Laparoscopic surgery contributes to a decrease in short-term complications in surgical ulcerative colitis patients during 2008–2017: a multicenter retrospective study in China

Background/Aims@#The aim of this study was to analyze the chronological changes in postoperative complications in surgical ulcerative colitis patients over the past decade in China and to investigate the potential parameters that contributed to the changes. @*Methods@#Ulcerative colitis patients who underwent surgery during 2008–2017 were retrospectively enrolled from 13 hospitals in China. Postoperative complications were compared among different operation years. Risk factors for complications were identified by logistic regression analysis. @*Results@#A total of 446 surgical ulcerative colitis patients were analyzed. Fewer short-term complications (24.8% vs. 41.0%, P=0.001) and more laparoscopic surgeries (66.4% vs. 25.0%, P<0.001) were found among patients who received surgery during 2014–2017 than 2008–2013. Logistic regression suggested that independent protective factors against short-term complications were a higher preoperative body mass index (odds ratio [OR], 0.870; 95% confidence interval [CI], 0.785–0.964; P=0.008), laparoscopic surgery (OR, 0.391; 95% CI, 0.217–0.705; P=0.002) and elective surgery (OR, 0.213; 95% CI, 0.067–0.675; P=0.009). The chronological decrease in short-term complications was associated with an increase in laparoscopic surgery. @*Conclusions@#Our data revealed a downward trend of short-term postoperative complications among surgical ulcerative colitis patients in China during the past decade, which may be due to the promotion of minimally invasive techniques among Chinese surgeons.

Association between body mass index and physical fitness index among secondary school students in Jiangxi Province / 中国学校卫生

Objective@#To measure the body mass index (BMI) of secondary school students and analyze its association with the physical fitness index, so as to improve the physical health of middle school students.@*Methods@#Using a randomized cluster stratified sampling method, 3 813 secondary school students from six cities (Ganzhou, Ji an, Fuzhou, Nanchang, Shangrao and Jiujiang) in Jiangxi Province, China, were selected in September 2022. Questionnaire survey was administered to obtain basic information and to assess the nutritional status and physical fitness tests were conducted among secondary school students. The study was stratified by gender and age, and the Kruskal Wallis H test was used to compare the differences in the mean values of grip strength, sit-ups, standing long jump performance and strength quality among secondary school students with different BMI levels, while the correlation between BMI and strength quality index was inferred by using curve regression analysis.@*Results@#There was statistical significance in the strength quality index of middle school students with different BMI level ( H=56.79, 8.84, P <0.05). Except 13 years old group, the difference of physical fitness by BMI grade strength quality index of boys in other age groups was statistically significant ( H =22.21, 16.23, 17.98, 18.21, 8.08), while the difference of physical fitness by BMI of girls at 14 years old was statistically significant ( H =9.11)( P <0.05). The curve fitting using regression showed that the physical fitness index and BMI of middle school students (boys and girls) show an inverted U-shaped curve. The physical fitness index was higher in the middle region of BMI ( Z-score) and lower in the two end regions, while showing a decreasing trend from the middle to the two ends.@*Conclusion@#An association is found between BMI and physical fitness among secondary school students in Jiangxi Province, and wasting and overweight/obesity are negatively correlated with physical fitness. Greater attention should be paid to the nutritional status of secondary school students to ensure the normal development of physical fitness.

Intraoperative inspection alone is a reliable guide to the choice of surgical procedure for enteroenteric fistulas in Crohn's disease

BACKGROUND/AIMS: Resection of the diseased segment and suture of the victim segment is recommended for enteroenteric fistula in Crohn's disease (CD). The main difficulty in this procedure remains reliable diagnosis of the victim segment, especially for fistulas found intraoperatively and inaccessible on endoscopic examination. We aimed to explore whether intraoperative inspection alone is reliable. METHODS: Patients undergoing conservative surgery between 2011 and 2016 for enteroenteric fistulas complicating CD were identified from a prospectively maintained database. Patients were divided according to whether the victim segment was evaluated by preoperative endoscopy + intraoperative inspection (PI group) or by intraoperative inspection alone (I group). Outcomes were compared. RESULTS: Of 65 patients eligible for the study, 37 were in in the PI group and 28 were in the I group. The baseline characteristics were similar between the groups, except for the rate of emergency surgery (0/37 in PI group vs. 5/28 in I group, P=0.012). Fistulas involved more small intestines (4/37 in PI group vs. 15/28 in I group, P 0.05). CONCLUSIONS: For fistulas found intraoperatively and inaccessible on endoscopic examination, intraoperative inspection was a reliable guide when choosing between en bloc resection and a conservative procedure.

