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Sobrado LF, Mori FNC, Facanali CBG, Camargo MGM, Nahas SC, Sobrado CW. RISK FACTORS FOR EARLY POSTOPERATIVE COMPLICATIONS IN ACUTE COLITIS IN THE ERA OF BIOLOGIC THERAPY. Arq Bras Cir Dig 2023; 36:e1770. [PMID: 37878974 PMCID: PMC10595074 DOI: 10.1590/0102-672020230052e1770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/30/2023] [Indexed: 10/27/2023]
Abstract
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.
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Affiliation(s)
- Lucas Faraco Sobrado
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | - Fernando Noboru Cabral Mori
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | | | - Mariane Gouvea Monteiro Camargo
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | - Sérgio Carlos Nahas
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | - Carlos Walter Sobrado
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
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Sobrado LF, Frugis MO, Sobrado CW. Laparoscopic Enterectomy With Intracorporeal Anastomosis for Stricturing Crohn's Disease of the Small Bowel. Dis Colon Rectum 2023; 66:e1047. [PMID: 37379159 DOI: 10.1097/dcr.0000000000002608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Affiliation(s)
- Lucas Faraco Sobrado
- Colorectal Surgery Division, Department of Gastroenterology, Clinics Hospital, University of São Paulo School of Medicine, São Paulo, Brazil
- Digestive Surgery Division, Hospital 9 de Julho, São Paulo, Brazil
| | | | - Carlos Walter Sobrado
- Colorectal Surgery Division, Department of Gastroenterology, Clinics Hospital, University of São Paulo School of Medicine, São Paulo, Brazil
- Digestive Surgery Division, Hospital 9 de Julho, São Paulo, Brazil
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Boarini LR, Sobrado CW, Mota GR, Villa LL, de Albuquerque IC, Queiroz NSF, Facanali CBG, Nadal SR, Cecconello I. Perianal fistulizing Crohn's disease is associated with a higher prevalence of HPV in the anorectal fistula tract. A comparative study. Clinics (Sao Paulo) 2023; 78:100219. [PMID: 37257365 PMCID: PMC10244904 DOI: 10.1016/j.clinsp.2023.100219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 05/03/2023] [Accepted: 05/12/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND & AIMS Perianal fistulizing Crohn's disease is the main risk factor for anal cancer in patients with inflammatory bowel disease. Whether this occurs due to a higher frequency of human papillomavirus remains unclear. The authors aimed to evaluate the prevalence of HPV and high-risk HPV in patients with perianal Crohn's disease, compared with a control group. METHODS The authors conducted a two-center cross-sectional study in which perianal fistulizing Crohn's disease patients were matched for age and sex with patients with anorectal fistula without Crohn's disease. Biopsy specimens were obtained from fistulous tracts during examination under anesthesia for both groups. The samples were sent for HPV detection and genotyping using the INNO-LiPA test. RESULTS A total of 108 subjects (54 in each group) were recruited. The perianal fistulizing Crohn's disease group showed a statistically higher frequency of HPV in the fistulous tract than the control group (33.3% vs. 16.7%; p = 0.046). Separate analyses on high-risk types demonstrated that there was a numerically higher frequency of HPV in the perianal fistulizing Crohn's disease group. In multiple logistic regression, patients with perianal fistulizing Crohn's disease were found to have a chance of HPV 3.29 times higher than patients without Crohn's disease (OR = 3.29; 95% CI 1.20‒9.01), regardless of other variables. The types most frequently identified in the perianal fistulizing Crohn's disease group were HPV 11 (12.96%) and HPV 16 (9.26%). CONCLUSION Perianal fistulizing Crohn's disease is associated with a higher prevalence of HPV than in patients with anorectal fistula without Crohn's disease.
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Affiliation(s)
- Lucas Rodrigues Boarini
- Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Carlos Walter Sobrado
- Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Giana Rabello Mota
- Centro de Investigação Translacional em Oncologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luisa Lina Villa
- Centro de Investigação Translacional em Oncologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Natalia Sousa Freitas Queiroz
- Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Ivan Cecconello
- Departamento de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Sobrado LF, Pinto RA, Sobrado CW. Laparoscopic Frykman-Goldberg procedure for internal rectal prolapse and chronic constipation - A video vignette. Colorectal Dis 2023; 25:344-345. [PMID: 36112143 DOI: 10.1111/codi.16333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/29/2022] [Accepted: 09/01/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Lucas Faraco Sobrado
- Colorectal Division, Hospital das Clínicas HCFMUSP, University of São Paulo, Brazil, São Paulo, Brazil
| | - Rodrigo Ambar Pinto
- Colorectal Division, Hospital das Clínicas HCFMUSP, University of São Paulo, Brazil, São Paulo, Brazil
| | - Carlos Walter Sobrado
- Colorectal Division, Hospital das Clínicas HCFMUSP, University of São Paulo, Brazil, São Paulo, Brazil
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Sobrado LF, Caldas TG, Facanali CG, Bustamente-Lopez L, Sobrado CW. Case Series of Right Colon Diverticulitis in the West: A Neglected Disease? Journal of Coloproctology 2022. [DOI: 10.1055/s-0042-1757953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
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.
