Is there a precise correlation between the lengths of the peritoneal reflection and the middle rectal valve?

Introduction: Pelvic anatomy remains a challenge, and thorough knowledge of its intricate landmarks has major clinical and surgical implications in several medical specialties. The peritoneal reflection is an important landmark in intraluminal surgery, rectal trauma, impalement, and rectal adenocarcinoma. Objectives: To investigate the correlation between the lengths of the middle rectal valve and of the peritoneal reflection determined with rigid sigmoidoscopy and to determine whether there are any differences in the location of the peritoneal reflection between the genders and in relation to body mass index (BMI) and parity. Design: We prospectively investigated the location of the middle rectal valve and of the peritoneal reflection via intraoperative rigid sigmoidoscopy in colorectal cancer patients undergoing elective colorectal surgery. Results: We evaluated 38 patients with a mean age of 55.5 years old (57.5% males) who underwent colorectal surgery at the coloproctology service of the Hospital Santa Marcelina, São Paulo, state of São Paulo, Brazil. There was substantial agreement between the lengths of the middle rectal valve and of the peritoneal reflection (Kappa = 0.66). In addition, the peritoneal reflection was significantly lower in overweight patients (p = 0.013 for women and p < 0.005 for men) and in women with > 2 vaginal deliveries (p = 0.009), but there was no significant difference in the length of the peritoneal reflection between genders (p = 0.32). Conclusion: There was substantial agreement between the lengths of the peritoneal reflection and of the middle rectal valve, and the peritoneal reflection was significantly lower in overweight patients and in women with more than two vaginal deliveries. (AU)

Risk factors for anastomotic leakage following total or subtotal colectomy

Introduction: A higher rate of anastomotic leakage (AL) is reported after ileosigmoid anastomosis (ISA) or ileorectal anastomosis (IRA) in total or subtotal colectomy (TSC) compared with colonic or colorectal anastomosis. Themain aimof the present studywas to assess potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity. Methods: We identified 180 consecutive patients in a prospective referral, single center database, in which 83 of the patients underwent TSC with ISA or IRA. Data regarding the clinical characteristics, surgical treatment, and outcome were assessed to determine their association with the cumulative incidence of AL and surgical morbidity. Results: Ileosigmoid anastomosis was performed in 51 of the patients (61.5%) and IRA in 32 patients (38.6%). The cumulative incidence of ALwas 15.6% (13 of 83 patients). A higher AL rate was found in patients under 50 years-old (p=0.038), in the electivelaparoscopic approach subgroup (p=0.049), and patients in the inflammatory bowel disease (IBD) subgroup (p=0.009). Furthermore, 14 patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA. Discussion: A relatively high incidence of AL after TSC was observed in a relatively safe surgical procedure. Our findings suggest that the risk of AL may be higher in IBD patients. According to our results, identifying risk factors prior to surgerymay improve short-term outcomes. (AU)

Revising our concepts about stoma covering a low rectal anastomosis

Introduction: There has been conclusive evidence that defunctioning stoma with either transverse colostomy or ileostomy mitigates the serious consequences of anastomotic leakage. However,whether transverse colostomy or ileostomy is preferred for defunctioning a rectal anastomosis remains controversial. The present study was designed to identify the best defunctioning stoma for colorectal anastomosis. Objective: To improve the quality of life in patients with rectal resection and anastomosis and reduce the morbidity before and after closure of the stoma. Patients and Methods The present study included 48 patients with elective colorectal resection who were randomly arranged into 2 equal groups, with 24 patients each. Group I consisted of patients who underwent ileostomy, and group II consisted of patients who underwent colostomy as a defunctioning stoma for a low rectal anastomosis. All surviving patients were readmitted to have their stoma closed and were followed-up for 6 months after closure of their stomas. All data regarding local and general complications of construction and closure of the stoma of the two groups were recorded and blotted against each other to clarify the most safe and tolerable procedure. Results: We found that all nutritional deficiencies, dehydration, electrolytes imbalance, peristomal dermatitis, and frequent change of appliances are statistically more common in the ileostomy group, while stomal retraction and wound infection after closure of the stoma were statistically more common in the colostomy group. There were no statistically significant differences regarding the total hospital stay and mortality between the two groups. Conclusion and Recommendation: Ileostomy has much higher morbidities than colostomy and it also has a potential risk of mortality; therefore, we recommend colostomy as the ideal method for defunctioning a distal colorectal anastomosis. (AU)

Principais achados manométricos e potencial da fisioterapia anorretal no tratamento de pacientes com distúrbios evacuatórios / Main manometric findings and potential for anorectal physical therapy in the treatment of patients with evacuation disorders

ABSTRACT BACKGROUND: Evacuation disorders are prevalent in the adult population, and a significant portion of cases may originate from pelvic floor muscle dysfunctions. Anorectal manometry (ARM) is an important diagnostic tool and can guide conservative treatment. OBJECTIVE: To evaluate the prevalence of pelvic dysfunction in patients with evacuation disorders through clinical and manometric findings and to evaluate, using the same findings, whether there are published protocols that could be guided by anorectal manometry. METHODS: A retrospective analysis of a prospective database of 278 anorectal manometries performed for the investigation of evacuation disorders in patients seen at the anorectal physiology outpatient clinic of Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto between January 2015 to June 2019 was conducted. The following parameters were calculated: resting pressure (RP), squeeze pressure (SP), high-pressure zone (HPZ), rectal sensitivity (RS) and rectal capacity (RC). The pressure measurements and manometric plots were reviewed to determine the diagnosis and to propose potential pelvic physical therapy procedures. Analysis of variance (ANOVA) and Fisher's exact test were used to compare the continuous variables and to evaluate the equality of variances between groups of patients with fecal incontinence (FI) and chronic constipation (CC). Results with a significance level lower than 0.05 (P-value <0.05) were considered statistically significant. Statistical analysis was performed using IBM® SPSS® Statistics version 20. RESULTS: The mean age of the sample was 45±22 years, with a predominance of females (64.4%) and economically inactive (72.7%) patients. The indications for exam performance were FI (65.8%) and CC (34.2%). Patients with FI had lower RP (41.9 mmHg x 67.6 mmHg; P<0.001), SP (85.4 mmHg x 116.0 mmHg; P<0.001), HPZ (1.49 cm x 2.42 cm; P<0.001), RS (57.9 mL x 71.5 mL; P=0.044) and RC (146.2 mL x 195.5 mL; P<0.001) compared to those of patients with CC. For patients with FI, the main diagnosis was the absence of a functional anal canal (49.7%). For patients with CC, the main diagnosis was outflow tract obstruction (54.7%). For patients with FI, the main protocol involved a combination of anorectal biofeedback (aBF) with tibial nerve stimulation (TNS) (57.9%). For patients with CC, the most indicated protocol was aBF combined with TNS and rectal balloon training (RBT) (54.7%). CONCLUSION: There was a high prevalence of pelvic floor changes in patients with evacuation disorders. There was a high potential for performing pelvic floor physical therapy based on the clinical and manometric findings.

