A Preliminary Investigation: Alvimopan Use to Prevent Post-Operative Ileus after Radical Cystectomy with Urinary Diversion

Background: Postoperative ileus (POI) is a common and frustrating patient complication after a urinary diversion by using a segment of bowel. Alvimopan is an oral selective antagonist to the peripheral μ-opioid receptor. Our study investigates the effect of alvimopan on POI in patients undergoing radical cystectomy. There are no documented studies on alvimopan’s efficacy in urologic surgery literature. Methods: Approval from the Institutional Review Board was obtained to conduct a retrospective review of patients’ records from August 2009 until August 2011. The study included sixteen patients who had undergone radical cystectomy with ileal diversion. Exclusion criteria included patients with chronic opioid use, previous colostomy or ileostomy, or significant comorbidities which could cause increased postoperative complications. Statistical analysis was performed to examine the association of alvimopan use with decreased time to dietary advancement and decreased length of hospital stay. Results: The alvimopan group advanced their diet more than 24 hours earlier in comparison with the alvimopan naive group (P < 0.0433), and the alvimopan group had a greater had a greater or 26% shorter hospital length (P < 0.0451) than one day. We showed a reduced risk of POI and subsequent decreased hospital course length. There was no significant difference in readmission rate or need for nasogastric tube (NGT). Interpretation: To our knowledge we report one of the first uses of alvimopan in reducing POI in the urological surgery literature. Our novel experience with using this drug is encouraging. Further research will ultimately determine if standard use of alvimopan to decrease POI in radical cystectomy with ileal diversion will be implemented.

Effect of ankle versus thigh tourniquets on post-operative pain in foot and ankle surgery

BACKGROUND Tourniquets are commonly used in elective extremity orthopaedic surgery to reduce blood loss,improve visualization in the surgical field,and to potentially reduce surgical time.There is a lack of consensus in existing guidelines regarding the optimal tourniquet pressure,placement site,and duration of use.There is a paucity of data on the relationship between the site of a tourniquet and postoperative pain in foot and ankle surgery.AIM To explore the relationship between tourniquet site and intensity of post-operative pain scores in patients undergoing elective foot and ankle surgery.METHODS Retrospective analysis of prospectively collected data on 201 patients who underwent foot and ankle surgery in a single institution was undertaken.Intraoperative tourniquet duration,tourniquet pressure and site,and postoperative pain scores using Visual Analogue Score were collected in immediate recovery,at six hours and at 24 h post-op.Scatter plots were used to analyse the data and to assess for the statistical correlation between tourniquet pressure,duration,site,and pain scores using Pearson correlation coefficient.RESULTS All patients who underwent foot and ankle surgery had tourniquet pressure of 250 mmHg for ankle tourniquet and 300 mmHg for thigh.There was no correlation between the site of the tourniquet and pain scores in recovery,at six hours and after 24 h.There was a weak correlation between tourniquet time and Visual Analogue Score immediately post-op(r=0.14,P=0.04)but not at six or 24 h post-operatively.CONCLUSION This study shows that there was no statistically significant correlation between tourniquet pressure,site and postop pain in patients undergoing foot and ankle surgery.The choice of using a tourniquet is based on the surgeon's preference,with the goal of minimizing the duration of its application at the operative site.

Perioperative Risk Factors for Post-operative Pneumonia after Type A Acute Aortic Dissection Surgery

Objective Type A acute aortic dissection(TAAAD)is a dangerous and complicated condition with a high death rate before hospital treatment.Patients who are fortunate to receive prompt surgical treatment still face high in-hospital mortality.A series of post-operative complications further affects the prognosis.Post-operative pneumonia(POP)also leads to great morbidity and mortality.This study aimed to identify the prevalence as well as the risk factors for POP in TAAAD patients and offer references for clinical decisions to further improve the prognosis of patients who survived the surgical procedure.Methods The study enrolled 89 TAAAD patients who underwent surgical treatment in Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan,Hubei province,China from December 2020 to July 2021 and analyzed the perioperative data and outcomes of these patients.Logistic regression analyses were used to identify the risk factors for POP.Results In the study,31.5%of patients developed POP.Patients with POP had higher proportions of severe oxygenation damage,pneumothorax,reintubation,tracheotomy,renal replacement therapy,arrhythmia,gastrointestinal bleeding,and longer duration of mechanical ventilation,fever,ICU stay,and length of stay(all with P<0.05).The in-hospital mortality was 2.3%.Smoking,preoperative white blood cells,and intraoperative transfusion were the independent risk factors for POP in TAAAD.Conclusion Patients who underwent TAAAD surgery suffered poorer outcomes when they developed POP.Furthermore,patients with risk factors should be treated with caution.

