Effect of perioperative rehabilitation exercise on postoperative outcomes in patients aged ≥65 years undergoing gastrointestinal surgery: A multicenter randomized controlled trial.

STUDY OBJECTIVES: This study aimed to assess the effect of perioperative rehabilitation exercise, initiated shortly after hospital admission, on postoperative outcomes in elderly patients. DESIGN: A prospective, multicenter, randomized, controlled, open-label, and assessor-blinded clinical trial. SETTING: Hospital wards. PATIENTS: Elderly patients (≥65 years, n = 160) scheduled for gastrointestinal surgery between June 2021 and November 2022 were enrolled and randomly assigned to the intervention or control group. INTERVENTIONS: Patients were divided into two groups base on whether they had received a specific type of exercise program initiated after hospital admission and continued until 30 days after surgery. MEASUREMENTS: The primary outcome was the Comprehensive Complications Index (CCI) measured at 30 days after surgery. Secondary outcomes were the rate of complications, number of complications, patient satisfaction, hospital readmission, postoperative length of stay, gastrointestinal function recovery, postoperative quality of life and psychological status. Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted. MAIN RESULTS: ITT analysis showed a significantly lower 30-day CCI in the intervention group (ß: -6.31; 95 % Confidence Interval [CI], -11.26 to -1.37, P = 0.013). Compared to controls, the intervention group had a decreased rate of hospital readmission (Odds Ratio: 0.00; 95 % CI, 0.00 to 0.32, P = 0.022), less number of complications (ß: -0.57; 95 % CI, -1.03 to -0.11, P = 0.016), as well as lower rate of postoperative anxiety (ß: -0.74; 95 % CI, -1.42 to -0.06, P = 0.033) and depression scores (ß: -1.13; 95 % CI, -0.97 to -1.30, P = 0.008). Additionally, the intervention group reported higher satisfaction (ß: 0.98; 95 % CI, 0.33 to 1.64, P = 0.004) and Euro quality of life-Visual Analogue Scale scores (ß: 8.88; 95 % CI, 2.48 to 15.28, P = 0.007). Similar results were found in the PP analysis. CONCLUSION: Perioperative rehabilitation exercise has a positive impact on postoperative complications, quality of life and psychological well-being in elderly patients undergoing gastrointestinal surgery, even when implemented after hospital admission.

Therapeutic drug monitoring of tenofovir disoproxil and emtricitabine in oral HIV pre-exposure prophylaxis (PrEP) users who have undergone gastrointestinal surgery.

OBJECTIVES: Oral HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV, but its efficacy depends on adequate absorption of drug, which may decrease following gastrointestinal surgery. METHODS: Clinicians across eight Genito-urinary Medicine clinics in the United Kingdom submitted data on PrEP users with history of gastrointestinal surgery who were referred to a national complex PrEP multi-disciplinary team between June 2021 and April 2023. Anonymised data were submitted on demographics, surgical history, PrEP regimen, and results of therapeutic drug monitoring (TDM) and HIV screening tests. Descriptive analyses were performed in SPSS version 29. RESULTS: Nine cases described cis-gender men-who-have-sex-with-men (MSM) with median age of 47.4 years (IQR = 43 - 56.5) taking tenofovir disoproxil (TDF)/emtricitabine (FTC) daily (n = 8) or event-based (n = 1) as PrEP. Median time between PrEP initiation and TDM was 53 days (IQR = 8.5-1705). The mean (±SD) trough concentration of tenofovir (TFV) and FTC were 90.2 ± 27.7 ng/mL and 76.0 ± 45.9 ng/mL, respectively. All patients had a negative HIV test at follow-up. CONCLUSIONS: Plasma trough concentrations of TFV observed in our cohort taking TDF/FTC were above the expected concentrations associated with PrEP efficacy as previously described in the literature, suggesting that PrEP can be safely given in this population, with TDM used for reassurance.

Cholecystocolonic fistula: an incidental intraoperative discovery managed laparoscopically.