RESUMO CONTEXTO: Os distúrbios evacuatórios são prevalentes na população adulta e uma parcela significativa dos casos pode ter origem a partir de disfunções da musculatura do assoalho pélvico. A manometria anorretal (MAR) é importante ferramenta diagnóstica e pode guiar o tratamento conservador. OBJETIVO: Avaliar a prevalência de disfunção pélvica em pacientes com distúrbios de evacuação por meio de achados clínicos e manométricos e avaliar, usando os mesmos achados, se existem protocolos publicados que possam ser guiados pela MAR. MÉTODOS: Conduziu-se uma análise retrospectiva de um banco de dados prospectivo de 278 manometrias anorretais realizadas para investigação de distúrbios evacuatórios em pacientes do ambulatório de fisiologia anorretal do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, de janeiro de 2015 a junho de 2019. Os seguintes parâmetros foram calculados: pressão de repouso (RP), pressão de contração voluntária (PVC), canal anal funcional (CAF), sensibilidade retal (SR) e capacidade retal (CR). As medidas pressóricas e os gráficos manométricos foram revisados para elaboração do diagnóstico e para a proposição dos potenciais procedimentos de fisioterapia pélvica. Para comparação das variáveis contínuas e avaliação da igualdade entre variâncias, utilizou-se a análise de variância (ANOVA) e o teste exato de Fisher, entre os grupos de pacientes com incontinência fecal (IF) e constipação crônica (CC). Resultados com nível de significância menor que 0,05 (P-valor <0,05) foram considerados estatisticamente relevantes. Para análise estatística utilizou-se o programa IBM® SPSS® Statistics, versão 20. RESULTADOS: A idade média dos pacientes foi de 45±22 anos de idade, com predomínio do sexo feminino (64,4%) e economicamente inativo (72,7%). As indicações para a realização do exame foram IF (65,8%) e CC (34,2%). Pacientes com IF apresentaram menores valores de PR (41,9 mmHg x 67,6 mmHg; P<0,001), PCV (85,4 mmHg x 116,0 mmHg; P<0,001) CAF (1,49 cm x 2,42 cm; P<0,001), SR (57,9 mL x 71,5 mL; P=0,044) e CR (146,2 mL x 195,5 mL; P<0,001), quando comparados aos pacientes com CC. Nos pacientes com IF, o principal diagnóstico foi de ausência de canal anal funcional (49,7%). Em pacientes com CI, o principal diagnóstico foi de obstrução da via de saída (54,7%). Para pacientes com IF, o principal protocolo foi a associação do biofeedback anorretal (BFa) com estimulação do nervo tibial (ENT) (57,9%). Já nos pacientes com CC, o protocolo mais indicado foi o de BFa associado à ENT e treinamento com balão retal (54,7%). CONCLUSÃO: Observou-se elevada prevalência de alterações no assoalho pélvico de pacientes com distúrbios evacuatórios. Verificou-se elevado potencial para realização de fisioterapia do assoalho pélvico com base nos achados clínicos e manométricos.

Prevalence of rectovaginal colonization by group B Streptococcus in pregnant women seen at prenatal care program of a health organization / Prevalência de colonização retovaginal por estreptococo do grupo B em gestantes de programa de atendimento pré-natal de instituição de saúde

ABSTRACT Objective To evaluate the prevalence of group B Streptococci in pregnant women of a corporate health program, as well as the epidemiological correlations. Methods This retrospective study used medical records of patients who participated of the prenatal care program at a private hospital in the city of São Paulo (SP), Brazil, from 2015 to 2016. Those who abandoned the program or had incomplete data in their medical records were excluded. Quantitative variables were described by means, standard deviations, median, minimal and maximal values. Parity and socioeconomic status were described by absolute frequency and percentages. We used logistic regression models in the software (SPSS) to analyze correlations of variables according to vaginal-rectal culture, considering a 95%CI and p-values. Variables were age, number of pregnancies, weight gain in pregnancy and gestational age at delivery. Results A total of 347 medical records were included, and after applying the exclusion criteria, 287 medical records composed the final sample. Patients' age ranged between 17 and 44 years. Mean age was 30.6 years, 67 patients had positive result for group B Streptococcus (prevalence of 23.3%; 95%CI: 18.7-28.5). Conclusion Considering the high prevalence of group B Streptococcus in our service, the antibiotic prophylaxis strategy based on rectovaginal culture screening approach seems to be cost-effective.

RESUMO Objetivo Identificar a prevalência de estreptococo do grupo B entre gestantes que frequentaram um programa de saúde corporativa, bem como as correlações com a colonização positiva. Métodos Estudo retrospectivo dos prontuários do pré-natal de um hospital privado em São Paulo, no período de 2015 a 2016. Foram excluídas as mulheres que abandonaram o programa ou apresentavam dados incompletos nos prontuários. As variáveis quantitativas foram descritas por média, desvios padrão, mediana, valores mínimos e máximos. A paridade e a condição socioeconômica foram descritos por frequência absoluta e percentagens. Utilizamos modelos de regressão logística no programa (SPSS) para analisar as correlações de variáveis de acordo com a cultura retovaginal, considerando IC95% e valores de p. As variáveis foram idade, número de gestações, peso ganho na gestação e idade gestacional no parto. Resultados Foram incluídos 347 prontuários e, após a aplicação dos critérios de exclusão, 287 prontuários compuseram a amostra final. A idade dos pacientes variou entre 17 e 44 anos. A média de idade foi de 30,6 anos, e 67 pacientes tiveram resultado positivo para o estreptococo do grupo B (prevalência de 23,3%; IC95%: 18,7-28,5). Conclusão Considerando a alta prevalência de estreptococos do grupo B em nosso serviço, existem evidências de que a estratégia de antibiótico profilaxia baseada na cultura retovaginal é custo-efetiva.

