Prótesis colónicas en el tratamiento paliativo del cáncer colónico. Nuestra evaluación tras 10 años de experiencia / Self-expanding metal stents in the palliative treatmentof coloncancer. Results of 10 years of experience

Introducción: la colocación de prótesis metálicas autoexpansibles (PAE) por vía endoscópica surge como opción terapéutica para la obstrucción colónica neoplásica en dos situaciones: como tratamiento paliativo y como puente a la cirugía curativa. Este procedimiento evita cirugías en dos tiempos y disminuye la probabilidad de colostomía definitiva y sus complicaciones con el consecuente deterioro de la calidad de vida. Objetivo: comunicar nuestra experiencia en la colocación de PAE para el tratamiento paliativo de la obstrucción colorrectal neoplásica. Diseño: retrospectivo, longitudinal, descriptivo y observacional. Material y métodos: se incluyeron todos los pacientes a quienes el mismo grupo de endoscopistas les colocó PAE con intención paliativa por cáncer colorrectal avanzado entre agosto de 2008 y diciembre de 2019. Fueron analizadas las variables demográficas y clínicas, el éxito técnico y clínico, las complicaciones tempranas y tardías y la supervivencia. Resultados: se colocó PAE en 54 pacientes. La media de edad fue 71 años. El 85% de las lesiones se localizó en el colon izquierdo. En el 57% de los pacientes se realizó en forma ambulatoria. El éxito técnico y clínico fue del 92 y 90%, respectivamente y la supervivencia media de 209 días. La tasa de complicaciones fue del 29,6%, incluyendo un 14,8% de obstrucción y un 5,6% de migración. La mortalidad tardía atribuible al procedimiento fue del 5,6%, ocasionada por 3 perforaciones tardías: 2 abiertas y 1 microperforación con formación de absceso localizado. Conclusiones: la colocación de PAE como tratamiento paliativo de la obstrucción neoplásica colónica es factible, eficaz y segura. Permitió el manejo ambulatorio o con internación breve y la realimentación temprana, mejorando las condiciones para afrontar un eventual tratamiento quimioterápico paliativo. Las mayoría de las complicaciones fueron tardías y resueltas endoscópicamente en forma ambulatoria. (AU)

Introduction: endoscopic placement of self-expanding metal stents (SEMS) emerges as a therapeutic option for neoplastic obstruction of the colon in two situations: as palliative treatment and as a bridge to curative surgery. This procedure avoids two-stage surgeries and reduces the probability of permanent colostomy and its complications with the consequent deterioration in quality of life. Objective: to report our experience in the placement of SEMS as palliative treatment in neoplastic colorectal obstruction. Design: retrospective, longitudinal, descriptive and observational study. Methods: all patients in whom the same group of endoscopists performed SEMS placement with palliative intent for advanced colorectal cancer between August 2008 and December 2019 were analyzed. Data collected were demographic and clinical variables, technical and clinical success, early and late complications, and survival. Results: SEMS were placed in 54 patients. The average age was 71 years. Eighty-five percent were left-sided tumors. In 57% of the patients the procedure was performed on an outpatient basis. Technical and clinical success was 92 and 90%, respectively, and median survival was 209 days. The complication rate was 29.6%, including 14.8% obstruction and 5.6% migration. Late mortality attributable to the procedure was 5.6%, caused by 3 late perforations: 2 open and 1 microperforation with localized abscess formation. Conclusions: The placement of SEMS as a palliative treatment for neoplastic colonic obstruction is feasible, effective and safe. It allowed outpa-tient management or brief hospitalization and early refeeding, improving the conditions to face an eventual palliative chemotherapy treatment. Most complications were late and resolved endoscopically on an outpatient basis. (AU)

Colonoscopic laxative instillation for the fecal-loaded colon: a case series

Context: Postoperative, critically ill, and elderly patients often have fecal loading or impaction. In a few such patients, disimpaction of fecalomas and colon cleansing are difficult. Bowel obstruction, megacolon, lower gastrointestinal bleeding, and gut perforation are complications that may ensue. Oral laxatives or enemas may only be partially effective. Surgical intervention may be needed for salvage or to treat complications. Series and Design: Fourteen hospitalized cases with defecation disorder due to fecal loading of the colon were enrolled for retrospective analysis. Colonoscopic instillation of mannitol and/or lactulose was undertaken as an intervention when the use of oral laxatives was either ineffective or unfeasible, and enema had yielded poor results. Results: Ten patients had satisfactory outcomes for fecal clearance, whereas four patients with poor or incomplete responses underwent repeat interventions or surgery. No significant complications were encountered due to this therapy. Conclusion: Colonoscopic instillation of mannitol or lactulose in fecal-loaded critically ill patients results in a safe and satisfactory fecal clearance. (AU)

Risk factors associated with colorectal cancer in octogenarians can help stratify the need for colonoscopy

Objective: Colonoscopy is increasingly performed in octogenarians for the detection of colorectal cancer (CRC), but its benefits may be outweighed by its risks. The aim of the present study was to identify the risk factors for CRC in octogenarians presenting for colonoscopy to help stratify the need for this procedure. Methods: A retrospective analysis of 434 patients aged ≥ 80 years referred for a colonoscopy between January 2018 and December 2019. Comparisons were made between those with and without CRC and advanced adenoma (AA). The primary endpoint was to identify the clinical variables predictive of CRC and AA, and the secondary endpoints were complications and death 30 days after the procedure. Results: Colonoscopy was performed in 434 octogenarians, predominantly for symptoms, with CRC in 65 (15.0%) patients. Iron deficiency was associated with a higher risk of having CRC identified on colonoscopy (odds ratio [OR]: 2.33; 95% confidence interval [95%CI] = 1.36-4.00), but not symptoms such as bleeding, weight loss, or diarrhea. A colonoscopy in the last 10 years was protective, with a lower risk of CRC (OR: 0.45; 95% CI = 0.22-0.93). Patients with both normal iron stores and a colonoscopy within 10 years had a 92.5% chance of not having CRC. No variables were predictive of AA. Patients with complications, including death, were older and more likely to have underlying cardiorespiratory disease. Conclusion: Iron status and colonoscopy within 10 years can be used to predict the risk of CRC in octogenarians. Those with low predicted risk, especially if older and with cardiorespiratory disease, should be considered for non-invasive tests, such as computed tomography (CT) colonography, over colonoscopy. (AU)

