Prevalence, Indirect Costs, and Risk Factors for Work Disability in Patients with Crohn's Disease at a Tertiary Care Center in Rio de Janeiro
BACKGROUND AND AIMS/OBJECTIVE:Crohn's disease (CD) can lead to work disability with social and economic impacts worldwide. In Brazil, where its prevalence is increasing, we assessed the indirect costs, prevalence, and risk factors for work disability in the state of Rio de Janeiro and in a tertiary care referral center of the state. METHODS:Data were retrieved from the database of the Single System of Social Security Benefits Information, with a cross-check for aid pension and disability retirement. A subanalysis was performed with CD patients followed up at the tertiary care referral center using a prospective CD database, including clinical variables assessed as possible risk factors for work disability. RESULTS:From 2010 to 2018, the estimated prevalence of CD was 26.05 per 100,000 inhabitants, while the associated work disability was 16.6%, with indirect costs of US$ 8,562,195.86. Permanent disability occurred more frequently in those aged 40 to 49Â years. In the referral center, the prevalence of work disability was 16.7%, with a mean interval of 3Â years between diagnosis and the first benefit. Risk factors for absence from work were predominantly abdominal surgery, anovaginal fistulas, disease duration, and the A2 profile of the Montreal classification. CONCLUSIONS:In Rio de Janeiro, work disability affects one-sixth of CD patients, and risk factors are associated with disease duration and complications. In the context of increasing prevalence, as this disability compromises young patients after a relatively short period of disease, the socioeconomic burden of CD is expected to increase in the future.
Perianal complete remission with combined therapy (seton placement and anti-TNF agents) in Crohn's disease: a Brazilian multicenter observational study
BACKGROUND:Perianal fistulizing Crohn's disease is one of the most severe phenotypes of inflammatory bowel diseases. Combined therapy with seton placement and anti-TNF therapy is the most common strategy for this condition. OBJECTIVES/OBJECTIVE:The aim of this study was to analyze the rates of complete perianal remission after combined therapy for perianal fistulizing Crohn's disease. METHODS:This was a retrospective observational study with perianal fistulizing Crohn's disease patients submitted to combined therapy from four inflammatory bowel diseases referral centers. We analyzed patients' demographic characteristics, Montreal classification, concomitant medication, classification of the fistulae, occurrence of perianal complete remission and recurrence after remission. Complete perianal remission was defined as absence of drainage from the fistulae associated with seton removal. DISCUSSION/CONCLUSIONS:A total of 78 patients were included, 44 (55.8%) females with a mean age of 33.8 (Â±15) years. Most patients were treated with Infliximab, 66.2%, than with Adalimumab, 33.8%. Complex fistulae were found in 52/78 patients (66.7%). After a medium follow-up of 48.2 months, 41/78 patients (52.6%) had complete perianal remission (95% CI: 43.5%-63.6%). Recurrence occurred in four (9.8%) patients (95% CI: 0.7%-18.8%) in an average period of 74.8 months. CONCLUSIONS:Combined therapy lead to favorable and durable results in perianal fistulizing Crohn's disease.
Wireless capsule endoscopy fragmentation in a patient with Crohn's disease [Case Report]
Pathologic complete response after neoadjuvant treatment for rectal cancer decreases distant recurrence and could eradicate local recurrence
BACKGROUND:The aim of this study was to evaluate the clinical implications of pathologic complete response (pCR) (i.e., T0N0M0) after neoadjuvant chemoradiation and radical surgery in patients with locally advanced rectal cancer. MATERIALS AND METHODS/METHODS:A single-center, prospectively maintained colorectal cancer database was queried for patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI undergoing long-course neoadjuvant chemoradiation followed by proctectomy with curative intent between 1997 and 2007. Patients were stratified into pCR and no-pCR groups and compared with respect to demographics, tumor and treatment characteristics, and oncologic outcomes. Outcomes evaluated were 5-year overall survival, disease-free survival, disease-specific mortality, local recurrence, and distant recurrence. RESULTS:The query returned 238 patients (73% male), with a median age of 57Â years and median follow-up of 54Â months. Of these, 58 patients achieved pCR. Patients with pCR vs no-pCR were statistically comparable with respect to demographics, chemoradiation regimens, tumor distance from anal verge, clinical stage, surgical procedures performed, and follow-up time. No patient with pCR had local recurrence. Overall survival and distant recurrence were also significantly improved for patients achieving pCR. CONCLUSIONS:Achievement of pCR after neoadjuvant chemoradiation is associated with greatly improved cancer outcomes in locally advanced rectal cancer. Future studies should evaluate the relationship between increases in pCR rates and improvements in cancer outcomes in this population.
Neoadjuvant therapy for rectal cancer: the impact of longer interval between chemoradiation and surgery
PURPOSE/OBJECTIVE:The aim of this study was to determine the effect of a longer interval between neoadjuvant chemoradiation and surgery on perioperative morbidity and oncologic outcomes. METHODS:A colorectal cancer database was queried for clinical stage II and III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. The neoadjuvant regimen consisted of long course external beam radiation and 5-fluorouracil chemotherapy. Patients with inflammatory bowel disease, hereditary cancer, extracolonic malignancy, urgent surgery, or non-validated treatment dates were excluded. Patients were divided into two groups according to the interval between chemoradiation and surgery (<8 and â‰¥ 8 weeks). Perioperative complications and oncologic outcomes were compared. RESULTS:One hundred seventy-seven patients were included. Groups were comparable with respect to demographics, tumor, and treatment characteristics. Perioperative complications were not affected by the interval between chemoradiation and surgery. Patients undergoing surgery â‰¥ 8 weeks after chemoradiation experienced a significant improvement in pathologic complete response rate (30.8% vs. 16.5%, p = 0.03) and had decreased 3-year local recurrence rate (1.2% vs. 10.5%, p = 0.04). A Cox regression analysis was performed to assess the compounding effect of a complete pathologic response on oncologic outcome. A longer interval correlated with less local recurrence, although statistical significance was not reached (p = 0.07). CONCLUSION/CONCLUSIONS:An interval between chemoradiation and surgery â‰¥ 8 weeks is safe and is associated with a higher rate of pathologic complete response and decreased local recurrence.
