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.

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.

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.

Global research trends in postoperative ileus from 2011 to 2023:A scientometric study

BACKGROUND Postoperative ileus(POI)is a common complication after abdominal surgery with high morbidity,which hinders patient recovery,prolongs hospitalization,and increases healthcare costs.Therefore,POI has become a global public health challenge.POI triggering is multifactorial.Autonomic and hormonal mechanisms are generally involved in POI pathogenesis.Recent studies have shown that beta adrenergic signaling of enteric glia is a POI trigger.Currently,the status quo,trends,and frontiers of global research on POI remain unclear.AIM To explore the current status,trends,and frontiers of POI research from 2011 to the present based on bibliometric analysis.METHODS Publications published on POI research from 2011 to 2023 were retrieved on June 1,2023,from the Web of Science Core Collection.CiteSpace 6.2.R2 and VOSviewer were used to conduct bibliometric visualization.RESULTS In total,778 POI records published from 2011 to 2023 were retrieved.Over the past few decades,the annual cumulative number of related articles has linearly increased,with China and the United States of America contributing prominently.All publications were from 59 countries and territories.China and the University of Bonn were the top contributing country and institution,respectively.Neurogastroenterology&Motility was the most prolific journal.The Journal of Gastrointestinal Surgery had the highest number of citations.Wehner Sven was the most productive author.Burst keywords(e.g.,colon,prolonged ileus,acupuncture,paralytic ileus,pathophysiology,rectal cancer,gastrointestinal function,risk)and a series of reference citation bursts provided evidence for the research frontiers in recent years.CONCLUSION This study demonstrates trends in the published literature on POI and provides new insights for researchers.It emphasizes the importance of multidisciplinary cooperation in the development of this field.

Chewing gum for postoperative ileus after colorectal surgery:A systematic review of overlapping meta-analyses

Background：Many meta-analyses investigating gum chewing for postoperative recovery after colorectal surgery have been published with inconsistent findings.Therefore,we performed this study to systematically review these overlapping meta-analyses and offer clinical recommendations based on the current best evidence for decision makers.Methods：Multiple databases,including PubMed,EMBASE,Cochrane Library,Chinese BioMedical Literature on disc（CBMdisc）,China National Knowledge Infrastructure（CNKI）,Chinese Wanfang and Chinese VIP,were searched through October 2016.We included meta-analyses investigating the effectiveness of chewing gum for postoperative ileus after colorectal resection.Two investigators independently scanned and evaluated eligible meta-analyses,extracted essential information,assessed the methodological quality with the Assessment of Multiple Systematic Reviews（AMSTAR） tool and Oxford Levels of Evidence,and used the Jadad decision algorithm at each step for all procedures.Heterogeneity ≤50%was accepted.Results：Ten meta-analyses were included in our study.The AMSTAR scores varied from 5 to 9,with a median of 7.7.Most heterogeneity fell into the acceptable range.After implementing the Jadad decision algorithm,two meta-analyses of RCTs were selected based on search strategies and the implications of selection.The available best evidence indicated that gum chewing significantly reduced time to first flatus,time to first bowel movement,time to first bowel sounds and length of hospital stay.However,these two meta-analyses reached inconsistent conclusions as to the complications and economic benefits.Conclusions：With the current best available evidence,we suggest gum chewing is beneficial for gastrointestinal function and reducing postoperative ileus.

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.

Pulmonary embolism after shoulder surgery:Is it a real threat?

Pulmonary embolism(PE)is a rare but devastating complication of shoulder surgery.Apart from increased morbidity and mortality rates,it may significantly impair postoperative recovery and functional outcome.Its frequency accounts for up to 5.7%of all shoulder surgery procedures with a higher occurrence in women and patients older than 70 years.It is most commonly associated with thrombophilia,diabetes mellitus,obesity,smoking,hypertension,and a history of malignancy.PE usually occurs secondary to upper or lower-extremity deep vein thrombosis(DVT).However,in rare cases,the source of the thrombi cannot be determined.Prophylaxis for PE following shoulder surgery remains a topic of debate,and the standard of care does not routinely require prophylactic medication for DVT prophylaxis.Early ambulation and elastic stockings are important preventative measures for DVT of the lower extremity and medical agents such as aspirin,low-molecular-weight heparin,and vitamin K antagonists are indicated for high-risk patients,long-lasting operations,or concomitant severe acute respiratory syndrome coronavirus 2 infection.The most common symptoms of PE include chest pain and shortness of breath,but PE can also be asymptomatic in patients with intrinsic tolerance of hypoxia.Patients with DVT may also present with swelling and pain of the respective extremity.The treatment of PE includes inpatient or outpatient anticoagulant therapy if the patient is hemodynamically unstable or stable,respectively.Hemodynamic instability may require transfer to the intensive care unit,and cardiovascular arrest can be implicated in fatal events.An important issue for patients with PE in the postoperative period after shoulder surgery is residual stiffness due to a delay in rehabilitation and a prolonged hospital stay.Early physiotherapy and range-of-motion exercises do not adversely affect the prognosis of PE and are highly recommended to preserve shoulder mobility and function.

