Impact of negative pressure wound therapy on enteroatmospheric fistulation in the septic open abdomen

AIM

The effect of negative pressure wound therapy (NPWT) on the pathogenesis and outcome of enteroatmospheric fistulation (EAF) in the septic open abdomen (OA) is unclear. This study compares the development and outcome of EAF following NPWT with that occurring in the absence of NPWT.

METHODS

Consecutive patients admitted with EAF following abdominal sepsis at a National Reference Centre for intestinal failure between 01 January 2005 and 31 December 2015 were included in this study. Patients were divided into two groups based on those that had been treated with NPWT and those that had not (non-NPWT) and characteristics of their fistulas compared. Clinical outcomes concerning nutritional autonomy at 4 years and time to fistula development, size of abdominal wall defect and complete fistula closure were compared between groups.

RESULTS

A total of 160 patients were admitted with EAF following a septic abdomen (31-NPWT and 129-non-NPWT). Median (range) time taken to fistulation after OA was longer with NPWT (18 [5-113] vs. 8 [2-60] days, p = 0.004); these patients developed a greater number of fistulas (3 [2-21] vs. 2 [1-10], p = 0.01), involving a greater length of small bowel (42.5 [15-100] cm vs. 30 [3.5-170] cm, p = 0.04) than those who did not receive NPWT. Following reconstructive surgery, nutritional autonomy was similar in both groups (77% vs. 72%) and a comparable number of patients were also fistula-free (100% vs. 97%).

CONCLUSIONS

Negative pressure wound therapy appears to be associated with more complex and delayed intestinal fistulation, involving a greater length of small intestine in the septic OA. This did not, however, appear to adversely affect the overall outcome of intestinal and abdominal wall reconstruction in this study.

HPB P19 Our experience comparing multi-visceral and single organ excision of retroperitoneal sarcomas from a HPB centre

Background

Sarcomas are a heterogenous set of soft tissue cancers with an estimated incidence of up to 5.0 cases per 100,00 worldwide. Retroperitoneal sarcomas (RPS) account for up to 20% of these. The aetiology behind the pathogenesis is not truly understood, but to date, surgery remains the only curative treatment. Owing to resistance, systemic chemotherapy only plays a role in attempts to downstage the tumour, or in the palliative setting.

RPS are slow growing and owing to the lack of symptoms have variable presentation. The ability to excise RPS traditionally was limited by vascular invasion, which increases the complexity of the resection and poses uncertainty about the long-term oncological benefit. Although small, emerging case series over the last couple of decades have established the feasibility of multi-visceral resection with vascular reconstruction.

Here we present our outcomes comparing multi-visceral resections with single organ resections with vascular reconstructions.

Methods

All patients who underwent excision of a retroperitoneal sarcoma between January 2005 and April 2021 were included in the analysis. Patients were identified from a database which was prospectively completed by the operating surgeon. Data collected included patient demographics, clinicopathologic characteristics and intra-operative variables. Endpoints included perioperative morbidity and mortality, oncological clearance status, recurrence status, and survival. Complications were graded using the Clavien-Dindo classification.

All patients were discussed in a local multi-disciplinary team meeting. When aortic/iliac artery involvement was suspected on pre-operative imaging (Computer Tomography or Magnetic Resonance Imaging), patients were referred appropriately to vascular for further pre-operative discussion regarding treatment and/or conduit plans.

Continuous data was presented as medians (range) and compared using ANOVA (analysis of variance). Survival probabilities were calculated using the Kaplan-Meier method and log-rank test. Normally distributed data was assessed with the Student's t-test, and skewed data with Mann-Whitney test. A two-sided p value < 0.05 was considered significant.

Results

From January 2005 to April 2021, 122 patients underwent 170 operations for RPS resections. 112 (68.9%) underwent a visceral resection (90 (53.0%) multi-visceral (MVR) and 22 (15.9%) single organ (SOR)).

