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1.
Transplant Proc ; 51(9): 2974-2976, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31607622

RESUMO

BACKGROUND: Gastrointestinal perforation (GIP) is a rare complication after adult liver transplant (LT) associated with high morbidity and mortality. Limited data are available about clinical risk factors and underlying pathogenic mechanisms. METHODS: The retrospective study included all GIP cases from a consecutive cohort of 361 LT recipients during the period 2005-2017. Clinical variables were investigated as potential risk factors for GIP, and radiologic and histopathologic evaluations were undertaken to identify any causative mechanism. RESULTS: A total of 22 patients developed at least 1 episode of GIP (prevalence 6.1%) at a median time of 18.5 [interquartile range, 12.5-28.5] days after LT. The perforations occurred in the small bowel (63.6%), transverse colon (27.3%), right colon (22.7%), left colon (9.1%), and stomach (9.1%). A total of 27.3% of patients developed multiple sites of GIP, and in 31% GIP recurred after curative surgery. The 30-day mortality rate after relaparotomy was 40%. A history of previous abdominal surgery (odds ratio, 2.5) and early post-LT relaparotomy due to other complications (odds ratio, 2.6) were significant risk factors for GIP. No thromboembolic or steno-occlusive complications of any splanchnic vessel were detected at computed tomography scan, while histopathology examination on perforated gastrointestinal segments excluded cytomegalovirus infection, graft-vs-host disease, and inflammatory bowel disease. In all the cases, ischemic necrosis with aspecific microangiopathy and microembolization were the pathologic features detected. CONCLUSIONS: GIP is a severe complication after LT with frequent multiple gastrointestinal involvement and recurrence after curative surgery. The pathologic underlying mechanism is usually microvascular ischemia. Clinical risk factors are history of previous abdominal surgery and early post-LT relaparotomy.


Assuntos
Perfuração Intestinal/etiologia , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias/etiologia , Gastropatias/etiologia , Adulto , Feminino , Humanos , Perfuração Intestinal/epidemiologia , Perfuração Intestinal/patologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/patologia , Prevalência , Estudos Retrospectivos , Fatores de Risco , Gastropatias/epidemiologia , Gastropatias/patologia
2.
Early Hum Dev ; 137: 104836, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31437732

RESUMO

BACKGROUND: Iatrogenic gastrointestinal perforations are rare, but life-threatening events in preterm infants. AIM: Aim of the study was to report on incidence, management, morbidity, and mortality. STUDY DESIGN: This was a retrospective analysis performed at a tertiary neonatal intensive care unit in Vienna, Austria. SUBJECTS: Extremely low birth weight infants (ELBW, birth weight < 1000 g) with perforations of the upper gastrointestinal tract (GIT) caused by gastric tubes were included. OUTCOME MEASURES: All ELBW infants born within the 6-year study period were identified and their discharge summaries or notes were screened for esophageal and gastric perforations. Data on incidence, management of GIT perforations, morbidity, and mortality were obtained. RESULTS: During a 6-year study period 646 ELBW infants were analyzed. Incidence of perforations was 1.1% (n = 7/646). Median gestational age was 23 + 3 (range: 23 + 0-24 + 5). Perforations occurred on the third day of life (=median, range: day 2-14) and were primarily managed conservatively. Enteral feeding was stopped for 6 days (range: 4-13 days), antibiotic therapy administered for 16 days (range: 8-22 days). In one infant, gastrorrhaphy was performed. CONCLUSIONS: Conservative treatment of upper GIT perforations led to spontaneous recovery without major complications in 85.7%.


Assuntos
Nutrição Enteral/efeitos adversos , Perfuração Esofágica/terapia , Doença Iatrogênica/epidemiologia , Recém-Nascido de muito Baixo Peso , Perfuração Intestinal/terapia , Áustria , Tratamento Conservador/métodos , Tratamento Conservador/estatística & dados numéricos , Perfuração Esofágica/epidemiologia , Perfuração Esofágica/etiologia , Feminino , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Perfuração Intestinal/epidemiologia , Perfuração Intestinal/etiologia , Masculino , Morbidade
3.
J Surg Res ; 244: 42-49, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31279262

RESUMO

BACKGROUND: The presentation of appendicitis in pediatrics is variable, and diagnostic imaging is often used. Magnetic resonance imaging (MRI) is replacing computed tomography in some centers, particularly after a nondiagnostic ultrasound (NDUS). Nonetheless, MRI is not widely used in this setting because of cost, procedure time, institutional capacity, and high rates of negative scans. We hypothesized that the Alvarado Score (AS) could be used to determine the additive diagnostic value of MRI after an NDUS. MATERIALS AND METHODS: Retrospective review of patients aged ≤18 y at a single tertiary care children's hospital who received an ultrasound for suspected appendicitis during 10 consecutive months in 2017. NDUS were defined as nonvisualization of the appendix or secondary signs without radiologic diagnosis. AS were retrospectively calculated from the electronic medical record. Primary outcomes were pathology-confirmed appendicitis, appendectomy, and perforation. RESULTS: AS was determined for 352 patients out of 463 who met inclusion criteria (76%). Sixty-two percent had an NDUS, and 45% of these patients received MRI. Patients with high-risk AS were significantly more likely to have MRI diagnostic of appendicitis (P = 0.0015), and low-risk AS patients were more likely to have a negative or equivocal MRI (P = 0.0169). Twenty-one MRI scans were required per each additional diagnosis of appendicitis in patients with low AS after NDUS versus 4.2 in intermediate-risk AS patients and 2.1 in high-risk AS patients. CONCLUSIONS: Risk stratification with AS can help assess the additive diagnostic utility of MRI after NDUS. MRI may be overutilized for diagnosing acute appendicitis in pediatric patients with low-risk AS.


