Seprafilm® and adhesive small bowel obstruction in colorectal/abdominal surgery: an updated systematic review.

BACKGROUND: The efficacy of Seprafilm® in preventing clinically significant adhesive small bowel obstruction (ASBO) is controversial and deserves further review. The aim of this review was to assess the utility of Seprafilm® in preventing clinically significant adhesive bowel obstruction after abdominal operations, with separate focus on colorectal resections. The secondary aim was to provide an updated literature review on the safety profile of this implant. METHODS: An up-to-date systematic review was performed on the available literature between 2000 and 2023 on PubMed, EMBASE, Medline, and Cochrane Library databases. The main outcome measures were rates of adhesive bowel obstruction, as well as rates of intervention. The secondary outcome was the clinical safety profile of Seprafilm® as described in current literature. RESULTS: A total of 17 observational studies were included, accounting for 62,886 patients. Use of Seprafilm® was associated with a significant reduction in adhesive bowel obstruction events (OR 0.449, 95% CI: 0.3271 to 0.6122, p < 0.001), with preserved efficacy seen in laparoscopic cases. This did not translate into a reduced rate of reintervention. Clinicians should also be aware of isolated reports of a paradoxical inflammatory reaction leading to fluid collections after Seprafilm® use, although they appear uncommon. CONCLUSION: Seprafilm® can be considered in select patients although further study to determine which patients will benefit most is required.

Palliative procedures for advanced obstructive colorectal cancer: a systematic review and meta-analysis.

PURPOSE: Advanced obstructive colorectal cancer (AOCC) presents surgical challenges. Consideration must be given to alleviating symptoms and also quality of life and survival time. This study compared prognostic efficacies of palliative self-expanding metal stents (SEMSs) and surgery to provide insights into AOCC treatment. METHODS: PubMed, Web of Science, MEDLINE, and Cochrane Library were searched for studies that met inclusion criteria. Using a meta-analysis approach, postoperative complications, survival rates, and other prognostic indicators were compared between patients treated with SEMSs and those treated surgically. Network meta-analysis was performed to compare prognoses between SEMS, primary tumor resection (PTR), and stoma/bypass (S/B). RESULTS: Twenty-one studies were selected (1754 patients). The odds ratio (OR) of SEMS for clinical success compared with surgery was 0.32 (95% confidence interval [CI] 0.15, 0.65). The ORs for early and late complications were 0.34 (95% CI 0.19, 0.59) and 2.30 (95% CI 1.22, 4.36), respectively. The ORs for 30-day mortality and stoma formation were 0.65 (95% CI 0.42, 1.01) and 0.11 (95% CI 0.05, 0.22), respectively. Standardized mean difference in hospital stay was - 2.08 (95% CI - 3.56, 0.59). The hazard ratio for overall survival was 1.24 (95% CI 1.08, 1.42). Network meta-analysis revealed that SEMS had the lowest incidence of early complications and rate of stoma formation and the shortest hospital stay. PTR ranked first in clinical success rate and had the lowest late-complication rate. The S/B group exhibited the lowest 30-day mortality rate. CONCLUSION: Among palliative treatments for AOCC, SEMSs had lower early complication, stoma formation, and 30-day mortality rates and shorter hospital stays. Surgery had higher clinical success and overall survival rates and lower incidence of late complications. Patient condition/preferences should be considered when selecting AOCC treatment.

Risk of bowel obstruction in patients with colon cancer responding to immunotherapy: an international case series.

BACKGROUND: Immunotherapy is used routinely for treating deficient mismatch repair (dMMR) colon cancer (CC). This case series highlights an emerging safety issue, where patients develop bowel obstruction associated with immunotherapy response. PATIENTS AND METHODS: Patients with dMMR CC who developed bowel obstruction while responding to immunotherapy were retrospectively identified. Data on patient, disease, treatment, and response-specific factors were explored for potential risk factors. Overall treatment numbers were used to estimate incidence. RESULTS: Nine patients from eight European centres were included. Common features were hepatic flexure location (5/9), T4 radiological staging (6/9), annular shape (8/9), radiological stricturing (5/9), and endoscopic obstruction (6/9). All received pembrolizumab and obstructed between 45 and 652 days after starting treatment. Seven patients underwent surgical resection; one was managed with a defunctioning stoma; and one was managed conservatively. One patient died from obstruction. Radiological response was seen in eight patients, including two complete responses. Pathological response was seen in all seven who underwent resection, including four complete responses. The overall incidence of immunotherapy response-related obstruction in these centres was 1.51%. CONCLUSIONS: Bowel obstruction associated with immunotherapy response may represent a rare treatment-related complication in dMMR CC. Clinicians must recognise this safety signal and share experience to maintain patient safety.

