Resultados quirúrgicos a corto y mediano plazo por enfermedad de Crohn ileocecal / Short and medium term results of the surgical management of ileocecal Crohn's disease

BACKGROUND: The treatment of Crohn's disease (CD) is based on medical therapy and surgery is reserved for failure of medical management or complications. AIM: To evaluate endoscopic, clinical, and surgical recurrence of CD after surgery. MATERIAL AND METHODS: In a prospectively maintained database, consecutive patients older than 15 years subjected to an ileocecal resection for ileocolic disease from January 2011 to April 2021, were identified. The diagnosis of CD was confirmed with the pathologic report. Patients with less than one year of follow-up were excluded. Information was obtained retrospectively from the database and clinical records. RESULTS: Fourteen patients were identified. The mean age at the time of surgery was 38 years. Surgery was performed at a median of 41.5 months (0-300) after the diagnosis of CD, nine elective and five emergency procedures. In five patients there were four major and two minor postoperative complications, with no anastomotic leakage. Six patients had endoscopic recurrence and seven had clinical recurrence (50%) at a mean of 15 months, one of whom required a second operation. There was no mortality. CONCLUSIONS: After the surgical treatment of CD, the clinical and endoscopic recurrence rate continues to be high.

Contracción paradojal del puborrectal como causa de defecación obstructiva: resultados a corto plazo del tratamiento con biofeedback y rehabilitación pelviperineal / Puborectal paradoxical contraction as a cause of obstructive defecation: short-term outcomes of treatment with biofeedback and pelviperineal rehabilitation

Resumen Introducción: En pacientes constipados crónicos por obstrucción de salida, la contracción paradojal del puborrectal (CPP) o "anismo" es frecuente. El tratamiento con Biofeedback y rehabilitación pelviperineal presenta resultados exitosos entre el 40-90%. Objetivo: Evaluar el resultado del tratamiento con Biofeedback y rehabilitación pelviperineal en pacientes con CPP a corto plazo. Materiales y Método: Serie de casos. Datos obtenidos prospectivamente de la Unidad de Piso Pelviano. Se incluyó pacientes entre 2008 y 2015 que cumplían criterios de constipación crónica secundaria a CPP, confirmado por manometría anorrectal y/o defeco-resonancia. Se analizaron datos demográficos, frecuencia de evacuaciones, uso de laxantes, enemas, pujo, Score de Altomare y Score de constipación de Wexner pre y post-tratamiento. Resultados: 43 pacientes, de los cuales 39 son mujeres. Edad media de 40 años (rango: 14-84). Duración de síntomas fue ≥ 5 años en el 72,5%. Mediana de sesiones de Biofeedback de 8 (6-10). El 62,8% presenta ≤ 2 evacuaciones semanales y disminuye a un 29,3% post-tratamiento (p < 0,001). El 76,2% requiere laxantes orales y el 42,9% enemas, disminuyendo a 35,1% (p < 0,001) y 5,4% (p < 0,001) respectivamente post-tratamiento. Sensación de evacuación incompleta/fragmentada en todos los intentos mejoró de 67,4% a 14,6% (p < 0,001) y el pujo excesivo en más de la mitad de intentos mejoró de 76,1% a 10,8% (p < 0,001). Score de Wexner para constipación y Altomare mejoró de 18 a 7 (p < 0,001) y de 16 a 5 (p < 0,001) respectivamente. Conclusión: El biofeedback y la rehabilitación pelviperineal son efectivas en el tratamiento de la CPP.

Introduction: In patients with chronic constipation by obstructive defecation syndrome Paradoxical Puborectalis Contraction or "anismus" is important. Successful results for Biofeedback treatment and Pelviperineal Rehabilitation it described between 40-90%. Aim: To evaluate the outcome of biofeedback and pelviperineal rehabilitation in patients with CPP in the short-term. Materials and Method: Case series. Data was obtained from the prospective database of Pelvic Floor Unit of Universidad Católica de Chile. Patients with anismus were included between 2008 and 2015. Diagnostic criteria were chronic constipation patients by anismus with anorectal manometry and/or defecoresonancy that confirms this disorder and discards other causes of obstruted defecation síndrome. Demographic variables, frequency of bowel movements, use of laxatives, enemas, pushing, Altomare Score and Wexner constipation Score were analyzed pre and post-treatment. Results: Series of 43 patients, 39 of whom where women. Median age: 40 years (range: 14-84). Duration of symptoms ≥ 5 years in 72.5%. Median of Biofeedback sessions: 8 (range 6-10). Pre-treatment, 62.8% had ≤ 2 evacuations weekly and 29.3% post-treatment (p < 0.001). Oral laxatives were required in 76.2% and 42.9% enemas, decreasing to 35.1% (p < 0.001) and 5.4% (p < 0.001) post-treatment respectively. Feeling of incomplete/evacuation fragmented all the time improved from 67.4% to 14.6% (p < 0.001) and excessive pushing in more than half of time improved from 76.1% to 10.8% (p < 0.001). Wexner Score for and Altomare Score improved from 18 to 7 (p < 0.001) and 16 to 5 (p < 0.001) respectively. Conclusion: Adult with chronic constipation by anismus can be treated effectively with Biofeedback and Pelviperineal Rehabilitation.

