RESUMEN

The small bowel has a crucial role in metabolic homeostasis. Small bowel endoscopic bariatric metabolic treatments (EBMTs) include several devices aimed at providing minimally invasive approaches for the management of metabolic disorders. The aim of this review is to provide an updated and exhaustive overview of the EBMTs targeting the small bowel developed to date, including the duodenal mucosa resurfacing, the duodenal-jejunal bypass liners, gastro-jejunal bypass sleeve, and the incisioneless magnetic anastomosis system, as well as to mention the future perspectives in the field.

Asunto(s)

Cirugía Bariátrica , Intestino Delgado , Obesidad , Humanos , Cirugía Bariátrica/métodos , Obesidad/cirugía , Obesidad/complicaciones , Intestino Delgado/cirugía , Enfermedades Metabólicas/terapia , Endoscopía Gastrointestinal/métodos , Derivación Gástrica/métodos

RESUMEN

ABSTRACT: Transmesentric hernias are a type of internal hernia, in which there is herniation of bowel loops through a defect in the mesentery. They present with a wide variety of symptoms without any specific radiological features, leading to a delay in diagnosis and high mortality rate. Here, we present a case series of four patients with this rare but fatal cause of small bowel obstruction. Three children presented to the emergency department with small bowel obstruction. The other baby was a preterm neonate with an antenatal scan showing small bowel obstruction. All children underwent emergency laparotomy and were found to have a mesenteric defect with herniation and gangrene of the small bowel. Resection anastomosis of the gangrenous segment and closure of the mesenteric defect were done. The differential for small bowel obstruction in children should include transmesentric hernia. Laboratory or imaging investigations are often inconclusive. Timely exploration can save lives in this rare but life-threatening condition.

Asunto(s)

Obstrucción Intestinal , Laparotomía , Mesenterio , Humanos , Mesenterio/cirugía , Mesenterio/anomalías , Masculino , Obstrucción Intestinal/cirugía , Obstrucción Intestinal/etiología , Obstrucción Intestinal/diagnóstico , Femenino , Recién Nacido , Laparotomía/métodos , Lactante , Resultado Fatal , Intestino Delgado/cirugía , Diagnóstico Diferencial , Hernia Interna/cirugía , Hernia Interna/complicaciones , Hernia Interna/diagnóstico , Gangrena/cirugía , Gangrena/etiología , Hernia Abdominal/cirugía , Hernia Abdominal/diagnóstico , Hernia Abdominal/complicaciones , Hernia Abdominal/diagnóstico por imagen , Hernia Abdominal/congénito

RESUMEN

Enteric duplication has cystic and tubular varieties. A male infant presented with a large cystic, well-demarcated mass in the right flank. On exploratory laparotomy, multiple cystic and tubular lesions were present adjacent to the mesenteric border of the small bowel along with malrotation of the small bowel. The tubule-cystic structure was excised along with the involved normal bowel segment and Ladd's procedure was performed. Histopathological evaluation revealed an intestinal duplication cyst. The occurrence of midgut malrotation and volvulus along with duplication is uncommon. The cyst's substantial size could have been an aetiological factor for malrotation and volvulus. The child's small bowel had adapted remarkably with time. This case highlights a new variant of duplication cysts.

Asunto(s)

Vólvulo Intestinal , Humanos , Masculino , Lactante , Vólvulo Intestinal/cirugía , Vólvulo Intestinal/diagnóstico , Intestino Delgado/anomalías , Intestino Delgado/cirugía , Intestino Delgado/patología , Quistes/cirugía , Laparotomía/métodos , Anomalías del Sistema Digestivo/cirugía , Anomalías del Sistema Digestivo/complicaciones , Anomalías del Sistema Digestivo/diagnóstico por imagen

RESUMEN

RATIONALE: Small bowel volvulus (SBV) is a rare cause of acute abdominal pain in adults, which requires surgical intervention to prevent small bowel necrosis. Primary SBV is rare, and its preoperative diagnosis is challenging. This report describes a case of primary SBV diagnosed preoperatively and treated laparoscopically. PATIENT CONCERNS: A 56-year-old man presented complaining of sudden-onset abdominal pain of 3-hour duration. Physical examination revealed tenderness in periumbilical and upper abdominal regions with no signs of peritonitis. DIAGNOSIS: Contrast-enhanced computed tomography revealed a 360°-clockwise rotation of the small intestine when viewed caudally at the mesenteric base. At this region, the superior mesenteric vein was interrupted. Although no dilation of the small intestine was observed, increased density in the mesentery of the affected area was observed. Minimal ascites was observed in the pelvic cavity. No evidence of congenital or secondary SBV was observed, supporting the diagnosis of primary SBV. INTERVENTIONS: Laparoscopic detorsion of the SBV was performed approximately 6 hours after the onset of symptoms. No signs of bowel necrosis were observed, and the procedure was concluded after releasing the torsion. OUTCOMES: Severe abdominal pain disappeared immediately after surgery. The postoperative course was uneventful, and the patient was discharged on the 8th postoperative day. LESSONS: This case highlights the importance of preoperatively diagnosing SBV, which enables early laparoscopic devolvulation without bowel resection.

