A prospective randomized controlled study evaluating efficacy of Daikenchuto in the treatment of postoperative abdominal pain and bloating following hepatectomy

BACKGROUND

The aim of this study was to evaluate the effectiveness and safety of TJ-100 TSUMURA Daikenchuto (DKT) Extract Granules in preventing post-hepatectomy digestive symptoms and the effects on small intestinal mucosal atrophy.

METHODS

Eligible patients were randomly assigned to the DKT therapy and usual care groups in a 1:1 ratio. The DKT therapy group was administered DKT for 14 days after surgery or until the day of discharge if the patient left the hospital before 14 days, and the usual care group did not receive DKT. We used the numeric rating scale to measure abdominal pain and bloating after surgery and compared the results between the two groups to determine the efficiency of DKT. We also evaluated postoperative small intestinal mucosal atrophy using diamine oxidase (DAO) and glucagon-like peptide-2 (GLP-2) activities in the serum, and postoperative complications.

RESULTS

No adverse effects were observed in the DKT group. No significant difference was observed in the area under the curve for postoperative abdominal pain or bloating throughout the study period. No differences were observed in DAO2, GLP2, and other nutrition assessment indicators. Four postoperative infections were observed in three patients (two with intra-abdominal surgical site infections [SSIs] and two with pneumonia). All cases of infection occurred in the control group.

CONCLUSIONS

Although DKT did not significantly improve postoperative symptoms, such as abdominal pain or bloating, it is widely used in Japan to improve bowel movement and is safely prescribed for patients undergoing hepatectomy with a tendency toward less postoperative infection.

Clinically significant portal hypertension in patients with primary biliary cholangitis: Clinicopathological features and prognostic value

INTRODUCTION AND OBJECTIVES

Primary biliary cholangitis (PBC) may progress to clinically significant portal hypertension (CSPH) before the development of cirrhosis. This study aimed to investigate CSPH incidence as well as the clinicopathological characteristics and predictive value of these features for the prognosis of patients with PBC, especially at early histologic stage.

PATIENTS AND METHODS

Patients diagnosed with PBC between January 2013 and April 2022 were retrospectively enrolled. The prognostic value of baseline clinicopathological characteristics for long-term outcomes in PBC patients with CSPH was assessed using Kaplan-Meier survival analysis and COX regression analysis.

RESULTS

Among 280 patients with PBC, 104 underwent liver biopsy and 68 were at early histologic stage. CSPH was present in 47.2% of participants with 20.6% at early histologic stage. CSPH was a risk factor for predicting the liver transplant-free survival in PBC patients (hazard ratio [HR], 6.78; 95% CI, 2.94-15.63), especially those at early stage. Perisinusoidal fibrosis and nodular regenerative hyperplasia (NRH) were common histopathological features in PBC patients with CSPH at the early stages. Fibrous septa formation in the hepatic lobules (HR, 4.85; 95% CI, 1.51-15.52) and cholestasis (HR, 7.70; 95% CI, 2.56-23.18) were independent predictors of adverse outcomes.

CONCLUSIONS

CSPH indicates an increased risk of adverse outcomes in PBC patients, especially those in early histologic stage. Perisinusoidal fibrosis and NRH are valuable histological features of CSPH in patients with early-stage PBC. Identification of clinicopathological features and assessment of portal hypertension (especially at early stage), contribute to the development of personalized strategies.

KIF18B: an important role in signaling pathways and a potential resistant target in tumor development

KIF18B is a key member of the kinesin-8 family, involved in regulating various physiological processes such as microtubule length, spindle assembly, and chromosome alignment. This article briefly introduces the structure and physiological functions of KIF18B, examines its role in malignant tumors, and the associated carcinogenic signaling pathways such as PI3K/AKT, Wnt/β-catenin, and mTOR pathways. Research indicates that the upregulation of KIF18B enhances tumor malignancy and resistance to radiotherapy and chemotherapy. KIF18B could become a new target for anticancer drugs, offering significant potential for the treatment of malignant tumors and reducing chemotherapy resistance.

Progress, challenges, and future perspectives of robot-assisted natural orifice specimen extraction surgery for colorectal cancer: a review

With the continuous advancements in precision medicine and the relentless pursuit of minimally invasive techniques, Natural Orifice Specimen Extraction Surgery (NOSES) has emerged. Compared to traditional surgical methods, NOSES better embodies the principles of minimally invasive surgery, making scar-free operations possible. In recent years, with the progress of science and technology, Robot-Assisted Laparoscopic Surgery has been widely applied in the treatment of colorectal cancer. Robotic surgical systems, with their clear surgical view and high operational precision, have shown significant advantages in the treatment process. To further improve the therapeutic outcomes for colorectal cancer patients, some scholars have attempted to combine robotic technology with NOSES. However, like traditional open surgery or laparoscopic surgery, the use of the robotic platform presents both advantages and limitations. Therefore, this study reviews the current research status, progress, and controversies regarding Robot-Assisted Laparoscopic Natural Orifice Specimen Extraction Surgery for colorectal cancer, aiming to provide clinicians with more options in the diagnosis and treatment of colorectal cancer.

Clinicopathologic features and surgery-related outcomes of duodenal adenocarcinoma: A multicenter retrospective study

BACKGROUND

The incidence of duodenal adenocarcinoma is increasing, with limited studies on this disease published. This multicenter retrospective study aimed to analyze the clinicopathologic features of duodenal adenocarcinoma and identify prognostic factors for postoperative survival.

METHODS

Demographic characteristics, clinicopathologic features, treatment outcomes, and survival of patients with duodenal adenocarcinoma undergoing surgical treatment at 16 Chinese medical centers from 2012 to 2023 were retrospectively analyzed.

RESULTS

Among the 2,189 patients with duodenal adenocarcinoma included, 50.07% had extra-ampullary duodenal adenocarcinoma and 49.93% had peri-ampullary duodenal adenocarcinoma. The 1-, 3-, and 5-year overall survival rates for patients who underwent radical surgery were 91.78%, 69.30%, and 55.86%, respectively. The median overall survival was 73 months (range, 64-84), and the median progression-free survival was 64 months (range, 52-76). No differences in survival were observed between the laparotomy and minimally invasive surgery groups (log-rank P = .562); furthermore, no significant between-group differences in operation time, lymph node dissection, postoperative complications, or in-hospital mortality were observed (P > .05). The minimally invasive surgery group experienced less intraoperative blood loss (250 mL vs 100 mL, P < .001), fewer intraoperative blood transfusions (24.97% vs 18.84%, P = .002), and shorter hospital stays (28 days vs 23 days, P < .001). Multivariate Cox regression analysis revealed that advanced age, advanced stage, longer operation time, intraoperative blood transfusion, and postoperative hemorrhage were independent risk factors for poor prognosis.

CONCLUSION

Radical surgery was associated with favorable overall survival among patients with duodenal adenocarcinoma, and no difference in survival was observed between patients with extra-ampullary duodenal adenocarcinoma and peri-ampullary duodenal adenocarcinoma. Minimally invasive surgery is a reliable alternative for duodenal adenocarcinoma treatment.

Multimodal modulation of hepatic ischemia/reperfusion-induced injury by phytochemical agents: A mechanistic evaluation of hepatoprotective potential and safety profiles

BACKGROUND

Hepatic ischemia-reperfusion (I/R) injury is a clinically fundamental phenomenon that occurs through liver resection surgery, trauma, shock, and transplantation.

AIMS OF THE REVIEW

This review article affords an expanded and comprehensive overview of various natural herbal ingredients that have demonstrated hepatoprotective effects against I/R injury through preclinical studies in animal models.

MATERIALS AND METHODS

For the objective of this investigation, an extensive examination was carried out utilizing diverse scientific databases involving PubMed, Google Scholar, Science Direct, Egyptian Knowledge Bank (EKB), and Research Gate. The investigation was conducted based on specific identifiable terms, such as hepatic ischemia/reperfusion injury, liver resection and transplantation, cytokines, inflammation, NF-kB, interleukins, herbs, plants, natural ingredients, phenolic extract, and aqueous extract.

RESULTS

Bioactive ingredients derived from ginseng, curcumin, resveratrol, epigallocatechin gallate, quercetin, lycopene, punicalagin, crocin, celastrol, andrographolide, silymarin, and others and their effects on hepatic IRI were discussed. The specific mechanisms of action, signaling pathways, and clinical relevance for attenuation of liver enzymes, cytokine production, immune cell infiltration, oxidative damage, and cell death signaling in rodent studies are analyzed in depth. Their complex molecular actions involve modulation of pathways like TLR4, NF-κB, Nrf2, Bcl-2 family proteins, and others.

CONCLUSION

The natural ingredients have promising values in the protection and treatment of various chronic aggressive clinical conditions, and that need to be evaluated on humans by clinical studies.

Surviving a classic heat stroke/hyperthermia > 42 °C - a case report

INTRODUCTION

Classic heat stroke is a severe trauma which can lead to multi-organ dysfunctions and is associated with a high mortality.

CASE PRESENTATION

In this case report we present a 73-year-old patient with a classic heat stroke. His initial core body temperature was over 42 °C and he had a GCS of 3. Due to severe burn injuries the patient was transferred to a specialized burn center. The patient developed different organ failures and showed a prolonged course on the intensive care unit. Although the patient demonstrated different impaired organ systems, he recovered completely after receiving painstaking supportive therapy.

