Extensive Bowel Resection Research Articles

Lynch Syndrome: Similarities and Differences of Recommendations in Published Guidelines.

In this review, we aimed to compare the recommendations for Lynch syndrome (LS). We compared the LS's guidelines of different medical societies, including recommendations for cancer surveillance, aspirin treatment, and universal screening. Most guidelines for LS patients recommend intervals of 1-2 years for performing colonoscopy, though there is disagreement regarding the age to begin CRC screening (dependent on status as a MLH1/MSH2 or MSH6/PMS2 carrier). There are inconsistencies between LS guidelines for gastric cancer surveillance. Most guidelines do not recommend routine surveillance of the pancreas and small bowel. Most but not all of the guidelines support endometrial and ovarian surveillance with transvaginal ultrasound and endometrial biopsy. Only two societies recommend urological surveillance, while others recommend surveillance among high-risk carriers with family history only. There is significant disagreement between the guidelines about the recommendation for limited or extended bowel resection among patients with CRC. Aspirin use is recommended by most societies, though some with reservations, and most of them recommend universal screening. There are significant disparities and disagreements in the guidelines and recommendations for patients with LS, causing confusion and difficulties for clinicians. Harmonization and cooperation are needed between the societies creating LS guidelines.

Totally thoracoscopic atrial fibrillation surgery following massive small bowel resection due to superior mesenteric artery embolization: report of two cases

BackgroundThromboembolic occlusion of the superior mesenteric artery (SMA) is a grave complication in individuals diagnosed with atrial fibrillation (AF). This condition often necessitates extensive bowel resection, culminating in short bowel syndrome, which presents challenges for anticoagulant administration and/or antiarrhythmic therapy.Case presentationPresented here are findings of two patients, aged 78 and 72 years, respectively, who underwent comprehensive thoracoscopic AF surgery subsequent to extensive small bowel resection following SMA embolization. In each, onset of AF precipitated an embolic event, while the concurrent presence of short bowel syndrome complicated anticoagulation management. Total thoracoscopic AF surgery, comprised stapler-closure of the left atrial appendage (LAA) and bilateral epicardial clamp-isolation of the pulmonary veins, an operative modality aimed at addressing AF rhythm control and mitigating embolic events such as cerebral infarction, led to favorable outcomes in both cases. Additionally, computed tomography (CT) conducted one month post-surgery revealed the absence of residual tissue in the LAA, with the left atrium demonstrating a well-rounded, spherical shape. At the time of writing, the patients have remained asymptomatic following surgery regarding thromboembolic and arrhythmic manifestations for 29 and 10 months, respectively, notwithstanding the absence of anticoagulant or antiarrhythmic pharmacotherapy. Additionally, electrocardiographic surveillance has revealed persistent sinus rhythm.ConclusionsThe present findings underscore the feasibility and efficacy of a total thoracoscopic AF surgery procedure for patients presented with short bowel syndrome complicating SMA embolization, thus warranting consideration for its broader clinical application.

Short-term outcomes of surgical treatment for primary ileocaecal Crohn's disease: Results of the Crohn's(urg) study, a multicentre, retrospective, comparative analysis between inflammatory and complicated phenotypes.

Recent evidence challenges the current standard of offering surgery to patients with ileocaecal Crohn's disease (CD) only when they present complications of the disease. The aim of this study was to compare short-term results of patients who underwent primary ileocaecal resection for either inflammatory (luminal disease, earlier in the disease course) or complicated phenotypes, hypothesizing that the latter would be associated with worse postoperative outcomes. A retrospective, multicentre comparative analysis was performed including patients operated on for primary ileocaecal CD at 12 referral centres. Patients were divided into two groups according to indication of surgery for inflammatory (ICD) or complicated (CCD) phenotype. Short-term results were compared. A total of 2013 patients were included, with 291 (14.5%) in the ICD group. No differences were found between the groups in time from diagnosis to surgery. CCD patients had higher rates of low body mass index, anaemia (40.9% vs. 27%, p < 0.001) and low albumin (11.3% vs. 2.6%, p < 0.001). CCD patients had longer operations, lower rates of laparoscopic approach (84.3% vs. 93.1%, p = 0.001) and higher conversion rates (9.3% vs. 1.9%, p < 0.001). CCD patients had a longer hospital stay and higher postoperative complication rates (26.1% vs. 21.3%, p = 0.083). Anastomotic leakage and reoperations were also more frequent in this group. More patients in the CCD group required an extended bowel resection (14.1% vs. 8.3%, p: 0.017). In multivariate analysis, CCD was associated with prolonged surgery (OR 3.44, p = 0.001) and the requirement for multiple intraoperative procedures (OR 8.39, p = 0.030). Indication for surgery in patients who present with an inflammatory phenotype of CD was associated with better outcomes compared with patients operated on for complications of the disease. There was no difference between groups in time from diagnosis to surgery.

