Efficacy of Daikenchuto in the prevention of bowel obstruction in patients with colorectal cancer undergoing laparoscopic surgery: An observational study using a Japanese administrative claims database.

PURPOSE: Daikenchuto is an herbal medicine widely used in Japan without clear evidence to prevent bowel obstruction after abdominal surgery. We evaluated the efficacy of Daikenchuto in laparoscopic surgery for colorectal cancer (CRC). METHODS: We included patients from the medical claims databases diagnosed with CRC between January 2012 and December 2019 and treated with laparoscopic surgery. We compared the Daikenchuto and control groups to evaluate early bowel obstruction (EBO) events for 1 year. The Daikenchuto group included patients prescribed Daikenchuto on postoperative day (POD) 0 or 1. An EBO event was defined as the use of a nasogastric tube, transnasal ileus tube, endoscopic balloon dilatation, or the requirement of reoperation for bowel obstruction from PODs 1 to 364. RESULTS: In total, 46,458 patients met the eligibility criteria; 2407 and 44,051 patients were included in the Daikenchuto and control groups, respectively. Some of the patient's characteristics were significantly different between the groups. The frequencies of EBO events in the Daikenchuto and control groups were 5.7% (95% confidence interval: 4.8-6.7) and 4.6% (4.4-4.8), respectively. The most frequent events were nasogastric tube (3.1%, 2.9%) and transnasal ileus tube insertions (1.4%, 0.8%) in the Daikenchuto and control groups, respectively. The hospital stay was significantly shorter in the Daikenchuto group than in the control; this trend was confirmed in the sensitivity analysis. CONCLUSIONS: Daikenchuto did not demonstrate efficacy for EBO. It might be adequate for shortening patient's hospital stay. Further studies are warranted.

OMT for the Prevention and Management of Chronic Constipation and Distal Intestinal Obstructive Syndrome in Cystic Fibrosis: A Pilot Study.

CONTEXT: Cystic fibrosis (CF) is an autosomal recessive genetic disorder primarily affecting the lungs and digestive system. Patients with CF often have multiorgan dysfunction, including chronic lung infections, pancreatic insufficiency, chronic constipation, and distal intestinal obstructive syndrome (DIOS). OBJECTIVE: To understand the impact of osteopathic manipulative treatment (OMT) on the prevention and management of gastrointestinal symptoms in patients with CF. METHODS: This study used OMT for physical manipulation of the viscera, spine, and other somatic components to improve bowel symptoms and prevent DIOS. These effects were achieved by releasing myofascial restrictions found in the abdomen and somatic structures with the intent to optimize the autonomic and lymphatic systems and improve range of motion. RESULTS: Four of 5 participants had a decrease in pain, and 3 participants had a reduced need for laxatives during treatment. Four participants had an overall increase in satisfaction with their bowel movements while being treated with OMT. CONCLUSION: These findings support the use of OMT as a method for the management of chronic constipation and DIOS in the CF population. However, because of the small population size, more research with larger populations is needed.

Prevention of meconium obstruction in very low birth weight preterm infants. / Prevención de la obstrucción meconial en recién nacidos prematuros de muy bajo peso.

INTRODUCTION: Delayed meconium expulsion is a cause of bowel obstruction in the extremely premature newborn (<28 WGE) weighing less than 1500g at birth. OBJECTIVE: To evaluate the efficacy of conservative treatment in the prevention of meconium obstruction in very-low-birt- weight preterm infants. METHOD: Descriptive and retrospective study performed at the Neonatal Intensive Care Unit of a tertiary level hospital. All very-low-birth-weight preterm infants who were born during the study period, from August 2016 to January 2017, and who had meconium obstruction were included. RESULTS: A sample of 42 newborn infants was obtained. Regarding the expulsion of meconium, 57.1% of the sample spontaneously ejected meconium, while 42.9% received different treatments. Of these, 72.2% were treated with saline enemas, 16% with acetylcysteine enemas, 16% with Gastrografin® and none required surgical treatment. CONCLUSION: Conservative treatment seems to be an effective therapeutic measure for the prevention of meconium obstruction in very-low-birth-weight preterm infants since it achieved the expulsion of meconium without having to apply surgical treatment.

