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2.
Updates Surg ; 73(4): 1419-1427, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32410158

RESUMO

Measurement of the psoas muscle area has been applied to estimate lean muscle mass as a surrogate marker of sarcopenia, but there is a paucity of evidence regarding the influence of sarcopenia on clinical outcomes following inflammatory bowel disease surgery. The aim of this study was to evaluate the association between MRI enterography defined sarcopenia and postoperative complications in patients undergoing elective ileocaecal resection for Crohn's disease. To obtain cross sectional area measurement of the psoas muscle, the freehand area tool was used to trace the margin of each psoas muscle at the level of L4, with the sum recorded as Total Psoas Area (TPA). The total cross sectional muscle area of the abdominal wall was recorded as Skeletal Muscle Area (SMA), while myosteatosis was measured by normalising the psoas muscle intensity with the mean intensity of the cerebrospinal fluid. The primary outcome was the incidence of 30-day postoperative complications in patients in the lowest quartile of TPA and SMA. 31 patients were included and ten patients (32.25%) developed postoperative complications within 30 days of surgery. The cut-off values for the lowest quartile for TPA were 11.93 cm2 in men and 9.77 cm2 in women, including a total of 8 patients (25.8%) with 5 patients in this group (62.5%) developing postoperative complications and 3 patients (37.5%) Clavien-Dindo class ≥ 3 complications. The cut-off values for the lowest quartile for SMA were 73.49 cm2 in men and 65.85 cm2 in women, with 4 patients out of 8 (50%) developing postoperative complications. Psoas muscle cross sectional area and skeletal mass area can be estimated on Magnetic Resonance Enterography as surrogate markers of sarcopenia with high inter-observer agreement.


Assuntos
Doença de Crohn , Sarcopenia , Doença de Crohn/diagnóstico por imagem , Doença de Crohn/patologia , Doença de Crohn/cirurgia , Feminino , Humanos , Imageamento por Ressonância Magnética , Espectroscopia de Ressonância Magnética , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Músculos Psoas/diagnóstico por imagem , Músculos Psoas/patologia , Estudos Retrospectivos , Fatores de Risco , Sarcopenia/diagnóstico por imagem , Sarcopenia/patologia
3.
Tech Coloproctol ; 24(9): 965-969, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32577847

RESUMO

BACKGROUND: Intraoperative assessment of the extent and location of Crohn's disease is not standardised and relies on a mixture of surgeons' experience, tactile feedback and macroscopic appearance. To overcome this variability, we developed a protocol for full intraoperative ultrasound scan of the small bowel and we here report the results of "Assessing the Feasibility and Safety of Using Intraoperative Ultrasound in Ileocolic Crohn's Disease-The IUSS CROHN Study". METHODS: This is a prospective single centre observational study with enrolment of all patients undergoing elective surgery for terminal ileal Crohn's disease from January 2019 to March 2020. Patients underwent laparoscopic ileocolic resection, according to a standardised technique. Ultrasound intraoperative quantitative assessment was performed according to the METRIC (MREnterography or ulTRasound in Crohn's disease) scoring guide. RESULTS: Intraoperative ultrasound was successfully performed in 6 patients from the ileocaecal valve to the proximal jejunum. The median time required was 23.5 min (range 17-37 min) as compared to 6.5 min (5-12 min) required for the macroscopic evaluation performed by the surgeon. In 3 patients, intraoperative ultrasound identified more disease than surgical evaluation. CONCLUSIONS: This feasibility study demonstrated the safety of intraoperative ultrasound and allowed the development of a standardised protocol for intraoperative ultrasound and the data collection required to inform a randomised multicentre study.


Assuntos
Doença de Crohn , Laparoscopia , Doença de Crohn/diagnóstico por imagem , Doença de Crohn/cirurgia , Estudos de Viabilidade , Humanos , Íleo , Intestino Delgado/diagnóstico por imagem , Intestino Delgado/cirurgia , Estudos Prospectivos
4.
Colorectal Dis ; 22(3): 342-345, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31652389

