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BACKGROUND: Inflammatory bowel diseases (IBD) are chronic inflammatory affections of recurrent nature whose incidence and prevalence rates have increased, including in Brazil. In long term, they are responsible for structural damage that impacts quality of life, morbidity and mortality of patients. OBJECTIVE: To describe the profile of physicians who treat IBD patients as well as the characteristics of IBD care, unmet demands and difficulties. METHODS: A questionnaire containing 17 items was prepared and sent to 286 physicians from 101 Brazilian cities across 21 states and the Federal District, selected from the register of the State Commission of the “Study Group of Inflammatory Bowel Disease of Brazil” (GEDIIB). RESULTS: The majority of the physicians who answered the questionnaire were gastroenterologists and colorectal surgeons. More than 60% had up to 20 years of experience in the specialty and 53.14% worked at three or more locations. Difficulties in accessing or releasing medicines were evident in this questionnaire, as was referrals to allied healthy professionals working in IBD-related fields. More than 75% of physicians reported difficulties in performing double-balloon enteroscopy and capsule endoscopy, and 67.8% reported difficulties in measuring calprotectin. With regard to the number of patients seen by each physician, it was shown that patients do not concentrate under the responsibility of few doctors. Infliximab and adalimumab were the most commonly used biological medicines and there was a higher prescription of 5-ASA derivatives for ulcerative colitis than for Crohn’s disease. Steroids were prescribed to a smaller proportion of patients in both diseases. The topics “biological therapy failure” and “new drugs” were reported as those with higher priority for discussion in medical congresses. In relation to possible differences among the country’s regions, physicians from the North region reported greater difficulty in accessing complementary exams while those from the Northeast region indicated greater difficulty in accessing or releasing medicines. CONCLUSION: The data obtained through this study demonstrate the profile of specialized medical care in IBD and are a useful tool for the implementation of government policies and for the Brazilian society as a whole.

Gastrointestinal stromal tumors, although rare, are the most common primary mesenchymal neoplasms of the gastrointestinal tract and originate from the interstitial cells of Cajal. They present slow growth and symptoms such as bleeding, abdominal pain or discomfort, and the presence of an abdominal mass. The most affected organs are the stomach and small intestine. Differential diagnoses for gastrointestinal stromal tumor include adenocarcinoma and small intestine lymphoma, metastasis, and carcinoid tumor. Gastrointestinal stromal tumors have been associated with familial syndromes such as type 1 neurofibromatosis, considered a predisposing factor for tumors in the small intestine. This study aimed to report a case of gastrointestinal stromal tumor in the jejunal region in a patient with type 1 neurofibromatosis, followed-up for two years, who underwent laparoscopic segmental enterectomy and diagnosis determined by histopathology and immunohistochemistry. The diagnosis of small intestine gastrointestinal stromal tumor is challenging because of its low incidence, nonspecific symptoms, relative inaccessibility of the small intestine to conventional endoscopic examination, broad spectrum of radiological appearances, and the fact that the nature of the mass is difficult to determine with imaging examinations of the abdomen alone. Thus, the small intestine gastrointestinal stromal tumor may be erroneously diagnosed as pancreatic, gynecological, or mesenteric tumors. The literature does not present many reports on the association of jejunal gastrointestinal stromal tumor with neurofibromatosis. Understanding the tumoral behavior of small intestine gastrointestinal stromal tumor in this subgroup of patients would allow better follow-up. Resumo: Os tumores estromais gastrointestinais, embora raros, são as neoplasias mesenquimais primárias mais comuns do trato gastrointestinal e originam-se das células