CONCLUSIONS

This is a rare case of a patient who fully recovered after a heat stroke with a temperature over 42 °C and severe sequelae.

Tailored lateral internal sphincterotomy (T-LIS) for chronic anal fissure by LigaSure Small Jaws©: a comparison with other non-conservative treatments for anal fissures

An anal fissure is a small tear in the thin tissue (mucosa) that lines the anus. Anal fissures typically cause pain and bleeding with bowel movements. The cause is not fully understood, but low intake of dietary fiber may be a risk factor. Chronic anal fissure was defined as a split or ulceration in the posterior or anterior anoderm for at least 6 weeks: have distinct anatomic features such as muscle fibers visible in the wound. Anal fissures can be attributed to constipation or repeated straining: a hard fecal bolus cut the mucosa of anal canal that is relatively thigh at sphincter level management and optimal treatment of the disease is controversial. Many studies recommend conservative and medical treatment modalities as the initial treatment options since they are non-invasive and do not have risks such as anal sphincter injury. Lateral internal sphincterotomy (LIS) is considered the gold standard for treatment of chronic anal fissure. Nonetheless, anal incontinence is one of the worrisome complications of LIS. Fissurectomy is another option among those techniques which address the issues with LIS. LigaSure© (Valleylab) is a bipolar electrosurgical device designed to deliver high current and very low voltage to tissue. It monitors tissue impedance between the jaws of the instrument and continuously adjusts the delivery of energy. The use of LigaSure Small Jaw was never reported for anal fissures in literature. We have applied the use of this device to a group of patients complaining for chronic anal fissure in order to verify if there is any advantage to perform it compared to traditional technique (blade, scissors, electrocautery).

Spinal Anesthesia for Awake Spine Surgery: A Paradigm Shift for Enhanced Recovery after Surgery

Awake surgery has been applied for various surgical procedures with positive outcomes; however, in neurosurgery, the technique has traditionally been reserved for cranial surgery. Awake surgery for the spine (ASFS) is an alternative to general anesthesia (GA). As early studies report promising results, ASFS is progressively gaining more interest from spine surgeons. The history defining the range of adverse events facing patients undergoing GA has been well described. Adverse reactions resulting from GA can include postoperative nausea and vomiting, hemodynamic instability and cardiac complications, acute kidney injury or renal insufficiency, atelectasis, pulmonary emboli, postoperative cognitive dysfunction, or malignant hyperthermia and other direct drug reactions. For this reason, many high-risk populations who have typically been poor candidates under classifications for GA could benefit from the many advantages of ASFS. This narrative review will discuss the significant historical components related to ASFS, pertinent mechanisms of action, protocol overview, and the current trajectory of spine surgery with ASFS.

The pro-inflammatory cytokines IL-1β and IL-6 promote upregulation of the ST6GAL1 sialyltransferase in pancreatic cancer cells

The ST6GAL1 sialyltransferase is overexpressed in multiple cancers including pancreatic ductal adenocarcinoma (PDAC). ST6GAL1 adds an α2-6-linked sialic acid to N-glycosylated membrane receptors, which consequently modulates receptor structure and function. While many studies have investigated the effects of ST6GAL1 on cell phenotype, there is a dearth of knowledge regarding mechanisms that regulate ST6GAL1 expression. In the current study, we evaluated the regulation of ST6GAL1 by two pro-inflammatory cytokines, IL-1β and IL-6, that are abundant within the PDAC tumor microenvironment. Cytokine activity was monitored using the Suit-2 PDAC cell line and two Suit-2-derived metastatic subclones, S2-013 and S2-LM7AA. For all three cell models, treatment with IL-1β or IL-6 increased the expression of ST6GAL1 protein and mRNA. Specifically, IL-1β and IL-6 induced expression of the ST6GAL1 YZ mRNA isoform, which is driven by the P3 promoter. The ST6GAL1 H and X isoforms were not detected. Promoter reporter assays confirmed that IL-1β and IL-6 activated transcription from the P3 promoter. We then examined downstream signaling mechanisms. IL-1β is known to signal through the NFκB transcription factor, whereas IL-6 signals through the STAT3 transcription factor. CUT&RUN experiments revealed that IL-1β promoted the binding of NFκB to the ST6GAL1 P3 promoter, and IL-6 induced the binding of STAT3 to the P3 promoter. Finally, we determined that inhibitors of NFκB and STAT3 blocked the upregulation of ST6GAL1 stimulated by IL-1β and IL-6, respectively. Together, these results highlight a novel molecular pathway by which cytokines within the tumor microenvironment stimulate the upregulation of ST6GAL1 in PDAC cells.

Neonatal Gastrointestinal Perforations: A 4-year Experience in a Single Centre

BACKGROUND

Gastrointestinal perforation (GIP) during the neonatal period is still a significant problem despite improved neonatal care. The study aimed to report on incidence, management, morbidity and mortality.

MATERIAL AND METHODS

Records of neonates with GIPs between October 2018 and November 2022 were retrospectively analysed.

RESULTS

There were 47 patients, 22 (46.8%) males and 25 (53.2%) females. The incidence of neonatal GIP was 0.39% amongst all newborns treated in the neonatal intensive care unit. The mean gestational age was 30.4 ± 4.5 (23-38) weeks, and the mean birth weight was 1493.08 ± 753 (580-2940) g. Of 47 neonates, 5 (10.6%) were full term and 42 (89.4%) were preterm. The mean age of surgery was 12.25 ± 9.89 (0-41) days. A laparotomy was performed in 43 (91.4%) of 47 neonates, while seven of the patients underwent surgical intervention after decompression by percutaneous drainage. Four patients were managed with peritoneal drainage alone due to poor general condition. The pathologies unrelated to necrotising enterocolitis (NEC) were the most common cause of GIPs (55.3%) and included spontaneous intestinal perforation (n = 18), stomach perforation (n = 4), segmental volvulus (n = 2), acute mesenteric ischaemia (n = 1) and meconium peritonitis (n = 1). Overall survival was 55.4%.

CONCLUSION

GIPs are one of the most significant causes of mortality in newborns. The most common cause of perforations is non-NEC entities and can be seen in the entire intestinal system from the stomach to the colon. Surgical exploration is still the primary management model.

Colorectal cancer cell dormancy: An insight into pathways

Cancer cell dormancy (CCD) in colorectal cancer (CRC) poses a significant challenge to effective treatment. In CRC, CCD contributes to tumour recurrence, drug resistance, and amplifying the disease's burden. The molecular mechanisms governing CCD and strategies for eliminating dormant cancer cells remain largely unexplored. Therefore, understanding the molecular mechanisms governing dormancy is crucial for improving patient outcomes and developing targeted therapies. This editorial highlights the complex interplay of signalling pathways and factors involved in colorectal CCD, emphasizing the roles of Hippo/YAP, pluripotent transcription factors such as NANOG, HIF-1α signalling, and Notch signalling pathways. Additionally, ERK/p38α/β/MAPK pathways, AKT signalling pathway, and Extracellular Matrix Metalloproteinase Inducer, along with some potential less explored pathways such as STAT/p53 switch and canonical and non-canonical Wnt and SMAD signalling, are also involved in promoting colorectal CCD. Highlighting their clinical significance, these findings may offer the potential for identifying key dormancy regulator pathways, improving treatment strategies, surmounting drug resistance, and advancing personalized medicine approaches. Moreover, insights into dormancy mechanisms could lead to the development of predictive biomarkers for identifying patients at risk of recurrence and the tailoring of targeted therapies based on individual dormancy profiles. It is essential to conduct further research into these pathways and their modulation to fully comprehend CRC dormancy mechanisms and enhance patient outcomes.

Celiac trunk arterial variations and their clinical implications: Role of imaging

The awareness of anatomical variations of hepatic arteries and celiac trunk is very important in interventional radiology, liver transplant and intra-abdominal oncologic surgeries. Radiology plays an important role in the identification of these variants non-invasively. Digital subtraction angiography was the gold standard for their identification. Computed tomography (CT) angiography non-invasively provides detailed knowledge of various anatomical vascular variations. This pictorial review highlights the role of multidetector computed tomography (MDCT) in the identification of celiac trunk-hepatic arterial system variations and clinical consequences.

Severe acute pancreatitis complicated with intra-abdominal infection secondary to trauma: A case report

BACKGROUND

Pancreatic trauma (PT) is rare among traumatic injuries and has a low incidence, but it can still lead to severe infectious complications, resulting in a high mortality rate. Acute pancreatitis (AP) is a common complication after PT, and when combined with organ dysfunction and sepsis, it will result in a poorer prognosis.

CASE SUMMARY

We report a 25-year-old patient with multiple organ injuries, including the pancreas, due to abdominal trauma, who developed necrotising pancreatitis secondary to emergency caesarean section, combined with intra-abdominal infection (IAI). The patient underwent performed percutaneous drainage, pancreatic necrotic tissue debridement, and abdominal infection foci debridement on the patient.

CONCLUSION

We report a case of severe AP and IAI secondary to trauma. This patient was managed by a combination of conservative treatment such as antibiotic therapy and fluid support with surgery, and a better outcome was obtained.