Laparoscopic resection for rectal cancer: a case-matched study
INTRODUCTION: The field of laparoscopic rectal cancer surgery is expanding. We compare short-term and early oncological outcomes after laparoscopic versus open resection in carefully matched rectal cancer patients. METHODS: All consecutive patients undergoing elective laparoscopic resection for rectal cancer were reviewed. Laparoscopic resections were matched 1:1 to open resections by age, gender, American Society of Anesthesiologists class, body mass index, neoadjuvant chemoradiation, and type of surgery. Data were analyzed using Fisher's exact, chi-square, Wilcoxon rank-sum tests, and Kaplan-Meier estimates. P-value <0.05 was considered statistically significant. RESULTS: Ninety-one rectal cancer patients with laparoscopic resection were included, 59% were male, and median age was 62 years. Conversion rate was 18.7%. Laparoscopic and open surgery had similar 30-day morbidity and mortality except wound infection, which was lower for the laparoscopic group (p = 0.02). Laparoscopic surgery had similar 30-day readmissions but shorter total length of hospital stay (5 versus 7 days, p < 0.01), time to first flatus (3 versus 4.5 days, p = 0.001), and time to first bowel movement (4 versus 5 days, p = 0.05) when compared with open surgery. The 3-year disease-free survival, local recurrence, and distant recurrence rates were also similar between the two groups. CONCLUSION: Laparoscopic surgery can be safely performed for rectal cancer, with better postoperative recovery and acceptable early oncological outcomes. Results from large ongoing randomized trials with longer follow-up time are pending to better define oncologic outcomes.
Ileorectal anastomosis and proctocolectomy with end ileostomy for ulcerative colitis
Until the development of the ileal pouch-anal anastomosis in the early 1980s, proctocolectomy with end ileostomy was the only definitive surgery for ulcerative colitis and colectomy with ileorectal anastomosis was the procedure of choice for affected patients who were reluctant to have a permanent ileostomy. Currently, ileal pouch-anal anastomosis is the most common procedure for patients with ulcerative colitis requiring surgical treatment. However, there is still a role for ileorectal anastomosis and proctocolectomy with end ileostomy for a selected group of patients. In this review, the authors summarize the current indications for ileorectal anastomosis and proctocolectomy with end ileostomy in patients with ulcerative colitis.
Hand-assisted laparoscopic colectomy: the learning curve is for operative speed, not for quality
AIM/OBJECTIVE:We aimed to define the learning curve for hand-assisted laparoscopic colectomy (HALC). METHOD/METHODS:A retrospective analysis of prospectively recorded data was performed. Consecutive segmental and total HALC performed by a single surgeon with no prior HALC experience was included. Operative time and quality-related outcomes, including conversions, operative and postoperative complications, length of stay, reoperations and readmissions were compared for consecutive cohorts of 25 HALC. A subgroup analysis of right, left, total and proctocolectomy performed in each cohort of 25 HALC was also performed. RESULTS:From December 2005 to February 2009, 200 HALC were performed. When evaluated in cohorts of 25 consecutive cases, operative times (155-206 min), operative complications (4-12%), postoperative complications (8-36%), length of stay (4-5 days), reoperations (0-8%) and readmissions (0-16%) were similar. In the subgroup analysis, there were no changes in the quality-related measures for any colectomy type or the operative time for right and proctocolectomy as experience was gained. Operative time decreased for left (183-127 min) and total HALC (259-218 min) after experience with 50 cases (P < 0.05). CONCLUSION/CONCLUSIONS:HALC operative times decreased with surgeon experience. For quality-related outcomes, there was no learning curve for HALC.
Downstaging without complete pathologic response after neoadjuvant treatment improves cancer outcomes for cIII but not cII rectal cancers
BACKGROUND: The aim of this study was to evaluate whether downstaging impacts prognosis in patients with cII versus cIII rectal cancer. MATERIALS AND METHODS: We identified from our colorectal cancer database 295 patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI who received 5-FU-based chemoradiation followed by R0 surgery after a median interval of 7 weeks during 1997-2007. The median radiotherapy dose was 5040 cGy. We excluded 58 patients with pathologic complete response (pCR) and compared among the remaining 162 patients pathologic downstaging (cII to ypI, cIII to ypII or ypI) versus no pathologic downstaging (c stage < or = yp stage). Outcomes evaluated were 5-year overall survival, 3-year cancer-specific survival, disease-free survival, overall recurrence, local recurrence, and distant recurrence. RESULTS: The median age was 58 years and median follow-up was 48 months. Patients with downstaging versus no downstaging were statistically comparable with respect to demographics, chemoradiation regimen, interval time between neoadjuvant chemoradiation and surgery, tumor distance from anal verge, surgical procedures performed, and follow-up time. With the exception of local recurrence rates, downstaging resulted in significantly improved cancer outcomes for cIII but not cII. CONCLUSIONS: Downstaging without pCR is a significant prognostic factor for patients with stage cIII rectal cancer. Tumor response to neoadjuvant chemoradiation should be taken into account when defining the optimal adjuvant chemotherapy regimen for patients with cIII rectal cancer.
Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs
BACKGROUND: Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4. METHODS: Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value <0.05 was considered statistically significant. RESULTS: In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p < 0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted. CONCLUSION: The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.