Causes of adverse outcomes in acute intestinal obstruction.

OBJECTIVES: The purpose of this study is to analyse the effectiveness of methods of diagnosis and treatment of patients with acute intestinal obstruction. METHODS: A total of 123 patients were examined, who were diagnosed based on history, an overview X-ray of the abdominal cavity, a contrast examination of the intestine, and contrast marks according to Yu. L. Shalkov and irrigoscopy. 57.4 % of patients had all typical aspects of the disease, 17.7 % - indolent aspects, and 4.8 % - atypical. In the case of colonic obstruction, the method of irrigoscopy is informative. To restore intestinal function, patients with acute intestinal obstruction of the small intestine are indicated with a Yu. L. Shalkov nasogastroenteral tube or a double-drainage nasointestinal tube. And with the colonic form of the disease, it is necessary to perform a Hartmann-type operation and establish a Maidl-type anastomosis. RESULTS: It was noted that with indolent or atypical aspects of the disease, patients received medical care late. It is shown that in the case of resection of necrotic areas of the intestine, it is informative to determine the resection boundary using the vasoscopy method using a 1 % aqueous solution of methylene blue. It was found that the optimal distance from the edge of the resection is 3 cm. CONCLUSIONS: The results of this study are of interest to clinicians who are engaged in the diagnosis and treatment of patients with acute intestinal obstruction.

Pectin based biologic Velcro effectively seals traumatic solid organ and small bowel injuries.

INTRODUCTION: Injuries to the liver and small bowel are common in multiple injuries. While there are currently a variety of accepted damage-control techniques to expeditiously manage such injuries, morbidity and mortality remain high. Pectin polymers have previously been shown to effectively seal visceral organ injuries ex vivo through physiochemical entanglement with the glycocalyx. We sought to compare the standard of care for the management of penetrating liver and small bowel injuries with a pectin-based bioadhesive patch in a live animal model. METHODS: Fifteen adult male swine underwent a laparotomy with standardized laceration to the liver. Animals were randomized to one of three treatment arms: packing with laparotomy pads (n = 5), suture repair (n = 5), or pectin patch repair (n = 5). Following 2 hours of observation, fluid was evacuated from the abdominal cavity and weighed. Next, a full-thickness small bowel injury was created, and animals were randomized to either a sutured repair (n = 7) or pectin patch repair (n = 8). The segment of bowel was then pressurized with saline, and the burst pressure was recorded. RESULTS: All animals survived the protocol to completion. There were no clinically significant differences between groups regarding baseline vitals or laboratory studies. On one-way analysis of variance, there was a statistically significant difference between groups regarding blood loss after liver repair (26 mL suture vs. 33 mL pectin vs. 142 mL packing, p < 0.01). On post hoc analysis, there was no statistically significant difference between suture and pectin ( p = 0.9). After repair, small bowel burst pressures were similar between pectin and suture repair (234 vs. 224 mm Hg, p = 0.7). CONCLUSION: Pectin-based bioadhesive patches performed similarly to the standard of care for the management of liver lacerations and full-thickness bowel injuries. Further testing is warranted to assess the biodurability of a pectin patch repair, as it may offer a simple option to effectively temporize traumatic intra-abdominal injuries.

[Correction of enteral distress syndrome in acute intestinal obstruction]. / Korrektsiya enteral'nogo distress-sindroma pri ostroi kishechnoi neprokhodimosti.

