Impact of the covid-19 pandemic on the emergency surgical treatment of colorectal cancer / Impacto da pandemia da covid-19 no tratamento cirúrgico emergencial do câncer colorretal

ABSTRACT BACKGROUND: Colorectal cancer (CRC) is the most common malignancy of the gastrointestinal tract and the third most common type of cancer worldwide. The COVID-19 pandemic, during the years 2020 and 2022, increased the difficulties in offering adequate early diagnosis and treatment to CRC patients worldwide. During this period, it was only possible to treat patients who evolved with complications, mainly intestinal obstruction and perforation. AIMS: To assess the impact of the COVID-19 pandemic on the treatment of patients with CRC. METHODS: A review of data from a total of 112 patients undergoing emergency surgical treatment due to complications of CRC was carried out. Of these, 78 patients underwent emergency surgery during the COVID-19 pandemic (2020/2021), and 34 were treated before the pandemic (2018/2019). Ethnic aspects, clinical symptoms, laboratory tests, histopathological variables, intra and postoperative complications, and 90-day postoperative follow-up were compared between the two groups. RESULTS: Between the years 2018 and 2019, 79.4% (27/34) of patients had intestinal obstruction, while 20.6% (7/34) had intestinal perforation. During the period of the COVID-19 pandemic (2020/2021), 1.3% (1/78) of patients underwent surgery due to gastrointestinal bleeding, 6.4% (5/78) due to intestinal perforation, and 92.3% (72/78) due to intestinal obstruction. No statistically significant differences were recorded between the two groups in ethnic aspects, laboratory tests, type of complications, number of lymph nodes resected, compromised lymph nodes, TNM staging, pre or intraoperative complications, length of stay, readmission, or mortality rate. When considering postoperative tumor staging, among patients operated on in 2018/2019, 44.1% were classified as stage III and 38.2% as stage IV, while during the pandemic period, 28.2% presented stage III and 51.3% stage IV, also without a statistically significant difference between the two periods. Patients operated on during the pandemic had higher rates of vascular, lymphatic and perineural invasion. CONCLUSIONS: The COVID-19 pandemic increased the rate of complications related to CRC when comparing patients treated before and during the pandemic. Furthermore, it had a negative impact on histopathological variables, causing worse oncological prognoses in patients undergoing emergency surgery.

RESUMO RACIONAL: O câncer colorretal (CCR) é a doença maligna mais comum do trato gastrointestinal sendo o terceiro tipo de câncer mais comum em todo o mundo. A pandemia de COVID-19 durante os anos de 2020 e 2022 aumentou as dificuldades em se oferecer diagnóstico e tratamento precoce adequado aos pacientes com CCR em todo o mundo. Nesse período, só foi possível tratar os pacientes que evoluíram com complicações representadas, principalmente, pela obstrução e perfuração intestinal. OBJETIVOS: Avaliar o impacto da pandemia de COVID-19 no tratamento de pacientes com CCR. MÉTODOS: Foi realizada uma revisão dos dados de um total de 112 pacientes submetidos ao tratamento cirúrgico de urgência devido complicações do CCR. Destes, 78 pacientes foram submetidos a cirurgia de emergência durante o período da pandemia de COVID-19 (2020/2021), e 34 pacientes foram operados no período anterior à pandemia (2018/2019). Aspectos étnicos, sintomas clínicos, exames laboratoriais, variáveis histopatológicas, complicações intra e pós-operatórias e acompanhamento pós-operatório de 90 dias foram analisados comparando os dois grupos. RESULTADOS: Entre os anos 2018 e 2019, 79,4% (27/34) dos pacientes apresentaram obstrução intestinal enquanto 20,6% (7/34) perfuração intestinal. Durante o período da pandemia de COVID-19 (2020/2021) 1,3% (1/78) dos pacientes foram operados por hemorragia digestiva baixa, 6,4% (5/78) por perfuração intestinal e 92,3% (72/78) por obstrução intestinal. Não foram registradas diferenças estatisticamente significativas entre os dois grupos nos aspectos étnicos, exames laboratoriais, tipo de complicações, número de linfonodos ressecados, linfonodos comprometidos, estadiamento TNM, complicações pré ou intraoperatórias, tempo de internação, readmissão e taxa de mortalidade. Ao considerar o estadiamento tumoral pós-operatório, entre os pacientes operados em 2018/19, 44,1% foram classificados como estágio III e 38,2% como estágio IV, enquanto no período pandêmico, 28,2% apresentaram estágio III e 51,3% estágio IV, também sem diferença estatisticamente significativa entre os dois períodos. Doentes operados durante a pandemia apresentaram maiores índices de invasão vascular, linfática e perineural. CONCLUSÕES: A pandemia de COVID-19 aumentou as taxas de complicações relacionadas ao CCR, comparando pacientes tratados antes e durante a pandemia. Além disso, teve impacto negativo nas variáveis histopatológicas, causando piores prognósticos oncológicos em pacientes submetidos a cirurgias de emergência.

Intra-abdominal desmoid tumors in familial adenomatous polyposis: How much do clinical and surgical variables interfere with their development?

Abstract Objective: Familial Adenomatous Polyposis is a complex hereditary disease that exposes the carrier to a great risk of Colorectal Cancer (CRC). After prophylactic surgery, intra-abdominal desmoid tumors are known to be one the most important cause of death. Therefore, recognition of increased-risk patients and modification of operative strategy may be crucial. Aim: The objective of this study was to estimate the desmoid tumor risk in relation to various surgical and clinical variables. Methods: Patients who had undergone polyposis since 1958 were included in the study. After exclusion criteria were met, those who had developed desmoid tumors were selected to undergo further evaluation. Results: The study revealed that the risk of developing desmoid tumors was associated with various factors such as sex ratio, colectomy, and reoperations. On the other hand, the type of surgery, family history, and surgical approach did not affect the risk of developing desmoid tumors. The data collected from 146 polyposis patients revealed that 16% had desmoid polyps. The sex ratio was 7:1, and the median age at colectomy was 28.6 years. Family history, multiple abdominal operations, and reoperations were some of the characteristics that were common in desmoid patients. Conclusion: Recognition of clinical (female sex) and surgical (timing of surgery and previous reoperations) data as unfavorable variables associated with greater risk may be useful during the decision-making process.

