Contrast Challenge Algorithms for Adhesive Small Bowel Obstructions Are Safe in Children: A Multi-Institutional Study.

OBJECTIVE: The purpose of this study was to evaluate the safety of a water-soluble contrast challenge as part of a nonoperative management algorithm in children with an adhesive small bowel obstruction (ASBO). BACKGROUND: Predicting which children will successfully resolve their ASBO with non-operative management at the time of admission remains difficult. Additionally, the safety of a water-soluble contrast challenge for children with ASBO has not been established in the literature. METHODS: A retrospective review was performed of patients who underwent non-operative management for an ASBO and received a contrast challenge across 5 children's hospitals between 2012 and 2020. Safety was assessed by comparing the complication rate associated with a contrast challenge against a pre-specified maximum acceptable level of 5%. Sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of a contrast challenge to identify successful nonoperative management were calculated. RESULTS: Of 82 children who received a contrast challenge, 65% were successfully managed nonoperatively. The most common surgical indications were failure of the contrast challenge or failure to progress after initially passing the contrast challenge. There were no complications related to contrast administration (0%; 95% confidence interval: 0-3.6%, P = 0.03). The contrast challenge was highly reliable in determining which patients would require surgery and which could be successfully managed non-operatively (sensitivity 100%, specificity 86%, NPV 100%, PPV 93%). CONCLUSION: A contrast challenge is safe in children with ASBO and has a high predictive value to assist in clinical decision-making.

Melatonin-Primed MSCs Alleviate Intrauterine Adhesions by Affecting MSC-Expressed Galectin-3 on Macrophage Polarization.

Intrauterine adhesion (IUA) is characterized by the presence of fibrosis in the uterine cavity. It is mainly caused by infection or trauma to the endometrium, and it imposes a great challenge to female reproductive health. Mesenchymal stem cells (MSCs) have been used to regenerate the human endometrium in patients with IUA, but stem cell therapy is not curative in some patients. Melatonin (MT) was reported as a potential modulator of MSCs. However, it remains unclear whether MSCs pretreated with MT exert an improved therapeutic effect on IUA. In this study, an IUA model was established using our invented electric scratching tool. Our results illustrated that MT-pretreated MSCs significantly attenuated the development of IUA. Moreover, MT-pretreated MSCs highly expressed galectin-3 (Gal-3), which enhanced MSC proliferation and migration and influenced macrophage polarization. Of note, IUA mice exhibited colonic injury, and MT-pretreated MSCs alleviated this injury by normalizing colonic microbial communities and recruiting macrophages. Furthermore, inhibition of sympathetic nerves had no effect on IUA progression but delayed colonic injury, and Gal-3 combined with norepinephrine better promoted M2-like macrophage polarization and inhibited M1-like macrophage polarization. Together, these data indicated that MT-primed MSCs can ameliorate injury of both the uterus and colon in an IUA model through high Gal-3 expression to influence sympathetic nerves and in turn affect the polarization and recruitment of macrophages.

Human amniotic mesenchymal stem cells promote endometrium regeneration in a rat model of intrauterine adhesion.

Human amniotic transplantation has been proposed to improve the therapeutic efficacy of intrauterine adhesions (IUAs). Human amniotic mesenchymal stem stromal cells (hAMSCs) can differentiate into multiple tissue types. This study aimed to investigate the mechanism by which hAMSCs transplantation promotes endometrial regeneration. The rat models with IUA were established through mechanical and infective methods, and PKH26-labeled hAMSCs were transplanted through the tail vein (combined with/without estrogen). Under three different conditions, hAMSCs differentiated into endometrium-like cells. HE and Mason staining assays, and immunohistochemistry were used to compare the changes in rat models treated with hAMSCs and/or estrogen transplantation. To define the induction of hAMSCs to endometrium-like cells in vitro, an induction medium (cytokines, estrogen) was used to investigate the differentiation of hAMSCs into endometrium-like cells. qRT-polymerase chain reaction (PCR) and western blotting were performed to detect the differentiation of hAMSCs into endometrium-like cells. A greater number of glands, fewer endometrial fibrotic areas, and stronger expression of vascular endothelial growth factor and cytokeratin in the combined group (hAMSCs transplantation combined with estrogen) than in the other treatment groups were observed. hAMSCs could be induced into endometrium-like cells by cytokine treatment (TGF-ß1, EGF, and PDGF-BB). Transplantation of hAMSCs is an effective alternative for endometrial regeneration after injury in rats. The differentiation protocol for hAMSCs will be useful for further studies on human endometrial regeneration.