Colitis de Crohn: resultados del tratamiento quirúrgico y evolución alejada / Outcome of surgery for Crohn's colitis: review of 28 cases

Background: Exclusive involvement of the colon or rectum in Crohn's disease, called Crohn's colitis, (CC) occurs in about 25% of these patients. Aim: To analyze early surgical results and long-term outcomes of patients undergoing surgery for CC. Material and Methods: Review of a prospective database, identifying patients with Crohn's disease operated between 2003 and 2015 and excluding those with ileocecal disease. We analyzed demographic data, pre and postoperative pharmacological treatment, operations, morbidity and the need for a second bowel resection at follow-up. Results: We reviewed data from 28 patients aged 17 to 72 years (15 men). Twenty-seven (96.4%) had previous pharmacological treatment, 11 received monoclonal antibodies. The most common indications for surgical treatment were failure of medical treatment in 15 cases, acute severe colitis in 12 and anemia/malnutrition in eight. Total colectomy was performed in 17 (61%) patients, proctocolectomy in 8 (29%) and segmental colectomies in 3 (11%). Sixteen (57%) were operated laparoscopically. Major postoperative complications were observed in 5 (18%). Four needed a reintervention. There was no operative mortality. During a 55 months median follow-up of 27 patients, seven (26%) required a second bowel resection, one of them for recurrence. Nineteen (70%) patients had an ostomy, which was permanent in 11. Fifteen patients are without medical treatment. Conclusions: Most of the reviewed patients required total colectomy for the control of the disease with a low surgical morbidity. Two-thirds required an ileostomy, which became permanent in half of them.

Factores asociados a morbilidad precoz en cirugía colorrectal laparoscópica / Factors associated with early morbidity in laparoscopic colorectal surgery

Introduction: different factors have been associated with increased risk of complications in laparosco-pic colorectal surgery. The aim of this study is to identify these factors in our series. Method: retrospective cohort. All patients undergoing laparoscopic colorectal surgery between january 2000 and june 2012 were included. Patients who had postoperative complications until 30 days postoperatively were identified and analyzed by univariate and multivariate logistic regression. A p value less than 0.2 was used was used as a criteria for entry into the multivariate model. Results: the series consists of 848 patients with a median age of 58 +/- 22 years. Main surgical indications were: neoplasia (42.3 percent), diverticular disease (27.8 percent) and inflammatory bowel disease (8.8 percent). Most frecuently-performed procedures were: sigmoidectomy (39.5 percent), anterior resection of the rectum (13.4 percent), right hemicolectomy (13 percent) and total colectomy (8.7 percent). On univariate analysis, factors associated with complications were age over 75 years (OR 1.82, 95 percent CI 1.02 to 3.25) and red blood cell transfusion (OR 8.47, 95 percent CI 3.69 to 19.43). On multivariate analysis, red blood cell transfusion (OR 7.9 95 percent CI 1.78 to 35.88) and ASA III or IV (OR 3.26 95 percent CI 1.01 to 17.23) were independent factors associated with postoperative complications. Conclusion: intraoperative red blood cell transfusion and ASA score III or IV are independent risk factors associated with complications in laparoscopic colorectal surgery.

