Bowel Reconstruction Research Articles

Reasons for reduced reproduction after colectomy in women with ulcerative colitis

Objectives Colectomy and subsequent bowel reconstruction in women with ulcerative colitis (UC) is associated with decreased fertility, this survey aims to investigate possible reasons for this. Material and methods Women with UC aged 18–44 years at colectomy 2000–2020 were identified and data were retrieved from the Swedish inflammatory bowel disease register (SWIBREG). Additional information was obtained using a study-specific questionnaire. Results The survey was completed by 214 (72.8%) out of 294 eligible women. Mean age at disease onset was 22.9 years (standard deviation 0.5). No reconstruction was made in 67 (31.3%) women, whereof 24 (35.8%) had a completion proctectomy. Reconstruction was performed with ileorectal anastomosis (IRA) in 66 (30.8%) women and ileal pouch anal anastomosis (IPAA) in 81 (37.9%). Included women had on average 1.67 children (95% confidence interval 1.53–1.81) at the end of follow-up. The desire to have children was negatively affected by disease onset (59.4%), colectomy (44.9%) and reconstruction (36.7%). Altogether, 39.4% estimated that they had fewer children and 9.5% restrained completely from having children because of the disease. Difficulties to conceive were reported by 36.5% including 18.9% who expressed that they could not conceive at all. Difficulties to conceive was more common after reconstruction with IPAA (Odds Ratio [OR] 5.54) than IRA (OR 2.57). Conclusions A majority of women with UC and colectomy expressed that the disease affected their desire to have children, more often limiting the number of children than completely refraining. For childless patients, difficulties to conceive was more common than voluntary childlessness.

Reconstruction Techniques and Associated Morbidity in Minimally Invasive Gastrectomy for Cancer: Insights From the GastroBenchmark and GASTRODATA databases.

Various anastomotic and reconstruction techniques are used for minimally invasive total (miTG) and distal gastrectomy (miDG). Their effects on postoperative morbidity have not been extensively studied. MiTG and miDG patients were selected from 9356 oncological gastrectomies performed in 2017-2021 in 43 centers. Endpoints included anastomotic leakage (AL) rate and postoperative morbidity tested by multivariable analysis. Three major anastomotic techniques [circular stapled (CS); linear stapled (LS); and hand sewn (HS)], and 3 major bowel reconstruction types [Roux (RX); Billroth I (BI); Billroth II (BII)] were identified in miTG (n=878) and miDG (n=3334). Postoperative complications, including AL (5.2% vs 1.1%), overall (28.7% vs 16.3%), and major morbidity (15.7% vs 8.2%), as well as 90-day mortality (1.6% vs 0.5%) were higher after miTG compared with miDG. After miTG, the AL rate was higher after CS (4.3%) and HS (7.9%) compared with LS (3.4%). Similarly, major complications (LS: 9.7%, CS: 16.2%, and HS: 12.7%) were lowest after LS. Multivariate analysis confirmed anastomotic technique as a predictive factor for AL, overall, and major complications. In miDG, AL rate (BI: 1.4%, BII 0.8%, and RX 1.2%), overall (BI: 14.5%, BII: 15.0%, and RX: 18.7%), and major morbidity (BI: 7.9%, BII: 9.1%, and RX: 7.2%), and mortality (BI: 0%, BII: 0.1%, and RY: 1.1%%) were not affected by bowel reconstruction. In oncologically suitable situations, miDG should be preferred to miTG, as postoperative morbidity is significantly lower. LS should be a preferred anastomotic technique for miTG in Western Centers. Conversely, bowel reconstruction in DG may be chosen according to the surgeon's preference.