Consistency analysis between preoperative CT enterography and intraoperative findings in patients undergoing surgery for Crohn's disease / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the diagnostic value of preoperative CT enterography (CTE) on obstruction, fistula and abscess formation compared to intraoperative findings in patients undergoing surgery for Crohn's disease(CD), aiming to provide reference to clinical practice.</p><p><b>METHODS</b>Preoperative CTE data of 176 CD patients confirmed by clinic, endoscopy, imaging, operation and pathology at the Department of General Surgery in Nanjing Jinling Hospital from January 2013 to December 2015 were enrolled in retrospective cohort study. All the patients underwent enhanced full abdominal CT scan using SIMENS SOMATOM Definition Flash 64 row dual-source CT machine. CTE scans were performed from the dome of diaphragm to the symphysis pubis. The CT images in arterial and venous phase were reconstructed with 1.0 mm thin layer, and then processed in MMWP 4.0 workstation including multi-planar recombination, surface recombination and maximum density projection. The sensitivity, specificity, positive and negative predictive value, false negative rate and accuracy of preoperative CTE on obstruction, fistula and abscess were compared with intraoperative findings.</p><p><b>RESULTS</b>Among 176 patients, 122 were males and 54 were females with median age of 29 (18 to 65) years, median disease duration of 48 (1 to 240) months, median time interval from CT scan to operation of 16(1 to 30) days, and median body mass index of 17.8 (10.8 to 34.7) kg/m. Twenty-six cases (14.8%) had nutritional risk (NRS2002≥3); 23 cases (13.1%) had lesions limited to ileum; 19 cases (10.8%) had lesions limited to colon; 126 cases (71.6%) had simultaneous lesions of ileum and colon, and 8 cases (4.5%) had lesion in upper gastrointestinal tract. A total of 199 lesions of small intestine were identified by preoperative CTE, including 131 of obstruction (65.8%), 42 of fistula (21.1%), and 26 of abscess (13.1%), while 235 lesions were confirmed by operation, including 133 of obstruction (56.6%), 74 of fistula (31.5%), 28 of abscess (11.9%). The modification of planned surgical procedure due to unexpected intraoperative findings were found in 29(16.5%) patients. The sensitivity, specificity, positive predictive value and negative predictive value of preoperative CTE were 86.4%, 78.8%, 86.9% and 76.0% for obstruction; 83.8%, 79.1%, 67.5% and 90.4% for fistula; and 96.2%, 98.0%, 90.1% and 99.3 for abscess, respectively.</p><p><b>CONCLUSION</b>Preoperative CTE can effectively evaluate the lesions of intestinal obstruction, fistula and abscess in CD patients, with the highest accuracy of abscess, and has quite good consistency with intraoperative findings, which may be used as the first choice of imaging diagnosis of CD.</p>

