Eron Fábio Miranda

ADALIMUMAB FOR MAINTENANCE THERAPY FOR ONE YEAR IN CROHN’S DISEASE: results of a Latin American single-center observational study

CONTEXT Adalimumab is a fully-human antibody that inhibits TNF alpha, with a significant efficacy for long-term maintenance of remission. Studies with this agent in Latin American Crohns disease patients are scarce. OBJECTIVES The objective of this study was to outline clinical remission rates after 12 months of adalimumab therapy for Crohns disease patients. METHODS Retrospective, single-center, observational study of a Brazilian case series of Crohns disease patients under adalimumab therapy. Variables analyzed: demographic data, Montreal classification, concomitant medication, remission rates after 1, 4, 6 and 12 months. Remission was defined as Harvey-Bradshaw Index ≤ 4, and non-responder-imputation and last-observation-carried-forward analysis were used. The influence of infliximab on remission rates was analyzed by Fischer and Chi-square tests (P<0.05). RESULTS Fifty patients, with median age of 35 years at therapy initiation, were included. Remission rates after 12 months of therapy were 54% under non-responder-imputation and 88% under last-observation-carried-forward analysis. After 12 months, remission on patients with previous infliximab occurred in 69.23% as compared to 94.59% in infliximab-naïve patients (P = 0.033). CONCLUSIONS Adalimumab was effective in maintaining clinical remission after 12 months of therapy, with an adequate safety profile, and was also more effective in infliximab naïve patients.

Epidemiological profile of 175 patients with Crohn's disease submitted to biological therapy

INTRODUCTION: There is currently an increasing use of biological agents in the management of Crohns disease (CD). There is lack of data regarding the epidemiological profile of patients on infliximab (IFX) and adalimumab (ADA) for CD in Brazil. OBJECTIVE: To identify the epidemiological characteristics of patients with CD who underwent biological therapy. METHOD: Retrospective multicenter study, with CD patients on biological therapy. Analyzed variables: gender, age at treatment initiation, Montreal classification, concomitant perianal disease and smoking status. RESULTS: 175 patients without previous exposure to biological agents were included, 93 (53%) were male. The mean age at treatment initiation was 35.5 (2-79) years old an the mean disease duration was 46.9 (0-480) months. Overall, 117 (66.9%) patients used IFX and 58 (33.1%), ADA. Montreal classification: age at diagnosis ― A1 (n=21; 12%), A2 (n=102; 58.3%), and A3 (n=52; 29.7%). CD location ― L1 (n=42; 24%), L2 (n=51; 29.1%), L3 (n=81; 46.3%), and L4 (n=1, 0.6%). Phenotype ―B1 (n=59; 33.7%), B2 (n=46; 26.3%), and B3 (n=70; 40%). Perianal disease was found in 89 (50.9%) patients. CONCLUSIONS: The epidemiological profile of patients was similar to the literature. There was a high prevalence of patients with fistulizing CD.

The influence of methylene blue on the healing of intestinal anastomoses subjected to ischemia and reperfusion in rats

PURPOSE To investigate the influence of methylene blue, on the healing of intestinal anastomoses subjected to ischemia and reperfusion in rats. METHODS Forty-five rats divided into the following three groups were used: control (G1); ischemia without methylene blue (G2); and ischemia with methylene blue (G3). A laparotomy was performed and the cranial mesenteric artery isolated. Whereas the cranial artery was temporarily occluded for 45 minutes in groups G2 and G3, prior to enterotomy and intestinal anastomosis, in group G1 the enterotomy and intestinal anastomosis were performed without prior lesion. Afterwards, 2mL of 0.5% methylene blue were instilled in the peritoneal cavities of the animals in group G3, and 2mL of isotonic saline solution in the peritoneal cavities of the animals in group G2. After the reperfusion, an enterectomy and intestinal anastomosis were performed. After the animals had been sacrificed on the seventh day after the operation, the abdominal cavity was examined by resection of a segment of the intestine containing the anastomosis in order to measure its strength and for histopathological examination. RESULTS Free fluid or abscesses in the peritoneal cavity were rare. When inflammation was analyzed, the group subjected to ischemia without methylene blue had a higher score for mononuclear cells (p=0.021) and granulation tissue (p=0.044). No significant difference was observed in the density of type I or type III collagens. CONCLUSION The methylene blue did not show beneficial effect on the healing of intestinal anastomoses subjected to ischemia and reperfusion in rats.