OBJECTIVE: On the basis of a comprehensive assessment of the functional state of the intestine in acute mechanical small bowel obstruction, to justify adequate schemes of its protection. MATERIAL AND METHODS: A clinical and laboratory study of 48 patients with acute small bowel obstruction developed against the background of abdominal adhesions, strangulated abdominal hernia was conducted. The first group (n=25) of patients who underwent laparotomy, removal of intestinal obstruction (adhesiolysis and/or herniation, hernial gate plastic surgery), intestinal intubation, standardized therapy after surgery. The second group (n=23) - patients, therapy included Remaxol (Polysan Pharmaceutical Plant, Petersburg): 400.0 enterally intraoperatively through a probe after nasointestinal intubation, evacuation of stagnant contents and intestinal lavage with isotonic saline solution; 400.0 - intravenously for 5 days. A number of indicators of homeostasis (endogenous intoxication, oxidative stress), structural and functional state of the intestine were evaluated. RESULTS: It was found that the inclusion of remaxol in complex therapy (intraoperatively and in the early postoperative period) leads to the optimization of the treatment process of patients with acute intestinal obstruction. The number of complications according to the Clavien-Dindo classification decreased from 17 (first) up to 5 (second group) (χ2=3.988, p=0.046). Hospital stay decreased from 12.8±1.1 to 10.1±0.8 bed days (p<0.05). The effectiveness of the developed scheme is based on its ability to correct the phenomena of enteral distress syndrome relatively quickly, which was confirmed by laboratory and instrumental methods. The most important manifestation of this was a significant decrease in the phenomena of endogenous intoxica tion against the background of a significant decrease in the activity of peroxidation of membrane lipids - triggers of catabolic intestinal lesions. CONCLUSION: Studies document the effectiveness of the developed treatment regimen for patients with acute intestinal obstruction. The inclusion of remaxol parenterally and enterally makes it possible to significantly optimize the course of the early postoperative period. One of the main objects of its implementation was the relatively rapid restoration of intestinal function, reduction of manifestations of enteral distress syndrome. This provided rapid relief of endogenous intoxication and, as a result, prevented the progression of the systemic inflammatory response syndrome, which together determined the optimization of the early postoperative period.

Lessons learned from successful autologous gastrointestinal reconstruction in patients with intestinal failure: a case series.

BACKGROUND: Intestinal failure (IF) is a rare but severe form of organ failure. The condition is defined as body's inability to absorb adequate fluids, macronutrients and minerals for growth and development, so that intravenous supplementation is necessary. A broad spectrum of diseases, trauma and complications of surgery might eventually end up with intestinal failure. Nowadays, intestinal failure patients are preferably cared for in intestinal rehabilitation units (IRU). Autologous gastrointestinal reconstruction (AGIR) refers to non-transplant operative management of IF patients designed to improve enteral tolerance and gut absorptive capacity. CASE PRESENTATION: Herein we present five cases with complications of surgeries due to peptic ulcer bleeding, blunt abdominal trauma, obesity and gastric tumor. The surgeries were complicated by anastomotic leak, peritonitis and fistula formation. By adopting multidisciplinary decisions and special care for each complication, all the five patients were successfully managed and discharged. DISCUSSION AND CONCLUSIONS: As presented, re-anastomosis in presence of abdominal contamination will probably fail. In patients with intestinal failure, PN should start as soon as possible to increase the success rate of future surgeries and prevent potential need for intestinal transplantation. We suggest referring patients with complicated outcomes of gastrointestinal surgeries to the IRUs to reduce morbidity and mortality.

Controversy in Nutrition Recommendations for Short Bowel Syndrome: How Type of SBS Impacts Response.

PURPOSE OF REVIEW: This review examines the current recommendations for dietary management of patients living with short bowel syndrome (SBS) and outlines the need for future research to provide optimal care for this unique group of patients. RECENT FINDINGS: Providers caring for patients with SBS lack sufficient data to help guide recommendations regarding diet. The majority of studies are conducted at a single medical institution on a small number of anatomically diverse patients. Multi-center studies would allow for inclusion of a larger number of patients and may lead to more individualized dietary recommendations. Patients with short bowel syndrome should be evaluated on an individual basis by a multidisciplinary team including physicians, dieticians, pharmacists, and nurses specializing in the care of these complex patients. Tailoring both medical and nutritional therapy will help realize the overarching goal for these patients of maintaining adequate nutrition with diet and medications, and achieving independence from parenteral support.

Novel Prognostic Factors in Resected Small Bowel Adenocarcinoma.