Effect of a clinical pathway in patients with Crohn's disease complicated with intestinal obstruction / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the effect of a clinical pathway for Crohn disease (CD) complicated with intestinal obstruction.</p><p><b>METHODS</b>CD patients complicated with intestinal obstruction in Inflammatory Bowel Disease(IBD) Center of Jinling Hospital were enrolled. One hundred and nineteen CD patients from March 2014 to September 2015 received treatment with the clinical pathway (CP), which was developed based on medical evidence and experience of the IBD center in February 2014, as CP group. The other 108 CD patients from September 2012 to February 2014 received treatment according to the management strategy made by individual attending physician as non-CP group. Rate of operation, rate of stoma, morbidity of surgical complications, hospital stay, hospital cost, and 6-month unplanned re-admission were compared between two groups.</p><p><b>RESULTS</b>The baseline data were similar between the two group (all P > 0.05). No significant differences were noted between these the two groups in terms of rate of operation (73.9% vs. 77.8%, P = 0.605), rate of stoma (15.9% vs. 25.0%, P = 0.197), and morbidity of surgical complications (23.9% vs. 27.4%, P = 0.724). However, the mean postoperative hospital stay was shorter (10.9 d vs. 13.2 d, P = 0.000), the mean hospital cost was less (78 325 Yuan vs. 85 310 Yuan, P = 0.031) and the rate of 6-month unplanned re-admission was lower(3.4% vs. 11.1%, P = 0.035) in CP group.</p><p><b>CONCLUSION</b>Treatment based on this CP for CD patients complicated with intestinal obstruction can reduce the rate of 6-month unplanned re-admission, shorten the postoperative hospital stay and decrease the hospital cost in patients requiring surgery.</p>

Serial Frozen Fecal Microbiota Transplantation in the Treatment of Chronic Intestinal Pseudo-obstruction: A Preliminary Study

BACKGROUND/AIMS: Chronic intestinal pseudo-obstruction (CIPO) is a serious, life-threatening motility disorder that is often related to bacterial overgrowth. Fecal microbiota transplantation (FMT) results in restoration of the normal intestinal microbial community structure. We investigated the efficacy of FMT in the treatment of CIPO patients. METHODS: Nine patients (age 18–53 years) with CIPO were enrolled in this prospective, open-label study. Patients received FMT for 6 consecutive days through nasojejunal (NJ) tubes and were followed up for 8 weeks after treatment. We evaluated the rate of clinical improvement and remission, feeding tolerance of enteral nutrition, and CT imaging scores of intestinal obstructions. Lactulose hydrogen breath tests were performed before FMT and 8 weeks after FMT to evaluate for the presence small intestinal bacterial overgrowth (SIBO). RESULTS: FMT significantly alleviated bloating symptoms, and symptoms of pain were relieved 2 weeks after FMT. Enteral nutrition administered through a NJ tube after FMT was well-tolerated by 66.7% (6/9) of patients. CT scores of intestinal obstructions were significantly reduced after FMT (P = 0.014). SIBO was eliminated in 71.0% (5/7) of patients. CONCLUSIONS: This pilot study demonstrated the safety of using FMT. FMT may relieve symptoms in selected patients with CIPO. FMT may also improve patient tolerance of enteral nutrition delivered via a NJ tube.

Short-term efficacy on fecal microbiota transplantation combined with soluble dietary fiber and probiotics in the treatment of slow transit constipation / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the efficacy and safety of fecal microbiota transplantation (FMT) combined with soluble dietary fiber and probiotics for slow transit constipation(STC).</p><p><b>METHODS</b>Twenty-three patients with STC from Jinling Hospital, Medical School of Nanjing University were prospectively enrolled between April 2015 and January 2016. STC patients received FMT combined with soluble dietary fiber and probiotics. Fresh stool(100 g) was immediately mixed in a blender with 500 ml of 0.9% sterile saline for several seconds, which was then filtered through a gauze pad and a decreasing number of gauze screen (2.0 to 0.5 mm). The fecal bacteria suspension was stored frozen at -20centi-degree. The preparation time of FMT material was less than 1 hour. Total time of treatment was 9 days. An initial oral antibiotics(vancomycin 500 mg orally twice per day) was given for 3 consecutive days. Then the fecal microbiota(100 ml) was infused slowly(5 min) through nasojejunal tube for 6 consecutive days. After FMT, patients were recommended to receive soluble dietary fiber (pectin, 8 g/d) and probiotics (bifid triple viable capsules, twice per day) for 4 weeks. Rates of clinical improvement and remission, adverse events, constipation-related symptoms (PAC-SYM scores), bowel movements per week and gastrointestinal quality-of-life index (GIQLI) were recorded during the 12-week follow-up. This study was registered in the Clinical Trials.gov (NCT02016469).</p><p><b>RESULTS</b>Among 23 patients, 7 were male, 16 were female, the mean age was (49.6±14.7) years, the body mass index was (21.2±2.2) kg/m, the duration of constipation was (8.3±5.9) years, and the defecation frequency was 1.8±0.7 per week. Compared with pre-treatment, PAC-SYM scores decreased significantly from 2.3±0.5 to 1.3±0.4 at week 12 (P<0.01), defecation frequency increased from 1.8±0.7 per week to 4.8±2.0 per week at week 12 (P<0.01), and patients felt satisfied with improved GIQLI score (from 78.5±15.5 to 120.8±21.3, P<0.01). During the follow-up, the clinical improvement and remission of STC patients reached 69.6%(16/23) and 52.2%(12/23), respectively. No serious adverse events were observed.</p><p><b>CONCLUSION</b>FMT combined with soluble dietary fiber and probiotics is safe and effective in treating slow transit constipation, which can improve the symptom and quality of life significantly.</p>

