Bacterial translocation in patients undergoing major gastrointestinal surgery and its role in postoperative sepsis

Bacteria of the human intestinal microflora have a dual role. They promote digestion and are part of a defense mechanism against pathogens. These bacteria could become potential pathogens under certain circumstances. The term “bacterial translocation” describes the passage of bacteria of the gastrointestinal tract through the intestinal mucosa barrier to mesenteric lymph nodes and other organs. In some cases, the passage of bacteria and endotoxins could result in blood stream infections and in multiple organ failure. Open elective abdominal surgery more frequently results in malfunction of the intestinal barrier and subsequent bacterial translocation and blood stream infections than laparoscopic surgery. Postoperative sepsis is a common finding in patients who have undergone non-elective abdominal surgeries, including trauma patients treated with laparotomy. Postoperative sepsis is an emerging issue, as it changes the treatment plan in surgical patients and prolongs hospital stay. The association between bacterial translocation and postoperative sepsis could provide novel treatment options.

Ingested fish bone: an unusual mechanism of duodenal perforation and pancreatic trauma

Ingestion of gastrointestinal foreign bodies represents a challenging clinical scenario. Increased morbidity is the price for the delayed diagnosis of complications and timely treatment. We present a case of 57-year-old female patient which was admitted in the emergency room department complaining of a mid-epigastric pain over the last twenty-four hours. Based on the patient's history, physical examination and elevated serum amylase levels, a false diagnosis of pancreatitis, was initially adopted. However, a CT scan confirmed the presence of a radiopaque foreign body in the pancreatic head and the presence of air bubbles outside the intestinal lumen. The patient was unaware of the ingestion of the foreign body. At laparotomy, after an oblique duodenotomy, a fish bone pinned in the pancreatic head after the penetration of the medial aspect of the second portion of the duodenal wall was identified and successfully removed. The patient had an uneventful postoperative recovery. Wide variation in clinical presentation characterizes the complicated fish bone ingestions. The strategically located site of penetration in the visceral wall is responsible for the often extraordinary gastrointestinal tract injury patterns. Increased level of suspicion is of paramount importance for the timely diagnosis and treatment.

Complicated cholelithiasis: an unusual combination of acute pancreatitis and bouveret syndrome

Bouveret syndrome is a rare form of gallstone ileus. The purpose of the present study was to present the unusual case of a female patient with complicated cholelithiasis manifested as a combination of acute pancreatitis and concomitant Bouveret syndrome. A 61-year-old female patient was admitted to the emergency department complaining of mid-epigastric and right upper quadrant abdominal pain radiating band-like in the thoracic region of the back as well as repeated episodes of vomiting over the last 24 h. The initial correct diagnosis of pancreatitis was subsequently combined with the diagnosis of Bouveret syndrome as a computed tomography scan revealed the presence of a gallstone within the duodenum causing luminal obstruction. After failure of endoscopic gallstone removal, a surgical approach was undertaken where gallstone removal was followed by cholecystectomy and restoration of the anatomy by eliminating the fistula. The concomitant pancreatitis complicated the postoperative period and prolonged the length of hospital stay. However, the patient was discharge on the 45th postoperative day. Attempts for endoscopic removal of the impacted stone should be the initial therapeutic step. Surgery should be reserved for cases refractory to endoscopic intervention and when definite treatment is the actual challenge.

The effect of a diverting ileostomy formation on nutritional status and energy intake of patients undergoing colorectal surgery

BACKGROUND AND AIMS

The effects of ileostomy construction and colonic bypass on the general nutritional status of the patients have not yet received much attention. The aim of the present study was to assess the effect of a diverting ileostomy formation, on the nutritional intake, body composition and nutritional status biochemical markers of patients with a newly formed ileostomy.

METHODS

This was an observational study. Patients scheduled for elective rectosigmoid resection at a surgical unit of a public university hospital, were considered for study inclusion. Patients in whom a diverting ileostomy was created were assigned to the ileostomy group (n = 41), and patients who underwent rectosigmoid resection without requiring a diverting ileostomy served as a control group (n = 37). Anthropometric characteristics, body composition, dietary intake and biochemical markers representative of nutritional status were assessed preoperatively and at 40 days postdischarge (NCT02036346).

