Journal of Coloproctology (Rio de Janeiro), Volume: 42, Issue: 1, Published: 2022
  • Can Fecal Calprotectin Reflect Your Colonic Status? Original Article

    Salama, Rasha Ibrahim; Ahmed, Mohammed Hussien

    Abstract in English:

    Abstract Background Organic colonic manifestation may be difficult to be differentiated from functional one. Inflammatory bowel disease (IBD) is a common chronic inflammatory and destructive disease of the bowel wall. Chronic inflammation is associated with ulcerations, strictures, perforations, and it is a risk factor for dysplasia and cancer. To reduce these long-standing complications, IBD patients are in a continuous need for early diagnosis1. Markers, such as erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP), fecal calprotectin (FC) have been widely used as noninvasive parameters for IBD monitoring. We aimed, in this current study, to evaluate the value of fecal calprotectin and other noninvasive biomarkers in predicting abnormal histologic findings in patients undergoing colonoscopy.in addition to determine the cutoff value which predict IBD2. Methods The present prospective study included 160 patients with complaint of colicky abdominal pain with frequent diarrhea associated with mucous and infrequent bleeding per rectum for more than 6 months. They presented partial improvement with medication and recurrence once stopping the treatment These patients had been recently diagnosed with IBD at many primary healthcare centers covering the areas of the Kafrelsheikh and Zagazik governorate in the North of Egyptian Nile delta. After complete history, clinical examination, and laboratory investigation, they were referred to the IBD clinic at Kafrelsheikh University Hospital for assessment and ileocolonoscopy with biopsies. Results There was a wide spectrum of age of the studied patients, with mean age 40.12±7.88 (minimum 18 and maximum 56 years). Regarding gender, males represented 87.5% of the studied patients. Forty percent of the patients with colonic manifestation were smokers, 57% preferred a spicy diet, and the majority had low educational level (77.5%). Forty percent had obvious blood in stool, 55% had occult blood, and raised ESR CRP occurred in 32.5% and 50%, respectively. Fecal calprotectin cutoff was>159, with sensitivity 92.8% and specificity 97.5%. Conclusions: Biomarkers (FC, ESR, CRP) can be used as noninvasive parameters for the early diagnosis and prediction of organic colonic disease. Fecal calprotectin in the IBD group revealed significant area under the curve (AUC) values and cutoff>159, with sensitivity 92.8% and specificity 97.5%.
  • Validation of a Brochure to Guide Health Professionals in the Dressing and Undressing of Personal Protective Equipment During the SARS-CoV-2 Pandemic Original Article

    Salomé, Geraldo Magela; Miranda, Flávio Dutra

    Abstract in English:

    Abstract Objective To develop and validate a brochure to guide health professionals in properly dressing and undressing the personal protective equipment (PPE) used in the SARS-CoV-2 pandemic. Methods To develop the brochure, an integrative literature review was conducted after searching the following databases: SciELO, LILACS, and MEDLINE. The brochure was evaluated by 38 health professionals (nurses, physical therapists, and doctors) employing the Delphi technique. The results were analyzed using the Content Validity Index. Results In the first evaluation cycle, the items in the brochure were considered by the panel of experts as ranging from “unsuitable” to “totally adequate”. After the appropriate corrections suggested by the experts, the brochure once again was sent to the second evaluation cycle, in which all items were rated as “adequate” or “totally adequate.” The result is a Content Validity Index of 1.0. Conclusion The present study allowed the development of a brochure and its validation by consensus among the evaluation group. The developed and validated brochure presents the reliability of the technique of dressing and undressing the PPE used by health professionals during the pandemic of COVID-19. This information contributes to the management of assistance with quality and safety for the frontline workers and patients.
  • Analysis of Patients Undergoing Colonoscopies and the Importance of Exam Quality for Colorectal Cancer Screening Original Article

    Furlanetto, Marcos Venícios; Zwierzikowski, Jaqueline Alves; Bertoldo, Carolina Fischer; Wistuba, Guilherme Andretta Sotto Maior; Tashima, Eduardo Issao Brand; Vieira, Ana Helena Bessa Gonçalves; Invitti, Henrique Luckow; Brenner, Antonio Sérgio

