Applicability of sodium butyrate preparations from a surgeon's and gastroenterologist's perspective

In recent years, much has been written about the possibilities of using exogenous sodium butyrate in the prevention and treatment of gastrointestinal diseases, in prehabilitation, in peri- and postoperative treatment, as well as its local application. It became possible thanks to the development of a special formulation (microencapsulation technique) enabling the delivery of unstable butyrate compounds to the large intestine, where it is used primarily as a source of energy. It also plays a key role in maintaining body homeostasis by maintaining the integrity of the intestinal epithelium and stimulating the intestinal immune system. There is growing evidence of the effectiveness of sodium butyrate in various areas of health. The following article discusses the possibilities of using microencapsulated sodium butyrate in the prevention and treatment of gastrointestinal diseases from the perspective of a gastroenterologist and gastrointestinal surgeon.

Persistent and newly developed gastrointestinal symptoms after surgery for intestinal malrotation in children: Dysmotility or disorders of gut and brain interaction?

OBJECTIVES

Surgery for intestinal malrotation (IM) aims to correct the defect and improve symptoms; however, many have persistent gastrointestinal (GI) symptoms postoperatively. We evaluated the incidence, clinical presentation, and long-term outcomes of children with surgically repaired IM and its possible association with disorders of gut and brain interaction (DGBI).

METHODS

Multicenter retrospective study was conducted in patients from 0 to 21 years old, who had surgery for IM from 2000 to 2021 across three pediatric tertiary care centers. Data analyzed included demographics, time to diagnosis, idiopathic diagnosis, incidental diagnosis, postoperative follow-up, surgical time, and the need for surgery including bowel detorsion. Outcome variables were the presence of postoperative GI symptoms and DGBIs, and overall resolution of symptoms. We also evaluated the potential association of demographics and other included variables with our outcome variables.

RESULTS

Ninety-two patients with surgically corrected IM were included, 54% were male, and median age of diagnosis and surgical correction was 4.9 and 7.8 months, respectively. Median follow-up after surgery was 64 months. A total of 77% had postoperative GI symptoms, and notably, 78% of patients without symptoms before surgery (incidental diagnosis) developed GI symptoms postoperatively and 27% of patients met Rome IV criteria for a one or more DGBI. No factors were associated to the presence of postoperative symptoms or DGBIs in multivariate analysis. Female gender was the only factor associated with lack of resolution of symptoms at follow-up.

CONCLUSION

Pediatric IM is commonly associated with postoperative GI symptoms and DGBI well beyond surgery. An increased awareness about the prevalence of DGBI in these patients may help reach a prompt and accurate diagnosis, and improve their quality of life.

Feasibility of S-1 adjuvant chemotherapy after major hepatectomy for biliary tract cancers: An exploratory subset analysis of JCOG1202

INTRODUCTION

Major hepatectomy (MH) may produce the impaired liver function and affect the feasibility of adjuvant chemotherapy in terms of early period after the surgery, but there have not been detailed investigations. JCOG1202 (UMIN000011688) is a randomized phase III trial demonstrating the superiority of adjuvant S-1 chemotherapy for biliary tract cancer (BTC). The aim of this study is to examine the influence of MH for BTC on adjuvant S-1.

MATERIALS AND METHODS

Of the total 424 patients, 207 received S-1 (S-1 arm) while the remaining 217 were not. We compared MH with non-major hepatectomy (NMH) for BTC.

RESULTS

In the S-1 arm, 42 had undergone MH, and 165 had undergone NMH. MH had similar pretreatment features to NMH, including the proportion of biliary reconstruction, to NMH, except for a lower platelet count (17.7 vs. 23.4 × 104/mm3, p < 0.0001) and lower serum albumin level (3.5 vs. 3.8 g/dL, p < 0.0001). The treatment completion proportion tended to be lower for MH than for NMH (59.5 % vs. 75.8 %; risk ratio, 0.786 [95 % confidence interval, 0.603-1.023], p = 0.0733), and the median dose intensity was lower as well (88.7 % vs. 99.6 %, p = 0.0358). The major reasons for discontinuation were biliary tract infections and gastrointestinal disorders after MH. The frequency of grade 3-4 biliary tract infection was 19.0 % in MH vs. 4.2 % in NMH.

CONCLUSION

The treatment completion proportion and dose intensity were lower in MH than in NMH. Caution should be exercised against biliary tract infections and gastrointestinal disorders during adjuvant S-1 after MH for BTC.

Abdominal computed tomography and exploratory laparotomy have high agreement in dogs with surgical disease

OBJECTIVE

To compare the results of abdominal CT with exploratory laparotomy in the dog.

ANIMALS

100 client-owned dogs from 1 academic institution.

METHODS

Medical records were searched for dogs that had undergone a preoperative abdominal CT scan read by a board-certified veterinary radiologist followed by an exploratory laparotomy. CT and surgical reports were compared.

RESULTS

The overall agreement between abdominal CT scan and exploratory laparotomy in all cases was 97%. Overall, there was no evidence that proportion agreement differed on the basis of body condition score, time interval between CT and surgery, or oncologic versus nononcologic disease.

CLINICAL RELEVANCE

Abdominal CT scan read by a board-certified diplomate is a sensitive presurgical diagnostic tool for surgical abdominal disease in the dog. When performing a specific abdominal surgery, it is acceptable for the surgeon to fully explore the abdomen or forego it for a smaller approach to the organ of interest if an abdominal CT was performed prior.

Persistent urinary incontinence in female Golden Retrievers following laser ablation of intramural ectopic ureters may be associated with the presence of historical urinary tract infection

OBJECTIVE

To identify predictive factors for postoperative continence in female Golden Retrievers following cystoscopic-guided laser ablation of intramural ectopic ureters (CLA-EU).

ANIMALS

41 client-owned female entire Golden Retrievers with uni- or bilateral intramural ectopic ureter(s) were retrospectively enrolled.

METHODS

Patients were diagnosed with ectopic ureters with a combination of ultrasonography and cystoscopy. CLA-EU was performed for all dogs so that each ureteral opening was considered to be in an appropriate position by a single operator. All dogs had short-term follow-up 4 weeks and long-term follow up > 10 weeks after the procedure via telephone, which included urinary continence scoring. Clinical factors and ultrasonographic and cystoscopic findings from initial presentation were evaluated to identify predictive factors for postoperative continence.

RESULTS

Short-term urinary continence was achieved in 46.3% of dogs with no additional medical therapies. Presence of historical urinary tract infections prior to CLA-EU (OR, 0.130; 95% CI, 0.020 to 0.621; P = .018) was negatively correlated and ureteral dilatation (OR, 34.260; 95% CI, 1.813 to 2,143; P = .043) was positively correlated with likelihood of urinary continence. Long-term urinary continence was achieved in 63.4% of dogs, and presence of historical urinary tract infections was negatively prognostic (OR, 0.173; 95% CI, 0.023 to 0.856; P = .048).

CLINICAL RELEVANCE

Female Golden Retrievers undergoing CLA-EU have similar outcomes to those reported for other mixed-breed cohorts with > 30% of dogs failing to regain urinary continence. Historical urinary tract infections were significantly associated with both short- and long-term urinary continence in our population.

Incidence and risk factors for postoperative gastrointestinal dysfunction occurrence after gastrointestinal procedures in US patients

BACKGROUND

Incidence of, and potential risk factors for, postoperative gastrointestinal dysfunction (POGD) after gastrointestinal procedures performed in US hospitals were examined.

METHODS

This retrospective study used hospital discharge data of inpatients who underwent ≥1 gastrointestinal procedures from 1-Jan-2016 to 30-Apr-2019. POGD incidence was calculated based on all hospitalizations for MDC-06 procedures. Predictors of POGD were assessed using multivariable logistic regression.

