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

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

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

Sporadic rectocolic polyps prevalence and management

Objective: To evaluate the prevalence of polyps and their treatments. Materials and Method: This is a retrospective study conducted in our department over 20 years and 3 months between January 2000 and March 2021. All patients with colorectal polyps who underwent endoscopic resection were included. We evaluated the resection techniques and the management of complications. Results: The total number of patients was 273, with a mean age of 57.26 ± 14.058 (18-90) and a M/W sex ratio of 2. The prevalence was 3.35% and the mean number of polyps was 1.33 ± 0.69. The most frequent symptoms were rectal bleeding (23.5%) and constipation (12.1%). The median size was 6 mm (4-12 mm). The left colonic location was the most frequent site (43%). All polyps were classified according to the Paris classification, with a predominance of sessile polyps in 45.75%, followed by pedunculated polyps, representing 42.4%. Endoscopic resection was performed either by biopsy forceps, polypectomy, or mucosectomy in 30.2%, 27.4%, and 25.4% of cases, respectively. Our study noted immediate bleeding in 1.5% of cases, and no perforations or late complications. All complications were treated endoscopically, and no patient required blood transfusion or surgical intervention. Conclusion: Endoscopic resection of rectocolic polyps is the ideal treatment for these lesions. In our department, the prevalence was 3.35%, the most used resection techniques were forceps resection and polypectomy, and the complication rate was 1.5%. (AU)

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

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

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

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

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

Complicaciones de la colonoscopia en pacientes de la tercera edad / Complications of colonoscopy in elderly patients

Antecedentes: la OMS define a todo individuo mayor de 60 años como persona de la tercera edad. Existen 3 grupos: edad avanzada (60-74 años), ancianos o viejos (75-90 años) y grandes ancianos o longevos (mayor de 90 años). Se señala un riesgo mayor en mayores de 80 años cuando se realiza una colonoscopia como método para diagnóstico o seguimiento del cáncer colorrectal. Objetivo: analizar la morbilidad según la edad de pacientes sometidos a colonoscopias. Material y métodos: se registraron todas las complicaciones a 30 días de realizada la endoscopia. Las complicaciones fueron eventos digestivos (perforación, sangrado, transfusiones, distensión, náuseas, vómitos, dolor abdominal) y no digestivos (deshidratación, infarto, ángor, otros). Se usó prueba de relaciones y proporciones y exacta de Fisher con corrección de Yates y chi cuadrado según el tipo de variable, considerando significativo p<0,05. Resultados: se registraron 11 746 colonoscopias y analizaron 11 042 (pérdida seguimiento de 704). Hubo 239 pacientes mayores de 80 años, 4070 entre 60 y 80 y 7437 menores de 60. El 57,8% fueron diagnósticas (6800), 2222 en mayores de 60 con un 99% de procedimientos ambulatorios. Se interrumpieron 15 procedimientos por intolerancia a la anestesia. Se registró una fibrilación auricular sin traducción clínica con reversión posterior. No hubo evento clínico mayor. Se registraron 14 complicaciones (0,12%), 6 en procedimientos terapéuticos (0,05%). No hubo morbimortalidad de relevancia asociada. Conclusiones: las complicaciones luego de una colonoscopia son escasas. Los estudios que hablan de un mayor riesgo en mayores de 60 años son discutibles. La prevención mediante colonoscopia es primordial y no tiene más complicaciones que en la población general en mayores de 60 años y es muy segura en mayores de 80 años en nuestra experiencia.

Background: For the World Health organization, elderly persons are those > 60 years, and classifies this age group in three sub-groups: the elderly (60-74 years), the old (75-90 years) and the long-lived (> 90 years). Patients > 80 years undergoing a colonoscopy for diagnosis or follow-up of colorectal cancer are believed to be at higher risk of complications. Objective: The aim of this study is to analyze the incidence of complications of colonoscopy by age. Material and methods: We conducted a retrospective analysis of a consecutive series of adult patients undergoing colonoscopy in three institutions between January 2005 and June 2017. All the complications occurring within 30 days of the procedure were recorded. Gastrointestinal complications included perforation, bleeding, transfusions, bloating, nausea, vomiting and abdominal pain. Dehydration, myocardial infarction and angina were non-gastrointestinal complications. The variables were compared using the Fisher's exact test with Yates correction or the chi square test, as applicable. A p 80 years, 4070 between 60 and 80 years and 7437 60 years and 99% were outpatient procedures. Fifteen procedures were cancelled due to intolerance to anesthesia. One patient presented atrial fibrillation with no clinical relevance. There were no major adverse events. Complications occurred in 14 patients (0.12%), 6 in therapeutic procedure (0.05%), There were significant morbidity or mortality associated. Conclusions: Complications after colonoscopy are rare. The higher risk reported in > 60 years is controversial. Screening for colorectal cancer is essential and the incidence of colonoscopy-related complications in > 60 years is similar to that of the general population. Colonoscopy is a safe procedure in patients > 80 years.

