Resultados quirúrgicos a corto y mediano plazo por enfermedad de Crohn ileocecal / Short and medium term results of the surgical management of ileocecal Crohn's disease

BACKGROUND: The treatment of Crohn's disease (CD) is based on medical therapy and surgery is reserved for failure of medical management or complications. AIM: To evaluate endoscopic, clinical, and surgical recurrence of CD after surgery. MATERIAL AND METHODS: In a prospectively maintained database, consecutive patients older than 15 years subjected to an ileocecal resection for ileocolic disease from January 2011 to April 2021, were identified. The diagnosis of CD was confirmed with the pathologic report. Patients with less than one year of follow-up were excluded. Information was obtained retrospectively from the database and clinical records. RESULTS: Fourteen patients were identified. The mean age at the time of surgery was 38 years. Surgery was performed at a median of 41.5 months (0-300) after the diagnosis of CD, nine elective and five emergency procedures. In five patients there were four major and two minor postoperative complications, with no anastomotic leakage. Six patients had endoscopic recurrence and seven had clinical recurrence (50%) at a mean of 15 months, one of whom required a second operation. There was no mortality. CONCLUSIONS: After the surgical treatment of CD, the clinical and endoscopic recurrence rate continues to be high.

Tratamiento quirúrgico de las complicaciones en la enfermedad de Crohn / Surgical Treatment of Complicated Crohn's Disease

Introducción: La enfermedad de Crohn consiste fundamentalmente en el control de los síntomas para alcanzar la remisión clínica, cuando esto no se logra o aparecen complicaciones, puede ser necesario el tratamiento quirúrgico. Objetivo: Evaluar los resultados del tratamiento quirúrgico de los pacientes con enfermedad de Crohn complicada. Método: Se realizó un estudio ambispectivo, descriptivo y longitudinal con una muestra de 20 pacientes con enfermedad de Crohn complicada que acudieron a la consulta de cirugía general y gastroenterología del Hospital Clínico Quirúrgico "Hermanos Ameijeiras" y del Instituto de Gastroenterología, en el periodo de enero del 2010 a mayo del 2019. Se recogieron todas las variables demográficas; estudios hemoquímicos, por imágenes y endoscópicos. Resultados: La mayor incidencia de las complicaciones por enfermedad de Crohn se observó en pacientes mayores de 50 años, con un tiempo de evolución entre 1 y 10 años. La fístula y el plastrón fueron las principales causas de tratamiento quirúrgico. La vía de acceso laparoscópica mostró ventajas respecto a la convencional. El desequilibrio hidromineral y la infección del sitio quirúrgico fueron las principales complicaciones postoperatorias, con mortalidad baja. Conclusiones: El tratamiento quirúrgico electivo, planificado y secuencial de pacientes con enfermedad de Crohn complicada ofrece buenos resultados y es posible utilizar la vía de acceso videoasistida con resultados alentadores en pacientes seleccionados(AU)

Introduction: The managment of Crohn's disease consists in symptoms control for achieving clinical remission. When this is not accomplished or complications reappear, surgical treatment may be necessary. Objective: To assess the outcomes of surgical treatment of patients with complicated Crohn's disease. Method: An ambispective, descriptive and longitudinal study was carried out with a sample of twenty patients with complicated Crohn's disease who attended the general surgery and gastroenterology consultation at Hermanos Ameijeiras Clinical Surgical Hospital and the Gastroenterology Institute, in the period from January 2010 to May 2019. All demographic variables were collected, as well as the results of hemochemical, imaging and endoscopic studies. Results: The highest incidence of complications from Crohn's disease was observed in patients over fifty years of age and with an evolution time between one and ten years. Fistula and plastron were the main causes for surgical treatment. The laparoscopic approach showed advantages over the conventional one. Hydromineral imbalance and surgical site infection were the main postoperative complications, with low mortality. Conclusions: Elective, planned and sequential surgical treatment of patients with complicated Crohn's disease offers good outcomes. It is possible to use the video-assisted approach, with encouraging outcomes in selected patients(AU)

Correlação entre níveis séricos de infliximabe e recorrência endoscópica pós-operatória em pacientes com doença de Crohn submetidos a ressecções ileocólicas: uma revisão sistemática / Correlation between trough levels of infliximab and postoperative endoscopic recurrence in crohn's disease patients submitted to ileocolonic resections: a systematic review

ABSTRACT BACKGROUND: The rates of postoperative endoscopic recurrence (PER) in patients with Crohn's disease (CD) are consistent. Anti-TNF therapy has been increasingly used in the postoperative setting, despite the lack of robust data in the literature on the measurement of trough levels and consequences of their use. OBJECTIVE: The aim of this review was to assess trough levels of infliximab (IFX) in CD patients after ileocolonic resections in correlation with the presence of PER. METHODS: We searched for studies that evaluated trough levels of IFX in patients with CD, who underwent ileocaecal resections, and correlated them with the presence of PER. We used MEDLINE through PubMed and CENTRAL Cochrane library databases, and after matching the inclusion criteria, the studies were methodologically evaluated with qualitative analysis of the data. RESULTS: A total of 155 studies were initially identified in the databases search and only four matched the inclusion criteria. They comprised one prospective cohort study, one randomized controlled trial and two retrospective cohort studies, the last one performed in pediatric patients. This evidence suggested the correlation of PER with low trough levels of IFX and the presence of antibodies to the drug. The quality of the evidence generated varied from very low to high, due to the heterogeneity found between the studies and the risks of bias that were identified. CONCLUSION: Low levels of IFX and the presence of antibodies to the drug were directly associated with increased PER rates in patients with CD, who underwent ileocolonic resections. Controlled and randomized clinical trials with adequate methodological quality are warranted to confirm the conclusions from this systematic review.