Asunto(s)

Vólvulo Intestinal , Intestino Delgado , Laparoscopía , Humanos , Vólvulo Intestinal/cirugía , Vólvulo Intestinal/diagnóstico , Masculino , Persona de Mediana Edad , Laparoscopía/métodos , Intestino Delgado/cirugía , Tomografía Computarizada por Rayos X , Dolor Abdominal/etiología , Dolor Abdominal/diagnóstico

RESUMEN

INTRODUCTION: Sufficient perfusion is essential for a safe intestinal anastomosis. Impaired microcirculation may lead to increased bacterial translocation and anastomosis insufficiency. Thus, it is important to estimate well the optimal distance of the anastomosis line from the last mesenterial vessel. However, it is still empiric. In this experiment the aim was to investigate the intestinal microcirculation at various distances from the anastomosis in a pig model. MATERIALS AND METHODS: On 8 anesthetized pigs paramedian laparotomy and end-to-end jejuno-jejunostomy were performed. Using Cytocam-IDF camera, microcirculatory recordings were taken before surgery at the planned suture line, and 1 to 3 mesenterial vessel mural trunk distance from it, and at the same sites 15 and 120 min after anastomosis completion. After the microcirculation monitoring, anastomosed and intact bowel segments were removed to test tensile strength. RESULTS: The proportion and the density of the perfused vessels decreased significantly after anastomosis completion. The perfusion rate increased gradually distal from the anastomosis, and after 120 min these values seemed to be normalized. Anastomosed bowels had significantly lower maximal tensile strength and higher slope of tensile strength curves than intact controls. CONCLUSION: Alterations in microcirculation and tensile strength were observed. After completing the anastomosis, the improvement in perfusion increased gradually away from the wound edge. The IDF device was useful to monitor intestinal microcirculation providing data to estimate better the optimal distance of the anastomosis from the last order mesenteric vessel.

Asunto(s)

Anastomosis Quirúrgica , Microcirculación , Modelos Animales , Sus scrofa , Resistencia a la Tracción , Animales , Factores de Tiempo , Yeyunostomía , Flujo Sanguíneo Regional , Yeyuno/irrigación sanguínea , Yeyuno/cirugía , Velocidad del Flujo Sanguíneo , Intestino Delgado/irrigación sanguínea , Intestino Delgado/cirugía , Femenino

RESUMEN

BACKGROUND: Tailoring the biliopancreatic limb length in one anastomosis gastric bypass is proposed as beneficial in retrospective studies, yet randomized trials are lacking. The aim of this double-blind, single-centre RCT was to ascertain whether tailoring biliopancreatic limb length based on total small bowel length (TSBL) results in superior outcomes after one anastomosis gastric bypass compared with a fixed 150 cm biliopancreatic limb length. METHODS: Eligible patients, meeting International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) criteria for metabolic bariatric surgery, scheduled for primary one anastomosis gastric bypass surgery, and willing to be randomized, underwent TSBL measurement during surgery. When TSBL measurement was feasible, patients were randomly assigned to a standard 150 cm biliopancreatic limb length or a tailored biliopancreatic limb based on TSBL: TSBL less than 500 cm, biliopancreatic limb 150 cm; TSBL 500-700 cm, biliopancreatic limb 180 cm; and TSBL greater than 700 cm, biliopancreatic limb 210 cm. The primary outcome was percentage total weight loss at 5 years. RESULTS: Between September 2020 and August 2022, 212 patients were randomized into the standard biliopancreatic limb group (105 patients) or the tailored biliopancreatic limb group (107 patients). The mean(s.d.) TSBL was 657(128) cm (range 295-1020 cm). In the tailored group, 150, 180, and 210 cm biliopancreatic limb lengths were applied to 8.4%, 53.3%, and 38.3% of patients respectively. The mean(s.d.) 1-year percentage total weight loss was 32.8(6.9)% in the standard group and 33.1(6.2)% in the tailored group (P = 0.787). Nutritional deficiencies and short-term complications showed no significant differences. CONCLUSION: Tailoring biliopancreatic limb length based on TSBL is safe and feasible. One year after surgery, it is not superior to a standard biliopancreatic limb length of 150 cm in terms of percentage total weight loss. REGISTRATION NUMBER: Dutch Trial Register, NL7945.

Asunto(s)

Derivación Gástrica , Intestino Delgado , Pérdida de Peso , Humanos , Derivación Gástrica/métodos , Masculino , Método Doble Ciego , Femenino , Adulto , Persona de Mediana Edad , Intestino Delgado/cirugía , Obesidad Mórbida/cirugía , Anastomosis Quirúrgica/métodos , Resultado del Tratamiento , Páncreas/cirugía