Efficacy of ileus tube combined with meglumine diatrizoate in treating postoperative inflammatory bowel obstruction after surgery

BACKGROUND Early postoperative inflammatory small bowel obstruction(EPISBO)is easy to be complicated after colorectal cancer surgery.Both intestinal obstruction catheter and meglumine can treat EPISBO.AIM To investigate the efficacy of an intestinal obstruction tube combined with meg-lumine diazo in treating EPISBO of colorectal cancer.METHODS Data from 60 patients with colorectal cancer and intestinal obstruction admitted to the Proctology Department of our hospital from April 2018 to May 2022 were collected and analyzed and divided into three cohorts according to different treatment regimens.Cohort A(n=20)received a transnasal intestinal obstruction catheter with panumglumine,and cohort B(n=20)received a transnasal intestinal obstruction catheter with liquid paraffin.Cohort C(n=20)received oral treatment with meglumine.The clinical efficacy,first exhaust/defecation time,length of hospital stay,gastrointestinal decompression time,relief time of abdo-minal pain,and relief time of abdominal distension were compared among the three cohorts.The levels of C-reactive protein(CRP),tumor necrosis factor-α(TNF-α),interleukin-6(IL-6),monocyte chemotactic protein-1(MCP-1),serum albumin,and transferrin were compared among the three cohorts before and after treatment.The occurrence of adverse reactions in the three cohorts was compared.RESULTS Compared with cohort C,the successful treatment rate of cohort A was signi-ficantly higher.There were statistically significant variations in the time of first exhaust/defecation,length of hospital stays,gastrointestinal decompression time,relief time of abdominal pain,and relief time of abdominal distention among the three cohorts.Compared with cohort C,cohort A’s first exhaust/defecation time,hospitalization time,gastrointestinal decompression time,abdominal pain relief time,and abdominal distension relief time was reduced(P<0.05).After treatment,serum CRP,TNF-α,IL-6,and MCP-1 expression levels increased,and serum albumin and serum transferrin levels increased in the three cohorts.The serum albumin level in cohort A was higher than in cohort C.Compared with cohort B and cohort C,the serum transferrin level in cohort A increased(P<0.05).Compared with cohort C,the total incidence of adverse reactions in cohorts A and B was significantly higher(P<0.05).The incidence of adverse reactions was similar between cohort A and cohort B.CONCLUSION Using an ileus tube combined with meglumine diatrizoate can effectively treat postoperative inflammatory ileus obstructions after surgery colorectal cancer and improve prognosis,inflammatory response,and nutritional status.

Closed loop ileus caused by a defect in the broad ligament:A case report

BACKGROUND Closed loop ileus caused by entrapment of bowel in a defect of the broad ligament is a rarity.Only a few cases have been reported in the literature.CASE SUMMARY We present the case of a 44-year-old,healthy patient with no prior history of abdominal surgery who developed a closed loop ileus due to an internal hernia secondary to a defect in the right broad ligament.She first presented to the emergency department with diarrhea and vomiting.As she had had no previous abdominal surgery,she was diagnosed with probable gastroenteritis and discharged.The patient subsequently returned to the emergency department due to a lack of improvement in her symptoms.Blood tests showed an elevated white blood cell count and a closed loop ileus was diagnosed on an abdominal computer tomography scan.Diagnostic laparoscopy revealed an internal hernia entrapped in a 2 cm large defect in the right broad ligament.The hernia was reduced and the ligament defect was closed using a running,barbed suture.CONCLUSION Bowel incarceration through an internal hernia may present with misleading symptoms and laparoscopy may reveal unexpected findings.

