Tratamento cirúrgico da estenose anal: resultados de 77 anoplastias

PURPOSE: Anal stenosis is a rare, incapacitating, and challenging condition, occurring mainly after hemorrhoidectomy, for which several surgical techniques have been devised. The purpose of this study was to describe early and late (1 year) results of 77 anoplasty operations performed in the Colorectal Unit of our institution. METHODS: From 1977 to 2002, 77 patients with moderate to severe anal stenosis underwent surgery using two sliding graft techniques: 58 underwent Sarner's operation and 19 underwent Musiari's technique. Bilateral flaps were used in 7 patients. RESULTS: Early morbidity was due to pruritus occurring in 2 patients, urinary infection in 1, and temporary incontinence in 1 patient. One patient needed early reoperation following suture line dehiscence. Late results (1 year) were classified as good in 67 cases (87%). There was no reoperation due to recurrence of stenosis. CONCLUSION: The ease of performance, good functional results, and lack of severe complications show that Sarner's and Musiari's flap advancement techniques are effective and safe methods for surgical correction of anal stenosis, particularly when cutaneous fibrosis plays a major role in its etiology.OBJETIVO: A estenose anal é uma condição rara, incapacitante e desafiadora que ocorre principalmente após hemorroidectomia, para a qual diversas técnicas cirúrgicas reparadoras foram desenvolvidas. O objetivo deste estudo é descrever os resultados precoces e tardios (um ano) de 77 anoplastias realizadas no Serviço de Cirurgia Colorretal. MÉTODOS: No período de 1977 a 2002, 77 pacientes com estenose anal moderada ou grave foram operados, utilizando-se duas técnicas diferentes de avanço de retalho: 58 foram submetidos à técnica de Sarner e 18 submetidos à Técnica de Musiari. Avanços bilaterais foram utilizados em sete pacientes. RESULTADOS: As complicações precoces foram: prurido em dois pacientes, infecção urinária em um paciente e incontinência fecal temporária em outro. Um paciente necessitou reoperação precoce por deiscência de linha de sutura. Os resultados tardios foram classificados como bons em 67 (87%). Não houve reoperação por recorrência de estenose. CONCLUSÃO: A facilidade técnica, os bons resultados funcionais e a ausência de complicações graves demonstraram que as técnicas de avanço de retalho de Sarner e Musiari são efetivas e seguras para correção de estenose anal, particularmente nos casos em que a fibrose cutânea é o principal fator etiológico

Cost-benefit in laparoscopic colorectal procedures: comparative analysis with conventional approach

A cirurgia colorretal por vídeo representa procedimento avançado, geralmente associado a custos elevados. No entanto, vantagens observadas na evolução dos pacientes operados por esta via permitem recuperação mais precoce com menor tempo de hospitalização. Uma questão relevante relacionada a este tema diz respeito à dúvida se essas vantagens da cirurgia colorretal por vídeo podem compensar os maiores custos associados a este método. O objetivo deste trabalho foi fazer uma análise crítica dos diversos aspectos envolvidos na relação custo-benefício desta via de acesso em operações colorretais, com base em uma revisão da literatura sobre essa questão.Laparoscopic colorectal surgery is now considered an advanced procedure often associated with great costs. However, the observed advantages in patient's outcome that are operated through this approach include faster recovery and less hospital stay. One important question regarding this issue is: is the laparoscopic colorectal surgery cost effective when compared to the conventional access? The scope of this paper was to make a critical analysis about the aspects that are involved in cost-effectiveness related to laparoscopic colorectal procedures, through a literature review

Preparo intestinal para colonoscopia: manitol vs fosfato de sódio. Resultados de estudo prospectivo e randomizado

