Rate Of Gastrointestinal Complications Research Articles

Comparison of clinical features of patients with or without severe gastrointestinal complications in aggressive gastrointestinal lymphomas.

Aggressive primary gastrointestinal non-Hodgkin lymphoma (PGINHL) is an uncommon and heterogeneous group of lymphoid malignancies, that differs from indolent lymphoma and has a high incidence of severe gastrointestinal complications (GICs). To investigate and compare the clinicopathological characteristics, treatments and outcomes in the GICs and No-GICs group with aggressive PGINHL. This retrospective analysis was performed on aggressive PGINHL patients between January 2013 and December 2021 at our hospital. The independent influence factors of GICs were obtained by univariate and multivariate Logistic regression analysis, the selected variables significantly related to GICs were selected as the final predictors to construct nomogram. Kaplan-Meier curves further analyzed the survival of patients in GICs and No-GICs groups. Survival analysis of GICs group was performed using Cox regression. We focused on 124 aggressive PGINHL cases, which had a relatively high incidence 48.4% (60/124 cases) of GICs, the most common histological type in GICs group was diffuse large B-cell lymphoma (DLBCL) (n = 49, 81.7%). In the GICs group, small intestine was the most common anatomic site of lesion (43.3%), followed by large intestine (31.7%), and then stomach and esophagus (25.0%). Multivariate Logistic regression analysis showed that the independent risk factors for GICs were the small intestine [odd ratio (OR) = 3.33; 95% confidence interval (CI): 1.47-9.41; P = 0.009), aggressive B-cell (OR = 0.09; 95%CI: 0.01-0.83; P = 0.033), maximum tumor diameter (OR = 1.25; 95%CI: 1.07-1.47; P = 0.005), invaded deep serous layer (OR = 3.38; 95%CI: 1.24-9.19; P = 0.017). We developed a nomogram to predict risk of GICs in aggressive PGINHL patients based on independent risk factors. The value of area under curve calculated by receiver operating characteristic curve was 0.815, and calibration curve and decision curve analysis further indicated that the prediction effect was superior. The majority of patients with GICs were given combination therapy (chemotherapy combined with surgery or radiation). Event-free survival and overall survival in GICs group were no worse than those in the No-GICs group. The complication rate of GICs in patients with aggressive PGINHL was relatively high, particularly in PGI-DLBCL. The independent risk factors for GICs were the small intestine, PGI-TNKL, bulky tumor, and depth of invasion. A combination treatment, involving surgery, improved survival in the GICs group.

Surgical management of peritoneal metastases from appendix and colon cancer in patients with inflammatory bowel disease

BackgroundInflammatory bowel disease (IBD) may compromise outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for peritoneal metastases (PM) from appendix/colon cancer. We evaluated CRS/HIPEC outcomes in patients with concurrent IBD. MethodsA matched cohort study using a prospective institutional CRS/HIPEC database (1998–2023) included appendix/colon cancer patients with PM. We matched IBD patients to IBD-free controls in a 1:5 ratio with nearest-neighbor propensity score for sex, age, and peritoneal cancer index (PCI), and exact matching for prior CRS/HIPEC and primary tumor. Perioperative variables, including Clavien-Dindo 90-day complications, were compared. Kaplan-Meier overall (OS) and progression-free survival (PFS) were compared using stratified Cox regression. ResultsOf 605 CRS/HIPECs for appendix/colon cancer, 14 (2.3%) had concurrent Crohn’s disease (n = 6) or ulcerative colitis (n = 8). Seventy IBD-free controls were matched. Nine (64.7%) IBD patients had an appendix primary. Complete cytoreduction (CC-0/1) was achieved in 10 (71.4%) IBD and 57 (81.4%) IBD-free patients (p = 0.468). IBD vs IBD-free patients tended to have more grade-III/IV complications (35.7% [n = 5] vs 15.7% [n = 11], p = 0.082) and had a higher rate of severe nausea/vomiting (35.7% vs 4.3 %, p < 0.001) and diarrhea (28.6% vs 8.6%, p = 0.035). Rates of anastomotic leak (7.1% [n = 1] vs 1.4% [n = 1], p = 0.200) and intraabdominal infections (7.1% [n = 1] vs 2.9% [n = 2], p = 0.430) were similar for IBD vs IBD-free, respectively. IBD did not affect OS (HR [95% CI]: 1.1 [0.4, 2.9]) or PFS (HR [95% CI]: 1.2 [0.4, 3.9]). ConclusionIBD is associated with a higher rate of gastrointestinal complications after CRS/HIPEC for appendix/colon cancer; however, it does not affect OS or PFS.

