Postoperative Diarrhea Research Articles

Preservation of the celiac branch of the vagus nerve reduces the incidence of postoperative diarrhea in gastric cancer: a cohort study

BackgroundTo investigate the short-term and long-term outcomes of preserving the celiac branch of the vagus nerve during laparoscopic distal gastrectomy.MethodsA total of 149 patients with prospective diagnosis of gastric cancer who underwent laparoscopic-assisted distal gastrectomy (LADG) combined with Billroth-II anastomosis and D2 lymph node dissection between 2017 and 2018 were retrospectively analyzed. The patients were divided into the preserved LADG group (P-LADG, n = 56) and the resected LADG group (R-LADG, n = 93) according to whether the vagus nerve celiac branch was preserved. We selected 56 patients (P-LADG, n = 56) with preservation of the celiac branch of the vagus nerve and 56 patients (R-LADG, n = 56) with removal of the celiac branch of the vagus nerve by propensity-matched score method. Postoperative nutritional status, weight change, short-term and long-term postoperative complications, and gallstone formation were evaluated in both groups at 5 years of postoperative follow-up. The status of residual gastritis and bile reflux was assessed endoscopically at 12 months postoperatively.ResultsThe incidence of diarrhea at 5 years postoperatively was lower in the P-LADG group than in the R-LADG group (p < 0.05). In the multivariate logistic analysis, the removal of vagus nerve celiac branch was an independent risk factor for the occurrence of postoperative diarrhea (odds ratio = 3.389, 95% confidential interval = 1.143-10.049, p = 0.028). In the multivariate logistic analysis, the removal of vagus nerve celiac branch was an independent risk factor for the occurrence of postoperative diarrhea (odds ratio = 4.371, 95% confidential interval = 1.418-13.479, p = 0.010).ConclusionsPreservation of the celiac branch of the vagus nerve in LADG reduced the incidence of postoperative diarrhea postoperatively in gastric cancer.Trial registrationThis study was registered with the Ethics Committee of the First Affiliated Hospital of Dalian Medical University in 2014 under the registration number: LCKY2014-04(X).

Comparison of prognosis and postoperative morbidities between standard pancreaticoduodenectomy and the TRIANGLE technique for resectable pancreatic ductal adenocarcinoma.

Radical surgery combined with systemic chemotherapy offers the possibility of long-term survival or even cure for patients with pancreatic ductal adenocarcinoma (PDAC), although tumor recurrence, especially locally, still inhibits the treatment efficacy. The TRIANGLE technique was introduced as an extended dissection procedure to improve the R0 resection rate of borderline resectable or locally advanced PDAC. However, there was a lack of studies concerning postoperative complications and long-term outcomes of this procedure on patients with resectable PDAC. To compare the prognosis and postoperative morbidities between standard pancreaticoduodenectomy (PD) and the TRIANGLE technique for resectable PDAC. Patients with resectable PDAC eligible for PD from our hospital between June 2018 and December 2021 were enrolled in this retrospective cohort study. All the patients were divided into PDstandard and PDTRIANGLE groups according to the surgical procedure. Baseline characteristics, surgical data, and postoperative morbidities were recorded. All of the patients were followed up, and the date and location of tumor recurrence, and death were recorded. The Kaplan-Meier method and log-rank test were used for the survival analysis. There were 93 patients included in the study and 37 underwent the TRIANGLE technique. Duration of operation was longer in the PDTRIANGLE group compared with the PDstandard group [440 (410-480) min vs 320 (265-427) min] (P = 0.001). Intraoperative blood loss [700 (500-1200) mL vs 500 (300-800) mL] (P = 0.009) and blood transfusion [975 (0-1250) mL vs 400 (0-800) mL] (P = 0.009) were higher in the PDTRIANGLE group. There was a higher incidence of surgical site infection (43.2% vs 12.5%) (P = 0.001) and postoperative diarrhea (54.1% vs 12.5%) (P = 0.001) in the PDTRIANGLE group. The rates of R0 resection and local recurrence, overall survival, and disease-free survival did not differ significantly between the two groups. The TRIANGLE technique is safe, with acceptable postoperative morbidities compared with standardized PD, but it does not improve prognosis for patients with resectable PDAC.

Risk factors of post-operative diarrhoea in patients with pancreatic cancer after neoadjuvant chemotherapy: A retrospective cohort study.

