Development of a telehealth monitoring service after colorectal surgery: A feasibility study

AIM

To evaluate the feasibility of a text-messaging system to remotely monitor and support patients after discharge following elective colorectal surgery, within an enhanced recovery protocol.

METHODS

Florence (FLO) is a National Health Service telehealth solution utilised for monitoring chronic health conditions, such as hypertension, using text-messaging. New algorithms were designed to monitor the well-being, basic physiological observations and any patient-reported symptoms, and provide support messages to patients undergoing colorectal surgery within an enhanced recovery after surgery protocol for 30 d after discharge. All interactions with FLO and physiological readings were recorded and patients were invited to provide feedback.

RESULTS

Over a four-week period, 16 out of 17 patients used the FLO telehealth service at home. These patients did not receive telephone follow-up at three days, as per our standard protocol, unless they reported being unwell or did not make use of the technology. Three patients were readmitted within 30 d, and two of these were identified as being unwell by FLO prior to readmission. No adverse events attributable to the use of the technology were encountered.

CONCLUSION

The utilisation of telehealth in the early follow-up of patients who have undergone major colorectal surgery after discharge is feasible. The use of this technology may assist in the early recognition and management of complications after discharge.

Novel technique of abdominal wall nerve block for laparoscopic colostomy: Rectus sheath block with transperitoneal approach

A 62-year-old man who had acute rectal obstruction due to a large rectal cancer is presented. He underwent emergency laparoscopic colostomy. We used the laparoscopic puncture needle to inject analgesia with the novel transperitoneal approach. In this procedure, both ultrasound and laparoscopic images assisted with the accurate injection of analgesic to the correct layer. The combination of laparoscopic visualization and ultrasound imaging ensured infiltration of analgesic into the correct layer without causing damage to the bowel. Twenty-four hours postoperatively, the patient’s pain intensity as assessed by the numeric rating scale was 0-1 during coughing, and a continuous intravenous analgesic was not needed. Colostomy is often necessary in colon obstruction. Epidural anesthesia for postoperative pain cannot be used in patients with a coagulation disorder. We report the use of a novel laparoscopic rectus sheath block for colostomy. There has been no literature described about the nerve block with transperitoneal approach. The laparoscopic rectus sheath block was performed safely and had enough analgesic efficacy for postoperative pain. This technique could be considered as an optional anesthetic regimen in acute situations.

Abdominal tuberculosis: Is there a role for surgery?

It is important that surgeons are familiar with the various manifestations of tuberculosis (TB). Although TB has been declining in incidence in the developed world, it remains an important problem in endemic areas of the developing world. The aim of the review was to elucidate the natural history and characteristics of abdominal TB and ascertain the indications for surgery. TB can affect the intestine as well as the peritoneum and the most important aspect of abdominal TB is to bear in mind the diagnosis and obtain histological evidence. Abdominal TB is generally responsive to medical treatment, and early diagnosis and management can prevent unnecessary surgical intervention. Due to the challenges of early diagnosis, patients should be managed in collaboration with a physician familiar with anti-tuberculous therapy. An international expert consensus should determine an algorithm for the diagnosis and multidisciplinary management of abdominal TB.

Perforation associated with endoscopic submucosal dissection for duodenal neoplasm without a papillary portion

AIM

To investigate predictors of perforation after endoscopic resection (ER) for duodenal neoplasms without a papillary portion.

METHODS

This was a single-center, retrospective, cohort study conducted between April 2003 and September 2014. A total of 54 patients (59 lesions) underwent endoscopic mucosal resection (EMR) (n = 36) and endoscopic submucosal dissection (ESD) (n = 23). Clinical features, outcomes, and predictors of perforation were investigated.

RESULTS

Cases of perforation occurred in eight (13%) patients (95%CI: 4.7%-22.6%). Three ESD cases required surgical management because they could not be repaired by clipping. Delayed perforation occurred in two ESD cases, which required surgical management, although both patients underwent prophylactic clipping. All patients with perforation who required surgery had no postoperative complications and were discharged at an average of 13.2 d after ER. Perforation after ER showed a significant association with a tumor size greater than 20 mm (P = 0.014) and ESD (P = 0.047).

CONCLUSION

ESD for duodenal neoplasms exceeding 20 mm may be associated with perforation. ESD alone is not recommended for tumor treatment, and LECS should be considered as an alternative.

Analysis of risk factors - especially different types of plexitis - for postoperative relapse in Crohn’s disease

AIM

To evaluate the presence of submucosal and myenteric plexitis and its role in predicting postoperative recurrence.

METHODS

Data from all patients who underwent Crohn’s disease (CD)-related resection at the University of Szeged, Hungary between 2004 and 2014 were analyzed retrospectively. Demographic data, smoking habits, previous resection, treatment before and after surgery, resection margins, neural fiber hyperplasia, submucosal and myenteric plexitis were evaluated as possible predictors of postoperative recurrence. Histological samples were analyzed blinded to the postoperative outcome and the clinical history of the patient. Plexitis was evaluated based on the appearance of the most severely inflamed ganglion or nerve bundle. Patients underwent regular follow-up with colonoscopy after surgery. Postoperative recurrence was defined on the basis of endoscopic and clinical findings, and/or the need for additional surgical resection.

RESULTS

One hundred and four patients were enrolled in the study. Ileocecal, colonic, and small bowel resection were performed in 73.1%, 22.1% and 4.8% of the cases, respectively. Mean disease duration at the time of surgery was 6.25 years. Twenty-six patients underwent previous CD-related surgery. Forty-three point two percent of the patients were on 5-aminosalicylate, 20% on corticosteroid, 68.3% on immunomodulant, and 4% on anti-tumor necrosis factor-alpha postoperative treatment. Postoperative recurrence occurred in 61.5% of the patients; of them 39.1% had surgical recurrence. 92.2% of the recurrences developed within the first five years after the index surgery. Mean disease duration for endoscopic relapse was 2.19 years. The severity of submucosal plexitis was a predictor of the need for second surgery (OR = 1.267, 95%CI: 1.000-1.606, P = 0.050). Female gender (OR = 2.21, 95%CI: 0.98-5.00, P = 0.056), stricturing disease behavior (OR = 3.584, 95%CI: 1.344-9.559, P = 0.011), and isolated ileal localization (OR = 2.671, 95%CI: 1.033-6.910, P = 0.043) were also predictors of postoperative recurrence. No association was revealed between postoperative recurrence and smoking status, postoperative prophylactic treatment and the presence of myenteric plexitis and relapse.

CONCLUSION

The presence of severe submucosal plexitis with lymphocytes in the proximal resection margin is more likely to result in postoperative relapse in CD.

Recent advances in the management of rectal cancer: No surgery, minimal surgery or minimally invasive surgery

Over the last decade, with the acceptance of the need for improvements in the outcome of patients affected with rectal cancer, there has been a significant increase in the literature regarding treatment options available to patients affected by this disease. That treatment related decisions should be made at a high volume multidisciplinary tumor board, after pre-operative rectal magnetic resonance imaging and the importance of total mesorectal excision (TME) are accepted standard of care. More controversial is the emerging role for watchful waiting rather than radical surgery in complete pathologic responders, which may be appropriate in 20% of patients. Patients with early T1 rectal cancers and favorable pathologic features can be cured with local excision only, with transanal minimal invasive surgery (TAMIS) because of its versatility and almost universal availability of the necessary equipment and skillset in the average laparoscopic surgeon, emerging as the leading option. Recent trials have raised concerns about the oncologic outcomes of the standard “top-down” TME hence transanal TME (TaTME “bottom-up”) approach has gained popularity as an alternative. The challenges are many, with a dearth of evidence of the oncologic superiority in the long-term for any given option. However, this review highlights recent advances in the role of chemoradiation only for complete pathologic responders, TAMIS for highly selected early rectal cancer patients and TaTME as options to improve cure rates whilst maintaining quality of life in these patients, while we await the results of further definitive trials being currently conducted.

