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.

Effect of partial rectal resection with transanal stapler in the treatment of rectum protrusion / 中国基层医药

Objective@#To investigate the clinical effect of transanal stapler partial rectal resection for rectocele.@*Methods@#From January 2012 to January 2018, 90 patients with rectocele treated in Changzhi Traditional Chinese Medicine Hospital were divided into control group (45 cases) and observation group (45 cases) according to the operation method.The control group was treated with closed transrectal repair, while the observation group was treated with partial rectal resection with anal stapler.The operative effect, incidence of postoperative complications, recurrence rate, degree of pain after operation, length of hospital stay and cost of treatment were compared between the two groups.@*Results@#The total effective rate of the two groups was 100.0%.The incidence of complications in the observation group was 2.2%(1/45), which was lower than that in the control group [17.8%(8/45)] (χ2=4.444, P=0.035). The recurrence rate in the observation group was 0(0/45), which was lower than that in the control group [13.3%(6/45)] (χ2=4.464, P=0.035). The hospitalization time in the observation group was shorter than that in the control group[(7.01±2.06)d vs.(11.31±2.42)d]. Compared with the control group, the treatment cost of the observation group was higher[(0.836±0.164)×104CNY vs.(0.605±0.136)×104CNY], and the post-operative pain score was lower[(4.24±1.33) vs.(6.45±1.17)](t=9.076, 7.273, 8.369, all P<0.001).@*Conclusion@#Transanal stapler partial rectal resection is effective in the treatment of rectocele, with less complications, lower recurrence rate and less pain after operation, but the cost of treatment is higher.

Effect of partial rectal resection with transanal stapler in the treatment of rectum protrusion / 中国基层医药

Objective To investigate the clinical effect of transanal stapler partial rectal resection for rectocele.Methods From January 2012 to January 2018,90 patients with rectocele treated in Changzhi Traditional Chinese Medicine Hospital were divided into control group (45 cases) and observation group (45 cases) according to the operation method.The control group was treated with closed transrectal repair ,while the observation group was treated with partial rectal resection with anal stapler.The operative effect ,incidence of postoperative complications , recurrence rate,degree of pain after operation ,length of hospital stay and cost of treatment were compared between the two groups.Results The total effective rate of the two groups was 100.0%.The incidence of complications in the observation group was 2.2%(1／45),which was lower than that in the control group [17.8%(8／45)] (χ2 ＝4.444, P＝0.035).The recurrence rate in the observation group was 0(0／45),which was lower than that in the control group [13.3%(6／45)] (χ2 ＝4.464,P＝0.035).The hospitalization time in the observation group was shorter than that in the control group[(7.01 ±2.06)d vs.(11.31 ±2.42)d].Compared with the control group ,the treatment cost of the observation group was higher[(0.836 ±0.164)×104CNY vs.(0.605 ±0.136)×104CNY],and the post-operative pain score was lower [(4.24 ±1.33) vs.(6.45 ±1.17)] ( t＝9.076,7.273,8.369,all P＜0.001).Conclusion Transanal stapler partial rectal resection is effective in the treatment of rectocele , with less complications, lower recurrence rate and less pain after operation ,but the cost of treatment is higher.

Clinical efficacy of laparoscopic and open total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis / 中华消化外科杂志