Complications resulting from an intragastric balloon in a patient without follow-up and monitoring.

The intragastric balloon (IGB) is recognised as a minimally invasive intervention for the treatment of obesity. Here, we detail a rare and life-threatening complication stemming from this procedure. A female patient in her 40s, who had an IGB in situ for 14 months, presented at the emergency department with septic shock characterised by abdominal guarding and emesis. These symptoms were a direct result of IGB-induced bowel obstruction. We emphasise that the patient missed the recommended 6-month removal window, which in our opinion is the decisive cause leading to deflated balloon migration and subsequent complications. In the course of managing multiple critical events, the patient required multiple operations related to the bowel obstruction, numerous nutritional and psychological challenges. Currently, the patient is living with short bowel syndrome, secondary to the chronic intestinal failure, necessitating the administration of parenteral nutrition 6 days per week.

Complications of the intragastric balloon treatment. Small bowel obstruction caused by migrated intragastric balloon - clinical case report and literature review.

INTRODUCTION: An endoscopic intragastric balloon (IGB) placement is one of the minimally invasive methods of obesity treatment. One of the rare serious complications is mechanical bowel obstruction requiring operative management. We report a case of a male patient with small bowel obstruction due to IGB migration and the literature review of complications during IGB treatment. Detailed Case Description: A patient with a BMI of 28 kg/m2 was admitted to the hospital with spontaneous deflation of an IGB. Due to the suspected location of IGB in the ileum laparoscopy was performed. The enterotomy was performed and the IGB removed. The procedure and the postoperative period were uneventful. DISCUSSION: Spontaneous IGB ruptures are reported in the literature with a frequency ranging from 0.6 to 23%. The majority of deflated devices are spontaneously excreted with the stool with no abdominal symptoms. Only 0.38% of IGBs cause mechanical bowel obstruction of requiring surgical management. Based on our own experience and literature review, we propose the diagnostic and therapeutic algorithm. CONCLUSION: Complications after IGB placement can range from mild to severe, that is why it is so important to make an early diagnosis based on the emerging symptoms and to implement prompt management to reduce or avoid serious complications. Any patient reporting disturbing symptoms occurring over a pro- longed period of time requires hospitalization and careful observation for the occurrence of gastrointestinal obstruction. The ideal option is hospitalization in the center which implemented the IGB and start with the algorithm we proposed.

Idiopathic encapsulating peritoneal sclerosis presenting with abdominal mass.

A man in his late 30s presented with a history of recurrent colicky abdominal pain, bilious vomiting and intermittent mass formation in the lower abdomen. The mass was mobile, non-tender and fluctuant, and appeared in the right iliac fossa during episodes of pain and disappeared once the pain subsided. Contrast-enhanced CT (CECT) scan revealed a thick membrane-like structure covering the clumped small bowel loops, suggestive of an abdominal cocoon. A midline laparotomy was carried out with extensive adhesiolysis, and a membrane incision was performed. The final histopathological diagnosis was primary encapsulating peritoneal sclerosis. Encapsulating peritoneal sclerosis of idiopathic origin is rare and typically presents as an acute or subacute intestinal obstruction. A CECT scan is the diagnostic modality of choice, with a thick peritoneal membrane covering the small bowel loops being the hallmark sign. Surgical intervention is the preferred treatment for idiopathic cases, while medical management may address secondary causes.

[Abdominal obstruction revealing colonic lymphoma: a case report]. / Occlusion abdominale révélant un lymphome colique: à propos d'un cas.

Colonic lymphoma is a rare malignant gastrointestinal tumor that can be revealed by an exceptional and serious complication: intestinal obstruction. Treatment is based on surgery and chemotherapy. We here report a case of diffuse colonic large B-cell lymphoma revealed by occlusion and diagnosed based on the examination of surgical specimen in a 64-year-old man who was in complete remission after six courses of R-CHOP.

Case Report: Acute large bowel obstruction with actinomycosis of the sigmoid colon mimicking neoplasm.

