Restoration Of Bowel Function Research Articles

The Role of Robotic Cystectomy in the Salvage and Palliative Setting: A Retrospective, Single-Center, Cohort Study.

Introduction: This article compares surgical and survival outcomes of robot-assisted and open radical cystectomy with cutaneous ureterostomy for the treatment of frail bladder cancer patients with limited life expectancy. Methods: The institutional database was searched for cystectomy cases with cutaneous ureterostomy, from 1 June 2016 to 31 August 2022. The study population was split into two groups, according to the surgical approach. The baseline characteristics and surgical outcomes were compared. Logistic regression analyses identified predictors of major bleeding events (hemoglobin loss ≥ 3.5 g/dL or blood transfusion) and re-operation within 30 days from surgery. The Kaplan-Meier method estimated the impact of the robotic approach on overall survival and Cox regression analysis assessed its predictors. Results: A total of 145 patients were included: 30% (n = 43) underwent robotic cystectomy. Patients' characteristics and tumor stages distribution were comparable in the two groups but those receiving a minimally invasive treatment showed significantly reduced times to flatus, bowel and hospital discharge (all p < 0.001). Although operation times were longer in this cohort, major bleeding events (60% vs. 89%) and postoperative severe complications (0 vs. 8%) (both p < 0.001) were less frequent compared to the open approach. A logistic regression showed that robotic surgery independently predicted major bleeding events (OR: 0.26; 95%CI 0.09-0.72; p = 0.02) but not the need for re-intervention. A Kaplan-Meier analysis showed that robotic cystectomy was associated with a significant advantage in terms of overall survival (LogRank = 0.03), and this result was confirmed by Cox regression analysis (HR: 0.39; 95%CI 0.14-0.94; p = 0.04). Conclusions: Robotic cystectomy with cutaneous ureterostomy may represent a viable option to treat frail bladder cancer patients, as the minimally invasive approach reduces the risk of bleeding and serious complications and provides a prompt restoration of bowel function and a shorter hospital stay compared to open surgery.

Tolerance to and postoperative outcomes with early oral feeding following elective bowel surgery: a systematic review with meta-analysis

Advancements in gastrointestinal surgery have directed attention toward optimizing recovery, including through the use of feeding methods that reduce prolonged postoperative hospital stays, complications, and mortality, among other undesirable outcomes. This study's primary goals were to identify current peer-reviewed literature reporting the postoperative outcomes of elective bowel surgery and to evaluate the clinical evidence of patients' tolerance to oral feeding following elective bowel surgery. An exhaustive literature search was conducted via PubMed and Scopus. The search results were screened for potential articles, and articles were assessed for eligibility based on prespecified eligibility criteria. The data were synthesized, and the results were reported and discussed thematically. The database search yielded 1,667 articles, from which 18 randomized controlled trials were chosen for inclusion in this study. This study included 874 early oral feeding (EOF) patients, 865 traditional oral feeding patients, and 91 patients whose postoperative care was unspecified. Data synthesis was done, and meta-analyses were conducted. The results showed that EOF patients required a significantly shorter time to tolerate a solid diet and had shorter hospital stays. In addition, bowel function was restored earlier in EOF groups. The results show good tolerance to EOF, shorter hospitalizations, and faster restoration of bowel function, suggesting that EOF after elective bowel surgery is relatively safe. However, further studies with similar baseline conditions should be conducted to verify these results.

Use and Outcomes of Dexamethasone in the Management of Malignant Small Bowel Obstruction.

To describe rates of dexamethasone use in the nonoperative management of malignant small bowel obstruction (mSBO) and their outcomes. mSBO is common in patients with advanced abdominal-pelvic cancers. Management includes prioritizing quality of life and avoiding surgical intervention when possible. The use of dexamethasone to restore bowel function is recommended in the National Comprehensive Cancer Network guidelines for mSBO. Yet, it is unknown how often dexamethasone is used for mSBO and whether results from nonresearch settings support its use. This is a multicenter retrospective cohort study including unique admissions for mSBO from January 1, 2019 to December 31, 2021. Dexamethasone use and management outcomes were summarized with descriptive statistics and multiple logistic regression. Among 571 admissions (68% female, mean age 63 years, 85% history of abdominal surgery) that were eligible and initially nonoperative, 26% [95% confidence interval (CI) = 23%-30%] received dexamethasone treatment (69% female, mean age 62 years, 87% history of abdominal surgery). Dexamethasone use by site ranged from 13% to 52%. Among dexamethasone recipients, 13% (95% CI = 9%-20%) subsequently required nonelective surgery during the same admission and 4 dexamethasone-related safety-events were reported. Amongst 421 eligible admissions where dexamethasone was not used, 17% (95% CI = 14%-21%) required nonelective surgery. Overall, the unadjusted odds ratio (OR) for nonelective surgery with dexamethasone use compared to without its use was 0.7 (95% CI = 0.4-1.3). Using multiple logistic regression, OR after adjusting for site, age, sex, history of abdominal surgery, nasogastric tube, and Gastrografin use was 0.6 (95% CI = 0.3-1.1). Dexamethasone was used in about 1 in 4 eligible mSBO admissions with high variability of use between tertiary academic centers. This multicenter retrospective cohort study suggested an association between dexamethasone use and lower rates of nonelective surgery, representing a potential opportunity for quality improvement.