Cholecystoenteric fistula is a rare complication of cholelithiasis, occurring in 3%-5% of patients with cholelithiasis. The symptoms are typically minimal and vague, with either acute or subacute presentations, rarely leading to bowel obstruction, and occasionally manifesting as chronic abdominal pain. In this case, a male patient in his early 30s presented with epigastric and right hypochondrial pain. On evaluation, he was diagnosed with gallstone disease and adenomyomatosis of the gallbladder. During laparoscopic cholecystectomy, a cholecystocolonic fistula was unexpectedly discovered. The fistula was managed laparoscopically using ENDOLOOP (prelooped chromic catgut ligature) ligation of the fistulous tract. The patient recovered without complications and was discharged on the third postoperative day. This case emphasises the importance of intraoperative vigilance and demonstrates a successful minimally invasive management approach.

Innovative needle-assisted technique for intracorporeal anastomosis: Simplifying closure of common enterotomy in laparoscopic gastrointestinal surgery.

BACKGROUND: Intracorporeal anastomosis offers notable advantages over extracorporeal techniques, including reduced tissue manipulation leading to faster recovery and potentially lower risks of surgical site infections and complications. However, it also involves several challenges, such as increased operative time and the need for experienced assistants and multiple trocars. Our novel technique addresses these problems. METHODS: We present a novel approach for closing common enterotomies during intracorporeal anastomosis by using a linear stapler. This technique involves the use of a 6-cm straight needle, which facilitates closure of the common enterotomy. The technique can be performed independently by a single surgeon without the need for additional trocars or assistants. RESULTS: This technique was applied for 20 patients undergoing laparoscopic gastrointestinal surgery between June 2023 and February 2024. The median age of the enrolled patients was 65 years, with laparoscopic right hemicolectomy with intracorporeal ileocolostomy being the most common procedure (60% of cases). The median anastomosis time was 22.5 min. No occurrence of anastomotic leakage was reported, and only one patient (5%) developed temporary postoperative bowel obstruction, which was managed conservatively. CONCLUSIONS: Our technique enables efficient and safe closure of common enterotomies during intracorporeal anastomosis, minimizing reliance on additional trocars and experienced assistants. It simplifies the procedure and ensures fullthickness stapling, potentially reducing the likelihood of complications. Because of its broad applicability across various laparoscopic surgeries, this technique offers substantial benefits and is worth recommending for intracorporeal anastomosis.

Machine learning as a tool predicting short-term postoperative complications in Crohn's disease patients undergoing intestinal resection: What frontiers?

The recent study, "Predicting short-term major postoperative complications in intestinal resection for Crohn's disease: A machine learning-based study" investigated the predictive efficacy of a machine learning model for major postoperative complications within 30 days of surgery in Crohn's disease (CD) patients. Employing a random forest analysis and Shapley Additive Explanations, the study prioritizes factors such as preoperative nutritional status, operative time, and CD activity index. Despite the retrospective design's limitations, the model's robustness, with area under the curve values surpassing 0.8, highlights its clinical potential. The findings align with literature supporting preoperative nutritional therapy in inflammatory bowel diseases, emphasizing the importance of comprehensive assessment and optimization. While a significant advancement, further research is crucial for refining preoperative strategies in CD patients.

The effect of intraoperative goal-directed fluid therapy in patients under anesthesia for gastrointestinal surgery.

