Reservoritis secundaria a infección por citomegalovirus: reporte de caso y revisión de la literatura / Pouchitis secondary to cytomegalovirus infection: Case report and literature review

Resumen La proctocolectomía total con reservorio ileal es el procedimiento quirúrgico de elección para la colitis ulcerativa refractaria (CUR) al tratamiento médico y la reservoritis es la complicación más frecuente y puede afectar hasta al 50% de los pacientes en los primeros 5 años del procedimiento. Aunque la etiología no está bien establecida, su presentación podría estar relacionada con disbiosis como resultado de la estasis fecal en individuos genéticamente susceptibles y con una respuesta inmunitaria alterada. Los síntomas típicos de reservoritis como diarrea, dolor abdominal, tenesmo, urgencia, incontinencia fecal y, menos frecuentemente, sangrado rectal no son específicos y el diagnóstico debe confirmarse mediante una evaluación endoscópica e histológica. La infección por citomegalovirus es infrecuente como causa de reservoritis; sin embargo, debe considerarse en pacientes con reservoritis refractaria al manejo antibiótico inicial. Las pruebas diagnósticas incluyen pruebas serológicas como la medición de anticuerpos, antigenemia y proteína C-reactiva (PCR) en sangre. El tratamiento de elección es el ganciclovir, medicamento de administración endovenosa que puede inducir complicaciones graves como mielosupresión, neutropenia y trombocitopenia. Se recomienda el seguimiento endoscópico posterior al tratamiento para asegurar la cicatrización mucosa, especialmente cuando hay sospecha de enfermedad de Crohn o compromiso del asa aferente en la endoscopia inicial.

Abstract Total proctocolectomy with ileal pouch is the surgical procedure of choice for ulcerative colitis refractory to medical treatment, and pouchitis is the most frequent complication. It can affect up to 50% of patients in the first five years of the procedure. Although the etiology is not well established, its manifestation could be related to dysbiosis resulting from fecal stasis in genetically susceptible individuals with altered immune responses. Typical symptoms of pouchitis, such as diarrhea, abdominal pain, tenesmus, urgency, fecal incontinence, and, less commonly, rectal bleeding, are nonspecific, and the diagnosis must be confirmed by endoscopic and histologic examination. Cytomegalovirus infection is an infrequent cause of pouchitis; however, it should be considered in patients with pouchitis refractory to initial antibiotic management. Diagnostic tests include serological tests such as the measurement of antibodies, antigenemia, and C-reactive protein (CRP) in blood. The treatment of choice is ganciclovir, an intravenous drug that can induce severe complications such as myelosuppression, neutropenia, and thrombocytopenia. Post-treatment endoscopic follow-up is recommended to ensure mucosal healing, especially when there is suspicion of Crohn's disease or involvement of the afferent loop on initial endoscopy.

Proctocolectomía total radical laparoscópica por poliposis familiar adenomatosa colorrectal asociada a cáncer de colon izquierdo / Laparoscopic radical total proctocolectomy by colorrectal adenomatous family polyposis associated with left colon cancer

Resumen Objetivo: Presentar el caso de una paciente mujer adulta, joven, con poliposis múltiple, asociado a cáncer colorrectal, evaluando su manejo quirúrgico oncológico. Materiales y Método: Datos e imágenes recopilados de la historia clínica del Hospital de Alta Complejidad Virgen de la Puerta (HACVP) EsSalud - La Libertad. Resultado: Mujer de 33 años que debuta con dolor abdominal en hemiabdomen izquierdo, más deposiciones con sangre. El hallazgo colonoscópico encuentra múltiples pólipos elevados, planos y sésiles en todo el colon, recto y ano compatible con displasias de alto y bajo grado; a nivel de colon izquierdo se halla lesión exofítica, estenosante cuyo resultado fue adenocarcinoma infiltrante moderadamente diferenciado. Por el gran riesgo de malignidad en todo el intestino grueso, incluyendo canal anal, se le realiza proctocolectomía total laparoscópica más ileostomía terminal. Discusión: La poliposis adenomatosa familiar (PAF) es un síndrome cuyo abordaje quirúrgico va desde una colectomía total con anastomosis ileorrectal, proctocolectomía con ileostomía terminal y proctocolectomía total con Pouch y anastomosis ileoanal. Conclusión: Individualizar el caso, sobre la mejor opción quirúrgica a adoptar para un adecuado manejo oncológico.