    Abstract in English:

    Summary Objective To determine the impact of the quality of colonoscopy examination for colorectal cancer screening. Methods Retrospective observational study ofmedical records from patients treated at the endoscopy and colonoscopy service of Hospital Universitário Evangélico Mackenzie (Curitiba, PR, Brazil) from January 2019 to January 2020. Results The analysis was based on 337 medical records from patients with adenomas identified during colonoscopy, and 1,385 medical records from patients without adenomas. The estimated occurrence rate of diagnosis of adenoma during colonoscopy in the target population of the study was of 19.6%, with a 95% confidence interval ranging from 17.7 to 21.5%. Of the 337 patients with adenoma, 136 (40.4%) presented the advanced form. Statistical analysis indicated a significant association between the quality of colonoscopy preparation and test completion. Conclusion The quality of colonoscopy images is a critical factor for colorectal cancer screening, as it leads to higher rates of adenoma detection and test completion.
  • Screening for Celiac Disease in Patients with Irritable Bowel Syndrome Fulfilling Rome III Criteria Original Article

    Al-Abachi, Khaldoon Thanoon

    Abstract in English:

    Abstract Background Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder. Celiac disease (CD), a treatable autoimmune enteropathy, with varied presentations, may simulate clinically symptoms of IBS. The aim of the present study is to screen for CD in patients with IBS diagnosed based on the Rome III criteria. Patients and Methods A cross-sectional study was conducted at a secondary care gastrointestinal unit in Al-Salam General Hospital in Mosul city, Iraq, from November 2015 to October 2016. All patients fulfilling the Rome III criteria for IBS were screened for CD using antitissue transglutaminase IgA antibodies (anti-tTG). Patients who tested positive were subjected to endoscopic duodenal biopsy to confirm the diagnosis of CD. Results A total of 100 patients were included in the present study (58 female and 42 male), the mean age of the participants was 40.8 years old (standard deviation [SD]±11.57). Ten patients (10/100, 10%) tested positive for anti-tTG antibodies. Five of the seropositive patients (5/10, 50%) showed positive biopsy results according to the Marsh classification, 3 of whom having diarrhea, and 2 with constipation. Conclusion Positive serology and biopsy results suggestive of CDare common among patients with IBS. Screening patients with IBS for CD is justified.
  • Diagnosis of Advanced Disease in Cases of Colorectal Cancer in a Developing Country Original Article

    Silva, Ricella Maria Souza da; Collaço, Polyana Maria Cruz; Cunha, Karin S.; Dias, Eliane Pedra

    Abstract in English:

    Abstract Objectives Colorectal cancer (CRC) is the second leading cause of cancer death in the world, with survival correlated with the extension of the disease at diagnosis. In many low-/middle-income countries, the incidence of CRC is increasing rapidly, while decreasing rates are observed in high-income countries. We evaluated the anatomopathological profile of 390 patients diagnosed with CRC who underwent surgical resection, over a six-year period, in the state of Paraíba, northeastern Brazil. Results Adenocarcinomas accounted for 98% of the cases of primary colorectal tumors, and 53.8% occurred in female patients. The average age of the sample was 63.5 years, with 81.8% of individuals older than 50 years of age and 6.4% under 40 years of age. The most frequent location was the distal colon; pT3 status was found in 71% of patients, and pT4 status, in 14.4%. Angiolymphatic and lymph-node involvements were found in 48.7% and 46.9% of the cases respectively. Distant metastasis was observed in 9.2% of the patients. Advanced disease was diagnosed in almost half of the patients (48.1%). The women in the sample had poorly-differentiated adenocarcinomas (p=0.043). Patients under 60 years of age had a higher rate of lymph-node metastasis (p=0.044). Tumor budding was present in 27.2% of the cases, and it was associated with the female gender, themucinous histological type, and the depth of invasion (pT3 and pT4). Conclusions We conclude that the diagnosis of advanced disease in CRC is still a reality, with a high occurrence of aggressive prognostic factors, which results in a worse prognosis.
  • Association between Fecal Incontinence and Lower Urinary Tract Symptoms and their Impact on the Quality of Life of Patients with Prostate Cancer Original Article

