SÓCIOS
Abril 2023

ARTIGOS DO MÊS
 

Decidimos escolher dois artigos (OPEN ACCESS) publicados este ano, pela actualidade e controvérsia despertada nos temas abordados.

1.
O primeiro aborda a dor pós-hemorroidectomia como frequente, podendo o espasmo do esfíncter anal interno contribuir para a sua ocorrência. Este trabalho de revisão sistemática e meta-análise comparou a eficácia de três tipos de intervenção dirigida ao esfíncter anal interno (esfincterotomia lateral interna; injecção de toxina botulínica; aplicação tópica de diltiazem ou nitroglicerina) na prevenção ou diminuição da dor pós-hemorroidectomia.
A evidência sugere que a esfincterotomia lateral, a administração de toxina botulínica e a aplicação de diltiazem tópica ou GTN podem reduzir a dor pós-operatória após a hemorroidectomia.
A esfincterotomia lateral não deve ser utilizada rotineiramente devido ao risco de incontinência.
 
Jin J, Unasa H, Bahl P, Mauiliu-Wallis M, Svirskis D, Hill A. Can Targeting Sphincter Spasm Reduce Post-Haemorrhoidectomy Pain? A Systematic Review and Meta-Analysis. World J Surg. 2023 Feb;47(2):520-533. doi: 10.1007/s00268-022-06807-3. Epub 2022 Nov 10. PMID: 36357803; PMCID: PMC9803754.

Abstract

Background: Haemorrhoidectomy is often complicated by significant post-operative pain, to which spasm of the internal anal sphincter is thought to be a contributing factor. This study appraises the evidence behind interventions aimed at lowering sphincter spasm to relieve post-haemorrhoidectomy pain.

Methods: A Preferred Reporting Items for Systematic Reviews and Meta-analyses compliant systematic review was conducted. Medline, EMBASE, and CENTRAL databases were systematically searched. All RCTs which compared interventions targeting the internal anal sphincter to relieve pain post excisional haemorrhoidectomy were included. The primary outcome measure was pain on the visual analogue scale.

Results: Of the initial 10,221 search results, 39 articles were included in a qualitative synthesis, and 33 studies were included in a meta-analysis. Topical glyceryl trinitrate (GTN) reduced pain on day 7 (7 studies, 485 participants), with a mean difference and 95% confidence interval (MD, 95% CI) of -1.34 (-2.31; -0.37), I2 = 91%. Diltiazem reduced pain on day 3 on the VAS, and the MD was -2.75 (-398; -1.51) shown in five studies (n = 227). Botulinum toxin reduced pain on day 7, in four studies with 178 participants, MD -1.43 (-2.50; -0.35) I2 = 62%. The addition of Lateral Internal Sphincterotomy to haemorrhoidectomy reduced pain on day 2 in three studies with 275 participants, MD of -2.13 (-3.49; -0.77) I2 = 92%. The results were limited by high heterogeneity and risk of bias.

Conclusion: Evidence suggests that lateral sphincterotomy, administration of botulinum toxin and the application of topical diltiazem or GTN can reduce post-operative pain after haemorrhoidectomy. Lateral sphincterotomy should not be routinely used due to the risk of incontinence.

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2.
Nesta revisão sistemática e meta-análise conduzida por investigadores da Universidade do Minho, foram comparadas as diferentes técnicas de abordagem cirúrgica na confecção de anastomoses colo-rectais (sutura manual, sutura mecânica, ou sutura compressiva) relativamente à ocorrência de complicações pós-operatórias.
Trata-se de uma meta-análise que integra 16 estudos, e que aponta diferenças estatisticamente significativas, mediante técnica usada, no tempo de Cirurgia e na necessidade de reintervenção.
Contudo, os autores concluem que os resultados obtidos não são suficientes para demonstrar qual a técnica mais adequada para realizar a anastomose cólica e rectal, uma vez que as complicações pós-operatórias foram semelhantes entre as técnicas de sutura manual, anastomose mecânica, ou de compressão, pelo que se mantém espaço para estudo sobre o tema das anastomoses colo-rectais no que concerne à técnica de confecção.
 
 
Oliveira A, Faria S, Gonçalves N, Martins A, Leão P. Surgical approaches to colonic and rectal anastomosis: systematic review and meta-analysis. Int J Colorectal Dis. 2023 Feb 23;38(1):52. doi: 10.1007/s00384-023-04328-6. PMID: 36814011; PMCID: PMC9947093.
 
Abstract

Purpose Postoperative complications after a colonic and rectal surgery are of significant concern to the surgical community. Although there are different techniques to perform anastomosis (i.e., handsewn, stapled, or compression), there is still no consensus on which technique provides the least number of postoperative problems. The objective of this study is to compare the different anastomotic techniques regarding the occurrence or duration of postoperative outcomes such as anastomotic dehiscence, mortality, reoperation, bleeding and stricture (as primary outcomes), and wound infection, intra-abdominal abscess, duration of surgery, and hospital stay (as secondary outcomes).

Methods Clinical trials published between January 1, 2010, and December 31, 2021, reporting anastomotic complications with any of the anastomotic technique were identified using the MEDLINE database. Only articles that clearly defined the anastomotic technique used, and report at least two of the outcomes defined were included.

Results This meta-analysis included 16 studies whose differences were related to the need of reoperation (p<0.01) and the duration of surgery (p=0.02), while for the anastomotic dehiscence, mortality, bleeding, stricture, wound infection, intraabdominal abscess, and hospital stay, no significant differences were found. Compression anastomosis reported the lowest reoperation rate (3.64%) and the handsewn anastomosis the highest (9.49%). Despite this, more time to perform the surgery was required in compression anastomosis (183.47 min), with the handsewn being the fastest technique (139.92 min).

Conclusions The evidence found was not sufficient to demonstrate which technique is most suitable to perform colonic and rectal anastomosis, since the postoperative complications were similar between the handsewn, stapled, or compression techniques.
Keywords Anastomosis · Colon · Rectum · Handsewn · Stapled · Compression

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