Post-operative diarrhoea is a common adverse event after pancreatic surgery. While the risk factors for this condition have been identified, the increasing trend of administering chemotherapy before surgery might change these factors. This study aimed to identify the risk factors of post-operative diarrhoea in patients with pancreatic ductal adenocarcinoma (PDAC) who underwent neoadjuvant chemotherapy. A retrospective cohort study. Patients who underwent neoadjuvant chemotherapy and pancreatectomy because of PDAC between 2021 and 2023 were included. The preoperative characteristics of, operative details of and post-operative outcomes in patients with and without post-operative diarrhoea were collected and compared. The independent risk factors of post-operative diarrhoea were identified using logistic regression analysis. STROBE checklist was used. Post-operative diarrhoea occurred in 65 out of 145 (44.8%) patients during hospitalization. Elevated white blood cell count, advanced tumour stage, and late abdominal drain removal were independent risk factors for post-operative diarrhoea (p < .001, p = .006 and p = .009, respectively). Some perioperative factors influence post-operative diarrhoea in patients who undergo neoadjuvant chemotherapy. More attention should be paid to patients at a higher risk of post-operative diarrhoea, with an emphasis on high-quality management for these patients.

Incidence and clinical relevance of postoperative diarrhea after minimally invasive gastrectomy for gastric cancer: a single institution retrospective study of 1476 patients.

Postoperative diarrhea (PD) remains one of the significant complications. Only a few studies focused on PD after minimally invasive surgery. We aimed to investigate PD after minimally invasive gastrectomy for gastric cancer. A total of 1476 consecutive patients with gastric cancer undergoing laparoscopic or robotic gastrectomy between 2009 and 2019 at our institution were retrospectively reviewed. PD was defined as continuous diarrhea for ≥ 2days, positive stool culture, or positive clostridial antigen test. The incidence, causes, and related clinical factors were analyzed. Of the 1476 patients, the median age was 69years. Laparoscopic and robotic approaches were performed in 1072 (72.6%) and 404 (27.4%), respectively. Postoperative complications with Clavien-Dindo classification grade of ≥ IIIa occurred in 108 (7.4%) patients. PD occurred in 89 (6.0%) patients. Of the 89 patients with PD, Clostridium difficile, enteropathogenic Escherichia coli, and methicillin-resistant Staphylococcus aureus were detected in 24 (27.0%), 16 (33.3%), and 7 (14.6%) patients, respectively. Multivariate analysis revealed that age ≥ 75years (OR 1.62, 95% CI [1.02-2.60], p = 0.042) and postoperative complications (OR 6.04, 95% CI [3.54-10.32], p < 0.001) were independent risk factors for PD. In patients without complications, TG (OR 1.88) and age of ≥ 75years(OR 1.71) were determined as independent risk factors. The incidence of PD following minimally invasive gastrectomy for gastric cancer was 6.0%. Older age and TG were obvious risk factors in such a surgery, with the latter being a significant risk even in the absence of complications.

Postoperative diarrhea in Crohn's disease: Pathogenesis, diagnosis, and therapy.

Diarrhea is a frequent symptom in postoperative patients with Crohn's diseases (CD), and several different mechanisms likely account for postoperative diarrhea in CD. A targeted strategy based on a comprehensive understanding of postoperative diarrhea is helpful for better postoperative recovery.

Single Anastomosis Duodeno-Ileal Bypass (SADI) as a Second Step After Failed Sleeve Gastrectomy: Systematic Review and Meta-analysis.