Hallazgo histopatológico de Strongyloides stercoralis en enfermedad de Crohn: reporte de caso / Histopathologic finding of Strongyloides stercoralis in a patient with Crohn's disease: Case report

Resumen Caso clínico: Se describe un caso clínico poco frecuente en un paciente inmunocomprometido con hallazgo histopatológico de infestación parasitaria. Es un paciente masculino de edad media que habita en zona subtropical con diagnóstico de enfermedad de Crohn tratado con corticoide e inmunomoduladores, presentaba dolor abdominal y anemia crónica de 1 año de evolución, analítica negativa para parásitos, reactantes de fase aguda normales, gastroscopia y colonoscopia previas (6 meses) sin hallazgos relevantes. Por la persistencia del cuadro clínico se repitieron los estudios endoscópicos en los que se visualizaron hemorragias subepiteliales con resultados histopatológicos de Strongyloides stercoralis. Conclusión: En el contexto de un paciente inmunocomprometido, en zona endémica y con evolución tórpida, debe obligar a realizar un diagnóstico diferencial en el que se debe sospechar siempre de infestación parasitaria. Aunque la endoscopia no se necesita para el diagnóstico de estrongiloidiasis, su intervención puede ser oportuna.

Abstract Clinical case: The following is a rare clinical case in an immunocompromised patient with histopathological findings of parasitic infestation. The patient is a middle-aged male who lives in a subtropical area and has a diagnosis of Crohn's disease treated with corticosteroids and immunomodulators. The patient presented with abdominal pain and chronic anemia for 1 year, with negative laboratory tests for parasites and normal acute phase reactants. Gastroscopy and colonoscopy were performed before the consultation (6 months) without relevant findings. Due to the persistence of the symptoms, endoscopic studies were repeated, finding subepithelial bleeding with histopathological results of Strongyloides stercoralis. Conclusion: In the context of an immunocompromised patient living in an endemic area and with a torpid evolution, a differential diagnosis should be made always suspecting a parasitic infestation. Although endoscopy is not necessary to diagnose strongyloidiasis, its use may be convenient.

No inferioridad entre dos agentes de bajo volumen (picosulfato de sodio/citrato de magnesio frente al sulfato de sodio/potasio/magnesio) en la preparación del colon para procedimientos diagnósticos: estudio observacional / Non-inferiority between two low-volume agents (sodium picosulfate/magnesium citrate vs. sodium sulfate/potassium/magnesium) to prepare the bowel for diagnostic procedures: an observational study

Resumen Introducción: el cáncer colorrectal es un problema de salud pública; sin embargo, la detección temprana reduce su morbimortalidad. La colonoscopia es el procedimiento de elección para detectar lesiones premalignas y el éxito depende de una limpieza adecuada. El objetivo es evaluar el desempeño de dos preparaciones de bajo volumen empleados en un hospital de alto nivel. Materiales y métodos: estudio prospectivo en adultos que asistieran a colonoscopia en la Fundación Santa Fe de Bogotá, Colombia. Las preparaciones se evaluaron con la escala de Boston, con puntaje ≥ 6 puntos para una limpieza adecuada. Se realizó un análisis de regresión logística para establecer la efectividad de los medicamentos con un cálculo de no inferioridad del 3 %-5 %. Resultados: 598 pacientes fueron evaluados. El 49 % (293) fue expuesto al picosulfato de sodio/citrato de magnesio y el 51 % (305) fue expuesto al sulfato de sodio/potasio/magnesio. Con un promedio de Boston de 6,98 ± 1,86 (78 % con puntaje de Boston ≥ 6) y 7,39 ± 1,83 (83 %), respectivamente (p = 0,649). Según el análisis de la presencia y frecuencia de síntomas no deseados, el picosulfato fue mejor tolerado (p < 0,001). Conclusiones: los estudios de preparación intestinal en pacientes de un escenario real son muy escasos. Los medicamentos de bajo volumen obtuvieron una efectividad global y por segmento de colon similar, confirmando la no-inferioridad; el picosulfato de sodio/citrato de magnesio fue mejor tolerado. Un estudio de costo-efectividad podría definir esto según las necesidades de la población de estudio.

Abstract Introduction: Colorectal cancer is a public health problem; however, early detection reduces morbidity and mortality. Colonoscopy is the procedure of choice for detecting precancerous lesions, and success depends on proper bowel cleansing. Objective: To evaluate the performance of two low-volume agents used in a high-level hospital. Materials and methods: Prospective study in adults who underwent colonoscopy at the Fundación Santa Fe in Bogotá, Colombia. Preparations were evaluated using the Boston Bowel Preparation Scale. A score ≥6 points indicated adequate preparation. A logistic regression analysis was carried out to establish the effectiveness of the medicines with a non-inferiority ratio of 3-5%. Results: 598 patients were evaluated. 49% (293) received sodium picosulfate/magnesium citrate and 51% (305) received sodium sulfate/potassium/magnesium, with an average Boston score of 6.98±1.86 (78% Boston ≥6) and 7.39±1.83 (83%), respectively (p=0.649). According to the analysis of the presence and frequency of unwanted symptoms, picosulfate was better tolerated (p < 0.001). Conclusions: Bowel preparation studies in patients from a real-life scenario are scarce. Low-volume agents had similar overall and segmental effectiveness in the colon, confirming non-inferiority; sodium picosulfate/magnesium citrate was better tolerated. A cost-effectiveness study could establish the best option according to the needs of the study population.

