Resection Of Gastrointestinal Tract Research Articles

Frailty and surgical outcomes in gastrointestinal cancer: Integration of geriatric assessment and prehabilitation into surgical practice for vulnerable patients.

As life expectancy increases, the older population continues to grow rapidly, resulting in increased requirement for surgery for older patients with gastrointestinal cancer. Older individuals represent a heterogeneous group in terms of physiological reserves, co-morbidity, cognitive impairment, and disability. Owing to the lack of treatment guidelines for vulnerable patients with gastrointestinal cancer, these patients are more likely to be at risk of undertreatment or overtreatment. Hence, the identification of frail patients with gastrointestinal cancer would improve cancer treatment outcomes. Although there is no standardized geriatric assessment tool, a growing body of research has shown associations of frailty with adverse postoperative outcomes and poor prognosis after resection of gastrointestinal tract and hepatobiliary-pancreatic cancers. Emerging evidence suggests that prehabilitation, which includes exercise and nutritional support, can improve preoperative functional capacity, postoperative recovery, and surgical outcomes, particularly in frail patients with gastrointestinal cancer. We reviewed major geriatric assessment tools for identification of frail patients and summarized clinical studies on frailty and surgical outcomes, as well as prehabilitation or rehabilitation in gastrointestinal tract and hepatobiliary-pancreatic cancers. The integration of preoperative geriatric assessment and prehabilitation of frail patients in clinical practice may improve surgical outcomes. In addition, improving preoperative vulnerability and preventing functional decline after surgery is important in providing favorable long-term survival in patients with gastrointestinal cancer. Further clinical trials are needed to examine the effects of minimally invasive surgery, and chemotherapy in frail patients with gastrointestinal cancer.

Sutureless functional end-to-end anastomosis using a linear stapler with polyglycolic acid felt for intestinal anastomoses.

BackgroundGastrointestinal anastomosis remains associated with a considerable burden of morbidity and, in some cases, mortality. Functional end-to-end anastomosis, whilst extremely efficient, is vulnerable to increased intestinal pressure in the immediate postoperative period, which may predispose to development of anastomotic leakage or bleeding. Therefore, there is a requirement for new techniques that facilitate safe and efficacious anastomotic procedures.Materials and methodsThis study examined the clinical application of functional end-to-end anastomosis with a stapler that automatically applies a bioabsorbable polyglycolic acid sheet (Endo GIA™ Reinforced Reload with Tri-Staple™ Technology). A porcine model was used to examine functional end-to-end anastomosis with and without application of a bioabsorbable polyglycolic acid sheet. As the crotch of the anastomosis is considered the weakest point, a probe was used to test the integrity of these anastomoses. Furthermore, we performed functional end-to-end anastomosis using the Endo GIA™ Reinforced stapler in a clinical series of 20 patients undergoing gastrointestinal tract resection. In all cases, functional end-to-end anastomosis was performed without suture reinforcement.ResultsSmall intestine anastomoses in the animal study exhibited no weakness at the crotch of the anastomosis, as tested with a probe, suggesting an increased resiliency to conventional complications of functional end-to-end anastomosis. In the clinical population, no postoperative complications were noted. No adhesive intestinal obstruction was noted.ConclusionSutureless functional end-to-end anastomosis using the Endo GIA™ Reinforced appears to be safe, efficacious, and straightforward. Reinforcement of the crotch site with a bioabsorbable polyglycolic acid sheet appears to mitigate conventional problems with crotch-site vulnerability.

Radical Surgery for Endometriosis: Analysis of Quality of Life and Surgical Procedure.

