Perforating and nonperforating indications in repeated surgeries for Crohn's disease.

BACKGROUND: Despite advances in medical therapy for Crohn's disease (CD), most patients with CD require repeated resection surgeries. AIM: To analyze the perforating and nonperforating indications of repeated CD operations and identify the anastomosis characteristics for postoperative CD. METHODS: We retrospectively reviewed 386 patients who underwent at least one resection for CD between 2003 and 2013.Clinical characteristics of each surgery were collected. Univariate and multivariate analyses were performed to determine risk factors for recurrence. RESULTS: The indication for reoperation in CD tends to be the same as that for primary operation, i.e., perforating disease tends to represent as perforating disease and nonperforating as nonperforating. Concordance was found between the first surgery and second surgery in terms of the indication for the operation (P = 0.006), and the indication for the third surgery was also correlated with that for the second surgery (P = 0.033). Even if the correlation of surgical indications between repeated operations, the rate of perforating indication for the second and third surgeries was significantly higher than that of the first surgery. In addition, the presence of perforating CD was a predictor of recurrence for both the first and second surgeries. Moreover, anastomotic lesions were the most common sites of recurrence after the operation. Based on the importance of anastomosis, anastomosis might be a new type of disease location for the classification of postoperative CD. CONCLUSION: CD not only has stable characteristics but also progresses chronically. Perforation is a progressive surgical indication for Crohn's disease. For CD after surgery, anastomosis may be a new classification of disease location.

Role of mesenteric component in Crohn's disease: A friend or foe?

Crohn's disease (CD) is a complex and relapsing gastrointestinal disease with mesenteric alterations. The mesenteric neural, vascular, and endocrine systems actively take part in the gut dysbiosis-adaptive immunity-mesentery-body axis, and this axis has been proven to be bidirectional. The abnormalities of morphology and function of the mesenteric component are associated with intestinal inflammation and disease progress of CD via responses to afferent signals, neuropeptides, lymphatic drainage, adipokines, and functional cytokines. The hypertrophy of mesenteric adipose tissue plays important roles in the pathogenesis of CD by secreting large amounts of adipokines and representing a rich source of proinflammatory or profibrotic cytokines. The vascular alteration, including angiogenesis and lymphangiogenesis, is concomitant in the disease course of CD. Of note, the enlarged and obstructed lymphatic vessels, which have been described in CD patients, are likely related to the early onset submucosa edema and being a cause of CD. The function of mesenteric lymphatics is influenced by endocrine of mesenteric nerves and adipocytes. Meanwhile, the structure of the mesenteric lymphatic vessels in hypertrophic mesenteric adipose tissue is mispatterned and ruptured, which can lead to lymph leakage. Leaky lymph factors can in turn stimulate adipose tissue to proliferate and effectively elicit an immune response. The identification of the role of mesentery and the crosstalk between mesenteric tissues in intestinal inflammation may shed light on understanding the underlying mechanism of CD and help explore new therapeutic targets.

Comparison of primary anastomosis and staged surgery in emergency treatment of complicated Crohn's disease.

OBJECTIVES: Staged surgery (SS) and primary anastomosis (PA) are alternatives to emergency surgery in Crohn's disease (CD). This study aimed to compare postoperative patient outcomes and medical cost of SS and PA for CD emergencies. METHODS: Consecutive patients with CD undergoing emergency surgery between December 1997 and January 2017 in three centers were included. The PA and SS groups were compared regarding patient outcomes including postoperative complications and surgical recurrence, as well as hospitalization costs. RESULTS: Altogether 96 (39.5%) patients underwent an emergency PA, and 147 (60.5%) underwent an emergency SS. The incidence of intra-abdominal septic complications (IASC) in the PA group was 15.6% compared with 7.5% in the SS group (P = 0.04). The length of hospitalization was longer (32.36 ± 1.76 d vs 19.33 ± 2.36 d, P <0.01) and the hospitalization cost was higher in the SS group (USD 15 811.1 ± 1697.1 vs USD 8345.3 ± 919.5, P <0.01) than the PA group. SS correlated with a lower surgical recurrence rate than PA (log-rank test, P = 0.04). Presence of diffuse peritonitis, perforating or colonic disease, decision of operation choice made by a senior consultant and more than two concurrent surgical indications were related to the need for SS in emergencies. Localized peritonitis, body mass index (>18.5 kg/m2 ) and iatrogenic perforation were significantly associated with a low risk of IASC in the PA group. CONCLUSION: SS can be performed with limited IASC and low surgical recurrence rates for surgical emergencies in CD, although it increases hospitalization costs and delays discharge.

