RESUMO
INTRODUCCIÓN: El cáncer colorrectal (CCR) es uno de los tipos de cáncer más comunes en todo el mundo y representa una de las principales causas de mortalidad relacionada con el cáncer. El CCR se origina en el colon o en el recto y suele desarrollarse a partir de pólipos que crecen en la pared intestinal. Estos pólipos pueden progresar a lesiones premalignas y malignas (CCR) que pueden propagarse a otras partes del cuerpo. La detección temprana del CCR mediante el cribado poblacional puede mejorar significativamente las tasas de supervivencia y reducir el coste del tratamiento. El cribado poblacional del CCR ha demostrado ser una herramienta efectiva para detectar esta enfermedad en una etapa temprana, aumentando las posibilidades de curación y mejorando el pronóstico de estas personas. Los métodos más utilizados en el cribado poblacional de CCR son la prueba de sangre oculta en heces (SOH), la sigmoidoscopia y la colonoscopia. En España, el programa de cribado de CCR se incorporó a la cartera común de servicios del Sistema Nacional de Salud (
INTRODUCTION: Colorectal cancer (CRC) is one of the most common types of cancer worldwide and represents a leading cause of cancer-related mortality. CRC originates in the colon or rectum and usually develops from polyps that grow in the intestinal wall. These polyps can progress to premalignant and malignant lesions (CRC) that can spread to other parts of the body. Early detection of CRC through population screening can significantly improve survival rates and reduce the cost of treatment. Population screening for CRC has proven to be an effective tool to detect this disease at an early stage, increasing the chances of cure and improving the prognosis of these people. There are several methods to perform screening for CRC in general population. The faecal occult blood test (FOBT), sigmoidoscopy and colonoscopy are currently the most used in population screening. In Spain, the CRC screening program was incorporated into the common portfolio of services of the National Health System (NHS) in 2014. The program offers the general population between 50 and 69 years of age a free FOBT test every two years. AIMS: To assess the effectiveness, safety and cost-effectiveness, ethical, patient, social, legal, organizational and environmental considerations, as well as to describe the research needs of expanding population-based CRC screening up to 74 years of age. METHODOLOGY: A systematic review (SR) was carried out of: 1) SR that evaluated the effectiveness/safety and/or diagnostic performance of population screening for CRC using FOBT tests (guaiac and immunological) as the first screening test followed by colonoscopy, as well as possible differences according to age groups and 2) economic evaluations that evaluated the cost-effectiveness of this screening strategy for the groups of interest. A search strategy was developed around the terms colorectal neoplasms, mass screening, and faecal occult blood in the electronic databases: MEDLINE, EMBASE, CINAHL, in several databases of IberoAmerican publications (IBECS, BRISA, LILACS, WPRIM, ARGMSAL, BINACIS, LIPECS), and in The Cost-Effectiveness Analysis (CEA) Registry in April 2023. The assessment of the methodological quality of the effectiveness and safety SRs was evaluated by two independent reviewers with the AMSTAR-2 scale and the economic evaluations were evaluated following the criteria of Drummond et al. The data extracted were those related to the identification of the study (authors, publication date, country where the study was carried out, funding, etc.), the design and methodology and the results of the study (CRC incidence, mortality, sensitivity and specificity, costs, effectiveness results and incremental cost-effectiveness ratio (ICER)). These data were collected in electronic sheets in Excel format (Microsoft) designed ad hoc. Only numerical results were extracted from the comparisons of interest: screening in the population aged 50-75 versus not screening and screening in the population aged 50-70 versus 50-75. A complete de novo economic evaluation was conducted out in which the costs and health outcomes of extending population-based CRC screening to age 74 were assessed from the perspective of the NHS. The analysis was based on a decision model that synthesizes the information obtained in the literature on the incidence of the disease, the effectiveness of screening, as well as the consequences of CRC (in terms of both costs and QALYs). In order to do this, a mathematical model was built that combines a decision tree and a Markov model with annual cycles. The time horizon was patient lifetime and a discount of a 3% was applied to both costs and effects. In addition, probabilistic and deterministic sensitivity analysis were carried out. Finally, a 5-year budget impact analysis (from 2023 to 2027) was performed to inform about the cost of extending current population screening for CRC in Spain to age 74. A scoping review was carried out through a series of manual searches in Google, Google Scholar and Pubmed using different combinations of keywords and their derivations using the search terms specific to the aspects evaluated in that section: ethics, acceptability, patient issues, organization, barriers, facilitators, implementation, equity, ageism, qualitative, interview. In addition, a patient association was contacted to find out their perspective. RESULTS: There is high-quality evidence, based on several population-based randomized trials with variable completion age, that the use of guaiac reduction-based FOBT screening (gFOBT) reduces CRC mortality (RR = 0.88, 95%CI: 0.82-0.93; k = 8; n = 598 933), but not its incidence or mortality from any cause. One trial showed that biennial gFOBT does not reduce mortality in patients between 70-80 years old, and in those aged 60-69 years it only did so in men (RR = 0.42, 95%CI: 0.27-0.66). There is low-quality