Enhancing thromboprophylaxis after colorectal cancer surgery in China: Bridging the gap between evidence and implementation through pathway optimization.

BACKGROUND: The CRC-VTE trial conducted in China revealed a significant occurrence of venous thromboembolism (VTE) in patients following colorectal cancer (CRC) surgery, raising concerns about implementing thromboprophylaxis measures. The present study aimed to identify and analyze inappropriate aspects of current thromboprophylaxis practices. METHODS: This study performed an analysis of the CRC-VTE trial, a prospective multicenter study that enrolled 1836 patients who underwent CRC surgery. The primary objective was to identify independent risk factors for VTE after CRC surgery using multivariate logistic regression analysis. Furthermore, among the cases in which VTE occurred, the appropriateness of thromboprophylaxis was assessed based on several factors, including pharmacologic prophylaxis, time to initiate prophylaxis, drug selection, drug dosage, and duration of pharmacologic prophylaxis. Based on the analysis of the current state of thromboprophylaxis and relevant clinical guidelines, a modified Delphi method was used to develop a clinical pathway for VTE prophylaxis after CRC surgery. RESULTS: In this analysis of 1836 patients, 205 (11.2%) were diagnosed with VTE during follow-up. The multifactorial analysis identified several independent risk factors for VTE, including age (≥70 years), female sex, varicose veins in the lower extremities, intraoperative blood transfusion, and the duration of immobilization exceeding 24 h. None of the patients diagnosed with VTE in the CRC trial received adequate thromboprophylaxis. The main reasons for this inappropriate practice were the omission of thromboprophylaxis, delayed initiation, and insufficient duration of thromboprophylaxis. We developed a specialized clinical pathway for thromboprophylaxis after CRC surgery to address these issues. CONCLUSIONS: This study offers a comprehensive nationwide evaluation of existing thromboprophylaxis practices in patients after CRC surgery in China. A specialized clinical pathway was developed to address the identified gaps and improve the quality of care. This clinical pathway incorporates explicit, tailored, detailed recommendations for thromboprophylaxis after CRC surgery.

Clinical study of enhanced recovery after surgery in laparoscopic appendectomy for acute appendicitis.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocol is a comprehensive management modality that promotes patient recovery, especially in the patients undergoing digestive tumor surgeries. However, it is less commonly used in the appendectomy. AIM: To study the application value of ERAS in laparoscopic surgery for acute appendicitis. METHODS: A total of 120 patients who underwent laparoscopic appendectomy due to acute appendicitis were divided into experimental group and control group by random number table method, including 63 patients in the experimental group and 57 patients in the control group. Patients in the experimental group were managed with the ERAS protocol, and those in the control group were received the traditional treatment. The exhaust time, the hospitalization duration, the hospitalization expense and the pain score between the two groups were compared. RESULTS: There was no significant difference in age, gender, body mass index and Sunshine Appendicitis Grading System score between the experimental group and the control group (P > 0.05). Compared to the control group, the patients in the experimental group had earlier exhaust time, shorter hospitalization time, less hospitalization cost and lower degree of pain sensation. The differences were statistically significant (P < 0.01). CONCLUSION: ERAS could significantly accelerate the recovery of patients who underwent laparoscopic appendectomy for acute appendicitis, shorten the hospitalization time and reduce hospitalization costs. It is a safe and effective approach.

CircVMP1 promotes glycolysis and disease progression by upregulating HKDC1 in colorectal cancer.

BACKGROUND: Circular RNAs (circRNAs) have been reported to play important roles in cancers. Here, we characterized circVMP1 (hsa_circ_0006508), an important circRNA which promoted glycolysis and disease progression in colorectal cancer (CRC). In this study, we aimed to explore the mechanism by which circVMP1 regulated tumor glycolysis and its related pathways in promoting CRC cell proliferation and metastasis. METHODS: The expression level of circVMP1 in CRC tissues and adjacent normal tissues was detected using quantitative PCR. In vitro and in vivo functional experiments were used to evaluate the effects of circVMP1 in the regulation of CRC cell proliferation and migration. Mitochondrial stress tests and glycolysis stress tests were conducted to detect the effect of circVMP1 on oxidative phosphorylation and glycolysis. Dual-luciferase reporter and RNA immunoprecipitation assays were used to evaluate the interaction between circVMP1, miR-3167, and HKDC1. RESULTS: We demonstrated that the level of circVMP1 was significantly upregulated in CRC tissues compared with normal tissues. In HCT116 and SW480 cells, overexpression of circVMP1 promoted proliferation, metastasis, and glycolysis. In vivo analysis indicated that circVMP1 accelerated the proliferation of xenograft tumors. As for the mechanism, overexpression of circVMP1 increased the levels of hexokinase domain component 1 (HKDC1) through competitive binding with miR-3167. CONCLUSION: Our study reported that circVMP1 was one of the tumor driver genes that promoted CRC malignant progression and glycolysis by upregulating HKDC1. CircVMP1/miR-3167/HKDC1 was a signaling axis that might be a target for CRC therapy.