Colonoscopic findings in patients aged 50 years and older: a critical analysis of 1614 exams / Achados colonoscópicos em pacientes a partir dos 50 anos: uma análise crítica de 1614 exames

ABSTRACT Introduction: Colonoscopy has shown to be useful in the diagnosis of various pathologies. By allowing the direct visualization of the mucosa, colonoscopy allows the adoption of therapeutic methods, such as the removal of polyps, dilation of stenoses, and biopsies. This method can also be applied in the detection of colorectal cancer, which currently represents an important cause of mortality in the world. Individuals considered to be at medium risk for the development of colorectal cancer should start screening at 50 years of age in order to detect early disease. Objective: To describe the main results of the exams for patients at least 50 years old who underwent colonoscopy. Method: Descriptive, case-series study of 1614 colonoscopies performed from 2014 to 2017 at a referral hospital in Salvador, Bahia. Results: The main indications for the study were intestinal bleeding (26.5%), neoplasia screening (20.7%), and abdominal pain (10.2%). The main results were diverticular disease (38.9%), polyps (38.8%), and normal examination (23.2%). Patients with indications for neoplasia screening had the presence of polyps (41.3%) as their main diagnosis. For patients with normal examination, 28.8% presented intestinal bleeding as an indication. There were 70 (4.3%) patients with a colonoscopic diagnosis of neoplasia. Conclusion: The present study, which demonstrated a majority of exams with considerable alterations, shows the usefulness of the examination, besides other advantages, as a form of diagnosis of colorectal cancer.

RESUMO Introdução: A colonoscopia mostra-se útil no diagnóstico de diversas patologias. Ao permitir a visualização direta da mucosa, possibilita a tomada de medidas terapêuticas, como a remoção de pólipos, dilatação de estenoses e realização de biopsias. Tal método pode ser empregado também no rastreio do câncer colorretal, que atualmente representa importante causa de mortalidade no mundo. Os indivíduos considerados de médio risco para o desenvolvimento do câncer colorretal, devem iniciar a triagem a partir dos 50 anos de idade, a fim de detectar precocemente a doença. Objetivo: Descrever os principais achados e indicações dos exames daqueles pacientes que realizaram colonoscopia com idade ≥ 50 anos. Método: Estudo descritivo, em série de casos, referente a 1.614 colonoscopias realizadas no período de 2014 a 2017 em hospital de referência em Salvador, BA. Resultados: As principais indicações para realização do exame foram sangramento intestinal (26,5%), rastreio de neoplasia (20,7%) e dor abdominal (10,2%). Os principais resultados encontrados foram doença diverticular (38,9%), pólipos (38,8%) e exame normal (23,2%). Os pacientes com indicação de rastreio de neoplasia tiveram como principal achado, a presença de pólipos (41,3%). Dos pacientes com exame normal; 28,8% apresentaram sangramento intestinal como indicação. Houve 70,0 (4,3%) pacientes com diagnóstico colonoscópico de neoplasia. Conclusão: O presente estudo, ao demonstrar uma maioria de exames com alterações consideráveis, evidencia a utilidade do exame, além de outras vantagens, como uma forma de diagnóstico do câncer colorretal.