Endoscopic and surgical treatment of jejunal gallstone ileus caused by cholecystoduodenal fistula:A case report

BACKGROUND Gallstone ileus is a rare complication of gallstone disease in which a stone enters the enteric lumen and causes mechanical obstruction usually by bilioenteric fistula.Gallstone ileus accounts for 25%of all bowel obstructions among the population>65 years of age.Despite medical advances over the last decades,gallstone ileus is still associated with high rates of morbidity and mortality.CASE SUMMARY An 89-year-old man with a history of gallstones was admitted to the Gastroenterology Department of our hospital,complaining of vomiting and cessation of bowel movements and flatus.Abdominal computed tomography showed cholecystoduodenal fistula and upper jejunum obstruction due to gallstones,pneumatosis in the gallbladder,and pneumobilia indicating Rigler’s triad.Considering the high risk of surgical management,we performed propulsive enteroscopy and laser lithotripsy twice to relieve the bowel occlusion.However,the intestinal obstruction was not relieved by the less invasive procedure.Then,the patient was transferred to the Department of Biliary-pancreatic Surgery.The patient underwent the one-stage procedure including laparoscopic duodenoplasty(fistula closure),cholecystectomy,enterolithotomy,and repair.After surgery,the patient presented with complications of acute renal failure,postoperative leak,acute diffuse peritonitis,septicopyemia,septic shock,and multiple organ failure,and finally died.CONCLUSION Early surgical intervention is the mainstay of treatment for gallstone ileus.For elderly patients with significant comorbidities,enterolithotomy alone is advised.

Surgical management of gallstone ileus after one anastomosis gastric bypass: A case report

BACKGROUND Gallstone ileus following one anastomosis gastric bypass(OAGB)is an exceptionally rare complication.The presented case report aims to highlight the unique occurrence of this condition and its surgical management.Understanding the clinical presentation,diagnostic challenges and successful surgical inter-vention in such cases is crucial for healthcare professionals involved in bariatric surgery.CASE SUMMARY We present a case report of gallstone ileus following OAGB and discuss its diagnosis and surgical management.A 66-year-old female with a history of OAGB presented to the emergency room with symptoms of small bowel obstru-ction.Computed tomography scan revealed a gallstone impacted in the distal ileum,causing obstruction.The patient underwent a laparoscopically assisted enterolithotomy,during which the gallstone was extracted and the enterotomy was closed.The patient had an uneventful recovery and was dis-charged on postoperative day four.CONCLUSION Gallstone ileus should be considered as a possible complication after OAGB,and prompt surgical intervention is usually required for its management.This case report contributes to the limited existing literature,providing insights into the management of this uncommon complication.

Acupuncture therapies in combination with conservative treatments for postoperative ileus:a systematic review and network meta-analysis

Background:Although acupuncture therapies have been widely used in combination with conservative treatments(CT)for postoperative ileus(POI),evidence of their safety and efficacy remains scarce.To evaluate and rank the efficacy of different acupuncture therapies combined with CT for POI.Methods:A comprehensive search was carried out in several databases(Embase,PubMed,Cochrane Library,Chinese National Knowledge Infrastructure,Wanfang Data,VIP Chinese Science and Technology Periodical Database and China Biology Medicine disc)for relevant randomized controlled trials(RCTs)investigating different acupuncture therapies for POI from inception to February 17,2023.The Cochrane risk of bias tool was used to determine the risks of bias of the included RCTs.The primary outcomes included the time to first defecation,time to first flatus,and time to first bowel movement;and the secondary outcome was the response rate.Pairwise meta-analysis was performed by Review Manager 5.3 software,and network meta-analysis was carried out by Stata v.15.0 software.The cumulative ranking curve was obtained with Stata v.15.0 and was utilized to rank the included treatments.Results:29 studies with 2,600 participants were included in this systematic review.This meta-analysis demonstrated that all acupuncture therapies combined with CT were superior to conservative treatments alone in time to first defecation,time to first flatus,time to first bowel movement,and response rate.Among 10 evaluated methods,auricular needle with CT was the most effective treatment to reduce the time to first defecation.Furthermore,moxibustion with CT was the most effective in reducing the time to first flatus,and warm needling with CT most markedly reduced the time to first bowel movement among 9 interventions.Moreover,manual acupuncture with CT showed the largest improvement in response rate.Conclusion:This meta-analysis revealed that all acupuncture therapies are effective and safe for POI,with warm needling+CT being the most effective way to relieve symptoms.These results indicated that acupuncture therapies combined with CT should be considered for POI patients.However,most of the included trials were ranked as moderate quality,and further large-scale,high-quality RCTs are required to confirm the optimal interventions for POI patients.