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Affiliation(s)
- Lucas Faraco Sobrado
- Division of Colorectal Surgery, Department of Gastroenterology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
- Department of Oncology and Proctology, Instituto de Gastrocirurgia, Oncologia e Proctologia (IGOP), São Paulo, São Paulo, Brazil
| | - Tarsila Gomes Caldas
- Division of Colorectal Surgery, Department of Gastroenterology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Carolina Graciolli Facanali
- Division of Colorectal Surgery, Department of Gastroenterology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Leonardo Bustamente-Lopez
- Division of Colorectal Surgery, Department of Gastroenterology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Carlos Walter Sobrado
- Division of Colorectal Surgery, Department of Gastroenterology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
- Department of Oncology and Proctology, Instituto de Gastrocirurgia, Oncologia e Proctologia (IGOP), São Paulo, São Paulo, Brazil
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Sobrado LF, Mori FNC, Sobrado CW. Laparoscopic mesh removal due to chronic pelvic pain following ventral rectopexy-a video vignette. Colorectal Dis 2022; 25:815-816. [PMID: 36318601 DOI: 10.1111/codi.16392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/21/2022] [Accepted: 10/23/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Lucas Faraco Sobrado
- Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas HCFMUSP, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Fernando Noboru Cabral Mori
- Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas HCFMUSP, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Carlos Walter Sobrado
- Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas HCFMUSP, University of São Paulo School of Medicine, São Paulo, Brazil
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Abstract
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
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Affiliation(s)
- Lucas Faraco Sobrado
- Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Pedro Averbach
- Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Vitória Ramos Jayme
- Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Mariane Gouvea Monteiro de Camargo
- Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Carlos Walter Sobrado
- Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Sergio Carlos Nahas
- Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
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Abstract
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.
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Affiliation(s)
- José Donizeti de Meira Júnior
- Colorectal Surgery Division, Department of Gastroenterology, Clinical Hospital, University of São Paulo - School of Medicine, São Paulo, SP, Brazil
| | - Lucas Faraco Sobrado
- Colorectal Surgery Division, Department of Gastroenterology, Clinical Hospital, University of São Paulo - School of Medicine, São Paulo, SP, Brazil
| | - Vivian M Guzela
- Colorectal Surgery Division, Department of Gastroenterology, Clinical Hospital, University of São Paulo - School of Medicine, São Paulo, SP, Brazil
| | - Sergio Carlos Nahas
- Colorectal Surgery Division, Department of Gastroenterology, Clinical Hospital, University of São Paulo - School of Medicine, São Paulo, SP, Brazil
| | - Carlos Walter Sobrado
- Colorectal Surgery Division, Department of Gastroenterology, Clinical Hospital, University of São Paulo - School of Medicine, São Paulo, SP, Brazil
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Abstract
Patient: Male, 63-year-old
Final Diagnosis: Spontaneous knot formation in central venous catheter
Symptoms: Central venous catheter whit any flow • associated with pain at the insertion site of the access
Medication: —
Clinical Procedure: Central venous catheterization
Specialty: General and Internal Medicine • Surgery
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Affiliation(s)
| | | | - Carlos Walter Sobrado
- Department of Gastroenterology, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Marcio Roberto Facanali
- Department of Gastroenterology, University of São Paulo, School of Medicine, Santos, SP, Brazil
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Sobrado CW, Sobrado LF, Nahas SC, Cecconello I. A NEW APPROACH FOR HEMORRHOID DISEASE: SELECTIVE DEARTERIALIZATION AND MUCOPEXY WITHOUT DOPPLER GUIDANCE. ACTA ACUST UNITED AC 2021; 34:e1560. [PMID: 34008704 PMCID: PMC8121048 DOI: 10.1590/0102-672020210001e1560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/20/2020] [Indexed: 12/05/2022]
Abstract
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.
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Affiliation(s)
- Carlos Walter Sobrado
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lucas Faraco Sobrado
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Ivan Cecconello
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Sobrado CW, de Almeida Obregon C, Sobrado LF, Bassi LM, Bacchi Hora JA, Silva e Sousa Júnior AH, Nahas SC, Cecconello I. The novel BPRST classification for hemorrhoidal disease: A cohort study and an algorithm for treatment. Ann Med Surg (Lond) 2021; 61:97-100. [PMID: 33437469 PMCID: PMC7785992 DOI: 10.1016/j.amsu.2020.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 10/29/2022] Open
Abstract
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.