Nutrition Therapy in Crohn’s Disease / 胃肠病学

Nutrition therapy is an important part of the treatment of Crohn’s disease(CD),which plays an important role in correcting malnutrition,inducing disease remission,and for the perioperative management. Nutrition therapy, especially enteral nutrition(EN),has been studied for its effect on CD. We have long been focusing on the use of nutrition therapy in the treatment of CD,especially the use of EN in the perioperative management of CD. Here,we reviewed the indications,effects,endpoints and the underlying mechanisms of preoperative nutrition therapy,through which we hope can shed light on improving the optimization of preoperative management as well as the standardization of preoperative nutrition therapy in CD.

Outcomes of laparoscopy combined with enhanced recovery pathway for Crohn's disease: a case-matched analysis / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare short-term outcomes of laparoscopic vs. open intestinal resection in patients with Crohn's disease (CD) under enhanced recovery after surgery(ERAS) program.</p><p><b>METHODS</b>Clinical data of 51 CD patients receiving laparoscopic surgery under ERAS program at our IBD center between January 2013 and March 2014 were retrospectively analyzed. Laparoscopic cases were matched to those undergoing open surgery from June 2011 to December 2012 with age, gender, location and behavior of disease. Intraoperative and postoperative data were collected.</p><p><b>RESULTS</b>Fifty-one laparoscopic cases were matched with 51 open cases. Laparoscopic group had a shorter median length of postoperative hospital stay (7 d vs. 9 d, P=0.034), shorter median time to first passage of gas(45 h vs. 59 h, P=0.024), shorter time to bowel movement(58 h vs. 76 h, P=0.018), less intraoperative estimated blood loss (35 ml vs. 75 ml, P=0.034) and longer median operative time (145 min vs. 105 min, P=0.003). Postoperative complications, reoperation and 30-day re-admission rates were similar and there was no mortality in the two groups.</p><p><b>CONCLUSION</b>Laparoscopic surgery is a safe and acceptable option for CD patients, and it promotes recovery of gastrointestinal movement and shortens postoperative hospital stay.</p>

Analysis of clinicopathological factors of metastatic lymph node ratio in colorectal cancer / 国际外科学杂志

Objective To investigate the clinicopathological factors related with the lymph node ratio (LNR) in colorectal cancer patients.Methods The clinical and pathological data of 177 colorectal cancer patients who were treated by surgery in Shanghai Jiao Tong University Affiliated Sixth People's Hospital from January 2011 to December 2013 were collected.The association between LNR and clinicopathological factors were evaluated by single factor analysis nsingx x2 test.Results Gender,age,tumor location,tumor size,gross type,depth of infiltration,infiltration extent around bowel wall and preoperative serum CA199 concentration were not related with LNR (P ＞0.05),but tumor histological type,tumor differentiation,preoperative serum CEA,CA125 concentration were related with LNR (P =0.001,0.004,0.004,0.025).Conclusions Tumor histological type,tumor differentiation,preoperative serum CEA,CA125 may be the important factors related with LNR in colorectal cancer.

