Tratamento cirúrgico de pacientes adultos com doença de Crohn e retocolite ulcerativa: um consenso da Organização Brasileira de Doença de Crohn e Colite (GEDIIB)

ZABOT, Gilmara Pandolfo; CASSOL, Ornella Sari; QUARESMA, Abel Botelho; GONÇALVES FILHO, Francisco de Assis; BAIMA, Júlio Pinheiro; IMBRIZI, Marcello; ROLIM, Alexandre de Sá; CARMO, Alexandre Medeiros do; ALVES JUNIOR, Antonio Jose Tiburcio; SANTOS, Carlos Henrique Marques dos; SOBRADO JUNIOR, Carlos Walter; MIRANDA, Eron Fábio; ALBUQUERQUE, Idblan Carvalho de; SOUZA, Mardem Machado de; KAISER JUNIOR, Roberto Luiz; PARRA, Rogerio Serafim; KOTZE, Paulo Gustavo; SAAD-HOSSNE, Rogério

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Arquivos de Gastroenterologia

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Sumário

ORIGINAL ARTICLE • Arq. Gastroenterol. 59 (suppl 1) • 2022 • https://doi.org/10.1590/S0004-2803.2022005S1-01 copiar

Tratamento cirúrgico de pacientes adultos com doença de Crohn e retocolite ulcerativa: um consenso da Organização Brasileira de Doença de Crohn e Colite (GEDIIB)

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

Contexto:

Apesar da terapia medicamentosa otimizada, o risco contemporâneo de cirurgia nas doenças inflamatórias intestinais (DII) após 10 anos do diagnóstico é de 9,2% em pacientes com retocolite ulcerativa (RCU) e de 26,2% na doença de Crohn (DC) na era biológica.

Objetivo:

Este consenso visa detalhar as orientações para os procedimentos cirúrgicos mais adequados em diferentes cenários da DII. Além disso, detalha as indicações cirúrgicas e o manejo perioperatório de pacientes adultos com DC e RCU.

Métodos:

Nosso consenso foi desenvolvido por cirurgiões colorretais e gastroenterologistas representantes da Organização Brasileira de Doença de Crohn e Colite (GEDIIB), com a metodologia de revisão rápida sendo conduzida para respaldar as recomendações. As recomendações cirúrgicas foram estruturadas e mapeadas de acordo com os fenótipos da doença, indicações cirúrgicas e técnicas. Após a estruturação das recomendações, a metodologia modificada do Painel Delphi foi utilizada para conduzir a votação por especialistas em cirurgia de DII e gastroenterologia. Esta consistiu em três rondas: duas com recurso a uma plataforma de votação online personalizada e anônima e uma reunião presencial. Sempre que os participantes não concordavam com afirmações ou recomendações específicas, era oferecida uma opção de delinear possíveis razões para permitir respostas em texto livre e dar a oportunidade para os especialistas elaborarem ou explicarem a discordância. O consenso de recomendações/declarações em cada rodada foi considerado alcançado se houve concordância ≥80%.

Resultados e conclusão

Este consenso abordou as informações mais relevantes para orientar o processo de tomada de decisão para o manejo cirúrgico adequado de DC e RCU. Ele sintetiza recomendações desenvolvidas a partir de evidências e conhecimento de alto nível. As recomendações cirúrgicas foram estruturadas e mapeadas de acordo com os diferentes fenótipos da doença, indicações para cirurgia e manejo perioperatório. O foco específico do nosso consenso foi dado aos procedimentos cirúrgicos eletivos e de emergência, determinando quando indicar a cirurgia e quais procedimentos podem ser os mais adequados. O consenso é direcionado a gastroenterologistas e cirurgiões interessados no tratamento e manejo de pacientes adultos com DC ou RCU e apoia a tomada de decisões de pagadores de saúde, líderes institucionais e/ou administradores.

Palavras-chave:
Doença de Crohn; colite ulcerativa; cirurgia; adultos; doenças inflamatórias intestinais; tratamento

Disease	Search strategy	Results (titles)
DC	(“inflammatory bowel disease “[Title] OR “IBD” [Title/Abstract] OR “Crohn” [Title] OR “DC” [Title/Abstract]) AND (“treatment” OR “management” OR “surgery” OR “surgical”) AND (“consensus” [Title] OR “guidelines” [Title]) AND ((y_5 [Filter]) AND (English [Filter]))	119
UC	(“inflammatory bowel disease” [Title] OR “IBD” [Title/Abstract] OR “ulcerative colitis” [Title] OR “UC” [Title/Abstract]) AND (“treatment” OR “management” OR “surgery” OR “surgical”) AND (“consensus” [Title] OR “guidelines” [Title]) AND ((y_5 [Filter]) AND (English [Filter]))	103