Revisão sistemática e meta-análise sobre técnicas de polipectomia de pólipos colorretais pequenos e diminutos / Best polypectomy technique for small and diminutive colorectal polyps: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Polypectomy of colorectal polyps is the mainstay of colorectal cancer prevention. Identification of the best polypectomy technique is imperative. OBJECTIVE: This review aims at comparing efficacy of nine different resection methods for small colorectal polyps (<10 mm). METHODS: We searched and selected only randomized controlled trials. Primary outcome was complete resection rates of small polyps by histological eradication. Secondary outcomes were: adverse events, retrieval tissue failures rates and duration of procedure. RESULTS: Eighteen trials including 3215 patients and 5223 polyps were analysed. Overall, cold polypectomy had a significantly shorter time of procedure than hot polypectomy (RD -5.92, 95%CI -9.90 to -1.94, P<0.05), with no statistical difference on complete histological eradication (RD 0.08, 95%CI -0.03 to 0.19, P>0.05). Regarding cold polypectomy techniques, cold snare was found superior to cold forceps on complete and en-bloc resection rates and less time consuming. When comparing endoscopic mucosal resection (EMR) with hot-snare and cold-snare, the latter showed no-inferiority on histological eradication, adverse events or retrieval tissue failure rates. CONCLUSION: Cold polypectomy is the best technique for resection of small colorectal polyps. Among cold methods, dedicated cold snare was found superior on histological eradication. Cold snare endoscopic mucosal resection might be considered an option for polyps from 5 to 9 mm.

RESUMO CONTEXTO: A polipectomia de pólipos colorretais é a base da prevenção do câncer colorretal. A identificação da melhor técnica de polipectomia é imperativa. OBJETIVO: Esta revisão tem como objetivo comparar a eficácia de nove diferentes métodos de ressecção para pólipos colorretais pequenos (<10 mm). MÉTODOS: Pesquisamos e selecionamos apenas ensaios clínicos randomizados. O desfecho primário foi taxas de ressecção completa de pólipos pequenos por confirmação histológica. Os desfechos secundários foram: eventos adversos, taxas de falha de recuperação do espécime e duração do procedimento. RESULTADOS: Dezoito estudos, incluindo 3215 pacientes e 5223 pólipos foram analisados. No geral, a polipectomia a frio teve um tempo de procedimento significativamente menor do que a polipectomia a quente (RD -5,92; IC 95% -9,90 a -1,94; P<0,05), sem diferença estatística na erradicação histológica (RD 0,08; IC 95% -0,03 a 0,19; P>0,05). Em relação às técnicas de polipectomia a frio, a alça fria foi considerada superior ao uso de pinça fria nas taxas de ressecção completa e em bloco, além de um menor tempo de procedimento. Ao comparar a ressecção endoscópica da mucosa utilizando alça quente ou alça fria, esta última mostrou não-inferioridade na erradicação histológica, eventos adversos ou taxas de falha do tecido de recuperação. CONCLUSÃO: A polipectomia a frio mostrou ser a melhor técnica para ressecção de pequenos pólipos colorretais. Entre os métodos frios, a alça fria dedicada foi considerada superior na erradicação histológica. ressecção endoscópica da mucosa com alça fria pode ser considerado uma opção para pólipos de 5 a 9 mm.

Complicaciones de las videocolonoscopias en los primeros once años en un equipo quirúrgico / Adverse events related to colonoscopy on the initial eleven years of a surgical team

Antecedentes: la videocolonoscopia es un procedimiento imprescindible para el diagnóstico y tratamiento de afecciones colorrectales que forma parte de los recursos del cirujano. Posee un índice de complicaciones que pueden ser graves y requieren un adecuado manejo. Objetivo: analizar la experiencia de complicaciones de once años de un equipo quirúrgico realizando videocolonoscopia, con revisión de la bibliografía actual. Material y métodos: análisis retrospectivo consecutivo sobre una base de datos prospectiva. Entre enero de 2005 y diciembre de 2016 se realizaron endoscopias digestivas altas y bajas, diagnósticas y terapéuticas. Se analizan puntualmente las complicaciones de las videocolonoscopias y su manejo por parte del equipo quirúrgico. Resultados: de 3218 videocolonoscopias, 8 pacientes registraron complicaciones (0,2%). Todas fueron perforaciones colónicas resueltas mediante cirugía, con rafia primaria y operación tipo Hartmann. No hubo mortalidad en la serie. Conclusiones: si bien los procedimientos endoscópicos tienen efectos adversos, pueden ser llevados a cabo con estándares de calidad por cirujanos. Es importante que el equipo actuante esté capacitado para la resolución de complicaciones.