In the MVR group, 23 (25.6%) involved a synchronous vascular resection with a complete resection margin in 94.7%. In the SOR group, 6 (27.3%) underwent a synchronous vascular resection with a 96.3% complete resection margin. Multi-visceral resections included 39 nephrectomies, 33 segmental colectomies, 16 liver resections, 16 splenectomies, pancreatic resections in 19, and partial gastrectomy in 12 cases. The inferior vena cava was resected in 17 and 5 cases in the MVR and SOR group, respectively. Aortic and iliac artery resection and reconstruction with Dacron graft took place in 4 cases.

Histologically, leiomyosarcomas and dedifferentiated liposarcomas were the most common subtype, accounting for 33 and 30 (36.7% and 33.3%) in the MVR group and 10 and 6 (37.0% and 22.2%) in the SOR group, respectively.

Overall 5-year survival for all resections was 60%. There was no significant difference in complication rate[HM1] [AR2], length of stay, 30-day mortality (2% and 1%) or 1- (71.1% and 77.8%) or 3-year (33.3% and 25.9%) survival between the MVR and SOR groups.

Conclusions

RPS are prone to localised invasion as well as into surrounding viscera. Although traditionally, these patients may not have been deemed suitable for surgical intervention, our case series shows multi-visceral resections with vascular resections can be undertaken safely with no impact on overall survival. The series also highlights the need for a multi-disciplinary surgical approach to address the technical complexities of the operation.

In conclusion, the need for multi-visceral resection or vascular resection and reconstruction should not deter surgical treatment, and these cases should be managed within a MDT with appropriate surgical expertise.

OC-022 MAINTAINING AN ELECTIVE ABDOMINAL WALL RECONSTRUCTION SERVICE DURING THE COVID 19 PANDEMIC

Aim

Elective surgery services suffered significantly due to the COVID-19 pandemic. The aim of this study was to analyse the impact and outcomes of abdominal wall reconstruction (AWR) performed during the COVID-19 pandemic, assessing safety and sustainability.

Material and Methods

A retrospective review of all patients undergoing AWR in a single NHS trust, multiple surgeons, between 23rd March 2020 and 22rd March 2022, the 2 years following U.K. Government imposed lockdown, was undertaken and compared with the pre-pandemic AWR activity. Procedures were initially undertaken at a cold site and when demonstrated to be safe, main site operating restarted. The primary outcome was 90 day mortality, secondary outcomes of COVID-19 infection within 7 days, length of stay, critical care requirement, and complication rate.

Results

In the study period, 173 patients underwent AWR, compared with 99 cases in a single year preceding lockdown. 90 day mortality rate was zero. No patients returned positive COVID tests to the trust within 7 days of AWR, and no patients were readmitted for COVID related symptoms. Critical care admission was required in 7 patients, 3 of these were planned admissions pre-operatively. The surgical site occurrence rate was 9.8% (17), infection 5.8% (10), seroma 2.3% (4) and haematoma 1.7% (3). There were no recurrences reported, with follow up ranging between 1 and 18 months.

Conclusion

Continuing AWR services during the COVID pandemic is feasible and safe. Peri-operative COVID infection rates are low, critical care requirements minimal, and there is no impact on patient morbidity or mortality.

P-135 FIRST EXPERIENCE WITH A NEW CLOSED INCISION NEGATIVE PRESSURE WOUND THERAPY, PREVENA™, IN ABDOMINAL WALL RECONSTRUCTION PATIENTS

Aim

Surgical site infection (SSI) contributes a significant proportion of post operative morbidity in patients undergoing abdominal wall reconstruction (AWR). Prevena™ closed incision negative pressure wound therapy (ciNPT) has been demonstrated to reduce SSI rates in the elective and emergency laparotomy setting. However, there is no evidence for Prevena™ use in AWR patients. The aim of this study was to assess the safety and feasibility of Prevena™ in AWR patients.

Materials and Method

Patients undergoing AWR at a single trust were selected at random to receive Prevena™. This was applied to the incision under sterile conditions, a continuous pressure of -125mmHg was applied for 7 days. The primary outcome measure was SSI, with secondary outcomes of 90 day mortality, complications and length of stay.