Peutz-Jeghers syndrome: management for recurrent intussusceptions.

Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder characterized by hamartomatous gastrointestinal polyps along with the characteristic mucocutaneous freckling. Multiple surgeries for recurrent intussusception in these children may lead to short bowel syndrome. Here we present our experience of management in such patients. From January 2015 to December 2023, we reviewed children of PJS, presented with recurrent intussusceptions. Data were collected regarding presentation, management, and follow-up with attention on management dilemma. Diagnosis of PJS was based on criteria laid by World Health Organization (WHO). A total of nine patients were presented with age ranging from 4 to 17years (median 9years). A total of eighteen laparotomies were performed (7 outside, 11 at our centre). Among 11 laparotomies done at our centre, resection and anastomosis of bowel was done 3 times while 8 times enterotomy and polypectomy was done after reduction of intussusception. Upper and lower gastrointestinal endoscopy (UGIE & LGIE) was done in all cases while intraoperative enteroscopy (IOE) performed when required. Follow-up ranged from 2months to 7years. Children with PJS have a high risk of multiple laparotomies due to polyps' complications. Considering the diffuse involvement of the gut, early decision of surgery and extensive bowel resection should not be done. Conservative treatment must be tried under close observation whenever there is surgical dilemma. The treatment should be directed in the form of limited resection or polypectomy after reduction of intussusception.

Acute superior mesenteric artery thrombosis in a 34-year-old male with thrombophilia: a case report

Introduction: Thrombophilic state, marked by extensive formation of blood clots within the vascular system poses a formidable peril, leading to loss of circulatory integrity and systemic well-being. Superior mesenteric artery (SMA) thrombosis is a serious medical disorder characterized by the obstruction of the arterial blood flow to the gastrointestinal tract, which is associated with significant morbidity and mortality. The condition has a plethora of etiological causes. Vague abdominal pain is a common clinical manifestation, and there is a very high mortality rate.Case Presentation: A 34-year-old Pakistani male presented with rapidly worsening acute abdominal pain over a 10-hour period. Clinical examination revealed elevated blood pressure, while other vital signs remained within normal limits. Abdominal examination findings were inconclusive compared to the patient's severe abdominal pain complaint. Contrast-enhanced CT scan indicated a large thrombus in the superior mesenteric artery with radiological features suggestive of intestinal ischemia, extending from the duodeno-jejunal flexure to the mid-transverse colon. Subsequently, the patient underwent exploratory laparotomy with extensive bowel resection and received anticoagulant therapy. He subsequently experienced compensated right lower limb ischemia, treated conservatively with high-dose anticoagulant therapy. Within days, bowel anastomotic leak developed, requiring multiple surgeries. Eventually, the patient progressed to septic shock, followed by multiorgan failure, culminating in a fatal cardiac arrest.Conclusion: Acute mesenteric ischemia, a rare abdominal emergency with an incidence of 6 per 100,000, is associated with a substantial mortality rate, ranging from 58% to 93% among diagnosed cases. The challenges posed by SMA thrombosis include diagnostic complexities, as it frequently manifests with symptoms disproportionate to clinical signs, and results in catastrophic complications, necessitating high suspicion index and prompt intervention.

Irreversible Transmural Intestinal Necrosis in Acute Mesenteric Ischemia: Retrospective Cohort Study from a High-Volume Hospital.