Seguridad y entrenamiento de las colonoscopias por cirujanos. Estudio multicéntrico / Safety and training of colonoscopies by surgeons. A multicenter study

RESUMEN Introducción: la seguridad de la colonoscopia realizada por cirujanos y el tratamiento de sus complica ciones han sido analizados aisladamente y en escasas publicaciones nacionales. Objetivos: el objetivo principal del estudio fue analizar las colonoscopias realizadas por cirujanos co lorrectales, sus complicaciones y resolución. El objetivo secundario fue comparar los resultados entre un hospital universitario y distintos centros del país dotados de cirujanos colorrectales que habían recibido entrenamiento en una residencia posbásica. Material y métodos: estudio multicéntrico, prospectivo a nivel nacional. Se incluyeron las colonosco pias realizadas entre 2011 y 2016 . Se analizaron como variables las complicaciones, edad, sexo, tipo de endoscopia, diagnóstico, tratamiento, sitio de realización y de entrenamiento del cirujano. Se ex presaron en promedios, porcentajes y rangos. El análisis estadístico consistió en el test exacto ordinal, relaciones y proporciones y exacto de Fisher. Se consideró significancia a p < 0,05. Resultados: de 24 907 procedimientos, 17 283 fueron diagnósticos y 17 202 provenían de centros del interior. Hubo 43 complicaciones (0,17%); 35 específicas: perforaciones (19), hemorragias (8), sín drome pospolipectomía (5) y técnicas (3), diagnosticadas y resueltas por el mismo equipo sin mor bimortalidad. No hubo diferencias en las complicaciones según el centro ni tipo de colonoscopia en incidencia o tratamiento. Todos los cirujanos se entrenaron en residencias de posgrado con programas de entrenamiento en colonoscopia. Conclusiones: existen similares resultados entre cirujanos provenientes de instituciones con residen cia posbásica y centros del interior al realizar colonoscopias. La colonoscopia realizada por cirujanos es un procedimiento seguro y posible de ser adquirido como competencia luego de un entrenamiento formal realizado en una residencia posbásica.

ABSTRACT Introduction: The safety of colonoscopies performed by surgeons and the management of their com plications has not been analyzed in depth in the low number of national publications. Objective: The primary endpoint of this study was to analyze the outcomes of colonoscopies perfor med by colorectal surgeons, in terms of complications. and their resolution. The secondary endpoint was to compare the results between a university hospital and different centers nationwide staffed with colorectal surgeons who had received formal training during a residency program in the surgical subspecialty. Material and methods: We conducted a multicenter, prospective and consecutive national study. The colonscopies performed between 2011 and 2016 were included. The variables analyzed included complications, age, sex, type of endoscopy, diagnosis, treatment, location were the procedure was performed and surgeon's training. The results were expressed as mean, percentage and range. The statistical analysis was performed using Fisher's exact test. A p value < 0.05 was considered statistically significant. Results: A total of 24,907 procedures were performed, 17,283 corresponded to diagnostic colonosco pies and 17,202 were made in provincial centers. Forty-four complications were recorded (0.17%), of which 35 were procedure-related complications: 19 perforations, 8 bleeding events, 5 post-polypec tomy syndromes and three related with the technique; all were diagnosed and solved by the same team without morbidity and mortality. There were no differences in the incidence of complications and how they were treated according to the center or type of colonoscopy. All the surgeons received colonoscopy training during a residency program in the surgical subspecialty. Conclusions: The results obtained in colonoscopies performed by surgeons trained in institutions with residency programs in surgical subspecialties are similar t Safe colonoscopies can be performed by surgeons who have been trained in institutions with a residency program in a surgical subspecialty and with a formal training program in colonoscopy.

Colitis ulcerativa extensa severa presentación caso / Severe extensive ulcerative colitis. Case presentation

RESUMEN La colitis ulcerativa es una enfermedad crónica recidivante del tracto gastrointestinal, que evoluciona por recaídas formando parte de las enfermedades inflamatorias intestinales (EII). Afecta la mucosa y submucosa del colon, caracterizada por un proceso ulcerativo y supurado de la mucosa. La diarrea crónica con sangre es el síntoma más importante. En su curso alternan periodos de remisión y de crisis. No existe un criterio patognomónico para su definición, su diagnóstico se basa en una serie de criterios clínicos, endoscópicos e histológicos. Esta entidad infrecuente en su forma extensa severa. Aparece en un paciente, que llega a la institución de salud refiriendo que hace aproximadamente dos años, presenta cuadros de diarreas intermitentes con sangre, tratadas en el área de salud. Se le realizó Rx y colonoscopia constatando presencia de eritema, granularidad mucosa, friabilidad, pérdida de la vascularización submucosa, erosiones y ulceraciones extensas, profundas, signos de edema, pseudopólipos, pérdida de haustras, rigidez, sangrado, tractos fibrosos y presencia de exudado luminal. Se diagnosticó colitis extensa ulcerativa severa y se orientó tratamiento médico endovenoso y se continuó por via oral, obteniendo la remisión del cuadro clínico desde el punto de vista clínico y endoscópico (AU).

ABSTRACT Ulcerative colitis is a chronic recidivist disease of the gastrointestinal tract, evolving by relapses and is one of the intestinal inflammatory diseases. It affects the colon mucosa and sub-mucosa, characterized for an ulcerative process and mucosa exudation. Chronic diarrhea with blood is the most important symptom. Periods of crisis and remission alternated in its course; there is not a pathognomonic criteria for its definition and its diagnosis is based in a series of clinical, endoscopic and histological criteria. This entity, infrequent in extensive severe form, appears in a patient arriving to the hospital referring having intermittent diarrheas with blood for two years, treated in the health area. He undergone a radiography and colonoscopy, showing the presence of an erythema, mucosa granularity, friability, lost of submucosa vascularization, deep extensive erosions and ulcerations, edema signs, pseudo polyps, haustras lost, stiffness, bleeding, fibrous tracts and presence of luminal exudates. Severe ulcerative extensive colitis was diagnosed and was prescribed an endovenous medical treatment, continued orally, achieving the disease remission from the clinical and endoscopic point of view (AU).

