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.

An exploratory analysis of the epidemiology and surgical management of perforated diverticular disease over a two-year period at a Referral Centre in the Caribbean / Análisis exploratorio de la epidemiología y el tratamiento quirúrgico de la enfermedad diverticular perforada durante un período de dos años en un Centro de Remisión en el Caribe

OBJECTIVE: We present an exploratory analysis of data collected on perforated diverticular disease (PDD) in Barbados and suggest possible areas for further study. SUBJECTS AND METHODS: All cases of perforated diverticular disease treated at the Queen Elizabeth Hospital (QEH) Barbados, between January 1, 2005 and December 31, 2006 were reviewed. The patient's age, gender, location of disease, Hinchey stage, operative procedure, rate of colostomy reversal, length of hospitalization, incidence of peri-operative morbidity and postoperative mortality were analysed using principal components analysis (PCA). RESULTS: Fourteen cases of PDD were treated at the QEH during this period. Six (43%) of the patients had perforated right-sided diverticulitis (PRSD). In the PCA, Dimensions 1 and 2 were the two dimensions examined, as they both had Eigenvalues over 1. Dimension 1 can be taken as an indicator of the intensity of the disease. On dimension 2, length of hospitalization had the highest component loading (0.875). The mean hospital stay was 10.6 days in PRSD, 9.5 in left-sided perforations with primary anastomosis, and 16.2 days for those with a Hartmann's procedure. The overall peri-operative morbidity was 28% and there was no mortality in the series. CONCLUSION: This preliminary study seems to show a relatively high incidence of PRSD in a predominantly Afro-Caribbean population. More research is needed to determine the exact aetiology of this disease. In our experience, primary anastomosis in carefully selected patients with either PRSD or perforated left-sided diverticulitis (PLSD) may result in shorter hospitalization.

OBJETIVO: Presentamos un análisis exploratorio de la enfermedad diverticular perforada (EDP) en Barbados, y sugerimos posibles áreas de análisis ulterior. SUJETOS Y MÉTODOS: Se revisaron todos los casos de enfermedad diverticular perforada tratados en el Hospital Queen Elizabeth (QEH) de Barbados, entre enero 1 de 2005 y diciembre 31 de 2006. Mediante el análisis de componentes principales (ACP), se analizaron los siguientes: edad del paciente, género, localización de la enfermedad, estadio de Hinchey, procedimiento operatorio, tasa de colostomía inversa, tiempo de hospitalización, incidencia de morbilidad perioperatoria, y mortalidad postoperatoria. RESULTADOS: Catorce casos de EDP fueron tratados en el HQE durante este período. Seis (43%) de los pacientes presentaban diverticulitis del lado derecho perforada (DLDP). En el ACP, las dimensiones 1 y 2 fueron las dos dimensiones examinadas, ya que ambas tenían valores propios por encima de 1. La dimensión 1 puede tomarse como indicador de la intensidad de la enfermedad. En la dimensión 2, el tiempo de hospitalización tuvo la carga de componente más alta (0.875). La estadía promedio en el hospital fue de 10.6 días en los casos de DLDP, 9.5 en las perforaciones del lado izquierdo con anastomosis primaria, y 16.2 días para aquellos con procedimiento de Hartmann. La morbilidad perioperatoria fue 28% y no hubo mortalidad en la serie. CONCLUSIÓN: Este estudio preliminar parece mostrar una incidencia relativamente alta de DLDP en una población predominantemente afro-caribeña. Se necesita más investigación a fin de determinar la etiología exacta de esta enfermedad. En nuestra experiencia, la anastomosis primaria en pacientes cuidadosamente seleccionados, que sufren de DLDP o padecen diverticulitis del lado izquierdo perforada (DLIP), puede tener por resultado una hospitalización más corta.

Intestinal injury from blunt abdominal trauma: a study of 47 cases

To determine the cause, presentation, anatomical distribution, diagnostic method, management and outcome of intestinal injuries from blunt abdominal trauma. The study included 47 patients who underwent laparotomy for intestinal injuries from blunt abdominal trauma over a period of 4 years. A retrospective study was conducted and the patients were analyzed with respect to the cause, presentation, anatomical distribution, diagnostic methods, associated injuries, treatment and mortality. 47 patients with 62 major injuries to the bowel and mesentery due to blunt abdominal trauma were reviewed. The male to female ratio was 8.4:1 and the average age was 34.98 years. There were 44 injuries to the small intestine including 1 duodenal injury, 11 colonic injuries and 7 injuries to the mesentry. 26 patients were injured in road traffic accidents. Out of 29 patients with intestinal perforation, free peritoneal air was present on plain abdominal and chest radiography in 23 patients. 18 patients underwent laparotomy on the basis of clinical findings alone. The commonest injury was a perforation at the antimesentric border of the small bowel. Treatment consisted of simple closure of the perforation, resection and anastomosis and repair followed by protective colostomy for colonic perforations. 3 [6.38%] deaths were recorded, while 8 [17.02%] patients developed major complications. Although early recognition of intestinal injuries from blunt abdominal trauma is difficult, it is very important due to its tremendous infectious potential. Intestinal perforations are often associated with severe injuries which are probably be the determining factors in survival

Non-biliary mishaps during laparoscopic cholecystectomy.