Transcriptome sequencing analysis of primary fibroblasts: a new insight into postoperative abdominal adhesion.

PURPOSE: The specific genes or pathways in fibroblasts responsible for the pathogenesis of postoperative abdominal adhesion (PAA) remain to be elucidated. We aim to provide a new insight into disease mechanisms at the transcriptome level. METHODS: Male Sprague-Dawley rats were used to establish a PAA model. Primary fibroblasts were separated from normal peritoneal tissue (NF) and postoperative adhesion tissue (PF). RNA sequencing was used to analyze the transcriptome in NF and PF. RESULTS: One thousand two hundred thirty-five upregulated and 625 downregulated DEGs were identified through RNA-Seq. A pathway enrichment analysis identified distinct enriched biological processes, among which the most prominent was related to immune and inflammatory response and fibrosis. HE staining and Masson's trichrome staining histologically validated the RNA-Seq results. Six hub genes, ITGAM, IL-1ß, TNF, IGF1, CSF1R and EGFR were further verified by RT-PCR. CONCLUSIONS: Our study revealed the roles of the immune and inflammatory responses and fibrosis in the process of PAA. We also found six hub genes that may be potential therapeutic targets for PPA.

Impact of Protocol Utilizing Water-Soluble Contrast for Adhesive Small Bowel Obstruction.

INTRODUCTION: Adhesive small bowel obstruction (ASBO) has classically been managed with nasogastric tube decompression and watchful waiting. Our group developed an evidence-based protocol to manage ASBO utilizing a water-soluble contrast (WSC) agent. We hypothesized the protocol would decrease the length of stay (LOS) for patients admitted with ASBO along with the time interval from admission to surgery. METHOD: From 2010 to 2018, a retrospective review was performed, including all patients admitted with a diagnosis of ASBO. These patients were divided into two groups: the preprotocol group included years 2010-2013 and the postprotocol group included years 2015-2018. A Student t-test and a two-proportion z-test were used for statistical analysis. RESULT: We captured 767 patients; 296 in the preprotocol group and 471 in the postprotocol group. We found a significant decrease in overall LOS between the preprotocol and postprotocol groups (6.56 d versus 4.08 d; P < 0.001) along with decreases in LOS for patients managed nonoperatively (5.36 d versus 3.42 d; P < 0.001) and operatively (16.09 d versus 9.47 d; P < 0.001). Time interval from admission to the operation was significantly decreased in the postprotocol group (3.79 d versus 2.10 d; P < 0.050). We identified a trend toward decreased rates of bowel ischemia and resections with our protocol. CONCLUSIONS: These results reaffirm previous reports of WSC's impact on overall LOS in ASBO while showing a similar impact on both operative and nonoperative groups. The decreased time interval between admission and operation may impact the incidence of bowel ischemia and resections.

Adhesive small bowel obstruction in elderly patients: a single-center analysis of treatment strategies and clinical outcomes.