Background: colonoscopy is essential for the diagnosis and treatment of colorectal conditions, and is part of the surgeon's resources. Complications associated with the procedure could be severe, and require an appropriate management. Objective: to analyze complications associated with colonoscopies done by a surgical team. Material and method: retrospective analysis on a prospective database. Diagnostic and therapeutic colonoscopies done by a surgical team between January 2005 and December 2016 were included. Complications and management strategies were analyzed. Results: of 3218 colonoscopies, 8 patients presented complications (0.2%). All were colon perforations solved by surgery, with primary closure and a kind of Hartmann's procedure. There was no mortality In this series. Conclusions: although endoscopic procedures may have adverse effects, they can be done under standards of quality by surgeons. It is important that the intervening team be qualified for the solution of complications.

Complicações em colonoscopia: experiência uni-institucional com 8968 pacientes / Colonoscopy complications: experience with 8968 consecutive patients in a single institution

RESUMO Objetivo: avaliar a incidência, características epidemiológicas, diagnóstico e evolução dos pacientes que retornaram às unidades de pronto atendimento (UPA) do Hospital Albert Einstein em São Paulo/SP com sinais e sintomas sugestivos de complicações até 30 dias após realização de colonoscopia. Métodos: estudo retrospectivo uni-institucional de pacientes submetidos à colonoscopia em 2014 e que retornaram, em até 30 dias após o procedimento, a uma UPA. Resultados: foram realizadas colonoscopias em 8968 pacientes, dos quais 95 (1,06%) tiveram queixa relacionada à possível complicação. A maioria dos procedimentos foi realizada eletivamente. Complicações menores (dor abdominal inespecífica/distensão) foram frequentes (0,49%) e a maioria dos pacientes recebeu alta após consulta na UPA. Complicações graves foram menos frequentes: perfuração (0,033%), hemorragia digestiva baixa (0,044%) e obstrução intestinal (0,044%). A procura à UPA em menos de 24 horas após o procedimento associou-se a maior índice de colonoscopias normais (P=0,006), mais diagnóstico de febre (P=0,0003) e síndrome dispéptica (P=0,043) e menos diagnóstico de colite/ileíte (P=0,015). A presença de febre em pacientes atendidos na UPA associou-se ao diagnóstico de pólipos na colonoscopia (P=0,030). Conclusão: os dados do presente estudo corroboram as evidências de segurança do exame de colonoscopia e apontam para redução nos índices de complicações mais graves deste exame.

ABSTRACT Objective: to evaluate the incidence, epidemiological characteristics, diagnosis and evolution of patients who returned to the emergency care units of the Albert Einstein Hospital in São Paulo/SP with signs and symptoms suggestive of colonoscopy complications up to 30 days after the procedure. Methods: we conducted a retrospective, uni-institutional study of patients submitted to colonoscopy in 2014 who returned to the Emergency department (ED) within 30 days after the procedure. Results: 8968 patients underwent colonoscopies, 95 (1.06%) of whom had complaints related to possible complications. Most of the procedures were elective ones. Minor complications (nonspecific abdominal pain/distension) were frequent (0.49%) and most of the patients were discharged after consultation at the ED. Severe complications were less frequent: perforation (0.033%), lower gastrointestinal bleeding (0.044%), and intestinal obstruction (0.044%). ED consultations in less than 24 hours after the procedure was associated with a higher index of normal colonoscopies (p=0.006), more diagnosis of fever (p=0.0003) and dyspeptic syndrome (p=0.043), and less diagnosis of colitis/ileitis (p=0.015). The observation of fever in patients treated at the ED was associated with the diagnosis of polyps at colonoscopy (p=0.030). Conclusion: the data corroborate the safety of the colonoscopy exam and points to a reduction in major complications rates.

Kidney injury and other complications related to colonoscopy in inpatients at a tertiary teaching hospital

OBJECTIVES: To describe clinical complications related to colonoscopy in inpatients with multiple diseases. Among the known complications, acute kidney injury was the primary focus. METHODS: This was an observational retrospective study of 97 inpatients. Data relating to age; gender; comorbidities; current medication; blood tests (renal function, blood glucose and LDL cholesterol levels); length of hospital stay; indication, results, and complications of colonoscopies; and time to the development of kidney injury were collected between June 2011 to February 2012. RESULTS: A total of 108 colonoscopies (9 screening and 88 diagnostic) were conducted in 97 patients. Renal injury occurred in 41.2% of the patients. The univariate analysis revealed that kidney injury was related to the use of diuretics, statins, calcium channel blockers, and angiotensin converting enzyme inhibitor; however, the multivariate analysis showed that only the use of diuretics was associated with kidney injury. The occurrence of kidney injury and the time to its development were independent of the previous glomerular filtration rate as calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. CONCLUSIONS: The use of diuretics was the only independent variable associated with the development of kidney injury in inpatients with multiple comorbidities who underwent colonoscopy. The occurrence of kidney injury and the time to its development were independent of previous CKD-EPI-based assessments of renal function. These results highlight the increased risk of colonoscopy in such patients, and its indication should be balanced strictly and perhaps avoided as a screening test.