Reduced preoperative serum choline esterase levels and fecal peritoneal contamination as potential predictors for the leakage of intestinal sutures after source control in secondary peritonitis

BackgroundThe high rate of stoma placement during emergency laparotomy for secondary peritonitis is a paradigm in need of change in the current fast-track surgical setting. Despite growing evidence for the feasibility of primary bowel reconstruction in a peritonitic environment, little data substantiate a surgeons’ choice between a stoma and an anastomosis. The aim of this retrospective analysis is to identify pre- and intraoperative parameters that predict the leakage risk for enteric sutures placed during source control surgery (SCS) for secondary peritonitis.MethodsBetween January 2014 and December 2020, 497 patients underwent SCS for secondary peritonitis, of whom 187 received a primary reconstruction of the lower gastro-intestinal tract without a diverting stoma. In 47 (25.1%) patients postoperative leakage of the enteric sutures was directly confirmed during revision surgery or by computed tomography. Quantifiable predictors of intestinal suture outcome were detected by multivariate analysis.ResultsLength of intensive care, in-hospital mortality and failure of release to the initial home environment were significantly higher in patients with enteric suture leakage following SCS compared to patients with intact anastomoses (p < 0.0001, p = 0.0026 and p =0.0009, respectively). Reduced serum choline esterase (sCHE) levels and a high extent of peritonitis were identified as independent risk factors for insufficiency of enteric sutures placed during emergency laparotomy.ConclusionsA preoperative sCHE < 4.5 kU/L and generalized fecal peritonitis associate with a significantly higher incidence of enteric suture insufficiency after primary reconstruction of the lower gastro-intestinal tract in a peritonitic abdomen. These parameters may guide surgeons when choosing the optimal surgical procedure in the emergency setting.

Reconstruction Techniques and Associated Morbidity after Minimally Invasive Gastrectomy for Cancer – Insights from the GastroBenchmark and GASTRODATA databases

Abstract Background Various anastomotic and reconstruction techniques are used to restore intestinal continuity after minimally invasive total (TG) and subtotal distal gastrectomy (DG). Aims Their effects on anastomotic leakage and postoperative morbidity have not been extensively studied. Methods Patients after minimally invasive TG and DG were selected from a cohort of 9356 oncological gastrectomies performed between 2017-2021 in 44 specialized centers. Results Three anastomotic techniques (circular stapled (CS, 3.7%); linear stapled (LS, 93.8%); hand sewn (HS, 2.5%)) and three types of bowel reconstruction (Roux (RX, 51.5%); Billroth I (BI, 23.1%); Billroth II (BII, 25.4%)) were identified after TG (n=878) and DG (n=3334). Postoperative morbidity was higher after TG compared to DG (AL 5.2% vs. 1.1%, p≤0.001; 90-day mortality 1.6% vs. 0.4%, p≤0.001; overall morbidity 28.6% vs. 16.3%, p≤0.001; major morbidity 15.4% vs. 8.0%, p≤0.001). Anastomotic leakage rate in the TG cohort was higher after CS (13.1%) and HS (7.9%) than after LS anastomoses (1.9%, p&amp;lt;0.001). Similarly, overall (CS: 43.9%, HS: 28.6%, LS: 23.1%) and major complications rates (CS: 25.2%, HS: 11.1%, LS: 12.0%) as well as mortality (CS: 4.7%, HS: 2.2%, LS: 0.8%) were higher after CS. Multivariate analysis confirmed anastomotic technique as a predictive factor for anastomotic leakage (Fig. 1), but not for occurrence of mortality, overall and major complications. In the DG cohort, most (98.7%), outcomes were similar for all types of bowel reconstruction: Anastomotic leakage (BI: 1.4%, BII 0.8%, RX 1.2%, p=0.440), 90-day mortality (BI: 0%, BII 0.1%, RY: 1.1%%, p=0.109), overall (BI: 14.5%, BII: 15.0%, RX: 18.7%, p=0.208) and major morbidity (BI: 7.9%, BII: 9.1%, RX: 7.2%, p=0.219). Conclusion In suitable situations, DG should be preferred to TG, as postoperative morbidity is significantly lower. In addition, LS should be the preferred method of anastomosis after TG. Conversely, the techniques for bowel reconstruction can be chosen according to the surgeon's preference.