Upfront surgery of small intestinal neuroendocrine tumors. Time to reconsider?

Small intestinal neuroendocrine tumors (SI-NETs) may demonstrate a widely variable clinical behavior but usually it is indolent. In cases with localized disease, locoregional resective surgery (LRS) is generally indicated with a curative intent. LRS of SI-NETs is also the recommended treatment when symptoms are present, regardless of the disease stage. Concerning asymptomatic patients with distant metastases, prophylactic LRS has been traditionally suggested to avoid possible future complications. Even the current European Neuroendocrine Tumor Society guidelines emphasize a possible effect of LRS in Stage IV SI-NETs with unresectable liver metastases. On the contrary, the 2017 National Comprehensive Cancer Network Guidelines on carcinoid tumors do not support the resection of a small, asymptomatic, relatively stable primary tumor in the presence of unresectable metastatic disease. Furthermore, a recent study revealed no survival advantage for asymptomatic patients with distant-stage disease who underwent upfront LRS. At the aforementioned paper, it was suggested that delayed surgery as needed was comparable with the upfront surgical approach in terms of postoperative morbidity and mortality, the length of the hospital stay and the rate of incisional hernia repairs but was associated with fewer reoperations for bowel obstruction. On the other hand, it is also important to note that some patients might benefit from a prophylactic surgical approach and our attention should focus on identifying this patient population.

Proton-Pump Inhibitors Reduce Gastrointestinal Events Regardless of Aspirin Dose in Patients Requiring Dual Antiplatelet Therapy.

BACKGROUND: The COGENT (Clopidogrel and the Optimization of Gastrointestinal Events Trial) showed that proton-pump inhibitors (PPIs) safely reduced rates of gastrointestinal (GI) events in patients requiring dual antiplatelet therapy (DAPT). However, utilization of appropriate prophylactic PPI therapy remains suboptimal, especially with low-dose aspirin. OBJECTIVES: The authors investigated the safety and efficacy of PPI therapy in patients receiving DAPT in low- and high-dose aspirin subsets. METHODS: Randomized patients with available aspirin dosing information in COGENT (N = 3,752) were divided into "low-dose" (≤ 100 mg) and "high-dose" (>100 mg) aspirin groups. The primary GI and cardiovascular endpoints were composite upper GI events and major adverse cardiac events, respectively. All events were adjudicated by independent, blinded gastroenterologists and cardiologists. RESULTS: Median duration of follow-up was 110 days. Low-dose aspirin users (n = 2,480; 66.1%) were more likely to be older, female, and have higher rates of peripheral artery disease, prior stroke, and hypertension, whereas high-dose aspirin users (n = 1,272; 33.9%) had higher rates of hyperlipidemia, smoking, a history of percutaneous coronary intervention, and were more than twice as likely to be enrolled from sites within the United States (80.4% vs. 39.8%). High-dose aspirin was associated with similar 180-day Kaplan-Meier estimates of adjudicated composite GI events (1.7% vs. 2.1%; adjusted hazard ratio: 0.88; 95% confidence interval: 0.46 to 1.66) and major adverse cardiac events (4.8% vs. 5.5%; adjusted hazard ratio: 0.73; 95% confidence interval: 0.48 to 1.11) compared with low-dose aspirin. Randomization to PPI therapy reduced 180-day Kaplan-Meier estimates of the primary GI endpoint in low-dose (1.2% vs. 3.1%) and high-dose aspirin subsets (0.9% vs. 2.6%; p for interaction = 0.80), and did not adversely affect the primary cardiovascular endpoint in either group. CONCLUSIONS: Gastroprotection with PPI therapy should be utilized in appropriately selected patients with coronary artery disease requiring DAPT, even if the patients are on low-dose aspirin. (Clopidogrel and the Optimization of Gastrointestinal Events Trial [COGENT]; NCT00557921).