BACKGROUND: The most important complications of laparoscopic cholecystectomy (LC) are biliary tract injuries. Non-biliary complications can be equally devastating, but have received less attention in literature. METHODS: The case files of 1748 patients who underwent LC over a period of seven years (1997-2003) in our department were retrospectively reviewed to identify non-biliary complications and their management. RESULTS: Nine patients (0.5%) sustained significant non-biliary injury while undergoing LC. The commonest was duodenal perforation during dissection of the Calot's triangle (3 cases). Other complications included diaphragmatic injury (2 cases), and small bowel injury while inserting the umbilical port, right external iliac artery injury during insertion of Veress needle, portal vein injury during dissection, and liver laceration while using a delivery system to extract the gall bladder (1 each). All these complications were detected and managed intra-operatively. During the same period, 10 patients sustained biliary injury. CONCLUSION: Intra-operative non-biliary injuries during LC occur as frequently as biliary injuries, and can be life-threatening and difficult to manage.

Perforated versus non perforated appendicitis: a comparative study

Two hundred and fifty eight cases of acute appendicitis were studied at the Surgical Department of Peoples' Medical College, Nawabshah between May 1989 to April 1995. Of these 85 [32.95%] patients had perforated and 173 [67.05%] non-perforated appendicitis. Majority of patients were males [223-86.43%] and in the third decade of life [122-47.29%]. Wound sepsis was the most common post-operative complication accounting for 11.56% cases in the non-perforated and 84.71% cases in the perforated group. The mean hospital stay was 17.47 days in the perforated group and 8.05 days in the non-perforated group. Transperitoneal drain was put in 44 [51.76%] perforated cases but did not work effectively as discovered on subsequent ultrasound examination. The overall mortality was 0.78% [2 cases, both in the perforated group]. Multiple factors were responsible for the high rate of perforation, like lack of health facilities, improper referral system, public ignorance about the disease and reluctance for surgery

Resection anastomosis the best surgical procedure for the enteric perforation

Perforation of the small gut during typhoid fever is a serious and life threatening problem which carries high morbidity and mortality. 1. To evaluate the male to female ratio of enteric perforation. 2. To know the distribution of disease in different age groups. 3. To evaluate the course of disease regarding the occurrence of the perforation in different weeks of illness. 4. To choose between conservative and operative treatment. 5. To select the best surgical procedure for the enteric perforation to lower the morbidity and mortality. SETTING: 108 cases of enteric perforation who presented at Tehsil Headquarters Hospital Chiniot and District Headquarters Hospital Jhang between January 1991 to January 1994. DESIGN: Case study. PROCEDURES: Simple closure of perforation, wedge resection, wedge resection and modified ileal patch application, resection anastomosis and right hemicolectomy. Male to female ratio was 3.1:1.9. Common age group was between 21-30 years of age. Common period of perforation was third week of illness. Resection anastomosis achieved lowest mortality [3.33%]. CONCLUSIONS: Resection anastomosis was found the best surgical procedure amongst all with lesser chances of leakage and with low morbidity and mortality

Perforación intestinal por fiebre tifoidea (1988-1993). Hospital de Niños Alejandro Mann, de la ciudad de Guayaquil

Se realizó un estudio retrospectivo de 309 casos condiagnóstico de fiebre tifoidea, en pacientes hospitalizados desde 1988-1993 en el Hospital de niños Alejandro Mann de la ciudad de Guayaquil. Se seleccionaron 32 casos en los que la perforación intestinal se presentó como complicación de la enfermedad. Todos fueron intervenidos quirúrgicamente y se encontró que la relación de edad y sexo fue de dos a uno (masculina /femenino) con mayor afectación en edades entre los 4 y los 7 años. El cuadro clínico característico fue de abdomen agudo perforativo; entre los síntomas más importantes se observó náusea (81.20 por ciento) y el signo de la scudida ded los rectos positivo (90.6). La Salmonella tiphi tiene una localización preferencial a nivel del ileon (11 a 20 cm de distancia de la válvula ileo cecal, 50 por ciento) el tipo de perforación fue única en el 68.7 por ciento, durante la segunda semana de evolución de la fiebre tifoidea se presentó el 53.1 por ciento de las perforaciones. Para corroborar el diagnóstico de los casos de perforación intestinal por salmonella thiphi se analizaron ciertos datos de laboratorio, radiológicos e histopatológicos...