Detection of residual stones by peroral direct cholangioscopy in patients with intrahepatic stones after hepaticojejunostomy: a prospective study (with video)

Background and AimsThe difficulty of radiographic confirmation of the presence of stones remains a challenge in the treatment of intrahepatic bile duct (IHBD) stones in patients after hepaticojejunostomy (HJ). Peroral direct cholangioscopy (PDCS) enables direct observation of the bile duct and is useful for detecting and removing residual stones; however, its effectiveness is not clearly established in this clinical context. MethodsThis single-center, single-arm, prospective study included 44 patients with IHBD who underwent bowel reconstruction with HJ during the study period. Stone removal was performed by short-type double-balloon enteroscopy (DBE). Following balloon-occluded cholangiography, the DBE was exchanged for an ultraslim endoscope through the balloon overtube for PDCS. The primary endpoint was the rate of residual stones detected by PDCS. Secondary endpoints were success rate of PDCS, residual stone removal with PDCS, procedure time for PDCS, procedure-related adverse events, and stone recurrence rate. ResultsPDCS was successful in 39/44 patients (89%), among whom residual stones were detected in 16 (41%) (95% CI: 28%–54%). Twelve patients (75%) had residual stones <5 mm. Stone removal was successful in 15 (94%) patients and median procedure time for PDCS was 16 (IQR: 10–26) min. The rate of procedure-related adverse events was 7% (3/44), all of which improved with conservative treatment. During median follow-up of 2.1 years (IQR: 1.4–3.3), the overall probability of recurrence-free status at 1, 2, and 3 years was 100%, 92%, and 86%, respectively. ConclusionsPDCS is a safe and effective procedure for complete stone removal in patients with IHBD stones after HJ.

Transverse Coloplasty Pouch versus Straight Coloanal Anastomosis Following Intersphincteric Resection for Low Rectal Cancer: the Functional Benefits May Emerge After Two Years

PurposeThis study aimed to compare the oncological and functional outcomes following intersphincteric resection (ISR) with transverse coloplasty pouch (TCP) or straight coloanal anastomosis (SCAA) for low rectal cancer. MethodsA single-center retrospective analysis was performed on patients with low rectal cancer who received ISR between January 2016 and June 2021. The primary endpoint was to compare the outcomes of bowel function within 1 year, 1 to 2 years, and 2 years after ileostomy closure in patients undergoing two different bowel reconstruction procedures (TCP or SCAA). The postoperative complications and oncological results were also compared between the two groups. ResultsA total of 235 patients were enrolled in this study (SCAA group: 166; TCP group: 69). There was no significant difference in complications, including grades A–C anastomotic leakage (9.6% vs 15.9%), 3-year local recurrence rates (6.1% vs 3.9%), disease-free survival (82.4%vs 83.8%), or overall survival (94.1% vs 94.7%) between the two groups. Two years after ileostomy closure, 52.7% of patients in the SCAA group were assessed as having major low anterior resection syndrome (LARS), which was significantly higher than the 25.9% of patients in the TCP group (P = 0.014), but no difference was found prior to 2 years. Similar differences were seen in Wexner scores 2 years after surgery (P = 0.032). Additionally, TCP was an independent protective factor for postoperative bowel function as measured by both the LARS (OR, 0.28; 95% CI, 0.10–0.82; p = 0.020) and Wexner scoring (OR, 0.28; 95% CI, 0.09–0.84; p = 0.023). ConclusionThis study suggests that TCP is a safe technique that may decrease bowel dysfunction after ISR for low rectal cancer compared with SCAA 2 years after ileostomy closure.