INTRODUCTION: The incidence of adhesive bowel obstruction (ASBO) progressively increases with age. Strong evidences on the influencing role of age on ASBO clinical course and management are still lacking. Aim of this study is to retrospectively analyze the clinical outcomes of patients older than 65 years of age admitted to a tertiary referral Emergency Department with a diagnosis of ASBO. MATERIALS AND METHODS: We reviewed the clinical records of patients admitted for ASBO in the period 2014-2019. Patients were divided in elderly (≥65 years) and non-elderly (<65 years). Primary endpoint was to compare the all-cause in-hospital mortality and the occurrence of major complications in the two groups. Secondary endpoint was a comparison of clinical presentation, clinical course and management. RESULTS: We enrolled 285 elderly and 492 non-elderly patients. Vomit was more frequent in the elderly (51.9% vs 34.6%; p < .001), while no difference was evidenced for the remaining symptoms of ASBO presentation. A higher rate of non-operative management (NOM) (26.3% vs 16.5%; p = .010), ICU admission (16% vs 0.6%; p < .001), mortality (2.1% vs 0.2%; p = .007) and cumulative major complications (8.8% vs 3.3%; p = .001), as well as a prolonged hospitalization (8.2 vs 5.4 days; p < .001) was evidenced in the ≥65 years group. Multivariate analysis identified increasing age (OR:2.8; 95%CI:1.09-7.2; p = .040) and Charlson comorbidity index ≥ 2 (OR:2.5; 95% CI:1.2-6.4; p = .050) as the only independent predictors of cumulative major complications. CONCLUSIONS: Despite the similarity in terms of clinical presentation, elderly patient present higher mortality rate and occurrence of major complications. A comprehensive geriatric assessment is recommended to optimize the diagnostic and clinical strategies in case of ASBO.

Non-operative Management of Small Bowel Obstruction in Patients with No Previous Abdominal Surgery: A Systematic Review and Meta-analysis.

While the contemporary management of adhesive small bowel obstruction (SBO) often includes a trial of non-operative management (NOM), surgical dogma dictates urgent operative exploration in patients without previous abdominal surgery. This dogma has been challenged by recent evidence suggesting most obstructions in this population are adhesive in nature. The objectives of this review were to evaluate the feasibility of NOM in patients with SBO and no history of previous abdominal surgery, to examine the etiologies of SBO in this population, and to explore the rate of adverse events seen following NOM. Embase, Medline, Cochrane, and Google Scholar were searched from inception to September 24, 2019. Articles reporting on NOM for SBO in patients without previous abdominal surgery and without clinical or radiographic features necessitating an emergent operation were included. Data were combined to obtain a pooled proportion of patients discharged without operation following a trial of NOM. 6 studies reporting on a total of 272 patients were included. The pooled proportion of patients discharged following NOM was 49.5% (95% CI 23.7-75.3%). Adhesions were found to be the predominant cause of obstruction. NOM did not appear to increase short-term complications. Most SBOs in patients without previous abdominal surgery are adhesive in nature and many patients can be discharged from hospital without surgery. While the short-term outcomes of NOM are acceptable, future studies are needed to address the long-term outcomes and safety of NOM as a treatment strategy for SBO in patients without previous abdominal surgery.

Paediatric adhesive bowel obstruction: a systematic review.

Adhesions following abdominal surgery remain a common cause of bowel obstruction. The incidence is between 1 and 12.6% in children who have had previous abdominal surgery. While conservative management is usually trialled in all patients (including children) suspected of having ASBO, the majority will require surgical intervention. New materials such as Seprafilm® have been studied in the paediatric population, with promising results of its use in index abdominal surgeries to prevent the formation of adhesions. In this article, we conducted a systematic review to present an overview of the current knowledge on the incidence, aetiology, pathophysiology, clinical presentation, and management of ASBO.

Long-term Inhibition of Soleus H-reflex with Epidural Adhesiolysis and Pulsed Radiofrequency in Lumbosacral Neuropathic Pain.

INTRODUCTION: Scientific data about neurophysiological changes subsequent to pulsed radiofrequency (PRF) are still lacking. The goal of this study was to evaluate sural nerve conduction and Hoffmann reflex (H-reflex) in soleus muscle following adhesiolysis and PRF in patients with unilateral chronic lumbosacral L5-S1 neuropathic radiating pain. METHODS: Seventeen patients received two cycles of 240 seconds high-voltage PRF and epidural adhesiolysis. Sural nerve action potential (SNAP) and the ratio of maximum H-reflex to maximum M response (H/M ratio) as well as pain scores were collected in both lower limbs before, immediately following, and 1 month after the treatment. RESULTS: At follow-up, a significant reduction in numeric rating scale (NRS) and Douleur Neuropathique 4 Questions (DN4) scores was observed in 53% of patients reporting pain improvement of ≥ 30% over baseline. The H/M ratio was decreased in the affected limb following PRF (P = 0.01) and 1 month after the treatment (P = 0.04). A direct correlation was observed between H/M ratio variation and NRS score at follow-up in the treated limb (P = 0.04). No significant difference in sural nerve latency, amplitude, and velocity was detected between affected and normal side after treatment and at follow-up. CONCLUSIONS: Epidural adhesiolysis and PRF of the dorsal root ganglion seem to significantly affect spinal reflexes in patients with lumbosacral neuropathic radiating pain.