Nutrition support trerapy in chronic intestinal radiation damage / 中华胃肠外科杂志

Chronic radiation enteritis(CRE) is a common complication after pelvic radiotherapy, which severely affects patients' quality of life. Surgical treatment of CRE is challenging both for surgical skills and perioperative treatment strategy. Proper preoperative nutrition support therapy can reduce the morbidity of postoperative complication and the use of stoma, while postoperative nutrition support therapy can avoid the intestinal failure. Enteral nutrition should be the primary route of perioperative nutrition support therapy in CRE as possible. Pharmaconutrients aiming at intestinal commensal microbiota and its metabolites may play a role in the management of radiation enteritis.

Operative and long term results after diseased bowel resection for chronic radiation enteritis complicated with intestinal obstruction / 中华外科杂志

<p><b>OBJECTIVE</b>To report operative and long-term results after surgery for chronic radiation enteritis and to evaluate the therapeutic efficacy of surgery and investigate the risk factors of postoperative survival rate.</p><p><b>METHODS</b>The 120 CRE patients performed with diseased bowel resection from June 2001 to March 2011 were analyzed retrospectively and followed up by telephone. There were 22 male and 98 female patients and their age were 23-82 years (median 52 years). Their demographic data, the cancer history, the characteristics of radiotherapy received (total dose, defined as the cumulative dose of external and endocavity radiation), the time interval between the first symptoms and the first surgical procedure, postoperative complications, length of residual small bowel, postoperative survival rate were recorded. Evaluate the therapeutic efficacy of surgery and investigate the risk factors of postoperative survival rate.</p><p><b>RESULTS</b>The postoperative overall complications and the incidence of moderate to severe complications (Clavien-Dindo Grade III-V) were 61.7% and 33.3%, respectively. The postopertive mortality was 2.5%. The survival probabilities were 96%, 60% and 37% at 1-, 5- and 10-years, respectively. At the end of follow up, the mean of body mass index (BMI) increased compared with the BMI of preoperatiive ((17.6 ± 3.0) kg/m(2) vs. (20.2 ± 3.0) kg/m(2), t = 6.01, P < 0.01). The 93% of patients can stop PN and regain full oral diet after operation (χ(2) = 164.1, P < 0.01). On multivariate analysis, survival was significantly decreased with residual neoplastic disease (HR = 4.082, 95%CI: 1.318-12.648), an American Society of Anesthesiologists score>3 (HR = 3.495, 95%CI: 1.131-10.800) and an age of chronic radiation enteritis diagnosis >70 years (HR = 2.800, 95%CI: 0.853-9.189).</p><p><b>CONCLUSIONS</b>The survival of patients with chronic radiation enteritis complicated with intestinal obstruction after intestinal resection was good and was mainly influenced by underlying comorbidities. Majority of the patients can stop PN and regain full oral diet after operation.</p>

Clinical significance of dynamic monitoring blood glucose in patients with severe traumatic brain injury / 中国中西医结合急救杂志

Objective To investigate the clinicial significance of continuous glucose monitoring(CGM)of patients with severe traumatic brain injury(sTBI). Methods By glucose monitoring method,80 patients with sTBI〔Glasgow coma score(GCS)3-8〕in Department of Critical Care Medicine of Qingyuan People's Hospital in Guangdong Province from January 2012 to December 2012 were divided into two groups:41 patients in CGM group and 39 in regular glucose monitoring(RGM)group. The continuous glucose monitoring system(CGMS)was applied to monitor glucose level in the CGM group,and the finger blood was taken by portable blood glucose meter in the RGM group. The two groups were treated with insulin on the basis of glucose level,respectively. The relationships between the condition of glycemic excursions and the acute physiology and chronic health evaluationⅡ(APACHEⅡ)score or prognosis and between the incidence of hypoglycemia and prognosis were seen in the two groups. Results The close linear correlations between APACHEⅡ score and glycemic excursion in two groups,i.e. mean amplitude of glycemic excursions(MAGE)and coefficient of variation of glucose(GluCV),were documented(both P<0.05). The MAGE of the especially severe patients(GCS 3-5)was obviously higher than that of severe ones(GCS 6-8),and with the increase of APACHEⅡ score,the MAGE of patients was gradually elevated,the difference being statistically significant(both P<0.05). The incidence of hypoglycemia(7.32%vs. 23.08%)and fatality rate of 30 days(12.20%vs. 30.77%)in CGM group were lower than those of RGM group(both P<0.05). The MAGE and fatality rate of 30 days were positively correlated in CGM group(r=0.597,P=0.007),and the GLuCV and fatality rate of 30 days were positively correlated in RGM group(r=0.622,P=0.019). Conclusion CGM is beneficial to timely observe condition of glycemic excursions in sTBI patients and avoid occurrence of hypoglycemia or hyperglycemia,guiding the treatment of insulin and improving patients' prognosis.