OBJECTIVEThe main aim of this study is to determine the improvement in quality of life in patients who have undergone radical surgery because of severe endometriosis.PATIENTS AND METHODSThis nonrandomized interventional study (quasi experimental) was carried out between January 2009 and September 2014. A total of 46 patients with diagnosis of severe endometriosis were included. Radical surgery, including hysterectomy, was performed. Acting as their own control group, the patients were asked to fill in a validated questionnaire of quality of life [Endometriosis Health Profile-5 (EHP-5)] and a visual analog scale of pain at the moment of the preoperative visit (one month prior to surgery) and six months after the surgery.RESULTSRadical surgery for endometriosis was performed in 46 patients at our center over the period of six years. Among the patients, 73.9% of them had undergone previous surgery for endometriosis. In 82.6% of cases, a complete laparoscopic resection was carried out. Gastrointestinal tract resection was performed in 21.7%, and urinary tract resection was necessary in 8.7%. The mean age of the patients was 38.6 years. The rate of complications was 30.4%. Six months after the surgery, all items of the EHP-5 questionnaire had a lower score, which means an improvement in all aspects of quality of life related to endometriosis. The difference obtained between the scores before and after the surgery was statistically significant. The mean visual analog scale score before the surgery was 8.5, whereas it decreased to 1.4 after the surgery (P < 0.001).CONCLUSIONPerforming a radical surgery is a difficult decision to make; however, it can provide optimal results in terms of improvement of quality of life and, therefore, should be considered when conservative therapy fails.

Submucosal injection solution for endoscopic resection in gastrointestinal tract: a traditional and network meta-analysis.

Objective. To explore and define the current optimal submucosal injection solution used in ESD and EMR for gastrointestinal tract neoplasms in terms of clinical outcomes and other aspects. Methods. PubMed, Cochrane Library, Embase, and clinical trials register center were searched with terms of “endoscopic resection” and “submucosal injection solution” to identify relevant randomized controlled trials (RCTs). Both direct comparison using traditional meta-analysis method and indirect comparison using network meta-analysis method were performed. Results. A total of 11 RCTs with 1152 patients were included. Meta-analysis showed that, compared with normal saline, other submucosal injection solutions induced a significant increase in terms of en bloc resection rate (I 2 = 0%, OR = 2.11, 95% CI (1.36, 3.26), and P = 0.008) and complete resection rate (I 2 = 0%, OR = 2.14, 95% CI (1.41, 3.24), and P = 0.0003); and there was no significant difference in the incidence of total complications (I 2 = 0%, OR = 0.87, 95% CI (0.59, 1.29), and P = 0.49). Conclusions. Other newly developed submucosal injection solutions significantly increased en bloc resection rate and complete resection rate and decreased bleeding rate and finical cost of endoscopic resection in gastrointestinal tract, while current evidence did not find the difference between them, which need to be explored by further studies.

Risk factor analysis and prevention of postoperative pancreatic fistula after distal pancreatectomy with stapler use

Postoperative pancreatic fistula (POPF) is a major, intractable complication after distal pancreatectomy (DP). Risk factor evaluation and prevention of this complication are important tasks for pancreatic surgeons. One hundred and six patients who underwent DP using a stapler for pancreatic division were retrospectively investigated. The relationship between clinicopathological factors and the incidence of POPF was statistically analyzed. Clinically relevant, Grade B or C POPF by International Study Group of Pancreatic Fistula criteria occurred in 52 patients (49.1 %). Age, American Society of Anesthesiologists score, body mass index, and concomitant gastrointestinal tract resection did not influence the incidence of POPF. Use of a double-row stapler and a thick pancreatic stump were significant risk factors for POPF in multivariate analysis. Compression index was also shown to be an important factor in cases in which the pancreas was divided by a stapler. The most important risk factor for POPF after DP was suggested to be the thickness of the pancreatic stump, reflecting the volume of remnant pancreas. A triple-row stapler seemed to be superior to a double-row stapler in preventing POPF. However, triple-row stapler use in a thick pancreas is considered to be a future problem to be solved.

Factors influencing the outcome of image-guided percutaneous drainage of intra-abdominal abscess after gastrointestinal surgery

PurposeTo improve the selection of patients for percutaneous abscess drainage (PAD) to treat postoperative intra-abdominal abscess after gastrointestinal surgery, we investigated the factors predictive of outcome.MethodsOf 143 consecutive patients with symptomatic postoperative intra-abdominal abscess after a gastrointestinal tract resection, 104 who underwent image-guided PAD as the initial treatment were reviewed. We assessed the possible associations between successful PAD and patient-, abscess-, surgical-, and drainage-related variables, and investigated the success rates of PAD for patients with vs. those without the factors related to successful outcome.ResultsBased on monitoring for 1 year after PAD, the success rate of this procedure was 85.6 % (89/104). Multivariate analysis revealed that the interval between surgery and the onset of abscess (p = 0.0234) and a single abscess (p = 0.0038) were independently associated with a successful outcome. Single late-onset abscess resolved completely within 10 weeks in 91.4 % of these patients.ConclusionsDespite new strategies aimed at preventing surgical site infection, PAD remains an important factor in the postoperative management of gastrointestinal surgery in Japan. Initial recognition of the day of onset and the number of abscesses are important prognostic factors.