Factors associated with abdominal pain in patients submitted to colonoscopy / Fatores associados à dor abdominal em pacientes submetidos à colonoscopia

ABSTRACT Objective: The study evaluated factors associated with abdominal pain during colonoscopy. Methods: This was a cross-sectional observational study that evaluated patients who underwent colonoscopy between February 2014 and February 2015. Physical characteristics, surgical history and previous colonoscopies, indication and current examination conditions, fentanyl and midazolam dose, and pain level were analyzed. Significance level adopted: p < 0.05. Chi-squared test was used for association of categorical variables, Student's t-test was applied for comparison of means, and Spearman's coefficient was used for correlation. Results: A total of 566 women and 391 men with mean age of 54.81 years and mean BMI of 27,064 were evaluated. Of the total, 29 (3.0%) had mild pain, 42 (4.4%) had moderate pain, and 18 (1.9%) had severe pain. Women were less tolerant (p = 0.011) and had longer cecal intubation times (p = 0.001). Mean duration of colonoscopy and mean dose of midazolam were higher in patients with pain (p = 0.001), (p < 0.001*). Among the 39 patients with an incomplete examination, 8 reported pain (p = 0.049). Conclusion: Female gender and prolonged intubation time were significantly associated with abdominal pain during colonoscopy. Patients with discomfort had a higher failure rate on the exam. Additional doses of midazolam given to patients with pain were not effective.

RESUMO Objetivo: O estudo avaliou fatores associados à dor abdominal durante a colonoscopia. Métodos: Estudo observacional transversal, que avaliou pacientes que realizaram colonoscopia entre Fevereiro de 2014 e Fevereiro de 2015. Analisou-se características físicas, histórico cirúrgico e colonoscopias prévias, indicação e condições do exame atual, dose de fentanil e midazolam e nível de dor. Nível de significância adotado: p <0,05. Utilizou-se teste Qui-quadrado para associação de variáveis categóricas, teste t de Student para comparação de médias e coeficiente de Spearman para correlação. Resultados: Avaliou-se 566 mulheres e 391 homens, com média de idade de 54,81 anos e IMC médio de 27,064. Do total, 29 (3,0%) tiveram dor leve, 42 (4,4%) dor moderada e 18 (1,9%) dor intensa. As mulheres foram menos tolerantes (p = 0,011) e tiveram maior tempo de intubação cecal (p = 0,001). A duração média da colonoscopia e dose média de midazolam administrada foram maiores nos pacientes com dor (p = 0,001), (p < 0,001*). Entre os 39 pacientes com exame incompleto, 8 relataram dor (p = 0,049). Conclusão: Gênero feminino e tempo de intubação prolongado tiveram associação significativa com dor abdominal durante a colonoscopia. Pacientes com desconforto tiveram uma taxa maior de insucesso no exame. Doses adicionais de midazolam administradas nos pacientes com dor não foram efetivas.

Eficacia y seguridad de la resección endoscópica en pacientes con pólipos colorrectales no pediculados grandes / Efficacy and safety of endoscopic resection in patients with large non-pedunculated colorectal polyps

Introducción: Los pacientes con pólipos colorrectales no pediculados grandes (PCNP-G) han sido tradicionalmente tratados quirúrgicamente. Los avances en la endoscopía terapéutica permiten que la resección endoscópica de estas lesiones pueda ser considerada como una alternativa a la cirugía. Objetivo: Evaluar la eficacia y seguridad de la resección endoscópica en pacientes con PCNP-G. Materiales y métodos: Cohorte prospectiva multicéntrica. Se incluyeron a todos los pacientes referidos para resección endoscópica de PCNP-G entre enero del 2012 y diciembre del 2015, seguidos hasta agosto del 2016. Se obtuvieron las tasas de resecciones exitosas, de recurrencia y de complicaciones. Se analizaron los factores predictivos asociados a resección no exitosa y a recurrencia. Resultados: Se incluyeron 107 pacientes con 115 PCNP-G. La tasa de resección exitosa fue de 92%. Las complicaciones más comunes fueron el sangrado (8,7%) y la perforación (2,6%). La tasa de recurrencia fue de 7%, todas tratadas endoscópicamente con éxito. Los factores predictivos de resección no exitosa fueron una medida >50 mm de la lesión resecada y la presencia de fibrosis; y el único factor predictivo de recurrencia fue una medida >50 mm del pólipo resecado. Conclusiones: La resección endoscópica de los PCNP-G es altamente eficaz y segura

