RISK FACTORS FOR EARLY POSTOPERATIVE COMPLICATIONS IN ACUTE COLITIS IN THE ERA OF BIOLOGIC THERAPY

BACKGROUND

Despite major advances in the clinical treatment of inflammatory bowel disease, some patients still present with acute colitis and require emergency surgery.

AIMS

To evaluate the risk factors for early postoperative complications in patients undergoing surgery for acute colitis in the era of biologic therapy.

METHODS

Patients with inflammatory bowel disease admitted for acute colitis who underwent total colectomy at a single tertiary hospital from 2012 to 2022 were evaluated. Postoperative complications were graded according to Clavien-Dindo classification (CDC). Patients with more severe complications (CDC≥2) were compared with those with less severe complications (CDC<2).

RESULTS

A total of 46 patients underwent surgery. The indications were: failure of clinical treatment (n=34), patients' or surgeon's preference (n=5), hemorrhage (n=3), toxic megacolon (n=2), and bowel perforation (n=2). There were eight reoperations, 60.9% of postoperative complications classified as CDC≥2, and three deaths. In univariate analyses, preoperative antibiotics use, ulcerative colitis diagnosis, lower albumin levels at admission, and preoperative hospital stay longer than seven days were associated with more severe postoperative complications.

CONCLUSIONS

Emergency surgery for acute colitis was associated with a high incidence of postoperative complications. Preoperative use of antibiotics, ulcerative colitis, lower albumin levels at admission, and delaying surgery for more than seven days were associated with more severe early postoperative complications. The use of biologics was not associated with worse outcomes.

Gastric and Duodenal Fistulas in Crohn's Disease, a Surgical Challenge: Report of 5 Cases and a Review of the Literature

BACKGROUND Fistulas involving the stomach and duodenum in Crohn's disease are rare (occurring in less than 1% of patients). Here, we reviewed registers from 855 patients with Crohn's disease treated in our service from January 2007 to December 2020 and found 4 cases of duodenal fistula and 1 case of gastric fistula. CASE REPORT The fistula origin was in the ileocolic segment in all cases, and all of the patients underwent preoperative optimization with improvement of nutritional status and infection control. They then underwent surgical treatment with resection of the affected segment and duodenal or gastric closure with covering by an omental patch. One case of a duodenal fistula was complicated by duodenal dehiscence. This was treated surgically with duodenojejunostomy. Each of the other patients had an uneventful postoperative course. All patients were successfully cured of their gastroduodenal fistulas, and at the time of this publication, none of them died or had fistula recurrence. CONCLUSIONS Fistulas with the involvement of the stomach and duodenum in patients with Crohn's disease are almost always due to inflammation in the ileum, colon, or previous ileocolic anastomosis. Management of this situation is complex and often requires clinical and surgical assistance; preoperative optimization of the patient's general condition can improve the surgical results. The surgical approach is based on resection of the affected segment and gastric or duodenal closure with covering by an omental patch. Gastrojejunostomy or duodenojejunostomy can be performed in selected patients with larger defects and minor jejunal disease. To prevent recurrence, prophylactic therapy with anti-TNF agents and early endoscopic surveillance are also essential for successful treatment.

The relationship of major depressive disorder with Crohn's disease activity

INTRODUCTION

Crohn's disease (CD) has been related to an increased prevalence of psychiatric disorders and suicide risk (SR). However, the nature of their relationship still deserves clarification. The aim of this study is to assess the prevalence of major depressive disorder (MDD) in patients with CD, and to investigate the relationship between MDD and CD outcomes.

METHODS

A cross-sectional study involving CD patients was performed. CD activity was evaluated by the Harvey-Bradshaw index and CD phenotype by the Montreal classification. The presence of MDD was assessed by the Patient Health Questionnaire score-9 (PHQ-9). Sociodemographic data and other characteristics were retrieved from electronic medical records.

RESULTS

283 patients with CD were included. The prevalence of MDD was 41.7%. Females had a risk of MDD 5.3 times greater than males. CD disease duration was inversely correlated with MDD severity. Individuals with active CD were more likely to have MDD (OR = 796.0; 95% CI 133.7‒4738.8) than individuals with CD remission. MDD was more prevalent in inflammatory behavior (45.5%) and there were no statistical differences regarding the disease location. 19.8% of the sample scored positive for SR.