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.

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.

Gallstone ileus,clinical presentation,diagnostic and treatment approach

Gallstone ileus is a mechanical intestinal obstruction due to gallstone impaction within the gastrointestinal tract. Less than 1% of cases of intestinal obstruction are derived from this etiology. The symptoms and signs of gallstone ileus are mostly nonspecific. This entity has been observed with a higher frequency among the elderly, the majority of which have concomitant medical illness. Cardiovascular, pulmonary, and metabolic diseases should be considered as they may affect the prognosis. Surgical relief of gastrointestinal obstruction remains the mainstay of operative treatment. The current surgical procedures are:(1) simple enterolithotomy;(2) enterolithotomy, cholecystectomy and fistula closure(one-stage procedure); and(3) enterolithotomy with cholecystectomy performed later(two-stage procedure). Bowel resection is necessary in certain cases after enterolithotomy is performed. Large prospective laparoscopic and endoscopic trials are expected.

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.

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.

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.

A prospective randomized trial of transnasal ileus tube vs nasogastric tube for adhesive small bowel obstruction

AIM:To study the therapeutic efficacy of a new transnasal ileus tube advanced endoscopically for adhesive small bowel obstruction.METHODS:A total of 186 patients with adhesive small bowel obstruction treated from September 2007 to February 2011 were enrolled into this prospective randomized controlled study.The endoscopically advanced new ileus tube was used for gastrointestinal decompression in 96 patients and ordinary nasogastric tube(NGT) was used in 90 patients.The therapeutic efficacy was compared between the two groups.RESULTS:Compared with the NGT group,the ileus tube group experienced significantly shorter time for relief of clinical symptoms and improvement in the findings of abdominal radiograph(4.1 ± 2.3 d vs 8.5 ± 5.0 d) and laboratory tests(P < 0.01).The overall effectiveness rate was up to 89.6% in the ileus tube group and 46.7% in the NGT group(P < 0.01).And 10.4% of the patients in the ileus tube group and 53.3% of the NGT group underwent surgery.For recurrent adhesive bowel obstruction,ileus tube was also significantly more effective than NGT(95.8% vs 31.6%).In the ileus tube group,the drainage output on the first day and the length of hospital stay were significantly different depending on the treatment success or failure(P < 0.05).The abdominal radiographic improvement was correlated with whether or not the patient underwent surgery.CONCLUSION:Ileus tube can be used for adhesive small bowel obstruction.Endoscopic placement of the ileus tube is convenient and worthy to be promoted despite the potential risks.

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.

Value of CT in the diagnosis and management of gallstone ileus

AIM:To retrospectively establish the diagnostic criteria of gallstone ileus on CT, and to prospectively apply these criteria to determine the diagnostic accuracy of CT to confirm or exclude gallstone ileus in patients who presented with acute small bowel obstruction (SBO). Another purpose was to ascertain whether the size of ectopic gallstones would affect treatment strategy. METHODS: Fourteen CT scans in cases of proved gallstone ileus were evaluated retrospectively by two radiologists for the presence or absence of previously reported CT findings to establish the diagnostic criteria. These criteria were applied in a prospective contrast enhanced CT study of 165 patients with acute SBO, which included those 14 cases of gallstone ileus. The hard copy images of 165 CT studies were reviewed by a different group of two radiologists but without previous knowledge of the patient's final diagnosis. All CT data were further analyzed to determine the diagnostic accuracy of gallstone ileus when using CT in prospective evaluation of acute SBO. The size of ectopic gallstone on CT was correlated with the clinical course. RESULTS: The diagnostic criteria of gallstone ileus on CT were established retrospectively, which included: (1) SBO; (2) ectopic gallstone; either rim-calcified or total-calcified; (3) abnormal gall bladder with complete air collection, presence of air-fluid level, or fluid accumulation with irregular wall. Prospectively, CT confirmed the diagnosis in 13 cases of gallstone ileus with these three criteria. Only one false negative case could be identified. The remaining 151 patients are true negative cases and no false positive case could be disclosed. The overall sensitivity, specificity and accuracy of CT in diagnosing gallstone ileus were 93%, 100%; and 99%, respectively. Surgical exploration was performed in 13 patients of gallstone ileus with ectopic stones sized larger than 3 cm. One patient recovered uneventfully following conservative treatment with an ectopic stone sized 2 cm in the long axis. CONCLUSION: Contrast enhanced CT imaging offered crucial evidence not only for the diagnosis of gallstone ileus but also for decision making in management strategy.