Utility of routine blood tests after elective laparoscopic cholecystectomy for symptomatic gallstones

AIM

To evaluate the value of blood testing after elective laparoscopic cholecystectomy and its association with procedure related complications.

METHODS

Charts of all patients undergoing elective laparoscopic cholecystectomy from January 2013 through December 2014 were reviewed retrospectively for demographics, indication for surgery, operative course and outcome. In our institution the decision to perform postoperative blood analysis is left for the discretion of the surgeon, therefore we had the possibility to compare the results of those who had blood analyses results to those who did not. Analysis was performed to identify variables associated with the decision to perform postoperative blood tests. Subsequently a univariate and multivariate analyses was performed comparing the two cohorts. Secondary subgroup analysis was performed to identify factors associated with procedure related complications.

RESULTS

Five hundred and thirty-two elective laparoscopic cholecystectomies for symptomatic gallstones were performed during the study period. Sixty-four percent of the patients (n = 340) had blood tests taken post operatively. Patients that had laboratory tests taken were older (P = 0.006, OR = 1.01), had longer surgery (P < 0.001, OR = 3.22) had more drains placed (P < 0.001, OR = 3.2) and stayed longer in the hospital (P < 0.001, OR = 1.2). A subgroup analysis of the patients who experienced complications revealed longer stay in the hospital (P < 0.001), higher body mass index (BMI) (P = 0.04, OR = 1.08), increased rates of drain placement (P = 0.006, OR = 3.1) and higher conversion rates (P = 0.01, OR = 14.6). Postoperative blood tests withdrawals were not associated with complications (P = 0.44). On Multivariate analysis BMI and drain placement were independently associated with complications.

CONCLUSION

The current study indicate that routine postoperative blood tests after elective laparoscopic cholecystectomy for symptomatic gallstones does not predict complications and may have an added benefit in diagnosis and management of cases were the surgeon encountered true technical difficulty during surgery.

Value of multi-disciplinary input into laparoscopic management of rectal cancer - An observational study

AIM

To assess the impact of multi-disciplinary teams (MDTs) management in optimising the outcome for rectal cancers.

METHODS

We undertook a retrospective review of a prospectively maintained database of patients with rectal cancers (defined as tumours ≤ 15 cm from anal verge) discussed at our MDT between Jan 2008 and Jan 2011. The data was validated against the national database to ensure completeness of dataset. The clinical course and follow-up data was validated using the institution’s electronic patient records. The data was analysed in terms of frequencies and percentages. Significance of any differences were analysed using χ² test. A Kaplan-Meier analysis was performed for overall survival and disease free survival.

RESULTS

Following appropriate staging, one hundred and thirty-three patients were suitable for potentially curative resections. Seventy two (54%) were upper rectal cancer (URC) - tumour was > 6 cm from the anal verge and 61 (46%) were lower rectal cancers (LRC) - lower extent of the tumour was palpable ≤ 6 cm. Circumferential resection margin (CRM) appeared threatened on pre-operative MRI in 19/61 (31%) patients with LRC requiring neo-adjuvant therapy (NAT). Of the 133 resections, 118 (89%) were attempted laparoscopically (5% conversion rate). CRM was positive in 9 (6.7%) patients; Median lymph node harvest was 12 (2-37). Major complications occurred in 8 (6%) patients. Median follow-up was 53 mo (0-82). The 90-d mortality was 2 (1.5%). Over the follow-up period, disease related mortality was 11 (8.2%) and overall mortality was 39 (29.3%). Four (3%) patients had local recurrence and 22 (16.5%) patients had distant metastases.

CONCLUSION

Management of rectal cancers can be optimized with multi-disciplinary input to attain acceptable long-term oncological outcomes even when incorporating a laparoscopic approach to rectal cancer resection.

International scientific communications in the field of colorectal tumour markers

AIM

To analyze scientometrically the dynamic science internationalization on colorectal tumour markers as reflected in five information portals and to outline the significant journals, scientists and institutions.

METHODS

A retrospective problem-oriented search was performed in Web of Science Core Collection (WoS), MEDLINE, BIOSIS Citation Index (BIOSIS) and Scopus for 1986-2015 as well as in Dervent Innovations Index (Derwent) for 1995-2015. Several specific scientometric parameters of the publication output and citation activity were comparatively analyzed. The following scientometric parameters were analyzed: (1) annual dynamics of publications; (2) scientific institutions; (3) journals; (4) authors; (5) scientific forums; (6) patents - number of patents, names and countries of inventors, and (7) citations (number of citations to publications by single authors received in WoS, BIOSIS Citation Index and Scopus).

RESULTS

There is a trend towards increasing publication output on colorectal tumour markers worldwide along with high citation rates. Authors from 70 countries have published their research results in journals and conference proceedings in 21 languages. There is considerable country stratification similar to that in most systematic investigations. The information provided to end users and scientometricians varies between these data-bases in terms of most parameters due to different journal coverage, indexing systems and editorial policy. The lists of the so-called “core” journals and most productive authors in WoS, BIOSIS, MEDLINE and Scopus along with the list of the most productive authors - inventors in Derwent present a particular interest to the beginners in the field, the institutional and national science managers and the journal editorial board members. The role of the purposeful assessment of scientific forums and patents is emphasized.

CONCLUSION

Our results along with this problem-oriented collection containing the researchers’ names, addresses and publications could contribute to a more effective international collaboration of the coloproctologists from smaller countries and thus improve their visibility on the world information market.

Acute calculous cholecystitis: Review of current best practices

Acute calculous cholecystitis (ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72 h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.

Trends with neoadjuvant radiotherapy and clinical staging for those with rectal malignancies

AIM

To see how patterns of care changed over time, and how institution type effected these decisions.

METHODS

A retrospective analysis was performed using the National Cancer Database, looking at all patients that were diagnosed with rectal cancer from 1998 to 2011. We tested differences in rates of treatment and stage migration using χ² tests and logistic regression models.

RESULTS

A review of ninety thousand five hundred and ninety four subjects underwent multimodality therapy for cancer of the rectum. Staging and response to treatment varied greatly between centers. Forty-six percent of the time staging was missing in academic practices, vs fifty-four percent of the time in community centers (P < 0.001). As a result, twenty-percent were down-staged and eight percent up-staged in academia, whereas only fifteen percent were down-staged and 8% up-staged in community practices (P < 0.001). Forty-two percent of individuals underwent radiation before surgery in 1998. Within two years this increased to fifty-three percent. This increased to eighty-six percent by 2011 (P < 0.001). Institution specific treatment varied greatly. Fifty-one percent received therapy before surgery in academic centers in 1998. Thirty-nine percent followed this pattern in the same year in the community (P < 0.001). By 2011, ninety-one percent received radiation before their procedure in academic centers, vs eighty-four percent in the community (P < 0.001). Rates of adoption were better in academia, although an increase was seen in both center types.

CONCLUSION

From the study dates of 1998 to 2011, preoperative treatment with radiation has been on the rise. There is certainly an increased rate of use of radiation in academia, however, this trend is also seen in the community. Practice patterns have evolved over time, although rates of assigning clinical stage are grossly underreported prior to initiation of preoperative therapy.

Five-year outcomes of laparoscopic sleeve gastrectomy as a primary procedure for morbid obesity: A prospective study

AIM

To prospectively evaluate the postoperative morbi-mortality and weight loss evolution of patients who underwent a laparoscopic sleeve gastrectomy (LSG) as a primary bariatric procedure during 5 years of follow-up.

METHODS

Since 2006, data from patients undergoing a highly restrictive primary LSG have been prospectively registered in a database and analysed. Preoperative co-morbid conditions, operating time, hospital stay, early and late complications rate and evolution of weight loss after 5 years of follow-up were analysed.