Resultados de un programa de recuperación mejorada (PRM) en cirugía colorrectal: efectos en la estadía hospitalaria / Shortening of hospital length of stay after the implementation of an Enhanced Recovery Program for elective colorectal surgery

Resumen Introducción Los Programas de Recuperación Mejorada (PRM) en cirugía colorrectal disminuyen las complicaciones y acortan la estadía hospitalaria. La implementación de un PRM representa un desafío en nuestro sistema de salud público, dado la alta demanda y recursos limitados. Objetivo Evaluar el efecto en la estadía hospitalaria (EH) posterior a la implementación de un PRM en cirugía colorrectal electiva en un hospital público. Materiales y Método Estudio retrospectivo, que incluyó pacientes entre 15 y 85 años operados electivamente de resecciones colorrectales en un hospital público entre 1 de enero de 2015 y 31 de diciembre de 2016. Se compararon dos grupos: 1) total de pacientes operados electivamente 1 año posterior a la implementación del PRM (post-PRM) y 2) total de pacientes operados electivamente un año previo a la implementación de PRM (pre-PRM), en términos de EH, reingresos, complicaciones y mortalidad a 30 días. Se realizó análisis de tiempo a evento para comparar la EH entre ambos grupos. Resultados Un total de 144 pacientes fueron incluidos: 92 en el grupo post-PRM y 52 en el grupo pre-PRM. No hubo diferencias clínicas entre ambos grupos. La mediana de EH en el grupo post-PRM fue 2 días menor que en el grupo control (5 vs 7 días, test de log-rank, p = 0,03). No hubo diferencia en complicaciones, reingresos ni mortalidad. Conclusión La implementación de un PRM en cirugía colorrectal electiva en un hospital público se asocia a una disminución de la EH sin aumento de morbimortalidad.

Background Enhanced Recovery Programs (ERP) in colorectal surgery has proved to decrease complications and shorten hospital stay. The implementation of an ERP could be a difficult task in a high-demanding public health system with limited resources. Aim Evaluate the effect on length of stay (LOS) after the implantation of an ERP for colorectal surgery in a resource-limited public hospital. Materials and Method This retrospective study included patients aged 15-85 years who underwent elective colorectal surgery at a resource-limited public hospital in Chile between January 1, 2015 and December 31, 2016. We compared two groups: (1) total number of patients operated electively after 1-year of ERP implementation (post-ERP group) and (2) total number of patients electively operated 1-year previous ERP (pre-ERP group) in terms of LOS, readmissions, complications, and 30-day mortality. A time to event analysis was performed to evaluate differences in LOS. Results A total of 144 patients were included in this study: 92 in the post-ERP group and 52 in the pre-ERP group. There were no clinical differences between groups. The median LOS in the post-ERP group was 2 days lower than that in the control group (5 vs 7 days, log-rank test p = 0.03). There were no differences in complications, readmissions, and 30-day mortality. Conclusions The implementation of an ERP for colorectal surgery in a resource-limited hospital was associated with decreased LOS without increasing morbidity.

Assessment of tolerance and acceptability between mannitol solution and polyethylene glycol as bowel preparation for colonoscopy: a three-center study / Evaluación de tolerancia y aceptabilidad entre la solución de manitol y el polietilenglicol como preparación intestinal para la colonoscopía: un estudio de tres centros

ABSTRACT Introduction: Adequate bowel preparation is one of the most important factors related to the yield of colonoscopy. Low quality bowel preparation has been associated with lower adenoma detection rates and increased healthcare expenses. Bowel preparation is a major impediment to undergo colonoscopy since it is perceived as an unpleasant experience by patients. Objective: This study was aimed to assess tolerance and acceptability of the bowel preparation using either polyethylene glycol (PEG) or mannitol solution. Materials and methods: We enrolled 140 patients with indications of screening for colorectal cancer or with suspected large bowel diseases. They received either mannitol solution or PEG as bowel preparation. Patients were asked to fill a questionnaire about the bowel preparation experience. Results: Patients perceived more burdensome the preparation with PEG than mannitol for the variables nausea overall experience, post-procedure discomfort, disagreeable flavor, volume ingested and cost (p<0.05). A similar tolerance was reported for abdominal pain, bloating and anal irritation (p>0.05). The acceptability was 82.9% and 71.4% in the Mannitol group and in the PEG group, respectively (p=0.10). Conclusion: Acceptance of the bowel preparation between mannitol solution and PEG was comparable. However, mannitol was better tolerated by the patients in regard to most of the evaluated items.

RESUMEN Introducción: La preparación intestinal adecuada es uno de los factores más importantes relacionados con el rendimiento de la colonoscopía. La preparación intestinal de baja calidad se ha asociado con tasas de detección de adenoma más bajas y mayores gastos de atención sanitaria. La preparación intestinal es un impedimento importante para someterse a una colonoscopía, ya que los pacientes la perciben como una experiencia desagradable. Objetivo: Este estudio tuvo como objetivo evaluar la tolerancia y la aceptabilidad de la preparación intestinal utilizando polietilenglicol (PEG) o solución de manitol. Materiales y métodos: Fueron incluidos 140 pacientes con indicación de pesquisa de cáncer colorrectal o con sospecha de enfermedades del intestino grueso. Los pacientes recibieron solución de manitol o PEG como preparación intestinal. Se pidió a los pacientes que completaran un cuestionario sobre la experiencia de preparación intestinal. Resultados: Los pacientes percibieron más agobiante la preparación con PEG que el manitol para las variables náuseas, experiencia general, molestias posteriores al procedimiento, sabor desagradable, volumen ingerido y costo (p<0,05). Se informó una tolerancia similar para el dolor abdominal, distensión abdominal e irritación anal (p>0,05). La aceptabilidad fue de 82,9% y 71,4% en el grupo de manitol y en el grupo de PEG, respectivamente (p=0,10). Conclusión: La aceptación de la preparación intestinal entre la solución de manitol y el PEG fue comparable. Sin embargo, el manitol fue mejor tolerado por los pacientes con respecto a la mayoría de las variables evaluadas.