Assuntos
Apendicite/diagnóstico , Apêndice/diagnóstico por imagem , Perfuração Intestinal/epidemiologia , Índice de Gravidade de Doença , Adolescente , Algoritmos , Apendicectomia , Apendicite/complicações , Apendicite/cirurgia , Apêndice/patologia , Apêndice/cirurgia , Criança , Diagnóstico Diferencial , Feminino , Humanos , Perfuração Intestinal/etiologia , Perfuração Intestinal/prevenção & controle , Imagem por Ressonância Magnética , Masculino , Estudos Retrospectivos , Medição de Risco/métodos , Ultrassonografia
4.
Br J Surg ; 106(8): 1075-1086, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31074507

RESUMO

BACKGROUND: Although self-expandable metal stent (SEMS) placement as bridge to surgery (BTS) in patients with left-sided obstructing colonic cancer has shown promising short-term results, it is used infrequently owing to uncertainty about its oncological safety. This population study compared long-term oncological outcomes between emergency resection and SEMS placement as BTS. METHODS: Through a national collaborative research project, long-term outcome data were collected for all patients who underwent resection for left-sided obstructing colonic cancer between 2009 and 2016 in 75 Dutch hospitals. Patients were identified from the Dutch Colorectal Audit database. SEMS as BTS was compared with emergency resection in the curative setting after 1 : 2 propensity score matching. RESULTS: Some 222 patients who had a stent placed were matched to 444 who underwent emergency resection. The overall SEMS-related perforation rate was 7·7 per cent (17 of 222). Three-year locoregional recurrence rates after SEMS insertion and emergency resection were 11·4 and 13·6 per cent (P = 0·457), disease-free survival rates were 58·8 and 52·6 per cent (P = 0·175), and overall survival rates were 74·0 and 68·3 per cent (P = 0·231), respectively. SEMS placement resulted in significantly fewer permanent stomas (23·9 versus 45·3 per cent; P < 0·001), especially in elderly patients (29·0 versus 57·9 per cent; P < 0·001). For patients in the SEMS group with or without perforation, 3-year locoregional recurrence rates were 18 and 11·0 per cent (P = 0·432), disease-free survival rates were 49 and 59·6 per cent (P = 0·717), and overall survival rates 61 and 75·1 per cent (P = 0·529), respectively. CONCLUSION: Overall, SEMS as BTS seems an oncologically safe alternative to emergency resection with fewer permanent stomas. Nevertheless, the risk of SEMS-related perforation, as well as permanent stoma, might influence shared decision-making for individual patients.


Assuntos
Neoplasias do Colo/cirurgia , Obstrução Intestinal/cirurgia , Implantação de Prótese , Stents Metálicos Autoexpansíveis , Idoso , Idoso de 80 Anos ou mais , Colo/lesões , Colo/cirurgia , Neoplasias do Colo/complicações , Tratamento de Emergência , Feminino , Humanos , Obstrução Intestinal/etiologia , Perfuração Intestinal/epidemiologia , Perfuração Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Países Baixos , Pontuação de Propensão , Implantação de Prótese/métodos , Implantação de Prótese/estatística & dados numéricos , Stents Metálicos Autoexpansíveis/efeitos adversos , Stents Metálicos Autoexpansíveis/estatística & dados numéricos , Resultado do Tratamento
5.
J Pediatr Surg ; 54(10): 2084-2091, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31084913

RESUMO

BACKGROUND: Spontaneous intestinal perforation (SIP) is an intestinal complication that occurs in very ill preterms. We investigated whether SIP survivors have worse neurodevelopmental and gastrointestinal outcomes and a poorer quality of life than controls. METHODS: A retrospective case-matched cohort study was performed involving infants treated for SIP in a NICU between August 1994 and April 2014. Controls and SIP patients were matched to gestational age, gender, and birth period. Medical records were reviewed. Telephone surveys were conducted to evaluate the medical condition, quality of life (PedsQL™ 4.0), neuropsychiatric and gastrointestinal outcome. McNemar's and Wilcoxon tests were performed, and generalized linear models were computed. RESULTS: Forty-nine SIP patients were included. The percentages of children with multiple disabilities (40% vs. 17%, OR = 3.3) and requiring physiotherapy (86% vs. 60%, OR = 4.77) were higher in the SIP group than in the control group. Intraventricular hemorrhage (IVH) led to a worse neurodevelopmental outcome regardless of SIP (OR = 8.79 for disability), and female gender was a protective factor against disability (OR = 0.06). Reported quality of life and gastrointestinal comorbidities did not differ between the two groups. CONCLUSION: SIP survivors tend to be at risk of multiple disabilities. IVH and female gender influence the neurodevelopmental outcome regardless of SIP. LEVELS OF EVIDENCE: Level III: case-control study.