A standardized postoperative bowel regimen protocol after spine surgery.

Spine surgery is associated with early impairment of gastrointestinal motility, with postoperative ileus rates of 5-12%. A standardized postoperative medication regimen aimed at early restoration of bowel function can reduce morbidity and cost, and its study should be prioritized. A standardized postoperative bowel medication protocol was implemented for all elective spine surgeries performed by a single neurosurgeon from March 1, 2022 to June 30, 2022 at a metropolitan Veterans Affairs medical center. Daily bowel function was tracked and medications were advanced using the protocol. Clinical, surgical, and length of stay data are reported. Across 20 consecutive surgeries in 19 patients, mean age was 68.9 years [standard deviation (SD) = 10; range 40-84]. Seventy-four percent reported preoperative constipation. Surgeries consisted of 45% fusion and 55% decompression; lumbar retroperitoneal approaches constituted 30% (10% anterior, 20% lateral). Two patients were discharged in good condition prior to bowel movement after meeting institutional discharge criteria; the other 18 cases all had return of bowel function by postoperative day (POD) 3 (mean = 1.8-days, SD = 0.7). There were no inpatient or 30-day complications. Mean discharge occurred 3.3-days post-surgery (SD = 1.5; range 1-6; home 95%, skilled nursing facility 5%). Estimated cumulative cost of the bowel regimen was $17 on POD 3. Careful monitoring of return of bowel function after elective spine surgery is important for preventing ileus, reducing healthcare cost, and ensuring quality. Our standardized postoperative bowel regimen was associated with return of bowel function within 3 days and low costs. These findings can be utilized in quality-of-care pathways.

Anaesthesia in Correction of Anorectal Defects in Children

Anorectal abnormalities are among the most common congenital malformations in children requiring emergency surgical interventions. The objective is to analyze existing domestic and foreign publications on the features of anesthesia in anorectal abnormalities in children. Subjects and Methods. The search for publications was carried out in the abstract bases of Russian Scientific Citation Index, PubMed and Scopus according to the key words: anorectal abnormalities, anesthesia, regional anesthesia, children. 105 publications were found, 49 studies were selected for analysis. Results. For the purpose of anesthesia, both general and regional anesthesia are used to correct anorectal anomalies. Among regional techniques, spinal and caudal anesthesia is most often used. The most effective anesthesia option for anorectal surgery is saddle anesthesia since it is accompanied by a significant decrease in the tone of the anal sphincter. Combined use of general anesthesia and caudal analgesia contributes to the reduction of intraoperative blood loss and early restoration of bowel functions. Conclusion. Further research is needed to establish rapid pos t-o perative recovery protocols for anorectal malformations in children.

Epidural blockade during liver transplantation

AIM: This study aimed to evaluate the efficacy and safety of epidural analgesia as a component of pain relief on orthotopic liver transplantation.&#x0D; MATERIALS AND METHODS: Forty-five patients who underwent orthotopic liver transplantation were examined. Epidural and opioid analgesics were used as a component of pain relief in groups 1 (n=24) and 2 (n=21), respectively. The following parameters were evaluated: intensity of postoperative pain, time of patient activation, incidence of postoperative nausea and vomiting, time of onset of enteral nutrition, restoration of bowel function, incidence of postoperative acute respiratory failure, need for opioid analgesics, and length of stay in the intensive care unit (ICU).&#x0D; RESULTS: Pain intensity and total postoperative need for tramadol and promedol were significantly lower in group 1 than in group 2. During the postoperative period, group 1 showed a decrease in postoperative nausea and vomiting, incidence of postoperative respiratory failure, and time spent in the ICU. No complications with the insertion and removal of the epidural catheter were observed.&#x0D; CONCLUSION: The use of epidural blockade for liver transplantation significantly reduces the severity of pain syndrome, accelerates the recovery of bowel function, and shortens the length of ICU stay. The use of EA reduces the risk of PONV during the use of opioid analgesics and causes an early start of enteral nutrition. Therefore, epidural analgesics can be used as a component of pain relief in patients undergoing orthotopic liver transplantation.