Mucin levels in glands of the colonic mucosa of rats with diversion colitis subjected to enemas containing sucralfate and n-acetylcysteine alone or in combination

ABSTRACT Purpose: To evaluate the tissue content of neutral and acidic mucins, sulfomucins and sialomucins in colonic glands devoid of intestinal transit after enemas containing sucralfate and n-acetylcysteine alone or in combination. Methods: Sixty-four rats underwent intestinal transit bypass. A colonic segment was collected to compose the white group (without intervention). After derivation, the animals were divided into two groups according to whether enemas were performed daily for two or four weeks. Each group was subdivided into four subgroups according to the substance used: control group: saline 0.9%; sucralfate group (SCF): SCF 2 g/kg/day; n-acetylcysteine group (NAC): NAC 100 mg/kg/day; and SCF+NAC group: SCF 2 g/kg/day + NAC 100 mg/kg/day.Neutral and acidic mucins were stained by periodic acid-Schiff and alcian-blue techniques, respectively. The distinction between sulfomucins and sialomucin was made by the high alcian-blue iron diamine technique. The content of mucins in the colonic glands was measured by computerized morphometry. The inflammatory score was assessed using a validated scale. The results between the groups were compared by the Mann-Whitney's test, while the variation according to time by the Kruskal-Wallis' test (Dunn's post-test). A significance level of 5% was adopted. Results: There was reduction in the inflammatory score regardless of the application of isolated or associated substances. Intervention with SCF+NAC increased the content of all mucin subtypes regardless of intervention time. Conclusions: The application of SCF+NAC reduced the inflammatory process of the colonic mucosa and increased the content of different types of mucins in the colonic glands of segments excluded from fecal transit.

Multiple Jejunal diverticulosis complicated by perforation: case report and a brief literature review

Background: Multiple small-bowel diverticulosis comprises a rare entity with probable underestimated incidence, and that may be the reason why it is sometimes overlooked when managing cases with peritonitis. Case report: In the present paper, we report the case of a 76-year-old male presenting abdominal pain and fever in an acute setting. Computed tomography (CT) scans revealed jejunal thickening and numerous images of saccular addition that were interpreted as jejunoileal diverticulitis. After an initial period of clinical treatment, surgical management was indicated based on a worsening clinical picture and the presence of an extraluminal focus of gas detected in a subsequent CT scan. Through a laparoscopic approach, multiple small-bowel diverticula and a tamponade perforation were found. A segmental intestinal resection was performed, and the patient was discharged after a ten days. Conclusions: Multiple jejunal diverticulosis is a rare condition that should be remembered in the setting of an acute abdomen. As it prevails among older patients, early diagnosis with radiological aid is crucial to establish the most adequate management, including intestinal resection, if necessary. (AU)

Is it possible to optimize stapled hemorrhoidopexy outcomes by enlarging operative criteria indications? results of a tailored procedure with associated resection in a comparative personal series / é possível otimizar os resultados da hemorroidopexia grampeada pela ampliação dos critérios de indicação operatória? resultados de um procedimento personalizado com ressecção associada em uma série comparativa pessoal

ABSTRACT BACKGROUND: Since its introduction, stapled hemorrhoidopexy has been increasingly indicated in the management of hemorrhoidal disease. AIM: Our primary end point was to evaluate the incidence of recurrent disease requiring another surgical intervention. On a secondary analysis, we also compared pain, complications, and patient's satisfaction after a tailored surgery. METHODS: We retrospectively reviewed 196 patients (103 males and 93 females) with a median age of 47.9 years (range, 17-78) who were undergoing stapled hemorrhoidopexy alone (STG; n=65) or combined surgery (CSG; n=131, stapled hemorrhoidopexy associated with resection). RESULTS: Complications were detected in 11 (5.6%) patients (4.6% for STG vs. 6.1% for CSG; p=0.95). At the same time, symptoms recurrence (13.8% vs. 8.4%; p=034), reoperation rate for complications (3.1% vs. 3.0%; p=1.0), and reoperation rate for recurrence (6.1% vs. 4.6%; p=1.0) were not different among groups. Grade IV patients were more commonly managed with simultaneous stapling and resection (63% vs. 49.5%), but none of them presented symptoms recurrence nor need reoperation due to recurrence. Median pain score during the first week was higher in CSG patients (0.8 vs. 1.7). After a follow-up of 24.9 months, satisfaction scores were similar (8.6; p=0.8). CONCLUSION: Recurrent symptoms were observed in 10% of patients, requiring surgery in approximately half of them. Even though the association of techniques may raise pain scores, a tailored approach based on amplified indication criteria and combined techniques seems to be an effective and safe alternative, with decreased relapse rates in patients suffering from more advanced hemorrhoidal disease. Satisfaction scores after hemorrhoidopexy are high.

RESUMO RACIONAL: Desde sua introdução, a hemorroidopexia por grampeamento tem sido cada vez mais indicada no manuseio da doença hemorroidária. OBJETIVOS: Nosso objetivo primário foi avaliar a incidência de doença recidivada que requeira tratamento cirúrgico. Numa análise secundária, também comparamos dor, complicações e satisfação do paciente após uma operação ajustada a cada caso. MÉTODOS: Foram revistos retrospectivamente 196 pacientes (103 homens e 93 mulheres) com idade média de 47,9 anos (17-78) submetidos a hemorroidopexia mecânica isoladamente (STG; n=65) ou cirurgia combinada (CSG; n=131, hemorroidopexia por grampeamento com ressecção). RESULTADOS: Complicações foram detectadas 11 (5,6%) pacientes (4,6% para STG vs. 6,1% para CSG; p=0,95). Ao mesmo tempo, recidiva de sintomas (13,8% vs. 8,4%; p=034), reoperações por complicações (3,1% vs. 3,0%; p=1,0) ou por recidiva (6,1 vs. 4,6%; p=1,0) não foram diferentes entre os dois grupos. Pacientes com grau IV foram mais comumente manuseados com grampeamento e ressecção simultâneos (63% vs. 49,5%), mas nenhum deles apresentou recidiva ou necessitou reoperação. O escore médio de dor na primeira semana foi maior no grupo CSG (0,8 vs. 1,7). Após seguimento de 24,9 meses, os índices de satisfação foram similares (8,6; p=0,8). CONCLUSÕES: Sintomas de recidiva foram observados em 10%, requerendo cirurgia em aproximadamente metade dos doentes. Embora a associação de técnicas aumente os escores de dor, um procedimento sob medida baseado em critérios ampliados de indicação e técnicas combinadas parece ser uma alternativa efetiva e segura, com menor recidiva em pacientes portadores de doença hemorroidária mais avançada. Os escores de satisfação após hemorroidopexia são altos.

