Pyridostigmine in chronic intestinal pseudo-obstruction - a systematic review.

BACKGROUND: Chronic intestinal pseudo-obstruction (CIPO) may be a primary or secondary phenomenon and is often multifactorial. Treatment is largely directed at improving colonic motility. The use of cholinesterase inhibitors such as pyridostigmine has been hypothesized to increase acetylcholine in the bowel, improving symptoms and transit times. METHODS: A systematic review of the use of pyridostigmine in CIPO was conducted using scientific and commercial search engines identifying scientific studies enrolling adult human subjects, published from 2000 to 2022 in the English language. RESULTS: Four studies were identified including two randomized controlled trials (RCT) and two observational studies. The studies had heterogenous inclusion criteria, dosing regimens and reported outcomes. Two studies were identified as being at high risk of bias. All studies reported improved patient outcomes with use of pyridostigmine, and low rates (4.3%) of mild cholinergic side effects. No major side effects were reported. CONCLUSION: The use of pyridostigmine in management of CIPO is biologically plausible due to its ability to increase colonic motility, and early studies on its role are uniformly suggestive of benefit with low side-effect profile. Four clinical studies have been conducted to date, with small sample sizes, heterogeneity and high risk of bias. Further high-quality studies are required to enable assessment of pyridostigmine's utility as an effective management strategy in CIPO.

A rare case of transient duodenal volvulus in an elderly patient.

Duodenal volvulus is an extremely rare condition, with few cases reported in the literature. We present the case of an 83-year-old man with spontaneous duodenal volvulus diagnosed on CT imaging. Findings included volvulus of the third part of the duodenum, the chjmirocteristic whirl pattern of the superior mesenteric vessels and medialisation of the gallbladder. He was treated with nasogastric tube decompression and follow-up CT demonstrated complete resolution of the volvulus.

Assessing the risk of viral infection from gases and plumes during intra-abdominal surgery: a systematic scoping review.

BACKGROUND: The aim of this study was to identify the current evidence regarding the risk of acquiring viral infections from gases or plumes during intra-abdominal surgery. Peritoneal fluids may contain cellular material and virus particles. Electrocautery smoke and plumes from energy devices may aerosolize harmful substances and viral particles. Insufflation and desufflation during laparoscopic surgery may also aerosolize and distribute biological material. A systematic scoping review was performed to assess the evidence and inform safe surgical practice. METHODS: A systematic search of the PubMed and Medline databases was undertaken until June 2020, observing Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology, to identify articles associating viral infection of operating room staff from surgical gases and plumes. All evidence levels were included. The search strategy utilized the search terms 'surgery', 'laparoscopy', 'laparoscopic' 'virus', 'smoke', 'risk', 'infection'. RESULTS: The literature search identified 74 articles. Eight articles relevant to the subject of this review were included in the analysis, two of which specifically related to intra-abdominal surgery. Of the remaining six, four involved gynaecological surgery and two were in-vitro studies. No evidence that intra-abdominal surgery was associated with an increased risk of acquiring viral infections from exsufflated gas or smoke plumes was identified. CONCLUSION: There is currently no evidence that respiratory viruses can be found in the peritoneal fluid. Whilst there is currently no evidence that desufflated carbon dioxide or surgical smoke plumes present a significant infectious risk, there is not a wealth of literature to inform current practice. Further clinical research in this area is required.

Robotic colorectal surgery in Australia: a cohort study examining clinical outcomes and cost.

Objective The aim of this study was to compare robotic versus laparoscopic colorectal operations for clinical outcomes, safety and cost. Methods A retrospective cohort study was performed of 213 elective colorectal operations (59 robotic, 154 laparoscopic), matched by surgeon and operation type. Results No differences in age, body mass index, median American Society of Anesthesiologists score or presence of cancer were observed between the laparoscopic or robotic surgery groups. However, patients undergoing robotic colorectal surgery were more frequently male (P = 0.004) with earlier T stage tumours (P = 0.02) if cancer present. Procedures took longer in cases of robotic surgery (302 vs 130 min; P < 0.001), and patients in this group were more frequently admitted to intensive care units (P < 0.001). Overall length of stay was longer (7 vs 5 days; P = 0.03) and consumable cost was A$2728 higher per patient in the robotic surgery group. Conclusion Robotic colorectal surgery appears to be safe compared with current laparoscopic techniques, albeit with longer procedure times and overall length of stay, more frequent intensive care admissions and higher consumables cost. What is known about the topic? Robotic surgery is an emerging alternative to traditional laparoscopic approaches in colorectal surgery. International trials suggest the two techniques are equivalent in safety. What does this paper add? This is an original cohort study examining clinical outcomes in Australian colorectal robotic surgery. The data suggest it may be safe, but this paper demonstrates key issues in the implementation and audit of novel surgical technologies in relatively low-volume centres. What are implications for practitioners? In our study, patients undergoing robotic colorectal surgery at a single centre in Australia had equivalent measured clinical outcomes to those undergoing laparoscopic surgery. However, practitioners may counsel patients that robotic procedures are typically longer and more expensive, with a longer overall hospital admission and a higher likelihood of intensive care admission.

