Search

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%., (Copyright © 2021 Colombia Medica.)

Background: Patients with Crohn's disease suffer from a higher rate of anastomotic leakages after ileocecal resection than patients without Crohn's disease. Our hypothesis was that microscopic inflammation at the resection margins of ileocecal resections in Crohn's disease increases the rate of anastomotic leakages., Patients and Methods: In a retrospective cohort study, 130 patients with Crohn's disease that underwent ileocecal resection between 2015 and 2019, were analyzed. Anastomotic leakage was the primary outcome parameter. Inflammation at the resection margin was characterized as "inflammation at proximal resection margin", "inflammation at distal resection margin" or "inflammation at both ends"., Results: 46 patients (35.4%) showed microscopic inflammation at the resection margins. 17 patients (13.1%) developed anastomotic leakage. No difference in the rate of anastomotic leakages was found for proximally affected resection margins (no anastomotic leakage vs. anastomotic leakage: 20.3 vs. 35.3%, p = 0.17), distally affected resection margins (2.7 vs. 5.9%, p = 0.47) or inflammation at both ends (9.7 vs. 11.8%, p = 0.80). No effect on the anastomotic leakage rate was found for preoperative hemoglobin concentration (no anastomotic leakage vs. anastomotic leakage: 12.3 vs. 13.5 g/dl, p = 0.26), perioperative immunosuppressive medication (62.8 vs. 52.9%, p = 0.30), BMI (21.8 vs. 22.4 m2/kg, p = 0.82), emergency operation (21.2 vs. 11.8%, p = 0.29), laparoscopic vs. open procedure (p = 0.58), diverting ileostomy (31.9 vs. 57.1%, p = 0.35) or the level of surgical training (staff surgeon: 80.5 vs. 76.5%, p = 0.45)., Conclusion: Microscopic inflammation at the resection margins after ileocecal resection in Crohn's disease is common. Histologically inflamed resection margins do not appear to affect the rate of anastomotic leakages. Our data suggest that there is no need for extensive resections or frozen section to achieve microscopically inflammation-free resection margins., Competing Interests: The authors have declared that no competing interests exist.

Intravital microscopy is an imaging technique aimed at the visualization of the dynamics of biological processes in live animals. In the last decade, the development of nonlinear optical microscopy has enormously increased the use of this technique, thus addressing key biological questions in different fields such as immunology, neurobiology and tumor biology. In addition, new upcoming strategies to minimize motion artifacts due to animal respiration and heartbeat have enabled the visualization in real time of biological processes at cellular and subcellular resolution. Recently, intravital microscopy has been applied to analyze different aspect of mucosal immunity in the gut. However, the majority of these studies have been performed on the small intestine. Although crucial aspects of the biology of this organ have been unveiled, the majority of intestinal pathologies in humans occur in the large intestine.Here, we describe a method to surgically expose and stabilize the large intestine in live mice and to perform short-term (up to 2 h) intravital microscopy.

Purpose: In the present study, we focused on the accessory middle colic artery and aimed to increase the safety and curative value of colorectal cancer surgery by investigating the artery course and branching patterns., Methods: We included 143 cases (mean age, 70.4 ± 11.2 years; 86 males) that had undergone surgery for neoplastic large intestinal lesions at the First Department of Surgery at Yamagata University Hospital between August 2015 and July 2018. We constructed three-dimensional (3D) computed tomography (CT) angiograms and fused them with reconstructions of the large intestines. We investigated the prevalence of the accessory middle colic artery, the variability of its origin, and the prevalence and anatomy of the arteries accompanying the inferior mesenteric vein at the same level as the origin of the inferior mesenteric artery., Results: Accessory middle colic artery was observed in 48.9% (70/143) cases. This arose from the superior mesenteric artery in 47, from the inferior mesenteric artery in 21, and from the celiac artery in two cases. In 78.2% (112/143) cases, an artery accompanying the inferior mesenteric vein was present at the same level as the origin of the inferior mesenteric artery; this artery was the left colic artery in 92, the accessory middle colic artery in 11, and it divided and became the left colic artery and the accessory middle colic artery in 10 cases., Conclusion: 3D CT angiograms are useful for preoperative evaluation. Accessory middle colic arteries exist and were observed in 14.9% of cases.