RESUMEN

Abdominal adhesions manifests following abdominal infections triggered by intestinal fistulas. The severity of such adhesions depends on the extent of fiber deposition and peritoneal fibrinolysis following peritoneal injury, which may be influenced by sustained inflammation within the abdominal cavity. In this regard, the visceral-to-subcutaneous fat area (VFA/SFA) ratio has been implicated as a potential marker of inflammation. This study aimed to explore the relationship between VFA/SFA and abdominal adhesions. This multicenter study was conducted across four tertiary institutions and involved patients who had undergone definitive surgery (DS) for intestinal fistula from January 2009 and October 2023. The presence of abdominal adhesions was determined intraoperatively. VFA/SFA was investigated as a potential risk factor for severe adhesions. The study comprised 414 patients with a median age of 50 [interquartile range (IQR) 35-66] years and a median body mass index of 20.0 (IQR 19.2-22.4) kg/m2, including 231 males with a median VFA/SFA of 1.0 (IQR 0.7-1.2) and 183 females a median VFA/SFA of 0.8 (0.6-1.1). VFA/SFA was associated with severe abdominal adhesions in males [odds ratio (OR) = 3.34, 95% CI 1.14-9.80, p = 0.03] and females (OR = 2.99, 95% CI 1.05-8.53, p = 0.04). J-shaped association between VFA/SFA ratio and severe adhesions was revealed in both sex. The increasing trend can be revealed when OR more than 0.8, and 0.6 in males and females respectively. Preoperative VFA/SFA demonstrates predictive value for statues of severe abdominal adhesions in DS for anastomotic fistula after small intestine resection.

Asunto(s)

Fístula Intestinal , Intestino Delgado , Grasa Intraabdominal , Grasa Subcutánea , Humanos , Masculino , Femenino , Adherencias Tisulares/etiología , Adherencias Tisulares/patología , Persona de Mediana Edad , Anciano , Adulto , Intestino Delgado/cirugía , Intestino Delgado/patología , Grasa Subcutánea/patología , Fístula Intestinal/etiología , Fístula Intestinal/cirugía , Complicaciones Posoperatorias/etiología , Factores de Riesgo

RESUMEN

INTRODUCTION: This study aimed to clarify the validity of laparoscopic surgery for lower gastrointestinal perforation by comparing the clinical outcomes of laparoscopic and open emergency surgery. METHODS: We reviewed the data of patients who underwent surgery for lower gastrointestinal perforation. Patients were categorized into two groups: the laparoscopic group who underwent laparoscopic surgery, and the open group who underwent laparotomy. Clinical and operative outcomes between the two groups were evaluated. RESULTS: A total of 219 patients were included in the study. There were 66 and 153 patients with small bowel and colorectal perforations, respectively. The median operative time in the laparoscopic group was shorter than that in the open group (126 min vs. 146 min, p = .049). The mean amount of intraoperative blood loss was significantly lower in the laparoscopic group (50.4 mL vs. 400.1 mL, p < .001). The incidence of postoperative complication was higher in the open group (20.0% vs. 66.5%, p < .001), especially wound infection (0% vs. 26.3%, p = .002). Median hospital stays were 14 days and 24 days in the laparoscopic and open groups, respectively (p < .001). In the laparoscopic group, hospital mortality was 0%. CONCLUSIONS: The laparoscopic approach for small bowel and colorectal perforation in an emergency setting is a safe procedure in carefully selected patients and may contribute to decreased intraoperative blood loss, shortened hospital stay, and decreased incidence of postoperative complications, especially wound infection.

Asunto(s)

Perforación Intestinal , Laparoscopía , Humanos , Laparoscopía/efectos adversos , Perforación Intestinal/cirugía , Perforación Intestinal/etiología , Femenino , Masculino , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Adulto , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiología , Tempo Operativo , Tiempo de Internación/estadística & datos numéricos , Anciano de 80 o más Años , Intestino Delgado/cirugía , Intestino Delgado/lesiones , Laparotomía

RESUMEN

BACKGROUND: High-output intestinal fistulas and small bowel enterostomies are associated with morbidity and mortality. Current standard treatment for output reduction consists of fluid and dietary restrictions and medical therapy. There is conflicting evidence regarding the use of somatostatin analogues for output reduction. AIM: The aim of this study is to investigate whether lanreotide, added to current standard treatment, further reduces intestinal output in patients with high-output fistulas and enterostomies. METHODS: This was an open-label, multicentre, randomised controlled trial. Adult patients with a high-output intestinal fistula (>500 mL/24 h) or small bowel enterostomy (>1500 mL/24 h) more than 4 weeks post-surgery and receiving standard medical treatment (dietary- and fluid restriction, PPI, loperamide and codeine) for at least 2 weeks were eligible for inclusion. We randomised patients 1:1 between continuing standard treatment (control), and subcutaneous lanreotide 120 mg every 4 weeks with standard treatment. The primary outcome was the number of responders, with response defined as an output reduction of ≥25%, 8 weeks after randomisation. We also investigated the proportional change in output. RESULTS: We randomised 40 patients; 17 had a fistula and 23 a small bowel enterostomy. There were 9/20 responders in the intervention group and 2/20 in the control group (p = 0.013). The proportional output reduction was -26% (IQR -4 to -38) in the intervention group, compared to an increase of 4% (IQR 20 to -13) in the control group (p = 0.004). CONCLUSIONS: In patients with a high-output fistula or small bowel enterostomy, addition of lanreotide to current standard treatment can provide a clinically relevant output reduction. TRIAL REGISTRATION: EudraCT: 2013-003998-10.