BACKGROUND: Intraoperative fluid management is an important aspect of anesthesia management in gastrointestinal surgery. Intraoperative goal-directed fluid therapy (GDFT) is a method for optimizing a patient's physiological state by monitoring and regulating fluid input in real-time. AIM: To evaluate the efficacy of intraoperative GDFT in patients under anesthesia for gastrointestinal surgery. METHODS: This study utilized a retrospective comparative study design and included 60 patients who underwent gastrointestinal surgery at a hospital. The experimental group (GDFT group) and the control group, each comprising 30 patients, received intraoperative GDFT and traditional fluid management strategies, respectively. The effect of GDFT was evaluated by comparing postoperative recovery, complication rates, hospitalization time, and other indicators between the two patient groups. RESULTS: Intraoperative blood loss in the experimental and control groups was 296.64 ± 46.71 mL and 470.05 ± 73.26 mL (P < 0.001), and urine volume was 415.13 ± 96.72 mL and 239.15 ± 94.69 mL (P < 0.001), respectively. The postoperative recovery time was 5.44 ± 1.1 days for the experimental group compared to 7.59 ± 1.45 days (P < 0.001) for the control group. Hospitalization time for the experimental group was 10.87 ± 2.36 days vs 13.65 ± 3 days for the control group (P < 0.001). The visual analogue scale scores of the experimental and control groups at 24 h and 48 h post-surgery were 3.38 ± 0.79 and 4.51 ± 0.86, and 2.05 ± 0.57 and 3.51 ± 0.97 (P < 0.001), respectively. The cardiac output of the experimental and control groups was 5.99 ± 1.04 L/min and 4.88 ± 1.17 L/min, respectively, while the pulse pressure variability for these two groups was 10.87 ± 2.36% and 17.5 ± 3.21%, respectively. CONCLUSION: The application of GDFT in gastrointestinal surgery can significantly improve postoperative recovery, reduce the incidence of complications, and shorten hospital stays.

Trend of robot-assisted surgery system in gastrointestinal and liver surgery: A bibliometric analysis.

BACKGROUND: Robot-assisted gastrointestinal and liver surgery has been an important development direction in the field of surgery in recent years and it is also one of the fastest developing and most concerning fields in surgical operations. AIM: To illustrate the major areas of research and forward-looking directions over the past twenty-six years. METHODS: Using the Web of Science Core Collection database, a comprehensive review of scholarly articles pertaining to robot-assisted gastrointestinal and liver surgery was researched out between 2000 and 2023. We used Citespace (Version 6.2.4) and Bibliometrix package (Version 4.3.0) to visualize the analysis of all publications including country, institutional affiliations, authors, and keywords. RESULTS: In total, 346 articles were retrieved. Surgical Endoscopy had with the largest number of publications and was cited in this field. The United States was a core research country in this field. Yonsei University was the most productive institution. The current focus of this field is on rectal surgery, long-term prognosis, perioperative management, previous surgical experience, and the learning curve. CONCLUSION: The scientific interest in robot-assisted gastrointestinal and liver surgery has experienced a significant rise since 1997. This study provides new perspectives and ideas for future research in this field.

Treatment of Colorectal Lung Metastases: Two Centers Retrospective Study.

INTRODUCTION: Clear guidelines for colorectal lung metastasis (LM) treatment are not available. This study aimed to provide insight into the treatment strategies and efficacy of local and systemic therapy in patients with LM eligible for (potentially) curative treatment. METHODS: This was a retrospective study of patients with ≤5 LM discussed in two tertiary referral centers. Patient and tumor characteristics were compared between treatment groups. Treatment strategies were compared between centers and survival data between treatment groups, local treatment modalities, and treating centers. RESULTS: Ninety-two patients (median 2 LMs) were included. Seventy-one (77%) patients underwent local treatment (17 surgery, 13 ablation, 38 radiotherapy, 3 combination of local treatments) and 21 (23%) with systemic therapy alone. The latter group more frequently had extrapulmonary metastases (81.0% vs. 26.8%, p < 0.001) and synchronous presentation of LM (23.8% vs. 7.0%, p = 0.045). Choice of local versus systemic therapy and time to start treatment after diagnosis (median 109 days, IQR 44-240 vs. 88 days, IQR 53-168) were comparable between centers. Three-year survival rates did not differ between treatment groups, local treatment modalities, or treating centers. CONCLUSION: Treatment strategies and oncological outcomes were rather similar between centers. Survival outcomes were not different between locally and systemically treated patients.

Falciform ligament abscess management.

Falciform ligament abscess (FLA) is a rare occurrence as a consequence of local inflammation. This report presents a case of FLA on a background of recent cholangitis and laparoscopic cholecystectomy complicated by superficial umbilical wound infection. Diagnosis was by clinical examination and CT imaging. Management was by laparoscopic drainage.