CONCLUSION

The present results support data showing an increased prevalence of MDD in individuals with CD. Additionally, it indicates that MDD in CD might be related to the activity of CD. Prospective studies are warranted to confirm these results and to address whether MDD leads to CD activity, CD activity leads to MDD or both ways are existent.

Case Series of Right Colon Diverticulitis in the West: A Neglected Disease?

Introduction Right colon diverticulitis (RCD) is an uncommon condition in Western populations, but its incidence has increased over the last decades. Due to its rarity, many surgeons are unfamiliar with this disease, which is often mistakenly diagnosed as acute appendicitis. The lack of data about the diagnosis and management of RCD in Western populations makes it difficult to establish the optimal therapeutic strategy.

Objective To evaluate the outcomes of patients treated for acute RCD and to propose a therapeutic algorithm for the diagnosis and treatment.

Methods A retrospective analysis of the medical records of patients treated for acute RCD between 2008 and 2020 by a single experienced colorectal surgeon was performed.

Results In total, 12 patients were identified, 8 male and 4 female subjects, with a mean age of 49.6 years; 9 of these patients were of Western origin. The median follow-up time was of 49 months (range: 12 to 144 months). The most frequent symptoms were abdominal pain (100%) and fever (66%). Diagnostic errors in imaging exams occurred in four patients. A total of 6 patients were managed clinically, and the other 6 underwent surgical treatment with right colectomy (n = 5) and total colectomy (n = 1), 2 via laparoscopy and 4 through a laparotomy. The anatomopathological examination confirmed RCD in all operated patients. There was no incidental finding of neoplasia and there were no deaths during the study period.

Conclusion Uncomplicated RCD can be treated conservatively with a high success rate. Recurrent cases that impact quality of life or complicated forms of RCD should undergo surgical treatment, preferably through a right laparoscopic colectomy. The authors present a diagnostic and therapeutic algorithm to facilitate the diagnosis and to guide the management of this uncommon disease.

Fournier’s Gangrene During Pregnancy in a Patient with Crohn’s Disease

Patient: Female, 29-year-old

Final Diagnosis: Crohn’s associated Perianal and perirectal abscess • Fournier’s gangrene

Symptoms: Anal pain

Medication: —

Clinical Procedure: —

Specialty: Surgery

Anorectal Mucosal Melanoma: A Case Report and Literature Review

BACKGROUND Anorectal mucosal melanoma (AMM) is a rare and aggressive neoplasm, with a 5-year survival rate of 10%. Due to its rarity and nonspecific symptoms, the diagnosis is often made late. Surgical resection remains the criterion standard for treatment of anorectal melanoma. CASE REPORT We present the case of an 81-year-old woman presenting with hematochezia, anal secretion, tenesmus, difficulty in defecation, and perianal pain. On physical examination, there was a prolapse of a 5-cm melanocytic nodule in the anal canal, hard on palpation. Biopsy confirmed anorectal melanoma. Staging revealed anal and metastatic disease, with adrenal, lymphatic, and hepatic involvement. As the patient continued to have bleeding, severe pain, and difficulty in defecation, she was submitted to a wide local excision. At 5-month follow-up, the anal lesion had relapsed, and the patient died 10 months after the procedure. CONCLUSIONS AMM is a rare and extremely aggressive tumor. Symptoms are nonspecific but early diagnosis should be pursued to allow curative treatment. Surgical resection with free margins is the goal of surgical treatment. New therapies are being studied, including immunotherapy, which can improve the dismal prognosis of this rare disease.

A NEW APPROACH FOR HEMORRHOID DISEASE: SELECTIVE DEARTERIALIZATION AND MUCOPEXY WITHOUT DOPPLER GUIDANCE

Background:

Transanal hemorrhoidal dearterialization (THD) is safe and effective minimally invasive treatment for hemorrhoidal disease, but reports regarding recurrence and postoperative complications (pain and tenesmus) vary significantly.

Aim:

To evaluate if selective dearterialization and mucopexy at the symptomatic hemorrhoid only, without Doppler guidance, achieves adequate control of the prolapse and bleeding and if postoperative morbidity is reduced with this technique.