RESUMO CONTEXTO: As taxas de recorrência endoscópica pós-operatória em pacientes com doença de Crohn (DC) são significativas. A terapia anti-TNF é cada vez mais usada no cenário pós-operatório, apesar da escassez de dados na literatura sobre dosagem de níveis séricos e anticorpos da droga. OBJETIVO: Realizou-se uma revisão sistemática com o intuito de se avaliar níveis séricos de infliximabe (IFX) em pacientes com DC submetidos a ileocolectomia e correlacionar com a presença ou não de recorrência endoscópica da doença. MÉTODOS: Buscou-se por estudos que avaliaram o nível sérico do IFX em pacientes com DC, submetidos a ileocolectomias, correlacionando-os à presença de recorrência endoscópica pós-operatória. Utilizou-se as bases de dados MEDLINE via PubMed e CENTRAL Cochrane Library, e após atingirem os critérios de inclusão, os estudos foram avaliados metodologicamente e foi realizada análise qualitativa dos dados. RESULTADOS: Um total de 155 estudos foram identificados e apenas quatro atingiram os critérios de inclusão. Um era estudo de coorte prospectivo, o segundo era um ensaio clínico randomizado e dois eram estudos de coortes retrospectivas, sendo o último exclusivamente em pacientes pediátricos. As evidências encontradas tendem a confirmar a correlação da recorrência endoscópica a baixos níveis séricos de IFX e presença de anticorpos anti-droga. A qualidade da evidência gerada variou de muito baixa a alta, devido à heterogeneidade encontrada entre os estudos e o risco de viés identificado. CONCLUSÃO: Baixos níveis séricos do IFX e presença de anticorpos contra a droga estão associados a probabilidade aumentada de recorrência endoscópica pós-operatória nos pacientes com DC submetidos a ileocolectomias. Ensaios clínicos controlados e randomizados com adequada qualidade metodológica são necessários para confirmar as conclusões desta revisão.

Rodeando al enemigo: colectomía derecha laparoscópica por enfermedad de Crohn estenosante y fistulizante / Surrounding the enemy: laparoscopic right colectomy for stenosing and fistulizing Crohn's disease

Introducción: La enfermedad de Crohn presenta una incidencia en aumento en los últimos años en los países industrializados. La afectación ileocecal es la forma de presentación más frecuente en esta patología. En una primera instancia los pacientes pueden recibir tratamiento médico, pero un porcentaje significativo de estos puede evolucionar hacia complicaciones de la enfermedad, como estenosis o fístulas. Cuando estas se presentan, deben ser tratadas quirúrgicamente, representando un desafío para el equipo quirúrgico, ya que se trata de pacientes en mal estado general y con un gran compromiso inflamatorio a nivel abdominal que dificulta la correcta identificación de los planos anatómicos. Descripción: Se presenta el caso de un paciente de 84 años que ingresa por guardia en nuestra institución por presentar diagnóstico de enfermedad de Crohn de 10 años de evolución, mal estado general y deterioro nutricional severo. En el examen físico se palpa tumor a nivel de flanco derecho y fosa ilíaca derecha. Entero-TC: Íleon terminal con fístula hacia colon derecho y transverso asociado a cavidad intermedia con colección de 3 cm (Fig.1 y 2). Laboratorio: glóbulos blancos: 12.000/mm3, albúmina: 1,3 gr/dl. Se decide internar al paciente e instaurar tratamiento antibiótico, medidas de sostén y nutrición parenteral total. A las 3 semanas presenta una mejoría en los parámetros nutricionales (albúmina de 2,1 gr/dl) y en el estado general, por lo cual se programa tratamiento quirúrgico de la patología. Se realiza una laparoscopía exploradora donde se evidencia gran tumor inflamatorio que involucra íleon terminal, colon derecho y transverso (fig. 3). Se logra la movilización completa de las estructuras mencionadas, las cuales se exteriorizan por una mini laparotomía mediana supraumbilical y se hace la resección en bloque del tumor inflamatorio, confeccionando una ileostomía terminal y abocando el colon transverso en tejido celular subcutáneo (fig. 4 y 5). La decisión de no realizar una anastomosis primaria se basó en el mal estado nutricional del paciente. Por otro lado, abocar el colon transverso en el tejido celular subcutáneo y no exteriorizar junto a la ileostomía es una técnica que facilita el manejo de la bolsa en el postoperatorio. Sin embargo, consideramos que la alternativa de exteriorizar el colon es válida. Lo que no se debe hacer en ningún caso es abandonar el cabo distal dentro de la cavidad abdominal, dado que, en caso de abrirse el cierre (lo cual es una posibilidad viendo el estado nutricional), conllevaría complicaciones sépticas que podrían requerir una reoperación.El paciente presenta una buena evolución postoperatoria y recibe el alta senatorial al séptimo día postoperatorio sin complicaciones. Conclusiones: El tratamiento quirúrgico de la enfermedad de Crohn representa un desafío para el cirujano. Si es realizado por vía laparoscópica y luego de optimizar al paciente desde el punto de vista clínico y nutricional, se pueden obtener buenos resultados postoperatorios. (AU)