Introducción: se han descrito factores que se asocian a mayor riesgo de complicaciones en cirugía laparoscópica colorrectal. El objetivo de este trabajo es identificar estos factores en nuestra serie. Método: cohorte histórica. Se incluyeron todos los pacientes sometidos a cirugía colorrectal laparoscópica entre enero de 2000 y junio de 2012. Se identificaron los pacientes que tuvieron complicaciones post operatorias hasta 30 días después de la operación. Se analizaron mediante regresión logística uni y multivariada. Se utilizó como criterio de entrada al modelo multivariado los p < 0,2 y como criterio de significancia un p = 0,05. Resultados: la serie consta de 848 pacientes, con una mediana de edad de 58 +/- 22 años. Las principales indicaciones operatorias fueron: neoplasia (42,3 por ciento), enfermedad diverticular (27,8 por ciento) y enfermedad inflamatoria intestinal (8,8 por ciento). Las operaciones realizadas con mayor frecuencia fueron: sigmoidectomía (39,5 por ciento), resección anterior de recto (13,4 por ciento), hemicolectomía derecha (13 por ciento) y colectomía total (8,7 por ciento). En el análisis univariado, los factores asociados a complicación fueron: la edad sobre 75 años (OR de 1,82; IC 95 por ciento 1,02-3,25) y la transfusión de glóbulos rojos (OR 8,47; IC 95 por ciento 3,69-19,43). En el análisis multivariado, la transfusión de glóbulos rojos (OR 7,9 95 por ciento IC 1,78-35,88) y el ASA III o IV (OR 3,26 95 por ciento IC 1,01-17,23) fueron factores de riesgo independientes de complicaciones en el postoperatorio. Conclusión: la necesidad de transfusión y el ASA III o IV son factores de riesgo independientes asociados a complicaciones en cirugía colorrectal laparoscópica.

Cáncer de recto: análisis de las complicaciones post operatorias y mortalidad de la resección radical en una serie de 10 años / Rectal cancer: early postoperative morbidity and mortality after radical resection

Introduction: there has been progress in surgical treatment of rectal cancer (CR) in the past decade due to a better knowledge of the disease and the adoption of new methods of preoperative staging and treatment. The aim of this report is to analyze the early postoperative morbidity and mortality in a ten year series of patients with CR submitted to radical resection. Methods: in the database of colorectal cancer patients prospectively maintained, all patients with CR submitted to curative radical resection electively between january 2000 and december 2010 were identified. Early postoperative (30 day) morbidity and mortality were described and analyzed in a multivariate analysis to identify predictive factors. Results: a total of 308 patients were included, 55.2 percent male with a median age of 62 years. Over two thirds of tumors were located in the mid or lower rectum. Anterior resection was performed in 83.1 percent, and neoadyuvant radio-chemotherapy was used in 37.7 percent. Overall morbidity and mortality were 13.6 percent and 0.3 percent respectively. In multivariate analysis, American Society of Anesthesiologists had an or of 3.343 (1.601- 6.982) for postoperative morbidity, and laparoscopic approach 0.188 (0.054-0.649). Conclusion: the morbidity rate of this series is similar to the one observed in other studies. The ASA score is an independent risk factor for postoperative complication and the laparoscopic approach would be a protective factor. In this series, preoperative chemoradiation was not a risk factor for postoperative morbidity.

Introducción: durante la última década ha habido progresos en el tratamiento del adenocarcinoma del recto (CR) derivado del mejor conocimiento de la enfermedad y de la incorporación de nuevas técnicas de etapificación y tratamiento. El objetivo de este trabajo es analizar la morbilidad y mortalidad en una serie de pacientes sometidos a resección radical (resección anterior o resección abdominoperineal) por CR. Método: estudio de cohorte histórica. Se identificaron los pacientes operados por CR, en forma electiva y con intención curativa entre enero de 2000 y diciembre de 2010. Se analizó la morbilidad global y mortalidad a 30 días. Además se realizó un análisis uni y multivariado para encontrar factores predictores de complicaciones. Resultados: La serie consta de 308 pacientes, 55,2 por ciento de sexo masculino con una mediana de edad de 62 años. Se observó una tasa de morbilidad global de 13,6 por ciento. Las complicaciones más frecuentes fueron el íleo prolongado (3,2 por ciento), filtración de anastomosis (2,3 por ciento) e infección de sitio quirúrgico (1,3 por ciento). La mortalidad operatoria fue de 0,3 por ciento. En el análisis multivariado, el puntaje ASA se asoció significativamente a morbilidad. El abordaje laparoscópico se asoció a una menor tasa de complicaciones. No se observó asociación con neoadyuvancia ni tipo de cirugía. Conclusión: en esta serie, la tasa de complicaciones es similar a lo comunicado en otras series. El puntaje ASA es un factor de riesgo independiente para complicación y, por el contrario, el abordaje laparoscópico sería un factor protector. La radioquimioterapia neoadyuvante no sería, según esta serie, un factor de morbilidad.