The impact of gastrointestinal tract resection in oral drug absorption

BackgroundGastrointestinal tract resection (GIR) results in a range of physiological changes that affect the absorption of nutrients, water, and electrolytes. These changes may also affect the absorption of orally medication...

Early Versus Traditional Postoperative Feeding in Patients Undergoing Resectional Gastrointestinal Surgery

A meta-analysis evaluating surgical outcomes following nutritional provision provided proximal to the anastomosis within 24 hours of gastrointestinal surgery compared with traditional postoperative management was conducted. Databases were searched to identify randomized controlled trials comparing the outcomes of early and traditional postoperative feeding. Trials involving gastrointestinal tract resection followed by patients receiving nutritionally significant oral or enteral intake within 24 hours after surgery were included for analysis. Fifteen studies involving a total of 1240 patients were analyzed. A statistically significant reduction (45%) in relative odds of total postoperative complications was seen in patients receiving early postoperative feeding (odds ratio [OR] 0.55; confidence interval [CI], 0.35 -0.87, P = .01). No effect of early feeding was seen with relation to anastomotic dehiscence (OR 0.75; CI, 0.39-1.4, P = .39), mortality (OR 0.71; CI, 0.32-1.56, P = .39), days to passage of flatus (weighted mean difference [WMD] -0.42; CI, -1.12 to 0.28, P = .23), first bowel motion (WMD -0.28; CI, -1.20 to 0.64, P = .55), or reduced length of stay (WMD -1.28; CI, -2.94 to 0.38, P = .13); however, the direction of clinical outcomes favored early feeding. Nasogastric tube reinsertion was less common in traditional feeding interventions (OR 1.48; CI, 0.93-2.35, P = .10). Early postoperative nutrition is associated with significant reductions in total complications compared with traditional postoperative feeding practices and does not negatively affect outcomes such as mortality, anastomotic dehiscence, resumption of bowel function, or hospital length of stay.

Surgical Services and Transformation of Civil Hospital During “August War 2008” in Georgia

Structural transformation of a civil hospital into a military one during "August War 2008" (August 8-12) in Georgia is presented. Damage-control principles, such as hemorrhage control, liver-packing and abdominal tamponade, gastrointestinal tract resection without formation of anastomoses, and other temporary interventions were prioritized. This provided a chance to empty the hospital in a short period to provide the admission of an increased number of combat casualties. There were soldiers from Georgian troops, civilians, and captives of war. The number of total admitted patients was 739. Fifty-two patients were operated on in the surgery department. The following operations were carried out: removal of foreign bodies from the neck region, 6 cases; isolated thoracotomy, pulmorrhaphy, and drainage, 2 cases; laparotomy, hepatorrhaphy, gastrorrhaphy, splenectomy, resection of small intestine, and colostomy, 18 cases; combined operations (thoracotomy plus laparotomy), 9 cases; extended debridement and dressing of wounds, 11 cases; angiosurgical operations, 4 cases; and coloplasty, 2 cases. There were 2 cases of mortality, 1 case of rethoracotomy, and 3 cases of relaparotomy: 2 because of intracavital bleeding and 1 because of sanation.