RESULTS

A total of 156 patients were included, 74.3% of whom were women. The mean age was 43.2 ± 13.1 years and the mean body mass index (BMI) was 41.5 ± 7.9 kg/m². Seventy patients (44.8%) presented a BMI under 40 kg/m². The mortality rate was 0%. The leakage rate was 1.2%, and the total 30-d morbidity rate was 5.1% (8/156). With a mean follow-up of 32.7 ± 28.5 (range 6-112) mo, the mean percent of excess of weight loss (%EWL) was 82.0 ± 18.8 at 1 year, 76.7 ± 21.3 at 3 years and 60.3 ± 28.9 at 5 years. The mean percent of excess of BMI loss (%EBMIL) was 94.9 ± 22.4 at 1 year, 89.4 ± 27.4 at 3 years and 74.8 ± 29.4 at 5 years. Patients with preoperative BMI less than 40 kg/m² achieved greater weight loss than did the overall study population. Diabetes remitted in 75% of the patients and HTA improved in 71.7%. CPAP masks were withdrawn in all patients with obstructive sleep apnoea.

CONCLUSION

LSG built with a narrow 34 F bougie and starting 3 cm from the pylorus proved to be safe and highly effective in terms of weight loss as a stand-alone procedure, particularly in patients with a preoperative BMI lower than 40 kg/m².

Feasibility of pancreatectomy following high-dose proton therapy for unresectable pancreatic cancer

AIM

To review surgical outcomes for patients undergoing pancreatectomy after proton therapy with concomitant capecitabine for initially unresectable pancreatic adenocarcinoma.

METHODS

From April 2010 to September 2013, 15 patients with initially unresectable pancreatic cancer were treated with proton therapy with concomitant capecitabine at 1000 mg orally twice daily. All patients received 59.40 Gy (RBE) to the gross disease and 1 patient received 50.40 Gy (RBE) to high-risk nodal targets. There were no treatment interruptions and no chemotherapy dose reductions. Six patients achieved a radiographic response sufficient to justify surgical exploration, of whom 1 was identified as having intraperitoneal dissemination at the time of surgery and the planned pancreatectomy was aborted. Five patients underwent resection. Procedures included: Laparoscopic standard pancreaticoduodenectomy (n = 3), open pyloris-sparing pancreaticoduodenectomy (n = 1), and open distal pancreatectomy with irreversible electroporation (IRE) of a pancreatic head mass (n = 1).

RESULTS

The median patient age was 60 years (range, 51-67). The median duration of surgery was 419 min (range, 290-484), with a median estimated blood loss of 850 cm³ (range, 300-2000), median ICU stay of 1 d (range, 0-2), and median hospital stay of 10 d (range, 5-14). Three patients were re-admitted to a hospital within 30 d after discharge for wound infection (n = 1), delayed gastric emptying (n = 1), and ischemic gastritis (n = 1). Two patients underwent R0 resections and demonstrated minimal residual disease in the final pathology specimen. One patient, after negative pancreatic head biopsies, underwent IRE followed by distal pancreatectomy with no tumor seen in the specimen. Two patients underwent R2 resections. Only 1 patient demonstrated ultimate local progression at the primary site. Median survival for the 5 resected patients was 24 mo (range, 10-30).

CONCLUSION

Pancreatic resection for patients with initially unresectable cancers is feasible after high-dose [59.4 Gy (RBE)] proton radiotherapy with a high rate of local control, acceptable surgical morbidity, and a median survival of 24 mo.

Laparoscopic retrosternal gastric pull-up for fistulized mediastinal mass

We describe the case of a patient successfully reconstructed with laparoscopic retrosternal gastric pull-up after esophagectomy for unresectable posterior mediastinal inflammatory myofibroblastic tumor, eroding into the esophagus and compressing the airways. A partial esophagectomy with esophagostomy was performed for treatment of esophageal pleural fistula and empyema, while the airways were managed with the placement of an endobronchial stent. Gastrointestinal reconstruction was performed using a laparoscopic approach to create a retrosternal tunnel for gastric conduit pull-up and cervical anastomosis. The patient was discharged uneventfully after 6 d, and has done very well at home with normal diet.

Resection of complex pancreatic injuries: Benchmarking postoperative complications using the Accordion classification

AIM

To benchmark severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing operation for severe pancreatic injuries.

METHODS

A prospective institutional database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. One hundred and thirty patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy, n = 20, distal pancreatectomy, n = 110), including 30 who had an initial damage control laparotomy (DCL) and later definitive surgery. AAST injury grades, type of pancreatic resection, need for DCL and incidence and ASGS severity of complications were assessed. Uni- and multivariate logistic regression analysis was applied.

RESULTS

Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. Nineteen patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had a revised trauma score (RTS) < 7.8, were shocked on admission, had grade 5 injuries of the head and neck of the pancreas with associated vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a pancreatoduodenectomy (PD) and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS < 7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant.

CONCLUSION

This ASGS-based study benchmarked postoperative morbidity after pancreatic resection for trauma. The detailed outcome analysis provided may serve as a reference for future institutional comparisons.

Delayed gastric emptying following pancreaticoduodenectomy: Incidence, risk factors, and healthcare utilization

AIM

To characterize incidence and risk factors for delayed gastric emptying (DGE) following pancreaticoduodenectomy and examine its implications on healthcare utilization.

METHODS

A prospectively-maintained database was reviewed. DGE was classified using International Study Group of Pancreatic Surgery criteria. Patients who developed DGE and those who did not were compared.

RESULTS

Two hundred and seventy-six patients underwent pancreaticoduodenectomy (PD) (> 80% pylorus-preserving, antecolic-reconstruction). DGE developed in 49 patients (17.8%): 5.1% grade B, 3.6% grade C. Demographic, clinical, and operative variables were similar between patients with DGE and those without. DGE patients were more likely to present multiple complications (32.6% vs 4.4%, ≥ 3 complications, P < 0.001), including postoperative pancreatic fistula (POPF) (42.9% vs 18.9%, P = 0.001) and intra-abdominal abscess (IAA) (16.3% vs 4.0%, P = 0.012). Patients with DGE had longer hospital stay (median, 12 d vs 7 d, P < 0.001) and were more likely to require transitional care upon discharge (24.5% vs 6.6%, P < 0.001). On multivariate analysis, predictors for DGE included POPF [OR = 3.39 (1.35-8.52), P = 0.009] and IAA [OR = 1.51 (1.03-2.22), P = 0.035].

CONCLUSION

Although DGE occurred in < 20% of patients after PD, it was associated with increased healthcare utilization. Patients with POPF and IAA were at risk for DGE. Anticipating DGE can help individualize care and allocate resources to high-risk patients.

Clinicopathological features and surgical outcome of patients with fibrolamellar hepatocellular carcinoma (experience with 22 patients over a 15-year period)

AIM

To evaluate the clinicopathological features and the surgical outcomes of patients with fibrolamellar hepatocellular carcinoma (FL-HCC) over a 15-year period.

METHODS

This is a retrospective study including 22 patients with a pathologic diagnosis of FL-HCC who underwent hepatectomy over a 15-year period. Tumor characteristics, survival and recurrence were evaluated.

RESULTS

There were 11 male and 11 female with a median age of 29 years (range from 21 to 58 years). Two (9%) patients had hepatitis C viral infection and only 2 (9%) patients had alpha-fetoprotein level > 200 ng/mL. The median size of the tumors was 12 cm (range from 5-20 cm). Vascular invasion was detected in 5 (23%) patients. Four (18%) patients had lymph node metastases. The median follow up period was 42 mo and the 5-year survival was 65%. Five (23%) patients had a recurrent disease, 4 of them had a second surgery with 36 mo median time interval. Vascular invasion is the only significant negative prognostic factor

CONCLUSION

FL-HCC has a favorable prognosis than common HCC and should be suspected in young patients with non cirrhotic liver. Aggressive surgical resection should be done for all patients. Repeated hepatectomy should be considered for these patients as it has a relatively indolent course.