Aim: To present the case of a young adult female patient with multiple polyposis associated with colorectal cancer, evaluating her surgical oncological management. Materials and Method: Data and images collected from the clinical history of the Hospital de Alta Complejidad "Virgen de la Puerta" (HACVP) EsSalud - La Libertad. Result: 33-year-old woman presenting with abdominal pain in the left hemiabdomen plus bloody stools. At colonoscopy multiple raised, flat and sessile polyps throughout the colon, rectum, and anus compatible with high-and low-grade dysplasias; an exophytic, stenosing lesion was found in the left colon, the result of which was moderately differentiated infiltrating adenocarcinoma. Due to the great risk of malignancy in the entire large intestine including the anal canal, a total laparoscopic proctocolectomy plus terminal ileostomy was performed. Discussion: Familial adenomatous polyposis (FAP) is a syndrome whose surgical approach ranges from a total colectomy with ileorectal anastomosis, proctocolectomy with terminal ileostomy and total proctocolectomy with Pouch and ileoanal anastomosis. Conclusión: Individualize the case, regarding the best surgical option to adopt for an adequate oncological management.

Surgical results and quality of life of patients submitted to restorative proctocolectomy and ileal pouch-anal anastomosis / Resultados cirúrgicos e qualidade de vida de pacientes submetidos à proctocolectomia total e reservatório ileoanal

ABSTRACT Purpose: restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice in some cases of familial adenomatous polyposis (FAP) and ulcerative colitis (UC). IPAA allows complete removal of the diseased colon and rectum, however, it is associated with substantial morbidity and potential consequences to patients' quality of life (QoL). Aims: to evaluate the surgical results, functional outcomes and QoL after IPAA; and to examine the impact of surgical complications upon QoL. Methods: we reviewed the records of 55 patients after IPAA, with emphasis on surgical outcomes. Forty patients answered the questionnaires. The Cleveland Global Quality of Life (CGQL), Inflammatory Bowel Disease Questionnaire (IBDQ), and Short Form 36 Health Survey Questionnaire (SF36). Results: the average age was 42.1±14.1 years. 63.6% of the patients were male, and 69.1% had FAP. Operative mortality was 1.8% and overall morbidity was 76.4%. Anastomotic leakage was the most frequent early complication (34.5%). Pouchitis (10.8%) and small bowel obstruction (9.1%) were the most common late complications. Patients with UC had the most severe complications (p=0.014). Pelvic complications did not have a negative effect on functional outcomes or QoL scores. Female patients had decreased pouch evacuation frequency, fewer nocturnal bowel movements, decreased bowel symptom impact on QoL (p=0.012), and better CGQL (p=0.04). Patients with better education had better QoL scores, and patients who had their pouches for more than five years scored lower. Conclusion: the high morbidity has no impact on function or QoL. Bowel function is generally acceptable. QoL is good and affected by sex, education and time interval since IPAA.

RESUMO Objetivo: a Proctocolectomia com reservatório ileoanal (PCT-RIA) é método de escolha em alguns casos de Polipose Adenomatosa Familiar (PAF) e Retocolite Ulcerativa (RCU). Embora tenha potencial curativo, apresenta morbidade considerável e pode afetar a qualidade de vida (QV) dos pacientes. Objetivos: avaliar resultados cirúrgicos e impacto das complicações pélvicas na função intestinal e QV. Métodos: foram avaliados retrospectivamente 55 pacientes submetidos a PCT-RIA, de janeiro de 2003 até abril de 2017, com ênfase na técnica operatória e morbidade. Quarenta pacientes responderam aos questionários Cleveland Global Quality of Life (CGQL), Inflammatory Bowel Disease Questionnaire (IBDQ) e Short Form 36 Health Survey Questionnaire (SF36). Resultados: A média de idade foi 42,1±14,1 anos, sendo 63,6% do sexo masculino e 69,1% com diagnóstico de PAF. A mortalidade cirúrgica foi 1,8% e morbidade 76,4%. Fístula anastomótica foi a complicação precoce mais frequente (34,5%) e, as tardias foram bolsite (10,8%) e obstrução intestinal (9,1%). As complicações precoces mais graves foram mais frequentes em pacientes com RCU (p=0,014). Não houve impacto das complicações na função intestinal nem na QV. As mulheres apresentaram menor frequência evacuatória e noturna, menor interferência dos sintomas intestinais na QV (p=0,012) e CGQL mais elevado (p=0,04). Melhor QV foi referida pelos pacientes com maior escolaridade e, foi observada piora em pacientes com mais de cinco anos de confecção do RIA. Conclusões: não se evidenciou impacto das complicações na função intestinal nem na QV. A função intestinal é satisfatória e a QV é boa na maioria dos pacientes, sendo influenciada pelo sexo, escolaridade e tempo de confecção do RIA.