New Developments in Anti-Reflux Surgery: Where Are We Now?

Background: Gastroesophageal reflux disease is one of the most common chronic diseases, affecting up to 28% of the western population. Therapeutic management ranges from conservative measures to endoscopic or surgical interventions. Laparoscopic Nissen fundoplication (LNF) still is considered as gold standard, but alternative procedures have been developed and evaluated within the past years. Summary: Magnetic sphincter augmentation (MSA), which aims to be a less disruptive and possibly more standardized laparoscopic procedure than LNF, shows satisfying results regarding short- and long-term follow-up as well as comorbidities. Alternatives, such as the RefluxStop™ procedure or Transoral incisionless fundoplication (TIF), combined with laparoscopic hiatal hernia repair (cTIF) show promising results for short-term follow-up, nevertheless further studies regarding long-term follow-up are necessary. Key Message: Although there definitely are upcoming and promising trends in upper GI surgery, LNF still represents today's gold standard and MSA is an equivalent alternative. RefluxStop™ and cTIF show promising results, nevertheless, further studies are necessary.

Non-invasive vagus nerve stimulation to reduce ileus after colorectal surgery: randomized feasibility trial and efficacy assessment (IDEAL Stage 2B).

AIM: Ileus is characterized by a period of intestinal dysmotility after surgery, leading to vomiting and constipation. In preclinical models, vagus nerve stimulation reduces intestinal inflammation and prevents smooth muscle dysfunction, accelerating the return of gut function. This study explored the feasibility of a definitive trial of non-invasive vagus nerve stimulation (nVNS) along with an early assessment of efficacy. METHOD: A multicentre, randomized feasibility trial (IDEAL Stage 2B) of self-administered nVNS was performed. Patients undergoing colorectal surgery were randomized to nVNS or sham before and after surgery. Feasibility outcomes comprised assessments of recruitment, compliance, blinding and attrition. Clinical outcomes were measures of intestinal function and adverse events. All participants were followed up for 30 days. Interviews with patients and health professionals explored barriers to feasibility and perspectives around implementation. RESULTS: In all, 125 patients were approached about the study and 97 (77.6%) took part. Across all randomized groups, the median compliance to treatment was 19 out of 20 stimulations (interquartile range 17-20). The incidence of adverse events was similar across groups. In this unpowered feasibility study, the time taken for the return of gut function (such as first passage of stool) was similar between nVNS and sham treatments. According to interviews, patients were highly motivated to use the device because it provided them with an opportunity to engage actively in their care. Health professionals were highly driven to tackle the problem of ileus. CONCLUSION: Powered assessments of clinical efficacy are required to confirm or refute the promise of nVNS, as already demonstrated in preclinical models. This feasibility study concludes that a definitive randomized assessment of the clinical benefits of nVNS is desired and feasible.

A "one in a million" case of colorectal carcinoma - A case report from a tertiary care centre in Mumbai, India.

INTRODUCTION: Colorectal Carcinoma (CRC) has recently been on the rise among children, bearing a prevalence of 1-2 children/adolescents per million people. Here, we present a rare case of CRC in a 14-year-old male, emphasizing the need for development of better screening techniques to diagnose CRC earlier and with adequate time for intervention. CASE PRESENTATION: A 14-year-old male visited our hospital with constipation, intermittent per rectal bleed and dull-aching pain abdomen for 2 months. On per rectal examination, a hard mass was identified, approximately 3 cm above the anal verge. Contrast-enhanced CT (Chest and Abdomen) and MRI Pelvis identified a circumferential thickening in the rectum predominantly involving the anterior rectal wall with effacement of fat planes with the Urinary Bladder without infiltrating it. Colonoscopic biopsy identified Signet Ring Adenocarcinoma. A multi-disciplinary decision was taken to treat him with neoadjuvant chemotherapy and radiotherapy (NACT-RT). MRI Pelvis, post-NACT-RT, showed that the previously- effaced fat plane was now clear and an Abdominoperineal Resection (APR) with permanent end- descending-colostomy was done. Histopathology report of the specimen identified a poorly undifferentiated mucin-secreting adenocarcinoma. DISCUSSION: At presentation, the patient could have been either planned for extensive surgery or NACT-RT. The choice of NACT-RT was justified in our patient and was advantageous as extensive surgery was prevented. CONCLUSION: We implore vigilance in cases of rectal masses due to the rising incidence of CRC among children. We also advocate that there must be no hesitation in subjecting adolescents to Chemotherapy and/or radiotherapy, as the benefits significantly outweigh the risks of with-holding.