evidence that screening with the immunological detection test for FOBT (iFOBT) up to age 69 reduces CRC mortality (RR = 0.90, 95%CI: 0.84, 0.95; an observational study). There is good quality evidence that iFOBT shows a sensitivity greater than 70% in the detection of CRC. There is no evidence of differences in effectiveness according to age. In terms of diagnostic performance, one study observed a worse sensitivity and specificity of the program in the range of 70-75 years, compared to 50-59 and 60-69. Given the non-invasive nature of faecal tests, the adverse effects of screening program refer to the possible complications of colonoscopy. There is evidence of a good safety profile of colonoscopy after a positive results of FOBT, with bleeding rates of 17.5 (95%CI: 7.6, 27.5) per 10,000 procedures, and perforation rates of 5.7 (95%CI 2.8, 8.7) per 10,000 procedures. Four systematic reviews of economic evaluations and 11 costeffectiveness references (corresponding to 10 studies) were included. No SRs were identified that exactly addressed the research question of this report. The included SRs concluded that all or almost all CRC screening strategies are cost-effective compared to no screening. All costeffectiveness studies, regardless of the test used for the FOBT analysis, concluded that biennial screening in the age group 50 to 74 (or 75) is costeffective compared to no screening. All ICERs, after being transformed into 2023 Spanish euros, were less than 20,000/QALY or /LY. The results of the de novo economic evaluation model carried out show that the extension of CRC screening up to 74 years of age is a dominant alternative (less expensive and more effective) compared to current screening up to 69 years of age. The results of the sensitivity analysis indicate that these results are robust. The budget impact analysis indicates that the expansion of CRC population screening could mean an expense for the NHS that could reach 10,918,777 in the fifth year of its expansion throughout the national territory, assuming 100% coverage and a rate participation of 36.26%. A manual scoping search was carried out in May 2023 and was expanded in November 2023. In this search of electronic databases and websites, 21 potentially relevant articles and a conference abstract were identified to be analysed in detail in full text. All of them were excluded due to the objective of this section. Only one ethical aspect was identified related to territorial inequality due to the different degrees of implementation and age coverage of the CRC screening program. This territorial inequality could decrease with the extension of the age to 74 years. CONCLUSIONS: Based on the evidence synthesized in the identified SRs and the primary studies included in them, as well as in the economic evaluations included in this report, it is not possible to answer the research question about the convenience of extending CRC screening from 69 to 74 years. There is high-quality evidence that gFOBT reduces CRC mortality in screening with variable completion age. Regarding differences by age, a population trial initiated in the 1980s in the United States did not obtain a significant effect from biennial screening in people between 70 and 80 years of age. In the case of iFOBT, the direct evidence is low quality, indicating a significant reduction in CRC mortality in patients up to 69 years of age with a mean follow-up of three years. There is no evidence of differential effectiveness according to age, and only one study reported differences in diagnostic performance, with worse sensitivity and specificity in the range of 70-75 years. The de novo cost-effectiveness analysis carried out in this report with data from Spain concludes that the extension of CRC population screening to 74 years of age is a dominant alternative from the NHS perspective (that is, less expensive and more effective alternative). The budget impact analysis estimates that the extension of CRC population screening up to 74 years of age could mean an additional expense of between 10,208,165 and 10,918,777 in the first and fifth year of its extension respectively. This analysis assumed 100% coverage and a participation rate of 36.26%.
Assuntos
Humanos , Neoplasias Colorretais/diagnóstico , Programas de Rastreamento/métodos , Colonoscopia/métodos , Sigmoidoscopia/métodos , Detecção Precoce de Câncer/métodos , Sangue Oculto , Avaliação em Saúde/economia , Análise Custo-Benefício/economiaRESUMO
Introducción. En la actualidad, el trauma de recto continúa siendo una situación clínica compleja y temida por ser potencialmente mortal. Su detección y manejo temprano es la piedra angular para impactar tanto en la mortalidad como en la morbilidad de los pacientes. Hoy en día, aún existe debate sobre la aproximación quirúrgica ideal en el trauma de recto y las decisiones de manejo intraoperatorias se ven enormemente afectadas por la experiencia y preferencias del cirujano. Métodos. Se realizó una búsqueda de la literatura en las bases de datos de PubMed, Clinical Key, Google Scholar y SciELO utilizando las palabras claves descritas y se seleccionaron los artículos más relevantes publicados en los últimos 20 años; se tuvieron en cuenta los artículos escritos en inglés y español. Discusión. El recto es el órgano menos frecuentemente lesionado en trauma, sin embargo, las implicaciones clínicas que conlleva pasar por alto este tipo de lesiones pueden ser devastadoras para el paciente. Las opciones para el diagnóstico incluyen el tacto rectal, la tomografía computarizada y la rectosigmoidoscopía. El manejo quirúrgico va a depender de la localización, el grado de la lesión y las lesiones asociadas. Conclusión. El conocimiento de la anatomía, el mecanismo de trauma y las lesiones asociadas permitirán al cirujano realizar una aproximación clínico-quirúrgica adecuada que lleve a desenlaces clínicos óptimos de los pacientes que se presentan con trauma de recto.