Pancreatic solid-pseudopapillary neoplasm in patients with familial adenomatous polyposis / Neoplasia sólida pseudopapilífera pancreática em pacientes com polipose adenomatosa familiar

ABSTRACT BACKGROUND: Solid pseudopapillary neoplasm of the pancreas is an uncommon pancreatic tumor, which is more frequent in young adult women. Familial adenomatous polyposis is a genetic condition associated with colorectal cancer that also increases the risk of developing other tumors as well. AIM: The aim of this study was to discuss the association of familial adenomatous polyposis with solid pseudopapillary neoplasm of the pancreas, which is very rare. METHODS: We report two cases of patients with familial adenomatous polyposis who developed solid pseudopapillary neoplasm of the pancreas of the pancreas and were submitted to laparoscopic pancreatic resections with splenic preservation (one male and one female). RESULTS: ß-catenin and Wnt signaling pathways have been found to play an important role in the tumorigenesis of solid pseudopapillary neoplasm of the pancreas, and their constitutive activation due to adenomatous polyposis coli gene inactivation in familial adenomatous polyposis may explain the relationship between familial adenomatous polyposis and solid pseudopapillary neoplasm of the pancreas. CONCLUSION: Colonic resection must be prioritized, and a minimally invasive approach is preferred to minimize the risk of developing desmoid tumor. Pancreatic resection usually does not require extensive lymphadenectomy for solid pseudopapillary neoplasm of the pancreas, and splenic preservation is feasible.

RESUMO RACIONAL: A neoplasia sólida pseudopapilífera do pâncreas é um tumor pancreático incomum, mais frequente em mulheres jovens. A polipose adenomatosa familiar, por sua vez, é uma condição genética associada a câncer colorretal e que também aumenta o risco de desenvolvimento de outros tumores. OBJETIVOS: Discutir a associação entre polipose adenomatosa familiar e neoplasia sólida pseudopapilífera, que é bastante rara. MÉTODOS: Reportamos dois casos de pacientes com polipose adenomatosa familiar, um homem e uma mulher, que desenvolveram neoplasia sólida pseudopapilífera do pâncreas e foram submetidos a ressecção laparoscópica com preservação esplênica. RESULTADOS: As vias de sinalização da ß-catenina e Wnt tem um papel importante na tumorigênese da neoplasia sólida pseudopapilífera, e sua ativação constitutiva devido a inativação do gene adenomatous polyposis coli na polipose adenomatosa familiar pode explicar a relação entre polipose adenomatosa familiar e neoplasia sólida pseudopapilífera. CONCLUSÕES: A ressecção do cólon deve ser priorizada, com preferência pela abordagem minimamente invasiva para minimizar o risco de desenvolvimento de tumor desmoide. A ressecção pancreática geralmente não requer linfadenectomia extensa para neoplasia sólida pseudopapilífera, portanto, a preservação esplênica é factível.

Multiple neuroendocrine neoplasia in a patient with type i neurofibromatosis (nf1): report of a new mutation (nf1, exons 2-30 deletion) and literature review / Neoplasia neuroendócrina múltipla em doente com neurofibromatose tipo 1 (nf1). descrição de uma nova mutação e revisão da literatura

ABSTRACT BACKGROUND: Plexiform neurofibromas represent a common neoplasia of type 1 neurofibromatosis in which neurofibromas arise from multiple nerves involving connective tissue and skin and rarely affect the colon and rectum. Co-occurrence of plexiform neurofibromas, neuroendocrine tumors with primary involvement of the rectum, and medullary thyroid carcinoma in patients with neurofibromatosis type 1 is a previously undescribed condition. The aim of this manuscript was to present a case of primary plexiform neurofibroma and neuroendocrine tumors of the upper rectum in a patient with neurofibromatosis type 1 whose genetic sequencing found a novel mutation in the neurofibromatosis type 1 gene and to review the literature. CASE REPORT: A 49-year-old woman with a familial history of neurofibromatosis type 1 complained of abdominal cramps for 6 months. She had previously been submitted for a total thyroidectomy due to medullary thyroid carcinoma. She was submitted to a colonoscopy, which identified a submucosa lesion located in the upper rectum. The patient was referred for a laparoscopic rectosigmoidectomy, and the histopathological study of the surgical specimen identified two different tumors. An immunohistochemical panel was done for histopathological confirmation of the etiology of both lesions. The results of the panel showed intense immunoexpression of S100 protein in the largest and superficial lesion, as well as positivity for chromogranin and synaptophysin in the minor and deep lesion confirming the diagnosis of rectal plexiform neurofibromas concomitant with neuroendocrine tumors. The proliferative activity rate using Ki-67 antibodies showed that both tumors had a low rate of mitotic activity (<1%). Genetic sequence panel identified an undescribed mutation in the neurofibromatosis type 1 gene (deletion, exons 2-30). The patient's postoperative evolution was uneventful, and she remains well, without recurrence, 3 years after surgery. CONCLUSION: The co-occurrence of medullary thyroid carcinoma, plexiform neurofibromas, and neuroendocrine tumors of the rectum in patients with neurofibromatosis type 1 is an exceptional and undescribed possibility, whose diagnosis can be confirmed by the immunohistochemical staining and genetic panel.

