Effects of early postoperative mobilization following gastrointestinal surgery: systematic review and meta-analysis

BACKGROUND

Early postoperative mobilization is considered a key element of enhanced recovery after surgery protocols. The aim of this study was to summarize the effect of early postoperative mobilization following gastrointestinal operations on patient recovery, mobility, the morbidity rate and duration of hospital stay.

METHODS

A systematic literature search was conducted in December, 2022, using PubMed, Web of Science and the Cochrane Central Register of Controlled Trials. Controlled trials reporting the effects of early postoperative mobilization after gastrointestinal surgery were included. The risk of bias was assessed using a modified Downs and Black tool and the Cochrane Collaboration tool for randomized trials. The outcomes of interest were gastrointestinal recovery (defined passage of first flatus or bowel movements), mobility (step count on postoperative day 3), the morbidity rate and duration of hospital stay.

RESULTS

After elimination of duplicates, 3678 records were identified, and 71 full-text articles were screened. Finally, 15 studies (eight RCTs) reporting on 3538 patients were included. Most trials evaluated early postoperative mobilization after different gastrointestinal operations, including upper gastrointestinal (n = 8 studies), hepatopancreatobiliary (n = 10 studies) and colorectal resections (n = 10 studies). The investigated early postoperative mobilization protocols, operative techniques (minimally invasive or open) and outcome parameters were heterogeneous between the studies. Early postoperative mobilization seemed to significantly accelerate clinical gastrointestinal recovery (mean difference, hours: -11.53 (-22.08, -0.97), P = 0.03). However, early postoperative mobilization did not significantly improve the morbidity rate (risk ratio: 0.93 (0.70, 1.23), P = 0.59), postoperative mobility of patients (step count mean difference: 1009 (-803, 2821), P = 0.28) or shorten the duration of hospital stay (mean difference, days: -0.25 (-0.99,0.43), P = 0.47) in randomized trials.

CONCLUSION

There is a large heterogeneity among the study cohorts, operations and interventions. The available evidence currently does not support specific early postoperative mobilization protocols as an isolated element to further reduce the morbidity rate and duration of hospital stay. Further well-designed trials are required to identify effective early postoperative mobilization protocols.

Neoadjuvant concurrent chemoradiotherapy with and without hyperthermia in retroperitoneal sarcomas: feasibility, efficacy, toxicity, and long-term outcome

Purpose

Retroperitoneal (RPS) sarcomas are associated with poor local and abdominal tumor control. However, the benefit of preoperative radio- or chemotherapy alone for these entities is currently unclear. Moreover, as intermediate- and high-grade sarcomas have a tendency toward early metastasis, exploration of neoadjuvant strategies is of high importance. This analysis reports the results of our 20-year single-institution experience with preoperative neoadjuvant concurrent chemoradiation.

Methods

From 2000–2019, 27 patients with intermediate- or high-grade RPS (12 dedifferentiated liposarcoma, 10 leiomyosarcoma, 5 others) were treated with radiotherapy (median dose: 50.4 Gy; range 45–75 Gy) and two cycles of chemotherapy (doxorubicin 50 mg/m² BSA/d3 q28 and ifosfamide 1.5 g/m² BSA/d1‑5 q28) in neoadjuvant intent. Chemotherapy consisted of doxorubicin alone in two cases and ifosfamide alone in one case. Fifteen patients (56%) additionally received deep regional hyperthermia.

Results

The median follow-up time was 53 months (±56.7 months). 92% of patients received two cycles of chemotherapy as planned and 92% underwent surgery. At 5 and 10 years, abdominal-recurrence-free survival was 74.6% (±10.1%) and 66.3% (±11.9%), distant metastasis-free survival was 67.2% (±9.7%) and 59.7% (±11.1%), and overall survival was 60.3% (±10.5%) and 60.3% (±10.5%), respectively. CTC grade III and IV toxicities were leukocytopenia (85%), thrombocytopenia (33%), and anemia (11%). There were no treatment-related deaths.

Conclusion

Neoadjuvant chemoradiotherapy with and without hyperthermia for retroperitoneal sarcomas is feasible and provided high local control of intermediate- and high-grade sarcoma.