RESUMO

AIM: Bowel preservation is paramount in Crohn's disease surgery as affected patients are typically young adults at risk of having several abdominal surgical procedures during their lifetime. Intra-operative assessment of the extent and location of Crohn's disease is not standardized and is left to a mixture of the surgeon's experience, tactile feedback, macroscopic appearance and preoperative imaging. The aim of this study was to describe the technical steps of a standardized protocol for intra-operative ultrasound assessment of the small bowel in patients undergoing surgery for ileocolic Crohn's disease. METHOD: After laparoscopic mobilization of the bowel, a periumbilical incision is performed for extracorporeal division of the mesentery and the resection and anastomosis. A gastrointestinal consultant radiologist, with expertise in Crohn's disease imaging and abdominal ultrasound, performs full intra-operative assessment of the small bowel by applying a sterile ultrasound probe directly to the bowel, prior to resection being performed by the surgeon. The bowel is assessed through the wound protector with a sterile technique and the length, location and number of segments is documented together with further quantitative assessment using the METRIC (MR enterography or ultrasound in Crohn's disease) scoring guide. RESULTS: A step-by-step protocol for intra-operative ultrasound evaluation of the entire small bowel is described. CONCLUSIONS: A standardized approach to intra-operative evaluation of the extent and location of Crohn's disease is desirable. Intra-operative ultrasound may provide added value for assessment of proximal and multifocal Crohn's disease.


Assuntos
Doença de Crohn , Laparoscopia , Anastomose Cirúrgica , Doença de Crohn/diagnóstico por imagem , Doença de Crohn/cirurgia , Humanos , Intestino Delgado/diagnóstico por imagem , Intestino Delgado/cirurgia , Ultrassonografia , Adulto Jovem
5.
Tech Coloproctol ; 23(11): 1085-1091, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31664551

RESUMO

BACKGROUND: Repeated intestinal resections may have disabling consequences in patients with Crohn's disease even in the absence of short bowel syndrome. Our aim was to evaluate the length of resected small bowel in patients undergoing elective and emergency surgery for ileocolic Crohn's disease. METHODS: A prospective observational study was conducted on patients undergoing surgery for ileocolonic Crohn's disease in a single colorectal centre from May 2010 to April 2018. The following patients were included: (1) patients with first presentation of ileocaecal Crohn's disease undergoing elective surgery; (2) patients with ileocaecal Crohn's disease undergoing emergency surgery; (3) patients with recurrent Crohn's disease of the distal ileum undergoing elective surgery. The primary outcomes were length of resected small bowel and the ileostomy rate. Operating time, complications and readmissions within 30 days were the secondary outcomes. RESULTS: One hundred and sixty-eight patients were included: 87 patients in the elective primary surgery group, 50 patients in the emergency surgery group and 31 in the elective redo surgery group. Eleven patients (22%) in the emergency surgery group had an ileostomy compared to 10 (11.5%) in the elective surgery group (p < 0.0001). In the emergency surgery group the median length of the resected small bowel was 10 cm longer than into the group having elective surgery for primary Crohn's disease. CONCLUSIONS: Patients undergoing emergency surgery for Crohn's disease have a higher rate of stoma formation and 30-day complications. Laparoscopic surgery in the emergency setting has a higher conversion rate and involves resection of longer segments of small bowel.


Assuntos
Colite/cirurgia , Doença de Crohn/cirurgia , Ileíte/cirurgia , Ileostomia , Intestino Delgado/cirurgia , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Colite/etiologia , Conversão para Cirurgia Aberta , Doença de Crohn/complicações , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Tratamento de Emergência/efeitos adversos , Feminino , Humanos , Ileíte/etiologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Readmissão do Paciente , Estudos Prospectivos , Recidiva
6.
Scand J Surg ; 108(1): 42-48, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29742985