Introduction: Crohn's disease has an increasing incidence in recent years in industrialized countries, and ileocecal involvement is the most frequent in this pathology. Firstly, patients can receive medical treatment, but many of them can present complications of the disease such as stenosis or fistulas. When these appear, they must be treated surgically, representing a challenge for the surgical team because these are patients in poor general condition and with a large abdominal inflammatory compromise that makes it difficult to correctly identify the anatomical planes. Description: We present the case of an 84-year-old patient who is admitted to our institution in Emergency Service for presenting a diagnosis of Crohn's disease of 10 years of evolution, poor general condition and severe nutritional deterioration. Physical examination revealed a palpable tumor at the level of the right flank and right iliac fossa. Entero-CT: Terminal ileum with fistula towards the right and transverse colon and intermediate cavity with a 3 cm collection. Laboratory: White blood cells: 12,000x10-9 / L, Albumin: 1.3 gr / dl. Decision is made to admit the patient, antibiotic treatment, support measures and total parenteral nutrition were instituted. At 3 weeks, the patient shows improvement in nutritional parameters and general condition, for which surgical treatment of the pathology is scheduled. An exploratory laparoscopy is performed where a large inflammatory tumor involving the terminal ileum, right and transverse colon is evidenced. Complete mobilization of the aforementioned structures is achieved, which are externalized by a supraumbilical median mini laparotomy, and enbloc resection of the inflammatory tumor is made, performing a terminal ileostomy and leaving the transverse colon in subcutaneous cellular tissue. We do not perform primary anastomosis given the compromised nutritional state of the patient. On the other hand, transverse colon is left in subcutaneous tissue because taking it out along with the ileostomy sometimes complicates the handling of the ileostomy. However, exteriorization is a possibility, but what a surgeon shouldn't do in no case is to abandon the distal end inside the abdominal cavity, because in case the closure fails (chances are real given the nutritional status) it would probably be a complication that would take a re operation. Patient presented good postoperative evolution, receiving a sanatorial discharge on the seventh postoperative day without complications. Conclusions: Surgical treatment of Crohn's disease represents a challenge for the surgeon. Performed laparoscopically and after optimizing the patient from a clinical and nutritional point of view, good postoperative results can be obtained. (AU)

Predictive factors for loss of response to anti-tnf in crohns disease / Fatores preditivos da perda de resposta aos anti-tnf na doença de crohn

ABSTRACT Background: Anti-TNF drugs are a fundamental part of the treatment of Crohn's disease (CD), so identifying factors related to loss of response is of great importance in clinical practice. Aim: Identify potential factors related to loss of response to anti-TNF agents in Crohn's disease patients. Methods: This is a prospective study of CD patients attending a specialized outpatient clinic using a specific form, including patients with more than one year of follow-up on anti-TNF (Infliximab, Adalimumab or Certolizumab pegol). The information obtained was tabulated and analyzed to identify possible reasons for the loss of response to anti-TNF agents; results were submitted to statistical analysis by chi-square teste considering significant p<0.05. Results: Sixty-four patients were included, most of them females (56.3%), predominant age group between 26 and 55 years, of whom 25 required optimization, 23 remained in remission with the usual dose and interval, and 16 required switch; most of those who needed switch had hematological problems such as anemia and/or had already undergone surgical treatment for CD. Conclusions: Anemia and prior CD surgery have been linked to loss of anti-TNF response.

RESUMO Racional: Os anti-TNF são parte fundamental no tratamento da doença de Crohn (DC), portanto, identificar os fatores relacionados à perda de resposta tem grande importância na prática clínica. Objetivo: Identificar potenciais fatores relacionados a perda de resposta aos agentes anti-TNF em pacientes com DC. Métodos: Trata-se de um estudo prospectivo de pacientes com DC frequentadores de ambulatório especializado por meio de formulário específico, incluindo-se pacientes com mais de um ano de acompanhamento em uso de anti-TNF (Infliximabe, Adalimumabe ou Certolizumabe pegol). As informações obtidas foram tabuladas e analizadas para identificação de eventuais motivos para a perda de resposta aos agentes; os resultados foram submetidos a tratamento estatístico por meio do teste qui-quadrado considerando-se significante p<0,05. Resultados: Foram incluídos 64 pacientes, sendo a maioria do sexo feminino (56,3%), faixa etária predominante entre 26 e 55 anos, dos quais 25 necessitaram otimização, 23 se mantiveram em remissão com a dose e intervalo habituais, e 16 necessitaram troca de medicamento; a maioria dos que necessitaram troca tinham alterações hematológicas como anemia e/ou já haviam sido submetidos a tratamento cirúrgico pela doença. Conclusões: Anemia e operação prévia por DC foram relacionados a perda de resposta aos anti-TNF.