Objectives: Bowel procedures are commonly performed as part of ovarian cancer cytoreduction. The aim of this study was to assess the postoperative complication rates among women with an ovarian malignancy undergoing bowel resection/repair at the time of cytoreductive surgery compared with a control group (cytoreductive surgery without bowel resection or repair)., Methods: Analysis of 4965 cytoreductive surgeries for suspected ovarian malignancies recorded in the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) datasets (2006-2017) was performed. One-way ANOVA, Kruskal-Wallis H and Chi-squared tests were used to evaluate and compare baseline characteristics between the groups and controls. Postoperative surgical site infection rates and other 30-day post-operative outcomes were assessed with multivariable logistic and linear regressions., Results: 8.3% (413/4965) of cytoreductive procedures had an associated repair of enterotomy (small or large bowel), 10.9% (541/4947) had an associated colectomy with primary anastomosis, and 2.1% (104/4965) had an associated colectomy with colostomy. Surgical site infections (SSI, either superficial incisional, deep incisional, organ space or wound dehiscence) were significantly more prevalent in the bowel resection/repair group (16.9% vs 5.7%, p < 0.0001). The odds of surgical infections were 2.67 times higher in patients who underwent a bowel resection or repair after controlling for age, BMI, ASA status, pre-operative weight loss, hypoalbuminemia, NSQIP morbidity score, length and complexity of surgical procedure., Conclusion: Patients undergoing bowel resection/repair at the time of cytoreductive surgery are at increased risk of surgical site infections, without increased risk of 30-day mortality. Interventions to mitigate the risk of infectious complications in these patients should be evaluated in a prospective fashion., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Recent studies suggest that some of the post-surgical morbidity in Hirschsprung disease (HSCR) is due to enteric nervous system structural defects in the proximal, ganglionated bowel that remains after surgery. We hypothesized that resection margin histology would predict intermediate-term outcomes in HSCR patients., Methods: Following IRB approval, HSCR patients with rectosigmoid disease born between 2009 and 2016 were reviewed and tissue blocks were obtained for new analyses. Proximal resection margins were analyzed for ganglion size, Hu + neurons/ganglion, and % nitric oxide synthase (NOS) neurons/ganglion as compared to control (non-HSCR) patient samples. Chart reviews were performed for 1- and 2-year outcomes. Patients were contacted for survey to determine Rintala bowel function score., Results: 45 patients had recto-sigmoid disease and were further analyzed. HSCR patients had significantly smaller individual ganglion size (4533 μm 2 , range 1744-16,287 vs. 6492 μm 2 , range 1932-30,838, p = 0.0192) and fewer HuC/D + neurons per ganglion (15, range 5.2-34 vs. 21, range 5.2-6.7, p = 0.0214). HSCR patients demonstrated a markedly increased percentage of NOS (relaxation neurotransmitter) neurons (50, range 22-85 vs. 37, range 16-80, p = 0.0266). None of the histology measures correlated with presence/absence of constipation at 1-2 year follow-up (p = NS). However, smaller ganglion size and higher percentage of NOS neurons correlated with decreased patient-reported quality of life (r = 0.3838, r =  - 0.1809)., Conclusion: 1-2 year follow-up may be insufficient to determine if resection margin histology correlates with outcomes. Patient-reported quality of life surveys, although limited in number, suggest that neurotransmitter imbalance at the resection margin may predict poor outcomes in HSCR patients. This study supports the concept that the ganglionated portion of the remaining colon post-surgery may not sustain normal bowel function.

Serrated polyps are classified into hyperplastic polyps, sessile serrated adenomas/polyps, and traditional serrated adenomas. Although all serrated polyps share characteristic colonic crypts serrations, distinguishing hyperplastic polyps from sessile serrated adenomas/polyps is challenging. Traditional serrated adenomas are cytologically dysplastic lesions; sessile serrated adenomas/polyps develop cytologic dysplasia as they progress to colorectal cancer. A flat and pale appearance of serrated polyps may make detection difficult. Endoscopic mucosal resection has higher rates of complete resection. Close surveillance is recommended for sessile serrated adenomas/polyps, sessile serrated adenomas/polyp with dysplasia, hyperplastic polyps ≥10 mm, and traditional serrated adenomas., Competing Interests: Disclosure The authors have no conflicts of interest to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

This work's objective was to review the entire literature on colorectal surgery in order to best define the surgical indications and their management specificities. The literature analysis was carried out according to High Authority for Health (HAS) methodology, by consulting the PubMed database (Medline), from the beginning of January 1995 until the end of June 2015., (Celsius.)

Background: Animal studies have shown that peritoneal injury can be minimized by insufflating the abdominal cavity with warm humidified carbon dioxide gas., Methods: A single-blind RCT was performed at a tertiary colorectal unit. Inclusion criteria were patient aged 18 years and over undergoing open elective surgery. The intervention group received warmed (37°C), humidified (98 per cent relative humidity) carbon dioxide (WHCO 2  group). Multiple markers of peritoneal inflammation and oxidative damage were used to compare groups, including cytokines and chemokines, apoptosis, the 3-chlorotyrosine/native tyrosine ratio, and light microscopy on peritoneal biopsies at the start (T 0 ) and end (T end ) of the operation. Postoperative clinical outcomes were compared between the groups., Results: Of 40 patients enrolled, 20 in the WHCO 2 group and 19 in the control group were available for analysis. A significant log(T end /T 0 ) difference between control and WHCO 2 groups was documented for interleukin (IL) 2 (5·3 versus 2·8 respectively; P = 0·028) and IL-4 (3·5 versus 2·0; P = 0·041), whereas apoptosis assays documented no significant change in caspase activity, and similar apoptosis rates were documented along the peritoneal edge in both groups. The 3-chlorotyrosine/tyrosine ratio had increased at T end by 1·1-fold in the WHCO 2 group and by 3·1-fold in the control group. Under light microscopy, peritoneum was visible in 11 of 19 samples from the control group and in 19 of 20 samples from the WHCO 2 group (P = 0·006). The only difference in clinical outcomes between intervention and control groups was the number of days to passage of flatus (2·5 versus 5·0 days respectively; P = 0·008)., Conclusion: The use of warmed, humidified carbon dioxide appears to reduce some markers related to peritoneal oxidative damage during laparotomy. No difference was observed in clinical outcomes, but the study was underpowered for analysis of surgical results. Registration number: NCT02975947 ( www.ClinicalTrials.gov/)., (© 2019 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.)

The current trends in the treatment of various surgical diseases of large bowel using minimally invasive operations are reviewed in the manuscript. It is shown that laparoscopy is currently possible in most cases for urgent large bowel diseases.