Background: Owing to the low incidence rate and nonspecific symptoms of acute mesenteric ischemia (AMI), the identification and prediction of irreversible transmural intestinal necrosis (ITIN) and extensive bowel resection (≥100 cm) (EBR) are difficult and critical. This study aimed to investigate the risk factors for ITIN and EBR in patients with AMI. Methods: The clinical data of 254 AMI patients were retrospectively analyzed. Furthermore, the incidence of ITIN and EBR were set as dependent variables, and relevant risk factors were screened using univariate and multivariate logistic regression analyses. The comparisons of surgical characteristics and postoperative recovery outcomes between the EBR and control group were also conducted. Results: The presence of hemorrhagic (odds ratio [OR] = 28.356, P < .001) or other types ascites (OR = 13.051, P = .003), peritonitis (OR = 8.463, P = .005), intestinal diameter >2.35 cm (OR = 5.493, P = .020), and serum creatinine (CREA) >95 μmol/L (OR = 4.866, P = .048) were identified as independent risk factors for ITIN in patients with AMI. In addition, serum C-reactive protein (CRP) >15 mg/L (OR = 38.023, P = .006), and CREA >100 μmol/L (OR = 6.248, P = .035) were proved to be independently associated with EBR for ITIN cases. Compared to the control group, EBR significantly increased the likelihood of requiring enterostomy (P = .001), blood transfusion (P = .002), and transfer to intensive care unit (P = .016), while also prolonging the recovery time for intestinal function (P = .014). Conclusions: The presence of ascites, peritonitis, intestinal diameter >2.35 cm, and serum CREA >95 μmol/L were independently correlated with ITIN for AMI cases, while serum CRP >15 mg/L and CREA >100 μmol/L independently increased the risk of EBR.

P433 Short-term outcomes of surgical treatment in primary ileocecal Crohn’s disease patients. Results of Crohn’s(urg) study, multicenter, retrospective, comparative analysis between indications for luminal and complicated phenotype

Abstract Background Recent evidence challenges the current standard of offering surgery to patients with ileocecal Crohn’s disease only when they present complications of the disease. Methods A retrospective, multicenter comparative analysis was performed including patients operated for primary ileocecal CD at 12 referral centers. Patients were divided in 2 groups, according to indication of surgery for inflammatory (ICD) or complicated (CCD) phenotype. Short-term results were compared. Patients operated on for primary isolated ileocaecal CD (last 50 cm of the terminal ileum and cecum), either for predominantly inflammatory phenotype or for complications of the disease (stricturing or fistulizing pattern), between January 2012 - December 2021 were considered eligible to participate in this study. Patients with previous abdominal procedures for CD, and patients who had activity of the disease in other intestinal segments other than the ileocaecal region at the time of surgery, were excluded from the study. Results 2013 patients were included, 291 (14.5%) in the ICD group. No differences were found between groups in time from diagnosis to surgery or in the levels of exposure to biologic drugs before indication of surgery. CCD patients had higher rates of low BMI, anemia (40.9 vs. 27%, p: &amp;lt; 0.001), and low albumin (11.3 vs. 2.6%, p: &amp;lt; 0.001). CCD patients had longer operations, lower rates of laparoscopic approach (84.3 vs. 93.1%, p: 0.001), and higher conversion rates (9.3 vs. 1.9%, p: &amp;lt; 0.001). CCD had longer hospital stay and higher postoperative complication rates (26.1 vs. 21.3%, p: 0.083). Anastomotic leakage and reoperations were also more frequent in this group. More patients in the CCD group required an extended bowel resection (14.1 vs. 8.3%, p: 0.017). In multivariate analysis, CCD was associated with prolonged surgeries (OR: 3.44, p: 0.001) and requirements of multiple intraoperative procedures (OR: 8.39, p: 0.030). Conclusion Indication of surgery in patients who present an inflammatory phenotype of CD was associated with better outcomes when compared to patients operated on for complications of the disease, without a difference between groups in time from diagnosis to surgery.

Large Inflammatory Tumor Due to Perforated Meckel′s Diverticulum Managed with Extensive Ileocoecal Resection

Meckel´s diverticulum is a remnant of the omphaloenteric duct and can cause different clinical symptoms, including Meckel´s diverticulitis and perforation. This case presented an unusual case of a Meckel´s diverticulitis with perforation and large inflammatory tumor involving the mesentery of the loops of the terminal ileum, that was also in close contact with the coecum. An extensive bowel resection was neccessary to resolve the situation.

Компьютерная томография при острой мезентериальной ишемии: диагностические возможности, ограничения и будущее