Prospective evaluation of intestinal decompression in treatment of acute bowel obstruction from Crohn's disease.

BACKGROUND: Conservative therapy for Crohn's disease (CD)-related acute bowel obstruction is essential to avoid emergent surgery. The present study aimed to evaluate the efficacy of using a long intestinal decompression tube (LT) in treatment of CD with acute intestinal obstruction. METHODS: This is a prospective observational study. Comparative analysis was performed in CD patients treated with LT (the LT group) and nasogastric tube (the GT group). The primary outcome was the avoidance of emergent surgery. Additionally, predictive factors for failure of decompression and subsequent surgery were investigated. RESULTS: There were 27 and 42 CD patients treated with LT and GT, respectively, in emergent situations. Twelve (44.4%) patients using LT were managed conservatively without laparotomy, while only nine (21.4%) patients in the GT group were spared from emergent surgery (P < 0.05). Both in surgery-free and in surgery patients, the time to alleviation of symptoms was significantly shorter in the LT groups than in the GT groups (both P < 0.01). C-reactive protein decrease after intubation and 48-hour drainage volume >500 mL were predictors of unavoidable surgery (both P < 0.05). The rate of temporary stoma and incidence of incision infection in the LT surgery group were significantly lower than those in the GT group (both P < 0.05). No significant differences were observed in the frequency of medical and surgical recurrences between the LT and GT groups (all P > 0.05). CONCLUSIONS: Endoscopic placement of LT could improve the emergent status in CD patients with acute bowel obstruction. The drainage output and changes in C-reactive protein after intubation could serve as practical predictive indices for subsequent surgery. Compared to traditional GT decompression, LT decompression was associated with fewer short-term complications and did not appear to affect long-term recurrence.

Bisindolylmaleimide alkaloid BMA-155Cl induces autophagy and apoptosis in human hepatocarcinoma HepG-2 cells through the NF-κB p65 pathway.

Bisindolylmaleimides, a series of derivatives of a PKC inhibitor staurosporine, exhibit potential as anti-cancer drugs and have received considerable attention in clinical trials. This study aims to investigate the effects of a bisindolylmaleimide alkaloid 155Cl (BMA-155Cl) with a novel structure on autophagy and apoptosis in human hepatocarcinoma HepG-2 cells in vitro and in vivo. The cell poliferation was assessed with a MTT assay. Autophagy was evaluated by MDC staining and TEM analysis. Apoptosis was investigated using Annexin V-FITC/PI and DAPI staining. The antitumor effects were further evaluated in nude mice bearing HepG-2 xenografts, which received BMA-155Cl (10, 20 mg/kg, ip) for 18 days. Autophagy- and apoptosis-associated proteins and their mRNA levels were examined with Western blotting, immunohistochemistry, and RT-PCR. BMA-155Cl (2.5-20 µmol/L) inhibited the growth of HepG-2 cells with IC50 values of 16.62±1.34, 12.21±0.83, and 8.44±1.82 µmol/L at 24, 48, and 72 h, respectively. Furthermore, BMA-155Cl (5-20 µmol/L) dose-dependently induced autophagy and apoptosis in HepG-2 cells. The formation of autophagic vacuoles was induced by BMA-155Cl (10 µmol/L) at approximately 6 h and peaked at approximately 15 h. Pretreatment with 3-MA potentiated BMA-155Cl-mediated apoptotic cell death. This compound dose-dependently increased the mRNA and protein levels of Beclin-1, NF-κB p65, p53, and Bax, but decreased the expression of IκB and Bcl-2. Pretreatment with BAY 11-7082, a specific inhibitor of NF-κB p65, blocked BMA-155Cl-induced expression of autophagy- and apoptosis-associated proteins. BMA-155Cl administration effectively suppressed the growth of HepG-2 xenografts in vivo, and increased the protein expression levels of LC3B, Beclin-1, NF-κB p65, and Bax in vivo. We conclude that the NF-κB p65 pathway is involved in BMA-155Cl-triggered autophagy, followed by apoptosis in HepG-2 cells in vitro and in vivo. Hence, BMA-155Cl could be a promising pro-apoptotic candidate for developing as a novel anti-cancer drug.