Our aim in this study is to assess single anastomosis duodeno-ileal bypass (SADI) as a salvage procedure following sleeve gastrectomy (SG), examining its technical feasibility, outcomes, and potential complications. A systematic review and meta-analysis were conducted, drawing data from PubMed, Medline, and the Cochrane library. The analysis encompassed 14 studies, involving 1,066 patients. We evaluated operative time, comorbidity resolution (hypertension, dyslipidemia, diabetes), post-operative diarrhea incidence, excess weight loss (EWL) at six, twelve, and twenty-four months, and post-operative leak rates. SADI as a salvage procedure following SG yielded positive outcomes. Mean operative time was 125.98 minutes (95% CI 102.50-149.46, I2=99%). Importantly, SADI led to comorbidity resolution in a notable proportion of cases: hypertension in 48% (95% CI 38-57%, I2=44%), dyslipidemia in 55% (95% CI 40-69%, I2=30%), and diabetes in 63% (95% CI 53-72%, I2=30%) of patients. Post-operative diarrhea incidence was relatively low at 2% (95% CI 1-9%, I2=75%). In terms of weight loss, SADI patients exhibited substantial EWL: 47.73% (95% CI 37.86-57.61, I2=95%) at six months, 59.39% (95% CI 51.18-67.61, I2=95%) at twelve months, and 23.84% (95% CI 5.76-41.92, I2=100%). At twenty-four months. Furthermore, post-operative leak rate was relatively low, reported in only 1% (95% CI 0-5%, I2=80%) of cases. SADI as a salvage procedure post-SG demonstrates technical feasibility and marked effectiveness. It offers substantial comorbidity resolution, significant weight loss, and low post-operative complication rates, notably post-operative leaks. Further research should investigate the long-term impact of SADI on patient nutritional status to facilitate its broader adoption.

Current status of influencing factors for postoperative anastomotic leakage in low rectal cancer

The incidence of anastomotic leakage, a common and serious postoperative complication of low rectal cancer, remains high. Clarifying the risk factors for anastomotic leakage in patients with low rectal cancer after surgery can help guide clinical treatment and help patients improve their prognosis. The current literature suggests that the risk factors affecting the occurrence of anastomotic leakage after low rectal cancer include three aspects: (1) individual factors: male gender, high body mass index, malnutrition, smoking, alcoholism, and metabolic diseases; (2) tumor factors: the lower margin of tumor <5 cm from the anal verge, tumor diameter >2.5 cm, late tumor stage, high level of tumor markers and preoperative intestinal obstruction; (3) surgical factors: long operative time (>180 min), intraoperative bleeding (≥70 ml), more than 2 cartridges of stapling for anastomosis, contamination of the operative field, epidural analgesia and intraoperative hypothermia. Notably, the surgical approach (laparoscopic, open and hand-assisted laparoscopic surgery) was not a factor influencing the occurrence of postoperative anastomotic leakage in low rectal cancer. The findings on the effects of receiving neoadjuvant therapy, gut microbiota,intestinal bowel preparation, insufficient time for preoperative antibiotic prophylaxis, left colonic artery dissection, intraoperative blood transfusion, pelvic drainage, transanal drainage and combined organ resection, and postoperative diarrhea on postoperative anastomotic leakage in low rectal cancer are controversial. However, clinical workers can still take measures to reduce the risk of anastomotic leakage according to the above risk factors by making a good assessment before surgery, actively avoiding them during and after surgery, and taking measures for each step, so as to bring maximum benefits to patients.

Effects of Modified Baizhu Shaoyao San on Postoperative Diarrhea in Colorectal Cancer Patients: A Single-Blind, Randomized Controlled Trial

Introduction: Postoperative gastrointestinal tract dysfunction is considered a common complication affecting patients undergoing intestinal surgery. This research aims to provide evidence to assess the efficacy and safety of Baizhu Shaoyao San (BSS) or modified BSS in treating postoperative diarrhea of colorectal cancer patients. Methods: Eighty patients with colorectal cancer were randomized within 2 weeks after surgery to receive either modified BSS or Loperamide combined with the respective dummy. The curative effect was evaluated with the traditional Chinese medicine (TCM) syndrome score. Determination of motilin and gastrin in plasma was conducted utilizing ELISA. Results: Compared with Loperamide therapy, the efficacy of modified BSS was statistically significant, the TCM syndrome score decreased, and the total effective rate increased. Levels of motilin and gastrin in plasma decreased. Conclusion: The curative effect and safety of modified BSS were statistically significant.