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Affiliation(s)
- Carlos Walter Sobrado
- Colorectal Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Carlos de Almeida Obregon
- Colorectal Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lucas Faraco Sobrado
- Colorectal Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lucas Morales Bassi
- Colorectal Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - José Américo Bacchi Hora
- Colorectal Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Sergio Carlos Nahas
- Colorectal Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Ivan Cecconello
- Colorectal Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
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Sakurai Kimura CM, Scanavini Neto A, Queiroz NSF, Horvat N, Camargo MGM, Borba MR, Sobrado CW, Cecconello I, Nahas SC. Abdominal Surgery in Crohn's Disease: Risk Factors for Complications. Inflamm Intest Dis 2020; 6:18-24. [PMID: 33850835 DOI: 10.1159/000510999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/17/2020] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Cintia Mayumi Sakurai Kimura
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Arceu Scanavini Neto
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Natally Horvat
- Department of Radiology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Marcelo Rodrigues Borba
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Carlos Walter Sobrado
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Department of Colon and Rectal Surgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Lima CCG, Queiroz NSF, Sobrado CW, Silva GLR, Nahas SC. CRITICAL ANALYSIS OF ANTI-TNF USE IN THE ERA OF NEW BIOLOGICAL AGENTS IN INFLAMMATORY BOWEL DISEASE. Arq Gastroenterol 2020; 57:323-332. [PMID: 33027484 DOI: 10.1590/s0004-2803.202000000-59] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/29/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Inflammatory bowel diseases (IBD), both Crohn's disease and ulcerative colitis, are chronic immune-mediated diseases that present a relapsing and remitting course and requires long-term treatment. Anti-tumor necrosis factor (anti-TNF) therapy has changed the management of the disease by reducing the need for hospitalizations, surgeries and improving patient´s quality of life. OBJECTIVE The aim of this review is to discuss the role of anti-TNF agents in IBD, highlighting the situations where its use as first-line therapy would be appropriate. METHODS Narrative review summarizing the best available evidence on the topic based on searches in databases such as MedLine and PubMed up to April 2020 using the following keywords: "inflammatory bowel disease'', "anti-TNF agents" and ''biologic therapy''. CONCLUSION Biological therapy remains the cornerstone in the treatment of IBD. In the absence of head-to-head comparisons, the choice of the biological agent may be challenging and should take into account several variables. Anti-TNF agents should be considered as first line therapy in specific scenarios such as acute severe ulcerative colitis, fistulizing Crohn's disease and extra-intestinal manifestations of IBD, given the strong body of evidence supporting its efficacy and safety in these situations.
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Affiliation(s)
- Camila Cunha Gonzaga Lima
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | | | - Carlos Walter Sobrado
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia e Divisão de Coloproctologia, São Paulo, SP, Brasil
| | - Gustavo Luís Rodela Silva
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia e Divisão de Endoscopia Digestiva, São Paulo, SP, Brasil
| | - Sérgio Carlos Nahas
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia e Divisão de Coloproctologia, São Paulo, SP, Brasil
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Facanali MR, Bortolozzo Graciolli Facanali C, Queiroz NSF, Sobrado CW, Nahas SC, Safatle-Ribeiro AV. #Crohn's: Historical Cohort of Twitter Activity. Crohns Colitis 360 2020; 3:otaa075. [PMID: 36777066 PMCID: PMC9802360 DOI: 10.1093/crocol/otaa075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Indexed: 11/13/2022] Open
Abstract
Background Analysis of the Twitter activity on #Crohn's, identifying individuals with interest in Crohn's disease on Twitter. Methods A historic cohort study was conducted about Twitter activity evaluation of #Crohn's analyzed over a period of 9 years. For the Twitter analysis, a health-care social media analytics tool, Symplur Signals, was adopted. Results From 2011 until 2019, 627,000 tweets of #Crohn's were detected, with 276,380 retweets by 109,937 users; of these users, 32.4% were patient advocates and 12.6% were doctors. There was a pattern of annual peak activity of the #Crohn's, mainly in May and December, and less activity, usually in July. Of all tweets, 52.5% were categorized as positive and 47.5% as negative. Conclusions Social media, especially Twitter, represents an important information tool, but it is still underutilized by gastroenterologists. This study suggests a significant interference of international awareness campaigns about inflammatory bowel disease in the activity of #Crohn's on Twitter, denoting an increase in debating this topic on the platform. Discussions on the subject by health professionals are still below expectations regarding the importance of the theme.
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Affiliation(s)
- Marcio Roberto Facanali
- Department of Gastroenterology of Hospital das Clínicas of University of São Paulo Medical School, São Paulo, São Paulo, Brazil
| | - Carolina Bortolozzo Graciolli Facanali
- Department of Gastroenterology of Hospital das Clínicas of University of São Paulo Medical School, São Paulo, São Paulo, Brazil,Address correspondence to: Carolina Bortolozzo Graciolli Facanali, MD, Avenida Doutor Arnaldo, 455, Bairro Cerqueira Cesar, CEP: 01246-903, São Paulo, SP, Brazil ()
| | | | - Carlos Walter Sobrado
- Department of Gastroenterology of Hospital das Clinicas of São Paulo, São Paulo, São Paulo, Brazil
| | - Sérgio Carlos Nahas
- Department of Gastroenterology of Hospital das Clinicas of São Paulo, São Paulo, São Paulo, Brazil
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Sobrado CW, Klajner S, Hora JAB, Mello A, Silva FMLD, Frugis MO, Sobrado LF. TRANSANAL HAEMORRHOIDAL DEARTERIALIZATION WITH MUCOPEXY (THD-M) FOR TREATMENT OF HEMORRHOIDS: IS IT APPLICABLE IN ALL GRADES? BRAZILIAN MULTICENTER STUDY. ACTA ACUST UNITED AC 2020; 33:e1504. [PMID: 32844877 PMCID: PMC7448859 DOI: 10.1590/0102-672020190001e1504] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 01/14/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Carlos Walter Sobrado
- Department of Gastroenterology, Faculty of Medicine, University of São Paulo, SP, Brazil
| | | | | | | | | | | | - Lucas Faraco Sobrado
- Department of Gastroenterology, Faculty of Medicine, University of São Paulo, SP, Brazil
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Queiroz NSF, Barros LL, de Azevedo MFC, Oba J, Sobrado CW, de Sousa Carlos A, Milani LR, Sipahi AM, Damião AOMC. Management of inflammatory bowel disease patients in the COVID-19 pandemic era: a Brazilian tertiary referral center guidance. Clinics (Sao Paulo) 2020; 75:e1909. [PMID: 32321117 PMCID: PMC7153358 DOI: 10.6061/clinics/2020/e1909] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/15/2022] Open
Abstract
The world is fighting the COVID-19 outbreak and health workers, including inflammatory bowel diseases specialists, have been challenged to address the specific clinical issues of their patients. We hereby summarize the current literature in the management of inflammatory bowel disease (IBD) patients during the COVID-19 pandemic era that support the rearrangement of our IBD unit and the clinical advice provided to our patients.
