Resumption Of Oral Diet Research Articles

Management of neo-esophagus-airway fistula after esophagectomy for oesophageal cancer: systematic literature review and meta-analysis.

Neo-oesophageal-airway fistula (NEAF) between gastric conduit and airway is a rare but life-threatening complication of oesophagectomy for oesophageal cancer. Optimal treatment remains unknown. A meta-analysis of good-quality case series may help determine whether nonoperative management (NOM) only, upfront surgery (S), or NOM followed by surgery is associated with better 1-year post-treatment mortality, resumption of oral diet and fistula recurrence. We systematically searched PubMed, EMBASE and Web of Science for publications in English reporting case series of management and survival in patients with NEAF. Of the 177 identified studies, 62 were duplicates and 95 were not relevant to our topic. Three studies were excluded after a full-text review, due to absence of reporting of 1-year survival. Exclusion criteria to identified publications were: abstract only, malignant NEAF, absence of oesophagectomy and esogastric anastomosis, fewer than 5 patients and NEAF not the main focus of the study. Data-extraction was conducted in accordance with MOOSE guidelines. Data were pooled using random-effects model. Seventeen studies (302 patients) were included. One-year post-treatment mortality was considerably lower with NOM followed by surgery [33%; 95% confidence interval (CI), 0.17-0.48] than with NOM (68%; 95% CI, 0.39-0.97) or S (67%; 95% CI, 0.36-0.98). Fistula location was not associated with 1-year mortality. Neither resumption of an oral diet nor fistula recurrence differed significantly across treatment strategies. NOM to prepare patients for surgery followed by surgical repair may provide the highest 1-year survival of patients with NEAF. However, patient selection criteria to each of 3 treatment strategies may have affected our findings.

TransOral UltraSonic surgery (TOUSS) for oral cavity, oropharyngeal and supraglottic malignancy: A prospective study of feasibility, safety, margins, functional and survival outcomes

Introduction/BackgroundWith the advent of TransOral Robotic Surgery (TORS) the ease of transoral procedures has been dramatically improved. TORS is already established for its feasibility, functional and oncological outcomes for selected lesions of oral cavity, oropharynx and laryngopharynx. This study reports on preliminary results with TransOral UltraSonic Surgery (TOUSS) for oncologic resections of oral cavity, oropharyngeal and supraglottic malignancies. Materials and methodsEighteen patients with malignancies of oral cavity, oropharynx and supraglottis underwent TOUSS with simultaneous neck dissection and adjuvant therapy as indicated, from January 2018 to April 2019. Essential equipment included the FK-retractor (Gyrus Medical, Tuttilngen, Germany) for TransOral exposure, the Olympus ENDOEYE Flex 5 mm 2D/10 mm 3D deflecting tip video laparoscopes, and 35 cm long ultrasonic harmonic scalpel (Thunderbeat). Parameters evaluated include tumor staging, mouth opening, TOUSS setup time, TOUSS primary removal time, surgical margins, blood transfusions, tracheostomy, postoperative complications, enteral feeding and resumption of oral diet, duration of hospital stay, and survival outcomes. ResultsEighteen patients underwent complete TransOral UltraSonic Surgery (TOUSS), with simultaneous unilateral or bilateral neck dissection. No procedure was abandoned intraoperatively due to difficulty in extirpation of the tumor. Margins were negative for ten patients (55.6%), close in five (27.8%), and positive in three patients (16.7%). Average TOUSS set-up time was 22.5 min (range, 10–30 min) and average TOUSS primary tumor removal time was 35.3 min (range, 15–60 min). Patients started tolerating oral feeds even in the second post op day (mean 6 days), and transitioning to complete oral feeds with removal of the nasogastric tube was achieved in all (mean, 16 days). The average hospital stay was 7.4 days (range 2–16 days). Secondary hemorrhage occurred in two cases and required an emergency tracheostomy and ligation of lingual artery. Minor cervicopharyngeal fistula occurred in four cases and settled in all with conservative non-surgical treatment. Overall survival at 3 years was 70.5%, and disease-specific survival was 94.4%. ConclusionTransOral UltraSonic Surgery (TOUSS) is a safe and sound alternative method of endoscopic surgical treatment of oral cavity, oropharynx and supraglottic neoplasms. Advantages of this technique include faster resection time, intraoperative assistance from Narrow Band Imaging, easy affordability compared to TORS, and excellent functional outcomes.