Hepatic cystic echinococcosis in Australia: an update on diagnosis and management.

BACKGROUND: Echinococcosis is an uncommonly encountered zoonotic disease caused by the taeniid Echinococcus. The only endemic species in Australia, Echinococcus granulosus, forms cysts in the liver in 70% of cases. The aim of this study was to review the literature to provide an evidence-based narrative update on the diagnosis and management of hepatic cystic echinococcosis in Australia. METHODS: We reviewed the literature, utilizing multiple research databases and citation tracking. Original research and review articles examining the diagnosis and management of hydatid disease in adults, published prior to 2016 and in the English language were included in our review. RESULTS: Ultrasound is the gold-standard screening test, whilst computed tomography has a role in emergency presentations and screening for multi-organ involvement. Magnetic resonance imaging is the preferred second-line imaging and better demonstrates biliary involvement. Medical therapy or PAIR (percutaneous aspiration, irrigation with scolicide and re-aspiration) may be appropriate in selected cases; however, surgery remains the definitive treatment for active, large (>5 cm), symptomatic or complicated cysts. A variety of surgical techniques have been described, including conservative, radical and minimally invasive procedures. There is currently no consensus approach; surgical modality should be tailored to patient factors, relevant anatomy, local facilities and surgeons' expertise. CONCLUSION: Diagnosis and therapy in hepatic hydatid cysts have been significantly advanced by imaging, interventional radiology and surgical approaches in recent years. Surgery remains the mainstay of treatment for large, active, complicated or symptomatic hepatic hydatid cysts.

Evaluation of bovine cutaneous delayed-type hypersensitivity (DTH) to various test antigens and a mitogen using several adjuvants.

The Bacillus Calmette Guerin (BCG)-induced/purified protein derivative (PPD)-elicited tuberculin skin test is a reliable measure of cell-mediated immune response (CMIR), specifically delayed-type hypersensitivity (DTH); however, its use in livestock may confound diagnosis of Mycobacterium tuberculosis. Therefore, various alternative antigen/adjuvant combinations were evaluated as inducers of DTH that were compared to the BCG/PPD test system with the purpose of finding a skin DTH protocol that does not cross-react with the tuberculin test and allows identification of high and low CMIR responder phenotypes. Specifically, 30 non-lactating cows (five/treatment) were sensitized on day 0 with mycobacteria [BCG, M. tuberculosis or Mycobacterium phlei cell wall extract (MCWE)], and ovalbumin (OVA) emulsified in Freund's complete adjuvant (FCA), non-ulcerative Freund's adjuvant (NUFA), complete NUFA or MCWE. On day 21, cows were injected intradermally with various test antigens including PPD tuberculin, phlein, and OVA. Phosphate buffered saline was included as the negative control and the T-cell mitogen phytohemagglutinin (PHA) was also administered. Double skin-fold thickness was evaluated before and at 6, 24, and 48 h post-injection. Skin biopsies were taken at 24 and 48 h to assess oedema, necrosis, and inflammatory cell infiltration. BCG/PPD and M. phlei/phlein treatments when given with a Freund's adjuvant induced equivalent DTH with peak reactions at 24-48 h after antigen injection. Cows receiving NUFA had fewer injection site granulomas than FCA or CNUFA treatments. The change in skin thickness response to PHA peaked at 6 h. Only cows receiving mycobacteria in NUFA had skin response to OVA, which peaked 6-24 h post-injection. Only sites tested with PPD or phlein had significantly higher lymphocyte infiltration than control, whereas neutrophils were significantly higher at PHA test sites and eosinophils predominated at the PHA test sites. Macrophages were significantly more numerous at the PPD and/or phlein test sites in treatment groups that received killed mycobacteria in a Freund's adjuvant and/or with BCG, and at the PHA test sites in all treatment groups. It was concluded that the M. phlei/phlein system did induce DTH and was similar to the DTH induced by the BCG/PPD system when MCWE was administered with a Freund's adjuvant. Therefore, this protocol is suitable for detecting high/low CMIR responders in research herds. However, cross-reaction to PPD was evident following induction of DTH using M. phlei. Hence, this protocol does not alleviate the problem of artificial induction of DTH cross-reactivity and would not be suitable for commercial herds where tuberculin testing is required.