Nonoperative management of gastrointestinal malignancies in era of neoadjuvant treatment

Cancers derived from the gastrointestinal(GI)tract are often treated with radical surgery to achieve a cure.However,recent advances in the management of GI cancers involve the use of a combination of neoadjuvant radiation and chemotherapy followed by surgical intervention to achieve improved local control and cure.Interestingly,a small proportion of patients with highly sensitive tumors achieved a pathological complete response(pCR)(no residual tumor cells in the resected specimen)to neoadjuvant chemoradiation therapy(nCRT).The desire for organ preservation and avoidance of surgical morbidity brings the idea of a nonoperative management(NOM)strategy.Because of the different nature of tumor biology,GI cancers present diverse responses to nCRT,ranging from high sensitivity(anal cancer)to low sensitivity(gastric/esophageal cancer).There is an increasing attention to NOM of localized GI cancers;however,without the use of biomarkers/imaging parameters to select such patients,NOM will remain a challenge.Therefore,this review intends to summarize some of the recent updates from the aspect of current nCRT regimens,criteria for patient selection and active surveillance schedules.We also hope to review significant sequelae of radical surgery and the complications of nCRT to clarify the directions for optimization of nCRT and NOM for oncologic outcomes and quality of life.

Pancreatic duct disruption and nonoperative management: the SEALANTS approach

Pancreatic-duct disruption (PDD) can be difficult to manage, with diverse etiologies and sequelae in a heterogeneous population. Common etiologies include pancreatitis, iatrogenic injury, and trauma. Sequelae of PDD include pseudocyst, pancreatic ascites,

Low serum albumin may predict poor efficacy in patients with perforated peptic ulcer treated nonoperatively

BACKGROUND Nonoperative management(NOM)is a promising therapeutic modality for patients with perforated peptic ulcer(PPU).However,the risk factors for poor efficacy and adverse events of NOM are a concern.AIM To investigate the factors predictive of poor efficacy and adverse events in patients with PPU treated by NOM.METHODS This retrospective case-control study enrolled 272 patients who were diagnosed with PPU and initially managed nonoperatively from January 2014 to December 2018.Of these 272 patients,50 converted to emergency surgery due to a lack of improvement(surgical group)and 222 patients were included in the NOM group.The clinical data of these patients were collected.Baseline patient characteristics and adverse outcomes were compared between the two groups.Logistic regression analysis and receiver operating characteristic curve analyses were conducted to investigate the factors predictive of poor efficacy of NOM and adverse outcomes in patients with PPU.RESULTS Adverse outcomes were observed in 71 patients(32.0%).Multivariate analyses revealed that low serum albumin level was an independent predictor for poor efficacy of NOM and adverse outcomes in patients with PPU.CONCLUSION Low serum albumin level may be used as an indicator to help predict the poor efficacy of NOM and adverse outcomes,and can be used for risk stratification in patients with PPU.

NonOperative Management of Blunt Solid Abdominal Organ Injury in Calabar, Nigeria

Background: Over the past several years, nonoperative management has been increasingly recommended for the care of selected blunt abdominal trauma patients with solid organ injuries. Objective: To evaluate the pattern and outcome of blunt abdominal trauma using haemodynamic stability and ultrasonography in the selection of patients for nonoperative management in a facility without computed tomogram. Methods: Patients admitted with blunt abdominal trauma between February 2005 and January 2010 were prospectively studied. Haemodynamic stability and sonography formed the basis for selecting patients for nonoperative management. Results: In total, 58 patients suffered blunt abdominal trauma and 19(33%) patients were successfully managed nonoperatively suffered blunt solid abdominal organ injuries. Road traffic accidents inflicted 17(89%) patients while 2(11%) patients sustained sports injury (football). The spleen was the commonest solid organ injured 12(60%), while the liver and kidney were injured in 6(30%) and 2(10%) respectively. Associated injuries were fractured left femur recorded in 3(16%) patients and fractured rib in a patient (5%). Conclusion: Nonoperative treatment is a safe and effective method in the management of haemodynamically stable patient with blunt solid abdominal organ injury. This translated to a reduction in hospital stay, absence of the risk of blood transfusion as well as attendant morbidity and mortality associated with laparotomy. Establishment of trauma system, provision of diagnostic and monitoring facilities, good roads, and education on road safety is recommended for improved outcome.