Temperature Measurement Timings and the Fever Detection Rate After Gastrointestinal Surgery: Retrospective Cross-Sectional Study.

BACKGROUND: Postoperative fever frequently indicates surgical complications and is commonly used to evaluate the efficacy of interventions against surgical stress. However, the presence of circadian rhythms in body temperature may compromise the accurate detection of fever. OBJECTIVE: This study aimed to investigate the detection rate of fever under intermittent measurement. METHODS: We retrospectively reviewed the clinical records of patients who underwent nonemergency gastrointestinal surgery between November 2020 and April 2021. Patients' temperature data were continuously collected every 4 seconds using a wireless axillary thermometer, and fever was defined as a temperature exceeding 38 °C within a day. To simulate intermittent measurement in clinical practice, the body temperature at each hour was selected from the continuously collected temperature dataset. Considering that temperatures are measured multiple times per day, all possible measurement plans using intermittent measurement were composed by combining 1-24 time points from the 24-hour daily cycle. Fever was clinically diagnosed based on the temperature readings at the selected time points per day. The fever detection rates for each plan, with varying measurement times, were listed and ranked. RESULTS: Based on the temperature data continuously collected by the thermometer, fever occurred in 60 (40.8%) of the 147 included patients within 3 days after surgery. Of the measurement plans that included 1-24 measurements daily, the fever detection rates ranged from 3.3% (2/60) to 85% (51/60). The highest detection rates and corresponding timings for measurement plans with 1, 2, 3, and 4 measurements daily were 38.3% (23/60; at 8 PM), 56.7% (34/60; at 3 AM and 7 or 8 PM), 65% (39/60; at 3 AM, 8 PM, and 10 or 11 PM), and 70% (42/60; at 12 AM, 3 AM, 8 PM, and 11 PM), respectively; and the lowest detection rates were 3.3% (2/60), 6.7% (4/60), 6.7% (4/60), and 8.3% (5/60), respectively. Although fever within 3 days after surgery was not correlated with an increased incidence of postoperative complications (5/60, 8.3% vs 6/87, 6.9%; P=.76), it was correlated with a longer hospital stay (median 7, IQR 6-9 days vs median 6, IQR 5-7 days; P<.001). CONCLUSIONS: The fever detection rate of the intermittent approach is determined by the timing and frequency of measurement. Measuring at randomly selected time points can miss many fever events after gastrointestinal surgery. However, we can improve the fever detection rate by optimizing the timing and frequency of measurement.

Antibiotic prophylaxis practice in gastrointestinal surgery in five hospitals in southern Benin.