Background: Surgical management of Hirschsprung disease (HD) involves fully excising the transition zone (TZ). The literature suggests that resection of ≥5 cm of ganglionic bowel proximal to the aganglionic segment is sufficient. Our primary aim was to evaluate the lengths of the TZ in a cohort of consecutive patients with HD. We reviewed the impact this had on the need for revision surgery. We hypothesized that the TZ can be highly variable and may lead to a TZ pull-through when the proximal donut is not reviewed intraoperatively., Methods: A retrospective review was conducted for all patients undergoing primary pull-through surgery between January 2012 and September 2018. Data was collected on demographics, need for staged surgery, and complications following surgery., Results: Forty-eight patients were eligible for inclusion. 11/48 (23%) patients presented late (>6 months). 27/48 (56%) patients needed a stoma prior to definitive surgery. The median age at pull-through was 6 months (1-84 months). The median TZ length was 1.7 cm (0.3-22.9 cm). 11/48 (23%) had a TZ >5 cm. 36/48 (75%) patients did not have intraoperative review of the donut resulting in three TZ pull-throughs., Conclusions: We would advocate circumferential intraoperative frozen section review of the proximal donut to minimize the risk of a TZ pull-through., Level of Evidence: Level III., (Copyright © 2019. Published by Elsevier Inc.)

Introduction: Patients with abdominal trauma appear frequently. The most vulnerable organs in these patients are the liver and the spleen. Injuries of the small and large intestines are relatively less frequent. The diagnostic process of these injuries is complex and requires an analysis of all results. Therefore it is highly probable that the final diagnosis can be delayed and so can be delayed an indication of surgical exploration of the abdominal cavity, which can have serious consequences on the morbidity and mortality of these patients with intestinal trauma., Methods: We collected our data using the WinMedicalc 2000 software. We searched for patients hospitalised in years 20082017 in the Department of Surgery, Faculty of Medicine in Pilsen subjected to surgical revision of the abdominal cavity for intestinal trauma., Results: Our set comprised 41 patients, including 30 men and 11 women. The mean age of the patients was 41 years, 4 of the patients were children. Twenty-three of the patients suffered from polytrauma, while 9 of the patients had a relatively isolated injury of either the small intestine or the colon. Six of the patients died. The small intestine was injured in 17 patients, the colon was injured in 14 patients and both were injured in 10 patients. The intestinal injury was diagnosed in 17 cases based on CT imaging (performed 31 times in total); 23 cases were diagnosed in the peroperative period., Conclusions: We assessed a set of patients with an intestinal injury in terms of specific diagnosis, severity of trauma, diagnostic process and treatment. The results are similar to the results of studies in large sets of patients. Even though imaging methods can help to reach the right diagnosis, they are insufficient as a sole diagnostic method, and physical examination plays a major role.

Background: Leakage of the anastomosis after colorectal surgery is a severe complication, and one of the most important causes is poor vascular supply. However, a microvascular deficit is often not detectable during surgery under white light. Near-infrared indocyanine green (ICG)-enhanced fluorescence may be useful for assessing microvascular deficits and conceivably preventing anastomotic leakage., Objectives: This paper presents a preliminary retrospective case series on robotic colorectal surgery. The aim is to evaluate the feasibility, safety and role of near-infrared ICG-enhanced ?uorescence for the intraoperative assessment of peri-anastomotic tissue vascular perfusion., Materials and Methods: From among more than 164 robotic colorectal cases performed, we retrospectively analyzed 28 that were all performed by the same surgeon (PCG) using near-infrared ICG-enhanced fluorescence technology: 16 left colectomies (57.1%), 8 rectal resections (28.6%), 3 right colectomies (10.8%) and 1 pancolectomy (3.6%)., Results: The rates of conversion, intraoperative complications, dye allergic reaction and mortality were all 0%. In two cases (7.1%)-1 left and 1 right colectomy-the level of the anastomosis was changed intraoperatively after ICG showed ischemic tissues. Despite the application of ICG, one anastomotic leak (after left colectomy for a chronic recurrent sigmoid diverticulitis with pericolic abscess) was observed., Conclusions: ICG technology may help to determine when to intraoperatively change the anastomotic level to a safer location. In our case series, ICG results led to a change in the level of the anastomosis in 7.1% of the cases. Despite the use of ICG, we observed one leak. This may have been related to vascularization-independent causes (e.g., infection in this case) or may reflect a need for better standardization of this ICG technology. In particular, we need a way to objectively assess the ICG signal and the related risk of leakage. More randomized, prospective, well-powered trials are needed to unveil the full potential of this innovative surgical technology.

Background: Anastomotic surgical recurrence after bowel resection in Crohn's disease patients is problematic. This study was performed to evaluate the increased risk of anastomotic surgical recurrence., Methods: From 2006 to 2016, we performed anastomoses in 215 consecutive Crohn's disease patients. The cohort was divided into two groups: Kono-S anastomosis (n = 117) and end-to-end anastomosis (n = 98). Multivariate analysis of predictors of anastomotic surgical recurrence and Kaplan-Meier analysis for the 5-year anastomotic surgical recurrence rate were evaluated., Results: The two groups showed no statistically significant differences in patient backgrounds. During a median follow-up of 54 months, 28 patients required anastomotic surgical recurrence [4 (3.4%) in the Kono-S group and 24 (24.4%) in the end-to-end group]. Six leaks (5.1%) were detected in the Kono-S group and 17 leaks (17.3%) in the end-to-end group; all were successfully treated conservatively. End-to-end anastomosis, leakage, age < 45 years, and body mass index of ≥ 18 kg/m 2 at the first surgery had a higher risk of anastomotic surgical recurrence. Kono-S anastomosis significantly reduced the risk of anastomotic surgical recurrence after 1 year (odds ratio, 0.14). Anastomotic leakage influenced anastomotic surgical recurrence within 1 year (odds ratio, 4.84). The 5-year surgery-free survival rate at the anastomosis site with Kono-S anastomosis (95.0%) was significantly higher than that with end-to-end anastomosis (81.3%; P < 0.001)., Conclusions: Anastomotic leakage after bowel resection in Crohn's disease patients increased anastomotic surgical recurrence within 1 year, and Kono-S anastomosis is associated with a low risk of anastomotic surgical recurrence after > 1 year.