Assuntos
Doenças do Recém-Nascido , Recém-Nascido de muito Baixo Peso , Perfuração Intestinal , Estudos de Casos e Controles , Deficiências do Desenvolvimento , Feminino , Humanos , Recém-Nascido , Doenças do Recém-Nascido/epidemiologia , Doenças do Recém-Nascido/fisiopatologia , Doenças do Recém-Nascido/terapia , Perfuração Intestinal/epidemiologia , Perfuração Intestinal/fisiopatologia , Perfuração Intestinal/terapia , Masculino , Qualidade de Vida , Estudos Retrospectivos , Resultado do Tratamento
6.
J BUON ; 24(2): 431-435, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31127987

RESUMO

PURPOSE: To assess outcomes of surgical management for iatrogenic colonic perforations and risk factors of worse outcome. METHODS: We reviewed the medical records of patients with colonic perforations during colonoscopies 2007 - 2016 at the National Cancer Institute. We collected patient demographic data, colonoscopic reports, perforations treatment and outcome. RESULTS: Perforation rate was 0.14% (23 of 16 186). Twenty were managed surgically. The most common location of perforation was the sigmoid colon in 12 cases (60%). The most used surgical technique was simple suture (11 cases - 55%), followed by resection with anastomosis (6 - 30%), and Hartman's procedure in 3 cases (15%). Postoperative morbidity and mortality rates were 45% and 15% - three patients died. No significant relationship between time to surgery (p=0.285), American Society of Anaesthesiologists (ASA) score (p=0.642) or patient age (p=0.964) and postoperative complication were found. CONCLUSIONS: Patients need to be informed of the complications of colonoscopy. We could not determine strong risk factors for worse outcomes.


Assuntos
Doenças do Colo/patologia , Colonoscopia/efeitos adversos , Doença Iatrogênica/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Anastomose Cirúrgica/efeitos adversos , Colo/patologia , Colo/cirurgia , Doenças do Colo/diagnóstico , Doenças do Colo/etiologia , Doenças do Colo/cirurgia , Feminino , Humanos , Doença Iatrogênica/prevenção & controle , Perfuração Intestinal/epidemiologia , Perfuração Intestinal/patologia , Perfuração Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/patologia , Fatores de Risco
7.
Surg Infect (Larchmt) ; 20(6): 453-459, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30932745

RESUMO

Background: Although uncomplicated acute diverticulitis has a benign disease course, some patients are at increased risk for complications. Identification of these patients may aid the selection of treatment strategies such as outpatient treatment. This study aimed to assess the rate and timing of a complicated disease course in initially computed tomography (CT)-proven uncomplicated diverticulitis, and to identify risk factors for the development of these diverticular complications. Patients and Methods: Computed tomography-proven, left-sided uncomplicated diverticulitis patients from two cohorts were included. Main outcome measure was complicated diverticulitis (perforation, abscess, obstruction, or fistula) within three months after presentation. Risk factors for diverticular complications were identified using multivariable logistic regression. Results: Of the 1,087 patients with initially CT-proven uncomplicated diverticulitis, 4.9% (53/1,087) developed complicated diverticulitis. Most perforations and abscesses (16/21) occurred during the first 10 days, whereas colonic obstruction and fistula occurred during three months of follow-up. Independent risk factors for the transition from uncomplicated to complicated diverticulitis were American Society of Anesthesiologists (ASA) classification 3/4 (odds ratio [OR] 4.43, 95% confidence interval [CI] 1.57-12.48), duration of symptoms before presentation longer than five days (OR 3.25, 95% CI 1.72-6.13), vomiting (OR 3.94, 95% CI 1.96-7.92), and C-reactive protein (CRP) above 140 mg/L (OR 2.86, 95% CI 1.51-5.43). Conclusion: Approximately one in 20 patients with CT-proven uncomplicated diverticulitis develops a complicated disease course within three months; perforation and abscess occur predominantly within 10 days after presentation. Patients with systemic comorbidity, symptoms for more than five days, those who vomit, or have high CRP levels at presentation are at risk for diverticular complications after an uncomplicated initial presentation and may warrant closer observation.