RESULTS

Anthropometric and body composition characteristics (weight, BMI and body fat percentage) significantly declined from 75 to 71.6 kg, 26.9 to 25.6 kg/m² and 28.6 to 25.6% respectively (p = 0.001 for all) in the ileostomy group, between the preoperative stage and 40 days postdischarge from the hospital. Furthermore, a significant reduction in mean daily energy intake from 1871 to 1713 kcal/day (p = 0.046) was observed in the ileostomy group 40 days after discharge compared to preoperative assessment. No significant changes in the above measured parameters were observed in the non-ileostomy group.

CONCLUSION

Diverting ileostomy can have a negative effect on general nutritional status and dietary intake of patients, during the first postoperative period. Nutritional assessment might need to be included in the routine clinical management of this patient category to prevent weight loss and impaired energy intake.

Mesocaval shunt for portal hypertensive small bowel bleeding documented with intraoperative enteroscopy

INTRODUCTION

Besides upper gastrointestinal tract, small bowel has also been implicated as a potential source of hemorrhage in patients with portal hypertension.

PRESENTATION OF CASE

We report an interesting case of recurrent massive small intestinal bleeding in a patient with portal hypertension secondary to liver cirrhosis treated with a mesocaval shunt. Endoscopic assessment with gastroscopy and colonoscopy failed to identify the source of hemorrhage. An intraoperative enteroscopy was conducted which revealed a diffuse bleeding pattern from the small bowel mucosa.

DISCUSSION

An interposition mesocaval shunt procedure was successfully carried out on an emergency basis that eventually managed to control bleeding.

CONCLUSION

In cases, where a diffuse pattern of hemorrhage exist or non-operative measures fail emergency mesocaval shunting seems to be an efficacious alternative treatment approach for portal hypertension related intestinal bleeding.

Current evidence regarding the role of adjuvant chemotherapy in rectal cancer patients with pathologic complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

PURPOSE

The aim of this meta-analysis was to investigate the role of adjuvant chemotherapy (AC) in rectal cancer patients with pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) and curative resection.

METHODS

This study was completed in accordance to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic scholar databases (Medline, Web of Science, Scopus) were screened for eligible articles. The level of evidence (LoE) was assessed using the GRADE methodology.

RESULTS

Overall, 23 non-randomized studies and 17,406 patients were included in the present meta-analysis. Pooled comparisons confirmed that AC improved overall survival (HR: 0.68, p=0.0003), but not disease-free (p=0.22) and recurrence-free survival (p=0.39). However, the LoE for all outcomes was characterized as "very low," due to the absence of RCTs.

CONCLUSIONS

Considering the study limitations and the lack of randomized studies, further high-quality RCTs are required to confirm the findings of our study.

Side-to-side anastomosis fashioned as stoma after sigmoid resection for sigmoid volvulus: a case report

PURPOSE

Colonic volvulus is one of the causes of large bowel obstruction with sigmoid colon being the most usually affected part. Surgery is the gold standard when signs of peritonitis are present or endoscopic decompression fails.

MATERIALS AND METHODS

We report the case of 65-year-old man with acute large bowel obstruction due to sigmoid volvulus who underwent a laparoscopic-assisted sigmoid resection on an emergency basis. The condition of the bowel wall precluded a primary anastomosis. But instead, a side-to-side anastomosis that its common blind stump was brought out as an end stoma was performed.

RESULTS

The postoperative period was eventless. The patient was discharged on the 6th postoperative day. Eight weeks after the initial operation, the patient was readmitted for the secondary closure of the anastomotic stoma. Local anesthesia and minor sedation were enough in order to perform the stoma take down.

CONCLUSION

Laparoscopic-assisted sigmoid resection is a useful adjunct to the surgical armamentarium when facing the problem of sigmoid volvulus. When a safe restoration of the alimentary tract continuity cannot be achieved safely with a primary anastomosis, the proposed anastomotic stoma technique is a useful and practical alternative.

Manual Reduction of Incarcerated Abdominal Wall Hernias. A Feasible Option during COVID-19 Pandemic: A Prospective Study

Background  Incarcerated hernia is a common surgical emergency with considerable morbidity or even mortality. Manual reduction (taxis) and elective surgery could be an alternative management approach. This study examines the role of taxis with the adjuvant use of the visual analogue scale (VAS) score in treating incarcerated hernias and thereby decreasing the emergency surgery rate, especially during the novel coronavirus disease 2019 (COVID-19) pandemic.