Laparoscopic versus open appendectomy: A comparative study

The current study was done to compare the effectiveness, safety and clinical outcome between Laparoscopic and Open Appendectomy in terms of operating time, complications and length of hospital stay. Patients undergoing Appendectomy by Laparoscopic and Open technique from November 2016 to October 2017 were enrolled in the study after fulfilling eligibility criteria. According to surgical approach patients were randomly divided into two groups Laparoscopic Appendectomy Group (LA group) & Open Appendectomy Group (OA group) respectively. The following parameters were assessed primarily in terms of operating time, resumption of oral diet, length of hospital stay, no. of analgesic doses, conversion rate, post-operative pain, Intraoperative and post operative complications like wound infection, prolong ileus, intraabdominal abscess, diarrhea and urinary tract infection. Results: We found that operating time was comparable in both groups, resumption of oral diet was earlier in LA Group as compare to OA Group (with p value of

Incidence and risk factors of oral feeding intolerance in acute pancreatitis: Results from an international, multicenter, prospective cohort study.

BackgroundInability to advance to an oral diet, or oral feeding intolerance, is a common complication in patients with acute pancreatitis associated with worse clinical outcomes. The factors related to oral feeding intolerance are not well studied.ObjectiveWe aimed to determine the incidence and risk factors of oral feeding intolerance in acute pancreatitis.MethodsPatients were prospectively enrolled in the Acute Pancreatitis Patient Registry to Examine Novel Therapies in Clinical Experience, an international acute pancreatitis registry, between 2015 and 2018. Oral feeding intolerance was defined as worsening abdominal pain and/or vomiting after resumption of oral diet. The timing of the initial feeding attempt was stratified based on the day of hospitalization. Multivariable logistic regression was performed to assess for independent risk factors/predictors of oral feeding intolerance.ResultsOf 1233 acute pancreatitis patients included in the study, 160 (13%) experienced oral feeding intolerance. The incidence of oral feeding intolerance was similar irrespective of the timing of the initial feeding attempt relative to hospital admission day (p = 0.41). Patients with oral feeding intolerance were more likely to be younger (45 vs. 50 years of age), men (61% vs. 49%), and active alcohol users (44% vs. 36%). They also had higher blood urea nitrogen (20 vs. 15 mg/dl; p < 0.001) and hematocrit levels (41.7% vs. 40.5%; p = 0.017) on admission; were more likely to have a nonbiliary acute pancreatitis etiology (69% vs. 51%), systemic inflammatory response syndrome of 2 or greater on admission (49% vs. 35%) and at 48 h (50% vs. 26%), develop pancreatic necrosis (29% vs. 13%), moderate to severe acute pancreatitis (41% vs. 24%), and have a longer hospital stay (10 vs. 6 days; all p < 0.04). The adjusted analysis showed that systemic inflammatory response syndrome of 2 or greater at 48 h (odds ratio 3.10; 95% confidence interval 1.83–5.25) and a nonbiliary acute pancreatitis etiology (odds ratio 1.65; 95% confidence interval 1.01–2.69) were independent risk factors for oral feeding intolerance.ConclusionOral feeding intolerance occurs in 13% of acute pancreatitis patients and is independently associated with systemic inflammatory response syndrome at 48 h and a nonbiliary etiology.

Modified biliary-enteric anastomosis for congenital choledochal cyst: clinical and prognostic analysis of 91 cases

PurposeTo report our experience with a modified biliary-enteric anastomosis procedure for the surgical treatment of congenital choledochal cysts.MethodsBetween January 2009 and December 2013, 91 children (19 boys, 72 girls; ages, 6–145 months) with congenital choledochal cysts were treated with our modified surgical procedure in our hospital. Of these patients, 69 had type I cysts, and 22 had type IV B cysts. The main parameters analyzed mainly included the operative time, duration of bowel recovery, resumption of diet, postoperative hospital stay, liver-function tests, postoperative complications, and prognosis.ResultsThe average operation duration was 129.34 ± 23.50 min. The time until first flatus and resumption of oral diet were 26.51 ± 4.13 h and 5.47 ± 0.77 day, respectively. The mean postoperative hospital stay was 11.84 ± 2.58 day. Postoperative complications occurred in six patients: intestinal obstruction (1 patient), postoperative bleeding (1 patient), postoperative pancreatitis (1 patient), and bile leakage (3 patients). During a follow-up of 2–7 years, four cases of occasional abdominal pain were found. Contrast agent reflux was detected on upper gastrointestinal imaging in three children. All children had good nutrition.ConclusionThe modified biliary-enteric anastomosis is a safe, simple, and reliable technique. However, longer follow-up and a larger sample size are necessary to prove its efficacy in the treatment of congenital choledochal cysts.