intersticiais de Cajal. Apresentam crescimento lento e manifestam sintomas como sangramento, dor ou desconforto abdominal e presença de massa abdominal. Os órgãos mais acometidos são estômago e intestino delgado. Os diagnósticos diferenciais para tumores estromais gastrointestinais incluem adenocarcinoma e linfoma de intestino delgado, metástases e tumor carcinoide. Os tumores estromais gastrointestinais têm sido associados a síndromes familiares como a neurofibromatose tipo 1, considerada um fator predisponente para tumores no intestino delgado. O objetivo desse trabalho é relatar um caso de tumor estromal gastrointestinal em região jejunal em paciente portadora de neurofibromatose tipo 1, com 2 anos de seguimento, submetida a enterectomia segmentar laparoscópica e diagnóstico determinados pela histopatologia e imuno-histoquímica. O diagnóstico de tumor estromal gastrointestinal do intestino delgado é desafiador, devido a sua baixa incidência, sintomas inespecíficos, relativa inacessibilidade do intestino delgado ao exame endoscópico convencional, amplo espectro de aparências radiológicas e difícil determinação da natureza da massa apenas com exames de imagens do abdome. Assim, tumor estromal gastrointestinal no intestino delgado podem ser erroneamente diagnosticados como tumores pancreáticos, tumores ginecológicos, ou tumores do mesentério. A descrição científica da associação de tumor estromal gastrointestinal de jejuno com neurofibromatose é incomum. Tais descrições permitem melhor seguimento dos pacientes a partir do momento que se entende o comportamento tumoral do tumor estromal gastrointestinal de intestino delgado nesse subgrupo de pacientes. Keywords: Gastrointestinal neoplasms, Gastrointestinal stromal tumors, Small intestine, Type 1 neurofibromatosis, Palavras-chave: Neoplasias gastrointestinais, Tumores do estroma gastrointestinal, Intestino delgado, Neurofibromatose tipo 1

Crohn's disease is a chronic, inflammatory bowel condition that can affect the entire digestive tract and in many cases lead to enteric fistula formation. The management of enteric fistulas can be challenging and often requires a multidisciplinary approach.

Purpose: the aim of this study was to identify the risk factors for readmission among patients submitted to colorectal surgery. Methods: a single-center colorectal quality-assessment database was queried for patients undergoing colorectal procedures with ileostomy during 2009. the sample was divided into readmitted vs. non-readmitted. readmission was defined as admission within the first 30 days after the index procedure. Groups were compared by pre, intra and postoperative characteristics. A multivariate analysis was performed to identify the risk factors for readmission. Results: the query returned 496 patients, [267 (54%) males, median age 48 years (iQr: 34-60)]. Eighty-three (17%) were readmitted; 296 patients (60%), were operated due to inflammatory bowel disease, 89 (18%) for cancer, 16 (3%) for diverticular disease and 95 (19%) for other diagnosis. the three most common procedures were total proctocolectomy with ileal pouch-anal anastomosis (iPAA) in 103 patients (21%), total colectomy with end ileostomy in 117 (24%) and small bowel resections (including enterocutaneous fistula takedown and J-pouch excision) in 149 (30%). the following variables were significantly more common in readmitted patients: current smoking (24% vs. 14%, p = 0.02), postoperative DVt/PE (10% vs. 4%, p = 0.04), wound infection (20% vs. 10% p = 0.01), sepsis (22% vs. 8% p < 0.001) and organ or space surgical site infection (orgSSi) (35% vs. 5%, p < 0.001). Postoperative orgSSi was the only independent factor associated with readmission in a multivariate analysis (p < 0.001). Conclusion: colorectal surgeons should be alert for orgSSi when facing an ileostomy patient readmitted after a colorectal procedure. Resumo: Objetivo: o objetivo deste estudo foi identificar os fatores de risco para readmissão em pacientes submetidos à cirurgia colorretal. Métodos: um banco de dados de avaliação da qualidade colorretal em um único centro foi consultado para pacientes submetidos à procedimentos colorretais com ileostomia em 2009. A amostra foi dividida em readmitidos versus não readmitidos. A readmissão foi