Low-Dose Enteric-Coated and Chewable Aspirin Are Not Equally Effective in Preventing Venous Thromboembolism in Total Knee and Hip Arthroplasty

BackgroundLow-dose aspirin is an effective venous thromboembolism (VTE) prophylactic medication in primary total joint arthroplasty, but the efficacy and safety of the formulations of chewable and enteric-coated aspirin have not been compared. The purpose of this study was to investigate the VTE and gastrointestinal (GI) complication rates of chewable and enteric-coated 81 mg aspirin bis in die for VTE prophylaxis in primary total joint arthroplasty. MethodsA retrospective, single-institution cohort study was performed on patients who underwent primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2017 to 2021. Comparisons were made between 4,844 patients who received chewable, noncoated aspirin 81 mg and 4,388 patients who received enteric-coated 81 mg aspirin. Power analysis demonstrated 1,978 and 3,686 patients were needed per group to achieve a power of 80% for 90-day VTE rates (using inferiority testing) and GI complications (using superiority testing), respectively. Patients had similar baseline characteristics. Statistical analyses were done using t-tests and Chi-squared tests, with statistical significance defined as a P value < .05. ResultsThere were no significant differences in the incidences of postoperative VTE (0.31% versus 0.55%; P = .111) or GI complications (0.14% versus 0.14%; P = 1.000) between patients who received either chewable or enteric-coated 81 mg aspirin bis in die in the overall comparison that included both THA and TKA patients combined, or THA patients alone. However, the VTE incidence for TKA patients alone was significantly lower with chewable than enteric-coated aspirin (0.22% versus 0.62%; P = .037), with no difference in GI complications (0.13% versus 0.19%; P = .277). ConclusionsLow-dose aspirin in enteric-coated formulation is inferior to chewable aspirin for VTE prophylaxis in primary TKA, but not inferior in THA patients. Both formulations have a similar GI complication rate. Therefore, it is reasonable to consider a transition from enteric-coated to uncoated chewable low-dose aspirin.

Risk factors for gastrointestinal perforation and anastomotic leak in patients submitted to cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)

BackgroundGastrointestinal leak is one of the most feared complications after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) and harbors significant postoperative morbidity and mortality. We aim to identify risk-factors for anastomotic leak (AL) and gastrointestinal perforation (GP) to optimize postoperative outcomes of this population. MethodsWe performed a retrospective analysis of 1043 consecutive patients submitted to CRS in a single institution. Potential risk factors for AL and GP, both related to patient overall condition, disease status and surgical technique were reviewed. ResultsAnastomotic leaks were identified in 5.2% of patients, and GPs in 7.0%. The independent risk-factors for AL were age at surgery (OR1.40; CI95% 1.10–1.79); peritoneal cancer index (PCI) (OR1.04, CI95% 1.01–1.07); Cisplatin dose >240 mg during HIPEC (OR3.53; CI95% 1.47–8.56) and the presence of colorectal (CR) or colo-colic (CC) anastomosis (OR5.09; CI95% 2.71–9.53, and 4.58; CI95% 1.22–17.24 respectively). Male gender and intraoperative red blood cell transfusions were the only independent risk factors for GP identified (OR1.70; CI95% 1.04–2.78 and 1.06; CI95% 1.01–1.12, respectively). Regarding 30-day and 90-day postoperative mortality, independent risk-factors were mainly related to patient's overall condition. ConclusionGastrointestinal leaks are a frequent source of postoperative morbidity, mainly at the expense of GP. A careful and systematic intraoperative revision of all potential gastrointestinal injuries is equally critical to perfecting anastomotic fashioning techniques to decrease gastrointestinal complication rates. We identified multiple risk-factors for AL and GP related to disease status and patient condition. Our study suggests that patient-related conditions are of paramount relevance, highlighting the importance of patient selection and preoperative patient optimization.

Comparison of Two Different Threshold Values for the Measurement of Gastric Residual Volume on Enteral Nutrition Support in the Neurocritically Ill Patients.