Can physiological stimulation prior to ileostomy closure reduce postoperative ileus? A prospective multicenter pilot study.

The aim of this study was to assess the impact of ileostomy closure following preoperative physiological stimulation (PPS) on postoperative ileus (POI) in patients with loop ileostomy after low anterior resection for rectal cancer. Patients who underwent ileostomy closure between January 2017 and February 2020 in two tertiary referral centers were prospectively included. PPS stimulation was compared to standard treatment. Stimulation was carried out daily during the 15days prior to ileostomy closure by the patient's self-instillation of 200ml of fecal contents from the ileostomy bag via the efferent loop, using a rectal catheter. Standard treatment (ST) consisted of observation. Outcomes measures were POI, morbidity, stimulation feasibility, and predictors to ileus. A total of 58 patients were included [42 males and 16 females, median age 67 (43-85) years]. PPS was used in 24 patients, who completed the entire stimulation process, and ST in 34 patients. No differences in preoperative factors were found between the two groups. POI was significantly lower in the PPS group (4.2%) vs the ST group (32.4%); p < 0.01, OR: 0.05 (CI 95% 0.01-0.65). The PPS group had a shorter time to restoration of bowel function (1day vs 3days) p = 0.02 and a shorter time to tolerance of liquids (1day vs 2days), p = 0.04. Age (p = 0.01), open approach at index surgery, p = 0.03, adjuvant capecitabine (p = 0.01). and previous abdominal surgeries (p = 0.02) were associated with POI in the multivariate analysis. C-reactive-protein values on the 3rd (p = 0.02) and 5th (p < 0.01) postoperative day were also associated with POI. PPS for patients who underwent ileostomy closure after low anterior resection for rectal cancer is feasible and might reduce POI.

Factors Determining Postoperative Ileus After Surgery for Colon Cancer: Comparison of Right- and Left-Sided Resections.

The passage of flatus and stool, as well as tolerating a solid diet, represents a crucial moment in recovery after colonic resections. The present study compares functional recovery after left and right colectomies for colon cancer. This is a retrospective analysis. Consecutive patients with elective left and right colon resections were examined. Primary analysis compared time to first bowel motion and development of postoperative ileus. Secondary analyses tried to define risk factors for prolonged restoration of bowel function in right- and left-sided resection groups. In total, 147 patients were included. While laparoscopic approach was preferred for both sides (87% vs. 87%; p=0.496), left colectomies took longer (183 vs. 153 min; p=0.012), the lymph node harvest was smaller (16 vs. 20; p=0.005), and there was an increased need for perioperative fluids (4451 vs. 4039ml; p=0.006). Epidural use, postoperative potassium level, and glycemia were similar. Also, no significant differences were observed for complications and length of stay. First flatus was observed at postoperative day 1, 9 (left), and 2.5 (right), respectively (p=0.002). There was no significant difference in passage of first stool and intake of first solid food. Twenty-seven patients (35%) needed a postoperative nasogastric tube after right colectomy compared to 11 patients (16%) after left colectomy (p=0.012). Right-sided colectomies required the tube for longer (6.1 vs. 3.4; p=0.005). Postoperative ileus was more frequent after right-sided colectomies despite shorter operative time. The reason for this finding is currently unknown and deserves further attention. For the time being, we can just be more cautious with early feeding after right colectomy.

Re-discovering an Old Standard: Ilio-Femoral Bypass, with Adjunctive Procedures, for Primary orSecondary Iliac Artery Occlusion