Asunto(s)

Enterostomía , Fístula Intestinal , Intestino Delgado , Péptidos Cíclicos , Somatostatina , Humanos , Somatostatina/análogos & derivados , Somatostatina/uso terapéutico , Masculino , Femenino , Persona de Mediana Edad , Anciano , Péptidos Cíclicos/uso terapéutico , Péptidos Cíclicos/administración & dosificación , Enterostomía/métodos , Resultado del Tratamiento , Intestino Delgado/cirugía , Adulto , Fístula Intestinal/tratamiento farmacológico , Fármacos Gastrointestinales/uso terapéutico

RESUMEN

Recurrence within one or two years is common after Crohn's disease (CD) resection. In this study, we seek to identify histologic features in CD resections that may predict earlier (≤18 months) recurrence to potentially guide post-operative management. A single-institution, retrospective review was performed on patients with first-time CD bowel resection specimens (2002-2007). Patient demographics and CD course were also documented. Slides were reviewed for inflammatory distribution and composition, small bowel (SB) pyloric metaplasia (PM), and presence and characteristics of submucosal fibrosis and granulomas. In our cohort, 14 of 41 patients experienced earlier clinical or endoscopic recurrence after initial resection. In the 38 patients who underwent SB resection (3 were colon only), PM was less common in those with earlier recurrence (6/12 [50%]) compared to those with later (>18 months) or no known recurrence (22/26 [85%]) (P = 0.045). PM was present even in patients with <1 year of known CD. Additionally, therapy with anti-tumor necrosis factor (TNF) prior to surgery was more common in earlier recurrence patients (7/14 [50%]) than later or no recurrence patients (4/27 [15%]) (P = 0.026). There was no significant difference in age, sex, smoking status, duration of CD, post-operative CD medication, distribution or features of inflammation, granulomas, or fibrosis. Overall, our results indicate that SB PM and pre-surgical anti-TNF therapy are possible helpful clinicopathologic features to evaluate for recurrence risk.

Asunto(s)

Enfermedad de Crohn , Intestino Delgado , Metaplasia , Recurrencia , Humanos , Enfermedad de Crohn/patología , Enfermedad de Crohn/cirugía , Masculino , Femenino , Estudios Retrospectivos , Metaplasia/patología , Adulto , Persona de Mediana Edad , Intestino Delgado/patología , Intestino Delgado/cirugía , Adulto Joven , Factores de Riesgo , Adolescente , Factores de Tiempo , Fibrosis/patología , Anciano

RESUMEN

Motorized spiral enteroscopy (MSE) enhances small bowel exploration, but the optimal target population for this technique is unknown. We aimed to identify the target population for MSE by evaluating its efficacy and safety, as well as detecting predictors of efficacy. A prospective multicenter observational study was conducted at 9 tertiary hospitals in Spain, enrolling patients between June 2020-2022. Analyzed data included demographics, indications for the procedure, exploration time, depth of maximum insertion (DMI), technical success, diagnostic yield, interventional yield, and adverse events (AE) up to 14 days from enteroscopy. Patients with prior gastrointestinal surgery, unsuccessful balloon enteroscopy and small bowel strictures were analyzed. A total of 326 enteroscopies (66.6% oral route) were performed in 294 patients (55.1% males, 65 years ± 21). Prior abdominal surgery was present in 50% of procedures (13.5% gastrointestinal surgery). Lower DMI (162 vs 275 cm, p = 0.037) and diagnostic yield (47.7 vs 67.5%, p = 0.016) were observed in patients with prior gastrointestinal surgery. MSE showed 92.2% technical success and 56.9% diagnostic yield after unsuccessful balloon enteroscopy (n = 51). In suspected small bowel strictures (n = 49), the finding was confirmed in 23 procedures (46.9%). The total AE rate was 10.7% (1.8% classified as major events) with no differences related to prior gastrointestinal/abdominal surgery, unsuccessful enteroscopy, or suspected small bowel strictures. The study demonstrates that MSE has a lower diagnostic yield and DMI in patients with prior gastrointestinal surgery but is feasible after unsuccessful balloon-enteroscopy and in suspected small bowel strictures without safety concerns.

Asunto(s)

Endoscopía Gastrointestinal , Intestino Delgado , Humanos , Masculino , Femenino , Anciano , Estudios Prospectivos , Persona de Mediana Edad , Endoscopía Gastrointestinal/métodos , Endoscopía Gastrointestinal/efectos adversos , Intestino Delgado/cirugía , Intestino Delgado/diagnóstico por imagen , España , Anciano de 80 o más Años , Adulto

RESUMEN

Transvaginal organ prolapse, such as small bowel evisceration, is a rare complication after radical cystectomy (RC) in female patients with invasive bladder cancer, However, it often requires emergency surgical repair. Here, we describe our experience with such a case and a review of similar previously reported cases, along with evaluation of the risk factors. We also propose a vaginal reconstruction technique to prevent this complication during robot-assisted laparoscopic radical cystectomy (RARC). A total of 178 patients who underwent laparoscopic radical cystectomy (LRC) or RARC were enrolled, 34 of whom (19%) were female. One of the 34 female patients had transvaginal small bowel evisceration after RARC. We evaluated our case and six such previously reported cases, to determine vaginal reconstruction techniques during RARC to prevent this complication postoperatively. Median age of these cases was 73 (51-80) years, and all patients were postmenopausal. The median time to small bowel evisceration was 14 (6-120) weeks postoperatively. In addition, we changed the methods of the vaginal reconstruction technique during RARC from the conventional side-to-side closure technique to the improved caudal-to-cephalad closure technique. Since implementing this change, we have not experienced any cases of vaginal vault dehiscence or organ prolapse. Transvaginal small bowel evisceration after RC can easily become severe. Therefore, all possible preventive measures should be taken during RARC. We believe that our vaginal reconstruction techniques might reduce the risk of developing this complication.