Análise dos fatores de risco e complicações pós-operatórias em pacientes portadores de doença de Crohn / Analysis of risk factors and postoperative complications in patients with crohn's disease

ABSTRACT BACKGROUND: The post-operative complications rate is greater in patients with Crohn's disease than in other abdominal surgeries due to other benign conditions. Prevention and management of such complications are important factors in the care of these patients. OBJECTIVE: The objectives of this research are to analyze the rate of postoperative complications and the major risk factors in patients with Crohn's disease. METHODS: A descriptive and retrospective study based on analysis of medical records of patients with Crohn's disease undergoing ileal and/or colonic resection, which analyzed the main surgical complications and their major risk factors. RESULTS: Forty-four surgical procedures and thirty-seven patients were analyzed. Most were female (56.7%). Postoperative complications were observed in 18 (40.9%) surgeries. The disease duration (P=0.04), the penetrating behavior (P=0.013), the time between diagnosis and the first surgery (P=0.04), malnutrition with low body mass index (BMI), duration of surgery (P=0.016), and the size of the removed specimen (P=0.014) were associated with higher rates of complications. The use of drugs blocking tumor necrosis factor up to eight weeks before surgery was not significantly associated with higher complications rates or increased need for reoperation. CONCLUSION: The complication rate observed in this study is similar to published data. The duration of the disease, the penetrating behavior, the size of the removed specimen, the duration of the surgery, and BMI are important risk factors for perioperative complications in Crohn's disease.

RESUMO CONTEXTO: O índice de complicações pós-operatórias é maior em pacientes com doença de Crohn do que em outras cirurgias abdominais decorrentes de outras afecções benignas. A prevenção e o manejo de tais complicações constituem importante fator no tratamento desses pacientes. OBJETIVO: Os objetivos deste trabalho são analisar a taxa de complicações pós-operatórias e os principais fatores de risco em pacientes portadores de doença de Crohn. MÉTODOS: Estudo descritivo e retrospectivo, baseado na análise dos prontuários dos pacientes com doença de Crohn submetidos a ressecções ileais e/ou colônicas, analisando as principais complicações cirúrgicas e os principais fatores de risco relacionados as mesmas. RESULTADOS: Foram analisados 44 procedimentos cirúrgicos em 37 pacientes. A maioria dos pacientes era do sexo feminino (56,7%). Complicações pós-operatórias foram observadas em 18 (40,9%) cirurgias. A duração da doença (P=0,04), o comportamento penetrante (P=0,013), o tempo entre o diagnóstico e a primeira cirurgia (P=0,04), a desnutrição com baixo índice de massa corpórea (IMC), o tempo de duração da cirurgia (P=0,016), e o tamanho do espécime retirado (P=0,014) estiveram associados a maiores taxas de complicações. O uso de fármacos bloqueadores do fator de necrose tumoral até oito semanas antes da cirurgia não foi significativamente associado a maiores taxas de complicações ou a maior necessidade de reoperação. CONCLUSÃO: A taxa de complicações observadas neste trabalho é semelhante aos dados da literatura. A duração da doença, o comportamento penetrante, o tamanho do espécime retirado, o tempo de duração da cirurgia e o IMC são importantes fatores de risco para complicações peri-operatórias em doença de Crohn.

Risk factors for postoperative complications in Crohn disease: analysis of 173 patients / Fatores de risco para complicações pós-operatórias na Doença de Crohn: análise de 173 pacientes

ABSTRACT Background and objectives: Surgery for Crohn disease has a wide range of factors that are being studied as possible risk factors for postoperative complications. The later are a major problem in those patients and are associated with longer hospital stays and increased mortality and morbidity. Despite the debate regarding the influence of patients' characteristics, preoperative and operative details, the risk factors are not fully identified. The debate has been focused on the new medical therapy and the time of surgery. Our goal was to help identify and confirm risk factors for postoperative complications. Materials and methods: A retrospective cohort study including all patients operated due to Crohn disease in São João Hospital Center from 2010 to 2015. We analyzed patient, preoperative and surgical characteristics. For postoperative complications data only those occurring within 30 days were included. Results: Neither age at diagnosis or previous corticotherapy/anti-TNF/ustekinumab was significantly associated with an increased risk in postoperative complications. Only age at surgery >40 years (Montreal Classification A1 + A2 vs. A3; OR = 4.12; p < 0.05) and the group others (occlusion vs. others [combination of intestinal perforation, mesenteric ischemia and postoperative complications] vs. fistula/abscess as indication for surgery; OR = 4.12; p < 0.05) remained as independent risk factors after multivariable regression analysis. Conclusions: We described clear associations between age at surgery >40 years and the group others (intestinal perforation, mesenteric ischemia and postoperative complications) and overall postoperative complications in Crohn disease. These results may suggest that surgery does not need to be delayed and, in some cases, should be anticipated.