Efficacy and safety of ultrasound-guided radiofrequency ablation combined with transhepatic artery embolization chemotherapy for hepatocellular carcinoma: A meta-analysis

OBJECTIVE

Meta-analysis was used to assess the efficacy and safety of ultrasound-guided radiofrequency ablation combined with transhepatic artery embolization chemotherapy for hepatocellular carcinoma.

METHODS

Randomized controlled studies on ultrasound-guided radiofrequency ablation combined with transhepatic artery embolization chemotherapy for hepatocellular carcinoma were searched in the databases of PubMed, Embase, Cochrane library, web of science with a search deadline of March 14, 2024. Data were analyzed using Stata 15.0.

RESULT

Six randomized controlled studies involving 520 individuals were finally included, the results of meta-analysis showed that ultrasound-guided radiofrequency ablation combined with TACE can improve objective response rate [RR = 1.52, 95%CI (1.28, 1.81)], improve disease control rate [RR = 1.15, 95%CI (1.06, 1.24)], The survival rate [RR = 1.34, 95%CI (1.19,1.51)] did not increase adverse reactions [RR = 1.34, 95%CI (1.00,1.79)].

CONCLUSION

Based on the findings of the current study, ultrasound-guided radiofrequency ablation combined with TACE was found to improve the objective remission rate, disease control rate, and did not increase adverse events in patients with hepatocellular carcinoma.

Short-term outcomes of Transrectal Natural Orifice Specimen extraction compared with conventional minimally invasive surgery for selected patients with colorectal cancer: a propensity score matching analysis and literature review

PURPOSE

Conventional minimally invasive surgery requires mini-laparotomy to extract the pathological specimen. However, by using a natural orifice as the delivery route, natural orifice specimen extraction (NOSE) surgery avoids the need for a large incision. This study analyzed the short-term outcome of NOSE compared with conventional mini-laparotomy (CL) for colorectal cancer surgery.

METHODS

We conducted a retrospective analysis of 1,189 patients who underwent surgery for primary colorectal cancer between the cecum and upper rectum. Propensity score analyses were applied to the NOSE and CL groups in a 1:1 matched cohort.

RESULTS

After propensity score matching, each group included 201 patients. The NOSE group and CL group did not differ significantly in terms of baseline characteristics. Postoperative morbidity and mortality rates were comparable. Compared with the CL group, the NOSE group experienced a shorter time to first flatus (1.6 ± 0.8 vs. 2.0 ± 1.2 days, p < 0.001), first stool (2.7 ± 1.5 vs. 4.1 ± 1.9, p < 0.001), liquid diet (2.3 ± 1.3 vs. 3.6 ± 1.8 days, p < 0.001), soft diet (3.9 ± 2.0 vs. 5.2 ± 1.9 days, p < 0.001) and a shorter hospital stay (5.1 ± 3.5 vs. 7.4 ± 4.8 days, p < 0.001). The NOSE group exhibited lower mean pain intensity and lower highest pain intensity on postoperative days 1, 2, and 3.

CONCLUSION

NOSE has several advantages over conventional mini-laparotomy following minimally invasive surgery for colon cancer. These advantages include reduced time to oral intake, shorter hospital stays, and less postoperative pain. NOSE can be adopted and applied to highly selective patients without additional risk of short-term complications.

Enhanced recovery after surgery: Progress in adapted pathways for implementation in standard and emerging surgical settings

The concept of enhanced recovery after surgery (ERAS) has been practiced for decades and has been implemented in numerous surgical specialties. ERAS is a global surgical quality improvement initiative, and it is an element in the field of perioperative care. ERAS had shown significant clinical outcomes, patient-reported satisfaction, and improvements in medical service cost. ERAS has been developed for specific surgical procedures, but with the fast progress of newly introduced surgical procedures, the original ERAS have been developed and modified. Recently appearing Topics and future research trends encompass ERAS protocols for other types of surgery and the enhancement of perioperative status, including but not limited to pediatric surgery, laparoscopic and robotic assisted surgery, bariatric surgery, thoracic surgery, and renal transplantation. The elements and pathways of ERAS have been developed with the introduction of up-to-date methodologies in the pre-operative, operative, and post-operative pathways. ERAS costs are higher than traditional care, but the patient's clinical outcome and satisfaction are higher. ERAS is in progress in the fields of anesthetic tasks, pediatric surgery, and organ transplantation. Although ERAS has shown significant clinical outcomes, there are needs to modify the protocol for specific cases, hospital facilities, resources, and nurses training on elements of ERAS. Several challenges and limitations exist in the implementation of ERAS that deserve consideration, it includes: Frailty, maximizing nutrition, prehabilitation, treating preoperative anemia, and enhancing ERAS adoption globally are all included.

Efficacy and safety of endoscopic nasobiliary drainage versus percutaneous transhepatic cholangial drainage in the treatment of advanced hilar cholangiocarcinoma: a systematic review and meta-analysis

OBJECTIVE

To evaluate and compare the efficacy and safety of Endoscopic Nasobiliary Drainage (ENBD) and Percutaneous Transhepatic Cholangiography Drainage (PTCD) in patients with advanced Hilar Cholangiocarcinoma (HCCA) through a meta-analysis of clinical studies.

METHODS

We searched Chinese and English databases, including China National Knowledge Infrastructure (CNKI), Wanfang database, PubMed, Embase, Scopus, and Web of Science, for relevant literatures on PTCD and ENBD for advanced HCCA clinical trials. Two investigators independently screened the literatures, and the quality of the included studies was evaluated using the Newcastle-Ottawa Scale (NOS). The primary endpoint was the success rate of biliary drainage operation, while secondary endpoints included Total Bilirubin (TBIL) change, acute pancreatitis, biliary tract infection, hemobilia, and other complications. R software was used for data analysis.

RESULTS

A comprehensive database search, based on predefined inclusion and exclusion criteria, yielded 26 articles for this study. Analysis revealed that PTCD had a significantly higher success rate than ENBD [OR (95% CI) = 2.63 (1.98, 3.49), Z=6.70, P<0.05]. PTCD was also more effective in reducing TBIL levels post-drainage [SMD (95%CI) =-0.13 (-0.23, -0.03), Z=-2.61, P<0.05]. While ENBD demonstrated a lower overall complication rate [OR (95%CI) = 0.60 (0.43, 0.84), Z=-2.99, P<0.05], it was associated with a significantly lower incidence of post-drainage biliary hemorrhage compared to PTCD [OR=3.02, 95%CI: (1.94-4.71), Z= 4.89, P<0.01].

CONCLUSIONS

This meta-analysis compares the efficacy and safety of ENBD and PTCD for palliative treatment of advanced HCCA. While both are effective, PTCD showed superiority in achieving successful drainage, reducing TBIL, and lowering the incidence of acute pancreatitis and biliary infections. However, ENBD had a lower risk of post-drainage bleeding. Clinicians should weigh these risks and benefits when choosing between ENBD and PTCD for individual patients. Further research is needed to confirm these findings and explore long-term outcomes.

An actinomycosis infection resembling peritoneal dissemination of rectal cancer: a case report

BACKGROUND

Actinomycosis is a suppurative and granulomatous inflammation commonly caused by Actinomyces israelii. Due to its rarity and the paucity of characteristic clinical features, diagnosis of intra-abdominal actinomycosis is challenging, especially when the patient has a treatment history of abdominal cancer.

CASE PRESENTATION

The patient is a 72-year-old man who has a history of multiple abdominal surgeries for rectal cancer, including low anterior resection for primary rectal cancer, partial hepatic resection for metachronous liver metastasis, and Hartmann surgery for local recurrence. The patient has also undergone parastomal hernia repair using the Sugarbaker method. One year after hernia repair, computed tomography (CT) identified a mass lesion between the abdominal wall and the mesh, suggesting the possibility of peritoneal recurrence of rectal cancer. The accumulation of fluorodeoxyglucose (FDG) was evident via positron emission tomography-CT (PET-CT), while tumor marker levels were within the normal range. On laparotomy, the small intestine, abdominal wall, mesh, colon, and stoma were observed to be associated with the mass lesion, and en bloc resection was carried out. However, postoperative histopathological examination revealed an actinomyces infection without any cancerous cells.

CONCLUSIONS

This case highlights the challenges faced by surgeons regarding preoperative diagnosis of actinomycosis, especially when it occurs after the resection of abdominal cancer. Also, this case reminds us of the importance of a histopathological examination for abdominal masses or nodules before starting chemotherapy.

Intratumoral CXCL13+ CD160+ CD8+ T cells promote the formation of tertiary lymphoid structures to enhance the efficacy of immunotherapy in advanced gastric cancer

BACKGROUND

Stage IV gastric cancer is a highly heterogeneous and lethal tumor with few therapeutic strategies. The combination of programmed cell death protein 1 inhibitors and chemotherapy is currently the standard frontline treatment regimen for advanced gastric cancer. Nevertheless, it remains a great challenge to screen the beneficiaries of immunochemotherapy and expand indications for this treatment regimen.