Acute mesenteric ischemia (AMI) represents a severe and potentially life-threatening condition caused by an abrupt reduction in intestinal blood flow. This ischemic event, if not promptly addressed, leads to intestinal necrosis. The clinical presentation of AMI is commonly nonspecific and variable, complicating early diagnosis. Without timely detection and intervention, AMI can progress to devastating complications including intestinal necrosis, sepsis, multiple organ dysfunction syndrome (MODS), or short bowel syndrome secondary to extensive bowel resection. Early identification is therefore paramount to optimizing treatment and reducing both morbidity and mortality associated with this condition. This review explores the pivotal role of computed tomography (CT) in the diagnosis of AMI, evaluates the diagnostic accuracy of CT in comparison with alternative imaging modalities, and discusses future advancements aimed at enhancing CT-based diagnostic capabilities. A comprehensive review of the existing literature was conducted, focusing on studies investigating the utility of CT and other imaging techniques in the evaluation of AMI. Relevant diagnostic parameters were analyzed, including bowel wall thickening, pneumatosis intestinalis, and damage within the superior mesenteric artery (SMA) and its branches. The role of CT angiography was also assessed in diagnosing abnormalities of the mesenteric arterial and venous systems. The findings underscore that CT is a highly effective diagnostic tool for AMI, offering superior sensitivity and specificity compared to other imaging technologies such as X-ray, ultrasound, and magnetic resonance imaging (MRI). However, certain limitations — such as suboptimal image quality in specific patient populations, the risks associated with ionizing radiation, and adverse reactions to contrast agents — must be acknowledged and addressed. Despite these challenges, CT has emerged as a cornerstone in the early detection and management of AMI, facilitating rapid and accurate assessments that are critical to improving patient outcomes. Advances in CT technology and integration of artificial intelligence and machine learning algorithms into CT imaging workflows could refine diagnostic accuracy and reduce time-to-diagnosis. A multidisciplinary approach that combines CT imaging with other diagnostic modalities may further optimize the patient management of with AMI. Keywords: acute mesenteric ischemia, mesenteric circulation disorder, computed tomography, CT angiography, early diagnosis, intestinal ischemia, superior mesenteric artery, artificial intelligence, machine learning, multidisciplinary approach. For citation: Kuznetsov M.R., Chernookov A.I., Atayan A.A., Belykh E.N., Kanadashvili O.V., Ramazanov A.A., Ivanova M.I., Tsedinov S.O. Computed tomography in acute mesenteric ischemia: diagnostic possibilities, limitations and the future. RMJ. 2024;10:23–26. DOI: 10.32364/2225-2282-2024-10-4

Antiperistaltic Transverse Coloplasty: A Salvage Procedure in Extensive Bowel and Colorectal Resections to Avoid Intestinal Failure

IntroductionAfter extensive small and colon resections, quality of life can be affected. We propose the antiperistaltic transverse coloplasty as a solution that allows for preservation of the transverse colon after both right and left colectomies while achieving a tension-free colorectal anastomosis slowing the transit and increasing the absorption time, resulting in better stool consistency and quality of life compared with an ileorectal anastomosis.MethodsThis technique was performed in a 41-year-old woman with Goblet cell adenocarcinoma of the appendix with peritoneal metastasis. The transverse colon is rotated anticlockwise over the axis of the middle colic vessels toward the left parietocolic flank and relocated to the usual position of the descending colon.ResultsAfter 1 year of follow-up, the patient led a normal life without parenteral nutrition with five bowel movements per day and a weight gain of 15%.ConclusionsThe use of an antiperistaltic transverse coloplasty may be worthwhile to perform in cases of extensive bowel resections during cytoreductive surgery leading to short-bowel syndrome to avoid a permanent stoma or intestinal failure and improve patient outcomes.

Factors associated with the need for long-term total parenteral nutrition in survivors of acute superior mesenteric artery occlusion.

Acute superior mesenteric artery (SMA) occlusion is an uncommon condition associated with high mortality. If extensive bowel resection is performed for patients with acute SMA occlusion and the patient survives, long-term total parenteral nutrition (TPN) may be needed due to short bowel syndrome. This study examined factors associated with the need for long-term TPN after the treatment of acute SMA occlusion. We retrospectively analyzed 78 patients with acute SMA occlusion. Patients were abstracted from a Japanese database from institutions with at least 10 patients with acute SMA occlusive disease from January 2015 through December 2020 RESULTS: Among the initial cohort there were 41/78 survivors. Of these, 14/41 (34%) required permanent TPN who were compared with those who did not require long-term TPN (27/41, 66%). Compared to patients in the non-TPN group, those in the TPN group had significantly shorter remaining small intestine (90.7 cm vs. 218 cm, P<0.01), more patients with time from onset to intervention >6 hours (P=0.02), pneumatosis intestinalis on enhanced computed tomography scan (P=0.04), ascites (Odds Ratio 11.6, P<0.01), and a positive smaller superior mesenteric vein sign (P= 0.03). These were considered significant risk factors for needing long-term TPN. Age, gender, underlying disease, presence of peritoneal sign, presence of shock requiring vasopressors, site of obstruction (proximal vs. distal), and initial treatment (surgery vs. interventional radiology vs. thrombolytic therapy) were not significantly different between the two groups. Long-term TPN was significantly associated with longer hospital stay (52 vs. 35 days, P=0.04). Multivariate analysis identified the presence of ascites as an independent risk factor for needing long-term TPN. The need for permanent TPN after treatment of acute SMA occlusion is significantly associated with longer hospital stay, longer time to intervention, and characteristic imaging findings (pneumatosis intestinalis, ascites, Smaller SMV sign). Ascites is an independent risk factor. III.