Endoscopic closure instead of surgery to close an ileal pouch fistula with the over-the-scope clip system.

An ileal pouch fistula is an uncommon complication after an ileal pouch anal anastomosis. Most patients who suffer from an ileal pouch fistula will need surgical intervention. However, the surgery can be invasive and has a high risk compared to endoscopic treatment. The over-the-scope clip (OTSC) system was initially developed for hemostasis and leakage closure in the gastrointestinal tract during flexible endoscopy. There have been many successes in using this approach to apply perforations to the upper gastrointestinal tract. However, this approach has not been used for ileal pouch fistulas until currently. In this report, we describe one patient who suffered a leak from the tip of the "J" pouch and was successfully treated with endoscopic closure via the OTSC system. A 26-year-old male patient had an intestinal fistula at the tip of the "J" pouch after an ileal pouch anal anastomosis procedure. He received endoscopic treatment via OTSC under intravenous anesthesia, and the leak was closed successfully. Endoscopic closure of a pouch fistula could be a simpler alternative to surgery and could help avoid surgery-related complications.

Docosahexaenoic Acid Attenuated Experimental Chronic Colitis in Interleukin 10-Deficient Mice by Enhancing Autophagy Through Inhibition of the mTOR Pathway.

BACKGROUND: In the battle against Crohn's disease, autophagy stimulation is a promising therapeutic option-one both new and newly rediscovered. In experimental models, docosahexaenoic acid (DHA)-a long-chain polyunsaturated fatty acid-has been demonstrated to be useful in the treatment of inflammatory bowel disease through inhibition of the nuclear factor-κB pathway. However, the impact of DHA on autophagy in the colon remains unclear. METHODS: Mice were divided into 3 groups: wild type (placebo), the interleukin 10 knockout group (IL-10-/-, placebo), and the DHA group (IL-10-/-, DHA). DHA was administered to IL-10-/- mice by gavage at a dosage of 35.5 mg/kg/d for 2 weeks. The severity of colitis, expression of proinflammatory cytokines, expression/distribution of LC3B, and mTOR signaling pathway were evaluated in the proximal colon tissues collected from all mice at the end of the experiment. RESULTS: DHA administration ameliorated experimental colitis in the IL-10-/- mice, as demonstrated by decreased proinflammatory cytokines (TNF-α and IFN-γ), reduced infiltration of inflammatory cells, and lowered histologic scores of the proximal colon mucosa. Moreover, in the DHA-treated mice, enhanced autophagy was observed to be associated with (1) increased expression and restoration of the distribution integrity of LC3B in the colon and (2) inhibition of the mTOR signaling pathway. CONCLUSION: This study showed that DHA therapy could attenuate experimental chronic colitis in IL-10-/- mice by triggering autophagy via inhibition of the mTOR pathway.

DHA protects against experimental colitis in IL-10-deficient mice associated with the modulation of intestinal epithelial barrier function.

A defect in the intestinal barrier is one of the characteristics of Crohn's disease (CD). The tight junction (TJ) changes and death of epithelial cells caused by intestinal inflammation play an important role in the development of CD. DHA, a long-chain PUFA, has been shown to be helpful in treating inflammatory bowel disease in experimental models by inhibiting the NF-κB pathway. The present study aimed at investigating the specific effect of DHA on the intestinal barrier function in IL-10-deficient mice. IL-10-deficient mice (IL-10(-/-)) at 16 weeks of age with established colitis were treated with DHA (i.g. 35.5 mg/kg per d) for 2 weeks. The severity of their colitis, levels of pro-inflammatory cytokines, epithelial gene expression, the distributions of TJ proteins (occludin and zona occludens (ZO)-1), and epithelial apoptosis in the proximal colon were measured at the end of the experiment. DHA treatment attenuated the established colitis and was associated with reduced infiltration of inflammatory cells in the colonic mucosa, lower mean histological scores and decreased levels of pro-inflammatory cytokines (IL-17, TNF-α and interferon-γ). Moreover, enhanced barrier function was observed in the DHA-treated mice that resulted from attenuated colonic permeability, rescued expression and corrected distributions of occludin and ZO-1. The results of the present study indicate that DHA therapy may ameliorate experimental colitis in IL-10(-/-) mice by improving the intestinal epithelial barrier function.