Results

10 patients received ciNPT in the study period, 8 female 2 male, mean BMI was 34.5. All patients had a Rives-Stoppa repair, with 2 patients also requiring bilateral transversus abdominal release (TAR). A vertical panniculectomy with umboplasty was used in 7 cases, fleur-de-lys panniculectomy with umboplasty in 2 cases, and a single case approached via transverse panniculectomy. There were no deaths within 90 days, median length of stay was 4 days. There was a single SSI managed with oral antibiotics, not requiring admission.

Conclusion

Prevena™ has been shown to reduce SSI rates in other patient cohorts and this small series demonstrates it is feasible and safe to use in the AWR setting. Larger studies are required to demonstrate SSI rate reduction in AWR patients.

Colorectal resections during the COVID-19 pandemic: a national survey of practice during first lockdown

INTRODUCTION

The first wave of the COVID-19 pandemic led to an unprecedented time for the management of colorectal cancer, with uncertainty as to cancer-specific risks and the circumventing of gold standard oncological strategies. Our study aimed to acquire a snapshot of the practice of multidisciplinary team (MDT) management and variability in response to rapidly emerging guidelines.

METHODS

The survey was disseminated to 150 colorectal cancer MDTs across England and Wales taken from the National Bowel Cancer Audit data set between 15 April and 30 June 2020 for completion by colorectal surgeons.

RESULTS

Sixty-seven MDTs responded to the survey. Fifty-seven centres reported that they continued to perform colorectal cancer resections during the initial lockdown period. Fifty centres (74.6%) introduced routine preoperative COVID-19 testing and 50 (74.6%) employed full personal protective equipment for elective cases. Laparoscopic resections were continued by 25 centres (42.1%), whereas 28 (48.3%) changed to an open approach. Forty-nine (79.0%) centres reported experiencing patient-led surgical cancellations in 0-25% of their listings. If surgery was delayed significantly then 24 centres (38.7%) employed alternative neoadjuvant therapy, with short-course radiotherapy being their preferred adjunct of choice for rectal cancer. Just over 50% of the MDTs stated that they were uncomfortable or very uncomfortable with their management strategies.

CONCLUSIONS

Our study demonstrates variability in the MDT management of colorectal cancer during the initial COVID-19 lockdown, incorporating adaptive patient behaviour and initially limited data on oncological safety profiles leading to challenging decision-making.

28 Colorectal Cancer Resections During COVID-19: To Do or Not to Do?

Introduction

Ascertaining the practice of colorectal cancer (CRC) resections during the COVID-19 pandemic in England and Wales.

Method

A list of all colorectal multi-disciplinary teams (MDTs) was obtained from the National Bowel Cancer Audit (NBOCA) database. A survey was designed using Google Forms and emailed to at least one consultant colorectal surgeon of each MDT. One response per MDT was used in the analysis. All responses were anonymous. Study duration was from 15^th April 2020 to 30^th June 2020.

Results

Sixty-eight of the 150 MDTs enlisted on the NBOCA database in England and Wales responded. 86.6% were performing CRC resections and 86% were screening patients pre-operatively for COVID-19. 84.9% were using full Personal Protective Equipment (PPE - FFP3 and eye protection) in all cases whereas 12.3% were using PPE only in suspected cases. 44.4% had resorted to open resections due to risk of laparoscopy being an aerosol generating procedure. 13.7% attributed post-operative complications to COVID-19 and 4 centres reported death due to COVID-19 related complications. 40% of MDTs used short course radiotherapy in rectal cancer patients where resections were postponed either by patient or by the team. 55% responded to feeling uncomfortable/very uncomfortable to cancel cancer resections while 31.7% were equivocal and others comfortable not to operate during the pandemic.

Conclusions

This survey demonstrates a snapshot of practice during the peak of the COVID-19 pandemic. The majority of the centres continued to perform CRC resections safely where possible. There has been obvious disruption to services and change to normal practice.

163 Morbidity of Presumed Temporary Loop De-Functioning Stomas in Patients with Colorectal Cancer

Objectives

The incidence of parastomal hernia (PSH) can be up to 80% of patients who have a stoma following abdominal surgery (1). Surgical intervention is required in 70% of patients due to pain, obstructive symptoms, or stoma appliance issues (2). This study aims to show the morbidity related to a presumed temporary loop stoma.