PI3K/Akt signaling pathway regulates autophagy induced by acute kid-ney injury in septic rats / 中国病理生理杂志

AIM:To investigate the autophagy induced by sepsis and acute kidney injury , and the regulation of phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt) signaling pathway in this process.METHODS: The rats were subjected to cecal ligation and puncture ( CLP) or sham operation .Histopathologic changes of the renal tissues were examined by HE staining .Blood urea nitrogen ( BUN) and serum creatinine ( SCr) were measured by chemical colorime-try.The protein expression of microtubule-associated protein light chain 3 I/II (LC3 I/II), beclin-1 and p-Akt at different time points after CLP was detected by Western blotting .In vitro, human proximal tubular epithelial cell line HK-2 were treated with LPS to induce autophagy .The protein expression of LC 3 I/II and p-Akt in the HK-2 cells after LPS treatment at different time points and different concentrations was detected by Western blotting .These molecules in HK-2 cells and apoptosis of HK-2 cells treated with LPS plus PI3K inhibitor or Akt inhibitor were also detected .RESULTS: Compared with sham group , the severe changes of renal histopathological injuries in CLP groups were observed , the levels of BUN and SCr in CLP groups were significantly increased .LC3 I/II, beclin-1 and phosphorylation of Akt gradually increased after CLP.After treatment with LPS, the expression of p-Akt (308) in the HK-2 cells gradually increased in a dose-and time-dependent fashion.The expression of beclin-1 and p-Akt (472) reached a peak at 8 h or 10 mg/L LPS treatment.Treat-ment with PI3K or Akt inhibitor down-regulated the expression of LC3 and promoted the apoptosis of HK-2 cells.CON-CLUSION:Autophagy in the kidney is induced by sepsis and acute kidney injury .PI3/Akt signaling pathway may be in-volved in this process .

Effects of ciprofloxacin on the enteritis of interleukin-10 knockout mice after ileocaecal resection / 中华消化杂志

Objective To investigate the effects of ciprofloxacin on anastomotic stoma,small intestinal inflammation and fibrosis in interleukin-10 knock-out mice (mice model of Crohn′s disease (CD)) after ileocaecal resection.Methods Twelve interleukin-10 knockout male C3H/HeJBir mice were evenly divided into control group and ciprofloxacin group.The mice model was established with ileocaecal resection and ileocolostomy.There was no intervention in control group.Ciprofloxacin (50 mg/kg per day)was orally administrated in ciprofloxacin group for four weeks.All the mice were executed.The intestine around anastomotic stoma was taken for hematoxylin-eosin (HE)and Sirius red staining and histological scoring.The level of interferon (IFN)-γand tumor growth factor (TGF)-βin intestine around anastomotic stoma and small intestine was detected by enzyme-linked immunosorbent assay (ELISA) method.The content of procollagen α1 was determined by real-time polymerase chain reaction.The data were analyzed by t test.Results The inflammatory reaction level of anastomotic stoma and small intestine in mice of ciprofloxacin group (2.50±0.55 and 1 .67±0.52)was significantly lower than those of control group (3.67±0.63 and 2.83±0.75 ,t=-8.273,-5 .188,both P <0.05 ).The IFN-γof anastomotic stoma and small intestine also significantly decreased ((0.72 ±0.22 )pg/mg vs (1 .76 ±0.43 )pg/mg, (0.23±0.12)pg/mg vs (0.78 ± 0.52 )pg/mg;t = - 7.354,- 5 .268,both P < 0.05).However, ciprofloxacin could not significantly decrease fibrosis in anastomotic stoma and small intestine of CD mice. There was no significant difference in the level of TGF-βcompared with control group.Conclusions The role of ciprofloxacin in improving inflammatory reation in anastomotic stoma of CD mice was limited. Maintenance therapy may be necessary to reduce the relapse of anastomotic stoma diseases.