METHODS

We conducted a pathological assessment to ascertain the importance of tertiary lymphoid structures based on the tissue samples collected from patients with stage IV gastric cancer (n=15) both prior to and following immunochemotherapy treatment. Additionally, we used spatial (n=10) and single-cell transcriptional analysis (n=97) to investigate the key regulators of tertiary lymphoid structures (TLSs). Multiplex immunofluorescence and image analysis (n=34) were performed to explore the association between tumor-infiltrating CXCL13+ CD160+ CD8+ T cells and TLSs. The relationship between CXCL13+ CD160+ CD8+ T cells and the responsiveness to immunotherapy was also evaluated by multiplex immunofluorescence and image analysis approaches (n=15). Furthermore, we explored the intrinsic characteristics of CXCL13+ CD160+ CD8+ T cells through various experimental techniques, including quantitative reverse transcription-PCR, western blot, and flow cytometry.

RESULTS

We found that responders exhibited higher levels of TLSs and CXCL13+ CD160+ CD8+ T cells in biopsy tissues prior to immunochemotherapy compared with non-responders. Following conversion therapy, responders also had a higher percentage of mature TLSs and a higher number of CXCL13+ CD160+ CD8+ T cells in surgical resections. Moreover, we discovered that vitamin B6 in CD160+ CD8+ T cells could reduce the ubiquitination modification of HIF-1α by MDM2, thereby attenuating the degradation of HIF-1α. Consequently, this led to the transcriptional upregulation of CXCL13 expression, facilitating the recruitment of CXCR5+ B cells and the formation of TLSs.

CONCLUSION

The number and maturity of TLSs, along with the extent of CXCL13+ CD160+ CD8+ T-cell infiltration, might function as potential indicators for assessing the effectiveness of immunotherapy in treating gastric malignancies. Furthermore, our research suggests that vitamin B6 could enhance the secretion of CXCL13 by CD160+ CD8+ T cells by reducing the degradation of HIF-1α. Additionally, we demonstrate that vitamin B6 supplementation or targeting pyridoxal kinase could substantially improve the efficacy of immunotherapies for gastric cancer.

Post-colonoscopy splenic injury: A case report on diagnostic challenges and treatment strategies

INTRODUCTION AND IMPORTANCE

Colonoscopy, while generally safe, can rarely lead to severe complications such as splenic injury. This article reports a case of splenic injury post-colonoscopy, highlighting clinical challenges, diagnostic approaches, and treatment strategies. The goal is to raise awareness among healthcare professionals and enhance knowledge on managing such complications.

CASE PRESENTATION

A 60-year-old woman with chronic constipation underwent a challenging colonoscopy. Twelve hours later, she had acute abdominal pain, bloating, and anemia. Examination revealed tachycardia and a distended abdomen. Urgent CT showed splenic hematoma and hemoperitoneum. Initially managed conservatively with fluids and transfusions, she developed worsening tachycardia and persistent anemia, necessitating emergency laparotomy. Surgery confirmed significant hemoperitoneum and bleeding splenic lesion, leading to splenectomy. She stabilized and was discharged on the fifth postoperative day with antibiotics and vaccinations.

CLINICAL DISCUSSION

Splenic injury, though rare, is a serious complication of colonoscopy, occurring in 0.002 % to 0.033 % of cases. Symptoms include abdominal pain, left shoulder pain, dizziness, and syncope. Prompt diagnosis with contrast-enhanced CT, which identifies 98.5 % of injuries, is crucial. Treatment ranges from conservative management to emergency splenectomy, based on injury severity and patient stability. Non-operative management is often successful in stable patients, while splenectomy may be necessary for those with significant hemodynamic instability. Early recognition and appropriate treatment are essential for favorable outcomes.

CONCLUSION

Splenic injury is a rare but severe complication of colonoscopy. Early recognition and appropriate management are crucial for positive outcomes. Conservative treatment is often effective, but surgery may be needed for severe cases.

Multidisciplinary team quality improves the survival outcomes of locally advanced rectal cancer patients: A post hoc analysis of the STELLAR trial

PURPOSE

We sought to determine the association between multidisciplinary team (MDT) quality and survival of patients with locally advanced rectal cancer.

METHODS

In a post hoc analysis of the randomized phase III STELLAR trial, 464 patients with distal or middle-third, clinical tumor category cT3-4 and/or regional lymph node-positive rectal cancer who completed surgery were evaluated. Disease-free survival (DFS) and Overall survival (OS) were stratified by Multidisciplinary team (MDT) quality, which was also included in the univariable and multivariable analyses of DFS and OS.

RESULTS

According to the univariable analyses, a significantly worse DFS was associated with a fewer specialized medical disciplines participating in MDT (<5 vs ≥ 5; P=0.049),a lower frequency of MDT meetings ( 200; P=0.039). In addition, a lower number of specialized medical disciplines participating in MDT (<5 vs ≥ 5; P<0.001), a lower frequency of MDT meetings ( 200; P=0.001) were the variables associated with OS. These 3 factors were considered when assessing MDT quality, which was classified into 2 categories: high quality or general quality. Patients treated in hospitals with high MDT quality had longer 3-year OS (90.5 % vs 78.1 %; P=0.001) and similar 3-year DFS (70.3 % vs 61.3 %; P=0.109) compared to those treated in hospitals of the general MDT quality group. Furthermore, multivariable analyses revealed a significance for DFS (HR, 1.648; 95 % CI, 1.143-2.375; P=0.007) and OS (HR, 2.771; 95 % CI, 1.575-4.877; P<0.001) in MDT quality.

CONCLUSIONS

The use of hospitals with optimized multidisciplinary infrastructure had a significant influence on survival of patients with locally advanced rectal cancer.

N-palmitoyl-d-glucosamine limits mucosal damage and VEGF-mediated angiogenesis by PPARα-dependent suppression of pAkt/mTOR/HIF1α pathway and increase in PEA levels in AOM/DSS colorectal carcinoma in mice

Chronic intestinal inflammation and neo-angiogenesis are interconnected in colorectal carcinoma (CRC) pathogenesis. Molecules reducing inflammation and angiogenesis hold promise for CRC prevention and treatment. N-Palmitoyl-d-glucosamine (PGA), a natural glycolipid analog with anti-inflammatory properties, has shown efficacy against acute colitis. Micronized PGA (mPGA) formulations exhibit superior anti-inflammatory activity. This study investigates the in vivo anti-angiogenic and protective effects of mPGA in a mouse model of colitis-associated CRC induced by azoxymethane/dextran sodium sulfate (AOM/DSS). CRC was induced in C57BL/6J mice using intraperitoneal azoxymethane followed by three cycles of 2.5% dextran sodium sulfate (DSS) in drinking water. Mice were treated with mPGA (30-150 mg/kg) with or without the PPARα inhibitor MK886 (10 mg/kg). At Day 70 post-azoxymethane injection, mice underwent anesthetized endoscopic colon evaluation. Post-mortem analysis of tumorigenesis and angiogenesis was performed using histological, immunohistochemical, and immunoblotting techniques. mPGA improved disease progression and survival rates in a dose- and PPARα-dependent manner in AOM/DSS-exposed mice. It reduced polyp formation, decreased pro-angiogenic CD31, pro-proliferative Ki67, and pro-inflammatory TLR4 expression levels, and inhibited VEGF and MMP-9 secretion by disrupting the pAkt/mTOR/HIF1α pathway. mPGA increased colon PEA levels, restoring anti-tumoral PPARα and wtp53 protein expression. Given its lack of toxicity, mPGA shows potential as a nutritional intervention to counteract inflammation-related angiogenesis in CRC.

Demographic, Clinical, Radiological, and Surgical Outcome of Patients with Intestinal Tuberculosis: A Single-Center Retrospective Study

Background

Intestinal tuberculosis (iTB) represents a potentially underrecognized clinical entity with limited clinical and radiological differentiating features. This study aims to assess the patterns of iTB clinical and radiological findings, along with the treatment approaches and the overall outcome.

Methods

This retrospective cross-sectional study included patients with histopathologically confirmed iTB who presented with acute abdomen and were surgically managed between September 2005 and October 2023. Clinical and sociodemographic variables, imaging features, surgical treatments, and overall outcomes were retrospectively analyzed.

Results

96 patients with iTB were included, with a mean age of 36.1 ± 11.5 years and a relatively proportionate gender distribution. Abdominal pain was the most common presenting symptom (45.8%). The radiological features varied by the modality. Plain imaging showed non-specific findings, while ultrasonography showed loculated ascites (25%), and lymphadenopathy (22%). In computed tomography scans, multi-segmental symmetric intestinal thickening (53.1%) was the most prevalent finding. The most commonly performed surgical procedure was adhesiolysis (29.2%), with the ileocecal junction being the most commonly involved structure (39.6%). Histopathological examination of all the tissue biopsies revealed epithelioid granulomas. Postoperative complications occurred in 19 patients (19.8%), with surgical site infection being the most common complication (10.4%).

Conclusion

Intestinal obstruction is an underrecognized manifestation of tuberculosis, particularly in endemic regions. The non-specific clinical presentation, coupled with the limited utility of laboratory and radiological tests, often leads to delayed recognition and treatment. Maintaining a high index of suspicion is essential, especially in younger patients, inhabitants of endemic areas, or those with laboratory findings indicative of chronic inflammation. Prompt recognition is crucial to ensure the timely initiation of anti-tuberculosis therapy and to optimize patient outcomes through appropriate follow-up.