Asunto(s)

Cistectomía , Intestino Delgado , Procedimientos de Cirugía Plástica , Complicaciones Posoperatorias , Procedimientos Quirúrgicos Robotizados , Neoplasias de la Vejiga Urinaria , Vagina , Humanos , Femenino , Cistectomía/métodos , Cistectomía/efectos adversos , Procedimientos Quirúrgicos Robotizados/métodos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Persona de Mediana Edad , Factores de Riesgo , Anciano , Intestino Delgado/cirugía , Vagina/cirugía , Neoplasias de la Vejiga Urinaria/cirugía , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Procedimientos de Cirugía Plástica/métodos , Procedimientos de Cirugía Plástica/efectos adversos , Anciano de 80 o más Años , Dehiscencia de la Herida Operatoria/prevención & control , Dehiscencia de la Herida Operatoria/etiología , Laparoscopía/métodos , Laparoscopía/efectos adversos

RESUMEN

Optimal treatment for adhesive small bowel obstruction (SBO) is not defined. Surgery is the only method of treatment for obvious strangulating SBO. Non-operative management (NOM) is widely used among patients with low risk of strangulation, i.e. no clinical, laboratory and CT signs. Randomized controlled trials (RCTs) are recommended to determine the optimal method (early intervention or NOM), but their safety is unclear due to possible delay in surgery for patients needing early intervention. MATERIAL AND METHODS: A RCT is devoted to outcomes of early operative treatment and NOM for adhesive SBO. The estimated trial capacity is 200 patients. Thirty-two patients were included in interim analysis. In 12 hours after admission, patients without apparent signs of strangulation were randomized into two clinical groups after conservative treatment. Group I included 12 patients who underwent immediate surgery, group II - 20 patients after 48-hour NOM. The primary endpoint was success of non-surgical regression of SBO and reduction in mortality. To evaluate patient safety, we analyzed mortality, complication rates and bowel resection in this RCT with previously published studies. RESULTS: In group I, all 12 (100%) patients underwent surgery. Only 4 (20%) patients required surgery in group II. Mortality, complication rates and bowel resection rates were similar in both groups. Strangulating SBO was found in 8 (25%) patients. Overall mortality was 6.3%, bowel resection rate - 6.3%, iatrogenic perforation occurred in 3 (18.8%) patients. These values did not exceed previous findings. CONCLUSION: Non-operative management within 48 hours prevented surgery in 80% of patients with SBO. Interim analysis found no significant between-group differences in mortality, complication rates and bowel resection rate. Patients had not been exposed to greater danger than other patients with adhesive SBO. The study is ongoing.

Asunto(s)

Tratamiento Conservador , Obstrucción Intestinal , Intestino Delgado , Humanos , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Obstrucción Intestinal/terapia , Masculino , Femenino , Tratamiento Conservador/métodos , Tratamiento Conservador/estadística & datos numéricos , Intestino Delgado/cirugía , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Adulto , Anciano , Resultado del Tratamiento , Tiempo de Tratamiento/estadística & datos numéricos , Adherencias Tisulares , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Federación de Rusia/epidemiología

RESUMEN

BACKGROUND: Anastomotic leakage (AL) is a dreaded complication following colorectal cancer surgery, impacting patient outcome and leads to increasing healthcare consumption as well as economic burden. Bowel perfusion is a significant modifiable factor for anastomotic healing and thus crucial for reducing AL. AIMS: The study aimed to calculate a cut-off value for quantified laser speckle perfusion units (LSPUs) in order to differentiate between ischemic and well-perfused tissue and to assess inter-observer reliability. METHODS: LSCI was performed using a porcine ischemic small bowel loop model with the PerfusiX-Imaging® system. An ischemic area, a well-perfused area, and watershed areas, were selected based on the LSCI colormap. Subsequently, local capillary lactate (LCL) levels were measured. A logarithmic curve estimation tested the correlation between LSPU and LCL levels. A cut-off value for LSPU and lactate was calculated, based on anatomically ischemic and well-perfused tissue. Inter-observer variability analysis was performed with 10 observers. RESULTS: Directly after ligation of the mesenteric arteries, differences in LSPU values between ischemic and well-perfused tissue were significant (p < 0.001) and increased significantly throughout all following measurements. LCL levels were significantly different (p < 0.001) at both 60 and 120 min. Logarithmic curve estimation showed an R2 value of 0.56 between LSPU and LCL values. A LSPU cut-off value was determined at 69, with a sensitivity of 0.94 and specificity of 0.87. A LCL cut-off value of 3.8 mmol/L was found, with a sensitivity and specificity of 0.97 and 1.0, respectively. There was no difference in assessment between experienced and unexperienced observers. Cohen's Kappa values were moderate to good (0.52-0.66). CONCLUSION: Real-time quantification of LSPUs may be a feasible intraoperative method to assess tissue perfusion and a cut-off value could be determined with high sensitivity and specificity. Inter-observer variability was moderate to good, irrespective of prior experience with the technique.