Introduction: Actinomycosis is an uncommon inflammatory bacterial disease caused by Actinomyces species, especially Actinomyces Israeli. Abdominopelvic forms are relatively rare and may involve the colon as a solid mass, mimicking a malignant tumor. Case presentation: A 68-year-old Tunisian man, with a history of diabetes, hypertension, penicillin allergy, and renal failure, presented to the emergency department with abdominal pain, vomiting, and bowel obstruction. CT scan showed an acute intestinal obstruction upstream with obstructive tissular mass at the sigmoid colon. Emergency surgery revealed a sigmoid mass and a pre-perforative cecum. Total colectomy was performed, with ileostomy and distal end closure. Histological examination confirmed Actinomyces infection. The patient was then placed on long-term doxycycline and Bactrim, with no recurrence over a 9-month follow-up period. Conclusion: Abdominal actinomycosis, though rare, presents diagnostic challenges. It can be mistaken for malignancy, leading to unnecessary surgery in non-complicated cases, since it is effectively treated by antibiotics. In complicated cases, a combined approach involving both surgery and antibiotic therapy is necessary until the infection is completely eradicated.

Neonatal mesenteric cyst in a 5-day-old patient: a case report.

Mesenteric cysts have been documented as a rare occurrence in children. They are mostly renowned to be benign intra-abdominal tumors with no known etiology. The symptoms are non-specific ranging from being asymptomatic to an acute abdomen. Most of the diagnoses are made below the age of 10 years with devoid of reports for the early neonatal occurrences. We report a case of an early neonatal mesenteric cyst in a 5-day-old female patient who presented with signs of intestinal obstruction markedly by abdominal distension, vomiting, and absolute constipation. Abdominal X-ray showed evidence of small bowel obstruction while abdominal ultrasound and computed tomography (CT) scan were used to reach the diagnosis of a mesenteric cyst, all laboratory baseline investigations were within a normal range. On laparotomy a 12 by 13 cm cyst that was firmly adhering to the proximal ileal wall was meticulously dissected, complete cystectomy was done with no segmental resection. Histopathologically there were no signs of malignancy and the patient successfully recovered with no signs of recurrences after being followed for a year and a half. Being a rare case in the early neonatal period with unspecific presentations; mesenteric cyst should be considered as one of the diagnoses best to be managed by surgical excision to prevent recurrences.

Case report: A clinical report of photodynamic neoadjuvant combined with fluorescent laparoscopic localization robotic surgery for the treatment of patients with advanced colorectal cancer combined with obstruction.

The incidence of colorectal cancer is relatively high in our country, with the majority of patients being diagnosed at an advanced stage. For individuals with advanced-stage colorectal cancer, conversion or neoadjuvant therapy is frequently necessitated to facilitate surgical intervention and achieve a curative effect. And about 10% to 30% of colon cancer patients are complicated with intestinal obstruction. Surgical intervention remains the primary treatment for managing intestinal obstructions, albeit with a considerable risk of perioperative mortality and an increased likelihood of postoperative complications. PDT, as a neoadjuvant treatment for colon cancer, can shrink the local tumor and relieve obstruction, and is effective in colon cancer combined with obstruction. Robotic surgery has the advantages of high stability and low trauma, and compared with laparoscopic colon cancer surgery, robotic surgery can achieve better results. Fluorescent laparoscopic clarifies the location and size of the tumor lesion, allowing for greater precision when removing colon cancer lesions in robotic surgery. Therefore, in the treatment of colon cancer, PDT can offer an opportunity for surgery after relieving obstruction in patients with obstructive colon cancer. Additionally, when combined with fluorescent laparoscopic robotic colon cancer surgery, it provides a novel treatment approach for patients with obstructive colon cancer. Preoperative photodynamic neoadjuvant therapy combined with robotic colon cancer surgery has not yet been reported. Here, we report a case of colon cancer with obstruction, preoperative TNM stage was T4N1, and the lesion had caused intestinal stenosis. After four sessions of PDT, the patient's intestinal lumen was unobstructed and the lesion had regressed. After evaluation, fluorescent laparoscopic localization and visualization of lymph nodes combined with robotic colon cancer resection were performed. Postoperative pathology showed that the patient's tumor regression grade was grade 1. The patient's tumor was completely resected with good resection effect. No tumor invasion was found on both sides of the resection margin, and the patient did not relapse after surgery.

Leg Pain-An Unexpected Twist.