Critical analysis of feeding jejunostomy following resection of upper gastrointestinal malignancies

AIM

To assess nutritional recovery, particularly regarding feeding jejunostomy tube (FJT) utilization, following upper gastrointestinal resection for malignancy.

METHODS

A retrospective review was performed of a prospectively-maintained database of adult patients who underwent esophagectomy or gastrectomy (subtotal or total) for cancer with curative intent, from January 2001 to June 2014. Patient demographics, the approach to esophagectomy, the extent of gastrectomy, FJT placement and utilization at discharge, administration of parenteral nutrition (PN), and complications were evaluated. All patients were followed for at least ninety days or until death.

RESULTS

The 287 patients underwent upper GI resection, comprised of 182 esophagectomy (n = 107 transhiatal, 58.7%; n = 56 Ivor-Lewis, 30.7%) and 105 gastrectomy [n = 63 subtotal (SG), 60.0%; n = 42 total (TG), 40.0%]. 181 of 182 esophagectomy patients underwent FJT, compared with 47 of 105 gastrectomy patients (99.5% vs 44.8%, P < 0.0001), of whom most had undergone TG (n = 39, 92.9% vs n = 8 SG, 12.9%, P < 0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups (14.7 d vs 17.1 d, P = 0.076). Upon discharge, 87 esophagectomy patients (48.1%) were taking enteral feeds, with 53 (29.3%) fully and 34 (18.8%) partially dependent. Meanwhile, 20 of 39 TG patients (51.3%) were either fully (n = 3, 7.7%) or partially (n = 17, 43.6%) dependent on tube feeds, compared with 5 of 8 SG patients (10.6%), all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients (6.4% vs 29.3%, P = 0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy (n = 11, 23.4% vs n = 7, 3.9%, P = 0.0001). FJT-specific complications requiring reoperation within 30 d of resection occurred more commonly in the gastrectomy group (n = 6), all after TG, compared to 1 esophagectomy patient (12.8% vs 0.6%, P = 0.0003). Six of 7 patients (85.7%) who experienced tube-related complications required PN.

CONCLUSION

Nutritional recovery following esophagectomy and gastrectomy is distinct. Operations are associated with unique complication profiles. Nutritional supplementation alternative to jejunostomy should be considered in particular scenarios.

Giant abdominal osteosarcoma causing intestinal obstruction treated with resection and adjuvant chemotherapy

Extraskeletal osteosarcoma (ESOS) is an uncommon tumor that accounts for 1% of all soft tissue sarcomas and 4% of all osteosarcomas. Its presentation may be atypical, while pain has been described as the most common symptom. Radiological findings include a large mass in the soft-tissues with massive calcifications, but no attachment to the adjacent bone or periosteum. We present the case of a 73-year-old gentle man who presented with a palpable, tender abdominal mass and symptoms of bowel obstruction. Computer tomography images revealed a large space-occupying heterogeneous, hyper dense soft tissue mass involving the small intestine. Explorative laparotomy revealed a large mass in the upper mesenteric root of the small intestine, measuring 22 cm × 12 cm × 10 cm in close proximity with the cecum, which was the cause of the bowel obstruction. Pathology confirmed the diagnosis of an ESOS. ESOS is an uncommon malignant soft tissue tumor with poor prognosis and a 5-year survival rate of less than 37%. Regional recurrence and distant metastasis to lungs, regional lymph nodes and liver can occur within the first three years of diagnosis in a high rate (45% and 65% respectively). Wide surgical resection of the mass followed by adjuvant chemotherapy or radiotherapy has been the treatment of choice.

Perinatal risk factors in newborns with gastrointestinal perforation

AIM

To investigate correlation of perinatal risk factors in newborns with gastrointestinal perforation (GIP).

METHODS

Single-center retrospective cohort study was conducted between January 1990 and December 2012. Medical records on all newborns with GIP were reviewed (n = 35). Surgical records and histopathologic examination of all perforated intestine samples were also reviewed.

RESULTS

The most common cause of GIP was necrotizing enterocolitis (51.4%). The most common site of perforation was large intestine. Mortality rate was 31%. Infants with GIP more frequently had very low birth weight (< 1500 g), especially birth weight below 10^th percentile according to gestational age. Ponderal index was not differing between infants with GIP and control subjects. In infants with GIP anemia was more frequently found than in control group.

CONCLUSION

GIP in newborns is mostly disease of infants with birth weight below 10^th percentile according to gestational age. GIP occurs more often in infants with anemia.

Enhanced recovery after surgery: Current research insights and future direction

Since the concept of enhanced recovery after surgery (ERAS) was introduced in the late 1990s the idea of implementing specific interventions throughout the peri-operative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol, leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery, rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes, described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS, e.g., the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better, more reliable patient outcomes.

Practice, training and safety of laparoscopic surgery in low and middle-income countries

Surgical management of diseases is recognised as a major unmet need in low and middle-income countries (LMICs). Laparoscopic surgery has been present since the 1980s and offers the benefit of minimising the morbidity and potential mortality associated with laparotomies. Laparotomies are often carried out in LMICs for diagnosis and management, due to lack of radiological investigative and intervention options. The use of laparoscopy for diagnosis and treatment is globally variable, with high-income countries using laparoscopy routinely compared with LMICs. The specific advantages of minimally invasive surgery such as lower surgical site infections and earlier return to work are of great benefit for patients in LMICs, as time lost not working could result in a family not being able to sustain themselves. Laparoscopic surgery and training is not cheap. Cost is a major barrier to healthcare access for a significant population in LMICs. Therefore, cost is usually seen as a major barrier for laparoscopic surgery to be integrated into routine practice in LMICs. The aim of this review is to focus on the practice, training and safety of laparoscopic surgery in LMICs. In addition it highlights the barriers to progress in adopting laparoscopic surgery in LMICs and how to address them.

Perforated peptic ulcer - an update

Peptic ulcer disease (PUD) affects 4 million people worldwide annually. The incidence of PUD has been estimated at around 1.5% to 3%. Perforated peptic ulcer (PPU) is a serious complication of PUD and patients with PPU often present with acute abdomen that carries high risk for morbidity and mortality. The lifetime prevalence of perforation in patients with PUD is about 5%. PPU carries a mortality ranging from 1.3% to 20%. Thirty-day mortality rate reaching 20% and 90-d mortality rate of up to 30% have been reported. In this review we have summarized the current evidence on PPU to update readers. This literature review includes the most updated information such as common causes, clinical features, diagnostic methods, non-operative and operative management, post-operative complications and different scoring systems of PPU. With the advancement of medical technology, PUD can now be treated with medications instead of elective surgery. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of PPU. Erect chest radiograph may miss 15% of cases with air under the diaphragm in patients with bowel perforation. Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. Exploratory laparotomy and omental patch repair remains the gold standard. Laparoscopic surgery should be considered when expertise is available. Gastrectomy is recommended in patients with large or malignant ulcer.

Uncommon presentation of a common disease - Bouveret's syndrome: A case report and systematic literature review

AIM

To investigate and summarise the current evidence surrounding management of Bouveret's syndrome (BS).

METHODS

A MEDLINE search was performed for the BS. The search was conducted independently by two clinicians (Yahya AL-Habbal and Matthew Ng) in April 2016. A case of BS is also described.

RESULTS

A total of 315 articles, published from 1967 to 2016, were found. For a clinically meaningful clinical review, articles published before 01/01/1990 and were excluded, leaving 235 unique articles to review. Twenty-seven articles were not available (neither by direct communication nor through inter-library transfer). These were also excluded. The final number of articles reviewed was 208. There were 161 case reports, 13 reviews, 23 images (radiological and clinical images), and 11 letters to editor. Female to male ratio was 1.82. Mean age was 74 years. Treatment modalities included laparotomy in the majority of cases, laparoscopic surgery, endoscopic surgery and shockwave lithotripsy.