Postoperative ileus: Impact of pharmacological treatment,laparoscopic surgery and enhanced recovery pathways

Almost all patients develop postoperative ileus (POI) after abdominal surgery.POI represents the single largest factor influencing length of stay (LOS) after bowel resection,and has great implications for patients and resource utilization in health care.New methods to treat and decrease the length of POI are therefore of great importance.During the past decade,a substantial amount of research has been performed evaluating POI,and great progress has been made in our understanding and treatment of POI.Laparoscopic procedures,enhanced recovery pathways and pharmacologic treatment have been introduced.Each factor has substantially contributed to decreasing the length of POI and thus LOS after bowel resection.This editorial outlines resource utilization of POI,normal physiology of gut motility and pathogenesis of POI.Pharmacological treatment,fast track protocols and laparoscopic surgery can each have significant impact on pathways causing POI.The optimal integration of these treatment options continues to be assessed in prospective studies.

Nomogram to predict prolonged postoperative ileus after gastrectomy in gastric cancer

BACKGROUND Prolonged postoperative ileus(PPOI)is one of the common complications in gastric cancer patients who underwent gastrectomy.Evidence on the predictors of PPOI after gastrectomy is limited and few prediction models of nomogram are used to estimate the risk of PPOI.We hypothesized that a predictive nomogram can be used for clinical risk estimation of PPOI in gastric cancer patients.AIM To investigate the risk factors for PPOI and establish a nomogram for clinical risk estimation.METHODS Between June 2016 and March 2017,the data of 162 patients with gastrectomy were obtained from a prospective and observational registry database.Clinical data of patients who fulfilled the criteria were obtained.Univariate and multivariable logistic regression models were performed to detect the relationship between variables and PPOI.A nomogram for PPOI was developed and verified by bootstrap resampling.The calibration curve was employed to detect the concentricity between the model probability curve and ideal curve.The clinical usefulness of our model was evaluated using the net benefit curve.RESULTS This study analyzed 14 potential variables of PPOI in 162 gastric cancer patients who underwent gastrectomy.The incidence of PPOI was 19.75%in patients with gastrectomy.Age older than 60 years,open surgery,advanced stage(III–IV),and postoperative use of opioid analgesic were independent risk factors for PPOI.We developed a simple and easy-to-use prediction nomogram of PPOI after gastrectomy.This nomogram had an excellent diagnostic performance[area under the curve(AUC)=0.836,sensitivity=84.4%,and specificity=75.4%].This nomogram was further validated by bootstrapping for 500 repetitions.The AUC of the bootstrap model was 0.832(95%CI:0.741–0.924).This model showed a good fitting and calibration and positive net benefits in decision curve analysis.CONCLUSION We have developed a prediction nomogram of PPOI for gastric cancer.This novel nomogram might serve as an essential early warning sign of PPOI in gastric cancer patients.

Preoperative albumin levels predict prolonged postoperative ileus in gastrointestinal surgery

BACKGROUND Prolonged postoperative ileus(PPOI) is a prolonged state of "pathological"gastrointestinal(GI) tract dysmotility. There are relatively few studies examining the influence of preoperative nutritional status on the development of PPOI in patients who underwent GI surgery. The association between preoperative albumin and PPOI has not been fully studied. We hypothesized that preoperative albumin may be an independent indicator of PPOI.AIM To analyze the role of preoperative albumin in predicting PPOI and to establish a nomogram for clinical risk evaluation.METHODS Patients were drawn from a prospective hospital registry database of GI surgery.A total of 311 patients diagnosed with gastric or colorectal cancer between June 2016 and March 2017 were included. Potential predictors of PPOI were analyzed by univariate and multivariable logistic regression analyses, and a nomogram for quantifying the presence of PPOI was developed and internally validated.RESULTS The overall PPOI rate was 21.54%. Advanced tumor stage and postoperative opioid analgesic administration were associated with PPOI. Preoperative albumin was an independent predictor of PPOI, and an optimal cutoff value of 39.15 was statistically calculated. After adjusting multiple variables, per unit or per SD increase in albumin resulted in a significant decrease in the incidence of PPOI of 8%(OR = 0.92, 95%CI: 0.85-1.00, P = 0.046) or 27%(OR = 0.73, 95%CI:0.54-0.99, P = 0.046), respectively. Patients with a high level of preoperative albumin(≥ 39.15) tended to experience PPOI compared to those with low levels(< 39.15)(OR = 0.43, 95%CI: 0.24-0.78, P = 0.006). A nomogram for predicting PPOI was developed [area under the curve(AUC) = 0.741] and internally validated by bootstrap resampling(AUC = 0.725, 95%CI: 0.663-0.799).CONCLUSION Preoperative albumin is an independent predictive factor of PPOI in patients who underwent GI surgery. The nomogram provided a model to screen for early indications in the clinical setting.