Risk factors of postoperative surgical site infection in colon cancer based on a single center database

Objective: To explore the incidence and risk factors of postoperative surgical site infection (SSI) after colon cancer surgery. Methods: A retrospective case-control study was performed. Patients diagnosed with colon cancer who underwent radical surgery between January 2016 and May 2021 were included, and demographic characteristics, comorbidities, laboratory tests, surgical data and postoperative complications were extracted from the specialized prospective database at Department of General Surgery, Peking Union Medical College Hospital. Case exclusion criteria: (1) simultaneously multiple primary colon cancer; (2) segmental resection, subtotal colectomy, or total colectomy; (3) patients undergoing colostomy/ileostomy during the operation or in the state of colostomy/ileostomy before the operation; (4) patients receiving natural orifice specimen extraction surgery or transvaginal colon surgery; (5) patients with the history of colectomy; (6) emergency operation due to intestinal obstruction, perforation and acute bleeding; (7) intestinal diversion operation; (8) benign lesions confirmed by postoperative pathology; (9) patients not following the colorectal clinical pathway of our department for intestinal preparation and antibiotic application. Univariate analysis and multivariate analysis were used to determine the risk factors of SSI after colon cancer surgery. Results: A total of 1291 patients were enrolled in the study. 94.3% (1217/1291) of cases received laparoscopic surgery. The incidence of overall SSI was 5.3% (69/1291). According to tumor location, the incidence of SSI in the right colon, transverse colon, left colon and sigmoid colon was 8.6% (40/465), 5.2% (11/213), 7.1% (7/98) and 2.1% (11/515) respectively. According to resection range, the incidence of SSI after right hemicolectomy, transverse colectomy, left hemicolectomy and sigmoid colectomy was 8.2% (48/588), 4.5% (2/44), 4.8% (8 /167) and 2.2% (11/492) respectively. Univariate analysis showed that preoperative BUN≥7.14 mmol/L, tumor site, resection range, intestinal anastomotic approach, postoperative diarrhea, anastomotic leakage, postoperative pneumonia, and anastomotic technique were related to SSI (all P<0.05). Multivariate analysis revealed that anastomotic leakage (OR=22.074, 95%CI: 6.172-78.953, P<0.001), pneumonia (OR=4.100, 95%CI: 1.546-10.869, P=0.005), intracorporeal anastomosis (OR=5.288, 95%CI: 2.919-9.577,P<0.001) were independent risk factors of SSI. Subgroup analysis showed that in right hemicolectomy, the incidence of SSI in intracorporeal anastomosis was 19.8% (32/162), which was significantly higher than that in extracorporeal anastomosis (3.8%, 16/426, χ(2)=40.064, P<0.001). In transverse colectomy [5.0% (2/40) vs. 0, χ(2)=0.210, P=1.000], left hemicolectomy [5.4% (8/148) vs. 0, χ(2)=1.079, P=0.599] and sigmoid colectomy [2.1% (10/482) vs. 10.0% (1/10), χ(2)=2.815, P=0.204], no significant differences of SSI incidence were found between intracorporeal anastomosis and extracorporeal anastomosis (all P>0.05). Conclusions: The incidence of SSI increases with the resection range from sigmoid colectomy to right hemicolectomy. Intracorporeal anastomosis and postoperative anastomotic leakage are independent risk factors of SSI. Attentions should be paid to the possibility of postoperative pneumonia and actively effective treatment measures should be carried out.

Clinical Application of Enteral Nutrition Combined with Microbial Preparation for Intestinal Preparation in Elderly Patients with Colorectal Cancer.

BackgroundThe purpose of this study was to determine the safety and efficacy of enteral nutrition in combination with microbial preparations for bowel preparation in elderly patients with colorectal cancer.Material/MethodsWere divided 160 patients diagnosed with colorectal cancer into a control group (n=80) and an experimental group (n=80) by random number table method. The control group took the traditional intestinal preparation, and the experimental group took oral enteral nutrition combined with microbial preparations. Both groups were treated by the same medical team. The postoperative recovery, complications, nutritional status, inflammation, and other indicators of the 2 groups were compared.ResultsThe nutritional status of the experimental group was significantly better than that of the control group, the incidence of tissue inflammation and postoperative complications was significantly lower than that of the control group, and the stool test results of patients with postoperative diarrhea were better than those of the control group, and the difference between groups was statistically significant.ConclusionsThe intestinal preparation using enteral nutrition combined with microbial preparations can alleviate the systemic inflammatory response in elderly patients, improve the nutritional status, reduce the occurrence of postoperative complications, and facilitate rapid postoperative recovery.

Disordered Gut Microbiota Correlates With Altered Fecal Bile Acid Metabolism and Post-cholecystectomy Diarrhea.