Method

This was a retrospective cohort study of all left-sided colorectal cancer resections undertaken in a single centre. Electronic healthcare records and Picture Archiving and Communication System (PACS) were used to gather data on patient demographics, operative details and details of de-functioning stoma fashioned. Morbidity related to de-functioning stoma was determined based on hospital admissions and length of inpatient stay related to stoma, complications in relation to the stoma, return to theatre, stoma reversal and fate of stoma site.

Results

147 patients (87 M; 60 F, median age 69 (23-93)) underwent left sided colorectal cancer resections at a single centre. In total, 50 de-functioning loop stomas were fashioned (49 loop ileostomies and 1 loop colostomy.) At a median follow-up of 23 months (8-44), prior to reversal, 12 PSH were identified. 38 of the de-functioning stomas were reversed at a median time of 11 months (1-44), 5 of which were emergency procedures due to obstruction (n = 3) or high output (n = 2). There were 9 stoma related re-admissions identified in 7 patients.

Conclusions

Presumed temporary defunctioning loop ileostomies in Low anterior resections is associated with significant morbidity, but low risk in terms of life-threatening complication.

Laparoscopic colorectal resections during the COVID-19 pandemic - business as usual?

INTRODUCTION

To analyse the outcomes of major colorectal resections performed during the COVID-19 pandemic, to assess safety and explore all precautionary measures.

METHOD

All patients who underwent major elective colorectal resections at St Helens and Knowsley Teaching Hospital NHS Trust between 24th March 2020 (the date that the Royal Colleges of Surgery produced their guidelines re operating during the pandemic) and 17th April 2020 were analysed from a prospectively maintained database. The primary outcome was 7-day mortality and secondary outcomes were the development of a positive COVID-19 test consequent to hospital stay and the overall complication rate.

RESULTS

In this 24 day time frame 27 patients (17 males) underwent elective colorectal resections at St Helens and Knowsley NHS Trust. The median age was 69 (41-84) years and median ASA was 2 (1-3). The median Body Mass Index was 30 (21-40.7). Twenty-five patients underwent surgery for cancer and two patients had urgent resections for low-grade sepsis secondary to diverticular colovesical fistulae. 24 patients underwent laparoscopic colorectal resections and 3 patients underwent planned open surgery. 7-day mortality was 0%, and no patients/staff contracted COVID-19 during the post-operative period. The overall complication rate was 14.8%. At a median follow-up of 29 (17-44) days via telephone, there have been no reported COVID-19 related symptoms in any of these patients.

CONCLUSION

Our experience demonstrated that it was possible to undertake laparoscopic colorectal resections despite the COVID-19 pandemic posing a major threat to humanity, providing that adequate and stringent precautions are undertaken.

O34 Colorectal cancer resections during COVID-19: to do or not to do?

Introduction

Ascertaining the practice of colorectal cancer (CRC) resections during the COVID-19 pandemic in England and Wales.

Method

A list of all colorectal multi-disciplinary teams (MDTs) was obtained from the National Bowel Cancer Audit (NBOCA) database. A survey was designed using Google Forms and emailed to at least one consultant colorectal surgeon of each MDT. One response per MDT was used in the analysis. All responses were anonymous. Study duration was from 15th April 2020 to 30th June 2020.

Result

Sixty-eight of the 150 MDTs enlisted on the NBOCA database in England and Wales responded. 86.6% were performing CRC resections and 86% were screening patients pre-operatively for COVID-19. 84.9% were using full Personal Protective Equipment (PPE—FFP3 and eye protection) in all cases whereas 12.3% were using PPE only in suspected cases. 44.4% had resorted to open resections due to risk of laparoscopy being an aerosol generating procedure. 13.7% attributed post-operative complications to COVID-19 and 4 centres reported death due to COVID-19 related complications. 40% of MDTs used short course radiotherapy in rectal cancer patients where resections were postponed either by patient or by the team. 55% responded to feeling uncomfortable/very uncomfortable to cancel cancer resections while 31.7% were equivocal and others comfortable not to operate during the pandemic.