HF01-15 THE ILEAL URETER: OVER A CENTURY OF UROLOGIC INNOVATION

You have accessJournal of UrologyCME1 Apr 2023HF01-15 THE ILEAL URETER: OVER A CENTURY OF UROLOGIC INNOVATION Mark Ninomiya, Linda Hasman, Ronald Rabinowitz, and Divya Ajay Mark NinomiyaMark Ninomiya More articles by this author , Linda HasmanLinda Hasman More articles by this author , Ronald RabinowitzRonald Rabinowitz More articles by this author , and Divya AjayDivya Ajay More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003243.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Early descriptions of the ileal ureter date back to the late 19th century. While this was an innovative technique to address ureteral substitution, multiple complications were reported, and novel methods to address them continue to be studied today. We review the history and evolution of the ileal ureter and subsequent surgical advancements. METHODS: A comprehensive literature review was performed in conjunction with our University’s librarian (LH). We used PubMed to identify contemporary medical literature, ILLiad to access archived texts and old surgical and urological textbooks to obtain additional historical information and references. RESULTS: The first use of ileum to replace ureter was described in 1888 by Tizzoni and Foggi in a canine model. Fenger, in 1893, proposed the concept in humans. The first successful in vivo procedure was reported by Shoemaker in 1909 in a two-stage model. The patient was a young woman suffering from tuberculosis who had a solitary kidney. Her strictured ureter was replaced with ileum which was brought to the skin much like an ileal conduit initially. Subsequently, it was anastomosed to the bladder. This was the basis for modern ileal ureter. In 1940, Nissen reported a similar case and in 1950, Muller attached the ureters to a loop of ileum that was anastomosed to the bladder in a woman with bilateral iatrogenic ureteral injuries due to gynecologic surgery for uterine malignancy. For a case of bilateral stenosis, Foret and Heugshem replaced both ureters with a single segment of ileum in 1953. In 1959, Goodwin reported a case series of various configurations of ileal ureters. As experience with bowel reconstruction for ureters increased through the 1960s and 1970s, complications became more apparent and resulted in refinements including metabolic, reflux, and minimally invasive techniques. CONCLUSIONS: Though the complications associated with this procedure have led to novel surgical advances, the modern ileal ureter utilizes the same method as first described more than a century ago. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e261 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mark Ninomiya More articles by this author Linda Hasman More articles by this author Ronald Rabinowitz More articles by this author Divya Ajay More articles by this author Expand All Advertisement PDF downloadLoading ...

Efficacy and Safety of the “Trisection Method” Training System for Robot-Assisted Radical Cystectomy at a Single Institution in Japan

To maintain a surgeon's concentration, reduce fatigue, and train young surgeons, surgical procedures for bladder cancer are divided into the following parts: robot-assisted radical cystectomy (RARC), bowel reconstruction, and totally intracorporeal urinary diversion (ICUD) (RARC+ICUD). Each part is performed by a different surgeon (Trisection method). We retrospectively evaluated the efficacy and safety of this approach at a single institution in Japan. One hundred consecutive patients who underwent RARC+ICUD at Gifu University Hospital between November 2018 and August 2022 were included in this study. The patient background, surgical outcomes, and postoperative complications were compared between surgeries by first-, second-, and third-generation surgeons. The overall survival (OS) and recurrence-free survival (RFS) were compared between surgeries by each generation. Of the 100 patients, 19, 38, and 43 RARCs were performed by first-, second-, and third-generation surgeons, respectively. There were 35, 25, and 39 patients who underwent ileal conduit, neobladder, and ureterocutaneostomy, respectively. No significant differences were found among the patients respective to the type of ICUDs. Although the first-generation surgeon had a significantly shorter operative time with RARC, the surgical time for bowel reconstruction, length of hospital stays, and incidence of postoperative complications were not significantly different among the groups. Additionally, OS and RFS did not differ significantly among the generations. The "Trisection method" is an effective and safe concept with no difference in outcomes between the generations of surgeons.

Intestinal necrosis due to mesenteric ischemia in COVID-19 patients. Reviewing 3 patients have been treated at Cho Ray University Hospital

Abstract Introduction: The Covid-19 pandemic has resulted in severe complications and even death in many patients globally. Beside the most common impairments in the lung, SARS-CoV-2 infection-related hypercoagulation is not rarely seen in outpatients as well as in hospitalized patients. Such adverse event could engender vascular embolism in various viscera. During the Covid-19 outbreak in the years of 2020-2022, there have been several post-Covid-19 cases with bowel necrosis due to mesenteric ischemia which were well recorded worldwide. The impact of Covid-19 infection and mesenteric ischemia should be investigated. Patients and methods: We reported three young patients aged less than 40 years old who were diagnosed with bowel necrosis after Covid-19 infection at our center. Clinical, paraclinical manifestations, computed tomography features, diagnosis, treatment and final outcomes were recorded. Results: All three patients had mesenteric ischemia which caused intestinal necrosis in some extents. The patients underwent bowel resection with temporary stoma. Postoperative anticoagulant administration, nutritional support and delayed bowel reconstruction were performed with good outcomes. Conclusion: Understanding the impact of Covid-19 infection on mesenteric vascular helps to prevent, early detect the occurrence of bowel necrosis and effectively treat this complication. Keywords: Covid-19, SARS-CoV-2, mesenteric ischemia, bowel necrosis, compensation of bowel fluid.