RESUMO

PURPOSES:: Over 80% of patients with primary ileocolic Crohn's disease have a surgical resection within 10 years of diagnosis, and 40%-50% of them need further surgery within 15 years. Laparoscopic surgery can be challenging due to a thickened mesentery and the potential for fistulas, abscesses, and phlegmons. Aim of this study is to analyze the short-term outcomes of laparoscopic redo ileocolic resections for Crohn's disease in patients with previous multiple laparotomies. METHODS:: All patients undergoing laparoscopic surgery for ileocolic Crohn's disease from March 2006 to February 2017 were prospectively evaluated. Short term outcomes of laparoscopic ileocolic resection were compared between patients with previous multiple major surgeries and recurrent Crohn's disease, and patients undergoing surgery for the first presentation of Crohn's disease and no history of previous surgery. Conversion rate and 30-day morbidity were the primary outcomes. Reoperations, readmissions, operating time and length of stay were the secondary outcomes. RESULTS:: 29 patients with recurrent Crohn's disease and previous multiple laparotomies were included: the number of laparotomies these patients previously underwent was 2 in 19 cases (65.5%), 3 in 9 (31%), and 4 in 1 (3.5%). In total, 90 patients with no history of any previous abdominal surgery, who underwent laparoscopic ileocecal resection for Crohn's disease, represented the control group. No differences were found in morbidity and conversion rate. Operating time was longer in patients with history of previous abdominal surgery. CONCLUSION:: Laparoscopic redo ileocolic resection for Crohn's disease is feasible and safe in patients with previous multiple laparotomies at the expense of longer operating time.


Assuntos
Colo/cirurgia , Doença de Crohn/cirurgia , Íleo/cirurgia , Laparoscopia , Laparotomia , Adulto , Anastomose Cirúrgica , Colectomia , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Prospectivos , Reoperação , Resultado do Tratamento
7.
Colorectal Dis ; 14(7): 838-43, 2012 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21920008

RESUMO

AIM: Preoperative short-course radiotherapy (SCRT) is increasingly recommended to reduce local recurrence after surgery for rectal cancer. Its avoidance may be beneficial, however, if the risk of local recurrence is low. We report a single centre experience which suggests that selective rather than uniform use of SCRT may be the best approach. METHOD: Analysis was carried out on a prospectively collected unselected series of 1606 patients with rectal cancer treated in one centre. Follow-up was 97% complete. SCRT was performed selectively and all patients had a mesorectal excision. RESULTS: Among 940 patients undergoing a potentially curative major resection the operative mortality was 4.6%, the permanent stoma rate 23% and the crude 5-year survival 61%. The local recurrence rate after curative anterior resection was 2.9% and 7.7% after abdominoperineal excision. The overall local recurrence rate after a potentially curative major resection was 4.0%. CONCLUSION: The routine use of preoperative radiotherapy for rectal cancer is probably not justified where local recurrence after curative rectal resection is uncommon.


Assuntos
Carcinoma/radioterapia , Carcinoma/cirurgia , Recidiva Local de Neoplasia/etiologia , Radioterapia Adjuvante , Neoplasias Retais/radioterapia , Neoplasias Retais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fístula Anastomótica/etiologia , Carcinoma/patologia , Colostomia/estatística & dados numéricos , Intervalo Livre de Doença , Feminino , Humanos , Ileostomia/estatística & dados numéricos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Recidiva Local de Neoplasia/prevenção & controle , Seleção de Pacientes , Neoplasias Retais/patologia , Taxa de Sobrevida
8.
Colorectal Dis ; 14(10): 1255-61, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22188371

RESUMO

AIM: Splenic flexure mobilization (SFM) is standard practice in anterior resections. No previous studies have compared outcomes with and without SFM in laparoscopic and open colorectal cancer surgery. This study aimed to determine whether routine or selective SFM should be advised. METHOD: Data were collected prospectively on all elective anterior resections for cancer in our unit between October 2006 and November 2009. RESULTS: Of 263 resections, SFM data were recorded in 216; 138 were laparoscopic (32% with SFM, 3.6% converted) and 78 open (68% with SFM). Eighty-eight were low anterior resections (LARs) for mid-low rectal cancers, with 54 laparoscopic (50% with SFM) and 34 open (91% with SFM). Comparing laparoscopic with SFM to without, differences were found in the proportion of LARs (61%vs 29%, P<0.001), defunctioning ileostomy rates (75%vs 46%, P=0.001) and operative time (median 255 vs 185 min, P<0.001), with no differences in age, gender, body mass index, American Society of Anesthesiology score, preoperative treatment, length of stay, lymph node yield, conversion rate, mortality, anastomotic leakage, reoperation, readmission and R0 resection. No differences in outcomes were seen between laparoscopic LARs with and without SFM or between open resections with and without SFM. CONCLUSION: Our results show no disadvantage in short-term clinical or oncological outcomes when SFM was avoided. Laparoscopic anterior resections with SFM take longer. A selective approach to SFM is safe during anterior resection (open or laparoscopic), including mid-low rectal cancers.