Incidence, prevention, risk factors, and prediction of venous thromboembolism in Chinese patients after colorectal cancer surgery: a prospective, multicenter cohort study.

BACKGROUND: Venous thromboembolism (VTE) is a common and serious complication after colorectal cancer (CRC) surgery. Few large-sample studies have reported VTE incidence and management status after CRC surgery in China. This study aimed to investigate the incidence and prevention of VTE in Chinese patients after CRC surgery, identify risk factors for developing VTE, and construct a new scoring system for clinical decision-making and care planning. METHODS: Participants were recruited from 46 centers in 17 provinces in China. Patients were followed up for 1 month postoperatively. The study period was from May 2021 to May 2022. The Caprini score risk stratification and VTE prevention and incidence were recorded. The predictors of the occurrence of VTE after surgery were identified by multivariate logistic regression analysis, and a prediction model (CRC-VTE score) was developed. RESULTS: A total of 1836 patients were analyzed. The postoperative Caprini scores ranged from 1 to 16 points, with a median of 6 points. Of these, 10.1% were classified as low risk (0-2 points), 7.4% as moderate risk (3-4 points), and 82.5% as high risk (≥5 points). Among these patients, 1210 (65.9%) received pharmacological prophylaxis, and 1061 (57.8%) received mechanical prophylaxis. The incidence of short-term VTE events after CRC surgery was 11.2% (95% CI 9.8-12.7), including deep venous thrombosis (DVT) (11.0%, 95% CI 9.6-12.5) and pulmonary embolism (PE) (0.2%, 95% CI 0-0.5). Multifactorial analysis showed that age (≥70 years), history of varicose veins in the lower extremities, cardiac insufficiency, female sex, preoperative bowel obstruction, preoperative bloody/tarry stool, and anesthesia time at least 180 min were independent risk factors for postoperative VTE. The CRC-VTE model was developed from these seven factors and had good VTE predictive performance ( C -statistic 0.72, 95% CI 0.68-0.76). CONCLUSIONS: This study provided a national perspective on the incidence and prevention of VTE after CRC surgery in China. The study offers guidance for VTE prevention in patients after CRC surgery. A practical CRC-VTE risk predictive model was proposed.

Short-term Outcomes of Elective Surgery Following Self-Expandable Metallic Stent and Neoadjuvant Chemotherapy in Patients With Left-Sided Colon Cancer Obstruction.