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Affiliation(s)
- Natália Sousa Freitas Queiroz
- Departamento de Gastroenterologia, Hospital das Clinicas
HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author.E-mail:
/
| | - Luísa Leite Barros
- Divisao de Gastroenterologia e Hepatologia Clinica,
Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina,
Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Matheus Freitas Cardoso de Azevedo
- Divisao de Gastroenterologia e Hepatologia Clinica,
Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina,
Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Jane Oba
- Divisao de Gastroenterologia e Hepatologia Clinica,
Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina,
Universidade de Sao Paulo, Sao Paulo, SP, BR
- Instituto da Crianca e do Adolescente (ICr), Hospital das
Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP,
BR
- Corresponding author.E-mail:
/
| | - Carlos Walter Sobrado
- Departamento de Gastroenterologia, Hospital das Clinicas
HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Alexandre de Sousa Carlos
- Divisao de Gastroenterologia e Hepatologia Clinica,
Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina,
Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luciane Reis Milani
- Divisao de Gastroenterologia e Hepatologia Clinica,
Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina,
Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Aytan Miranda Sipahi
- Departamento de Gastroenterologia, Hospital das Clinicas
HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Laboratorio de Gastroenterologia Clinica e Experimental
(LIM07), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo,
Sao Paulo, SP, BR
| | - Aderson Omar Mourão Cintra Damião
- Divisao de Gastroenterologia e Hepatologia Clinica,
Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina,
Universidade de Sao Paulo, Sao Paulo, SP, BR
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Martins CDA, Moss AC, Sobrado CW, Queiroz NSF. Practical Aspects of Proactive TDM for Anti-TNF Agents in IBD: Defining Time Points and Thresholds to Target. Crohn's & Colitis 360 2019. [DOI: 10.1093/crocol/otz049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract
Serum biologic drug concentrations have been associated with favorable therapeutic outcomes in inflammatory bowel diseases, while low or undetectable drug levels have been linked to immunogenicity and treatment failure. Therapeutic drug monitoring (TDM) in the context of clinical relapse can guide decision making and is supported by professional groups. Proactive TDM consists of measurement of trough concentration with the goal of optimizing drug concentration in patients with clinical response/remission. Recent findings suggest that this approach can improve the efficacy of antitumor necrosis factor agents (anti-TNF). In this article, we summarize the rationale for proactive TDM for anti-TNF agents in practice, identify limitations in this evidence base, and provide practical advice for use in the clinic.
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Affiliation(s)
- Camilla de Almeida Martins
- Department of Gastroenterology and Division of Colorectal Surgery, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Alan C Moss
- Director of Crohn’s & Colitis Program, Boston Medical Center, Boston, MA
| | - Carlos Walter Sobrado
- Department of Gastroenterology and Division of Colorectal Surgery, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Natália Sousa Freitas Queiroz
- Department of Gastroenterology and Division of Colorectal Surgery, University of Sao Paulo School of Medicine, São Paulo, Brazil
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Abstract
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.
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Affiliation(s)
- Carlos Walter Sobrado
- Discipline of Coloproctology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Lucas Faraco Sobrado
- Discipline of Coloproctology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, SP, Brazil
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Sobrado CW, Leal RF, Sobrado LF. THERAPIES FOR CROHN'S DISEASE: a clinical update. Arq Gastroenterol 2016; 53:206-11. [PMID: 27438429 DOI: 10.1590/s0004-28032016000300016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/09/2016] [Indexed: 01/22/2023]
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.