Assuntos
Abscesso Abdominal/epidemiologia , Fístula do Sistema Digestório/epidemiologia , Diverticulite/complicações , Diverticulite/diagnóstico , Obstrução Intestinal/epidemiologia , Perfuração Intestinal/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Radiografia Abdominal , Fatores de Risco , Tomografia Computadorizada por Raios X
8.
Korean J Gastroenterol ; 73(3): 152-158, 2019 03 25.
Artigo em Inglês | MEDLINE | ID: mdl-31013558

RESUMO

Background/Aims: Despite the many reports of colonoscopy complications worldwide, few studies have been performed at the population level in Korea. In this study, a population-based study was performed to evaluate the incidence of post-colonoscopy perforations compared to a control group. Methods: Between January 2011 and December 2011, data for all cases (age over 45) who underwent a colonoscopy were collected from National Health Insurance Service using a random sampling method. The clinical characteristics and perforation incidence (within 30 days after the colonoscopy) of cases were identified, and cases were then compared with controls who had not undergone a colonoscopy. Results: Among 1,380,000 subjects, 31,177 cases and 62,354 controls were identified. Perforation occurred in 14 patients (0.04%) in the case group and one patient (<0.01%) in the control group (RR, 28.0; 95% CI 3.7-212.9, p<0.001). Subgroup analysis was followed according to the endoscopic procedure, gender and age. In subgroup analysis, colonoscopy-associated perforations occurred more in the therapeutic procedure (RR, 26; 95% CI 1.46-461.46), male (RR, 50; 95% CI 2.96-844.41), and age of 45-60 years (RR, 30; 95% CI 1.71-525.23). Conclusions: A colonoscopy procedure is related to an increased risk of perforation at the population level. In addition, the therapeutic procedure, male, and age of 45-60 years appeared to be associated with an increased risk of perforation.


Assuntos
Colonoscopia/efeitos adversos , Perfuração Intestinal/etiologia , Idoso , Estudos de Casos e Controles , Bases de Dados Factuais , Feminino , Humanos , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/epidemiologia , Masculino , Pessoa de Meia-Idade , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores de Risco
9.
Rinsho Shinkeigaku ; 59(3): 153-156, 2019 Mar 28.
Artigo em Japonês | MEDLINE | ID: mdl-30814443

RESUMO

We analyzed 14 patients in our hospital, who underwent levodopa-carbidopa intestinal gel (LCIG) treatment through a percutaneous endoscopic gastrojejunostomy (PEG-J). The PEG-J related complications were observed in 10 patients (71.4%). Detailed complications are as followings: J-tube related complications such as kinking (3 cases, 21.4%), pump malfunctions (3 cases, 21.4%), skin troubles in the gastrostoma (7 cases, 50.0%), duodenal perforation, peritonitis, and ulcers (2 cases, 14.3%). These results indicated that the sufficient care for PEG-J associated complications are important in LCIG treatment.


Assuntos
Antiparkinsonianos/administração & dosagem , Carbidopa/administração & dosagem , Endoscopia Gastrointestinal/efeitos adversos , Gastrostomia/efeitos adversos , Jejunostomia/efeitos adversos , Levodopa/administração & dosagem , Doença de Parkinson/tratamento farmacológico , Adulto , Idoso , Combinação de Medicamentos , Duodenopatias/epidemiologia , Duodenopatias/etiologia , Úlcera Duodenal/epidemiologia , Úlcera Duodenal/etiologia , Endoscopia Gastrointestinal/instrumentação , Endoscopia Gastrointestinal/métodos , Feminino , Gastrostomia/instrumentação , Gastrostomia/métodos , Géis , Humanos , Perfuração Intestinal/epidemiologia , Perfuração Intestinal/etiologia , Jejunostomia/instrumentação , Jejunostomia/métodos , Masculino , Pessoa de Meia-Idade , Peritonite/epidemiologia , Peritonite/etiologia , Estudos Retrospectivos , Dermatopatias/epidemiologia , Dermatopatias/etiologia , Estomas Cirúrgicos
10.
Ann Afr Med ; 18(1): 36-41, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30729931

RESUMO

Background: Acute perforation of the appendix is one of the complications of appendicitis that is associated with increased morbidity and mortality and hence regarded as a surgical emergency. Risk factors for perforated appencidicits include extremes of age, male sex, pregnancy, immunosuppression, comorbid medical conditions and previous abdominal surgery. Objectives: This study focuses on the pattern of presentation, risk factors, morbidity and mortality of patients managed for perforated appendicitis in our centre. Subjects and Methods: We conducted a seven-year retrospective review of consecutive adult patients who had surgery for perforated appendicitis in our centre. Results: The perforation rate in the study was 28.5%. The peak age of presentation was between 21-30 years. Forty-two (71.1%) of the patients under study were males. Only 3 (5.1%) of the cohorts had history of recurrent abdominal pain. Majority of the patients were in the American Society of Anesthesiologists (ASA) II (44.1%) and III (42.4%) categories. Surgical site infections (SSI) (18.6%), wound dehiscence (15.2%) and pelvic abscess (13.5%) were the most common complications. The Incidence of SSI was found to correlate with male gender, (P = 0.041), co-morbidity (P = 0.037) and ASA score (0.03) at 95% confidence interval. Routine use of intraperitoneal drain after surgery for perforated appendicitis did not appear to reduce the incidence of pelvic abscess. No mortality in the studied population. Conclusion: Appendiceal perforation was more common in male patients with first episode of acute appendicitis. Previous abdominal surgery and comorbid medical conditions were of lesser risk factors for appendiceal perforation in our patients. Surgical site infection was the commonest complication after surgery.