Impact of Spousal Mental Illness on Healthcare Utilization Among Patients With Gastrointestinal Cancer

BACKGROUND

Informal caregiving involves increased responsibilities, with financial and emotional challenges, thereby affecting the well-being of the caregiver. We aimed to investigate the effect of spousal mental illness on hospital visits and medical spending among patients with gastrointestinal (GI) cancer.

METHODS

Patients who underwent GI cancer surgery between 2013 and 2020 were identified from the IBM Marketscan database. Multivariable regression analysis was used to examine the association between spousal mental illness and healthcare utilization.

RESULTS

A total of 6,035 patients underwent GI surgery for a malignant indication. Median age was 54 years (IQR: 49-59), most patients were male (n = 3592, 59.5%), and had a CCI score of ≤ 2 (n = 5512, 91.3%). Of note, in the 1 year follow-up period, 19.4% (anxiety: n = 509, 8.4%; depression: n = 301, 5.0%; both anxiety and depression: n = 273, 4.5%; severe mental illness: n = 86, 1.4%) of spouses developed a mental illness. On multivariable analysis, after controlling for competing factors, spousal mental illness remained independently associated with increased odds of emergency department visits (OR 1.20, 95% CI 1.05-1.38) and becoming a super healthcare utilizer (OR 1.37, 95% CI 1.04-1.79), as well as 12.1% (95% CI 10.6-15.3) higher medical spending.

CONCLUSION

Among patients with GI cancer spousal mental illness is associated with higher rates of outpatient visits, emergency department visits, and expenditures during the 1-year postoperative period. These findings underscore the importance of caregiving resources and counseling in alleviating caregiver burden, thereby reducing the overall burden on the healthcare system.

Chinese national clinical practice guideline on diagnosis and treatment of biliary tract cancers

BACKGROUND

Biliary tract carcinoma (BTC) is relatively rare and comprises a spectrum of invasive tumors arising from the biliary tree. The prognosis is extremely poor. The incidence of BTC is relatively high in Asian countries, and a high number of cases are diagnosed annually in China owing to the large population. Therefore, it is necessary to clarify the epidemiology and high-risk factors for BTC in China. The signs associated with BTC are complex, often require collaborative treatment from surgeons, endoscopists, oncologists, and radiation therapists. Thus, it is necessary to develop a comprehensive Chinese guideline for BTC.

METHODS

This clinical practice guideline (CPG) was developed following the process recommended by the World Health Organization. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the certainty of evidence and make recommendations. The full CPG report was reviewed by external guideline methodologists and clinicians with no direct involvement in the development of this CPG. Two guideline reporting checklists have been adhered to: Appraisal of Guidelines for Research and Evaluation (AGREE) and Reporting Items for practice Guidelines in Healthcare (RIGHT).

RESULTS

The guideline development group, which comprised 85 multidisciplinary clinical experts across China. After a controversies conference, 17 clinical questions concerning the prevention, diagnosis, and treatment of BTC were proposed. Additionally, detailed descriptions of the surgical principles, perioperative management, chemotherapy, immunotherapy, targeted therapy, radiotherapy, and endoscopic management were proposed.

CONCLUSIONS

The guideline development group created a comprehensive Chinese guideline for the diagnosis and treatment of BTC, covering various aspects of epidemiology, diagnosis, and treatment. The 17 clinical questions have important reference value for the management of BTC.

Post-colonoscopy appendicitis: A systematic review

Post-colonoscopy appendicitis is an infrequent complication of colonoscopy. This systematic review aimed to summarize the literature's current notions, clinical features, and management of post-colonoscopy appendicitis. PubMed and Embase were searched from inception until December 31, 2023. Two reviewers independently screened titles/abstracts and full-text papers for any study design about post-colonoscopy appendicitis and abstracted data. 56 articles with a total of 67 patients were included in the systematic review. The median age was 54.9 years (range 24-84), with more male individuals affected (64.2 %). The main indication of colonoscopy was investigation (37.3 %). Forty-three patients had colonoscopy with additional procedures (64.2 %). Most patients (79.1 %) presented with symptoms within two days after the colonoscopy. The clinical manifestation was the same as acute appendicitis. The diagnosis of post-colonoscopy appendicitis was confirmed in 70.2 % of the cases, mainly with abdominal computed tomography or, alternatively, ultrasound. Most patients were successfully treated with surgery (88.1 %), either open (56.8 %) or laparoscopic appendectomy (31.3 %). The conversion rate of laparoscopic appendectomy was 19.2 %. Non-operative management with intravenous antibiotics was attempted in 17 patients with a success rate of 41.2 %. Histopathology revealed acute appendicitis in 30 cases (44.8 %) and complicated appendicitis in 29 (49.2 %). Fecalith was found in 21 cases (31.3 %). Post-colonoscopy appendicitis is an infrequent but potential complication of colonoscopy. The onset of symptoms, especially pain, fever, nausea, and vomiting after a colonoscopy, should raise suspicion of this entity. A satisfactory outcome depends on timely diagnosis and appropriate management.

Postoperative physical rehabilitation in the elderly patient after emergency surgery. Influence on functional, cognitive and quality of live recovery: study protocol for a randomized clinical trial

BACKGROUND

The progressive aging of the population has meant the increase in elderly patients requiring an urgent surgery. Older adults, especially those with frailty, have a higher risk for complications, functional and cognitive decline after urgent surgery. These patients have their functional and physiological reserve reduced which makes them more vulnerable to the effects of being bedridden. The consequences are at multiple levels emphasizing the functional loss or cognitive impairment, longer stays, mortality and institutionalization, delirium, poor quality of life and increased use of resources related to health. We aim to determine whether postoperative physical rehabilitation can prevent functional and cognitive decline and modify the posterior trajectory.

METHODS/DESIGN

This study is a randomized clinical trial, simple blinded, conducted in the Department of Surgery of a tertiary public hospital in Navarra (Hospital Universitario de Navarra), Spain. Patients >  = 70 years old undergoing urgent abdominal surgery who meet inclusion criteria will be randomly assigned to the intervention or control group. The intervention will consist of a multicomponent physical training programme, which will include progressive and supervised endurance, resistance and balance training for 4 weeks, twice weekly sessions with a total of 8 sessions, and the group control will receive the usual care. The primary outcome measure is the change in functional (SPPB) and cognitive status (Mini-Mental State Examination) and the change of quality of life (EuroQol-5D-VAS) during the study period. The secondary outcomes are postoperative complications, length of stay, delirium, mortality, use of health resources, functional status (Barthel Index and handgrip strength tests), cost per quality-adjusted life year and mininutritional assessment. The data for both the intervention group and the control group will be obtained at four different times: the initial visit during hospital admission and at months 1, 3 and 6 months after hospital discharge.

DISCUSSION

If our hypothesis is correct, this project could show that individualized and progressive exercise programme provides effective therapy for improving the functional capacity and achieve a better functional, cognitive and quality of life recovery. This measure, without entailing a significant expense for the administration, probably has an important repercussion both in the short- and long-term recovery, improving care and functional parameters and could determine a lower subsequent need for health resources. To verify this, we will carry out a cost-effectiveness study. The clinical impact of this trial can be significant if we help to modify the traditional management of the elderly patients from an illness model to a more person-centred and functionally oriented perspective. Moreover, the prescription of individualized exercise can be routinely included in the clinical practice of these patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05290532. Version 1. Registered on March 13, 2022.

Resistance to 5-fluorouracil: The molecular mechanisms of development in colon cancer cells

Colon cancer is a significant health problem worldwide as it is one of the most common and deadliest cancers. The standard approach for the treatment of colon cancer is 5-fluorouracil (5-FU) based chemotherapy, which is limited by the development of resistance to this drug. Therefore, our study aimed to establish 5-FU resistance in SW-480 and HT-29 colon cancer cells and to precisely determine the molecular mechanisms and biomarkers that contribute to its development, both after short-term exposure and in cells with already developed resistance (SW-480-5FUR and HT-29-5FUR). The expression of various molecules involved in the different mechanisms of resistance development was monitored at the gene (qPCR) and protein (immunocytochemistry) levels. Based on the obtained results, alterations in the 5-FU anabolic pathway, biotransformation, drug efflux, mismatch repair, and apoptosis process together contributed to the development of 5-FU resistance in SW-480 and HT-29 colon cancer cells. In addition, UMPS, ABCC1, ABCC5, and MLH1, as well as the disturbed ratio of pro-apoptotic BAX and anti-apoptotic BCL2, should be taken into consideration as potential targets for the discovery of 5-FU resistance-related biomarkers in colon cancer cells. We suggest that future investigations focus on further validation of these findings by additional in vitro and in vivo testing, which is a limitation of our study.

High prevalence of erectile dysfunction within the first year after surgery for rectal cancer: A systematic review and meta-analysis

OBJECTIVE

We aimed to determine the prevalence of erectile dysfunction following rectal cancer surgery within the first year.

SUMMARY BACKGROUND DATA

Erectile dysfunction is a late complication of surgery for rectal cancer. Intraoperative mechanical nerve damage is a probable cause, but it can also be attributed to radio- and chemotherapy.

METHODS

We conducted a systematic review per our protocol (CRD42023472998), searching PubMed, Embase, and Cochrane CENTRAL in August 2023. We included studies reporting on men having surgery for rectal cancer and providing a prevalence of erectile dysfunction based on validated questionnaires published after 1997. The prevalence was estimated through forest plots. Bias was evaluated according to a checklist from the Joanna Briggs Institute.