Postoperative topical analgesia of hemorrhoidectomy with policresulen and cinchocaine: a prospective and controlled study

OBJECTIVE To evaluate the effects of topical policresulen and cinchocaine in the postoperative pain behavior of open hemorrhoidectomy. METHODS We conducted a prospective, double-blinded, controlled study. The control group received the usual guidelines with oral medications. The topical treatment group received, in addition, the application of the ointment and was comprised of two subgroups (policresulen + cinchocaine, and placebo). Pain intensity was recorded with the visual analogue scale. RESULTS 43 patients were operated on: control group - n = 13, one excluded; placebo - n = 15; and policresulen + cinchocaine - n = 15. The mean age was 45.98 years and 37.2% were men. The average pain intensity was 4.09 (immediate postoperative), 3.22 (hospital discharge), 5.73 (day 1) , 5.77 (day 2), 5.74 (day 3), 5.65 (day 7), 5.11 (day 10), 2.75 (day 15) and 7.70 (first bowel movement), with no difference between groups in all periods. CONCLUSION This study showed no reduction in pain after hemorrhoidectomy with the use of topical policresulen and cinchocaine.

Análise das complicações tardias em operações anorretais: experiência de um serviço de referência em coloproctologia

INTRODUCTION: anorectal procedures consist 80% of surgical cases in colorectal surgery practice. The exact rate of long-term complications after anorectal surgery is unknown. This number is variable according to the medical centres and the type of procedures. OBJECTIVE: to evaluate the long-term complications secondary to anorectal procedures, as well as the risk factors that might be associated with these complications. METHOD: retrospective analysis, including anorectal procedures performed between January 2007 and July 2009. The characteristics analyzed were: sex, age, type of surgery, health system, long-term complications and reoperations performed. RESULTS: 430 patients submitted to 453 anorectal procedures were studied (54,4% female). Hemorrhoidectomy was the most common procedure (50,3% of all operations). The mean period of follow-up was 164,7 days and 102 long-term complications were identified, occurring in 22,52% of all procedures. Residual fissure in ano was the most frequent complication (54%, n=55). Only 38 patients needed reoperation (8,83% of all cases). There was no statistical significance between sex, age, health system and type of surgery in relation to the complications found. CONCLUSIONS: the long-term complication rate was 22,52%, with reoperations performed in 8,83% of all patients. There was no risk factor for long-term complications identified in this case series.

Necrose pelvi-perineal pós-radioterapia para câncer de próstata: relato de caso

Around 75% of the patients submitted to radiotherapy for prostate cancer will develop anorectal symptoms, such as fecal urgency, bleeding, rectal pain and tenesmus. Perineal necrosis is a very rare event in these cases. The purpose of this report is the description of a diffuse perineal necrosis due to radiotherapy for the treatment of prostate cancer. This is a report of a 77-year old male, submitted to radiotherapy with 70 Gy of pelvic radiation for prostate cancer treatment. He came to outpatient practice after 4 months with anorectal complaints. Further investigation revealed severe radiation proctitis, with a perineal wound and external anal sphincter damage. The patient was submitted to a loop transverse colostomy with extended perineal debulking due to diffuse necrosis of pelvic structures, such as prostate, pelvic floor muscles and anterior rectal wall. Hyperbaric oxygen therapy was started for the extended perineal wound, with success. Prevention is the key to avoid radiation damage in pelvic organs. Doses above 70 Gy are associated with high risk of associated pelvic complications. The treatment of diffuse perineal necrosis must be prompt and aggressive. Fecal diversion is mandatory in cases with extended sphincter destruction.