Conclusion

This survey demonstrates a snapshot of practice during the peak of the COVID-19 pandemic. The majority of the centres continued to perform CRC resections safely where possible. There has been obvious disruption to services and change to normal practice.

Take-home Message

COVID-19 led to an unprecedented situation where safe guidance had to be implemented at short notice to enable safe surgical practice. This survey aimed to establish how colorectal MDTs in England and Wales were adapting their colorectal cancer resection practice in light of new guidance amidst the first wave of the pandemic.

Laser depilation as adjuvant therapy in prevention of recurrence of pilonidal sinus disease: initial experience of a district general hospital in the UK

INTRODUCTION

Pilonidal disease is a chronic condition involving the sacrococcygeal area. It can have a significant impact on quality of life, social activities and occupation. Surgery is the mainstay of treatment. However, laser depilation has been proposed as an adjunct to surgery and has shown improved results in some studies. We present our experience of laser depilation in the treatment of pilonidal disease in a district general hospital setting in the UK.

MATERIALS AND METHODS

A prospectively maintained database of all consecutive patients who received laser depilation after elective surgery for pilonidal disease was analysed. Patients were offered a minimum of two sessions of laser depilation. The primary outcome measure was disease recurrence. Evidence of new symptoms or signs of pilonidal disease after one year from the latest surgical intervention was defined as recurrent disease. Data are presented as medians with interquartile ranges.

RESULTS

A total of 64 patients underwent laser depilation after elective surgery between 1 June 2013 and 1 June 2018; 57 were eligible for final analysis. Sixty-five per cent of patients received six or more sessions of laser treatment. There were no short- or long-term complications related to laser depilation. Patients who had more than two sessions of laser depilation showed an improved recurrence rate. Overall, recurrence rate in our series was 12% at a median follow-up of 172 weeks.

CONCLUSION

Laser depilation is a safe and effective adjunct to surgery in minimising the recurrence of pilonidal disease. Patients with primary pilonidal disease and those who are undergoing minimally invasive surgery may also benefit from adjuvant laser depilation. Further high-quality control trials are required to assess its efficacy and safety.

Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy

Background

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.

Methods

The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.

Results

A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.

Conclusion

Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.

A Rare Case of Life-Threatening Bleeding Caused by a Jejunal GIST

Gastrointestinal Stromal Tumours (GISTs) are rare mesenchymal tumours that are specific to GI tract. GISTs usually associated with advanced age and have a slight male preponderance. GISTs are commonly found in stomach. Jujunal GISTs are the rarest and account for about 0.1-3% of all GI tumours [1]. The most common clinical manifestation of symptomatic GISTs includes intermittent bleeding due to mucosal ulceration. Massive, life threatening gastrointestinal (GI) bleeding is a rare occurrence. We report a rare case of bleeding Jejunal GIST in a 32-year-old female who presented with haemorrhagic shock that required resuscitative laparotomy. Histopathology and immunohistochemistry confirmed the tumour to have features of GIST with clear margins and post-operative cross-sectional imaging excluded any metastatic deposits.

Ileo-anal pouch excision and permanent ileostomy - Indications and outcomes from a tertiary centre

PURPOSE

Pouch excision is a major complication of ileoanal pouch surgery. Current practice is for this type of surgery to be performed in a specialist centre. We present a series of patients undergoing pouch excision surgery in a high volume centre in the UK and assess the outcomes in these patients.

METHODS

All patients undergoing pouch excision at the Royal Liverpool Hospital between 1995 and 2015 under the care of a single surgeon were included. Demographics and outcomes were taken from patients' notes and a dedicated retrospectively compiled database.

RESULTS

35 patients underwent pouch excision surgery during this period. Around half the patients had their original pouch surgery elsewhere and were referred for management of complications. Median time to pouch excision was 13 years from the original operation. Overall complication rate was 31% with 11% requiring re-intervention post-operatively. There was no mortality in this series.

CONCLUSION

Pouch excision is a complex, high-risk procedure that should be carried out in specialist centres. Our series shows that in such settings, good outcomes can be achieved for these patients.