definida como a admissão dentro dos primeiros 30 dias após o procedimento índice. os grupos foram comparados em relação à características pré, intra e pós-operatórias. A análise multivariada foi realizada para identificar os fatores de risco para readmissão. Resultados: a consulta identificou 496 pacientes, [267 (54%) do sexo masculino, idade média de 48 anos (ViQ: 34 -60)]. oitenta e três (17%) foram readmitidos; 296 pacientes (60%) foram operados por doença inflamatória intestinal, 89 (18%) por câncer, 16 (3%) por doença diverticular e 95 (19%) devido a outro diagnóstico. os três procedimentos mais comuns foram proctocolectomia total com anastomose anal e bolsa ileal (iPAA) em 103 pacientes (21%), colectomia total com ileostomia final em 117 (24%) e ressecções do intestino delgado (incluindo a remoção de fístula enterocutânea e excisão da bolsa em J) em 149 (30%). As seguintes variáveis foram significativamente mais comuns em pacientes readmitidos: tabagismo atual (24% vs. 14%, p = 0,02), tVP/EP pós-operatório (10% vs. 4%, p = 0,04), infecção da ferida cirúrgica (20% vs. 10% p = 0,01), sepse (22% vs. 8%, p < 0,001) e infecção de órgão/espaço do sítio cirúrgico (ioSC) (35% vs. 5%, p < 0,001). A infecção do ioSC pós-operatório foi o único fator independente associado com a readmissão na análise multivariada (p < 0,001). Conclusão: os cirurgiões colorretais devem estar alertas para ioSC diante de um paciente com ileostomia readmitido após um procedimento colorretal. Keywords: ileostomy readmission, Palavras-chave: ileostomia readmissão

PURPOSE: To investigate the correlation between bursting pressure and breaking strength on the 7th postoperative day following left colonic anastomosis in rats. METHODS: Seventy rats were randomly divided into seven groups of ten animals each. All of the animals underwent segmental resection of the left colon and end-to-end anastomosis. The animals in groups I to VI underwent surgical laparoscopies with pneumoperitoneums using carbon dioxide or helium at pressures of 5, 12 or 20 mmHg. In Group VII, open laparotomy was performed. The animals were reoperated on postoperative day 7 to measure the bursting pressure and the breaking strength of the anastomosis. RESULTS: The anastomosis bursting pressure in 70 animals was 193.10±55.56 mmHg. There was no significant difference between the groups (p=0.786). The breaking strength of the anastomosis was 0.26±0.12 N. There was no significant difference between the groups (p=0.356). Pearson's correlation test showed a low correlation (r=0.231) lacking statistical significance (p=0.054). CONCLUSION: There was no correlation between the bursting pressure and breaking strength of left colonic anastomoses in rats on the 7th postoperative day.

Objective: Laparoscopic approach should be offered for most patients requiring colectomy, as it is a safe procedure, associated with shorter hospitalization, better cosmetic results, and does not affect negatively the oncological outcomes of patients with colon cancer. However, there is no consistent data on the safety of laparoscopic surgery training during residency. Therefore, the aim of this study was to assess whether or not the resident par- ticipation in laparoscopic colectomy affected the postoperative outcomes. Methods: The database of the American College of Surgeons National Surgical Quality Im- provement Program (ACS-NSQIP) was searched for patients undergoing laparoscopic col- ectomies between 2005 and 2007. We excluded patients with no data regarding whether or not there was a resident participation in the operation. The study population was divided into 2 groups (resident and nonresident), according to residents participation in the surgi- cal procedure. Perioperative variables and postoperative complications were compared be- tween groups. A multivariate analysis was performed to evaluate the association between postoperative complications and resident participation in the operation. Results: The search yielded 5,912 patients with a median age of 63 years. Of these, 3,112 (53%) were female and 3.887 (66%) had a resident involved in their operation. The resident group had a significantly longer mean operative time (163 ± 64 min vs 138 ± 58 min, p < 0.0001). Other variables did not differ significantly