Abordagem diagnóstica e de manuseio da pouchite em doença inflamatória intestinal / Diagnostic and management approach to pouchitis in inflammatory bowel disease

ABSTRACT In patients with ulcerative colitis refractory to medical therapy, total proctocolectomy and posterior ileal-anal pouch anastomosis is the standard surgical therapy. One of the possible complications is pouchitis. Depending on the duration of the symptoms, it can be classified as acute, recurrent, or chronic. The latter, according to the response to therapy, can be defined as antibiotic-dependent or refractory. The treatment of pouchitis is based on the use of antibiotics and probiotics. Thiopurine and biological therapy have been suggested in patients with refractory pouchitis. Special care should be taken in the endoscopic surveillance of these patients, especially if they present risk factors such as dysplasia or previous colorectal cancer, primary sclerosing cholangitis or ulcerative colitis for more than 10 years.

RESUMO Em pacientes com colite ulcerativa refratária à terapia médica, a proctocolectomia total e anastomose de bolsa ileal-anal posterior é a terapia cirúrgica padrão. Uma das possíveis complicações é a pouchite. Dependendo da duração dos sintomas, pode ser classificado como aguda, recorrente ou crônica. Esta última, de acordo com a resposta à terapia, pode ser definida como dependente de antibióticos ou refratária a eles. O tratamento da pouchite baseia-se no uso de antibióticos e probióticos. A thiopurina e a terapia biológica têm sido sugeridas em pacientes com pouchite refratária. Um cuidado especial deve ser tomado na vigilância endoscópica desses pacientes, especialmente se apresentarem fatores de risco, como displasia ou câncer colorretal anterior, colangite esclerosante primária ou colite ulcerativa por mais de 10 anos.

Reservoritis/pouchitis: fisiopatología y manejo basado en la evidencia / Reservoirs/pouchitis: physiopathology and evidence-based management

Pouchitis is a frequent complication following proctocolectomy with ileal pouch-anal anastomosis, mainly in patients with ulcerative colitis. Though etiology is still unknown, evidence shows that there is a relation with host microbiota. Management of chronic refractory pouchitis is challenging, and current evidence showns that the use of biologic agents may have a favourable response.

La reservoritis es una complicación frecuente en pacientes en quienes se ha practicado una proctocolectomía con reservorio ileal, principalmente en pacientes con colitis ulcerosa. La etiología si bien es desconocida, la evidencia actual apunta a que exista una relación con la microbiota del huésped. La reservoritis refractaria crónica es un desafio en el manejo y actualmente ha surgido evidencia que apunta que el uso de biológicos puede tener una respuesta favorable.

Resultados inmediatos y alejados del reservorio ileal con anastomosis reservorio-anal practicado en forma simultánea o diferida con la proctocolectomía en pacientes portadores de colitis ulcerosa / Ileal pouch-anal anastomosis performed simultaneously or delayed with the proctocolectomy: short and long-term results in patients with ulcerative colitis

Objetivo: Analizar las diferencias en los resultados quirúrgicos entre 2 grupos en colitis ulcerosa: proctocolectomía, reservorio ileal y anastomosis reservorio-anal (RIARA), simultáneo con la proctocolectomía (grupo 1) o diferido (grupo 2). Material y método: Estudio retrospectivo en 126 pacientes sometidos a RIARA. En todos los pacientes se confeccionó un RIARA en «J¼, excepto en 4 que se hizo en «S¼. Todos fueron protegidos con ileostomía. Complicaciones Clavien-Dindo II-V fueron registradas. Resultados: Pacientes con una mediana de edad de 37 años (12-61), 72 eran de género femenino (57%). Se practicó proctocolectomía y RIARA en 24 pacientes (19%) y proctectomía y RIARA en 102 (81%). Se observaron complicaciones postoperatorias en 19 pacientes (13%). Infección de la herida y sepsis pelviana, en 4% respectivamente, fueron las más frecuentes. Tres pacientes fueron reintervenidos: 2 por hemoperitoneo y uno por necrosis isquémica del reservorio. No hubo mortalidad postoperatoria. No se observó diferencia significativa en la morbilidad postoperatoria entre los grupos. Se observaron complicaciones a largo plazo en 48 pacientes (38%): obstrucción intestinal en 18 pacientes (14%), fístula reservorio-vaginal (FRV) en 9 (12,5%), y reservoritis crónica en 8 (6,9%) fueron las más frecuentes. Al comparar los 2 grupos, se observó mayor frecuencia de FRV en el grupo 1 (p = 0,02). Conclusión: En este estudio no se demostró diferencia en la morbilidad postoperatoria entre el grupo 1 y 2. En los resultados alejados hubo mayor frecuencia significativa de FRV en el grupo 1.