Nutritional correction after extensive combined bowel resections: new approaches to rehabilitation

Introduction . Metabolic correction of the consequences of extensive (especially combined) intestinal resections requires enormous efforts due to weight loss, a decrease in plasma albumin concentration of less than 30 g/l, electrolyte disorders, organ failure, etc. There are consequences in the form of short small intestine syndrome, postcolectomy syndrome and the combined consequences of resections of the small and large intestine. The most severe changes are after combined thin-thick-intestinal resections, the prevalence of which continues to increase. Nevertheless, the data on the occurrence of combined resections (thin-colon) are very contradictory. Aim . To analyze the effectiveness of nutritional correction programs in SBS syndrome due to extensive combined small-colonic resections and to characterize possible ways of correcting metabolic complications with the help of nutritional correction, taking into account the optimization of absorption in the intestine. Materials and methods . We examined 208 patients with combined extensive resection of the small intestine with right-sided hemicolectomy (65% of men and 35% of women). Metabolic changes, nutritional characteristics and reparation under the influence of nutritional correction in this category of patients are described. Results . Data on the restoration of lost functions are presented, which is based on the analysis of the mechanisms of adaptation and cellular regeneration. Regenerative aspects of hormonal (enteroglucagon) regulation of intestinal functions after its extensive resection and artificial alimentation are closely related. Conclusion . It is advisable to introduce teduglutide into the treatment structure to stimulate rehabilitation absorption processes after extensive combined intestinal resections.

Management of acute mesenteric ischaemia: Results of a worldwide survey

Acute mesenteric ischaemia (AMI) is a condition with high mortality. This survey assesses current attitudes and practices to manage AMI worldwide. A questionnaire survey about the practices of diagnosing and managing AMI, endorsed by several specialist societies, was sent to different medical specialists and hospitals worldwide. Data from individual health care professionals and from medical teams were collected. We collected 493 individual forms from 71 countries and 94 team forms from 34 countries. Almost half of respondents were surgeons, and most of the responding teams (70%) were led by surgeons. Most of the respondents indicated that diagnosis of AMI is often delayed but rarely missed. Emergency revascularisation is often considered for patients with AMI but rarely in cases of transmural ischaemia (intestinal infarction). Responses from team hospitals with a dedicated special unit (14 team forms) indicated more aggressive revascularisation. Abdominopelvic CT-scan with intravenous contrast was suggested as the most useful diagnostic test, indicated by approximately 90% of respondents. Medical history and risk factors were thought to be more important in diagnosis of AMI without transmural ischaemia, whereas for intestinal infarction, plasma lactate concentrations and surgical exploration were considered more useful. In elderly patients, a palliative approach is often chosen over extensive bowel resection. There was a large variability in anticoagulant treatment, as well as in timing of surgery to restore bowel continuity. Delayed diagnosis of AMI is common despite wide availability of an adequate imaging modality, i.e. CT-scan. Large variability in treatment approaches exists, indicating the need for updated guidelines. Increased awareness and knowledge of AMI may improve current practice until more robust evidence becomes available. Adherence to the existing guidelines may help in improving differences in treatment and outcomes.

The role of gastrostomy feeding during intestinal rehabilitation for children with short bowel syndrome.