Background: Benin's healthcare system is characterized by a lack of local guidelines for surgical antibiotic prophylaxis (SAP), which is essential to prevent surgical site infection. Aim: To audit compliance for SAP practices in gastrointestinal surgery. Methods: Data were prospectively collected from gastrointestinal surgery departments in five hospitals. Over a four month period, SAP was assessed using five conventional criteria (indication, choice of antibiotic, dosage, timing, and duration of administration) among patients admitted for Altemeier class 1 or 2 procedures. Three guidelines were used as reference: World Health Organization (WHO), American Society of Health-System Pharmacists (ASHP)and French Society of Anaesthesia and Intensive Care Medicine (SFAR). Findings: Of 68 surgical interventions, overall compliance with WHO, ASHP, and SFAR was observed in zero (0.0%), one case (1.5%) and two cases (2.9%), respectively. Compliance with indication varied according to the guidelines: 65 (95.6%) were compliant with WHO and ASHP and 47 cases (69.11%) with SFAR. Among compliant cases, the antibiotics administered were rarely selected according to guidelines: WHO, 2 (2.9%) and ASHP, 2 (2.9%), and SFAR, 3 (4.4%). Drug dosage compliance varied from 20 (29.4%) (SFAR) to 49 (72.0%) (ASHP). Timings were respected in 47 (69.1%; WHO), 45 (66.2%; ASHP) and 9 cases (13.2%; SFAR). The number of cases compliant with antibiotic prophylaxis duration were 13 (19.1%; WHO), 17 (25.0%; ASHP) and 16 (23.5%; SFAR). Conclusion: The SAP compliance rate in gastrointestinal surgery based on the five conventional criteria was very low. SAP guidelines must be implemented appropriately for local bacteriological epidemiology.

Enhancing Preoperative Outcome Prediction: A Comparative Retrospective Case-Control Study on Machine Learning versus the International Esodata Study Group Risk Model for Predicting 90-Day Mortality in Oncologic Esophagectomy.

Risk prediction prior to oncologic esophagectomy is crucial for assisting surgeons and patients in their joint informed decision making. Recently, a new risk prediction model for 90-day mortality after esophagectomy using the International Esodata Study Group (IESG) database was proposed, allowing for the preoperative assignment of patients into different risk categories. However, given the non-linear dependencies between patient- and tumor-related risk factors contributing to cumulative surgical risk, machine learning (ML) may evolve as a novel and more integrated approach for mortality prediction. We evaluated the IESG risk model and compared its performance to ML models. Multiple classifiers were trained and validated on 552 patients from two independent centers undergoing oncologic esophagectomies. The discrimination performance of each model was assessed utilizing the area under the receiver operating characteristics curve (AUROC), the area under the precision-recall curve (AUPRC), and the Matthews correlation coefficient (MCC). The 90-day mortality rate was 5.8%. We found that IESG categorization allowed for adequate group-based risk prediction. However, ML models provided better discrimination performance, reaching superior AUROCs (0.64 [0.63-0.65] vs. 0.44 [0.32-0.56]), AUPRCs (0.25 [0.24-0.27] vs. 0.11 [0.05-0.21]), and MCCs (0.27 ([0.25-0.28] vs. 0.15 [0.03-0.27]). Conclusively, ML shows promising potential to identify patients at risk prior to surgery, surpassing conventional statistics. Still, larger datasets are needed to achieve higher discrimination performances for large-scale clinical implementation in the future.

The clinical utility of multidisciplinary team meetings for patients with complex benign upper gastrointestinal conditions.

Patients with benign upper gastrointestinal (UGI) conditions such as achalasia, gastroparesis and refractory gastroesophageal reflux disease often suffer from debilitating symptoms. These conditions can be complex and challenging to diagnose and treat, making them well suited for discussion within a multidisciplinary meeting (MDM). There is, however, a paucity of data describing the value of a benign UGI MDM. The aim of this study was to assess the impact of our unit's benign UGI MDM service and its outcomes. This was a retrospective analysis of prospectively collected data for all consecutive patients reviewed in the monthly benign UGI MDM between July 2021 and February 2024. The primary outcome was the incidence that MDM review changed clinical treatment. Secondary outcomes included change in diagnosis, additional investigations and referrals to subspecialists. A total of 104 patients met inclusion criteria. A total of 73 (70.2%) patients had a change in their overall management following MDM review; 25 (24.0%), 31 (29.8%) and 48 (46.2%) patients had changes in pharmacological, endoscopic and surgical interventions respectively. Most changes in pharmacological and endoscopic intervention involved treatment escalation, whereas most changes in surgical intervention involved treatment de-escalation. A total of 84 (80.8%) patients had a documented diagnosis post-MDM with 44 (42.3%) having a change in their pre-MDM diagnosis. 50 (48.1%) patients had additional investigation/s requested and 49 (47.1%) had additional referral pathway/s recommended. Over two thirds of patients had at least one aspect of their management plan changed following MDM review. These changes occurred across pharmacological, endoscopic, and surgical interventions.