Surgical management of Crohn's disease complicated with duodenal fistula / 中华消化外科杂志

Objective To investigate the surgical management of Crohn's disease complicated with duodenal fistula.Methods The clinical data of 1 012 patients with Crohn's disease who were admitted to the Nanjing General Hospital of Nanjing Military Connnand from January 2002 to January 2014 were retrospectively analyzed.Of the 1 012 patients,22 were complicated with duodenal fistula,including 12 with ileocolonic anastomosis-duodenal fistula,7 with colo-duodenal fistula,2 with sigmoido-duodenal fistula and 1 with duodeno-enteric fistula.All patients received duodenal fistula repair + resection of diseased intestine.Patients were followed up via out-patient examination,phone call and email till May 2014.The condition of patients before and after enteral nutrition support was compared using the t test.Non-normal data were analyzed using the Mann-Whitney u test.Results Two patients with abdominal infection and 1 with gastrointestinal bleeding received emergent operation,and the other 19 patients received enteral nutrition support prior to operation.Three patients received emergent colostomy.Two patients had fistula at the duodenal anastomosis,and 1 patient was cured by enteral nutrition support + drainage for 12 days and the other 1 received reoperation.The energies provided by enteral nutrition and enteral + parenteral nutrition were (25.3 ± 2.1) cal/g and (28.5 ± 3.2) cal/g,respectively,and the time for nutrition support was (31 ± 5)days.The level of C-reaction protein and Crohn's disease activity index were decreased from 25 mg/L and 207 ± 111 before treatment to 2 mg/L and 117 ± 71 after treatment,with significant difference (u =53.000,t =0.942,P ＜ 0.05).The levels of body mass index,albumin and blood sedimentation rate were (17.0 ± 2.1) kg/m2,(35 ± 5) g/L and 26 mm/h before treatment,and (17.9 ± 2.8) kg/m2,(38 ± 5) g/L and 23 mm/h after treatment,with no significant differences (t =0.482,1.170,u =67.500,P ＞ 0.05).One patient was cured by enternal nutrition.Five patients received intestinal stoma and the other 13 patients received intestinal anastomosis.Twenty-two patients were followed up with the median time of 13.4 months (range,4.0-37.0 months).One patient had recurrence of ileocolonic anastomosis-duodenal fistula and received reoperation,and complications were not observed in the other 21 patients.Conclusions Selective operation is recommended for patients with Crohn's disease complicated with duodenal fistula.Enteral nutrition support is the first choice during the interoperative management.Resection of diseased intestine combined with repair of duodenal fistula after alleviation of Crohn's disease and malnutrition could achieve satisfactorv effect.

Risk Factors for Postoperative Intra-abdominal Septic Complications in Crohn ’s Disease / 胃肠病学

Background:As postoperative intra-abdominal septic complications( IASCs)in Crohn’s disease( CD)are difficult to manage,it is of great importance to prevent this condition in CD patients after surgery. Till now,there are no large sample studies on risk factors for postoperative IASCs in CD in China. Aims:To determine the risk factors for postoperative IASCs in CD for guiding the formulation of preventive strategies. Methods:This retrospective study was based on a computerized database of CD patients who had undergone surgery for CD complications between 1999 and 2014 at Nanjing General Hospital of Nanjing Military Command,PLA. Patients were divided into IASCs group and non-IASCs group. Thirty potential variables were selected,and both univariate and multivariate( Logistic regression)analyses were performed to identify the risk factors for IASCs after surgery. Results:Seven hundred and sixteen operations were reviewed,and IASCs occurred in 41 cases(5. 7%). By univariate and multivariate analyses,IASCs were significantly associated with one stage anastomosis(OR=1. 656,95% CI:1261-3. 279),preoperative low albumin level( 10 mg/L)(OR=8. 641,95% CI:3. 376-16. 364),preoperative steroids use ≥3 months(OR=3. 785,95% CI:1. 237-4. 671)and presence of intra-abdominal abscess or infection at the time of surgery(OR=1. 784,95% CI:1. 155-3. 826). However,enterostomy(OR =0. 125,95% CI:0. 062-0. 561)and preoperative enteral nutrition ≥ 1 month( OR =0. 147,95% CI:0. 078-0. 781 ) were found to be the independent protective factors. Conclusions:Malnutrition,active CD and preoperative long-term steroids use increase the risk of postoperative IASCs in CD. Patients with these risk factors should not receive immediate surgery. If surgery is inevitable, enterostomy instead of resection and anastomosis should be the first choice. Preoperative enteral nutrition is helpful for reducing the occurrence of IASCs after surgery.