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Affiliation(s)
- Carlos Walter Sobrado
- Disciplina de Coloproctologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brasil
| | - Raquel Franco Leal
- Departamento de Cirurgia, Unidade de Coloproctologia, Universidade de Campinas (UNICAMP), Brasil
| | - Lucas Faraco Sobrado
- Disciplina de Coloproctologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brasil
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Bassi MA, Podgaec S, Dias Júnior JA, Sobrado CW, D´Amico Filho N, Abrão MS. Endometriose intestinal: uma doença benigna? Rev Assoc Med Bras (1992) 2009; 55:611-6. [DOI: 10.1590/s0104-42302009000500029] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2008] [Accepted: 03/29/2009] [Indexed: 11/22/2022] Open
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Sobrado CW, Cotti GCDC, Coelho FF, Rocha JRMD. Initial experience with stapled hemorrhoidopexy for treatment of hemorrhoids. Arq Gastroenterol 2007; 43:238-42. [PMID: 17160242 DOI: 10.1590/s0004-28032006000300016] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2005] [Accepted: 12/16/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND Introduction of stapled hemorrhoidopexy by Longo in 1998 represented a radical change in the treatment of hemorrhoids. By avoiding multiple excisions and suture lines in the perianal region, stapled hemorrhoidopexy is intended to offer less postoperative pain than with conventional techniques. OBJECTIVE To report and analyze the intra and postoperative results gained during initial experience with stapled hemorrhoidopexy. METHODS One hundred and fifty five patients (67 males) with average age of 39.5 years (21-67 years) underwent stapled hemorrhoidopexy between June 2000 and December 2003 with symptomatic third-degree (n = 74) and fourth-degree (n = 81) hemorrhoids. Mean follow-up period was 20 months (14-60 months). RESULTS Preoperative symptoms were prolapse (96.7%) and anal bleeding (96.1%). Overall mean operative time was 23 minutes (16-48 minutes). We observed one case of stapler failure and one case of failure to introduce the stapler occurred in a patient with previous anal surgery. Additional sutures for hemostasis were required in 103 patients (66.5%). Resection of skin tags was performed in 45 cases (29%). Postoperatively scheduled analgesia with oral dipyrone and celecoxib was enough for pain control in 131 patients (84.5%). Rescue analgesia was necessary in 24 cases (15.5%). Five patients needed opiates for pain control. Hospital discharge took place on the first postoperative day in 140 patients (90.3%). First defecation without pain was reported by 118 patients (76.1%). Postoperative complications were anal bleeding (10.3%), severe pain (3.2%), urinary retention (3.9%), fever without any signs of perianal infection (1.9%), incontinence for flatus (1.9%), hemorrhoidal thrombosis (1.3%). Two patients presented symptoms of recurrent hemorrhoidal disease and were successfully treated by conventional hemorrhoidectomy. They were no cases of anal stenosis, permanent incontinence, chronic pain or deaths in this series. CONCLUSIONS Hemorrhoidopexy can be considered a feasible and safe alternative technique to conventional hemorroidectomy for select patients.
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Marques CFS, Nahas SC, Nahas CSR, Sobrado CW, Habr-Gama A, Kiss DR. Early results of the treatment of internal hemorrhoid disease by infrared coagulation and elastic banding: a prospective randomized cross-over trial. Tech Coloproctol 2006; 10:312-7. [PMID: 17115317 DOI: 10.1007/s10151-006-0299-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Accepted: 02/14/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rubber band ligation (RBL) is probably the most commonly performed nonsurgical therapy for hemorrhoidal disease. Infrared coagulation (IRC) is one of the most recent advances based on the use of "heat". Recent studies have demonstrated similar efficacy for both modalities. This prospective randomized crossover trial compared IRC and RBL for pain, complications, effectiveness, and patient satisfaction and preference in the treatment of internal hemorrhoids (IH). METHODS Patients were randomized to receive either RBL (Group A) or IRC (Group B) for treatment of the first hemorrhoid; in a second procedure two weeks later, patients underwent the other procedure on the second hemorrhoid, thereby serving as their own control. The procedure preferred by the patient was employed two weeks later for the third hemorrhoid. Post-treatment pain was evaluated on a visual analog scale and on the basis of the percentage of patients requiring analgesics. Bleeding and early outcome of treatment were also recorded, together with the patient's satisfaction. RESULTS A total of 94 patients were included in this study (47 patients in each group). At 30 minutes and 6 hours after treatment, pain scores were significantly higher in patients treated with RBL than in those treated with IRC (p<0.01). There was no significant difference in pain scores between the two procedures immediately and 24 hours after the procedures (p<0.05). After 72 hours and one week, the pain scores for RBL and IRC were similar. The percentage of patients using analgesics was significantly higher in RBL group than in IRC group at 6 hours (29.6% vs. 19.2%, respectively; p<0.05) and 24 hours (22.5% vs. 13.5%, respectively; p<0.05) after treatment. However, significant differences were not noted at 72 hours (12.7% vs. 6.4%; p<0.05) and one week (5.6% vs. 7.1%; p>0.05) after the procedures. There were significantly higher incidences of bleeding immediately, 6 hours, and 24 hours after RBL compared to IRC (immediate: 32.4% vs. 4.3%; 6 hours: 13.4% vs. 3.6%, 24 hours: 26.8% vs. 10.2%, respectively; p<0.01). However, there were no significant differences noted regarding the incidence of bleeding between the two groups at 72 hours. Complications were more likely after RBL than IRC, however this difference was not significant (p>0.05). Overall, 91 patients (96.8%) were successfully treated and 93 patients (99%) were very satisfied with the treatment. In the third treatment session, 50% of patients selected RBL and 50% chose IRC. CONCLUSIONS Both RBL and IRC were well-accepted and highly efficacious methods for the treatment of IH; in addition, both procedures were associated with relatively minor complications. However, RBL was associated with more pain than IRC in the 24-hour postoperative period.