RESULTS

Of the 4105 records identified in the search, we included 74 studies reporting on 9006 patients operated for rectal cancer. The studies evaluated erectile dysfunction through six validated questionnaires, especially the International Index of Erectile Function (IIEF) version 5 or 15 (84 %). The meta-analysis on 22 studies using IIEF showed that the prevalence of moderate to severe erectile dysfunction was 35 % (95 % CI 24-47 %) within the first year after surgery with very low certainty of evidence. Meta-regression on the prevalence of moderate to severe erectile dysfunction did not show a decrease in erectile dysfunction within the first year postoperatively.

CONCLUSIONS

Around every third patient experienced moderate to severe erectile dysfunction within the first year after surgery for rectum cancer, and the prevalence of erectile dysfunction did not improve within the first year after surgery.

MINI-ABSTRACT

This is a meta-analysis investigating the prevalence of erectile dysfunction following rectal cancer surgery within the first year. Erectile dysfunction was determined on the base of validated self-administered questionnaires. Moderate to severe erectile dysfunction was seen in one-third of patients within the first year after surgery for rectal cancer.

Symptom Cluster Assessment Tools for Gastric Cancer Care in China: A Comprehensive Review

Gastric cancer is a common malignant tumor, and its incidence rate ranks first among malignant tumors of the digestive tract, seriously endangering human physical and mental health. Changes in the physiological state of gastric cancer patients can bring about many physical and psychological symptoms and have a serious impact on their quality of life. Symptom clusters are 2 or more concurrently occurring and interrelated symptoms, with the core symptoms within the cluster remaining stable over time and the symptoms in the cluster being independent of each other. The prerequisite for solving this problem is to screen out appropriate symptom assessment tools according to the clinical situation. The aim of this study was to provide a reference for the development of assessment tools suitable for symptom clusters of gastric cancer patients in China, and to provide evidence for the subsequent optimization of symptom management and some clinical decisions. The contents, application, advantages, and disadvantages of symptom cluster assessment tools for gastric cancer patients in China and abroad were reviewed, and the basic situation and contents of each assessment tool were compared. In China, most of the assessment tools used in domestic gastric cancer research institutes were imported from foreign scales, with a long time span and low specificity for symptoms in various stages of disease development at present. Scholars should be encouraged to develop time-specific assessment tools for the disease characteristics of gastric cancer patients in China, and actively explore the pathogenesis and influencing factors of symptom clusters in this population.

Multibiomarker panels in liquid biopsy for early detection of pancreatic cancer - a comprehensive review

Pancreatic ductal adenocarcinoma (PDAC) is frequently detected in late stages, which leads to limited therapeutic options and a dismal overall survival rate. To date, no robust method for the detection of early-stage PDAC that can be used for targeted screening approaches is available. Liquid biopsy allows the minimally invasive collection of body fluids (typically peripheral blood) and the subsequent analysis of circulating tumor cells or tumor-associated molecules such as nucleic acids, proteins, or metabolites that may be useful for the early diagnosis of PDAC. Single biomarkers may lack sensitivity and/or specificity to reliably detect PDAC, while combinations of these circulating biomarkers in multimarker panels may improve the sensitivity and specificity of blood test-based diagnosis. In this narrative review, we present an overview of different liquid biopsy biomarkers for the early diagnosis of PDAC and discuss the validity of multimarker panels.

Stronger control of eating 3 months after sleeve gastrectomy predicts successful weight loss outcomes at one year

Background

Weight loss response to sleeve gastrectomy (SG) is variable and predicting the effectiveness of surgery is challenging and elusive. The aim of our study was to assess and quantify the association between eating control and weight loss outcomes and identify the control of eating (CoE) attributes during the early postoperative period that might predict good vs. poor response to SG at one year.

Methods

A prospective longitudinal cohort study using the Control of Eating Questionnaire (CoEQ) was designed as a series before and at 3-, 6-, and 12-months post-SG. Primary outcomes were changes in CoE attributes and percent of total weight loss (%TWL) 12-months post-surgery. Subjects were categorized based on %TWL as good (GR, ≥25 %) or poor responders (PR, <25 %). A receiver operating characteristic and logistic regression analyses were performed.

Results

We included 41 participants (80.5% females, 51.2% Hispanic, mean age 41.7±10.6, median baseline body mass index (BMI) 43.6 kg/m2 [range 35.2-66.3]) who completed the CoEQ at all four timepoints. The "Difficulty to control eating" score at 3 months revealed the highest area under the curve (AUC) (AUC 0.711; 95%CI 0.524-0.898; p=0.032). In a trade-off between a high Youden index and high sensitivity, the "Difficulty to control eating" score of 7 at 3 months was identified as the optimal cut-off for distinguishing between GRs and PRs. Score ≤7 at 3 months was strongly independently associated with a successful weight loss target of 25%TWL at one-year post-SG (Relative Risk 4.43; 95%CI 1.06-18.54; p=0.042).

Conclusion

"Difficulty to control eating" score at 3 months post-SG is an independent early predictor of optimal response (achieving a successful TWL target of ≥25 % at one-year post-SG). Our results support the utility of this easy-to-administer validated tool for predicting the effectiveness of SG and may assist in identifying individuals with suboptimal response early and helping them with interventions to attain optimal weight loss targets.

Reno-protective effect of nicorandil and pentoxifylline against potassium dichromate-induced acute renal injury via modulation p38MAPK/Nrf2/HO-1 and Notch1/TLR4/NF-κB signaling pathways

BACKGROUND

Occupational and environmental exposure to chromium compounds such as potassium dichromate (PDC) (K2Cr2O7) has emerged as a potential aetiologic cause for renal disease through apoptotic, and inflammatory reactions. The known potent antioxidants such as nicorandil (NIC) and/or pentoxifylline (PTX) were studied for their possible nephroprotective effect in PDC-treated rats.

METHODS

Forty male Wistar rats were divided into five groups; control, PDC group, NIC+PDC, PTX+PDC group, and combination+PDC group. Nephrotoxicity was evaluated histopathologically and biochemically. Invasive blood pressure, renal function parameters urea, creatinine, uric acid and albumin, glomerular filtration rate markers Cys-C, Kim-1 and NGAL, inflammatory markers IL-1β, IL-6, TNF-α, TGF-β, COX-II, p38MAPK, NF-κB and TLR4, oxidative stress SOD, GSH, MDA, MPO, HO-1 and Nrf2 and apoptotic mediators Notch1 and PCNA were evaluated. Besides, renal cortical histopathology was assayed as well.

RESULTS

PDC led to a considerable increase in indicators for kidney injury, renal function parameters, invasive blood pressure, oxidative stress, and inflammatory markers. They were markedly reduced by coadministration of PDC with either/or NIC and PTX. The NIC and PTX combination regimen showed a more significant improvement than either medication used alone. Our results demonstrated the nephroprotective effect of NIC, PTX, and their combined regimen on PDC-induced kidney injury through suppression of oxidative stress, apoptosis, and inflammatory response.

CONCLUSION

Renal recovery from PDC injury was achieved through enhanced MAPK/Nrf2/HO-1 and suppressed Notch1/TLR4/NF-κB signaling pathways. This study highlights the role of NIC and PTX as effective interventions to ameliorate nephrotoxicity in patients undergoing PDC toxicity.

Research progress of DNA methylation in colorectal cancer (Review)

DNA methylation is one of the earliest and most significant epigenetic mechanisms discovered. DNA methylation refers, in general, to the addition of a methyl group to a specific base in the DNA sequence under the catalysis of DNA methyltransferase, with S‑adenosine methionine as the methyl donor, via covalent bonding and chemical modifications. DNA methylation is an important factor in inducing cancer. There are different types of DNA methylation, and methylation at different sites plays different roles. It is well known that the progression of colorectal cancer (CRC) is affected by the methylation of key genes. The present review did not only discuss the potential relationship between DNA methylation and CRC but also discussed how DNA methylation affects the development of CRC by affecting key genes. Furthermore, the clinical significance of DNA methylation in CRC was highlighted, including that of the therapeutic targets and biomarkers of methylation; and the importance of DNA methylation inhibitors was discussed as a novel strategy for treatment of CRC. The present review did not only focus upon the latest research findings, but earlier reviews were also cited as references to older literature.

Isolated tubercular cholecystitis: A rare diagnostic challenge

Abdominal tuberculosis, particularly affecting the hepatobiliary system, presents a diagnostic challenge due to its rarity and its tendency to mimic neoplastic conditions. Tuberculosis of the gallbladder, especially in the absence of pulmonary infection, is exceedingly rare. We present a case of isolated tubercular cholecystitis in a 41-year-old female initially suspected to have neoplastic etiology. Radiological imaging revealed thickened gallbladder wall with heterogenous enhancement extending into the subcutaneous plane. Histopathological examination post-cholecystectomy confirmed tubercular etiology with epithelioid cell granulomas and focal necrosis, alongside the presence of acid-fast bacilli. Such cases pose diagnostic dilemmas due to overlapping clinical and radiological features with gallbladder carcinoma. This report emphasizes the importance of considering tuberculosis in differentials, particularly in endemic regions like India, even without pulmonary symptoms. Treatment involves postoperative administration of anti-tubercular drugs, with the preoperative diagnosis being challenging and rarely achieved due to the avoidance of invasive procedures like fine needle aspiration in suspected carcinoma cases. The rarity of isolated gallbladder tuberculosis underscores the necessity for comprehensive diagnostic evaluations and awareness among clinicians in endemic regions.