Disease duration before surgical resection for chronic pancreatitis impacts long-term outcome

Many patients with chronic pancreatitis (CP) undergo a step-up approach with interventional procedures as first-line treatment and resection reserved for later stages. The aim of this study was to identify predictive factors for a significant clinical improvement (SCI) after surgical treatment.All patients operated for CP between September 2012 and June 2017 at our center was retrospectively reviewed. A prospective patient survey was conducted to measure patients postoperative outcome. The primary endpoint SCI was defined as stable health status, positive weight development and complete pain relief without routine pain medication. Additionally, risk factors for relaparotomy were analyzed.A total of 89 patients with a median follow-up of 38 months were included. In most cases, a duodenum-preserving pancreatic head resection (n = 48) or pancreatoduodenectomy (n = 28) was performed. SCI was achieved in 65.3% (n = 47) of the patients after the final medium follow-up of 15.0 months (IQR: 7.0-35.0 months), respectively. Patients with a longer mean delay (7.7 vs 4 years) between diagnosis and surgical resection were less likely to achieve SCI (P = .02; OR .88; 95%CI .80-98). An endocrine insufficiency was a negative prognostic factor for SCI (P = .01; OR .15; 95%CI .04-68). In total, 96.2% of the patients had a complete or major postoperative relief with a mean pain intensity reduction from 8.1 to 1.9 on the visual analogue scale.The results support that surgical resection for CP should be considered at early stages. Resection can effectively reduce postoperative pain intensity and improve long-term success.

New design of a multi-jet target for quasi phase matching

An improved dual-gas quasi-phase matching (QPM) foil target for high harmonic generation (HHG) is presented. The target can be setup with 12 individual gas inlets each feeding multiple nozzles separated by a minimum distance of 10 μm. Three-dimensional gas density profiles of these jets were measured using a Mach-Zehnder Interferometer. These measurements reveal how the jets influence the density of gas in adjacent jets and how this leads to increased local gas densities. The analysis shows that the gas profiles of the jets are well defined up to a distance of about 300 μm from the orifice. This target design offers experimental flexibility, not only for HHG/QPM investigations, but also for a wide range of experiments due to the large number of possible jet configurations. We demonstrate the application to controlled phase tuning in the extreme ultraviolet using a 1 kHz-10 mJ-30 fs-laser system where interference between two jets in the spectral range from 17 to 30 nm was observed.

Coherent spectral enhancement of carrier-envelope-phase stable continua with dual-gas high harmonic generation

Attosecond science is enabled by the ability to convert femtosecond near-infrared laser light into coherent harmonics in the extreme ultraviolet spectral range. While attosecond sources have been utilized in experiments that have not demanded high intensities, substantially higher photon flux would provide a natural link to the next significant experimental breakthrough. Numerical simulations of dual-gas high harmonic generation indicate that the output in the cutoff spectral region can be selectively enhanced without disturbing the single-atom gating mechanism. Here, we summarize the results of these simulations and present first experimental findings to support these predictions.

Pulsed operation of a high average power Yb:YAG thin-disk multipass amplifier

An Yb:YAG thin-disk multipass laser amplifier system was developed operating in a 10 Hz burst operation mode with 800 µs burst duration and 100 kHz intra-burst repetition rate. Methods for the suppression of parasitic amplified spontaneous emission are presented. The average output pulse energy is up to 44.5 mJ and 820 fs compressed pulse duration. The average power of 4.45 kW during the burst is the highest reported for this type of amplifier.

Coherent control of high harmonic generation via dual-gas multijet arrays

High harmonic generation (HHG) is a central driver of the rapidly growing field of ultrafast science. We present a novel quasiphase-matching (QPM) concept with a dual-gas multijet target leading, for the first time, to remarkable phase control between multiple HHG sources (>2) within the Rayleigh range. The alternating jet structure with driving and matching zones shows perfect coherent buildup for up to six QPM periods. Although not in the focus of the proof-of-principle studies presented here, we achieved competitive conversion efficiencies already in this early stage of development.

Yb:YAG Innoslab amplifier: efficient high repetition rate subpicosecond pumping system for optical parametric chirped pulse amplification

We report on a Yb:YAG Innoslab laser amplifier system for generation of subpicsecond high energy pump pulses for optical parametric chirped pulse amplification (OPCPA) at high repetition rates. Pulse energies of up to 20 mJ (at 12.5 kHz) and repetition rates of up to 100 kHz were attained with pulse durations of 830 fs and average power in excess of 200 W. We further investigate the possibility to use subpicosecond pulses to derive a stable continuum in a YAG crystal for OPCPA seeding.