Post-cholecystectomy diarrhea (PCD) is a common complication of gallbladder removal, and gut microbiota changes have been determined in PCD patients. Bile acid diarrhea (BAD) is supposed to be the main pathogenic factor for PCD due to the disrupted fecal bile acid metabolism in diarrheal patients. However, the profiling of bile acid metabolite alteration in PCD is unclear and whether changed gut microbiota and fecal bile acid metabolism are correlated is also underdetermined. The fecal bile acid metabolites from fecal samples were profiled by targeted UPLC/MS (ultra-high-performance liquid chromatography coupled with a triple-quadrupole mass spectrometer) and the composition of fecal bile acid metabolites in PCD patients was demonstrated to be distinct from those in Non-PCD and HC groups. In addition, the quantification of bile acid excretion in feces of diarrheal patients was significantly elevated. Furthermore, 16S rRNA sequencing results revealed that PCD patients had the lowest operational taxonomic units (OTU) and significant reduction in microbial richness and evenness. Bacterial composition was remarkably shifted in PCD patients, which mainly lay in dominated phyla Firmicutes and Bacteroidota. Besides, the co-abundance network among genus bacteria declined in PCD. Among the genera, Prevotella, Enterococcus, and Erysipelotrichaceae_UCG-003 were enriched, but Alistipes, Bacteroides, Ruminococcus, and Phascolarctobacterium were reduced. Moreover, these disease-linked genera were closely associated with several diarrheal phenotypes. Notably, changed bile acid metabolites exhibited strong correlations with gut microbiota as well. Conclusively, this study reveals associations between PCD-linked microbes and bile acid metabolites, which may synergistically correlate to postoperative diarrhea.

Long-Term Outcome of Patients with Postoperative Refractory Diarrhea After Tailored Nerve Plexus Dissection Around the Major Visceral Arteries During Pancreatoduodenectomy for Pancreatic Cancer.

For pancreatic ductal adenocarcinoma (PDAC) surgery, extended dissection of the nerve plexus (pl) around the superior mesenteric artery (SMA) or celiac artery (CA) is sometimes necessary. This consequently results in postoperative refractory diarrhea. This study aimed to evaluate the clinical impact of extended nerve plexus dissection around major arteries on postoperative diarrhea. Patients who underwent pancreatoduodenectomy (PD) for PDAC between January 2013 and December 2016 were included. The frequency of diarrhea (defined as a condition requiring opioid antidiarrheal drug for at least 6months after surgery) and its short- and long-term outcomes were reviewed. Of 200 consecutive patients who underwent PD, 78 (39.0%) developed postoperative refractory diarrhea (diarrhea group), and 73 of them (93.6%) underwent hemi-circumferential or more nerve dissection for SMA or CA; both plSMA and plCA dissection were associated with diarrhea. Borderline resectable artery (BR-A) PDAC was included more in the diarrhea group (32.0% vs. 13.1%, P = 0.001); however, the local recurrence rate in the diarrhea group was significantly lower than that in the non-diarrhea group (14.1% vs. 26.2%, P = 0.036). The completion of adjuvant chemotherapy and overall survival were comparable between the two groups. The pre-albumin level improved in 2years, and 61.3% of patients with diarrhea could stop opioid antidiarrheal drugs within 3years of surgery. Although the frequency of diarrhea increased following nerve plexus dissection around arteries, diarrhea was controllable and resulted in a reduced local recurrence rate. Aggressive dissection of the nerve plexus may be justified for local disease control in BR-A PDAC.

Predictors and clinical impact of postoperative diarrhea after colorectal cancer surgery: a prospective, multicenter, observational study (SHISA-1602)

PurposePostoperative diarrhea, including high-output stoma (HOS), frequently occurs after colorectal surgery; its risk factors and clinical implications on subsequent complications remain unknown. This study aimed to evaluate the risk factors and clinical implications of postoperative diarrhea after primary colorectal cancer (CRC) surgery.MethodsThis prospective observational study included patients with CRC who underwent radical surgery at six hospitals between June 2016 and December 2017. The patients were categorized into three groups (non-stoma, colostoma, and ileostoma groups).ResultsA total of 178 patients participated in the study. In the non-stoma group, the incidence of postoperative diarrhea was 18.4% (27/147). The incidence of HOS was 28.6% (4/14) in the ileostoma group, and 0% in the colostoma group. Multivariable analyses of the incidence of diarrhea in the non-stoma group indicated that habitual smoking and hypertension were significantly associated with postoperative diarrhea (P = 0.012 and P = 0.0274, respectively). Postoperative diarrhea was more likely to occur in patients with rectal cancer than in those with colon cancer (P = 0.0501). In the non-stoma and ileostoma groups, the probability of the occurrence of other complications with Clavien–Dindo (C-D) grades II or higher was significantly higher in patients with C-D grade I diarrhea, including HOS, than in patients without diarrhea (39.3% vs. 14.6%, P = 0.0061).ConclusionsSmoking and hypertension are the independent predictors of postoperative diarrhea after an elective CRC surgery. Rectal cancer surgery seems to be associated with postoperative diarrhea more than colon cancer surgery does. Mild postoperative diarrhea may lead to more severe complications.