Controlling postoperative ileus by vagal activation

Postoperative ileus is a frequently occurring surgical complication, leading to increased morbidity and hospital stay. Abdominal surgical interventions are known to result in a protracted cessation of bowel movement. Activation of inhibitory neural pathways by nociceptive stimuli leads to an inhibition of propulsive activity, which resolves shortly after closure of the abdomen. The subsequent formation of an inflammatory infiltrate in the muscular layers of the intestine results in a more prolonged phase of ileus. Over the last decade, clinical strategies focusing on reduction of surgical stress and promoting postoperative recovery have improved the course of postoperative ileus. Additionally, recent experimental evidence implicated antiinflammatory interventions, such as vagal stimulation, as potential targets to treat postoperative ileus and reduce the period of intestinal hypomotility. Activation of nicotinic receptors on inflammatory cells by vagal input attenuates inflammation and promotes gastrointestinal motility in experimental models of ileus. A novel physiologicalintervention to activate this neuroimmune pathway is enteral administration of lipid-rich nutrition. Perioperative administration of lipid-rich nutrition reduced manipulation-induced local inflammation of the intestine and accelerated recovery of bowel movement. The application of safe and easy to use antiinflammatory interventions, together with the current multimodal approach, could reduce postoperative ileus to an absolute minimum and shorten hospital stay.

Transcutaneous electroacupuncture alleviates postoperative ileus after gastrectomy: A randomized clinical trial

AIM To investigate the efficacy and safety of transcutaneouselectroacupuncture(TEA) to alleviate postoperative ileus(POI) after gastrectomy.METHODS From April 2014 to February 2017, 63 gastric cancer patients were recruited from the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China. After gastrectomy, the patients were randomly allocated to the TEA(n = 33) or control(n = 30) group. The patients in the TEA group received 1 h TEA on Neiguan(ST36) and Zusanli(PC6) twice daily in the morning and afternoon until they passed flatus. The main outcomes were hours to the first flatus or bowel movement, time to nasogastric tube removal, time to liquid and semi-liquid diet, and hospital stay. The secondary outcomes included postoperative symptom assessment and complications.RESULTS Time to first flatus in the TEA group was significantly shorter than in the control group(73.19 ± 15.61 vs 82.82 ± 20.25 h, P = 0.038), especially for open gastrectomy(76.53 ± 14.29 vs 87.23 ± 20.75 h, P = 0.048). Bowel sounds on day 2 in the TEA group were significantly greater than in the control group(2.30 ± 2.61/min vs 1.05 ± 1.26/min, P = 0.017). Time to nasogastric tube removal in the TEA group was earlier than in the control group(4.22 ± 1.01 vs 4.97 ± 1.67 d, P = 0.049), as well as the time to liquid diet(5.0 ± 1.34 vs 5.83 ± 2.10 d, P = 0.039). Hospital stay in the TEA group was significantly shorter than in the control group(8.06 ± 1.75 vs 9.40 ± 3.09 d, P = 0.041). No significant differences in postoperative symptom assessment and complications were found between the groups. There were no severe adverse events related to TEA.CONCLUSION TEA accelerated bowel movements and alleviated POI after open gastrectomy and shortened hospital stay.

Gallstone ileus:One-stage surgery in a patient with intermittent obstruction

Gallstone ileus, an uncommon complication of cholelithiasis, is described as a mechanical intestinal obstruction due to impaction of one or more large gallstones within the gastrointestinal tract. The clinical presentation is variable, depending on the site of obstruction, manifested as acute, intermittent or chronic episodes. A 51-year-old female patient was referred to our hospital with 3 events of intestinal obstruction during the previous 7 d. At admission, there were clinical signs of intestinal obstruction; abdominal film demonstrated dilated bowel loops, air-fluid levels and a vague image of a stone in the inferior left quadrant. Once stabilized, a laparotomy was performed. Surgical findings were distention of the jejunum and ileum proximal to a palpable stone in the ileum as well as gallstones and a cholecystoduodenal fistula in the gallbladder. An enterolithotomy, repair of the cholecystoduodenal fistula and cholecystectomy were performed. The postoperative course was uneventful. There is no uniform surgical procedure for this disease. When the patient is too ill or when biliary surgery is not advisable, an enterolithotomy is the best option. The one-stage procedure should be the offered to adequately stabilized patients when local and general conditions, such as good cardiorespiratory and metabolic reserve permit a more prolonged surgical procedure.