Methods:

Twenty consecutive patients with grade II and III hemorrhoids were treated with this new approach and were evaluated for postoperative complications and recurrence.

Results:

Control of prolapse and bleeding was achieved in all patients (n=20). Postoperative complications were tenesmus (n=2), external hemorrhoidal thrombosis (n=2) and urinary retention (n=2). After a mean follow-up of 13 months no recurrences were diagnosed.

Conclusion:

Selective dearterialization and mucopexy is safe and achieves adequate control of prolapse and bleeding and, by minimizing sutures in the anal canal, postoperative morbidity is diminished. Doppler probe is unnecessary for this procedure, which makes it also more interesting from an economic perspective.

Is it Safe to Perform Elective Colorectal Surgical Procedures during the COVID-19 Pandemic? A Single Institution Experience with 103 Patients

OBJECTIVES

Since the outbreak of the novel coronavirus disease 2019 (COVID-19), all health services worldwide underwent profound changes, leading to the suspension of many elective surgeries. This study aimed to evaluate the safety of elective colorectal surgery during the pandemic.

METHODS

This was a retrospective, cross-sectional, single-center study. Patients who underwent elective colorectal surgery during the COVID-19 pandemic between March 10 and September 9, 2020, were included. Patient data on sex, age, diagnosis, types of procedures, hospital stay, mortality, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) preoperative screening tests were recorded.

RESULTS

A total of 103 colorectal surgical procedures were planned, and 99 were performed. Four surgeries were postponed due to positive preoperative screening for SARS-CoV-2. Surgical procedures were performed for colorectal cancer (n=90) and inflammatory bowel disease (n=9). Laparoscopy was the approach of choice for 43 patients (43.4%), 53 (53.5%) procedures were open, and 3 (3%) procedures were robotic. Five patients developed COVID-19 in the postoperative period, and three of them died in the intensive care unit (n=3/5, 60% mortality). Two other patients died due to surgical complications unrelated to COVID-19 (n=2/94, 2.1% mortality) (p<0.01). Hospital stay was longer in patients with SARS-CoV-2 infection than in those without (38.4 versushttps://doi.org/10.3 days, respectively, p<0.01). Of the 99 patients who received surgical care during the pandemic, 94 were safely discharged (95%).

CONCLUSION

Our study demonstrated that elective colorectal surgical procedures may be safely performed during the pandemic; however, preoperative testing should be performed to reduce in-hospital infection rates, since the mortality rate due to SARS-CoV-2 in this setting is particularly high.

The novel BPRST classification for hemorrhoidal disease: A cohort study and an algorithm for treatment

BACKGROUND

The classification for HD was developed by Goligher in 1980 and does not contemplate important aspects of this disease, which limits its use in guiding treatment. The aim of this study if to apply in clinical practice the new classification for hemorrhoids named BPRST (bleeding, prolapse, reduction, skin tags, thrombosis), to compare it with the original classification proposed by Goligher and to propose an algorithm for treatment.

MATERIALS AND METHODS

This is a prospective study conducted at the University of São Paulo's teaching hospital and Hospital 9 de Julho. Patients with HD treated from March 2011 to July 2013 were included. Patients were classified according to BPRST and Goligher classifications and treated according to personal experience and most updated guidelines. The association between both classifications and the treatment adopted was compared and an algorithm for treatment was developed.

RESULTS

229 patients were included in this study and 28 patients were lost due to follow-up. According to Goligher, 29, 61, 85 and 26 were classified as grades I, II, III and IV, respectively. According to the BPRST, 23 were classified as stage I, 95 as stage II and 83 as stage III. Six patients classified as Goligher I were reclassified as BPRST stage III and required conventional hemorrhoidectomy, either due to thrombosis (n = 4) or intolerable skin tags (n = 2). The BPRST classification was more closely associated with the type of treatment employed and had few outliers than Goligher (p < 0.001).

CONCLUSION

There are limitations to the use of Goligher's classification in clinical practice. The novel BPRST classification includes important aspects of HD that should be considered when deciding the best treatment option. Our algorithm for treatment contemplates the most commonly used techniques and can help to guide the treatment of this complex disease.