Following extensive bowel resection, many children with short bowel syndrome (SBS) are routinely offered a placement of gastrostomy tube (G-tube) for feeding. This nutritional pathway is aimed to accommodate the gastric and small bowel motor disturbances related to SBS, and to promote weaning off parenteral nutrition (PN) to achieve enteral autonomy (EA). The aim of this study was to investigate the effect of gastrostomy feeding in outcomes of children with SBS. A retrospective cohort of all SBS children managed at our multidisciplinary Intestinal Rehabilitation Center as part of an Intestinal Rehabilitation Program. SBS was defined as PN dependence for more than six weeks following extensive bowel resection. Patients treated with G-tube feeding were compared with patients without G-tube in terms of PN duration, reaching EA, physical development, and surgical parameters. A total of 36 SBS patients diagnosed between 2003 and 2022 were included. The most common etiologies included congenital intestinal atresia (31%) and necrotizing enterocolitis (25%). SBS-G-tube (group A) contained 20 children, and SBS (group B) contained 16 children. A total of 21 children reached EA (58%); ten from group A (50%), and 11 from group B (69%) (p > 0.05). Within EA patients, mean PN duration was 49 ± 44months in group A, and 24 ± 33months in group B (p > 0.05). Patients who reached EA had 22% longer residual small bowel when compared with PN-dependent patients (p = 0.003). However, the outcomes were adjusted for residual small and large bowel length and percentages, a residual ileocecal valve, and a colon in continuity with no differences between the groups. Two-thirds of children from group A reported G-tube related complications (mechanical, bleeding, or infections). We did not find differences in mean height and weight percentiles between the groups (p > 0.05). We did not find significant advantage of gastrostomy feeding in reaching EA. Because there are surgical and mechanical complications related to this procedure, further prospective studies are required to determine G-tube relevance for children with SBS.

HM15912, a Novel Long-Acting Glucagon-Like Peptide-2 Analog, Improves Intestinal Growth and Absorption Capacity in a Male Rat Model of Short Bowel Syndrome.

Extensive bowel resection caused by various diseases that affect the intestines, such as Crohn's disease, volvulus, and cancer, leads to short bowel syndrome (SBS). Teduglutide is the only approved glucagon-like peptide-2 (GLP-2) drug for SBS; however, it requires daily administration. A novel GLP-2 analog with a prolonged duration of action to reduce dosing frequency and promote a greater efficacy may provide patients with a better quality of life. In the present study, the sustained exposure of HM15912 was characterized in normal male rats. The efficacy of HM15912 on intestinal growth and absorption capacity was also evaluated in normal male mice, rats, and SBS rats. HM15912 exhibited a remarkably extended half-life (42.3 hours) compared with teduglutide (0.6 hours) in rats. Despite somewhat lower in vitro potency on GLP-2 receptor than human GLP-2 or teduglutide, this longer-lasting mode of action promotes HM15912 to be more effective in terms of small intestinal growth than existing GLP-2 analogs even with a less frequent dosing interval of as little as once a week in rodents, including SBS rats. Furthermore, the small intestinal weight was approximately doubled, and the D-xylose absorption was significantly increased after pre-treatment of existing GLP-2 analogs on the market or under clinical development followed by HM15912 in rodents. These results indicate that HM15912 possesses a significant small bowel trophic effect driven by continuously increased exposure, supporting that HM15912 may be a novel treatment option with greater efficacy and the longest dosing interval among existing GLP-2 analogs for SBS with intestinal failure. SIGNIFICANCE STATEMENT: HM15912, a novel long-acting glucagon-like peptide-2 (GLP-2) analog, has a significant small bowel hypertrophic effect in rodents with a reduced frequency of administration compared to the existing GLP-2 analogs on the market or currently under clinical development. This study supports the possibility that HM15912 could be administered much less frequently than other long-acting GLP-2 analogs for patients with short bowel syndrome.

Impact of bowel rotation and fixation on obstructive complications in congenital diaphragmatic hernia

Aim of the studySmall bowel obstruction (SBO) is a known complication after congenital diaphragmatic hernia (CDH) repair, which can require surgery and even extensive bowel resection causing short bowel syndrome (SBS). We investigate whether specific bowel rotation and fixation can be used as a predictor for SBO including volvulus. MethodsA retrospective review of 256 CDH survivors following repair from 2003 to 2020 was performed. Operative notes and upper gastrointestinal series (UGI) were screened to determine the rotation and fixation of the bowel. Primary outcomes included SBO occurrence, SBO treated surgically, and volvulus. For statistical analysis Fisher's exact test was utilized. ResultsTwenty-two (9%) patients presented with SBO and majority, 19 (86%), required surgery. Adhesion were observed in 10 (45%), recurrence in 5 (23%), and extensive volvulus leading to SBS in 3 (14%). Both rotation and fixation were recorded in 117 (46%). Presence of left CDH with malrotation and nonfixation was a significant predictor for SBO requiring surgery (P<0.05 vs all other groups). All 3 patients with extensive volvulus had left CDH with nonfixed bowel (100%), however only 1 had malrotation (33%). ConclusionsMalrotation and nonfixation are associated with increased SBO in CDH. Normal rotation is not protective and patients are still at risk for volvulus resulting in SBS. SBO requiring surgical intervention is common in CDH. Bowel rotation and fixation are important determinants that, should be routinely documented and education about the risk of SBO should be included in family counseling. Level of EvidenceLevel IV – Case Series