Endoscopic ultrasonography-guided bilateral drainage with antegrade stenting in patient with malignant hilar biliary obstruction after bowel reconstruction.

Endoscopic ultrasonography-guided bilateral drainage with antegrade stenting in patient with malignant hilar biliary obstruction after bowel reconstruction.

Management of pediatric intestinal failure related to short bowel syndrome

Intestinal failure (IF) secondary to short bowel syndrome is a challenging and complex medical condition with significant risk for surgical and medical complications. Significant advancements in the care of this patient population have led to improved survival rates. Due to their intensive medical needs children with IF are at risk for long-term complications that require comprehensive management and close monitoring.The purpose of this paper is to review the available literature emphasizing the surgical aspects of care for children with IF secondary to short bowel syndrome. A key priority in the surgical care of this patient population includes strategies to preserve available bowel and maximize its function. Utilization of novel surgical techniques and autologous bowel reconstruction can have a significant impact on children with IF secondary to short bowel syndrome related to the function of their bowel and ability to achieve enteral autonomy. It is also important to understand the potential long-term complications to ensure strategies are put in place to mitigate risk with early detection to improve long-term outcomes.

The Safety and Efficacy of Apixaban (Eliquis) in 5017 Post-bariatric Patients with 95.3% Follow-up: a Multicenter Study.

Thromboprophylaxis in bariatric surgery is widely debated; however, few large articles evaluate treatment plans and their efficacy. Herein, we make the first large-scale report of the safety and efficacy of apixaban (Eliquis) for thrombus prevention following bariatric surgery. To evaluate the safety and efficacy of apixaban following bariatric surgery. Three private institutes, USA. Data from 5017 consecutive bariatric patients that were placed on postoperative apixaban for thromboprophylaxis were used for retrospective analysis. The dose prescribed to patients was 2.5mg PO BID for a total of 30days starting on day 3 postoperatively. In total, of the 5017 patients, 59.7%, 31.2%, 4.4%, 2.5%, 1.8%, and 0.1% of the patients had undergone sleeve gastrectomy (SG), single-anastomosis duodeno-ileal bypass with SG (SADI-S), Roux-en-Y gastric bypass (RYGB), conversion from SG to SADI, small bowel reconstruction, and RYGB reversal, respectively. The 30-day follow-up rate was 95.3%. In total, 1.7% of patients experienced apixaban-related side effects. The most common side effects were menorrhagia and rash. Two (0.03%) side effects developed into Clavien-Dindo grade II complications. Overall, 10 (0.1%) patients experienced thromboembolic complications (five (0.09%) PVTs and five (0.09%) PEs). In each case, the protocol was not followed for extenuating circumstances. There were no deaths or thromboembolic events in cases where the protocol was able to be fully followed. In conclusion, 30days of postoperative apixaban appears to be safe and effective with minimal side effects while preventing thromboembolic events.

Antecolic versus retrocolic reconstruction after partial pancreaticoduodenectomy.