TRANSANAL HAEMORRHOIDAL DEARTERIALIZATION WITH MUCOPEXY (THD-M) FOR TREATMENT OF HEMORRHOIDS: IS IT APPLICABLE IN ALL GRADES? BRAZILIAN MULTICENTER STUDY

Background:

Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades.

Aim:

To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades.

Method:

Seven hundred and five consecutive patients with Goligher’s grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48).

Results:

Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively.

Conclusion:

The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

A New Classification for Hemorrhoidal Disease: The Creation of the "BPRST" Staging and Its Application in Clinical Practice

Purpose

Present an updated classification for symptomatic hemorrhoids, which not only guides the treatment of internal hemorrhoids but also the treatment of external components. In addition, this new classification includes new treatment alternatives created over the last few years.

Methods

Throughout the past 7 years, the authors developed a method to classify patients with symptomatic hemorrhoids. This study, besides presenting this classification proposal, also retrospectively analyzed 149 consecutive patients treated between March 2011 and November 2013 and aimed to evaluate the association between the management adopted with Goligher classification and our proposed BPRST classification.

Results

Both classifications had a statistically significant association with the adopted management strategies. However, the BPRST classification tended to have fewer management discrepancies when each stage of disease was individually analyzed.

Conclusion

Although there is much disagreement about how the classification of hemorrhoidal disease should be updated, it is accepted that some kind of revision is needed. The BPRST method showed a strong association with the management that should be adopted for each stage of the disease. Further studies are needed for its validation, but the current results are encouraging.

Post-esophagectomy Symptomatic Dunbar Syndrome: A rare diagnosis of abdominal pain after surgery

•

Median Arcuate Ligament syndrome (MALS) is also known as Durban syndrome.

•

MALS is a rare condition.

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MALS must be considered in case of refractory post-surgical abdominal pain.

•

Angiotomography is accessible and reliable for making the diagnosis.

Introduction

Dunbar syndrome is a rare anatomical abnormality characterized by the extrinsic compression of the celiac trunk by the median arcuate ligament (MAL). Though it is rarely misdiagnosed, the clinical diagnosis may be difficult, especially after complex visceral surgery such as esophagectomy.

Presentation of case

A 62-year-old male patient with a squamous cell carcinoma of the distal esophagus, placed under trimodal treatment (chemotherapy, radiotherapy followed by hybrid minimal invasive 2-field esophagectomy) presented with abdominal pain refractory to analgesics, anti-spasmodic, opioids, and neuronal celiac plexus ablation in the late post-operative period. He was diagnosed with extrinsic celiac trunk compression based on abdominal angiotomography findings. Retrospectively, similar images were found in conventional abdominal tomography at pre-operative staging, but this time, the patient had only dysphagia. After surgical treatment of MAL, the patient had total relief of pain and symptoms.

Discussion

Abdominal pain after complex surgical procedures is very frequent and its investigation is mandatory, even more after refractory clinical management. Dunbar syndrome is related to ambiguous abdominal pain. It is uncommon and its diagnosis with angiotomography is accessible.

Conclusion

Vascular disorders should be investigated in cases of abdominal pain after complex surgical procedures.

Local treatment of colostomy prolapse with the MESH STRIP technique: A novel and highly efficient day hospital technique

OBJECTIVE

Stoma prolapse is an intussusception of the bowel through a mature stoma. It can be caused by increased intra-abdominal pressure, excessively mobile bowel mesentery and/or a large opening in the abdominal wall at the time of stoma formation. It occurs predominantly in loop stomas, and correction methods include conservative modalities, such as local reduction to the prolapsed bowel, or surgical treatment. The purpose of this study was to describe our experience with the treatment of colostomy prolapse using a novel mesh strip technique.

METHODS

Between February 2009 and March 2018, ten consecutive male patients underwent correction of colostomy prolapse under local anesthesia by peristomal placement of a polypropylene mesh strip. Operation time, short- and long-term complications, and recurrence rates were recorded and analyzed.

RESULTS

No postoperative complications, morbidity or mortality were observed. The median length of the prolapse ranged from 6-20 cm, and the median operative time was 30 minutes. The median duration of follow-up was 25 months (range, 12-89 months). No relapse, mesh strip extrusion, local infection or granuloma formation were found.