[New approaches in conservative treatment of acute adhesive small bowel obstruction]. / Novye podkhody v konservativnom lechenii ostroi spaechnoi tonkokishechnoi neprokhodimosti.

OBJECTIVE: To improve the outcomes of therapy of acute adhesive small bowel obstruction via development of a comprehensive management including CT, deep endoscopy-assisted nasointestinal drainage of small bowel with injection of a water-soluble contrast. MATERIAL AND METHODS: There were 128 patients with acute adhesive small bowel obstruction for the period from 2015 to 2018. The study included 2 groups of patients depending on therapeutic approach and duration of treatment. In the first group, conventional approach for acute adhesive small bowel obstruction was applied. Upon admission, all patients with confirmed acute adhesive small bowel obstruction underwent gastric intubation for decompression of the upper gastrointestinal tract. Barium sulfate injection followed by X-ray examination was performed to assess an effectiveness of therapy. In the second group, computed tomography was performed in addition to X-ray examination and ultrasound. Moreover, conservative treatment included deep endoscopy-assisted nasointestinal drainage and subsequent administration of a water-soluble contrast in addition to traditional approaches. RESULTS: Therapy was effective in 99 (71.2%) patients; 39 (28.8%) ones required surgery. Deep endoscopy-assisted nasointestinal drainage with injection of a water-soluble contrast was effective in 45 (78.9%) patients. Overall mortality in traditional approach was 1.4%, postoperative mortality - 3.7%. There were no lethal outcomes in case of a new approach. CONCLUSION: Deep endoscopy-assisted nasointestinal drainage with injection of a water-soluble contrast is the most effective therapeutic method for acute adhesive small bowel obstruction (78.9%). These findings can significantly improve treatment outcomes in these patients.

[Timing of surgery, intestinal ischemia and other real factors of mortality in acute adhesive small bowel obstruction: a multiple-center study]. / Faktory riska letal'nogo iskhoda pri ostroi spaechnoi tonkokishechnoi neprokhodimosti. Rezul'taty mnogotsentrovogo issledovaniya.

OBJECTIVE: To analyze the factors of mortality in patients with acute adhesive small bowel obstruction (ASBO). MATERIAL AND METHODS: A retrospective multiple-center study included 143 (85.6%) patients with ASBO out of 167 consecutive patients with small bowel obstruction for the period 2017-2019. All patients were divided into 3 groups: early surgery group (within 12 hours after admission), late surgery (after 12 hours), non-surgical management group. The outcomes and Kaplan-Meier survival were compared in all groups. RESULTS: ASBO was resolved without surgery in 77 (53.8%) patients 19.6±17.4 (M=14) hours. In the Early Surgery Group (n=36), 24 patients had strangulation, 12 ones had non-strangulated bowel obstruction. In the Late Surgery Group (n=30), 15 patients had strangulation and 15 ones had no strangulation. Mortality was similar in early and late surgery (p=0.287), early and late surgery in patients with strangulation (p=0.940), early and late surgery in patients without strangulation (p=0.76). Patients died (n=10) after surgery only. Thus, postoperative mortality was 15.2%, overall mortality - 7.0%. All patients who underwent surgery after 24 hours (n=14) survived. Surgery increased the mortality risk compared to non-surgical management (95% CI 0 - 15.9, p=0.001). There was no effect of surgery time (more or less than 12 hours) on mortality for strangulation (95% CI 13.0-16.7, p 0.788) and non-strangulated obstruction (95% CI 29.4-5.4, p=0.061), bowel resection (95% CI 33.3-14.0, p=0.187), presence of bowel ischemia (95% CI 14.3-17.9, p 0.613). CONCLUSION: Delayed surgery may be advisable in patients with ASBO and no obvious signs of strangulation due to less mortality.