Introduction. Currently, rectal trauma continues to be a complex clinical and potentially fatal situation. Its early detection and management is the cornerstone to avoid both mortality and morbidity of patients. Today there is still debate about the ideal surgical approach in rectal trauma, and intraoperative management decisions are greatly affected by the experience and preferences of the surgeon. Methods. A literature search was performed in the PubMed, Clinical Key, Google Scholar and SciELO databases using the keywords described. The most relevant articles published in the last 20 years were selected. Articles written in English and Spanish were considered.Discussion. The rectum is the organ less frequently injured in trauma; however, the clinical implications of overlooking this injury can be devastating for the patient. Options for diagnosis include digital rectal examination, computed tomography and rectosigmoidoscopy. Surgical management will depend on the location, degree of the injury and the associated injuries. Conclusion. Knowledge of the anatomy, the mechanism of trauma and the associated injuries will allow the surgeon to make an adequate clinical-surgical approach that leads to optimal clinical outcomes in patients presenting with rectal trauma.
Assuntos
Humanos , Reto , Traumatismo Múltiplo , Sigmoidoscopia , Ferimentos e Lesões , Tomografia Computadorizada por Raios X , Cirurgia Colorretal , DiagnósticoRESUMO
Introduction: Pelvic anatomy remains a challenge, and thorough knowledge of its intricate landmarks has major clinical and surgical implications in several medical specialties. The peritoneal reflection is an important landmark in intraluminal surgery, rectal trauma, impalement, and rectal adenocarcinoma. Objectives: To investigate the correlation between the lengths of the middle rectal valve and of the peritoneal reflection determined with rigid sigmoidoscopy and to determine whether there are any differences in the location of the peritoneal reflection between the genders and in relation to body mass index (BMI) and parity. Design: We prospectively investigated the location of the middle rectal valve and of the peritoneal reflection via intraoperative rigid sigmoidoscopy in colorectal cancer patients undergoing elective colorectal surgery. Results: We evaluated 38 patients with a mean age of 55.5 years old (57.5% males) who underwent colorectal surgery at the coloproctology service of the Hospital Santa Marcelina, São Paulo, state of São Paulo, Brazil. There was substantial agreement between the lengths of the middle rectal valve and of the peritoneal reflection (Kappa = 0.66). In addition, the peritoneal reflection was significantly lower in overweight patients (p = 0.013 for women and p < 0.005 for men) and in women with > 2 vaginal deliveries (p = 0.009), but there was no significant difference in the length of the peritoneal reflection between genders (p = 0.32). Conclusion: There was substantial agreement between the lengths of the peritoneal reflection and of the middle rectal valve, and the peritoneal reflection was significantly lower in overweight patients and in women with more than two vaginal deliveries. (AU)
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Cavidade Peritoneal/anatomia & histologia , Reto/irrigação sanguínea , Reto/anatomia & histologia , Perfil de Saúde , Índice de Massa Corporal , Caracteres Sexuais , Sigmoidoscopia , Parto ObstétricoAssuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Neoplasias Colorretais/diagnóstico , Programas de Rastreamento , Detecção Precoce de Câncer/métodos , Neoplasias Colorretais/etiologia , Tomografia Computadorizada por Raios X , Risco , Colonoscopia/métodos , Fatores Etários , Sigmoidoscopia , Guias de Prática Clínica como Assunto , Detecção Precoce de Câncer/efeitos adversos , Sangue OcultoRESUMO
RESUMEN Se presentó un caso de una paciente de 78 años de edad, procedente del municipio de Calimete, con antecedentes patológicos personales de infarto agudo miocárdico sin elevación del segmento ST e hipertensión arterial. Llegó a la Unidad de Cuidados Intensivos de Emergencia, de Colón con un estado toxico infeccioso severo. Fue intervenida quirúrgicamente con el diagnóstico presuntivo de una trombosis mesentérica. Se constató dicho diagnóstico complementario a una neoplasia maligna de colon sigmoides. Falleció producto a un shock séptico refractario a aminas. En la necropsia se reportaron hallazgos de interés.