Pancreatic cancer remains one of the five leading causes of cancer deaths in industrialised nations. For adenocarcinomas in the head of the gland and premalignant lesions, partial pancreaticoduodenectomy represents the standard treatment for resectable tumours. The gastro- or duodenojejunostomy after partial pancreaticoduodenectomy can be reestablished via either an antecolic or retrocolic route. The debate about the more favourable technique for bowel reconstruction is ongoing. To compare the effectiveness and safety of antecolic and retrocolic gastro- or duodenojejunostomy after partial pancreaticoduodenectomy. In this updated version, we conducted a systematic literature search up to 6 July 2021 to identify all randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Library 2021, Issue 6, MEDLINE (1946 to 6 July 2021), and Embase (1974 to 6 July 2021). We applied no language restrictions. We handsearched reference lists of identified trials to identify further relevant trials, and searched the trial registries clinicaltrials.govand World Health Organization International Clinical Trials Registry Platform for ongoing trials. We considered all RCTs comparing antecolic with retrocolic reconstruction of bowel continuity after partial pancreaticoduodenectomy for any given indication to be eligible. Two review authors independently screened the identified references and extracted data from the included trials. The same two review authors independently assessed risk of bias of included trials, according to standard Cochrane methodology. We used a random-effects model to pool the results of the individual trials in a meta-analysis. We used odds ratios (OR) to compare binary outcomes and mean differences (MD) for continuous outcomes. Of a total of 287 citations identified by the systematic literature search, we included eight randomised controlled trials (reported in 11 publications), with a total of 818 participants. There was high risk of bias in all of the trials in regard to blinding of participants and/or outcome assessors and unclear risk for selective reporting in six of the trials. There was little or no difference in the frequency of delayed gastric emptying (OR 0.67; 95% confidence interval (CI) 0.41 to 1.09; eight trials, 818 participants, low-certainty evidence) with relevant heterogeneity between trials (I2=40%). There was little or no difference in postoperative mortality (risk difference (RD) -0.00; 95% CI -0.02 to 0.01; eight trials, 818 participants, high-certainty evidence); postoperative pancreatic fistula (OR 1.01; 95% CI 0.73 to 1.40; eight trials, 818 participants, low-certainty evidence); postoperative haemorrhage (OR 0.87; 95% CI 0.47 to 1.59; six trials, 742 participants, low-certainty evidence); intra-abdominal abscess (OR 1.11; 95% CI 0.71 to 1.74; seven trials, 788 participants, low-certainty evidence); bile leakage (OR 0.82; 95% CI 0.35 to 1.91; seven trials, 606 participants, low-certainty evidence); reoperation rate (OR 0.68; 95% CI 0.34 to 1.36; five trials, 682 participants, low-certainty evidence); and length of hospital stay (MD -0.21; 95% CI -1.41 to 0.99; eight trials, 818 participants, low-certainty evidence). Only one trial reported quality of life, on a subgroup of 73 participants, also without a relevant difference between the two groups at any time point. The overall certainty of the evidence was low to moderate, due to some degree of heterogeneity, inconsistency and risk of bias in the included trials. There was low- to moderate-certainty evidence suggesting that antecolic reconstruction after partial pancreaticoduodenectomy results in little to no difference in morbidity, mortality, length of hospital stay, or quality of life. Due to heterogeneity in definitions of the endpoints between trials, and differences in postoperative management, future research should be based on clearly defined endpoints and standardised perioperative management, to potentially elucidate differences between these two procedures. Novel strategies should be evaluated for prophylaxis and treatment of common complications, such as delayed gastric emptying.

Hyperplastic polyp of the ileum causing intestinal intussusception

In this study, the management of an adult patient with a mechanical small bowel obstruction caused by intussusception due to hyperplastic polyp is presented. A 25-year-old man presents to the emergency department for abdominal pain accompanied by nausea and vomiting. In the abdominal examination, the patient had sensitivity in all abdominal quadrants. Contrast-enhanced abdominal computed tomography (CT) showed enlargement of the intestinal loops, air-fluid levels, and intertwined intestinal segments in the pelvic region. On exploration with a midline incision, it was observed that the 40-cm ileal segment, starting 70 cm proximal to the ileocecal valve, was invaginated into the distal ileal segment with its mesentery. After 40 cm ileal resection, bowel reconstruction was performed with a side-to-side anastomosis with a linear stapler. The patient was discharged on the seventh postoperative day without any complications. In the histopathological evaluation of the resection material, there was a hyperplastic polyp measuring 20 × 15 mm. According to the pathology result, no additional intervention was considered for the patient.