    Azevedo, Natália Burgos Freire; Abreu, Glícia Estevam de

    Abstract in English:

    Abstract Objective To evaluate the association of fecal incontinence (FI) and lower urinary tract symptoms (LUTS) in patients diagnosed with initial prostate cancer (PC) and after any therapeutic approach (surgery and radiotherapy). Methods Cross-sectional study using the Cleveland Clinic Incontinence Score (CCIS), the Fecal Incontinence Quality of Life (FIQL) questionnaire, and the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB). Results A total of 84 patients with PC were included: 40 of them had not started treatment, 31 were submitted to radical prostatectomy (RP), and 13 were submitted to radiotherapy (RT). Those submitted to RT presented higher scores on the ICIQ-OAB (p=0.01). When comparing the whole sample reagarding the patients with and without FI, we observed that the incontinents presented a higher frequency of urinary incontinence (UI) (p<0.001). Moreover, when comparing patients with/without FI within their treatment groups regarding the presence of UI and FIQL scores, we identified that patients undergoing RP presented an association between UI and FI (p<0.001) and a greater impact of FI on the FIQL (p<0.001). Conclusion Patients submitted to RT present more intense LUTS. Moreover, patients with FI present a higher association with UI, and this association is more marked in those with FI submitted to RP.
  • Risk Factors for Anastomotic Leakage Following Total or Subtotal Colectomy Original Article

    Ocaña, J.; Pastor-Peinado, P.; Abadía, P.; Ballestero, A.; Ramos, D.; García-Pérez, JC.; Fernández-Cebrián, JM.; Die, J.

    Abstract in English:

    Abstract Introduction A higher rate of anastomotic leakage (AL) is reported after ileosigmoid anastomosis (ISA) or ileorectal anastomosis (IRA) in total or subtotal colectomy (TSC) compared with colonic or colorectal anastomosis. Themain aimof the present studywas to assess potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity. Methods We identified 180 consecutive patients in a prospective referral, single center database, in which 83 of the patients underwent TSC with ISA or IRA. Data regarding the clinical characteristics, surgical treatment, and outcome were assessed to determine their association with the cumulative incidence of AL and surgical morbidity. Results Ileosigmoid anastomosis was performed in 51 of the patients (61.5%) and IRA in 32 patients (38.6%). The cumulative incidence of ALwas 15.6% (13 of 83 patients). A higher AL rate was found in patients under 50 years-old (p=0.038), in the electivelaparoscopic approach subgroup (p=0.049), and patients in the inflammatory bowel disease (IBD) subgroup (p=0.009). Furthermore, 14 patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA. Discussion A relatively high incidence of AL after TSC was observed in a relatively safe surgical procedure. Our findings suggest that the risk of AL may be higher in IBD patients. According to our results, identifying risk factors prior to surgerymay improve short-term outcomes.
  • A Comparison between Different Management Surgical Approaches in the Treatment of Splenic Flexure Colon Cancer Original Article

    El-Hendawy, Elsayed I.; Amin, Mohamed Farouk; Fahmy, Ahmed M.; Alattar, Ahmed Z.; Elshorbagy, Shereen; Harb, Ola A.; Gomaa, Ahmed Fathy; Embaby, Ahmed; Elsayed, Ahmed M.; Osman, Gamal; Ali, Ramadan M.

    Abstract in English:

    Abstract Background There are many surgical approaches which described extent of resection of the colon for adequate surgicalmanagement of splenic flexure cancer, but up till now there is no established surgical procedure, this is because the presence of double lymphatic drainage of themesenteric vessels. Segmental resection of the colon for the management of splenic flexure cancer was a recently accepted surgical procedure. Objective In the present study, we aimed to compare three surgical management techniques to clarify the best management approach of Egyptian patients with splenic flexure cancer regarding operative, clinical, and oncological outcomes: segmental resection, and extended left or right hemicolectomy,. Materials and Methods In the present study, we included 90 patients with splenic flexure cancer. Cases were divided into 3 groups. Each group included 30 patients in order to compare three surgical techniques: segmental resection, extended left hemicolectomy, and extended right hemicolectomy. Results We have found no statistically significant differences between the three included groups regarding operative findings, postoperative complications, local recurrence, distant recurrence, disease progression, recurrence-free survival rate, progression-free survival rate, and overall survival rate. The operative time was longer, and the number of lymph nodes was higher in the extended right hemicolectomy group (p<0.001). Conclusion We have shown that segmental resection of the splenic flexure is surgically and clinically suitable for the adequate management of operable cases of carcinoma of the splenic flexure.
  • Tissue Factor Expression in Colorectal Adenocarcinoma: Association with Angiogenesis and Clinical and Pathological Aspects Original Article