Adhesive Small Bowel Obstruction: Predictive Radiology to Improve Patient Management.

Adhesive small bowel obstruction (SBO) remains one of the leading causes of emergency room visits and is still associated with high morbidity and mortality rates. Because the management of adhesive SBO has shifted from immediate surgery to nonoperative treatment in the absence of ischemia, it is crucial to rapidly detect or predict strangulation, which requires emergent surgery. CT is now established as the best imaging technique for the initial assessment of patients suspected of having adhesive SBO. CT helps confirm the diagnosis of mechanical SBO, locate the site of obstruction, establish the cause, and detect complications. This article is a review of the role of imaging in answering specific questions to help predict the management needs of each individual patient. It includes (a) an update on the best CT signs for predicting ischemia and a need for bowel resection; (b) a discussion of the CT features that help differentiate open-loop from closed-loop obstruction and a single adhesive band from matted adhesions and how these differences can influence the management; and (c) a review of the main CT predictors of the success or failure of nonoperative management in adhesive SBO.

Collagen Scaffold with Human Umbilical Cord Mesenchymal Stem Cells Remarkably Improves Intrauterine Adhesions in a Rat Model.

BACKGROUND: Intrauterine adhesion (IUA) is the second leading cause of secondary infertility in women. Research has shown that stem cells can promote endometrial regeneration and that biomaterials are also helpful in tissue regeneration. Therefore, we compared the efficacy of a collagen scaffold combined with either human umbilical cord mesenchymal stem cells (hUCMSC) or estrogen for the treatment of IUA. METHODS: The IUA-induced rats were injected with hUCMSCs or estrogen, and with a collagen scaffold. The endometrial glands and amount of fibrosis were assessed using hematoxylin and eosin and Masson staining. The extent of fibrosis and levels of regeneration-related cytokines were examined by real-time quantitative PCR, and the expression levels of the estrogen receptor, KI67 and cytokeratin were analyzed using an immunochemistry assay. In addition, human nuclear antigen (HuNu) and vimentin were examined by immunofluorescence microscopy. RESULTS: The collagen scaffold administered with hUCMSCs markedly increased the number of endometrial glands and reduced the area of fibrosis compared with either the collagen scaffold or hUCMSCs alone. In addition, the collagen scaffold with hUCMSCs significantly regulated the expression levels of fibrosis, estrogen, and differentiation-related genes relative to the collagen scaffold or hUCMSCs alone. Furthermore, the hUCMSCs alone or in combination with the collagen scaffold increased the expression of HuNu and vimentin in the IUA-induced rat model. In addition, protein levels of the p-transcriptional co-activator with PDZ-binding motif, stromal cell-derived factor-1, and C-X-C chemokine receptor type 4 were upregulated in the group that received the collagen scaffold in combination with -hUCMSCs. CONCLUSION: Our results suggest that the combination of the collagen scaffold with hUCMSCs may be an alternative approach for treating IUA.

Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications.

