Ivan Folchini de Barcelos

CORREÇÃO DE FÍSTULA RETOVAGINAL COM RETALHO DE MARTIUS: UMA SÉRIE DE CASOS

Introdução: Os tumores mioepiteliais de partes moles são raros, localizados principalmente nos membros, sem relato na literatura de ocorrência no reto. Apresenta-se, em geral, como massa dolorosa, bem delimitada e não encapsulada, a maioria é benigna. A imuno-histoquímica (IIQ) é essencial para o diagnóstico conclusivo. Faz diagnóstico diferencial com tumor estromal gastrointestinal, leiomioma e tumor glômico. O tratamento consiste na excisão cirúrgica com margens livres. A sobrevida em cinco anos varia de 36 a 88% nas lesões de alto e baixo grau, respectivamente. A taxa global de recorrência é de 20% e ocorre metástase em torno de 30% dos casos malignos. Objetivo: Relatar o primeiro caso de mioepitelioma retal, correlacionar com dados da literatura desse tipo de tumor de outras localizações. Relato de caso: Sexo feminino, 35 anos, em investigação de dor abdominal, fez ressonânica de pelve com achado de nódulo sólido em transição anorretal. O exame físico revelou nodulação subepitelial do reto de 3 cm, adjacente à musculatura esfincteriana, não aderida a planos profundos. Colonoscopia normal. A ecoendoscopia identificou lesão em camada muscular do reto e o anatomopatológico da punção aspirativa foi neoplasia mesenquimal ou epitelioide com degeneração mixoide. IIQ sugeriu tumor glômico. Submetida a exérese transanal. A anatomia patológica e a IIQ confirmaram o diagnóstico de mioepitelioma de partes moles. Discussão: Como no presente caso, a idade média de ocorrência do mioepitelioma de partes moles é de 38 anos. Apesar de não haver publicações prévias, diante de lesões subepiteliais nesse órgão, deve-se incluir o mioepitelioma como diagnóstico diferencial. Fica evidente a importância da ressecção cirúrgica e da análise IIQ no diagnóstico e tratamento definitivos. Conclusão: Trata-se de um caso inédito na literatura, de extrema importância para aumentar o grau de suspeição diante de lesões semelhantes, possibilita diagnóstico e tratamento corretos.

CISTO PILONIDAL RECIDIVADO TRATADO COM RETALHO CUTÂNEO DE LIMBERG

Introdução: As manifestações das doenças anorretais podem estar associadas a atraso na avaliação médica, que pode ser explicado por fatores como dificuldade na percepção dos sintomas, variações comportamentais e infraestrutura precária dos serviços de saúde. Objetivo: Caracterização temporal do período entre o início dos sintomas e a primeira avaliação médica e identificar os fatores que contribuíram para atraso em pacientes com doenças anorretais benignas. Método: Estudo retrospectivo de consultas feitas em um ambulatório médico de especialidade do interior de São Paulo. De janeiro a julho de 2015, foram avaliados 161 pacientes com doenças anorretais benignas. A idade média dos pacientes foi de 49,8 ± 16,2 anos. A maioria do sexo masculino (52,2%), com baixo nível de escolaridade (74,5%) e economicamente inativos (62,1%). As principais manifestações observadas foram: dor anorretal (55,3%), descarga anal (42,9%), sangramento anal (21,7%), massa anal (9,9%) e prurido anal (6,2%). As doenças diagnosticadas foram: plicomas anais (32,3%), fístula anal (28%), fissura anal (21,1%). A mediana da duração dos sintomas na primeira consulta foi de 12 meses (intervalo interquartil, 836 meses) e apenas 5% das consultas foram feitas dentro dos três primeiros meses do início das manifestações. As justificativas para o atraso foram: medo de doença grave (46,6%), negligência dos sintomas (26,1%), dificuldades no agendamento da consulta (20,5%) e timidez (7,5%). Conclusões: Em pacientes com doenças anorretais benignas, notou-se longo período entre o início dos sintomas e a avaliação pelo médico, que pode ser explicada por questões comportamentais e dificuldade de acesso aos serviços de saúde.

P-124 Adalimumab for Maintenance Therapy for One Year in Crohnʼs Disease: Results of a Latin American Single-center Observational Study

