Evaluation of abdominal exercises after stoma surgery: a descriptive study.

PURPOSE: To evaluate the feasibility of exercises for the abdominal muscles in patients after colostomy or ileostomy formation on the following parameters: muscle activity, pain, discomfort, and difficulty of performing the exercises. MATERIALS AND METHODS: Patients with a new stoma were divided into groups based on time after surgery: Early group, 0-2 weeks (n = 12); Intermediate group, 2-6 weeks (n = 15); and Late group, 6-12 weeks (n = 10). During a single individual test session, participants in each group performed a different set of 10-11 abdominal coordination and strengthening exercises for the abdominal muscles. Activity of the abdominal muscles was measured with electromyography. Pain, discomfort, and difficulty were rated for each exercise. RESULTS: For the Early group, muscle activity reaching a predetermined threshold was measured for half of the participants in a few exercises. In both the Intermediate group and the Late group, muscle activity reaching the onset criteria was measured for all muscles for a high percentage of participants in several exercises. Both strengthening and coordinating exercises were feasible based on low ratings of pain, discomfort, and difficulty. CONCLUSIONS: This study identified feasible exercises that activated the abdominal muscles at different time points after stoma formation. The observations can be used as guidance for the choice of exercises in clinical practice and future research.Implications for rehabilitationThe findings of this study can be used in clinical practice as guidance for choice of exercise at different time points after surgery.This study identified useful exercises for activating the abdominal muscles in rehabilitation after stoma surgery from two weeks on.In the first two postoperative weeks, there was limited involvement of the abdominal muscles with the evaluated exercises.Most of the evaluated abdominal exercises were feasible after stoma surgery based on pain, discomfort, and difficulty.

Geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer: a protocol for a randomised controlled trial (GEPOC trial).

BACKGROUND: The incidence of colorectal cancer (CRC) increases with age. Older patients are a heterogeneous group ranging from fit to frail with various comorbidities. Frail older patients with CRC are at increased risk of negative outcomes and functional decline after cancer surgery compared to younger and fit older patients. Maintenance of independence after treatment is rarely investigated in clinical trials despite older patients value it as high as survival. Comprehensive geriatric assessment (CGA) is an evaluation of an older persons' medical, psychosocial, and functional capabilities to develop an overall plan for treatment and follow-up. The beneficial effect of CGA is well documented in the fields of medicine and orthopaedic surgery, but evidence is lacking in cancer surgery. We aim to investigate the effect of CGA on physical performance in older frail patients undergoing surgery for CRC. METHODS: GEPOC is a single centre randomised controlled trial including older patients (≥65 years) undergoing surgical resection for primary CRC. Frail patients (≤14/17 points using the G8 screening tool) will be randomised 1:1 to geriatric intervention and exercise (n = 50) or standard of care along (n = 50) with their standard surgical procedure. Intervention includes preoperative CGA, perioperative geriatric in-ward review and postoperative follow-up. All patients in the intervention group will participate in a pre- and postoperative resistance exercise programme (twice/week, 2 + 12 weeks). Primary endpoint is change in 30-s chair stand test. Assessment of primary endpoint will be performed by physiotherapists blinded to patient allocation. Secondary endpoints: changes in health related quality of life, physical strength and capacity (handgrip strength, gait speed and 6 min walking test), patient perceived quality of recovery, complications to surgery, body composition (Dual-energy X-ray absorptiometry and bioelectric impedance), serum biomarkers, readmission, length of stay and survival. DISCUSSION: This ongoing trial will provide valuable knowledge on whether preoperative CGA and postoperative geriatric follow-up and intervention including an exercise program can counteract physical decline and improve quality of life in frail CRC patients undergoing surgery. TRIAL REGISTRATION: Prospectively registered at Clinicaltrials.gov NCT03719573 (October 2018).

Long-term outcomes in patients after ligation of the intersphincteric fistula tract.