High harmonic generation by novel fiber amplifier based sources

Significant progress in high repetition rate ultrashort pulse sources based on fiber technology is presented. These systems enable operation at a high repetition rate of up to 500 kHz and high average power in the extreme ultraviolet wavelength range via high harmonic generation in a gas jet. High average power few-cycle pulses of a fiber amplifier pumped optical parametric chirped pulse amplifier are used to produce µW level average power for the strongest harmonic at 42.9 nm at a repetition rate of 96 kHz.

High average and peak power few-cycle laser pulses delivered by fiber pumped OPCPA system

We report on a high power optical parametric amplifier delivering 8 fs pulses with 6 GW peak power. The system is pumped by a fiber amplifier and operated at 96 kHz repetition rate. The average output power is as high as 6.7 W, which is the highest average power few-cycle pulse laser reported so far. When stabilizing the seed oscillator, the system delivered carrier-envelop phase stable laser pulses. Furthermore, high harmonic generation up to the 33(th) order (21.8 nm) is demonstrated in a Krypton gas jet. In addition, the scalability of the presented laser system is discussed.

Fiber-amplifier pumped high average power few-cycle pulse non-collinear OPCPA

We report on the performance of a 60 kHz repetition rate sub-10 fs, optical parametric chirped pulse amplifier system with 2 W average power and 3 GW peak power. This is to our knowledge the highest average power sub-10 fs kHz-amplifier system reported to date. The amplifier is conceived for applications at free electron laser facilities and is designed such to be scalable in energy and repetition rate.

Treatment of Postcraniotomy Tension Pneumocephalus via Endoscopic Closure of the Nasofrontal Recess

Tension pneumocephalus can be a life-threatening complication following cranial surgery. We report a 14-year-old female who developed tension pneumocephalus following her most recent external approach to a recurrent pilocytic astrocytoma of the skull base and clivus. Because the risk of devascularization of the recently placed bone grafts was a concern, an endoscopic approach was chosen instead of a cramotomy. Endoseopic decompression was accomplished by opening the anterior ethmoid and frontal recess air cells after performing an uncinectomy. The nasofrontal recess areas were then packed from below with grafts of muscle and fascia lata. Follow-up magnetic resonance imaging (MRI) at three and eight months showed complete resolution of the intracranial air. At two-year follow-up, the patient is still asymptomatic. This case report presents treatment of tension pneumocephalus through endoscopic decompression and closure of the nasofrontal recess as a viable option if significant risks are associated with craniotomy and the status of the mucosa of the nasal frontal recess is known.

Tracheal stenosis and congenital heart disease in patients with Down syndrome: diagnostic approach and surgical options

Upper airway obstruction is a prevalent feature in patients with Down syndrome. However, these patients may be completely asymptomatic in the early months of life. The recognition of a problem within the airway quite often occurs when these children present for cardiac surgery, diagnostic radiography with sedation, or during the induction and intubation for anesthesia. Tracheal stenosis is rare in the general population, but is seen somewhat more frequently in patients with Down syndrome. The incidence of tracheal stenosis in children with congenital heart disease, which is seen in 40% of patients with Down syndrome, has been reported to be 1.2%. Patients with Down syndrome also tend to have other upper airway obstructive pathology such as nasopharyngeal, oropharyngeal, and subglottic compromise. These entities, combined with the high incidence of cardiac disease, put these children at risk for acute and chronic cardiopulmonary compromise. We present two patients with Down syndrome and congenital heart disease who were found to have significant tracheal stenosis at the time of their cardiac surgery. The perioperative management of their airway defects including diagnostic evaluation and treatment modalities are discussed.

Extraluminal laryngotracheal fixation with absorbable miniplates

OBJECTIVE

To determine if miniplates made of polydioxanone can be used successfully for extraluminal laryngotracheal fixation.

DESIGN

Twelve rabbits underwent anterior and posterior laryngotracheofissure with extraluminal fixation of the divided segments with polydioxanone miniplates. Three control animals did not undergo plating. Animals were killed after 2, 4, and 12 weeks. Larynges were removed and examined to determine the intraluminal area and histologic status of the repair site.