BACKGROUND: Adalimumab (ADA) is a fully-human antibody that inhibits TNF alpha, with a significant efficacy and defined safety profile for long-term maintenance of remission. Studies with this agent in Latin American Crohn’s disease (CD) patients are scarce. The primary objective of this study was to outline clinical remission rates after 12 months of ADA therapy for CD patients. Secondary objectives were to analyze demographic data, remission rates after 1, 4 and 6 months of therapy, adverse events (AE) and the influence of previous Infliximab (IFX) on remission rates. METHODS: Retrospective, single-center, observational study of a Brazilian case series of CD patients under ADA therapy. Inclusion criteria: CD patients, that had ADA therapy at any moment of their treatment. Exclusion criteria: patients with ulcerative colitis or indeterminate inflammation, with stomas and CD patients with less than 2 months of ADA therapy. Variables analyzed: demographic data, Montreal classification, concomitant medication, remission rates after 1, 4, 6 and 12 months, presence of AE and previous IFX. Remission was defined as Harvey-Bradshaw Index (HBI) ⩽ 4, and non-responder-imputation (NRI) and last-observation-carried-forward (LOCF) analysis were used. Data were described with frequency tables and 95% confidence intervals (CI). The influence of IFX on remission rates was analyzed by Fischer and Chi-square tests, as well as with the inverted Kaplan-Meier method (P < 0.05). RESULTS: Fifty patients, with median age of 35 years at therapy initiation, were included. Mean CD duration was 73.6 months. Ileocolic CD was observed in 58% of the cases studied; 76% had penetrating disease, and perianal involvement was observed in 78% of patients. In relation to the remission rates, in LOCF analysis, after 12 months from the beginning of ADA therapy, 44 patients (88%) were in clinical remission (CI 95% 0.790–0.970). By taking into account the NRI evaluation, clinical remission rate decreased to 27 patients, corresponding to 54% of the cases (CI 95% 0.402–0.678). These findings are described in Figure 1. AE occurred in 16% of the patients, with only one serious event observed (herpes zoster infection). After 12 months, remission on patients with previous IFX occurred in 69.23% as compared to 94.59% in IFX-naïve patients (P = 0.033), detailed in Figure 2. CONCLUSIONS: ADA therapy resulted in significant rates of CD clinical remission, reaching 54% of the patients after 12 months of therapy according to the NRI analysis and 88% according to the LOCF analysis. AE were observed in only 16% of the patients, and only 1 event was considered to be severe. The main cause for ADA discontinuation was the loss of access to the drug in the public health care system. The remission rates observed in patients with prior IFX therapy were lower than in those without previous exposure before ADA initiation. The importance of the findings in the present study, that must be interpreted with caution, is based on the fact that they constitute the first experience with ADA in the maintenance therapy for CD management in Latin American patients. Figure. No caption available. Figure. No caption available.

Complication Rates After Bowel Resections for Crohnʼs Disease: A Brazilian Single-Center Comparison Between Laparoscopic And Conventional Surgery: P-110

was >12% (vs. 3% in the base case). When the model length was decreased to 1or 2-years, the IFX strategy dominated, but at all other model lengths, surgery dominated. CONCLUSION(S): Our model, which included complications of both surgery and IFX, suggested that for patients who are failing maximal non-biologic medical therapy for chronic ulcerative colitis, IFX therapy is a cost-effective short-term strategy, while surgery is the cost-effective long-term strategy. Given the sensitivity of our model to discounting of future health states, patient perceptions of treatments for ulcerative colitis are a vital part of the decision-making process in this population.

Sarcoidosis During Therapy With Adalimumab in a Crohn’s Disease Patient: Consequence of the Therapy or Association With the Disease Itself?: P-11

Biological therapy represented an advance in the management of granulomatous and rheumatologic conditions. Adalimumab (ADA) is approved for the management of Crohn’s disease (CD) since 2007, and the experience with its safety profile and possible adverse events is expanding over the last years. Induced sarcoidosis due to anti-TNF therapy is described in some patients with rheumatologic and skin conditions. There are only two reported CD patients who developed sarcoidosis after anti-TNF initiation, one with Infliximab and another one with Natalizumab. The aim of this report is to present one of the first described CD patients with the diagnosis of sarcoidosis during ADA therapy, with emphasis on the differential diagnosis with hepatosplenic T-cell lymphoma and on the obscure relation between CD and this condition. Short report with detailed clinical description of a young CD patient who developed sarcoidosis during therapy with ADA. This is the case of a 25 year-old female with diagnosis of ileocolic CD for 18 months (Montreal classification A2L3B3). She first came to our unit after 8 months of medical therapy with ADA, Azathioprine (AZA) and steroids, and presented with an abdominal abscess secondary to fistulizing abdominal CD. She was submitted to laparotomy, ileocolic resection and retroperitoneal abscess drainage, without further complications. Prevention of postoperative recurrence with ADA and AZA was maintained, and a colonoscopy 6 months after surgery revealed endoscopic recurrence. Ten months after surgery, she presented with subacute cough and respiratory symptoms. Further investigation with CT-scan revealed bilateral nodules on the mediastinum with perihilar infiltrate, as well as multiple nodules on the spleen. A hypothesis of hepatosplenic T-cell lymphoma was made. A mediastinoscopy with biopsy of the nodes was performed, and histology demonstrated clear pattern of sarcoidosis, with no lymphoproliferative characteristics. After discussion with the pneumology department, AZA therapy was interrupted and biological treatment with ADA was maintained under strict supervision. Oral prednisolone was initiated and the patient improved. She is still in monotherapy with ADA as steroids were withdrawn after 3 months, and persisted asymptomatic. The correct mechanism that explains the occurrence of sarcoidosis in CD patients is not clear. It can be related to anti-TNF therapy or even to an association between these two conditions that can be explained due to immunological basis (paradoxical effect). The resolution of the signs and symptoms of sarcoidosis after anti-TNF interruption could elucidate the causative factor of the drug. In the present report, the decision regarding the maintenance of ADA was difficult, and supported by the literature in some reported cases with other conditions. The risk of severe recurrence and further need for surgery in a young patient with worse prognostic features led to this treatment issues. Multidisciplinary and individualized decisions are advised in complex cases as this.