PWE-026 Role of pyloric and duodenal self expandable metal stents (sems) for malignant gastric outflow obstruction in palliative patients

<h3>Introduction</h3> Stent placement for malignant gastric outflow obstruction (GOO) is recommended for palliative management for patients with unresectable disease. Gastrojejunostomy is an alternative but may not be appropriate due to poor performance status and prognosis. Endoscopic SEMS for GOO is less invasive and has been shown to be safe and effective method for relieving symptoms of GOO. Previously reported endoscopic success rate of GOO stenting is 92–100%.¹ Our aim was to assess the safety and efficacy of pyloric and duodenal stents (SEMS) for gastric outflow obstruction caused by malignancy. <h3>Method</h3> Retrospective audit between Jan 2012 to Dec 2014, reviewing medical notes and electronic patient records. All procedures were performed using Through the Scope (TTS) technique and fluoroscopic guidance. End-points were technical success (correct SEMS placement confirmed radiologically and endoscopically at time of procedure) and clinical success (resolution of obstructive symptoms, resumption of oral diet). <h3>Results</h3> 63 patients were identified (median age 71 years). 50 patients (79%) had malignant stricture due to primary cancers (gastric 33%, pancreatic 25%). 13 patients had GOO from metastases (20%). Median ASA grade was 3. <h3>Procedural Success</h3> 4 patients did not require stent placement when evaluated endoscopically. Of the remaining 59 patients 55 were stented successfully (93.2%). In 4 patients stents could not be deployed as stricture could not be traversed with wire or cannula. Of the 55 patients who were stented clinical success was 96% (2 patients needed repeat procedure within one week). 13 patients (25%) required further interventions due to stent blockage from tumour ingrowth or food debris and all successfully managed with restenting. The mean time for further intervention 98 day. 83 procedures were carried in total with an overall success rate of 95.2%. There were no major complications reported, no perforation or procedure related mortality. Two patient had stent migrated proximally into stomach and one patient needed repeat procedure due to lack of stent expansion, all managed with successful restenting. <h3>Survival</h3> 78% were alive at 30 days, 32% were alive at 6 month with 4 patients yet to reach 6 month end point, 33% alive at 1 year. <h3>Conclusion</h3> Stenting for GOO is a safe procedure and avoids the need for surgical gastroenterojejunostomy in over 93% of palliative patients. Stent dysfunction can happen due to tumour overgrowth, food debris or stent migration. In our study all 25% of patients needing reintervention within 4 months were successfully managed with restenting. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Gaidos JKJ. Treatment of malignant gastric outlet obs truction with endoscopically placed self -expandable metal stents. World J Gastroenterol 2009;15(35):4365–4371

Should Subcostal and Lateral Trocars Be Used in Laparoscopic Cholecystectomy? A Randomized, Prospective Study

Three to four trocars are commonly used when performing laparoscopic cholecystectomy (LC). Subcostal and lateral trocars are used for the grasper to retract the gallbladder. These graspers are seldom extracted or exchanged with other instruments. Based on this, it seems that the subcostal and lateral trocars are of minimal importance. The aim of this study was to evaluate the validity and benefits of performing LC without subcostal and lateral trocars (LCWSL). From June 2006 to June 2007, 60 patients diagnosed with gallbladder disease were enrolled in this randomized, controlled trial to compare the result of LCWSL to conventional LC (CLC). Operation time, complication, pain scale, cosmetic effect, and hospital cost were compared. There were no differences in operation time and intra- or postoperative morbidity. Total blood loss, pain, duration until resumption of oral diet, and duration of hospital stay were similar. Total cost of LCWSL was cheaper than CLC by $397 USD (P < 0.05), and total incision length was smaller than CLC by 11 mm. LCWSL seems to be an acceptable procedure, having the same morbidity and better economic and cosmetic outcome, as compared to CLC.