between groups. Moreover, multivari- ate analysis showed no association between resident participation and the occurrence of postoperative complications. Conclusion: Laparoscopic training during residency may be safely performed without threatening the patient's integrity. Resumo: Objetivo: Cirurgia videolaparoscópica é a via preferencial para colectomias eletivas por ser um procedimento seguro, associado à menor tempo de internação, melhores resultados estéticos e por não influenciar negativamente os resultados oncológicos dos pacientes com câncer de cólon. Entretanto, ainda não existem dados consistentes sobre a segurança do treinamento em cirurgia laparoscópica durante a residência. Sendo assim, o objetivo deste estudo foi avaliar se a participação do residente em colectomias laparoscópicas afetou os resultados pós-operatórios. Métodos: A base de dados do American College of Surgeons National Surgical Quality Im- provement Program (ACS-NSQIP) foi pesquisada para colectomias laparoscópicas entre os anos de 2005 e 2007. A população do estudo foi dividida em dois grupos de acordo com a participação ou não do residente na cirurgia: residente vs. não residente. Os grupos foram comparados em relação às variáveis perioperatórias e complicações pós-operatórias. Uma análise multivariada foi realizada para investigar possível associação entre complicações pós-operatórias e o envolvimento de residentes na operação. Resultados: A pesquisa retornou 5.912 pacientes, com mediana de idade de 63 anos. Em 3.887 casos (66%) o residente estava envolvido na operação. O grupo Residente apresentou tempo operatório mediano significantemente maior que o grupo Não Residente (163 ± 64 min vs. 138 ± 58 min, p < 0.0001). Todas as outras variáveis estudadas não diferiram signifi- cativamente entre os grupos. Além disso, a análise multivariada não demonstrou nenhuma associação entre o envolvimento do residente na operação e a ocorrência de complicações pós-operatórias. Conclusão: O treinamento laparoscópico durante a residência pode ser realizado com segu- rança sem colocar em risco a integridade do paciente operado. Keywords: Videolaparoscopy, Colectomy, Palavras-chave: Videolaparoscopia, Colectomia

Objective: Colorectal surgeons often struggle to explain to administrators/payers reasons for prolonged length of stay (LOS). This study aim was to identify factors associated with increased LOS after colorectal surgery. Design: The study population included patients from the 2007 American-College-of-Sur- geons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database undergoing ileocolic resection, segmental colectomy, or anterior resection. The study population was divided into normal (below 75th percentile) and prolonged LOS (above the 75th percentile). A multivariate analysis was performed using prolonged LOS as dependent variable and ACS- NSQIP variables as predictive variables. P-value < 0.01 was considered significant. Results: 12,269 patients with a median LOS of 6 (inter-quartile range 4-9) days were includ- ed. There were 2,617 (21.3%) patients with prolonged LOS (median 15 days, inter-quartile range 13-22). 1,308 (50%) were female, and the median age was 69 (inter-quartile range 57-79) years. Risk factors for prolonged LOS were male gender, congestive heart failure, weight loss, Crohn's disease, preoperative albumin < 3.5 g/dL and hematocrit < 47%, base- line sepsis, ASA class ≥ 3, open surgery, surgical time ≥ 190 min, postoperative pneumonia, failure to wean from mechanical ventilation, deep venous thrombosis, urinary-tract in- fection, systemic sepsis, surgical site infection and reoperation within 30-days from the primary surgery. Conclusion: Multiple factors are associated with increased LOS after colorectal surgery. Our results are useful for surgeons to explain prolonged LOS to administrators/payers who are critical of this metric. Resumo: Objetivo: Os cirurgiões proctologistas muitas vezes enfrentam dificuldades para explicar aos administradores/contribuintes as razões para o prolongamento do tempo de interna- ção hospitalar (TIH). O objetivo deste estudo foi identificar os fatores associados ao aumen- to do TIH após cirurgia colorretal. Método: A população do estudo incluiu pacientes que constam do banco de dados do Ame- rican