BackgroundAlthough recommendations on gastric residual volume (GRV) have been applied to the clinical practice of patients who are intubated, evidence-based data about the GRV of patients who are neurocritically ill are still lacking. We conducted this study to investigate the safety of increased GRV in patients who are neurocritically ill on enteral nutrition (EN) support.MethodsPatients who are neurocritically ill feeding through intragastric enteral tubes were recruited consecutively between July 2018 and June 2021. Patients were divided into a control group (GRV 100 ml) and a study group (GRV 200 ml). Demographic data, admission diagnosis, and severity scores were collected from the patient medical records. The frequency of diet volume ratio (diet received/diet prescribed), the incidence of gastrointestinal complications, and outcome variables were evaluated.ResultsThere were 344 patients enrolled, of whom 197 had mechanical ventilation support. High GRV events in the control group were more frequent than those in the study group (38.1 vs. 22.8%, p = 0.002). The total gastrointestinal complication rate did not differ significantly between the two groups (study group: 61.1%, 102/167 vs. control group: 67.9%, 114/168). In the study group, two patients had aspiration (1.2 vs. 0%, p = 0.245). The study group showed a superior diet volume ratio, but the difference was not significant. The outcomes of the study group were slightly better than those of the control group; however, no significant differences were observed between the two groups concerning the length of stay in the neurointensive care unit (19.5 days vs. 25.3 days) and mortality (10.8 vs. 14.9%) at discharge.ConclusionOur results suggest that 200 ml may be a safe normal limit for GRV in patients who are neurocritically ill.

Effect of Dexmedetomidine-Assisted Intravenous Anesthesia on Gastrointestinal Motility in Colon Cancer Patients After Open Colectomy.

BackgroundTo explore the effect of dexmedetomidine (Dex)-assisted intravenous anesthesia on gastrointestinal motility in patients with colon cancer (CC) after open colectomy.MethodsA total of 102 patients with CC, undergoing open colectomy in our hospital from January 2018 to January 2020, were selected and randomly divided into an observation group (n = 51) and a control group (n = 51). The patients in the control group received a routine combination of intravenous and inhalation anesthesia (CIIA), while those in the observation group received a Dex-assisted CIIA. The systolic blood pressure (SBP), the diastolic blood pressure (DBP), heart rate (HR), and the mean arterial pressure (MAP) were compared at different time points between the two groups. In addition, the intraoperative general conditions, the dosage of anesthetics, and the recovery of gastrointestinal functions were also compared between the two groups. Moreover, before operation and at 24 h after operation, the levels of serum gastrin (GAS) and plasma motilin (MTL) were detected by radioimmunoassay, and the level of plasma cholecystokinin (CCK) was detected by an enzyme-linked immunosorbent assay. The incidence of gastrointestinal complications was recorded in both groups.ResultsAt T1-T3, the HR, SBP, DBP, and MAP levels were lower in both groups than those at T0. In addition, they were also lower in the observation group than those in the control group, showing significant differences (p < 0.05). The dosage of propofol and remifentanil in the observation group was lower than that in the control group, and there was a significant difference (p < 0.05). In the observation group, the postoperative first exhaust time, first defecation time, first ambulation time, and first feeding time were all earlier than those in the control group with significant differences (p < 0.05). After the operation, the observation group had higher levels of GAS and MTL but a lower level of CCK than the control group, and the differences were significant (p < 0.05). The incidence rate of gastrointestinal complications in the observation group (7.04%) was lower than that in the control group (19.61%), and there was a significant difference (χ2 = 4.346, p < 0.05).ConclusionsDex-assisted intravenous anesthesia can facilitate the recovery of gastrointestinal motility, can regulate the levels of gastrointestinal hormones, and can stabilize the levels of hemodynamic indexes in patients with CC after open colectomy.

Impact of tobacco use on perioperative complications and readmission rates following primary anatomic and reverse total shoulder arthroplasty

BackgroundThe purpose of this study is to investigate the relationship between tobacco use and outcomes following both aTSA and rTSA, with the hypothesis being that tobacco users will have inferior postsurgical outcomes compared to nontobacco users. MethodsThe Nationwide Readmission Database (NRD) was queried from 2016 to 2018 to identify qualifying cases of aTSA (n = 16,241) and rTSA (n = 23,975). These groups were further subdivided based on tobacco use status. Demographic and hospital characteristics were first compared between groups. The unadjusted incidence of postoperative medical and shoulder-specific complications, mortality, revisions, and readmissions were then compared. Finally, the groups were assessed for the same variables after controlling for demographic factors and comorbidities. ResultsFor both aTSA and rTSA, statistically significant differences exist in regard to age, sex, primary expected payer, median household income, hospital region, hospital teaching status, and total number of comorbidities between tobacco users and nonusers (all P < .05). Tobacco users undergoing aTSA experienced higher rates of gastrointestinal complications (0.07% vs. 0.01%, P = .021) and readmissions (15.3% vs. 13.6%, P = .007), while tobacco users undergoing rTSA experienced higher rates of acute renal failure (2.5% vs. 1.9%, P = .005), acute respiratory distress (1.3% vs. 0.9%, P = .002), and the need for ventilator assistance (1.2% vs. 0.7%, P < .001). Adjusted analysis showed that tobacco users were more likely to develop acute respiratory distress syndrome (OR = 1.292, P = .036) and require ventilator assistance (OR = 1.376, P = .008), and are more likely to have at least one readmission (P = .026). ConclusionThe results of this study demonstrate that tobacco users undergoing primary aTSA and rTSA are at an increased risk for several perioperative complications and are more likely to be readmitted following surgery compared to nontobacco users. These findings highlight the importance of determining a patient's tobacco use status as consideration should be given to not performing a TSA until tobacco use has stopped. Level of evidenceLevel III; Retrospective Cohort Treatment Study

Gastrointestinal manifestations of SARS-CoV-2 infection in an Italian population of hospitalized patients.