Short-term outcomes of endoscopic pilonidal sinus treatment

INTRODUCTION

Endoscopic treatment for pilonidal disease was initially described by Meinero in 2013. This minimally invasive technique has both technical and aesthetic advantages. The diagnostic application helps identify the anatomy of the pilonidal disease and the operative phase ablates and cleans the infected cavity. Our aim was to study the short-term outcomes of endoscopic treatment for pilonidal disease and to evaluate complications and recurrence rates.

MATERIALS AND METHODS

A prospectively maintained database of all consecutive patients who underwent endoscopic treatment for pilonidal disease by a single surgeon in a district general hospital from 1 November 2014 to 31 March 2018 was analysed. Follow-up was available until 30 September 2018.

RESULTS

A total of 74 patients (56 men) underwent endoscopic treatment for pilonidal disease. The median age was 21 years (range 16-62 years). All patients underwent the procedure as daycase procedures, seven under local anaesthesia. There were no immediate postoperative complications and no return to theatre or readmission within 90 days. On a median follow-up of 52 weeks (range 2-114 weeks), 57 patients healed completely and 8 lost to follow-up. We achieved primary healing rates of 67% (44/66) and delayed healing rate of 77% (51/66).

CONCLUSIONS

Endoscopic treatment for pilonidal disease is a safe and effective minimally invasive technique that should be considered as first-line treatment in selected cases of pilonidal sinus disease, thereby reducing morbidity related to conventional procedures.

Video-assisted anal fistula treatment: a high volume unit initial experience

Introduction Perianal fistulas are a common problem. Video-assisted anal fistula treatment is a new technique for the management of this difficult condition. We describe our initial experience with the technique to facilitate the treatment of established perianal fistulas. Methods We reviewed a prospectively maintained database relating to consecutive patients undergoing video-assisted anal fistula treatment in a single unit. Results Seventy-eight consecutive patients had their perianal fistulas treated with video-assistance from November 2014 to June 2016. Complete follow-up data were available in 74 patients, with median follow-up of 14 months (interquartile range 7-19 months). There were no complications and all patients were treated as day cases. Most patients had recurrent disease, with 57 (77%) having had previous fistula surgery. At follow-up, 60 (81%) patients reported themselves 'cured' (asymptomatic) including 5 patients with Crohn's disease and one who had undergone 10 previous surgical procedures. Logistical stepwise regression did not demonstrate any statistically significant factors that may have been considered to affect outcome (age, gender, diabetes, previous I&D, Crohn's disease, smoking, type of fistula). Conclusions Our data have shown that video-assisted anal fistula treatment is safe and effective in the management of perianal fistulas in our patients and this suggests it may be applied to all patients regardless of comorbidity, underlying pathology or type of fistula.

Laparoscopic median gastrectomy for stenosis following sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become an established primary bariatric procedure. Gastric stenosis after LSG has been reported in a few studies and often occurs at the level of incisura or midbody because of a technical operative error and could be associated with a leak. This can be managed by endoscopic dilations or revision surgery. The objective of this study is to describe a novel technique to deal with sleeve stenosis and its outcome.

METHODS

Two patients presented with sleeve stenosis after LSG and underwent a novel technique. The patients were followed up for 18 months.

RESULTS

We describe a novel technique of laparoscopic median gastrectomy in 2 patients that involved resection of the stenotic segment followed by a hand-sewn, gastrogastric, end-to-end anastomosis. Both patients had successfully recovered from stenosis related symptoms, although one required an endoscopic dilation of the anastomosis.

CONCLUSION

Laparoscopic median gastrectomy is a feasible and effective option in patients who have failed conservative management of stenosis after LSG and in whom there is a desire to avoid seromyotomy or conversion to gastric bypass.

Radiation enteritis leading to intestinal failure: 1994 patient-years of experience in a national referral centre

BACKGROUND/OBJECTIVES

Chronic radiation enteritis (RE) has been reported in up to 20% of patients receiving pelvic radiotherapy and can lead to intestinal failure (IF), accounting for 3.9% of new registrants for home parenteral nutrition (HPN) in the UK annually. Our aim is to report nutritional and survival outcomes for patients with RE referred to a national IF unit.

SUBJECTS/METHODS

A retrospective study of all new admissions over a 13-year period at the Intestinal Failure Centre, Manchester, UK. Data are presented as median (range).