RESULTS

POGD incidence was 5.8% among 638 611 inpatient hospitalizations. Major bowel procedures, peritoneal adhesiolysis, and appendectomy were the most notable predictors of POGD among gastrointestinal procedures assessed (adjusted odds ratios [95% confidence intervals]: 2.71 [2.59-2.83], 2.48 [2.34-2.64], and 2.15 [2.03-2.27], respectively; all p < 0.05). Procedures performed by colorectal/gastroenterology specialists (0.86 [0.84-0.89]), and those performed percutaneously (0.55 [0.54-0.56]) were associated with significantly lower odds of POGD (both P < 0.05).

CONCLUSIONS

Findings may help clinicians tailor management plans targeting patients at high-risk of POGD.

Regular use of low-dose of opioids after gastrointestinal surgery may lead to postoperative gastrointestinal tract dysfunction in children: a Chinese national regional health center experience sharing

BACKGROUND

The need for pain management is increasing in pediatrics, but the side effects of overuse or abuse of analgesics can be harmful to children's health and even life-threatening in severe cases.

METHODS

Patients who underwent resection of Meckel's diverticulum at the Children's Hospital of Chongqing Medical University from July 1, 2019, to July 1, 2022, were included in this study. Opioids were administered through patient-controlled analgesia (PCA). Based on the preoperative choices made by the legal guardians, patients were stratified into two groups: PCA Group (PCAG) and Non-PCA Group (NPCAG). Data pertaining to the clinical characteristics and prognoses of these patients were subsequently collected and analyzed to assess the impact of opioid administration.

RESULTS

In the study, a total of 126 patients were enrolled, with 72 allocated to the Patient-Controlled Analgesia Group (PCAG) and 54 to the Non-Patient-Controlled Analgesia Group (NPCAG). When compared to the NPCAG, the PCAG exhibited a longer duration of postoperative fasting (median 72 vs. 62 h, p = 0.044) and increased utilization of laxatives (12[16.7%] vs. 2[3.7%], p = 0.022). However, the PCAG also experienced higher incidences of intestinal stasis and abnormal intestinal dilation (13[18.1%] vs. 3[5.6%], p = 0.037). No statistically significant differences were observed in pain assessments at the conclusion of the surgical procedure (0 vs. 1[1.9%], p = 0.429) or within the first 24 h postoperatively (16[22.2%] vs. 18[33.3%], p = 0.164). Additionally, NPCAG patients did not necessitate increased administration of rescue analgesics (2[2.8%] vs. 4[7.4%], p = 0.432).

CONCLUSIONS

The administration of opioids did not demonstrably ameliorate postoperative pain but was associated with a heightened incidence of postoperative gastrointestinal tract dysfunction. The retrospective nature of the current research should be considered and should be clarified further.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

An International Comparison of the Management of Gastrointestinal Surgical Emergencies in Octogenarians-England Versus United States: A National Population-based Cohort Study

OBJECTIVE

To compare the United States and England for the utilization of surgical intervention and in-hospital mortality from 5 gastrointestinal emergencies in octogenarians.

BACKGROUND

The proportion of older adults is growing and will represent a substantial challenge to clinicians in the next decade.

METHODS

Between 2006 and 2012, the rate of surgical intervention and in-hospital mortality for 5 index conditions for octogenarians were compared between the United States and England: appendicitis, incarcerated/strangulated abdominal hernia, perforation of esophagus, small or large bowel, and peptic ulcer. Univariate and multivariate analyses were performed to adjust for underlying differences in patient demographics.

RESULTS

Thirty-two thousand one hundred fifty-one admissions of octogenarians in England for 5 index surgical emergencies were compared with 162,142 admissions in the USA.Surgical intervention was significantly more common in the USA than in England for all 5 conditions: appendicitis [odds ratio (OR) 4.63, 95% confidence interval (95% CI) 4.21-5.09], abdominal hernia (OR 2.06, 95% CI 1.97-2.15), perforated esophagus (OR 1.71, 95% CI 1.31-2.24), small and large bowel perforation (OR 4.33, 95% CI 4.12-4.56), and peptic ulcer perforation (OR 4.63, 95% CI 4.27-5.02). In-hospital mortality was significantly more common in England than in the USA for all 5 conditions: appendicitis (OR 3.22, 95% CI 2.73-3.78), abdominal hernia (OR 3.49, 95% CI 3.29-3.70), perforated esophagus (OR 4.06, 95% CI 3.03-5.44), small and large bowel perforation (OR 6.97, 95% CI 6.60-7.37), and peptic ulcer perforation (OR 3.67, 95% CI 3.40-3.96).

CONCLUSION

Surgery is used less commonly in England for emergency gastrointestinal conditions in octogenarians, which may be associated with a high rate of in-hospital mortality from these conditions compared with the USA.

Principles of Intramural Surgery

Intramural surgery is a minimally invasive surgical technique based on flexible endoscopy. The first step involves the initial mucosal incision for entry point. Then a submucosal tunnel is dissected to the site of the target anatomy. The procedure performed may include myotomy or lesion removal. When complete, the initial mucosal incision is closed. This technique separates the mucosal flap from the surgical site, minimizing the risk of full-thickness perforation and gastrointestinal leakage. Peroral endoscopic myotomy is the most studied application of intramural surgery but other procedures have emerged. This article explores principles of intramural surgery and summarizes its applications.

The impact of properly diagnosed sarcopenia on postoperative outcomes after gastrointestinal surgery: A systematic review and meta-analysis

Background

Sarcopenia is defined as the loss of muscle mass combined with loss of muscle strength, with or without loss of muscle performance. The use of this parameter as a risk factor for complications after surgery is not currently used. This meta-analysis aims to assess the impact of sarcopenia defined by radiologically and clinically criteria and its relationship with complications after gastrointestinal surgeries.

Materials and methods

A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO registration number: CRD42019132221). Articles were selected from the PUBMED and EMBASE databases that adequately assessed sarcopenia and its impact on postoperative complications in gastrointestinal surgery patients. Pooled estimates of pre-operative outcome data were calculated using the odds ratio (OR) and 95% confidence interval (CI). Subgroup analysis were performed to assess each type of surgery.

Results

The search strategy returned 1323, with 11 studies meeting the inclusion criteria. A total of 4265 patients were analysed. The prevalence of sarcopenia between studies ranged from 6.8% to 35.9%. The meta-analysis showed an OR for complications after surgery of 3.01 (95% CI 2.55–3.55) and an OR of 2.2 (95% CI 1.44–3.36) for hospital readmission (30 days).

Conclusion

Sarcopenia, when properly diagnosed, is associated with an increase in late postoperative complications, as well as an increase in the number of postoperative hospital readmissions for various types of gastrointestinal surgery. We believe that any preoperative evaluation should include, in a patient at risk, tests for the diagnosis of sarcopenia and appropriate procedures to reduce its impact on the patient’s health.

A T Drain Approach to Anastomotic Leaks: Another Important Tool in the General Surgeon's Armamentarium

BACKGROUND

Following an intestinal anastomotic leak, stoma creation may be the safest approach. However, this method may be challenging and cause significant morbidity. In selected cases, a T drain approach can be beneficial and a stoma can be avoided.

OBJECTIVES

To present one group's experience with a T drain approach for anastomotic leaks.

METHODS

Data on patients who underwent emergent re-laparotomy following gastrointestinal anastomotic leaks were retrieved retrospectively and assessed with a new intra-operative leak severity score.