Authors	Title	Domain 1 score	Domain 2 score	Domain 3 score	Domain 4 score	Domain 5 score	Domain 6 score	Overall assessment
Adamina et al., 2020	ECCO guidelines on therapeutics in crohn’s disease: surgical treatment	100.0	61.1	87.5	100.0	8.3	100.0	76.2
Bemelman et al., 2017	ECCO-ESCP consensus on surgery for Crohn’s disease	66.7	61.1	81.3	100.0	33.3	100.0	73.7
Biroulet et al., 2016	French national consensus clinical guidelines for the management of Crohn’s disease	66.7	61.1	33.3	83.3	0.0	50.0	49.1
Bouchard et al., 2018	Management of anoperineal lesions in Crohn’s disease: a French National Society of Coloproctology national consensus	66.7	66.7	54.2	100.0	8.3	50.0	57.6
Brown et al., 2018	The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease	66.7	66.7	87.5	100.0	50.0	100.0	78.5
Choi et al., 2017	Second Korean guidelines for the management of ulcerative colitis.	72.2	38.9	68.8	77.8	37.5	58.3	58.9
de Simone et al., 2021	WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting	100.0	66.7	72.9	94.4	45.8	100.0	80.0
Gionchetti et al., 2016	3rd European evidence-based consensus on the diagnosis and management of Crohn’s disease 2016: part 2: surgical management and special situations.	66.7	61.1	87.5	100.0	8.3	100.0	70.6
Holubar et al.,	The American Society of Colon and rectal surgeons clinical practice guidelines for the surgical management of ulcerative colitis.	66.7	66.7	87.5	100.0	50.0	100.0	78.5
Lamb et al., 2019	British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults	100.0	100.0	100.0	100.0	95.8	100.0	99.3
Lee et al., 2017	Association of coloproctology of Great Britain and Ireland Consensus Exercise on Surgical Management of Fistulating Perianal Crohn’s Disease	66.7	66.7	14.6	61.1	0.0	100.0	51.5
Lightner et al., 2020	The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn’s Disease	66.7	66.7	89.6	94.4	54.2	100.0	78.6
Magro et al., 2017	Third European Evidence-based Consensus on diagnosis and management of ulcerative colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance, surgery, and ileo-anal pouch disorders.	77.8	61.1	70.8	88.9	62.5	83.3	74.1
Matsuoka et al., 2018	Evidence-based clinical practice guidelines for inflammatory bowel disease	83.3	61.1	66.7	83.3	50.0	66.7	68.5
Park et al., 2018	Second Korean guidelines for the management of Crohn’s disease	88.9	72.2	85.4	88.9	58.3	58.3	75.3
Sood et al., 2019	Diet and inflammatory bowel disease: the Asian Working Group guidelines	66.7	50.0	27.1	61.1	0.0	50.0	42.5
Spinelli et al., 2021	ECCO Guidelines on therapeutics in ulcerative colitis: surgical treatment.	100.0	61.1	87.5	100.0	8.3	100.0	76.2
Steinhart et al., 2019	Clinical practice guideline for the medical management of perianal fistulizing Crohn’s Disease: the Toronto Consensus	77.8	72.2	79.2	72.2	66.7	83.3	75.2
Wei et al., 2017	Management of Crohn’s disease in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease	55.6	38.9	25.0	61.1	37.5	8.3	37.7

Instituto Brasileiro de Estudos e Pesquisas de Gastroenterologia e Outras Especialidades - IBEPEGE. Rua Dr. Seng, 320, 01331-020 São Paulo - SP Brasil, Tel./Fax: +55 11 3147-6227 - São Paulo - SP - Brazil
E-mail: secretariaarqgastr@hospitaligesp.com.br

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[1] Corresponding author: Marcello Imbrizi. E-mail: marcelloimbrizi@gmail.com

P	Adults (≥18 years) with abdominal CD
I	Elective surgery
C	Not applicable
O	Criteria for indication of elective surgery
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with abdominal CD
I	Surgical management
C	Not applicable
O	• Nutrition
	• Prophylaxis of venous thromboembolism events (VTE)
	• Sepsis control
	• Corticosteroids
	• Immunosuppressants
	• Anti-TNF
	• Anti-integrin
	• Anti-interleukin
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with luminal CD of small intestine and colonic
I	Management of perianal or rectovaginal fistulizing disease
C	Not applicable
O	• Management of intra-abdominal abscess
	• Percutaneous drainage guided by imaging
	• Clinical treatment of intra-abdominal abscess
	• Surgical treatment of intra-abdominal abscess
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with small bowel and colonic CD
I	Management of Stenosing CD
C	Not applicable
O	• Endoscopic treatment
	• Surgical Treatment (Stenoplasty and Resection)
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with small bowel and colonic CD
I	Management of CD - Anal stenosing disease
C	Not applicable
O	• Clinical and surgical treatment of anal stenosing disease
Type of study	International guidelines and/or consensus published after 2016º

P	Adults (≥18 years) with small bowel and colonic abdominal CD with acute appendicitis
I	Management of Crohn’s disease as an incidental finding of appendicitis.
C	Not applicable
O	Clinical and surgical treatment of CD as an incidental finding of acute appendicitis
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with luminal CD
I	Elective surgery for disease with complex perianal fistula
C	Not applicable
O	Surgical techniques for disease with complex perianal fistula
	• Seton placement
	• Endoanal flap advancement
	• Fibrin glue
	• LIFT (Ligation of the intersphincteric fistula tract)
	• Anal plug
	• VAAFT (Video-assisted anal fistula treatment)
	• FILAC Laser (laser closure tract)
	• Stem Cells: allogeneic and autologous
	• Intestinal diversion
	• Total proctocolectomy with ileostomy
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with perianal fistulizing CD
I	Refractory pelvic sepsis treatment
C	Not applicable
O	• Clinical and surgical treatment of refractory pelvic sepsis
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with active UC
I	Elective surgery
C	Not applicable
O	Eligibility criteria for indication of elective surgery
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with refractory moderate to severe UC
I	Perioperative management
C	Not applicable
O	• Nutrition
	• Prophylaxis of VTE
	• Corticosteroids
	• Immunosuppressants
	• Anti-TNF
	• Anti-integrin
	• Anti-interleukin
	• JAK inhibitors
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with severe UC
I	Not applicable
C	Not applicable
O	Complications related to the ileal pouch:
	• Fistulas and dehiscence of anastomosis
	• Pouchitis (acute, chronic, and refractory)
	• Ileoanal pouch failure
Type of study	International guidelines and/or consensus published after 2016

P	Adults (≥18 years) with ASC
I	Urgent and emergency surgery
C	Not applicable
O	Criteria for indication of urgent and emergency surgery
Type of study	International guidelines and/or consensus published after 2016