Timing of Loop Ileostomy Closure Does Not Play a Pivotal Role in Terms of Complications-Results of the Liquidation of iLEOstomy (LILEO) Study.

Loop ileostomy is commonly performed by colorectal and general surgeons to protect newly created large bowel anastomoses. The optimal timing for ileostomy closure remains debatable. Defining the timing associated with the best postoperative outcomes can significantly improve the clinical results for patients undergoing ileostomy closure. The LILEO study was a prospective multicenter cohort study conducted in Poland from October 2022 to December 2023. Full data analysis involved 159 patients from 19 surgical centers. Patients were categorized based on the timing of ileostomy reversal: early (<4 months), standard (4-6 months), and delayed (>6 months). Data on demographics, clinical characteristics, and perioperative outcomes were analyzed for each group separately and compared. No significant differences were observed in length of hospital stay (p = 0.22), overall postoperative complications (p = 0.43), or 30-day reoperation rates (p = 0.28) across the three groups. Additional analysis of Clavien-Dindo complication grades was performed and did not show significant differences in complication severity (p = 0.95), indicating that the timing of ileostomy closure does not significantly impact perioperative complications or hospital stay. Decisions on ileostomy reversal timing should be personalized and should consider individual clinical factors, including the type of adjuvant oncological treatment and the preventive measures performed for common postoperative complications.

Cognitive impairment induced by sevoflurane anesthesia is mediated by the cholinergic system after gastrointestinal surgery in older patients: A randomized, controlled trial.

Delayed neurocognitive recovery after surgery is associated with increased morbidity and mortality. However, its mechanism of action remains controversial and complex. A prospective, double-blind, randomized controlled trial was performed at the Affiliated Hospital of Zunyi Medical University. Older patients (aged 65 years and older) who underwent gastrointestinal surgery were randomly divided into sevoflurane-based or propofol-based anesthesia groups. The Mini-Mental State Examination was performed to evaluate cognitive function. Peripheral venous blood was collected to test the levels of choline acetyltransferase and acetylcholinesterase. A total of 75 patients were enrolled and 30 patients in each group completed the study. On Day 1 postoperation, patients in the sevoflurane group showed worse performance on the Mini-Mental State Examination than patients in the propofol group. Lower blood choline acetyltransferase concentrations and higher acetylcholinesterase concentrations were observed in patients who had sevoflurane anesthesia than in patients who had propofol anesthesia 1 day postoperative. At 3 days postoperation, patients with sevoflurane- or propofol-based general anesthesia did not differ regardless of Mini-Mental State Examination score or choline acetyltransferase and acetylcholinesterase levels. Sevoflurane-based anesthesia has short-term delayed neurocognitive recovery in older surgical patients, which may be related to central cholinergic system degeneration.

Spontaneous haemoperitoneum caused by a bleeding gastric gastrointestinal stromal tumour.

Spontaneous haemoperitoneum is described as a collection of blood in the peritoneal cavity due to non-traumatic aetiology. Common causes in the literature include splenic, hepatic and gynaecological pathology. Patients with spontaneous haemoperitoneum usually present with non-specific dull aching abdominal pain. Spontaneous haemoperitoneum can only be radiologically diagnosed and, if not treated in time, is life threatening. Rupture of a gastrointestinal stromal tumour (GIST) presenting as a spontaneous haemoperitoneum is a rare event. Gastric GIST presents as ambiguous abdominal pain, complications of which include melena, obstruction and rupture. This is a report of a male patient in his early 60s who presented with acute abdominal pain. A contrast-enhanced CT of the abdomen showed haemoperitoneum with an unknown source of origin. Diagnostic laparoscopy showed a bleeding exophytic mass arising from the stomach, which was resected. Thus, early diagnosis with proper imaging and prompt treatment has a favourable outcome.