S1027 Short Bowel Syndrome Is Associated With Increased Morbidity and Health-Care Utilization but Not Mortality in Patients Hospitalized for Crohn’s Disease Flare: Analysis From National Inpatient Database

Introduction: Crohn’s disease is an inflammatory disorder of the gastrointestinal tract that can affect any part of the tract, ranging from the mouth to the perianal area. Depending on the location and severity of inflammation, small bowel resections might be necessary to control disease. Short Bowel Syndrome (SBS) is a common complication arising after extensive bowel resection, especially in medically refractory Crohn’s disease. These patients are at a high risk of adverse outcomes when hospitalized. The aim of this study was to analyze the impact of SBS for patients hospitalized for Crohn’s disease flare. Methods: All adult hospitalized patients from January 2016 to December 2019 in the nationwide inpatient sample (NIS) were captured. The sample population included all patients with a primary diagnosis of Crohn’s disease using ICD-10 codes (International Classification of Diseases, tenth edition). We then identified patients with a secondary diagnosis of SBS. The Crohn’s disease population was divided into patients with SBS (study group) and without SBS (control group). Linear regression was used for comparing continuous variables and Chi-square tests for categorical variables. Morbidity, mortality and healthcare utilization were analyzed using multivariate logistic and linear regression models where appropriate. Results: The sample size included 374,745 patients admitted for Crohn’s disease flare, of which 99.75% did not have underlying SBS while 0.25% did. Study group had a higher incidence of Hospital-acquired pneumonia (Adjusted OR (aOR) =2.93), Catheter related blood-stream infection (aOR=7.71) and Sepsis (aOR=2.99), all with p< 0.05 or less. There was also a higher risk of hyponatremia (aOR=1.79) and Iron-deficiency anemia (aOR=1.68) in the study group. No difference was noted in venous thromboembolism rates. The adjusted mean change in hospitalization charge was $44,359 and mean change in length of stay was 6.35 days in study group vs control. Mortality though was higher in SBS group, this lost significance following multivariate analysis. (Figure) Conclusion: SBS increases the risk of infections, electrolyte deficiency and anemia in patients admitted for Crohn’s disease flare but venous thromboembolism and mortality rates of both groups remains similar. This proves to be a huge burden on both the patients and the healthcare. The outcomes of patients with SBS could be greatly improved by more effective prevention of these complications, and treatment of high-risk Crohn’s patients more vigilantly. (Table) Table 1. - In-hospital outcomes Variables Crohn’s with no SBS* (Control) Crohn’s with SBS* (Study) p-value Hospital acquired pneumonia 0.78% 3.36% < 0.001 Adjusted odds ratio1=2.93 0.042 Catheter related blood-stream infection 0.1% 1.68% < 0.001 Adjusted odds ratio1=7.71 0.005 Sepsis 1.19%% 5.88% < 0.001 Adjusted odds ratio1=2.99 0.006 Septic shock 0.51% 2.52% 0.002 Adjusted odds ratio1 = 2.36 0.15 Hyponatremia 6.07% 16.81% < 0.001 Adjusted odds ratio1=1.79 0.02 Venous thrombo-embolism 0.77% 2.52% 0.02 Adjusted odds ratio1=1.84 0.29 Iron deficiency anemia 12.49% 31.09% < 0.001 Adjusted odds ratio1=1.68 0.045 Mean total hospitalization charge ($) $44,911 $100,203 < 0.001 Mean change in charges1 = $44,359 < 0.001 Mean length of stay (days) 4.78 12.53 < 0.001 Mean change in length of stay1 = 6.35 < 0.001 In-hospital mortality 0.2% 0.84% 0.11 Adjusted odds ratio1=2.44 0.39 *SBS- Short Bowel Syndrome 1Adjusted for Age, Sex, Race, income, hospital characteristics and Elixhauser score. Figure 1.: Graph 1.

