloc resection was rated as low because of its marked inconsistency. CONCLUSIONS: Duodenal ESD produced acceptable outcomes in terms of the en-bloc R0 resection, but the incidence of procedure-related adverse events is high (PROSPERO register, CRD42017057110).


Assuntos
Duodeno/cirurgia , Ressecção Endoscópica de Mucosa/efeitos adversos , Mucosa Intestinal/cirurgia , Pólipos Intestinais/cirurgia , Duodeno/patologia , Humanos , Mucosa Intestinal/patologia , Pólipos Intestinais/patologia , Complicações Pós-Operatórias/etiologia
18.
Int J Surg Pathol ; 27(6): 609-612, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30942096

RESUMO

Vascular abnormalities and lesions of the small bowel and colon are rare. A florid vascular proliferation (FVP) associated with colon obstruction and intussusception has been described and can mimic malignant vascular tumors such as angiosarcoma. In this article, we report a case of colonic FVP associated with colon obstruction, a case of small bowel FVP associated with a Meckel's diverticulum, and a case of small bowel FVP with intussusception. All cases occurred in older adults (mean 73 years of age, range 62-80 years of age). FVP grossly appeared as a mass-like lesion in one small bowel case, while the other cases did not demonstrate a grossly identifiable mass. Histologically, all cases demonstrated a transmural vascular proliferation with plump endothelial cells. No significant cytologic atypia was seen, and mitotic figures were rare. No recurrence was seen in all cases with an average follow-up of 22 months. It is important to be aware of this entity as it appears to be a nonneoplastic reactive process, unlike some of its histologic mimics.


Assuntos
Neoplasias do Colo/diagnóstico , Células Endoteliais/patologia , Hemangiossarcoma/diagnóstico , Mucosa Intestinal/patologia , Divertículo Ileal/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Proliferação de Células , Colectomia , Colo/irrigação sanguínea , Colo/patologia , Colo/cirurgia , Neoplasias do Colo/complicações , Neoplasias do Colo/cirurgia , Diagnóstico Diferencial , Endotélio Vascular/citologia , Endotélio Vascular/patologia , Feminino , Hemangiossarcoma/complicações , Humanos , Íleo/irrigação sanguínea , Íleo/patologia , Íleo/cirurgia , Mucosa Intestinal/irrigação sanguínea , Mucosa Intestinal/cirurgia , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Intussuscepção/etiologia , Intussuscepção/patologia , Intussuscepção/cirurgia , Masculino , Divertículo Ileal/complicações , Divertículo Ileal/cirurgia , Pessoa de Meia-Idade
19.
Gastroenterology ; 157(2): 451-461.e2, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30981791

RESUMO

BACKGROUND & AIMS: Endoscopic mucosal resection (EMR) with submucosal injection is an established method for removing colorectal polyps, although the en bloc resection rate decreases when polyp size exceeds 10 mm. Piecemeal resection increases local recurrence. Underwater EMR (UEMR) is an effective technique for removal of sessile colorectal polyps and we investigated whether it is superior to conventional EMR (CEMR). METHODS: We conducted a multicenter randomized controlled trial at 5 institutions in Japan. Patients with endoscopically diagnosed, intermediate-size (10-20 mm) sessile colorectal lesions were randomly assigned to undergo UEMR or CEMR. Only the most proximal lesion was registered. The UEMR procedure included immersion of the entire lumen in water and snare resection of the lesion without submucosal injection of normal saline. We analyzed outcomes of 108 colorectal lesions in the UEMR group and 102 lesions in the CEMR group. R0 resection was defined as en bloc resection with a histologically confirmed negative resection margin. The primary endpoint was the difference in the R0 resection rates between groups. RESULTS: The proportions of R0 resections were 69% (95% confidence interval [CI] 59%-77%) in the UEMR group vs 50% (95% CI 40%-60%) in the CEMR group (P = .011). The proportions of en bloc resections were 89% (95% CI 81%-94%) in the UEMR group vs 75% (95% CI 65%-83%) in the CEMR group (P = .007). There was no significant difference in median procedure time (165 vs 175 seconds) or proportions of patients with adverse events (2.8% in the UEMR group vs 2.0% in the CEMR group). CONCLUSIONS: In a multicenter randomized controlled trial, we found that UEMR significantly increased the proportions of R0 resections for 10- to 20-mm sessile colorectal lesions without increasing adverse events or procedure time. Use of this procedure should be encouraged. Trials registry number: UMIN000018989.


Assuntos
Ressecção Endoscópica de Mucosa/métodos , Mucosa Intestinal/patologia , Pólipos Intestinais/cirurgia , Complicações Pós-Operatórias/epidemiologia , Prevenção Secundária/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Colo/diagnóstico por imagem , Colo/patologia , Colo/cirurgia , Ressecção Endoscópica de Mucosa/efeitos adversos , Feminino , Humanos , Mucosa Intestinal/diagnóstico por imagem , Mucosa Intestinal/cirurgia , Pólipos Intestinais/diagnóstico por imagem , Pólipos Intestinais/patologia , Japão , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Reto/diagnóstico por imagem , Reto/patologia , Reto/cirurgia , Resultado do Tratamento , Água
20.
Biomed Res Int ; 2019: 6983896, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31032359

RESUMO

Aim: The aim of the study was to evaluate costs associated with colonic endoscopic submucosal dissection (ESD) for treatment of colorectal cancer. Methods: The study is a retrospective analysis of data on 395 patients treated by colonic ESD. Results: The operation, consumable items, and medication accounted for 71% of the total costs for colonic ESD treatment. Medication and consumable items' costs were higher if lesions occurred in the transverse colon and right hemicolon compared to the left hemicolon. Medication, consumable items, and total costs were higher for larger lesions. Lesion numbers and carcinoma were associated with higher medication, consumable items, operation, and total costs. Positive surgical margins and complications of hemorrhage or perforation were positively correlated with higher costs for medication, consumable items, and total costs. Conclusion: Labor costs for doctors and nurses remain low in China. Costs for medication and consumable items were higher for treatment involving the transverse colon or right hemicolon (vs. the left hemicolon), larger lesions, carcinoma, and a positive surgical margin. A benchmark cost estimate for ESD treatment including 4 days of postoperative hospitalization was determined to be approximately 5400 USD.


Assuntos
Colo/cirurgia , Neoplasias Colorretais/cirurgia , Custos e Análise de Custo , Ressecção Endoscópica de Mucosa/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , China/epidemiologia , Colo/patologia , Colonoscopia/economia , Neoplasias Colorretais/economia , Neoplasias Colorretais/patologia , Feminino , Humanos , Mucosa Intestinal/patologia , Mucosa Intestinal/cirurgia , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Fatores de Risco , Resultado do Tratamento
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