RESUMO Introdução e objetivos: Vários fatores têm sido estudados como possíveis fatores de risco para complicações pós-operatórias na doença de Crohn. Estas complicações estão associadas a estadias mais prolongadas no hospital e a um aumento da mortalidade. Apesar do debate relativo à influência das características dos pacientes, pré-operatórias e operatórias, os fatores de risco ainda não estão completamente identificados. Atualmente, o debate centra-se nos avanços da terapia médica e no melhor momento para realizar a operação. O objetivo era identificar os fatores de risco para complicações pós- operatórias. Materiais e métodos: Realizamos um estudo retrospectivo incluindo todos os pacientes operados devido à doença de Crohn no Hospital São João desde 2010 até 2015. Analisamos as características dos doentes, as pré e as pós-operatórias. Apenas foram incluídos os dados relativos a complicações no período de 30 dias após a cirurgia. Resultados: A idade ao diagnóstico e o uso prévio de corticoterapia/anti-TNF/ustekinumab não foram associados a um aumento no risco de complicações pós-operatórias. Apenas a idade na cirurgia superior aos 40 anos (Classificação de Montreal A1 + A2 vs. A3; OR = 4.12; p < 0.05) e o grupo 'outros' (oclusão vs. outros [combinação de perfuração intestinal, isquemia mesentérica e complicações pós-operatórias] vs. fistula/abscesso como indicação para cirurgia; OR = 4.12; p < 0.05) são fatores de risco independentes. Conclusões: Descrevemos uma associação clara entre a idade na cirurgia superior aos 40 anos e o grupo 'outros' e a existência de complicações pós-operatórias na doença de Crohn. A cirurgia não deve ser adiada e, em alguns casos, seria benéfico antecipá-la.

Colitis de Crohn: resultados del tratamiento quirúrgico y evolución alejada / Outcome of surgery for Crohn's colitis: review of 28 cases

Background: Exclusive involvement of the colon or rectum in Crohn's disease, called Crohn's colitis, (CC) occurs in about 25% of these patients. Aim: To analyze early surgical results and long-term outcomes of patients undergoing surgery for CC. Material and Methods: Review of a prospective database, identifying patients with Crohn's disease operated between 2003 and 2015 and excluding those with ileocecal disease. We analyzed demographic data, pre and postoperative pharmacological treatment, operations, morbidity and the need for a second bowel resection at follow-up. Results: We reviewed data from 28 patients aged 17 to 72 years (15 men). Twenty-seven (96.4%) had previous pharmacological treatment, 11 received monoclonal antibodies. The most common indications for surgical treatment were failure of medical treatment in 15 cases, acute severe colitis in 12 and anemia/malnutrition in eight. Total colectomy was performed in 17 (61%) patients, proctocolectomy in 8 (29%) and segmental colectomies in 3 (11%). Sixteen (57%) were operated laparoscopically. Major postoperative complications were observed in 5 (18%). Four needed a reintervention. There was no operative mortality. During a 55 months median follow-up of 27 patients, seven (26%) required a second bowel resection, one of them for recurrence. Nineteen (70%) patients had an ostomy, which was permanent in 11. Fifteen patients are without medical treatment. Conclusions: Most of the reviewed patients required total colectomy for the control of the disease with a low surgical morbidity. Two-thirds required an ileostomy, which became permanent in half of them.

Specificities of presentation of Crohn's disease in childhood / Especificidades da apresentação da doença de Crohn na infância

ABSTRACT The incidence of inflammatory bowel disease in the pediatric population has increased in the last years. The most common form of inflammatory bowel disease is Crohn's disease and, according to its form and age of presentation, it is possible to predict the evolution of the disease.

RESUMO A incidência de doença inflamatória intestinal aumentou na população pediátrica nos últimos anos. A forma mais comum de doença inflamatória intestinal é a doença de Crohn e, conforme sua forma e a idade de apresentação é possível prever a evolução da doença.

Postoperative complication rates between Crohn's disease and Colorectal cancer patients after ileocolic resections: a comparative study / Complicações pós-operatórias após ressecções ileocólicas na doença de Crohn e no câncer colorretal: um estudo comparativo

ABSTRACT Introduction: Ileocolic resection (ICR) is the most common surgical procedure performed for Crohn's disease (CD). Similarly, right-sided Colorectal cancer (CRC) is treated by the same operation. The primary aim of this study was to analyze and compare the frequency and profile of early postoperative complications of ICR between patients with CD and CRC. Methods: Retrospective and observational study with patients submitted to ICR from two Brazilian tertiary referral units in colorectal surgery. We included patients with diagnosis of CD or CRC, treated with ICR, at any stage of follow-up. Variables analyzed: age at surgery, gender, diagnosis, surgical approach (open or laparoscopy), type of anastomosis (hand-sewn/stapled; end-to-end/side-to-side), presence and type of early postoperative complications (30 days) and mortality, among others. Results: 109 patients were included, 73 with CD (67%) and 36 with CRC (33%). CD patients were younger (42.44 ± 12.73 years vs. 66.14 ± 11.02 years in the CRC groups, p < 0.0001) and had more previous resections (20 ± 27.4 in CD and 0 in CCR, p = 0.001). There were no significant differences between the groups in terms of overall early postoperative complications [17/73 (23.3%) in the CD and 5/36 (13.9%) in the CRC groups (p = 0.250)]. There was no significant difference between the groups in relation to anastomotic leakage (p = 0.185), surgical site infections (p = 0.883), other complications (0.829) and deaths (p = 0.069). Conclusions: There was no significant difference in early postoperative complications in patients with CD or CRC submitted to ICR.

