Sthela Maria Murad‐Regadas

Surgical resection in Crohn’s disease: is immunosuppressive medication associated with higher postoperative infection rates?

Aim  The aim of this study was to analyse postoperative infection in patients undergoing surgery for Crohn’s disease (CD) according to the use of preoperative immunosuppressants, including infliximab.

Prospective Multicenter Trial Comparing Echodefecography With Defecography in the Assessment of Anorectal Dysfunction in Patients With Obstructed Defecation

BACKGROUND: Defecography is the gold standard for assessing functional anorectal disorders but is limited by the need for a specific radiologic environment, exposure of patients to radiation, and inability to show all anatomic structures involved in defecation. Echodefecography is a 3-dimensional dynamic ultrasound technique developed to overcome these limitations. OBJECTIVE: This study was designed to validate the effectiveness of echodefecography compared with defecography in the assessment of anorectal dysfunctions related to obstructed defecation. DESIGN: Multicenter, prospective observational study. PATIENTS: Women with symptoms of obstructed defecation. SETTING: Six centers for colorectal surgery (3 in Brazil, 1 in Texas, 1 in Florida, and 1 in Venezuela). INTERVENTIONS: Defecography was performed after inserting 150 mL of barium paste in the rectum. Echodefecography was performed with a 2050 endoprobe through 3 automatic scans. MAIN OUTCOME MEASURES: The &kgr; statistic was used to assess agreement between echodefecography and defecography in the evaluation of rectocele, intussusception, anismus, and grade III enterocele. RESULTS: Eighty-six women were evaluated: median Wexner constipation score, 13.4 (range, 6–23); median age, 53.4 (range, 26–77) years. Rectocele was identified with substantial agreement between the 2 methods (defecography, 80 patients; echodefecography, 76 patients; &kgr; = 0.61; 95% CI = 0.48–0.73). The 2 techniques demonstrated identical findings in 6 patients without rectocele, and in 9 patients with grade I, 29 with grade II, and 19 patients with grade III rectoceles. Defecography identified rectal intussusception in 42 patients, with echodefecography identifying 37 of these cases, plus 4 additional cases, yielding substantial agreement (&kgr; = 0.79; 95% CI = 0.57–1.0). Intussusception was associated with rectocele in 28 patients for both methods (&kgr; = 0.62; 95% CI = 0.41–0.83). There was substantial agreement for anismus (&kgr; = 0.61; 95% CI = 0.40–0.81) and for rectocele combined with anismus (&kgr; = 0.61; 95% CI = 0.40–0.82). Agreement for grade III enterocele was classified as almost perfect (&kgr; = 0.87; 95% CI = 0.66–1.0). LIMITATIONS: Echodefecography had limited use in identification of grade I and II enteroceles because of the type of probe used. CONCLUSIONS: Echodefecography may be used to assess patients with obstructed defecation, as it is able to detect the same anorectal dysfunctions found by defecography. It is minimally invasive and well tolerated, avoids exposure to radiation, and clearly demonstrates all the anatomic structures involved in defecation.

Ileal pouch-anal anastomosis in elderly patients: is there a difference in morbidity compared with younger patients?

Aim  The aim of this study was to review the recent results of ileal pouch–anal anastomosis (IPAA) in elderly patients compared with younger patients.

The role of 3-dimensional anorectal ultrasonography in the assessment of anterior transsphincteric fistula.

PURPOSE: The aim of this study was to evaluate the role of 3-dimensional anorectal ultrasonography in the choice of surgical technique according to the position of the fistulous tract in patients with anterior transsphincteric anal fistula. METHODS: A total of 33 patients (18 male) with anterior transsphincteric fistulas were evaluated by ultrasonography. The length of the external and internal anal sphincters, the position of the internal opening, the length of the compromised sphincter, and the percentage of sphincter muscle to be transected during surgery were measured, compared between sexes, and used in planning the surgery. Postoperative incontinence symptoms were quantified with a Wexner score. RESULTS: The external and internal sphincters were longer and the position of the internal opening was higher in males. The position where the tract crossed the external sphincter was in both sexes, but the percentage of compromised muscle was higher in females because of the smaller length of the external sphincter. Seton placement followed by fistulotomy or advanced flap repair were indicated in 11 of 18 males and 13 of 15 females as the tract crossed the external sphincter above 50.0%. The mean postoperative follow-up was 12 months. Overall, minor fecal incontinence symptoms were identified in 16 (48.0%) patients. Of these, 11 (73.0%) females and 5 (28.0%) males had a mean incontinence score of 2.9 and 3.0, respectively. CONCLUSIONS: Three-dimensional ultrasonography was shown to be useful in the preoperative assessment of anterior transsphincteric fistulas by quantifying the length of muscle to be transected, contributing to the choice of a safe treatment approach and to the reduction of the rate of postoperative continence disorders.

Short‐term outcome of infliximab and other medications on patients with inflammatory bowel disease undergoing ileostomy reversal

Aim  We evaluated the impact of immunosuppressive drugs on the short‐term outcome following loop ileostomy closure in patients with inflammatory bowel disease.

Anatomic characteristics of anal fistula on three-dimensional anorectal ultrasonography.