BACKGROUND: Colonic stenting reduces morbidity and stoma formation for left-sided colon cancer obstruction, and a prolonged interval between stenting and surgery with neoadjuvant chemotherapy administered might result in a lower stoma rate and tumor reduction. OBJECTIVE: The study aimed to evaluate the short-term outcomes of elective surgery following colonic stenting compared with elective surgery following colonic stenting and neoadjuvant chemotherapy in patients with left-sided colon cancer obstruction. DESIGN: This is a prospective multicenter cohort study. SETTINGS: This study was conducted at 5 medical centers. PATIENTS: Patients ( n = 100) with acute left-sided colon cancer obstruction undergoing colonic stenting between December 2015 and December 2019 were included. INTERVENTIONS: Patients were assigned to the stenting-alone or chemotherapy group. MAIN OUTCOME MEASURES: The primary outcomes measured were laparoscopic surgery and stoma rate. RESULTS: Of the 100 patients who underwent colonic stenting, 52 were assigned to the stenting group and 48 were assigned to the chemotherapy group. No statistically significant differences were detected in stent-related complications. The adverse events associated with neoadjuvant chemotherapy were well tolerated. The level of hemoglobin (117.2 vs 107.6 g/L; p = 0.008), albumin (34.2 vs 31.5 g/L; p < 0.001), and prealbumin (0.19 vs 0.16 g/L; p = 0.001) was significantly increased, and the bowel wall thickness (1.09 vs 2.04 mm; p < 0.001) was significantly decreased preoperatively in the chemotherapy group compared with the stenting group. The number of mean harvested lymph nodes was greater in the chemotherapy group than in the stenting group (25.6 vs 21.8; p = 0.04). Laparoscopic surgery was performed more frequently (77.1% vs 40.4%; p < 0.001) and a stoma was created less frequently (10.4% vs 28.8%; p = 0.02) in the chemotherapy group than in the stenting group. LIMITATIONS: This trial was limited by the nonrandomized design and a short follow-up period. CONCLUSIONS: This study suggests that elective surgery following neoadjuvant chemotherapy and colonic stenting is a safe, effective, and well-tolerated treatment approach with a high laparoscopic resection rate and a low stoma rate. See Video Abstract at http://links.lww.com/DCR/B980 . RESULTADOS A CORTO PLAZO DE LA CIRUGA ELECTIVA SEGUIDO DE STENT METLICO AUTOEXPANDIBLE Y QUIMIOTERAPIA NEOADYUVANTE EN PACIENTES CON OBSTRUCCIN POR CNCER DE COLON IZQUIERDO: ANTECEDENTES:La colocación de stents colónicos reduce la morbilidad y la formación de estomas por obstrucción por cáncer de colon izquierdo, y el intervalo prolongado entre la colocación de stents y la cirugía con quimioterapia neoadyuvante administrada podría resultar en una menor tasa de estomas y reducción del tumor.OBJETIVO:Evaluar los resultados a corto plazo de la cirugía electiva después de la colocación de stent en el colon en comparación con la cirugía electiva después de la colocación de stent en el colon y la quimioterapia neoadyuvante en pacientes con obstrucción por cáncer de colon izquierdo.DISEÑO:Estudio prospectivo de cohorte multicéntrico.ENTORNO CLINICO:Este estudio se realizó en 5 centros médicos.PACIENTES:Se incluyeron pacientes (n=100) con obstrucción aguda por cáncer de colon izquierdo que se sometieron a colocación de stent colónico entre diciembre de 2015 y diciembre de 2019.INTERVENCIONES:Los pacientes fueron asignados al grupo de stent solo o quimioterapia.MEDIDAS DE RESULTADO PRINCIPALES:Los resultados primarios medidos fueron la cirugía laparoscópica y la tasa de ostomía.RESULTADOS:De los 100 pacientes que se sometieron a la colocación de stent colónico, 52 fueron asignados al grupo de colocación de stent y 48 al grupo de quimioterapia. No se detectaron diferencias estadísticamente significativas en las complicaciones relacionadas con el stent. Los eventos adversos asociados con la quimioterapia neoadyuvante fueron bien tolerados. Hemoglobina (117,2 g/l vs. 107,6 g/l; p = 0,008), albúmina (34,2 g/l vs. 31,5 g/l; p < 0,001) y prealbúmina (0,19 g/l vs. 0,16 g/l; p = 0,001) aumentaron significativamente y el grosor de la pared intestinal (1,09 mm vs. 2,04 mm; p < 0,001) disminuyó significativamente antes de la operación en el grupo de quimioterapia en comparación con el grupo de colocación de stent. El número medio de ganglios linfáticos extraídos fue mayor en el grupo de quimioterapia que en el grupo de stent (25,6 vs. 21,8; p = 0,04). La cirugía laparoscópica se realizó con mayor frecuencia (77,1 % vs. 40,4 %; p < 0,001) y se creó un estoma con menos frecuencia (10,4 % vs. 28,8 % ; p = 0,02) en el grupo de quimioterapia que en el grupo de colocación de stent.LIMITACIONES:Este ensayo estuvo limitado por el diseño no aleatorio y el corto período de seguimiento.CONCLUSIONES:Este estudio sugiere que la cirugía electiva después de la quimioterapia neoadyuvante y la colocación de stent colónico es un tratamiento seguro, efectivo y bien tolerado, con una alta tasa de resección laparoscópica y una baja tasa de estoma. Consulte Video Resumen en http://links.lww.com/DCR/B980 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Current practice for the treatment of obstructive left-sided colon cancer in China: a nationwide cross-sectional survey.