Aim: To compare the surgical results of both groups: Simultaneous with the proctocolectomy (SRP) (group 1) or delayed after colectomy (DRP) (group 2). Material and methods: Retrospective study on 126 patients submitted to RP. All patients had a J-pouch, except 4 S. All of them protected with a loop ileostomy. The median time between colectomy and IPAA was 5 months (4-6 range). Clavien-Dindo II-V complications were registered. Results: 126 patients had IPAA. Age median 37 years (12-61 range); 72 (57%) women. SRP in 24 (19%) and DRP was performed in 102 (81%). Postoperative complications were recorded in 19 patients (13%). Wound infection and pelvic sepsis were observed in 4% each. Three patients needed early reoperation: two for hemoperitoneum and one for ischemic necrosis of the pouch. There was no post-operative mortality. No significant difference in 30 days postoperative complication rate was found between SRP and DRP. On long-term follow-up: Intestinal obstruction in 18 patients (14%), pouch-vaginal fistula (PVF) in 9 (12.5%) and chronic pouchitis in 8 (6.9%) were the most common complications. PVF was significantly more frequent on group 1. Conclusion: In this series, no significant difference was found in the early surgical results between group 1 and 2. In the long term, PVF was significantly more common in group 1.

Surgical complications and metachronous rectal cancer risk in patients with classic familial adenomatous polyposis / Complicações cirúrgicas e risco de câncer retal metacrônico em pacientes com polipose adenomatosa familiar clássica

INTRODUCTION: Familial adenomatous polyposis (FAP), an autosomal dominant disease characterized by development of numerous adenomatous polyps in the colon and rectum, is caused by germline mutations in the Adenomatous Polyposis Coli (APC) gene. METHODS: To determine the surgical morbidity in patients with classical familial adenomatous polyposis and determine the incidence of metachronous colorectal cancer (CRC) in those undergoing total colectomy (TC) with ileorectal anastomosis or restorative total proctocolectomy (TPC) and ileal pouch anal anastomosis. We analyzed patients with familial adenomatous polyposis who received treatment and regular follow-up at the A.C. Camargo Cancer Center from 1994 to 2013. RESULTS: Operative complications occurred in 22 patients (34.3%), 16 (25%) being early complications and 8 (12.5%) late complications. No mortality occurred as a result of postoperative complications. The incidence of metachronous rectal cancer after total proctocolectomy was 2.3% and after total colectomy 18.18% (p = 0.044). CONCLUSIONS: In order to provide better quality of life for individuals with familial adenomatous polyposis, total colectomy is commonly offered, as this simple technique is traditionally associated with lower rates of postoperative complications and better functional outcomes. However, it has become a less attractive technique in patients with familial adenomatous polyposis in its classical or diffuse form, since it has a significantly higher probability of metachronous rectal cancer. (AU)

INTRODUÇÃO: Polipose adenomatosa familiar (PAF), uma doença autossômica dominante caracterizada pela formação de numerosos pólipos adenomatosos no cólon e reto, é causada por mutações da linha germinativa no gene da polipose adenomatosa do cólon (PAC). MÉTODOS: Para determinar a morbidade cirúrgica em pacientes com PAF clássica e determinar a incidência de câncer colorretal (CCR) metacrônico naqueles pacientes submetidos à colectomia total (CT) com anastomose íleo-retal ou submetidos à proctocolectomia restaurativa (PCT) e anastomose bolsa ileal-anal, foram analisados pacientes com PAF que foram tratados e tiveram acompanhamento periódico no A. C. Camargo Cancer Center de 1994 até 2013. RESULTADOS: Ocorreram complicações cirúrgicas em 22 pacientes (34,3%); 16 (25%) tiveram complicações precoces e 8 (12,5%) complicações tardias. Não houve mortes como resultado de complicações pós-operatórias. A incidência de câncer de reto metacrônico após PCT foi de 2,3% e após CT foi de 18,18% (p = 0,044). CONCLUSÕES: A fim de proporcionar melhor qualidade de vida para os pacientes com PAF, CT é comumente oferecida, pois esta técnica simples está tradicionalmente associada com menores percentuais de complicações pós-operatórias e melhores resultados funcionais. No entanto, CT se tornou uma técnica menos atraente em pacientes com PAF em sua forma clássica ou difusa, uma vez que traz consigo uma probabilidade significativamente maior de câncer retal metacrônico. (AU)

Surgical treatment of familial adenomatous polyposis: ileoretal anastomosis or restorative proctolectomy? / Tratamento cirúrgico da polipose adenomatosa familiar: anastomose íleo-retal ou bolsa ileal?