RESULTS

Of 1684 gastrointestinal surgeries performed from 2014 to 2018, 41 (2.4%) cases of anastomotic leaks were taken for re-laparotomy. Cases included different sites and etiologies. Twelve patients were treated with a T-tube drain inserted through the leak site, 18 had a stoma taken out, 6 re-anastomosis, 4 were treated with an Endosponge, and one primary repair with a proximal ileostomy was conducted. T drain approach was successful in 11 of 12 patients (92%) with full recovery. One patient did not improve and underwent reoperation with resection and re-anastomosis. A severity score of anastomotic integrity is provided to help surgeons in decision making.

CONCLUSIONS

A T drain approach can be an optimal solution in selected cases following an intestinal anastomotic leak. When the leak is limited, the remaining anastomosis is intact and the abdominal environment allows it, a T drain can be used and a stoma can be avoided.

Endoscopy during the Covid-19 outbreak: experience and recommendations from a single center in a high-incidence scenario

A dramatic SARS-Cov-2 outbreak is hitting Italy hard. To face the new scenario all the hospitals have been re-organised in order to reduce all the outpatient services and to devote almost all their personnel and resources to the management of Covid-19 patients. As a matter of fact, all the services have undergone a deep re-organization guided by: the necessity to reduce exams, to create an environment that helps reduce the virus spread, and to preserve the medical personnel from infection. In these days a re-organization of the endoscopic unit, sited in a high-incidence area, has been adopted, with changes to logistics, work organization and patients selection. With the present manuscript, we want to support gastroenterologists and endoscopists in the organization of a "new" endoscopy unit that responds to the "new" scenario, while remaining fully aware that resources, availability and local circumstances may extremely vary from unit to unit.

Association between preoperative levels of 25-hydroxyvitamin D and hospital-acquired infections after hepatobiliary surgery: A prospective study in a third-level hospital

Introduction

Evidence implicates vitamin D deficiency in poorer outcomes and increased susceptibility to hospital-acquired infections (HAIs). This study examined the association between serum vitamin D levels and HAIs in a population of hepatobiliary surgery patients.

Methods

Participants in this prospective analytical observational study were patients who underwent hepatobiliary surgery in a tertiary hospital in Aragon, Spain, between February 2018 and March 2019. Vitamin D concentrations were measured at admission and all nosocomial infections during hospitalization and after discharge were recorded.

Results

The mean 25-hydroxyvitamin D concentration of the study population (n = 301) was 38.56 nmol/L, which corresponds to vitamin D deficiency. Higher vitamin D concentrations were associated with a decreased likelihood of developing a HAI in general (p = 0.014), and in particularly surgical site infection (p = 0.026). The risk of HAI decreased by 34% with each 26.2-nmol/L increase in serum vitamin D levels.

Conclusions

Vitamin D levels may constitute a modifiable risk factor for postoperative nosocomial infections in hepatobiliary surgery patients.

Efficacy of non-rigid registration technique for misregistration in 3D-CTA fusion imaging

PURPOSE

To assess whether fusion 3D-CTA images can be corrected using non-rigid registration (NRR) for gastroenterology imaging.

METHODS

This study included 55 patients before gastroenterology surgery who underwent preoperative 3D-CTA prior to gastroenterological surgery. We recorded the coordinate of measurement points on the arterial vessels (X, Y, and Z) in each portal phase, original image of the arterial phase, and arterial phase with NRR. The distance of misregistration between the two points was calculated with the coordinate of the original image with NRR and that of the portal phase as true value.

RESULTS

The distance of misregistration between the two points in the original arterial and portal phase images was significantly higher than that in the arterial phase image with NRR on all directions (p < 0.01).

CONCLUSIONS

This study showed that NRR may correct misregistration on fusion 3D-CTA imaging. Hence, it can visualize correctly the anatomy of the vessel.

Endoscopic Suturing Results in High Technical and Clinical Success Rates for a Variety of Gastrointestinal Pathologies

PURPOSE

We report our institution's experience with endoscopic suturing and hypothesize that it has high technical and clinical success.

METHODS

This is a retrospective review of patients who underwent a procedure with the endoscopic suturing system between April 2010 and March 2019. Definitions of technical and clinical success were established for each application.

RESULTS

Overall technical and clinical success in 151 procedures was 97.4% and 74.2%, respectively. Endoscopic suturing was used 24 times to treat leaks or fistulas, with a clinical success rate of 55.6%. The clinical success of stent fixations (11) was 72.7%. Intentional mucosal and submucosal defects were closed 20 times with a clinical success of 83.3%. Iatrogenic perforations (9) were repaired with a clinical success of 87.5%. Marginal ulcers were oversewn (5), with an 80% clinical success rate. Diverticulopexy in the esophagus was clinically successful in two patients. Endoscopic suturing was used in endoscopic sleeve gastroplasty in 10 patients and endoscopic gastrojejunostomy revision in 70 patients; weight loss was observed in both groups at up to 2 and 5 years, respectively.

CONCLUSIONS

Endoscopic suturing was used successfully in numerous situations spanning the gastrointestinal tract with high rates of technical and clinical success.

The Water-Holding Procedure for Ensuring Postoperative Continence Prior Restoring Intestinal Continuity

BACKGROUND

A defunctioning stoma can become necessary in a relevant number of patients undergoing gastrointestinal surgery. As a matter of course, patients seek an early closure of the stoma. However, preoperative management of these patients varies and the prediction of continence after stoma removal can become challenging. Patients might be fully continent despite low manometric pressures and vice versa. An easy and reliable way to predict continence after stoma reversal would improve patients' management and outcome. Although frequently performed in various surgical centers in Germany, there is no published data on the water-holding test. Hence, this is the first study evaluating the role of the test in clinical practice.

METHOD

We performed a prospective pilot study to evaluate the role of anorectal manometry and the water-holding procedure as a predictor of postoperative continence prior to stoma reversal. Inclusion criteria were a successfully passed water-holding test, any type of fecal diversion and the possibility of restoring intestinal continuity. Preoperative low manometric pressure levels were not an exclusion criteria for stoma reversal. Fifty-two patients with ostomy were consecutively enrolled in this study between October 2013 and February 2016. Anorectal manometry was performed in all patients prior to stoma reversal. After stoma removal, patients were followed-up for 6 months. Postoperative incontinence was determined using the Wexner incontinence score.

RESULTS

A total of 52 patients (38 males, 14 females) were included at an average age of 59 (range 33-83) years. Most frequent indications for intestinal diversion were rectal cancer surgery, IBD-related surgery, or surgery for diverticular disease. Low anterior rectal resection was performed in 17 patients (32.7%), followed by a proctocolectomy in 9 (17.3%), colectomy in 9 (17.3%), and recto-sigmoid resection in 7 patients (13.5%). Median time from stoma creation to reversal was 206 days (range 48-871 days). All patients had successfully passed the standardized water-holding test. At the same time, the majority of patients had low preoperative manometric pressure values and would normally not have been reversed at that point. The median postoperative Wexner incontinence score was at 1.5 (range 0-20), 0.5 (range 0-14), and 0 (range 0-11) at 14, 60, and 180 days after stoma reversal. Low preoperative manometric squeeze and/or resting pressure levels were not associated with a higher postoperative incontinence score at 14, 60, or 180 days after stoma reversal.

CONCLUSION

A standardized water-holding test can function as an easy and reliable method before stoma reversal to predict sufficient postoperative fecal continence. In case of a sufficient water-holding test despite low manometric pressure levels, the risk for postoperative anal incontinence seems to be low. Preoperative manometric pressure levels do not appear to predict postoperative continence.