Mesopancreas Level 3 Dissection in Robotic Pancreaticoduodenectomy

Introduction: There is no study regarding mesopancreas dissections using the robotic approach in pancreaticoduodenectomy in the literature. This study is to evaluate the feasibility and justification of mesopancreas level 3 dissection in robotic pancreaticoduodenectomy (RPD). Method: Surgical outcomes after RPD and open pancreaticoduodenectomy (OPD) were evaluated and compared. Results: There were 289 RPD and 162 OPD patients. Postoperative diarrhea occurred in 34.5% by mesopancreas level 3 dissection, higher than those for level 2 and 1. Blood loss in the RPD group was higher by mesopancreas level 3 dissection, with a median of 263 ml. The rate of R0 resection with margin >1 mm by mesopancreas level 3 dissection was 93.8%, higher than 72.2% by level 2 dissection. Lymph node yield by mesopancreas level 3 dissection in RPD was higher, with a median of 21, vs. 18 by level 2 and 14 by level 1. Compared with mesopancreas level 1 and 2 dissections in RPD groups, level 3 dissection did not increase in surgical mortality, postoperative complications including postoperative pancreatic fistula, delayed gastric emptying (DGE), postpancreatectomy hemorrhage, chyle leakage, bile leakage, and wound infection. Compared with OPD, mesopancreas level 3 dissection in RPD was associated with less blood loss, no DGE, and lower chyle leakage. Conclusion: Mesopancreas level 3 dissection in RPD is not only justified with increasing oncological radicality but also feasible without compromising the surgical risks. Therefore, RPD can be recommended as a safe alternative to OPD for mesopancreas level 3 dissection.

Multicenter Randomized Phase II Trial of Prophylactic Right-Half Dissection of Superior Mesenteric Artery Nerve Plexus in Pancreatoduodenectomy for Pancreatic Head Cancer

Introduction: Right-half dissection of the superior mesenteric artery (SMA) nerve plexus in pancreatoduodenectomy for pancreatic cancer was initiated to accomplish R0 resection; however, subsequent refractory diarrhea was a major concern. This study aimed to evaluate the necessity of this technique. Method: From April 2014 to June 2018, 74 patients with pancreatic head cancer were randomly allocated to either Group A, in which right-half dissection of the SMA nerve plexus was performed (n = 37), or Group B, in which total preservation of the nerve plexus was performed (n = 37). Short-term, long-term, and survival outcomes were prospectively compared between the groups. Results: The patient demographics, including the R0 resection rate, were not significantly different between the groups. Postoperative diarrhea occurred in 26 (70.3%) patients in Group A and 18 (48.6%) patients in Group B. There was a tendency for the development of severe diarrhea in Group A within 1 year postoperatively, and the frequency of diarrhea gradually decreased within 2 years, although that did not affect tolerance to adjuvant chemotherapy. There was no difference in either locoregional recurrence (27.0% vs. 32.4%) or systemic recurrence (46.0% vs. 46.0%). The median overall survival time in Groups A and B was 37.9 and 34.6 months, respectively (P = 0.77). Conclusions: We did not demonstrate a clinical impact of right-half dissection of the SMA nerve plexus on locoregional recurrence or survival. Therefore, the prophylactic dissection of the SMA nerve plexus is unnecessary, given that refractory diarrhea could be induced by this technique (UMIN000012241).

Incidence and risk factors of nonalcoholic fatty liver disease after total pancreatectomy: A first multicenter prospective study in Japan.