CONCLUSION

There is limited evidence in the literature about the appropriate approach. We suggest an algorithm for management of BS.

Triple tube drainage for “difficult” gastroduodenal perforations: A prospective study

AIM

To prospectively study the outcome of difficult gastroduodenal perforations (GDPs) treated by triple tube drainage (TTD) in order to standardize the procedure.

METHODS

Patients presenting to a single surgical unit of a tertiary hospital with difficult GDPs (large, unfavourable local and systemic factors) were treated with TTD (gastrostomy, duodenostomy and feeding jejunostomy). Postoperative parameters were observed like time to return of bowel sounds, time to start enteral feeds, time to start oral feeds, daily output of all drains, time to clamping/removal of all drains, time for skin to heal, complications, hospital stay, and, mortality. Descriptive statistics were used.

RESULTS

Between December 2013 and April 2015, 20 patients undergoing TTD for GDP were included, with mean age of 44.6 ± 19.8 years and male:female ratio of 17:3. Mean pre-operative APACHE II scores were 10.85 ± 3.55; most GDPs were prepyloric (9/20; 45%) or proximal duodenal (8/20; 40%) and mean size was 1.83 ± 0.59 cm (largest 2.5 cm). Median times of resumption of enteral feeding, removal of gastrostomy, removal of duodenostomy, removal of feeding jejunostomy and oral feeding were 4 d (4-5 IQR), 13 (12-16.5 IQR), 16 (16.25-22.25 IQR), 18 (16.5-24 IQR) and 12 d (10.75-18.5 IQR) respectively. Median hospital stay was 22 d (19-26 IQR) while mortality was 4/20 (20%).

CONCLUSION

TTD for difficult GDP is feasible, easy in the emergency, and patients recover in two-three weeks. It obviates the need for technically demanding and riskier procedures.

Bevacizumab and gastrointestinal bleeding in hereditary hemorrhagic telangiectasia

We report a case of severe, refractory gastrointestinal (GI) bleeding in a patient with hereditary hemorrhagic telangiectasia (HHT) whose massive transfusion dependence was lifted shortly after treatment with bevacizumab, an anti-vascular endothelial growth factor. The patient’s bleeding had been refractory to repeated endoscopic interventions, tranexamic acid, and tamoxifen. However, following treatment with bevacizumab at 5 mg/kg every other week, nearly 300 units of packed red blood cell transfusions were avoided in one year’s time. Despite its relatively high cost, bevacizumab may have a more active role in the management of severe GI bleeding in HHT if such remarkable response can be consistently demonstrated.

Abdominosacral resection for locally recurring rectal cancer

AIM

To investigate feasibility and outcome of abdominal-sacral resection for treatment of locally recurrent rectal adenocarcinoma.

METHODS

A population of patients who underwent an abdominal-sacral resection for posterior recurrent adenocarcinoma of the rectum at the National Cancer Institute of Milano, between 2005 and 2013, is considered. Retrospectively collected data includes patient characteristics, treatment and pathology details regarding the primary and the recurrent rectal tumor surgical resection. A clinical and instrumental follow-up was performed. Surgical and oncological outcome were investigated. Furthermore an analytical review of literature was conducted in order to compare our case series with other reported experiences.

RESULTS

At the time of abdomino-sacral resection, the mean age of patients was 55 (range, 38-64). The median operating time was 380 min (range, 270-480). Sacral resection was performed at S2/S3 level in 3 patients, S3/S4 in 3 patients and S4/S5 in 4 patients. The median operating time was 380 ± 58 min. Mean intraoperative blood loss was 1750 mL (range, 200-680). The median hospital stay was 22 d. Overall morbidity was 80%, mainly type II complication according to the Clavien-Dindo classification. Microscopically negative margins (R0) is obtained in all patients. Overall 5-year survival after first surgical procedure is 60%, with a median survival from the first surgery of 88 ± 56 mo. The most common site of re-recurrence was intrapelvic.

CONCLUSION

Sacral resection represents a feasible approach to posterior rectal cancer recurrence without evidence of distant spreading. An accurate staging is essential for planning the best therapy.

Contemporary review of minimally invasive pancreaticoduodenectomy

AIM

To assess the current literature describing various minimally invasive techniques for and to review short-term outcomes after minimally invasive pancreaticoduodenectomy (PD).

METHODS

PD remains the only potentially curative treatment for periampullary malignancies, including, most commonly, pancreatic adenocarcinoma. Minimally invasive approaches to this complex operation have begun to be increasingly reported in the literature and are purported by some to reduce the historically high morbidity of PD associated with the open technique. In this systematic review, we have searched the literature for high-quality publications describing minimally invasive techniques for PD-including laparoscopic, robotic, and laparoscopic-assisted robotic approaches (hybrid approach). We have identified publications with the largest operative experiences from well-known centers of excellence for this complex procedure. We report primarily short term operative and perioperative results and some short term oncologic endpoints.

RESULTS

Minimally invasive techniques include laparoscopic, robotic and hybrid approaches and each of these techniques has strong advocates. Consistently, across all minimally invasive modalities, these techniques are associated less intraoperative blood loss than traditional open PD (OPD), but in exchange for longer operating times. These techniques are relatively equivalent in terms of perioperative morbidity and short term oncologic outcomes. Importantly, pancreatic fistula rate appears to be comparable in most minimally invasive series compared to open technique. Impact of minimally invasive technique on length of stay is mixed compared to some traditional open series. A few series have suggested that initiation of and time to adjuvant therapy may be improved with minimally invasive techniques, however this assertion remains controversial. In terms of short-terms costs, minimally invasive PD is significantly higher than that of OPD.

CONCLUSION

Minimally invasive approaches to PD show great promise as a strategy to improve short-term outcomes in patients undergoing PD, but the best results remain isolated to high-volume centers of excellence.

Complete rectal prolapse in young Egyptian males: Is schistosomiasis really condemned?

AIM

To investigate the assumption that schistosomiasis is the main cause of rectal prolapse in young Egyptian males.

METHODS

Twenty-one male patients between ages of 18 and 50 years with complete rectal prolapse were included in the study out of a total 29 patients with rectal prolapse admitted for surgery at Colorectal Surgery Unit, Ain Shams University hospitals between the period of January 2011 and April 2014. Patients were asked to fill out a specifically designed questionnaire about duration of the prolapse, different bowel symptoms and any past or present history of schistosomiasis. Patients also underwent flexible sigmoidoscopy and four quadrant mid-rectal biopsies documenting any gross or microscopic rectal pathology. Data from questionnaire and pathology results were analyzed and patients were categorized according to their socioeconomic class.

RESULTS

Twelve patients (57%) never contracted schistosomiasis and were never susceptible to the disease, nine patients (43%) had history of the disease but were properly treated. None of the patients had gross rectal polyps and none of the patients had active schistosomiasis on histopathological examination. Fifteen patients (71%) had early onset prolapse that started in childhood, majority before the age of 5 years. Thirteen patients (62%) were habitual strainers, and four of them (19%) had straining dating since early childhood. Four patients (19%) stated that prolapse followed a period of straining that ranged between 8 mo and 2 years. Nine patients (43%) in the present study came from the low social class, 10 patients (48%) came from the working class and 2 patients (9%) came from the low middle social class.

CONCLUSION

Schistosomiasis should not be considered the main cause of rectal prolapse among young Egyptian males. Childhood prolapse that continues through adult life is likely involved. Childhood prolapse probably results from malnutrition, recurrent parasitic infections and diarrhea that induce straining and prolapse, all are common in lower socioeconomic classes.