Evacuation of sand from the equine intestine with mineral oil, with and without psyllium.

The aim of this study was to determine the evacuation of sand from the equine intestine after a double treatment with psyllium and mineral oil or mineral oil only. A crossover study was conducted. Twelve healthy horses were fed 1 kg sand once a day for 5 days. Subsequently, these horses were divided into two groups: A and B. From day 6-10, both groups were treated with 2 l of mineral oil once a day and group B received an additional 0.5 kg of psyllium twice a day. The trial was repeated after 2 weeks with treatment crossover of groups A and B. The horses were housed sand free and 1.8 kg hay/100 kg body weight was offered to meet the maintenance energy requirement. Prior to the sand administration, faeces were collected from each horse for 3 days and the crude ash was determined to establish a baseline output of ash. There was no difference between the baseline crude ash output of the first and second treatment. From day 6-10, faeces were collected daily and the fresh weight and the dry matter and the crude ash contents were determined. For administration, sand or psyllium was mixed with 1 l of Irish mash (concentrate mixed with water), respectively, and mineral oil was administered via a nasogastric tube. All horses showed higher crude ash excretion when treated with psyllium and mineral oil compared with the mineral oil administration only. On the second, third and fourth day of the treatment, the difference was significant. Faeces crude ash weight corrected for baseline crude ash output while treated with psyllium plus oil and oil solely, reached a mean of 51.0 (SD 20.5) and 26.1 (SD 17.7) % of the administered sand mass, respectively. The results of this trial show that the ash output differed highly between the horses. Nevertheless, all horses showed a higher total ash output within the 5 days treatment period when the psyllium semen and mineral oil were used for the treatment than when treated with mineral oil solely.

The preventive effect of Daikenchuto on postoperative adhesion-induced intestinal obstruction in rats.

The present study investigated the effect of Daikenchuto (DKT) on postoperative intestinal adhesion in rats. We evaluated the effects of DKT, constituent medical herbs and active compounds on talc-induced intestinal adhesion in rats and DKT-induced contractions using isolated guinea pig ileum. DKT significantly prevented adhesion formation, and this action was inhibited by pretreatment with atropine or ruthenium red. The constituent medical herbs, Zanthoxylum Fruit and Maltose Syrup Powder significantly prevented adhesion formation. Moreover, hydroxy sanshool (HS) prevented adhesion formation, and this action was inhibited by pretreatment with ruthenium red. In contrast, DKT-induced contractions were inhibited by tetrodotoxin, atropine, and capsazepine. These results suggested that DKT had a preventive action on postoperative adhesive intestinal obstruction, and that this action was mediated by sensory and cholinergic nerves. Furthermore, HS was found to be one of the active compound of DKT, and its action was mediated by sensory nerves.

Small volume enemas do not accelerate meconium evacuation in very low birth weight infants.

We hypothesized that small volume enemas accelerate meconium evacuation in very low birth weight (VLBW) infants. In a randomized controlled trial, VLBW infants (n = 81) received either repeated daily small volume enemas if complete spontaneous meconium passage failed within 24 h or no intervention. Small volume enemas did not accelerate complete meconium evacuation, which occurred after 6.0 to 9.6 (95% CI) d in the intervention group and after 7.7 to 11.0 (95% CI) d in the control group. No adverse events were observed. Daily administration of small volume enemas had no effect on total meconium evacuation defined by the time of last meconium passage.

[A case of pulmonary embolism and a case of ileus as complications after laparoscopic radical prostatectomy].