Correlação entre a indicação de colonoscopia, comorbidades e neoplasia colorretal no paciente idoso e muito idosos / Correlation between the indication of colonoscopy, comorbidities and colorretal cancer in the elderly and very elderly patient

OBJETIVO: O objetivo do estudo é verificar a associação da indicação do exame com a presença de neoplasia na análise anatomopatológica além da associação entre comorbidades e câncer colorretal. MÉ- TODOS: É um estudo descritivo transversal epidemiológico, em que foram analisadas colonoscopias concluídas em pacientes idosos internados em hospital especializado. A amostra de 212 pacientes foi dividida em dois grupos com base na idade: 60-79 anos composto por 135 indivíduos, o outro grupo com 80 anos ou mais com 77 indivíduos. RESULTADOS: No grupo 60-79 anos, houve uma incidência de câncer colorretal de 9%, já no grupo 80 anos ou mais, foi de 10%. Existe associação entre anemia e adenocarcinoma, onde 92,9% dos pacientes com adenocarcinoma possuem anemia. Foi evidenciado associação entre os pacientes diabéticos e o desenvolvimento do câncer colorretal (p=0,004). CONCLUSÃO: Indivíduos com adenocarcinoma colorretal possuem maior probabilidade de apresentar anemia. Diabetes melittus é uma doença que mostrou associação relevante ao câncer colorretal, podendo sugerir um novo fator de risco.

OBJECTIVE: The objective of the study is to verify the association between the indication of conoloscopy and the presence of cancer in the anatomopathological analysis and the association between comorbidities and colorectal cancer. METHODS: This is a descriptive cross-sectional epidemiological study in which all colonoscopies completed in elderly patients admitted to a specialized hospital were. The sample of 212 pacientes was divided into two groups based on age: 60-79 years with 135 individuals, the other group 80 years or older with 77 individuals. RESULTS: In the group 60-79 years there was an incidence of colorectal cancer in 9%, while in the group 80 years or more it was 10%. There is an association between diabetes and colorrectal cancer (p=0,004). CONCLUSION: Individuals with adenocarcinoma are more likely to have anemia. Diabetes melittus is a common disease that may be associated with colorectal cancer, that could sugest a new risk factor.

Comportamiento del cáncer colorrectal diagnosticado por colonoscopia en el Hospital Militar "Mario Muñoz Monroy". Matanzas / Behavior of the colorectal cancer diagnosed by colonoscopy in the hospital military "Mario Muñoz Monroy". Matanzas

RESUMEN Introducción: el cáncer colorrectal constituye un serio problema de salud por su alta incidencia. Es una entidad que afecta significativamente a la humanidad y conlleva a una alta mortalidad. Objetivo: determinar el comportamiento de los pacientes con cáncer colorrectal diagnosticado por colonoscopia en el Hospital Militar "Mario Muñoz", Matanzas. Materiales y Métodos: se realizó un estudio observacional, descriptivo y prospectivo en pacientes con sangre oculta en heces fecales y diagnóstico colonoscópico de cáncer colorrectal, desde enero del 2015 a noviembre del 2018. El universo quedó conformado por 135 pacientes que cumplieron con los criterios de selección. Se estudiaron variables como: grupo etario, sexo, factores de riesgo, síntomas y signos, localización y estadio. Se utilizó una planilla de recolección de datos. Se emplearon métodos de estadística descriptiva y los resultados fueron presentados en tablas. Resultados: en 722 colonoscopias realizadas a pacientes con sangre oculta positiva, en el 18.7 % se diagnosticó cáncer colorrectal. Predominó el grupo etario de 61-70 años con un 30.4 % de los pacientes y el sexo masculino (41.4%). Los factores de riesgos más frecuentes) fueron: dieta inadecuada (46.6%), sedentarismo (25.2%) y enfermedad inflamatoria intestinal (29.6%). Los síntomas más frecuentes fueron: diarrea (45.9%), dolor abdominal (31.1%) y dispepsia (25.2%). La localización que predominó fue el recto (24.4%), seguido del colon ascendente (22.2%). Predominaron los pacientes en un estadio II con 42.2%. Conclusiones: el cáncer colorrectal se presentó con mayor frecuencia en pacientes de la 6ta década de vida tal como se reporta en la literatura, asociado a malos hábitos dietéticos e inadecuado modo y estilo de vida que pueden ser modificados a través de estrategias educativas que garanticen la salud de la población (AU).

SUMMARY Introduction: Colorectal cancer [cancer colorectal (CCR) in Spanish] is a serious health problem due to its high incidence. It is an entity affecting the human kind and producing a high mortality. Objective: to determine the behavior of the colorectal cancer diagnosed by colonoscopy in the Military Hospital "Mario Muñoz", Matanzas. Material and methods: a prospective, descriptive, observational study was carried out in patients with hidden blood in fecal feces and colonoscopic diagnosis of colorectal cancer from January 2015 to November 2018. The universe was formed by 135 patients who fulfilled the selection criteria. The studied variables were age group, gender, risk factors, symptoms, locations and stage. A form was used for collecting data. Methods of descriptive statistics were used and the results are showed in charts. Results: In 722 colonoscopies carried out to patients with positive hidden blood, 18.7 % was diagnosed as colorectal cancer. The 61-70 years-old age group (30.4 %) and male gender (41.4 %) predominated. The most frequent risk factors were improper diet (46.6 %), sedentary life style (25.2 %), and inflammatory intestinal disease (29.6 %). The most frequent symptoms were diarrhea (45.9 %), abdominal pain (31.1 %) and dyspepsia (25.2 %). The predominant location was the rectum (24.4 %), followed by ascending colon (22.2 %). Stage II patients predominated, with 42.2 %. Conclusions: colorectal cancer appeared more frequently in patients in their sixth decade of life as it is reported in the literature, associated to bad dietary habits and to an inadequate style and way of life that could be modified through educative strategies warranting the population's health (AU).