Asunto(s)

Isquemia , Laparoscopía , Imágenes de Contraste de Punto Láser , Animales , Laparoscopía/métodos , Porcinos , Isquemia/etiología , Isquemia/diagnóstico por imagen , Imágenes de Contraste de Punto Láser/métodos , Fuga Anastomótica/diagnóstico por imagen , Fuga Anastomótica/etiología , Modelos Animales de Enfermedad , Intestino Delgado/irrigación sanguínea , Intestino Delgado/cirugía , Intestino Delgado/diagnóstico por imagen , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Ácido Láctico/metabolismo

RESUMEN

BACKGROUND: Acute small intestinal obstruction is a common surgical emergency in the sub-Saharan region. Over the decades, complicated inguinal hernias have been identified as a leading cause. However, we observed from our clinical practice that complicated inguinal hernias were not the most common etiology. AIMS AND OBJECTIVES: This study aimed to evaluate the common etiology of acute small bowel obstruction in the study center and compare our findings with that from other centers and existing literature. MATERIALS AND METHODS: This was a retrospective, cross sectional study carried out over a period of five years (January 2017 to December 2021). This study looked at the patients presenting with acute, mechanical, small bowel obstruction that did not respond to conservative treatment in our hospital facility. Relevant information were extracted from patients' clinical details and entered into the proforma prepared for this study. RESULTS: A total of 147 patients were recruited into this study out of which 85(57.8%) were males and 62 (42.2%) were females (M:F=1.44:1). Majority (80.3%) of the patients that presented with post-operative bowel adhesion had previous appendectomy. Simple bowel obstruction was seen in 93 (63.3%) patients while strangulated obstruction and gangrenous bowel were seen in 26 (17.7%) patients and 22 (15.0%) patients respectively. Majority (47.6%) of the patients had adhesiolysis done while others had bowel resection. CONCLUSION: The common cause of acute small bowel obstruction as observed in this study is post-operative adhesions arising from previous appendectomy and laparotomies.

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Résumé Contexte:Une faible obstruction intestinale a une urgence chirurgicale commune dans la région sub-saharienne. Au cours des décennies, des hernies inguiniques compliquées ont été identifiées comme une cause de premier plan. Cependant, nous avons observé de notre pratique clinique selon laquelle des hernies inguinales compliquées n'étaient pas l'étiologie la plus commune.Objectifs et objectifs:Cette étude visait à évaluer l'étiologie commune de l'obstruction aiguë aux petites interses dans le centre d'études et de comparer nos constatations avec celle d'autres centres et de la littérature existante.Matériaux et méthodes:C'était une étude rétrospective en coupe transversale réalisée sur une période de cinq ans (janvier 2017 à 2021). Cette étude a examiné les patients présentant une obstruction aiguë, mécanique et petite intestinale qui ne répondait pas au traitement conservateur dans notre installation hospitalière. Des informations pertinentes ont été extraites des détails cliniques des patients et ont conclu dans la proforma préparé pour cette étude.Résultats:Un total de 147 patients ont été recrutés dans cette étude dont 85 (57,8%) étaient des hommes et 62 (42,2%) étaient des femelles (M: F = 1.44: 1). La majorité (80,3%) des patients présentés par l'adhésion intestinale post-opératoire avaient une annexe antérieure. Un obstruction d'intestin simples a été observée dans des patients de 93 (63,3%) alors que l'obstruction étrangère et l'intestin gangreneux ont été observés dans des patients de 26 (17,7%) et respectivement respectivement les patients de 22 (15,0%). La majorité (47,6%) des patients avaient une adhésiose faite pendant que d'autres avaient une résection de l'intestin.Conclusion:La cause commune de l'obstruction aiguë aux petites interses comme observé dans cette étude est des adhérences post-opératoires découlant de l'appendecectomie et des laparotomies précédentes.

Asunto(s)

Obstrucción Intestinal , Intestino Delgado , Humanos , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Masculino , Femenino , Nigeria/epidemiología , Estudios Retrospectivos , Estudios Transversales , Adulto , Intestino Delgado/cirugía , Intestino Delgado/patología , Persona de Mediana Edad , Anciano , Enfermedad Aguda , Apendicectomía , Adolescente , Adulto Joven , Adherencias Tisulares/cirugía , Adherencias Tisulares/complicaciones , Hernia Inguinal/cirugía , Hernia Inguinal/complicaciones , Complicaciones Posoperatorias/epidemiología