Aim To investigate the efficacy and safety of the single-step surgery in elderly patients with obstructive colorectal cancer. Methods All patients who underwent single-step surgery and primary anastomosis for obstructive colorectal cancer in the period between January 2021 December 2017 were evaluated in this study. The patients were divided into two groups: younger than 65 (Group Young) and older than 65 (Group Old). Demographic data, American Society of Anesthesiologists scores (ASA) scores, comorbidities, preoperative albumin levels, type of surgery, postoperative morbidity and mortality, pathological stages, and overall survival rates were investigated. Results A total of 89 patients were included: 49 (54%) were older than 65 (Group Old). In Group Old, the mean age was 75 (65-97), of which 28 (58.3%) were males. There were 41 patients younger than 65 (Group Young) with the mean age of 52.6 (41-64 years of age), of which 21 (51.2%) were males. There was no difference between groups according to albumin level. There was no statistical difference between two groups according to tumour localization, pathological stage and type of surgery, as well as according to surgical complications. The median overall survival rate was 11 months in both groups (0-66) (p=0.320). Conclusion Meticulous preparation of older patients (correction of anaemia, electrolyte levels and pH ) paves the road for successful surgeries, including single-step resection and primary anastomosis., (Copyright© by the Medical Assotiation of Zenica-Doboj Canton.)

Objectives: The aim of this study was to investigate the risk factors for postoperative complications (POCs) and optimal interval between a self-expandable metallic stent (SEMS) placement and elective surgery, "bridge to surgery (BTS)" in patients with malignant large bowel obstruction., Materials and Methods: BTS strategy was attempted in 49 patients with malignant large bowel obstruction from January 2013 to March 2017 in our institution. Two of these patients were excluded because they had undergone emergency surgery for SEMS migration., Results: Of these 47 patients, 8 had developed POC (Clavien-Dindo grading ≥II), whereas 39 patients had no such complications. Multivariate analysis identified only the interval between SEMS and surgery as an independent risk factor for POC. Furthermore, a cutoff value of 15 days for interval between SEMS and surgery was identified by receiver operating characteristic curve analysis., Conclusions: An interval of over 15 days is recommended for minimizing POC in patients undergoing elective surgery in a BTS setting.

Backgrounds: We sought to describe the outcomes of endoscopic therapy of luminal strictures in patients with Crohn's disease (CD) at a large tertiary referral center., Methods: All patients who had undergone endoscopic dilation of CD strictures between January 1, 1990 and November 30, 2013 were identified. Demographics, disease characteristics including medication use and history of surgeries, details of endoscopic procedures, and long-term outcomes were analyzed. A successful procedure was defined as ability of the endoscope to pass through the stricture after dilation or effacement of the dilating balloon under fluoroscopy. Kaplan-Meier and Cox proportional hazards analysis were used., Results: For this study 286 index procedures for CD-related stricture dilation were performed in 273 patients (53.8% women) with median age of 45.9 years (range, 14.9-92.2). The most common stricture locations were ileocolonic anastomosis (36.4%) and colon (13.9%). One hundred fourteen (41.8%) patients had a second dilation. The cumulative probability of need for a second dilation following the index procedure was 33.6% at 1 year (95% CI, 25.9%-38.7%), 53.9% at 3 years (45.9%-61.2%), and 60.2% at 5 years (51.4%-67.5%). Six adverse events occurred after the first procedure: 4 perforations, 1 patient with bleeding, and 1 patient with abdominal pain requiring hospitalization. A total of 82 (30%) patients required surgery for their stricture., Conclusions: In a large cohort, endoscopic stricture dilation in CD was safe and effective. About 33% of patients required a second dilation at 1 year after the initial dilation; younger age and smaller inner diameter of the index stricture predicted need for a second dilation. 10.1093/ibd/izy049&#95;video1izy049.video15794820307001.

Background: The main defence against bacterial infection is oxidative killing by neutrophils, which requires molecular oxygen in wounded tissues. High inspired-oxygen fractions increase tissue oxygenation. But, whether improving tissue oxygenation actually reduces surgical-site infection (SSI) remains controversial. We therefore tested the primary hypothesis that supplemental oxygen (80% vs 30%) reduces the risk of a 30-day composite of deep tissue or organ-space SSI, healing-related wound complications, and mortality., Methods: In an isolated suite of operating rooms, the inspired-oxygen concentration was alternated between 30% and 80% at 2-week intervals for 39 months. The analysis was restricted to patients who had major intestinal surgery lasting at least 2 h. Qualifying operations (5749) were analysed, including 2843 (49%) colorectal resections, 1866 (32%) lower gastrointestinal therapeutic procedures, 373 (6%) small-bowel resections, and 667 (13%) other colorectal procedures., Results: The 80% and 30% oxygen groups were well balanced on all of the demographic, baseline, and procedural variables. The oxygen intervention had no effect on the composite primary outcome or any of its components. The overall observed incidence of the composite outcome was 10.8% (314/2896) in the 80% oxygen group and 11.0% (314/2853) in the 30% group. The estimated relative risk was 0.99 (95% CI: 0.85, 1.14) for 80% vs 30%, P=0.85., Conclusions: Supplemental oxygen does not prevent major infection and healing-related complications after major intestinal surgery., Clinical Trial Registration: NCT01777568., (Copyright © 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Protein can modulate the surgical stress response and postoperative catabolism. Enhanced Recovery After Surgery (ERAS) protocols are evidence-based care bundles that reduce morbidity. Objective: In this study, we compared protein adequacy as well as energy intakes, gut function, clinical outcomes, and how well nutritional variables predict length of hospital stay (LOS) in patients receiving ERAS protocols and conventional care. Design: We conducted a prospective cohort study in adult elective colorectal resection patients after conventional ( n = 46) and ERAS ( n = 69) care. Data collected included preoperative Malnutrition Screening Tool (MST) score, 3-d food records, postoperative nausea, LOS, and complications. Multivariable regression analysis assessed whether low protein intakes and the MST score were predictive of LOS. Results: Total protein intakes were significantly higher in the ERAS group due to the inclusion of oral nutrition supplements (conventional group: 0.33 g · kg -1 · d -1 ; ERAS group: 0.54 g · kg -1 · d -1 ; P < 0.02). This group difference in protein intake was maintained in a multivariable model that controlled for differences between baseline and surgical variables ( P = 0.001). Oral food intake did not differ between the 2 groups. The ERAS group had shorter LOS ( P = 0.049) and fewer total infectious complications ( P = 0.01). Nausea was a predictor of protein intake. Nutrition variables were independent predictors of earlier discharge after potential confounders were controlled for. Each unit increase in preoperative MST score predicted longer LOSs of 2.5 d (95% CI: 1.5, 3.5 d; P < 0.001), and the consumption of ≥60% of protein requirements during the first 3 d of hospitalization was associated with a shorter LOS of 4.4 d (95% CI: -6.8, -2.0 d; P < 0.001). Conclusions: ERAS patients consumed more protein due to the inclusion of oral nutrition supplements. However, total protein intake remained inadequate to meet recommendations. Consumption of ≥60% protein needs after surgery and MST scores were independent predictors of LOS. This trial was registered at clinicaltrials.gov as NCT02940665., (© 2017 American Society for Nutrition.)