Colonoscopic findings in patients younger than 40 years

ABSTRACT Objective: To analyze the main endoscopic findings in patients under 40 years of age and the main indications for colonoscopy in these patients. Methods: A retrospective study with 362 reports of patients under 40 years of age who underwent colonoscopy from January 2014 to June 2017 at the colonoscopy service of the General Hospital Roberto Santos. Colon preparation was performed with mannitol and the patients underwent sedation as the anesthetist criteria. Results: Of the 362 patients analyzed, 192 (53%) were female. The mean age was 25 years (25.58 ± 11.95). The most frequent indications were inflammatory bowel disease in 24.3% (88) of the patients, bleeding in the lower digestive tract in 24% (87), and chronic diarrhea in 20.2% (73). The main colonoscopic findings were polyposis in 21.3% (77) of the patients and inflammatory alterations in 20.7% (75). Conclusion: With the analysis of the data provided by the colonoscopies, it was possible to conclude that, when the investigation is adequate and the examination is well indicated, even under the age of 40, colonoscopy can help in the diagnostic and treatment of several pathologies, including those that may increase the risk of colorectal cancer.

RESUMO Objetivo: Analisar os principais achados endoscópicos nos pacientes com idade inferior a 40 anos e as principais indicações para realização das colonoscopias. Métodos: Estudo retrospectivo, com análise de 362 laudos de pacientes com idade inferior a 40 anos submetidos à colonoscopia, no período de Janeiro de 2014 até Junho de 2017 no serviço de coloproctologia do Hospital Geral Roberto Santos. Foi realizado preparo de cólon com manitol e os pacientes foram submetidos à sedação á critério do anestesista. Resultados: Dos 362 pacientes analisados, 192 (53%) eram do sexo feminino. Em relação à idade: média de 25 anos (25,58 ± 11,95). As indicações mais frequentes foram doença inflamatória intestinal em 24,3% (88) dos pacientes, sangramento digestivo baixo em 24% (87); e diarreia crônica 20,2% (73). Os principais achados colonoscópios foram polipose em 21,3 (77) dos pacientes e alterações inflamatórias em 20,7% (75). Conclusão: Com análise dos dados fornecidos pelos exames colonoscópios e suas indicações foi possível concluir que quando a investigação é adequada e o exame é bem indicado, mesmo abaixo dos 40 anos, a colonoscopia pode auxiliar no diagnóstico e tratamento de diversas patologias, inclusive as que podem aumentar o risco de câncer colorretal.

Caso Clínico: Enfermedad de Crohn en Pediatría, el Desafío de un Diagnóstico Temprano / Case Report: Crohn´s Disease in Pediatrics, the Challenge of an Early Diagnosis

INTRODUCCIÓN: La enfermedad de Crohn, clasificada como una enfermedad inflamatoria intestinal, es una patología inflamatoria crónica con afectación transmural y segmentaria de cualquier parte del tracto digestivo. Se caracteriza por presentar sintomatología clásica como dolor abdominal, diarrea y pérdida de peso; en la población pediátrica ocasiona alteración de la velocidad del crecimiento y desarrollo sexual. Un diagnóstico oportuno y el establecimiento de un tratamiento eficaz son elementales para obtener remisión y garantizar la calidad de vida del paciente. CASO CLÍNICO: Paciente de sexo femenino, de 12 años de edad; consultó por historia de un mes de evolución, caracterizada por fiebre y sintomatología abdominal inespecífica, la misma que incluyó: dolor abdominal, nausea, vómito, pérdida de peso y poliartralgias. Posteriormente el cuadro se exacerbó, presentando deposiciones líquidas sanguinolentas, motivo por el que se decidió su admisión hospitalaria. EVOLUCIÓN: Se descartó patología infecciosa o inmunológica; se realizó endoscopía y colonoscopía donde se encontraron lesiones erosivas hemorrágicas en ciego. El estudio histopatológico fue compatible con enfermedad de Crohn. CONCLUSIÓN: La enfermedad de Crohn, constituye una patología a considerarse en la lista de diagnósticos diferenciales del paciente que consulta por sintomatología abdominal inespecífica. Si bien su prevalencia e incidencia son bajas en la población local, las consecuencias relacionadas con la afectación del desarrollo pondoestatural, desarrollo sexual y la salud psicosocial del paciente; obligan el establecimiento de un diagnóstico y tratamiento oportunos(au)

BACKGROUND: Crohn's disease, classified as an inflammatory bowel disease, is a chronic inflammatory condition that causes transmural and segmental involvement of any part of the digestive tract. It is characterized by presenting classic symptoms such as abdominal pain, diarrhea and weight loss; in pediatric population affects growth and sexual development. An opportune diagnosis¿ and the establishment of an effective treatment are essential to obtain remission and guarantee the quality of life. CASE REPORT: 12 year-old, female patient; with 1 month history of fever and nonspecific abdominal symptoms that include abdominal pain, nausea, vomiting, weight loss and polyarthralgia. Later, the patient presented bloody stools, being admitted for the respective evaluation. EVOLUTION: Infectious and immunological origin was ruled out; an endoscopy and colonoscopy were performed; erosive hemorrhagic lesions were found in the cecum. The histopathological study was compatible with Crohn's disease. CONCLUSION: Crohn's disease is an entity to be considered in the list of differential diagnosis of the patient who complaints of nonspecific abdominal symptoms. Although its prevalence and incidence are low in local population, the consequences related to the affectation of pondoestatural development, sexual development and the psychosocial health of the patient; force the establishment of an opportune diagnosis and treatment.(au)

Evaluación comparativa en calidad de vida de pacientes con RAUB, RAUBIE vs RAP por cáncer de recto. Informe preliminar / Comparative evaluation in quality of life of patients with RAUB, RAUBIE vs APR for rectal cancer. Preliminary report

Resumen Introducción: La resección abdominoperineal (RAP) era el tratamiento estándar del cáncer de recto medio o bajo quedando el paciente sin ano y con una ostomía permanente. En los últimos 20 años el desarrollo de nuevas técnicas quirúrgicas, con adecuados resultados quirúrgicos y oncológicos, han permitido ofrecer al paciente la preservación del aparato esfinteriano, sin embargo, éstas pueden presentar problemas de tipo funcional lo que podría derivar en una alteración de la calidad de vida del paciente. Objetivo: Comparar la alteración en la calidad de vida en pacientes sometidos a RAP versus técnicas con preservación de esfínter anal en pacientes operados por cáncer de recto. Materiales y Método: Estudio de cohorte transversal con pacientes operados por cáncer de recto medio-bajo en nuestro hospital entre los años 2009 a 2015. Se utiliza el instrumento EuroQuol-5D2,3 validado en español chileno. Resultados: Se incluyen 39 pacientes, 11 corresponden a colostomía definitiva y 28 a preservación de esfínter. En el análisis por dominios se observaron diferencias significativas en el grupo con ostomía definitiva en el ítem de actividades habituales y a favor de la preservación de esfínter en el ítem sexualidad. Conclusiones: La técnica quirúrgica utilizada en pacientes con cáncer rectal medio-bajo altera la calidad de vida, razón por la cual debe ser adecuadamente seleccionada y además advertir al paciente de las consecuencias que dicha cirugía puede ocasionar.