BACKGROUND: Small bowel adenocarcinoma (SBA) is a rare malignancy affecting approximately 3000 patients per year in the United States, and there is limited evidence prognosticating patients with resected SBA. We aimed to evaluate prognostic factors and the role of adjuvant therapy in patients with resected SBA. PATIENTS AND METHODS: Two hundred forty-one patients who had resected stage I-III SBA were retrospectively identified at a single tertiary referral institution. Overall survival (OS) analysis was performed by the Kaplan-Meier method, and Wilcoxon tests were used for statistical comparisons. Cox proportional hazards were performed to identify significant variables by univariate and multivariate analysis. RESULTS: Median OS for the entire group was 54.5 months (95% confidence interval [CI], 37.2-81.2 months), with 5- and 10-year OS of 48% and 35%. Median follow-up was 113.7 months (95% CI, 97.9-126.6 months). For patients with stage III disease who received adjuvant therapy, the median OS was 33.8 months (95% CI, 27.8-78.8) compared to 24.7 months (95% CI, 11.5-37.8) for patients with no adjuvant therapy (P < .01). Male sex, advanced T stage, advanced N stage, increased positive lymph node ratio, lymphocyte-to-monocyte ratio < 1.56, presence of residual disease, and earlier date of diagnosis predicted worse survival on univariate analysis. Age > 60 years, lymphocyte-to-monocyte ratio < 1.56, and advanced T stage were identified as independent negative predictors of OS for all patients by multivariate analysis. CONCLUSION: Advanced age, advanced T stage, and lymphocyte-to-monocyte ratio < 1.56 independently predicted survival in resected SBA. Adjuvant therapy is associated with improved survival in patients with resected stage III SBA.

Experimental study on prophylactic effects of vardenafil in ischemia-reperfusion model with intestinal volvulus injury in rats.

AIM: An experimental study was performed to evaluate the effects of Vardenafil on ischemia-reperfusion (I/R) injury in an experimental volvulus model by histochemical and biochemical methods. MATERIALS AND METHODS: Thirty-five male Wistar rats were divided in five groups (n = 7). In Group 1, a 5 cm segment of small intestine 2 cm proximal to cecum was excised to have a control group. In the second group, 5 cm segment of small intestine 2 cm proximal to cecum was rotated 360° clockwise direction and sutured with 4/0 polyglactin to generate an experimental model of volvulus. At the end of 2 h of ischemia, the same intestinal segment was sampled. In group 3, after achieving ischemia similar to group 2, two hours of reperfusion injury was obtained by removing the sutures. Rats in Group 4 received vardenafil after 1.5 h of ischemia and then 2 h of reperfusion. And finally, in Group 5, vardenafil was administered 2 h before laparotomy and 5 cm of intestine was removed without I/R injury. Intestinal segments were evaluated for total antioxidant status (TAS), total oxidant status (TOS) and oxidative stress index (OSI) with biochemical and histopathological analysis. RESULTS: Serum TOS levels and OSI were not significantly different between groups (p = 0.910, P = 0,43 respectively). The serum TAS level was decreased in group 3 as compared to vardenafil groups 4 and 5, without a statistical significance (p = 0.428). In histopathologic analysis, we found that vardenafil, partially reduced I/R injury. The villus structure was preserved but, congestion and inflammation were moderate. CONCLUSION: Vardenafil partially reduced I/R injury histopathologically on intestine. Our study shows that it does not have statistically antioxidant effect on intestinal I/R injury in experimental model of volvulus. However, effects of vardenafil in I/R injury of liver, kidney, heart, testis, over and brain which were cited in literature were not confirmed with I/R injury on intestine.

Clinical Characteristics of Intussusception with Surgical Reduction: a Single-Center Experience with 568 Cases.

BACKGROUND: Intussusception is among the most common acute abdominal emergencies in infancy, but only some cases need surgical reduction. This study assessed the clinical characteristics of patients undergoing surgical reduction of intussusception. METHODS: This retrospective study reviewed 568 pediatric patients who failed air-enema reduction and underwent surgical reduction for intussusception in our department between 2008 and 2017. RESULTS: The series comprised 376 boys and 192 girls (2.0:1, male:female ratio) and most of the intussusceptions were primary, which is typical before the age of 1 year. The success rate of air-enema reduction in our hospital was 94.2%. Patients over 3 years old had the highest rate of surgical reduction (ca. 11.8%). The probabilities of primary and secondary intussusception were equal above 2 years old. Intussusception caused by intestinal malignant lymphoma was diagnosed above 2 years of age with atypical symptoms. Gender was irrelevant regarding the presence of bloody stools (P = 0.594), but the younger patients and children with complex/compound intussusception had a higher proportion of bloody stools (n = 148, 40.0%, P = 0.000) and intestinal necrosis (n = 44, 42.3%, P = 0.024). The occurrence time of bloody stools (OTBS) in complex/compound intussusception was shorter than for other types. CONCLUSIONS: This retrospective study analyzed the clinical features of patients undergoing surgical reduction for intussusception and summarized the characteristics and management of complex/compound intussusception.