In recent years, the use of laparoscopic techniques for surgical operations has been increasing, because this procedure is less invasive and is excellent in regard to patient's quality of life. Normally, complications are rare in laparoscopic surgery. However, we experienced a case of pulmonary embolism and one case of ileus as complications after laparoscopic radical prostatectomy. Especially, in this type of operation, the danger of complications is increased due to the severe head down and lithotomy position, which is employed to ensure a good view during operation. In this particular case, the long duration of operation may have been another related risk factor. There were no risk factors for pulmonary embolism such as those encountered when a patient is aged, obese, or bed ridden for a long time. However, an intermittent air massage must be applied to the lower legs to prevent thrombus due to poor blood circulation of the lower extremities below the knee during the surgery. It is also necessary to change the posture of the patient frequently after the operation. In addition, the administration of low molecular weight heparin may also be effective.

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer.

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 +/- 75 mg/dl vs. 231 +/- 24 mg/dl; P < 0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient's life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option.

Effects of somatostatin analogues and vitamin C on bacterial translocation in an experimental intestinal obstruction model of rats.

The passage of viable endogenous bacteria and their products across the intact intestinal mucosal barrier, disseminating to the mesenteric lymph nodes, peritoneal cavity, spleen, liver, and circulation, is defined as bacterial translocation. Intestinal obstruction induces bacterial translocation due to mucosal disruption, motility dysfunction, and increased intestinal volume, leading to bacterial overgrowth. In a rat model of intestinal obstruction, the effects of both high-dose vitamin C (350 microg/kg), an antioxidant agent known to have a cytoprotective effect in ischemia-reperfusion injury, and somatostatin (20 microg/kg), a gastrointestinal antisecretory agent, in preventing bacterial translocation were studied. Both intestinal and liver samples from the rats was observed, and it was found that the rate of bacterial translocation was 100% in the control group, and only 43% for the rats who were given intraperitoneal vitamin C and somatostatin. The difference was statistically significant. In conclusion, we are convinced that vitamin C and somatostatin analogues may have protective effects against bacterial translocation in mechanical bowel obstruction.

Effects of Dai-kenchu-to on intestinal obstruction following laparotomy.

To confirm the usefulness of Dai-kenchu-to for intestinal obstruction, investigation of the effects of Dai-kenchu-to on postoperative intestinal adhesion was conducted. Repeated administrations of Dai-kenchu-to (100 or 300 mg/kg) significantly inhibited the formation of intestinal obstruction. Motor disturbance and inflammation are thought to be involved in the etiology of intestinal adhesion. A single treatment of Dai-kenchu-to (300 mg/kg) significantly reduce intestinal transit time in postoperative ileus and chemically induced ileus. Dai-kenchu-to (10(-4) g/ml) significantly inhibited COX-2 activity. These results suggest that Dai-kenchu-to prevents postoperative intestinal adhesion by gastroprokinetic and anti inflammatic effects. Dai-kenchu-to thus demonstrates positive effect on postoperative ileus.

Failure of psyllium mucilloid to hasten evaluation of sand from the equine large intestine.

OBJECTIVE: To examine the efficacy of psyllium mucilloid in evacuating sand from the equine large intestine. ANIMALS: 12 clinically healthy pony geldings. PROCEDURE: Twelve ponies were assigned to 2 groups of six each. One group was treated with psyllium and the second was a control group. All ponies had an exploratory celiotomy and 10 g/kg body weight of sand was placed into the cecum. Ponies were fed a grain mixture alone at 1 g/kg (controls), a grain mixture plus psyllium pellets, each at 1 g/kg body weight (3 ponies), or fed a grain mixture and given psyllium powder by nasogastric tube at 1 g/kg body weight divided into two daily doses in 3 L of water (3 ponies). Radiographs were taken on days 1 (3 per group), 5 (all ponies), and 11 (3 per group) to monitor sand transit through the large intestine. Ponies were euthanatized 11 days after surgery. Sand was collected from the contents of the cecum, ventral colon, dorsal colon, and small colon. Dry weight of the recovered sand was compared between the two treatment groups as a percentage of the dry weight of sand placed in the cecum. RESULTS: No significant differences were detected in the mean percentage of sand recovered between the two treatment groups (P < .05), with 39.2% recovered in ponies treated with psyllium and 27.4% recovered in control ponies. CLINICAL RELEVANCE: Psyllium mucilloid had no apparent effect on sand evacuation from the equine large intestine. When intake of sand is prevented, the equine large intestine can reduce and possibly eliminate its sand burden.

