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

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

Risk factors for a definitive colostomy in patients with squamous cell anal cancer and stomas formed before chemoradiation

Introdução: O carcinoma espinocelular (CEC) anal é um tumor relativamente raro mas de incidência crescente. O tratamento padrão com quimiorradioterapia (QRT) concomitante permite que muitos pacientes evitem a amputação abdominoperineal de reto e a colostomia definitiva. No entanto, tumores avançados podem se apresentar com complicações locais que requerem uma derivação intestinal previamente ao início da QRT. O desfecho destes estomas é incerto e pouco estudado na literatura. O objetivo deste estudo é avaliar os pacientes com CEC anal submetidos à derivação intestinal previamente à QRT em relação ao desfecho do estoma e aos fatores de risco associados à sua permanência definitiva. Métodos: Foi realizado estudo de coorte retrospectivo através de análise de prontuários de pacientes tratados no Instituto do Câncer do Estado de São Paulo (ICESP-HCFMUSP) entre janeiro de 2008 e dezembro de 2020, diagnosticados com CEC anal e submetidos à derivação intestinal previamente ao início da QRT com intuito curativo. Foram excluídos pacientes tratados com intuito paliativo. Foram avaliados dados demográficos, clínicos, do estadiamento do tumor, do tratamento oncológico, sobre o desfecho do estoma e as suas complicações a curto e longo prazo. Foram analisados a taxa de reversão dos estomas pré-QRT e os fatores de risco relacionados à sua permanência definitiva. Resultados: No período estudado foram tratados 651 pacientes com CEC anal no ICESP-HCFMUSP. Destes, 82 foram submetidos à derivação intestinal previamente à QRT, mas 17 foram excluídos deste estudo, sendo 11 por doença metastática ao diagnóstico e 6 por óbito antes de iniciar o tratamento oncológico. Ao final, 65 pacientes foram avaliados. Os motivos para confecção da colostomia foram obstrução intestinal (n=28, 43,1%), fístula retovaginal (n=13, 20%) e infecção perianal (n=24, 36,9%). Após seguimento médio de 35,8 ± 27,6 meses, 9 pacientes (13,8%) reconstruíram o trânsito intestinal. Em análise univariada, sexo masculino (p=0,013), baixo status funcional (ECOG 2) (p=0,023), tumores volumosos (p=0,045), infecção perianal (p=0,010), QT com cisplatina (p=0,047) e interrupções na RT por período maior que sete dias (p=0,010) foram fatores de risco de permanência definitiva do estoma. Conclusão: A maioria das colostomias realizadas pré-QRT nos pacientes com CEC anal são definitivas. Os fatores de risco associados à sua permanência são: sexo masculino, baixo status funcional (ECOG 2), tumores volumosos, derivação intestinal por infecção perianal, QT com cisplatina e interrupções na RT por período maior que 7 diasIntroduction: Squamous cell anal cancer (SCC) is a relatively rare gastrointestinal tumor although the incidence has increased over the last decades. The current standard of care is concurrent chemoradiation (CRT), which allows for tumor eradication while preserving the anal sphincter and possibly avoiding a definitive stoma. However, advanced tumors with local complications, such as intestinal obstruction, rectovaginal fistulas or perianal sepsis, may require pretreatment stomas in order to alleviate symptoms and avoid interruptions during CRT. The fate of pretreatment stomas is uncertain and limited data exist in the literature. The aim of this study is to evaluate the reversal rate of pretreatment stomas and the risk factors associated with a definitive stoma. Methods: This was a retrospective cohort study, which included patients treated at the Instituto do Câncer do Estado de São Paulo (ICESP-HCFMUSP) from January 2008 to December 2020, diagnosed with anal SCC, in whom a stoma was formed before CRT. Palliative patients were excluded. Demographic data, reason for stoma creation, tumor-related characteristics, chemotherapy regimen, radiotherapy dose and interruptions, reversal of the stoma, short- and long-term complications, and the risk factors associated with a definitive stoma were evaluated. Results: 651 patients with anal SCC were identified and 82 required pretreatment stomas. 17 were excluded, either due to metastatic disease (n=11) or death prior to initiating CRT (n=6). Finally, 65 patients were included. A stoma was needed for intestinal obstruction (n=28, 43.1%), rectovaginal fistula (n=13, 20%) and perianal sepsis (n=24, 36.9%). A total of 9 patients (13.8%) reversed their stomas after a mean follow-up of 35.8 ± 27.6 months. In univariate analysis, male gender (p=0.013), low performance status (ECOG 2) (p=0.023), large tumors (p=0.045), perianal sepsis (p=0.010), cisplatin-based chemotherapy (p=0.047) and interruptions during RT for more than 7 days (p=0.010) were associated with a definitive stoma. Conclusion: Pretreatment stomas are unlikely to be reversed and the risk factors for a definitive stoma are: male gender, perianal sepsis, low performance status (ECOG 2), large tumors, cisplatin-based chemotherapy and interruptions during radiotherapy for more than 7 day

TREATMENT OF ANEMIA AND IMPROVEMENT OF QUALITY OF LIFE AMONG PATIENTS WITH CROHN'S DISEASE: experience using ferric carboxymaltose