PURPOSE: This study surveyed the current practice of surgical treatment of obstructive left-sided colon cancer (OLCC) in China. METHODS: All colorectal surgery departments at tertiary or secondary hospitals in China were invited to complete a web-based questionnaire between August 27 and September 2, 2020. RESULTS: Overall, completed questionnaire were received from 357 hospitals. Emergency surgery was the mainstay of treatment for OLCC, with the open approach accounting for up to 61.62%. The stoma rate of emergency surgery was up to 80%, mainly due to inadequate bowel preparation and severe edema of colon walls. Hartmann's procedure (61.62%) was the most preferred operation. A total of 243 hospitals (68.7%) reported that they would consider the use of a self-expanding metallic stent (SEMS) as a bridge for elective surgery. More than 50% of the hospitals participating in this study reported the success rate of SEMS placement, as well as the resolution rate of obstruction more than 80%, and the stent-related perforation rate was < 5%. A total of 126 hospitals considered carrying out a strategy of SEMS followed by neoadjuvant chemotherapy prior to elective surgery and believed that it might further improve treatment outcomes. CONCLUSIONS: SEMS is a feasible option for the treatment of OLCC in addition to traditional emergency surgery, and its clinical benefits have been preliminarily recognized.

Treatment of anal fistula using a decellularized porcine small intestinal submucosa plug: A non-inferiority trial.

BACKGROUND: Using small intestinal submucosa (SIS) has increasingly become the standard method for the treatment of anal fistula. The porcine SIS manufactured by Biosis Healing is a novel biological material that has several advantages for the safe and effective repair of tissues. Our study aimed to verify the efficacy and safety of the decellularized porcine SIS (VIDASIS) anal fistula plug. METHODS: We conducted a non-inferiority multicenter, randomized, controlled clinical trial involving patients with chronic anal fistula. Patients from 3 centers across China were randomized 1:1 to Biosis SIS vs commercial SIS. The primary endpoint was the healing rate and secondary endpoints included recurrence within 6 months, rate of copracrasia, healing time, pain using a visual analog scale, and patient and doctor satisfaction. RESULTS: A total of 186 patients were randomized. Of these, 82 patients in the Biosis SIS and 81 in the control (commercial) SIS completed the trial (per-protocol set). The healing rate at the 6-month follow-up (full analysis set) was 92.0% for the Biosis SIS and 89.8% for the control SIS (P = .620). The rate difference of 2.2% (full analysis set; 95% confidence interval: -6.4% and 10.7%, respectively) was within the pre-specified non-inferiority margin of -10%. There were no differences between the 2 groups with regard to the secondary endpoints. No serious adverse event or death occurred. CONCLUSION: Our study shows that the VIDASIS anal fistula plug manufactured by the company Biosis Healing is safe and effective and is not inferior to existing commercial SIS materials.

The Presence of Blastocystis in Tibetan Antelope (Pantholops hodgsonii).

Blastocystis is a protozoan that parasitizes the intestines. A number of hosts of Blastocystis have been found, including human and animals. However, there has been no research on the prevalence of Blastocystis in Tibetan antelope. Here, a molecular test was performed using 627 Tibetan antelope fecal samples collected on Tibet in China from 2019 to 2020. The result showed that 30 (4.8%) samples were Blastocystis positive. The highest prevalence of Blastocystis was in Shuanghu County (25/209, 12.0%), followed by Shenza County (2/103, 1.9%), Nyima County (3/182, 1.6%), and Baigoin County (0/133, 0.0%). In addition, logistic regression analysis showed that the gender, sampling year, and area of Tibetan antelope were risk factors for Blastocystis prevalence. Three subtypes (ST10, ST13, and ST14) of Blastocystis were found in Tibetan antelope through a subtype sequence analysis, and ST13 was identified to be the dominant subtype. This is the first investigation for the infection of Blastocystis in Tibetan antelope. Collectively, the data in this study have expanded the host range of Blastocystis and provided basic information for the distribution of Blastocystis subtypes, which could support the prevention of Blastocystis infection in wild animals.

Prevalence and Characterization of Cryptosporidium Species in Tibetan Antelope (Pantholops hodgsonii).