RESUMO Introdução: A ileocolectomia direita (ICD) é a operação mais realizada no manejo cirúrgico da doença de Crohn (DC). Da mesma forma, é o procedimento de escolha no tratamento do câncer colorretal (CCR) quando localizado à direita. O objetivo deste estudo foi analisar e comparar as complicações cirúrgicas em pacientes submetidos a ICD por DC e CCR em uma coorte de pacientes. Método: Estudo longitudinal, retrospectivo e observacional, de uma coorte de pacientes submetidos a ICD provenientes de 2 centros de referência em coloproctologia. Os critérios de inclusão foram pacientes com DC ou CCR, submetidos a ICD, em qualquer estágio de acompanhamento. As variáveis analisadas foram: idade à cirurgia, gênero, diagnóstico, abordagem (aberta ou laparoscópica), tipo de anastomose, presença e tipo de complicações pós-operatórias precoces (até 30 dias) e óbito. Resultados: Foram incluidos 109 pacientes, 73 com DC (67%) e 36 com CCR (33%). Os grupos foram homogêneos em todas as variáveis, à exceção da idade (42,44 ± 12,73 na DC e 66,14 ± 11,02 no CCR, p < 0,0001). Não houve diferença entre os grupos em relação às complicações precoces, com 17/67 (23,3%) na DC e 5/36 (13,9%) no CCR, p = 0,250. Da mesma forma, não houve diferença entre os grupos em relação a deiscência de anastomose (p = 0,185), infecções do sítio cirúrgico (p = 0,883), outras complicações (0,829) e óbitos (p = 0,069). Conclusões: Não houve diferença nas complicações pós-operatórias em pacientes submetidos a ICD entre portadores de DC e CCR.

Caso Clínico: Abordaje Quirúrgico de la Enfermedad de Crohn / Caso Clínico: Abordaje Quirúrgico de la Enfermedad de Crohn

INTRODUCCIÓN: La enfermedad de Crohn es infrecuente en nuestro medio, su etiología se desconoce, y se caracteriza por afectar cualquier parte del tubo digestivo. El 30% de los pacientes con enfermedad de Crohn tienen afectación del intestino delgado (en particular el íleon terminal), otro 20% el colon, y hasta un 45% tienen afectación en ambos (intestino delgado y colon). El objetivo de la publicación de este caso fue describir el tratamiento quirúrgico de esta enfermedad. CASO CLÍNICO: Se trata de un paciente masculino de 71 años de edad con múltiples comorbilidades que presentó un cuadro clínico con síntomas digestivos de 6 años de evolución; fue diagnosticado con enfermedad de Crohn 3 años antes y recibió tratamiento a base de corticoides y biológicos durante dos años, sin presentar una respuesta satisfactoria; por ello, se decidió realizar una hemicolectomía derecha + íleo-transverso anastomosis termino-lateral por vía laparoscópica. EVOLUCIÓN: Tres meses después presentó una fístula entero-cutánea de 24 mm a nivel de sitio quirúrgico que requirió resolución quirúrgica. Quince meses después de la primera intervención se realizó un control colonoscópico que evidenció reactivación de la enfermedad, por lo que se reinició tratamiento con terapia biológica. CONCLUSIÓN: La enfermedad de Crohn tiene un alto índice de recidiva y el riesgo se incrementa según los hábitos del paciente. Los objetivos principales de la cirugía son aliviar las complicaciones y contribuir a mejorar en lo posible la calidad de vida del paciente(AU)

BACKGROUND: Crohn's disease is not frequent in our environment; its etiology is unknown and may affect any part of the digestive tube. 30% of patients with Crohn's disease have small intestine affectation (particularly of the terminal ileum), other 20% only the colon, and around 45% of them have both affected. The aim of this case report was to describe the surgical treatment of this disease. CASE REPORT: It is about a 71-years old male patient with much comorbidity who had digestive symptoms for 6 years. He was diagnosed with Crohn's disease 3 years before and was treated with corticosteroids and biological medicine for 2 years with no-satisfactory response; so a right hemicolectomy + ileum-transverse end-to-side anastomosis was performed by laparoscopy. EVOLUTION: The patient developed a 24 mm enterocutaneous fistula three months later; it was located at the surgical site and required surgical resolution. A colonoscopy was performed fifteen months after first intervention; it evidenced Crohn's reactivation so the biological therapy was restarted. CONCLUSION: Crohn's disease has a high recurrence rate and the risk increases in relation of patient's habits. The main objectives of surgery are to relieve complications and contribute to improve life quality as possible.(AU)

Guía de práctica clínica para el tratamiento de la enfermedad de Crohn en población adulta / Clinical practice guideline for treatment of Crohn's Disease in adult population

Generar recomendaciones informadas en la evidencia para el tratamiento de los pacientes con enfermedad de Crohn. Apoyar al tratamiento oportuno y seguro de los pacientes de enfermedad de Crohn considerando las minimización de secuelas y la hospitalización. Apoyar a los tomadores de decisiones a formular políticas para el manejo adecuado de la enfermedad de Crohn. Grupos que se consideran: Pacientes mayores de 16 años con diagnóstico de Enfermedad de Crohn independiente del tiempo de evolución y estado clínico de la enfermedad sin importar régimen de aseguramiento.