<h3>Introduction and Objective</h3> Endovascular techniques constitute first-line treatment for iliac artery occlusions and enjoy outstanding primary and long-term durability. Some iliac occlusions are not amenable to endovascular repair because of calcification, chronic occlusion, and failed stents. Twenty-eight patients with unilateral iliac occlusion who were not candidates for or failed endovascular repair underwent ilio-femoral bypass. Extra-anatomical bypass was avoided because of previous contralateral procedures or risk to the contralateral extremity. This abstract reviews one surgeon's experience with ilio-femoral bypasses from December, 2014 to November, 2020. <h3>Case Report</h3> Twenty-eight (28) patients, 74% males, with an average patient age of 63.8 years and unilateral iliac occlusion, underwent ilio-femoral bypass. 88% were smokers, 38% were diabetics, and 30% had severe heart disease. Two patients had severe kidney disease requiring dialysis. Twenty-four patients underwent previous attempts at revascularization: 14 received iliac stents and 4 patients had failed aorto bifemoral or axillo/ilio femoral bypasses. There were 6 previous open interventions involving the femoral arteries. Two patients sustained rupture while undergoing endovascular procedures and required emergent bypasses. Indications for intervention were rest pain in 11, tissue loss in 8, and disabling claudication in 5. There were 3 urgent interventions: two required immediate intervention following rupture of an iliac artery angioplasty, and a third occurred during insertion of a thoracic stent. One procedure was performed fora 2-year-old infected iliac bypass with impending rupture. All operations were performed under general anesthesia. Proximal retro-peritoneal exposure of the iliac arteries was obtained via a curvilinear incision in the ipsilateral lower quadrant. Twenty-four (24) patients received a Dacron conduit, 2 PTFE, 1 bovine, and 1 femoral vein. Thirty-five (35) adjuvant procedures were done in conjunction with the bypass. In 14 cases (54%,) retrograde endarterectomy/thrombectomy/stent extraction was performed. Eleven patients (35%) required a femoral endarterectomy/thrombectomy. Angiography was used selectively if inflow was deemed inadequate. Six (6) intraoperative angiograms were needed with 2 patients requiring proximal stent insertions. Two patients received simultaneous femoral to distal bypasses done for tissue loss. <h3>Results</h3> Procedures were technically successful in 100% of patients. All bypasses were patent at the time of their loss to follow-up or death. Patients were followed for an average of 22.3 months. No secondary interventions were required. There was 1 groin infection that required excision of the graft; one above knee amputation was required for an infected knee prothesis. There was one groin hematoma. Two patients died within thirty days (8%), one from SIRS (multi-organ system failure following recent myocardial infarction) and one patient died of a coagulopathy following rupture of a calcified common iliac artery during angioplasty. There were no amputations due to vascular disease. 100% patency in this series was enhanced by adjunctive procedures. Ilio-femoral bypasses done to symptomatic elderly patient with occluded superficial femoral arteries frequently enjoyed relief of rest- pain without the morbidity of distal incisions. This group required endarterectomy of the common and deep femoral arteries. No hernias, local nerve injuries, lymphorrhea, damage to ureters, or major infections occurred. One groin infection was a catabolic, nursing home patient with an infected, ischemic, above knee residual limb. He required excision of the exposed graft. Patients tolerate the retroperitoneal approach usually without paralytic ileus and prompt restoration of bowel function. Respiratory insufficiency is also minimal since a major body cavity is not entered. The majority of patients were extubated before transfer to the post-operative acute care unit. <h3>Discussion</h3> Historically, ilio-femoral bypass is considered a durable operation with a cumulative patency of 92% 3- year patency and exhibit superior patency when compared to extra-anatomical bypasses that demonstrate a 73% 3-year patency. The operation has been largely supplanted by endovascular procedures which are equally durable and less invasive. There is a subset of patients in whom angioplasty/stents are not possible or who have failed endovascular intervention and require in flow procedures. In this series, ilio femoral bypass was only performed in 5 patients (19%) with claudication.The remaining patients had critical limb ischemia and required intervention for limb preservation. Ilio-femoral bypass with adjunctive procedures provided acceptable short term and mid-term results in complicated patients, 85% of whom had previously undergone ipsilateral vascular intervention.

Клінічний випадок гострої кишкової непрохідності під час вагітності в пацієнтки з ектракорпоральним заплідненням та великим інтергенетичним інтервалом

The great importance in the development of acute intestinal obstruction (AIO) is the change in intestinal kinetics during pregnancy. In pregnant women, the rhythmic function of the intestine slows down due to an increase in the threshold of excitability of its receptors to biologically active substances. The article provides an overview of modern literary sources on the problem of acute intestinal obstruction in pregnant women. According to foreign literature sources, the incidence of intestinal obstruction in pregnant women is 1:3600–1:66000, and complications of diseases of the digestive system rank 4th among the causes of maternal mortality during pregnancy — 9%. According to domestic scientific sources, the frequency with which intestinal obstruction occurs in pregnant women is 1:40000–1:50000 births, mortality reaches 35–50%, stillbirth — 60–75%. The development of the disease is caused by physiological changes in the body of a pregnant woman. With increasing gestational age there are changes in the anatomical arrangement of the abdominal organs. From the second trimester of pregnancy, the uterus extends beyond the pelvis and gradually occupies the entire abdominal cavity. The increase in the size of the uterus due to hypertrophy and hyperplasia of muscle fibers, amniotic fluid, fetal growth, leads to increased intraabdominal pressure, displacement of the small intestine and lumbar colon up, thereby creating conditions for compression of intestinal loops, nodules, development. The modern classification, clinic, diagnostics and methods of treatment of this surgical pathology are presented. The author presents his own clinical case of acute intestinal obstruction in a 51-year-old pregnant woman with the sixth desired pregnancy, which occurred as a result of assisted reproductive technologies and a large intergenetic interval. Both surgeon and obstetrician-gynecologist treat intestinal obstruction in pregnant women. Conservative treatment is carried out simultaneously with diagnostic procedures. No effect of conservative therapy for 2 hours is an indication for surgery. The main purpose of surgery is to eliminate the causes of intestinal obstruction and restore bowel function. The scope of surgery is determined in each case individually and depends on the type of AIO and the age of the disease. The chosen tactics of the preoperative period, the volume of surgery, anesthesia and adequate management of the postoperative period can cure acute surgical pathology, maintain the desired pregnancy, avoid the development of obstetric and surgical purulent-septic complications. The research was carried out in accordance with the principles of the Helsinki declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: sharp bowel obstruction, pregnancy, extracorporal impregnation, large intergenic interval.