In the present study we aimed to prospectively assess the current prevalence and risk factors of nonalcoholic fatty liver disease (NAFLD) after total pancreatectomy (TP). Between August 2015 and December 2017, we prospectively collected data from 68 Japanese centers on 148 consecutive patients who underwent TP whose computed tomography (CT) attenuation values were evaluated for 12months. We defined post-TP NAFLD as a liver parenchyma CT value of less than 40 Hounsfield units (HU). Data on perioperative variables were retrieved from all patients and evaluated using univariate and multivariate analyses to identify the perioperative risk factors of NAFLD. In this prospective cohort study, supplementation of pancreatic exocrine enzymes was provided to all 148 patients, and 97% of them were treated with high-titer pancrelipase (median dosage: 1800mg) postoperatively. Indeed, 29 patients (19.6%) developed NAFLD within a year after TP. Multivariate analysis revealed that female sex (P=.002), higher body mass index (BMI) (P=.001), and postoperative diarrhea (P=.038) were independent risk factors for post-TP NAFLD. However, post-TP NAFLD ameliorated in 11 patients (37.9%) at 12months after surgery. Among patients with risk factors such as female sex, higher BMI, and postoperative diarrhea, attention should be paid to the occurrence of NAFLD after TP.

Arterial Divestment and Resection in Post-neoadjuvant Pancreatic Adenocarcinoma.

IntroductionThe advent of neoadjuvant therapy in the management of pancreatic adenocarcinoma has significantly improved the prognosis of the disease. Nevertheless, the only chance of long-term disease-free survival in pancreatic cancer is achieved with complete tumor resection, and artery involvement by the tumor is one of the major determinants in its resectability. We aim to evaluate the feasibility of a novel technique, namely, the periarterial divestment, which has allowed surgeons to clear the tumor tissues off the visceral arteries without the need for arterial reconstruction.Materials and methodsIn this single-center, retrospective, descriptive, cross-sectional study done between August 2019 and July 2021, seven consecutive patients with histologically confirmed pancreatic ductal adenocarcinoma (PDAC) who underwent neoadjuvant therapy were included. Arterial divestment was performed in six of seven patients and arterial reconstruction was performed in one of the patients. The data on perioperative and the early oncological outcome were recorded.ResultsFive patients underwent periarterial divestment, one underwent sub-adventitial divestment, and one underwent superior mesenteric artery reconstruction due to deeper tumor infiltration into the arterial wall. The intraoperative frozen section of periarterial tissue was positive in three cases and the final histopathological specimen after the divestment showed a positive margin in two of the cases. The clinically significant postoperative pancreatic fistula was noted in two patients, and one patient experienced grade C post-pancreaticoduodenectomy hemorrhage due to a hepatic artery pseudoaneurysm. Four patients, all of whom underwent periarterial divestment, experienced postoperative diarrhea. There were no mortality and the median postoperative hospital stay was seven days.ConclusionThe need for arterial reconstruction in borderline and locally advanced pancreatic cancer can be avoided by using the periarterial divestment technique. Divestment of arteries is technically feasible and can be carried out safely without compromising the patient's oncological outcome. However, further validation of this technique must be done by well-designed studies with a greater sample size.

Gastrostomy and fundoplication in neurologically impaired children: A benefit-risks confrontation

Background For children with neurological impairment (NI) and swallowing incoordination feeding gastrostomy is usually required. This procedure may cause or aggravate preexisting gastroesophageal reflux disease (GERD). Fundoplication has been advocated at the time of gastrostomy placement in these patients. The purpose of this study is to evaluate clinical impact and risk-benefit balance of fundoplication and gastrostomy tube placement in patients with NI due to cerebral palsy, Hypoxic ischemic encephalopathy, brain tumors, and Dandy-Walker syndrome. Methods This study is a ten-year retrospective analysis including 180 cases of gastric tube placement in neurologically impaired children performed in a single institution. Results One hundred eighty patients underwent gastrostomy tube (GT)placement (94 open versus 86 laparoscopic). Concomitant fundoplication was performed in 44 cases. Three different types of tube were used during the procedures. There were differences between the two groups in gender but not in age distribution or comorbidity. Fundoplication was laparoscopic in 29 cases (33.7%) and open in 15 (16.0%). Postoperative diarrhea was more frequently observed with the Mickey tube (p=0.008). the hospital stay was longer after Mic tube placement (p=001). Sequelae after gastrostomy tube placement were observed in 21 cases (p=0.015). five postoperative cases of death were noted (p=0.015). The recurrence rate of reflux was 71% and mortality rate was 63% on long term follow-up. Conclusions In this study on NI and swallowing disorder unresponsive to medical treatment, open or laparoscopic fundoplication and gastrostomy reduced nausea and pain after feeding, but not Apparent life-threatening event in infancy (ALTE). Potential increased risk of complications and the procedure results instability may indicate the implementation of new management guidelines. Key words Fundoplication; Gastrostomy; Neurological impairment; Children, Outcome.