Context: Controversy regarding the best operative choice for familial adenomatous polyposis lays between the morbidity of restorative proctocolectomy and the supposed mortality due to rectal cancer after ileorectal anastomosis. OBJECTIVES: To evaluate operative complications and oncological outcome after ileorectal anastomosis and restorative proctocolectomy. Methods: Charts from patients treated between 1977 and 2006 were retrospectively analyzed. Clinical and endoscopic data, results of treatment, pathological reports and information regarding early and late outcome were recorded. Results: Eighty-eight patients - 41 men (46.6 percent) and 47 women (53.4 percent) - were assisted. At diagnosis, 53 patients (60.2 percent) already had associated colorectal cancer. Operative complications occurred in 25 patients (29.0 percent), being 17 (19.7 percent) early and 8 (9.3 percent) late complications. There were more complications after restorative proctocolectomy (48.1 percent) compared to proctocolectomy with ileostomy (26.6 percent) and ileorectal anastomosis (19.0 percent) (P = 0,03). There was no operative mortality. During the follow-up of 36 ileorectal anastomosis, cancer developed in the rectal cuff in six patients (16,6 percent). Cumulative cancer risk after ileorectal anastomosis was 17.2 percent at 5 years, 24.1 percent at 10 years and 43.1 percent at 15 years of follow-up. Age-dependent cumulative risk started at 30 years (4.3 percent), went to 9.6 percent at 40 years, 20.9 percent at 40 years and 52 percent at 60 years. Among the 26 patients followed after restorative proctocolectomy, it was found cancer in the ileal pouch in 1 (3.8 percent). Conclusions: 1. Operative complications occurred in about one third of the patients, being more frequently after the confection of ileal reservoir; 2. greater age and previous colonic carcinoma were associated with the development of rectal cancer after ileorectal anastomosis; 3. patients treated...

Contexto: As controvérsias quanto a melhor forma de tratamento da polipose adenomatosa familiar confrontam a morbidade da proctocolectomia restauradora contra a suposta mortalidade decorrente de câncer retal após íleo-reto anastomose. OBJETIVOS: Avaliar as complicações operatórias e a evolução oncológica dos pacientes submetidos a íleo-reto anastomose ou proctocolectomia restauradora. Métodos: Analisaram-se os dados dos doentes tratados entre 1977 e 2006, procedendo ao levantamento de dados clínicos gerais, endoscópicos, resultados do tratamento cirúrgico, dados anatomopatológicos e informações sobre a evolução precoce e tardia dos pacientes. Resultados: Foram tratados 88 pacientes, sendo 41 homens (46,6 por cento) e 47 mulheres (53,4 por cento). Por ocasião do diagnóstico, 53 pacientes (60,2 por cento) já tinham câncer colorretal associado à polipose. Registraram-se complicações operatórias em 25 doentes (29,0 por cento) dentre os 86 operados, sendo 17 (19,7 por cento) precoces e 8 (9,3 por cento) tardias. Houve mais complicações após proctocolectomia restauradora (48,1 por cento) em comparação às proctocolectomias com ileostomia (26,6 por cento) e íleo-reto anastomose (19,0 por cento) (P = 0,03). Não houve mortalidade operatória. O risco cumulativo de câncer retal após íleo-reto anastomose foi de 17,2 por cento após 5 anos, 24,1 por cento após 10 anos e 43,1 por cento após 15 anos de seguimento pós-operatório. Já o risco cumulativo idade-dependente começou a existir a partir de 30 anos (4,3 por cento), passando para 9,6 por cento aos 40 anos, 20,9 por cento aos 40 anos e 52 por cento aos 60 anos. Entre os pacientes submetidos a bolsa ileal com seguimento (26), apenas 1 doente (3,8 por cento) desenvolveu câncer na bolsa ileal. Conclusões: 1. Ocorreram complicações operatórias em cerca de 1/3 dos pacientes, sendo mais frequentes após a confecção de bolsa ileal; 2. idade maior, tempo de seguimento e câncer colônico prévio se associaram...

Inflamación del remanente rectal (Cuffitis) posterior a una proctocolectomía total con reservorio ileal: reporte de caso y enfoque actual de tratamiento / Rectal cuff inflammation (Cuffitis) after total proctoclectomy with ileal pouch anal anastomosis: case report and current approach to treatment

La alternativa quirúrgica de elección para los pacientes con colitis ulcerosa (CU) refractaria al tratamiento médico es la proctocolectomía total con una reconstrucción a través de la confección de un reservorio ileal y una anastomosis ileo-anal. Esta cirugía permite la curación de la enfermedad con buen resultado funcional. A pesar de las demostradas ventajas, no está exenta de complicaciones. Una de las complicaciones es la inflamación sintomática del remanente rectal o cuffitis. Esta genera controversias importantes acerca de la técnica que debe utilizarse para la anastomosis ileo-anal debido a la asociación que presenta con la preservación de mucosa rectal en técnicas de sutura mecánica. El presente trabajo propone la revisión del tema y el análisis del enfoque actual de tratamiento, basada en un caso clínico.