Minimally invasive surgery for resection of duodenal carcinoid tumors: endoscopic full-thickness resection under laparoscopic observation

Carcinoid tumors of the duodenum are rare, and the most effective treatment for duodenal carcinoid tumors remains debatable. Because carcinoid tumors of the gastrointestinal tract tend to spread to the submucosal layer even during the early stages of the disease, the possibility of tumor seeding in the vertical margin of the tumor cannot be eliminated by conventional endoscopic mucosal resection (EMR). In addition, because the duodenal wall is thinner than the gastric wall, EMR performed for duodenal lesions may be associated with a high risk of accidental perforation. In this article, we introduce a minimally invasive endoscopic full-thickness resection technique after laparoscopic repair for the local resection of duodenal carcinoid tumors. Under general anesthesia, after the duodenum was mobilized laparoscopically, the duodenal serosa at the site of the lesion was suctioned under laparoscopic observation, and full-thickness resection of the duodenum was performed using a cap-fitted endoscope, i.e., EMR-c, without injecting hypertonic saline-epinephrine. The sample was retrieved endoscopically after resection. After confirming that the full-thickness resection of the duodenal wall with enough surgical margins was achieved and that there was no active bleeding, the wound was sutured by the laparoscopic hand-suturing technique. We have performed this surgical procedure in two cases of duodenal carcinoid tumor. The mean operation time was 116 +/- 14 minutes, and the estimated blood loss was 2.5 +/- 0.5 ml. The postoperative courses were uneventful in both cases. The technique of endoscopic full-thickness resection of gastrointestinal tract under laparoscopic observation is a safe, simple, and can be radical surgical procedure for a small duodenal carcinoid tumor. This surgical procedure may be applicable in the case of other gastrointestinal tumors.

Leiomyosarcoma of the gastro-intestinal tract: general pattern of metastasis and recurrence

Clinically, epithelial cancers (squamous cell carcinoma and adenocarcinomas) metastasize primarily by the lymphatic route, while mesenchymal sarcomas more frequently enter the blood stream directly. Nevertheless metastatic involvement of regional nodes has been seen in 13% of patients with soft tissue sarcomas and in 7% of bone sarcomas at initial presentation (29). About one-third of the leiomyosarcomas of the gastro-intestinal tract developed metastasis and about 90% of the metastasis were intra-abdominal (45). Liver is the most common site of metastasis, followed by peritoneal seeding and local recurrence or extension. Regional nodal metastasis also has been noted both initially and subsequently. The most important criterion of diagnosing leiomyosarcoma appears to be the presence of mitosis. Leiomyosarcoma with 1 mitosis per 2 high power fields or epithelioid leiomyosarcoma with 1 mitosis per 5 fields behaved aggressively. Additional criteria useful for diagnosing and for determining prognosis of malignancy include the presence of necrosis, cellular atypia, and the gross size of the tumor. In general, almost all tumors larger than 5 cm in diameter should be viewed with suspicion. For patients with gastric leiomyosarcomas, a proportion, sometimes as high as 14%, had perigastric lymph node involvement at diagnosis (9), and about 7% of those who relapsed had regional nodal metastasis (Table 2). For patients with leiomyosarcoma of the small intestine, about 5% of the patients had nodal metastasis initially, and 9% subsequently (Table 4). Regional lymphatic metastasis also has been reported in leiomyosarcoma of the colorectum. It is believed that wide resection of normal tissues (at least 10 cm margin on either side of tumor) and adjacent mesentery (with routine omentectomy for gastric lesions) not only may discover a higher frequency of occult metastasis in the regional lymph node, but will also decrease the chance of loco-regional relapse and the occurrence of sarcomatosis. As a result of this review and a previous one (30), the surgeon ought to consider when faced with a smooth muscle tumor of the gastro-intestinal tract a wide segmental resection including the adjacent mesentery and omentum, because (a) the precise histologic nature of the lesion (benign vs. malignant) is hard to define even by permanent sections; (b) the possibility of involvement of draining nodes exists and (c) little or no increase in morbidity is anticipated between a wide, as against a limited wedge or segmental resection of gastrointestinal tract. The last point does not need elaboration, except for the very unusual lesions of the duodenum, distal stomach or lower rectum. When adherence to this principle would require a pancreaticoduodenectomy, near total gastrectomy or abdominoperineal resection, it may be wise to establish a definitive histologic diagnosis of the primary lesion first, and to use a more conservative procedure initially.

Experimental study of Intestinal absorption after resection of Gastrointestinal tract with special reference to sucrose absorption

Experimental study of Intestinal absorption after resection of Gastrointestinal tract with special reference to sucrose absorption