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Affiliation(s)
- C F S Marques
- Colorectal Unit, Department of Gastroenterology, School of Medicine University of São Paulo, São Paulo, Brazil
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Abstract
OBJECTIVE To prospectively compare immediate postoperative results of the surgical treatment of haemorrhoidal disease (HD) by Milligan-Morgan technique using either the CO(2) laser or cold scalpel. METHODS Forty patients with grade III/IV HD were prospectively randomized to undergo surgical treatment (Milligan-Morgan) using either the CO(2) laser (group A) or the cold scalpel method (group B). Data were compared regarding postoperative pain, complications, healing time, return to normal activity and patient satisfaction. Patients were blinded to treatment method until the completion of the study. Postoperative outcomes were assessed by patient questionnaire and outpatient follow-up visits. Pain was assessed by Visual Analogue Scale and analgesic consumption. RESULTS Twenty patients were randomized into each group and were comparable relative to mean age, gender and grade of HD. There were no statistically significant differences regarding postoperative pain measured (P =0.17) or consumption of oral (P = 0.741) and parenteral analgesics (P = 0.18) between the two groups. Mean pain score at the first bowel movement was significantly higher in group A (P = 0.035), although the use of analgesics was similar in both the groups. There were no differences regarding complications, mean healing time, return to normal activities and patient satisfaction. CONCLUSION There were no differences in the immediate results after Milligan-Morgan haemorrhoidectomy using either the CO(2) laser or cold scalpel regarding postoperative pain, complications, healing time, return to normal activities or patient satisfaction.
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Affiliation(s)
- L C Pandini
- Department of Digestive Surgery, University of Sao Paulo, Sao Paulo, Brazil.
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Sobrado CW, Pires CEF, Habr-Gama A, Kiss DR. Avaliação do tempo de trânsito colônico com marcadores radiopacos: estudo com voluntários assintomáticos. Rev Col Bras Cir 2005. [DOI: 10.1590/s0100-69912005000300002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Com a introdução de marcadores radiopacos para avaliação do tempo de trânsito intestinal, tornou-se possível mensurar não apenas o tempo de trânsito total, como também o segmentar. Visando a simplificação da técnica, especialmente no que diz respeito à diminuição da exposição à irradiação, foi descrito novo método com número menor de radiografias. Os autores apresentam estudo do tempo de transito colônico total e segmentar em indivíduos normais. MÉTODO: Quinze voluntários adultos e assintomáticos, oito do sexo feminino e sete do masculino, foram submetidos a exame radiológico com marcadores radiopacos para medida do tempo de trânsito colônico total e segmentar (cólon direito, esquerdo e retossigmóide). RESULTADOS: A média do tempo de trânsito colônico total foi de 36,61 ± 3,48 horas. Dos tempos de trânsito segmentares obtivemos as médias de 11,51 ± 2,28 horas para o cólon direito; de 12,14 ± 2,19 horas para o cólon esquerdo; e de 12,96 ± 2,23 horas para o retossigmóide. CONCLUSÕES: A técnica descrita é método simples e útil para a avaliação do tempo de trânsito colônico total e segmentar e quando aplicada a indivíduos assintomáticos reproduziu resultados comparáveis aos da literatura e aos obtidos a partir de outras técnicas.
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Abstract
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.
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Abstract
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.
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Affiliation(s)
- Angelita Habr-Gama
- Colorectal Unit, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
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Abstract
Umbilical nodes are rare. The metastatic involvement of the region was first described in 1846. Sister Mary Joseph was the first observer to establish the correlation between carcinomas and umbilical nodes. The umbilical node may be the sole presenting sign of cancer and is usually associated with advanced disease and poor prognosis. A 64-year-old woman, previously healthy, presented vague abdominal discomfort and a hard umbilical nodule for 1 week, which was first diagnosed as an incarcerated umbilical hernia. She underwent a new clinical assessment and biopsy. After immunohistochemical analysis and computerized tomography, she was diagnosed with pancreatic cancer. The clinical staging showed advanced disease with distant metastasis. She received palliative chemotherapy. After 8 months, she was alive in poor clinical condition. Clinical suspicion should lead to a careful additional evaluation whenever an umbilical nodule presents with malignant signs.
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Affiliation(s)
- Fábio Crescentini
- Department of Gastroenterology, Division of Gastrosurgery and Coloproctology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
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30
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Abstract
A defecografia é exame de imagem valioso no estudo da fisiologia anorretal e, portanto, com extensa aplicação na avaliação e diagnóstico de diversas afecções coloproctológicas que cursam com sintomas de constipação, sensação de evacuação incompleta, incontinência fecal, dor pélvica obscura, proctalgia e tenesmo, entre outras. Além disso, em algumas situações após cirurgia anorretocólica, pode ser utilizada como método de avaliação do resultado e acompanhamento pós-operatório. Nas últimas décadas tem-se observado aumento do interesse da comunidade médica pelo exame, em parte, pelo melhor entendimento da fisiopatologia dos distúrbios colorretais e, também, pelo aprimoramento da técnica, como é o exemplo da videodefecografia dinâmica computadorizada, que permitiu maior difusão e melhora na qualidade do exame. Diversos aspectos da defecografia são discutidos neste artigo, desde indicações para o exame, metodologia, até interpretação dos resultados. A técnica do exame, incluindo princípios básicos e os avanços mais recentes, também foi abordada.