    Fillmann, Lúcio Sarubbi; Fillmann, Laura Pinho; Oliveira, Leonardo Zarpelon de; Fillmann, Henrique Sarubbi; Carvalhal, Gustavo Franco

    Abstract in English:

    Abstract Introduction Tissue factor (TF) expression has been described in various neoplasms and was correlated with angiogenesis and metastases. Objectives To describe TF expression in colorectal cancers, correlating it with microvessel density and clinical and pathological variables. Methods Immunohistochemistry was used to determine TF expression and microvessel density. The Student t-test was used to compare high and low TF expression with microvessel density andwith age. The chi-squared test was used for other comparisons, and Kaplan-Meier curves were used for survival analyses. Results Forty-three patients were operated with curative intent. Their mean age was 58.1±12.6 years old, and 62.8% were male. The rectum was the most common location (60,4%), and most tumors reached the serosa and peri-intestinal fat (72.1%). Lymph nodes were positive in 46.5%, and 72.1% of the tumors were moderately differentiated adenocarcinomas. Death occurred in 27.6±12.8months in 51.1% of the patients who had recurrence. Tissue factor expression was intense in 88.4%. There was a positive correlation between TF expression and microvessel density (p=0.02), and between TF and older age (p<0.01). There was no correlation between TF expression and other variables (gender, histological type, penetration into the intestinal wall, and lymphatic and systemic metastases). Tissue factor expression did not correlate with survival. Conclusion Tissue factor expression correlated with increased microvessel density and older age. Further studies are necessary to ascertain the clinical relevance of TF in colorectal cancer.
  • The Value of Terminal Ileum Intubation During Colonoscopy Original Article

    Alkhalidi, Nawal; Alrubaie, Abdulhadi; Rezqallah, Raed Esttaifan; Kenber, Maitham

    Abstract in English:

    Abstract It is uncertain whether terminal ileum intubation should be performed routinely during colonoscopy, as there is uncertainty regarding its diagnostic value. The aim of the present study is to assess the diagnostic yield of terminal ileum intubation during colonoscopy according to indications for colonoscopy. This is a cross-sectional study in which the results of 294 total colonoscopy procedures were reviewed; ileal intubation was performed in 269 (91.49%) patients. The indications for colonoscopy, the results of ileoscopy, and the histopathological results of ileal biopsies were evaluated. A total of 54 (20%) out of 269 patients who had successful intubation into the terminal ileumshowed macroscopic abnormalities on the terminal ileum. Biopsies were positive in 4 out of 54 (7.4%); all were of Crohn disease. Two were erosions (9.5%.) and 2 were ulcers (18.8%). The two erosions were presented as abdominal pain, abdominal pain and alternating bowel motion. Those with ulcers were presented with diarrhea and perianal disease. Conclusions Considering the low diagnostic yield of ileal intubation during colonoscopy, the decision to performileoscopy or not during colonoscopy needs to bemade on a case-by-case basis. However, routine ileal intubation, brief attempts should be considered despite low diagnostic yield.
  • Comparative Analysis of Anal Colposcopy with Histology in the Follow-Up of Patients under Treatment for Anal Condyloma Original Article

    Manzione, Thiago da Silveira; Nadal, Sidney Roberto; Gonçalves, Antônio José

    Abstract in English:

    Abstract Objectives To compare morphological abnormalities on anal colposcopy against histology to determine anal high-grade squamous intraepithelial lesions (HSILs). Methods This is a retrospective data assessment of HIV-negative and HIV-positive patients undergoing outpatient follow-up. The sample comprised 54 patients presenting acetowhite lesions on anal colposcopy. Acetowhite lesions were classified according to their morphology into punctation, verrucous, mosaic, ulcerated, or hypervascularized, and biopsies of these specimens were classified as anal HSIL, low-grade squamous intraepithelial lesion (LSIL), or normal. The data were analyzed using SPSS forWindows version 13.0 (SPSS Inc., Chicago, IL, USA). The results were analyzed using the nonparametric Mann-Whitney test, the Fisher exact test and the chi-squared parametric test. A 95% confidence interval (CI) was used and a level of significance<5% was adopted for all statistical tests. Results Fifty-four patients (50 males, 80% HIV+) with biopsied acetowhite lesions were assessed. There were 31 punctation lesions, 1 classified as HSIL (3.2%; 95%CI: 0- 40.0), 17 verrucous lesions, 3 HSIL (17.7%; 95%CI: 0-10.7), and 1 ulcerated, classified as HSIL (100%), and 4 mosaic and 1 atypical vessel lesion, all classified as LSIL. The results showed no association of presence of anal HSIL with positivity for HIV infection or with counts above or below 500/μl in HIV+patients. Statistical analysis was performed using the Mann-Whitney nonparametric test, the Fisher exact test, and the chi-squared parametric test. Conclusion The comparison of morphological findings on anal colposcopy against histology revealed no morphological pattern suggesting anal HSIL.
  • Prognostic Factors and Management of Colorectal Gastrointestinal Stromal Tumors Review Article

    Reis, Nuno Rafael Pereira; Barbosa, Laura Elisabete Ribeiro

    Abstract in English:

    Abstract Introduction The gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. Even though it can be found in any location of the digestive tract, the colorectal GIST is rare. With this study, we aim to review the current knowledge regarding the prognosis and management of colorectal GIST. Methods A literature search was conducted in PubMed, and 717 articles were collected. After analyzing these studies, 60 articles were selected to use in this review. Results The mitotic index, as well as tumor size and location were identified as good discriminators of prognosis in various studies. Surgery remains the only curative therapy for potentially resectable tumors. However, even after surgical resection, some patients develop disease recurrence and metastasis, especially those with highrisk tumors. Therefore, surgical resection alone might be inadequate for the management of all colorectal GISTs. The discovery of GIST’s molecular pathway led to a shift in its therapy, insofar as tyrosine kinase inhibitors became part of the treatment schemes for this tumor, revolutionizing the treatment’s outcome and prognosis. Discussion/Conclusion The controversy concerning colorectal GIST prognosis and treatment can be, in part, attributed to the limited number of studies in the literature. In this review, we gathered the most recent knowledge about the prognosis and management of GIST in this rare location and propose two algorithms for its approach. Lastly, we highlight the importance of an individualized approach in the setting of a multidisciplinary team.
  • Physiotherapeutic Approaches to Treat Anal Incontinence in Women after Obstetric Trauma Review Article

    Freitas, Mayanna Machado; Moura, Lara Elma Franco; Saquetto, Denise; Rodrigues, Iane Castro; Carvalho, Valéria Conceição Passos de; Uchôa, Silvana Maria Macedo

    Abstract in English:

    Abstract Introduction Anal incontinence is defined as the loss of voluntary control of fecal matter or gases with a recurrence period longer than 3 months in individuals aged ≥ 4 years; it has a female predominance. Among the treatment modalities is pelvic physiotherapy, the second line of treatment, which promotes the reeducation, coordination, and strengthening of the muscles of the pelvic floor to enable patients to return to their regular activities of daily living. Objective To perform a systematic review on the physiotherapeutic treatments used in women between the ages of 18 and 65 years with a diagnosis of anal incontinence. Material and methods Clinical studies written in Portuguese, Spanish and English were searched on the the following databases: Science Direct, Medical Literature Analysis and Retrieval System Online (Medline) via PubMed, Physiotherapy Evidence Database (PEDro), Scientific Electronic Library Online (SciELO), and Scopus. Results Of the 998 articles found, only 4 studies met the inclusion criteria of the present systematic review. The physiotherapeutic approaches to treat women with anal incontinence are biofeedback, Kegel exercises, electrostimulation, and training of the pelvic floor muscles. The average score on the PEDro scale was of 6.25, which indicates that the methodological quality was good. Conclusion Although pelvic physiotherapy is effective to treat anal incontinence, it must be promoted through the performance of evidence-based scientific research.
  • Therapeutics in Radiation-induced Proctopathy: A Systematic Review Review Article