Assuntos
Dor Abdominal/etiologia , Apendicectomia/estatística & dados numéricos , Apendicite/cirurgia , Drenagem/métodos , Perfuração Intestinal/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , Apendicite/epidemiologia , Feminino , Humanos , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/epidemiologia , Perfuração Intestinal/mortalidade , Masculino , Pessoa de Meia-Idade , Morbidade , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Distribuição por Sexo , Resultado do Tratamento
11.
Rheumatology (Oxford) ; 58(Suppl 1): i34-i42, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30806708

RESUMO

To facitinib and baricitinib are two of the currently available Janus kinase (JAK) inhibitors for the treatment of patients with RA. Randomized controlled trials have shown that these JAK inhibitors are as efficacious as biological DMARDs. Safety profiles of these JAK inhibitors in randomized controlled trials and their long-term extension studies have been demonstrated; however, real world evidence remains to be established to bridge the gap between randomized controlled trials and rheumatology clinics. Fundamentally, no difference in the screening, prevention, and monitoring of infections between JAK inhibitors and biological DMARDs exists. However, increased risk of herpes zoster is probably common to all JAK inhibitors. No indication of increased risk for malignancy in patients with RA treated with JAK inhibitors has been reported. To evaluate risks of relatively rare serious adverse events such as thromboembolic events, gastrointestinal perforation, and interstitial lung disease in clinical settings, accumulation of cases with these events are needed. Continuous pharmacovigilance activity is absolutely warranted to establish the safety of JAK inhibitors in patients with RA and other rheumatic diseases.


Assuntos
Artrite Reumatoide/tratamento farmacológico , Doenças Cardiovasculares/epidemiologia , Perfuração Intestinal/epidemiologia , Inibidores de Janus Quinases/uso terapêutico , Doenças Pulmonares Intersticiais/epidemiologia , Tromboembolia Venosa/epidemiologia , Gastroenteropatias/epidemiologia , Herpes Zoster/epidemiologia , Humanos , Neoplasias/epidemiologia , Farmacovigilância , Risco , Medição de Risco
12.
J Surg Res ; 238: 113-118, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30769247

RESUMO

BACKGROUND: Numerous factors contribute to advanced disease or increased complications in patients with acute appendicitis (AA). This study aimed to identify risk factors associated with AA perforation, including the effect of system time (ST) delay, after controlling for patient time (PT) delay. In this study, PT was controlled (to less than or equal to 24 h) to better understand the effect of ST delay on AA perforation. METHODS: Medical records of patients who underwent surgery for AA at a tertiary referral hospital from October 2009 through September 2013 were reviewed. Data collected included demographics, body mass index, presence of fecalith, PT (i.e., duration of time from symptom onset to arrival in emergency department), and ST (i.e., duration of time from arrival in emergency department to operating room). AA was classified as simple (acute, nonperforated) versus advanced (gangrenous, perforated). RESULTS: Seven hundred forty-seven patients underwent surgery for AA. After excluding patients with PT > 24 h, 445 patients fit the study criteria, of which 358 patients with simple AA and 87 patients with advanced disease. Advanced appendicitis patients were older and had higher body mass index, longer PT, higher WBC, and higher incidence of fecaliths. Both groups had similar ST. Risk factors for advanced appendicitis after multiple regression analysis are age >50 y old, WBC >15,000, the presence of fecaliths, and PT delay >12 h. CONCLUSIONS: Once PT delay was limited to ≤24 h, the ST delay of >12 h did not adversely affect the incidence of advanced AA. Age >50 y, WBC >15,000, PT delay >12 h, and the presence of fecaliths were identified as risk factors associated with advanced AA.


Assuntos
Apendicectomia/estatística & dados numéricos , Apendicite/cirurgia , Impacção Fecal/epidemiologia , Perfuração Intestinal/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Apendicite/complicações , Serviço Hospitalar de Emergência/estatística & dados numéricos , Impacção Fecal/etiologia , Impacção Fecal/cirurgia , Feminino , Humanos , Incidência , Perfuração Intestinal/etiologia , Perfuração Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Adulto Jovem
13.
Gastrointest Endosc ; 90(1): 116-124, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30797835