Effects of exclusive enteral nutrition on the mucosal healing in adult patients with active Crohn's disease / 中华消化杂志

Objective To explore the effects of exclusive enteral nutrition (EEN) on the mucosal healing under endoscopy in adults with active Crohn's disease (CD).Methods From August 2011 to August 2012,adults with active CD met the inclusion criteria were prospectively enrolled and treated with EEN for four weeks.CD activity index(CDAI) score,C-reactive protein (CRP) were evaluated once enrolled and by the end of the second and fourth week.Colonoscopy or small intestinal endoscopy examination was conducted once enrolled and by the end of fourth week,and CD simplified endoscopic score (SES-CD) was also caculated.Wilcoxon test was applied to compare the efficacy.Results Eight patients met inclusion criteria and finished the study.Seven cases achieved clinical remission.Compared with those before treatment,both CDAI score and CRP level decreased significantly after treatment (both Z=2.52,both P=0.012).After treatment,two patients achieved mucosal healing and the mucosa of six cases improved.The mucosa healing rate and improvement rate of terminal ileum was higher than that of colon (3/8 vs 1/6; 5/8 vs 3/6).Compared with those before treatment,SES-CD total score and SES-CD score of ileum decreased significantly after treatment (Z=2.23,2.07; P=0.026,0.038).There was no significant difference in SES-CD score of colon before and after treatment (P =0.102).Conclusions EEN could induce clinical remission in adults with active CD,and promote the healing of mucosal ulcer under endoscopy.The healing rate of colon was lower than that of small intestine.

Transumbilical single-incision laparoscopic surgery for gastrointestinal disease with homemade single port device and its perioperative nutritional management / 肠外与肠内营养

Objective: We present our preliminary experience of using a homemade transumbilical single-port access for performing transumbilical single port access (SPA) laparoscopic surgery for gastrointestinal disease and its perioperative nutritional management.Methods: During Nov.2009-Dec.2009,five patients received SPA surgery and nutritional management following the protocol of fast track surgery.A patient with stomach GIST received partial gastrectomy,a patient with ascending colon lymphoma received right hemicolectomy,a patient with rectal cancer received anterior resection,a patient with jejunum GIST received partial small bowel resection,and a patient with early gastric cancer received distal subtotal gastrectomy (D1+α). Results: Transumbilical SPA surgery were successfully done in five patients without conversion.The mean length of incision was 3 cm,the mean time for operation was 138 (60-240)min,and the mean blood loss was 50 (10-100)ml.All patients could mobilize and orally drink on the 1st day after operation,have soft diet the 3st days after operation,their mean postoperative hospital stay was 4 days.No complication occurred.Mean body weight loss was 2.6 kg on discharge compared with at admission.Conclusion: Transumbilical SPA surgery with the protocol of fast-track surgery had advantages including shorter incision,less trauma,faster recovery,and less body weight loss.

A new strategy for medical therapy of Crohn's disease: the top-down approach / 肠外与肠内营养

Altering the natural history of disease has been the goal of medical therapy for Crohn's Disease (CD) in recent years. The conventional approach has been thestep-up therapy. With the introduction of biological agents (such as infliximab) , there is growing evidence that the top-down approach is justified in a subgroup of high-risk patients. The new algorithms is not only associated with superior clinical remission rates, but also may have the potential to alter the natural history of the disease, including inducing mucosal healing, reducing the rate of complications, surgeries and mortality. Further study will have to determine which subgroup of patients will benefit most from this early aggressive biological therapy approach.