Celastrol ameliorates experimental colitis in IL-10 deficient mice via the up-regulation of autophagy.

BACKGROUND: Celastrol had been proved effective in the treatment for IBD, probably with the modulation of oxidative stress, inflammatory cytokines and intestinal homeostasis. This study was aimed to investigate whether celastrol could ameliorate the inflammation of IL-10 deficient mice, a murine model of Crohn's disease (CD) with the induction of autophagy. MATERIAL AND METHODS: The mice included were divided into four groups, ##WT group, IL-10(-/-) group, Cel group and Control group (celastrol+3-Methyladenine). Celastrol (2 mg/kg) treatment by gavage was administered to mice daily over one week. 3-Methyladenine (autophagy inhibitors) was administered at a dose of 30 mg/kg by intraperitoneal injection. The histological evaluation of the colon, tissue myeloperoxidase (MPO), and colon inflammation of mice in the four groups was evaluated and compared. Furthermore, the PI3K/Akt/mTOR pathway and the status of autophagy in intestine affected by celastrol were also assessed. RESULTS: The one-week administration of celastrol ameliorated established colitis in IL-10 deficient mice, associated with a reduction of marked histological inflammation, a decreased colon MPO concentration and suppression of colonic proinflammatory cytokine. Furthermore, the decreased neutrophil infiltration in proximal colon and improvement of inflammation in the Cel group was much more obvious than that in the Control group. The Western blotting analysis of the PI3K/Akt/mTOR pathway and autophagy showed that celastrol treatment up-regulated the autophagy of colon tissue by suppressing the PI3K/Akt/mTOR signaling pathway. CONCLUSIONS: Celastrol ameliorates experimental colitis in IL-10 deficient mice via the up-regulation of autophagy by suppressing the PI3K/Akt/mTOR signaling pathway.

Effectiveness of a clinical pathway for inpatients undergoing ileal/ileocecal resection for chronic radiation enteritis with intestinal obstruction.

Surgery is associated with elevated morbidity and mortality in chronic radiation enteritis (CRE). The objective of this study was to evaluate the effect of a fast-track clinical pathway (CP) on postoperative outcomes in patients undergoing ileal/ileocecal resection for CRE with intestinal obstruction. There were 85 patients with CRE (January 2011 to March 2013) with intestinal obstruction admitted to our department for ileal/ileocecal resection. The patients were divided into a prepathway group and a pathway group. The clinical outcomes were then assessed and compared. The postoperative lengths of hospital stay were 8.52 days for the pathway group and 11.32 days for the prepathway group (P = 0.02). The pathway group had a lower stoma rate (21.6 vs 56%, P = 0.033) and fewer postoperative moderate to severe complications (8.1 vs 25%, P = 0.043) compared with the prepathway group. Implementation of the CP may reduce stoma rate, postoperative moderate to severe complications, and postoperative length of hospital stay for patients undergoing ileal/ileocecal resection for the treatment of CRE with intestinal obstruction.

Impact of enteral nutrition on energy metabolism in patients with Crohn's disease.

AIM: To investigate the impact of enteral nutrition (EN) on the body composition and metabolism in patients with Crohn's disease (CD). METHODS: Sixty-one patients diagnosed with CD were enrolled in this study. They were given only EN (enteral nutritional suspension, TPF, non-elemental diet) support for 4 wk, without any treatment with corticosteroids, immunosuppressive drugs, infliximab or by surgical operation. Body composition statistics such as weight, body mass index, skeletal muscle mass (SMM), fat mass, protein mass and inflammation indexes such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and CD activity index (CDAI) were recorded before and after EN support. RESULTS: The 61 patients were divided into three groups according to CDAI before and after EN support: A (active phase into remission via EN, n=21), B (remained in active phase before and after EN, n=19) and C (in remission before and after EN, n=21). Patients in group A had a significant increase in SMM (22.11±4.77 kg vs 23.23±4.49 kg, P=0.044), protein mass (8.01±1.57 kg vs 8.44±1.45 kg, P=0.019) and decrease in resting energy expenditure (REE) per kilogram (27.42±5.01 kcal/kg per day vs 22.62±5.45 kcal/kg per day, P<0.05). There was no significant difference between predicted and measured REE in active CD patients according to the Harris-Benedict equation. There was no linear correlation between the measured REE and CRP, ESR or CDAI in active CD patients. CONCLUSION: EN could decrease the hypermetabolism in active CD patients by reducing the inflammatory response.