RESUMO RACIONAL: Os neurofibromas plexiformes representam uma neoplasia frequente na neurofibromatose tipo 1 onde os neurofibromas surgem de múltiplos nervos envolvendo, também, o tecido conjuntivo e a pele raramente acometendo o cólon e o reto. A co-ocorrência de neurofibromas plexiformes, tumores neuroendócrinos, com envolvimento primário do reto, e carcinoma medular de tireoide em pacientes com neurofibromatose tipo 1 é uma condição ainda não descrita. O objetivo deste manuscrito é descrever um caso de neurofibromas plexiformes e tumores neuroendócrinos primários do reto superior, em paciente com neurofibromatose tipo 1, cujo sequenciamento genético identificou uma nova mutação no gene neurofibromatose tipo 1 e revisar a literatura sobre o tema. DESCRIÇÃO DO CASO: Mulher de 49 anos, com história familiar de neurofibromatose tipo 1 queixava-se de cólicas abdominais há seis meses. Tinha sido previamente submetida a tireoidectomia total por carcinoma medular de tireoide. Foi submetida a colonoscopia, que identificou lesão submucosa localizada no reto superior. A doente foi encaminhada para retossigmoidectomia laparoscópica, cujo estudo histopatológico do espécime cirúrgico identificou dois tumores distintos. Realizou-se painel imuno-histoquímico para confirmação histopatológica da etiologia de ambas as lesões. O resultado do painel mostrou intensa imunoexpressão da proteína S-100 da lesão superficial e de maior tamanho,e positividade para cromogranina e somatofisina da lesão mais profunda e de menores dimensões confirmando o diagnóstico de neurofibromas plexiformes retal e tumores neuroendócrinos. O índice de atividade proliferativa utilizando o anticorpo ant-Ki-67 mostrou que ambos os tumores apresentavam baixa índice mitótico (<1%). O painel genético identificou mutação no gene neurofibromatose tipo 1 (deleção, exons 2-30) ainda não descrita. A doente apresentou evolução pós-operatória sem intercorrências, permanecendo bem, sem recorrência, três anos após a cirurgia. CONCLUSÕES: A co-ocorrência de carcinoma medular de tireoide, neurofibromas plexiformes e tumores neuroendócrinos do reto em pacientes com neurofibromatose tipo 1 é uma possibilidade excepcional e ainda não descrita, cujo diagnóstico pode ser confirmado pela coloração imuno-histoquímica e painel genético.

Surgical technique and considerations about transanal transection and single-stapled (TTSS) anastomosis: the search for a perfect anastomosis

The evaluation of preventivemeasures and risk factors for anastomotic leakage has been a constant concern among colorectal surgeons. In this context, the description of a new way to perform a colorectal, coloanal or ileoanal anastomosis, known as transanal transection and single-stapled (TTSS) anastomosis, deserves an appreciation of its qualities, and a discussion about its properties and technical details. In the present paper, the authors review themost recent efforts aiming to reduce anastomotic dehiscence, and describe the TTSS technique in a patient submitted to laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Surgical perception raises important advantages such as distal rectal transection under visualization, elimination of double-stapling lines (with cost-effectiveness and potential protection against suture dehiscence), elimination of dog ears, and the opportunity to be accomplished via a transanal approach after open, laparoscopic, or robotic colorectal resections. Future studies to confirm these supposed advantages are needed. (AU)

Sucralfate enemas reduce the oxidative tissue damage and preserves the contents of E-cadherin and Β-catenin in colonic mucosa without fecal stream

ABSTRACT Purpose: To evaluate the effects of sucralfate enemas in tissue contents of E-cadherin and ?-catenin in an experimental diversion colitis. Methods: Thirty-six male Wistar rats were submitted to a proximal colostomy and a distal mucous fistula. They were allocated into three groups: first group received daily saline enemas (2 mL/day) and the two other groups daily enemas with sucralfate at dosage of 1 or 2 g/kg/day, respectively. Six animals of each group were euthanized after two weeks and six animals after four weeks. The inflammation of the excluded mucosa was evaluated by histological analysis. The oxidative damage was quantified by measurement of malondialdehyde tissue levels. The expression of E-cadherin and ?-catenin was identified by immunohistochemistry, and its contents were quantified by computer-assisted image analysis. Results: Sucralfate enemas reduced inflammation in animals subjected to treatment with 2 g/kg/day by four weeks, and the levels of oxidative damage in mucosa without fecal stream irrespective of concentration and time of intervention. E-cadherin and ?-catenin content increased in segments without fecal stream in those animals subjected to treatment with sucralfate. Conclusions: Sucralfate reduces the inflammation and oxidative stress and increases the tissue content of E-cadherin and ?-catenin in colonic mucosa devoid to the fecal stream.

Enema de sulcralfato pode prevenir colite em segmentos colônicos sem trânsito fecal? / Can sucralfate enema prevent colitis in colonic segments without fecal transit?

RESUMO - RACIONAL: O estresse oxidativo é um dos principais mecanismos associados à ruptura dos mecanismos de defesa que formam a barreira epitelial cólica e reduz o conteúdo tecidual das proteínas claudina-3 e ocludina principais constituintes das junções de oclusão intercelulares. O sucralfato, possui atividade antioxidante e tem sido usado para tratar diferentes formas de colite. OBJETIVO: Mensurar o conteúdo tecidual de claudina-3 e ocludina da mucosa do cólon sem trânsito fecal, submetido à intervenção com sucralfato. MÉTODO: Trinta e seis ratos foram submetidos à colostomia do cólon esquerdo e fístula mucosa distal. Os animais foram divididos em dois grupos de acordo com a eutanásia ser realizada duas ou quatro semanas após a intervenção. Cada grupo foi dividido em três subgrupos de acordo com o tipo de intervenção realizada diariamente: solução salina isolada; sucralfato a 1 g/kg/dia ou sucralfato a 2g/kg/dia. A colite foi diagnosticada por análise histológica adotando escala de validação prévia. A expressão tecidual de ambas as proteínas foi identificada por imunoistoquímica. O conteúdo das proteínas foi quantificado por análise de imagem assistida por computador. RESULTADOS: O escore inflamatório foi maior nos segmentos cólicos sem trânsito fecal e os enemas com sucralfato reduziram o escore inflamatório nesses segmentos, principalmente nos animais submetidos à intervenção com sucralfato em maior concentração e por período mais longo de intervenção. Houve aumento no conteúdo tecidual das proteínas claudina-3 e ocludina, relacionado com a concentração de sucralfato. O conteúdo tecidual de ambas as proteínas não se modificou com a duração da intervenção. CONCLUSÃO: Enemas com sucralfato reduzem a inflamação e aumentam o conteúdo tecidual de claudina-3 e ocludina na mucosa cólica sem trânsito intestinal.