BACKGROUND: Small bowel obstruction (SBO) is a major cause of postoperative mortality and morbidity following abdominal and pelvic surgery, with 225,000-345,000 annual admissions. SBO may be classified based on onset from day of surgery. Early SBO occurs within the first 30 days following surgery, whereas late SBO occurs after the initial 30-day postoperative window. The majority of either type of bowel obstruction is believed to be secondary to intra-abdominal adhesions. Early SBO warrants special attention because of the difficulty in distinguishing between mechanical and nonmechanical obstruction during this period. Whereas conservative management often leads to resolution of nonmechanical obstruction and some partial SBO, surgical management is associated with a higher rate of complications compared to surgery for late SBO because of the presence of hypervascular adhesions in the early postoperative period. The current literature regarding SBO, and early SBO in particular, following hysterectomy is limited. Given that approximately 400,000 hysterectomies are performed annually, understanding the risk factors associated with SBO following these types of surgeries is imperative for improving patient outcomes. OBJECTIVE: The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO) after hysterectomy for benign indications. MATERIALS AND METHODS: This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Data on patient demographics and clinical and surgical factors were obtained. Patients were then stratified into those with and those without SBO. Pairwise comparison was performed using the Wilcoxon rank-sum test and Fisher exact tests. Multivariable logistic regression was used to identify significant independent predictors of SBO. RESULTS: Of 47,937 hysterectomies, SBO occurred in 286 patients, at a rate of 5.9 per 1000 hysterectomies. Comparing patients with and without SBO, those with an obstruction were older (49 vs 46 years, P <.001) and were more likely to smoke (21.0% vs 15.8%, P = .02), to have a history of prior abdominal surgery (73.4% vs 65.4%, P = .005), and to have medical comorbidities such as hypertension and dyspnea. Patients experiencing SBO were also more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, P < .001), adhesiolysis (5.2% vs 2.1%, P < .001), appendectomy (1.7% vs 0.5%, P = .02), and cystotomy repair (1.0% vs 0.3%, P = .002). After logistic regression, route of hysterectomy was not a significant risk factor for SBO, whereas wound class ≥3 (adjusted odds ratio [aOR], 5.96; 95% confidence interval [CI], 2.71-12.99) and perioperative transfusion (aOR, 5.01; 95% CI, 3.54-7.13) were the most significant risk factors. Additional risk factors for early SBO included nonwhite race (aOR, 1.84; 95% CI, 1.33-2.48), increasing age (aOR, 1.04; 95% CI, 1.02-1.05), prior abdominal or pelvic surgery (aOR, 1.49; 95% CI, 1.17-2.03), operating times >170 minutes (aOR, 1.90; 95% CI, 1.37-2.58), uterine weight >250 g (aOR, 1.54; 95% CI, 1.11-2.14), lysis of adhesions (aOR, 2.10; 95% CI, 1.23-3.66), and concurrent appendectomy (aOR, 2.64; 95% CI, 1.06-6.65). CONCLUSION: Early SBO is a rare complication of benign hysterectomy. Although route of hysterectomy was not found to be a significant risk factor for early SBO, variables typically associated with abdominal hysterectomy compared to minimally invasive hysterectomy, including higher wound class, larger uteri, and perioperative transfusion (a marker of intraoperative blood loss), were strongly correlated with subsequent development of early obstruction.

A Significant Proportion of Small Bowel Obstructions Require >48 Hours to Resolve After Gastrografin.

BACKGROUND: Gastrografin (GG)-based nonoperative approach is both diagnostic and therapeutic for partial small bowel obstruction (SBO). Absence of X-ray evidence of GG in the colon after 8 h is predictive of the need for operation, and a recent trial used 48 h to prompt operation. We hypothesize that a significant number of patients receiving the GG challenge require >48 h before an effect is seen. METHODS: A post hoc analysis of an Eastern Association for the Surgery of Trauma multi-institutional SBO database was performed including only those receiving GG challenge. Successful nonoperative management (NOM) was defined as passage of flatus or nasogastric tube (NGT) removal. NOM was considered a failure if operative intervention was required. Multiple logistic regression was performed to identify predictors of delayed (>48 h) GG challenge effect and expressed as odds ratios with 95% confidence intervals. RESULTS: Of 286 patients receiving GG, 208 patients (73%) were successfully managed nonoperatively. A total of 60 (29%) NOM patients had NGT decompression for >48 h (n = 54) or required >48 h to pass flatus (n = 34), with some requiring both (n = 28). Prior abdominal operations and SBO admission were protective of delayed GG effect (0.411 [0.169-1.00], P < 0.05; 0.478 [0.240-0.952], P < 0.036). CONCLUSIONS: A significant proportion of patients at 48 h (29%) "failed" the GG challenge as they had yet to pass flatus or still required NGT but were nonetheless successfully managed nonoperatively. Extending the GG challenge beyond 48 h may help avoid unnecessary operations. LEVEL OF EVIDENCE: Level II.

Disease Severity and Cost in Adhesive Small Bowel Obstruction.