Cryptosporidium is an enteric apicomplexan parasite, which can infect multiple mammals including livestock and wildlife. Tibetan Antelope (Pantholops hodgsonii) is one of the most famous wildlife species, that belongs to the first class protected wild animals in China. However, it has not been known whether Tibetan Antelope is infected with Cryptosporidium so far. The objective of the present study was to determine the prevalence and characterization of Cryptosporidium species infection in Tibetan Antelope and the corresponding species by using molecular biological method. In the current study, a total of 627 fecal samples were randomly collected from Tibetan Antelope in the Tibet Autonomous Region (2019-2020), and were examined by PCR amplification of the small subunit ribosomal RNA (SSU rRNA) gene. Among 627 samples, 19 (3.03%, 19/627) were examined as Cryptosporidium-positive, with 7 (2.33%, 7/300) in females and 12 (3.67%, 12/327) in males. The analysis of SSU rRNA gene sequence suggested that only two Cryptosporidium species, namely, C. xiaoi and C. ubiquitum, were identified in this study. This is the first evidence for an existence of Cryptosporidium in Tibetan Antelope. These findings extend the host range for Cryptosporidium spp. and also provide important data support for prevention and control of Cryptosporidium infection in Tibetan Antelope.

Outcomes of colorectal cancer surgery in nonagenarian patients: a multicenter retrospective study.

BACKGROUND: The use of surgery in patients with colorectal cancer (CRC) aged ≥90 years remains controversial. This study aimed to evaluate the short-term postoperative and long-term oncologic outcomes of CRC surgery in patients within this age group. METHODS: A total of 151 consecutive nonagenarian patients who underwent CRC surgery were included from 3 different hospitals. The Comprehensive Complication Index (CCI) was used to grade postoperative complications. Univariate and multivariate analyses were conducted to identify factors associated with CCI and overall survival (OS). RESULTS: The patients had a mean age of 92.8 years (standard deviation ±1.9 years). Forty-six patients (30.5%) underwent emergency surgery, and 105 patients (69.5%) underwent elective surgery. The postoperative complications rate was 66.2% (100/151), and the mean CCI was 26.3 (±30.8). Twenty-three patients (15.2%) died postoperatively, and the perioperative mortality rates for elective surgery and emergency surgery were 7.6% (8/105) and 32.6% (15/46), respectively (P<0.001). The 1-, 3-, and 5-year survival rates were 77.5%, 53.9%, and 38.6%, respectively. Multivariate analysis revealed emergency surgery and American Society of Anesthesiologists (ASA) score to be predictors of postoperative complications. Advanced tumor stage, palliative surgery, ASA score ≥4, and CCI >17 were associated with poor OS. CONCLUSIONS: CRC surgery should not be denied to nonagenarian patients. Surgical treatment can be performed with acceptable morbidity and mortality, and achieves long-term survival in a select group.

Successful diagnosis and treatment of jejunal diverticular haemorrhage by full-thickness enterotomy: A case report.

BACKGROUND: Jejunal diverticula are the rarest of all small bowel diverticula and usually have no classic clinical symptoms. Jejunal diverticular haemorrhage (JDH) is a rare complication and can be difficult to identify and manage, hence it always resulting in a diagnostic delay and unsatisfactory clinical outcomes. Although with the advances in endoscopic technology, no consensus have been reached on the diagnosis and management of JDH, the conventional surgical intervention still remains the mainstream for the management of JDH. We report an unique case of a 63-year-old male who presented with massive haemorrhage from jejunal diverticula, which was successfully managed by initial resuscitation and definitive surgery. CASE SUMMARY: A 63-year-old male was admitted as an emergency with 6 h history of haematemesis and melena. The haematemesis appeared to be bright red, with volume exceeding 100 mL. The amount of melena was estimated to be 200 mL. Initially, the patient received fluid resuscitation and three unit blood transfusion. Then, in order to localize the bleeding sites, colonoscopy, upper gastrointestinal endoscopy, and mesenteric angiography were utilized but failed to identify the source of haemorrhage. Informed consent form was obtained for further treatment, and he was treated with an exploratory laparotomy and the bleeding site was successfully located during the procedure. He was diagnosed with JDH. The postoperative period was uneventful, and he was discharged on day 18 after surgery. No rebleeding occurred at the 1-year follow-up. CONCLUSION: In patients with gastrointestinal bleeding, if various techniques fail to identify the cause of haemorrhage in small bowel and haemodynamic instability is sustained with continuous resuscitation, we recommend surgical intervention should be the ultimate treatment of choice.

Stent as a bridge to surgery versus urgent surgery for malignant right colonic obstruction: A multicenter retrospective study.