Clinico-pathological evaluation and co-morbidities in superior mesenteric artery thrombosis

Background: Mesenteric artery thrombosis (MAT) is a condition involving occlusion of the arterial vascular supply of the intestinal system. It is a severe and potentially fatal illness typically of the superior mesenteric artery (SMA), which provides the primary arterial supply to the small intestine and ascending colon. The occlusion may occur due to underlying atherosclerotic disease or embolic occlusion from a distant source, as atrial fibrillation. The condition possesses a high mortality rate and prompt recognition and treatment are of utmost importance.Methods: A retrospective, observational, single hospital base study done during the period from 2015 to 2020 in the department of surgery, Gandhi Medical College, Bhopal. Sample size was taken 50 patients.Results: In our study, out of 50 patients, 34% patients were in the age group between 55-65 years, history of smoking was present in 44%, hypertension in 36%, past history of atrial fibrillation in 10%, signs of peritonitis were present in 62% patients. Out of 50 patients, 42% was operated while 58% were managed conservatively. Amongst operated patients, in 72% partial bowel resection was done while in 28% extensive bowel resection was done, 66% were discharged while 28% patients died, amongst 21 operated patients, 57% were discharged while 43% died.Conclusions: In this study, SMA thrombosis is more common in patients with smoking, cardiac diseases (hypertension, atrial fibrillation, ischemic heart disease, CVA), dyslipidaemia. Early intervention as thrombolysis or bypass surgery is needed to prevent complications like extensive bowel ischemia.

Autologous Intestinal Reconstruction Surgery in Short Bowel Syndrome: Which, When, and Why.

Short bowel syndrome (SBS), secondary to any natural loss or after any extensive bowel resection for congenital malformations or acquired disease, is the most common cause of intestinal failure in children. Extensive introduction of parenteral nutrition (PN) has dramatically changed the outcome of these patients, allowing for long-term survival. The main goal in children with SBS remains to be increasing enteral tolerance and weaning from PN support. Post resection intestinal adaptation allows for achievement of enteral autonomy in a subset of these patients, but the inability to progress in enteral tolerance exposes others to long-term complications of PN. Autologous intestinal reconstruction surgery (AIRS) can facilitate the fulfilment of enteral autonomy, maximizing the absorptive potential of the remaining gut. All the different intestinal reconstruction techniques, from simple procedures like tapering, reversed segments, and colon interposition, to more complex lengthening procedures (LILT: longitudinal intestinal lengthening and tailoring, STEP: serial transverse enteroplasty, and SILT: spiral intestinal lengthening and tailoring) and techniques designed for peculiar problems like controlled intestinal tissue expansion or duodenal lengthening are presented. AIRS indications, clinical applications, and results reported in the literature are reviewed.

ACUTE SUPERIOR MESENTERIC VESSEL THROMBOSIS CAUSING BOWEL ISCHEMIA – A 5 CASE SERIES

Background: Acute mesenteric ischemia consists of the sudden, partial or complete, interruption of the blood ow in superior or inferior mesenteric vessels that result in intestinal ischemia. The incidence was exponentially increasing with age and no difference has been observed between sexes. Aim: The Aim of this case series was to highlight clinical presentation, the difculty in diagnosis and importance of early intervention and the prognosis of superior mesenteric vessel thrombosis with bowel ischemia. This article presented a case series of intestinal infarction through obstruction of superior mesenteric vessels – three cases of acute mesenteric artery thrombosis, two case of acute mesenteric vein thrombosis. Materials and methods: The materials for this case series was collected from patients diagnosed and admitted as acute superior mesenteric vessel thrombosis in various surgical units in Department of General Surgery, Govt. Kilpauk Medical College &amp; Hospital &amp; Govt Royapettah Hospital,Chennai. All 5 cases have been analyzed for this study during period of 18 months from March 2020 to Augest 2021. All Cases with superior mesenteric vessels thrombosis were included.No exclusion criteria. Results: This case series consisted of 5 cases, three cases of acute mesenteric artery thrombosis and two case of acute mesenteric vein thrombosis. In this case series, superior mesenteric artery thrombosis was more common with male preponderance. 4 out of 5 cases were male in which Superior mesenteric artery was more common when compared to vein thrombosis. Out of 5 cases, 2 cases were asymptomatic with mild abdominal discomfort. Most common complaints of 5 cases were sudden onset of abdominal pain with or without vomiting. Abdominal distension/ Constipation were not seen in all cases. Out of 5 cases, 2post- operative stay and no complications after surgery. 2 cases developed postop complications.1 case had deceased because of late presentation. Conclusion: The diagnosis of AMI is difcult and mostly delayed resulting in irreversible bowel ischemia which requires emergency intervention. Mortality and morbidity for AMI remains high, and in patients requiring extensive bowel resection the survival rate was low. As AMI mostly affects the elderly population physicians have to be aware of the possibility of this condition when facing the elderly patient even with mild sudden onset of abdominal pain complaints. An interdisciplinary collaboration is must, since patients are not initially evaluated by surgeons.