A importância da fibra alimentar na terapia nutricional enteral / The importance of dietary fiber in enteral nutrition

Os autores revisam e discutem os conhecidos efeitos benéficos da fibra alimentar na prevenção ou tratamento de várias afecções, como diabetes mellitus, arterosclerose, câncer de cólon, síndrome do intestino curto e a doença diverticular. As fibras alimentares aumentam o volume das evacuações, promovem regulação no tempo de trânsito intestinal e diminuem a pressão da luz intestinal. Outrossim, atuam no metabolismo dos carboidratos e no controle da glicemia, na redução dos triglicerídeos e colesterol sanguíneo e como substrato para a formação de ácidos graxos de cadeia curta, os quais atuam na regeneração e adaptação do intestino remanescente após a ressecção maciça intestinal. São apresentadas as necessidades diárias para o consumo de fibras em alimentos naturais, mas com o advento de dietas enterais, tornaram-se disponíveis novos preparados de fibras com indicações específicas

Polyunsaturated phosphatidylcholine prevents stricture formation in a rat model of colitis.

BACKGROUND & AIMS: Polyunsaturated phosphatidylcholine stimulates collagen breakdown in experimental models of liver cirrhosis. Bowel strictures are characterized by excess deposition of collagen in the intestinal wall. The aim of this study was to investigate the effect of polyunsaturated phosphatidylcholine in the prevention of bowel strictures. METHODS: Colitis was induced by trinitrobenzenesulfonic acid. On day 21, the presence of strictures was assessed in control rats, rats with colitis, and phosphatidylcholine-fed (100 mg/day) rats with colitis. Furthermore, serum transforming growth factor beta1, collagen deposition, and collagenase activity in colonic tissue were measured in all groups. RESULTS: None of the control rats but 12 of 16 rats with colitis developed colonic strictures. In contrast, only 2 of 15 phosphatidylcholine-fed rats with colitis showed strictures. Collagen content was much higher in rats with colitis than in phosphatidylcholine-fed rats with colitis and control rats. Phosphatidylcholine-fed rats showed significantly higher collagenase activity in colonic tissue than rats with colitis and control rats. In an ancillary study, free linoleic acid-fed rats showed no differences when compared with rats with colitis. Stimulation of transforming growth factor beta1 was similar in all rats with colitis. CONCLUSIONS: Oral supplementation with polyunsaturated phosphatidylcholine prevents the accumulation of collagen in inflamed intestinal tissue and the formation of strictures. This effect is associated with an enhanced collagen catabolism.

Perioperative pain management.

The clinical anesthesia, general surgery, and gynecology literature addressing the pathophysiology and management strategies for perioperative pain were reviewed. There are few prospective, randomized studies from which to draw meaningful conclusions. Nevertheless, a theoretical construct has been developed which may help the gynecologic surgeon optimizing pain management. The era of managed care and shorter hospital stays has focused physicians and, in particular, surgeons on elements of patient care that can be addressed and improved. Reducing or eliminating postoperative pain without excessive sedation promotes rapid mobilization and return to self-care. Strategies for pain management can be adopted that reduce postoperative ileus and other adverse reactions to analgesics.

[Use of acupuncture for restoring motor and transit functions of the stomach and intestines in suppurative peritonitis]. / Primenenie iglorefleksoterapii dlia vosstanovleniia motorno- évakuatornoi funktsii zheludka i kishechnika pri gnoinom peritonite.

With the aim of restoration of motor-evacuatory function of the stomach and intestine, the acupuncture was used in 220 patients with purulent peritonitis. The positive effect after single procedure was noted in all the patients with local peritonitis. In 100 patients with diffuse peritonitis, 2-3 procedures were required to achieve clinical effect. There was no effect in 20 patients. The total lethality was 9.1%, in diffuse forms of peritonitis--14%.