BACKGROUND: Adhesive small bowel obstruction (ASBO) severity has been associated with important clinical outcomes. However, the impact of ASBO severity on hospitalization cost is unknown. The American Association for the Surgery of Trauma (AAST) developed an Emergency General Surgery (EGS) disease severity grading system for ASBO. We stratified patients' ASBO severity and captured hospitalization costs hypothesizing that increased disease severity would correlate with greater costs. METHODS: This was a single-center study of hospitalized adult patients with SBO during 2015-2017. Clinical data and estimated total cost (direct + indirect) were abstracted. AAST EGS grades (I-IV) stratified disease severity. Costs were normalized to the median grade I cost. Univariate and multivariate analyses evaluated the relationship between normalized cost and AAST EGS grade, length of hospital and ICU stay, operative time, and Charlson comorbidity index. RESULTS: There were 214 patients; 119 (56%) were female. AAST EGS grades included: I (62%, n = 132), II (23%, n = 49), III (7%, n = 16), and IV (8%, n = 17). Relative to grade I, median normalized cost increased by 1.4-fold for grade II, 1.6-fold for grade III, and 4.3-fold for grade IV disease. No considerable differences in patient comorbidity between grades were observed. Pair-wise comparisons demonstrated that grade I disease cost less than higher grades (corrected p < 0.001). Non-operative management was associated with lower normalized cost compared to operative management (1.1 vs. 4.5, p < 0.0001). In patients who failed non-operative management, normalized cost was increased 7.2-fold. Collectively, the AAST EGS grade correlated well with cost (Spearman's p = 0.7, p < 0.0001). After adjustment for covariates, AAST EGS grade maintained a persistent relationship with cost. CONCLUSION: Increasing ASBO severity is independently associated with greater costs. Efforts to identify and mitigate costs associated with this burdensome disease are warranted. LEVEL OF EVIDENCE: III, economic/decision.

Adipose-derived stem cells transplantation improves endometrial injury repair.

Endometrial injury is an important cause of intrauterine adhesion (IUA), amenorrhea and infertility in women, with limited effective therapies. Recently, stem cells have been used in animal experiments to repair and improve injured endometrium. To date, our understanding of adipose-derived stem cells (ADSCs) in endometrial injury repair and their further therapeutic mechanisms is incomplete. Here, we examined the benefit of ADSCs in restoration of injured endometrium by applying a rat endometrial injury model. The results revealed by immunofluorescence showed that green fluorescent protein (GFP)-labelled ADSCs can differentiate into endometrial epithelial cells in vivo. At 30 days after ADSCs transplantation, injured endometrium was significantly improved, with increased microvessel density, endometrial thickness and glands when compared with the model group. Furthermore, the fertility of rats with injured endometrium in ADSCs group was improved and had a higher conception rate (60% vs 20%, P = 0.014) compared with the control phosphate-buffered saline (PBS) group. However, there was no difference in the control group compared with the sham group. In addition, expression levels of the oestrogen receptor Eα/ß (ERα, ERß) and progesterone receptor (PR) detected by western blot and enzyme-linked immunosorbent assay (ELISA) were higher in the ADSCs group than in the PBS group. Taken together, these results suggested that ADSC transplantation could improve endometrial injury as a novel therapy for IUA.

Evaluation of the efficacy of epiduroscopic adhesiolysis in failed back surgery syndrome

Background/aim: We aimed to compare the results of the treatment of the patients with failed back surgery syndrome (FBSS) by mechanical lysis and steroid hylase injection via epiduroscopy due to their stabilization status and to detect the effect of pathological diagnostic markers on prognosis and ongoing treatment protocol. Materials and methods: Eighty-two patients with FBSS symptoms were included. Two groups were composed as group I (stabilized) and group II (nonstabilized). All patients were evaluated using the oswestry disability index (ODI) and visual analogue scale (VAS) scores before and after treatment at 1, 3, 6, and 12 months and using the patient satisfaction scale at 12 months following treatment. Epidural scar tissue visual and mechanical signs were also recorded. Results: Mean VAS scores were 7.8 and 3.28 points in group I (P < 0.001) and 7.51 and 2.74 points in group II (P < 0.001) at the beginning and at 12 months, respectively. Mean ODI scores were 34.05 and 22.16 points in group I (P < 0.001) and 30.74 and 19.46 points in group II (P < 0.001) at the beginning and at 12 months. VAS and ODI scores decreased significantly in both groups, but were more significant in the nonstabilized group (P < 0.001). Moderate or severe fibrous tissue was observed in 86.58% of the patients and patient satisfaction scores were very good or good in 78.06% of the patients. During the procedure, a dura rupture developed in four patients in the stabilization group and in two patients in the nonstabilization group; however, none of these patients developed a spinal headache and no significant permanent complication arose. Conclusion: We suggest that epidural adhesiolysis, hyaluronidase, and steroid injection in patients with FBSS chronic low back pain and/or radicular symptoms may give reliable information about the quality of life, accuracy of diagnosis, and the possible course of the present findings and may be more effective in nonstabilized patients