Disease Duration Did Not Influence the Rates of Loss of Efficacy of the Anti-TNF Therapy in Latin American Crohn's Disease Patients

Background/Aims: The efficacy of both Infliximab (IFX) and Adalimumab (ADA) can be reduced over time. The aim of this study was to analyze the incidence of loss of efficacy (LOE) of both IFX and ADA, and outline the influence of disease duration on its occurrence. Methods: Retrospective, multicenter, observational cohort study, with CD patients treated with anti-TNF therapy. LOE was defined as the need for steroids, occurrence of major abdominal surgery during treatment, dose increase, interval shortening or switching of the anti-TNF agent. Patients were allocated in three subgroups based on disease duration (DD): <24 months, between 24 and 60 months and >60 months. Results: 175 patients were included in the study (117 under IFX and 58 under ADA therapy). LOE occurred in 32% of patients with DD <24 months, in 33.3% with DD between 24 and 60 months and in 31.3% of subjects with DD over 60 months (p = 0.975). Conclusions: Disease duration (DD) did not influence LOE rates. These results suggest that in real-world observational practice, patients with early CD might have the same rates of LOE than patients with a disease prolonging for a longer duration.

Infestação por miíase em prolapso retal: relato de caso e revisão de literatura

INTRODUCTION: myiasis is an infection of human tissues with dipterous fly larvae. It is commonly located in human skin, however, it is described in natural orifices. This condition is treated by mechanical extraction of larvae associated with damaged tissue ressection. OBJECTIVE: case report of a patient with myiasis infection of rectal prolapse, emphasizing its incidence, symptoms and treatment options. CASE REPORT: L.C.S., a 36-year-old male, with rectal prolapse complaints for one year, with bad sanitary conditions. Proctological examination revealed rectal prolapsed with necrosis areas affected by myiasis. Larvae remotion was realized with necrotic tissue resection. A loop-sigmoid colostomy was performed due to extensive perineal wound and internal sphincter damage. CONCLUSIONS: rectal prolapse with myiasis infection is rare, and must have prompt diagnosis and treatment. A simple perineal examination is essential. We emphasize continous health education and basic hygiene measures for the population.

Análise da prevalência de entidades coloproctológicas nos pacientes idosos do serviço de coloproctologia de um hospital universitário

INTRODUCTION: It is expected that in 2020, elderly people will reach 13% of the Brazilian population. This involves epidemiologic and medical concerns. There is few data in the literature regarding colorectal and anal diseases in this population. OBJECTIVE: to compare data about colorectal and anal conditions in elderly people (older than 60 years) with younger patients, including associated diseases, surgical procedures and complications. METHOD: The charts of the patients of the outpatient colorectal unit were retrospectively reviewed. They were divided in two groups: older than 60 years (group I) and younger than 60 years (controls, group II). RESULTS: 1126 patients were included in this study. 19,36% were older than 60 years. The average number of complaints in the group I was 1,21. Abdominal pain, constipation, diarrhea and positive fecal occult blood test were more frequent in the elderly. Anorectal complaints were more prevalent in the control group. The more prevalent conditions in group I, with statistical significance, were: diverticular disease, colorectal polyps and colorectal cancer. In group I, 58,36% had associated diseases. There was no statistical significance between the groups regarding surgical procedures and complications. CONCLUSIONS: Colonic diseases were more prevalent in the elderly group. They had more associated diseases compared with younger patients. There was no statistical difference between the groups regarding surgical treatment and complications.

VEDOLIZUMABE NA INDUÇÃO E MANUTENÇÃO DA REMISSÃO NA RETOCOLITE ULCERATIVA: UM ESTUDO PILOTO OBSERVACIONAL E MULTICÊNTRICO

Fernanda da Silva Barbosa a,b,c,d,e, Ramir Luan Perin a,b,c,d,e, Paulo Gustavo Kotze a,b,c,d,e, Eron Fabio Miranda a,b,c,d,e, Cristina Flores a,b,c,d,e, Aderson Omar Mourão Cintra Damião a,b,c,d,e, Fábio Vieira Teixeira a,b,c,d,e a Hospital Universitário Cajuru (HUC), Curitiba, PR, Brasil b Hospital de Clínicas, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil c Hospital das Clínicas (HC), Faculdade de Medicina (FM), Universidade de São Paulo (USP), São Paulo, SP, Brasil d GastroClinica, Marília, SP, Brasil e Pontifícia Universidade Católica do Paraná (PUC-PR), Curitiba, PR, Brasil