RESULTS

Twenty-three (3.8%) of 611 patients were admitted with IF secondary to RE. The primary site of malignancy was genitourinary in 17 (74%) patients. Radiotherapy was administered 9.5 (1-42) years previously. Patients underwent 2 (1-5) laparotomies prior to intestinal failure unit (IFU) admission. Twelve (52%) patients were admitted with intestinal obstruction and 11 (48%) with intractable weight loss and/or high output fistulae/stomas. Additional conditions contributing to IF were noted in 11 (48%) patients. Twenty-two (96%) patients had 2 (1-5) laparotomies prior to IFU referral. At discharge, 5 (22%) patients resumed oral diet without the need for artificial nutrition support, 3 (13%) required enteral feeding and 13 (56%) commenced HPN. The 10-year survival of the patient cohort was 48.2%.

CONCLUSIONS

Surgical intervention is infrequently required, whereas the majority of patients with IF secondary to RE require long-term HPN. The judicious use of surgery in selected patients, coupled with an aggressive medical strategy to detect and treat contributing factors, and optimal enteral feeding may allow a modest proportion of patients with IF secondary to RE to achieve independence from PN.

Late perforation at the jejuno-jejunal anastomosis after laparoscopic gastric bypass for morbid obesity

BACKGROUND

Although marginal ulceration and perforation at the gastrojejunal anastomosis is an established, albeit rare, risk after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity, little is known about the risk of late perforation at the jejuno-jejunal (J-J) anastomosis. The objective of this study was to identify the incidence of J-J perforation and describe management options and sequelae.

METHODS

This is a retrospective review of the database of all patients who underwent LRYGB. The results are presented as mean (range) where appropriate.

RESULTS

Between April 2002 and April 2012, 1652 patients underwent LRYGB (1577 primary and 75 revision procedures). The operative mortality was .18%. Three patients developed late perforation of the J-J anastomosis (.18%) at 7, 9, and 18 weeks, respectively. Two patients were managed with resection and reanastomosis of the perforation by laparotomy, and a third patient was managed laparoscopically with peritoneal lavage and transcutaneous tube jejunostomy of the perforation. All patients recovered well postoperatively. However, the third patient represented 42 days later with sepsis and died secondary to recurrent J-J ulcer perforation.

CONCLUSION

Perforation of the J-J anastomosis is a rare and life-threatening delayed complication after LRYGB and usually presents within 2-8 months postoperatively. It poses difficulties with diagnosis and management and should be dealt with judiciously.

Autologous reconstruction of massive enteroatmospheric fistulation with a pedicled subtotal lateral thigh flap

Background

Reconstruction of massive contaminated abdominal wall defects associated with enteroatmospheric fistulation represents a technical challenge. An effective technique that allows closure of intestinal fistulas and reconstruction of the abdominal wall, with a good functional and cosmetic result, has yet to be described. The present study is a retrospective review of simultaneous reconstruction of extensive gastrointestinal tract fistulation and large full-thickness abdominal wall defects, using a novel pedicled subtotal thigh flap.

Methods

The flap, based on branches of the lateral circumflex femoral artery, was used to reconstruct the abdominal wall in six patients who were dependent on artificial nutritional support, with a median (range) of 4·5 (3–23) separate intestinal fistulas, within open abdominal wounds with a surface area of 564·5 (204–792) cm2. Intestinal reconstruction was staged, with delayed closure of a loop jejunostomy. Median follow-up was 93·5 (10–174) weeks.

Results

Successful healing occurred in all patients, with no flap loss or gastrointestinal complications. One patient died from complications of sepsis unrelated to the surgical treatment. All surviving patients gained complete nutritional autonomy following closure of the loop jejunostomy.

Conclusion

Replacement of almost the entire native abdominal wall in patients with massive contaminated abdominal wall defects is possible, without the need for prosthetic material or microvascular free flaps. The subtotal pedicled thigh flap is a safe and effective method of providing definitive treatment for patients with massive enteroatmospheric fistulation.