Research progress of different bowel reconstructions for postoperative functional protection during low anterior resections of rectal cancer

Straight coloanal anastomosis (SCA), colonic J-pouch anastomosis (CJP), transverse coloplasty pouch anastomosis (TCP), and side-to-end anastomosis (SEA) are the most commonly used procedures of bowel reconstructions in the low anterior resections (LAR) of rectal cancer. Different bowel reconstruction procedures greatly affect postoperative bowel function, urinary function and sexual function. SCA is the most traditional procedure. CJP has been studied extensively and well-developed reconstruction method; however, recent studies have shown that CJP has the highest morbidity of complications, so the clinical application of CJP is limited. SEA is not inferior to CJP and SCA in the short-term and long-term defecation function, urination function, and sexual function, with reliable operational safety, so it is expected to become an alternative to SCA and CJP. The research on TCP is lacking, but there are some related clinical trials currently underway, and the results are worth expecting. The improvement and innovation of bowel reconstructions provide a bright prospect for better functional prognosis in patients with rectal cancer.

Presentation and surgical management of a gossypiboma presenting with small bowel obstruction

Gossypiboma is a cotton-based foreign body retained within the human body following a surgical procedure. Transmural migration of intra-abdominal gossypiboma into the small bowel is rare; however, it can present with life-threatening complications. We report a case of a 28-year-old male who presented with small bowel obstruction due to gossypiboma, 11 years after the initial surgical procedure. Due to the size of the retained surgical swab, 40 cm × 40 cm, an open surgical approach was preferred. Following removal of the retained swab and bowel reconstruction, the patient was followed in clinic and discharged without complications. Staff education and adherence to operating room record-keeping protocols can prevent gossypiboma. To the best of our knowledge such a long interval between the initial surgery and presentation of gossypiboma that large has not been previously reported in the literature.

Label-free detection of human enteric nerve system using Raman spectroscopy: A pilot study for diagnosis of Hirschsprung disease

BackgroundHirschsprung disease (HSCR) is characterized by the absence of an enteric nerve system (ENS). To remove aganglionosis, bowel reconstruction is only a curative treatment. It is mandatory to identify the extent of aganglionosis during surgery. Raman spectroscopy is a nondestructive chemical analysis technique that provides detailed information regarding molecular vibrations. The purpose of this study is to detect the ENS using Raman spectroscopy in the human intestine for diagnosis of HSCR. MethodsThe Raman spectra of each layer of the gastrointestinal wall were collected from surgical specimens of the human rectum. Based on collected spectral data, principal component analysis was performed to determine the ENS. Subsequently, the Raman spectra of HSCR sections were analyzed. ResultsMolecular structures of the gastrointestinal wall were characterized by Raman spectroscopy. Raman spectroscopy could discriminate between ganglion and muscle layers, and the spectra of the border between muscle layers in the aganglionosis were collagen-associated peaks. Either absence on presence of ENS was also confirmed in HSCR material. ConclusionsLabel-free detection of the ENS was successfully demonstrated using Raman spectroscopy. Since this is a preliminary study, the strategy which may contribute to differentiate between ganglionic and aganglionic segments using noninvasive techniques in HSCR should be evaluated by prospective studies in near future.

Treatment outcomes, including risk factors of stone recurrence, for hepatolithiasis using balloon-assisted endoscopy in patients with hepaticojejunostomy (with video).

Endoscopic treatment outcomes for hepatolithiasis in patients with altered anatomy are not well known. The aim of this study was to evaluate the treatment outcomes of hepatolithiasis in patients with hepaticojejunostomy (HJ) using short-type double-balloon endoscopy (sDBE) and to assess the risk factors for stone recurrence. This was a retrospective cohort study that consisted of 73 patients with hepatolithiasis who underwent bowel reconstruction with HJ at an academic center. Stone removal was performed using sDBE. After balloon-occluded cholangiography using sDBE, peroral direct cholangioscopy (PDCS) using ultraslim endoscopy was performed to check for residual stones, depending on the bowel reconstruction method. Recurrence was defined as the development of cholangitis from stones. The success rate of reaching the HJ site was 92% (67/73), and the complete stone removal rate was 93% (62/67) with multiple sessions (mean number 1.5 ± 0.9). The occurrence rate of procedure-related adverse events was 6.8%. Among 58 patients evaluated for stone recurrence, 13 (22%) developed recurrence during a median follow-up period of 2.7years (interquartile range: 1.5-4.8). Multivariate analyses determined that a stone diameter ≥ 8mm [odds ratio (OR), 5.57; 95% confidence interval (CI), 1.39-37.2; p = 0.013] and performing PDCS (OR, 0.16; 95% CI, 0.0084-0.90; p = 0.036) were significant factors for stone recurrence. Endoscopic treatment using sDBE for hepatolithiasis was effective and safe. PDCS might reduce the rate of stone recurrence by detecting stones that are too small to confirm on fluoroscopic images.