RESUMO

BACKGROUND AND AIMS: The aim of this study was to examine clinical outcomes and adverse events (AEs) of self-expandable metal stents (SEMSs) in the management of malignant colonic obstruction (MCO). METHODS: Patients with SEMSs for MCO treated at our institution from 2007 to 2016 were included. Clinical success was defined as successful oral intake after the procedure and technical success as stent deployment across the stricture in the desired location. RESULTS: Of 199 patients, the mean age was 58, 54% were men, and 99% had stage IV cancer. MCO etiology was colorectal cancer in 82% and extrinsic compression in 17%. Technical success was achieved in 99.5% and clinical success in 89%. The SEMSs were palliative in 97% and were a bridge to surgery in 4%. MCO occurred in the left side of the colon in 90%, transverse in 4.5%, and ascending colon in 5.5%. SEMSs were placed in curved segments in 30% and straight segments in 70%. Tandem SEMSs were required in 27 patients. Forty-six patients had 48 AEs (24%), including 2% periprocedure, 15% postprocedure, and 83% after 72 hours. Stent-related AEs (n = 25) included persistent obstruction (n = 14), occlusion (n = 10), and failure of expansion (n = 1). Procedural AEs (n = 23) included minor bleeding (n = 2), perforations (n = 4), abdominal pain (n = 12), stent migration (n = 4), and respiratory insufficiency (n = 1). Repeat procedures were performed in 21 of 46 patients. After SEMSs, 48 patients underwent surgery, including resection with primary anastomosis (n = 8), resection with definitive stoma (n = 18), and diverting stoma without resection (n = 19). Mean time to surgery after SEMS placement was 175 days. Postsurgical AEs occurred in those with resections (leak, 2; infection, 2). Of 104 receiving bevacizumab, 22% had AEs, including 1 perforation compared with 3 in the nonbevacizumab group (P = .549). Mean overall survival was 5.6 months. Extrinsic compression and curved strictures were associated with poor clinical success by univariate analysis and etiology (noncolonic with poor outcome) by multivariate analysis. CONCLUSIONS: SEMSs for MCO has high technical but suboptimal clinical success. Curved strictures and extrinsic compression are associated with poor outcomes. The perforation rate was not higher in the bevacizumab compared with the nonbevacizumab group, although this should be further validated in a larger population.


Assuntos
Antineoplásicos Imunológicos/uso terapêutico , Bevacizumab/uso terapêutico , Colonoscopia , Neoplasias Colorretais/terapia , Obstrução Intestinal/cirurgia , Complicações Pós-Operatórias/epidemiologia , Stents Metálicos Autoexpansíveis , Dor Abdominal/epidemiologia , Idoso , Anastomose Cirúrgica , Colectomia , Neoplasias Colorretais/complicações , Neoplasias Colorretais/patologia , Colostomia , Constrição Patológica , Feminino , Humanos , Obstrução Intestinal/etiologia , Perfuração Intestinal/epidemiologia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias/complicações , Cuidados Paliativos , Falha de Prótese , Estudos Retrospectivos , Taxa de Sobrevida
14.
World J Gastroenterol ; 25(2): 190-204, 2019 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-30670909

RESUMO

Colonoscopy is a widely used method for diagnosing and treating colonic disease. The number of colonoscopies is increasing worldwide, and concerns about associated adverse events are growing. Large-scale studies using big data for post-colonoscopy complications have been reported. A colon perforation is a severe complication with a relatively high mortality rate. The perforation rate, as reported in large studies (≥ 50,000 colonoscopies) published since 2000, ranges from 0.005-0.085%. The trend in the overall perforation rate in the past 15 years has not changed significantly. Bleeding is a more common adverse event than perforation. Recent large studies (≥ 50,000 colonoscopies) have reported post-colonoscopy bleeding occurring in 0.001-0.687% of cases. Most studies about adverse events related to colonoscopy were performed in the West, and relatively few studies have been conducted in the East. The incidence of post-colonoscopy complications increases in elderly patients or patients with inflammatory bowel diseases. It is important to use a unified definition and refined data to overcome the limitations of previous studies. In addition, a structured training program for endoscopists and a systematic national management program are needed to reduce post-colonoscopy complications. In this review, we discuss the current trends in colonoscopy related to adverse events, as well as the challenges to be addressed through future research.


Assuntos
Doenças do Colo/diagnóstico por imagem , Colonoscopia/efeitos adversos , Educação Médica Continuada/tendências , Saúde Global/tendências , Complicações Pós-Operatórias/epidemiologia , Doenças do Colo/epidemiologia , Colonoscopia/educação , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/etiologia , Saúde Global/estatística & dados numéricos , Humanos , Incidência , Perfuração Intestinal/epidemiologia , Perfuração Intestinal/etiologia , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento
15.
J Gastroenterol Hepatol ; 34(5): 857-863, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30357907