Endoscopic Suturing Results in High Technical and Clinical Success Rates for a Variety of Gastrointestinal Pathologies

PURPOSE

We report our institution's experience with endoscopic suturing and hypothesize that it has high technical and clinical success.

METHODS

This is a retrospective review of patients who underwent a procedure with the endoscopic suturing system between April 2010 and March 2019. Definitions of technical and clinical success were established for each application.

RESULTS

Overall technical and clinical success in 151 procedures was 97.4% and 74.2%, respectively. Endoscopic suturing was used 24 times to treat leaks or fistulas, with a clinical success rate of 55.6%. The clinical success of stent fixations (11) was 72.7%. Intentional mucosal and submucosal defects were closed 20 times with a clinical success of 83.3%. Iatrogenic perforations (9) were repaired with a clinical success of 87.5%. Marginal ulcers were oversewn (5), with an 80% clinical success rate. Diverticulopexy in the esophagus was clinically successful in two patients. Endoscopic suturing was used in endoscopic sleeve gastroplasty in 10 patients and endoscopic gastrojejunostomy revision in 70 patients; weight loss was observed in both groups at up to 2 and 5 years, respectively.

CONCLUSIONS

Endoscopic suturing was used successfully in numerous situations spanning the gastrointestinal tract with high rates of technical and clinical success.

Gastrointestinal symptoms in relation to quality of life after metabolic surgery in adolescents

BACKGROUND

Adolescent obesity is associated with significant co-morbidities, including decreased quality of life (QOL). QOL improves after metabolic and bariatric surgery (MBS), but recent studies have demonstrated that certain gastrointestinal symptoms (GIS) worsen after surgery, including reflux symptoms, nausea, bloating, and diarrhea.

OBJECTIVE

The aim of this study was to evaluate QOL and the effect of these symptoms on QOL after bariatric surgery.

SETTING

Five academic centers that perform adolescent MBS in the United States.

METHODS

We prospectively studied 228 adolescents undergoing MBS using the Teen-Longitudinal Assessment of Bariatric Surgery cohort. GIS and QOL scores were assessed before surgery, at 6 months, and yearly to 5 years after surgery. Analysis involved linear models examining QOL and the association between GIS and QOL adjusting for a priori determined covariates.

RESULTS

Adjusting for body mass index change over time, the physical component score (PCS) of the Short Form-36 (SF-36) increased after surgery from 44.2 at baseline to 54.4 at 5 years (P < .0001). The mental component score did not significantly change over time. The SF-36 domains that showed the biggest increase after surgery were physical functioning, physical role functioning, and general health. The SF-36 PCS decreased significantly over time post surgery in those with GIS of reflux, nausea, and diarrhea but remained higher than baseline SF-36 PCS. There was no statistically significant change in mental component score or impact of weight on quality of life-KIDS scores in those with or without GIS.

CONCLUSION

QOL, specifically the SF-36 PCS, increases after MBS. Reflux symptoms, nausea, and diarrhea reduce the degree of improvement in QOL in adolescents after MBS. Patients should be monitored and treated for these symptoms to address this decreased QOL.

Delta neutrophil index as a predictor of disease severity, surgical outcomes, and mortality rates in gastrointestinal diseases: Rationale for a meta-analysis of diagnostic test accuracy

BACKGROUND

Delta neutrophil index (DNI) is the ratio of the number of immature granulocytes and the total neutrophil count in peripheral circulation. DNI precedes changes in white blood cell or neutrophil counts due to the course of granular leukocyte differentiation in infectious and inflammatory conditions, beginning with immature granulocyte formation. The role of DNI as a biomarker of various infectious or inflammatory conditions has been reported. However, no studies explored the potential role of DNI as an initial biomarker for predicting disease severity, surgical outcomes, and mortality rates of gastrointestinal diseases with pooled diagnostic test accuracy. This study aims to provide evidence that DNI is a predictor of disease severity, surgical outcomes, and mortality rates in patients with gastrointestinal diseases in emergency medical departments.

METHODS

MEDLINE, EMBASE, and the Cochrane Library will be searched using common keywords (inception to July 2019) by 2 independent evaluators. Inclusion criteria will be patients with gastrointestinal diseases, DNI measurements performed in the emergency department, indices of diagnostic performance (sensitivity, specificity, predictive values, and likelihood ratios) of DNI for predicting severity, surgical outcomes, and mortality rate of gastrointestinal diseases. True and false positives and negatives will be calculated based on the diagnostic indices of each study. All types of study designs with full-text literature written in English will be included. Risk of bias will be assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Descriptive data synthesis will be conducted and quantitative synthesis (bivariate and hierarchical summary receiver operating characteristic model) will be performed if the included studies are sufficiently homogenous. Meta-regression, sensitivity analysis, publication bias, and Fagan nomogram will be analyzed and described.

RESULTS

The pooled synthesis of the diagnostic performance of various gastrointestinal diseases with different cut-off values for DNI may limit the interpretation of uniform diagnostic validity. The authors will contact the corresponding authors for the missing values, requesting the original data in each study. However, if there are no responses from these authors, these studies will be excluded.

CONCLUSION

This study will provide diagnostic validity of DNI as an initial marker for the prediction of severity, surgery, and mortality of gastrointestinal diseases.

Probiotic research in neonates with congenital gastrointestinal surgical conditions - Now is the time

Neonates with congenital gastrointestinal surgical conditions (CGISC) receive parenteral nutrition, get exposed to multiple courses of antibiotics, undergo invasive procedures, and are nursed in intensive care units. They do not receive early enteral feeding and have limited opportunities for skin to skin contact with their mothers. Many of these infants receive gastric acid suppression therapies. All these factors increase the risk of gut dysbiosis in these infants. Gut dysbiosis is known to be associated with increased risk of infections and other morbidities in ICU patients. Experimental studies have shown that probiotics inhibit gut colonization with pathogenic bacteria, enhance gut barrier function, facilitate colonization with healthy commensals, protect from enteropathogenic infection through production of acetate, reduce antimicrobial resistance, enhance innate immunity, and increase the maturation of the enteric nervous system and promote gut peristalsis. Through these mechanisms, probiotics have the potential to decrease the risk of sepsis and inflammation, improve feed tolerance and minimise cholestasis in neonates with CGISC. Among preterm non-surgical infants, evidence from more than 35 RCTs and multiple observational studies have shown probiotics to be safe and beneficial. A RCT in neonates (N=24) with gastroschisis found that probiotic supplementation partially attenuated gut dysbiosis. Two ongoing RCTs (total N=168) in neonates with gastrointestinal surgical conditions are expected to provide feasibility data to enable the conduct of large RCTs. Rigorous quality assurance of the probiotic product, ongoing microbial surveillance and clinical vigilance are warranted while conducting such RCTs.

Solutions for submucosal injection: What to choose and how to do it

During the past decades, endoscopic resection techniques have gradually improved and gained more importance for the management of premalignant lesions and early cancers. These endoscopic resection techniques can be divided in 3 major groups: snare polipectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The use of submucosal injection is essential for the majority of EMR techniques and is an integral part of ESD, whereas during polipectomy it is not crucial in most cases except to prevent bleeding in large polyps and/or those with large stalks as an alternative to mechanical methods. Injection provides a lifting up effect of the lesion separating it from the muscular layer, thereby reducing thermal injury and the risk of perforation and bleeding while also facilitating en-bloc resection by improving technical feasibility. With this work, we aim to review the most common endoscopic resection techniques and the importance of submucosal injection in each one of them. For that, we present some of the most commonly used submucosal injection solutions, taking into account their advantages and disadvantages. We also discuss, based on current recommendations and our own experience, how and when to preform submucosal injection, depending on lesions features and endoscopic resection technique that´s being used, to assure complete resection and to prevent associated adverse events. Finally, we also present and discuss some new proposed submucosal injection solutions, endoscopic resection techniques and devices that may have a major impact on the future of therapeutic endoscopy.