RESUMEN

INTRODUCTION: Despite advances in medical therapy, approximately 33% of Crohn's disease (CD) patients will need surgery within 5 years after initial diagnosis. Several surgical approaches to CD have been proposed including small bowel resection, strictureplasty, and combined surgery with resection plus strictureplasty. Here, we utilize the American College of Surgeons (ACS) national surgical quality registry (NSQIP) to perform a comprehensive analysis of 30-day outcomes between these three surgical approaches for CD. METHODS: The authors queried the ACS-NSQIP database between 2015 and 2020 for all patients undergoing open or laparoscopic resection of small bowel or strictureplasty for CD using CPT and IC-CM 10. Outcomes of interest included length of stay, discharge disposition, wound complications, 30-day related readmission, and reoperation. RESULTS: A total of 2578 patients were identified; 87% of patients underwent small bowel resection, 5% resection with strictureplasty, and 8% strictureplasty alone. Resection plus strictureplasty (combined surgery) was associated with the longest operative time (p = 0.002). Patients undergoing small bowel resection had the longest length of hospital stay (p = 0.030) and the highest incidence of superficial/deep wound infection (44%, p = 0.003) as well as the highest incidence of sepsis (3.5%, p = 0.03). Small bowel resection was found to be associated with higher odds of wound complication compared to combined surgery (OR 2.09, p = 0.024) and strictureplasty (1.9, p = 0.005). CONCLUSION: Our study shows that various surgical approaches for CD are associated with comparable outcomes in 30-day related reoperation and readmission, or disposition following surgery between all three surgical approaches. However, small bowel resection displayed higher odds of developing post-operative wound complications.

Asunto(s)

Enfermedad de Crohn , Intestino Delgado , Humanos , Enfermedad de Crohn/cirugía , Intestino Delgado/cirugía , Intestino Delgado/patología , Estudios Retrospectivos , Resultado del Tratamiento , Masculino , Femenino , Adulto , Tiempo de Internación , Complicaciones Posoperatorias/etiología , Readmisión del Paciente , Reoperación , Persona de Mediana Edad , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Sistema de Registros

RESUMEN

A 46-year-old man presented with a small bowel prolapsing through the anus after straining on the toilet, which was starting to become ischaemic. He admitted to inserting a plastic object in his rectum about half an hour before straining. The bowel was kept moist by placing an intravenous drip line with saline dripping onto a wet swab. In theatre, the bowel was found to be prolapsing through a hole in the upper rectum and out through the anus. It was reduced back into the abdominal cavity through the same perforation, which was 4 cm long, without needing to extend it. This was sutured with polydioxanone (PDS) 2-0 as there was no contamination with faeces or pus. Due to improvement in the appearance of a small bowel and an extremely bruised mesentery, a re-look was planned in 24 hours. At the re-look the small bowel appeared healthy, therefore no resection was performed. However, a loop colostomy was fashioned to protect the upper rectal perforation repair. This shows that resection is not always required in such cases.

Asunto(s)

Intestino Delgado , Humanos , Masculino , Persona de Mediana Edad , Intestino Delgado/cirugía , Perforación Intestinal/cirugía , Perforación Intestinal/etiología , Colostomía/métodos , Recto/cirugía , Prolapso Rectal/cirugía , Canal Anal/cirugía

RESUMEN

OBJECTIVE: Small bowel obstruction (SBO) is a common and important surgical emergency. Our aim in this study is to describe the clinical, laboratory, and computed tomography (CT) findings to facilitate the objective identification of SBO patients in need of operative treatment in this patient population. METHODS: This retrospective study included 340 patients hospitalized due to a preliminary diagnosis of ileus. Retrieved data of patients included age, gender, comorbidities, previous hospitalization due to ileus, surgical history, physical examination findings, complete blood count and biochemistry test results, and CT findings at admission. RESULTS: The study included 180 (52.9%) male and 160 (47.1%) female patients. Treatment was conservative in 216 patients and surgery in 124 patients. Of the patients included in the study, 36.4% needed surgery. Of the female patients, 38.90% received conservative treatment and 61.30% underwent surgery. Adhesions were the most common cause of obstruction in operated patients (43.50%). CONCLUSION: We have found that female gender, vomiting, guarding, rebound, C-reactive protein levels above 75 mg/L, increased bowel diameter, and a transition zone on CT images indicate a strong need for surgery, but a history of previous hospitalization for ileus may show that surgery may not be the best option.

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OBJETIVO: Describir los hallazgos clínicos, de laboratorio y de tomografía computarizada (TC) para facilitar la identificación objetiva de los pacientes con obstrucción del intestino delgado que necesitan tratamiento quirúrgico. MÉTODO: Este estudio incluyó 340 pacientes. Los datos obtenidos fueron edad, sexo, comorbilidad, hospitalización previa debida a íleo, historia quirúrgica, hallazgos de la exploración física, hemograma completo y resultados de las pruebas bioquímicas, y hallazgos de la TC al ingreso. RESULTADOS: El estudio incluyó 180 (52.9%) varones y 160 (47.1%) mujeres. El tratamiento fue conservador en 216 pacientes y quirúrgico en 124 pacientes. De los pacientes incluidos en el estudio, el 36.4% necesitaron cirugía. De las mujeres, el 38.90% recibieron tratamiento conservador y el 61.30% se sometieron a cirugía. CONCLUSIONES: Encontramos que el sexo femenino, los vómitos, la guardia, el rebote, los niveles de proteína C reactiva superiores a 75 mg/l, el aumento del diámetro intestinal y una zona de transición en las imágenes de TC indican una fuerte necesidad de cirugía.