Management of Opioid-Induced Constipation and Bowel Dysfunction: Expert Opinion of an Italian Multidisciplinary Panel.

The prescribing and use of opioid analgesics is increasing in Italy owing to a profusion in the number and types of opioid analgesic products available, and the increasing prevalence of conditions associated with severe pain, the latter being related to population aging. Herein we provide the expert opinion of an Italian multidisciplinary panel on the management of opioid-induced constipation (OIC) and bowel dysfunction. OIC and opioid-induced bowel dysfunction are well-recognised unwanted effects of treatment with opioid analgesics that can profoundly affect quality of life. OIC can be due to additional factors such as reduced mobility, a low-fibre diet, comorbidities, and concomitant medications. Fixed-dose combinations of opioids with mu (μ) opioid receptor antagonists, such as oxycodone/naloxone, have become available, but have limited utility in clinical practice because the individual components cannot be independently titrated, creating a risk of breakthrough pain as the dose is increased. A comprehensive prevention and management strategy for OIC should include interventions that aim to improve fibre and fluid intake, increase mobility or exercise, and restore bowel function without compromising pain control. Recommended first-line pharmacological treatment of OIC is with an osmotic laxative (preferably polyethylene glycol [macrogol]), or a stimulant laxative such as an anthraquinone. A second laxative with a complementary mechanism of action should be added in the event of an inadequate response. Second-line treatment with a peripherally acting μ opioid receptor antagonist (PAMORA), such as methylnaltrexone, naloxegol or naldemedine, should be considered in patients with OIC that has not responded to combination laxative treatment. Prokinetics or intestinal secretagogues, such as lubiprostone, may be appropriate in the third-line setting, but their use in OIC is off-label in Italy, and should therefore be restricted to settings such as specialist centres and clinical trials.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-021-01766-y.

Postoperative Ileus after Stimulation with Probiotics before Ileostomy Closure.

Loop ileostomy closure after colorectal surgery is often associated with Postoperative ileus, with an incidence between 13–20%. The aim of this study is to evaluate the efficacy and safety of preoperative stimulation of the efferent loop with probiotics prior to ileostomy closure in patients operated on for colorectal carcinoma. For this, a prospective, randomized, double-blind, controlled study is designed. All patients who underwent surgery for colorectal carcinoma with loop ileostomy were included. Randomized and divided into two groups, 34 cases and 35 controls were included in the study. Postoperative ileus, the need for nasogastric tube insertion, the time required to begin tolerating a diet, restoration of bowel function, and duration of hospital stay were evaluated. The incidence of Postoperative ileus was similar in both groups, 9/34 patients stimulated with probiotics and 10/35 in the control group (CG) with a p = 0.192. The comparative analysis showed a direct relationship between Postoperative ileus after oncological surgery and Postoperative ileus after reconstruction surgery, independently of stimulation. Postoperative ileus after closure ileostomy is independent of stimulation of the ileostomy with probiotics through the efferent loop. There seem to be a relationship between Postoperative ileus after reconstruction and the previous existence of Postoperative ileus after colorectal cancer surgery.

Machine learning algorithm of ultrasound-mediated intestinal function recovery and nursing efficacy analysis of lower gastrointestinal malignant tumor after surgery.

Objectives:In this paper, machine learning algorithms was used to explore the application value of ultrasound contrast in the early evaluation of neoadjuvant chemotherapy in patients with gastrointestinal malignant liver metastases, and analyzes the effect of sports nursing methods on intestinal function recovery.Methods:Forty-seven patients with gastrointestinal malignancies were divided into 25 patients (combined chemotherapy group) and 22 cases (chemotherapy group) from April 2018 to April 2019. Two groups of patients were treated with CEUS. The effective lesion patients and invalid quantitative parameters were compared between the two groups before and after treatment, and the postoperative routine nursing was implemented.Results:Chemotherapy group effective in 18 cases, accounting for 81.82%; 4 cases, 18.18%. Combination chemotherapy patients 21 cases, accounting for 84.00%; 4 cases, accounting for 16.00%.Conclusion:Based on early is important to assess the efficacy of neoadjuvant chemotherapy in patients with liver metastases peak intensity ultrasound contrast parameters of the machine learning algorithms malignant tumors in the gastrointestinal tract, post-operative care movement helps to restore bowel function.