Ascorbic acid-induced oxalate nephropathy: a case report and discussion of pathologic mechanisms.

Oxalate nephropathy is associated with hereditary hyperoxaluria, Crohn disease, and previous gastric or intestinal surgery, especially in the setting of increased oxalate intake or ethylene glycol ingestion. We present a patient whose intake of vitamin C supplements (2 g/day), exacerbated by predisposing factors of prior small bowel obstruction and resection, and benign prostate hyperplasia (BPH), resulted in acute kidney injury due to oxalate nephropathy. We review past reports of vitamin C-induced oxalate nephropathy and discuss the underlying precipitating factors.

[Primary Small Bowel Tumor with Simultaneous Lung Metastases from Rectal Cancer - A Case Report].

A 56-year-old woman was diagnosed with rectal cancer and liver metastases(Stage IV), and underwent low anterior resection and laparoscopic partial hepatectomy. The patient received adjuvant chemotherapy(mFOLFOX6 for 24 weeks), but developed multiple lung metastases 11 months later. Before undergoing a pulmonary resection, the patient presented with acute small bowel obstruction. Abdominal computed tomography showed small bowel stenosis due to a tumor, and we suspected peritoneal metastases from the rectal tumor. We performed partial resection of the small intestine, and histopathological examination revealed a primary small bowel tumor. The patient was discharged to her home without complications, and later underwent pulmonary resections for bilateral lung metastases. We usually suspect that small bowel obstruction is due to peritoneal metastases in patients with advanced colorectal tumors, but must consider the rare possibility of a separate primary small bowel tumor, especially in patients with a solitary lesion. We report a rare primary small bowel tumor after FOLFOX treatment in a patient with Stage IV rectal cancer.

Clinical Utility of Capsule Endoscopy and Double-Balloon Enteroscopy in the Management of Obscure Gastrointestinal Bleeding.

BACKGROUND: Obscure gastrointestinal bleeding (OGIB) is a common but embarrassing problem for gastroenterologists. Most bleeding lesions associated with OGIB are present in the small intestine and sometimes cannot be identified due to the difficulty associated with physical accessibility. Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) have enabled in the process of diagnosing and have evolved to become approaches to treating OGIB. SUMMARY: CE is a minimally invasive procedure and has a high diagnostic yield in patients with OGIB. DBE offers additional advantage of biopsy collection for pathological diagnosis and therapeutic intervention, but it should be noted that it sometimes causes severe adverse events such as acute pancreatitis, intestinal bleeding, and intestinal perforation. CE should be performed early in the workup course of OGIB. Positive CE findings enhance the diagnostic yield of subsequent DBE, and the effective therapeutic intervention improves the clinical outcomes of OGIB patients. On the contrary, there are no clear guidelines for further investigation of patients with negative CE findings at the present. Although patients in stable general condition may only require follow-up, repeated CE is useful to detect positive findings in patients with evidence of sustained bleeding and progressing anemia. We have revealed that repeated CE has higher positive finding rate than DBE in OGIB patients with negative CE findings in a preliminary study. Key Messages: CE and DBE have complementary roles in the management of OGIB, and the precise timing and proper sequence may be important for the approach to treating OGIB.

A surgical solution to regain bowel continuity following an extended left colectomy-reviving and extending the indication for a "Flip-Flop" procedure.

BACKGROUND AND AIMS: Extended left hemicolectomy might be necessary for several indications. Once the resection is completed, it would be difficult or impossible to anastomose the transverse colon to the rectum due to the difficulty in mobilizing the transverse colon to reach for a tension-free rectal anastomosis. The aim of this report is to present the "Flip-Flop" technique to overcome this challenging situation. The procedure is based on a surgical technique published in the early 1960s to avoid permanent stoma after proctectomy and consists of changing the location of the right colon to reach the rectum. METHODS: Clinical parameters, surgical aspects, and postoperative outcome of patients that underwent the flip-flop procedure following an extended left colectomy in our medical service was reviewed. RESULTS: Three patients underwent a flip-flop procedure after an extended left colectomy performed for various reasons. The surgical technique is detailed in a step by step manner. Patients had uneventful postoperative recovery with an adequate functional outcome. CONCLUSIONS: We believe that this approach should be revived and be considered also in cases when the full length of the rectum is preserved to avoid ileo-rectal anastomosis or a high-tension colocolonic anastomosis. Popularization of this surgical solution among surgeons is highly important.