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Sobrado CW, Kiss DR, Nahas SC, Araújo SEA, Seid VE, Cotti G, Habr-Gama A. Surgical treatment of rectal prolapse: experience and late results with 51 patients. ACTA ACUST UNITED AC 2004; 59:168-71. [PMID: 15361980 DOI: 10.1590/s0041-87812004000400003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The "best" surgical technique for the management of complete rectal prolapse remains unknown. Due to its low incidence, it is very difficult to achieve a representative number of cases, and there are no large prospective randomized trials to attest to the superiority of one operation over another. PURPOSE: Analyze the results of surgical treatment of complete rectal prolapse during 1980 and 2002. METHOD: Retrospective study. RESULTS: Fifty-one patients underwent surgical treatment during this period. The mean age was 56.7 years, with 39 females. Besides the prolapse itself, 33 patients complained of mucous discharge, 31 of fecal incontinence, 14 of constipation, 17 of rectal bleeding, and 3 of urinary incontinence. Abdominal operations were performed in 36 (71%) cases. Presacral rectopexy was the most common abdominal procedure (29 cases) followed by presacral rectopexy associated with sigmoidectomy (5 cases). The most common perineal procedure was perineal rectosigmoidectomy associated with levatorplasty (12 cases). Intraoperative bleeding from the presacral space developed in 2 cases, and a rectovaginal fistula occurred in another patient after a perineal rectosigmoidectomy. There were 2 recurrences after a mean follow-up of 49 months, which were treated by reoperation. CONCLUSION: Abdominal and perineal procedures can be used to manage complete rectal prolapse with safety and good long-term results. Age, associated medical conditions, and symptoms of fecal incontinence or constipation are the main features that one should bear in mind in order to choose the best surgical approach.
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Affiliation(s)
- Carlos Walter Sobrado
- Department of Gastroenterology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil.
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Sobrado CW, Mester M, Nadalin W, Nahas SC, Bocchini SF, Habr-Gama A. Radiation-induced total regression of a highly recurrent giant perianal condyloma: report of case. Dis Colon Rectum 2000; 43:257-60. [PMID: 10696901 DOI: 10.1007/bf02236991] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We report a case of a highly recurrent giant perianal condyloma, or Buschke-Lowenstein tumor, which was successfully treated by telecobalt therapy. We conclude that radiation therapy is an optional treatment modality for the management of giant perianal condylomata in selected cases.
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Affiliation(s)
- C W Sobrado
- Colorectal Unit, Hospital das Clínicas, São Paulo, Brazil
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Sobrado CW, Bringel RW, Nahas SC, da Silva JH, Habr-Gama A. [Ambulatory anorectal surgery under local anesthesia: analysis of 351 procedures]. Rev Hosp Clin Fac Med Sao Paulo 1998; 53:277-82. [PMID: 10413941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Three hundred and twenty-eight patients with anorectal diseases were submitted ambulatory surgery, under local anesthesia, in a three-year period. Three hundred and fifty one operations were performed in outpatient service. Local anesthesia by Hook-Needle Puncture technique was used in 37 operations and the rest of them by classical technique through infiltration of both lateral anal quadrants. Hemorrhoids, fistulas, fissures and pilonidal cysts were the most frequent diseases treated (71.6%). The incidence of early and late complications was 19.6% and 4.8%, respectively. The most common complication was severe pain (16.1%). Five patients (1.5%) required hospitalization due postoperative complications. The surgery on an outpatient basis was a well-accepted procedure for two hundred eighty-eight patients (88%). The main benefit reported by patients was the possibility of recovery at home, which is more comfortable. The ambulatory anorectal surgery under local anesthesia is a safe and effective method, with the additional advantage of the costs saved and increase of available beds for more complex surgery.
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Affiliation(s)
- C W Sobrado
- Departamento de Gastroenterologia da Faculdade de Medicina da Universidade de São Paulo
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Bringel RW, Sobrado CW, Nahas SC, Habr-Gama A. [Transsacral rectopexy for treatment of bleeding rectal prolapse in a patient with severe liver disease: case report]. Rev Hosp Clin Fac Med Sao Paulo 1998; 53:317-20. [PMID: 10413948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Rectal procidentia is an uncommon but debilitating condition that often affects elderly patients with significant medical problems. Fecal incontinence is usually frequent. Abdominal rectopexy with or without sigmoid resection repeatedly demonstrate lower recurrence rates (2-4%) but in high-risk patients, morbidity and mortality may be significant. Perineal or transacral approaches may be used in these patients to avoid the complications of abdominal procedures and general anesthesia. The lack of experience with transacral approach has limited your utilization by colon and rectal surgeons. We describe a case of rectal procidentia in patient with severe liver disease (Child C) sucssefull treated with transacral rectopexy, detailing the technique used.