Gallstone ileus: Case report and literature review

Gallstone ileus(GI)is characterized by occlusion of the intestinal lumen as a result of one or more gallstones.GI is a rare complication of gallstones that occurs in1%-4%of all cases of bowel obstruction.The mortality associated with GI ranges between 12%and 27%.Classical findings on plain abdominal radiography include:(1)pneumobilia;(2)intestinal obstruction;(3)an aberrantly located gallstone;and(4)change of location of a previously observed stone.The optimal management of acute GI is controversial and can be:(1)enterotomy with stone extraction alone;(2)enterotomy,stone extraction,cholecystectomy and fistula closure;(3)bowel resection alone;and(4)bowel resection with fistula closure.We describe a case to highlight some of the pertinent issues involved in GI management,and propose a scheme to minimize recurrent disease and postoperative complications.We conclude that GI is a rare condition affecting mainly the older population with a female predominance.The advent of computed tomography and magnetic resonance imaging has made it easier to diagnose GI.Enterotomy with stone extraction alone remains the most common surgical method because of its low incidence of complications.

Cholecystoenteric fistula with and without gallstone ileus: A case series

Background: A cholecystoenteric stula (CEF) is an uncommon complication of gallstone disease. The aim of this study was to present our experience of a series of patients with CEF, presenting with or without gallstone ileus, along with their surgical outcomes. Methods: From 2015 to 2018, 3245 consecutive patients underwent cholecystectomy for gallbladder disease at our institution, of which 15 were diagnosed with a CEF. All electronic medical records were retrospectively reviewed. Results: Fifteen patients presented with CEF. Ten patients presented cholecystoduodenal stula, four pa- tients cholecystocolonic, and one patient cholecystogastric counterparts. Twelve patients were female. The median patient age was 61 years (range 33 86 years). Five patients presented with gallstone ileus treated by laparotomy and enterolithotomy. In ten patients, a laparoscopic approach was attempted, but conversion to open surgery was necessary for eight of them. The median operative time was 140 min (range 60 240 min), and the median operative blood loss was 50 mL (range 10600mL). The procedure-related morbidity and mortality rates were 13.3% and 6.7%, respectively. Conclusions: There is no consensus on the best treatment modality for a CEF, as the treatment outcome is mostly dependent on the surgeon’s expertise and the patient’s condition. Not all CEFs are accompanied by gallstone ileus. For such case, the main purpose is to resolve the intestinal obstruction and, unless necessary, avoidance of the gallbladder area.

Management and outcome of recurrent gallstone ileus:A systematic review

AIM: To help the surgeon in decision making whentreating a patient with recurrent gallstone ileus(RGSI). METHODS: A systematic review related to RGSI was performed using the databases CINAHL, EMBASE, MEDLINE via Pub Med from May 1912 to April 2015. All languages were included and the grey literature was also searched. The abstracts were explored for relevance to the topic and full texts obtained as appropriate. A manual search was carried out by scrutinising the reference lists of all the full text articles and further articles were identified and obtained. Total of 903 articles were identified, 656 were excluded after abstract review, 247 full text articles were reviewed and 91 articles selected for final analysis. There were 113 cases of RGSI. RESULTS: There were 113 cases of RGSI reported in 91 articles. The majority of the recurrences, 62.6%, occurred within 6 wk of the index event. The male to female ratio was 1:7. The mean age was 69.6 years(SD 11.2) with a range of 38-95 years. The small bowel was the commonest site of impaction(92.2%). Treatment data was available for 104 patients. The two main operations performed were:(1) Enterolithotomy without repair of biliary fistula in 70.1% of all patients with a procedural mortality rate of 16.4%(12/73) and(2) a single stage surgery approach involving enterolithotomy with cholecystectomy and repair of the biliary enteric fistula in 16.3% with a procedural mortality of 11.7%(2/17). A subset analysis over last 25 years showed mortality from eneterolithotomy was 4.8% while single stage mortality was 22.2%. Enterolithotomy alone was the commonest operation performed for RGSI with four patients(5.4%) having a further recurrence of gallstone ileus. CONCLUSION: Enterolithotomy alone or followed by a delayed two-stage treatment approach is the preferred choice offering low mortality and reduced risk of recurrence.