Objectives - Anemia is the most common hematological alteration in patients with Crohn's disease, and is frequently related to intestinal inflammatory activity. Its cause is multifactorial and mostly associated with absolute iron deficiency (iron deficiency anemia) and/or functional iron deficiency (inflammation anemia or anemia of chronic disease). It may also be identified through other causes, such as folic acid or vitamin B12 deficiency and secondary to adverse effects from medications (salicylic derivatives and immunosuppressive drugs). In the present study, patients with active Crohn's disease and anemia were evaluated and treated with intravenous ferric carboxymaltose. We discuss the therapeutic schemes (doses), safety, results and improvement of quality of life. Methods - In the present prospective study, 10 consecutive patients with Crohn's disease, with moderate to severe activity, with anemia (Hb: 6.7 to 10 g/dL), who were attended between March 2014 and March 2015, were evaluated. Six (60%) were men and four were women, all with moderate or severe anemia (hemoglobin <10 g/dL). They were treated with a maximum of three intravenous infusions of 1000 mg of ferric carboxymaltose, of at least 15 minutes in duration. It was also sought to correlate the inflammatory Crohn's disease activity degree (measured using the Crohn's Disease Activity Index, CDAI) and C-reactive protein level with the severity of anemia. The primary outcome was an increase in Hb of &#8805;2 g/dL and the secondary outcome was the normalization of anemia (Hb &#8805;12 g/dL for women and &#8805;13 g/dL for men) and the improvement in quality of life seen 12 weeks after the last application of carboxymaltose. Results - Among the 10 patients studied, parenteral iron supplementation was administered in three cases during hospitalization and the others received this on an outpatient basis. The total iron dose ranged from 1,000 to 2,000 mg, with an average of 1,650 mg. Crohn's disease activity measured using CDAI and C-reactive protein correlated with the intensity of anemia. An increase of 2 g/dL occurred in eight (80%) patients after 12 weeks and normalization of anemia was found in seven (70%) patients. Improvements in quality-of-life scores were found for all (100%) patients after 12 weeks. Carboxymaltose was well tolerated. Three patients presented adverse reactions (two with nausea and one with headache) of mild intensity. Conclusions - Anemia is a frequent complication for Crohn's disease patients. Intravenous iron therapy has been recommended for Crohn's disease patients, because for these patients, oral iron absorption is very limited. This is because of the inflammatory state and "blocking" of iron entry into enterocytes through hepcidin action on ferroportin, along with the elevated rates of gastrointestinal adverse events that compromise adherence to treatment and possibly aggravate the intestinal inflammatory state. The degree of Crohn's disease activity, as measured using CDAI and C-reactive protein, correlates with the severity of anemia. Carboxymaltose is a safe drug, which can be administrated in high doses (up to 1,000 mg per application per week) and corrects anemia and iron stocks over a short period of time, with consequent improvement in quality of life

THERAPIES FOR CROHN'S DISEASE: a clinical update

ABSTRACT 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

Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria

The aim of this study was to evaluate the published professional association guidelines regarding the current diagnosis and treatment of functional intestinal constipation in adults and to compare those guidelines with the authors’ experience to standardize actions that aid clinical reasoning and decision-making for medical professionals. A literature search was conducted in the Medline/PubMed, Scielo, EMBASE and Cochrane online databases using the following terms: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Conclusively, chronic intestinal constipation is a common condition in adults and occurs most frequently in the elderly and in women. Establishing a precise diagnosis of the physiopathology of functional chronic constipation is complex and requires many functional tests in refractory cases. An understanding of intestinal motility and the defecatory process is critical for the appropriate management of chronic functional intestinal constipation, with surgery reserved for cases in which pharmacologic intervention has failed. The information contained in this review article is subject to the critical evaluation of the medical specialist responsible for determining the action plan to be followed within the context of the conditions and clinical status of each individual patient. Resumo: O objetivo deste trabalho foi avaliar os consensos de sociedade de especialistas e guidelines publicados sobre o diagnóstico e tratamento da constipação intestinal crônica em adultos, e confrontar com a experiência dos autores, a fim de padronizar condutas que auxiliem o raciocínio e a tomada de conduta do médico. Foi realizada busca na literatura científica, mais precisamente nas bases de dados eletrônicos Medline/Pubmed, Scielo, EMBASE and Cochrane, tendo sido utilizado os seguintes descritores: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Pode-se concluir que constipação crônica é condição comum em adultos, ocorrendo com maior frequência em idosos e mulheres. Identificar com precisão a fisiopatologia presente na constipação crônica funcional é complexo, requerendo a realização de testes funcionais nos casos refratários. O entendimento da motilidade intestinal e do mecanismo defecatório é importante para o manejo da constipação intestinal crônica funcional, sendo o tratamento cirúrgico indicado para casos selecionados, onde à abordagem medicamentosa não surtiu efeito. As informações contidas neste artigo de revisão devem ser submetidas à avaliação e à crítica do médico especialista responsável pela conduta a ser tomada, frente à sua realidade e ao estado clínico de cada paciente. Keywords: Chronic constipation, Outlet obstruction, Colonic inertia, Laxatives, Surgical treatment, Palavras-chave: Constipação crônica, Disfunção do assoalho pélvico, Inércia cólica, Laxativos, Tratamento cirúrgic

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) (po0.01). Hospital stay was longer in patients with SARS-CoV-2 infection than in those without (38.4 versus 10.3 days, respectively, po0.01). 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

Alternative Techniques for Lateral and Medial Posterior Root Meniscus Repair Without Special Instruments

Improved understanding and treatment of posterior medial and lateral meniscus root tears have attracted increasing interest. These lesions significantly compromise meniscal function, which can result in an outcome resembling total meniscectomy, and are also a potential cause of knee instability. Despite facilitating repair procedures and reducing the operative time for these lesions, all-inside meniscal repair devices are not available in all circumstances or registered for use in all countries worldwide. Furthermore, all-inside arthroscopic devices can be expensive. Therefore, low-cost alternatives for the treatment of these lesions must be identified. We present 2 efficient and safe techniques: an outside-in technique for repairing medial meniscus root tears and a technique using a simple needle inserted through the transtibial tunnel for lateral meniscal root repairs, neither of which requires the use of specific instruments, thus enabling appropriate treatment of posterior medial and lateral meniscus root tears