Role of platelet-rich plasma in the treatment of rotator cuff tendinopathy

Shoulder pain is a common musculoskeletal complaint,and rotator cuff(RC)pathologies are one of the main causes.The RC undergoes various tendinopathic and avascular changes during the aging process.Other degenerative changes affecting its healing potential make it an appealing target for biological agents.Platelet-rich plasma(PRP)has demonstrated the potential to deliver a high concentration of several growth factors and anti-inflammatory mediators,and its clinical use is mainly supported by experiments that demonstrated its positive effect on muscle,ligaments,and tendinous cells.This review aimed to specify the role of PRP and its future applications in RC tendinopathies based on the current clinical evidence.Due to the different characteristics and conflicting outcomes,clinicians should use PRP with moderate expectations until more consistent evidence is available.However,it is reasonable to consider PRP in patients with contraindications to corticosteroid injections or those with risk factors for inadequate healing.Its autologous origin makes it a safe treatment,and its characteristics make it a promising option for treating RC tendinopathy,but the efficacy has yet to be established.

Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention

Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast followthrough and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.

Are radiological modalities really necessary for the long-term follow-up of patients having blunt solid organ injuries? A single center study

Dear editor, During the past two decades, management of blunt solid organ injuries had shifted from conventional surgery to more conservative approach, namely nonoperative management (NOM).[1] The non-operative approach mainly depends on the trauma experience of surgeons and the institution, quality of radiographic imaging and its interpretation.[2-5] If the surgeon decides to observe the patients by NOM, close monitoring of vital signs and frequent physical examinations must be done accordingly with radiological evaluations if needed.

Hydrogen gas and preservation of intestinal stem cells in mesenteric ischemia and reperfusion

BACKGROUND Patients with mesenteric ischemia frequently suffer from bowel necrosis even after revascularization.Hydrogen gas has showed promising effects for ischemiareperfusion injury by reducing reactive oxygen species in various animal and clinical studies.We examined intestinal tissue injury by ischemia and reperfusion under continuous initiation of 3%hydrogen gas.AIM To clarify the treatment effects and target cells of hydrogen gas for mesenteric ischemia.METHODS Three rat groups underwent 60-min mesenteric artery occlusion(ischemia),60-min reperfusion following 60-min occlusion(reperfusion),or ischemiareperfusion with the same duration under continuous 3%hydrogen gas inhalation(hydrogen).The distal ileum was harvested.Immunofluorescence staining with caspase-3 and leucine-rich repeat-containing G-protein-coupled 5(LGR5),a specific marker of intestinal stem cell,was conducted to evaluate the injury location and cell types protected by hydrogen.mRNA expressions of LGR5,olfactomedin 4(OLFM4),hairy and enhancer of split 1,Jagged 2,and Neurogenic locus notch homolog protein 1 were measured by quantitative polymerase chain reaction.Tissue oxidative stress was analyzed with immunostaining for 8-hydroxy-2'-deoxyguanosine(8-OHdG).Systemic oxidative stress was evaluated by plasma 8-OHdG.RESULTS Ischemia damaged the epithelial layer at the tip of the villi,whereas reperfusion induced extensive apoptosis of the cells at the crypt base,which were identified as intestinal stem cells with double immunofluorescence stain.Hydrogen mitigated such apoptosis at the crypt base,and the LGR5 expression of the tissues was higher in the hydrogen group than in the reperfusion group.OLFM4 was also relatively higher in the hydrogen group,whereas other measured RNAs were comparable between the groups.8-OHdG concentration was high in the reperfusion group,which was reduced by hydrogen,particularly at the crypt base.Serum 8-OHdG concentrations were relatively higher in both reperfusion and hydrogen groups without significance.CONCLUSION This study demonstrated that hydrogen gas inhalation preserves intestinal stem cells and mitigates oxidative stress caused by mesenteric ischemia and reperfusion.