Asunto(s)

Obstrucción Intestinal , Intestino Delgado , Tomografía Computarizada por Rayos X , Humanos , Femenino , Masculino , Estudios Retrospectivos , Persona de Mediana Edad , Anciano , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Obstrucción Intestinal/diagnóstico por imagen , Intestino Delgado/diagnóstico por imagen , Intestino Delgado/cirugía , Adulto , Anciano de 80 o más Años , Ileus/etiología , Ileus/diagnóstico por imagen , Proteína C-Reactiva/análisis , Tratamiento Conservador , Adherencias Tisulares/diagnóstico por imagen , Adherencias Tisulares/complicaciones , Adherencias Tisulares/cirugía , Adulto Joven

RESUMEN

RATIONALE: The mesodiverticular band (MDB) of a Meckel's diverticulum (MD) is a rare, yet notable etiology of small bowel obstruction (SBO) in adults. Due to the nonspecific symptoms and challenging diagnosis thereof, preoperative clinical suspicion and strategic management are crucial for achieving optimal outcomes. Therefore, we presented a case in which laparoscopic surgery was strategically performed to alleviate ileus, due to a preoperative diagnosis of SBO, suspected to be secondary to an MD with a concomitant MDB. PATIENT CONCERNS: A 32-year-old male patient presented with a half-day's duration of epigastric pain, abdominal distension, and tenderness, resulting in the working diagnosis of SBO. DIAGNOSES: Initial non-contrast computed tomography (CT) revealed SBO without signs of strangulation, postulated to be caused by an MD and concomitant MDB, resulting in conservative management. The symptoms persisted, necessitating contrast-enhanced CT. However, the dilated bowel loop suggestive of an MD that had been observed on non-contrast CT could not be confirmed on contrast-enhanced CT. INTERVENTIONS: Decompression therapy using a long tube provided minimal relief, prompting laparoscopic surgery on the 5th day post-admission for diagnostic and therapeutic purposes. OUTCOMES: An MD resection effectively relieved the SBO. The histopathological analysis revealed a true diverticulum with ectopic pancreatic tissue, confirming the diagnosis of an MD. At the band site, vascular and neural structures were encased in a sheath, consistent with the remnants of the vitelline duct mesentery; and histopathologically diagnosed as an MDB. The postoperative course was uneventful, and the patient was discharged on the 9th day, postoperatively. LESSONS: Decompression therapy and strategic laparoscopic surgery based on the preoperative working diagnosis of SBO yielded favorable outcomes, highlighting the importance of the early clinical suspicion of an MD and a concomitant MDB, as the etiology of SBO. The imaging variability and rarity of an MD in adults emphasizes the need for a heightened awareness and an accurate diagnosis for optimal management. Early intervention should be deliberated for patients with suspected intestinal ischemia. However, this case accentuates the clinical implications of strategic planning and employing minimally invasive techniques in the management of an MD-related SBO in adults.

Asunto(s)

Obstrucción Intestinal , Intestino Delgado , Laparoscopía , Divertículo Ileal , Humanos , Divertículo Ileal/cirugía , Divertículo Ileal/complicaciones , Divertículo Ileal/diagnóstico , Adulto , Masculino , Laparoscopía/métodos , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Intestino Delgado/cirugía , Tomografía Computarizada por Rayos X

RESUMEN

OBJECTIVES: Single-balloon enteroscopy (SBE) is an effective tool for the detection of small intestine lesions. Because it is conventionally performed by two operators, the efficacy of single-operator SBE method has not yet been elucidated. We aimed to evaluate the diagnostic yield, total enteroscopy rate, procedure time, and complications of single-operator SBE for small intestinal disease. METHODS: This was a single-center, retrospective study including consecutive patients who underwent single-operator SBE for suspicious small intestinal disorders or required therapeutic interventions between December 2014 and January 2019. The SBE procedures were performed by four endoscopists. Diagnostic yield, total enteroscopy rate, procedure time, incubation depth, and complications were analyzed, and stratification analysis was performed. RESULTS: Altogether 922 patients with 1422 SBE procedures were included for analysis, among whom 250, 172, and 500 patients underwent SBE via the oral route, the anal route and a combined route, respectively. The overall diagnostic yield was 78.52% (724/922). And 253 patients achieved total enteroscopy, with a total enteroscopy rate of 56.10%. The average procedure time for the oral and anal routes were 69.28 ± 14.72 min and 64.95 ± 13.87 min, respectively. While the incubation depth was 389.95 ± 131.42 cm and 191.81 ± 83.67 cm, respectively. Jejunal perforation was observed in one patient, which was managed by endoclips. Stratification analysis showed that the diagnostic yield and total enteroscopy rate significantly increased with operation experience together with decreased procedure time. CONCLUSION: Single-operator SBE is effective and safe for the detection of small intestinal lesions, and is easy to master.

Asunto(s)

Enfermedades Intestinales , Intestino Delgado , Enteroscopia de Balón Individual , Humanos , Estudios Retrospectivos , Masculino , Femenino , Enteroscopia de Balón Individual/métodos , Persona de Mediana Edad , Adulto , Intestino Delgado/diagnóstico por imagen , Intestino Delgado/cirugía , Enfermedades Intestinales/diagnóstico , Enfermedades Intestinales/diagnóstico por imagen , Anciano