CONCLUSION

A simple, fast, and low-cost operation under local anesthesia using a mesh strip is a valuable option to treat colostomy prolapse.

Anoplastia com plicoma sentinela para o tratamento de fissura anal crônica

RESUMO Objetivo: avaliar os resultados de longo prazo da correção de fissuras anais crônicas em pacientes sem hipertonia anal usando a técnica de anoplastia com o plicoma sentinela. Métodos: estudo prospectivo de pacientes com fissura anal crônica refratários ao tratamento conservador e sem hipertonia anal, submetidos à operação de anoplastia com utilização do plicoma anal para cobrir a área cruenta. Foi confirmada a ausência de hipertonia anal através do toque retal e da eletromanometria. Foi aplicado um questionário de dor visual e o escore de incontinência fecal da Cleveland Clinic, antes e após a cirurgia. Resultados: quinze pacientes com fissura anal crônica foram acompanhados por um período médio de 29 meses (12 a 56). A média de idade foi 41 anos (29 a 69) e a duração dos sintomas variou entre seis meses e cinco anos. A cicatrização ocorreu entre três e seis semanas para 13 pacientes (86,7%). Os outros dois pacientes foram submetidos a desbridamento e nova anoplastia, com sucesso. Em nenhum paciente ocorreu necrose do plicoma ou estenose anal. O escore de incontinência anal não se alterou após o procedimento e todos os pacientes referiram melhora da dor. Após 12 meses de seguimento, nenhum paciente apresentou recorrência ou incontinência anal e 93,3% (14/15) dos pacientes responderam estar muito satisfeitos. Conclusão: fissurectomia e anoplastia com o uso do plicoma sentinela é uma técnica segura que resulta em melhora da dor sem alterações da continência fecal e com altas taxas de satisfação.

MANAGEMENT OF ACUTE SEVERE ULCERATIVE COLITIS: A CLINICAL UPDATE

Introduction:

Acute severe colitis is a potentially lethal medical emergency and, even today, its treatment remains a challenge for clinicians and surgeons. Intravenous corticoid therapy, which was introduced into the therapeutic arsenal in the 1950s, continues to be the first-line treatment and, for patients who are refractory to this, the rescue therapy may consist of clinical measures or emergency colectomy.

Objective:

To evaluate the indications for and results from drug rescue therapy (cyclosporine, infliximab and tacrolimus), and to suggest a practical guide for clinical approaches.

Methods:

The literature was reviewed using the Medline/PubMed, Cochrane library and SciELO databases, and additional information from institutional websites of interest, by cross-correlating the following keywords: acute severe colitis, fulminating colitis and treatment.

Results:

Treatments for acute severe colitis have avoided colectomy in 60-70% of the cases, provided that they have been started early on, with multidisciplinary follow-up. Despite the adverse effects of intravenous cyclosporine, this drug has been indicated in cases of greater severity with an imminent risk of colectomy, because of its fast action, short half-life and absence of increased risk of surgical complications. Therapy using infliximab has been reserved for less severe cases and those in which immunosuppressants are being or have been used (AZA/6-MP). Indication of biological agents has recently been favored because of their ease of therapeutic use, their good short and medium-term results, the possibility of maintenance therapy and also their action as a "bridge" for immunosuppressant action (AZA/6-MP). Colectomy has been reserved for cases in which there is still no response five to seven days after rescue therapy and in cases of complications (toxic megacolon, profuse hemorrhage and perforation).

Conclusion:

Patients with a good response to rescue therapy who do not undergo emergency operations should be considered for maintenance therapy using azathioprine. A surgical procedure is indicated for selected cases.

THERAPIES FOR CROHN'S DISEASE: a clinical update

The main objectives of clinical therapy in Crohn's disease are clinical and endoscopic remission without the use of corticosteroids for long periods of time, prevention of hospitalization and surgery, and improvement of quality of life. The main limitation of drug therapy is the loss of response over the long term, which makes incorporation of new drugs to the therapeutic arsenal necessary. This review analyses the main drugs currently used in clinical treatment of Crohn's disease.