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.

Bouveret's syndrome complicated by a distal gallstone ileus

AIM:Gastric outlet obstruction caused by duodenal impaction of a large gallstone migrated through a cholecystoduodenal fistula has been referred as Bouveret's syndrome.Endoscopic lithotomy is the first-step treatment, however,surgery is indicated in case of failure or complication during this procedure. METHODS:We report herein an 84-year-old woman presenting with features of gastric outlet obstruction due to impacted gallstone.She underwent an endoscopic retrieval which was unsuccessful and was further complicated by distal gallstone ileus.Physical examination was irrelevant. RESULTS:Endoscopy revealed multiple erosions around the cardia,a large stone in the second part of the duodenum causing complete obstruction,and wide ulceration in the duodenal wall where the stone was impacted.Several attempts of endoscopic extraction by using foreign body forceps failed and surgical intervention was mandatory.Preoperative ultrasound evidenced pneumobilia whilst computerized tomography showed a large stone,5 cm×4 cm×3 cm,logging at the proximal jejunum and another one,2.5 cm×2 cm×2 cm, in the duodenal bulb causing a closed-loop syndrome.She underwent laparotomy and the jejunal stone was removed by enterotomy.Another stone reported as located in the duodenum preoperatively was found to be present in the gallbladder by intraoperative ultrasound.Therefore, cholecystoduodenal fistula was broken down,the stone was retrieved and cholecystectomy with duodenal repair was carried out.She was discharged after an uneventful postoperative course.CONCLUSION: As the simplest and the least morbid procedure, endoscopic stone retrieval should be attempted in the treatment of patients with Bouveret's syndrome.When it fails, surgical lithotomy consisting of simple enterotomy may solve the problem. Although cholecystectomy and cholecystoduodenal fistula breakdown is unnecessary

Three-year results of small incision lenticule extraction and wavefront-guided femtosecond laser-assisted laser in situ keratomileusis for correction of high myopia and myopic astigmatism

AIM： To compare and calculate the 3-year refractive results, higher-order aberrations （HOAs）, contrast sensitivity （CS） and dry eye parameters after small incision lenticule extraction （SMILE） and wavefront-guided femtosecond laser-assisted laser in situ keratomileusis （FS-LASIK） for correction of high myopia and myopic astigmatism. METHODS： In this prospective, non-randomized comparative study, 78 eyes with spherical equivalent （SE） of -8.11±1.09 diopters （D） received a SMILE surgery, and 65 eyes with SE of -8.05±1.12 D received a wavefront-guided FS-LASIK surgery with the VisuMax femtosecond laser （Carl Zeiss Meditec, Jena, Germany） for flap cutting. Visual acuity, manifest refraction, CS, HOAs, ocular surface disease index （OSDI） and tear break-up time （TBUT） were evaluated during a 3-year follow-up. RESULTS： The difference of uncorrected distance visual acuity （UDVA） postoperatively was achieved at lmo and at 3mo, whereas the difference of the mean UDVA between two groups at 3y were not statistically significant （t=-1.59, P=-0.13）. The postoperative change of SE was 0.89 D in the FS-LASIK group （t=5.76, P=0.00）, and 0.14 D in the SMILE group （t=-0.54, P=0.59） from lmo to 3y after surgery. At 3-year postoperatively, both HOAs and spherical aberrations in the SMILE group were obviously less than those in the FS-LASIK group （P=0.00）, but the coma root mean square （RMS） was higher in the SMILE group （0.59±0.26） than in the FS-LASIK group （0.29±0.14, P=0.00）. The mesopic CS values between two groups were not statistically significant at 3y postoperatively. Compared with the FS-LASIK group, lower OSDI scores and longer TBUT values were found in the SMILE group at Imo and 3mo postoperatively. With regard to safety, no eye lost any line of CDVA in both groups at 3y after surgery. CONCLUSION： Both SMILE and wavefront-guided FS- LASIK procedures provide good visual outcomes. Both procedures are effective and safe, but SMILE surgery achieve more stable long-term refractive outcome and better control of early postoperative dry eye as compared to FS-LASIK.