Introduction: Patients with large non-pedunculated colorectal polyps (L-NPCP) have been traditionally treated with surgery. Advances in therapeutic endoscopy allow endoscopic resection of these lesions and can be considered as an alternative to surgery. Objective: To evaluate the efficacy and safety of endoscopic resection in patients with L-NPCP. Methods: A prospective multicentric cohort. All patients referred for endoscopic resection with L-NPCP between January 2012 and December 2015, followed until August 2016, were included. Rates of successful resection, recurrence and complications were obtained. Predictive factors associated with unsuccessful resection and recurrence were analyzed. Results: 115 L-NPCP in 107 patients were included. The rate of successful resection was 92%. The most common complications were bleeding (8.7%) and perforation (2.6%). The recurrence rate was 7%, all successfully treated with a new endoscopic session. Predictors of unsuccessful resection were a measure >50 mm of the lesion and the presence of fibrosis; and the only predictor of recurrence was a size of the polyp resected >50 mm. Conclusions: Endoscopic resection of L-NPCP is very efficacious and safe

Neumoperitoneo poscolonoscopia sin evidencia de perforación colónica / Post-Colonoscopy neumoperitoneum without evidence of colonic perforation

Objetivo: Reportar el caso de una complicación poscolonoscopia de tratamiento complejo. Caso clínico: Presentamos el caso de una mujer de 82 años, a quien se practicó una colonoscopia total por sangrado rectal, reportando úlcera anal. Dos días después presentó dolor abdominal y distensión abdominal. En las imágenes se encontró gran neumoperitoneo; se realizó laparotomía exploradora sin encontrar lesión en el colon. Presentó buena evolución postoperatoria. Se hace una revisión de la literatura respectiva.

Aim: To report a case of one of the most complex complication post-colonoscopy and is treatment. Case report: We report the case of a 82 years old woman, who was taken to complete colonoscopy for rectal bleeding, then reporting an anal ulcer. Two days later, she has abdominal pain and bloating. In images she has a great pneumoperitoneum. At laparotomy it was not found any injury to the colon. She has a good post-operative evolution. Respective literature review is done.

Absence seizure associated with coloprep consumption in colonoscopy / Convulsão de ausência com o uso de Coloprep em colonoscopia

Coloprep is a bowel preparatory solution given before endoscopic procedures to get a unobscured internal vision. It has among its constituent's sodium sulphate, potassium sulphate and magnesium sulphate which produce an osmotic effect in the bowel. However, the use of such agents in hyponatremic and patients predisposed to seizures can have adverse ramifications. The current case outlines manifestation of absence seizure in a 52-year-old male patient who was administered Coloprep for colonoscopy. There was absence of other predisposing factors and the symptoms were ameliorated using timely identification and rectification of the underlying derangements.

Coloprep é uma solução preparatória intestinal administrada antes de procedimentos endoscópicos, com o objetivo de se ter uma visão interna não obscurecida. Entre os constituintes de Coloprep, observa-se sulfato de sódio, sulfato de potássio e sulfato de magnésio, que provocam efeito osmótico no intestino. Mas o uso de tais agentes em pacientes hiponatrêmicos e com predisposição para convulsões pode ter ramificações adversas. O caso em tela delineia uma manifestação de convulsão de ausência em paciente do gênero masculino com 52 anos e que recebeu Coloprep para colonoscopia. Não havia outros fatores predisponentes e os sintomas melhoraram graças à oportuna identificação e correção dos transtornos subjacentes.