INTRODUCTION: Ligation of the intersphincteric fistula tract (LIFT) to treat transsphincteric fistulae has yielded varied but promising results. However, it has been shown that long-term follow-up (> 250 days) is vital to obtain the correct surgical outcome. Here, we present the long-term results of patients undergoing the LIFT procedure at Herlev Hospital, Denmark. METHODS: The study was based on a retrospective chart review of 65 consecutive patients who underwent the LIFT procedure for transsphincteric fistula-in-ano in 2011-2015. RESULTS: At the first follow-up, at a median 50 (interquartile range (IQR): 29-92) days, there were 28 recurrences of which 17 were transsphincteric. At the long-term follow-up, a median of 274 (IQR: 162-573) days, 16 patients (ten of whom were asymptomatic at the first follow-up) presented with a recurrence, of which seven were transsphincteric; 27 patients (42%) showed complete fistula healing following their initial LIFT surgery. Another 29 patients presented complete healing after repeated surgical treatment (additional LIFT, advancement flap and/or simple incision/fistulotomy), yielding a positive outcome in 86% of our patients. CONCLUSION: The present study shows that the LIFT procedure is a viable treatment option for transsphincteric fistulae. Furthermore, a second LIFT procedure is a plausible option for recurrent transsphincteric fistulae. In the case of recurrence, the fistula was frequently downgraded to a more benign intersphincteric variant. The study supports previous findings showing that long-term follow-up is required to successfully measure the outcome of LIFT surgery. FUNDING: none. TRIAL REGISTRATION: not relevant.

Automatic and unbiased assessment of competence in colonoscopy: exploring validity of the Colonoscopy Progression Score (CoPS).

Background and aims: Colonoscopy is a difficult procedure to master. Increasing demands for colonoscopy, due to screening and surveillance programs, have highlighted the need for competent performers. Valid methods for assessing technical skills are pivotal for training and assessment. This study is the first clinical descriptive report of a novel colonoscopy assessment tool based on Magnetic Endoscopic Imaging (MEI) data and the aim was to gather validity evidence based on the data collected using the "Colonoscopy Progression Score" (CoPS). Methods: We recorded 137 colonoscopy procedures performed by 31 endoscopists at three university hospitals. The participants performed more than two procedures each (range 2 - 12) and had an experience of 0 - 10 000 colonoscopies. The CoPS was calculated for each recording and validity was explored using a widely accepted contemporary framework. The following sources of validity evidence were explored: response process (data collection), internal structure (reliability), relationship to other variables (i. e. operator experience), and consequences of testing (pass/fail). Results: Identical set-ups at all three locations ensured uniform data collection. The Generalizability coefficient (G-coefficient) was 0.80, and a Decision-study (D-study) revealed that four recordings were sufficient to ensure a G-coefficient above 0.80. We showed a positive correlation between CoPS and experience with Pearson's r of 0.61 (P < 0.001). A pass/fail standard of 107 points was established using the contrasting group method to explore the consequences of testing. Conclusion: This study provides evidence supporting the validity of the CoPS for use in assessing technical colonoscopy performance in the clinical setting. STUDY REGISTRATION: NCT01997177.

Accuracy of abdominal auscultation for bowel obstruction.

AIM: To investigate the accuracy and inter-observer variation of bowel sound assessment in patients with clinically suspected bowel obstruction. METHODS: Bowel sounds were recorded in patients with suspected bowel obstruction using a Littmann(®) Electronic Stethoscope. The recordings were processed to yield 25-s sound sequences in random order on PCs. Observers, recruited from doctors within the department, classified the sound sequences as either normal or pathological. The reference tests for bowel obstruction were intraoperative and endoscopic findings and clinical follow up. Sensitivity and specificity were calculated for each observer and compared between junior and senior doctors. Interobserver variation was measured using the Kappa statistic. RESULTS: Bowel sound sequences from 98 patients were assessed by 53 (33 junior and 20 senior) doctors. Laparotomy was performed in 47 patients, 35 of whom had bowel obstruction. Two patients underwent colorectal stenting due to large bowel obstruction. The median sensitivity and specificity was 0.42 (range: 0.19-0.64) and 0.78 (range: 0.35-0.98), respectively. There was no significant difference in accuracy between junior and senior doctors. The median frequency with which doctors classified bowel sounds as abnormal did not differ significantly between patients with and without bowel obstruction (26% vs 23%, P = 0.08). The 53 doctors made up 1378 unique pairs and the median Kappa value was 0.29 (range: -0.15-0.66). CONCLUSION: Accuracy and inter-observer agreement was generally low. Clinical decisions in patients with possible bowel obstruction should not be based on auscultatory assessment of bowel sounds.

Intestinal Pseudoobstruction Caused by Chronic Lyme Neuroborreliosis. A Case Report.