Background:Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus enters the cells via angiotensin-converting enzyme 2 receptor; therefore, tissues expressing this receptor are potential targets for infection. Although many studies have observed gastrointestinal (GI) symptoms in coronavirus disease 2019 (COVID-19) patients, prevalence and clinical impact are still uncertain due to the heterogeneity of reports and obstacles to generalization.Methods:In this cross-sectional study, we included symptomatic patients requiring hospital admission, with a confirmed diagnosis of COVID-19 by nasopharyngeal polymerase chain reaction test, between 18 March and 30 May 2020. Demographic data, symptoms at onset, vital signs, and laboratory tests at admission were recorded.Results:In all, 300 patients were included (57%M, 43%F). GI symptoms were mainly diarrhea (13%), anorexia (4.3%), vomiting (3%), and abdominal pain (2.3%). Overall, males were younger (68 years versus 76 years; p = 0.01); patients with GI manifestations at disease onset required significantly faster hospital admission and showed larger GI complication rates. GI symptoms were associated with abnormal high aspartate aminotransferase and alanine aminotransferase serum titers, especially in male patients.Conclusion:Our study on an Italian population during the outbreak of the COVID-19 pandemic shows that GI symptoms are part of the spectrum of the SARS-CoV-2 infection and could be the only manifestations at disease onset. Although patients with GI symptoms were associated with faster hospital admission and liver involvement, prognosis was not affected.

Outcomes of Women Undergoing Excision of the Retained Cervix After Supracervical Hysterectomy.

To characterize the indications for and complication rates of excision of the retained cervix after supracervical hysterectomy. We performed a retrospective cohort study of women undergoing excision of the retained cervix after supracervical hysterectomy in the 2010-2014 National Inpatient Sample. International Classification of Diseases, Ninth Revision codes were used to identify indication for the procedure and surgical complications. We weighted the hospital-level data to obtain nationwide estimates of patient characteristics, surgical complications, and length of stay. Nationwide, 1,140 women underwent excision of the retained cervix after hysterectomy. Their mean age was 49 years, and the majority were White and privately insured. Leiomyomas were the most commonly coded indication (35%, 95% CI 29-42), followed by prolapse (14%, 95% CI 9-18). Eighteen percent (95% CI 13.0-23.1) were performed for malignancy, including 5.3% (95% CI 2.3-8.2) for cervical cancer. Only 11.5% (95% CI 7.3-15.6) of cases were performed laparoscopically. The overall complication rate was high (38%, 95% CI 32-45), particularly for bleeding complications (26%, 95% CI 20-31) and transfusion (15%, 95% CI 11-20). Gastrointestinal complication rates were second highest (8%, 95% CI 5-12); ileus was the most common gastrointestinal complication (7.0%, 95% CI 3.7-10.4). The median length of stay was 2 days (range 0-34). Women who undergo excision of the retained cervix after supracervical hysterectomy experience high rates of complications, the most common of which was bleeding. Patient counseling regarding removal of the cervix at the time of hysterectomy should include this information.

Gastrointestinal complications after cardiac surgery: Incidence, predictors, and impact on outcomes.

The purpose of this study was to investigate the incidence, predictors, and long-term impact of gastrointestinal (GI) complications following adult cardiac surgery. Index Society of Thoracic Surgeons (STS) adult cardiac operations performed between January 2010 and February 2018 at a single institution were included. Patients were stratified by the occurrence of postoperative GI complications. Outcomes included early and late survival as well as other associated major postoperative complications. A subanalysis of propensity score-matched patients was also performed. A total of 10,285 patients were included, and the overall rate of GI complications was 2.4% (n = 246). Predictors of GI complications included dialysis dependency, intra-aortic balloon pump, congestive heart failure, chronic obstructive pulmonary disease, and longer aortic cross-clamp times. Thirty-day (2.6% vs. 24.8%), 1- (6.3% vs. 41.9%), and 3-year (11.1% vs. 48.4%) mortality were substantially higher in patients who experienced GI complications (all p < .001). GI complication was associated with a threefold increased hazard for mortality (hazard ratio = 3.1, 95% confidence interval = 2.6-3.7) after risk adjustment, and there was an association between the occurrence of GI complications and increased rates of renal failure (39.4% vs. 2.5%), new dialysis dependency (31.3% vs. 1.5%), multisystem organ failure (21.5% vs.1.0%), and deep sternal wound infections (2.6% vs. 0.2%; all p < .001). These results persisted in propensity-matched analysis. GI complications are infrequent but have a profound impact on early and late survival, and often occur in association with other major complications. Risk factor modification, heightened awareness, and early detection and management of GI complications appear warranted.