Proctitis crónica hemorrágica por radioterapia en el Instituto Nacional de Enfermedades Neoplásicas del Perú, 2011-2013 / Radiotherapy associated chronic hemorrhagic proctitis at the National Institute of Neoplastic Diseases of Peru, 2011-2013

Objetivo: Estudiar las características clínicas y endoscópicas de la proctitis crónica hemorrágica por radioterapia en el Instituto Nacional de Enfermedades Neoplásicas del Perú. Materiales y métodos: Estudio descriptivo, retrospectivo y longitudinal, con una población de 588 pacientes con esta patología, en el periodo 2011-2013, de donde se seleccionaron 114 pacientes por muestreo probabilístico aleatorizado. Se usó la estadística descriptiva e inferencial para el análisis de las variables cualitativas y cuantitativas. Resultados: La investigación encontró como principales resultados, un periodo de latencia de 439,96 días; la severidad de rectorragia clínica fue grado II y III en el 86,84%, la hemoglobina media fue de 11,63 gr/dl, los hallazgos endoscópicos fueron severidad moderada en el 58,77%, extensión solo rectal en el 92,11%, friabilidad leve del 43,86%, compromiso menor del 33% de la superficie rectal en el 71,93% y una longitud media de 7,28 cm. Los hallazgos inflamatorios fueron de cicatrices en el 0,88%, erosiones del 0,88%, de úlceras del 7%, de fístula del 0,88% y del 3,51% de estenosis rectales, el tratamiento de argón plasma coagulación (APC) único o combinado se ofreció en el 96% de los casos. Conclusiones: La proctitis crónica hemorrágica por radioterapia fue una complicación importante de la radioterapia pélvica, con hallazgos clínicos y endoscópicos característicos.

Objective: To study the clinical and endoscopic features of chronic hemorrhagic proctitis by radiotherapy in the National Institute of Neoplastic Diseases of Peru. Materials and methods: The study was descriptive, retrospective and longitudinal, with a population of 588 patients with this pathology, in the period 2011-2013, from which 114 patients were selected by randomized probabilistic sampling. Descriptive and inferential statistics were used for the analysis of qualitative and quantitative variables. Results: The main results were a latency period of 439.96 days; the severity of clinical rectal bleeding was grade 2 and 3 in 86.84%, the mean hemoglobin in chronic hemorrhagic proctitis by radiotherapy was 11.63 g / dl, the endoscopic findings were moderate severity in 58.77%, extension rectal only in 92.11%, slight friability of 43.86%, compromise less than 33% of the rectal surface in 71.93% and an average length of 7.28 cm. The inflammatory findings were 0.88% scars, erosions of 0.88%, ulcers of 7%, fistula of 0.88% and 3.51% of rectal stenosis, single or combined argon plasma coagulation (APC) treatment was offered in 96% of cases. Conclusion: Chronic hemorrhagic proctitis is an important complication of pelvic radiotherapy, with characteristic clinical and endoscopic findings.

Clinical and manometric investigation in constipated Chagasic patients with and without megacolon / Investigação clínica e manométrica de pacientes chagásicos constipados com e sem megacolon

ABSTRACT Background: Chagasic colopathy is the second most common digestive manifestation, and constipation is the main symptom. The absence of the Rectoanal Inhibitory Reflex plays an important role in constipation and anal manometry is crucial for appropriate evaluation. Purpose: Evaluate anal manometry findings (mainly Rectoanal Inhibitory Reflex) in Chagasic patients with chronic constipation, with and without megacolon and correlate these findings with clinical and demographic data. Methods: Cross-sectional study of patients with chronic constipation who underwent Chagasic serologic test, barium enema, and anal manometry. The absence of Rectoanal Inhibitory Reflex was evaluated using the mid-P Exact Test. Results: 64 Patients were included: 23 Chagasic patients with megacolon/megarectum (G1), 21 Chagasic patients without megacolon/megarectum (G2) and 20 non-Chagasic patients without megacolon/megarectum (G3). Chagasic patients with megacolon had a higher incidence of fecaloma (39%) compared to the other two groups (9.5% and 10% for G2 and G3, respectively, p = 0.03). Rectal capacity on manometry was statically higher for G1 patients. Rectoanal Inhibitory Reflex was absent in 91.3% of patients in G1, 47.29% in G2 and present in all patients in G3. There was a significant difference in the absence of the Rectoanal Inhibitory Reflex when comparing the groups (G1 vs. G2: p = 0.002, G1 vs. G3: p < 0.001, G2 vs. G3: p < 0.001). Conclusion: The absence of RAIR confirms the diagnosis of Chagasic colopathy and endorses surgical treatment whenever clinical treatment fails. The presence of the RAIR in patients with positive serology for Chagas disease without megacolon/megarectum might not be due chagasic colopathy and other causes should be considered.

RESUMO Fundamento: A colopatia chagásica é a segunda manifestação digestiva mais comum e a constipação é o principal sintoma. A ausência do Reflexo Inibitório Retoanal desempenha um papel importante na constipação e a manometria anal é crucial para avaliação adequada. Objetivo: Avaliar os achados da manometria anal (principalmente o Reflexo Inibitório Retoanal) em pacientes chagásicos com constipação crônica, com e sem megacólon, e correlacionar esses achados com dados clínicos e demográficos.Métodos: Estudo transversal de pacientes com constipação crônica submetidos ao teste sorológico para doença de chagas, enema de bário e manometria anal. A ausência de Reflexo Inibitório Retoanal foi avaliada por meio do Teste Exato de Ponto Médio. Resultados: Foram incluídos 64 pacientes: 23 chagásicos com megacólon/megarreto (G1), 21 chagásicos sem megacólon/megarreto (G2) e 20 não chagásicos sem megacólon/megarreto (G3). Os pacientes chagásicos com megacólon apresentaram maior incidência de fecaloma (39%) em comparação aos outros dois grupos (9,5% e 10% para G2 e G3, respectivamente, p = 0,03). A capacidade retal na manometria foi estatisticamente maior nos pacientes do G1. O Reflexo Inibitório Retoanal estava ausente em 91,3% dos pacientes do G1, em 47,29% no G2 e presente em todos os pacientes do G3. Houve diferença significativa na ausência do Reflexo Inibitório Retoanal quando comparados os grupos (G1 vs. G2: p = 0,002, G1 vs. G3: p < 0,001, G2 vs. G3: p < 0,001). Conclusão: A ausência de RIRA confirma o diagnóstico de colopatia chagásica e endossa o tratamento cirúrgico sempre que o tratamento clínico falhar. A presença de RIRA em pacientes com sorologia positiva para doença de Chagas, sem megacólon/megarreto, pode não ser devida à colopatia chagásica e outras causas devem ser consideradas.