BACKGROUND: Surgery for anal fistula is often associated with continence disorders due to the transection of sphincter muscles. Extensive knowledge of anal canal anatomy and anal fistula can help prevent this outcome. OBJECTIVE: This study aimed to correlate the anatomical conformation of the anal canal, the fistula track, and the internal opening according to sex and hemicircumference (anterior vs posterior) by use of 3-dimensional ultrasonography. METHODS: One hundred sixty-five patients with fistula were evaluated with 3-dimensional ultrasound and grouped according to sex, fistula type, internal opening, and track position. Fistulas were transsphincteric in 128 subjects and intersphincteric in 37 subjects. The study measured the external and internal anal sphincter, the puborectalis, the distance from the internal opening to the distal edge of the external and internal sphincter, the length of the internal and external sphincter compromised by the track, and the percentage of compromised muscle. RESULTS: The anal canal muscles were longer in males. The distance from the internal opening to the internal sphincter was greater for the posterior hemicircumference. The point where the fistulous track crossed the anterior external sphincter was similar for the 2 sexes, but the percentage of compromised muscle was greater in females. The point where the fistulous track crossed the internal sphincter was similar for the 2 sexes, but the percentage of compromised internal sphincter was greater in males for the posterior hemicircumference. The study was limited by the absence of testing for interobserver and intraobserver agreement. CONCLUSION: The anal canal muscles are longer in males and the pectinate line is asymmetrical. In females, the percentage of compromised external sphincter was greater in the anterior hemicircumference because of the shorter external sphincter, whereas in males the percentage of compromised internal sphincter was greater in the posterior hemicircumference.

Effect of soluble fiber or fructooligosaccharide supplementation upon trinitrobenzenesulphonic acid induced colitis in rats.

PURPOSE To evaluate the effect of soluble fiber or fructooligosaccharide (FOS) supplementation upon trinitrobenzene sulphonic acid (TNBS)-induced colitis in rats. METHODS 64 Wistar rats were given water, soluble fiber or FOS intragastrically during 14 days prior to colitis induction with TNBS (n=48) or rectal enema with water (n=16; control group). On the 7th or 14th day following colitis induction the rats were weighed and euthanized in order to determine the colon weight/length ratio and macroscopic and microscopic scores. RESULTS On the 7th day following colitis induction the body weight had decreased significantly, the colon weight/length ratio had increased and macroscopic and microscopic colon lesions were observed. On the 14th day following colitis induction no difference in body weight was observed, in spite of the persistence of macroscopic and microscopic lesions and increased colon weight/length ratio. Supplementation with soluble fiber or FOS did not revert colon lesions or any of the study parameters. Supplementation with FOS, but not with fiber, was associated with increased colon weight/length ratio on the 14th day. CONCLUSION Supplementation with soluble fiber or FOS produced no significant impact on TNBS-induced colitis in rats.

NEUROMODULAÇÃO SACRAL PARA TRATAMENTO DOS DISTÚRBIOS DO ASSOALHO PÉLVICO. ASPECTOS TÉCNICOS PARA IMPLANTE EFETIVO

intestinal, permaneceu assintomático. Foi a óbito em março de 2017 por causas decorrentes da neoplasia de pâncreas. Discussão: Uma vez implantados, os stents se expandem lentamente, conseguem assim a permeabilidade da anatomia obstruída. Esse método pode ser usado como uma medida paliativa definitiva ou pode ser usado como tratamento provisório ate a estabilização do paciente para posteriormente fazer a cirurgia. É bem estabelecido o uso de stents metálicos em obstrução intestinal, contudo os dados da literatura sobre seu uso por compressões extrínsecas são escassos. Conclusão: Este caso veio corroborar a literatura em relação à boa eficácia e segurança na uso de stents metálicos colorretais nos casos de obstrução intestinal.

Correlation Between Echodefecography and 3-Dimensional Vaginal Ultrasonography in the Detection of Perineal Descent in Women With Constipation Symptoms

BACKGROUND: Defecography is an established method of evaluating dynamic anorectal dysfunction, but conventional defecography does not allow for visualization of anatomic structures. OBJECTIVE: The purpose of this study was to describe the use of dynamic 3-dimensional endovaginal ultrasonography for evaluating perineal descent in comparison with echodefecography (3-dimensional anorectal ultrasonography) and to study the relationship between perineal descent and symptoms and anatomic/functional abnormalities of the pelvic floor. DESIGN: This was a prospective study. SETTING: The study was conducted at a large university tertiary care hospital. PATIENTS: Consecutive female patients were eligible if they had pelvic floor dysfunction, obstructed defecation symptoms, and a score >6 on the Cleveland Clinic Florida Constipation Scale. INTERVENTIONS: Each patient underwent both echodefecography and dynamic 3-dimensional endovaginal ultrasonography to evaluate posterior pelvic floor dysfunction. MAIN OUTCOME MEASURES: Normal perineal descent was defined on echodefecography as puborectalis muscle displacement ⩽2.5 cm; excessive perineal descent was defined as displacement >2.5 cm. RESULTS: Of 61 women, 29 (48%) had normal perineal descent; 32 (52%) had excessive perineal descent. Endovaginal ultrasonography identified 27 of the 29 patients in the normal group as having anorectal junction displacement ⩽1 cm (mean = 0.6 cm; range, 0.1–1.0 cm) and a mean anorectal junction position of 0.6 cm (range, 0–2.3 cm) above the symphysis pubis during the Valsalva maneuver and correctly identified 30 of the 32 patients in the excessive perineal descent group. The &kgr; statistic showed almost perfect agreement (&kgr; = 0.86) between the 2 methods for categorization into the normal and excessive perineal descent groups. Perineal descent was not related to fecal or urinary incontinence or anatomic and functional factors (sphincter defects, pubovisceral muscle defects, levator hiatus area, grade II or III rectocele, intussusception, or anismus). LIMITATIONS: The study did not include a control group without symptoms. CONCLUSIONS: Three-dimensional endovaginal ultrasonography is a reliable technique for assessment of perineal descent. Using this technique, excessive perineal descent can be defined as displacement of the anorectal junction >1 cm and/or its position below the symphysis pubis on Valsalva maneuver.