    Omer, Nathália Nascentes Coelho dos Santos; Araujo, Ivana Duval de; Cruz, Geraldo Magela Gomes da; Rodrigues, Fábio Gontijo

    Abstract in English:

    Abstract Malignant neoplasms are increasingly prevalent in the daily clinical practice. Up to 61% of patients with pelvic malignancies undergo pelvic radiotherapy in different doses, which may cause intestinal damage, and the rectum is the segment most frequently affected due to its fixed position in the pelvis. Currently, there are several strategies to minimize the effects of radiation on the tissues surrounding the neoplastic site; despite those strategies, radiotherapy can still result in serious damage to organs and structures, and these injuries accompany patients throughout their lives. One of the most common damages resulting from pelvic radiotherapy is acute proctitis.The diagnosis is confirmed by visualizing the rectal mucosa through rigid or flexible rectosigmoidoscopy and colonoscopy. The objective of the present study was to review the forms of radiation-induced proctopathytherapy, and to evaluate the results of each method to propose a standardization for the treatment of this pathology. Despite the prevalence of radiation-induced proctopathy, there is no definitive standardized treatment strategy so far. The first approach can be tried with local agents, such as mesalazine and formalin. For refractory cases, control can usually be achieved with argon plasma coagulation, hyperbaric oxygen, and radiofrequency ablation therapies. Regarding the study of radiation-induced proctopathy, there is a lack of robust studies with large samples and standardized therapies to be compared. There is a lack of double-blinded, randomized controlled studies to determine a definitive standard treatment algorithm.
  • Multiple Jejunal Diverticulosis Complicated by Perforation: Case Report and a Brief Literature Review Case Report

    Carmo, Luiz Carlos Benjamin do; Campos, Fábio Guilherme; Barreto, Renato; Fontes, Diogo; Ibiapina, Thiago; Gontscharow, Sérgio

    Abstract in English:

    Abstract Background Multiple small-bowel diverticulosis comprises a rare entity with probable underestimated incidence, and that may be the reason why it is sometimes overlooked when managing cases with peritonitis. Case report In the present paper, we report the case of a 76-year-old male presenting abdominal pain and fever in an acute setting. Computed tomography (CT) scans revealed jejunal thickening and numerous images of saccular addition that were interpreted as jejunoileal diverticulitis. After an initial period of clinical treatment, surgical management was indicated based on a worsening clinical picture and the presence of an extraluminal focus of gas detected in a subsequent CT scan. Through a laparoscopic approach, multiple small-bowel diverticula and a tamponade perforation were found. A segmental intestinal resection was performed, and the patient was discharged after a ten days. Conclusions Multiple jejunal diverticulosis is a rare condition that should be remembered in the setting of an acute abdomen. As it prevails among older patients, early diagnosis with radiological aid is crucial to establish the most adequate management, including intestinal resection, if necessary.
  • Primary Adenocarcinoma at Colostomy Site: Report of a Clinical Case Case Report

    Sardiñas, Carlos; Nouri, Bagher; Cifuentes, Andrea; Oropeza, María Eugenia

    Abstract in English:

    Abstract Colorectal cancer (CRC) is the fourth most frequently diagnosed cancer in the United States and it is found in 17% of patients thought to have complicated diverticular disease. However, primary adenocarcinoma rarely occur in the colostomy site and the risk of developing malignancy is similar to that of any other colonic segment. Polyps found in CRC screenings can be divided into the following types: hyperplastic polyps, polyps with no malignant potential, adenomatous polyps, polyps with malignant potential, and malignancies. Local complications of the colostomy can appear in the immediate, early, or late postoperative period, with an incidence ranging from 15 to 30%; neoplasia is even less common.
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