Evaluación de factores de riesgo asociados a dehiscencia anastomótica en cirugía colorrectal: análisis multivariado de 748 pacientes / Evaluation of the risk factors associated with anastomotic dehiscence in colorectal surgery: multivariate analysis of 748 pacients

INTRODUCCIÓN: La dehiscencia anastomótica (DA) es una complicación severa en cirugía colorrectal con una incidencia que oscila entre 2 y 19%. La literatura internacional muestra numerosos estudios sobre la identificación de factores de riesgo (FR), mientras que en la nacional existen solo dos series que analizan esta complicación. OBJETIVO: Realizar una caracterización descriptiva de resultados institucionales y establecer la tasa de DA, sus factores de riesgo asociados y la mortalidad. MATERIALES Y MÉTODO: Serie de casos no concurrente, cuya muestra son pacientes consecutivos intervenidos de patología colorrectal con anastomosis primaria con o sin ostoma derivativo entre los años 2004 y 2016. Se realiza modelo de regresión logística univariable y multivariable. RESULTADOS: Se obtuvieron 748 pacientes, 50,5% mujeres, media de edad fue 56,2. Las indicaciones quirúrgicas más frecuentes fueron cáncer colorrectal en 381 (50,9%) pacientes y enfermedad diverticular en 163 (21,8%). La DA fue de 5,6% (42/748) y la mortalidad fue de 2% (15/748), siendo de 1% para los electivos (7/681). En el análisis univariado encontramos que los FR que tuvieron significancia estadística fueron la albúmina (p < 0,001), altura anastomosis (p < 0,001), transfusión (p < 0,001), localización (colon derecho > izquierdo) (p = 0,011), mientras que en el análisis multivariado fueron la albúmina (p = 0,002) con un OR 3,64 (IC 95% 1,58-8,35) y transfusión (p = 0,015) con un OR 7,15 (IC 95% 1,46-34,91). CONCLUSIÓN: Nuestra serie es la más grande reportada en Chile, con resultados similares a estudios internacionales y nacionales. Establecemos que la hipoalbuminemia y la presencia de transfusiones intraoperatorias se asocian a alta tasa de DA.

INTRODUCTION: Anastomotic leakage (AL) is a severe complication in colorectal surgery, its incidence ranges from 2 to 19%. In international literature, we found numerous studies on the identification of risk factors (RF), while in the national there are only two series that analyze this complication. AIM: Perform a descriptive characterization of institutional results and establish the AL rate, its associated risk factors and mortality. MATERIALS AND METHOD: Non-concurrent series of cases, whose sample is consecutive patients operated for colorectal pathology with primary anastomosis with or without a derivative ostoma between 2004 and 2016. Univariate and multivariable logistic regression model was performed. RESULTS: There were 748 patients, 50.5% women, mean age was 56.2. The most frequent surgical indications were colorectal cancer in 381 (50.9%) patients and diverticular disease in 163 (21.8%). The AL was 5.6% (42/748) and the mortality was 2% (15/748), being 1% for the electives (7/681). In the univariate analysis, we found that the RF that had statistical significance were albumin (p < 0.001), anastomosis height (p < 0.001), transfusion (p < 0.001), location (right colon > left) (p = 0.011), while that in the multivariate analysis were albumin (p = 0.002) with an OR 3.64 (IC 95% 1.58-8.35) and transfusion (p = 0.015) with an OR 7.15 (IC 95% 1.46-34.91). CONLUSION: Our series is the largest reported in Chile, with similar results to international and national studies. We establish that hypoalbuminemia and the presence of intraoperative transfusions are associated with a high rate of AL.

Características manométricas en niños con estreñimiento crónico y patología anorrectal adquirida / Manometric characteristics in children with chronic constipation and acquired anorectal pathology

Objetivos: Describir los resultados de las manometrías anorrectales (MAR) en pacientes pediátricos con estreñimiento crónico y patología anorrectal adquirida. Materiales y métodos: Se revisaron los expedientes de pacientes pediátricos referidos entre 2004 y 2016 al Laboratorio de Motilidad Gastrointestinal del Hospital San José Tec de Monterrey para evaluación por manometría anorrectal y que presentaron patología anorrectal adquirida. Resultados: Se revisaron 170 expedientes. Edad 7,18 ± 4,51 años. La prevalencia de patología anorrectal (PA) fue de 73%. Síntomas con mayor incidencia: dificultad para evacuar (78%), dolor al evacuar (67%), heces duras (50%) e incontinencia fecal asociado (49%). El 44% de los pacientes con esfínter anal externo (EAE) hipotónico presentaron incontinencia y 74% estos últimos, presentaron menor volumen máximo tolerable (VMT). Los valores manométricos con mayor significancia: presión en reposo del EAE (promedio ± DE) 14,16 ± 10,19 en PA y de 26,08 ± 13,65 en SPA; presión en contracción del EAE 48,4 ± 34,1 en PA y 68,3 ± 37,7 en SPA; VMT 120,8 ± 60,4 en PA y de 173,2 ± 78,0 en SPA. El 97,97% de los pacientes en los que se evaluó la coordinación abdomino-pélvica tuvieron disinergia del piso pélvico. Conclusiones: A diferencia de la población adulta, los valores manométricos de niños con patología anorrectal se encontraron dentro de rangos normales excepto por el EAE y el VMT los cuales estuvieron disminuidos. Esto puede sugerir un mecanismo diferente en la población pediátrica. La disinergia del piso pélvico podría explicar el estreñimiento crónico en estos pacientes.

Objective: To describe the anorectal manometry results in the pediatric population with chronic constipation and acquired anorectal disease. Materials and methods: We reviewed the records of children who were referred to the Motility and Pelvic Floor Laboratory of the Hospital San Jose Tecnologico de Monterrey between 2004-2016 for further evaluation with anorectal manometry and who presented acquired anorectal disease. Results: We reviewed 170 records. The mean age was 7.18 ± 4.51 years old. The prevalence of anorectal disease was 73%. The symptoms more frequently presented were difficult evacuation (78%), painful defecation (67%), large and hard stool (50%) and fecal soiling (49%). 44% of patients with hypotonic external anal sphincter (EAS) presented with soiling and 74% of those had diminished critical volume. Significant manometric values (p<0.05) were EAS resting pressure, maximal squeeze pressure, and critical volume. 97.7% of those who underwent abdomino pelvic coordination evaluation had pelvic floor dyssynergia (anismus). Conclusions: Contrary to adult population, the manometric values in children with acquire anorectal pathology were within normal values except for the EAS resting pressure and critical volume that were diminished. This could suggest a different mechanism in the pediatric population. Pelvic floor dyssynergia could explain chronic constipation in these patients.

Oncological outcomes in extended time intervals between preoperative chemoradiotherapy with capecitabine and surgery in operable rectal adenocarcinoma / Resultados oncológicos en intervalos extendidos de tiempo entre quimioradioterapia preoperatoria con capecitabina y cirugía en adenocarcinoma rectal operable