[Preliminary experience on construting research-based gastrointestinal surgery department of Nanfang Hospital]

Construction of research-based surgery department includes standardizing surgical practices, collecting and analyzing clinical data, discovering problems in clinical practices, designing and conducting reliable and high-level clinical research, improving and innovating surgical technologies according to research conclusions, working out technical specifications and promoting them through clinical education, and creating new clinical research needs arised by innovative and cutting-edge technologies and theories. By integrating technology, research, standardization, promotion and evaluation, and making close connections between different parts of clinical practices, scientific research and clinical teaching, it helps achieve coordinated development of surgical practices and translational research, and will finally promote the cultivation of medical talents and the progress of medical technologies. Since 2010, the General Surgery Department of Nanfang Hospital has established the basic idea of subject construction of "research-oriented surgery with data as the core, minimally invasive surgery with laparoscopic as the characteristic, and specialized surgery with high-efficiency service as the guidance", and has taken a series of measures to build it into a well-known research-based gastrointestinal surgery in China. The achievements of this speciaty have emerged from nothing, research platforms from few to many, the talent echelon from following to leading, and the influence from regional to international. The discipline construction has achieved a leap from quantitative to qualitative changes.

[Training and cultivation of non-technical skills in gastrointestinal surgeons]

Non-technical skill (NTS) in gastrointestinal surgeon is an important part of surgical performance and surgical education. NTS is essential for safe and effective surgery. NTS has four aspects: situation awareness, decision making, communication and teamwork, and leadership. There is evidence that training and assessment of NTS of professional physicians is very important for doctors' career and plays an important role in improving medical quality and ensuring patient safety. The training and assessment of NTS is a great reference to the training of gastrointestinal surgeons in China. In addition, the establishment of a training system for professional gastrointestinal surgeons in line with China's characteristic as soon as possible will improve the overall quality of professional gastrointestinal surgeons in China and better serve the vast number of patients.

Management and Outcomes Following Surgery for Gastrointestinal Typhoid: An International, Prospective, Multicentre Cohort Study

BACKGROUND

Gastrointestinal perforation is the most serious complication of typhoid fever, with a high disease burden in low-income countries. Reliable, prospective, contemporary surgical outcome data are scarce in these settings. This study aimed to investigate surgical outcomes following surgery for intestinal typhoid.

METHODS

Two multicentre, international prospective cohort studies of consecutive patients undergoing surgery for gastrointestinal typhoid perforation were conducted. Outcomes were measured at 30 days and included mortality, surgical site infection, organ space infection and reintervention rate. Multilevel logistic regression models were used to adjust for clinically plausible explanatory variables. Effect estimates are expressed as odds ratios (ORs) alongside their corresponding 95% confidence intervals.

RESULTS

A total of 88 patients across the GlobalSurg 1 and GlobalSurg 2 studies were included, from 11 countries. Children comprised 38.6% (34/88) of included patients. Most patients (87/88) had intestinal perforation. The 30-day mortality rate was 9.1% (8/88), which was higher in children (14.7 vs. 5.6%). Surgical site infection was common, at 67.0% (59/88). Organ site infection was common, with 10.2% of patients affected. An ASA grade of III and above was a strong predictor of 30-day post-operative mortality, at the univariable level and following adjustment for explanatory variables (OR 15.82, 95% CI 1.53-163.57, p = 0.021).

CONCLUSIONS

With high mortality and complication rates, outcomes from surgery for intestinal typhoid remain poor. Future studies in this area should focus on sustainable interventions which can reduce perioperative morbidity. At a policy level, improving these outcomes will require both surgical and public health system advances.

Magnet foreign body ingestion: rare occurrence but big consequences

PURPOSE

To review the outcomes of magnet ingestions from two children's hospitals and develop a clinical management pathway.

METHODS

Children <18years old who ingested a magnet were reviewed from 1/2011 to 6/2016 from two tertiary center children's hospitals. Demographics, symptoms, management and outcomes were analyzed.

RESULTS

From 2011 to 2016, there were 89 magnet ingestions (50 from hospital 1 and 39 from hospital 2); 50 (56%) were males. Median age was 7.9 (4.0-12.0) years; 60 (67%) presented with multiple magnets or a magnet and a second metallic co-ingestion. Suspected locations found on imaging were: stomach (53%), small bowel (38%), colon (23%) and esophagus (3%). Only 35 patients (39%) presented with symptoms and the most common symptom was abdominal pain (33%). 42 (47%) patients underwent an intervention, in which 20 (23%) had an abdominal operation. For those undergoing abdominal surgery, an exact logistic regression model identified multiple magnets or a magnet and a second metallic object co-ingestion (OR 12.9; 95% CI, 2.4 - Infinity) and abdominal pain (OR 13.0; 95% CI, 3.2-67.8) as independent risk factors.

CONCLUSION

Magnets have a high risk of requiring surgical intervention for removal. Therefore, we developed a management algorithm for magnet ingestion.

LEVEL OF EVIDENCE

Level III.

Effect of Yikou-Sizi powder hot compress on gastrointestinal functional recovery in patients after abdominal surgery: Study protocol for a randomized controlled trial

BACKGROUND

Postoperative gastrointestinal dysfunction (PGD) is a common complication of patients who have undergone surgery. The clinical manifestations cause great discomfort to postoperative patients and can severely affect postoperative recovery. However, although various pharmacologic agents have been explored for several years, success has been limited. Because some commonly used drugs have caused adverse reactions and because abdominal surgery patients generally cannot consume food or medication during the perioperative period, we were prompted to try an external Chinese medicine treatment method. Yikou-Sizi powder hot compress is an efficient therapy in our hospital, but there is a lack of rigorous studies to certify the safety and effectiveness of its external use to improve gastrointestinal motility. This study aimed to introduce the clinical trial design and test the ability of Yikou-Sizi powder hot compress treatment to accelerate gastrointestinal functional recovery after abdominal surgery.

METHODS

This study is a randomized controlled clinical trial. The participants will undergo laparoscopic colorectal cancer surgery and laparoscopic total hysterectomy. The primary outcome measure will be the gastrointestinal functional evaluation index, including the time to first passage of flatus, first defecation, first normal bowel sounds, and first consumption of liquid/semigeneral diet foods. According to good clinical practice (GCP), we will evaluate the clinical efficacy and safety of Yikou-Sizi powder hot compress and objectively study the acting mechanism of ghrelin. This pilot trial will be a standard, scientific, and clinical study designed to evaluate the effect of Yikou-Sizi powder hot compress for the recovery of gastrointestinal function after surgery and determine its overall safety.

DISCUSSION

This is the first study to describe the use of Yikou-Sizi powder hot compress to accelerate the recovery of gastrointestinal function after abdominal surgery. The study is designed as a randomized, controlled, clinical, large sample size and pilot trial. Evaluation will consist of combining the primary outcome measures with secondary outcome measures to ensure the objectivity and scientific validity of the study. Due to the observational design and the limited follow-up period, it is not possible to evaluate to what extent the connection between the observed improvement and the interventions represents a causal relationship. Efficient comparison between groups will be analyzed by chi-square test.