BACKGROUND: The impact of self-expandable metal stent (SEMS) for malignant right colonic obstruction remains undefined. The aim of this study was to compare short-term postoperative and long-term oncologic outcomes of colonic stenting as a bridge to surgery (SBTS) and urgent colectomy for patients with malignant right-sided obstruction. METHODS: A total of 98 consecutive patients who underwent SEMS placement during the period 2004-2015 from three hospitals were included. For comparative analyses, patients were matched (1:2) with 196 patients treated with emergency colectomy from our prospective database. RESULTS: The two groups were comparable in terms of demographics and tumor characteristics. The proportion of patients who underwent laparoscopic colectomy was higher in SBTS group than urgent colectomy group (75.5% vs. 37.2%; p < 0.001). Patients treated with SBTS were less likely to have a temporary stoma constructed (3.1% vs. 10.7%; p = 0.024). SBTS was associated with significantly less median estimated blood loss (90 vs. 100 ml; p = 0.029), shorter length of hospital stay (11 vs. 12 days; p < 0.001), lower overall postoperative complication rate (18.4% vs. 31.3%; p = 0.018), and wound-related complication rate (5.1% vs. 14.3%; p = 0.019) compared with urgent surgery. Reoperation rate, 30-day mortality, and lymph nodes harvested were not significantly different between two groups. Disease-free survival rate and overall survival rate were similar between the two groups. CONCLUSIONS: SEMS insertion is safe and feasible for treating malignant right-sided obstruction. SBTS is associated with better short-term outcomes and equivalent long-term oncologic results compared with urgent colectomy.

Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic review and meta-analysis.

AIM: Extralevator abdominoperineal excision (ELAPE) for rectal cancer leaves a greater perineal defect which might result in significant perineal morbidity, and how to effectively close perineal defects remains a challenge for surgeons. This study aimed to comparatively evaluate the perineal-related complications of biologic mesh reconstruction and primary closure following ELAPE. METHOD: The electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science were searched to screen out all eligible studies, which compared biologic mesh reconstruction with primary closure for perineal-related complications following ELAPE. Pooled data of perineal-related complications including overall wound complications, hernia, infection, dehiscence, chronic sinus, and chronic pain (12 months after surgery) were analyzed. RESULTS: A total of four studies (one randomized controlled trial and three cohort studies) involving 544 patients (346 biologic mesh vs 198 primary closure) were included. With a median follow-up of 18.5 months (range, 2-71.5 months). Analysis of the pooled data indicated that the perineal hernia rate was significantly lower in biologic mesh reconstruction as compared to primary closure (OR, 0.38; 95% CI, 0.22-0.69; P = 0.001). There were no statistically significant differences between the two groups in terms of total perineal wound complications rate (P = 0.70), as well as rates of perineal wound infection (P = 0.97), wound dehiscence (P = 0.43), chronic sinus (P = 0.28), and chronic pain (12 months after surgery; P = 0.75). CONCLUSION: Biologic mesh reconstruction after extralevator abdominoperineal excision appears to have a lower hernia rate, with no differences in perineal wound complications.

The application possibility of acellular dermal matrix decorated with nano-silver in the reconstruction of contaminated abdominal wall.

Acellular dermal matrix (ADM) is a biomaterial, which commonly used for repair of tissue defects; however, infection is the main factor underlying the failure of treatments involving ADM. To enhance the anti-infection ability of ADM, we constructed a new form of ADM that was decorated with nano-silver ('NS-ADM'). The introduction of nano-silver did not destroy the decellularized structure of ADM, and no significant difference was detected with regards to the maximum tensile force when compared between NS-ADM and ADM (P = 0.351). NS-ADM was not cytotoxic to cell growth when the concentration of nano-silver solution ≤ 25 ppm and exhibited strong antibacterial activity in vitro. Besides, when rats were inoculated with 104 CFU/mL, there were significantly lower bacterial counts in the NS-ADM group than in the ADM group when assessed seven days after surgery (P = 0.047); no significant differences were detected on days 14 and 28. Although there were no significant differences in bacterial counts on days 7, 14, or 21 between the two groups (rats were inoculated with 106 CFU/mL), the number of rats showing reduced bacterial counts or clearing was higher in the NS-ADM group than in the ADM group. Rats that were inoculated with 108 CFU/mL showed repair failure. Overall, NS-ADM is a promising antibacterial biomaterial for repairing contaminated soft-tissue defects, in which antibacterial properties are superior to ADM. The antibacterial activity of NS-ADM was limited for severe infections, and further in vivo studies are needed to evaluate its efficacy and biosafety.

Effects of an anal fistula plug on anal function after surgery for treatment of a trans-sphincteric anal fistula.