Thromboelastography can Identify Postoperative Active Bleeding and Evaluate Blood Product Requirements in Abdominal Surgery.

BACKGROUND/AIMS: Hemorrhage after abdominal surgery remains a frequent clinical complication, and associated with prolonged length of stay, increased complications and mortality. Indication of blood product requirements accurately and promptly is very important for recovery of patients. Thrombelastography (TEG) as a tool for evaluation of bleeding and effects of blood components and blood products is increasing. We investigated that whether TEG can identify postoperative active bleeding and evaluate blood product requirements in abdominal surgery. METHODOLOGY: Between June to December in 2012, there were 55 patients who had bleeding after operation in SICU of Jinling Hospital. Recorded data included vital signs (MAP, heart rate, respiratory rate, blood oxygen saturation), urine volume per hour, blood routine (Hb, Hct, Plt), the coagulation tests (Fib, PT, aPTT, INR), TEG parameters (R, K, Angle, MA, Cl) and blood product requirements within 24h. Patients were divided into active bleeding group and non-active bleeding group based on the findings of reoperation or digital subtraction angiography (DSA). To compare vital signs, laboratory values, TEG values and blood product requirements in two groups. RESULTS: Vital signs (MAP, heart rate, respiratory rate, blood oxygen saturation), urine volume per hour and the coagulation tests (Fib, PT, INR) showed no significant correlations with subsequent blood product requirements, but aPTT (R = 0.546, P = 0.000) and MA (R = 0.665, P = 0.000) correlated with the blood products use. MA values of patients had more blood loss was significantly lower and had a descending tendency which did not showed in aPTT values. 25 patients had postoperative active bleeding confirmed by reoperation or DSA. They had significantly increased use of blood products, and significantly lower MA, Hb, Hct, and Fib values, whereas aPTT exhibited no significant differences. CONCLUSION: MA can not only identify postoperative active bleeding together with hemoglobin, hematocrit, and fibrinogen, but also evaluate blood product requirements in abdominal surgery.

[A comparative study of induction of remission and cost-effectiveness of enteral nutrition versus infliximab in moderate-to-severe Crohn's disease].

OBJECTIVE: To compare the induction of remission and cost-effectiveness of enteral nutrition (EN) and infliximab (IFX) in moderate-to-severe active Crohn's disease(CD). METHODS: Moderate-to-severe active CD patients were divided into IFX group and EN group. Remission rate, time to remission and treatment cost were compared between the two groups. Clinical remission was defined as Crohn's disease activity index (CDAI) < 150. The quality of life was evaluated by inflammatory bowel disease questionnaire of quality of life (IBDQ). RESULTS: A total of 100 patients were analyzed, including 48 patients in IFX group and 52 patients in EN group. IFX group had higher remission rate [87.5% (42/48) vs 67.3% (35/52) , P = 0.017] and shorter time to remission [(11.00 ± 8.35) days vs (33.94 ± 14.60) days, P < 0.001] than EN group. Treatment costs before remission were similar in two groups (P = 0.351) . The increase of IBDQ scores before and after treatment in IFX group was much higher than that of EN group (42.74 ± 27.50 vs 7.57 ± 22.77, P < 0.001) . Similarly, patients in EN group had greater increase of body mass index (BMI) than that of IFX group [(1.32 ± 0.29)kg/m(2) vs (0.51 ± 0.07) kg/m(2), P < 0.001]. For patients with CDAI < 280, remission rate was not significantly different [85.7% (24/28) vs 81.8% (18/22) , P = 0.718] between the two groups, while treatment cost in EN group was less than that of IFX group [(16.1 ± 5.9)×10(3) RMB vs (22.9 ± 11.9)×10(3) RMB, P = 0.021]. CONCLUSIONS: For patients with severe CD (CDAI ≥ 280), IFX has higher remission rate, shorter time to remission and comparable treatment cost than EN. But for patients with CDAI < 280, EN group has comparable remission rate to IFX group with lower cost.