RESUMO

BACKGROUND AND AIM: Vascular Ehlers-Danlos syndrome (vEDS) is a rare connective tissue disorder due to heterozygous mutations in the COL3A1 gene with a dominant negative effect. Spontaneous bowel perforation and intra-abdominal organ rupture are common complications of vEDS. Other gastrointestinal (GI) manifestations may occur but have not been extensively characterized. We herein describe the natural history of GI events and surgery-related complications in patients with vEDS. METHODS: A retrospective review of GI events in a large cohort of molecularly proven vEDS patients was conducted, after exclusion of mild forms of the disease. RESULTS: Of 133 patients, 41% had a history of GI manifestations with 112 events, mean 2.0 ± 1.3 events per patient. There was an earlier occurrence of GI events in men (P 0.008). Cumulative incidence was 58% for all patients, higher in men and in patients with splice-site variants. Recurrence of GI events was reported in more than 50% of patients. Colonic perforation was the first digestive event for 47% of patients. Of 85 GI surgeries, 37 (43%) were complicated with 43 events. Nine deaths were reported in this population. CONCLUSIONS: Vascular Ehlers-Danlos syndrome is characterized not only by bowel perforation but also by a wide variety of GI complications that occur in close to half (41%) of patients. The pattern of GI fragility seems more severe in males and splice-site variants. Complications of GI surgery are common and are related with tissue fragility/friability.


Assuntos
Síndrome de Ehlers-Danlos/complicações , Perfuração Intestinal/etiologia , Adulto , Colágeno Tipo III/genética , Síndrome de Ehlers-Danlos/genética , Feminino , Humanos , Incidência , Perfuração Intestinal/epidemiologia , Masculino , Pessoa de Meia-Idade , Mutação , Estudos Retrospectivos , Fatores Sexuais , Fatores de Tempo , Adulto Jovem
16.
Digestion ; 100(2): 100-108, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30466078

RESUMO

BACKGROUND/AIMS: Recent trends in complications following inpatient therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) remain poorly defined. We studied trends of gastrointestinal (GI) hemorrhage, perforation, and mortality following inpatient therapeutic ERCPs from 2000 to 2012 with the hypothesis that ERCPs would have down trending complication rates. METHODS: First, we isolated therapeutic ERCPs in patients 18 years or older using the International Classification of Diseases, Ninth Edition in the 2000 to 2012 National Inpatient Sample databases. Procedures complicated by hemorrhage, perforation, and mortality were identified. Multivariate logistic regressions were used to calculate trends in complication rates and secondary variables, including hospital and patient demographics. Time series regressions were then built for each complication to assess for trends from 2000 to 2012. RESULTS: The mortality rate decreased from 1.77 to 1.24%, a trend that was confirmed by time series regression. Perforation rates increased from 0.07 to 0.10% for therapeutic ERCPs. However, time series regression did not show a significant trend. GI hemorrhage rates increased from 1.36 to 1.57% and this uptrend was confirmed by our time series regression. CONCLUSION: Therapeutic ERCPs have become safer, as demonstrated by a down trending mortality rate. Over the same time, GI hemorrhage rates trended upwards, while no change was noted in perforation rates.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Hemorragia Gastrointestinal/epidemiologia , Mortalidade Hospitalar/tendências , Perfuração Intestinal/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia Gastrointestinal/etiologia , Humanos , Perfuração Intestinal/etiologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estados Unidos/epidemiologia , Adulto Jovem
17.
Arthritis Care Res (Hoboken) ; 71(4): 498-511, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-29856128

RESUMO

OBJECTIVE: Using the UK Clinical Practice Research Datalink, we examined the incidence of glucocorticoid (GC)-related serious adverse events (SAEs) in rheumatoid arthritis (RA) and non-RA patients and quantified the risk of SAEs in patients with RA. METHODS: We matched incident patients with RA to an age- and sex-matched, non-RA comparison group of equal size. In a cohort analysis, we estimated incidence rates (IRs) and IR ratios (IRRs) for GC-related AEs (i.e., diabetes mellitus [DM], osteoporosis, fractures, glaucoma, hypertension, gastrointestinal [GI] perforation or bleeding, thrombotic stroke or myocardial infarction [MI], or death), stratified by GC use. We conducted a series of nested case-control analyses among patients with RA, evaluating the effects of increasing cumulative and average daily GC dose. Cases of each outcome were matched to controls for age, sex, and general practice. We calculated adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) for each outcome. RESULTS: Patients with RA had a higher incidence for all investigated SAEs except glaucoma, compared to non-RA patients. IRRs were greater in those patients prescribed a GC than in those without. In patients with RA, GCs were associated with an elevated risk of DM (adjusted OR 1.33 [95% CI 1.14-1.56]), osteoporosis (adjusted OR 1.41 [95% CI 1.25-1.59]), thrombotic stroke or MI (adjusted OR 1.28 [95% CI 1.07-1.52]), serious infection (adjusted OR 1.28 [95% CI 1.11-1.48]), and death (adjusted OR 1.33 [95% CI 1.19-1.48]). There was a trend of increasing risk with increasing cumulative and average daily GC dose for all outcomes other than glaucoma, hypertension, and GI perforations or bleeding (P < 0.05). CONCLUSION: Patients with RA had an increased incidence of GC-related AEs. Increasing cumulative and average daily GC doses were found to be associated with an increasing risk of developing an AE.