The Role of Nutritional Access in Malnourished Elderly Undergoing Major Surgery for Acute Abdomen: A Propensity Score-Matched Analysis.

About 50% of the elderly undergoing emergency abdominal surgery are malnourished. The role of timely surgical nutritional access in this group of patients is unknown. We analyzed the National Inpatient Sample database from 2009 through the first three-quarters of 2015 of patients aged ≥65years who were malnourished and underwent major abdominal surgery for the acute abdomen within the first 2days of hospital admission. Of 3246721 patients analyzed, 4311 patients met inclusion criteria. Of these, only 507 (11.8%) patients had surgical nutritional access (gastrostomy or jejunostomy) (group I), while 3804 patients (88.2%) did not (group II). In the propensity score-matched population, there were 482 patients in each group. The patients in group I had lower odds of mortality and postoperative gastrointestinal complications (paralytic ileus, anastomotic dehiscence, and intestinal fistulae) (P-value <.01, respectively). Elderly who receive surgical nutritional access have lower rates of gastrointestinal complications and mortality.

Low Incidence of Severe Gastrointestinal Complications in COVID-19 Patients Admitted to the Intensive Care Unit: A Large, Multicenter Study

Patients hospitalized with Coronavirus Disease 2019 (COVID-19) often have gastrointestinal symptoms, including diarrhea, nausea, vomiting, and abdominal pain.1 However, the rate of gastrointestinal complications in patients with COVID-19 is less well described. Recent reports from a single center have suggested an alarmingly high rate of serious gastrointestinal complications in critically ill patients with COVID-19.2,3 In a retrospective review of 92 patients with severe COVID-19 admitted to the intensive care unit (ICU), 44 patients (48%) had ileus, 4 (4%) had intestinal ischemia, and 2 (2%) had Ogilvie syndrome.

Early Gastrointestinal Complications From Ventricular Assist Devices is Increased by Non-Pulsatile Flow

Measurements of organ flow and perfusion during cardiopulmonary bypass suggest that perfusion of the splanchnic bed can be impaired by non-pulsatile flow. We postulated that non-pulsatile flow from centrifugal ventricular assist devices might also compromise splanchnic blood flow and cause bowel ischaemia especially in the period of circulatory instability early post-implant. The aim of the present studies was to compare the incidence of gastrointestinal (GI) complications in patients having a non-pulsatile device with the incidence in those having a pulsatile device. In a pilot study, the initial 12 patients who received the Ventrassist (Ventracor, Sydney, NSW, Australia) centrifugal, non-pulsatile device during the period from June 2003 to September 2005 at the Alfred Hospital, Melbourne were compared with 11 patients who received a Thoratec (Thoratec, Pleasanton, CA, USA), pulsatile, positive displacement device and the incidence was recorded of GI complications requiring an intervention either surgical, endoscopic or by interventional radiology. This was followed by a larger (full) study of a second cohort of similar ventricular assist device (VAD) patients from January 1992 until December 2012 comparing 53 patients having non-pulsatile devices and 110 having pulsatile devices. In the pilot study, the overall incidence of complications in the non-pulsatile group (67%) was almost double that in the pulsatile group (36%) but the difference was not statistically significant (p = 0.15) because of the small number (n = 23) of participants. In the full study, all GI complications with either device occurred within the first 3 weeks post-implant. In the non-pulsatile patients, there was a higher incidence of GI bleeding, 23% vs 4% (p = 0.002), endoscopies, 24% vs 12% (p = 0.049). More patients with a non-pulsatile flow device had delayed absorption of nasogastric feeds than their pulsatile counterparts, 35% vs 7% (p < 0.0001). Patients with a non-pulsatile flow device had a higher overall rate of gastrointestinal complications than patients had with a pulsatile flow device, 56% vs 20% (p < 0.0001). After correcting for the other predictors, the odds of developing a gastrointestinal complication in the pulsatile group was significantly lower (odds ratio 0.07) than in the non-pulsatile device group (p < 0.0001). We conclude that the use of non-pulsatile centrifugal VADs compared with pulsatile positive displacement VADs is associated with a higher incidence of both haemorrhagic and ischaemic complications in the gastro-intestinal system especially in the very early post-implant period. Whether these complications could be reduced in centrifugal devices by increasing their pulsatility is not clear and merits further research.