Microscopic analysis of patients with chronic diarrhea without macroscopic disease / Análise microscópica de pacientes com diarreia crônica sem doença macroscópica

BACKGROUND: Colonoscopy is part of the current diagnostic armamentarium. However, in some patients with chronic diarrhea, a colonoscopy may show normal mucosa; in these cases, serial biopsies can provide important information for the diagnosis and treatment of patients. AIM: To analyze patients with chronic diarrhea having a macroscopically normal colonoscopy, by evaluating histological changes. METHODS: 30 patients with chronic diarrhea and normal colonoscopy were prospectively evaluated and submitted to serial biopsies of the terminal ileum, ascending colon and rectum. RESULTS: The sample of 30 patients showed a ratio of 18 men (60%) and 12 women (40%). On histological types, it was found that 13 patients (43.3%) had lymphoid hyperplasia, eosinophilic inflammation in 4 (13.3%), nonspecific inflammation in 4 (13.3%), regenerative changes in 3 (10%), lymphocytic colitis in 2 (6.6%) and changes consistent with Crohn's disease in 1 (3.3%). CONCLUSIONS: One can observe that even chronic diarrhea patients, without other associated factors, benefited from colonoscopy with biopsy, because it held the etiologic diagnosis in some cases as also excluded by histopathology. It was noticed that the frequency of patients with altered biopsy and less dragged diarrheal episodes (84.2%) was large, should consider their achievement.

INTRODUÇÃO: A colonoscopia faz parte do arsenal de diagnóstico atual. Porém, em alguns pacientes com diarreia crônica, a colonoscopia pode evidenciar mucosa normal; nesses casos biópsias seriadas podem trazer informações importantes para o diagnóstico e tratamento dos pacientes. OBJETIVO: Analisar pacientes com diarreia crônica submetidos à colonoscopia macroscopicamente normal, avaliando assim histologicamente as alterações. MÉTODOS: Análise prospectiva da histologia 30 pacientes com diarreia crônica e colonoscopias normais, submetidos a biópsias seriadas de íleo terminal, cólon ascendente e reto. RESULTADOS: A amostra de 30 pacientes mostrou uma proporção de 18 homens (60%) e 12 mulheres (40%). Sobre os tipos de alterações histológicas, foi verificado que 13 pacientes (43,3%) apresentaram hiperplasia linfóide, inflamação eosinofílica em 4 (13,3%), inflamação inespecífica em 4 (13,3%), alterações regenerativas em 3 (10%), colite linfocítica em 2 (6,6%) e alterações compatíveis com Doença de Crohn em 1 (3,3%). CONCLUSÕES: Observou-se que mesmo pacientes com diarreia crônica, sem outros fatores associados, beneficiaram-se da colonoscopia com biópsia, pois a mesma realizou o diagnóstico etiológico em alguns casos como também o excluiu através da histopatologia. Verificou-se que a frequência de pacientes com biópsia alterada e quadros diarreicos menos arrastados (84,2%) foi grande, devendo-se considerar a realização do exame.

Enfermedad de Crohn fistulizante perianal, manejo médico-quirúrgico / Fistulizing perianal Crohn’s Disease, medical and surgical management

Crohn’s disease (CD) and ulcerative colitis (UC) are immunologically mediated chronic digestive diseases, with a trend to progressive damage, which generally have an onset at young age and a course characterized by remission and relapse. Its incidence and prevalence present a steady upward trend globally. CD is characterized by transmural inflammation in the digestive tract and it is a complex disease. The perianal involvement –“p”, abscesses or perianal fistulas– is considered a condition that is different from penetrating phenotype, a condition that indicates an aggressive behavior of CD. Early identification and proper treatment of fistulas, including correct diagnosis and classification are essential elements to establish an appropriate treatment plan. A multidisciplinary approach is essential including medical and surgical approach.

La Enfermedad de Crohn (EC) y la colitis ulcerosa (CU) son enfermedades digestivas crónicas, progresivas, mediadas inmunológicamente, que en general, tienen un inicio durante la edad adulta-joven y un curso que se caracteriza por remisión y recaída. Su incidencia y prevalencia ha presentado una tendencia constante de incremento a nivel global. La EC se caracteriza por comprimo transmural del tracto digestivo y por ser una patología compleja. El compromiso perianal –“p”, abscesos o fístulas perianales– se considera una condición diferente al fenotipo penetrante, señalándose en la actualidad como una variable modificadora del comportamiento de la patología y de gravedad. La identificación dirigida y precoz de trayectos fistulosos, su correcto diagnóstico y clasificación son elementos primordiales para poder establecer un plan terapéutico apropiado. Es imprescindible un abordaje multidisciplinario, en el cual exista integración médico-quirúrgica.