ABSTRACT - BACKGROUND: Oxidative stress is one of the main mechanisms associated with the rupture of the defense mechanisms of the colonic epithelial barrier; it reduces the tissue content of the claudin-3 and occludin proteins, which are the main constituents of intercellular tight junctions. Sucralfate (SCF) has antioxidant activity and has been used to treat different forms of colitis. AIM: This study aimed to measure the tissue claudin-3 and occludin content of the colon mucosa without fecal transit, subjected to intervention with SCF. METHODS: Thirty-six rats were subjected to left colon colostomy and distal mucous fistula. They were divided into two groups according to euthanasia that was performed 2 or 4 weeks after the intervention. Each group was divided into three subgroups according to the enema applied daily: saline alone, SCF at 1 g/kg/day, or SCF at 2 g/kg/day. Colitis was diagnosed by the histological analysis adopting the previous validate scale. The tissue expression of both proteins was identified by immunohistochemical technique. The content of proteins was quantified by computer-assisted image analysis. RESULTS: The inflammatory score was high in colonic segments without fecal transit, and enemas with SCF reduced the inflammatory score in these segments, mainly in those animals submitted to intervention with SCF in greater concentration and for a longer period of intervention. There was an increase in tissue content of claudin-3 and occludin, related to SCF concentration. The tissue content of both proteins was not related to the intervention time. CONCLUSION: Enemas with SCF reduced the inflammation and increased the tissue content of claudin-3 and occludin in colonic mucosa without fecal stream.

General recommendations to the colorectal surgeon during the COVID-19 pandemic / Recomendações gerais ao coloproctologista durante a pandemia do COVID-19

Abstract The COVID-19 pandemic has shown our country in an unfavorable light, as Brazil has reported the second highest number of deaths to date. When the social isolation phase is finished, professional activities (including the medical ones) will resume their routines and the specialist must be updated in order to provide effective and safe care. Although many published recommendations are based on low levels of evidence, disclosing them has become necessary, since the coronavirus infection may affect operative outcomes. Overall, it is suggested that physicians adopt preventive measures, starting with the medical appointment, and extending them to the surgical procedure. Furthermore, it is also necessary to provisionally change criteria for operative indications and conducts. Currently, postponing elective surgeries seems to be a universally agreed decision. Moreover, we need to establish the early diagnosis of the viral infection, before or after the surgery. Several safety measures related to minimally-invasive procedures have been reported, disclosing the risks of aerosol dissemination by the pneumoperitoneum and smoke from energy-powered devices. The present article aimed to bring to the colorectal surgeon the current recommendations and general safety measures in order to prevent infection dissemination, to improve surgical planning in terms of timing and specific technical aspects.

Resumo A pandemia pelo COVID-19 colocou o Brasil hoje numa situação de destaque negativo, porque somos o segundo país com maior número de casos no mundo. Ao finalizarmos o período de afastamento social, as atividades profissionais, incluindo as médicas, serão restabelecidas, e o especialista necessita estar atualizado a fim de prover o melhor nível de trabalho, de maneira segura. Apesar de muitas das recomendações estarem baseadas em opiniões e estudos sem muito grau de evidência, sua divulgação nesse momento torna-se necessária, uma vez que a infecção pelo coronavírus afeta os resultados operatórios. De maneira geral, o médico deve assumir medidas preventivas desde o momento em que agenda uma consulta até a realização do procedimento cirúrgico. Além disso, é necessário considerar a necessidade de mudar provisoriamente os critérios de indicação cirúrgica, e até as condutas operatórias. Parece existir um pensamento uniforme no sentido de adiar cirurgias eletivas. Da mesma forma, devemos reconhecer a infecção viral precocemente, antes ou após a cirurgia. Diversas medidas preventivas relacionadas aos procedimentos minimamente invasivos já foram descritas, realçando o poder de disseminação pelo aerossol gerado nesses procedimentos e no uso de instrumentos de energia. O presente artigo visou apresentar ao coloproctologista as recomendações atuais e cuidados gerais para prevenir disseminação da infecção, e como planejar o tratamento cirúrgico com mais segurança em termos de momento da cirurgia e aspectos técnicos específicos.

Potential impact of COVID-19 on colorectal disease management / Impacto potencial da COVID-19 no manuseio das doenças colorretais

Abstract The current recommendations for management of colorectal diseases are still evolving, due to the limited experience on this issue. As the new coronavirus can be transmitted through breath droplets, by contact and orofecally, there is no consensus of how this fact may affect the investigation and treatment of anorectal diseases. Thus, high-quality multicenter studies are urgently needed to provide better information to both patients and the multiprofessional team, in order to build an effective pandemic response plan in our specialty. As a greater operative risk for infected patients has already been demonstrated, the next step lies on the identification of new therapeutic strategies that could minimize this effect on an individual basis. There is a present understanding that the COVID-19 pandemic should change some traditional practices. Therefore, the surgical treatment of suspected or known COVID-19 case demands specific insights. This article analyses potential influences regarding the treatment of patients with Colorectal Cancer (CRC) and Inflammatory Bowel Diseases (IBD). At present, elective surgery must be avoided, and the colorectal surgeon must carefully evaluate the risks and benefits of such decision. Within this context, a change toward nonsurgical and less aggressive modalities of CRC treatment may help to postpone definitive treatment. We also discuss the concerns regarding the viral infection among the population, the influence on clinical symptoms and the proposed modifications on therapeutic schemes.

Resumo As recomendações atuais para manuseio das doenças colorretais ainda estão em evolução, devido à limitada experiência nesse tema. Como o novo coronavírus pode ser transmitido em gotículas da respiração, por contato ou por via oro-fecal, ainda não existe consenso de como este fato pode afetar a investigação e o tratamento de doenças anorretais. Assim, são necessários estudos multicêntricos de qualidade para prover melhor informação ao paciente e equipe multiprofissional, possibilitando a formulação de uma resposta efetiva à pandemia em nossa especialidade. Uma vez que o risco operatório de pacientes infectados é maior, o passo subsequente reside em identificar novas estratégias terapêuticas que possam minimizar esse efeito individualmente. Assim, reconhece-se atualmente que a pandemia pelo COVID-19 deve alterar algumas práticas tradicionais. Consequentemente, o tratamento cirúrgico de um doente infectado ou suspeito demanda reflexões específicas. Esse artigo analisa influências potenciais relacionadas ao tratamento do Câncer Colorretal (CCR) e Doenças Inflamatórias Intestinais (DII). No atual momento, cirurgias eletivas devem ser postergadas e o cirurgião colorretal deve avaliar cuidadosamente os riscos e benefícios dessa decisão. Nesse contexto, uma mudança na direção de modalidades não-cirúrgicas e menos agressivas do CCR pode favorecer a prorrogação do tratamento definitivo. Aqui também se discutem as preocupações sobre a infecção viral em pacientes com DII, sua influência sobre os sintomas clínicos e as modificações propostas nos esquemas terapêuticos.