Background: Inadequate perioperative fluid therapy impairs gastrointestinal function. Studies primarily evaluating the impact of goal-directed fluid therapy on primary postoperative ileus are missing. The objective of this study was to determine whether goal-directed fluid therapy reduces the incidence of primary postoperative ileus after laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program., Methods: Randomized patient and assessor-blind controlled trial conducted in adult patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. Patients were assigned randomly to receive intraoperative goal-directed fluid therapy (goal-directed fluid therapy group) or fluid therapy based on traditional principles (control group). Primary postoperative ileus was the primary outcome., Results: One hundred twenty-eight patients were included and analyzed (goal-directed fluid therapy group: n = 64; control group: n = 64). The incidence of primary postoperative ileus was 22% in the goal-directed fluid therapy and 22% in the control group (relative risk, 1; 95% CI, 0.5 to 1.9; P = 1.00). Intraoperatively, patients in the goal-directed fluid therapy group received less intravenous fluids (mainly less crystalloids) but a greater volume of colloids. The increase of stroke volume and cardiac output was more pronounced and sustained in the goal-directed fluid therapy group. Length of hospital stay, 30-day postoperative morbidity, and mortality were not different., Conclusions: Intraoperative goal-directed fluid therapy compared with fluid therapy based on traditional principles does not reduce primary postoperative ileus in patients undergoing laparoscopic colorectal surgery in the context of an Enhanced Recovery After Surgery program. Its previously demonstrated benefits might have been offset by advancements in perioperative care.

Background: Laparoscopic surgery has become the standard treatment for colorectal cancer. A tumor that does not involve serosa is invisible intraoperatively, and manual palpation of the tumor during laparoscopy is not possible. Therefore, accurate localization of the neoplastic infiltrate remains one of the most important tasks prior to elective laparoscopic surgery. The aim of this study was to evaluate the utility of a magnetic endoscopic imaging (MEI) for precise preoperative endoscopic localization of neoplastic infiltrate within the large bowel., Materials and Methods: The study enrolled 246 patients who underwent elective surgery for colorectal cancer in 2012-2015 with accurate preoperative colonoscopic localization of the tumor. The analysis concerned patients with neoplastic infiltrate localized more than 30 cm from the anal verge. For evaluative purposes and accuracy of localization, the intestine was divided anatomically into 13 parts. Colonoscopic examinations were conducted with two types of endoscopes: group I-with MEI and group II-without MEI. Patients were assigned to the groups by random allocation. Ultimate confirmation of the tumor localization was accomplished by intraoperative evaluation., Results: Group I involved 127 patients and group II 129. The two groups were compared in terms of age, sex, BMI and frequency of previous abdominal procedures. Proper localization of the lesion was confirmed in 95.23 % of group I patients and in 83.19 % of group II patients (p < 0.05). The greatest discrepancy in localization occurred in 8.9 % of patients from group I and 20 % of patients from group II in which the lesion was assessed primarily in the distal sigmoid., Conclusions: A magnetic endoscopic imaging allows more accurate localization of neoplastic infiltrate within the large intestine compared to standard colonoscopy alone, especially within the sigmoid colon. This method can be particularly useful in planning and performing laparoscopic procedures to diminish the likelihood of improper bowel segment resection. CLINICALTRIALS., Gov Number: NCT01688557.

The aim of the study was to observe cytokine and T-cell-related toll-like-receptor (TLR) changes in intestinal samples of neonatal necrotizing enterocolitis patients.Four necrotic bowels were collected from neonatal NEC patients with gestational ages of 28 to 29 weeks in our hospital, whereas 4 neonatal patients who underwent intestinal atresia surgery served as the controls. Intestinal flora was examined and IL-1, IL-2, IL-4, IL-6, IL-8, IL-10, TNF-α, IFN-γ, and IL-17 expressions in resected intestine samples, as well as in isolated gamma delta T (γδT) cells, were analyzed immunohistochemically and via quantitative RT-PCR. γδT cells were isolated from the intestinal intraepithelial lymphocytes (IELs) and their TLR4/TLR9 distribution in the intestinal tissues was determined by flow cytometry.The bacterial flora of the neonatal NEC patients' contained significantly higher amounts of Gram-negative Enterobacteriaceae, Klebsiella, and Bacteroides but anaerobic Gram-positive Bifidobacteria occurred significantly less in the NEC than the control group. IL-1, IL-2, IL-4, IL-6, IL-8, IL-10, TNF-α, IFN-γ, and IL-17 expressions in the resected intestine samples and in isolated γδT cells were enhanced in NEC samples compared to the controls. γδT cells were less prevalent in NEC-derived intestinal tissues, but their TLR4/TLR9 expressions were significantly enhanced.The changed bacterial flora in preterm neonatal NEC patients led to an obvious inflammation of the intestines, which was accompanied by reductions of γδT cell localizations to the intestine and a shift of their surface expressions to TLR4 and TLR9.