The effects of preoperative intestinal dysbacteriosis on postoperative recovery in colorectal cancer surgery: a prospective cohort study

BackgroundAccumulating evidence suggests a critical role of intestinal dysbacteriosis in surgical site infections and anastomotic leakage after abdominal surgery. However, a direct correlation between pre-existing dysbacteriosis and postoperative infectious complications has not yet been established clinically.MethodsA total of 353 consecutive patients who underwent colorectal cancer (CRC) surgery were enrolled. Gram-stained faecal smears were tested at admission and the first defecation after surgery. Intestinal dysbacteriosis was graded into three groups: normal or slightly decreased intestinal microflora (grade 1), moderate dysbacteriosis (grade 2), and severe dysbacteriosis (grade 3). Clinical outcomes were postoperative infections and anastomotic leakage within 30 days after surgery.ResultsAt the preoperative assessment, 268 (75.9%) patients had normal or slightly decreased intestinal microflora, 58 (16.4%) patients had moderate dysbacteriosis, and 27 (7.6%) patients had severe dysbacteriosis. The patients with preoperative dysbacteriosis had a higher rate of early postoperative diarrhoea (grade 2: OR = 4.53, 95% CI 2.28–9.00, grade 3: OR = 4.52, 95% CI 1.81–11.31), total complications (grade 3 40.7% vs. grade 2 25.9% vs. grade 1 12.7%, P < 0.001), and anastomotic leakage (grade 3 11.1% vs. grade 2 5.2% vs. grade 1 1.5%, P = 0.002). An interaction effect among preoperative dysbacteriosis and early postoperative diarrhoea on total complications was observed in rectal cancer patients (P for interaction = 0.007).ConclusionsAn imbalance of the intestinal microbiome exists in a considerable proportion of CRC patients before surgery. Preoperative dysbacteriosis is associated with higher rates of early postoperative diarrhoea, which further correlates with infectious complications and anastomotic leakage. However, the contribution of preoperative dysbacteriosis to the occurrence of anastomotic leakage needs to be clarified in further studies.Trial registration ChiCTR, ChiCTR1800018755. Registered 8 October 2018—Retrospectively registered, http://www.chictr.org.cn/ChiCTR1800018755.

Diarrhea as a postoperative complication of surgically treated retroperitoneal neurogenic tumors in children

BACKGROUND: Diarrhea as a result of skeletonization of the superior mesenteric artery (SMA) and celiac trunk after retroperitoneal lymph node dissection is a common complication in adult patients with malignant neoplasms of the pancreas, colon, and retroperitoneal tumors. The reports mentioning this complication in the treatment of neurogenic tumors in children are scarce.&#x0D; AIM: This study aims to improve the surgical treatment results of locally advanced retroperitoneal neuroblastomas by studying which factors influence the development of prolonged postoperative diarrhea.&#x0D; MATERIALS AND METHODS: An analysis of the treatment results in patients with locally advanced neurogenic retroperitoneal neoplasms at the Dmitry Rogachev national medical research center of pediatric hematology, oncology, and immunology from 2018 to 2020 was conducted. All patients from this cohort underwent SMA and celiac trunk dissection.&#x0D; RESULTS: During this period, surgeries with dissection of the SMA and celiac trunk were performed in 29 patients. In four (13%) cases, prolonged diarrhea was noted (median duration, 136.5 days with a frequency of up to 13 times a day). Assessment of the dependence of diarrhea frequency on complete dissection or preservation of the tumor component in the SMA and celiac trunk showed no significant differences.&#x0D; CONCLUSIONS: The complete removal of a neurogenic tumor improves prognosis in patients with a locally advanced form of the disease, but it is associated with the risk of long-term intractable complications. This study does not confirm the opinion that preservation of the tumor component on the SMA prevents its denervation and postoperative diarrhea.