Assuntos
Artrite Reumatoide/tratamento farmacológico , Doenças Cardiovasculares/induzido quimicamente , Diabetes Mellitus/induzido quimicamente , Glucocorticoides/efeitos adversos , Osteoporose/induzido quimicamente , Artrite Reumatoide/mortalidade , Doenças Cardiovasculares/epidemiologia , Estudos de Casos e Controles , Diabetes Mellitus/epidemiologia , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/epidemiologia , Glaucoma/induzido quimicamente , Glaucoma/epidemiologia , Humanos , Incidência , Perfuração Intestinal/induzido quimicamente , Perfuração Intestinal/epidemiologia , Masculino , Pessoa de Meia-Idade , Osteoporose/epidemiologia , Reino Unido/epidemiologia
18.
Pediatr Emerg Care ; 35(1): 45-49, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27749630

RESUMO

OBJECTIVE: The aim of this study was to assess whether increased time from emergency department (ED) triage to appendectomy is associated with a greater risk of children developing appendiceal perforation. METHODS: We performed a multicenter retrospective cohort study of children younger than 18 years hospitalized with appendicitis. To avoid enrolling patients who had perforated prior to ED arrival, we included only children who had a computed tomography (CT) scan demonstrating nonperforated appendicitis. Time to appendectomy was measured as time from ED triage to incision. The main outcome was appendiceal perforation as documented in the surgical report. Variables associated with perforation in bivariate analysis (P < 0.05) were adjusted for using logistic regression. RESULTS: Overall, 857 patients had a CT scan that demonstrated nonperforated appendicitis. The median age was 12 years (interquartile range, 9-15 years), and 500 (58%) were male. The median time to appendectomy was 11 hours (interquartile range, 8-15 hours). In total, 111 patients (13%) had perforated appendicitis at operation. Children who developed perforation were more likely to require additional CT scans and return to the ED and had a significantly longer length of stay. After adjusting for potential confounders, every hour increase in the time from ED triage to incision was independently associated with a 2% increase in the odds of perforation (P = 0.03; adjusted odds ratio, 1.02; 95% confidence interval, 1.00-1.04). CONCLUSIONS: Delays in appendectomy were associated with an increase in the odds of perforation. These results suggest that prolonged delays to appendectomy might be harmful for children with appendicitis and should be minimized to prevent associated morbidity.


Assuntos
Apendicectomia/estatística & dados numéricos , Apendicite/cirurgia , Perfuração Intestinal/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos , Adolescente , Apendicite/complicações , Criança , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Humanos , Perfuração Intestinal/etiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X
19.
Minerva Chir ; 74(2): 137-145, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29795067

RESUMO

INTRODUCTION: Small bowel non-Meckelian diverticulitis (SBNMD) is not so an uncommon cause of admission in departments of emergency surgery. Our aim is to highlight signs and symptoms for early diagnosis and report proper surgical treatments. EVIDENCE ACQUISITION: The systematic review protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P). EVIDENCE SYNTHESIS: Twelve studies met our inclusion criteria. A total of 527 patients diagnosed with SBNMD were analyzed: there were 159 (30%) cases of diverticular bleeding, 125 (23%) cases of perforated SBNMD, 91 (17.26%) cases of intestinal obstruction, 79 (14.9%) cases of non-complicated diverticulitis, and 36 (6.8%) cases of ileal diverticulosis. Among bleeding patients, endoscopy procedures were performed in 51 (32%) cases. Surgery was necessary in 77/159 (48.4%) cases. Medical treatment was sufficient in 15/159 (9.4%) cases. In case of perforation, 93/125 (74.4%) patients were submitted to surgery, with open technique in 78/93 (83.8%) patients, by laparoscopy in 2/93 (2.1%) with conversion rate of 1.07%. Eight of 125 (6.4%) cases received medical treatment. In case of obstruction, non-operative management was effective in 3/91 (3.2%) cases. Surgery was performed in 74/91 (78%) cases, with open technique in 64/91 (86.4%) cases, by laparoscopy in 3/74 (4%), with one patient converted in laparotomy. CONCLUSIONS: Diagnosis of SBNMD is often made at emergency surgical exploration with high morbidity and mortality rate. SBNMD must be considered in elderly patients presenting with abdominal pain. A multidisciplinary approach to the patient (involving a radiologist, a surgeon, and a gastroenterologist) is necessary to make an early diagnosis. In case of complicated SBNMD, the emergency surgeon must choose the right surgical treatment.


Assuntos
Diverticulite/diagnóstico , Doenças do Íleo/diagnóstico , Intestino Delgado , Doenças do Jejuno/diagnóstico , Abdome Agudo/etiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Diverticulite/complicações , Diverticulite/terapia , Doença Diverticular do Colo , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/epidemiologia , Humanos , Doenças do Íleo/complicações , Doenças do Íleo/terapia , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/epidemiologia , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/epidemiologia , Doenças do Jejuno/complicações , Doenças do Jejuno/terapia , Masculino , Pessoa de Meia-Idade , Distribuição por Sexo , Avaliação de Sintomas , Adulto Jovem
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