Current treatment paradigms in pediatric short bowel syndrome.

Pediatric short bowel syndrome (SBS) is a serious condition which occurs in children with congenital or acquired reduction in length of the small intestine. SBS results in excessive fluid loss, nutrient malabsorption, electrolyte abnormalities, increased susceptibility to infections, parenteral nutrition associated complications and affects weight gain and growth. In children, SBS is debilitating and uniformly fatal without treatment. The primary goal of treatment is to restore enteral autonomy and reduce long-term dependence on parenteral support by increasing the absorptive potential of the remnant intestine. In this review, the medical and surgical management of SBS including pharmacologic agents, parenteral nutrition, dietary strategies, surgical lengthening procedures, and small bowel transplant will be discussed.

Synchronous peritoneal metastases of small bowel adenocarcinoma: Insights into an underexposed clinical phenomenon.

BACKGROUND: The aim of this population-based study was to provide insight into the incidence, risk factors and treatment-related survival of patients with peritoneal metastases (PM) of small bowel adenocarcinoma (SBA). METHODS: Data from the Netherlands Cancer Registry were used. All patients diagnosed with SBA between 2005 and 2014 were included. The influence of patient and tumour characteristics on the odds of developing PM was analysed. Subsequently, for all further analyses, patients without synchronous PM of SBA were excluded. The log-rank test and Kaplan-Meier analyses were conducted to estimate survival, and the Cox proportional hazards model was used to evaluate the risk of death. RESULTS: Of the 1428 included patients diagnosed with SBA, 181 (13%) presented with synchronous PM. Synchronous PM was found in 9% of the duodenal tumours and in 17% of the more distal tumours. Median overall survival of all patients with PM was 5.9 months, whereas survival of both 11 months was observed in patients treated with primary tumour resection or palliative chemotherapy and 32 months after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS+HIPEC). Poor prognostic factors for survival were age ≥70 years (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.1-2.2), systemic metastases other than PM (HR 2.0, 95% CI 1.4-2.9) and an advanced (HR 1.9, 95% CI 1.3-3.0) or unknown T-stage (HR 2.1, 95% CI 1.2-3.5). CONCLUSIONS: Synchronous PM was frequently encountered in SBA. Without treatment, prognosis was extremely poor. Survival was higher after primary tumour resection, palliative chemotherapy and CRS+HIPEC, but selection bias probably played a significant role calling for further clinical research.

Recurrence and Survival Outcomes After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Small Bowel Adenocarcinoma.

BACKGROUND: Peritoneal dissemination of small bowel adenocarcinoma (SBA) is rare but is associated with a dismal prognosis. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is a promising treatment option. We evaluated our experience of CRS-HIPEC for the treatment of SBA. PATIENTS AND METHODS: Sixteen consecutive patients underwent CRS-HIPEC for small bowel malignancy between 2003 and 2016. Clinopathological and treatment-related factors were obtained from a prospective database. The study's endpoints of disease-free (DFS) and overall (OS) survival were evaluated using the Kaplan-Meier method. Prognostic variables were identified through univariate and multivariate analyses. RESULTS: Follow-up was complete in all patients. The median follow-up was 20.6 (range=0.2-62) months. The was no in-hospital mortality and grade III/IV morbidity was 25%. The median OS after CRS-HIPEC was 24.7 months, with a 36-month survival of 34%. The median DFS was 11.3 months, with a 36-month DFS of 8%. Two factors were associated with a poorer OS on univariate analysis; only peritoneal cancer index >10 was associated with a poorer OS on multivariate analysis (p=0.032). CONCLUSION: CRS-HIPEC in selected patients with peritoneal dissemination of SBA is associated with reasonable mid-term survival outcomes but treatment failure is common. High disease burden, quantified by the PCI is associated with poor outcomes. A large, prospective, multi-institutional study is needed to further evaluate the outcomes of CRS-HIPEC for SBA.

Antioxidant potential of Himanthalia elongata for protection against ischemia-reperfusion injury in the small bowel.