PURPOSE: The aim of this study was to evaluate the anal function in patients with trans-sphincteric anal fistulas who underwent an anal fistula plug procedure, and analyze risk factors that might affect post-operative anal function. METHODS: This was an observational, retrospective study of patients diagnosed with trans-sphincteric anal fistulas and initially underwent anal fistula plug procedures between August 2008 and September 2012 at our institute. The analysis includes clinical characteristics, anal fistula healing, and the Wexner score for pre- and post-operative anal function (0 = no incontinence to 20 = complete incontinence). RESULTS: A total of 123 patients who had an adequate follow-up in the end were included. The median duration of follow-up was 8 years (range 72-121 months). The overall healing rate was 56% (69/123), and 33 (26.8%) patients had decreased anal function after surgery. The post-operative Wexner score on anal function was significantly higher than that before the operation (p < 0.001), as well as scores of gas, liquid stool, solid stool incontinence, and alteration in lifestyle (p < 0.05). Based on multiple logistic regression analysis, a high body mass index (p < 0.001) and long distance between the external opening and anal verge (p = 0.003) were significantly associated with a decline in post-operative anal function. CONCLUSIONS: As a sphincter-preserving technique for the treatment of anal fistulas, the anal fistula plug procedure might impair the anal function. Especially for patients with obesity or long distance between the external opening of anal fistula and anal verge, the reduced anal function is more likely to occur after treatment with anal fistula plug therapy.

Long-Term Clinical Results of Use of an Anal Fistula Plug for Treatment of Low Trans-Sphincteric Anal Fistulas.

BACKGROUND An anal fistula plug is a sphincter-sparing procedure that uses biological substances to close an anorectal fistula. This study aimed to evaluate the long-term therapeutic effect of an anal fistula plug procedure in patients with trans-sphincteric fistula-in-ano and to determine the risk factors affecting fistula healing. MATERIAL AND METHODS A single-center retrospective study was performed assessing long-term treatment outcomes of patients with low trans-sphincteric anal fistulas who initially underwent anal fistula plug procedures between August 2008 and September 2012. Risk factors affecting fistula healing were identified using univariate and multivariate analyses. RESULTS A total of 135 patients who had low trans-sphincteric anal fistulas and underwent anal fistula plug procedures were analysed. The overall healing rate was 56% (75/135) with a median follow-up time of 8 years (range, 72-121 months). The primary reasons for treatment failure were plug extrusion (n=12, 20%) and surgical site infection (n=9, 15%), occurring within 30 days after surgery. Multiple logistic regression analysis showed that the duration of anal fistula ≥6 months was significantly associated with treatment failure using an anal fistula plug (OR=3.187, 95% CI: 1.361-7.466, P=0.008). Of the patients who failed initial treatment with an anal fistula plug, 6 (9%) had anal fistulas that healed spontaneously after 2-3 years without additional treatment. CONCLUSIONS As a sphincter-preserving procedure, the anal fistula plug can effectively promote healing of low trans-sphincteric anal fistulas. The long-term efficacy is good and the procedure warrants wider use in clinical practice.

Successful management of tubular colonic duplication using a laparoscopic approach: A case report and review of the literature.

BACKGROUND: Alimentary duplication is a rare congenital disease with a reported incidence of 1 per 4500 persons, although the exact incidence has been difficult to ascertain. According to previous reports, the most common site of duplication is the ileum, and colonic duplication is rare. Due to different types and locations of the duplication, the manifestations are varied, which makes establishing an accurate diagnosis before surgery a challenge. CASE SUMMARY: A 17-year-old female patient sought evaluation in our department with constipation and chronic abdominal pain for 12 years; she had difficulty defecating and had dry stools since she was a child. An abdominal computed tomography revealed two extremely enlarged loops of bowel full of stool-like intestinal contents in the left lower abdomen, which led us to consider the possibility of colonic duplication. A laparoscopic exploration was performed, which revealed a tubular duplicated colon that shared a common opening with the transverse colon. A left hemi-colectomy was performed with a side-to-side anastomosis. The pathologic results confirmed the diagnosis. At the 6-mo follow-up, the patient was doing well without constipation or abdominal pain. CONCLUSION: Colonic duplication is a rare alimentary abnormality in adults. Due to the non-specific manifestations and low incidence, it is usually difficult to make an accurate diagnosis pre-operatively. Surgery is the mainstay of treatment, even though some patients are asymptomatic.