Methods  All adult patients admitted to the emergency department of our hospital with incarcerated hernias of anterior abdominal wall were prospectively submitted to hernia manual reduction. The VAS score was used as an adjuvant tool for monitoring the success of this maneuver. Patients with successful taxis and low VAS score were hospitalized for a 24-hour period of observation. On their discharge, they were scheduled for an elective hernia repair. Patients with unsuccessful taxis or with less than a 50% reduction in VAS score after successful taxis were submitted to emergency surgical repair. Age, sex, type of hernias, time until taxis, VAS scores before and after taxis, length of hospital stay, and adverse events for both groups were recorded.

Results  Between September 2018 and September 2020, 86 patients with incarcerated hernias were included. The types of hernias were incisional in 8 patients, umbilical in 15 patients, inguinal in 56 patients, and femoral in 7 patients. Taxis was successful in 66% of patients with a mean reduction in VAS score from 83 to 17 mm. Following successful taxis, patients were hospitalized for a 24-hour period of observation. No taxis-related complications were observed. Fifty-two patients were safely discharged from hospital and scheduled for an elective repair during the first month. Thirty-four patients were operated emergently. Five patients had successful taxis but with a reduction of posttaxis VAS score less than 50% (a mean reduction from 86 to 62 mm), while taxis failed in twenty-nine patients. Patients with emergency surgery had longer time until reduction and longer stay of hospitalization. In this group, two patients required admission to the intensive care unit while one patient died.

Conclusion  In this protocolized approach, taxis is a safe and feasible option for most patients with incarcerated hernias. It should be kept in our armament, especially in times when emergency surgery capabilities are under strain like the ongoing COVID-19 pandemic.

Laparoscopic bilateral inguinal hernia repair: Should it be the preferred technique?

Inguinal hernias are amongst the most common conditions requiring general surgical intervention. For decades, the preferred approach was the open repair. As laparoscopy became more popular and available and more surgeons became familiarized with this modality, laparoscopic inguinal hernia repair became an alternative. The aim of this study is to assess the effectiveness of laparoscopic inguinal repair, with a focus on bilateral inguinal hernias. Initial reports have shown promising clinical outcomes compared to those of conventional repair of bilateral hernias. However, there are only a few studies concerning laparoscopic repair of bilateral hernias. It is yet to be proven that laparoscopy is the “gold standard” in the treatment of bilateral inguinal hernias. So far, the choice of an inguinal hernia repair technique has been up to each surgeon, depending on their expertise and available resources after taking into consideration each patient’s needs.

Prophylactic Administration of Alpha Blocker for the Prevention of Urinary Retention in Males Undergoing Inguinal Hernia Repair Under Spinal Anesthesia: Interim Analysis of a Randomized Controlled Trial

INTRODUCTION

This randomized controlled study aims to investigate the prophylactic effect of tamsulosin on the development of postoperative urinary retention (POUR) in men undergoing elective open inguinal hernia (IH) repair under spinal anesthesia. The study also focused on potentially predisposing factors for POUR.

METHODS

100 eligible patients were randomized into two groups. Patients in the experimental group were given two doses of tamsulosin 0.4 mg orally 24 hours and 6 hours before surgery. In the control group, two doses of placebo were administered, in the same manner as the study group. The following parameters were also recorded: the International Prostate Symptom Score (IPSS) questionnaire scores, the presence of scrotal hernia, operation duration, perioperative administration of IV opioids and/or atropine, postoperative pain, and preoperative anxiety.

RESULTS

Overall, the incidence of POUR was 37% (37/100) with no difference between the two groups. Among patients receiving tamsulosin, 39.2% (20/51) developed POUR, compared to 34.7% (17/49) in the control group. Preoperative patients' high anxiety visual analog scale (VAS) score (>51mm) (P=0.007) and the intraoperative use of atropine (P=0.02) were detected as risk factors for POUR.

CONCLUSION

This interim analysis of our prospective randomized trial showed no benefit from the prophylactic use of tamsulosin in preventing POUR after IH repair under spinal anesthesia. This type of anesthesia was also correlated with an overall high incidence of POUR. Preoperative anxiety and administration of atropine were identified as statistically significant factors for POUR. In patients with preoperative high anxiety, VAS score a different type of anesthesia may be used.