Assuntos
Colo Transverso/cirurgia , Laparoscopia , Neoplasias Retais/cirurgia , Reto/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Colo Sigmoide/cirurgia , Feminino , Humanos , Ileostomia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
9.
Ann R Coll Surg Engl ; 93(8): 603-7, 2011 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-22041236

RESUMO

INTRODUCTION: Laparoscopic colorectal surgery has gained widespread acceptance. While many studies have compared laparoscopic and open left-sided resections, there is limited literature on right colonic resections. We aimed to analyse the short-term outcome of laparoscopic (LRH) and open right hemicolectomy (ORH) in our unit. METHODS: Consecutive patients undergoing elective right hemicolectomies over a period of 28 months were included in the study. No selection criteria were used to allocate the surgical approach. Study parameters included surgical technique, demographic details, ASA grade, body mass index (BMI), length of hospital stay (LOS), post-operative mortality and morbidity, readmission rate and histopathological data. RESULTS: A total of 164 patients underwent right hemicolectomies during the study period (LRH: 89, ORH: 75). Both groups were comparable in age, sex, BMI, ASA grade, tumour stage and lymph node harvest. Four patients (4.5%) in the laparoscopic group required conversion to open surgery. In resections with curative intent, microscopic margins were positive in two patients (3%) in the ORH group compared with one (1%) in the LRH group. Seven ORH patients had an adverse post-operative outcome (three anastomotic leaks, four deaths); there were no deaths/immediate complications in the LRH group (p<0.05). The median LOS for LRH patients (4 days, range: 2-21 days) was significantly shorter than for ORH patients (8 days, range: 3-38 days) (p<0.0001, Mann-Whitney U test). By day 5, 77% of LRH patients were discharged compared with only 21% of patients in the ORH group. There were two readmissions (2.7%) in the ORH group and nine (10.1%) in the LRH group. CONCLUSIONS: Our findings demonstrate advantages in favour of LRH in terms of a shorter hospital stay and reduced post-operative major complications. LRH is safe and should therefore be available to all patients requiring colonic resection.


Assuntos
Colectomia/métodos , Neoplasias do Colo/cirurgia , Laparoscopia/métodos , Idoso , Idoso de 80 Anos ou mais , Neoplasias do Colo/patologia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Reoperação/estatística & dados numéricos , Resultado do Tratamento
10.
Br J Surg ; 95(9): 1140-6, 2008 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-18623058

RESUMO

BACKGROUND: The aim was to identify the patients with colorectal symptoms most likely to benefit from whole colonic imaging (WCI) to diagnose colorectal cancer and those for whom flexible sigmoidoscopy (FS) may be initially sufficient. METHODS: This prospective observational study (16 years) included 16 433 newly referred patients with symptoms or signs of colorectal cancer. RESULTS: Colorectal cancer was diagnosed in 946 patients (diagnostic yield 5.8 per cent), 815 (86.2 per cent) in the rectum or sigmoid (distal) and 131 (13.8 per cent) in the proximal colon. Some 15 829 patients (96.3 per cent) presented with symptoms alone (without iron deficiency anaemia or abdominal mass). Of 787 cancers in these patients, 750 (95.3 per cent) were distal. The prevalence of proximal cancer above and below the age of 60 years was 0.4 per cent (33 of 8249) and 0.1 per cent (four of 7580) respectively. Of 16 256 patients having FS, 5665 (34.8 per cent) had WCI. Of the other 10 591, five subsequently presented with proximal cancers. FS missed ten (1.3 per cent) of 796 cancers. CONCLUSION: Patients with iron deficiency anaemia or a mass require WCI. However, in patients with symptoms alone, FS detects 95 per cent of cancers, and the diagnostic yield of WCI after FS is very low. Alternative management strategies need to be developed to avoid unnecessary investigations in this low-risk group.


Assuntos
Neoplasias Colorretais/diagnóstico , Sigmoidoscopia/métodos , Idoso , Idoso de 80 Anos ou mais , Anemia/etiologia , Estudos de Coortes , Erros de Diagnóstico , Enema , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sangue Oculto , Estudos Prospectivos , Encaminhamento e Consulta , Fatores de Risco
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