[Current Situations and Prospects of Preoperative 3D Simulation in Gastrointestinal Surgery]

Recently, three-dimensional(3D)simulation in liver surgery has become common in Japan because it is covered by medical insurance. The benefits of 3D simulation for liver surgery, such as an enhanced understanding of tumor anatomy, estimation of liver volume and assessment of irrigation area, have been previously reported. However, in the conventional system, the reconstructed 3D liver model is fixed and rigid. In addition, we were not able to observe every moment of cutting or the intrahepatic vessels. Therefore, we have developed a novel real-time virtual hepatectomy simulation software program, Liversim, to present the real-time motion and deformation of the liver. Recently, the usefulness of 3D-printed organ models based on preoperative computed tomography(CT)for hepatectomy has been reported. We have developed a novel 3D-printed liver frame model for hepatectomy, which made the procedure easier, reduced the production cost, and improved the visibility. Recently, indocyanine green(ICG)has been used for surgical navigations because it emits fluorescence upon exposure to near-infrared illumination. In addition, research and development of real-time navigation surgery like car navigation is expected.

Body mass index and complications following major gastrointestinal surgery: a prospective, international cohort study and meta-analysis

AIM

Previous studies reported conflicting evidence on the effects of obesity on outcomes after gastrointestinal surgery. The aims of this study were to explore the relationship of obesity with major postoperative complications in an international cohort and to present a meta-analysis of all available prospective data.

METHODS

This prospective, multicentre study included adults undergoing both elective and emergency gastrointestinal resection, reversal of stoma or formation of stoma. The primary end-point was 30-day major complications (Clavien-Dindo Grades III-V). A systematic search was undertaken for studies assessing the relationship between obesity and major complications after gastrointestinal surgery. Individual patient meta-analysis was used to analyse pooled results.

RESULTS

This study included 2519 patients across 127 centres, of whom 560 (22.2%) were obese. Unadjusted major complication rates were lower in obese vs normal weight patients (13.0% vs 16.2%, respectively), but this did not reach statistical significance (P = 0.863) on multivariate analysis for patients having surgery for either malignant or benign conditions. Individual patient meta-analysis demonstrated that obese patients undergoing surgery for malignancy were at increased risk of major complications (OR 2.10, 95% CI 1.49-2.96, P < 0.001), whereas obese patients undergoing surgery for benign indications were at decreased risk (OR 0.59, 95% CI 0.46-0.75, P < 0.001) compared to normal weight patients.

CONCLUSIONS

In our international data, obesity was not found to be associated with major complications following gastrointestinal surgery. Meta-analysis of available prospective data made a novel finding of obesity being associated with different outcomes depending on whether patients were undergoing surgery for benign or malignant disease.

The Role of Noncontrast CT in the Evaluation of Surgical Abdomen Patients

Acute surgical abdomen is commonly encountered in the ED and CT is widely used as an informative diagnostic tool to evaluate potential surgical indications. However, the adverse effects of contrast material used in CT scanning have been documented. We sought to delineate the role of noncontrast CT in the evaluation of patients with acute surgical abdomen. Between August 2015 and December 2015, patients with nontraumatic surgical abdomen who underwent preoperative CT were enrolled in the current study. The patients for whom the CT results permitted surgical decision-making were the focus of this study. The disease entities included acute appendicitis, acute cholecystitis, hollow organ perforation, mechanical bowel obstruction, intra-abdominal abscess that could not be drained percutaneously, and ischemic bowel disease. The results of contrast-enhanced and noncontrast CT were compared and analyzed. The surgical conditions identifiable by noncontrast CT were recorded. In total, 227 patients were enrolled in the study. In 90.7 per cent of patients overall, the findings indicating the need for surgical treatment were visualized on both the noncontrast and contrast-enhanced images (acute appendicitis: 89.3%, acute cholecystitis: 89.7%, hollow organ perforation: 97.4%, bowel obstruction: 100%, intra-abdominal abscess: 100%, and ischemic bowel disease: 55.6%). Noncontrast CT provides benefit for critical decision-making. Body mass index may affect the accuracy of noncontrast imaging in the evaluation of patients with surgical abdomen. In some specific situations, contrast enhancement remains necessary.

A five year CT surveillance of ciliated retroperitoneal foregut cyst resembling a cystic pancreatic lesion: A case report

INTRODUCTION

Ciliated retroperitoneal foregut cysts are rare, and to obtain a preoperative definitive diagnosis of this condition is relatively difficult. In addition, the exact mechanism and formation of ciliated retroperitoneal foregut cysts remains unknown.

CASE PRESENTATION

Here, we report a case of a 47-year-old woman who presented with an unusual shaped cystic lesion associated with a patch of solid components between the pancreas and the left kidney, initially misdiagnosed as a cystic pancreatic lesion 5 years previously to presentation at our clinic. During the past years, reports relating to the surveillance of these lesions described that their shapes progressively change while its volumes remain invariably unchanged. We did not observe this phenomenon in any literatures to our knowledge. The patient was diagnosed with ciliated retroperitoneal foregut cyst with remote hemorrhage, after the laparoscopic surgery.

CONCLUSIONS

Ciliated retroperitoneal foregut cysts have characteristic manifestations. From this case, we summarized that cysts in the retroperitoneum, associated with a changing shape of the lesion, highly suggest the diagnosis of foregut cysts, which are safe under long-term surveillance.

Gastrointestinal complications after lung transplantation in Japanese patients

PURPOSE

Gastrointestinal complications after lung transplantation (LTx) are an important postoperative morbidity associated with malnutrition and the malabsorption of drugs. We reviewed our experience of managing gastrointestinal complications after LTx.

METHODS

Between June, 2008 and April, 2017, 160 lung transplants were performed at our institution, as living-donor lobar lung transplants in 77 patients, and as deceased-donor lung transplants in 83. We reviewed, retrospectively, the incidence, type and management of gastrointestinal complications.

RESULTS

Among the 160 LTx recipients, 58 (36.3%) suffered a collective 70 gastrointestinal complications, the most frequent being gastroparesis, followed by gastroesophageal reflux disease. Two complications were managed surgically, by Nissen fundoplication for gastroesophageal reflux disease in one recipient and Hartmann's operation for sigmoid colon perforation in one. The other 68 complications were managed medically. Two patients died of complications: one, of aspiration pneumonia caused by gastroparesis; and one, of panperitonitis caused by a gastric ulcer. There were no significant differences in overall survival or chronic lung allograft dysfunction-free survival between the patients with and those without gastrointestinal complications.

CONCLUSIONS

Gastrointestinal complications are not uncommon in LTx recipients and may be serious; therefore, early detection and appropriate treatment are imperative. Surgical management is required for some complications, but most can be managed medically.

Comparison of the use of fresh-frozen canine cadavers and a realistic composite ex vivo simulator for training in small animal flexible gastrointestinal endoscopy

OBJECTIVE To compare the usefulness of fresh-frozen canine cadavers (FFCCs) and a validated canine simulator model for training veterinary students in basic gastrointestinal endoscopic procedures. DESIGN Randomized trial. SAMPLE 48 veterinary students in their final year of training. PROCEDURES Students were randomly assigned to receive basic gastrointestinal endoscopic training on a canine simulator or FFCC. All students were trained as assigned in esophagogastroduodenoscopy, endoscopic gastric biopsy, and gastric foreign body removal for 2 h/d for 5 days. They then performed each procedure on a live dog, and procedure completion time and performance ability were compared between groups. Two experienced endoscopists used a validated Likert-type procedural rating scale to rate the students' performance. Students completed a survey to rate their training model. RESULTS No significant differences were identified between groups in quality of performance of the 3 endoscopic procedures on a live dog. Students required significantly less time to complete the procedures on a live dog when trained on an FFCC versus canine simulator. Although both training models were considered equally useful by students, training on the simulator was significantly more stimulating. CONCLUSIONS AND CLINICAL RELEVANCE Students showed the same skill level in performing basic endoscopic procedures on live dogs regardless of the training model used, although students who trained on the FFCC completed these procedures faster than students trained on the canine simulator. Use of the simulator appeared to be a viable alternative to use of FFCCs for veterinary endoscopic training, providing students with a good level of proficiency before performing endoscopic procedures on live dogs.