Effects of probiotics on bowel function restoration following ileostomy closure in rectal cancer patients: a randomized controlled trial.

The aim was to determine the efficacy of probiotics in restoring bowel function following ileostomy reversal in patients with rectal cancer. This was a pilot, randomized, double-blind, placebo-controlled trial. The probiotic used in this study, Lactobacillus plantarum CJLP243, was derived from kimchi. Patients were randomly allocated to a probiotic or placebo group and medication was taken once daily from preoperative day 1 to day 21. Primary outcomes were the Memorial Sloan Kettering Cancer Centre Bowel Function Index (MSKCC BFI) instrument and the low anterior resection syndrome score. The secondary outcomes were the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and CR29 questionnaire responses. Forty patients were enrolled, and 36 patients (probiotics, n=17; placebo, n=19) completed the primary outcomes. Total scores for the MSKCC questionnaire (56.2±12.0 vs. 55.0±10.7, P=0.356) and low anterior resection syndrome scores (33.3±7.6 vs. 36.0±5.3, P=0.257) were not significantly different between the probiotic and placebo groups, respectively. In the MSKCC BFI, the postoperative dietary scale score at week 1 was significantly higher in the probiotic group (13.1±3.8 vs. 9.0±3.0, P<0.001). There were no other significant differences between the two groups for any other questionnaire scores. There were no significant effects supporting the use of a probiotic for improved bowel function in patients following ileostomy reversal. Nevertheless, the administration of probiotics showed trends toward improvements in some subscale bowel function measures, suggesting further studies may be warranted.

Needs, priorities, and attitudes of individuals with spinal cord injury toward nerve stimulation devices for bladder and bowel function: a survey.

Study Design:Survey.Objectives:To investigate the needs and priorities of people with spinal cord injury for managing neurogenic bladder and bowel function and to determine their willingness to adopt neuromodulation interventions for these functions.Methods:Anonymous online survey. It was advertised by word-of-mouth by community influencers and social media, and by advertisement in newsletters of advocacy groups.Results:Responses from 370 individuals (27% female, 73% male) were included. Bladder emptying without catheters was the top priority for restoring bladder function, and maintaining fecal continence was the top priority for restoring bowel function. The biggest concerns regarding external stimulation systems were wearing a device with wires connecting to electrodes on the skin and having to don and doff the system daily as needed. The biggest concerns for implanted systems were the chances of experiencing problems with the implant that required a revision surgery or surgical removal of the whole system. Respondents were willing to accept an external (61%) or implanted (41%) device to achieve improved bladder or bowel function.Conclusions:Bladder and bowel dysfunction remain important unmet challenges for individuals living with SCI who answered our survey. These individuals are willing to accept some potential risks of nerve stimulation approaches given potential benefits. Additional consumer input is critical for guiding both research and translation to clinical use and personalized medicine.

Efficacy and safety of wait and see strategy versus radical surgery and local excision for rectal cancer with cCR response after neoadjuvant chemoradiotherapy: a meta-analysis

BackgroundNeoadjuvant therapy can shrink tumors, increase anus preservation rate, and protect anal function. Radical surgery need cut off the diseased bowel, clean up the lymph nodes, and then restore bowel function. It could bring traumatic effect and poor postoperative quality of life to the patient. Local resection requires removal of the diseased bowel with circular negative margin. The surgical trauma is small, and the postoperative quality of life is good. In this meta-analysis, we aimed to evaluate the efficacy and safety between wait and see strategy (WS), radical surgery (RS), and local excision (LE) of rectal cancer patients with clinical complete response (cCR) response after neoadjuvant chemoradiotherapy.MethodsWe searched PubMed, Cochrane Library, CNKI (China National Knowledge Infrastructure), and Wanfang databases to compare wait and see strategy with radical surgery and local excision for rectal cancer with cCR response after neoadjuvant chemoradiotherapy up to March 2020. We collected the data of local recurrence, distant metastasis, cancer-related death, overall survival, and disease-free survival and used RevMan 5.0 to carry out the meta-analysis. Continuous data were evaluated by the standardized mean differences (SMD) with 95% confidence intervals (95% CIs), and dichotomous data were evaluated by relative risks (ORs or RRs) with 95% CIs. We aimed to compare the advantages and disadvantages of the three groups.ResultsEleven English studies with 1131 patients were included. There were 412 patients in WS group, 678 patients in RS group, and 41 patients in LE group. WS group had a higher local recurrence rate than RS group (OR 7.32, 95% CI 3.58 to 14.95, P < 0.001). There was no significant difference in the other data between the three groups.ConclusionCompared with the RS group, the WS group had an increased risk of local recurrence. However, the WS group had a similar DFS and OS compared with the RS group and the local excision group. Hence, we speculated that the WS group would have similar results as the surgery group for patients with cCR status.