Objective: To assess whether extended time intervals (8-12, 13-20 and >20 weeks) between the end of neoadjuvant chemoradiotherapy and surgery affect overall survival, disease-free survival. Materials and methods: Retrospective study in 120 patients with rectal adenocarcinoma without evidence of metastasis (T1-4/N0-2/M0) at the time of diagnosis that underwent surgery with curative intent after neoadjuvant chemoradiotherapy with capecitabine and obtained R0 or R1 resection between January 2010 to December 2014 at the National Cancer Institute of Peru. Dates were evaluated by Kaplan-Meier method, log- rank test and Cox regression analysis. Results: Of the 120 patients, 70 were women (58%). The median age was 63(26-85) years. All received neoadjuvant chemoradiotherapy. No significant difference was found between the association of the median radial (0.6, 0.7 and 0.8 cm; p=0.826) and distal edge (3.0, 3.5 and 4.0 cm; p=0.606) with time interval groups and similarly the mean resected (18.8, 19.1 and 16.0; p=0.239) and infiltrated nodules (1.05, 1.29 and 0.41); p=0.585). The median follow-up time of overall survival and desease free survival was 40 and 37 months, respectively. No significant differences were observed in overall survival (79.0%, 74.6% and 71.1%; p=0.66) and disease-free survival (73.7%, 68.1% and 73.6%; p=0.922) according to the three groups studied at the 3-year of follow-up. Conclusions: We found that widening the time intervals between the end of neoadjuvant chemoradiotherapy and surgery at 24 weeks does not affect the overall survival, disease-free survival and pathological outcomes. It allows to extend the intervals of time for future studies that finally will define the best time interval for the surgery

Objetivo: Evaluar si los intervalos de tiempo extendidos (8-12, 13-20 y >20 semanas) entre el fin de la quimioradioterapia neoadyuvante y la cirugía afectan la sobrevida global, y la sobrevida libre de enfermedad. Material y métodos: Estudio retrospectivo de 120 pacientes con adenocarcinoma rectal sin evidencia de metástasis (T1-4/N0-2/M0) al momento del diagnóstico que se sometieron a cirugía con intención curativa luego de quimioradioterapia neoadyuvante con capecitabina y tuvieron resección R0 o R1 entre enero 2010 y diciembre 2014 en el Instituto Nacioanal de Enfermedades Neoplásicas de Perú. El análisis se hizo con el método de Kaplan-Meier, la prueba log-rank y la regresión de Cox. Resultados: De 120 pacientes, 70 fueron mujeres (58%). La mediana de la edad fue 63 años (26-85 años). Todos recibieron quimioradioterapia neoadyuvante. No hubo diferencia significativa entre la asociación de las medianas de los bordes radial (0,6, 0.7 y 0,8 cm; p=0,826) y distal (3,0, 3,5 y 4,0 cm; p=0,606) con los intervalos de tiempo de los grupos y similarmente con la media de los ganglios resecados (18,8, 19,1 y 16,0; p=0,239) e infiltrados (1,05, 1,29 y 0,41; p=0,585). No se observaron diferencias significativas en sobrevida global (79,0%, 74,6% y 71,1%; p=0,66) y sobrevida libre de enfermedad (73,7%, 68,1% y 73,6%; p=0,922), en los tres grupos estudiados a 3 años de seguimiento. Conclusiones: Encontramos que aumentar los intervalos de tiempo entre el fin de la quimioradioterapia neoadyuvante y la cirugía hasta 24 semanas no afecta la sobrevida global, sobrevida libre de enfermedad ni los desenlaces patológicos. Esto permitiría extender los intervalos de tiempo en estudios futuros para definir el mejor intervalo de tiempo para la cirugía

Impact on sexual function of surgical treatment in rectal cancer

ABSTRACT Introduction The development of new surgical techniques and medical devices, like therapeutical multimodal approaches has allowed for better outcomes on patients with rectal cancer (RCa). Owing to that, an increased awareness and investment towards better outcomes regarding patients' sexual and urinary function has been recently observed. Aim Evaluate and characterize the sexual dysfunction of patients submitted to surgical treatment for RCa. Materials and Methods An observational retrospective study including all male patients who underwent a surgical treatment for RCa between January 2011 December 2014 (n=43) was performed, complemented with an inquiry questionnaire to every patient about its sexual habits and level of function before and after surgery. Discussion All patients were male, with an average of 64yo. (range 42-83yo.). The surgical procedure was a rectum anterior resection (RAR) in 22 patients (56%) and an abdominoperineal resection (APR) in 19(44%). Sixty three percent described their sexual life as important/very important. Sexual function worsening was observed in 76% (65% with complains on erectile function, and 27% on ejaculation). Fourteen patients (38%) didn't resume sexual activity after surgery. Increased age (p=0.007), surgery performed (APR) (p=0.03) and the presence of a stoma (p=0.03) were predictors of ED after surgery. A secondary analysis found that the type of surgery (APR) (p=0.04), lower third tumor's location (p=0.03) and presence of comorbidities (p=0.013) (namely, smokers and diabetic patients) were predictors of de novo ED after surgery. Conclusions This study demonstrated the clear negative impact in sexual function of patients submitted to a surgical treatment for RCa. Since it is a valued feature for patients, it becomes essential to correctly evaluate/identify these cases in order to offer an adequate therapeutical option.

Aplicabilidad del Colon Leakage Score como predictor de filtración anastomótica en cirugía de cáncer colorrectal / Applicability of the Colon Leakage Score as an anastomotic leakage predictor in colorectal cancer surgery

Introducción: La filtración anastomótica (FA) en cirugía colorrectal aumenta la morbimortalidad. La identificación de factores de riesgo y la creación de un modelo predictivo ayudaría en la decisión de crear un ostoma desfuncionalizante, hecho que, actualmente, recae en el criterio del cirujano. Dekker creó el Colon Leakage Score (CLS) estableciendo criterios objetivos. Objetivo: Establecer el CLS en pacientes intervenidos por cáncer de colon izquierdo y recto en Clínica INDISA, estableciendo valores de corte locales, su sensibilidad y especificidad. Pacientes y Método: Corresponde a un estudio de pruebas diagnósticas, cuya intervención es la aplicación del CLS comparándolo con la presencia de filtración anastomótica (gold standard), definida por criterios clínicos y radiológicos. Se utilizó análisis de curvas ROC, índice de Youden y regresión logística. Resultados: De 180 pacientes, hubo FA en 12 (6,6%). La media de CLS en quienes hubo FA fue de 11,5 y en quienes no hubo FA de 6,9 (p = 0,0001). El área bajo la curva para predicción de FA con el CLS fue de 0,829 (IC 95% 0,69-0,96), con un valor de corte de 11, sensibilidad de 67% y especificidad de 89%. En el análisis de regresión logística, el OR para la predicción de FA utilizando el CLS fue de 1,48 (IC 95% 1,22-1,79 p < 0,001). Conclusión: El CLS es una herramienta que permite predecir el riesgo de FA en pacientes intervenidos por cáncer de colon izquierdo y recto. Ante un valor mayor o igual a 11 se debería crear un ostoma protector, generando un cambio en la práctica clínica.