Roux-en-Y augmented gastric advancement: An alternative technique for concurrent esophageal and pyloric stenosis secondary to corrosive intake

Select group of patients with concurrent esophageal and gastric stricturing secondary to corrosive intake requires colonic or free jejunal transfer. These technically demanding reconstructions are associated with significant complications and have up to 18% ischemic conduit necrosis. Following corrosive intake, up to 30% of such patients have stricturing at the pyloro-duodenal canal area only and rest of the stomach is available for rather less complex and better perfused gastrointestinal reconstruction. Here we describe an alternative technique where we utilize stomach following distal gastric resection along with Roux-en-Y reconstruction instead of colonic or jejunal interposition. This neo-conduit is potentially superior in terms of perfusion, lower risk of gastro-esophageal anastomotic leakage and technical ease as opposed to colonic and jejunal counterparts. We have utilized the said technique in three patients with acceptable postoperative outcome. In addition this technique offers a feasible reconstruction plan in patients where colon is not available for reconstruction due to concomitant pathology. Utility of this technique may also merit consideration for gastroesophageal junction tumors.

Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors

Gastroesophageal reflux disease (GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors (PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental (such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH/impedance-pH monitoring) and clinical features (such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.

Treatment options for spontaneous and postoperative sclerosing mesenteritis

Sclerosing mesenteritis is a rare pathology with only a few described cases in the literature. The etiology is unclear; however, several potential triggers, including abdominal surgery and abdominal trauma, have been discussed. The pathology includes a benign acute or chronic inflammatory process affecting the adipose tissue of the mesenterium. Despite it being a rare disease, sclerosing mesenteritis is an important differential diagnosis in patients after abdominal surgery or patients presenting spontaneously with signs of acute inflammation and abdominal pain. We present here three cases with sclerosing mesenteritis. In two cases, sclerosing mesenteritis occurred postoperatively after abdominal surgery. One patient was treated because of abdominal pain and specific radiological signs revealing spontaneous manifestation of sclerosing mesenteritis. So far there are no distinct treatment algorithms, so the patients were treated differently, including steroids, antibiotics and watchful waiting. In addition, we reviewed the current literature on treatment options for this rare disease.

Pitfalls in histoacryl glue injection therapy for oesophageal, gastric and ectopic varices: A review

Histoacryl glue is used increasingly for the treatment of gastric and ectopic varices, and there is experience in its use for oesophageal varices. It is an effective treatment, yet numerous reports of complications have accumulated. This review of the literature describes the technique, explores circulatory and vascular consideration unique to portal hypertension and categorises the complications into: “Embolisation”, “local venous thrombosis”, “fistulisation and extravascular injection”, “ulceration, erosion and extrusion”, and “nidus of infection”. A case is then made for standardisation of the technique and the consent process.

Critical analysis of the literature investigating urogenital function preservation following robotic rectal cancer surgery

AIM

To analyses the current literature regarding the urogenital functional outcomes of patients receiving robotic rectal cancer surgery.

METHODS

A comprehensive literature search of electronic databases was performed in October 2015. The following search terms were applied: “rectal cancer” or “colorectal cancer” and robot* or “da Vinci” and sexual or urolog* or urinary or erect* or ejaculat* or impot* or incontinence. All original studies examining the urological and/or sexual outcomes of male and/or female patients receiving robotic rectal cancer surgery were included. Reference lists of all retrieved articles were manually searched for further relevant articles. Abstracts were independently searched by two authors.

RESULTS

Fifteen original studies fulfilled the inclusion criteria. A total of 1338 patients were included; 818 received robotic, 498 laparoscopic and 22 open rectal cancer surgery. Only 726 (54%) patients had their urogenital function assessed via means of validated functional questionnaires. From the included studies, three found that robotic rectal cancer surgery leads to quicker recovery of male urological function and five of male sexual function as compared to laparoscopic surgery. It is unclear whether robotic surgery offers favourable urogenital outcomes in the long run for males. In female patients only two studies assessed urological and three sexual function independently to that of males. In these studies there was no difference identified between patients receiving robotic and laparoscopic rectal cancer surgery. However, in females the presented evidence was very limited making it impossible to draw any substantial conclusions.

CONCLUSION

There seems to be a trend towards earlier recovery of male urogenital function following robotic surgery. To evaluate this further, larger well designed studies are required.

Gallstone ileus associated with impaction at Meckel’s diverticulum: Case report and literature review

Gallstone ileus due to erosion of one or more gallstones into the gastrointestinal tract is an uncommon cause of small bowel obstruction. The site of impaction is usually distal ileum, and less commonly the jejunum, colon, duodenum, or stomach. We report a rare case of gallstone ileus with impaction at the proximal small bowel and at a Meckel’s diverticulum (MD) in a 64-year-old woman managed with laparoscopic converted to open small bowel resections. Patient was discharged home in stable condition and remained asymptomatic at 6-mo follow up. We review the current literature on surgical approaches to MD and gallstone ileus. Diverticulectomy or segmental resection is preferred for complicated MD. For gallstone ileus, simple enterolithotomy or segmental resection are the most the most favored especially in older co-morbid patients due to lower mortality rates and the rarity of recurrent gallstone ileus. In addition, laparoscopy has been increasingly reported as a safe approach to manage gallstone ileus.

Impact of laparoscopic surgery training laboratory on surgeon's performance

Minimally invasive surgery has been replacing the open standard technique in several procedures. Similar or even better postoperative outcomes have been described in laparoscopic or robot-assisted procedures when compared to open surgery. Moreover, minimally invasive surgery has been providing less postoperative pain, shorter hospitalization, and thus a faster return to daily activities. However, the learning curve required to obtain laparoscopic expertise has been a barrier in laparoscopic spreading. Laparoscopic surgery training laboratory has been developed to aid surgeons to overcome the challenging learning curve. It may include tutorials, inanimate model skills training (box models and virtual reality simulators), animal laboratory, and operating room observation. Several different laparoscopic courses are available with specific characteristics and goals. Herein, we aim to describe the activities performed in a dry and animal-model training laboratory and to evaluate the impact of different kinds of laparoscopic surgery training courses on surgeon’s performance. Several tasks are performed in dry and animal laboratory to reproduce a real surgery. A short period of training can improve laparoscopic surgical skills, although most of times it is not enough to confer laparoscopic expertise for participants. Nevertheless, this short period of training is able to increase the laparoscopic practice of surgeons in their communities. Full laparoscopic training in medical residence or fellowship programs is the best way of stimulating laparoscopic dissemination.

Acute pain management in symptomatic cholelithiasis

AIM

To review the evidence for the use of different non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of biliary colic.

METHODS

The strategies employed included an extensive literature review for articles and studies related to biliary colic from electronic databases including PubMed, Science Direct, Wiley Inter Science, Medline and Cochrane from last 15 years. Keywords: “Biliary colic”, “management of biliary colic”, “non-steroidal anti-inflammatory drugs”, “cholelithiasis” and “biliary colic management”. Six randomized control trials, 1 non-randomized trial and 1 meta-analysis were included in this review. The outcomes of these studies and their significance have been reviewed in this paper.

RESULTS

Current evidence suggests there are no set protocols for biliary colic pain management. NSAIDs are potent in the management of biliary colic, not only in terms of symptom control but in disease progression as well. Apart from the studies on diclofenac and ketorolac, there are studies which have shown that intravenous tenoxicam and injectable flurbiprofen are equally effective in managing biliary colic. The efficacy of NSAIDs is superior in terms of lower number of doses and longer duration of action in comparison to other analgesic agents.

CONCLUSION

This literature review has found that NSAIDs are safe and effective for pain control in biliary colic, and reduce the likelihood of further complications.