Background/aims: We aimed to evaluate the prognostic factors that can aid in the prevention of first and second surgeries in patients with Crohn's disease (CD)., Methods: The clinical records of 115 patients with CD whose disease onset was between January 1987 and July 2012 were retrospectively investigated. The cumulative rate of bowel resection for CD-related intestinal manifestations following onset until the first surgery and the cumulative rate of reoperation following the first to second surgeries were estimated using the Kaplan-Meier method, and the relationship to each factor was statistically analyzed using the log-rank test. The background factors that influenced the cumulative rate of the first surgery and reoperation were evaluated using univariate and multivariate analyses., Results: The cumulative bowel resection rate was significantly higher in patients with ileocolitis-type CD (p = 0.0018) and in those with CD with smoking habits (p = 0.0315). And the cumulative reoperation rate was significantly higher in patients with ileocolitis-type CD (p = 0.0161) and those without early intervention with infliximab (p = 0.0161)., Conclusions: Ileocolitis-type CD and smoking habit might be initiating factors for bowel resection due to CD-related intestinal manifestations. Early intervention with infliximab likely prevents reoperation for CD recurrence., (© 2017 S. Karger AG, Basel.)

Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interest to declare (refer to signed statement by the corresponding author).

Objective: To compare the enhanced recovery after surgery (ERAS) protocol compliance and clinical outcomes depending on the weekday of surgery., Settings: Cohort of consecutive non-selected patients undergoing elective colorectal surgery from January 2012 to March 2015. This retrospective analysis of our prospective database compared patients operated early in the week (Monday and Tuesday) with patients operated in the second half (late: Thursday, Friday)., Primary Outcome Measures: Compliance with the ERAS protocol, functional recovery, complications and length of stay., Results: Demographic and surgical details were similar between the early (n=352) and late groups (n=204). Overall compliance with the ERAS protocol was 78% vs 76% for the early and late groups, respectively (p=0.009). Significant differences were notably prolonged urinary drainage and intravenous fluid infusion in the late group. Complication rates and length of stay, however, were not different between surgery on Monday or Tuesday and surgery on Thursday or Friday., Conclusions: Application of the ERAS protocol showed only minor differences for patients operated on early or late during the week, and clinical outcomes were similar. A fully implemented ERAS programme appears to work also over the weekend., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

The purpose of this retrospective study was to compare the outcome for dogs with surgically treated large versus small intestinal volvulus between October 2009 and February 2014. A total of 15 dogs met the inclusion criteria and underwent an abdominal exploratory. Nine dogs were diagnosed with large intestinal volvulus during the study period, and all nine had surgical correction for large intestinal volvulus. All dogs were discharged from the hospital. Of the seven dogs available for phone follow-up (74 to 955 days postoperatively), all seven were alive and doing well. Six dogs were diagnosed with small intestinal volvulus during the study period. One of the six survived to hospital discharge. Three of the six were euthanized at the time of surgery due to an extensive amount of necrotic bowel. Of the three who were not, one died postoperatively the same day, one died 3 days later, and one dog survived for greater than 730 days. Results concluded that the outcome in dogs with surgically corrected large intestinal volvulus is excellent, compared with a poor outcome in dogs with small intestinal volvulus. The overall survival to discharge for large intestinal volvulus was 100%, versus 16% for small intestinal volvulus.

For the adhesive disease of peritoneum (ADP) viscerolysis was performed in 235 patients, of them in 47--a total one, while a great omentum cicatricial-adhesive involvement occurred, so in 33--a partial omental resection was performed. The volume and technique of operative intervention have had depended on the number of operations performed and intestinal changes present. Individualized approach to choice of the surgical method of treatment have permitted to improve its result essentially in ADP, complicated by an acute ileus, in early and remote postoperative period. ; acute adhesive ileus.

Background: Honey has long been used for the treatment of number of ailments and diseases including surgical wounds. Current study evaluates the effectiveness of Tualang honey (TH) for large bowel anastomotic healing in Wistar rats., Methods: Thirty male Wistar rats were given a 3 centimeter infra-umbilical laparotomy wound, in`flicted on their abdomen. The colonic transection was performed at 5 cm distal to caecum, with end to end anastomosis of colon segment. They were divided into two groups. Group I was fed with standard rat chow and water. Meanwhile, Group II apart from standard feed, was also given TH 1.0 g/kg every morning until day seven post operatively. Afterwards, anastomotic bursting pressures were measured and histopathological examination on the anastomosis line was performed with light microscopes. The data from two groups were analyzed by Independent paired t test for continuous variables., Results: It was found that the tensile strength of colon anastomosis (95 % CI; p = <0.001) and the histopathological study including fibroblast count (p = <0.001) and inflammatory cells (p = 0.002) showed statistically significant difference in the favor of TH-treated group. Meanwhile, neovascularization formation was not statistically significant (p = 0.807); however, the overall count in the TH group was high., Conclusion: Oral treatment with TH enhances anastomotic wound healing by increasing the number of fibroblasts and by decreasing inflammatory cells leading towards increased wound strength.