Introduction: Anastomotic filtration increases morbidity and mortality in colorrectal surgery. Identification of risk factors and creation of a predictive model would help the decision of creating a defunctionalizing ostoma, that currently is taken by the surgeon. Dekker created de Colon Leakege Score (CLS) with objective criteria. Objective: Establish CLS in patients that underwent left colon and rectum surgery with cancer diagnosis in Clinica INDISA, define the local cutting value, it's specificity and sensibility. Patients and Methods: Corresponds to a diagnostic test's study, that intervention is CLS application, comparing with the presence of anastomotic filtration (gold standard), defined by clinical and radiologic criteria. For the analysis, ROC curves, Youden's index and logistic regression. Results: From 180 patients, anastomotic filtration was present in 12 (6.6%). Average CLS score in patients with anastomotic filtration was 11.5 and in those without anastomotic filtration was 6.9 (p = 0.0001). Area under the curve for anastomotic filtration prediction using CLS was 0.829 (CI 95% 0.69-0.96) with a cutting value of 11, 67% of sensibility and 89% of specificity. Logistic regression analysis, OR for anastomotic filtration prediction using CLS was 1.48 (CI 95% 1.22-1.79 p < 0.001). Conclusion: CLS is a tool that permits predicting anastomotic filtration risk in patients that underwent left colon and rectum surgery. With a CLS value equal or more than 11, we should create a protective ostoma, generating a clinical practice local change.

Abordaje microquirúrgico transanal. Experiencia inicial. Indicaciones y resultados / Transanal microsurgical approach. Initial experience. Indications and results

Introducción: El tratamiento quirúrgico de las afecciones del recto bajo se encuentra en permanente revisión intentando mantener una adecuada función de continencia y urogenital. Una opción reciente es el abordaje microquirúrgico transanal. El objetivo del trabajo es evaluar una serie de pacientes tratados mediante dicho abordaje, analizando indicaciones, resultados inmediatos y alejados. Material y método: Se seleccionaron 41 pacientes operados en el período comprendido entre febrero de 2009 y febrero de 2015. Resultados: En 41 pacientes, las afecciones tratadas fueron: pólipos, 22; cáncer de recto, 14; estenosis de anastomosis, 2; absceso retrorrectal, 1; endometriosis, 1; poliposis adenomatosa familiar, 1. Los pacientes con pólipos llegaron a consulta: por primera vez, 15; recidivados, 4; segunda recidiva, 2; tercera recidiva, 1. Los procedimientos realizados fueron: resección local, 29; microcirugía transanal transabdominal (TATA), 6; dilatación de estenosis, 4; biopsia transrectal, 3; drenaje de absceso retrorrectal, 1; control de hemorragia, 1; colocación de stent, 1. En cáncer de recto: resección local, 7; biopsia transrectal, 2; TATA, 4; colocación de stent, 1. El tiempo operatorio promedio fue 48,6 minutos, y la estadía hospitalaria promedio 2,21 días. De los 29 pacientes en quienes se realizó resección local, fueron controlados 25 durante un período de 6 a 72 meses. Se complicaron 11 pacientes, sin mortalidad ni recidivas locales. Conclusiones: Este abordaje permite tratar lesiones del recto y último segmento del colon sigmoides. Otorga mejor visión permitiendo una disección más exacta, mejorando resultados postoperatorios inmediatos y alejados en patología benigna y maligna, minimizando la posibilidad de recidivas. (AU)

Introduction: The surgical treatment of conditions located at the low rectum is in constant review, triying to maintain proper urogenital and continence function. One of the most recent options is the transanal microsurgical. The aim of this paper is to analyze a series of patients treated with this approach, its indications, immediate and long term results. Material and Methods: 41 patients were analyzed retrospectively in the period between February 2009 and February 2015. Results: In these patients, treated conditions were polyps: 22; rectal cancer: 14; anastomotic stricture: 2; retrorectal abscess: 1; endometriosis: 1; familial adenomatous polyposis: 1. Patients affected with polyps reached the first consultation in 15 opportunities; 4 on first recurrence; 2 with second recurrence; 1 with third recurrence. The procedures were 29 local resections; 6 transanal transabdominal resections (TATA); 4 dilations of stenosis; 3 transrectal biopsies; 1 retrorectal abscess drainage; 1 hemorrhage control; 1 stent placement. In rectal cancer were: 7 local resection; 2 transrectal biopsies; 4 TATA; 1 stent placement. Mean operative time was 48.6 minutes and mean hospital stay was 2.21 days. Of the 29 patients in whom local resection was performed, 25 were controlled for a period of 6 to 72 months. 11 patients were complicated; no deaths or local recurrences were registered. Conclusions: This approach allows to treat lesions located throughout the rectum and the last segment of sigmoid colon. A better insight is obtained allowing a more accurate dissection, thus improving the immediate and remote postoperative results and minimizes the possibility of recurrence, particularly when it comes to benign conditions. (AU)

Postoperative outcomes and functional results after Deloyer's procedure - a retrospective cohort study / Desfechos pós-operatórios e resultados funcionais após o procedimento de Deloyer ­ um estudo de coorte retrospectivo

ABSTRACT Introduction: The objective of our study was to describe surgical outcomes of Deloyers procedure in our referral center, and to compare the results of patients with and without protective ileostomy. Methods: Patients undergoing a Deloyers procedure from 2013 to 2016 were prospectively included. General characteristics, intraoperative variables, postoperative course, and functional outcomes were analyzed. Patients were compared into two groups: group (1) patients undergoing Deloyers procedure without ileostomy, and group (2) Deloyers procedure with protective ileostomy. Results: Sixteen patients undergoing isoperistaltic transposition of the right colon remnant were included, of which 9 (63%) were males with a median age of 47 (range 22-76) years. The main surgical indication was the restoration of bowel transit (62.5%). There was higher major morbidity rate in the Deloyers procedure with protective ileostomy group, but without statistical significance (20% vs. 9%, p = 0.92). No leaks or deaths were reported. The length of hospital stay was 7 days. The mean number of bowel movements per day was 4 at 18 months of follow up. Only four (25%) patients used irregularly loperamide. Conclusions: The Deloyers procedure has satisfactory results and is reproducible with low morbidity. The major and minor morbidity rates were similar between groups, suggesting that the costs and risks of a second procedure can be avoided by providing a safe primary anastomosis.

RESUMO Introdução: O objetivo de nosso estudo foi descrever os resultados cirúrgicos do procedimento de Deloyer em nosso centro de referência e comparar os resultados de pacientes com e sem ileostomia de proteção. Métodos: Pacientes submetidos ao procedimento de Deloyer de 2013 a 2016 foram incluídos prospectivamente. Foram analisadas as características gerais, as variáveis intraoperatórias, o curso pós-operatório e os desfechos funcionais. Os pacientes foram comparados em dois grupos: Grupo 1) pacientes submetidos ao procedimento de Deloyer (PD) sem ileostomia, e grupo 2) procedimento de Deloyer com ileostomia de proteção (IP). Resultados: Foram incluídos 16 pacientes submetidos à transposição isoperistáltica da porção remanescente do cólon direito, dos quais 9 (63%) eram do sexo masculino com idade média de 47 anos (variação de 22-76) anos. A principal indicação cirúrgica foi a restauração do trânsito intestinal (62,5%). Houve maior morbidade maior no grupo IP, mas sem significância estatística (20% vs. 9%, p = 0,92). Nenhum vazamento ou óbito foi relatado. A duração da hospitalização foi de 7 dias. O número médio de evacuações por dia foi 4, aos 18 meses de seguimento. Apenas quatro (25%) pacientes utilizaram irregularmente a loperamida. Conclusões: O procedimento de Deloyer tem resultados satisfatórios e é reprodutível com baixa morbidade. As taxas de morbidades maiores e menores foram semelhantes entre os grupos, sugerindo que os custos e riscos de um segundo procedimento podem ser evitados proporcionando-se uma anastomose primária segura.