RESULTS

The intraluminal area of the animals in the experimental group was 1.6 times that of those in the control group. The trachea was relined with respiratory mucosa by 2 weeks. Little inflammatory reaction was evident. Plate resorption was almost complete at 12 weeks.

CONCLUSION

Polydioxanone plating is a feasible and well-tolerated method of extraluminal laryngotracheal fixation. It may be useful in the treatment of grade 2 or 3 subglottic stenosis.

Rib-muscle pedicle flap for the repair of congenital tracheal stenosis

Congenital tracheal stenosis (CTS) is an uncommon congenital anomaly that presents early in life with symptoms of biphasic stridor. Most cases require surgical correction. Techniques have included dilation, resection of the involved segment, and tracheoplasty. Today pericardium and costal cartilage are the most frequently used materials for tracheoplasty, but patients still often encounter problems with the graft, with the procedure, or with late complications. This preliminary study was undertaken to determine the feasibility of a rib-intercostal muscle pedicle flap for the treatment of CTS. Tracheoplasties were performed on seven 3.5- to 5.5-kg piglets with a pedicled segment of the right fourth rib via a lateral thoracotomy incision. The method was found to be technically feasible, and pedicles of greater than 2.5 cm were easily developed. The repair provided good structural support and an airtight seal at high ventilator pressures. Histologic examination after 2 weeks showed the flap to be incorporating into the native trachea and to be without degenerative changes. This "vital" composite flap has several real and theoretic advantages over current methods of repair and may prove to be valuable in the treatment of CTS. The clinical application of this myo-osseous pedicle graft in the treatment of patients with stenoses not amenable to surgical resection and primary anastomosis should be explored.

Reconstruction of the pediatric airway with an open stented tracheotomy tube

Reconstructive techniques for the stenotic pediatric airway have greatly enhanced the otolaryngologists ability to decannulate the tracheotomy-dependent child. Stents have played an important role in this process by both maintaining the reconstructed lumen and acting as a scaffold. However, decannulation is often not achieved after the first surgical intervention with some patients requiring two, three or more procedures. In an effort to improve upon the design of today's stents, an open stented tracheotomy tube was evaluated at our institution. This stent is designed to provide advantages of immediate postoperative voice and nutrition, and ease of evaluation, as well as to provide for safe and adequate healing. Four patients underwent laryngotracheal reconstruction with this stent over a 10-month period. All patients could vocalize and eat immediately postoperatively but recalcitrant granulation tissue and restenosis has prevented decannulation in three of the cases. The experience with this stent exemplifies the persistent difficulties of stent use in pediatric airway reconstruction. It also points out that progress is still needed in current reconstructive techniques as well as in the development of new techniques.

Auricular injury as a presentation of child abuse

Child abuse causes serious physical and emotional injury. Those abused, however, are usually unable or unwilling to gain access to agencies that might help them. The otolaryngologist, while usually not the patient's primary physician, may be in the position to detect child abuse. We describe a 3-year-old boy who sustained auricular trauma as the result of child abuse. The importance of physician recognition of an abuse case and the institution of appropriate measures are discussed.

An enteric duplication cyst occurring in the anterior two-thirds of the tongue

Enteric duplication cysts are cysts that are attached to the alimentary tract and that are lined by some type of gastrointestinal mucosa. Such cysts are especially rare when found in the oral cavity. We report the case of an 8-month-old female with an unusual duplication cyst in the anterior two-thirds of the tongue. Eighteen cases of intraoral cysts have been previously reported in the literature, this one being the 7th case of a true duplication cyst of the anterior two-thirds of the tongue which contains gastric mucosa. The case presents many aspects of the diagnosis and management of this unusual lesion. The literature and present etiological theories are discussed.

An electronic device for rehabilitation of senile dementia patients

Senile dementia patients are usually considered hopeless--incapable of learning or improving. There is hope for improvement in such patients, however, and certain techniques effective in enhancing alertness in other brain-damaged patients can be helpful to these patients. A simple, widely available electronic television game is used, and a special training technique was designed to teach the patients how to successfully play the game. The fascinating attraction of this game engages the patient's attention, and success in playing the game promotes alertness. The training method encourages the patient to succeed at the game and thereby enhances his interest in his surroundings and his competence and self-esteem.