Perineal colostomy: an alternative to avoid permanent abdominal colostomy: operative technique, results and reflection / Colostomia perineal: uma alternativa para evitar a colostomia abdominal definitiva: técnica operatória, resultados e reflexão

BACKGROUND: The most common injury to indicate definitive stoma is rectal cancer. Despite advances in surgical treatment, the abdominoperineal resection is still the most effective operation in radical treatment of malignancies of the distal rectum invading the sphincter and anal canal. Even with all the effort that surgeons have to preserve anal sphincters, abdominoperineal amputation is still indicated, and a definitive abdominal colostomy is necessary. This surgery requires patients to live with a definitive abdominal colostomy, which is a condition that modify body image, is not without morbidity and has great impact on the quality of life. AIM: To evaluate the technique of abdominoperineal amputation with perineal colostomy with irrigation as an alternative to permanent abdominal colostomy. METHOD: Retrospective analysis of medical records of 55 patients underwent abdominoperineal resection of the rectum with perineal colostomy in the period 1989-2010. RESULTS: The mean age was 58 years, 40 % men and 60 % women. In 94.5% of patients the indication for surgery was for cancer of the rectum. In some patients were made three valves, other two valves and in the remaining no valve at all. Complications were: mucosal prolapse, necrosis of the lowered segment and stenosis. CONCLUSION: The abdominoperineal amputation with perineal colostomy is a good therapeutic option in the armamentarium of the surgical treatment of rectal cancer. .

RACIONAL: O câncer de reto é o agravo mais frequente para a indicação do estoma abdominal definitivo. Apesar dos avanços no tratamento cirúrgico, a amputação abdominoperineal ainda é a operação indicada mais efetiva nesta indicação com invasão de esfíncter e de canal anal, o que impõe aos pacientes colostomia abdominal definitiva, condição que altera a imagem corporal e grande repercussão na qualidade de vida. OBJETIVO: Avaliar a técnica de amputação abdominoperineal mais colostomia perineal com irrigação como alternativa à colostomia abdominal definitiva. MÉTODO: Análise retrospectiva de prontuário médico de cinquenta e cinco pacientes submetidos à amputação abdominoperineal do reto mais colostomia perineal no período de 1989 a 2010. RESULTADOS: A média de idade foi de 58 anos sendo 40% em homens e 60% em mulheres. Em 94,5% dos pacientes a indicação cirúrgica foi por câncer de reto. Em alguns foram confeccionadas três válvulas, em outros duas e nos demais não foi confeccionada nenhuma válvula. As complicações foram: prolapso mucoso, necrose do segmento abaixado e estenose. CONCLUSÃO: A técnica de amputação abdominoperineal mais colostomia perineal é boa opção terapêutica no arsenal do tratamento cirúrgico do câncer de reto. .

Enfermedad de Crohn: presentación de caso clínico y revisión de la literatura / CrohnÆs disease: clinical case and review of the literature

Se presenta el caso de un adolescente de sexo masculino, de 15 años de edad, con cuadro clínico de más de 2 años. El paciente presenta dolor abdominal difuso con episodios de oclusión intestinal parcial; diarrea recurrente; disminución de peso no cuantificada y periodos de alza térmica. Los análisis de laboratorio evidenciaron los siguientes resultados: PCR 92,17; albú- mina 3,2 gr/dl; anemia microcítica hipocrómica (10 gr%). En imágenes presentó: ecografía abdominal: hepatoesplenomegalia; TAC abdominal: engrosamiento de íleon distal y colon derecho con líquido libre laminar en cavidad abdominal; Radiografía de tránsito intestinal: estenosis en íleon distal. En la colonoscopía se observó: colon derecho con úlceras y áreas de mucosa infiltrada. Biopsias sugestivas de enfermedad de Crohn. Mientras que en cápsula endoscópica: ileítis ulcerativa. El paciente es dado de alta con tratamiento de prednisona y azatioprina, pero ante persistencia de episodios de oclusión intestinal se decide conducta quirúrgica. La evolución fue favorable. En el tratamiento médico posoperatorio se indicó Infliximab (Remicade). Se discuten opciones de tratamiento médico y quirúrgico...

We present a 15 year male patient with more than 2 years of clinical symptoms. Patient has abdominal pain with episodes of partial intestinal occlusion, recurrent diarrhea, weight loss and fever. Lab findings were PCR: 92, 17: albumine: 3,2 gr/dl, microcitic hipocromic anemia (10 gr%). Hepatoesplenomegaly in the Echo in TAC there was a thickness of the distal ileum and right colon with free liquid in the abdominal cavity. Intestinal transit: Stenosis of the distal ileum. In a colonoscopy: ulcers in the right colon with biopsies that suggest Crohn disease. Endoscopic capsule: ulcerative ileitis. The patient was discharged with prednisone and azatioprine but because there were new episodes of intestinal occlusion surgery was decided. The outcome was good and in the post surgery treatment Infliximab was used. We discuss medical and surgical treatment options...