Transoral robotic surgery for oropharyngeal squamous cell carcinoma: A prospective study of feasibility and functional outcomes

To investigate the feasibility of transoral robotic surgery as a method of surgical treatment of oropharyngeal squamous cell carcinoma. Prospective case study. Forty-five patients with previously untreated oropharyngeal squamous cell carcinoma underwent transoral robotic surgical removal of the tumor with or without neck dissection and with or without adjuvant therapy. Patients were observed and data were recorded on surgical time, blood loss, surgical complications, tracheostomy tube course, enteral feeding, and resumption of oral diet, speech outcomes, swallowing outcomes, and tumor recurrence. All 45 patients underwent complete transoral robotic surgical excision with simultaneous unilateral or bilateral neck dissection. Margins were negative for tumor. Mean operating time for tumor removal was 71.3 minutes for the last 35 cases. There were 15 stage T1 tumors, 18 T2 tumors, 3 T3 tumors, and 9 T4a tumors. Twenty-six patients had base of tongue primary tumors and 19 had tonsillar fossa tumors. Fourteen patients had a tracheostomy tube placed at surgery, and all patients had their tracheostomy tube removed (mean duration of use, 7.0 days). Twenty-two patients (48.9%) had a nasogastric feeding tube placed, and all patients had their feeding tube removed (mean duration of use, 12.5 days). Eight patients had percutaneous gastrostomy (PEG) tubes placed, and all eight eventually had their PEG tubes removed (mean duration of use, 140.3 days). Average hospital stay was 3.8 days. There were no major complications and no procedure was aborted because of an inability to remove the tumor. Transoral robotic surgery is a safe and efficacious method of surgical treatment of oropharyngeal neoplasms. Advantages of the technique include adequate ability to visualize and manipulate with two hands lesions in the base of tongue. Patients were able to retain or rapidly regain oropharyngeal function in the majority of cases.

Resumption of oral intake following percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) provides enteral nutrition to patients who cannot swallow. Few studies have prospectively evaluated its long-term outcomes or eventual resumption of oral intake. Consecutive PEG patients were prospectively recruited from a tertiary hospital over 12 months and followed until all had met the primary endpoints of death or resumption of oral diet with PEG extubation. Data was collected by standardised periodic phone interview. Forty patients (24 males, median age 74 years) were followed for up to 8.4 years (median 5.3 months, interquartile range [IQR] 13.6 months). The end-of-study mortality rate was 70% (median 6.8 months, IQR 19.9 months) and the only predictor of mortality was head injury as the indication for PEG (Cox regression HR 5.90, 95% CI: 1.2-28.4). At two years following PEG, 30% of patients had resumed oral intake (median 2.9 months, IQR 7.2 months) and 19% remained on PEG-feeding. Predictors of resumption of oral intake were the ability to tolerate some oral intake at 3 months (HR: 248.5, 95% CI: 8.7-7065.3) and 6 months (HR: 6.3, 95% CI: 1.03-38.9) but not at 12 months. Cumulative survival was highest for ear nose and throat (ENT) tumour and worst for acute head injury (log rank P = 0.048). Half of all PEG patients remained alive at 2 years using PEG or have resumed full oral intake. A supervised trial of oral intake at 3 or 6 months may help predict eventual resumption of per oral diet.

An Enhanced-Recovery Protocol Improves Outcome After Colorectal Resection Already During the First Year

This study was designed to investigate the clinical outcome and recovery before and immediately after implementation of the enhanced recovery after surgery enhanced recovery after surgery protocol in colonic and rectal resection. One hundred and sixty-eight consecutive patients in a single center underwent colorectal surgery before (traditional, n = 69) and immediately after implementing enhanced recovery after surgery (n = 99). Rectal surgery was performed in 77 patients. Postoperative food and fluid intake, mobilization, physiologic function, and clinical outcome were measured prospectively. Resumption of oral diet was achieved on postoperative day postoperative day 1 in the enhanced recovery after surgery group. In the enhanced recovery after surgery group, mobilization more than 6 hours daily was achieved on postoperative day 2 to 3 and passage of stool occurred on postoperative day 2 vs. postoperative day 5 in the traditional group (P < 0.0001). Muscle strength and lung function were less reduced in the enhanced recovery after surgery group (P < 0.05). Median hospital stay was reduced by 2 days (P < 0.01). Readmission rates increased (4 percent vs. 15 percent, P < 0.01) but total hospital stay was still lower in the enhanced recovery after surgery group (P < 0.01). After colonic resection, postoperative complications decreased in enhanced recovery after surgery (37 percent vs. 18 percent, P < 0.05), whereas no change was found after rectal resection. Immediately after implementing enhanced recovery after surgery, recovery was improved and length of hospital stay was reduced. Notably, postoperative morbidity decreased only in patients undergoing colonic resection.