Goblet cell carcinoids of the appendix: Tumor biology, mutations and management strategies

Malignant neoplasms of the appendix are rare and represent less than 1% of gastrointestinal cancers. Goblet cell carcinoids (GCC) tumors are a distinctive group of heterogeneous appendiceal neoplasm that exhibit unique clinical and pathologic features. This review focuses on the current diagnostic procedures, pathogenesis, possible signaling mechanisms and treatment options for GCC. Perspectives for future research are discussed. The tumor likely arises from pluripotent intestinal epithelial crypt base stem cells. Previous findings of Notch signaling as a tumor suppressor in Neuroendocrine tumors may have a similar role in this tumor too. Loss of Notch signaling may be the driver mutation with other successive downstream mutations likely favors them into progressing and behavior similar to poorly differentiated adenocarcinoma with minimal neuroendocrine differentiation. A multidisciplinary approach is suggested for optimal outcomes. Surgery remains the main treatment modality. Simple appendectomy may be sufficient in early stages while right hemicolectomy is recommended for advanced tumors. Cytoreductive surgery with heated intraperitoneal chemotherapy may improve survival in a select few with metastatic peritoneal disease. These tumors have an unpredictable behavior even in early stages and local recurrence and delayed metastases may be seen. Lifelong surveillance is warranted.

Peptide-based enteral formula improves tolerance and clinical outcomes in abdominal surgery patients relative to a whole protein enteral formula

AIM

To compare a dipeptide- and tripeptide-based enteral formula with a standard enteral formula for tolerance and nutritional outcomes in abdominal surgery patients.

METHODS

A retrospective study was performed to assess the differences between a whole-protein formula (WPF) and a dipeptide- and tripeptide-based formula (PEF) in clinical outcomes. Seventy-two adult intensive care unit (ICU) patients with serum albumin concentrations less than 3.0 g/dL were enrolled in this study. Patients were divided into two groups (WPF group = 40 patients, PEF group = 32 patients). The study patients were fed for at least 7 d, with ≥ 1000 mL of enteral formula infused on at least 3 of the days.

RESULTS

The mean serum albumin level on postoperative day (POD) 10, prealbumin levels on POD-5 and POD-10, and total lymphocyte count on POD-5 were significantly higher in the PEF group compared to those in the WPF group (P < 0.05). The average maximum gastric residual volume of the PEF patients during their ICU stays was significantly lower than that for WPF patients.

CONCLUSION

Dipeptide- and tripeptide-based enteral formulas are more efficacious and better tolerated than whole-protein formulas.

Phase II study of docetaxel, cisplatin and capecitabine as preoperative chemotherapy in resectable gastric cancer

AIM

To investigate the feasibility of preoperative docetaxel, cisplatin and capecitabine (DCC) in patients with resectable gastric cancer.

METHODS

Patients with resectable gastric cancer fulfilling the inclusion criteria, were treated with 4 cycles of docetaxel (60 mg/m²), cisplatin (60 mg/m²) and capecitabine (1.875 mg/m² orally on day 1-14, two daily doses) repeated every three weeks, followed by surgery. Primary end point was the feasibility and toxicity/safety profile of DCC, secondary endpoints were pathological complete resection rate and pathological complete response (pCR) rate.

RESULTS

All of the patients (51) were assessable for the feasibility and safety of the regimen. The entire preoperative regimen was completed by 68.6% of the patients. Grade III/IV febrile neutropenia occurred in 10% of all courses. Three patients died due to treatment related toxicity (5.9%), one of them (also) because of refusing further treatment for toxicity. Of the 45 patients who were evaluable for secondary endpoints, four developed metastatic disease and 76.5% received a curative resection. In 3 patients a pCR was seen (5.9%), two patients underwent a R1 resection (3.9%).

CONCLUSION

Four courses of DCC as a preoperative regimen for patients with primarily resectable gastric cancer is highly demanding. The high occurrence of febrile neutropenia is of concern. To decrease the occurrence of febrile neutropenia the prophylactic use of granulocyte colony-stimulating factor (G-CSF) should be explored. A curative resection rate of 76.5% is acceptable. The use of DCC without G-CSF support as preoperative regimen in resectable gastric cancer is debatable.

Advances in minimally invasive neonatal colorectal surgery

Over the last two decades, advances in laparoscopic surgery and minimally invasive techniques have transformed the operative management of neonatal colorectal surgery for conditions such as anorectal malformations (ARMs) and Hirschsprung’s disease. Evolution of surgical care has mainly occurred due to the use of laparoscopy, as opposed to a laparotomy, for intra-abdominal procedures and the development of trans-anal techniques. This review describes these advances and outlines the main minimally invasive techniques currently used for management of ARMs and Hirschsprung’s disease. There does still remain significant variation in the procedures used and this review aims to report the current literature comparing techniques with an emphasis on the short- and long-term clinical outcomes.

Incidental non-benign gallbladder histopathology after cholecystectomy in an United Kingdom population: Need for routine histological analysis?

AIM

To analyse the range of histopathology detected in the largest published United Kingdom series of cholecystectomy specimens and to evaluate the rational for selective histopathological analysis.

METHODS

Incidental gallbladder malignancy is rare in the United Kingdom with recent literature supporting selective histological assessment of gallbladders after routine cholecystectomy. All cholecystectomy gallbladder specimens examined by the histopathology department at our hospital during a five year period between March 2008 and March 2013 were retrospectively analysed. Further data was collected on all specimens demonstrating carcinoma, dysplasia and polypoid growths.

RESULTS

The study included 4027 patients. The majority (97%) of specimens exhibited gallstone or cholecystitis related disease. Polyps were demonstrated in 44 (1.09%), the majority of which were cholesterol based (41/44). Dysplasia, ranging from low to multifocal high-grade was demonstrated in 55 (1.37%). Incidental primary gallbladder adenocarcinoma was detected in 6 specimens (0.15%, 5 female and 1 male), and a single gallbladder revealed carcinoma in situ (0.02%). This large single centre study demonstrated a full range of gallbladder disease from cholecystectomy specimens, including more than 1% neoplastic histology and two cases of macroscopically occult gallbladder malignancies.

CONCLUSION

Routine histological evaluation of all elective and emergency cholecystectomies is justified in a United Kingdom population as selective analysis has potential to miss potentially curable life threatening pathology.

Increasing trend in retained rectal foreign bodies

AIM

To highlight the rising trend in hospital presentation of foreign bodies retained in the rectum over a 5-year period.

METHODS

Retrospective review of the cases of retained rectal foreign bodies between 2008 and 2012 was performed. Patients’ clinical data and yearly case presentation with data relating to hospital episodes were collected. Data analysis was by SPSS Inc. Chicago, IL, United States.

RESULTS

Twenty-five patients presented over a 5-year period with a mean age of 39 (17-62) years and M: F ratio of 2:1. A progressive rise in cases was noted from 2008 to 2012 with 3, 4, 4, 6, 8 recorded patients per year respectively. The majority of the impacted rectal objects were used for self-/partner-eroticism. The commonest retained foreign bodies were sex vibrators and dildos. Ninty-six percent of the patients required extraction while one passed spontaneously. Two and three patients had retrieval in the Emergency Department and on the ward respectively while 19 patients needed examination under anaesthesia for extraction. The mean hospital stay was 19 (2-38) h. Associated psychosocial issues included depression, deliberate self-harm, illicit drug abuse, anxiety and alcoholism. There were no psychosocial problems identified in 15 patients.

CONCLUSION

There is a progressive rise in hospital presentation of impacted rectal foreign bodies with increasing use of different objects for sexual arousal.

Acute appendicitis: Epidemiology, treatment and outcomes- analysis of 16544 consecutive cases

AIM

To investigate the epidemiology, treatment and outcomes of acute appendicitis (AA) in a large population study.

METHODS

This is a retrospective cohort study derived from the administrative dataset of the Bergamo district healthcare system (more than 1 million inhabitants) from 1997 to 2013. Data about treatment, surgery, length of stay were collected. Moreover for each patients were registered data about relapse of appendicitis and hospital admission due to intestinal obstruction.