Effects of anti-TNF-α in experimental diversion colitis

Abstract Purpose: To evaluate the effects of infliximab on the inflammation of the colonic mucosa devoid from fecal stream. Methods: Twenty-four rats were submitted to a Hartmann's procedure. They remained for 12 weeks with the fecal derivation to development of diversion colitis on excluded colorectal stump. After this period, they were divided into 3 groups: one group received intervention with saline (2.0 mL / week), other group infliximab at doses of 5 mg/kg/week and the other 10 mg/kg/week for five consecutively weeks. Concluded the intervention period, the animals were euthanized to remove colon segments with and without fecal stream. Colitis was diagnosed by histological analysis and the degree of inflammation by validated score. The neutrophilic infiltrate was evaluated by tissue expression of myeloperoxidase identified by immunohistochemical. The tissue content of myeloperoxidase was measured by computer-assisted image analysis. Results: The inflammatory score was high in colonic segments without fecal stream. The intervention with infliximab reduced the inflammatory score in excluded colonic segments. The content of myeloperoxidase was reduced in colonic segments of animals treated with infliximab mainly in high concentrations. Conclusion: Intervention with infliximab reduced the inflammation and the neutrophil infiltrate in colonic segments devoid of the fecal stream.

Adoption rates of laparoscopic techniques for colorectal resections among Brazilian surgeons: limiting factors affecting incorporation into daily practice / Adoção de técnicas laparoscópicas em ressecções colorretais entre cirurgiões brasileiros. Fatores limitantes que afetam a incorporação na prática diária

ABSTRACT Routine adoption of laparoscopy in clinical practice and Medical Residency has not been widely evaluated in Brazil so far. Aim: To take an overview on the adoption and limitations concerning the use of laparoscopic techniques among Brazilian colorectal surgeons. Methods: A questionnaire was sent to 1870 SBCP filiated members, containing personal and professional data such as sex, age, length and local of practice, SBCP filliation, number of procedures, treatment of cancer and laparoscopy limitations. Results: 418 members (22.4%) sent their response (80% men and 20% women). 110 members (26.3%) affirmed they don't perform any laparoscopic procedure, while 308 (73.7%) have already adopted laparoscopy as a routine. An average number of 7.6 laparoscopic colorectal procedures were declared to be performed per month (1 to 40 procedures). Laparoscopic adoption rates were favourably influenced by young age members (46% vs. 28%) and affiliation to University hospitals (p = 0.01). Conversely, surgeons from private clinic showed a greater tendency of no adoption. Among the 308 responders, 106 (34.4%) have already surpassed more than 100 laparoscopic cases, and 167 (54.2%) reported an experience of more than 50 operated patients. The group of surgeons not using minimally invasive techniques incriminated lack of training (73.6%) and laparoscopic instruments availability (27.3%) as the main reasons for no adoption. Conclusions: Adoption rate of laparoscopic techniques to treat colorectal diseases is still low (at least 17%). Future efforts should focus on providing supervised training, proctorship during the initial experience and help instrumental acquisition in centers willing to change their routine and perspectives.

RESUMO Durante as últimas décadas, a incorporação de técnicas minimamente invasivas no tratamento de doenças colorretais testemunhou um progresso lento e firme, principalmente após o reconhecimento da segurança oncológica e melhor evolução. A adoção rotineira na prática clínica e na Residência Médica no Brasil ainda não amplamente avaliada até agora. Objetivos: O presente estudo visou avaliar a adoção e as limitações relativas ao uso de técnicas laparoscópicas entre cirurgiões colorretais brasileiros. Métodos: um questionário foi enviado a 1870 membros filiados à Sociedade Brasileira de Coloproctologia (SBCP) em 2006. As questões foram enviadas por email, incluindo dados pessoais (sexo, idade) e profissionais (tempo e local de prática, filiação à SBCP, número mensal de procedimentos laparoscópicos, tratamento de câncer e limitações para realizar laparoscopia na rotina. Resultados: Entre os 1870 membros, 418 (22.4%) mandaram sua resposta, com uma maior participaçãoo de homens (80%) em comparação às mulheres (20%). A idade média foi de 43 (28-80) anos. A distribuição entre membros titulares e não titulares foi semelhantes (48% vs. 52%). As atividades profissionais foram desenvolvidas em clínica privada (84%), hospitais privados (73%), hospitais públicos (50%) e hospitais universitários (53%). Entre os que responderam (418), 110 (26.3%) não realizavam procedimentos laparoscópicos, enquanto 308 (73.7%) já haviam adotado o acesso laparoscópico rotineiramente na prática clínica. Um número médio de 7.6 procedimentos colorretais laparoscópicos são realizados por mês (1-40). Cerca de 13% dos cirurgiões iniciaram sua experiência laparoscópica diretamente com procedimentos colorretais, enquanto a maioria (87%) começaram por outros procedimentos no trato digestivo. A adoção da laparoscopia foi positivamente influenciada pela idade jovem dos membros (46% vs. 28%) e pela filiação a hospitais universitários (p = 0,01). Inversamente, cirurgiões trabalhando na prática privada demonstraram uma menor tendência em adotar o método. A maioria dos cirurgiões (93%) que adoraram a laparoscopia afirmou incluir pacientes com câncer colorretal em suas indicações operatórias. Entre os que responderam 106 (34,4%) já realizaram mais de 100 procedimentos laparoscópicos, e 167 (54,2%) reportaram experiência maior que 50 casos. Dentre aqueles que não adotaram técnicas minimamente invasivas, a falta de treinamento (73,6%) ou a indisponibilidade de instrumental laparoscópico (27,3%) foram incriminadas como os principais fatores limitantes. Conclusões: o índice de adoção de técnicas laparoscópicas no tratamento de doenças intestinais ainda é baixo (pelo menos 17%) entre cirurgiões colorretais brasileiros. Esforços futuros de nossa Sociedade Médica devem focar na provisão de treinamento supervisionado, na criação de oportunidades para preceptoria durante a experiência inicial e na obtenção de instrumental em centros que queiram mudar sua rotina e perspectivas.