The different dosages of estrogen affect endometrial fibrosis and receptivity, but not SDF-1/CXCR4 axis in the treatment of intrauterine adhesions.

OBJECTIVE: The study was to evaluate whether fibrotic markers, endometrial receptivity markers and SDF-1/CXCR4 had been changed in the treatment of intrauterine adhesions (IUAs) by different dosages of estrogen. STUDY DESIGN: A total of 39 patients with IUAs were treated with EV 4 mg or 9 mg randomly post-surgery. TGF-ß1/MMP-9, VEGF/αvß3 and SDF-1/CXCR4 were detected in endometrial tissue before and after treatment by real-time PCR and Western blot. RESULTS: TGF-ß1 and MMP-9 expression significantly decreased after treatment for 3 months than before (p < .05), the falling range was larger with EV 4 mg than 9 mg in the mild-moderate degree IUAs (p < .05); Integrin avß3 expression significantly increased after treatment for 3 months than before (p < .05), the variation range was larger with EV 4 mg than 9 mg (p < .05); CXCR4 expression had no significant change after treatment 3 months compared to that before treatment (p > .05). SDF-1 presented an upward tendency at early phase, and it came back to the level of pre-surgery. But there were no significant difference between treatment with 4 mg and 9 mg in the rate of menstrual restoration and pregnancy follow-up 3 months after the treatment. CONCLUSIONS: Endometrium fibrosis may be inhibited and endometrium receptivity may be improved by estrogen with moderate dosage therapy. Compared to the large one, it seems to be advantageous.

Treatment with oestrogen or manual separation for labial adhesions - initial outcome and long-term follow-up.

BACKGROUND: Topical oestrogen and manual separation are the main treatments for labial adhesions. The aim was to evaluate treatment of labial adhesions and compare the outcome of topical oestrogen treatment with that of manual separation. METHOD: All girls aged 0-12 years admitted to a tertiary centre for paediatric surgery for labial adhesions were included. The study design was dual: The first part was a retrospective chart review of the treatment success according to the medical charts. The second part was a cross-sectional parent-reported long-term outcome study (> 6 months after last treatment finished). RESULTS: In total 71 patients were included and the median follow-up time for the chart study was 84 (6-162) months after treatment with oestrogen or manual separation. Oestrogen was the first treatment for 66 patients who had an initial successful rate of 62% but this was followed by recurrences in 44%. Five patients had manual treatment as their first treatment and they had a 100% initial success rate followed by recurrences in 20%. Therefore, for the first treatment course there was a final success rate of 35% for oestrogen and 80% for manual separation (p = 0.006). Corresponding final success rates including all consecutive treatments over the study period were 46/130 (35%) for oestrogen and 21/30 (70%) for manual separation (p = 0.001). The success rate for oestrogen did not differ if treatment was given in a course length of 0-4 weeks (39% success) or > 4 weeks (32% success) (p = 0.369). In the parent-reported long-term outcome study the response rate was 51% (36/71). Parents reported that recurrences of adhesions after last prescribed/performed treatment were frequent: in total 25% of patients still had adhesions corresponding to 8/29 (29%) of those whose last treatment was oestrogen and 1/9 (11%) of those whose last treatment was manual separation. CONCLUSION: Due to the results recurrences are common after both oestrogen and manual separations. However, the overall final outcome after manual separation seems to be more successful when compared to that of topical oestrogen treatment.