Increased Efficacy and Safety of Enteral Nutrition Support with a Protocol (ASNET) in Noncritical Patients: A Randomized Controlled Trial

BackgroundUnintentional underfeeding is common in patients receiving enteral nutrition (EN), and is associated with increased risk of malnutrition complications. Protocols for EN in critically ill patients have been shown to enhance adequacy, resulting in better clinical outcomes; however, outside of intensive care unit (ICU) settings, the influence of a protocol for EN is unknown. ObjectiveTo evaluate the efficacy and safety of implementing an EN protocol in a noncritical setting. DesignRandomized controlled clinical trial. Participants and settingsThis trial was conducted from 2014 to 2016 in 90 adult hospitalized patients (non-ICU) receiving exclusively EN. Patients with carcinomatosis, ICU admission, or <72 hours of EN were excluded. InterventionThe intervention group received EN according to a protocol, whereas the control group was fed according to standard practice. Main outcome measuresThe proportion of patients receiving ≥80% of their caloric target at Day 4 after EN initiation. Statistical analyses performedStudent t test or Wilcoxon rank-sum test were used for continuous variables and the difference between the groups in the time to receipt of the optimal amount of nutrition was analyzed using Kaplan-Meier curves. ResultsForty-five patients were randomized to each group. At Day 4 after EN initiation, 61% of patients in the intervention arm had achieved the primary end point compared with 23% in the control group (P=0.001). In malnourished patients, 63% achieved the primary end point in the intervention group compared with 16% in the control group (P=0.003). The cumulative deficit on Day 4 was lower in the intervention arm compared with the control arm: 2,507 kcal (interquartile range [IQR]=1,262 to 2,908 kcal) vs 3,844 kcal (IQR=2,620 to 4,808 kcal) (P<0.001) and 116 g (IQR=69 to 151 g) vs 191 g (IQR=147 to 244 g) protein (P<0.001), respectively. The rates of gastrointestinal complications were not significantly different between groups. ConclusionsImplementation of an EN protocol outside the ICU significantly improved the delivery of calories and protein when compared with current standard practice without increasing gastrointestinal complications.

Gastrointestinal Complications Following Radical Cystectomy Using Enhanced Recovery Protocol

BackgroundThe development of enhanced recovery after surgery (ERAS) protocols for patients undergoing radical cystectomy (RC) represents a significant advance in perioperative care. ObjectiveTo evaluate gastrointestinal (GI) complications following RC and urinary diversion (UD) using our institutional ERAS protocol. Design, setting, and participantsWe identified 377 consecutive cases of open RC and UD for which our ERAS protocol was used from May 2012 to December 2015. Exclusion criteria were consent refusal; non-bladder primary disease; palliative, salvage, or additional surgery; and prolonged postoperative intubation. A matched cohort of 144 patients for whom a traditional postoperative protocol (pre-ERAS) was used between 2003 and 2012 was selected for comparison. Results and limitationsA total of 292 ERAS patients with median age of 70 yr were included in the study, 65% of whom received an orthotopic neobladder. The median time to first flatus and bowel movement was 2 d. The median length of stay was 4 d. GI complications occurred in 45 patients (15.4%) during the first 30 d following RC, 93% of which were of minor grade. The most common GI complication was postoperative ileus (POI) in 34 cases (11.6%). Some 22 patients (7.5%) required a nasogastric tube, and parenteral nutrition was required in three patients. The rate of 30-d GI complications was significantly lower in the ERAS cohort than in the control group (13% vs 27%; p=0.003), as was the rate of POI (7% vs 23%; p<0.001). This effect was independent of other variables (hazard ratio 0.38, 95% confidence interval 0.18–0.82; p=0.01). ConclusionsOur institutional ERAS protocol for RC is associated with significantly improved perioperative GI recovery and lower rates of GI complications. This protocol can be tested in multi-institutional studies to reduce GI morbidity associated with RC. Patient summaryIn this study, we showed that an enhanced recovery protocol for patients undergoing radical cystectomy for bladder cancer was associated with a significantly shorter length of hospital stay and lower rates of gastrointestinal complications, especially postoperative ileus.