Restorative proctocolectomy with ileal pouch is the treatment of choice in the majority of patients with ulcerative colitis (UC) refractory to medical treatment. This surgery can cure the disease with good functional outcome. Despite the proven benefits, is not without complications. One of the complications is symptomatic inflammation of the rectal remnant or cuffitis. This generates significant controversy about the technique to be used for the Ileo-anal anastomosis because of the association presented to the preservation of rectal mucosa in mechanical suture techniques. This paper proposes the review of the topic and analysis of the current approach to treatment based on one case.

Doença de Crohn em recém-nascido / Crohn's disease in newborn baby: report of case

A Doença de Crohn ocorre, principalmente, em adultos jovens. Sua incidência entre membros da mesma família aproxima-se de 10 por cento. Atualmente, os sintomas aparecem cada vez mais precocemente em crianças e adolescentes. No caso que relatamos, um paciente aos três dias de vida iniciou quadro de extensa lesão perianal, desenvolvendo, ulteriormente, outras complicações da Doença de Crohn. Esta criança apresentava, em sua história familiar, dois irmãos com a mesma doença, porém que não sobreviveram às complicações abdominais pós-operatórias. Chamou-nos a atenção a precocidade e a intensidade com que tais manifestações se apresentaram, implicando em sérias conseqüências ao paciente, já na primeira semana de vida.

Crohn's Disease occurs, mainly, in young adults. The incidence of this disease in other members of the same family is nearly 10 percent. Nowadays the symptoms start precociously in children and teenagers. In the present case, the perianal disease was detected in three days old baby who developed different complications throughout his life. The child had two siblings with the same problems, but none of them survived after post-operative abdominal complications.

Polipose gastroduodenal em doentes com polipose adenomatosa familiar Pós-Retocolectomia / Gastroduodenal polyposis in patients with familiar adenomatous polyposis after rectocolectomy

RACIONAL: As manifestações extracólicas, como os pólipos gastroduodenais e o tumor do duodeno, são fatores que influenciam a morbimortalidade dos doentes com polipose adenomatosa familiar no seguimento pós-retocolectomia total. OBJETIVO: Investigar a freqüência destas alterações em doentes com polipose adenomatosa familiar e verificar a eficácia do rastreamento endoscópico. MÉTODO:No período de 1984 a 2005, 62 doentes com polipose adenomatosa familiar pós-retocolectomia foram estudados retrospectivamente pelo Grupo de Coloproctologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas, SP. O tempo de seguimento médio pós-operatório foi de 81,9 meses, sendo que em 53 (85,5 por cento) foi possível analisar a ocorrência de pólipos gastroduodenais. RESULTADOS: Dos 53 doentes em seguimento, 27 (50,9 por cento) apresentavam pólipos gastroduodenais. Em 8 (15,4 por cento) os pólipos adenomatosos eram gástricos, 14 (27 por cento) pólipos duodenais e 5 (9,6 por cento) pólipos gástricos e duodenais. Dois doentes (3,8 por cento) desenvolveram adenoma duodenal com displasia de alto grau. E outro (1,9 por cento), adenocarcinoma em papila duodenal. CONCLUSÃO: O rastreamento endoscópico, desta forma, é de grande importância e o objetivo é detectar, o mais precocemente possível, os casos de adenocarcinoma duodenal e pólipos gastroduodenais com displasia de alto grau.

BACKGROUND: The extra colonic manifestations, like upper gastrointestinal tract polyps and duodenal cancer are disorders that affect long-term morbidity and mortality of patients with familial adenomatous polyposis, after rectocolectomy. AIM: To describe the frequency of those disorders in patients with familial adenomatous polyposis and to review efficacy of upper gastrointestinal endoscopic surveillance. METHODS: Between 1984 and 2005, 62 patients with familial adenomatous polyposis after rectocolectomy, were studied retrospectively, by Coloproctology Group, Medical Sciences Faculty, State University of Campinas, SP, Brazil. It was possible to analyze 53 patients (85,5 percent) in this study. RESULTS: Twenty seven (50,9 percent) of 53 patients in follow-up had upper gastrointestinal polyps. Eight (15,4 percent) had gastric adenomatous polyps, 14 (27 percent), duodenal polyps and 5 (9,6 percent) duodenal and gastric polyps. Two patients (3,8 percent) had adenomatous duodenal polyps with severe dysplasia, and one (1,9 percent) had adenocarcinoma of the duodenal papilla. CONCLUSION: The upper gastrointestinal endoscopic surveillance has importance and the aim is to detect as early as possible the occurrence of duodenal adenocarcinoma and upper gastrointestinal polyps with severe dysplasia.