Introduction: The abdominoperineal resection (APR) was the standard treatment of middle-low rectal cancer, in the last 20 years the development of sparing techniques with sphincter preservation with adequate surgical and oncological results has allowed to offer the patient the sphincter apparatus preservation, avoiding the definitive colostomy, however, these techniques may present secondary incontinence to the loss of the rectum. Both surgical options can affect the quality of life of the patient and this element should be considered. Objective: To compare the change in quality of life of patients undergoing APR vs sphincter preserving techniques in patients operated for rectal cancer. Materials and Method: Cross-sectional cohort study with medium-low rectal cancer patients, operated in our hospital from 2009 to 2015. The instrument EuroQuol-5D2, validated in chilean spanish is used. Results: 39 patients were included (11 definitive colostomy and 28 sphincter preservation). In the analysis by domains, significant differences were observed favor to definitive colostomy in the Item of "Habitual Activities" and favor to sphincter preservation in the Item "Sexuality". Conclusions: In patients with middle-low rectal cancer, the choice of surgical technique have a measurable impact on the patient's quality of life.

Avaliação do serviço de coleta para exame colpocitológico pela escala SERVQUAL / Evaluación del servicio de recolección para examen colpocitológico por la escala SERVQUAL / Avaliação do serviço de coleta para exame colpocitológico pela escala SERVQUAL

ABSTRACT Objective: To analyze women's perception of the quality of the service provided for colposcopy test in the city of Belém (PA), Brazil. Method: Quantitative-descriptive study on 400 women who underwent Pap test on the public healthcare network, using the Service Quality (SERVQUAL) model. We used the Cronbach's alpha index to measure the reliability of the scale, and data were analyzed by quartiles of the gaps of the dimensions: tangibility, responsiveness, reliability, assurance, and empathy. Results: The assurance dimension, corresponding to the knowledge and courtesy of staff, featured the highest degree of importance to users; and empathy, which corresponds to the staff's concern with women's needs, featured the lower degree. The most expressive negative gaps concerned the structure of services and the attitude of healthcare professionals when collecting the material. Conclusion: All gaps featured negative relationship between what was expected and perceived, expressing dissatisfaction regarding the service.

RESUMEN Objetivo: Analizar la percepción de mujeres acerca de la calidad del servicio de colpocitología oncótica en Belém (PA). Método: Estudio cuantitativo-descriptivo con 400 mujeres que realizaron el examen de colpocitología oncótica en la red pública de salud, utilizando el modelo Service Quality (SERVQUAL). Se utilizó el Alpha de Cronbach para medir la confiabilidad de la escala, y los datos fueron analizados por los cuartiles de los gaps de las dimensiones: tangibilidad, responsividad, confiabilidad, credibilidad y empatía. Resultados: La dimensión credibilidad, correspondiente al conocimiento y a la cortesía de los funcionarios, presentó mayor grado de importancia para las usuarias; y la empatía, que corresponde a la preocupación demostrada por los funcionarios con las necesidades de las mujeres, exhibió menor grado. Los gaps negativos más expresivos se refieren a la estructura de los servicios y a la actitud de los profesionales con ocasión de la recolección del material. Conclusión: Todos los gaps presentaron relación negativa entre lo esperado y lo percibido expresando la insatisfacción con relación al servicio.

RESUMO Objetivo: Analisar a percepção de mulheres acerca da qualidade do serviço de colpocitologia oncótica em Belém (PA). Método: Estudo quantitativo-descritivo com 400 mulheres que realizaram o exame de colpocitologia oncótica na rede pública de saúde, utilizando o modelo Service Quality (SERVQUAL). Utilizou-se o Alpha de Cronbach para medir a confiabilidade da escala, e os dados foram analisados pelos quartis dos gaps das dimensões: tangibilidade, responsividade, confiabilidade, credibilidade e empatia. Resultados: A dimensão credibilidade, correspondente ao conhecimento e cortesia dos funcionários, apresentou maior grau de importância para as usuárias, e a empatia, que corresponde à preocupação demonstrada pelos funcionários com as necessidades das mulheres, exibiu menor grau. Os gaps negativos mais expressivos dizem respeito à estrutura dos serviços e a atitude dos profissionais por ocasião da coleta de material. Conclusão: Todos os gaps apresentaram relação negativa entre o esperado e o percebido expressando a insatisfação em relação ao serviço.

Rectal ulcer due to Kayexalate deposition - an unusual case

SUMMARY Sodium polystyrene sulfonate (PSP) or Kayexalate is a cation-exchange resin, widely used in the management of hyperkalaemia due to renal disease. A rare, yet potentially dangerous, adverse event related to sodium polystyrene sulfonate use is intestinal mucosal injury, especially in the colon. The injury to the gastrointestinal mucosa can range from mild and superficial to wall necrosis and bowel perforation. The mechanism that leads to mucosal damage remains unclear. However, it is believed that sorbitol, commonly given to counteract PSP's tendency to cause constipation, may play an important role in the development of gastrointestinal injury. Other potential risk factors are uraemia or end-stage renal disease, hemodynamic instability, solid organ transplantation, postoperative status and concomitant opioid administration. The authors present a case of diarrhoea and haematochezia after the administration of PSP without sorbitol, in a patient with hyperkalaemia due to acute kidney injury, in the absence of other risk factors. A colonoscopy was performed and revealed a rectal ulcer which histological findings were suggestive of mucosal injury due to Kayexalate deposition. This case supports the concept that this widely used drug can itself, without sorbitol, cause injury to the gastrointestinal wall. Even though this is a rare adverse effect, the widespread use of this medication may put a large population at risk.