The results of reconstructive-restoration operations, performed after obstructive resection of large bowel for colorectal cancer, were analyzed. The postoperative complications rate have constituted 11.7%. The most frequent cause of morbidity, 3.9%, was partial insufficiency of sutures of interintestinal anastomosis, formatted in the end to end fashion. Lethality have constituted 1.1%.

Colostomy was done in 49 patients, suffering an acute obturative impassability of large bowel (AOILB). In 28 patients (1st group) colostomy was conducted in accordance to standard method; in 21 (2nd group)--in accordance to the method, proposed by us. Application of the method proposed for surgical treatment of AOILB have guaranteed a reduction of postoperative paracolostomal complications rate in 6.8 times, of postoperative lethality--in 2.2 times, duration of the patient stationary treatment--in 1.4 times, the rate of dressings and the dressing material expanses--in 10 times.

Hernias are routine general surgical problems that may present in any age group, regardless of the patient's socioeconomic status. We present a rare case of a complicated ventral hernia leading to short bowel. This is an unusual case and is very rarely reported in the literature. This current case report describes a 54-year-old gentleman who presented to the hospital with a giant strangulated ventral hernia causing massive bowel ischemia and resulting in a short bowel. The literature on large abdominal wall hernias leading to short bowel is reviewed, and a discussion on short bowel syndrome is also presented.

Aim: A systematic review of the literature was performed to establish evidence to support the practice that in the presence of a colonoscopically diagnosed colorectal cancer immediate endoscopic excision of synchronous polyps should not be performed due to the risk of malignant cell implantation at the polypectomy site., Method: A systematic literature search was performed using Medline, Embase and the Cochrane Central Register of Controlled Trials to identify studies comparing the rate of implantation of colorectal cancer cells in normal and damaged colonic mucosa and reports of colorectal cancer cells seeding into sites of damaged mucosa after polypectomy., Results: No randomized controlled trials were identified. Three studies involving mammalian models of colonic mucosal damage were included. Pooling relevant results revealed that out of 59 exposed mammals only one developed tumour cell implantation at a site of colonic mucosal damage. This equates to a mammalian in vivo experimental risk of malignant cell implantation of 1.6%., Conclusion: The topic of colorectal cancer seeding following endoscopic procedures has received little attention. This review suggests that in the presence of a proximal colonic carcinoma there is a negligible risk of malignant implantation if a more distal polyp is endoscopically excised., (Colorectal Disease © 2015 The Association of Coloproctology of Great Britain and Ireland.)

A 7-year-old boy presented in septic shock secondary to appendicitis with generalised peritonitis. Following crystalloid resuscitation, he underwent surgery. Faecopurulent contamination and free air were found. This was secondary to a perforated and gangrenous appendix, multiple large and small bowel segments with perforations, patches of necrosis, interspersed with healthy bowel and segments of questionable viability. There was also a perforated duodenal ulcer. Necrotic segments were resected using a 'clip-and-drop' technique to shorten operative duration and guide resection to preserve bowel length. After six laparotomies and multiple bowel resections, the child was discharged home with an ileostomy that was subsequently reversed. He is currently on a normal diet and pursuing all activities appropriate for his age. Perforated appendicitis can be associated with widespread bowel necrosis and multiple perforations. A conservative damage limitation approach using the 'clip-and-drop' technique and relook laparotomies is useful in the management of extensive bowel necrosis in children., (2015 BMJ Publishing Group Ltd.)

Every surgical intervention is associated with the risk of intraoperative complications. These occur in approximately 2-12% of patients but significantly influence the postoperative outcome, overall complication and mortality rates. This article presents the treatment of typical intraoperative complications during surgery of the lower gastrointestinal tract with a focus on the prevention and identification of risk factors. Especially changes in the regular anatomy caused by previous surgery, inflammation, tumors and emergency situations carry the risk of iatrogenic injuries to the bowels, spleen, ureter and blood vessels. These risk factors must be considered when choosing a surgical procedure, a surgical approach or an appropriate surgeon. The early detection of complications with a definitive restoration is the essential step for a successful treatment without long-term sequelae. Every delay in therapy is associated with an increased morbidity and mortality and should be avoided.

Perioperative complications following surgical procedures of the lower gastrointestinal tract still represent a relevant problem. The perioperative morbidity may negatively affect short and long-term outcomes of treatment of individual patients. The additional diagnostics and treatment required also lead to additional costs that burden the healthcare system. Ideally, complications should be avoided by preventive measures. In the event of a complication, early detection is essential for appropriate treatment.Surgical site infections (SSI) have been described as the most common complication in the postoperative period and may occur in up to 30% of cases. Through various perioperative measures up to 40-60% of SSI are preventable. Depending on the location, the reported anastomotic leakage rate ranges from 1% to 23%. The therapeutic strategy ranges from conservative measures through interventional methods up to surgical revision. An early postoperative burst abdomen occurs in about 3% of cases. A midline closure with small stitches and small suture distances (suture length to wound length ratio of 4) seems to be superior to large stitches with long distance intervals. A rare but potentially fatal complication is bleeding. The identification of patients with relevant risk factors is of great importance. This article summarizes the prevention, recognition and treatment of perioperative complications after surgery of the lower gastrointestinal tract.

Objectives: Adult literature supports the elimination of mechanical bowel preparation (MBP) for elective colorectal surgical procedures. Prospective data for the pediatric population regarding the utility of MBP are lacking. The primary aim of this study was to compare infectious complications, specifically anastomotic leak, intraabdominal abscess, and wound infection in patients who received MBP with those who did not., Methods: A randomized pilot study comparing MBP with polyethylene glycol with no MBP was performed. Patients, 0 to 21 years old, undergoing elective colorectal surgery were eligible and randomized within 4 age strata. Statistical analyses were performed using χ or Fisher exact test for categorical data and t test or Wilcoxon 2-sample test for continuous data., Results: Forty-four patients were enrolled in the study from December 2010 to February 2013, of which 24 (55%) received MBP and 20 (45%) did not. Two patients (5%) had anastomotic leak, 4 (9%) had intraabdominal infection, and 7 (16%) had wound infections. The rate of anastomotic leak, intraabdominal abscess, and wound infection did not differ between the 2 groups., Conclusions: MBP for elective colorectal surgery in children does not affect the incidence of infectious complications. A larger multiinstitutional study is necessary to validate the results of this single-institution pilot study.