Tratamiento quirúrgico de la rectocolitis ulcerativa: ¿Qué podemos ofrecerle a nuestros pacientes?

Introducción: La Rectocolitis Ulcerativa es una enfermedad cuyo tratamiento primordial es médico, pero la cirugía es una opción terapéutica eventualmente considerada. El objetivo de esta revisión es exponer la evolución histórica, indicaciones y resultados alcanzados con las intervenciones quirúrgicas propuestas para pacientes con Rectocolitis Ulcerativa. Métodos: Análisis de artículos pertinentes al tratamiento quirúrgico de la RCU identificados electrónicamente a través de búsqueda en PubMed, Lilacs y revisión manual de las referencias bibliograficas de dichos artículos. Resultados: Las indicaciones quirúrgicas de pacientes con Rectocolitis Ulcerativa incluyen: situaciones de emergencia, displasia, cáncer colorrectal y efectos secundarios inmanejables o falta de respuesta al tratamiento médico. En las situaciones de emergencia la opción más adecuada es la colectomía subtotal o total con ileostomía terminal. La cirugía electiva cuenta con diferentes opciones. La operación más funcional es la Proctocolectomía con Reservorio Ileoanal. Esta intervención ha sido ampliamente practicada, estudiada y aceptada mundialmente y brinda al paciente resultados satisfactorios. Conclusiones: La evolución del tratamiento quirúrgico para la Rectocolitis Ulcerativa ha sido contínua. Actualmente, las intervenciones quirúrgicas propuestas ofrecen una calidad de vida adecuada. Sin embargo, ya que las opciones quirúrgicas modifican la fisiología intestinal, debe discutirse ampliamente con el paciente las expectativas postoperatorias. Dado que en nuestro país es baja la frecuencia de enfermedades inflamatorias intestinales, parece razonable establecer grupos de trabajo multidisciplinarios, que conjuguen atención medico-quirúrgica, nutricional, de enfermería y psicológica, para ofrecer a estos pacientes la mejor y más actualizada atención posible.

Background: treatment for Ulcerative Colitis is mainly medical; however, surgery is a suitable option for some patients. The aim of this review article is to delineate the historical development of surgery for ulcerative colitis, and to analyze current surgical indications and outcomes of surgical options for patients with Ulcerative Colitis. Methods: Review of suitable articles identified electronically using PubMed and Lilacs search and manual checking of the references of the cited articles. Results: Surgical indications are: emergency conditions, dysplasia-colorectal cancer and unacceptable secondary effects or lack of response to medical treatment. Either subtotal or total colectomies with terminal ileostomy are the most accepted options for those patients in an emergency situation. There are several proposed elective interventions, and, currently, restorative proctocolectomy with the creation of an ileoanal reservoir is the best option. Such intervention has been widely performed through different centers with satisfactory results worldwide. Conclusions: Surgical treatment for Ulcerative Colitis has evolved continuously. Currently, surgical options can bring to the patients an adequate quality of life. Since surgical interventions modify intestinal physiology, physicians, surgeons and patients should have a comprehensive preoperative discussion, so the patients may have reasonable postoperative expectations. On the other hand, in areas with low prevalence of Inflammatory Bowel Disease, such as Venezuela, seems reasonable to establish multidisciplinary teams to offer the best care for patients with such diseases.

Experiencias clinicoquirúrgicas con 51 bolsas ileales / Clinical and surgical experiences with 51 ileal bags