Chronic intestinal pseudoobstruction is often classified as idiopathic. The condition is associated with poor quality of life and high morbidity, and treatment options are often unsatisfactory. A case of chronic intestinal pseudoobstruction in a 66-year-old woman, presenting with back and abdominal pain, urinary retention and severe constipation is described. The patient lived in an area in which Lyme disease is endemic and had been bitten by ixodes ticks. Intrathecal synthesis of anti-borrelia IgM and IgG and lymphocytosis in the cerebrospinal fluid was found, consistent with chronic Lyme neuroborreliosis since symptoms had lasted for more than six months. The patient's gastrointestinal function recovered and the pain subsided significantly following treatment with antibiotics. Lyme neuroborreliosis (LNB) often results in palsy, but rarely affects the autonomic nervous system. Three patients have been described with intestinal pseudoobstruction due to acute LNB. However, this is the first described case of intestinal pseudoobstruction due to chronic Lyme neuroborreliosis. LNB must be suspected in patients with intestinal pseudoobstruction, in particular in patients who have been bitten by an ixodes tick and in patients living in an endemic area.

Sealing of gastrointestinal anastomoses with fibrin glue coated collagen patch.

BACKGROUND: Colorectal cancer (CRC) is the most common cancer of the gastrointestinal tract. In Denmark is CRC the 3. most frequent form of cancer and the 3. leading cause of cancer-related death. Anastomoses: Surgical resection is the only curative treatment of CRC and in Denmark about 85% of patients with CRC are therefore operated. An anastomosis will be established in most cases. Colorectal anastomoses are established in the treatment of benign diseases too, i.e. as part of the surgical treatment of inflammatory bowel disease and in acute surgery. Furthermore anastomoses are conducted in other parts of the gastrointestinal tract i.e. esophagus, stomach, small bowel and bile system. Anastomotic leakage (AL): AL is the most serious complication of gastrointestinal surgery with a 30-day mortality of 13-27%. The reported AL rate ranges from 1 to 39%. In addition to immediate clinical consequences AL is an independent predictor of reduced general and cancer-specific survival. Leakage can manifest as generalized peritonitis, requiring acute resurgery or as a more localized accumulation/abscess or as a subclinical leakage. Sealing of anastomoses: Numerous studies on anastomotic sealing have been conducted with the aim of reducing the number of AL's. The results of these are conflicting and predominantly disappointing. The drug Tacho-Sil (TS) consists of a collagen patch, which on the one side is coated with fibrin glue (FG), which gives it an adhesive property. TS is registered for use in surgical hemostasis. Animal models: Spontaneous AL in animals is infrequent. It is therefore necessary to use a model of AL. No such model exists and must be developed. OBJECTIVE: To clarify if the sealing of anastomoses with TS is feasible and safe in an experimental design. To develop a standardized model of AL in pigs. To clarify if sealing of colon-anastomoses with TS can reduce the number of clinical ALs in an experimental design. To clarify whether there is evidence that FG influences healing of gastrointestinal anastomosis. STUDIES: Safety study, that examines whether it is safe to seal anastomoses with a TS. Experimental study on pigs. Two anastomoses on each pig, one sealed with TS. After 1-6 weeks of observation the anastomosis were examined for AL, stenoses, strength and compared microscopic. RESULTS: No difference between sealed and unsealed anastomosis. This study is completed and published. Model study, to develop model of AL on pigs. A total of 22 pigs had an anastomosis of colon. All anastomoses were left with a standardized defect on 5-21 mm. The pigs were observed in order to assess how big the defect should be before the pigs developed visible leakage and/or fecal peritonitis. RESULTS: Model developed. 21 mm defect significant. This study is completed and published. Efficacy study, testing if TachoSil can seal an AL and thus prevent that this becomes clinically significant. A total of 20 pigs had a colon-anastomoses with a standardized defect of 21 mm. The pigs were randomized to sealing with TS or no sealing. Re-laparotomy after 7 days examining for visible leakage and/or fecal peritonitis. RESULTS: TachoSil® able to seal the defect (p=0.0055). This study is completed and published. Systematic review, with the purpose to study whether there is evidence that FG influence the healing of gastrointestinal anastomosis. RESULTS: Conflicting. FG does not seem to have an effect. This study completed and published. CONCLUSIONS: Sealing of GI-anastomosis with TachoSil is safe and feasible. A defect of at least 21mm must be left in colon anastomosis to induce clinical peritonitis. Sealing of defect colon-anastomosis in pigs with TachoSil can prevent clinical leakage and peritonitis. FG has no positive effect on microscopically healing of GI-anastomosis.

Fibrin glue does not improve healing of gastrointestinal anastomoses: a systematic review.