BACKGROUND: Obturator hernia is a rare condition, often presenting with non-specific symptoms, such as thigh pain, groin pain, nausea, or vomiting. Obturator hernias are most common in thin, elderly women. Oftentimes, they are diagnosed late in the disease course resulting in complications and high morbidity and mortality. CASE REPORT: We present the case of a 75-year-old female who presented with right thigh pain with no other symptoms. After computed tomography (CT) of the abdomen/pelvis, the patient was found to have an incarcerated obturator hernia complicated by a small bowel obstruction, ultimately requiring urgent surgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the very general symptoms associated with the condition, the diagnosis of obturator hernia can easily be missed, leading to a delayed diagnosis, more complications, and a higher morbidity and mortality rate. Due to the risk associated with a delayed diagnosis, it is important for emergency physicians to maintain a high clinical suspicion for the diagnosis.

Metastatic lung adenocarcinoma presenting with small bowel obstruction.

Lung cancer is one of the most lethal solid organ malignancies. Metastasis commonly spreads to the liver, adrenal glands and bone. We report a case of a male patient who presented with an 8 week history of cramping abdominal pain and vomiting. Subsequent investigation revealed evidence of an obstructing small bowel lesion. He underwent a small bowel resection. Histopathology revealed evidence of lung adenocarcinoma as the likely primary disease. Although metastasis of lung adenocarcinoma to the small bowel is rare, early recognition may prevent potentially life-threatening sequelae including bowel perforation and peritonitis.

Interval operative management in patients admitted with acute obstruction due to incarcerated paraesophageal hernia.

BACKGROUND: Acute incarcerated paraesophageal hernias (PEH) have historically been considered a surgical emergency. Emergent operations have a higher rate of morbidity and mortality compared to elective surgery. Our institution has adopted a strategy of initial conservative management in patients presenting with acute obstruction from an incarcerated PEH who are clinically stable. Patients are given at least 24 h for their symptoms to improve (selective nasogastric decompression). If symptoms resolve, contrast on an upper GI study passes to the small bowel, and liquids are tolerated, patients are discharged with planned interval repair. We sought to characterize the outcomes of this interval surgical strategy for incarcerated PEH. METHODS: A retrospective chart review was performed to identify patients admitted to a single institution between October 2019 and September 2023 with an incarcerated PEH. Patients taken directly to surgery within 24 h were excluded. RESULTS: A total of 45 patients admitted with obstruction from an incarcerated PEH were identified. Ten patients (22%) were taken urgently to surgery due to clinical instability and were excluded. Of the remaining 35 patients, 23 (66%) resolved their obstruction with conservative non-operative management and were offered planned interval PEH repair (successful conservative management). In the successful conservative management cohort, there was one unplanned readmission before interval PEH repair. Average time between discharge and repair was 25 days. Complication rates did not differ in those who failed and in those who had a successful conservative management result. The cumulative length of stay for those who succeeded in conservative management (including days for the interval surgery) was equivalent with those who underwent PEH repair during the index admission. CONCLUSION: A trial of conservative management in clinically stable patients with symptomatic incarcerated PEH appears to be safe and often avoids emergent repair without increasing perioperative complications or total days in the hospital.

Short-term and three-year long-term outcomes of laparoscopic surgery versus open surgery for obstructive colorectal cancer following self-expandable metallic stent placement: a meta-analysis.

BACKGROUND: A bridge to surgery (BTS) after self-expandable metallic stent (SEMS) placement is a widely recognized treatment strategy for obstructive colorectal cancer. However, there is still a lack of evidence for the efficacy and safety of laparoscopic surgery following SEMS placement. The aim of this systematic review and meta-analysis was to compare the short-term and long-term outcomes of laparoscopic surgery with those of open surgery following SEMS placement in patients with obstructive colorectal cancer. METHODS: An electronic literature search through to December 2022 was performed to identify studies comparing short-term and long-term outcomes between laparoscopic and open surgery following SEMS placement for obstructive colorectal cancer. The main outcome measures were postoperative complication rates and mortality. Secondary outcome measures were the 3-year recurrence-free survival (RFS) and 3-year overall survival (OS) rates. The meta-analysis was performed using fixed-effect or random-effects methods to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs). RESULTS: The meta-analysis included 15 studies and 883 patients, of whom 467 (52.9%) underwent laparoscopic surgery and 416 (47.1%) underwent open surgery following SEMS placement. The postoperative complication rate was significantly lower in the laparoscopic surgery group than in the open surgery group (OR 0.47, 95% CI 0.32-0.67, P < 0.001). There was no significant difference in the 3-year RFS rate or 3-year OS rate between the laparoscopic and open surgery groups (3-year RFS, OR 0.78, 95% CI 0.50-1.24, P = 0.30; 3-year OS, OR 0.68, 95% CI 0.41-1.12, P = 0.13). CONCLUSION: This meta-analysis found that the short-term outcome was better in patients who underwent laparoscopic surgery following SEMS placement than in those who underwent open surgery. Furthermore, there was no significant difference in long-term outcomes between the two groups. Laparoscopic surgery following SEMS placement may be a safe and effective treatment option for obstructive colorectal cancer.