ABSTRACT The authors present the case of a 78-years-old female patient from the municipality of Calimete, with personal pathological antecedents of acute myocardial infarct without ST segment elevation and arterial hypertension. She arrived to the Emergency Intensive Care Unit of Colon with a severe toxic-infectious status. She underwent a surgery with a presumptive mesenteric thrombosis. It was stated that diagnosis, complementary to a sigmoid colon malignant neoplasia. She died as a product of an amine-refractory septic shock. The autopsy showed findings of interest.
Assuntos
Humanos , Feminino , Idoso , Doenças do Colo Sigmoide/complicações , Doenças do Colo Sigmoide/diagnóstico , Neoplasias do Colo Sigmoide/cirurgia , Neoplasias do Colo Sigmoide/complicações , Neoplasias do Colo Sigmoide/diagnóstico , Neoplasias do Colo Sigmoide/mortalidade , Neoplasias Colorretais/complicações , Neoplasias Colorretais/diagnóstico , Oclusão Vascular Mesentérica/complicações , Oclusão Vascular Mesentérica/diagnóstico , Peritonite , Choque Séptico , Colostomia , Sistema Cardiovascular/fisiopatologia , Dor Abdominal/diagnóstico , Sigmoidoscopia , Taxa de Filtração Glomerular , Falência Renal Crônica , Laparotomia , NeoplasiasAssuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Neoplasias Colorretais/diagnóstico , Colonoscopia/estatística & dados numéricos , Detecção Precoce de Câncer/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Fatores de Tempo , Neoplasias Colorretais/epidemiologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Programas de Rastreamento/métodos , Programas de Rastreamento/normas , Programas de Rastreamento/estatística & dados numéricos , Colonoscopia/normas , Sigmoidoscopia/normas , Sigmoidoscopia/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Detecção Precoce de Câncer/métodos , Detecção Precoce de Câncer/estatística & dados numéricos , Sangue OcultoRESUMO
Few authors have proposed therapeutic protocols to manage retained rectal foreign bodies (RFBs). All patients with retained RFBs in hospitals across Trinidad and Tobago over 5 years were identified. Hospital records were retrieved and manually reviewed to extract the following data: demographics, history, foreign body retrieved, clinical signs at presentation, management strategy, duration of hospitalization, and morbidity and mortality. There were 10 patients with RFBs over the study period. The annual incidence of this phenomenon was 0.15 per 100,000 population. All patients were men at a mean age of 50.6 years (range: 27-83; SD = 15.3) who presented after a voluntary delay of 1.4 days (range: 0.5-2.5; SD = 0.7). Only one patient gave an accurate history on presentation, but all eventually admitted to self-insertion for sexual gratification. At presentation, one patient had a spontaneous rectal perforation (10%). The remaining nine patients had attempts at bedside transanal extraction, which was unsuccessful in 89% (8/9) of cases. The RFB was pushed beyond the grasp of forceps, making removal under anesthesia unsuccessful in 62.5% (5/8) cases. These patients required more invasive extraction methods including transanal minimally invasive surgery (1), laparoscopic-assisted advancement with transanal retrieval (1), and open surgery with transmural extraction and anastomoses (3). A management algorithm is proposed for the management of RFBs. Important points in this algorithm are the importance of clinician-patient rapport, early surgical referral, avoidance of bedside extraction in the emergency room, early examination under anesthesia, and the inclusion of emerging therapies such as transanal minimally invasive surgery.
Assuntos
Algoritmos , Corpos Estranhos/epidemiologia , Corpos Estranhos/cirurgia , Reto , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sigmoidoscopia , Trinidad e Tobago/epidemiologiaRESUMO
PURPOSE:To evaluate the effects of L-lysine on the intestinal and urothelial epithelium of rats subjected to ureterosigmoidostomy (new model for surgical carcinogenesis).METHODS:Forty-two rats, 9 weeks of age, were divided into 6 groups. Animals in groups A, B, C were subjected to ureterosigmoidostomy (US) and treated with L-lysine, celecoxib and H2O, respectively. Groups D, E and F (non-operated controls) received L-lysine, celecoxib and H2O, respectively. The L-lysine dose was 150 mg/kg and that of celecoxib was 20 mg/kg. The colon was analyzed for the presence of aberrant crypt foci (ACF) under a stereomicroscope.The tissue was stained with hematoxylin and eosin and PAS alcian blue.RESULTS:There were rare ACF, and there was no statistically significant difference between the groups. Histopathologic study of the ureteral epithelium identified moderate to severe urothelial hyperplasia in rats with ureterosigmoidostomy. Transitional hyperplasia in the ureters of animals receiving L-lysine (A) showed an apparent difference compared to the control (C) (P=0.2424). There was no dysplasia or atypiaCONCLUSION:L-lysine does not promote carcinogenesis of the intestinal and urethelial epithelium of rats subjected to ureterosigmoidostomy at the doses and times studied.(AU)