Resección total del mesorrecto por vía transanal en cáncer de recto: análisis de resultados de una serie preliminar en un hospital universitario / Transanal total mesorectal excision in rectal cancer: analysis of a preliminary series in universitary hospital

Introducción: La resección total del mesorrecto por vía transanal es un abordaje híbrido que combina el uso de una plataforma transanal y laparoscopia convencional. Objetivos: Realizar el análisis de casos seleccionados con cáncer de recto medio e inferior en los cuales se utilizó un abordaje transanal combinado para su resolución y la descripción de la técnica quirúrgica. Materiales y métodos. Corresponde a una serie prospectiva de pacientes con diagnóstico de cáncer de recto de tercio medio e inferior con resección mesorrectal asistida por monopuerto endoanal entre octubre de 2012 y diciembre de 2015, en Hospital Clínico Universidad de Chile. Se utilizó estadística descriptiva para el análisis de los datos. Resultados: Fueron sometidos a cirugía por cáncer de recto medio e inferior un total de 29 pacientes utilizando monopuerto transanal. De estos, 22 fueron de sexo masculino y 7 de sexo femenino, con edad promedio de 55,5 años e IMC de 26,4. La distancia media al margen anal fue 4,8 cm. Todos recibieron neoadyuvancia. Se realizaron 17 Ta-TME (58,6%) y 12 Ta-TME con abordaje interesfintérico (41,4%). La anastomosis fue coloanal manual en 15 pacientes (51,7%) y grapada en 14 (48,3%). El abordaje laparoscópico se utilizó en 26 pacientes y el abierto en 3, registrando 4 conversiones (15,4%). El tiempo operatorio promedio fue de 282 min. La estadía hospitalaria media fue de 9 días. Conclusión: El monopuerto endoanal aparece como una herramienta útil en la disección total del mesorrecto por su seguridad y factibilidad. Creemos que es necesaria la realización de trabajos prospectivos aleatorizados, donde es relevante la comparación de resultados oncológicos y funcionales a largo plazo.

Introduction: Transanal total mesorectal excision is a hybrid approach that combines the use of a conventional laparoscopic and a transanal platform. Objectives: To conduct an analysis of selected cases with medium and lower rectal cancer, were a combined transanal approach was used and description of the surgical technique. Materials and methods: Prospective series of patients diagnosed with middle and lower third rectal cancer with mesorectal resection assisted by endoanal single port, between October 2012 and December 2015 at University of Chile Clinical Hospital. Descriptive statistics were used for data analysis. Results: A total of 29 patients underwent surgery for middle and lower rectal cancer using a transanal single port. Gender distribution was 22 male and 7 female patients, with a mean age of 55.5 years and a mean BMI of 26.4. The mean distance from the anal margin was 4.8 cm. All patients received neoadjuvant therapy. The surgeries performed were 17 Ta-TME (58.6%) and 12 Ta-TME with intersphincteric approach (41.4%). The colo-anal anastomosis was hand sewn in 15 patients (51.7%), and stapled in 14 (48.3%). The laparoscopic approach was used in 26 patients and the open approach in 3, with 4 conversions (15.4%). The mean operative time was 282 min. The mean hospital stay was 9 days. Conclusion: The endoanal single port appears as a useful tool in total mesorectal dissection for its safety and feasibility. We believe we need randomized prospective studies, where comparison of oncological and functional long-term results is relevant.

Anogenital infection by Chlamydia trachomatis and Neisseria gonorrhoeae in HIV-infected men and women in Salvador, Brazil

ABSTRACT Background: Infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae are the most common bacterial sexually transmitted infections throughout the world. These sexually transmitted infections are a growing problem in people living with HIV/AIDS. However, the presence of these agents in extra genital sites, remains poorly studied in our country. The objective of this study was to estimate the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae anal and genital infection in people living with HIV/AIDS followed in a reference center in Salvador, Brazil. Methods: Cross-sectional study, from June 2013 to June 2015. Proven HIV-infected people attending this reference center were invited. Clinical and epidemiological data were obtained through interview with standardized form. Chlamydia trachomatis and Neisseria gonorrhoeae screening was performed using qPCR (COBAS 4800® Roche). Results: The frequency of positive cases of Chlamydia trachomatis and Neisseria gonorrhoeae was 12.3% in total, 9.2% cases amongst women and 17.1% amongst men. We found 14.0% of positive cases in anus and 3.1% in genital region in men, while 5.6% and 3.6%, in women, respectively. Among men, anal infection was associated with age <29 years (p = 0.033), report of anal intercourse (p = 0.029), pain during anal intercourse (p = 0.028). On the other hand, no association between genital infection and other variables were detected in bivariate analysis. Among women, we detected an association between Chlamydia trachomatis genital infection and age <29 years (p < 0.001), younger age at first sexual intercourse (p = 0.048), pregnancy (p < 0.001), viral load >50 copies/mL (p = 0.020), and no antiretroviral use (p = 0.008). Anal infection in women was associated with age <29 years old (p < 0.001) and pregnancy (p = 0.023), and was not associated with report of anal intercourse (p = 0.485). Conclusion: Missed opportunities for diagnosis in extra genital sites could impact on HIV transmission. The extra genital sites need to be considered to break the HIV and bacterial sexually transmitted infections chain-of-transmission.