RESUMO O polistireno sulfonato de sódio (PSP) ou kayexalato é uma resina de troca iônica, amplamente usada no tratamento da hipercalemia associada à doença renal. Um efeito adverso raro, mas potencialmente grave, dessa terapêutica é a agressão à parede do trato gastrointestinal, principalmente ao nível do cólon, que pode ser ligeira e superficial ou culminar em necrose e perfuração intestinal. O mecanismo pelo qual o PSP lesa a mucosa intestinal não é totalmente conhecido. Contudo, pensa-se que o sorbitol, frequentemente administrado em simultâneo para contrabalançar o efeito obstipante do PSP, possa ter um papel preponderante no desenvolvimento de lesão gastrointestinal. Outros potenciais fatores de risco são a presença de uremia ou doença renal em estágio terminal, instabilidade hemodinâmica, pós-operatório, pós-transplante renal e a administração concomitante de opioides. Os autores descrevem um caso de diarreia e hematoquesias após a administração de PSP sem sorbitol, numa paciente com hipercalemia secundária a lesão renal aguda, sem outros fatores de risco para o desenvolvimento desse efeito adverso. A investigação etiológica com colonoscopia revelou a presença de uma úlcera retal, cujo estudo histológico foi compatível com lesão por deposição de cristais de kayexalato. Este relato incomum reforça o conceito de que este fármaco de uso frequente, mesmo na ausência de sorbitol, pode ser lesivo para a mucosa intestinal. Assim, e apesar de este ser um efeito adverso raro, a utilização difundida do PSP coloca uma vasta população em risco.

Experiencia del trasplante de microbiota fecal a través de colonoscopía en el tratamiento de la infección por Clostridium difficile recurrente / Fecal microbiota transplantation through colonoscopy for Clostridium difficile recurrent infection: report of eight cases

Background: Most cases of Clostridium difficile infection (CDI) respond to a standard course of antibiotics, however recurrent CDI is becoming common and alternative therapeutic strategies are needed. In this scenario, fecal microbiota transplantation (FMT) has been suggested. Aim: To describe the efficacy and safety of FMT for the treatment of recurrent CDI. Patients and Methods: Review of medical records of all patients with recurrent CDI treated with FMT between April 2013 and April 2017. Demographic and clinical data were abstracted including details of treatment prior to FMT, rate of FMT treatment success and clinical course during follow-up period. Telephone surveys were conducted to determine patient satisfaction. Results: Eight patients aged 19 to 82 years (six women) underwent FMT. They experienced a median of four previous episodes of CDI (range 3-8). The mean duration of CDI was 18 days (range 3-36) before FMT. All procedures were performed by colonoscopy. Effectiveness with one session of FMT was 100%. During the follow-up period (median 24 months, range 7-55), two patients developed CDI, one of them after using antibiotics. Adverse events were reported in three patients. Two had bloating and one patient with Crohn's disease and a history of bacteremia had an episode of Escherichia coli bacteremia. All patients would use FMT again if necessary. Conclusions: FMT through colonoscopy appears to be a safe, effective and long-lasting therapy in cases of recurrent CDI.

Diagnóstico y seguimiento de pacientes con sangre oculta positiva en heces fecales / Diagnosis and follow-up of patients with positive hidden blood in fecal feces

Introducción: la hemorragia digestiva se define como toda pérdida de sangre procedente de cualquier sitio del tubo digestivo, desde la boca hasta el ano, incluyendo las hemorragias digestivas originadas en órganos que drenan en la luz intestinal. Objetivo: realizar el diagnóstico y seguimiento de pacientes con sangre oculta positiva en heces fecales. Materiales y métodos: se realizó un estudio epidemiológico descriptivo en el municipio de Unión de Reyes, provincia de Matanzas, entre los años 2014-2015. El universo y muestra estuvo constituida por 130 pacientes a los cuales el test de sangre oculta en heces fecales fue positivo, teniendo entre las variables características sociodemográficas de los pacientes, diagnóstico y seguimiento. Resultados: dentro de los resultados obtenidos las edades comprendidas entre 50-69 años fueron las más frecuentes, así como el sexo femenino donde la positividad del test fue mayor al igual que en negros y mestizos. Los medicamentos que más incidencia tuvieron fueron los antiinflamatorios no esteroideos y la aspirina. El test le fue indicado a 115 pacientes por atención primaria siendo 76 por pesquisa. A 80 pacientes no se les comunicó con que intensión se indicaba el examen. Del total de pacientes 43 tuvieron enfermedades relacionadas con el tracto digestivo alto y 44 del bajo. Conclusiones: uno de cada cinco pacientes presentó alguna tumoración del tracto digestivo. Se consideró que el trabajo de los equipos de salud fue deficiente en el diagnóstico y seguimiento de los pacientes (AU).

Introduction: digestive hemorrhage is defined as any blood loss that stems from any site of the alimentary canal, from the mouth to the anus, including digestive hemorrhages occurring in organs draining in the intestinal lumen. Objective: to diagnose and follow-up patients with positive hidden blood in fecal feces. Materials and methods: a descriptive epidemiologic study was carried out in the municipality of Unión de Reyes, province of Matanzas, in the period 2014-2015. The universe and sample were formed by 130 patients whose test of hidden blood in fecal feces was positive, taking as variables the socio-demographic characteristics of the patients, their diagnosis and follow-up. Results: some of the obtained results were the predominance of ages between 50 and 69 years, and also the female sex with higher test positivity like in black and mestizo patients. The medications having more incidence were the non-steroidal antiinflammatory ones and aspirin. The test was indicated to 115 patient in the primary health care, being 76 in the screening. 80 patients were no informed of the intentionality when the test was indicated. From the total of the patients, 43 had diseases related with the upper digestive tract, and 44 with the low one. Conclusions: one form each five patients showed any tumor of vthe digestive tract. The work of the health teams was considered deficient in relation with the patients' diagnosis and follow-up...(AU)