BACKGROUND/AIM: Anastomotic leakage remains a frequent and serious complication in gastrointestinal surgery. In order to reduce its incidence, several clinical and experimental studies on anastomotic sealing have been performed. In a number of these studies, the sealing material has been fibrin glue (FG), and the results in individual studies have been varying. The positive effect of anastomotic sealing with FG might be due to the mechanical/physical properties, the increased healing of the anastomoses or both. The aim of this systematic review was to evaluate the existing evidence on the healing effects of FG on gastrointestinal anastomoses. METHODS: PubMed, EMBASE and the Cochrane databases were searched for studies evaluating the healing process of gastrointestinal anastomoses after any kind of FG application. The search period was from 1953 to December 2013. RESULTS: Twenty-eight studies were included in the qualitative synthesis. These studies were all experimental studies, since no human studies used histological or biochemical evaluation of healing. In 7 of the 28 studies, a positive effect of FG on healing was found, while 8 studies reported a negative effect and 11 studies found no effect. Furthermore, 2 studies reported unclear results. The difference in the study outcome was independent of the study design and the type of FG used. CONCLUSION: In the available studies, FG did not consistently have a positive influence on the healing of gastrointestinal anastomoses. It is consequently plausible that the positive effect of FG sealing of gastrointestinal anastomoses, if there is any, may be due to a mechanical sealing effect rather than due to improved healing per se.

Sealing of gastrointestinal anastomoses with a fibrin glue-coated collagen patch: a safety study.

Sealing of anastomoses has previously been tested with several methods, including sealing with liquid fibrin glue. Sealing with a collagen patch coated with fibrin glue components has never been systematically examined. The aim of the present study was to determine the safety of sealing gastrointestinal anastomoses with a collagen patch coated with fibrin glue. The study is a prospective, experimental animal study comparing sealed and unsealed gastrointestinal anastomoses. Laparotomy was performed in 11 pigs under general anesthesia. In each pig two anastomoses were performed on the small intestine. One of the anastomoses was sealed with a collagen patch coated with fibrin glue components (TachoSil). The other anastomosis contained no sealing. The pigs were observed for 1 to 6 weeks. The observation period was followed by in vivo examination under general anesthesia and included observation for anastomotic leakage, signs of present or former peritonitis, abscess, adhesions to the anastomoses, and signs of intestinal obstruction. In addition, the anastomotic diameter was measured with barium and radiography. Finally, bursting pressure was measured in each segment. After the pigs were sacrificed, the bowel segments were microscopically examined. There were no differences between the sealed and the unsealed anastomoses with respect to abdominal pathology, in vivo bursting pressure, or degree of stenosis. The collagen fleeces were in situ in all anastomoses. Microscopically, we found no difference in healing or signs of infection.

Leakage of colon anastomoses: development of an experimental model in pigs.

BACKGROUND: In order to investigate anastomotic leakage, a number of experimental animal studies have been previously carried out. Due to the low frequency of spontaneous anastomotic leakages, there have been studies on gastrointestinal anastomoses with iatrogenically produced leakages. A leakage model has only been developed in one gastric bypass study. The aim of the present study was to develop a leakage model of pig colon anastomoses. This type of study has never been performed before. MATERIALS AND METHODS: Anastomosis was performed in 22 pigs. In all anastomoses a standardized rupture in the anastomotic line was made. The rupture ranged from 5 mm in the first group of pigs, increasing subsequently to 21 mm in the last group. Autopsy was performed after 7 days. The end points were macroscopic leakage and fecal peritonitis. RESULTS: 6 out of the 6 pigs with a 21-mm rupture developed leakage and fecal peritonitis. In the groups with smaller ruptures, most of the pigs did not develop any signs of leakage or fecal peritonitis. The difference is significant. The group of pigs with peritonitis had significantly fewer adhesions to the anastomoses than the group without peritonitis. CONCLUSION: A model of anastomotic leakage on pig colon is developed with creation of a 21-mm rupture in the anastomotic line.

[Magnetic items cause perforation of the bowel]. / Magneter som årsag til tarmperforationer.

Two cases of bowel perforation after ingestion of two or more magnetic foreign bodies by children are described. Both patients had only minor gastrointestinal symptoms when submitted to hospital. In both cases, acute exploratory laparatomy was performed and bowel perforation was found. The literature describes no consensus to surgical strategy in such cases. Based on the present cases, our recommendation is that an acute abdominal x-ray should be made, followed by either an acute endoscopy or acute laparatomy, even if the patient shows no signs of gastrointestinal symptoms.