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Sobrado CW, Mackdisse F, da Rocha JR, Mester M, Nahas SC, Habr-Gama A. [True splenic cyst treated with++videolaparoscopy. Case report and review of the literature]. Rev Hosp Clin Fac Med Sao Paulo 1998; 53:260-2. [PMID: 10436637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
True non-parasitic splenic cysts are uncommon, their real incidence is difficult to determine since over 30% are asymptomatic. Preoperatively these cysts are rarely diagnosed correctly and they are often findings on examinations. Partial or total splenectomy is the treatment of choice after ruling out splenic hydatidosis, since it is responsible for two thirds of global incidence. Currently, with the technological advances of surgery, especially of videolaparoscopy, some authors have proposed its use for partial cystectomy or splenectomy. The authors present the case of a true splenic cyst (epidermoid) which was resected videolaparoscopically and they discuss aspects of diagnosis and management.
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Sobrado CW, Nahas SC, da Silva e Souza Júnior AH, Habr-Gama A. [Muscle-aponeurotic transposition for treatment of anal incontinence]. Rev Hosp Clin Fac Med Sao Paulo 1998; 53:205-13. [PMID: 9922503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
The management of anal incontinence varies. It can be treated either clinically or surgically depending on its etiology and the intensity of the signs and symptoms. The variety of procedures and techniques employed in its treatment is proof of the incomprehension of the pathophysiological mechanisms involved as well as their diversity. Sphincteroplasties are indicated for those patients with well-defined muscle injury, usually resulting from obstetrical trauma, iatrogenic surgery or vehicular accidents. In cases of persistent anal incontinence after previous sphincteroplasty or those in which extensive destruction of the sphincteric musculature is confirmed, muscle-aponeurotic transpositions are an attractive option. A detailed survey of the literature of the chief techniques utilized and their results is presented.
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Affiliation(s)
- C W Sobrado
- Departamento de Gastroenterologia da Faculdade de Medicina da Universidade de São Paulo
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Abstract
Rectovaginal fistulas are difficult to manage and cause significant morbidity. A new technique for large rectovaginal fistula repair is presented; it is based on the creation of a neovagina associated with an established abdominal pull-through operation. This technique has been used since 1970 in selected cases, with very little morbidity and no operative mortality.
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Affiliation(s)
- O S Simonsen
- Colorectal Unit, Hospital das Clínicas, University of São Paulo Medical School, SP, Brazil
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Abstract
PURPOSE Anorectal surgery has been increasingly performed as an ambulatory procedure using general, regional, and local anesthesia. Local anesthesia is classically performed through infiltration of four quadrants around the anal verge, which renders the procedure painful and uncomfortable for most surgeons and patients. We present a new, painless technique of local anesthesia for anorectal surgery. METHODS Patients with surgical risk Classes I and II (American Society of Anesthesiologists) bearing anorectal pathologies were sedated and placed on the operating table in the prone jackknife position. After local antisepsis, the anal canal was lubricated with 2 percent lidocaine gel, and the mucosa was punctured by a hook-shaped, curved, 22-gauge needle just above the pectinate line. A solution of local anesthetics was slowly infused in all four quadrants to the submucosal level. If needed, more anesthetics were infused during the operation. RESULTS This technique was easily and painlessly applied in more than 60 patients and permitted execution of several ambulatory anorectal procedures with comfort and safety. CONCLUSIONS The hook-needle puncture for local anesthesia is an effective and safe procedure and may be routinely used for ambulatory anorectal surgery in selected patients.
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Affiliation(s)
- C W Sobrado
- Colorectal Unit, Hospital das Clínicas, University of São Paulo Medical School, Brazil
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Abstract
PURPOSE Retrorectal tumors are rare entities often found in females during reproductive age. Reports of retrorectal tumors complicating pregnancy are scant. This study presents two cases of retrorectal tumors complicating pregnancy and a literature review. METHODS Two patients bearing retrorectal tumors diagnosed during pregnancy were referred to our care at the postpartum period. Both then underwent exploratory laparotomy. RESULTS One patient had premature delivery by cesarean section because of hemorrhage from abruptio placentae followed by fetal mortality. Attempts to resect the tumor immediately after delivery had been unfruitful. The tumor was also unresectable on exploratory laparotomy. Biopsy studies of the tumor were consistent with low-grade myosarcoma. Another patient had a benign cystic mass that had been conservatively monitored throughout pregnancy. A healthy baby was delivered at term by cesarean section. The cyst was later resected via Kraske's incision and was diagnosed as cystic teratoma. CONCLUSIONS Retrorectal tumors may cause significant local effects such as complicated pregnancy. Early detection in the population at risk is needed, as correct diagnosis and treatment may be done only on surgical exploration. During pregnancy, careful monitoring of advanced tumors is mandatory and may be sufficient to prevent maternal and fetal complications.
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Affiliation(s)
- C W Sobrado
- Department of Surgery, Hospital do SESI, São Paulo, Brazil
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