Successful endoscopic treatment of colonic gallstone ileus using electrohydraulic lithotripsy

The surgical management of gallstone ileus is complex and potentially highly morbid.Initial management requires enterolithotomy and is generally followed by fistula resection at a later date.There have been reports of gallstone extraction using various endoscopic modalities to relieve the obstruction,however,to date,there has never been a published case of endoscopic stone extraction from the colon using electrohydraulic lithotripsy.In this report,we present the technique employed to successfully perform an electrohydraulic lithotripsy for removal of a large gallstone impacted in the sigmoid colon.A cavity was excavated in an obstructing 4.1 cm lamellated stone in the sigmoid colon using electrohydraulic lithotripsy.A screw stent retractor and stent extractor bored a larger lumen which allowed for guidewire advancement and stone fracture via serial pneumatic balloon dilatation.The stone fragments were removed.Electrohydraulic lithotripsy is a safe and effective method to treat colonic obstruction in the setting of gallstone ileus.

Chewing gum for declining ileus and accelerating gastrointestinal recovery after appendectomy

Objective: Ileus usually occurs after abdominal surgery and is allied with complication and delays recovery. It is hypothesized that chewing gum reduces postoperative ileus by improving early recovery of gastrointestinal function. This study aimed to explore whether chewing gum after appendectomy accelerates the recovery of gastrointestinal function.Methods: Randomized control trial was used in this study. This study was conducted in the General Surgery Department at Zagazig University Hospital. A total of 240 patients undergoing appendectomy were involved in this study; they were divided into the chewing sugar-free gum group(120) and the control group(120). Two tools were utilized in this study. Tool I: Structured Interviewing Schedule: part 1: assessment of personnel characteristics. Part 2: assessment of anthropometric measurements of the studied subjects as well as pre-and intraoperative indicators of them. Tool II: postoperative assessment sheet: assessed postoperative parameters of the intestinal function, occurrence of postoperative ileus, and related symptoms were assessed among studied participants.Results: There were highly significant statistical differences in the time of resumption of gastrointestinal functions and postoperative ileus symptoms between the two groups(P<0.001), which was significantly shorter in the chewing gum group compared to the control group.Conclusions: The use of chewing gum is a useful and cheap method that can be employed to cut down the time to recover and accelerate normalization of gastrointestinal function. Chewing sugar-free gum after abdominal surgery is recommended to be added to the protocol of nursing care in the surgery units as well as its involvement in the nursing curriculum.

Penehyclidine Hydrochloride Premedication Is Not Associated with Increased Incidence of Post-Operative Cognitive Dysfunction or Delirium:A Systemic Review and Meta-Analysis

Objective Post-operative cognitive dysfunction(POCD)and post-operative delirium(POD)are two common post-operative cerebral complications.The current meta-analysis was to systematically review the effects of penehyclidine hydrochloride(PHC)on POCD and POD in surgical patients.Methods Electronic databases were searched to identify all randomized controlled trials comparing PHC with atropine/scopolamine/placebo on POCD and POD in surgical patients.Primary outcomes of interest included the incidences of POCD and POD;the secondary outcomes of interest included peri-operative minimental state examination(MMSE)scores.Two authors independently extracted peri-operative data,including patients'baseline characteristics,surgical variables,and outcome data.For dichotomous data(POCD and POD occurrence),treatment effects were calculated as odds ratio(OR)and 95%confidential interval(Cl).Each outcome was tested for heterogeneity,and randomized-effects or fixed-effects model was used in the presence or absence of significant heterogeneity.For continuous variables(MMSE scores),treatment effects were calculated as weighted mean difference(WMD)and 95%CI.Statistical significance was defined as P<0.05.Results Our search yielded 33 studies including 4017 patients.Meta-analysis showed that,the incidence of POCD in PHC group was comparable to that in saline group(OR=0.97;95%Ck 0.S8-1.64;P=0.92),scopolamine group(OR=0.78;95%CI:0.48-1.27;P=0.32)and atropine group(0R=1.20;95%Ch 0.86-1.67;P=0.29).The incidence of POD in PHC group was comparable to that in saline group(OR=1.53;95%CI:0.81-2.90;P=0.19)and scopolamine group(OR=0.53;95%CI:0.06-4.56;P=0.56),but higher than that in atropine group(OR=4.49;95%CI:1.34-15.01;P=0.01).Conclusions PHC premedication was not associated with increased incidences of POCD or POD as compared to either scopolamine or placebo.