[Secondary osteoporosis. Bone metabolism disorder after gastrointestinal surgery.]

Bone metabolism disorder caused by surgery and diseases of the gastrointestinal tract has been reported formerly, however the awareness of these disorder is not high. Calcium is absorbed mainly from the duodenum to the upper jejunum, moreover gastric acid plays an important role in digestion and absorption of calcium. Therefore, it is easy to imagine that gastrectomy will cause bone metabolism disorder. Furthermore, bone metabolism disorder accompanies with inflammatory bowel disease is drawing attention in recent years. Bone metabolic disorder accompanying with gastrointestinal dysfunction is not rare, accordingly clinician needs to understand the pathological condition. In this report, we will outline bone metabolism disorder caused by gastrointestinal surgery and diseases.

Weekend admission and mortality for gastrointestinal disorders across England and Wales

BACKGROUND

Little has been reported on mortality following admissions at weekends for many gastrointestinal (GI) disorders. The aim was to establish whether GI disorders are susceptible to increased mortality following unscheduled admission on weekends compared with weekdays.

METHODS

Record linkage was undertaken of national administrative inpatient and mortality data for people in England and Wales who were hospitalized as an emergency for one of 19 major GI disorders.

RESULTS

The study included 2 254 701 people in England and 155 464 in Wales. For 11 general surgical and medical GI disorders there were little, or no, significant weekend effects on mortality at 30 days in either country. There were large consistent weekend effects in both countries for severe liver disease (England: 26·2 (95 per cent c.i. 21·1 to 31·6) per cent; Wales: 32·0 (12·4 to 55·1 per cent) and GI cancer (England: 21·8 (19·1 to 24·5) per cent; Wales: 25·0 (15·0 to 35·9) per cent), which were lower in patients managed by surgeons. Admission rates were lower at weekends than on weekdays, most strongly for severe liver disease (by 43·3 per cent in England and 51·4 per cent in Wales) and GI cancer (by 44·6 and 52·8 per cent respectively). Both mortality and the weekend mortality effect for GI cancer were lower for patients managed by surgeons.

DISCUSSION

There is little, or no, evidence of a weekend mortality effect for most major general surgical or medical GI disorders, but large weekend effects for GI cancer and severe liver disease. Lower admission rates at weekends indicate more severe cases. The findings for severe liver disease may suggest a lack of specialist hepatological resources. For cancers, reduced availability of end-of-life care in the community at weekends may be the cause.

Evaluation of the reasons for and outcomes of gastrointestinal tract surgery in pet pigs: 11 cases (2004-2015)

OBJECTIVE To evaluate the reasons for and outcomes of gastrointestinal tract surgery in pet pigs. DESIGN Retrospective case series. ANIMALS 11 pigs. PROCEDURES The medical record database of a teaching hospital was searched to identify pet pigs that underwent at least 1 celiotomy because of a possible gastrointestinal tract obstruction between 2004 and 2015. For each pig, information extracted from the medical record included history; signalment; clinical signs; physical examination, diagnostic imaging, and diagnostic test results; perioperative management; surgical diagnosis, duration, and procedures performed; postoperative complications; and outcome. Descriptive data were generated. RESULTS 11 pet pigs underwent 12 celiotomies during the study period. Five pigs with intestinal obstructions caused by foreign bodies survived to hospital discharge. Four pigs were euthanized during surgery: 2 because of extensive adhesions that prevented correction of an intestinal obstruction, 1 because of a perforated spiral colon, and 1 because of neoplasia. One pig with a fecal impaction in the spiral colon died during anesthetic recovery. A diagnosis was not achieved for 1 pig, which was euthanized after surgery because of a deteriorating clinical condition. For the pig that underwent 2 celiotomies, the first procedure was an enterotomy for removal of a foreign body, and the second was an intestinal bypass of a stricture caused by adhesions at the previous enterotomy site. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated prognosis was good for pet pigs following surgical removal of gastrointestinal foreign bodies; however, the presence or development of intra-abdominal adhesions appeared to adversely affect prognosis.

Advances in paediatric gastroenterology

Recent developments in paediatric gastrointestinal surgery have focused on minimally invasive surgery, the accumulation of high-quality clinical evidence, and scientific research. The benefits of minimally invasive surgery for common disorders like appendicitis and hypertrophic pyloric stenosis are all supported by good clinical evidence. Although minimally invasive surgery has been extended to neonatal surgery, it is difficult to establish its role for neonatal disorders such as oesophageal atresia and biliary atresia through clinical trials because of the rarity of these disorders. Advances in treatments for biliary atresia and necrotising enterocolitis have been achieved through specialisation, multidisciplinary management, and multicentre collaboration in research; similarly robust clinical evidence for other rare gastrointestinal disorders is needed. As more neonates with gastrointestinal diseases survive into adulthood, their long-term sequelae will also need evidence-based multidisciplinary care. Identifying cures for long-term problems of a complex developmental anomaly such as Hirschsprung's disease will rely on unravelling its pathogenesis through genetics and the development of stem-cell therapy.

Gastrointestinal disorders in Curry-Jones syndrome: Clinical and molecular insights from an affected newborn

Curry-Jones syndrome (CJS) is a pattern of malformation that includes craniosynostosis, pre-axial polysyndactyly, agenesis of the corpus callosum, cutaneous and gastrointestinal abnormalities. A recurrent, mosaic mutation of SMO (c.1234 C>T; p.Leu412Phe) causes CJS. This report describes the gastrointestinal and surgical findings in a baby with CJS who presented with abdominal obstruction and reviews the spectrum of gastrointestinal malformations in this rare disorder. A 41-week, 4,165 g, female presented with craniosynostosis, pre-axial polysyndactyly, and cutaneous findings consistent with a clinical diagnosis of CJS. The infant developed abdominal distension beginning on the second day of life. Surgical exploration revealed an intestinal malrotation for which she underwent a Ladd procedure. Multiple small nodules were found on the surface of the small and large bowel in addition to an apparent intestinal duplication that seemed to originate posterior to the pancreas. Histopathology of serosal nodules revealed bundles of smooth muscle with associated ganglion cells. Molecular analysis demonstrated the SMO c.1234 C>T mutation in varying amounts in affected skin (up to 35%) and intestinal hamartoma (26%). Gastrointestinal features including structural malformations, motility disorders, and upper GI bleeding are major causes of morbidity in CJS. Smooth muscle hamartomas are a recognized feature of children with CJS typically presenting with abdominal obstruction requiring surgical intervention. A somatic mutation in SMO likely accounts for the structural malformations and predisposition to form bowel hamartomas and myofibromas. The mutation burden in the involved tissues likely accounts for the variable manifestations.