MÉTODOS: Oitenta pacientes foram prospectivamente randomizados para receber 750 ml de manitol a 10% (M) ou 180 ml de solução à base de fosfato de sódio (FS), como preparo intestinal para colonoscopia eletiva. Todos os pacientes foram submetidos a avaliação laboratorial (hemoglobina, hematócrito, sódio, potássio, fósforo, cálcio e osmolaridade sérica) antes e depois do preparo. Completado o preparo intestinal, antes da realização do exame, os pacientes foram avaliados por questionário com a finalidade de identificar efeitos indesejáveis e tolerabilidade inerentes à solução empregada. A qualidade do preparo foi avaliada pelo colonoscopista, que desconhecia o tipo de solução empregada. RESULSTADOS: A análise bioquímica demonstrou elevação significativa dos níveis séricos de sódio e fósforo no grupo do FS, bem como uma queda mais acentuada do pótassio e cálcio séricos neste grupo, mas nenhuma destas alterações foi clinicamente sintomática. Não houve diferença significante na incidência de seis efeitos colaterais pesquisados. Seis de oito pacientes do grupo FS que em exame colonóscopico anterior haviam recebido manitol, manifestaram melhor tolerabilidade com a solução de FS. A qualidade do preparo foi considerada excelente ou boa em 85% dos casos preparados com FS e em 82,5% do grupo M (p=0.37). CONCLUSÃO: As duas soluções foram similares quanto à qualidade do preparo e incidência de efeitos colaterais. O menor volume necessário para o preparo com FS parece estar relacionado com uma melhor tolerabilidade desta solução. No entanto, a retenção dos íons sódio e fosfato com o uso da solução de FS torna desaconselhável seu emprego em pacientes com insuficiência renal, cirrose e insuficiência cardíaca.METHOD: Eighty patients were prospectively randomized for precolonoscopic cleansing either with 750 ml of 10% mannitol (Group M) or 180 ml of a sodium phosphate preparation (Group NaP). Laboratory examinations before and after preparation on all patients included hemoglobin, hematocrit, sodium, potassium, phosphorous, calcium and serum osmolarity. A questionnaire was used to assess undesirable side effects and patient tolerance to the solution. The quality of preparation was assessed by the endoscopist who was unaware of the solution employed. RESULTS: Statistically significant changes were verified in serum sodium, phosphorous, potassium and calcium between the two groups, but no clinical symptoms were observed. There were no significant differences in the frequency of side effects studied. Six of the eight patients in Group NaP who had taken mannitol for a previous colonoscopy claimed better acceptance of the sodium phosphate solution. The endoscopic-blinded trial reported excellent or good bowel preparation in 85% prepared with sodium phosphate versus 82.5% for mannitol (p=0.37). CONCLUSIONS: Quality of preparation and frequency of side effects was similar in the two solutions. The smaller volume of sodium phosphate necessary for preparation seems to be related to its favorable acceptance. Nevertheless, the retention of sodium and phosphate ions contraindicates the use of sodium phosphate in patients with renal failure, cirrhosis, ascites, and heart failure

Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Computerized videodefecography versus defecography: do we need radiographs?

CONTEXT AND OBJECTIVE: Defecography has been recognized as a valuable method for evaluating patients with evacuation disorders. It consists of the use of static radiography and fluoroscopy to record different situations within anorectal dynamics. Conventionally, rectal parameters are measured using radiograms. It is rare for fluoroscopy alone to be used. Computer software has been developed with the specific aim of calculating these measurements from digitized videotaped images obtained during fluoroscopy, without the need for radiographic film, thereby developing a computerized videodefecography method. The objective was thus to compare measurements obtained via computerized videodefecography with conventional measurements and to discuss the advantages of the new method. DESIGN AND SETTING: Prospective study at the radiology service of Hospital das Clínicas, Universidade de São Paulo. METHOD: Ten consecutive normal subjects underwent videodefecography. The anorectal angle, anorectal junction, puborectalis muscle length, anal canal length and degree of anal relaxation were obtained via the conventional method (using radiography film) and via computerized videodefecography using the ANGDIST software. Measurement and analysis of these parameters was performed by two independent physicians. RESULTS: Statistical analysis confirmed that the measurements obtained through direct radiography film assessment and using digital image analysis (computerized videodefecography) were equivalent. CONCLUSIONS: Computerized videodefecography is equivalent to the traditional defecography examination. It has the advantage of offering reduced radiation exposure through saving on the use of radiography