Anesthesia for Combined Heart-Liver Transplantation: A Narrative Review

In 1984, 21 years after the first liver transplantation, Thomas Starzl achieved a milestone by performing the world's first combined heart-liver transplantation. While still uncommon, the practice of combined heart-liver transplants is on the rise globally. In this review, the authors delve into the current literature on this procedure, highlighting the evolving landscape and key considerations for anesthesiologists. Over the years, there has been a remarkable increase in the number of combined heart-liver transplantations conducted worldwide. This surge is largely attributed to the growing population of adult survivors with single-ventricle physiology, palliated with a Fontan procedure, who later present with late Fontan failure and Fontan-associated liver disease. Research indicates that combined heart-liver transplantation is an effective treatment option, with reported outcomes comparable with isolated heart or liver transplants. Managing anesthesia during a combined heart-liver transplant procedure is challenging, especially in the context of underlying Fontan physiology. International experience in this field remains somewhat limited, with most techniques derived from expert opinions or experiences with single-organ heart and liver transplants. These procedures are highly complex and performed infrequently. As the number of combined heart-liver transplants continues to rise globally, there is a growing need for clear guidance on periprocedural surgical and anesthetic management. Anesthesiologists overseeing these patients must consider multiple factors, balancing various comorbidities with significant hemodynamic and metabolic shifts. An increase in (multicenter) studies focusing on specific interventions to enhance patient and organ outcomes is anticipated in the coming years.

Single-Center Randomized Trial Comparing Feeding Jejunostomy with Nasojejunal Tube Placement in Patients Undergoing Transhiatal Esophagectomy Post-Neoadjuvant Therapy for Esophageal Cancer

BACKGROUND

Enteral nutrition is the preferred mode of nutrition following esophagectomy. However, the preferred mode of enteral nutrition (feeding jejunostomy (FJ) vs. nasojejunal (NJ) tube) remains contentious. In this randomized controlled trial (RCT), we compared FJ with NJ tube feeding in terms of safety, feasibility, efficacy, and quality-of-life (QOL) parameters in Indian patients undergoing trans-hiatal esophagectomy (THE) for carcinoma esophagus.

MATERIALS AND METHODS

This single-center, two-armed (FJ and NJ tube), non-inferiority RCT was conducted from March 2020 to January 2024. Forty-eight patients underwent THE with posterior-mediastinal-gastric pull-up and were randomized to NJ and FJ arms (24 in each group). The postoperative complications, catheter efficacy, and QOL parameters were compared between the two groups till the 6-week follow-up.

RESULTS

In this RCT, we found no significant difference in the occurrence of catheter-related complications, postoperative complication rate, catheter efficacy, and visual analog pain scores between patients with NJ tube and FJ, following THE for esophageal cancer. There was a significantly better self-reported physical domain QOL score noted in the NJ group, both at the time of discharge (44.7 ± 6.2 vs 39.8 + 5.6; p value, 0.005) and at the 6-week follow-up (55.4 ± 5.2 vs 48.6 ± 4.5; p value, < 0.001).

CONCLUSION

Based on the findings of our RCT, we conclude that both enteral access methods (NJ vs. FJ) exhibit comparable incidences of catheter-related complications. The use of NJ tube is a viable alternative to a surgical FJ, has the benefit of early removal, and saves the distress associated with a tube per abdomen.

Blood perfusion assessment by near-infrared fluorescence angiography of epiploic appendages in prevention of anastomotic leakage after laparoscopic intersphincteric resection for ultra-low rectal cancer: a case-matched study

BACKGROUND

The role of intraoperative near-infrared fluorescence angiography with indocyanine green in reducing anastomotic leakage (AL) has been demonstrated in colorectal surgery, however, its perfusion assessment mode, and efficacy in reducing anastomotic leakage after laparoscopic intersphincteric resection (LsISR) need to be further elucidated.

AIM

Aim was to study near-infrared fluorescent angiography to help identify bowel ischemia to reduce AL after LsISR.

MATERIAL AND METHODS

A retrospective case-matched study was conducted in one referral center. A total of 556 consecutive patients with ultra-low rectal cancer including 140 patients with fluorescence angiography of epiploic appendages (FAEA)were enrolled. Perfusion assessment by FAEA in the monochrome fluorescence mode. Patients were divided into two groups based on perfusion assessment by FAEA. The primary endpoint was the AL rate within 6 months, and the secondary endpoint was the structural sequelae of anastomotic leakage (SSAL).

RESULTS

After matching, the study group (n = 109) and control group (n = 190) were well-balanced. The AL rate in the FAEA group was lower before (3.6% vs. 10.1%, P = 0.026) and after matching (3.7% vs. 10.5%, P = 0.036). Propensity scores matching analysis (OR 0.275, 95% CI 0.035-0.937, P 0.039), inverse probability of treatment weighting (OR 0.814, 95% CI 0.765-0.921, P 0.002), and regression analysis (OR 0.298, 95% CI 0.112-0.790, P = 0.015), showed that FAEA was an independent protector factor for AL. This technique can significantly shorten postoperative hospital stay [9 (6-13) vs. 10 (8-13), P = 0.024] and reduce the risk of SSAL (1.4% vs. 6.0%, P = 0.029).

CONCLUSIONS

Perfusion assessment by FAEA can achieve better visualization in LsISR and reduce the incidence of AL, subsequently avoiding SSAL after LsISR.

Early drain site tumor recurrence post adjuvant chemotherapy for locally advanced colon carcinoma: Case report and literature review

INTRODUCTION

Colon carcinoma is the most common type of gastro-intestinal cancer. Despite radical surgery, locoregional recurrence has been observed in 4-11.5 % of patients. Abdominal wall metastasis at the drainage site is an extremely rare finding and only a few cases are described in the literature. The mechanism of this metastasis is unknown, and its management remains unclear due to the rarity of the condition.

CASE PRESENTATION

A 66-year-old patient underwent left colectomy for locally advanced colonic adenocarcinoma. Eight months after the end of adjuvant chemotherapy, the patient complained of a progressive mass of the left lumbar centered on the previous drain site scar. Abdominal wall recurrence was suspected. The patient had R0 mass excision. Histopathologic examination showed a parietal infiltration by a colloid adenocarcinoma. The patient underwent adjuvant chemotherapy. No recurrence was observed.

DISCUSSION

Since 1999 only six cases of colon cancer drainage site metastasis have been reported. Metachronous solitary abdominal wall metastasis after radical colectomy may occur via cancer cell implantation, lymphatic or hematogenous route, or direct invasion. In case of drain site metastasis, the most likely hypothesis is the implantation of tumor cells into the abdominal wall through the drainage route performed during surgery.

CONCLUSION

The appearance of abdominal wall mass after colon cancer resection must always be considered suspicious. To reduce the risk of abdominal wall metastasis we recommend minimizing tumor manipulation, resection the route of previous percutaneous drainage and performing a radical surgery. Metastasis resection combined with chemotherapy is the appropriate approach to treat these metastases.

Chimerism-Mediated Tolerance in Intestinal Transplantation

In this review, the authors outlined concepts and strategies to achieve immune tolerance through inducing hematopoietic chimerism after solid organ transplantation and introduced challenges and opportunities in harnessing two-way alloresponses to improve outcomes after intestinal transplantation (ITx). Next, the authors discussed the dynamics and phenotypes of peripheral blood and intestinal graft T-cell subset chimerism and their association with outcomes. The authors also summarized studies on other types of immune cells after ITx and their potential participation in chimerism-mediated tolerance. The authors further discussed strategies and future directions to promote chimerism-associated tolerance after ITx to overcome rejection and minimize immunosuppression.

Surgical Management of the Horrible Gallbladder

Laparoscopic cholecystectomy is one of the most frequently performed operations by general surgeons, with up to 1 million cholecystectomies performed annually in the United States alone. Despite familiarity, common bile duct injury occurs in no less than 0.2% of cholecystectomies, with significant associated morbidity. Understanding biliary anatomy, surgical techniques, pitfalls, and bailout maneuvers is critical to optimizing outcomes when encountering the horrible gallbladder. This article describes normal and aberrant biliary anatomy, complicated cholelithiasis, ways to recognize cholecystitis, and considerations of surgical approach.

Massive gastropathy due to gallstone obstruction of the duodenum (Bourveret syndrome)

Gallstones are common in the general population and are often asymptomatic, but they can also cause complications such as cholecystitis and pancreatitis. In rare instances, they can lead to the formation of a cholecystoduodenal fistula and gallstone ileus. Gastric dilatation and distension following gallstone ileus are extremely uncommon and have rarely been reported in the literature. We report a fatal case of massive gastropathy as a result of Bouveret syndrome secondary to gallstone obstruction.

Analysis of patients with Crohn's disease and intestinal obstruction: a National Inpatient Sample study

Background

Crohn's disease (CD) predisposes patients to intestinal obstruction (IO), a severe complication. This study examined the outcomes and healthcare utilization of patients with CD and IO using data from the National Inpatient Sample (NIS).