Effect of long-lasting nutritional prehabilitation on postoperative outcome in elective surgery for IBD

Preoperative patient care optimisation appears to be crucial for obtaining good surgical outcomes. Enhanced Recovery After Surgery (ERAS) underlines the necessity to recognize and treat malnutrition perioperatively and to prehabilitate with interventions that can modulate the lean body mass before and after surgery. This procedure has been extensively reported in colorectal cancer patients but in Inflammatory Bowel Disease (IBD) it has not yet been clearly evaluated. The aim of this study was to implement the perioperative nutritional items in surgical Crohn's disease (CD) and ulcerative colitis (UC) patients electively operated in an ERAS setting, thus to clarify the impact of a long-lasting prehabilitation program in IBD. Consecutive adult patients (age ≥18) were included as soon as scheduled for elective surgery for CD or UC. The nutritional intervention included personalized dietary counseling and oral nutritional supplements when necessary. Data prospectively recorded in each phase were: FFM, FM, FFMI and phase angle detected with BIVA, weight, BMI, unintended weight loss, DASI, energy and nutritional intake, gastrointestinal symptoms and bowel functions. Nutritional risk was detected according to the NRS 2002 screening tool. The impact of early oral nutrition on postoperative recovery was analysed. A total of 61 IBD patients (45 CD and 16 UC) were included. Muscle wasting was present at baseline assessment in 28% of cases, significantly associated with the presence of ileostomy (p<0.011) and of a previous IBD surgery (p<0.011). During the preoperative phase, there was a significant improvement in weight, BMI, FFM (CD p=0.035; UC p=0.017), FFMI (CD ns; UC p=0.011) and phase angle (CD p=0.014; UC p=0.027). During the intra-hospital phase, weight and FFM decreased due to the catabolic effect of surgery, but in the whole perioperative period, both CD and UC patients did not change significantly in terms of body composition. Patients with earlier resumption of oral feeding had a significantly shorter hospital stay and a faster recovery of bowel function with no significant relationship with early postoperative complications. Nutritional prehabilitation positively modulated the body composition of IBD patients scheduled for elective surgery and therefore could represent a beneficial strategy to attenuate the impact of the surgical stress response on lean tissue in an ERAS setting. This effect is even more evident in high nutritional risk patients. Early postoperative oral feeding seems feasible and well tolerated in IBD. This approach positively influences the restoration of bowel function and the duration of hospital stay.

Robotic vs laparoscopic right colectomy – the burden of age and comorbidity in perioperative outcomes: An observational study

BACKGROUNDSeveral studies have shown the safety, feasibility and oncologic adequacy of robotic right hemicolectomy (RRH). Laparoscopic right hemicolectomy (LRH) is considered technically challenging. Robotic surgery has been introduced to overcome this technical limitation, but it is related to high costs. To maximize the benefits of such surgery, only selected patients are candidates for this technique. In addition, due to progressive aging of the population, an increasing number of minimally invasive procedures are performed on elderly patients with severe comorbidities, who are usually more prone to post-operative complications.AIMTo investigate the outcomes of RRH vs LRH with regard to age and comorbidities.METHODSWe retrospectively analyzed 123 minimally invasive procedures (68 LRHs vs 55 RRHs) for right colon cancer or endoscopically unresectable adenoma performed in our Center from January 2014 until September 2019. The surgical procedures were performed according to standardized techniques. The primary clinical outcome of the study was the length of hospital stay (LOS) measured in days. Secondary outcomes were time to first flatus (TFF) and time to first stool evacuation. The robotic technique was considered the exposure and the laparoscopic technique was considered the control. Routine demographic variables were obtained, including age at time of surgery and gender. Body mass index and American Society of Anesthesiologists physical status were registered. The age-adjusted Charlson Comorbidity Index (ACCI) was calculated; the tumor-node-metastasis system, intra-operative variables and post-operative complications were recorded. Post-operative follow-up was 180 d.RESULTSLOS, TFF, and time to first stool were significantly shorter in the robotic group: Median 6 [interquartile range (IQR) 5-8] vs 7 (IQR 6-10.5) d, P = 0.028; median 2 (IQR 1-3) vs 3 (IQR 2-4) d, P < 0.001; median 4 (IQR 3-5) vs 5 (IQR 4-6.5) d, P = 0.005, respectively. Following multivariable analysis, the robotic technique was confirmed to be predictive of significantly shorter hospitalization and faster restoration of bowel function; in addition the dichotomous variables of age over 75 years and ACCI more than 7 were significant predictors of hospital stay. No outcomes were significantly associated with Clavien-Dindo grading. Sub-group analysis demonstrated that patients aged over 75 years had a longer LOS (median 6 -IQR 5-8- vs 7 -IQR 6-12- d, P = 0.013) and later TFF (median 2 -IQR 1-3- vs 3 -IQR 2-4- d, P = 0.008), while patients with ACCI more than 7 were only associated with a prolonged hospital stay (median 7 -IQR 5-8- vs 7 -IQR 6-14.5- d, P = 0.036).CONCLUSIONRRH is related to shorter LOS when compared with the laparoscopic approach, but older age and several comorbidities tend to reduce its benefits.