Relation of Right Atrial Volume, Systemic Venous Dimensions, and Flow Patterns to Right Atrial Pressure in Infants and Children

Echocardiographic assessment of right atrial (RA) volume, inferior vena cava (IVC) diameter, and hepatic vein flow velocity independently correlate with the RA pressure by direct catheter measurement in adults. We prospectively collected invasive RA pressure measurements and echocardiographic data in infants and young children with the goal of developing a predictive model to noninvasively determine normal RA pressure. All subjects had a central venous catheter through which RA pressure could be transduced. Specific inclusion criteria consisted of (1) biventricular heart, (2) absence of inotropes, (3) sinus rhythm, and (4) at least 24 hours from surgery. Two-dimensional echocardiography (2DE)-Doppler and 3DE-Doppler were used to measure RA volume, systemic venous diameters, and flow velocity. Regression equations of RA pressure with RA volume, systemic venous size, and flow velocity were explored. Of 46 studies, 43 (93%) had echocardiograms adequate for analysis. RA pressure did not correlate with body surface area or age (p = 0.69, p = 0.87). The mean indexed RA volume by 3DE-Doppler was significantly higher than by 2DE (p <0.005). On multivariable analysis, only IVC systolic flow velocity and systolic 2D Simpson's derived indexed RA volume demonstrated significant independent correlation with RA pressure, resulting in the equation: RA pressure (mm Hg) = 7.35 - 0.0025 × IVC systolic flow velocity (cm/s) + 0.119 × indexed RA volume by systolic 2D Simpson's (ml/m²). RA pressure did not show correlation with systemic venous diameters or systolic and diastolic flow velocities in the SVC and hepatic veins. In conclusion, regression incorporating 2DE-derived RA volume and IVC systolic flow velocity provided the best noninvasive estimate of normal RA pressure in infants and children. The model derived requires validation in an independent sample.

[Clinical efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter in the treatment of puborectalis syndrome with high anal pressure]

OBJECTIVE

To explore the efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter(IAS) in the treatment of puborectalis syndrome with high anal pressure.

METHODS

Twenty-five cases of puborectalis syndrome with high anal resting pressure in the preoperative examination received the operation of partial resection of puborectalis combined with mutilation of IAS in Zhongnan Hospital of Wuhan University between January 2013 and May 2015. The position of puborectalis was confirmed by touching with the exposure under the transfixion device, and a transverse incision was made by electrotome between 3 and 5 o'clock direction of puborectalis, then partial puborectalis was lifted by vessel clamp at 5 o'clock direction, and about 0.5 cm of muscular tissue was resected. Between 8 to 10 o'clock direction of anal tube, about 1 cm length of transverse incision was made by electrotome, then partial IAS was lifted by vessel clamp and cut off. Preoperative and postoperative 3-month anorectal manometry and defecography were carried out. Wexner constipation score and Cleveland Clinic incontinence score were implemented before surgery and 3, 6, 12 months after operation. This study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-ORB-16007695).

RESULTS

Of the 25 cases, 18 were male and 7 were female, the average age was 55 years old and the average course of disease was 9 years. Compared with pre-operation, the postoperative 3-month anal resting pressure and maximal squeeze pressure were significantly decreased [(53.56±9.05) mmHg vs. (92.44±7.06) mmHg, (142.80±20.35) mmHg vs. (210.88±20.56) mmHg, respectively, both P=0.000]; anorectal angulation at resting state and forced defecation state increased significantly [(102.32±4.96)degree vs. (95.88±4.01)degree, (117.88±5.95)degree vs. (89.52±3.25)degree, respectively, both P=0.000]. Wexner constipation score of postoperative 3-month, 6-month, 12-month (8.28±3.91, 7.40±3.64 and 8.04±4.74) was significantly lower than the preoperative score (16.00±3.69, all P<0.05), while the score was not significantly different among 3 time points after operation (P>0.05). Cleveland Clinic incontinence score was 0 at postoperative 6 and 12 months, and revealed 20 cases were effective among all the surgical patients(80%).

CONCLUSION

Partial resection of puborectalis combined with mutilation of internal anal sphincter can effectively reduce anal pressure and improve symptoms of outlet obstruction, which is an effective method in the treatment of puborectalis syndrome with high anal pressure.

Quality of life of patients on chronic parenteral nutrition before and after gastrointestinal tract continuity restoration

The issue of the quality of life considering patients with a temporary or permanent intestinal stoma, as well as the necessity for chronic parenteral nutrition at home remain a poorly understood problem. Daily care of the intestinal stoma and the need to comply with sterile procedures required for parenteral nutrition require such patients to commit their time, which secondarily is associated with the broad aspects of social and personal life. The aim of the study was to analyse the quality of life considering patients with intestinal stomas subjected to chronic parenteral nutrition, before and after gastrointestinal tract continuity restoration.

MATERIAL AND METHODS

The survey was conducted between May and July, 2014 on a group of 71 patients (33 female and 38 male) who were under the care of the Department of General Surgery and Clinical Nutrition, Warsaw Medical University, operated during the period between 2007 and July, 2014 with a present stoma (32 patients - 45%), as well as after stoma closure (39 patients - 55%). The analysed questionnaire contained 31 questions, and the SF-36 questionnaire was additionally used, determining the quality of life.

RESULTS

Analysis of the study material showed differences in the quality of life, considering three most important determinants. Significantly worse assessment of the quality of life was reported by patients with a stoma and subject to intravenous nutrition (83.2±30.5), as compared to those after stoma closure subject to normal nutrition (52.3±33.8). Based on the SF-36 questionnaire differences between patients with a stoma and those without amounted to t(69)=2.84 (p=0.006) demonstrating that those with a stoma reported a lower quality of life. Analysis between younger and older patients, based on the SF-36 questionnaire (t(62.87)=2.49; p=0.016) showed that younger patients achieved lower results, considering dissatisfaction with life (61.55±27.5), as compared to the elderly (80.8±36.9).

CONCLUSIONS

The group of patients without a stoma seem to be more independent- the vast majority do not use the help of family members (43.6%), or friends (64.1%). Patients with a stoma more often withdraw from social life. The factor that mostly reduces the quality of life is the presence of a stoma, which impairs daily functioning a lot more than the sterile procedures associated with parenteral nutrition. All patients after stoma closure consider that their overall functioning has significantly improved.

[RESULTS OF TREATMENT IN PATIENTS, SUFFERING STENOSIS OF CAROTID ARTERIES IN COMBINATION WITH DISEASES OF OTHER SYSTEMS]

Results of treatment in 2010 - 2015 yrs of 187 patients, suffering haemodynamically significant stenosis of carotid arteries, on background of upcoming surgical treatment of the lower extremities tissues chronic ischemia, an ischemic heart disease or diseases of digestive system, were analyzed. In generalized atherosclerosis and an acute disorder of the brain blood circulation in anamnesis it is necessary to conduct the carotid arteries affection screening. In haemodynamically significant stenosis of carotid arteries in patients, suffering an ischemic heart disease and the digestive system diseases, as a first stage a carotid endarterectomy was performed for reduction of the occurrence risk for ischemic insult after operation performed for the main disease.

Mesenchymal stromal cell-based therapy: Regulatory and translational aspects in gastroenterology

The past decade has witnessed an outstanding scientific production focused towards the possible clinical applications of mesenchymal stromal cells (MSCs) in autoimmune and chronic inflammatory diseases. This raised the need of novel standards to adequately address quality, efficacy and safety issues of this advanced therapy. The development of a streamlined regulation is currently hampered by the complexity of analyzing dynamic biological entities rather than chemicals. Although numerous pieces of evidence show efficacy in reducing intestinal inflammation, some inconsistencies between the mechanisms of action of rodent vs human MSCs suggest caution before assigning translational value to preclinical studies. Preliminary evidence from clinical trials showed efficacy of MSCs in the treatment of fistulizing Crohn’s disease (CD), and preparations of heterologous MSCs for CD treatment are currently tested in ongoing clinical trials. However, safety issues, especially in long-term treatment, still require solid clinical data. In this regard, standardized guidelines for appropriate dosing and methods of infusion could enhance the likelihood to predict more accurately the number of responders and the duration of remission periods. In addition, elucidating MSC mechanisms of action could lead to novel and more reliable formulations such as those derived from the MSCs themselves (e.g., supernatants).