Gunsight Procedure Versus the Purse-String Procedure for Closing Wounds After Stoma Reversal: A Multicenter Prospective Randomized Trial.

BACKGROUND: Stoma reversal is associated with a high risk of wound infection. The gunsight and purse-string closure techniques are both effective alternatives for stoma reversal, but comparative studies are lacking. OBJECTIVE: The purpose of this study was to compare the gunsight procedure with the purse-string closure technique when closing wounds after loop stoma reversal. DESIGN: This was a nonblinded, multicenter prospective randomized study (clinicaltrials.gov No. NCT02053948). SETTINGS: The study was conducted at a general surgery unit of 7 tertiary academic medical centers. PATIENTS: A total of 143 patients undergoing loop stoma reversal were included in the study (72 in the gunsight group and 71 in the purse-string group) between November 2013 and December 2017. INTERVENTION: Patients were randomly assigned to undergo either gunsight or purse-string closure procedure. MAIN OUTCOME MEASURES: Primary outcome was wound healing time. Secondary outcomes were the incidence of surgical site infection, morbidity, and patient satisfaction. RESULTS: No differences were found between the 2 groups in terms of surgical site infection, intraoperative blood loss, and postoperative hospital stay. The gunsight procedure had a shorter wound healing time compared with the purse-string procedure (17 vs 25 d; p < 0.001). A patient satisfaction questionnaire showed that the gunsight group had a higher score level of patient satisfaction with respect to wound healing time (p < 0.001) and total patient satisfaction score (p = 0.01) than the purse-string group. LIMITATIONS: Treatment teams were not blinded, and there was operator dependence of techniques. CONCLUSIONS: The gunsight and purse-string techniques are effective procedures for stoma reversal and both have a low incidence of surgical site infection. The gunsight technique is associated with shorter wound healing time, higher levels of patient satisfaction with regard to healing time, and overall final score and is recommended as the closure technique of choice. See Video Abstract at http://links.lww.com/DCR/B319. EL PROCEDIMIENTO DE GUNSIGHT VERSUS EL PROCEDIMIENTO DE JARETA, PARA EL CIERRE DE HERIDAS, DESPUéS DE REVERSIóN DE ESTOMA: UN ENSAYO, MULTICéNTRICO, PROSPECTIVO Y RANDOMIZADO: La reversión de estoma está asociada con un alto riesgo de infección de la herida. Las técnicas de gunsight y de jareta, son eficaces alternativas en la reversión de estoma, pero faltan estudios comparativos.Comparar el procedimiento de gunsight con la técnica de jareta, después de la reversión de estoma en asa.Estudio multicéntrico, prospectivo y randomizado ciego (NCT02053948).Realizado en la unidad de cirugía general, de siete centros médicos académicos terciarios.Se incluyeron en el estudio, un total de 143 pacientes sometidos a reversión de estoma de asa (72 en el grupo de gunsight y 71 en el grupo de jareta) entre noviembre de 2013 y diciembre de 2017.Los pacientes fueron asignados aleatoriamente, para someterse a un procedimiento de cierre de gunsight o de jareta.El resultado primario fue el tiempo de cicatrización de la herida. Los resultados secundarios fueron la incidencia de infección del sitio quirúrgico, morbilidad y satisfacción del paciente.No se encontraron diferencias entre los dos grupos en términos de infección del sitio quirúrgico, pérdida de sangre intraoperatoria o estadía hospitalaria postoperatoria. El procedimiento de gunsight tuvo un tiempo más corto en la cicatrización de la herida, en comparación con el procedimiento de jareta (17 días frente a 25 días, p <0,001). Un cuestionario de satisfacción del paciente, mostró que el grupo de gunsight tenía una puntuación más alta en relación al tiempo de cicatrización de la herida (p <0.001) y la puntuación total en satisfacción del paciente (p = 0.01), que en el grupo de jareta.Los equipos de tratamiento quirúrgico, no fueron cegados y hubo en los cirujanos, dependencia en las técnicas.Las técnicas de gunsight y de jareta son procedimientos efectivos para la reversión de estoma y ambas tienen una baja incidencia de infección en el sitio quirúrgico. La técnica de gunsight está asociada con un tiempo más corto en cicatrización de heridas, mejores niveles en satisfacción del tiempo de cicatrización y en la puntuación general final. Se recomienda como la técnica de cierre de elección. Consulte Video Resumen en http://links.lww.com/DCR/B319. (Traducción-Dr Fidel Ruiz Healy).