Sampling reflex as a new manometric marker in the diagnosis of defecation disorders: systematic review

Introduction: Distension of the rectum wall and subsequent momentary relaxation of the internal anal sphincter (IAS) trigger a reflex called the rectoanal inhibitory reflex (RAIR). This same rectal distension causes a reflex contraction of the external anal sphincter (EAS), responsible for conscious continence called rectoanal excitatory reflex (RAER). This set of reflexes are named sampling reflex. Objectives: The sampling reflex is necessary to initiate defecation or flatulence. The objective of this study is to evaluate the sampling reflex and its practical applicability as a manometric marker of the main defecation disorders. Methodology: This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) items. The development method consisted of searching for articles in the research platforms BVS, PubMed, Cochrane Library, SciELO and ScienceDirect and for the selection of articles the Rayyan Platform was used. The articles resulting from the search strategies were added to the platform and five collaborators were invited for the blind selection. Finally, 6 articles were included in the final review. Results: An intact sampling reflex allows the individual to facilitate discrimination between flatus and stool and to choose whether to discharge or retain rectal contents. On the other hand, an impaired sampling reflex can predispose an individual to incontinence. Therefore, it was observed that patients with defecation disorders had an impaired sampling reflex, since it was found that constipated patients have incomplete opening of the IAS, lower amplitude of RAIR and increase of RAER. Most incontinent patients present a failure in the recruitment of the EAS, a decrease in the RAER and an increase in the RAIR, in duration and amplitude. (AU)

Malignant transformation of abdominal wall endometriosis to clear cell carcinoma: case report

ABSTRACT BACKGROUND: Malignant transformation of endometriosis in the abdominal wall is a rare and still poorly understood event. Less than 30 cases have been reported in the worldwide literature. Most cases of solid tumors are report in a previous abdominal scar with malignant transformation of a focus of endometriosis. Presence of lymph node metastases in nearby chains is frequent and is associated with poor prognosis. CASE REPORT: We report a case of a 42-year-old woman with a history of abdominal surgery (Pfannenstiel) to resect abdominal wall endometriosis. Physical examination revealed a solid mass of approximately 10 cm x 6 cm in the anterior wall of the abdomen. Computed tomography (CT) of the abdomen and pelvis showed a heterogeneous, predominantly hypoattenuating expansive formation measuring 10.6 cm x 4.7 cm x 8.3 cm. The patient underwent exploratory incisional laparotomy, block resection of the abdominal mass and lymphadenectomy of the external and inguinal iliac chains. The abdominal wall was reconstructed using a semi-absorbable tissue-separating screen to reconstitute the defect caused by resection of the tumor. Histological evaluation revealed infiltration by malignant epithelioid neoplasia, thus confirming the immunohistochemical profile of adenocarcinoma with clear cell components. Lymphadenectomy showed metastatic involvement of an external iliac chain lymph node. CONCLUSION: Resection of the mass along with the abdominal wall, with wall margins, is the most effective treatment. Reconstruction is a challenge for surgeons. The patient has been followed up postoperatively for eight months, without any evidence of disease to date.

Impact of bariatric surgery on the inflammatory state based on cpr value / Impacto da cirurgia bariátrica no estado inflamatório baseado no valor da pcr

ABSTRACT Background: PCR (C-reactive protein), produced in the liver after stimuli of inflammatory mediators, is determined as a marker of inflammatory activity (adipocytokines) and is present within adipocyte cells; besides being an inflammatory product, many studies have shown to be a predictor of complications. Aim: To determine if the inflammatory state of the obese patient decreases after bariatric surgery, based on pre and post-operative PCR. Methods: A prospective, observational study in patients undergoing Roux-en-Y gastric by-pass surgery followed up for three months after surgery, with serum preoperative CRP in 30, 60 and 90 days after surgery. Results: A total of 19 patients, who had a mean CRP value before the surgical procedure of 0.80(±0.54) mg/dl, were followed, and when compared to the CRP with 30 days of surgery, they presented a significant increase to 2.68 mg/dl (p=0.012). When compared with the PCR of 60 days after the surgical procedure, it was also higher with the value of 3.32 mg/dl (p=0.27). However, at three months after surgery, the CRP showed a decrease when compared to the preoperative mark, with value of 0.45 mg/dl (p=0.0042). Conclusion: Roux-en-Y gastric bypass was able to decrease the chronic inflammation status of these patients, based on the value of CRP, with three months of surgery.

RESUMO Racional: PCR (proteína C-reativa) produzida no fígado após estímulos de mediadores inflamatórios é determinada como um marcador de atividade inflamatória (adipocitocinas) e está presente nos adipócitos; além de ser um produto inflamatório, muitos estudos já mostraram ser ela um preditor de complicações. Objetivos: Determinar se o estado inflamatório do paciente obeso diminui após a realização de cirurgia bariátrica, com base na PCR do pré e pós-operatório. Métodos: Estudo prospectivo, observacional em pacientes submetidos à operação de by-pass gástrico em Y-de-Roux acompanhados por três meses após o procedimento com dosagem sérica da PCR no pré-operatório, 30, 60 e 90 dias após. Resultados: Foram acompanhados 19 pacientes, que apresentaram valor médio da PCR antes do procedimento cirúrgico de 0,80(±0,54) mg/dl e quando comparado à PCR com 30 dias de operados ela apresentou aumento significativo para 2,68 mg/dl (p=0,012). A análise da PCR de 60 dias após o procedimento cirúrgico mostrou-se maior também com o valor de 3,32 mg/dl (p=0,27). Entretanto no 3º mês após ela mostrou queda quando comparado ao pré-operatório (0,45 mg/dl (p=0,0042). Conclusão: O bypass gástrico em Y-de-Roux foi capaz de diminuir o estado de inflamação crônico desses pacientes com três meses de pós-operatório.

Tratamento não cirúrgico bem sucedido de pneumoretroperitônio causado por CPRE / Successful nonsurgical treatment of pneumoretroperitoneum following ERCP

Complicações relacionadas à colangiopancreatografia retrógrada endoscópica (CPRE) incluem pancreatite, hemorragia, colangite e perfuração. A perfuração relacionada à CPRE é infrequente, entretanto apresenta taxas de mortalidades elevadas. O diagnóstico requer um alto grau de suspeição clínica para a detecção precoce para permitir o tratamento adequado da perfuração e melhor prognóstico. O tratamento depende da localização e mecanismo da perfuração. Relatamos um caso de tratamento não operatório de um paciente com extenso retropneumoperitônio após perfuração por CPRE.

Complications related to endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, hemorrhage, cholangitis, and perforation. ERCP-related perforation is uncommon, but mortality rates are high. Diagnosis requires a high clinical suspicion for early detection to allow optimalmanagement of the perforation and a better prognosis. Treatment depends on the location and mechanism and increasingly involves nonoperative management. We report a case of successful nonsurgical treatment of a patient with extensive air involving the peritoneum, retroperitoneum, thorax, mediastinum, and subcutaneous tissues following an ERCP perforation.