Methods

This retrospective analysis of NIS data from 2016-2020 compared hospitalized adult CD patients with and without IO. Outcomes studied include in-hospital mortality, length of stay (LOS), hospitalization charges, and the requirement for intervention, using regression models for adjustment.

Results

Among the 304,149 CD patients, 27,024 had IO. These patients experienced higher in-hospital mortality (3.9% vs. 1.8% for non-IO, adjusted odds ratio [aOR] 1.78, 95% confidence interval [CI] 1.09-2.89; P=0.02), longer mean LOS (7.23 vs. 4.53 days for non-IO, P<0.001), and higher average hospitalization charges ($71,775 vs. $43,717 for non-IO, P<0.001). Additionally, they had higher odds of requiring admission to the intensive care unit (aOR 1.99, 95%CI 1.45-2.73; P<0.001), intubation (aOR 2.53, 95%CI 1.74-3.68; P<0.001), balloon dilation (aOR 1.50, 95%CI 1.132-1.98; P=0.005), or intestinal resection (aOR 2.29, 95%CI 2.11-2.49; P<0.001).

Conclusions

CD patients with IO face considerable challenges, including greater mortality, longer hospital stays, and higher hospitalization costs. The need for intensive care and surgical interventions highlights the urgent need for improved management and treatment strategies to enhance outcomes for these patients.

Radiologic Occult Metastases in Pancreatic Cancer: Analysis of Risk Factors and Survival Outcomes in the Age of Contemporary Neoadjuvant Multi-agent Chemotherapy

BACKGROUND

Radiologic occult metastatic disease (ROMD) in patients with pancreatic ductal adenocarcinoma (PDAC) who undergo contemporary neoadjuvant chemotherapy (NAC) has not been well studied. This study sought to analyze the incidence, risk factors, and oncologic outcomes for patients who underwent the NAC approach for PDAC.

METHODS

A retrospective review analyzed a prospectively maintained database of patients who had potentially resectable PDAC treated with NAC and were offered pancreatectomy at our institution from 2011 to 2022. Multivariable regression analysis was performed to assess risk factors associated with ROMD. Kaplan-Meier curves with log-rank analyses were generated to estimate time-to-event end points.

RESULTS

The study enrolled 366 patients. Upfront and borderline resectable anatomic staging comprised 80% of the cohort, whereas 20% had locally advanced disease. The most common NAC regimen was FOLFIRINOX (n = 274, 75%). For 55 patients (15%) who harbored ROMD, the most common site was liver-only metastases (n = 33, 60%). The independent risk factors for ROMD were increasing CA19-9 levels during NAC (odds ratio [OR], 7.01; confidence interval [CI], 1.97-24.96; p = 0.008), indeterminate liver lesions (OR, 2.19; CI, 1.09-4.39; p = 0.028), and enlarged para-aortic lymph nodes (OR, 6.87; CI, 2.07-22.74; p = 0.002) on preoperative cross-sectional imaging. Receipt of palliative chemotherapy (p < 0.001) and eventual formal pancreatectomy (p = 0.04) were associated with survival benefit in the log-rank analysis. The median overall survival (OS) of the patients with ROMD was nearly 15 months from the initial diagnosis, with radiologic evidence of metastases occurring after a median of 2 months.

CONCLUSIONS

Radiologic occult metastatic disease remains a clinical challenge associated with poor outcomes for patients who have PDAC treated with multi-agent NAC.

Impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy: a NSQIP retrospective cohort analysis of 25,848 patients

BACKGROUND

Efforts to preoperatively risk stratify and optimize patients before pancreaticoduodenectomy continue to improve outcomes. This study aims to determine the impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy and outline optimal hypoalbuminemia cut-off values in this population.

METHODS

The ACS-NSQIP (2016-2021) database was used to extract patients who underwent pancreaticoduodenectomy, comparing those with hypoalbuminemia (< 3.0 g/L) to those with normal albumin. Demographics and 30-day outcomes were compared. Multivariable modeling evaluated factors including hypoalbuminemia to characterize their independent effect on serious complications, and mortality. Optimal albumin cut-offs for serious complications and mortality were evaluated using receiver-operating characteristic curves.

RESULTS

We evaluated 25,848 pancreaticoduodenectomy patients with 2712 (10.5%) having preoperative hypoalbuminemia. Patients with hypoalbuminemia were older (68.2 vs. 65.1; p < 0.0001), and were significantly more likely to be ASA class 4 or higher (13.9% vs. 6.7%; p < 0.0001). Patients with hypoalbuminemia had significantly more 30-day complications and after controlling for comorbidities hypoalbuminemia remained a significant independent factor associated with 30-day serious complications (OR 1.80, p < 0.0001) but not mortality (OR 1.37, p = 0.152).

CONCLUSIONS

Hypoalbuminemia plays a significant role in 30-day morbidity following pancreaticoduodenectomy. Preoperative albumin may serve as a useful marker for risk stratification and optimization.

Seniority of Surgeon in Chronic Subdural Hematoma Recurrence: A Systematic Review and Meta-analysis

Chronic subdural hematoma (CSDH) is increasingly common, particularly in the older and multimorbid population. Surgical proficiency in management is required in the early years of U.K. neurosurgical training with most cases performed by nonconsultant-grade surgeons. The aim of this systematic review was to examine the effect of surgeon seniority on recurrence for patients with CSDH. Full-text articles comparing surgical treatment for CSDH with a "senior" (consultant/attending level) or "junior" (resident/registrar or similar) lead surgeon were identified. MEDLine and EMBASE databases were searched. The primary outcome of this study was recurrence. Secondary outcomes included postoperative complications and mortality rate. A random effects meta-analysis was performed. The risk of bias was assessed using the National Institute of Health risk of bias toolkit. Five studies were included in the final analysis (n = 941 total patients). Individually, no study identified a significant difference in recurrence rate and postoperative complications between senior and junior neurosurgeons. On meta-analysis, junior-led evacuations had lower recurrence rates on pooled univariable analysis (12.0% vs. 17.9% [odds ratio 0.48, 95% confidence interval 0.29-0.78, I2 = 0%]) (3 studies). Seniority of surgeon was not associated with increased rates of recurrence patients undergoing CSDH surgery. Complexity of operation may be a confounding factor in observed lower recurrence rates with more junior operators.

Diagnosing and managing small bowel neuroendocrine tumors presenting as acute obstruction in an elderly patient: A case report and comprehensive management overview

INTRODUCTION AND IMPORTANCE

Neuroendocrine tumors (NETs) of the small bowel are rare but clinically significant due to their challenging diagnostic pathways and potential for insidious progression. Early identification is critical for effective management and improved prognosis in these cases.

CLINICAL PRESENTATION

Here, we present a case of a 75-year-old patient with no significant medical history who presented acutely with diffuse abdominal pain, vomiting, and signs of bowel obstruction. Diagnostic workup, including CT imaging, revealed a distal ileal neuroendocrine mass with mesenteric lymphadenopathy, necessitating urgent surgical intervention.

DISCUSSION

This case underscores the diagnostic complexities and therapeutic challenges associated with small bowel NETs. Surgical resection with meticulous lymph node dissection remains the cornerstone of treatment, aimed at achieving complete tumor excision and optimal disease control. The role of imaging modalities and biochemical markers in guiding clinical decisions and postoperative management strategies is discussed considering the patient's clinical course.

CONCLUSION

Timely recognition and intervention are crucial in the management of small bowel NETs, given their potential for late presentation and nonspecific symptoms. Despite diagnostic and procedural challenges highlighted in this case, early surgical intervention and comprehensive follow-up are essential for achieving favorable outcomes and minimizing recurrence risks in patients with small bowel NETs.

Patterns and Outcomes in Pediatric Abdominal Tuberculosis: A Single Centre Cohort Study

INTRODUCTION

Abdominal tuberculosis presents in a variety of ways. Different testing modalities must be applied in addition to having a high clinical suspicion to diagnose and initiate therapy. Medications have a good response; however, morbidity has been seen following surgical management of complicated presentations like intestinal obstruction and perforation. There is a paucity of studies in the pediatric age group which evaluate response to the different treatment regimen and identify factors associated with poorer outcomes in children with abdominal tuberculosis.

METHODS

Patient records of 75 children with abdominal tuberculosis at a single center were evaluated using a questionnaire, covering a 14-year period from 2007 to 2021. Demographic features, presenting signs and symptoms, investigations and treatment details were studied. In- person or telephonic follow-up was conducted to identify treatment outcomes.

RESULTS

Incidence of abdominal TB was 7%, of all TB children with a mean age of 10.1 years. Mesenteric lymph nodes were involved in 67% and small intestine in 33% cases. Surgery was required in 22 children. 85% children completed treatment. Small intestine involvement had higher probability of undergoing surgery. Of the 70 children with complete follow up, 64 were well and 6 children succumbed to the disease. Older age, small intestine involvement and surgery were independently associated with higher mortality.

CONCLUSION

Intestinal involvement is associated with greater need for surgical intervention and greater mortality. Adolescents have poorer outcomes. Further studies are required focusing on these individual subgroups to understand the patterns of presentation, causes for mortality and prevention.

LEVEL OF EVIDENCE

Level 5.