Objective To compare the short-term and long-term outcomes between laparoscopic and open total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC).Methods The retrospective cohort study was conducted.The clinical data of 150 UC patients who underwent total proctocolectomy with IPAA in the Renji Hospital of Shanghai Jiaotong University between January 2003 and December 2016 were collected.Among 150 patients,87 undergoing laparoscopic total proctocolectomy with IPAA and 63 undergoing open total proctocolectomy with IPAA were respectively allocated into the laparoscopy group and open group.Observation indicators:(1) comparisons of intra-and post-operative situations;(2) postoperative complications;(3) follow-up situation.Follow-up using outpatient examination and telephone interview was performed to detect postoperative recovery and complications up to December 2017.Measurement data with normal distribution were represented as x-±s and comparison between groups was analyzed using the t test.Comparison between groups of count data was analyzed using the chi-square test.Results (1) Comparisons of intra-and post-operative situations:operation time,volume of intraoperative blood loss,time of initial intestinal stoma exsufflation and duration of hospital stay were respectively (306±3) minutes,(197± 12) mL,(62.1±1.8) hours,(8.2±0.4) days in the laparoscopy group and (224±4) minutes,(308±24) mL,(75.6±2.0) hours,(10.1±0.6) days in the open group,with statistically significant difference between groups (t =16.23,4.33,5.03,2.61,P＜ 0.05).All patients discharged successfully from hospital.All the 150 patients underwent stoma reversion of ileum at 3-12 months postoperatively,and the average time in the laparoscopy group and open group was respectively (6.0±5.6) months and (6.0±4.6)months,with no statistically significant difference between groups (t =0.01,P＞ 0.05).(2) Postoperative complications:cases with postoperative wound infection,retention of urine and frequency of defecation ＞ 4 times / day were respectively 2,8,21 in the laparoscopy group and 8,15,29 in the open group,with statistically significant differences between groups (x2 =5.25,4.37,0.96,P＜0.05).The cases with postoperative intestinal obstruction,anastomotic leakage,pelvic infection,pouch infection,pouch-related Crohn's disease and hyperplasia of ileal pouch were respectively 3,10,5,23,2,1 in the laparoscopy group and 8,7,4,24,1,0 in the open group,with no statistically significant differences between groups (x2=3.65,0.11,0.01,0.96,0.17,0.82,P＞0.05).Patients with postoperative complications were improved by acid suppression,fasting,anti-infection and fluid infusion.(3) Follow-up situation:150 patients were followed up for 12-60 months,with a median time of 48 months.There was no abnormality of postoperative anastomotic stoma and intestinal mucosa through comparison of colonoscopy results between pre-operation and 5 year postoperatively.During the follow-up,50 patients had shapeless stool and irregular defecation (times ＞ 4 times / day) at 3 years after stoma reversion of small intestine bypass,including 21 in the laparoscopy group and 29 in the open group,with a statistically significant differences between groups (x2 =4.72,P＜0.05).Eleven and 10 patients in the laparoscopy group and open group had shapeless stool and irregular defecation at 5 years postoperatively,but status were improved compared with the preoperative status,with no statistically significant difference between groups (x2=0.32,P ＞ 0.05).Conclusion The security of laparoscopic total proctocolectomy with IPAA for UC is equivalent to that of open total proctocolectomy,with the better short-term and long-term outcomes.

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.

Factores pronósticos en colitis ulcerosa de reciente diagnóstico / Prognostic factors of ulcerative colitis at the moment of diagnosis

The clinical presentation of ulcerative colitis at the moment of diagnosis is variable, and its clinical course is difficult to predict. It can range from a quiescent to a refractory chronic course that may require hospitalization and surgical procedures. It can also have complications such as colorectal cancer. In this review we discuss the role of demographic, clinical, endoscopic, histological and associated factors, which can help to predict the clinical course of the disease at the moment of diagnosis, and to individualize therapy according to this clinical risk. Accurate identification of patients with a newly diagnosed ulcerative colitis who are at high risk of an unfavorable outcome is still a challenge. However, an effective evaluation allows an early diagnosis, a timely and effective treatment.

Finite element analysis of the effects of individual extralevator abdominoperineal excision for rectal neoplasms below levator hiatus on pelvic floor / 天津医药

Objective To evaluate the effects of individual extralevator abdominalperineal excision (ELAPE) for rectal neoplasms below levator hiatus on pelvic floor by finite element analysis. Methods MIMICS 10.01, GeoMagic Studio 12 and ANSYS Workbench 14.0 were used to deal with magnetic resonance data of 27 healthy nulliparous volunteers'pelvic, and then three types of finite element models were developed:intact models, ELAPE models and individual ELAPE models. The maximum stress in non levator ani tissue under the same load were measured in three types of models, and levator ani 's maximal stresses were measured in intact model and individual ELAPE and their stress distributions under the same pressure were analyzed and compared. Results The maximal stresses of non-levator ani tissue were (1.963±0.061) MPa, (5.127±0.070) MPa and (4.703±0.110) MPa for intact model, ELAPE model and individual ELAPE model respectively. The maximal stress was lower in individual ELAPE model than that in ELAPE model, but which was higher than that of intact model (P<0.01). The high-stress zone was found at the joints with surrounding structures on both sides of intact model and ELAPE model. The high-stress zone was found in front of the joints with surrounding structures on both sides in individual ELAPE model. The maximal stresses of three types of models were found in front of both sides. In intact model levator ani 's maximal stress was (0.812 ± 0.042) MPa, which was higher than that of individual ELAPE model (0.719 ± 0.027) MPa (P<0.01). The high-stress zone of intact model was found in front of the joints on both sides. The maximal stress was showed at ventral ends on both sides. For the individual ELAPE model the high-stress zone was found at the anterior part of the levator ani muscle and the surrounding structure. The maximum stress appeared at the top end of the left and right sides. Conclusion This individual ELAPE is able to decrease the stress of non-levator ani tissue, which suggests that the risk of postoperative pelvic floor hernia is relatively reduced.