Anastomosis ileorrectal en el tratamiento quirúrgico de la colitis ulcerosa: resultados a largo plazo / Ileorectal anastomosis in the surgical treatment of ulcerative colitis: long-term results

Background: Total colectomy with ileorectal anastomosis (IRA) is an alternative to the ileoanal pouch for the surgical treatment of ulcerative colitis in a selected group of patients. This technique leaves rectal mucosa Hable to develop persistent proctitis, dysplasia and cancer Aim: To describe short and long-term results of IRA and to assess the presence of dysplasia. Material and methods: Descriptive study of patients treated with IRA. The data were obtained from the clinical records, and the present status was evaluated with an interview. A proctoscopy and biopsy was offered free of cost to the contacted patients. Results: Between 1978 and 2005, 26 patients were operated. One patient presented an anastomotic leakage that was treated with a loop ileostomy There was no operative mortality. Twenty-three patients were followed for a períod of 1 to 23 years. Three patients evolved as Crohn 's disease and two of them needed a proctectomy. Three patients died of non-related diseases. In the remaining 17, the average evacuation rate was 3.7/24 h and all were continent. None developed a rectal cancer Only two patients had their planned annual endoscopic surveillance. In 2 of the 11 patients who accepted endoscopy and biopsy, a low-grade dysplasia was found. Conclusions: IRA has low morbidity and acceptable functional results in this selected group of patients. No patient present high-grade dysplasia or cancer; however, the adherence to the endoscopic follow-up ispoor.

Estudio endoscópico en familiares de primer grado de pacientes operados por cáncer colorrectal / Screening colonoscopy among first degree relatives of patients with colorectal carcinoma

Background: First degree relatives of patients with colorectal carcinoma are at a higher risk of having the disease than the general population. Therefore, they should be subjected to screening colonoscopy. Aim: To assess the effectiveness of colonoscopy among first degree relatives of patients with colorectal carcinoma. Material and methods: A free colonoscopy was offered to first degree relatives of patients operated on for colorectal cancer between 1998 and 2000. As inclusion criteria, subjects had to be asymptomatic, older than 40 years or less than 10 years younger than the index case. Each subject was contacted twice, inviting him/her to have a colonoscopy performed. Results: Two hundred forty three relatives were contacted for the study and in 76, a colonoscopy was performed. Among the latter, a neoplasm was found in 13 (17 percent): One adenocarcinoma and 12 adenomas. Three of these lesions were located in the right colon. The main reason given by the 176 subjects that did not agree to have a colonoscopy was lack of interest. Conclusions: Screening colonoscopy is effective to detect adenoma and adenocarcinomaamong first degree relatives of patients with colorectal carcinoma, however only 31 percent of all potential relatives agreed to undergo a colonoscopy.

Resultados del tratamiento quirúrgico en inercia colónica / Results of surgical treatment in colonic inertia

Introducción: Inercia colónica (IC) es un síndrome clínico que afecta principalmente a mujeres, caracterizado por constipación refractaria al tratamiento médico y tránsito colónico lento. El objetivo de este trabajo fue evaluar los resultados de la cirugía en pacientes con diagnóstico de IC. Material y Método: Se revisó en forma retrospectiva los pacientes con diagnósticos de IC refractorios al uso de laxantes, y operados en el Hospital Clínico de la Universidad Católica desde septiembre de 1994 hasta mayo de 2002. Resultados: Se evaluó 11 pacientes a los que se les practicó una colectomía total con anastomosis ileorrectal. Todos los pacientes fueron mujeres, con una edad promedio de 46,5 años (21-67 años). Todas las pacientes presentaban al menos 2 años de constipación refractaria al uso de laxantes. El 100 por ciento de las pacientes presentaba estudio de tránsito colónico alterado (20 por ciento o más de los marcadores distribuidos difusamente en el colon después de 5 días). A 9 pacientes se les realizó una manometría anorrectal preoperatoria, y a 2 pacientes se les realizó defecografía que fueron informados como normales descartando una patología del piso pélvico. Las 11 pacientes fueron sometidas a una colectomía total más ileorrectal anastomosis (9 en forma convencional y 2 en forma laparoscópica). Histológicamente ningún paciente presentaba ausencia de plexos neuroentéricos. La frecuencia defecatoria promedio postoperatorio con una media de seguimiento de 29,2 meses fue de 2,66 veces por día (vs 1,8 veces por semana en el preoperatorio). El 100 por ciento de las pacientes se encuentra satisfecha con el procedimiento: 9,2 (escala de 1-10). Conclusión: La colectomía total más anastomosis ileorrectal es una buena alternativa terapéutica en pacientes bien seleccionadas con IC confirmada, y asegurando que no existe obstrucción de salida fecal.