Enemas with mesalazine increase the tissue contents of mucins in the colonic mucosa devoid of fecal stream

Abstract Purpose: To evaluate the inflammatory reaction and measure the content of mucins, in the colonic mucosa without fecal stream submit to intervention with mesalazine. Methods: Twenty-four rats were submitted to a left colostomy and a distal mucous fistula and divided into two groups according to euthanasia to be performed two or four weeks. Each group was divided into two subgroups according daily application of enemas containing saline or mesalazine at 1.0 g/kg/day. Colitis was diagnosed by histological analysis and the inflammatory reaction by validated score. Acidic mucins and neutral mucins were determined with the alcian-blue and periodic acid of Schiff techniques, respectively. Sulfomucin and sialomucin were identified by high iron diamine-alcian blue technique. The tissue contents of mucins were quantified by computer-assisted image analysis. Mann-Whitney test was used to analyze the results establishing the level of significance of 5%. Results: Enemas with mesalazine in colonic segments without fecal stream decreased the inflammation score and increased the tissue content of all subtypes of mucins. The increase of tissue content of neutral, acid and sulfomucin was related to the time of intervention. Conclusion: Mesalazine enemas reduce the inflammatory process and preserve the content of mucins in colonic mucosa devoid of fecal stream.

Evaluation of enemas containing sucralfate in tissue content of muc-2 protein in experimental model of diversion colitis / Avaliação de enemas com sucralfato no conteúdo tecidual da proteina muc-2 em colite de exclusão experimental

ABSTRACT Background: The effects of topical application of sucralfate (SCF) on the tissue content of MUC-2 protein have not yet been evaluated in experimental models of diversion colitis. Aim: To measure the tissue content of MUC-2 protein in the colonic mucosa diverted from fecal stream submitted to the SCF intervention. Methods: Thirty-six rats underwent derivation of intestinal transit through proximal colostomy and distal mucous fistula. The animals were divided into three groups which were submitted application of enemas with saline, SCF 1 g/kg/day and SCF 2 g/kg/day. Each group was divided into two subgroups, according to euthanasia was done after two or four weeks. The colitis diagnosis was established by histopathological study and the inflammatory intensity was evaluated by previously validated scale. The MUC-2 protein was identified by immunohistochemistry and the tissue content was measured computerized morphometry). Results: The application of enemas with SCF in the concentration of 2 g/kg/day reduced inflammatory score of the segments that were diverted from fecal stream. The content of MUC-2 in diverted colon of the animals submitted to the intervention with SCF, independently of intervention period and the used concentration, was significantly greater than animals submitted to the application of enemas containing saline (p< 0.01). The content of MUC-2 after the intervention with SCF in the concentration of 2 g/kg/day was significantly higher when compared to the animals submitted to the application containing SCF at concentration of 1.0 g/kg/day (p<0.01). The tissue content of MUC-2 reached the highest values after intervention with SCF in the concentration of 2 g/kg/day for four weeks (p<0.01). Conclusion: The preventive application of enemas containing SCF reduces the inflammatory score and avoids the reduction of tissue content of MUC-2, suggesting that the substance is a valid therapeutic strategy to preserve the mucus layer that covers the intestinal epithelium.

RESUMO Racional: Os efeitos da aplicação tópica de sucralfato (SCF) no conteúdo tecidual da proteína mucina-2 (MUC-2) ainda não foram avaliados em modelos experimentais de colite de exclusão. Objetivo: Mensurar o conteúdo tecidual da proteína MUC-2 na mucosa cólica sem trânsito intestinal submetida à intervenção com SCF. Método: Trinta e seis ratos foram submetidos à derivação intestinal por colostomia proximal terminal e fístula mucosa distal. Foram divididos em três grupos segundo recebessem clisteres contendo solução fisiológica (SF), SCF 1 g/kg/dia e SCF 2 g/kg/dia. Cada grupo foi dividido em dois subgrupos, segundo a eutanásia ser realizada após duas ou quatro semanas. O diagnóstico de colite foi estabelecido por estudo histopatológico e a intensidade inflamatória foi avaliada por escala validada. A expressão tecidual da MUC-2 foi identificada por imunoistoquímica e seu conteúdo mensurado por morfometria computadorizada. Resultados: A aplicação de clisteres com SCF na concentração de 2 g/kg/dia reduziu a intensidade inflamatória no cólon sem trânsito fecal. O conteúdo tecidual de MUC-2 no cólon sem trânsito dos animais submetidos à intervenção com SCF, independente do tempo de intervenção e da concentração utilizada, foi maior quando comparado aos animais tratados com SF (p<0,01). O conteúdo de MUC-2 após a intervenção com SCF na concentração de 2 g/kg/dia foi maior quando comparado aos animais submetidos à intervenção com concentração menor (p<0,01). O conteúdo de MUC-2 foi maior após intervenção com SCF na concentração de 2 g/kg/dia por quatro semanas (p<0,01). Conclusão: A aplicação preventiva de clisteres com SCF reduz o grau de inflamação e preserva o conteúdo tecidual de MUC-2, em segmentos desprovidos de trânsito intestinal, mostrando-se uma estratégia terapêutica válida para preservar a camada de muco que recobre o epitélio intestinal.