Introduction: Emergency large bowel surgery (ELBS) is known to carry an increased risk of morbidity and mortality. Previous studies have reported morbidity and mortality rates up to 14.3%. However, there has not been a recent study to document the outcomes of ELBS following several major changes in surgical training and provision of emergency surgery. The aim of this study was therefore to explore the current outcomes of ELBS., Methods: A retrospective review was performed of a prospectively maintained database of the clinical records of all patients who had ELBS between 2006 and 2013. Data pertaining to patient demographics, ASA (American Society of Anesthesiologists) grade, diagnosis, surgical procedure performed, grade of operating surgeon and assistant, length of hospital stay, postoperative complications and in-hospital mortality were analysed., Results: A total of 202 patients underwent ELBS during the study period. The mean patient age was 62 years and the most common cause was colonic carcinoma (n=67, 33%). There were 32 patients (15.8%) who presented with obstruction and 64 (31.7%) had bowel perforation. The overall in-hospital mortality rate was 14.8% (n=30). A consultant surgeon was involved in 187 cases (92.6%) as either first operator, assistant or available in theatre., Conclusions: ELBS continues to carry a high risk despite several major changes in the provision of emergency surgery. Further developments are needed to improve postoperative outcomes in these patients.

Background: Colonic stenting has failed to show an improvement in mortality rates in comparison with emergency surgery for acute large-bowel obstruction. However, it remains unclear which patients are more likely to benefit from this procedure., Objective: The aim of this study is to identify factors that may be predictive of successful outcome of colonic stenting in acute large-bowel obstruction., Design: All patients undergoing colonic stenting for acute large-bowel obstruction between 1999 and 2013 were studied. The demographics and characteristics of the obstructing lesion were analyzed., Settings: This investigation was conducted at a district general hospital., Patients: A total of 126 (76 men; median age, 76 y; range, 42-94 y) with acute large-bowel obstruction were included in the analysis., Intervention: The insertion of a self-expanding metal stent was attempted for each patient to relieve the obstruction., Main Outcome Measures: The primary outcomes measured were technical success in the deployment of the stent, clinical decompression, and perforation rates., Results: Technical deployment of the stent was accomplished in 108 of 126 (86%) patients; however, only 89 (70%) achieved clinical decompression. Successful deployment and clinical decompression was associated with colorectal cancer (p = 0.03), shorter strictures (p = 0.01), and wider angulation distal to the obstruction (p = 0.049). Perforation was associated with longer strictures (p = 0.03)., Limitations: This study was limited by its retrospective nature., Conclusion: Colonic stenting in acute large-bowel obstruction is more likely to be successful in shorter, malignant strictures with less angulation distal to the obstruction. Longer benign strictures are less likely to be successful and may be associated with an increased risk of perforation.

Purpose: We sought to evaluate the feasibility and safety of open or robotic radical prostatectomy (RP) after rectum, sigmoid, or colon surgery., Materials and Methods: Sixty-four patients with a median age of 65 years (range, 46-73 years) who underwent RP after previous pelvic surgery were included. Twenty-four patients (38%) underwent robotic RP and 40 patients (62%) underwent open RP. Bilateral lymph node dissection and nerve preservation were performed in 50 patients (78%) and 35 patients (55%), respectively. Variables evaluated included demographic characteristics, perioperative complications, and functional and oncological outcomes. The median hospitalization and follow-up periods were 2 days (range, 1-12 days) and 21 months (range, 1-108 months), respectively., Results: No conversions from robotic to open surgery were performed and there were no intraoperative complications. Surgical margins were positive in 13 patients (20%), seminal vesicle involvement was detected in 6 patients (9%), and lymph node involvement was found in 2 patients (3%). Postoperative complications included lymphocele in 1 patient, urethral stricture in 1 patient, and bowel obstruction and persistent bladder leakage in 2 patients. Eighty-eight percent of the patients were continent at 7 months and 80% of patients were able to achieve erection with or without medical aid., Conclusions: Open or robotic RP can be done safely and effectively in patients who have previously undergone pelvic surgery. Although prior pelvic surgery of the large intestine was associated with increased morbidity, it should not be considered a contraindication for robotic or open RP.

Surgical tactics in Crohn's disease (CD) was elaborated by the authors, basing, on analysis of modern views on pathogenesis, peculiarities of clinical course, possibility of diagnosis and experience of treatment of the disease. It envisages a modern diagnosis of the disease, prognostication of the recurrence and postoperative complications occurrence, the indications optimization, the choice of surgical treatment method Application of the surgical tactics elaborated for CD in 121 patients have permitted to improve objective estimation of the disease severity, to prognosticate the complications occurrence, to optimize indications for surgical treatment and the choice for method o conditionally radical, restorational, reconstructive--restoration stages of operative intervention, to reduce the disease recurrence rate, postoperative complications and postoperative lethality.

Transient ileus is a normal physiologic process after surgery. When prolonged, it is an important contributor to postoperative complications, increased length of stay and increased healthcare costs. Efforts have been made to prevent and manage postoperative ileus; alvimopan is an oral, peripheral μ-opioid receptor antagonist, and the only currently US FDA-approved medication to accelerate the return of gastrointestinal function postoperatively.