Long term outcome and side effects in patients receiving low-dose I125 brachytherapy: a retrospective analysis

ABSTRACT Objectives: To retrospectively evaluate the disease free survival (DFS), disease specific survival (DSS),overall survival (OS) and side effects in patients who received low-dose rate (LDR) brachytherapy with I125 stranded seeds. Materials and methods: Between july 2003 and august 2012, 274 patients with organ confined prostate cancer were treated with permanent I125 brachytherapy. The median follow-up, age and pretreatment prostate specific antigen (iPSA) was 84 months (12-120), 67 years (50-83) and 7.8 ng/mL (1.14-38), respectively. Median Gleason score was 6 (3-9). 219 patients (80%) had stage cT1c, 42 patients (15.3%) had stage cT2a, 3 (1.1%) had stage cT2b and 3 (1.1%) had stage cT2c. The median D90 was 154.3 Gy (102.7-190.2). Results: DSS was 98.5%.OS was 93.5%. 13 patients (4.7%) developed systemic disease, 7 patients (2.55%) had local progression. In 139 low risk patients, the 5 year biochemical freedom from failure rate (BFFF) was 85% and 9 patients (6.4%) developed clinical progression. In the intermediate risk group, the 5 year BFFF rate was 70% and 5 patients (7.1%) developed clinical progression. Median nPSA in patients with biochemical relapse was 1.58 ng/mL (0.21 – 10.46), median nPSA in patients in remission was 0.51 ng/mL (0.01 – 8.5). Patients attaining a low PSA nadir had a significant higher BFFF (p<0.05). Median D90 in patients with biochemical relapse was 87.2 Gy (51 – 143,1). Patients receiving a high D90 had a significant higher BFFF (p<0.05). Conclusion: In a well selected patient population, LDR brachytherapy offers excellent outcomes. Reaching a low PSA nadir and attaining high D90 values are significant predictors for a higher DFS.

Rectosigmoidectomía perineal para el tratamiento del prolapso rectal completo / Perineal rectosigmoidectomy for the treatment of rectal prolapse

Objetivo: Presentamos nuestra experiencia en el tratamiento quirúrgico de esta patología con la técnica de la rectosigmoidectomía perineal. Material y método: Se trata de una serie retrospectiva, consecutiva de 17 pacientes. Resultados: Predomina el género femenino y el promedio de edad es de 62 años. La morbilidad alcanza el 23%, aunque casi toda de menor gravedad, con solo un paciente reoperado. La recidiva es del 6%, con mejoría de los síntomas en un 88%. Conclusión: Concluimos que es una técnica segura, con una morbilidad controlada y con buenos resultados a mediano plazo con un adecuado control de la recidiva y mejoría de la continencia en un alto porcentaje de los pacientes.

Aim: We present our experience with perineal rectosigmoidectomy for the treatment of rectal prolapse. Material and method: It is a retrospective, consecutive series of 17 patients. Results: Predominantly female and the average age is 62 years. Morbidity reached 23%, but almost all less serious, with only one reoperation. Recurrence is 6%, and the improvement in continence is 88%. Conclusion: We conclude that it is a safe technique with a controlled morbidity and good results with low recurrence and improvement of continence in a high percentage of patients.

Microscopic analysis of patients with chronic diarrhea without macroscopic disease / Análise microscópica de pacientes com diarreia crônica sem doença macroscópica

BACKGROUND: Colonoscopy is part of the current diagnostic armamentarium. However, in some patients with chronic diarrhea, a colonoscopy may show normal mucosa; in these cases, serial biopsies can provide important information for the diagnosis and treatment of patients. AIM: To analyze patients with chronic diarrhea having a macroscopically normal colonoscopy, by evaluating histological changes. METHODS: 30 patients with chronic diarrhea and normal colonoscopy were prospectively evaluated and submitted to serial biopsies of the terminal ileum, ascending colon and rectum. RESULTS: The sample of 30 patients showed a ratio of 18 men (60%) and 12 women (40%). On histological types, it was found that 13 patients (43.3%) had lymphoid hyperplasia, eosinophilic inflammation in 4 (13.3%), nonspecific inflammation in 4 (13.3%), regenerative changes in 3 (10%), lymphocytic colitis in 2 (6.6%) and changes consistent with Crohn's disease in 1 (3.3%). CONCLUSIONS: One can observe that even chronic diarrhea patients, without other associated factors, benefited from colonoscopy with biopsy, because it held the etiologic diagnosis in some cases as also excluded by histopathology. It was noticed that the frequency of patients with altered biopsy and less dragged diarrheal episodes (84.2%) was large, should consider their achievement.

INTRODUÇÃO: A colonoscopia faz parte do arsenal de diagnóstico atual. Porém, em alguns pacientes com diarreia crônica, a colonoscopia pode evidenciar mucosa normal; nesses casos biópsias seriadas podem trazer informações importantes para o diagnóstico e tratamento dos pacientes. OBJETIVO: Analisar pacientes com diarreia crônica submetidos à colonoscopia macroscopicamente normal, avaliando assim histologicamente as alterações. MÉTODOS: Análise prospectiva da histologia 30 pacientes com diarreia crônica e colonoscopias normais, submetidos a biópsias seriadas de íleo terminal, cólon ascendente e reto. RESULTADOS: A amostra de 30 pacientes mostrou uma proporção de 18 homens (60%) e 12 mulheres (40%). Sobre os tipos de alterações histológicas, foi verificado que 13 pacientes (43,3%) apresentaram hiperplasia linfóide, inflamação eosinofílica em 4 (13,3%), inflamação inespecífica em 4 (13,3%), alterações regenerativas em 3 (10%), colite linfocítica em 2 (6,6%) e alterações compatíveis com Doença de Crohn em 1 (3,3%). CONCLUSÕES: Observou-se que mesmo pacientes com diarreia crônica, sem outros fatores associados, beneficiaram-se da colonoscopia com biópsia, pois a mesma realizou o diagnóstico etiológico em alguns casos como também o excluiu através da histopatologia. Verificou-se que a frequência de pacientes com biópsia alterada e quadros diarreicos menos arrastados (84,2%) foi grande, devendo-se considerar a realização do exame.

Safety of 12 core transrectal ultrasound guided prostate biopsy in patients on aspirin

Objective: To prospectively assess safety outcome of TRUS guided prostate biopsy in patients taking low dose aspirin. Materials and methods: Consecutive patients, who were planned for 12 core TRUS guided prostate biopsy and satisfied eligibility criteria, were included in the study and divided into two Groups: Group A: patients on aspirin during biopsy, Group B: patients not on aspirin during biopsy, including patients in whom aspirin was stopped prior to the biopsy. Parameters included for statistical analysis were: age, serum prostate specific antigen (PSA), prostate volume, hemoglobin (Hb %), number of hematuria episodes, number of patient reporting hematuria, hematuria requiring intervention, number of patient reporting hematospermia and number of patient reporting rectal bleeding. Results: Of 681 eligible patients, Group A and B had 191 and 490 patients respectively. The mean age, prostate volume, serum PSA and pre-biopsy hemoglobin were similar in both Groups with no significant differences noted between them. None of the post-biopsy complications, including number of hematuria episodes (p=0.83), number of patients reporting hematuria (p=0.55), number of patients reporting hematospermia (p=0.36) and number of patients reporting rectal bleeding (p=0.65), were significantly different between Groups A and B respectively. None of the hemorrhagic complication in either group required intervention and were self limiting. Conclusion: Continuing low dose aspirin during TRUS guided prostate biopsy neither alters the minor bleeding episodes nor causes major bleeding complication. So, discontinuation of low dose aspirin prior to TRUS guided prostate biopsy is not required.