Mortality risk of patients with intestinal obstruction.

BACKGROUND: Intestinal obstruction represents a severe intestinal disease associated with higher mortality rates. However, the determinants of mortality in patients with intestinal obstruction remain inadequately understood. This study sought to elucidate the potential risk factors associated with mortality in the context of intestinal obstruction during the COVID-19 pandemic. METHODS: A retrospective analysis was performed on a cohort of 227 patients diagnosed with intestinal obstruction at the First Hospital of Hebei Medical University, spanning the period from September 7, 2022, to January 7, 2023. The primary endpoint of the study was mortality within four weeks following discharge. Univariate and multivariable logistic regression models were utilized to evaluate the risk factors associated with mortality outcomes. RESULTS: A cohort of 227 patients diagnosed with intestinal obstruction (median age, 59.02 years [IQR, 48.95-70.85 years]) was included in our study. Malignant bowel obstruction (MBO) and COVID-19 were identified as independent risk factors for mortality among these patients. Notably, the mortality rate increased significantly to 38.46% when MBO was concomitant with COVID-19. Furthermore, postoperative pulmonary complications (PPC) (OR, 54.21 [death]; 95% CI, 3.17-926.31), gastric cancer (OR, 9.71 [death]; 95% CI, 1.38-68.18), VTE (Caprini Score ≥ 5) (OR, 7.64 [death]; 95% CI, 1.37-42.51), and COVID-19 (OR, 5.72 [death]; 95% CI, 1.01-32.29) were all determined to be independent risk factors for postoperative mortality. Additionally, gastric cancer could have emerged as one of the most severe risk factors for mortality in individuals with intestinal obstruction within the cohort of cancer patients, of which gastric cancer exhibited higher mortality rates compared to individuals with other forms of cancer. CONCLUSION: The study identifies MBO, gastric cancer, COVID-19, PPC, and VTE as potential risk factors for mortality in cases of intestinal obstruction. These findings highlight the necessity for continuous monitoring of indicators related to these mortality risk factors and their associated complications, thereby offering valuable insights for the management and treatment of intestinal obstruction.

Central congenital diaphragmatic hernia presenting as intestinal obstruction.

Presentation of congenital diaphragmatic hernia in adulthood is rare. Further, most cases are attributable to Bochdalek and Morgagni hernias with central tendon hernias being particularly uncommon. We report a case of central congenital diaphragmatic hernia in an adult presenting as large intestinal obstruction and respiratory failure. Open repair of the hernia was performed, which brought about the resolution of the patient's symptoms. This case report highlights the possibility for congenital diaphragmatic hernia to present in adulthood and the importance of early diagnosis and treatment in these situations.

A Comparative Analysis between Enhanced Recovery after Surgery and Traditional Care in the Management of Obstructive Colorectal Cancer.

Enhanced Recovery After Surgery (ERAS) represents evidence-based transformation in perioperative care, which has been demonstrated to reduce both recovery times and postoperative complication rates. The aim of the present study was to evaluate the clinical significance of the ERAS program in comparison with conventional postoperative care. This longitudinal cohort observational study enrolled 120 consecutive patients diagnosed with intestinal obstruction caused by colorectal cancers, with 40 patients in the ERAS group and 80 patients receiving conventional postoperative care forming the non-ERAS group. Our study compares the effectiveness of ERAS protocols to non-ERAS methods, focusing on the time to first flatus, defecation, the resumption of normal diet, and early mobilization. The main endpoints are morbidity and hospitalization length. The results showed that despite a longer admission-to-surgery interval in the ERAS group, median hospitalization was significantly shorter compared to the non-ERAS group (p = 0.0002). The ERAS group showed a tendency towards a lower incidence of overall postoperative complications, indicating that implementing the ERAS protocol does not increase the risk of postoperative complications, ensuring the safety of enhanced recovery strategies for patients. Also, ERAS patients had notably fewer stomas than those in the non-ERAS group, indicating the potential effectiveness of reducing stoma necessity. This study shows that ERAS surpasses conventional care for colonic or rectal surgery patients, reducing hospital stays and costs while enhancing recovery. This highlights the comprehensive advantages of adopting ERAS in surgical settings.