RESULTS

From 1997 to 2013 in the Bergamo district we collected 16544 cases of AA, with a crude incidence rate of 89/100000 inhabitants per year; mean age was 24.51 ± 16.17, 54.7% were male and the mean Charlson’s comorbidity index was 0.32 ± 0.92. Mortality was < 0.0001%. Appendectomy was performed in 94.7% of the patients and the mean length of stay was 5.08 ± 2.88 d; the cumulative hospital stay was 5.19 ± 3.36 d and 1.2% of patients had at least one further hospitalization due intestinal occlusion. Laparoscopic appendectomy was performed in 48% of cases. Percent of 5.34 the patients were treated conservatively with a mean length of stay of 3.98 ± 3.96 d; the relapse rate was 23.1% and the cumulative hospital stay during the study period was 5.46 ± 6.05 d.

CONCLUSION

The treatment of acute appendicitis in Northern Italy is slowly changing, with the large diffusion of laparoscopic approach; conservative treatment of non-complicated appendicitis is still a neglected option, but rich of promising results.

Short-term and middle-term evaluation of laparoscopic hepatectomies compared with open hepatectomies: A propensity score matching analysis

AIM

To compare short-term results between laparoscopic hepatectomy and open hepatectomy using a propensity score matching.

METHODS

A patient in the laparoscopic liver resection (LLR) group was randomly matched with another patient in the open liver resection (OLR) group using a 1:1 allocated ratio with the nearest estimated propensity score. Patients of the LLR group without matches were excluded. Matching criteria included age, gender, body mass index, American Society of Anesthesiologists score, potential co-morbidities, hepatopathies, size and number of nodules, preoperative chemotherapy, minor or major liver resections. Intraoperative and postoperative data were compared in both groups.

RESULTS

From January 2012 to January 2015, a total of 241 hepatectomies were consecutively performed, of which 169 in the OLR group (70.1%) and 72 in the LLR group (29.9%). The conversion rate was 9.7% (n = 7). The mortality rate was 4.2% in the OLR group and 0% in the LLR group. Prior to and after propensity score matching, there was a statistically significant difference favorable to the LLR group regarding shorter operative times (185 min vs 247.5 min; P = 0.002), less blood loss (100 mL vs 300 mL; P = 0.002), a shorter hospital stay (7 d vs 9 d; P = 0.004), and a significantly lower rate of medical complications (4.3% vs 26.4%; P < 0.001).

CONCLUSION

Laparoscopic liver resections seem to yield better short-term and mid-term results as compared to open hepatectomies and could well be considered a privileged approach and become the gold standard in carefully selected patients.

Minimally invasive management of anastomotic leaks in colorectal surgery

Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient’s quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.

Eosinophilic ascites: A diagnostic and therapeutic challenge

Eosinophilic gastroenteritis (EGE) is a rare condition characterized by eosinophilic infiltration of the gastrointestinal tract. Depending on the dominant layer of infiltration it is classified into three types namely, mucosal, muscularis and subserosal. The most uncommon variant is the subserosal type characterized by primarily subserosal disease, eosinophilic ascites and peripheral hypereosinophilia. The clinical features are non-specific with history of atopic predisposition and allergy. Endoscopic biopsy is frequently non-diagnostic due to an uninvolved gastrointestinal mucosa rendering its diagnosis a challenge. The mainstay of diagnosis is peripheral hypereosinophilia and eosinophil-rich ascitic fluid on diagnostic paracentesis. Oral steroid therapy is usually the first line of treatment with dramatic response. Due to a propensity for relapse, steroid-sparing therapy should be considered for relapses of EGE. We report a case of subserosal EGE with diagnostic clinical features and treatment response and review the current strategy in the management of eosinophilic ascites.

Update on medical and surgical options for patients with acute severe ulcerative colitis: What is new?

Acute severe ulcerative colitis (UC) is a highly morbid condition that requires both medical and surgical management through the collaboration of gastroenterologists and colorectal surgeons. First line treatment for patients presenting with acute severe UC consists of intravenous steroids, but those who do not respond require escalation of therapy or emergent colectomy. The mortality of emergent colectomy has declined significantly in recent decades, but due to the morbidity of this procedure, second line agents such as cyclosporine and infliximab have been used as salvage therapy in an attempt to avoid emergent surgery. Unfortunately, protracted medical therapy has led to patients presenting for surgery in a poorer state of health leading to poorer post-operative outcomes. In this era of multiple medical modalities available in the treatment of acute severe UC, physicians must consider the advantages and disadvantages of prolonged medical therapy in an attempt to avoid surgery. Colectomy remains a mainstay in the treatment of severe ulcerative colitis not responsive to corticosteroids and rescue therapy, and timely referral for surgery allows for improved post-operative outcomes with lower risk of sepsis and improved patient survival. Options for reconstructive surgery include three-stage ileal pouch-anal anastomosis or a modified two-stage procedure that can be performed either open or laparoscopically. The numerous avenues of medical and surgical therapy have allowed for great advances in the treatment of patients with UC. In this era of options, it is important to maintain a global view, utilize biologic therapy when indicated, and then maintain an appropriate threshold for surgery. The purpose of this review is to summarize the growing number of medical and surgical options available in the treatment of acute, severe UC.

Total pancreatectomy: Short- and long-term outcomes at a high-volume pancreas center

AIM

To identify the current indications and outcomes of total pancreatectomy at a high-volume center.

METHODS

A single institutional retrospective study of patients undergoing total pancreatectomy from 1995 to 2014 was performed.

RESULTS

One hundred and three patients underwent total pancreatectomy for indications including: Pancreatic ductal adenocarcinoma (n = 42, 40.8%), intraductal papillary mucinous neoplasms (n = 40, 38.8%), chronic pancreatitis (n = 8, 7.8%), pancreatic neuroendocrine tumors (n = 7, 6.8%), and miscellaneous (n = 6, 5.8%). The mean age was 66.2 years, and 59 (57.3%) were female. Twenty-four patients (23.3%) underwent a laparoscopic total pancreatectomy. Splenic preservation and portal vein resection and reconstruction were performed in 24 (23.3%) and 18 patients (17.5%), respectively. The 90 d major complications, readmission, and mortality rates were 32%, 17.5%, and 6.8% respectively. The 1-, 3-, 5-, and 7-year survival for patients with benign indications were 84%, 82%, 79.5%, and 75.9%, and for malignant indications were 64%, 40.4%, 34.7% and 30.9%, respectively.

CONCLUSION

Total pancreatectomy, including laparoscopic total pancreatectomy, appears to be an appropriate option for selected patients when treated at a high-volume pancreatic center and through a multispecialty approach.

Rubber band ligation of hemorrhoids: A guide for complications

Rubber band ligation is one of the most important, cost-effective and commonly used treatments for internal hemorrhoids. Different technical approaches were developed mainly to improve efficacy and safety. The technique can be employed using an endoscope with forward-view or retroflexion or without an endoscope, using a suction elastic band ligator or a forceps ligator. Single or multiple ligations can be performed in a single session. Local anaesthetic after ligation can also be used to reduce the post-procedure pain. Mild bleeding, pain, vaso-vagal symptoms, slippage of bands, priapism, difficulty in urination, anal fissure, and chronic longitudinal ulcers are normally considered minor complications, more frequently encountered. Massive bleeding, thrombosed hemorrhoids, severe pain, urinary retention needing catheterization, pelvic sepsis and death are uncommon major complications. Mild pain after rubber band ligation is the most common complication with a high frequency in some studies. Secondary bleeding normally occurs 10 to 14 d after banding and patients taking anti-platelet and/or anti-coagulant medication have a higher risk, with some reports of massive life-threatening haemorrhage. Several infectious complications have also been reported including pelvic sepsis, Fournier’s gangrene, liver abscesses, tetanus and bacterial endocarditis. To date, seven deaths due to these infectious complications were described. Early recognition and immediate treatment of complications are fundamental for a favourable prognosis.