Traumatic Splenic Injuries in Khartoum, Sudan

Background: Spleen injuries are most commonly associated with blunt abdominal trauma and represent a potentially life-threatening condition. Objectives: To study the pattern of splenic injuries of the patient, management instituted and its outcome at Khartoum. Patients and Methods: This is a prospective, analytic and hospital-based multicenteric study, conducted at the three main Teaching hospitals at Khartoum. The study was carried over a period from April 2012 to February 2013. It includes all patients, diagnosed as traumatic splenic injury. Excluded were patients with history of splenic disease, iatrogenic injury or spontaneous rupture. Results: The study included 47 patients: their mean age was 26.4 years (SD ± 14.5). Most of them 41 (87.2%) were in the first four decades of life. Males were predominant 41 (87.2%), with a male to female ratio of 6.8:1. The majority of our patients had blunt abdominal trauma 39 (83%), of whom, road traffic accident accounted for 51.1% and none reported cases of gunshot. Isolated splenic injury was found in 23 (48.9%), and Haemodynamic stability was seen in 27 (57.4%) on presentation. The initial haemoglobin assessment revealed <9 gram/dl in 53.2%. CT scan was performed to 24 (51.1%), of whom 66 patients were Grade I and II and none of our patients were diagnosed as Grade V. Blood transfusion was required in 42 (89.4%). Operative treatment was adopted in 66% (61.7% total splenectomy and 4.3% splenorrhaphy), while selective non-operative management was successful in 16 (34%) of the patients. Higher intra-operative grade of splenic injury was found to be significantly associated with blunt abdominal trauma, haemodynamic instability and associated intra-abdominal injuries. 44 patients (93.6%) were discharged home in a general good condition. The morbidity and mortality were seen in 8.5% and 6.4% respectively. Conclusion: Splenic injuries usually follow blunt abdominal trauma, particularly after road traffic accidents. It is common during the first four decades of life with males being frequently affected. The great success rate of adopting selective non-operative management is worthwhile.

Emergency department management of an occult renal laceration following a minor fall

We present a case of a pediatric patient with high grade renal injury following a minor fall,where clinical suspicion of occult injury resulted in diagnosis.Additionally,we review the management of high grade renal lacerations in children,including the role of ultrasound in managing these injuries.

Emergency strategies and trends in the management of liver trauma

The liver is the most frequently injured organ during abdominal trauma.The management of hepatic trauma has undergone a paradigm shift over the past several decades,with mandatory operation giving way to nonoperative treatment.Better understanding of the mechanisms and grade of liver injury aids in the initial assessment and establishment of a management strategy.Hemodynamically unstable patients should undergo focused abdominal sonography for trauma,whereas stable patients may undergo computed tomography,the standard examination protocol.The grade of liver injury alone does not accurately predict the need for operation,and nonoperative management is rapidly becoming popular for high-grade injuries.Hemodynamic instability with positive focused abdominal sonography for trauma and peritonitis is an indicator of the need for emergent operative intervention.The damage control concept is appropriate for the treatment of major liver injuries and is associated with significant survival advantages compared with traditional prolonged surgical techniques.Although surgical intervention for hepatic trauma is not as common now as it was in the past,current trauma surgeons should be familiar with the emergency surgical skills necessary to manage complex hepatic injuries,such as packing,Pringle maneuver,selective vessel ligation,resectional debridement,and parenchymal sutures.The present review presents emergency strategies and trends in the management of liver trauma.

Non-operative management for abdominal solidorgan injuries: A literature review

The philosophy of abdominal injury management is currently changing from mandatory exploration to selective non-operative management (NOM). The patient with hemodynamic stability and absence of peritonitis should be managed non-operatively. NOM has an overall success rate of 80%—90%. It also can reduce the rate of non-therapeutic abdominal exploration, preserve organ function, and has been defined as the safest choice in experienced centers. However, NOM carries a risk of missed injury such as hollow organ injury, diaphragm injury, and delayed hemorrhage. Adjunct therapies such as angiography with embolization, endoscopic retrograde cholangiopancreatography with stenting, and percutaneous drainage could increase the chances of successful NOM. This article aims to describe the evolution of NOM and define its place in specific abdominal solid organ injury for the practitioner who faces this problem.