BACKGROUND: Seaweed has been associated with the prevention and/or treatment of various diseases related to oxidative stress because of its antioxidant activity. We investigated the protective potential of extract of Himanthalia elongata against ischemia-reperfusion (I/R) injury in the intestine of rats. METHODS: Seventy-two (72) male Wistar albino rats were randomly assigned into 12 groups as follows: sham, I/R only, I/R plus vehicle at 3 time points, and I/R plus extract at 3 time points. The degree of intestinal injury was determined by oxidative stress using lipid peroxidation, superoxide dismutase, catalase, and glutathione peroxidase after mesenteric ischemia-reperfusion. A histological study was also performed. RESULTS: The algae extract helps to maintain normal enzymatic levels because, for all the studied parameters, groups treated with the extract showed significant differences (P < .05) compared with the I/R groups, and there were no differences compared with the sham group. The histological study showed that damage to the intestinal mucosa was less severe in animals treated with extract of H elongata after up to 24 hours of reperfusion compared with the I/R group. CONCLUSION: These results suggest that the extract of H elongata can protect intestinal tissue against ischemia-reperfusion injury.

Surgical Management of Crohn Disease in Children: Guidelines From the Paediatric IBD Porto Group of ESPGHAN.

The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.

Routine contrast enema is not required for all infants prior to ostomy reversal: A 10-year single-center experience.

INTRODUCTION: The incidence of intestinal stricture is low for most conditions requiring a primary small bowel stoma in infants. Routine performance of contrast enemas (CE) prior to stoma closure adds cost and radiation exposure. We hypothesized that routine CE prior to ostomy reversal is not necessary in all infants, and sought to identify a subset of patients who may benefit from preoperative CE. METHODS: Medical records of infants under age 1 (N=161) undergoing small bowel stoma reversal at a single institution between 2003 and 2013 were retrospectively reviewed. Student's T-test was used to compare groups. RESULTS: Contrast enemas were performed on 80% of all infants undergoing small bowel ostomy reversal during the study period. Infants with necrotizing enterocolitis (NEC) were more likely to have a CE than those with intestinal atresia (p=0.03) or those with all other diagnoses combined (p=0.03). Nine strictures were identified on CE. Of those, 8 (89%) were in patients with NEC, and only 4 were clinically significant and required operative resection. The overall relevant stricture rate was 2.5%. No patient that underwent ostomy takedown without CE had a stricture diagnosed intraoperatively or an unrecognized stricture that presented clinically after stoma takedown. CONCLUSIONS: Routine CE is not required prior to small bowel ostomy reversal in infants. We recommend judicious use of enema studies in patients with NEC and high likelihood of stricture.

Refeeding Syndrome: An Important Complication Following Obesity Surgery.

BACKGROUND: Refeeding syndrome (RFS) is an important and well-known complication in malnourished patients, but the incidence of RFS after obesity surgery is unknown and the awareness of RFS in obese patients as a postsurgical complication must be raised. We present a case of RFS subsequent to biliopancreatic diversion in a morbidly obese patient. CASE REPORT: A 48-year-old female patient with a BMI of 41.5 kg/m2 was transferred to our hospital due to Wernicke's Encephalopathy in a global malabsorptive syndrome after biliopancreatic diversion. Parenteral nutrition, vitamin supplementation and high-dosed intravenous thiamine supplementation were initiated. After 14 days, the patient started to develop acute respiratory failure, and neurological functions were impaired. Blood values showed significant electrolyte disturbances. RFS was diagnosed and managed according to the NICE guidelines. After 14 days, phosphate levels had returned to normal range, and neurological symptoms were improved. CONCLUSION: Extreme weight loss following obesity surgery has been shown to be associated with undernutrition. These patients are at high risk for evolving RFS, even though they may still be obese. Awareness of RFS as a postsurgical complication, the identification of patients at risk as well as prevention and correct management should be routinely performed at every bariatric center.

Two cases of small bowel obstruction secondary to a swallowed potato.

Bowel obstruction due to bezoars (compaction of ingested material within the gastrointestinal tract) is a rare, but well documented occurrence. In this paper, we present two cases of potato-induced small bowel obstruction. Both patients were approximately 50 years old and had cerebral palsy and learning disabilities, respectively. They presented with abdominal pain and bilious vomiting, with no medical or surgical history. Diagnosis of small bowel obstruction was confirmed by CT prior to taking the patients to the operating theatre, where whole potatoes were found to be obstructing each patient's bowel lumen. Both patients underwent laparotomy with enterotomy and removal of the potato. They both made a good recovery. Through a literature review of bezoar-induced bowel obstruction, these cases highlight important diagnostic and management principles.