Incidence of perforated gastrojejunal anastomotic ulcers after laparoscopic gastric bypass for morbid obesity and role of laparoscopy in their management

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) is a well-established procedure to treat morbid obesity. Gastrojejunal anastomotic (GJA) ulcers can develop after surgery with subsequent perforation. Our aim was to evaluate the incidence, presentation and outcome of management of perforated GJA ulcer disease after laparoscopic RYGB.

METHODS

The database of all patients at the senior author's bariatric institutions was retrospectively reviewed. The results are presented as mean (range).

RESULTS

From April 2002 to April 2010, 1213 patients underwent laparoscopic RYGB, which included 1184 primary and 29 revision procedures. The operative mortality was .15%. Ten patients developed perforated GJA ulcers (.82%) at a mean of 13.5 (6-19) months. The patients who presented to bariatric surgeons (n = 5) were treated with laparoscopic closure and an omental patch, and those who presented to nonbariatric surgeons (n = 5) were treated with laparotomy. The morbidity and mortality rate was 30% and 10%, respectively, and the mean postoperative hospital stay for the survivors was 14 (5-44) days.

CONCLUSION

Perforated GJA ulcers can develop in 1 of 120 patients after laparoscopic RYGB and can be effectively managed by laparoscopic repair with an omental patch, if expertise is available.

Enhancement of bioavailability and anthelmintic efficacy of albendazole by solid dispersion and cyclodextrin complexation techniques

The objective of this study was to improve the oral bioavailability and therapeutic efficacy of albendazole (ABZ) employing solid dispersion and cyclodextrin complexation techniques. Solid dispersion (dispersion) was prepared using ABZ and polyvinylpyrrolidone (PVP) polymer (1:1 weight ratio). Ternary inclusion complex (ternary complex) was prepared using ABZ, hydroxypropyl beta-cyclodextrin (HPbetaCD) and L-tartaric acid (1:1:1 molar ratio). In rabbits with high gastric acidity (gastric pH approximately 1), ternary complex and solid dispersion showed a bioavailability enhancement of 3.2 and 2.4 fold respectively, compared to a commercial suspension (p < 0.05). The rise in gastric pH (pH > 5) caused a 62% reduction in AUC (area under the plasma level curve) for the commercial suspension, whereas the reduction in case of PVP dispersion and ternary complex was only 43% and 37% respectively. The rapid absorption of the drug from solid dispersion and ternary complex was reflected in improved anthelmintic efficacy against the systemic phases of Trichinella spiralis. The ternary complex was significantly more efficient than solid dispersion and exhibited the highest larvicidal activity (90%) at a dose of 50 mg x kg(-1) (p < 0.05). These results suggest that the bioavailability and therapeutic efficacy of the ternary complex might be high even if there is a great variation in the gastric pH.

Inhibition of albendazole crystallization in poly(vinylpyrrolidone) solid molecular dispersions

The main aim of the study was to investigate the mechanisms of the stabilizing effect of poly(vinylpyrrolidone) (PVP) on amorphous albendazole (ABZ). Solid dispersions of ABZ with PVP polymers and with a copolymer containing poly(vinylacetate) (PVP/VA) were prepared using the solvent casting method. The effects of PVP molecular weight, composition and content on the crystallization of ABZ from the amorphous state were investigated using differential scanning calorimetry. Stability of the amorphous drug with respect to isothermal crystallization was studied at different polymer concentrations and storage temperatures. Solid dispersions were found to be X-ray amorphous and exhibited a single glass transition temperature (Tg). Onset of crystallization and extent of inhibition increased with concentration and molecular weight of the homopolymer. In spite of its having a higher molecular weight, replacement of about 40% of vinylpyrrolidone monomers with vinylacetate groups (as in the copolymer) resulted in reduced inhibition of crystallization. ABZ crystallized from the amorphous state in the absence of polymer even when stored below the Tg. The solvent casting method greatly reduced the requirement for polymer to achieve X-ray amorphous solid dispersions. Such dispersions exhibited a significant increase in induction time and reduction in the rate of crystallization at polymer concentrations as low as 5% and at temperatures as high as 70 degrees C. Factors other than mobility, such as drug-polymer hydrogen bonding' were also found to be involved in crystallization inhibition.