College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) no ano de 2007 e que foram submetidos à ressecção ileocólica, colectomia segmentar ou res- secção anterior. A população do estudo foi dividida em normal (abaixo do percentil 75) e TIH prolongado (acima do percentil 75). A análise multivariada foi realizada usando o TIH prolongado como variável dependente e as variáveis do ACS-NSQIP como preditivas. Um valor de p < 0,01 foi considerado significativo. Resultados: No total, 12.269 pacientes com um TIH mediano de 6 dias (intervalo interquartil, 4-9) foram incluídos. Havia 2.617 pacientes (21,3%) com TIH prolongado (mediana, 15 dias; in- tervalo interquartil, 13-22). A idade média dos pacientes era de 69 anos (intervalo interquartil, 57-79) e 1.308 (50%) eram do sexo feminino. Os fatores de risco para TIH prolongado foram sexo masculino, insuficiência cardíaca congestiva, perda de peso, doença de Crohn, albu- mina < 3,5 g/dL e hematócrito < 47% no pré-operatório, sepse basal, classe ASA ≥ 3, cirurgia aberta, tempo cirúrgico ≥ 190 minutos, pneumonia no pós-operatório, falha no desmame da ventilação mecânica, trombose venosa profunda, infecção do trato urinário, sepse sistêmica, infecção do sítio cirúrgico e reoperação dentro de 30 dias da cirurgia primária. Conclusão: Vários fatores estão associados ao aumento do TIH após a cirurgia colorretal. Nossos resultados são úteis para que os cirurgiões possam explicar os TIH prolongados aos administradores/contribuintes que são críticos dessa métrica. Keywords: Colectomy, Morbidity, Length of stay, Palavras-chave: Colectomia, Morbidade, Tempo de internação

Enterocutaneous fistula (ECF) associated with cancer or radiation injury increases the complexity of normal management. Factors such as timing of additional adjuvant therapy or palliative care, technical considerations for operating on irradiated bowel, poor wound healing, increased risk of additional ECF, and decreased likelihood of spontaneous ECF closure all need to be considered in this scenario. Here the authors focus specifically on the management of ECF associated with cancer and/or radiation-induced injury to the bowel.

PURPOSE: Issues related to body image and a permanent stoma after abdominoperineal resection may decrease quality of life in rectal cancer patients. However, specific problems associated with a low anastomosis may similarly affect quality of life for patients undergoing low anterior resection. The aim of this study was to compare quality of life of low rectal cancer patients after undergoing abdominoperineal resection versus low anterior resection. METHODS: Demographics, tumor and treatment characteristics, and prospectively collected preoperative quality-of-life data for patients undergoing low anterior resection or abdominoperineal resection for low rectal cancer between 1995 and 2009 were compared. Quality of life collected at specific time intervals was compared for the two groups, adjusting for age, body mass index, use of chemoradiation, and 30 days postoperative complications. The short-form-36 questionnaire was used to determine quality of life. RESULTS: The query returned 153 patients (abdominoperineal resection = 68, low anterior resection = 85) with a median follow-up of 24 (3-64) mo. The after abdominoperineal resection group had a higher mean age (63 ± 12 vs. 54 ± 12, p < 0.001) and more American Society of Anesthesiologists classification 3/4 patients (65 percent vs. 43 percent, p = 0.03) than low anterior resection. Other demographics, tumor stage, use of chemoradiation, overall postoperative complication rates, and quality-of-life follow-up time were not statistically different in both groups. Patients undergoing abdominoperineal resection had a lower baseline short-form-36 mental component score than those undergoing low anterior resection. However, 6 mo after surgery this difference was no longer statistically significant and essentially disappeared at 36 mo after surgery. CONCLUSION: Patients undergoing abdominoperineal resection for low rectal cancer have a similar long-term quality of life as those undergoing low anterior resection. These findings can help clinicians to better counsel patients with low rectal cancer who are being considered for abdominoperineal resection.