Pelvic Anastomosis Without Protective Ileostomy is Safe in Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

During cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), surgeons are reluctant to perform unprotected pelvic anastomosis despite lack of supporting data. We analyzed pelvic anastomosis outcomes and factors that influence ostomy creation in CRS/HIPEC patients. A single-center, descriptive study of patients with rectal resection during CRS/HIPEC was conducted using a prospective database. Surgical variables were reviewed. Multinomial logistic regression of outcomes (end or protective ostomy) was performed with pre- and intraoperative factors as predictors. Overall, 274 of 789 CRS/HIPEC patients underwent rectal resection, including 243 (89%) with pelvic anastomosis [232 (85%) without ostomy, 11 (4%) with protective ileostomy] and 31 (11%) with no anastomosis [16 (6%) with end colostomy, 15 (5%) with end ileostomy]. The median age was 57 and 29% (79) were male. Of 243 pelvic anastomosis patients, 3 (1.2%) had rectal anastomotic leaks, including 1 with a protective ileostomy. Other anastomotic leaks occurred in 3.6%. Overall, 13% had Clavien-Dindo complications ≥ IIIB and the readmission rate was 30%. Mortality at 30days and 100days was 0.4% and 2.2%, respectively. Male gender and primary rectal cancer were associated with protective ileostomy [odds ratio (OR) = 7.01, 95% CI: 1.6-31.5, p = 0.011, and OR = 16.4, 95% CI: 3-88.4, p = 0.001, respectively). Male gender and prior pelvic surgery were associated with end colostomy (OR = 13.9, 95% CI: 3.7-53, p < 0.0001, and OR = 17.2, 95% CI: 3.8-78.6, p < 0.0001). Pelvic bowel reconstruction without protective or end ostomy during CRS/HIPEC is safe. Protective ileostomy is associated with male gender and primary rectal cancer. End colostomy is associated with male gender and prior pelvic surgery.

P1794CHANGES IN PHARMACOKINETIC PROFILE OF MYCOPHENOLATE MOFETIL AND TACROLIMUS IN THE TRANSPLANTED PATIENT AFTER BOWEL SURGERY: A PROSPECTIVE COHORT STUDY

Abstract Background and Aims Considering the particular pharmacokinetic (PK) profile of mycophenolate (MMF/MPS) with the important contribution of enterohepatic recirculation (EHC) and the potential alteration in tacrolimus (TAC) exposure, a PK study in solid-organ transplant patients who had undergone intestinal resection was carried out. Method This is a prospective single-center study of MMF/MPS and TAC exposure changes after bowel resection and after reconstruction. Whole blood samples were collected at the following time points: 0, 0.5, 1, 1.5, 2, 4, 6, 8 and 12 hours post-dose. Areas under the curves (AUCs) were determined in both conditions: with ileostomy and after bowel reconstruction. Results Six renal and two cardiac transplant recipients were included. Four subjects completed both pre- and post-reconstruction surgery procedures. Different intestinal anatomic resections were performed (Table 1). Patients with terminal ileostomy showed an under exposure to MMF/MPS. In three patients, initial MPA levels were on target, but they decreased &amp;gt;80% after 4 hours post-drug administration. After bowel reconstruction, the AUC increased maintaining MMF/MPA levels during 12h (Table 2). Before bowel reconstruction, TAC trough levels were within therapeutic target but, after reconstruction, AUCs normalized by dose were much higher than the expected. Conclusion Transplant recipients with ileostomy showed infra-exposure to mycophenolate. After 4 hours post-dose, MMF/MPA was undetectable because of the absence of EHC, which was recovered after anatomical correction. TAC exposure was higher after bowel reconstruction suggesting changes in the absorption. The use of mTORi in such clinical situations would be an alternative.