[Surgical treatment for idiopathic abdominal cocoon].

OBJECTIVE: To investigate diagnosis and treatment of abdominal cocoon. METHODS: Clinical data of patients received treatment for abdominal cocoon from January 2000 to January 2011 was retrospectively analyzed. RESULTS: A total of 67 patients underwent treatment in our hospital were analyzed, the preoperatively diagnosis rate was only 47.8% (32/67). Patients who received preoperatively nutrition support have a lower postoperative complication (8/27 vs.13/20, χ(2) = 5.815, P < 0.05) and patients with less extent of intestine involved had a lower early postoperative inflammatory ileus (EPII) rate (9/25 vs. 1/22, χ(2) = 6.912, P < 0.05) when compared with large extent. CONCLUSIONS: Appropriate perioperative management play an important role in the prognosis of abdominal cocoon. The main treatment is surgery while preoperatively nutrition support can reduce postoperative complications.

[Damage control surgery directed surgical treatment of Crohn disease].

Damage control surgery (DCS) has been widely used in the management of surgical patients. Crohn disease (CD) patients requiring surgery are usually severe and associated with high surgical risk, while the concept of DCS has not gained adequate attention in surgery for CD. Surgery is indicated in patients with CD to control symptoms, therefore major surgery should not be performed when the general health of the patients is not satisfactory. Use of DCS to guide surgery can reduce risk of treatment and improve clinical outcome The review is to discuss the necessity, objective, and methods of damage control surgery in the surgical treatment of Crohn disease.

[Timing of surgery in inflammatory bowel disease].

Surgery is an integral part in the treatment of inflammatory bowel disease. Timely surgery is very necessary and can reduce the risk of postoperative complications. Overemphasizing the importance of medical therapy and prolonged use attempting to evade surgery can not maximize the efficacy of medical treatment, but may miss the optimal chance of surgical treatment. It has already been confirmed that ineffective medical treatment, corticosteroid use, malnutrition and infection are the risk factors of surgical complications and should be avoided. Emergency operation and operation at active stage of IBD also increase the surgical risk. Gastroenterologists should be responsible for the judgment of surgery timing and create surgical conditions for the patients with surgical indications.

[Influence of preoperative nutritional support on surgical outcomes of chronic radiation enteritis patients complicated with intestinal obstruction].

OBJECTIVE: To investigate the effect of preoperative nutritional support in the management of patients with chronic radiation enteritis (CRE) with intestinal obstruction undergoing resectional surgery. METHODS: Clinical data of 158 CRE patients undergoing diseased bowel resection from 2001 to 2011 were analyzed retrospectively. A total of 130 patients received preoperative nutritional support, including 28 patients with enteral nutrition support, 60 patients with total parenteral nutrition support, and 42 patients with combined nutritional support. The nutritional parameters, procedures, operation-related complications, and postoperative hospital stay were recorded. RESULTS: After aggressive nutritional support in 130 patients, patients nutritional index, such as serum prealbumin, transferrin, serum albumin improved significantly preoperatively, while the change of body mass index and hemoglobin was not significant. Compared to those without preoperative nutritional support, those who received preoperative nutritional support had lower stoma rate (31.5% vs. 53.6%, P=0.027), less postoperative infection rate (13.8% vs. 32.1%, P=0.019), shorter postoperative hospital stay [(14.1±7.3) d vs. (18.8±15.8) d, P=0.013). Enteral nutrition group had less postoperative infection rate (7.1% vs. 21.7%, P=0.017), lower stoma rate (28.6% vs. 48.3%, P=0.02), and shorter postoperative hospital stay [(15.5±9.6) d vs. (21.7±19.0) d, P=0.025) as compared to total parenteral nutrition group. CONCLUSIONS: Preoperative nutritional support can decrease the stoma rate, postoperative infection rate, and shorten hospital stay in CRE patients complicated with intestinal obstruction. If tolerated, enteral nutrition support should be chosen.

Conservative treatment of early postoperative small bowel obstruction with obliterative peritonitis.