Les perforations intestinales d'origine typhique à Brazzaville

Les perforations intestinales d'origine typhique sont encore frequentes et graves au Congo. En 2 ans; de mars 1988 a fevrier 1990; 26 perforations ont ete traitees. Parmi les patients 16/26 soit 61 pour cent ont moins de 20 ans. La perforation siegeait sur la derniere anse ileale entre 5 et 50 cm de la volvule de bauhin. les delais entre l'installation du premier signe et le moment de l'operation varient de 24 heures a 21 jours. Il a ete realise une suture simple; 5 ileostomies laterales; 8 resection-anastomoses; et 12 ilestomies terminales

Spontaneous gastrointestinal perforation in the neonate.

Twenty seven cases of spontaneous gastro-intestinal perforation were treated from 1981 to 1990. Four perforations were in the stomach, 17 in the small bowel and seven in the large bowel. One of them had dual perforation, one in the stomach and another in the duodenum. The exact etiology remained obscure. Various factors observed were maternal obstetric complications, prematurity and perinatal asphyxia. Stress should be laid on early diagnosis by following up 'at risk neonates' thus, giving a better overall survival rate.

Resección primaria en las complicaciones agudas del colon : análisis de los resultados inmediatos / Primary resection of the acute complications of the colon : analysis of the inmediate results

La resección primaria en las complicaciones agudas del colon puede ser realizada en forma electiva o por necesidad. Se analizan 58 pacientes a los que se les efectuaron distintas colectomías por complicaciones agudas entre 1980 y 1989. El número de resecciones del lado izquierdo fue similar para la perforación y la obstrucción (27,6 por ciento); en tanto del lado derecho predominó la obstrucción (22,4 por ciento) sobre la perforación (10,3 por ciento). Las causas más frecuentes fueron: cáncer, enfermedad diverticular y vólvulos. La morbilidad global fue del 37,9 por ciento, y la mortalidad del 32,7 por ciento, que fue similar en cada sector analizada de acuerdo con la resección. En cambio fue del 13,8 por ciento en la obstrucción, 43,5 por ciento en la perforación, 66,6 por ciento en la hemorragia y 100 por ciento en la isquemia.

La obstrucción y/o perforacción en el carcinoma colo-rectal / Obstruction and perforation in colorectal carcinoma

Se presentan 73 pacientes con obstrucción y/o perforación en el carcinoma colo-rectal en el período 1980-1989, experiencia de la División Cirugía del Hospital Municipal C. Argerich y de la práctica privada. Se hacen consideraciones clínico-diagnósticas y del tratamiento quirúrgico. Se enumeran las complicaciones posoperatorias generales, dehiscencias, reintervenciones y mortalidad operatoria. Se enfatiza en los nuevos procedimientos durante la intervención-lavado intraoperatorio y el tubo-puente intracolónico-que tienen por objeto disminuir las complicaciones posoperatorias, sobre todo las fistulas y/o peritonitis

Carcinoma rectocolónico complicado / Complicated colorectal carcinoma

Se operaron 421 pacientes con carcinoma colorrectal entre 1971 y 1986. De ellos el 19% fueron por complicaciones agudas, 14,9% por obstrucción, 2,63% por obstrucción y perforación, 1,4% perforación y 0,23% por obstrucción y hemorragia copiosa. A pesar del elevado porcentaje de tumores con invasión a otros órganos, metástasis a distancia y carcinosis peritoneal (30,86%), pudo resecarse un 78% de los mismos. En este período dominó la cirugía en un tiempo en la localización derecha y la cirugía en etapas en la izquierda. La cirugía resectiva secundaria se realizó en el 76% de los enfermos con carcinomas localizados en el colon izquierdo y la colostomía se cerró en el 59% de éstos. En la estadificación de Dukes predominó la clase C 45,83%, seguida de la B 29,16%, D 32,61% y A 1,38%. Las complicaciones inmediatas fueron del 48%, destacándose las sépticas, cardiovasculares y respiratorias. La mortalidad postoperatoria inmediata fue del 8,6%, sobrevive a los 5 años de operado el 24,69% de los enfermos y menos de 5 años con un promedio de 30 meses el 12%. El porcentaje de sobrevida a los 5 años fue del 38% para la clase B de Dukes, 24% para la clase C y no hubo sobrevida a los 5 años para la clase D.