Prospective Association of Serum Opioid Levels and Clinical Outcomes in Patients With Cancer Pain Treated With Intrathecal Opioid Therapy.

Opioids remain the mainstay of cancer pain management but are associated with systemic toxicity. In refractory cancer pain, intrathecal therapy (ITT) is associated with improved pain control, reduced systemic side effects, and improved survival. It has been assumed that ITT decreases systemic serum opioid levels and their associated toxicity, but there are limited data to support this assumption. This study hypothesizes that serum opioid levels decrease with ITT. Secondary objectives include comparative measures of pain, bowel function, and other cancer-related symptoms. Fifty-one cancer patients undergoing ITT for cancer pain were recruited in a prospective observational study. Daily oral morphine equivalency (OME) dose, serum opioid levels, Brief Pain Inventory (BPI), MD Anderson Symptom Inventory (MDASI), and a constipation questionnaire were obtained at the time of implant, and 4 and 8 weeks postoperatively. Average baseline daily OME was 375 mg (median, 240; interquartile range, 150-405; range, 0-3160), mean serum morphine concentration was 53.7 ng/mL (n = 17), and mean oxycodone concentration was 73.7 ng/mL (n = 20). At 4 weeks, 87.5% of patients had discontinued non-IT opioids, and 53% had undetectable (<2 ng/mL) serum opioid concentrations. At 8 weeks, 92% remained off all non-IT opioids and 59% had undetectable serum opioid levels. IT morphine doses >4.2 mg/d were invariably associated with detectable serum levels; with doses <4.2 mg, morphine was undetectable in 80% of subjects. IT hydromorphone doses >6.8 mg/d were detectable in the serum. Using linear mixed model analyses, there were statistically significant decreases in the mean "worst pain," "average pain," and MD Anderson symptom severity and interference scores at 4 and 8 weeks. This change was independent of serum opioid levels; when analyzed separately, there was no difference in the pain scores of subjects with detectable serum opioid levels compared to those with undetectable levels at 4 and 8 weeks. Constipation ranked as "quite a bit" or "very much" decreased from 58.7% to 19.2% of subjects at week 4 (P < .001) and to 37.5% at 8 weeks (P = .23). A very low complication rate was observed. ITT for cancer pain was associated with a marked reduction in serum opioid concentrations, with the majority of patients having undetectable serum levels. Reducing serum opioid concentrations in cancer patients may have implications with respect to restoring bowel function, improving fatigue, and promoting the integrity of antitumor immune function and warrants further study.

A retrospective study on efficacy of the ERAS protocol in patients undergoing surgery for Crohn disease: A propensity score analysis

BackgroundEnhanced Recovery After Surgery (ERAS) offers many benefits for patients with colorectal cancer. However, its application to patients with Crohn’s disease (CD) is questioned. AimThe aim of this propensity-matched study was to validate the results of ERAS protocol on CD patients. MethodsPatients undergoing ileocolic resection for primary or relapsed CD from 2007 to 2018 were retrospectively analyzed and propensity-matched into two equal groups (ERAS vs standard of care). Demographic characteristics, length of stay, bowel function, oral intake, and perioperative morbidity were analyzed. ResultsNinety four out of 299 patients were selected for analysis. No significant difference was observed for age, gender, American Society of Anesthesiologists score, body mass index, previous surgery and therapy, operative time and laparoscopy. The median length of stay in ERAS and non-ERAS groups was 6 and 8 days (p < 0.001). Median postoperative days of first bowel movement and solid oral intake were day 1 and day 2 p < 0,001, and day 2 and day 4.5 p < 0,001 in ERAS and non-ERAS group, respectively. No statistically differences in other postoperative outcomes were shown. ConclusionsERAS implementation showed decreased length of stay, faster bowel function restoration and earlier solid oral intake in patients who underwent laparoscopic or open ileocolic resection for primary or relapsing CD.