Antecedentes. La proctocolectomía total con reconstrucción con bolsa ileal (BI) se ha convertido en la cirugía para pacientes con colitis ulcerativa (CU) y las diferentes formas de síndromes polipósicos (SP). Propósito. Informar los resultados de ocho años de experiencia con la proctocolectomía total por enfermedad inflamatoria intestinal y SP y la reconstrucción con bolsa ileal. Métodos. Se evaluaron en forma prospectiva 51 pacientes sometidos a BI desde 1994 al 2002. El diagnóstico histopatológico preoperatorio fue CU (n=39), síndromes de poliposis múltiple (n=10), dos enfermos con Crohn y una resección masiva de colon por cáncer. Se obtuvo información referente a los aspectos demográficos, tipo y duración de la enfermedad, cirugías previas e indicación de la cirugía. Se registraron las complicaciones tempranas (30 días después de la cirugía) y las tardías. El seguimiento incluye la funcionalidad de la bolsa al año, el examen físico, y las biopsias de la bolsa y la zona de transición cuando ésta estaba indicada. Resultados. Los 51 pacientes (24 mujeres) tuvieron un seguimiento promedio de 44,5 meses (rango de 12 a 108 meses), el diagnóstico histopatológico se cambió en dos pacientes de CU a EC. La tasa de mortalidad global fue de 2% (un paciente), relacionada con sepsis perianal 45 meses después de realizarle la BI. La morbilidad global es de 65% (73 complicaciones en 33 pacientes; tempranas 39% y tardías en 49%), la estancia promedio fue de 8,9 días (rango de 6 a 25 días). Las complicaciones más frecuentes fueron las obstructivas en 36% (20% tempranas), sépticas en 22% (18% tempranas) y las reintervenciones en 26% (15% tempranas). La complicación tardía, más frecuente fue la "pouchitis" en 29,4%. La bolsa ileal se retiró en un paciente (2%) y en todos los demás es funcional. El índice de satisfacción fue de bueno-excelente en 82%, regular en 16% y malo en 2%. Conclusiones. La proctocolectomía total con reconstrucción con bolsa ileal es un procedimiento seguro, con baja mortalidad pero con una alta morbilidad. Aunque la morbilidad total es apreciable, los resultados funcionales son buenos y la satisfacción del paciente es aceptable.

Background: Restorative proctocolectomy and ileal pouch (IP) has become an established surgery for patients with chronic ulcerative colitis and poliposis syndromes. Purpose: The authors report the results of 8-year experience of restorative proctocolectomy and IP. Methods: Chart review was performed for 51 patients undergoing IP from 1994 through 2002. Preoperative histopathologic diagnoses were ulcerative colitis (n=39), poliposis syndromes (n=10), 2 Crohn disease and 1 patient with colorectal cancer and extended resection. Information was obtained regarding patient demographics, type and duration of diseases, previous operations, and indications for surgery. Early (within 30 days after surgery) and late complications were noted. Follow-up included an annual function, physical examination, and biopsies of the pouch and anal transitional zone when were indicated. Results: Of the 51 patients (24 women) with mean follow-up time of 44,5 months (range 12-108 months), histopathologic diagnoses of ulcerative colitis were changed for Crohn’s disease in 2 patients. The overall mortality rate was 2% (1 patient), one death was related to perineal sepsis 45 months after ileal pouch. The overall morbidity rate was 65% (73 complications in 33 patients; early 39%; late 49%) the mean hospitalary stancy was 8,9 days (range 6-25 days). Small bowel obstruction, septic complication and reoperation rates were 36%, 22% and 26%, respectively. The most frecuent late complication was "pouchitis" (31,8%). The ileal pouch was removed in 1 patient, and it is functional in 50 (98%). There was a satisfactory index with 82% with excelent-good results, and 16% and 2% with regular and bad results. Conclusions: Restorative proctocolectomy with an IP is a safe procedure, with low mortality and major morbidity rates. Although total morbidity rate is appreciable, functional results generally are good and patient satisfaction is acceptable.

Ileostomia continente com preservação da papila íleo-cecal

The authors report three cases of patients submitted to definitive continent ileostomy and three cases of temporary continent ileostomy. Five of them had inflammatory bowel disease and one had familial adenomatous polyposis associated to lower rectal cancer. It was used the continent ileostomy technique, keeping the ileocecal sphincter and a small border of cecal wall. The ileal flow in the first week of post operative does not overflow 430 ml per day. They conclude that the continent ileostomy is useful procedure in selected cases when we need to keep an efficient control of the intestinal effluent.

Seis doentes foram submetidos a ileostomia continente com preservação da papila íleo-cecal, como tempo cirúrgico complementar à proctocolectomia e à colectomia totais, para tratamento de doença inflamatória intestinal e polipose adenomatosa familiar, associada a pólipo degenerado no reto inferior. A técnica utilizada de ileostomia continente preserva a papila íleo-cecal e uma pequena borda circular de parede cecal exteriorizados na parede abdominal. O débito ileal, na primeira semana pós-operatória, não ultrapassou 430 ml/dia, não houve complicações do procedimento e o aspecto estético ficou excelente. Conclui-se que a ileostomia continente com preservação da papila íleo-cecal, definitiva ou temporária, é um procedimento cirúrgico eficiente, em casos selecionados, quando se deseja manter um controle eficaz do efluente intestinal.