[retracted article]: evaluation of enemas containing sucralfate in tissue content of muc-2 protein in experimental model of diversion colitis / [artigo retratado]: avaliação de enemas com sucralfato no conteúdo tecidual da proteina muc-2 em colite de exclusão experimental

ABSTRACT Background: The effects of topical application of sucralfate (SCF) on the tissue content of MUC-2 protein have not yet been evaluated in experimental models of diversion colitis. Aim: To measure the tissue content of MUC-2 protein in the colonic mucosa diverted from fecal stream submitted to the SCF intervention. Methods: Thirty-six rats underwent derivation of intestinal transit through proximal colostomy and distal mucous fistula. The animals were divided into three groups which were submitted application of enemas with saline, SCF 1 g/kg/day and SCF 2 g/kg/day. Each group was divided into two subgroups, according to euthanasia was done after two or four weeks. The colitis diagnosis was established by histopathological study and the inflammatory intensity was evaluated by previously validated scale. The MUC-2 protein was identified by immunohistochemistry and the tissue content was measured computerized morphometry). Results: The application of enemas with SCF in the concentration of 2 g/kg/day reduced inflammatory score of the segments that were diverted from fecal stream. The content of MUC-2 in diverted colon of the animals submitted to the intervention with SCF, independently of intervention period and the used concentration, was significantly greater than animals submitted to the application of enemas containing saline (p< 0.01). The content of MUC-2 after the intervention with SCF in the concentration of 2 g/kg/day was significantly higher when compared to the animals submitted to the application containing SCF at concentration of 1.0 g/kg/day (p<0.01). The tissue content of MUC-2 reached the highest values after intervention with SCF in the concentration of 2 g/kg/day for four weeks (p<0.01). Conclusion: The preventive application of enemas containing SCF reduces the inflammatory score and avoids the reduction of tissue content of MUC-2, suggesting that the substance is a valid therapeutic strategy to preserve the mucus layer that covers the intestinal epithelium.

RESUMO Racional: Os efeitos da aplicação tópica de sucralfato (SCF) no conteúdo tecidual da proteína mucina-2 (MUC-2) ainda não foram avaliados em modelos experimentais de colite de exclusão. Objetivo: Mensurar o conteúdo tecidual da proteína MUC-2 na mucosa cólica sem trânsito intestinal submetida à intervenção com SCF. Método: Trinta e seis ratos foram submetidos à derivação intestinal por colostomia proximal terminal e fístula mucosa distal. Foram divididos em três grupos segundo recebessem clisteres contendo solução fisiológica (SF), SCF 1 g/kg/dia e SCF 2 g/kg/dia. Cada grupo foi dividido em dois subgrupos, segundo a eutanásia ser realizada após duas ou quatro semanas. O diagnóstico de colite foi estabelecido por estudo histopatológico e a intensidade inflamatória foi avaliada por escala validada. A expressão tecidual da MUC-2 foi identificada por imunoistoquímica e seu conteúdo mensurado por morfometria computadorizada. Resultados: A aplicação de clisteres com SCF na concentração de 2 g/kg/dia reduziu a intensidade inflamatória no cólon sem trânsito fecal. O conteúdo tecidual de MUC-2 no cólon sem trânsito dos animais submetidos à intervenção com SCF, independente do tempo de intervenção e da concentração utilizada, foi maior quando comparado aos animais tratados com SF (p<0,01). O conteúdo de MUC-2 após a intervenção com SCF na concentração de 2 g/kg/dia foi maior quando comparado aos animais submetidos à intervenção com concentração menor (p<0,01). O conteúdo de MUC-2 foi maior após intervenção com SCF na concentração de 2 g/kg/dia por quatro semanas (p<0,01). Conclusão: A aplicação preventiva de clisteres com SCF reduz o grau de inflamação e preserva o conteúdo tecidual de MUC-2, em segmentos desprovidos de trânsito intestinal, mostrando-se uma estratégia terapêutica válida para preservar a camada de muco que recobre o epitélio intestinal.

Influence of the application of enemas with oily extract of curcumin (Curcuma longa) on the tissue content of neutral and acidic mucins in the colonic mucosa without fecal stream / Influência da aplicação de clisteres contendo extrato oleoso de curcumina (Curcuma longa) no conteúdo tecidual de mucinas neutras e ácidas na mucosa cólica sem trânsito intestinal

ABSTRACT Purpose: To verify if the application of enemas containing oily extracts of curcumin preserves the tissue content of mucins in the glands of the colonic mucosa without fecal stream. Method: Thirty-six Wistar rats were submitted to diversion of the fecal stream by proximal colostomy and distal mucous fistula. The animals were subdivided into three groups, and accordingly received enemas with saline and oily extract of curcumin at concentrations of 50 mg/kg/day or 200 mg/kg/day. After two or four weeks of intervention, the irrigated colic segments were removed. Neutral and acidic mucins were identified by Periodic-acid Schiff and Alcian-Blue techniques, respectively. The content of both mucin subtypes was measured by computerized morphometry. Mann-Whitney test was used to analyze the results, adopting a significance level of 5% (p ≤ 0.05). Results: There was an increase in the tissue content of neutral mucins in animals treated with curcumin at a concentration of 50 mg/kg/day for four weeks, whereas in the group treated with 200 mg/kg/day there was an increase independent of the time of intervention. The content of acidic mucins increased in animals treated with 200 mg/kg/day regardless of the intervention time, whereas in those treated with 50 mg/kg/day an increase was observed only after four weeks. Conclusion: Enemas with curcumin preserve the content of neutral and acidic mucins in the colonic epithelium without fecal stream.

RESUMO Objetivo: Verificar se a aplicação de clisteres com extrato oleoso de curcumina preserva o conteúdo de mucinas nas glândulas da mucosa cólica sem trânsito intestinal. Método: Trinta e seis ratos Wistar foram submetidos à derivação intestinal por colostomia proximal e fístula mucosa distal. Os animais foram subdivididos em três grupos, segundo receberem clisteres com soro fisiológico 0,9%, extrato oleoso de curcumina nas concentrações de 50 mg/kg/dia ou 200 mg/kg/dia. Após duas ou quatro semanas de intervenção foram removidos os segmentos cólicos irrigados. As mucinas neutras e ácidas foram identificadas pelas técnicas do PAS e Alcian-Blue, respectivamente. O conteúdo tecidual de ambos os subtipos de mucinas foi mensurado por morfometria computadorizada. Utilizou-se teste de Mann-Whitney para análise dos resultados adotando-se nível de significância de 5% (p ≤ 0,05). Resultados: Houve aumento no conteúdo de mucinas neutras nos animais tratados com curcumina na concentração de 50 mg/kg/dia por quatro semanas, enquanto nos tratados com 200 mg/kg/dia houve aumento independente do tempo de intervenção. O conteúdo de mucinas ácidas aumentou nos animais tratados com 200 mg/kg/dia independente do tempo de intervenção, enquanto nos tratados com 50 mg/kg/dia encontrou-se aumento apenas após quatro semanas. Conclusão: Clisteres com curcumina preservam o conteúdo de mucinas neutras e ácidas no epitélio cólico sem trânsito intestinal.