Extraperitoneal vs Transperitoneal Robot-Assisted Radical Prostatectomy in the Setting of Prior Abdominal or Pelvic Surgery

During robot-assisted radical prostatectomy (RARP), the prostate may be approached extraperiteoneally (extraperitoneal robot-assisted radical prostatectomy [eRARP]) or transperitoneally (transperitoneal robot-assisted radical prostatectomy [tRARP]). The former avoids the abdominal cavity, which might be of benefit in patients who have had prior abdominal or pelvic surgery (PAPS). Our objective was to compare the outcomes of patients with PAPS undergoing either technique. A retrospective review of patients treated with RARP from July 1, 2003 to December 31, 2014 with a minimum follow-up of 3 months was undertaken. Of 2927 patients, 620 were identified as having undergone RARP (without concomitant unrelated procedures) and PAPS (excluding patients with prior inguinal hernia repair with mesh or unclear surgical histories) for prostate adenocarcinoma without prior pelvic radiotherapy. Of these, 340 patients underwent eRARP and 280 patients underwent tRARP. Patients in the eRARP group were younger (61.04 years vs 62.32, p = 0.02), had a higher body mass index (29.65 vs 28.98, p = 0.09), lower American Society of Anesthesiologists scores (p = 0.03), and lower D'Amico risk classification disease (p < 0.0001). The two groups had similar rates of 1, 2, and >2 PAPS. On univariate analysis, the eRARP group had lower operative time (188.96 minutes vs 197.92 minutes, p = 0.003), extensive lysis of adhesions (0.9% vs 14.3%, p < 0.0001), length of hospital stay (LOS) (1.13 days ±0.45 vs 1.33 day ±1.08, p = 0.003), and higher estimated blood loss (210.74 mL vs 190.79 mL, p = 0.06). The eRARP group had a lower rate of gastrointestinal complications (0% vs 3.21%, p = 0.0007), a trend toward lower early post-operative complications (8.53% vs 12.86%, p = 0.08), and lower overall complications (9.41% vs 15%, p = 0.03). In regression analysis with model selection, only LOS was lower in the eRARP group (p = 0.02). Both methods are safe in patients with prior abdominal surgeries. A lower incidence of gastrointestinal complications and a shorter length of stay were noted in the extraperitoneal cohort.

Radical cystectomy for bladder cancer: сomparison of early surgical complications during laparoscopic, open-access, and video-assisted surgery

Objectives. To evaluate peri- and postoperative morbidity and functional results of LRC in a single-site cohort of patients, comparing it with standard open approach (ORC) and laparoscopic cystectomy with open urinary diversion (HALRC). Subjects and methods. A prospective analysis was performed in 51 muscle-invasive and locally advanced BCa patients who underwent RC between February 2012 and March 2014 in N. N. Petrov Research Institute of Oncology, Saint-Petersburg. The final cohort included 21 ORC, 21 LRC and 9 HALRC patients. Mean patients age was 64 (38–81) years old and did not differ in all groups. Pathological stage were similar in all groups. Multivariable logistic and median regression was performed to evaluate operating time, perioperative and postoperative complications (30-d and 90-d), readmission rates, length of stay (LOS) – totally and in ICU. Results. Operating time during LRC and HALRC was longer than that of ORC (398 min vs 468 min vs 243 min, respectively). Despite that, there was no statistically significant influence of type of surgery on intraoperative complications – 14.3 % in ORC group, 11.1 % in HALRC and 4.7 % in LRC patients. Major complication rates (Clavien grade  3; 23.8 % vs 33.3 % vs 19.4 %) were similar between all groups. However, LRC had 4,0 times lower rate of minor complications (Clavien grade 1–2) compared to ORC (4.7 % vs 19.0 %). LRC had a significantly shorter LOS (27.8 d vs 32.6 d vs 22.6 d in ORC, HALRC and LRC groups, respectively), but no significant differences in ICU stay existed (5.1 d vs 3.1 d vs 2.1 d). Morbidity were present by one patient in each group (medium rate 5,8 %). The common transfusion rate during and after surgical intervention was 19.6 % and was higher in ORC group (33.3 % vs 4.7 % in LRC); as well, intraoperative bleeding was lower in minimally invasive techniques – the average volume of blood loss was 285 ml in LRC and did not differ between HALRC and ORC groups – 468 and 577 ml, respectively. Depending on the timing of complications, there were 30-d complications in 19 patients (37,2 %) and 90-d in 27 (52,9 %). The greatest difference was observed between any grade gastrointectinal complications (foremost, ileus) with significantly better outcomes in LRC patients – 14.2 %, compared with 47.6 % and 55 % in ORC and HALRC, respectively. Conclusions. We found that LRC is safe and associated with lower blood loss, decreased postoperative ileus and lower LOS compared with ORC. Using a population-based cohort, we found that laparoscopic surgery for bladder cancer decreased minor complications (mainly due to lower bleeding and gastrointestinal complication rate) and had no impact on major complications.

Randomized study to compare nasojejunal with nasogastric nutrition in critically ill patients without prior evidence of altered gastric emptying.