AIM: To investigate the effect of somatostatin and dexamethasone on early postoperative small bowel obstruction with obliterative peritonitis (EPSBO-OP). METHODS: This prospective randomized study included 70 patients diagnosed with EPSBO-OP from June 2002 to January 2009. Patients were randomized into two groups: a control group received total parenteral nutrition and nasogastric (NG) tube feeding; and an intervention group received, in addition, somatostatin and dexamethasone treatment. The primary endpoints were time to resolution of bowel obstruction and length of hospital stay, and the secondary endpoints were daily NG output and NG feeding duration, treatment-related complications, postoperative obstruction relapse, and patient satisfaction. RESULTS: Thirty-six patients were allocated to the intervention group and 34 to the control group. No patient needed to undergo surgery. Patients in the intervention group had an earlier resolution of bowel obstruction (22.4 ± 9.1 vs 29.9 ± 10.1 d, P = 0.002). Lower daily NG output (583 ± 208 vs 922 ± 399 mL/d, P < 0.001), shorter duration of NG tube use (16.7 ± 8.8 vs 27.7 ± 9.9 d, P < 0.001), and shorter length of hospital stay (25.8 vs 34.9 d, P = 0.001) were observed in the intervention group. The rate of treatment-related complications (P = 0.770) and relapse of obstruction (P = 0.357) were comparable between the two groups. There were no significant differences in postoperative satisfaction at 1, 2 and 3 years between the two groups. CONCLUSION: Somatostatin and dexamethasone for EPSBO-OP promote resolution of obstruction and shorten hospital stay, and are safe for symptom control without increasing obstruction relapse.

Restricted intravenous fluid regimen reduces fluid redistribution of patients operated for abdominal malignancy.

BACKGROUND/AIMS: Recent studies indicate that perioperative fluid restriction leads to better preserved clinical data as well as reduced complication rates. This study aimed to determine the probable mechanism of fluid restriction influence on the complication rate of patients undergoing gastrointestinal surgery for malignancy. METHODOLOGY: Patients (n = 174) undergoing restricted fluid regimen (R group) or standard fluid regimen (S group) were included in this prospective, randomized trial over 16 months. Fluid distribution was determined by Bioelectrical Impedance Analyzer (BIA) and the difference between two groups was compared regarding complications and the relationship between complications and fluid distribution changes. RESULTS: The restricted intravenous fluid regimen significantly reduced perioperative intravenous fluid volume. Weight gained in S group and was not significantly changed in R group after surgery, especially in POD2 (media; R vs. S; 61.17 vs. 65.40 kg, p = 0.017). The number of patients with postoperative complications was reduced in R group compared with in S group (34.5% vs. 47.8%, p = 0.076). Systemic complications were significantly reduced in R group (t = -5.895, p = 0.000). Patients with complications had an average of 1.6 complications in R group vs. 2.0 in S group (t = -1.345, p = 0.183). The multivariate analysis suggested that perioperative fluid distribution changes were associated with the development of postoperative complications. CONCLUSIONS: Perioperative fluid restriction could effect on fluid distribution and reduce tissue and cellular edema, and further, could reduce postoperative complication rates.

[Impact of disease activity on postoperative recurrence and complications after bowel resection for Crohn's disease].

OBJECTIVE: To determine whether the perioperative disease activity is associated with recurrence and complications after bowel resection for Crohn's disease (CD). METHODS: Clinical data of patients underwent bowel resection for CD at the Nanjing General Hospital of Nanjing Military Command from January 2002 to January 2011 was retrospectively analyzed. Postoperative recurrence and complications in patients with active disease were compared with those in patients with remission. RESULTS: A total of 90 patients underwent bowel resection for CD, active disease were seen in 43 patients at the time of surgery, while the rest 47 patients were in remission. The postoperative cumulative endoscopic recurrence rate was 8.5% at 1 year, 27.7% at 2 years and 44.7% at 3 years in the patients with remission, and was 27.9% at 1 year, 37.2% at 2 years and 53.5% at 3 years in patients with active disease. Data indicated the endoscopic recurrence were statistically significant in the first year after surgery (χ² = 4.605, P = 0.032). Additional, the postoperative complication rates in patients with remission (14.9%) was significantly lower than that in patients with active disease (51.2%) (χ² = 6.979, P < 0.001). CONCLUSION: Patients with active disease at the time of surgery were encountered with early postoperative recurrence and increased complications after intestinal resection for CD.