Preservation of renal function in juxtarenal and suprarenal abdominal aortic aneurysm repair

Deterioration in renal function is a common cause of morbidity in patients treated surgically for juxtarenal and suprarenal abdominal aortic aneurysms. We reviewed our experience over the last 8 years with 65 consecutive patients undergoing juxtarenal (n = 31) or suprarenal (n = 34) abdominal aortic aneurysm repair. The aneurysms were repaired with a transabdominal (n = 8), thoracoabdominal (n = 4), retroperitoneal (n = 22), or thoracoretroperitoneal (n = 31) approach. Proximal aortic clamps were placed at the suprarenal, supra-superior mesenteric artery, or supraceliac level. Renal hypothermia with cold heparinized saline solution renal artery perfusion was used to protect renal function in 38 patients with either preoperative renal insufficiency or with anticipated prolonged renal ischemia (> 30 minutes). Concomitant renal artery reconstruction was required in 30 patients. Significant operative morbidity developed in 23 (35.3%) patients. There was one (1.53%) perioperative death (0 to 90 days). Temporary dialysis was necessary in two patients. Preoperative renal insufficiency was a significant risk factor on multivariate analysis for a decline in renal function during the first postoperative week. However, serum creatinine concentration had returned to baseline or improved in all patients but two (3.1%) at the time of discharge. In spite of significantly longer renal ischemia, discharge creatinine levels were, on univariate analysis, statistically less than baseline creatinine levels in patients with suprarenal aneurysms, patients requiring renal reconstruction, and patients treated with renal hypothermia. The location of the proximal aortic clamp was not a factor in postoperative morbidity. There was no significant difference between juxtarenal and suprarenal aneurysms with respect to operating room time, transfusion requirements, days intubated, resumption of oral diet, or the length of hospitalization. Careful consideration of the route of exposure, location of the proximal aortic clamp, and the preservation of renal function with renal hypothermia and with the repair of significant renal artery lesions will result in minimal morbidity and mortality in patients requiring surgery for juxtarenal or suprarenal abdominal aortic aneurysms.

Preservation of renal function in juxtarenal and suprarenal abdominal aortic aneurysm repair

Purpose: Deterioration in renal function is a common cause of morbidity in patients treated surgically for juxtarenal and suprarenal abdominal aortic aneurysms. We reviewed our experience over the last 8 years with 65 consecutive patients undergoing juxtarenal (n = 31) or suprarenal (n = 34) abdominal aortic aneurysm repair.Methods: The aneurysms were repaired with a transabdominal (n = 8), thoracoabdominal (n = 4), retroperitoneal (n = 22), or thoracoretroperitoneal (n = 31) approach. Proximal aortic clamps were placed at the suprarenal, supra-superior mesenteric artery, or supraceliac level. Renal hypothermia with cold heparinized saline solution renal artery perfusion was used to protect renal function in 38 patients with either preoperative renal insufficiency or with anticipated prolonged renal ischemia (> 30 minutes). Concomitant renal artery reconstruction was required in 30 patients.Results: Significant operative morbidity developed in 23 (35.3%) patients. There was one (1.53%) perioperative death (0 to 90 days). Temporary dialysis was necessary in two patients. Preoperative renal insufficiency was a significant risk factor on multivariate analysis for a decline in renal function during the first postoperative week. However, serum creatinine concentration had returned to baseline or improved in all patients but two (3.1%) at the time of discharge. In spite of significantly longer renal ischemia, discharge creatinine levels were, on univariate analysis, statistically less than baseline creatinine levels in patients with suprarenal aneurysms, patients requiring renal reconstruction, and patients treated with renal hypothermia. The location of the proximal aortic clamp was not a factor in postoperative morbidity. There was no significant difference between juxtarenal and suprarenal aneurysms with respect to operating room time, transfusion requirements, days intubated, resumption of oral diet, or the length of hospitalization.Conclusions: Careful consideration of the route of exposure, location of the proximal aortic clamp, and the preservation of renal function with renal hypothermia and with the repair of significant renal artery lesions will result in minimal morbidity and mortality in patients requiring surgery for juxtarenal or suprarenal abdominal aortic aneurysms.