Background and Aims:Studies comparing jejunal and gastric nutrition show inconsistent results regarding pneumonia. The aim of this study was to evaluate the incidence of pneumonia comparing gastric with jejunal nutrition. Secondarily, we evaluated 28th day Intensive Care Unit (ICU) mortality rate and other complications related to enteral feeding.Subjects:Age >18 years; need for enteral nutrition without contraindication for placement of an enteral tube, duration of ICU stay > than 48 h.Methods:Patients were randomly assigned to receive enteral feed via a gastric or jejunal tube. Jejunal tubes were inserted at bedside and placement was confirmed radiographically.Results:A total of 115 patients were enrolled, with 61 patients into the gastric tube group and 54 patients into the jejunal group tube. Baseline characteristics were similar. There was no difference in pneumonia or ICU mortality rates, ICU length of stay and ventilator days. Complications rates were similar.Conclusions:We conclude that the enteral nutrition through a jejunal tube does not reduce the rate of pneumonia in comparison to a gastric tube. In addition, we did not observe differences in rates of gastrointestinal complications or ICU mortality. The routine placement of a jejunal tube in critically ill-patients cannot be recommended.

Perioperative and postoperative morbidity after sacrocolpopexy according to age in Korean women.

ObjectiveThis study aimed to compare perioperative and postoperative morbidity of older and younger women undergoing sacrocolpopexy (SCP).MethodsA retrospective study included 271 patients who underwent laparotomic SCP for symptomatic pelvic organ prolapse from November 2008 to June 2013 at our institution. By the review of medical records, perioperative and postoperative data including the length of the surgery, estimated blood loss, blood transfusion, the length of hospital stay, wound complications and febrile morbidity were collected. In addition, cardiovascular, pulmonary, gastrointestinal, genitourinary, or neurological adverse events were retrieved. The need for an indwelling urinary catheter or performance of clean intermittent self-catheterization, mesh erosion rate and the number of days required for each were included in the postoperative outcomes. For the outcome variable analyzed in this study, the patients was dichomotized into women aged 65 and older and those younger than 65.ResultsOne hundred and thirty-five (49.8%) patients were younger than 65 and 136 (50.2%) were aged 65 and older. Older women had higher body mass index, vaginal parity and prior surgery for hysterectomy than younger women (P<0.05). And older women had higher baseline comorbidities, such as hypertension, diabetes, cardiac disease (P<0.05), and their American society of Anesthesiologist class was higher (P<0.001). In the perioperative and postoperative complication, older group showed no differences in most of the operation-related complication rates, but gastrointestinal complication rate. Also, mesh erosion rate was not found to be significantly different between the two groups at the last visit.ConclusionOlder women undergoing laparotomic SCP have similar perioperative and postoperative morbidities as younger women, suggesting surgeons can counsel older and younger women similarly in terms of operative risks.

High-dose-rate interstitial brachytherapy in combination with androgen deprivation therapy for prostate cancer: are high-risk patients good candidates?

To evaluate the effectiveness of high-dose-rate interstitial brachytherapy (HDR-ISBT) as the only form of radiotherapy for high-risk prostate cancer patients. Between July 2003 and June 2008, we retrospectively evaluated the outcomes of 48 high-risk patients who had undergone HDR-ISBT at the National Hospital Organization Osaka National Hospital. Risk group classification was according to the criteria described in the National Comprehensive Cancer Network (NCCN) guidelines. Median follow-up was 73 months (range 12-109 months). Neoadjuvant androgen deprivation therapy (ADT) was administered to all 48 patients; 12 patients also received adjuvant ADT. Maximal androgen blockade was performed in 37 patients. Median total treatment duration was 8 months (range 3-45 months). The planned prescribed dose was 54 Gy in 9 fractions over 5 days for the first 13 patients and 49 Gy in 7 fractions over 4 days for 34 patients. Only one patient who was over 80 years old received 38 Gy in 4 fractions over 3 days. The clinical target volume (CTV) was calculated for the prostate gland and the medial side of the seminal vesicles. A 10-mm cranial margin was added to the CTV to create the planning target volume (PTV). The 5-year overall survival and biochemical control rates were 98 and 87 %, respectively. Grade 3 late genitourinary and gastrointestinal complications occurred in 2 patients (4 %) and 1 patient (2 %), respectively; grade 2 late genitourinary and gastrointestinal complications occurred in 5 patients (10 %) and 1 patient (2 %), respectively. Even for high-risk patients, HDR-ISBT as the only form of radiotherapy combined with ADT achieved promising biochemical control results, with acceptable late genitourinary and gastrointestinal complication rates.