Colite isquêmica após colonoscopia de rotina: relato de dois casos / Ischemic colitis after a routine colonoscopy: report of two cases

Objetivo: colite isquêmica após colonoscopia é evento raro. Vamos relatar dois pacientes que tiveram esta evolução. Apresentação - Caso 1: paciente do sexo feminino, 67 anos de idade, DPOC compensado, foi submetida à colonoscopia para prevenção de CCR. Tinha relato de cirurgia pélvica prévia, o preparo de cólon estava bom, os parâmetros fisiológicos permaneceram normais durante procedimento, que foi longo, difícil e com grande distensão gasosa. Seis horas após a alta hospitalar sem eventualidade, iniciou sangramento vivo pelo ânus, que evoluiu com dor abdominal agravada 20 horas após. Abdome flácido, porém doloroso à palpação profunda no quadrante inferior esquerdo. CT abdominal mostrou espessamento de parede do reto e do sigmoide e coágulos em seu interior. Evoluiu bem com tratamento conservador. Caso 2: paciente do sexo feminino, 82 anos de idade foi submetida à colonoscopia para procura de tumor sincrônico em pré-operatório de adenocarcinoma de sigmoide. Mucosectomia de adenoma plano de sigmoide foi realizada, seguida de tatuagem com nanquim acima e abaixo da lesão neoplásica no sigmoide. Procedimento realizado sem eventualidade, embora, ao cabo de 3 horas, tenha evoluído com dor, distensão abdominal e suboclusão em nível do tumor primário, confirmada por rotina radiológica. Admitida ao hospital, tratada de forma conservadora sem, no entanto, descompressão colônica. Evoluiu em 20 horas com sinais de irritação peritoneal e laparotomia exploradora, e mostrou se tratar de colite isquêmica confirmada em hemicolectomia direita. Conclusão: para evitarmos colite isquêmica após colonoscopia, o paciente deverá ter alta com o mínimo de distensão possível após o procedimento.

Introduction: ischemic colitis following colonoscopy is rare. We report two cases after uneventful colonoscopy. Presentation - Case 1: a 67 year old white female with COPD was submitted to screening colonoscopy. She had a previous pelvic surgery. The bowel was well prepared. The blood pressure was kept normal during the procedure that was difficult, time consuming with hyperinflation. Beside this, she was discharged without complain. Six hour later she started to pass bright red blood from the rectum and complaining of abdomen pain that got worse 20 hour later. At this time, the abdomen was soft to palpation with tenderness on the left lower quadrant of the abdomen. Computed tomography (CT) scans showed diffuse wall thickness of the sigmoid and the rectum with blood clot inside the lumen. High Protein C reactive was observed. She had uneventful recovery 5 days after a conservative treatment. Case 2: a 82 year old white female with an adenocarcinoma of the sigmoid colon was submitted to a colonoscopy to rule out a synchroid tumor. We performed an endoscopic mucosal resection for a benign lesion of the cecum. A tatoo close to a sigmoid tumor was done to facilitate surgery. The procedure was uneventful and she was discharged without complain. Three hours later she was distressed with abdominal distension and pain. The abdomen was soft and the bowel sounds were hyperactive. She underwent a routine chest and abdominal X ray that disclosed only hyperdistension and no free air. Twenty hours later she got worse with clinical sings of peritonitis. Right hemicolectomy was performed for ischemic colitis. Conclusion: we describe an Ischemic coliti following an uneventful colonoscopies. Both patients had reduced blood flow with damage to microvasculature probably due to a high intra luminal pressure related to hyperinflation. On the first case the cause was the long procedure time and in the second a partial colonic obstruction due to a sigmoid tumor. As a risk factor we found only a previous abdominal surgery on the first case. It is important to pay attention to a colonoscopic procedure time, hyperinflation and hyperextension. We always should leave the patient with the least possible amount of gas.

Splenic Rupture following Colon Polypectomy: A Case Report and Review of Literature / 대한소화기학회지

Colonoscopy is a safe procedure performed routinely worldwide. Splenic rupture is a rare complication of colonoscopy with several reported cases since 1974. We report the first case of a complication in the Republic of Korea. The literature on this rare complication is also reviewed here, with focus on the analysis of risk, diagnosis, and treatment. A 77-year-old patient receiving oral aspirin underwent colonoscopy with polypectomy. After 24 hours, the patient experienced dizziness and hypotension. Colonoscopy was performed to exclude intestinal bleeding, which could be diagnosed with hemoperitoneum. A computed tomography scan showed copious abdominal free blood and a splenic rupture. An urgent splenectomy was performed, which was the recognized procedure of choice. Physicians should have greater awareness of the possibility of splenic rupture following colonoscopy in order to avoid delay of diagnosis and treatment for this life-threatening complication.