Abdominal Surgery in Crohn's Disease: Risk Factors for Complications.

INTRODUCTION: Abdominal surgery in patients with Crohn's disease (CD) is challenging, especially in the biologic era. The aim of this study was to evaluate factors associated with increased risk for postoperative complications in CD. METHODS: A retrospective study was conducted with consecutive patients who underwent abdominal surgery for CD from January 2012 to January 2018. RESULTS: Of 103 patients, 32% had postoperative complications. Gender, age, disease location and phenotype, hemoglobin and albumin levels, previous abdominal surgery, and preoperative optimization did not differ between the groups with or without complications. Thirty-five percent of the patients were under anti-TNF therapy, and this medication was not associated with increased risk for postoperative complications. Time since the onset of the disease was significantly higher in patients with complications (12.9 vs. 9.4, p = 0.04). In multivariate analysis, creation of ostomy and urgent surgery were the only variables independently associated with increased risk for complications (OR 3.2, 95% CI 1.12-9.46 and OR 2.94, 95% CI 0.98-9.09, respectively). CONCLUSION: Urgent surgery for CD should preferably be performed in specialized centers, and creation of stoma is not necessarily associated with lower rate of postoperative complications but rather less severe complications.

Transanal endoscopic microsurgery for residual rectal cancer after neoadjuvant chemoradiation therapy is associated with significant immediate pain and hospital readmission rates.

BACKGROUND: Transanal endoscopic microsurgery may represent appropriate diagnostic and therapeutic procedure in selected patients with distal rectal cancer following neoadjuvant chemoradiation. Even though this procedure has been associated with low rates of postoperative complications, patients undergoing neoadjuvant chemoradiation seem to be at increased risk for suture line dehiscence. In this setting, we compared the clinical outcomes of patients undergoing transanal endoscopic microsurgery with and without neoadjuvant chemoradiation. METHODS: Thirty-six consecutive patients were treated by transanal endoscopic microsurgery at a single institution. Twenty-three patients underwent local excision after neoadjuvant chemoradiation therapy for rectal adenocarcinoma, and 13 patients underwent local excision without any neoadjuvant treatment for benign and malignant rectal tumors. Chemoradiation therapy included 50.4 to 54 Gy and 5-fluorouracil-based chemotherapy. All patients underwent transanal endoscopic microsurgery with primary closure of the rectal defect. Complications (immediate and late) and readmission rates were compared between groups. RESULTS: Overall, median hospital stay was 2 days. Immediate (30-d) complication rate was 44% for grade II/III complications. Patients undergoing neoadjuvant chemoradiation therapy were more likely to develop grade II/III immediate complications (56% vs 23%; P = .05). Overall, the 30-day readmission rate was 30%. Wound dehiscence was significantly more frequent among patients undergoing neoadjuvant chemoradiation therapy (70% vs 23%; P = .03). Patients undergoing neoadjuvant chemoradiation therapy were at significantly higher risk of requiring readmission (43% vs 7%; P = .02). CONCLUSION: Transanal local excision with the use of endoscopic microsurgical approach may result in significant postoperative morbidity, wound dehiscence, and readmission rates, in particular, because of rectal pain secondary to wound dehiscence. In this setting, the benefits of this minimally invasive approach either for diagnostic or therapeutic purposes become significantly restricted to highly selected patients that can potentially avoid a major operation but will still face a significantly morbid and painful procedure.

Tratamento da doença de Crohn com infliximabe: primeira opção? / Treatment of Crohn's disease with infliximab: first choice?

RACIONAL: A doença de Crohn é uma inflamação crônica do trato gastrointestinal ainda de difícil tratamento. Há busca permanente de novos agentes que possam colaborar com a melhoria dos resultados. O infliximabe é um anticorpo monoclonal quimérico anti-fator de necrose tumoral alfa e está indicado na doença de Crohn refratária e fistulizante. OBJETIVO: Observar os resultados do tratamento da doença de Crohn com o anti-fator de necrose tumoral alfa. MÉTODOS: Estudo prospectivo de 60 doentes com doença de Crohn no período de seis anos. Foram considerados como critérios de exclusão: infecção atual ou nos últimos três meses; diagnóstico de tuberculose; quadro clínico e/ou radiológico de oclusão intestinal parcial ou total; gravidez ou amamentação. Todos os doentes foram previamente submetidos à radiografia do tórax, leucograma e intradermo reação para tuberculose. Foram tratados com infliximabe na dose de 5mg/kg de peso, aplicado por via endovenosa a intervalos de dois meses. Os doentes foram divididos em três grupos de acordo com o tempo de doença, isto é, grupo 1 aqueles com até cinco anos de diagnóstico, grupo 2 com seis até 10 anos e grupo 3 com mais de 10 anos de diagnóstico. Os resultados foram considerados subjetivamente através de protocolo após cada aplicação como: melhor, pior ou inalterado em relação ao estado geral do doente, sintomas intestinais e doença perianal. RESULTADOS: No tratamento inicial 76% dos pacientes responderam ao anticorpo. Observou-se que após a primeira dose da medicação, os com mais de 10 anos de doença e submetidos à operação abdominal tiveram resultado satisfatório semelhantemente aqueles doentes com menos de cinco anos de doença e não operados (62,5% e 80% respectivamente dos doentes que melhoraram), sendo este resultado estatisticamente significativo. CONCLUSÃO: O tratamento com infliximabe mostrou-se eficaz e tolerável no manejo dos sintomas dos pacientes com doença de Crohn ativa que não respondem ao tratamento convencional.

BACKGROUND: Crohn´s disease is a chronic inflammatory disorder of the gastrointestinal tract with difficult management. Infliximab is a chimeric IgG1 monoclonal antibody against tumor necrosis factor and is indicated for refractory luminal and fistulization in Crohn's disease. AIM: To observe the outcome of 60 patients with diagnosis of Crohn´s disease treated with infliximab. METHODS: Prospective study with 60 patients with Crohn´s disease in six years of observation. Exclusion criteria were: clinical infection in at last three months; tuberculosis; intestinal occlusion; pregnancy. All patients were submitted to thorax X-rays, leukogram, tuberculosis cutaneous test. They were treated with infliximabe 5mg/kg each two months. They were divided into three groups according to the time of the diagnosis: 5 years, 6 to 10 and more than 10 years. The results were considered better, worse or unchanged. RESULTS: After the initial treatment, 76% of the patients achieved a response. At the first dose, the ones with 10 years and with associated abdominal surgery had good results and similar to the ones with less than 5 years with no operations. CONCLUSION: The treatment with infliximab was effective and tolerable in the managing of symptoms in patients with active Crohn´s disease, refractory to the conventional treatment and can be a reasonable approach to avoid the surgical treatment.

Acesso vídeo-laparoscópico no tratamento cirúrgico da diverticulite aguda / The vídeolaparoscopic access in the surgical treatment of acute diverticular disease

A revisão de conceitos baseada na literatura recente relacionada ao tratamento da doença diverticular dos cólons pelo acesso vídeolaparoscópico é apresentada ao lado das indicações de formas de tratamento clássicas. A dupla abordagem videolaparoscópica, imediata para tratamento da peritonite seguida da ressecção tornada eletiva é a modalidade nova na literatura, mas ainda não padronizada. Discutem os autores dados relativos a esta tática e de outros estudos que podem ampliar o emprego desta abordagem.

This review is based on standards of treatment for diverticular disease, both classical and new ones due to cumulated videolaparoscopic experience. The sequential double videolaparoscopic procedure for acute diverticulitis is discussed along with data from other studies supporting this novel modality of surgical treatment.